HOSPITAL COURSE: Fish?? admission history and physical for details
Posted By: Amy on 2008-01-31
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Subject: HOSPITAL COURSE: Fish?? admission history and physical for details
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maybe admission H&P (history and physical). NM
Subject: maybe admission H&P (history and physical). NM
x
refer to the admission agency?? for details
Subject: refer to the admission agency?? for details
H & P- history and physical...nm
Subject: H & P- history and physical...nm
m
History and physical word help
Subject: History and physical word help
The doctor say chief complaint, S/l appendidiver HPI... Any suggestions? Thanks for everyone's help..
Should history and physical be capitalized?
Subject: Should history and physical be capitalized?
Sentence reads p/t is here today for a complete history and physical...... Should history and physical be capitalized? Thanks.
History & Physical Headings
Subject: History & Physical Headings
I am trying to head a H & P what do I list the bladder and groin under?
History & Physical Headings+1>?
Subject: History & Physical Headings+1>?
Thanks. One more question. What headings do you add if not transcribed to the H & P?
Neurological History and Physical
Subject: Neurological History and Physical
This is going to probably sound crazy....but it s/l "whirring imbalance."
Might just be the History and Physical that's back at the office, or the H&P. nm
Subject: Might just be the History and Physical that's back at the office, or the H&P. nm
s
Neurological History and Physical Exam
Subject: Neurological History and Physical Exam
Any help on this would be appreciated. This is a neurology history and physical and the doc is dictating the Assessment/Plan. She states, "This patient with a _________ imbalance. She did have normal imaging before, but did not get a MRA". My brain is mush and I just cannot understand what type of imbalance she is referring to. Thank you for any assistance.
Hospital experience as what? a doctor? a nurse? Or are you speaking of hospital experience as an
Subject: Hospital experience as what? a doctor? a nurse? Or are you speaking of hospital experience as an
experience is, it lacks credibility especiall when you base it on YOUR experience. Who are you? How much experience do you actually have? What kind of experience do you have? How many diabetic patients have you encountered in your years of experience?
You can't expect to make a sweeping generalization like "all diabetics have hypertension" and not get called out on it. Come on! Know your place. Arrogance is an unattactive personality trait.
BVP was 8/8...on obstetrics admission...sm
Subject: BVP was 8/8...on obstetrics admission...sm
Is BVP correct, I can't find this abbreviation anywhere??? Thanks!
ER admission note help please
Subject: ER admission note help please
The patient had diminished sphincter tone. The patient did receive cow littix prior to the exam.
This patient had been in a car accident, she was intubated, combative, and had 2 broken legs. Any ideas?
s/l MOD was called for admission. sm
Subject: s/l MOD was called for admission. sm
the patient was hemodynamically stable, s/l MOD was called for admission secondary to GI bleed. the patient was transferred to the s/l MOD service ???
Under past medical history - history of abnormal s/l petatrie functioning. I really cannot make *sm
Subject: Under past medical history - history of abnormal s/l petatrie functioning. I really cannot make *sm
it out. It is a foreigner. He is saying it very fast. History of abnormal petatrie functioning is what is sounds like to me. I have no clue.
history of colorectal history with metastasis to the liver and lymph nodes
Subject: history of colorectal history with metastasis to the liver and lymph nodes
its in a list of meds on admission, no dosage
Subject: its in a list of meds on admission, no dosage
pt has diabetes, asthma, migraines, gastroparesis
Do admission orders need to be expanded? eg. C&S, CBC, STAT
Subject: Do admission orders need to be expanded? eg. C&S, CBC, STAT
Thanks for your help.
more details?
Subject: more details?
SM for details.
Subject: SM for details.
I searched on eneel.com for words starting with "v" and ending with "age" by giving the search string v*age. I think the result could be
Vantage
but you can also check for other options by visiting the link.
more details?
Subject: more details?
!
He might. Need more details on the other.
Subject: He might. Need more details on the other.
IF OS like he's spelling it or saying it? and could you use in context?
no details
Subject: no details
Sorry about that. She is having leg pain problems (sciatica, maybe) and has taken some injections. Perhaps it could be Formadrol? I’ll relisten. Thanks.
Outpatient hold admission versus inpatient
Subject: Outpatient hold admission versus inpatient
Please read this with a little grain of salt, since I don't have enough info to be sure in this case, but this has happened to me before. Most hospitals and most insurance companies have a "24 hour hold bed" policy of some sort. The patient is considered an outpatient, (and charged the lesser "hold bed" charge) even though admitted to the hospital, for the first 24 hours, or 23 hours and 59 minutes. Maybe this doc is saying that the EKG was done at that time in the admission - hour #23, minute #____. Again, use caution, and if this is the case, the doctor sure SHOULD have said "at 23 hours X minutes after" admission or clarified it somehow. But this is just food for thought, since I have had docs dictate using the number of hours since the patient was admitted, though I'm happy to say they the docs always made it known that that's the way they were counting down the hold bed time.
just guessing, could it be admission and disch (A&D)so pt can get hospice care afterwards?
Subject: just guessing, could it be admission and disch (A&D)so pt can get hospice care afterwards?
re: Just says for heel, no details
Subject: re: Just says for heel, no details
fistula-in-ano (SM for details)
Subject: fistula-in-ano (SM for details)
According to http://www.emedicine.com/ped/byname/Fistula-in-Ano.htm as well as other references.
meant to add details...
Subject: meant to add details...
Patient has anemia, hypertension, mrsa, diabetes, abdominal abscess. Recently underwent total colectomy, laparotomy, tracheotomy.
tisbar injection? located in a list of meds on admission
Subject: tisbar injection? located in a list of meds on admission
HER-2 FISH (i believe)
x
Actually, how about fish oil? nm
Subject: Actually, how about fish oil? nm
s
Fish oil? nm
Subject: Fish oil? nm
//
Probably fish oil
Subject: Probably fish oil
How omega-3 fats reduce heart disease is not known, but they lower blood triglycerides and blood pressure, prevent clotting, are anti-inflammatory, and reduce abnormal heart rhythms.
Hi, Amy, PORT score is for pneumonia severity on admission, predicted outcome.....nm
Subject: Hi, Amy, PORT score is for pneumonia severity on admission, predicted outcome.....nm
nm
More details would help, but maybe a factor V Leiden effect? nm
,
no details known -- just listed as a medication of patient nm
Subject: no details known -- just listed as a medication of patient nm
well you didn't give any details....until now, smart***, LOL, j/k - nm
Subject: well you didn't give any details....until now, smart***, LOL, j/k - nm
Without more details, I'd transcribe: double documented.
Subject: Without more details, I'd transcribe: double documented.
.
butchiery type physiology ?? See mg for details. Thanks
Subject: butchiery type physiology ?? See mg for details. Thanks
The remainder of the liver was heterogenous on the portal phase study, which maybe due to contrast bolus. However, extension of the tumor into the right lobe cannot be excluded. Possibility of butchiery type physiology should be considered since the IVC was slit-like. Splenomegaly was noted along with ascites consistent with portal hypertension. There was evidence of focal chronic pancreatitis.
Don't you all get tired of cross-examining these people for details? NM
NM
completely *outeristic/alteristic* procedure - sm for details
Subject: completely *outeristic/alteristic* procedure - sm for details
Doc has a bit of an accent, so not sure what he is saying...
Donating a kidney should be a completely *outeristic/alteristic* procedure and that one should never feel obligated or coerced to donate.
HER2 FISH, plse see msg.
Doc says HER2 FISH is positive. Is this the correct way to type this, should it be FSH instead of FISH? I would always hear HER2/neu, now he threw me a curve! Thx
Cytology and FISH procuedure...
Subject: Cytology and FISH procuedure...
TIA!!
There is a fish-tank granuloma.
Subject: There is a fish-tank granuloma.
Guess here... fish oil and borage oil?
Subject: Guess here... fish oil and borage oil?
dialysis Fish line?
Subject: dialysis Fish line?
It is important that the patient does not get a fish line in light of her advanced age.
Ear surgery: s/l Eagle Fish perforator?
Subject: Ear surgery: s/l Eagle Fish perforator?
x
fluorescence in situ hybridization (FISH)
Subject: fluorescence in situ hybridization (FISH)
x
any genetics whizzes? FISH analysis - sm
Subject: any genetics whizzes? FISH analysis - sm
deletion in the STS gene ... s/l ficalmin gene was intact suggesting cutaneous involvement only. TIA!
listed in med supplements: fish oil s/l boragna. Thanks
Subject: listed in med supplements: fish oil s/l boragna. Thanks
I'm going to replay it, but it sounded just like fish line to me. Thank you!
Subject: I'm going to replay it, but it sounded just like fish line to me. Thank you!
x
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