Transcript presentation skills

Medical Terminology, abbreviations
and interpreting clinical notes
Objectives

Provide an introduction to medical terminology,
abbreviations and the presentation of information

Describe the use of clinical information in patients’
notes

To overview patient assessment and SOAP analysis

Demonstrate using cases
Medical Terminology and abbreviations
A good resource is;
http://ec.hku.hk/mt/
prefix
The
of a word is before the main part of the word.
E.g. poly- so polypharmacy means multiple medicines
suffix
A
follows the end of a word and forms a new word.
A suffix gives an indication about the meaning of a word.
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 “neuropathy', or disease of nerves.
Polyneuropathy means disease of many nerves or similar
Understanding Terminology
Hyperkalaemia
Prefix = Hyperkalaemia = high
Root = Hyperkalaemia = potassium
Suffix = Hyperkalaemia = blood
Meaning = raised potassium concentration in the blood.
The Prefix

Describes position

Provides a description

Describes number and measurement
Describes Position
Provides a description
Colours
Grey
glauc(o)
(Glaucoma)
Red
erythr(o)
Erythrocyte
Black
melan(o)
melanin
White
leuc(o), leuk(o)
leukomyelitis
Blue
cyan(o)
cyanopsia
Yellow
cirrh(o)
cirrhosis
Green
chlor(o)
chloroma
Describes number and measurement
Suffix

Disease or change in the body

Surgery and incisions

Others
Disease or change in the body
Suffix
Meaning
Example
-algia
pain
Neuralgia (nerve)
-(a)emia
blood
leuk(a)emia (white)
-itis
inflammation
Hepatitis (Liver)
-malacia
softening
Osteomalacia (bone)
-megaly
enlargement
Splenomegaly
(spleen)
-phagia
eating, swallowing
Dysphagia (difficult )
-plegia
paralysis,stroke
Hemiplegia (half )
-rrhea
discharge,flow of watery stools diarrhea
-spasm
Involuntary contraction,
twitching
Bronchospasm
(bronchus)
Surgery and incisions
Suffix
Meaning
Example
-desis
binding ,
stabilization
Pleurodesis
pleural membrane
(lining of the lung)
-plasty
formation,
plastic repair
Angioplasty (blood
vessel)
-lysis
loosen, free
form adhesions,
destruction
Thrombolysis (blood)
-tripsy
to crush
Cholelithotripsy
gallstone
On –line Medical Dictionary

Medline Plus
http://www.nlm.nih.gov/medlineplus/mplusdictionary.html

MondoFacto
http://www.mondofacto.com/facts/dictionary
This contains lists of prefixes and suffixes and abbreviations
Suggested Task

Look at the medicines data sheet of a commonly
used drug; e.g. prednisone or fluoxetine or
omeprazole

Look at the adverse reactions, indications and
contraindiactions sections

Try to recognise all the terms

If there are words and term you don’t understand
look them up in a medical dictionary
Patient’s Notes:
Health Care Language
 Presentation
 Patient
 Medical
of information
notes and charts
abbreviations
 Medical terminology
Information in Notes 1







Overview and demographics – 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
Information in Notes 2




DH = drug history
Biochemical data and other results
Provisional diagnosis
Action Plan
Role of Clinical Pharmacist

Read and interpret notes


Clinical reconciliation (as part of the team)






Including lab values
Match diagnosis with appropriste treatment (espcially
pharmacotherapy)
Identify subjective and objective data
Make an assessment and identify problem list
Prioritise problams
Make a plan which will include optimising drug
treatment
Any advice along the from admission to discharge
Subjective data includes:



Patient complaints
Observations of the patient (that are
subjective in nature)
eg, patient complains of shortness of breath
or pain
Other medicines tried
Objective data (can be
measured)






Haematology results
Biochemistry results
Microbiology reports
ECG
X rays
A collection of symptoms that are diagnostic
Case 1




A very simple case to start with to start getting
used to some of the terminology
Mr AA
Admitted with worsening SOB and DOE
Very edematous with tachycardia, distressed and
anxious
HPC symptoms have worsened in last few days,
unable to do simple tasks.
PMH





CHF (NYHA Grade 3)
AF
Hypertension
COPD
Osteoarthritis
Case 2 (continued)

Current Medicines








Enalapril 10 mg daily
Frusemide 20 mg daily
Digoxin 0.125 mg daily
Salbutamol Inhaler as required
Fluticasone inhaler 100 mcg BD
Naproxen 250 mg BD
Omeprazole 20 mg daily
Paracetamol 500 mg Two tabs PRN
Case 1 (continued)





Age 71
Former smoker 20 pack years; stopped 3
years ago
Wt 87 kg
No other meds or alcohol
Lives with wife who is healthy and active
We will come back to this case !!
S.O.A.P Analysis
S.O.A.P. Analysis
Technique for assessing and
evaluating individual
pharmaceutical problems
What does S.O.AP. Stand for?




S
O
A
P
Subjective
Objective
Analysis or Assessment
Plan
Assessment










Review subjective and objective data
Consider drug therapy and OTCs
Are any symptoms related to an ADR or interaction?
Is treatment appropriate? Dose optimal?
Consider evidence based therapy.
Consider dose, route, duration and timing
Consider hepatic and renal function
Allergy status?
Does each drug have an indication
Consider patient compliance
Clinical application of S.O.A.P. analysis
Prescription or Chart
Identify problem list and prioritise
Medical (M) Pharmaceutical (P)
Link medical and pharmaceutical problems
Identify gaps and areas for improvements
Returning to Case 1
Case 1




Identfy some problems that AA has
Mr AA
Admitted with worsening SOB and DOE
Very edematous with tachycardia, distressed and
anxious
HPC symptoms have worsened in last few days,
unable to do simple tasks.
PMH





CHF (NYHA Grade 3)
AF
Hypertension
COPD
Osteoarthritis
Case 2 (continued)

Current Medicines








Identify any changes in drug therapy that
Enalapril 10 mg daily
might reduce these problems
Frusemide 20 mg daily
Digoxin 0.125 mg daily
Salbutamol Inhaler as required
Fluticasone inhaler 100 mcg BD
Naproxen 250 mg BD
Omeprazole 20 mg daily
Paracetamol 500 mg Two tabs PRN
We will return to the case of AA
as the course progresses
The case will get more complex !
Suggested Task





Access some medical notes for a patient on a ward
You could ask to accompany the clinical pharmacist
for that ward
Try to interpret the information and abbreviations
ans see if you can recognise what they mean
Note the abbreviations you don’t know and ask for
advice about these (you can ask pharmacists,
doctors or nurses).
Asking your more experienced colleagues is a great
way to learn !
Suggested Task 2


Start a clinical pharmacy log book
Record interventions and contributions


Interactions and ADRs indentified
Advice given

Outline what you learnt and how the learning can be
incorporated into practice

Share these with other clinical pharmacists for peer
review and shared learning