chief complaints

Basics for the Wards: Suggestions for improving your SOAP notes

When I was a first year we had basically no guidance on our notes, and as a result I was lazy with mine and developed bad habits. When I got to clinical rotations during third year my notes were horrible and it took a lot of feedback and effort to improve them. 

In my experience helping med students improve their notes, as well as feedback on my own notes, here are some suggestions. This is mostly oriented towards an outpatient-type SOAP note, but also relevant to inpatient SOAP notes.

1. Note writing is different from anything else you’ve written before.
And it does not come intuitively, it is a skill that you work on. While a SOAP note or H&P may be a page or more, it is not an essay. You do not need to write “The patient says the cough causes pain in her left side,” when “Painful cough, left side” will do. You do not have to have perfect grammar and sentence structure. Why?

2. Condense condense condense.
Because nobody has time to read or write a novel. Be as brief as possible while still communicating the relevant info (what is the complaint? when did it start? inciting event? exacerbating/relieving factors? if their is paint what is the quality/radiation/level on a scale of 10, etc). This may mean you scribble notes in the patient encounter and then distill them in your SOAP note.

3. Organize the complaints.
Do not give me three separate sentences about the cough with an interjection in the middle that the patient stopped taking their headache medicine. Group your complaints together, with the chief complaint (AKA why they are there) at the top.

4. The subjective.
ALWAYS start your subjective with “Patient Q is a xyz year old M/F who presents with blah blah blah”. EVERY. NOTE. EVERY. TIME.

The subjective is where you write what people tell you. Everything in your subjective will be coming from the patient unless otherwise specified. YOU DO NOT HAVE TO WRITE ‘PATIENT SAYS’ or ‘HE/SHE STATES’ EVERY SENTENCE. We know the patient is saying those things, putting that in there makes your subjective wordy to read and time consuming to write. Remember, sentence structure doesn’t have to be perfect.

Every subjective should have a brief review of systems of things not included in the chief complaint. It does not take very much time and ensures that you are being thorough. Ones I always hit on are: headaches, fevers, fatigue, vision changes, nasal congestion, sore throat, cough, trouble breathing, chest pain, nausea, vomiting, abdominal pain, constipation, diarrhea, trouble peeing, muscle/joint pain, rashes, swelling.

Your do not need to put past medical/surgical/family history in your SOAP note unless something has changed or it is relevant to the visit (Ex: “Bobby is a previously healthy 5 year old boy with a history of asthma who presents today complaining of wheezing and shortness of breath” OR “MaryAnn is a 77 year old lady with a past history of multiple abdominal surgeries for diverticulitis who presents with a left sided abdominal bulge”). Otherwise, that info is in the H&P that was done when the patient was first admitted to the hospital or began coming to clinic. Your SOAP note is not a history and physical.

5. Objective
This is where data goes, things you see with your eyeballs or feel or hear. Most objectives are organized like this:
Vitals
Labs (CMP, CBC, etc)
Physical exam (that you do!)
Imaging (ultrasound, chest x-ray, etc)

6.Objective: Vitals
If you are hand-writing your note vitals go on one line like this:
BP HR T RR O2 (L/RA)
Not
BP
HR
T
RR
O2 (L/RA)

6. Objective: Physical exam
The biggest thing I have noticed is the first years either aren’t doing a physical exam or they write ‘normal’ or ‘no significant physical exam findings’. DO NOT EVER EVER EVER EVER DO THIS. Why? Well, for starters, your normal and my normal may be two very different things. ‘Normal’ does not tell me what you looked at, what it looked like/felt like, or help me see how you used your physical exam to arrive at your diagnosis. Finally, IT IS LAZY AND ARROGANT. As students we have not had the necessary clinical experience to say what normal is.

7. Assessment
OK, time to regroup. There has been a lot of information. Summarize all your findings and what you think is going on, along with a differential. Example: Patient is an ### yo M/F with a chief complaint of XYZ, relevant objective findings such as vitals, labs, physical exam, imaging. Suspect patient has blah blah blah due to evidence, but differential includes yakkety yak and whatever.

8. Plan
I suggest grouping plan under each problem. So, if a patient is here with cough and sore throat but also has hypertension and needs a med refill, those would be two separate problems each with their own plan. Be sure to list dose of med and directions for taking it, as well as a return to clinic if (such as, return to clinic if no improvement in 3 weeks, consider antibiotics and imaging). This will help if someone sees the patient for followup after you. For clarity sake, I suggest formatting like this:

Problem 1 (chief complaint)
- plan
- plan

Problem 2 (second most important problem)
- plan
- plan

And so on.

Good luck!

Patient assessment

For everyone entering or returning to school, welcome back and I am officially back!

What I am about to go over is basic stuff today, but it seems we all get a bit lax with and I feel review for us all is important at this time.

Patient assessment falls on the back steps at times. It is key for our jobs as medical professionals, but quickly forgotten when we use to our tools. We get tunnel vision at times and treat what we hear. This is true of EMTs, Nurses, PAs, NPs, MDs and any others.

Chest pain usually means the following things

  • Vitals
  • EKG
  • Labs
  • Chest X-ray
  • IV/IV fluids
  • Nitro
  •  ASA

We as providers are trained to think heart attack first. While it is good to put this in your differentials, it’s not always good to jump the gun to it either.

Doorway Impression

A doorway impression is simple that. When you walk in, what do you see?

If you’re in the hospital, how they got to their room, where they sit, how their physical appearance is can all be clues. While we shouldn’t judge, seeing an obese male in his 60’s with a pack of cigarettes in his pockets, you can probably put cardiac related issues in the “possible” pile.

If you see a 20-year-old college student who appears in shape that is curled up with his knees to his chest and taking rapid shallow breaths, your first opinion might not be cardiac, so it should shift in your list possible Dx.

That first impression won’t give tell you what it is most the time, but it might have a few clues.

ABC’s

If these weren’t pounded into your skull in medical school at any level, we need to chat later.

Airway, breathing and circulations are easy tools and tell you a lot. I will throw in their mental stats here as well.

If they are talking with you, their skin is warm dry and pink, and pulses are strong regular-regular radial; It’s safe to assume that they probably aren’t having a major issue at the moment. Their airway is patent, breathing appears unlabored and after some auscultation lungs to be clear to be sure. Strong pulses that are regular-regular is helpful. Skin condition tells you they’re probably not in shock.

You walk in to a patient that is pale, diaphoretic, barely able to get a few words out, before taking gasping breaths. That alone should tell you something is up. Airway may be patent, but breathing obviously isn’t good. Lung sounds might present with wheezing, which will give you the impression of allergic reaction or asthma attack. When do feel a pulse, is it bounding or stringy might give you a bit more information. This is all just from assessing their ABC’s.

Now, if they are not breathing and there is no pulse, for the love of god, start CPR!

Patient history

Time to get the story down. There is a lot to ask the patient, start with why they seek medical attention at this time. What is the chief complaint.

You’ll then go through you OPQRST and SAMPLE. Ask you these questions, you can add things that may assist in leading you toward what is going on with them. Remember not get tunnel vision when you find a single detail, but try having some solid follow up questions.

Tip: try to have the describe things. Don’t give them a lot of “yes” or “no” questions.

Vitals

Vitals can say a lot and pending where you work, they maybe be done early on in your assessment process and that is perfectly fine. They will play a role in determining if your patient is stable or unstable, but this can still determine early without vitals.

Testing

Now you can get their testing, but with it won’t be just chest pain now. You might be looking for an MI, but PE. There maybe be a bruise on that 20-year-old chest from when he got hit with a bat three days ago. You patient that came in with difficulty breathing might have a Hx of COPD and today just got worse.

Test should be done here to assist with further Dx of the pt. This is where you do your EKG, BG, X-rays, and everything else.

Final Notes

Diagnosing a patient is more than a few tests when related to a chief complaint. It is a series of steps that require you as health care provider to look at and break things down. The list above is not a steadfast list either, it is a general outline that we should all look at as the basics.

Ultimately, how you perform these steps pends on how you work and the way you develop your questioning habits. The major point of this is that we need to get past our labs, ekgs, x-rays, TCs and other toys. We need to look at the patient first and ask ourselves what are all the possibilities and then begin looking through out differentials and picking our exams from there.

Written by: MedDaily

Simple Man

Originally posted by deanjackles

Summary: Reader has a break in one night and meets Officer Dean Winchester, the one person who might ruin everything…

Pairing: cop!Dean x reader

Word Count: 2,200ish

Warnings: language

A/N: I hope you enjoy this first part of some gruff cop Dean…


Keep reading

  • ❝  That barely covered vagina of yours deserves better than that. ❞
  • ❝  I appreciate your anger. ❞
  • ❝  Your chief complaint is not that I screwed someone; it is who I screwed. That’s what it’s about, right? ❞
  • ❝  Your issue with us is purely driven by a societal insecurity, not to mention a culturally infused female competition. My heart goes out to you ladies. ❞
  • ❝  My therapist suggested I attend a twelve step program, for recovery from a love addiction and romantic obsession… ❞
  • ❝  I cheated on you. ❞
  • ❝  You’re not an addict. You’re just a whore. ❞
  • ❝  I did let someone put a protein bar up my ass once. ❞
  • ❝  I will straight up murder you if you do not sign this immediately. ❞
  • ❝  I love kids. Kids love me. I basically am a kid. ❞
  • ❝  But I would still choose you. Possibly because you’re uninterested. Most likely because you’re stunning and successful. ❞
  • ❝  Sexual anorexia. It’s like depriving yourself of sex because of low self-esteem, or abuse or other gnarly shit. ❞
  • ❝  I’m telling you, someone’s gonna murder us if you keep screaming. ❞
  • ❝  Was this supposed to be a date? Oh shit, it was… Oh hell. I’m an idiot. I’m sorry, I’m a dick. ❞
  • ❝  You’re a catch! It’s true. You know, I’m serious. You’ve got a strong vocabulary. You look dynamite in a tank top. ❞
  • ❝  You know, little girls are told someday they’ll find The One. What they don’t tell you guys is that The One might be a complete fucking dickhead with a boring heroin penis that turns you all into a sex addict. ❞
  • ❝  Some have suggested that I have a little bit of a problem staying faithful… for long periods of time… or possibly at all. ❞
  • ❝  Look, once I come to the realization that I’m with- the wrong girl, I don’t know how to end it. ❞
  • ❝  So you sabotage it by sleeping with other people. ❞
  • ❝  Then comes the big old rigmarole of like ‘you’re afraid to commit’ and it’s like 'no, I just don’t want to commit to you.’ But I can’t say that, because that’s like mean on top of mean… So instead I’d rather just say something like: 'I fucked your sister.' ❞
  • ❝  Whoa, since when are you a porn star with killer grammar? ❞
  • ❝  Look, she’s my best friend and I would say by circumstance and certainly duration, you would be my next best friend. ❞
  • ❝  It is a cascading shit storm that is your creation. ❞
  • ❝  A tremendous amount of Malcolm Gladwellian logic jumps. ❞ 
  • ❝  We’ll you’ve spent ten thousand hours fucking my life up. ❞
  • ❝  Dude get the fuck out of here, I got it. ❞
  • ❝  I appreciate your concern, Superman! Fly away. ❞
  • ❝  Baby. Just breathe will you. Okay? Will you? Here, come on, sit down. You’re gonna be okay. It’s alright, you just got to breathe. Please. Okay? Yeah. There you go. ___ , this is just fear. ❞
  • ❝  You take this risk when you start sleeping with people. You know, you risk losing them. So for me, I’ve never slept with someone I wasn’t willing to lose. Except one time. ❞
  • ❝  And it kills me that you’re probably gonna go to ___. And it kills me that I can’t ask you to stay, because I have no right to, you know. ❞
  • ❝  Welcome to the hell scape that is my son’s birthday party. ❞
  • ❝  Dude… are you really using your kid to hit on my friend? ❞
  • ❝  First part false. Second part true. ❞
  • ❝  Do not gaslight me with SAT words and sliding scale morality. ❞
  • ❝  You want to tell me about it? ❞
  • ❝  You never told him to make a choice, you know. ❞
  • ❝  Are we in love with each other? ❞
  • ❝  I love you for free. ❞
  • ❝  Unfortunately I don’t sleep with men in relationships anymore. ❞
  • ❝  I stopped cheating anyway. ❞
  • ❝  We’re getting a chance to start over. ❞
  • ❝  Goodbye forever. ❞
  • ❝  Hey, did you know they don’t have a separate jail for cool people who fucked up? There’s just one big old jail for everyone. ❞
  • ❝  I sort of beat he shit out of him. Fucked up his life a little bit. ❞
  • ❝  I just really miss you. ❞
  • ❝  Yeah, I think about you like, all the time. Even the word “think” is wrong, because I don’t actively do anything. You’re just here. ❞
  • ❝  I’d rather fail with you, than win with anyone else. ❞
  • ❝  I love hearing you say my name. ❞
  • ❝  Okay honey, you’re on speaker phone in a police station. Be very careful what you say. ❞
A few characters in the world of the Royal Prophecy Complaint Bureau

Unnamed Queen: (probably the fourth of her name, the child of a loving marriage between a dwarf and a dryad. In her 30th year of ruling. Has many enemies but the majority of them are outside of her kingdom. She has banned Hu’brys from ever setting foot in her palace. That’s all I know about her so far)

Knight Captain Beow Halflore: Head of the Queen’s security and a pretty famous warrior, though he’s a little better known for philanthropic efforts. Son of the former Knight Captain, a gigantic orc known for single-handedly saving the kingdom from the Wyrm-Queen several decades ago. Considering that Halflore looks like a dark-elf with stone skin, no one is sure if he was adopted or if he just takes after the other parent. The former Knight Captain was a fairly private orc, so no one ever asked. Beow gained a reputation for dealing with catastrophic doomsday prophecies (and one or two Protagonists who decided to side with enemy kingdoms), and has become a bit of a byword for “situation so bad we have to call this guy or we’re all gonna die”. He hates that.

Cleft-Helm Offices

Chief Inspector Olganoth Stoneclub: No-nonsense head of investigations, always fills his paperwork out on time and disapproves of coworkers letting reports pile up. Has a degree in law enforcement from the all-orc Split-Mountain University and a degree in literature from the Mab Institute for Higher Learning. Is uncomfortable around children of most species, but gets along alright with the dwarves. Has a pet miniature mountain goat named Algernon.

Teakettle-on-Moors Offices

Director Bernadette Rockhewer: Good-natured but increasingly exasperated head of the department. Is getting tired of filing prophecies that never come true, but prefers those to the ones that end up dragging Protagonists into the Realm. Telegraphs her parents once a day, usually during her lunch break. Has a little bit of a soft spot for poor Inspector Clarek, who worries about the Protagonists far more than most of the other inspectors. She worries that he won’t be able to handle the job without getting emotionally involved. (She’s right, he can’t)

Inspector Ache Clarek: City-elf not used to the rural community of Teakettle-on-Moors. Grew a scruffy beard in an attempt to make a good impression on Director Rockhewer. She thinks it looks ridiculous but would never tell him. Worries about the Protagonists constantly, especially the ones that come in without families. He’s tempted to just make himself the resident villain requiring prophecies to defeat him so that he can ensure the Protagonists are safe and have a place to stay if required.

Misc

Soothsayer Hu’brys: eccentric soothsayer obsessed with spitting out prophecies that usually result in a human Protagonist being dragged into the Realm. No one is quite certain why Hu’brys does this. Is possibly just bored. Prophecies from Hu’brys are often very dangerous, and the Protagonists summoned by them recently have been without families. Director Rockhewer suspects that this is just to avoid the occasional parent or sibling with inherent magic coming through to get them back and stall the prophecy (which has happened six times before and was a huge mess), but she can’t prove it yet. She’s still working with the Mage Union to try and get her shut down.

Granny Featherfly: EXTREMELY eccentric elf woman living up the mountain. Most of her “prophecies” are just very strange predictions, most of which come true. (A dryad getting a foot fungus on the Fall Equinox, for instance, and leading to a new medical discovery). The ones that do result in human Protagonists tend to be somewhat vague and can be interpreted a variety of ways that keep the Protagonist safe.

Dark Lord Keralc: Definitely not Ache Clarek. Definitely. Who’s Clarek? Sounds like a cool fellow. Also probably not hiding six Protagonists in his castle. And definitely not filing for custody of those six Protagonists he is not hiding in his castle. Why would you even assume that? Maybe you’re hiding Protagonists in this castle!

Why the "look” of Star Trek: Discovery was never going to please everyone and why you should get over it

Star Trek debuted on September 8th, 1966 and was widely held as a controversial and progressive series… for its time. I could spend hours dissecting just how racist and sexist The Original Series is, but that’s really not the point of this article.

The point of this story is that trying to keep a fandom going after more than 50 years is bound to get problematic in terms of aesthetics and continuity. Technology, fashion, makeup, and special effects have come a long way since 1966. A chief complaint of Star Trek: Discovery is that it’s supposed to be set 10 years before The Original Series, and therefore, it looks too “edgy” or “out of place” to fit in with the timeline.

I for one would have preferred a series that picked up after the events of Deep Space Nine and Voyager, but that’s not what we’re getting. And as I’m a diehard Trek fan through and through, I approach Star Trek a bit like marriage: I love the good, accept the bad, and understand that no matter how much I wish I could, there’s no changing what is. So here we go… another prequel. I’m keeping an open mind. In regards to what I think it should look like, I’m forced to ask myself: do I want something that looks like it seamlessly fits in with a “historical” account of a made up future, or do I want something that looks good and looks like it was produced in 2017 for an audience in 2017?

Star Trek has always served as a lens for the time in which it was created in terms of fashion and aesthetic. The Original Series looks like it belongs in the late 1960s. That’s because it does

Space hippies. ‘Nuff said. 

Star Trek: The Next Generation looks like a snapshot of the late 1980s and early 1990s. I’m surprised they didn’t have beige carpeting on the ceiling.

Neoprene body suits. Oh, and those leotards. Teeheehee.

Star Trek: Voyager was right at home in the late 1990s. Remember that time Captain Janeway and the gang traveled back to the year 1996 to prevent a temporal explosion in the 29th century that would destroy the entire solar system in the episode “Future’s End?” In commenting on the fashion worn by late 20th century inhabitants of Los Angeles, Tuvok even remarked, “We could’ve worn our Starfleet uniforms. I doubt if anyone would’ve noticed.”

Seriously, it looks like there was a fire sale over in the Seinfeld wardrobe department.

And so where does that leave Star Trek: Discovery? If we were going to follow the route of fitting in with the actual period it airs, it looks like it very much belongs in 2017. 

You know, 2017, where the thought of an Asian woman running shit with a black female sidekick isn’t “silly talk” and the best makeup they can come up with for an alien goes beyond pointy ears. 

But if we’re so hell bent on making it look like it could have been ten years before the beehive hairdos, miniskirts, and Beatles mania we see in The Original Series, it would probably have to look something more like this:

Hey, at least I still left room for two female leads, right? It’s so progressive! [And white]

And to follow the rabbit hole to completion, Star Trek: Enterprise, the other prequel which was set in the middle of the 22nd century, probably should have just looked like this all the time:

Archer and T’Pol: robbing stagecoaches and school marming since 2152. 

I’m 31 years old. I grew up watching The Next Generation, Deep Space Nine, Voyager, and Enterprise, and I loved each of them because they spoke to real issues of the day. Each incarnation of the series almost serves as a mile marker, a perfect little time capsule to remind us of what life was like when it aired. 

I watch The Original Series and can see a world that looks like it’s on the verge of being torn apart by racial strife, fears of Communism, and nuclear armageddon. Part of what makes that series so special to me is being able to watch it with a modern eye and know that things got better. I look at The Next Generation and see themes relating to everything from the AIDS crisis to the end of the Cold War, and I think “Hell yeah world! We got through it!” Sort of. We have a long way to go, but the show reminds us how far we’ve come. Star Trek: Enterprise has 9/11 and the Global War on Terror written all over it. How things will end from that fiasco is still sadly yet to be determined.

So as a fan, I want a series that highlights life as we know it and is progressive for our time, not life as we think it should look according to a canonical pretend sci-fi timeline. If we’re really set on the idea that Discovery should literally fit a time just before The Original Series, there would be no female starship captains. In the TOS episode, “Turnabout Intruder,” Janice Lester tells Captain Kirk, "Your world of starship captains doesn’t admit women.“ There probably wouldn’t be women on the bridge at all, given that Captain Pike actually says, “I can’t get used to having a woman on the bridge” in the TOS episode, “The Cage.” It would be nice if we could have a show that both perfectly weaves itself into canon and speaks for the current generation, but if given the choice between the two, I’d take the second one every time. 

Given that there are already so many inconsistencies with canon as it is - the Klingon and Romulan foreheads look a little different with each telling and don’t even get me started on the stardates in The Original Series - can we just try to appreciate Discovery for what it is without dismissing it before it even airs just because it doesn’t fit into an ideal mold of what the year 2255 should theoretically look like according to canon? 

None of us have seen it. It might well end up being terrible. There are horrendous episodes in each series (anyone remember “Spock’s Brain” from TOS or “Angel One” from TNG?), and some series were definitely better than others. But I still appreciate each series for what it tried to accomplish, and good, bad, or ugly, I’ll appreciate Star Trek: Discovery too. I would never say you should automatically love something just because it’s Star Trek, but if you’re truly a fan, you’ll at least give it a chance

TSK: Chief Complaint: “I took my stitches out too early”

Yes, you should’ve left those in for the 10-14 days as instructed, instead of believing your “healthcare friend who thought they looked ready to come out” on post-repair day 3.

No, I’m not putting in new stitches now, 2 weeks afterwards.

Yes, your scar is going to be more visible than it would have been.

No, our Urgent Care does not have a plastic surgeon on-call in-house for second opinions on super-delayed closure of superficial hand lacerations.

Day 6: I need a doctor.

This one is the one I enjoyed writing the most, and I hope you’ll like it. 

Sam’s life is a weird place, right from when he was born and up to this day everything that happens to Sam is not supposed to happen.

For example, when he first thought seriously about going to college, being a lawyer was what he wanted. Near nine years later Sam finds himself a resident doctor in a small town’s health center.

Yeah, getting into the med school? Not his smartest move, no matter what his mother says. The hours of work alone can be a deal breaker, and the fact that small towns like the one he got stuck in has only limited number of health workers doesn’t help one bit. He’s constantly tired, and stressed and he never sleeps more than four hours and on top of that there’s Dean.

Dean is the town’s mechanic, and general hero, the guy every woman is in love with and every old lady wants to invite for dinner. He’s that guy who gives half his sandwich to a stray and mows loan for free. He also happens to be the one driving Sam crazy.

No, not like that. Well, maybe a little like that too. But when Sam thinks “divining him crazy” it’s not about crushes or one-sided love. It’s more about Dean’s obsession with being sick.

“Dean. You’re here, again.” Sam knows it’s unprofessional but he can’t keep the wry tone out of his voice, this is Dean’s fifth visit this week, and he’s completely healthy and has nothing to worry about. It doesn’t stop Dean from coming over and pretending to be sick, and since Sam can’t call him out on it, he’s been trying really hard not to commit murder. He hasn’t slept is the past 42 hours if anybody’s wondering.

“So how can I help you?” Sam asks at last, proud that he’s keeping the snarl strictly in his head. It’s only Dean left, and after that it’s doctor’s Collins’ turn to suffer.

“I think there’s something wrong with my heart,” Dean says, and he sounds so sincere Sam can’t help but believe that Dean’s not pretending to be sick, maybe he just thinks he is.

“Dean, you’ve said that the last times too.” He starts gently “I’ve examined you and there’s nothing wrong with your heart,”

“There is,” Dean insists, sounding more frustrated, he scrunches his nose and lifts a hand to rub over his chest and Sam can’t not think of it as adorable.

Yeah, he’s kind of in love with his obsessive patient, sue him.

 They met near the time Sam got the job here, three months ago. Sam’s car broke down and Dean had taken a look at it. He was just the gorgeous stranger who ran to help Sam, Sam didn’t even know that he was the town’s mechanic till Dean winked at him  and said “Free of charges, doc.”

“Okay,” Sam scratches his forehead and pushes his hair back, it's  terribly wrong for a doctor to act so obviously annoyed, but he’s way beyond caring at the moment. “We went through this last time, but are you sure there are no other symptoms?”

“I..em..” Dean answers eloquently, and Sam feels like he’ll pop a nerve anytime now. “Like what?”

“Sweating, agitation, tremors.” Sam lists, this is exactly like how their conversation went the last time, Sam asked about everything because you just don’t take a patient complaining from his heart lightly, specially at Dean’s age. But so far they found nothing, either Dean’s problem was psychological, or Dean was pretending to be sick for one reason or another.

After ton more questions, Sam starts perfuming cardiac examination, they’ve been through this numerous times too, but he has no choice. They don’t have anything to ask for a more advanced test, and  Sam feels the urge to bang his head against the wall increasing.

“The only thing out of ordinary is your heart rate, is it always this fast? Do you feel exhausted all the time?”

“It only ever beats this fast when I’m here,”

And that happens to a number of people, could be easily explained as a white coat phobia. Sam takes a breath and let it out slowly. Decides to go over this one more time before he sends Dean home.

“When you say there’s something wrong with your heart, you don’t mean pain, do you?” He knows the answer to that is no, the whole procedures won’t be the same if Dean’s chief complaint was chest pain.

“No, it doesn’t hurt. Just weird, and it only happens around you,” Dean looks almost pained now, helpless. Sam stares at him, noting the almost plea in Dean’s emerald eyes, the raw need in his features. And it clicks.

Oh.

Oh.

“I think I know what’s wrong,”

Dean cocks his head to the side and Sam spares a second to wish he’s not wrong before he leans in and kisses Dean. It’s just a brush of lips, Dean remains stock still and Sam worries if maybe he read it wrong. But then Dean’s fingers are in his hair and his tongue is pushing inside Sam’s mouth and Sam loses it.

He presses harder against Dean, and Dean stumbles back and lose his footing. Thankfully falling on the chair instead of the floor. He pulls Sam with him, and Sam ends up straddling his lap and clinging to his neck. Talk about unprofessional doctor/patient relationship.

They break the kiss but they don’t pull back, and Sam feels Dean’s smile against his lips, he moves his head till he can look at Dean.

“How’s your heart doing?”

Dean’s smile gets impossibly wider, but his cheeks flush as he detangles Sam’s arms from around his neck and places Sam’s hands on his chest. Holding them in place with his own hands over them.

Below Sam’s palm, Dean’s heart is going crazy, thudding like a drum; fast and strong. Sam’s heart is playing a similar rhythm. They stare at each other for another second, and Dean captures Sam’s mouth in another breathtaking kiss.

“So what’s wrong with my heart, doctor?” Dean breathes against his lips.

Sam opens his eyes and takes Dean in, Dean is looking at him like he can’t see anything else.

“You’re in love,” Sam tells him “I’ve got no pills for that, I’m afraid.”

Dean nods at him but continues to stare, completely entranced. Sam has never felt so sure about someone’s love before, and it’s written so clear on Dean’s face he wonders how the hell he didn’t see it before.

“So, what are my options?” Dean asks, and Sam blinks dumbly, mind blank for a moment before he remembers the game they’re playing.

“You have to go to the person you love,”

“Yeah?”

“Look them in the eye.” Dean locks his gaze with Sam and nods “And tells them how you feel,”

“What if they don’t feel the same?”

Sam inhales deeply “Bad prognosis is always a case scenario, but we’re hopeful about this one,”

“Sam,” Dean’s voice is hoarse, too raw “I love you,”

Sam kisses him, holding on so hard till both of them can’t draw in air anymore. “Me, too.’‘ 

Just going to add that I had the ’'My heart is hurting” line used on me too many times, no one was as hot as Dean though. XD


Just one quick question: would it be possible for you to write an entire book based on this ficlet, with their meeting and the previous times Dean went to see Sam and their following dates and everything? Cause I want to read a book about this doctor/mechanic romance so bad. And then have a movie based on the book. And also a TV show! If you can’t already say, I loved this ficlet so much! This was so adorable. Oh God. Pure cuteness. I also love how unprofessional Sam is :D But I can’t believe people actually used that line on you IRL; how and why did they think it would work?? Anyway. Yes, hit me up if you write a novel about this ;)

TSK: The Full-Moon OBTW strikes again

Chief Complaint: “Migraine headaches not responding to medications + cough and history of asthma + diarrhea x 1 week and feeling lightheaded…”

*2 hours later, nebs + IV fluids + headache meds are working, patient is finally ready for discharge, and then…*

Oh By the Way, doc: “I’ve had this rash on my shoulder for 6 years, it’s, uh, pretty much gone right now but what do you think it is?”

[fic] chief complaint 1/?

have i told you guys about my med school/internship au? because i have a med school/internship au because experiencing it in real life is apparently not enough for me and i have to write about it too

it’s mostly just in the planning phase bc i have way too many AUs already but it’s basically just about intern!Yuuri harboring a crush on pediatric resident!Viktor and vice versa. (meanwhile, Georgi is being salty in the background because he has to pick up the slack BECAUSE SOMEONE KEEPS ON FLIRTING WITH THE INTERN INSTEAD OF DOING THEIR JOB!)

General Data

YK, a 25 year old Japanese male, currently residing in [address redacted], is an intern at the GP General Hospital. He was born on November 19, 1992 in Hasetsu, Japan, and is currently not involved in a relationship.

Chief Complaint

Premature ventricular arrhythmias.

+++

Med school is hell.

Yuuri knows this. Has known this for the past so-and-so years, which he’d somehow survived fueled only by a noxious mixture of intense sleep deprivation, self-hatred, and a ridiculous amount of coffee and energy drinks that he can hear his own heart beat without the help of a stethoscope. It’s an actual miracle how he hasn’t landed himself in the ER even once for caffeine toxicity.

Med school is hell, but it’s fucking Elysium compared to the utter insanity that is internship.

Specifically, the OB/GYN rotation.

Keep reading

TSK: Chief Complaint “Yellow liquid coming out of belly button.”

60-something Patient: IT’S NOT EVEN MY ORIGINAL BELLY-BUTTON, IT’S A NEW BELLY-BUTTON THAT JUST SWELLED UP A FEW DAYS AGO!

Patient: NO, IT CAN’T BE AN INCARCERATED HERNIA ERODING THROUGH MY BELLY SKIN, HERNIAS ONLY HAPPEN IN YOUR PRIVATES!

Patient: I AIN’T GOING TO NO EMERGENCY ROOM FOR POSSIBLE EMERGENCY SURGERY, JUST GIVE ME A CREAM TO PUT ON IT!

Patient: FINE I’LL GO TO THE ER.

Patient: BUT AIN’T NOBODY DOING SURGERY ON ME TODAY!

3 HOURS LATER - Operating Room Board: “[Patient] Emergent Add-On, Incarcerated Ventral Hernia, Abd Wall Abscess”

9

Sir Ambrose Carrington

Appearance -

  • Gender: Male
  • Race: Human
  • Height: 5′11″
  • Eye Color: Blue
  • Hair Color: Blonde

The Facts -

  • Name Day: January 13, 1415.
  • Occupation: Knight of the Order of the Garter, hunter of the Vigil.
  • Sexual identification: Heterosexual. 
  • Romantic identification: Heteroromantic.
  • Alignment: True neutral approaching neutral good. 
  • Criminal History: Looting and pillaging.  He took part in several raids and chevauchée, though his interests were kept to monetary pursuits and he did intervene if others sought otherwise.

Favorites –

  • Favorite food: Any form of beef.
  • Favorite drink: Wine.
  • Favorite artist: Walter of Durham.
  • Favorite scents: The fresh air of England. 
  • Favorite person(s): His sister, Lady Amice Baldwin (née Carrington).

Ten facts about your muse:

⚫  Ambrose is the second born son and the youngest of three children.  He was destined to become a knight as far as he was concerned and from an early age invested himself entirely into that pursuit.  

⚫  Though Ambrose does not often speak of it, the House of Carrington is not particularly wealthy.  If not for his looting and exploits in France during the 100 Years War, his family would not have been able to find suitable marriage for Amice.  He takes great pride in being the one to actually provide for his sister.  He routinely writes to his sister, detailing the things he has seen and offering her advice on how to best ensure her marriage remains comfortable.  The unwitting self-awareness in these letters amuse her, such as lines stating: “no man desires a wife that is so clever that she cannot allow him to be the better in a conversation.  Know yourself well enough to sate his curiosity, and know him well enough to realize there is little else that interests him.” 

⚫  Ambrose’s older brother, Randel, is known as a charming though quiet man.  There has always been some rivalry between the brothers, as Ambrose views his brother as little more than a means by which their family might squander coin and opportunity. All the same, he would readily defend him if he was insulted by another.  For his effort, Randel appears patient with Ambrose and encourages him in his pursuits… which has benefited the both of them monetarily and politically.

⚫ Although hardly considered a wit by many, Ambrose is well read and has some grasp on philosophy and the humanities.  He prefers to appear brusque at times, but his actions are generally motivated by a morality that has been defined since first he set foot in France.  He can also speak French fluently and has been studying Latin, though he has no natural ear for it. 

⚫ He is the nephew of Sir Waldorf Burland by way of his mother, Matilda Burland.  This makes him a relative to the future Master Hunter, Malcolm Burland of the Massachusetts chapter of the Vigil.  Likewise, he is also a relative to Matthew Carrington, a future Ventrue and eventual Prince of Atlanta.  Furthermore, if Amice’s marriage is considered he also shares blood with Alfred Baldwin, the Ventrue primogen of Fresno. 

⚫  Ambrose likely suffers from the onset of PTSD brought on by finding himself both at the Battle of Cravant and Verneuil.  He speaks of battle as where he “finds himself,” but this is largely because when he is not in battle his tensions feel out of place and at times, lead him to make rash decisions. 

⚫  He believes firmly in England’s rights to France and though his party of hunters is multinational, does not go out of his way to beleaguer the point though it is frequently a topic of discussion.   Between the number of lives lost in the war and the years that have gone into it, he believes with the Siege of Orleans the Dauphin will be forced to surrender and at long last the fighting can come to its end. 

⚫ Ambrose was born left handed, but because sinister served him so poorly, he learned to fight with his right hand.  This does not make him ambidextrous: if his right hand were to be lost, he would be virtually useless in a fight until he retrained himself in how to move and function in battle. 

⚫ Though a romantic at heart, he keeps that sealed away within him and often behind cold bars made of iron.  His interests in love and romance rarely find their way to his lips and exist most often as but sparks in his eyes that die as the harsh world’s realities find him.  This is also why he is so readily disgusted with people that cast aside notions such as chivalry or that claim to be knights but put little meaning in the title.  To him, these are worse than rabid commoners for they disgrace the legacy they were born into. 

⚫ Should he live to see the War of the Roses, Ambrose will certainly serve as a staunch Yorkist.  This, in large, is due to the fact that the mismanagement of the war will be a defining point in his mind and the ineptitude of Henry VI will be chief among his complaints.  More than likely, his family’s connection to the House of York will lead to its sad state when Matthew Carrington comes of age. 

Five Things -

Things they like:

  • Fighting.
  • Winning.
  • Poetry.
  • Riding.
  • Chivalrous pursuits.

Things they dislike:

  • Losing.
  • Waiting.
  • Arguing with his inferiors.
  • The lower class.
  • Incompetent nobles.

Good habits:

  • Too arrogant to lie.
  • Relatively guileless.
  • Clever enough to know when he’s wrong.
  • Strict discipline.
  • Good leader.

Bad Habits:

  • Arrogant.
  • Often says what he thinks.
  • Finds himself wrong before he realizes it.
  • Merciless when others are slovenly or weak.
  • Poor follower.

Personalities they gravitate toward:

  • People that are consistent.
  • People that are realistic.
  • People that value results.
  • People that value justice.
  • People that value honor.

Personality types they avoid:

  • Liars.
  • Hypocrites.
  • Those that are easily changed.
  • Deceptive persons or identities.
  • Two-faced persons.

Fears:

  • Failure.
  • Becoming like his father.
  • Disappointing his sister.
  • Saddening his mother.
  • Proving his brother right.

TAG:
whoever wants to do this, idk dude

“ り、心身の不調を訴える子どもの数は確実に減っています」“――The way I see and understand the data from the distributed document, the number of children who (are being admitted with a chief complaint for) psychosomatic disorders are certainly decreasing”
「導入から一年半、効果はきちんと上がっているというわけね」“Since (the clinic’s) introduction a year and a half ago, (the data) means that it’s efficacy is steadily rising.”
サクラが言うと、説明係の医療忍者は、「はい、十分に」とうなずいた。緊張しているのか、少し頬が赤い。(After Sakura stated that), the medical ninja who was in charge of explaining (the document) then continued: “Yes. It’s satisfactory“ she nodded. Her small cheeks and face were red with tension and nervousness.
「症状が長引いて、対話によるカウンセリングでの改善が見られない場合は、院内の他の科とも連携して、薬の処方なども含めた対応をとるようにしています」“As the symptoms are prolonged, improvements will not be observed through counseling with conversations. As for those cases, we will be collaborating with the other departments within the hospital. We’ll make sure that prescription medicine and so forth will even be included in support (of their recovery). “ - Sakura Hiden Chapter 1

I’m reading Sakura Hiden (finally) and….fuck me up. Sakura has such a big heart. Nobody cared for those children until she came along. I’m proud tbh.