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

• Social work eval s/l full-'scaled' or 'skilled' survey sm - tiny
  • Full-scale survey - x

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Diagnosis:  Back pain, myalgias, hip pain, chronic fatigue, depression, muscular tenderness.

CBC, CPK, TSH, s/l "biotrin, biatrin" survey.

for systemic lupus erythematosus.

Otherwise, s/l "manlo biochem" survey, TSH, and CBC.

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!

When typing amount of cigarettes, is three-quarters a pack a day correct or would you use numerals?

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...

The therapist is saying 1-1/2 fingers breath from the chest.  How should this be typed?  Fingersbreadth or fingerbreadths? 

This was under mental status:

Mood was stressed and angry with a S/L: VER-EH-BY affect. 

I definately hear the long "i" sound at the end.  Unless he is saying "variable" wrong...

Thanks!

Psych eval.

Scores were invalid during his testing because he refused to cooperate on certain tasks - doc dictates:

"Interpretation of WISC-IV scores for him is given consciously, due to the s/l: manual refusal behaviors noted during testing."

Manual refusal behaviors?  Is this right?  Thanks!

This patient is on Zoloft and has a history of Oppositional Defiant Disorder, ADHD, and anxiety.

This is under AXIS I:

1.  Generalized Anxiety Disorder, 300.02.

2.   S/L Dysplymic or Disemployment Disorder, 300.4.

It does not sound like dysthymic.  Thanks,

Under Axis Formulation:

AXIS I:  Schizoaffective Disorder, Bipolar s/l: subtag.

I have not encountered this word and tried to google subtag to no avail.

Thanks.

This is under the discussion part of the dictation and it is a continuation, of which I was not the typist for the first part of the evaluation...

My assessment of him reveals many strengths, including long-term friendships, good relations with family members, solidly normal intelligence including strong S/L: visual enhance auto reasoning, and absence of any “behavior problems” in the usual sense of the word.

Does this make sense???  Thanks for any help.

Psych eval for a 7-year-old student with ADHD...

He says the following:

He showed a moderately delayed score in the working memory area when he had difficulty recalling S/L: wrote, auditorily presented information.  Weakness in this area may impact his ability to remember, recite, and manipulate sequences for academic tasks.

WROTE auditorily presented information?  TIA

The patient is having an OT evaluation.  He is in a wheelchair.  The sentence is under ADLs and states, "He uses (s/l liftlocks or lislocks) on his shoes and these work well." 

He has some mild anxiety about S/L: WALT issues but does not have any symptoms suggestive of an anxiety disorder. 

He was diagnosed with ADHD and PDD.

TIA

S/L spacuda step testing.  Football player with concussion after helmet-to-helmet hit, now complaining of dizziness and headaches. 

The sentence is:

"His *Spacuda?* step testing was intact."

She is doing dynamic balance testing on him.

Thanks! 

I have an extremely difficult dictator with a thick accent.  Sound like:  "Full" lesion of actinic keratosis.  Is there some other word that starts with an F that precedes lesion commonly because I am not sure if that is what he is saying?

Urinalysis:  Positive nitrite with large leukocytes, "full fluid" WBC.

He has had only minimal response to prednisone and s/l serum form Albuterol inhaler.  

Thank you