Medical Reports

Medical Reports

Associate Level Material
Medical Report

This assignment is for you to create a screening tool for potential hires in your health care facility. As the health care administrator, you would want to ensure that your future employees have a strong understanding of medical reports and medical terminology. You are writing these reports for the applicants to read, interpret, and answer a set of questions you have developed. Refer to the samples of medical records reports on pages (142-144, 196, & 261-263) of the textbook. Each medical record should be completed and contain two questions you would ask of the potential hires.

The following suggestions will help you get started:

• Sometimes it is easier to start at the end. Think of the diagnosis the patient will receive. If you know what the end diagnosis will be, it makes it easy to know what symptoms, signs, and diagnostic methods would be used to achieve that diagnosis.

• For the History of Present Illness, consider what questions the physician might ask the patient about his or her chief complaint and symptoms and then chart that in this section. This section serves as an account of what the patient would report, based on their symptoms. Remember, symptoms are subjective, in that they are conditions experienced by the patient, and are therefore included in the patient history.

• For Past Medical History, document anything the patient may indicate in terms of past medical conditions that would be relevant to his or her current illness.

• For the Physical Exam section, document the observable signs. Signs are objective, in that they are measurable conditions, and therefore included in the physical exam. This includes vital signs or anything observed by performing the patient physical exam.

• For the Diagnostic/Lab Results, include the testing or procedures required to prove this diagnosis.

• For the Impression/Discussion, indicate the patient diagnosis and what the plan is for his or her. This includes treatment, preventative measure to take, or follow-up.

Templates provided on the following pages.

Use the following templates for the assignment. Complete each section, save, and then submit as an attachment.

Chapter 3 – Medical Record
History of Present Illness

Past Medical History

Physical Examination

Diagnostic/Lab Results

Impression/Discussion

Two Questions for prospective hires

References

Chapter 4 – Medical Record
History of Present Illness

Past Medical History

Physical Examination

Diagnostic/Lab Results

Impression/Discussion

Two Questions for prospective hires

References

Chapter 5 – Medical Record
History of Present Illness

Past Medical History

Physical Examination

Diagnostic/Lab Results

Impression/Discussion

Two Questions for prospective hires

References

ISBN 1-256-09271-1
Medical Language, Second Edition, by Susan Turley. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc.
ISBN 1-256-09271-1
Medical Language, Second Edition, by Susan Turley. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc.
Measure Your Progress:
Learning Objectives
After you study this chapter, you should be able to
1. Identify the structures of the gastrointestinal system.
2. Describe the process of digestion.
3. Describe common gastrointestinal diseases and conditions,
laboratory and diagnostic procedures, medical and
surgical procedures, and drug categories.
4. Give the medical meaning of word parts related to the
gastrointestinal system.
5. Build gastrointestinal words from word parts and
divide and define gastrointestinal words.
6. Spell and pronounce gastrointestinal words.
7. Analyze the medical content and meaning of a
gastroenterology report.
8. Dive deeper into gastroenterology by reviewing
the activities at the end of this chapter and online
at Medical Terminology Interactive.
Medical Language Key
To unlock the definition of a medical word, break it into word parts.
Define each word part. Put the word part meanings in order, beginning
with the suffix, then the prefix (if present), then the combining form(s).
Gastroenterology: The study of the stomach and intestines
(and related structures).
Word Part Word Part Meaning
Suffix -logy the study of
Combining Form gastr/o- stomach
Combining Form enter/o- intestine
Figure 3-1 ■ Gastrointestinal
system.
The gastrointestinal system consists of
organs and glands connected in a
pathway. Food enters the body, is
digested, and undigested wastes are
eliminated from the body.
gastr/omeans
stomach
gastr/o- enter/o- -logy
enter/omeans
intestine
-logy
means
the study of
ISBN 1-256-09271-1
Medical Language, Second Edition, by Susan Turley. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc.
Gastroenterology | Chapter 3 89
Anatomy and Physiology
The gastrointestinal (GI) system is an elongated body system that begins at
the mouth, continues through the thoracic cavity, and fills much of the
abdominopelvic cavity (see Figure 3-1 ■). The upper gastrointestinal system
includes the structures from the mouth through the stomach. The lower gastrointestinal
system includes the structures from the small intestine through
the anus. The purpose of the gastrointestinal system is to digest food, absorb
nutrients, and remove undigested material (waste) from the body.
WORD BUILDING
system (SIS-tem)
gastrointestinal
(GAS-troh-in-TES-tih-nal)
gastr/o- stomach
intestin/o- intestine
-al pertaining to
Word Alert
The gastrointestinal system is also known as the gastrointestinal tract,
the digestive system or digestive tract, and the alimentary canal. Each
name highlights a different characteristic of this body system.
1. Tract: a continuing pathway
2. Digestive: describes the purpose of the system
3. Alimentary: refers to food and nourishment
4. Canal: a tubular channel
digestive (dy-JES-tiv)
digest/o- break down food;
digest
-ive pertaining to
alimentary (AL-ih-MEN-tair-ee)
aliment/o- food; nourishment
-ary pertaining to
Anatomy of the Gastrointestinal System
Oral Cavity and Pharynx
The gastrointestinal system begins in the mouth or oral cavity (see Figure
3-2 ■). It contains the teeth, gums, tongue, hard palate, and soft palate with
its fleshy, hanging uvula. The oral cavity is lined with mucosa, a mucous
palate (PAL-at)
tongue (TUNG)
lingu/o- tongue
-al pertaining to
The combining form gloss/o- also
means tongue.
oral (OR-al)
or/o- mouth
-al pertaining to
Oral is the adjective form for mouth.
The combining form stomat/o- also
means mouth.
uvula (YOO-vyoo-lah)
Figure 3-2 ■ Oral cavity and pharynx.
The oral cavity contains the teeth, gums, tongue, and
palate. Food passes from the oral cavity into the pharynx
(throat) and then into the esophagus.
Soft palate
Uvula
Pharynx
Esophagus
Hard palate
Oral cavity
Trachea
Tongue
Mandible
Teeth
Epiglottis
Larynx
mucosa (myoo-KOH-sah)
ISBN 1-256-09271-1
Medical Language, Second Edition, by Susan Turley. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc.
90 Chapter 3 | Gastroenterology
membrane that produces thin mucus. The sense of taste is also associated
with the gastrointestinal system. Receptors on the tongue perceive taste
and send this information to the gustatory cortex in the brain.
The sight, smell, and taste of food cause the salivary glands to release
saliva into the mouth. Saliva is a lubricant that moistens food as it is chewed
and swallowed. Saliva also contains the enzyme amylase that begins the
process of digestion. There are three pairs of salivary glands: the parotid
glands, sublingual glands, and submandibular glands (see Figure 3-3 ■).
The teeth tear, chew, and grind food during the process of mastication.
The tongue moves food toward the teeth and mixes food with saliva.
Swallowing or deglutition moves food into the throat or pharynx. The
pharynx is a passageway for food as well as for inhaled and exhaled air.
When food is swallowed, the larynx moves upward to close against the
epiglottis, so that food in the pharynx does not enter the larynx, trachea,
and lungs. If the entrance to the larynx is not closed when food is in the
back of the pharynx pressing on the uvula, this initiates the gag reflex.
Figure 3-3 ■ Salivary glands.
The large, flat parotid glands are on either side of the
head in front of the ear. The sublingual glands are under
the tongue. The submandibular glands are under the
mandible (lower jaw bone). Ducts from these glands
bring saliva into the oral cavity.
Parotid
gland
Submandibular
gland
Sublingual
gland
Tongue
Oral cavity
Teeth
gustatory (GUS-tah-TOR-ee)
gustat/o- the sense of taste
-ory having the function of
saliva (sah-LY-vah)
salivary (SAL-ih-VAIR-ee)
saliv/o- saliva
-ary pertaining to
The combining form sial/o- also
means salivary gland or saliva.
parotid (pah-RAWT-id)
par- beside
ot/o- ear
-id resembling; source or origin
sublingual (sub-LING-gwal)
sub- below; underneath; less than
lingu/o- tongue
-al pertaining to
submandibular
(SUB-man-DIB-yoo-lar)
sub- below; underneath; less than
mandibul/o- mandible (lower jaw)
-ar pertaining to
mastication (MAS-tih-KAY-shun)
mastic/o- chewing
-ation a process; being or having
deglutition (DEE-gloo-TISH-un)
degluti/o- swallowing
-tion a process; being or having
pharynx (FAIR-ingks)
pharyngeal (fah-RIN-jee-al)
pharyng/o- pharynx (throat)
-eal pertaining to
Across the Life Span
Pediatrics. The first food for many babies is colostrum from the
mother’s breast. Colostrum is rich in nutrients and contains maternal
antibodies. For the first few days of life, the newborn’s intestinal tract is
permeable and allows these antibodies to be absorbed from the intestine into
the blood, where they provide passive immunity to common diseases.
Geriatrics. Older adults often complain that food does not seem as flavorful
as when they were younger. The aging process causes a very real decline in the
ability to smell and taste food as the number of receptors in the nose and on
the tongue decreases.
WORD BUILDING
ISBN 1-256-09271-1
Medical Language, Second Edition, by Susan Turley. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc.
Gastroenterology | Chapter 3 91
Esophagus
The esophagus is a flexible, muscular tube that connects the pharynx to the
stomach. It is lined with mucosa that produces mucus. With coordinated
contractions of its wall—a process known as peristalsis—the esophagus
moves food toward the stomach.
Esophagus
Cardia
Body
Pyloric
sphincter
Duodenum
Pancreas
(posterior
to stomach)
Pylorus
Omentum
Rugae
Lower Fundus
esophageal
sphincter
esophagus (eh-SAWF-ah-gus)
peristalsis (PAIR-ih-STAL-sis)
peri- around
stal/o- contraction
-sis process; condition; abnormal
condition
cardia (KAR-dee-ah)
pylorus (py-LOR-us)
fundus (FUN-dus)
pyloric (py-LOR-ik)
pylor/o- pylorus
-ic pertaining to
rugae (ROO-gee)
The singular form ruga is seldom used.
chyme (KIME)
sphincter (SFINGK-ter)
intestine (in-TES-tin)
intestinal (in-TES-tih-nal)
intestin/o- intestine
-al pertaining to
The combining form enter/o- also
means intestine.
WORD BUILDING
esophageal (eh-SAWF-ah-JEE-al)
esophag/o- esophagus
-eal pertaining to
Stomach
The stomach (see Figure 3-4 ■) is a large, elongated sac in the upper abdominal
cavity. It receives food from the esophagus. The stomach is divided into
four regions: the cardia, fundus, body, and pylorus (see Figure 3-4). The gastric
mucosa is arranged in thick, deep folds or rugae that expand as the
stomach fills with food. The stomach produces hydrochloric acid, pepsinogen,
and gastrin to aid in the digestion of food. The mucosa produces
mucus that protects the lining of the stomach from the hydrochloric acid.
Two sphincters (muscular rings) keep food in the stomach. The lower
esophageal sphincter (LES) is located at the distal end of the esophagus.
The pyloric sphincter is located at the distal end of the stomach. Chyme
is a semisolid mixture of partially digested food, saliva, digestive enzymes,
and fluids in the stomach. An hour or so after eating, the pyloric
sphincter opens and waves of peristalsis propel the chyme into the
small intestine.
Small Intestine
The small intestine or small bowel is a long, hollow tube that receives
chyme from the stomach. The small intestine produces three digestive
enzymes: lactase, maltase, and sucrase. The small intestine consists of
three parts: the duodenum, jejunum, and ileum (see Figure 3-5 ■). The
Figure 3-4 ■ Stomach.
The stomach has four regions. The cardia is the
small area where the esophagus joins the stomach.
The fundus is the rounded top of the stomach. The
body is the large, curved part of the stomach. The
pylorus is the narrowed canal at the end.
gastric (GAS-trik)
gastr/o- stomach
-ic pertaining to
Gastric is the adjective form for
stomach.
ISBN 1-256-09271-1
Medical Language, Second Edition, by Susan Turley. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc.
92 Chapter 3 | Gastroenterology
Figure 3-5 ■ Small and large intestines.
The small intestine consists of the duodenum, jejunum, and ileum. The large intestine consists of
the cecum (and appendix),colon, rectum, and anus. The colon can be divided into the ascending
colon, transverse colon, descending colon, and sigmoid colon. The bends (flexures) in the colon are
landmarks that are mentioned in x-ray reports. The bend near the liver is the hepatic flexure. The
bend near the spleen is the splenic flexure.
Jejunum
Spleen
Stomach
Liver Esophagus
Descending
colon
Sigmoid
colon
Ascending
colon
Cecum
Appendix
Rectum
Anus
Anal sphincter
Ileum
Transverse
colon
Duodenum
jejunum (jeh-JOO-num)
Large Intestine
The large intestine or large bowel is a larger, hollow tube that receives
undigested material and some water from the small intestine. The large intestine
consists of the cecum, colon, rectum, and anus (see Figure 3-5). The
cecum is a short sac. Hanging from its external wall is the appendix, a thin
tube that is closed at its distal end.
The walls of the large intestine contain haustra (puckered pouches) that
can greatly expand as needed. Waves of peristalsis slowly move undigested
material through the large intestine as water is absorbed through the intestinal
wall and into the blood.
ileum (IL-ee-um)
villi (VIL-eye)
The singular form villus is seldom
used.
lumen (LOO-men)
jejunal (jeh-JOO-nal)
jejun/o- jejunum
-al pertaining to
ileal (IL-ee-al)
ile/o- ileum
-al pertaining to
cecal (SEE-kal)
cec/o- cecum
-al pertaining to
appendiceal (AP-pen-DIS-ee-al)
appendic/o- appendix
-eal pertaining to
cecum (SEE-kum)
appendix (ah-PEN-diks)
append/o- small structure
hanging from a larger structure
-ix a thing
haustra (HAW-strah)
The singular form haustrum is
seldom used.
WORD BUILDING
duodenum (DOO-oh-DEE-num)
(doo-AWD-ah-num)
duodenal (DOO-oh-DEE-nal)
(doo-AWD-ah-nal)
duoden/o- duodenum
-al pertaining to
duodenum is a 10-inch, C-shaped segment that begins at the stomach
and ends at the jejunum. Digestive enzymes from the gallbladder and
pancreas flow through ducts into the duodenum. The jejunum, the second
part of the small intestine, is an 8-foot segment that repeatedly
twists and turns in the abdominal cavity. Digestion continues in the jejunum.
Peristalsis slowly moves the chyme along for several hours until
it reaches the ileum, the final part of the small intestine. The ileum is a
12-foot segment where absorption of nutrients is completed. The ileum
contains villi, thousands of small, thin structures that project into the
lumen (central, open area) and increase the amount of surface area to
maximize the absorption of food nutrients and water through the intestinal
wall and into the blood. The remaining undigested material (waste)
and water move into the large intestine.
ISBN 1-256-09271-1
Medical Language, Second Edition, by Susan Turley. Published by Prentice Hall. Copyright © 2011 by Pearson Education, Inc.
Gastroenterology | Chapter 3 93
Did You Know?
The appendix or vermiform appendix can be up to 8 inches in length.
Vermiform is a Latin word meaning wormlike. The appendix plays no
role in digestion. It is part of the lymphatic system and the immune
response (discussed in “Hematology and Immunology,” Chapter 6).
The colon is the longest part of the large intestine. It travels through all
four quadrants of the abdomen as the ascending colon, transverse colon,
descending colon, and sigmoid colon (see Figure 3-5). As the ascending
colon nears the liver, it bends in a right angle at the hepatic flexure. As
the transverse colon nears the spleen, it bends in a right angle at the
splenic flexure. The sigmoid colon bends toward the midline in an
S-shaped curve that joins the rectum. The rectum is a short, straight segment
that connects to the outside of the body. The anus, the external
opening of the rectum, is located between the buttocks. The anal sphincter
is a muscular ring whose opening and closing is under conscious, voluntary
control.
Clinical Connections
Immunology (Chapter 6). Some parts of the gastrointestinal system
are also part of the body’s immune response. Saliva contains antibodies that
destroy microorganisms in the food we eat. Small areas on the walls of the
intestines (Peyer’s patches) and in the appendix contain white blood cells that
destroy microorganisms. However, ingested microorganisms can still cause
gastrointestinal illness.
colon (KOH-lon)
colonic (koh-LAWN-ik)
colon/o- colon
-ic pertaining to
The combining form col/o- also
means colon.
Abdomen and Abdominopelvic Cavity
The anterior abdominal wall can be divided into four quadrants or nine regions
(discussed in “The Body in Health and Disease,” Chapter 2).
The abdominopelvic cavity contains the largest organs (viscera) of the
gastrointestinal system. The peritoneum is a double-layer serous membrane.
One layer lines the walls of the abdominopelvic cavity. The other
layer surrounds each of the organs. The peritoneum secretes peritoneal
fluid, a watery fluid that fills the spaces between the organs and allows
them to slide past each other during the movements of digestion.
The peritoneum extends into the center of the abdominopelvic cavity as
the omentum (see Figure 3-4). The omentum supports the stomach and
hangs down as a fatty apron to cover and protect the small intestine. The
peritoneum also extends as the mesentery, a thick, fan-shaped sheet that
supports the jejunum and ileum.
The blood supply to the stomach, small intestine, liver, gallbladder,
and pancreas comes from the celiac trunk of the abdominal aorta, the
largest artery in the body.
Accessory Organs of Digestion
The liver, gallbladder, and pancreas are accessory organs of digestion. They
contribute to, but are not physically involved in, the process of digestion.
sigmoid (SIG-moyd)
The combining form sigmoid/omeans
sigmoid colon.
rectal (REK-tal)
rect/o- rectum
-al pertaining to
The combining form proct/o- also
means rectum.
anal (AA-nal)
an/o- anus
-al pertaining to
anus (AA-nus)
rectum (REK-tum)
abdominal (ab-DAWM-ih-nal)
abdomin/o- abdomen
-al pertaining to
The combining forms celi/o- and
lapar/o- also mean abdomen.
abdominopelvic
(ab-DAWM-ih-noh-PEL-vik)
abdomin/o- abdomen
pelv/o- pelvis (hip bone; renal
pelvis)
-ic pertaining to
peritoneal (PAIR-ih-toh-NEE-al)
peritone/o- peritoneum
-al pertaining to
The combining form periton/o- also
means peritoneum.

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