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Gallbladder removal...Impression is "questionalbe evolving s/l PYRANASE vs phlebitis R/O - AL
Posted: Apr 14, 2012
Gallbladder was removed, and the impression was "questionable evolving *PYRANASE* versus phelbitis"...anyone know? I have no clue! :(
well, not phlebitis - hmmm
[ In Reply To ..]
Phlebitis is a condition that affects one's legs. So your word may end with "itis" but you need to re-listen to what comes before that. (I think you mean phlebitis but you spelled phelbitis? so maybe I'm off base). I *know* I know the word, but cannot bring it to mind just now. I'll keep thinking, tho.
The role of the MT is always evolving. No doubt we are all trying to figure out a way to stay afloat. One of those ways could be for the MT to go beyond just transcription into assisting with the clinical documentation (including the complicated ICD-10). Some doctors believe that medical transcription is one of the least efficient parts of their medical practice. Certainly, many MT's have moved beyond transcription into speech recognition Medical Editors ...
Negative for pulmonary embolism or dissection. Moderate coarse infiltrate left lower lobe. Scattered area of ground glass infiltrates and s/l normal focus of parasegments on the right. Abnormal hilar lymph node s/l pipathy with asymmetric enlargement nodes s/l axial lateral left greater than right. ...
I've been an MT for over 10 years and have always just typed IMPRESSION, even when there are multiples, but I'm seeing other MT's type "IMPRESSIONS" and also "PLANS" when there are more than one, even when the doctor is only dictating IMPRESSION (though we would change DIAGNOSIS to SES if more than one but not dictated).
I searched the archives and found one mention of this before, but there wasn't much conclusion on the matter.
So what say ye? ...
I know that according to AAMT we are not supposed to put abbreviations in the Impression/Diagnoses sections, but does that include ALL abbreviations? Or just ones pertaining to diseases? For instance, are we supposed to spell out MRI in the impression? Or just diseases, like PUD or COPD?
I'm a bit confused because I put "MRI" in the impression and QA left that as is, but I also put "PT" and they expanded it out to "physical therapy."
Does anyone know?
Thanks in a ...
I got a style error minor deduction for this, because it could also refer to "benign prostatic hyperplasia." I was actually aware of this terminology controversy in the medical community in terms of what the actual meaning is, but I've never once had "benign prostatic hyperplasia" dictated in over 18 years of MT, regardless (has anyone else?). However, I should somehow intuit that Nuance wants it done this way (though I've been expanding it for over 2 years now with never a corre ...
Ultrasound showed small echogenic ____ s/l non-shedding focus. Differential diagnosis was polyp versus _____ s/l timif active sludge, but there is no _____ sl/l shedding calculus. (Her shedding sounds like sharing). ...
After the procedure -
The wound was clean and dry. Xeroform and dry sterile dressings were applied. (s/l) Gauze, Kling and ace bandage was then applied as a hand dressing.
Why would they use guaze and Kling together? Can this be correct? ...
I'm typing a report for a removal of a left subclavian subcutaneous tunneled venous access device and reservoir.
The doctor reports the following as the findings:
Intact left subclavian (___) and port. It s/l he is says "singulum."
Does anyone have an idea of what it could be?
Thank you so much. ...
First time I've heard this one! Of course don't get this doc often so here we go. He's removing a nasal polyp and he says:
Using the 3:16 s/l microgurbator at the polypoid tissue was 3:18 s/l microgerbated down to the level of the middle meatus.
The 3:16 & 3:18 are for my contractor to listen to if I can't find "microgerbator"
Thanks in advance. Tammie ...
I can hear the "k" at the beginning (I think I can hear the "y" at the end) and s/l straight Kelly clamp
The skin tag is on the neck. They apparently use this clamp in plastic surgery procedures but not sure if there's another type that would be more fitting for a simple skin tag removal.
New ones on me:
_______with intraoperative Doppler
S/L incination or encination - guess it could be uncination but does not s/l that at all
Recurrent arteries of ______were identified bilaterally and then working through the frontal gyrus....
Just curious - anyone know? ...