Tiếng Anh Chuyên Ngành Y Khoa Cho Người Mới Bắt Đầu

Sách anh văn chuyên ngành Y Đa Khoa, dành cho các bạn sinh viên y dược mới bắt đầu tiếp cận đến tiếng anh chuyên môn. Với từng chủ đề dễ dàng tiếp cận trong lâm sàng sẽ giúp các bạn dễ dàng ghi nhớ và tiếp thu tốt kiến thức MEDICAL ENGLISH Than Lan Con English Center Learning material is made by Hoang Bao Long, MD and is the property of Than Lan Con English Center

MEDICAL ENGLISH

This learning material is made by Hoang Bao Long, MD and is the property of Than Lan Con English Center

Introduction

Some of you may have seen the second version of this document This time, we decided to do something different So here you are looking at Than Lan Con’s study material for the Medical English course, version 3.0

Am I suitable for the course?

Read the checklist below and check you match all criteria If you do, you are a candidate for the class

 1 I am a medical/nursing student or graduated from a medical/nursing school

 2 I can understand the main points of conversations or writing pieces about common matters in work, school, leisure, etc (equivalent to CEFR B1/IELTS 5.0)

 3 I want to learn medical English to read medical literature and write about medicine in English

What can I learn from the course?

Our course is designed:

1 To provide learners with common English medical terms and expressions in clinical practice;

2 To provide learners with skills for active and efficient learning;

3 To introduce self-study methods and encourage learners to continue self-study after the course You, therefore, will be provided with (1) fundamental context-based vocabulary and structures, (2) brief instructions on relevant skills, and (3) exercises to guide you on self-study We recommend you review this document carefully before and after going to the ME class at TLC

How is this document arranged?

Contents briefly presents the knowledge points given in each lesson Vocabulary will be the most important part in medical English; however, Writing/Speaking and Skills enable you to use medical English more efficiently

The lessons are divided into sections and exercises The Reading and Vocabulary sections introduce new words and structures, which will be explained in detail in following exercises We also review essential grammar points to strengthen your reading and writing skills Other skills are integrated into exercises

Reading and listening materials are taken from case reports, books, journal articles, and websites All documents used in the study material are listed in References

Where should I start?

The simplest way is to register a class at TLC You have a teacher and your classmates, and there are lectures and homework that limit boredom and improve your skills

If you are unable to join the class (e.g., living in a distant town), start with checking the material is suitable and reviewing the contents thoroughly Once you feel ready, start learning the lessons one by one You do not have

to (and should not) rush—make sure you understand everything in the lessons

OK, let’s go! We wish you joy while learning medical English with our study material and wish you success

Contents

V O C A B U L A R Y W R I T I N G / S P E A K I N G S K I L L S

> Hospital

> Latin medical terms

> Words for describing a symptom > Describing history of present

illness

> The SVO structure

> Quality of pain > Taking a history

> Describing history of present illness

> Modifiers

> Describing past history

> Body systems and anatomical positions > Describing the relationship

between body organs

> Describing the components of

> Presenting case reports

> Presentation skills

> Heart anatomy and physiology

> Cardiovascular signs and symptoms

> Valvular heart diseases

> Thromboembolism

> Presenting case reports > Illustrating knowledge

> Presentation skills

> Anatomy of the respiratory system

> Respiratory signs and symptoms

> Some imaging methods and interventions

> Skimming and scanning

> Blood cells and conditions relating to changes in

cell counts

> Laboratory tests and test results

> Reading flow diagrams

> Lung and pleural conditions: signs and

symptoms, treatment

> Arterial blood gas

> Describing laboratory results

11 The differential diagnoses page 39

> Diagnosis and diagnostic criteria > Explaining diagnostic

approach

> Anatomy of the gastrointestinal system

> Acute abdomen

> The suffices -scopy and -graphy

> Presenting case reports

> Cirrhosis

> Peptic ulcer disease

> Presenting case reports

> Anatomy of the genitourinary system

> Causes of acute abdominal pain

> Urology: symptoms, investigations, procedures

> Kidney disease

> Introducing a disease

> Microbiology and infectious diseases

> Anatomy of the nervous system

> Common neurologic conditions

> Clinical trials > Presenting statistics

Visiting the hospital 7

1 Visiting the hospital

Reading

Chung, a 40-year-old officer, had been experiencing a high fever for several days He had thought it was just

some viral infection until he started to feel short of breath He was taken to the emergency room (ER) in a provincial hospital Upon examination, he had a high fever, pulse rate and blood pressure were within normal

ranges, his breathing was fast, and oxygen saturation was low His chest X-ray showed lung consolidations

Chung was diagnosed with pneumonia and respiratory failure, so he was given supplemental oxygen However, his condition did not improve and required mechanical ventilation Because the hospital did not have ventilators, the ER doctor transferred him to a central hospital

At the central hospital, Chung was admitted to the intensive care unit (ICU) He was intubated and ventilated Further investigations also revealed anemia Chung was treated with antibiotics and blood transfusion He recovered after two weeks staying in the ICU and was transferred to the Respiratory department Two weeks later, he was discharged home with some prescription medications and the ward doctor asked him to return to the outpatient clinic (OPC) after one month for follow-up

Exercise

Choose a word from the text to fill in the gaps

1 Words to describe “a place for receiving and

treating patients”

(1) room (2)

(3) (4)

(5)

2 Two places in a hospital where a patient can

come for check-up

(1) _

(2) _

3 _ treats critically

ill patients

4 Some patients can return home, but some

have to be _ to the hospital

5 Blood tests and imaging like chest X-ray are

called _

6 He was _ with pneumonia

7 If a hospital is unable to manage a patient,

they can _ the patient to

2 temperature, pulse rate, blood pressure, breathing rate _

3 admission _

4 to send patients to another hospital for evaluation, but not discharge them _

5 medication _

Nouns and verbs

admission _ assessment _ discharge _ diagnose

examine improve manage treat

Types of hospitals

In Vietnam, there are district, provincial/town, and regional/central/national hospitals Many are general

hospitals—they manage patients with all sorts of medical conditions The others specialize in a group of diseases and are often called by the group of diseases that they treat (e.g., a surgical hospital treats patients with surgical conditions)

Name some hospitals you know and classify them

Vocabulary

Warm-up

Underline the part you think is in common

1 endoscopy, endovascular, endothelium

2 cardiac, pericardiectomy, cardiovascular

3 cellulitis, retinitis, meningoencephalitis

Which part is equivalent to the following words?

heart inflammation inside

Can you guess what is “an inflammation inside the heart”?

Latin medical terms

There are three major components of a Latin medical

term: roots, prefixes (before the roots), and suffixes

(after the roots)

H Y P E R G L Y C E M I A

hyper- glyc(o)- -emia

elevated glucose condition of

the blood

Elevated blood glucose

-logist a person who studies something

-logy the study of

_ inflammation of the nerves

_ the study of tumors, especially cancer

_ inflammation of the joints

What are the names of other medical specialties that you know? Can you explain the roots in those names?

Visiting the hospital 9

Vocabulary

Jobs in the hospitals

Read the job descriptions below Who will do these

works?

1 managing and dispensing

medicines to medical staff or

2 assisting pregnant women in

3 responding to emergency

calls and giving first aid _

4 taking and reading x-rays and

5 performing surgeries _

6 providing temporary loss of

sensation for surgery or other

10 giving drugs to patients and

taking care of them _

Exercise

Below are the stories of some doctors Can you guess

what their jobs are?

“The patient was sent to us in cardiac arrest

for 15 minutes But no one among us gave

up His heart beat again somehow Since

then he visits us every year on this day.”

“She was a tiny angel, born with an extremely low

birth weight Her heart stopped beating every now

and then They told me I was wasting my time doing

CPR This is the picture she drew when she started

primary school.”

“Two years ago, a young man shot himself to his

head I quickly sent him to the operating room

Last week, he sent me a photo of his newborn

son.”

“A young, very thin girl with severe lupus

nephritis came to us in distress Others believed

she didn’t have much time I told them it’s not the

end Now she plays tennis on the days she

doesn’t have to go to the Dialysis center.”

Reading

A full course in Vietnamese medical schools takes six

years We begin clinical rotations in the second semester of the third year with Internal Medicine and Surgery One rotation often lasts six to ten weeks In

these rotations, we learn how to take history, detect clinical signs, and summarize patients’ clinical presentation

A typical day starts at 7:30 AM when we join the morning meeting In the meeting, doctors present newly admitted patients and severe patients who need monitoring during their night shift

Afterward, we divide into small groups to different rooms and ask some patients about their disease and

examine them We usually need to write case reports

and submit them to our teachers The cases can also

be presented in front of the class during clinical

lectures in the morning In the afternoon, we return to

our school to study theoretical lectures

We have one to three shifts every week Students do all

sorts of activities during the shifts We monitor severe

patients, complete medical records, send samples to the lab, get the test results from the lab, and transfer

patients to other units We learn a lot in a shift, but it can also be very boring sometimes

Choose a word from the text to fill in the gaps

1 We plan to submit a _ to the BMC Gastroenterology

2 Blood _ should be taken and sent to the _ for culture within two hours

3 To review these cases, we’ll need to borrow their _ from the General Planning Department

4 I’ve been having night _ every Sunday

5 When’s your next _? It’s Infectious diseases, isn’t it?

Writing

Tell us about your life as a student and a doctor or nurse

Think about your first day at the hospital:

- What did you expect before you started?

- What have you actually learned, and did they

meet your expectations?

- One of your most impressive experiences in the

hospitals

2 Your first case report

Reading

Read the following paragraph in a case report 1 and fill in the gaps

A 23-year-old unemployed Caucasian man presented to our Emergency Department with a twelve-hour history of severe right upper and lower quadrant pain This pain originated in his epigastrium and was associated with nausea, multiple episodes of non-bilious vomiting and anorexia His background history was unremarkable He was on no regular medications, did not smoke and was a social drinker

 talk about _ history (PMH)

Tick details about the symptoms that can be found in the paragraph In the gaps, write the number of the phrases describing the details

Write a complete sentence using the prompts

1 43, M, Sri Lankan, acute febrile illness, 3

4 71, M, white, French, bilateral blurry

vision, epistaxis, nausea, two weeks5

_

Vocabulary

Describing a symptom

Add the words in the box to the mind map How will you arrange words with opposite meanings?

pain acute moderate intermittent chronic generalized fatigue severe

sudden nausea constant episodic mild vomiting localized malaise

Your first case report 11

New words

Choose an appropriate word in the box to fill in the

gaps Change word forms if needed

last associate report radiate note deny

develop accompany occur relieve

1 Fourteen days before the current admission,

anorexia and fatigue _, along

with pain and tightness in the back and

calves.6

2 Bowel movements _

approximately every hour, and the patient was

unable to sleep.7

3 She _ a weight gain of 4.5 kg

during the previous month, occasional

episodes of confusion, and two episodes of

burning chest pain during exercise that had

_ for 2 minutes each and were

_ with rest.8

4 His wife _ that he was unresponsive, “gurgling,” and diaphoretic in the early morning.9

5 Approximately 6 weeks before admission, severe pain developed that _ down her left leg to her ankle.10

6 On further history, he _ any dyspnea, shortness of breath, or cough.11

7 She had had a sore throat, which lasted for a few days, _ by fever, rigors, and myalgia.12

8 A 31-year-old Caucasian female smoker was admitted to the hospital with a 7-week history

of fever _ with night sweats, joint pains, myalgia and nasal congestion.13

Review of grammar

The SVO structure

Examples

1 HIVis an infectious disease

2 The doctorprescribed atenolol

3 Severe post-splenectomy infectionhas an

incidence of 0.42–7.16/100 persons per year

Analyzing sentences using the SVO principle

 Locate the verb(s)

 The subject(s) precedes the verb(s)

 The object(s) follows the verb(s)

Exercise

Circle the verbs and underline the subjects

(1) Intravascular hemolysis is the destruction of red

blood cells in the circulation with the release of cell

contents into the plasma Mechanical trauma from a

damaged endothelium, complement fixation and

activation on the cell surface, and infectious agents

may cause direct membrane degradation and cell

destruction.14

(2) The goal of the clinical examination is to identify

patients who require immediate surgical evaluation

and those whose symptoms suggest a more serious

underlying condition such as malignancy or

infection Patients with signs of cauda equina

syndrome, require urgent surgical referral.15

(3) We aimed to evaluate the performance of this new scoring system for liver fibrosis compare to histologic evaluation of liver biopsies

(4) Appendicitis has different progressions and among them, generalized peritonitis which is dangerous because it might cause sepsis

Writing

Warm-up

Use the prompts to write a complete sentence Add more words if needed

1 45 years old, male,

Below are patients’ answers Rewrite them in the language of medicine

1 I have been feeling so tired for

two weeks _

2 It doesn’t hurt much And only

around my belly button The

pain started 3 days ago _

3 No, I don’t see any blood in my

stool _

4 When I felt that pain in my leg, I

took a pill of paracetamol and

the pain’s gone _

5 Yes, she also complained of

headache and dizziness (the

To say that someone has /

does not have a symptom

Where does it hurt? 13

3 Where does it hurt?

Listening

Listen to the dialogue 16 and write the order of the details which the doctor asks the patient about

Aggravating factors Associated symptoms Chief complaint

New words

Listen to the dialogue again and fill in the gaps with missing words Then, match each question in the left column with one question in the right column 17

1 What’s you along today? When did it start?

2 How have they been bothering

you? Is it sharp, dull, pulsating, cramping, or pressure-like?

3 Which part of your head is ? How can I help you today?

4 Can you the pain? Where does it hurt?

Speaking

Read the dialogue below and practice with the prompts

Doctor: Good morning, Mr Henderson How

can I help you today? (1) chest pain, 3 weeks, middle chest, come and go (2) swollen ankles, 2 months, both feet

(3) stomachache, 10 hours, epigastric, constant, cramping

(4) back pain, 7 days, low back, dull but sometimes gets sharp

REVIEW

1 Which terms can be used to describe a pain that started a few hours/days ago?

2 Which terms can be used to describe “come and go”?

Patient: Well, I’ve got a terrible leg pain lately

Doctor: When did it start?

Patient: A few days ago

Doctor: Where does it hurt?

Patient: My two calves

Doctor: Is it constant, or does it come and

go?

Patient: It comes and goes, but it gets worse

after I walk a few blocks

Review of grammar

Using modifiers

How do you analyze the structure of a twelve-hour history of severe right

upper and lower quadrant pain? Look at the flow diagram on the right

“History” is the central noun and “twelve-hour” provides additional meaning

to the noun—or we say “twelve-hour” modifies “history” And “severe” and

“RUQ/RLQ” modify “pain” These elements are called modifiers

Modifiers can help shorten the sentences and make your expression sound

more “scientific” However, excessive use of modifiers also creates complicated

sentences and often brings about confusion for readers

Types of modifiers

Adj + N The patient complained of severe chest pain

N + V-ing/V-ed The patient complained of severe chest pain radiating to the back, accompanied

by dyspnea and fever

N + relative clause The patient complained of severe chest pain that occurred while he was lifting a

heavy box

N + prep + N The patient complained of severe chest pain behind the sternum

N + adj + prep + N The patient complained of severe chest pain unresponsive to nitroglycerin

Exercise

Read the text, underline the central nouns, and highlight their modifiers

(1) In patients with advanced HIV infection, the most common causes of focal brain lesions with mass effect are toxoplasmosis and lymphoma.18

(2) When there is an associated aneurysm of the aortic root, conventional surgical therapy has consisted of the combined replacement of the aorta and valve with reimplantation of the coronary arteries.19

(3) Children have a proportionately greater body surface area to weight ratio, and as a result, have a higher degree of absorption for the same amount applied.20

(4) Examination of her skin and oral cavity reveals violaceous, polygonal papules, mainly on the flexural aspect of the wrists and ankles and in the lumbar region, as well as erosions associated with a lace-like, white-line network apparent in the posterior buccal mucosa.21

(5) A total of 352 patients with unstable ischemic symptoms, ECG changes, or troponin elevation were randomized at 13 hospitals to immediate (at a median 70 minutes after enrollment) versus delayed (at a median 21 hours) angiography and revascularization.22

Rewrite the following sentences using modifiers

1 Adolescents with Crohn’s disease often have a

history of weight loss It precedes the onset of

abdominal symptoms by 18 months.23

2 On the 6th day, MRI of the lumbar spine revealed

multiple abscesses They involved the psoas

muscles bilaterally.24

3 Four days before hospitalization, she developed

fever and a rash on her extremities and trunk The

rash was diffuse, non-itchy, and erythematous.3

Where does it hurt? 15

frontal headaches, 3mos

worse in a.m – “dull, throbbing”

relieved by lying down

also c/o deafness

1 What do the abbreviations stand for?

M _

a.m _

c/o _

2 Why is “dull, throbbing” in quotation marks?

Rewrite your summary using modifiers

Vocabulary

Quality of pain

Match the terms relating to quality of pain with their definitions

1 burning low intensity, unclear about location

2 colicky medium to significant intensity, clearly

located

3 cramping feeling like a knife stabbing into the body

4 crushing feeling like something is crushing/squeezing

the organ

5 dull hot as if exposed to fire or chemical agents

6 insidious feeling like something is punching into the

body, can be associated with a feeling of a beating pulse

7 sharp a pain that runs quickly, directly, and severely

across a region of the body

8 shooting low intensity but persisting, often gradually

increasing, and sometimes comes and goes

9 stabbing severe, feeling like an internal organ is being

gripped

10 tearing feeling like needles are punching into the skin

11 throbbing a sudden painful tightening in a muscle

12 tingling a very painful feeling as if the body part were

(2) A construction worker came to our ED last night He was 32 years old He had a pain in the region of the appendix five days ago The pain was mild, but it did not come and go

(3) A 22-year-old student suddenly had a feeling of shortness of breath while he was hitting the gym one day ago The shortness of breath was severe and never stopped, and he also felt chest pain (4) A retired officer came to the ED with

an extremely severe chest pain He experienced the chest pain 45 minutes before admission The chest pain was sudden and most prominent behind the sternum and radiated to his left

shoulder

4 The past also matters

Reading

Read the following case reports Before each type of history, write the number of the phrase that describes it

The patient had a long history of leg pain that was associated with activity and was relieved with rest,

attributed to claudication, which was different from his current symptoms He had had diabetes mellitus, hypertension, and hyperlipidemia for more than 10 years.25

His medical history includes diabetes mellitus, hypertension, and hyperlipidemia He has a family history

of diabetes and hypertension His medication history includes subcutaneous Novomix®, telmisartan 20 mg once a day, amlodipine 10 mg once a day, atorvastatin 20 mg once a day and aspirin 150 mg once a day He underwent saucerization surgery to remove carbuncles in Jan 2011.26

Her menstrual periods were usually regular in interval and she rarely suffered from menorrhagia She had two myomectomies about 25 years ago.27

He had a long history of alcohol abuse (up to 1 liter of vodka per day) He had declined detoxification treatment, disulfiram therapy, and referral to support groups for alcoholism He did not smoke or use illicit drugs He had no known allergies.18

A 55-year-old man of East African descent presented to our community hospital with a history of repeated falls, postural dizziness, progressive fatigue, generalized weakness and 30-lb weight loss over the course of three to six months He is a vegetarian.28

Types of history

Past medical history (PMH) Past surgical history (PSH)

Exercise

Fill in the gaps with one word

1 The patient had a of injected drug use and unprotected sex

2 She had hypertension and chronic kidney disease for about 5 years

Write a term that corresponds to the definition

_ Consuming too much ethanol, resulting in health problems

_ Blood discharge from the uterus via the vagina, often happening monthly

_ Use of tobacco, cigarettes, or equivalents

_ People who avoid meat in diet

_ Enabling the body to recognize an organism so the body can protect itself against the

organism

The past also matters 17

Speaking

Ask appropriate questions for the following answers

(1) Yes Last year, I had my appendix removed

(2) Yes I am allergic to penicillin

(3) I have two brothers They are both living healthy

(4) My period is not regular

(5) Yes I am taking amlodipine for hypertension (6) No, I don’t drink

(7) I have two children One is 5, and the other 2 (8) Yes, my son hasn’t missed any vaccination

Writing

Describing past history

To say the patient

has a history his/her history includes + history

To say the patient

does not have a

history

deny + (any) + history report no + history

She denied any rash or blisters on the skin

The child’s mother reports no history of neonatal jaundice

(2) My husband is 58 years old He kept complaining about his knee pain for nearly two weeks He has had this joint pain for 10 years Every time it became red and swollen, he said it was very painful and he would go

to a private doctor in the village The doctor gave him some injections and the pain went away after several days This time, it came back He also developed a fever as his knee joint became painful and swollen I told him to go to the hospital, so we went to our district hospital He said his fever got worse and the joint was very painful They treated him with some drugs, both injected and oral I can’t remember their names, but I

kept the bottle (you check the bottle, they are dexamethasone, piroxicam, and gentamicin) He stayed in the

district hospital for 12 days, and his fever and joint pain didn’t get better He told me that he felt extremely unwell We were very worried, so the doctor transferred him to the provincial hospital There he stayed there for several hours and suddenly fainted I called the doctor, they checked his blood pressure and told me that

he was in shock They gave him fluid, then transferred him to this hospital

ID/CC _ HPI _

_ _ PMH _

ID/CC _ HPI _

_ _ _ _ PMH _

Exercise

Complete the following sentences using the above terms

1 Myocardial infarction is a _ disease A lot of MI patients are diabetic; therefore, they should also be managed by an _

2 Systemic lupus erythematosus involves the skin and joints, so patients often visit _ or _ when they first have symptoms At times, they might develop lupus cerebritis, which requires consultation of a _

Terms of anatomical position29

Tips

- Superior and superficial both have “super” (above) Superficial means “above the surface”

- Anterior and posterior come from ante (before) and post (after) Refer to AM and PM (before and after midday)

- Distal relates to “distance, distant” (far)

Anatomy 21

Writing

Describing anatomical relationship

Use the following structure to write sentences about positional relationship of anatomical details

Describing components of an organ

The following table explains how to describe the components of an organ

organ + be divided into + (number of

parts:) + components

The nervous system is divided into the central nervous

system (CNS) and the peripheral nervous system (PNS)

organ + include / be composed of / consist

of + components The CNS includes the autonomous nervous system (ANS) and the somatic nervous system (SNS)

there is/are + number of parts + unit + (in

the organ): components There are three meningeal layers: dura mater, arachnoid mater, and pia mater

Exercise

Describe the following anatomical details

1 vertebra, region: cervical spine, thoracic

spine, lumbar spine, sacrum, coccyx _

2 hand, finger: thumb, index finger, middle

finger, ring finger, little finger _

3 cerebral cortex, lobe: frontal lobe, parietal

lobe, temporal lobe, occipital lobe _

4 stomach, part: cardia, fundus, body,

antrum, pylorus _

5 electrical conduction system of the heart,

main structures: SA node, AV node, Bundle

of His, Purkinje fibers _

Which examination techniques can detect the following signs? In the examination of which organ/system can

you detect them? You will have to look for the definition of the signs There is no need to memorize their

meanings right now You just need to understand the definitions to answer the questions in this exercise

9 Murmur at the right renal artery

10 Facial nerve paralysis

Examination instruments and supplies

Match the name of examination instruments and supplies with the pictures

On examination 23

Writing

Describing examination findings

Read the sentences and write the number of the structure used to describe examination findings

1 sign + was/were present/absent

6 there was/were + sign

(1) A physical examination showed erythematous, violaceous plaques that involved more than 90% of the patient’s body-surface area.30

(2) On examination, the oxygen saturation was 99% while

the patient was breathing ambient air Ankle, knee, and brachioradialis reflexes were absent.31

(3) There was ptosis of the left upper eyelid, and the patient was unable to elevate the left eyelid.32

(4) Scaly, erythematous plaques were also present on the extensor surfaces of both elbows and both knees The patient had

no joint tenderness, swelling, or stiffness.33

3 heart: S1, S2: normal; audible S3, no

S4; murmur: systolic, 3/6, apex,

radiating to left axilla

_

4 chest: symmetrical; no use of

accessory muscles _

5 admission: deep coma, no response

to voice and pain stimuli _

6 liver span: 17 cm (right midclavicular

7 abdomen: firm, tender, guarding

_

8 abdomen: no enlarged kidneys, no

costovertebral angle tenderness _

9 both knees: good range of motion,

moderate crepitus _

10 alert, try to answer questions,

difficult in finding words _

Speaking

Present these case reports using the prompts

- 72 M

- C/O: periumbilical pain, inability to pass flatus

(11 hours)

- PMH: chronic lymphocytic leukemia (on

ibrutinib), type 2 DM, chronic Hep-B

- O/E: PR 155, BP 83/52 Abdomen: diffusely tender

(most severe pain: RUQ)

- 58 M

- C/O: exertional dyspnea

- PMH: 12 years—aortic stenosis, bioprosthetic aortic valve replacement

- O/E: BP 142/57 Auscultation: holodiastolic murmurs Corrigan’s pulse, Quincke’s pulse

- 61 M

- C/O: right eye vision loss, ptosis (4 days)

- PMH: type 2 DM, coronary artery disease,

hypertension

- O/E: No fever Right eye: ptosis, right pupil—

fixed, mydriatic, non-reactive to light

_ PMH _

PE

_

A beating heart 25

7 A beating heart

Vocabulary

Anatomy of the heart

Complete the table of heart anatomy

(4) _

Heart valves and vessels

(3) (4) (4) (1) (2) (2)

Heart sounds

Draw a cardiac cycle that includes all the following terms

systole

diastole

S1 (first heart sound)

S2 (second heart sound)

M1 (valve)

T1 (valve)

A2 (valve)

P2 (valve)

Valvular heart disease

Fill in the gaps with an appropriate term

1 An abnormality of the heart valve causing it to be unable to fully open,

thus restricting the blood flow pumped through its orifice _

2 An abnormality of the heart valve causing it to be unable to fully close,

thus letting the blood flow leak through its orifice _

3 The valve between LA and LV does not fully open; therefore, the blood

4 The valve between LV and aorta does not fully close; therefore, blood

flows backward into the LV during systole _

5 The valve between the RA and RV does not fully close; therefore, blood

flows backward into the RA during systole _

6 The valve between the RV and pulmonary artery does not fully open;

therefore, the blood cannot flow properly into the PA _

Describing a murmur

Warm-up

Study the example and write the correct number before each characteristic of the murmur

Cardiac examination revealed a soft 2/6 systolic crescendo-decrescendo murmur loudest at the

right upper sternal border preceded by an ejection click.38

Characteristics of a murmur

1 Timing systolic/diastolic/continuous

pre-, mid-, holo-, pan-, early, late

2 Location loudest at, heard best at

3 Radiation radiating to; non-radiating

4 Intensity (grade) X/6 (4/6: thrill present)

5 Quality soft, harsh, machinery-like, etc

6 Shape crescendo, decrescendo

7 Pitch low-, mid-, high-pitched

8 Associated sounds preceded by, followed by, accompanied by

A beating heart 27

Reading

Thromboembolism

A woman is cooking dinner in the kitchen While cutting a carrot, she accidentally cuts her finger and bleeds

The bleeding is stopped after several minutes by the vessels forming a blood clot or thrombus (pl thrombi)

Blood clot formation (coagulation) stops bleeding (hemostasis) and helps repair the damaged vessels

Thrombi are constantly created in the vessels but fibrinolysis—a process to break down the clots—helps clear

up these tiny blood clots The balance between coagulation and fibrinolysis helps the blood flow smoothly inside the vessels If the fibrinolysis is weakened, or the coagulation pathways are more activated, a person is

at higher risk for thrombosis

Sometimes, fragments of thrombi can break down, move along the bloodstream, and are stuck in smaller vessels The blood cannot flow through these blocked vessels, and the tissues supplied by the vessels become

short of oxygen and nutrition This condition is called ischemia If ischemia is not resolved, the tissues will eventually die and be replaced by fibrotic tissues, a condition called infarction

Other materials, such as air bubbles, fat, or tissues, also behave the same way with thrombi and cause tissue

ischemia and infarction; they are generally called emboli These materials can move inside the bloodstream and get stuck somewhere, causing a blockage This is called embolism

Exercise

Fill in the gaps with an appropriate term

1 A 71-year-old male patient complained of substernal chest

pain PCI showed a segment of the coronary artery completely

narrowed by thrombus Heart ultrasound after several weeks

showed a hypokinetic left ventricle (meaning a part of the

heart muscles is dead) He was diagnosed with myocardial

_

2 A woman with a history of type-2 diabetes mellitus presented

with numbness and pain in her left diabetic foot She was

diagnosed with peripheral arterial disease (PAD), a condition

where arteries become damaged and narrowed, and blood

flow is reduced to the limbs PAD has caused limb

_

3 A patient with thrombophilia was admitted due to difficulty

breathing Doppler ultrasound showed a large thrombus

running along the inferior vena cava Subsequent chest HRCT

scan revealed a significant loss of blood supply to the right

lung A/an _ is the cause of his dyspnea

This condition is called pulmonary _

4 A young girl was admitted with a syncope Heart ultrasound

showed large damage to the aorta, which the doctors believed

was caused by bacteria Her neurologic symptoms are probably

due to septic _

5 Ventilated patients are often immobilized for a long time

Blood clots might form in the deep veins of the lower

extremities, then break down and move to the lung vessels,

causing cardiovascular and respiratory compromise

Therefore, these patients need prevention of venous

of tissues, cells, or substances

-ism condition

N-ism: N is the name of (1) the cause or (2) the description of the condition

Examples

- embolism = a condition caused by emboli

- hyperaldosteronism (hyper-: increase) = an abnormal condition where the level of aldosterone is increased

Speaking

Present these case reports using the prompts

- 79 M

- C/O: progressive dyspnea on exertion (3

months), no palpitation

- PMH: hyperlipidemia

- O/E: bradycardia (HR 49), normotension (BP

127/50), normal S1 & S2, no murmur

- 78 M

- C/O: dyspnea at rest, orthopnea, paroxysmal nocturnal dyspnea (PND)

- PMH: coronary artery disease

- O/E: tachycardic (HR 105), normotensive (BP 120/55); 4/6 diastolic murmur (left sternal border)

- 58 M

- C/O: weight loss, dysphagia (2 months)

- PMH: hypertension (on valsartan &

hydrochlorothiazide)

- Admission: regular heart rhythm (HR 81)

- After 4 hours: irregular rhythm, EKG: atrial

fibrillation

- 65 F

- C/O: face and limb edema, severe fatigue

- PMH: cold and fever (1 week before admission)

- O/E: confused, shock: tachycardic (HR 130), hypotensive (BP 80/40), severe edema (arms and legs) Heart sounds: normal

Vocabulary

Hemodynamic status

Complete the table

Vital sign Root (noun) Root (adjective) Increased Normal Decreased

Pulse / heart rate _ _ _ (no term) _ Blood pressure _ _ _ _ _

in the gaps

1 heart beating fast and strong (e.g., when worried) _

2 shortness of breath (SOB) _

3 SOB when doing physical

4 sudden SOB at night _

5 SOB that forces patients to sit

6 swelling due to fluid

I can’t breathe 29

8 I can’t breathe

Vocabulary

Anatomy of the respiratory system

Number the parts of the respiratory tract

bronchus larynx lung

nose pharynx trachea

Complete the text with appropriate terms

The serosa covering the lungs is called ,

consisting of two layers Between these two layers is the Normally, it only has a small amount of fluid

The lungs are to the heart and the

, which is the compartment containing the heart

The lungs are to the _—

the main respiratory muscle Other muscles involved in the breathing function (e.g., intercostal muscles), are called _ respiratory muscles Together they produce the two main respiratory movements: breathing in ( ) and breathing out ( )

Both the heart and the two lungs are protected by the rib

cage ( )

Examination of the lungs include:

- for chest asymmetry and abnormal movements

- to check

- to look for changes in lung resonance

- to breath sounds and for any added sounds

Reading

Skimming and scanning

> Skimming is reading a text to provide a brief understanding of the content by identifying the main ideas

Main ideas are often extracted from the headings, key sentences (usually first and/or last lines of a

paragraph) or the first and/or last paragraphs

> Scanning is reading a text quickly to find specific information, such as figures or names Information

collected by scanning is used to answer questions (true/false, what, how, etc.)

> Reading often serves two purposes: (1) to learn

new knowledge, and (2) to look for an answer for

a question

In any case, reading begins with skimming so

that readers can know briefly what the

document is about, often by making a mind

map Then depending on the reading purpose,

readers can either continue to build the mind

map or scan the document to look for the

content related to the question

A mind map under development during skimming 44

Exercise

Read the following text 39 and answer the questions

Added sounds

Listen for any added, or adventitious, sounds that are superimposed on the usual breath sounds Detection of

adventitious sounds—discontinuous sounds: crackles (a.k.a rales), and continuous sounds: wheezes and rhonchi—is an important part of your examination, often leading to a diagnosis of cardiac and pulmonary

conditions

Crackles

If you hear crackles, especially those that do not clear after coughing, listen carefully for the following characteristics These are clues to the underlying condition:

- Quality (loudness, pitch, and duration), summarized as fine or coarse crackles

- Number, few to many

- Timing in the respiratory cycle

- Location on the chest wall

- Persistence of their pattern from breath to breath

- Any change after a cough or change in the patient’s position

In some normal people, crackles may be heard at the anterior lung bases after maximal expiration Crackles

in dependent portions of the lungs may also occur after prolonged recumbency

Crackles have two leading explanations (1) They result from a series of tiny explosions when small airways, deflated during expiration, pop open during inspiration This mechanism probably explains the late

inspiratory crackles of interstitial lung disease and early heart failure (2) Crackles result from air bubbles flowing through secretions or lightly closed airways during respiration This mechanism probably explains

at least some coarse crackles

- Late inspiratory crackles may begin in the first half of inspiration but must continue into late inspiration They are usually fine, fairly profuse, and persist from breath to breath They appear first

at the bases of the lungs, spread upward as the condition worsens, and shift to dependent regions with changes in posture Causes include interstitial lung disease (such as pulmonary fibrosis) and early heart failure

- Early inspiratory crackles appear and end soon after the start of inspiration They are often coarse and relatively few in number Expiratory crackles are sometimes associated Causes include chronic bronchitis and asthma

- Mid-inspiratory and expiratory crackles are heard in bronchiectasis but are not specific for this diagnosis Wheezes and rhonchi may be associated

Wheezes and rhonchi

If you hear wheezes or rhonchi, note their timing and location Do they change with deep breathing or coughing?

Wheezes occur when air flows rapidly through bronchi that are narrowed nearly to the point of closure They are often audible at the mouth as well as through the chest wall Causes of wheezes throughout the chest include asthma, chronic bronchitis, COPD, and heart failure (cardiac asthma) In asthma, wheezes may be heard only in expiration or in both phases of the respiratory cycle Rhonchi suggest secretions in the larger airways In chronic bronchitis, wheezes and rhonchi often clear with coughing

Occasionally in severe obstructive pulmonary disease, the patient is unable to force enough air through the narrowed bronchi to produce wheezing The resulting silent chest is ominous and warrants immediate attention

Persistent localized wheezing suggests partial obstruction of a bronchus, seen with a tumor or foreign body

It may be inspiratory, expiratory, or both

Pleural rubs resemble crackles acoustically, although they are produced by different pathologic processes The sounds may be discrete, but sometimes are so numerous that they merge into a seemingly continuous sound A rub is usually confined to a relatively small area of the chest wall, and typically is heard in both phases of respiration When inflamed pleural surfaces are separated by fluid, the rub often disappears

Mediastinal crunch (Hamman’s sign)

A mediastinal crunch is a series of precordial crackles synchronous with the heartbeat, not with respiration Best heard in the left lateral position, it is due to mediastinal emphysema (pneumomediastinum)

Skimming

1 What is the text about?

2 List the added sounds described in the

b Number the characteristic

that has the descriptions profuse late inspiratory fine not cleared with cough inferior 1/3 portion of the right lung

2 Explain the mechanisms of added sounds

Crackles: (1) (2) _ Wheezes: Rhonchi: _ Pleural rub: Hamman’s sign:

3 True (T) or False (F)?

A Crackles might not reflect an abnormal condition because they are also heard in normal people B In interstitial lung diseases, the inflammatory and fibrotic processes of the pulmonary membranes result in crackles heard during the early inspiration

C Both crackles and wheezes can be detected on lung auscultation in patients with asthma

D Mid-inspiratory crackles are not specific for bronchiectasis

E The Hamman’s sign is also a type of crackles

F Because the pleurae move during inspiration and expiration, pleural rubs are always discontinuous G Wheezes can be heard in obstruction of the bronchial lumen due to a lung tumor

Vocabulary

Respiratory signs and symptoms

“Dyspnea” is difficulty (dys-) breathing

(pnea) Write the terms for other conditions

_ fast breathing

_ slow breathing

_ no breathing

This device is a pulse It measures

oxygen saturation in the capillary blood (SpO2) This method is called

A patient with low SpO2 ( ) might have blue discoloration of the skin, or It’s a sign of respiratory

What are other instruments that have the same root (“a device to measure”)?

Chest imaging

Provide the name of the following imaging methods

Things to do with respiratory failure patients

Provide the name of the following interventions/investigations

Review

Interpret the following parameters Then write a summary

Case report: 50 M, C/O: SOB, chest pain, fatigue

Which instruments do you use to evaluate these vital signs?

You need some blood tests 33

9 You need some blood tests

Vocabulary

Blood cells

Match the names of blood cells with the pictures

basophil eosinophil erythrocyte leukocyte lymphocyte macrophage mastocyte

monocyte neutrophil reticulocyte plasmocyte thrombocyte

Exercise

Read the descriptions and guess which term they describe

1 leukonychia generalized skin redness

2 erythroderma (belonging to) lysis of blood clots

3 lymphadenopathy difficulty swallowing

4 macrocytic white nail

5 thrombolytic enlarged lymph nodes

6 dysphagia (belonging to) big cells

Reading

Flow diagram

A flow diagram (or flowchart) is a type of diagram that represents an algorithm, workflow, or process,

showing the steps as boxes of various kinds, and their order by connecting them with arrows Reading flow diagrams is simple: start from the single box (often on the top), then, based on the actual situation (guided by the next question), follow the appropriate arrows to see what to do next

In medical practice, flow diagrams are used to approach patients with a certain condition They help doctors narrow the list of diagnoses and guide what investigations to include in the workup Therapeutic flow

diagrams also help doctors choose the most appropriate therapy for patients

Exercise

Use the flow diagram 45 to interpret the clinical pictures and the complete (full) blood count results

1 26 M, sudden pallor and jaundice, associated with dark urine, flank pain

and chills Hb 90 g/L, MCV 83, MCHC 316, Ret 4.2%, PBS: RBC fragments

2 30 F, gradual pallor, and fatigue, also c/o menstruation disorders Hb 110

g/L, MCV 73, MCHC 290, RDW 17.1%, Ret 1.5%, serum iron: decreased

3 45 M, history of total gastrectomy, pallor, loss of appetite, fatigue Hb 78

You need some blood tests 35

Vocabulary

Changes in cell counts

Match the names of conditions with the complete

blood count results

anemia leukocytosis leukopenia neutrophilia

Given “pan-” is the prefix for “all”, what is the term

for “decreased cell counts of all three lineages”?

Biochemistry testing and urinalysis

How do you name these conditions?

elevation (adj elevated), rise, raise, high

-ia abnormal condition

- -emia: blood condition

- -uria: urine condition

Other tests

Can you name these tests?

10 The lungs and the pleura

Vocabulary

Name the conditions In each condition, which signs and symptoms do patients have?

pleural effusion pneumonia pneumothorax

1 Sharp chest pain, triggered every time a patient breathes _

3 Two sides of the chest do not look the same _

4 The patient’s breathing looks labored You can see very clearly the

retraction of the intercostal muscles _

5 Percussion on the half of the chest affected by pneumothorax can

6 Percussion on the part of the chest affected by pleural effusion can

Exercise

Name these conditions

1 The patient’s pleural cavity is severely infected with bacteria and the

2 Cytology of the pleural fluid drained from an injured patient shows

3 Analysis of the pleural fluid confirms that its milky white presence

4 Cirrhosis, heart failure, and nephrotic syndrome might cause this

5 Pneumothorax that happens spontaneously in young, thin males _

6 Pneumothorax that occurs due to medical errors _

7 Pneumothorax that is caused by a one-way valve, leading to

The lungs and the pleura 37

Vocabulary

Procedures

Name the procedures

aspiration pleurodesis thoracentesis thoracotomy tube thoracostomy

Exercise

Fill in the gaps with an appropriate term

1 taking venous blood by making

an incision of the vein (phlebo-) _

2 making an opening into the

trachea to insert a tube _

3 removal of a portion of the

4 removal of a lobe (lobo-) of the

5 a puncture into the joint cavity _

6 removal of the stomach _

7 making an opening into the

centesis puncture -ectomy making an excision,

removal -ostomy making an opening/a

hole

if there are names of two organs before -ostomy: making an opening connecting two organs

Complete the following sentences using the above terms

1 We need some pleural fluid for analysis Let’s prepare _

2 Talc, tetracycline, or povidone iodine can be used for _

3 We’ll consider _ because the patient needs drainage for several days

Reading

Interpreting an arterial blood gas

Below is a case adapted from a NEJM interactive case 46 Read the case and answer the questions

A 72-year-old woman with a history of dementia is found in a park in a confused state, with empty

medication bottles

Arterial Blood Gas

* Pco2 denotes the partial pressure of carbon

dioxide, and Po2 the partial pressure of oxygen

1 Does the patient have an acidemia or an alkalemia?

Since the pH is greater than 7.4, the patient has an alkalemia

2 Is the primary problem metabolic or respiratory?

Since the Pco2 is low, the patient has a respiratory alkalosis

3 Is the anion gap normal?

The range for a normal anion gap is usually considered

to be 10 to 12, but values of 9 to 14 may be considered normal in some laboratories An anion gap that is greater than 20, even in the presence of alkalemia, suggests a metabolic acidosis

4 Is the metabolic compensation appropriate?

- If the patient had an acute respiratory alkalosis, the expected bicarbonate compensation would be:

Exercise

True (T) or False (F)?

1 The first step to interpret a blood gas is evaluating the pH

2 In alkalosis, a high partial pressure of carbon dioxide

suggests a respiratory disorder

3 The anion gap is not important in evaluating alkalosis

4 We need to evaluate compensation because it can reveal a

superimposed disorder

5 In a patient with compensated respiratory alkalosis, the

bicarbonate in the acute condition is higher than in the

chronic condition

6 The patient’s ABG reveals a respiratory alkalosis mixed

with a respiratory acidosis

Speaking

Use the following structures to report the test results in the case

1 test + was/were negative/positive

2 test + was/were + value

3 test + showed/revealed + component + of + value

4 test + showed/revealed* + condition

5 test + was/were normal/within normal range

*: for imaging, “to demonstrate” is also commonly used

The differential diagnoses 39

11 The differential diagnoses

Reading

Read the case 17 and answer the questions

History

HPI 46 y.o M c/o chest pain Chest pain started 40 minutes before the patient presented to the

ER The pain woke the patient from sleep at 5 A.M with a steady 7/10 pressure sensation in the middle of his chest that radiated to the left arm and the neck Nothing makes it worse

or better Nausea, sweating, and dyspnea are also present Similar episodes have occurred during the past 3 months, 2–3 times/week These episodes were precipitated by walking up the stairs, strenuous work, sexual intercourse, and heavy meals Pain during these episodes was less severe, lasted for 5–10 minutes, and disappeared spontaneously or after taking antacids

ROS Negative except as above

Allergies NKDA

Medications Maalox, diuretic

PMH Hypertension for 5 years, treated with a diuretic High cholesterol, managed with diet

GERD 10 years ago, treated with antacids

SH One PPD (pack per day) for 25 years; stopped 3 months ago Occasional EtOH, occasional

cocaine (last used yesterday afternoon) No regular exercise; poorly adherent to diet

FH Father died of lung cancer at age 72 Mother has peptic ulcers No early coronary disease

Physical Examination

Appearance Patient is in severe pain

VS BP 165/85 (both arms), RR 22

Neck No JVD, no bruits

Chest No tenderness, clear symmetric breath sounds bilaterally

Heart Apical impulse not displaced; RRR; normal S1/S2; no murmurs, rubs, or gallops

Abdomen Soft, non-distended, nontender, BS (+), no hepatosplenomegaly

Extremities No edema, peripheral pulses 2+ and symmetric

Summarize the case with few keywords

Speaking

Present the case using the keywords above

Use the following flow diagram 47 to support your diagnostic approach

What are potential diagnoses?