Medical history
Encyclopedia
The medical history or anamnesis (abbr. Hx) of a patient
is information gained by a physician
by asking specific questions, either of the patient or of other people who know the person and can give suitable information (in this case, it is sometimes called heteroanamnesis), with the aim of obtaining information useful in formulating a diagnosis and providing medical care to the patient
. The medically relevant complaints reported by the patient or others familiar with the patient are referred to as symptom
s, in contrast with clinical signs, which are ascertained by direct examination on the part of medical personnel. Most health encounters will result in some form of history being taken. Medical histories vary in their depth and focus. For example, an ambulance
paramedic
would typically limit his history to important details, such as name, history of presenting complaint, allergies, etc. In contrast, a psychiatric history
is frequently lengthy and in depth, as many details about the patient's life are relevant to formulating a management plan for a psychiatric illness.
The information obtained in this way, together with clinical examination, enables the physician to form a diagnosis
and treatment
plan. If a diagnosis
cannot be made, a provisional diagnosis may be formulated, and other possibilities (the differential diagnoses
) may be added, listed in order of likelihood by convention. The treatment plan may then include further investigations to clarify the diagnosis.
History-taking may be comprehensive history taking (a fixed and extensive set of questions are asked, as practiced only by health care students such as medical students, physician assistant students, or nurse practitioner students) or iterative hypothesis testing (questions are limited and adapted to rule in or out likely diagnoses based on information already obtained, as practiced by busy clinicians). Computer
ized history-taking could be an integral part of clinical decision support system
s.
a specific condition may seem restricted to, it may be reasonable to review all the other systems in a comprehensive history.
s. In such cases, it may be necessary to perform a so called heteroanamnesis of other people who know the person and can give suitable information, which, however, generally is more limited than a direct anamnesis.
Medical history taking may also be impaired by various factors impeding a proper doctor-patient relationship
, such as transitions to physicians that are and unfamiliar to the patient.
History taking of issues related to sexual
or reproductive medicine
may be inhibited by a reluctance of the patient to disclose intimate or uncomfortable information. Even if such an issue is on the patient's mind, he or she often doesn't start talking about such an issue without the physician initiating the subject by a specific question about sexual or reproductive health
. Some familiarity with the doctor generally makes it easier for patients to talk about intimate issues such as sexual subjects, but for some patients, a very high degree of familiarity may make the patient reluctant to reveal such intimate issues. When visiting a health provider about sexual issues, having both partners of a couple present is often necessary, and is typically a good thing, but may also prevent the disclosure of certain subjects, and, according to one report, increases the stress level.
Patient
A patient is any recipient of healthcare services. The patient is most often ill or injured and in need of treatment by a physician, advanced practice registered nurse, veterinarian, or other health care provider....
is information gained by a physician
Physician
A physician is a health care provider who practices the profession of medicine, which is concerned with promoting, maintaining or restoring human health through the study, diagnosis, and treatment of disease, injury and other physical and mental impairments...
by asking specific questions, either of the patient or of other people who know the person and can give suitable information (in this case, it is sometimes called heteroanamnesis), with the aim of obtaining information useful in formulating a diagnosis and providing medical care to the patient
Patient
A patient is any recipient of healthcare services. The patient is most often ill or injured and in need of treatment by a physician, advanced practice registered nurse, veterinarian, or other health care provider....
. The medically relevant complaints reported by the patient or others familiar with the patient are referred to as symptom
Symptom
A symptom is a departure from normal function or feeling which is noticed by a patient, indicating the presence of disease or abnormality...
s, in contrast with clinical signs, which are ascertained by direct examination on the part of medical personnel. Most health encounters will result in some form of history being taken. Medical histories vary in their depth and focus. For example, an ambulance
Ambulance
An ambulance is a vehicle for transportation of sick or injured people to, from or between places of treatment for an illness or injury, and in some instances will also provide out of hospital medical care to the patient...
paramedic
Paramedic
A paramedic is a healthcare professional that works in emergency medical situations. Paramedics provide advanced levels of care for medical emergencies and trauma. The majority of paramedics are based in the field in ambulances, emergency response vehicles, or in specialist mobile units such as...
would typically limit his history to important details, such as name, history of presenting complaint, allergies, etc. In contrast, a psychiatric history
Psychiatric history
A psychiatric history is the result of a medical process where a clinician working in the field of mental health systematically records the content of an interview with a patient...
is frequently lengthy and in depth, as many details about the patient's life are relevant to formulating a management plan for a psychiatric illness.
The information obtained in this way, together with clinical examination, enables the physician to form a diagnosis
Diagnosis
Diagnosis is the identification of the nature and cause of anything. Diagnosis is used in many different disciplines with variations in the use of logics, analytics, and experience to determine the cause and effect relationships...
and treatment
Therapy
This is a list of types of therapy .* Adventure therapy* Animal-assisted therapy* Aquatic therapy* Aromatherapy* Art and dementia* Art therapy* Authentic Movement* Behavioral therapy* Bibliotherapy* Buteyko Method* Chemotherapy...
plan. If a diagnosis
Diagnosis
Diagnosis is the identification of the nature and cause of anything. Diagnosis is used in many different disciplines with variations in the use of logics, analytics, and experience to determine the cause and effect relationships...
cannot be made, a provisional diagnosis may be formulated, and other possibilities (the differential diagnoses
Differential diagnosis
A differential diagnosis is a systematic diagnostic method used to identify the presence of an entity where multiple alternatives are possible , and may also refer to any of the included candidate alternatives A differential diagnosis (sometimes abbreviated DDx, ddx, DD, D/Dx, or ΔΔ) is a...
) may be added, listed in order of likelihood by convention. The treatment plan may then include further investigations to clarify the diagnosis.
Process
A practitioner typically asks questions to obtain the following information about the patient:- Identification and demographics: name, age, height, weight.
- The "chief complaintChief complaintThe Chief Complaint formally known as CC in the medical field, or termed Presenting Complaint in the UK, is a concise statement describing the symptom, problem, condition, diagnosis, physician recommended return, or other factor that is the reason for a medicalencounter...
(CC)" - the major health problem or concern, and its time course (e.g. chest pain for past 4 hours). - History of the present illnessHistory of the present illnessIn a medical encounter, a history of the present illness refers to a detailed interview prompted by the chief complaint or presenting symptom ....
(HPI) - details about the complaints, enumerated in the CC. (Also often called 'History of presenting complaint' or HPC.) - Past Medical HistoryPast medical historyIn a medical encounter, a past medical history , is the total sum of a patient's health status prior to the presenting problem.-Questions to include:...
(PMH) (including major illnesses, any previous surgery/operations, any current ongoing illness, e.g. diabetes). - Review of systemsReview of systemsA review of systems is a technique used by health-care providers for eliciting a history from a patient. It is often structured as a component of an admission note covering the organ systems, with a focus upon the subjective symptoms perceived by the patient...
(ROS) Systematic questioning about different organ systems - Family diseasesFamily history (medicine)In medicine, a family history consists of information about disorders from which the direct blood relatives of the patient have suffered. Genealogy typically includes very little of the medical history of the family, but the medical history could be considered a specific subset of the total history...
- especially those relevant to the patient's chief complaint. - Childhood diseases - this is very important in pediatrics.
- Social history (medicine)Social history (medicine)In medicine, a social history is a portion of the Admission note addressing familial, occupational, and recreational aspects of the patient's personal life that have the potential to be clinically significant.-Components:...
- including living arrangements, occupation, marital status, number of children, drug use (including tobacco, alcohol, other recreational drug use), recent foreign travel, and exposure to environmental pathogens through recreational activities or pets. - Regular and acute medications (including those prescribed by doctors, and others obtained over-the-counter or alternative medicineAlternative medicineAlternative medicine is any healing practice, "that does not fall within the realm of conventional medicine." It is based on historical or cultural traditions, rather than on scientific evidence....
) - AllergiesAllergyAn Allergy is a hypersensitivity disorder of the immune system. Allergic reactions occur when a person's immune system reacts to normally harmless substances in the environment. A substance that causes a reaction is called an allergen. These reactions are acquired, predictable, and rapid...
- to medications, food, latex, and other environmental factors - SexualHuman sexualityHuman sexuality is the awareness of gender differences, and the capacity to have erotic experiences and responses. Human sexuality can also be described as the way someone is sexually attracted to another person whether it is to opposite sexes , to the same sex , to either sexes , or not being...
history, obstetric/gynecological history, and so on, as appropriate.
History-taking may be comprehensive history taking (a fixed and extensive set of questions are asked, as practiced only by health care students such as medical students, physician assistant students, or nurse practitioner students) or iterative hypothesis testing (questions are limited and adapted to rule in or out likely diagnoses based on information already obtained, as practiced by busy clinicians). Computer
Computer
A computer is a programmable machine designed to sequentially and automatically carry out a sequence of arithmetic or logical operations. The particular sequence of operations can be changed readily, allowing the computer to solve more than one kind of problem...
ized history-taking could be an integral part of clinical decision support system
Clinical decision support system
Clinical decision support system is an interactive decision support system Computer Software, which is designed to assist physicians and other health professionals with decision making tasks, as determining diagnosis of patient data. A working definition has been proposed by Dr...
s.
Review of systems
Whatever systemSystem
System is a set of interacting or interdependent components forming an integrated whole....
a specific condition may seem restricted to, it may be reasonable to review all the other systems in a comprehensive history.
Inhibiting factors
Factors that inhibit a proper medical history taking include physical inability of the patient to communicate with the physician, such as unconsciousness and communication disorderCommunication disorder
A communication disorder is a speech and language disorder which refers to problems in communication and in related areas such as oral motor function. The delays and disorders can range from simple sound substitution to the inability to understand or use language...
s. In such cases, it may be necessary to perform a so called heteroanamnesis of other people who know the person and can give suitable information, which, however, generally is more limited than a direct anamnesis.
Medical history taking may also be impaired by various factors impeding a proper doctor-patient relationship
Doctor-patient relationship
The doctor-patient relationship is central to the practice of healthcare and is essential for the delivery of high-quality health care in the diagnosis and treatment of disease. The doctor-patient relationship forms one of the foundations of contemporary medical ethics...
, such as transitions to physicians that are and unfamiliar to the patient.
History taking of issues related to sexual
Sexual medicine
Sexual medicine is a medical specialty that deals with sexual health. At times heavily influenced by current local views on morality, with heavy cultural overlay, in broad terms this specialty is concerned with diagnosing, assessing and treating all aspects which relate to sexuality.Issues can be...
or reproductive medicine
Reproductive medicine
Reproductive medicine is a branch of medicine that deals with prevention, diagnosis and management of reproductive problems; goals include improving or maintaining reproductive health and allowing people to have children at a time of their choosing...
may be inhibited by a reluctance of the patient to disclose intimate or uncomfortable information. Even if such an issue is on the patient's mind, he or she often doesn't start talking about such an issue without the physician initiating the subject by a specific question about sexual or reproductive health
Reproductive health
Within the framework of the World Health Organization's definition of health as a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity, reproductive health, or sexual health/hygiene, addresses the reproductive processes, functions and system...
. Some familiarity with the doctor generally makes it easier for patients to talk about intimate issues such as sexual subjects, but for some patients, a very high degree of familiarity may make the patient reluctant to reveal such intimate issues. When visiting a health provider about sexual issues, having both partners of a couple present is often necessary, and is typically a good thing, but may also prevent the disclosure of certain subjects, and, according to one report, increases the stress level.
See also
- CatamnesisCatamnesisCatamnesis is the follow-up history of a patient after he is discharged from treatment or a hospital. the history of a patient after the onset of a medical or psychiatric illness. The medical history of a patient following an illness; the follow-up history. The medical history of a patient from...
- GenogramGenogramA genogram is a pictorial display of a person's family relationships and medical history. It goes beyond a traditional family tree by allowing the user to visualize hereditary patterns and psychological factors that punctuate relationships...
- Historian (medical)Historian (medical)"Historian" is a term used by medical professionals to describe a narrator of a medical history.Medical history is usually divided into surgical history , social history , family history , and health or personal...
- Medical recordMedical recordThe terms medical record, health record, and medical chart are used somewhat interchangeably to describe the systematic documentation of a single patient's medical history and care across time within one particular health care provider's jurisdiction....
- MedicineMedicineMedicine is the science and art of healing. It encompasses a variety of health care practices evolved to maintain and restore health by the prevention and treatment of illness....
- Physical examinationPhysical examinationPhysical examination or clinical examination is the process by which a doctor investigates the body of a patient for signs of disease. It generally follows the taking of the medical history — an account of the symptoms as experienced by the patient...
- PsychoanalysisPsychoanalysisPsychoanalysis is a psychological theory developed in the late 19th and early 20th centuries by Austrian neurologist Sigmund Freud. Psychoanalysis has expanded, been criticized and developed in different directions, mostly by some of Freud's former students, such as Alfred Adler and Carl Gustav...
(Freud uses the term anamnesis to describe neurotics' recounting of their symptoms)