Top posts
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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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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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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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Virgule
A virgule is a punctuation mark “/”. It is also called a diagonal, separatrix, shilling mark, stroke, slant, or forward slash. Ø In dates, the month, date, and year are separated by virgule, mostly in demographics. For example: ADMISSION DATE: 01/01/2006...
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Sample Report Stereotactic Biopsy of Brain Tumor
Preoperative Diagnosis: Malignant primary versus metastatic left parietal brain tumor. Postoperative Diagnosis: Malignant primary versus metastatic left parietal brain tumor. Procedure Performed: Left parietal bur hole and CT-guided biopsy of same with...
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Common Terms by Procedure
Herniated Disk Repair Aesculap retractor system benzoin bipolar electrocautery Black Max drill Cobb periosteal dissector crystalloid diskectomy disk herniation disk space downbiting epineural herniated disk laminotomy ligamentum flavum Love nerve root...
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Sample Report Laminectomy with Resection of Tumor
Preoperative Diagnosis: Likely metastatic tumor to spine, epidural T2-3 with spinal cord compression. Postoperative Diagnosis: Metastatic epidural intraspinal tumor consistent with the lung mass, sarcomatoid carcinoma. Procedure Performed: T12-L3 laminectomy...
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Sample Report Herniated Disk Repair
Preoperative Diagnosis: Herniated disk with left sciatica. Postoperative Diagnosis: Herniated disk with left sciatica. Procedure Performed: Left L4-5 laminotomy, medial facetectomy, and diskectomy with microscope. Anesthesia: General endotracheal anesthesia....
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Nerves of the Abdomen and Pelvic Regions
Nerve: Cavernous nerve Origin: Parasympathetic fibers of prostatic nerve plexus Course: Perforates perineal membrane to reach erectile bodies of penis Innervation: Helicine arteries of cavernous bodies; stimulation produces engorgement at arterial pressure...
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Sample Report Electroencephalogram
Clinical History: The patient is a 76-year-old female who presents with spells consisting of tingling sensation and taste dysfunction. She also had a previous stroke. She is on Synthroid, Coumadin, Zoloft, and Cardizem. Technical Description: This is...
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Acronyms and Initialism
In general usage, the term acronym is commonly used to describe all abbreviations made from initial letters, regardless of pronunciation. Initialisms originally referred to abbreviations formed from initials, without reference to pronunciation. Many writers...
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Sample Report Craniotomy and Hematoma Evacuation
Preoperative Diagnosis: Epidural hematoma with right temporal fracture, coma. Postoperative Diagnosis: Epidural hematoma with right temporal fracture, coma. Procedure Performed: Right temporal parietal craniotomy, evacuation of epidural hematoma, coagulation...
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Sample Report Trigeminal Nerve Decompression
Preoperative Diagnosis: Left trigeminal neuralgia. Postoperative Diagnosis: Left trigeminal neuralgia. Procedure Performed: Left retrosigmoid craniotomy, microvascular decompression of left trigeminal nerve and drilling of petrous bone with microscope....
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Nerves of the Head and Neck Region
Nerve: Anterior femoral cutaneous Origin: Femoral nerve Course: Arises in femoral triangle, fasciae latae of thigh along path of sartorius muscle Innervation: Skin on medial and anterior aspects of thigh Nerve: Calcaneal branches Origin: Tibial and sacral...
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Nerves of the Ear Region
Nerve: Cochlear Origin: Division of vestibulocochlear nerve Course: Traverses internal acoustic meatus, enters modiolus with spiral ganglia and peripheral processes in spiral lamina Innervation: Spiral organ Nerve: Posterior auricular Origin: As first...
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Nerves of the Back and Spinal Region
Nerve: Accessory Origin: Medulla and cervical spinal cord Course: Spinal root ascends into cranial cavity via foramen magnum; exits via jugular foramen; traverses posterior triangle of neck Innervation: Sternocleidomastoid and trapezius Nerve: Dorsal...
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Nerves of the Shoulder and Arm Region
Nerve: Anterior interosseous Origin: Median nerve in distal cubital fossa Course: Inferiorly on interosseous membrane Innervation: Flexor digitorum profundus, flexor pollicis longus, pronator quadrates Nerve: Axillary Origin: Terminal branch of posterior...
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Drugs by Indication A to Z
ALZHEIMER DISEASE Acetylcholinesterase Inhibitor Aricept® [US/Can] Cognex® [US] donepezil Exelon® [US/Can] rivastigmine tacrine Acetylcholinesterase Inhibitor (Central) galantamine Reminyl® [US] Cholinergic Agent Exelon® [US/Can] rivastigmine Ergot Alkaloid...
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Sample Report Polysomnography Study
Clinical History: The patient is a 50-year-old female who presents with a chief complaint of, "I have trouble falling asleep and staying asleep. Once I wake up at night, I have trouble going back to sleep. I often wake up with a headache." She measures...
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Nerves of the Legs and Feet
Nerve: Anterior femoral cutaneous Origin: Femoral nerve Course: Arises in femoral triangle, fasciae latae of thigh along path of sartorius muscle Innervation: Skin on medial and anterior aspects of thigh Nerve: Calcaneal branches Origin: Tibial and sacral...
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Muscles of the Thorax and Abdomen
Muscles Of The Posterior Abdominal Wall Muscle: Psoas major Origin: Sides of T12-L5 vertebra and disk; transverse processes Insertion: Lesser trochanter of femur Nerve: Anterior rami of L1, L2, and L3 Action: Flexes and rotates thigh laterally at hip;...
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Drugs by Indication: Gout - Muscle Spasm
Gout Antigout Agent colchicine colchicine and probenecid Nonsteroidal Antiinflammatory Drug (NSAID) Aches-N-Pain® [OTC] Advil® [OTC] Aleve® [OTC] Anaprox® Apo®-Diclo (Can) Apo®-Ibuprofen (Can) Apo®-Indomethacin (Can) Apo®-Napro-Na (Can) Apo®-Naproxen...
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PT 2
A Abdomen abduction abnormal abnormality Abrasion AC Joint acceleration acceleration of gravity accessory movement acquired disease active motion active range of motion Acute adduction adipose tissue agonist alignment amphiarthrosis anatomic position...
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Drugs by Indication: Back Pain - Epicondylitis
Back Pain Analgesic, Narcotic codeine Codeine Contin® (Can) Analgesic, Nonnarcotic Anacin® [OTC] Arthritis Foundation® Pain Reliever [OTC] Arthropan® [OTC] Ascriptin® [OTC] aspirin Asprimox® [OTC] Bayer® Aspirin [OTC] Bayer® Buffered Aspirin [OTC] Bayer®...
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Drugs by Indication: Pain I
Pain Analgesic, Narcotic acetaminophen and codeine Actiq® Oral Transmucosal Alfenta® alfentanil Anexsia® Anodynos-DHC® aspirin and codeine Bancap HC® belladonna and opium B&O Supprettes® Buprenex® buprenorphine butalbital compound and codeine butorphanol...