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HIIM134 Medical Terminology
Assignment #3 165 Points (point value for each question is located in parentheses by each item)
Assignment Objectives: After completing this assignment you will be able to: Apply your new knowledge of terms and abbreviations related to psychiatry, pharmacology,
oncology, radiology, and general office visit reports to interpret medical terms in their proper
context.
Perform searches of the internet and other reference materials to answer questions (not
Wikipedia). Instructions: Read the medical reports in the boxes and answer the questions that follow each of the
reports. Use your textbook, Google/Bing, and other reference materials to answer the questions;
however, do not use Wikipedia for your assignment (points may be deducted). Some of the medical
terms are in another chapter of your textbook, so you can use your index in the back of the textbook to
help you locate where a particular term might be found. Appendix II (Abbreviations) and Appendix III (Lab
values) in the back of your book are also extremely helpful. This will be similar to what you will find
yourself doing on the job. You will understand much of a report, but you may have to check reference
materials to understand the remaining information. Many medical reports are written in real life using
abbreviations, although the Joint Commission is discouraging their use. However, we would like you to
become familiar with them since they may still be found in reports, especially in physician offices. If you
cannot locate a particular abbreviation, go to Google (www.Google.com) or Bing (www.bing.com) and
enter the abbreviation in the search box. You should then be able find the results in a variety of links that
become available. Information about medications can also be found by entering the medication name in
Google/Bing if you do not have a drug reference book.
Place your name and answers on the assignment answer sheet. Assume you are a student by the name
of James Smith. Save your answer sheet as Assign3.Answers.HIIM134.Smith.J.doc (substituting your
name). Send your assignment answer sheet to the instructor through Canvas. Do not copy and
paste your completed worksheet in the homework assignment dialog box. Do not send via email
as an attachment.
Grading Rubric
Student answered all
questions correctly
Proper grammar,
spelling and punctuation
were present
Student placed name on
paper and renamed the
worksheet digital file
according to instructions Poor
Points Range: 0-111
0%-74% of the answers were
correct
Points Range: 0-2
Answer sheet contains
numerous grammatical,
punctuation, or spelling errors
Points Range: 0
Not present. Fair
Points Range: 112-134
75%-89% of the answers
were correct
Points Range: 3-8
Answer sheet contains some
grammatical, punctuation, or
spelling errors
Points Range: 3
One present, not both. Good
Points Range: 135-150
90%-100% of the answers
were correct
Points Range: 9-10
Answer sheet contains few
grammatical, punctuation,
or spelling errors
Points: 5
Both are present and done
according to instructions PSYCHIATRY – Consultation
REASON FOR CONSULTATION: Dr. Jane Doe ordered a psychological consultation of this patient,
who is currently in the Emergency Department.
CONTACT PERSON: Barbara Green. She identified herself as a friend. There is a Release of
Information authorization form that was signed by the patient for me and the hospital staff to discuss
his situation with Ms. Jones. I do not know how long she has known the patient; however, she
identified herself as a friend of the family.
HISTORY OF PRESENT ILLNESS AND REASON FOR ADMISSION: This 48-year-old white male
had indicated that he took six Percocet last night. His medical record shows admissions to the
Psychiatric Unit of this hospital for a number of different dates during the past ten years. In addition, this patient had been admitted to several psychiatric facilities in the past with a diagnosis of bipolar
affective disorder or manic depressive illness, not otherwise specified. The patient is reportedly on a
variety of psychiatric medications, including Depakote. The patient did not indicate a history of
outpatient treatment. I am unable to determine how well he followed up on any outpatient care.
There is a history of self-harm behavior. The patient stated that he had had suicidal thoughts, and he
said the last time was one year ago; however, he did take a recent overdose. History of violent
behavior is unknown. However, the friend reported that there is a history of some kind of violence on
this patient's part. This patient made threatening statements of harm to his brother-in-law today, who
assaulted him recently. His sister called the police who brought him to the Emergency Room of this
hospital. The patient's friend, Barbara Green, is with him in the ER and she reported that the patient
has been hallucinating and has been getting progressively worse. She also reported that he took 16
Percocet, and not six, as he said.
EMERGENCY DEPARTMENT CHIEF COMPLAINT: The chief complaint was an overdose.
MEDICAL HISTORY: The medical history of this patient is unknown, other than he has various bruises
on his body. Allergies are unknown as this patient did not respond to questions concerning that.
SUBSTANCE ABUSE HISTORY: The patient did not respond to questions regarding substance
abuse. It should be noted that this patient is a very poor historian and was very confused at the time of
the examination.
SOCIAL HISTORY: The patient reported he was born in 19XX. He states that he was raised by his
parents and his grandfather. Regarding siblings, he says that he has two sisters. He also made
reference to something like six, but was not clear. The family psychiatric history is unknown. The
patient reports he has two years of college. He states he is retired, but his prior occupations are
unknown. The patient reported he was married two times and is presently divorced. He has three
children. The patient reportedly lives alone in a hotel. The only local social support identified was a
friend of the family, who is Barbara Green, the contact person.
WEAPONS OR MEDICATIONS FOR OVERDOSE AVAILABLE: This is unknown.
MENTAL STATUS: This patient took a recent overdose of Percocet. The patient has threatened harm
to his brother-in-law and had taken 16 Percocet, but only acknowledged having taken six. The patient
showed grossly normal development and physique. Grooming and personal hygiene were poor. The
patient showed pressured speech and depression. The patient's thought process was somewhat
tangential. The patient expressed that he is having auditory hallucinations and expressed paranoid
delusions. The patient had severely impaired judgment and poor insight. The patient showed impaired
attention and concentration. His thought process was disorganized. His fund of knowledge and
orientation were quite poor. The patient's affect was labile. He was alert and agitated. He was
pessimistic in his attitude and his mood was irritable. Regarding dangerousness, the patient had
expressed homicidal ideation, ideation of harm to others, and he had indicated self-harm
behavior. The patient showed impaired physical coordination and some psychomotor agitation.
DIAGNOSTIC IMPRESSION:
Bipolar 1 disorder, most recent episode mixed, with psychotic features.
Bruises to various regions of body.
Recent assault.
RECOMMENDATIONS: This patient should remain admitted, as he is psychotic and is a danger to
himself and others. Following inpatient psychiatric stabilization, he will need outpatient psychiatric
follow-up. 1. Percocet contains a narcotic pain reliever. This statement is (1)
A. true
B. false
2. Define Bipolar 1 disorder. Define Bipolar 2 disorder. (2) 3. Depakote is used to treat what three neurologic or psychiatric disorders? What is its use in this
particular patient? (2)
4. What is meant by labile affect? (1)
A. Little speech and negative or minimal thoughts and behavior.
B. Sadness, hopelessness, depressive mood.
C. Exaggerated feeling of well-being.
D. Variable; undergoing rapid emotional change; emotional instability.
5. The patient indicated that he had paranoid delusions. What is this? (1)
A. A person experiences a great deal of fear or anxiety, intensified by believing things that are
false. Overly suspicious system of thinking; fixed delusion that one is being harassed,
persecuted, or unfairly treated.
B. The fear of situations in which the person is open to public scrutiny.
C. A breakdown in memory, identity or perception.
D. A false belief that you are much greater, powerful or influential than you really are.
6. The patient had pressured speech. What does this mean? (1)
A. He has delayed speech and language skills.
B. He has a tendency to talk rapidly and frenziedly, is difficult to interrupt, and may be too fast or
too unrelated for the listener to understand.
C. He has uncontrollable repetition of a particular a word, phrase, or gesture, despite the
absence or stopping of a stimulus.
D. He is unable to carry on a normal conversation with another due to a psychosis.
7. Define the following terms: (5)
Tangential thought process
Auditory hallucination
Homicidal ideation (Include the meaning of both terms in your definition)
Impaired physical coordination
Psychomotor agitation PSYCHIATRY and PHARMACOLOGY – History and Physical
HISTORY OF PRESENT ILLNESS: The patient is a 69-year-old single Caucasian female with a past
medical history of schizoaffective disorder, diabetes, osteoarthritis, hypothyroidism, GERD, and
dyslipidemia who presents to the emergency room with the complaint of "manic" symptoms due to
recent medication adjustments. The patient had been admitted to General Hospital on March 21, 20xx
for altered mental status and at that time, the medical team discontinued Zyprexa and lithium.
In the Emergency Room, the patient reported euphoria, pressured speech, irritability, decreased
appetite, and impulsivity. She also added that over the past three days, she felt more confused and
reported having blackouts as well as hallucinations about white lines and dots on her arms and face
from the medication changes. She was admitted voluntarily to the inpatient unit and medications were
not restarted for her.
On the unit this morning, the patient is loud and non-redirectable, she is singing loudly and speaking in
a very pressured manner. She reports that she would like to speak with Dr. Philip Anders, the
psychiatrist, who saw her at General Hospital, because she "trusts him." The patient is somewhat
reluctant to answer questions stating that she has answered enough of people's questions; however,
she is talkative and reports that she feels as though she needs a sedative. The patient reports that she
is originally from Minneapolis, and she moved to Seattle about a year ago to be with her daughter. She
also expressed frustration over the fact that her daughter wanted her removed from the apartment she
was in initially and had her placed in a nursing home due to inability to care for herself. The patient also
complains that her daughter is "trying to tell me what medications to take." The patient sees her
internist, Dr. Jonathan Baker, for outpatient care of her general medical problems.
PAST PSYCHIATRIC HISTORY: According to her medical records, the patient has been mentally ill
for over 30 years with past diagnoses of bipolar disorder, schizoaffective disorder, and schizophrenia.
She has been stable on lithium and Zyprexa according to her daughter and was recently taken off those medications, changed to Seroquel, and the daughter reports that she has decompensated since
then. It is not known whether the patient has had prior psychiatric inpatient admissions; however, she
denies that she has.
MEDICATIONS:
1. Seroquel 100 mg, 1 p.o. b.i.d.
2. Risperdal 1 mg tab, 1 p.o. t.i.d.
3. Actos 30 mg, 1 p.o. daily.
4. Lipitor 10 mg, 1 p.o., h.s.
5. Gabapentin 100 mg, 1 p.o. b.i.d.
6. Glimepiride 2 mg, 1 p.o. b.i.d.
7. Levothyroxine 25 mcg, 1 p.o. q.a.m.
8. Protonix 40 mg, 1 p.o. daily.
ALLERGIES: No known drug allergies.
FAMILY HISTORY: According to her medical records, her mother died of stroke, father died of alcohol
abuse and diabetes, one sister is alive with diabetes, and one uncle died of leukemia.
SOCIAL HISTORY: The patient is from Minneapolis and moved to Seattle approximately one year ago.
She lived independently in an apartment until about one month ago when her daughter moved her into
a nursing home. She has been married once, but her spouse left her when her three children were
young. Her children are ages 47, 49, and 51. She had one year of college, and she currently is retired
after working in the Minneapolis public school system for 20 or more years. She reports that her
spouse was physically abusive to her. She reports occasional alcohol use and quit smoking 11 years
ago.
MENTAL STATUS EXAM:
GENERAL: The patient is an obese, white female who appears older than stated age, seated in a chair
wearing large dark glasses.
BEHAVIOR: The patient is singing loudly and joking with interviewers. She is pleasant, but noncooperative with interviewers.
SPEECH: Increased volume, rate, and tone. Normal in flexion and articulation.
MOTOR: Agitated.
AFFECT: Mood is elevated and congruent.
THOUGHT PROCESSES: Tangential and logical at times.
THOUGHT CONTENTS: Denies suicidal or homicidal ideation. Denies auditory or visual hallucination.
Has both positive grandiose delusions and positive paranoid delusions.
INSIGHT: Poor to fair.
JUDGMENT: Impaired. The patient is alert and oriented to person, place, date, year, but not day of the
week.
PHYSICAL EXAMINATION:
GENERAL: Alert and oriented, in no acute distress.
VITAL SIGNS: Blood pressure 152/92, heart rate 81, and temperature 97.2.
HEENT: Normocephalic and atraumatic. PERRLA. EOMI. Moist mucous membranes.
NECK: Supple. No lymphadenopathy, no JVD, and no bruits.
CHEST: Clear to auscultation bilaterally.
CARDIOVASCULAR: RRR. S1 and S2 heard. No murmurs, rubs, or gallops.
ABDOMEN: Obese, soft, nontender, and nondistended. Positive bowel sounds.
EXTREMITIES: No cyanosis, clubbing, or edema.
ASSESSMENT: This is a 69-year-old Caucasian female with a past medical history of schizoaffective
disorder, diabetes, hypothyroidism, osteoarthritis, dyslipidemia, and GERD who presents to the
emergency room with complaints of inability to sleep, irritability, elevated mood, and impulsivity over
the past three days, which she attributes to a recent change in medication after an admission to
General Hospital during which time the patient was taken off her usual medications of lithium and
Zyprexa. The patient is manic and disinhibited and is unable to give a sufficient interview at this time.
DIAGNOSES: 1. Schizoaffective disorder. 2. Diabetes, hypothyroidism, osteoarthritis, GERD, and
dyslipidemia. 3. Family strife and recent relocation. PLAN: The patient was admitted voluntarily to General Hospital Inpatient Psychiatric Unit under Dr.
Anders’s care. Medications resumed include Zyprexa, Actos, levothyroxine, Lipitor, Protonix,
glimepiride, and folate. We will order an EKG, and we will monitor the patient and make further
adjustments to her medications as necessary.
1. The patient was diagnosed with schizoaffective disorder. What is meant by that condition? (1)
2. Lithium is used for what type of condition in a mentally ill patient? (1)
A. Hypochondriasis
B. Dissociative disorder
C. Delirium tremens
D. Mania
3. In the Emergency Room the patient reported euphoria. What is this condition?(1)
A. An involuntary persistent idea or emotion
B. Exaggerated feeling of well-being or feeling “high”
C. Sadness, hopelessness, depressive mood, or feeling “low.”
D. Emotionally cold and aloof; indifferent to the feelings of others
4. Human behavior without adequate thought, the tendency to act with less forethought than do most
individuals of equal ability and knowledge, or a predisposition toward rapid, unplanned reactions to
internal or external stimuli without regard to the negative consequences of these reactions. This
describes (1)
A. impulsivity
B. dysthymia
C. fugue
D. histrionic disorder
5. In the Past Psychiatric History section of the report, it states that the patient’s medication was
changed to Seroquel. What did the daughter report happened as a result of the change? (1)
A. The patient got better and her mood improved.
B. The patient had worsening of symptoms to the state of a serious mental disorder.
C. The patient’s hallucinations disappeared.
D. The patient had increased preoccupation with body aches and pains.
6. What one word in the Past Psychiatric History means the same as your answer in question #5? (1)
7. What do the letters stand for in the following abbreviations in the context of this medical report?
Do NOT define. If you are unsure, check the back of your textbook, or go to Google and enter
“medical abbreviations”. To be considered correct you must only use the meaning that applies to the
medical report of this patient. (5)
GERD
PERRLA
JVD
RRR
S1, S2 (as it relates to the heart)
8. Describe the hallucinations that she had when she discontinued her medications? What did the
patient see? (1)
9. Define the following terms – be specific: (3)
Clubbing (related to the hands/fingers)
Bruits
Dyslipidemia
10. The patient was started on Zyprexa. What are the two purposes of this drug that apply to this patient’s
condition? (1)
a. Schizophrenia and delirium tremens
b. Bipolar disorder and generalized anxiety disorder
c. Bipolar disorder and schizophrenia
d. Antisocial personality disorder and delirium tremens 11. Complete the table below to include the dose, frequency and purpose or use of the drugs for each of
the eight medications that the doctor has listed for this patient (for the purpose of the drug, be
brief: one to four word phrases are enough). Use the dose and frequency the doctor has listed in
the MEDICATIONS section of the patient’s History and Physical Report. Use NO abbreviations when
completing the table. Convert all abbreviations to complete words including the dose, frequency
and purpose. One point will be taken off for each abbreviation that you enter. You may use regular
numbers rather than English for the numbers – for example, you can write 2 instead of two. For
example if Brofutin (a drug) is listed as 3 mm 1 PO q4h and its use is to relieve pain, tenderness,
swelling, and stiffness caused by osteoarthritis and rheumatoid arthritis, you would enter for Brofutin
in the appropriate boxes: 3 millimeters, every 4 hours, osteoarthritis and rheumatoid arthritis. Note:
he patient had 1 of each drug, so that has already been included in its own column for you. Do
not repeat it in the dose or frequency columns (24)
USE NO ABBREVIATIONS
Drug Name
Brofutin Seroquel
Risperdal
Actos
Lipitor
Gabapentin
Glimepiride
Levothyroxine
Protonix Amount/Route
1 orally Dose Frequency Purpose or use of drug 3 millimeters Every 4 hours Osteoarthritis and rheumatoid
arthritis 1 orally
1 tablet orally
1 orally
1 orally
1 orally
1 orally
1 orally
1 orally ONCOLOGY – Consultation Report
REASON FOR CONSULTATION: Newly diagnosed head and neck cancer.
HISTORY OF PRESENT ILLNESS:
The patient is a very pleasant 61-year-old gentleman who was recently diagnosed with squamous cell
carcinoma of the base of the tongue bilaterally with downward extension into the right tonsillar fossa.
He was also noted to have palpable enlarged level 2 cervical lymph nodes. His staging is T3 N2c M0
Stage IV invasive squamous cell carcinoma of the head and neck. The patient comes in to the clinic
today after radiation oncology consultation. His otolaryngologist performed a direct laryngoscopy with
biopsy on July 29, 20xx. The patient reports that in the previous December-January timeframe, he had
noted some difficulty swallowing and ear pain. He had a work up by his local internist that was
relatively negative, and he was treated for gastroesophageal reflux disease. His symptoms continued
to progress, and he developed difficulty with his speech, dysphagia, otalgia and odynophagia. He was
then referred to Dr. Stone and examination revealed a mass at the right base of the tongue that
extended across the midline to include the left base of the tongue as well as posterior extension
involved in the right tonsillar fossa. He was noted to have enlarged neck nodes bilaterally. His biopsy
was positive for squamous cell carcinoma.
PAST MEDICAL HISTORY: Significant for mild hypertension. He has had cataract surgery,
gastroesophageal reflux disease and a history of biceps tendon tear.
ALLERGIES: Penicillin.
CURRENT MEDICATIONS: Lisinopril/hydrochlorothiazide 20/25 mg q.d., alprazolam 0.5 mg q.d.,
omeprazole 20 mg b.i.d., Lortab 7.5/500 mg q 4h p.r.n.
FAMILY HISTORY: Significant for father who has stroke and grandfather with lung cancer.
SOCIAL HISTORY: The patient is married but has been separated from his wife for many years; they
remain close. They have two adult sons. He is retired from the Air Force and currently works as an
engineer for Boeing. He was born and raised in New York. He has about a pack a day 20-year smoking
history and he reports quitting on July 27. He drinks alcohol socially. No use of illicit drugs. REVIEW OF SYSTEMS: The patient's chief complaint is fatigue. He has difficulty swallowing and
dysphagia. He is responding well to acetaminophen and hydrocodone for pain control. He denies any
chest pain, shortness of breath, fevers, chills and night sweats. The rest of his review of systems is
negative.
PHYSICAL EXAM:
VITALS: BP: 115/70. HEART RATE: 62. TEMP: 97.4. Weight: 93.6 kg.
GEN: He is very pleasant and in no acute distress. He has noticeable mass on his left neck.
HEENT: Pupils are equal, round, and reactive to light. Sclerae anicteric. His oropharynx is notable for
scalloped tongue and he has no oral ulcers. Upon protrusion of his tongue, he has deviation to the
right.
NECK: Noticeable for bilateral palpable adenopathy with a large palpable mass in the left neck.
LUNGS: Clear to auscultation on the right. He has some mild vesicular breath sounds in the left.
CV: Regular rate; normal S1, S2, no murmurs.
ABDOMEN: Soft. He has positive bowel sounds. No hepatosplenomegaly. No axillary inguinal
adenopathy.
EXT: No lower extremity edema.
LABORATORY STUDIES:
1. A PET/CT scan shows a large hypermetabolic mass involved in the posterior aspect of the tongue,
which is predominantly right-sided but extends across the midline to involve the right posterior aspect
of the tongue as well.
2. Extensive bulky hypermetabolic cervical lymphadenopathy bilaterally.
3. No evidence of distant hypermetabolic metastatic disease.
4. His biopsy of the right base of the tongue shows invasive squamous cell carcinoma. Biopsy of the
left base of the tongue shows invasive squamous cell carcinoma, moderately differentiated.
ASSESSMENT/PLAN: This is a pleasant but unfortunate 61-year-old gentleman who was diagnosed
with stage IV, a squamous cell carcinoma of the oropharynx. He has met with radiation oncology to
discuss the plan and he has also been in close contact with his dentist. He has a known abscess and is
in need of some bridge work. I discussed issues with his dentist; the patient will be seeing her this
Friday for cleaning. One of the things that we will need to coordinate is evaluation of the involvement of
his salivary glands. There needs to be a discussion as to whether or not he would be better off with the
tooth extraction prior to radiation. We will coordinate this between myself, radiation oncology, and his
dentist.
As far as his chemotherapy treatment, the plan at this point is to proceed with two cycles of induction
chemotherapy. The first cycle will include docetaxel, cisplatin and 5-fluorouracil plus Erbitux. Typical
administration is docetaxel, cisplatin and 5-fluorouracil on day 1 with continuous infusion of 5fluorouracil through day 4. Erbitux will be administered on day 1 and day 8 of the first cycle. We will
plan to proceed with the second cycle to include docetaxel, cisplatin and continuous infusion of 5fluorouracil without the Erbitux. Following induction chemotherapy, we plan to obtain a PET/CT scan.
Again, this will be closely coordinated with radiation onset if they can do with planning CT at that time
of the PET. Radiation will be planned with concurrent Erbitux. This will be given, the first dose will be
one week prior to starting the radiation and then given weekly throughout radiation. I briefly discussed
with the patient the possibility of admission for the induction chemotherapy. The patient was not very
excited at this particular discussion. I feel with him living in the Everett area that a hospital inpatient
admission to the Oncology unit may be our best bet and would also be a way of being able to closely
monitor his kidney function and administer the necessary hydration. He is scheduled for chemo
education on August 16. He received prescription refi...
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