Case History and Case Report

Dr. Dilip Kr. Goswami*

*Corresponding Author: Dr. Dilip Kr. Goswami ^*, B.A.M.S. MD(Ayurveda), Ph. D.  Associate Professor, Agada Tantra and vidhi Ayurveda (Toxicology and Forensic Medicine) Govt. Ayurvedic College, Guwahati, Assam, India.

   Received Date:  August 20, 2020

   Publication Date: September 01,2020

Case History

A case history can be defined as the detailed description of a patient about his/her disease. It includes.
(1) The details of the identity of the patient (name, age, sex, religion, address in detail) – it is mainly important for identification.

(2) Chief complaints – At this step, only the sufferings of the patient are listened to and noted in his/her language. From the statement of the patient in this step an idea about the system involved in the disease process can be guessed. 

(3) History of present illness – It contains the detail about the course of the disease (starting, development of the signs and symptoms up to the stage when the patient visited the doctor). If this step can be completed skillfully then the system involved in the disease procedure can be identified almost with surety.

(4) History of past illness – At this step, the physician has to ask the patient about his/her past health status. If the patient gives any history of suffering from any disease in the past then a detail about the signs and symptoms, course of development, the treatment has taken should be noted. A good history can help the physician to find out the present disease whether an independent one or a complication.

(5) Personal history – The points asked and noted in this heading are personal information, like marital status, hobby, addiction, food habits, profession, etc. All these help in deciding the personality of the patient which suggests the possibility of getting attacked by some selected diseases. It is known to all that, the disease has also related to food habits, business, hobby, addiction, etc.

(6) Family history – This heading includes a brief description of the family of the patient including number, their health status, and also some important information regarding the health of the ancestors as far as possible. It helps in the exclusion or inclusion of the chance of hereditary diseases.  

An experienced physician can come closure to diagnosis from history and also a good idea can be developed about the quality of the patient.

In this reference, it is considered important to be informed that, in the ancient Indian Medical science, Ayurveda, a detailed description of history taking is not furnished, but the physicians are advised to try to read the internal of the patient with knowledge and intelligence. Otherwise, it is not possible to diagnose the disease which is the key to the success of treatment. This indicates the importance of talking with the patient with full concentration and friendliness by the physician. Very interestingly, in Ayurvedic Toxicology, about poisoning with some specific types of poisons, it is advised to ask the patient these questions-

(1) Can you remember whether you have taken any suspicious food? If the answer comes as “yes” then it should be followed by these 2 questions.

(2) When you have taken such food and

(3) With whom you have taken the food? This information’s especially help in the diagnosis of some types of poisoning which are commonly given with food by some others (homicidal). This can be considered as an important and unique concept of Ayurvedic scholars.

Case Report

A case report is another document and preparation of a good case report can be considered as an essential duty of a medical personal. It contains a summary of the case history reflecting the important facts about the patient and the disease along with the medicines and other advice given during the entire course of treatment. 

In ancient times education was a system of transferring the knowledge and experience of the teacher to the disciples. So, there was a limitation of the spread of knowledge and experience. The next generation of the family of the physician was taught. But in most of the cases, there was missing basically due to the unwillingness of the next generation and sometimes due to lack of appropriate hierarchy.  The process of preparation of written case reports, publications in different media, electronic storage systems, etc. are helping the whole globe and generation to preserve the documents even for many years. 

The ancient scholars of Ayurveda (the age-old health science of the world) also advise the doctors to gather knowledge, especially about the identification and use of plants as medicine, even from the persons who have no institutional education and lives/moves in the forest as they are well accustomed with the character, behavior, etc. of the plants.

Briefly, it can be said that case history writing and case report preparation are two important duties not only of a physician but also of the other personals related to health science.

Appropriate skills should be developed by each and everyone in the field to give necessary support to the others by preparing a good history sheet and case report.

The learned ones should train the new generation with skill and expertness in the field.  

Volume 1 Issue 3 September 2020

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