Basic
Dictation
|
Sacramento Bee
3/2/10
|
Jerry Brown will officially
join race for California governor
Brown will be the sole Democratic candidate for governor. In
the general election, he'll likely face either Meg
Whitman, the billionaire former CEO of the online auction firm
eBay, or Steve
Poizner, another wealthy former Silicon Valley CEO who officially
filed for governor Monday.
For months, Brown insisted he had not yet decided whether to
run while quietly assembling a small campaign staff operated partly by
volunteers. Brown's campaign held $12.1 million in cash on hand at the
end of last year.
That sum, collected in large part from union contributions,
pales in comparison to the $19 million already spent by Whitman last
year.
She's invested $39 million of her own money in the campaign
and had $10.5 million in cash on hand at the end of last year, not
including the $20 million she put into her campaign in January.
Veteran Democratic strategist Darry
Sragow, a longtime colleague of Brown's, said the attorney general
was right in waiting until this month to announce his candidacy,
despite worries of some Democrats that he was letting Whitman gain in
the polls.
"It's smart to wait and see what Poizner ends up doing,"
Sragow said. "The job of taking on Whitman in this campaign cycle
belongs to Steve Poizner, not to Jerry Brown."
Whitman communications director Tucker
Bounds said the candidate looks forward to a "spirited campaign
where we will examine his true record and explain to voters why a vote
for Jerry Brown is a vote in the wrong direction."
(B10)
|
Sacramento Bee
4/2/05
|
Outdated technology slows state
to a crawl
Decades after the birth of the computer industry, much of it right
here in California, the state's massive information technology systems
are disorganized, outdated and deficient.
The state can trace some of its problems to its failure to invest
earlier in new technology. But observers say the main reason is that,
for too
long, the state has scattered the authority for its computer systems
over
hundreds of departments, with little centralized coordination or
oversight.
That lack of monitoring, in turn, led the state to waste hundreds of
millions of dollars on failed upgrade projects.
"It's really the politics, meaning the politics of department by
department by department making their own technology and business
decisions," said Gregory G. Curtin, director of the Center for
E-Government at the University of Southern California. "In this day and
age, that will kill the promise of technology."
Efforts are under way to change that. Building on an enterprise that
began before he took office, Gov. Arnold Schwarzenegger last year
released a strategic plan for overhauling the way the state manages
computer projects. Several major technology upgrades also are in
progress. They include a
$100 million effort to switch the payroll program to a faster and more
flexible system.
(B11) |
Sacramento Bee
4/2/05
|
Appeals
court refuses to rehear Moussaoui's case
RICHMOND, Va. -- A federal
appeals court has denied a rehearing for convicted Sept. 11 conspirator
Zacarias Moussaoui (zak-uh-REE'-uhs moo-SOW'-ee).
He is serving a life prison term after pleading guilty to
helping plan the attacks. Since his sentencing, he has said he lied
when testifying that he plotted to hijack a fifth jetliner in the 2001
terrorist attacks.
A three-judge panel of the 4th U.S.
Circuit Court of Appeals in January rejected his claims that he was
denied access to evidence and the right to choose his own attorney.
Moussaoui asked for a rehearing before the full appeals court.
The court issued a two-paragraph order Tuesday denying the motion.
Moussaoui's attorney, Justin
Antonipillai (ahn-TOHN-uh-puh-lay), did not immediately return a
telephone message.
(B15) |
Sacramento Bee
4/2/05
|
Russians join U.S. bioterror
program
The Cold War is off; a war against terrorism is on. That explains,
in short, why Lepeshkin and three other visitors from Russia are
ensconced at the Monterey Institute of International Studies, trying to
become conversant with terms such as "dangerous pathogens," "infectious
agents" and "probability of accidents."
The fellows are the first of what the institute hopes will be a long
procession of scientists to come to Monterey as part of a new
anti-bioterrorism program run by the U.S. State Department.
Called the BioIndustry Initiative, it was created after the Sept. 11,
2001, terrorist attacks with the aim of helping former bioweapons
scientists apply their skills to peaceful ends, such as by producing
vaccines and drugs.
If they can speak English and make friends here, the idea goes, the
scientists will be more likely and able to collaborate with American
businesses on projects that jibe with U.S. interests - and less likely
to work with enemies of this country.
"It's a complete win-win situation," said Raymond Zilinskas, a
microbiologist and authority on biological weapons at the Monterey
Institute's Center
for Nonproliferation Studies. "We occupy them, keep them from the bad
guys
and at the same time, we get good stuff out of them."
(B20) |
wjla.com
8/25/05
|
Medicare Patients Warming Up to
Drug Plan
Thursday August 25, 2005 1:53pm (selected excerpts)
Washington (AP) - Elderly patients are warming up to the prescription
drug benefit that begins next year for Medicare recipients, a survey
shows. Even so, the number of people who plan on not enrolling in a
drug plan exceeds the number who say they will enroll, according to a
survey from the Kaiser Family Foundation.
"The positive drum beat has caught up with the negative one," said Drew
Altman, president and CEO of the Kaiser Family Foundation, which
specializes in health research. "But on an individual basis, most
seniors still can't answer the big question: 'What does it mean for
me?'"
In the survey, which was conducted earlier this month, the percentages
of people who viewed the drug benefit favorably and unfavorably stood
at 32 percent each. The remaining 36 percent said they didn't have
enough information to give an opinion.
About 1,200 adults participated in the telephone survey, including 300
respondents age 65 and older. The margin of error for the questions
asked only of the elderly was plus or minus 6 percentage points.
Enrollees will pay a monthly premium averaging about $32 a month, but
the amount of the premium will vary from region to region, and millions
of
poor people will pay no premium. Beneficiaries will also have a $250
deductible, meaning they will have to pay that amount for their
prescriptions before
the drug plan covers expenses. Again, millions of poor beneficiaries
will
not have any deductible.
On that front, the Kaiser survey shows there is still much work to do.
More than two-thirds of respondents described their understanding of
the benefit as "not too well" or "not well at all." Meanwhile, only 31
percent said they understood the benefit "very well" or "somewhat well."
AARP officials said they have seen a shift in attitude similar to what
the Kaiser poll indicated.
"I would guess the awareness needle is continuing to climb," said
George Keleman of the AARP.
Sen. Frank Lautenberg, D-N.J., said Wednesday that he believes the
government's outreach effort would improve with some changes to the
official Medicare Web site, , which he said is woefully inadequate. For
example, he said,
the only explanation of the benefit was on the fifth link down the
page,
in a format that requires additional software to
read.http://www.medicare.gov
"At this critical time, CMS should have a user-friendly, informative
and easy to understand Medicare Web page," Lautenberg said in a letter
to McClellan. "Unfortunately, the only web at the current Medicare site
is a web of confusion."
A CMS official said he had not seen the senator's letter, but the
agency would consider his suggestions for improving the site. The
official said the agency has had numerous organizations look at the
site to suggest ways it could be improved.
(B30) |
Sacramento Bee
12/2/05
|
Lear to keep supplying DaimlerChrysler
DETROIT (AP) - A circuit court judge has ordered Lear Corp. to keep
supplying automaker DaimlerChrysler AG with a steady stream of seats
and interior trim for the time being even though the parts maker has
argued that higher oil prices have driven its costs sharply higher.
Oakland County Circuit Judge Colleen O'Brien issued a temporary
restraining order Thursday in a rare example of an automaker taking a
supplier to court to force compliance with their contract. She set a
Dec. 14 hearing on whether to extend the order.
DaimlerChrysler said it was the first time it has sued a supplier, and
Lear said it was the first time it has been sued by an automaker.
Jim Gillette, a supplier analyst with the consulting firm CSM
Worldwide, said Friday that suppliers have been asking automakers to
pay more for their parts because of the high cost of raw materials such
as steel, and in most cases automakers have quietly agreed to pay more.
Lear said its problem is the rising cost of oil, which is used to make
resin for plastic parts.
Lear informed DaimlerChrysler it would absorb those increases for one
month but would transfer the increases to DaimlerChrysler after that.
The supplier also said it would stop shipping parts to DaimlerChrysler,
according to the lawsuit.
DaimlerChrysler said it depends on Lear parts and would lose $54
million per day if Lear stops shipments. The Stuttgart, Germany-based
automaker said it would have to close 12 plants in the United States,
Canada, Mexico and Germany within two days if the shipments end.
"It's really to protect us from production disruption," DaimlerChrysler
spokesman Markus Mainka said.
|
| (A10) |
Advanced Dictation
|
Sacramento Bee
4/2/05
|
Minor discrepancies with other
budget documents
The figures given here for national defense (function 050) or
international affairs (function 150) or do not match those in the
"Historical Tables" exactly (see Table 8.1, "Outlays by Budget
Enforcement Act Category: 1962--2009" [xls], [pdf]). The presentation
in Table 8.1 of the "Historical Tables," as noted there, lists data for
discretionary spending. If the numbers presented here using the Public
Budget Database were to exclude the relatively small amounts in
functions 050 and 150 consisting of mandatory spending, the
numbers would match exactly.
(A20) |
www.morganstanley.com
2003
|
Latest OMB Budget Estimates
How do we reconcile our smaller deficit estimate for 2003? On the
receipt side of the ledger, the OMB estimate includes an unclassified
-$15 billion adjustment for "uncertainty." This accounts for the entire
gap between our own revenue number and the administration's latest
figure ($1771 billion versus $1756 billion). The differences on
the spending side are larger -- amounting to $40 billion. The bulk of
this gap is concentrated in a catchall component of spending that we
call “miscellaneous outlays.” This category accounts for less than 15%
of total outlays.
The optimistic assessment of the economy's growth prospects is
exemplified by the FOMC members' forecast. The estimates imply a pickup
to about +3.5% GDP growth during the second half of 2003. More
important, the range of estimates for 2004 GDP growth is +3.5% to
+5.25% (on a Q4/Q4 basis), with a central tendency of +3.75% to +4.75%.
Our own 2004 forecast is +4.5%, and the latest Blue Chip consensus is
+3.7%. Clearly, Fed policy makers
are even more optimistic than private forecasters.
Following the recent reversal in the Canadian dollar that had prompted
a significant easing in monetary conditions and signs in Friday's
strong June employment report that the impact of the SARS crisis in
Toronto has faded, the Bank of Canada surprised the markets on Tuesday
by cutting
its overnight target 25 bp to 3.00%. This followed hard on the heels of
25-bp rate hikes on April 15 and March 4, which were followed quickly
by the SARS outbreak, a sharp ramp higher by the Canadian dollar from
C$1.45/US$1
on April 15 to a peak of C$1.33/US$1 two months later, a surprisingly
sluggish post-war U.S. economy that has weighed heavily on Canadian
manufacturing output, and a decisive reversal in previously surging
Canadian inflation
(with the BoC's core CPI measure falling from +3.3% to +2.3% in the
past
four months). In retrospect, therefore, the April rate hike looks
ill-timed,
and the Bank of Canada appears to have taken the opportunity to reverse
the
move and at the same time to deal with the consequences for the
inflation
and growth outlook of the Canadian dollar’s sharp appreciation.
(A21) |
www.morganstanley.com
7/16/03
|
ANALYST STOCK RATINGS
Overweight (O). The stock's total return is expected to exceed the
average total return of the analyst's industry (or industry team's)
coverage
universe, or the relevant country MSCI index, on a risk-adjusted basis
over the next 12-18 months. Equal-weight (E). The stock's total return
is expected to be in line with the average total return of the
analyst's
industry (or industry team's) coverage universe, or the relevant
country
MSCI index, on a risk-adjusted basis over the next 12-18 months.
Underweight
(U). The stock's total return is expected to be below the average total
return of the analyst's industry (or industry team's) coverage
universe,
or the relevant country MSCI index, on a risk-adjusted basis over the
next 12-18 months. More volatile (V). We estimate that this stock has
more
than a 25% chance of a price move (up or down) of more than 25% in a
month,
based on a quantitative assessment of historical data, or in the
analyst's
view, it is likely to become materially more volatile over the next
1-12
months compared with the past three years. Stocks with less than one
year
of trading history are automatically rated as more volatile (unless
otherwise
noted). We note that securities that we do not currently consider "more
volatile" can still perform in that manner.
|
|
Medical Dictation
|
Nuance
|
Sample Dictation
|
AAOS
|
New Techniques to Restore Articular Cartilage
Articular cartilage is a tough, elastic tissue that covers the
ends of bones in joints and enables the bones to move smoothly over one
another. However, when articular cartilage is damaged through injury or
a lifetime of use, it does not heal as rapidly or effectively as other
tissues in the body. Instead, the damage tends to spread, allowing the
bones to rub directly against each other and resulting in pain and
reduced mobility.
Advances in technology and biological engineering are giving new hope
to the thousands of Americans who annually suffer injuries to the
articular cartilage
of the knee. Several techniques are now using the patient's own cells
and
tissues to restore cartilage to weightbearing sections of bone. These
new
techniques include:
Osteochondral grafting. A plug of bone and healthy cartilage is
harvested from one area and transplanted to the injury site.
Autologous chondrocyte implantation, or ACI. Healthy cartilage cells
are harvested, cultivated and implanted over the lesion.
Mesenchymal stem cell (MSC) regeneration. MSCs are "undifferentiated,"
which means they have not yet developed into a particular type of cell
(such as bone or muscle). Research suggests that MSCs can be withdrawn
from the individual’s bone marrow, placed in a gel matrix, and
implanted at the defect, where they develop into new cartilage.
Osteochondral grafting
An osteochondral graft can use either the individual's own tissue
(autograft) or a matched graft from another source (allograft). If an
autograft is planned, the plug of bone and cartilage must come from a
non-weightbearing area that has little contact with other bones. This
fact limits its application to treating
smaller lesions. For larger injuries, an allograft is more appropriate,
provided
that a tissue match can be found or the graft processed to modify the
genetic
differences and help prevent rejection.
Autologous chondrocyte implantation
Chondrocytes are mature cartilage cells. In this two-step procedure,
surgeons first use arthroscopic techniques to harvest the cells from a
healthy, non-weightbearing area of the knee joint. The chondrocytes are
then treated so they will multiply over several days.
During the second surgery, the surgeon cleans the injury site and
removes a piece of the soft tissue (periosteal) that covers the tibia.
The periosteal tissue is sutured and secured over the injury, and the
cultured chondrocytes are then injected beneath the patch. There, the
chondrocytes will eventually produce a form of cartilage that is very
much like the original articular cartilage.
Because ACI uses the patient's own cells, there is no danger of
rejection by the immune system. Complications are rare and, in most
cases, the procedure results in a restoration of joint movement without
pain.
However, ACI isn't appropriate for everyone. Several factors must be
considered in decision-making, including the size of the defect, the
number and type of previous surgeries, the patient's demands and
expectations, the location of the injury and the presence of coexisting
lesions. The patient's age and the reason for cartilage deterioration
must also be considered. An older person
with advanced osteoarthritis is not a candidate for ACI, but a younger
person
with a traumatic injury to the knee might be.
Mesenchymal stem cell regeneration
The newest technique being developed uses mesenchymal stem cells
(MSCs). MSCs are relatively undifferentiated, embryonic-like cells with
the potential to develop into various types of cells. They are found in
adult bone marrow and in the periosteum, a tissue layer over the areas
of bone not covered by
articular cartilage.
Doctors anticipate harvesting MSCs by a simple bone marrow aspiration
and biopsy. Research is being done on the possibility of placing MSCs
in a gel, then inserting the gel into the cartilage defect. Because
MSCs appear to be
capable of organizing in the same way that cartilage is structured, it
is
hoped that they will be able to regenerate articular cartilage.
|
MedWord.com
More Samples
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|
Dermatology
more
|
Sample 1
|
Patient has a history of a lesion
affecting the right anterior lower leg for the past eight months. This
occasionally becomes tender and has also apparently shown drainage in
the past. He denies a history of pruritus or excoriation. There is no
past history of other
significant skin disorders and his general health is good.
Exam: Revealed a small pustule with surrounding post-inflammatory
hyperpigmentation on the right anterior leg. The pustule was drained
and a swab for wound
culture was obtained. There did not appear to be any other underlying
process
at present. The remainder of the cutaneous examination was unremarkable.
I believe this is a small furuncle or possibly a foreign body reaction.
He will start on simple topical therapy with further review in two
weeks.
Diagnosis: Pyoderma of right leg -- differential diagnosis to include
furuncle and foreign body reaction.
Plan: Warm compresses followed by Bactroban ointment t.i.d.
|
Sample 2
|
Patient has a history of a lesion
affecting the right anterior lower leg for the past eight months. This
occasionally becomes tender and has also apparently shown drainage in
the past. He denies a history of pruritus or excoriation. There is no
past history of other
significant skin disorders and his general health is good.
Exam: Revealed a small pustule with surrounding post-inflammatory
hyperpigmentation on the right anterior leg. The pustule was drained
and a swab for wound
culture was obtained. There did not appear to be any other underlying
process
at present. The remainder of the cutaneous examination was unremarkable.
I believe this is a small furuncle or possibly a foreign body reaction.
He will start on simple topical therapy with further review in two
weeks.
Diagnosis: Pyoderma of right leg -- differential diagnosis to include
furuncle and foreign body reaction.
Plan: Warm compresses followed by Bactroban ointment t.i.d.
Thank you for asking me to see this pleasant patient and for your
referral note. She presents for assessment of symptoms of hair-shedding
and thinning noticeable over the past one year. She has not developed
any areas of focal alopecia. Her menstrual cycles are regular and there
is no history of significant acne or hirsutism. Her general health is
good, although she has a history of previous schizophrenia and is on
long-term Haldol, 1mg daily. Review
of the family history is positive for androgenetic alopecia.
Exam: Revealed an increased frontal part-width and mild thinning of the
frontal to vertex region of the scalp. A gentle hair-pull test showed
1-3 telogen hairs per pull. The remainder of the examination was
unremarkable.
I feel that this represents early androgenetic alopecia. Screening
investigations including ferritin and TSH have been performed and are
within normal limits. I do not feel that any further investigations are
necessary at present.
Topical minoxidil therapy was discussed and she will start on 5%
solution
with further review in six months.
Diagnosis: Androgenetic alopecia.
Plan: 5% minoxidil solution applied b.i.d.
Thank you for referring this patient to me. He has a history of a
lesion affecting the right anterior lower leg for the past eight
months. This
occasionally becomes tender and has also apparently shown drainage in
the
past. He denies a history of pruritus or excoriation. There is no past
history of other significant skin disorders and his general health is
good.
Exam: Revealed a small pustule with surrounding post-inflammatory
hyperpigmentation on the right anterior leg. The pustule was drained
and a swab for wound
culture was obtained. There did not appear to be any other underlying
process
at present. The remainder of the cutaneous examination was unremarkable.
I believe this is a small furuncle or possibly a foreign body reaction.
He will start on simple topical therapy with further review in two
weeks.
Diagnosis: Pyoderma of right leg -- differential diagnosis to include
furuncle and foreign body reaction.
Plan: Warm compresses followed by Bactroban ointment t.i.d.
|
|
ENT
more
|
Sample 1
|
This patient is a 67-year-old diabetic who
has been on insulin for a year now. Before, she was on oral
anti-diabetic medication for 10 years. The patient was hospitalized a
month ago because of severe preauricular pain and jaw pain. She was
thought to have had a heart attack. She was in ICU for five days.
Eventually, angiogram demonstrated there was no obstruction of the
coronary artery. While in the hospital in ICU one day, she was half
asleep and she heard a big banging noise in her left ear which woke her
up. She also feels the left ear is somewhat stuffy since she came out
of hospital. She has no tinnitus or dizziness. She had a dental checkup
and there is no evidence of dental sepsis. She still has occasional
pain along
the left jaw and the submandibular area and she takes Tylenol analgesic
for
that.
On Exam: Both eardrums are normal. There is no middle-ear
effusion. Audiogram and tympanogram were all within normal limits.
Flexible fibreoptic endoscopy showed the nasal cavity, nasopharynx,
hypopharynx, and laryngeal openings to be normal. Palpation of the
major salivary glands were all normal. Palpation of the floor of mouth
was unremarkable.
The cause of this left periauricular pain is still unclear. I did not
see any sign of middle ear or external ear pathology.
|
Sample 2
|
This patient is a 63-year-old patient who
complains of always having excessive mucous in her throat. Sometimes,
she even has a low-grade sore throat radiating to the ears. Her barium
swallow seemed to
indicate some degree of reflux problem. She has been treated with
different types of antireflux medication without much improvement. She
has Type II diabetes. The patient is leaving for a trip in two days'
time and will not be back for three months.
On Exam: Examination with the flexible fibreoptic scope revealed
the vocal cords are moving well. There is no mucosal disease on the
vocal cord surface. Hypopharynx is normal. However, there is some
hypertrophic mucosa at the posterior commissure, suggesting she may
indeed have some reflux
problem causing this hypertrophy of the posterior laryngeal mucosa.
I prescribed some Gaviscon lozenges for her and she will come back
after her trip for a follow-up examination.
Diagnosis: Gastroesophageal reflux, causing hypertrophic change
of the posterior laryngeal mucosa.
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|
Emergency
more
|
Sample 1
|
Diagnosis: Cyanotic Congenital Heart
Disease
Baby boy Doe was born at about 0500 hours in the morning to a
multiparus woman after an induced labour and via a vaginal delivery.
The neonate was noted to have cyanosis shortly after delivery without
signs of respiratory distress and the additional supplemental oxygen
only marginally improved oxygen saturation. Capillary blood glucose was
within normal limits, but an
AP portable chest x-ray demonstrated a heart with a globular
configuration and normal pulmonary vasculature. The possibility of
cyanotic congenital heart
disease as an underlying diagnosis was entertained.
A complete physical examination, as well as a review of all available
laboratory investigations and x-rays, was performed by myself when I
arrived
in the neonatal nursery at 0530 hours. This revealed a term male
newborn
who was in no respiratory distress, but who had an oxygen saturation of
about
75% on room air. There were no dysmorphic features, but the newborn was
clearly cyanosed. The fontanelle was soft, the chest was clear to
auscultation and no cardiac murmur was audible. There was also no
gallop rhythm. There was no hepatosplenomegaly and femoral pulses were
normal.
This newborn was connected up to a cardiac monitor and placed in an
incubator. He was transferred via ambulance to the Emergency Department
at Super Care Hospital to undergo an urgent echocardiogram and
cardiology consultation. He was suspected of having transposition of
the great vessels.
|
Sample 2
|
Diagnoses: Coma; Generalized Seizure
I was paged to Great Care General Hospital to assess, stabilize and
prepare this 12-year-old girl for transport to the Intensive Care Unit
at Super Care Hospital.
This child presented to the Emergency Department at Great Care General
Hospital on the evening of March 15, 2002, complaining of sudden
onset of retro-orbital headache associated with nausea and vomiting.
She subsequently collapsed and was taken to the Emergency Department
where the child was found to be comatose on admission with deviation of
the eyes to one side. However, the child was hemodynamically stable
without a fever or rash and there were no signs of head injury or toxic
ingestion.
Initial resuscitative interventions included sedation with intravenous
midazolam and then endotracheal intubation and hyperventilation with
100% oxygen. A nasogastric tube was inserted to decompress the stomach
and a Foley
catheter was inserted into the bladder. The child was subsequently
paralyzed
with pancuronium and given an intravenous broad-spectrum antibiotic
(ceftriaxone).
The endotracheal tube was repositioned as it appeared that it had
entered the right main stem bronchus and was secured there during the
initial intubation. Further sedation was undertaken with intravenous
midazolam and morphine.
The patient was ultimately transferred to the Intensive Care Unit at
Super Care for further observation and investigation.The most likely
underlying diagnosis of this child's acute decrease in level of
consciousness was a generalized seizure with a postictal phase.
|
|
Ophthalmology
more
|
Sample 1
|
This 55-year-old woman complains of her
vision being blurred, especially with reading, and in the right eye
more than the left. She also feels as if the right eye is puffy; the
eye is watering. She
still drives a vehicle and has no difficulty doing that with her
glasses which are three years old.
Medical History: Angina. Skin cancer with a graft to the nose.
Ocular History: Unremarkable.
Family History: Father with cataracts.
Meds: Nitrong, Acebutolol.
Allergies: ASPIRIN causing GI upset.
With her current spectacles her vision is 20/50 in both eyes. A
refractive change improves that to 20/40 in the right and 20/30 in the
left. She has central corneal guttate with mild pigmentation and
cataracts which are not dense enough to be entirely responsible for the
acuity. The pressures are normal. The left iris shows a small ectropion
uvea at the 4:30 to 5:00 position and a small translucent nodule with
adjacent pigment flecks on the iris surface. The fundus shows some soft
drusen with pigmentation and atrophy in both
fundi.
Impressions: 1) Small iris melanoma, right eye.
2) Age-related macular degenerative changes.
3) Mild cataracts.
I have sent her for a photograph of the iris changes. What is there at
present is very mild and does not require intervention but does need
good documentation and follow-up. She does have cataracts but it is the
combination of the cataract of the macular changes not the cataract
alone which is making her vision blurred. At this point in time, there
is no treatment required to the macular degeneration but, again, she
should be followed in six months for the combination, especially if she
is still driving.
|
Sample 2
|
This 47-year-old woman appears much
younger than her stated age. She helps run a family business at home
and organizes the lives of her family including a very bright young
son. She has had a rather unusual problem.
She comes for ocular review because she gets aching around and behind
the left eye and over the left malar area in conjunction with episodes
of
shingles. However, the shingles affect the left trunk, show up in a
definite
dermatome patch in the lumbar area and there have never been associated
vesicles or redness in the trigeminal distribution. There is no
associated
redness or discharge with the aching but she does become photophobic.
The first episode of the zoster occurred three years ago while she was
away hiking. The second episode occurred last year in November.
Subsequently, she has had one in January, two in September and one in
November of this year.
She never gets the orbital ache without the episodes of zoster and each
time
she gets the zoster there are vesicles to see and some numbness or
tingling.
She has not had associated labial herpes, cold sores or other
abnormalities.
There is no history of facial fractures or injuries. There is no
history
that sounds like thyroid disease.
Medical History: Otherwise well.
Ocular History: Unremarkable.
Family History: Mother with Type II diabetes.
Meds: Valacyclovir or famciclovir.
Allergies: None known.
Ocular exam shows a decrease in her refractive error with best
corrected acuity of 20/15 in both eyes. The ocular, orbital and facial
neurologic exam was completely normal in both eyes. There was no
evidence of redness, no
abnormal corneal vasculature or scarring, no facial scars or lesions,
no
change in her hearing, and no change in the corneal sensation. There
was no
evidence of proptosis. The intraocular pressures were 18 bilaterally
and the
anterior chambers showed no evidence of inflammation. There was no
evidence of previous uveitis or iritis episodes. The dilated fundus
exam showed absolutely no abnormalities at the vitreous, choroid or
optic nerve.
Impressions: 1) Mild refractive change.
2) Suspect migraine equivalent.
She may have something resembling cluster migraine brought on by these
episodes, although she has no history of it in the past. I do not find
any zoster-like effects around the eye and I am somewhat puzzled by the
overall syndrome. I have suggested to her that she should see
Dr.Amazing and apparently arrangements have already been made for this.
The frequency of the zoster recurrence is in the absence of the
uncompromising disease also seems a little
unusual and I am sure Dr. Amazing will help to sort this out.
If sorting out the zoster does not completely alleviate her symptoms,
a neurologic evaluation is probably in order. The other alternative is
that she develop unilateral photophobia which is extremely variable in
nature
and can be brought on by anything including headache, neurologic
disturbance
or general illness and this is what she is complaining of around the
left
eye.
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Orthopedic
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Sample 1
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Mrs. Doe F/38yrs
C/O pain both knees-1yr non-radicular pain.
No H/O clicking/locking.
No H/O instability.
No H/O other major joint involvement.
No H/O swelling.
H/O trivial trauma 1 year ago: missed step on staircase.
No H/O fever.
No H/O TB contact.
No H/O other medical problems.
H/O occasional pain on climbing stairs.
L/E of knees: - Right Left
Swelling: Absent Absent
Effusion: Absent Absent
Tenderness: Medial femoral condyle Medial
femoral condyle
Flexion deformity: Absent Absent
Joint line tenderness: Absent Absent
Patellar tenderness: Mild Mild
Varus/valgus: Absent Absent
Range of movement: 0° -130°
0° -130°
Medial ligament laxity: Absent Absent
Lateral ligament laxity: Absent Absent
Cruciates: Intact Intact
McMurray's test: Negative Negative
"Q" angle: Quadriceps wasting:
Absent Absent
Power: Grade 5 Grade 5
Patellar crepitus: Present Present
Retro patellar tenderness: Present
Present
Distal pulsations well felt
Hips normal
Clinical diagnosis: Patello-femoral arthritis.
Investigations: - CBC; ESR; RA Test; S; Uric acid; X-rays, both knees,
standing, Skyline view
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Sample 2
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Psychiatry
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Sample 1
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This patient is a 27-year-old Caucasian
married female, who has been feeling depressed, sad, unhappy,
withdrawn, apathetic, lacking energy and ambition to do much. She feels
miserable in the morning and gets a bit better as the day progresses.
She is feeling guilty most
of the time. She is afraid to be by herself. She his constantly worried
of hurting herself.
This patient did attempt suicide 2½ years ago. Following this,
she was treated as an in-patient for a brief period of time.
Medical History
Is significant for head injury aged three. Seizures since age 11.
Medication
Effexor, 37.5 mg twice a day; Buspar, 10 mg t.i.d.; Trazodone, 50 mg q.
h.s.; Serax, 15 mg b.i.d.; Ativan, 1 mg p.r.n.
Family History
This patient was brought up in a dysfunctional family. She used to be
abused by her mother. Parents were divorced when she was 16. She
completed
Grade 12. Currently, she is working as a waitress at Best Burgers.
She has one brother who is functioning well.
Current Mental State
This patient is looking her age. She is pleasant and cooperative. Her
orientation is full for time, place and person.
Her mood is depressed and sustained. Affect is flat. Thinking is
logical and coherent. Thought content is informative. Cognitive
functioning is intact. No obsessions, compulsions or phobias noted. She
has some insight into her present state and her judgement is intact.
Assessment
Axis I -- Major depression, recurrent.
Axis II -- Deferred.
Axis III -- Head injury aged three. ? post-traumatic seizure disorder.
Rule out pseudoseizures.
Axis IV -- Moderately-severe psychosocial stress.
Axis V -- GAF is 55.
Plan
Discontinue Buspar, trazodone, and Serax. Increase Effexor XR to 150 mg
oncea day and Ativan, 1 mg three times a day.
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Sample 2
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This patient is a 21-year-old single male
who
has been complaining of depression, tiredness, fatigue, lack of energy
and
motivation to do anything over the past few months. He is constantly
preoccupied
with multiple somatic symptoms arranging from pain in his stomach,
hands,
body, shoulders, and chest. He just cannot do anything in life because
of
these aches and pains.
This patient is constantly sad and unhappy. He is worried about his
health most of the time. He does not feel good when he gets up in the
morning. He feels a bit better as the day goes by. When he is tense, he
experiences a ringing noise in his ears.
Family History
Noncontributory.
Medical History
Not contributory.
Personal History
This patient was born and raised in Montana. Full term normal delivery.
Milestones of development were normal. He came to Texas when he was 15.
Initially, he found it difficult to adjust to life here. Now, he is
gradually
settling into the local community.
Medication
Luvox, 50 mg q.d.
Current Mental State
This patient is looking his age. He is somewhat withdrawn. He is alert.
His orientation is full for time, place and person. Mood is depressed
and sustained. Affect is flat. He has marked psychomotor retardation.
His concentration is impaired. Cognitive functioning is intact. No
obsessions or compulsions noted. No phobias or panic attacks noted.
Denies any hallucinations. He has limited insight into his present
state and his judgement is intact.
Assessment
Axis I -- Major depression, recurrent. Rule out somatization disorder.
Axis II -- Deferred.
Axis III -- No problems identified.
Axis IV -- Moderate psychosocial stress.
Axis V -- GAF is 50.
Plan
Discontinue Luvox. Start on Serzone, 100 mg b.i.d. and increase the
dosage of Serzone to 300 to 400 mg a day based on his tolerance and
response. I will review him at my office in 2-3 weeks' time for
necessary support and counselling.
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Radiology
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Sample 1
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STERNUM
A bony defect is seen at the junction of the manubrium and sternum and
although this may represent a metastasis, I am more inclined to suggest
that
it is a healing undisplaced fracture. The remainder of the sternum is
unremarkable.
SACRUM AND SI JOINTS
This examination demonstrates a healing fracture at the junction of the
first and second sacral segments. No bone destruction is demonstrated
to
suggest that this is due to a metastasis. Mild degenerative changes are
seen
within both sacroiliac joints.
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Sample 2
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RIGHT WRIST
An ill-defined 1.0 mm bony fragment is seen on the dorsal aspect of the
wrist which could represent a small avulsion fracture from either the
capitate or lunate bone. No evidence of any joint disease is seen.
CHEST
Small patchy areas of pneumonitis are noted within the right middle
lobe and the lingula. This is not associated with any pleural effusion
or evidence of heart disease. Follow-up films are recommended.
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Rheumatology
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Sample 1
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This pleasant 37-year-old woman has had
low back pain since she was 15 years old. She developed right buttock
area discomfort with a tight sensation in the last several years. This
comes and goes. She's quite stiff and sore in the morning for half an
hour or so. She has difficulty getting a sock on. When she's up and
around it does loosen up and doesn't bother her as much. She does have
a chronic low grade degree of low back pain, however, tells me lately
that this has been less problematic. It is there usually on a daily
basis and perhaps monthly she has an increased degree of pain lasting a
day or so.
She notes that pulling the garage door produces an aching in her hands
perhaps twice, with soreness in the interspace between the first and
second digits, more so on the right hand. She's tender if she pokes at
this area. She notes that she's tender in the shoulder area if she
presses on them but
otherwise they don't bother her. She had some soreness in her knees
last
year when she without a car for three months. At one point her knees
were
quite swollen for several days. They still feel weak at times. She
finds
walking for more than half an hour is sometimes uncomfortable and
sometimes
the knees are sore to straighten out.
She's going through some considerable emotional upset at the moment.
She's currently going to the psychiatric day program at Great Care
Hospital and is halfway through the program. She is troubled by low
self esteem, marked shyness and other problems which she's working on.
She's not currently taking any medications other than vitamins. She has
concern about some hair loss.
Past History: Includes a sinus operation three times for some
unusual type of polyps. She has had tonsillectomy, wisdom teeth out.
She went through a period where she was feeling quite unwell and
getting worse, having several courses of antibiotics. She then went to
some alternative health care and with that she felt better.
She's married with three teenage children. She's not working currently.
On Exam: BP was 90/60. Head and neck exam was all clear.
Funduscopic examination was normal. She had no oral or nasal ulcers.
She had no lymphadenopathy or bruits. Heart sounds were normal and the
chest seemed clear, as did the abdominal exam. She has increased lumbar
lordosis. She's able to bend forward and touch her toes but her back
does not reverse curvature with that. She had no sacroiliac joint
tenderness to stressing. She was tender to direct pressure over the
lower lumbar spine and sacrum. She had slight tenderness with full
range of movement of her right hip. No tenderness on the left. She did
not have widespread soft tissue tenderness. She had no tender or
swollen
joints in the hands. She had no flexor tendon nodules or nodules
anywhere
else.. She had a full range of movement of her knees and no tender or
swollen
joints in the feet.
Blood work in October showed ESR of 10, negative ANA, weakly positive
rheumatoid factor of 24.
I have called for her lumbar spine xrays from two years ago.
Impression: I do not feel that she has fibromyalgia and reassured
her. At this point, there's no clinical evidence to support a diagnosis
of rheumatoid arthritis.
She has been told that she has degenerative disease in her spine on
xray, and has been reviewed by a chiropractor as well. I suspect
this is the source of her pain in the low back as well as the right
buttock area. I will review the xrays for myself as well.
I have encouraged her to get into a more aggressive exercise program.
She has a weight machine at home. I've suggested that she start off
with
10–15 minutes of warm up, do some stretching and then go through a
routine
of both upper and lower body work to try to strengthen her trunk
muscles.
I gave her some suggestions such as capsaicin cream.
I have asked her to return for review in four months or so.
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Sample 2
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This 67-year-old woman states that she has
problems with several joints. She complains of swelling, stiffness and
pain. She has been stiff in the morning over the summer and fall. She
recalls being concerned because she had difficulty holding on to the
waterskiing rope because of weakness. The most recent problems
began with pain in the right foot
after being stepped on in October. This seemed to take much longer than
expected. She then developed pain in the right big toe with swelling,
marked
pain, but no redness. In November, she developed pain in her fingers as
well
as her shoulders. She could barely grip the steering wheel in the
morning.
Her bilateral thumb IP joints were painful and slightly swollen in
early
November. Subsequently, she developed problems with her elbows and
knees
with pain but no noted swelling. She feels that since she has had an
intermittent
involvement of the joints with individual joints coming and going.
She has been taking Relafen in the morning. She feels that she limps
until about 11:00 a.m. and then loosens up. The best time of day is
about 3:30 in the afternoon. She stiffens up overnight and indeed wakes
up through the night. At night her left arm, right leg and knees have
been bothering her. Three days ago her right wrist was swollen. She
gets an intermittently sore neck.
Prior to the Relafen she had tried Naprosyn which didn't help after six
weeks.
She has had no oral or nasal ulcers. She may have had a slight increase
in hair loss. She denies any chest pain or pleurisy. She has had no
Raynaud's. She has had no sicca symptoms.
She had shingles in 1998. She had an arthrodesis of her left ankle in
1997. This was an old injury which had bothered her for years. Since
then,
the arthrodesis has not been painful. She had a hysterectomy 30 years
ago.
She has no allergies. She doesn't smoke. She has alcohol occasionally.
She is trying glucosamine sulfate.
She is a widow. She has 3 grown children and 2 grandchildren so far.
On Exam: BP was 176/80. Head and neck exam was all clear.
Funduscopic examination was normal. She had no oral or nasal ulcers.
She had no lymphadenopathy or bruits. Heart sounds were normal and the
chest seemed clear, as did the abdominal exam. She had no palmar or
periungual erythema. She had stress pain of the right hand second,
third and fourth digit IP joints. She had slight
puffiness in the region of the left second and third MCPs with
tenderness of the second and third IPs as well as the MCP and
tenderness to pressure over the area. She had no flexor tendon nodules
or nodules anywhere else.. She had no tenderness or swelling in joints
of the wrists, elbows,shoulders, hips, knees or ankles. The left ankle
was fused and the ankle and subtalar joint. She had stress pain of the
right second MTP joint.
Lab: Blood work in November showed ESR of 16, uric acid 278,
negative ANA and a weakly positive rheumatoid factor of 22.
Impression: I would agree that she appears to have early
rheumatoid arthritis. I have suggested she try taking the Relafen two
tablets in the evening rather than in the morning. This might help her
have a more restless sleep overnight and loosen her up first thing in
the morning.
She weighs 135 pounds or about 61 kilos. I've suggested that she start
Plaquenil 400 mg a day. I explained that this may take several months
before we determine whether or not it's going to work.
At the moment, I felt that she did not require lowdose prednisone,
but if she gets more sore and stiff , adding 7.5 to 10 mg of prednisone
in the morning may make a clinical difference with minimal side
effects.
The idea would be to continue with the secondline therapy and
hopefully
get her off the prednisone reasonably quickly.
I've asked her to return for review in about three months, or to call
if she's having any problems.
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Urology
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Sample 1
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Thank you for asking me to see Mr. Doe in
a repeat consultation who was seen in January. He is a pleasant
35-year-old male who was seen regarding having his left testicle
removed. He has had a
right testicular prosthesis inserted in the 1980's after a right
orchiectomy. He, unfortunately continues to have discomfort in the left
testicle and would like to have this removed. He was originally seen
back in April of 1998, and I suggested to him he try to live with this
discomfort, but he returns now about a year-and-a-half later stating
that he is fed up and would like to have it removed and a second
prosthesis inserted on the left side which would render him hypogonadic
and would require testosterone replacement permanently.
Past medical history is as above. He has no allergies and is on no
medications.
Physical examination revealed a 35-year-old male in no acute distress.
Head and neck and chest are clear. Abdominal exam revealed no masses,
no tenderness and no organomegaly. Genitalia exam shows an atrophic
left testis that is high at the external ring and also a right
testicular implant that is somewhat small.
To recap, Mr. Doe is a 34-year-old male who wishes to have a left
orchiopexy and also a change of the right testicular prosthesis. He
understands that this will render him hypogonadic and would require
testosterone replacement. I have asked Dr. Amazing to review the
patient to see if he is agreeable with the above with respect to his
replacement hormones post-op and we will place him on the waiting list.
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Sample 2
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The patient was seen in consultation on January 15. She is a
pleasant 28-year-old female who was seen regarding urinary urgency and
urgency incontinence. This has been ongoing for the last few months.
She has incontinence two to three times per day. She denies any stress
incontinence, however. She has no nocturia. Her flow is normal. She has
frequency four to five times in
the daytime. She has no hematuria or dysuria or flank or abdominal
pain. She
has had normal abdominal ultrasounds. She drinks three glasses of water
and
also two diet Pepsi's per day.
Past medical history is unremarkable. Allergies nil. Medications nil.
She doesn't smoke or drink alcohol. Family history is negative.
Physical examination revealed a 28-year-old female in no acute
distress. Head and neck and chest are clear. Abdominal exam revealed no
masses, no tenderness and no organomegaly. .
To recap, Ms. Doe is a 28-year-old female with significant urgency and
urgency incontinence. Differential diagnosis includes detrusor
instability and interstitial cystitis or bladder polyps or stones. I
will arrange for a cystoscopy for a definitive diagnosis and then she
will be seen for further management.
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Legal Dictation
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