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Mar 20 07:55
• pls listen to wav + thanks
Sat Mar 20 12:27:52 2010 thanks
Periactin 4 mg b.i.d., Flomax 0.4 mg a day, Mag-Ox 400 once a day, Mobic 7.5 mg once a day, ___ 20 mg a day, Prilosec 20 mg once a day, morphine for pain.
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• Stood up to go back to bed and *syncofies* + m e d e c n
Sat Mar 20 12:25:32 2010 m e d e c n
She stood up to go back to bed and _______. She has a bruise on her left knee and some pain on the left great toe.
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Sat Mar 20 12:27:53 2010 you can),
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• Something subcu... Pls see msg + p g l k l m
Sat Mar 20 12:03:29 2010 p g l k l m
We will start him on octreotide. Today, after a 100-mcg subcu _____ (s/l tess tose), he had Sandostatin LAR 30 mg.
(Patient has metastatic bronchial carcinoid with documented liver metastases.)
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Sat Mar 20 12:07:44 2010 nm
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Sat Mar 20 12:09:34 2010 Thank you!
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• s/l toe-ping wrist fracture x-ray + sm
Sat Mar 20 11:34:27 2010 sm
RADIOGRAPHIC EVALUATION
X-rays taken today demonstrate further healing and consolidation at the fracture site of the left wrist distal radius. She has some mild collapse, but it is unchanged from her previous x-rays. Ulnar styloid appears to actually have healed back nicely. She has a little dorsal __________ (toping?) as well, but again no new changes on x-ray today.
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Sat Mar 20 12:41:14 2010 my guess
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Sat Mar 20 11:56:21 2010 mt
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• psycho consult, plse sm for context (s/l E-T-O) + mt
Sat Mar 20 11:33:37 2010 mt
Upon interview, the patient was somnolent and irritable. He had been given Benadryl 50 mg x1 s/l "as a E-T-O" due to increased agitation on the unit.
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Sat Mar 20 11:41:41 2010 p i o j g p
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Sat Mar 20 11:33:56 2010 mt
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Sat Mar 20 11:41:27 2010 ltt
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Sat Mar 20 11:45:46 2010 mt
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• ortho help plse sm + mt
Sat Mar 20 10:03:15 2010 mt
Patient is being evaluated for an ankle fracture in the ER.
At the end of the dictation, Dr. says clinical exam is correlated with what appears to be a right s/l cubital fracture.
any ideas what he may mean? (cubital is the elbow)
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Sat Mar 20 10:06:57 2010 mt
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• med list s/l a-trip-to-flex no dosage given either - nm
Sat Mar 20 10:01:57 2010 nm
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Sat Mar 20 10:04:33 2010 FSMT
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• another WAV file. I have 3 blanks right together in this. Thanks. + WAV
Sat Mar 20 09:44:54 2010 WAV
She did have lisinopril 20 mg twice daily, but during hospital course her blood pressure has been normal without it, so hence she can _____ at the nursing home with _____ monitoring and if needed can be started _____ if it is elevated.
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Sat Mar 20 10:05:02 2010 mt
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Sat Mar 20 10:06:46 2010 OP
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Sat Mar 20 09:54:57 2010 Thanks.Sm
She did have lisinopril 20 mg twice daily, but during hospital course her blood pressure has been normal without it, so hence she can recheck at the nursing home with _____ monitoring and if needed can be restarted at her primary care clinic’s office there if it is elevated.
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Sat Mar 20 09:53:08 2010 d f l l n n
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Sat Mar 20 10:06:11 2010 mt
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Sat Mar 20 10:37:07 2010 d f l l n n
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Sat Mar 20 09:50:18 2010 d f l l n n
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• She does have a "tin pannus" that covers her trach. Tried Google and OneLook w/ + i e g l e n
Sat Mar 20 09:40:31 2010 i e g l e n
different variations. I know I should know this, but I'm coming up blank this morning. :(
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Sat Mar 20 09:59:58 2010 perhaps?
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Sat Mar 20 09:46:47 2010 guess
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Sat Mar 20 09:51:38 2010 hmmm
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Sat Mar 20 09:58:09 2010 ??
tympanous
Of or relating to tympanites; tympanitic.
tympanitic /tym·pa·nit·ic/ (-nit´ik)
1. pertaining to or affected with tympanites.
2. bell-like; tympanic.
tym·pa·nit·ic (tmp-ntk)
adj.
1. Of or relating to tympanites.
2. Of or relating to the quality of sound elicited by percussing over the inflated intestine or over a large pulmonary cavity; tympanic.
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Sat Mar 20 10:02:44 2010 hmm
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Sat Mar 20 12:35:08 2010 -
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Sat Mar 20 09:53:08 2010 i e g l e n
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Sat Mar 20 09:59:55 2010 me
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Sat Mar 20 09:59:25 2010 Txczech
pannus, pl. panni
A membrane of granulation tissue covering a normal surface:
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Sat Mar 20 10:01:22 2010 i e g l e n
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Sat Mar 20 10:01:06 2010 sm
see where that could cover the trach if patient is morbidly obese.
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Sat Mar 20 10:01:51 2010 i e g l e n
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• Medication list. S/l Sigh-no-taz-all 100 mg p.o. twice daily. sm + Thanks.
Sat Mar 20 09:39:01 2010 Thanks.
This is an addendum so I have no diagnoses or any history. The addendum is just medications.
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Sat Mar 20 09:44:46 2010 guess
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Sat Mar 20 09:46:00 2010 of. OP
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Sat Mar 20 09:52:09 2010 me again
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Sat Mar 20 09:55:40 2010 Thanks again.
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• s/l "size 8 port, fixed tracheostomy" + carrob
Sat Mar 20 09:36:55 2010 carrob
Neck: She has a "size 8 port, fixed tracheostomy in place." There is some blood around the tracheostomy tube.
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Sat Mar 20 09:46:36 2010 CARROB
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• s/l frying + sm
Sat Mar 20 09:36:54 2010 sm
RADIOGRAPHIC EVALUATION
X-rays taken of her shoulder show what appears to be a calcific rotator cuff tendinopathy. No other acute bony abnormalities are appreciated.
PLAN
I explained to her to be working on mild pendulum exercises, as well as walking her finger up the wall, but she really should not be actively ___________ (frying?) her muscles at this time, and she understood.
(Patient is following with ortho doc after taking Fosamax a few times and now has extreme joint/muscle/bone pain.)
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Sat Mar 20 09:38:18 2010 nmt
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Sat Mar 20 09:42:45 2010 OP
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• Never heard of blue top before. psm and thanks + sm
Sat Mar 20 09:24:54 2010 sm
At that juncture, I suggested due to the fact that she had the rather sudden onset of upper quadrant chest pain and she was on oral contraceptives that we do a D-dimer. She was agreeable to this and, unfortunately, we had not drawn a s/l blue top and this had to be redrawn.
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Sat Mar 20 09:33:55 2010 i i l e m b
with sodium citrate in it.
Pathology uses different colored tubes for blood tests (red, green, blue, brown & so on.
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Sat Mar 20 09:50:58 2010 OP
blue top in labs and got zilch. Same with google. Makes it difficult when you have to put exact words in that were put in before.
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Sat Mar 20 10:03:53 2010 nmt
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Sat Mar 20 10:29:38 2010 nm
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Sat Mar 20 09:26:02 2010 nmt
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Sat Mar 20 09:33:06 2010 OP
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• medication list: Tylenol _____ - WAV file.
Sat Mar 20 09:24:31 2010 WAV file.
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Sat Mar 20 09:30:47 2010 a c d a c a
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Sat Mar 20 09:37:34 2010 OP
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• Does breathing make sense here? Last sentence. + a c d a c a
Sat Mar 20 09:07:49 2010 a c d a c a
On January 22nd, he was returned to the operating room for exploration, small bowel resection and repair of the abdominal wound dehiscence. He tolerated the procedure well without obvious complications. Following the wound dehiscence repair, the patient was progressing well and remained off the ventilator. Four days later, however, the patient developed abdominal breathing and due to risk of recurrent wound dehiscence, he was reintubated.
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Sat Mar 20 09:24:08 2010 nm
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Sat Mar 20 09:14:03 2010 sm
sense to me. Check out some of these hits. I'm no expert, but just researching it a bit and it seems to make sense.
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Sat Mar 20 09:18:53 2010 a c d a c a
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Sat Mar 20 10:24:26 2010 eople would remember
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Sat Mar 20 09:13:04 2010 anon
Diaphragmatic breathing, abdominal breathing, belly breathing, deep breathing or costal breathing is the act of breathing deep into one's lungs by flexing one's diaphragm rather than breathing shallowly by flexing one's rib cage. This deep breathing is marked by expansion of the stomach (abdomen) rather than the chest when breathing
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Sat Mar 20 09:14:04 2010 a c d a c a
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Sat Mar 20 09:15:06 2010 nm
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Sat Mar 20 09:18:08 2010 a c d a c a
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Sat Mar 20 09:18:04 2010 anon
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Sat Mar 20 09:19:18 2010 a c d a c a
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• Radical excision of the left hemivulva. Risks of surgery have been explained..... + sg
Sat Mar 20 07:45:09 2010 sg
including lymphedema in the leg, infection, wound breakdown, and *lymphisis* formation.
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Sat Mar 20 08:03:21 2010 l o m b b d
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• general question. I have a doctor who always says mom or dad. In the BOS + a c d a c a
Sat Mar 20 07:00:16 2010 a c d a c a
2nd Edition page 169, it says to change that to mother or father. I am not comfortable with changing the dictation that way. Do you all change it?
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Sat Mar 20 09:09:36 2010 billybob
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Sat Mar 20 09:20:31 2010 a c d a c a
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Sat Mar 20 09:09:06 2010 nm
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Sat Mar 20 08:26:30 2010 nm
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Sat Mar 20 08:05:19 2010 nm
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Sat Mar 20 08:25:53 2010 a c d a c a
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Sat Mar 20 07:50:14 2010 nm
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Sat Mar 20 07:22:52 2010 nm
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Sat Mar 20 07:19:02 2010 nm
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Sat Mar 20 07:31:05 2010 a c d a c a
be changing the style of dictation. Thanks. Just wondered if it was a common practice or not.
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Sat Mar 20 08:16:17 2010 letter.
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Sat Mar 20 08:27:47 2010 NM
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Sat Mar 20 12:38:41 2010 plain silly.
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Sat Mar 20 09:09:05 2010 a c d a c a
to change something like that. So, I guess, yes, I would pick which rule to follow.
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• anastomosis stenosis - do you change that to anastomotic? + a c d a c a
Sat Mar 20 06:57:50 2010 a c d a c a
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Sat Mar 20 08:25:23 2010 sm
I think it is like fibular fracture or fibula fracture. Whichever is dictated is fine - at least to me.
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Sat Mar 20 08:27:16 2010 a c d a c a
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Sat Mar 20 08:05:41 2010 nm
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Sat Mar 20 08:26:44 2010 a c d a c a
things that I wonder about.
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• Chest: Rare crackles, no s/l E to A change, rubs, rales or wheeze. - a k b c l d
Sat Mar 20 06:45:13 2010 a k b c l d
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Sat Mar 20 06:46:58 2010 LiliK
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Sat Mar 20 06:47:39 2010 nm
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• How does this look? The sentence that starts with yes looks a little funny to me. + thanks!!!
Sat Mar 20 06:31:32 2010 thanks!!!
I touched him where he said he was having pain. I said, "Is this the area?" "Yes," he said that is the area where he is having pain.
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Sat Mar 20 07:51:40 2010 end. Your choice.
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Sat Mar 20 06:45:00 2010 nm
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Sat Mar 20 07:10:17 2010 nm
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• possible inferior subendocardial *hard* myocardial infarction + sm
Sat Mar 20 06:06:13 2010 sm
My initial reading of the EKG finds sinus tachycardia. There is a question on the computer reading of possible inferior subendocardial *hard* myocardial infarction. My finding is that there is no STEMI. There are no PVCs. PR interval is normal.
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Sat Mar 20 08:38:08 2010 sylvester
s
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Sat Mar 20 06:16:57 2010 LiliK
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Sat Mar 20 06:21:37 2010 nm
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Sat Mar 20 06:19:05 2010 thanks
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• Think I'm hearing "somatic," but not sure it makes sense in this sentence. + p g l k l m
Sat Mar 20 04:59:56 2010 p g l k l m
CT scan of the chest and pelvis showed mildly increased _____ (s/l somatic) thickening of the bladder wall.
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Sat Mar 20 05:06:32 2010 nm
Of, relating to, or affecting the body, especially as distinguished from a body part, the mind, or the environment; corporeal or physical. See synonyms at bodily.
Of or relating to the wall of the body cavity, especially as distinguished from the head, limbs, or viscera.
Of or relating to the portion of the vertebrate nervous system that regulates voluntary movement.
Of or relating to a somatic cell or the somatoplasm.
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Sat Mar 20 05:07:57 2010 p g l k l m
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• Part of physical examination. S/l Myotideo reflexes are +2 and symmetrical. - nm
Sat Mar 20 04:59:41 2010 nm
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Sat Mar 20 06:26:04 2010 wag
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• Is anyone else having a hard time with chemocare.com website this morning? - chell
Sat Mar 20 04:55:03 2010 chell
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Sat Mar 20 05:01:33 2010 b a d a l l
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Sat Mar 20 05:16:07 2010 chell
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Sat Mar 20 05:53:17 2010 b a d a l l
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• SM + nm
Sat Mar 20 04:12:44 2010 nm
Since her last visit, she has had an MRI, as well as an MRA of her head, which have been reported as normal. She has a normal finding of minimal calcifications of s/l fox or vox.
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Sat Mar 20 04:21:13 2010 nm
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Sat Mar 20 04:23:01 2010 nm
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• MP3 help with ESL doctor... + p g l k l m
Sat Mar 20 04:08:28 2010 p g l k l m
(the effect of tamoxifen on incidence of colon cancer, the effect of tamoxifen on incidence of cervical cancer, bone _____ effect of tamoxifen).
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Sat Mar 20 04:17:44 2010 ???
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Sat Mar 20 04:12:21 2010 nm
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• WAV file, thanks. Can anyone get the blood pressure? + a c d a c a
Sat Mar 20 04:00:16 2010 a c d a c a
Vital signs
Blood pressure ___/88, pulse 88, respiratory rate 24, temperature afebrile.
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Sat Mar 20 04:04:24 2010 a c d a c a
Will flag and send in.
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• MP3 help with ESL doctor. Not sure I'm on track. + p g l k l m
Sat Mar 20 01:15:59 2010 p g l k l m
1. She had full-term vaginal delivery in 2008 at 39 weeks, _____ (birth weight?) of 5.14.
2. She had an abnormal Pap with LEEP in 2006.
3. _____ (Severe chlamydia?) in 2008.
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Sat Mar 20 01:26:59 2010 h c l o k c
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Sat Mar 20 01:26:26 2010 p g l k l m
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• WAV + h k j p d h
Sat Mar 20 00:02:42 2010 h k j p d h
PX is seen today in followup placement of _______ at Dr. Arthur X's office. PX has been started on some Crestor 5 mg a day for her hypercholesterolemia overall
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Sat Mar 20 00:14:45 2010 nm
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Sat Mar 20 01:00:59 2010 h k j p d h
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• Never heard of this and not really documenting. Anyone familiar? + p g l k l m
Fri Mar 19 23:37:08 2010 p g l k l m
Medicare has refused to pay for "proof of therapy."
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Sat Mar 20 01:29:58 2010 h c l o k c
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Fri Mar 19 23:40:00 2010 p g l k l m
Medicare has refused to pay for "proof of therapy," and he is going through Medicaid. Apparently, Medicaid will pay for only some medications, mainly his pain medications, but will not pay for the medication _____.
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Fri Mar 19 23:40:43 2010 p g l k l m
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Fri Mar 19 23:45:24 2010 Margaret
for reimbursement. I cannot discern the exact words, though.
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Fri Mar 19 23:48:21 2010 p g l k l m
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Fri Mar 19 23:53:49 2010 Margaret
http://www.google.com/search?hl=en&rls=com.microsoft:en-us&rlz=1I7GGLD_en&ei=cnOkS7vFDaOKtAOziOG8BA&sa=X&oi=spell&resnum=0&ct=result&cd=1&ved=0CAUQBSgA&q=mycosis+fungoides+PUVA&spell=1
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Fri Mar 19 23:47:11 2010 p g l k l m
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Fri Mar 19 23:51:29 2010 Margaret
to pay for the most recently described meds to deal with a particular problem. I believe this is justified by them as a "cost-saving" measure.
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Sat Mar 20 00:00:27 2010 Margaret
Would that they would also grind "exceedingly fine." Pardon my scepticism, but I'm not led by what I observe to believe that, indeed, they do! :-)
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• s/l Rivaeda + ryanN
Fri Mar 19 23:32:21 2010 ryanN
Patient has HIV. He is on Norvir, Truvada, and <Rivaeda>. Allergies none.
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Sat Mar 20 06:34:15 2010 nm
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• s/l tinge sutures + ?
Fri Mar 19 22:22:10 2010 ?
Chest x-ray reveals a <tinge sutures> in the right mid lung, otherwise clear lungs.
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Fri Mar 19 22:25:51 2010 Margaret
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Fri Mar 19 22:36:03 2010 ?
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• s/l polysec - drug + ruthy
Fri Mar 19 21:37:28 2010 ruthy
Patient has hypertension and diabetes.
Current medications: Metformin, Lipitor, lisinopril, <polysec>, glyburide, nifedipine, Systane, hydrochlorothiazide.
Thank you
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Fri Mar 19 21:59:51 2010 Mgt
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Fri Mar 19 22:16:29 2010 kaz
telling you everything.
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• derm + MT1
Fri Mar 19 20:28:38 2010 MT1
Bright red slightly urticarial-appearing plaque diffusely covering anterior neck and the V of chest.
vee of chest?
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Fri Mar 19 21:00:29 2010 punctuation needed
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Fri Mar 19 21:05:41 2010 respectfully
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Fri Mar 19 22:24:58 2010 FSMT
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Fri Mar 19 22:50:56 2010 another.
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Fri Mar 19 21:09:20 2010 yes it is needed
the color is simply part of the description
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Fri Mar 19 21:26:30 2010 kaz
of a sentence would need to be set off with commas. If the sentence were "Red urticarial plaque diffusely covering anterior neck..." would you still want commas around plaque? One wouldn't normally have a comma at the end of a series of adjectives immediately preceding a noun. Indeed, I think the comma after you suggest after "red" is open to (friendly) debate. I could be persuaded of the need for a comma AFTER plaque, but I think it depends on what you believe the understood phrase is: "plaque [that is] diffusely covering" (in which case no comma) or "plaque, [which is] diffusely covering" (which needs a comma). Where commas are concerned, many clients feel that fewer is generally better.
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Fri Mar 19 22:04:27 2010 respectfully
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Fri Mar 19 21:58:49 2010 Win
and majored in English in college. The only reason the client is wanting less punctuation is they quibble over every extra character as 5 characters equal a word usually!!
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Sat Mar 20 09:18:10 2010 admin
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Fri Mar 19 22:05:59 2010 lol
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Fri Mar 19 22:08:33 2010 d f l l n n
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Fri Mar 19 23:01:27 2010 looking at
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Fri Mar 19 22:55:21 2010 was not just SM
punctuation - but even if it were, I would say red urticarial plaque, diffusely covering...
I do not understand why you would want a comma after red. I agree with someone above who said the less commas, the better. Why would you put one there? But aside from that, your suggestion was not just punctuation, it was leaving out words that were dictated - a major no, at least where I work.
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Fri Mar 19 22:14:58 2010 kaz
The dictator specifies BRIGHT red blood (as opposed to dark red blood or just plain old blood), and the color of the blood may be very important in indicating a certain medical condition. Similarly, the dictator cautiously says that the plaque is slightly urticarial-appearing. If you take out those qualifiers, you are radically changing his meaning by removing any element of doubt as to whether this plaque is or isn't urticarial. Those kind of drastic changes can't be justified, IMO, and could land someone in a legal mess.
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Fri Mar 19 23:04:02 2010 correctomundo
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Fri Mar 19 23:10:41 2010 kaz
not be removed unless demonstrably redundant, and only with caution even then, depending on account specifics. But I think Win may have been commenting on my paraphrased example, not the original.
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Sat Mar 20 07:56:20 2010 nm
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Fri Mar 19 23:13:36 2010 agreed
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Fri Mar 19 22:25:32 2010 kaz
paraphrase, not the original sentence - I hope! ;-)
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À Á Â Ã Ä Å à á â ã ä å
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