‫ نغم فيصل \ احمد غازي‬: ‫مدرس المادة‬

Case study
1- ID - PERSONAL INFORMATIOM -
INTERVIEW
*It is written as a story
Name , age , sex , marital status , occupation , level of education ,
religion , address , next of kin , blood group and RH , date of
admission

2- Chief compliant C.C and it is duration

 The primary problem that lead the patient to seek medical
care and its duration

3- History of present illness : *Start with known case of

(mention any chronic disease such as hypertension, diabetes
mellitus , ischemic heart disease...). -'Analysis of chief
compliant (asking about ): How and when the illness starting ?
_Changes in the course of the illness Drugs given (any benefit
or no benefit ) and any investigation Mention the effect of the
illness on (appetite, sleep activity, and weight).

*It is written as a story

Systemic review
Pain: a sensation in which a person experiences discomfort,
distress or suffering. *Types of pain:
1) Acute pain: pain that occurs only in a defined period (less
than 6 months)
2) Chronic pain: prolonged, persistent, nonmalignant pain, its
period more than 6 months
3) Malignant pain: recurrent and acute episodes of pain, which
may also include chronic pain

Pain analysis (assessment)

1) Location (site)
A) Area of the body.
B) Diffuse or localized C) Radiates and area involved.
2) Onset: A) sudden (such as MI). B) Gradual (such as
Angina).
3) Radiation: Radiated to neck, shoulder jaw or any part of the
body
4) Duration: Constant or intermittent
5) Character (Quality): Sharp: for example pleura Dull: e.g.
liver. Burning e.g. esophageal pain Stabbing: e.g. pericarditis.
Crushing: e.g. back
6) Reliving factor: _For example: rest in case of angina
7) Aggravating factor: examples: _activity in case of A. heavy
meal in case of esophageal pain. Coughing in case of pleura
8) Intensity or severity: on pain scale 1 2 3……..10

4- Past medical history: *previous illness, previous

hospitalization *previous surgeries (time type, any
complication). *previous trauma or accidents. *drugs allergies
especially ask about penicillin , and food allergies. *history of
medication intake ( name, dose, route, duration ).

5-Family history : ask about first degree relations of the

parents, siblings, and sons) _similar condition in the patient
family history of common genetic disease (D.M. , H.T, IHD).
premature death (cause, age on death ).

6) Life style history : smoking (cigarette per day) alcohol

intake sleep pattern (night sleep hours, sleep problems like
snoring or night mares

7) social history : The general condition of the family, the

status of the house, the number of family members, the
number of rooms in the house, have you traveled recently,
domestic animals