Social history
Posted By: Lola on 2005-09-30
In Reply to:
Subject: Social history
I forget the proper transcription for this regarding numbers--
Occasional tobacco use, 1-2 half-packs per day.
Should 1-2 be spelled out and is half-pack hyphenated? Thanks a lot!
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Past social history
Subject: Past social history
When typing amount of cigarettes, is three-quarters a pack a day correct or would you use numerals?
social history - denies smoking, alcohol or girls. sm
Subject: social history - denies smoking, alcohol or girls. sm
I can't think of anything else he might be saying, it really sounds like girls. Do you think this is correct? I just think it sounds weird.
BTW the only medical history I have for this patient is Ewing sarcoma...
Social indiscriminability
Subject: Social indiscriminability
ok I don't think indiscriminability is a word. discriminability is. i don't know what to put and I hate blanks
Social indiscriminately ?
Subject: Social indiscriminately ?
dd
Under past medical history - history of abnormal s/l petatrie functioning. I really cannot make *sm
Subject: Under past medical history - history of abnormal s/l petatrie functioning. I really cannot make *sm
it out. It is a foreigner. He is saying it very fast. History of abnormal petatrie functioning is what is sounds like to me. I have no clue.
anti-social personality disorder
Subject: anti-social personality disorder
It could be ASPD. They found a link between sexually transmitted diseases in people who have ASPD. Oh, the irony!
Social Security disability determination...sm
Subject: Social Security disability determination...sm
Social Security is a proper name and is always capitalized as such, but disability is not part of an official program name. The other proper name associated with SS is Supplemental Security Income (SSI), which is the proper name of a program administered by Social Security. (Don't ya just love government stuff?) ;)
socially indiscriminate or social indiscrimination? nm
Subject: socially indiscriminate or social indiscrimination? nm
nm
There is an S sound in the word, also not system or social
Subject: There is an S sound in the word, also not system or social
history of colorectal history with metastasis to the liver and lymph nodes
Subject: history of colorectal history with metastasis to the liver and lymph nodes
Upper or lower case: Social Security Disability...
Subject: Upper or lower case: Social Security Disability...
___ is a 50-year-old man who is referred by the ___ for the purpose of the Social Security Disability determination. Should I capitalize the first letters or type in lower case? Thanks!
Social work eval s/l full-'scaled' or 'skilled' survey sm
Subject: Social work eval s/l full-'scaled' or 'skilled' survey sm
hx of baby with head injury
Full-scaled survey seems to make the most sense- can anyone verify this?
TIA
history
Subject: history
s/ true, screw, tew.
A 20 gauge____ guide monoptic coaxial system was employed to obtain 2 core biopsies of the lesion
OB history
Subject: OB history
CAMT- In my BOS second edition- page 290: Separate GPS sections by commas:
G4, P3, A1 
History of?
Subject: History of?
Could the dictator be saying "history of" cholecystectomy," instead of "her 'seri' cholecystectomy?
history of **leg TB**? sm
Subject: history of **leg TB**? sm
it's on a numbered list so i really dont have anything else to work on. THANKS!
not sure but her history is.....
Subject: not sure but her history is.....
pt had a surgery recently from a MVA and had several broken bones, also history of hypertension, diabetes and peripheral vascular disease. thanks
??? not sure, not really any history
Subject: ??? not sure, not really any history
sounds just like Caprix
patient history
Subject: patient history
Patient presents with history of ***Lemure*** disease? s/l Lemirro
family history
Subject: family history
7yo girl with pneumonia. no family history of asthma or other chronic lung disease, immune deficiency or decreased sl-fertility.
H & P- history and physical...nm
Subject: H & P- history and physical...nm
m
history of ?ceilingectocies
Subject: history of ?ceilingectocies
Family history
Subject: Family history
Internal Medicine clinic notes:
Family history: S/L Vonastroms with accent on "strums" at the end of the word. Tape cuts out on the first part, but I can hear the strums at the end.
Thanks
s/l atremic history
Subject: s/l atremic history
PATH history
Subject: PATH history
Past history would cover you on all corners. Did the doc dictate any history? Unless she has significant OB/GYN pathology, which the doc would probably make note of, vaginal bleeding and "path" history don't go together. Hope that helped.
HELP-- pt has history of heroin and
Subject: HELP-- pt has history of heroin and
s/l aniculary drug use???????
It may be, but I don't know if she has a history of alcoholism. ..
Subject: It may be, but I don't know if she has a history of alcoholism. ..
I just left it blank for QA. Thanks for the suggestion, though.
Not really. Perhaps just "former history"?? nm
Subject: Not really. Perhaps just "former history"?? nm
x
pro forma history? See ref.
Subject: pro forma history? See ref.
Main Entry:pro for*ma
Pronunciation:(*)pr*-*f*r-m*
Function:adjective
: done or existing as a matter of form
says s/l history of DVD/PE ? - on anticoagulation
Subject: says s/l history of DVD/PE ? - on anticoagulation
Psychiatry - history of s/l TEE-H-SHE (sm)
Subject: Psychiatry - history of s/l TEE-H-SHE (sm)
history of s/l TEE-H-SHE times 2 years, ectasy times 2 years, and significant alcohol use. ??? TIA
Patient with history
of femoropopliteal bypass graft. Pulses palpable at s/l PTTP???? I am brain dead here. TIA
could it be history of hypertension?
Subject: could it be history of hypertension?
nm
history of pneumonia?
Subject: history of pneumonia?
Need help with two words please.
History of pneumonia and s/l bi-e-ma status post s/l e-cor-ti-cation
Bony______ (history)
Subject: Bony______ (history)
Chief complaint: Hit the wall with hand.
maybe infectious history
Subject: maybe infectious history
surgical history s/l all-tee
Subject: surgical history s/l all-tee
Patient is being seen for balance problems. There is a lot of focus in the report on various tests and her previous tethered cord, lumbar stenosis, laminectomy, etc.
Past surgical history includes: "repair of a spinal fluid leak and (s/l all-tee) then the lumbar spine fusion."
Any ideas as to what the all-tee might be? At first I thought it was the doctor stumbling over her words, but upon re-listening, I'm not so sure!
as in he personally has history of.... NM
Subject: as in he personally has history of.... NM
7-year history.....
Subject: 7-year history.....
I get confused, too! well-defined hypen; the hyphen is well defined. That is how I think of the hyphens, but I'm no BOS guru - just been in the biz for a long time.
I do not in surgical history. I only
Subject: I do not in surgical history. I only
expand it if in an op report heading of Procedure Performed:
Surgical History
Subject: Surgical History
"significant for hip replacement, "appy"????
1-year history
Subject: 1-year history
How would you type the patient has a 1-year history of pain....tia.
Pt with history of LGSIL Pap sm
Subject: Pt with history of LGSIL Pap sm
A: History of LGSIL Pap, s/l ***full colpscopy*** with 1 directed biopsy obtained.
I don't have much experience at all in anything related to GYN procedures and not sure if there is a distinction between a colposcopy and a full colposcopy - the only other thing it s/l is ***for colposcopy*** with 1 directed biopsy obtained.
Hope I made sense here. Thanks for any help.
Patient has history of anemia..sm
secondary to s/l "naneocrosis". Any suggestions?
Past medial history
Subject: Past medial history
The patient is admitted from the clinic where CT visuals showed recurrence of the disease.
I'm not sure if that's what the doctor is saying. Does it sound right?
Just says she is on embriol IM weekly for history of RA.
Subject: Just says she is on embriol IM weekly for history of RA.
x
Past medical history
Subject: Past medical history
Under history of present illness he has that the patient has a history of IV drug abuse.
Past medical history: IODINE ALLERGY WITH SHORTNESS OF BREATH AND HIVES FOLLOWING IV SPREE THREE YEARS PTA.
Could that be what he's saying? Thanks.
History significant for "IPP" at age 6?
Subject: History significant for "IPP" at age 6?
I don't see anything in my Abbr. book that might fit this. s/l IPP or IPT. Any ideas anyone? THanks!
under past medical history...
Subject: under past medical history...
Past medical history
Subject: Past medical history
Surgeries: Small bowel obstruction, THA/BA for cholecystectomy.
I'm not sure if he said BA or BA with another letter on the end. Help! Thanks.
history of sl-path pneumonia
Subject: history of sl-path pneumonia
past medical history of sl-path pneumonia in 2002.
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