maybe admission H&P (history and physical). NM
Posted By: gamt on 2008-10-09
In Reply to: refer to the admission agency?? for details - Angela
Subject: maybe admission H&P (history and physical). NM
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HOSPITAL COURSE: Fish?? admission history and physical for details
Subject: HOSPITAL COURSE: Fish?? admission history and physical for details
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..
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?
Neurological History and Physical
Subject: Neurological History and Physical
This is going to probably sound crazy....but it s/l "whirring imbalance."
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
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.
BVP was 8/8...on obstetrics admission...sm
Subject: BVP was 8/8...on obstetrics admission...sm
Is BVP correct, I can't find this abbreviation anywhere??? Thanks!
ER admission note help please
Subject: ER admission note help please
The patient had diminished sphincter tone. The patient did receive cow littix prior to the exam.
This patient had been in a car accident, she was intubated, combative, and had 2 broken legs. Any ideas?
s/l MOD was called for admission. sm
Subject: s/l MOD was called for admission. sm
the patient was hemodynamically stable, s/l MOD was called for admission secondary to GI bleed. the patient was transferred to the s/l MOD service ???
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
its in a list of meds on admission, no dosage
Subject: its in a list of meds on admission, no dosage
pt has diabetes, asthma, migraines, gastroparesis
refer to the admission agency?? for details
Subject: refer to the admission agency?? for details
Do admission orders need to be expanded? eg. C&S, CBC, STAT
Subject: Do admission orders need to be expanded? eg. C&S, CBC, STAT
Thanks for your help.
Outpatient hold admission versus inpatient
Subject: Outpatient hold admission versus inpatient
Please read this with a little grain of salt, since I don't have enough info to be sure in this case, but this has happened to me before. Most hospitals and most insurance companies have a "24 hour hold bed" policy of some sort. The patient is considered an outpatient, (and charged the lesser "hold bed" charge) even though admitted to the hospital, for the first 24 hours, or 23 hours and 59 minutes. Maybe this doc is saying that the EKG was done at that time in the admission - hour #23, minute #____. Again, use caution, and if this is the case, the doctor sure SHOULD have said "at 23 hours X minutes after" admission or clarified it somehow. But this is just food for thought, since I have had docs dictate using the number of hours since the patient was admitted, though I'm happy to say they the docs always made it known that that's the way they were counting down the hold bed time.
just guessing, could it be admission and disch (A&D)so pt can get hospice care afterwards?
Subject: just guessing, could it be admission and disch (A&D)so pt can get hospice care afterwards?
tisbar injection? located in a list of meds on admission
Subject: tisbar injection? located in a list of meds on admission
Hi, Amy, PORT score is for pneumonia severity on admission, predicted outcome.....nm
Subject: Hi, Amy, PORT score is for pneumonia severity on admission, predicted outcome.....nm
nm
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
What do you mean by PTs? Physical therapists?
Subject: What do you mean by PTs? Physical therapists?
.
s/l physical examination
Subject: s/l physical examination
s/l chaos lesions (Skin, no evidence of ___ lesions)
Physical Exam
Subject: Physical Exam
s/l duprichen contractions of both hands
Physical exam
Subject: Physical exam
New acct. Dr. states: Lungs were congested with s/l "rasmus" Any ideas? Thanks for the help.
physical exam
Subject: physical exam
thanks ss. Unfortunately, not rales or rhonchi. He dictates that quite often and it sounds nothing like it! I might be stuck on this one.
physical exam help
Subject: physical exam help
Patient converses in appropriate (s/l fashion _____ only). She is s/l confident imminently or eminently. Does this make sense??
physical exam help
Subject: physical exam help
He starts off Temperature 98, heart rate 73, then goes on to just list numbers like 20, 46/70, 91%. Do some doctors just list the numbers without the words. I am assuming it is the respirations and BP and maybe oxygen sat.
physical exam help
Subject: physical exam help
Examination of the head and neck reveals no s/l "antognic kerio" posture.
physical exam help
Subject: physical exam help
Antalgic carrying posture?
physical exam help
Subject: physical exam help
patient is in for left shoulder pain.
PE: No focal deficits are appreciated with neurovascular exam. s/l favored patrick's is equivocal.
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