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我最近在美国北部临床见习，为了方便大家学习原汁原味的医学英语，鄙人花了九牛二虎之力手抄了他们神经外科医生向另一个医生转病人的信（见下文），现与诸位同仁共享。诸位可以从中看出人家认真负责的态度，在美国，所有病史文件都是由医生口述录音成电子文件，然后由专门的工作人员打成文字存在病例管理系统里的。这类打字工作人员根本不到医院上班，他们只是每天从网络上下载录音文件，然后打完字后再将文本文件上传即可。美国之所以走在世界第一的位置，从人家医生的工作效率可见一斑。我在美国见过有些老医生也是用两个食指打字的。他们70多岁仍在工作，因为他们只要能说话就行了。

cc：为保护医生和病人的隐私，姓名已作相关处理，请谅解！本资料仅作学习参考用，请勿随意转载本资料，否则后果自负。

December 13, 2006

R. H. L., MD

RE: S. M. H.
MR#: XXXXXXXX
DOS: 12-13-2006

Dear Dr. L:

I like to keep you informed on your patient, S. H., whom I saw in conjunction with Dr. W. T. in Neurosurgery Clinic. As you recall, she is currently being followed up for intracranial venous sinus thrombosis, intracranial hypertension, papilledema, and meningioma. She states that she is currently off all of her blood thinners except for a daily 81 mg aspirin. She does continue have headaches which have not significant changed. She did have 1 episode of vertigo back in September 2006 that lasted for a few days and was treated with what sounds like to me meclizine. In the November 2006, she had a one severe headache with some increased sensation of pulling on her left eyeball. She does feel like her vision in both of her eyes but more specifically left eye has become more fussy over the last several months. he does not fit her glasses that she brought in July 2006 with a new prescription at that time. She feels like she needs a new prescription now. She does report that her workup for hypercoagulability by Dr. P. was without significant finding. She has no new focal complaints today.

Objective exam reveals well-nourished, well-developed, 62-year-old Caucasian female in no apparent distress. Alert and oriented x3. She has clear and fluent speech. Normal affect. Pleasant personality throughout today's encounter. Cranial nerves 2 through 12 are grossly intact on my examination. She has full strength throughout upper and lower extremities. Nonantalgic gait with no significant difficulty in walking today.

Review by Dr. T. and myself of her MRI and MRV that were completed today shows that her left transverse sinus appears to be patent at this point. There is no significant change in her tumor in terms of size or density.

It appears that Ms. H. is essentially unchanged from her previous condition. We were concerned about performing a lumbar puncture today due to her aspirin. We discussed with the patient it is being reasonable to put that off for several weeks until she is off her aspirin for at least a week prior to attend minimized risk of an epidural hematoma. We did discuss what
the risk and benefits during this and feel that she is stable enough that she will not have a significant neurological decline in the short term by waiting for this to occur. We will have her return nearly prior to January 2006 to complete her lumbar puncture for evaluation of opening pressures. She did discuss scheduling this and do acknowledge the need to be off aspirin for 1 week prior to this.

As always, Dr. T. and I appreciate the opportunity to help provide care for your patients. Should you have any questions, please feel free to contact at your convenience.

Sincerely,
R. D. R., PA (Physician Assistant)

XXXXXX-XXXXX-JOB: XXXXXX
DD: 12-13-2006 12:15 DT: 12-15-2006 06:19

cc: D. A. H., DO
C. L. P.,



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