Module 02 Course Project Assignment Template

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Rasmussen College *

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HSC1531

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Nursing

Date

Apr 29, 2024

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docx

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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 1. Kay is complaining of lower back pain. What is the medical term used to describe the lower back? Lumbago 2. In the subjective and plan sections of this SOAP note, the abbreviation OTC is used. What does this mean? Over the counter (medication) 3. 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. Flex means to bend forward which causes the spine stretch/elongated into arch 4. 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) Cervicalgia 5. The abbreviation ROM is used twice in this SOAP note. What does ROM mean in this context? Range of motion 6. Kay’s physical exam revealed hypertrophy of her muscles. Describe what this means. What is the abnormality present? Hypertrophy is the increase of muscle mass. This increase has caused pain, spasms and reduced the ROM of the spine. 7. In the assessment section of this document, the abbreviation DDX is used. This is a very commonly used abbreviation. What does DDX stand for? Differential diagnosis. This is described when symptoms could be multiple diagnoses and more testing is needed for a definite diagnosis. 8. The doctor has determined that Kay may have radiculopathy. Describe what this word means in a way that an average patient could understand. Radiculopathy is when the nerves in the spine become pinched or injuried. Page 1 of 3

9. The word “unilateral” is used to describe the possible disk herniation. What does unilateral mean? Unilateral means occurring on one side. An example is right arm or left arm but not both arms. 10. Find an image of a “vertebral disk herniation.” Describe (in your own words) what is happening to the anatomical structures of the spine. A portion of the inner disc is pushed through the exterior of the disc which pushes on spinal nerves. 11. 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. It means that the patient is needing further testing/evaluation to determine if they have lumbar and sacrollic radiography. Lumbar is the lower portion of the back. Sacroiliac is the joint area between the sacrum and ilium. Radiography is when a nerve root gets pinched or injuried in the spine which cause multiple problems. 12. This patient may need a follow-up MRI. What does this abbreviation stand for? Magnetic resonance imaging Patient B – Virginia Thompson 13. 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.) ichthyosis 14. In the objective section of this SOAP note, the macules are described as “erythematous.” What color is this word referring to? red 15. The lesion of concern is located in the anterolateral shoulder. How would you describe the location of this lesion in your own words? On the front/side of the shoulder 16. In which section of this SOAP note (Subjective, Objective, Assessment, Plan) do you find a term that means “pertaining to the acromion and clavicle”? Objective 17. What is the definition of a “macule”? Discolored spot of the skin. Page 2 of 4

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