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Actual Medical Records

Actual transcripts of an Emergency room..
Dedicated to all my  friends who are nurses.

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.
 
 

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 1993.
 
 

Patient was released to outpatient department without dressing.
 
 

I have suggested that he loosen his pants before standing, and then,
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. Smith
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.
 
 

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 picture of acute pulmonary edema at home while having sex which
gradually deteriorated in the emergency room.
 
 

The patient had waffles for breakfast and anorexia for lunch.
 
 

Since she can't get pregnant with her husband, I thought you would
like to work her up.
 
 

Skin: somewhat pale but present.
 
 

Admitted in error.
 
 

Patient was seen in consultation by Dr Jones, who felt that we should
sit on the abdomen and I agree.
 
 

Large brown stool ambulating in the hall.
 
 

Patient has two teenage children but no other abnormalities.


 
 
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