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UNDERSTANDING CLINICAL MATERIAL. An introduction to medical terminology and abbreviations Dr Ian Coombes University of Queensland. Objectives. Describe the structure of clinical information, Provide an introduction to medical terminology,

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UNDERSTANDING CLINICAL MATERIAL

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Understanding clinical material l.jpg

UNDERSTANDING CLINICAL MATERIAL

An introduction to medical

terminology and abbreviations

Dr Ian Coombes

University of Queensland


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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.


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Language of Health Care

  • Presentation of information

  • Medical abbreviations

  • Medical terminology


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A case from the clinic

Cardiac referral

Elderly lady,

AF

Base INR 1.1

LD warfarin 8mg x3

Counselled in clinic

Went home.


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But …………….

Appeared confused

TIA

Home visit

GP visit

CP visit

Solution?


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Presenting case Material

  • Not a logical structure

  • Lacked information

  • Lacked detail

  • Used abbreviations & terminology 


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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.


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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


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Structure of Information

  • DH = drug history

  • Biochemical data and other results

  • Provisional diagnosis

  • Action Plan


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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


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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 andmucopurulentexpectoration.

Chest paino palpitationsohaemoptysisoWt losso


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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.


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Understanding Terminology

Hyperkalaemia

Prefix = Hyperkalaemia = high

Root = Hyperkalaemia= potassium

Suffix = Hyperkalaemia = blood

Meaning = raised potassium concentration in the blood.


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The Prefix

  • Describes position

  • Provides a description

  • Describes number and measurement


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Describes Position


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Provides a description


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Colours


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Describes number and measurement


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Suffix

  • Disease or change in the body

  • Surgery and incisions

  • Others


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Disease or change in the body


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Surgery and incisions


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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 andmucopurulentexpectoration.

Chest paino palpitationsohaemoptysisoWt losso


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Interpretation

Mucopurulent

Containing mucus mingled with pus as in a sputum

sample

Haemoptysis

Blood stained sputum


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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. JoAoC++CloO++

Scattered rhonchi and bilateral basal crepitations.

Hepatomegaly. Moderately confused and disorientated.


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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 A&W); two sons – 38 and 34 yrs – both

A&W.


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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?


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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.


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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 (?)


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Case History (cont.)

Biochemical Results

Na+141 mmoles/L (135-145)

K+3.8 mmoles/L (3.5 -5.0)

Urea8 mmoles/L (2.5 – 7.0)

Cr185 µmoles/L (40 -120)

Hb17.7 g/dL (14-16)

Hct0.57 (0.36 – 0.46)

WCC18.1 x 109/L ( 4-11)

pH7.16 (7.32-7.42)

PaCO211.21 kPa (4.5-6.1)

PaO210.23 kPa (12-15)


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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?


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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


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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


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Medical abbreviations and terminology

Questions?

Professor JG Davies

Academic Director of Clinical Studies, School of Pharmacy and BMS,

University of Brighton


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