IPP - Exercise 2-1 Interpreting Abbreviations

AROM B Les WNL

Active range of motion bilateral lower extremities within normal limits.

CPT x 20 min; P&V RLL

Chest physical therapy for 20 minutes, percussion and vibration to right lower lobe

MRI revealed mod L MCA CVA

Magnetic resonance imaging revealed moderate left middle cerebral artery cerebral vascular accident

MMT 3/5 R quads

Manual muscle test 3/5 right quadriceps

Medical dx: R hip fracture ¯c ORIF

Medical diagnosis: right hip fracture with open reduction, internal fixation.

PROM R ankle DF 5°

Passive range of motion of right ankle dorsiflexion is 5 degrees

PMH: IDDM x 5 yr, HBP x 10 yr

Past medical history: insulin-dependent diabetes mellitus for 5 years, high blood pressure for 10 years

Pt. can stand ¯s A for 30 sec ¯s LOB

Patient can stand without assistance for 30 sec without loss of balance.

Pt. can transfer bed → w/c ¯c mod A using SB

Patient can transfer from bed to wheelchair with moderate assistance using sliding board

Pt. instructed in performing R SAQ, 3 sets x 10 reps

Patient instructed in performing right short arc quads, 3 sets of 10 reps

Pt. Instructed in use of TENS unit, on prn basis

Patient instructed in use of transcutaneous electrical nerve stimulator unit as needed

Pt. instructed to perform HEP b.i.d., 10 reps each ex

Patient instructed to perform home exercise program 2 times per day, 10 reps per exercise

Pt. was d/c'd from NICU on 3/3/09

Patient was discharged from neonatal intensive care unit on 3/3/90

Received Rx from MD for WBAT on L LE

Received order from (or prescription from) medical doctor for weight bearing as tolerated on left lower extremity

Pt. admitted to ER 10/12/09 with GCS of 4

patient admitted to emergency department on 10/12/09 with Glasgow Coma Scale score of four