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saw the patient, and the impression was s/l brass sediment impaction?(

Posted By: mz on 2007-10-19
In Reply to: sentence please? - MT50

Subject: saw the patient, and the impression was s/l brass sediment impaction?(




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s/l brass sediment impaction?? pt. has sinus problems
Subject: s/l brass sediment impaction?? pt. has sinus problems


'Boney' impaction or 'bony impaction'?
Subject: 'Boney' impaction or 'bony impaction'?

This is in reference to a dental report.
s/l sediment unit...sm
Subject: s/l sediment unit...sm

The HCG beta ____ s/l (sediment )unit was normal at less than 5. 


This was part of testing done for a tumor. 


TIA 


 


no don't think so, I really hear a "Br, more like Braus instead of brass"
Subject: no don't think so, I really hear a "Br, more like Braus instead of brass"


septal impaction
Subject: septal impaction

not sure what the "brass" would be though.
How about gross impaction?
Subject: How about gross impaction?

That would make sense.


wild guess - "fresh cerumen" impaction?
Subject: wild guess - "fresh cerumen" impaction?


cerumen impaction is it! But can there be any other word in front of it instead of fresh?
Subject: cerumen impaction is it! But can there be any other word in front of it instead of fresh?


ok - I hear impaction now but not sure about gross it still s/l govis/gauvis
Subject: ok - I hear impaction now but not sure about gross it still s/l govis/gauvis


Help with IMPRESSION
Subject: Help with IMPRESSION

Should this be dictated like this?


1.  Hyponatremia, rule out subdural hematoma. 


OR


1. Hyponatremia.


2.  Rule out subdural hematoma.


impression
Subject: impression

type it with a semicolon in between.
Impression
Subject: Impression

Hi Shirl -

Hang in there, this will be old hat to you after a while. Radiology reports are usually pretty standard. Same phrases/terms used by all radiologists.

Some usual headings in a radiology report are:

CLINICAL INDICATION: or INFORMATION: or HISTORY, or variations of any of these.

FINDINGS: or RESULTS:

IMPRESSION: or OPINION:

Start adding the common phrases, like "lung markings" and all the various possible headers as above, to whatever word expander program you have. You'll be flying through reports in no time!
Impression
Subject: Impression

In the impression the doctor says the patient probably has a small perforation of his colonic cancer.
Impression
Subject: Impression

Status post laceration, rigth wrist with repair of partial tear to the s/l FC or FCE tendon.
she may say it again in impression if you haven't got there. nm
Subject: she may say it again in impression if you haven't got there. nm


IMPRESSION prob
Subject: IMPRESSION prob

I have a problem under impression ...


"D: IMPRESSION:  Occipital neuralgia probable acute gastroenteritis"


question: how will I transcribe that? coz Occipital neuralgia is not related to "probable acute gastroenteritis" isn't it? or possibly there was a 2 impression. one, is occipital neuralgia and secondly, acute gastroenteritis?... What's the meaning by the dictator?


NOTE: but the dictator did not dictate any numbering.... 


Assessment or Impression
Is it an AAMT rule to automatically number the diagnoses in the Assessment or Impression of an H&P or soap even if the dictator does not?  TIA!
No, but it is either part of the Impression, or
Subject: No, but it is either part of the Impression, or

the a new section after it.

Thanks :)
Impression - hypertension
Subject: Impression - hypertension

This is under impression on a history and physical examination.


It is a numbered list.


[Sodiunduradine] is hypertension.


Any suggestions would be great!


It was under the impression section
Subject: It was under the impression section

I have heard of that also, but it was under his impressions. This doctor is such a mumble mouth! *sigh*
On impression: MR say pat uremeia.
Subject: On impression: MR say pat uremeia.

Pt with mental retardation.
I would not abbrev it if it is in the IMPRESSION as the poster said.
Subject: I would not abbrev it if it is in the IMPRESSION as the poster said.


it's impression and lung markings....
Subject: it's impression and lung markings....


No, not as a listed diagnosis or impression.
Subject: No, not as a listed diagnosis or impression.


impression, SP - status post
Subject: impression, SP - status post

nm
GI help: Is it diaphragmatic compression or impression
Subject: GI help: Is it diaphragmatic compression or impression

Trying to distinguish between diaphragmatic compression or diaphragm and compression or diaphragmatic impression.  Help appreciated.



Ahhh...that's diaphragmatic impression. nm
Subject: Ahhh...that's diaphragmatic impression. nm


Thanks. Duh. I have to spell out abbreviations in impression. Just could not think. NM
Subject: Thanks. Duh. I have to spell out abbreviations in impression. Just could not think. NM

ss
That is the complete sentence. It is his IMPRESSION.
Subject: That is the complete sentence. It is his IMPRESSION.


Could you post the impression? Might help to shed light. nm
Subject: Could you post the impression? Might help to shed light. nm


impression: bronchiolitis s/l sublets? or other process
Subject: impression: bronchiolitis s/l sublets? or other process


s/l ID or ID8 urine culture. for impression and plan
Subject: s/l ID or ID8 urine culture. for impression and plan


Extrinsic impression ? on the sigmoid colon
Subject: Extrinsic impression ? on the sigmoid colon


I was under the impression it was JCAH mandated to write ml instead of cc. NM
Subject: I was under the impression it was JCAH mandated to write ml instead of cc. NM


Got first one - he says in impression "flow limiting stenosis"
Subject: Got first one - he says in impression "flow limiting stenosis"


Impression: Right MPJ extensor hood rupture SM
Subject: Impression: Right MPJ extensor hood rupture SM

(s/l shrowd ligament rupture).
nevermind it's 'off' axis. He repeated it in the impression much more clearly!
Subject: nevermind it's 'off' axis. He repeated it in the impression much more clearly!


I was under the impression that VAC is an acronym for vacuum-assisted closure.
Subject: I was under the impression that VAC is an acronym for vacuum-assisted closure.

Both Stedmans acronyms and Tessier surgical have it as VAC.
Firstly, would it be Impression: (instead of "colon") Negative mammography...
Subject: Firstly, would it be Impression: (instead of "colon") Negative mammography...


The dictation after just went straight into the impression, so I didn't include it. nm
Subject: The dictation after just went straight into the impression, so I didn't include it. nm

nm
So, if I were to have this abbreviation in the impression or diagnosis, should I expand to carcinoma
Subject: So, if I were to have this abbreviation in the impression or diagnosis, should I expand to carcinoma


Lumbar spine MRI. He says: Impression - ?quiet? degenerative changes.
Subject: Lumbar spine MRI. He says: Impression - ?quiet? degenerative changes.


Cardio. Dictates ostium to TM in Impression. Can't find expansion...
Subject: Cardio. Dictates ostium to TM in Impression. Can't find expansion...

 that makes sense in any references and nothing in rest of dictation that connects.  Got any ideas?


Gracias!


doc dictates "the patient has 120 pack year smoking history", patient is 75...is that right???
Subject: doc dictates "the patient has 120 pack year smoking history", patient is 75...is that right???? NM


Patient is here for an s/l eflex injection. Patient previously had Orthovisc.
Subject: Patient is here for an s/l eflex injection. Patient previously had Orthovisc.

nm
OB patient - s/l The patient has a 'null' sign.
Subject: OB patient - s/l The patient has a 'null' sign.


A1c; patient is to follow up in 2 weeks; patient has a followup in 2 weeks.
Subject: A1c; patient is to follow up in 2 weeks; patient has a followup in 2 weeks.

nm
Patient given PPD - sm pls
Subject: Patient given PPD - sm pls

Patient given PPD S/L "agreed" or "read" within the next 72 hours.
Patient does have a UTI but would it
Subject: Patient does have a UTI but would it


same doc. same patient
Subject: same doc. same patient

the lesion was vascular in natureand most likely _____ malformation.


S/L avio-lymphatic


HIV patient. Please sm.
Subject: HIV patient. Please sm.

Doc is dictating a test in relationship to patient's HIV.  He states s/l "firal row"is negative and T-cell count has actually risen since last visit.


Thanks for any/all help!