Yes, it's discharge diagnoses-First
Posted By: Country MT on 2007-11-05
In Reply to: Is that the entire sentence? - MT50
Subject: Yes, it's discharge diagnoses-First
one is enterobacter septicemia due to line infection.
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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.
Do you guys expand AIDS/HIV in admit or discharge diagnoses? Normally I expand COPD, CAD, etc.. sm
Subject: Do you guys expand AIDS/HIV in admit or discharge diagnoses? Normally I expand COPD, CAD, etc.. sm
not sure in this case. Account goes by BOS, not super nitpicky, but I'm wondering what y'all do.
discharge
Subject: discharge
They eyes have discharge bilaterally. (secretions etc)
discharge
Subject: discharge
DISCHARGE DIAGNOSES:
1. biacardia
2. PAS.
3. HD with recent stints.
4. GI bleed, post stint.
discharge med.
Subject: discharge med.
It's just in a list of 19 discharge medications for a guy who has a heel ulcer, renal failure, and is hemodialysis dependent. It's 1 mL p.o. daily.
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.
Preemie discharge
Subject: Preemie discharge
S/l the doc is saying that the baby was fed initially with 22-kilocavity fortified breast milk fortified with NuSure Powder
I can't verify the italic words???? Anyone?
Discharge summary
Subject: Discharge summary
A diagnosis of pneumomediastinum, presumed from catheter placement, was made. An x-ray showed air under the (high , five, thigh) diaphragm. I can't make out what he's saying here, but those are the words it sounds like he's saying. Thanks.
A discharge summary. Thank you
Subject: A discharge summary. Thank you
x
HPs, Consults, Ops and Discharge
Subject: HPs, Consults, Ops and Discharge
Summaries. Is that what you are looking for?
discharge summary
Subject: discharge summary
pt. had cardiac cath
Condition upon discharge: Stable, up and walking without <bike line> complications.
Help please, very hard to understand ESL
discharge summary help
Subject: discharge summary help
Patient is a 46-year-old white female with past medical history significant for motor vehicle accident in 1976 with closed head injury profound mental retardation. Since then *** feedings at home. Started to have diarrhea a week prior to her admission S/L "onfactive" feedings at home any suggestions? thanks so much!!!
is this an OP or a discharge summary or what?
Subject: is this an OP or a discharge summary or what?
it is a discharge summary
Subject: it is a discharge summary
discharge, drainage, or pus IMO nm
Subject: discharge, drainage, or pus IMO nm
x
discharge summary
Subject: discharge summary
could possibly be "discharging Marcus John Doe" i.e. discharge summary?
discharge medications
Subject: discharge medications
When this doctor is dictating the discharge medications it sounds like she is saying Claritin 10 mg 2 PEG once a day. The patient is on PEG tube. Could that be it? Never heard that before.
Not sure. In the discharge meds. PT has
Subject: Not sure. In the discharge meds. PT has
1. Folliculitis.
2. Oral thrush.
3. Congestive heart failure exacerbation.
4. Mastoiditis.
5. Bilateral upper lobe pneumonia. Rule out tuberculosis.
6. HIV/AIDS.
7. Urinary tract infection.
MSIR discharge RX
Subject: MSIR discharge RX
He lists it as one of her current (discharge) meds--go figure. I certainly appreciate the help.
Seems odd to me...
discharge summary
Subject: discharge summary
I am working on a Discharge Summary and in the medication list "folic 12.5 one p.o. b.i.d." is listed. (This is a male pt.) I can't find 12.5 as a dosage available anywhere and also, isn't "folic" as in folic acid usually for women? the diagnoses are.... chf, cellulitis, cardiomyopathy and morbid obesity. I don't see what "folic" would be prescribed for. Any ideas? Thanks, this is driving me crazy!
discharge medication
Subject: discharge medication
I cannot find reference to this medication anywhere, but it sounds like "quinopen 30.5 mg p.o. nightly."
Any ideas?
discharge summary
Subject: discharge summary
I cannot make out this word at all. Any suggestions?
On admission his INR and PTT were both elevated and his hemoglobin and hematocrit were 12.9 and 38.1. We applied pressure dressingand gave 4 units of plasma. We then gave subcutaneous Vitamin K. The bleeding has stopped and we have *bal ized tip* and are sending him home on outpatient dialysis.
discharge summary
Subject: discharge summary
stabilized him?
discharge summary help
Subject: discharge summary help
does this sound right?
On admission his INR and PTT were elevated. His hemoglobin and hematocrit were 13.2 and 37.2. We applied pressure dressing and gave 7 units of fresh frozen plasma with vitamin K. The bleeding has since stopped overnight and we have *dialyzed him* this morning. We are sending him home to continue with his outpatient dialysis schedule.
Discharge status
Subject: Discharge status
Psychiatric discharge summary: Sounds like OPT NSD 'discharge'.
He's probably saying suppuration or discharge of pus from the ear.
Subject: He's probably saying suppuration or discharge of pus from the ear.
^-^
Under discharge medications, the doc says:
Subject: Under discharge medications, the doc says:
Nutritional supplement L shakes b.i.d.
Discharge Summary?
Subject: Discharge Summary?
I'm practicing an assignment for my class and I figured this was the best place to post a question about it.
I know that it's a discharge summary but I'm completely stumped as to the layout. It doesn't seem to fit the layouts in my books so I don't know what I should do. I don't want to get a bad grade on the assignment and would love to get the format right the first time.
If anybody is willing to, I would love to e-mail the file to you so you can possibly give me an idea?
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
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....
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