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Medical Records

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.

1. By the time he was admitted, his rapid heart had stopped, and he was feeling better.

2. Patient has chest pain if she lies on her left side for over a year.

3. The patient states there is a burning pain in his penis which goes to his feet.

4. On the second day the knee was better and on the third day it had completely disappeared.

5. She has had no rigors or shaking chills, but her husband states she was very hot in bed last night.

6. The patient has been depressed ever since she began seeing me in 1983.

7. 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.

8. The patient is tearful and crying constantly. She also appears to be depressed.

9. Discharge status: Alive but without permission. The patient will need disposition, and therefore we will get Dr. Blank to dispose of him.

10. Healthy appearing decrepit 69 year-old male, mentally alert but forgetful.

11. The patient refused an autopsy.

12. The patient has no past history of suicides.

13. The patient expired on the floor uneventfully.

14. Patient has left his white blood cells at another hospital.

15. Patient was becoming more demented with urinary frequency.

16. The patient's past medical history has been remarkably insignificant with only a 40 pound weight gain in the past three days.

17. She slipped on the ice and apparently her legs went in separate directions in early December.

18. 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.

19. The patient left the hospital feeling much better except for her original complaints.

20. Rectal examination revealed a normal-size thyroid.

21. Examination of genitalia reveals that he is circus sized.

22. The lab test indicated abnormal lover function.

23. Skin: somewhat pale but present.

24. Large brown stool ambulating in the hall.

25 . Patient has two teenage children but no other abnormalities

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