actual writings on hospital charts
1. she has no rigors or shaking chills, but her husband
states she was very hot in bed last night.
2. Patient has chest pain if she lies on her left side for
over a year.
3. On the second day the knee was better, and on the third
day it disappeared.
4. The patient is tearful and crying constantly. She also
appears to be depressed.
5. The patient has been depressed since she began seeing me
in 1993.
6. Discharge status: Alive but without my permission.
7. Healthy appearing decrepit 69 years old male, mentally
alert but forgetful.
8. The patient refused autopsy.
9. The patient has no previous history of suicides.
10. Patient has left white blood cells at another
hospital.
11. Patient's 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. She is numb from her toes down.
14. While in ER, she was examined, x-rated and sent home.
15. The skin was moist and dry.
16. Occasional, constant infrequent headaches.
17. Patient was alert and unresponsive.
18. Rectal examination revealed a normal size thyroid.
19. She stated that she had been constipated for most of
her life, until she got a divorce.
20. I saw your patient today, who is still under our car
for physical therapy.
21. Both breasts are equal and reactive to light and
accommodation.
22. Examination of genitalia reveals that he is circus
sized.
23. The lab test indicated abnormal lover function.
24. The patient was to have a bowel resection. However, he
took a job as a stock broker instead.
25. Skin: somewhat pale but present.
26. The pelvic exam will be done later on the floor.
27. Patient was seen in consultation by Dr. Blank, who felt
we should sit on the abdomen and I agree.
28. Large brown stool ambulating in the hall.
29. Patient has two teenage children, but no other
abnormalities.
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