BSBMED301: Assessment 1
What you have to do
This assessment consists of the following questions and tasks.
You are required to:
Break down the structure of a medical term
Define 10 general medical terms
Define 10 common medical abbreviations
Produce a short discharge summary from audio
Review a medical report by answering a series of questions
You can use your learning resource, the Internet, your glossary of medical terms, a medical
dictionary or medical textbook to assist you with this assessment.
Complete this assessment once you have covered all topics in the learner resource up to
The Human body and including the cardiovascular body system.
Task 1 Basic word structure
Research the meaning of the following medical terms and provide the correct root, suffix and
prefix of each one. The first one has been completed for you.
Medical term Meaning Prefix Root Combining Suffix
vowel
Arthralgia pain in the joint - ARTHR - ALGIA
Dermatitis irritation of the skin DERMAT ITIS
Myorrhaphy suture of muscle MY O RRHAPHY
tissue
Arthroscopy repair of joints ARTHR O SCOPY
Polydipsia excessive Thirst POLY DIPS IA
Hysterectomy merely removal of HYSTER ECTOMY
the uterus
Rhinoplasty facial cosmetic RHIN O PLASTY
procedure
Hyperthyroidism overactive thyroid HYPER THYROID ISM
Hypoglycaemia low blood sugar HYPO GLYC A EMIA
Lymphoma a tumour of the LYMPH OMA
lymphoid tissue
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© New South Wales Technical and Further Education Commission, 2017 (TAFE NSW), Archive version 1, November 2017
Task 2 General medical terms
Give the meaning of the following general medical terms:
Medical Term Meaning
Diagnosis Process of determining which disease or condition explains
a person's symptoms and signs
Prognosis The forecast of the probable outcome or course of a
disease; the patient's chance of 'recovery.
Symptom Is a departure from normal function or feeling which is
apparent to a patient, reflecting the presence of an unusual
state, or of a disease
Sign Any objective evidence of disease, as opposed to a
symptom, which is, by nature, subjective.
Chronic Is used to refer to any disease or condition that persists
over time or is frequently recurring
Systemic Means affecting the entire body, rather than a single organ
or body part
Local Involving or affecting only a restricted part of the organism
Silent Producing no detectable signs or symptoms, said of certain
diseases or morbid processes.
Acute Connotes an illness that is of short duration, rapidly
progressive, and in need of urgent care
Biopsy The removal of a sample of tissue for examination under a
microscope to check for cancer cells or other abnormalities
Task 3 Common medical abbreviations
Expand the following common medical abbreviations:
Abbreviation Expanded meaning
C/O Complains of
FH Familial hypercholesterolemia
NBM Nothing by mouth
IV Intravenous
O/E On examination
BP blood pressure
GA General Anaesthetic
CXR Chest X-ray
URTI Upper respiratory tract infection
SOB Shortness of breath
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© New South Wales Technical and Further Education Commission, 2017 (TAFE NSW), Archive version 1, November 2017
Task 4 Fields of medical practice
CARDIOLOGY
You will find the following medical terms and abbreviations are included in the discharge
summary you are to complete in Task 5. Using the internet or a medical dictionary, research
each medical term and give a brief meaning for each one.
Ensure you can spell and pronounce each word correctly before creating the discharge
summary.
Medical Term Definition
A disease is considered asymptomatic if a
Asymptomatic patient is a carrier for a disease or infection
but experiences no symptoms
Is a heart block in the right bundle branch of
Right bundle branch block the electrical conduction system
(RBBB)
Is a feeling of general discomfort,
Malaise uneasiness, or pain, often the first sign of an
infection or other disease
Is the medical term for shortness of breath,
Dyspnoea sometimes described as “air hunger
Partial or complete loss of consciousness
Syncope with interruption of awareness of oneself and
one's surroundings
Is a medical test that detects cardiac (heart)
ECG abnormalities by measuring the electrical
activity generated by the heart as it contracts
Is a hospital ward specialized in the care of
CCU patients with heart attacks, unstable angina,
cardiac dysrhythmia and (in practice) various
other cardiac conditions that require
continuous monitoring and treatment
A bluish-purple discoloration of skin and
Cyanosed mucous membranes usually resulting from a
deficiency of oxygen in the blood
Having a bulbous enlargement of the tip with
Clubbed convex overhanging nail.
Normal breathing that is soft and low-pitched
Vesicular breath sounds when heard in auscultation.
Relating to the head or the head end of the
Cephalic body
Is a small electronic device implanted under
Pacemaker the skin that sends electrical impulses to the
heart muscle to maintain a suitable heart
rate and to prevent slow heart rates
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© New South Wales Technical and Further Education Commission, 2017 (TAFE NSW), Archive version 1, November 2017
Task 5 Complete the discharge summary
Instructions:
Complete the discharge summary from the audio file downloaded with this assessment.
Listen to the instructions carefully and enter paragraphs as dictated. Insert full stops and
make new paragraphs when requested. Separate each paragraph with a clear line of space.
You will find that the patient information has been entered for you at the top of the summary.
You are to enter the paragraphs (the body of the summary) where it states [start your
summary here]. Remove this sentence before you submit your assessment.
Ensure the discharge summary is on a page on its own. Remember you are aiming to
complete the document to meet current business standards. This means you should
proofread your work, checking the spelling and grammar to ensure there are no errors and
refer to the table in Task 4 for the correct spelling of the medical terms.
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© New South Wales Technical and Further Education Commission, 2017 (TAFE NSW), Archive version 1, November 2017
Prince Andrew Hospital
Cardiology Unit
Hospital Road
SYDNEY NSW 2000
DISCHARGE SUMMARY
Patient: Joan Dorothy Smith
DIAGNOSIS: Complete heart block
Admitted 3 February 20XX
Discharged 5 February 20XX
This 78 year old lady had been in a good health until 2010 when a routine check by her local
medical officer showed on ECG that she has a left bundle branch block. She was
asymptomatic.
Her problems began 2 weeks prior to admission when she had an onset of general malaise,
dyspnoea on mild exertion and dizziness on more significant exertion. She had no syncope or
chest pain. She was referred to Dr. West.
On examination by Dr. West an ECG showed complete heart block. She was not cyanosed or
clubbed. Breath sounds were vesicular. Abdomen was soft with no masses.
A permanent pacemaker was inserted via the right cephalic vein. The lead was a type 030-
224 serial number 003344 telectronics.
The patient was monitored in the coronary care unit overnight where she was found to be
pacing satisfactorily. She was discharged well and will be followed up at the pacemaker
clinic in 6 months time.
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© New South Wales Technical and Further Education Commission, 2017 (TAFE NSW), Archive version 1, November 2017
Task 6 Extracting information from a medical report
The following medical report details information on a patient who has had serious heart
problems for more than 10 years. He has had two operations. During the last six months he
has developed increasing pain in the chest and is having more trouble breathing. His
cardiologist, Dr Stevens has now admitted him to Grove Medical Centre for further tests.
Read the report and answer the questions that follow.
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© New South Wales Technical and Further Education Commission, 2017 (TAFE NSW), Archive version 1, November 2017
Grove Medical Centre
History
Personne Robert J.
DATE 14 December 2017
PRESENTING PROBLEM The patient was admitted for left heart catheterisation
and coronary arteriography to investigate the diagnosis
of cardiomyopathy and cardiac transplant.
HISTORY OF PRESENT ILLNESS The patient is a 63-year-old male with a known history
of coronary artery disease. The patient had 4-vessel
bypass surgery nine years ago.
The patient was re-hospitalised at Grove Hospital in
2008 because of acute chest pain with electrocardiogram
changes consistent with acute inferior myocardial
infarction for which the patient was given Warfarin. He
underwent evaluation and assessment, including heart
catheterisation and coronary arteriography.
PAST MEDICAL HISTORY Past illnesses: There is no personal history of
hypertension or diabetes. The patient has a known hiatus
hernia, but is asymptomatic at this time. Allergies: No
known allergies. Medications: Warfarin. Previous
operations: See above.
FAMILY HISTORY Father died of coronary artery disease at age 48.
Paternal uncle also died of coronary artery disease.
Maternal uncle and grandfather are both diabetic. The
patient has two siblings. Nil other significant family
history.
PHYSICAL EXAMINATION On examination the patient looked well and not in
distress. There were no carotid bruits. Blood pressure:
120/80. Pulse: 70 and regular.
Heart CT revealed cardiomegaly. There was no murmur.
There was an equivocal third heart sound.
Lungs There are a few basilar rales.
Abdomen No visceromegaly. Bowel sounds were normal. No
masses or tenderness were felt on palpation.
DIAGNOSIS Coronary artery disease on a background of previous
anterior myocardial infarction in 2008 requiring
coronary bypass surgery. Patient admitted for
investigation of end-stage cardiomyopathy.
HISTORY AND PHYSICAL Cardiac catheterisation and coronary angiography were
discussed with the patient, including the risks and
potential complications. The patient understands and
wishes to proceed.
P. Stevens, MD
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© New South Wales Technical and Further Education Commission, 2017 (TAFE NSW), Archive version 1, November 2017
Questions
6.1 Research the meaning of the following medical terms and provide a brief definition for
each one. Use your favourite medical dictionary to assist you.
Cardiomegaly Is used to refer to the physical finding of an enlarged
heart and is not a disease itself
Dyspnoea Refers to sudden and severe shortness of breath, or
difficulty in breathing
Hiatus hernia Protrusion of part of the stomach upward into the
chest cavity through the passage in the diaphragm
for the esophagus usually with movement of the
opening of the esophagus into the stomach to a
position above the diaphragm
Visceromegaly Is enlargement of the organs inside the abdomen,
such as the liver, spleen, stomach, kidneys, or
pancreas
Myocardial infarction The medical term for heart attack, literally means
"heart tissue damage or death”
Angina Chest pain due to an inadequate supply of oxygen to
the heart muscle
6.2 The patient is to be admitted to hospital. Name the tests the patient will undertake.
Answer: Heart catheterisation, coronary arteriography and CT scan
6.3 Name the surgery the patient underwent nine years ago.
Answer: 4-vessel bypass surgery
6.4 Why was the patient admitted to Grove Hospital in 2008?
Answer: Acute chest pain
6.5 The doctor has diagnosed coronary artery disease. Give a brief definition of this.
Is the narrowing or blockage of the coronary arteries, usually caused by atherosclerosis.
Atherosclerosis is the build-up of cholesterol and fatty deposits on the inner walls of the
arteries.
Checklist
I have:
answered all questions in the space provided on the assessment
proofread my work to ensure there are no spelling or formatting errors
saved my assessment in a zipped folder in readiness for submitting.
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