Organ System/Issue | Problem Reported by Computer History but not Hospital Chart | Patients with Problem |
---|---|---|
Heart | Symptoms heart failure (dyspnea on exertion, paroxysmal nocturnal dyspnea, marked fatigue, pitting edema) with no prior diagnosis | 10 |
 | Symptoms decompensated heart failure in patients with prior diagnosis | 2 |
 | "Cardiac asthma" versus reactive airway disease | 4 |
 | Prior diagnosis angina with chest pain | 1 |
 | Symptoms effort-induced angina versus reactive airway disease manifest as chest tightness | 1 |
 | Effort induced chest pain, no prior diagnosis angina | 3 |
 | Prior MI no invasive treatment | 2 |
 | Prior MI and angioplasty in last year | 1 |
 | Syncope | 1 |
 | Hypertension | 8 |
 | Uncontrolled hypertension by self-reported BP | 3 |
 | Arrhythmia | 12 |
Peripheral | Symptoms compatible with intermittent claudication | 5 |
Vascular | Symptoms intermittent claudication versus spinal stenosis | 1 |
System | TIAs in patients with prior CVA | 2 |
 | TIAs in patient with no prior CVA | 2 |
 | History carotid artery surgery | 1 |
 | History peripheral arterial surgery | 1 |
 | Symptomatic asthma in patients with prior diagnosis but no rescue or control meds | 5 |
 | History treated TB | 1 |
 | Symptoms obstructive sleep apnea | 1 |
 | Symptoms sleep apnea | 1 |
Pulmonary | 34 old woman with daily cough and sputum throughout year. Onset as child. (Computer and physician history reported new onset fever and dyspnea with history pneumonia 4 months prior to admission) | 1 |
GI | GERD, AM cough and hoarseness in patient with asthma | 1 |
 | Symptoms active ulcer disease in patient with prior upper GI bleed | 1 |
 | Daily aspirin use in patient with prior upper GI bleed | 1 |
 | Dysphagia in patient with scleroderma | 1 |
 | Erectile dysfunction | 5 |
GU/GYN | Symptoms urinary obstruction in elderly men | 7 |
 | Stress incontinence (women) | 2 |
 | Symptoms estrogen deficiency in patients taking HRT | 1 |
 | Symptoms recurrent cystitis and back pain in woman | 1 |
 | Urinary incontinence since prostate surgery 1 year PTA plus 6 months dysuria, back pain and polyuria/polydypsia. | 1 |
Endocrine/Metabolic | Uncertain thyroid status in patients treated previously for hyperthyroidism | 3 |
 | Polyuria/dyspsia, recent onset blurred vision | 1 |
 | Gout; no symptoms in last 1 year | 1 |
 | Polyphagia with no weight gain | 1 |
 | Diabetics with symptoms hypoglycemia | 13 |
 | Diabetics not monitoring or inadequately monitoring blood glucose | 5 |
 | Diabetics unaware of treatment regime for blood sugar | 5 |
 | Glaucoma | 2 |
 | Tunnel vision in patient with no prior diagnosis glaucoma | 1 |
 | Symptoms CNS vasculitis in patient with diagnosis SLE | 1 |
 | Episodic diplopia | 1 |
 | Tinnitus, hearing loss but no vertigo | 1 |
 | Current evidence major depression. No treatment. | 2 |
 | Major depression in setting of bereavement. No treatment. | 1 |
 | Current evidence moderate depression. No treatment | 1 |
 | Past history depression; not currently depressed; no meds | 1 |
 | Past history mania | 1 |
 | Prior diagnosis bipolar disorder not currently depressed | 1 |
 | Symptoms migraine; no prior diagnosis; positive FH migraine | 1 |
Neurology | Multiple hospitalizations for falls; negative AUDIT score | 3 |
 | High risk for falling because of motor weakness, unsteady gait, past history falls not requiring hospitalization | 10 |
 | Episodic dizziness and abnormal gait in patient with positive AUDIT score | 1 |
 | Hodgkin's treated with XRT 3 years prior to admission. Now on chemo for 2nd recurrence. | 1 |
 | Renal cell cancer treated with surgery and radiation 20 years prior to admission. No recurrence. | 1 |
Oncology Rheumatology | Active rheumatoid arthritis on steroids | 1 |
Life Style | Active smokers seeking help to stop smoking | 2 |
 | Positive AUDIT score | 5 |
 | Multiple 1st and 2nd degree relative with breast cancer | 1 |
Family History | Multiple 1st degree relatives with diabetes in patient with history gestational diabetes and recent onset chest pain provoked by emotional upset. | 1 |
Vegetative | Night sweats | 1 |
Symptoms | Weight loss > 10 pounds in non-dieting patient | 1 |