case history

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case history

a record of a person's background, medical history, etc., esp one used for determining medical treatment

Case History


(in Russian, anamnez), information on the life history of a patient prior to a given illness and the entire history of the illness itself. The case history is an indispensable part of every personal medical study, frequently affording the indications necessary for diagnosis. A distinction is made between the general case history and the case history of a particular illness. Under the former are included illnesses of parents and nearest relatives, such as hereditary diseases, malignant tumors, psychiatric illnesses, tuberculosis, and syphilis; previous illnesses and surgical operations of the patient; life-style, including family status and nutrition; personal habits (alcohol, tobacco); sex life; profession; and all domestic conditions. The specific case history of a given illness concerns the onset, course, and treatment of the illness up to the time of the given medical study. Case histories are compiled from information supplied by the patient himself or by his associates.

In veterinary practice, case histories are compiled by consulting persons in charge of the animal and from documentary data on the history of the illness and other aspects. The origin of the animal, the state of health of its parents, the presence of disease on the particular farm, and the situation regarding maintenance and care (feeding and watering, living quarters, working conditions) are all determined. Previous illnesses are ascertained, along with the onset of the present illness, its signs, similar cases on the same farm, and information on treatment so far given.


Shkliar, B. S. Diagnostika vnutrennikh boleznei. Kiev, 1960.
Klinicheskaia diagnostika vnutrennikh boleznei sel’skokhoziaistvennykh zhivotnykh, 2nd ed. [Edited by V. I. Zaitsev.] Moscow, 1964.
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