CASE REPORT vocabulary A mega Horvat Senior Lecturer

CASE REPORT vocabulary A. Žmegač Horvat Senior Lecturer Medical English azmegac@mef. hr

CASE REPORT sections 1. 2. 3. 4. 5. 6. 7. Patient info Present complaint Past medical history On exam Investigations Diagnosis Treatment + Abbreviations & Acronyms Layout

PATIENT INFO o also: Personal information o e. g. 45 -year-old man / male (patient) 52 -year-old woman / female (patient) o if relevant: occupation, marital status, children

PRESENT COMPLAINT o presents with o complains of (c/o) o arrives/-d at the Emergency Room/Department o is/was brought (by an ambulance) o admitted to (the) hospital

MEDICAL HISTORY (MH) o 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) o Past medical history (if relevant, past tenses) PMH o Family history (if relevant) FHx o Habits: smoking, alcohol, drugs (Present Simple) o Allergies: no known allergies NKA

ON EXAM (O/E) o general condition: build, height, weight o vital signs (vs): t p rr BP o alert, oriented to time, place, and person o mucous membranes well perfused, moist o dyspn(o)ea /dyspn(o)eic, eupn(o)ea /eupn(o)eic o thorax and abdomen visually NAD (no abnormalities detected)

ON EXAM (O/E) o Heart: rate & rhythm rubs, gallops, murmurs o Lungs: clear to auscultation rales, ronchi (sg. ronchus), wheezing o Abdomen: soft, (non)tender, normal bowel sounds no palpable masses neg. hepatosplenomegaly neg. abdominal bruits

INVESTIGATIONS (LABS) o o o o o CBC, RBC, WBC, PLT, H&H liver function tests (LFT: AST, 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 o also: Management Hospital course o proceeded uneventfully o developed complications o discharged/released from hospital ((in)to home care)

ABBREVIATIONS & ACRONYMS: GENERAL o o o o pt = patient sx = symptoms dx = diagnosis tx = treatment D/C = discontinue S/P = status post WNL = within normal limits o o DNR = do not resuscitate DNI = do not intubate CMO = comfort measures only AMA = against medical advice

ABBR & ACR: HOSPITAL LOCATIONS o o o 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 o o o o HEENT RS CVS GIS GUS CNS MSS = head, eyes, ears, nose, and throat = respiratory system = cardiovascular system = gastrointestinal system = genitourinary system = central nervous system = musculoskeletal system

ABBR & ACR: HEENT o PERRLA = pupils equal, round, reactive to light & accomodation o EMI = extraocular movements intact

ABBR & ACR: CNS o Lo. C = level of consciousness = loss of consciousness o A&O x 3 = alert & oriented to time, place, and person o CVA = cerebrovascular accident o TIA = transient ischemic attack o TBI = traumatic brain injury

ABBR & ACR: CVS o o o RRR = regular rate & rhythm NSR = normal sinus rhythm M/R/G = murmurs/rubs/gallops o o o CPR = cardiopulmonary resusciation AED = automated external defibrillator BVM (Ambu. Bag) = bag valve mask o o o o 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 o o Lungs CTA = clear to auscultation B/L = bilaterally BS = breath sounds SOB = short of breath o o COPD = chronic obstructive pulmonary disease PE = pulmonary embolism OSA = obstructive sleep apnea ARDS = acute respiratory distress syndrome

ABBR & ACR: GIS o ABD = abdomen o BS = bowel sounds o BM = bowel movement o N/V = nausea & vomiting o GERD = gastroesophageal reflux disease o IBS = irritable bowel syndrome

ABBR & ACR: GUS o UTI = urinary tract infection o CKD = chronic kidney disease o ESRD / ESRF = end-stage renal disease/failure o BPH = benign prostatic hyperplasia o PSA = prostate specific antigen

ABBR & ACR: MSS o DTR = deep tendon reflexes o ROM = range of movement o OA / DJD = osteoarthritis / degenerative joint disease

LAYOUT o top right-hand corner: name, year of studies, academic year o minimum 1. 5 line spacing !!! o spelling: don’t mix British & American !!! o end of course: original & corrected version stapled together