Medical Records (Part 1)
These are actual, unedited doctor's notes on patient's charts:
1. Patient has chest pain if she lies on her left side for over a year.
2. On the 2nd day the knee was better and on the 3rd day it disappeared completely.
3. She has had no rigors or shaking chills, but her husband states she was very hot in bed last night.
4. The patient has been depressed ever since she began seeing me in 1993.
5. The patient is tearful and crying constantly. She also appears to be depressed.
6. Discharge status: Alive but without permission.
7. Healthy appearing decrepit 69 year-old male, mentally alert but forgetful.
8. The patient refused an autopsy.
9. The patient has no past history of suicides.
10. Patient has left his white blood cells at another hospital.
11. Patient's past medical history has been remarkably insignificant with only a 40 pound weight gain in the past three days.
12. Patient had waffles for breakfast and anorexia for lunch.
13. Between you and me, we ought to be able to get this lady pregnant.
14. Since she can't get pregnant with her husband, I thought you might like to work her up.
15. She is numb from her toes down.
16. While in the ER, she was examined, X-rated and sent home.
17. The skin was moist and dry.
18. Occasional, constant, infrequent headaches.
19. Patient was alert and unresponsive.
20. Rectal exam revealed a normal size thyroid. (ouch!)
21. She stated that she had been constipated for most of her adult life, until she got a divorce.
22. I saw your patient today, who is still under our car for physical therapy.
23. Both breasts are equal and reactive to light and accommodation.
24. Exam of genitalia reveals that he is circus sized.
25. The lab test indicated abnormal lover function.
26. The patient was to have a bowel resection. However, he took a job as a stockbroker instead.
27. Skin: Somewhat pale but present.
28. The pelvic examination will be done later on the floor.
29. Patient was seen in consultation by Dr. Blank, who felt we should sit on the abdomen and I agree.
30. Large brown stool ambulating in the hall.
31. Patient has two teenage children, but no other abnormalities.