Case Taking Principles

Question 1

What are the two parts of case taking?

Answer 1

Part 1 - Question the patient about the chief complaint - the bulk of the case taking
Part 2 - Investigate the patient in a systematic way - the shorter part of case taking

Question 2

What questions should you ask about the chief complaint?

Answer 2

• Why the patient is coming to see you?
• Onset
• Location
• Quality
• Quantity
• Evolution
• Etiology (if known)
• Treatment
• Adverse effects from treatment

Question 3

When investigating the patient in a systematic way, what questions should you ask?

Answer 3

Ask about

• other conditions
• past medical history
• energy
• temperature / sun / perspiration
• weather
• sleep / dreams
• appetite / food / thirst
• GI
• Menses / leucorrhea
• sex
• nature
• sensitivities
• general (trauma, limitations, memory)
• Review of systems
• family history
• Objectives (description of pt appearance)
• Exams / lab results
• Anxieties / fears

Question 4

When asking about the patient’s anxieties and fears, what is the difference between anxieties and fears?

Answer 4

Anxieties: diffuse, unpleasant, vague sense of apprehension
Fear: emotional response to a known or definite threat

Question 5

What are Sankaran’s 7 levels of experiencing the world?

Answer 5

1 - Name
2 - Fact
3 - Feeling
4 - Delusion
5 - Sensation
6 - Energy
7 - 'Blank, consciousness'

Question 6

What are 3 core conditions for any therapeutic environment?

Answer 6

Congruent / integrated
Unconditional positive regard for the patient
Empathetic understanding

Question 7

When recording symptoms, how do you underline for intensity?

Answer 7

0 underline = Sx not clear, is very vague, rarely felt
1 underline = Sx is more clear, present and more intense
2 underlines = Sx is very clear, intensity is moderate to high and occurrence is more than occasional
3 underlines = highest clarity and intensity is very often
4 underlines = extra-ordinary intensity (very rare) ex. Some who eats only meat at every meal