Medical history

Patient information gathered by a physician

Not to be confused with History of medicine.

For the journal, see Medical History (journal).

The medical history, case history, or anamnesis (from Greek: ἀνά, aná, "open", and μνήσις, mnesis, "memory") refers to the information collected by a physician from a patient during a medical interview. It serves as a fundamental component in assessing the patient's condition, guiding medical diagnosis, and formulating appropriate medical treatments.

Medical history is typically obtained through direct questioning of the patient, and when necessary, from close relatives or caregivers to ensure reliable and objective information. The patient's self-reported issues are classified as symptoms, while findings discovered through direct examination by medical professionals are referred to as clinical signs.

The depth and focus of a medical history vary depending on the context. For example:

• An ambulance paramedic may only gather essential details such as name, history of the presenting complaint, and allergies.
• A psychiatric history is often extensive, involving many aspects of the patient’s life to formulate an effective management plan for a psychiatric disorder.

A comprehensive history, combined with a physical examination, helps healthcare providers establish a diagnosis and develop an appropriate treatment plan. If a conclusive diagnosis is not immediately possible, a provisional diagnosis is formulated, and further diagnostic testing may be ordered to narrow down potential conditions (the differential diagnosis).

History and Physical (H&P)

The history and physical (H&P) is the standard method by which physicians collect and organize patient information to support clinical decision-making. The history involves structured questioning, while the physical examination focuses on relevant clinical findings.

A typical medical history follows a standardized structure:

1. Chief complaint (CC): The primary reason for the patient’s visit.
2. History of present illness (HPI): A detailed exploration of the current complaint.
3. Past medical history (PMH): Previous illnesses, hospitalizations, and ongoing medical conditions.
4. Past surgical history (PSH): Record of previous surgeries and operations.
5. Family history (FH): Genetic and hereditary conditions relevant to the patient's health.
6. Social history (SH): Lifestyle factors such as occupation, living arrangements, smoking, alcohol use, and recreational drug use.
7. Medication history: Current and past medications, including over-the-counter drugs and alternative medicine.
8. Allergies: Drug, food, and environmental allergies.
9. Review of systems (ROS): A systematic assessment of symptoms affecting different organ systems.

Following the history, a focused physical examination is conducted to assess the chief concern. Based on these findings, physicians may order additional laboratory tests or medical imaging to confirm a diagnosis and determine appropriate treatment.

Process

Example of a pediatric history form

A practitioner typically gathers the following key details:

• Identification and demographics: Name, age, sex, height, weight.
• Chief complaint (CC): The primary medical issue and its duration (e.g., chest pain for four hours).
• History of present illness (HPI): Detailed description of symptoms, their onset, and progression.
• Past medical history (PMH): Previous illnesses, surgeries, chronic conditions (e.g., diabetes mellitus, hypertension).
• Review of systems (ROS): Systematic questioning of different organ systems to uncover additional symptoms.
• Family history (FH): Inherited conditions and illnesses affecting close relatives.
• Childhood diseases: Particularly relevant in pediatrics.
• Social history (SH): Living situation, occupation, marital status, lifestyle habits, recreational drug use, exposure to infectious diseases, etc.
• Medication history: Current and past prescription and non-prescription medications.
• Allergy history: Known allergies to medications, foods, or environmental triggers.
• Sexual and gynecological history: If relevant, details about reproductive health, past pregnancies, and sexually transmitted infections.
• Conclusion and follow-up: Establishing a treatment plan, scheduling further testing, or recommending specialist consultation.

Medical history can be collected using different approaches:

• Comprehensive history-taking: A detailed and standardized interview, often conducted by medical students, physician assistants, or nurse practitioners.
• Hypothesis-driven history-taking: A more targeted approach, used by experienced clinicians to rule in or out likely diagnoses efficiently.
• Computerized history-taking: Increasingly integrated into electronic health records, this method allows for structured and standardized patient data collection.

Review of Systems (ROS)

Main article: Review of systems

A review of systems (ROS) systematically checks for symptoms in various organ systems, ensuring that no significant medical issues are overlooked. It often includes:

• Cardiovascular system: Chest pain, dyspnea, palpitations, ankle swelling.
• Respiratory system: Cough, hemoptysis, wheezing, chest pain worsened by breathing.
• Gastrointestinal system: Abdominal pain, vomiting, diarrhea, constipation, hematemesis.
• Genitourinary system: Dysuria, changes in urine color, abnormal discharge, incontinence.
• Nervous system: Headache, dizziness, loss of consciousness, memory problems.
• Cranial nerves: Vision changes, facial numbness, hearing loss, difficulty swallowing.
• Endocrine system: Weight loss, polydipsia, polyuria, changes in appetite.
• Musculoskeletal system: Joint pain, joint swelling, muscle weakness.
• Skin: Rash, recent changes in cosmetics or sun exposure reactions.

Inhibiting Factors

Several factors may impede effective history-taking:

• Physical barriers: Unconsciousness, communication disorders, or cognitive impairment.
• Psychosocial barriers: Language barriers, anxiety, stress, or reluctance to disclose sensitive health information.
• Lack of continuity in care: Changing physicians may lead to fragmented patient histories.
• Cultural and personal sensitivities: Patients may hesitate to discuss sexual health, mental health, or substance use.

When patients cannot provide their own history, physicians may rely on collateral history (heteroanamnesis) from family members or caregivers.

Computer-Assisted History Taking

Main article: Computer-assisted history taking

Computer-assisted history taking systems have been developed since the 1960s to enhance efficiency and accuracy. These systems allow patients to enter medical information electronically before their appointment.

Advantages:

• Reduces social desirability bias, leading to more honest reporting of lifestyle habits.
• Integrates seamlessly with electronic medical records for easy access.
• Saves time and reduces paperwork.

Disadvantages:

• Lacks the ability to detect non-verbal cues that may provide critical clinical insights.
• Some patients may feel less comfortable discussing personal health concerns with a computer.
• Studies show that some individuals (14%) find computerized history-taking uncomfortable in sensitive areas like sexual history.

See Also

• Genogram
• Medical record
• Medicine
• Physical examination
• Psychoanalysis (Freud's use of anamnesis in exploring past experiences)

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