Among the skills necessary for a good doctor is their ability to establish fluent communication and, thus, arrive at an accurate diagnosis and effective treatment.
The medical history, one of the pillars of this communication, goes far beyond simple questions and answers. It is a process that involves empathy, attention, and the ability to extract valuable information from the patient's account.
In this article, you will understand what a good medical history is and how to conduct one.
What is an anamnesis?
The anamnesis is a medical document created from an interview with the patient, and aims to qualify the diagnosis and reveal details for a more appropriate and effective treatment.
It can also be summarized as a critical assessment made by the doctor based on the patient's report, going beyond just a set of described symptoms.
In other words, the anamnesis gathers information from the patient's clinical history, considering everything from current complaints to habits and psychosocial history that may influence diagnosis and treatment.
Why conduct a medical history taking?
Unlike a superficial assessment, anamnesis offers a much broader field for analyzing symptoms, considering habits, sociodemographic issues, family history, and various other factors.
Through this information, other conditions can be identified, such as occupational diseases or disorders with diffuse symptoms.
In other cases, a patient with a seemingly simple case of gastroenteritis may already have a history that suggests a diagnosis of gastritis or an ulcer, for example.
Both situations can be identified beforehand through a well-conducted and detailed interview combined with clinical analysis.
It's important to remember that the medical history is not a static document and should be viewed as a tool for continuous updating during patient follow-up, serving as a source of information and possibilities for other treatments.
When should the medical history be taken?
Ideally, the medical history should be taken at the beginning of the consultation, whether it's medical, psychological, physiotherapy, etc.
This is because it is through this information that the attending physician directs the patient to examinations and tests that confirm the initial diagnosis, determining a course for treatment.
How to conduct a medical history taking?
First and foremost, healthcare professionals must understand that a good medical history is the result of the ability to listen to and interpret what the patient shares.
Furthermore, conducting a thorough medical history assessment requires preparation. It is important for the physician to review the patient's medical record to understand the patient's basic information.
From this point, one can begin constructing the medical history.
A classic medical history should include the following topics:
- Identification;
- Main complaint;
- History of present illness;
- Systematic or symptomatic questioning;
- Personal and family background;
- Lifestyle habits;
- Psychosocial history (socioeconomic and cultural conditions).
Identification
It may seem obvious that the medical history begins with collecting basic patient data, but in this case, the identification goes beyond just name and age, acting as a sociodemographic profile.
Therefore, the data collected at this stage of the anamnesis are:
- Name;
- Age;
- Sex;
- Race/ethnicity;
- Marital status;
- Occupation;
- Education level;
- Religion;
- Place of birth;
- Current place of residence;
- Degree of reliability.
Certain factors, such as race and religion, may initially cause confusion regarding the need for this information. However, they are necessary to identify susceptibility to certain pathologies or to determine lifestyle habits, impacting customs, diet, and leisure.
Other categories such as occupation, place of birth, and place of residence are essential for screening for potential exposures to diseases.
Main complaint
At this point, the patient expresses for the first time the reason that led them to seek care.
"What brought you here today?" is almost always the standard question to start this dialogue.
This is the starting point for diagnosis, so it's essential that the patient feels comfortable and open to sharing more details. But don't just focus on what's said; pay attention to body language as well.
She is the one who can provide possible clues about its severity or impact on the patient's life.
History of present illness
It is important to encourage the patient to provide as much detail as possible, since the history of the current illness is one of the main determining factors for a diagnosis.
To do this, start by looking for a timeline of events based on the start date. From there, determine the total duration of the illness, its location, whether there is radiation, the quality or how the symptoms manifest, and their intensity.
The patient may offer this information spontaneously, but seek more specific details such as: whether the symptoms have progressed, their relationship to other complaints, and factors that improve or worsen them (if any).
Systematic or symptomatic questioning
Even after addressing the chief complaint and medical history, it's important to investigate other body systems to ensure the patient hasn't missed any other symptoms.
Some suggested questions that can be asked are:
- And what about breathing?
- Have you been feeling tired or fatigued?
- And as for food, everything alright?
Just avoid asking overly detailed questions so as not to interfere with what the patient has to say.
Background
For an even broader view of the patient's health, it is always important to check their history, from personal history such as previous surgeries and pre-existing health problems, to family history of diseases and disorders. This helps to understand whether the current illness is an isolated case, a crisis resulting from a pre-existing condition, or a sign of something that needs further investigation.
Lifestyle habits
Aspects such as diet, physical exercise, and sleep quality should be considered as factors influencing the patient's health.
It is also necessary to ask whether the individual consumes or uses alcohol, tobacco, and other substances.
The importance of welcoming the patient during the anamnesis (medical history taking)
It is important to remember that even though the medical history is a clinical document and should be prepared critically, patient care does not follow the same principles.
In reality, during the consultation and interview process, the professional should always be as understanding and warm as possible, since this is the initial moment of connection between doctor and patient.
Building a relationship between the parties is essential both for understanding the initial problem and for the course of treatment. It is important that the patient feels comfortable opening up about their issues and trusts the doctor's guidance.
The same applies to the doctor-caregiver relationship. In cases where the patient, for any reason, is unable to report their own complaints, the bond between doctor and caregiver/companion becomes essential.
