please follow the step

part1

Medical terminology is the professional and uniform language utilized in medical professions. Take a moment and reflect upon your experience with and exposure to medical terminology so far. Have you taken a previous course on medical terminology? Do you use medical terminology in your current job? Are you close to someone who has a medical condition where you had to learn some medical terminology? Is this your first time being exposed to medical terminology?

part 2

Directions:

After completing Module 01, take a moment to self-reflect. What were your successes? What areas do you need to improve upon? Did you manage your time well or do you need to make adjustments? Did you take advantage of any Rasmussen College’s Library Learning Service resources? Did you utilize any specific study techniques that you found to be helpful? Identify and discuss the obstacles you face with this course and learning medical terminology.

In your reply post, provide suggestions for the obstacles your peers have identified. Share what worked for you or suggest a resource or study skill that might help your classmates be successful in overcoming their challenges. Don’t forget to include resources that are available through Rasmussen College’s Library Learning services, online, and/or through a mobile device.

Part 3

Directions:

Understanding and retaining knowledge of medical terminology is vital in every healthcare profession. Research and think about why it is so vital in your desired profession to have the knowledge of medical terminology, and share your thoughts. How do you foresee using medical terminology in your day-to-day role and responsibilities in your desired profession? How will you maintain your knowledge of medical terminology after this course?

In your reply post, share at least 3 medical terms that you think you might use in your future career. For instance, if you plan to pursue a career in surgery, you may want to share medical terms that describe surgical procedures. Be sure to provide a brief definition of the terms you provide. Think outside the box here! You are encouraged to find medical terms that have not yet been mentioned in your textbook reading or course content.

part 4

In this course project assignment, you are presented with a medical history for two different patients. A medical history can be fairly brief or extremely lengthy, depending on the patient’s health history. Basic components of a medical history generally include the following pieces of information:

• Patient demographics: Includes name, date of birth, gender, race etc.
• Chief complaint: Specifies the primary reason for the patient seeking care
• History of present illness: Includes details of chief complaint in chronological order
• Past medical history: Includes a list of current and past medical conditions
• Family history: Includes pertinent diagnoses of close family members
• Social history: Includes information about patient’s lifestyle and characteristics
• Medication history: Includes list of current and prior medication use
• Review of systems: Includes subjective findings from a head-to-toe examination
• Physical examination: Includes objective findings from a head-to-toe examination

You will be exploring the medical terminology used in these medical histories and will be asked to interpret the meanings of various words and abbreviations.

To complete this assignment, do the following:

Module 03 Course Project: Medical History
Each question is associated with the medical histories provided. Refer to these when answering each
question. Please type your answer in the “Click here to enter text” space.
Patient A – Eric Rodriguez
1. Eric reported a motor vehicle accident in his past medical history that involved his femur. What
does the abbreviation before femur mean?
Click here to enter text.
2. Which of Eric’s relatives has experienced a neurological health issue?
Click here to enter text.
3. What type of neurologic injury does Eric report in the PMH related to his football career? Define
this medical term.
Click here to enter text.
4. The abbreviation “BG” is used in the nutrition section of this PMH. What does “BG” mean in this
context?
Click here to enter text.
5. One of Eric’s diagnoses is bipolar disorder. Identify the prefix in this word and its meaning.
Click here to enter text.
6. Eric has a history of hypertension. What 3-letter abbreviation (besides HBP) could be used for this
medical term?
Click here to enter text.
7. The abbreviation “PE” is used under the objective heading for Eric’s visit in January. What is the
appropriate meaning of PE in this objective heading?
Click here to enter text.
8.
Eric reported a major illness he had as a child, from which he fully recovered. What is the illness
and what does it mean?
Click here to enter text.
Page 1 of 3
9.
In the ROS section of this chart, Eric reports a neurological issue with both of his upper limbs. Find
the medical term used here and define the term.
Click here to enter text.
10. In the subjective portion of this patient visit, the patient denies any “LOC and syncope.” What
does LOC stand for in this context?
Click here to enter text.
11. Eric is being referred to a specialist. What type of specialist is recommended in this patient chart?
Click here to enter text.
Patient B – Jaclyn M DeMonte
12. Under Family Health History, two of Jaclyn’s relatives had been diagnosed with an endocrine
disorder affecting the adrenal glands? Which two relatives of Jaclyn had/have an endocrine
disorder affecting the adrenal glands?
Click here to enter text.
13. Jaclyn’s chief complaint is _______ and weight gain. (Identify and define the missing word.)
Click here to enter text.
14. Jaclyn’s PCP ruled out mononucleosis. What does PCP stand for?
Click here to enter text.
15. The most recent diagnosis for this patient is hypothyroidism. Identify and define the 3 word parts
that make up this medical term.
Click here to enter text.
16. Jaclyn has been prescribed a medication pending the results of her lab tests. What is the medical
abbreviation of how often she would take this medication?
Click here to enter text.
17. Her family health history states that her father has experienced two diseases. Which of these
would be considered an endocrine disorder?
Click here to enter text.
18. Jaclyn experienced acute inflammation of which endocrine organ in July of 2006?
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Page 2 of 3
19. Her physician has ordered two lab tests and one imaging test. Name and briefly describe the
imaging test ordered.
Click here to enter text.
20. Jaclyn may need to be referred to a specialist. What is the medical term for a physician who
specializes in diagnosing and treating endocrine disorders?
Click here to enter text.
References
You will primarily use your textbook as a reference this week. Provide a citation for your textbook (in
APA format) here:
Click here to enter text.
You will also likely need to use other course materials or resources to answer all of this assignment’s
questions. If you used other references, cite them here:
Click here to enter text.
*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 the type of reference you used.
Page 3 of 3
Encounter – Date of service: 01/05/17 Patient: Eric R Rodrigue…
PATIENT
Eric R Rodriguez
DOB
AGE
SEX
PRN
https://static.practicefusion.com/apps/ehr/?c=1385407302#/PF/…
FACILITY
ENCOUNTER
T (999) 999-9999
1234 Sunshine Way
100
Minneapolis, MN 99999
NOTE TYPE
SEEN BY
DATE
AGE AT
DOS
Not signed
Northstar Physicians Center
03/01/1965
52 yrs
Male
EP108956
SOAP Note
Nazir Ashaad
01/05/2017
51 yrs
Chief complaint
insomnia
Patient identifying details and demographics
FIRST NAME
MIDDLE NAME
LAST NAME
SSN
Eric
R
Rodriguez
–
SEX
DATE OF BIRTH
DATE OF DEATH
PRN
Male
03/01/1965
EP108956
ETHNICITY
PREF.
LANGUAGE
RACE
STATUS
Hispanic or
Latino
English
Patient declined
to specify
Active patient
CONTACT INFORMATION
ADDRESS LINE 1
ADDRESS LINE 2
CITY
STATE
ZIP CODE
783 Washington
Ave
Hollytown
NH
33220
CONTACT BY
EMAIL
HOME PHONE
MOBILE PHONE
OFFICE PHONE
OFFICE
EXTENSION
Home Phone
ericr@testpatient
.com
(555) 555-5555
(555) 555-5555
–
FAMILY INFORMATION
NEXT OF KIN
RELATION TO PATIENT
PHONE
ADDRESS
1 of 4
Margie Norotz
Sibling
5555555555
–
PATIENT’S MOTHER’S
MAIDEN NAME
–
4/6/17, 3:19 PM
Encounter – Date of service: 01/05/17 Patient: Eric R Rodrigue…
https://static.practicefusion.com/apps/ehr/?c=1385407302#/PF/…
Active Medications
MEDICATION
SIG
START/STOP
ASSOCIATED DX
Eszopiclone 2 MG Oral Tablet
02/14/17 –
Insomnia
LamoTRIgine 25 MG Oral Tablet
04/06/17 –
–
Lisinopril 10 MG Oral Tablet
07/02/14 –
Hypertension
Provider comment: Patient reported daily use. Prescribed by prior clinic. by Nazir Ashaad on 04/05/17
Historical Medications
MEDICATION
SIG
START/STOP
ASSOCIATED DX
LamoTRIgine 25 MG Oral Tablet
03/27/17 04/06/17
Bipolar disorder,
unspecified
LamoTRIgine 25 MG Oral Tablet
– 04/06/17
–
Zaleplon 5 MG Oral Capsule
01/03/17 02/14/17
Insomnia
Smoking History
2 of 4
STATUS
EFFECTIVE DATE
Never smoker
04/05/2017
4/6/17, 3:19 PM
Encounter – Date of service: 01/05/17 Patient: Eric R Rodrigue…
https://static.practicefusion.com/apps/ehr/?c=1385407302#/PF/…
Past medical history
MAJOR EVENTS
MVA 10/31/1978 – Fx femur, full recovery
Patient reports multiple concussions from history as collegiate football career. Did not pursue Tx.
Meningitis as a young child- full recovery
ONGOING MEDICAL PROBLEMS
Hypertension – Dx in 2014, Tx with antihypertensive medications
Weight management
FAMILY HEALTH HISTORY
Father- Hypertension, hypercholesterolemia, died from complications of stroke
Mother- Diabetes Type II, hyperthyroidism
Paternal Grandfather- Hypertension, congestive heart failure
Maternal Grandfather- Dementia, possible Alzheimers disease
Paternal Grandmother- Heart problems (unspecified)
Maternal Grandmother- Died of breast cancer
SOCIAL HISTORY
Education: Some college
Occupation: Financial manager
Disability: None
Substance Use/Abuse: Drinks alcohol (usually beer) 3-5 drinks/week. Does not smoke. No history of smoking.
Marital status: Divorced
NUTRITION HISTORY
Patient was advised to decrease carbohydrate intake in 2014 when a wellness check showed prediabetic levels of blood
glucose. He has monitored BG annually since that visit and BG has been WNL since that time.
Patient is advised to decrease saturated fat intake, increase water intake, and increase green, leafy vegetable intake.
Dietary changes will continue to be assessed. Dietician consult may be needed.
Family health history
DIAGNOSIS
ONSET DATE
No Family health history recorded
Subjective
HPI
Eric is a 38 year old man with a history of hypertension here because he has had difficulty sleeping two weeks ago lasting
for 1 week. He states that he thinks he was fine but his wife made him come because he was keeping her up all night.
He said he was staying awake all night because he felt “unstoppable.” He was writing papers during the night although
he notes that he never seemed to finish one because half way through a new topic interested him. He reports that his
wife complains that he was extremely or almost too talkative during dinner, and he says he got in trouble at work for
making a sexual advance on a co-worker, which is very unlike him. He works in human resources at an investment bank.
He denies any weight loss, fevers, chills, or night sweats. He denies any drug use. He also denies any thoughts of
harming himself or others. Of note, he says his mom takes “some sort of metal” for her mood swings. He says today he
3 of 4
4/6/17, 3:19 PM
Encounter – Date of service: 01/05/17 Patient: Eric R Rodrigue…
https://static.practicefusion.com/apps/ehr/?c=1385407302#/PF/…
feels “a little down” but denies any suicidal or homicidal ideation. He denies any LOC or syncope.
Review of Systems
Constitutional: per HPI
Neurological: Patient reports paresthesia in bilateral upper limbs.
Respiratory: No chest pain, cough, or shortness of breath.
Cardiovascular: No chest pain
Gastrointestinal: No abdominal pain, distension, or change in bowel movements.
Genitourinary: no painful, increased, or decreased urination
Musculoskeletal: negative
Endocrine: negative
Objective
PE:
General: Sitting down, not making eye contact
Cardiovascular: RRR, no MRG, 2+ radial and DP pulses bilaterally
Abdominal: soft, non-tender
Respiratory: lungs clear
Neurologic: CN2-12 intact, normal gait, reflexes normal and symmetric
HEENT: Atraumatic normocephalic. PERRL. No bleeding from nasal septum. No lymphadenopathy.
Psych: flat affect, no SI&HI
Assessment
Otherwise healthy man with symptoms concerning of bipolar disorder but currently not manic or suicidal
Diagnoses attached to this encounter:
(I10) Hypertension
(F31.9) Bipolar disorder, unspecified
(G47.00) Insomnia
Plan
Referral to psychiatrist for evaluation of possible mood disorder.
Continue hypertension medication b.i.d.
Free cloud based EHR
Encounter – Office Visit Date of service: 02/05/17 Patient: Jacl…
PATIENT
Jaclyn M DeMonte
DOB
AGE
SEX
PRN
https://static.practicefusion.com/apps/ehr/?c=1385407302#/PF/…
FACILITY
ENCOUNTER
T (999) 999-9999
1234 Sunshine Way
100
Minneapolis, MN 99999
NOTE TYPE
SEEN BY
DATE
AGE AT
DOS
Not signed
Northstar Physicians Center
10/21/1985
31 yrs
Female
JE742116
SOAP Note
Nazir Ashaad
02/05/2017
31 yrs
Chief complaint
Lethargy and weight gain
Patient identifying details and demographics
FIRST NAME
MIDDLE NAME
LAST NAME
SSN
Jaclyn
M
DeMonte
–
SEX
DATE OF BIRTH
DATE OF DEATH
PRN
Female
10/21/1985
JE742116
ETHNICITY
PREF.
LANGUAGE
RACE
STATUS
Not Hispanic or
Latino
English
White,Asian
Active patient
CONTACT INFORMATION
ADDRESS LINE 1
ADDRESS LINE 2
CITY
STATE
ZIP CODE
323 Elast Drive
Brownsville
PA
49300
CONTACT BY
EMAIL
HOME PHONE
MOBILE PHONE
OFFICE PHONE
OFFICE
EXTENSION
Home Phone
Jaclyn.demonte@
testpatient.com
(555) 555-5555
(555) 555-5555
–
FAMILY INFORMATION
NEXT OF KIN
RELATION TO PATIENT
PHONE
ADDRESS
1 of 5
Marie Demonte
Mother
5555555555
–
PATIENT’S MOTHER’S
MAIDEN NAME
–
4/6/17, 3:40 PM
Encounter – Office Visit Date of service: 02/05/17 Patient: Jacl…
https://static.practicefusion.com/apps/ehr/?c=1385407302#/PF/…
Active Medications
MEDICATION
SIG
START/STOP
ASSOCIATED DX
04/06/17 –
Hypothyroidism
START/STOP
ASSOCIATED DX
Ampicillin 250 mg oral capsule
04/10/14 05/10/14
–
Penicillin V Potassium 250 MG Oral
Tablet
05/01/14 10/06/16
Chronic sinusitis
Levothyroxine Sodium (Levoxyl) 100
MCG Oral Tablet
Historical Medications
MEDICATION
SIG
Smoking History
2 of 5
STATUS
EFFECTIVE DATE
Former smoker
04/06/2008
4/6/17, 3:40 PM
Encounter – Office Visit Date of service: 02/05/17 Patient: Jacl…
https://static.practicefusion.com/apps/ehr/?c=1385407302#/PF/…
Past medical history
MAJOR EVENTS
Fx radius- 1998
Septoplasty- December 2002
Acute pancreatitis- July 2006
Pregnancy and vaginal birth- November 2013
Hospitalized with abdominal px due to IBS- 2014
ONGOING MEDICAL PROBLEMS
Irritable Bowel Syndrome- In remission currently
Seasonal allergies
FAMILY HEALTH HISTORY
Mother- Irritable Bowel Syndrome, pancreatitis,
Addison disease
Father- CVD, Type II diabetes
Maternal GM- Stroke, Thyroid disease
Maternal GF- Died of myocardial infarction
Paternal GM- Cushing syndrome, Died of complications of thyroid cancer
Paternal GF- Unknown
Two maternal aunts diagnosed with breast cancer
PREVENTIVE CARE
Avoids allergens, controls IBS with strict diet
SOCIAL HISTORY
Nonsmoker. Quit in 2008.
NUTRITION HISTORY
Restricts seafood due to allergy.
High fiber diet helps to regulate IBS symptoms.
Small, frequent meals.
Describes her diet as “mostly vegan”.
Family health history
DIAGNOSIS
ONSET DATE
No Family health history recorded
Subjective
HPI
Jacyln presents today complaining of lethargy and weight gain. She has not changed her diet, nor exercise routine. She
denies night sweats, or chills, She denies visual changes, headache, neck pain, or nuchal rigidity. She had a septoplasty a
half-decade ago for a deviated septum and reports that it was successful and had increased her ease of breathing. She
reports seasonal allergies. She works as a dental hygienist are denies any recent trauma or lifestyle changes.
Review of Systems
Constitutional: per HPI
3 of 5
4/6/17, 3:40 PM
Encounter – Office Visit Date of service: 02/05/17 Patient: Jacl…
https://static.practicefusion.com/apps/ehr/?c=1385407302#/PF/…
HEENT: Prior septoplasty for chronic sinusitis resistant to 4 weeks of ampicillin treatment. Patient reports head cold 7
weeks ago. Her PCP ruled out mononucleosis and treated with 1 g of ampicillin daily for 4 weeks. Today, she still reports
nasal congestion, drainage, low grade subjective fevers, and facial pain.
Respiratory: Congestion due to sinusitis
Cardiovascular: negative
Gastrointestinal: occasional epigastric abdominal pain associated with IBS
Genitourinary: negative
Musculoskeletal: negative
Endocrine: Lethargy, weight gain
Objective
PHYSICAL EXAM:
General: Sitting up, concerned. Swollen appearance. Pale face. Weight gain of 12 pounds since last visit 4 months ago.
Head & Neck: No anterior or posterior cervical or auricular lymphadenopathy, maxillary sinuses tender bilaterally to
light tapping. Enlarged, tender thyroid gland
Eyes & Ears: PEERL. Tympanic membranes normal appearing without inflammation, erythema. Normal light reflex.
Oral Cavity: Posterior pharynx is mildly erythematous.
Cadiovascular: No complaints.
Gastrointestinal: No complaints of dysphagia, nausea, vomiting, or change in stool pattern, consistency, or color. She
complains of epigastric pain, burning in quality, approximately twice a month, which she notices primarily at night.
Genitourinary: No complaints of dysuria, nocturia, polyuria, hematuria, or vaginal bleeding.
Musculoskeletal: She complains of widespread aching within the last 4 months. She complains of no other arthralgias,
muscle aches, or pains.
Neurological: She reports occasional disorientation.
Assessment
DDX: Hypothyroidism
Diagnoses attached to this encounter:
(E03.9) Hypothyroidism, unspecified
Acute
Plan
Order CBC, Thyroid panel, Ultrasound of thyroid gland.
Pending results of lab tests- Levoxyl BID
Referral to specialist may be necessary. Will discuss this during follow-up visit.
Medications attached to this encounter:
Levothyroxine Sodium (Levoxyl) 100 MCG Oral Tablet
4 of 5
4/6/17, 3:40 PM
Encounter – Office Visit Date of service: 02/05/17 Patient: Jacl…
https://static.practicefusion.com/apps/ehr/?c=1385407302#/PF/…
Free cloud based EHR