The medical anamnesis is the most important part of the consultation. It allows the doctor or the medical profession to better consider the patient, his symptoms or his illness, and to make the diagnosis, which is then confirmed by the clinical examination. Procedure and sample questions.
Definition: what is an anamnesis?
The history is questioning which makes it possible to recover the elements of the history of a patient or an illness. The goal being to have the medical and/or medico-surgical history of the patient, as well as symptoms which led him to consult.
What is the purpose of a history?
The purpose of the history is to “investigate” a patient’s history and symptoms. In other words, it is a question of recovering the medical information of the patient. “History taking is the retrieval of the patient’s history and symptoms as far back as he can remember. During this interrogation, the doctor’s questions will help guide the patient.” explains Pr Nicolas Noel, PU-PH in internal medicine at Bicêtre Hospital. “The anamnesis is literally to listen to the patient, to hear his symptomatic complaint and to try from a symptom to characterize him and to seek the possible complementary symptoms to thus formulate one or more diagnostic hypotheses, which will be (have) refined ( (s) then by clinical examination”, he specifies.
Which doctor can take an anamnesis?
The anamnesis is the essential part of any medical consultation. “80 to 90% of the diagnosis will be made thanks to the anamnesis. The examination of the patient will then be its extension. Complementary examinations representing only 1 to 2% of the diagnosis”he says. From the 2nd year of medicine, students are trained in anamnesis. Depending on the profiles of the patients, the anamnesis is more or less easy to carry out and the medical expertise will facilitate this time of questioning: “throughout his practice, the doctor will improve his anamnesis, will develop his knowledge through his trainingand through his expertise be able to properly unfold the anamnesis to better consider the patient and his symptoms“, emphasizes Professor Noel.
What are the stages of a history?
The anamnesis will take place in the form of various questions that will categorize the information as follows:
► The reason for consultation or hospitalization: “what the patient is there for”;
► The antecedents “the frame of the picture”: medical, personal, surgical, gynecological, psychiatric and family history: “all the medical past: anteriorities of surgery, past illnesses or chronic illnesses, followed“. You should know that in the majority of situations, the symptom that a patient presents can be linked to a symptom that he has already had, and this when there is a history. There are also genetic diseases and family that we will be able to detect on a symptom.
► The treatments taken (asthma, diabetes, hypertension, etc.):many people having treatment for hypertension, for example, say they are no longer hypertensive. While it is thanks to the treatment that hypertension is taken care of and stabilized”explains Professor Noel.
► The lifestyle : For example : where do people live? How ? Are they socially surrounded, isolated? Are they from another country? Do they have a job? Recreation ? Do they smoke or do they have specific consumptions? These questions allow put a frame which will then be completed by the second part of the anamnesis: the history of the disease or the symptoms.
► Relatives can also be questioned in different situations: the parents of a sick child, the caregivers of a sick elderly person, the entourage in the event of a life-threatening emergency or loss of consciousness.
What are the risks and limits of a history?
The risks of the anamnesis are to want questioning too quickly, “closing the door” on the expression of symptoms (for example, finishing the patient’s sentences for him) and/or polarizing the diagnosis by preconceived ideas (stopping the anamnesis on an idea of diagnosis and thus transforming the patient’s reality). There is no limit to the anamnesis, it is the most important time of the consultation.
Thanks to Pr Nicolas Noel, internal medicine, Bicêtre hospital (AP-HP), faculty of medicine of the University of Paris-Saclay