TRAINING IN THE USE OF ICPC

Vignettes of the book ICPC-1 (1987)

1. A woman, aged 18, returns to your office and requests to have the sutures removed from the laceration on her right hand. She also complains that the antihistamine tablets you gave her for hay fever make her very sleepy during the day and the hay fever is troubling her. On examination you find watering eyes, nasal obstruction with a clear nasal discharge, and she sneezes several times. You also examine the laceration on her right hand, which has healed perfectly. You remove the sutures. You replace the antihistamine tablets with a prescription for sodium chromoglycate, after explaining that she may have to compromise on total relief from the symptoms of hay fever as it is better not to overreact in treating the symptoms of the condition.

Problem n°#	Entry task	Process before	Appreciation	Process after
1	S54	S31	S18	S54
2	A85		A85	A45
3	R97	R31	R97	R50





2. A 23-year old woman working as a typist and also an avid tennis player complains of pain in the left elbow over the last ten days. Her main problem is that she cannot use the left hand during work. On examination you find pain over the left radial epicondyl and the radial muscle group, which feels firmer than on the other side. You diagnose a tennis elbow and you infiltrate the affected area with 1 ml of a corticosteroid solution.

Problem n°#	Entry task	Process before	Appreciation	Process after
1	L10/L28	L31	L93	L55





3. A labourer, aged 55 years and weighing 115 kg, complains of having had increasing bouts of coughing and shortness of breath for one week. When asked, he tells you than he has been sweating and felt feverish for 3 days. You find a temperature of 38.2°C, a red pharynx, and moist sounds and wheezes are audible in all areas on auscultation of the chest, particularly on the left side. You diagnose an acute bronchitis and you treat him with amoxycillin and an expectorant. You use this opportunity to calculate his Body Mass Index, which is 32.8, and to express your concern with his gross overweight. You advise him strongly to follow the diet you give him and he agrees that his obesity is a real problem. He would like to have some support in his effort to lose weight and you refer him for this reason to a dietician (nutritionist) who will be able to see him in about six weeks.

Problem n°#	Entry task	Process before	Appreciation	Process after
1	R05/R02	R31	R78	R50
2	T64	T31	T82	T45/T66





4. You do a house call for a seven-year-old boy, because he has had fever and a sore throat for three days and a rash since early that morning. On examination his temperature is 39.3°C and he has a blush-like erythema of the face and trunk. The tonsillar lymphnodes are markedly enlarged and his throat is bright red with pus on his large tonsil. You diagnose scarlet fever, you prescribe penicillin and arrange a follow-up in a week

Problem n°#	Entry task	Process before	Appreciation	Process after
1	A03/R21/S07	R30	R72	R50/R63





5. A 34-year-old woman comes in for frequency and dysuria. She is also afraid that she suffers from hypertension. In the fresh midstream urine you find 50-60 white blood cells per field (there are no complaints of a vaginitis). You prescribe an antibiotic and you arrange for a urine test in ten days. To your surprise her blood pressure reading are repeatedly 170/100. You decide to measure her blood pressure again when she returns for the results of her urine test in ten days.

Problem n°#	Entry task	Process before	Appreciation	Process after
1	U01/U02	U35	U71	U50/U33
2	K25	K31	K85	K63





6. The same patient from encounter 5 returns to get the result of the urine test and to have you check her blood pressure again. The urine test is negative and you tell her that this episode of cystitis is concluded as far as you are concerned and you give her advice on how to deal with a repeat infection. You measure her blood pressure and the readings are now practically normal : 140/90 and 145/95. You explain the results and advise her not to change her lifestyle and to have her blood pressure checked in 6-9 months.

Problem n°#	Entry task	Process before	Appreciation	Process after
1	U63/U60	U33	U71	U45
2	K63/K31	K31	K85	K45/K63





7. A woman, aged 25, who has had two previous babies thinks she may be pregnant again. Her last period was seven weeks previously. The urine test during consultation confirms the results of the physical examination. She is pregnant. You refer her to a midwife (obstetrician). While you write the referral letter she asks you to remove a mole from in front of her left car. You have time to do so and you excise the mole. One suture is sufficient to close the wound and you send the mole to a pathologist for further examination.

Problem n°#	Entry task	Process before	Appreciation	Process after
1	W02	W31/W33	W78	W67
2	S52	S31	S82	S52/S37





8. A 52 year-old man complains that he feels very tired and that he has an urge to cry. He agrees that he feels depressed, but despite all this he has managed to continue to do his job. However, this has become increasingly difficult. He also complains about his working conditions, which are very bad mostly because he cannot cooperate with his boss. You find that your patient is definitely depressed. He is troubled by early morning waking and morning tiredness. He has a decreasing interest in his usual activities. He feels worthless and inappropriate. You diagnose a depression and you propose treatment with an antidepressant. During the 15-minute session you discuss with him both the nature of his depression and how it relates to his working conditions. A prescription for amitryptiline is given and an appointment for next week is made.

Problem n°#	Entry task	Process before	Appreciation	Process after
1	A04/P03	P58	P76	P50/P63
2	Z05		Z05	Z58





9. A 42-year-old man complains of having had a plugged feeling in both ears and pain in his right shoulder for ten days. He also wants you to check his blood pressure. On examination you find wax in both ears, which you remove. You find a limited abduction and limited exorotation of the right shoulder, which is painful. There is local tenderness and you inject corticosteroids after telling the patient that he is suffering from a frozen shoulder. There is elevated blood pressure of 170/105 and you advise the patient to return in ten days.

Problem n°#	Entry task	Process before	Appreciation	Process after
1	H13	H31	H81	H51
2	K31	K31	K85	K63
3	L08	L31	L92	L55/L31





10. Your patient returns for his shoulder. He wants to have a simple analgesic, because although the pain in his shoulder is much better it now bothers him during the night. He also wants to have his blood pressure checked again. You find that there is practically no limitation remaining in the right shoulder and you prescribe two tablets of paracetamol at night. The blood pressure is definitely too high : 180/110 in two readings. You do a partial examination where no other abnormalities are found. Your patient is certainly not overweight and there is no evidence of secondary involvement of heart, kidney, brain, or eye due to hypertension. You order an EKG and some blood testes. You tell him that he suffers from hypertension and you advise him to use a salt-restricted diet during the next two weeks. When he returns for the results you will check his blood pressure again and decide whether or not it is advisable that he be treated with drugs. You ask the patient to return in two weeks.

Problem n°#	Entry task	Process before	Appreciation	Process after
1	L63/L50	L31	L92	L50
2	K63/K31	K31	K86	K34/K42/K50/ K45/K63





11. Your patient returns because of his hypertension. He feels all right. He also complains of having had a red and painful nose, for two days. You find his blood pressure is 180/105 and you advise your patient to start using diuretics and to return in four weeks. There is a small boil in the vestibulum of the nose which you open and drain a drop of pus. You prescribe some antiseptic ointment.

Problem n°#	Entry task	Process before	Appreciation	Process after
1	K63/K86	K31	K86	K50/K63
2	R08	R31	R73	R51/R50