Ch. 3 Chart Note Analysis - Sep 3 2017 - 5-44 PM.pdf

Ch. 3 Chart Note Analysis - Sep 3 2017 - 5-44 PM.pdf -...

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Unformatted text preview: 9/3/2017 PRINTED BY: dfda9305b52al [email protected] Printing is for personal, private use only. No part of this book may be reproduced or Medical Terminlogy Express: A Short Course by Body System. 2nd edition transmitted without publisher's prior permission. Violators will be prosecuted. 70 CHAarta 31'!me ABBREVIATIONS The following table introduces abbreviations assodamd with the integumentary system. Abbreviation an; Meaning f . . l _ "' l Abbreviation-gamma , u BCC basal cell carcinoma I&D incision and drainage; irrigation and débridement Bx. bx biopsy PE physical mmination; pul- monary embolism; pressure- equalizing (tube) DH diabetes mellitus SCC squamous cell aminoma FH fimily history UV ultraviolet CHART NOTES Chart notes comprise part of the medical record and are used in various types of health care facilities. The chart notes that follow were dictated by the patient's physician and reflect common clinical events using medical terminology to document the patient’ 5 care. Studying and completing the terminology and chart note analysis sections below will help you learn and understand terms associated with the medical specialty of dermatology. Terminology The following terms are linked to chart notes in the specialty of dermatology. first, practice pronouncing each m aloud. Then, use a medical dictionary such as Taber’s CylopedicMedimlIXdionarfi'Appmdk/J: Glossary of Medical WordEIemmtr, or other resouroes to define each term. Mali" gland 3mm New sthHU ocsau-i or cud BAR-to-lin *0 NW“ 09m (WM ”MM 5944“ VkalM- cow; em "m PVUQW (‘W an m in who , ko-Liatts e W m am or \nPecJasuQ. diabetes mellitus R ‘i "We o’r NW Ni V‘QM'l'in 4m: dI-a-BE-m LIE-Imus W sue-J, or to unmask (high low autumn} diaphoresis 3w cot-Hwy , 1:392:24ij +0 m \kSuud dr—a-fo-RE—m (xx/3 rub? (L3 “Stigma-om bed/g W. enter]? 3n$\o.«\M-H om oil-Mu 'm ¥.8+’\V\1«- én-lEr- ~tis , hupszllereader.chegg.ooml#/booksl978080364211 9Icfil100!/[email protected]:62.4 1/3 SIS/2017 Medical Tenninlogy Express: A Short Course by Body System. 2nd edition PRINTED BY: [email protected] Printing is for personal, private use only. No part of this book may be reproduced or transmitted without publisher‘s prior permission. Violators will be prosecuted. +0 mLMWm Mud unwra- histlocynoma (A W‘- W guess 5*5 6‘: his-ee-o-si-T0~mi More ow macules PM 6? smn war ts “Honest—In MAK—lllz Coch‘ bvuk— m‘r CW - 1e, wamunual. mus—IA. Sekrak vim/pm lag-r312. of SuueAUW. pruritus Wammj oG—smn proo—RI-fis psoriasis a, smxmd‘rm WeLba MA ( sO-RI-i-sis 13¢an 3 , g ad ‘3 pad—dus. “Wm“ W or‘ imiwr‘oM-Lck‘ b‘j sldE~ROST S cJ mSfiS s e wears—(“j “38.3 59 wnSc/T cum: fine W by LM\ enb'towk 9MSM‘L‘ vulgaris arm W3 be geranium. vfil—GA—ris Wsit Medical Terminal Egress at DavisP/us Online Resource Center. ' 7 DaVlS?M$’ I Use it to practice pmfinaanons and reinforce the meanings of the farms in this chart now. u u. $2? Psoriasis Read the following chart note aloud. Underline any mm you have trouble pronouncing or cannot define. If needed, refer to the Terminology section above for correct prommciations and meanings of terms. This is a 32-year-old woman who experienced intermittent Esoriasis since her early teens in various stages of severity. Her condition has become more troublesome over the past year because of an increase of amtoms after being exposed to the sun. Her past history indicates she had chronic sinusitis of 3 years' duration. Eur Bartholin gland was excised in 2020:. She has had pruritus of the scalp and abdominal regions. There is no PR of psoriasis. An uncle has had diabetes mellitus since age 43. Patient has {concurred} httpszllereader.chegg.ooml#lbooksl9780803642119Icfi[email protected]:62.4 91312017 PRINTED BY: dfda9305b52al [email protected] Printing is for personal, private use only. No put of this book may be repmduoed or Medical Terminiogy Express: A Short Course by Body System, 2nd edition hansmitted without publisher's prior permission Violators will be prosecuted. 72 CHAPTER 3 I Way-nun occasional abdominal pain: accompanist! by diaphnreois and/or syncope. P3 showed the pationt hail psoriatic involvement of the scalp, external «to, trunk, and, to a lesser agree, legs. There are my sutmdw (light ruby colored) thiokanod plaques covered by thick yellowish white scales. A flew areas on the logs and am show multiple, aoleroaed, brown mules and pupal“ . Diagnoses : 1. Psoriasis vulgaris. 2. unitiple hishiocytmn. 3. Linda-111131 pains, by history. 4. Rule out colitis, regional enteritis. Chart Note Analysis memspmodingchmnomsdectthemodimlwordthntmuei i.discoloredareaontheskinfiiati5noteievated:_Mm—__~_____ 2. condition that cm and goes: ‘Y‘S’ixflfkfli ,_. -.____m_‘ .__-.,_____ ___ 3. fainting episode: $3 our 99—: 4.common cranium- V Ufigyrfi 5. inflammation or the colon: wig—‘3... _ no. .__.~-____ 6. of long duration: Mbw 7.hardened: %0\ mid 8» inflammation of smai! intestine: 6“ *‘9155‘ S _ 9.severe itching: [email protected]'(‘\M‘\ m— i0. mucous giand at the vaginal opening Befmhk 3i mod->5- ”. «ndmmmmoymmmmmnmmww ilredrms ofthe skin caused by capillary diianon. fW—A— i3 inflammtionofthesinuscavity: SMLL’é EM“..— 14 elevated lesion cormining pus (as seen in acne and psoriasis): Wm 15. synonymous with hyperhidrosis and Moresis: 5“ “9PM (”Z/S ‘LS Wyvm:0wckmmmhAppmdkB.Anmrchonm367.llwiewmrialdnt youdidnotumoonudy CorrectAnmens [5 X6.61- \ x htlps:/Ieraader.cl1999.ooml#lbooksl9780803842119Icfil1 00lI4/[email protected]:62.4 313 ...
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