working on a psychiatry consulation report and there are only a few headings dictated. "History of Present Illness", "Review of Past Medical Records", "Developmental Background", and "Diagnosis". Under "Review of Past Medical Records" there are several paragraphs dictated without headings and each one starts out with "Doctor (doctors name is cut off) diagnosed (or indicates) etc....., examples:
Doctor diagnosed head injury, loss of consciousness, bilateral clavicle fractures, right scapula ...
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? ...
In a patient with lower extremity claudication; Dictator is saying: Patient has a high degree of stenosis in the (s/l) NACE limb above the bifurcation.
I've looked up NAC, NACE, NASE and don't seem to find anything that fits.
Later in the report he says: She was counseled on options and due to her severe level of cardiac disease was precluded from having a reconstruction of her NACE.
It's a long report and except for that I'm almost done so if someone cou ...
Has anyone ever heard the initials PNK or TNK for cath procedure. Patient having multiple procedures done and all I know is that it is a thrombolytic agent. I have looked up both in the abbreviation site and find nothing for TNK (which sounds more like it), but PNK??? Any thoughts or ideas, some med I would assume but I have stumped on this one.
Thanks ...
Because of the combination of illnesses and particularly because of left arm weakness and s/l ("front coordination") as well as memory impairments she fells she cannot return to work doing clerical duties.
...
At the end of the report the doctor says Axis I -Adjustment disorder with anxiety, moderate in degree. Then he says "New paragraph, Psychogenic amnesia", then he says Axis II . Do I skip a line after Axis I, then write Psychogenic amnesia? How do I set that up? Please help, Thanks. ...
"The turbinates were pink and there was no mucopurulence. Afrin/________ was applied."
It sounds like "PONT-uh-geen", but I've tried every spelling variation I can come up with. Thanks in advance! ...
Cannot make sense of what dr is dictating here...gave a few of the sentences before and after so you can get the context from this consultation report.
Recurrent severe chest pain attributed to mitral valve prolapse increasing in frequency and intensity. History of global poor left ventricular function. Cannot rule out cardiomyopathy so I will be careful as regards negative. No trophic agents such as Inderal. Suggest that Inderal and Isordil be discontinued.&n ...
that is less than 30 lines; dictator who repeats every sentence with 1 subtle change; DEAD AIR, etc. It is stressful enough that I'm losing money today but to be stressed out about line count and being perfect...I CAN'T TAKE IT ANYMORE!!!!!! ...
Patient will be undergoing CABG and dictator stated:
"AP 2 wide 12 assay will be obtained to evaluate the level of platelet inhibition"
AP 2 Y 12?
a P2Y12?
I can't find anything.
TIA
...
I am new MT (sort of). I am doing a cardiac cath from an ESL with marbles in his mouth. This is a false positive stress test, and I am going nuts with one phrase. It is:
"The left anterior descending artery was large, 5 mm in diameter. (s/l tran sif ico) was mildly tortuous but no focal lesions."
I googled the phrase and found it, and was led to this site, but it is not here. Anybody have a clue on the (s/l trans sif ico)? ...
patient had postoperative complications of cardiac arrest with pericardial effusion which led to "cardiac tamponade". The doctor pronounces it like "decardiac tamponaude." Is there another version I am not familiar with?
Thanks!
Abby ...