WordNet

a piece of fiction that narrates a chain of related events; "he writes stories for the magazines"
look over, usually with the intention to rob; "They men cased the housed"
the quantity contained in a case (同)caseful
a specific state of mind that is temporary; "a case of the jitters"
(printing) the receptacle in which a compositor has his type, which is divided into compartments for the different letters, spaces, or numbers; "for English, a compositor will ordinarily have two such cases, the upper case containing the capitals and the lower case containing the small letters" (同)compositor''s case, typesetter''s case
a glass container used to store and display items in a shop or museum or home (同)display case, showcase, vitrine
bed linen consisting of a cover for a pillow; "the burglar carried his loot in a pillowcase" (同)pillowcase, slip, pillow slip
a portable container for carrying several objects; "the musicians left their instrument cases backstage"
nouns or pronouns or adjectives (often marked by inflection) related in some way to other words in a sentence (同)grammatical case
an occurrence of something; "it was a case of bad judgment"; "another instance occurred yesterday"; "but there is always the famous example of the Smiths" (同)instance, example
a person requiring professional services; "a typical case was the suburban housewife described by a marriage counselor"
a problem requiring investigation; "Perry Mason solved the case of the missing heir"
a statement of facts and reasons used to support an argument; "he stated his case clearly"
the actual state of things; "that was not the case"
the aggregate of past events; "a critical time in the schools history"
the continuum of events occurring in succession leading from the past to the present and even into the future; "all of human history"
a record or narrative description of past events; "a history of France"; "he gave an inaccurate account of the plot to kill the president"; "the story of exposure to lead" (同)account, chronicle, story
all that is remembered of the past as preserved in writing; a body of knowledge; "the dawn of recorded history"; "from the beginning of history"
the discipline that records and interprets past events involving human beings; "he teaches Medieval history"; "history takes the long view"
the enclosing frame around a door or window opening; "the casings had rotted away and had to be replaced" (同)case
the outermost covering of a pneumatic tire
enclosed in a case
covered or protected with or as if with a case; "knights cased in steel"; "products encased in leatherette" (同)encased, incased

PrepTutorEJDIC

〈C〉(事実に基づいた)『話』,実話 / 〈C〉(架空の,人を楽しませる)『物語』,話 / 〈U〉(小説,詩,劇,映画などの)筋,プロット / 〈C〉(新聞などの)記事,事件の報道 / 〈C〉(ある人の言う)言葉,申し立て / 〈C〉《話》《子供が,また子供に対して用いる》うそ(lie)
〈C〉(…の)『実例』,事例《+『of』+『名』》 / 《the case》『実情』,真相 / 〈C〉〈U〉『場合』,情況,事情,立場 / 〈C〉(…の)(決定すべき)問題,重大事《+『of』+『名』》 / 〈C〉『訴訟』[『事件』],裁判 / 〈C〉(正当な)論拠,弁護;(被告または原告の)主張,申し立て / 〈C〉病状,容態;(症状から見た)患者 / 〈C〉〈U〉格(名詞・代名詞の語形変化)
(運搬・保管用のいろいろな)『箱』,ケース / (各種の)『容器』,筒,さや,袋,おおい / (標本・陳列用の)ガラス箱,戸だな / (戸・窓などの)わく / 活字箱 / …'を'箱(袋,さやなど)に入れる《+『名』+『up,』+『名』+『up』》
〈U〉『歴史』;歴史学 / 〈C〉『歴史書』 / 〈C〉(人の)『経歴』,来歴;(物事の)過去,由来 / 〈C〉史劇
箱,包装,おおい / (電線・タイヤなどの)被覆,(ソーセージの)皮 / (ドア・窓などの)わく;額縁

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出典(authority):フリー百科事典『ウィキペディア（Wikipedia）』「2014/08/27 09:31:11」(JST)

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The medical history or (medical) case history (also called anamnesis, especially historically)^[1]^[2]^[3] (often abbreviated hx or Hx) of a patient is information gained by a physician by asking specific questions, either of the patient or of other people who know the person and can give suitable information (in this case, it is sometimes called heteroanamnesis), with the aim of obtaining information useful in formulating a diagnosis and providing medical care to the patient. The medically relevant complaints reported by the patient or others familiar with the patient are referred to as symptoms, in contrast with clinical signs, which are ascertained by direct examination on the part of medical personnel. Most health encounters will result in some form of history being taken. Medical histories vary in their depth and focus. For example, an ambulance paramedic would typically limit his history to important details, such as name, history of presenting complaint, allergies, etc. In contrast, a psychiatric history is frequently lengthy and in depth, as many details about the patient's life are relevant to formulating a management plan for a psychiatric illness.

The information obtained in this way, together with the physical examination, enables the physician and other health professionals to form a diagnosis and treatment plan. If a diagnosis cannot be made, a provisional diagnosis may be formulated, and other possibilities (the differential diagnoses) may be added, listed in order of likelihood by convention. The treatment plan may then include further investigations to clarify the diagnosis.

Process

Example

A practitioner typically asks questions to obtain the following information about the patient:

Identification and demographics: name, age, height, weight.
The "chief complaint (CC)" - the major health problem or concern, and its time course (e.g. chest pain for past 4 hours).
History of the present illness (HPI) - details about the complaints, enumerated in the CC. (Also often called 'History of presenting complaint' or HPC.)
Past medical history (PMH) (including major illnesses, any previous surgery/operations (sometimes distinguished as "Past Surgical History" or PSH), any current ongoing illness, e.g. diabetes).
Review of systems (ROS) Systematic questioning about different organ systems
Family diseases - especially those relevant to the patient's chief complaint.
Childhood diseases - this is very important in pediatrics.
Social history (medicine) - including living arrangements, occupation, marital status, number of children, drug use (including tobacco, alcohol, other recreational drug use), recent foreign travel, and exposure to environmental pathogens through recreational activities or pets.
Regular and acute medications (including those prescribed by doctors, and others obtained over-the-counter or alternative medicine)
Allergies - to medications, food, latex, and other environmental factors
Sexual history, obstetric/gynecological history, and so on, as appropriate.
Conclusion & closure

History-taking may be comprehensive history taking (a fixed and extensive set of questions are asked, as practiced only by health care students such as medical students, physician assistant students, or nurse practitioner students) or iterative hypothesis testing (questions are limited and adapted to rule in or out likely diagnoses based on information already obtained, as practiced by busy clinicians). Computerized history-taking could be an integral part of clinical decision support systems.

Review of systems

Whatever system a specific condition may seem restricted to, all the other systems are usually reviewed in a comprehensive history. The review of systems often includes all the main systems in the body that may provide an opportunity to mention symptoms or concerns that the individual may have failed to mention in the history. Health care professionals may structure the review of systems as follows:

Cardiovascular system(chest pain, dyspnea, ankle swelling, palpitations) are the most important symptoms and you can ask for a brief description for each of the positive symptoms.
Respiratory system (cough, haemoptysis, wheezing, pain localized to the chest that might increase with inspiration or expiration).
Gastrointestinal system (change in weight, flatulence and heart burn, dysphagia, abdominal pain, vomiting, bowel habit).
Genitourinary system (frequency in urination, pain with micturition, urine color, any urethral discharge, altered bladder control like urgency in urination or incontinence, menstruation and sexual activity).
Nervous system (Headache, loss of consciousness, dizziness and vertigo, speech and related functions like reading and writing skills and memory).
Cranial nerves symptoms (Vision, diplopia, facial numbness, deafness, oropharyngial dysphagia, limb motor or sensory symptoms and loss of coordination).
Endocrine system (weight loss, polydipsia, polyuria, increased appetite and irritability).
Musculoskeletal system (any bone or joint pain accompanied by joint swelling or tenderness, aggravating and relieving factors for the pain and any positive family history for joint disease).
Skin (any skin rash, recent change in cosmetics and the use of sunscreen creams when exposed to sun).

Inhibiting factors

Factors that inhibit a proper medical history taking include physical inability of the patient to communicate with the physician, such as unconsciousness and communication disorders. In such cases, it may be necessary to perform a so-called heteroanamnesis of other people who know the person and can give suitable information, which, however, generally is more limited than a direct anamnesis.

Medical history taking may also be impaired by various factors impeding a proper doctor-patient relationship, such as transitions to physicians that are unfamiliar to the patient.

History taking of issues related to sexual or reproductive medicine may be inhibited by a reluctance of the patient to disclose intimate or uncomfortable information. Even if such an issue is on the patient's mind, he or she often doesn't start talking about such an issue without the physician initiating the subject by a specific question about sexual or reproductive health.^[4] Some familiarity with the doctor generally makes it easier for patients to talk about intimate issues such as sexual subjects, but for some patients, a very high degree of familiarity may make the patient reluctant to reveal such intimate issues.^[4] When visiting a health provider about sexual issues, having both partners of a couple present is often necessary, and is typically a good thing, but may also prevent the disclosure of certain subjects, and, according to one report, increases the stress level.^[4]

Computer-assisted history taking

Computer-assisted history taking systems have been available since the 1960s.^[5] However, their use remains variable across healthcare delivery systems.^[6]

One advantage of using computerized systems as an auxiliary or even primary source of medically related information is that patients may be less susceptible to social desirability bias.^[6] For example, patients may be more likely to report that they have engaged in unhealthy lifestyle behaviors. Another advantage of using computerized systems is that they allow easy and high-fidelity portability to a patient's electronic medical record.

One disadvantage of current (2012) medical history systems is that they cannot detect non-verbal communication, which may be useful for elucidating anxieties and treatment plans. Another disadvantage is that people may feel less comfortable communicating with a computer as opposed to a human. In a sexual history-taking setting in Australia using a computer-assisted self-interview, 51% of people were very comfortable with it, 35% were comfortable with it, and 14% were either uncomfortable or very uncomfortable with it.^[7]

The evidence for or against computer-assisted history taking systems is sparse. For example, as of 2011, there are no randomized control trials comparing computer-assisted versus traditional oral-and-written family history taking to identifying patients with an elevated risk of developing type 2 diabetes mellitus.^[8]

References

^ Many medical practitioners no longer understand the term "anamnesis", but dictionaries still list it, but they often find it necessary (based on their databanks) to distinguish its meaning nowadays from the modern term "medical (case) history". Oxford: a patient’s account of their medical history. Merriam-Webster: a preliminary case history of a medical or psychiatric patient.
^ Georg Klemperer (1904). The Elements of clinical diagnosis. Macmillan.
^ Plinio Prioreschi (1998). Roman medicine. 3 series=A History of Medicine (reprint ed.). Horatius Press. ISBN 978-1-888456-03-5.
^ ^a ^b ^c Quilliam, S. (2011). "'The Cringe Report': Why patients don't dare ask questions, and what we can do about that". Journal of Family Planning and Reproductive Health Care 37 (2): 110–2. doi:10.1136/jfprhc.2011.0060. PMID 21454267.
^ Mayne, JG; Weksel, W; Sholtz, PN (1968). "Toward automating the medical history". Mayo Clinic proceedings. Mayo Clinic 43 (1): 1–25. PMID 5635452.
^ ^a ^b Cash-Gibson, Lucinda; Pappas, Yannis; Car, Josip (2012). "Computer-assisted versus oral-and-written history taking for the management of cardiovascular disease". In Car, Josip. Cochrane Database of Systematic Reviews. doi:10.1002/14651858.CD009751.
^ Tideman, R L; Chen, M Y; Pitts, M K; Ginige, S; Slaney, M; Fairley, C K (2006). "A randomised controlled trial comparing computer-assisted with face-to-face sexual history taking in a clinical setting". Sexually Transmitted Infections 83 (1): 52–6. doi:10.1136/sti.2006.020776. PMC 2598599. PMID 17098771.
^ Pappas, Yannis; Wei, Igor; Car, Josip; Majeed, Azeem; Sheikh, Aziz (2011). "Computer-assisted versus oral-and-written family history taking for identifying people with elevated risk of type 2 diabetes mellitus". In Car, Josip. Cochrane Database of Systematic Reviews. doi:10.1002/14651858.CD008489.pub2.

UpToDate Contents

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1. 術前の止血状態評価 preoperative assessment of hemostasis
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English Journal

A novel mutation in the MECP2 gene in a Korean patient with Rett syndrome.

Lee EY, Chung HJ, Ki CS, Yoo JH, Choi JR.SourceDepartment of Laboratory Medicine, Yonsei University College of Medicine, Seoul, Korea.
Annals of clinical and laboratory science.Ann Clin Lab Sci.2011 Fall;41(1):93-6.
Rett syndrome (RTT) is a severe X-linked dominant neurodevelopmental disorder. Mutations in the MECP2 gene on chromosome Xq28 have been shown to be the cause of RTT. Using DNA samples from a RTT patient and her parents, we sequenced three exons and flanking intron regions of the MECP2 gene using the
PMID 21325263

A heparin binding site Arg79Cys missense mutation in the SERPINC1 gene in a Korean patient with hereditary antithrombin deficiency.

Yoo JH, Maeng HY, Kim HJ, Lee KA, Choi JR, Song J.SourceDepartment of Laboratory Medicine, National Health Insurance Corporation, Ilsan Hospital, Goyang, Korea.
Annals of clinical and laboratory science.Ann Clin Lab Sci.2011 Fall;41(1):89-92.
We describe a case of heparin binding site Arg79Cys mutation in the gene encoding antithrombin, SERPINC1, in a Korean patient with hereditary antithrombin (AT) deficiency. The patient was a 34-year-old Korean man who presented with deep vein thrombosis (DVT) in his right leg without precipitating fa
PMID 21325262

Japanese Journal

GCKR mutations in Japanese families with clustered type 2 diabetes.

Tanaka Daisuke,Nagashima Kazuaki,Sasaki Mayumi,Yamada Chizumi,Funakoshi Shogo,Akitomo Kimiyo,Takenaka Katsunobu,Harada Kouji,Koizumi Akio,Inagaki Nobuya
Molecular genetics and metabolism 102(4), 453-460, 2011-04
… [Subjects and methods]:We recruited Japanese families with a 3-generation history of diabetes. … Because we detected a MODY3 mutation HNF1A R583G in one case, we excluded this case from further investigation. …
NAID 120002970864

異時性両側精巣腫瘍に対し精巣部分切除を施行した1例

皆川真吾,服部一紀,遠藤文康,黒部匡広,藤崎章子,岩渕敏久,志賀淑之,安士正裕,村石修
泌尿器科紀要 57(3), 147-149, 2011-03-31
… A malignant tumor could not be ruled out completely based on examinations and his medical history. …
NAID 120003001363

Related Pictures

★リンクテーブル★

リンク元	「story」「anamnesis」「medical history」「clinical history」「case study」
関連記事	「history」「case」「histo」「casing」