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HIM 4610 CU Female With Headache Patient History and Physical Review

HIM 4610 CU Female With Headache Patient History and Physical Review


Translate into medical terms or abbreviations the common terms found in the history and physical (H&P) of a patient who presented to an emergency room with a number of issues. Spell all medical terms or abbreviations and common terms correctly on the provided template.

This second assessment continues to explore medical terminology related to various body systems and general structures and functions of the human body, including the digestive system, nervous system, and psychiatry. Our focus in this assessment will be on the nervous system. The nervous system is a complex network of nerves and cells that carries messages to and from the brain and spinal cord to various parts of the body. The nervous system includes the central peripheral nervous systems. Your suggested resources address how the nervous system functions and what jobs it performs. They also focus on diseases, treatments, and diagnostic studies related to the nervous system. 

In the assessment you will review a patient’s history and physical (H&P), another common document found in acute care settings. You will translate the common terms in the H&P into the correct medical terms or abbreviations.

Demonstration of Proficiency

By successfully completing this assessment, you will demonstrate your proficiency in the course competencies through the following assessment scoring guide criteria:

Competency 2: Use medical terminology and abbreviations related to general structures and functions of the human body.  

Identify common terms related to general structures and functions of the human body correctly.

  • Translate common terms related to general structures and functions of the human body into medical terms or abbreviations correctly.

Competency 3: Use medical terminology and abbreviations related to body systems.

  • Identify common terms related to body systems correctly.
  • Translate common terms related to body systems into medical terms or abbreviations correctly.
  • Competency 6: Spell and pronounce basic medical terms.

Spell common and medical terms or abbreviations correctly.

  • Competency 7: Communicate in a professional manner.
  • Provide citations and references in APA style.
  • Instructions

Review the H&P below for a patient who presented in the emergency room with a number of issues. Pay close attention to the present and past history, medications, allergies, social and family history, review of systems, physician exam, and assessment and plan. Next, download the Patient History and Physical Template [DOCX] and complete all of the following on the template:   

  • Select 15 common terms from the H&P.
  • Translate the 15 selected common terms into medical terms or abbreviations.

Spell the common and medical terms correctly.

  • Cite in correct APA style the references you used to perform your translation. Click APA Style and Format for additional guidance on how to ensure your citations and references conform to APA guidelines.

Patient H&P

History of Present Illness:

This is a 54-year-old female who presented to the emergency room with a headache in the back of her head and double vision. She also complains of being able to see only from half of her eye. These symptoms began suddenly while she was out walking her dog about 45 minutes ago. A family member brought patient directly to the emergency room for evaluation.

Past Medical History:

  • High blood pressure.
  • High cholesterol.
  • Irregular, rapid heartbeat.
  • IBS.

Cholelithiasis with cholcystectomy.


Diovan 80 mg with hydrochlorothiazide 12.5 mg daily.



Social History:

  1. Non-smoker, no alcohol.
  2. Family History:
  3. Both parents and older sibling died from a stroke. Grandparents had extensive colon polyps.  
  4. Review of Systems:
  5. She has bilateral vision defects. Denies dizziness, weakness, or numbness. Denies shortness of breath, problems breathing, and chest pain. Denies nausea, vomiting, and blood in stool. No bladder or bowel changes. No edema or skin changes to arms and legs.

Physician Exam:

General: Patient appears to be a well-developed, well-nourished female. Alert and oriented to person, place, and time.

Vital Signs: Stable.

Skin: No discoloration, no tissue breakdown.

Head, Eyes, Ears, Nose, Throat: Pupils equal, round, and reactive to light; eye muscle movements are intact.

Chest: Clear.

Heart: Irregular, rapid rhythm.

Abdomen: No guarding, some tenderness related to the IBS.

Arms and Legs: No leg swelling.

Assessment and Plan:

Headache in the back of the head with vision changes. Obtain a computed tomography scan and magnetic resonance imaging scan. Depending on test results may need to consider an artery repair procedure.

High blood pressure: Continue home meds.

  • Irregular, rapid heartbeat: Continue home meds.

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