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It is trachea midline. Fonts you can leave

Posted By: sm on 2009-02-10
In Reply to: PE words help - Neta

Subject: It is trachea midline. Fonts you can leave

if your client permits "slang." Personally I would spell it out to fontanelles. No idea on mertz.


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First would be trachea midline. I have
Subject: First would be trachea midline. I have

seen lungs "wet" but not sure about 2nd.
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Subject: HEENT: Trachea is midline. No s/l subculary in the neck. Help?


fascia was nicked in the midline or knicked in the midline.....was QA'd
Subject: fascia was nicked in the midline or knicked in the midline.....was QA'd

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trachea
Subject: trachea


trachea help
Subject: trachea help

A longitudinal incision was made directly over the trachea and his trachea was dissected.  Thyroid was extracted.  A second tracheal ring oversized, # 6 _S/L shally______ was inserted and secured.


 


Thanks


can't you just leave it abbreviated, or do you have to spell it out. I would leave as dictated.
Subject: can't you just leave it abbreviated, or do you have to spell it out. I would leave as dictated.


No, bronchitis is inflammation of the bronchi, nothing to do with trachea or nose. nm
Subject: No, bronchitis is inflammation of the bronchi, nothing to do with trachea or nose. nm

.
broncho has to do with the trachea or tracheal area. It is not in the foot.
Subject: broncho has to do with the trachea or tracheal area. It is not in the foot.


If it was dictated like that & you can leave abbrvns in, then leave it
Subject: If it was dictated like that & you can leave abbrvns in, then leave it

s
midline raphe
Subject: midline raphe

Excerpts from Dorland's:

raphe (ra·phe) (ra´fe) gen. raphçs pl. ra´phae [Gr. rhaphç] [TA] a seam; anatomic terminology for the line of union of the halves of any of various symmetrical parts.

abdominal r. linea alba.


MLS=midline shift? sm
Subject: MLS=midline shift? sm

another wild guess here, but perhaps on the CT scan they can see a posterior MLS (midline shift)...caused by the hemorrhage...and now showing up as a hematoma or contusion within the midline shift???
s/l mean/main is: midline
Subject: s/l mean/main is: midline

midline
probably midline raphe ?
Subject: probably midline raphe ?


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Subject: Atacand and midline ???


entered in the midline?
Subject: entered in the midline?


Probably midline laceration...nm
Subject: Probably midline laceration...nm


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Subject: Thanks! Must be 'calcified pineal is midline'.


a firm s/l cicotrix in the midline
Subject: a firm s/l cicotrix in the midline

of the lower lip. 
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Subject: doing tracheotomy...the midline s/l ruf-fae was then opened. nm

d
Could it be "uvula" test is midline?
Subject: Could it be "uvula" test is midline?


entered sharply in the midline
Subject: entered sharply in the midline


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Subject: I usually hear "trachea midline, no JVD, no lymphadenopathy. nm

.
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Subject: asap please s/l villainy midline palatine prominence nm


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Subject: postpartum.....diastasis, separation of the midline muscles...nm

s
First could be midline of the abdominal skin sharply through (or down to) the fascia..nm
Subject: First could be midline of the abdominal skin sharply through (or down to) the fascia..nm

s
Abdomen with midline s/l rafay weakness without hernia
Subject: Abdomen with midline s/l rafay weakness without hernia

Thanks!
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Subject: cervix is parous, freely moveable, midline and


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Subject: It is over the rhomboid area. No s/l CF or midline pain. Limited range of motion.

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Subject: "Spine: Midline without spinal "peers" or spinal

x
I would leave in under PMH sm
Subject: I would leave in under PMH sm

it probably is part of what is being said.  And, it is a lab value (said it was negative) not a date. l
I would leave as is - sm
Subject: I would leave as is - sm

I have heard this phrase many times, and always leave it as is.  They are referring to prerenal azotemia. 
I'd leave it as is. nm
Subject: I'd leave it as is. nm

x
just leave the S off
Subject: just leave the S off

nm
Then that is how I will leave it! Thanks
Subject: Then that is how I will leave it! Thanks


leave as is
Subject: leave as is

Torso is an anatomical term for the central part of the many animal bodies (including that of the human) from which extend the neck and limbs. It is sometimes referred to as the trunk. The torso includes the thorax and abdomen
I would leave it the way he says it. nm
Subject: I would leave it the way he says it. nm


I'd leave them just how you have them.
Subject: I'd leave them just how you have them.


I would leave as is
Subject: I would leave as is


i would leave as is
Subject: i would leave as is

You never know with labs, they can be tricky. If you are really concerned you could always add a marker for it to be double checked but I would leave as dictated.
I would leave it.
Subject: I would leave it.

I think you are correct. I believe they are three separate things. There is general pain that stars to localize to one spot. There is rebound pain where they press on your abdomen slowly, but then unexpectedly let go. And there is guarding pain if when they examin or stomach you they press or attempt to press and you instinctively try to guard your abdomen with your hands.
i would leave as is.......
Subject: i would leave as is.......

i would leave as is.......
Thanks, but I had to leave a QA...
Subject: Thanks, but I had to leave a QA...

nm
Leave them in (sm)
Subject: Leave them in (sm)

I would leave them in.  Yes, it is redundant, but it's also what the doctor dictated.  The only exception would be, in my opinion, if there were account specifics covering this and then I would follow the account specifics. 
Leave it
Subject: Leave it

where it is. Put a hypen in between tib-fib and a comma after fib.
I leave them out
Subject: I leave them out

You can overdue on hyphens and commas. Well child check, well woman's visit, well baby check. Looks better without. Just my take. :-)
I would just leave it at sm
Subject: I would just leave it at sm

exacerbating the anal pain.
I would leave it as he said. He knows what it means...sm
Subject: I would leave it as he said. He knows what it means...sm

TM stands for appx 20 or more things, so you cannot guess which one. Also,the same goes for LAM. It stands for seven different things and you cannot guess which one.

I was taught in this situation to leave it as said. My account even specifies in assessment and plan to never abbreviate except in this case when you cannot 100% verify what the doc means if there is more than one meaning to the abbreviation.

Hope this helps
I would leave lami as is
Subject: I would leave lami as is

I have never heard of that before, but you really do not know what the doc wants. You should not try to guess at something like that. I wouldn't.
I would leave it blank then
Subject: I would leave it blank then

Sometimes docs do not spell things correctly; but when I cannot find something that they spell, I will send it to QA and let them figure it out. Sorry I could not be of more help to you.
Had to leave a blank. nm
Subject: Had to leave a blank. nm

x