Name________________________________________Period_____________Date________________________
Pilgrim Medical Terms 2015/16
Chart Note Transcription:
The chart note below contains 10 phrases that can be reworded with a medical term
that you learned in this unit. Each phrase is identified with an underline. Determine
the medical term then write your answer in the spaces provided.
Chief Complaint:
Past History:
Signs & Symptoms:
Diagnosis:
Treatment:
A 64- year old man with an open sore on his right calf is seen
by the specialist who studies and treats skin.
Patient states he first noticed an area of pain, severe itching,
and redness of the skin just below his right knee about six
weeks ago. Patient notes severe swelling followed by raised
spots containing pus one week later. Patient states the raised
spots ruptured and the open sore appeared.
Patient has a deep, pus producing, open sore 5 x 3 cm: It is 4cm
distal to the knee on the lateral aspect of the right leg. It
appears to extend into the middle layer of skin, and the edges
show signs of tissue death. A sample of the drainage was grown
in the lab to identify the microoganism and determine the best
antibiotic. Culture revealed Staphylococcus bacteria in the open
sore.
Cellulitis
Removal of the damaged tissue of the open sore followed by
application of antibiotic cream. Patient was instructed to
return to the specialist in 2 weeks or sooner if the open sore
does not heal, or if it begins draining pus.
1) ____________________________________
6) ____________________________________
2) ____________________________________
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3) ____________________________________
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4) ____________________________________
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5) ____________________________________
10)____________________________________
Name________________________________________Period_____________Date________________________
Pilgrim Medical Terms 2015/16
Follow Up Questions:
1) Was this a primary or secondary lesion? Why?
2) What is Cellulitis?
3) Highlight the portion of the chart that describes (with the greatest detail) where
the lesion is. Draw in the wound in the diagram provided.