normal female ???? peak-- dictated in pelvic exam
Posted By: just me on 2005-10-27
In Reply to:
Subject: normal female ???? peak-- dictated in pelvic exam
thanks
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Female exam, s/l urethral pillars normal
Subject: Female exam, s/l urethral pillars normal
Pelvic exam revealed normal external genitalia, s/l; *DUS*, clear vagina,... nm
Subject: Pelvic exam revealed normal external genitalia, s/l; *DUS*, clear vagina,... nm
Is non-OB pelvic ultrasound ever dictated?
Subject: Is non-OB pelvic ultrasound ever dictated?
It s/l that's what he's saying, but ESL doc and a little fuzzy.
s/l normal female ascusion?
Subject: s/l normal female ascusion?
talking about a pelvic exam.
Throat exam is normal, as were the rest of her neck, face, and skull exam.
Subject: Throat exam is normal, as were the rest of her neck, face, and skull exam.
Pelvic exam
Subject: Pelvic exam
Doc says:
Adnexa appears symmetrically (Sounds like) "sived" (long i sound) with some mild tenderness, left greater than right. No adnexal masses felt. No tenderness on palpation of the uterus.
She is being seen for right lower quadrant pain. TIA
Pelvic exam
Subject: Pelvic exam
It's BUS...Bartholin's, urethral and Skene's glands....
pelvic exam
Subject: pelvic exam
Speculum exam minimal pelvic. Nelly paracervix estrogenized pink mucosa.
Should it read... Speculum exam: Minimal pelvic. If so, what does the minimal pertain to?
Should it read.. Nelly paracervix. Estrogenized pink mucosa.
No idea what the nelly paracervix is about.
Ahhhhhhh!!!
Pelvic exam
Subject: Pelvic exam
Sounds like EGVS or EGVD in pelvic exam.
pelvic exam
Subject: pelvic exam
externally s/l mear clear.
Thanks!
on PE (pelvic exam)? OR sm
Subject: on PE (pelvic exam)? OR sm
might be saying something like this: No adnexal masses. On UA ---? Really need the surrounding phrases.
male or female exam? nm
Subject: male or female exam? nm
Pelvic exam question
Subject: Pelvic exam question
Has anyone heard of "cream-colored cervical lymphadenopathy" of the cervix? I sent this to QA but it came back filled in as dictated. I have never heard of this and did not find a source on Google. I thought it should be perhaps "discharge." TIA
Pelvic exam +valsalver
Subject: Pelvic exam +valsalver
Vaginal exam is done with her in sitting, standing and with valsalver in the supine position. The last part of this does not make sense to me- it sounds like valsalver in the supine position. Can anyone shed any light on this for me?
Female, part of the physical exam. NM
Subject: Female, part of the physical exam. NM
x
Pelvic exam question please see message..
Subject: Pelvic exam question please see message..
Cervix is visualized and appears normal. A s/l D&A probe is obtained.
Pelvic exam showed 'clidomegaly'
Subject: Pelvic exam showed 'clidomegaly'
normal looking vagina and cervix. Pap smear taken.
Pelvic exam: No s/l da ma sil stress urinary incontinence
Subject: Pelvic exam: No s/l da ma sil stress urinary incontinence
Thanks for any help.
Pelvic exam - sounds like "no exalative mass" nm
Subject: Pelvic exam - sounds like "no exalative mass" nm
on pelvic exam for sexual assault....There was some redness at the posterior S/L Freshet...sm
Subject: on pelvic exam for sexual assault....There was some redness at the posterior S/L Freshet...sm
could it be FACET? TIA 
I have had this dictated with the abdominal exam,
Subject: I have had this dictated with the abdominal exam,
GU exam, and specifically the back exam. If dictated under a heading, put it where it is dictated.
3+ is referring to size as dictated during exam. nm
Subject: 3+ is referring to size as dictated during exam. nm
3+ is referring to size as dictated during exam. sm
Subject: 3+ is referring to size as dictated during exam. sm
Gleason score relates to prostate tumor size.
DTRs were dictated in sensory exam. Thanks for your help! Still stumped!
Subject: DTRs were dictated in sensory exam. Thanks for your help! Still stumped!
Breast exam: CMP or CMT normal bilaterally? nm
Subject: Breast exam: CMP or CMT normal bilaterally? nm
nm
s/l GCS is 15 with normal gait on neuro exam. TIA nm
Subject: s/l GCS is 15 with normal gait on neuro exam. TIA nm
x
on exam of newborn, S/L normal "roving" reflex......is this right....TIA
Subject: on exam of newborn, S/L normal "roving" reflex......is this right....TIA
breast exam normal no _____ ORANGE?
Subject: breast exam normal no _____ ORANGE?
PE report - Breast exam normal. No (undetectable word) or S/L orange.
Any help out there???
Motor Exam: s/l diminished tone, normal (sm)
Subject: Motor Exam: s/l diminished tone, normal (sm)
no atrophy.
the patient had a stroke and has no residual except for dysarthria. Can a motor exam show diminished tone and still be considered normal?
Physical exam: Head is normalized normal.
Subject: Physical exam: Head is normalized normal.
Just a well-child check, no special diagnosis or medical history.
HEENT: exam normal with "elastic" membranes
Subject: HEENT: exam normal with "elastic" membranes
x
JUDE or JUTE exam. Patient has normal genitalia.
Subject: JUDE or JUTE exam. Patient has normal genitalia.
I've been listening and searching on this one - it's probably something simple.... Hope someone can help me - thanks in advance.
Throat exam is normal (s/l) mal hempaty 2. Please help me as I have typed this before, just drawing
Subject: Throat exam is normal (s/l) mal hempaty 2. Please help me as I have typed this before, just drawing
a complete blank...TIA
Neuro exam: Weber lateralized to right ear, (s/l) Renee normal on both sides. (nm)
Subject: Neuro exam: Weber lateralized to right ear, (s/l) Renee normal on both sides. (nm)
CNS physical exam, cranial nerve???, motor, cerebellum??? and sensory were normal...thanks.ASAP
Subject: CNS physical exam, cranial nerve???, motor, cerebellum??? and sensory were normal...thanks.ASAP
s/l female female thromboembolic disease
Subject: s/l female female thromboembolic disease
but not female, as it is family hx with father.
s/l pelvic vas or maybe pelvic vest.. does anyone know? thanks
The patient is 8-10 weeks post repair for recurrent cystourethrocele in cuff. She is still not healed. She is a diabetic, and it had been lowering her hormones. She had granulation tissue, which we cauterized. She will continue vaginal cream "in the pelvic vas", and will see her back in 2 weeks.
or maybe "and the pelvic vest" does anyone know? thank you
peak PA pressures.
Subject: peak PA pressures.
x
peak and troughs nm
Subject: peak and troughs nm
peak flow?
Subject: peak flow?
peak pressure
Subject: peak pressure
I cannot tell if he is saying 6-7 liters or 67 liters.
cresting as in the peak of the URI?
Subject: cresting as in the peak of the URI?
As in full blown, and should start going down the other side??
Just as you have it if that's what was dictated. If "one fourth" was dictated, sm
Subject: Just as you have it if that's what was dictated. If "one fourth" was dictated, sm
it would be 1/4 pill or one fourth of a pill.
Def an 'N' dictated - Diabetes unsure of - no PMH dictated
Subject: Def an 'N' dictated - Diabetes unsure of - no PMH dictated
help with peak flow values...
Subject: help with peak flow values...
Help... s/l peak flows were 20 and 626-10? I can't find any peak flow values that aren't percentages, except maybe just the 626? Thank you in advance!
How do you type peak flow
Subject: How do you type peak flow
values? In vital signs, doc is dictating: Peak flows 293, 60 360. How would you correctly type that? I’ve not dealt with this before.
Thanks for your help!
no dont think so, the two line prior are LFTS normal and Chem-7 was normal
Subject: no dont think so, the two line prior are LFTS normal and Chem-7 was normal
Oops I meant peak and trough
Subject: Oops I meant peak and trough
I would use saline since it's the solution he's changing from half-normal to normal, not the
Subject: I would use saline since it's the solution he's changing from half-normal to normal, not the
s
peak flow measures how fast you breathe out when
Subject: peak flow measures how fast you breathe out when
you try your hardest, so it should go up into the 600's....
We type it as dictated, if dictated
Subject: We type it as dictated, if dictated
c spine we transcribe C-spine, if cervical then cervical spine.
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