health and illness: September 2008 Archives

live from medical records

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I used to have to deal with a dictation/transcription service that was probably outsourced. We had some choice typos, but we usually managed to catch and correct the most egregious. My favorite was the misinterpretation of "She hit a deer with her car" which somehow became "She had a beer with her car"
The choice selections below were sent to me recently. Enjoy!

* The lab test indicated abnormal lover function.
* The baby was delivered, the cord clamped and cut, and handed to the pediatrician, who breathed and cried immediately.
* Exam of genitalia reveals that he is circus sized.
* She stated that she had been constipated for most of her life until 1989 when she got a divorce.
* The patient was in his usual state of good health until his airplane ran out of gas and crashed.
* Rectal exam revealed a normal size thyroid. (Long fingers?)
* Between you and me, we ought to be able to get this lady pregnant.
* A midsystolic ejaculation murmur heard over the mitral area.
* The patient lives at home with his mother, father, and pet turtle, who is presently enrolled in day care three times a week.
* Both breasts are equal and reactive to light and accommodation.
* She is numb from her toes down.
* Exam of genitalia was completely negative except for the right foot.
* The patient was to have a bowel resection. However, he took a job as stockbroker instead.
* When she fainted, her eyes rolled around the room.
* Examination reveals a well-developed male lying in bed with his family in no distress.
* She has no rigors or chills but her husband says she was very hot in bed last night.
* She can't get pregnant with her husband, so I will work her up.
* Whilst in Casualty she was examined, X-rated and sent home.
* On the second day the knee was better and on the third day it had completely disappeared.
* The patient has been depressed ever since she began seeing me in 1983.
* I will be happy to go into her GI system, she seems ready and anxious.
* Patient was released to outpatient department without dressing.
* 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. Blank to dispose of him.
* Healthy-appearing, decrepit 69 year old male, mentally alert but forgetful.
* 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.
* Patient was becoming more demented with urinary frequency.
* 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.
* Patient has chest pains if she lies on her left side for over a year.
* He had a left-toe amputation one month ago. He also had a left-knee amputation last year.
* By the time he was admitted, his rapid heart had stopped, and he was feeling much better.
* The patient is a 79-year-old widow who no longer lives with her husband.
* The patient refused an autopsy.
* Many years ago the patient had frostbite of the right shoe.
* The bugs that grew out of her urine were cultured in the Casualty and are not available. I WILL FIND THEM!!!
* The patient left the hospital feeling much better except for her original complaints.

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About this Archive

This page is a archive of entries in the health and illness category from September 2008.

health and illness: August 2008 is the previous archive.

health and illness: December 2008 is the next archive.

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