Module 3 – Unit 2: Exploring the Topic
Terminology in a Patient’s Chart
Read the excerpt below from a patient’s chart. As you read, underline all of the words, phrases, and abbreviations used to describe the patient’s condition.
The patient is a 60-year-old African American female who presented in the ER with complaints of SOB on exertion and “ palpitations.” On examination, her HR was regular at 84/min, B.P 140/90. Her skin was of normal color and tone. She denies any chest pain at the present. An EKG was done which showed no evidence of M.I or arrhythmia. Patient states that ever since her younger brother died of a heart attack two months ago, she suffers from “the jitters” about having a heart attack herself.
- List the symptoms the woman has when she arrives at the Emergency Room (ER).
- List the underlined words that would be used mostly by a health professional to describe a patient’s condition and those that would be used mostly by a patient.
- Use medical terms, abbreviations, or lay terms from the patient history to fill in the chart below.
Medical Term or Abbreviation |
Lay Term |
anxiety |
|
out of breath |
|
arrhythmia |
|
physical activity |
|
blood pressure |
|
heart rate |
|
M I |
Write several questions that another health professional might ask this patient’s physician about the information in the chart. Then write the answers.
Example
Q: How old is the patient?
A: She’s 60 years old.
Q: Did she have any chest pain?
A: No, she didn’t.