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Case Report

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Perez Martinto
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13 views21 pages

Case Report

Uploaded by

Perez Martinto
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPT, PDF, TXT or read online on Scribd
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Notes about a clinical history

SURNAME Gretty FIRST NAMES Marion Thomas

AGE 57 MARITAL STATUS Single

OCCUPATION Junior High Teacher

REASON FOR ADMISSION


Refers frontal headaches, some fever two days ago

O/E: HS normal P 78/min BP 175/130

IMMEDIATE PAST HISTORY


Suffered from hepatitis when younger
Mother died of CA
A Case Presentation is a formal
communication between health care
professionals (doctors, pharmacists,
nurses, therapists, nutritionists, etc.)
regarding a patient's clinical information.
Identification

Reason for consultation/admission

Chief complaints (CC) - what made


patients to seek medical attention.

History of present illness (HPI) -


circumstances relating to chief
complaints.
Past medical history (PMH)

Past surgical history (PSH)

Current medications

Allergies

Family history (FH)

History of present illness (HPI)


Physical examination (PE)

Laboratory results (Lab results)

Other investigations (imaging, biopsy


etc.)

Diagnosis (Dx)

Management plans or treatment (TX)

Follow up
What is your name?

What brought you to my office today?

What is your main complaint?

Have you suffered from any disease ?

Have you undergone a surgery before?


Are you taking any medication?

Do you suffer from any type of allergy?

Has anyone in your family suffered from


any disease?
What did you find on the physical exam?

Can you give details about the lab


results?

Did you order other investigations?

What is the most likely diagnosis?

What is the treatment in this case ?

Do you have to see the patient again?


BP
Bachelor of Pharmacy
Birthplace
Body Part
Boiling Point
Bronchopulmonary

Blood pressure
Examples of common medical
abbreviations

A & W - alive and well


c/o - complains of
DD – dangerous drugs
O/E – on examination
GP - General Practitioner (UK)
ENT – ear, nose and throat
TX – treatment
Substitute the underlined words with the
corresponding abbreviations

A 20-year-old boy was referred by the


General Practitioner to the
otorhinolaryngologist because he
complained of a severe sore throat. He
is not allergic and has no history of
taking dangerous drugs. On
examination, there were no other
significant findings.
Substitute the underlined words for the
corresponding abbreviations

A 20-year-old boy was referred by the


General Practitioner (GP) to the
otorhinolaryngologist (ENT) because he
complained of (c/o) a severe sore throat.
He is not allergic and has no history of
taking dangerous drugs (DD) . On
examination, (O/E) there were no other
significant findings.
Case presentation

A 30 year old football player came to the


Emergency Room( ER) with a terrible pain
at the front part of his chest followed by
spreading to the back and arms. Nausea,
dizziness and excessive sweating were
also present. Some investigations were
performed and he was admitted to the
coronary intensive care unit.
The patient recovered from chest pain
and was referred to our clinic to undergo
coronary angiography.
Patient´s history was normal except for
smoking. We knew that he had played
football since he was a kid but the day of
admission he had started playing without
warm- up exercises.
His family history included no risk
factors regarding coronary artery
disease. His BP was 120/70 , pulse was
88 beats /min and the other findings
were normal.
Electrocardiography showed ST
segment elevation on anterior leads and
T negative, echocardiography detected
minor aneurism in the left ventricular
apex.
Sports requiring heavy effort were
prohibited and the patient was
discharged with prescriptions of
acetylsalicylic acid (ASA) 300 mg
every day. At the follow-up visit
three months later he had no
complaint.
Find the missing information in the case
presented before

Chief complaint

Symptoms

Investigations

Treatment
Find the missing information in the case
presented before

Chief complaint a terrible pain at the front


part of his chest
Symptoms Nausea, dizziness and
excessive sweating
Investigations Electrocardiography and
echocardiography
Treatment heavy effort sports were
prohibited and aspirin was
indicated
Provide the missing information
according to the video
Physical examination:
Respiratory rate: normal
Heart rate: 136 beats per minute
Rest of physical examination: normal
Symptoms of neonatal infection:
poor vitality tachycardia tachypnea
cyanosis paleness jaundice
respiratory distress
Use the information below and be
ready to present a case

40 - year – old taxi driver/ CC severe


chest pain radiating to back and neck /
BP: 140/90, pulse: 95/min / ECG: ST
segment elevation and T wave invertion/
no other relevant findings on
investigation / TX: aspirin

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