In this course project assignment, you are presented with a medical history for two different patients. A medical history can be fairly brief or extremely lengthy, depending on the patient’s health history. Basic components of a medical history generally include the following pieces of information:
- Patient demographics: Includes name, date of birth, gender, race etc.
- Chief complaint: Specifies the primary reason for the patient seeking care
- History of present illness: Includes details of chief complaint in chronological order
- Past medical history: Includes a list of current and past medical conditions
- Family history: Includes pertinent diagnoses of close family members
- Social history: Includes information about patient’s lifestyle and characteristics
- Medication history: Includes list of current and prior medication use
- Review of systems: Includes subjective findings from a head-to-toe examination
- Physical examination: Includes objective findings from a head-to-toe examination
You will be exploring the medical terminology used in these medical histories and will be asked to interpret the meanings of various words and abbreviations.
To complete this assignment, do the following:
- Download the clinical notes for the two patients:
- Download, complete, and submit the document below. This document contains questions you will answer regarding the medical histories for each patient.
Module 03 Course Project Assignment Template (The 4 captures are the questions, please answer on microsoft word)