Читать книгу The Complete Confessions of a GP - Benjamin Daniels - Страница 33

It is always drummed into us how important it is for us to keep clear, coherent and detailed medical notes. These are apparently real extracts from medical notes. They have been doing the rounds as an e-mail.

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

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 on the third day it disappeared.

4 The 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 history of suicides.

10 Patient has left white blood cells at another hospital.

11 Patient’s medical history has been remarkably insignificant with only a 40-pound weight gain in the past three days.

12 Patient had waffles for breakfast and anorexia for lunch.

13 She is numb from her toes down.

14 While in ER, she was examined, X-rated and sent home.

15 The skin was moist and dry.

16 Occasional, constant infrequent headaches.

17 Patient was alert and unresponsive.

18 Rectal examination revealed a normal-sized thyroid. (Thyroid gland is in the neck!)

19 She stated that she had been constipated for most of her life, until she got a divorce.

20 I saw your patient today, who is still under our car for physical therapy.

21 Both breasts are equal and reactive to light and accommodation.

22 Examination of genitalia reveals that he is circus-sized.

23 The lab test indicated abnormal lover function.

24 The patient was to have a bowel resection. However, he took a job as a stockbroker instead.

25 Skin: somewhat pale but present.

26 The pelvic examination will be done later on the floor.

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

28 Large brown stool ambulating in the hall.

29 Patient has two teenage children, but no other abnormalities.

30 The patient experienced sudden onset of severe shortness of breath at home while having sex, which gradually deteriorated in the emergency room.

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

32 Patient was released to out patient department without dressing.

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

34 The baby was delivered, the cord clamped and cut, and handed to the paediatrician, who breathed and cried immediately.

35 When she fainted, her eyes rolled around the room.