History is a set of information obtained by interviewing the patient and used for diagnosis, treatment and prognosis of the disease. If the patient is in severe or unconscious, the history is obtained by questioning his relatives and others violence. Collection of anamnesis is preceded by an objective examination. Such a sequence is appropriate because it allows you to make contact with the patient, which is extremely important for further research and treatment, and to plan future research.
Despite the development of instrumental and laboratory methods of diagnostics, picking up the history of great importance to identify the initial forms of the disease.
In addition, the diagnosis of some diseases can be supplied mainly with questions (such as angina).
The interrogation shall be conducted according to the plan. The scheme of questions: 1) complaints of the patient, his feelings and experiences; 2) History of this disease (History of illness); 3) History of previous life of the patient (the History of life, or the General history); 4) data on heredity (family history).
Complaints of patients can be very diverse, but the defeat of one or the other systems of the organism are usually peculiar to certain claims; for example, palpitations, shortness of breath, swelling of the defeat of the cardiovascular system. After listening to the complaints of the patient should ask him a series of leading questions; for example, if the patient complains of pains in the abdomen, it is necessary to clarify their nature, distribution, with what the patient binds their appearance, solution, side effects (vomiting, diarrhea , and so on).
The anamnesis of disease should help to establish the nature of onset (acute or progressive), its further course (progressive, weakening or intermittent) and earlier treatment.
The anamnesis of life must contain those features biographies of the patient and his or her living conditions that could be the cause of the development of this disease. To find out what diseases suffered ill in the past, since this disease can be a complication or exacerbation of a previous illness. It is necessary to clarify the reaction of the patient to conducted treatment (intolerance to certain medicines). Because the social environment has a certain impact on the occurrence of diseases in anamnesis gathering should be paid more attention to the investigation of everyday conditions in all age periods of life of the subject, conditions of work and rest. You must determine the presence of harmful habits: Smoking (number of smoked cigarettes per day) and alcohol use (quantity, frequency).
Next, you need to find out the state of health of the next of kin of the patient (parents, children) - family history. This is important from the point of view of hereditary diseases.
Find out the data about the availability of a similar disease in relatives, indicating the degree of kinship and the number of healthy and sick relatives. The frequency of any disease in relatives itself does not mean pathogenetic significance of hereditary predisposition to the origin of this disease, as the latter can be called appropriate same external conditions of life.
An epidemiological anamnesis includes a set of information about the patient, the staff, in which he works, and the territory where they could be infected. This information is used for the diagnosis of infectious disease, determine the sources of infection and the development of the actions that prevent its further spread. The collection of epidemiological anamnesis carried out in infectious hospitaland epidemiological inspection of the hearth, which attract secondary health care workers. The results of epidemiological history is recorded in the history of the disease and the form № 171 - map of epidemiological survey.
Anamnesis in children. Anamnestic data on children collected by interviewing parents, sometimes people caring for a child. We cannot exclude the survey and the child (school and even pre-school age). Anamnesis in children has some peculiarities. Clearly the collected history helps diagnosis, gives an idea of a sick child in General and allows to identify individual characteristics of reactions of its organism on the environment and disease.
In General, the history should be clarified course of pregnancythan were sick mother in the different periods of pregnancy, the nature of its work, nutrition and physical living conditions.
On the neonatal period, you must obtain the following information: what were childbirth (rapid or prolonged); cried out whether the child immediately after birth or after the measures taken (Pat and so on); the child was born at term or premature and what is the cause of premature births; what is the weight of the child at birth; when put to the breast immediately Lee took the breast as he sucked: when no longer the umbilical cord, as healed umbilical wound; whether jaundice, when she appeared, and for how long; when issued child from the maternity hospital; what are the living conditions and individual hygienic mode of the child.
Data on infant feeding in the first year of life history should belong to a significant place. Find out the nature of feeding from birth (breast, and so on), when started complementary feeding, and what (if earlier, why)when the child was weaned from the breast, the frequency of feeding. Did vitamins, juices, fish oil.
When asking about the progress of development of the child should be clarified, as did the weight gain when the child started to keep your head, sit, stand, walk, when the first teeth, how many were there to year, when I started to understand and speak.
An important place in the history of the child is concerned with family health and heredity. It should seek to collect information about the greatest possible number of relatives. Special attention should be paid to the identification of repeated cases of the same disease in the family.
It is necessary to clarify in sequential order than the child was sick like endured infectious diseases, where and how it was treated, and what is the result of treatment. For school-age children need to find out the reaction to the labor regime in school. It is important to have information about vaccinations, when and what was done and how they suffered a child.
History of present illness figure out how the disease occurs that preceded it, when I applied for the first time to the doctorwhat treatment was carried out, etc.