It's just under and Objective/General section
Posted By: es on 2009-06-09
In Reply to: Don't know what kind of study.... - hotpink
Subject: It's just under and Objective/General section
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quick section (as in frozen section) is correct.
Subject: quick section (as in frozen section) is correct.
x
Here's a general ROS in general order : sm
Subject: Here's a general ROS in general order : sm
(they go from head to toe):
Constitutional, HEENT, Respiratory, (sometimes they give lymphatics before respiratory), Gastrointestinal, Genitourinary, Musculoskeletal (sometimes they say Neuromuscular),
Neurologic,
Endocrinologic, Hematologic,
Psychiatric,
Immunologic/Allergies.
What's missing in your review?
Please help with objective . . .
Subject: Please help with objective . . .
The wound has been cleaned by the nurse, and it looks very good. s/l Pride flesh is starting to form.
TIA for any suggestions!
Objective portion
Subject: Objective portion
does this make sense to anyone
GU and rectum s/l farum are rectal sphincter muscle tone
a few hints for you - when doing the objective
Subject: a few hints for you - when doing the objective
findings, when doc says, for instance, "In general, the patient is..." you are putting that under the "general" subheading, so you don't need to repeat the "in general" part - meaning it would just be GENERAL: The patient is....
same with the skin exam that you have there - if doc is saying "skin is warm and dry," and you are putting it under the "skin" subheading, it should just be "SKIN: Warm and dry" ...and so on.
also, in the HEENT section, it should be "sclerae" and "conjunctivae" - doc is referring to the plural form here.
Does that make sense? This is the way it's usually done, but you'll need to follow the instructions you've been given, of course.
Subjective, Objective, Assessment, Plan=SOAP..
Subject: Subjective, Objective, Assessment, Plan=SOAP..
Twenty-five years ago, SOAP format was still the in-thing, but doctors slowly trended away from it, probably due to medical transcription and formats changing over time. They are easy to do though. 
OBJECTIVE: Left s/l "EEC" is occluded with soft cerumen.
Subject: OBJECTIVE: Left s/l "EEC" is occluded with soft cerumen.
diagnosis: Cerumen impaction.
Objective: Head is held straight with no s/l "lift or lisp"
Subject: Objective: Head is held straight with no s/l "lift or lisp"
C-section or cesarean section sm
Subject: C-section or cesarean section sm
Not cAesarean section - contrary to popular belief, it was not named after Julius Caesar.
C-section or cesarean section nm
Subject: C-section or cesarean section nm
Help with general term...sm
Subject: Help with general term...sm
She says this in the past medical history - negative for any health problems or s/l "renal or anginal disease." But that doesn't make sense as a general term to say.
Thanks!
S/L general ways
Subject: S/L general ways
Patient is ready to be admitted for outpatient surgery tomorrow for right hemicolectomy. When awakened this morning he felt this sharp pain in his right upper quadrant, started having some nausea *** to upper fever of way over 102. (after nausea is sounds like he says general ways to upper fever..."can that be right)? thanks
general malaise? nm
Subject: general malaise? nm
General anesthesia with the use of an s/l LME?
Subject: General anesthesia with the use of an s/l LME?
What is the general consensus on this....sm
Subject: What is the general consensus on this....sm
20-pack-year smoking history or ????
Thanks in advance.
ps: Tara, if your online, I've got the file you need. I'll zip it and send......
general word help
Subject: general word help
On physical doc says slight s/l cog wheeling or something to that nature to explain upper extremities at the elbow. Any ideas?? Cannot find word.
GET - general endotracheal
Subject: GET - general endotracheal
Yes, that's right. It means in general.
Subject: Yes, that's right. It means in general.
Can a general anesthesia be..
Subject: Can a general anesthesia be..
given in "intravenous intubation"? I thought intubation was only a tube in a hollow organ, like the stomach.
General surgeon does, too. nm
Subject: General surgeon does, too. nm
General exam would be fine. (nm)
Subject: General exam would be fine. (nm)
.
Just a general question on format
Subject: Just a general question on format
I have been using these forums for a while now and I keep seeing people using "nm" and "sm". What does this mean?
nm = no message
sm = see message
Just a guess
This is probably so off the mark, but could it be general mask?
Subject: This is probably so off the mark, but could it be general mask?
general range or gommelin????
Subject: general range or gommelin????
Not able to apply my logic.
Her _____(gommelin / general range) is unchanged and she is pleased with it.
The patient has headaches and also for knee problem. Also not dictating under physical examination.
catheter general hear or read it as smi
Subject: catheter general hear or read it as smi
JR5 (Judkins right 5) (JL5 Judkins left 5) etc
Could they be a GM (General Motors) employee? Can't find much else under G's and J's in Flo
Subject: Could they be a GM (General Motors) employee? Can't find much else under G's and J's in Florida. nm
s
I work for a general surgeon who dictates...sm
Subject: I work for a general surgeon who dictates...sm
sestamibi scan on all his parathyroid patients...........
and google to back it up:
Sestamibi Scan for parathyroid disease and Sestamibi x-ray for parathyroid tumors. The Sestamibi scan finds the diseased parathyroid gland.
www.parathyroid.com/sestamibi.htm - 49k - Cached - Similar pages |
Sestamibi Scan for parathyroid disease and hyper-parathyroid disease. The parathyroid Sestamibi scan finds the diseased parathyroid gland and can be used ...
parathyroid.com/Sestamibi-Technical.htm - 65k - Cached - Similar pages |
Hgh quality sestamibi scan shows a single parathyroid adenoma. ... The Sestamibi scan will display the hyperactive gland which is causing ...
www.endocrineweb.com/sestamibi.html - 9k - Cached - Similar pages |
A sestamibi scan of the parathyroid gland is a nuclear medicine procedure which is performed to identify hyperparathyroidism (or parathyroid adenoma). ...
en.wikipedia.org/wiki/Sestamibi_scan - 17k - Cached - Similar pages |
doc says under general infant does not appear to be s/l Coxic???does he mean colicky?
Subject: doc says under general infant does not appear to be s/l Coxic???does he mean colicky?
Is this epidural or general? They usually test the skin if
Subject: Is this epidural or general? They usually test the skin if
s
He is under general anesthesia so in no pain, not awake.. nm
Subject: He is under general anesthesia so in no pain, not awake.. nm
.
"bare" stellate block or general sm
Subject: "bare" stellate block or general sm
We are going to go ahead and schedule this patient for surgery for a left carpal tunnel release and a left first dorsal compartment release under a stellate block. The patient may have a s/l "bare" block or a general depending on what her and the anesthesiologist decide.
BloodSTOP™ Hemostatic General Gauze?
Subject: BloodSTOP™ Hemostatic General Gauze?
General rule of thumb for hyphenation is - sm
Subject: General rule of thumb for hyphenation is - sm
If you can't find it as one word in the Merriam-Webster dictionary, then you should hyphenate it.
ENT? general anesthesia with apneic oxygenation - nm
Subject: ENT? general anesthesia with apneic oxygenation - nm
x
it's general term to describe the statin drugs
Subject: it's general term to describe the statin drugs
nm
Probably general LMA (laryngeal mask airway) anesthesia. nm
Subject: Probably general LMA (laryngeal mask airway) anesthesia. nm
s
Put under GENERAL looking at face and commenting on findings, flat affect. nm Ta
Subject: Put under GENERAL looking at face and commenting on findings, flat affect. nm Ta
.
in general, would not put an 's after word ending in S. Saw one ref. Gross' solution preserv
Subject: in general, would not put an 's after word ending in S. Saw one ref. Gross' solution preservative.
in general sentence, not capitalize; if stating a specific department,
Subject: in general sentence, not capitalize; if stating a specific department,
nm
I know the general rule, been MTing 15 years, thought clinic was maybe different.
Subject: I know the general rule, been MTing 15 years, thought clinic was maybe different.
Hartmann _______ procedure - general surgeon talking about colostomy
Subject: Hartmann _______ procedure - general surgeon talking about colostomy
He's definitely saying Hartmann's ________ procedure, and the blank sounds like "lung."
Thanks so much!
In general surgery, Cook-Thomasen fascial closure device. sm
Subject: In general surgery, Cook-Thomasen fascial closure device. sm
It sounds like Thomasen or Tomasen. I can't find anywhere. Any help greatly appreciated. Thanks!
physical exam under general: the patient appeared s/l kick ectic? nm
Subject: physical exam under general: the patient appeared s/l kick ectic? nm
In general physical exam, aox3, non-toxic s/l thiness ot tin-ness?
Subject: In general physical exam, aox3, non-toxic s/l thiness ot tin-ness?
Please help. It is in the ROS section (SM)
There has been no eye inflammtion. No problems with alopecia. There has been no eye inflammation. No s/l "sick ahm plot" complex or oral lesions.
Can't figure this out. Thank you for any help you might be able to offer.
Chickadee 
c-section
Subject: c-section
pt with McDonald's cerclage and frank breech presentation with sl-ancervical dilatation.
C-section
Subject: C-section
At the time of cord clamp sl-all I can hear is "sol" at the end 2 grams is given in the OR to the patient
C section
Subject: C section
PAST SURGICAL HISTORY: C section or C-section ?
C-section. nm.
Subject: C-section. nm.
nm
please help with OB C-section
Subject: please help with OB C-section
I don't usually type OP reports, but I got this one and need a little help with a C-section. It's a primary low-flap transverse C-section due to breech presentation.
He says the rectus muscles were separated and taken down. Then: The superior most aspect of the s/l "perineum" was nicked. Thought this should be peritoneum.
Then: Bowel floor s/l "was placed" a low marginal incision.
any help?
Doing a C-section, doc says SM
Subject: Doing a C-section, doc says SM
the IFE was attached and removed after vertex was delivered. What is IFE? Thanks.
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