You’re The Doc!   

Case History Directions

Patient’s Age:  Make it up, keeping in mind the circumstances of the disorder.

Patient’s Sex: Make it up, but again, consider what would apply.

Presenting Problem: Reasons why the patient went to the doctor.  These would usually be the same as symptoms.  Generally all the symptoms of a disease would not be present, but they could be.  Remember, what could a patient know?

History: How long has the patient had the symptoms?  Include any previous treatments, anything that makes the symptoms worse, life style information, etc.

Family History:  If the disease could possibly inherited, you’ll need a lot of information in this section. Do mother, father, or siblings have the disease?  Who else in the family has it?  What have other family members died from?  Include anything that could be pertinent.

Exam Results: General gross observations made by the physician during an office visit. A stethoscope might be used to listen to heart, lung, or bowel sounds; an otoscope or opthalmoscope might be used; blood pressure might be taken or the doctor may examine by palpating.  What could a doctor tell from an office exam?

Laboratory Studies:  What would any type of lab information pertinent to this case show? Might include X-rays or other imaging studies (MRI, CAT scan), blood counts, urinalysis, etc.  Consider what studies would be done on a person with “your” disease, and what those studies would show.  Blood counts and urinalysis are generally routine and could be unremarkable, depending on what applied.

Diagnosis:  Name of the disease.

Course of Treatment: What can be done?  Consider both immediate and long-term treatments, hospitalization, surgery, medication, therapy, homecare counseling, etc.  Include probable length of treatment.

Prognosis: Detailed long-term expectation.

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