Actual Medical Records

The following quotes were taken from
actual medical records dictated by physicians.
They were reprinted in a column written by
Dr. Richard Lederer for the Journal of Court Reporting.

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


Occasional, constant, infrequent headaches.


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


The patient was in his usual state of good health until his airplane ran out of gas and crashed.


When she fainted, her eyes rolled around the room.


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


Patient has chest pain if she lies on her left side for over a year.


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.


Discharge status: Alive but without permission. The patient will need disposition, and therefore we will get Dr. Blank to dispose of him.


The patient refused an autopsy.


Patient has left his white blood cells at another hospital.


The patient's past medical history has been remarkably insignificant with only a 40-pound weight gain in the past three days.


The patient left the hospital feeling much better except for her original complaints.


The patient is tearful and crying constantly. She also appears to be depressed.


The patient has no past history of suicides.


She is numb from her toes down.


Skin: Somewhat pale but present.


Patient has two teenage children, but no other abnormalities.


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