Write Out Five Medical Terms, Abbreviations, Or Acronyms From The Record And Define Them

Read the medical record below. Write out five medical terms, abbreviations, or acronyms from the record and define them. This assignment isn’t timed.

CC: Epigastric pain

HPI: This 66-year-old male presents for a re-evaluation of his epigastric pain. He continues to report epigastric pain secondary to chronic pancreatitis. He states he has also been diagnosed with a tumor on his pancreas, and he is going to begin chemotherapy. He is taking MS Contin 60 mg at 7 a.m. and 9 p.m. This does help his pain without side effects. He denies renal or hepatic dysfunction.

Active Problems:

1. Chronic pancreatitis

2. Hypercholesterolemia

3. Essential hypertension

4. Degenerative arthritis of both hands

5. h/o right hip fx in 2009

PHYSICAL EXAM: Reveals a well-developed, well-nourished patient in no acute distress. He is alert and answers questions appropriately. HEENT: Head is normocephalic, atraumatic. NECK: Supple with no thyromegaly. ABDOMEN: There is no tenderness to palpation throughout the abdomen. There is no rebound tenderness. CARDIOVASCULAR: Regular rate and rhythm. RESPIRATORY: Clear to auscultation bilaterally. No wheezes, rales, or rhonchi. EXTREMITIES: No clubbing, cyanosis, or edema.

IMPRESSION:

Chronic epigastric pain secondary to chronic pancreatitis

PLAN:

Rx MS Contin 60 mg at 7 a.m. and 9 p.m.

RTO in 3 months

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