It is the medical history (often abbreviated hx or Hx) of a patient through information obtained by a doctor by asking specific questions.
Either the patient or other people who know the person can provide adequate information (in this case, sometimes called heteroanamnesis ) to obtain valuable information to formulate a diagnosis and provide medical care to the patient.
Medically relevant complaints reported by the patient or others familiar with the patient are known as symptoms, in contrast to clinical signs determined by direct examination by medical personnel.
Most health encounters will lead to some history.
The clinical histories vary in-depth and focus. For example, an ambulance paramedic would typically limit your account to essential details, such as name, history of complaint presentation, allergies, etc.
In contrast, a psychiatric history is often long and profound, as many details about the patient’s life are relevant to formulating a management plan for a psychiatric illness.
A doctor usually asks questions to obtain the following information about the patient:
- Identification and demographic information: name, age, height, weight.
- The “main complaint”: the main problem or health concern and its temporary course (for example, chest pain during the last 4 hours).
- History of the current disease: details about the complaints listed in the CC. (It is also often referred to as the “File of a Complaint History” or HPQ).
- Past medical history: (which includes serious illnesses, previous operations/operations (sometimes distinguished as “past surgical history” or PSH), any current disease in progress, for example, diabetes).
- System review: Systematic questions about different organ systems.
- Family diseases, especially those relevant to the patient’s main complaint.
- Childhood diseases: this is very important in pediatrics.
- Social history (medicine): including housing arrangements, occupation, marital status, number of children, use of drugs (including tobacco, alcohol, and other recreational drug use), recent trips abroad, and exposure to environmental pathogens through recreational activities or pets.
- Regular and acute (including those prescribed by doctors and others obtained without medical prescription or alternative medicine).
- Allergies: to medications, food, latex, and other environmental factors.
- Sexual history: obstetric/gynecological history, etc., as appropriate.
Factors that inhibit the proper medical history taking include the patient’s physical inability to communicate with the doctor, such as unconsciousness and communication disorders.
In such cases, it may be necessary to carry out a so-called heteroanamnesis of other people who know the person and can provide adequate information, which is generally more limited than a direct anamnesis.
The taking of medical history can also be affected by various factors that prevent a good doctor-patient relationship, such as transitions to doctors who are not familiar with the patient.
The taking of antecedents of questions related to sexual or reproductive medicine can be inhibited by the reluctance of the patient to divulge personal or uncomfortable information.
Even if this issue is in the patient’s mind, they often do not start talking about a problem without the doctor initiating the case with a specific question about sexual or reproductive health.
Usually, a certain familiarity with the doctor makes it easier for patients to talk about intimate issues, such as sexual issues. Still, for some patients, a high degree of familiarity can make them reluctant to reveal such personal problems.
When visiting a health services provider on sexual matters, it is usually necessary to have both spouses present, and it is generally a good thing. Still, it can also prevent the disclosure of specific topics and, according to a report, increases the level of stress.
Computer-assisted history taking
Computer-aided history-making systems have been available since the 1960s. However, their use remains variable in all methods of health service delivery.
An advantage of using computerized systems as an auxiliary or even primary source of related medical information is that patients may be less susceptible to the bias of social desirability. For example, patients are more likely to report engaging in unhealthy life behaviors.
Another advantage of computerized systems is that they allow easy portability and high fidelity to the patient’s electronic medical record.
Also, an advantage is that it saves money and paper. A disadvantage of current medical history systems (2012) is that they can not detect nonverbal communication, which can help elucidate anxieties and treatment plans.
Another disadvantage is that people may feel less comfortable communicating with a computer than with a human being.