Download Diapositiva 1

GOING TO THE DOCTOR
Prof. Teresita Rojas González
Notes about a clinical history
SURNAME Gretty
AGE
57
FIRST NAMES Marion Thomas
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 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 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
abbreviations
common
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
medical
Substitute the underlined words for 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
excessive sweating
Investigations
Electrocardiography and
echocardiography
heavy effort sports were
prohibited and aspirin was
indicated
Treatment
and
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
cyanosis
paleness
respiratory distress
tachypnea
jaundice
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
inversion/ no other relevant findings on
investigation / TX: aspirin