suggestions on how to transcribe 0 negative 3 positive
Posted By: OpMT on 2008-01-07
In Reply to:
Subject: suggestions on how to transcribe 0 negative 3 positive
This is dictated in a neuro operative report on a patient with Parkinson disease. The doctor is doing insertion of bilateral deep brain stimulators:
Macro stimulation using 0 negative 3 positive pulse width of 90, frequency 145 resulted in tingling of the left side at threshold of 2.5.
or would it be easier to understand like this?
Macro stimulation using 0-/3+ pulse width of 90, frequency 145 resulted in tingling on the left side at threshold of 2.5.
I honestly don't really understand what I'm transcribing here, so maybe a comma should be after the 0-/3+.
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negative/positive
Subject: negative/positive
I don't know what to say about that if you are sure she is saying negative and posistive. Maybe someone else can help you.
They're positive or negative
Subject: They're positive or negative
or equivocal for pain in the sciatic nerve distribution. It's not a test to see if the patient can do it.
Here is a link for neuro tests.
http://www.stanleyconsulting.ns.ca/Files/Neuro_Ortho_Tests.pdf
Doc says blood type O positive negative, can this be? (nm)
Subject: Doc says blood type O positive negative, can this be? (nm)
Two out of two positive gram negative rods?
Subject: Two out of two positive gram negative rods?
Does that sound right? What's the right way for it to be transcribed?
HPV is human papillovirus which was positive. Pap smear negative.
Subject: HPV is human papillovirus which was positive. Pap smear negative.
Low titer ANA with positive ENA with negative "sub serologies"
Subject: Low titer ANA with positive ENA with negative "sub serologies"
subserologies? sub-serologies? subserologies?
UA shows negative ketones, positive *clinna* test?
Subject: UA shows negative ketones, positive *clinna* test?
Blood type and screen is *O positive negative.* Hemoglobin... sm
Subject: Blood type and screen is *O positive negative.* Hemoglobin... sm
Ok, I'm wondering if I'm missing something here... Should be either O+ or O-, not both as stated or am I totally in the dark here?
Does this make sense? Last Pap Smear was one year ago. Negative, with positive HPV. Tks! nm
Subject: Does this make sense? Last Pap Smear was one year ago. Negative, with positive HPV. Tks! nm
xx
There is also coagulase-negative and coagulase positive. I am probably way off on that one though. n
Subject: There is also coagulase-negative and coagulase positive. I am probably way off on that one though. 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.
Wet-prep shows negative whiff, 10-20 WBCs, negative clue, few s/l "LB's". Is LB's right?
Subject: Wet-prep shows negative whiff, 10-20 WBCs, negative clue, few s/l "LB's". Is LB's right? nm
gram-negative, lactose-negative rods is correct. I found a couple of interesting websites SM
Subject: gram-negative, lactose-negative rods is correct. I found a couple of interesting websites SM
after doing a google search for gram-negative, lactose-negative rods. Basically testing organisms to see if they ferment lactose (positive) or not (negative).
Also, just FYI, gram-negative is not capitalized.
Probably too late, I'm sure. Better late than never, I guess. 
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!!!
Ortho - negative straight leg raise and negative s/l Lasek??
Subject: Ortho - negative straight leg raise and negative s/l Lasek??
She had a negative s/l clasp thumb test and a negative Finkelstein's.
Subject: She had a negative s/l clasp thumb test and a negative Finkelstein's.
:-)
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
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.
:-)
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?
McMurray's negative. Lachman's negative. nm
Subject: McMurray's negative. Lachman's negative. nm
McMurray negative. Lachman negative. No 's at end
Subject: McMurray negative. Lachman negative. No 's at end
x
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
..
Patient has a negative wrist extension sign on the right and a negative s/l 3rd finger sign on the R
Subject: Patient has a negative wrist extension sign on the right and a negative s/l 3rd finger sign on the R
Thanks for the suggestions
Subject: Thanks for the suggestions
It was almost midnight last night and my Stedman book lists about 15 "M" signs. I was hoping someone could help narrow the search, and yes, of course, I would look up any definition before using it. I sent it to QA due to the late hour. I'll have more time to devote to it today.
Thanks!
d~
Thank you all for your suggestions . . .
Subject: Thank you all for your suggestions . . .
and it still may be what he is saying, but as you guys mentioned, rather than 'maneuver' it is usually followed by either 'sign' or 'test'. It really sounds like Dover's (or 'there was'), so I am just not sure.
Thanks again for the thoughts.
Tried your suggestions, but they
Subject: Tried your suggestions, but they
did not work. I wound up for a second losing sound through my headphones. I'll try again when I have a little time to spare. It is actually just this one particular doc I have to turn up, so usually it is not really a big deal, but man, is it loud for this guy. I cannot seem to locate the spellcheck under your second suggestion. Thanks so much for replying. I really appreciate it. 
Thanks for the suggestions, but I think
Subject: Thanks for the suggestions, but I think
spirochete got butchered by a false start --
You're right, though . . . pretty disgusting stuff (ewwwww!)
Happy 4th!
A few suggestions...
Subject: A few suggestions...
Angiogenic, angiolupoid, angioma, angiomatoid, angiosarcoma
Hope that helps!
Any suggestions?
Subject: Any suggestions?
The dictator says, "G4, P1, 1-1-3" What does the 1-1-3 mean and how do I express it?
any other suggestions.
Subject: any other suggestions.
Does anyone have any other suggestions?
EXTREMITIES: Extremities show [hemerisnos] bilaterally.
P*?! Any suggestions?
Subject: P*?! Any suggestions?
nephrolethiasis with status post pyelolethotomy? s/l.
Thanks so much for the suggestions
Subject: Thanks so much for the suggestions
I am looking them up and listening again. I am pretty sure you got it! Thanks again.
Thanks for all the suggestions, I still don't think I have it.
Subject: Thanks for all the suggestions, I still don't think I have it.
Darnit. He speaks English very plainly, so unless there is a skip on the tape or something, I have no idea. I think I'm going to have to leave a blank this time. There is no mention of this diagnosis anywhere else in the report either. I wonder if QA will be able to get it.
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
Good suggestions, but he says it clearly sm
Subject: Good suggestions, but he says it clearly sm
each time I get him. I sent both of today's reports to QA. I'll let you know what I find out. Thanks!
Thanks for the good suggestions
Subject: Thanks for the good suggestions
It may have been gutters and he was just mumbling it...I already flagged and sent it, but thanks for the help.
Thanks for all the suggestions.. I am leaving it for QA since i am not sure! thanks for help
Subject: Thanks for all the suggestions.. I am leaving it for QA since i am not sure! thanks for help
Any more suggestions besides Thyamex?
Subject: Any more suggestions besides Thyamex?
Most likely vomitus. Thanks for all the suggestions!
Subject: Most likely vomitus. Thanks for all the suggestions!
Thanks for excellent suggestions, sm
Subject: Thanks for excellent suggestions, sm
I'm sure she is saying some version of "mentating" or "orientation" but I will have to send blank, as it is so not clear exactly what it is.
Medication s/l Sirculax...any suggestions? NM
Subject: Medication s/l Sirculax...any suggestions? NM
x
wasn't trying to be rude, just the suggestions--sm
Subject: wasn't trying to be rude, just the suggestions--sm
given had absolutely nothing to do with the low back, which she specifically mentioned in her post. Not all MTs are way off in what they are asking about or looking for and some of these suggestions that have nothing to do with their requests can be very misleading, as well. JMO and again, not meant to be rude.
thanks for the suggestions, but i definitely hear a P sound. =) nm
Subject: thanks for the suggestions, but i definitely hear a P sound. =) nm
x
SL subacute O-DEN infarction??? Any suggestions???
Subject: SL subacute O-DEN infarction??? Any suggestions???
Mr.___ today denies any worst headaches in his life or history of intracranial hemorrhage. He has had the episode of left side weakness in the past and findings on the MRI suggested for subacute ** infarction.
S/L space difficulty?? any suggestions? thanks!!1
Subject: S/L space difficulty?? any suggestions? thanks!!1
Mr. ___ today denies any worst headaches in his life or history of intracranial hemorrhage. He has had the episode of left side weakness in the past and findings on the MRI suggested for subacute old infarction. He denies any new symptoms and today has stated some visual symptoms of blurring but no binocular visual loss, new focal motor weakness, ***difficulty or sensory loss.
Thank you both. I'm not sure. It sounds like both suggestions at different times.
Subject: Thank you both. I'm not sure. It sounds like both suggestions at different times.
got it!!! C. trachomatis... thanks for your correct suggestions!
Subject: got it!!! C. trachomatis... thanks for your correct suggestions!
tc
None of your suggestions make any sense
Subject: None of your suggestions make any sense
with the word impingement, however. Impingement of a walker, leg brace or artificial knee joint does not make sense if it's a hip, as the sites I found suggest. The sites I found suggest it is another name for a specific part of the femoral head.
that is what I was thinking but wanted to see if anyone else had any other suggestions. Thanks.
Subject: that is what I was thinking but wanted to see if anyone else had any other suggestions. Thanks.
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