Medical history

Encyclopedia : M : ME : MED : Medical history

For another possible meaning of this term see History of medicine.

The medical history of a patient (sometimes called anamnesis [link][link] ) is information gained by a physician by asking specific questions, either of the patient or of other people who know the person and can give suitable information (in this case, it is sometimes called heteroanamnesis). This kind of information is called the symptoms, in contrast with clinical signs, which are ascertained by direct examination.

A physician typically asks questions to obtain the following information about the patient:

The name, age, height, and weight
The "chief complaint" — the major health problem or concern, and its history
Past medical history (including major illnesses, any previous surgery/operations, any current ongoing illness, eg diabetes)
Systematic questioning about different organ systems
Family diseases
Childhood diseases
Social status (including living arrangements), occupation, drug use (including tobacco, alcohol, other recreational drug use)
Regular medications (including prescribed by doctor, and others obtained over the counter)
Allergies
Sex life, obstetric/gynecological history and so on as appropriate.

The information obtained in this way, together with clinical examination, enables the physician to form a diagnosis and treatment plan. If a diagnosis cannot be made then a provisional diagnosis may be formulated, and other possibilties (the differential diagnosis) may be added, by convention listed in order of likelihood. The treatment plan may then include further investigations to try and clarify the diagnosis.

It may be comprehensive history taking (as practised only by the young medical students) or iterative hypothesis testing (as practised as rule of thumb by busy clinicians). Computerised history-taking could be an integral part of clinical decision support systems.

Medical history

See also