Knowledge of Medical Terminology • Very valuable – Increases your understanding – Saves you time – Increases credibility with other providers Beyond Neurological Status: Finding and Recognizing Pertinent Information in the Medical Record Kyla C. Sherrard Ph.D., CCC-SLP Chief, Speech-Language Pathology Division of Otolaryngology Scott & White Hospital Temple, Texas Carol A.Venus Ph.D., CCC-SLP Supervisor, Speech-Language Pathology Central Texas Veterans Healthcare System Temple-Waco-Austin, Texas To Review a Medical Record • • • • • Decide what you need to know Bypass irrelevant information Locate and recognize useful information Interpret useful information Apply information to your – Understanding of the case – Evaluation – Treatment Planning • Inform your discussions with staff • Easy to acquire – Self-paced texts – Courses About Medical Terminology • • • • Uses components to build terms Prefixes, suffixes and roots Often derived from Latin or Greek Example: • “Dyspnea” – “dys” = “difficulty” – “pnea” = “breathing” • More than jargon: increased precision • “Edema” is not just a fancy word for “swelling” Record Review What you want to know • Why were you consulted? • When and why was pt. admitted? • What medical conditions might be compromising communication or swallow in this case? • When did these conditions develop? – Long before admission – Around time of admission – After admission • Are these conditions improving/worsening? • How are these conditions being treated? More you want to know • Are there other conditions or circumstances that are important in this case? • What is the overall prognosis? • How much do behavior and medical conditions fluctuate from day to day or hour to hour? Chart Tabs • PROGRESS NOTES OR “NOTES” • Physicians’ and Surgeons’ notes – May include History and Physical (HxPx) – May include Consult Replies from specialists – Frequency of notes depends on level of care (ICU, acute, long term care) – Distinguish between attending and consultant notes – Distinguish between attending versus residents versus medical students • Nurses’ notes – Nursing credentials vary • Allied Healthcare Providers’notes: – SLP, Audiology, PT, OT – Dieticians – Social Workers, Psychologists How the Record is Organized • Reverse chronological order • Chart Tabs in order of Occurrence – PROBLEM LIST • Diagnoses and conditions with date first recorded Limitations of the problem list Chart Tabs • ORDERS • • • • Activity Orders (bedrest? up in chair?) Nursing Orders (isolation precautions?) Diet Orders (what diet is pt receiving vs NPO) Medications (anti-anxiety drugs? IV fluids? antibiotics?) • Orders for Lab Tests • Radiology (or “Imaging” Orders) • Consult Requests Chart Tabs • CONSULTS or “CONSULT REPLIES” • • • • • • • • • Pulmonary Medicine Gastroenterology Cardiology Nephrology Infectious Diseases Oncology Endocrinology Psychiatry Opthalmology Chart Tabs • SURGICAL REPORTS or “Report of Operation” • Descriptions of surgical procedures that have been done • May include pathology reports, biopsies • DISCHARGE SUMMARIES • Summaries of previous hospital stays, dictated at the time of discharge from hospital Chart Tabs • Lab Tests • Radiology (or “Imaging”) Reports • Other Finding what you need to know • Look in Notes, Consults, Labs, Imaging Reports to find out: – Are these conditions improving, maintaining or worsening? – How are these conditions being treated? – Are there other conditions that are important in this case? (as above, also HxPx) – What is the overall prognosis? • Look especially in notes by nurses, dieticians and therapists to find: – How much do behavior and medical conditions fluctuate from day to day or hour to hour? Finding what you need to know • Why were you consulted? – Check Consults for SLP request – Note reason for request – Note name and role of requester RELEVANT MEDICAL CONDITIONS • If reason not clear, read progress notes by requester and other progress notes around the time the consult was requested • If still not clear, discuss with requestor • If consult not really for SLP, forward consult Finding what you need to know • When and why was pt. admitted? (HxPx) • What medical conditions might be compromising communication or swallow in this case? (HxPx, Progress Notes, Consults) • When did these conditions develop? – Long before admission (HxPx, Discharge Summaries, Consult Replies) – Around time of admission (HxPx) – After admission (Progress Notes, Consults) Sensory Impairments • Hearing Impairment • Visual impairment Congenital Traumatic Cataract Glaucoma Macular Degeneration Diabetic Retinopathy Visual field cut or visual inattention Mental Status/Psychiatric Impairment • • • • Altered mental status or AMS (waste-basket term) Agitation Combativeness Mental Confusion disorientation and impaired attention-focus • Delirium acute and relatively sudden decline in attention-focus perception cognition Mental Status/Psychiatric Conditions • • • • Dementia Definition Severity Etiology – – – – – – Multi-Infarct Dementia (MID) Dementia of the Alzhemier’s Type (DAT) Anoxic Encephalopathy Parkinson’s Disease Wernicke’s Encephalopathy Many others Mental Status/Psychiatric Conditions • • • • • • • Post Traumatic Stress Disorder Depressive Disorder Anxiety Disorder Personality Disorder Conversion Disorder Schizophrenia Schizophrenia, Paranoid Type Diabetes Mellitus Type I due to failure to release insulin - often childhood onset - must control carbohydrate intake - always insulin-dependent Type II due to insulin resistance and impaired glucose transport - often adult onset (assoc with obesity, family history, lack of physical exercise, ethnicity, age) - must control carbohydrate intake - can be managed with diet, oral medication - can be insulin-dependent in later stages Diabetes Mellitus • Criterion is Fasting Blood Sugar (FBS) of 126mg/dl or higher • Effective treatment normalizes blood glucose and decreases complications • Glucometer used to measure blood sugar (glucose) on day to day basis including on ward Diabetes Mellitus Blood Glucose Levels/Glucometer Readings • Low: below 70mg/dl = hypoglycemia can compromise mental status until normalized • Normal: 70 to 100mg/dl can be higher if less than 2hrs after a meal • High: 100mg/dl to more than 600mg/dl the greater the elevation the greater the risk of complications such nephropathy, retinopathy, and peripheral neuropathy. Infection Diabetes Mellitus • Regardless of glucose control, diabetics have increased risk for - Cardiovascular disease and other heart disease - Cerebrovascular disease such as stroke • Many diabetics also have HTN and hyperlipidemia, further increasing their risk of vascular disease Nephropathy – Kidney Disease • Renal Failure • Often caused by vascular disease • Hepatic encephalopathy • waste products and toxins accumulate in the blood and brain • lethargy, AMS, paranoia, hallucinations, slurred speec • Kidney Dialysis – Temporarily cleanses the blood – Can alter mental status temporarily – Usually must be repeated indefinitely once it is needed Creatinine Level • Breakdown of creatine phosphate in muscle, usually produced at a fairly constant rate – Most commonly used measure of renal function – BUN (blood urea nitrogen) to creatinine ration with BUN higher is suggestive of dehydration • Systemic such as septicemia or localized such as pneumonitis, UTI or infected wound • Isolation precautions? • Infectious organisms seen in hospitals – – – – – Staphalococcus aureus “staph” Methycillin resistant staphalococcus aureus “MRSA” Clostridium difficile (“c-diff”) Tuberculosis HIV Infection • Sepsis, whole-body inflammatory state caused by infection – Systemic inflammatory response syndrome – General inflammation, fever, leukocytosis, tachycardia, tachypnea – Septic shock, decreased tissue perfusion and oxygen delivery causing organ failure and death Electrolyte Imbalance: Altered Blood Chemistry • Sodium hyponatremia – overhydrated or diuretic use hypernatremia – dehydrated or diuretic use • Potassium hypokalemia – diuretic or N/V hyperkalemia – kidney failure • Calcium hypocalcemia – widespread infection, decreased parathyroid hormone, Vit D deficiency hypercalcemia – seen with cancer Albumin • Used to diagnose disease, monitor changes in nutrition/health status or disease progression • Indicative of kidney or liver dysfunction • Low = inflammation, shock, malnutrition (impairs healing process) • High = dehydration (goes along with AMS) Blood Pressure/Hypertension • Systolic – pressure generated when heart contracts • Diastolic – pressure generated when heart relaxes 120-139/80-89 prehypertensive 140-159/90-99 Stage I HTN 160+/100+ Stage II HTN Metabolic acidosis/alkalosis Altered Blood Chemistry • Acidosis – excess acid – H/A, lethargy, CNS depression • Alkalosis – excess base bicarbonate – Alkalosis – excess base bicarbonate hypoventilation, twitching, irritability, N/V, tachycardia, cyanosis, apnea Cardiovascular Disease • Either with or without accompanying neurological symptoms, you will be asked to evaluate patients with cardiac related cognitive or swallow issues. • Patients may be post MI, CHF, or surgery such as CABG or Aortic valve replacement. • Patients may have associated altered mental status affecting communication and swallow. Cardiac Rate/rhythm • • • • Normal resting heart rate for adults – 60-90 bpm Tachycardia, increased heart rate Bradycardia, decreased heart rate Atrial fibrillation (A-fib) or irregular heart beat of the atria – common source of emboli resulting in stroke – high percentage of elderly experience either acute or chronic a-fib – can be treated medically or with cardioversion Cardiovascular Diseases • CAD, coronary artery disease – blockages of heart vessels – source of emboli to brain • PVD, peripheral vascular disease – blockages in peripheral vessels – souce of emboli to brain • MI/NSTEMI, myocardial infarction/heart attack – death of heart tissue – possible anoxic event, generalized decrease in brain function – possible emboli with resultant CVA Cardiovascular Diseases • CHF, congestive heart failure – – – – heart pumping decreases, oxygenation decreases leads to decreased kidney function build-up of fluid and respiratory failure pulmonary edema will directly impact ability to inhibit inhalation during swallow • Endocarditis, inflammation/infection of heart – vegetative growth on the valves or lining of the heart – produces emboli that can travel to brain and cause infection/CVA – patients frequently have AMS/aphasia with resultant affects on communication and swallow Pulmonary • Consults will be primarily for swallow assessment as patients will have higher risk involved with aspiration due to compromised pulmonary status. • Again, mental status may be impaired and patients may be medically complex and debilitated. Oxygen • Oxygen Saturation amount of oxygen dissolved in a given medium • Hypoxia = <90% • Pulse oximeter relies on light absorption characteristics of saturated hemoglobin • ABG, arterial blood gas analysis is more accurate Breath Sounds • Rales, rhonchi, and crackles • Site of sound – tracheal, bronchi, lung • Timing of sound – beginning or end of cycle, on inspiration or expiration • Wet phlegmy breathing/voicing • Interferes with bedside swallow assessment Pulmonary Conditions • Pneumonia – chronic illness and debilitation are predisposing factors – Viral – Bacterial – Aspiration pneumonia – All sources are aspirated whether by breathing in particulates (noxious fumes/chemicals, viruses, oral intake, reflux, poor oral hygiene, impaired cough reflex) Pulmonary Conditions • Pulmonary edema – Multiple causes, symptom – Swelling and/or fluid accumulation in lungs (thoracentesis may be required to remove fluid) – Impaired gas exchange – Respiratory failure – Altered mental status – Difficulty inhibiting inhalation in swallow cycle Pulmonary Conditions Tracheostomy Tube • Adult respiratory distress syndrome (ARDS) – Form of pulmonary edema that causes respiratory failure requiring ventilation and possibly tracheostomy in vent weaning – Causes stiffening of the lung tissue and impairs oxygenation of pulmonary capillary blood, possible fatal hypoxemia Ventilation • Ventilation through oral intubation, facial mask, or tracheostomy – mechanical insufflation/exsufflation, provides deep volume of air followed by a forced expiration – CPAP – continuous positive airway pressure, delivered by mask, keeps obstructed airway open and expands lungs, does not help the muscles of inspiration – BiPAP – bi-level positive airway pressure, a method of ventillatory assistance Ventilation • Indications for cuffed tube – Normally the initial tube inserted in ICU – Necessary to maintain appropriate ventilation pressures – Not to prevent aspiration • Protocol of weaning from ventilation and tracheostomy tube – – – – – – – – Ventilation • Speech involvement with trach care varies • Tracheotomy – open surgical vs. percutaneous opening of the trachea • Trach tubes (Shiley or Bivona) – Outer cannula, inner cannula, obturator – Cuffed or cuffless • Air or water cuff • Tight to shank • Single or double – fenestrated Fully assisted/controlled respiration CPAP BiPAP T-collar (mini trach mask) with deflation of cuff Downsizing from initial diameter Speaking valve Capping of trach Decannulation Communication/Swallow • Communication – Speaking valve (Passey-Muir), in-line or on trach tube – Finger occlusion of trach • Swallow – – – – Bedside or fluorographic assessment Cuff deflated Risks of tracheal irritation/perforation if inflated Possible generalized debility and/or tethering of laryngeal excursion for airway protection Gastroenterology • Interpretation of the assessment of oral and pharyngeal levels of swallow often requires incorporation of information provided by the radiologist about the esophagram, barium swallow, or UGI. • This requires understanding of esophageal function as well as gastric and intestinal functions. GI Conditions • Achalasia – esophageal dysmotility – Pt c/o food sticking and getting full quickly – Impaired peristalsis – LES (lower esophageal sphincter) fails to relax • Esophageal stricture – pt c/o food sticking midsternum • Esophageal diverticulae – most common with dysphagia is Zenker’s diverticula at the UES Gastroenterology • Patients referred with oral-pharyngeal swallow deficits may have co-occurring gastroenterological problems that impact the oral-pharyngeal level. • Slow gastric emptying can give distention and slow down esophageal emptying putting pressure at the UES and decreasing appetite due to a feeling of fullness. Gastroenterology • Esophageal contractions – primary – triggered by volitional swallow, travels length of esophagus – secondary – circular contraction triggered by distention of the primary wave – tertiary – simultaneous contractions at multiple levels GI Conditions • Esophagitis • inflammation secondary to caustic irritation or fungal infection • Candidiasis – fungal infection • Oral – creamy to bluish-white patches, burning sensation, odynophagia • GI – retrosternal pain, regurgitation, odynophagia • Stomatitis • Inflammation of gums and oral mucosa • Difficulty chewing, odynophagia GI Conditions • GERD – gastroesophageal reflux disease • cough especially at night • heartburn • feeling of lump in throat and food sticking at UES • LPR – laryngopharyngeal reflux • cough, hoarse voice, may not have heartburn GI Conditions Negating Immediate Swallow Assessment • Paralytic ileus – a section of intestine that does not function post abdominal surgery or due to electrolyte imbalance, particularly hypokalemia – Precipitates NPO status and hold on tube feeds until bowel sounds return • PUD – peptic ulcer disease • may be cause of upper GI bleed • Pancreatitis – inflammation of the pancreas • complication of gall bladder disease or ETOH use • severe abdominal cramping/pain, n/v Types of Cancer • Cancers are named for type of cells from which they originate – Carcinoma: skin cells or from tissues that line or cover internal organs – Neuroma: nerve cells – Sarcoma: bone, cartilage, fat, muscle, blood vessels, other connective or supportive tissues – Leukemia: blood-forming tissues such as bone marrow – Lymphoma, multiple myeloma: cells of the immune system Nutrition Support • Oral supplementation at and between meals to improve nutritional status • Enteral supplementation in an oral feeder • Total enteral feeds – Nasal feeding tube (Dobhoff) – relatively short term – not NG-tube for stomach emptying – Gastic or jejunal tube – longer term or better choice in agitated pt or one with severe reflux – TPN – total parenteral nutrition (thru vein) Cancer Staging of Carcinoma (Amer. Joint Committee on Cancer) • Stages • • • • A general term Abnormal cells divide without control Can invade nearby tissues Can spread to other parts of the body – Through bloodstream – Through lymphatic system – – – – – Stage 0 (minimally extensive carcinoma) Stage 1 Stage 2 Stage 3 Stage 4 (very extensive carcinoma) • Stages are derived from TNM Classification – Primary Tumor (T), (0 to 4) – Regional Lymph nodes (N), ( 0 to 3) – Distant Metastasis (M), ( 0 or 1) Treatments for Cancer • Chemotherapy: treatment with drugs toxic to cancer cells (less toxic to slower-growing cells) • Radiation therapy (XRT): treatment with high-energy radiation to kill cancer cells and shrink tumors – Radiation burn is a temporary side-effect – Radiation fibrosis can be a permanent side-effect – Frequently generates swallow assessment or communication assessment consults • Surgery: excision or surgical reduction of tumors – Adjacent structures may be affected Life After Chart Review • Until you gain experience, chart review can seem daunting, but with time you will be able to weed out what you don’t need and feel prepared to: – Discuss current status with nursing – Assess the patient – Discuss assessment/treatment with caregivers, nursing, and physicians – Document – Write orders at the doctor’s discretion – Treat your patient! Appendix • Medical abbreviation list • Resources – Nursing Education Texts, e.g. Handbook of Diseases, Springhouse – Medical dictionary – eMedicine.com – Nursing, RT, OT/PT, and MD colleagues COMMON MEDICAL ABBREVIATIONS AAA AAO ABG ABR ADA ADL AF AFO AHA AKA Alb ALL ALS AMA AMI AML Angio A-P A&P AMS APS ARC ARDS ARF AROM ASCVD ASD ASHD AVM AVR Ba BCLS BiPAP BP BPD BPH BS Bx A abdominal aortic aneurysm awake, alert, oriented arterial blood gas auditory brainstem response test American Diabetic Association activities of daily living anterior fontanel ankle foot arthosis American Heart Association above the knee amputation albumin acute lymphocytic leukemia amyotrophic lateral sclerosis American Medical Assoc. Against medical advice Advanced maternal age acute myocardial infarction acute myelogenous leukemia angiogram anterior to posterior auscultation and percussion altered mental status adult protective services AIDS related complex adult respiratory distress syndrome acute renal failure active range of motion atherosclerotic cardiovascular disease atrial septal defect atherosclerotic heart disease arteriovenous malformation aortic valve replacement B barium basic cardiac life support biphasic positive airway pressure blood pressure borderline personality disorder Bronchopulmonary dysplasia benign prostatic hypertrophy breath sounds biopsy CA CABG CAD Cal CAT or CT CBC CBF CC c/o CHF CHI Chole CLL CNS COPD C-P CPAP Creat CTA CUC CV CVA D/C DJD DM DME DNKA DNR/DNI DOB DTR DTs Dx ECG/EKG ECHO EEG EDG EOB EOM ESRD ETOH C carcinoma (cancer) Central apnea coronary artery bypass graft cornary artery disease calorie computerized axial tomography complete blood count cerebral blood flow chief complaint complains of congestive heart failure closed head injury cholecystectomy chronic lymphocytic leukemia central nervous system chronic obstructive pulmonary disease cerebral palsy continuous positive airway pressure creatinine clear to auscultation chronic ulcerative colitis cardiovascular cerebrovascular accident D discharge Discontinue degenerative joint disease diabetes mellitus durable medical equipment did not keep appt do not rescusitate/do not intubate date of birth deep tendon reflexe delirium tremens diagnosis E electrocardiogram echocardiogram electroencephalogram esophagogastroduodenoscopy edge of bed extra-ocular movement end stage renal disease alcohol FEF FEV1 FNA FT Fx GSW GT G-tube HA HEENT HO HOB HR HTN Hx IC ICH ICP I/E IPH IV IVF IVH JPEG J-tube K+ Kcal KCl Kg Lap LE LES LLE LLL LTAC LUE F forced expiratory flow forced expiratory volume in 1 second fine needle aspiration (biopsy) feeding tube fracture G gunshot wound gastrostomy tube gastric tube H headache head, ears, eyes, nose, throat house officer head of bed heart rate hypertension history I inspiratory capacity intracranial hemorrhage intracranial pressure inspiratory/expiratory intraparenchymal hemorrhage intravenous intravenous fluids intraventricular hemorrhage J jejunal percutaneous endoscopic gastrostomy jejunostomy tube K potassium kilocalorie potassium chloride kilogram L laparotomy lower extremity Lupus erythematous lower esophageal sphincter left lower extremity left lower lobe (lung) long term acute care left upper extremity LUL LVH MAO MAOI MCC Med/meds MEFR Mets MI MIFR MRI MRN MS MVA MVC MVPA Na NaCl NG-tube NH NHL NIDDM NKA NKDA NPO n/s NSTEMI OBS OD OM OOB ORIF OS OTC PCP PEEP PEG left upper lobe (lung) left ventricular hypertrophy M monoamine oxidase monoamine oxidase inhibitor motorcycle collision medication/s maximum expiratory flow rate metastasis myocardial infarction maximum inspiratory flow rate magnetic resonance imaging medical record number multiple sclerosis Mental status motor vehicle accident motor vehicle collision motor vehicle pedestrian accident N sodium sodium chloride nasogastric tube nursing home non-Hodgkins lymphoma non-insulin dependent diabetes mellitus no known allergies no known drug allergies nothing by mouth normal saline non ST elevated myocardial infarct O organic brain syndrome overdose Right eye (occulus dexter) otitis media out of bed open reduction internal fixation (hip) left eye (occulus sinister) over the counter P pneumocystis carinii pneumonia positive end expiratory pressure percutaneous endoscopic gastrostomy PERRLA PMHx POD# PPD# prn PROM PT pt PTA PUD PVR q qd qh q4h qhs qid qn qod RA RBC RDS re Rehab REM RLE RLL r/o ROM RT RTC RUE RUL SAH SCI Sed rate SNF pupils equal, react to light and accommodation prior medical history post operative day (1,2, etc.) post partum day as needed When required passive range of motion physical therapy patient prior to admission PT aide peptic ulcer disease post void residual Q every every day every hour every 4 hours every night at bedtime four times a day every night every other day R room air Rheumatoid arthritis Right atrium red blood count respiratory distress syndrome regarding rehabilitation rapid eye movement right lower extremity right lower lobe (lung) rule out range of motion Right otitis media respiratory therapy recreational therapy return to clinic right upper extremity right upper lobe (lung) S subarachnoid hemorrhage spinal cord injury sedimentation rate skilled nursing facility SOAP SOB SOM s/s STAT sx T&A TB TD TFs tid TORB TPN Trach Tx UES UGI URI UTI Vent VORB VS WBC w/c WNL w/ w/o y/o subjective, objective, assessment, plan short of breath serous otitis media signs and symptoms immediately suction T tonsillectomy & adenoidectomy tuberculosis tardive dyskinesia tube feedings three times a day telephone order read back total parenteral nutrition tracheostomy therapy treatment transfusion U upper esophageal sphincter upper gastrointestinal upper respiratory infection urinary tract infection V ventilator verbal order read back vital signs W white blood count wheelchair within normal limits with without Y year old