How do doctors take accurate medical histories
History: The conversation with the doctor
The term "anamnesis" comes from the Greek and means "memory". It describes the doctor's conversation with the patient. As a rule, the doctor leads the conversation with in-depth questions.
What is the anamnesis used for?
An anamnesis has several goals: The doctor tries to understand the patient's complaints and to gain medically relevant information for his further course of action. In addition, the doctor also wants to lay the foundation for a good medical relationship of 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 topics are sometimes uncomfortable for those affected and it can take courage to talk about them. However, when the doctor and patient treat each other in a trusting manner, 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 proceed with the anamnesis?
The anamnesis is as individual as each patient. How it works depends on the respective situation. Nevertheless, doctors often orientate themselves on a scheme. The order of the individual points can vary. At the end or during the anamnesis, the doctor notes all the important information so that it can be accessed again later.
It usually starts with the patient's current symptoms. "What brings you to me?" is a frequently chosen introductory question by the doctor. The patient describes his symptoms. The doctor listens and asks if he needs further details in order to make suspicious diagnoses and plan his course of action for further treatment of the patient.
The personal history is about the patient's previous or medical history. This includes, for example, information on:
• previous illnesses
• 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 complaints. Much that does not fall under the term "medical history" at first glance is often of interest: For example, information about possible pregnancies and long-distance trips in the recent past, the so-called "travel history", can be used to find the cause help with complaints.
Some diseases are genetic, or at least there is a greater susceptibility to these diseases due to the genetic make-up. These include, for example, rheumatic diseases and certain types of cancer. So-called lifestyle diseases such as high blood pressure and diabetes also occur more frequently in families. Often they also have at least some of their genetic causes. In addition, patients can become infected with infectious diseases in the family environment. When taking a family history, the doctor asks about frequent illnesses in living relatives, but also about the causes of death of relatives who have already died.
In contrast, the vegetative anamnesis focuses on the patient's body functions. The doctor asks whether food intake, excretory functions and breathing are abnormal or have changed recently. Specifically, for example, it's about
• Loss of appetite
• Weight gain or loss
• Problems with bowel movements and urination
• Sleep disorders
If the performance, such as climbing stairs or walking long distances, has deteriorated significantly, this should also be mentioned.
The drugs that patients are already taking refer to the current therapy for existing diseases. During the medication history, the doctor is interested in which medication the patient is taking, for what reasons and in what dosage. Drug allergies are also discussed here. Patients often forget to mention drugs such as contraceptives (the "pill"), insulin, or over-the-counter medicines. However, it is important for the doctor to know about such preparations. For example, they can influence the way other drugs work.
Anamnesis for luxury foods
The medical history enables the doctor to assess the patient's risk factors. Alcohol, cigarettes and drugs can trigger or worsen various diseases. Even if this is an uncomfortable topic, the doctor can ask more precisely here: it is often important how much and how long stimulants have been consumed. For example, high alcohol consumption can lead to fatty liver disease, and very long-term alcohol consumption often also affects the pancreas. Precisely because the topic is very sensitive, a trusting discussion framework is of great importance. It can therefore happen that any accompanying persons (these 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.
The social history illuminates the social situation and role of the patient. Occupational risk factors play an important role here: so-called occupational diseases can arise from stress that is 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 disorders. In addition, the doctor asks in the social anamnesis how comprehensive and stable the patient's social environment is: Does the patient suffer from family conflicts? Does he get support when he's sick? May he live alone and need care?
How can patients prepare?
Especially with a long medical history, it can be useful to make notes about previous illnesses and therapies. Patients who know when and why they have presented themselves to which doctor or hospital often make it easier for them to make a diagnosis. Unnecessary duplicate examinations can also be avoided by giving precise details.
Often patients already bring a list of the drugs they are taking with them. This reduces the risk of accidentally forgetting a preparation. Often, general practitioners give their patients such a list on request when they need to see another doctor. In certain cases, the vaccination certificate you have brought with you can also help.
Of course, there are also situations in which the anamnesis is very shortened. If you present yourself to the emergency room with acute symptoms such as shortness of breath or a broken bone, the attending physician will probably omit parts of the above-mentioned sections and focus the questions on the current problems and their immediate treatment.
When can other people help?
Sometimes it can make sense for other people to provide the doctor with information. For example, when a patient has passed out. Or when it comes to breathing pauses at night, for example, relatives usually have more detailed information to report. Such information is called a third-party history.
In principle, the doctor is subject to confidentiality. The contents of the anamnesis therefore remain confidential.
1. Neurath M, Lohse A: Checklist anamnesis and clinical examination, 5th edition, Stuttgart Thieme Verlag 2018
2. Seiderer-Nack J, Sternfeld A: Anamnesis and physical examination, 3rd edition, Berlin lehmanns media 2012
3. Willms L, Hayer L, Kattner A et al .: Practical instructions: Patient discussion - Brief anamnesis etiquette. In: Via medici 2010, 15: 52-54
This article contains general information only and should not be used for self-diagnosis or self-treatment. He can not substitute a visit at the doctor. Unfortunately, our experts cannot answer individual questions.
Well prepared for a doctor's consultation
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