Me1 – Paragraph 2

After the opening paragraph (PRPPD), we write the admission related paragraph. It is called the Me1 Paragraph. We include only the recent medical history of the patient in this paragraph.

It is the patient’s Recent Medical History.
It is written in Past Tense.
Generally we follow the PADC.TDT order.

Me1 includes some / all of the following:

Patient’s name.
Presenting complaint.
Presenting date.
Vitals, Tests, Findings.
Diagnosis / symptoms suggestive.
Treatment (Surgery, medication)

NB: Do not include any social information in this area.

Me1 Sample 1

Patient: John Miller.
Visit: Today.
Complaint: Fever, cough, shortness of breath for 4 days.
Tests: Chest X-ray (bilateral infiltrates), CBC (leukocytosis), COVID-19 negative.
Diagnosis: Community-acquired pneumonia.
Treatment: Ceftriaxone, Azithromycin, Paracetamol, Oxygen.

Sample Answer

Mr Miller visited on 14th May, 2025, with fever, cough and shortness of breath for the last 4 days. His chest X-ray revealed bilateral infiltrates, CBC showed leukocytosis; however, his COVID-19 tests showed negative. He was diagnosed with community-acquired pneumonia and his treatment was commenced on Ceftriaxone, Azithromycin, Paracetamol along with Oxygen administration.

Me1 Sample 2

Patient: Mr Peter Parker, 33 years

Today’s Visit (02/03/25)

Complaint: Chest pain, dizziness.
Tests: ECG (normal), BP 160/95, Troponin negative.
Diagnosis: Hypertension exacerbation.
Treatment: Increased Amlodipine to 10mg, lifestyle advice.
Progress: Monitoring response.

Sample Answer

Mr Parker visited on 2nd March, 2025 complaining of chest pain and dizziness. His ECG showed normal, blood pressure was 160/95 and troponin was negative. He was diagnosed with an exacerbation of hypertension for which his Amlodipine dosage was increased to 10 mg along with lifestyle advice. His progress was closely monitored.

NB: Remember, from Me1 (Paragraph 2) onwards, we write an adult patient’s last name and a minor patient’s first name.