For this training, we would like you to read aloud for a few minutes while the computer listens to you and learns how you speak. When you have finished reading, we will make some adjustments, and then you will be able to talk to your computer and see the words appear on your screen.

You are about to read a number of sample medical reports from different medical specialties for this training session. All names and dates have of course been changed.

Cardiac catheterization
Consultation and procedure report

Patient name: Chris Male
Referring physicians: Dr. Adams and Dr. Smith

History:
The patient is a 72-year-old gentleman who was referred to us through the courtesy of Dr. Adams and Dr. Smith for cardiac catheterization.
The patient has a long-standing history of diabetes mellitus.

He presented to the medical center with unstable angina pectoris with transient anterior wall T-wave changes. He is now referred for cardiac catheterization. The patient has had no enzyme evidence of myocardial infarction.

Procedure:
The risks, benefits, and possible consequences of cardiac catheterization were discussed fully with the patient and accepted.

The patient was premedicated with 25 mg of meperidine and 1 mg of Versed intravenously for mild sedation. An IV of D5W was started in the patient's left forearm.

The inguinal areas were prepped and draped in the usual sterile fashion. The right inguinal area was infiltrated with 2% Xylocaine hydrochloride for local anesthesia.

Using a modified Seldinger technique, the right femoral vein was entered and a 7 French USCI sheath was inserted and flushed. A 7 French Critikon catheter was inserted under fluoroscopic guidance into the right atrium.

Intracardiac pressures were then recorded in a sequential fashion from the right atrium, right ventricle, pulmonary artery and pulmonary capillary wedge position.

A pullback was performed into the pulmonary artery. A blood sample was obtained for oximetry. A right heart pullback was then performed, and the catheter was positioned in the distal inferior vena cava.

Attention was then turned to the right femoral artery. Using a similar modified Seldinger technique, the right femoral artery was entered and a 7 French USCI sheath was inserted and flushed.

A 7 French Cordis high flow JL4 catheter was inserted into the descending aorta. The catheter was flushed and systemic pressure was recorded.

Then, 5000 units of heparin sulfate was administered intra-arterially. A blood sample was obtained for oximetry. The catheter was positioned under fluoroscopic and hemodynamic control into the left coronary ostia.

Selective left coronary arteriography was performed in both the left and right anterior oblique projections, as well as the left lateral projection. Varying degrees of cranial and caudal angulation were simultaneously utilized. Injections were performed before and after the administration of intravenous nitroglycerin.

The catheter was replaced with a 7 French high flow Cordis JR4 catheter. The catheter was positioned under fluoroscopic and hemodynamic control into the right coronary ostia and right coronary arteriography was performed in a similar fashion.

This catheter was then replaced with a 7 French high flow Cordis pigtail catheter and under fluoroscopic and hemodynamic guidance the left ventricle was entered retrograde across the aortic valve and pressure was recorded.

Ventriculography was then performed in both the RAO projection and the LAO projection with cranial angulation. All catheters were removed and the heparin effect was reversed with 20 mg of protamine sulfate.

The sheaths were removed and pressure was applied until hemostasis and a satisfactory pulse were assured. The patient was returned to the floor in satisfactory condition.

Complications: None.
Results, hemodynamics: Please refer to the attached hemodynamic work.

Results, left main coronary artery:
The left main coronary artery bifurcates into the left anterior descending and circumflex vessels. The left main coronary artery is free of disease.

There is excellent collateral filling of the distal vessel provided principally by the right coronary artery vessel. The left anterior descending artery gives rise to a small bifurcating first diagonal branch, which also contains a 90% stenosis.

Results, circumflex coronary artery:
The circumflex coronary artery is a large nondominant vessel containing a 90% stenosis before a bifurcating posterior marginal system.

Results, right coronary artery:
The right coronary artery originates from the right sinus of Valsalva. The right coronary artery is dominant giving rise to the posterior descending branch.

The right coronary artery contains serial proximal and mid stenoses that narrow the lumen to 80% and 70% respectively. As noted, the right coronary artery provides collaterals to the left anterior descending artery.

Results, left ventricular angiography:
The left ventricular cavity is of normal size and configuration. The left ventricular systolic function is well preserved with no regional wall motion abnormalities noted except for a very mild anterolateral wall hypokinetic area.

Conclusion:
Severe multivessel coronary artery disease as outlined above.
Normal resting left ventricular systolic function.

Jane Miller, M.D.
TRINITY MEDICAL CENTER, Chattanooga, Tennessee

CLINIC NOTE
BARKER, LISA

HISTORY:
Ms. Barker is a 36-year-old white female who has been seen here in this clinic in visits in the past.

She is here today complaining of multiple joints hurting, especially her right elbow and her left knee. She says that she had been a patient of Dr. Stetter several years ago and had been diagnosed with rheumatoid arthritis. She quit seeing him and had only been taking aspirin in the interim period.

Over the last year, she has had increasing difficulty and pain in her joints and especially a lot of stiffness in the morning that takes at least 45 minutes to an hour to work out. She said multiple joints give her trouble, including her right elbow, both of her knees, both of her ankles and her wrists and some in her fingers.

After the stiffness leaves in the morning, she will usually be okay at work during the afternoon, and then it will return once she relaxes at night. It has become so in the last few days and weeks that she just could not tolerate it any more and needed attention. She also complains of chronic fatigue and just a little energy for several months.

Says her appetite has been good but she has been gaining weight without really trying to. She has noted no cold intolerance, no changing in her voice, no heart palpations. She has no GI complaints and no respiratory complaints.

CURRENT MEDICATIONS: Aspirin.
ALLERGIES: No known drug allergies.

FAMILY HISTORY:
Rheumatoid arthritis in her grandparents. Mother with hypertension and a stroke at age of 52. Father with heart disease.

SOCIAL HISTORY:
She smokes a pack a day for at least 12 years, rarely uses alcohol. Denies intravenous drug use. She works in a janitorial position.

PHYSICAL EXAMINATION:
In general, pleasant, in no apparent distress. Alert and oriented times 4.

No gland lymphadenopathy or JVD. Chest is clear to auscultation bilaterally. Cardiac exam regular rate and rhythm. No murmurs, rubs or gallops. Abdomen soft nontender, nondistended. Normal active bowel sounds. No organomegaly. Extremities without edema, strong distal pulses.

MUSCULOSKELETAL EXAMINATION:
There are no trigger points noted. No crepitus in the joints is noted. There is some synovial thickening throughout the MCPs and PIPs and bilateral hands. Some mild active synovitis between the second and third MCP on the left. No rheumatoid nodules noted. No rashes. No effusions in her knees. She has full range of motion in all joints.
