Interpreting Medical Notes

Question 1

Why do we have patient notes

Answer 1

Notes act as a communication tool to monitor a patient through hospital as we aim to treat them
There are many health professionals, we must have consice notes that are easy to read

Question 2

Abbreviations and medical shorthand

Answer 2

• Investigations Ix
• Chest Xray CXR
• Differential diagnosis DDx or 2 -treatemnt plan an/or further Ix
• A list is on the Pharmacy toolkit

Question 3

General layout

Answer 3

Inpatient admissions
Outpatient notes
Investigations and reports
Letters

Clarking for an admission usually follows a standard format
Questions, investigation, results from investigation

Question 4

Case history- start of an admission

Answer 4

General info- name, age, gender 
Presenting complaint- PC 
History of presenting complaint-HPC 
Past medical history- PMH 
Direct questioning-DQ
Drug history-DH OR DHx 
Allergies- NKDA if none 
Social history- SH 
Family history-FH

Question 5

Patient examination

Answer 5

Observation (O/E)- physical look (pale, sweaty, SOB; Jaundice, cyanosed)
Techniques
Palpitations- abs, liver
Percussion- 2 finger tap- assess lungs
Auscultation- via stethoscope listen on heart, lungs, chest cavity
Smell- poor hygiene, keto acidosis, alcohol

Question 6

Cardiovascular system

Answer 6

Heart size (via CXR), rate and rhythm (via ECG)
Heart sounds
BP
Jugular venous pressure (JVP)- right sided HF
Pain
Dyspnoea/oedema
Fluid balance

Question 7

Respiratory system

Answer 7

• CXR
• Inspection of chest (Barrel chest= COPD)
• Percussion- is resonance equal on both sides; High pitch= solid tissue; dull sound= fluid accumulation
• Auscultation- listening- if there is normal air entry, collapse= wheezing (could be swelling) ; Crackles= increased fluid
• Respiratory rate RR
• Cough
• Sputum
• Pulse oximetry- measure oxygen saturation of blood -SaO2, below 80% is generally an emergency
• Hand exam- clubbing
• Face= cyanosed
• Vocal resonance

Question 8

Different lung sounds

Answer 8

Hyper-resonance- low pitch sound = pneumothorax
Dull sound= fluid accumulation
Decrease in breath sounds= collapsed or obstructed
Wheezing= reduced airflow obstruction
Crackles= increased fluid
Rubs= creaking sounds is plural inflammation

Question 9

Respiratory

Answer 9

Hand examination- clubbing, nicotine staining 
Face- cyanosis 
Chest expansion 
Vocal resonance 
Fever or sweats

Question 10

GI system

Answer 10

-Site of pain
-Palpation
-Enquiries:+ frequency and type of bowel movement
Appetite, weight loss
Nausea/ vomiting
Haematemesis (vomiting blood)
Stool consistency, colour, slime, melaena (blood), flatulence
Heartburn, pain
Jaundice
Ascites- fluid accumulation, liver dysfunction
Coffee ground vomit= blood in stomach

Question 11

GI tract

Answer 11

Represented as a hexagon

Question 12

Nervous system

Answer 12

• Pins and needles, pain, speech, headache, faints, co ordination, memory and personality
• Glasgow coma scale- level of conscious
• Mental status
• Cranial nerves- smell, hearing, gag reflex
• Senses
• Cerebellar examination- co ordination problems

Question 13

Bones and joints

Answer 13

• Only if pain, weakness, or physical trauma
• Symptoms
• Mobility range
• Visual range
• Biochemical tests
• Radiographic changes
• Blood tests: Florescent Anti-nuclear Ab (RA, SLE); Rheumatoid factor; CRP

Question 14

Investigative procedures

Answer 14

-Radiography- X-ray
-Tomography- Xray of layers
-MRI- imagine of the brain
-Ultrasonography
-Endoscopy/colonoscopy
-Electrography- changes in electrical potienal
ECG= heart EEG= brain

Question 15

Pros and cons of electronic records

Answer 15

Benefits
Sharing info between care providers
Less delay in decision making and treatment
Reduce investigational costs

Worries-
Cost 
Data protection 
Cyber attack 
Clinical errors