Case history

Case history is a detailed account of the background, symptoms, and progression of a patient's condition. It is an essential component in the field of medicine, psychology, and other health-related disciplines. A case history typically includes information about the patient's medical history, family history, lifestyle, and any other factors that may be relevant to the diagnosis and treatment of the condition.

Components of a Case History

A comprehensive case history generally includes the following components:

Patient Information

• **Personal Details**: Name, age, gender, and contact information.
• **Medical Record Number**: A unique identifier for the patient within the healthcare system.

Chief Complaint

• **Primary Symptom**: The main reason the patient is seeking medical attention.
• **Duration**: How long the primary symptom has been present.

History of Present Illness

• **Symptom Onset**: When and how the symptoms began.
• **Symptom Progression**: How the symptoms have changed over time.
• **Associated Symptoms**: Any other symptoms that may be related to the primary complaint.

Past Medical History

• **Previous Illnesses**: Any significant past medical conditions.
• **Surgeries**: Details of any surgical procedures the patient has undergone.
• **Medications**: Current and past medications, including dosages and duration.

Family History

• **Genetic Conditions**: Any hereditary conditions present in the family.
• **Family Illnesses**: Health conditions of immediate family members.

Social History

• **Lifestyle Factors**: Smoking, alcohol consumption, drug use, diet, and exercise.
• **Occupation**: The patient's job and any occupational hazards.

Review of Systems

• **Systematic Inquiry**: A comprehensive review of symptoms related to different bodily systems (e.g., cardiovascular, respiratory, gastrointestinal).

Importance in Diagnosis

A thorough case history is crucial for accurate diagnosis and effective treatment. It helps healthcare providers understand the context of the patient's condition and identify any underlying issues that may not be immediately apparent.

Related Pages

• Medical history
• Diagnosis
• Treatment
• Symptom
• Healthcare