Clinical Notes

Module 02 Course Project: Clinical Notes

Each question is associated with the clinical notes provided. Refer to these when answering each question. Please type your answer in the “Click here to enter text” space.

Patient A – Kay June Salisbury

Kay is complaining of lower back pain. What is the medical term used to describe the lower back?

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In the subjective and plan sections of this SOAP note, the abbreviation OTC is used. What does this mean?

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In the objective section of this SOAP note, the doctor noted that the patient has limited flexion in the lumbar spine. Describe what means to “flex” the spine.

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If Kay had also mentioned during this visit that she has been experiencing neck pain, which medical term could be used to describe this complaint? (Use the appropriate suffix for pain)

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The abbreviation ROM is used twice in this SOAP note. What does ROM mean in this context?

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Kay’s physical exam revealed hypertrophy of her muscles. Describe what this means. What is the abnormality present?

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In the assessment section of this document, the abbreviation DDX is used. This is a very commonly used abbreviation. What does DDX stand for?

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The doctor has determined that Kay may have radiculopathy. Describe what this word means in a way that an average patient could understand.

 

The word “unilateral” is used to describe the possible disk herniation. What does unilateral mean?

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Find an image of a “vertebral disk herniation.” Describe (in your own words) what is happening to the anatomical structures of the spine.

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In the plan section of this SOAP note, the patient is being referred for lumbar and sacroiliac radiography. What does this mean? Define each word: lumbar, sacroiliac, and radiography.

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This patient may need a follow-up MRI. What does this abbreviation stand for?

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Patient B – Virginia Thompson

If Virginia’s physician had noted any dry or scaly skin during this visit, which medical term might he have used to describe it? (Hint: Think about the word roots you studied this week.)

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In the objective section of this SOAP note, the macules are described as “erythematous.” What color is this word referring to?

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The lesion of concern is located in the anterolateral shoulder. How would you describe the location of this lesion in your own words?

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In which section of this SOAP note (Subjective, Objective, Assessment, Plan) do you find a term that means “pertaining to the acromion and clavicle”?

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What is the definition of a “macule”?

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In this SOAP note, the terms “benign” and “malignant” are used to describe both the skin lesions. Define these terms.

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In the plan section of this SOAP note, the doctor plans to perform a biopsy. Briefly describe this procedure.

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Which word found in this SOAP note means “black tumor”?

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Which word found in this SOAP notes refers to a solid, elevated lesion?

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References

You will primarily use your textbook as a reference this week. Provide a citation for your textbook (in APA format) here:

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*If you are unfamiliar with APA citation, please see the Rasmussen College APA Guide: http://guides.rasmussen.edu/apa Select “References” on the left-hand panel and choose “Books” to learn how to properly cite your textbook for this course.

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