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please help! Past medical history includes s/l spilling? cardiac enzymes. Thanks!

Posted By: tealight on 2008-04-09
In Reply to:

Subject: please help! Past medical history includes s/l spilling? cardiac enzymes. Thanks!




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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. 
Past medical history
Subject: Past medical history

Under history of present illness he has that the patient has a history of IV drug abuse.


Past medical history: IODINE ALLERGY WITH SHORTNESS OF BREATH AND HIVES FOLLOWING IV SPREE THREE YEARS PTA.


Could that be what he's saying? Thanks.


under past medical history...
Subject: under past medical history...


Past medical history
Subject: Past medical history

Surgeries: Small bowel obstruction, THA/BA for cholecystectomy.


I'm not sure if he said BA or BA with another letter on the end. Help! Thanks.


past medical history
Subject: past medical history

This is the only information I have and it sounds like **Ba-dex Ex-lo-dian** under past medical history. Thanks for any suggestions!
Past medical history
Subject: Past medical history

Past medical history: Positive for arthritis, asthma, and "vic-in-plant-ous". She also has a dystonia that has been longstanding. This is on an ortho note, so this is the only thing said about this. Thanks for checking it out!
Past medical history help
Subject: Past medical history help

Under past medical history he states "Basal cell **and blue** carcinoma.


My apologies if this is something simple, but this is what it sounds like and I am not finding anything to point me in the right direction. Thanks!


past medical history?
Subject: past medical history?

If it is past medical history, could he be saying something like history of Legg's disease. Try looking at it that way.
What is in Past Medical History
Subject: What is in Past Medical History

That could help determine what the drug is for.
What is the past medical history? - nm
Subject: What is the past medical history? - nm


what's in the past medical history?
Subject: what's in the past medical history?


past medical history of thrash?
Subject: past medical history of thrash?

The patient is a 3 1/2 month old with a past medical history of ____.  S/L thrash
CARDIO Past medical history
Subject: CARDIO Past medical history

CABG 1998 and s/l CVAA SPVD status post right lower extremity amputation and hypertension.


Thank you


Deborah


In past medical history - the only thing
Subject: In past medical history - the only thing

listed is s/l Berjay's disease.


I've Googled every spelling I can think of and have come up blank 


He only mentioned it once in the past medical history...(sm)
Subject: He only mentioned it once in the past medical history...(sm)

Didn't even mention it again in the final diagnoses with the rest.  I think the poster below found it.  Thanks.
the doctor said that only in the past medical history :(
Subject: the doctor said that only in the past medical history :(


H&P heading help again.. Past Medical History
Subject: H&P heading help again.. Past Medical History

dictator says: Past medical history for hypertension. Past surgical history is arthroscopy of his right knee. Allergies are to Demerol and Penicillin. Do I put Headings over each one and keep the exact dictation like this:  PAST MEDICAL HISTORY (type under this title) Past medical history for hypertension OR just Hypertension. Other part of my question.  ROS subheadings: dictator says this: Cardiovascular has a history of hypertension.  do I need to put a colon in there and cap the Has? or leave as I have typed in bold? Do I add a subheading of GI/GU: for this sentence - No GI/GU problems. Does this sentence also need colon?  Musculoskeletal I stated in the HPI. No neurological or hematological discorders.  Thanks for any help, sorry if these seem like dumb questions...but I really need the help.


Past medical history s/l ben rr ma gene
Subject: Past medical history s/l ben rr ma gene

Under past medical history, dictator is saying s/l ben r r ma gene.  Or banner arma gene.  ??? 


Patient also has hypertension, dyslipidemia, asymptomatic stroke, sleep apnea, renal insufficiency.  Any ideas?


No clues in the past medical history? n/m
Subject: No clues in the past medical history? n/m

X
afib dictated as past medical history...
Subject: afib dictated as past medical history...

how do you write that out?


atrial fibrillation, afib? 


Too early for me right now.


Can you give the diagnosis or past medical history.
Subject: Can you give the diagnosis or past medical history.

Do you anything that this medication might be for?
Past medical history: Significant for s/l uterine CA.
Subject: Past medical history: Significant for s/l uterine CA.


doc is dictating past medical history and said exactly what was quoted with nothing else regarding i
Subject: doc is dictating past medical history and said exactly what was quoted with nothing else regarding it. nm

Thanks.
Need help with past medical history list s/l - please see message
Subject: Need help with past medical history list s/l - please see message

Bipolar disorder, dyslipidemia, hypertension, type 2 diabetes, s/l pax dee a tosis (?ptosis).

That what it sounds like!! Thanks for any help!
Past Medical History: Significiant, only as noted...??
Subject: Past Medical History: Significiant, only as noted...??

JMO
Past medical history: Bilateral pleural effusion, then s/l
Subject: Past medical history: Bilateral pleural effusion, then s/l

chronic stasis - period.  Would that be right?
Child with shoulder injury with past medical history of
Subject: Child with shoulder injury with past medical history of

s/l spheriocytoma. The closest I found was esthesioneurocytoma, but he is not saying "neuro" in between, and that he takes folic acid. Any ideas? Unfortunately, the doc never makes mention again about this diagnosis anywhere on the report.
in list of past medical history....hypothyroidism secondary to sm
Subject: in list of past medical history....hypothyroidism secondary to sm

s/l "dis-turds" versus anemia.  The doc is is seriously mumbling but I think he says something like this.


foley site in the s/l avera? this is listed in past medical history
Subject: foley site in the s/l avera? this is listed in past medical history


Past medical history significant for s/l wrekal sinus excision
Subject: Past medical history significant for s/l wrekal sinus excision


Maybe serial cardiac enzymes or just serial enzymes? Are they ruling out an MI? nm
Subject: Maybe serial cardiac enzymes or just serial enzymes? Are they ruling out an MI? nm

s
Cardiac enzymes
Subject: Cardiac enzymes

Acute MI rulilng out with s/l zero cardiac enzymes.  Could this be correct or do you think he is saying serum and it just sounds like zero?  TIA
cardiac enzymes
Subject: cardiac enzymes

It is "serial" cardiac enzymes.
cardiac enzymes
Subject: cardiac enzymes

I have a format question.  Not sure how to punctuate this sentence. This is listed under "Laboratory Data"


Cardiac enzymes CPK were high, but his MBs were normal. 


Would it be correct like it is, or would it be "Cardiac enzymes: CPKs were high, but his MBs were normal."


I also don't know if I should edit CPK to CPKs or leave it as is.


cardiac enzymes
Subject: cardiac enzymes

thanks, that's how I had it but wasn't sure. And wasn't sure about editing to CPKs or leaving it as CPK (without the "s"). Thanks again.
cycling cardiac enzymes?
Subject: cycling cardiac enzymes?


This may be all related to hypoxia since the patient was essentially unresponsive with airway obstruction on EMS arrival; however, cannot rule out other causes of syncope or a seizure. As such, we will go ahead s/l cycle his cardiac enzymes and check an echocardiogram. 


Does cycle sound right?


Does cardiac enzymes fit your situation?
Subject: Does cardiac enzymes fit your situation?

Might be helpful to know the patient's diagnoses to know what the right answer is.
is it serial cardiac enzymes?
Subject: is it serial cardiac enzymes?


Cardiac patient's list of medications includes
Subject: Cardiac patient's list of medications includes

s/l Diameril.  Help?
Or 'serial cardiac enzymes...'? Ruling out for an MI? More context would help! nm
Subject: Or 'serial cardiac enzymes...'? Ruling out for an MI? More context would help! nm

s
Here is a good link to all the cardiac enzymes. Look thru here and listen again and you may be able
Subject: Here is a good link to all the cardiac enzymes. Look thru here and listen again and you may be able

to figure out what he/she is saying.

http://classes.kumc.edu/son/nurs420/unit5/cardiac_enzymes.htm
Personally... Cardiac enzymes: CPK were high, but his MBs were normal.
Subject: Personally... Cardiac enzymes: CPK were high, but his MBs were normal.


how about typing Past Medical History heading and then typing what he says under the heading nm
Subject: how about typing Past Medical History heading and then typing what he says under the heading nm

xx
Might be how they're referring to the first set of the 3 sets of cardiac enzymes to rule out
Subject: Might be how they're referring to the first set of the 3 sets of cardiac enzymes to rule out

s
Past medial history
Subject: Past medial history

The patient is admitted from the clinic where CT visuals showed recurrence of the disease.


I'm not sure if that's what the doctor is saying. Does it sound right?


Past social history
Subject: Past social history

When typing amount of cigarettes, is three-quarters a pack a day correct or would you use numerals?


B&B in past surgical history
Subject: B&B in past surgical history

Anyone know what that could be?
Would that be under past surgical history though as he says it is? nm
Subject: Would that be under past surgical history though as he says it is? nm

nm
HTN dictated under past history...
Subject: HTN dictated under past history...

Is it best to leave it as dictated or write out hypertension?  Account is not verbatim.


I'm thinking maybe past history? nm
Subject: I'm thinking maybe past history? nm


past surgical history
Subject: past surgical history

She has had repair of cataracts s/l "in aretnas". I couldn't hear retina. Anyone?