Not my day. exam of the chest and states (sm)
Posted By: quietmoods on 2007-09-20
In Reply to:
Subject: Not my day. exam of the chest and states (sm)
the "pox" is 90 and felt 87, and she is on oxygen. This in the exam of the chest. What could "pox" be?
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Chest exam on H&P, chest is symmetrical, free of dull s/l dull suspence straight, and without pectus
Subject: Chest exam on H&P, chest is symmetrical, free of dull s/l dull suspence straight, and without pectus
excurvatum. No sure of "free of dull suspence straight"
Chest exam s/l *WP* or *WB* is negative
Subject: Chest exam s/l *WP* or *WB* is negative
any ideas?
question about chest exam
Subject: question about chest exam
Sorry for so many questions tonight. They started me on a new account and this guy is hard!
Chest is clear without wheezing, rales, s/l flare or retractions.
chest exam: s/o "breh-too-then" is unremarkable..tia! -nm
Subject: chest exam: s/o "breh-too-then" is unremarkable..tia! -nm
Phys Exam, Chest section
Subject: Phys Exam, Chest section
Dictator is Indian.
Chest: Decreased "ENtipul pieces" bilaterally, secondry effort. No rhonchi, no wheezes.
By the way, also states in AAMT BOS2 that 0 is correct for sutures as per The United States Pharmaco
Subject: By the way, also states in AAMT BOS2 that 0 is correct for sutures as per The United States Pharmacopeia system sizes...
Breast exam reveals no masses in the tail or s/l spence. Pt with a gunshot wound to the chest. TIA
Subject: Breast exam reveals no masses in the tail or s/l spence. Pt with a gunshot wound to the chest. TIA
Just me, but I do not unless the CP states to do so.
Subject: Just me, but I do not unless the CP states to do so.
New standard states:
Subject: New standard states:
And I quote: "Numerals, or figures, stand out from the surrounding text and serve a functional purpose in medical reports, where they should be used almost exclusively as opposed to spelled-out numbers.
Exceptions: Judgment and discretion are need when deciding but adjacent numbers require one to be spelled out to avoid confusion.
Use a comma to separate adjacent unrelated numerals if neither can be readily expressed in words and the sentence cannot be readily reworded.
Use numerals for fractions.
Spell out numbers that begin a sentence.
Zero is always spelled out when it stands alone.
Spell out numbers used as pronouns.
That should get you started!
ENT always states S/L "verbrossi SM
Subject: ENT always states S/L "verbrossi SM
were clippped." It seems to mean nose hair, except I cannot document verbrossa. I have looked and looked. I could have spelling completely wrong. As stated, ENT doctor, doing sinus/ septal surgery, at the beginning of the report, along with prep and drape.
Thanks for any help.
HELP please!! Dr. states this 3 times
Subject: HELP please!! Dr. states this 3 times
It sounds like "Malin-body 4 airway." Any help would be greatly appreciated. Thanks
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.
Pt with Raynaud's...doctor states sm
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Subject: Doc only states what s/l cervitol 15 mg at night...
dictates this with about 20 other meds....no mention of any stool issues. If it is sorbitol can it be a 15 mg dose?? May have to leave it blank.
Thanks but no "Trans" just states s/l Varisol..nm
Subject: Thanks but no "Trans" just states s/l Varisol..nm
x
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Subject: States current medication..
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Subject: The consult by the neurologist states that sm
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when doc states g-y-n, are all letters capped or only first? nm Thanks!
Subject: when doc states g-y-n, are all letters capped or only first? nm Thanks!
s/l "multitude" tenaculum - states the
Subject: s/l "multitude" tenaculum - states the
cervix was grasped with a "multitude" tenaculum? TIA
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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
dr. states "as the isotype would likely pool
Subject: dr. states "as the isotype would likely pool
on the infected colon" - do you think I'm hearing that correctly? would it be "pool"?
thanks in advance
Great link to cities/states
Subject: Great link to cities/states
Never heard of runmyass, but here's a great link to find all the cities in the state.
http://dir.yahoo.com/Regional/U_S__States/Louisiana/Cities/wp_A/
Not that one either:) States clearly 'Viag', like leaving off the end of Viagra. nm
Subject: Not that one either:) States clearly 'Viag', like leaving off the end of Viagra. nm
..
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Subject: ESL states twice..allergies s/l tetrum toxoid. nm
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Subject: born 3 weeks s/l "pro-states"
Thought this may be post-age, but didn't know if there was a word for premature other than after due date????
makes since as after he states there is adequate stability. Thanks a lot.
Subject: makes since as after he states there is adequate stability. Thanks a lot.
It also states to "precede by # or No. if the word 'number' is dictated. sm
Subject: It also states to "precede by # or No. if the word 'number' is dictated. sm
"Keep in mind that 'French' is linked to diameter size and is not the eponymic name of an instrument. Thus, it is a 15-French catheter, not a French catheter, size 15."
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Subject: Nevermind, I am going to flag it as he specifically states "inhaler," thanks anyway.
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Subject: He states childs platelet count normal...
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States problem as Bourne Willaburn's Disease??? tia..
Subject: States problem as Bourne Willaburn's Disease??? tia..
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Subject: Not enuresis. The PURR is definitely there. He states it about five times in the dictation. nm
Don't know if there are other diagnoses involved, but this is what the drug index states it is us
Subject: Don't know if there are other diagnoses involved, but this is what the drug index states it is used for:
to treat chronic hives, premenstrual depression, attention deficit hyperactivity disorder in children, and bedwetting.
25 mg would be the proper dosage also.
P. 337 of BOS states it should be typed "pro time" as 2 words; sm
Subject: P. 337 of BOS states it should be typed "pro time" as 2 words; sm
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that is what I had. Just double checking becasue she states it different later in report. Thanks
Subject: that is what I had. Just double checking becasue she states it different later in report. Thanks
nm
Never? (dr states "there is tenderness on ballotting the knee?")
Subject: Never? (dr states "there is tenderness on ballotting the knee?")
Yes, I know. My post below states that and I answered her, can be indexes or indices
Subject: Yes, I know. My post below states that and I answered her, can be indexes or indices
even BOS states that follow-up is an acceptable version of followup. sm
Subject: even BOS states that follow-up is an acceptable version of followup. sm
Isn't it funny how this profession dwells on simple little things like this.
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Subject: patient's prior surgeries---states THA/BA1 or VA1 or ?? What would be assoc with THA
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Subject: Sorry..nope...it is so clear and states twice "Buta vent". ??
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
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Subject: Question about eye exam...when everting lids on eye exam (sm)
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Subject: Stedman's derm book states Tindall effect. nm
x
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Subject: During a tonsillectomy states tonsils removed using s/l a flat bovie?? Thanks
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Subject: eNos is a gene therapy & still in testing, OP states doc said it was old treatment. NM
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Subject: In my opinion either would be correct. If MD states neurologic standpoint, that is what I would transcribe.
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Subject: It would be STEMI in hpi and spell it out in diagnoses (unless client profile states otherwise)
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