case report vocabulary a. Žmegač horvat senior lecturer medical english [email protected]
TRANSCRIPT
CASE REPORT sections
1. Patient info2. Present complaint3. Past medical history4. On exam5. Investigations6. Diagnosis7. Treatment
+ Abbreviations & Acronyms Layout
PATIENT INFO
also: Personal information
e.g. 45-year-old man / male (patient) 52-year-old woman / female (patient)
if relevant: occupation, marital status, children
PRESENT COMPLAINT
presents with complains of (c/o)
arrives/-d at the Emergency Room/Department is/was brought (by an ambulance) admitted to (the) hospital
MEDICAL HISTORY (MH) Immediate medical history / History of the present illness HPI e.g. has been feeling sick for 2 days has vomited repeatedly in the past 5 hours has lost consciousness twice since the morning (Pres. Perfect: linked to the present moment)
Past medical history (if relevant, past tenses) PMH
Family history (if relevant) FHx
Habits: smoking, alcohol, drugs (Present Simple) Allergies: no known allergies NKA
ON EXAM (O/E)
general condition: build, height, weight
vital signs (vs): t p rr BP
alert, oriented to time, place, and person
mucous membranes well perfused, moist
dyspn(o)ea /dyspn(o)eic, eupn(o)ea /eupn(o)eic
thorax and abdomen visually NAD (no abnormalities detected)
ON EXAM (O/E)
Heart: rate & rhythm rubs, gallops, murmurs
Lungs: clear to auscultation rales, ronchi (sg. ronchus), wheezing
Abdomen: soft, (non)tender, normal bowel sounds no palpable masses neg. hepatosplenomegaly neg. abdominal bruits
INVESTIGATIONS (LABS)
CBC, RBC, WBC, PLT, H&Hliver function tests (LFT: AST, ALT, ALP)kidney function tests (UA, lytes, BUN, cr, GFR)chem 7/14 = basic/comprehensive metabolic panelFBG = fasting blood glucose(o)GTT = (oral) glucose tolerance test ABGs = arterial blood gases ESR = erythrocyte sedimentation rate (SED rate)(a)PTT = activated partial thromboplastin timePT = prothrombin time (pro time)
DIAGNOSIS (Dx)
TREATMENT
also: Management Hospital course
proceeded uneventfully
developed complications
discharged/released from hospital ((in)to home care)
ABBREVIATIONS & ACRONYMS: GENERAL pt = patient sx = symptoms dx = diagnosis tx = treatment D/C = discontinue S/P = status post WNL = within normal limits
DNR = do not resuscitate DNI = do not intubate CMO = comfort measures only AMA = against medical advice
ABBR & ACR: HOSPITAL LOCATIONS
ER/ED = emergency room/department OR = operating room ICU/ITU = intensive care/treatment unit CCU = coronary care unit LTC = long-term care PACU = post-anesthesia care unit
ABBR & ACR: ORGAN SYSTEMS
HEENT = head, eyes, ears, nose, and throatRS = respiratory systemCVS = cardiovascular systemGIS = gastrointestinal systemGUS = genitourinary systemCNS = central nervous systemMSS = musculoskeletal system
ABBR & ACR: HEENT
PERRLA = pupils equal, round, reactive to light & accomodation
EMI = extraocular movements intact
ABBR & ACR: CNS
LoC = level of consciousness = loss of consciousness
A&O x 3 = alert & oriented to time, place, and person
CVA = cerebrovascular accident TIA = transient ischemic attack TBI = traumatic brain injury
ABBR & ACR: CVS
RRR = regular rate & rhythmNSR = normal sinus rhythmM/R/G = murmurs/rubs/gallops
CPR = cardiopulmonary resusciationAED = automated external defibrillatorBVM (AmbuBag) = bag valve mask
MI = myocardial infarctionCAD = coronary artery diseaseCHF = congestive heart failuraDVT = deep vein thrombosisAAA = abdominal aortic aneurysmA-fib / AF = arterial fibrillationV-fib / VF = ventricular fibrillation
ABBR & ACR: RS
Lungs CTA = clear to auscultationB/L = bilaterally BS = breath sounds SOB = short of breath
COPD = chronic obstructive pulmonary diseasePE = pulmonary embolismOSA = obstructive sleep apneaARDS = acute respiratory distress syndrome
ABBR & ACR: GIS
ABD = abdomen
BS = bowel soundsBM = bowel movement
N/V = nausea & vomiting
GERD = gastroesophageal reflux diseaseIBS = irritable bowel syndrome
ABBR & ACR: GUS
UTI = urinary tract infection CKD = chronic kidney disease ESRD / ESRF = end-stage renal disease/failure
BPH = benign prostatic hyperplasia PSA = prostate specific antigen
ABBR & ACR: MSS
DTR = deep tendon reflexesROM = range of movement
OA / DJD = osteoarthritis / degenerative joint disease
LAYOUT top right-hand corner: name, year of studies, academic year
minimum 1.5 line spacing !!!
spelling: don’t mix British & American !!!
end of course: original & corrected version stapled together