A Study Guide for Reading Your Medical Records
There is something very disconcerting about watching a nurse or physician annotate your medical chart. As a patient, you have the right to read your medical records. I would never discourage you from doing so, but please peruse them with an understanding that they contain words, phrases and abbreviations that you, as a non-healthcare professional, may find offensive or misleading.
I have drafted a layperson’s study guide for medical chart review. Think of it as “Cliffs Notes,” but with a clinical spin. If you made it through Billy Budd, Sailor, you can certainly decipher what your doctor thought of your last check up or stress test.
If you have ever had an overnight stay in a hospital, you probably found the subsequent bill to be a figurative “f/u,” but did you know that there are also literal “f/u”s typed throughout your chart? Before you take offense, please know that it means something different in a medical report than is does in traffic. “F/u” is short for “follow up,” as in “come back in for another appointment.”
If you have ever picked up a copy of your child’s records from the doctor’s office in order to deliver them to the daycare center, you were probably hurt to see that the seemingly-affectionate pediatrician secretly finds your little darling to be, in all ways, a rather unremarkable child. “Eyes/ears/nose: unremarkable. Lungs: unremarkable.” Well excuse me, but I happen to think my daughter has the most beautiful eyes in the whole wide world! Unremarkable?! Please know that “unremarkable” is a wonderful word to see in your child’s chart. It basically means “it seems normal to me.”
If “unremarkable,” in a clinical context, is a good adjective, then “impressive” is a bad one. Again, it seems contrary after a life spent trying to be impressive on the baseball field, the board room, or the blogosphere, but trust me on this one, you don’t want to be “impressive” in the radiology suite. You don’t want an impressive liver or gallbladder, and while it is understood that a tumor is bad news, you certainly don’t want an impressive tumor.
If something in your body is tortuous, it means it has a distorted, windy shape or path. You could have a tortuous esophagus, for example. A tortuous aorta or tortuous colon. When doctor describes a part of the body as “tortuous,” it sounds as though he is being very dramatic, that he feels that part of your body is inflicting excessive, unbearable amounts of pain, but really he is describing that particular part of the body’s shape. (Note: I have watched lots of people with a tortuous esophagus try to eat, and it really kind of looks like torture sometimes.)
Like “f/u,” “sob” has a very vulgar connotation. Doctors, nurses and therapists will often write “sob” to indicate that a patient is “short of breath.” It isn’t the best problem to have, being winded, but all things being equal, you are probably more comfortable taking criticism on your respiratory status than your personality. (Assuming you don’t have COPD or some other severe pulmonary disease, you can probably improve your breathing. There isn’t much to be done with you, though, if you’re a big jerk.)
Your medical chart may make references to your social history, but it isn’t what it sounds like. It isn’t the sorority for which you pledged, the book club you attend or the inter-mural softball team for which you play short stop. “Social history” is a euphemistic way to describe a very bad habit. If you are a smoker, drinker or recreational drug user, these habits will be outlined in your social history.
I wish you good health, reader. If I can be of further assistance regarding medical terminology, please remember that questions can be left in the “comments” section, so f/u!