Stigmatizing Medical Documentation History and Physical
Instructions: Read the following History and Physical. As you read, click on any individudal words or phrases which you identify as using potentially stigmatizing language.
Mr. Joe Smith is a 24-year-old male with a history of intravenous drug abuse, primarily heroin. He also reports heavy use of cocaine in the past. He’s a frequent flyer of our facility and I have met him several times before. He returned several hours ago with general malaise and fatigue, but now with aches all over his body, diaphoresis, and anxiety. He had been clean for about two years but starting using again a few weeks ago because of some stressful issues that he’s dealing with.
Pan-positive.
No known medication allergies.
Polysubstance abuse.
Says his parents were both addicts. His mom was an abuser of alcohol and his dad was a junkie.
Denies tobacco use but reports extensive drug use.
He's had previous admissions for abscesses.
He is in moderate distress. He is non-cooperative. Appears he’s been using a lot. Otherwise his vital signs are normal and the remaining exam is unremarkable.
24-year-old IV drug user presents with withdrawal vs drug-seeking behavior.
1. He is a chronic relapser and NEEDS TO STOP USING HEROIN.
2. Will treat symptomatically.
3. May benefit from medication-assisted treatment. Will have social work see him.
Improved wording: “history of intravenous drug use”
Why: The word “abuse” implies the person is morally culpable for their illness, with connotations of other forms of abuse such as sexual abuse and child abuse.