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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
UNDERSTANDING CLINICAL MATERIAL

An introduction to medical

terminology and abbreviations

Dr Ian Coombes

University of Queensland

objectives
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.
language of health care
Language of Health Care
  • Presentation of information
  • Medical abbreviations
  • Medical terminology
a case from the clinic
A case from the clinic

Cardiac referral

Elderly lady,

AF

Base INR 1.1

LD warfarin 8mg x3

Counselled in clinic

Went home.

slide5
But …………….

Appeared confused

TIA

Home visit

GP visit

CP visit

Solution?

presenting case material
Presenting case Material
  • Not a logical structure
  • Lacked information
  • Lacked detail
  • Used abbreviations & terminology 
presenting clinical material golden rules
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.
structure of information
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
structure of information9
Structure of Information
  • DH = drug history
  • Biochemical data and other results
  • Provisional diagnosis
  • Action Plan
case history
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

slide11

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

medical terminology learning the language http ec hku hk mt
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.

understanding terminology
Understanding Terminology

Hyperkalaemia

Prefix = Hyperkalaemia = high

Root = Hyperkalaemia= potassium

Suffix = Hyperkalaemia = blood

Meaning = raised potassium concentration in the blood.

the prefix
The Prefix
  • Describes position
  • Provides a description
  • Describes number and measurement
suffix
Suffix
  • Disease or change in the body
  • Surgery and incisions
  • Others
slide23

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

interpretation
Interpretation

Mucopurulent

Containing mucus mingled with pus as in a sputum

sample

Haemoptysis

Blood stained sputum

case history cont
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.

case history cont27
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.

case history cont28
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?

case history cont29
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.

case history cont30
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 (?)

case history cont31
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)

case history cont32
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?
case history cont33
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
case history cont34
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

medical abbreviations and terminology
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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