Medical Terminology
Case Study:
You are a medical scribe working in the emergency department. Your patient is a 28-year-old man named James. The following is James’s explanation of events leading to his trip to the emergency department:
“I was reroofing my house when a gust of wind caught me just right. It blew me right off the roof. I thought I was in luck because I was able to twist around and land on my feet, but when I hit, I heard a loud SNAP! My leg bone broke through my pants and I lost the feeling in my foot.”
On arrival, James was given a pain-killer to help him stay still while the doctor did an exam and X-rays were taken because he was in a great deal of pain. The physician found a break in the femur of the left leg that was offset and shifted (the type of break). James had muscle weakness below the break, and some fluid buildup in his knee on the other side. No other issues were noted in the physical exam and review of systems. An X-ray confirmed the offset and shifted fracture.
A bone doctor was called for consult, and she decided that the best course of action was to return the bones to their original position surgically, and to anchor plates to the bone to fix it in place. Following the surgery, James will need to follow-up with his bone doctor in ten days, and a physical therapist 8 weeks after surgery.
Instructions:
List the phrases/words in red text and build medical terms (or abbreviations where appropriate) to replace them. Next, make a SOAP note in the patient’s chart with appropriate terminology including CC, HPI, PE and imaging findings, a diagnosis, and the plan of care including follow-on appointments.
