GUIDE TO CASE PRESENTATION

Summary report of the essential aspects contained in the dialogue based

on the following questions
•  What is the age and sex of the patient?
My case is a . year old man/ woman, boy/ girl.
I' m reporting the case of a.
I have a patient of . years. It's a man/woman
I would like to report a case. It's a man/woman/boy/ girl aged.
• Why did the patient come to hospital?
He/she came to hospital to see me because he/she had/was feeling/has had.
This patient told me that he/she.
The reason this patient came was.
 
•  What were the patient's symptoms?
When I questioned the patient I could see/ notice/ know that he/she had.
The patient had the following symptoms.
 
•  What diseases have the patient suffered from?
This patient has suffered from . which he had a treatment of.
In his/her family there is a history of.
He/she has been healthy all his/her life.
 
•  What medication has the patient been prescribed for the disease(s) he/she
suffered from?
H e /she took/ has not taken/ didn't take/ doesn't take any medication
He/ s he is allergic to.
 
•  What are the patient's habits?
He/she usually/ often/ sometimes/ never.
He/she doesn't.
 
•  What aspects did you find on the physical examination?
When I examined him/her I found/ noticed.
On the physical exam I could see / find.
He/she suffers from. / does not suffer from any disease.
He/she seems very healthy/ he/she appears to be healthy.
 
•  What is your diagnosis?
According to what I have presented/ stated. I think He/she should/must .have.
My treatment is.
I prescribed/ suggested/ indicated him/ her to.
 
•  What is your prognosis?
The prognosis is reserved/ good if the patient follows the treatment because.
 
•  What tests and medications did you indicated the patient for the present
illness?
I prescribed .because I think/ consider that the most likely diagnosis is . and the
chances/ the possibilities/ possibility to overcome/ get over/ recover from the
disease is/ are . if he/she.because.
 

11. Describe the possible complications in case he/she doesn't follow the
treatment.
 

 
SOAP Examples
Example #1
S: 9 y/o Hispanic male c/o "hives and itching on his feet and hands." Mother
reports she first noticed rash on his buttocks 2 days ago. The following morning
the hives had spread to the back, chest, and legs. The rash is a raised red
vesicle on an erythematous base. That evening his itching intensified with
swelling to the feet and hands. He received a baby aspirin 2 days ago after
falling from his bike and skinning his knee. He is allergic to ceclor, but mother
reports he has not recently been on any antibiotics. He currently is taking
Guianfed PD and Rynatan for allergies to mold and dust. He denies any SOB or
chest tightness in his throat.
O: General: 98-88-18 104/78. Alert, well nourished 9y/o with extensive hives
covering most of his body.
Skin: Confluent wheals over trunk of his body. Skin is warm to touch with good
turgor. He reports rash is improving, less red, no new lesions
Mouth/throat: Mucosa pink, no erythema, lymphadenopathy
Chest: Lung sounds CTA
Heart: RRR
A: resolving urticaria probably as a result of allergic reaction to unknown
substance.
P: Diagnostic plan: none
Therapeutic plan: Benadryl elixir q 4-6 hours for itching
Education plan: no aspirin or aspirin containing product should be administered
to child.
Return to clinic 2 days

 
SOAP Example 2
S: 20 y/o secretary with an itchy rash on her left hip of 5 days duration. The site
consists of a 4-cm annular lesion.
O: Has made no changes in laundry detergents or bath soaps. Denies exposure
to irritants.
 
SOAP Example 3
S: 80 y/o woman c/o "feeling tired all the time" and SOB on exertion. She
reported not being able to work as long as she used to. She has had these
symptoms for four weeks. She has been in generally good health up until now.
Denies HTN, cardiac or respiratory problems.
O: General: Alert and oriented, obese female. 98-78-26 110/50
Skin: pale. warm, and dry. No cyanosis
Chest: RR=26 and regular, appears SOB
Trachea midline
Lung sounds: crackles bases bilaterally
Heart rate 94 irregular
Extremities: 3+ pitting pedal edema
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Taking a Medical History
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Basic's: Allow the patient to talk. Do not interrupt. When patient is finished then
ask open ended type questions. Always ask: Is there anything else?
There are many methods and guides used for history taking and as time goes
by you will develop your own style. Below are examples of a Medical History:
Classical Medical History
1. Chief Complaint: chronological narrative of problem.
1. onset
2. quality
3. severity
4. timing (duration, frequency)
5. what makes worse/better
6. associated manifestations
2. Past Medical History
1. general state of health
2. childhood illnesses
3. immunizations
4. adult illnesses
5. psychiatric illnesses
6. surgeries
7. injuries
8. hospitalizations
9. ALLERGIES

3. Current Medications
4. Diet
5. Sleep Pattern
6. Habits
1. smoking
2. dipping
3. ETOH intake
7. Family History
1. HTN
2. TB
3. HA
4. Stroke
5. heart disease
6. diabetes
7. mental illness
8. Psychosocial History
1. life style, home situation, significant others
2. school
3. job
4. financial
5. recreation
9. Review of Systems
1. General
1. usual weight
2. weight change
3. weakness, fatigue, fever
2. Skin
1. rashes
2. lumps
3. itching
4. dryness
5. color changes
6. hair and nails
3. Head
1. HA
2. head injury
4. Eyes
1. vision
2. corrective lens use; type
3. last eye exam
4. pain
5. redness
6. tearing
7. double vision
5. Ears
1. hearing
2. tinnitus
3. vertigo
4. pain, earache
5. infection
6. discharge
6. Nose & Sinuses
1. frequent colds, nasal stuffiness
2. hay fever, atopy
3. nosebleeds
4. sinus trouble
7. Mouth & Throat
1. teeth and gums
2. last dental exam
3. sore tongue
4. frequent sore throat
5. hoarseness
8. Neck
1. lumps in neck
2. pain
9. Breasts
1. lumps
2. nipple discharge
3. pain
4. self-exam
10. Respiratory
1. cough
2. sputum (color, quantity)
3. hemoptysis
4. wheezing
5. asthma
6. bronchitis
7. pneumonia
8. TB, last PPD
9. pleurisy
10. last CXR
11. Cardiac
1. heart trouble
2. HTN
3. rheumatic fever
4. heart murmurs
5. dyspnea/orthopnea
6. edema
7. chest pain/palpitations
8. last EKG
12. Gastrointestinal
1. trouble swallowing
2. heartburn
3. appetite
4. nausea
5. vomiting
6. vomiting blood
7. indigestion
8. frequency of BM's, last BM, change in habit
9. rectal bleeding or tarry stools
10. constipation
11. diarrhea
12. abdominal pain
13. food intolerance
14. excessive belching or farting
15. hemorrhoids
16. jaundice, liver or gall bladder trouble, hepatitis
13. Urinary
1. frequency of urination
2. polyuria
3. nocturia
4. dysuria
5. hematuria
6. urgency, hesitancy, incontinence
7. urinary infections and STD's
8. stones (renal calculi)
14. Genito-reproductive
1. MALE
1. discharge from or sores on penis
2. STD hx and treatment, Last HIV test
3. hernias
4. testicular pain or masses
5. frequency of intercourse, libido, difficulties
2. FEMALE
1. 1st menarche, regularity, frequency
2. flow duration, amount
3. bleeding between periods or after intercourse
4. last PAP, results
5. number of pregnancies, deliveries, abortions
(spontaneous & induced)
6. STD's hx and treatments, Last HIV test
15. Musculoskeletal
1. joint pain/stiffness, arthritis, backache.
(describe location and swelling, redness, pain, weakness,
ROM)
2. past injuries, treatments
16. Neurologic
1. fainting, blackouts, seizures, paralysis, weakness,
numbness, tingling, tremors, memory
17. Psychiatric
1. mood, affect
2. nervousness, tension, depression
3. past care
18. Endocrine
1. thyroid trouble
2. heat or cold intolerance
3. excessive sweating, thirst, hunger, urination
4. diabetes
19. Hematologic
1. anemia
2. ease of bruising, bleeding
3. past transfusions and any reactions
ANOTHER FASTER WAY TO TAKE A MEDICAL HISTORY IS BY USING THE
KEY WORD "SAMPLE PQRST"
S: Symptoms
A: Allergies
M: Medicine taken
P: Past history of similar events
L: Last meal
E: Events leading up to illness or injury
P: Provocation/Position - what brought symptoms on, where is pain located.
Q: Quality - sharp, dull, crushing etc...
R: Radiation - does pain travel
S: Severity/Symptoms Associated with - on scale of 1 to 10, what other
symptoms occur
T: Timing/Triggers - occasional, constant, intermittent, only when I do this.
(activities, food)
EXAMPLE:
S) 21 y/o male c/o sore throat. No known allergies. Taking no meds. Have
approx (2) ST per year. Eating and drinking normally. Was fine until
yesterday morning when woke up with ST. Denies fevers, chills, sweats,
SOB, & HA.
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COMMON LATIN ABBREVIATIONS
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WORD/PHRASE ABBREVIATION MEANING
Ad Ad Up to
Ana aa Of each
Ante ciboa a.c. Before meals
Aqua Aq Water
Aures utrae a.u. Each ear
Aurio dextra a.d. Right ear
Aurio laeva a.l. Left ear
Bis in die b.i.d. Twice a day
Capsula Caps. Capsule
Composit us Comps. Compounded
Cum c With
Et ----- And
Gutta Gtt A drop, drops
Hora somni H.S. At bedtime
Non repetatur Non rep. Do not repeat
Oculo utro O.U. Each eye
Oculo dexter O.D. Right eye
Oculo sinister O.S. Left eye
Per os p.o. By mouth
Post cibos p.c. After meals
Pro re nata p.r.n. When necessary
Quaque q. Each, every
Quantum satis Q.S. As much as is sufficient
Quarter in die q.i.d. Four times a day
Semis ss A half
Sine s Without
Statim Stat. Immediately
Tabella tab Tablet
Ter in die t.i.d. Three times daily
Ut dictum Ut Dict. As directed
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EXPLORACIONES COMPLEMENTARIAS
 
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Exploraciones del aparato Gastro intestinal tract
Digestivo investigations
   
Tubo digestivo Alimentary tract
Examen de las heces Examination of the faeces
E xamen microscópico Microscopic examination
Células de pus Pus cells
Hematíes Red blood cells
Examen parasitológico Ova/parasites
Cultivo Culture
   
Análisis químico Chemical examination
Sangre oculta en las he Occult blood in the faeces
Grasa fecal Faeces fats
   
Examen Radiológico Radiology
   
Radiografías simples de abdomen Plain radiographs of the abdomen
   
En bipedestación Erect
En decúbito Supine
   
Tránsito esofagogastroduodenal Barium meals
   
Enema baritado Barium enema
   
Angiografía Angiography
   
Examen endoscópico Endoscopic examination
   
Gastroscopía Gastroscopy
   
Rectoscopía Proctoscopy
   
Sigmoidoscopía Sigmoidoscopy
   
Colonoscopía Colonoscopy
   
Biopsia Biopsy
   
Hígado Liver
   
Pruebas funcionales hepáticas Liver function test
   
Bilirrubina total Total bilirubin
   
Bilirrubina directa Direct bilirubin
   
Fosfatasa alcalina Alkaline phosphatase
   
Gamma-GT Gamma-GT
   
Proteína sérica Serum protein
   
Albúmina Albumin
Globulina Globulin
   
Tranasaminasas séricas Serum aminotransferase
SGOT (ASAT) AST
   
SGPT (ALAT) ALT
   
Colesterol sérico Serum cholesterol
   
Tiempo de protrombina Prothrombin time
   
Hierro sérico Serum iron
   
Otros exámenes biológicos Others
Alfafetoproteína Alpha fetoprotein
Antígeno superficial de la hepatitis B Hepatitis B surface antigen
   
Gammagrafía Isotope scan
Ecografía Ultrasound scan
TAC CAT scanning
Punción-biopsia hepática Needle biopsy of liver
   
Vesícula y vías biliares Gall-bladder and bile ducts
   
Exámen radiológico
Radiological examination
Colecistografía oral
Oral cholecystography
Colangiografía intravenosa
Intravenous cholangiography
Colangiopancreatografía
Endoscopic retrograde
endoscópica
cholangiopancreatography
retrógrada
 
 
Colangiografía transhepática
Percutaneous transhepatic cholan.
percutánea
 
 
Páncreas Páncreas
   
Exámenes biológicos Biology
Amilasa sérica Serum amilase
Lipasa sérica Serum lipase
Prueba de tolerancia a la glucosa Glucose tolerance test
   
Exploraciones del aparato Respiratory system
respiratorio investigations
   
Examen de esputos Examination of the sputum
   
Examen directo Direct examination
Tinción de Gram Gram stain
   
Cultivo y antibiograma Culture and sensitivity
   
Búsqueda del bacilo de Koch Examination for AAFB
   
Citología Cytology
Búsqueda de celulas malignas Examination for malignant cells
   
Pruebas de sangre Blood test
Hemograma completo Full blood count and differential
Hemocultivos Blood culture
   
Examen de la pleura Examination of the pleura
   
Punción pleural Pleural aspiration
Bioquímica del líquido pleural Biochemestry of the pleural fluid
Trasudado Transudate
Exudado Exudate
Biopsia pleural Pleural biopsy
   
Pruebas intradérmicas Intradermal test
   
Prueba de la tuberculina Tuberculin test
   
Prueba de Kweim Kweim test
   
Pruebas alérgicas cutáneas Skin sensitivity test
   
Pruebas de función pulmonar
Lung function test
Espirometría
Spirometry
Capacidad vital
Vital capacity
Volumen espiratorio máximo en 1
Forced expiratory volume at 1 sec
seg
Blood gases
Gases en sangre
 
 
Examen radiológico Radiology
Rx de tórax Chest X -ray
Anteroposterior Posterior- anterior view
Laterales Lateral view
Tomografía Tomography
Angiografía pulmonar Pulmorary angiography
Broncografía Bronchography
   
Grammagrafía pulmonar Radionucleide lung scanning
Gammagrafía de ventilación Lung ventilation scan
Gammagrafía de perfusión Lung perfusion scan
   
Broncoscopia Bronchoscophy
   
Lavado broncoalveolar Bronchoalveolar lavage
   
Exploraciones del aparato Cardiovascular system
ardiovascular investigations
   
ECG Stress ECG
ECG en reposo Resting ECG
ECG de esfuerzo Electrocardiogram
   
Enzimas cadíacas Cardiac enzymes
   
CPK CPK
LDH LDH
SGOT(ASAT) AST
   
Ecocardiografía Echocardiography
Doppler Doppler cardiography
Arteriografía coronaria Coronary arteriography
Fonocaria Pus cells
   
Análisis de sangre Blood test
Urea Urea
Creatinina Creatinine
Electrólitos Electrolytes
Na Sodium
K Potassium
Ca Calcium
   
Aclaramiento de creatinina Creatinine clearance
   
Ex. Radiológico Radilogy
Rx. Simple de abdomen Plain film of the abdomen
Urografía intravenosa Excretion urography
Cistografía miccional Micturating cystography
   
Cistoscopia Cystoscopy
Biopsia renal Renal biopsy
   
Exploraciones del aparato genital Gynecological investigations
   
Pruebas de embarazo Pregnancy test
Frotis cervical Cervical smears
Dilatación y legrado Dilatation and curettage
Histerosalpingografía Histerosalpingography
Laparoscopia   Laparoscopy
Biopsia cervical Biopsy of the cervix
   
Exploraciones del sistema neurológico
 
  Fundi
Fondo de ojo
Lumbar puncture
Punción lumbar
Examination of the cerebrospinal
Ex. Del líquido cefalorraquídeo
fluid
 
 
Aspecto Appearance
Citología Cell count
Proteínas Protein
Glucosa Glucose
Bacteriología Bacteriology
Serología Serology
   
Neurorradiología Neuroradiology
Rx. De cráneo Skull X-ray
Rx. De columna Radiographs of the spine
Mielografía Myelography
Resonancia magnética nuclear Magnetic resonance imaging
   
EEG Electroencephalogram
Electromiograma Electromyogram
Potenciales evocados Evoked potentials recording
   
Exploraciones del aparato
Locomotor system investigations
locomotor
 
 
Artroscopia Arthroscopy
Biopsia ósea Bone biopsy
   
Exploraciones endocrinológicas Endocrine investigations
   
Niveles plasmáticos Plasma levels
Glucosa Glucose
   
Exploraciones hematológicas Haematological investigations
   
Hemograma completo  
Hb Full blood count
Hematíes Haemoglobin
Hto Red blood cells
Volumen corpuscular medio Haematocrit
Concentración de Hb Mean corpuscular volume
corpuscular medi Mean corpuscular Hb
Reticulocitos Concentration
Leucocitos Reticulocytes
Diferencial White blood cells
Neutrófilos Differential
Eosinófilos Neutrophils
  Eosinophils
Basófilos Basophils
Linfócitos Lymphocytes
Monocitos Monocytes
Plaquetas Platelets
   
Eritrosedimentación Erythrocyte sedimentation rate
Fe sérico Serum iron
Ferritina Ferritin
B12 sérica Serum B12
Folato Folate
Coagulación Coagulation
   
Tiempo de protombina
Prothrombin
Tiempo de tromboplastina parcial
Partial thromboplastin time
Fibrinógeno
Fibrinogen
Productos de degradación de la
Fibrin degradation products
fibrina
Bone marrow aspiration
Mielograma
 
 
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English For Medicine
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HISTORY TAKING: PAIN
The doctor often begins by inviting the patient to describe the pain in his her
own words. For example, "Tell me about the pain". However, if the patient
doesn't provide all the information the doctor needs, he may asks specific
questions.
 
Site Where is it?/Show me where the pain is
Radiation Does it go anywhere?/Does it stay in that one place?
Character What is it like?/What kind of pain is it?/Is it sharp?
Severity How bad is it?/What do you do when it comes?
Do you have to stop what you are doing?
Time of onset When did you first notice it?/When did it begin?
Type of onset Did it come on suddenly or gradually?
Duration How long does it last?
Frequency How often do you get it?
Progress Has it changed in any way?/Is it getting better?
Time of occurrence When do you get it?/Do you get it at any special
time?/Does it come on after meals?
Precipitating factors Has anything brings it on?
Aggravating factors Does spicy food make it worse?/ Do you have any
Problem climbing stairs?
Relieving factors Does milk make it better?/ Is it better if you lie still?
Accompanying symptoms Do you have any vomiting?/Have you had any
diarrhea?
 
 
Character refers to the quality of a pain. The most common words used by
patients are sharp (knife-like) and dull (not sharp). Sharp pains are often acute
and localized ; dull pains are often chronic and diffuse . An ache is a
persistent dull pain. A discomfort is a mild pain.
 
Character condition
 
Stabbing (punzante) neuralgia
Piercing (penetrante, lacerante) pleurisy
Burning ( ardiente,quemante) peptic ulcer, cystitis, gastritis
Boring (taladrante) peptic ulcer
Crushing / oppressive myocardial infarction, angina
Cramping ( retortijones) intestinal obstruction, dysmenorrhea
 
Severity The list below indicates how patients may describe the severity of the
pain:
 

Excruciating
Agonizing
Terrible
Severe
Bad
Mild

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SECTION 1: THE HUMAN BODY

Back
The human body is divided into three main parts.
PRONUNCIATION PRACTICE:
head Upper limbs
trunk Lower limbs
LANGUAGE EXPLANATORY NOTE.
Use "the" when referring to parts of the body
THE HEAD.
The head contains the brain, the base of the skull, the cranial bones, and the
face.
The brain is the cranial part of the central nervous system, which is contained in
the cavity in the skull.
The face is the front of the head.
PRONUNCIATION PRACTICE.
brain ear
skull cheek
cranial bone jaw
face chin
hair mouth
forehead nose
eye eyebrow

THE UPPER LIMB.

The upper limbs are attached  to either side of the trunk.
PRONUNCIATION PRACTICE.
shoulder little finger
arm ring finger
hand middle finger
elbow index finger
wrist thumb
Axilla (armpit) Fingernail
forearm Palm
  Dorsum
THE LOWER LIMB.
The lower limbs extend downwards from the trunk.

PRONUNCIATION PRACTICE.
thigh ankle
knee heel
leg first toe ( the big toe)
shin second toe
foot third toe
feet fourth toe
calf fifth toe (the little toe)
hip toenail
  dorsum
  sole
THE TRUNK.
 The trunk consists of two main cavities: the THORAX and the ABDOMEN,
which are separated by a muscle known as the diaphragm.
The BREASTS are located in the upper chest. They are also known  as
MAMMARY GLANDS.
The ABDOMEN comprises two parts: the abdominal cavity proper and the
pelvic cavity.
PRONUNCIATION PRACTICE.
trunk diaphragm
thorax (chest) abdominal cavity
abdomen pelvic cavity
navel  
breast  
SECTION 2: THE HUMAN SKELETON.
   
 

SECTION 3: INTERNAL ORGANS AND GLANDS

THORACIC ORGANS.            

                            Lungs                                                             Heart

 

ORGANS OF DIGESTION.
PRONUNCIATION PRACTICE:
esophagus gall bladder
liver small intestine
stomach  
spleen  
pancreas  

THE CONTENTS OF THE PELVIS.

The pelvic cavity, or pelvis, lies below the abdominal cavity.
The contents of the pelvis are: the urinary bladder, the lower part of the large
intestine, the rectum and some of the reproductive organs.
PRONUNCIATION PRACTICE:
pelvis ureter
urinary bladder kidney
rectum urethra
spleen  

THE REPRODUCTIVE ORGANS.

FEMALE REPRODUCTIVE ORGANS.
PRONUNCIATION PRACTICE:
EXTERNAL  GENITALS: INTERNAL  GENITALS:
pubis fallopian tubes
labia majora ovary
labia minora cervix
clitoris vagina
hymen uterus
vulva  
MALE REPRODUCTIVE ORGANS.
PRONUNCIATION PRACTICE:
EXTERNAL  GENITALS: INTERNAL  GENITALS:
penis prostate gland
uretral orifice testis
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The SOAP Format
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S: "Subjective": information that the therapist gains from interviewing or talking
with the patient, a family member, a significant other, or any individual who
provides information that is pertinent to the care of the patient.
O: "Objective": information that the therapist acquires from the physical
examination (includes observations, specific measurements, special tests, etc.).
"O" also includes treatment administered to the patient, and the patient's
performance of the treatment.
A: "Assessment": this is the physical therapist's 'opinion section'. It contains
the therapist's professional opinion of what is going on with the patient, the
therapist's assessment of the patient's condition and/or progress, the therapist's
prognosis, treatment goals, and the therapist's recommendations.
P : "Plan": reflects future treatments, interventions, or actions by the physical
therapist.
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SOAP Note
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•  Purpose: written documentation of a pharmacists care plan
•   Structure:
•  S = Subjective
•  O = Objective
•  A = Assessment
•  P = Plan
 
Structure :
•  Subjective
•  What the patient relates to you
•  Correlates with the health care need or chief compliant of the patient
•  Example: AJ comes into the pharmacy complaining of itchy eyes, runny
nose, and sneezing
 
•  Objective
•  Quantitative, observable or measurable data
•  Should support or refute information provided by the patient in
subjective
•  Example: Pharmacist K observes that AJ has erythematous and watery
eyes, sneezes several times during the conversation and is constantly
wiping her nose with a tissue.
•  Example: Laboratory values, test results
 
•  Assessment
•  Analysis based on S and O
•  Drug therapy problem/medical problem
•  Example: AJ has seasonal allergies currently not being treated.
•  For IPPE1: the assessment should revolve around whether the patient
can appropriately manage their health and medications
 
•  Plan
•  Recommendation for therapy and monitoring
•  Example: Pharmacist K recommends that AJ utilize take antihistamine X
and will monitor for relief of symptoms and sedation as a side effect
•  For IPPE1: Plan should outline methods that could be utilized by the
patient or health care providers to improve the patients ability to manage
their health and medications.
 
Steps for SOAPing a problem
•  Creation of a list of related subjective parameters
•  Creation of a list of related objective parameters
•  Assessment and documentation of the problem
•  Documentation of the therapeutic plan for addressing the problem

Steps for writing your SOAP in IPPE1

 
•  Identify a list of subjective information that supports or refutes the
patient's ability to manage their health and medications
•  Identify a list of objective information that supports or refutes the
patient's ability to manage their health and medications
•  Assess based on the information above the level at which you belief the
patient can manage their health and medications
•  Recommend a plan that could be utilized by the patient or their
healthcare providers for increasing the level at which the patient manages
their health and medications
 
Traditional SOAP Note 
•  S: M.S. is a 75 year old white male who reports that he is having severe
pain in this lower back and hips and that his medicine is not decreasing
his pain. He has been taking APAP/codeine 1 or 2 tablets up to 3 times
daily. The pain decreases slightly after a dose, but his relief dissipates
quickly. He is not experiencing nausea, and his last bowel movement was
3 days ago.
 
O = M.S. is a 75 year old white male with prostate cancer and a recent
increase in pain intensity. Current prescribed pain medication is
APAP/Codeine 30 mg 1 or 2 tablets every 3-6 hours prn. Vital signs: BP
140/70, P 78, RR 16, afebrile. Weight 71 kg ( 75 kg 4 weeks ago) Pertinent
labs: PSA 171, alk phos 350
 
A = Severe pain, most likely secondary to metastatic prostate cancer.
Adjustment in his pain medication to decrease pain and resume normal
activities is necessary. Constipation due to codeine.
P: Add ibuprofen 600 mg po tid pc. If APAP/codeine continued,
recommend giving on scheduled basis (1 po q 4h) with prn dose for
breakthrough pain (1 q 2-3 h prn pain). Use pain scale daily until patient
experiences relief to monitor the effectiveness of this regimen. An
endpoint of 0 is desirable. Add docusate calcium 240 mg po bid for
constipation. If constipation continues for > 2-3 days, consider adding
MOM 30 ml bid prn.
 
IPPE Example Note
 
S = C.W. is a 65 year old white female who lives in her own home with her
husband. She has no chronic medical conditions although she has been
suffering from pain in her left buttock for the last 6 weeks. She indicates
that she has tried several medications (Motrin, Vioxx, Skelaxin, and
Flexeril) with no relief. She has visited several doctors and chiropracter.
She indicates frustration with the healthcare system and has been waiting
3 weeks for a referral to the physical therapist. The pain causes her
difficulty sleeping for which she has been taking Xanax.
O = C.W. currently takes 1 aspirin per day, 1 garlic tablet per day, 500 mg
calcium per day. Xanax 0.125 mg po prn sleep. She had prescriptions for
Vioxx and Skelaxin but is currently not taking them.
A = C.W. appears to be able to manage her health and medications. She
lives independently, is mobile has had appointments with primary care
providers, has filled prescriptions and is able to relate what she is taking
and not able to take and why
P = To improve C.W.'s ability to manger her health and medications, I
would recommend 1) keeping a log of dates and symptoms that she has
as well as what medications she has tried and what the result was; 2)
encourage timely follow-up with the physicians office to obtain the PT
referral; 3) encourage C.W. to call PT offices and make own appointment.
Back
 
 
USEFUL LANGUAGE HINTS
Identifying data
 A (25) year old (Angolan female medical student)...
 A (Cuban male nurse) aged (40)...
 A (French male nurse) of (56)...
 This (Caucasian man had persistent proteinuria at the age of 9 in 1959.
He was
Main complaint (A)
•  ... presented to (his general practitioner/ family physician/ the emergency
room/ the
casualty department ...
•  ... was admitted to hospital because (he had fallen from a tree).
•  ... was brought into (the emergency room/ the casualty department...)
•  ... attended the (surgical outpatient clinic/ orthopedic clinic...)
•  ... was sent/ referred to (me/ the eye doctor...)
•  ... came to (me/ the clinician/ the neurologist...)
Main complaint (B)
•  with a complaint of (severe abdominal pain).
•  complaining of (back pain).
•  because (he/she had fallen from a tree).
•  because of (increasing breathlessness).
•  after (having several episodes of hemoptysis).
•  with a history of (continuous wheezing and breathlessness for two days).
•  with a (two-week) history of (fever and arthralgia).
•  with no history of (recent travel).
•  with (shortness of breath).
History of the present illness
•  On this occasion/ On arrival/ At the time of admission/ On admission/ On
direct questioning/ On closer questioning/ On further questioning:
- he/she was (in obvious distress/ pale/ in pain/ having fits).
- he/she said he/she had had (frequent attacks of asthma since childhood).
- he/she admitted having experienced (a similar pain/ nausea and vomiting).
- he/she reported (a sore throat three weeks previously...)
Past history
•  Over the previous (three years/ months/ days/ hours...)
•  One year/ week/ month/ before (he/she) had had (a nagging cough...)
•  (One year) before (his/her) admission...
•  The only past history of note was ( a lump in her left breast one week before).
•  On further questioning he/she had been (in remarkably good health all his/her
life).
•  (The pain) had been present (for several months...)
•  For the past (couple of months/ days/ hours/ years...)
•  He/she had (lost 8 kg in weight).
•  He/she had complained of (left-sided abdominal pain).
•  He had developed (renal failure two years before admission).
•  He/she had had (several episodes of vomiting).
Family History
•  His/her father/ mother was/is diabetic.
•  His/her father/ mother complains of... complained of.../ died of.../ had had...
•  There was/ is no family history of (hypertension).
•  Both his/ her parents/ children are (healthy).
•  Other family members were also diagnosed as having...
Social history
 He/she has been on that job for years.
 He/she has changed jobs many times in the last couple of years.
 He/she has never taken any physical exercise.
 He/she has been happily married for (many years).
 His/her wife/husband passed away recently.
 He/she comes from a poor/ wealthy/ well-to-do family.
Habits and medication
•  He/she admits to drinking (several bottles of brandy weekly).
•  He/she smokes (30 cigarettes daily).
•  He/she occasionally smokes (cigars).
•  He/she has never drunk alcohol in excess.
•  He/she is allergic to (penicillin).
•  He/she has an allergy to (iodine).
•  She's been on (the pill) for some time.
•  He/she's taking (water pills) at present.
•  He/she often takes (sedatives/ painkillers/ antacids).
•  He/she used to smoke (20 cigarettes) daily but he quit (a few months ago).
Physical Examination
•  There were no significant findings on examination
•  There was nothing remarkable/significant on examination.
•  There were (no abnormal signs in the lung fields/ no localized neurological
signs.
•  There was (no evidence of heart failure/ no tenderness/ no ankle edema).
•  There was mild rebound tenderness.
•  His/her general condition was satisfactory/ poor.
•  His/ her (BP was 100/60/ pulse...)
•  His/her BP was well controlled.
•  His/her (abdomen was not distended).
•  His liver was palpable to (three) finger-breadths.
•  He/she had (a BP of 100/60/ a pulse of 90/minute/ a dry tongue).
•  BP (100/60) / Pulse...)
•  No (palpable masses) were felt.
•  (Bowel sounds) were absent.
•  (In the lungs) there were ...
•  Neither (liver, kidneys nor spleen) were palpable.
•  On examination he/ she was or was found to be/ shown to be/ observed to be
(obese, pale, overweight, healthy, jaundiced, febrile).
•  Examination of the chest showed evidence of (emphysema).
•  Examination of the abdomen revealed (an enlarged liver).
•  On rectal examination there were ( no masses).
•  On bimanual examination (the uterus felt bulky).
•  On vaginal examination (her uterus was enlarged to 30 weeks size).
•  On (pelvic) examination she had (an ill-defined mass in he right adnexum).
Lab tests. Diagnostic procedures and investigations
•  Chest X-ray showed (pleural effusion/ a mass)
•  (Abdominal X-ray) suggested the presence of (intraperitoneal fluid)
•  (Ultrasonogram (revealed...)
•  (Endoscopy) showed...
•  Hemoglobin -Hg-) rose initially to (11 g/dl / decreased to 8g/dl)
•  A follow-up (electrocardiography) revealed (resolution of the pericardial
effusion)
•  (The findings on examination) reveal (a significant rise in the systemic venous
pressure)
•  His/her erythrocyte sedimentation rate (ESR) was elevated at(62)
•  His total protein was just normal at (60)
•  His calcium was low at (1.96) with a (normal) phosphate and a (normal)
magnesium.
•  (ESR) was considerably elevated.
•  (Plasma valine) decreased from (1500 µmol/l to 721µmol/l)
•  Cultures of (blood, bone marrow, urine and cerebrospinal fluid -CSF-) were
(negative)
•  (Cerebral magnetic resonance imaging -MRI-) showed...
•  (Nephrocalcinosis) was seen on plain radiographs.
•  Laboratory results are shown in the table...
Differential Diagnosis. Discussion
•  A variety of illnesses may mimic (myocardial infarction). The most common
conditions are (acute pericarditis, myocarditis,)...
•  Although no history of (trauma or seizures) were reported....
•  The possibility of (splenic rupture) should not be excluded.
•  (This disease) may present with (severe neurological manifestations)...
•  It may be that (the gastroenteritis) contributed to the crisis in this patient.
•  (Vitamin B 12 ) deficiency was found to be the cause ...
•  (Splenomegaly) found in our patient is also a manifestation of...
•  In this case, patients may present with (heart failure)...
•  This illness responds well to (antibiotic treatment).
•  (Tungsten) may cause (lung fibrosis or dermatitis) in...
•  Our patient did not develop (renal failure).
•  In this patient (clinical, hematological and histological) features were initially
suggestive of ...
•  The lack of a clinical response (with steroids) prompted us to think again.
•  His/her symptoms could be produced by (many different disease processes).
•  A striking feature of the history is (the absence of dyspnea).
•  (Blood loss from piles) may certainly be sufficient to cause anemia.
•  It is difficult to evaluate (the left chest pain).
•  (A number of points) must be considered in his personal history.
•  (He/she is a heavy smoker) which predisposes him to ...
•  His/her alcohol intake is sufficient to cause significant tissue damage.
•  (Duodenal ulceration) has a tendency to recur.
•  His/her (anemia) may be due to (the bleeding from the duodenum rather than
the piles).
•  It is impossible to exclude (this possibility) (without further barium studies).
•  (The firmness and lack of tenderness of the liver) suggest that...
•  (Many of the features of congestive heart failure) are present.
•  There is no history/ evidence of (chronic pulmonary disease).
•  The etiology was/ was assumed to be/ could be/...
•  The signs (in the chest) are (those of a pleural effusion).
•  (This) would not account for (his/her recent deterioration).
•  A diagnosis of (myocardial infarction) does not fit in with (the pattern of his
previous illnesss).
•  (Pericardial tamponade) is a very likely diagnosis/ highly probable.
•  (Hypoproteinemia) might cause ...
•  (A chest X-ray) may show/ reveal/ showed/ revealed...
•  (Endoscopy) confirmed the presence of...
•  It is probable that (the precipitation of left ventricular failure in this woman)
was the result of (the intravenous infusion of salbutamol).
•  (A number of factors) were undoubtedly contributory to (the onset of
pulmonary edema).
•  (Dietary and alcoholic excesses) can also cause (an acute gastritis).
•  (Acute pancreatitis) can cause (pain of similar severity and radiation), but/
however/...
•  (A peptic ulcer) is a possible but unlikely diagnosis due to (the absence of...)
•  (Absence of fever and of lower abdominal pain) make (appendicitis) very
unlikely.
Diagnosis. Prognosis
 Features such as a (preference to be alone, a short attention span...)
should alert
 the clinician to
 the diagnosis.
 All the features of the history and examination are consistent with a
diagnosis of (pain due to gallstones).
 The history of... points to the diagnosis of...
 This was confirmed (by histology) as being (an adenocarcinoma).
 The diagnosis was not finally confirmed until (some months later) (when
a lymph node finally appeared) (and we biopsied that and...)
 If the presumptive diagnosis of ... is supported by the investigations...
then...
 A diagnosis of (sarcoidosis) was made.
 He/she was diagnosed (as having) (hepatitis)
 No diagnosis was made.
 The prognosis is good/ poor/ guarded/ bad.
Management
 He/she was given (two units of packed red blood cells)
 He was started on (prednisolone)...
 He/she was prescribed (oral ampicillin).
 He/she was treated with (a course of antibiotics).
 He was commenced on (triple therapy with)...
 He/she was transfused because of (his anemia).
 He/she was sent home (on oral iron).
 He/she was referred to (the dermatologist).
 He/she was sent to (a reference center).
 The patient was hemodialyzed.
 He/she developed acute pulmonary edema.
 The patient's (fever) persisted.
 (Hydrolazine) was added to the treatment.
 The drug/medication was changed to...
 (Cephalexin) was continued.
 Treatment with (oral sodium bicarbonate) was started.
 Vit B12 was started.
 An IV (salbutamol) infusion was set up.
 (A digital examination) should be/ should have been made/ and
(sigmoidoscopy) should be/ should have been/ performed as a routine.
 (An ultrasound examination) is essential in the assessment of...
 There is no need for (an emergency laparotomy) if there is no evidence
of (peritonitis or...)
 (Urine) should be tested for (bile pigments).
 (An ultrasound of the gallbladder) will show both (the presence of
gallstones) and may reveal (additional information if inflammation and
thickening of the gallbladder wall are seen).
 Peritoneal dialysis is often advocated for treatment.
¨ OTHER USEFUL PHRASES
•  His/ her symptoms subsided.
•  He/ she relapsed with identical symptoms.
•  He/she had new/ different complaints/ signs/ symptoms
•  He/she was symptom-free.
•  He was readmitted...
•  He was discharged on...
•  At outpatient review...
•  At follow-up he continued to (lose weight).
•  His/her general condition deteriorated.
•  He/she improved very quickly
 
LANGUAGE REFERRING TO GRAPHS AND TABLES.
GRAPHS HAVE: HORIZONTAL AND VERTICAL AXIS.  
GRAPHS MAY BE: PIE CHARTS
VENN DIAGRAM
SCATTER DIAGRAM
BAR CHARTS
HISTOGRAMS

TABLES. THEY HAVE RAWS ( ) AND COLUMNS ( )

 
 
IMPORTANT WORDS USED WHEN DESCRIBING GRAPHS AND TABLES.  

IT.. ROSE FROM MINIMALLY

INCREASED TO SLIGHTLY SIGNIFICANTLY
WENT UP BY GRADUALLY MARKEDLY
STEADILY CONSIDERABLY
SHARPLY
FELL RAPIDLY
DECREASED STEEPLY
WENT DOWN
DROPPED
DECLINED
 
 
THERE ..... IS ... A ... MINIMAL ..... RISE ... IN ...
WAS SLIGHT INCREASE
GRADUAL
STEADLY FALL
DROP
SIGNIFICANT DECREASE
MARKED REDUCTION
CONSIDERABLE DECLINE
SHARP
RAPID
STEEP
SUDDEN
IT FLUCTUATED ...... BETWEEN
 
IT REMAINED ........ CONSTANT .. AT
STEADY .... AT
 
IT ........ PEAKED .... AT
 
IT ....... LEVELLED OFF ... AT
 
IT ...... PLUNGED ....
 
THERE IS/ WAS .. A .. BLIP ... BETWEEN .

 
T SHOWS /
LI
H DOTTED REPRESE
NE
E NTS...
BROKE
     
N
UNBRO
     
KEN
CONTIN
     
UOUS
  HEAVY    
  SOLID    
 

THE INDICAT THAT.

RESULT E (S) ..
S
THESE
SHOW
RESULT  
(S)
S
TABLE SUGGES
 
III T (S)
IS / ARE
TABLE
EVIDENC  
V & VII
E (OF)
THIS
   
GRAPH
 

TABLE1
FIGRE 2
IT CAN BE SEEN CHART3
FROM
AS CAN BE THE CHART THAT....
IN
SEEN TABLE
GRAPH
DIAGRAM
ACCORDING TO
IN    
AS (IS ) SHOWN
 
 
 
 
IT INCREASED EIGHTFOLD IN...... ( IN 1965 ).
(EIGHT TIMES)  
 
 

SOLID SQUARE
 

OPEN SQUARE
 
 

............. DOTTED LINE BROKEN LINES

 
- - - - - - - - - - - - - - - - - - - - - - - DASHED LINE THIN LINE..
 
. - . - . - . - . - . - . - . - . - . - . - . - . DOTTED AND DASHED LINE (THEY SHOW
PROJECTION OF THE WORK)

HEAVY LINE UNBROKEN OR CONTINUOUS LINE

SOLID LINE
THICK LINE
(THEY SHOW REAL RESULTS OF
___________________________ THIN LINE THE WORK)
LIGHT LINE
DIFFERENT TYPES OF GRAPHS AND TABLES.
 

PIE CHART VENN DIAGRAM

BAR CHART

ER GRAPHS AND TABLES. THE WAY YOU ARE GOING TO USE THEM
DEPENDS ON YOUR OWN PERSONAL CHARACTERISTICS OR ON THE
TYPE OF WORK YOU ARE TO DO.
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utilities
 
Glossary of layman and medical terminologies
Layman Terms Medical Terms
Absence of period     amenorrhea
cerebral hemorrhage,   stroke,
Apoplexy    
thrombosis
Bad breath halitosis
Baldness   alopecia
Belly/tummy    abdomen /stomach
Black motions/stools melena
Bleeding   hemorrhage
Blood in the urine     hematuria
Blur vision loss of vision    acuity
Bowel   intestine
Breathlessness/short of breath dyspnea
Breastfeeding     lactation
Bruise ecchymosis
Burning on passing water   dysuria
Buzzing/ringing in the ears   tinnitus
Chicken pox varicella
Deafness    loss of hearing
Difficulty in swallowing dysphagia
Dizziness vertigo
Doble vision diplopia
Earache   otalgia
Fever   pyrexia
First period     menarche
Give birth     deliver a baby
Heartburn      pyrosis
Hoarseness     dysphonia
Indigestion   dyspepsia
Itching     pruritus
Jaundice     icterus
Loose motions diarrhea
Loss of appetite anorexia
Loss of memory   amnesia
Loss of vision   blindness
Lump     ass/tumor
Miscarriage  spontaneous   abortion
Missed period   amenorrhea
Mumps Parotitis
New born      neonate
Pain on intercourse     dyspareunia
Pass water void/urinate
Period menstruation
Phlegm sputum
Piles hemorrhoids
Pink eye conjunctivitis
Pins and needles paresthesia
Runny nose rhinorrhea
Sexual intercourse coitus
Stool feces
Sugar diabetes mellitus
Sweating perspiration
Swelling edema
The pill oral contraception
Vaginal discharge/whites leucorrhea
Voice box larynx
Vomiting/throw up emesis
Waterworks urinary tract
Weakness asthenia
Windpipe trachea
Womb uterus