Terms and Strategies

for Medical Records

Reading and Writing
 Lesson 8
Orthopedic Unit
 Orthopedic Unit

Learning Goals:
➢Learning about an orthopedic case
➢Reading an admission note
➢Writing an admission note
➢ESP grammar
 Anatomy
The Human Skeleton
 Anatomy
The Vertebral Column
 Anatomy
Divisions of the Skeleton
Anatomy
 Anatomy

“Success depends on your

Did you know? _________________, not your
ligament: wishbone.”
attaches bone to bone

fascia:
attaches muscle to muscle

tendon:
attaches muscle to bone Answer: backbone
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I. Change the following nouns into their adjective forms.
Noun Adjective * Note 1
midclavicular
spine
subclavian vein
vertebra vertebral
cervix * Note 2
encourage ambulation
clavicle* clavicular
ambulatory care
thorax ambulatory surgery
sacrum
femur femoral
ambulation*
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II. Read the following progress note and answer the questions. There
can be more than one correct answer.
S: mild back pain
tolerated with walking
urination smooth
O: T: 36°C P: 70/min R: 16/min
BP: 122/80 mmHg
Vital signs stable, consciousness clear
Breathing sound: clear Abdomen: soft and flat
Surgical wound: 8 cm with gauze cover on back, clear and dry, no discharge
Function: Right Left
hip flexion 5 5
knee extension 5 5
ankle dorsiflexion 5 5
big toe dorsiflexion 5 5
plantarflexion 5 5
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A: Recurrent L5-S1 herniation of the intervertebral disc (HIVD)

OP: year/month/date diskectomy
P: MBD (May be discharged) today
Wound care: aquatic-beta iodine
Medication: pain control with acetaminophen, NSAID, narcotics
Antibiotics: shift to oral form for 3 days
Rehabilitation: encourage ambulation

______ 1. What did the patient say about his pain?

A. He feels mild pain in his back. B. He cannot tolerate it.
C. He has abdominal pain. D. He feels no pain at all.

______ 2. Which of the following is not about the patient’s vital signs?
A. T: 36°C P: 70/min B. R: 16/min BP: 122/80 mmHg
C. Vital signs stable D. Surgical wound: clear and dry

______ 3. What medications were given on the day of discharge?

A. acetaminophen B. narcotics C. antibiotics D. aspirin
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III. Match the meanings with their combining forms.
A. spinal cord; bone marrow E. bone I. ribs
B. joint F. spine J. immovable; fixed
C. cartilage G. bones of the fingers and/or toes K. tendon
D. ligament H. bursa

Combining Form Meaning

1. chondr/o
2. ligament/o
3. oste/o
4. arthr/o
5. phalang/o
6. myel/o
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A. spinal cord; bone marrow E. bone I. ribs

B. joint F. spine J. immovable; fixed
C. cartilage G. bones of the fingers and/or toes K. tendon
D. ligament H. bursa

Combining Form Meaning

7. burs/o
8. cost/o
9. ten/o; tend/o; tendin/o
10. ankyl/o
11. spondyl/o; rachi/o
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V. Write the following parts of the body in the appropriate sections.
1. humerus 7. metatarsal 13. patella
2. radius 8. metacarpal (metacarpus) 14. fibula
3. ulna 9. proximal phalanx 15. talus
4. carpal 10. middle phalanx 16. calcaneus
5. distal phalanx 11. calf 17. tibia
6. femur 12. anterior cruciate ligament (ACL)
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VI. Match the words with the types of movements.
____ 1. movement of legs, fingers, or toes away from the body

_____ 2. movement of legs, fingers, or toes towards the body or each other

A. dorsiflexion E. eversion
B. abduction F. adduction
C. plantar flexion G. extension
D. inversion H. flexion