Interpret and Apply Medical Terminology: Case Study Assessment

Case Study Assessment Criteria Unit code, name and release number BSBMED301 - Interpret and apply medical terminology appropriately (1) Qualification/Course code, name and release number HLT33115 – Certificate III in Health Services Assistance (2) HLT37315 - Certificate III in Health Administration (2) HLT47315 - Certificate IV in Health Administration (2) HLT43015 – Certificate IV in Allied Health Assistance (2) HLT57715 – Diploma of Practice Management (1) Student details Student number 801309623 Student name Dulcie Pilotti Document title: BSBMED301_AE_CS_2of3 Page 1 of 12 Resource ID: TBS_18_013_BSBMED301_AE_CS_2of3 STUDENT NAME:

Version: 1.0 Date created: 1 December 2023 Date modified: 30/11/2023 For queries, please contact: Technology and Business Services SkillsPoint Building B, Level G, Corner Harris Street and Mary Ann Street, Ultimo NSW 2007 © 2019 TAFE NSW, Sydney RTO Provider Number 90003 | CRICOS Provider Code: 00591E This assessment can be found in the: Learning Bank The contents in this document is copyright © TAFE NSW 2019, and should not be reproduced without the permission of the TAFE NSW. Information contained in this document is correct at time of printing: 30 November 2023. For current information please refer to our website or your teacher as appropriate. Document title: BSBMED301_AE_CS_2of3 Page 2 of 12 Resource ID: TBS_18_013_BSBMED301_AE_CS_2of3 STUDENT NAME:

Assessment instructions Table 1 Assessment instructions Assessment details Instructions Assessment overview The objective of this assessment is to assess your knowledge and performance as would be required to interpret and apply medical terminology. Assessment Event number 2 of 3 Instructions for this assessment This is a case study assessment and it will be assessing you on your knowledge and performance of skills required by the unit. This assessment is 1. Case studies – Female Reproductive System, Blood System Submission instructions On completion of this assessment, you are required to upload it or hand it to your trainer for marking. Ensure you have written your name at the bottom of each page of this assessment. It is important that you keep a copy of all electronic and hardcopy assessments submitted to TAFE and complete the assessment declaration when submitting the assessment. What do I need to do to achieve a satisfactory result? To achieve a satisfactory result for this assessment all questions must be answered correctly. What do I need to provide? Pen or suitable electronic device. If this assessment is being used for online/distance delivery, the student must upload the assessment. What the assessor will provide? Computers and access to the internet. Access to the case studies. Due date and time allowed As per the training plan Assessment feedback, review or appeals Appeals are addressed in accordance with Every Students Guide to Assessment. Specific task instructions Document title: BSBMED301_AE_CS_2of3 Page 3 of 12 Resource ID: TBS_18_013_BSBMED301_AE_CS_2of3 STUDENT NAME:

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The instructions and the criteria in the case study below will be used by the assessor to determine whether you have satisfactorily completed the Case Study Scenario. Use these instructions and criteria to ensure you demonstrate the required knowledge. Document title: BSBMED301_AE_CS_2of3 Page 4 of 12 Resource ID: TBS_18_013_BSBMED301_AE_CS_2of3 STUDENT NAME:

Part 1: Case study – Female Reproductive System To complete this part of the assessment, you will be required to read the Case Study Scenario below. Once you have read the information, you are required to complete your written responses to questions 1 – 7 in the spaces provided in this document. Once completed you will need to submit this assessment to your assessor for marking. Case Study Scenario: Patient: Susan Smith Susan Smith has recently consulted with her Gynaecologist for a routine check-up and Pap smear. Susan is generally a healthy, active woman with no previous history of abnormal readings on her smears. Please review the report below and then answer the following questions: PATIENT SMITH, Susan DATE TO BE ADMITTED MAY 9, 2019 CHIEF COMPLAINT Right ovarian cyst HISTORY OF PRESENT ILLNESS Susan is a 34-year-old Caucasian female who had a routine examination on April 21, 2018, at which time the examination revealed the right ovary to be approximately two to three times normal size. Otherwise, all was normal. The Pap smear performed at the time revealed atypical cells of undetermined significance. The patient returned for a colposcopy, and this revealed what appeared to be squamous epithelial lesions CIN I-II. Biopsies were performed which revealed chronic cervicitis and no evidence of CIN. The patient was placed on Lo-Ovral for two cycles and then was rechecked. The right ovary continued to enlarge and got to the point where it was approximately 4 x 5 cm, floating anteriorly in the pelvis, and was fairly firm to palpation. A pelvic ultrasound confirmed the clinical findings. Superior to the right adnexa was a 4 x 5 cm mass, possibly with haemorrhage into either a paraovarian cyst or a dermoid cyst. The patient is to be admitted now for an exploratory laparotomy. PAST MEDICAL HISTORY The patient had the usual childhood diseases and has had good health as an adult. Previous Surgery The patient had a Hymenotomy and dilatation and curettage in 2006. Menstrual History Menstrual cycle is 28 days, averaging a three to six day flow. Obstetrical History The patient is a Gravida 0. FAMILY HISTORY Heart disease in the family. Father died of lung cancer. Mother L/W. REVIEW OF SYSTEMS Non-contributory. Document title: BSBMED301_AE_CS_2of3 Page 5 of 12 Resource ID: TBS_18_013_BSBMED301_AE_CS_2of3 STUDENT NAME:

S. Cunningham MD Physical examination GENERAL The patient is a well-developed, well-nourished Caucasian female in no acute distress. VITAL SIGNS Height: 170 cm Weight: 61 kg Blood Pressure: 110/82. Normal. The trachea is in the midline. The thyroid is not enlarged. CHEST Lungs: Clear to percussion and auscultation. Heart: Regular sinus rhythm with no murmur. Breasts: Normal to palpation. ABDOMEN Soft and flat. No scars or masses. PELVIC The outlet and vagina are normal. The cervix is moderately eroded. The uterus is normal size and anterior. The left adnexa is negative. The right adnexa has a firm, irregular cystic ovary that is anterior and approximately 5 × 5 cm. This is mobile and non-tender. EXTREMITIES Normal. Reflexes are grossly intact. DIAGNOSIS Right ovarian cyst. PLAN The patient is to be admitted for exploratory laparotomy and ovarian cystectomy. S. Cunningham, MD Short Answer Questions: 1. State the patient’s current diagnosis (50 words maximum) Patients has a cyst in the right ovary approximately two to three times its normal size. 2. Define the term “Pap smear”. A pap smear is a cervical cancer test that involves collecting cells from the cervix and area around it. A pap smear can also be helpful in finding other infections/inflammation in that area. 3. Dr Cunningham performed a colposcopy. Describe this procedure. What were the findings on Colposcopy? (50 words maximum) A colposcopy is a procedure done to examine the cervix, vagina and vulva for abnormalities in the Document title: BSBMED301_AE_CS_2of3 Page 6 of 12 Resource ID: TBS_18_013_BSBMED301_AE_CS_2of3 STUDENT NAME:

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cells. The colposcopy revealed what appeared to be squamous epithelial lesions CIN I-II. 4. The ultrasound performed revealed a mass that was considered to be a cyst. What possible type of cyst did this prove to be? They found a mass that was 4 x 5 cm, possibly with haemorrhage into either a paraovarian cyst or a dermoid cyst. 5. List and define the two surgeries performed on Susan Smith in 2006: 1. Hymenotomy: A minor procedure that surgically opens or removes your hymen. 2. Dilation and curettage: A operation where the cervix is dilated using a dilator so that the uterus can be scraped to remove abnormal tissue 6. How many children has Susan Smith had? Report does not indicate any children 7. Susan Smith is due to be admitted to hospital. List and define the surgeries that have been planned for this admission? 1. Exploratory laparotomy; A surgery to open up the abdomen so that the abdominal cavity can be examined to determine any problems that cannot be diagnosed 2. Ovarian Cystectomy: A surgery to remove a cyst for the ovaries Case study – The blood system To complete this part of the assessment, you will be required to read the Case Study Scenario below. Once you have read the information, you are required to complete your written responses to questions 1 – 4 in the spaces provided in this document. Document title: BSBMED301_AE_CS_2of3 Page 7 of 12 Resource ID: TBS_18_013_BSBMED301_AE_CS_2of3 STUDENT NAME:

Once completed you will need to submit this assessment to your assessor for marking. Patient: Harry Lindsay Harry Lindsay has had a history of feeling unwell, losing his appetite and weight loss. After consultation with his family doctor Dr Stevens, Harry was referred on for additional tests. He has now come under the care of Dr Ellis (Oncologist) Please review the report below and then answer the following questions: Document title: BSBMED301_AE_CS_2of3 Page 8 of 12 Resource ID: TBS_18_013_BSBMED301_AE_CS_2of3 STUDENT NAME:

Department of Oncology/Haematology Outpatient Report PATIENT : Lindsay, Harry DATE: March 25, 2018 Mr Lindsay is a 58-year-old man seen for myelodysplasia while hospitalised on March 17, 2018. He was transfused with 4.0 U of packed cells during that hospitalisation. A bone marrow revealed histology consistent with chronic myelomonocytic leukaemia (myelodysplasia). A follow-up blood count was obtained through Dr. Stevens’ office on March 20, 2018, and revealed a haemoglobin of 11.0 G/DL and a haematocrit of 31.0%. There have been no fevers, sweats or anorexia; but he has noted some weight loss. There has been no bleeding. There has been no nausea, vomiting or dark and bloody stools. ON EXAMINATION Weight: 78 kg. Blood Pressure: 120/50. Temperature: 37°C. Pulse: 88. Respirations: 18. Mild gum atrophy and inflammation. Neck: Supple. Lymph nodes: There is no adenopathy. Lungs: Clear. Cardiovascular: Normal. Abdomen: Soft and non-tender. The spleen is enlarged. Extremities: Without oedema or petechiae. CURRENT LABORATORY RESULTS Complete blood count reveals a total leukocyte count of 6600/cu mm, a haemoglobin of 8.0 G/DL, a haematocrit of 23.0%, and a platelet count of 149,000/cu mm. CLINICAL DIAGNOSIS Chronic myelomonocytic leukaemia (myelodysplastic syndrome). The patient is transfusion dependent. The patient will be typed and cross matched today and will be transfused with 2.0 U of packed red blood cells through the Oncology Day Facility tomorrow on March 26, 2018. I have asked the patient to follow up with Dr. Stevens next week and with me in two weeks. Anna Ellis MD A ELLIS, MD Document title: BSBMED301_AE_CS_2of3 Page 9 of 12 Resource ID: TBS_18_013_BSBMED301_AE_CS_2of3 STUDENT NAME:

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1. Provide a brief definition for the following medical terms found in the above medical report: Oedema Fluid retention. Too much fluid is trapped in body’s tissues Petechiae A small or red purple spot caused by bleeding into the skin Anorexia An eating disorder where food intake is restricted leading to low body weight Atrophy Thinning or loss of muscle tissue Adenopathy Large or swollen lymph glands Histology Study of microscopic structure or tissues 2. Identify Mr. Lindsay’s diagnosis and give a brief description of it (50 words max) Diagnosis: Mr Lindsay’s diagnosis is chronic myelomonocytic leukaemia. Description: Chronic myelomonocytic leukaemia is blood cancer where a person’s bone marrow does not make blood effectively 3. Mr Lindsay has enlarged spleen. Provide the correct medical term for this condition: Splenomegaly 4. Dr Ellis has developed a treatment plan for Mr Lindsay. List the three elements to this plan: 1.Mr Lindsay is transfusion dependent 2. The patient will be typed and cross matched today and will be transfused with 2.0 U of packed red blood cells through the Oncology Day Facility tomorrow on March 26, 2018 3. Follow up with Dr Stevens next week and Dr Ellis in two weeks Document title: BSBMED301_AE_CS_2of3 Page 10 of 12 Resource ID: TBS_18_013_BSBMED301_AE_CS_2of3 STUDENT NAME:

Document title: BSBMED301_AE_CS_2of3 Page 11 of 12 Resource ID: TBS_18_013_BSBMED301_AE_CS_2of3 STUDENT NAME:

Assessment Feedback NOTE: This section must have the assessor signature and student signature to complete the feedback. Assessment outcome ☐ Satisfactory ☐ Resubmission Required ☐ Unsatisfactory Assessor feedback ☐ Was the assessment event successfully completed? ☐ If no, was the resubmission/re-assessment successfully completed? ☐ Was reasonable adjustment in place for this assessment event? If yes, ensure it is detailed on the assessment document. Comments: Assessor name, signature and date Document title: BSBMED301_AE_CS_2of3 Page 12 of 12 Resource ID: TBS_18_013_BSBMED301_AE_CS_2of3 STUDENT NAME:

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LA024996_BSBMED301_AE_CS_2of3

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