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Pt with migraines with aura, in review of systems, episodic visual s/l C D O's. nm

Posted By: tracy on 2008-11-13
In Reply to:

Subject: Pt with migraines with aura, in review of systems, episodic visual s/l C D O's. nm




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nope, wish I could...but now I hear episodic visual hee tee ooo's ??
Subject: nope, wish I could...but now I hear episodic visual hee tee ooo's ??


It is Review of Systems and not Review of Symptoms.
Subject: It is Review of Systems and not Review of Symptoms.


Thats all in Review of systems.
Subject: Thats all in Review of systems.

Thanks though!
Under review of systems...
Subject: Under review of systems...

Sounds like dictator is saying:


Abdomen:  Soft. Flat. Obese.  Pressure: Soft. Obese.  No point of splenomegaly was noted.


However, it doesn't seem to me that this would fit.  He may be saying another heading instead of pressure but it is too jumbled to tell. 


Also this may be: No signs of [something] or splenomegally is noted.


 


Thanks in advance!


Review of Systems
On Review of Systems, he's saying . . ."@#$#&*&(" : No recent skin rash.  and then something else "@#$#$" : No anemia or lymph gland problems.  Psychiatric - No recent depression.    Can anyone tell me what these headings could possibly be?   I can't even get enough to give you a "sounds like".
In Review of Systems
Subject: In Review of Systems

There is no history of diabetes, polyuria, polydipsia, seizure, stroke, TIA, loss of strength or sensation, or DVT s/l pulmonary mesin around level bleeding. 


It might be 'pulmonary embolism' but I might just be wanting to hear that, it's kind of a stretch.  But the rest...


Any ideas??? Thanks.


Review of systems
Subject: Review of systems

Review of systems include shortness of breath and s/l ricacaria?? Anyone ...help???
Q in Review of Systems
Subject: Q in Review of Systems

When the doc says - Rest of systems: Negative.  do we write it that way or list the systems with Negative next to them all?


Do you want to know was ROS is? Review of systems.
Subject: Do you want to know was ROS is? Review of systems.


review of systems twice
Subject: review of systems twice

The doc says his normal ROS. At the end of his thought he pauses for a LONG TIME and then says "ROS, on the line, otherwise negative."
So should I do it like I have below or what are your suggestions?

REVIEW OF SYSTEMS: blah blah blah.
A review of systems is otherwise negative.


In review of systems he says,
Subject: In review of systems he says,

"no fevers, chills or sweat s/l size-or-trizer?
Review of Systems
Subject: Review of Systems

Of course...You are correct. I was typing too fast. :-)
Review of Systems
Subject: Review of Systems

I knew that is what you meant.
Not saying ROS of review of systems is negative? nm
Subject: Not saying ROS of review of systems is negative? nm


The patient has migraines and he has no visual disturbance or s/l scomatoma. TIA!!
Subject: The patient has migraines and he has no visual disturbance or s/l scomatoma. TIA!!


Other review of systems showed s/l OS negative
Subject: Other review of systems showed s/l OS negative

Other "review of systems" ____ showed s/l "OS"  negative. 
Do you hear scotoma at all, very frequent visual disturbance/migraines....nm
Subject: Do you hear scotoma at all, very frequent visual disturbance/migraines....nm

nm
Review of systems: See HPI (History of Present Illness.)
Subject: Review of systems: See HPI (History of Present Illness.)


review of systems is "pan positive" with a lot of problems. Is this right? nm
Subject: review of systems is "pan positive" with a lot of problems. Is this right? nm


Is this right "A "ten part" review of systems reveal?
Subject: Is this right "A "ten part" review of systems reveal?

n/t
"Female: Negative" under a male's Review of Systems?
Subject: "Female: Negative" under a male's Review of Systems?

This is the only doc i have ever seen do this... can someone explain?  I'm confused.
Review of systems: Chills, night sweats,*commerfid*
Subject: Review of systems: Chills, night sweats,*commerfid*

TIA!
14 point review of systems was done s/l weighted, dated and placed in chart. Is that right?
Subject: 14 point review of systems was done s/l weighted, dated and placed in chart. Is that right?

n/t
?break in dictation for MT instruction? i see "add this to review of systems above the extremity
Subject: ?break in dictation for MT instruction? i see "add this to review of systems above the extremity section" in your s/l ?? nm ??


In Review of systems: Hem/Lymph: Has long-term bruising, no s/l atreemia, noncontributory. nm
Subject: In Review of systems: Hem/Lymph: Has long-term bruising, no s/l atreemia, noncontributory. nm


I know, but on head and neck exam in review of systems, it is very usual for Dr. to make mention of
Subject: I know, but on head and neck exam in review of systems, it is very usual for Dr. to make mention of ,,,,

all the usual complaints of the specific region, as in neck, no lyphadenopathy, chest, no rales or wheezes, etc., it is a consult. What does he say about something green on the guy's head????
VDUs is visual display unit...VAS is visual analog (pain) scale..sm
Subject: VDUs is visual display unit...VAS is visual analog (pain) scale..sm

don't know if this helps at all...just a longshot in the dark.
First one maybe aura ?...nm
Subject: First one maybe aura ?...nm

x
Prodrome and aura was right!
Subject: Prodrome and aura was right!

Thanks! :-)
oops meant an aura...nm
Subject: oops meant an aura...nm

x
Here are some of these systems. Will look around more. sm
Subject: Here are some of these systems. Will look around more. sm

Apogee



Vaginal Vault Prolapse Repair System


Perigee



Transobturator Anterior Prolapse Repair


Monarc



Subfacial Hammock


SPARC



Sling System


BioArc SP



Sling System


BioArcTO



Subfascial Hammock


InteDerm



Allograft Dermal Matrix


InteXen



Porcine Dermal Matrix


In-Fast Ultra



Sling System


Straight-In



Sacral Colpopexy System


Visual Acuity
Okay, I don't know if this is the right thread to post this, but Doc is saying Visual Acuity right eye 20/nothing, left eye 20/nothing.  How would that be transcribed??  Thanks.
Visual Acuity
Subject: Visual Acuity

Hearing dictator saying "visual acuity is NA"  Does he mean non-applicable? and if so should I type out non applicable.


 


Thanks


Visual halo ???
Subject: Visual halo ???

dd
Is this for migraines? sm
Subject: Is this for migraines? sm

MIDAS score, Migraine Disability Assessment Scale, just an idea.  Do you have any other info?
also has migraines
Subject: also has migraines


visual field types
Subject: visual field types

Here are some uncommon ones that might help in the future.  Monocular visual field.   Visual field superior 36 taped-and-untaped (checking for lid droop).   Mac-to-red visual field (macular threshold to red, for patients that use Plaquenil).   Hope this helps.


Visual acuity test - sm
Subject: Visual acuity test - sm

Second cranial nerve is intact with normal visual acuity by s/l snylan's test.


TIA!


Thanks for that link! Very helpful visual -
Subject: Thanks for that link! Very helpful visual -

nm
chronic migraines
Subject: chronic migraines

The word you are looking for is Decadron.
Relpax for migraines?-nm
Subject: Relpax for migraines?-nm

xx
Could it be: He has taken Fioricet for the migraines?
Subject: Could it be: He has taken Fioricet for the migraines?


Pt with migraines, seizures, s/l ...sm
Subject: Pt with migraines, seizures, s/l ...sm

"bla ha meet" phenomenon.
Phonophobia?? As in migraines? nm
Subject: Phonophobia?? As in migraines? nm

nm
All other systems are reviewed and are negative
Subject: All other systems are reviewed and are negative

okay i need help. is he saying....."all other systems are reviewed and are negative" or "all of the systems are reviewed and are negative"???????? it is under the heading, REVIEW OF SYSTEMS.


CSF fluid: There was no s/l agrezoclaminomia by visual inspection.
Subject: CSF fluid: There was no s/l agrezoclaminomia by visual inspection.


found it, visual estimated technique yay! lol nm
Subject: found it, visual estimated technique yay! lol nm


has a right visual field cut and positive right s/l marcuscund
Subject: has a right visual field cut and positive right s/l marcuscund

nm
Opthalmology - Omedi visual fields?
Subject: Opthalmology - Omedi visual fields?

s/l Omedi   


He says her omedi visual fields show relatively little deficit. 


 


He is a very clear dictator. 


Decreased visual field on the right s/l 2 threat or throughout?
Subject: Decreased visual field on the right s/l 2 threat or throughout?

I don't know if this makes sense. 


Decreased visual field on the right s/l 2 threat or 2 throughout.  Do either of these make sense, or something else?


(s/l) Leer-i-ka 15 mg h.s. (pt with migraines and insomnia)
Subject: (s/l) Leer-i-ka 15 mg h.s. (pt with migraines and insomnia)