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Medical Writings |

The Language of Medical Case Histories

William J. Donnelly, MD
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Edward Hines, Jr. Veterans Affairs Hospital; Hines, IL 60141 Note: Earlier versions of this paper were presented as “Constructing Ethical Medical Case Histories” as part of the workshop “Narrative Ethics Under Construction” for the Annual Meeting of the Society for Health and Human Values, 15 October 1995, San Diego, California, and at the Spring Meeting of the Society for Health and Human Values, 13 April 1996, Knoxville, Tennessee. Requests for Reprints: William J. Donnelly, MD, Medical Service (111), Edward Hines, Jr. VA Hospital, Hines, IL 60141.

Copyright ©2004 by the American College of Physicians

Ann Intern Med. 1997;127(11):1045-1048. doi:10.7326/0003-4819-127-11-199712010-00035
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Questionable language pervades case histories, the professional accounts of illness and medical care constructed by students and practitioners of medicine every day in teaching hospitals. In the archetypal configuration taught to medical students, the case history begins with the patient's chief complaint and concludes with an interim or final summary of diagnoses, course, and care. I use the term case history generically to refer to both the medical record and its numerous offspring, such as oral case presentations and published case reports. However, I give greatest attention to the written record. As the official, permanent account of professional medical care, the medical record not only shapes the style and focus of its various progeny but also determines what students take seriously in an antecedent activity, the medical interview [1].

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