Unraveling Medical Terminology: An Exploration of IP Case 4

QUESTION

Instructions:

Read the inpatient history and physical report, IP Case 4. (at the bottom)

1. Identify at least 10 different medical terms that can be broken down into word parts (prefix, root word, or suffix).
2. Identify the medical term along with the components and lay meanings.
3. The format of your 10 words should be listed as shown in the examples below.

• DO NOT use the term Parkinsonism or the terms listed in the examples.
• Note: Not all medical words will have all three-word parts (see example 2)

Example 1: Subgastric = Sub/gastr/ic = pertaining to below the stomach

Prefix: Sub = below

Root: gastr = stomach

Suffix: ic = pertaining to

 

Example 2: Arthritis = Arthr/itis = inflammation of a joint

Prefix: none

Root: arthr = joint

Suffix: itis = inflammation

 

IP CASE 4

DATE: 09/11/YYYY CHIEF COMPLAINT: Progressive unsteadiness of gait.

HISTORY OF PRESENT ILLNESS: This is one of multiple admissions for this 65 year old

female whose past medical history is significant for Parkinsonism, a bleeding disorder

and cervical spondylolisthesis. She was in her usual state of fair health until the

week prior to admission when she noted the onset of fever, chills, myalgias and nausea

and associated with loose, brown, watery bowel movements without frank blood or

melena. This abated after 2 days and she attributes this to a flu-like syndrome. Over

the last 2 to 3 weeks she states that she has noted progressive unsteadiness of gait.

She has fallen repeatedly at home. She also notes more increased tremor and diffuse

muscular weakness. She states that she is unable to even write or make her own bed and

she feels that these symptoms have been getting worse. The patient has had a history

of Parkinsonism and has been treated by Dr. Beach for this disorder. Other pertinent

review the patient notes the episodic occurrence of left hand numbness and tingling.

She states that this does not occur in her right hand and she attributes this to her

cervical disc disease. Also the patient has noted increasing sinus drainage and some

sinus-type of headache associated with these symptoms. The patient denies any loss of

consciousness, any orthostatic signs or symptoms. She denies any problems with speech

or memory. She denies any problems with seizure-like activity.

PAST MEDICAL HISTORY: Childhood – unremarkable. Adulthood – the patient has a history

of Parkinsonism, as stated above in the History of Present Illness. She has a history

of chronic sinusitis. She has a history of cervical disc disease secondary to motor

vehicle accident. She has a history of a bleeding disorder for which she underwent

splenectomy. It sounds from her description as though this might be a bleeding

disorder secondary to a platelet disorder such as the immune thrombocytopenia. In 1985

the patient underwent bilateral cataract removal with intraocular lens implantation.

Medications – Symmetrel 100 milligrams by mouth twice a day, Parafon Forte 250

milligrams by mouth three times a day, Decongex 3 1 capsule by mouth twice a day, and

Naludar 300 milligrams by mouth every night at bedtime. Allergies – the patient states

she is allergic to sulfa drugs.

FAMILY HISTORY: Her mother’s sister suffered from Parkinsonism as did a distant great

aunt. Her mother died at the age of 74 from a carcinoma of unknown type. Her father

died in his 60’s from myocardial infarction and he had emphysema. The patient has

three brothers. History is positive for Chronic Obstructive Pulmonary Disease,

myocardial infarction, and carcinoma of the colon. They suffered from no Parkinsonism

themselves. There is no history of anemia and no history of thyroid disease.

SOCIAL HISTORY: The patient has never smoked cigarettes or used tobacco in any form.

She states that at one time she was a heavy drinker but presently drinks only socially

approximately once per week and not to the point of being intoxicated.

REVIEW OF SYSTEMS: Head, eyes, ears, nose, throat – negative. Cardiopulmonary –

negative. No shortness of breath, no cough, no hemoptysis. No sputum production. No

pleuritic-type chest pain. No palpitations, edema, orthopnea, post nasal discharge,

dyspnea on exercise, or shortness of breath. Abdominal – diarrhea as stated 2 days

last week. The patient also gives a history of heartburn and a long standing history

of chronic constipation for which she takes laxatives daily. Genitourinary – no

dysuria, frequency, hesitancy or hematuria. Neurological – as per History of

Present Illness.

GENERAL: Reveals a well-developed, cachectic-appearing elderly white female who

appeared to be visibly anxious.

TEMPERATURE: 98.0 PULSE: 70 RESPIRATIONS: 20 BLOOD PRESSURE 150/90 WEIGHT: 108 pounds.

No orthostatic changes were noted.

HEAD: General appearance about the head and neck, although their appearance was normal

in anatomically, during the examination the patient exhibited spastic-type movements

with flexion of the neck. The patient seemed to be unaware that she was doing this,

would be most closely described as a torticollis-type of movement which would be

relaxed if you stated to the patient to relax herself. The patient was noted not to be

making any lip smacking or any other abnormal head movements.

EYES EARS NOSE THROAT: Eyes – Left eye noted a superior iridectomy scar. Right eye

noted artificial lens noted in the anterior chamber. Funduscopic examination was

unremarkable. Pupils were somewhat irregular but reactive to light and accommodation.

Extra-ocular muscles were intact with some lateral gaze nystagmus noted which was felt

to be within normal limits. The patient was able to elevate and depress ocular

movement as directed. Visual fields were noted to be intact bilaterally. Ears –

Tympanic membranes were pearl gray and moist without exudates or fluid. No injection.

Nose – large amounts of mucopurulent discharge noted bilaterally, mucosa appeared

boggy. No mass lesions were noted. Some dry blood was also noted in the vault. Throat

– the patient is edentulous. No mass lesions are noted in the oral pharynx. Throat was

clear without injection, without exudates. No blood was noted.

BACK: Examination showed slight kyphosis noted. No costovertebral angle tenderness.

LUNG: Clear to auscultation and percussion bilaterally.

NECK: Supple without lymphadenopathy. Carotids were 2+ bilaterally without bruit.

Thyroid gland was not palpable.

CARDIAC: No jugular venous distention, no hepatojugular reflux, S-1 and S-2 were

normal, no S-3 or S-4. No murmurs, rubs or clicks were noted.

PERIPHERAL PULSES: 2+ bilaterally throughout with no bruit.

ABDOMEN: Scaphoid in appearance, soft, nontender, no guarding or rigidity, no rebound.

Kidneys not palpable. Spleen not palpable. Surgical scar was noted in the left upper

quadrant. Liver edge was not palpable below the costal margin and not enlarged to

percussion. No fluid wave was appreciated. No masses were palpable.

RECTAL & GYNECOLOGICAL: Deferred.

EXTREMITIES: Reveals clubbing of the upper extremity and the lower extremity. This was

noted to be quite severe. No edema was noted. No cyanosis was noted.

NEUROLOGICAL: Mental status examination showed the patient appeared to be quite

anxious, affect was somewhat flat although congruent at all times. Her memory was

intact for distant memory, recent memory and immediate recall were noted to be intact

bilaterally. Motor examination – there was decreased muscle bulk noted with atrophy

noted of the interthenar and hypothenar muscle groups. Muscles were hypertonic with

cogwheeling rigidity noted in the upper extremities. Strength was 3+- 4+ in all flexor

and extensor groups out of 5+ A rest tremor was noted in the hands bilaterally. Deep

tendon reflexes – the patient was felt to be diffusely hyperreflexic without spread,

good return. No Babinski signs were noted. No Hoffman’s signs were noted. Sensory

examination – normal to pin prick and light touch. Cerebellar examination – no

intentional tremor. Gait examination – patient was noted to have a shuffling gait with

heal to toe walking noted. The patient was noted to step with the dorsiflexed foot.

Gait was circumscribed shuffling and the patient was noted to be observing the

movement of her feet at all times. Her gait was also noted to be quite unsteady with

the patient continuing to fall to the right side.

ADMISSION DIAGNOSIS: 1. Parkinsonism, recent exacerbation of symptoms. 2. Bleeding

disorder, platelet-type bleeding disorder, history of. 3. Sinusitis, probably

bacterial in etiology. 4. Status post cataract removal with intraocular lens

placement. 5. Status post gastroenteritis one week, probable viral etiology. 6.

Cervical disc disease secondary to motor vehicle accident, clinically worsened.

ANSWER

Unraveling Medical Terminology: An Exploration of IP Case 4

Introduction

Medical terminology forms the cornerstone of medical communication, enabling precise articulation of conditions and symptoms. This essay dissects the medical terms found in the inpatient history and physical report (IP Case 4), unraveling their components and providing lay meanings. By deciphering these terms, we bridge the gap between healthcare professionals and patients, fostering clearer understanding.

Cervical Spondylolisthesis

Prefix: Cervic = neck
Root: Spondyl = vertebra
Suffix: olisthesis = slipping
Lay Meaning: Slipping of a vertebra in the neck region

Myalgias

Root: My = muscle
Suffix: algias = pain
Lay Meaning: Muscle pain

Nausea

Root: Nause = seasickness
Lay Meaning: Feeling of sickness, typically leading to vomiting

Myocardial Infarction

Root: Myocard = heart muscle
Suffix: Infarction = tissue death due to lack of blood flow
Lay Meaning: Death of heart muscle tissue due to inadequate blood supply

Iridectomy

Root: Irid = iris (eye structure)
Suffix: ectomy = surgical removal
Lay Meaning: Surgical removal of part of the iris

Anemia

Prefix: An = without
Root: Emia = blood
Lay Meaning: Condition of having insufficient red blood cells or hemoglobin

Torticollis

Root: Torti = twisted
Suffix: collis = neck
Lay Meaning: Abnormal twisting of the neck

Cachectic

Prefix: Cach = bad
Root: Ectic = condition
Lay Meaning: State of ill health, malnourishment, and physical wasting

Dysuria

Prefix: Dys = painful, difficult
Root: Ur = urine
Suffix: ia = condition
Lay Meaning: Painful or difficult urination

Hypothenar

Prefix: Hypo = below
Root: Thenar = palm of hand
Lay Meaning: Area on the palm below the thumb

Deciphering these medical terms highlights the intricate language used in healthcare. By demystifying complex terms, healthcare professionals enhance patient understanding, empowering informed decision-making and promoting effective communication.