CASE HISTORY

Definition
⚫Case history refers to a file containing relevant
information pertaining to an individual.
⚫Case history is a record of information related to
medical condition of a person.
⚫A case history is defined as a planned professional
conversation that enables the patient to
communicate his/her symptoms, feelings and fear
to the clinician which are used to obtain an insight
into the nature of patient’s illness & his/her attitude
towards them.
Objectives
⚫To establish a positive professional relationship.
⚫To provide the clinician with information concerning
the patient’s past medical and personal history.
⚫To provide the clinician with the information that may
be necessary for making a diagnosis.
⚫To provide information that aids the clinician in
making decisions concerning the treatment of the
patient.
Steps in case history taking
1. Assemble all the available facts gathered from
statistics, chief complaint, medical history and
diagnostic tests.
2. Analyze and interpret the assembled clues to
reach the provisional diagnosis.
3. Make a differential diagnosis of all possible
complications.
4. Select a closest possible choice-final diagnosis.
5. Plan an effective treatment accordingly.
Methods of obtaining the patient history

There are 3 methods:

1) Interview
2) Health questionnaire
3) Combination of both
1) INTERVIEW: In this the patient is asked about his or her
health in an organized fashion. The patient is allowed to
discuss any problem fully.

Disadvantages:
a) Method depends on the skill as an interviewer.
b) The interviewer may skip some important topics.
c) The interviewer requires time to be done well.
2) HEALTH QUESTIONNAIRE:
Health questionnaire is a printed list of heath related
questions that the patient is requested to answer at the first
appointment.

Advantages:
1) It takes little time.
2) It offers a standardized approach for each patient.

Disadvantages:
1) Little time to build rapport with the patient.
2) The questions or their format may be interpreted inaccurately
by some patient.
3) COMBINATION OF INTERVIEW & QUESTIONNAIRE:

1.The combined method is considered by the authors

to be the best appropriate technique for history
taking in the routine practice.
2.This approach uses the advantages of both techniques
and reduces the disadvantages after reviewing a
completed health questionnaires, the doctor
discusses the response with the patient.

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COMPONENTS
⚫ Statistics ⚫ Provisional diagnosis
⚫ Chief complaint ⚫ Investigations
⚫ Medical history ⚫ Final diagnosis
⚫ Personal history ⚫ Treatment plan
⚫ Physical examination
 STATISTICS
⚫ Patient registration number
⚫ Date
⚫ Name
⚫ Age
⚫ Sex
⚫ Address
⚫ Occupation
⚫ Marital status
Patient Registration Number
1. Maintaining a record
2. Billing purposes
3. Medico legal aspects

DATE
1. Time of admission
2. Reference during follow up visits
3. Record maintenance
NAME
1. To communicate with the patient
2. To establish a rapport with the patient
3. Record maintenance
4. Psychological benefits

AGE
1. For diagnosis
2. Treatment planning
3. Behavioral management techniques
Calculation of dose on the basis of Age:

CHILD DOSE
1) YOUNG RULE = child’s age adult dose
age + 12
2) CLARK RULE =

child age at next birthday adult dose

24

3) DILLING RULE = age adult dose

20
SEX
1. Significance: Certain diseases are gender specific.
A. Diseases common in males: Leukolpakia, cancer like
squamous cell carcinoma, melanoma, lymphoma.
B. Diseases common in females: Iron deficiency anemia,
Sjogren’s syndrome, osteoporosis, recurrent aphthous ulcers.

2. Drug interaction: In females, special consideration

must be given to pregnancy & lactation.
ADDRESS
1. For future correspondence.

2. Gives a view of socioeconomic status to know

about the nourishment, hygiene & payment
capacity of the patient.

3. Prevalence of diseases like fluorosis as a result of

the increase level of fluorides in water is spread
differently in various parts of the country.

.
 OCCUPATION
1. To assess the socioeconomic status.
2. Prediction of diseases in different occupations. For eg:
COPD is common in persons working in coal and gold
mining, farming, grain handling, cement and cotton
industries.

MARITAL STATUS
1. To see any history of consanguineous marriages.
2. The high consanguinity rates coupled by the large
family size in some communities could induce the
expression of autosomal recessive diseases.
 CHIEF COMPLAINT
●The chief complaint is usually the reason for
the patient’s visit.
●It is stated in patient’s own words in chronological
order of their appearance and severity.
●The chief complaint aids in diagnosis and
treatment therefore should be given utmost
priority.
 HISTORY OF PRESENT ILLNESS
● Elaborate on the chief complaint in detail
● Ask relevant associated symptoms
● Symptoms can be elaborated in terms of:
 Severity
 Duration
 Location-localized, diffuse, radiating
 Progression-contineous or intermittent
 Aggravating & relieving factors
 MEDICAL HISTORY
● Medical history includes the information about
past and present illness.
● All diseases suffered by patient should be
recorded in chronological order.
 FAMILY HISTORY
● Family members share their genes as well as
their environment, lifestyles and habits.
● Risk for diseases such as asthma, diabetes, heart
disease, hypertension, stroke and certain cancers
is higher in family.
● There are also several inherited anomalies and
abnormalities that can affect different types of
organs.
 PERSONAL HISTORY
● It includes:
 Diet
 Appetite
 Bowel & micturition habit
 Sleep
 Oral hygiene measures
 Oral habits
 Adverse habits
 PHYSICAL EXAMINATION
● PICCLE: Pallor, Icterus, Cyanosis, Clubbing,
Lymphadenopathy & Edema
● Vital signs: Temperature, Pulse rate, Respiration
rate & Blood pressure
● HEENT: Head, Eyes, Ears, Nose & Throat
● Cardiovascular system
● Respiratory system
● Gastrointestinal system
● Genitourinary system
● Central nervous system
● Extremities
 PROVISIONAL DIAGNOSIS
● It is also called tentative diagnosis or working
diagnosis.
● It is formed after evaluating the case history and
performing the physical examination.
 INVESTIGATIONS
● Routine biochemical investigations
● Complete blood count
● Urine examination
● Radiological investigations: CT scan, MRI, X- rays
● Other investigations: ECG, ECHO
 FINAL DIAGNOSIS
● Final diagnosis can usually be reached following
chronological organization and critical evaluation of
the information obtained from:
 Patient history
 Physical examination
 Laboratory and radiological examination
 TREATMENT PLAN
● A detailed plan with information about:
 Patient's disease
 Goal of treatment
 Treatment options for the disease
 Possible side effects
 Expected length of treatment