Actual Writing on Hospital Actual Writing on Hospital ChartsCharts

By DoctorsBy Doctors

Patient has chest pains if she lies on Patient has chest pains if she lies on her left sideher left side

…….for over a year..for over a year.

On the second day the knee was betterOn the second day the knee was better

and on the third day it disappeared.and on the third day it disappeared.

The patient is tearful and crying The patient is tearful and crying constantly.constantly.

She also appears to be depressed.She also appears to be depressed.

The patient has been depressed since The patient has been depressed since she started seeing meshe started seeing me

in 1993.in 1993.

Discharge Status: AliveDischarge Status: Alive

but without my permission.but without my permission.

Healthy appearing decrepit 69 year old Healthy appearing decrepit 69 year old male, mentally alert male, mentally alert

but forgetful.but forgetful.

The patient refusedThe patient refused

autopsy.autopsy.

The patient had no previous history ofThe patient had no previous history of

suicides.suicides.

Patient has left white blood cellsPatient has left white blood cells

at another hospital.at another hospital.

Patient’s medical history has been Patient’s medical history has been remarkably insignificant with only a remarkably insignificant with only a

40 pound weight gain40 pound weight gain

in the past three days.in the past three days.

Patient had waffles for breakfastPatient had waffles for breakfast

and anorexia for lunch.and anorexia for lunch.

She is numb from her toesShe is numb from her toes

down.down.

While in ER, she was examined,While in ER, she was examined,

X-ratedX-rated

and sent home.and sent home.

The skin was moistThe skin was moist

and dry.and dry.

Occasional, constantOccasional, constant

infrequent headaches. infrequent headaches.

The patient was alertThe patient was alert

and unresponsive.and unresponsive.

Rectal examination revealedRectal examination revealed

a normal sized thyroid.a normal sized thyroid.

She stated that she had been She stated that she had been constipated for most of her lifeconstipated for most of her life

until she got a divorce.until she got a divorce.

I saw your patient today, I saw your patient today,

who is still under our car for physical who is still under our car for physical therapy.therapy.

Both breasts are equal and reactiveBoth breasts are equal and reactive

to light and accommodation.to light and accommodation.

The lab test indicated abnormalThe lab test indicated abnormal

lover function.lover function.

The patient was to have a bowel The patient was to have a bowel resection.resection.

However, he took a job as a stock However, he took a job as a stock broker instead.broker instead.

Skin: Somewhat paleSkin: Somewhat pale

but present.but present.

Patient was seen in consultation by Dr. Patient was seen in consultation by Dr. Blank,Blank,

who felt we should sit on the abdomen who felt we should sit on the abdomen and I agree.and I agree.

Large brown stoolLarge brown stool

ambulating in the hall.ambulating in the hall.

Patient has two teenaged children,Patient has two teenaged children,

but no other abnormalities.but no other abnormalities.