Read codes from general practice patient records and examples of accompanying free text
| Code | Accompanying text |
|---|---|
| N06z.11 Arthritis | Generally worse—quite immobile at times—knees and wrists swollen |
| N245.14 Hand pain | Pain in small joints in both hands—some hurt more than others. Wrists also in problem. O/E—tender over MCP and PIP joints of the index finger in both hands. Wrist movement painful. No joint swelling |
| 6A…00 Patient reviewed | Increased joint pains, concerned if SE of hydroxychloroquine. Pain in shoulders and hands on mobilisation—more likely to be Rh A, awaiting appointment at rheumatology |
| 8C1B.00 Nursing care blood sample taken | FBC, ESR, UE, SLFT, fasting glucose, TFT, CHOL, CRP, PSA, urate |
| 1992.00 Vomiting | Since waking this morning. No haemoptysis. O/E—looks pale and unwell. Abdomen soft, bowel normal. Had a motion this morning/normal. Stop prednisolone and indometacin. Twice omeprazole and take gaviscon (QDS). Do Hb/ESR/CRP to check progress of arthritis. Symptoms of arthritis completely disappeared. No history of indigestion |
CHOL, cholesterol; CRP, C reactive protein; ESR, erythrocyte sedimentation rate; FBC, full blood count; Hb, haemoglobin; MCP, metacarpophalangeal; O/E, on examination; PIP, proximal interphalangeal; PSA, prostate specific antigen; Rh A, rheumatoid arthritis; SE, side effect; SLFT, liver function test; TFT, thyroid function test; UE, urea and electrolytes.