Opinions needed See MSSG

Question: would you put "Romberg negative.  No pronator drift.  Gait is normal." under extremities or neuro?    Thanks

EXTREMITIES:  No clubbing, cyanosis, or edema.  Distal pulses are 2+ and equal throughout.  Romberg negative.  No pronator drift.  Gait is normal.

NEUROLOGIC:  Cranial nerves II-XII are intact.  DTRs are 2+ and equal throughout.  Romberg negative.  No pronator drift.  Gait is normal.

• Opinions needed See MSSG - SuZEE
  • Always been under neuro for me, too. nm - wanderer
  • per neurologists i type for... - aa

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Here's my tweaking:   I think it looks okay except for the last sentence.  Can anyone help me make that last sentence look better?  Thank you.

Dear xxxx :

I am pleased to write a letter of recommendation for XXX who is applying to your program.  XXX spent a week with me in my internal medicine office this past summer.  He is currently a student at XXX and has decided on a career in a medicine.  In the process of starting his medical career, xxx has spent time with multiple physicians to show that he is serious about a career in medicine.  He has excellent personal skills, as you will see when you interview him. 

During the time I spent with xxx  he asked intelligent questions and showed a genuine interest.  His thought process seemed both logical and rational during our discussions.

Based on my experiences with x,  I recommend highly that he be accepted in your training to become an xxx physician.  I believe he has all the makings of good physician, intelligence hard-working, motivated, and personal. 

Not sure if this is what you are looking for, but check out:

Immune-related hydrops fetalis (IHF) results from alloimmune hemolytic disease or Rh isoimmunization. The mother is sensitized and has antibodies against fetal blood cells, causing hemolysis in the fetus when circulated maternal antibodies (immunoglobulin G [IgG]) cross the placenta to reach fetal circulation. Most cases occur because of antibodies to D-positive Rh antigen, although some cases can occur because of antibodies to C-positive and E-positive Rh antigens. Rare blood group antibodies, such as the Kell (K) system and the Duffy (Fy) system, also can cause hydrops.

ASSESSMENT/PLAN 

ASSESSMENT/PLAN 

1.      Thyroid carcinoma – a TSH and free T4 have been requested.  Review of laboratory studies requested by Dr. X in June of 2005 demonstrated an elevated TSH level at 8.  Apparently s/l DOE DOSE adjustment was made.  We will need to discuss thyroid suppression and goal of TSH with Dr. x.    She is due for thyroid scan.

It is definately not low dose.  It sounds like doe dose.  Am i missing something ???

Wondering what most people type for dosing units in the millions:

3 million units or 3,000,000 units

From what I see in BOS II, it can be typed either way.  I just typed 3,000,000 units thinking it may be a little more clear on a medication list, but now I am second-guessing, so I am looking for opinions on this.  Thanks

1) Miralax is generally given 17 g - half would 8.5 g.  That one grabs me more than the abbreviation issue.

2) g is an acceptable abbreviation for grams, but a lot of clients prefer it written out when used alone - much like the word liter when used alone.  It can sometimes be difficult to discern in the report.  If your client has no preference, I would continue to use g and just chalk it up to the QA's preference. 

this -  the dictator says the nodule was FNA'd or I&D'd, etc.  It just seems awkward.

The patient was seen by Dr. John Smith of the cardiology service.

OR

The patient was seen by Dr. John Smith of the Cardiology Service.

This always messes me up!  I've done it the second way for many moons, but I'm training a new girl who says according to the BOS, I'm wrong.  Just wondering how everyone else does it.

The patient has no discharge drainage or pus.

Initially I thought "drainage, discharge" with the comma but does it make sense without the comma? 

I got cystoproctography, but does cystoproctoscopy exists as i could not find it in  stedman also,

thank u

james

How do you type this?  I never did ob/gyn before.  What does miss mean, and how do I format?  Any help is appreciated.  Thank you.

PAST MEDICAL HISTORY

1.      Gynecologic – G3, P2, 1 miss.  She had been followed by Dr. XXXXXXXX   Her last Pap smear was approximately two years ago, as was mammogram.  Menses are on a q 28-30 day cycle, but there are periods where she will skip and have a menses q.o. month.

Need help with words in bold.  Thank you.

SKIN:  Lots of seborrheic keratoses.  He does have an elevated 9 mm papule on left side of the face, which has some vascularization and central core.  It almost looks like acanthokeratosis, but basal cell carcinoma cannot be fully ruled out.  No other suspicious lesions.  He does have some miliary rubra on the back. 

leiomyoma, singular; leiomyomata, pleural. Leiomyomatas is not a word.

My doctor keeps saying psoricytic arthritis. I transcribe for him a lot, but this is what he is saying.

I am thinking he means psoriatic arhtritis. What do you think?

Doing a rotator cuff tear repair.  two words 

Procedure: 1) Left shoulder arthroscopy, subacromial decompression with MINIMUMFER?  procedure.

the left upper extremity was prepped and draped in the usual sterile manner utliizing 8 pounds of traction in the ARTHREX?? arm holder?

THANKS

This is a 4-year-old with metabolic-type cardiomyopathy who required "Amikin chest tube treatment".

I see that Amikin is an antibiotic, but do not feel comfortable with the references I have found with chest tube and/or cardiomyopathy. I would appreciate any opinions on this. Thanks!