The patient history (medical history) represents an important component in the diagnosis of thoracic trauma (chest injury).
To assess the nature and extent of thoracic trauma, it is important to reconstruct how the accident occurred. If the victim is unresponsive, accident witnesses must be consulted.
Current anamnesis/systemic anamnesis (somatic and psychological complaints).
- How did the injuries occur (accident history)?
- Blunt trauma:
- Traffic accident?
- Sports accident?
- Accident in the house?
- Entrapment?
- Been rolled over?
- Burial accident?
- Fall from a greater height
- Brawl?
- Abuse?
- Open trauma
- Gunshot wound?
- Stab wound?
- Impalement injury?
- Blunt trauma:
- Might the accident have been preceded by a precipitating event?
- Where is the pain localized? Do you radiate?
- Is the pain sharp, pressing, burning, dull?
- Do you suffer from chest pain? If so, where exactly?
- Do you suffer from shortness of breath? If yes,
- Is it getting worse?
- How long have you had the discomfort? Did the complaints come on suddenly or did they develop subsequently?
- Are the complaints position-dependent?
- Do the complaints or pain change over time? Do they increase or decrease?
Vegetative anamnesis incl. nutritional anamnesis.
- When was the last time you ate something?
- Do you smoke? If so, how many cigarettes, cigars or pipes per day?
- Do you drink alcohol? If yes, what drink(s) and how many glasses per day?
- Do you use drugs? If yes, what drugs and how often per day or per week?
Self history incl. medication history.
- Pre-existing conditions (diabetes mellitus)
- Operations
- Allergies
- Pregnancy
- Medication history (e.g., anticoagulants/anticoagulants, analgesics/pain medications).
