The term “anamnesis” comes from the Greek and means “memory”. It describes the conversation between the doctor and the patient. As a rule, the doctor guides the conversation with in-depth questions.
What is the anamnesis for?
An anamnesis has several goals: The doctor tries to understand the patient’s symptoms and to gain medically relevant information for his further procedure. In addition, the doctor also wants to lay the foundation for a good medical relationship of trust, which is usually an important prerequisite for being able to treat the patient successfully. For example, the doctor often has to ask about psychological, social and professional backgrounds. Such topics are sometimes uncomfortable for those affected and it sometimes takes courage to talk about them. However, if doctor and patient treat each other with trust, feelings and stressful circumstances are easier to express. An atmosphere of mutual respect also helps to weigh up the next steps together.
How do doctors take anamnesis?
The anamnesis is as individual as each patient. How it works depends on the situation. Nevertheless, doctors often orient themselves to a scheme. The order of the individual points may vary. At the end or during the anamnesis, the doctor writes down all the important information so that he can access it again later.
At the beginning there are usually the current symptoms of the patient. “What brings you to me?” is a frequently chosen initial question from the doctor. The patient describes his symptoms. The doctor listens and asks if he needs more details in order to make suspected diagnoses and plan his course of action for the further treatment of the patient.
personal medical history
The personal anamnesis is about the previous or medical history of the patient. This includes, for example, information on:
• previous illnesses
• operations
• chronic health disorders (previous illnesses)
• allergies and food intolerances.
Even if, for example, blood pressure or cholesterol levels have normalized while taking medication, the disease still exists and should be mentioned. Overall, such information can often provide clues as to the cause of the current symptoms. Much that at first glance does not fall under the term “medical history” is also often of interest: For example, information about possible pregnancies and long-distance trips in the recent past, the so-called “travel anamnesis”, can sometimes be used in the search for the cause help with complaints.
family history
Some diseases are genetic, or at least there is a greater susceptibility to these diseases because of genetics. These include, for example, rheumatic diseases and certain types of cancer. Diseases of civilization such as high blood pressure and diabetes also tend to run in families. Often they also have at least partial genetic causes. In addition, patients in the family environment can become infected with infectious diseases. When taking the family history, the doctor therefore asks about common illnesses in living relatives, but also about the causes of death in relatives who have already died.
Vegetative anamnesis
In contrast, the vegetative anamnesis focuses on the patient’s bodily functions. The doctor asks whether food intake, excretory functions and breathing are abnormal or have changed recently. Specifically, for example, it is about
• Loss of appetite
• Nausea
• Weight gain or loss
• Problems with bowel movements and urination
• Fever
• Trouble sleeping
• Dizziness
If performance has deteriorated significantly, such as climbing stairs or walking long distances, this should also be mentioned.
medication history
The drugs that patients are already taking refer to the current therapy for existing diseases. During the medication history, the doctor is interested in what medication the patient is taking, for what reasons and in what dosage. Drug allergies are also discussed here. Patients often forget to mention preparations such as contraceptives (the “pill”), insulin, or over-the-counter medicines. However, it is important for the doctor to also know about such preparations. For example, they can affect the way other medicines work.
History of stimulants
The anamnesis of stimulants enables the doctor to assess the patient’s risk factors. Alcohol, cigarettes and drugs can trigger or worsen various diseases. Even if this is an unpleasant topic, the doctor can ask more precisely: it is often important how much and how long stimulants have been consumed. For example, high alcohol consumption can lead to fatty liver, and prolonged alcohol consumption often also affects the pancreas. Precisely because the topic is very sensitive, a trusting framework for the conversation is of great importance. It can therefore happen that any accompanying persons (this can also be parents or partners from a certain age of children) are asked by the doctor to leave the room if the patient desires more privacy.
social history
The social history illuminates the social situation and role of the patient. Occupational risk factors play an important role here: So-called occupational diseases can arise from stress typical of the workplace. For example, many bakers suffer from allergic asthma caused by flour dust, the so-called “baker’s asthma”. However, generally high physical and mental stress at work can also trigger health disorders. In addition, in the social anamnesis, the doctor asks how comprehensive and stable the patient’s social environment is: Does the patient suffer from family conflicts? Does he receive support when he is ill? Does he possibly live alone and need care?
How can patients prepare?
Especially with a long medical history, it can be useful to make notes about previous illnesses and therapies. Patients who know when and why they presented themselves to which doctor or hospital often make it easier to find the diagnosis. Even unnecessary double examinations can sometimes be avoided by providing precise information.
Patients often bring a list of the medications they are taking with them. This reduces the risk of accidentally forgetting a preparation. General practitioners often give their patients such a list on request if they have to see another doctor. In certain cases, the vaccination card you brought with you can also help .
Of course, there are also situations in which the anamnesis is greatly abbreviated. If you present to the emergency room with acute symptoms such as shortness of breath or a fractured bone, the attending physician will probably omit parts of the above sections and focus the questions on the current problems and their immediate treatment.
When can more people help?
Sometimes it can be useful for other people to give the doctor information. For example, when a patient has fainted . Or when it comes to nocturnal breathing pauses , for example, relatives usually know more precisely to report. Such information is called a third-party anamnesis.
Basically, the doctor is subject to confidentiality. The contents of the anamnesis therefore remain confidential.