Medical Terms and Lay Descriptions

QUESTION

Instructions:

• Read the inpatient history and physical report, IP case 7, at the bottom of the instructions.
  • Identify at least 10 different medical terms used within the report.
  • Provide the lay description of each term using the format shown in the example. DO NOT use the word in the example.
  • Example: hyperkalemia = high potassium

IP CASE 7

CHIEF COMPLAINT: Frequent falls, dizziness and weakness of rapid onset. HISTORY OF PRESENT ILLNESS: The patient is a 64-year-old white female who presented to the Emergency Room today with the story that over the past month or so she has had progressive weakness and episodes of dizziness. On the day prior to admission, she became very weak and was having difficulty walking and was falling frequently in her apartment. These episodes of falling happened without any sudden onset of weakness but more from instability. She was also dizzy and had difficulty getting herself back in bed or back in a chair. She denies any palpitations, chest pain, shortness of breath, change in her vision, unilateral weakness, or numbness. She has been followed by Dr. Black and seen by Dr. Flight, a neurologist at Strong, for her Parkinson’s disease. She has been tried on Sinemet which caused instability and staggering and was later changed to Symmetrel 100 milligrams twice a day which she tolerated well, but when she ran out of the medication, she felt just as well as when she had been on it, so it was decided to keep her off for a while. She also has complained of insomnia and restlessness at night not associated with depression or anxiety. She has no history of cerebrovascular disease or cardiovascular disease. PAST MEDICAL HISTORY: Significant for her Parkinson’s disease, status post left inguinal hernia repair and diaphragmatic hernia repair. She was also status post splenectomy for diagnosis of thrombocytopenia and has a history of alcoholism and hepatitis in the past. She also has been hospitalized for pneumonia. She does not smoke; she reports that she does not currently drink alcohol – she has an allergy to Sulfa medications. She is currently on no medication at all. She was in the hospital for a lens implant that was unsuccessful last year. SOCIAL HISTORY: She lives by herself in Rose Apartments. Her brother lives just out of town. His name is Jonathan. REVIEW OF SYSTEMS: Negative for nausea, vomiting, hematemesis, hemoptysis; she has not had any melena or bleeding per rectum. She does tend to be somewhat constipated but this is not a new problem. She denies any pedal edema, orthopnea or dyspnea on exertion. She has no Paroxysmal nocturnal dyspnea. She also denies headaches or sudden changes in her vision. FAMILY HISTORY: Significant for an aunt who died of Parkinson’s disease, a mother who died of colon cancer, and patient’s brother was also operated on for colon cancer. GENERAL: The patient is an elderly, slim, white female in no acute distress. She is alert and oriented times 3. She is cooperative with the exam. BLOOD PRESSURE: 160/92 TEMPERATURE: 99.9 orally PULSE: 96 RESPIRATIONS: 9-12 and somewhat deep. She is in no respiratory distress EENT: Pupils are equal, round, and reactive to light and accommodation. Extraocular movements are full. Fields are intact to confrontation. Right disc was visualized and was sharp. Left funduscopic exam was difficult secondary to patient’s inability to cooperate. Mouth and pharynx were clear. Patient was edentulous with dentures not in. Tympanic membranes were normal bilaterally. NECK: Supple, without thyromegaly or adenopathy. LUNGS: Clear to auscultation. CARDIAC: Reveals rapid, regular rate without clicks, rubs, or murmurs. No carotid bruits. BREASTS: Without masses, dimpling, or discharge. Adnexa were free of masses. ABDOMEN: Soft and nontender with normal bowel sounds throughout. She had a right upper quadrant scar and left inguinal scar. EXTREMITIES: There were bilateral femoral bruits but pulses distally were 2+ and equal. She had no varicosities or edema. Deep tendon reflexes were 2+ and equal and toes were down going bilaterally. She had full range of motion at the knee and hip without rigidity or cogwheeling. She did have a mild degree of cogwheeling in the left arm on flexion and extension but none detected in the right arm. Her strength in her upper extremities was about 4 out of 5 and in her lower extremities about 3 out of 5. Her left hip was sore deep inside specifically on external rotation and so that was x-rayed which is pending at this time. NEUROLOGICAL: Extraocular movements were full. Cranial nerves 2-12 were grossly intact and she was intact to light touch and motor testing throughout. Toes were down going bilaterally. She had a negative Romberg sign but on attempting to ambulate was very uncertain and hesitant and tended to lean forward over the feet. Blood gases obtained in the Emergency Room showed a hydrogen ion concentration of 7.46, PC0 2 of 43, and a partial pressure of oxygen of 71 on room air. Complete blood count showed a white count of 6,700, hematocrit of 34.2% and platelet count of 141,000. She had 35 segmented cells, 56 lymphocytes, 5 monocytes, 4 eosinophils and an occasional atypical lymph. Her blood alcohol level was 0 and her SCG II was remarkable for a potassium of 3.3, serum glutamic oxalacetic transaminase of 70 and lactic dehydrogenase of 325 and a normal bilirubin. Electrocardiogram was also within normal limits. ASSESSMENT: 64-year-old woman with progressive onset of weakness and vertigo and tendency to fall. This could be secondary to Parkinsonism, cerebral basilar, vertebral basal insufficiency or viral syndrome given patient’s slightly abnormal differential and elevated temperature. PLAN: Admit her and start her back on her Symmetrel 100 milligrams twice a day in case this represents an acute exacerbation of her Parkinsonism. She will be put to bed rest and observed closely. Her electrolyte abnormalities were corrected. We will also follow her liver enzymes.

ANSWER

Medical Terms and Lay Descriptions

Parkinson’s disease: A neurological disorder causing progressive tremors, muscle stiffness, and difficulty with movement.
Symmetrel: A medication used to manage symptoms of Parkinson’s disease, such as tremors and stiffness.
Splenectomy: Surgical removal of the spleen.
Thrombocytopenia: A condition characterized by low platelet count in the blood, leading to an increased risk of bleeding.
Cerebrovascular disease: Conditions affecting blood vessels supplying the brain, including stroke.
Cardiovascular disease: Conditions affecting the heart and blood vessels.
Inguinal hernia repair: Surgical correction of a hernia in the groin area.
Diaphragmatic hernia repair: Surgical correction of a hernia involving the diaphragm.
Hepatitis: Inflammation of the liver, often caused by viral infection.
Edentulous: Lacking teeth, usually referring to being toothless.
Femoral bruits: Abnormal sounds heard over the femoral artery, indicating potential blood flow issues.
Cogwheeling: A movement abnormality characterized by a jerky, ratchet-like resistance during passive limb movement.
Romberg sign: A test of balance where a person standing with eyes closed sways more if there’s an underlying issue.
Hydrogen ion concentration: Measure of acidity or alkalinity in body fluids.
PCO2:Partial pressure of carbon dioxide in the blood.
Complete blood count: Blood test to assess various components including red and white blood cells and platelets.
Serum glutamic oxalacetic transaminase: An enzyme found in the liver; elevated levels indicate potential liver damage.
Lactic dehydrogenase: Enzyme present in various body tissues; elevated levels may indicate tissue damage.

Conclusion

This inpatient history and physical report introduces various medical terms related to the patient’s condition and medical history. Understanding these terms and their lay descriptions is crucial for effective communication between healthcare professionals and patients, ensuring accurate diagnosis and treatment.