Patient’s Reflexes Documented in Medical Record, Perplexed Medical Student Didn’t See Examination

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DENVER, CO – Third-year medical student, Samantha Mullerton, is rotating through the Memorial Hospital emergency room as part of her clinical rotations.  She recently called GomerBlog in regards to a developing story regarding an attending physician whom she was shadowing.

"You saw me check reflexes, right?"
“You saw me check reflexes, right?”

“I don’t recall Dr. Ernestios checking the patient in room 4’s reflexes,” said Mullerton.  “I’ve been following him all day long and I don’t recall ever seeing a reflex hammer, yet alone him using it on the patient.”

According to Mullerton, Dr. Ernestios documented in the medical record that reflexes were 2+ in all extremities and cranial nerves 2-12 were all “grossly intact.”  She was surprised to see this documented, since she didn’t see it happen.

“In addition to not checking reflexes, I never saw him ask the patient to stick out their tongue or check sensation on his face.  How can he say CN 2-12 grossly intact?”

The patient in question came to the ER on Sunday for a sports physical that was due on Monday.  The family claimed they were busy all week and their son needed this physical done today or he couldn’t play baseball.

Mid-story, Mullerton started to change her mind.  “There is no way a medical professional would document something that didn’t happen for billing purposes alone, or if it was a check box in a long list of check boxes that all were being checked meticulously,” said Mullerton.

“He probably did do the exam in a manner that I wasn’t taught,” said Mullerton. “Like he has some some Jedi sense.  Oh, boy I sure have a lot to learn before I graduate!”

  • Show Comments

  • Avatar
    Ammie Woodward Allor

    I like “+2 pedal pulses” on a double amputee. ;)

  • Avatar
    Tiel Lover

    so true!!

  • Avatar
    Janet Gann Brown

    or patients coming in with pneumonia who have lung sounds that are clear and unlabored.

  • Avatar
    Michelle Cordoba Kissee

    My fav are all the people admitted for afib with RVR who miraculously have RRR on their exam.

  • Avatar
    Harold Arthur Fowler

    biar di bilang eksis saya harus tetap komen,walaupun sebenarnya saya lagi offline Gomerblog

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