Doubt with cervical myelogram
Posted By: sami on 2008-10-07
In Reply to:
Subject: Doubt with cervical myelogram
Dictating in 2 position:
1. _____(codstone) bone graft is in excellent position.
2. HIs ____(po*city) of bone formation along the edges of _____(c*stone) graft, which is unexpected in more cortical nature.
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cervical MYELOGRAM
Subject: cervical MYELOGRAM
Sorry for the typo!
cervical myelogram
Subject: cervical myelogram
You're very welcome.
Pt with cervical spine pain. She has completed her CT myelogram as well as s/l tunnel gram.?? tia
Subject: Pt with cervical spine pain. She has completed her CT myelogram as well as s/l tunnel gram.?? tia
dynamic cervical changes (i.e. opening and closing of the inner cervical os during examination
Subject: dynamic cervical changes (i.e. opening and closing of the inner cervical os during examination
Would it be appropriate to say cervical paraspinal or cervical paraspinous? SM. TIA.
Subject: Would it be appropriate to say cervical paraspinal or cervical paraspinous? SM. TIA.
He was diffusely tender in the lumbar paraspinal or paraspinous? and spinous process area.
doubt
Subject: doubt
_____ (Evos) of a 40-year-old female who comes in to the office for follow up on chronic.....
You are without a doubt - sm
Subject: You are without a doubt - sm
a very unhappy person. I feel very sorry for you.
Any doubt
Subject: Any doubt
on vitals or med doses...ALWAYS A BLANK. :-)
equivocal - no doubt about it.....*LOL*
Subject: equivocal - no doubt about it.....*LOL*
Well, I doubt that would help her diet!!
Subject: Well, I doubt that would help her diet!!
I would - but I doubt they'd listen
Subject: I would - but I doubt they'd listen
If you're QA, though, I can nominate you for QA of the month! You deserve it.
Strongly doubt it
Subject: Strongly doubt it
nm
grammar doubt
Subject: grammar doubt
today for routine (follow up or followup) of hypertension.
grammar doubt
Subject: grammar doubt
follow up
doubt with radiology again
Subject: doubt with radiology again
Bony _____ (s* ---- tion) projects the distal right of the radial styloid process, which does not appear to be posttraumatic.
CT Brain doubt
Subject: CT Brain doubt
A 5-mm-thick _____ obtained through the brain with intravenous administration of contrast.
THANKS-don't you hate it when you doubt yourself?
Subject: THANKS-don't you hate it when you doubt yourself?
In degrees of ROM or in end range or ROM? I doubt sm
Subject: In degrees of ROM or in end range or ROM? I doubt sm
it is Dupuytren etc. nm
Thanks for replying. You confirmed it for me so no doubt now.
Subject: Thanks for replying. You confirmed it for me so no doubt now.
Ct abdomen and pelvis doubt
Subject: Ct abdomen and pelvis doubt
multiloculated or ____ (simi subtrated) cyst in the pancreatic map.
No, I doubt it since grip strength was 35/50..
Subject: No, I doubt it since grip strength was 35/50..
something else starting with a T that is only 11-12 pounds.
Using a question mark to indicate doubt or uncertainty sm
BOS says:
Use an ending question mark to indicate doubt or uncertainty.
Sometimes, particularly with diagnoses, a question mark is placed before a
statement in order to indicate uncertainty.
Placement either before or after the questionable material is acceptable, but
do not place the question mark both before and after.
Ex:
His cholesterol levels were high normal (or minimally elevated?).
D: Diagnosis: Angina question mark
T: Diagnosis: Angina?
or Diagnosis: ?Angina.
not Diagnosis: ?Angina?
Note: There is no space after the question mark in ?Angina.
=)
Rennie
www.renesue.com
I doubt highly that a stricture or lesion would
Subject: I doubt highly that a stricture or lesion would
improve a patient's nutritional status., but rather do the complete opposite. I think the physician meant to dictate "GI" physician since he/she mentioned the dysphagia in the dictation, which is also a common place for strictures or lesions to develop.
Client preferences rule here. If in doubt, sm
Subject: Client preferences rule here. If in doubt, sm
here's what I've always done:
He was given a do-not-resuscitate order.
I think my high school English teacher would prefer it thusly;)
He was given a "do-not-resuscitate" order.
Like Txczech said, sometimes these are bolded and capitalized to alert treating physicians of patients' wishes, similar to allergy statements. Client preference, again.
Unless you know for sure that the client does not have a special order called the Do-Not-Resuscitate Order, lowercase it. (I think this is what you might have been considering.)
Yes, you look them up and learn which are band name, which are generic. When in doubt, look up again
Subject: Yes, you look them up and learn which are band name, which are generic. When in doubt, look up again. nm
c
Meds and dosages scare me, so when in doubt...
Subject: Meds and dosages scare me, so when in doubt...
I always blank/flag it. 
Doubt you give 15 refills for narcotics.
Subject: Doubt you give 15 refills for narcotics.
x
Exam is consistent with pancreatitis. I seriously doubt s/l stumpitis
Subject: Exam is consistent with pancreatitis. I seriously doubt s/l stumpitis
I would think it is herald unless he is speaking of a person with the name Herold, which I doubt.
Subject: I would think it is herald unless he is speaking of a person with the name Herold, which I doubt.
Yep...not an easy one. Would doubt it if he hadn't said it so many times. Thinking something lik
Subject: Yep...not an easy one. Would doubt it if he hadn't said it so many times. Thinking something like coronary obstruction artery "something" syndrome...? Just can't get it :( THanx though!
It's too late to tell you to leave a blank. Doubt "os finder." nm
x
I doubt it, as appendiceal is relating to the appendix and cystocele relating to the bladder.
Subject: I doubt it, as appendiceal is relating to the appendix and cystocele relating to the bladder.
try cervical os
Subject: try cervical os
cervical rib
Subject: cervical rib
Cervical os
Subject: Cervical os
xx
cervical??
Subject: cervical??
ss
cervical os
Subject: cervical os
how about cervical?
Subject: how about cervical?
especially if he is slurring, it won't even sound like cervical...just a guess.
RE: Pt with cervical strain..
Subject: RE: Pt with cervical strain..
s/l Flannel
re a spine dx could it be
foramina or foraminal?
Cervical can mean other than spine..(sm)
Subject: Cervical can mean other than spine..(sm)
it's also used as a general reference to the "neck" portion of a structure. So where you would probably say cysts in the neck of the pancreas, he's saying cervical (meaning here neck of the pancreas) cysts.
cervical syrinx
Subject: cervical syrinx
I found syrinx, a fluid filled cavity thatdevelops in the spinal cord
could it be just C2 - the cervical vertebrae?
Subject: could it be just C2 - the cervical vertebrae?
x
Doing cervical spine and it seems he is saying
Subject: Doing cervical spine and it seems he is saying
there is normal s/l imbrication. Also, he says what sounds like "There is no listhesis." Help please, I am new at this.
Thanks much :)
C3, C4, and C5 for cervical spine
Subject: C3, C4, and C5 for cervical spine
It is in the AAMT BOS.
Cervical spine OP
Subject: Cervical spine OP
Following decompression, a s/l coddler was used to protect the exposed dura.
This guy is an ESL, and I cannot verify a term for this. Thanks for any help!
cervical radiculopathy?
Subject: cervical radiculopathy?
nm
cervical s/l geneketics . . .
Subject: cervical s/l geneketics . . .
it's in the preoperative diagnosis, procedure performed is cervical epidural injection. Thanks
cervical stenosis...
Subject: cervical stenosis...
It sounds like this doctor is saying pigmotic or thigmotic os. The patient has a history of extreme cervical stenosis. Any ideas would be appreciated.
Sorry cervical instead of cerical.
Subject: Sorry cervical instead of cerical.
Sorry, cervical spine..........sm
Subject: Sorry, cervical spine..........sm
Doc dictates: There does appear to be good decompression of the neural elements with arthrodesis across these regions.
Yes, after cervical spine.
Subject: Yes, after cervical spine.
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