Imagine you are a radiologic technologist working for a neuroradiologist. You talk to the patient before assisting with a procedure and take notes using abbreviations. The neuroradiologist asks you for your assessment before beginning the procedure. In this activity, you will translate your notes into medical terminology.
Step 1: Read Over Your Notes
45-year-old female pt, VSS, PERRLA with h/o CVA and CVD
c/o HA and N/V for 3 days
Tests: CSF, CT head
R/o inflammation of the blood vessels, hernia of the spinal cord
Step 2: Translate Your Notes
45-year-old female patient, vital signs stable, pupils equal, round, and reactive to light and accommodation with history of cerebrovascular accident and cardiovascular disease
Complaining of headache and nausea/vomiting for 3 days
Tests: cerebrospinal fluid analysis, computed tomography head
Rule out inflammation of the blood vessels, herniation of the spinal cord