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Medical Records Lecture 9 of the Course “Medical English” for Sophomore Medical Students of Taipei Medical University

Medical Records Lecture 9 of the Course “Medical English” for Sophomore Medical Students of Taipei Medical University School of Medicine Taipei Medical University . Winston W. Shen, M.D. Professor and Chairman Department of Psychiatry

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Medical Records Lecture 9 of the Course “Medical English” for Sophomore Medical Students of Taipei Medical University

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  1. Medical Records Lecture 9 of the Course “Medical English” for Sophomore Medical Students of Taipei Medical University School of Medicine Taipei Medical University Winston W. Shen, M.D. Professor and Chairman Department of Psychiatry Taipei Medical University College of Medicine and Chief, Department of Psychiatry TMU-Wan Fang Medical Center Taipei, TAIWAN E-mail address: Shenwinw@gmail.com

  2. The Schedule for the Course “Medical English” (Version of 4/23/07) • Week 1 (March 1) The Digestive System • Week 2 (March 8) The Respiratory System • Week 3 (March 15) The Cardiovascular System • Week 4 (March 22) The Musculoskeletal System (Turning in a 400-word essay on “My Visit to the Clinic (Hospital)” (in double-line space hard copy) • Week 5 (March 29) The Central Nervous System • Week 6 (April 5) No class (Spring break) • Week 7 (April 12) Urinary and Reproductive Systems • Week 8 (April 19) The First Examination • Week 9 (April 26) Medical Records (Turning in a 400-word essay on “My Favorite Book” (in double-line space hard copy) • Week 10 (May 3) Scientific Papers • Week 11 (May 10) Hematology • Week 12 (May 17) Infectious Diseases • Week 13 (May 24) EENT and the Skin • Week 14 (May 31) Endocrinology (Turning in a 400-word essay on “How to Be a Good Physician” (in double line space hard copy) • Week 15 (June 7) Immunology • Week 16 (June 14) Oncology • Week 17 (June 21) No Class • Week 18 (June 28) Final (The Third) Examination

  3. Elements of Medical Records (Inpatient Services) Admission History Progress Notes Consultation Notes Operation Notes Transfer Notes Discharge Summary (Clinical Resume)

  4. Elements of Medical Records (Outpatient Services) Intake History Clinic Notes Prescriptions

  5. Admission History • Identifying Data • Chief Complaint (s) • History of Present Illness • Past History • Review of Systems • Social History • Family History • Substance Abuse History • Physical Examination • Mental Status Examination • Summary • Diagnoses • Treatment Plans

  6. Chief Complaint (CC) Case 1 (1/4) “I have been feeling lousy and not effective in my work as a teacher for the past month.”

  7. History of Present Illness (HPI) Case 1 (1/3) This 32-year old single female Taiwanese patient, a mathematics high school teacher, was seen on April 23, 2007 at the psychiatry clinic of TMU-Wan Fang Medical Center. The patient came in and complained, “I have been feeling lousy and not effective in my work as a teacher for the past month.” The patient described that one month ago she started to experience depressive feeling, lack of

  8. History of Present Illness (HPI) Case 1 (2/3) interest, decreased appetite with the weight loss of four kg, sleep disturbances, decreased psychomotor activities, feeling fatigue, poor concentration ability, and suicidal idea. She reported that everything she used to do easily has become an effort for her in the past month. Therefore, she had to take a leave of absence from her work last month. She has been staying home living a distressed unproductive life. The patient admitted that she suffered from a similar episode of depressive mood at her age of 25

  9. History of Present Illness (HPI) Case 1 (3/3) years while she was studying at a graduate school and she took almost 15 months to get recovered from that illness without receiving any treatment. Throughout the history of the present illness, the patient denied any experience of having hallucinations or delusion.

  10. Past History • General health: Giving general impression of his physical states through life, mentioning the greatest and smallest body weight, average weight. • Previous diseases: • Vaccination history and sera status: • Previous hospitalizations and operations: • Accidents or injury: • Drug sensitivity:

  11. Review of Systems (1/4) Skin: Rashes, urticaria, pruritus, pigmentation, hair change Head: Trauma, head Eyed: Vision, diplopia, scotoma, pain Ears: Hearing, discharge from ear cannal, tinnitus Nose: Sense of smell, discharge, obstruction. epistaxis Throat: Hoarseness, sore throat, tonsillitis Mouth: Oral sores, bleeding

  12. Review of Systems (2/4) The Cardio-respiratory System: Cough, sputum, hemeptysis, night sweat, painful respiration, precordial pain, wheezing, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, palpitation of the heart, edema . . . The Digestive System: Appetite change, food intake, food intolerance, nausea, vomiting, dysphagia, hiccough, gas flatus, jaundice, colic pain, hematemesis, stool character and frequency, bloody or tarry stool, hemorrhoid, anal fistula, rectal abscess, hernia . . .

  13. Review of Systems (3/4) The Genito-urinary System: ٠Urine: frequency, oliguria, polyuria, dysuria, hematuria, pyuria, retention, incontinence, urinary stone, difficulty in stating urination ٠Venereal diseases: names of VD, symptoms, treatment ٠ In the male: Erectile ability ٠ In the female: Menstruation, interval between periods, duration, amount of flow, (number of pads used) regularity , date of menopause, menopausal symptoms, previous pregnancies, termination, still births, abortion, complication

  14. Review of Systems (4/4) The Neuro-muscular System: Ability tododaily activities, headache, cranial pain, dysarthria, dizziness, syncope or fainting, facial numbness, ataxia, involuntary movement, deficit of muscle power, sensations, weakness of extremities, intermittent claudication, sphincter control.

  15. Social History Daily routine: Sleep pattern, exercise, recreation spiritual life Education: Highest level of education Occupations: All kinds of work in the past and the present time, the duration of employment, history of exposure to toxic substances Family relocations: Previous residencies Military services Marital history: duration of the marriage, the marital relationship, age and heath status of the spouse and children

  16. Family History Siblings: State the health and age of brothers and sisters, Causes of death if deceased Parents: State the health and age of parents, Causes of death if deceased Uncles, aunts, and cousins: Roughly state the diseases among them, Roughly state causes of death if deceased Grand parents: State the health and age of grand parents, Causes of death if deceased *Cancer, diabetes, hypertension, tuberculosis, bleeding, arthritis, heart or kidney diseases, CNS diseases, psychiatric diseases

  17. Substance Abuse History • Social drugs - Alcohol - Nicotine - Caffeine • Street drugs - Marijuana - Cocaine - Amphetamine - Opioid - Anxiolytic/sedative/hypnotic - Phencyclidine (PCP) - LSD - Solvent • Other abused substances

  18. Physical Examination (PE) Case 1 (1/5) Body weight: 70 kg Height 168 cm Temperature: 37 degree C Pulse rate: 78 beats per minute (bpm) Respiration rate: 20 times per minute General conditions: The patient was a well-developed, and well-nourished adult female. The patient was not in acute distressed physical condition without any cardio-respiratory embarrassments.

  19. Physical Examination (PE) Case 1 (2/5) Head: Normal contour, no traumatic injury. No visible scars were seen. Eyes: Not anemic and not congested in conjuntivas, isocornic in both eyes, reactive pupils to light, No nystagmus. The patients had full movement in all directions. ENT: Normal hearing ability, intact tympamnic membrance (ear drums), no abnormal discharge from both ear canals; Normal contour of the nose, no septal deviation; Uvula was centrally located. The throat was not congested.

  20. Physical Examination (PE) Case 1 (3/5) Neck: Supple without any nuchal rigidity, no palpable mass, no bruits. The trachea was centrally located. Chest: Symmetric with normal contour in both sides, full expansion with normal contour, normal breathing sounds without audible rales. Regular forceful heart beats without audible murmurs. Abdomen: Soft all over the abdomen, no palpable mass. Gurgling sounds of the intestine were audible.

  21. Physical Examination (PE) Case 1 (4/5) Genitalias: Not abnormal discharge, the Bartholin’s glands were not enlarged, no palpable masses in cervix, fundus and adnexas in the pelvis examination. Rectal Examination: No bloody stool, no hemorrhoids, no anal fissure, normal sphincter tone.

  22. Physical Examination (PE) Case 1 (5/5) Locomotor System: No traumatic scars were seen. The patient had no restriction in movements, no abnormal curvature, no swelling or tenderness in knee joints, normal gaits in walking. The Nervous Systems: Intact function in all 12 cranial nerves, no sensory or motor deficits in all extremities. Normal deep tendon reflexes in elbows and the knee joints.

  23. Mental Status Examination (MSE) (1/3) • Appearance, Behavior, and Attitude Normal, neat, well-groomed, unkempt, well-dressed, look as stated age, “spacing out”, grimacing No disorganized behavior, no bizarre behavior, pacing on the floor, posturing, mannerism Cooperative, uncooperative, hostile, trying to answer questions, la belle indifference • Stream of Thought Coherence, incoherence (formal thought disorder, disorganized speech, looseness of associations), clang association Normal rate and rhythm of speech, mutism, blocking, slow mental activity, pressured speech

  24. Mental Status Examination (MSE) (2/3) • Affect and Mood Affect is the momentary emotional expression to reflect the thought inside. Affect is understood as the concept of “weather.” Other descriptions should be placed elsewhere except defining three dimensions: - Stable, unstable (labile) - Appropriate, inappropriate - Flat, branded, restricted, shallow, narrow, within normal range, supersharp. The clues for range are from facial expression, intonation, and body languages Mood is the pervasive emotional expression to reflect the thought inside. Mood is understood as the concept of “climate.” The choice of three possibilities is decided by the examiner and is not by what the patient says in the interview: depressed, normal (even, euthymic) and elated • Contents of Thought Hallucinations, delusion, suicidal risk, homicidal risks Obsession, phobia, preoccupation, delusion of jealousy, nihilistic idea, delusion of poverty, déjà vu, jamais vu

  25. Mental Status Examination (MSE) (3/3) • Sensorium and Mental Capacities - Clear (not clouded) confused, stupor, semi-comatose, coma - Recent memory - Apraxia, aphasia, agnosia, - Executive functioning (planning, organizing, sequencing and abstract thinking) • Insight and Judgment Three levels of insight: - Intellectual insight - Emotional insight - Behavioral insight Judgment (reasoning ability) tested only by actual hypothetical questions rather than extrapolating from histories

  26. Laboratory Examinations The patient’s number of white blood cell count was 18, 000 cells/mm. The roentgenological finding of the posterior- anterior (PA) view of the upright chest X ray film showed some radiolucent air density under diaphrem.

  27. Summary of the Case Case 1 This 32-year old single female Taiwanese patient, was seen for his second episode of major depressive disorder. The patient has a history of one depressive episode when she was 25 years old. The patient was physically healthy. The patient has classical symptoms and signs of depression. She did not have any evidences of dementic or psychotic Symptoms.

  28. Diagnoses Major depressive disorder, recurrent Treatment Plans • Antidepressant therapy • Clinic follow-up

  29. Ten Commandments to Write Better English 1. Thou shalt always use correct grammar • Original versions • The patients theredid not look better conditionthanme.

  30. Ten Commandments to Write Better English 2. Thou shalt use simpler sentences (1/2) Original versions • A hospital is where I used to go when I was a child because of my poor health, so I am very familiar with it.I am in the opinion that the hospital is. . . • Everyone was busy on their business and no one noticed me. • According to others’ word,my face was pale at that moment. • This is one memory of mine about going to a doctor. • I still remember the clinic that I went to the most often.It was a clinic in the downtown of Kaohsiung.

  31. Ten Commandments to Write Better English 4. Thou shalt use more active voice. • Original version • The price was less than NT$100,000. NT$100,000 wasconsidered as a great sumfor me.

  32. Ten Commandments to Write Better English 5. Thou shalt avoid redundancies • Original versions • The medical equipment made me nervous and anxious. • Every one was busy on the business and no one noticed • me.

  33. Ten Commandments to Write Better English 8. Thou shalt use the parallel construction Original versions • He even paid no sight onme but in his computer. • To begin with. . . What’s more. . . Last but not the least. • “Esophagus” is a muscular tube that in adult humans • is about9inches (23 centimeters) in length and one • inch (2.5 centimeters) in diameter.:

  34. Ten Commandments to Write Better English 9. Thou shalt avoid using empty phrases (1/2) Original versions • Last month there was something wrong with my skin. I appeared some strange red little spots. • I feel that communicating with people is not just a piece of cake as I thought before. • He would feel terribly dizzy just like the sky and the ground spinning and having heavy throwing up feeling. • During the time that I was about ten years old, I had to go to the hospital almost once a week.

  35. Ten Commandments to Write Better English 10. Thou shalt be specific in using words Original versions • I brought patients to X-ray or CT. • I really anticipate that our hospital can become a much nicer hospital than . . . • We had to make introduction to the conference guests. • We had to memorize all the details of the hospital • and made introduction when foreigner delegates of • the East Asia Medical Student Conference came here • after during the conference. • My consciousness was not clear. • I felt sick and unwilling to go to school.

  36. Exercises VI Copy-editing the following sentences • Because courses at senior high school were difficult, I spent a lot of time in my lessons, so I did not sleep enough and my health is frail. One day on my way to a cram school, it rained cats and dogs, but I did not have umbrella with me. I had no other choose but to beexposed to the rain. 17. I seldom go to hospital when I am sick. I would rather ask a sick leave for the class ant rest in my dormitory for there is no need to scare myself again in my adulthood. As a student of medical department, I regard the experience as a precious lesson. 18. I once caught a cold. The high fever and headache was killing me and keeping me rooted on the bed. I had not recovered for the whole week.

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