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 May 24, 2004 11:44 AM
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