Under assessment: UNCOMPELLING EMG results
Posted By: sm on 2008-01-31
In Reply to:
Subject: Under assessment: UNCOMPELLING EMG results
Is uncompelling a word?
Or is it noncompelling?
Thanks!
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Assessment
Subject: Assessment
ASSESSMENT: Family history of AAA. Will proceed with -- s/l "root" ----- to evaluate.
Anyone have any idea what this is?? I'm drawing a blank.
TY!!
Help with assessment
Subject: Help with assessment
Hypertension with s/l "realciaporosis"...??
Any ideas??
TIA 
assessment ?
Subject: assessment ?
Patient had an s/l EIP - EPL transfer.
in the assessment i would, otherwise no
Subject: in the assessment i would, otherwise no
Assessment ?
Subject: Assessment ?
Assessment ?
Subject: Assessment ?
Can you have an abbreviation like URI in an assessment? Thx. Tina
Assessment
Subject: Assessment
Thank you for the assessment info!!
CAGE assessment?
Subject: CAGE assessment?
CAGE Assessment (Alcohol Abuse)
Powered by:. CAGE Assessment (Alcohol Abuse). For most people who drink, alcohol
is a pleasant addition to eating and to other social activities. ...
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Here's another one: Under Assessment/Plan
Subject: Here's another one: Under Assessment/Plan
1. Erythrocytosis – the patient did have a hemoglobin of 17 on blood work one year ago. I asked him to repeat it, but he forgot. We will recheck his CBC with NORRIS REPREEDIN level today and work this up accordingly. He is not symptomatic.
I keep listening over and over to this, and this is all I can make out. Any clue what he might be referring to??? TIA
It was not a test. It was the assessment.
Subject: It was not a test. It was the assessment.
nm
assessment&plan help!
Subject: assessment&plan help!
If the doctor says assessment and plan together, do I put the header together? I am confused because when he gives the assessment he numbers them 1) 2) then when he gives the plan he numbers them as well but does not say plan any help?
ASSESSMENT:
- Bilaterally arm numbness.
- Nausea.
- Health maintenance recommendations.
PLAN:
- Patient’s critical examination was hyperreflexia suspicious for possible cervical lesion. She will be referred for MRI with cervical spine. Patient may need EMG to further access her numbness.
- Patient will be tried on Nexium, although she does not have any overt symptoms of heartburn. She does have chronic nausea and this may be a sign of stomach reflux. She will be tried on Nexium 40 mg one q.d. Other diagnostic possibilities include slow gastric emptying. The patient does not eat breakfast or lunch and has her largest meal at about 8:00 at night. We discussed the need to consume breakfast and ideally eat 3-5 meals per day, smaller meals to encourage her metabolism. ___ problem health maintenance and in regards to increase her exercise and changing her diet. Patient will be referred to OB/GYN for Pap and pelvic and also will be referred for a screening mammogram. When she follows up to see me we will discuss potential options for colon screening. Patient is to follow-up with me in approximately 1 month time.
assessment and plan
Subject: assessment and plan
I hate when docs do that - mine do it a lot. I think you're good either way but I would put "A&P" as the heading and then just type it the way the doc says it.
Assessment or Impression
Is it an AAMT rule to automatically number the diagnoses in the Assessment or Impression of an H&P or soap even if the dictator does not? TIA!
Should EKG be expanded in Assessment?
Subject: Should EKG be expanded in Assessment?
ASSESSMENT: Abnormal EKG.
question about assessment
Subject: question about assessment
Doc states CABG and mitral valve repair. He clearly states this together. Can this be listed as one assessment? Or should mitral valve repair be next number??
pulmonary assessment
Subject: pulmonary assessment
admitted for elective mediastinoscopy, s/l radio-gram-coscopy?? and left bronchotomy.
Assessment: Vaginitis DX. I never heard of DX?? thanks
Subject: Assessment: Vaginitis DX. I never heard of DX?? thanks
Assessment: Dry skin (s/l ictiosis).
Subject: Assessment: Dry skin (s/l ictiosis).
:-)
Geriatric Assessment Unit
Subject: Geriatric Assessment Unit
.
Oh...assessment is diagnosis..so I would type it out nm
Subject: Oh...assessment is diagnosis..so I would type it out nm
xx
"HO" assessment (alcoholism)
Subject: "HO" assessment (alcoholism)
Has anybody ever heard "EtOH" pronounced as "aitch oh"? Or know what "HO assessment" could mean in relation to alcohol treatment?
"Patient was not eligible for HO assessment."
Thank you!
ANA results
Subject: ANA results
ANA was markedly positive at one to twenty-five sixty
any ideas on this one. 1:25 60
Help on CT results
Subject: Help on CT results
This is a woman with Stage IV malignant mesothelioma. I'm a little lost on the CT results here. For part of it I got the words I think, but since I don't totally understand it I'm not sure exactly where commas go, etc. Then there's the part where I'm not getting the words. I'll put that part in brackets. So here goes if anyone can help.
"On the CT, the impression is chronic occlusion of the central left internal jugular and brachiocephalic (actually sounds more like bronchocephalic but that doesn't seem to be a word so does brachiocephalic make sense here?) right subclavian [vena porous SVC with compression against noticed?] and tracheal deviation."
Help with MRI results
Subject: Help with MRI results
Doctor is saying, "...central disc herniation at the C3-C4 level impressing the ventral cord and a central disc protrusion at C6-C7, which s/l bifaces the ventral subarachnoid cord."
It sounds like he's saying bifaces. Could that be correct? If not, any suggestions?
Please help with BMP results
Subject: Please help with BMP results
Wondering how the results below should be transcribed.
Yesterday in the ER he had blood work, which showed normal renal function and electrolytes and an INR of 2.0. His BMP was beneath the threshold for his age at 1-3-8-8. (dictated "one, three, eight, eight")
TIA!!! 
ENG results
Subject: ENG results
There was no s/l gaitous position nor spontaneous nystagmus. I know I should know this but am drawing a blank.
Lab results.
Subject: Lab results.
Her ionized calcium was 1.10 with ??____________ 1.12 to 1.32.
s/l *acility
MRI results
Subject: MRI results
Hey all! My doc just dictated what sounds like "MRI showed some frying in the white matter." I'm sure frying is not the correct word. Any ideas? THANKS!!
MRI results
Subject: MRI results
Right-sided weakness; rule out for MS
help with MRI results
Subject: help with MRI results
I think doc has cutoff the beginning of word:
2) s/l "..frain/frame" of the posterior horn and medial meniscus and changes consistent with previous partial meniscectomy
Thanks for any help
s/l topo or tolpol for fetal assessment
Subject: s/l topo or tolpol for fetal assessment
Hi! Need help as soon as possible. Typing history and physical for admission of a woman in labor. Here is what is dicated:
Fetal heart rate tracing is in the 140s and reassuring with good variability, accelerations, and no decelerations. (s/l topo or tolpol) is minimal if at all.
Thanks in advance!!
It is Mallampati. A classification used in ariway assessment.
Subject: It is Mallampati. A classification used in ariway assessment.
The number would be Class IV
Thanks for your reply. I will type CAM in the assessment and see what my manager says. nm
Subject: Thanks for your reply. I will type CAM in the assessment and see what my manager says. nm
nm
Assessment: s/l maseno fracture right ankle. nm
Subject: Assessment: s/l maseno fracture right ankle. nm
CIWA-Clinical Institute Withdrawal Assessment nm
Subject: CIWA-Clinical Institute Withdrawal Assessment nm
Subjective, Objective, Assessment, Plan=SOAP..
Subject: Subjective, Objective, Assessment, Plan=SOAP..
Twenty-five years ago, SOAP format was still the in-thing, but doctors slowly trended away from it, probably due to medical transcription and formats changing over time. They are easy to do though.
He goes right into the Assessment of elevate PSA and bilat. iguin. hernia
Subject: He goes right into the Assessment of elevate PSA and bilat. iguin. hernia
CIWA-Clinical Institute Withdrawal Assessment
Subject: CIWA-Clinical Institute Withdrawal Assessment
score
Think you need CIWA - Clinical Institute Withdrawal Assessment nm
Subject: Think you need CIWA - Clinical Institute Withdrawal Assessment nm
x
results are established ?
Subject: results are established ?
...before arterial blood gas results are established 
QA results on help from yesterday
Subject: QA results on help from yesterday
Sure enough, the sentence read "somewhat flattened affect" You guys are the best! Thank you so much for the help.
help on MRI of the head results
Subject: help on MRI of the head results
The patient had an MRI with gadolinium of the head. I'm having some trouble understanding the results because this is unfamiliar to me. She is a cancer patient with metastatic melanoma and the MRI was ordered due to severe vomiting and blurry vision. He says the MRI "revealed no definite metastatic disease, significant [s/l hypotense? maybe hypodense or hypertensive?] [s/l mara signal?] of the cervical spine of unclear significance, heterogeneous [s/l coabnormality?], for which in matter of fact these cannot be excluded." That last phrase sounds a little weird too, but I'm pretty sure that's what he says. Any ideas?
Mammogram results help
Subject: Mammogram results help
This is from someone who mumbles and stumbles over words all the time, so I'm not sure how helpful my sounds likes are going to be, but I'll give it a try.
"Mammograms were performed and compared to previous studies available. There was no [s/l change breaths or chains breast] or heterogeneous [s/l stem cell?]. There is a rectangular density in the superior portion of the right oblique view, which may represent a residual from a previous [s/l porta or porter] drain."
Would heterogenous stem cell fit there? I think that's possible she's saying that, but not sure if that would be from a mammogram result. I haven't heard that one before.
anemia results?
Subject: anemia results?
Last visit she had some mild anemia as well at 12.7 and 37.6.
Any clues on the 12.7 and 37.6? rbc or hemoglobin?
I tried that, and just tried again, but I google gives me 0 results.sm
Subject: I tried that, and just tried again, but I google gives me 0 results.sm
I'm sure I know the word, because it sounds very familiar, but I just can't quite get it.
Urinalysis results...
Subject: Urinalysis results...
Dictated: UA shows some ketones, large occult blood, many white cells, some moderate red cells, and *10 to 50* bacteria.
Should that be 10:50 bacteria or 10-50?
Thanks!
trouble with ESL and lab results...
Subject: trouble with ESL and lab results...
I can't really understand this one, very fast speaking ESL and any help is greatly appreciated.
S/l *Laboratory results show white blood cell count of *2.1*, hematocrit of 36.2, and *___* at 217.
Thanks!
Foot x-ray results
Subject: Foot x-ray results
Doc is giving foot x-ray results as follows.
IMPRESSION: Oblique fracture, which is postoperative at the level of the first metatarsal. S/L "Os-like" displacement at the fracture site is noted.
Anyone ever hear of something like that? Thanks
laboratory results
Subject: laboratory results
the laboratory results s/l CEO ?? and is there a lab result spelled alpha feta-protein or is it alpha beta-protein?
culture results
Subject: culture results
when referring to culture results - is the lower or upper case form of "pseudomonas" "lactobacillus" and "enterococcus" used?
I assume these are lab results ??
Subject: I assume these are lab results ??
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