1 History Taking#97AC

8/10/2019 1 History Taking#97AC

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ANAMNESIS

Dr. Sorin Stamate

Octombrie 2008


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PATIENT

EXAMNINATION

ANAMNESIS

1) PERSONAL AND PRELIMINARY DATA

2) CHIEF COMPLAINT

3) PRESENT ILLNESS

4) PAST HISTORY-PHYSIOLOGICAL DATA

5) PAST HISTORY-PATHOLOGICAL DATA6) FAMILY HISTORY

7) PERSONAL AND SOCIAL HISTORY

PHYSICAL

EXAMINATION

GENERAL CLINICAL

EXAMINATION

DETAILED EXAMINATION OF SYSTEMS

1. GENERAL SURVEY

2. SKIN, MUCOSAE, HAIR AND NAILS

3. SUBCUTANEOUS TISSUES

4. THE MUSCULAR SYSTEM

5. THE SKELETON

6. THE LIMPH NODES

7. THE PERIPHERAL VASCULAR

SYSTEM AND NERVES


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GENERAL

SURVEY

POSTURE (DECUBITUS)

SPEECH AND MENTAL EVALUATION

WEIGHT AND HEIGHT

NUTRITION STATUS

PATIENTS BUILD

FACIES

STANDING AND MARCHING


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ANAMNESIS = Remembering

Definition:the totality of information

gathered by the physician from the patient

or the persons accompanying him, or frommedical papers, claiming to establish the

diagnosis, prognostic or treatment.


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ANAMNESIS

TECHNIQUE:

1. Physicians experience

2. Knowing patients psychology

3. Medical information

4. Amount of time available

5. Patients mental status

6. Adapting the language

7. Patients reliability


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ANAMNESIS

Anamnesis

Difficulties

DIRECT ANAMNESISDomination of subjective symptoms

Temporal and spatial non-concordance between symptomsanamnesis

Type of complaint

MEDIATED

Data are not emerging directly from the source

clinical observation depends on the skill and interest of the

observers

Timing of observation

(eventually) incomplete medical documents

DIRECT

MEDIATED


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ANAMNESIS

STEPS

1) PERSONAL AND PRELIMINARY DATA

2) CHIEF COMPALINT

3) DETAILS OF THE PRESENT ILLNESS

4) PAST HISTORY- PHYSIOLOGICAL DATA (APF)

5) PAST HISTORY- PATHOLOGICAL DATA (APP)

6) FAMILY HISTORY (AHC)

7) SOCIAL DATA


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PERSONAL AND PRELIMINARY DATA

1. NAME

2. AGE

3. GENDER

4. PLACE OF BIRTH

5. PLACE OF LIVING

6. ETHIC OR RACIAL APARTENENCE

7. PROFESSION AND EMPLOYMENT

HISTORY

A


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PERSONAL AND PRELIMINARY DATA

1. DATE OF ADMISSION

2. DATE OF DISCHARGE

3. MEDICAL LEAVE AFTER DISCHARGE

4. REFFERAL DIAGNOSIS

5. DIAGNOSIS AT ADMISSION/ 24/48/72 HOURS

6. DIAGNOSIS AT DISCHARGE

7. PATIENTS STATUS AT DISCHARGE

B DURATION OFHOSPITALIZATION


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CHIEF COMPLAINT (REASON FOR ADMISSION)

A LIST of SYMPTOMS and/or SIGNS that THE

PHYSICIAN considers to be THE MOST

RELEVANT.

N.B. * NO diagnostics!


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ACTUAL ILNESS

Immediat: a chronological, detailed description of all the

symptoms and/or signs presented by the patients asrelated with the present illness, from the moment of their

start or worsening until the contact with the physician

(that is taking the history) or admission, and the

description of their evolution.

IMMEDIAT

H ISTORY OF


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IMMEDIATE ACTUAL ILLNESS (actual moment)

MUST obtain:

1) Description of all symptoms and signs2) Their evolution

3) Pharmacologic treatment, and dosing

4) Paraclinical investigations

5) Medical consultations

6) Accomplishment of medical recommendations by the

patient

7) Relationship between the symptoms and medical gests

N.B. PREVIOUS ESTABLISHED DIAGNOSIS

CAN BE USED


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HISTORY OF PRESENT ILLNESS

A general description of the principal moments of

patients illness from its start until the moment

when immediate symptoms occurred.

N.B. *PREVIOUS DIAGNOSIS CAN BE USED

SUCH HISTORY CAN M ISS


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PAST HISTORY- PHYSIOLOGICAL DATA

Most important:

In children:Pediatric data

In women:

1. Age at menarche

2. Last menstrual period

3. Periods: regularity, duration, amount of bleeding

4. Number of pregnancies5. Number of abortions-spontaneous or induced

6. Number and type of deliveries

I n children

I n women


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Examples

a)Menarche 14 y. LP: 3 oct 2005/28/3

P=5 D=2 SA: 1 IA: 2

b) MENARHA 14 ani. UM: 3 oct 2005/24-35/2-7

G=6 P=0 A=6


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PAST HISTORY- PATHOLOGICAL DATA

A.Pathologies that MUST be noted

B. Pathologies that are noted only if they were present


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Past history

A. Pathologies that MUST be noted

1) I nfectious diseases of chi ldhood

2) Acute viral hepati tis

3) Major trauma

4) Surgical interventions

5) Epilepsy/ convulsions

6) Tuberculosis

7) Sexually transmi tted diseases


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PAST HISTORY

B. PATHOLOGIES THAT ARE NOTED ONLY IF

THEY WERE PRESENT

Most important diseases that are not related with

the actual illness, nor represent moments of its

evolution


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FAMILY HISTORY

Most important illnesses of the siblings,

brothers/sisters, parents and grandparents are

noted, but also for the persons living in the same

home.

For deceased persond, age at abnd cause of death

are noted.


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SOCIAL DATA

A. Alcohol consumption

B. Tobacco use (type, frequency)

C. I l l ici t drug abuse

D. Working environment

E. I ntensity of physical activity and exercise habits

F. Allergy history

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