Teaching Spanish Medical Students How to Write a Case History

Abstract

A case history is a detailed account of the facts affecting the development or condition of a person or group under treatment or study, especially in medicine. It has also been defined as a detailed recension, generally written, of all particulars of a patient’s familial, medical, and social involvements related to a condition or disease process. Therefore, all the information gained by the physician during the doctor-patient interview must appear in this text which should not be confused with the case report, a different medical genre usually published in journals for the benefit of the scientific community. In fact, the case report is usually based on a case history, which is used as an “internal” document in hospitals, clinics, or health care centres. Unfortunately, there is not enough literature, including studies, textbooks, or other similar material which may help English for Specific Purposes (ESP) instructors to teach students how to write these texts. Last decade, when English for Medicine became an optional course at Universidad Alfonso X el Sabio in Madrid, Spain, case histories were included as part of the syllabus of this subject. Since there were neither studies nor textbooks on the teaching of case histories found at the time, it was decided that the material had to be created. Hence, the purpose of this chapter is to share with other ESP instructors what was done, why, and how.

Appendices

Appendix 1: Adapted Case History

Example of a case history adapted from the Internet.

1. Read the following case history and observe the way it is written.

Example of a Case History

Linda Chroniak, a 26-year-old secretary presented at 13 days postpartum to an emergency department with severe, stabbing, right flank pain. The pain had been present since postpartum day 2, with associated fever (temperature 39.5 degrees centigrade) and chills. At that time, diagnosis of urinary tract infection was made by urinalysis and culture which confirmed Escherichia coli as the infective organism, and the patient was treated with amoxicillin based on the sensitivity results. Unfortunately, the pain did not resolve. There was no associated vaginal bleeding, nausea, or vomiting.

On examination, the patient was afebrile and had tenderness in the umbilical and right flank area. Ultrasonography was not performed after the delivery because it was not considered appropriate.

Her antenatal period was uneventful. She had a spontaneous vaginal delivery of a live bornterm female. The immediate postpartum period was unremarkable. There was no other significant past medical or surgical history.

Investigations showed white blood cell count of 12.6 × 10⁹/L, haemoglobin of 114 g/L, and reactive thrombocytosis with a platelet count of 587 × 10⁹/L. The rest of the laboratory investigations were within normal limit. A pelvic computed tomography showed findings consistent with a thrombosed right ovarian vein, measuring 8 × 5 × 5 cm.

A consult to internal medicine was subsequently made, the diagnosis confirmed, and the patient was initiated on therapy of low-molecular-weight heparin (Dalteparin sodium) at a dose of 12,500 units/day by subcutaneous injection and discharged home, to be followed up with internal medicine.

Appendix 2: Examples of Warm-Up Questions

Warm-Up Questions

• What is a case history?

• What is the purpose of a case history?

• What is the format of a case history?

• What information is usually found in a case history?

• Have you ever seen one in Spanish?

Appendix 3: Training Exercises

These exercises, from 1 to 4, were always done before asking students to write a full case history. The last exercise, Exercise 5, is the first case history students had to write. Regarding the review of the passive voice, the exercises were taken from the textbook used in class, English for Health Sciences (Milner, 2006).

Exercise 1

Make the following sentences/information sound more “case history-like”. You should only change the sections that had been underlined only.

• 1. Diana is 19 years old. She is a college student. Her GP referred her to our private dental office with symptoms of dental hypersensitivity and gingival recession.

• 2. The first step in therapy was removal of the traumatic agent, after which the patient underwent scaling and root planning procedures. After these basic procedures, the patient’s periodontal status was healthy and her oral hygiene acceptable. We obtained a diagnostic cast to help in surgical planning. We achieved correction of the mucogingival defect through a subepithelial connective tissue graft …

• 3. Julie Smith is 25 years old. She is an accountant. She is a practising Jehovah’s Witness. She lives with her retired parents. Her GP referred her with an abrupt onset of psychotic symptoms.

Exercise 2

Fill in the gaps with the following verbs:

was taken has begun describes has become began experiences has withdrawn

The patient...............................an eight-month history of anxiety symptoms, which ...................... two months after a car accident. She................................ apprehensiveness when out of her home, inability to cope with anything out of the ordinary, initial insomnia and irritability, and she...............................socially. More recently she has had trouble concentrating on her work. Five days ago, she....................... to her local GP after experiencing a typical attack in the supermarket. She....................... housebound since, ruminating that “I’m terrified of suffering a heart attack and dying suddenly like my mother”. She................... drinking up to a bottle of wine a day in an effort, she says, “to calm myself down and make things more bearable”.

Exercise 3

Using the following information obtained from a Case Note, write a paragraph that could be part of the “On Examination” section of a Case History.

• a. CVS & RS NAD

• b. BP normal. 130/82

• c. PR 80 bpm

• d. RR 14 bpm

Exercise 4

Read the following case history. There are seven sentences that are not “case-history-like”. Underline them and make the necessary corrections. The headings of each section have been added for you.

Chief Complaint

The patient, Stacey Chan, was a teacher who was 46 years old and had a 6-month history of occipital pain. It had been gradual in onset and no exciting cause had been identified. The pain was worse on waking in the morning although her sleep was not disturbed.

On Examination

She had an increased cervical lordosis and restriction of right rotation. There was tenderness at the level of the second and third cervical apophyseal joints.

Diagnosis

I told her that she had severe cervical lordosis.

Treatment

I used mobilising techniques on the tender joints and local acupuncture. I gave her advice on posture, especially in sleeping. I told her to make herself a ‘Butterfly’ pillow by tying a ribbon tightly around the centre and to fit the narrow area into her neck before settling down to sleep. This has the effect of restricting tossing and turning while asleep and gives support in the side lying position. I also showed her how to work the posterior neck muscles in a simple neck bracing exercise which could be done lying in bed before sleeping and on waking in the morning. After 3 treatments her symptoms were gone. I informed her about the importance of maintaining the butterfly pillow and the postural correction neck bracing exercise

Exercise 5: Writing a Case History

Read the following case notes . Write a case history using the information on them.

SURNAME: Steinberg FIRST NAME: Simon

AGE 59 SEX M MARITAL STATUS M

OCCUPATION: Office Worker

PRESENT COMPLAINT c/o headaches, L side for 3/52, unrelieved by aspirin. Initially flu-like symptoms. Unable to sleep. Slight weight loss. “Weak and tired”.

O/E General Condition Good T 37.4° ENT NAD RS NAD CVS P 80/min. reg. BP 160/95 HS normal L temporary artery palpable. GIS GUS CNS No neck stiffness. Neck movts. full with no pain.

IMMEDIATE PAST HISTORY

POINTS OF NOTE

INVESTIGATIONS ESR rate: 80 mm, 1st hour Neutrophils—85% MRI normal Biopsy showed the changes of giant cell arteritis.

DIAGNOSIS Temporal cell arteritis.

1. Erythrocyte Sedimentation Rate: A measurement of how quickly red blood cells fall to the bottom of a test tube. Generally, the faster the blood cells fall, the more severe the inflammation