SKIN: She has a couple of dermal nevi, nothing that looks suspicious. A few MILEAM on the nose. nm

• SKIN: She has a couple of dermal nevi, nothing that looks suspicious. A few MILEAM on the nose. nm - Dermatology help needed. THANK YOU.
  • Milia - Dee

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He has a 4 mm nevus on his right cheek with some color variation and TYMPANINE appearing nevi of the neck.   He also has lipomas which are nontender over the left flank and left posterior quad.   

MD slurring his words again.  any guess?

he went on to have an aortic valve replacement with a "number tommy five" bioprosthetic valve as well as bypass "sinus tree" vessels

pseudo normal LV filling pressure with "chronkomittent" abnormal relaxation

Patient is New York Heart Association class III in the setting of ischemic cardiomyopathy and "he feels" compensated

Can't catch what Mr. Mush-mouth is saying. 

Postoperative serial white blood cell count demonstrated a stable white blood cell count at 11,900.  s/l *hemansa* hemoglobin stable at 28.9 and 9.4. 

First to address the issue of subcu - Joint Commission created a list several years ago that deals with this wording - and JC trumps BOS.  From Joint Commissions List of Dangerous Abbreviations:

Abbreviation: S.C. or S.Q. (for subcutaneous)

Potential Problem:  Mistaken as SL for sublingual, or "5 every"

Preferred Term:  Write "Sub-Q", "subQ", or "subcutaneously"

As far as what the man was trying to express to you was his opinion that truncated words (partial words used to express a complete word) should be avoided.  Trach is not a word.  Trachea, tracheostomy, etc., are words.  Alk is not a word.  Alkaline is a word.  There are also lab and other words that are commonly acceptable in their abbreviated form, such as INR, CPAP, MRI, etc.

There are acceptable abbreviations of certain words that are commonplace.  For example, lab is widely accepted to represent laboratory.  Exam is acceptable to represent examination.  HIV is another example.

If you understand the difference between the use of an abbreviation and avoiding the use of truncated words, your work will reflect a much clearer intent of the dictation.

Your company needs to decide which side of the fence it wants to sit on, and it appears there may be some changes in your QA future.  If this man is in charge of QA and you want to continue working there, you might want to begin taking note of what he is saying.

Jehovah's Witness

myoclonic gammopathy?  not myoclinic

possibly *gammopathy*

*h* in Jehovah's Witness

s/l *jo-lie-tandis* pain with hyperflexion.  (knee)

Negative s/l  *feralmis* test.  (wrist)

TIA!

This study is a right ilia-femoral ultrasound. 

Is it ilia-femoral or iliac-femoral, and what about the hyphen?

ALSO......

I cannot figure out what he is saying here:

PROCEDURE REPORT:  The abdominal aorta and right ilia-femoral (see above..) systems were S/L: insinated or instinated with a Doppler ultrasound transducer. 

Thanks for any help!!