5. Pattern for a good Case sheet…
Demographics
Presenting History
Description of History
Past history
General Examination
Systemic examination
Local examination
Special examination
Investigations
Provisional Diagnosis
Treatment plan
Diagnosis
Treatment modifications
Course in hospital
Discharge advice
Outcome
6. Demographic Data…
Before interrogating about the complaints of the patient,
it is a good practice to know the patient first. That means the following headings
should be noted in the history-sheet
7. NAME.— It is very important to know the patient by name.
The patients like to be asked by name,
AGE.— Congenital anomalies mostly present since birth,
e.g. cystic hygroma, cleft lip, cleft palate, Acute
osteomyelitis in teenage, and arthritis & degenerative
disorders & carcinomas in the old age.
SEX.— diseases of the thyroid, cystitis are common in
females while carcinomas of the stomach, lungs, kidneys
are commoner in males.
Religion:- Carcinoma of penis is hardly seen in Jews and
Muslims , kangri cancers common in kashmiris.
OCCUPATION.—For example, varicose veins are commonly
seen among bus conductors. While Workers in aniline dye
factories are more prone to urinary bladder. Injury to the
medial semilunar cartilage of the knee is common among
footballers and miners.
8. Chief Complaints.—
In Patient’s own words – No Leading
Questions
Record in chronological order of
occurrence
Eg: 'What brings you here?'.
"How long have you been suffering
(a) Swelling in the neck — 1 year.
(b) Fever (mostly in the evening) — 10 months.
(c) Slight pain in the swelling — 6 months.
(d) Sinus in the neck — 1 month.
9. History of Present Illness.
The mode of onset of the Symptoms
— whether sudden or gradual,
The progress of the disease with
evolution of symptoms
The treatment which the patient might
have received
To know the progress of the disease, the patient
is asked, "What is the next thing that happened?“
–
Can Put Leading Questions
10. Past History
All the diseases suffered by the
patient, previous to the present one,
Should be noted and recorded in a
chronological order.
Diseases like Asthma, Diabetes, TB, HT,
diphtheria, rheumatic fever, bleeding
tendencies, syphilis, gonorrhoea, etc.
11. Drug history / History of allergy
Steroids, Blood thinners, insulin, Antihypertensives,
Diuretics, Hormone replacement therapy, contraceptive pills etc.
Personal history.-
Smoking , Drinking of alcohol (quality and quantity),
Diet (regular or irregular,vegetarian or non-vegetarian, takes spicy food or not etc.)
Marital status
In women, the menstrual history—Regular or Irregular, associated with pain or not, and last date of
menstruation.
The number of pregnancies and miscarriages , whether the deliveries were normal or LSCS
12. Family history
Many diseases do recur in families.
Haemophilia, tuberculosis, diabetes, essential hypertension,
peptic ulcer, majority of the cancers particularly the breast
cancer and certain other diseases like fissure-in-ano, piles etc.
run in families.
15. PROVISIONAL DIAGNOSIS
At this stage the clinician you should be able to make
a provisional diagnosis.
You should also keep in mind the differential
diagnosis.
You will now require a few investigations to come to
the proper clinical diagnosis.
If you diagnose a rare disease, you will be rarely correct'.
22. Consent
Very Important Document In a Hospital Practice
Consent is required for :
Examination of a patient / To conduct Investigations
To undertake any procedure on the patient
To Perform Surgery / Delivery
To Record the Patient details for Academic Purpose
23. Types of Consent
Informed Consent
Written Consent
High risk Consent
Video Consent
Vicarious Consent
A Consent Should be signed by Patient/ Attendant / Treating Doctor & a
Witness
