- •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)
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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)
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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)
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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
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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!)
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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 |
VI.Reading Medicine Labels
Match A and B to understand the information medicine labels contain:
1)
|
A |
B |
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KORPEX Relieves coughs, fever, headaches Aspirin, coriniol, hexaperon Wonder Drugs, USA 2 tablets every 3 hours KORPEX tablets can be chewed or swallowed No more than 10 tablets daily over a 1-week period Not advisable for pregnant women May cause drowsiness |
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2)
|
A |
B |
|
Apply 1-2 times daily, continuing for 2-3 weeks after lesions have healed Occasional local irritation and hypersensitivity reactions include mild burning sensation, erythema, and itching, rare blistering; treatment should be discontinued if these are severe Fungal skin infections SULKANAZOLE NITRATE Extraderm, Hungary Contact with eyes and mucous membranes should be avoided |
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3)
|
A |
B |
|
Anti-viral throat spray as a part of complex therapy ANAFERON KID SPRAY No registed cases of overdosage Is not used for infants under 1 month The recommended scheme requires 3-5 times a day usage Interferon gamma antibodies White colour can (contains colourless liquid with pleasant smell) with a special spray tube “MateriaMedCompany”, Moscow, Russia |
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Think up a medicine label of a drug used for the treatment of:
Heart failure;
Diarrhea;
Headaches.