Wednesday, May 4, 2011

So a PA walks into a bar...

Good for a yuck, these are items forwarded to me by one of my professors as actual patient notes from the real world. Some are typos, some are just plain poor word choice, others are clearly intended correctly but got lost in translation by the poor transcriptionist assigned to decode someone's horrible hand writing or crackly/muffled tape cassette dictation. And let me just say - from my personal experience in the medical profession: no, I don't think these are made up ;) Enjoy! xo Mego

1) Patient has two teenage children, but no other abnormalities
2) patient has chest pain if she lies on her left side for over a year
3) on the second day, the knee was better, and then on the third day it disappeared
4) Patient is tearful and crying constantly. She also appears to be depressed
5) The patient has been depressed since she began seeing me in 1993.
6) Discharge status: alive, but without my permission
7) healthy-appearing decrepit 69-year old male mentally alert but forgetful
8) The patient refused autopsy.
9) The patient has no previous histry of suicides
10) Patient has left White Blood Cells at another hospital.
11) Patient's medical history has been remarkably insignificant with only a 40lbs weight gain in the past 3 days
12) PAtient had waffles for breakfast and anorexia for lunch
13) Between you and me, we ought to be able to get to get this lady pregnant.
14) She is numb from her toes down
15) While in the ER, she was examined x-rated and sent home
16) The skin was moist and dry
17) Occasional, constant, infrequent headaches
18) Patient was alert and unresponsive
19) She stated that she had been constipated for most of her life until she got a divorce.
20) Rectal examination revealed a normal-size thyroid.
21) I saw your patient today who is still under our car for physical therapy
22) The lab test indicated abnormal lover function
23) The patient was to have a bowel resection. However, he took a job as a stockbrocker instead
24) Skin: somewhat pale but present
25) The pelvic exam will be done later on the floor
26) Patient was seen in consultation by Dr. ______, who felt we should sit on the abdomen and I agree
27) Large brown stool ambulating in the hall
28) She has no rigors or shaking chills but her husband states she was hot in bed last night
29) Patient was found in bed with her power mower.

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