Might just be the History and Physical that's back at the office, or the H&P. nm
Posted By: wanderer on 2006-07-04
In Reply to: is there a physical exam. term HNP? - Rebecca
Subject: Might just be the History and Physical that's back at the office, or the H&P. nm
s
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H & P- history and physical...nm
Subject: H & P- history and physical...nm
m
History and physical word help
Subject: History and physical word help
The doctor say chief complaint, S/l appendidiver HPI... Any suggestions? Thanks for everyone's help..
maybe admission H&P (history and physical). NM
Subject: maybe admission H&P (history and physical). NM
x
Should history and physical be capitalized?
Subject: Should history and physical be capitalized?
Sentence reads p/t is here today for a complete history and physical...... Should history and physical be capitalized? Thanks.
History & Physical Headings
Subject: History & Physical Headings
I am trying to head a H & P what do I list the bladder and groin under?
History & Physical Headings+1>?
Subject: History & Physical Headings+1>?
Thanks. One more question. What headings do you add if not transcribed to the H & P?
Neurological History and Physical
Subject: Neurological History and Physical
This is going to probably sound crazy....but it s/l "whirring imbalance."
Neurological History and Physical Exam
Subject: Neurological History and Physical Exam
Any help on this would be appreciated. This is a neurology history and physical and the doc is dictating the Assessment/Plan. She states, "This patient with a _________ imbalance. She did have normal imaging before, but did not get a MRA". My brain is mush and I just cannot understand what type of imbalance she is referring to. Thank you for any assistance.
in the physical exam s/l back, kethotic???
Subject: in the physical exam s/l back, kethotic???
HOSPITAL COURSE: Fish?? admission history and physical for details
Subject: HOSPITAL COURSE: Fish?? admission history and physical for details
If md says at end of report, go back to physical and add Hemmocult negative, sm
Subject: If md says at end of report, go back to physical and add Hemmocult negative, sm
Is Hemoccult always under rectal? Thank you very much
s/l Tiazine 2 mg at night. Patient with nack and back pain history
Subject: s/l Tiazine 2 mg at night. Patient with nack and back pain history
thank you
Under past medical history - history of abnormal s/l petatrie functioning. I really cannot make *sm
Subject: Under past medical history - history of abnormal s/l petatrie functioning. I really cannot make *sm
it out. It is a foreigner. He is saying it very fast. History of abnormal petatrie functioning is what is sounds like to me. I have no clue.
history of colorectal history with metastasis to the liver and lymph nodes
Subject: history of colorectal history with metastasis to the liver and lymph nodes
office???
Subject: office???
Could be..
You don't know my office...
Subject: You don't know my office...
It would appear that not only do they not go by AAMT, but they make it up as they go along. And if there are two rules contradicting each other, better pray the document is not the one they pick for QA.
If you are saying like dr smith's office
Subject: If you are saying like dr smith's office
would it be John Smith's,MD or would it be John Smith, MD's office? Where would the appostrophe go?
This was an office visit. Thanks
Subject: This was an office visit. Thanks
Could it be office appointment?
Subject: Could it be office appointment?
Office visit H&P- Thanks! nm
Subject: Office visit H&P- Thanks! nm
That's it!! Just confirmed via office, too. Thank you!! (nm)
Subject: That's it!! Just confirmed via office, too. Thank you!! (nm)
xx
office note help
Subject: office note help
I am doing a otology office note and the doctor dictates "during his ___ (s/l relic or realick) surgery, there was recurrent cholesteatoma and during dissection, the _____ (s/l flick-plate)became free
EKGs in my office?
Subject: EKGs in my office?
Thanks for the help, Im going to flag it for the office to relisten. nm
Subject: Thanks for the help, Im going to flag it for the office to relisten. nm
He says "I did a bi ox today in the office and was 99-100% on room air.
Subject: He says "I did a bi ox today in the office and was 99-100% on room air.
back pain, given dura-back if needed for spasm. nm
Subject: back pain, given dura-back if needed for spasm. nm
s
Would depend on the context. In the office setting, it could be. I don't
Subject: Would depend on the context. In the office setting, it could be. I don't
s
Context, please! What are you doing - xray, scan, office visit, etc.?
/
Check my spelling--I'm nowhere near my office. Calibri forceps. nm
Subject: Check my spelling--I'm nowhere near my office. Calibri forceps. nm
x
yes it is capitalized; referring to Dr. Smith's specifric office
Subject: yes it is capitalized; referring to Dr. Smith's specifric office
nm
Gals in my office are taking a vote, we are arguing about 7-French SM
Is it 7-French diagnostic sheath. Hypen or no? Driving me bonks, someone clear this up? Many references state different things.
A urinalysis in the office showed a moderate amount of blood. Serum was subsequently sent for sm
Subject: A urinalysis in the office showed a moderate amount of blood. Serum was subsequently sent for sm
A urinalysis in the office showed a moderate amount of blood. Serum was subsequently sent for an R&M C&S which returned unremarkable.
I know what C&S is. What is the R&M????? help please Donna
Maybe 'hold, on call' to hold the patient in the office for the on call xray? nm
Subject: Maybe 'hold, on call' to hold the patient in the office for the on call xray? nm
s
Physical exam
Subject: Physical exam
Height: Six feet.
I'm having trouble remembering all my rules on numbers for stats and such. Is this right? Thank you.
On physical exam.. S/L
Subject: On physical exam.. S/L
or maybe slight disks bilaterally? I'm drawing a blank... HELP PLEASE and THNX!
Physical exam
Subject: Physical exam
The doctor dictated "no jugular venous distension at 30 degrees" under heart of the physical exam. Shouldn't it go under neck? Thank you.
physical exam-GU
Subject: physical exam-GU
obese 9 year old--phallus difficult to examine as the patient has a large sl-paptha- and has a concealed phallus.
re physical exam
Subject: re physical exam
PHYSICAL EXAMINATION: Significant findings for left lower quadrant tenderness. Blood pressure was 124/78, pulse rate of 96, and respiratory rate of 20. Heart: S1 and S2. Lungs: Clear to auscultation bilaterally.
I would type it this way or at least make it present tense. On my accounts, I am required to categorize these things.
PHYSICAL EXAMINATION:
Abdomen: Significant findings for left lower quadrant tenderness. Vital signs: Blood pressure 124/78, pulse rate 96, respiratory rate 20. Heart: S1 and S2. Lungs: Clear to auscultation bilaterally.
GI physical exam
Subject: GI physical exam
In the physical exam, s/l thenar and epithilial wasting. He is listing liver disease stigmata and I just blanked out on this. Help!
This is on physical exam
Subject: This is on physical exam
thanks for trying.
physical exam help
Subject: physical exam help
Physical exam, under Extremities, doctor states ___ pulses throughout.
It sounds like temporis pulses. I know of temporal pulses, but would that be throughout the extremities? Thank you!
Physical exam help?
Subject: Physical exam help?
EXAMINATION: No costovertebral angle tenderness. Abdomen has normal active bowel sounds in all quadrants. It is supple. Extremely tender left upper quadrant and going down not quite into the groin. Difficult to check the (s/l sternal) border because of increased tenderness but the spleen may be mildly enlarged but no distinct masses felt. I am unable to check for rebound or guarding because she is so exquisitely tender with even a very light touch.
ASSESSMENT: Acute left upper quadrant pain.
s/l sternal border? Any help would be great?
physical exam
Subject: physical exam
Probably just means + (the plus sign), as in positive S1, S2...just means he heard 1st and 2nd heart sounds clearly (as opposed to sounds to distant or obscured by extra sounds). If something was dictated before that, I would put a comma and use the plus sign, i.e., PREVIOUS TEXT, + S1, S2. If nothing precedes it, I would type positive S1, S2. If account wants verbatim, give it to them.
It was just a physical exam, and I don't know
Subject: It was just a physical exam, and I don't know
However, I do think it was "cervical or" inguinal adenopathy. This guy is a real mush mouth. THANK YOU ALL SO MUCH FOR YOUR HELP! I am sorry I wasn't clear enough earlier in my first message. I really do appreciate your help. This is a great board to come to--everyone is so knowledgeable!
Need help with physical exam please
Subject: Need help with physical exam please
I am wondering if, in the last sentence, where "drop can arc" is dictated . . . would she be referring to three tests/maneuvers such as Drop Arm, Empty Can, and an Arc test, or is it correct as is?
She has excellent range of motion of the shoulder. Good grip strength. Distal pulses and sensation are intact. She can do a full drop can arc.
TIA
Please help with physical exam (sm)
Subject: Please help with physical exam (sm)
Over the central aspect of the wound there is s/l shelfing of the superior aspect of the skin
This is in the physical examination. Thanx for trying
Subject: This is in the physical examination. Thanx for trying
Physical examination... sm
Subject: Physical examination... sm
Examination of female patient.
Musculoskeletal: No (s/l) keps, pains, or pedal edema...
Genitourinary: No (s/l) [cussforteeballing or maybe cusp or teeballing], or area tenderness.
Thanks in advance!
Physical exam help.....
Subject: Physical exam help.....
The calf was nontender. The lower leg was s/l nonpeeing. Nonpitting? Not pitting? Help, please!
Physical Examination
Subject: Physical Examination
Happy Monday everyone! Hope you all had a great weekend! I'm doing a report and wondering if any of you can point me in the right direction!
"There is good capillary refill and s/l preson to cultures over both lower extremities." Any thoughts? Any good physical examination websites?
Physical exam help
Subject: Physical exam help
HEENT: It sounds like she is saying 'TO' mucosa pink and moist. Or TL mucosa.
Any ideas?
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