Recommendation and plan in patient with metastatic melanoma
Posted By: mandiemt on 2007-10-23
In Reply to:
Subject: Recommendation and plan in patient with metastatic melanoma
To maintain DENSE intensity for neutropenic fever precautions, we have ordered Nuelasta 6 mg subcutaneous injection on 10/18.07.
For the life of me, I can't figure out dense intensity. Any ideas?
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Patient is status post melanoma excision s/l....
Subject: Patient is status post melanoma excision s/l....
Past medical history is significant for melanoma. She has had surgery in September for this s/l "essential" excision of melanoma from her right lower extremity.
He says earlier the patient has prostate cancer metastatic to the bone, so I'm thinking it's p
Subject: He says earlier the patient has prostate cancer metastatic to the bone, so I'm thinking it's prob. "has had known"
Patient with pneumonia - plan for... s/l R-cat consult??
Subject: Patient with pneumonia - plan for... s/l R-cat consult??
Patient in for Plan B birth control. sm
Subject: Patient in for Plan B birth control. sm
P: Pt is placed on oral bc. Discussed missed dose protocol. Reviewed ACHES (doc spells this out).
Thanks.
Patient with right ankle sprain. Plan: Gave please sm
Subject: Patient with right ankle sprain. Plan: Gave please sm
s/l "Murray ice compression device". Thanks for any help.
Patient with foot ulcer. Under plan, "She has been switched to 1/2-strength s/l Day-gin SM
Subject: Patient with foot ulcer. Under plan, "She has been switched to 1/2-strength s/l Day-gin SM
solution daily.
Patient is status-post s/l ex-plan of the left total knee. nm
Subject: Patient is status-post s/l ex-plan of the left total knee. nm
Not sure but comprehensive 65 plan, may be referring to age/healthcare plan?
Subject: Not sure but comprehensive 65 plan, may be referring to age/healthcare plan?
Sorry, tried to help. Have a nice weekend.
.. cont'd. However, that's an AAMT? recommendation only, and your
Subject: .. cont'd. However, that's an AAMT? recommendation only, and your
s
negative for metastatic disease
Subject: negative for metastatic disease
Melanoma
Subject: Melanoma
Doctor dictates what sounds like "malignant melanoma in site 2 with all the celotic margins free" I keep looking but can't find anything on this. Help!
D
MRI, s/l in ofen ocious metastatic focus
Subject: MRI, s/l in ofen ocious metastatic focus
MRI of the brain did show a 6-mm area of restricted diffusion involving the midline aspects of the splenium of the corpus callosum, which was representing an acute to subacute infarct process. Was less likely to be considered for a metastatic focus. Right-sided parietal calvarial 7-mm lesions were also noted, suggestive of an s/l inofenocious metastatic focus.
metastatic breast cancer (as in metastasis) nm
Subject: metastatic breast cancer (as in metastasis) nm
Metastatic colorectal cancer to lung nm
Subject: Metastatic colorectal cancer to lung nm
"Y" excision of melanoma?
Subject: "Y" excision of melanoma?
Anyone heard of this? Sounds like "Y" excision, but I can't find it.
Thanks!!
Are you sure it says melanoma vaccine?
Subject: Are you sure it says melanoma vaccine?
Melanoma is a type of skin cancer...there is no vaccine for that.
Uh, melanoma resection? nm
Subject: Uh, melanoma resection? nm
s
intertrigonal melanoma
Subject: intertrigonal melanoma
Would this be correct? Dr did a bx of this.
s/l coserata melanoma
Subject: s/l coserata melanoma
The pt is a T2b, N0, M0, Clark’s level IV, 1.5 millimeter "coserata" melanoma.
long shot, but ? microscopic metastatic disease
Subject: long shot, but ? microscopic metastatic disease
x
melanoma vaccine with S/L "interlocking two"
Subject: melanoma vaccine with S/L "interlocking two"
Oncologist with a THICK russian accent
Help
tia~
I thought melanoma but clearly not stating that...nm
Subject: I thought melanoma but clearly not stating that...nm
x
lung cancer PET scan shows extensive metastatic
Subject: lung cancer PET scan shows extensive metastatic
s/l fosi
thanks
doc spells "Mardynia" related to metastatic carcinoid tumor
Subject: doc spells "Mardynia" related to metastatic carcinoid tumor
cannot document Mardynia... any takers??
help - melanoma chemo drug s/l petefulon? NM
Subject: help - melanoma chemo drug s/l petefulon? NM
Well, could it be Lentigo maligna melanoma is more prevalent on chronically sun-damaged skin of the
Subject: Well, could it be Lentigo maligna melanoma is more prevalent on chronically sun-damaged skin of the head, neck, and arms.
..
another guess - could the artron be Intron? for hepatitis, leukemia, lymphoma, melanoma....etc. nm
Subject: another guess - could the artron be Intron? for hepatitis, leukemia, lymphoma, melanoma....etc. nm
could the ocious part be osseous? as in osseous metastatic disease
Subject: could the ocious part be osseous? as in osseous metastatic disease
maybe the inofen is inoperable?
Plan
Subject: Plan
CBC with differential, type and cross for 20 units, electrolytes P3, P4, PT, PTT, EKG, PA and lateral chest pulmonary function test.
I'm just in school for Med Trans. I love this website. I'm always confused when it comes to listing labs. I need help on the above. Thank you so much.
Plan help please!
Subject: Plan help please!
I am a new, and need some help. after the doctor says plan he lists the medications he has prescribed. He does not number them and I am used to them saying medications and then listing (1, 2, 3) Do they usual do that? Should I leave it like he says it? Example:
PLAN:
Ecotrin 1 p.o. b.i.d. with meals. Keflex 500 mg p.o. q.i.d. for 4 days.. Follow-upl with me within the next 10 days.
thanks!
Plan help please!
Subject: Plan help please!
That all depends on the QA person reviewing the report.
I have been told both are correct and both are wrong, other than if there is only one item (in which case you never number).
I have been audited and smacked down (points) for NOT numbering when the dictator did not number on meds and on diagnoses, etc., even on a verbatim account. I would love if someone could explain why. The client profile for the account says "do not number" if the dictator does not number.
Plan.... UA and CNS or C&S?? thank you
Subject: Plan.... UA and CNS or C&S?? thank you
Do you have to have a plan?
Subject: Do you have to have a plan?
Where I work, if they don't say "plan", they don't get a "plan".
That's what I plan to do.
Subject: That's what I plan to do.
I do not like to guess. Now it says for prostate cancer, so it might be. I will just flag it and put a s/l, just in case. I don't want them to think I didn't try to look it up either.
Here's another one: Under Assessment/Plan
Subject: Here's another one: Under Assessment/Plan
1. Erythrocytosis – the patient did have a hemoglobin of 17 on blood work one year ago. I asked him to repeat it, but he forgot. We will recheck his CBC with NORRIS REPREEDIN level today and work this up accordingly. He is not symptomatic.
I keep listening over and over to this, and this is all I can make out. Any clue what he might be referring to??? TIA
assessment&plan help!
Subject: assessment&plan help!
If the doctor says assessment and plan together, do I put the header together? I am confused because when he gives the assessment he numbers them 1) 2) then when he gives the plan he numbers them as well but does not say plan any help?
ASSESSMENT:
- Bilaterally arm numbness.
- Nausea.
- Health maintenance recommendations.
PLAN:
- Patient’s critical examination was hyperreflexia suspicious for possible cervical lesion. She will be referred for MRI with cervical spine. Patient may need EMG to further access her numbness.
- Patient will be tried on Nexium, although she does not have any overt symptoms of heartburn. She does have chronic nausea and this may be a sign of stomach reflux. She will be tried on Nexium 40 mg one q.d. Other diagnostic possibilities include slow gastric emptying. The patient does not eat breakfast or lunch and has her largest meal at about 8:00 at night. We discussed the need to consume breakfast and ideally eat 3-5 meals per day, smaller meals to encourage her metabolism. ___ problem health maintenance and in regards to increase her exercise and changing her diet. Patient will be referred to OB/GYN for Pap and pelvic and also will be referred for a screening mammogram. When she follows up to see me we will discuss potential options for colon screening. Patient is to follow-up with me in approximately 1 month time.
assessment and plan
Subject: assessment and plan
I hate when docs do that - mine do it a lot. I think you're good either way but I would put "A&P" as the heading and then just type it the way the doc says it.
starts plan
Subject: starts plan
it starts the plan then says ??? flonase 2 sprays each nostril
Sounds like a plan to me!!
Subject: Sounds like a plan to me!!
Thanks!!
s/l her-plan-jet-ick lesions
Subject: s/l her-plan-jet-ick lesions
s/l her-plan-jet-ick lesions in the mouth and throat
this is a 17 month old with excessive drooling and fever.
that sounds like a plan
Subject: that sounds like a plan
nm
Is this directions for something or what? A plan at the end of a scan? nm
Subject: Is this directions for something or what? A plan at the end of a scan? nm
s
In plan he very plainly says says need to rule out
Subject: In plan he very plainly says says need to rule out
Patient fell and injured right ankle. Sentence in question: She is significantly tender in the s/l coronal ligament s/l and the (or in the) right ankle.
Plan: MRI to rule out coronal ligament tear.
This is very clear - just cannot document it anywhere and don't want to flag it as it's very clear - just unsure and hoping for documentation or someone that has heard it.
Where would you begin the PLAN if the dictator does not say so?
Subject: Where would you begin the PLAN if the dictator does not say so?
ASSESSMENT: We discussed options for Jeff. At this point, a month after the injury, an MRI, potential surgical interventions, etc., ultimately doing as well as he is, he is just going to keep it in mind and be careful with his lifting. He drives a forklift, apparently on a regular basis, but we are going to forego further work up at this point. We also got int a discussion of routine health care maintenance. He will plan on complete physical in October, starting this year. I will put a standing order at lab at this point for him, for a UA basic metabolic fasting lipid panel and PSA. We will go from there.
Help with sentence. This is doc's treatment/plan: sm
Subject: Help with sentence. This is doc's treatment/plan: sm
The sentence just doesn't seem right to me. Any input appreciated!
" Examination, evaluation, simple avulsion nail plate, 3rd left lateral aspect nail plate avulsed paronychium performed under anesthesia."
Plan: Check CMP and s/l iris ads
Subject: Plan: Check CMP and s/l iris ads
In plan, doc says check s/l FH LSH. How would this be typed --
Subject: In plan, doc says check s/l FH LSH. How would this be typed --
plan of coagulation? planned? WAG
Subject: plan of coagulation? planned? WAG
ASSESMENT/PLAN COMBINED?
Subject: ASSESMENT/PLAN COMBINED?
WHen doing a SOAP NOTE
Can you Combine Assessment/Plan or are you supposed to seperate?
Even if doctor doesn't dictate a new paragraph? Thanks!
Thanks!!! no he says pila plan but cant find that--see more
Subject: Thanks!!! no he says pila plan but cant find that--see more
he diagnosed condition as blepheritis so that will work. thank you!!!!!
is this under procedures? plan? could you give the whole sentence?
Subject: is this under procedures? plan? could you give the whole sentence?
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