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| History of present illness |
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| Head, ears, eyes, nose and throat |
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| Pupils equal, round, and reactive to light and accommodation |
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Subjective: that which the patient describes
Objective: observable information
Assessment: patient's progress and evaluation
Plan: decision to proceed or alter the plan strategy |
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| directives for care prescribed by the attending doctor |
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| Nurse's notes or physician's progress notes |
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| chronicle patients care throughout the stay |
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| details operation including method of incision, technique, instruments, type of suture, method of closure and patients response |
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| Note additional procedures and therapies, including diagnostic tests and pathology reports |
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| Final hospital document recorded at the time of discharge which includes date of admission, diagnosis, course of treatment, final diagnosis and date of discharge |
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| a process which changes the electrical charge of atoms |
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| Imaging that utilizes x-rays to produce images |
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| computed axial tomography. Cross-sectional x-rays compiled into a 3D image |
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| Magnetic Resonance Imaging. Non-ionizing technique using magnetic fields and radiofrequency waves to visualize anatomic structures |
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| Magnetic Resonance Angiography. Uses magnetic resonance technology to study blood flow |
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| Use of sound waves to visualize anatomic structures |
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| Enhances the visualization of structures. examples include barium, iodinated compounds, gas, etc. |
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| Sharp, having intense severe symptoms |
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| A condition that develops slowly and persists for a long period of time |
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| Gradual deterioration of normal cells and body function |
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| Study of the cause of a disease |
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| Increase in the severity of a disease, with aggravation of symptoms |
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| A period in which symptoms and signs stop or abate |
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| a condition occurring without a clearly identified cause |
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