The
following quotes were taken from actual medical records dictated by
physicians. They appeared in a column
written by Richard Lederer, Ph.D., for the Journal of Court Reporting. Doctor’s reports
By the time he was admitted, his rapid heart
had stopped, and he was feeling better.
Patient
has chest pain if she lies on her left side for over a year.
The
patient states there is a burning pain in his penis which goes to his feet.
On
the second day the knee was better and on the third day it had completely
disappeared.
She
has had no rigors or shaking chills, but her husband states she was very hot in
bed last night.
The
patient has been depressed ever since she began seeing me in 1983.
I
will be happy to go into her GI system; she seems ready and anxious.
Patient
was released to outpatient department without dressing. I have suggested that he loosen his pants
before standing, and then, when he stands with the help of his wife, they
should fall to the floor.
The
patient is tearful and crying constantly.
She also appears to be depressed.
Discharge
status: Alive but without
permission. The patient will need
disposition, and therefore we will get Dr. Blank to dispose of him.
Healthy
appearing decrepit 69 year-old male, mentally alert
but forgetful.
The
patient refused an autopsy.
The
patient has no past history of suicides.
The
patient expired on the floor uneventfully.
Patient has left his white blood cells at another hospital.
Patient
was becoming more demented with urinary frequency.
The
patient's past medical history has been remarkably insignificant with only a 40 pound weight gain in the past three days.
She
slipped on the ice and apparently her legs went in separate directions in early
December.
The
patient experienced sudden onset of severe shortness of breath with a picture
of acute pulmonary edema at home while having sex which gradually deteriorated
in the emergency room.
The
patient left the hospital feeling much better except for her original
complaints.
1. Patient has chest pain if she lies on her left
side for over a year.
2. On the 2nd day the knee was better and on the
3rd day it disappeared completely.
3. The patient has been depressed ever since she
began seeing me in 1993.
4. The patient is tearful and crying constantly.
She also appears to be depressed.
5. Discharge status: Alive but without
permission.
6. Healthy appearing decrepit 99
year-old male, mentally alert but forgetful.
7. The patient refused an autopsy.
8. The patient has no past history of suicides.
9. Patient has left his white blood cells at
another hospital.
10. Patient's past medical history has been
remarkably insignificant with only a 40 pound weight
gain in the past three days.
11. Patient had waffles for breakfast and
anorexia for lunch.
12. She is numb from her toes down.
13. While in the ER, she was examined, X-rated
and sent home.
14. The skin was moist and dry.
15. Occasional, constant, infrequent headaches.
16. Patient was alert and unresponsive.
17. Rectal exam revealed a normal size thyroid.
18. She stated that she had been constipated for
most of her life, until she got a divorce.
19. I saw your patient today, who is still under
our Car for physical therapy.
20. The patient was to have a bowel resection.
However, he took a job as a stockbroker instead.
21. Skin: Somewhat pale but present.
22. Patient was seen in consultation by Dr.
Blank, who felt we should sit on the abdomen and I
agree.
23. Patient has two teenage children, but no
other abnormalities.