1. CASE REPORT vocabulary
A. Žmegač Horvat
Senior Lecturer Medical English

2. CASE REPORT sections Patient info Present complaint
Past medical history
On exam
Investigations
Diagnosis
Treatment
+ Abbreviations & Acronyms
Layout

3. PATIENT INFO also: Personal information
e.g. 45-year-old man / male (patient)
52-year-old woman / female (patient)
if relevant: occupation, marital status, children

4. PRESENT COMPLAINT presents with complains of (c/o)
arrives/-d at the Emergency Room/Department
is/was brought (by an ambulance)
admitted to (the) hospital

5. MEDICAL HISTORY (MH) Immediate medical history / History of the
present illness HPI
e.g. has been feeling sick for 2 days
has vomited repeatedly in the past 5 hours
has lost consciousness twice since the morning
(Pres. Perfect: linked to the present moment)
Past medical history (if relevant, past tenses) PMH
Family history (if relevant) FHx
Habits: smoking, alcohol, drugs (Present Simple)
Allergies: no known allergies NKA

6. ON EXAM (O/E) general condition: build, height, weight
vital signs (vs): t p rr BP
alert, oriented to time, place, and person
mucous membranes well perfused, moist
dyspn(o)ea /dyspn(o)eic, eupn(o)ea /eupn(o)eic
thorax and abdomen visually NAD (no abnormalities
detected)

7. ON EXAM (O/E) Heart: rate & rhythm rubs, gallops, murmurs
Lungs: clear to auscultation
rales, ronchi (sg. ronchus), wheezing
Abdomen: soft, (non)tender, normal bowel sounds
no palpable masses
neg. hepatosplenomegaly
neg. abdominal bruits

8. INVESTIGATIONS (LABS)
CBC, RBC, WBC, PLT, H&H
liver function tests (LFT: AST, ALT, ALP)
kidney function tests (UA, lytes, BUN, cr, GFR)
chem 7/14 = basic/comprehensive metabolic panel
FBG = fasting blood glucose
(o)GTT = (oral) glucose tolerance test
ABGs = arterial blood gases
ESR = erythrocyte sedimentation rate (SED rate)
(a)PTT = activated partial thromboplastin time
PT = prothrombin time (pro time)

9. DIAGNOSIS (Dx)

10. TREATMENT also: Management Hospital course proceeded uneventfully
developed complications
discharged/released from hospital ((in)to home care)

11. ABBREVIATIONS & ACRONYMS: GENERAL
pt = patient
sx = symptoms
dx = diagnosis
tx = treatment
D/C = discontinue
S/P = status post
WNL = within normal limits
DNR = do not resuscitate
DNI = do not intubate
CMO = comfort measures only
AMA = against medical advice

12. ABBR & ACR: HOSPITAL LOCATIONS
ER/ED = emergency room/department
OR = operating room
ICU/ITU = intensive care/treatment unit
CCU = coronary care unit
LTC = long-term care
PACU = post-anesthesia care unit

13. ABBR & ACR: ORGAN SYSTEMS
HEENT = head, eyes, ears, nose, and throat
RS = respiratory system
CVS = cardiovascular system
GIS = gastrointestinal system
GUS = genitourinary system
CNS = central nervous system
MSS = musculoskeletal system

14. ABBR & ACR: HEENT PERRLA = pupils equal, round, reactive to light &
accomodation
EMI = extraocular movements intact

15. ABBR & ACR: CNS LoC = level of consciousness = loss of consciousness
A&O x 3 = alert & oriented to time, place, and person
CVA = cerebrovascular accident
TIA = transient ischemic attack
TBI = traumatic brain injury

16. ABBR & ACR: CVS RRR = regular rate & rhythm NSR = normal sinus rhythm
M/R/G = murmurs/rubs/gallops
CPR = cardiopulmonary resusciation
AED = automated external defibrillator
BVM (AmbuBag) = bag valve mask
MI = myocardial infarction
CAD = coronary artery disease
CHF = congestive heart failura
DVT = deep vein thrombosis
AAA = abdominal aortic aneurysm
A-fib / AF = arterial fibrillation
V-fib / VF = ventricular fibrillation

17. ABBR & ACR: RS Lungs CTA = clear to auscultation B/L = bilaterally
BS = breath sounds
SOB = short of breath
COPD = chronic obstructive pulmonary disease
PE = pulmonary embolism
OSA = obstructive sleep apnea
ARDS = acute respiratory distress syndrome

18. ABBR & ACR: GIS ABD = abdomen BS = bowel sounds BM = bowel movement
N/V = nausea & vomiting
GERD = gastroesophageal reflux disease
IBS = irritable bowel syndrome

19. ABBR & ACR: GUS UTI = urinary tract infection
CKD = chronic kidney disease
ESRD / ESRF = end-stage renal disease/failure
BPH = benign prostatic hyperplasia
PSA = prostate specific antigen

20. ABBR & ACR: MSS DTR = deep tendon reflexes ROM = range of movement
OA / DJD = osteoarthritis / degenerative joint
disease

21. LAYOUT top right-hand corner: name, year of studies, academic year
minimum 1.5 line spacing !!!
spelling: don’t mix British & American !!!
end of course: original & corrected version stapled
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