Sitting in a room reading medical records can get a little dull but every now and then I come across an error or something that really makes me chuckle in the charts. A few weeks ago a co-monitor brought me a chart and pointed out this gem written during a Physical Exam: "Deaf in both eyes"
A friend forwarded me an email chain with some more so here is your chuckle for the day:
1. The patient refused an autopsy.
2. The patient has no previous history of suicides.
3. She stated that she had been constipated for most of her life, until she got a divorce.
4. Patient has chest pain if she lies on her left side for over a year.
5. On the second day, the knee was better, and on the third day it disappeared.
6. The patient is tearful and crying constantly. She also appears to be depressed.
7. Healthy appearing decrepit 69-year old male, mentally alert but forgetful.
8. She is numb from her toes down.
9. The skin was moist and dry.
10. Occasional, constant infrequent headaches.
11. Patient was alert and unresponsive.
12. Rectal examination revealed a normal size thyroid.
13. Both breasts are equal and reactive to light and accommodation.
14. Skin: somewhat pale but present.
15. Patient has two teenage children, but no other abnormalities.
Feel free to post a comment if you've come across anything just as silly - thanks!
6 comments:
Hi Nadia,
Some times monitoring can be so much fun. This post is a perfect example of it.
Thanks for sharing this with us. You are linked to my blog now.
Cheers,
Naveen
www.clinicalresearchzone.blogspot.com
Thank you for the laugh!
How about this one:
"Patient denies incontinence, but stated he sometimes has "moist underpants".
wa! wa! wa! this is most funny! revisit #5!
I really saw the following in a subject-completed medical history questionnaire in a chart.
To the question "What type(s) of birth control do you currently use?" the subject responded "My personality."
I would probably have gotten along very well with that guy.
Thank you, I really needed a laugh!
Once I found on a chart: "patient indicates he is experiencing hair growth in unusual places". Patient initials: CAT
I once read "the patient had chocolate covered stool after last night's dinner"
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