TAKING FULL CASE HISTORY
Keywords:
Medical history, Patient interview, Diagnosis, Symptoms, Healthcare, Case history components, Clinical examination, Medical documentation, Doctor-patient communication, History taking techniquesAbstract
Taking a full case history is a critical step in medical practice that enables healthcare professionals to accurately diagnose conditions, guide investigations, plan treatment, monitor progress, and establish trust with patients. A comprehensive case history includes key components such as patient demographics, chief complaints, history of present illness, past medical history, medication history, family history, social history, and a review of systems. Effective history-taking techniques involve creating a comfortable environment, using open-ended questions, practicing active listening, and adapting to special patient populations, including pediatric, geriatric, psychiatric, and emergency cases. By following a structured and patient-centered approach, medical professionals can enhance clinical decision-making and optimize patient care.Downloads
References
Bates, B. (2017). Bates' Guide to Physical Examination and History Taking (12th ed.). Lippincott Williams & Wilkins.
Epstein, R. M., & Street, R. L. (2011). Patient-Centered Communication in Cancer Care: Promoting Healing and Reducing Suffering. National Cancer Institute.
Macleod, J. (2018). Macleod's Clinical Examination (14th ed.). Elsevier.
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Talley, N. J., & O’Connor, S. (2021). Clinical Examination: A Systematic Guide to Physical Diagnosis (9th ed.). Elsevier.
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