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How do you reach to correct diagnosis? Why is a case history essential? A case history is very important. Without a correct case history, the diagnosis can be wrong. Without a correct case history, case management can go wrong. How do you start asking for a case history? What should you ask in a case history? The answer to this question varies depending on the symptoms, signs, and nature of consultation. There may not be any symptoms or signs. The nature of consultation may be a general check-up, ante-natal care, vaccination, screening, or follow-up. Is the patient conscious, oriented in time, space, and person? What specific questions should you ask in this context? Where is the patient? What questions should you ask about mobility? You need to verify the answers. Can the patient talk? Can the patient respond to verbal questions accurately? Does the patient respond to painful stimulus? Ask the patient these questions: Where are you now? What time is it? What is your name? What is your real, birth name? Where and when were you born? How old are you? Can the patient walk on his/her own? Is the patient able to eat on his own? Can patient go to the toilet on his/her own? Who brought the patient to the hospital? Referral, follow-up. Walk in: or Who referred the patient? What is the reason for referral? What are the vital signs? What are the findings after a physical examination? In case of injured patient: Where exactly is the injury? What type of injury is it? When and how did this injury occur? What facts should be included in the incident report? Are any tests or lab investigations required? Why are the tests or lab investigations required? Why couldn't they diagnose and manage the situation within their area? What is the reason for admission to the hospital? A medical doctor sometimes needs a surveillance report from social workers, nurses, independent sources, relatives, police, intelligence, others. What are the activities of the patient in the family, building, road, community, and various settings? What is a normal day like for the patient? Where and how long was this surveillance done? Who compiled the report, and how? Are there any complaints against him or her? What are the complaints? Are these complaints genuine or based on bias and/or prejudice? If you don't know, what is it? What causes it? You can't manage it. How long, far, and fast can the patient walk? Can the patient walk as fast as you? Is there any discomfort? Where is the discomfort? Why are you here today? What seems to be the problem? What is the main reason for your visit today? Can you describe the problem? How long have you had this problem? Have you had this before? What treatments have been tried for this problem? How long does the problem last? Is anything else occurring at the same time? Yes��__ No__ If yes, please explai n. Nausea__ Rash__ Headache__ Other__ Is the problem constant or variable? When did you first notice the problem? 2 days ago__ 2 weeks ago__ 1 month ago__ Other__ Does anything help or make the problem worse? Moving around__ Standing__ up Lying on side__ Other__ Does the problem interfere with your normal functions? Can I help you? Can you describe the symptoms? What's the matter? What brings you here? Describe what's wrong. Can you tell me what's wrong? Has this been a problem before? Have you had this problem before? Have you had this problem long? Pain Fever Depending on the situation.(Further questions) Family Health History Personal Health History Getting your medical history Do you smoke? Do you use alcohol? Do you abuse any drugs? If yes. Where did you purchase the drugs? Who is the manufacturer? Do you have any allergies? Can you get to the grocery store or pharmacy on your own? Are you allergic to any medications? Are you on medication? Are you on any medications? Are you on a special diet? Do you have any chronic condition like hypertension, diabetes, asthma, etc.? Were you ever on any medication for more than one week? What was the indication of medication? Were you ever hospitalized? What was the indication? How do you commute? Do you need any assistance? Why do you need assistance? What is your eyesight number? Who gave you this eyesight number? How did they calculate this number? Did you ever have any surgery? When and where did you have the surgery? What was the procedure? Where are the surgical notes? Are you allergic to penicillin? How do we verify the case history? Can I talk to any of your friends or relatives? Are there any witnesses? This question is important. What did you hear and see? However, I can't, we can't, base our decision on what you heard and saw. I have to, we have to, take other factors into account. How are you related? How often do you meet? Can you tell me briefly about him/her? I came to know you weren't feeling well. I came to know you aren't feeling well. How are you feeling now? What was the problem? What is the problem? How long has this problem been? Have you experienced this before? Have you experienced this for the first time? Is there any bad incident or situation you would like to tell me about? Has there been any harmful or bad incident you would like to tell me about? Can I help you? What is your height? What is your weight? What is the color of your skin? What is the color of your hair? What is good human character? What is good human behavior? How often do I take a bath, brush my teeth, exercise, pray, clean the bed, floor, kitchen, stove, refrigerator, sinks, tub, toilet, put out garbage? Daily. How often do you take a bath, brush your teeth, exercise, pray, clean the bed, floor, kitchen, stove, refrigerator, sinks, tubs, toilet, put out garbage? Daily. Work What work do you do? What do you do? How do you do it? How is performance measured? Do you have World Wide Web presence? What are your working hours? Where do you work? How would you describe your role? What are your main responsibilities? What hours do you work? Who do you work with? How many work in your office? Does anyone assist you? Who assists you? What will happen if you don't get this assistance? What special skills or qualities do you need for your job? Why did you choose this type of work? What training do you receive/have you done? Do you use any tools or equipment? What do you like/dislike about your job? What are the particular challenges in your work? How do you see your future? Did you ever face any one of the following? 1) Psychological Torture 2) Physical Torture 3) Discrimination 4) Deprivation of rights 5) Malicious provoking and crushing techniques 6) Malicious harassment, stress, entrapment techniques 7) Disruption 8) Exclusion 9) Did you challenge any? Who? How? When? Where? 10) Did you face retaliation? 11) Negligence 12) Oppression 13) Administrative abuse Family How do you define a family? Where are your parents? What is your father�s name? What is your mother�s name? Do you have any brothers and sisters? How many brothers and sisters do you have? How old are they? How many children do you have? Do you have any domestic pets? Food What food do you eat every day? Where do you eat daily? What is your favorite food? Who cooks for you? How far is nearest grocery store? How many meals do you have each day? How long do you wait between two meals? Remuneration What is source of your remuneration/income? How much is your remuneration/income per year? Do you get it with debt card or ration card? Do you get it cash? Who issues these resources? What is their mailing address? Has this remained the same in the past five years? Do you feel it is enough? Do you own land, house, apartment, unit, or room in the state where you live? Do you own land, house, apartment, unit, or room in any other state? Medication guidelines: What is the name of the medication? What is the difference between a brand name and a generic name? Who gives the brand name and who gives the generic name? How is the medicine extracted and manufactured? What is the exact formula and process of manufacture? What are the indications of this medication? What is the mechanism of action? What is the therapeutic index? What is the difference between bioavailability, efficacy, and therapeutic index? What is the route of intake? What is the starting dose? What is the maximum dose? What are the adverse effects of therapy? What are the contraindications of the therapy? Where do you get this medication? How many total medicines are you taking? What specific medicine have you taken in the past month? What is the name and dose you are taking? Who prescribed the medicine? When did he/she prescribe the medicine? What is the most likely diagnosis? What is the diagnosis? Diagnosis AuditHow do you do a diagnosis audit?You elaborate on the diagnosis. Does the patient have these symptoms, signs, lab parameters? How do you do a treatment audit? What are the treatment options? Is this the best treatment option among all options? What are the goals of the treatment? Is the treatment appropriate for this diagnosis? Does this meet international standards, recent advances, and preventive and curative concepts of medicine? How do you do a conduct audit? Does your character and behavior meet these standards? How do you do audits of other harms, like vicarious liability or incompetence? What was the exact day, date, and time the patient was brought to the hospital? When exactly did the incident happen? What was the exact day, date, and time the incident happened? Who was the first person to witness or report the incident? What were the vitals? Was the patient conscious, oriented in time, space, and person? Was the patient able to speak? Was the patient able to answer questions coherently? Who brought the patient to the hospital? Do you expect complete recovery? Will there be any residual functional deficit? What is the treatment? When will the treatment plan be reviewed next? Who will do it? What is the configuration of the ventilator? What exact medication is the patient receiving now? Does this patient require any further workup? How would you treat this patient? How could this be prevented? |