Terms and Strategies

for Medical Records

Reading and Writing
 Lesson 3
Gastrointestinal Unit
 Gastrointestinal Unit

Learning Goals:
Learning about the signs and symptoms
of a gastrointestinal disease
Reading an admission note
Writing exercise
ESP grammar
Gastrointestinal Unit
Anatomy
 Warm-Up
I. Answer the following questions.
1. Can you identify the location of the epigastric area in your body?
________________________________________________________________
Epigastric area is the area directly above the umbilicus. (The stomach is
located within the sternal angle and the area is known as the epigastric
2. Amy said that she has experienced heartburn (pyrosis). Is heartburn a heart
area.)
problem?
________________________________________________________________
Heartburn is a burning sensation of the stomach.

3. Do you know what GERD is?

GERD stands for gastroesophageal reflux disease.
________________________________________________________________

4. What are the signs and symptoms (S/S) of GERD?

________________________________________________________________
Burning sensation in the esophagus, acid regurgitation, or esophagitis.

5. What would be your advice to a person with GERD?

Rest in a sitting position for 30 minutes after meals, avoid caffeine and
________________________________________________________________
peppermint, avoid food or drink 2 hours before bedtime.
 Warm-Up
II. Write down the meanings of the combining forms.

Combining Form Meaning

esophag/o esophagus
gastr/o stomach
pylor/o pylorus
hepat/o liver
cholecyst/o gallbladder
chol/e gall or bile
choledoch/o choledochus
cholangi/o bile duct
pancreat/o pancreas
 Warm-Up
III. Complete the following chart using the list of combining forms and
organs on the left.
Combining Form Organ
stomat/o mouth
1. jejunum
cheil/o lips
2. gums
3. swallow gingiv/o gums
4. ileum dent/o teeth
5. teeth tongue
lingu/o
6. spleen
7. mouth gloss/o tougue
8. tongue phag/o swallow
9. intestine
splen/o spleen
10. duoden/o
11. gloss/o enter/o intestine
12. cheil/o duoden/o duodenum
jejun/o jejunum
ile/o ileum
 Warm-Up
IV. Complete the following chart with the correct nouns
and adjectives. Listen and repeat.

Noun Adjective
mouth oral
esophagus esophageal
stomach gastric
duodenum duodenal
liver hepatic
pancreas pancreatic
digestion digestive
 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. hepatitis B (HBV)-related liver cirrhosis 9. frequently falling asleep

2. Child B (Child-Pugh stage B) 10. disoriented to time and place
3. ascites 11. weakness of all limbs
4. T2N0M0 hepatocellular carcinoma (HCC) 12. hyponatremia
5. transcatheter arterial chemoembolization 13. high ammonia levels
(TACE) 14. focal neurological lesion
6. pneumonia complicated with hypoxic 15. constipation
respiratory failure
16. diarrhea
7. s/p ET + MV (endotracheal tube insertion
17. dyspnea
and mechanical ventilation application)
18. mild cough with whitish
8. drowsy
sputum
 Pre-Reading

1. hepatitis B (HBV)-related
3. ascites liver cirrhosis
8. drowsy 2. Child B (Child-Pugh stage B)
9. frequently falling asleep 4. T2N0M0 hepatocellular
10. disoriented to time and place carcinoma (HCC)
11. weakness of all limbs 6. pneumonia complicated
12. hyponatremia with hypoxic respiratory
13. high ammonia levels failure
14. focal neurological lesion
15. constipation
16. diarrhea
17. dyspnea 5. transcatheter arterial
18. mild cough with whitish sputum chemoembolization (TACE)
7. s/p ET + MV (endotracheal
tube insertion and
mechanical ventilation
application)
 Reading
Admission Note
Chief Complaint
Change in level of consciousness since this morning

Present Illness
This 63-year-old man has a history of hepatitis B (HBV)-related liver cirrhosis
(Child B) and ascites. He also has T2N0M0 hepatocellular carcinoma (HCC),
previously treated four times with transcatheter arterial chemoembolization
(TACE) with recurrence. He also has hypertension controlled with
antihypertensive agent. He received regular follow-ups at our Metabolic OPD
(outpatient department) and GI OPD and was hospitalized due to pneumonia
complicated with (C/W) hypoxic respiratory failure s/p ET + MV (endotracheal
tube insertion and mechanical ventilation application) on February 17.
 Reading

He was then discharged after his symptoms improved. Back at home, from the
morning of February 23, his son found him drowsy, frequently falling asleep,
disoriented to time and place, and with weakness of all limbs. The patient was
brought to our ER again, where hyponatremia and high ammonia levels were
noted. His son stated that there was no fever or symptoms of focal neurological
lesion, constipation, diarrhea, or dyspnea. However, the patient was found to
have a mild cough with whitish sputum in the ER, and he was admitted for
further evaluation and treatment.
 Reading
Reading Comprehension
Answer the questions. There can be more than one correct answer.

D
______ 1. How many times has the patient been treated for HCC with
transcatheter arterial chemoembolization (TACE)?
A. 1 time B. 2 times C. 3 times D. 4 times

A
______ 2. What medication did the patient take for his hypertension?
A. antihypertensive agent
B. aspirin
C. nonsteroidal anti-inflammatory drugs (NSAIDs) p.r.n.
D. all of the above

A
______ 3. Why was the patient hospitalized on February 17?
A. pneumonia complicated with hypoxic respiratory failure
B. hepatitis B (HBV)-related liver cirrhosis
C. Child B
D. ascites
 Reading

D
______ 4. How did the patient’s son find him on the morning of February 23?
A. drowsy
B. frequently falling asleep
C. disoriented to time
D. all of the above

______
A / D 5. What symptoms were found at the ER?
A. hyponatremia and high ammonia levels
B. fever
C. focal neurological lesion
D. mild cough with whitish sputum
 Reading
Word Bank
 Reading Strategy
I. Skimming Exercise
Quickly read the admission note again and correct these sentences.

1. He receive regular follow-up at our Metabolic OPD and GI OPD.

receive → received follow-up → follow-ups
________________________________________________________________

2. He is then discharged after his symptoms improve.

is → was improve → improved
________________________________________________________________

3. However, the patient was found to have a mild cough with yellowish sputum in
the ER.
yellowish → whitish
________________________________________________________________
 Reading Strategy
II. Scanning for Symptoms
Symptoms are often important information in an admission note. You can
scan (quickly read for specific information) to find the important symptoms in
the passage.

liver
1. This 63-year-old man has a history of HBV-related _______________
cirrhosis
_______________ ascites
and _______________.

hypertension controlled with _______________

2. He also has _______________ antihypertensive agent.

drowsy
3. Back at home, his son found him _______________, frequently
_______________ falling
disoriented weakness

asleep, _______________ to time and place, and with _______________ of

all limbs.
Reading Strategy

suppository
 Grammar Focus
1. how to express time
a period of time in a day • yesterday morning
• this morning
• Monday morning
• Friday evening
a period of time on a specific day • 2/26 morning

2. find + O. + present participle / adj. (active voice)

His son found him drowsy.
His son found him falling asleep frequently.
The nurse found the patient lying on the floor.

3. be found + O. + infinitive / adj. (passive voice)

He was found to have a duodenal ulcer after esophagogastroduodenoscopy
(EGD).
He was found to have been infected by helicobacter pylori (HP).
He was found disoriented to time.
His fecal occult blood test (FOBT) was found positive.
 Grammar Focus

Did you know?

1. PPD = packs per day
2. LMD = local medical doctor
 Tenses and Time Phrases
Fill in the blanks using the most appropriate tenses for the verbs in
parentheses.

1. He ___________
has had esophageal varices bleeding for more than 3 days. (have)

has complained about progressive abdominal distension without pain for

2. He _______________

3 months. (complain)
has been bothered
3. He ____________________ by diarrhea, vomiting, and constipation recently.
(be bother)
was
4. A fever episode _________ noted one month ago, which might be related to
the spontaneous bacterial peritonitis (SBP). (be)
lost / has lost
5. He ____________ more than 10 kgs in 10 days. (lose)
went
6. He _________ to a local medical doctor for help three days ago. (go)
 Tenses and Time Phrases

7. This morning, the 43-year-old male patient ___________

signed the consent form for
the operation. (sign)

was performed
8. The operation ___________________ during the summer of 1987. (perform)

had passed out

9. The patient _________________ by the time the doctor arrived. (pass out)

didn’t have
10. The patient _________________ his right leg amputated until 6 weeks ago.
(not / have)

lasted
11. All of his 4 limbs began to shake. The episode __________ for less than 2
minutes. (last)

pressed
12. During the night shift, the patient ____________ the PCA (patient-controlled
analgesia) machine only once. (press)
 Guided Writing
Fill in the blanks with the following time phrases (A-F). Use each
phrase only once.

A. During the periods D. during the past 6 weeks

B. until 6 weeks ago E. in the past (previously, prior to this admission)
C. periods of 3-to-4 day F. 3 days ago (3 days before, 3 days earlier)

The 75 y/o/f complains of a significant change in her bowel habits

D
(1) _________. Her bowel movements (BMs) were regular (once/day),
B
(2) _________.

C
She experienced (3) _________ constipation alternating with non-bloody
diarrhea. Although most of her bowel movements resulted in formed stools
F
which were brown in color and of normal caliber, (4) _________, she passed a
stool with streaks of blood on the surface.
 Guided Writing

A. During the periods D. during the past 6 weeks

B. until 6 weeks ago E. in the past (previously, prior to this admission)
C. periods of 3-to-4 day F. 3 days ago (3 days before, 3 days earlier)

A
(5) _________ of constipation, she felt bloated and had mild discomfort in
the lower abdomen.

The pain was relieved by defecation.

The patient was not alarmed because she has suffered from bleeding
E
hemorrhoids (6) _________.
 Listening for Fun
I. Listen to the conversation and tick the best answers.
1. What is the patient’s problem?
□ He has low blood pressure.
□ He is suffering from chest tightness.

□ He has passed black stools.

2. What is the patient’s description of his stools?

□ It’s like coffee grounds.
□ bloody and watery
□sticky and malodorous
 Listening for Fun
II. Listen again and answer the following questions.

1. Why is it hard for Mr. Anderson to stick to his plans these days?
Because he gets fatigued very easily.
________________________________________________________________

2. Does Mr. Anderson drink martinis?

Yes. He drinks 2-3 martinis at lunch.
________________________________________________________________

3. Is Mr. Anderson taking any medication?

Yes. He has been taking medication for hypertension for the past 8 years.
________________________________________________________________
 Listening for Fun
III. Listen to the conversation one more time and fill in the blanks.
Doctor: What brought you here?
passed (2) ________
Mr. Anderson: I have (1) ________ black (3) ________
stools for the past
three days. I am wondering if that is why I feel kind of light-
headed these days.

Doctor: Are there any other (4) discomforts

___________?
keep (6) ________
Mr. Anderson: I found that it’s harder for me to (5) ________ up
with
(7) ________ my usual schedule because I get fatigued very
easily.

Mr. Anderson: I have chronic epigastric burning which has been a problem
on
(8) ________ and
(9) ________ off
(10) ________ for the past several
years.

Doctor: What about smoking?

Mr. Anderson: I smoke two packs of cigarettes a day (PPD) over the past twenty
years and have an (11) occasional
__________ cigar.
 Listening for Fun: Audio Transcripts
(D: Doctor M.A.: Mr. Anderson)
D: Are you Mr. Anderson?
M.A.: Yes.
D: What brought you here?
M.A.: I have passed black stools for the past three days. I am wondering if that is
why I feel kind of light-headed these days.
D: Are there any other discomforts?
M.A.: I found that it’s harder for me to keep up with my usual schedule because I
get fatigued very easily.
D: What exactly is the color of the stools you passed?
M.A.: They are not only black but also sticky and malodorous.
D: I see. And do you drink?
M.A.: Yes. I usually drink 2-3 martinis at lunch with clients and have another
cocktail or glass of wine with dinner. Oh yes, and I have chronic epigastric
burning, which has been a problem on and off for the past several years.
D: What about smoking?
M.A.: I’ve smoke two packs of cigarettes a day over the past twenty years and
have an occasional cigar.
D: Are you taking any medication now?
M.A.: Yes. I have been taking medication for hypertension for the past 8 years.
 Vocabulary Building
Study the following chart of doctors and their specialties. What do you call a
doctor who specializes in treating peptic and duodenal ulcers, acid reflux, bowel
disease, and colon cancer?

Specialty Doctor Field

neurology neurologist nervous system diseases
neurosurgery neurosurgeon nerve-related surgery
dermatology dermatologist skin
urology urologist urinary diseases
endocrinology endocrinologist glands of internal secretion
oncology oncologist neoplasms (new growths)
cardiology cardiologist heart
ophthalmology ophthalmologist eye
 Vocabulary Building

Specialty Doctor Field

otorhinolaryngology otorhinolaryngologist ear, nose, and throat
gynecology gynecologist female diseases
pregnancy, birth, and
obstetrics obstetrician
puerperium
geriatrics geriatrician old age
pediatrics pediatrician children
deformities, disorders, or
orthopedics orthopedist
injuries of the skeleton
gastroenterology gastroenterologist
____________________ digestive system
 Appendix
Signs and Symptoms (S/S) 17. frequently falling asleep
1. abdominal cramping pain 18. heartburn
2. abdominal CT 19. hematemesis
3. abdominal distension 20. hiccup (hiccough)
4. abdominal fullness 21. high ammonia levels
5. ascites 22. hyponatremia
6. coffee grounds 23. jaundice
7. constipation 24. melena
8. cramp 25. mild cough with whitish sputum
9. diarrhea (watery diarrhea) 26. nausea
10. disoriented to time and place 27. nausea/vomiting (N/V)
11. drowsy 28. pass bloody stool (bloody stool passage)
12. dyspnea 29. poor appetite
13. emesis 30. postprandial vomiting
14. epigastric pain 31. pyrosis
15. fatigue 32. rebounding pain
16. focal neurological lesion 33. shifting dullness
 Appendix
34. tarry stool 49. panendoscopy (PES)
35. tenderness 50. upper GI series
36. throw up blood clots Diagnosis
37. vomiting 51. adenocarcinoma
38. weakness of all limbs 52. adhesion
39. weight loss 53. appendicitis
Diagnostic Test 54. bowel obstruction
40. abdominal echo 55. Child B (Child-Pugh stage B)
41. endoscopic retrograde 56. cholangitis
cholangiopancreatography (ERCP) 57. cholecystitis
42. endoscopy (endoscopic examination) 58. cholelithiasis
43. esophagogastroduodenoscopy (EGD) 59. enteritis
44. fecal occult blood test (FOBT) 60. erosive esophagitis
45. guaiac test 61. esophageal varices
46. helicobacter pylori (HP) 62. esophagitis
47. laparoscope 63. esophagorrhagia
48. laparoscopy 64. gastritis
 Appendix
65. gastroesophageal reflux disease (GERD) 81. pyloric stenosis
66. hepatic encephalopathy (HE) 82. splenomegaly
67. hepatitis 83. upper GI bleeding
68. hepatitis B virus (HBV) Treatment & Care
69. hepatocellular carcinoma (HCC) 84. abdominocentesis
70. hepatoma 85. antacid
71. hepatomegaly 86. antiemetic
72. ileus (adhesion ileus) 87. appendicectomy
73. intussusception 88. avoid coarse fiber
74. liver cirrhosis 89. blood transfusion (BT)
75. pancreatitis 90. cholecystectomy
76. peptic ulcer disease (PUD) 91. cholelithotomy
77. perforated peptic ulcer (PPU) 92. endoscopic variceal ligation (EVL)
78. peritonitis 93. esophageal variceal ligation treatment
79. pneumonia complicated with hypoxic 94. exploratory laparotomy
respiratory failure 95. hepatic lobectomy
80. polyp 96. hepatorrhaphy
 Appendix
Related Terms
97. ileocolic anastomosis 110. acute pancreatitis
98. intravenous (IV) drip 111. ALK-P
99. laparotomy 112. antihypertensive agent
100. laxative 113. belting position
101. nasogastric (NG) decompression 114. bowel sound
102. nothing by mouth (NPO) 115. chillness
[ Latin nulla per os] 116. cholangiocarcinoma
103. oral hypoglycemic agent (OHA) 117. conscious drowsiness
104. proton pump inhibitor (PPI) 118. dilated intrahepatic duct (IHD)
105. s/p ET + MV (endotracheal tube insertion 119. elevated liver enzyme
and mechanical ventilation application)
120. flatus passage
106. transcatheter arterial chemoembolization
(TACE) 121. generalized weakness

107. transcatheter arterial embolization (TAE) 122. hemogram

108. vasoconstrictor 123. heterogeneous mass lesion

109. vasopressor 124. hyperbilirubinemia

125. hyperlipidemia
 Appendix
126. hypertriglyceridemia
127. IHD dilatation
128. intermittent nausea
129. left hepatic tumor
130. leukocytosis
131. lipase level
132. malaise
133. multiple metastatic lymphadenopathy (LAP)
134. nasogastric tube (NG tube)
135. osmolarity
136. pass gas
137. persistent dull pain
138. stoma
139. thirst sensation
140. thrombocytopenia
141. type II diabetes mellitus (DM)
 Supplementary Reading
Diffused Abdominal Pain
Chief Complaint
Diffused abdominal pain for 3 days

Present Illness
This 54-year-old female had an appendectomy on February 2, 2013. This time,
she suffered from progressive abdominal pain. No fever, diarrhea, nausea, or
vomiting was noted. She visited a local hospital first and then was transferred to
our hospital. In the ER, diffused abdominal pain with moderate rebounding pain
and muscle guarding were noted. Abdominal CT showed mural thickening of the
small bowel (jejunum & proximal ileum) and minimal ascites, but no definite
pneumoperitoneum was seen.
 Supplementary Reading

Enteritis was suspected. Lab data showed WBC 8000, CRP 46 and lipase 28.
Liver function impairment was also noted. General surgery (GS) was consulted,
and no emergent operation was indicated. Abdominal pain improved after NPO
and IV infusion. She was admitted for further evaluation and follow-up
management.
 Supplementary Reading
I. ESP Vocabulary Building
Check the appropriate columns.

Synonym Antonym Family

abdominal / abdomen 
local / general 
progressive / progress 
moderate / extreme 
rebounding / bounding 
suspected / assumed 
 Supplementary Reading
II. Reading Comprehension
Answer the questions.

______
A 1. What did the woman undergo on February 2, 2013?
A. appendectomy B. X-ray
C. gastroscopy D. organ transplant

______
C 2. Which of the following is not one of the patient’s symptoms?
A. muscle guarding B. progressive abdominal pain
C. diarrhea D. diffused abdominal pain

B / D 3. What didn’t the abdominal CT show?

______
A. mural thickening B. pneumoperitoneum
C. minimal ascites D. tumor

______
B 4. What reduced the patient’s abdominal pain?
A. IV infusion B. NPO and IV infusion
C. passing tarry stools D. taking medicine
 Supplementary Reading
III. Cloze Test
Fill in the blanks with the choices provided.

1. This time, she suffered from ______________

progressive abdominal pain.
(suppressive / massive / progressive)

to
2. She visited a local hospital first and then was transferred ______________ our

hospital. (into / to be / to)

diffused
3. In the ER, ______________ abdominal pain with moderate rebounding pain
and muscle guarding were noted. (diffused / diffusing / diffusively)

definite
4. Abdominal CT showed mural thickening of the small bowel (jejunum &
proximal ileum) and minimal ascites, but no ______________
pneumoperitoneum was seen. (definitely / definite / definition)
 Lesson 3
Gastrointestinal Unit
-The End-