Module 2 course project Medical terminology PDF

Preview

Summary

Course project for module 2 with all answers correct and for medical terminology....

Description

Module 02 Course Project: Clinical Notes Each question is associated with the clinical notes provided. Refer to these when answering each question. Please type your answer in the “Click here to enter text” space. Patient A – Kay June Salisbury 1. Kay is complaining of lower back pain. What is the medical term used to describe the lower back? The medical term used to describe the lower back is Lumbar. 2. In the subjective and plan sections of this SOAP note, the abbreviation OTC is used. What does this mean? The OTC abbreviation means over the counter medicine. 3. In the objective section of this SOAP note, the doctor noted that the patient has limited flexion in the lumbar spine. Describe what means to “flex” the spine. “Flex” the spine means to bendover forward to stretch the back. 4. If Kay had also mentioned during this visit that she has been experiencing neck pain, which medical term could be used to describe this complaint? (Use the appropriate suffix for pain) The medical term used to describe neck pain would have been Cervicalgia. 5. The abbreviation ROM is used twice in this SOAP note. What does ROM mean in this context? In this context, ROM means range of motion. 6. Kay’s physical exam revealed hypertrophy of her muscles. Describe what this means. What is the abnormality present? Hypertrophy means the enlargement of an organ or tissue from the increase in size of its cells. The abnormality would be that the cells are larger than the normal sized cells in her muscles. 7. In the assessment section of this document, the abbreviation DDX is used. This is a very commonly used abbreviation. What does DDX stand for? DDX stands for differential diagnoses. 8.

The doctor has determined that Kay may have radiculopathy. Describe what this word means in a way that an average patient could understand.

Page 1 of 3

9.

The word “unilateral” is used to describe the possible disk herniation. What does unilateral mean?

Unilateral means affecting one side of the body. 10. Find an image of a “vertebral disk herniation.” Describe (in your own words) what is happening to the anatomical structures of the spine. The spinal nerve is being compressed, pinched, and the spine is bending in a painful way. 11. In the plan section of this SOAP note, the patient is being referred for lumbar and sacroiliac radiography. What does this mean? Define each word: lumbar, sacroiliac, and radiography. The patient is being referred to get an xray of the lumbar, sacrum and ilium. Lumbar means pertaining to the loins. Sacroiliac means pertaining to the sacrum and ilium. Radiography means to get xray pictures. 12. This patient may need a follow-up MRI. What does this abbreviation stand for? The abbreviation for MRI means Magnetic Resonance Imaging. Patient B – Virginia Thompson 13. If Virginia’s physician had noted any dry or scaly skin during this visit, which medical term might he have used to describe it? (Hint: Think about the word roots you studied this week.) The medical term he might have used would be Xerosis. 14. In the objective section of this SOAP note, the macules are described as “erythematous.” What color is this word referring to? The color it is referring to is red. 15. The lesion of concern is located in the anterolateral shoulder. How would you describe the location of this lesion in your own words? The location would be the front of the shoulder. 16. In which section of this SOAP note (Subjective, Objective, Assessment, Plan) do you find a term that means “pertaining to the acromion and clavicle”? The term for “pertaining to the acromion and clavicle” would be found in the Objective. 17. What is the definition of a “macule”? The definition of macule is a discolored spot or patch on the skin neither elevated nor depressed of various color, sizes, and shapes.

Page 2 of 3

18. In this SOAP note, the terms “benign” and “malignant” are used to describe both the skin lesions. Define these terms. The term Benign means not recurrent or progressize. The term malignant means growing worse. 19. In the plan section of this SOAP note, the doctor plans to perform a biopsy. Briefly describe this procedure. By doing a biopsy, the dr would make a small excision of the tissue and put it under a microscope the exam the tissue more thoroughly. 20. Which word found in this SOAP note means “black tumor”? Black tumor means melanoma. 21. Which word found in this SOAP notes refers to a solid, elevated lesion? The word that refers to a solid, elevated lesion would be papules.

References You will primarily use your textbook as a reference this week. Provide a citation for your textbook (in APA format) here: Taber, C.W. (1870) Tabers Cyclopedic Medical Dictionary. Philadelphia: F.A. Davis Company Gylys, B.A. (2013) Medical Terminology Systems. Philadelphia: F.A. Davis Company

*If you are unfamiliar with APA citation, please see the Rasmussen College APA Guide: http://guides.rasmussen.edu/apa Select “References” on the left-hand panel and choose “Books” to learn how to properly cite your textbook for this course.

Page 3 of 3...