Anamnesis of life and present illness

The history of life (anamnesis vitae) includes information of a general biographical nature: place of birth, education, place and conditions of life in the past and in the present, material security, marital status, interest in hobbies, habits, recreation, degree of physical activity.

Characterized by professional activities, taking into account the possible occupational hazards, the presence of similar clinical manifestations in other workers of this production.

Among professional factors, one should keep in mind the inhalation of dust, including silicon dioxide, asbestos, etc., vibration, radiation stress, exposure to lead, mercury, solvent vapors, carbon monoxide, beryllium. In this case, it is necessary to specify the availability of protective measures, the provision of preventive measures and periodic medical examinations and their completeness.

Particular attention is paid to the transmitted diseases, their course. It is possible to identify chronic pathological processes, information about which should be transferred to the history of the present disease. Special attention should be paid to postoperative operations, complications in the pre- and postoperative period, bleeding and blood transfusions, and donation, in which the likelihood of infection with hepatitis B and C viruses increases (the cause of many visceral lesions).

An important issue is the so-called bad habits (smoking, drinking alcohol). One should always strive for a quantitative description of them, since smoking and drinking are among the important risk factors for a number of pathological conditions. Characteristics of smoking (age of smoking, number of cigarettes smoked, etc.) patients give fairly objectively. However, alcohol consumption is often underestimated by patients. In this regard, it is necessary to ask relatives and relatives of the patient in addition and pay attention to some so-called alcoholization markers (including when assessing the appearance of the patient). It is necessary to take into account the periods of the patient's stay in countries with unusual climate and living conditions (tropics), the possibility of parasitic invasions.

The general anamnesis should include information about the sexual function. Women are questioned about the course of menstruation (regularity, profuse, soreness), the course of pregnancy and childbirth, the time of stopping menstruation - climax and the accompanying manifestations (tides, manifestations of neurosis). These data are important for explaining some of the symptoms, in particular heart pain. Here you should also ask about contraceptive measures, in particular about taking hormonal drugs, long-term use of which can lead to serious complications.

Heredity can play the role of a factor predisposing to a disease, which usually develops under the influence of external influences. Information about the diseases and causes of death of parents and close relatives can be valuable for diagnosis and especially foresight. For example, the disease and especially the death of one of the parents at a relatively young age from coronary heart disease or cerebral stroke, as well as the presence of diseases such as diabetes mellitus, coronary heart disease, hypertension, gout, tuberculosis, are of great importance. The family status of the patient, family relations, who conducts the household, who helps the patient in everyday life, if necessary, are found out.

The disease can occur in relatives of the same sex. So, only men are affected by hemophilia, but the disease is transmitted from grandfather to grandson only through an apparently healthy daughter.

When assessing the psychological condition of the patient, the manner of telling (inhibition or, conversely, agitation, verbosity), the patient's reaction to various types of psychological stress, including a real illness, is taken into account - whether it causes excessive fear and fear of an unfavorable forecast, or there is an underestimation of the seriousness of the situation, which entails a violation of the regime, inaccurate reception or even a latent cessation of medication, etc. It is advisable to seek a more frank conversation with the patient, giving at the same time a psychological atmosphere of confidence, the patient's confidence in the necessity and importance of the diagnostic and therapeutic measures being conducted, and faith in the doctor.

In a special way, a patient's relationship with a medical student, who is entrusted with curating, can develop. In any case, even a short meeting should begin with acquaintance, clarifying the name and patronymic, basic information about the patient, his complaints, and preferably (at least briefly) - and anamnesis of the disease. Then a survey is conducted, sometimes selectively by one or the other organ. In any case, the patient must see in the student one of the doctors who are trying to help him.

Anamnesis of the present disease

Studying the patient's complaints is closely intertwined with the history of the development of the present disease (anamnesis morbi).

Objectives of studying the patient's anamnesis:

1. Make contact with the patient.
2. Get the information you need to diagnose.
3. Estimate the probable severity of the disease.
4. Establish other possible sources of information (relatives, other doctors, etc.).
5. Evaluate the personality of the patient and his reaction (attitude) to developing disease (ie internal picture of the disease).

"Since when do you consider yourself sick?" - often this is the first question. The doctor and the patient seek to trace the development of the disease from the appearance of the first signs to the present day. The periods of exacerbations are characterized, information on the results of the examination and treatment, including the extracts from the case histories, is included. All this, of course, deserves close attention, but also critical attitude, verification.

It is especially important to evaluate the results of the therapy, it is advisable to know the effective doses of certain drugs, for example, a diuretic such as furosemide.

It is important to clarify the patient's possible causes that caused the disease or its aggravation (the transferred infection, bias in the diet, insolation, cooling). Questions are necessarily asked about the tolerability of medications, the likely allergic manifestations.

The data of the anamnesis should be generalized and presented together with complaints in the form of a schedule.

As well as the study of patient complaints, the clarification of the anamnesis requires sufficient knowledge of the corresponding pathology, the laws of its development. Often, especially with a difficult and unclear diagnosis, the history of this disease must be returned, looking for new information that can become decisive. In the process of getting acquainted with an anamnesis, the doctor should give the patient an opportunity to speak, however the patient's story should be constantly accompanied by questions, the answers to which are important for the doctor. Particular attention is paid to the last period preceding hospitalization, its causes and purpose. Studying an anamnesis, like questioning in general, is not just a list of questions and answers to them. From the style of conversation between the doctor and the patient, the psychological compatibility depends, which in many ways determines the ultimate goal - the alleviation of the patient's condition.

[1], [2], [3], [4], [5]