Description
Translate into common terms the medical terms contained in a progress note for a patient with a skin condition. Spell all medical and common terms correctly on the provided template.
In this first assessment you will begin your exploration of the structure of medical terminology. The first step is to review how to build a medical term. Then you will examine the skin and musculoskeletal systems; in particular, we will focus on the diagnosis and treatment of the integumentary, or skin system. The skin is the largest organ of the body with a total area of about 20 square feet. The skin protects us from microbes and the elements, helps regulate body temperature, and permits the sensations of touch, heat, and cold. Your suggested resources address the three layers of skin, skin conditions, diseases, treatment, and diagnostic studies.
In the assessment, you will review a progress note. This is a common document found in a health care record in doctors’ offices and hospitals. You will then translate the medical terms in the progress note into common terms.
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:
Skin 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, at which time 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 extremities 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.
- Continue Cortisone 10 intensive cream for eczema.
