Introduction
A case history refer to a record of an individual or a group. Case Studies are used in many disciplines such as psychology, sociology, medicine, psychiatry etc. A case Study consists of all important information about an individual.
In medicine a case history refers to a specific record that reveals the personal information, medical condition, the medication that has been used and special conditions of the individuals. Having a case history can be very beneficial even in the case of mental treatments.
However, a case history does not necessarily have to be connected to an individual; it can even be of an event that took place. The case history is a recording that narrates a sequence of events. Such a narrative allows the researcher to look at an event that took place.
The aims of a case history are-
1) To establish whether a mental disorder or other condition requiring the attention of a psychiatrist is present;
2) To collect data sufficient to support differential diagnosis and a comprehensive clinical formulation;
3) To collaborate with the patient to develop an initial treatment plan that will foster treatment adherence, with particular consideration of any immediate interventions that may be needed to address the safety of the patient and others’or, if the evaluation is a reassessment of a patient in long-term treatment, to revise the plan of treatment in accordance with new perspectives gained from the evaluation;
4) In the course of any evaluation, it may be necessary to obtain history from other individuals (e.g., family or others with whom the patient resides; individuals referring the patient for assessment, including other clinicians). Although the default position is to maintain confidentiality unless the patient gives consent to a specific intervention or communication, the psychiatrist is justified in attenuating confidentiality to the extent needed to address the safety of the patient and others In addition, the psychiatrist can elicit and listen to information provided by friends or familywithout disclosing information about the patient to the informant. The purpose of the evaluation influences the focus of the examination and the form of documentation. The reason for the evaluation usually includes (but may not be limited to) the chief complaint of the patient. It should be elicited in sufficient detail, including the patient’s words, to permit an understanding of the duration of the complaint and the patient’s specific goals for the evaluation. If the symptoms are of long standing, the reason for seeking treatment at this specific time is relevant; if the evaluation was occasioned by a hospitalization, the reason for the hospitalization is also relevant. If the patient did not initiate the evaluation, the reason another individual or entity may have requested or required it should be noted. The opinions of other parties, including family, can also assist in establishing a reason for evaluation. Under some circumstances (e.g., with psychotic or uncommunicative patients), input from others may be crucial. Confidentiality must always be observed. However, in cases ofsuicidal/homicidal risk and child abuse, an exception may have tobe made. Patients suffering from psychiatric disorders are usually no more violent than the general population. However, it is important to ensure safety if any risks are apparent. It is best to start the interview by obtaining some identification data which may include Name, sex, age, Religion, and Socioeconomic background, as appropriate according to the setting. It is useful to record the source of referral of the patient. In medico legal cases, in addition, two identification marks should also be recorded.
5) IDENTIFICATION DATA:
It is best to start the interview by obtaining some identification data which may include Name, sex, age, Religion, and Socioeconomic background, as appropriate according to the setting. It is useful to record the source of referral of the patient. In medico legal cases, in addition, two identification marks should also be recorded.
6) INFORMANTS
7) Since sometimes the history provided by the patient may be incomplete, due to factors such as absent insight or uncooperativeness, it is important to take the history from patient’s relatives or friends who act as informants and sources of collateral information. It is important to take the patient’s consent before taking this collateral history unless the patient does not have capacity to consent.
8) PRESENTING COMPLAINS:
9) The presenting complaints and/or reasons for consultation should be recorded. Both the patient’s and the informant’s version should be recorded, if relevant. If the patient has no complaints (due to absent insight) this fact should also be noted. It is important to use patient’s own words and to note the duration of each presenting complaint. Some of the additional points which should be noted include:
10) 1. Onset of present illness/symptom.
11) 2. Duration of present illness/symptom.
12) 3. Course of symptoms/illness.
13) 4. Predisposing factors.
14) 5. Precipitating factors (include life stressors).
15) 6. Perpetuating and/or relieving factors.
16) PERSONAL HISTORY-
The personal history consists of three parts: natal, pre-natal and post-natal. The pre-natal period is when the mother of the client is pregnant. All the information during the per-natal period is collected, as for example, the vaccination of the mother, any kind of illness or injury etc. Difficulties in pregnancy (particularly in the first three months of gestation) such as any febrile illness, medications, drugs and/or alcohol use; abdominal trauma, any physical or psychiatric illness should be asked. Other relevant questions may include whether the patient was a unwanted child, date of birth, whether delivery was normal, any instrumentation needed, where born (hospital or home), any prenatal complications (cyanosis, convulsions, jaundice). The natal period is the time when the delivery is taken place. The information regarding the type of delivery, the cry of the baby, weight and colour of the baby is recorded. In the post-natal period of the baby, the information regarding the vaccination, illness or injury of the baby during infancy is recorded. This personal history is very important in taking the case history as any kind of illness or injury, or lack of nutrition may lead to problems in later periods of life.
FAMILY HISTORY-
The family history usually includes the ‘family of origin’ (i.e. the patient’s parents, siblings, grandparents, uncles, etc.). The ‘family of procreation’ (i.e. the patient’s spouse, children and grandchildren) is conventionally recorded under the heading of personal history. Family history is usually recorded under the following headings:
1. Family structure: Drawing of a ‘family tree’ (pedigree chart) can help in recording all the relevant information in very little space which is easily readable. It should be noted whether the family is a nuclear, extended nuclear or joint family. Any consanguineous relationships should be noted. The age and cause of death (if of family members should be asked any)
2. 2. Family history of similar or other psychiatric illnesses, major medical illnesses, alcohol or drug dependence and suicide (and suicidal attempts) should be recorded.
3. 3. Current social situation: Home circumstances, per capita income, socioeconomic status, leader of the family (nominal as well as functional) and current attitudes of family members towards the patient’s illness should be noted.
BEHAVIORAL PROBLEMS-
Issue regarding the behavior of the client that is troubling his/ her personal, professional and other social life. Questions regarding their habits, their routines must be asked.
SCHOOL HISTORY:
Information regarding the school and college life of the client must be collected. Questions need to be asked regarding any kind of
issue in school. The relationships with the teachers as well as the classmates were proper or not have be to known by the investigator.
OCCUPATIONAL HISTORY-
The age at starting work; jobs held in chronological order; reasons for changes; job satisfactions; ambitions; relationships with authorities, peers and subordinates; present income; and whether the job is appropriate to the educational and family background, should be asked. DEVELOPMENTAL MILESTONES:
Skills such as taking the first step, smiling for the first time, speaking the first word, are called developmental milestones. Children reach milestones in how they play, learn, speak, act and move. The information regarding the developmental milestone would give the idea of any kind of developmental delay in the client.
Case study is a research method used to investigate an individual, a group of people, or a particular phenomenon. Case studies are conducted in many sciences; for example, in sociology, psychology, political science. A case study allows the researcher to gain an in-depth understanding of the topic. To conduct a case study, the researcher can use a number of techniques. Forexample, observation, interviews, usage of secondary data such as documents, records, etc. A case study usually goes on for a longer period because the researcher has to explore the topic deeply.
Case histories are used in many disciplines such as psychology, sociology, medicine, psychiatry, etc. A case history consists of all the necessary information of the individual. In medicine, a case history refers to a specific record that reveals the personal information, medical condition, the medication that has been used and special conditions of the individual. Having a case history canbe very beneficial even in the case of mental patients so that it can be used before treatments.
ABOUT THE ORGANIZATION
Shri Mahant Indiresh hospital is a famous hospital that consists of 1000 bedded multi special and this hospital is situated in the heart of the city nearby 2 km from both the railway station & bus terminal. The Hospital serves to about 2000 patients on a daily basis under the direct supervision & humane touch of the medical specialists. The staff of the hospital includes about 300 doctors and 500 paramedicals. There are many Facilities like MRI, 3D CT scan, Digital X-Rays, utmost modern diagnostic equipments in central reference laboratory, full fledged ICU with a number of ventilators, dialysis unit, plastic & burn unit, neurology and urological units, medical retina unit with laser treatment and above all 24 hrs emergency & trauma units are available. Similarly all the other specialties in the hospital impart quality patient care.