OPTHALMOLOGY TEST FILES

OPTHALMO_T1

Ophthalmology

HISTORY AND PHYSICAL EXAMINATION

PREOPERATIVE DIAGNOSES

1.  Cataract of left eye.

2.  Pseudophakia of the right eye.

3.  Dermatomyositis.

4.  Rheumatoid arthritis.

HISTORY OF PRESENT ILLNESS:  Patient is a 71-year-old woman who had an uncomplicated cataract extraction with lens implant of the right eye and had a good improvement in her visual function.  She is also bothered by blurred vision from a cataract in the left eye and enters for a similar procedure on the left eye.  She has had dry eyes and uses artificial tears frequently.  She has had ectropion repair of the right lower lid.  She has had dermatomyositis and rheumatoid arthritis for many years and has used cortisone for this.

She is presently taking Persantine twice daily and Inderal 40 mg twice daily.  She is allergic to penicillin, aspirin, codeine, and does not tolerate Tylenol because of constipation.

PHYSICAL FINDINGS

VITAL SIGNS:  Blood pressure 110/80, pulse 76 and regular.

HEENT:  Recent eye examination showed best vision of 20/50+ in the right eye and 20/200 in the left.  Pupils and extraocular motility were normal.

Intraocular pressures were 18.  Slit-lamp examination showed the eyelids in good position with weakness of the orbicularis and facial muscles.  There was a clear corneal epithelium and the normal pseudophakia of the right eye and a dense nuclear cataract on the left.  Fundus examination in each eye was normal.

Tympanic membranes are normal.

The oral cavity showed dentures in place.  The pharynx had no lesions.  The neck showed a slight right carotid bruit, and the left was normal.

CHEST:  The chest was clear to auscultation.

HEART:  Heart had a regular sinus rhythm without murmur.

EXTREMITIES:  Extremities showed ulnar deviations of the hands and mild ecchymoses in the legs.

PLAN:  Plan is a cataract extraction with lens implant of the left eye under local anesthetic as an outpatient.  The risks of the procedure, including possible loss of the eye, were discussed.

OPTHALMO_T2

Ophthalmology

DISCHARGE SUMMARY

HISTORY OF THE PRESENT ILLNESS:  The patient is 85-year-old white male who underwent scleral buckling of the left eye for retinal detachment in December and again in February.  A second scleral buckling operation was complicated by subretinal hemorrhage at the time of release of subretinal fluid.  The subretinal hemorrhage reabsorbed.  The patient did well until 2 weeks prior to admission, when he noted he could not see from the left eye.

Examination showed recurrence of the retinal detachment with an open retinal break at about the 5:30 position.

PAST OCULAR HISTORY:  The left eye underwent cataract extraction with placement of an iris-fixated lens in the past.  The patient has had corneal edema of the left eye, more pronounced after each scleral buckling procedure.  He uses topical sodium chloride agents for the corneal edema.  The history of the right eye is that there is age-related macular degeneration.

PAST MEDICAL HISTORY:  The patient has non-Hodgkin lymphoma, currently in remission.  He has had splenectomy.  He has had a tonsillar carcinoma treated surgically and with radiotherapy.  There is mild hypertension.

Current medications include allopurinol 300 mg daily, Tagamet 400 mg q.h.s., multivitamins daily, vitamin C, and the previously described topical agents for the left eye.

PHYSICAL EXAMINATION:  Vision 20/60 in the right eye and the detection of hand motion in the left eye.

Intraocular pressure was normal in each eye.

Examination of the right eye showed mild lens changes and macular scar.  Examination of the left eye showed ptosis of the upper lid and malpositioning of the lower lid.  There was evidence of previous ocular surgery.  Slit-lamp examination showed aphakia with an iris-fixated lens.  There was corneal edema and thickening present.  Fundus examination showed total retinal detachment with the evidence of a previously placed scleral buckle from about 2 to 10 o’clock, reinforced with a radial sponge at 5 o’clock, and an open retinal break at about 5:30.

LABORATORY DATA:  CBC:  There was mild elevation of the white blood count and slight reduction of the red count.  There was also reduced hemoglobin and hematocrit.  Urinalysis was negative.  Blood chemistries, including electrolytes, glucose, and BUN, were normal.  Chest x-ray showed mild changes consistent with obstructive pulmonary disease but no acute changes.  ECG showed right ventricular conduction defect and a left axis deviation.

HOSPITAL COURSE:  Under general anesthesia, the scleral buckle was revised by removing the radial element at about 5 o’clock and replacing it with a trimmed #507 implant placed circumferentially.  This resulted reinforcement of the buckle from about 4:30 to 6 o’clock, closing the retinal break.  A vitrectomy was also performed through the pars plana.  A gas-fluid exchange was performed, first using air, intravitreal and subretinal cannulated fluid extrusion.  A 30% mixture of expansile gas was then placed in the vitreous cavity.  A previously placed #276 silicone implant and #40 band were left in situ.  The buckle extended from 2 to 10 o’clock.

Postoperatively, the retina was reattached, and the patient was discharged from the hospital to be followed as an outpatient.  Discharge medications included a cycloplegic agent and topical antibiotics with sodium chloride to the left eye.

FINAL DIAGNOSES

1.  Retinal detachment, left eye.

2.  Pseduophakia, left eye.

3.  Corneal edema, left eye.

4.  Macular degeneration, right eye.

OPERATION:  Revision of scleral buckle, vitrectomy, air-gas-fluid exchange.

OPTHALMO_T3

Ophthalmology

HISTORY AND PHYSICAL EXAMINATION

DIAGNOSES

1.  Cataract of left eye.

2.  Pseudophakia of the right eye.

3.  Hypertension.

HISTORY OF THE PRESENT ILLNESS:  Patient is a 67-year-old woman who had an uncomplicated cataract extraction with lens implant of the right eye and had a good visual result.  She is bothered by blurred vision from a cataract on the left eye and desires an improvement in vision.  She added this cataract distraction for lens implant of the left eye.  She enters for cataract extraction with lens implant of the left eye.  She has had a mild amblyopia, although had best correctable vision of 20/40.

PAST HISTORY:  She is being treated for hypertension.  She takes Aldoril and, in addition, started Lasix 40 mg daily.  She takes Tagamet for ulcer disease.  She has arthritis, requires infrequent Kenalog injections, and thyroid 0.3 mg daily.  Prior surgery includes an appendectomy, tubal ligation, cholecystectomy, and a fusion procedure on the right hand.  She has many allergies, including pencillin, Keflex, iodine ,IVP dyes, Betadine, aspirin, and nonsteroidal analgesics.

REVIEW OF SYSTEMS:  Review of systems revealed a history of easy bruising but no bleeding.  No reactions to anesthetics.

Cardiopulmonary:  No shortness of breath, asthma, or angina.  Gastrointestinal Review:  Normal bowel habits.  Genitourinary:  No dysuria.

PHYSICAL FINDINGS

VITAL SIGNS:  Blood pressure 180/95, pulse 80 and regular.

EYES:  Recent eye examination showed best vision of 20/25 in the right eye and 20/80 minus in the left.  Pupils and extraocular motility and visual field by confrontation are normal.

Slit-lamp exam of the right eye showed a normal pseudophakia, and the left eye had a normal cornea and endothelium, and there was a dense nuclear and central posterior subcapsular cataract.  Intraocular pressure was 15 in the right eye and 17 in the left, and dilated fundus examination in each eye was normal.

EARS, NOSE, AND THROAT:  Tympanic membranes were normal.  The oral cavity should dentures in place, and the pharynx had no lesions.

NECK:  The neck had normal carotids without bruits.

CHEST:  Chest was clear to auscultation.

HEART:  Heart had a regular sinus rhythm without murmur.

PLAN:  Plan is a cataract extraction with lens implant of the left eye under local anesthetic as an outpatient.  She understands the major risks, such as loss of the eye, and that an implant may not be done because of surgical problem.

OB-GYN TEST FILES

OB-GYN_T1

OB-GYN CHART NOTE

SUBJECTIVE:  This is a 19-year-old single white female college student who is seen with reference to vulvar pain and urinary burning of 2 to 2-1/2 days’ duration.  She denies any prior GU infections.  She is sexually active with multiple partners but seldom uses condoms.  She is on oral contraceptive.  Gravida 0.  LMP about 2 weeks ago.  She noted onset of vulvar itching and burning on Monday afternoon associated with pain on voiding.  This has become steadily worse to the point where she can now hardly void at all.  She thinks she may have had some fever last night.  She has noted slight increase in vaginal discharge.  She has had no urinary frequency, no blood in the urine, no flank pain, chills, nausea, but she has been anorexic.  Some headaches in the past 24 hours.  She is on no medicine except Demulen, and Advil for her pain, which is not helping.

OBJECTIVE:  This is a very distraught young lady.  She is tearful and obviously in considerable physical and mental distress.  Temperature is 99.8, pulse 100, blood pressure 132/78.  Her skin is pale, warm, and dry.  Examination limited to the genitourinary system reveals a cluster of shallow, discrete ulcers on the left labium minus, and these are surrounded by an angry erythema, and their bases are covered with a shaggy, grayish exudate.  There is generalized edema and erythema of the vulva.  There is a moderate amount of excessive secretion at the introitus, nonspecific in character.  Several tender lymph nodes are palpable in both groins.  Bimanual examination is deferred because of the severity of the patient’s symptoms at this time.  However, abdominal examination shows no bladder distention.  Scrapings are taken from 2 ulcers with a #15 blade and smeared and stained immediately by the Tzanck technique with toluidine O.  Examination of the smear shows giant cell formation typical of viral infection.

ASSESSMENT:  Herpes simplex virus infection, left labium minus, type II, probably primary.

PLAN

1.  The diagnosis and its implication were fully discussed with the patient, in association with a female counselor, and she was given printed literature to take with her.  She was advised that she is presently infectious and must abstain from sexual contact until she is well.  She was advised that recurrences are not invariable and that she may not have any.  She was advised that should she have a recurrence, she will again be infectious, but that recurrences are typically milder than the primary infection. She was advised that she has an increased risk of cervical dysplasia and neoplasia and needs annual Pap smears from here on out.  She was advised that should she have a recurrence near term of pregnancy, she would need cesarean section.  She was advised to inform any prospective marriage partner of her diagnosis.  Though obviously upset, she verbalized comprehension of these instructions.  She was given some further counseling by the counselor after I left the room and will be seen in follow-up by them and as well as by me on a p.r.n. basis.

2.  Zovirax 200 mg p.o. q.4h. for 5 doses a day x 10 days.

3.  Tylenol No. 3 one or 2 tabs q.4-6h. p.r.n. for pain.

4.  Zinc oxide ointment to be applied to the lesions as often as needed to prevent urinary burning, protecting the finger with a finger cot or condom.

5.  She is to watch bladder function and to call the clinic day or night if she cannot void.

6.  She will be scheduled back here in 1 to 2 weeks for pelvic examination, Pap smear, and STD screen, including Thayer-Martin, Chlamydia slide test, and a wet mount for Candida, Gardnerella, and Trichomonas.

OB-GYN_T2

OB-GYN CHART NOTE

The verbal report of the cervical biopsies was positive for large-cell carcinoma with both deep margins positive.  Will arrange to have all slides sent to the office, and they can either be sent or hand carried.  Have asked her to schedule an abdominopelvic CT scan and also a chest x-ray and mammogram.

Will need to be able to take all these films with her for her referral appointment.  If she has any questions, she has to call.

CHART NOTE

Comes in today for annual examination.  Her son is a little over a year old and doing well.  She usually has a menstrual period about every month, has totally missed 1; menses do tend at times to be somewhat irregular.  She is late for her current period but feels as if she is going to get one soon.  She has no intermenstrual bleeding.  This is the same pattern as menses were prior to becoming pregnant the first time.

First pregnancy was complicated by preeclampsia, Pitocin induction of labor at 37-1/2 weeks.  Her son weighed 6 pounds 8 ounces and did well.  Blood pressure was persistently elevated postpartum, and at 6-week examination was 150/86.  For this reason she did not use oral contraceptive pills but has used foam and condoms for contraception.  She would like to become pregnant again.  I have told her that it is not likely that she will have preeclampsia again, but she may have some problems with hypertension.

EXAMINATION:  Breasts without masses or nipple discharge.  Abdomen soft and nontender without masses or organomegaly.  Pelvic examination reveals external genitalia are normal.  Vagina rugous.  Cervix clean.  Uterus is of normal size, shape, and consistency.  Adnexa clear, nontender.  Rectovaginal examination confirms.

Pap smear was obtained.

ASSESSMENT:  Normal examination, considering another pregnancy.

PLAN:  Follow up in a year or sooner if pregnant.

CHART NOTE

Comes in today for annual examination.  Menses are regular without intermenstrual bleeding.  Her galactorrhea is unchanged.  She continues to take bromocriptine 2.5 mg p.o. b.i.d.  She takes chlorthalidone 50 mg daily and also daily potassium supplement.  When seen a year ago, she felt fatigued.  Blood work at that time showed her to be hypokalemic.  She resumed a potassium supplement at that time, and felt much better.  She has no headaches.  She had some vaginal itching and discharge off and on during the summer but currently does not have any.  She has never had a mammogram.

EXAMINATION:  Breasts without masses.  There is bilateral galactorrhea.  There was no axillary adenopathy.  Abdomen soft and nontender.  Pelvic examination reveals external genitalia are normal.  Vagina rugous with small amount of yellow discharge.  Cervix clean.  Uterus is anterior, mobile, nontender; normal size, shape, and consistency.  Adnexa clear, nontender.  Rectovaginal examination confirms.

Pap smear is obtained.

Wet smear is unremarkable.

ASSESSMENT

1.  Long history of galactorrhea.  Prolactins have been well controlled on Parlodel, as have her menses.

2.  Has taken chlorthalidone daily for many years.  This is for fluid retention.

PLAN

1.  Parlodel 2.5 mg p.o. b.i.d. is renewed for a year.

2.  Chlorthalidone 50 mg daily and potassium supplement 1 daily is renewed.

3.  Serum prolactin and serum potassium levels are obtained.

CHART NOTE

Comes in today for annual examination.  On hormone replacement therapy consisting of Premarin 0.625 mg days 1 through 25, and Provera 10 mg days 16 through 25.  She has regular withdrawal bleeds, which are not heavy, and has no bleeding or spotting at any other time.

EXAMINATION:  Breasts without masses or nipple discharge.  Abdomen soft and nontender without masses or organomegaly.  Pelvic examination reveals external genitalia are normal.  Vagina rugous.  Cervix clean.  Uterus is normal size, shape, and consistency, slightly deviated to the left.  Adnexa clear, nontender.  Rectovaginal examination confirms.

PLAN:  Have offered to change her to continuous Premarin and Provera, but she is satisfied with her current regimen, and will continue with it as described above.  Follow-up will be in a year.

NEUROLOGY TEST FILES

NEURO_T1

Neurology

CONSULTATION

CHIEF COMPLAINT:  Left hemiparesis.

PERTINENT HISTORY:  Apparently, this patient has an extensive past history of alcohol abuse but claims that he abruptly discontinued alcohol intake approximately 12 years ago.  He had the acute onset of left hemiparesis.  Currently, this problem has apparently been quite responsive to rehabilitation, with the patient’s primary physical residual being upper extremity weakness.  Patient reports that he is within normal limits in terms of his gait ability at the present time.

The patient’s neurorehabilitation program has apparently been successful as planned.  A psychological consult was requested in order to assist in discharge planning issues--particularly in identifying the patient’s ability to return to his employer.

OBSERVATIONS AND TEST DATA:  The patient was interviewed and examined on an exercise mat within the physical therapy area.  The environment was relatively distracting for the patient.  He was in mild discomfort, claiming that his “back hurt”.  Otherwise, the patient appeared to be alert and was able to articulate his recent and past history for me in a fairly coherent fashion.

The patient’s speech is marked by some slurring as he speaks more quickly.  There is also a flat quality (monotone quality) to his speech.  Content of his speech is appropriate.  No evidence of tangential or circumlocutory speech was displayed.

The patient was able to count backwards from 20, albeit his performance was very slow.  The patient was able to recite the alphabet without difficulty—-again, slowly.  His recollection for long-term history and events was unimpaired.  Short-term memory was impaired.  Patient was able to recall 1 object of 3 in 3 minutes.

Patient’s recall of the past 5 presidents was excellent.  His orientation was x 4.

The patient’s insight and judgment appear to be poor.  He offered little insight into the need for careful review of his mental status prior to returning to work, claiming that since he had a chauffeur, there would be no difficulty.  He also claimed that since he was in management, there would be no difficulty, failing to recognize that a management position of the sort that he described would require excellent mental status.  It is difficult to determine whether the patient’s poor judgment and insight represent some preexisting or premorbid tendency.  Obviously, further evaluation would be necessary.

CONCLUSIONS AND IMPRESSION:  To conclude, this 62-year-old victim of CVA (cerebrovascular accident) with resulting left hemiparesis was recently evaluated.  On mental status evaluation, reduced insight and judgment and short-term memory were displayed.  Some evidence of articulation difficulty in speech was also displayed.  For example, in 45 seconds the patient was able to produce only 5 words starting with the letter “f”.  A normal result for an individual of his age would be approximately 15 words.  At the present time, it is recommended that further formal psychometric testing is indicated.  We will try to complete as much testing as possible tomorrow in the a.m. prior to the patient’s discharge.  Whatever remaining assessment needs to be conducted would be arranged on an outpatient basis.

Thank you for this referral.  As always, please contact me if I might be further assistance.

MUSCULOSKELETAL TEST FILES

ORTHO_T1

PREOPERATIVE DIAGNOSIS:  Failed total hip, right.

POSTOPERATIVE DIAGNOSIS:  Failed total hip, right.

OPERATION PERFORMED:  Revision total hip, right.

GROSS FINDINGS:  The patient has had a failed total hip, manifested by migration of the cement as well as the prosthesiss distally and accompanied by considerable amounts of pain.

PROCEDURE:  Preceded by Betadine soak and a Betadine scrub, Monocid, and isolated with U drapes, a straight lateral incision was made and carried down to the femur.  A small fragment of the greater trochanter was identified to have been reattached by a fibrous union.

The gluteus medius and minimus were detached anteriorly, and the gluteus maximus was reflected posteriorly.  The fascia lata was divided to accomplish this move.

The capsule was then excised sufficiently to identify the head, which was readily dislocated.

The subjacent area of the femoral neck was debrided, and then using an impactor, the head was tapped, and the prosthesis, a Zimaloy prosthesis, was removed with no accompanying cement.  Then the shaft, which was covered with a fibrous material outside the cement (that is, there was the prosthesis, the fibrous material, the cement, and then more fibrous material), was identified, and essentially the total amount of the cement was removed.

Then it was necessary to ream the distal fragment. This was accomplished by inserting a drill down the center of the Synthes wire guide utilizing it as a centering device, and the distal plug was reamed.  Then a guide wire for the flexible reamers was inserted, then using serial reamers up to 14, the shaft was minimally enlarged at the isthmus, and the cement at the plug was all removed.  Copious amounts of antibiotic irrigation were utilized during the course of the procedure.

When this had been accomplished, the trials were used to ream the proximal end.  A 14 could not be inserted far enough distally, and a 12 was ultimately decided upon.

Two packages of freeze-dried bone were ground up together with some chips, and were inserted into the shaft prior to and at the time of the insertion of the permanent stem.

Initially a minus 5 stem was used and it was felt to be too short.  It was removed, and a neutral neck was utilized.

With the neutral neck and debridement of the acetabular base, the reduction was accomplished with the skid with some difficulty but provided a very substantial fit.

A drill was then made in the greater trochanter, and the loose fragment of bone together with the gluteus minimus and medius was reattached.

Tevedek #1 was used for this purpose.  Then #1 Vicryl was used to reapproximate the heavier fascial and muscular structures.  A Jackson-Pratt was inserted.

The balance of the closure was accomplished with 2-0.  Ultimately skin clips were used on the skin. Blood loss was estimated to be 800 CC.

The patient received 1 unit of blood during the procedure.

The patient received an additional gram of Ancef during the course of the procedure.

ORTHO_T2

Orthopedics

OPERATIVE REPORT

PREOPERATIVE DIAGNOSES

1.  Loose body, right shoulder.

2.  Recurrent anterior dislocation.

POSTOPERATIVE DIAGNOSES

1.  Loose body.

2.  Recurrent anterior-inferior dislocations.

PROCEDURES

1.  Arthroscopic debridement.

2.  Bankart shoulder repair.

INDICATIONS:  An 18-year-old recently seen and examined under an anesthetic, with some presumed posterior instability.  Because of the uncertainty at the time of surgery, she was rescheduled for x-ray studies before an open procedure.  She is now brought to the operating room for a diagnostic arthroscopy and debridement followed by an arthrotomy.

OPERATIVE FINDINGS:  Under arthroscopic examination, the patient was found to have a rather large loose body that appeared to be attached at the inferior lip of the glenoid.  This was an obvious source of the impingement.  The biceps tendon was inspected and was normal.  The patient had some degenerative changes of her labrum which were debrided at the time of arthroscopy.  She had a Bankart lesion that was noted at approximately 5 o’clock.  At the time of her open procedure, the patient was found to have similar findings, with the loose body being removed and the Bankart lesion reattached utilizing a single stitch.

PROCEDURE:  After obtaining informed consent, the patient was taken to the operating room where she was given an inhalant anesthetic.  She was placed in the lateral decubitus position with the right arm draped free, utilizing approximately 15 pounds of skin traction.  A posterior portal was used for the introduction of the scope, with an anterior portal being used for triangulation, as well as the shaver.  The 25-degree scope was introduced into the shoulder for diagnostic arthroscopy.  The patient’s rotator cuff was seen and was normal.  The patient was noted to have a large, approximately 2 X 2 cm defect about the posterolateral aspect of her humerus.  This was beyond the bare area and involved a portion of the articular surface of the humerus.  The patient’s glenoid was inspected carefully and was normal.  The scope was then removed, with a reprep and drape in the beach chair position.  The right arm was draped free.

A midaxillary line incision was utilized as the operative approach.  The skin folds were used to ensure cosmetic appearance.  The dissection was carried down deep to the skin and subcutaneous tissues between the deltopectoral interval.  The cephalic vein was retracted laterally, which allowed visualization of the clavipectoral fascia.  This was divided, followed by a detachment of the subscapularis approximately 1.5 cm lateral to its attachment.  Tag stitches were inserted prior to its medial displacement.  A humeral head retractor was then inserted which allowed visualization of the underlying articular surface.  This had to be removed to remove the large loose body which was attached to the inferior lip.  The wound was irrigated with saline, followed by identification of the Bankart lesion.  The lesion was approximately a centimeter and located at about 5 o’clock on the glenoid rim.  A drill hole was made along the articular surface, followed by a reattachment of the glenoid labrum after roughening the outer surface.  It was apparent that the loose body had attached to this portion of the glenoid.  The wound was then irrigated followed by a meticulous repair of the subacapularis muscle utilizing the same suture, i.e., #2 Tevdek.  The wound was irrigated further, followed by an approximation of the deltopectoral interval as well as a layered closure usint 1-0 and 1-0 Vicryl and an intracuticular stitch for the skin.  Steri-Strips and a small Hemovac drain were both applied, with the patient being placed in a sling and transferred to the recovery room stable condition.  She tolerated the procedure well, and there were no intra-operative complications.

LOM TEST FILES

INTRO_T1

Dear Medical Transcription Student:

Welcome to the exciting and vitally important career of medical transcription.  I hope that you will maintain an eager interest and excitement about your course of study.  Soon, you will begin to experience the fascination and appreciation for medicine that working medical transcriptionists have come to enjoy.  Because medicine is ever changing and because people and their problems are never boring, I can assure you that you will be always learning and interested in your work.

Medical transcription is both an exacting science and an artistic accomplishment.  It is important to have a combination of skills including spelling, proofreading, knowledge of medical terminology, and typing; and a firm background in English grammar, structure, and style.  The successful medical transcriptionist has both accuracy and speed; a broad knowledge of anatomy; and a thorough knowledge of medical, surgical, drug, and laboratory terms.  In addition, it is important to know how to use standard medical and nonmedical reference materials.

An exciting career as a medical transcriptionist awaits you. I wish you the best for the future.

Sincerely,

INTRO_T2

CRITICISM

Criticism first became a subject for conversation in my life about 21 years ago when I went to work for a prominent thoracic and cardiovascular surgeon.  During the course of the interview, he asked me if I were able to take criticism gracefully.  Well, I was stumped.  No one had ever asked before.  They had just handed it out, and I really did not know how gracefully I had accepted what I had had so far.  It depended on who was dishing it out, I guess.  I thought about my response, worrying that my prospective job somehow hinged on what I had to say one way or the other.  I felt he would have liked for me to say something like “Oh, I love criticism,” or even “I never need it!”  Evidently I gave the right answer, however (he did hire me), when I replied, “Well, I guess we’ll have to find out, won’t we?”  This answer implied to him that he would hire me, and that we would both see how his criticism and my acceptance of it went along.

But I was now on the alert.  I was forewarned that criticism was, in fact, a big possibility, and I worked very hard against the day when “we” would find out how gracefully I could accept it.

I really did not know where it would come from.  There were a lot of possibilities; the day seemed fraught with them.

That was just the first day.

By the second day, I found out.  That was the day my first transcripts were returned.  Large permanent blue-black ink circles covered the many carefully prepared documents.  It was hard to be graceful when I looked at the ruination of a half-day’s labors (actually, half a night, too, as I had spent long hours at home researching unfamiliar words).

We had weeks of that, and I was getting discouraged; still graceful, I presume, but discouraged.  The errors were becoming fewer and fewer, but that did not seem to help much, since I wanted them to disappear.  It was harder and harder to face upto them somehow.  Now that I was feeling more secure in the job, grace was wearing thin.  He never said anything.  I never said anything.  I just retyped.  A lot.

Now 2 things happened.  The surgeon’s wife came into the office on Saturday morning when he proofread and busily marked up my work.  She watched, appalled.  Monday morning shortly after I arrived for work, she called “to see how you’re taking it.”  “Fine,” I said.  She was relieved and reported that she had talked to him about it, feeling that he had been too harsh.  “Well, she won’t learn if I don’t teach her, and she’s worth teaching.”  I learned about grace that day.  He took his precious time to teach and to help me.  He had a BS in journalism and knew his Greek and Latin roots to a fine degree as well.  I was pretty much humbled by his constant criticism, his love of perfection, and his belief in my potential for growth.

All of our lives we are both subjected to and the dispensers of criticism.  If we can remember to accept it with the spirit in which it is given, realizing it took some time to critique our performance, and that it was done because of our ultimate potential, we then must accept it not only with grace but with thanks.  Secondly, we must try to remember to give our criticism only with graciousness, knowing that we can help someone in whom we see the potential for personal or professional betterment, and not criticize to showcase our own skills.  If we cannot criticize fairly, with love, and in private, then we need to withhold it.

This is a lifelong relationship, us and criticism.  We never should feel we have outgrown the need.  If we protect ourselves by not doing anything new anymore, sticking to only what we do perfectly, then we will no longer grow in grace and wisdom.

GASTRO TEST FILES

GASTRO_T1

Gastroenterology

LETTER

Date

Name

Address

City, State, Zip

Re:

Dear Bob:

This is a follow-up letter to our brief discussion.  As a background, she has had 20 years of “nervous stomach,” describing abdominal discomfort with certain foods and stress.  She would get relief intermittently with Donnatal, Di-Gel, and Maalox.  Additionally, she has been taking 8 Excerdrin per day for approximately 20 years.

More recently for her shoulder problem, she was treated with prednisone, Naprosyn, Flexeril, and Excedrin with codeine, Tylenol No: 3 Percodan, having been off all prednisone and Naprosyn for approximately 4 weeks.  However, despite being off those medications, she still describes some “indigestion,” described as a midepigastric discomfort associated with mild nausea.  This discomfort is worse with food and with tight clothes.  She describes loss of appetite and basically being afraid to eat anything.  She has no visible bloating, vomiting, acid regurgitation, nocturnal symptoms, or dysphagia.  She does describe some improvement in the symptoms with soda crackers, creme de menthe, and liquid Maalox, as well as belching.  She continues to take 8 Excedrin per day.

Her physical examination was remarkable for findings of a right pleural effusion, and her stool was Hemoccult positive.

In view of her many years of dyspeptic symptoms, her recent multiple drug ingestion, as well as the continued aspirin intake, one has to presume that her midepigastric discomfort and nausea are due to these multiple medications and the continued use of aspirin.  In view of this likelihood, it would seem most reasonable to treat her presumptively with Tagamet as well as taking her off regular aspirin and placing her on Ectorin (the enteric-coated aspirin), which seems to have less gastroduodenal effects.  To this end we started her on Ecotrin, Tagamet, and should she have no improvement in her symptoms over the next several weeks, then endoscopy is recommended to evaluate the source of her pain.

Thank you, Bob, for asking me to see me this patient, and should she have no improvement, I will keep you informed of the results of her endoscopy.

Sincerely,

Name.

GASTRO_T2

Gastroentrology

CONSULTATION

PRESENT ILLNESS:  She is admitted to the hospital because of vomiting and epigastric discomfort for 1 or 2 days prior to admission.  At the time of admission, x-rays of the abdomen showed small bowel air-fluid levels and 1 dilated loop of small bowel.  A Gastrografin study was subsequently done, which showed no obstruction, transit through the small bowel in 45 minutes, with contrast material reaching the colon 45-minutes.  No dilated loops were observed at the time of Gastrografin studies were done.  Today she is much better, has no pain or obstruction or distention in the abdomen.  She has had previous abdominal surgeries including cholecystectomy and uterine suspension.  Other details of the history will be documented by the attending physician.

EXAMINATION:  A brief examination is done, shows that she has a pacemaker, and the heart is regular at about 70 per minute.  She does have a high-pitched systolic murmur at the apex of the heart suggestive of mitral insufficiency.  Breath sounds are good, lungs are clear.  The abdomen is slightly rounded.  The abdomen is soft, no enlarged organs or masses are palpated, and there is no tenderness.  Careful listening to the abdomen fails to disclose any bruit.  A brief neurological examination shows that the pupils are equal and react light, and extraocular muscles are normal. 

Grip strength is normal and equal.  Finger-to-nose test and heel-to-shin test are normal.

Knee jerks are normal.

The question at this point is to try to determine a cause for her presenting symptoms.  I should note that she has had similar symptoms on several occasions in the past, and also has a history of having had a stroke before as well as other medical conditions for which she is being treated.

DIFFERENTIAL DIAGNOSES:  Differential of diagnoses must include

1.  Ileus due to compression fracture of spine.  She had a compression fracture involving T8 and T12.  At the present time she is not complaining of any back pain.  However, compression fracture is a good cause of ileus.

2.  Ileus due to obstructive colon lesion.  This is possible.  It would have to be an intermittent obstruction in her case.  If there were a type of partial obstruction of the colon so that there was intermittent backup into the small intestine, there is a possibility that such a picture could occur.  A barium enema would be helpful.

3.  Ileus due to ischemia.  She is in the right age group for mesenteric ischemia.  I did question her closely as to the possibility of pain after meals and particularly pain after large meals.  She denies having any pain.  If this is a consideration, mesenteric angiography would be helpful, but abdominal angina is not a common condition.

4.  Ileus due to a stroke, TIA (transient ischemic attack), or other CNS (central nervous system) event.

I could not find a neurological deficit on my examination today.  However, the fact that she has had a stroke in the past makes this a possibility.  A CT (computed tomography) head scan might be helpful.

5.  Pseudo-obstruction due to diabetes, thyroid, or parathyroid lesion.  She quite obviously does not have familial Pseudo-obstruction, as she has not had these symptoms from the childhood.  However, she does have maturity-onset diabetes.  The transit time through the small bowel was not slowed, which lessons the likelihood that this is the explanation for these symptoms.  However, it is worth a consideration, and I believe that getting a thyroid panel would be helpful and to recheck the serum ionized calcium.  Her present calcium level at 8.9 is normal, but her albumin is quite low at 2.4, which means that her ionized calcium might be high.

6.  Pseudo-obstruction due to drugs.  She is taking very few medications.  Lomotil is on order for her, but she and the nursing home personnel deny that she had any diarrhea or had any need for Lomtil during the days prior to this event.

7.  Pseudo-obstruction due to collagen disease, amyloidosis, or other such chronic disease.  Other signs of these diseases are not present.  These are unlikely.

COMMENT:  I am suggesting that this patient have a barium enema as soon as it is feasible for her to do so.  I am also getting an order for a thyroid panel and serum ionized calcium.  Other tests as suggested above will depend more upon how the clinical picture develops in the future.

ENT TEST FILES

ENT_T1

CHART NOTE

The patient comes in stating he has some irritation in his right ear.  He does wear an ITE (in-the-ear) aid on that side.  He also has what he terms a smell hallucination in that there is kind of a musty smell in his nose when he inhales and exhales.  He has been using some Ocean and spray from time to time.

PHYSICAL EXAMINATION

Examination of the ears reveal that in the right ear, external canal is slightly irritated at the outer third, but the inner two-thirds is okay.  Tympanic membrane is intact and not inflamed.  Left ear is clear.  There is no cerumen in either side.  Examination to the nose reveals the airway is quite adequate.  Septum slightly deviated to the right.  No evidence of polyps or abnormal discharge.  Throat reveals normal mucous membrane.  No evidence of inflammation.  Neck reveals no adenopathy.

IMPRESSION:  Mild right external otitis.

DISPOSITION:  Recommended the 0.5% hydrocortisone cream in the outer ear and a couple drops of alcohol at night before he goes bed.  Try to keep the canal dry.  Nasal irritation using a normal saline solution, and he was asked to return if symptoms progress and we will go ahead and get a sinus view.

CHART NOTE

Examination of his right ear reveals some inflammation of the tympanic membrane, a little moisture in the canal.  I am sure he has a serious otitis back there, but rather than put a tube in at the present time, give him some Ceclor 250 mg #30 and ask him to return in 2 weeks for tube insertion.

CHART NOTE

PHYSICAL EXAMINATION:  Right ear canal is small and swollen, difficult to work with, and required the operating microscope.  By use of both suction and hydrogen peroxide irrigation, a rather large bolus of fungus was removed from the tympanic membrane.  Tympanic membrane appeared intact.

Spectazole was then applied after drying the canal, and she was asked to return for follow-up.

IMPRESSION:  External otitis.

DISPOSITION:  Spectazole and follow-up.

ENT_T2

LETTER

Date

Name

Address

City, State, Zip

Re:

Gentlemen

At the request of my patient, I am forwarding this brief medical report.

HISTORY:  The patient, a 24-year-old woman, was seen in consultation regarding problems referable to her nasal breathing.  The patient complains of progressive congestion, a pressure sensation within the nose, sniffing, and stuffiness.  In addition, she has had episodes of sneezing, itching, and watery eyes.  She has more problems breathing through the right side of the nose than the left.

EXAMINATION:  Examination reveals the nasal septum to have somewhat of an S-shaped configuration with the midsection curved to the right of the midline and the caudal edge of the quadrilateral cartilage to the left of the midline.  There is marked obstruction of the right nasal passage.  She has some asymmetry to the dorsal nose as well.

DIAGNOSES:

1.  Inadequate nasal airway.

2.  Deviated nasal septum.

3.  Possible rhinitis.

COMMENTS:

1.  I have discussed with the patient the treatment of this condition with a nasal septoplasty with partial submucous resection.

2.  In addition, simultaneously a modified rhinoplasty would be performed.

3.  The patient would appreciate a letter from Blue Cross stating that these treatments would be covered on her health insurance program.

4.  The surgery would be performed in an office setting and would not require any hospitalization.

Sincerely

Name

ENT_T3

ENT

LETTER

Date

Re:

To Whom It May Concern

Michelle was first seen by me in February.  At that time she was complaining of vague symptoms.  She was under stress, but this was related to her work.  She also had a history of a kidney stone.

On examination at that time, she had red scaly patches under her ears, which subsequently turned out to be an allergy to her hair spray.  She had a left cervical posterior triangle node which was mobile and nontender, a scar over her right scapula where she had a hemangioma at age 6 weeks, and bilateral mammary inplants.

All the blood tests that were obtained were negative except for a low ferritin, related to her menstruating and her 2 pregnancies.  She was put on iron supplements.  She had a chest x-ray that was entirely normal.

She was seen again about a month later.  Her cervical node and axillary node had disappeared by then.  Because her nodes disappeared, she did not see a hidden head and neck surgeon, and on examination today she certainly does not have these nodes.  A copy of her lab data is enclosed, and this was all essentially normal aside from the low ferritin.

In 1986, her blood pressure was 92/56 and she weighed a 109-1/4 pounds.  Today her blood pressure is 106/60 and she weighs 111 pounds.  There has been no change in her blood pressure or her weight.

On examination today she still has the scar over her right shoulder blade.  I cannot today feel any axillary or cervical node enlargement whatever.  She still has the bilateral breast implants and a low C-section scar.  She tells me that she had a recent pelvic, Pap smear, and rectal examination by her gynecologist, and this was not done.  At the moment she is asymptomatic.  Indeed, she is only seeing me now because she is apparently having some trouble in getting medical insurance-this despite the fact that she has not seen a physician for any problems since last seeing me for a routine check-up.

I have ordered no routine or other blood studies at the time of this dictation.  She has had a recent Pap smear, is asymptomatic, is taking iron, and blood tests were essentially negative.  She has continued to feel good, not required medical care, and informs me that she has been in good health and seen no other physician during this time.

Sincerely yours

Name.