Medical Language for Modern Health Care: Lesson 5.4-Case Report: Medical Terms in Documentation Directions: 1) Read the Case Report below and underline or circle any medical terms related to the liver, gallblad bile ducts, and pancreas. (2) List and briefly define the identified terms below (use additional paper if needed). (3) Then, answer the question at the bottom of the page. (1) Medical Terms in Patient Documentation YOU ARE A medical assistant employed by Susan Lee, MD, a primary care physician. YOUR PATIENT IS Mrs. Sandra Jacobs, a 46-year-old mother of four Your task is to document her care: Mrs. Sandra Jacobs, a 46-year-old mother of four, presents in Dr. Lee's primary care clinic with episodes of crampy pain in her right upper quadrant associated with nausea and vomiting. The pain often occurs after eating fast food. She has not noticed fever or jaundice. Physical examination reveals an obese white woman with a positive Murphy's sign. Her BP is 170/90 and she has slight pedal edema. A provisional diagnosis of gallstones has been made. She has been referred for an ultrasound examination and an appointment has been made to see Dr. Walsh in the surgery department. I explained to her the etiology of her stones, the need for surgical removal of the stones, and discussed with her a low-fat, 1500 calorie diet sheet. -Luis Guitterez, CMA 1430 hrs. 06/12/13. Medical terms 1
Medical Language for Modern Health Care: Lesson 5.4-Case Report: Medical Terms in Documentation Directions: 1) Read the Case Report below and underline or circle any medical terms related to the liver, gallblad bile ducts, and pancreas. (2) List and briefly define the identified terms below (use additional paper if needed). (3) Then, answer the question at the bottom of the page. (1) Medical Terms in Patient Documentation YOU ARE A medical assistant employed by Susan Lee, MD, a primary care physician. YOUR PATIENT IS Mrs. Sandra Jacobs, a 46-year-old mother of four Your task is to document her care: Mrs. Sandra Jacobs, a 46-year-old mother of four, presents in Dr. Lee's primary care clinic with episodes of crampy pain in her right upper quadrant associated with nausea and vomiting. The pain often occurs after eating fast food. She has not noticed fever or jaundice. Physical examination reveals an obese white woman with a positive Murphy's sign. Her BP is 170/90 and she has slight pedal edema. A provisional diagnosis of gallstones has been made. She has been referred for an ultrasound examination and an appointment has been made to see Dr. Walsh in the surgery department. I explained to her the etiology of her stones, the need for surgical removal of the stones, and discussed with her a low-fat, 1500 calorie diet sheet. -Luis Guitterez, CMA 1430 hrs. 06/12/13. Medical terms 1
Chapter10: Medication Administration Essentials
Section: Chapter Questions
Problem 22RQ
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system case study
ument/d/1 mv4ci3iDoMt2aR6GRUGIEGPKLOtreGnr3LPoGqFdy8Q/edit
Medical Language for Modern Health Care:
Lesson 5.4 - Case Report: Medical Terms in Documentation
X
(3) Then, answer the question at the bottom of the page.
(1) Medical Terms in Patient Documentation
Medical terms
Gl system case study - Google x G
Directions:
1) Read the Case Report below and underline or circle any medical terms related to the liver, gallbladder,
bile ducts, and pancreas.
(2) List and briefly define the identified terms below (use additional paper if needed).
1
YOU ARE A medical assistant employed by Susan Lee, MD, a primary care physician.
YOUR PATIENT IS Mrs. Sandra Jacobs, a 46-year-old mother of four
Request edit access
Your task is to document her care: Mrs. Sandra Jacobs, a 46-year-old mother of four, presents
in Dr. Lee's primary care clinic with episodes of crampy pain in her right upper quadrant
associated with nausea and vomiting. The pain often occurs after eating fast food. She has not
noticed fever or jaundice. Physical examination reveals an obese white woman with a positive
Murphy's sign. Her BP is 170/90 and she has slight pedal edema. A provisional diagnosis of
gallstones has been made. She has been referred for an ultrasound examination and an
appointment has been made to see Dr. Walsh in the surgery department. I explained to her the
etiology of her stones, the need for surgical removal of the stones, and discussed with her a
low-fat, 1500 calorie diet sheet. — Luis Guitterez, CMA 1430 hrs. 06/12/13,
hp
JE
O
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