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Diagnostic Tests
All Diagnostic Tests CAT scan Positron Emission Tomography Magnetic Resonance Imaging Ultrasound X-ray MUGA scan Endoscopy Esophagogastroduodenoscopy Colonoscopy Endoscopic Retrograde Cholangiopancreatography Bronchoscopy Cystoscopy Hysteroscopy Arthroscopy...
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What is Medical Transcription?
Medical Transcription as the name suggests is the diligent process of converting a health care provider’s dictated notes in to accurate and readable data records. The medical transcriptionist is the one who can converts the dictation into medical reports...
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Guidelines with Dates
The ideal format for writing dates is in month, day, year format where the year is separated from month and day by a comma. For example: The patient will undergo repair on January 9, 2006. However, when military date format is used, i.e. date, month,...
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Grammar Guidelines in medical Transcription
Abbreviations An abbreviation is a shortened, contracted, or brief form of words or phrase. Physicians mostly use abbreviations while dictating in order to speed up communication. Sometimes, abbreviations can instead lead to confusion in the report or...
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Capitalization Guidelines
Capitalization has always been a nagging question especially for the early beginners of transcription. Here we discuss some basic rules of capitalization that are to be kept in mind when transcribing medical reports: v Capitalize all the proper nouns-...
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Eponymous Diseases
A Aarskog syndrome Aase syndrome Abderhalden-Kaufmann-Lignac syndrome Achard-Thiers syndrome Addison 's disease Aicardi syndrome Alexander disease Alpers' disease Alice in Wonderland syndrome Alport syndrome Andersen's Disease Angelman syndrome Apert...
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List of Human Anatomical Parts Named after People
A B Achilles' tendon Bartholin's gland Adam's apple Bowman's capsule Alderman's nerve B owman's membrane Aortic sinus Broca's area Artery of Adamkiewicz Brodmann area Auerbach's plexus Bundle of His C D Central sulcus Duct of Bellini Circle of Willis...
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Tersm used in Physical Examination
General: Apgar score (newborn) Apgar score was 8 at one minute and 9 at five minutes arousable awake, alert and oriented awake, alert and oriented X 3 (times 1, 2 or 3) cachectic/cachexia Cheyne-Stokes breathing comatose cushingoid diaphoretic dyspnea...
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Transcription Words Formation
in psychiatry files it is "thought racing" not rising It is always "acute on chronic" the patient complains of the patient comes in with complaint of at the present time" and not at 'at present time detrimental NOT decremental Pseudomonas pneumonia always...
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Nerves of the Eye Region
Nerve: Anterior ethmoidal Origin: Nasociliary nerve Course: Arises in orbit, passes via anterior ethmoidal foramen to cranial cavity then cribriform plate of ethmoid to nasal cavity Innervation: Dura of anterior cranial fossa; mucous membranes of sphenoidal...
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Nerves of the Facial Region
Nerve: Auriculotemporal Origin: Mandibular nerve Course: Passes between neck of mandible and external acoustic meatus to accompany superficial temporal artery Innervation: Skin anterior to auricle, posterior temporal region, tragus, helix of auricle,...
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Nerves of the Hand
Nerve: Common palmar digital Origin: Median and superficial branch of ulnar nerve Course: Runs distally between long flexor tendons of palm, bifurcating in distal palm Innervation: Proper palmar digital nerve; skin and joints of palmar and dorsal aspect...
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Nerves of the Thoracic Region
Nerve: Abdominopelvic splanchnic Origin: Lower thoracic and lumbar segments of sympathetic trunk Course: Passes medially and inferiorly to prevertebral ganglion of paraaortic plexus Innervation: Abdominopelvic blood vessels and viscera Nerve: Cardiac...
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Sample Report Cerebrospinal Fluid Leak Repair
Preoperative Diagnosis: Cerebrospinal fluid leak with headache secondary to dural tears. Postoperative Diagnosis: Cerebrospinal fluid leak with headache secondary to dural tears. Procedure Performed: Left L4-5 laminotomy and primary repair of tiny dural...
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Sample Report Craniotomy For Clip Ligation
Preoperative Diagnosis: Left posterior communicating artery aneurysm. Postoperative Diagnosis: Left posterior communicating artery aneurysm. Procedure Performed: Left pterional craniotomy for clip ligation, posterior communicating artery aneurysm. Anesthesia:...
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Sample Report Evoked Potential Study
Clinical History: The patient is a 45-year-old male who presents with back pain and sensory disturbance, particularly involving the left side of the body. Apparently, he has tingling sensation in the hands and feet. No medications are listed. Details...
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Sample Report Suboccipital Craniotomy
Preoperative Diagnosis: Left suboccipital depressed skull fracture. Postoperative Diagnosis: Left suboccipital depressed skull fracture. Procedure Performed: Left suboccipital craniotomy for elevation of depressed skull fracture. Anesthesia: General endotracheal....
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Sample Report Ventriculoperitoneal Shunt Revision
Preoperative Diagnosis: Ventriculoperitoneal shunt failure. Postoperative Diagnosis: Ventriculoperitoneal shunt failure. Procedure Performed: Ventriculoperitoneal shunt revision and cranioplasty. Anesthesia: General endotracheal. Estimated Blood Loss:...
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Sample Report Cardiac Catheterization
Title of Procedure 1. Left heart catheterization. 2. Coronary angiography. 3. Left ventriculography. 4. Saphenous vein graft angiography. 5. Left internal mammary graft angiography. Procedure in Detail: After informed consent was obtained and premedications...
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Sample Report Fiberoptic Bronchoscopy
Title of Procedure 1. Fiberoptic bronchoscopy. 2. Endobronchial and transbronchial biopsies with fluoroscopy. Description of Procedure: The patient was premedicated with Versed. Approximately 4 mg was given prior to introduction of the scope. A total...
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Sample Report Left Chamberlain Procedure
Title of Procedure 1. Left Chamberlain procedure. 2. Right video-assisted thoracoscopic surgery. 3. Segmental resection of right upper lobe pulmonary nodule. Procedure in Detail: After adequate general anesthesia and double-lumen endotracheal intubation,...
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Sample Report Mitral Valve Replacement
Title of Procedure 1. Mitral valve replacement with size 27 CarboMedics valve. 2. Repair of left ventricular rupture, secondary to myocardial infarction. Procedure in Detail: The neck, chest, abdomen and legs were prepped with Betadine solution. Combination...
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Common Terms by Procedure Fiberoptic Bronchoscopy
arytenoid region bronchial tree brushings carina endobronchial epiglottis esophagus false cords fiberoptic fluoroscopy hilum hypopharyngeal region hypopharynx landmarks lingula mucus naris obstructive apnea orifice phonate Romazicon stenosis submucosal...
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Common Terms by Procedure Echocardiogram
aneurysm anticoagulation aortic insufficiency aortic valve ascending aorta atherosclerosis blind intubation chamber color Doppler contrast bubble study descending thoracic aorta diastolic compliance echo ejection fraction embolus free wall hypertrophy...
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Common Terms by Procedure Cardiac Catheterization
bifurcation caliber circumflex concentric coronary angiography damping 30-degree view end-diastolic pressure femoral triangle global hypokinesis gradient graft heart catheterization Hemaquet hemostasis internal mammary artery Judkins technique left anterior...