Doc dictates "The patient has a history of chronic kidney disease (stage 4 to stage 5) ?!?! is that how it is transcribed per the BOS II ... I just moved and cannot locate my book for verification. ...
A 57-year-old woman with chronic kidney disease. In the Plan, dr (soft spoken with heavy accent) says "We will do a (s/l) P-urea or (s/l) Fe-urea.'' ?
Thanks very much for any help. ...
Doctor is giving list of diagnoses and says "s/l dough polycystic kidney disease." Does anyone anyone know if there is a distinction among the types of polycystic kidney disease that might sound like dough/doh? I know there is a genetic type, but not sure about anything else. This doc is notorious for adding nonsensical syllables here and there (why can' he say "um" like everybody else??). Any help would be greatly appreciated.
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I've seen kidney disease classifications both Arabic and Roman. Which is correct? I've been using Arabic, but I just had an editor change a report to Roman. I'm confused and can't find it in BOS2. Thanks! ...
Nothing in BOS, at least that I could find. Couldn't find anything on Loma Linda University site. Don't recognize the Google hits for arabic. Anyone know? Thanks. ...
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? ...
The patient was referred for left-sided hydronephrosis and a CT scan was dictated as consistent with a UPJ obstruction. Upon my review of the films, the picture did not appear to be consistent with a classic UPJ obstruction (it was not a box kidney).
TIA!!! :) ...
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.
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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! ...