GOING TO THE DOCTOR Prof. Teresita Rojas González

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 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 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 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 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. (GP) (ENT) (c/o) (DD) (O/E)

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.

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 Symptoms Nausea, dizziness and excessive sweating Investigations Investigations Electrocardiography and echocardiography Treatment Treatment heavy effort sports were prohibited and aspirin was indicated Find the missing information in the case presented before

Provide the missing information according to the video Physical examination: Respiratory rate: Heart rate: Rest of physical examination: Symptoms of neonatal infection: poor vitality tachycardia tachypnea poor vitality tachycardia tachypnea cyanosis paleness jaundice cyanosis paleness jaundice respiratory distress respiratory distress normal 136 beats per minute normal

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