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 andmucopurulentexpectoration. Chest paino palpitationsohaemoptysisoWt 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

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 andmucopurulentexpectoration. Chest paino palpitationsohaemoptysisoWt 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. JoAoC++CloO++ Scattered rhonchi and bilateral basal crepitations. Hepatomegaly. Moderately confused and disorientated.

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

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