Progress Note: Heart without ?, Help please
Posted By: katlar121@att.net on 2009-01-16
In Reply to:
Subject: Progress Note: Heart without ?, Help please
Heart without _____ (s/l extra absoftness) without edema.
Also in same report, dictator says:
Urine shows 5-10 red cells, occasional white cells, moderate bacteria, negative glucose, negative
_____ (s/l glucoside esterase).
Does anyone know what those 2 blanks might be? I see “glucosylceramidase assay” in the Stedman’s Lab Words book, but I don’t hear that in the dictation.
I would appreciate any help at all.
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progress note
Subject: progress note
On this progress note it sounds like the doctor says "blood pressure 167/82, heart rate is 90, resperate 20, T max is 100.8."
Should that be respirations 20, temperature at max 100.8? thanks
progress note
Subject: progress note
thanks so much for your help you are right!!!
progress note
Subject: progress note
thanks for your help!!!
progress note help please!!!
Subject: progress note help please!!!
Blood pressure 167/82. Heart rate is 90, respiratory rate 20, Temperature at max is 100.8. No JVD lungs and expiratory wheezes. There are some rales in the right base. Heart without ** and edema. **120, **3.4, chloride 94, ** 25, glucose 91, BUN 9, creatinine .6, calcium 8.5, white count is 5.7, hemoglobin 8.9 down from 10 yesterday, platelet count 234,000, 6 lymphs, 10 minus 1 basophiles, 7 bands, 76 segs.~~~~ after heart without--it sounds like a extremity then ssss sound. the other sounds like Sims 120. the other sounds like seven and a 3.4. the other sounds like bacum. ANY HELP WOULD BE GREATLY APPRECIATED!!!!
Progress note help
Subject: Progress note help
Heart: Without? lower extremity edema. Sodium 120, potassium 3.4, chloride 94, bicarb 25.
Also, probably should be temperature T-max is 100.8. No JVD. Lungs: End-expiratory wheezes.
progress note help
Subject: progress note help
You are wonderful. I can't thank you enough!!!!!!!!!!
help with progress note
Subject: help with progress note
This pat has a cough and post-nasal drip, as well as GERD
Begins s/l *effuncting* nausea and abnormal liver enzymes. This could be a title or description of the nausea, but I can’t find anything.
Then,
s/l *Cardiovicular*. She reports the nausea has resolved. . . . has post-nasal drip .. .cough is not constant. Reflux is under good control
Edit/Delete Message
Progress Note headings?
Subject: Progress Note headings?
I really want to hear Chief Complaint, but I’m sure he starts with Cardio. Thanks anyway.
Progress Note headings?
Subject: Progress Note headings?
I can’t hear the “tat” part, but that sure makes sense. I like the cardiovascular, too, except this is talking about GERD - could that be connected to Cardiovascular system?
s/l careic? lesions. dental progress note
Subject: s/l careic? lesions. dental progress note
progress note--right lower lobe pneumonia
Subject: progress note--right lower lobe pneumonia
this is what the doctor is saying--"She has been on half-normal. Her (saline/sodium) drop will change to normal saline of 50cc an hour." in the second sentence of this I am not sure if he is saying saline or sodium? any help?
Making progress
Subject: Making progress
He said the first 3 letters again and spelled them:
I, B as in Bictor (meaning V as in Victor), F Laboratory.
So now we have IVF icksee Laboratory.
making a little progress
Subject: making a little progress
with this one, thanks to your answers... still hearing something like "Pradus" but instead of obturate, was saying on THE RIGHT. definitely NOT piriformis or sure does not sound like it, then goes on to gluteus medius and maximus.
It could be. If there is failure to progress. sm
Subject: It could be. If there is failure to progress. sm
I had to have an emergency C-section and they ruptured my membrane. They used this crochet hook looking thing. So it could possibly be assisted or even abrupt.
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
Work under progress on Word Board...
Subject: Work under progress on Word Board...
You may experience posting problems on Word Help Board only for next couple of hours.
Sorry for the trouble,
MTStars Administration.
diagnosis for operation includes intrauterine pregnancy at term, failure to progress and sm
Subject: diagnosis for operation includes intrauterine pregnancy at term, failure to progress and sm
and fetal s/l "a-sink-qua-sism".
noteworthy; note worthy; note-worthy
Subject: noteworthy; note worthy; note-worthy
Just wondering if there is any general rule about transcribing noteworthy.
Also, status post; status-post.
Thank you.
HEART:
Subject: HEART:
Sounds like, "The PMI 2L SV." Is this correct? Thank you. 
Heart
Subject: Heart
Both heart tones present without murmurs, lifts, heels or gallops.
Is that right?
Heart
Subject: Heart
Heart: Irregular rhythm with normal S1-S2 without murmurs, gallops or friction rubs.
I'm not sure if he said " a regular rhythm or irregular rhythm."
I figured I'd come to the you guys for the answer. You always come through for me. Thanks.
PE heart
Subject: PE heart
She states Heart: Adynamic s/l re-cor-gum
I know I have heard this before, but I am not finding it thanks
COR: ... (heart)
Subject: COR: ... (heart)
heart
Subject: heart
possibly ascending aorta (AA ?)
Heart
Subject: Heart
New account today. Heart: Trigger rates ______ (sounds like trigger rates "in general" without murmur?" General MD doing basic physical exam. Help please!!!
heart
Subject: heart
He has said that on previous patients on this tape. However, for whatever reason he definately starts with "trigger" on this one! Thanks.
Cor is heart.
Subject: Cor is heart.
heart.
Subject: heart.
x
heart
Subject: heart
There were (s/l mershersher gallops)
TIA!
Op note ref. SM
Subject: Op note ref. SM
http://www.mtdesk.com/frame.php?frame=resources
ER note
Subject: ER note
? pulse ox 99% on room air which is normal per ______ interpretation.
ER note thanks
Subject: ER note thanks
Thanks, practically sure it was per the ER physician reading. So, will be ready for next time!
At the end of OP note, he says
Subject: At the end of OP note, he says
what sounds like "mick" instrument and needle count.
On another, says "sponge, _____and instrument" and that sounds like "lab". Any clues are appreciated. Thank you!
OP note help please sm...
Subject: OP note help please sm...
mild (s/l-fibulations-) with changes on the surface of the condyle
Of note..... I want
Subject: Of note..... I want
to thank everyone so much for all the help I have received on this website since I have become an MT. Bless everyone of you. I hope one day to help those also asking questions as you all have me.
Op note
Subject: Op note
Dictator says: Local Xylocaine 1% anesthesia 'arfate' cannulated.
What is the 'a' word?
me again - same op note :(
Subject: me again - same op note :(
The wound was irrigated and rough edges were S/L RASSED. 
op note help
Subject: op note help
Using an up-biting basket and a S/L 405 shaver a medial meniscectomy was performed.
TIA!
OP NOTE HELP
Subject: OP NOTE HELP
The iliotibial band was then split inline with the incision and retracted anteriorly and posteriorly with a _____ bow. s/l charming.....
The procedure is a cemented bipolar hemiarthroplasty left hip.
OP NOTE STILL
Subject: OP NOTE STILL
Should have went further in the note...sorry...another blank is
Attention was directed to the proximal femur, which was prepared with a box-cutting chisel, _____ canal finder and a trochanteric router this sounds like "chauney"
ESL help with op note
Subject: ESL help with op note
She says: With forceps and a S/L barpotta knife the lesion was excised. (This is excision of a lid nodule).
have another on this same note - sm
Subject: have another on this same note - sm
Bilateral elbow rheumatoid arthritis. The left side is more advanced with (s/l)'spectus articulusdamage than appears on the right side
op note help
Subject: op note help
This is an excision of a breast nodule. Two questions:
1. The area was prepped with s/l Cloraprep
2. The needle was grasped with an S/L Alice clamp
See note below
Subject: See note below
This is the context of the report. It sounds just like Waddellian. He says this quite a bit and it stumps me every time....
PSYCHIATRIC: The patient was alert and oriented x3 with a somewhat depressed and scattered mood, being very jumpy and quickly agitated by minimal movements or pressures in various areas such as supporting the leg while doing musculoskeletal motor examination for neurologic examination. The patient definitely showed some ____________________ symptoms through our examination. When the idea of psychiatric help in this manner was brought up in this case, the patient seemed almost excited to know this was a coming event.
op note help
Subject: op note help
This is a partial medial meniscectomy and synovectomy.
large s/l type 1 plica present - is type 1 correct?
This was resected back to a stable configuration using an s/l oslite shaver or 8 inch shaver (he mumbles) ???
op note help
Subject: op note help
This is for an amputation of the left hallux.
Upon induction of IV sedtion a total of 10 ml of 0.5% Marcaine plain was infiltrated in a S/L Mayo block type fashion.
Mayo block???
note, no h on the end.
Subject: note, no h on the end.
x
Op note help
Subject: Op note help
ORIF surgery: Intraoperative s/l FLORA showed excellent alignment of the implants.
Note put above
Subject: Note put above
what does it mean when she dictates "note, put above..." before a sentence? i'm confused.
not 100% sure, but I don't think so--also, another note
Subject: not 100% sure, but I don't think so--also, another note
should your first part of your message say "afferent pupillary defect" ?? instead of papillary
See note
Subject: See note
This is what you are looking for.
http://www.fda.gov/cdrh/pdf/p000040.html
Lilly
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