WNL: ‘Within Normal Limits’ or ‘We Never Listened’?

An octogenarian with a broken hip arrived in preop holding. She was hyperventilating, moaning that she could not breathe. After I quickly applied oxygen and reassurance, a focused physical exam revealed no râles, but a grade 4/6 harsh systolic murmur suggestive of aortic stenosis. I anxiously awaited the agonizingly slow awakening of the computer to access her electronic medical records (EMRs). The medicine resident’s daily notes and cardiology consult all indicated RRR but did not mention any murmurs. Thinking this was a new onset cardiac murmur, my resident telephoned the medicine resident who stated: “Oh, yeah, she’s had a murmur; nothing new.” A quick refresh of the computer screen on my end noted that the medicine resident had changed her latest progress note to indicate there was now a heart murmur.She might have covered her tracks, but all her previous notes and the cardiology consult still mentioned no heart...