- •Case history/medical documentation
- •I.Basic Parts of Case History
- •II.Taking Medical History
- •III.Medical Examination
- •IV.Abbreviations Used in Clinical Notes
- •V.Medical Kits
- •VI.Reading Medicine Labels
- •VII.Practising Medicine – Case History
- •VIII.Practising Medicine: Case Report
- •IX.Medical Record
- •X.Problem Solving
IV.Abbreviations Used in Clinical Notes
Match the notes given in the Case History on the left with their meanings on the right:
A)
F 29 yrs Overactive thyroid 10 yrs ago Stomach trouble Depressed 1 yr. Librium. Sleepy. Wt 2010 – 9 st 2011 – 8 st 1 lb Bowels – constipated Periods – reg; 1 child (5yrs) Family: 1S+1B, AW O/E – rather staring eyes Thyroid palpable, enlarged 3-4 cm No tremor CVS: P – 72 reg Ht – not enlarged Ht sounds – N BP – 120/80 CNS: Reflexes not exaggerated |
pulse alive and well weight years regular central nervous system brother stone (6,34 kg) normal cardiovascular system on examination blood pressure female sister centimeters heart pound (453,6 grams) |
B)
Mr.Johnson, 35 с/o ankle swelling SH married with 1 daughter 25 cigs/day 50 units alcohol/week PH n/i FH father d. 42 MI mother a&w OE obese P – 110/min reg BP – 100/60 Ht sounds - N CXR enlarged Ht Ds.: MI |
normal diagnosis on examination Social History regular no information heart died minutes complains of alive and well Past History cigarettes chest X-ray Family History blood pressure myocardial infarction pulse |
C)
M born nocte 3 a.m. DOB – 11/11/2011 ND SH unfavourable Para.6+5 BWt – 3050g HS&HR – norm ENT: standard measures of treatment GIS: normal stool
|
normal delivery birth weight ear-nose-throat full term pregnancies 6, abortions 5 heart sounds gastro-intestinal system grams male ante-meridiem heart rate Social History at night date of birth |
V.Medical Kits
Compose a suitable medical emergency kit for:
home;
car;
travel.
(Some items may be used for different kits)
(Add some individually required remedies!)
Sterile gauze dressing Cotton applicators Thermometer Aspirin Iodine Petroleum jelly Distilled water Rubbing alcohol Cough syrup Cups Splint Honey Activated charcoal Paracetamol Salt Baking soda Hemostyptic pencil Painkillers Pair of scissors Medical gloves Eye drops Adhesive plaster Mustard plaster Brilliant green solution Manganese crystals Disposable syringes Pump oxygenator Blood pressure measurement apparatus Enema syringe Purgative medicine Antiemetic medicine Hematogen Vitamin C Bandage Earplugs Cloth tourniquet Validol Nasal drops |