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Neurosurgical note. Back pain. nm

Posted By: charlie on 2007-12-14
In Reply to: What does the patient have as a diagnosis? - MT50

Subject: Neurosurgical note. Back pain. nm

xx


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back pain, given dura-back if needed for spasm. nm
Subject: back pain, given dura-back if needed for spasm. nm

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Subject: Drug name - s/l amarek, for back pain and neck pain

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Subject: nEck pain and back pain

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Subject: Pain clinic note - sm

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CC: Back pain
Subject: CC: Back pain

Thanks for taking the time on this . . .

While the CC: is back pain, the subjective describes . . .

This is an 81-year-old female who, for the last month, has had some intermittent pain next to her right shoulder blade. She is right-handed, and she has been doing a lot of gardening and weed whacking. It does not bother her much during the day, but at night when she sits, and then when she is lying in bed at night, she feels what she describes as a muscle spasm with twinges. She also at times has some diffuse pain from her elbow radiating up to her neck when she “overdoes it”, but that has been going on for quite some time, and she does not feel like that has recently changed.
it is just that she has low back pain..sm
Subject: it is just that she has low back pain..sm

Since that time, she has had increasing low back pain.  She did do the s/l-Ergosco-  method.  She had no relief.  She did have an injection to her SI joint region, which had a terrible reaction.  Since that time, she has had low back pain. 
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Subject: Pt with low back pain sm

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Back pain
Subject: Back pain

The patient has chronic back pain with severe s/l spurring and osteoarthritis.   


TIA


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discogenic back pain
Subject: discogenic back pain


Patient has low back pain
Subject: Patient has low back pain

She has normal lumbar lordosis with tenderness at right PSI? and sacral sciatic notch?
s/l NAMBUTONE for back pain
Subject: s/l NAMBUTONE for back pain

He is also on _____ 500 mg twice a day as needed for severe back pain.
Amryx for back pain? nm
Subject: Amryx for back pain? nm


Patient with low back pain. She is on ....sm
Subject: Patient with low back pain. She is on ....sm

She is on s/l oral phenadrin/fenadrine (may be saying orphenadrine) and Cataflam for this.
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Subject: s/l peributtock back pain??


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Subject: Patient in mid back pain

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Subject: S/L-ergosco method (for back pain)?


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Subject: medication - s/l somatalez for back pain? TIA


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Subject: I'd say positive for musculoskeletal back pain.


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Subject: Dx of low back or sciatic pain? Maybe Laseague's? nm

s
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Subject: s/l "conjoined" back and neck pain.

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Subject: lower back pain due to s/l fitskating

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Subject: Pt's back pain is thought to be from her S/L "estalon" radiculopathy. TIA nm


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Subject: trigger point injection for back pain

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Subject: patient with back pain, s/l policing eight paucet tumor??? nm

nm
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Subject: patient with back pain. s/l lichen does help but it makes him drowsy. Thanks. nm

nm
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nm
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nm
Lower back pain" is probably the most common use in AE - though "lumbalgia" is a real word
Subject: Lower back pain" is probably the most common use in AE - though "lumbalgia" is a real word in English medicine...it's rarely used.

.
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Subject: sl/l positive bordel sign (from flexing neck and causes back pain)


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Subject: s/l Tiazine 2 mg at night. Patient with nack and back pain history

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Subject: Oh, now she is adding she forgot to mention insomnia and low back pain (scream!) NM

nm
Patient states the pain is located in the posterior lower back or **box** region. This is a new PA
Subject: Patient states the pain is located in the posterior lower back or **box** region. This is a new PA

student dictating but I have never heard this term used. Any help would be appreciated.  Thxs
Pt has low back pain. Patient exhibits no signs of "caudo-aquino syndrom"? I have no clue!!
Subject: Pt has low back pain. Patient exhibits no signs of "caudo-aquino syndrom"? I have no clue!! nm


Need neurosurgical word help, PLEASE
Subject: Need neurosurgical word help, PLEASE

Doc doing left parietal craniotomy with gross total resection using MRI brain s/l laboratory tactical navigation?  QA blanked this in an earlier dictation, but I did not want to blank it again if I can help it.
Neurosurgical report: s/l *grid wrapping* resection?
Subject: Neurosurgical report: s/l *grid wrapping* resection?

x

Psych note Axis III s/l VPS and neuropathy. No health history in the note. Only meds listed psych
Subject: Psych note Axis III s/l VPS and neuropathy. No health history in the note. Only meds listed psych


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Subject: possibly occult sciatic pain ( pain hidden/concealed/not manifest) ? nm


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Subject: if it's in the spine, it could be "discogenic" pain versus "facet"-related pain


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Subject: could be TKA-total knee amputation. pain could be "ghost" pain --nm

///
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noteworthy; note worthy; note-worthy
Subject: noteworthy; note worthy; note-worthy

Just wondering if there is any general rule about transcribing noteworthy.


Also, status post; status-post.


 


Thank you.


 


Op note ref. SM
Subject: Op note ref. SM

http://www.mtdesk.com/frame.php?frame=resources
ER note
Subject: ER note

? pulse ox 99% on room air which is normal per ______ interpretation.


 


ER note thanks
Subject: ER note thanks

Thanks, practically sure it was per the ER physician reading. So, will be ready for next time!

At the end of OP note, he says
Subject: At the end of OP note, he says

what sounds like "mick" instrument and needle count. 


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OP note help please sm...
Subject: OP note help please sm...

mild (s/l-fibulations-) with changes on the surface of the condyle