The Vitality of Case History in Medicine

Case History is also known as Medical History.It works as a vital tool for health professionals to understand a patient’s health status. When treating a patient, information gathered by any means can crucially guide and direct care. Many initial encounters with patients will include asking the patient’s medical history

In general, a medical history includes an inquiry into the patient’s medical history, past surgical history, family medical history, social history, allergies, and medications the patient is taking or may have recently stopped taking. There are five major ways to access your medical history –

  • Keep your risks for hereditary disease.
  • Keep track of medications
  • Alerting other family members about disease.
  • Your medical history can be more valuable in case of emergency
General Questions asked during history taking
  •  Weight – Increased, decreased or constant
  •  Sleep – Change in sleeping pattern or difficulty in getting sleep.
  •  Energy – Weakness or malaise.
There are few steps to take case history which are as follows :
  • General Approach –   Always record personal details like name, age, address, sex, occupation, religion, marital status and record date of  examination.
  • Chief Complaint – The patients describe the problem in their own words.It should be specific in one clear sentence communicating the present problem.
  • History of Present Illness – it is gathering detailed information about the present condition. This information is about the onset,duration, severity of symptoms.Record Associated and aggravated factors also. Gain as much information you can about the specific complaint. For example in case of chest pain you should ask and check the site of pain, onset, character, radiation, tome course, relieving factor and severity.
  • Past Medical History – It starts by asking the patient if they have any past medical problems. It includes previous surgeries, history of trauma and hospitalizations. Patients are usually not interested in telling past events. The relevant past history pertaining to the present symptoms is to be asked by the physician. At times, It will become essential to communicate with doctors that have treated the patient in the past.
  • Drug History – Inquire about all the medications the patient is currently taking, including prescription drugs, over-the-counter medications, herbal remedies, vitamins, and dietary supplements. Its duration of use, Effectiveness and Side Effects, Allergies and Sensitivities should be recorded.
  • Family History –  Inquire about the patient’s immediate family members’ medical history, including parents, siblings, and children. Note any hereditary diseases, genetic disorders, or significant medical conditions that may have a familial link.
  • Social History – It includes alcohol intake , use of tobacco , any kind of employment history and specific travel history. Explore occupational exposures, living conditions, and any social factors that may contribute to the patient’s health or illness. Find out who lives with the patient and explore the patient’s background.
  • Review of Systems – Systematically inquire about symptoms or issues related to various organ systems, even if they do not appear directly related to the chief complaint. It includes general features like fatigue, fever, weakness and change of weight. Systems include cardiovascular system, respiratory system, urinary system, nervous system , genital system and musculoskeletal system.
  • Assessment and planning – Access each active problem after making a list. Give a differential diagnosis and explain a brief investigation and management treatment plan.
Case History Taking In Children

In the case of children , it is important to establish trust with both the child and their guardians. Create a child – friendly and welcoming environment using different communication techniques and involving parents’ interest in the case history taking process. In children’s case, following questions should be asked from mother or other responsible person :

  • How many other children are there in the family ? 
  • Is there any history of illness in parents ?
  • What was his birth weight ?
  • What are ages and sexes ?
  • Was the mother well during pregnancy ?

It is important to take case history in a specific manner, which may vary depending on the patient’s health condition. Explain the plan to the patient which may include further diagnostic tests and treatment options.Thank the patient for sharing their information and for their cooperation throughout the case history.End the case history with a professional and courteous closing, such as wishing the patient well or expressing your commitment to providing them with the best possible care.

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