Grand Strand Regional Medical

Speech Therapy Department

Intern Overview Packet & Study Guide

Table of Contents

Patient Assessment/Status………….…………………………………………………………2 Aphasia……………………………….………………………………………………………….3 Swallowing Mechanism……………………………………….……………………………..…4 Dysphagia…………………………………………,………………………….……………….5­7 Cognitive Diagnostic Tests………………………………………………….……………...6­12 Stroke………………………………………………..………………………………………13­15 Brain Function & Brain Injury………………………………………………………….….16­23 Vocabulary and Abbreviations……………………………………………………..……..24­29

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Patient Assessment/Status

Level of Consciousness

Awake (A), Alert (A), Oriented (O): Normally a person is awake, alert, and oriented knowing who they are, where they are, the date, the time, and what has happened or the current situation. When a patient is assessed in the hospital their level of consciousness is measured by their AAO on the scale shown below:

AAOX4 The person knows person, place, time and situation.

AAOX3 The person knows person, place and time, but not situation.

AAOX2 The person knows person and place, but not time and situation.

AAOX1 The person knows person, but not place, time and situation.

AAOX0 The person is awake and alert, but is disoriented.

http://www.nols.edu/alumni/leader/02summer/patientassessment.shtml

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Aphasia

Definition

Communication disorder that causes difficulty in speaking, listening, and reading. Individuals who suffer from aphasia do not decline cognitively and most likely still have the ability to understand others, but they have difficulty speaking fluently or finding and saying the appropriate words. There are various causes, symptoms, and types of aphasia.

Causes:

Stroke, Brain Injury, Neurological Disorder, Dementia

Types:

Expressive/Nonfluent/Broca’s Aphasia: The person has difficulty saying exactly what they want to say however, they know what they want to stay and understand language. Receptive Aphasia/Fluent/Wernicke’s Aphasia: The person has difficulty understanding and comprehending the meaning of spoken words. The patient can speak fluently but the words often do not make sense. Anomic Aphasia: These individuals have difficulty with word­finding and have a hard time saying what they want to say. Global Aphasia: These individuals have difficulty speaking and understanding as well as inability to read or write. This is the most severe type of aphasia and is often seen immediately following a stroke. Primary Progressive Aphasia: These individuals slowly lose their ability to read, write, talk, and understand. http://www.webmd.com/brain/aphasia­causes­symptoms­types­treatments

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Swallowing Mechanism

Swallowing Stages 1. Oral Phase: Food is chewed and mixed with saliva to form a bolus. The tongue

is responsible for propelling the bolus from the front to the back of the mouth. 2. Pharyngeal Phase: The food has reached the upper throat area and the

following occurs: a. The soft palate rises b. The epiglottis closes off the trachea to prevent food from entering the

airway. 3. Esophageal Stage: The bolus reaches the esophagus and is propelled down to

the stomach through muscle contractions.

http://www.uwhealth.org/voice­swallow/stages­of­swallowing/11463

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Dysphagia

Definition

Difficulty chewing or swallowing foods or liquids in different phases of the swallowing process. Poor swallow function can lead to aspiration which can then lead to pneumonia making it extremely important to diagnose dysphagia and alter the individual’s food and liquid intake until swallow function improves.

Common Causes

Stroke, Brain or Spinal Cord Injury, Parkinson’s disease, Multiple Sclerosis, Cerebral Palsy, ALS, Alzheimer's Disease, Neck Injury, Throat or Mouth Cancer.

Types

Oropharyngeal: Difficulty in the initial stage of the swallowing process Oral Difficulties

Difficulty sucking from a straw Difficulty forming a bolus Difficulty moving the bolus to the back of the mouth

Pharyngeal Difficulties: Difficulty closing off the airways properly causing food or liquid to move

toward the trachea Difficulty holding food or liquid in the mouth causing food or liquid to reach

the throat before the swallow is triggered. Esophageal:

Food or liquid does not reach the stomach properly and often stops in the esophagus

Aspiration: When food or liquid enters the airway (trachea) below the vocal folds. A SLP’s responsibility is to evaluate a patient’s swallow to determine whether or not they are showing signs and symptoms of aspiration. The patient is given a variety of liquids and solids of different viscosities and consistencies to determine the safest diet for the patient. The dysphagia solid and liquid levels are outlined below. Signs and Symptoms

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Coughing after swallowing food or liquid Throat clearing after swallowing food or liquid Difficulty breathing (fast, slow, gurgling lung sounds) A change in voice Fever (dizzy, sweating, chill)

Dysphagia Diets Liquids:

Thin: These are liquids of normal or everyday thickness such as: Water Coffee Juice Broth Milk Soda Tea Ice Cream

Nectar­Thick: Mildly Thick These are thin liquids that have been thickened using a nectar thickening

packet

Honey­Thick: Moderately Thick

These are thin liquids that have been thickened using a honey thickening packet.

Pudding Thick: Extra Thick

Solids: 6

Regular: No restrictions Reduced Level 1: Mechanical Soft Diet

Easy to chew foods Avoid dry, crunchy, chewy or hard foods

Reduced Level 2: Pureed Diet Pudding­like consistency; no chewing Anything that is pureed or blended

Evaluation:

To test the patient’s ability to swallow liquids the SLP often gives the patient the following liquids in the following order. If the patient shows signs or symptoms of aspiration the SLP will thicken the liquid as listed below:

1. Thin Water 2. Nectar Thickened Water 3. Honey Thickened Water

To test the patient’s ability to chew and swallow solids the SLP often gives the

patient the following food items in the following order. If the patient shows signs or symptoms of aspiration the SLP will often not test further

1. Reduced Level 2: Applesauce, Pudding 2. Reduced Level 1: Fruit Cup 3. Regular: Graham Cracker, Granola Bar

Further Testing Methods

Modified Barium Swallow: This procedure is performed in radiology and the patient eats and drinks foods/liquids that are covered in barium paste. The swallowing process is visible as a video x­ray.

FEES: Fiberoptic Endoscopic Evaluation of Swallow A scope is inserted through the nose and rests near the esophagus. The swallow

can be viewed on a screen while the procedure is done at the patient’s bedside. http://www.asha.org/public/speech/swallowing/Swallowing­Disorders­in­Adults/#signs

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Cognitive Diagnostic Tests

ROSS Information Processing Assessment Second Edition (RIPA)

Subtest 1: Immediate Memory “Say these after me: 4­3­7”

Subtest 2: Recent Memory “How long have you been in the hospital?”

Subtest 3: Temporal Memory (Recent Memory) “What year is it?”

Subtest 4: Temporal Orientation (Remote Memory) “What are the days of the week?”

Subtest 5: Spatial Orientation “What city are you in now?”

Subtest 6: Orientation to Environment “Who is your doctor?”

Subtest 7: Recall of General Information “Who is our president?”

Subtest 8: Problem Solving and Abstract Reasoning “You are driving on the highway and run out of gas. What do you do?”

Subtest 9: Auditory Processing and Retention “Name as many animals as you can in one minute.” “What are birds, cats, and camels?”

Subtest 10: Problem Solving and Concrete Reasoning “Does it take longer to put on a hat than shoes?”

ROSS Information Processing Assessment­ Geriatric (RIPA­G)

Subtest 1: Immediate Memory “Say these numbers after me: 5­2­4­8”

Subtest 2: Recent Memory “How many children do you have?”

Subtest 3: Temporal Orientation “What year is it?”

Subtest 4: Spatial Orientation “Where were you born?”

Subtest 5: Orientation to Environment “What meals have you eaten today?”

Subtest 6: Recall of General Information

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“Who was your favorite president?” Subtest 7: Problem Solving and Abstract Reasoning

“What would you do if you needed to go to the bathroom?” Subtest 8: Organization of Information

“Name as many animals as you can in one minute.” “What are cats, dogs, birds?”

Subtest 9: Auditory Processing and Comprehension “Does a sheet go over a blanket?”

Subtest 10: Problem Solving and Concrete Reasoning What can you do if a piece of food is too large?”

http://overlake.virtual­space.net/SLP/RG.pdf

Galveston Orientation Amnesia Test (GOAT)

The GOAT is administered to measure attention and orientation. The GOAT is often used to determine whether or not a patient suffers from amnesia after a traumatic brain injury. A score of 78 or more on 2 consecutive occasions is considered to indicate post­traumatic amnesia (PTA). Scoring 76­100: Normal 66­75: Borderline <66: Impaired

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http://scale­library.com/pdf/Galveston_Orientation_Amnesia_Test.pdf

Montreal Cognitive Assessment Test (MOCA)

The MOCA is used as a quick screening tool for mild cognitive dysfunction. The test takes about 10 minutes to administer. Scoring: 26­30: Normal Assesses:

Attention and Concentration Executive Functioning Memory Language Visuoconstructional Skills Conceptual Thinking

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Calculations Orientation

http://www.parkinsons.va.gov/Consortium/MoCA.asp

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Mini­Mental State Examination (MMSE):

The MMSE is used to measure cognitive impairment and often used for dementia. The MMSE is best used to follow progress over time and notice change due to treatment. The test takes approximately 5­10 minutes to administer. Scoring: 15 and below: Absolute Dementia 20 and below: Dementia 21­25: Borderline 26>: Normal Assesses:

Registration Attention and Calculation Recall Language Ability to Follow Commands Orientation

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Stroke Definition: A stroke occurs when one of the arteries that supplies blood to the brain is blocked. This alters or inhibits blood flow to the brain causing brain malfunctions and alterations. A stroke normally happens on one side of brain which affects coordination and control of the opposite side of the body. Overview of the Effects of a Stroke

Dysphagia: Swallowing difficulty Dysarthria

Mild­ Slurred Speech Severe­ Inability to coordinate speech; cannot be understood

Hemiparesis: Weakness or paralysis on one side of the body Memory Problems Loss of Judgement Increased Impulsivity Loss of Sensation Vision Problems Difficulty with thinking, attention, learning, comprehension

If the stroke occurs on the right side of the body:

Paralysis or loss of coordination and function on the left side of the body Vision problems and difficulty Quick, abrupt behavior Memory loss

If the stroke occurs on the right side of the body: Paralysis or loss of coordination and unction on the right side of the body Speech/language problems Slow behavior Memory loss

Types TIA: Transient Ischemic Attack/Mini­Stroke

A TIA occurs when blood flow to the brain is only blocked for a short amount of time causing temporary problems.

Ischemic Stroke: Occurs when an artery in the brain is blocked Embolic: A blood clot forms somewhere outside of the brain, but eventually travels to

the brain and blocks an artery. Thrombosis: A blood clot forms in an artery that is directly supplying blood to the brain.

Hemorrhagic Stroke: Occurs when a blood vessel in the brain bursts Intracerebral: Occurs when a blood vessel bursts and bleeds into brain tissue causing

decline in this area of the brain

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Subarachnoid: Occurs when a blood vessel bursts near the brain and then leaks into the space between the brain and the skull.

http://www.allinahealth.org/Health­conditions­and­treatments/Health­library/Patient­education/Understanding­Stroke/Effects­of­stroke/Physical­effects­on­either­side­of­the­brain/ The link below provides more information on strokes and their effect on the body and function. https://www.stroke.org/sites/default/files/resources/ExplainingStrokeBrochure.pdf

NIH Stroke Scale

Assesses: Consciousness Brain Function Vision Sensation Movement Speech Language

Scoring: 0= No Stroke 1­4= Minor Stroke 5­15= Moderate Stroke 15­20= Moderate/Severe Stroke 21­42= Severe Stroke

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The Brain

Brain Sections

Cerebrum: The largest part of the brain that is responsible for majority of the brain’s function.

Divided into 4 Lobes: Frontal Lobe: Self­awareness, creative thought, problem solving,

intellect, judgement, reasoning, behavior, attention, abstract thinking, physical reactions, coordinated movements, smell, personality, decision making

Broca’s Area: Language processing and comprehension, speech

Parietal Lobe: Visual function, language, reading, internal stimuli, tactile sensation, and sensory comprehension

Sensory Cortex: Receives information relayed from the spinal cord related to the position of body parts and their movement.

Motor Cortex: Monitors and controls movement throughout the body

Temporal Lobe:Visual and auditory memories, speech and hearing capabilities, behavior, and language.

Wernicke’s Area: Controls expressive language Occipital Lobe: Controls vision

Cerebellum: Regulation and coordination of movement, posture, and balance Limbic System: Controls and relays emotions

Amygdala: Helps the body respond to emotions, memories, and fear Hippocampus: Controls learning memory and the conversion of temporary

memories into permanent memories Thalamus: Controls attention span and sensations.

Brainstem: Controls basic life functions; heart rate, blood pressure, breathing Midbrain Pons Medulla Oblongata

Spinal Cord: Carries messages between the brain and the rest of the body. Blood Vessels: Carry blood to the brain

http://www.md­health.com/Parts­Of­The­Brain­And­Function.html

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Brain Injury

Brain Injury Types

Traumatic Brain Injury: Change in brain function caused by an external force Falling, motor vehicle accident, object penetrating skull

Non­Traumatic Brain Injury: Caused by an illness or disruption/lack of oxygen flow to the brain

Strokes, aneurysms, cardiac arrest, drowning, tumors, infections

Possible Effects of Brain Injury

Frontal Lobe

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Difficulty making decisions, focusing attention on tasks, planning tasks and problem solving.

Easily distracted Stubborn Personality changes Difficulty maintaining socially appropriate behavior Repeats the same action or words over and over without realizing it Mood swings Word finding problems

Parietal Lobes Difficulty with hand­eye coordination Inability to recognize touch sensation on the opposite side of the body Right Side

Difficulty drawing Lack of awareness of certain body parts

Left Side Difficulty naming objects, doing math problems, writing words

Temporal Lobes Memory problems Changes in sexual interest Aggressive behavior Right Side

Difficulty recognizing faces, understanding spoken words, recognizing music

Persistent talking Left Side: Wernicke’s Area

Inability to read or understand what someone is saying Occipital Lobe

Difficulty in vision, locating objects, recognizing colors, reading and writing Inability to recognize words or accurately see objects

*For further information seek Grand Strand Regional Medical Center: Guide to Brain Injury

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Right vs. Left

Injury to Right Side

Difficulty in understanding language, speaking Depression and anxiety Impaired logic Inability to sequence events Decreased control over the right side of body

Injury to Left Side Visual impairment Inattention to left side of body Altered creativity Loss of big picture type thinking Decreased control of left side of body

http://brainmadesimple.com/left­and­right­hemispheres.html

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Diagnosing Severity of Brain Injury Glascow Coma Scale: Estimates and categorizes the outcome of brain injury based on motor, verbal, and eye opening responses. Eye Opening Response • Spontaneous­­open with blinking at baseline 4 points • To verbal stimuli, command, speech 3 points • To pain only (not applied to face) 2 points • No response 1 point Verbal Response • Oriented 5 points • Confused conversation, but able to answer questions 4 points • Inappropriate words 3 points • Incomprehensible speech 2 points • No response 1 point Motor Response • Obeys commands for movement 6 points • Purposeful movement to painful stimulus 5 points • Withdraws in response to pain 4 points • Flexion in response to pain (decorticate posturing) 3 points • Extension response in response to pain (decerebrate posturing) 2 points • No response 1 point Categorization: Coma: No eye opening, no ability to follow commands, no word verbalizations (3­8) Severe Head Injury­­­­GCS score of 8 or less Moderate Head Injury­­­­GCS score of 9 to 12 Mild Head Injury­­­­GCS score of 13 to 15 http://www.cdc.gov/masstrauma/resources/gcs.pdf

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Ranchos Los Amigos Scale: Used to determine the patient’s level of activity following brain injury by measuring levels of awareness, cognition, behavior, and environmental interaction.

Level 1: No reaction ­ The brain­injured person is unconscious. They appear to be sleeping. They do not react to any stimuli. This comatose state can last for seconds, minutes, hours, days, weeks or months.

Level 2: Generalized reaction ­ The brain­injured person will react but inconsistent and without purpose. The reaction is often broad body movement or garbled words and the reaction is usually the same regardless of what the stimulus is. The first reaction is usually to deep pain.

Level 3: Localized reaction ­ The brain­injured person is improving. They will react more specifically to different stimuli but the reaction is different each time. For example, they may occasionally turn their head in the direction of a speaker's voice. They may have a vague awareness of their body. They may sometimes follow simple commands such as "close your eyes" or "squeeze my hand".

Level 4: Confused/Agitated ­ The brain­injured person has become very active but they are not yet able to understand what's going on. The behavior might become bizarre. They might cry out or try to remove the feeding tube. They may be hostile and uncooperative but they are not acting out of anger or fear. This is a reaction to their confusion.

Level 5: Confused/Inappropriate ­ The brain­injured person has become less agitated. They react to simple commands in a more consistent manner. If the commands are more complicated, they get confused and react incorrectly. They may become agitated if they are in a noisy or "busy" environment. They will not take the first step. They will react best to body aches and pains, to their own comfort and to close family members. Memory is severely damaged and they are unable to learn new information. At this level, they are in danger of "wandering off."

Level 6: Confused/Appropriate ­ Things are looking up. The brain­injured person is motivated but still depends on others to lead the way. Reactions will be more appropriate. If they are uncomfortable, they will complain. They are beginning to recognize therapy staff and are much more aware of self and family. They can easily follow simple directions. Memory of the past has improved greatly but memory of recent events is still damaged.

Level 7: Automatic/Appropriate ­ The brain­injured person seems to act appropriately in the hospital and at home. They know who they are, where they are, the date and time. All seems well but things are still not completely right. They go through daily routines automatically like a robot. Although they can dress, wash and feed themselves without help, they need guidance to stay safe.

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Judgment and problem­solving skills are still damaged and they cannot make realistic plans for the future.

Level 8: Purposeful/Appropriate ­ At last! The brain­injured person remember show the past fits with the future. They are independent and can function well in society. They may still have some difficulty with reasoning, judgment and learning, especially in high stress, unusual or emergency situations. They may be actively involved in a vocational rehabilitation program, learning a new way to live.

http://www.mc.vanderbilt.edu/documents/traumasurvivors/files/The%20Rancho%20Los%20Amigos%20Scale.pdf

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Vocabulary AAC (Augmentative and Alternative Communication): All forms of communication

other than oral speech. Aided AAC: Rely on the user’s body to convey the message such as body

or sign language Unaided AAC: Requires the use of tools or equipment in addition to

gestures or body language ranging from paper/pencil to communication boards, or electronic devices to create messages.

Agnosia: Inability to recognize objects when using a specific sense such as visual, auditory, and touch

Agraphia: Inability to produce written language Amnesia: Loss of memory due to brain injury, shock or illness.

Anterograde: Loss of memories that were formed before the injury. Retrograde: Loss of ability to form new memories after the injury. Post Traumatic Amnesia: State of confusion immediately following

traumatic brain injury. During PTA the individual cannot store new events in memory or remember events that occur after the injury and is often confused and disoriented.

Anosognosia: The denial or unawareness of one’s neurological deficits Aphasia: Difficulty understanding, speaking, reading, and writing while cognitive

function is normally intact. Normally caused by damage to the left side of the brain Types:

Expressive: Have trouble speaking and writing; also known as Broca’s Aphasia

Only able to say 1 or 2 words at a time Have trouble thinking of the words they want to say Leave words out of sentences Have problems spelling Have trouble putting together sentences that make sense

Receptive: Have trouble reading and understanding; also known as Wernicke’s Aphasia

Only able to follow simple directions Trouble following a conversation Need to have information repeated Need visual or touch cues to help them understand Have trouble understanding what they read

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Say words that don’t make sense but don’t know that others can’t understand them.

Global: Have trouble with speaking, writing, reading, and understanding Aphonia: Loss of voice Apraxia: The inability to perform a movement or sequence of movements

despite intact sensation and understanding of the task; difficulty controlling mouth to speak clearly

Mix up sounds in words Say the wrong sounds Say words and sounds differently each time Struggle to say sounds

Articulation: Producing speech sounds Aspiration: Inhaling of a liquid or object into the airway

Signs and Symptoms Coughing after swallowing food or liquid Throat clearing after swallowing food or liquid Difficulty breathing (fast, slow, gurgling lung sounds) A change in voice Fever (dizzy, sweating, chill)

Ataxia: Lack of coordination fine and gross motor activity Bolus: Mass of food prepared by the mouth for swallowing (after chewing). CABG: A surgical procedure that improves and restores normal blood flow to the

heart for people with coronary heart disease. Cerebrovascular Accident: Decreased blood flow to the brain caused by a

blocked artery that results in the death of brain cells, also known as a stroke. Cerebral Palsy: Neurological disorder that permanently affects body movement,

muscle coordination, and balance. Cognitive­Communication Disorders: Problems with memory, reasoning,

problem­solving, and attention Dysarthria: Slurred quiet speech caused by muscle weakness Dysphagia: Difficulty chewing and swallowing food and drink Esophageal Dysphagia: Occurs when foods or liquids do not reach the stomach

properly commonly caused by the backing up of stomach acid into the esophagus due to reflux problems making it harder for the esophagus to pass foods to the stomach.

Oropharyngeal Dysphagia: Difficulty with the initial stage of the swallowing process resulting problems moving food from the front to the back of the mouth.

Dysphasia: Impairment of speech due to brain damage. Dyspnea: Shortness of breath

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Edema: Medical term for swelling or when blood vessels release fluid into nearby tissues

Embolus: A blood clot that has been carried in the bloodstream and eventually lodges into a blood vessel in a new location to cause a stroke

Encephalopathy: General term for brain disease or brain damage; symptoms include memory loss, altered mental state, personality changes, dementia, seizures, or coma.

Endotracheal Intubation: A procedure in which a tube is placed into the trachea through the mouth or nose to support breathing and open the airway to give oxygen.

Fluoroscopy: X­ray study of moving body structures; used to watch a patient’s swallow.

Hematoma: The collection of blood outside of the vessel most commonly due to damage to the vessel wall. These look like bruises under the skin but can also happen in places that are not visible.

Hemorrhage: An escape of blood from a ruptured blood vessel; rapid, uncontrollable loss of blood.

Brain Hemorrhage: Localized bleeding in the brain due to the bursting of an artery in the brain. This causes swelling in the brain and increases the pressure in the brain, which kills brain cells.

Hydrocephalus: Abnormal accumulation of cerebrospinal fluid in the brain that causes it to swell. It can lead to brain damage and physical, developmental, and cognitive impairments.

Hyperlipidemia: High number of lipids or fats, most commonly referred to as high cholesterol

Infarct: An area of dead tissue resulting from lack of blood supply Ischemic Stroke: Occurs when blood vessels connected to the brain are

clogged or blocked. A clot forms and blocks the flow of blood to certain areas of the brain causing the stroke to occur.

Labial: Pertaining to the lips. Language: Words we use and understand Larynx : Valve structure between the trachea (windpipe) and the pharynx (the

upper throat) that is the primary organ of voice production Lesion: A region or zone of an organ or tissue that has suffered damage. Lingual: Pertaining to the tongue Modified Barium Swallow: The use of videofluoroscopy to evaluate a patient’s

swallow. Multiple Sclerosis (MS): A disease of the central nervous system affecting the

brain and the spinal cord.

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Muscle Atrophy: The loss of muscle ability due to underuse or neglect. Myalgia: Muscle pain Nasal Emission: Airflow through the nose, usually audible and indicative of an

incomplete seal between the nasal and oral cavities Necrosis: Death of most or all of the cells in an organ or tissue Paraesthesia: An abnormal tingling/numbness (pins and needles) sensation

usually in upper and lower extremities Paresis: Muscle weakness. Parkinson’s Disease: A progressive disease that disrupts movement.

Symptoms include tremors, slowed movement impaired posture and balance, decreased ability to perform automatic movements, speech and writing changes.

Perseveration: Repetition of a particular response (word or phrase) and repeatedly bringing up a topic that is no longer appropriate

Phonics: The relationships between written letters and their spoken sounds “Phone” spelled with a /ph/, not an /f/ as in “fone” Phonological Awareness: Awareness of individual sounds in spoken words as

well as how those sounds go together and how they can be changed to make new words

Phonology: How speech sounds go together/follow patterns to make words Speech: How we say sounds and put them together into word Thrombus: A blood clot that forms within the vascular system. Tracheostomy: A procedure done to create an opening in the trachea to provide

an airway and remove lung secretions. Often used in patients who have an object blocking the airway, or lack of ability to breathe.

Total Parenteral Nutrition (TPN): All nutritional needs are met through an IV or intravenously.

Abbreviations: A/P: anterior­posterior A&O: alert and oriented ad lib: as much as needed ADL: activities of daily living ARDS: acute respiratory distress syndrome bm: bowel movement BS: breath sounds c: with C/O: complaining of c/o: complains of CA: cancer

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CABG: coronary artery bypass grafting CN: cranial nerves CNS: central nervous system COLD: chronic obstructive lung disease COPD: chronic obstructive pulmonary disease CP: chest pain CPAP: continuous positive airway pressure CSF: cerebrospinal fluid CVA: cerebrovascular accident CXR: chest x­ray DAI: diffuse axonal injury DAT: diet as tolerated DC: discharge DJD: degenerative joint disease DM: diabetes mellitus DNR: do not resuscitate DOA: dead on arrival DOE: dyspnea on exertion DVT: deep venous thrombosis DX: diagnosis ECG: electrocardiogram EMT: eyes, motor, verbal response ENT: ears, nose, throat ETT: endotracheal tube FTT: failure to thrive FU: follow­up FVC: forced vital capacity Fx: fracture HA: headache HBP: high blood pressure HO: history of HOB: head of bed HPI: history of present illness HTN: hypertension Hx: history LLL: left lower lobe LLQ: left lower quadrant LML: left middle lobe LOC: level of consciousness

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LP: lumbar puncture LUL: left upper lobe LUQ: left upper quadrant MVA: motor vehicle accident NAD: no active disease NAS: no added salt NG: nasogastric NKA: no known allergies NPO: nothing by mouth NT: nasotracheal OPPT: oriented to person place and time PMH: previous medical history PO: by mouth PRN: as needed Pt: patient PTA: posttraumatic amnesia qd: everyday RLL: right lower lobe RLQ: right lower quadrant RML: right middle lobe ROM: range of motion RUL: right upper lobe RUQ: left upper quadrant RV: residual volume Rx: treatment s: without s/s: signs and symptoms SCI: spinal cord injury SOAP: Subjective, Objective, Assessment, Plan SOB: shortness of breath Sx: symptoms TLC: total lung capacity TPN: total parenteral nutrition TV: tidal volume Tx: treatment UGI: upper gastrointestinal VC: vital capacity VO: verbal or voice disorder VSS: vital signs stable

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WF: white female WM: white male WN: well nourished WNL: within normal limits yo: year old

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