A case history report is conventionally prefaced by a brief description of the patient and their complaint. This serves to orientate the reader and also to summarize data that will subsequently be important for both diagnosis and treatment.
Patient details
- Age, sex, occupation
- Race, ethnic group
- Place of normal residence; recent travel
- Build, weight
- Route of admission
- Main complaint
- General appearance
Past medical history (PMH)
- Illnesses since childhood (including current chronic conditions)
Medication history
- Current medication (prescription, OTC) – effectiveness and adverse effects
- Past medication problems
Family history (FH)
- Relatives’ (living and dead) medical history
Social history (SH)
- Social drug use
- Domestic and financial situation
- Mobility
- How is patient coping (home, work and leisure)
- History of presenting complaint
- Onset, nature and intensity of symptoms
- Changes; provoking and relieving factors
- Referrals and outcomes
- Medication
Systematic examination
- Directed questioning: each body system
- Physical examination: each body system
Investigations (Ix)
- Blood, urine analysis
- Radiography etc.
Diagnosis (Dx)
- Differential, provisional or confirmed
Management (Rx)
For each current problem
- Aims
- Modes
- Monitoring
- Outcome(s)
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