Surgical History
Posted By: victoriapage on 2009-06-07
In Reply to:
Subject: Surgical History
"significant for hip replacement, "appy"????
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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!
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:
B&B in past surgical history
Subject: B&B in past surgical history
Anyone know what that could be?
Would that be under past surgical history though as he says it is? nm
Subject: Would that be under past surgical history though as he says it is? nm
nm
past surgical history
Subject: past surgical history
She has had repair of cataracts s/l "in aretnas". I couldn't hear retina. Anyone?
Past surgical history is? nm
Subject: Past surgical history is? nm
nm
Do you write out D&C for surgical history?
Subject: Do you write out D&C for surgical history?
I know that most of the time we write out acronyms in the surgical history, but for some tests and procedures, the acronym is okay. (Like CT scan, etc)
Past Surgical History
Subject: Past Surgical History
Doc is dictating patient's past surgical history. States she had s/l a budd kay or e malformation based on her MRI at the hospital. Any clues b/c I am at a loss with this one! 
Sounds like past surgical history.
Subject: Sounds like past surgical history.
x
If he's listing past surgical history then
Subject: If he's listing past surgical history then
I'd put appendectomy, three D&C's, tonsillectomy.
D&C stands for dilation and curettage
He only says BTTI under past surgical history and nothing else
Subject: He only says BTTI under past surgical history and nothing else
Is there any past surgical history that might give some clues? nm
Subject: Is there any past surgical history that might give some clues? nm
x
s/l toration of the intestines... past surgical history
Subject: s/l toration of the intestines... past surgical history
Surgical History: s/l harris rods in her spine. SM
Subject: Surgical History: s/l harris rods in her spine. SM
Does not sound like Harrington... sounds just like "Harris rods"
No it was just part of the surgical history, so no content clues available. NM
Subject: No it was just part of the surgical history, so no content clues available. NM
Under surgical history: s/l carpal tunnel ?effers? nm TIA
Subject: Under surgical history: s/l carpal tunnel ?effers? nm TIA
Nothing in the PMH/surgical history or current meds. to give you a clue? nm
Subject: Nothing in the PMH/surgical history or current meds. to give you a clue? nm
s
in past surgical history for a teen *slazon* removal from the eye. ?? TIA! nm
Subject: in past surgical history for a teen *slazon* removal from the eye. ?? TIA! nm
nm
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.
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
Proctectomy: Surgical resection of the rectum or Prostatectomy: Surgical removal of the prostate gla
Subject: Proctectomy: Surgical resection of the rectum or Prostatectomy: Surgical removal of the prostate gland.
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
surgical help
Subject: surgical help
is it put like this? Sticky U-drape, is the S capitalized? thanks alot!!!!!
GYN surgical help
Subject: GYN surgical help
Not used to this specialty:
Doc is doing an anterior/posterior colporrhaphy with placement of mesh and a s/l ""perigee""?
Thanks for any help!!
Social history
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!
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
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.
1-year history
Subject: 1-year history
How would you type the patient has a 1-year history of pain....tia.
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