PPA-1-ABBREVIATIONS CHART Abbreviation Letters Represent Context Definition or Application within the Patient’s Chart Source Document From Jane’s Dare Medical Record found on bottom of Medical Record pages… 1. ICD International Classifications of Diseases‚ Ninth Revision Published by WHO This is a systematic classification of diagnosis codes. These codes are numeric and alphanumeric codes that represent medical diagnoses ADMISSION SUMMARY 2. CM Clinical Modification This abbreviation
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PEDIATRIC NEUROLOGY CLINIC CONSULT_____________________ Patient Name: Grace Pereira PCP: Reed Phillips‚ MD Patient ID: 017990 DOB: 06/24/2007 Age: 7 Sex: F Date of Exam: 05/05/2015 Reason for Visit: Follow-up of behavior‚ patient accompanied by mother‚ records are unavailable. HISTORY: Grace a 7-year-old girl has a history of severe behavioral problems‚ ADHD‚ bipolar disorder‚ borderline mental retardation‚ and significant past medical history of congenital hydrocephalous associated
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SOCIAL HISTORY He is disabled. No history of tobacco use PHYSICAL EXAMINATION VITAL SIGNS: T 103.2‚ P 105‚ RSP 20‚ BP 155/95 GENERAL: Obese‚ English speaking Caucasian male EENT: No gross abnormalities‚ Pupils restricted‚ poor dental hygiene NECK: Neck supple. No palpable nodes CHEST: Lungs are clear. HEART: Heart is regular‚ no murmurs. ABDOMEN: Soft with no palpable masses. EXTREMITIES: Examination of the left lower extremity revealed a generalized area of tender cellulitis with a moderate amount
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slithered up her sweater. Laura felt the dirt sewing her feet down and joining the rolling roots of the Douglas firs‚ which wriggled up her legs and coiled about her hips. Leaves and soil kissed her bound ankles. A horribly familiar claw rose to meet her neck. She wailed‚ only to find her mouth clamped shut and something burrowed inside. Writhing‚ scraping‚ and raking away at her‚ smothering every orifice‚ every sense and limb. I don’t want to die‚ I don’t want to die. No one even knows I’m here. Gathering
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Lyme Disease Chief Complaint: Parents report that their son has been febrile for a few days and “he has been rubbing his right ear off and on”. SUBJECTIVE: HPI: A six-year-old male patient was brought into the clinic accompanied by both parents (mother and father). They said there son was feverish over the last few days reporting the highest fever of a 100.1. Parents noticed him recently touching his right ear as if he had an ear infection. The mother treated her son with Children’s Tylenol
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Mount Carmel College of Nursing Columbus‚ Ohio Nursing 521: Advanced Pathophysiology CASE STUDY#1: CONGESTIVE HEART FAILURE Stephanie Barber September 21‚ 2011 INITIAL HISTORY: 66 year-old white male increasing shortness of breath over the last month noticed feet and ankles swelling by end of the day has occasional episodes of chest tightness has been waking up in the middle of the night with acute
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pulse Shall keep his native progress‚ but surcease. No warmth‚ no breath shall testify thou livest.The roses in thy lips and cheeks shall fade To paly ashes‚ thy eyes’ windows fall Like death when he shuts up the day of life. Each part‚ deprived of supple government‚ Shall‚ stiff and stark and cold‚ appear like death. And in this borrowed likeness of shrunk death Thou shalt continue two and forty hours‚And then awake as from a pleasant sleep. Now‚ when the bridegroom in the morning comes To rouse thee
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female in no acute distress. Alert and oriented‚ answers questions appropriately Skin- Skin is warm‚ dry‚ clean and intact. No lesions or rashes noted HEENT- Normcephalic‚ no conjunctival or scleral injection‚ ears are patent and clear bilaterally‚ neck is supple no thyromegaly or nodules‚ oral mucosa is pink and
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abnormalities. Physical Examination: Vital Signs: BP 130/80‚ P 92‚ T 98.5 General: This is a well-developed and well-nourished anxious black male in mild distress. Head and neck are normocephalic‚ atraumatic. Sclerae clear. The oropharynx is clear. The neck is supple with free range of motion and no thyromegaly. The trachea is midline and mobile. There is no crepitus noted. Lungs are clear
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Rheumatism and Arthritic conditions. This should all be written within the individuals care plan as well as a step by step plan on that has been agreed with them on how to move and handle them. We need to understand that elderly people are not as supple as younger people and even if they do not suffer movement restriction through a medical condition. They bruise easier too and so great care has to be taken when handling‚ moving and positioning them especially when assisting them to sit up or when
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