Actual Writings on Hospital Charts
April 4th, 2007
- 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 years 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.
- . The lab test indicated abnormal lover function.
- . The patient was to have a bowel resection. However, he took a job as a stock broker 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.
- . Patient has two teenage children, but no other abnormalities.
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