Lies, Damned Lies, and Medical Records


Annotation of Iroquois Medical Records

6/27

  1. At no time have I ever been told that I have acute metabolic encephalopathy.
  2. I have not been diagnosed with, or treated for, dehydration in about twelve years.
  3. I had two UTIs when I was admitted to hospital in May and they were cleared with antibiotic treatment; thereafter, I never was tested for a UTI.
  4. There is no such thing as “DM insipidus.”   I have nephrogenic diabetes insipidus and diabetes mellitus, type 2.
  5. I do not have spinal stenosis.  The psychologist who was attending me had spinal stenosis and was scheduled for surgery the following week.
  6. I am not aware of any current diagnosis of personality disorder.  The most recent psych testing was done around 2008 and showed no signs of any psychopathology.
  7. What I do have are cognitive loss, depression, impulsivity and irritability consequent to chronic hyperglycemia.
  8. Un-noted in notes:  I also have left ventricular hypertrophy; right branch bundle block; pulmonary fibrosis (with shortness of breath when I get out of bed); cervical and lumbar arthritis; and immune dysfunction, type 2, with hypersensitivity to medications.

 

N.B.  This block of incorrect and incomplete diagnoses is carried forward in virtually every note.

9.  “History of suicide attempts” was from 1974 to 2003, caused by antidepressants, which I stopped taking.  There was a singular attempt ten years later, when my glucose was 484 and I was told no further treatment was available; it was a combination of rational choice and hyperglycemic impulsivity.

10.  “Psychiatrist Dr. Fisch”—actually, psychologist Dr. Fish.

11.  “Whom she considers her son Steve”—actually, it was the ER physician who referred to Steve as my “acting son.”  Dr. Stephen Wechsler is my trustee, Health Care Proxy, and Power of Attorney; throughout the notes he is referred to as “Steve” with no last name given.

12.  Upper and lower partial plates both cover teeth roots.

13.  “Resident chose” no further treatment because of the intolerable distress caused by medications, see also immune dysfunction.

14.  “HX of multiple suicide attempts” caused by antidepressants ten to forty years ago.

15.  “Mood easily changes to irritability or agitation” due to chronic hyperglycemia.

16.  “SW will continue to observe moods and behaviors and provide intervention as needed.”  Why wasn’t SW called prior to me being removed from Iroquois for psych eval?

17.  “Dr. Lockwood saw resident for admission assessment,” written by nurse Krista Hardter, who was present in the room.  Actually, Dr. Lockwood saw resident for about 90 seconds, long enough to shake hands and say he hadn’t read hospital discharge summary.  Contact took place before supper; note was not entered till 11:30 p.m.  See previous notes which report me to be “alert and oriented X3,” “alert and oriented X4,” and “understands what is said to her,” and following note that states “alert and oriented.”

6/28

  1. Note from Nursing Supervisor Susan Greer does not reflect that I asked her for visit from Dr. Lockwood. She stated that he had already seen me [handshake] and in nursing homes the doctor only sees the patient every 30 days unless there is some specific need.  I told her I needed to see the doctor about medication needs.
  2. Nowhere is it noted that my blood sugar level has been over 350 for about two years.

 

Too tired to comment on notes thereafter, except—

7/1  ADMISSION HISTORY AND PHYSICAL (6/28)   Richard H. Lockwood, M.D.

  1. “Fingersticks were discontinued” thereby depriving the nursing staff of any understanding of the patient’s behavior.
  2. “She is normally followed by Dr. Fish of psychology.”  Fact:  She is normally followed by Dr. Katherine Lewis; Dr. Fish was covering while Dr. Lewis was on vacation.
  3. “She was seen by physical therapy”—I was seen at Crouse Hospital, not the Iroquois.  The physical therapy assessment consisted solely of me shuffling twenty feet with a walker, which I never had used previously; the physician rejected the PT evaluation as inadequate.
  4. No ECG was done at the Iroquois.
  5. I was managed wonderfully at Crouse by Dr. Marty Lebowitz, who is a member of the Iroquois board of directors, and who continues to follow me with concern.
  6. “She is taking Klonopin”—I have never in my life taken Klonopin; I was taking clonidine—and being attended by a physician who doesn’t know the difference.
  7. “Dr. Ghali”—actually, Dr. Nasri Ghaly.
  8. “Very intelligent.  Very informative.”  Upon checking, you will find this to be a direct quote from the Crouse discharge, probably from Dr. Lebowitz.  Dr. Lockwood never had sufficient conversation to report this from his own experience, not to mention that he has never been known to say anything positive about me.
  9. “She takes when she wants when she wants.”  No one who has read this has the slightest notion what it means.
  10. “Without shortness of breath” as long as I remain in bed; constant shortness of breath walking to bathroom or around bedroom, with varying severity.
  11. “Central Nervous System:  Without . . . but has diabetes insipidus.”  I do not have neurogenic DI; it is nephrogenic DI consequent to lithium poisoning, which also caused immune dysfunction, type unknown, and which Lockwood would have known if he’d either (a) interviewed me or (b) read what he cut-and-pasted under Past Medical History.
  12. Physical Examination:  Dr. Lockwood did not do one.
  13. Laboratory Data:  No lab work was done at the Iroquois.
  14. “Recommend to avoid benzodiazepines”:  Dr. Lockwood prescribed Xanax, which is a benzodiazepine.
  15. “Will update her vaccines.”  Vaccinations had already been refused because of immune dysfunction.

N.B.  Nurse Manager Valery Findlay (sp?) interviewed me at Crouse Hospital, admitted me to the Iroquois, wrote spot-on notes, and was on vacation when Greer and Lockwood railroaded me for a psychiatric evaluation.  I keep wondering what would have happened if Valery had been on duty.

About annecwoodlen

I am a tenth generation American, descended from a family that has been working a farm that was deeded to us by William Penn. The country has changed around us but we have held true. I stand in my grandmother’s kitchen, look down the valley to her brother’s farm and see my great-great-great-great-great-grandmother Hannah standing on the porch. She is holding the baby, surrounded by four other children, and saying goodbye to her husband and oldest son who are going off to fight in the Revolutionary War. The war is twenty miles away and her husband will die fighting. We are not the Daughters of the American Revolution; we were its mothers. My father, Milton C. Woodlen, got his doctorate from Temple University in the 1940’s when—in his words—“a doctorate still meant something.” He became an education professor at West Chester State Teachers College, where my mother, Elizabeth Hope Copeland, had graduated. My mother raised four girls and one boy, of which I am the middle child. My parents are deceased and my siblings are estranged. My fiancé, Robert H. Dobrow, was a fighter pilot in the Marine Corps. In 1974, his plane crashed, his parachute did not open, and we buried him in a cemetery on Long Island. I could say a great deal about him, or nothing; there is no middle ground. I have loved other men; Bob was my soul mate. The single greatest determinate of who I am and what my life has been is that I inherited my father’s gene for bipolar disorder, type II. Associated with all bipolar disorders is executive dysfunction, a learning disability that interferes with the ability to sort and organize. Despite an I.Q. of 139, I failed twelve subjects and got expelled from high school and prep school. I attended Syracuse University and Onondaga Community College and got an associate’s degree after twenty-five years. I am nothing if not tenacious. Gifted with intelligence, constrained by disability, and compromised by depression, my employment was limited to entry level jobs. Being female in the 1960’s meant that I did office work—billing at the university library, calling out telegrams at Western Union, and filing papers at a law firm. During one decade, I worked at about a hundred different places as a temporary secretary. I worked for hospitals, banks, manufacturers and others, including the county government. I quit the District Attorney’s Office to manage a gas station; it was more honest work. After Bob’s death, I started taking antidepressants. Following doctor’s orders, I took them every day for twenty-six years. During that time, I attempted%2
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