The Importance of Good History Taking: A Case Report

Durga Ghosh; Premalatha Karunaratne

Disclosures

J Med Case Reports. 2015;9(97) 

In This Article

Abstract and Introduction

Abstract

Introduction Early comprehensive geriatric assessment (CGA) with good history-taking is essential in assessing the older adult.

Case presentation Our patient, a 75-year-old Caucasian woman, was originally admitted to hospital for investigation of iron deficiency anemia. During admission, she developed pneumonia and new intermittent atrial fibrillation in association with a right-sided weakness, which was felt to be new at the time.

Following this episode, she was treated for a further chest infection and, despite clinical improvement, her inflammatory markers failed to settle satisfactorily.

She was transferred to her local hospital for a period of rehabilitation where further neurological findings made the diagnosis of solely stroke questionable; these findings prompted further history-taking, investigations and input from other disciplines, thereby helping to arrive at a working diagnosis of vasculitic neuropathy.

Conclusions The case aims to highlight the importance of taking a good history and performing an early comprehensive assessment in the older adult.

Introduction

Good history-taking, an essential part of a comprehensive assessment in an older adult,[1] helped reveal an underlying debilitating neuropathy.

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