Transcript HUPE-IATEFL-TESOL CONFERENCE Opatija, April 2011

CASE REPORT vocabulary
A. Žmegač Horvat
Senior Lecturer Medical English
[email protected]
CASE REPORT sections
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Patient info
Present complaint
Past medical history
On exam
Investigations
Diagnosis
Treatment
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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)
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CBC, RBC, WBC, PLT, H&H
liver function tests (LFT: AST, ALT, ALP)
kidney function tests (UA, lytes, BUN, cr, GFR)
chem 7/14 = basic/comprehensive metabolic panel
FBG = fasting blood glucose
(o)GTT = (oral) glucose tolerance test
ABGs = arterial blood gases
ESR = erythrocyte sedimentation rate (SED rate)
(a)PTT = activated partial thromboplastin time
PT = 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
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pt = patient
sx = symptoms
dx = diagnosis
tx = treatment
D/C = discontinue
S/P = status post
WNL = within normal limits
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DNR = do not resuscitate
DNI = do not intubate
CMO = comfort measures only
AMA = against medical advice
ABBR & ACR: HOSPITAL
LOCATIONS
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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
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HEENT = head, eyes, ears, nose, and throat
RS
= respiratory system
CVS
= cardiovascular system
GIS
= gastrointestinal system
GUS
= genitourinary system
CNS
= central nervous system
MSS
= 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
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RRR = regular rate & rhythm
NSR = normal sinus rhythm
M/R/G = murmurs/rubs/gallops
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CPR = cardiopulmonary resusciation
AED = automated external defibrillator
BVM (AmbuBag) = bag valve mask
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MI = myocardial infarction
CAD = coronary artery disease
CHF = congestive heart failura
DVT = deep vein thrombosis
AAA = abdominal aortic aneurysm
A-fib / AF = arterial fibrillation
V-fib / VF = ventricular fibrillation
ABBR & ACR: RS
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Lungs CTA = clear to auscultation
B/L = bilaterally
BS = breath sounds
SOB = short of breath
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COPD = chronic obstructive pulmonary disease
PE = pulmonary embolism
OSA = obstructive sleep apnea
ARDS = acute respiratory distress syndrome
ABBR & ACR: GIS
 ABD = abdomen
 BS = bowel sounds
 BM = bowel movement
 N/V = nausea & vomiting
 GERD = gastroesophageal reflux disease
 IBS = 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 reflexes
 ROM = 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