Wednesday, October 8, 2008

Actual Notes in Hospital Charts by Physicians

1. Rectal examination revealed a normal sized thyroid. [Ouch!]

2. She stated that she has been constipated for most of her life until she got a divorce.

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

4. Discharge status: Alive but without my permission.

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

6. The patient refused autopsy.

7. The patient has no previous history of suicides.

8. Patient has left their white blood cells at another hospital.

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

10. She is numb from her toes down.

11. While in ER, she was examined, X-rated and sent home.

12. Occasional, constant, infrequent headaches.

13. Patient was alert and unresponsive.

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

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

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

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

18. Examination of genitalia reveals that he is circus sized.

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

20. Skin: Somewhat pale but present.

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

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

23. Large brown stool ambulating in the hall.

24. Patient has two teenage children, but no other abnormalities.

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

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

1 comment:

Gwen E. Kirby said...


Thank you so much for your comment on my blog! I am glad I was not the only one who felt that way. Did you find my blog through the Carleton website?

Those hospital notes are pretty special. :)