I would say in this instance if dictator is referring to diagnoses, sm
Posted By: MWMT on 2005-08-18
In Reply to: hypertension - confused
Subject: I would say in this instance if dictator is referring to diagnoses, sm
it probably is hyper given that he is diagnosed with hypertension but is on meds for that. his bp is low today so he wants to decrease the norvasc as it is over working. the patient isn't diagnosed with hypotension, it is only hypo due to medication dosaging.
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- hypertension - confused
- I would say in this instance if dictator is referring to diagnoses, sm - MWMT
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Wild guess here...Could the dictator be referring to two separate medications, i.e. "she had been
Subject: Wild guess here...Could the dictator be referring to two separate medications, i.e. "she had been given a refill for her birth control pills and Cefprozil (antibiotic?).
I think dictator is referring to renal arteries and iliac arteries, probably okay as is ? NM
Subject: I think dictator is referring to renal arteries and iliac arteries, probably okay as is ? NM
save in this instance would be except ...sm
Subject: save in this instance would be except ...sm
except the base, which was cauterized. I would re-word to say: The scope was passed down to the cecum. A polyp was present, multiple biopsies removed it save for its base which was cauterized.
Sorry, only have transcribed sharp in that instance.
Subject: Sorry, only have transcribed sharp in that instance.
in this instance they are being used as proper nouns and should be capped. NM
Subject: in this instance they are being used as proper nouns and should be capped. NM
:
Impart is incorrect in this instance. Use 'in part'
Subject: Impart is incorrect in this instance. Use 'in part'
s
In this instance, Sted's Lab & Path words said this organism is capitalized. nm
Subject: In this instance, Sted's Lab & Path words said this organism is capitalized. nm
s
holiday...is the dictator an Arab dictator? nm
Subject: holiday...is the dictator an Arab dictator? nm
x
type what dictator said, dictator is not incorrect.....
Subject: type what dictator said, dictator is not incorrect.....
.
is this dictator ESL (foreign dictator)?....
Subject: is this dictator ESL (foreign dictator)?....
if ESL, I would either blank him or give him that Avodart but the other one I haven't a clue and would have to blank there too. Sorry :(
tracks as in 'makes tracks' in this instance. nm
Subject: tracks as in 'makes tracks' in this instance. nm
s
I think it is only the diagnoses that need....
Subject: I think it is only the diagnoses that need....
to be spelled out. This part is more like the plan.
diagnoses
Subject: diagnoses
Axis I - VI are not arms of one diagnosis, but of many diagnoses, in different systems and considerations. They include psychiatric diagnoses, functional diagnoses, physical illness diagnoses, etc., etc.
Diagnoses...
Subject: Diagnoses...
Croup and bronchitis.
Procedures: nasogastric tube feed and OPM study. Also says that OPM study indicated silent aspiration.
Any other diagnoses?
Subject: Any other diagnoses?
diagnoses
Subject: diagnoses
Debility.
Dementia with acute confusional state.
Abrasion to shoulder.
Metastatic disease.
Dehydration.
End-stage COPD.
Arthritis.
SIADH.
Hypokalemia.
Hyponatremia.
Bowel obstruction, etiology undetermined.
Urinary tract infection.
Septic condition of blood.
diagnoses
Subject: diagnoses
Diagnoses as follows:
paroxysmal atrial fibrillation, end-stage renal disease, Lown-Ganong-Levine syndrome, hypertension, hypopituitarism, acromegaly, hyperparathyroidism, hypothyroidism, insulinoma.
does that help?
Diagnoses....
Subject: Diagnoses....
Hypertension, chronic edema, hypothyroidism, pacemaker placement, mitral valve prolapse, DVT, hyperlipidemia, GERD, proteinuria, right-sided heart failure
No, see diagnoses. Thanks.
Subject: No, see diagnoses. Thanks.
1. Acute left chest pain.
2. Esophagitis.
3. Coronary artery disease.
4. Hypertension, severe.
5. Probable renal artery stenosis.
6. Peripheral vascular disease.
7. AKI.
8. Malnutrition.
9. Anemia.
Two diagnoses nm
Subject: Two diagnoses nm
k
are these diagnoses...
Subject: are these diagnoses...
correct? He rambles them all together, not sure if I am correct with what I am hearing.
DIAGNOSES:
1. HARDWARE PAIN, RIGHT SECOND METATARSAL FUSION WITH A HISTORY OF DEEP INFECTION AFTER HAMMERTOE PROCEDURE, RIGHT SECOND TOE
2. PAIN AFTER KNEE REPLACEMENT
3. PAIN, LEFT FOOT
tia.
is this 2 or 3 diagnoses?
Subject: is this 2 or 3 diagnoses?
DIAGNOSES:
1. LEFT KNEE LATERAL MENISCUS TEAR
2. OSTEOCHONDRAL DEFECT
3. RIGHT KNEE DEGENERATIVE JOINT DISEASE
Not sure if Right knee degenerative joint disease should be number 3. tia.
I should have put the diagnoses which are..
Subject: I should have put the diagnoses which are..
1. GOUTY ARTHROPATHY
2. NEURALGIA PAIN
3. FAT PAD ATROPHY
Would it still be hallux shoes and also if so would Hallux be capitalized? Thanks for your help.
on diagnoses -diseases
Subject: on diagnoses -diseases
DISCHARGE DIAGNOSES
- Relapse acute myelomonocytic<soundslike> leukemia.
- Severe pancytopenia due to bone marrow hypopasia secondary to cancer chemotherapy.
- Sepsis, possibly due to staphylococcus lubdenensis.
- Ogroshong<soundslike> catheter exit site infection.
- Hypocholemia.
Any diagnoses for the patient? nm
Subject: Any diagnoses for the patient? nm
s
Doc says in diagnoses list...
Subject: Doc says in diagnoses list...
Status post PCIA with stents in the left anterior descending.
Can't find PCIA. Did find PCI - percutaneous coronary intervention. Or does he mean PTCA?
Are they receiving TPN? Or do you have any diagnoses? nm
Subject: Are they receiving TPN? Or do you have any diagnoses? nm
s
Any diagnoses on this patient? nm
Subject: Any diagnoses on this patient? nm
s
Yes, it's discharge diagnoses-First
Subject: Yes, it's discharge diagnoses-First
one is enterobacter septicemia due to line infection.
could definitely fit in with diagnoses and problems
Subject: could definitely fit in with diagnoses and problems
Thanks so much!
Have a great day!
any diagnoses or dosage?
Subject: any diagnoses or dosage?
one diagnosis or more diagnoses
Subject: one diagnosis or more diagnoses
DIAGNOSIS: INTERNAL DERANGEMENT, RIGHT KNEE
TEAR OF THE LATERAL MENISCUS, RULE OUT MEDIAL MENISCUS TEAR
EARLY DEGENERATIVE ARTHRITIS
Not sure if this is all one diagnosis or more. Any ideas. The only thing that I think makes it sound to be one is because he doesn't mention which knee for any of the others. If it is one how would you punctuate. Sorry for so many questions but I am confused..tia.
Final Diagnoses
Subject: Final Diagnoses
1. Congestive heart failure.
2. Cellulitis, right leg.
3. Cardiomyopathy.
4. Morbid obesity.
Do you know the diagnosis or diagnoses?
Subject: Do you know the diagnosis or diagnoses?
Normally, you don't number diagnoses
Subject: Normally, you don't number diagnoses
within an axis. We do this.
Axis I: xxxxx
xxxxxx
Axis II: xxxxx
etc. Each diagnosis is on a separate line, but not numbered.
The SSA was given in a list of diagnoses. sm
Subject: The SSA was given in a list of diagnoses. sm
Totally occluded bilateral SSA stenosis. Patent s/l "profundal" arteries.
Also in list is of diagnoses is the following....Coronary artery bypass graft and "SVG to LAD", "SVG to OM"... not sure on these abbreviations... can you tell I am completely lost....
It's a list of discharge diagnoses...
Subject: It's a list of discharge diagnoses...
DKA, then s/l Right leg varicose, then obesity. He says it later in the report and it definitely s/l varicose.
listed in diagnoses, no sentence
Subject: listed in diagnoses, no sentence
.
Was that a typo? I've never had VI diagnoses, only 5.nm
Subject: Was that a typo? I've never had VI diagnoses, only 5.nm
I believe the are 2 separate diagnoses and would transcribe as such.
Subject: I believe the are 2 separate diagnoses and would transcribe as such.
.
whats the diagnoses?---this ending could be a lot of
Subject: whats the diagnoses?---this ending could be a lot of
diff meds, first one that comes to my mind is
fluoxetine
Can you look in the pt's diagnoses for clues? Think your PT/INR phrase
Subject: Can you look in the pt's diagnoses for clues? Think your PT/INR phrase
s
context, sentence? - diagnoses?....nm
Subject: context, sentence? - diagnoses?....nm
can you give the patient's diagnoses?
Subject: can you give the patient's diagnoses?
Any past history or diagnoses? nm
Subject: Any past history or diagnoses? nm
s
any diagnoses or problem list?
Subject: any diagnoses or problem list?
Differential diagnosis or diagnoses? nm
Subject: Differential diagnosis or diagnoses? nm
senescent changes (fyi no abbrev in your diagnoses too...) nm
Subject: senescent changes (fyi no abbrev in your diagnoses too...) nm
I would keep it as you have it, (3 diagnoses) just put periods at the end of each sentence. :)
Subject: I would keep it as you have it, (3 diagnoses) just put periods at the end of each sentence. :)
3 diagnoses, the 2nd and 3rd caused by Diabetes...nm
Subject: 3 diagnoses, the 2nd and 3rd caused by Diabetes...nm
nm
All my university docs tell me it is diagnoses, so I have used that for 8 years.
Subject: All my university docs tell me it is diagnoses, so I have used that for 8 years.
nm
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