OP report
Posted By: countryMT on 2007-07-20
In Reply to:
Subject: OP report
general s/l elam anesthesia. New to OP reports! TIA
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EKG report
Subject: EKG report
"No weeshnoblomotion abnormalities are identified." What is that word?
thanks everyone. One more report and then I am going to bed.
Subject: thanks everyone. One more report and then I am going to bed.
nothing more to add about the report unless
Subject: nothing more to add about the report unless
the patient had an implanted pacemaker which is not eluded to here. Just a note, adenosine is not capitalized except to start a sentence.
Maybe you will hear something back.
d~
Sorry, same report...
Subject: Sorry, same report...
"CPK and _______ were negative" s/l intraconals??
Still on the pulmonologist's report...
EEG report
Subject: EEG report
Anyone ever heard of an EEG performed on a Nikon Codon machine? Thanks.
just sent the report on.........nm
Subject: just sent the report on.........nm
x
op report sm
Subject: op report sm
What kind of surgery is it? If he used "lap" laparotomy pads may be the second one. They usually say sponge, needle and instrument counts. Will keep thinking on this one. Type of surgery would help.
You don't say where in the report -- sm
Subject: You don't say where in the report -- sm
this is given, or any other context, so I have to wonder if this isn't a problem list perhaps giving more than one diagnosis/problem here (as in (1) portosystemic shunt and (2) nephrolithiasis)...
Just a thought
ENT report - sm
Subject: ENT report - sm
Does include sinus surgeries, Caldwel-Luc surgery. Is also on Flonase. Patient is actually here regarding Grave's disease. I'm wondering if this is Relpax D, but I'm not able to verify that as a drug. Any suggestions?
ENT OP report help, please...
Subject: ENT OP report help, please...
Vocal cord lesion biopsy -
Peripheral -s/l orb or oral- sinuses were intubated to their apices and were normal.
Specimen was sent -s/l informal- and for pathology.
TIA!
OP report
Subject: OP report
OP report, lumbar spine
Next, fluoroscopy was used to place new screws at the L2-3 segment. Starting points were identified at the confluence of the midpoint of the transverse process, the **manloid** process, and the pars interarticularis
He really mumbles through this part, so I am just not sure, but I have not heard this term used before. Thanks!
op report help please sm...
Subject: op report help please sm...
FINDINGS: Epidurogram revealed normal (s/l-cephaloquadet-) contrast flow outlining the right L5 nerve root sleeve in the epidural space with good flow achieved medial to the right L5 pedicle. The patient did experience some concordant L5 symptoms on the right side during the injection. Vital signs remained stable throughout.
OP Report
Subject: OP Report
Hi all! I am doing an OP for a lumbar spine surgeon, but this is just for an I&D. He says the area was probed with "sucker tips" and was found to be subfascial. I am not too comfortable with what I am finding online for this. Has anyone heard this before? Thanks!
OP report help, please
Subject: OP report help, please
Patient was premedicated with intravenous s/l Benadryl.
Would that be right?
report does not say .. but says she is on BC
Subject: report does not say .. but says she is on BC
help with op report
Subject: help with op report
I never do op notes! The sentence reads:
The S/L RAFFAY between the anterior and middle deltoids was then opened. TIA!
Doing EMG report sm
Subject: Doing EMG report sm
The patient has focal severe slowing primarily in sensory fibers in the right upper extremity, on multiple restimulation unable to elicit a response to both s/l "Palmar 8" studies.
I can't find this anywhere. Anybody have any ideas? Thanks!
I wish I could see the report, but
Subject: I wish I could see the report, but
could she be saying communication, as in an opening has formed between 2 sinuses or something?
It is so frustrating to be given only a tidbit of a report instead of being able to puzzle it out from what is going on with the patient.
Thanks, but as I'm into the report it
Subject: Thanks, but as I'm into the report it
sounds like this is some weird wording for microscopic blood.
I've done thousands of endoscopy reports and GI consults, but I can't think why he'd say "affobiddy positive stool" instead of something about occult blood or microscopic blood.
ER report. Sm please
Subject: ER report. Sm please
The patient has a 4 mm calcification on the pelvis on the right which may represent a s/l flevolith, thus a right ureteral calculus could not be entirely occluded.
Thanks! That's how I did it in the report nm
Subject: Thanks! That's how I did it in the report nm
OP report
Subject: OP report
s/l -fecal lift- at the base of the appendix
C-sec report
Subject: C-sec report
Does this by some chance have to do with cephalodisproportion, because I looked up Jill Cohen - C-section in google, and there is somebody named Jill Cohen and it talks about labor and delivery and C-section and something this lady wrote about it. Could this be it. Check it out on google.
PT report
Subject: PT report
S/l ESTEEM for pain management?
report
Subject: report
Does any one know focal tics of sounds like aphitical movements. Thank could use the help.
TEE report - Need help
Subject: TEE report - Need help
" NO BUBBLES ___________ FROM RIGHT TO LEFT SIDE" s/l caused. He also said bubble study was done with 9 mL normal saline and "a cc" of air. Is this written 1 mL? 
per report
Subject: per report
The only diagnosis is bipolar, duh!
was my last report of the day
Subject: was my last report of the day
and he was getting to me! my least favorite account, lots of bad dictators
MRI report s/m
Subject: MRI report s/m
MRI of the brain shows what looks to be an acute infarct on DWI on the right brainstem area, which were also changes seen on the T2 weighted - s/l anuses - suggesting that this is probably an infarct, which occurred 7-10 days ago.
any ideas cuz I'm pretty sure there are no weighted "anuses" in the brain, at least not identifiable by MRI.
op report help
Subject: op report help
Doc states that the the articular surface of the lateral tibial plateau was then s/l stacked as was the weightbearing surface of the lateral femoral condyle.
Thanks
It's an EGD report .... sm
Subject: It's an EGD report .... sm
He states, "Instruments used were a Fujinon esophagogastroduodenoscope and a ________ bougie #54."
He later states, "The ________ bougie was passed easily."
GU op report help please
Subject: GU op report help please
I tried to dilate the urethra with s/l male sounds, but they would not pass easily due to the false passes. (Talking about bladder stones).
He says it clearly, but I've never heard of these nor can I find it. Can't find anything under "Mayo" either thinking perhaps it was an instrument of some kind.
GU op report help please
Subject: GU op report help please
Could it be Dittel?
CXR report...SM
Subject: CXR report...SM
The findings of the daily CXR on this patient are stable and unchanged, but the dictator gets to the "impression" and says: s/l peri-grass--ity of the chest radiograph.
I'm sure this is something simple and I should know it - it's probably a "normal" word. But my brain is just not working tonight. Help?
OB/GYN report...
Subject: OB/GYN report...
x
ORS Report??
Subject: ORS Report??
Hi I am typing an ER report that says this:
The patient had an ORS?? report performed that shows he has had 24 prescriptions for narcotics.
I know there is a report the doctors can get but I cannot find it anywhere! Please help!!!
This is it. He said it again later in the report
Subject: This is it. He said it again later in the report
 thanks.
H & P Report
Subject: H & P Report
On an H & P report after you have typed the plan and then they repeat the vital signs is that a new category and if so what should the heading be, or is is set off in a new paragraph, or is just part of the plan. I'm a little confused as to how to put it at the end of the report.
H & P Report
Subject: H & P Report
Depends on your company or facility. My personal preference is to insert VITAL SIGNS into the physical exam portion of the dictation, right after GENERAL APPEARANCE or PHYSICAL EXAM. However, you have to follow the dictates of your employer.
H & P Report
Subject: H & P Report
She does indicate that info under VITAL SIGNS in the beginning. This is like a recheck at the end of her report. This is what she says:
His repeat vital signs: His heart rate was down to 107. His blood pressure was 124/86, and he was able to stand and move with greater ease.
ER report
Subject: ER report
CHIEF COMPLAINT
Leg swelling and pain.
Patient is admitted for an (s/l extorium). Patient is an alcoholic and usually drinks hard liquor.
Help! MRI Report
Subject: Help! MRI Report
In the MRI he says what sounds like zyncomal or xyncomal lesion (whole sentence is: ________ lesion such as a hemangioma or neurogenic tumor is less likely a malignant process.) Any ideas? I've been looking for an hour.
An operative report...SM
Subject: An operative report...SM
We have three options for the nasal fill area. We discussed allowing this to heal by secondary intention, full-thickness skin graft, and _____ tissue transfer.
Report is inside. Thanks for your help.
Subject: Report is inside. Thanks for your help.
ADENOSINE ECG STRESS TEST
The patient underwent Adenosine ECG stress testing according to protocol. She received 40.6 mg of IV Adenosine.
Baseline blood pressure 156/70 mmHg. Baseline heart rate 70 bpm.
Blood pressure transiently decreased to 132/72 mmHg. Heart rate was unchanged.
She experienced no anginal chest pain during the infusion.
Baseline pre-Adenosine EKG reveals A sensed V paced versus V pacing. There was no change during the infusion. There was no evidence of arrhythmia.
IMPRESSION:
- No Adenosine induced chest pain.
- No significant arrhythmia.
- Nondiagnostic Adenosine EKG test for ischemia.
Is it an OB/GYN report - what is the worktype?
Subject: Is it an OB/GYN report - what is the worktype?
Sounds like they're describing a cervix, maybe nulliparous?
Operative report
Subject: Operative report
She required a microround, a minute of Dopamine to maintain her pressure.
I'm not sure if microround is what he is saying. Do they use that term? Thank you.
Ortho report
Subject: Ortho report
Anyone hear of s/l "staunamen pin" It's for fixation of a femur fracture.
He said more clearly in another report. You're right! nm
Subject: He said more clearly in another report. You're right! nm
Operative report
Subject: Operative report
I am having a really hard time understanding this doctor. I've researched this term (or what I think he's saying) without any luck. I always turn to you guys last and you always seem to come up with the answer. Thanks for the help! At the end of the report he dictates anesthesia, IV fluids etc. Then he says something that sounds like this " Line: LB and RT line or Line: Albi and ulti line. "
Consultation report...sm
Subject: Consultation report...sm
EKG demonstrated normal sinus rhythm s/l normal axis, low transition LVH by voltage.
Mumble, mumble, mumble! 
Help with term used in OB/GYN report
Subject: Help with term used in OB/GYN report
This is from a laparoscopically assisted total vaginal hysterectomy with right salpingo-oophorectomy:
The procedure was commenced on the patient’s left side, where the tripolar forceps were used to cauterize and cut the tube proximally. The uteroovarian ligament was then clamped with the tripolar and then cut once it had been completely desiccated. The broad ligament was then taken serially in the same manner. The round ligament was taken down. Ocupuration was used to create a bladder flap, which was then taken across the midline with Metzenbaum laparoscopic scissors.
I've checked my Stedman's OB/GYN, but I do not find my answer there and can't seem to find it googling either. Anyone have any ideas?
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