Dee tra emphasis? heading under neurologic..
Posted By: nnnnewbie on 2009-04-21
In Reply to:
Subject: Dee tra emphasis? heading under neurologic..
Under physical exam, neurologic, this is given as a subheading....
s/l dee tra emphasis:
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neurologic insults? neurologic lateralization? nm
Subject: neurologic insults? neurologic lateralization? nm
nm Ace inhibitor with the emphasis on the R.
Subject: nm Ace inhibitor with the emphasis on the R.
how about typing Past Medical History heading and then typing what he says under the heading nm
Subject: how about typing Past Medical History heading and then typing what he says under the heading nm
xx
"ON POSS"/?EMPHASIS
Subject: "ON POSS"/?EMPHASIS
Maybe this is a mush-mouth 'emphasis'? (It would make [weird] sense...)
I did find that, but I can't hear that. It sound like end out, with emphasis on the "d" in
Subject: I did find that, but I can't hear that. It sound like end out, with emphasis on the "d" in end. nm
That's the only thing that makes sense, but he puts an emphasis on the "a". But that must
Subject: That's the only thing that makes sense, but he puts an emphasis on the "a". But that must be it. nm
nm
Neurologic:
Subject: Neurologic:
Neurologic: Cranial nerves II through XII are intact. Deep tendon reflexes are 2+. Strength is 5 out of 5. Sensation is grossly intact. Toes are downgoing. Gait is normal. *s/l* bramburg test is normal....
thanks in advance.
neurologic
Subject: neurologic
The word you are looking for is Romberg.
neurologic help please!!
Subject: neurologic help please!!
NEUROLOGIC: A full neurologic examination was performed. Cranial nerves II-XII were grossly intact. ***cerebelli was fine. No *** or drift. Patient’s muscle strength was 5/5 throughout. Patient’s reflexes were +3 upper extremity and also +3 patellar. Toes: The patient had withdrawal response bilaterally.  S/L MILL CEREBELLI WAS FINE. S/L NO POR OR DRIFT...
Neurologic help please, please, please!
Subject: Neurologic help please, please, please!
He has ringing in his ears, as well as s/l vaso "something" episodes when he gets up. Doctor has a cold and he is in a big hurry. Help me.
Neurologic help
Subject: Neurologic help
vasovagal episodes?
NEUROLOGIC.
Subject: NEUROLOGIC.
x
Need help on a neurologic test (sm)
Subject: Need help on a neurologic test (sm)
On neurologic testing he reported diffuse s/l illness to pinprick in both hands. It doesn't sound like numbness at all.
TIA!
neurologic deterioration? nm
Subject: neurologic deterioration? nm
x
Under neurologic, it s/l estrixes.
Subject: Under neurologic, it s/l estrixes.
Neurologic exam help please
Subject: Neurologic exam help please
Doctor dictates: Motor: Strength, bulk and tone are normal throughout. There is no evidence of s/l cogwilling or rigidity.
neurologic or HEENT?
Subject: neurologic or HEENT?
Where will you put "No pain or swelling over the sinus" in the PE?
Neurologic or HEENT.
Neurologic exam
Subject: Neurologic exam
Oh my word - I am LOST! Neurologic exam. Dr. dictates "Cranial ___eros intact" There are possibly two or three words. He has dictated this on two patients in a row - and mummbles on each one. Thanks for any help.
neurologic examination
Subject: neurologic examination
sounds like doc is saying "neurologic examination higher critical function", but could she be saying "neurologic examination hilar cortical function"?
Neurologic exam
Subject: Neurologic exam
Doctor dictates - "There is no localized _____ findings for this age group. (Is for a 1-1/2 year old.)
Sounds kind of like "in-see-nus"
neurologic or neurological
Subject: neurologic or neurological
doc always says, "from a neurologic standpoint." Shouldn't it be from a neurological standpoint?
Musculoskeletal/Neurologic
Subject: Musculoskeletal/Neurologic
You need to head it the way I did in the subject above...
cor is the heading. sm
Subject: cor is the heading. sm
Some say Cardiac: S1 S2 etc. Some say COR: which means heart. They are just using that heading instead of CARDIAC, HEART,etc.
What heading would you use?
Subject: What heading would you use?
Okay to add headings on OP report. MD states: "Staples for skin" in the upper area with diagnoses, complications, condition....
Thanks.
Under what heading would you SM
Subject: Under what heading would you SM
put inguinal hernia in a PE? Would it be abdomen?
TIA
EKG can be a Heading
Subject: EKG can be a Heading
I would put under EKG alone as
EKG: EKG today show no ST wave changes.
Heading?
Subject: Heading?
This is for a psych. consult. After saying "New paragraph", he says "Review of past medical records." and then launches into: Doctor diagnosed tachycardia..etc.
I haven't seen a consult. with a heading, main or sub, with Review of Past Medical Records. Past Medical History, yes, but not the other. Any ideas?
Neurologic- s/l prineal moves
Subject: Neurologic- s/l prineal moves
Prinale moves 2-12 in text, each within normal limits??? I know this isn't correct. ideas?
PMH s/l spa-la-mic stroke, no neurologic sequella. nm
Subject: PMH s/l spa-la-mic stroke, no neurologic sequella. nm
d
Hoffman's is neurologic sign
Subject: Hoffman's is neurologic sign
Sorry about that.
Neurologic Exam... S/L 11 Ryandi?
Subject: Neurologic Exam... S/L 11 Ryandi?
NEUROLOGIC: 11 "Ryandi" x2. 2+ CTA
mumbled neurologic exam
Subject: mumbled neurologic exam
positive cervical s/l COMP test (neck)
S/L com test or comp test - I dunno. He has a mouth full of cotton balls.
See this link under neurologic exam etc. sm
Subject: See this link under neurologic exam etc. sm
http://mtdesk.com/word-lists/
CMT maybe...it's a debilitating neurologic disorder.
Subject: CMT maybe...it's a debilitating neurologic disorder.
Charcot Marie Tooth
Oops, used same heading, need help
Subject: Oops, used same heading, need help
Sterile vaginal exam of 3 cm dilatation, 50% s/l "patient moderest through eustachian".
Thanks
IV abbreviated in heading
Subject: IV abbreviated in heading
Can IV FLUIDS be a heading or does it need to be INTRAVENOUS FLUIDS per the BOS?
under abdomen heading
Subject: under abdomen heading
s/l "the PICC was created" or "the tic was created"
Angie
Is it in the heading or in a sentence?
Subject: Is it in the heading or in a sentence?
I wouldn't change it in the heading, but if it sounds awkward in the sentence and your client doesn't want verbatim....
Thanks! But which book under what heading? I tried with
Subject: Thanks! But which book under what heading? I tried with
s
I think doc left heading out sm
Subject: I think doc left heading out sm
He dictates, "Skull does reveal evidence of hydrocephalus with enlarged cranium. Asymmetrical, moving equally with respiration. HEART: PMI could not be localized. S1 and S2, distant heart sounds. No S3 gallop. No murmur. LUNGS: Clinically clear.
What would be asymmetrical here?
I would put it under a heading of NECK. sm
Subject: I would put it under a heading of NECK. sm
One of the tests for meningitis is to bend your chin to your chest or to your shoulders. So if the pateint can to this, they have no meningeal signs or meningismus.
MUSCULOSKELETAL heading?
Subject: MUSCULOSKELETAL heading?
Newbie here. I'm typing an H&P and under instruction to supply appropriate headings & subheadings if they are not dictated, esp. in an H&P.
Under the Physical Examination, the Dr. dictated most headings, but under ABDOMEN, she continued with what I think is more of a musculoskeletal exam:
ABDOMEN: His abdomen is rotund, nontender, nondistended, and soft. He has no costovertebral angle (CVA) tenderness to percussion. He has no thoracic tenderness to palpation. His pain begins at approximately L2 down to his sacrum, with pain greater down his right gluteus versus his left, but does have pain. He has slow movement and grimaces with any movement. He is able to stand. Decreased range of motion secondary to pain. Straight-leg reflex painful in both legs. Reflexes are diminished bilaterally.
Here is my question: I cannot find a precedent for adding the MUSCULOSKELETAL subheading. Yet beginning from "His pain" and following is not really under an ABDOMEN exam, is it? At the very least, I feel I should start a new paragraph, but then my format is messed up b/c everything else has a subheading!
Needless to say, it stresses me out a bit. Any advice is definitely appreciated!
A lot of facilities use the heading
Subject: A lot of facilities use the heading
"laboratory" or "laboratory data" to include labs, EKGs, radiology, etc.
what PE heading would you put pilonidal under?
Subject: what PE heading would you put pilonidal under?
Just wondering under what physical exam heading other MTs put this finding under.
TIA!
No it is definetly not a heading.
Subject: No it is definetly not a heading.
I believe he is trying to say bladder urine was obtained. It could be his mis-spoke. I just wasn't sure. Thanks for your help.
A doctor can put in any heading they
Subject: A doctor can put in any heading they
want. I would use it and go on.
Followup as heading?
Subject: Followup as heading?
I'm embarrassed to have to ask this, but as a heading, which is correct--followup, follow-up, or follow up?
"nystagodenesia" neurologic exam for concussion. thanks
Subject: "nystagodenesia" neurologic exam for concussion. thanks
Guillain-Barre? neurologic syndrome/ds.....nm
Subject: Guillain-Barre? neurologic syndrome/ds.....nm
x
Neurologic... don't know why that one didn't cross my mind thank you
Subject: Neurologic... don't know why that one didn't cross my mind thank you
Sorry, new to plastic surgery. I believe that lateralization is correct. thank you all!!
No dx. It is just in a list of meds in a neurologic note
Subject: No dx. It is just in a list of meds in a neurologic note
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