Medically it would fit, could you give patient's chief complaints and diagnoses? nm
Posted By: Cyndiee on 2009-01-25
In Reply to: Genitoperitoneal signs - AmyBesa
Subject: Medically it would fit, could you give patient's chief complaints and diagnoses? nm
nm
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- Genitoperitoneal signs - AmyBesa
- Medically it would fit, could you give patient's chief complaints and diagnoses? nm - Cyndiee
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can you give the patient's diagnoses?
Subject: can you give the patient's diagnoses?
No dx? No chief complaint? No planned tx? Give us a clue here! nm
Subject: No dx? No chief complaint? No planned tx? Give us a clue here! nm
s
What is patient's diagnosis or complaints?
Subject: What is patient's diagnosis or complaints?
Question "BIA"? "VIA" ??? CNS complaints in patient.
Subject: Question "BIA"? "VIA" ??? CNS complaints in patient.
The patient has CNS complaints (ataxia, weakness) and moderate stenosis in carotid arteries.
Doctor dictates under plan: Female with question of "BIA", question vascular etiology for her complaints.
Under VIA or BIA I cannot find anything that might fit. Any ideas? Thanks!
I am unable to definitively diagnose patient's complaints regarding her right palm s/l 3rd ray.
Subject: I am unable to definitively diagnose patient's complaints regarding her right palm s/l 3rd ray.
Please give the diagnoses etc so we can have a chance to figure this out. nm
Subject: Please give the diagnoses etc so we can have a chance to figure this out. nm
Any diagnoses for the patient? nm
Subject: Any diagnoses for the patient? nm
s
Any diagnoses on this patient? nm
Subject: Any diagnoses on this patient? nm
s
The "Impression" part of the dictation reflects diagnoses; a patient can have many.
Subject: The "Impression" part of the dictation reflects diagnoses; a patient can have many.
.
oops, it has been a long day... Medically stable..
Subject: oops, it has been a long day... Medically stable..
Is patient being fitted for something that might give a clue as to
Subject: Is patient being fitted for something that might give a clue as to
s
Epigastric/right upper quadrant pain. give the patient some pam-e-am 5 mg twice a day. nm
Subject: Epigastric/right upper quadrant pain. give the patient some pam-e-am 5 mg twice a day. nm
thanks
Can you give us some info about the patient, i.e. past history, current complaint, etc?
Subject: Can you give us some info about the patient, i.e. past history, current complaint, etc?
Many drugs sound similar, can u give context of sentence/patient problems? NM
Subject: Many drugs sound similar, can u give context of sentence/patient problems? NM
nm
chief complaint
Subject: chief complaint
H & P~the doctor says chief complaint:?? sounds like a-pen-ded di-ver (crazy, I know)
The patient awakened that morning with right upper quadrant pain, nausea, fever. The patient has colonic cancer? thanks for any help
Well, it is neurology with a chief
Subject: Well, it is neurology with a chief
complaint of unsteadiness of gait. she has a lot of problems, but he says "past medical history: Medical Illnesses: FBS 110. Would you think that would fall under medical illnesses? I'm pretty sure that is what he is saying, though
Chief Complaint
Subject: Chief Complaint
Chief complaint right foot right shin pain. Fell and went to emergency room and had s/l radiax of her ankle,shin, elbow and wrist on the right side. Nothing about her head. :-(
Can you hear Chief Complaint in there? nm
Subject: Can you hear Chief Complaint in there? nm
?? Eye complaints ?? NM
Subject: ?? Eye complaints ?? NM
Do you know the complaints or anything else?
Subject: Do you know the complaints or anything else?
It's a chief complaint. Just put it in quotes and you're done.
Subject: It's a chief complaint. Just put it in quotes and you're done.
(like you have it)
A little crazy is okay if it's in quotes, LOL.
:oD
I type it the way you have it..no complaints so far
Subject: I type it the way you have it..no complaints so far
/
how 'bout GI/GU complaints ??? (nm)
Subject: how 'bout GI/GU complaints ??? (nm)
QA ended up changing it to "right" in chief complaint
Subject: QA ended up changing it to "right" in chief complaint
any more info? Type of exam, chief complaint, anything at all.
Subject: any more info? Type of exam, chief complaint, anything at all.
dd
Chief complaint: s/l Stiler enalrgement with hyperthyroidism. Help???
Subject: Chief complaint: s/l Stiler enalrgement with hyperthyroidism. Help???
vocal physical complaints?
Subject: vocal physical complaints?
He denies any __________ s/l vocal physical complaints except for some fatigue.
The pt has only complained about stress in life and having trouble sleeping. It sounds like vocal or local.
yes its eye complaints, I am off to bed now LOL!!! thanks a mill but I could just not "hear" t
Subject: yes its eye complaints, I am off to bed now LOL!!! thanks a mill but I could just not "hear" that... I have done too much today! n/m
Pt has some internalizing with anxious, depressed, and somatic complaints on the "ocka bock"
Subject: Pt has some internalizing with anxious, depressed, and somatic complaints on the "ocka bock"
Pt has no cardiac, pulmonary complaints, s/l (geology) symptoms, chills, fevers, night sweats etc.
Subject: Pt has no cardiac, pulmonary complaints, s/l (geology) symptoms, chills, fevers, night sweats etc.
You hear trialed all the time. Give 'em what they give you! Can't drive yourself friggin'
Subject: You hear trialed all the time. Give 'em what they give you! Can't drive yourself friggin'
s
Does it give the dosage? Could you give more of the sentence? nm
Subject: Does it give the dosage? Could you give more of the sentence? nm
d
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.
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
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.
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