This is in regard to the patient's
Posted By: sm on 2007-08-10
In Reply to: _____ status? (Psychiatric word help) - SG
Subject: This is in regard to the patient's
orientation and part of his total overall mental status exam. They will always assess if the patient is oriented to person, place, time and situation. So the unclear word would be related to oriented, orientation, or more specific to your example to time, and the patient's perception of current reality and time (some patients who are disoriented do not know common knowledge everyday things and think the current president is maybe Clinton or Daddy Bush. So again, try to pick up on anything to do with orientation or time and date.
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I always change that to *in regard*..sm
Subject: I always change that to *in regard*..sm
as for toward/towards, afterward/afterwards......both are acceptable as you said per the dictionary......so it depends on the MD I'm working for...I have one that is a stickler so I give him afterwards and towards as he says them.
In regard with what you said about MTs being responsible
Subject: In regard with what you said about MTs being responsible
for content, yes we are in some ways. However the examples you give of a physician's dictation - a new MT may not know that 100 mg of Synthroid is not a correct dosage, the MT types what is said and it is the DOCTOR who approves what is in the transcribed report. None of us know everything, the only thing we can do is accurately transcribe the dictation the dictation, not edit what we think should or should not be included.
I have never heard "p" with regard to
Subject: I have never heard "p" with regard to
x
Is it in regard to varicose veins?
Subject: Is it in regard to varicose veins?
What is it about?
I'll do a search with that in mind. Unfortunately, he doesn't say anything more in that regard
Subject: I'll do a search with that in mind. Unfortunately, he doesn't say anything more in that regard. sm
Before the s/l sentence, he says:
He can toe-and-heel walk. Tandem walking is somewhat off. Reflexes are diminished in the upper extremities, 1+ or trace at knees and at ankles. His motor power is generally full throughout upper and lower extremities. The right hand intrinsic muscles seem to be significantly affected and were about 3+/5. There is some atrophy of his first web space, which may be related also to significant subluxation of the thumb. The light touch sensation is generally okay.
His past surgical history is stent placement in 2004, status post cervical laminectomy/fusion.
Doctor is placing on Neurontin to see if he gets response regarding the paresthesias he's experiencing.
If this gives anyone a clue, I appreciate it a lot.
doc dictates "the patient has 120 pack year smoking history", patient is 75...is that right???
Subject: doc dictates "the patient has 120 pack year smoking history", patient is 75...is that right???? NM
Patient is here for an s/l eflex injection. Patient previously had Orthovisc.
Subject: Patient is here for an s/l eflex injection. Patient previously had Orthovisc.
nm
OB patient - s/l The patient has a 'null' sign.
Subject: OB patient - s/l The patient has a 'null' sign.
A1c; patient is to follow up in 2 weeks; patient has a followup in 2 weeks.
Subject: A1c; patient is to follow up in 2 weeks; patient has a followup in 2 weeks.
nm
Patient given PPD - sm pls
Subject: Patient given PPD - sm pls
Patient given PPD S/L "agreed" or "read" within the next 72 hours.
Patient does have a UTI but would it
Subject: Patient does have a UTI but would it
same doc. same patient
Subject: same doc. same patient
the lesion was vascular in natureand most likely _____ malformation.
S/L avio-lymphatic
HIV patient. Please sm.
Subject: HIV patient. Please sm.
Doc is dictating a test in relationship to patient's HIV. He states s/l "firal row"is negative and T-cell count has actually risen since last visit.
Thanks for any/all help!
do you have a Dx on this patient, and
Subject: do you have a Dx on this patient, and
if not, what is the chief complaint?
new patient
Subject: new patient
 On a new patient is this how it should be put? the doctor says it with chief complaint~~~~CHIEF COMPLAINT: New patient, arm pain.
OD q.d.? Is it for the patient's eye? nm
Subject: OD q.d.? Is it for the patient's eye? nm
x
cc: the patient
Subject: cc: the patient
then he said, note to the transcriptionist, make sure that a copy of the mri scan results is sent to the patient with this letter.
What is the patient's dx? nm
Subject: What is the patient's dx? nm
Are you sure the patient isn't
Subject: Are you sure the patient isn't
very spiritual, and is hoping for healing through a prayer line? Many churches do have prayer lines and pray for sick people. Usually they don't intend that the person shouldn't seek medical help like it sounds like this patient would be talking about.
How old is this patient?
Subject: How old is this patient?
The patient has a ... (sm)
Subject: The patient has a ... (sm)
. . . distal radius fracture. It s/l the doctor dictates *there is a cast and flink* to right arm. I thought it might be *splint*, but it really does not sound like that. Any idea?
Thanks, Melissa
Patient is p.o.ing well??????
Subject: Patient is p.o.ing well??????
POing??? or just change to eating? It's a 3-month-old baby girl.
What is the patient
Subject: What is the patient
in the hospital for? Main symptoms? Specialist seeing the patient?
Is patient ill otherwise? sm
Subject: Is patient ill otherwise? sm
I know you say it is not positive exudate but if the patient is ill or has upper respiratory symptoms, positive could actually be right.
Doc is saying the patient is this PDI-3 or
Subject: Doc is saying the patient is this PDI-3 or
Peduli-3? Never heard of a patient being that, but I have heard of a resident doctor being a PGY-3 after their name. Otherwise, I have no idea. Sorry.
The patient has both, so you must be...
Subject: The patient has both, so you must be...
correct!!! THANK YOU!!!!!! 
but patient has URI, not UTI, yes? (nm)
Subject: but patient has URI, not UTI, yes? (nm)
nm
Patient with AML,
Subject: Patient with AML,
Sentence reads: We have been watching her counts closely due to the fact that she has blood antibodies and requires s/l "spark of platelets" OR "sparkle platelets". Any ideas? TIA.
Thank you but the patient..sm
Subject: Thank you but the patient..sm
only came in for refill of birth control. She was out of insurance for a time period. No infections or anything.
Thank you for trying though. I do appreciate it. This dictator loves to ramble and sometimes not very clear.
The patient is on s/l T P.
Subject: The patient is on s/l T P.
It is definitely some sort of ventilator.
patient
Subject: patient
It is difficult to say whether his shortness of breath is secondary to coronary artery disease. Ventricular function, underlying pulmonary disease, i.e. s/l a-co-sis, or his weight.
What is patient seen for?
Subject: What is patient seen for?
Perhaps it has to do with what he is seeing the patient for..
Subject: Perhaps it has to do with what he is seeing the patient for..
?
Patient on s/l flo-air
Subject: Patient on s/l flo-air
could he mean the patient
Subject: could he mean the patient
can CONTINUE routine regimen of Prelief with these other meds?
is this patient HIV?
Subject: is this patient HIV?
Sustiva and Epizicom are given in conjunction for HIV
Patient has hep C
Subject: Patient has hep C
treated with s/l pegasus and ribaviran. These are not listed in my drug book, nor the one online. Not sure of spelling or whether capped. Thank you for your help.
No, the patient is in her 40s.
Subject: No, the patient is in her 40s.
:-)
Patient needs I&D - please sm for s/l
Subject: Patient needs I&D - please sm for s/l
Patient has an abscess and will need I&D and IV antibiotics. Arranged for admission with s/l IPOF or IPOTH.
Thank you.
This is a patient whom/who I have been seeing??? nm
Subject: This is a patient whom/who I have been seeing??? nm
nm
Per patient, he has not been... (nm)
Subject: Per patient, he has not been... (nm)
nm
It's possible the patient could be sm
Subject: It's possible the patient could be sm
taking one VicodIn as needed or one every eight hours. This means that maybe she can take one Vicodin for pain and that works for that episode, but when she has a longer bout of pain she takes one every eight hours until the pain is gone.
patient's UA
Subject: patient's UA
nm
This patient has .......
Subject: This patient has .......
syptoms of diarrhea, vomiting, abdominal pain, and dehydration. Have you heard of a ___stasis word that could go with that problem? patient needs IV fluid hydration for ____? I really appreciate the suggestion!! Thank you!!
Abby
Patient also needs
Subject: Patient also needs
IV fluid hydration for venous stasis. Adquate hydration is advised to help prevent this problem.
The patient's abdominal...
Subject: The patient's abdominal...
s/l PANNUCK has an area of early developing erythema, which encompasses about 4 to 6% body surface area.
TIA....Lisa
Does the patient have a pacemaker?
Subject: Does the patient have a pacemaker?
If so then one of the leads to it is broken.
This is a patient with an appendectomy.
Subject: This is a patient with an appendectomy.
A window was created at the base of the appendix at the junction with the cecum. This was confirmed by splaying of the s/l tinea or pinna. I know these are both wrong, but the closest sound alikes I could muster up. I got the hospital's bad boys today...
Exam on patient with MS
Subject: Exam on patient with MS
Cranial nerve exam revealed left homonymous hemianopsia, as well as *slowsecots* to the left, ocular dysmetria.
Thank you so much for any ideas. This is backup account. Never heard this before.
patient says she has had mono and s/l CNB or CMB or C&B
Subject: patient says she has had mono and s/l CNB or CMB or C&B
No cap. It's just the way they position the patient. nm
Subject: No cap. It's just the way they position the patient. nm
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