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Comment & Response
November 2015

Use of Descriptive Terms in Medical Records

Author Affiliations
  • 1Department of Neurology, University of Texas Health Sciences at Houston, Houston
JAMA Neurol. 2015;72(11):1379. doi:10.1001/jamaneurol.2015.2648

To the Editor Dr Berger1 introduced a topic of traditional interest in the practice of medicine. What should the initial statement of a case presentation contain?

The case report to follow may shed light on the relative importance of each bit of data: “An 84-year-old left-handed, hypertensive, diabetic, African American male arrived at the emergency department with slurred speech and difficulty swallowing evident on awakening in the morning 5 hours ago. Neurologic examination revealed a blood pressure of 150/110 mm Hg, regular pulse of 80 beats/min, bilateral weakness of the soft palate, and dysarthria.”

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