The medical history plays an important role in the diagnosis of diseases and is usually carried out by a doctor or other medical personnel. It is the targeted asking of questions with the aim of obtaining all relevant medical background information that is important for making a correct diagnosis or therapy. However, the anamnesis is by no means always the same.
The questions can vary enormously, depending on the illness and condition of the patient. Thus the anamnesis can be viewed and classified from different points of view. One of the most important basic requirements for an anamnesis is a good doctor-patient relationship. If a patient feels that he or she is in good hands with the doctor treating him or her, it is more likely that unpleasant details that could be important for the diagnosis are also shared with the doctor.
Classification
The medical history is usually divided into four major groups. Thus, an anamnesis can be divided according to the person interviewed. An anamnesis based on the statements of the patient is called a personal anamnesis.
If the statements about the person concerned are made by family members or other persons because the patient is not able to make the statements about himself/herself for various reasons, this is called a foreign anamnesis. Another frequent classification of the anamnesis depends on the subject of the interview. The main distinction here is between the current medical history Vegetative medical history Drug history Drug history Psychological medical history Social and family medical history Drug/drug history In an extensive medical history (e.g. during an initial consultation with the future family doctor) all the points mentioned should be discussed.
In certain situations of acute illness, not all possible questions typically need to be answered. Another way of classifying the anamnesis is to ask about a specific topic. For example, different topics are of interest for the symptom of acute shortness of breath than for abdominal pain.
All questions that cannot be subordinated to a specific topic area fall under the general anamnesis in this classification, whereas specific questions fall under a special or acute anamnesis. A final, special classification of the anamnesis refers to certain medical specialties. For example, in the fields of urology and gynaecology, but also in certain fields of internal medicine, there are special questions which are particularly relevant and therefore must not be missing from any medical history in these institutions. – Current anamnesis
- Vegetative anamnesis
- Medical history
- Psychic anamnesis
- Social and family anamnesis
- Food and drug history
Procedure
It is difficult to describe the course of a “typical” anamnesis, because the anamnesis can be very different depending on the specialty and reason for the doctor-patient contact. In addition, every attending physician has a slightly different style with regard to the sequence of the anamnesis, so that for this reason, too, the individual anamnesis can be different. Depending on the type of anamnesis, a uniform scheme is not always possible.
For example, a social anamnesis differs from a psychological anamnesis in many ways. There are, however, some basic requirements that should be met by most regular anamnesis. For example, in an anamnesis there should be a relationship of trust between the treating doctor and the person concerned.
This includes that, if not absolutely necessary, no other persons should stay in the room than the doctor and the person interviewed. A pleasant and calm atmosphere should be created in which the patient feels comfortable answering even intimate questions, as these may be helpful in finding a diagnosis. An anamnesis is before the beginning of most medical actions.
Before a patient can be helped, it is important to obtain background information about the person, as well as about events, habits or previous illnesses that could possibly influence treatment. This usually starts with an open question, so that the patient can present his medical history without interruption. This is followed by concrete questions from the therapist about the problems described.
In the case of an anamnesis that is disease-related, i.e. is carried out due to a specific problem, an acute anamnesis must first be carried out. By describing the acute problem, the attending physician can determine whether there is an acute need for action or whether the rest of the anamnesis can be carried out at rest. The description of the acute symptoms, which should include the patient’s fears or worries in addition to the symptoms, is usually followed by the general medical history.
Depending on the specialty, however, the focus of the anamnesis is on the psychological or social issues, which is why the general anamnesis takes a back seat. A thorough anamnesis is particularly important for diseases with a psychological background, as this can play a decisive role in making the right diagnosis. However, the specific questions for making a diagnosis are typically very different from those in general practice.
The acute anamnesis deals with symptoms that are currently in the foreground. It is in the foreground and at the beginning in many situations, as it is intended to ensure that no life-threatening situations are overlooked before moving on to other, less acute questions. In the case of severe pain, for example, there may be a need for action even after the acute medical history has been taken, before moving on to the vegetative history.
Typically, the acute anamnesis is performed with so-called “W questions”. These are intended to describe the quantity and quality of the complaints in more detail. The location (Where?
), the type (What? ), the severity (How strong? ), the temporal connection (When?
), possible triggering factors (What causes? ), as well as the so-called degree of disability (What is not possible?) are to be mentioned in connection with the complaints.
This information ultimately helps the attending physician to make the correct diagnosis and initiate countermeasures. However, the current anamnesis does not only deal with the complaints that are currently present, but also includes a question about the course of the disease. It is important to know when and how long the illness has been going on, and whether the person with the illness may have an explanation for his or her own complaints. The question about existing previous illnesses can also fall into the category of acute anamnesis, as this provides information about the probability of the presence of some illnesses.