TAKING A FULL CASE HISTORY
Keywords:
Case history, medical assessment, diagnosis, patient-centered care, medical history, review of systems, effective communication, health records, treatment planning.Abstract
A case history is an essential element of medical assessment, offering a structured and detailed overview of a patient's health. It plays a crucial role in diagnosing conditions accurately and formulating effective treatment plans. This paper explores the key components of a case history, including patient identification, chief complaint, history of present illness, past medical history, medications, family and social history, and review of systems. Additionally, it highlights the significance of effective communication in obtaining comprehensive patient information. A well-documented case history enables healthcare professionals to deliver patient-centered care, improving overall health outcomes.
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References
Bickley, L. S. (2020). Bates’ Guide to Physical Examination and History Taking. Lippincott Williams & Wilkins.
Tierney, L. M., McPhee, S. J., & Papadakis, M. A. (2021). Current Medical Diagnosis & Treatment. McGraw-Hill.
World Health Organization (WHO). (2022). Patient Assessment and Medical History Guidelines. Retrieved from www.who.int
Epstein, R. M., & Street, R. L. (2019). Patient-Centered Communication in Medical Practice. Oxford University Press.
U.S. National Library of Medicine. (2023). Medical History and Examination: Best Practices. Retrieved from www.nlm.nih.gov
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