Archive for August, 2009

???

August 22, 2009

Had a doc dictate the following yesterday…

“Physical exam reveals he was pleasantly confused.”

LOL!  I guess that’s better than the alternative! 🙂

What Exam?

August 21, 2009

VR came up with this gem the other day…

“Her Catholic exam was normal.”

Ha!  So glad to hear it!  lol

(Should have been “metabolic panel was normal.”)

LPH

August 12, 2009

Those 3 little letters consume my work day.  I’m happy to say that after only 3 months I am actually making production with my company, which is 130 lines per hour.  But I want MORE.  My long-term goal is 200 lph.  But honestly, I have no idea if that’s even realistic.  Although, I think it has to be.  I checked my stats at one point this morning and I was at 201!  But by the end of the day I was down to 130 exactly.  Those two 15 minute straight transcription H&Ps at the end of the day did me in, I think (I am much faster at VR editing I have found).  Oh, and also the long ESL consult that VR had trouble translating (as did I).  =\

Oh well, tomorrow is another day to rack up those lines. 🙂

Ewwwww….

August 11, 2009

Okay, the medical profession can be really gross.  One of the key reasons I prefer to sit at a desk and type rather than actually be involved in patient care is that I just don’t have the stomach for it.  Well, even behind my desk I’m not spared altogether.  Had a doc dictate a progress report this morning on a woman who’s been admitted to the hospital for, among other things, rectal bleeding, annnndddd, she apparently passed a clot the size of an egg overnight.

Ew, ew, ew, ew, ew.  =\

Thought this was cute…

August 11, 2009

Just a quick note before getting to work this morning.

The other day a doctor was dictating a progress report on a 90+ year-old lady who had been in the hospital for 5 days at that point.  I forget what her illness was, but what stood out to me was that in the doc’s physical exam he included the fact that she had her “wig in place.”  Made me wonder about this elderly lady and how it was important to her to have her wig on even in the hospital. 🙂

First Cardiac Surgery

August 7, 2009

I transcribed my first cardiac surgery today.  It was an aortic valve replacement.  Pretty interesting.  Here’s the new stuff I pulled out to look up…


cardioplegia
Paralysis of the heart, as may be done electively in stopping the heart during cardiac surgery.  Cardioplegia may be done using chemicals, cold (cryocardioplegia) or electrical stimulation

Interesting…the doc dictated this as giving a dose of cardioplegia but didn’t elaborate on the method.

inotropic support – Pertaining to the use of agents to increase the force or energy of muscular contractions, particularly those of the heart.

manubriumHandle-like structure or part.  In the chest it is the upper part of the sternum, which articulates with the clavicles and the first two pairs of ribs.

There’s also a manubrium in the middle ear, attached to the tympanic membrane.

LEMS

August 6, 2009

So…I’ve been a working MT for all of 3 months now.  And so far the reports I’ve been doing have been pretty standard… GI/GU surgeries, run-of-the-mill ER cases, some labor and deliveries, progress notes.  Really, nothing particularly exotic or with terribly unfamiliar terminology.  Until this week it seems.  Don’t know if it’s just the reports that are coming in, or if my supervisor has released more difficult ones to be available to me, or what…but I’m sure finding it interesting.

Today I transcribed a report for a woman with a history of Lambert-Eaton myasthenic syndrome.  Say what?!  Never heard of that one before.  Looked it up and here’s what it is:

Lambert-Eaton myasthenic syndrome:  An autoimmune disease characterized by weakness and fatigue of the proximal muscles (those near the trunk), particularly the muscles of the pelvic girdle (the pelvis and hips) and the thighs, with relative sparing of eye and respiratory muscles. Lambert-Eaton myasthenic syndrome (LEMS) is associated in 40% of cases with cancer, most often with small cell cancer of the lung and less often with other tumors. The neuromuscular defect in LEMS is due to insufficient release of the neurotransmitter acetylcholine by nerve cells.

VR Bloopers

August 6, 2009

There have been a few this past week…I think I’m going to title these in the future “If it weren’t for the transcriptionist…”

…a woman’s record would have listed one of her past surgeries as a nephrectomy, rather than the mastectomy she actually had.

…a patient taking oxycodone might have been surprised to see Trazodone on his medication list. 

…another patient might have been shocked to find VR had made background noise into “He is full code.”  (Thankfully it didn’t decide to put “He is DNR.”) !

There’s a lot of controversy surrounding the move toward voice recognition software in the medical transcription field.  But I don’t worry…transcriptionists will never become obsolete.  Not when the software comes up with stuff like that!

New Knowledge

August 6, 2009

I had a couple of reports today with the most complicated terminology I’ve come across so far in my short career.  I love to learn new stuff though. 😀

homonymous hemianopsiaa type of partial blindness resulting in a loss of vision in the same visual field of both eyes.

hereditary hemorrhagic telangiectasiaan autosomal dominant vascular anomaly characterized by the presence of multiple small telangiectases of the skin, mucous membranes, gastrointestinal tract, and other organs, associated with recurrent episodes of bleeding from affected sites and gross or occult melena.

telangiectasiaa vascular lesion caused by dilation of a group of small blood vessels to form a small, discolored lesion on the skin.

Why?…

August 4, 2009

…does a man whose hand was cut to the bone by the samurai sword he was holding by the blade when a friend pulled it out of his hand wait 4 hours at one ER, getting all the way through x-ray, anesthetization, wound cleansing, only to walk out to go to another ER right as the doc was coming in to close the wound?  I just don’t understand.  (Not even going to try to figure out what he was doing holding the wrong end of the sword.)