impression: bronchiolitis s/l sublets? or other process
Posted By: huh on 2007-10-05
In Reply to:
Subject: impression: bronchiolitis s/l sublets? or other process
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bronchiolitis obliterans?
Subject: bronchiolitis obliterans?
nm
say-a-lytic process
Subject: say-a-lytic process
Probably cellulitic process --
?olecranon process nm
Subject: ?olecranon process nm
nm
s/l faxis process
Subject: s/l faxis process
The claimant also had recent faxis process which seemingly is resolved.
I was way off but I got it. some interosseous process. nm
Subject: I was way off but I got it. some interosseous process. nm
nm
s/l APPENDERS-like process sm
Subject: s/l APPENDERS-like process sm
The patient was noted to have a _02:26_ like process in the proximity of her chronic wound. It is not friable.
Help with IMPRESSION
Subject: Help with IMPRESSION
Should this be dictated like this?
1. Hyponatremia, rule out subdural hematoma.
OR
1. Hyponatremia.
2. Rule out subdural hematoma.
impression
Subject: impression
type it with a semicolon in between.
Impression
Subject: Impression
Hi Shirl -
Hang in there, this will be old hat to you after a while. Radiology reports are usually pretty standard. Same phrases/terms used by all radiologists.
Some usual headings in a radiology report are:
CLINICAL INDICATION: or INFORMATION: or HISTORY, or variations of any of these.
FINDINGS: or RESULTS:
IMPRESSION: or OPINION:
Start adding the common phrases, like "lung markings" and all the various possible headers as above, to whatever word expander program you have. You'll be flying through reports in no time!
Impression
Subject: Impression
In the impression the doctor says the patient probably has a small perforation of his colonic cancer.
Impression
Subject: Impression
Status post laceration, rigth wrist with repair of partial tear to the s/l FC or FCE tendon.
"siatic" process? On wound. sm
The patient has a necrotic wound on calf. Dictates..."there is no s/l siatic process".... Ideas?
"say-a-lytic" process ??
Subject: "say-a-lytic" process ??
The patient has a nonhealing ulcer of the foot. Dictates what sounds like "No evidence of active "say-a-lytic" process.
I feel like this is on the tip of my tongue, but can't get it.
Help! Thanks!
ENT question regarding process of the malleus
Subject: ENT question regarding process of the malleus
The patient has a TM perforation. S/L Olm? process of the malleus has been eroded. The incus and stapes are absent.
concomit disease process
Subject: concomit disease process
The patient's s/l concomit diesease process make him difficult to treat.
do they normally say spinous process is at C5 or C spine
Subject: do they normally say spinous process is at C5 or C spine
never min, it was "the spinal process"
Subject: never min, it was "the spinal process"
subandroseus process in the pelvis on x-ray
Subject: subandroseus process in the pelvis on x-ray
Drawing a blank here. Can anyone help?
Plades ? reactive process
Subject: Plades ? reactive process
MRI showed some mild left neuroforaminal narrowing,plades ? reactive process and some facet hypertrophy. Any guesses?
SMA-7 "CO2 30" ? by process of elimination... sm
Subject: SMA-7 "CO2 30" ? by process of elimination... sm
SMA-7=sodium, potassium, chloride, bicarbonate (or CO2), glucose, BUN, creatinine. Glucose and bicarbonate are your missing values; 30 is a normal value for CO2...so my guess is they're saying "CO2 30" and leaving out the glucose value....
she may say it again in impression if you haven't got there. nm
Subject: she may say it again in impression if you haven't got there. nm
IMPRESSION prob
Subject: IMPRESSION prob
I have a problem under impression  ...
"D: IMPRESSION: Occipital neuralgia probable acute gastroenteritis"
question: how will I transcribe that? coz Occipital neuralgia is not related to "probable acute gastroenteritis" isn't it? or possibly there was a 2 impression. one, is occipital neuralgia and secondly, acute gastroenteritis?... What's the meaning by the dictator?
NOTE: but the dictator did not dictate any numbering.... 
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!
No, but it is either part of the Impression, or
Subject: No, but it is either part of the Impression, or
the a new section after it.
Thanks :)
Impression - hypertension
Subject: Impression - hypertension
This is under impression on a history and physical examination.
It is a numbered list.
[Sodiunduradine] is hypertension.
Any suggestions would be great!
It was under the impression section
Subject: It was under the impression section
I have heard of that also, but it was under his impressions. This doctor is such a mumble mouth! *sigh*
On impression: MR say pat uremeia.
Subject: On impression: MR say pat uremeia.
Pt with mental retardation.
s/l Borhaws? type process (cardiology?)
Subject: s/l Borhaws? type process (cardiology?)
Doctor says....objective data not consistent with pericarditis or s/l Borhaws type process....? No luck with google, maybe I'm missing something. TIA.
sm... "Brachial pulse **process normal."
Subject: sm... "Brachial pulse **process normal."
dictation, "Examination shows the left arm to be normal in appearance.
Left radial pulse is normal. Brachial pulse **process normal. There
are no visible veins in the left arm."
I'm trying to help a friend. Thanks, Robyne
spine surg: s/l D process lamina...
Subject: spine surg: s/l D process lamina...
The muscularature was reflected off the s/l D process lamina.
Would it be correct to say "transverse of spinous process"??
Subject: Would it be correct to say "transverse of spinous process"??
He has a C5 fracture. Doctor is kind of mumbling so maybe it should be "transverse and spinous process."
Any help would be appreciated.Thanks
the radial styloid process is a part - sm
Subject: the radial styloid process is a part - sm
of the radius bone. google stylus, which is the needle tip inserted to carry the voltage to test the pacemaker leads. I don't think it is styloid. She sent it to QA, so now they can worry about it. Ha!
I would not abbrev it if it is in the IMPRESSION as the poster said.
Subject: I would not abbrev it if it is in the IMPRESSION as the poster said.
it's impression and lung markings....
Subject: it's impression and lung markings....
No, not as a listed diagnosis or impression.
Subject: No, not as a listed diagnosis or impression.
impression, SP - status post
Subject: impression, SP - status post
nm
GI help: Is it diaphragmatic compression or impression
Subject: GI help: Is it diaphragmatic compression or impression
Trying to distinguish between diaphragmatic compression or diaphragm and compression or diaphragmatic impression. Help appreciated.
Ahhh...that's diaphragmatic impression. nm
Subject: Ahhh...that's diaphragmatic impression. nm
Thanks. Duh. I have to spell out abbreviations in impression. Just could not think. NM
Subject: Thanks. Duh. I have to spell out abbreviations in impression. Just could not think. NM
ss
That is the complete sentence. It is his IMPRESSION.
Subject: That is the complete sentence. It is his IMPRESSION.
Each vertebra has 2 transverse processes and 1 spinous process.
Subject: Each vertebra has 2 transverse processes and 1 spinous process.
So, depending on what the doc says, the spinous process of C5 would be correct. Also, the spinous processes of the cervical spine would be a correct statement. Spinous process of the cervical spine would be incorrect as there are 7 cervical vertebral bodies with 3 processes each.
pterygoids (bilateral pterygoid bone/process)-nm
Subject: pterygoids (bilateral pterygoid bone/process)-nm
She has several missing teeth and is in the process of having extractions due to chronic please sm
Subject: She has several missing teeth and is in the process of having extractions due to chronic please sm
s/l piaria, gingivitis and caries. Thanks!
s/l "five hood lamina or spinous process"
Subject: s/l "five hood lamina or spinous process"
This patient had some lumbar spine x-rays which showed only a "five hood lamina" or spinous process.....
Has anyone heard of anything like "five hood lamina?"
Thanks!!
Abby
Could you post the impression? Might help to shed light. nm
Subject: Could you post the impression? Might help to shed light. nm
s/l ID or ID8 urine culture. for impression and plan
Subject: s/l ID or ID8 urine culture. for impression and plan
Extrinsic impression ? on the sigmoid colon
Subject: Extrinsic impression ? on the sigmoid colon
I was under the impression it was JCAH mandated to write ml instead of cc. NM
Subject: I was under the impression it was JCAH mandated to write ml instead of cc. NM
Got first one - he says in impression "flow limiting stenosis"
Subject: Got first one - he says in impression "flow limiting stenosis"
Impression: Right MPJ extensor hood rupture SM
Subject: Impression: Right MPJ extensor hood rupture SM
(s/l shrowd ligament rupture).
I know there is a mamillary process of the vertebra, so I suspect he is making up his own words
Subject: I know there is a mamillary process of the vertebra, so I suspect he is making up his own words
as he goes. Thanks for trying though.
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