Change the
medical terms in a progress note for a patient with a skin condition
into common terms. Spell all medical and common terms correctly on the
provided template.
The first step in completing this
assessment is to review how to build a medical term. A medical term is
built from three parts. The first part is the prefix or the beginning of
the word. The second part is the word root or the main part of the
word. The last part is the suffix or the ending of the word.
This assessment also covers the following body systems:
Musculoskeletal
Definition: Is the muscles and bones
Integumentary
Definition: Is the skin.
INSTRUCTIONS:
Review the progress note below, including the subjective and objective notations. Next, download the Skin Progress Note Template [DOCX] and complete all of the following on the template:
Select 12 medical terms from the progress note.
On the template, place one term per line. For example: Actinic
keratosis should not be on the same line, Actinic should be on one line
and keratosis on a second line.
Change the 12 selected medical terms into commonly used terms.
Use medical terminology skills to break the medical term into its
word parts. For example: keratosis is kerato, which means horny tissue
and osis, which means condition of. Putting these together keratosis
means condition of horny tissue
Select three drugs from the progress note. For each drug, identify a skin condition that the selected drug treats.
Spell all medical terms, common terms, and drugs correctly.
PROGRESS NOTE:
Subjective: The patient is a 49-year-old female who
comes in with the complaint of having bumps on her arms. She states some
of the bumps have been there a long time. Recently the bumps have been
increasing in number and size. She was last seen about two years ago for
eczema and was prescribed cyclosporine, at that time. However, she did
not have these bumps. The bumps are not itchy or painful.
Objective: Very pleasant, alert, and oriented x3
female in no apparent distress. A full integumentary exam of the upper
arms was performed today. The left radial aspect demonstrated
erythematous macules. The right ulnar aspect demonstrated actinic
keratosis. Bilateral hands appeared dry with linear excoriation and
fissuring of her fingertips. Bilateral upper arms demonstrated
superficial and deep masses. Deep subcutaneous masses are mobile and may
represent lipomas. Superficial masses appear to be sebaceous cysts.
Assessment and Plan:
Actinic keratosis of the right ulnar aspect was treated with liquid nitrogen.
Possible lipomas: Schedule surgical biopsy of larger masses.
Sebaceous cysts: Punch biopsy performed today; await pathology report. Apply Neosporin to biopsy site.
Start Hydrocortisone intensive cream.
Start Prednisone as directed.
Format: Ensure you complete all columns on the Skin Progress Note Template.
Scoring Guide: Be sure to read the scoring guide for this assessment to understand how your faculty member will evaluate your work.
ATTACHED IS THE CHART TO FILL UP.
SCORING GUIDE:
1. Identifies all medical terms related to general structures and functions of the human body, without errors.
2. Changes all medical terms related to general structures and functions of the human body into common terms, without errors.
3. Identifies all medical terms related to body systems, without errors.
4. Changes all medical terms related to body systems into common terms, without errors.
5. Spells at least 15 medical and common terms correctly.
6. Identifies at least three drugs correctly.
7.Specifies the correct reason for the drug’s use in all cases, without errors.
