HIM FPX 4610 Assessment 2 History and Physical (H&P): The Nervous System
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Capella University
HIM FPX 4610 Medical Terminology
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Date
Patient History and Physical (H&P) Template
This template serves as a guide for documenting patient history and physical examination findings. It includes common medical terms and abbreviations along with their definitions to aid in accurate and concise record-keeping.
Table 1: Common Terms and Their Definitions
| Number | Common Term | Medical Term or Abbreviation | Example |
|---|---|---|---|
| 1 | Femur | The large bone in the upper part of the leg | Example 1 |
| 2 | Tendonectomy | Excision or removal of a tendon | Example 2 |
| 3 | ENT | Ears, nose, throat | Example 3 |
| 4 | Hypercholesterolemia | High cholesterol | |
| 5 | Diplopia | Double vision | |
| 6 | Hematochezia | Blood in stool | |
| 7 | Angina/Angina Pectoris | Chest pain | |
| 8 | MRI | Magnetic resonance imaging scan | |
| 9 | Cephalgia | Headache | |
| 10 | Cholelithiasis | Gallstones in the bladder | |
| 11 | IBS | Irritable Bowel Syndrome | |
| 12 | PMH | Past medical history | |
| 13 | Hemianopsia | Seeing only from half of the eye | |
| 14 | Emesis | Vomiting | |
| 15 | Hypertension/HTN | High blood pressure | |
| 16 | SOB | Shortness of breath | |
| 17 | Cholecystectomy | Surgical removal of gallbladder | |
| 18 | ROS | Review of systems |
HIM FPX 4610 Assessment 2 History and Physical (H&P): The Nervous System
References
Allied Health Resources: Medical Terminology Resources (2023). Retrieved from https://edcc.ibguides.com/ahe
Ehrlich, A., Schroeder, C., Ehrlich, L., & Schroeder (2021). Medical Terminology for Health Professions (9th ed.). ISBN: 978-0-3575-1369-9
Henderson, B., & Dorsey, J. L. (2019). Medical terminology for dummies. John Wiley & Sons.
MedlinePlus (n.d.). Appendix A: Word Parts and What They Mean. Retrieved from https://medlineplus.gov
The Importance of Medical Terminology in the Healthcare Field (2017). Retrieved from https://climb.pcc.edu
HIM FPX 4610 Assessment 2 History and Physical (H&P): The Nervous System
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