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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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