Sample Transcription and Medical Terminology
January 23, 2004
Joyce Carvel, M.D. 2025 N. Wickman Tampa, FL
RE: Jack Parton
Dear Dr. Carvel:
I saw Dr. Parton in the office on January 23, 2004 for evaluation of his stiffness and muscle cramps.PRESENT ILLNESS:
Dr. Parton is a very pleasant 79-year-old right handed gentleman, who states that towards the end of last year, he began to notice significant muscle cramps, as well as a tightness behind his knees. He also notices feeling stiff first thing in the morning, but says he will loosen up towards the end of the day. He was hospitalized in October of last year with a small bowel obstruction and numerous complications, including hemothorax, bilateral pneumonias and significant emaciation, having lost 50 lb. Recently, he was still concerned about the muscle cramps and lowered the Lipitor that he was on from 20 mg down to 10 mg and found that this did improve the muscle cramps and then two weeks ago, he stopped the Lipitor entirely and the muscle cramps have essentially resolved. He still does complain of some tension behind his knees.PAST MEDICAL HISTORY:
His past medical history is significant for exploratory laparotomy, appendectomy, Japanese B encephalitis in 1951, endocarditis in 1964, Meniere’s disease, gastroesophageal reflux, basal cell carcinomas, cardiovascular disease status post stent and Wenckebach small bowel obstruction, hemothorax. His current medications are Aciphex 20 to 40 mg a day, Plavix, Flomax, B-12, lorazepam, Lipitor, aspirin and iron.NEUROLOGIC EXAMINATION:
He is a well-appearing gentleman. He is well-developed and in no acute distress. There are no abnormalities of development or body habitus. Nutrition appears to be good.
Carotid pulses are full bilaterally and no bruits are identified. Heart tones are normal and the rhythm is regular, without audible murmur. Peripheral pulses are full and there is no limb edema.
The patient is alert and oriented to time, place and person. There are no abnormalities of recent or remote memory, and attention span and concentration are normal. Naming, repetition and comprehension are normal. The patient displays a good fund of information.
Cranial nerves II-XII are intact. Specifically, visual fields are full and the pupils are equally reactive bilaterally. Funduscopic examination show normal optic discs, without abnormalities of vessel caliber. No hemorrhages or exudates are seen. Eye movements are full in all directions. There is no impairment of facial sensation. Facial grimace and eye closure are symmetrical and strength is good. There is no impairment of hearing to confrontation (finger rub). The palate moves symmetrically and shoulder shrug and sternocleidomastoid strength are normal. The tongue protrudes in the midline and there is no wasting or fasciculation.
Motor tone, bulk and strength are symmetrical in both upper and lower extremities at all levels. There was no significant cogwheeling, no bradykinesia.
Sensation is intact to touch, pin, position, vibration and double simultaneous stimulation.
Reflexes are 2+, however, absent at both ankles. Both toes are downgoing.
Coordination, finger-to-nose, heel-to-shin and rapid alternating movement testing are performed without difficulty.
Station and gait was normal.
The patient has evidence of myalgias and cramps that have resolved with discontinuing the Lipitor. My impression at this point is that this is most likely a combination of a statin-induced myalgia, as well as arthritic complaints. I will go ahead and check a CPK and ESR, but I assured him that I did not see any significant neurologic disease.
Travis Cohen, M.D.
Kent Bowman returned to the office at Charles Guardia′s request.
He had seen several physicians with complaints of lower extremity weakness, balance problems and numbness and the question was raised whether or not he had a peripheral neuropathy or lumbar radiculopathies. Christy had performed nerve conduction studies, which revealed almost no motor responses; however, there were no sensory responses performed. In addition, there was significant denervation by EMG. His MRI scans shows the possibility of arachnoiditis and the question is whether or not he should proceed with surgery.
Today I performed nerve conduction studies, which revealed normal serial sensory responses, but absent H reflexes. This, in combination with the previous studies done by Christy Sherman, confirmed that there is no evidence of peripheral neuropathy, but that there is severe lumbar radiculopathies.
I have asked him to come back to your office to see whether or not surgery would be beneficial for him at this point, but I certainly do not see any evidence that this is related to a peripheral component.
RE: Thomas Rogers
Tom is a 63-year-old patient of Dr. Miles Carter, who presents at the office today for a lumbar puncture with the diagnosis of vasculitic neuropathy.
Patient was placed in the seated position for the LP, which was attempted at the L3-4 site. Following a complete Betadine prep, a total of 6 cc of 1% lidocaine was used to anesthetize the site. Several attempts were made to enter the subarachnoid space unsuccessfully at the L3-4 site. The interspace directly above was then anesthetized with an additional 5 cc of 1% lidocaine and again, attempts were unsuccessful to enter the subarachnoid space. Dr. Chittman further attempted at both anesthetized sites with no success. Following the procedure, the patient became mildly diaphoretic and pale and was placed in the right lateral decubitus position for five minutes.
All post-procedure instructions were reviewed with the patient, who verbalized understanding.
The patient was further instructed that an LP under fluoroscopy would be set up, as soon as possible. He will be scheduled at Good Sam with a request for spinal fluid testing to include routine glucose, protein, cell count with differential and cytology.
Patricia Romley, RN, MS, CVNS
Neuroscience Clinical Nurse Specialist
RE: Marcia Palmer
Ms. Palmer returned to the office today for follow-up evaluation of her multiple sclerosis.
Since her last visit, we had treated her with ten days of IV Solu-Medrol and this improved her symptoms somewhat, although she is still not back to where she was before and still requiring a scooter. I had a long conversation with her concerning the different therapeutic options and, unfortunately, because she is getting chemotherapy, aggressive immuno-modulatory therapy would not work. Also, plasmapheresis would not work, because she is receiving weekly Herceptin. I did discuss the possibility of IV Ig with her and she will discuss that with Dr. Cratcher. In addition, we will hold off on the Avonex, because she hates the side effects and will start Copaxone in one month′s time.