Features

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. Sincerely, Travis Cohen, M.D. PROGRESS NOTE 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 DATE: 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 DATE: 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.

Notes for transcriptionist: Following are short notes to be typed one after another in a short paragraph format. Many physicians prefer this style of note. After being transcribed, it is usually clipped into the patient chart. Each short paragraph represents an individual chart note. Although the format provided here is not the standard type of format presented in the samples contained in the introduction, this is a variation of a typical progress note. Letters are also included and can be transcribed using the standard format. * * * OB-GYN At 40 weeks gestation, the patient went into spontaneous labor and on 01/15, had UVD over midline episiotomy of a healthy female with Apgars of 8/9 and weight of 8 lb 4 oz. Delivery and postpartum course were unremarkable. At 40 weeks gestation, the patient underwent labor induction because of a ripped cervix and previous C-section. Following a relatively long labor, under epidural anesthesia, she had the vacuum extraction delivery over midline episiotomy on 12/15 of a healthy male with Apgars 8/10 and weight 8 lb 11 oz. Delivery was complicated by postpartum hemorrhage secondary to retained placenta, probably secondary to a partial placenta increta. Blood loss was estimated at 1500 cc and bleeding maintained by a D&C and manual removal. The postpartum hemoglobin was 8.7 and she otherwise had no postpartum complications. Maria returns for follow-up. We discussed the potential complications involved. I explained to her and her husband the risks, and went over the usage of RhoGAM or Gamulin Rh. I addressed isoimmunization in Rh-negative women. They understand and will proceed as agreed. I returned Jonna’s phone call this evening. I explained that MetroGel has the same efficacy as her current regimen. She is a nurse at the hospital, so I gave her some basic information, and that the cure rate is the same with q.hs and bid dosing. Vaginally applied metronidazole could be absorbed in sufficient amounts to produce systemic effects. She is aware of the need for caution with patients with CNS diseases; her family has a history of seizures and neuropathy. I wish to do some checking with Drs. Knoll and Petrusky before proceeding. Katrina called. We discussed the use of danazol. I explained that we would begin with 400 mg. PO bid then titrate downward to a dose sufficient to maintain amenorrhea for three to six months, for up to nine months. I want to check her history first for fibrocystic breast disease. She is not a diabetic, so that is not a consideration at this time. The patient is now two weeks status post diagnostic laparoscopy for hemorrhagic left ovarian cyst and possible endometriosis. The surgery is discussed in detail with the patient, especially concerning the possibility of endometriosis and recurrent disease. She had bleeding for approximately one week after surgery, which is now resolved. She has had a normal period with much less menstrual cramps. She also notes no leftsided pain. Physical exam: The puncture wounds are intact and well-healed. Impression: Normal two week postop check. Plan: Return on a p.r.n. basis should symptoms again become noticeable. The patient is a 49-year-old white married female, G4 P4 seen for annual care, pap smear and estrogen replacement. Her only gyn complaint currently is an approximately one week vaginal irritation, itching, burning around the opening of the vagina and perirectally. She had a TAH-BSO approximately six years ago secondary to abnormal bleeding and has been on intermittent estrogen replacement since that time, and off for the last several months. Her last exam and pap smear was over a year-and-a-half ago. She did have a mammogram approximately one year ago. Upon physical exam, her abdomen reveals a healed appendectomy scar and healed Pfannenstiel. Breasts – Implants bilaterally with the left one being somewhat firm, but no masses palpable. Vaginal cuff is closed, cervix and uterus are absent as are the adnexa. Bimanual exam reveals no masses palpable. Impression: Normal exam with yeast vaginitis. Plan: 1. Pap smear. 2. SBE encouraged. Mammo recommended in one year. 3. Premarin, 0.625 mg Mon – Fri. 4. Monistat vaginal cream. Dr. Kline called this morning regarding Katie Helms. Katie is a former patient and she has moved to Albany. Dr. Kline and I have discussed Katie’s situation. He is recommending emergency contraception. I spoke with him about taking the first dose as soon as possible, then an identical dose 12h later. Each dose is either two pills of Ovral or Ogestrel. The same could be used with 4 pills of Levlen or Levora. If vomiting occurs within one hour of taking either dose, consider whether or not to repeat that dose and give an antiemetic, 1h prior. At 40 weeks gestation on 07/17, the patient had the SVD of midline episiotomy of a healthy male with Apgars 7/9, a cord pH of 7.192 and a weight of 8 lb, 7 oz. Delivery was complicated by terminal bradycardia, but otherwise the postpartum course was unremarkable. The patient is seen today for possible vaginitis. She notes a complete course of antibiotics one to two weeks ago and since that time, has had itching, burning, foul-smelling discharge. She tried a course of Monistat III with partial relief, but again notes the return of symptoms. Physical exam: Ext. genitalia – Slightly erythematous. Vagina – Rugae with whitish discharge, which on wet mount reveals yeast. Impression: Yeast vaginitis. Plan: Micostatin Cardiology S: Peter has been feeling more dyspneic with exertion lately. He tires easily. Medications include Covera-HS 240mg/day; Lanoxin, 0.125 q.d.; Cardizem t.i.d. and aspirin. O: Pulse is 60 and regular. Blood pressure 68/88. Lungs are clear. Heart unchanged with mild AS and moderate AI. There is perhaps trivial distal edema noted. A: 1) Suspect recent diminution of exercise tolerance is the effects of glucose tolerance and present insufficiency. 2) Status post permanent pacemaker implantation. 3) Mild chronic renal failure. P: 1) Increase his Cardizem back to 60 p.o. t.i.d., as the increase has not obviously helped him. 2) Hydralazine, 25 mg p.o. t.i.d. 3) Will consider switching to Lasix with his next visit. 4) Will be due for a follow-up Doppler echo sometime after the first of the year. 5) We will see him for follow up in two weeks. -current date- Thomas Patterson, D.O. Circle One Branson, MO RE: Harriet Davis Dear Dr. Patterson: I saw Harriet in the office today after her recent coronary angiogram at Mercy Care Center last week. She has fairly well-preserved left ventricular function, except for a small infra-apical area of hypokinesis, compatible with previous infarction in that region. She has total occlusion of the native LAD, as well as occlusion of the first obtuse marginal branch of the circumflex. Her right coronary artery is a small, diffusely diseased vessel with a subtotal rib stenosis distal to the RCA graft anastomosis. The obtuse marginal graft is occluded. The LAD graft is widely patent with a few distal rub-offs. Correlation may be experiencing intermittent ischemic symptoms on the basis of her coronary disease. The vessel is, however, so small that I do not believe that it poses either a major threat of major infarction or that medically there is anything we can do about that very small vessel. I would neither rebypass that nor attempt to angioplasty it. The left ventricular function is overall well-maintained and her major graft is patent. We have opted for a continued course of medical therapy, noninclusive of sustained release Verapamil, 240 mg p.o. q.d. and a single aspirin per day. She did have intermittent right upper chest atypical, more musculoskeletal sounding, discomfort last weekend, but she is moving and doing more activity than would likely be advisable. In addition to that, she has been under a fair amount of stress. I doubt that her chest discomfort is on the basis of myocardial ischemia at this time. A 12-lead EKG performed in the office today was unremarkable. Overall, I think that Harriet is doing quite well and again do not believe that her recurrent chest discomfort is on the basis of myocardial ischemia, but cannot exclude this completely. The possibility exists of ischemic induced arrhythmias. I feel it is appropriate to continue her on her medical therapy as noted above. She has also mentioned that her serum cholesterol has been significantly elevated in the past and I believe this should be repeated after a good attempt at weight loss and dietary restrictions. Should her serum cholesterol remain above 230, then I would strongly consider initiation of Novistatin therapy. I am also recommending treadmill stress testing at least on an annual basis. Dr. Patterson, thanks again for allowing me to participate in the care of this pleasant, challenging lady with you. If I can be of any further assistance, please don't hesitate to contact me. Sincerely, Perry DeWitt, M.D. 13657 W. McDowell Rd., Su 118 Goodyear, AZ 85338 RE: Jennifer Landry Dear Dr. DeWitt: Your patient, Jennifer Landry, returned to my office for re-evaluation of MS. She says that she is having increasing difficulties with lower extremity strains and constantly with her gait. She does have some discomfort, particularly at night, in her lower extremities. She says that her hand coordination and therefore, her ability to write, also has diminished. She has seen Dr. Delia Cranston, in Tucson, for psychiatric evaluation and Dr. Cranston has suggested an occupational therapy evaluation. She says that her mood is relatively stable, although she says that her physical problems are depressing, at times. On examination, she’s walking stably, with a walker, but lower extremity strains remain 4-/5 bilaterally (and probably slightly weaker than in April, though the number is the same). There’s a very mild dysmetria in finger-to-nose testing. Eye movements remain full and smooth. Cognitive functioning is superficially intact. IMPRESSION: MS, secondarily progressive. RECOMMENDATIONS: 1. Continue Prozac 40 mg daily. 2. Continue Ditropan. 3. Continue Neurontin 300 mg TID. 4. Continue baclofen, but change dosing to 10 mg at breakfast and lunch or 20 mg at dinner and 30 mg at bedtime (I have attempted to reduce daytime dosing to improve strength and increase the evening dosage to improve comfort; she will try this only for a period of a week and if it’s not beneficial, she will revert to her old dosage of 20 mg QID). 5. Provigil 100 mg every morning. 6. Valium 5 mg PRN at bedtime. 7. Continue Betaseron. 8. Continue to follow up with Dr. Cranston. Dr. Cranston can provide her with a name of an appropriate occupational therapist. 9. Consider the possibility of using some atypical medications, such as 4-aminopyridine (for example, an initial dosage of 5 mg BID). This is not a recognized medication in MS. It has been used, favorably, in many settings, including University of Texas Southwestern, with symptomatic improvement in patients. Ms. Landry will consider this possibility. I would be happy to write for it to be compounded, if she is interested. I will see her again in January or if she calls sooner, if there are problems in the interim. Sincerely, Neurology Kenneth Fishman, M.D. 2520 Coldwell Place Irving, TX RE: Benton Grovers Dear Ken: Your patient, Benton Grovers, returned to my office for re-evaluation of headaches. In the interim since his last visit, he has discontinued Thera-Gesic and Naprosyn and tizanidine and has limited his intake of triptans (Axert or Frova) to about once a week. He is no longer taking Duragesic. He says that he is feeling much greater clarity intellectually, but he says that headaches and neck aches persist, at about the level that they were a month ago. He says that D.H.E. 45 (I gave him a sample) appears to work better than a triptan. I am pleased that Mr. Grovers has been able to get off his symptomatic medications. At the present, he has been taking Lexapro 40 mg daily, Gabitril 4 mg daily, once weekly triptan, melatonin and bedtime Klonopin. I suggested that he discontinue Gabitril, since it doesn’t appear to be beneficial. I suggested that rather than Frova or Axert, he had D.H.E. 45 nasal spray, limited intake to one or two doses per week maximally. He will continue on Lexapro, melatonin and Klonopin and return to see me in six to eight weeks. RE: Rhonda Avery Dear Larry: Your patient, Rhonda Avery, returned to my office. She says that she’s been doing well, in general. She says that her energy is generally good and that she’s generally happy. She says that she’s not troubled by her headache frequency, because she gets prompt relief with Imitrex, even the tablet form, or the injector form. Her headache frequency is varied between five and 12 times per month. I prescribed Topamax and afterward, she had a marked reduction in headache frequency, but it produced unacceptable side effects and she is not interested in trying other prophylaxis at this time. She would, in fact, like to taper off Neurontin (which I told her is acceptable). Screening assessment is normal. IMPRESSION: Migraine. PLAN: 1. Continue amitriptyline 100 mg nightly. 2. Taper Neurontin over the next week. 3. Continue Imitrex per injection at the onset of headache. 4. Return visit in January. Sincerely, Hospital/Operative REPORT OF CONSULTATION Ms. Burns is a 31-year-old female who was doing relatively well until she went into labor. Apparently, the patient developed active labor earlier this morning. She suddenly became hypotensive. Her obstetrician, gynecologist, Dr. Myers, was called over. However, she was found to be hypotensive and taken for C-section. Preliminary diagnosis at that time was possibly a uterine rupture and abruptio placenta. The patient was stablized in surgery. Blood pressure became stable and she had a C-section. Following C-section, she once again became quite hypotensive and was transferred to the intensive care unit, intubated and on a ventilator. I was called to see her by Dr. Myers and by Dr. Nichols. Upon arrival in the intensive care unit, the patient was tachycardiac at about 176. Blood pressure was 30 to 40 systolic, but the patient was awake and urine output was markedly diminished. Over the next hour, the patient was given fresh frozen plasma, packed cells, intravenous fluid, Dopamine as well as Pitocin for bleeding status post C-section. Swan-Ganz catheter was passed by myself and with this, we found the pulmonary artery pressure to be 34/10 with a wedge of 67 and a cardiac index of 3.8. Significant laboratory work other than the above revealed leukocytosis with a mild left shift. No toxic granules or bodies. Hemoglobin and hematocrit 14 and 39. PT mildly elevated at 14.4. PTT normal at 34. Platelet count 300,000. Fibrinogen was 365 mg percent. Arterial blood gases revealed a pO2 on 100% of 538 with a CO2 of 28 and a pH 7.26. On the ventilator her pO2 was 260, CO2 26, pH 7.46. Chest x-ray was reviewed and radiograph revealed no cardiomegaly, no infiltrates. EKG revealed low voltage throughout, but no signs of acute injury or other abnormalities. Electrolytes were normal, except for potassium which was 5.4. On physical examination, the patient was intubated, followed with feeble pulses. Her blood pressure at the time seen was 70/40, pulse rate was 140. The head and neck exam, the funduscopic was benign. There was some ecchymosis noted. The trachea was normal. There was no palpable adenopathy. The chest was symmetrical. Breath sounds revealed expiratory rhonchi bilateraly and coarse inspiratory rales. The heart, apical rate was equal to 140 with a I/VI apical systolic murmur, but no gallops or heaves or thrills. The abdomen was tender and post C-section distended. The extremities revealed no clubbing, edema or cyanosis. IMPRESSION: 1. Acute hypotensive episode with the current status post surgery, etiology unclear at this time. Possibility would include pulmonary embolus although present arterial blood gas findings and pulmonary capillary wedge pressure, diastolic gradients speak against this. 2. Rule out amniotic fluid embolus. 3. Rule out anaphylaxis, etiology cause unknown, other than Demerol, which the patient received preoperatively. 4. Rule out an occult bleed. 5. Rule DIC. PLAN: 1. Try to wean her ventilator. 2. Continue intravenous fluids, monitor wedge. 3. Blood cultures. 4. Continue Cefoxitin. 5. Hematology consultation. 6. Cardiac enzymes. 7. Monitor urine for both quantity and check BUN and creatinine. Further recommendations pending the above. REPORT OF CONSULTATION HEMATOLOGY CONSULTATION REASON FOR CONSULTATION: Post partum bleed. HISTORY: The patient is a 31-year-old Caucasian female whom I was asked to see in emergency consultation due to a post partum hemorrhage. The patient was in labor for the birth of her first child when after a contraction, she apparently became hypotensive and was coded by the anesthesiologist. Following successful coding procedure, her child was delivered by cesarean section and she was transported up to the Intensive Care Unit. She became hypotensive again and was coded for a second time. Following this, she was found to have excessive vaginal bleeding without the formation of clots and I was asked to see her in consultation. I initially met her when I was asked to evaluate her for von Willebrand's disease. At that time, I found her Factor VIII activity to be normal, but she had a low normal Factor VIII antigen. In addition, her von Willebrand factor was slightly depressed. However, her ristocetin platelet aggregation was normal as was her bleeding time. At that time, I could not confirm a diagnosis of von Willebrand's disease and felt that if she had any type, she had a very mild variant and it would not cause her any form of bleeding dyscrasia in that her bleeding time was 3. I feel the same at this point in time. When I was asked to see her postoperatively, her start bleeding time was 3 minutes, which is well within the normal range. In fact, it is low normal. However, some of her coagulation parameters were somewhat perplexing. Her PT was elevated at 14.5 with a PTT elevated at 37.0. Her fibrinogen was 378. Her fibrinogenous products were greater than 40. She was transfused with cryoprecipitate, plasma and blood products. When I did see her, she was intubated, but she was alert and responsive. PAST MEDICAL HISTORY: Is positive for endometriosis, as well as gastritis. She has never had any type of anaphylactic reaction. PAST SURGICAL HISTORY: Is positive for laparoscopy, perforated appendix, abdominal abscess x 2. In addition, she has had D&Cs. FAMILY HISTORY: There is no problem with bleeding in either parent, but an aunt and cousins have several bleeding problems. Her father has coronary artery disease. Her brother has no medical problems. One sister has cystic breast disease. SOCIAL HISTORY: She does not drink nor does she use cigarettes. She admits to bruising very easily. She has had frequent nose bleeds as a child, but has never required any hospitalization for the same. She admits to minimal exertional dyspnea. PHYSICAL EXAMINATION: Finds her to be alert and oriented on the ventilator. Her vital signs are presently stable, except for tachycardia. Pupils are equal. She has no scleral icterus. Neck is supple. There is no supraclavicular or cervical adenopathy. Breasts are cystic and consistent with pregnancy state. Lungs revealed decreased breath sounds in all fields. Abdomen has a new incision on it and I was not able to adequately evaluate her abdomen. She has no peripheral edema. She has no pathologic neurologic reflexes. IMPRESSION: 1. The etiology of her hypotension x 2 is unknown and it appears to have resolved. 2. Post partum coagulopathy. Rule out secondary to hypotensive episodes. 3. Low fibrinogen for a pregnant state with a normal PT and PTT. Rule out primary fibrinolysis. RECOMMENDATIONS: Appropriate tests have been ordered. OPERATIVE RECORD SURGEON: R. Myers, M.D. ANESTHESIOLOGIST: T. White, M.D. PREOPERATIVE DIAGNOSIS: Intrauterine pregnancy at term, severe bradycardiac, post maternal hypertensive episode. Rule out uterine rupture. Rule out ruptured placenta. POSTOPERATIVE DIAGNOSIS: No uterine rupture nor ruptured placenta found. The same as above. PROCEDURE: Emergency primary cesarean section. Radical skin incision, low flap transverse. After successful induction of the general anesthesia, the patient was prepped very quickly for an abdominal procedure. A fast vertical radial skin incision was performed and carried down to the fascia which was incised upwards and downwards. Then the rectus muscle was split in the midline. The peritoneum was identified, grasped with two hemostats and incised upwards and downwards. Then the lower end of the bowels were retracted and placed behind the symphysis pubis and the peritoneum covering the lower uterine segment was incised in a smiling fashion. The uterine segment was also incised in a smiling fashion and a viable baby boy, Apgar 4/7 was delivered. Normal placenta grossly inspected with no suggestion of a ruptured placenta. Inspection was done obviously after the manual delivery of the placenta. The baby was handed out to the pediatricians, Drs. Smith and Haverhill, who were present in the operating room. The baby was resuscitated quite fast. Then the uterus was inspected. Both tubes and ovaries were found to be normal. The uterus was found to be within normal limits. No free blood in the abdominal cavity noted other than the blood generated by the cesarean section itself. The endometrial cavity was irrigated with antibiotics and the uterine cavity was reapproximated in three imbricated layers. The bladder flap was also reapproximated. By the way, a Foley catheter was inserted prior to the surgery and the urine output was within normal limits all throughout the procedure. The patient was stable through the procedure. After the correct counts of instru-ments, the abdominal wall was closed in layers. Estimated blood loss 300-400 cc. The patient was transferred to the intensive care unit for further care. Her urine output at the end of the procedure was about 450 cc. OPERATIVE REPORT SURGEON: C. Donaldson, D.O. PREOPERATIVE DIAGNOSIS: Prolonged hypotension and shock. POSTOPERATIVE DIAGNOSIS: Prolonged hypotension and shock. OPERATION: Swan-Ganz insertion. PROCEDURE: With the patient in a supine position, intubated in the Intensive Care Unit, an area over the left internal jugular was cleansed with Betadine and draped in sterile manner. Following this, a Cordis was introduced into the left internal jugular under sterile technique without complication. The Swan-Ganz was then passed via the Cordis. Initial pulmonary artery pressures were 34/10 with a pulmonary capillary wedge pressure of 5 to 6. The procedure was well-tolerated. There were no complications. LABORATORY REPORT GROSS: The specimen is labeled "placenta". It consists of a mature placenta with attached umbilical cord stump. The placenta measures 19.0 x 17.0 cm in diameter and 2.5 cm in average thickness. The maternal surface appears to be complete. The membranes on the fetal surface of the placenta are smooth and shiny. A few slightly depressed yellowish-white to brown areas, measuring less than 3.0 cm in maximum dimensions are present in the placenta, beneath the fetal surface. The vascular pattern on the fetal surface is unremarkable. The umbilical cord stump is attached in an eccentric location. It measures 36.5 cm in length and 1.5 cm in average diameter. On cut sections, it is seen to have the usua three vessels. There is considerable meconium staining of the fetal membranes. The specimen container also includes a few blood clots. Sections of placenta and umbilical cord are in two cassettes. MICROSCOPIC: The slides carry sections of placenta and umbilical cord. The placenta sections present the pattern of a mature term placenta. The chorionic villi are covered by a single layer of trophoblast and show a well-developed vascular pattern. The trophoblastic buds are small and cytologically uniform. There is no evidence of inflammation, vasculitis or viral inclusions. Occasional scattered foci of hyalinization and calcification are present in the placenta, primarily just beneath the fetal membranes. The fetal membranes are unremarkable, with no evidence of inflammation. The umbilical cord section presents the usual pattern of two arteries and one vein set in a loose myxomatous fibrous connective tissue stroma which shows no evidence of in-flammation. There is no evidence of malignancy. DIAGNOSIS: "Placenta". Term placenta with meconium staining of fetal membranes Rheumatology S: Conrad Davies is seen today on a semi-urgent basis. Over the past five days, he has noted increased pain and swelling of the right knee. He has had no trauma or infectious symptoms. He has recently been restarted on antihypertensive medication Afeditab O: Limited examination shows 1-2+ swelling of the right knee with palpable effusion. There is tenderness with forced flexion. A: 1. Rheumatoid arthritis. 2. Right knee effusion P: Arthrocentesis of the left knee followed by intra-articular corticosteroid injection. The obtained synovial fluid will be sent for studies. S: Andrew Mathias is seen today. He has a longstanding history of rheumatoid arthritis and this has been followed previously by Dr. Carolyn Meyer in Cincinnati. He has been on trials of different disease-modifying agents, including injectable gold, which was not beneficial. Enbrel and Remicade were initially helpful, although not after a period of time. He was on Remicade at a dosage of up to 10 mg per kg every four weeks and did not find it to be helpful at that dosage eventually. He has been maintained on maximal dosage of methotrexate at 25 mg oral weekly and chronic narcotic analgesic agent with OxyContin at 10 mg b.i.d. and Percocet up to 2 tablets daily. Unfortunately, he has an insurance plan that will not cover any disease-modifying agents or OxyContin. He has morning stiffness for up to 1-2 hours. He apparently also has a history of osteopenia and did have a recent bone mineral density test six to seven months ago. He does continue on Fosamax 70 mg weekly and feels that he cannot afford the medication. Past Medical History: Pertinent for hypertension and diabetes mellitus. He was previously on corticosteroids, although not currently. O: Weight: 238 pounds. He is afebrile. Vital signs: BP 114/76. Joint examination shows synovitis involving the proximal interphalangeal, metacarpophalangeal and wrist joints and limitation with wrist flexion. No subcutaneous nodules. Active shoulder and hip range of motion was intact. There was mild swelling of the right knee, although without significant effusion. There was swelling of the ankles and decreased inversion, eversion and subtalar motion. There was swelling of the foot metatarsophalangeal joints. A: 1. Rheumatoid arthritis with active synovitis. 2. Chronic disease modifying therapy as discussed above. 3. Chronic opioid therapy as discussed above. 4. Osteopenic bone disease. P: Because of his poor insurance coverage, we will change the long-acting narcotic analgesic to MS Contin 30 mg. b.i.d. and limit the use of Percocet for breakthrough pain only. He may be a candidate for one of the new research protocols coming up. We will plan a follow-up within the next six to eight weeks. Recent hand x-rays are requested and we will check with the primary care physician’s office regarding the most recent laboratory studies. Addendum: I have reviewed previous records from Dr. Meyer. In addition to what I have mentioned in my history, Mr. Mathias has also been on a previous treatment for rheumatoid arthritis with Imuran and Minocycline. Apparently, he did develop proteinuria with injectable gold. He had nerve conduction studies done in four years ago, which did document carpal tunnel syndrome. He had previous evaluation for what was apparently felt to be severe rheumatoid arthritis involving the shoulders.

This is an introductory exercise to familiarize yourself with the basic forms of root words, but it is not necessary to memorize. The following are prefixes and suffixes that we have found most common in our transcription through the years. Especially noteworthy are those prefixes or suffixes that sound alike, such as "colo" and "chole." It can be confusing when words sound alike on an audio recording. A medical transcripitonist must often be able to distinguish words from context and root terms. (Note: sometimes a prefix or suffix will apply to more than one category). Some prefixes and suffixes can be used more than once, overlap, or differ slightly.There is an insert in your binder that provides an answer key for matching or you can go online to (https://www.msu.edu/~defores1/gre/roots/gre_rts_afx2.htm) or (http://www.awrsd.org/oak/Library/greek_and_latin_root_words.htm). Prefix Definition abdomino abdomen acr extremities, top acu sharp, sudden amni pertaining to embryonic sac arteri artery arthr joint axill armpit broncho pertaining to bronchial carcin cancer chem drug, chemical chir hand chole gallbladder (Note: Often "chole" meaning gallbladder and "colo" meaning colon are confused. Be especially careful to note context when using these prefixes.) chondr cartilage chron time cib meals cis to cut col colon or large intestine cost rib cutane skin duct to lead, carry encephal brain eosin rosy-colored COMMON ANATOMICAL TERMINOLOGY Including Terms Referring to Parts/Divisions of Body There are many more anatomical terms than are listed here. The following are the most commonly used terms in medical dictation. Some definitions can be obtained by context, the sample sentence and root words. If the term is more obscure, recognizing it as a body part is adequate. abdomen/abdominal _______________ _______________________________________________ _______________________________________________ Ex.: The abdomen is soft without masses or tenderness. abductor digiti quinti _______________ _______________________________________________ _______________________________________________ Ex.: Examination demonstrates that he had weakness in three muscles, including abductor pollicis, abductor digiti quinti and opponens digiti minimi. acetabulum _______________ _______________________________________________ _______________________________________________ Ex.: Flattening bony deformity of the left acetabulum and femoral head with associated slight left hip joint space narrowing. Achilles _______________ _______________________________________________ _______________________________________________ Ex.: The Achilles reflexes are symmetrically depressed. LABORATORY & PATHOLOGY electronystagmography _______________ _______________________________________________________________ _______________________________________________________________ Ex.: I believe that further studies to pursue etiologic causes should be undertaken, and to this end, would suggest ENT evaluation with electronystagmography. EMG _______________ _______________________________________________________________ _______________________________________________________________ Ex.: The plan is to consider the patient for EMG, as well as MRI of the spine and abdomen. extracorporeal shock wave lithotripsy (ESWL) _______________ _______________________________________________________________ _______________________________________________________________ Ex.: This patient underwent extra corporeal shock wave lithotripsy for renal lithiasis. FEV1 _______________ _______________________________________________________________ _______________________________________________________________ Ex.: He also had an FEV1 done, which was consistent with some chronic obstructive pulmonary lung disease. five-view (not "5-u" as may be heard on tape) a type of x-ray Ex.: A five-view chest x-ray series was obtained. These same formats are used to teach terminology for each specialty covered in our program. The next few pages will show you some samples of the dictation you will be typing during the program. OB-GYN The patient is a 35-year-old G2 P2 female seen for annual care and pap smear. Her only gyn complaint is several days prior to the onset of menses, she will have premenstrual spotting. She continues on Ortho-Tricyclen without significant problems otherwise. She is seriously considering permanent sterilization to solve the spotting problem. Physical exam: Neck – Supple, thyroid normal. Lung fields – Clear to auscultation. Heart – Normal sinus rhythm without murmurs, rubs or gallops. Breasts – Symmetrical without masses or tenderness. Abdomen – Soft without organs, masses or tenderness. Pelvic exam: External genitalia – Normal female. Vagina – Rugae without discharge. Cervix Parous and unremarkable. Uterus – Retroverted, 90-100 gm, mobile, nontender. Adnexa – Palpably normal. Impression: Normal gyn exam. Plan: Pap smear. SBE encouraged. Ortho-Cyclen x 12 mo. Tubal sterilization and laparoscopy, including procedure risks, indications and failure rate, are discussed with the patient. She will consider and verbally acknowledges risks associated. I discussed the pathology report of adenomatous hyperplasia with Audrey over the telephone. There was no evidence of atypia and at this point in time, we may simply attempt to treat this condition with monthly progestational agents to see if it will reverse the adenomatous hyperplasia. It was stressed to Audrey that she must have follow-up, however, because this can be a precancerous condition and that in six to 12 months, she should have an endometrial sampling repeated. If her heavy bleeding continues or increases, hysterectomy would be a viable option. Audrey will come by the office to pick up a prescription for Provera 10 mg to be taken days 15 to 26 each month. ORTHOPEDICS SOCIAL HISTORY: He is an occasional tobacco user. He does admit to drinking quite heavily and admits to consumption of approximately a 12-pack of beer a day and up to 48 beers per weekend. He states that he is unable to quit and has been to Alcoholics Anonymous and counseling in the past. His last liver check was one year ago. His occupation is an engineer. FAMILY HISTORY: Multiple for diabetes mellitus. REVIEW OF SYSTEMS: Noncontributory. PHYSICAL EXAMINATION: Examination on this date revealed an alert, oriented, white male who is obese, in no apparent distress. HEENT was unremarkable. Heart was regular rate and rhythm S1 greatest at the base. There were no murmurs noted. Lungs were clear to auscultation. Abdomen was soft. Liver approximately 5 cm. beneath the right costal margin and nontender. Extremities are with crepitus and painful range of motion at the right knee. He did have good range of motion of the left knee. Lab analysis on this date revealed elevated glucose at 193, BUN and creatinine .9 and 4 respectively. Alkaline phosphatase is elevated to 130, GGT is markedly elevated at 185, H&H is 17.1 and 50.2 respectively. Due to the initial elevation of the random blood sugar, the patient was referred for a five-hour glucose tolerance test, which was positive. Diagnosis other than the torn medial meniscus include 1) noninsulin dependent diabetes mellitus Type II 2) exogenous obesity, 3) tobacco abuse, 4) alcoholism with alcohol abuse, 5) elevated liver enzymes secondary to #4. RECOMMENDATIONS: I certainly agree with your plan to perform an arthroscopy on this patient. The patient will return to our office to further discuss his medical problems and perhaps a trial of oral hypoglycemics will be instituted, as I don’t feel this patient would be compliant with diet. I have encouraged this patient to obtain further counseling for his alcohol abuse and we will be following his liver enzymes with periodic checks. CARDIOLOGY S: John has noted a recurrence of his preangioplasty chest discomfort occurring at low levels of activity. He is now on Cardizem, 60 p.o. q.i.d. and topical nitrites in addition to his aspirin a day. O: Pulse is 64 and regular. Blood pressure is 130/70. Lungs clear. Heart - atrial gallop. 12- lead EKG is normal. A: Suspected stenosis of previously angioplastied LAD segment. P: 1) Maintain his activity at the low level over the weekend. 2) Continue his medications as above. 3) Call back for any interim questions or problems. 4) Anticipate proceeding with recatheterization and possible angioplasty this upcoming weekend under the auspices of Dr. Smith. S: She had a bit of a nonproductive cough over the last few days. Her rings have been a bit tighter and she was advised to increase her Lasix to 120 mg a day for yesterday and today. She continues on her Capoten 25 mg p.o. t.i.d.; Micro-K 70 mg a day but taking an extra potassium with the extra Lasix per day and Lanoxin 0.25 mg p.o. q.d. in addition to Tamoxifen and Diabinese 250 mg p.o. q.d. O: Pulse is about 94 and regular. Blood pressure 110/60. Lungs are actually fairly clear. Heart demonstrates prominent atrial and ventricular gallops with perhaps a bit of an increase in her friction rub. No distal edema is noted. A: 1) Severe end-stage congestive and probable restrictive cardiomyopathy. 2) Probable mild congestive heart failure. 3) Type II diabetes mellitus. 4) Metastatic breast carcinoma. P: 1) I have advised her to take the 120 mg of Lasix for today and depending on how she feels tomorrow, either resume her usual 40 p.o. b.i.d. of Lasix versus an additional day of 120 mg of Lasix. 2) We will set her up for a follow-up echocardiogram within the next week or so and see her for follow-up on a more or less p.r.n. basis. OPHTHALMOLOGY Pertinent Physical Findings: Reveal visual acuity for distance vision with his present glasses at 20/20 -2 with the right eye and 20/20 –1 in the left eye. The intraocular pressures are 19mm Hg in each eye by applantation, which is within the upper limits of normal. Confrontation of visual fields reveal a peripheral scotoma occupying both the upper and lower quarters of the left visual field in the left eye. This is macula sparing. There is some question about there being a possible lesser scotoma in the left visual field of the right eye. External examination revealed normal findings. The pupils are round and regularly react to light, directly and indirectly to convergence. He is orthophoric. His fixation is good central and maintained bilaterally. Slit lamp exam reveals completion of the sclerotic cataract in the right eye. He has pseudophakia in the left eye. Mydreatic fundoscopy, as well as indirect in the 90 diopter lens examination revealed the retina in both eyes to be intact. There are no holes or tears. These are essentially normal fundoscopic findings. He does have posterior vitreous detachments in both eyes which are within normal limits. Working Impression: 1. Blepharoconjunctivitis left eye. Pseudophakia of the left eye. Cataract to the right eye. Plan: Ordered visual fields be done on the patient both central and peripheral. Have him be seen by Dr. Carter on the following day to confirm whether or not there is truly a visual field loss in one or both eyes. The visual fields as observed by Dr. Carter the following day, reveal the peripheral vision of the right eye was not involved. The left eye showed field changes which were more typically that of glaucoma and upon reviewing the history of this patient, he was worked up for possible glaucoma and seen by a glaucoma specialist, Dr. O’Neal. Dr. Carter accordingly referred back to Dr. O’Neal for a re-evaluation regarding glaucoma. The one concern I have, if the patient is really having a loss of temporal vision that is macula sparing in the left eye, which apparently was transient, then the patient needs an evaluation of his cartoid arteries, since that could possibly cause a transient visual field loss NEUROLOGY Dear Pamela: Your patient, Faye Keller, returned to my office yesterday. She has improved in the interim since her last visit. Her leg strength is improving. She is no longer requiring a cane and she is walking stably. Iliopsoas strength is between 5- and 5 bilaterally (probably a little less on the left than on the right). She says that she’s had some shadows in her vision, but no true diplopia. I can’t find specific extraocular muscle problem on her exam today. She is also complaining of some fatigue and discomfort, but she says that her medications partially mitigate these problems. PLAN: Continue Copaxone. Continue Neurontin 900 mg per day in divided dosage. Continue amantadine 100 mg TID. Request once monthly IV methylprednisolone infusion, until the effect of Copaxone can independently be protected as an immuno-modulating agent. Return visit in December, or sooner, if problems arise in the interim. Sincerely, RADIOLOGY RADIOGRAPHIC REPORT AP PELVIS, LATERAL RIGHT HIP: 10/29. Compared with 10/20. Left hip prosthesis again noted in place, showing no obvious interval change in position or bony alignment. Small amount of heterotopic soft tissue calcifications surrounding the greater trochanter of the proximal left femur. Osteoporosis and degenerative changes, as well as atherosclerotic vascular calcifications. Code: Signature RADIOGRAPHIC REPORT PORTABLE CHEST: Heart and mediastinum are normal to position. Two left chest tubes are seen in place. There is a small left pleural effusion and minimal linear atelectasis at the left base. A small left apical pneumothorax is seen. The pneumothorax is slightly smaller than on the previous exam of 07/09. Code: Signature RHEUMATOLOGY S: Phyllis Bevins has continued to experience multiple symptoms including malaise, fatigue, as well as chest pain and exertional dyspnea and chronic back pain. She has chronic headaches. She is on no specific medication. She has had a longstanding history of chest pain and shortness of breath dating back to 1999. I did review all of her records that she brought in which showed, as we had obtained from her history previously, negative cardiology and pulmonary evaluations. O: Temp 99.6 F, BP 128/70. Weight 152 pounds. We did review extensive laboratory studies done through our office. CBC, ESR and chemistry profiles were all normal. C-reactive protein was normal. TSH normal. Cryoglobulins were negative as were ANCA studies. Urinalysis showed no protein or casts. Rheumatoid factor was negative. ANA was 1:320 homogeneous pattern; however, all autoantibody studies were negative and complement levels were normal. CPK normal. A: ANA seropositivity without evidence clinically of connective tissue disease, inflammatory arthritis or other autoimmune illness. P: Observation only at this time. We will follow up more on an as-needed basis should she develop additional signs, symptoms or laboratory findings of connective tissue disease or autoimmune illness. S: Belinda Stanford is seen today. She is unchanged with regard to the symptoms in her knees. She also describes a more diffuse musculoskeletal pain and states that she has been diagnosed previously with “fibromyalgia.” Her current medications include Celexa, Mobic 15 mg daily and temazepam. O: The MRI of the knees shows a process that seems most consistent with osteoarthritis. A: Generalized osteoarthritis. Osteoarthritis of the knees. Secondary fibromyalgia syndrome. P: Continue the current treatment program. We will also add a trial of supplemental analgesia with tramadol. We have discussed a trial of intra-articular hyaluronate injections to the knees, although the osteoarthritis does appear to be somewhat severe, especially involving the right knee.