ANAMNESIS

Dr. Sorin Stamate Octombrie 2008

1) 2) 3) 4)

ANAMNESIS

5) 6)

7)

PERSONAL AND PRELIMINARY DATA CHIEF COMPLAINT PRESENT ILLNESS PAST HISTORY-PHYSIOLOGICAL DATA PAST HISTORY-PATHOLOGICAL DATA FAMILY HISTORY PERSONAL AND SOCIAL HISTORY

1. EXAMNINATION 2. 3. GENERAL CLINICAL 4. EXAMINATION 5. 6. 7. PHYSICAL EXAMINATION

PATIENT

GENERAL SURVEY SKIN, MUCOSAE, HAIR AND NAILS SUBCUTANEOUS TISSUES THE MUSCULAR SYSTEM THE SKELETON THE LIMPH NODES THE PERIPHERAL VASCULAR SYSTEM AND NERVES

DETAILED EXAMINATION OF SYSTEMS

POSTURE (DECUBITUS) SPEECH AND MENTAL EVALUATION WEIGHT AND HEIGHT

GENERAL SURVEY

NUTRITION STATUS PATIENTS BUILD FACIES STANDING AND MARCHING

ANAMNESIS = Remembering

Definition: the totality of information gathered by the physician from the patient or the persons accompanying him, or from medical papers, claiming to establish the diagnosis, prognostic or treatment.

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

ANAMNESIS Anamnesis
DIRECT MEDIATED

Difficulties DIRECT ANAMNESIS

Domination

of subjective symptoms Temporal and spatial non-concordance between symptoms anamnesis 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

ANAMNESIS

STEPS
1) 2) 3) 4) 5)

PERSONAL AND PRELIMINARY DATA CHIEF COMPALINT DETAILS OF THE PRESENT ILLNESS PAST HISTORY- PHYSIOLOGICAL DATA (APF) PAST HISTORY- PATHOLOGICAL DATA (APP)

6)
7)

FAMILY HISTORY (AHC)

SOCIAL DATA

PERSONAL AND PRELIMINARY DATA

1. 2. 3. 4. 5. 6.

NAME AGE GENDER PLACE OF BIRTH PLACE OF LIVING ETHIC OR RACIAL APARTENENCE

7.

PROFESSION AND EMPLOYMENT

HISTORY

PERSONAL AND PRELIMINARY DATA

1. 2. 3. 4. 5. 6.

DATE OF ADMISSION DATE OF DISCHARGE

DURATION OF HOSPITALIZATION

MEDICAL LEAVE AFTER DISCHARGE REFFERAL DIAGNOSIS DIAGNOSIS AT ADMISSION/ 24/48/72 HOURS DIAGNOSIS AT DISCHARGE

7.

PATIENTS STATUS AT DISCHARGE

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!

ACTUAL ILNESS
IMMEDIAT HISTORY OF

Immediat: a chronological, detailed description of all the symptoms and/or signs presented by the patients as related 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.

IMMEDIATE ACTUAL ILLNESS (actual moment) MUST obtain: 1) Description of all symptoms and signs 2) Their evolution 3) Pharmacologic treatment, and dosing 4) Paraclinical investigations
5) 6)

Medical consultations Accomplishment of medical recommendations by the patient

7)

Relationship between the symptoms and medical gests

N.B. PREVIOUS ESTABLISHED DIAGNOSIS CAN BE USED

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 MISS

PAST HISTORY- PHYSIOLOGICAL DATA Most important: In children: Pediatric data In women:
1.

In children In women

Age at menarche

2.
3. 4. 5. 6.

Last menstrual period Periods: regularity, duration, amount of bleeding Number of pregnancies Number of abortions-spontaneous or induced Number and type of deliveries

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

PAST HISTORY- PATHOLOGICAL DATA

A. B.

Pathologies that MUST be noted Pathologies that are noted only if they were present

Past history A. Pathologies that MUST be noted

1) 2) 3)

Infectious diseases of childhood Acute viral hepatitis Major trauma

4)
5) 6) 7)

Surgical interventions
Epilepsy/ convulsions Tuberculosis Sexually transmitted diseases

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

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.

SOCIAL DATA
A. B. C.

Alcohol consumption Tobacco use (type, frequency) Illicit drug abuse

D.
E. F.

Working environment
Intensity of physical activity and exercise habits Allergy history