Activities
AMB and up ad lib
ambulatory and up as desired
FUO up to 104° F for 2 weeks
Fever of unknown origin up to 104 degrees Fahrenheit for 2 weeks
CAD and CHF
coronary artery disease and congestive heart failure
ABG and O2 to be performed by RT
Arterial blood gas and oxygen to be performed by respiratory therapy
AMA
Against Medical Advice
OOB with BRP
out of bed with bathroom privileges
lungs CTA
clear to auscultation but CTA also stands for Computed Tomography Angiography
MI and CKD
Myocardial Infarction and Chronic Kidney Disease
UA C/S and WBC
urinalysis and culture sensitivity, and white blood cells
Dressing clean, dry, and intact
c/o GI/GU discomfort when toileting
complaints of gastrointestinal and genitourinary discomfort
pt c/o hx of IBD and IBS
The patient complains of a history of inflammatory bowel disease and irritable bowel syndrome
PE, ROS negative for DVT
Physical exam and range of systems negative for deep vein thrombosis
PS- sometimes people write PE and they mean pulmonary emboli
CXR and ECG
Chest X-ray and electrocardiogram
Pt had BMx2 using BSC
pt had 2 bowel movements using the bedside commode
MAE with NAD
moves all extremities with no apparent distress
PMS, PMDD, and PID
Premenstrual syndrome, Premenstrual dysphoric disorder, and pelvic inflammatory disease
Draw LFTs, lytes, and BUN from pt IV line
Draw liver funtion test, electrolytes, and blood urea nitrogen from patients intravenous line
TPR with BP
Temperature, pulse, respiration, with blood pressure
Keep HOB at 45°, pt to maintain CBR
Keep head of bed at 45 degrees, pat is to maintain complete bed rest
OOB q4 c assist of PCT
out of bed every 4 with the assistance of patient care technician
NG tube to LIWS for abd distension
nasogastric tube to low intermittent wall suction for abdominal distension
pt c/o L h/a and N/V. hx of ca
DOUBLE JEOPARDY
Patient complains of left headache and nausea and vomiting. history of cancer
CBC, CMP, Mag, Phos
Complete blood count, comprehensive metabolic panel, magnesium, and phosphorus
PT, OT to bedside s/p BKA
Physical Therapy, Occupational therapy to bedside status post below knee amputation