Keywords
Abstract
Taking a full case history is a fundamental skill required for medical students and practicing doctors across all specializations. This process assesses both communication skills and medical knowledge, ensuring that a comprehensive patient history is obtained to facilitate accurate diagnosis and treatment planning. This article outlines a structured approach to taking a case history, covering key steps such as presenting complaints, history of present illness, past medical and drug history, family and social history, review of systems, and patient feedback. It also highlights the importance of collateral history in cases where patients have impaired cognitive function. The guide follows a systematic approach to ensure completeness and accuracy while emphasizing ethical considerations and patient-centered communication.
References
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