Published in:
Open Access 01-12-2015 | Case report
The importance of good history taking: a case report
Published in: Journal of Medical Case Reports | Issue 1/2015
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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.