A medical history is the information a health professional gathers about a patient’s health through conversation with the patient and, when appropriate, people who know them. This lesson explains how the history supports clinical decisions and how it fits into the standardized history and physical examination, or H&P.
A medical history, also called a case history or anamnesis, is a set of medically relevant information collected during interviews. The word anamnesis comes from Greek roots meaning “again” and “memory.” Information may come directly from the patient or, when needed, from people close to them. Gathering reliable information helps clinicians understand the problem and make informed decisions.
All flashcards
What is a medical history?
It is medically relevant information collected through interviews with a patient and, when appropriate, people close to them, to support clinical assessment and care.
How do symptoms differ from clinical signs?
Symptoms are complaints or experiences reported by the patient or another person. Clinical signs are findings ascertained through direct examination by health personnel.
What is the purpose of the H&P?
The history and physical combines information about past and present health with physical examination findings to guide diagnosis, investigations, and treatment.
What is a differential diagnosis?
It is a set of alternative possible explanations for a patient’s condition, often arranged in order of likelihood when one diagnosis is not yet established.
How do comprehensive and iterative history taking differ?
Comprehensive history taking uses a fixed, extensive set of questions. Iterative history taking adapts questions to information already gathered and to the diagnoses being considered.
Quiz questions
What is a symptom in the context of medical history taking?Answer: A medically relevant complaint reported by the patient or someone familiar with them.
What does the chief concern usually identify?Answer: The main reason the patient is seeking care, including its time course.
How does the review of systems contribute to a medical history?Answer: It systematically asks about symptoms across body systems, including concerns not already mentioned.
A patient’s information does not establish one definite diagnosis. What may the clinician do next?Answer: Record a provisional diagnosis, consider alternatives, and use further investigations if needed.
Why might a psychiatric history be more extensive than an emergency paramedic’s history?Answer: Many details of a patient’s life may be relevant to planning psychiatric care, while emergency histories may prioritize immediately important details.
Based on the Wikipedia article Medical history, licensed CC BY-SA 4.0. Adapted into a summary, flashcards and quizzes.