Medical Transcription and Healthcare Experience Sharing

There are a variety of medical reports created every day in physician offices, clinics, and hospitals. A Medical Transcriptionist needs to be familiar with the medical reports dictated in each work setting. Types of reports dictated in private physician practice include: 1. Office chart notes 2. Letters 3. Initial office evaluations 4. History and physical examinations Types of reports dictated in hospitals and medical centers are numerous. The reports include dictations from a basic four which are: 1. History and Physical Examinations 2. Consultation Reports 3. Operative Reports 4. Discharge Summaries In addition to the above reports emergency department reports, hospital progress notes and diagnostic studies are often also dictated. The chart note is also called progress note or follow-up note is dictated by the physician after talking with, meeting with, or examining a patient usually in an outpatien...

HORMONAL ASSAYS: Free T4 0.8-2.0 ng/dl Free T3 2.3-4.2 pg/ml TSH 0.25-4.30 microunits/ml Serum T3 70-200 ng/dl Serum T4 4.0-11.0 micrograms/dl Serum Calcitonin 0.02-0.04 ng/ml Parathormone Not detectable to 27 ng/dl Follicle Stimulating Hormone Male Not detectable to 20 miu/ml Female Follicular Phase 5-20 miu/ml Midcycle Peak 15-35 miu/ml Luteal Peak 5-20 miu/ml Post- Menopausal 40-200 miu/ml Luteinising Hormone Male Not detectable to 25 miu/ml Female Post-Menopausal 5-20 miu/ml Ovulating Females Follicular Phase Upto 8 miu/ml Mid-cycle Peak 7-50 miu/ml Luteal Phase Upto 7 miu/ml Prolactin Male Not detectable to 15 ng/ml Female Not detectable to 20 ng/ml In Pregnancy I Trimester 7-31 ng/ml II Trimester 31-182 ng/ml III Trimester 84-232 ng/ml One day Post-partum 20-319 ng/ml Testosterone Male 300-1300 ng/dl Female 3-5 ng/dl Free Testosterone Male 9-30 ng/dl Female 0.3-1.9 ng/dl 17- Ketosteroids ...

GENERAL CHEMISTRY: Acetone 0.3 - 2.0 mg% Albumin 3.5 - 5.0 gm/dL alkaline phosphatase 32 - 110 U/L anion gap 5 - 16 mEq/L Ammonia 11 - 35 µmol/L Amylase 50 - 150 U/dL AST,SGOT (Male) 7 - 21 U/L AST,SGOT (Female) 6 - 18 U/L bilirubin, direct 0.0 - 0.4 mg/dL bilirubin, indirect total minus direct bilirubin, total 0.2 - 1.4 mg/dL BUN 6 - 23 mg/dL calcium (total) 8 - 11 mg/dL carbon dioxide 21 - 34 mEq/L carbon monoxide Symptoms at greater than or equal to 10% saturation Chloride 96 - 112 mEq/L creatine (Male) 0.2 - 0.6 mg/dL creatine (Female) 0.6 - 1.0 mg/dL Creatinine 0.6 - 1.5 mg/dL Ethanol 0 mg%; Coma: greater than or equal to 400 - 500 mg% folic acid 2.0 - 21 ng/mL Glucose 65 - 99 mg/dL (diuresis greater than or equal to 180 mg/dL) HDL (Male) 25 - 65 mg/dL HDL (Female) 38 - 94 mg/dL Iron 52 - 169 µg/dL iron binding capacity 246 - 455 µg/dL lactic acid 0.4 - 2.3 mEq/L lactate 0.3 - 2.3 mEq/L lipase 10 - 140 U/...

HEMATOLOGY: Red Blood Cells RBC (Male) 4.2 - 5.6 M/µL RBC (Female) 3.8 - 5.1 M/µL RBC (Child) 3.5 - 5.0 M/µL White Blood Cells WBC (Male) 3.8 - 11.0 K / mm3 WBC (Female) 3.8 - 11.0 K / mm3 WBC (Child) 5.0 - 10.0 K / mm3 HEMOGLOBIN: Hgb (Male) 14 - 18 g/dL Hgb (Female) 11 - 16 g/dL Hgb (Child) 10 - 14 g/dL Hgb (Newborn) 15 - 25 g/dL HEMATOCRIT: Hct (Male) 39 - 54% Hct (Female) 34 - 47% Hct (Child) 30 - 42% MCV 78 - 98 fL MCH 27 - 35 pg MCHC 31 - 37% neutrophils 50 - 81% bands 1 - 5% lymphocytes 14 - 44% monocytes 2 - 6% eosinophils 1 - 5% basophils 0 - 1% COAGULATION: ACT 90 - 130 seconds APTT 21 - 35 seconds platelets 140,000 - 450,000 /ml plasminogen 62 - 130% PT 10 - 14 seconds PTT 32 - 45 seconds FSP Less than 10 µg/dL fibrinogen 160 - 450 mg/dL bleeding time 3 - 7 minutes thrombin time 11 - 15 seconds In the next lesson, we will see NORMAL LAB VALUES OF HEART.. Come ...

Medical terminology is a LANGUAGE helping us to learn medical science effectively. Medical terminology anlysis each word in medical science and divide each word into 1. SUFFIX 2. PREFIX 3. COMBINING VOWEL OR ROOT By this division we can understand better about medical words. IMPORTANCE OF MEDICAL WORD ANALYSIS:The first important foremost thing is to understand medical terminology by the technique ofword analysis method. Using division of words by this method makes us understand easilydifficult medical terms with relation to its meaning.The aim of this lesson is to analyze medical words or medical terminology.some medical words or medical terms are same in pronounciation, but their spellings aredifferent.For instance see these words:ilium and ileumthese are same in pronounciation, but the meanings are different.ilium is part of the hip bone. ileum is part of the small intestine.and note these words urethra and ureter, these two words resemble like the same word, bu...

ROOT: This is the foundation of the word.  All medical terms consists of one or more ROOTS.eg. pulmonology in this word pulm/ is the ROOT, which means lung.  See some more examples: 1. gastritis (inflammation of the intestine) - gastr/o is the ROOT, which means intestine. 2. hepatitis (inflammation of the liver) - hepa/o is the root, which means liver 3. cardiology (study of heart) - cardi/0 means heart 4. adenoma (tumorous mass) - aden/o means gland 5. arthritis (inflammation of the joint) - arthr/o means joint 6. biology (study of life) - bio/o means life 7. carcinoma (cancerous tumor) - carcin/o means cancerous tumor 8. cardiology - cardi/o means heart 9. cephalic - cephal/o means head 10. incision - cis/o means cutting into 11. endocrine - crini/o means gland 12. cytology - cyt/o means cell 13. cystoscopy - cyst/o means bladder 14. dermatitis- derm/o means skin 15. dermatology - dermat/o means skin 16. electrocardiogram - electro/o means electricity 17....

To know the relationship of one location of the body to the another, we should understand about body positional and directional terms of Medical terminology. (1) Anterior or ventral:- This position refers to front side of the body. Ex:- chest is anterior to the back. In a human anterior and ventral are the same position, but in four-legged animals anterior refers to front side of the body near the head and ventral refers to the abdomen side. (2) Posterior or dorsal:- Posterior or dorsal refers to the back side of the body. Back is the posterior or dorsal to the chest. (3) Deep:- This refers to away from the surface. Ex:- Bullet went deep into the chest. (4) Superficial:- This refers to on the surface. The shore is on the superficially infected. (5) Proximal:- This position refers to near the point of attachment or near the beginning of a structure. Ex:- The proximal end of the femur attaches with the hip bone. (6) Distal:- This position refers to far f...