Lab Data and Diagnostic Medical Transcription Terms

NOTE:  Always refer to your normal lab value sheet for normal ranges. The values indicated in this webpage are unique to each patient's specific disease/condition!! 

LABORATORY DATA:  White count on admission 9700, hemoglobin 14.4, hematocrit 44.6, and platelets 225,000.  Sodium 140, potassium 4.2, chloride 101, CO2 30, BUN 14, creatinine 1.2, glucose 103, calcium 9.2, total bilirubin 0.7, and total protein 8.1.  AST 195, ALT 116, alkaline phosphatase 120, albumin 4.1, lipase 241, and troponin I is less than 0.1.  Urinalysis shows trace protein, 1+ occult blood, negative nitrites, negative leukocyte esterase, 5-10 red blood cells and less than 2 wbc's, trace bacteria, trace mucus, and rare epithelial cells.  Valproic acid level is 61.6.

EKG showed no ST changes.  Abdominal x-ray showed a possible bezoar and distended loop of bowel.  Chest x-ray showed no acute pulmonary process with a positive gastric air bubble.

LABORATORY DATA:  On admission labs, white blood cell count 6.5, H&H 13.5 and 39.1, platelets 251,000, sodium is 134, potassium 4.1, chloride 102, bicarbonate 25, BUN and creatinine 13 and 1.2, and platelet 364,000.  PT 12.2, INR 0.8, PTT 29, D-dimer is 0.43.  Alkaline phosphatase 103, AST was 35, ALT 497.  cardiac enzymes x3 were negative.

LABORATORY DATA:  White blood count 5500, hemoglobin 14.4, hematocrit 40.6, and platelets 234,000.  Sodium 135, potassium 3.7, chloride 103, bicarbonate 25, BUN 5, creatinine 1.2, glucose 107, calcium 8.8, and albumin 4.3.  Alkaline phosphatase 83, AST 65, ALT 68, total bilirubin 0.6.  UA revealed trace blood.  Chest x-ray was normal.

LABORATORY DATA:  Laboratories on admission; blood gases show pH 7.39; pCO2 40.5, normal; pO2 60.2, decreased.  O2 saturation 90.8.  Urine drug screening came back positive for benzodiazepines and cannabinoids.  CK, myoglobin elevated.  Troponin was normal.  CBC shows WBC 6800, H&H 12.3 and 39.  Platelets normal at 262,000.  Chemistry profile on admission showed sodium 146.  Rest of the electrolytes are normal.  BUN, creatinine, and blood sugar were normal.  Liver profile was unremarkable.  Dilantin level on admission was 4.3.

LABORATORY DATA:  Laboratory workup showed hemoglobin of 10.5, hematocrit 31.8, WBC count of 7900, and platelet count of 92,000, bands 16 and polys 73.  Chemistry showed BUN of 13.9, creatinine of 2.8, glucose 148, calcium 9.5, albumin of 3.3, SGOT 46, SGPT 56, alkaline phosphatase 202, and anion gap of 10.

X-ray of the chest showed evidence of congestive heart failure.  EKG showed sinus rhythm and left ventricular hypertrophy with ischemia.

LABORATORY DATA:  Chest x-ray done in the ER showed a right lower lobe infiltrate, questionable infiltrate in left lower lobe.  CMP showed sodium 139, potassium 3.6, chloride 102, bicarbonate 22, BUN 11, creatinine 0.8, and blood glucose of 243.  Her CBC showed white blood cell count of 13,900, hemoglobin 13.2, hematocrit of 39.7, and platelets of 234,000.  The poly count was 90.5% and the lymphocytes were 6.4.  Also, the patient's amylase was 74 and lipase 29.  Albumin 4.3.  Calcium 9.3.  AST, ALT, and alkaline phosphatase were within normal limits.

LABORATORY STUDIES:  Initial white count of 6600 with hemoglobin of 13.8 gm%, segs of 78%.  Another white count was 7130 and 7370 and hemoglobin ranging from 13 to 14.7, segs remained increased at 85% and 78%.  Urinalysis showed presence of sugar and a small amount of blood, protein.  No leukocyte esterase, wbc's negative, and bacteria trace.  Subsequent urine was negative.  Admission electrolytes showed sodium 142, chloride 99, blood sugar 156, creatinine 1.4, BUN 14, subsequent BUN was 11 and creatinine of 1.3.  LFTs showed normal studies and the magnesium initially was only 1.21, improving to 1.9 and 2.2.  TSH was 1.33, troponin I was 0.  Urine culture was negative.

A 12-lead EKG showed functioning pacemaker.  CAT scan of the pelvis without contrast was unremarkable.  CAT scan of the abdomen was also unremarkable except for punctate granuloma at the base of the lung.  No ascites.  Abdominal ultrasound showed a tiny 3 mm left renal calculus, which was nonobstructing.  HIDA scan was negative.  Chest x-ray showed low lung volume without any acute disease.

PERTINENT LABORATORY DATA:  On admission, CBC was 13.1.  Hemoglobin and WBC were fine.  Then, followup of the hemoglobin was down to 11.2.  Urinalysis was unremarkable.  BMP and electrolytes were normal.  BUN was a little bit high at 20.  Creatinine was a little bit high at 1.4.  Blood sugar was 172.  I did not do the followup.  The kidney function was done, back to normal.  Blood sugar was down to 72.  Electrolytes were unremarkable.  Magnesium level is low at 1.8.  The blood gases on admission; the pO2 was 76 with normal pH and pCO2.

We did a KUB on admission.  No change in position of the right ureteral stone at the level of the sacroiliac joint.  Chest x-ray:  The heart is normal, no active infiltrate.  EKG showed regular sinus rhythm.  No fascicular block or evidence of any acute changes.  Cardiac enzymes were unremarkable.

TEST RESULTS:

1.  Chest x-ray:  Cardiomegaly, otherwise unremarkable.
2.  CT of the abdomen and pelvis revealed circumferential diffuse wall thickening of the colon, most likely Clostridium difficile colitis and prominent cardiomegaly, otherwise unremarkable.
3.  CT, pelvis part; diverticulosis of sigmoid, thickening of the entire colon and rectosigmoid, Clostridium difficile colitis.
4.  White blood cells on hospital discharge down to 7400, hemoglobin 12.1, and platelets 275,000.  Sodium 135, potassium 4, creatinine 0.5.  Digoxin level is 0.9.  ALT is 31-39, normal.

LABORATORY AND X-RAY DATA:  At the time of admission, the patient had leukocytosis.  At discharge, her white blood count was normal.  Her hemoglobin had gone from 10.1 on admission to 9.5 at discharge.  Diagnosis of probable iron-deficiency anemia had been made.  The patient was found to have elevated fasting glucoses.  Her electrolytes were normal.  Admission urinalysis showed a trace of glucose, large ketones, and trace leukocyte esterase.

Chest x-ray showed some right minor fissure thickening with no acute cardiopulmonary disease.  Final pathology showed a portion of the cecum and appendix with gangrenous appendicitis, perforation, formation of periappendiceal abscess, and a portion of the large bowel with submucosal edema, mural and subserosal, acute inflammation without any evidence of malignancy.

LABORATORY STUDIES:  Electrolytes were normal.  BUN 17, creatinine 1.2, and blood sugar 99 mg%.  Magnesium 1.8, troponin 0, digoxin level was 0.69, subsequent troponin level remained 0.  PT was 12.6 with INR of 1.1.  White count was 9880 with 76% segs.  Urinalysis was unremarkable.

A 12-lead EKG showed functioning pacemaker.

LABORATORY STUDIES:  Sodium 133, potassium 4.2, and BUN 24.  Random blood sugar was 147 mg%.  Troponin I was 0.  Blood sugar 144.  T4 was 6.4.  TSH was 1.57, which is normal.  Initial white count was 20,000 with hemoglobin 17.9 mg%, hematocrit 53 mg%, 85 segs.  Repeat white count 2 days later was 11,400 and later this came down to 8400.  Urinalysis was negative.  Subsequent BUN went up to 36 mg% with creatinine of 1.3.  His PSA level was 3.2.  A repeat ABG showed pH of 7.37, pCO2 of 44, and pO2 of 114 on 36% of oxygen.  The urine culture did not grow any organism.

A 12-lead EKG on admission showed supraventricular tachycardia.  Followup EKG showed sinus rhythm with heart rate down to 83 per minute without any acute changes.  Chest x-ray showed chronic obstructive pulmonary disease with granulomatous lung disease and a tiny, small pleural effusion.  No definite pneumonia.  Renal ultrasound showed no evidence of hydronephrosis.  There was a 5.7 simple cyst in the right kidney.  Bladder ultrasound showed postvoid of 340 mL, which is very significant.

LABORATORY EXAMINATION:  Hemoglobin 12.3, hematocrit 35.5, white blood cell count 4070, and platelet count of 164,000.  Sedimentation rate of 5.  UA shows no blood, no protein, no nitrites.  Sodium 142, potassium 4.5, chloride 102, CO2 31.5, BUN 17, creatinine 1.1, glucose 88, protein 6.7, albumin 3.8, calcium 9.3.  Bilirubin 0.51, AST 14, ALT 31, alkaline phosphatase 85.  Amylase 48 and lipase 180.  Triglyceride 88, cholesterol 164, HDL 53, LDL 93.  PSA 1.78.  Iron 125, TIBC 344.  B12 of 247, folic acid of 14.  Herpes zoster IgG was 81, herpes zoster IgM was 15.  Serum protein electrophoresis was normal.  Urine culture was negative.

LABORATORY EXAMINATION:  Hemoglobin 10.3, hematocrit 32, white blood cell count 10,800, and platelet count 384,000.  UA showed no protein, no blood, and no glucose.  Sodium 142, potassium 3.2, chloride 103, CO2 of 25, BUN 9, creatinine 1.2, glucose 107, protein 6.1, albumin 2.9, calcium 8.2.  Bilirubin 0.4, AST 16, ALT 37, alkaline phosphatase 87.  Amylase 96, lipase 547, repeat lipase 494.  Magnesium 1.4.  Iron 24, TIBC 282.  C-reactive protein 16.  CEA 2.2.  RPR negative, rheumatoid factor negative, ANA negative, pH 7.35, pCO2 34, pO2 80, and bicarbonate of 19.  Urine negative.

Read more »

OR Report (Laparoscopic cholecystectomy)

PREOPERATIVE DIAGNOSIS:  Stage III gastric carcinoma requiring long-term intravenous access for chemotherapy treatment.

POSTOPERATIVE DIAGNOSIS:  Stage III gastric carcinoma requiring long-term intravenous access for chemotherapy treatment with poor peripheral venous access.

OPERATION PERFORMED:  Insertion of a 7.8 French pre-assembled Deltec ProPort via right subclavian.

SURGEON:  John Doe, MD

ASSISTANT:  None.

ANESTHESIA:  Local 0.25% Marcaine with MAC.

ANESTHESIOLOGIST:  Jane Doe, MD

ESTIMATED BLOOD LOSS:  Minimal.

BLOOD TRANSFUSED:  None.

DRAINS:  None.

SPECIMENS:  None. 

INDICATIONS:  The patient is a very pleasant (XX)-year-old female who is now one month status post subtotal gastrectomy for a stage III gastric carcinoma.  She was found to have positive node that is localized for which Dr. Doe has requested that we place a port for adjuvant chemotherapy.  The procedure risks, complications including but not limited to bleeding, infection, pneumothorax and underlying pneumothorax were explained to the patient and her daughter, who was present, and agreed to proceed.

DESCRIPTION OF OPERATION:  With the patient in the main operating room under adequate IV sedation and carefully monitored by anesthesia, Kefzol was given at the time of induction.  A small towel was placed in the intrascapular area.  Both arms were tucked at the side and adequately padded.  The entire upper chest, on both sides, including the neck and shoulder area were prepped with iodoform and draped in the usual sterile fashion.  The patient was placed in Trendelenburg position.  Attention was first directed to the left infraclavicular region.  This was anesthetized using 0.25 % Marcaine.  Here, using a standard percutaneous Seldinger technique, I was unable to identify the subclavian vein, and I opted to go on the right side. 

At this point, the right infraclavicular region was anesthetized using 0.25% Marcaine.  Here, using a standard percutaneous Seldinger technique, I was able to identify the right subclavian vein with no difficulty.  Blood was aspirated.  The guidewire was then placed through the needle, guided along the subclavian vein, superior vena cava at the atrium as confirmed by fluoroscopy.  Next, a small pocket was then fashioned just below the entrance of the guidewire.  Hemostasis was then obtained within this pocket where a 7.8 French pre-assembled Deltec ProPort was then placed within the pocket and secured.  A catheter was then tunneled up to the entrance of the guidewire.  The catheter was then cut to appropriate length and flushed using heparin saline.

At this point, a dilator with a peel-away sheath was placed over the guidewire.  The guidewire along with the dilator was subsequently removed.  The catheter tube was then placed with the peel-away sheath.  As the catheter was then guided down, the subclavian vein, superior vena cava-right atrial junction was confirmed by fluoroscopy.  Blood was aspirated from this catheter with no difficulty and this was then also flushed with heparin saline with no difficulty.  At this point, hemostasis was then obtained. 

The small incisions were approximated using #3-0 Vicryl.  The skin was approximated using running subcuticular #4-0 Monocryl.  Steri-Strips were applied to the wound.  Before placing the dressing, the catheter was accessed one more time with absolutely no difficulty, flushed again using heparin saline and sterile dressing was applied to the wound. 

The estimated blood loss was minimal and none was transfused.  No drains were placed.  Sponge and instrument counts were correct x2 at the end of the case.  The patient subsequently tolerated the procedure well and was then returned to her room in stable condition.

OPERATION PERFORMED:  Laparoscopic cholecystectomy.

DESCRIPTION OF OPERATION:  The patient was brought to the operating room and placed in the supine position. Following induction of general anesthesia, the abdomen was prepped with Betadine and draped sterilely. This patient had received Zosyn preoperatively. A 1.5 cm incision was made at the lower border of the umbilicus, dissection carried down through the skin and subcutaneous tissue. The umbilical raphe was visualized and placed on upward traction. A transverse incision was then made at the base of the raphe and the abdomen thus directly entered. A Hasson trocar was introduced and the abdomen insufflated with carbon dioxide to about 12 to 13 mmHg pressure. The 0-degree laparoscope was then introduced and the gallbladder inspected. It was very distended and thick-walled with obvious acute cholecystitis changes about it. Additional trocars were then placed into position in the right lateral, the right subcostal, and the epigastric area. The gallbladder was unable to be grasped due to its distention; therefore, it was decompressed with a needle through the right subcostal port. Following this, the grasper in the right lateral port was used to close the opening where the aspiration had been performed and to place the gallbladder on upward traction. The infundibulum was then placed on outward traction and the edematous tissue about the tapering of the infundibulum was clearly teased away to identify the cystic duct. There appeared to be several stones impacted in the neck. The cystic duct was cleaned free of surrounding tissue and then triply clipped with the endoclips applier and divided. Likewise, the cystic artery which ran adjacent to this was triply clipped and divided. The gallbladder was then removed from the liver bed with the cautery device and blunt dissection. Once removed, it was placed in an EndoCatch bag and then retrieved and removed through the umbilical port under direct vision. Inspection of the operative area was then carried out again, and since there was some mild oozing in the gallbladder fossa, it was felt best to drain this area postoperatively. Therefore, a #10 Jackson-Pratt was placed into the abdomen in Morison pouch and brought out through the right lateral trocar site. All irrigant was removed and returns were clear. The patient was then placed back in the flat supine position instead of the head upward position and all returns were further aspirated from the irrigant. Carbon dioxide was evacuated and the ports removed under direct vision, with no evidence of any oozing. The fascia at the umbilical and epigastric areas was then closed with interrupted 2-0 Vicryl and all skin incisions with 5-0 subcuticular Monocryl and Steri-Strips. Sterile bandage was applied and the patient then awakened and returned to recovery in good condition.

Read more »

OB DISCHARGE SUMMARY

ADMITTING DIAGNOSIS: Cystocele with urinary incontinence.

FINAL DIAGNOSIS: Cystocele with urinary incontinence.

PROCEDURE: Anterior repair.

COMPLICATIONS: None

HISTORY: This is a 65-year-old woman who had had a previous hysterectomy, who developed urinary incontinence, and was found to have a large cystocele.

Physical examination was unremarkable except for the cycstocele.

Lab work, including a panel, CBC, EKG, and chest x-ray, was essentially within normal limits. Following surgery the patient has done well. The vaginal pack was removed this date and the Foley catheter. She will be checked for residual. IF the residual is over 150 cc, the Foley will be replaced and the patient taught to use the catheter plug, and she will be discharged. She will be seen in the office in approximately one week for follow-up.

Read more »

Emergency Room Report (OB-Ectopic pregnancy)

ADMITTING DIAGNOSIS: Ectopic pregnancy

CHIEF COMPLAINTS: The patient presents to the emergency room this morning complaining of lower abdominal pain.

HISTORY OF PRESENT ILLNESS: The patient states that she has been having vaginal bleeding more like spotting over the past month. She denies the chance of pregnancy although she state that she is sexually active and using no birth control.

GYNECOLOGIC HISTORY: Patient is gravida 2, para 1, abortus 1. Her only child is a 15-year-old daughter who lives in Texas with her grandmother.

PAST MEDICAL HISTORY: Positive for Hepatitis-B.

PAST SURGICAL HISTORY: Pilonidal cyst, remove in the remote past. Had plastic surgery on her ears as a child.

SOCIAL HISTORY: Married, has one daughter, patient works as a substitute teacher. Smokes one pack of cigarettes on a daily basis. Denies ETOH. Smoked marijuana last night. No IV drug abuse.

ALLERGIES: Tightness.

MEDICATION: None.

REVIEW OF SYSTEM
Patient complaints of a lower abdominal pain for the past week that apparently got much worst last night and by this morning was intolerable. The patient is also having some nausea and vomiting. Denies hematemesis, hematokesia and melena. The patient has had vaginal spotting over the past month with questionable vaginal discharge as well. Denies urinary frequency, urgency, and hematuria. Denies arthralgias. Review of system is otherwise essentially negative.

PHYSICAL EXAMINATION
VITAL SIGNS: Shows temperature 97degrees, pulse 53, respirations 22, blood pressure 108/60.
GENERAL: Physical examination reveals a well developed, well-nourish, 35-year-old white female in a moderate amount of distress at the time of the examinations.
HEENT: Unremarkable except for poor dentition.
NECK: Soft and supple.
CHEST: Lungs are clear in all fields.
HEART: Regular rate and Rhythm.
ABDOMEN: Soft with positive tenderness of her lower abdominal area. Fundus was not palpable above the pubic area. Left adnexa are more tender than the right.
VAGINAL EXAMINATION: The cervix is close. A moderate amount of mucopurulent vaginal discharge is noted. The patient would not allow me to perform a bi-manual examination due to the patient pain. So the speculum was withdrawn.
EXTREMITIES: No clot. No edema.
NEUROLOGIC EXAMINATION: Intact. Oriented x3, No neurologic deficits.

DIAGNOSTIC DATA
ADMISSION: Hemoglobin 12.8 g and Hematocrit 36.6%.
URINALYSIS: Essentially Negative.
BETA HCG: Positive with WBC count of 23,278.

RADIOLOGY
Pelvic Ultrasound shows a 7 week 4 day old viable ectopic pregnancy per radiology. The patient was given Demerol 25 mg, and Phenergan 25 mg. IV for the pain after her report was obtained. The patient also given claperan 1g IV.

I page Dr. Gerard, patient’s GYN, physician, as soon as I receive the ultra-sound report at approximately 10a.m. He was not in North Miami office. I page the South Miami office and reach Dr. Gerard’s office at approximately 10:15a.m. His office personnel advice me that he is not on call, Dr. Bomback is on call. I spoke with Dr. Bomback at approximately 10:25a.m. and she will be here to take the patient to the operating room.

ADMITTING DIAGNOSIS: Left ectopic first trimester pregnancy.
Disposition: The patient receive and IV of lactated ringer upon arrival at the emergency room. This was switch to normal saline while we were awaiting Dr. Bomback’s arrival. The surgical procedure was explained to the patient and her husband. All risk and benefits were discussed. They understand the necessity for immediate surgery and informed consent was signed. No old records are available for review.

Read more »

History and Physical Sample Report

REASON FOR ADMISSION: Urinary tract infection and fever.

CHIEF COMPLAINT: "Problems with bladder."

HISTORY OF PRESENT ILLNESS: The patient is a 49-year-old white male with a history of urinary frequency, burning, and recent fever. His urine was loaded with white cells in the office, and he is being admitted for intravenous antibiotics. Last night, he presented to the ER and had a temperature to 102.5 degrees, then subsequently developed worsening fever. His fever ultimately broke about 2:30 in the morning with a temperature that ended at approximately 103 degrees.

PAST MEDICAL HISTORY: Significant for oral agent diabetes mellitus and hypertension.

REGULAR MEDICATIONS: Include: (1) Glucovance. (2) Avandia. (3) Zantac. (4) Tricor. (5) Zestril.

ALLERGIES: PENICILLIN (he is unsure of the reaction - he thinks it has something to do with swelling).

FAMILY HISTORY: Significant for a father who died of myocardial infarction and mother died of a stroke. He has had a previous urinary tract infection, Escherichia coli type, in 1998, with admission to the hospital then. He has not had any other hospitalizations.

SOCIAL HISTORY: He is a truck driver. He is not an abuser of alcohol or tobacco.

REVIEW OF SYSTEMS: Significant for dysuria; PSA score of only 3.

PHYSICAL EXAMINATION:
VITAL SIGNS: Recorded in nursing notes: Temperature maximum of 101.5 degrees. He is slightly hypertensive at 145/75. His pulse oximetry is normal. His pulse rate is in the low 90s. His respiratory rate is 16.
GENERAL APPEARANCE: His mood and affect are normal. He is alert and oriented x 3. He is an excellent historian.
HEAD, EYES, EARS, NOSE, AND THROAT: Examination reveals he is normocephalic, atraumatic. Extraocular movements are intact.
NECK: Supple without jugular venous distention or thyromegaly.
CHEST: Grossly clear.
HEART: Rate is regular. Peripheral pulses appear to be normal.
LYMPHATICS: He has no abnormal adenopathy in the axillary, supraclavicular, cervical, or inguinal lymph node regions.
ABDOMINAL EXAMINATION: Soft, nontender, slightly protuberant. No evidence of inguinal, umbilical, or other fascial hernias are noted.
GENITOURINARY: The testes and phallus are normal. Prostate is about 20 g in size and significantly tender on the right hand side.

LABORATORY DATA: Indicative of a white blood cell count of 13.7. Hemoglobin and platelet count are well within normal limits. Comprehensive metabolic panel reveals a normal creatinine. Urinalysis reveals white cells present. Urine culture has been sent.

 DIAGNOSTIC IMPRESSION:
1. Probable prostatitis.
2. Urinary tract infection.

PLAN: Admission. Will do non-contrast CT scan to evaluate him for possible stone. No apparent prostate abscess is present and he will be treated with intravenous antibiotics.

Copyright 2005-2009 Copied with Permission from the web site,
"Patients and Medical Transcription" at http://www.mt-stuff.com

Read more »

Emergency Room Report

CHIEF COMPLAINT:
Colic.

 HISTORY OF PRESENT ILLNESS:
This 6-week-old enters with colicky pain and increasing flatus and crampy abdominal pain that she gets mostly at night. She is not constipated. She has had no blood in her stool and normal urine and normal intake and no nausea or vomiting. She has not had any fever. 

PAST MEDICAL HISTORY:
Other than the above, symptoms is negative. 

PAST SURGICAL HISTORY:
Negative.

SOCIAL HISTORY:
Negative. Both parents are present and appropriately concerned.

FAMILY HISTORY:
Negative.

REVIEW OF SYSTEMS:
The complete review of systems is essentially negative except for colicky abdominal pain and increased flatus. The patient is on formula with iron and does not use a gas decreasing bottle system. Has been on Gaviscon but has gotten only one dose a night apparently. The rest of the review of systems is negative.

PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 98.9. Pulse 130. Respirations 52. Pulse oximetry is 96% on room air.
GENERAL APPEARANCE: She is alert and is moving all extremities.
HEENT: The pharynx is wet. The tympanic membranes are normal. The fontanel is soft and ballotable.
NECK: Supple. There is no induration of the throat and there is no adenopathy.
LUNGS: Clear. There is no dyspnea.
HEART: Shows a regular rhythm without murmurs.
ABDOMEN: Somewhat distended. She had some flatus several times, I might add, and then it diminishes. It is totally nontender. She has good tone.
NEUROLOGIC: Intact for age including a positive Moro.
SKIN: She has no skin lesions, icterus, or jaundice, and the pulses are 2+ and equal.

DATABASE:
X-rays: Upright abdominal and chest combination is normal except for gas in the bowel, which shows no obstruction.

DISCUSSION:
I think this is colic. I have suggested the following: (1) To change to formula without iron. (2) To use soy based formula. (3) To increase the Gaviscon to 3 drops q.i.d. at least. (4) They should follow up with their own doctor.

CLINICAL IMPRESSION:
Colic.

PLAN:
Gaviscon, changing the formula, no iron, and see their doctor in 1-7 days.

CONDITION ON DISCHARGE:
Good


Copyright 2005-2008, Copied with Permission from the web site,
"Patients and Medical Transcription" at http://www.mt-stuff.com

Read more »

Commonly used Transcription rules

1	Spacing With Punctuation Marks
		Do Not Type a Space ... before or after a hyphen before or after a slash before or after a dash between a number and percent sign between parentheses and the enclosed material between any word and the punctuation following it. between the number and the colon used to indicate a dilute solution or ratio, e.g. 1:4 on either side of the colon when expressing the time of day before an apostrophe before or after a comma used within numbers before or after an ampersand in abbreviations, e.g., C&S on either side of the colon when expressing ratios e.g. 1:1 after the closing parenthesis if another mark of punctuation follows when using the word “times” as x – e.g., x3 Type One Space... between words after a comma after a semicolon after a period following an initial after the closing parenthesis on each side of the x in an expression of dimension, e.g. 4 x 4 type 2 spaces... after punctuation at the end of a sentence after a colon except when expressing time or a dilution ratio
2	Numbers
		Spell out WHOLE numbers zero through nine, use numerals for 10 and above (this may change in the near future as the AAMT is trying to standardize using numerals only. Use numerals when numbers are directly used with symbols. Use numerals when expressing ages. If it is an approximate age, spell it out. Use numerals to express size and measurements. Use numerals for everything metric. Centimeters, millimeters, liters, etc. Use numerals in all expressions pertaining to drugs - this includes strength, dosage and directions. Z-PAK 2 daily on day 1, then 1 daily on days 2-5. Spell out and hyphenate fractions standing alone. He drank one-half a gallon of apple juice. Use numerals to express mixed fractions. 1 1/2 years. Use commas only if there are 5 or more digits when expressing numbers. e.g. 10,000, 4000. Use numerals when expressing vital statistics including height, weight, blood pressure, pulse and respiration. Substitute a hyphen for the word "to". He is to take 1-2 tablets of Tylenol every 4-6 hours p.r.n. Leave a space between numerals and measurements unless they form a compound modifier. It is 6 cm below the ...... It is 1200 mL....... A 4-cm nevus....... A 2 x 2-mm lesion....... Always use 0 in front of the decimal point if the number is not a whole number. 0.75 mg Use decimal fractions with metric measurements. 1.5 cm Use mixed fractions with English system measurements. 1 1/2 inch Use numerals for: Ages, units of measure, vital statistics, lab values and in other instances where it is important to communicate clearly the number referenced. Examples: 4 inches, 3-year-old. She has three dogs who have eight fleas each. A total of 7 basal cell carcinomas removed from his left arm. (7 for clarity) Do not start a sentence using a number. Spell out the number or recast the sentence. Dictated as: 10 milligrams of Reglan was administered stat. Transcribe as: Reglan 10 mg was administered stat. Exception - It is acceptable to begin a sentence with a date. Example - 2004 is going to be a prosperous year. Plurals - do not use an apostrophe to form plural numbers. 4 x 4s She was in her 20s or twenties (this is acceptable because it is not a definite number). She was born in the 1970s. Series of numbers - Use numerals if at least one is greater than nine or if there is a mixed or decimal fraction. Example - Jeff has 1 job, 1 place of employment and 18 hours a day to do the work. Cranial nerves - Preferred: Roman numerals I-XII Diabetes type 1 and type 2, not Roman numerals I and II - this was recently standardized by the American Diabetes Association. Apgar scores - Use numerals for ratings and spell out numbers relating to minutes. Rationale - to draw attention to the scores. Example: The Apgar scores were 6 and 9 at one and five minutes. Apgar is not an acronym. Time Examples 8:30 a.m. - morning 8:30 p.m. - evening noon, not 12:00 noon midnight, not 12:00 midnight or 12 'o'clock or 12:00 p.m.
3	Measurements
		Spell out all nonmetric measurements. Feet, inches, pounds, ounces, yards, grain, dram, etc. Exceptions: Use tsp for teaspoon Use tbsp for tablespoon Abbreviate all metric measurements. Use F for Fahrenheit IF accompanied by the symbol for degree. 98.6°F Spell out Fahrenheit IF degree is spelled out. 98.6 degrees Fahrenheit. Use C for Celsius IF accompanied by the symbol for degree. 36°C Spell out Celsius IF degree is spelled out. 36 degrees Celsius. In tables and technical documents: Use ft or ' for feet Use " for inches Use yd for yard Use pt for pint Use oz for ounce Use fl oz for fluid ounce Abbreviate most unusual units of measure when accompanied by numerals Dictated as Transcribed as: 0.8 centimeters squared 0.8 sq cm 22 millimeters of mercury 22 mmHg 3.0 liters per minute 3.0 L/min 40 millimeters per hour 40 mm/h 8 grams percent 8 gm%
4	Symbols
		Spell out a symbol when used alone (with no number). Use symbols when they are used with numbers Common Symbols Dictated as Transcribed as: Four to five 4-5 Number 3 0 #3-0 Twenty-twenty vision 20/20 BP 120 over 80 120/80 Grade two over six 2/6 A positive A+ Three point five centimeters 3.5 cm Point five centimeters 0.5 cm
5	Capitalization
		Capitalize... Abbreviations when the words they represent are capitalized The first word following a colon if it begins a complete sentence or is part of an outline entry Most abbreviations of English words The first letter of chemical elements The names of the days of the week, months, holidays, historic events and religious festivals The names of specific departments or sections in the institution only when the institution name is included The names of diseases that include proper nouns, eponyms or genus names The trade or brand names of drugs A quote when it is a complete sentence The names of races, peoples, religions and languages. Black, as a race designation would be capitalized, however client preferences may differ. Do Not Capitalize... The spelled out names of the chemical elements The seasons of the year The common names of diseases The names of viruses unless they include a proper noun Generic drug names The common noun following the brand name. Example - Tylenol tablets The names of medical or surgical specialties Designations based on skin color, like "a tall white man."
6	Hyphenation
		These prefixes do not require the use of a connecting hyphen in compound terms: ante intra semi anti micro sub bi mid super co non supra contra over trans
7	Stage, Type, and Fracture Classifications
		Lowercase the words "stage" and "type," and use roman numerals. For subdivisions of stages, follow The AAMT Book of Style rules for cancer classifications, and add on-line capital letters without spaces or hyphens: Examples complex regional pain syndrome stage I stage II-III type I radioulnar synostosis type II open fracture type IIIB Garden II femoral neck fracture Salter VI fracture
8	Grade
		Lowercase the word "grade" and use arabic numerals: Examples: grade 1 chondromalacia patellae grade 2 grade 3-4
9	Level, Phase, and Class
		Lowercase the words "level," "phase," and "class," and use arabic or roman numerals according to the system being referenced: Examples: Radiation Therapy Oncology phase III Haggitt level 4 colorectal adenocarcinoma physical status class 2E
10	Wrist Arthroscopy Portals
		Use arabic numerals. Two numbers should be hyphenated without spaces; add on-line capital letters with no space: Examples: 1-2 portal portal 3-4 6U wrist portal source: http://www.mt911.com

Read more »