Nothing in the PMH/surgical history or current meds. to give you a clue? nm
Posted By: passing thru on 2006-04-25
In Reply to: Review of systems: Chills, night sweats,*commerfid* - disease.???? Any help? TIA!
Subject: Nothing in the PMH/surgical history or current meds. to give you a clue? nm
s
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Can you give us some info about the patient, i.e. past history, current complaint, etc?
Subject: Can you give us some info about the patient, i.e. past history, current complaint, etc?
Is there any past surgical history that might give some clues? nm
Subject: Is there any past surgical history that might give some clues? nm
x
Listed in current meds s/l PAIRosh? Any help?
Subject: Listed in current meds s/l PAIRosh? Any help?
Can anyone give me a clue . .
. . . as to what this might be? ESL dictation and I can't seem to make out what he's saying. I THINK I have an idea, but I wanted to run it by some of you ladies (and gentlemen) to see if your ideas are similar.
Sounds like he's saying the following:
Patient doesn't have much cough. Orsh-a-lavasta have a little bit of blood coming out. (This is on a patient with a trach.)
Any ideas?
Give us a clue--where you at in the body and what are they doing?
.
Does her name give you a clue to her ethnicity? Maybe saying she's a native of some
Subject: Does her name give you a clue to her ethnicity? Maybe saying she's a native of some
s
any info prior to P.E. that might give a clue?
Subject: any info prior to P.E. that might give a clue?
Is there a chief complaint or admission dx?
Is patient being fitted for something that might give a clue as to
Subject: Is patient being fitted for something that might give a clue as to
s
How about a full sentence to give us a clue??? nm
Subject: How about a full sentence to give us a clue??? nm
s
Ortho consult for thoracic pain after spontaneous pulmonary embolism. In list of current meds.
Subject: Ortho consult for thoracic pain after spontaneous pulmonary embolism. In list of current meds.
No dx? No chief complaint? No planned tx? Give us a clue here! nm
Subject: No dx? No chief complaint? No planned tx? Give us a clue here! nm
s
I have docs who almost never pronounce any medications well enough to give me a clue. :-)
Subject: I have docs who almost never pronounce any medications well enough to give me a clue. :-)
surgical history s/l all-tee
Subject: surgical history s/l all-tee
Patient is being seen for balance problems. There is a lot of focus in the report on various tests and her previous tethered cord, lumbar stenosis, laminectomy, etc.
Past surgical history includes: "repair of a spinal fluid leak and (s/l all-tee) then the lumbar spine fusion."
Any ideas as to what the all-tee might be? At first I thought it was the doctor stumbling over her words, but upon re-listening, I'm not so sure!
I do not in surgical history. I only
Subject: I do not in surgical history. I only
expand it if in an op report heading of Procedure Performed:
Surgical History
Subject: Surgical History
"significant for hip replacement, "appy"????
B&B in past surgical history
Subject: B&B in past surgical history
Anyone know what that could be?
Would that be under past surgical history though as he says it is? nm
Subject: Would that be under past surgical history though as he says it is? nm
nm
past surgical history
Subject: past surgical history
She has had repair of cataracts s/l "in aretnas". I couldn't hear retina. Anyone?
Past surgical history is? nm
Subject: Past surgical history is? nm
nm
Do you write out D&C for surgical history?
Subject: Do you write out D&C for surgical history?
I know that most of the time we write out acronyms in the surgical history, but for some tests and procedures, the acronym is okay. (Like CT scan, etc)
Past Surgical History
Subject: Past Surgical History
Doc is dictating patient's past surgical history. States she had s/l a budd kay or e malformation based on her MRI at the hospital. Any clues b/c I am at a loss with this one! 
Sounds like past surgical history.
Subject: Sounds like past surgical history.
x
If he's listing past surgical history then
Subject: If he's listing past surgical history then
I'd put appendectomy, three D&C's, tonsillectomy.
D&C stands for dilation and curettage
He only says BTTI under past surgical history and nothing else
Subject: He only says BTTI under past surgical history and nothing else
s/l toration of the intestines... past surgical history
Subject: s/l toration of the intestines... past surgical history
Surgical History: s/l harris rods in her spine. SM
Subject: Surgical History: s/l harris rods in her spine. SM
Does not sound like Harrington... sounds just like "Harris rods"
No it was just part of the surgical history, so no content clues available. NM
Subject: No it was just part of the surgical history, so no content clues available. NM
Under surgical history: s/l carpal tunnel ?effers? nm TIA
Subject: Under surgical history: s/l carpal tunnel ?effers? nm TIA
in past surgical history for a teen *slazon* removal from the eye. ?? TIA! nm
Subject: in past surgical history for a teen *slazon* removal from the eye. ?? TIA! nm
nm
We'd need context. Give some history and
Subject: We'd need context. Give some history and
the full sentence plus maybe the sentence before and after. More (information) is more.
Does the past surgical hx give you any clues as to sm
Subject: Does the past surgical hx give you any clues as to sm
if the patient had any major GI surgery in the past, like a Billroth II or Whipple? If so, stumpitis may be correct. Let me know! It's a long shot and it would be slang, but I need to know history to tell you for sure.
Can you give the diagnosis or past medical history.
Subject: Can you give the diagnosis or past medical history.
Do you anything that this medication might be for?
When it comes to meds, if it's not absolutely certain I give them a well-deserved blank. sm
Subject: When it comes to meds, if it's not absolutely certain I give them a well-deserved blank. sm
If there's even the slightest doubt as to what med is being referred to (and no backup info to narrow it down to just one) they SHOULD get a blank, IMO. It's not the place for a best-guess, probably-meant, oh-it-must-be-___________, no matter how much our services/accounts would like blank-free reports at whatever cost.....
[That rant wasn't directed at you :-), but rather at the dictator and the current state of the MT position. :-)
Please give the entire sentence/context of the word, have lost of Ortho/Surgical/Rad accounts...nm
Subject: Please give the entire sentence/context of the word, have lost of Ortho/Surgical/Rad accounts...nm
nm
does not give. Listed with other meds Coumadin, metoprolol, Lasix, Synthroid, calcon, potassium. nm
Subject: does not give. Listed with other meds Coumadin, metoprolol, Lasix, Synthroid, calcon, potassium. nm
nm
Psych note Axis III s/l VPS and neuropathy. No health history in the note. Only meds listed psych
Subject: Psych note Axis III s/l VPS and neuropathy. No health history in the note. Only meds listed psych
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
Proctectomy: Surgical resection of the rectum or Prostatectomy: Surgical removal of the prostate gla
Subject: Proctectomy: Surgical resection of the rectum or Prostatectomy: Surgical removal of the prostate gland.
no speciality. final diagnosis was uti. these meds were admit meds, only hist was hypertension
Subject: no speciality. final diagnosis was uti. these meds were admit meds, only hist was hypertension
You hear trialed all the time. Give 'em what they give you! Can't drive yourself friggin'
Subject: You hear trialed all the time. Give 'em what they give you! Can't drive yourself friggin'
s
T current and T max?
Subject: T current and T max?
Can someone tell me the correct way to transcribe "T current and T max"? Thanks a bunch!
I was told by my QA T-current and T-max,
Subject: I was told by my QA T-current and T-max,
but someone else may have a different opinion. If the account I am doing is not verbatim then I transcribe current temperature and maximum temperature because I consider those terms to be slang. Again, others may have different opinions but I haven't had any complaints.
under current medications
Subject: under current medications
S/L: HYDRO-CO-LOR-OX 25 mg
hydrochlorics ??
Current medications: s/l *en-do-said* 7.5/500 one b.i.d. p.r.n. tia/nm
Subject: Current medications: s/l *en-do-said* 7.5/500 one b.i.d. p.r.n. tia/nm
URBY current?
Subject: URBY current?
In a standard pull-type fashion, an 8-mm biliary sphincterotomy was performed using s/l Urbee/Erbee current, without any complications.
current not an issue?
Subject: current not an issue?
That is my current guess.
Subject: That is my current guess.
About to turn it in blank.
States current medication..
Subject: States current medication..
she is being seen for left arm numbness. Does that help any? Nothing in history.
The current trend seems to be to do away with hyphens when possible
Subject: The current trend seems to be to do away with hyphens when possible
That doesn't make it correct, but that's what I've been told to do on several accounts, including the last time I worked in-house.
current medication s/l mobaz nm tia
Subject: current medication s/l mobaz nm tia
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