For another possible meaning of this term see History of medicine.
The medical history or anamnesis (abbr. Hx) 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 patient's 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.
Contents
1 Process
2 Taking a Medical History in the UK
3 Review of systems
4 See also
5 References
//
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 (four stages):
STAGE ONE
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). (Another
helpful mnemonic, common in emergency medicine in the US is OPQRST,
sometimes extended to OPQRSTI-ASPN: O - onset, P -
provocation/palliation, Q - quality, S - severity, T - time, I -
interventions, AS - associated signs, PN - pertinent negatives.)
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.
STAGE TWO
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 & COPD 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).
STAGE THREE
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.
STAGE FOUR
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?...(and so on)
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