HIM FPX 4610 Assessment 1 Progress Note- The Skin

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HIM-FPX 4610 Medical Terminology

Prof. Name

November, 2024

Medical Term Skin Progress Note Template

A skin progress note template is a standard document that medical professionals use to monitor the progression of a patient’s skin condition over time (Burch et al., 2021). It is used in settings such as dermatology and wound care, and sometimes in general healthcare, where the status, changes, and results of treatments for skin concerns, such as wounds, lesions, infections, or chronic skin conditions, are noted. These templates usually contain sections to be filled out with information regarding patient demographics, and data related to the skin assessment like location, size, color, and texture of the involved area, pain level, and signs of infection or healing. Treatment interventions and medications applied are also recorded for maintaining continuity of care and to facilitate monitoring of the effectiveness of the treatment plan by providers. The use of a standardized template ensures better communication among the providers and promotes evidence-based, patient-centered care.

Common Term 

Gastritis

Gastritis is the inflammation or irritation of the stomach lining, and it may be caused by infections, mostly Helicobacter pylori bacteria, long-term use of nonsteroidal anti-inflammatory drugs, too much alcohol, or stress (Choi et al., 2024). The common symptoms may include upper abdominal pain, nausea, vomiting, and feeling bloated or full. There are acute cases that are sudden and intense and chronic cases that take a more gradual approach over time. If left untreated, chronic gastritis may lead to peptic ulcers or further pose a risk of developing stomach cancer. General treatments for gastritis consist of lowered levels of gastric acid through medication and correction of the cause itself, such as the eradication of the H. pylori infection if it is present.

Esophagogastroduodenoscopy (EGD)

More popularly known as EGD, Esophagogastroduodenoscopy is a minimally invasive procedure  (Quake et al., 2022). Doctors can inspect a small part of the GI tract, which comprises the very beginning of the small intestine. It is also referred to as the duodenum, as well as the stomach and the esophagus. A doctor could identify inflammation, ulcers, tumors, or any other type of bleeding that could be caused by abnormal growth in the mucosal lining. EGD is particularly useful for the diagnosis of causes of symptoms such as chronic heartburn, abdominal pain, or difficulty swallowing. The procedure can be enhanced to obtain small tissue samples, or biopsies, when needed, which help diagnose such conditions as gastritis, celiac disease, or Barrett’s esophagus.

  1. Integumentary – Covering or skin (Caon, 2020)
  2. Eczema – Inflammation of the skin
  3. Dermatitis – General term for inflammation of the skin
  4. Psoriasis – Chronic skin condition marked by red, scaly patches
  5. Melanoma – A type of skin cancer that develops from melanocytes
  6. Alopecia – Hair loss from the scalp or body
  7. Seborrhea – Excessive discharge of sebum, which causes oily skin
  8. Urticaria – Hives; a skin reaction with red, itchy welts
  9. Carcinoma – A cancer that begins in the skin or tissues lining organs
  10. Pruritus – Intense itching sensation
  11. Cellulitis – A bacterial infection of the skin, leading to redness and swelling
  12. Vitiligo – The loss of pigment in the skin with resulting white patches
  13. Lesion – A change or lesion in tissue, but commonly referring to the skin
  14. Fissure – A groove or split in the skin, especially as a result of dryness
  15. Hyperpigmentation – Darkening of the skin due to increased melanin

HIM FPX 4610 Assessment 1 Conclusion

In summary, knowledge of procedures and terminology regarding gastrointestinal and integumentary health is very important for proper diagnosis and treatment. The EGD procedure is very important in the identification of abnormalities within the upper gastrointestinal tract, hence helping healthcare providers diagnose problems such as gastritis and celiac disease (Ferrari & Tadros, 2024). On the other hand, common dermatological terms, including eczema, psoriasis, and melanoma, help healthcare professionals to address problems related to the skin more accurately. Knowledge of both systems, therefore, allows clinicians to provide integral care that goes beyond just the treatment of visible symptoms but also encompasses the conditions that may influence a patient’s overall health and quality of life. This way, a holistic approach results in better patient outcomes and allows for a greater understanding of the interconnectedness of the body’s systems.

HIM FPX 4610 Assessment 1 Reference

Burch, J., Boyles, A., Maltby, E., Marsden, J., Martin, N., McDermott, B., & Voegeli, D. (2021). Keep it simple: peristomal skin health, quality of life, and well-being. British Journal of Nursing, 30(Sup6), 5–24. https://doi.org/10.12968/bjon.2021.30.sup6.1

Caon, M. (2020). Integumentary system. Examination Questions and Answers in Basic Anatomy and Physiology, 157–172. https://doi.org/10.1007/978-3-030-47314-3_5

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