My summer holidays

TAKING PATIENT’S CASE HISTORY

When we become doctors we should always remember the following things. As soon as the patient enters the doctor’s consulting-room we should begin observation immediately. We look for external signs and symptoms as long as the professional visit lasts. The first requirement is to develop a feeling of sympathy for the patient by your questions, your actions, your interest in him and his troubles.

When the patient begins to tell you his complaints, signs and symptoms you should carefully note what he is telling you. When the patient has finished his description, now it is your turn to make clear some points in details. Your questions must be understood well by the patient to get a meaningful answer. Never hurry the patient – that is the worst thing you can do. When the patient has finished his story, it is the time to carry out physical examination.

A good physical examination is important. Note all the visible signs and symptoms in all the regions of the body. For determining a disease it is very important to know the aetiology and pathogenesis of the disease as well as its symptoms. They can be objective, for example haemorrhage, vomiting or edema and subjective, for example, headache, dizziness or nausea, since they are evident only to the patient.

The case history must always be written very accurately and consist of exact and complete information.