Medical history

The medical history or anamnesis^[1][2] (abbr. Hx) of a patient is information gained by a physician by asking specific questions, either of the patient or of other people who know the person and can give suitable information (in this case, it is sometimes called heteroanamnesis), with the aim of obtaining information useful in formulating a diagnosis and providing medical care to the patient. The medically relevant complaints reported by the patient or others familiar with the patient are referred to as symptoms, in contrast with clinical signs, which are ascertained by direct examination on the part of medical personnel. Most health encounters will result in some form of history being taken. Medical histories vary in their depth and focus. For example an ambulance paramedic would typically limit their history to important details such as name, history of presenting complaint, allergies etc. In contrast, a psychiatric history is frequently lengthy and in depth as many details about the patient's life are relevant to formulating a management plan for a psychiatric illness.

The information obtained in this way, together with clinical examination, enables the physician to form a diagnosis and treatment plan. If a diagnosis cannot be made then a provisional diagnosis may be formulated, and other possibilities (the differential diagnoses) may be added, by convention listed in order of likelihood. The treatment plan may then include further investigations with the purpose of clarifying the diagnosis.

Process

A physician typically asks questions to obtain the following information about the patient:

• Identification and demographics: The name, age, height, weight.
• The "chief complaint (CC)" — the major health problem or concern, and its time course.
• History of present illless (HPI) - details about the complaints enumerated in the CC.
• Past Medical History (PMH)(including major illnesses, any previous surgery/operations, any current ongoing illness, eg diabetes)
• Review of systems (ROS) Systematic questioning about different organ systems
• Family diseases
• Childhood diseases
• Social history- including living arrangements, occupation, drug use (including tobacco, alcohol, other recreational drug use), recent foreign travel and exposure to environmental pathogens through recreational activities or pets.
• Regular medications (including those prescribed by doctors, and others obtained over the counter or alternative medicine)
• Allergies
• Sex life, obstetric/gynecological history and so on as appropriate.

History-taking may be comprehensive history taking (a fixed and extensive set of questions are asked, as practised only by medical students) or iterative hypothesis testing (questions are limited and adapted to rule in or out likely diagnoses based on information already obtained, as practised by busy clinicians). Computerised history-taking could be an integral part of clinical decision support systems.

Taking a medical history in the UK

Medical students are taught to follow a structured guide when learning how to take a medical history on the wards :

• Presenting complaint (PC): Ask the patient an open question, getting them to tell you what has happened: "Tell me what happened that made you come into hospital today?" The PC should be recorded in the patient's own words, eg. "could not catch my breath" rather than "dyspnoea".
• History of presenting complaint (HPC): Getting more details about how everything started and how it progressed: When did this start? What happened next? Have you had that before?
• If the patient describes having pain, a helpful mnemonic to remember is SOCRATES: S - site, O - onset (gradual/sudden), C - character, R - radiation, A - associations (other symptoms), T - timing/duration, E - exacerbating and alleviating factors, S - severity (rate the pain on a scale of 1-10).
• Another helpful mnemonic, common in emergency medicine in the US is OPQRST, sometimes extended to OPQRSTI-ASPN: O - onset, P - provocation/palliation, Q - quality, S - severity, T - time, I - interventions, AS - associated signs, PN - pertinent negatives.)
• Another useful mnemonic that may be used to analyse any symptom is as follows:

Site ,Radiation ,Character ,Severity ,Associated features,Precipitating factors,Aggravating factors ,Relieving factors ,Onset ,Progression ,Cessation ,Duration ,Periodicity

To make is easy to remember, these features may be grouped together as follows:

Position (site and radiation),Character, Quantity (severity) ,Transmission (associated features – transmitted from index symptom) ,Modifying factors (precipitating, aggravating, relieving factors) ,Rate (onset, progression, cessation, duration- as it is related to timing the word rate is used),Rhythm (periodicity)

This give the mnemonic

Please Carefully Question This Method For Reliability and Resilience

This method may be used for analysis of any symptom and in addition it may be used for analysis of functions that are evaluated during physical examination (for example pulse, respiration, murmurs etc)

• Direct questioning is used to ask specific questions about the diagnosis you have in mind or exclude diagnoses on the differentials list. A review of the relevant system is done and associated risk factors are considered, as this would be a good time to ask pertinent questions.

• Perform the Functional Enquiry/Systems Review to help uncover undeclared symptoms

• Past medical history (PMH) and past surgical history (PSH): Ever been to hospital before? (when, where, why, etc). Do you suffer from any illnesses or conditions? Have you had any operations or procedures? Ask specifically about these diseases; another helpful mnemonic is JAM THREADS:

   J - jaundice
   A - anaemia & other haematological conditions 
   M - myocardial infarction
 
   T - tuberculosis
   H - hypertension & heart disease
   R - rheumatic fever
   E - epilepsy
   A - asthma & COPD
   D - diabetes
   S - stroke

• Drug history (DH): Do you take any (regular) medication? Tablets? Injections? Any over the counter drugs? Any prescriptions? Any herbal remedies? Contraceptive pill? Do you have any allergies? If none, record as NKDA (no known drug allergies).

• Family history (FH): Are your family in good health? Parents - alive & well, or cause of death? Grandparents? Children? Spouse? Some areas of the FH may need detailed questioning, eg. to determine if there is a significant FH of heart disease or cancer. Be TACTFUL when asking about a FH of malignancy: "I know this is difficult but it is important for us to have the correct information..." It may be useful to draw a family pedigree tree.
• Social history (SH): Probe without prying! Who else lives with you? Occupation. Marital status. Spouse's job and health. Housing - house or apartment? stairs, how many? Who visits - family, neighbours, GP, nurse? Any dependents? Mobility - walking aids needed? Who does the cooking and shopping? Is there anything the patient can't do due to illness? Note: it is often a good idea to get this information from a patient's GP if for whatever reason you can not ask the patient yourself. Alcohol, tobacco and recreational drugs - How much? How long? When did you stop? Quantify alcohol intake in terms of units and smoking in terms of pack-years. Note: patients frequently 'underestimate' how much they drink and smoke, be inclined to double any quantities stated. A helpful mnemonic for this psychosocial aspect is SAD LADDERS:

   S - Smoking
   A - Alcohol use
   D - Drug use

   L - Living Situation
   A - Activities of Daily Living
   A - Anxiety
   D - Depression
   D - Diet
   E - Exercise
   R - Relationships
   S - Sexual history
   S - Support

Review of systems

Whatever system a specific condition may seem restricted to, it may be reasonable to review all the other systems in a comprehensive history.

See also

• Genogram
• Historian (medical)
• Medical record
• Medicine
• Physical examination
• Psychoanalysis (Freud uses the term anamnesis to describe neurotics' recounting of their symptoms)

References

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