Difference between revisions of "Academic Medicine wiki-based narrative"
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=Active medical problems= | =Active medical problems= | ||
− | <span style="color:red">''This is the core of the medical wiki and could be arranged by subheadings, as here, or across multiple linked pages.</span> | + | <span style="color:red">''This is the core of the medical wiki and could be arranged by subheadings, as here, or across multiple linked pages. Each active problem can be split into multiple sub-headings, such as the diagnosis and treatment subheadings here.</span> |
==[https://ncit.nci.nih.gov/ncitbrowser/ConceptReport.jsp?dictionary=NCI_Thesaurus&version=16.08e&ns=NCI_Thesaurus&code=C4872&key=1825553084&b=1&n=null Breast carcinoma]== | ==[https://ncit.nci.nih.gov/ncitbrowser/ConceptReport.jsp?dictionary=NCI_Thesaurus&version=16.08e&ns=NCI_Thesaurus&code=C4872&key=1825553084&b=1&n=null Breast carcinoma]== | ||
− | + | ===Diagnosis=== | |
+ | ===Treatment=== | ||
==[https://en.wikipedia.org/wiki/Diabetes_mellitus_type_2 Diabetes mellitus type 2]== | ==[https://en.wikipedia.org/wiki/Diabetes_mellitus_type_2 Diabetes mellitus type 2]== | ||
− | + | ===Diagnosis=== | |
+ | ===Treatment=== | ||
==[https://en.wikipedia.org/wiki/Hypertension Hypertension]== | ==[https://en.wikipedia.org/wiki/Hypertension Hypertension]== | ||
− | + | ===Diagnosis=== | |
+ | * Initially noticed to have white-coat hypertension at age 42, developed into hypertension by age 46 per [https://www.aafp.org/afp/2014/1001/p503.html JNC Guidelines] | ||
+ | ===Treatment=== | ||
+ | <span style="color:red">''Note that by linking to the medication list below, details do not necessarily need to be repeated here.''</span> | ||
+ | ====Current==== | ||
+ | *[[#Medications|Lisinopril]], with excellent BP control | ||
+ | ====Previous==== | ||
+ | *Diet and exercise | ||
+ | *HCTZ for 3 years, initially effective but then was no longer working | ||
=Resolved medical problems= | =Resolved medical problems= | ||
==[https://en.wikipedia.org/wiki/Peripheral_neuropathy Peripheral neuropathy]== | ==[https://en.wikipedia.org/wiki/Peripheral_neuropathy Peripheral neuropathy]== |
Revision as of 16:50, 19 June 2018
The purpose of this page is to illustrate how a wiki-based clinical document might appear; the content is based on a series of notes that can found here. These details are derived from the de-identified EHR of a real patient but details have been changed such that any resemblance to a real patient is entirely coincidental.
Note: some of the links below are to external websites such as Wikipedia and the NCI Thesaurus. In a true medical wiki, these external links would likely be replaced with application programming interfaces (APIs), which would enforce HIPAA-compliant authentication and authorization.
Demographics
Note: the linked "Gender" is to a value set that specifies a set of structured choices for gender, as an example of how wiki-based formatting can be linked to structured concepts. Likewise, the "Race" and "Ethnicity" concepts can be linked directly to the CDC Race and Ethnicity Code Set Version 1.0, which is required for certified EHRs. Note also that some versions of wiki software can calculate dates, such as the current age based on DOB (not currently enabled here).
- Patient Name: PatientX
- Gender: Female
- DOB: January 1, 1960
- Race: White (2106-3)
- Ethnicity: Not Hispanic or Latino (2186-5)
- Note that "concept codes" such as 2106-3 do not have to be shown, and can be toggled/hidden.
Active medical problems
This is the core of the medical wiki and could be arranged by subheadings, as here, or across multiple linked pages. Each active problem can be split into multiple sub-headings, such as the diagnosis and treatment subheadings here.
Breast carcinoma
Diagnosis
Treatment
Diabetes mellitus type 2
Diagnosis
Treatment
Hypertension
Diagnosis
- Initially noticed to have white-coat hypertension at age 42, developed into hypertension by age 46 per JNC Guidelines
Treatment
Note that by linking to the medication list below, details do not necessarily need to be repeated here.
Current
- Lisinopril, with excellent BP control
Previous
- Diet and exercise
- HCTZ for 3 years, initially effective but then was no longer working
Resolved medical problems
Peripheral neuropathy
Notice how this problem is linked to the drug that caused it (on a separate page) and to the disease for which it was used.
- Cause: Paclitaxel (Taxol) chemotherapy, given for breast cancer
- Treatment: removal of paclitaxel from the treatment regimen
- Resolution: nearly complete, with some minor residual tingling in the fingertips
Allergies
- Morphine
- Category: Medication
- Reaction: Maculopapular rash
- Level of certainty: Confirmed
Medications
This section illustrates a sortable table, which can be re-arranged by clicking on any of the columns. Notice that each drug name is linked to the structured concept of that drug in the RxNorm ontology, and some indications are linked back to the problem list section of the wiki. Here, aspirin is labeled as an NSAID, which is technically true but may not reflect the prescribed purpose. A user could update this drug class to anti-platelet medication.
Class of drug | Drug | Dose | Route | Frequency | Scheduled or prn | Indication |
---|---|---|---|---|---|---|
Anti-diabetic | Metformin | 500 mg | PO | once per day | Scheduled | T2 DM |
Anti-hypertensive | Lisinopril | 5 mg | PO | once per day | Scheduled | HTN |
NSAID | Aspirin | 81 mg | PO | once per day | Scheduled | Primary prevention of MI/CVA |
Anti-emetic | Ondansetron | 4 mg | ODT | TID | prn | Prevention of CINV |
Family history
- Mother: living, with dementia
- Father: d. of cerebral aneurysm, age 64
- Sister #1: alive and well
- Sister #2: alive and well
Social history
Alcohol
- Occasional drinks
Tobacco
- Former smoker
- Smoked 1/2 PPD x 5 years
- Quit 20 years ago