s/l Fabray is positive on musculoskeletal exam.....(nm) TIA!
Posted By: tootie on 2008-01-07
In Reply to:
Subject: s/l Fabray is positive on musculoskeletal exam.....(nm) TIA!
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I'd say positive for musculoskeletal back pain.
Subject: I'd say positive for musculoskeletal back pain.
Musculoskeletal Exam
Subject: Musculoskeletal Exam
Does this make sense to anyone? Active range of motion of the left knee is approximately 0 to 100?
Musculoskeletal Exam
Subject: Musculoskeletal Exam
There are no [s/l dermaternal?] changes noted in upper and lower extremities.
Musculoskeletal exam
Subject: Musculoskeletal exam
Sensation is intact for the s/l fil-a-mon test.
Musculoskeletal exam: The patient has good s/l RAM.
Subject: Musculoskeletal exam: The patient has good s/l RAM.
She says this twice. Clearly not sounding like range of motion. Thanks for any help!
GYN exam reveals a positive *shanglere*
Subject: GYN exam reveals a positive *shanglere*
Neuro exam: Positive s/l minitiller
Subject: Neuro exam: Positive s/l minitiller
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Neuro exam: Positive s/l minitiller.
Subject: Neuro exam: Positive s/l minitiller.
Can you give us any more to go on? What is the patient being seen for? What is the chief complaint?
In abdl exam a positive glovasea sign? nm
Subject: In abdl exam a positive glovasea sign? nm
shoulder exam: A mildly positive s/l apitkon's sign
Subject: shoulder exam: A mildly positive s/l apitkon's sign
Thank you!
Pt has shoulder pain. On exam has positive s/l scarf sign.
Subject: Pt has shoulder pain. On exam has positive s/l scarf sign.
I know I've heard this before - s/l Fabray's disease. nm
Subject: I know I've heard this before - s/l Fabray's disease. nm
nm
Abdomen: Positive wave sign appreciated, "caps out" is positive as well. sm
Subject: Abdomen: Positive wave sign appreciated, "caps out" is positive as well. sm
Abdomen tympanic to percussion, diffuse tenderness, no point tenderness appreciated. Positive wave sign appreciated, "caps out" is positive as well.
Positive grasp response and positive s/l palmo mentonian on the right. TIA!!!
Subject: Positive grasp response and positive s/l palmo mentonian on the right. TIA!!!
musculoskeletal
Subject: musculoskeletal
Thanks for your advise, but...
Yes, that is what I would put, but dictators are very specific and do not want their verbiage changed, but cannot find a correct spelling of this anywhere!
Musculoskeletal help
Subject: Musculoskeletal help
I am doing a musculoskeletal exam. I cannot figure out what he is saying and cannot find a list of common tests done. Does anyone have a clue?
s/l Trendellenburg's test, (s/l bactruse) test, (s/l ulise) test, (s/lserial halls) test (s/l spurring) and straight leg raising negative.
Thanks in advance.
estrogen-progesterone receptor positive (as in ER-positive),
Subject: estrogen-progesterone receptor positive (as in ER-positive),
In Ortho, positive s/l Meniere, positive Hawkins?
Subject: In Ortho, positive s/l Meniere, positive Hawkins?
xx
no just saying positive pH or KOH? Not exactly your S/L though. Or positive whiff test said fast? nm
Subject: no just saying positive pH or KOH? Not exactly your S/L though. Or positive whiff test said fast? nm
Figured out the musculoskeletal one... still looking for the other...
Subject: Figured out the musculoskeletal one... still looking for the other...
MUSCULOSKELETAL heading?
Subject: MUSCULOSKELETAL heading?
Newbie here. I'm typing an H&P and under instruction to supply appropriate headings & subheadings if they are not dictated, esp. in an H&P.
Under the Physical Examination, the Dr. dictated most headings, but under ABDOMEN, she continued with what I think is more of a musculoskeletal exam:
ABDOMEN: His abdomen is rotund, nontender, nondistended, and soft. He has no costovertebral angle (CVA) tenderness to percussion. He has no thoracic tenderness to palpation. His pain begins at approximately L2 down to his sacrum, with pain greater down his right gluteus versus his left, but does have pain. He has slow movement and grimaces with any movement. He is able to stand. Decreased range of motion secondary to pain. Straight-leg reflex painful in both legs. Reflexes are diminished bilaterally.
Here is my question: I cannot find a precedent for adding the MUSCULOSKELETAL subheading. Yet beginning from "His pain" and following is not really under an ABDOMEN exam, is it? At the very least, I feel I should start a new paragraph, but then my format is messed up b/c everything else has a subheading!
Needless to say, it stresses me out a bit. Any advice is definitely appreciated!
Musculoskeletal/Neurologic
Subject: Musculoskeletal/Neurologic
You need to head it the way I did in the subject above...
She has a positive Tinel's sign, positive Phalen's sign, and positive s/l Durkin's sign.
Subject: She has a positive Tinel's sign, positive Phalen's sign, and positive s/l Durkin's sign.
:-)
It is Amrix, a musculoskeletal relaxant- nm
Subject: It is Amrix, a musculoskeletal relaxant- nm
xx
Roxitan is correct....musculoskeletal and
Subject: Roxitan is correct....musculoskeletal and
xx
A positive, direct "Kums" positive
Subject: A positive, direct "Kums" positive
This is for a 3-day-old baby with hyperbilirubinemia. He is A positive and "Kums"positive. What is the Kums positive?
She has a grayish, frothy discharge that is KOH ____ test positive. S/l 'with' test positive?
Subject: She has a grayish, frothy discharge that is KOH ____ test positive. S/l 'with' test positive? nm
..
Sorry meant ER-positive or PR-positive) might also be HER-2/neu
Subject: Sorry meant ER-positive or PR-positive) might also be HER-2/neu
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.
if you are positive that he what he/she is trying to say.
x
It is HER-2/neu positive
Subject: It is HER-2/neu positive
and node positive sounds right to me, meaning lymph node is positive.
Almost positive it's T max. This is how I have it in my
Subject: Almost positive it's T max. This is how I have it in my
x
possible? positive?
Subject: possible? positive?
ANA positive at 1-80 or 1:80....nm TIA
Subject: ANA positive at 1-80 or 1:80....nm TIA
x
DHC Positive ?
Subject: DHC Positive ?
Cold agglutinin induced hemoloytic anemia – DHC POSTIVE FOR 3CD ? -
any guesses
O positive
Subject: O positive
maybe "...and a positive S4" ??
Subject: maybe "...and a positive S4" ??
ER 3+ positive?
Subject: ER 3+ positive?
I have never seen the 3+ before...is this would you would write it? I can't find this...
"The prognostic markers in the biopsy specimen were ER 3+ positive, PR 3+ positive and HER-2/neu negative by FISH."
I positive?
Subject: I positive?
dictated phrase:
History of left breast cancer, stage I with extensive DCIS, T1 N0, I-positive sentinel lymph node on hormonal therapy
I've never run into I-positive before, and this surgeon has never used this phrase before. Am I typing it correctly?
heme positive
Subject: heme positive
The hospital I have worked at for 15 years says no. So we don't hyphenate heme positive. Don't know what the BOS says though, we don't really use it.
It's "heme positive"
Subject: It's "heme positive"
nm
ASCA and S/L OP-C positive
Subject: ASCA and S/L OP-C positive
DIctated: colitis ASCA and S/L OP-C positive since ......
TIA!!
Positive chandilier - sm
Subject: Positive chandilier - sm
CT pelvis....History was positive chandilier ...never heard of it, and cannot reference. In the body of the report he stated possible PID, bilateral tuboovarian abscesses...if that helps. The whole sentence was "Positive chandiler" ???anyone?? TIA
No, it wasn't positive (sm)
Subject: No, it wasn't positive (sm)
And I just meant I hadn't ever heard "plus" in front of S1, S2 before. That was what I was questioning. Thanks for taking the time to reply!
1/20 nodes positive
Subject: 1/20 nodes positive
nm
Positive lomberg?
Subject: Positive lomberg?
I have a follow up report that I am doing and in the physical exam, under CNS, she says "positive finger-to-nose test and negative lomberg". I cannot find the term lomberg see how it is spelled or even what it is. Any help is appreciated.
Thanks, Stacy
s/l *a positive kew-ture*
Subject: s/l *a positive kew-ture*
This is podiatry.
There is pain on palpation at the inferior aspect of the right heel at the plantar fascial insertion. This pain is actually existant right over the inferior aspect of the calcaneus. It then runs along the course of the plantar fascia. It also exists in the medial band of the plantar fascia and the midfoot region. Dorsiflexion of toes exlicits pain in this region. There is tight plantar fascial band noted ______ is noted.
Thanks for any ideas!
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