Case history is an important and integral part of Treatment, a treatment of a disease or a condition satrts with it’s proper diagnosis and this can be done sucessfully only by taking down a proper Case History.
It is very important to take a proper case history which will further lead to a proper diagnosis and a perfect Treatment with good Prognosis.
I remebered a line which my professor use to tell:
“Accurate diagnosis of a disease depends on the art of taking Case Hisyory.”
Now coming to the most important question:
What is Case History?
Case history is considered to be a planned professional conversation that enables the patient to communicate their symptoms, feelings and fear complex to the physician.
Ideally Case history is taken in a consultation Room or a Private Office in which the surroundings and the conditions are entirely friendly and not like the Dental Operating room.
In many occasions a properly prepared Case History alone is sufficient to Diagnose the Disease without examining the patient.
Hence a Properly prepared case history is of utmost importance in any speciality in Medical Field.
Steps in Case – History Preparation:
- General Information
- History Recording
- Examination of the patient
- Establishment of provisional diagnosis
- Necessary investigations
- Final Diagnosis
- Treatment plan
- Prognosis
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yeah friend you are absolutely right. I am agree with your professor”Accurate diagnosis of a disease depends on the art of taking Case Hisyory”.
hi.. i wanted to ask that we record the chief complaint of the patient in his own words but what is the reason behind it ? why do we record the chief complaint in patient s own words ?
chief complaint in patients words can be helpfull in determinig the primary problem of the patient, and this will help us decide what should be treated first,
For Ex: the patient will be having a swelling from the past 1 year but pain in another area from the past 1 day which has bought her to your clinic, what we think is that the swelling is the main concern but actually the patient has come only due to pain, so we have first concentrate on the pain factor.
This is the reason why we have to take the chief complaint in patients words so that we can decide the treatment plan, and help the patient by decreasing her main problem first.
That’s definitely right
the chief complaint should be in the patient’s own words for medicolegal reasons as well.It can be used as a proof that the patient is being treadted for the problem stated by him and not any other.
Well the subjective complaint from patient is pivotal. As his/her treatment consultant, our best job is to focus on their main concern and complication. pain, then so be it, but still on any regular circumstances, pain must be removed by all due respect. pain management the name is.