The medical history or anamnesis12 of a patient is information gained by a physician or other healthcare professional 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 symptoms, 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 their 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 patients 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 then a provisional diagnosis may be formulated, and other possibilities (the differential diagnoses) may be added, by convention listed in order of likelihood. The treatment plan may then include further investigations with the purpose of clarifying the diagnosis.
Process
A physician typically asks questions to obtain the following information about the patient:
- Identification and demographics: The name, age, height, weight.
- The "chief complaint (CC)" — the major health problem or concern, and its time course.
- History of present illless (HOPI) - details about the complaints enumerated in the CC.
- History of past illness (HPI)(including major illnesses, any previous surgery/operations, any current ongoing illness, eg diabetes)
- Review of systems(ROS) Systematic questioning about different organ systems
- Family diseases
- Childhood diseases
- Social history- including living arrangements, occupation, drug use (including tobacco, alcohol, other recreational drug use), recent foreign travel and exposure to environmental pathogens through recreational activities or pets.
- Regular medications (including those prescribed by doctors, and others obtained over the counter or alternative medicine)
- Allergies
- Sex life, 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 practised only by medical students) or iterative hypothesis testing (questions are limited and adapted to rule in or out likely diagnoses based on information already obtained, as practised by busy clinicians). Computerised history-taking could be an integral part of clinical decision support systems.
Taking a Medical History in the UK
Medical students are taught to follow a structured guide when learning how to take a medical history on the wards:
- Presenting complaint (PC): Ask the patient an open question, getting them to tell you what has happened: "Tell me what happened that made you come into hospital today?" The PC should be recorded in the patient's own words, eg. "could not catch my breath" rather than "dyspnoea".
- History of presenting complaint (HPC): Getting more details about how everything started and how it progressed: When did this start? What happened next? Have you had that before? If the patient describes having pain, a helpful mnemonic to remember is SOCRATES: S - site, O - onset (gradual/sudden), C - character, R - radiation, A - associations (other symptoms), T - timing/duration, E - exacerbating and alleviating factors, S - severity (rate the pain on a scale of 1-10).
- Direct questioning is used to ask specific questions about the diagnosis you have in mind or exclude diagnoses on the differentials list. A review of the relevant system is done and associated risk factors are considered, as this would be a good time to ask pertinent questions.
- Past medical history (PMH) and past surgical history (PSH): Ever been to hospital before? (when, where, why, etc). Do you suffer from any illnesses or conditions? Have you had any operations or procedures? Ask specifically about these diseases; another helpful mnemonic is MJ THREADS: M - myocardial infarction, J - jaundice, T - tuberculosis, H - hypertension & heart disease, R - rheumatic fever, E - epilepsy, A - asthma & bronchitis, D - diabetes, S - stroke.
- Drug history (DH): Do you take any (regular) medication? Tablets? Injections? Any over the counter drugs? Any prescriptions? Any herbal remedies? Contraceptive pill? Do you have any allergies? If none, record as NKDA (no known drug allergies).
- Family history (FH): Are your family in good health? Parents - alive & well, or cause of death? Grandparents? Children? Spouse? Some areas of the FH may need detailed questioning, eg. to determine if there is a significant FH of heart disease or cancer. Be TACTFUL when asking about a FH of malignancy: "I know this is difficult but it is important for us to have the correct information..." It may be useful to draw a family pedigree tree.
- Social history (SH): Probe without prying! Who else lives with you? Occupation. Marital status. Spouse's job and health. Housing - house or apartment? stairs, how many? Who visits - family, neighbours, GP, nurse? Any dependents? Mobility - walking aids needed? Who does the cooking and shopping? Is there anything the patient can't do due to illness? Note: it is often a good idea to get this information from a patient's GP if for whatever reason you can not ask the patient yourself. Alcohol, tobacco and recreational drugs - How much? How long? When did you stop? Quantify alcohol intake in terms of units and smoking in terms of pack-years. Note: patients frequently 'underestimate' how much they drink and smoke, be inclined to double any quantities stated.
- Finish the history by performing the Functional Enquiry/Systems Review to help uncover undeclared symptoms.
Review of systems
Whatever system a specific condition may seem restricted to, it may be reasonable to review all the other systems in a comprehensive history. A review of system (ROS) should cover these 14 subheadings according to the legal billing policies in the US:
- Constitutional symptoms (e.g., fever, weight loss)
- Eyes
- Ears, nose, mouth, and throat
- Cardiovascular
- Respiratory
- Gastrointestinal
- Genitourinary
- Musculoskeletal
- Integumentary
- Neurological
- Psychiatric
- Endocrine
- Hematologic/lymphatic
- Allergic/immunologic
How to perform a Systems Review/Functional Enquiry:
- General questions may be the most significant, e.g. unexplained weight loss? night sweats? fatigue/malaise/lethargy? sleeping pattern? appetite? fever? itch/rash? recent trauma? lumps/bumps/masses? unexplained falls?
- Cardio-respiratory symptoms: chest pain (see: socrates)? shortness of breath? exercise tolerance? PND? orthopnoea? oedema? palpitations? faintness? loss of consciousness? cough? sputum? wheeze? haemoptysis?
- GI symptoms: abdominal pain (see: socrates)? First ask about weight loss, and relate it to eating (i.e. can weight loss be explained by a poor food intake, or is it unexplained?) If food intake is poor, ask why: does the patient not want to eat or can they physically not eat (e.g. pain, difficulty swallowing)? Then work your way down the GI tract, from mouth to anus: difficulty swallowing? indigestion? nausea/vomiting/haematemesis? bowel habit? stool (enquire about colour, consistency, blood [melaena], smell, difficulty flushing away, tenesmus [feeling of incomplete evacuation] or urgency)?
- GU symptoms: Micturition - incontinence (stress or urge), dysuria (pain), haematuria, nocturia (getting up at night to urinate), frequency, polyuria (excessive urination), hesitancy, terminal dribbling (dribbling after the flow has ended)? Vaginal - discharge, pain (see SOCRATES)? Menses - frequency, regularity, heavy or light (ask about excessive use of pads/tampons, staining of clothes, clots always indicate heavy bleeding), duration, pain, first day of last menstrual period (LMP), how many times she has been pregnant (this includes miscarriages, abortions, etc), menarche, menopause, contraception (if relevant), date of last smear test and result.
- Neurological symptoms: Special senses - any changes in sight, smell, hearing and taste? seizures, faints, fits, funny turns? headache? pins and needles (paraesthesiae) or numbness? limb weakness, poor balance? speech problems? sphincter disturbance? higher mental function and psychiatric symptoms. Assess function.
- Musculoskeletal symptoms: pain, stiffness, swelling of the joints? variation with time of day? functional deficit?
- Thyroid symptoms: Hyperthyroid - prefer cold weather, mood swings, sweaty, diarrhoea, oligomenorrhoea, weight loss despite increased appetite, tremor, palpitations, visual disturbances. Hypothyroid - prefer hot weather, slow, tired, depressed, thin hair, croaky voice, heavy periods, constipation, dry skin.
References
- ^ http://books.google.com/books?vid=OCLC13821145&id=sePtO3Y5EMwC&pg=PA4&lpg=PA4&dq=anamnesis
- ^ http://books.google.com/books?vid=ISBN1888456035&id=H3ZaIYAaOSQC&pg=PA489&lpg=PA489&dq=anamnesis+%22medical+history%22&sig=INJCevRz3As9iZb3jKjJz6tmvhkhttp://www.brusselsivf.be/default_en.aspx?ref=AFAIAB&lang=EN
Oxford Handbook of Clinical Medicine, 7th Ed., Longmore, Wilkinson, Turmezei and Cheung. Oxford University Press 2007.
See also
