Terms and Strategies

for Medical Records

Reading and Writing
 Lesson 5
Endocrine Unit
 Endocrine Unit

Learning Goals:
Learning about the signs and
symptoms of endocrine disorders
Reading an endocrine disorder
admission note
Writing an admission note
ESP grammar
Anatomy
The Endocrine System
Anatomy
 Warm-Up
I. Match the word parts with their meanings.

1. hypo A. eat
2. glyc B. glucose
3. poly C. thirst
4. uria D. low
5. dipsia E. many
6. phagia F. urine
7. retin/o G. kidney
8. pathy H. nerve
9. nephr/o I. retina
10. neuro J. disease
 Warm-Up

Did you know?

OHA:
oral hypoglycemic agent

hypoglycemia:
low blood sugar

hyperglycemia:
high blood sugar
 Warm-Up
II. Listen and repeat.

polyuria hypoglycemia
polydipsia hyperglycemia
polyphagia thrombocytopenia
retinopathy leukocytosis
nephropathy hyperbilirubinemia
neuropathy lymphadenopathy (LAP)
triopathy cholangiocarcinoma
 Warm-Up
III. What do the following combining forms mean?
1. thyroid/o thyroid gland
________________
2. parathyroid/o ________________
parathyroid gland
3. pancreat/o ________________
pancreas
4. oophor/o ________________
ovary
5. adren/o adrenal gland
________________
6. orchid/o testis
________________
(orchi/o)
 Warm-Up
IV. Use the word parts below to make words that mean the following:
1. an increase in the number of white 2. the condition of high bilirubin in
blood cells the blood
3. any disease process affecting lymph
glands

leukocyte -osis -penia hyper -emia bilirubin

lymph/o aden/o -pathy cholangi/o carcinoma

leukocytosis
1._______________________________________________________________

hyperbilirubinemia
2._______________________________________________________________

lymphadenopathy
3._______________________________________________________________
 Pre-Reading
I. Medical Vocabulary from the Main Reading
Do you know which group each of the following terms belongs to? Write
them in the correct boxes below.

1. polyuria 7. HHS 13. ALK-P

2. myocardial infarction (MI) 8. OHA 14. hyperbilirubinemia
3. persistent dull pain 9. acute pancreatitis 15. abdominal echo
4. abdominal distension 10. diabetes mellitus (DM) 16. abdominal CT
5. passing tarry stools 11. compesolon 2# tid
6. lipase level 12. hemogram
 Pre-Reading

1. polyuria 6. lipase level

3. persistent dull pain 12. hemogram
4. abdominal distension 13. ALK-P
5. passing tarry stools 15. abdominal echo
16. abdominal CT

2. myocardial infarction (MI) 8. OHA

7. HHS 11. compesolon 2# tid
9. acute pancreatitis
10. diabetes mellitus (DM)
14. hyperbilirubinemia
 Pre-Reading
II. What does the picture below say about the DM diet?
 Pre-Reading
1. According to the food pyramid, what types of food should be restricted
for a diabetic?

the types on top of the pyramid

2. Can you name three vegetables which are good for DM patients?
broccoli, bananas, carrots

3. How many portions of low-sugar fruits should be eaten daily?

2-4 servings
Pre-Reading
 Pre-Reading
III. Think Before You Read

1. Can you explain the following terms?

a. endocrine system
the glands and parts of glands that produce endocrine secretions, help to integrate
____________________________________________________________
and control bodily metabolic activity, and include especially the pituitary, thyroid,
parathyroids, adrenals, islets of Langerhans, ovaries, and testes

b. ductless glands
a____________________________________________________________
gland (as the thyroid or the pituitary) that produces an endocrine secretion

c. hormone secretion
the production of hormones by part of a plant or animal; hormones produced and
____________________________________________________________
given off by a plant or animal part

d. nerve stimulation
the stimulating action of various agents on nerves by which activity is evoked
____________________________________________________________
 Pre-Reading

e. exophthalmos
abnormal protrusion of the eyeball
____________________________________________________________

f. blurred vision
the inability to see clearly
____________________________________________________________

g. intolerance to cold
the inability to bear the cold
____________________________________________________________

h. restlessness
the state of feeling nervous or bored and tending to move around a lot
____________________________________________________________
 Pre-Reading
2. What symptoms does a patient have when he/she suffers from diabetes
mellitus?
polyphagia, polydipsia and polyuria
________________________________________________________________

3. What are some related diseases that can surface when a patient has poor
control of DM?
retinopathy, nephropathy and neuropathy
________________________________________________________________

4. Are the liver, gallbladder, and the pancreas parts of the digestive tract?
Do they perform any function in digestion?
________________________________________________________________
No.
________________________________________________________________
Yes. The pancreas is a glandular organ that secretes digestive enzymes
(internal secretions) and hormones.

Did you know?

fasting blood glucose
 Reading
Admission Note
Chief Complaint
Poor intake with polyuria for one week

Present Illness
The 69-year-old female patient with a past history of hypertension, myocardial
infarction, and DM without regular control came to our ER on year/month/date
with chief complaint of poor oral intake with polyuria for one week. She was
recently diagnosed with hypertriglyceridemia. She suffered from increased thirst
sensation with generalized weakness and malaise. Conscious drowsiness
was noted by her family. But she denied fever, shortness of breath, or blurred
vision. Her bowel habit was said to be normal. At ER, her blood sugar was above
600 mg/dl, and high osmolarity was noted. So hyperosmolar hyperglycemic state
(HHS) was diagnosed, and IV fluid was given.
 Reading

Then this morning she suffered from upper abdominal pain. It was a dull and
persistent pain which radiated to the back and relieved a little when the patient
bent forward. There was no precipitating factor for her pain, nor was the pain
associated with abdominal distension. She denied chest pain, cold sweating,
nausea, or vomiting. There was no passing of tarry stools either. The result of
lipase level checkup was 1916. Under the impression of HHS with acute
pancreatitis, she was admitted to our ward for further evaluation and
management.
 Reading
Reading Comprehension
Answer the questions. There can be more than one correct answer.

A______
/ C / D 1. The patient has a past history of _____.
A. hypertension B. right paraventricular infarct
C. DM without regular control D. hypertriglyceridemia

A______
/ B / C 2. What signs and symptoms does the patient have?
A. increased thirst sensation B. generalized weakness and malaise
C. conscious drowsiness D. fever and SOB

A / B 3. What signs and symptoms helped the doctor in the diagnosis of

______
hyperosmolar hyperglycemic state (HHS)?
A. blood sugar above 600 mg/dl
B. high osmolarity
C. abdominal pain
D. fever
 Reading
C
______ 4. Which of the following is not correct about the pain?
A. It’s dull and persistent.
B. It radiated to the back.
C. It is due to abdominal distension.
D. It could be associated with acute pancreatitis.

A
______ 5. What treatment was done at the ER?
A. IV fluid
B. OHA
C. chest X-ray
D. diet modification
 Reading
Word Bank

Did you know?

hyperthyroidism s/p subtotal thyroidectomy
• s/p means “status post (post status of)”
 Vocabulary Building
Adjective Endings

Adjectives can be formed in many ways. Knowing the most common adjective
endings can help you identify adjectives and differentiate them from other word
forms.
Did you know?
Look at the following adjectives.
Write down the different adjective r/o hyperthyroidism
endings. • r/o means “to exclude” or “to rule out”
• r/o means something is not an issue
-ive
1. __________ progressive for the case
-ent
2. __________ intermittent
3. __________
-al abdominal What is the purpose of ankle
4. __________
-al exertional brachial index (ABI)?
5. __________ colored • Ankle brachial index (ABI) can be
-ed
-ed
6. __________ elevated used to assess the vascular status of
-ous
7. __________ heterogenous the lower extremities. A normal ABI is
-ed
8. __________ dilated 1 or higher.
 Reading Strategy
Predicting

Before you read, it’s helpful to review what you already know about the topic. This
will help you predict the things you will read about and will increase your
understanding of the reading.

Go back to the Admission Note. Look at the chief complaint. Which

of these things do you think the reading will mention?

1. ______ diabetes 6. ______ DM hx

2. ______ emergency room 7. ______ NPO

3. ______ abdominal echo 8. ______ cancer

4. ______ abdominal CT 9. ______ HHS

5. ______ passing tarry stools 10. ______ blood sugar

 Admission Note Writing
Write an admission note using the following information.

Chief Complaint
Sudden onset of dizziness and right face palsy 1 week ago

Present Illness
1. age: 74 y/o
2. gender: female
3. past history:
a. hx of bronchiectasis, allergic rhinitis, gastritis x 5 years
b. received treatment at Pulmonary OPD
c. sudden onset of dizziness and right face palsy 1 week ago
d. Bell’s palsy noted at Neurologic OPD
e. medication: compesolon 2# tid and kentamin 1# qid
f. DM hx denied
g. (year/month/date) health checkup found fasting hyperglycemia
4. abd. pain: denied
5. BW loss: denied
6. SOB: denied
7. syncope: denied
 Admission Note Writing
8. hand anesthesia: denied
9. vertigo: denied
10. blood sugar 402 mg/dl noted at ER
11. admitted for further management

This 74 y/o female patient had . . . a history of bronchiectasis, allergic

rhinitis, and gastritis for five years. She received treatment at our pulmonary
OPD. She suffered from sudden onset of dizziness and right face palsy 1
week ago and came to our neurologic OPD for help, where Bell’s plasy was
noted. She then received treatment of compesolon 2# tid. and kentamin 1#
qid. D.M hx was denied, but fasting hyperglycemia was noted on
year/month/date during health checkup. She also denied abd. pain, BW loss,
SOB, syncope, hand anesthesia or vertigo. She was sent to our ER for help,
where blood sugar 402 mg/dl was noted. Therefore, she was
. . . admitted for further management.
 Grammar Focus
1. since vs. ago
“Since” is often used with the perfect tense to refer to a starting point of
an action or a situation. It should be placed before the point of time in a
sentence. “Ago” is used with the past tense to indicate when an event
happened, going back from today to the past. It should be placed after
the period of time in a sentence.
She has had progressive poor appetite with general weakness since July.
She suffered from sudden onset of dizziness and right face palsy 1 week ago.

2. during
“During + N.” is used to show at what point in time an event took place.
Fasting hyperglycemia was noted on year/month/date during the health
checkup.

3. , where
“, where” is used in a nonrestrictive relative clause to provide additional
but nonessential information about the antecedent.
She came to our Neurologic OPD for help, where Bell’s palsy was noted.
 Grammar Focus
Fill in the Blanks
Complete the sentences with the choices provided.

since ago during , where

1. Mrs. Hill went to Chang Gung Memorial Hospital ________

, where her husband was

hospitalized. ago
2. His abdominal pain started two hourssince
________.
3. Randy’s father has had polyuria ________ 2010.
4. Amy went out for dinner last night. Unfortunately, she began to feel sick
during
________ the meal. during
5. John read a lot of books and magazines
since ________ his hospitalization.
, where the first day he was hospitalized.
6. John has tried to quit smoking ________
7. Her husband was sent to the ER ________ MRI was done.ago
8. The patient wasago
discharged from the hospital two days ________.
9. Three years ________, he began to suffer from since
high blood pressure.
10. His blood pressure has been under control ________ he started the
medication.
 ESP Grammar

The passive voice is an important feature in the writing of medical records.

Usually the person (i.e. the doctor, the nurse, or the patient) mentioned is
omitted because he or she is not the important information. Also, when you see
a sentence in the passive voice, the subject is very likely to be something
instead of someone. For example:

1. The patient’s vital signs were taken (by the nurse).

2. The operation was done (by the doctor).

3. Discharge teaching was done (by the nurse).

 ESP Grammar
Change the following sentences from the active voice to the passive voice.

1. The doctor corrected the patient’s hyperglycemia with OHA.

Hyperglycemia was corrected (by the doctor) with OHA.
_________________________________________________________________

2. The medication controlled his AC sugar at around 120 mg/dl.

AC sugar was controlled (by the medication) at around 120 mg/dl.
_________________________________________________________________

3. The doctor treated his hypertension with antihypertensive agents.

Hypertension was treated (by the doctor) with antihypertensive agents.
_________________________________________________________________

4. The doctor consulted a neurologist for Bell’s palsy.

A neurologist was consulted (by the doctor) for Bell’s palsy.
_________________________________________________________________
 ESP Grammar

5. The doctor arranged BAEP (brainstem auditory evoked potentials) study to

exclude brainstem lesion.
BAEP (Brainstem auditory evoked potentials) study was arranged (by
_________________________________________________________________
the doctor) to exclude brainstem lesion.

6. She refused thyroid echo and aspiration.

Thyroid echo and aspiration were refused (by her).
_________________________________________________________________

7. The doctor discharged the patient on June 2nd.

The patient was discharged (by the doctor) on June 2nd.
_________________________________________________________________
 Listening for Fun
I. Listen to the conversation and tick □ the best answers.
1. What is the patient’s problem?
□ He has high blood pressure.
□ His blood sugar reading is too low.
□
 His blood sugar reading is too high.

2. What is the most important tool for diabetics?

□ blood pressure meter (sphygmomanometer)
□ Doppler
□ glucometer
 Listening for Fun
II. Listen again and answer the following questions.
B
______ 1. What is the nurse taking for the patient?
A. a random blood sugar test
B. a post meal blood sugar test
C. a fasting blood sugar test

B
______ 2. What is true about a random blood sugar test?
A. A random blood sugar test measures your blood sugar after a meal.
B. A random blood sugar test measures your blood sugar before a meal.
C. A random blood sugar test measures your blood sugar at any time.

A
______ 3. What is a normal post meal blood sugar level?
A. Post meal blood sugar should be controlled under 180 mg/dl.
B. Post meal blood sugar should be controlled under 365 mg/dl.
C. Post meal blood sugar should be controlled under 100 mg/dl.
 Listening for Fun
III. Listen to the conversation one more time and fill in the blanks.
Patient: What’s my blood sugar?
over (2) _______
Nurse: It’s 356 mg/dl. Your blood sugar is (1) _______ the limit
(3) _______.

Do you know what the blood sugar range for diabetic patients after
meals should be?
Patient: I am not quite sure, but I feel fine. result
in
Nurse: You endure it very well, but it is very dangerous. It might (4) _______
under and kidney
(5) _______ eye, nerve, 180 problems. Your blood sugar should

be controlled (6) _______ (7) _______ mg/dl.

Patient: I had no idea about it before this admission.
for education
Nurse: Here is a diabetes diabetics
booklet for you. We have patient education
classes (8) _______ (9) ________ every day. Why don’t you join us?
Patient: All right.
 Listening for Fun: Audio Transcripts

Mr. Bulls, a 64-year-old obese male patient, was admitted to the hospital for blood
sugar control.
Nurse: Mr. Bulls, it’s time to check your post meal blood sugar. I will clean your
skin first.
Patient: Sure.
Nurse: Please take a deep breath. Done.
Patient: What’s my blood sugar?
Nurse: It’s 356 mg/dl. Your blood sugar is over the limit. Do you know what the
blood sugar range for diabetic patients after meals should be?
Patient: I am not quite sure, but I feel fine.
Nurse: You endure it very well, but it is very dangerous. It might result in eye,
nerve, and kidney problems. Your blood sugar should be controlled under
180 mg/dl.
 Listening for Fun: Audio Transcripts

Patient: I had no idea about it before this admission.

Nurse: Here is a diabetes education booklet for you. We have patient education
classes for diabetics every day. Why don’t you join us?
Patient: All right.
Nurse: You are welcome to come see me if you have any problems, or you can
discuss any questions with your diabetic educator.
Patient: I will.
Nurse: You’d better rest now and drink more water while I notify the doctor to
check on you to see if there is a need to change your diet and medicine.
 Progress Note
Put the following terms in the correct spaces below.

A. Right leg pain is getting better D. plasty

B. not icteric E. Right foot necrotizing fascitis
C. Physical therapy F. Diabetes mellitus

Necrotizing Fascitis & Cellulitis

S:
A
(1)_________.

O:
T: 37°C P: 90/min R: 18/min BP: 133/71 mmHg
Vital signs: hemodynamically stable with fever
Consciousness: clear

HEENT:
Conjunctiva: not pale B
sclera: (2) _________
Chest:
Shape: grossly normal, symmetrically expanding
Breathing sound: bilateral coarse with coarse crackles
 Progress Note
A. Right leg pain is getting better D. plasty
B. not icteric E. Right foot necrotizing fascitis
C. Physical therapy
F. Diabetes mellitus
Abdomen: Wound:
Soft and no tenderness Necrosis with extending erythema
Bowel sound: normoactive Painful tender and lumping edema
Post-fasciotomy

A: P:
E (F)
(3) _________ C
(5) _________
Right leg cellulitis Analgesia
Right knee cellulitis r/o septic knee Wound care with sulfasil cream bid
Esophageal stenosis D
Consult (6) _________
F (E)
(4) _________ Check sugar AC PC 3PM 9PM
Hypertension IVF support
 Appendix
Signs and Symptoms (S/S) 17. twitching
1. abdomen distension 18. weight loss
2. diaphoresis Diagnostic Test
3. fatigue (extremely tired) 19. abdominal CT
4. fine hand tremor 20. abdominal echo
5. glucosuria 21. ALK-P
6. hot flush 22. ankle brachial index (ABI)
7. insomnia 23. bone mass measurement
8. lethargy 24. fasting blood sugar (FBS)
9. limb numbness 25. finger stick (F/S)
10. moon face 26. glycosylated hemoglobin (HbA1c)
11. nervous 27. hemogram
12. night sweat 28. lipase level
13. passing tarry stools 29. oral glucose tolerance test (OGTT)
14. persistent dull pain Diagnosis
15. polyuria 30. acromegaly
16. thirsty 31. acute pancreatitis
 Appendix
32. diabetes insipidus (DI) 48. syndrome of inappropriate antidiuretic
hormone (SIADH)
33. diabetes mellitus (DM)
49. thyrotoxic crisis (thyroid storm)
34. diabetic ketoacidosis (DKA)
50. Type 1 (insulin-dependent DM; IDDM)
35. gestational diabetes mellitus (GDM)
51. Type 2 (noninsulin-dependent DM; NIDDM)
36. glycated hemoglobin (GHB)
37. goiter Treatment & Care
38. Graves’ disease 52. above knee amputation (AKA)
39. hyperbilirubinemia 53. below knee amputation (BKA)
40. hyperosmolar hyperglycemic state 54. diet modif ication
(HHS) 55. erythropoietin (EPO)
41. hyperosmolar non-ketoacidosis (HNK) 56. hypophysectomy
42. hyperthyroidism 57. oral hypoglycemic agent (OHA)
43. hypoparathyroidism 58. thyroidectomy
44. hypothyroidism Related Terms
45. menopause 59. ACCU-CHEK glucometer
46. myocardial infarction (MI) 60. bone mineral density (BMD)
47. osteoporosis 61. endocrinologist
 Appendix
62. endocrinology 79. sugar substitute
63. etiology 80. sugar-free
64. exogenous insulin dependency 81. tendency to ketoacidosis
65. inspect (foot)
66. lipoatrophy
67. lipodystrophy
68. nutritionist (dietician)
69. obese
70. obesity or normal weight
71. onset in youth
72. pedometer
73. postpartum
74. pregnancy
75. prescribe
76. progress
77. some endogenous insulin production
78. subtotal thyroidectomy
 Supplementary Reading
Poor DM Control
Chief Complaint
Headache, dizziness, and vertigo for 3 days

Present Illness
This 64-year-old female has had a history of hyperlipidemia and DM for 7 years,
taking oral hypoglycemic agents (OHAs) until recently. She was diagnosed with
DM retinopathy. She has experienced numbness in her left hand for about 3 to 4
years. Her blood sugar control was poor, and her fasting blood glucose ranged
from 200 mg/dl to 400 mg/dl. She noted that her blood sugar was about 400
mg/dl during the past month. About 1 year ago, she started to feel left foot
numbness, and then the numbness also involved her right toes in the past
several months. About 2 months ago, the OHA was switched to insulin due to her
poor blood sugar control. However, she started to experience headaches,
dizziness, vertigo, nausea, vomiting, and general weakness from then on. These
symptoms appeared when she became nervous or angry.
 Supplementary Reading

About 1 week ago, she noted swelling in all four extremities. She also has had
persistent headaches, dizziness, and vertigo for the last 3 days. Her HbAlc was
10. Peripheral arterial pressure was checked. The ankle brachial index (ABI) was
1.32 for the left side and 1.24 for the right. Under the impression of poor DM
control, she was admitted to our ward for further insulin adjustment.
 Supplementary Reading
I. ESP Vocabulary Building
Check the appropriate columns.

Synonym Antonym Family

numbness / numb 
fasting / fast 
nausea / nauseous 
nervous / calm 
extremities / limbs 
persistent / constant 
 Supplementary Reading
II. Reading Comprehension
Answer the questions.

______
C 1. When did the patient start feeling left foot numbness?
A. 7 years ago B. 1 year ago C. 3 years ago
D. when she was diagnosed with DM retinopathy

D
______ 2. Which of the following is true about the patient’s symptoms?
A. Her HbAlc was 100.
B. The ABI was 1.32 for the right side.
C. The ABI was 1.24 for the left side.
D. Her 4 limbs were swollen.

D
______ 3. Which of the following symptoms was not found 3 days ago?
A. headache B. dizziness C. vertigo D. nausea
 Supplementary Reading
III. Cloze Test
Fill in the blanks with the choices provided.

1. This 64-year-old female has had a history of hyperlipidemia and DM for 7

taking
years, _____________ oral hypoglycemic agents (OHAs) until recently.
(takes / took / taking)

2. Her blood sugar control was poor, and her fasting blood glucose
ranged
_____________ from 200 mg/dl to 400 mg/dl. (ranged / ranging / to range)
during
3. She noted that her blood sugar was about 400 mg/dl _____________ the past
month. (under / during / since)
4. About 1 year ago, she started to feel left foot numbness, and then the
involved
numbness also _____________ her right toes in the past several months.
(evolved / revolved / involved)
experience headaches, dizziness, vertigo,
5. However, she started to _____________
nausea, vomiting, and general weakness from then on.
(appear / experience / complain)
 Lesson 5
Endocrine Unit
-The End-