Name__________________________________________________
Senses Terminology
Charting Notes Activity
Exchange the bolded type for the correct abbreviation/terminology:
A 60 year old man with a history of (1) cerebrovascular disease is accompanied today by
her granddaughter. The daughter requests a (2) study of the nervous system consult
because of concerns she about her grandmothers mental health. She describes her
symptoms as being short term (3) memory impairment, mood changes, disorientation
and confusion. These could be related to her (4) history of CVD or a variety of disorders
including (5) progressive neurological disorder or possible side effects from her current
medications.
Plan: the physician suggests further testing to (6) rule out some possibilities by obtaining
a (7) computerized tomography and (8) magnetic resonance imaging study along with
various blood tests. She is to return to the physician’s office in 2 weeks for further
evaluation.
1. ______________________________________
2. ______________________________________
3. ______________________________________
4. ______________________________________
5. ______________________________________
6. ______________________________________
7. ______________________________________
8. ______________________________________
Name__________________________________________________
Nervous System Terminology
Charting Notes Activity
Key
Exchange the bolded type for the correct abbreviation/terminology:
A 60 year old man with a history of (1) cerebrovascular disease is accompanied today by
her granddaughter. The daughter requests a (2) study of the nervous system consult
because of concerns she about her grandmothers mental health. She describes her
symptoms as being short term (3) memory impairment, mood changes, disorientation
and confusion. These could be related to her (4) history of CVD or a variety of disorders
including (5) progressive neurological disorder or possible side effects from her current
medications.
Plan: the physician suggests further testing to (6) rule out some possibilities by obtaining
a (7) computerized tomography and (8) magnetic resonance imaging study along with
various blood tests. She is to return to the physician’s office in 2 weeks for further
evaluation.
1. ________CVD_________________
2. _______neurology_______________________
3. ______dementia___________________
4. _______hx____________________
5. _______alzheimers disease______________
6. ______r/o_______________________
7. _____CT______________________
8. ______MRI_____________________
Name__________________________________________________
Nervous System Terminology
Activity 2
Review the following medical record and answer the questions:
Hospital Summary
ADMISSION: June 5, 2011
DISCHARGE: June 10, 2011
ADMISSION DX: Severe headaches with presence of nausea and vomiting
DISCHARGE DX: Migraine, acute onset
HISTORY: Patient presents in the emergency room as a 42 year old Caucasian female
complaining of extremely severe headache with blurred vision, vomiting, and occipital
pain.
A CT scan was performed and showed no bleeding of the subarachnoid or evidence of
aneurysms. Neurologically, the patient was found to be within normal limits. Vital signs
were within normal range other than slight increase in blood pressure.
The patient was hospitalized with severe vomiting related to the headaches and was given
5mg Morphine IM. A lumbar puncture was performed to r/o possible meningitis which on
exam was ruled out as possible cause of the headaches. Patient was kept on low dose
maintenance of pain medication for discomfort and antiemetics for vomiting. An IV of NS
was administered to prevent dehydration. Patient placed on modified bedrest with head
elevation of 45° or better and ambulation to BR only. Regular diet as tolerated.
1. What was the patient admitted for? __________________________________________________
2. What type of tests was performed and for what reason? ___________________________
3. What types of treatment were used to control the pain? ____________________________
4. Why was the IV administered? _________________________________________________________
5. What limitations was the patient given? ______________________________________________