Sorry, this should have been under heading Physical Examination.
Posted By: Jellybean on 2006-07-22
In Reply to: Under review of systems... - Jellybean
Subject: Sorry, this should have been under heading Physical Examination.
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i would say Examination and Evaluation needs to be put as a heading.
Subject: i would say Examination and Evaluation needs to be put as a heading.
just my thoughts.
This is in the physical examination. Thanx for trying
Subject: This is in the physical examination. Thanx for trying
Physical examination... sm
Subject: Physical examination... sm
Examination of female patient.
Musculoskeletal: No (s/l) keps, pains, or pedal edema...
Genitourinary: No (s/l) [cussforteeballing or maybe cusp or teeballing], or area tenderness.
Thanks in advance!
Physical Examination
Subject: Physical Examination
Happy Monday everyone! Hope you all had a great weekend! I'm doing a report and wondering if any of you can point me in the right direction!
"There is good capillary refill and s/l preson to cultures over both lower extremities." Any thoughts? Any good physical examination websites?
s/l physical examination
Subject: s/l physical examination
s/l chaos lesions (Skin, no evidence of ___ lesions)
CPX=complete physical examination nm
Subject: CPX=complete physical examination nm
hair tourniquet--which put of physical examination would this go in??
Subject: hair tourniquet--which put of physical examination would this go in??
I looked up "hair tourniquet" to find that it affects mostly infants, a hair wrapped tightly around an extremity or the external genitalia causing extreme discomfort. I've got a rambling dictator who states things in no particular order. Does anyone have an opinion on where this is most properly put?
on physical examination his BBI was greater than 1. Whats a BBI???? - nm
Subject: on physical examination his BBI was greater than 1. Whats a BBI???? - nm
ENT-physical examination reveals *syn___ectomy* without palpable adenopathy??? Thanks- nm
Subject: ENT-physical examination reveals *syn___ectomy* without palpable adenopathy??? Thanks- nm
The only other s/l mammalian is a slight pectus excavatum, otherwise normal physical examination.
Subject: The only other s/l mammalian is a slight pectus excavatum, otherwise normal physical examination.
x
Abdominal examination - s/l no jaboya by examination? TIA
Subject: Abdominal examination - s/l no jaboya by examination? TIA
how about typing Past Medical History heading and then typing what he says under the heading nm
Subject: how about typing Past Medical History heading and then typing what he says under the heading nm
xx
examination ?
Subject: examination ?
leg examination
Subject: leg examination
s/l Omin sign is negative.
any idea? The patient has calf muscle tendernes.
cor is the heading. sm
Subject: cor is the heading. sm
Some say Cardiac: S1 S2 etc. Some say COR: which means heart. They are just using that heading instead of CARDIAC, HEART,etc.
What heading would you use?
Subject: What heading would you use?
Okay to add headings on OP report. MD states: "Staples for skin" in the upper area with diagnoses, complications, condition....
Thanks.
Under what heading would you SM
Subject: Under what heading would you SM
put inguinal hernia in a PE? Would it be abdomen?
TIA
EKG can be a Heading
Subject: EKG can be a Heading
I would put under EKG alone as
EKG: EKG today show no ST wave changes.
Heading?
Subject: Heading?
This is for a psych. consult. After saying "New paragraph", he says "Review of past medical records." and then launches into: Doctor diagnosed tachycardia..etc.
I haven't seen a consult. with a heading, main or sub, with Review of Past Medical Records. Past Medical History, yes, but not the other. Any ideas?
right knee examination...pls s/m. Thank you!!!
Subject: right knee examination...pls s/m. Thank you!!!
Patient did lack a "co-le-sure" extension of the left knee and was able to flex the knee about 100 degrees. (???) Thank you!!!
tissue examination
Subject: tissue examination
tissue for ERA, PRA, DNA, poly harvested in one slide.
HEENT examination
Subject: HEENT examination
under HEENT examination the doctor states -
Extraocular muscles intact. Bilateral "turigeum". Fundi not visualized.
TIA
TYPE OF EXAMINATION
Subject: TYPE OF EXAMINATION
I was wondering if anyone has heard of SIMM CARD EXAM positive for BV. I have searched the Internet and am not able to find this term. Thanks a bunch
EUA--examination under anesthesia?
Subject: EUA--examination under anesthesia?
examination? catheterization? nm
Subject: examination? catheterization? nm
.
neurologic examination
Subject: neurologic examination
sounds like doc is saying "neurologic examination higher critical function", but could she be saying "neurologic examination hilar cortical function"?
Exam/Examination
Subject: Exam/Examination
Is exam considered a complete word or just an abbreviation of examination?
No, this is a knee examination. :( nm
Subject: No, this is a knee examination. :( nm
nm
MVA accident examination- sm
Subject: MVA accident examination- sm
doc doing an examination on 14=year-old female and says, Her pelvis is stable to compression. She has negative, sounds like body roll bilaterally?? Has anybody every heard of that. Thanks!!!
Oops, used same heading, need help
Subject: Oops, used same heading, need help
Sterile vaginal exam of 3 cm dilatation, 50% s/l "patient moderest through eustachian".
Thanks
IV abbreviated in heading
Subject: IV abbreviated in heading
Can IV FLUIDS be a heading or does it need to be INTRAVENOUS FLUIDS per the BOS?
under abdomen heading
Subject: under abdomen heading
s/l "the PICC was created" or "the tic was created"
Angie
Is it in the heading or in a sentence?
Subject: Is it in the heading or in a sentence?
I wouldn't change it in the heading, but if it sounds awkward in the sentence and your client doesn't want verbatim....
Thanks! But which book under what heading? I tried with
Subject: Thanks! But which book under what heading? I tried with
s
I think doc left heading out sm
Subject: I think doc left heading out sm
He dictates, "Skull does reveal evidence of hydrocephalus with enlarged cranium. Asymmetrical, moving equally with respiration. HEART: PMI could not be localized. S1 and S2, distant heart sounds. No S3 gallop. No murmur. LUNGS: Clinically clear.
What would be asymmetrical here?
I would put it under a heading of NECK. sm
Subject: I would put it under a heading of NECK. sm
One of the tests for meningitis is to bend your chin to your chest or to your shoulders. So if the pateint can to this, they have no meningeal signs or meningismus.
MUSCULOSKELETAL heading?
Subject: MUSCULOSKELETAL heading?
Newbie here. I'm typing an H&P and under instruction to supply appropriate headings & subheadings if they are not dictated, esp. in an H&P.
Under the Physical Examination, the Dr. dictated most headings, but under ABDOMEN, she continued with what I think is more of a musculoskeletal exam:
ABDOMEN: His abdomen is rotund, nontender, nondistended, and soft. He has no costovertebral angle (CVA) tenderness to percussion. He has no thoracic tenderness to palpation. His pain begins at approximately L2 down to his sacrum, with pain greater down his right gluteus versus his left, but does have pain. He has slow movement and grimaces with any movement. He is able to stand. Decreased range of motion secondary to pain. Straight-leg reflex painful in both legs. Reflexes are diminished bilaterally.
Here is my question: I cannot find a precedent for adding the MUSCULOSKELETAL subheading. Yet beginning from "His pain" and following is not really under an ABDOMEN exam, is it? At the very least, I feel I should start a new paragraph, but then my format is messed up b/c everything else has a subheading!
Needless to say, it stresses me out a bit. Any advice is definitely appreciated!
A lot of facilities use the heading
Subject: A lot of facilities use the heading
"laboratory" or "laboratory data" to include labs, EKGs, radiology, etc.
what PE heading would you put pilonidal under?
Subject: what PE heading would you put pilonidal under?
Just wondering under what physical exam heading other MTs put this finding under.
TIA!
No it is definetly not a heading.
Subject: No it is definetly not a heading.
I believe he is trying to say bladder urine was obtained. It could be his mis-spoke. I just wasn't sure. Thanks for your help.
A doctor can put in any heading they
Subject: A doctor can put in any heading they
want. I would use it and go on.
Followup as heading?
Subject: Followup as heading?
I'm embarrassed to have to ask this, but as a heading, which is correct--followup, follow-up, or follow up?
Neuropsych examination blanks...sm
Subject: Neuropsych examination blanks...sm
Cranial nerves 2-12 S/l** pretty realstine thiatmean around ____ 59 15** No signs of a a/l ** false ictal state** are appreciated.
This is a patient with a question of seizure disorder.
Speed talking doctor on a subject I'm not very familiar with and my Neuro word book has not yet arrived.
BJE is Bones and Joints Examination
Subject: BJE is Bones and Joints Examination
BJE is Bones and Joints Examination
It is usually slit lamp examination
Subject: It is usually slit lamp examination
Lung examination... see message
Subject: Lung examination... see message
The doc is saying: The lungs are with diffuse rhonchi. No wheezes audible. S/L "IDE" 1:1.
s/l "Q2" pupillometer examination?
Subject: s/l "Q2" pupillometer examination?
BJE - Bone and joint examination
Subject: BJE - Bone and joint examination
nm
In my opinion, should be spelled out in heading
Subject: In my opinion, should be spelled out in heading
nm
Not the OP, but a skin prep would be under a different heading
Subject: Not the OP, but a skin prep would be under a different heading
s
Heading in exam? COR: Cardiac etc.
Subject: Heading in exam? COR: Cardiac etc.
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