The medical history plays an important role in the diagnosis of diseases and is usually carried out by a doctor or other medical staff.
It involves asking specific questions with the aim of finding out all the 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 differ enormously, depending on the illness and condition of the sick person. In this way, the anamnesis can be viewed and divided from different points of view.
One of the most important basic requirements for taking an anamnesis is a good doctor-patient relationship. If a patient feels that they are in good hands with the treating doctor, it is more likely that unpleasant details, which can be of importance for the diagnosis, are shared with the doctor become.
The anamnesis is usually in divided into four large groups.
In this way, an anamnesis can be classified according to the person interviewed. An anamnesis based on the Statements of the patient is based, is Personal history called.
If the Statements about the affected person from family members or other people because the patient is not able to make statements about himself for various reasons, one speaks of a Foreign anamnesis.
Another frequent classification of the anamnesis is directed according to the subject the survey. A distinction is mainly made between the
Current medical history
Vegetative medical history
Social and family history
Luxury food / drug history
All points mentioned should be discussed in a comprehensive anamnesis (for example, during an initial consultation with the future family doctor). In certain situations of acute illness, not all possible questions typically need to be answered.
Another way of classifying the anamnesis is one Survey on a specific topic. For example, other 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 subject area fall under the General medical history, whereas special questions are under a Special or acute medical history fall.
A final, special classification of the anamnesis relates to certain medical specialties. Particularly in the fields of urology and gynecology, but also in certain fields of internal medicine, there are special questions that are particularly relevant and therefore must not be missing in any anamnesis in these facilities.
The description of the course of a "typical" anamnesis is difficult, because depending on the specialty and the reason for the doctor-patient contact, the Medical history can vary widely. Also has every attending physician has a slightly different style, as far as the order of the anamnesis is concerned, so that the individual anamnesis can also be different for this reason. Depending on the type of anamnesis, there is a uniform scheme not always possible. For example, a social anamnesis differs from a psychological anamnesis in many ways.
However, there are some basic requirements that should be met for most regular medical histories. So should be with an anamnesis a relationship of trust between the attending physician and the person concerned to rule. This includes, if not absolutely necessary, yourself no other people in the room should stop than the doctor and the interviewee. It should be a pleasant and calm atmosphere be created in which the Patient feels good to answer intimate questions as well, as these may be helpful in establishing a diagnosis.
A medical history precedes most medical acts. Before a patient can be helped, it is important Background information about humans to learn as well as about Events, habits or previous illnessesthat could possibly affect treatment.
It usually starts with a open questionso that the patient can present his or her medical history without interruption. Then follow specific questions from the therapist to the problems described.
At a Medical history, which is disease-related, is carried out due to a special problem, a Acute medical history respectively. By describing the acute problem, the treating doctor can determine whether there is an acute need for action or whether the rest of the anamnesis can be carried out in peace. After describing the acute symptoms, which should include the patient's fears and worries as well as the symptoms, the general anamnesis usually follows.
Depending on the subject, however, the anamnesis focuses on psychological or social issues, which is why the general anamnesis takes a back seat. A thorough anamnesis is particularly important for illnesses with a psychological background, as this can play a decisive role in making the correct diagnosis. However, the specific questions for making a diagnosis typically differ greatly from those in general medicine.
Acute medical history
The acute anamnesis deals with complaints that are currently in the foreground. It is in the foreground and at the beginning in many situations, as it is to be ensured that no life-threatening situations are overlooked before moving on to other, less acute questions.
In the case of severe pain, there may be a need for action after the acute anamnesis, before the vegetative anamnesis is taken.
Typically, the acute anamnesis is carried out with so-called "W questions". These should describe the quantity and quality of the complaints in more detail. So is the place (Where?), the kind (What?), the severity (How strong?), the temporal connection (When?), possible triggering factors (By what?), as well as the so-called degree of disability (What is not working?) 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 exclusively deal with the symptoms that are currently present, but also includes a question about the course of the disease. So it is important when and how long the illness has lasted, as well as whether the sick person may have an explanation for their own symptoms. The question of existing previous illnesses can also fall into the category of acute anamnesis, as this provides information about the likelihood of the presence of some illnesses.
The vegetative anamnesis deals with the purely physical background of the complaints. These include Weight changes in both directions in the last few months, sleep disorders, appetite, Allergies, such as bowel movement and the Urination. In women, the vegetative anamnesis also includes Questions about your menstrual period a.
The Medication history is an important part of the anamnesis in almost every situation. She delivers Information about taking current medication and can thus decisively influence the diagnosis and therapy. Under certain circumstances, the medication history can also be an indication of certain symptoms and the presence of illnesses if the patient can no longer remember the illness but has the tablets with him.
The psychological history is an important part in diagnosing diseases such as depression, Anxiety disorders, such as psychotic illnesses. Especially when diagnosing depression, the anamnesis is the only way to reliably identify it. It is particularly important that there is a relationship of trust between the patient and the doctor so that the questions are answered honestly and the meaningfulness of the anamnesis is not weakened.
Social and family history
A social history provides the attending physician with an overview of the situation in which the person concerned is. It is necessary because of the influences of the social environment, Conflicts, Relationships, and cultural backgrounds one Influence on disease perception and processing are.
It is also important to provide information about the lifestyle that is led, which provides an insight into how to deal with illness and an assessment of the given risk factors.
In certain situations there is a Assessment via the social network of a patient of enormous importance for a later therapy. A person living alone may need to be hospitalized if a person who lives with a relative or a partner can be cured at home.
The social history includes a question about that current or mainly practiced occupation in order to exclude exposure to certain relevant substances and to be able to assess the physical demands of the occupation.
The Family history provides information on whether certain illnesses occur more frequently among immediate relatives and could possibly be the cause of the current complaints. Genetically inherited diseases who are known to have relatives suffering from them can also be an indication of existing diseases.
Luxury food and drug history
Questions about the weekly consumption from nicotine, alcohol and other drugs represent a sensitive topic for many patients. However, since it has an enormous role in the development of a number of clinical pictures, questions about this are obvious.
It is important that the patient answers these questions honestly so that a diagnosis can be made and the correct therapy initiated. A strong relationship of trust between doctor and patient is particularly important when it comes to these questions.
In certain situations the priority of an anamnesis moves into the background. The emergency services use a less detailed anamnesis, which only deals with the things that are important for the acute, possibly life-threatening situation.
A Foreign anamnesis, that is, an anamnesis of a person who cannot or does not want to answer questions for himself, can with very old or sick people, unconscious people, children, non-German speaking patients, as well as if the attending physician has doubts about the correctness of the patient's statements.
What follows after taking an anamnesis?
In most cases, the anamnesis is followed by other medical diagnostic methods.
This includes a physical examination of the victim, imaging studies (Ultrasonic, MRI, CT, roentgen), as well as a Blood draw for the determination of diagnostically relevant values in the blood.
After the diagnosis has been made, therapy is initiated, which is initially discussed with the patient concerned. In this conversation, the patient may get an insight into the extent to which their own information contributed to the correct diagnosis being made.