Doctor dictates "OB history" and "GYN history" on a Discharge Summary, under Past Medical history. Should I spell out Obstetric and Gynecological is it okay to leave as dictated. I forgot. jn ...
I'm having huge problems with this pulmonary dictation. "Chest CT 2010, no interstitial fibrosis. Mild linear (s/l clinical) scarring in the lower lobes, right middle lobe, and lingual. PFTs-moderate restrictive lung disease. (s/l Mild decrease and diffuse in capacity.) Repeat PFTs - no significant change - (s/l duke) pulmonary - diffusion problem. (s/l also 2 homo 2.) Desats."
On the 'also 2 homo 2', she does seem like she is stumbling over her word ...
"She continues to require O2. She did see a pulmonologist who agreed with the management of pulmonary s/l processees. She feels that her left arm is actually less stiff now that she has had the EMG."
I was wondering if the word could be either processes or prostheses. This is a rheumatologist, so she doesn't cover much on the subject of the patient's pulmonary issues. ...
Right upper lobe anterolateral segment irregular noncalcified mass, size 2.5 cm with a pleural tag and local pleural inflammatory reaction versus infiltration with possible small right S/L *PRE-CORE-I-NAL" at 2 o'clock, small lymph node as well as a right lower lobe prominent pulmonary artery. ...
What I hear: Moderate cylindrical bronchiectasis with normal alpha92%, subchloric and the IDG studies.
The highlighted words I cannot figure out. Help please! Thanks! ...
This pt has pulmonary nodules.
As dictated: Repeat CT of the chest shows no change in these bilateral small areas of s/l ground valescent opacification.
and I repeat...I am not a radiology MT and appreciate your help!!!!!! ...
I have a dictator that is saying "status post _____ for pulmonary fibrosis" numerous times during this report. Sounds like she is saying "BOLT"???? Any ideas? Thanks in advance :) ...
What is the correct way to transcribe FEF 25-75%? Since the BOS says to write percentages 25% to 75% instead of using a dash, is that how the name of the test is supposed to be transcribed, FEF 25% to 75%? ...
How do I tell the difference? I'm getting confused on -us and -ism. If a diagnosis dictated is "No evidence for pulmonary emboli" would it be the -us or -ism? ...
The patient is referred with fever, chills and progressive shortness of breath with a history of IV drug abuse and alcoholism. The patient is a poorly-nourished 44-year-old Hispanic male in "s/l seria desperator" distress and agitated. Could the doctor mean severe respiratory distress? ...
This doctor is doing a pulmonary exam and says "no eedae or gothy" and I'm not familiar with these words and have not found anything remotely like this. It is possible she is describing heart sounds as she is bouncing all around in this dictation. HELP! ...
Patient has pulmonary hypertension and is on sildenafil and s/l lethirus. What is it?? I feel like I should know what this is, but I just can't get it. Can anyone help? Thanks. ...
"There is diffuse s/l desenal adenopathy." This is a heavy ESL dictator, so if someone could even point th way to what kind of adenopathy or lymphadenopathy someone with lung problems might have, I'd appreciate it. ...