Is this before the surgery or as you're entering the abd on the op report? nm
Posted By: wanderer on 2007-01-19
In Reply to: OB question - C-section - PAMT~MDM
Subject: Is this before the surgery or as you're entering the abd on the op report? nm
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- OB question - C-section - PAMT~MDM
- Is this before the surgery or as you're entering the abd on the op report? nm - wanderer
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Need help with surgery report...
Subject: Need help with surgery report...
Working on hemorrhoidectomy operation and not having much luck with equipment used, namely brand names which I can't seem to find reference for. Thanks.
'Once anesthesia had been noted to be induced, s/l Kelly clips were placed at the area of the right posterior pedicle and subsequently retracted laterally.'
'The s/l Bakes were taken to extend the hemorrhoid base from the underlying sphincter muscle and subsequently the harmonic scalpel was used to excise the lesions at their base in a hemostatic fashion.'
'As such, a s/l golfball dressing was applied to the patient’s anus and further dressing was applied.
ortho surgery report
Subject: ortho surgery report
doctor dictates: Aesculap Spectra anterior cervical plate with MTF bone, s/l drain 1 deep JP.
does that make sense that way??? drain 1 deep JP
While entering into the bladder, *a small, uh, pose* passage... (SM)
Subject: While entering into the bladder, *a small, uh, pose* passage... (SM)
was noted in the urethra. We then changed to a 70-degree lens, and the bladder was systematically scoped in the usual fashion.
ESL seems to be correcting himself, but I can't figure out. Any ideas?
He said more clearly in another report. You're right! nm
Subject: He said more clearly in another report. You're right! nm
Sounds like you're Q/Aing my report I sent in today! Those were the words I couldn't make out!
.
takedown surgery vs take down surgery--which is correct? nm
Subject: takedown surgery vs take down surgery--which is correct? nm
I personally transcribe buttock if they're referring to one side, and buttocks if they're refe
Subject: I personally transcribe buttock if they're referring to one side, and buttocks if they're referring to both or the whole thing....nm
pardon me? of course they're science terms, but they're also MEDICAL terms...see link
Subject: pardon me? of course they're science terms, but they're also MEDICAL terms...see link
http://www.americanmedicalsystems.com/womens_product_category_objectname_female_vaginal_prolapse_prod.html
Eye-orbit-surgery or I orbit surgery for a fracture
Subject: Eye-orbit-surgery or I orbit surgery for a fracture
Nothing else to add, it was in the past surgical history thanks all.
EKG report
Subject: EKG report
"No weeshnoblomotion abnormalities are identified." What is that word?
thanks everyone. One more report and then I am going to bed.
Subject: thanks everyone. One more report and then I am going to bed.
nothing more to add about the report unless
Subject: nothing more to add about the report unless
the patient had an implanted pacemaker which is not eluded to here. Just a note, adenosine is not capitalized except to start a sentence.
Maybe you will hear something back.
d~
Sorry, same report...
Subject: Sorry, same report...
"CPK and _______ were negative" s/l intraconals??
Still on the pulmonologist's report...
EEG report
Subject: EEG report
Anyone ever heard of an EEG performed on a Nikon Codon machine? Thanks.
just sent the report on.........nm
Subject: just sent the report on.........nm
x
op report sm
Subject: op report sm
What kind of surgery is it? If he used "lap" laparotomy pads may be the second one. They usually say sponge, needle and instrument counts. Will keep thinking on this one. Type of surgery would help.
You don't say where in the report -- sm
Subject: You don't say where in the report -- sm
this is given, or any other context, so I have to wonder if this isn't a problem list perhaps giving more than one diagnosis/problem here (as in (1) portosystemic shunt and (2) nephrolithiasis)...
Just a thought
ENT report - sm
Subject: ENT report - sm
Does include sinus surgeries, Caldwel-Luc surgery. Is also on Flonase. Patient is actually here regarding Grave's disease. I'm wondering if this is Relpax D, but I'm not able to verify that as a drug. Any suggestions?
ENT OP report help, please...
Subject: ENT OP report help, please...
Vocal cord lesion biopsy -
Peripheral -s/l orb or oral- sinuses were intubated to their apices and were normal.
Specimen was sent -s/l informal- and for pathology.
TIA!
OP report
Subject: OP report
OP report, lumbar spine
Next, fluoroscopy was used to place new screws at the L2-3 segment. Starting points were identified at the confluence of the midpoint of the transverse process, the **manloid** process, and the pars interarticularis
He really mumbles through this part, so I am just not sure, but I have not heard this term used before. Thanks!
op report help please sm...
Subject: op report help please sm...
FINDINGS: Epidurogram revealed normal (s/l-cephaloquadet-) contrast flow outlining the right L5 nerve root sleeve in the epidural space with good flow achieved medial to the right L5 pedicle. The patient did experience some concordant L5 symptoms on the right side during the injection. Vital signs remained stable throughout.
OP Report
Subject: OP Report
Hi all! I am doing an OP for a lumbar spine surgeon, but this is just for an I&D. He says the area was probed with "sucker tips" and was found to be subfascial. I am not too comfortable with what I am finding online for this. Has anyone heard this before? Thanks!
OP report help, please
Subject: OP report help, please
Patient was premedicated with intravenous s/l Benadryl.
Would that be right?
report does not say .. but says she is on BC
Subject: report does not say .. but says she is on BC
help with op report
Subject: help with op report
I never do op notes! The sentence reads:
The S/L RAFFAY between the anterior and middle deltoids was then opened. TIA!
Doing EMG report sm
Subject: Doing EMG report sm
The patient has focal severe slowing primarily in sensory fibers in the right upper extremity, on multiple restimulation unable to elicit a response to both s/l "Palmar 8" studies.
I can't find this anywhere. Anybody have any ideas? Thanks!
I wish I could see the report, but
Subject: I wish I could see the report, but
could she be saying communication, as in an opening has formed between 2 sinuses or something?
It is so frustrating to be given only a tidbit of a report instead of being able to puzzle it out from what is going on with the patient.
Thanks, but as I'm into the report it
Subject: Thanks, but as I'm into the report it
sounds like this is some weird wording for microscopic blood.
I've done thousands of endoscopy reports and GI consults, but I can't think why he'd say "affobiddy positive stool" instead of something about occult blood or microscopic blood.
ER report. Sm please
Subject: ER report. Sm please
The patient has a 4 mm calcification on the pelvis on the right which may represent a s/l flevolith, thus a right ureteral calculus could not be entirely occluded.
OP report
Subject: OP report
general s/l elam anesthesia. New to OP reports! TIA
Thanks! That's how I did it in the report nm
Subject: Thanks! That's how I did it in the report nm
OP report
Subject: OP report
s/l -fecal lift- at the base of the appendix
C-sec report
Subject: C-sec report
Does this by some chance have to do with cephalodisproportion, because I looked up Jill Cohen - C-section in google, and there is somebody named Jill Cohen and it talks about labor and delivery and C-section and something this lady wrote about it. Could this be it. Check it out on google.
PT report
Subject: PT report
S/l ESTEEM for pain management?
report
Subject: report
Does any one know focal tics of sounds like aphitical movements. Thank could use the help.
TEE report - Need help
Subject: TEE report - Need help
" NO BUBBLES ___________ FROM RIGHT TO LEFT SIDE" s/l caused. He also said bubble study was done with 9 mL normal saline and "a cc" of air. Is this written 1 mL?
per report
Subject: per report
The only diagnosis is bipolar, duh!
was my last report of the day
Subject: was my last report of the day
and he was getting to me! my least favorite account, lots of bad dictators
MRI report s/m
Subject: MRI report s/m
MRI of the brain shows what looks to be an acute infarct on DWI on the right brainstem area, which were also changes seen on the T2 weighted - s/l anuses - suggesting that this is probably an infarct, which occurred 7-10 days ago.
any ideas cuz I'm pretty sure there are no weighted "anuses" in the brain, at least not identifiable by MRI.
op report help
Subject: op report help
Doc states that the the articular surface of the lateral tibial plateau was then s/l stacked as was the weightbearing surface of the lateral femoral condyle.
Thanks
It's an EGD report .... sm
Subject: It's an EGD report .... sm
He states, "Instruments used were a Fujinon esophagogastroduodenoscope and a ________ bougie #54."
He later states, "The ________ bougie was passed easily."
GU op report help please
Subject: GU op report help please
I tried to dilate the urethra with s/l male sounds, but they would not pass easily due to the false passes. (Talking about bladder stones).
He says it clearly, but I've never heard of these nor can I find it. Can't find anything under "Mayo" either thinking perhaps it was an instrument of some kind.
GU op report help please
Subject: GU op report help please
Could it be Dittel?
CXR report...SM
Subject: CXR report...SM
The findings of the daily CXR on this patient are stable and unchanged, but the dictator gets to the "impression" and says: s/l peri-grass--ity of the chest radiograph.
I'm sure this is something simple and I should know it - it's probably a "normal" word. But my brain is just not working tonight. Help?
OB/GYN report...
Subject: OB/GYN report...
x
ORS Report??
Subject: ORS Report??
Hi I am typing an ER report that says this:
The patient had an ORS?? report performed that shows he has had 24 prescriptions for narcotics.
I know there is a report the doctors can get but I cannot find it anywhere! Please help!!!
This is it. He said it again later in the report
Subject: This is it. He said it again later in the report
thanks.
H & P Report
Subject: H & P Report
On an H & P report after you have typed the plan and then they repeat the vital signs is that a new category and if so what should the heading be, or is is set off in a new paragraph, or is just part of the plan. I'm a little confused as to how to put it at the end of the report.
H & P Report
Subject: H & P Report
Depends on your company or facility. My personal preference is to insert VITAL SIGNS into the physical exam portion of the dictation, right after GENERAL APPEARANCE or PHYSICAL EXAM. However, you have to follow the dictates of your employer.
H & P Report
Subject: H & P Report
She does indicate that info under VITAL SIGNS in the beginning. This is like a recheck at the end of her report. This is what she says:
His repeat vital signs: His heart rate was down to 107. His blood pressure was 124/86, and he was able to stand and move with greater ease.
ER report
Subject: ER report
CHIEF COMPLAINT
Leg swelling and pain.
Patient is admitted for an (s/l extorium). Patient is an alcoholic and usually drinks hard liquor.
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