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She lay in bed, present tense....sm

Posted By: Another opinion on 2006-02-05
In Reply to: She lay in bed most of the day. nm - Winnie Ruth

Subject: She lay in bed, present tense....sm

she laid in bed all day Saturday (past tense).........


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past tense or present tense.sm.

in PE.  Doctors love to toggle back and forth between is, are, and was, and were!  On ASR we are told not to over edit!  What would you do.... anybody :)


on all reps I try for present tense except
Subject: on all reps I try for present tense except


to the best of my knowledge it is a word (past/versus present tense)
Subject: to the best of my knowledge it is a word (past/versus present tense)


I think it a doctor tense of tenodesis and have been typing that tense "tenodese" for years (s
Subject: I think it a doctor tense of tenodesis and have been typing that tense "tenodese" for years (sm)

There is an article from the Journal of the American Society for Surgery of the Hand that spells it that way too http://linkinghub.elsevier.com/retrieve/pii/S1531091404000981 -
probably tense.............
Subject: probably tense.............

x
s/l ice on tense?
Subject: s/l ice on tense?

fossa fluid collections surrounding the cerebellar hemispheres, which are also (ice on tense) to CSF
past tense of I & D (I & D'd?)
Subject: past tense of I & D (I & D'd?)

doc says ...four years ago. It was I & D'd at that time.
how about "a tense effusion"
Subject: how about "a tense effusion"


tense effusion
Subject: tense effusion

Rapid onset (within two hours) of a large, tense effusion suggests rupture of the anterior cruciate ligament or fracture of the tibial plateau

(www.aafp.org/afp/20030901/907.html)
since he "laid" down -- past tense (sm)
Subject: since he "laid" down -- past tense (sm)

lay is usually for inanimate objects

lie would be present tense
if its past tense... it would be laid
Subject: if its past tense... it would be laid

/
it is laid if it is past tense
Subject: it is laid if it is past tense


Rules for tense in a report?
I always thought it was past tense.  I have a doc who started the first 2 sentences using past tense and then suddenly switched to present test.  IV sedation IS administered, Patient IS positioned.  Do you change present to past or type as is?  Nothing in the CP about it.
Biceps tense up well when he exerts
Subject: Biceps tense up well when he exerts

Does this make sense?  Here is the previous sentence. 


Tenderness over the anterior shoulder at the site of biceps insertion.  Biceps tense up well when he exerts. 


You are absolutely correct. It is lay...past tense has nothing to do with it in this case!
Subject: You are absolutely correct. It is lay...past tense has nothing to do with it in this case!

/
I would say the dictator made up his/her own tense to the word bursitis, would flag it and have QA l
Subject: I would say the dictator made up his/her own tense to the word bursitis, would flag it and have QA let you know.


which is present??
Subject: which is present??

after her surgery. Could mean "still present" after her surgery
s/l vertebrae Why's present
Subject: s/l vertebrae Why's present

Pt has vertebral anomalies, only 16 thoracic and lumbar vertebrae s/l Why's present.  I thought maybe lumbar vertebrae Ys, not sure though.


Thanks for any help


can present doppler
Subject: can present doppler

Doesn't sound like comprehensive.  Are dopplers done by percentages?  Like 10% doppler was performed?  Thanks.
S/l tar-loff-sis is present in the sacrum.
Subject: S/l tar-loff-sis is present in the sacrum.

Can't give much more relative info than that. Any help would be appreciated. Thanks!
s/l dorsal *kelostity* present...
Subject: s/l dorsal *kelostity* present...

Podiatry again.


There are hammertoe contractures that are increasing in size of digits 2-5 of the right foot.  There is dorsal ______ present at digits three and four at the PIPJ, this is increasing as well especially since this patient is not wearing shoes. 


Thanks in advance!


Could the first part be comprehensive instead of can present?
Subject: Could the first part be comprehensive instead of can present?


See HPI. (as in see history of present illness)
Subject: See HPI. (as in see history of present illness)


Bilateral Rouse? are present
Subject: Bilateral Rouse? are present


ABDOMEN: Normal. No edema. Bilateral rouse? are present.


Any idea? Thanks


s/l on UA she had cass present as well as mucus threads
Subject: s/l on UA she had cass present as well as mucus threads


Echo- no wall motion in the s/l value is present?
Subject: Echo- no wall motion in the s/l value is present?


HEENT s/l early calazian is present......nm
Subject: HEENT s/l early calazian is present......nm


Not sure, but "Per History of Present Illness?
Subject: Not sure, but "Per History of Present Illness?

Would my guess work? I just checked my Sloan Medical Abbreviations and Eponyms book and found neither "PHPI" nor "CHPI" listed. These abbreviations can be soooo difficult!
I type it History of Present Illness
Subject: I type it History of Present Illness

but that's the way the employer wants it. If it's verbatim I'd type just what he said HPI.
Review of systems: See HPI (History of Present Illness.)
Subject: Review of systems: See HPI (History of Present Illness.)


Under HEENT, very slight s/l arca senilis is present.
Subject: Under HEENT, very slight s/l arca senilis is present.

TIA!
extremities- positive s/l esquail edema is present
Subject: extremities- positive s/l esquail edema is present


Procedures: s/l can present my vehicle of venous doppler
Subject: Procedures: s/l can present my vehicle of venous doppler


Skin: s/l icthius present antecubital region
Subject: Skin: s/l icthius present antecubital region


tachycardia present with a rate of 175 s/l atropic beats
Subject: tachycardia present with a rate of 175 s/l atropic beats


Symptoms of epigastric discomfort present s/l *de novo*
Subject: Symptoms of epigastric discomfort present s/l *de novo*

Has anyone heard of de novo being used in this context?  TIA!!
Unless treatment in the report indicates those conditions are present, would just leave blanks. nm
Subject: Unless treatment in the report indicates those conditions are present, would just leave blanks. nm

s
Pt with a miscarriage. A complete placenta appeared to be present w/o any missing SM
Subject: Pt with a miscarriage. A complete placenta appeared to be present w/o any missing SM

s/l caudal lee-dent.
s/l: "The ___ dens space is present indicating atrophy" (sm)
Subject: s/l: "The ___ dens space is present indicating atrophy" (sm)

s/l  There is some ___ choroid dens space is present


blank sounds like supraventricular but not supratentorial. 


I don't know...static on line.  This is to rule out acoustic neuroma. 


Thank You!


Multiple internal s/l syneckyi are present within this popliteal cyst. I know this word....grr!
Subject: Multiple internal s/l syneckyi are present within this popliteal cyst. I know this word....grr!


Apparently, the "flame sign" may be present, due to disruption and depression of the lateral c
Subject: Apparently, the "flame sign" may be present, due to disruption and depression of the lateral canthal tendon (according to Emedicine)


T1 high-grade disease, but no *neeb-teeb muscle* was present. SM for context
Subject: T1 high-grade disease, but no *neeb-teeb muscle* was present. SM for context

Pt has a history of T1 high-grade urothelial carcinoma treated with BCG in the past.  Recent biopsy demonstrated T1 high-grade disease, but no *neeb-teeb muscle* was present.


Too much background noise and ESL.  Any ideas?


4 liter high humidity nasal canula with present requirements 21 to 22%, _________
Subject: 4 liter high humidity nasal canula with present requirements 21 to 22%, _________

baby on high humidity oxygen. 


  s/l pos _______ of 94 to 95%. 


"the joint sting" osteophytic spurring is present at the medial compartment. knee x-ray. nm
Subject: "the joint sting" osteophytic spurring is present at the medial compartment. knee x-ray. nm

x