Obstetrical history and physical

When arrival to Baptist Hospital, he was in significant respiratory distress, ABG’s were checked and initial pH-7.25, pCO2-69, S/L "it appeared" to 128, bicarb 30 and S/L "IO2" or could it be "SO2" to 40%. Thank you ...

The sentence starts off with Admission which I know would be capped but what about the rest (History and Physical)? Thanks... ...

I am hearing "Patient is pregnant 7+1 weeks. I can only think this means 7 weeks one day, I have always seen that expressed as 7 weeks, 1 day or 7 1/7 weeks. Am I hearing this correctly? ...

3-day-history or 3 day history? ...

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 ...

In the physical exam the dictator says "no perineum _______?______ " it sounds like hosslecourse. I know that's not a real word but that is what it sounds like, and I can't find anything that resembles it. ...

Extremities: 3+ edema. s/l kidneys bilaterally. What could "kidneys" be? ...

Typing on Physical Examination, I hear this: Abdomen was nontender; no liberetch, no spleen tip... "liberetch"?! I think I am going crazy. What is this? ...

Cardiovascular system: Heart sounds regular. No murmurs. No gallops heard. s/l "percussed" respiratory sounds masking the heart sounds. Abdomen soft. Patient with URI symptoms. Does this make sense in this context? Thanks! ...

I've been thinking about going into coding, but what is it like physically? The immobility of transcription drives me crazy sometimes, as well as the eye strain of editing, so I am wondering if the actual physical work of coding includes the same stress. Or maybe I will just get a job on my feet, stocking in a warehouse? ...

I transcribing a dictation where "physical examination" was already dictated after the history of present illness and before the past medical history. Now she's dictated it again after the review of systems. Is it possible that the first one should have gone under the history of present illness heading? Also, in her review of systems, she numbers each heading...should I transcribe it as such or leave the numbers out? ...

Patient called ("on later heart exam") as late as 2000. No murmurs, rubs, or gallops ("----") and moderate entry. Clear abdomen, soft nontender. It might say 1 over 2000? ...

Physical examination status post C-section, under "genitourinary" - Normal female external genitalia. _______ was mild. s/l luke hair or low care. ...

The dictation talks about a blood culture, then a chest x-ray, then says glucose 78 and then after that i cant tell it sounds like they say few in 8, cracken 0.4 then goes on to talk about the electrolytes, please any help will be appreciated. ...

Typing phy. therapy and s/l aura suppression or orris impression? ...

I am typing a new doc that does not dictate the headings in his physical exam, however i am required to add them in. I am horrible sometimes at determining the headings so i am hoping to get some input on this file. A moderate hematoma persists over the proximal anterior tibial area which is somewhat fluctuant but not tender. Lumbar flexion is 60 degrees. Lumbar extension is 20 degrees. Lateral flexion is decreased to the left as compared to the right. The l ...

EXTREMITIES: There is lower extremity edema present on the s/l ocburt extremity. On the forearms and hands are tattoos. Thank you. ...

Dictated .... Her affect is somewhat tense, a little anxious. Speech is S/L lunar and lucid. TIA ...

I'm having trouble with one part of this physical exam... NECK: Supple. Trachea is midline. The patient has s/l "emanciation of aphasees" but no signs of skin breakdown. LUNGS: Clear to auscultation... I feel like I know what he's trying to say, but I can't put my finger on it. Thanks so much for your help! ...

The patient is afebrile. Af_____ is appropriate. Heart rate 110. any suggestions on what the blank could be? TIA ...

s/l pullashuks...thanks ...

Under physical exam of a patient with back pain the doctor states what sounds like "pain is reproduced by flexion, extension and "side orientator side" of his back. Has anyone heard of a phrase that sounds like that? ...

Disks sharp on funduscopy. Cranial nerves 2-12 intact. No signs of appendicular s/l "cori ditosis", dysmetria, ataxia. Reflexes were 1/4 bilaterally with no asymmetries. thanks. ...

S/l he is saying "scariotristic???? changes of the skin" ...

I really have a problem under the Physical Examination trying to figure out what goes where when the headings aren't dictated. For instance, in this dictation, she dictates lungs, describes her exam of them, then goes on to say, "Mass in the back and the left paraspinous area is measured..." Would this stay under the lungs or would I make a new heading...if so, if "Back" an acceptable heading? Next, she talks about the pelvis...would this go under a heading with a "Pelvis" labe ...

In the derm part of this physical exam, the patient has "s/l mediastatious changes in the lower legs." This condition is not referred to anywhere else in the dictation. The patient has diabetes, OA, fibromyalgia, and she is obese. ...

Never seen or heard before. New doc states in extremities portion...No clubbing, cyanosis or edema. EDVLSWNL. At least that what is sounds like. Could possibly be EDVLSWNO but don't know what that would be either. Has anyone here heard of this? Thanks! ...

Anybody good with PT/rehab terms? PT assessment Patient performs s/l "clenched transfers" or "clinched transfers" or "Clint's transfers". I can't find any of them. Thanks distraction ...

This is an ESL doctor who is a very good dictator, but for some reason this part always trips me up. She says what sounds like: "Cardiovascular: S1, S2, plus 0. No murmurs, rubs, or gallops." It's the plus 0 part that gets me. Any ideas? ...

Obstetrical history and physical - Jan

Doc just dictated - the letters? NM

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