I use IMAGING as the heading for EKG, CAT scans, etc.
Posted By: MTISME on 2008-09-24
In Reply to: EKG-cardio or labs? - michelle
Subject: I use IMAGING as the heading for EKG, CAT scans, etc.
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sounds like he means it is a vicious circle going from CAT scans to PET scans and back again...nm
Subject: sounds like he means it is a vicious circle going from CAT scans to PET scans and back again...nm
ultrasound? 3D imaging, digital imaging...
Subject: ultrasound? 3D imaging, digital imaging...
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
s/l go-wan 2 3 uptake scans nm.
Subject: s/l go-wan 2 3 uptake scans nm.
d
bone scans
Subject: bone scans
Recently had a bone scan which indicated osteopenia with a hip of minus 1.1.
Is that the result of the hip (part of body) or does hip stand for something else? New to this and slightly confused 
inside the two scans?
Subject: inside the two scans?
first one is transverse and longitudinal scans
Subject: first one is transverse and longitudinal scans
k
localizer scans are often used, but not sure if you are hearing a name brand or not? nm
Subject: localizer scans are often used, but not sure if you are hearing a name brand or not? nm
x
they give oral contrast for CT scans also.
Subject: they give oral contrast for CT scans also.
,
Pt with dyspnea on exertion. Test s/l macro allogetted albumen lung scans"
Subject: Pt with dyspnea on exertion. Test s/l macro allogetted albumen lung scans"
The patient went through an extensive workup that included cardiopulmonary exercise testing, __ lung scans, CT angiograms, cardiocatheterization, echocardiograms, and pulmonary function testing.
imaging
Subject: imaging
neuroimaging
imaging help please sm
Subject: imaging help please sm
The patient has an MRI from February 2008. There is degenerative disk disease at L5-S1 with loss of s/l-tituated- signal and collapse of 10%.
pan CT imaging?
Subject: pan CT imaging?
Hello there, it sounds like my doctor is saying "pan CT imaging." Does the "pan" part seem right?
orthopedic imaging
Subject: orthopedic imaging
All pedicle screws appear perfectly placed. There is s/l wa-bat-i-cal im-eth of the lumbar spine.
Thank you!
MRI? T-2 ?waited imaging
Subject: MRI? T-2 ?waited imaging
The pt is "Status post left image guided fiberoptic endoscopic sinus surgery/frontal trephination for left chronic frontal sinusitis. Status post septoplasty for septal deviation. History of sub-periostial abscess. History of frontal subdural empyema. Possible frontal bone osteomyelitis"
MRI with and without gadolinium obtained today shows evidence of a signal enhancement in the frontal recess and the frontal sinus on "T 2 waited" images."
What is the proper way to transcribe "T2 s/l ?waited? images?
Thanks in advance
weighted imaging. sm
Subject: weighted imaging. sm
Here is link from Wheeless with more info on T2 weighted imaging.
MRI: T2 Discussion - Wheeless' Textbook of Orthopaedics
MRI: T2 Discussion ... T2 in milliseconds is the time necessary to reduce transverse
magnetization to 37 % of its original value following the RF pulse; ...
www.wheelessonline.com/ortho/mri_t2_discussion - 27k - Cached - Similar pages
Here is MRI glossary.
http://www.cis.rit.edu/htbooks/mri/gloss.htm
Doppler imaging?
Subject: Doppler imaging?
nm
MAA total-body imaging? sm
Subject: MAA total-body imaging? sm
Abnormal brain perfusion demonstrated by Tc-99m MAA total-body ...
This paper describes abnormal brain perfusion unexpectedly demonstrated by Tc-99m MAA total-body imaging in two children with intracardiac right-to-left ...
www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9839493&dopt=Abstract - Similar pages |
I googled it and got a hit on Open Imaging
Subject: I googled it and got a hit on Open Imaging
nm
Just my opinion but I would go with neuro imaging
Subject: Just my opinion but I would go with neuro imaging
bio-fluorescence imaging microscope?
Subject: bio-fluorescence imaging microscope?
repeat imaging of the "cerinex?
Subject: repeat imaging of the "cerinex?
This sounds like cerinex or serinex and has to do with right sided numbness and tingling. Any ideas?
s/l secar resolution imaging
Subject: s/l secar resolution imaging
(2 mm secar) resolution images obtained
Google Open Imaging of Redwood for that
Subject: Google Open Imaging of Redwood for that
nm
A place for x-rays s/l 8alanick imaging* in NJ. Thanks. nm
Subject: A place for x-rays s/l 8alanick imaging* in NJ. Thanks. nm
I can find Ceretec as an imaging agent. nm
Subject: I can find Ceretec as an imaging agent. nm
s
Hi, usually "lamina" would following in diagnostic imaging and neuro.....nm
Subject: Hi, usually "lamina" would following in diagnostic imaging and neuro.....nm
nm
So far all I have found is TIM for total imaging matrix. Will keep digging. nm
Subject: So far all I have found is TIM for total imaging matrix. Will keep digging. nm
Tim (Total imaging matrix
HPI Radiology Imaging Wrokds and Phrases shows ...
Subject: HPI Radiology Imaging Wrokds and Phrases shows ...
tail of Spence.
From internet: The tail of Spence (axillary tail) is the portion of the breast that extends into the axillary ...
Pt with headaches had an MRI open imaging "of redwood". Nm
Subject: Pt with headaches had an MRI open imaging "of redwood". Nm
blunting. Hear it often in imaging studies of the knee.
Subject: blunting. Hear it often in imaging studies of the knee.
x
s/l either "multiplanar or multiplane" and multisequence MR imaging of the right shoulder was
Subject: s/l either "multiplanar or multiplane" and multisequence MR imaging of the right shoulder was SM
performed. I am new at this MRI stuff and when I google it, multiplanar has more hits than multiplane... but it sounds more like multiplane... Any idea?
actually, it's BI-RADS (Breast Imaging-Reporting and Data System) nm
Subject: actually, it's BI-RADS (Breast Imaging-Reporting and Data System) nm
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?
was then passed into the superior vena cava under fluoroscopic imaging with 10-French peelelanducer
Subject: was then passed into the superior vena cava under fluoroscopic imaging with 10-French peelelanducer
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.
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