CASE HISTORY

Dr. Haider Yousif

MD., MSc. Clinical Oncology
Assistant Professor of Clinical Oncology
2021
INTRODUCTION

A case history is defined as a planned professional

conversation that enables the patient to communicate his/her
symptoms, feelings and fears to the clinician so as to obtain
a comprehension into the nature of patient’s illness & his/her
attitude towards them.
Objectives:-
n To establish a positive professional relationship.
n To provide the clinician with information concerning the
patient’s personal history , past medical & surgical .
n To provide the clinician with the information that may be
necessary for making a diagnosis.
n To provide information that aids the clinician in making
decisions concerning the treatment of the patient.
Methods of obtaining the patient history

There are 3 methods :-

v Interview
v Health questionnaire
v Combination of these
General Approach
• Greet the patient by name: "Good morning, Mr. X / Mrs. Y ."
• Introduce yourself and explain that you are a medical student.
• Shake the patient's hand, or if they are unwell rest your hand
on theirs.
• Ensure that the patient is comfortable.
• Confidentiality and respect patient privacy.

Listening

Questioning: simple/clear & avoid medical terms

 Taking the history & Recording:

n Always record personal details: NASEOMADR+BN .

n Name,
n Age,
n Address,
n Sex,
n Ethnicity
n Occupation,
n Religion,
n Marital status.
n Date of admission / examination
n Blood group
n Next of kin
n Patient registration number
Useful for-
1. Maintaining a record,
2. Billing purposes,
3. Medico-legal aspects.

n Date of admission
Useful for-
1. Determine time of admission
2. Reference during follow up visits
3. Record maintenance.
NAME:
n Communicate with the patient
n Establish a rapport with the patient
n Record maintenance
n Psychological benefits

AGE
— Age related diseases
— For diagnosis
— Treatment planning
— Behavioral management techniques
— In children used to calculate the dose of the drug.
eg : DILLING RULE = age/20 x adult dose
SEX
SINGNIFICANCE-Certain diseases are gender specific :
n Diseases common in males:

Sequamous cell carcinoma, melanoma, lymphoma etc

n Diseases common in females:

Iron deficiency anemia, osteoporosis, etc

n Drug interaction :- in females, special consideration must be
given to pregnancy & lactation.

n Record maintenance
n Psychological benefits
ADDRESS/Residence

For future communication

View of socio-economic status

Prevalence & geographical

distribution

OCCUPATION
To asses the socioeconomic status.
Predilection of diseases in different occupations for eg:
hepatitis B is common in dentists & surgeons.
n MARITAL STATUS
n To see any history of relative marriages (having the same ancestry
or descent; related by blood ), this could induce the expression of
autosomal recessive diseases.

n Religion
n Predilection of diseases in certain Religion
Ø Muslim : liver cirrhosis and liver cancer hepatitis B, gastric
ulcer
Ø Jewish cystic fibrosis
Ø Hondurans : Diabetes

§ To identify festive periods when religious people are

reluctant to undergo treatment
 Complete History Taking

n Chief complaint & duration

n History of present illness
n Past medical /surgical history
n Systemic review
n Family history
n Drug /blood transfusion history
n Social history
n Gynecological /obstetric history.
Chief Complaint

v The main reason push the patient to seek for visiting a

physician or for help

v Usually a single symptoms, occasionally more than one

complaints
eg: chest pain, palpitation, shortness of breath, ankle swelling etc

v The patient describe the problem in their own words and it

should be recorded in patient’s own words [No medical terms] .

v In chronological order of their appearance & their severity{

Brief & Duration }
Chief Complaint (CC): Continuous……
The chief complaint aids in diagnosis & treatment therefore
should be given utmost priority.
Make clear – patient was free from any complaint before the
period mentioned.
To elicit the chief complaint, ask broad questions:
– What brings you in today?
– Tell me what has been going on.
– What seems to be the problem?
– What are your complaints?
- How can I help you ?
Chief Complaint (CC): Continuous……

n Short/specific in one clear sentence communicating

present/major problem/issue.
As:
n Timing – fever for last two weeks or since Friday
n Recurrent –recurring episode of abdominal pain/cough

Duration: tips
Exact duration.
For how long you are ill.
When you were completely normal.
Is this complain for the first time or
you have other episodes.
Common Chief Complaints : continuous…..
Most complaints are

n Pain
n Fever
n Swelling
n Ulcer
n Vomiting
n Bleeding
n Discharge
n Diarrhea
 HISTORY OF PRESENT ILLNESS
Details & progression, regression of the Chief Complaint
n Elaborate on the chief complaint in detail
n Ask relevant associated symptoms
n The symptoms can be elaborated in terms of:-
Mode & cause of onset
Duration
Location-localized ,diffuse ,referred, radiating.
Progression- continuous or intermittent.
Aggravating & relieving factors
Treatment taken
Leading questions – to help the patient
Negative answers – more valuable to exclude the disease

If patient has more than one symptom, like chest pain, swollen legs and
vomiting, take each symptom individually and follow it through fully
mentioning significant negatives as well.
 History of Present Illness - Tips
Avoid medical terminology & make use of a
descriptive language that is familiar to them
Ask OPQ3RS2TA for each symptom:
Onset of disease : mode of onset (abrupt or gradual), progression
(continuous or intermittent – if intermittent ask frequency/ nature.)
Position/site
Quality, nature, character – burning sharp, stabbing, crushing;
also explain depth of pain – superficial or deep.
Relationship to anything or other bodily function/position.
Radiation: where moved to
Relieving or aggravating factors – any activities or position
Severity – how it affects daily work/physical activities. Wakes him up at
night, cannot sleep/do any work.
Timing – duration
Treatment received or/and outcome.
Are there any Associated symptoms? .
 Past Medical /Surgical History
Note the past history in chronological order
All diseases – previous to present – noted
Past Medical History
n Start by asking the patient if they have any medical problems
n IHD/Heart Attack/DM/Asthma/HT/RHD, TB/Jaundice/Fits :
E.g. if diabetic- mention time of diagnosis/current medication/clinic
check up
Past surgical/operation history
E.g. time/place/ what type of operation.
n Note any blood transfusion / blood grouping & any excessive
bleeding during these procedures.
n History of trauma/accidents : time/place/ and what type of
accident
n Any minor operations or procedures including endoscopies, &
biopsies.
 Treatment or Drug History

n Ask about the drugs the patient was on.

n Special enquiry on –

Steroids / Anti-hypertensives, HRT, contraceptivs pills,

Anti-diabetic drugs etc.
n Treatment for the current illness & doctor treated

n Always use generic name or put trade name in brackets with

dosage, timing &how long.
n Example: Ranitidine 150 mg BID PO

n Note: do not forget to mention: Vitamins / Blood transfusion.

Family History

n Family members share their genes, as well as their

environment, lifestyles and habits.
n Certain diseases run in families -
Diabetes, IHD , HT, peptic ulcer , asthma etc.
Developmental delay, asthma, albinism.
Infections running in families as TB, Leprosy , Cholera,
typhoid in case of epidemics.
Cancers – breast, thyroid, should be noted
n Enquire about family members – alive or dead / current
illnesses / consanguinity among family
Social History

n Smoking history - amount, duration & type. A strong risk

factor for IHD
n Alcohol history - amount, duration & type.
n Occupation, social & education background, family social support
& financial situation.
n Social class.
n Home conditions as:
Water supply.
Sanitation status in his home & surrounding.
Animals / birds in his/her house.
 Social History: continuous ……
Smoking notes:
n The most important cause of preventable diseases.
n Smoking history - amount, duration & type.
n Amount: pack”year calculations( A pack year : is defined as twenty
cigarettes smoked every day for one year ).
n Duration: continuous or interrupted.
n Deep inhalation or superficial.
n Active or passive smoker.
n Type: packs, self-made, Cigars, Shesha , chewing etc.
n Ask the smoker whether he is willing to quit or not.
n Any trials of quitting & how many.
n Do not forget to encourage the smoker to quit whenever contacting a
smoker as it is proved to increase quitting rate.
n If he is willing to quit, but can not, help him by NRT ( Nicotine
replacement therapy ) . No. of cigarettes per day x No. of years smoked
Pack years=
20
 Other Relevant History

n Gynaecological/Obstetric history if female

n Gravida, pararity, abortions, SZ sections, antenatal care & screens as
for Hep B & C.
n Immunization if small child
n Note: Look for the child health card.
n Travel / sexual history if suspected STDs or infectious disease

Note: If small child, obtain the history from the care giver.
Make sure; talk to right care giver.
 System Review (SR)

This is a guide not to miss anything

Any significant finding should be moved to HPC or PMH

depending upon where you think it belongs.

Do not forget to ask associated symptoms of present compliant

with the System involved

When giving verbal reports, say no significant finding on systems

review to show you did it. However when writing up patient notes,
you should record the systems review so that the relieving doctors
know what system you covered.
 System Review

Cardiovascular
•Chest pain
•Paroxysmal , Nocturnal dyspnoea
•Orthopnoea
•Short Of Breath (SOB)
•Cough/ sputum (pinkish/frank blood)
•Swelling of ankle (SOA)
•Palpitations
•Cyanosis
 System Review

Gastrointestinal/Alimentary
•Appetite (anorexia/weight change)
•Diet
•Nausea/vomiting
•Regurgitation/heart burn/flatulence
•Difficulty in swallowing
•Abdominal pain/distension
•Change of bowel habit
•Haematemesis, melaena
•Jaundice
 System Review

Respiratory System
•Cough(productive/dry)
•Sputum (colour, amount, smell)
•Haemoptysis
•Chest pain
•SOB/Dyspnoea
•Tachypnoea
•Hoarseness
•Wheezing
 System Review

Urinary System
•Frequency
•Dysuria
•Urgency
•Hesitancy
•Terminal dribbling
•Nocturia
•Back/loin pain
•Incontinence
•Character of urine: color/ amount (polyuria) & timing
•Fever
 System Review

Nervous System
•Visual/Smell/Taste/Hearing/Speech problem
•Head ache
•Fits/Faints/ loss of consciousness (LOC)
•Muscle weakness/numbness/paralysis
•Abnormal sensation
•Tremor
•Change of behaviour or psyche.
•Pariesis.
 System Review

Genital system
•Pain/ discomfort/ itching
•Discharge
•Unusual bleeding
•Sexual history
•Menstrual history – menarche/ LMP/ duration & amount of
cycle/ Contraception
•Obstetric history – Para/ gravida /abortion
 System Review

Musculoskeletal System
•Pain – (muscle, bone, joint)
•Swelling
•Weakness/movement
•Deformities
•Gait
SOAP
Subjective: how patient feels/thinks about him. How does he look.
Includes Present complaints and general appearance / condition of
patient

Objective – relevant points of patient complaints/vital sings,

physical examination/daily weight ,fluid balance, diet/laboratory
investigation and interpretation

Assessment – address each active problem after making a

problem list. Make differential diagnosis.

Plan – about management, further investigation, treatment,

follow up and rehabilitation
 GRATITUDE
FOR ATTENTION