Musculoskeletal exam
Posted By: mtmt on 2009-05-31
In Reply to:
Subject: Musculoskeletal exam
Sensation is intact for the s/l fil-a-mon test.
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Musculoskeletal Exam
Subject: Musculoskeletal Exam
Does this make sense to anyone? Active range of motion of the left knee is approximately 0 to 100?
Musculoskeletal Exam
Subject: Musculoskeletal Exam
There are no [s/l dermaternal?] changes noted in upper and lower extremities.
s/l Fabray is positive on musculoskeletal exam.....(nm) TIA!
Subject: s/l Fabray is positive on musculoskeletal exam.....(nm) TIA!
x
Musculoskeletal exam: The patient has good s/l RAM.
Subject: Musculoskeletal exam: The patient has good s/l RAM.
She says this twice. Clearly not sounding like range of motion. Thanks for any help!
musculoskeletal
Subject: musculoskeletal
Thanks for your advise, but...
Yes, that is what I would put, but dictators are very specific and do not want their verbiage changed, but cannot find a correct spelling of this anywhere!
Musculoskeletal help
Subject: Musculoskeletal help
I am doing a musculoskeletal exam. I cannot figure out what he is saying and cannot find a list of common tests done. Does anyone have a clue?
s/l Trendellenburg's test, (s/l bactruse) test, (s/l ulise) test, (s/lserial halls) test (s/l spurring) and straight leg raising negative.
Thanks in advance.
Figured out the musculoskeletal one... still looking for the other...
Subject: Figured out the musculoskeletal one... still looking for the other...
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!
Musculoskeletal/Neurologic
Subject: Musculoskeletal/Neurologic
You need to head it the way I did in the subject above...
It is Amrix, a musculoskeletal relaxant- nm
Subject: It is Amrix, a musculoskeletal relaxant- nm
xx
Roxitan is correct....musculoskeletal and
Subject: Roxitan is correct....musculoskeletal and
xx
I'd say positive for musculoskeletal back pain.
Subject: I'd say positive for musculoskeletal back pain.
Throat exam is normal, as were the rest of her neck, face, and skull exam.
Subject: Throat exam is normal, as were the rest of her neck, face, and skull exam.
Eye exam: s/l "sub-lamp" exam shows left side has multiple small punctations in the cornea.(t
Subject: Eye exam: s/l "sub-lamp" exam shows left side has multiple small punctations in the cornea.(thanks)
Physical exam on eye exam, s/l Cardinal Welk's space?? noted.NM
Subject: Physical exam on eye exam, s/l Cardinal Welk's space?? noted.NM
What kind of doc is doing the exam? And where in the exam is this test mentioned? nm
Subject: What kind of doc is doing the exam? And where in the exam is this test mentioned? nm
s
Question about eye exam...when everting lids on eye exam (sm)
Subject: Question about eye exam...when everting lids on eye exam (sm)
It is EVERT, not AVERT, right? I have always typed it with an E but I have a PA who keeps insisting it is A. I always thought Avert applied to gaze, as if to look away. Just want to make sure everting the eyelid is the right term. TIA.
Which is correct? self-breast exam or breast self-exam (nm)
Subject: Which is correct? self-breast exam or breast self-exam (nm)
xx
s/l lob's exam
Subject: s/l lob's exam
There is an abbreviation, LOB, which stands for "loss of balance"
not sure this is what you're looking for. Either way, I do believe what the dictator would have said was "loss" of protective sensation..., not "lots" Hope this helps!
Ear exam - see msg
Subject: Ear exam - see msg
Ears reveal normal s/l "tina" and normal external auditory canals. Thanks for the help in advance!
eye exam
Subject: eye exam
small sl-PAFs were noted near the interior chamber haptic positions temporally in the left eye.
eye exam
Subject: eye exam
Think that might be "anterior" chamber instead of interior chamber.
eye exam
Subject: eye exam
cup-to-disc ratio was 0.5 with sl-temporal slipping OU
eye exam
Subject: eye exam
temporal sloping
GYN exam
Subject: GYN exam
Have you ever heard the phrase--the uterus to be midplane and anteflexed? I've heard of anteflexed, but not midplane
thanks
eye exam
Subject: eye exam
foreign body in eye.
this lesion did stain with fluorescein; however, it was noted to be sl-sidal negative.
he also says the lesion is at the 7 o'clock sl-clock R position.
Eye exam
Subject: Eye exam
There is contraction across the entire field of vision in both eyes. Impression is _____ ischemia with field defect, stable.
S/L sanis
Eye exam
Subject: Eye exam
Eyes: Refractory s/l Air FOGs glasses
Thanks.
Eye exam
Subject: Eye exam
Yes! Thanks you two. First time I've used this. Appreciate the help.
eye exam
Subject: eye exam
It was, "refractive error for which he uses glasses". Sounded so clear after you gave me the 'refractive error' part. The doctor's British accent was charming but confusing too.
gen exam
Subject: gen exam
 New doctor.
Under PE. General: She is alert sind.
Please help with the "sind " part. I know it is short for something.
Neurological: s/l just gross and nonfocal.
Maybe nerves gross and nonfocal? Aahhhh!
exam
Subject: exam
the exam is in the middle of the report under LABS in office SIM CARD EXAM showed positive for BV. The first part of the exam said she had a vaginal infection that had discharge and a rotten odor.
Need eye exam help please
Subject: Need eye exam help please
Best corrected vision with the refraction of plano minus quarter axis 130, 20/20 right eye. Is this worded correctly or should there be some commas in there??
Also, does this look right? "The patient required a +1 addition add for reading."
Eye exam
Subject: Eye exam
Could it be anisocoria?
The size of the pupils are not equal.
Please help with exam...sm
Subject: Please help with exam...sm
Doc is doing a well exam on a child 10 1/2 months old.
States: "Weight, height: S/l No FC ?
Thank you so much.
eye exam
Subject: eye exam
normal color vision and normal s/l disc confusion.
Any idea of above term? Thanks
eye exam help please sm
Subject: eye exam help please sm
Patient has 3+ SPK with s/l "absolute thicka"
Could just be saying exam
Subject: Could just be saying exam
Sometimes they get to mumbling and you only hear part of the word.
Eye Exam
Subject: Eye Exam
The doc is saying, "good holes on all field of vision at 90 degrees." The word I am unsure of is holes. I have tried googling it but I am not coming up with anything solid. Does this statement make sense in regards to an eye exam? Thank you.
Eye exam (sm) TIA
Subject: Eye exam (sm) TIA
s/l negative 6 diopters? I have never heard of this term before.
eye exam help
Subject: eye exam help
The patient has diminishment in his vision as well as diamond-like flashing S/L sitopsia or satopsia or sytopsia in his remaining visual field. ????
EI exam?
Subject: EI exam?
anybody have any idea what this word is. Dr. says "EI" exam showed a tender liver. Heavy accent so can't figure out what "EI" is
Eye exam
Subject: Eye exam
Examination of the eyes shows some left ? nystagmus
It maybe sounds like the work begins with b but I am really not sure. Any help greatly appreciated.
eye exam
Subject: eye exam
left beating nystagmus
ear exam
Subject: ear exam
doc doing ear exam - s/l impedence stapedometry?
eye exam - please sm
Subject: eye exam - please sm
She had a recent evaluation by her ophthalmologist which did show some cataracts in the RT eye, some vitreous floaters s/l pseudophacia. Thanks!
exam name help
Subject: exam name help
I cannot understand any clue to help with name.. maybe someone is familiar with what type exam is done
I conducted a exam with the patient whose standing intolerance is limited to minutes. I completed a prescription for a motor scooter for the patient to use for his community mobility.
Exam name
Subject: Exam name
Standing |
|
The most logical test for orthostatic tolerance is standing itself. . |
name of exam
Subject: name of exam
s/l: if you hear 'prolee' it is maybe 'blood pooling' in this reference.
eye exam
Subject: eye exam
s/l manifest refraction shows s/l lay-opia with a slight astigmatism
rx after eye exam +250 add
Subject: rx after eye exam +250 add
manifest refraction with a +250 add? how is this written?
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