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,
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
 Presentation
of information
 Medical abbreviations
 Medical terminology
A case from the clinic
Cardiac referral
Elderly lady,
AF
Base INR 1.1
LD warfarin 8mg x3
Counselled in clinic
Went home.
But …………….
Appeared confused
TIA
Home visit
GP visit
CP visit
Solution?
Presenting case Material

Not a logical structure

Lacked information

Lacked detail

Used abbreviations & terminology 
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







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 Information




DH = drug history
Biochemical data and other results
Provisional diagnosis
Action Plan
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
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
Medical Terminology – learning the language.
(http://ec.hku.hk/mt/)
prefix
The
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.
suffix
A
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
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
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
Interpretation
Mucopurulent
Containing mucus mingled with pus as in a sputum
sample
Haemoptysis
Blood stained sputum
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 (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 (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 (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 (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 (cont.)
Biochemical Results
Na+
K+
Urea
Cr
Hb
Hct
WCC
pH
PaCO2
PaO2
141 mmoles/L
3.8 mmoles/L
8 mmoles/L
185 µmoles/L
17.7 g/dL
0.57
18.1 x 109/L
7.16
11.21 kPa
10.23 kPa
(135-145)
(3.5 -5.0)
(2.5 – 7.0)
(40 -120)
(14-16)
(0.36 – 0.46)
( 4-11)
(7.32-7.42)
(4.5-6.1)
(12-15)
Case History (cont.)
Diagnosis
Acute exacerbation of COPD – 2o infection
Plan
1.
2.
3.
4.
Introduce nebulised bronchodilators
Oxygen
Start antibiotic therapy
Consider switching to IV theophylline and steroids?
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 (cont.)
Key elements of pharmaceutical care plan
2.
Advise nursing staff on:
Administration of IV antibiotics
Administration of nebulised bronchodilators
Administration of IV theophylline – bolus or infusion?
3.
Advise patient on:
Use of inhalers and technique
Use of medicines – risk/benefit information
Need for regular flu jab
Medical abbreviations and
terminology
Questions?
Professor JG Davies
Academic Director of Clinical Studies, School of Pharmacy and BMS,
University of Brighton