Medical Case History Taking
Medical history or Case history (often abbreviated hx or Hx) of a patient is information gained by a physician by asking specific questions, either of the patient or of 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.
Medical Case History Taking : A practitioner typically asks questions to obtain the following information about the patient :
1. Identification and demographics
- Name,
- Age,
- Sex,
- Address,
- Occupation,
- Height,
- Weight,
- Marital status.
2. Chief complaint (CC)
- Main reason for visiting a doctor or for help i.e. the major health problem or concern, and its time course, recurrent (e.g. chest pain for past 4 hours, palpitation).
3. History of the Present Illness (HPI) 0r History of presenting complaint (HPC)
- Details about the complaints, enumerated in the CC. i.e. In details of present problem with time of onset, mode of evolution, any investigation, treatment & outcome/associated + ve or – ve symptoms. (Prefer in chronological order)
e.g Patient complaining about pain
- Onset of disease
- Postition or site
- Quality, Nature, Character – Burning sharp, stabbing, crushing, Depth – superficial or deep
- Relationship to anything or other bodily function/position
Radiation where moved to
Relieving or aggravating factors – any activities/position - Severity
- Timing : Mode of onset (abrupt or gradual), progression (continuous or intermittent if intermittent ask about frequency & nature)
- Treatment received or/and outcome
4. Past Medical History (PMH)
Including
- any previous surgery/operations e.g. time, place, what type of operation.
- major illnesses or any current ongoing illness e.g. IHD, Heart attack, Asthma, HT, RHD, TB, Jaundice, diabetes. if diabetic, mention time of diagnosis, current medication, clinic check up).
- history of trauma or accidents.
5. General Physical Examination (GHE)
- Built
- Nourishment
- Orientation to time, place & person
- Vital data : Pulse, Respiratory rate, Blood pressure, Temperature, Generalised lymphadenopathy, Cyanosis, Oedema
6. Drug History (DH)
- Always use generic name with dosage, timing & how long. i.e. now and past, prescribed and over-the-counter, allergies.
7. Family History
- Any familial disease running in families especially those relevant to the patient’s chief complaint e.g. IHD, DM, HTN, Asthma.
8. Social History (SH)
- Smoking : amount, duration & type
- Alcohol : amount, duration & type
- Occupation, social & education background, ADL, social support, pets and hobbies.
9. Childhood diseases
- This is very important in pediatrics.
10. Other relevant history
- Gyane/obs history if female
- Immunization if small child. Look for the child health card.
- Allergies history
- Sexual history & so on, as appropriate.
11. Review of systems (ROS)
Gather a short amount of information regarding the other systems in the body that are not covered in your HPC. Any significant finding should be moved to HPC or PMH depending upon where you think it belongs. Ask associated symptoms of PC with the system involved.
These are the main systems you should cover:
- CVS
- Respiratory
- GI
- Neurology
- Genitourinary/renal
- Musculoskeletal
- Psychiatry etc.
Systems Review |
| General | Weakness, Fatigue, Anorexia, Change in weight, Fever, Night Sweats, Lumps |
| CVS | Chest pain, Dyspnea, Ankle swelling, Palpitations, Short of breath, Cyanosis |
| Respiratory system | Cough, Haemoptysis, Epistaxis, Wheezing, Sputum, Chest pain, Tachypnoea, Dyspnoea |
| GIT | Appetite, Diet, Regurgitation/Flatulence/Heart burn, Dysphagia, Odynophagia, Hematemesis, Melena, Hematochezia, Abdominal pain, Nausea, Vomiting, Bowel habit |
| Genitourinary system | Frequency in urination, Pain with micturition (dysuria), Urine color, Any urethral discharge, Altered bladder control like urgency in urination or incontinence, Menstruation and Sexual activity |
| Nervous System | Headache, Loss of consciousness, Head ache, Dizziness and vertigo, Speech and related functions like reading and writing skills and memory |
| Endocrine system | Weight loss, Polydipsia, Polyuria, Increased appetite (polyphagia) and irritability). |
| Musculoskeletal system | Pain (muscle, bone, joint), Swelling, Weakness, Gait. |
12. Conclusion & closure
