I'd just leave it a paragraph at the end. NM
Posted By: AnnuderMT on 2009-05-17
In Reply to: H & P Report - Cora
Subject: I'd just leave it a paragraph at the end. NM
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can't you just leave it abbreviated, or do you have to spell it out. I would leave as dictated.
Subject: can't you just leave it abbreviated, or do you have to spell it out. I would leave as dictated.
If it was dictated like that & you can leave abbrvns in, then leave it
Subject: If it was dictated like that & you can leave abbrvns in, then leave it
s
Here's the paragraph................
Subject: Here's the paragraph................
"The rest of his past history, review of systems, and social history is otherwise noncontributory, except that he is status post coronary artery bypass graft surgery and has had a pacemaker and is on Coumadin in conjunction with his cerebral vascular disease. He also takes amiodarone, s/l Trazadec, Toprol, Ambien, Cozaar, and Effexor."
The patient is being evaluated by a neurologist for leg and back pain. Thanks.
does this fit at the end of this paragraph? See msg pls.
Subject: does this fit at the end of this paragraph? See msg pls.
Patient is getting back on his medications and will be following up with his psychiatrist Dr. X. They are due within the next few weeks, he says, to recheck his Depakote levels, (Dr. take a drink and says)S/L hemolith normal. (new paragraph)
not sure, here's the paragraph...
Subject: not sure, here's the paragraph...
Neurologic exam/history and physical exam does reveal the patient with parkinsonian features. We are going to go ahead and change him from Sinemet 25/100 mg to Stalevo 100 mg, one in the morning and one at midday, since he really only takes it twice a day. If this does not help, we may try going back to the Sinemet and then trying Azilect for the freezing. I think that may be of great benefit to him, despite the MALB inhibitor.
Here's the rest of the paragraph. I need someone to look at this.
Subject: Here's the rest of the paragraph. I need someone to look at this.
This is listed under the PMH: Do these numbers look right? My question is really the
"FEF 25 to 75 1.66 (65%). " Does this look right? not sure how to type the 75 1.66. ... MD says it like this:
"FEF 25 to 75 one point six six and parentheseses 65%"
Pulmonary – status post pulmonary embolus, status post a prolonged road trip. Coumadin was discontinued in April and MTHFR Heterozygote with an elevated homocysteine level. She has been maintained on Folate. She has also been treated for asthma. Pulmonary function tests in December of 2002 demonstrated a FEV1 of 1.86 (79%), and FVC of 2.41 (83%) an FEV1 of 77% and FEF 25 to 75 1.66 (65%). In March of 2004, a diagnostic polysomnogram demonstrated obesity, hypoventilation; no evidence of obstructive sleep apnea. She has been maintained on 2 liters q.h.s. A repeat study in June of 2005 confirmed that treatment.
if i give you the paragraph for this ....
Subject: if i give you the paragraph for this ....
could you be able to tell if it were a line infection? I will send what they did. thanks
Paragraph numbering
Subject: Paragraph numbering
1.
a.
b.
c.....etc.
When you get all the way through z, how do you number or letter after z? Thanks so much.
Here's the context paragraph...sm
Subject: Here's the context paragraph...sm
Patient recently had a positive culture infection with group B strep. He was treated with some Cipro and he says he is actually voiding better now than he has for some time. He probably has been having a little small "ring" prostatitis going on.
paragraph punctuation help..please...
Subject: paragraph punctuation help..please...
MRI scan indicates status post patellar tendon, bone, and anterior cruciate ligament construction, cystic degeneration of the graft with little remaining low signal fibers is noted, tendon enlargement in the tibial tunnel with cystic erosion through the anterior cortex medially to the patellar tendon, extension into the anterior subcutaneous fat of the proximal right lower leg.
Note the doctor does say construction, not reconstruction can this also be correct? TIA.
I found one paragraph re patients ...sm
Subject: I found one paragraph re patients ...sm
not sure but I found one paragraph thru google about dacron wool........being used on a patient:
Once cooling to -79 C was complete the patient was lifted out of the Silcool bath, the outer, Silcool wetted plastic bag was stripped off and the patient was placed within a polyester cloth bag which was in turn placed inside a standard aluminum neurocan which had been precooled to -90 and packed with dacron
wool. Temperature probes were left externalized to the neurocan for subsequent cooling to -196 C.
I don't really think this is going to help you though but I tried!! 
your paragraph has many grammatical errors
Subject: your paragraph has many grammatical errors
along with punctuation - not sure if you just typed it fast and are aware or not? If you more help, let me know.
Go to format/paragraph and you'll see it. nm
Subject: Go to format/paragraph and you'll see it. nm
Based on the following paragraph written by
Subject: Based on the following paragraph written by
Vanderbilt University in relationship to Troubleshooting PICC problems, in particular; "My patient's arm is red, swollen, and/or painful."
A. How does the arm look in comparison to the arm without a PICC line.
B. If redness is involved, is it a red streak up the arm along the vein tract.
C. If swelling is involved, what is the difference in the girth of the two arms.
Your sound-alike brings to my mind: gorge; as engorged. Definition: gorge, glut; especially: to fill with blood to the point of congestion. Just an educated guess though. Good luck.
This paragraph shows AZT for baby -see message
Subject: This paragraph shows AZT for baby -see message
If an HIV positive woman is taking AZT then it will probably be recommended that her baby is given AZT (usually as a syrup) for the first six weeks of its life starting 8-12 hours after birth. Alternatively, if the mother has taken AZT and 3TC during labour then an effective regime for the baby would be one week of AZT and 3TC.
If only limited AZT is available then one week of AZT can be given to the baby. If only single dose AZT is available then the baby can have this combined with a single dose of NVP, and if no AZT is available then the baby can have a single dose of NVP to help protect it.
Here is the paragraph for the s/l line infection evaluation..
Subject: Here is the paragraph for the s/l line infection evaluation..
Patient here today for a post-op s/l line infection evaluation. She has been doing daily wet to dry dressing changes and today the wound breadown area is less than a cm across and with probing with a Q-tip will not extend any greater than 2 cm in the area. I do not think that this continues to require any packing. I have recommended that she just keep gauze over the area for the drainage. thank you
Stumped - rheumatology. Please see paragraph for context.
Subject: Stumped - rheumatology. Please see paragraph for context.
Patient is a little girl with an area of atrophic and hyperpigmented skin on her forehead (morphea/linear scleroderma en coup de sabra).
"In addition, there is a secondary area which is approximately 2 cm in diameter and 6 cm in length which is hyperpigmented and lateral to the s/l inituary/immisuary, with again subcutaneous atrophy, but without erythema or adherence."
Totally stumped but hate to give up --- Thanks for any help.
does she want you to put in a heading, or include more in prior paragraph
Subject: does she want you to put in a heading, or include more in prior paragraph
nm
Thx! I made it through a whole paragraph of tests, with this being the last one and couldn't get
Subject: Thx! I made it through a whole paragraph of tests, with this being the last one and couldn't get the last one! :) Thx for your help!
does this paragraph sound right and is it punctuated correctly
Subject: does this paragraph sound right and is it punctuated correctly
There were findings of a posterior horn tear of the medial meniscus, a small chondral injury of the medial tibial plateau, grade 4 out of 4, chondromalacia of the medial femoral condyle, grade 3 out of 4, chondromalacia patella and trochlea notch of the femur, grade 3 out of 4.
The doctor speeds through this paragraph at 75mph..does it make sense and is the punctuation correct? TIA.
s/l linear partial tear also does this paragraph
Subject: s/l linear partial tear also does this paragraph
make sense?
There is a focal tear of the posterior supraspinatus tendon noted. No other tear or retraction evident. There is also S/L linear partial tear of the long head of the biceps tendon noted. Mild degenerative changes to the glenohumeral joint also indicated. TIA.
Just make it the last paragraph in the report. Does it Have to have a title? Maybe Note, Comment,
Subject: Just make it the last paragraph in the report. Does it Have to have a title? Maybe Note, Comment,
s
I would leave in under PMH sm
Subject: I would leave in under PMH sm
it probably is part of what is being said. And, it is a lab value (said it was negative) not a date. l
I would leave as is - sm
Subject: I would leave as is - sm
I have heard this phrase many times, and always leave it as is. They are referring to prerenal azotemia.
I'd leave it as is. nm
Subject: I'd leave it as is. nm
x
just leave the S off
Subject: just leave the S off
nm
Then that is how I will leave it! Thanks
Subject: Then that is how I will leave it! Thanks
leave as is
Subject: leave as is
Torso is an anatomical term for the central part of the many animal bodies (including that of the human) from which extend the neck and limbs. It is sometimes referred to as the trunk. The torso includes the thorax and abdomen
I would leave it the way he says it. nm
Subject: I would leave it the way he says it. nm
I'd leave them just how you have them.
Subject: I'd leave them just how you have them.
I would leave as is
Subject: I would leave as is
i would leave as is
Subject: i would leave as is
You never know with labs, they can be tricky. If you are really concerned you could always add a marker for it to be double checked but I would leave as dictated.
I would leave it.
Subject: I would leave it.
I think you are correct. I believe they are three separate things. There is general pain that stars to localize to one spot. There is rebound pain where they press on your abdomen slowly, but then unexpectedly let go. And there is guarding pain if when they examin or stomach you they press or attempt to press and you instinctively try to guard your abdomen with your hands.
i would leave as is.......
Subject: i would leave as is.......
i would leave as is.......
Thanks, but I had to leave a QA...
Subject: Thanks, but I had to leave a QA...
nm
Leave them in (sm)
Subject: Leave them in (sm)
I would leave them in. Yes, it is redundant, but it's also what the doctor dictated. The only exception would be, in my opinion, if there were account specifics covering this and then I would follow the account specifics.
Leave it
Subject: Leave it
where it is. Put a hypen in between tib-fib and a comma after fib.
I leave them out
Subject: I leave them out
You can overdue on hyphens and commas. Well child check, well woman's visit, well baby check. Looks better without. Just my take. :-)
I would just leave it at sm
Subject: I would just leave it at sm
exacerbating the anal pain.
I would leave it as he said. He knows what it means...sm
Subject: I would leave it as he said. He knows what it means...sm
TM stands for appx 20 or more things, so you cannot guess which one. Also,the same goes for LAM. It stands for seven different things and you cannot guess which one.
I was taught in this situation to leave it as said. My account even specifies in assessment and plan to never abbreviate except in this case when you cannot 100% verify what the doc means if there is more than one meaning to the abbreviation.
Hope this helps
I would leave lami as is
Subject: I would leave lami as is
I have never heard of that before, but you really do not know what the doc wants. You should not try to guess at something like that. I wouldn't.
I would leave it blank then
Subject: I would leave it blank then
Sometimes docs do not spell things correctly; but when I cannot find something that they spell, I will send it to QA and let them figure it out. Sorry I could not be of more help to you.
Had to leave a blank. nm
Subject: Had to leave a blank. nm
x
I leave it as whatever the doc dictates.
Subject: I leave it as whatever the doc dictates.
It's not my job to keep them politically correct.
Personally, I would leave out the myself--sm
Subject: Personally, I would leave out the myself--sm
that would be like saying "I me personally use the drug." verbatim or not, it is not good grammar, but it is your call. JMO.
P.S. Yes, leave out the commas nm
Subject: P.S. Yes, leave out the commas nm
.
Leave a blank sm
Subject: Leave a blank sm
If a doctor can't take the time to spell something like that, which is not a medical term and not something you would be expected to know, then they deserve to fill in the blank themselves.
JMHO.
Thanks. Had to leave it blank.
Subject: Thanks. Had to leave it blank.
xxx
i would have to leave a blank.
Subject: i would have to leave a blank.
...sorry
Think I will have to leave a blank...sm
Subject: Think I will have to leave a blank...sm
on this one. Thank you all very much. Everything you are offering makes sense but doesnt fit. She is probably pronouncing it wrong.. I appreciate the help very much.
Leave the word
Subject: Leave the word
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