pls. help for eye exam report
Posted By: gina on 2008-03-17
In Reply to:
Subject: pls. help for eye exam report
Examination: The pupils are equal and reactive without afferent papillary defect. Confrontational visual field of full to finger-counting in both eyes. Burgeons are full. (not sure what is Burgeons or Bergens) thanks for the help!
Complete Discussion Below:  marks the location of current message within thread
The messages you are viewing
are archived/old.
To view latest messages and participate in discussions, select
the boards given in left menu
Other related messages found in our database
psychiatric report for a child, on the physical exam......
Subject: psychiatric report for a child, on the physical exam......
He says something that sounds very garbled and I cannot figure out what it is. Here is the paragraph:
PHYSICAL EXAMINATION: Weight is 52 pounds. Height 49.25 inches. Head circumference 52 c m. S/L palpeple fishery 27 mm bilaterally. Cranial nerves and cerebellar function were intact.
Thanks for any ideas.
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.
Eye exam: s/l "sub-lamp" exam shows left side has multiple small punctations in the cornea.(t
Subject: Eye exam: s/l "sub-lamp" exam shows left side has multiple small punctations in the cornea.(thanks)
Physical exam on eye exam, s/l Cardinal Welk's space?? noted.NM
Subject: Physical exam on eye exam, s/l Cardinal Welk's space?? noted.NM
What kind of doc is doing the exam? And where in the exam is this test mentioned? nm
Subject: What kind of doc is doing the exam? And where in the exam is this test mentioned? nm
s
Question about eye exam...when everting lids on eye exam (sm)
Subject: Question about eye exam...when everting lids on eye exam (sm)
It is EVERT, not AVERT, right? I have always typed it with an E but I have a PA who keeps insisting it is A. I always thought Avert applied to gaze, as if to look away. Just want to make sure everting the eyelid is the right term. TIA.
Which is correct? self-breast exam or breast self-exam (nm)
Subject: Which is correct? self-breast exam or breast self-exam (nm)
xx
EKG report
Subject: EKG report
"No weeshnoblomotion abnormalities are identified." What is that word?
thanks everyone. One more report and then I am going to bed.
Subject: thanks everyone. One more report and then I am going to bed.
nothing more to add about the report unless
Subject: nothing more to add about the report unless
the patient had an implanted pacemaker which is not eluded to here. Just a note, adenosine is not capitalized except to start a sentence.
Maybe you will hear something back.
d~
Sorry, same report...
Subject: Sorry, same report...
"CPK and _______ were negative" s/l intraconals??
Still on the pulmonologist's report...
EEG report
Subject: EEG report
Anyone ever heard of an EEG performed on a Nikon Codon machine? Thanks.
just sent the report on.........nm
Subject: just sent the report on.........nm
x
op report sm
Subject: op report sm
What kind of surgery is it? If he used "lap" laparotomy pads may be the second one. They usually say sponge, needle and instrument counts. Will keep thinking on this one. Type of surgery would help.
You don't say where in the report -- sm
Subject: You don't say where in the report -- sm
this is given, or any other context, so I have to wonder if this isn't a problem list perhaps giving more than one diagnosis/problem here (as in (1) portosystemic shunt and (2) nephrolithiasis)...
Just a thought
ENT report - sm
Subject: ENT report - sm
Does include sinus surgeries, Caldwel-Luc surgery. Is also on Flonase. Patient is actually here regarding Grave's disease. I'm wondering if this is Relpax D, but I'm not able to verify that as a drug. Any suggestions?
ENT OP report help, please...
Subject: ENT OP report help, please...
Vocal cord lesion biopsy -
Peripheral -s/l orb or oral- sinuses were intubated to their apices and were normal.
Specimen was sent -s/l informal- and for pathology.
TIA!
OP report
Subject: OP report
OP report, lumbar spine
Next, fluoroscopy was used to place new screws at the L2-3 segment. Starting points were identified at the confluence of the midpoint of the transverse process, the **manloid** process, and the pars interarticularis
He really mumbles through this part, so I am just not sure, but I have not heard this term used before. Thanks!
op report help please sm...
Subject: op report help please sm...
FINDINGS: Epidurogram revealed normal (s/l-cephaloquadet-) contrast flow outlining the right L5 nerve root sleeve in the epidural space with good flow achieved medial to the right L5 pedicle. The patient did experience some concordant L5 symptoms on the right side during the injection. Vital signs remained stable throughout.
OP Report
Subject: OP Report
Hi all! I am doing an OP for a lumbar spine surgeon, but this is just for an I&D. He says the area was probed with "sucker tips" and was found to be subfascial. I am not too comfortable with what I am finding online for this. Has anyone heard this before? Thanks!
OP report help, please
Subject: OP report help, please
Patient was premedicated with intravenous s/l Benadryl.
Would that be right?
report does not say .. but says she is on BC
Subject: report does not say .. but says she is on BC
help with op report
Subject: help with op report
I never do op notes! The sentence reads:
The S/L RAFFAY between the anterior and middle deltoids was then opened. TIA!
Doing EMG report sm
Subject: Doing EMG report sm
The patient has focal severe slowing primarily in sensory fibers in the right upper extremity, on multiple restimulation unable to elicit a response to both s/l "Palmar 8" studies.
I can't find this anywhere. Anybody have any ideas? Thanks!
I wish I could see the report, but
Subject: I wish I could see the report, but
could she be saying communication, as in an opening has formed between 2 sinuses or something?
It is so frustrating to be given only a tidbit of a report instead of being able to puzzle it out from what is going on with the patient.
Thanks, but as I'm into the report it
Subject: Thanks, but as I'm into the report it
sounds like this is some weird wording for microscopic blood.
I've done thousands of endoscopy reports and GI consults, but I can't think why he'd say "affobiddy positive stool" instead of something about occult blood or microscopic blood.
ER report. Sm please
Subject: ER report. Sm please
The patient has a 4 mm calcification on the pelvis on the right which may represent a s/l flevolith, thus a right ureteral calculus could not be entirely occluded.
OP report
Subject: OP report
general s/l elam anesthesia. New to OP reports! TIA
Thanks! That's how I did it in the report nm
Subject: Thanks! That's how I did it in the report nm
OP report
Subject: OP report
s/l -fecal lift- at the base of the appendix
C-sec report
Subject: C-sec report
Does this by some chance have to do with cephalodisproportion, because I looked up Jill Cohen - C-section in google, and there is somebody named Jill Cohen and it talks about labor and delivery and C-section and something this lady wrote about it. Could this be it. Check it out on google.
PT report
Subject: PT report
S/l ESTEEM for pain management?
report
Subject: report
Does any one know focal tics of sounds like aphitical movements. Thank could use the help.
TEE report - Need help
Subject: TEE report - Need help
" NO BUBBLES ___________ FROM RIGHT TO LEFT SIDE" s/l caused. He also said bubble study was done with 9 mL normal saline and "a cc" of air. Is this written 1 mL?
per report
Subject: per report
The only diagnosis is bipolar, duh!
was my last report of the day
Subject: was my last report of the day
and he was getting to me! my least favorite account, lots of bad dictators
MRI report s/m
Subject: MRI report s/m
MRI of the brain shows what looks to be an acute infarct on DWI on the right brainstem area, which were also changes seen on the T2 weighted - s/l anuses - suggesting that this is probably an infarct, which occurred 7-10 days ago.
any ideas cuz I'm pretty sure there are no weighted "anuses" in the brain, at least not identifiable by MRI.
op report help
Subject: op report help
Doc states that the the articular surface of the lateral tibial plateau was then s/l stacked as was the weightbearing surface of the lateral femoral condyle.
Thanks
It's an EGD report .... sm
Subject: It's an EGD report .... sm
He states, "Instruments used were a Fujinon esophagogastroduodenoscope and a ________ bougie #54."
He later states, "The ________ bougie was passed easily."
GU op report help please
Subject: GU op report help please
I tried to dilate the urethra with s/l male sounds, but they would not pass easily due to the false passes. (Talking about bladder stones).
He says it clearly, but I've never heard of these nor can I find it. Can't find anything under "Mayo" either thinking perhaps it was an instrument of some kind.
GU op report help please
Subject: GU op report help please
Could it be Dittel?
CXR report...SM
Subject: CXR report...SM
The findings of the daily CXR on this patient are stable and unchanged, but the dictator gets to the "impression" and says: s/l peri-grass--ity of the chest radiograph.
I'm sure this is something simple and I should know it - it's probably a "normal" word. But my brain is just not working tonight. Help?
OB/GYN report...
Subject: OB/GYN report...
x
ORS Report??
Subject: ORS Report??
Hi I am typing an ER report that says this:
The patient had an ORS?? report performed that shows he has had 24 prescriptions for narcotics.
I know there is a report the doctors can get but I cannot find it anywhere! Please help!!!
This is it. He said it again later in the report
Subject: This is it. He said it again later in the report
 thanks.
H & P Report
Subject: H & P Report
On an H & P report after you have typed the plan and then they repeat the vital signs is that a new category and if so what should the heading be, or is is set off in a new paragraph, or is just part of the plan. I'm a little confused as to how to put it at the end of the report.
H & P Report
Subject: H & P Report
Depends on your company or facility. My personal preference is to insert VITAL SIGNS into the physical exam portion of the dictation, right after GENERAL APPEARANCE or PHYSICAL EXAM. However, you have to follow the dictates of your employer.
H & P Report
Subject: H & P Report
She does indicate that info under VITAL SIGNS in the beginning. This is like a recheck at the end of her report. This is what she says:
His repeat vital signs: His heart rate was down to 107. His blood pressure was 124/86, and he was able to stand and move with greater ease.
ER report
Subject: ER report
CHIEF COMPLAINT
Leg swelling and pain.
Patient is admitted for an (s/l extorium). Patient is an alcoholic and usually drinks hard liquor.
Help! MRI Report
Subject: Help! MRI Report
In the MRI he says what sounds like zyncomal or xyncomal lesion (whole sentence is: ________ lesion such as a hemangioma or neurogenic tumor is less likely a malignant process.) Any ideas? I've been looking for an hour.
An operative report...SM
Subject: An operative report...SM
We have three options for the nasal fill area. We discussed allowing this to heal by secondary intention, full-thickness skin graft, and _____ tissue transfer.
|
