The medical history or anamnesis[1][2] (abbr. Hx) of a patient 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), with the aim of obtaining information useful in formulating a diagnosis and providing medical care to the patient. The medically relevant complaints reported by the patient or others familiar with the patient are referred to as symptoms, in contrast with clinical signs, which are ascertained by direct examination on the part of medical personnel. Most health encounters will result in some form of history being taken. Medical histories vary in their depth and focus. For example, an ambulance paramedic would typically limit his history to important details, such as name, history of presenting complaint, allergies, etc. In contrast, a psychiatric history is frequently lengthy and in depth, as many details about the patient's life are relevant to formulating a management plan for a psychiatric illness.
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, a provisional diagnosis may be formulated, and other possibilities (the differential diagnoses) may be added, listed in order of likelihood by convention. The treatment plan may then include further investigations to clarify the diagnosis.
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A practitioner typically asks questions to obtain the following information about the patient:
History-taking may be comprehensive history taking (a fixed and extensive set of questions are asked, as practiced only by health care students such as medical students, physician assistant students, or nurse practitioner students) or iterative hypothesis testing (questions are limited and adapted to rule in or out likely diagnoses based on information already obtained, as practiced by busy clinicians). Computerized history-taking could be an integral part of clinical decision support systems.
Whatever system a specific condition may seem restricted to, it may be reasonable to review all the other systems in a comprehensive history.
Factors that inhibit a proper medical history taking include physical inability of the patient to communicate with the physician, such as unconsciousness and communication disorders. In such cases, it may be necessary to perform a so called heteroanamnesis of other people who know the person and can give suitable information, which, however, generally is more limited than a direct anamnesis.
Medical history taking may also be impaired by various factors impeding a proper doctor-patient relationship, such as transitions to physicians that are and unfamiliar to the patient.
History taking of issues related to sexual or reproductive medicine may be inhibited by a reluctance of the patient to disclose intimate or uncomfortable information. Even if such an issue is on the patient's mind, he or she often doesn't start talking about such an issue without the physician initiating the subject by a specific question about sexual or reproductive health.[3] Some familiarity with the doctor generally makes it easier for patients to talk about intimate issues such as sexual subjects, but for some patients, a very high degree of familiarity may make the patient reluctant to reveal such intimate issues.[3] When visiting a health provider about sexual issues, having both partners of a couple present is often necessary, and is typically a good thing, but may also prevent the disclosure of certain subjects, and, according to one report, increases the stress level.[3]
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