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Medical Terminology, abbreviations and interpreting clinical notes
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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
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Medical Terminology and abbreviations
A good resource is; The prefix of a word is before the main part of the word. E.g. poly- so polypharmacy means multiple medicines A suffix 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
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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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Provides a description Describes number and measurement
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 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
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Describes number and measurement
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Disease or change in the body Surgery and incisions Others
Suffix Disease or change in the body Surgery and incisions Others
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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)
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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
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On –line Medical Dictionary
Medline Plus MondoFacto This contains lists of prefixes and suffixes and abbreviations
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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
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Patient’s Notes: Health Care Language
Presentation of information Patient notes and charts Medical abbreviations Medical terminology
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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
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Information in Notes 2 DH = drug history
Biochemical data and other results Provisional diagnosis Action Plan
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Role of Clinical Pharmacist
Read and interpret notes Including lab values Clinical reconciliation (as part of the team) 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
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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
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Objective data (can be measured)
Haematology results Biochemistry results Microbiology reports ECG X rays A collection of symptoms that are diagnostic
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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
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Case 2 (continued) Current Medicines Enalapril 10 mg daily
Frusemide 20 mg daily Digoxin 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
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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 !!
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S.O.A.P Analysis
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S.O.A.P. Analysis Technique for assessing and evaluating individual pharmaceutical problems
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What does S.O.AP. Stand for?
S Subjective O Objective A Analysis or Assessment P Plan
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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
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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
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Returning to Case 1
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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
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Case 2 (continued) Current Medicines Enalapril 10 mg daily
Frusemide 20 mg daily Digoxin 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 Identify any changes in drug therapy that might reduce these problems
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We will return to the case of AA as the course progresses
The case will get more complex !
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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 !
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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
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