After spending four years in med school, one year of internship, three years of residency and some time as a hospitalist, you tend to get the hang of how things work and sometimes writing patient histories and writing orders on the patient chart becomes semi automatic somehow. But sometimes, some things get lost in translation from the native tongue to the standard English language the as the following allegedly actual chart entries in one of the biggest government hospitals might attest to.
Patient has chest pain if she lies over her left side for over a year.
On the second day, the knee was better and on the third day, it disappeared.
She has no rigors or shaking chills, but her husband states that she was very hot in bed last night.
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.
The patient refused autopsy.
The patient has no previous history of suicides.
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 showed a normal sized thyroid.
She stated that she had been constipated for most of her life, until she got separated.
The lab test showed abnormal lover function.
The patient was to have a bowel resection. However, he took a job as a stockbroker instead.
Skin: somewhat pale but present.
Patient has two teenage children, but no other abnormalities.
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