At the first contact between patient and doctor, getting to know each other plays a special role. Questions about the current symptoms, as well as information about the life of the patient so far, are important for the doctor in order to make a diagnosis and treat the patient well. The word "anamnesis" comes from the Greek and means memory - and that is the purpose of the medical history: remembering all the essential information from the previous patient life. The anamnesis gives the doctor or treating therapist information about the patient's current condition and overall condition. In addition, he gets an insight into the personality of the patient, so that he can get an idea of how the patient experiences his illness.
Since the anamnesis is at the beginning of the doctor-patient relationship, it is particularly important for establishing a relationship of trust - when a patient feels well cared for by his therapist, he is more willing to address even unpleasant topics, to endure a painful diagnosis and to accept the proposed therapy.
What is the history?
The current main complaints are the first building block of the medical history: where exactly does it hurt? Since when is this? For example, is pain radiating? In addition to localization, radiation and time of onset of the symptoms is also about intensity (increasing or decreasing symptoms), character (change in the course) and related to certain activities spoken.
Then the further personal history is created: What other diseases were there? Has the patient been operated on before? What kind of teething problems did the patient have? Are there any drug revenues in the past? What about women with gynecological history? In order not to forget anything, every organ system is frequently queried individually. Next, information about family and work is important.
In the family history, there is a specific talk about metabolic and vascular diseases as well as psychiatric illnesses, because they occur frequently in the family.
The biographical anamnesis with marital status, occupation and leisure time activities rounds off the patient's image and can provide information on stress situations that pave the way for the current illness.
The vegetative anamnesis gives an overview of the body functions of the patient. In addition to size and weight, water and stool excretion, cough, appetite, thirst, sleep and stimulant use (nicotine, alcohol, drugs) are particularly important.
Last but not least, the medication history should be included: In addition to the details of the current medication (which drugs are used and how often), vaccination status and known allergies are important for further treatment.
Is there a different approach to taking a case history?
Usually, the doctor or treating therapist will begin the anamnesis interview with a question to which the patient can respond individually. This so-called open question form makes it easier for the patient to describe his symptoms in his own way. The doctor will then narrow down the conversation with more focused questions, covering all areas of the patient's history. Mostly he will take only a few notes to be able to devote himself to the patient in detail and not to interrupt the flow of the patient.
However, the type of case history also depends heavily on the doctor's specialty: for example, a first-time psychiatric or neurological history contains many linguistic elements that test the patient during the history-taking process - that is, an anamnesis and "brain" examination in one. This medical history is therefore usually more extensive than a medical history of a doctor who works in an operative field and after medical history and body examination on several technical examination procedures such as X-rays or ECG.
How important is the history?
90 percent of all diagnoses can be made with the help of anamnesis and physical examination - if the doctor is experienced and evaluates all received information correctly. A good doctor or therapist masters the art of filtering out the crucial information from all the information and then making the right diagnosis. The form of the interview is crucial - a patient who feels valued and decreases his doctor, that he cares in the best possible way to him, will make a significant contribution to ensure that all relevant information to the doctor!
How detailed must a medical history be?
The success of further treatment depends largely on what information the doctor receives through the history and physical examination. Therefore, he will handle the anamnestic survey in varying degrees depending on the type of complaint and the area of expertise as well as on his experience. His goal is yes, with the help of the anamnesis and physical examination to make a suspected diagnosis, which he can then secure with further investigations and then treat the patient optimally.
So there is no fixed duration of an anamnesis, it can last 5 minutes (eg in known patients), but also 50 minutes! Frequently, the initial history is supplemented by further information in the course of the treatment process, so that the doctor over time receives an increasingly detailed picture of his patient.
When is a history omitted?
The more life-threatening the disease state of the person affected, the more the history taking of life-saving first measures is pushed into the background.
The motto in the rescue service is: SIMPLE - in addition to the symptoms of allergies (immune reactions), drugs, the patient history, the last relevant information for the problem (eg in gynecological patients after the last menstruation) and the acute event asked. Meanwhile, all measures are taken to stabilize the patient, ie to avert his life-threatening condition. All other anamnestic information will be collected later if the patient is aware of the acute danger.
In unconscious patients often only the external medical history - that is the questioning of third - give important clues to the underlying disease: In someone with diabetes, a diabetic coma may have occurred in drug addiction may be an overdose in question, known heart disease is a heart attack excluded,
Even with mentally confused patients who can not provide information about their person and their complaints, relatives and caregivers often need to be interviewed. However, this does not preclude a specific medical questioning of the patient - thus the degree of confusion can be determined and controlled as to whether a change occurs with appropriate medication.
What happens after the medical history?
Once the doctor has received all the relevant information, he determines the further course of action. In many disciplines, the history taking is accompanied by the physical examination, so that the next step is followed by the first examinations that require technical equipment such as blood samples, X-rays or ultrasound. Even the first therapeutic measures are initiated - whether the administration of a painkiller or the intravenous administration of fluid with an infusion.
Particularly important is the documentation of the anamnesis with the suspected diagnosis, so that even with a change of doctor remains apparent why the attending physician has opted for the chosen procedure with regard to examinations and therapy. Usually, all information is entered in standardized medical history sheets, so that missing information can be noticed and added. In some hospitals, medical history and admission findings are now dictated immediately, so that the anamnesis is available in digital form to all departments.