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Study the Case history form below and answer the questions:
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ü What parts does it consist of?
ü What information does each part of the patient’s case history contain?
8. Read the text and check your predictions:
Case history taking
Advances in technology, genetic testing, and genomic medicine are revolutionizing patient care. Yet the mainstay of diagnostic work is still the patient history. The patient’s case history, medical history, or anamnesis (Greek: ἀνά, aná, ″open″ and μνήσις, mnesis, ″memory″) is the information gained by a physician by asking specific questions either the patient or other people who know the person and can give suitable information, with the aim of obtaining information useful in formulating a diagnosis and providing medical care to the patient. The medically relevant complaints reported by the patient (persons familiar with the patient) are referred to as symptoms, in contrast with clinical signs, which are ascertained by direct examination on the part of medical personnel and results in a form of history taking.
Medical history form may exist in paper compiled variant and electronic one. The advantage of using computerized systems is an easy and high-fidelity portability to a patient's electronic medical record. Also it is an advantage to have saved a lot of money and paper nowadays.
The medical history is a longitudinal record of events to have happened to the patient since birth. It chronicles diseases, major and minor illnesses, as well as growth landmarks. As a result, it may often give clues to current disease state. The method by which doctors gather information about a patient’s past and present medical condition in order to make informed clinical decisions is called the history and physical (H&P). The history requires that a clinician is skilled in asking appropriate and relevant questions that can provide with some insight as to what the patient may be experiencing. The standardized format for the history starts with:
Identification and demographics: name, age, height, weight.
Chief complaint (CC): the major health problem or concern, and its time course.
History of the present illness (HPI): details about presenting complaints, enumerated in the CC (also often called 'History of presenting complaint ' or HPC), including investigations, treatment and referrals already arranged and provided.
Past medical history (PMH): major illnesses, any previous surgery/operations (sometimes distinguished as ‘ Past Surgical History ’ or PSH), any current ongoing illness. It may have dates of operations, operative reports, and/or the detailed narrative of what the surgeon did, including complications, trauma.
Immunization (obligatory for children): vaccination schedule, when the patient was vaccinated and the type of vaccine got.
Review of systems (ROS): systematic questioning about different organ systems: cardiovascular system, respiratory system, gastrointestinal system, nervous system, and others.
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Family history (especially those relevant to the patient's chief complaint): the health status of immediate family members, siblings and parents, as well as their causes of death (if known).
Social history: a chronicle of human interactions - living arrangements, occupation, marital status, number of children, drug use (including tobacco, alcohol, recreational drugs), recent foreign travel, and exposure to environmental pathogens through recreational activities or pets, his/her careers and trainings, and religious training.
Regular and acute medications: those prescribed by a doctor and others obtained over-the-counter or alternative medicine.
Allergie s to medications, food, latex, and other environmental factors
Obstetric/gynecological history (for females). The obstetric history lists prior pregnancies and their outcomes, complications.
Conclusion & closure: a primary diagnosis based on the information above.
Programmed questionnaires and direct questioning comprise the two most common methods used in gathering a case history. To save patient and office time, many doctors utilize a type of personal history form which requires only a simple "Yes" or "No" answer which can be checked or encircled by the patient. A questionnaire gives the doctor an opportunity to review the data prior to seeing the patient so that he may formulate some of the basic questions in his mind prior to contact. Yet the patient’s interview is still the main method of history taking. The basis of a true history is good communication between doctor and patient. An understanding of the goals of the interview, how to handle the presenting symptom and present illness during the interview, how to cope with patient anxiety, and what notes to take are obligatory in developing the art of clinical inquiry.
The value of a case history is directly proportional to its completeness and accuracy. Accurate, well-documented patient medical histories provide a foundation for patient diagnosis and treatment. An inaccurate patient history can potentially lead to a delay in diagnosis and unnecessary testing.
The obtained information through the history taking, together with the physical examination, enables the physician and other health professionals to form a diagnosis and treatment plan.
9. 
Try to answer the questions in ‘Case History Quiz’
1. What is patient’s medical history?
o a record of patient’s life, birth, marriage, graduation
o a record of events since patient’s birth: diseases, major and minor illnesses
o a record of the patient’s interesting events
2. What is a symptom?
o the medically relevant signs reported by the patient
o the medically relevant events reported by the patient
o the medically relevant complaints reported by the patient
3. What is ‘identification and demographics ’?
o chief symptom
o name, age, height, weight
o citizenship
4. What is a chief complaint?
o the major health problem or concern, and its time course
o the major health history, and its time course
o the major health symptom or sign, and its time course
5. What is a history of the present illness?
o presenting symptoms including investigations, treatment and referrals already arranged and provided
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o presenting complaints including investigations, treatment and referrals not arranged and provided yet
o presenting complaints including investigations, treatment and referrals already arranged and provided
6. What is a past medical history?
o minor illnesses, any previous surgery/operations including complications, trauma
o major illnesses, any previous surgery/operations including complications, trauma
o major illnesses, any previous surgery/operations including allergies
7. What is a review of systems?
o systematic questioning about different organ systems
o systematic questioning about different conditions
o systematic questioning about different complaints
8. What is a family history?
o the health status of immediate family members, uncles, aunts, and parents, as well as their causes of death
o the health status of immediate family members, cousins and parents, as well as their causes of death
o the health status of immediate family members, siblings and parents, as well as their causes of death
9. What is a social history?
o a chronicle of human reactions
o a chronicle of human interrelationship
o a chronicle of human interactions
10. What are two most common methods used in history taking?
o two programmed questionnaires
o programmed questionnaires and direct questioning comprise
o a series of interview
10. Write the first two letters of the word:
_ _ story, _ _ tient, _ _ amnesis, _ _ mptom, _ _ mplaint, _ _ gn, _ _ lergy, _ _ agnosis, _ _ inician, _ _ cord, _ _ curacy.
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