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agree, leave as dictated, those are very elevated liver function tests. nm

Posted By: anon on 2008-05-09
In Reply to: Doctor dictates ALT 1413 and AST 681? Should it be 14.31 and 6.81? TIA! - ak

Subject: agree, leave as dictated, those are very elevated liver function tests. nm

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he had liver function tests in your....
Subject: he had liver function tests in your....

office which continued to show a mild elevation of his GGPT and CPK.


Is the GGPT correct?  Thank you


Probably "LFTs" - liver function tests. .nm
Subject: Probably "LFTs" - liver function tests. .nm

.
bilinogen? re: liver function tests more
Subject: bilinogen? re: liver function tests more

s/l U bilinogen and C bilinogen. There are some hits on google, but I want to make sure I type them accurately. Thanks!
could it be LFTs (liver function tests)?
Subject: could it be LFTs (liver function tests)?

xx
LFT fine as in liver function tests?
Subject: LFT fine as in liver function tests?

I'm confused by your sentence . ... could you provide the sentence with your S/L in it?
maybe "LFTs" (liver function tests)
Subject: maybe "LFTs" (liver function tests)


Do you hear "function" as in liver function tests?
Subject: Do you hear "function" as in liver function tests?


can't you just leave it abbreviated, or do you have to spell it out. I would leave as dictated.
Subject: can't you just leave it abbreviated, or do you have to spell it out. I would leave as dictated.


Maybe elevated liver enzyme(s)? nm
Subject: Maybe elevated liver enzyme(s)? nm

s
If it was dictated like that & you can leave abbrvns in, then leave it
Subject: If it was dictated like that & you can leave abbrvns in, then leave it

s
elevated liver functions, previous cholecystectomy.
Subject: elevated liver functions, previous cholecystectomy.

CT showed (S/L) ''normobilia''??  (have looked everywhere and cannot find--thanks for any help.)


By the data numbers, could be SGPT and SGOT, liver function studies????......nm
Subject: By the data numbers, could be SGPT and SGOT, liver function studies????......nm

nm
Leave as dictated...sm
Subject: Leave as dictated...sm

I've seen them that high before. You might see transaminitis in the diagnosis or something like that.
I would leave it as dictated,
Subject: I would leave it as dictated,

x
Leave as dictated.
Subject: Leave as dictated.

x
I would leave it the way dictated unless
Subject: I would leave it the way dictated unless

you have been told to change it. A lot of them use K instead of potassium. It means I am pretty sure normal saline with 20 mEq of potassium at 100 mL per hour, but you are taking a leap typing it out; where I work we don't expand things like that, we leave it as dictated.
i would leave as dictated
Subject: i would leave as dictated


I would be correct to leave it as dictated because..sm
Subject: I would be correct to leave it as dictated because..sm

vas simply means vessel. Dorland's defines it as follows: a vessel: any canal for carrying a fluid; a general term for such channels, especially those carrying blood, lymph, or spermatozoa. When one hears vasectomy, one usually automatically thinks in terms of the vas deferens in the male, but that is not always necessarily the case.
my view is leave it as dictated.
Subject: my view is leave it as dictated.


IMHO I would leave as dictated
Subject: IMHO I would leave as dictated

many doc, at least mine, have used generic and then brand name when dictating within the same note.  That has been my experience.
Doc says liver 'mets', which I believe means metastasis, and is ok to leave as mets? nm
Subject: Doc says liver 'mets', which I believe means metastasis, and is ok to leave as mets? nm

,,
I would leave it as dictated, esp if verbatim account. nm
Subject: I would leave it as dictated, esp if verbatim account. nm

x
40-some-odd stitches is fine. Leave as dictated, but you need hyphens.
Subject: 40-some-odd stitches is fine. Leave as dictated, but you need hyphens.


Brand name is ACTOplus met - so guess should leave as dictated?
Subject: Brand name is ACTOplus met - so guess should leave as dictated?


I think what doc is intending is that pt had a vasovagal episode, so IMO I would leave as dictated.
Subject: I think what doc is intending is that pt had a vasovagal episode, so IMO I would leave as dictated. nm

.
Then I would agree as stated below with higher cortical function
Subject: Then I would agree as stated below with higher cortical function


I agree - Symptoms of early or mild dehydration include: elevated BUN
Subject: I agree - Symptoms of early or mild dehydration include: elevated BUN


agree - leave as is
Subject: agree - leave as is


Yes - agree leave off the "s" - thats what I was told too
Subject: Yes - agree leave off the "s" - thats what I was told too


I agree with Keri. If "systolic" is dictated then I
Subject: I agree with Keri. If "systolic" is dictated then I


I agree here. Even when I know what the word will be, I leave a blank.
Subject: I agree here. Even when I know what the word will be, I leave a blank.

dd
elevated s/l c-ract? protein of 1.8 and a slight elevated glucose at 108.
Subject: elevated s/l c-ract? protein of 1.8 and a slight elevated glucose at 108.

This one Dr. can be very difficult to understand. Please help! :)
Elevated ?GDT?...later says elevated SGOT and SGPT. What is GDT??
Subject: Elevated ?GDT?...later says elevated SGOT and SGPT. What is GDT??


Just as you have it if that's what was dictated. If "one fourth" was dictated, sm
Subject: Just as you have it if that's what was dictated. If "one fourth" was dictated, sm

it would be 1/4 pill or one fourth of a pill.


Def an 'N' dictated - Diabetes unsure of - no PMH dictated
Subject: Def an 'N' dictated - Diabetes unsure of - no PMH dictated


We type it as dictated, if dictated
Subject: We type it as dictated, if dictated

c spine we transcribe C-spine, if cervical then cervical spine.
elevated s/l elk fas
Subject: elevated s/l elk fas

...elevated LDH, elevated s/l elk fas, elevated LFTs...


Any input would be appreciated.


with an elevated BUN (sm)
Subject: with an elevated BUN (sm)

I'm wondering if he's saying prerenal azotemia and not leukemia. Is that possible?
Elevated LFT
Subject: Elevated LFT

I am struggling with identifying some lab tests that are mentioned in a report- the end of the report states, "

 repeat liver function tests, consider TSH, ANA, serum plasma and PTA.  I know I do not have the last two right- but it sounds like serubo plasman and PTA?  Any ideas? 


LB or LD function
Subject: LB or LD function

The doc lists a number of pt. problems and throws in "normal LB or LD function."  Which would it be LB or LD?  thanks!
elevated troponin
Subject: elevated troponin

The elderly patient had elevated troponin and mental status change.  S/L dictator is saying patient was treated for possible "enstemmie" ???  (He said this twice during discharge summary and both times sounded like "enstemmie"??  Thanks for any help.


 


listened again - why would it be elevated?
Subject: listened again - why would it be elevated?


Re: Elevated bili and low HDL ? ..sm
Subject: Re: Elevated bili and low HDL ? ..sm

He has a history of (s/l Jilldira)______ disease, which is the elevated bilirubin and slightly low HDL.  


 


 


says pt has elevated PSA on s/l Plueroscar?
Subject: says pt has elevated PSA on s/l Plueroscar?


NSTEMI for non-ST elevated MI. nm
Subject: NSTEMI for non-ST elevated MI. nm

nm
Normal 10-66 but could be elevated in CKD.nm
Subject: Normal 10-66 but could be elevated in CKD.nm

nm
They also say the tourniquet was elevated
Subject: They also say the tourniquet was elevated


Ptx has elevated BUN and creatinine.....
Subject: Ptx has elevated BUN and creatinine.....

xx
Pt with elevated BUN and creatinine.....
Subject: Pt with elevated BUN and creatinine.....

nm
Pt with elevated BUN and creatinine....
Subject: Pt with elevated BUN and creatinine....

nm
renal function
Subject: renal function

Doc says....


Her echo  showed a severely compromised ventricle as well as severely compromised renal function.


Can renal function be seen on an echocardiogram?