Doctors Progress Notes

Ok, I had a couple of different ideas for my blog today. Then I was cleaning out my closet, no, really,it's not a metaphor or anything (although I don't mind listenening to Eminem every now and then). I really was cleaning out my closet and I came across some doctors progress notes that I had copied way back when I was working my first job. I had to make them the subject of the blog. Now, as a nurse, you can get a lot of good information from the doctors progress notes, if you can read them that is. They write about their findings and their plan for the patients care. There was this doctor, who shall remain nameless, who wrote all kinds of weird stories and very odd orders. Needless to say he is excentric, but his patients loved him. His handwriting was atrocious which made deciphering his orders and notes that much more difficult.
I hope you enjoy and get a good chuckle from this actual prgress note.
Chief Complaint:
" I fell honey."
History of present illness:
This 92-year-old white female fell out of bed and she was brought here by the squad. Dr.____ phoned me and said she broke her right hip, which is correct. The lady has a history of electrolyte imbalance, hypothyroidism and postural hypotension. She is 92 and demented. I made my way to ____ Emergency Room, while every erstwhile administrator or attorney had taken vacation through Wednesday, because after all, you know it is Independence Day on Tuesday. However, there is no Independence for the lacky physicians, as myself, who struggle along for a pittance of remuneration. Perhaps I ought to have a Boston Tea Party. In any event, 'the patient' was lying there in the gurney with her two daughters present. She knew old Doc ____ , the kindly old soul.
Physical Examination:
Vital Signs. Her blood pressure was 130/80, heart rate 82 and respirations 12
Lungs: The lungs were clear.
Heart: The heart was sinus rhythm.
Extremities: The right hip was swollen with decreased motion.
Plan:
I said I would get ______, an orthopedist, Dr.___ to clear her heart-wise and Dr._________ to evaluate her sensorium. Therefore, we feel it is safe to admit Mrs._____ and we pray for her.
Wow, that is a piece of art isn't it? I am not sure if this particular physician is still practicing. But, I remember him still carrying the old leather doctors bag with him everyday...once we got a peek inside, it was full of saltine crackers and ginger ale from the refrigerator on the unit. Go figure, huh? Remember...first do no harm.