Actual Entries on Hospital Charts

Actual Entries on Hospital Charts

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.
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