Case Sheet Writing/ History Taking / Case writing

It is further classified into

1. Vital Data
2. Vital Signs

I. VITAL DATA

Will collect important information about patient, his family, surroundings and discomfort with what
he is suffering to make our way of diagnosis easy

1.Name

 To gain the confidence of the patient

 For information in between many similar names or course
 To obey the medical legal aspects

2 Age

 Certain disorders are particular to certain age group example: Incidence of Osteoarthritis
degenerative joint disorder usually occurs after 50 age, menopausal syndrome usually occurs
45+ in women, Benign prostatic hypertrophy after the age of 40 in males

3. Sex/Gender of the patient

 Should know as certain disorders are gender specific
 Example: patient with deficiency in micturition, by knowing gender, BPH can be suspected.
 Menopausal syndrome occurs only in female . Males are more prone to cardiovascular system
disorders
 Male with the kind of chest discomfort should be evaluated with ECG, ECO and all..
 To fix the dose of the medicine as full strength in males and moderate strength in females.

4. PLACE
 Should know as environment of places where patient is located may have influence on disorders
from what patient is suffering with.
 Example: filariasis, elephantiasis are more in coastal belts
 Incidence of bronchitis ashthama in more cold breeze
 People located near to industrial area like cloth mining, cement more prone to end up with
lower respiratory tract disorders.
 People located in jaangala pradesha more prone to end up with vataja vyadhi, where as in
anupa pradesha end up with kaphaja vyadhi..

5.Occupation
  Should know as many disorders have direct impact or influence of patient by knowing which we
can advice either change the job Or make some modulations with the same.
 Example: people working in current factory, cloth industry, mining area are more prone to lower
respiratory tract infections.
 Policeman standing to control traffic may end up with vericose veins, Ulcer formation also.
 Labour work in construction prone to end up with contact dermititis etc..

6. Marietal status
 In case of STD to advice to know the source of infection should know the marietal status
 In case of mental stress should know the marietal status as it may be the reason of stress
 Need to know as to educate the copartner regarding the lines and duration of treatment to
expect cooperation..

7. Date of Admission and Date of discharge

 For medico legal aspects should know date of admission and date of discharge
 To know the duration of stay in the hospital to know completed course of basti, katibasti etc..

8. Chief complaint or main complaint

 The discomfort which makes the patient to seek the medical advice or the discomfort
which trouble and bothers the patient more.
 Example: pain in neck region along with headache ringing noise in the ear in which neck
pain or stiffness is considered as main complaint because by treating it headache and
ringing noise will become down.

9.Associated complaints

10.History of present illness

 Elaborate form of chief complaints or the mode of manifestation or main complaint of patient
will be written
 Example: main complaint is pain in both the knee joint

History of present illness goes as

Patient was set apparently normal pain in both knee joint which was mild initially, worsened later
for which consulted near by physician but didn’t get any relief Hence got consulted or admitted our
hospital.
11. History of past illness

 Should document whether patient suffered with the same (related to main complaint)
 Whether patient took any kind of treatment or hospitalized for long duration for more than
15 days

12. History of comarbids

The set of disorders which will have influence on patient’s body and disorder as well they are..

 Diabetes mellitus
 Hypertension
 Ischemic heart disorder
 Coronary artery disorder
 Bronchial asthama
 Tuberculosis

13. Medical history

 Should document whether patient took any kind of treatment for long duration that is
more than 15 days Or a month
 Any history of allergic reactions to any kind of medicines
 What kind of medicines patient is on presently

14.Family history

 Should document whether anyone in the family suffering with the same
 Whether any one in the family died because of sudden or unexplained death which
indicates possibilities of IHD
 Which helps to guide the patient in prognosis and to follow certain diets, medicines and
activities.

15.Personal history

 Diet – Vegetarian or mixitarian

 Appetite – should document the status of digestive fire before suffering with disorder
and after started suffering with disorder..
 Bowel habits – should document
 The episodes
 Consistency
 Any difficulty to pass the stool
 Any associated material like blood puss…
 Addictions.
  Micturition – should document – frequency

 Any difficulties in passing urine as in BPH person face difficulty to pass the urine
 Any color change normally it is straw color
 Change in color eg. Deep yellow color indicates clinical jaundice
 Less comsumption of water
 Reddish color of urine indicates association of blood in urine ( haematuria)
indicates acute renal failure, injury anywhere in external genital organ.,
Nephritis

 Sleep

Should document

 Quality of sleep – sound or disturbed or not getting sleep at all (insomnia)