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Musculoskeletal/Neurologic

Posted By: Ashley on 2009-01-23
In Reply to: If not verbatim account and you are allowed - see message

Subject: Musculoskeletal/Neurologic

You need to head it the way I did in the subject above...


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neurologic insults? neurologic lateralization? nm
Subject: neurologic insults? neurologic lateralization? nm


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.


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 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.
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
I'd say positive for musculoskeletal back pain.
Subject: I'd say positive for musculoskeletal back pain.


s/l Fabray is positive on musculoskeletal exam.....(nm) TIA!
Subject: s/l Fabray is positive on musculoskeletal exam.....(nm) TIA!

x
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!


Neurologic:
Subject: Neurologic:

Neurologic:  Cranial nerves II through XII are intact. Deep tendon reflexes are 2+. Strength is 5 out of 5. Sensation is grossly intact. Toes are downgoing. Gait is normal. *s/l* bramburg test is normal....


 


thanks in advance.


neurologic
Subject: neurologic

The word you are looking for is Romberg.
neurologic help please!!
Subject: neurologic help please!!

NEUROLOGIC:  A full neurologic examination was performed.  Cranial nerves II-XII were grossly intact.  ***cerebelli was fine.  No *** or drift.   Patient’s muscle strength was 5/5 throughout.  Patient’s reflexes were +3 upper extremity and also +3 patellar.  Toes:  The patient had withdrawal response bilaterally.    S/L MILL CEREBELLI WAS FINE.  S/L NO POR OR DRIFT...


Neurologic help please, please, please!
Subject: Neurologic help please, please, please!

He has ringing in his ears, as well as s/l vaso "something" episodes when he gets up.  Doctor has a cold and he is in a big hurry.  Help me. 
Neurologic help
Subject: Neurologic help

vasovagal episodes?
NEUROLOGIC.
Subject: NEUROLOGIC.

x
Need help on a neurologic test (sm)
Subject: Need help on a neurologic test (sm)

On neurologic testing he reported diffuse s/l illness to pinprick in both hands. It doesn't sound like numbness at all.


TIA!


neurologic deterioration? nm
Subject: neurologic deterioration? nm

x
Under neurologic, it s/l estrixes.
Subject: Under neurologic, it s/l estrixes.


Neurologic exam help please
Subject: Neurologic exam help please

Doctor dictates:  Motor: Strength, bulk and tone are normal throughout.  There is no evidence of s/l cogwilling or rigidity.
neurologic or HEENT?
Subject: neurologic or HEENT?

Where will you put "No pain or swelling over the sinus" in the PE?


Neurologic or HEENT.


Neurologic exam
Subject: Neurologic exam

Oh my word - I am LOST!  Neurologic exam.  Dr. dictates "Cranial ___eros intact"  There are possibly two or three words.  He has dictated this on two patients in a row - and mummbles on each one.  Thanks for any help.
neurologic examination
Subject: neurologic examination

sounds like doc is saying "neurologic examination higher critical function", but could she be saying "neurologic examination hilar cortical function"?
Neurologic exam
Subject: Neurologic exam

Doctor dictates - "There is no localized _____ findings for this age group.  (Is for a 1-1/2 year old.)


Sounds kind of like "in-see-nus"


neurologic or neurological
Subject: neurologic or neurological

doc always says, "from a neurologic standpoint."  Shouldn't it be from a neurological standpoint? 
Neurologic- s/l prineal moves
Subject: Neurologic- s/l prineal moves

Prinale moves 2-12 in text, each within normal limits???  I know this isn't correct.  ideas?
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Subject: PMH s/l spa-la-mic stroke, no neurologic sequella. nm

d
Hoffman's is neurologic sign
Subject: Hoffman's is neurologic sign

Sorry about that.
Neurologic Exam... S/L 11 Ryandi?
Subject: Neurologic Exam... S/L 11 Ryandi?

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mumbled neurologic exam
Subject: mumbled neurologic exam

positive cervical s/l COMP test (neck)

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See this link under neurologic exam etc. sm
Subject: See this link under neurologic exam etc. sm

http://mtdesk.com/word-lists/
Dee tra emphasis? heading under neurologic..
Subject: Dee tra emphasis? heading under neurologic..

Under physical exam, neurologic, this is given as a subheading....


s/l dee tra emphasis:


CMT maybe...it's a debilitating neurologic disorder.
Subject: CMT maybe...it's a debilitating neurologic disorder.

Charcot Marie Tooth
"nystagodenesia" neurologic exam for concussion. thanks
Subject: "nystagodenesia" neurologic exam for concussion. thanks


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Subject: Guillain-Barre? neurologic syndrome/ds.....nm

x
Neurologic... don't know why that one didn't cross my mind thank you
Subject: Neurologic... don't know why that one didn't cross my mind thank you

Sorry, new to plastic surgery. I believe that lateralization is correct. thank you all!!
No dx. It is just in a list of meds in a neurologic note
Subject: No dx. It is just in a list of meds in a neurologic note


Your sentence is part of a neurologic exam. N/M
Subject: Your sentence is part of a neurologic exam. N/M

Unless you have one of the neurologic docs that splits his neuro exam down into separate headings (CRANIAL NERVES, MOTOR, REFLEXES, ETC.), the sentence with orientation and fundi both describe neurologic findings.
s/l shopping cart sign neurologic exam
Subject: s/l shopping cart sign neurologic exam

patient undergoing lumbar decompression
Maybe RIND - reversible ischemic neurologic deficit (nm)
Subject: Maybe RIND - reversible ischemic neurologic deficit (nm)

x
Probably RIND - reversible ischemic neurologic defect.
Subject: Probably RIND - reversible ischemic neurologic defect.

x
Does it make sense that Dr would say under Phys Exam: Neurologic: physiologic ?
Subject: Does it make sense that Dr would say under Phys Exam: Neurologic: physiologic ?


In my opinion either would be correct. If MD states neurologic standpoint, that is what I would tran
Subject: In my opinion either would be correct. If MD states neurologic standpoint, that is what I would transcribe.


Pt on neurologic exam: Copying "laurea" figures (triangles). nm
Subject: Pt on neurologic exam: Copying "laurea" figures (triangles). nm


Neurologic: No headaches or seizures. Focal weakness of all ??parathesis??
Subject: Neurologic: No headaches or seizures. Focal weakness of all ??parathesis??


On neurologic examinations if they are doing cognitive performance studies such as mood, sleep, memo
Subject: On neurologic examinations if they are doing cognitive performance studies such as mood, sleep, memory, reasoning and vigilance then it would be higher critical function being examined.


There is neck dystonia (neurologic condition affecting the muscles of the neck)?
Subject: There is neck dystonia (neurologic condition affecting the muscles of the neck)?


Verbatim, neuro checks. Non, neurologic checks.
Subject: Verbatim, neuro checks. Non, neurologic checks.

x