Medical Record Quotes

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.
   * 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 in1983.
   * 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.