122 Medical Terminology: Mastering the Basics CHART NOTE Patient Name: Gundrum, Ida ID Number: 98774 Examination Date: October 11, 20xx SUBJECTIVE 29-year-old female complains of epigastric discomfort, which she describes as a constant burning for several weeks. Initial treatment was successful with Tagamet ® (drug that reduces gastric acid secretions), but discomfort has recurred several times over a 2-week period. She complains of nausea. No vomiting or hematemesis. Tagamet ® partially relieves her symptoms. She has been under considerable stress at work due to job downsizing and outsourcing of personnel. Headache relief in the form of Tylenol ® or Motrin ® has been unsuccessful and seems to exacerbate (worsen) her condition. OBJECTIVE Abdomen is soft, fl at, and nontender with normal bowel sounds. No masses or organomegaly. ASSESSMENT Gastritis, probably exacerbated by NSAIDs (nonsteroidal anti-infl ammatory drugs), and stress. PLAN We discussed several methods of stress reduction, including support group websites. She will stop using Motrin ® and Tylenol ® for headaches. She was given a sample of Prilosec ® 20 mg q.i.d. (4 times a day) to be taken for one month. The patient will return in 3–4 weeks for a follow-up visit. Assessment Interpret Ida Gundrum’s Chart Note Directions: After listening to the dictated recording and reading the chart note on Ida Gundrum, provide the medical term that matches each defi nition below. Example: abnormal condition of gallstones Answer: cholelithiasis 1. enlargement of an organ ________________________________________________ 2. vomiting blood ________________________________________________ 3. infl ammation of the stomach ________________________________________________ 4. pertaining to the area above the stomach ________________________________________________ SCORECARD: How Did You Do? Number correct (_____), divided by 4 (_____), multiplied by 100 equals _____ (your score)