Medical history : Interview with the doctor. In the anamnesis, the doctor asks the patient questions, such as complaints, lifestyle habits and previous illnesses.
The term "medical history" comes from the Greek and means "memory". It describes the doctor's conversation with the patient. As a rule, the doctor leads the conversation through in-depth questions.
What is the medical history for?
A medical history has several goals: The doctor tries to understand the patient's complaints and to obtain medically relevant information for his further procedure. In addition, the doctor also wants to lay the foundation for a good medical relationship based on trust, which is usually an important prerequisite for successfully treating the patient. For example, the doctor often has to ask about psychological, social and professional backgrounds. Such issues are sometimes uncomfortable for those affected and sometimes it takes courage to speak about them. However, if the doctor and patient treat each other with confidence, feelings and stressful circumstances are easier to express. An atmosphere of mutual respect also helps to weigh up the next steps together.
How do doctors take the medical history?
The medical history is as individual as every patient. How it works depends on the respective situation. Nevertheless, doctors often follow a pattern. The order of the individual points can vary. At the end or during the medical history, the doctor notes down all the important information so that you can access it again later.
It usually begins with the patient's current symptoms. "What brings you to me?" is a frequently asked entry question by the doctor. The patient describes his complaints. The doctor listens and asks if they need further details to make suspicious diagnoses and plan their course of action in the further treatment of the patient.
Personal history
The personal history is about the patient's previous or medical history. This includes, for example, information on:
- • previous illnesses
- • operations
- • chronic health disorders (previous illnesses)
- • allergies and food intolerances.
Even if, for example, blood pressure or cholesterol levels have normalized while taking medication, the disease still exists and should be mentioned. Overall, such information can often provide clues as to the cause of the current complaint. A lot of things that do not fall under the term "medical history" at first glance are often of interest: For example, information about possible pregnancies and long-distance trips in the recent past, the so-called "travel history", may be used when searching for the cause help from complaints.
family history
Some diseases are genetically determined, or at least because of the genetic makeup there is a greater susceptibility to these diseases. These include, for example, rheumatic diseases and certain types of cancer. So-called civilization diseases such as high blood pressure and diabetes also occur in families. Often they also have genetic causes, at least in part. In addition, patients in the family can contract infectious diseases. When taking a family history, the doctor therefore asks about common illnesses of living relatives, but also about the causes of death of relatives who have already died.
Vegetative history
In contrast, the vegetative anamnesis focuses on the patient's bodily functions. The doctor asks whether food intake, excretion functions and breathing are noticeable or have changed recently. In concrete terms, for example
- • Loss of appetite
- • Nausea
- • Weight gain or loss
- • Problems with bowel movements and urination
- • Fever
- • Sleep disorders
- • Dizziness
If performance, such as climbing stairs or walking long distances, has deteriorated significantly, this should also be mentioned.
drug history
The medications that patients are already taking refer to the current therapy for existing diseases. During the medication history, the doctor is interested in what medication the patient is taking, for what reasons and in what dosage. Drug allergies are also discussed here. Patients often forget to mention contraceptives (the "pill"), insulin, or over-the-counter medicines. However, it is important for the doctor to also know about such preparations. For example, they can affect the effects of other medications.
Tobacco history
The history of luxury foods enables the doctor to assess the patient's risk factors. Alcohol, cigarettes and drugs can cause or worsen various illnesses. Even if this is an uncomfortable topic, the doctor can ask more precisely here: it is often important how much and how long luxury foods have been consumed. For example, high alcohol consumption can lead to fatty liver formation, and very long-lasting alcohol consumption often also affects the pancreas. It is precisely because the topic is very sensitive that a trusting discussion framework is of great importance. It is therefore possible that accompanying persons (which can also be parents or partners from a certain age of children) are asked by the doctor to leave the room if the patient wants more privacy.
social history
The social anamnesis illuminates the social situation and role of the patient. Occupational risk factors play an important role here: So-called occupational diseases can arise from stresses typical of the workplace. For example, many bakers suffer from allergic asthma diseases caused by flour dust, the so-called "baker's asthma". But generally high physical and psychological stress at work can also trigger health problems. In addition, the doctor's social history asks how extensive and stable the patient's social environment is: does the patient suffer from family conflicts? Does he get support when he is sick? Does he possibly live alone and needs care?
How can patients prepare?
Especially if you have a long medical history, it can make sense to make notes about previous illnesses and therapies. Patients who know when and why they came to which doctor or hospital often make diagnosis easier. Even unnecessary double examinations can sometimes be avoided with precise information.
Patients often bring along a list of the medications they are taking. This reduces the risk of accidentally forgetting a preparation. Frequently, general practitioners provide their patients with such a list on request when they need to see another doctor. In certain cases, the vaccination certificate you have brought with you will also help.
Of course, there are also situations in which the anamnesis is greatly shortened. If you present yourself with acute complaints such as shortness of breath or a broken bone in the emergency room, the attending doctor will likely omit parts of the above sections and focus on the current problems and their immediate treatment.
When can other people help?
Sometimes it can make sense for other people to tell the doctor. For example, when a patient fainted . Or when it comes to nocturnal breathing interruptions , relatives usually know more about it. Such information is called anamnesis.
In principle, the doctor is obliged to maintain confidentiality. The contents of the anamnesis remain confidential.
Source:
1. Neurath M, Lohse A: Anamnesis and clinical examination checklist, 5th edition, Stuttgart Thieme Verlag 2018
2. Seiderer-Nack J, Sternfeld A: Anamnesis and physical examination, 3rd edition, Berlin lehmanns media 20123. Willms L, Hayer L, Kattner A et al .: Practical instructions: Patient discussion - small history-etiquette. In: Via medici 2010, 15: 52-54
No comments:
Post a Comment