Actual writings from hospital charts:
- The patient refused autopsy.
- The patient has no previous history of suicides.
- Patient has left white blood cells at another hospital.
- 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 permission.
- Healthy appearing decrepit 69-year old male, mentally alert but forgetful.
- 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.
- Skin: somewhat pale but present.
- The pelvic exam will be done later on the floor.
- Patient has two teenage children, but no other abnormalities