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if it is OB, could it be uterine infection eval?

Posted By: backandforth on 2007-08-01
In Reply to: OB longshot..here today for a post-op s/l wine infection evaluation..if you need more info let me - Deborah

Subject: if it is OB, could it be uterine infection eval?

nm


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uterine cry is an audible sound heard during D&C indicating that solid uterine tissue
Subject: uterine cry is an audible sound heard during D&C indicating that solid uterine tissue


may be "nidus of" infection (i.e. source/focus of infection) .nm
Subject: may be "nidus of" infection (i.e. source/focus of infection) .nm


Type of infection s/l merse infection?
Subject: Type of infection s/l merse infection?

I'm stumped.  New doctor for me and I have never heard anything like this.  Sounds like merse infection?  Any ideas?
Jerovecki infection or Gerovecki infection...see more
Subject: Jerovecki infection or Gerovecki infection...see more

The prophylactic antibiotic that I probably would give her would be something to avoid Pneumocystis corinii "Gerovecki infection" or "Jerovecki infection."
ENT eval
Subject: ENT eval

Furuncle
PT eval
Subject: PT eval

The therapist is saying 1-1/2 fingers breath from the chest.  How should this be typed?  Fingersbreadth or fingerbreadths? 


Psych eval
Subject: Psych eval

This was under mental status:


Mood was stressed and angry with a S/L: VER-EH-BY affect. 


I definately hear the long "i" sound at the end.  Unless he is saying "variable" wrong...


Thanks!


Psych eval
Subject: Psych eval

Psych eval.


Scores were invalid during his testing because he refused to cooperate on certain tasks - doc dictates:


"Interpretation of WISC-IV scores for him is given consciously, due to the s/l: manual refusal behaviors noted during testing."


Manual refusal behaviors?  Is this right?  Thanks!


Psych eval question
Subject: Psych eval question

This patient is on Zoloft and has a history of Oppositional Defiant Disorder, ADHD, and anxiety.


This is under AXIS I:


1.  Generalized Anxiety Disorder, 300.02.


2.   S/L Dysplymic or Disemployment Disorder, 300.4.


It does not sound like dysthymic.  Thanks,


 


Is this correct?? (Psych Eval)
Subject: Is this correct?? (Psych Eval)

Under Axis Formulation:


AXIS I:  Schizoaffective Disorder, Bipolar s/l: subtag.


I have not encountered this word and tried to google subtag to no avail.


Thanks.


Psych eval question
Subject: Psych eval question

This is under the discussion part of the dictation and it is a continuation, of which I was not the typist for the first part of the evaluation...


My assessment of him reveals many strengths, including long-term friendships, good relations with family members, solidly normal intelligence including strong S/L: visual enhance auto reasoning, and absence of any “behavior problems” in the usual sense of the word.


Does this make sense???  Thanks for any help.


thought attrition?? Psy eval
Subject: thought attrition?? Psy eval

At this time, he denies any ideas of reference, no thought broadcasting, no thought ATTRITION??
Child psych eval...please sm
Subject: Child psych eval...please sm

Psych eval for a 7-year-old student with ADHD...


He says the following:


He showed a moderately delayed score in the working memory area when he had difficulty recalling S/L: wrote, auditorily presented information.  Weakness in this area may impact his ability to remember, recite, and manipulate sequences for academic tasks.


WROTE auditorily presented information?  TIA


s/l liftlocks on shoes-OT eval
Subject: s/l liftlocks on shoes-OT eval

The patient is having an OT evaluation.  He is in a wheelchair.  The sentence is under ADLs and states, "He uses (s/l liftlocks or lislocks) on his shoes and these work well." 


Psych eval - speech?
Subject: Psych eval - speech?

Speech, attention shows s/l circumstantially evasive and guarded. circumstantially?
DNP, CBC to eval for s/l neocult anemia
Subject: DNP, CBC to eval for s/l neocult anemia


Psych Eval. s/l *egomastria.* Please SM.
Subject: Psych Eval. s/l *egomastria.* Please SM.

She is in a state of emotional disequilibrium.  This includes problems with depression, irritability, agitation, lassitude and malaise, as well as lack of s/l *egomastria,* indicating she has trouble with regard to clear thought processes associated with her disturbance in regards to her auditory hallucinations and delusional ideation.   TIA
PT Eval - s/m emtican test? nm
Subject: PT Eval - s/m emtican test? nm

Thanks!
Any ideas on this one appreciated! Psych eval...
Subject: Any ideas on this one appreciated! Psych eval...

He has some mild anxiety about S/L: WALT issues but does not have any symptoms suggestive of an anxiety disorder. 


He was diagnosed with ADHD and PDD.


TIA


psych eval - never heard of a similar word...sm
Subject: psych eval - never heard of a similar word...sm

I also believe the diagnosis of Disruptive Behavior Disorder Not Otherwise Specified should be ruled out for her given high levels of concerns of these types seen for her at school.  However, it does seem possible that some of these behaviors are related to issues with attention span and/or learning, and in particular, auditory memory; conceivably, as these issues are successfully addressed, we may see less pronounced S/L: SUP-TUNE-IS on her part, at least in the classroom. 
Spacuda step test? Vestibular eval
Subject: Spacuda step test? Vestibular eval

S/L spacuda step testing.  Football player with concussion after helmet-to-helmet hit, now complaining of dizziness and headaches. 


The sentence is:


"His *Spacuda?* step testing was intact."


She is doing dynamic balance testing on him.


Thanks! 


Patient had laparoscopic cholecystectomy. Returns for eval of "subsactal" wound ??
Subject: Patient had laparoscopic cholecystectomy. Returns for eval of "subsactal" wound ??

Please help, I'm clueless.  Sounds like sub zactal, subsactal??   Thanks!
Social work eval s/l full-'scaled' or 'skilled' survey sm
Subject: Social work eval s/l full-'scaled' or 'skilled' survey sm

hx of baby with head injury


Full-scaled survey seems to make the most sense- can anyone verify this?


TIA


uterine
Subject: uterine

maybe "parenchyma"?
uterine cri
Subject: uterine cri

it is generally referred to as the uterine cri. It is a specific term used in the performing of abortions. They stop the suctioning when they obtain the uterine cri.
Uterine?
Subject: Uterine?

x
Desensus uterine?
Subject: Desensus uterine?

The patient has a desensu uterine.  Help!!
There is uterine myoinvasion.
Subject: There is uterine myoinvasion.

x
Per Stedman's - uterine cry.
Subject: Per Stedman's - uterine cry.

x
s/l uterine antonie
Subject: s/l uterine antonie

this is for a C-section....


There was uterine antonie during surgery...


THANKS!


uterine atony. nm
Subject: uterine atony. nm

nm
ENT eval: she had a "fur-on-gole interior canal wall of her left ear which was opened & purulenc
Subject: ENT eval: she had a "fur-on-gole interior canal wall of her left ear which was opened & purulence

hard to hear this, she rattles it off so fast I could have it completely off.  
Sounds like - good uterine cry, or cri
Subject: Sounds like - good uterine cry, or cri

any guesses?
Your supervisor is nuts, its uterine cry. nm
Subject: Your supervisor is nuts, its uterine cry. nm

x
RUMI uterine manipulator - nm
Subject: RUMI uterine manipulator - nm

nm
sounds ok. uterine CA (carcinoma)
Subject: sounds ok. uterine CA (carcinoma)


uterine cry is the accepted form. nm
Subject: uterine cry is the accepted form. nm

.
? dysfunctional uterine bleeding
Subject: ? dysfunctional uterine bleeding


RUMI uterine manipulator nm
Subject: RUMI uterine manipulator nm

nm
and lower uterine segment? nm
Subject: and lower uterine segment? nm

.
s/l Valchez uterine manipulator nm
Subject: s/l Valchez uterine manipulator nm


There is a Kahn uterine cannula. nm
Subject: There is a Kahn uterine cannula. nm


uterine contraction frequency ?
Subject: uterine contraction frequency ?


I think "cry" would be correct there (uterine cry,
Subject: I think "cry" would be correct there (uterine cry,

having to do with the texture of the uterus, I think) - I have always used "cry," but I think "cri" is also acceptable.
followed by sharp curettage with a good uterine cyr/cri sm
Subject: followed by sharp curettage with a good uterine cyr/cri sm

This was followed by suction curettage with a 10- mm suction cannula, then followed by sharp curettage with a good uterine cyr/cri
OB.. early s/l into uterine pregnancy.. or intrauterine?? thanks
Subject: OB.. early s/l into uterine pregnancy.. or intrauterine?? thanks


hysterectomy....s/l Roomy?? uterine manipulator?? Thanks again
Subject: hysterectomy....s/l Roomy?? uterine manipulator?? Thanks again


uterine CA. Some doctors use CA as short for cancer.
Subject: uterine CA. Some doctors use CA as short for cancer.


found it VCare uterine manipulator
Subject: found it VCare uterine manipulator


Meigs uterine or endometrial curette?
Subject: Meigs uterine or endometrial curette?


It's not a clamp, but my first guess was Hulka uterine manipulator. sm
Subject: It's not a clamp, but my first guess was Hulka uterine manipulator. sm

There is also a Hulka uterine cannula and tenaculum.

Don't know what you mean by "service of the uterine elevator." That doesn't sound right.