Pt advised to increase her oral intake of fluids based on S/L ?leuk est? was trace. ?UNC&S? ordered
Posted By: marie on 2009-04-23
In Reply to:
Subject: Pt advised to increase her oral intake of fluids based on S/L ?leuk est? was trace. ?UNC&S? ordered
NM
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He will increase his fluid intake by a s/l **factor 3**. Pt has acute viral syndrome. TIA
Subject: He will increase his fluid intake by a s/l **factor 3**. Pt has acute viral syndrome. TIA
leuk esterase? nm
Subject: leuk esterase? nm
nm
Could it be "incision"? Be advised, this is just a guess...
Subject: Could it be "incision"? Be advised, this is just a guess...
s/l theig intake??
Subject: s/l theig intake??
I&O or intake and output. nm
Subject: I&O or intake and output. nm
.
yep intake and output
Subject: yep intake and output
adminoshortal intake? Gastro.
Subject: adminoshortal intake? Gastro.
His pre albumin is low at 5 mg/dL, and as such, this again may reflect an underlying hepatic dysfunction. Although, there may also be a component of __________ s/l adminoshortal intake.
Intake and output (of liquids)
Subject: Intake and output (of liquids)
(nm)
ൠ-hour intake" maybe? NM
Subject: ൠ-hour intake" maybe? NM
PT/NOT ordered
Subject: PT/NOT ordered
For a patient who had back surgery and then came back with severe leg spasms. She was treated with IV Ancef, IV fluids at 80 and IM Toradol every 6 hours. She was on a PCA, which was later stopped and changed to oral medication. She received IV Decadron x 1 for the spasms, IV Pepcid x 1 and PT/NOT was ordered.
What would the PT/NOT stand for?
nevermind, it was 'dig' intake. He's taking Digoxin.
Subject: nevermind, it was 'dig' intake. He's taking Digoxin.
.
s/l Lu-kid-si-des-trace
Subject: s/l Lu-kid-si-des-trace
yes if it was ordered stat
Subject: yes if it was ordered stat
The UA was not obatined per s/l CAP, which was ordered.
Subject: The UA was not obatined per s/l CAP, which was ordered.
Have not heard of this one. Suggestions?
trace dependent
Subject: trace dependent
Yes, but without the dash. Trace means "slightly"
on UA says trace of s/l monoleukocytes? and
Subject: on UA says trace of s/l monoleukocytes? and
calcium oxalate? crystals.
Regarding tests ordered for cancer...sm
Subject: Regarding tests ordered for cancer...sm
I talked with the patient and I will order the CA-125, CEA and ____ (s/l Alasa) to rule out any problems.
Pt worried about having cancer and wanted tests ordered.
TIA
Regarding tests ordered for cancer...sm
Subject: Regarding tests ordered for cancer...sm
PSA???
male/female?
Maybe pending as in ordered, but not yet performed?
Subject: Maybe pending as in ordered, but not yet performed?
increase in pancreas?
In recent, increase in pancreas has responded with some improvement. As such, I would suggest that his diarrhea and difficulties are most consistent with pancreatic insufficiency.
Helpppp!
INDICATION: Increase in ? (s/l VAR)
Subject: INDICATION: Increase in ? (s/l VAR)
Dialysis patient with stenosis in access graft. help me help me please
yes, they say bump, as in increase
Subject: yes, they say bump, as in increase
nm
10-degree increase or 10 degree increase? TIA nm
Subject: 10-degree increase or 10 degree increase? TIA nm
Maybe it's "encouraged to increase..."
Subject: Maybe it's "encouraged to increase..."
nm
Blood trace LICE
Subject: Blood trace LICE
He's giving the specifics about a urine dip.
UA trace slice? blood ?
Subject: UA trace slice? blood ?
trace leukocytes 2+ blood?
Subject: trace leukocytes 2+ blood?
UA positive for "trace leukocytes two plus blood"
how should i type this?
s/l trace lysed blood
Subject: s/l trace lysed blood
On her urinalysis, she had s/l trace lysed blood.
Is this correct?
Yup, you got it, know of trace-lysed blood in UA....nm
Subject: Yup, you got it, know of trace-lysed blood in UA....nm
nm
is there a lactic acid dyestat? says it was ordered and was 1.54
Subject: is there a lactic acid dyestat? says it was ordered and was 1.54
lupus screen with ANA and s/l antha? DNA was ordered
Subject: lupus screen with ANA and s/l antha? DNA was ordered
s/l night pride and Esmolol were ordered nm
Subject: s/l night pride and Esmolol were ordered nm
nm
Pt with restless leg syndrome. Lab work ordered. sm
Subject: Pt with restless leg syndrome. Lab work ordered. sm
Serum protein electrophoresis normal, ANA negative, _______ ??? vasculity is negative.
iron repletion, "once a day" as ordered?
Subject: iron repletion, "once a day" as ordered?
S/l * pet megate * to increase appetite. TIA!
Subject: S/l * pet megate * to increase appetite. TIA!
? blood trace, leukocyte esterase - nm
Subject: ? blood trace, leukocyte esterase - nm
x
says trace edema up to the s/l mid-pubic line?
Subject: says trace edema up to the s/l mid-pubic line?
Labs: s/l trace morpo cells. nm
Subject: Labs: s/l trace morpo cells. nm
Ordered for albuterol inhaler "H F A" 2 puffs q.4 hours prn. nm
Subject: Ordered for albuterol inhaler "H F A" 2 puffs q.4 hours prn. nm
could it be titrate (slowly decrease or increase)
Subject: could it be titrate (slowly decrease or increase)
Could the patient have been slowly titrated off of the drug/weaned off
Kim, if you think a mentor would help increase your line count,
Subject: Kim, if you think a mentor would help increase your line count,
.
s/l-EOA-) demonstrated he had 2+ to the front, trace to the back, 1 to the bottom.
Subject: s/l-EOA-) demonstrated he had 2+ to the front, trace to the back, 1 to the bottom.
nm
Maybe found to have changed, more dilation, increase in station, etc. nm
Subject: Maybe found to have changed, more dilation, increase in station, etc. nm
s
After this increase in Lithium the patient seemed to have less effective lability.
Subject: After this increase in Lithium the patient seemed to have less effective lability.
Could that be correct? This is in a discharge summary.
There was increase in carrying angle and *recruvardum* of the knees. nm Thanks
Subject: There was increase in carrying angle and *recruvardum* of the knees. nm Thanks
nm
labs showed trace nitrates and s/l large blood thank you
Subject: labs showed trace nitrates and s/l large blood thank you
IV fluids..?
Subject: IV fluids..?
z
IV fluids -- sm
Subject: IV fluids -- sm
How would you write the following:
1. "placed on D5 and a 1/2-normal saline at maintenance and a quarter."
2. and then later she says: "IV fluids, D5 and a 1/2 with 20 of KCl per liter"
These fractions confuse me. I assume the 1/2 goes with the normal saline in the first instance and maybe the "normal saline" is implied in the second instance, but how do I express these fractions? Did I do the "quarter" right in the first instance?
Fluids
Subject: Fluids
How about intravenous fluids were or was administered as in normal saline?
Prostate cancer: 1. This will be the 3rd serial PSA. S/L ?S1? has revealed a slight increase
Subject: Prostate cancer: 1. This will be the 3rd serial PSA. S/L ?S1? has revealed a slight increase
and therefore starting IV fluids? nm
Subject: and therefore starting IV fluids? nm
x
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