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Firstly, would it be Impression: (instead of "colon") Negative mammography...

Posted By: MT50 on 2008-01-30
In Reply to: s/l colon negative mammography and birentalin. ??? Thanks in advance. - Jenn

Subject: Firstly, would it be Impression: (instead of "colon") Negative mammography...




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s/l colon negative mammography and birentalin. ??? Thanks in advance.
Subject: s/l colon negative mammography and birentalin. ??? Thanks in advance.


Mammography word
Subject: Mammography word

Hi, the doc dictates


"The right mammogram unilateral digital examination was performed which demonstrated no mammographic "corila" to benign cystic changes. 


I am not sure what corila is or the correct spelling.


Any help would be appreciated. 


Thank you. 


BI-RADS score, Lauren!!!!! It classifies mammography results comprehensively.
Subject: BI-RADS score, Lauren!!!!! It classifies mammography results comprehensively.

Aacck = correct that report


BI-RADS
Wet-prep shows negative whiff, 10-20 WBCs, negative clue, few s/l "LB's". Is LB's right?
Subject: Wet-prep shows negative whiff, 10-20 WBCs, negative clue, few s/l "LB's". Is LB's right? nm


gram-negative, lactose-negative rods is correct. I found a couple of interesting websites SM
Subject: gram-negative, lactose-negative rods is correct. I found a couple of interesting websites SM

after doing a google search for gram-negative, lactose-negative rods.  Basically testing organisms to see if they ferment lactose (positive) or not (negative).


Also, just FYI, gram-negative is not capitalized.


Probably too late, I'm sure.  Better late than never, I guess. 


Ortho - negative straight leg raise and negative s/l Lasek??
Subject: Ortho - negative straight leg raise and negative s/l Lasek??


She had a negative s/l clasp thumb test and a negative Finkelstein's.
Subject: She had a negative s/l clasp thumb test and a negative Finkelstein's.

:-)
McMurray's negative. Lachman's negative. nm
Subject: McMurray's negative. Lachman's negative. nm


McMurray negative. Lachman negative. No 's at end
Subject: McMurray negative. Lachman negative. No 's at end

x
Patient has a negative wrist extension sign on the right and a negative s/l 3rd finger sign on the R
Subject: Patient has a negative wrist extension sign on the right and a negative s/l 3rd finger sign on the R


Help with IMPRESSION
Subject: Help with IMPRESSION

Should this be dictated like this?


1.  Hyponatremia, rule out subdural hematoma. 


OR


1. Hyponatremia.


2.  Rule out subdural hematoma.


impression
Subject: impression

type it with a semicolon in between.
Impression
Subject: Impression

Hi Shirl -

Hang in there, this will be old hat to you after a while. Radiology reports are usually pretty standard. Same phrases/terms used by all radiologists.

Some usual headings in a radiology report are:

CLINICAL INDICATION: or INFORMATION: or HISTORY, or variations of any of these.

FINDINGS: or RESULTS:

IMPRESSION: or OPINION:

Start adding the common phrases, like "lung markings" and all the various possible headers as above, to whatever word expander program you have. You'll be flying through reports in no time!
Impression
Subject: Impression

In the impression the doctor says the patient probably has a small perforation of his colonic cancer.
Impression
Subject: Impression

Status post laceration, rigth wrist with repair of partial tear to the s/l FC or FCE tendon.
she may say it again in impression if you haven't got there. nm
Subject: she may say it again in impression if you haven't got there. nm


IMPRESSION prob
Subject: IMPRESSION prob

I have a problem under impression ...


"D: IMPRESSION:  Occipital neuralgia probable acute gastroenteritis"


question: how will I transcribe that? coz Occipital neuralgia is not related to "probable acute gastroenteritis" isn't it? or possibly there was a 2 impression. one, is occipital neuralgia and secondly, acute gastroenteritis?... What's the meaning by the dictator?


NOTE: but the dictator did not dictate any numbering.... 


Assessment or Impression
Is it an AAMT rule to automatically number the diagnoses in the Assessment or Impression of an H&P or soap even if the dictator does not?  TIA!
No, but it is either part of the Impression, or
Subject: No, but it is either part of the Impression, or

the a new section after it.

Thanks :)
Impression - hypertension
Subject: Impression - hypertension

This is under impression on a history and physical examination.


It is a numbered list.


[Sodiunduradine] is hypertension.


Any suggestions would be great!


It was under the impression section
Subject: It was under the impression section

I have heard of that also, but it was under his impressions. This doctor is such a mumble mouth! *sigh*
On impression: MR say pat uremeia.
Subject: On impression: MR say pat uremeia.

Pt with mental retardation.
I would not abbrev it if it is in the IMPRESSION as the poster said.
Subject: I would not abbrev it if it is in the IMPRESSION as the poster said.


it's impression and lung markings....
Subject: it's impression and lung markings....


No, not as a listed diagnosis or impression.
Subject: No, not as a listed diagnosis or impression.


impression, SP - status post
Subject: impression, SP - status post

nm
GI help: Is it diaphragmatic compression or impression
Subject: GI help: Is it diaphragmatic compression or impression

Trying to distinguish between diaphragmatic compression or diaphragm and compression or diaphragmatic impression.  Help appreciated.



Ahhh...that's diaphragmatic impression. nm
Subject: Ahhh...that's diaphragmatic impression. nm


Thanks. Duh. I have to spell out abbreviations in impression. Just could not think. NM
Subject: Thanks. Duh. I have to spell out abbreviations in impression. Just could not think. NM

ss
That is the complete sentence. It is his IMPRESSION.
Subject: That is the complete sentence. It is his IMPRESSION.


Could you post the impression? Might help to shed light. nm
Subject: Could you post the impression? Might help to shed light. nm


impression: bronchiolitis s/l sublets? or other process
Subject: impression: bronchiolitis s/l sublets? or other process


s/l ID or ID8 urine culture. for impression and plan
Subject: s/l ID or ID8 urine culture. for impression and plan


Extrinsic impression ? on the sigmoid colon
Subject: Extrinsic impression ? on the sigmoid colon


I was under the impression it was JCAH mandated to write ml instead of cc. NM
Subject: I was under the impression it was JCAH mandated to write ml instead of cc. NM


Got first one - he says in impression "flow limiting stenosis"
Subject: Got first one - he says in impression "flow limiting stenosis"


Impression: Right MPJ extensor hood rupture SM
Subject: Impression: Right MPJ extensor hood rupture SM

(s/l shrowd ligament rupture).
nevermind it's 'off' axis. He repeated it in the impression much more clearly!
Subject: nevermind it's 'off' axis. He repeated it in the impression much more clearly!


I was under the impression that VAC is an acronym for vacuum-assisted closure.
Subject: I was under the impression that VAC is an acronym for vacuum-assisted closure.

Both Stedmans acronyms and Tessier surgical have it as VAC.
saw the patient, and the impression was s/l brass sediment impaction?(
Subject: saw the patient, and the impression was s/l brass sediment impaction?(


The dictation after just went straight into the impression, so I didn't include it. nm
Subject: The dictation after just went straight into the impression, so I didn't include it. nm

nm
So, if I were to have this abbreviation in the impression or diagnosis, should I expand to carcinoma
Subject: So, if I were to have this abbreviation in the impression or diagnosis, should I expand to carcinoma


Lumbar spine MRI. He says: Impression - ?quiet? degenerative changes.
Subject: Lumbar spine MRI. He says: Impression - ?quiet? degenerative changes.


Cardio. Dictates ostium to TM in Impression. Can't find expansion...
Subject: Cardio. Dictates ostium to TM in Impression. Can't find expansion...

 that makes sense in any references and nothing in rest of dictation that connects.  Got any ideas?


Gracias!


HER negative
Subject: HER negative

Flybye is correct because he definitely said HER negative, not HER2/neu.  Thanks!
With a negative WBC? nm
Subject: With a negative WBC? nm


negative CT?
Subject: negative CT?

nm
O negative
Subject: O negative

j
ER/PR-, HER-2/neu- or can use HER-2 negative...sm
Subject: ER/PR-, HER-2/neu- or can use HER-2 negative...sm

stands for estrogen receptor, progesterone receptor and HER-2/neu gene. 


URI, RSS negative
Subject: URI, RSS negative

Can anyone tell me what the RSS stands for or did I mishear it? 
Seidel negative
Subject: Seidel negative

http://www.mrcophth.com/ophthalmologyhalloffame/seidel.html