Poor Historian

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Sentinel Events

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Begin recording
The following is a recorded medical record of my initial evaluation of patient John Doe (coma)
MRN 99075251 (coma) on today's date January fourth (coma) two thousand twenty-three (coma)
At current time thirteen thirty (period)
Pt is of unknown age and origin presenting an unremarkable clinical picture post diagnostic testing(period)
Pt was initially found unresponsive on a commuter train (period)
Pt was transported to Orlando Medical ED via emergency services (period)
Upon arrival patient became conscious and alert while exhibiting AMS with apparent delusional behavior (period) Patient is a poor historian of recent and past events and is unable to articulate name (coma) origin (coma) and date of birth (period)
Patient is currently admitted to Florida Psychiatric Institute for further evaluation (period)
No medical abnormalities noted during hospitalization with vital signs and lab values observed within normal limits (period)
Patient presents currently as a healthy Caucasian male with no signs of bodily injury or trauma (period)

Hello, my friend, my name is Dr. Herwig and we are here today to do an evaluation and to get to know each other a little bit. Is that OK?
I'll be recording our conversation. All right, let's begin.
Can you tell me your name?
My name? I can't remember.
Do you know where we are right now?
We're in a hospital?
What is last thing you can remember?
Honestly, I don't remember anything I just have all these lyrics and songs stuck in my, lyrics and songs stuck in my, lyrics and songs stuck in my, lyrics and songs stuck in my head, stuck in my head, stuck in my head.

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