Questions and Answers
What do Physician's orders to PT per w/c turn Pt.qh indicate?
What is the diagnosis indicated by Dx: RA; R/O SLE?
Rheumatoid arthritis, rule out systemic lupus erythematosus
What is the intervention plan stated for the patient in PT note?
See Pt. once per day for activities of daily living training including transfer training, correcting for balance issues, ultrasound at 1.0 to 1.5 watts per centimeter squared for 5 minutes.
What does c/o SOB p bilat. UE PNF exercises mean?
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What does Dx: multiple sclerosis; R/O OBS indicate?
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What is the patient's condition regarding their limb as noted in PT?
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What should you document regarding the patient's heart rate after self-care activities?
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What does the PT note indicate regarding the patient's mobility?
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What is stated about upper extremity strength in the PT or OT note?
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What is the anticipated goal regarding patient transfers?
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What does the patient complain about following ambulation?
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What should be documented regarding weight bearing?
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What does D/C US in area of (R) SI joint indicate?
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What is the medical diagnosis noted for the patient?
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What was the fasting blood sugar level upon admission?
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What does the chronic renal failure (CRF) diagnosis mean?
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What does the manual muscle test reveal?
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What does the X-ray examination reveal?
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What must be written to occupational therapy?
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What is noted about the patient's impression regarding their nerves?
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What is the term for a tumor of the bone?
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What does hypoglycemia refer to?
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What does subcutaneous mean?
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What does suprapubic refer to?
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What does dorsal or posterior refer to?
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What does cephalad mean?
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What does erythema refer to?
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What does intercostal mean?
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What does anterior or ventral refer to?
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What does afferent refer to?
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What does symphysis pubis refer to?
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What is cardiomegaly?
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What does meniscectomy refer to?
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What does chondroma refer to?
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What does arthrodesis mean?
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What does craniotomy refer to?
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What does neurology study?
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What does anesthesia refer to?
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What is phlebitis?
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What does hypertension refer to?
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What is arthritis?
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What does arthroscopy entail?
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What is myopathy?
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What does dyspnea mean?
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What is ataxia?
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What does chondromalacia mean?
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What is encephalitis?
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What is meningioma?
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What does hemiplegia refer to?
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What does subclavicular mean?
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What does analgesia mean?
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What does bilateral refer to?
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What does contralateral mean?
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What does aphasia refer to?
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What is tendinitis?
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What does bradykinesia mean?
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What does dysphagia mean?
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What does arthralgia mean?
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What is cerebromalacia?
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What does costochondral refer to?
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Study Notes
Physician Orders and Medical Records
- "to PT per w/c turn Pt.qh" indicates patient is to go to physical therapy in a wheelchair and be turned every hour.
- Diagnoses in medical records include "Dx: RA; R/O SLE" for rheumatoid arthritis and the need to rule out systemic lupus erythematosus.
- Intervention plans in physical therapy may include activities of daily living (ADL) training, ultrasound treatments, and specific knee care.
Patient Complaints and Vital Signs
- Complaint of shortness of breath (SOB) post bilateral upper extremity exercises noted as "c/o SOB p bilat.UE PNF exercises."
- Heart rate increase after self-care activities documented as "Pt.HR ^ 20 BPM p 2 min. of self-care ADL."
Patient Abilities and Assessment
- Ambulation ability in the parallel bars requires minimal assistance and is noted with full weight-bearing (FWB) status.
- Upper extremity strength assessment reports as 5/5 bilaterally.
Rehabilitation Goals and Orders
- Anticipated rehabilitation goals aim for decreased dependence in transfers within one week.
- Documented orders for physical and occupational therapy must include the verbal order of physicians.
Medical Diagnoses and Definitions
- Conditions like multiple sclerosis (Dx: multiple sclerosis; R/O OBS) and chronic renal failure (Dx: CRF) are recorded.
- Fractures and joint issues, such as fractures of the left clavicle and left sternoclavicular subluxation, are critical components of medical documentation.
Common Medical Terms
- Abnormal conditions such as hypoglycemia (low blood sugar), erythema (redness of skin), and ataxia (lack of coordination) are important clinical observations.
- Anatomical terms like subcutaneous (beneath the skin), suprapubic (above the symphysis pubis), and contralateral (opposite side) are essential for precise communication.
Surgical Procedures and Physical Assessment
- Terms like craniotomy (surgical opening of the skull) and arthroscopy (inspection of a joint with a scope) describe various procedures.
- Conditions such as tendinitis (inflammation of a tendon), arthritis (joint inflammation), and dysphagia (difficulty swallowing) are commonly encountered in patient assessments.
Neurological Observations
- Neurological terms include neurology (study of the nervous system), myopathy (disease of muscle), and hemiplegia (paralysis of one half of the body).
- Other relevant conditions include encephalitis (inflammation of the brain) and meningioma (tumor of the meninges).
Synonyms and Clinical Context
- Terms like analgesia (without pain) and bradykinesia (slowness of movement) describe patient experiences in clinical settings.
- Key demonstrated knowledge includes understanding of cardiovascular terms such as hypertension (high blood pressure) and cardiomegaly (enlargement of the heart).
Miscellaneous Medical Conditions
- Conditions like osteoma (bone tumor), chondroma (cartilaginous tumor), and chondromalacia (softening of cartilage) contribute to orthopedic assessments.
- Observations of joint pain, such as arthralgia (pain in joints) and chronic conditions necessitating pain management.
Key Abbreviations and Terminology
- Recognize abbreviations like B/K for below-the-knee amputation and PWB for partial weight-bearing.
- Important clinical abbreviations include D/C for discontinue, c for with, and R/O for rule out.
This summary encapsulates key medical terms, patient assessment notes, and essential clinical concepts necessary for understanding medical documentation and patient care protocols.
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Description
Test your knowledge of common medical abbreviations with this quiz. Each card provides a term or abbreviation commonly used in physician's orders and medical records, along with its definition. Enhance your understanding of medical terminology and improve your communication in healthcare settings.