When a patient visits a doctor with complaints, the anamnesis always comes first in the diagnosis and treatment. This is because getting to know the other person plays a special role in the first contact between patient and physician. Questions about current complaints, but also information about the patient’s previous life are important for the doctor to be able to make a diagnosis and treat the patient well. You can learn interesting facts about the process and goals of anamnesis here.
Definition: what is a medical history?
The word “anamnesis” comes from the Greek for memory – and that is exactly the purpose of the medical history: to recall all the essential information from the patient’s life so far. Anamnesis is a conversation between doctor and patient, rather a systematic questioning. It provides the physician or treating therapist with information about the patient’s medical history, current complaints and overall condition. It also gives him an insight into the patient’s personality, so that he can form a picture of how the patient experiences his illness. Sometimes the anamnesis is also carried out in writing in the first step via a so-called anamnesis sheet, i.e. a special questionnaire on the patient’s state of health, which lays the foundation for the further conversation.
Anamnesis: conversation builds trust
Since the anamnesis is at the beginning of the doctor-patient relationship, it is particularly important for building a relationship of trust – if a patient feels in good hands with his therapist, he is more willing to address even unpleasant topics, endure a painful diagnosis and accept the proposed therapy.
What all belongs in a case history?
The current chief complaint is the first building block of the case history: where exactly does it hurt? How long has it been like this? For example, does pain radiate? In addition to localization, radiation and time of onset of symptoms, intensity (increasing or decreasing discomfort), character (change in progression) and connection with certain activities are also discussed. Then the further personal history is taken: What other illnesses have there been? Has the patient been operated on before? What childhood diseases did the patient have? Are there any medications taken in the past? What is the gynecological history of women? In order not to forget anything, each organ system is often asked about individually. Next, information on family and occupation is important. In the family history, metabolic and vascular diseases as well as psychiatric illnesses are specifically discussed, because they occur more frequently in families. The biographical anamnesis with marital status, occupation and leisure activities rounds off the patient’s picture and can give indications of stressful situations that prepare the ground for the current illness. The vegetative anamnesis provides an overview of the patient’s bodily functions. In addition to height and weight, water and stool excretion, cough, appetite, thirst, sleep and use of stimulants (nicotine, alcohol, drugs) are particularly important. The last component that must not be missing is the medication history: In addition to the exact details of the current medication (which medications are taken and how often? Do you also take remedies that you obtain from the pharmacy?), vaccination status and known allergies are important for further treatment.
Procedure for taking a medical history
In most cases, the physician or treating therapist will begin the medical history interview with a question to which the patient can respond individually. This so-called open-ended form of questioning makes it easier for the patient to describe his or her complaints in his or her own way. The physician will then narrow down the conversation with more specific questions to cover all areas of the medical history. In most cases, he will take only a few notes so that he can devote himself to the patient in depth and not interrupt the patient’s flow of speech. However, the type of history taking also depends greatly on the physician’s specialty: for example, a psychiatric or neurological initial history contains many linguistic elements that test the patient during the history taking – it is thus a history and “brain” examination in one. This anamnesis is thus usually more extensive than an anamnesis of a physician working in a surgical specialty who, after anamnesis and physical examination, resorts to several technical examination procedures such as X-ray or ECG.
How important is medical history?
90 percent of all diagnoses can be made with the help of the medical history and physical examination – if the doctor is experienced and correctly evaluates all the information received. A good doctor or therapist has mastered the art of filtering out what is crucial from all the information and then making the correct diagnosis. In this context, the way the conversation is conducted is crucial – a patient who feels valued and who takes it from his or her doctor that he or she is taking care of him or her in the best possible way will be instrumental in ensuring that all relevant information reaches the doctor.
How detailed does a medical history need to be?
The success of further treatment depends largely on what information the physician obtains from the medical history and physical examination. Therefore, he will handle the anamnestic questioning in varying degrees of detail, depending on the symptoms and specialty as well as his experience. His goal is to establish a tentative diagnosis with the help of the history and physical examination, which he can then substantiate with further examinations in order to then be able to treat the patient optimally. There is therefore no set duration for an anamnesis; it can last 5 minutes (for example, in the case of known patients), but also 50 minutes. Often, the initial history is supplemented by further information in the course of the treatment process, so that the doctor gets an increasingly detailed picture of his patient over time.
When is a medical history not taken?
The more life-threatening the patient’s medical condition, the more the taking of a medical history is eclipsed by life-saving initial measures. The motto in emergency medical services is SIMPLE:
- Next to the symptoms
- Is searched for allergies (immune reactions),
- Medications,
- The patient’s medical history,
- The last information relevant to the problem (for example, for gynecological patients, after the last menstruation).
- And the acute event asked.
Meanwhile, all measures are taken to stabilize the patient, that is, to avert his life-threatening condition. All other anamnestic information is obtained later, when the acute danger has been averted for the patient.
Extraneous anamnesis – what does it mean?
In unconscious patients, often only the extraneous history – that is, questioning a third party – can provide important clues about the underlying illness: In someone with diabetes, a diabetic coma may have occurred; if the patient is addicted to drugs, an overdose may be a possibility; if the patient has known heart disease, a heart attack should be ruled out. Relatives and caregivers must also often be questioned in the case of mentally confused patients who are unable to provide information about themselves and their medical conditions. However, this does not preclude specific questioning of the patient by a physician – this can be used to determine the degree of confusion and to monitor whether there is a change with appropriate medication.
What happens after the history is taken?
Once the physician has obtained all relevant information, he or she determines the next course of action. In many specialties, taking a medical history goes hand in hand with the physical examination, so the next step is the first examinations, for which technical equipment is needed, such as blood tests, X-rays or ultrasound. The first therapeutic measures are also initiated – be it the administration of a painkiller or the intravenous administration of fluid with an infusion. It is particularly important to document the medical history with the suspected diagnosis, so that even if there is a change of physician, it remains clear why the attending physician decided on the selected procedure with regard to examinations and therapy. In most cases, all information is entered in standardized medical history forms so that missing information is noticed and can be added. In some hospitals, the medical history and admission findings are now dictated immediately, so that the medical history is available in digital form to all departments.
