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Neurological History and Physical

Posted By: Sherlyn on 2009-02-12
In Reply to: what does it sound like, what are you hearing? - nn

Subject: Neurological History and Physical

This is going to probably sound crazy....but it s/l "whirring imbalance."


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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.
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..


maybe admission H&P (history and physical). NM
Subject: maybe admission H&P (history and physical). NM

x
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?
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
HOSPITAL COURSE: Fish?? admission history and physical for details
Subject: HOSPITAL COURSE: Fish?? admission history and physical for details


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


No. That is neurological and this is GI. Thanks.
Subject: No. That is neurological and this is GI. Thanks.


neurological
Subject: neurological

Neurologic:                  Her morrow is symmetric, and her tone is pretty good, although some *** ( “head-like"?)  and some mild *** (subster?) is noted.


Neurological.
Subject: Neurological.

x
neurological scale help
Subject: neurological scale help

This dictator is slurring - here is the sentence and is under Physical Examination


Motor strength, reflexes, gait and sensation are normal.  s/l leven scale zero. 


Diagnosis is gliobastoma multiforme


Any suggestions you have would be most appreciated. 


neurologic or neurological
Subject: neurologic or neurological

doc always says, "from a neurologic standpoint."  Shouldn't it be from a neurological standpoint? 
Neurological: Normal mero?
Subject: Neurological: Normal mero?

The patient is a 17-day-old infant


Neurological:  Normal ___.


Blank s/l normal ma-row perhaps mero?


tnx! any clue on the neurological part?
Subject: tnx! any clue on the neurological part?

Thanks I'm going to listen to it now.


Still in need of help with the neurological


Just gross and nonfocal


She says this in a nanosecond   Thanks again.


s/l ab-sant - neurological term. Thanks nm
Subject: s/l ab-sant - neurological term. Thanks nm


psych neurological insults
Subject: psych neurological insults

His difficulties with language are likely secondary to neurological insults sustained either prenatally and/or resulting from his early deprivation.


 


is insults the correct word?


Would CNS and Neurological exam be the same thing?
Subject: Would CNS and Neurological exam be the same thing?


If neurological or back, maybe facet?
Subject: If neurological or back, maybe facet?

x
neurological testing sign
Subject: neurological testing sign

Fokudo's sign?  Anyone know the correct spelling?  That's what it sounds like phonetically but I can't find it...thanks in advance.
reversible ischemic neurological deficit. See ref.
Subject: reversible ischemic neurological deficit. See ref.

Patients with reversible ischemic neurological deficit (RIND) have ...




Fifteen patients with amaurosis fugax (AF), 37 with hemispheric TIA and 35 with reversible ischemic ...
www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve& db=PubMed&list_uids=3290358&dopt=Abstract - Similar pages


No focal motor or neurological deficits
Subject: No focal motor or neurological deficits

nm
Not sure what you are typing about but there is myasthenia, a neurological dysfunction.
Subject: Not sure what you are typing about but there is myasthenia, a neurological dysfunction.


Neurological test, s/l Belull sign
Subject: Neurological test, s/l Belull sign

Patient with tarsal tunnel. Positive Tinel sign. Negative *s/l Velull or Belull* sign. Says it twice and I'm still clueless. TIA.
Neurological: Moving all 4 extremities and s/l withdrawing to sensation.

Yes, I think that would be part of neurological testing which would be nuchal rigidity.
Subject: Yes, I think that would be part of neurological testing which would be nuchal rigidity.


Maybe sclerae-gray test, that would be more for neurological, but maybe a possibility.
Subject: Maybe sclerae-gray test, that would be more for neurological, but maybe a possibility.


I would say urogenic, unless the patient has other neurological/nerve associated diagnosis i.e. neur
Subject: I would say urogenic, unless the patient has other neurological/nerve associated diagnosis i.e. neurofibromatosis, etc. Just my opinion.


Physical exam
Subject: Physical exam

Height: Six feet.


I'm having trouble remembering all my rules on numbers for stats and such. Is this right? Thank you.


On physical exam.. S/L
Subject: On physical exam.. S/L

or maybe slight disks bilaterally?  I'm drawing a blank... HELP PLEASE and THNX!
Physical exam
Subject: Physical exam

The doctor dictated "no jugular venous distension at 30 degrees" under heart of the physical exam. Shouldn't it go under neck? Thank you.
physical exam-GU
Subject: physical exam-GU

obese 9 year old--phallus difficult to examine as the patient has a large sl-paptha- and has a concealed phallus.


re physical exam
Subject: re physical exam

PHYSICAL EXAMINATION: Significant findings for left lower quadrant tenderness. Blood pressure was 124/78, pulse rate of 96, and respiratory rate of 20. Heart: S1 and S2. Lungs: Clear to auscultation bilaterally.


I would type it this way or at least make it present tense.  On my accounts, I am required to categorize these things. 


PHYSICAL EXAMINATION:


Abdomen:  Significant findings for left lower quadrant tenderness. Vital signs:  Blood pressure 124/78, pulse rate 96, respiratory rate 20. Heart: S1 and S2. Lungs: Clear to auscultation bilaterally.


 


GI physical exam
Subject: GI physical exam

In the physical exam, s/l thenar and epithilial wasting.  He is listing liver disease stigmata and I just blanked out on this.  Help!


This is on physical exam
Subject: This is on physical exam

thanks for trying.
physical exam help
Subject: physical exam help

Physical exam, under Extremities, doctor states ___ pulses throughout.


It sounds like temporis pulses. I know of temporal pulses, but would that be throughout the extremities? Thank you!


Physical exam help?
Subject: Physical exam help?

EXAMINATION:  No costovertebral angle tenderness.  Abdomen has normal active bowel sounds in all quadrants.  It is supple.  Extremely tender left upper quadrant and going down not quite into the groin.  Difficult to check the (s/l sternal) border because of increased tenderness but the spleen may be mildly enlarged but no distinct masses felt.  I am unable to check for rebound or guarding because she is so exquisitely tender with even a very light touch.


 


ASSESSMENT:  Acute left upper quadrant pain.


s/l sternal border?  Any help would be great?


physical exam
Subject: physical exam

Probably just means + (the plus sign), as in positive S1, S2...just means he heard 1st and 2nd heart sounds clearly (as opposed to sounds to distant or obscured by extra sounds). If something was dictated before that, I would put a comma and use the plus sign, i.e., PREVIOUS TEXT, + S1, S2. If nothing precedes it, I would type positive S1, S2. If account wants verbatim, give it to them.
It was just a physical exam, and I don't know
Subject: It was just a physical exam, and I don't know

However, I do think it was "cervical or" inguinal adenopathy.  This guy is a real mush mouth.  THANK YOU ALL SO MUCH FOR YOUR HELP!  I am sorry I wasn't clear enough earlier in my first message.  I really do appreciate your help.  This is a great board to come to--everyone is so knowledgeable! 
Need help with physical exam please
Subject: Need help with physical exam please

I am wondering if, in the last sentence, where "drop can arc" is dictated . . . would she be referring to three tests/maneuvers such as Drop Arm, Empty Can, and an Arc test, or is it correct as is?


She has excellent range of motion of the shoulder.  Good grip strength.  Distal pulses and sensation are intact.  She can do a full drop can arc.


TIA


Please help with physical exam (sm)
Subject: Please help with physical exam (sm)

Over the central aspect of the wound there is s/l shelfing of the superior aspect of the skin 
This is in the physical examination. Thanx for trying
Subject: This is in the physical examination. Thanx for trying


Physical examination... sm
Subject: Physical examination... sm

Examination of female patient. 


Musculoskeletal:  No (s/l) keps, pains, or pedal edema...


Genitourinary:  No (s/l) [cussforteeballing or maybe cusp  or teeballing], or area tenderness.


Thanks in advance!


Physical exam help.....
Subject: Physical exam help.....

The calf was nontender. The lower leg was s/l nonpeeing.  Nonpitting? Not pitting? Help, please!
Physical Examination
Subject: Physical Examination

Happy Monday everyone!  Hope you all had a great weekend!  I'm doing a report and wondering if any of you can point me in the right direction!


"There is good capillary refill and s/l preson to cultures over both lower extremities."  Any thoughts?  Any good physical examination websites?


Physical exam help
Subject: Physical exam help

HEENT: It sounds like she is saying 'TO' mucosa pink and moist.  Or TL mucosa.


Any ideas?


Under physical exam...
Subject: Under physical exam...

I know this is probably really easy...BUT, the doc is rattling it off and he's new to me...


ABDOMEN:  Soft, nontender, nondistended, ___ to bowel sounds. 


 


Is it normal to bowel sounds?


 


Thanks....


yes, physical therapists
Subject: yes, physical therapists