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