Life history and present illness

Life history (anamnesis vitae) includes information of a general biographical nature: place of birth, education, place and living conditions in the past and present, financial security, marital status, hobbies, habits, leisure activities, level of physical activity.

Professional activity is characterized taking into account possible occupational hazards and the presence of similar clinical manifestations in other workers in this production.

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

Particular attention is paid to past illnesses and their course. It is possible to identify chronic pathological processes, information about which should be transferred to the history of the current disease. It is especially necessary to ask about past surgeries, complications in the pre- and postoperative period, bleeding and blood transfusions, donation, which sharply increases the likelihood of infection with hepatitis B and C viruses (the cause of many visceral lesions).

An important issue is the so-called bad habits (smoking, alcohol consumption). It is always necessary to strive for their quantitative characteristics, since smoking and alcohol consumption are important risk factors for a number of pathological conditions. Patients provide quite objective characteristics of smoking (age of smoking initiation, number of cigarettes smoked, etc.). However, patients very often underestimate alcohol consumption. In this regard, it is necessary to additionally question the patient's relatives and friends and pay attention to some so-called markers of alcoholism (including when assessing the patient's appearance). It is necessary to take into account periods of the patient's stay in countries with an unusual climate and living conditions (tropics), the possibility of parasitic invasions.

The general anamnesis should include information about sexual function. Women are asked about the course of menstruation (regularity, abundance, painfulness), the course of pregnancies and childbirth, the time of cessation of menstruation - menopause and its accompanying manifestations (hot flashes, manifestations of neurosis). These data are important for explaining some 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 illnesses and causes of death of parents and close relatives can be valuable for diagnostics and especially prognosis. For example, illness and especially death of one of the parents at a relatively young age from ischemic heart disease or cerebral stroke are of great importance, as well as the presence of such diseases in relatives as diabetes mellitus, ischemic heart disease, hypertension, gout, tuberculosis. The patient's marital status is determined, what kind of relationships there are in the family, who runs the household, who provides assistance to the patient in everyday life if necessary.

The disease can manifest itself in relatives of the same sex. Thus, only men suffer from hemophilia, but the disease is transmitted from grandfather to grandson only through an apparently healthy daughter.

When assessing the psychological state of the patient, the manner of telling the story (inhibition or, conversely, excitement, verbosity), the patient's reaction to various types of psychological stress, including a real illness - whether it causes excessive fear and apprehension of an unfavorable prognosis or whether there is an underestimation of the seriousness of the situation, which entails a violation of the regimen, careless administration or even covert cessation of medication, etc. It is advisable to strive for the most frank conversation with the patient, while simultaneously creating a psychological atmosphere of trust, confidence in the patient in the necessity and importance of the diagnostic and therapeutic measures being carried out, faith in the doctor.

The patient's relationship with the medical student who is assigned to supervise him may be special. In any case, even a short meeting should begin with an introduction, finding out the patient's name and patronymic, basic information about the patient, his complaints, and preferably (at least briefly) - anamnesis of the disease. Then an examination is carried out, sometimes selectively of one or another organ. In any case, the patient should see the student as one of the doctors who are trying to help him.

History of the present disease

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

The objectives of studying the patient's medical history:

1. Establish contact with the patient.
2. Obtain the information needed for diagnosis.
3. Assess the probable severity of the disease.
4. Identify other possible sources of information (relatives, other doctors, etc.).
5. Assess the patient’s personality and his reaction (attitude) to the developing disease (i.e. the internal picture of the disease).

"Since when do you consider yourself ill?" - this is often the first question. The doctor and the patient try to trace the development of the disease from the appearance of the first signs to the present time. Periods of exacerbation are characterized, information on the results of the examination and treatment, including extracts from medical records, is included. All this, of course, deserves close attention, but also a critical attitude, verification.

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

It is important to clarify with the patient the possible causes that caused the disease or its exacerbation (past infection, dietary errors, insolation, cooling). Questions about the tolerance of medications, probable allergic reactions are always asked.

It is advisable to summarize the anamnesis data and present it together with the complaints in the form of a graph.

As with studying the patient's complaints, clarifying the anamnesis requires sufficient knowledge of the corresponding pathology and the patterns of its development. Often, especially with a difficult and unclear diagnosis, it is necessary to return to the history of the current disease, looking for new information that may become decisive. In the process of familiarization with the anamnesis, the doctor should give the patient the opportunity to speak out, but the patient's story should always be accompanied by questions, the answers to which are important for the doctor. Particular attention is paid to the last period preceding hospitalization, its reasons and purpose. Studying the anamnesis, like questioning in general, is not just a list of questions and answers to them. The psychological compatibility that largely determines the final goal - alleviating the patient's condition - depends on the style of conversation between the doctor and the patient.

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