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Les bases de la présentationA clinical case presentation in English follows a logical structure that helps doctors communicate clearly. You will usually hear the chief complaint first, then the history of present illness, past medical history, physical exam, and finally the assessment and plan. Understanding this order helps you follow a case even if you miss a word. The same structure is used in oral presentations and written reports. Learning key phrases will make you more confident during hospital rounds.
📖 Définition
Chief complaint (CC) : the main symptom or problem the patient reports, in the patient's own words.
🔍 Exemple
A 45-year-old man presents with chest pain for two hours.
💡 À retenir : A clinical case presentation follows a logical order: CC, HPI, PMH, PE, A/P.
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Décrire les symptômesTo describe symptoms, you need precise vocabulary: pain, fever, cough, fatigue, nausea, dizziness. Always ask about onset, location, duration, severity, and factors that make it better or worse. For pain, use the OPQRST method: Onset, Provocation, Quality, Radiation, Severity, Time. This helps you collect complete information and understand the patient's story. Common phrases include 'The pain started suddenly' or 'It radiates to the left arm'.
📢 Rappel
Question words: when, where, how long, how severe, what makes it better or worse.
📖 Définition
HPI = History of Present Illness : detailed story of the current problem from start to now.
🔍 Exemple
The pain started suddenly and radiates to the left arm.
💡 À retenir : Use OPQRST for pain: Onset, Provocation, Quality, Radiation, Severity, Time.
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Examen et constantesVital signs are always reported in the same order: blood pressure (BP), heart rate (HR), respiratory rate (RR), temperature (T), and oxygen saturation (SpO2). You will hear numbers and abbreviations, so learn the units: mmHg for BP, beats per minute for HR, breaths per minute for RR, degrees Celsius for T, and percent for SpO2. The physical exam findings are described from head to toe or by system. Understanding these numbers helps you assess if a patient is stable.
📖 Définition
BP = blood pressure, measured in mmHg (millimeters of mercury).
🔍 Exemple
BP 120/80 mmHg, HR 72 bpm, RR 16, T 37.0°C, SpO2 98%.
⭐ À retenir
Always state the unit after each vital sign: mmHg, bpm, breaths/min, °C, %.
💡 À retenir : Vital signs are always given in the same order: BP, HR, RR, T, SpO2.
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Du diagnostic au planThe assessment summarizes the most likely diagnosis based on the history and exam. The plan lists the next steps: tests to order, treatments to start, and follow-up. A differential diagnosis is a list of possible causes that must be ruled out. Understanding this part helps you know what the doctor is thinking and what will happen next. Common phrases include 'The most likely diagnosis is...' and 'We will order a chest X-ray.'
📖 Définition
Differential diagnosis : list of possible conditions that could explain the patient's symptoms.
🔍 Exemple
Differential diagnosis includes pneumonia, bronchitis, and pulmonary embolism.
⭐ À retenir
The plan should be specific: which test, which treatment, and when to follow up.
💡 À retenir : The assessment states the most likely diagnosis; the plan lists next steps.