Medical history

The medical history (from the Greek ἀνάμνησις, anamnesis, "memory" ) is the result of a survey as part of medical activity. The history summarizes the history of a patient suffering together from his personal experience, the recording concerned the treating therapist.

As part of the medical duty of care, together with a careful survey of the history of a diagnosis possible, which may be a prerequisite for proper treatment. The history is levied generally on or before of medical examination or is part of the investigation, for example, to create a psycho- pathology.

History

In Corpus Hippocraticum the term history does not occur. The Hippocratic physician asked the patient not systematic, but only sporadically; the medical history is not the diagnosis, but the prognosis. The first work that deals exclusively with the questioning of the patient, comes from Rufus of Ephesus.

In the Middle Ages, the history does not play a role as a means for making a diagnosis or prognosis. Only Rhazes uses the term again as Rufus. He complained that doctors use the knowledge they had acquired from third parties about the patient to amaze him with alleged medical knowledge. Only Montanus calls, the doctor must " ... talk to the patients themselves " to learn everything, " which is important for the detection of the disease ." So that the history is associated with the first diagnosis.

The raising of the disease and medical history is in the 17th and 18th centuries an integral and required part of the diagnosis. Capivaccio and Possevinus Write first monographs with which the history of directed history is.

Boerhaave, the chronological biographical history before the examination findings in his case histories. For steel and his followers, the history is a kind of confession, as " the man for his sins will eventually get sick ." The medical history will be assigned at the end of the Baroque pathology. Does not matter if the history is recognized by questions or anamnestic signs and symptoms. In Diderot's Encyclopédie include the anamnestic signs to semiotics, pari passu with the diagnostic and prognostic sign. German Essays on the practice of " medical exam " from the Age of Enlightenment combine history, cathartic self-presentation of the patient and the current status of the patient.

Schoenlein and Wunderlich demand as opposed to separate the subjective from the objective medical history findings; the finding is assigned a priority for the diagnosis.

Content and forms

The contents of a history corresponding to the current memory, the collection is always dependent on the situation, the basic procedure is, however, often the same: It is asked for current and past physical ailments as well as previous treatments and after taking medication. Information about physical strain during work or during leisure time, eating habits or abroad should also provide clues to the causes of ill health. Other parts of the history are questions about the mental health or condition and according to the social position of the patient.

Equity and debt history

The personal history is the result of the questioning of the patient. The biographical history also includes the entire life history of the patient. A careful survey includes biological, psychological and social issues. The information gained by it often allow conclusions about risk factors and causal relationships.

The third case history results from the survey of persons associated with the patient. You can bring to light important additional information because outsiders notice things that can not even perceive the patient or wants. For persons who can not communicate sufficiently, it is often the only means to obtain information on medical history. Of importance is also the foreign medical history with regard to the information itself can not provide the patient, for example because they only occur during sleep.

Family and social history

Will be asked, among other things, marital status, the profession as well as by religious affiliation. Family history is part of the equity or debt history. Information on the relatives of a patient can provide clues to genetic disorders and susceptibility to certain diseases. This applies for example to the increased incidence of tumors, allergies, infectious diseases, cardiovascular diseases or mental disorders.

With the social history of the social position of the patient is to be detected.

History in the emergency service

Even in the emergency service includes a comprehensive medical history to work on the patient. Is widespread in the preclinical stage, the so-called " SAMPLE mnemonic ". This can be supplemented by the R:

Beginning of the complaints / pain, localization, course / duration, influences that lead to the exacerbation / deterioration, type / quality of pain, severity / intensity

Long-term medication → conclusion on the underlying disease, exclusion of complications with emergency drugs

Pre-existing conditions (eg, hypertension, diabetes mellitus, cardiac arrhythmias, etc. ) if necessary. is patient ID ( eg pacemaker patients)

What? How much? Hard? Liquid?

Events that led to the emergency / accident, eg Mechanism of injury or activity shortly before entry of complaints circumstances

What risks accompany the action / the patient?

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