Case history taking

General rules

• Not just completing a form
• Tell patient your name and explain why you are seeing him

More important for medical students

• Could be started before patient’s talk
• Give patient whole your attention
• Doctor should be an empathetic listener

Consent

• Type of consents:
• Oral
• Behavioral
• Written consent
• Why:
• To get adequate information about case
• Avoid medico-legal complains

Set the stage

• Provide safe environment
• Your behavior and appearance
• Shake hands
• Avoid the patient’s personal space
• Inquire about patient’s feelings
• Avoid unfamiliar or street terms
• Note taking
• Signs of uneasiness

Guidelines for taking case history

• Questions should be open ended (encourage)
• Guidance of conversation but not restricting
• Avoid leading questions (‘yes’ or ‘no’ answers)
• Clear & specific questions
• Ask one question at a time
• Cover various aspects of diseased organ
• Direct questions may be required sometimes
• Patient symptoms in his own words??