HIM FPX 4610 Assessment 2 History and Physical (H&P): The Nervous System

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Capella university

HIM-FPX 4610 Medical Terminology

Prof. Name

November, 2024

Patient History and Physical (H&P) Template 

A Patient History and Physical (H&P) document is a detailed report covering the medical history of the patient, their current condition, and results from any physical examination (Rieger et al., 2023). The history section usually covers the following: chief complaint, the patient’s past medical and surgical history, family history, social history, and allergies to certain medications, thus helping healthcare practitioners understand the patient’s personal background and risk factors that may be associated with such a case. The physical examination section involves a comprehensive assessment of all body systems and accounts of the patient’s vital signs, general appearance, and abnormal findings. All this together is what an H&P represents as a cornerstone in the process of establishing diagnoses, creating treatment plans, and communicating between different members of the health team.

Number Common Term Medical Term or Abbreviation 

Example 

  1. Chest Pain | CP | A feeling of pressure, discomfort, or pain in the chest, which could be indicative of a heart problem.
  2. Magnetic Resonance Imaging | MRI | An imaging procedure using magnetic fields and radio waves to generate images of organs and tissues without being invasive.
  3. Shortness of Breath | SOB | A feeling of being unable to breathe or get enough air.
  4. High Blood Pressure | Hypertension (HTN) | A chronic condition where there is always an increase in the pressure of blood in arteries.
  5. Heart Attack | Myocardial Infarction (MI) | Caused due to blockage of blood flow towards the heart muscle; tissue damage is caused.
  6. Blood Sugar | Glucose | The chief sugar in the blood, required for the production of energy; in diabetic patients, levels are often checked.
  7. Complete Blood Count | CBC | A blood test that diagnoses overall health and detects conditions such as anemia and infection.
  8. Electrocardiogram | ECG or EKG | A test where it depicts the electrical activity of the heart to diagnose anomalies.
  9. Chronic Obstructive Pulmonary Disease | COPD | A chronic lung condition encompassing airflow obstruction, meaning it is difficult to breathe.
  10. Diabetes Mellitus | DM | It includes any number of disorders in which there is an elevation of blood sugar levels over time.
  11. Urinary Tract Infection | UTI | It is an infection within any part of the urinary system and creates painful urination and urgency.
  12. Acute Respiratory Distress Syndrome | ARDS | Serious condition that comes with an accumulation of fluid in air spaces of the lungs, thus producing respiratory failure.
  13. Coronary Artery Disease | CAD | Disease caused by coronary arteries buildup of plaque. This leads to reduced blood flow in the heart.
  14. Stroke | Cerebrovascular Accident (CVA) | Medical Emergency in which the supply of blood to a particular region of the brain is disturbed, leading to cell death.
  15. Abdominal Pain | AP | The Pain or discomfort happening in the abdomen may result from any of the above diseases.
  16. High Cholesterol | HLD | Seriously high levels of cholesterol present in the blood that, possibly increase the risk factor of developing heart disease.
  17. Rheumatoid Arthritis | RA | A disorder in which one’s immune system attacks his/her own body, primarily associated with joints and the areas surrounding them due to constant inflammation.
  18. Osteoporosis | OP | A disorder characterized by weakening bones in such a way that there is brittleness in addition to their increased tendency to break.
  19. Asthma | Asthma | A chronic lung condition characterized by wheezing, shortness of breath, and coughing.
  20. Human Immunodeficiency Virus | HIV | An attacking virus on the body, the human immune system through specifically targeting the CD4 cells that make it incredibly weak.

HIM FPX 4610 Assessment 2 Conclusion

Overall, learning common medical terms and their abbreviations is important to achieve effective communication within the healthcare field (Hannawa et al., 2022). Knowing that CP stands for chest pain or MRI stands for magnetic resonance imaging increases the capability of healthcare professionals to quickly convey important information while enabling accurate diagnoses and timely treatment. This helps in clinical practice and empowers the patients to take a more active role in their care. This also forms a bridge between medical jargon and patient comprehension, and healthcare providers can foster better patient outcomes and enhance the overall quality of care.

HIM FPX 4610 Assessment 2 Reference

Hannawa, A. F., Wu, A. W., Kolyada, A., Potemkina, A., & Donaldson, L. J. (2022). The aspects of healthcare quality that are important to health professionals and patients: A qualitative study. Patient Education and Counseling, 105(6), 1561–1570. ScienceDirect. https://doi.org/10.1016/j.pec.2021.10.0168

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