Actual Entries on Hospital Charts

This item was sent to me by my old buddy whom I call "Jawn". He's a psychologist, and his brother Jim is indeed an M.D.

Jawn sends: "When I recently visited my brother Jim, a family practitioner, I had some time to kill while he finished office hours. So I idly leafed through some patient "charts" that were stacked on his desk. As you see, good writing runs in our family."

Actual Entries on Hospital Charts

  • She has no rigors or shaking chills, but her husband states she was very hot in bed last night.

  • Patient has chest pain if she lies on her left side for over a year.

  • On the second day the knee was better, and on the third day it disappeared.

  • The patient is tearful and crying constantly. She also appears to be depressed.

  • The patient has been depressed since she began seeing me in 1993.

  • Discharge status: Alive but without my permission.

  • Healthy appearing decrepit 69-year-old male, mentally alert but forgetful.

  • The patient refused autopsy.

  • The patient has no previous history of suicides.

  • Patient has left white blood cells at another hospital.

  • Patient's medical history has been remarkably insignificant with only a 40-pound weight gain in the past three days.

  • Patient had waffles for breakfast and anorexia for lunch.

  • She is numb from her toes down.

  • While in ER, she was examined, x-rated and sent home.

  • The skin was moist and dry.

  • Occasional constant infrequent headaches.

  • Patient was alert and unresponsive.

  • Rectal examination revealed a normal-size thyroid.

  • She stated that she had been constipated for most of her life, until she got a divorce.

  • I saw your patient today, who is still under our car for physical therapy.

  • Both breasts are equal and reactive to light and accommodation.

  • Examination of genitalia reveals that he is circus sized.

  • The lab test indicated abnormal lover function.

  • The patient was to have a bowel resection. However, he took a job as a stockbroker instead.

  • Skin: somewhat pale but present.

  • The pelvic exam will be done later on the floor.

  • Patient was seen in consultation by Dr. Blank, who felt we should sit on the abdomen, and I agree.

  • Large brown stool ambulating in the hall.

  • Patient has two teenage children but no other abnormalities.

    Posted August 10, 2012

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