Medical Terminology in Acute Care – Translating Common Terms in a Patient’s History and Physical

Medical Terminology in Acute Care – Translating Common Terms in a Patient’s History and Physical

Number	Common Term	Medical Term or Abbreviation
Example 1	The large bone in the upper part of the leg	Femur
Example 2	Excision or removal of a tendon	Tendonectomy
Example 3	Ears, nose, throat	ENT
1.	A severe pain in the head, often described as a feeling of intense pressure or throbbing	Headache
2.	A condition where the same image is seen as double or duplicated by one or both eyes	Diplopia
3.	A partial or complete loss of vision in half of the visual field of one or both eyes	Hemianopsia
4.	A chronic condition characterized by elevated blood pressure levels	Hypertension
5.	An abnormally high concentration of fatty molecules called lipids in the blood	Hyperlipidemia/Hypercholesterolemia
6.	An irregular and rapid beating of the heart chambers	Arrhythmia/Tachycardia
7.	A disorder characterized by abdominal pain, bloating, and altered bowel habits	Irritable Bowel Syndrome (IBS)
8.	The presence of solid particles or stones in the gallbladder	Cholelithiasis
9.	The surgical removal of the gallbladder	Cholecystectomy
10.	A medication used to treat high blood pressure by blocking angiotensin II receptors	Valsartan/Diovan
11.	A diuretic medication used to treat high blood pressure by increasing urine output	Hydrochlorothiazide
12.	A lack of feeling dizzy, unbalanced, or having a spinning sensation	Denies Vertigo
13.	A lack of weakness or loss of strength in muscles	Denies Paresis/Paralysis
14.	A lack of numbness, prickling, or loss of sensation in any area	Denies Paresthesia
15.	A lack of shortness of breath or difficulty breathing	Denies Dyspnea
16.	A lack of nausea, an uncomfortable feeling of needing to vomit	Denies Nausea
17.	A lack of vomiting, the forcible expulsion of stomach contents	Denies Emesis/Vomiting
18.	A lack of blood in bowel movements or stool	Denies Hematochezia
19.	A lack of swelling or buildup of fluid in tissues	Denies Edema
20.	An imaging technique that uses X-rays and a computer to create cross-sectional pictures of the body	Computed Tomography (CT) Scan

 References 

Chabner, D. (2017). The language of medicine (11th ed.). St. Louis, MO: Saunders.

Huether, S. E., & McCance, K. L. (2021). Understanding pathophysiology (7th ed.). St. Louis, MO: Elsevier.

Tintinalli, J. E., Ma, O. J., Yealy, D. M., Meckler, G. D., Cline, D. M., Thomas, S. H., & Cydulka, R. K. (2021). Tintinalli’s emergency medicine: A comprehensive study guide (9th ed.). McGraw-Hill Education.

U.S. National Library of Medicine. (2023). MedlinePlus medical encyclopedia. https://medlineplus.gov/encyclopedia.html

World Health Organization. (2022). International statistical classification of diseases and related health problems (ICD-11). https://icd.who.int/

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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 several issues. Spell all medical terms or abbreviations and common terms correctly on the provided template.

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Introduction
This second assessment continues to explore medical terminology related to various body systems, general structures, and functions of the human body, including the digestive and nervous systems, as well as psychiatry terminology. 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 system. 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.