Ministry of Health of Ukraine Vinnitsa National Medical University named after. M.I. Pirogov. Anamnesis - what is it in medicine, why is it needed, and how is it collected? Disease history history data are established

) - a set of information obtained during a medical examination by questioning the person being examined and/or people who know him. The study of anamnesis, like questioning in general, is not just a list of questions and answers to them. The style of conversation between the doctor and the patient determines the psychological compatibility, which largely determines the ultimate goal - alleviating the patient’s condition.

Anamnesis data (information about the development of the disease, living conditions, previous diseases, operations, injuries, pregnancies, chronic pathology, allergic reactions, heredity, etc.) is determined by the medical worker for the purpose of using them for diagnosis, choosing a method of treatment and/or prevention. Taking anamnesis is one of the main methods of medical research. In some cases, in combination with a general examination, it allows an accurate diagnosis to be made without further diagnostic procedures. Taking an anamnesis is a universal diagnostic method used in all areas of medicine.

Types of medical history (the list is not complete)

History of illness (novolat. Anamnesis morbi)

The onset of the disease, the dynamics of symptoms from the onset of the disease to the moment of treatment, what factors the patient associates with this disease, what studies and what treatment were carried out and what the results are, etc.

Life history (novolat. Anamnesis vitae)

Previous diseases, existing chronic pathology of various organs and organ systems, operations, injuries, etc. And also where he lives and in what conditions.

Obstetric history

Have you had any pregnancies before, how did they proceed, what was their outcome.

Gynecological history

Past gynecological diseases and surgeries on the female genital organs, the menstrual cycle, its features, frequency, pain, etc.

Family history

The presence of similar symptoms in blood relatives, hereditary diseases, etc.

Allergy history

Allergic reactions, including to medications, vaccines, foods, plants, etc. The nature of manifestations during the development of allergies.

History of the patient's diet

Collecting information about the nature of the food eaten, the frequency of its consumption and diet over a certain period of time (usually 2-5 days). Such information allows the doctor to formulate simple nutrition-related recommendations.

Insurance (Expert) history

Availability/absence of a compulsory medical insurance (VHI) policy, period of incapacity for work for any reason over the last 12 months (“how long was on sick leave”).

Links

• // Encyclopedic Dictionary of Brockhaus and Efron: In 86 volumes (82 volumes and 4 additional ones). - St. Petersburg. , 1890-1907.

Wikimedia Foundation. 2010.

• Gonfaloniere
• La Rioja

See what “Anamnesis” is in other dictionaries:

ANAMNESIS- (from the Greek anamnesis memory), represents honey. biography of the patient, presented by periods of life. According to A., it is possible to establish how the victim’s body reacted to all those external conditions of life and harmfulness that were in its past. History... ... Great Medical Encyclopedia

ANAMNESIS- the result of a survey of the patient with information about his previous life, the course of the disease, well-being, etc., recorded as a memory. A complete dictionary of foreign words that have come into use in the Russian language. Popov M., 1907. ANAMNESIS information about the previous condition ... Dictionary of foreign words of the Russian language

ANAMNESIS Modern encyclopedia

Anamnesis- (from the Greek anamnesis memory), information about the patient (life history) and his illness (illness history), collected during a survey of the patient and (or) people who know him, in order to establish a diagnosis, prognosis of the disease, select the optimal methods for it ... ... Illustrated Encyclopedic Dictionary

anamnesis- a, m. anamnèse f. gr.anamnesis memory. Information about living conditions, previous diseases, history of the disease, obtained from the patient or his relatives. BAS 2. Lex. Yuzhakov: anamnesis; SIS 1937: anamne/z; BAS 1 1948: ana/mnez… Historical Dictionary of Gallicisms of the Russian Language

anamnesis- (incorrect medical history). Pronounced [anamnesis]... Dictionary of difficulties of pronunciation and stress in modern Russian language

Anamnesis- an integral part of a medical examination is information, a list of information about the course of the disease, previous diseases, injuries, surgical interventions, residual effects. The most valuable information is about diseases associated with nervous, cardiovascular... Dictionary of business terms

ANAMNESIS- [ne], ah, husband. (specialist.). A set of medical information obtained by interviewing the subject and people who know him. Allergic a. Psychiatric a. | adj. anamnestic, oh, oh. Ozhegov's explanatory dictionary. S.I. Ozhegov, N.Yu. Shvedova. 1949 1992 … Ozhegov's Explanatory Dictionary

anamnesis- noun, number of synonyms: 1 message (87) ASIS Dictionary of Synonyms. V.N. Trishin. 2013… Synonym dictionary

Anamnesis- information about a person’s life, diseases suffered by him, their onset and course, data on the professional, mental and physical performance of the employee, his behavior in the team and family...

A distinctive characteristic of medicine is the large number of terms from Latin and Greek. Because of this, many people do not understand what we are talking about. One of the unknown and mysterious words is “anamnesis”. What does this term mean? What types are there? This will be discussed in this article.

History - what is it?

In order to make a correct diagnosis, the doctor asks a series of questions to the patient. This process is called anamnesis.

If the patient is a child or a mentally ill person, then in this case the parents of the children or relatives around them are interviewed, respectively. Then we are talking about heteroanamnesis.

During the examination, the complaints received constitute symptoms of the disease.

The patient's history may vary in duration. It depends on situation. Thus, emergency doctors ask the patient about his personal data and specific complaints.

In turn, psychiatric practice differs in that an anamnestic study can last several hours.

A therapist can spend about 15 minutes interviewing a patient.

After information obtained through anamnesis, patient complaints, as well as physical examination, a treatment plan is formed. If the situation is controversial, then a preliminary diagnosis is made.

What is the classification of anamnesis?

There are two large groups of this study. The first is the life history. It, in turn, is divided into 10 types. The next large group is considered to be the history of the disease. Based on the name of the classification, one can guess what we are talking about. Each of them will be discussed in more detail in the following sections of the article.

What does anamnestic life study include?

In order to make a correct diagnosis, it is necessary to identify the individual characteristics of the patient. This information is included in the life history. Here the specialist receives information about the psychological, social, and physical development of the patient.

If the situation is such that emergency care is needed, then a series of questions are asked that will help obtain information for making a diagnosis and prescribing the correct therapy.

As mentioned earlier, the anamnestic study of life is divided into several types, such as gynecological and obstetric, social and pediatric, professional and climatic, endemic and epidemiological, genealogical and allergological.

Some of them will be discussed in more detail in the following sections.

What is anamnestic study of the disease?

In order to make a preliminary diagnosis, information about the initial signs of the pathological condition and the characteristics of its course is important. An anamnestic study of the disease is necessary to clarify the factors. The latter contribute to the development of the clinical picture of the disease. Also, the data that will be obtained during the conversation will help the specialist differentiate an acute condition from a recurrent one.

How is anamnestic examination carried out?

The foundations for compiling the history of the disease were created already in the 19th century. Today, practically nothing has changed.

So, in the previous section the answer to the question “Anamnesis - what is it?” was given, then we will consider the order of its implementation.

First, the doctor must ask the patient for his personal information. Namely, in this case we mean his last name, first name, patronymic, age, place of residence and work. After this, the specialist is interested in the reasons for visiting this hospital. As a rule, the patient describes the symptoms that bother him and the time of their onset.

After this, the doctor evaluates the patient’s living and working conditions under which the disease began to develop. Then a series of questions are asked about self-medication attempts and the presence of chronic diseases.

In some countries, computerized technologies are used to collect anamnesis, since the patient is sometimes embarrassed to talk openly about his ailments. Then this method is very necessary. But the disadvantage is that the computer cannot pick up non-verbal information, such as anxiety.

Currently, this method is practically not practiced in Russia. The specialist conducts such a study through conversation and asks a series of questions.

A little about your allergy history

Through questioning, the specialist determines whether the patient has hypersensitivity reactions. This type of patient history is necessary in order to prevent possible consequences when taking certain medications. If the patient has a sensitization reaction to medications, the doctor finds out which ones. The symptoms that occur after using these medications are also clarified.

What is a gynecological anamnestic examination?

In order to assess the state of the female reproductive system, facts come to the rescue. They, in turn, must correlate with the endocrine and reproductive systems of the body. A gynecological history helps the specialist make preliminary conclusions. Afterwards they are either refuted or confirmed using other diagnostic examination methods.

To collect anamnesis in gynecology, the specialist asks a series of questions to the patient about the nature of menstruation, sexual function and the condition of the reproductive organs. Then the doctor finds out what infectious and inflammatory diseases of the female reproductive system there are.

Next, a series of questions are asked about fertility. This includes information on the number of abortions, pregnancies, miscarriages and births. In addition, during this study, the last thing the specialist asks about is surgical interventions.

Aggravated gynecological history: what are we talking about?

Some diseases are dangerous to a woman’s health and pose a threat to the normal functioning of the female reproductive system. This diagnosis is made to the patient if she has previously suffered from pathological conditions. This type of medical history helps the doctor analyze the causes of the disease.

A burdened gynecological history during pregnancy also occurs. They talk about it when there is late toxicosis, which is also known as gestosis, hypertonicity, anomalies of placental attachment and previously suffered gynecological diseases, infections of the genitourinary system. Also, a burdened medical history is evidenced by delivery by cesarean section, the birth of children with developmental defects and stillbirths, abortions and miscarriage.

Child's history

This type of information is collected from the words of parents or close relatives. The specialist can ask some questions to a child who is of preschool or school age. The physician should be aware that his answers should be taken with caution.

When finding out a child’s medical history, you need to get information about how he is in the family, about the degree of development at an early age, about communication with peers.

In addition to all this, the specialist determines the availability of all necessary vaccinations and tuberculin tests. Then he asks a series of questions about possible contacts with pathogens of infectious diseases.

History - what is it? This question was answered at the very beginning of the article. This study should not be taken lightly, since it is from it that the specialist draws conclusions on making the correct diagnosis and prescribing treatment.

Before carrying out diagnostic measures, doctors try to obtain as much information as possible from the patient himself. This helps not only to suggest a possible diagnosis, but also to establish the scope of the upcoming examinations. The totality of the data obtained is referred to as “history”. What it is and why it is needed is unknown to many patients.

History - what is it in medicine?

To understand what the word “history” means in medicine, you can consult a dictionary of medical terminology. This definition is usually used to denote the totality of all information about the patient and his diseases, which was obtained by interviewing the patient himself and his relatives and loved ones. The information obtained as a result is used to determine the cause of the disease, make a diagnosis and for the purpose of further choosing a method of treatment and prevention.

The method of interviewing patients was purposefully developed and introduced into clinical practice by the following well-known medical figures: Zakharyin, Mudrov, Ostroumov. Even in modern medicine, anamnesis continues to occupy a leading position in the process of obtaining information about the disease and the patient’s health status. It is given paramount importance in the process of diagnosing mental illnesses and a number of somatic diseases.

Uncomplicated anamnesis

Having understood the term anamnesis and what it is, it is necessary to highlight its main forms. When collecting information about the patient and further making a diagnosis, doctors pay attention to the features of the medical history. Doctors talk about such a variety as an uncomplicated anamnesis if the patient has no symptoms.

Chronic inflammatory and infectious processes in the body, the patient’s water-salt balance is normal. In other words, an unburdened history is the complete absence of prerequisites for the development of the alleged pathology. In clinical practice, this occurs rarely, since the disease is almost always the result of a disorder or malfunction in the human body.

Aggravated medical history

Doctors use the term “complicated anamnesis” when the patient’s history contains information about the presence of other pathologies that affect the outcome of the underlying disease. The term “complicated obstetric history” is often used - it is applicable to a situation where there is a serious threat to the process of intrauterine development of the fetus and normal delivery. In obstetric practice, this anamnesis is used based on the presence of concomitant problems that occurred during previous gestations:

Anamnesis of life

Anamnesis of this type is practically the entire life history of the patient. The life history includes information about the physical, mental and social development of the subject. The amount of information received varies and depends directly on the conditions in which medical care is provided. In case of emergency conditions, doctors find out only the main points that are necessary for diagnosis and treatment. The more details the life history contains, the better the doctor can understand the patient and his individual characteristics.

Having this information, doctors are able to accurately diagnose, make a prognosis regarding the identified disease, and give individual recommendations regarding the prevention of complications. Among the basic information obtained during the collection of a life history:

• features of mental and physical development;
• living conditions and characteristics of family life;
• bad habits;
• past illnesses;
• allergy history.

Family history

Family or genealogical history - information about the patient regarding the composition of his family, the situation in it, and the diseases of its individual members. The family history contains information about the age of the patient’s parents, the characteristics of their profession, and the financial condition of the family. Information about each family member is collected in detail:

• when and what childhood diseases did he suffer from;
• how many children are in the family;
• developmental characteristics of each child.

Such an anamnesis may also contain information about visits to preschool institutions, school, features of the daily routine, academic performance and additional loads. A complete picture helps to identify all predisposing factors to the development of a particular pathology. Special attention is paid to identifying hereditary diseases.

Medical history

When doctors compile a medical history, anamnesis is always one of its first components. Specialists collect information about the occurrence and course of the disease. Cases have been established when the pathology does not manifest itself in any way after the appearance of the first symptoms, but then a complication develops, which experts mistakenly mistake for the onset of the disease. Separately install:

• sequence of complaints;
• features of the onset of the disease.

The information obtained gives reason to suspect whether a malignant process is observed, an acute disease or a chronic pathological process. Given this option, doctors first try to establish the causative factors and circumstances contributing to the development of the disease. Then they pay attention to the reason that served as the basis for contacting doctors. The medical history details:

• sequence of the disease;
• changes in subjective and objective information about the disease;
• the presence of periods of remission and their duration.

Gynecological history

Girls visiting a gynecologist for the first time are unfamiliar with the term anamnesis: what it is in gynecology and what it is used for is unknown to them. This type of information is obtained directly from the patient herself. The questions asked by the doctor concern the woman’s reproductive function. The specialist determines the nature of menstruation, its frequency, and the volume of discharge. He also pays attention to the presence of abortions or miscarriages in the past. The gynecological history contains information about past gynecological diseases, the time of menopause and menopause.

Obstetric history

Obstetric medical history is an integral part of the life history, which contains information regarding the generative function of the female body. Doctors determine the number of pregnancies, the characteristics of their course and the process of delivery, and the nature of the complications that have arisen. Pay attention to:

• pregnant woman's regime;
• number of births in the past;
• for what and for what duration was treatment carried out.

Later they find out:

• whether the pregnancy ended at term;
• whether the child was not full term or was born later than expected;
• what kind of maternity benefit was used.

Allergy history

This type of history includes information about identified allergic diseases in the patient and his relatives. Allergic reactions can develop when the body is exposed to a wide range of allergens. Thus, the pharmacological and allergological history contains information about the patient’s intolerance to certain groups of drugs. If possible, determine the type of allergen. When compiling an anamnesis, the observed manifestations of allergies are clarified:

• hives;
• swelling of the mucous membranes of the nose.

Psychological history

The psychological history contains complete information regarding the characteristics of the patient’s mental development and heredity. Experts pay attention to:

• personality type;
• features of professional activity;
• range of interests of the patient.

Special attention is paid to family relationships - misunderstanding and lack of constant contact with loved ones can lead to the development of serious mental pathologies. It is worth noting that psychological history can be subjective and objective.

Doctors pay much attention to the second type of medical history. This is due to the peculiarities of the development of the pathology: the patient, due to his illness, cannot normally interpret what happened to him in the past. During the survey, doctors should carefully examine hereditary burden:

• mother's condition during pregnancy;
• features of the birth process;
• early delivery;
• physical and .

How is anamnesis collected?

Young specialists who know almost everything about medical history: what it is, what it is needed for, do not always know how to collect it correctly. Anamnesis is collected taking into account the rules of deontology. During this procedure, the doctor should try to achieve mutual understanding in communication with the patient.

The dialogue should be built on trust - this way the specialist will be able to collect more valuable information that patients are not always ready to share. Specialists must guarantee compliance with medical confidentiality, so anamnesis is taken in the absence of other patients. First, the doctor listens to the patient, recording everything he says, and then begins to ask questions.

Anamnesis data

Before collecting anamnesis, doctors conduct a thorough examination of the patient. This allows us to assume the type of possible pathology, which determines the nature and number of questions addressed to the patient. The list of specified parameters may change. However, there are a number of questions that the specialist asks all patients. The information obtained is entered into the medical history.

Case history - example

A correctly collected anamnesis (we have already found out what it is) helps to make a preliminary diagnosis. The patient's medical history is included in his medical history.

Anamnesis (from the Greek anamnesis - memory) is the sum of information that a person being examined - a sick or healthy person (during medical examination) - reports about his state of health, about his illness, about his experiences and feelings in connection with the disease, about the reactions of his body to external influences. The doctor uses this information when establishing a diagnosis and prognosis, as well as when prescribing treatment. Questioning about the possible (from the patient’s point of view) causes of the disease, its onset, development and course is a historical method of studying the disease, with the goal of establishing the correct diagnosis. Currently, this method continues to become increasingly widespread, including data on the reactivity of the body, its compensatory abilities, etc. This includes data of great practical importance on allergic reactions, individual intolerance, complications, hematological and other manifestations of use of antibiotics, corticosteroids, etc.

The most important condition for the correct recognition of the disease is a thorough methodological examination of the patient, consisting of two sections: the study of the manifestations of the disease that are felt only by the patient (subjective symptoms of the disease, revealed by taking an anamnesis, questioning), and the study of signs of the disease accessible to medical observation (an objective examination of the patient using physical, as well as various laboratory, instrumental and other research methods).

Collecting the patient's medical history precedes an objective examination of him (see Diagnosis). Contrasting these examination methods, as well as underestimating one of them, is wrong, since they complement each other and provide the study of the body as a whole. In each individual case, depending on the individual characteristics of the patient and the nature of the disease, any of these methods may be of greater or lesser importance. The anamnestic method allows us to study the patient’s personality and the nature of nervous processes, which brings us closer to understanding the type of higher nervous activity. The combination of all examination methods allows us to make a conclusion about the diagnosis of the disease, prognosis and treatment.

Outstanding Russian doctors M. Ya. Mudrov, S. P. Botkin and especially G. A. Zakharyin played a major role in the development and development of the anamnestic method.

Anamnesis is of great importance for studying the disease in its development and dynamics. Based on the anamnesis, it is possible to establish more or less accurately the origin, causes and conditions of the disease; study diseases suffered in the past (as well as the body’s reactions to certain influences), the living conditions of the subject, the presence of prof. hazards, bad habits, etc. With the help of anamnesis, it is possible to recognize functional disorders that manifest themselves in the patient’s subjective sensations during the period of illness, when there are no organic changes available for objective examination. When collecting anamnesis and questioning, it is important to pay attention not only to what the patient reports, but also to how he reports, his manner of behavior, manner of speaking, his reaction to questions, etc. This allows you to study the patient’s personality, characteristics his character, behavior, neuropsychic state. An interview between a doctor and a patient promotes contact between them and trust in the doctor, which helps in recognizing the disease and especially in treatment, in particular in psychotherapy. One of the important tasks when examining a patient, establishing a diagnosis and treatment is to clarify those individual characteristics that characterize the manifestations of a given disease in a given patient. The same disease occurs differently in different people, with its own characteristics, which depends on age, hereditary characteristics, reactivity and other properties of the patient’s body. Anamnesis data contribute to the clarification of these features, along with an objective examination. Like all examination methods, taking an anamnesis must be carried out in a certain sequence and according to a clear plan. The more facts - signs, symptoms - based on questioning and an objective examination a doctor can collect, the more accurate the diagnosis of the disease will be.

It is customary to distinguish between the anamnesis of this disease - the anamnesis of the disease (anamnesis morbi) and the anamnesis of the patient’s life, or general anamnesis (anamnesis vitae).

The medical history includes information related to the present disease. It is the first stage in examining the patient, on the basis of which the doctor creates an initial idea, a hypothesis about the nature of the disease.

The medical history should answer the following questions.
1. What does the patient complain about? The patient reports his feelings and experiences, as well as other information about the manifestations of the disease (for example, pain in the heart, palpitations, vomiting, black stools). The patient’s complaints enable the doctor to suggest disturbances in one or another system of the body (cardiovascular, digestive) and, without deviating from the study of the body as a whole, pay special attention to this system.

2. When did the patient get sick, when did the first signs of the disease appear? This question allows you to decide with a significant degree of accuracy whether the disease is acute or chronic.

3. How did the disease arise, what were its first signs, what preceded them? The diagnostic significance of this question lies in the fact that some diseases have a characteristic onset with a sequential development of the clinical picture (for example, a sudden onset in lobar pneumonia and a gradual, slower development in bronchopneumonia).

4. The course of the disease, its development from the moment of its onset to the present. Clarification of this issue makes it possible to identify the dynamics of the disease, the gradual development of symptoms and various manifestations of the disease, the alternation of periods of improvement and deterioration, exacerbation of the disease, what treatment was carried out and what the effect was.

When collecting anamnesis, it is necessary to critically evaluate the patient's complaints. Taking an anamnesis is a creative act of studying the subjective symptoms of a disease, their comprehension, comparison, scientific and logical interpretation. Listening to the patient's story and questioning him, the examining doctor must always remember the most important position of I. P. Pavlov about the integrity of the organism, about the unity of the organism and the environment. Behind the patient’s complaints and subjective symptoms, the doctor must see the pathological process occurring in the body, the significance of the damage and the degree of participation of certain organs and systems in the development of the disease picture.

When collecting an anamnesis of the patient’s life, those features of the biography and conditions of his life are noted that may have been important in the formation of the constitutional type and type of the nervous system and could play a role in the occurrence of this disease. The type of higher nervous activity is formed under the influence of the external environment on the inherited characteristics of the body. In this regard, when collecting anamnesis, it is necessary to pay attention to the hereditary characteristics of the patient, the health status of the closest relatives and their history of the disease.

Social factors play a particularly important role in the formation of the typical characteristics of an organism. Therefore, during questioning, material and living conditions, working conditions, the presence of occupational hazards, recreational conditions, etc. are clarified in detail. An important place is occupied by clarifying diseases suffered in the past, since each disease can be a consequence, complication or exacerbation of either suffered in the past or chronically ongoing diseases. It must be remembered that taking an anamnesis is only part of the work that precedes making a diagnosis, and that even a very detailed and carefully collected anamnesis does not give the right to make a final diagnosis without objective research data.

The questioning should be detailed and systematic, especially for chronic diseases. In acute diseases, especially in conditions that threaten the patient’s life, it can be short. In these cases, the doctor does not have time to collect a detailed history, but urgent, immediate action is required to save the patient’s life. For unconscious patients, anamnestic information is obtained from relatives or people around them.

How does a doctor question a patient’s medical history?

Medical history anamnesis morbi. Upon questioning (history of illness), the doctor reveals:

• when did the disease begin;
• how it started;
• how it proceeded;
• what studies were conducted and what their results were;
• what treatment was carried out and what was its effectiveness.

In the process of such questioning, a general idea of ​​the disease often emerges. When figuring out the nature of its manifestations, you should first of all find out whether the disease began acutely or gradually and whether similar symptoms preceded it earlier. It is necessary to understand the possible causes and conditions for the occurrence of the disease, their connection with hypothermia or contact with an infectious patient. The conditions of work, rest, and nutrition are clarified. Of no small importance are various medical interventions used previously (tooth extraction, injections, etc.), and the use of medications. If the patient presents with these symptoms for the first time, then his actions aimed at reducing their manifestations are clarified. If the patient has had similar complaints before, then the frequency of their occurrence is determined (the presence of relapses or exacerbations, periods of remission and their duration). At the same time, previously conducted examinations and their results, the means of therapy used (antibiotics, hormones or cardiac glycosides, etc.), and the effectiveness of their use are clarified.

It is necessary to clarify the immediate motives that forced the patient to apply to this treatment and prevention institution (stopping a relapse, clarifying the diagnosis, etc.).