A Case Report Demonstrating The Importance of History-Taking

A 75-year-old woman was admitted to the hospital for investigation of her iron-deficiency anaemia. Her past medical history included type II diabetes mellitus (for which she had been taking insulin), hypertension, and chronic obstructive pulmonary disease.

During her stay at the hospital, she acquired pneumonia accompanied by new intermittent atrial fibrillation and speech difficulties. The doctors noticed right-sided weakness in her which was perceived to be a ‘new’ finding.

As her CT brain scan did not show any acute changes, she was treated for ischemic stroke based on the clinical findings. An MRI brain revealed atrophy with small vessel disease. She was further treated for her pneumonia and later transferred for stroke rehabilitation to her local hospital.

The possibility of an acute neurological process was ruled out in the Rehabilitation and Assessment Directorate as there was no such documentation in the previous transfer records of the patient. Favourably, the patient’s daughter was present during one of the ward rounds where she reveals her mother’s mobility had gradually been declining over the past 18 months. According to the patient’s son, speech difficulty was the only novel finding in his mother’s reports probably following the stroke.

On contacting the patient’s General Practitioner later, it was found that the patient had been diagnosed with a Bell’s Palsy and Third Nerve Palsy previously due to her diabetes. An underlying debilitating neuropathy was discovered after the collection of good comprehensive history. The fact that the patient had been carrying chronic neurological signs evaded detection for a very long time. Had it been detected earlier, the further neurological deterioration could have been prevented.

A complete and focused history in diabetic patients comprises the following:

  • Diabetes type and age of onset
  • Blood glucose levels, frequency of monitoring
  • Last Glycated Haemoglobin with the date (HbA1c)
  • Previous episodes of hypoglycemia/diabetic ketoacidosis/hyperosmolar hyperglycemic state
  • Renal function
  • Cardiac function
  • Immunization History (Influenza, Hepatitis B, Herpes Zoster)
  • Family History of autoimmune diseases
  • Diet and exercise habits
  • Current medications

Apart from this, it is essential to note previous histories of:

  • Unexplained hypoglycemia or hypoglycemic unawareness
  • Episodes of polyuria, polydipsia, weight loss
  • Retinopathy
  • Nephropathy
  • Hypertension
  • Hyperlipidemia
  • Smoking/Alcohol consumption
  • Coronary Artery Disease
  • Peripheral Vascular Disease
  • Stroke
  • Neuropathy (autonomic/peripheral)
  • Repeated foot ulcers
  • Frequent infections

The above-mentioned case report emphasises on how a comprehensive geriatric assessment during the patient’s admission at the hospital would have probably helped initiate a treatment plan that would have certainly improved her quality of life. This throws light on to why clinical history and physical examination still remain the cornerstone of diagnosis, prognosis, and treatment selection in older adults.

Arintra is a history-taking tool that serves this purpose. It captures a focused and comprehensive patient history before the consultation. This includes chief complaints, history of presenting illness, past medical history and comorbidities, current and past medical history, and social and family history. This data can be used to prepopulate the existing EMR and therefore doctors can have a more focused and personalized interaction with the patient. Such detailed history ensures that no relevant information is overlooked.

Case Reference

Ghosh D, Karunaratne P. The importance of good history taking: a case report. Journal of Medical Case Reports. 2015;9:97. DOI: 10.1186/s13256-015-0559-y.