Medical history

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1], Associate Editor(s)-In-Chief: Priyamvada Singh, M.B.B.S. [2]

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Overview

The medical history or anamnesis[1][2] 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. This kind of information is called the symptoms, in contrast with clinical signs, which are ascertained by direct examination. 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 diagnosis) may be added, by convention listed in order of likelihood. The treatment plan may then include further investigations to try and clarify the diagnosis.

Essential Parts of Medical history taking [3] [4] [5] [6] [7]

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. A physician typically asks questions to obtain the following information about the patient:

Identification and demographics

  • The name, age, height, weight.

Presenting complaint (PC)

  • This is the most important part to determine the reason patient seeks care. Important to consider using the patient’s terminology. This almost always provides you a “title” for the encounter.

History of presenting complaint (HOPC)

  • This provide a thorough description of the chief complaint and current problem. The suggested format is as follow: P-Q-R-S-T.
  • P: precipitating and palliative factors: It is essential to identify factors that make symptom worse and/or better; any previous self-treatment or prescribed treatment, and patient's response.
  • Q: quality and quantity descriptors: Allow her/him to identify own rating of symptom (e.g., pain on a 1–10 scale) and descriptors (e.g., numbness, burning sensation, stabbing).
  • R: region and radiation: Ask enough questions to identify the exact location of the symptom and any area of radiation
  • S: severity and associated symptoms: Try to identify the symptom’s severity (e.g., how bad at its worst) and any associated symptoms (e.g., presence or absence of nausea and vomiting, caused dyspnea, associated with chest pain).
  • T: timing and temporal descriptions: This helps to identify when complaint was first noticed; how it has changed/progressed since onset (e.g., remained the same or worsened/improved); whether onset was acute or chronic; whether it has been constant, intermittent, or recurrent.
  • Another mnemonic used sometimes is 'SOCRATES' with questions Site, Onset, Character, Radiation, Association, Timing of complaint, Exacerbating, and Alleviating factor and Severity.

Direct question about the differential

  • Direct question regarding differential diagnosis and the associated risk factors with these diagnosis.

Past medical history (PMH)

Drug history

  • Over the counter (OTC) drugs
  • Prescription drugs
  • Tablets/Injections
  • Allergies
  • Herbal remedies

Smoking, alcohol, recreational drug history

  • General question - Duration, quantity, when stopped (if stopped)
  • Smoking - Ask in terms of pack year. 1 pack year = 20 cigarettes / day / year
  • Alcohol - CAGE questionnaire

CAGE questionnaire

The CAGE questionnaire, named for its four questions, is a method to screen for Alcoholism.

Two "yes" responses indicate that the respondent should be investigated further.

The questionnaire asks the following questions:

  1. Have you ever felt you needed to Cut down on your drinking?
  2. Have people Annoyed you by criticizing your drinking?
  3. Have you ever felt Guilty about drinking?
  4. Have you ever felt you needed a drink first thing in the morning (Eye-opener) to steady your nerves or to get rid of a hangover?[8][9]

Family history

  • A carefully taken family history helps to identify potential sources of hereditary diseases. A genogram (if possible) is helpful; the minimum includes first degree relatives (parents, siblings, children), although 2–3 orders for each topics are helpful. skin lesions,
  • Similar presenting complaints in family
  • Stroke, Epilepsy, anesthesia problems
  • Heart disease in family can be elicited by the following questions: disease in patient's grandfather and male sibling, smoking, hypertension, hyperlipidaemia, and claudication before 60 years of age.
  • TB, Bronchitis, asthma
  • Diabetes
  • Malignancy
  • Allergies, food intolerance
  • History of oral and genital ulcerations

Social history

Be polite and careful while taking a sociocultural history. These questions will help to identify occupational and recreational activities and experiences, living environment, financial status/support as related to patient's health care, needs, travel, lifestyle, etc.

  • Occupation
  • Marital status
  • Spouse job and health
  • Living arrangements,? Do family friends visit often? Are there any dependent in the family (useful in geriatrics, neuropsychiatric patients)
  • Stair cases in home, walking aids (useful in geriatrics patients)
  • Habits: Sleep and exercise patterns (e.g., tea and coffee consumption in the evening may aggravate frequency of urination at night (Differential diagnosis of nocturia should always kept in mind).
  • Recent foreign travel and exposure to environmental pathogens through recreational activities or pets.
  • Sex life, obstetric/gynecological history and so on as appropriate.

Review of systems

  • Review a list of possible symptoms that the patient may have noted in each of the body systems. Systematic questioning about different organ 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 (Significant in TB, cancer, and endocrine disorders). Take history of:
    • Fatigue
    • Fever
    • Night sweats
    • Trauma
    • Sleeping pattern
    • Appetite
    • Weight loss
    • Lumps
    • Rash
  • Cardiovascular
  • Gastrointestinal
    • Abdominal pain
    • Swallowing
    • Indigestion
    • Nausea, vomiting, bloody vomiting (hematemesis)
    • Bowel (quantity, quality, color, smell, blood, slime, sticky, tenesmus, urgency, tenesmus)
    • Melaena
  • Genitourinary
    • Incontinence
    • Urinary retention
    • Bloody urine (hematuria)
    • Increased frequency (Polyuria)
    • Painful urination (dysuria)
    • Nocturia (waking up at night for urination)
    • Difficulty starting urination (hesitancy)
    • Terminal dribbling
  • Musculoskeletal
    • Pain
    • Swelling
    • Mobility
    • Diurnal variation
  • Neurological
  • Endocrine
    • Hypothyroidism - Depression, fatigue, thin hair, hoarse voice, dry skin, tolerate warm weather well, constipation, heavy periods
    • Hyperthyroidism - tolerate cold weather well, sweaty, weight loss, increased appetite, decreased menses.
  • Respiratory
  • Integumentary
  • Eyes
  • Psychiatric
  • Ears, nose, mouth, and throat
  • Hematologic/lymphatic
  • Allergic/immunologic

References

  1. http://books.google.com/books?vid=OCLC13821145&id=sePtO3Y5EMwC&pg=PA4&lpg=PA4&dq=anamnesis
  2. http://books.google.com/books?vid=ISBN1888456035&id=H3ZaIYAaOSQC&pg=PA489&lpg=PA489&dq=anamnesis+%22medical+history%22&sig=INJCevRz3As9iZb3jKjJz6tmvhk][http://www.brusselsivf.be/default_en.aspx?ref=AFAIAB&lang=EN
  3. Goolsby MJ, Grubbs L. Interpreting findings and formulating differential diagnoses. FA Davis. (2006) ISBN 0-8036-1363-6
  4. Ebell, M.H. (2001). Evidence-Based Diagnosis: A Handbook of Clinical Prediction Rules. New York: Springer. ISBN 0387950257
  5. Elstein, A.S., Schwartz, A. Evidence base of clinical diagnosis: Clinical problem solving and diagnostic decision making: Selective review of the cognitive literature. BMJ 2002, 324: 729–732. PMID 11909793
  6. Gross, R. (2001). Decisions and Evidence in Medical Practice: Applying Evidence-Based Medicine to Clinical Decision Making. St. Louis: Mosby. ISBN 0323011691
  7. Guyatt, G., Rennie, D. (2008). Users’ Guides to the Medical Literature: A Manual for Evidence-Based Clinical Practice. Chicago, IL: AMA Press. ISBN 007159034X
  8. Ewing, John A. “Detecting Alcoholism: The CAGE Questionnaire” JAMA 252: 1905-1907, 1984
  9. CAGE Questionnaire (PDF)

See also


bg:Анамнеза da:Anamnese (sygehistorie) de:Anamnese (Medizin)eu:Anamnesiid:Riwayat kesehatan it:Anamnesi (medicina) lb:Anamnes (Medezin) hu:Anamnézis nl:Anamnese (medisch) no:Anamnesesk:Anamnéza (medicína) sr:Анамнеза (медицина) sh:Anamneza (medicina) fi:Anamneesi (lääketiede)


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