FORMAT OF THE CASE REPORT Identifi Hospitals and clinics usually have printed sheets or cards for recording case reports. At the top of the first page of the first history sheet there is usually a space for date of inter- view and indentification of the patient. In any Case, the date, the full name (preferably with the name ot the grandparent), the age, sex, occupation, address, hospital number, etc., must be recorded at the top of the first history sheet, separated clearly from the history by a heavy line. A complete identi- fication of this kind will provide adequate information about the patient and ample data for statistical evaluation of disease patterns in a given area. Order of Case Recording ion of the Patient Previous admissions Chief complaints History of the present illness Past illnesses Functional inquiry (System review) Personal history Family history Physical examination NYAWSYN= tial diagnosis ion or final diagnosis4 sudden onset of back pain while lifting up a heavy object, Of epigastric pain coming on soon after a spicy meal, chest ain on deep respiration, et, Suggest causeeand-effect rela- tionships. Then ask whether the sign of symptom was inter- mittent of persistent, shortslved_ or constant, steady ot tinge Teasing in severity. Also try to find out if other signs and Symptoms have developed with the Chief Complaint, 3. Character and location. A clear description of the Complaint is necessary. For example, an abdominal pain may be burning, aching, dull or sharp in character Furthermore, the location of the Complaint should be precise, In the case cof abdominal pain, the patient should be asked to define the area of pain as clearly as possible, Find out if the pain spre- ads or radiates to other areas and describe the extent and manner of radiation. Also find out if thete ate factors or conditions that relieve ot aggravate the Chief Complaint. 4. Exacerbations and remissions. These are likely to be ‘mentioned while dealing with the course and duration of the ‘present illness. However, especialy in chronic diseases, the + and nature of exacerbation and remission should be ine ed in relation to the present complaint in order to have “a better understanding of the disease of treatment, Patients may have ate dg of therapy prior to_admision to a hospital been taken properly, they may have Nes, they may have. worsened or jay have had no effect what ent's expenses nt for a phenylbutazone for transeot Joint pans may have continued the drug until he or she resents with haematemesis: a dia: betic may be taking steroid for Suspected arthritis and present with poor control of his diabetes or miliay tuberculosis, Sim- ilarly, & patient who has viral hepatitis may have exacerbation of symptoms under strenuous physical exercise, Therefor, it is important to record such factors in the History of the Pre: sent Illness. 4. *Neguvepatve’ semen hss vey signe aspect of the History of Present Ines, It includes lation of review_of the affected. _Of suspected system(s), and ingly into other telatedsytems aswel as medicinal, hereditary environmental and other conditions directly related to the CChief Complaint, These inquiries are conducted as ‘thoroughly 5 possible with a view-to constructing a differmtial diagnosis, ‘A negative statement may be as important as a postive statement, These statements ae expresed in terms of signs and symploms but not diseases. For example, in a paint see i repay eae ae7. Colour, strength and weight. The last paragraph of ‘the History of the Present Illness should state how the patient came to hospital, i. on a stretcher, walking, urge’by his ti- ends’ advice, etc. Also, there should be mention of {nycolour, strength ot weight changes. These factors will give some’ know- ledge of the general condition of the patient Thus, a completed History of the Present Illness will con- tain a clear picture of the date and mode of onset of the Chief Complaint(s), the course, duration, character, location with areas of spread or radiation, relieving or aggravating fact- ‘ors, exacerbation and remission, the effects of therapy, mode cof admission, and changes in colour, strength and weight, Past Illnesses Thisisa simple listing of oes ied lh proet illness, experienced in the past, including childhood diseases, setious injuries and surgery not requiring hospitalization. A brief mention of each disease with an approximate date, seve- rity, duration, complications and sequelae (consequences) is rate system, simply record "See or refer to the HPI or Past Illnesses.” In the functional inquiry, a sign or symptom also requires as complete a description as in the History of the Present Illness. Furthermore, the absence of signs or symptoms ig as important as their presence. Very often, the unwary student questions the significance of recording negative state- ments, However, it should be emphasized that failure to docu- ment both the absence and the presence of signs and symp- toms related to each system will result in: (@) omissions be- cause the examiner forgot to ask necessary questions, (b) a record that will appear incomplete to a reader at a later date. The reader is uncertain whether the examiner has specifically inquited about the signs and symptoms in question. For eram ple, if the examiner has recorded, under the title “Head”, headache, but has omitted head injury, the reader of thisre- cord, when the patient presents with coma and localizing neu- ological signs, is in doubt whether the examiner has asked about head injury. The functional inquiry should be recorded as follows: HEEN.T.* Head: Headache, injury. Ears: Pain or earache,a brad difficulties which may be the cause of 4 Fer lta es . Cae Note as follows: Sigs: Lit nee A 1 date and cause of death, en With ages, health (if dead, mention cause of Family disease: Tuberey Aisorders, migraine Ph sical Examination Success in tecording complete physical findi 00 & step-by-step and systematic Bea ae noe method of approach will enable the student to arrive at a meaningful diagnosis, A selective use of common terms, in chronolgical order, brevity and simplicity often give a beter Picture of the patient than @ long-winded and casually scribbled record. The student should be encouraged to record his fin- dings with simple tabulation and, wherever posible, wih i- ams, eg. site of tenderness or mass in the abdomen, heart ‘rms, reflenes ec. As in the Functional Inquiry, depending on the system involved or suspected, negative reports are as significant as positive ones. The four catidinal methods, in- spection, palpation, percussion and auscultation, should be strictly observed, especially when examining the respiratory, catdioves ala and gastrointestinal system. In the following out, which Should serve as a guide in performing a physical examination the student should be advised to adhere to all details unt bei well versed in the order and terminology. Later on, ie. during practice, the physician will automatically avoid unnecessary detasexept when be is dealing wth one or more systems loss, diabetes melitu, hypertensiva demanding thorough examination. Tepe C. (orl, rectal or aly) “peri. (eg, reply rela, or iregulary-regulat). per min Blood pressure ... mm Hg (right or left arm; lying or supine) Weight ..... Kg Height .. om. General appearance: Severity and acuteness of illness, Physique, constitution and nutritional state, Posture, Emotional state, facial expression and colour chenges, HEENT. Head: Shape, sie, masses, depressions and tenderness of skull, Amount, colour, texture and distribution of bar. Scars and cleanliness (lice, etc.) of scalp. Ears: Mastoid tenderness, tophi, cerumen (wax) fun- tal or other lesions in the external canal. Colour, light Teflex, injection, bulging, retraction or scarting, perforation (with or without discharge) of the tympanic membranes, (eardrums), Eyes: Lid lag, ptosis, exophthalmos, lacrimation, xan thelasma, periorbital oedema, strabismus, nystagmus and visual aid (pectaces). Conjunctival pallor ition, haemorrhage and trachomatous changes. Scleral colour, ‘pterygia and granulation. Fundi: clarity of disc outline, apilloedema or changes in the physiological cup, itregu- laity in vascular calibre, tortuosity, silver-wire appeat- ance of arteries, arteriovenous (A/V) nicking, exudates, haemorrhages, pigmentation and granulomas. ‘Note: Fundoscopic findings can be presented with a diagram, wing Figure |. overleaf.Motor: Volume (size), tone, power, fasciculation and presence at absence of involuntary moverient of muscle group Sensory: Superficial ght touch, pain and temperatute, Deep, (proprioceptive) - postion sense, passive motion, deep pain, vie tration, Romberg’s sign, ataxic gait, Cortical. stereognosis (recognition of form, size, shape and ‘weight of object), two-point discrimination, Cerebellar finger-to- nose or finget-to-finger test, heel-to-shin test, supination and pronation of the forearm, rapidly alternating movements of fingers, rebound phenomenon, cerebellar gait or ataxia, ters: Nuchal rgiity, Kerniy's sign, Bruzinsi's sig, (hemiplegic, partic, Parkinsonian, etc), Ausaltation eyeballs and skull. ‘Record using the fllonng format as an example 0 to 4+: 4 Sunmary 1. Subjective. This wil include those relevant points obtained from the Chief Comlaints, the History of the Present ness, the Functional Inquiry, Personal and Fatmily His tory. 2 Objective. Thi wil nude only the positive phys find ings Not: Both the subjetve and objative findings should be recoded wing brie sentences and appropriate words chronologically in the nd they are bined in he istry an phys tamination, Avoid ky designs and snes, i Differential Diagnosis,PROGRESS NOTES Once the patient is admitted to a hospital, the day-to- day course of his illness must be recorded in a systematic manner. If the illness of the Patient is acute and severe, Bess notes should be written every day of more frequently epending on the nature of the condition, In chronic illnesses, » Progress notes should be written once or twice a week. Progtess notes recorded in a logical and concise manner Will be of advantage in the Proper management of the patient Will facilitate arrival at a final diagnosis, will avoid medico- Hegal problems and will permit satisfactory scientific data co- lection, There are two methods of writing progress notes: 1. The traditional method, which includes the folloning 1s: feDeeliacat of ‘new signs and symptoms as ell as improvement or worsening of the presenting co- jew of the physical examination primarily per- (b) A review of the physical 7 Plan: Diagnose Therapeutic Patient education Example Pres: Estep Sabjete: Butning eiastie pain 2 hours afer a meal, wor flloving spicy fod and aol, wakes up the puteat at about 1-2 am, and relieved by milk. Objective: Examination of lungs, heart and abdomen was hormal except for epigastric tenderness, Barium meal revealed deformed duodenal bulb, Stool was negative for occult blood. Assessment: Duodenal ulcer,DISCHARGE SUMMARY ak ‘wie summary of the history (subjective) and positive physical findings (objective) as in “summary” (see page 2), However relat Degative history and physical find- 1ngs are also informative in some cases, y Relevant laboratory findings, Tadiography and other diag- Rostic procedures, . Diagnosis. A brief discussion of diagnoses or differentia) Glagnoses considered in the couse of the hospitalization, and method) of confirmation ofthe clinical impresion. |. Treatment, Tnclude all modes of therapy and whenever Indicated, specify the reasons for prescribing a specific drug or therapy. Also, specify the type of drugs, dosage, route of administration and duration of treatment. Ex- plain why a drug is discontinued. . Course in Hospital, Plan and Recommendation. Describe success or failure of treatments, development of other signs and symptoms during hospitalization, final condition -of the patient and prognosis, Outline a plan of future ‘management and followup dais inde | | THE REFERRAL LETTER AA letter containing facts recorded in the History of the Present Illness, Socal History and Discharge Summary must be sent to the referring doctor or health centre promptly. In areas where there are few, scattered and inadequately staffed and equipped medical services, a referal eter is. of Paramount importance for various reasons: 4) It contributes towards the welfare of the patient, (b) It enables medical personnel to render better care tothe patient (©) It enables medical personnel working in a rural area to upgrade their knowledge of Medicine, (d) It is courteous to respond with such a letter to a refer Ting doctor ot other medical personnel, Conversely, the referring doctor or medical personnel Should wite all the relevant subjective and objetv indigs and final opinion about the patient, ith clear spetiation of the reasons for the referral, (See . Sample Referral Letter.)Cardiovascular system- See History of Present Mliness. No leg swelling, synocope or history of hypertension, Gastrointestinal! system: See HPL. No nausea, vomiting, ebdo- minal pain, jaundice ot melaena. Regular bovel habits. Genitourinary system: No dysuria, urgency, hesitancy, dribbling, haematuria ot pyuria, Urinary fequency: D/N 3) No hisotry of venereal disease. natary sytem: The hair tends to be dry and to fal but when combed. The skin is moist and has no rashes or ulcers. No clubbing of the ails. Allergy: No asthma, drug. sensitivity, hay fever, urticaria of serum sensitivity. Locomotor system: No joint pain of swelling, bony deformities ‘or muscle wasting, Ceattal nervous system: Good memory. No seizures, nervous breakdown, vertigo or anaesthesia, Personal History Early development: He was born in the vl Metekel, Gojjam, where he isi herd until he was 16. as a farmer. He+ He lved in his i : parents’ big hut and There are no houses with modern tlie : He eats bread made ie from barley and “ef”, He pe ate. He occasionally took ‘Status: He marie, x , at the ago of 24 daughter Sen fi bs sa ‘Marriage 8 justment tk birth of 2 healthy girls, 1 and ae ‘mother: The father . » age 50, is very health 251 fre The mt el he 18 years of age. A broter di Sst at oa HEENT. Head: Eyes: Nose: ‘Mouth and throat: The breath has bad odour (halitsis). Normal size atid. shape. No scat Normal hair distribution. Normal contour of pinnae Clear exterpal at canal. Intact tympanic membrane with shiny light reflex. Good and equal hearing. Normal eyebrows, No. periorbital oedema, ptosis, cxophthalmos, excessive lacrimation or strabismus, The conjuctivae are pale. The selerae are not icteric, The pupils are equal in size. The fundi reveal clear disc margins and. the vesels are of normal calibre, Thee is no AJV nicking, exudates, haemorrhages or granuloma ‘The nasal septum is slightly deviated conver to the right and the turbinates appear enlar- ged. There is no polyp of unusual discharge, ‘The lips show no fissute, ulceration ot herpes. The gums are intact ‘and clean, There is 00 catious tooth. The tongue is slightly dry and coated with whitish material. The buccal mucosa is also slightly dry. The tonsils atef ‘ = rapection: There is no cyanosis or club- ; oak Shallow and rapid. There cc. val Muscles. Slight intéreo- Prlpatn: The tack rates dead inthe let the lager, is ge inspiration, be | g i Palpation: The point of maximum impulse is felt where itis visible, It is loclied. Thete is a mild parasternal heave. There sino thrill anywhere. Percussion: The cardiac: dullness is within the limit of normal Auscltatin; Both heart sounds are nofmal in intensity cover each valvular area except for an actentuated second heart sound over the pulmnic are, There is no gallop, opening snap, ejection “chk” or pericardial “knock”. There is & systolic ejection murmur, grade 2/6, best heard oer the apex and without radiation. oe 1 T ; ' ' i) \ \ 1 1 a & 8 Heart sounds over the pulmonic rea, showing acentuaed heatGastrointestinal 5 i : ee Inspection The abdomen is scaphoid, era ts mt respiration, Thete are no lank = » Sears oF masses. The umbilicus is inver- ahead There is no tenderness, muscle spasm or mass, aang mie x i eo nara i 7 firm and without t spleen was not palpable. There was no le eras oe dullness, flank or supra- tat dallas. ahah ee of the liver along the ETI bone! aia ot friction rub over the Rectum: There is no fissure, heemorthoid or fistula. The sphincter tone i tight. There is no mass ot i Bese i tenderness in the ‘tectum. The prostate is grade 2/4, firm, Bee a stem: There is no costowvertebral ange tender pe ee ye Desk mbt haletat oor : LEN Se Bs Cranial nerves: NI Smells aleohol via each nostri NAM. Norma! visual acuity, good visual fis ant colour appreciation. ions, Nill IV &VI. The eyes can move in all det ‘Ther is no nystagmus of diplopia. The pupils are round and regular in outing. They react to light rectly and consensually and acom- modate normally NY. Pain, touch and temperature are intact the face, Normal contraction of the mpo- rals and masseter muscles. Taste for salt over the anterior 2/3 of the tongue Is otmal over N.VIL, The face is symmetrical both at rest and éut- ing voluntary movements, Lt when smiling. whistling, shutting eyes, ¢t. He heats the ticking of a watch bilaterally Rinné' test reveals ait conduction better than bone conduction in each ear, and Weters test is not lateralized. There is no nystagmus te isin the midline when s~ ag ofl i intact and tee of dysphagia.However the to fasciculation. me and power are normal and there is no = geleg ain and temperature sensations are eo Position sense, vibration and passive ius appreciated by tho patient. There is no aap peta Notmal recognition of form, en Of & coin as well as two-point discrimination, a “Finger-to-nose or finger-to-finger and heel-to-shin, supination and pronation of the forearms and rapid ting movements of the hands and fingers are al intact There is no cerebellar ataxia. Others: There is no nuchal Tigidity or nerve trunk thickness Reflexes: (a) Superficial 2. Objective: Temperature of 378°C and pulse 100/min, Malnourished and wasted. Pale conjuctivae. Nasal septum devi- ation to the right. Shotty cervical, axillary and inguinal lymph nodes, Shallow breathing, slight tracheal deviation to the left, decreased chest expansion and left diaphragmatic excut- sion, Decreased tactile fremitus and air entry over the left lower half of the chest. Coarse creptation over the left upper and lower lobes of the lung. Systolic, apical, grade 2/6 ejection murmur without radiation. Liver edge palpable 2. om below the right costal margin. Differential Diagnosis Pulmonary tuberculosis Bronchietais of undetermined cause (lft side) 1 2 4. Carcinoma of the lung 4. Chronic bronchitis Discussion of Differential Diagnosis 1, Chronic bronchitis: Although the patient experienced chronic cough produc- tive of purulent and bloody sputum, the presenting signs ‘not conform with the arbitrary defini ‘bronctitis, ie. ‘cough with production ‘most days for at least three mon ‘two years.” He never smo- night sweats, weight ant haemioptysis are unusual reveal ronchi, The fever et, pez= td diagnosis of chronic bronchitis is mainly made oa No specific test or procedures are in- ny case. A chest X-ray and forcec expiratory Aun (FEY) night be Wl bat te dagnsis. of bronchitis is very unlikely in this case Carcinoma of the lung: Anoretia, ‘aga pleuritc chest pain, chronic cough suggestive of carcinoma of the lung. On © other hand, night Sweats and purulent ane are not typical of uncomplicated carcinoma of the lung. lata en of the lung is uncommon in this 0 the patient is young and does not smoke ae many of the signs and symptoms do not enclusion of the diagnosis readily. Fever, pale conjunctivae and the different chest fi e findi ia the possibility of carcinoma of the ie ty jopathy and hepatomegaly may imply metasta- The high erythrocyte sedimentation rate and the haem- ‘oglobin are in keeping with malignancy. fae ciclude the diagnosis, the following should be done: neh ‘bronchoscopy, sputum cytology and posibly, Bris of wetted cane (et si) The clevated erythrocyte sedimentation rate and the low haemoglobin are in Keping with long standing broach ectasis but the establishment of this diagnosis requires a chest Xoray and left bronchography. Urinalysis done in the side laboratory was negative for profeinuria and hence there is no evidence for secondary amyloidosis. Grams stain did not reveal significant bacteria 4, Pulmonary tuberculosis: The course of the illness, night sweats, anorexia, weight Joss, chronic cough, haemoptysis, @ similar history ina rember ofthe familly, and failure to respond to broad spectrum antibiotic strongly favour the diagnosis of pul- monary tuberculosis Fever, wasting, pale conjunctivae associated with sign ficant haemoptysis, lymphadenopathy, all the chest findings and hepatomealy are abo suggestive of pulo- nary tuberculosis, The elevated erythrocyte sedimentation rate, the low hae- roglobin and normal total white cell count are in keeping with the diagnosis. The staining of the sputum with Ziehl- ‘Nelsen revealed acidcfast bacilli, Since the sputum exa- rmination result has confirmed the diagnosis, there is n0 need to do lymph node or liver biopsy. The following tetsand procedures shoud be don: the SGOT, SGPT, all- i ‘blood morphology, serum iron for morphology and ton, rum transaminases andFal Digs Pulmonary tuberculosis, Progress Notes heb 108s, |. Problem: Nausea, Vomiting and anorexia, Subjective Oh Gradual onset of nausea, Vomiting and a = fourth ity i‘ admission, Less cough and admission. w-grade fe 1 gm IM daly and TB 4) tl ub bi’ a ee ‘Objective (0): Examination of chest, chest, CVS and ab roe {erythrocyte Sedimentation ate}-96 a et a (haemoglobin}9.s ‘gm per cent. Sputum flats in both ei es ae fase Bre ate eh se lobes, and several small Assessment (A): Side effects of thiacetazone. Diagnostic: Stop thiacetazone. Delay bar Teese Vir oA es : saa, i anorexia oe start ethambutol 400 mg id po and pyridonine 25 mg dal Talon tn: Pol ge Assessment (A): Blood loss and partly nutritional anaemia Plan (P): Diagnostic: Peripheral blood morphology, serum iton and TIBC (total iron binding capacity) and bone marrow aspiration with iron stain BUN (blood urea nitrogen), stool for ove and. parasites ‘Therapeutic: After diagnostic procedures, maintain a balanced diet and start on ferrous luconate 300 mg tid po. Patient education: Advised to eat well and continue his treatment until the blood picture improved. 28 Feb. 1978. 4. Problem: Epigastric pain after spicy meals. Subjective (8): Epigastrio pain immediately after eating ‘ijera-wat”, burning in character ‘but without the rhythmicity and. periodicity of duodenal ulcer. Cough and sputum have row subsided. No more haemoptysis. Eating well and gaining weight. Continues on streptomycin, INH, ethambutol, pyti doxing and ferrous gluconate. Objective (0): Less crepitation on auscultation of the chest. Liver edge is no longer palpable. ESR-7 mm in the first hour. Sputum smear still negative for AFB. Blood mor: phology revealed microytic, hhypochromic cells. The serum tron was 60 microg 100 ml and the TIBC was 300 a marrow revealed increased depletion of iton store.Therapeutic: Continue. with of 18 months, strept pe ths, ethambutol 400 Neve epigastric pain. Trestment to continue at home and in the nea. by Health Center. for the total duration was emphasized, If blurring of Mislon occurs, patient to discontinue ethambutol seek advice. To Stop streptomycin if buzting te in the ears |S experienced. Also, he was advised to take his wife and children to Health Centre for check- up. Discharged with a summary note and with strong advice to. respect follow-up appointments. Discharge Summary ‘ate ofAdisin:28 Jn, 1S, Date of Dichure:28F, 198s, On Admission Sabjetne Chronic cough of 12 months’ duration’ of 3 months duration, fever, anoreia, loss, night sweats and easy fatiguabilty. oer died. after protracted cough and haemopyss. efve- Pale. Temperature of 37 and pulse) ‘Nasal septum deviation to the right. Shotty Iymph nods. ae 2. Laboratory Data and Diagnostic Procedures The erythrocyte sedimentation rate vas 96 mm/hour The haemoglobin was 9.5 gm’, the total WBC was 6 S00) tom? and the stool was negative for occult blood, ova. and Parasites. After about 10 days of hospitalization, the haem- globin came down to 8.2 gm’. The peripheral blood film Showed microcytosis and hypochromia, The serum iron was 6 micrograms per 100 ml and the TIBC was. 300. micro- grams pet 100 ml. The bone marrow revealed increased ery- throid hyperplasia and depletion of iron store, The blood urea nitrogen was 10 mg’. Sputum smear with Ziehl-Neelsen stain revealed acid-fast bacili, The chest X-ray showed extens sive infiltrates in both left upper and lower lobes with cavities in the lft upper lobe. 3. Diagnosis (a) Pulmonary tuberculosis (confirmed bacteriloial) (b) Blood loss anaemia due to prolonged haemopyis 4. Treatment Streptomycin | gm IM daily for 2 months. INH 100 mg tid po. for 18 months, ethambutol 400 mg bid p.o. for 12 months, Pyridoxine 25 mg daily for 3 weeks. Ferrous glucon- ‘ate 300 mg tid p.o. for 9 weeks. High protein and high calo- nie diet, Antacids. pra. 4, Course in Hospital, Plan and Recommendation The course of hospitalization was complicated by 2 events: ist, the Kia, nausea and vomiting ent which subsided very he became weaker be- ain these symptoms im- ith ferrous gluconate. or problem but itim- rse of his hospitalizationWas steady improvement until he was free of 5 cough, hi Plyss, fever and anorexia. He guned 8 kilos and i eae Tose to 11 gm’ by the time he was discharge ® dH was informed of the good prognosis of his ae! : He was advised (a) to complete his treatment wit fall (ee under Treatment), (b) to discontinue tl ad seek advice if blurring of vision occurs, (c) to Stop taking streptomycin if sensation of ringing in the eat occurs, (to te followed by the Health Centre near his village where he Should have his streptomycin injections complted and where ‘he should have periodic physical examination and chest X-ray, (©) to take his family to the Heath Centre for a checkup and (f} to have rest. and good nutrition for 36 months A referal letter to the Health Centre was given to the patient A SAMPLE REFERRAL LETTER Hospital (City or leat) 2B February 1985 Deat doctor or Ato ____ -_ Re Ato Deteje Mamo Mekasha-age 28 years (Hosp. No, oni): ‘ The patient did not return to FinoteSelam Hospital alth- ough the cough increased in frequency and became, productive of copious amount of sputum. He had anorexia and was losing weight, He was easly tired and had nocturnal sweating Three months prior to the admission, he began having increa- sing haemoptysis. The sputum was purulent, amounting to 2 Arabic coffeecups per day. The maximum amount of blood cxpectorated. was about one half cup per day He denied orthopnoea and paroxysmal nocturnal dyspnoea He never smoked cigarettes and aid not have calf pain or tenderness. He denied treuma to the chest or a tendency to bled easily flloving minor injuries. However, he remembered seeing his brother die after a protracted cough with gross haemoptysis. The positive findings on physical examination are 1. Temp-37.8°C (oral). BP-110/80 mm Hg. Pulse-100/min. Resp. rate- 28min, Ht-162 em. Wt45 kg. He appeared malnourished, wasted and older than his tated age. He was coughing frequently and producing blood: tinged greeishyellow sputum, He preferred to le prop- ped up in bed. 2. The conjuctivae and nails wete pale and the nasal septum was deviated to the right. t eralized Iymphadenopathy, mainly in the ying in size between 0.5 and | cm, tender and frecly mobile. ie trachea was slightly shifted and left diaphragmatic ctile fremitus and air entry eft lower half of the chest. the whole left lung6 seta 7 palpable 2 cm below the Tight cbstal . WU was sharp, smooth, firm and non-tend total Yettcal span, by percussion, along the a We clavicular line, was 15 om, : The relevant laboratory dat i ei et rosie i 1, The ESR was 96 mm/hr. The haemoglobi fi yglobin was 9.5 gm’, and, Uy ‘ater, 82 gm, The total WBC ms Gat ou eae blood film showed microcystosis 2, The stool examination was negative for occult blood, ova and parasites. : 3, The serum iron was 60 micrograms per 100 ml, the TIBC 300. The blood urea nitrogen was 10 mg’, 4. A bonemarrow aspirate revealed increased erythroid hyper- plasia and depletion of iron stores. §. The sputum smear with Ziehl-Neelsen stain revealed acid- fast. bacilli The chest X-ray showed extensive infiltrates in both left upper and lower lobes, with several small cats in the former. The diagnosis of open pulmonary tuberculosis was thus confirmed bacieriologically on the fist day of admission, and an iron-deficiency oF blood joss (haemoptysis) anacmia was confitmed. by r logy, serum iron and bone mar iis daily was added to the treatment. However, hatmoptysis con- tinued, the haemoglobin fell, and he was started on ferrous luconate 300 mg tid p.o. He improved steadily: his cough, subsided, haemoptysis stopped and the sputum became scanty. By the time he was discharged, he had gained 8 kg, and his haemoglobin was 11 gm. ‘Also his lymphadenopathy and enlarged lver were. no lon- eer palpable. He has 2 children and lives by subistence farming, He reeds rest and good nutrition, which need to be discussed with his father and relatives. We hope your clinic will provide the necessary drugs until he completes treatment, His wife and children should have Mantoux test and chest X-ray. If the children show positive Mantoux but negative chest X-ray they should be treated with INH for 12 months. The patient should continue bis treatment as follows 1, INH 300 mg daly (once or in 3 divided doses) po. for a total of 18 months. Ethambutol 400 mg bid p.o. for 12 months. Streptomycin 1 gm IM daily for 2 months. 4, Ferrous gluconate 300 mg tid p.o. for another 5 weeks. The streptomycin should be given at your“tlinic, as there are no trained medical personnel in his village, He should have follow-up chest X-rays every 3 months for the duration of ther ty year after that, depending on your evalu- as been advised to stop streptomycin and MD.THE WRITING OF ORDERS TO THE NURSING STAFF The writing of ordets should be clear and orderly. Writ : tentative or Achnitve diagnosis diagnoses. at ite of order sheet, Also, if the patient gives a history of allergy to drugs, indicate with red ink or pencil, both at the top of the order sheet and on the cover of the medical chart, as, for txample, ALLERGIC TO PENICILLIN. The emaniet of the orders should include the desied activities, diet, nursing care, vital sign, (temp., pulse, BP and respiratory rate) clinical ‘investigation, diagnostic procedures, treatment, miscellaneous orders such as consults and discharge instructions. Thus, ot dets can be written according to the following format, for Tanai (or defintve) diagnos: Vital epatis with pre coma. Activities: Bed rest with commode privilege. Restriot protein to 40 gm per day. Investigations: a) ESR, haematocrit, WBC (total and differential count), prothrombin time, platelets and peripheral blood mor- phology. ¥) Urinary bilirubin and urobilinogen. ©) Stoo! for ova and parasites. 4) SGOT, SGPT, alkaline phosphatase, total and direct bilirubin, BSP, serum protein and electrophoresis. ) Hepatitis B surface antigen (HBSAg), heterophile antibodies (Paul Bunnell test) and E.B. virus anti- bodies f) Chest X-ray, PA view. Diagnostic procedure: Liver biopsy with Menghini needle on Thursday, next week (give date ) at 9:00 am. ‘Treatment: a) No sedatives or hypnotics. ) 1900 calorie diet per day. ) Vitamin Ki 10 mg IM daily for 3 days. 4) Neomycin 280 mg tid, pro. for 7 days. ¢) Magnesium sulfate 15 gm daily, p.o. for 5 days.PRESCRIPTIONS _ Different physicians write prescriptions in different ways. Wis, therfore, diffialt to dcate a uniform vay of presi ‘ing treatment Hopever, it should be emphaszad that any rescuption should include the following: 1, The date the prescription is written. 2. The full name of the patient. 3. The hospital record number. 4, The generic name, with the trade name in parenthe- Si, of the drug, the exact dose, the frequiy at which the drug should be taken, the route of admi- istration apd the total treatment period, eg. Digotin (Lanoxin) 025 mg daily, p.o. for 6 months; Diaze- pam (Valium) $ mg tid p.o. for 21 days; etc. 5. The signature of the licensed or qualified physician, ‘Note: The medical student is legally forbidden to write prescriptions to patents. é COMMON ABBREVIATIONS The stodent should famillarie himself with the abbrevia tions given below. Since some physicians still use the old words and phrases when prescribing drugs, the most comm of thee are also shown, though nowadays the English version is more acceptable ont cian) (Laci) before meals (puta) (Latin - ops ad lip (libitum) (Latin)- freely Hb ~ haemoglobin APB aids HbeAg-heputs B sui angen AV» aerienas HEEN.T, «Ha, Eas, Eyes, (tis de Lave each ay ae ss o Hot presure iaeegenees Me = ‘i hr, hrs hour, hours WON thot we oe 1s (ora som) (Lat) -at etn Cede atthe hou of seep’nl ine ‘mom + millimetre ‘mm) - cubic milimete ‘amjbour- millimetre pet hour mm Hg milimeire of mercury P pale PA. view -Poser-Anteior_iew 1% (post cium) (Latin) « after meals (0. por cs) (Latin) by mouth git ela as the need PT - postr i ime {i en a, RR stespiraory rate SOAP Sbjeine, Obie Assi nd Pan SGOT- serum gluamic orice transaminase ‘SGPT - serum glutamic pyruvic ‘transaminase Stat (avin) (Latin) - immediately T temperature TB, sonic 300 mg ps hace tone 150 mg TB 450- isoriaid 300mg plus hia- etarone 150 mg (also known as TB) tab - tablet temp - temperature tid (er indie) (Latin)-three times each day TIBC- Total lon Binig Cpaciy ‘WBC - Whi Boodcell Count COMMON WORDS AND EXPRESSIONS USED AS COMPLAINTS BY ETHIOPIAN PATIENTS Different nationalities have different ways of expressing their symptoms to their doctors, The less medically informed the palient is, the mote difficult it is to convey symptoms to his doctor in the scientific manner in which the latter conceives disease processes, Some complaints and descriptions of symptoms by Ethiopian patients are often difficult to comprehend, as they ‘end tobe related to myths, cultural beliefs, folklore, and individual ‘or group misconceptions of disease processes, as well as of anato- mic locations of organs and systems.The expatriate andthe medical student who lack experience and/or are brought up ina city with limited contact with people from the countryside may find some of these words and expressions misleading and, at times, mean- inglss. On the other hand the patient explains his symptoms in his ova way, using what he considets correct expressions. Thus, doctor-patient communication may fail and the wrong ‘management may be prescribed to the patient with the resultant untoward effects, _ Some expressions are so totally unrelated to known seas process that the dator ot the medical student may be at «loss trying to grou ing si patientie re The vervws sytem: The word i that one. wonders if thsi national ee ae a “it makes me go around”. However, careful questioning . ae ‘hat it implies lght-headedness or dines but ah Vertigo. Further explanations by the patient may clude PAF PAP PRCA BceTN Lhe (it My eyes", “it curtains my eyes"), which describes and blurring of vision which may grow worse down or on suddenly rising from a siting pos- a nation that fasts (omitting breakfast and avo- products) so many days in a year, such compla- Tot be surprising. However, there may also be other need to be considered, of patients, using their hands in a demonstra- , divide theit body vertically along the midline ichead to the level of the ground along the sym- js and Say: WE NILILU theM® dor, While directly states that half of the body is numb sch a pet mide and iplatera anatonia is never proven on neutological examination. The orig of this complaint is unknown. The expresions hd- Gh LINEA ASAD! ORLY CDAD AL PKA bites the inside of my head”, “it burns the top andthe soles of my fet") either Peet cea Gee ene. often effectively with tranguilies. zE us iy FE . FEE i 3 F é = Sey i} = E 2 Be 5 e. teen treated with fla ot “Holy Water” at sever pla cts before seeing a medical doctor. Some patients simply say fawn (“it makes me fall”) Ears, eyes, nose, mouth and throat: Earache and tinnitus may be descibed as ger faenewA ("it pricks my eas”) and Fen poeuAita (my eat shouts) respectively, while ex cessive flow of teats is described as Raga ("it makes me weep”). A patient with a sore throat, with or without tonsilitis may complain of pY#A o€f,A(°my tonsils have descended") This complait may persist even if the patient is aware that his tonsils have been removed by the traditional local expert Respiratory system: The French concept of courant dir (current of air draught) as a possible cause of pneumonia is shared by most Ethiopians, who describe pneumonia ot an upper sespiratory infection as PCR AAS ("a disease of cold weather or draught)". If a man presents with signs and symptoms suggestive of respiratory infection, he has been struck or caught by the cold (ice 72). What may be interpreted as pneumonia by the patient may also be called agen #% (“a lung struck by cold”). It is not unusual to see patients who have been struck by the cold on specified and circumscribed areas of the chest. An irritating dry cough may be described as hth BARA ("it makes me say titi’), while haemopysis(“my heart melts"). Very oiten the physician is oblig to rephrase his questions in several diet ways nee a ‘Convinced that the patient experiences dyspnoea. 9° “4h (“reduction of blood”) may mean anaemia cr hypotension. Again, the student or the doctor must try to distinguish be- ‘tween the two unrelated complaints. The untreated or unco- atrolled. hypertensive patient may complain: Ads 498 | B4AA (“my head is exploding ‘or boiling”), The expression AN, ore (Cimy heart is beating”) usually means palpitation, but the naive student may congratulate the patient for the normal ‘action of the heart which permuts the patient to live! Gastrointestial system: Some patients express anorexia a8 OD ARENAAT (‘my parasites will not accept the food”), It appears that these patients believe that parasites are normal inhabitants of the gastrointestinal tract, and that these parasites control the appetite of the individual, Thus when a patient says ON Tit ONE heTa(“my parasite shouts” of ‘my parasite wants”), he is suggsting good oppe- tite. Beware of the anatomical location of AV (‘my hear IF asked specifically, the patient points to the epigastium ‘but not to the precordium. Thus AM had (‘it burns:my heart”) means “T experience epigastric burning pain”, ond AMY EPA (it grits my heart”) refers to #C oF heartburn. “Some ethnic groups may use the expression Teal LATA (“it makes me push upwards”), whereas others may say ‘Phdahi'a, both meaning emesis (vomiting). The opposite to Te BATA is AA (“_makes me push Sat fly around the indus ile ect resulted in Re 1H" Fateals ss in deseribing, abd: ome cowl but sometimes. @ bi ww bed at night, and this en from rural areas tend to be at ‘ninal symptoms such as those of pyloric ae a vividly deseribe unidentified living, beings MBNIE sounds within the abdomen and, in the process, caus comfort, anxiety and fear. Others trace a defined pathway slong which an unwanted parasite travels within the abdomen iho causing chaos, pai and. general ill health. Tn auch as, uiding specific questions may bring out the exact pre ol the patient, If a patient starts to talk of turd (haemo- uid) traveling upwards tothe top of the head, one may fave to reassure the patient that one is dealing with simple ani treatable haemortholds and. not rectal carcinoma. Genitourinary system: A number cof patients describe the colour of their morning urine as f+ £4? BeNAA ("reds like blood”), The unwary student or doctor may immediately em- rk on extensive investization to rule out causes of haema- (ura. However microscopic analysis of such concentrated urine sa- ingles will eval no microscopic haematuria. Theres a tendency tv ascribe lower abdominal pain to gynaecological structures ty some female patients. Thus, pains originating from thelower quadrants of the abdomen are referred to as PRE) £7 A (T have pain in the womb”). A post-partum haemorrhage sway be desribed as gy? o9,)°F ("the blood hit me”), and the pushing down pain of the patient in labour may be de seribed as JF gey'ia (‘Something pushes down”). ere are patients who believe that products of canmcxplion i sway cae (as indfem is pilooReyin » LhetexA ("it pulls me up ot ripples me"). ‘Usually such complaints refer to the We aaa ‘While the patient is convinced of these descriptive complaints, cone often finds the patient walking into and out of the exa- ‘mination room in the most impressive erect posture of Homo -sapiens. What these complaints convey in terms of aetiological ‘concepts remains un-known, ‘Whereas other nationalities are ashamed to talk about ‘venereal disease, even ifthey have hadit, one finds the Ethiopian only too ready to explain his symptoms of deep-seated mus- ‘culoskeletal aches and pains ot other vague feelings by wc, 1% (“Lam put to shame”, ot “T have had it alrear dy”, or “I have syphilis"), which is often not true. Tn summary, there ate specific words and expressions ‘used by Ethiopian patients which originate from myths, cult- ‘ural beliefs and individual or group misconceptions of disease ‘and anatomical locations of organs and systems. | The student and the doctor ought to appreiate these in order “to arate ient relationships and so (0 achieve ak : SUGGESTED READING | JS. 1977, Physical diagnasy. i ination of me —oien. ‘The history and examination of edition, St. Louis: The CV.Mosby Company. 2, Hunter, D., and Bomford, RR. 1975. Hutchison’s Cl. ical Methods. 16th edition. London: Bailliere, Tindal, & Cassill. 3, DeGown, EL, and DeGown, RL. 1969. Bedside Diag site Examination 2nd edition. London: The Mac Millan Company, Colli-MacMillan Ltd. 4, Major, RL, and Delp, MH. 1975, Physical Diagnosis, fth edition. Philadelphia and London: W.B, Sau ders Company. 5. Halley, H. 1973, Physical Signs in Clinical Surgery. 1Sh edition. Bristol: John Wright & Sons, Ltd 6, Weed, LiL. 1968. Medical records that guide and teach New Engl.J. Med, 278: $93 and 652. 1, Feinstein ALR. 1973, The problems of the ‘“problen- oriented” medical record. Ann, Int, Med. 78.151 8. Goldfinger, SIE. 1973. The problem-oriented record A aie from a believer. New Engl. J. Med. 2%: 1, Prior, J.A., and Silbersteta,