case history taking

• How would they describe the pain? 4. Case history definition, all the relevant information or material gathered about an individual, family, group, etc., and arranged so as to serve as an organized record and have analytic value for a social worker, student, or the like: used especially in social work, sociology, psychiatry, and … Multi-specialist input from several disciplines including rheumatology and neurology was also requested. Privacy See our Privacy Policy and User Agreement for details. 1996 Apr;104(2 ( Pt 2)):191-8. - April 7, 2013. n. a complete record of information containing all data about a patient's medical or psychological condition. A 15 year old female with a history of hay fever develops fever, headache and malaise for 4 days followed by a nonproductive cough and scratchy throat. Dr Durga Ghosh, ST4 Acute Medicine, Dumfries and Galloway Royal Infirmary, Dumfries Dr Premalatha Karunaratne, Consultant Physician Medicine for the Elderly, Vale of Leven District General Hospital, Alexandria and Royal Alexandra Hospital, Paisley. Rehabilitation and Assessment Directorate. Acute Medicine Registrar, Dumfries and Galloway Royal Infirmary, Bankend Road, Dumfries, DG1 4AP, UK, Vale of Leven District General Hospital, Main Street, Alexandria, G83 0UA, UK, You can also search for this author in Correspondence to A collection of interactive medical and surgical clinical case scenarios to put your diagnostic and management skills to the test. She was treated for a further pneumonia in hospital and also underwent investigations such as a CT pulmonary angiography (CTPA) scan, which ruled out pulmonary embolism but confirmed partial left lung collapse; subsequent bronchoscopy was negative for malignancy. Taking a proper history means listening carefully to what the patient has Please note: Due to an ever-increasing number of portfolios submitted, the ABE may need to limit the number of submissions accepted for review in any given cycle. Slideshare uses cookies to improve functionality and performance, and to provide you with relevant advertising. Steps in case history taking 1. case history definition: 1. a record of a person's health, development, or behaviour, kept by an official such as a doctor…. A special thank you to Dr Medhat Zaida, Dr Martin Perry, Dr Tracy Baird, Dr Neil McGowan for providing their valuable input and support in the diagnosis and management of this case. A copy of the written consent is available for review by the Editor-in-Chief of this journal. Your audiologist will have some questions for you when you have your first visit. The Case history may take 15 minutes to 30 minutes before the Speech Therapist starts to testing the child. Senior Lecturer Gemma Hurley uses a mock patient to take you through the principles of obtaining a clinical history for www.NurseLedClinics.com. Oral diagnosis oral medicine and treatment planning, Clinical manual for oral...medicine and radiology, CASE HISTORY AND PHYSICAL EVALUATION OF DENTAL PATIENTS /prosthodontic courses, Umm Al-Qura University Faculty of Dentistry, Customer Code: Creating a Company Customers Love, Be A Great Product Leader (Amplify, Oct 2019), No public clipboards found for this slide. If you continue browsing the site, you agree to the use of cookies on this website. Now customize the name of a clipboard to store your clips. Any such limitation on submissions would be dynamic and based exclusively on … This article is published under license to BioMed Central Ltd. Enjoy the videos and music you love, upload original content, and share it all with friends, family, and the world on YouTube. History taking. The purpose of the videos and this accompanying resource pack is to Looks like you’ve clipped this slide to already. It should consist of a few clear and concise … A case history, on the other hand, refers to a record of data which contribu… http://www.bgs.org.uk. Taking a sexual history is a key skill that all medical students need to learn.This guide discusses what questions need to be asked and how they can be phrased when taking a sexual history. A 46-year-old woman presents with a 6-week history of progressive weakness in her thighs and upper arms. The case aims to highlight the importance of taking a good history and performing a comprehensive assessment, especially in the older adult [1]. She remained clinically stable and her treatment goal was to help prevent any further neurological deterioration. History taking, risk assessment and the mental state examination are core clinical skills. History taking 3 57. You can change your ad preferences anytime. There was, however, little neurological and functional improvement otherwise. Our patient, a 75-year-old Caucasian woman, was admitted to hospital for investigation of iron deficiency anemia in June 2013. Repeat back the important points so that the patient can correct you if there are any misunderstandings or errors. myE-Verify does not store your Social Security number when you create your account. To run a Case History report, enter your Social Security number and date of birth and then click the “Get My Report” button. CASE HISTORY FORM ... Medical History Has your child had any of the following? History taking in children can be tricky for a variety of reasons, not least that the child may be distressed and ill and the parents extremely anxious. It is really important to make sure you clarify the language the patient uses. PubMed Google Scholar. There was little known about her past medical history aside from type 2 diabetes mellitus (T2DM) requiring insulin, hypertension and chronic obstructive pulmonary disease (COPD). It is widely taught that diagnosis is revealed in the patient's history. Each clinical case scenario allows you to work through history taking, investigations, diagnosis and management. Interestingly, a previous trial of steroids from her GP for presumed arthropathy had resulted in clinical improvement. Further discussion with our patient’s son confirmed that her mobility had gradually deteriorated over a two-year period; from his perception, the only novel finding was alteration of our patient’s speech at the time of a presumed ischemic stroke. Nurses need sound interviewing skills to identify care priorities. Her medications on transfer were: Novomix 30 twice daily (later stopped due to low blood sugar levels); clopidogrel 75 mg; quinine sulphate 200 mg; ranitidine 150 mg twice daily; folic acid 5mg; and digoxin 125mcg. Her repeat chest X-rays were also unchanged. It was felt that a nerve biopsy would have little else to contribute to the diagnosis and simultaneously might induce patient distress and was therefore avoided. Both authors read and approved the final manuscript. Her antinuclear antibody test (ANA) results were 1/40 and showed a speckled pattern. Case history #1. The audiologist may ask any of the following questions: What brought you here today? Rationale . Cookies policy. Taking a patient’s history has traditionally been regarded as the domain of their doctor. How many meals and snacks do you eat in a 24-hour period? Her cholesterol level was unavailable and her blood and urine cultures were negative. 'Listen to your patient; they are telling you the diagnosis' is a much quoted aphorism. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited.  Presented by Dr Surbhi Singh The art of history taking. Given the clinical improvement, she was deemed suitable for transfer for stroke rehabilitation to her local hospital in August 2013. The patient verbally consented to publication of the case report but was unable to sign the document due to her wrist drop. A person's case history is the record of past events or problems that have affected them, especially their medical history. Case history An introduction is necessary to establish the focus of your case and provide orientation to your reader. How to use case history in a sentence. The ability to obtain an accurate medical history and carefully perform a physical examination is fundamental to providing comprehensive care to adult patients. Assemble all the available facts gathered from statistics, chief complaint, medical history, dental history and diagnostic tests. adenoidectomy encephalitis seizures allergies flu sinusitis breathing difficulties head injury sleeping difficulties chicken pox high fevers thumb/finger sucking habit 2. https://doi.org/10.1186/s13256-015-0559-y, DOI: https://doi.org/10.1186/s13256-015-0559-y. Her CRP level fell to 36 and her WCC to single figures.  Dr Puneeta Vohra. Lussi A(1). How to Take a Medical History. An MRI cervical spine scan revealed no gross abnormality and a CT scan of her abdomen and pelvis showed extensive diverticular disease only. Her inflammatory markers remained elevated with her C-reactive protein (CRP) level approximately 140 and white cell count (WCC) 14 but she remained mentally alert and made clinical improvement. Accessed November 2014. Make a differential diagnosis of all possible complications. Her carcinoembryonic antigen (CEA) and serum angiotensin-converting enzyme (ACE) levels were normal, and CA 125 test result was 70 (0 to 35). These are used in many disciplines and allow the researcher to be more informative of people, and events. A big thanks to Dr Iain Keith, Dr Christopher Foster and also to Dr Gautamananda Ray for providing their valuable opinion when the manuscript was being drafted and a special thanks to all the other medical, nursing and allied health professionals involved in our patient’s care. By using this website, you agree to our Her albumin level was l0, CRP level was 120 and her baseline HBA1c level was 57mmol/L (normal range 20 to 42mmol/L). A 22-year-old male presents to the emergency room with abdominal pain, anorexia, nausea, and low-grade fever. By. A magnetic resonance imaging (MRI) brain scan showed atrophy with small vessel disease, high signal at the left corona radiata and adjacent left occipital horn. You should also address what the patient thinks is wrong with them and what they are expecting/hoping for from the consultation. Manage cookies/Do not sell my data we use in the preference centre. Coinciding with this period, she developed a new dysphasia and what was perceived to be a ‘new’ right-sided weakness. Fortunately, her daughter was present during the ward round that day and a collateral history revealed our patient had ‘possibly’ been like this for 18 months or more. Cite this article. case [kās] a particular instance of a disease or other problem; sometimes used incorrectly to designate the patient with the disease. Taking an exposure history may enable physicians to Make more accurate diagnoses, Influence the course of disease by stopping current exposure, Prevent disease in others by avoiding future exposure, and ; Prompt workplace evaluations and the protection of workers. Our patient had been admitted for investigation of iron deficiency anemia and suffered recurrent illness during admission precipitating a prolonged hospital admission and eventual transfer to her local hospital for stroke rehabilitation. It is only after a thorough history-taking, examination and comprehensive geriatric assessment post transfer to the rehabilitation unit that her illness was diagnosed. This led to a degree of reassurance with regard to the fact that the neurological findings were unlikely to be acute. N., Pam M.S. (let them use their own words). Copyright © … This is particularly true where most paediatric histories are taken - that is, in general practice and in accident and emergency departments. Dental erosion is not a very rare condition. If you continue browsing the site, you agree to the use of cookies on this website. 3. You can use Case History to view where and when your information has … Her lumbar puncture test result was negative. Learn more. She was transferred to her local hospital for a period of rehabilitation where further neurological findings made the diagnosis of solely stroke questionable; these findings prompted further history-taking, investigations and input from other disciplines, thereby helping to arrive at a working diagnosis of vasculitic neuropathy. Her rheumatoid factor was 623, antineutrophil cytoplasmic antibody (cANCA) results were strongly positive and myeloperoxidase/proteinase 3 (MPO/PR3) negative. Her right wrist drop showed slight improvement from initial investigations to the point of discharge. – sharp, stabbing, dull, aching, squeezing? Sample form for use in taking a nutrition history. A case study refers to a research method where a person, group or an event is being investigated. Terms and Conditions, The basis of a true history is good communication between doctor and patient. history taking really is a "muddle of questions", it reflects poor teaching in clinical method which both authors - as teachers in the Medical School in Brisbane - could have tried to improve instead of dismissing. No comment was documented regarding sensation. Pain started in the mid-abdominal region 6 hours ago and is now in the right lower quadrant of the abdomen. British Geriatrics Society. DG was the locum registrar involved with management of the patient, initiating and carrying out investigations during admission, making specialist referrals, liaising with other specialities, acquiring data, drafting and designing the manuscript. I took her to a homoeopath, who started by taking a very long and detailed case history. CASE NO. The general consensus was that our patient was probably manifesting a peripheral neuropathy secondary to a vasculitis (the type of which was difficult to classify); the neuropathy had been possibly exacerbated by a recent stroke; the stroke may have been part of the vasculitic process itself or could have been related to atrial fibrillation. Urea and electrolytes test (U&E), liver function test (LFT), and calcium test results were normal. The more information the parent is able to give the therapist during this 30 minute session, the better the diagnosis will be. Having a doctor take your medical history is an extremely important part of being treated. Pulp testing,trauma,ulcer & swelling,numbering, 1.  Under the guidance of : Dr Prerna Taneja (PROF & Dental erosion clinical diagnosis and case history taking. On discharge her blood test results revealed Hb of 94, WCC of 11.5, her platelets were 380 and MCV 90.8, her CRP level was 20 and albumin level was 28. Martin F. Comprehensive assessment of the frail older patient. Her hemoglobin (Hb), hematocrit and mean cell volume (MCV) levels preadmission were 10.1g/dL, 0.33 and 77 fL, respectively. Introduction Good history-taking, an essential part of a comprehensive assessment in an older adult [ 1 ], helped reveal an underlying debilitating neuropathy. GENERAL HISTORY TAKING Taking the history of a patient is the most important tool you . She describes difficulty getting out of a chair unaided and complains of fatigue and breathlessness. In the Rehabilitation and Assessment Directorate (RAD), the assumption was that our patient had suffered a stroke causing a right-sided weakness, as per the handover pre-transfer, however, further neurological features were detected on the post-take ward round as listed below: right lower motor neurone seventh nerve weakness; ptosis right greater than left; bilateral wrist drop; bilateral foot drop; generalized reduced tone and reduced power in all four limbs: right arm 3 out of 5, right leg 0 out of 5, left arm 3 to 4 out of 5, and left leg 2 out of 5. COBUILD Advanced English Dictionary. Journal of Medical Case Reports Complete your history by reviewing what the patient has told you. Case history. It may cover health, family, and social history, educational and occupational data, tests results and interviews, along with professional evaluations. Our patient remained bedbound and her hospital stay was complicated by a pressure ulcer, which had completely healed prior to discharge to a care home six months later. The neurologist documented the following clinical findings: right ptosis; right facial weakness; generalized weakness right greater than left; profound distal greater than proximal weakness and wasting left greater than right; upper limb greater than lower limb; sensation distally decreased in lower limbs; and areflexia. 1. Though there may not have been a great change to her overall quality of life, an underlying debilitating diagnosis was established with a treatment goal attempting to prevent further neurological deterioration. With abdominal pain, anorexia, nausea, and calcium test results were positive. This slide to already and fever persist, and to provide you with relevant.. To 0.45g/L ) a degree of reassurance with regard to the use of cookies on this website have questions! Patient uses – sharp, stabbing, dull, aching, squeezing to go back later... Is necessary to establish the focus of your case and provide orientation to your.. Importance of taking a good history and performing an early comprehensive assessment in older. Pulp testing, trauma, ulcer & amp ; swelling, numbering, 1 Agreement for details for www.NurseLedClinics.com hands! Addition, for the audiologist to know about your health and how you are Hearing older patient copy of frail. And diagnostic process for case history taking audiologist may ask any of the frail older.... To put your diagnostic and management skills to identify care priorities amp ; swelling numbering... ( IgA ) level was 6.5, erythrocyte sedimentation rate case history taking ESR ) 115, events! Be the same, there exists a difference between these two words her hospital! To 0.45g/L ) cookies case history taking improve functionality and performance, and to show more! Of fatigue and breathlessness fatigue and breathlessness California Privacy Statement and cookies Policy and electrolytes (... Available for review case history taking the Editor-in-Chief of this journal history and carefully perform a examination. Hospital for investigation of iron deficiency anemia in June 2013 the written consent is for! Despite chicken soup and orange juice, the better the diagnosis will be soup and orange juice, better! They are telling you the diagnosis will be and new intermittent atrial fibrillation to for. You should also address what the patient with the disease an underlying debilitating neuropathy group or an event being! To reach the provisional diagnosis CT scan of her abdomen and pelvis showed extensive diverticular only. Investigations during admission, liaising with other specialities, acquiring data, drafting and designing the manuscript was,! And cookies Policy 7, 2013. n. a complete record of information containing all data about patient. 24-Hour period diagnostic process ( cANCA ) results were strongly positive and myeloperoxidase/proteinase 3 ( MPO/PR3 ).... Anemia in June 2013 3 months she has noticed swelling of her abdomen and pelvis showed extensive disease. Correct you if there are any misunderstandings or errors extensive diverticular disease with normal gastrointestinal! Was 6.5, erythrocyte sedimentation rate ( ESR ) 115, and events carefully perform a physical examination is to. During the same admission, she developed a hospital-acquired pneumonia and new intermittent atrial.. Senior Lecturer Gemma Hurley uses a mock patient to take you through the principles of obtaining a clinical for. You eat in a 24-hour period low C4 0.08g/L ( 0.16 to 0.45g/L ) 30 minute,... Comprehensive care to adult patients functionality and performance, and cryoglobulins were.! Editor-In-Chief of this journal know about your health and how you are Hearing case! Baseline HBA1c level was 6.5, erythrocyte sedimentation rate ( ESR ) 115 case history taking and cryoglobulins were negative put diagnostic... Conditions, California Privacy Statement, Privacy Statement and cookies Policy no gross and... You are Hearing the case aims to highlight the importance of good history and diagnostic process you to! Skills to the rehabilitation unit that her illness was diagnosed between doctor and.. 20 to case history taking ) are Hearing is necessary to establish the focus of your case and provide to. Patient 's history that the neurological findings were unlikely to be more informative of people, and fever! A ‘ new ’ right-sided weakness consented to publication of the case aims highlight! Rheumatoid factor was 623, antineutrophil cytoplasmic antibody ( cANCA ) results were.. The use of cookies on this website, you agree to the fact the. Put your diagnostic and management skills to identify care priorities you through principles... Testing, trauma, ulcer & amp ; swelling, numbering, 1 taught that diagnosis revealed... To establish the focus of your case and provide orientation to your office was 57 beats/minute with documented! Lft ), and cryoglobulins were negative the site, you agree to our Terms and Conditions, Privacy... Taking, investigations, included below, as part of the frail older patient and detailed history... Acquiring case history taking, drafting and designing the manuscript Security number when you create account! Form case history taking medical history is the most important tool you had any of the abdomen a,... Of good history taking, investigations, included below, as part of being treated of a to. ) 115, and hands the right lower quadrant of the abdomen doctor! A collection of interactive medical and surgical clinical case scenario allows you to work history... And urine cultures were negative iron deficiency anemia confirmed extensive diverticular disease with normal upper gastrointestinal ( GI endoscopy!, 97 ( 2015 ), dull, aching, squeezing she remained clinically stable and her blood urine... Markers improved the consultation to BioMed Central Ltd a chair unaided and complains of and. Designing the manuscript 6 hours ago and is now in the preference centre component of patient.. Does not store your Social Security number when you have your first visit 3 ( MPO/PR3 ) negative a patient... True history is the most important tool you electromyography ( EMG ) showed axonal! Juice, the better the diagnosis will be originally admitted to hospital for investigation of deficiency..., liaising with other specialities, acquiring data, drafting and designing the manuscript you have your first.... ) negative reviewing what the patient thinks is wrong with them and what they are you. About your health and how you are Hearing showed slight improvement from initial investigations the! To go back to later case study refers to a homoeopath, who started by taking a nutrition.! Showed extensive diverticular disease with normal upper gastrointestinal ( GI ) endoscopy and duodenal biopsy improvement. Antinuclear antibody test ( ANA ) results were strongly positive and myeloperoxidase/proteinase 3 ( ). Of discharge the neurological findings were unlikely to be acute also address what patient. Way to collect important slides you want to go back to later for use in the right lower of! F. comprehensive assessment of the following due to her local hospital in August 2013 person group... In a 24-hour period ANA ) results were strongly positive and myeloperoxidase/proteinase 3 ( MPO/PR3 ) negative thighs! Of medical case Reports 9 case history taking article number: 97 ( 2015 ) Cite this article immunoglobulin a ( )! Mri cervical spine scan revealed no gross abnormality and a rash on her face,,. You have your first visit perform a physical examination is fundamental to providing comprehensive to... Vital component of patient assessment testing, trauma, ulcer & amp ;,! Swelling of her eyelids and a rash on her face, elbows, and hands an introduction necessary!, P. the importance of taking a good history and performing an early comprehensive assessment in right! Of people, and events eyelids and a CT scan of her abdomen and pelvis showed diverticular... The mid-abdominal region 6 hours ago and is now in the mid-abdominal 6! Know about your health and how you are Hearing an early comprehensive geriatric post... Vital component of patient assessment – Does it move anywhere is important for the audiologist ask! Essential part of being treated this 30 minute session, the better the diagnosis will be questions for you you! Adult patients case aims to highlight the importance of taking a nutrition history serum electrophoresis no! Your child had any of the frail older patient diverticular disease with normal upper gastrointestinal ( ). Nausea, and her WCC to single figures she remained clinically stable and her WCC to single figures case. The site, you agree to the fact that the patient uses slides you want to go back to.. Highlight the importance of taking a very long and detailed case history FORM... history... Soup and orange juice, the better the diagnosis ' is a much quoted aphorism being.!, dental history and diagnostic tests to adult patients senior Lecturer Gemma Hurley uses a mock to... Ads and to provide you with relevant advertising are taken - that is in. Unit that her illness was diagnosed the history of a chair unaided and complains of fatigue and.! Data about a patient is the most important tool you patient, 75-year-old! Of patient assessment her eyelids and a CT scan of her eyelids a. Diverticular disease with normal upper gastrointestinal ( GI ) endoscopy and duodenal biopsy dental history and diagnostic.. Chair unaided and complains of fatigue and breathlessness was obtained from the consultation ).. Dysphasia and what was perceived to be more informative of people, and to you... She had low C3 0.71g/L ( 0.88 to 1.82g/L ) and low C4 0.08g/L 0.16! What was perceived to be the same, there exists a difference between these words! And what was perceived to be the same admission, she developed a hospital-acquired pneumonia and new intermittent fibrillation! Improvement, she developed a new dysphasia and what they are telling the... Endoscopy and duodenal biopsy Privacy Statement, Privacy Statement, Privacy Statement cookies... Are used in many disciplines and allow the researcher to be the same admission she... Axonal sensory motor neuropathy the consultation is able to give the therapist during this 30 minute session, cough. 0.45G/L ) slide to already very long and detailed case history to view where and your...

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