Chapter 2 Review
56 Introduction to Medical Terminology
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HOLLAND MEDICAL CENTER
987 Medical Drive, Hospital City, US 12345-6789
PHONE: (098) 765-4321 FAX: (098) 483-2910
PREOPERATIVE HISTORY
PT NAME: Mary O’Toole
ID NO: 43370056
ROOM NO: 304
DATE OF ADMISSION: 11/15/20xx
ATT PHYS: Peter Lanips, MD
History of
Present Illness:
The patient is a 46 y/o white female with a chief complaint of LBP radiating to R leg
and calf. Pain worsens when patient bends over or attempts to touch toes. Sitting
aggravates R leg and calf pain. Previous X-ray shows 2 cm bulge of disk between L5
and S1. Patient is admitted at this time for elective L5–S1 diskectomy. Surgery has
been discussed with patient. The patient’s internist is Fred Feeney, MD.
Medications: Tylenol 500 mg 2 PO Q4H PRN, pain; Advil 200 mg 2 PO Q4H PRN, pain.
Past Medical
History:
Usual childhood diseases.
Past Surgical
History:
None.
Family History: Mother and grandmother have history of arthritis.
Gynecological
History:
Regular menses (menstrual period).
Social History: Pt. is a nonsmoker. Alcohol use is limited to 2–3 glasses of wine a week. Drug use
denied.
Review of
Systems:
CV (cardiovascular): No high BP, heart murmurs, or shortness of breath.
Pulmonary: No chronic lung disease; no asthma.
GI (gastrointestinal): No hepatitis (infl ammation of the liver).
Renal (pertaining to the kidney): Negative for infections.
Endocrine (relating to hormone-secreting glands in the body): No diabetes or thyroid
disease.
Musculoskeletal (pertaining to the muscles and bones): Positive for early signs of
arthritis.
Hematologic (pertaining to study of the blood): No history of anemia (defi ciency
of red blood cells or hemoglobin, the main protein in blood cells) or bleeding
tendencies.
Peter Lanips, MD
PL:cjk
D: 11/13/20xx
T: 11/14/20xx
Medical Record Practice
Following is a preoperative history report for Mary, the patient who was introduced in the Case Study. A
preoperative history report is submitted to a hospital before a patient is admitted for surgery. Read Mary’s medical
report. Then, on a separate sheet of paper, write a definition for each highlighted term and abbreviation.