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CASE HISTORY
u,stor,
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• Dr. Murali. U M.S; M.B.A.
Prof of Surgery
D Y Patil Medical College
Mauritius.
Definition
• 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 an insight into the nature ofpatient's
illness & his/her attitude towards them.
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Objectives
• To establish a positive professional relationship.
• To provide the clinician with information
concerning the patient's past medical I surgical &
personal history.
• To provide the clinician with the information that
may be necessary for making a diagnosis.
• To provide information that aids the clinician in
mal(ing decisions concerning the treatment of the
patient.
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Steps - Involved
• Assemble all the available facts gathered from
statistics, chief complaints, history ofpresenting
complaints and relevant history.
• Analyze and interpret the Examination details to
reach the provisional diagnosis.
• Make a differential diagnosis of all possible
complications.
• Select a closest possible choice-final diagnosis.
• Plan a effective treatment accordingly.
Components
• Particulars - Patient • General examination
• Chief complaint • Local examination
• History ofpresent illness • Other Systems exam.
• Past history • Provisional diagnosis
• Personal history • Investigations
• Family history • Final diagnosis
• Treatment history • Treatment plan
Self Introduction
• Greet the patient by name: "Good morning,
Mr.XI 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.
Pa rticu la rs
• Patient registration number
• Date
• Name
• Age
• Sex
• Address
• Occupation
• Religion
Pt. Reg. No. Date
• Maintaining a record • Time of admission
• Billing purposes • Ref- follow up visits
• Medico legal aspects • Record maintenance
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Name Age
• To communicate with • Age related diseases
the patient
• To establish a rapport • For diagnosis
with the patient
• Record maintenance
• Treatment planning
• Psychological benefits
Sex Residence / Address
• Certain diseases - • For future
gender specific correspondence
• View of socio-economic
• Record maintenance status
• Prevalence &
geographical
• Psychological benefits
distribution
Occupation Religion
• To assess socio- • Predilection of diseases
economic status in certain Religion
• Predilection of diseases • To identify festive
in different occupations periods when religious
people are reluctant to
undergo treatment
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Chief Complaints
• The chief complaint is usually the reason for the
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patients . .
• It is stated in patient's own words [No medical terms]
in chronological order of their appearance & their
severity. { Brief & Duration}
• Make clear - patient was free from any complaint
before the period mentioned.
• The chief complaint aids in diagnosis & treatment
therefore should be given utmost priority.
History of Present Illness
• Elaborate on the chief complaint in detail
• The symptoms can be elaborated in terms of-
- Mode & cause of onset
- Course & Duration of disease
- Symptom related & Relation to constitutional factors
- Special character & Effects - nearby structures
• Treatment taken
• Leading questions - to help the patient
• Negative answers - more valuable to exclude the di seas
Common Chief Complaints
• Pain
• Swelling
• Ulcer
• Vomiting
• Bleeding
• Discharge
• Deformity
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Past History
• Note the past history in chronological order
• All diseases - previous to present - noted
{ Attention to diseases lil<e - Diabetes,
Bleeding disorders, Tuberculosis, SHT,
Asthma etc. }
• Previous operations or Accidents - noted
• Mneumonic -THREAD
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Personal History
• Diet
• Habit ofsmoking & drinking ofalcohol
• Bowel & micturition habits
• Sleep
• Allergy to any drug [or] diet
• Marital status
• Females - Menstrual history
[ regularity I menarche ,menopause I no. of
pregnancy - normal or LSCS I any discharge
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Family History
• Family members share their genes, as well as
their environment, lifestyles and habits.
• Certain diseases run in families - Diabetes,
cancers - breast, thyroid, SHT, piles, peptic
ulcer etc. should be noted
• Enquire about family members - alive or
dead I current illnesses I consanguinity
among family
Treatment or Drug History
• Asl< about the drugs the patient was on.
• Special enquiry on - Steroids I
Antihypertensives, HRT, contraceptivs pills,
Antidiabetic drugs etc.
• Treatment for the current illness & doctor
treated
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General Survey or Examination
• Analyze the patient entering the clinic for
gait, built & nutrition, attitude and mental
status.
• Check for any pallor, cyanosis, jaundice,
clubbing, any skin eruptions and edema.
• Record vital signs li/(e
TURP
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Local Examination
• Most important part - definite clue to arrive at a
diagnosis.
• Examination of affected region.
• Inspection - looking at affected part
• Palpation - fee ling of affected part
• Percussion - listening to the effects of affected part
• Auscultation - listening to the sounds produced
• Movements & Measurements
• Lymph node examination
• Visual assessment of the patient.
• Make sure good ligh ting is available.
• Pos ition and expose body parts so that all surface can
be viewed.
• Inspect each area ofsize, shape, colour, symmetry,
position and abnormalities.
• Ifpossible, compare each area inspected with the same
area on the opposite side of the body.
• Varies to the presentation of the complaints.
• A technique in which the hands andfingers are used to
gather information by touch.
• Palmar surface offingers and finger pads are used to
palpate for
-Texture
-Masses
- Fluid
• For assessing skin temperature - dorsal surface
• Client should be relax and positioned comfortably
because muscle tension during palpation impair its
effectiveness.
Palpation - Types
• Light palpation
• Deep palpation
• Bimanual palpation
• Bidigital palpation
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Percussion
• Percussion involve tapping the body with the
fingertips to evaluate the size, border and nature of
body organs.
• Used to evaluate for presence of
air or fluid in body tissues
• Sound waves heard as percussion tones.
• Direct Percussion
- It is by tapping the affected area directly using flexed
finger.
• Indirect Percussion
- It can be performed by using two fingers. Lt middle
finger [pleximeter finger} is placed over the area and its
middle phalanx is tapped with the tip of Rt middle finger
or index finger [percussing finger].
• Fist Percussion
- It involves placing one hand flat against the body
surface and striking the back of the hand with a clenc
fist of the other hand.
Auscultation
Headset
• Auscultation is listening
to sound produce by the Eartlp ----=-- -
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body.
• Following characteristics
of sound are noted:-
- Pitch
- Loud or soft
- Duration Stem ~ Chestpiece
- Quality
• Done by stethoscope.
Other systems - Examination
Head & Neck
• Cranial nerves -3,4,5, 6, 7, 9,11&12 - examined
• Eyes - visual field, pupils, movements
• Mouth & pharynx - teeth & gum, tongue &
tonsil
• Movements of nee!(, nee!( veins & lymph
glands, carotid pulse & thyroid gland
Upper Limbs
• Arms & hand - Power, tone, reflexes &
sensations
• Axillae & Lymph nodes
• Joints
• Finger nails
Lower Limbs
• Legs & feet - Power, tone, reflexes &
sensations
• Varicose vein
• Joints
• Oedema
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Thorax
• Type of chest
• Breasts
• Dilated vessels & pulsations
• Position of trachea
• Apex beat Pigure 1
• Lungs - whole
• Heart - whole A. extillaUon B. Ma,clmal lnhnlatk>n
Abdomen
• Abdominal wall - umbilicus, scars, dilated veins
• Visible peristalsis or pulsations
• Hernial orifices
• Generalised examination
• Inguinal glands
• Rectal examination
• Gynaecological examination - if required
Spine
• Curvature ofspine observe for:-
• Lordosis I Scoliosis I Kyphosis
• Pain & Tenderness
• Swellings
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Provisional Diagnosis
• It is also called tentative diagnosis or
worl<ing diagnosis.
• It is formed after evaluating the case history
& performing the physical examination.
Investigations
Routine Special
• Blood • FNAC
- CBP/TC/DC!ESR • Doppler
-BT/CT • UIS
- Sr. Electrolytes I RFT • CT
• Urine complete • MRI
• Pus - C/S • Invasive procedures
• X-ray
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Differential Diagnosis
• The process of listing out of 2 or more
diseases having similar signs and symptoms
ofwhich only one could be attributed to the
patient's disease.
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Final Diagnosis
• The final diagnosis can usually be reached following
chronologic organization and critical evaluation of the
information obtained from the :
- patient history
- physical examination and
- the result of radiological and laboratory examination.
• The diagnosis usually identifies the diagnosis for the
patient primary complaint first, with subsidiary
diagnosis of concurrent problems.
Treatment Plan
• The formulation of treatment plan will depend on both
knowledge & experience of a competent clinician and
nature and extent of treatment facilities available.
• Evaluation of any special risks posed by the
compromised medical status in the circumstance of the
planned anesthetic diagnostic or surgical procedure.
• Medical assessment is also needed to identify the need
of medical consultation and to recognize significant
cleviation from normal health status that may affect
management.
Prognosis
• It is defined as act offoretelling the course of
disease that is the prospect ofsurvival & recovery
from a disease as anticipated from the usual course
of that disease or indicated by special features of
the case.
• Clinical diagnosis is an art,
and the mastery of an art has no end;
you can always be a better diagnostician.
- Logan Clendening
