Re: [Gnumed-devel] vocabulary question - doctors, please speak up

[Richard Terry]

On Wednesday 29 November 2006 02:23, Karsten Hilbert wrote:
> Hi all,
>
> we have so far used the term "health issue" as one of the
> (optional) grouping concepts in GNUmed. I feel we should
> change the label for the concept to something better suited
> to English clinical use.
>
> By "health issue" we mean
>
> - an underlying, fundamental condition
> - of longer-term significance but with
> - either continuous or on-off activity levels
> - much like a past history item (probably identical)
> - which may or may not manifest itself in various body systems
>
> Examples are:
>
> - Crohn's disease
> - acute myocardial infarction
> - appendectomy
> - Diabetes
> - Lupus
> - polytrauma
> - ...
>
> So, often "chronic" diseaese/conditions. Probably identical
> to "past history items".

In AU we tend to think of these as past history 
items/diseases/conditions/problems and list them on active/inactive problem 
lists.

When I'm using an electronic record and the patient comes to see me I'd add 
notes under the headings of say, Hypertension, Depression. I would select the 
condition from their past history list, and say by right mouse clicking on it 
I'd select an option such as 'new contact' or 'add progress notes for 
depression'.

A new undifferentiated problem may be coded as eg Abdominal Pain NOS.

Undifferentiated notes my have no heading or no coding at all in progress 
notes, ie never be linked to anything

IE a paper/html representation of a typical consult may look like:
----------------------------------------------------------------------
Hypertension

BP = 120/70 script tenormin.
-------------------------------------------------------------------------
Depression

Seems stable, things settling at home, has decreased his ssri to 10mg and 
wants to get off it over next couple of months. Discussed in detail.
------------------------------------------------------------------------------------
Abdominal Pain (NOS)

Vague upper abdominal pains, ?colicky, ?related to food, but sometimes
worse with movement, gets a little reflux, possibly loose bowels.
O/E: NAD, 
Dx ? see if dosn't settle for further Ix
--------------------------------------------------------------------------
Now there could be some notes you don't really need to put anywhere:

eg. - next visit - check his BP, and ask about his mums breast cancer.

Next when the patient comes in, this entire sheet is in front of you on the 
page/html so you can see exactly what you did. If you wanted to filter out 
just all the consults for hypertension, you could click over that and just 
display that.



> Now, the term "health issue" is poorly chosen as Ian brought
> me to understand when he attended gnumed.conf.de.

We don't tend to have health issues. We tend to group other non-medical things 
also on the problem list.


Richard

> In German we use "Grunderkrankung" which means "basal/
> fundamental/ primary/ constitutive afflication".
>
> What do native speakers think we should use ? Just stick to
> "past history item" ?

>
> BTW, "Fundamental Freedoms" as in Human Rights are
> "Grund-Rechte" (Fundamental Rights) in German - just
> like "Grund-Erkrankung".
>
> constitutive
> constitutional
> constituing
> primary
> primal
> prime
> underlying
> basic
> basal
> base
> fundamental
> seminal
> elemantary
> essential
> material
>
>
> Karsten