UNDERSTANDING CLINICAL MATERIAL

1
UNDERSTANDING CLINICAL MATERIAL

• An introduction to medical
• terminology and abbreviations
• Dr Ian Coombes
• University of Queensland

2
Objectives

• Describe the structure of clinical information,
• Provide an introduction to medical terminology,
• Use a case history to illustrate issues relating
  to medical terminology and abbreviations,
• List the essential ingredients of a presentation,
• Provide advice on presentation techniques,
• Highlight some common problems.

3
Language of Health Care

• Presentation of information
• Medical abbreviations
• Medical terminology

4
A case from the clinic

• Cardiac referral
• Elderly lady,
• AF
• Base INR 1.1
• LD warfarin 8mg x3
• Counselled in clinic
• Went home.

5

• But .
• Appeared confused
• TIA
• Home visit
• GP visit
• CP visit
• Solution?

6
Presenting case Material

• Not a logical structure
• Lacked information
• Lacked detail
• Used abbreviations terminology ?

7
Presenting Clinical Material Golden Rules

• Always maintain patient confidentiality code of
  ethics as a health care practitioner e.g. Mrs
  Beryl Thomas Mrs BT or Mrs T.
• Be concise present only relevant material.
• Relevant should include negative or nil findings
  e.g. allergies, where appropriate
• Present material in a logical and structured
  manner
• Provide detail where appropriate e.g. smoking
  habit.

8
Structure of Information

• Brief into of page age, gender problem
• C/O complains of
• HPC history of presenting complaint
• PMH past medical history
• O/E on examination may include a RoS (review
  of systems)
• FH family history
• SH social history

9
Structure of Information

• DH drug history
• Biochemical data and other results
• Provisional diagnosis
• Action Plan

10
Case History

• Mr CP, 68 year-old gentleman admitted to hospital
  
• in a confused state.
• C/O (Complains of) cough, vomiting.
• HPC (History of presenting complaint)
• 2/52 history of worsening confusion, increasing
• cough and mucopurulent expectoration.
• Chest paino palpitationso haemoptysiso Wt losso

11
Case History
Mr CP, 68 year-old gentleman admitted to hospital
in a confused state. C/O (Complains of) cough,
vomiting. HPC (History of presenting
complaint) 2/52 history of worsening confusion,
increasing cough and mucopurulent expectoration.
Chest paino palpitationso haemoptysiso Wt losso
12
Medical Terminology learning the language.
(http//ec.hku.hk/mt/)

• The prefix of a word is before the main part of
  the word.
• If you can recognize the meaning of the prefix,
  you will be
• able to guess the word's definition more
  accurately.
• A suffix  follows the end of a word and forms a
  new word.
• A suffix provides important clues about a word's
  definition.
• For instance, the suffix, 'pathy', means disease.
  
• In most cases when you see a word ending in
  'pathy', you
• know it refers to a disease, as in 'angiopathy',
  which means
• disease of the blood vessels.

13
Understanding Terminology

• Hyperkalaemia
• Prefix Hyperkalaemia high
• Root Hyperkalaemia potassium
• Suffix Hyperkalaemia blood
• Meaning raised potassium concentration in the
  blood.

14
The Prefix

• Describes position
• Provides a description
• Describes number and measurement

15
Describes Position
16
(No Transcript)
17
Provides a description
   
18
Colours
19
Describes number and measurement
20
Suffix

• Disease or change in the body
• Surgery and incisions
• Others

21
Disease or change in the body
22
Surgery and incisions
23
Case History
Mr CP, 68 year-old gentleman admitted to hospital
in a confused state. C/O (Complains of) cough,
vomiting. HPC (History of presenting
complaint) 2/52 history of worsening confusion,
increasing cough and mucopurulent expectoration.
Chest paino palpitationso haemoptysiso Wt losso
24
Interpretation

• Mucopurulent
• Containing mucus mingled with pus as in a sputum
• sample
• Haemoptysis
• Blood stained sputum

25
Case History (cont.)

• PMH (past medical history)
• Chesty for over 20 years COPD
• RA for 15 years. PUD 2002.
• O/E (on examination)
• Dyspnoeic and centrally cyanotic. JVP raised by
  3cms.
• Moderate pitting oedema over both legs.
• BP 140/90 P 98 regular. JoAoCCloO
• Scattered rhonchi and bilateral basal
  crepitations.
• Hepatomegaly. Moderately confused and
  disorientated.

26
(No Transcript)
27
Case History (cont.)

• FH and SH (Family history and social history)
• Pensioner - ex-baker (30 yrs) lives on the 12th
  floor of a
• tower block.
• Both parents dead. Mother (64 yrs) following long
  history of
• IHD and 2x MI.
• Married (65yrs old AW) two sons 38 and 34 yrs
  both
• AW.

28
Case History (cont.)

• DH (Drug history)
• Prescribed medicines name, dose and duration?
• OTC medicines name, dose and duration?
• Complimentary medicines name, dose and
  duration?
• Allergies and adverse drug experiences?
• Smoking habits how long, how many?
• Alcohol intake units/week?
• Recreational drugs habits?
• Compliance assessment when and how do you use
  your
• medicines?

29
Case History (cont.)

• DH
• Salbutamol Inhaler 2 puffs PRN
• Ipratropium Inhaler 2 puffs qds
• Lasix 2 tabs mane
• Prednisolone 7.5mg daily
• Theophylline 300mg bd
• Simple linctus 5-10 mL PRN
• OTCo Complimentaryo
• Allergies Nil Known
• Ex-smoker stopped 3 yrs ago. Smoked 30 a day
  for 30 years.
• Alcohol Rarely. Did drink 55 units/week for
  many years.
• No recreational drugs.
• Compliant with medicines Son and wife manage
  this for him.

30
Case History (cont.)

• RoS (Review of Systems)
• General then
• CVS, RS, AS, GUS, CNS,
• Endocrine, Locomotor
• RS
• RR respiratory rate 28 bpm (tachypnoeic)
• PEFR peak expiratory flow rate 220 L/min
• Chest X-ray areas of consolidation infection
  (?)

31
Case History (cont.)

• Biochemical Results
• Na 141 mmoles/L (135-145)
• K 3.8 mmoles/L (3.5 -5.0)
• Urea 8 mmoles/L (2.5 7.0)
• Cr 185 µmoles/L (40 -120)
• Hb 17.7 g/dL (14-16)
• Hct 0.57 (0.36 0.46)
• WCC 18.1 x 109/L ( 4-11)
• pH 7.16 (7.32-7.42)
• PaCO2 11.21 kPa (4.5-6.1)
• PaO2 10.23 kPa (12-15)

32
Case History (cont.)

• Diagnosis
• Acute exacerbation of COPD 2o infection
• Plan
• Introduce nebulised bronchodilators
• Oxygen
• Start antibiotic therapy
• Consider switching to IV theophylline and
  steroids?

33
Case History (cont.)

• Key elements of pharmaceutical care plan
• Advise medical staff on
• Antibiotic choices and doses (given renal
  impairment)
• Dosage regimen for bronchodilators
• IV Hydrocortisone dose from oral prednisolone
• Plasma concentration monitoring for theophylline

34
Case History (cont.)

• Key elements of pharmaceutical care plan
• Advise nursing staff on
• Administration of IV antibiotics
• Administration of nebulised bronchodilators
• Administration of IV theophylline bolus or
  infusion?
• Advise patient on
• Use of inhalers and technique
• Use of medicines risk/benefit information
• Need for regular flu jab

35
Medical abbreviations and terminology

• Questions?
• Professor JG Davies
• Academic Director of Clinical Studies, School of
  Pharmacy and BMS,
• University of Brighton