Anamnesis vitae (an anamnesis of life) is information about the life of an individual, which allows you to understand some of the characteristics of the body, and is also important to establish the nature of the pathology and determine the factors of its occurrence. The doctor collects information about the patient’s life history by interviewing him following a specific plan.
Patient Life Information Collection Plan
Consider a sketchy example of how to write a history of life. All information received from the patient is entered into the medical history in a certain order, including several mandatory sections.
Biographical data:
- place of birth - is of particular importance, as specific diseases are common in some areas;
- at what age were the parents when the patient was born;
- how the pregnancy progressed - the use of medications during gestation, infectious diseases, the threat of miscarriage, etc .;
- delivery - the degree of full-term, what is the account of the child in the family and from which childbirth;
- natural, mixed or artificial feeding;
- living conditions in childhood and adolescence - the region, housing conditions, family circumstances, food;
- physical and mental development - what are the features;
- puberty - the time of onset;
- factors that caused the pathology and conditions affecting the course and outcome of the disease - malnutrition, poor care, violation of sanitary standards, poor physical development, etc.
Past infections:
- diphtheria, chickenpox, scarlet fever, rubella, measles, mumps, their clinic and the presence of consequences;
- colds;
- congenital infectious diseases and chronic foci of infection (for example, caries, sinusitis), in addition, it turns out whether there were trips to countries unfavorable for the epidemiological situation.
Information about previously transferred diseases.
Data on work in hazardous industries.
Pernicious addictions - substance abuse, alcoholism, smoking, drug addiction.
Family and hereditary history - find out the state of health of the next of kin. For example, if there is a patient with tuberculosis in the family, then there is a chance of infection of all family members. In addition, a predisposition to phenotypic diseases is revealed. With the existing hereditary pathologies that are transmitted to each new generation, they find out the type of carriage and the degree of expression of the gene, as well as the type of inheritance.
Allergic history - is there an allergy in the patient or his relatives to medicines, products, etc.
Each section is described in detail by the doctor.
Life Information Collection
Citing an example of a child’s life history, it is worth noting that he has some features that are associated with his age. The doctor’s task is to ask the baby’s mother in detail about the following periods:
- prenatal - intrauterine development;
- Intranatal - from the onset of labor to birth;
- early postnatal - from birth to self-feeding;
- information about life in infancy.
All the smallest details are important, which indicate how the development of the baby was carried out. To analyze all of the above stages of development is especially important when writing a medical history. On the example of an anamnesis of the life of babies up to the age of three, we consider what other information is collected:
- about the features of education;
- about diseases that the baby suffered at an early age, as well as hereditary pathologies;
- living conditions in which the child grows and develops;
- feeding - artificial, natural or mixed;
- what vaccinations were given and the reaction to them;
- epidemiological situation.
Collection of information on the life of young children
An example of a life history of a young child:
- What is the account of the child and from what pregnancy. Describes all the previous ones and indicates how they ended.
- The course of pregnancy - were there any toxicosis, as manifested. The presence of chronic diseases, past infections, occupational hazards in the mother, treatment in a hospital, taking medications.
- Food and daily routine while waiting for the baby. Was the woman on maternity leave?
- Duration and complications during childbirth, as well as: when and how the baby cried, weight, height, when they put it on the chest for the first time and how often it was applied, how it sucked, on which day they were discharged home and weight at discharge.
- Development in the first three years of life - physical, static and motor, mental.
- The behavior of the baby in a home and unfamiliar environment. Attitude to adults and children around him.
- Duration of sleep.
- Type of feeding, feeding schedule, timing of lures. Diet to the onset of the disease.
- Was vitamin D prescribed and when.
- When the first tooth appeared, how others erupted and in what order. Number of teeth by the end of the first year of life.
- What and when were the operations, diseases.
- Vaccination - what vaccinations and reaction to them. Mantoux and the result.
- Allergic reactions.
- Infectious contacts.
Collection of information on the life of older children
An example of a life history of a child 12 years old and older:
- What kind of child is in the family?
- Development in early childhood.
- Behavior in a home environment and team. School performance, a propensity for what subjects it has.
- Pernicious addictions.
- Postponed surgical interventions and diseases.
- Vaccine prophylaxis.
- Allergic history.
- Infectious contacts.
Family history
The above are examples of the history of the life of a child at different ages. However, this includes the collection of information about the family. The doctor finds out the following information:
- Age and information from the passport of both parents.
- The health status of official guardians and close relatives on both sides.
- The presence in the family of infectious, oncological, mental, allergic, nervous, endocrine pathologies.
- Bad habits of parents - smoking, alcoholism.
- Occupational hazards.
- A genealogical map is being compiled. The scope of this study is determined by the doctor.
Then a conclusion is made, that is, the information obtained during the survey is processed and negative factors are identified that could affect the development of this disease and aggravate its course.
Some features of filling out a medical history
The child’s medical history is kept from the beginning of the patient’s admission to the hospital-type healthcare facility. This is the so-called examination protocol for a sick child. Which reflects the main types of studies, expert opinions, preliminary, basic, differential and final diagnosis, various information about the patient, including a history of the child’s life. An example of filling out this part of the medical history is as follows. The information for this section is in the direction drawn up at the outpatient institution, an extract from the outpatient card of the baby or the child’s development history, in the doctor’s notes on admission to the hospital, which reflects the results of the initial examination. To collect an anamnesis of the life of a baby up to three years, the doctor interviews his parents:
- The number of pregnancies, how they ended, the state of health and the age of the children. If there are dead, then the cause of death and age are found out.
- Antenatal period - the state of health of the expectant mother during the period of bearing the baby, previous illnesses, pharmacotherapy.
- The course of childbirth is premature, urgent, their duration, complications.
- The baby's reaction - when he screamed, a loud or weak scream.
- Weight and height at birth.
- When they put the newborn to his chest, he sucked, he took his chest.
- On what day the mother and baby were discharged. The body weight of the baby at discharge.
- Diseases during the neonatal period.
- Development: physical in the first year of life, statics and motor skills, mental.
- Feeding, breastfeeding frequency. At what age was complementary foods introduced. The nature of nutrition at the time of this disease.
- When the first teeth appeared, their number was at the beginning of the second year of life.
- Past diseases, operations, injuries, complications and consequences.
- Vaccinations, indicates the age when the vaccination was carried out and the reaction to its introduction.
- The presence of allergies.
- Infectious contacts.
An example of a life history of a patient older than three years:
- What kind of child is in the family?
- Development in early childhood.
- Behavioral characteristics.
- Past illnesses, injuries, operations.
- Vaccination and tuberculin tests.
- Allergic reactions.
- Infectious contacts.
An example of a medical history
When collecting information from an individual with a suspicion of kidney disease, pay attention to the following information:
- The risk factors for kidney pathology are dying - prolonged residence in an unheated room, regular hypothermia, work in a draft or on the street.
- Past diseases of the genital area, diabetes mellitus, tuberculosis.
- It turns out whether work is related to weight lifting, long walking, or riding, as this negatively affects the course of kidney diseases and provokes attacks of renal colic.
- Heredity - whether there were abnormalities of the kidneys, amyloidosis, urolithiasis in relatives. They are interested in women about pregnancy, because it can be a provocateur of nephropathy or exacerbation of chronic pathology.
Information about the patient with a dental profile
An anamnesis of the patient’s life for the doctor is important, since it allows one to more reliably assess the patient’s current condition and make a prognosis of therapy. An example of a medical history of a patient admitted to dental surgery:
- The doctor interviews the individual about the conditions of life, rest, labor, diet, physical activity.
- Information about the health of parents.
- The course of pregnancy and delivery.
- Bad habits.
- Hereditary pathologies regarding congenital malformations of the maxillofacial region.
- Development in childhood, type of feeding, previous infectious and other diseases, therapy results.
- The obstetric history is taken into account.
- Past diseases, their course, treatment and outcome are also taken into account.
Upon receipt of information about the family history, the presence of autoimmune and allergic pathologies, tumors of the malignant course, mental disorders, syphilis, tuberculosis in the relatives is analyzed.
Filling out medical records
A medical history or in another way, a questioning of a patient begins with questions that are necessary to fill out a medical history. Using the example of a medical history, consider what information doctors are interested in:
- Some biography information about the patient.
- Transferred during previous periods of the disease’s life.
- Pernicious addictions.
- Hereditary factors.
In all of the above paragraphs, doctors will be interested in those issues that are directly related to this pathological process. Therefore, depending on the profile of the disease, the list of questions may differ.
History collection chart
Thanks to a well-developed scheme, each doctor, when compiling a medical history, can take an example of an anamnesis of adult life:
- Where he was born.
- Age of parents at birth.
- The nature of the course of pregnancy.
- Information about childbirth.
- Type of feeding.
- Permorbid conditions: rickets, malnutrition, etc.
- Physical and mental development.
- The timing of puberty.
- The causes of the disease, the conditions affecting its course, and the outcome.
- Infectious diseases for children.
- The frequency of colds.
- Congenital pathologies, including infectious ones.
- Working conditions and occupational hazards.
- Harmful addictions.
- Well-being of close relatives.
Male Patient Life Information
What questions does the doctor ask the strong half of humanity during the survey, let us consider an example of a man’s life history. Information collection plan for recording a medical history:
- Biography - the place and year of birth, in which family was born, what kind of child, how he developed and grew.
- Education.
- Military service, participation in hostilities.
- Was in prison.
- Are there any intimate problems?
- Family status.
- Work history - at what age and where did he start working, conditions and working hours, night shifts, occupational hazards.
- Housing conditions, how many people live together.
- Finding in areas unfavorable for ecology.
- Diet, diet.
- Pernicious addictions - at what age smokes, drinks alcohol or fakes and in what quantity, use of narcotic, toxic substances.
- Diseases that were previously diagnosed, injuries, concussions, operations and injuries are listed in chronological order and indicating the age when they were. And also describes the duration of treatment, the presence of complications. If blood or its components were transfused, then they describe whether there was a reaction to this procedure.
- Vaccine prophylaxis - what vaccinations are given, when, the date of the last. Past infectious, sexually transmitted diseases, tuberculosis, hepatitis.
- Was there an allergy and what allergen, seasonality, if any.
- Information on temporary disability certificates, their duration for the current year. Is there a disability and which group, its cause and date of establishment.
- Well-being of close relatives. Is there a burdened heredity, the presence of cancer, cardiovascular, endocrine pathology, mental illness, alcoholism. A history of suicide attempts, mental health problems, tuberculosis or syphilis.
- An example of a life history epidemiological is a possible source of infection, route of infection, immune status. Contact with infectious patients is revealed. Stay in an epidemically disadvantaged area. Participation in the hunting of wild animals, caring for them and contact.
- Sexual history - casual relationships, lack of protected sex, frequency of change of partners. Sexually transmitted and infectious pathologies in partners.
- Whether the treatment used the methods of alternative medicine, acupuncture, Tibetan medicine, treatment by healers and shamans, the effectiveness of such an alternative treatment method.
An example of a woman’s life history
The collection of information about the life of a woman has some features, it is collected according to the scheme:
- Biography starting in infancy.
- Pathological conditions that an individual has had since childhood, including mental, venereal, oncological, viral, nervous, endocrine.
- Operations and injuries.
- Gynecological history - how many pregnancies, delivery, abortion were, when menstruation began, their regularity, date of the last menstruation, time when the menopause began.
- The presence of allergies and the type of allergen.
- Whether there was a sick leave during the current year, their duration, whether there is a disability and for what disease.
- Whether there were blood transfusions and when, the reason.
- Family status.
- Conditions of work and life.
- Bad habits - taking alcohol-containing drinks, drugs, smoking.
- Hereditary pathology.
As can be seen from this example, the anamnesis of a woman's life covers a wider range of issues.
Conclusion
An anamnesis of life is a kind of medical history giving a socio-biological characterization of an individual. The result of his analysis is the diagnosis, as well as the prognosis. It contains information about work and living conditions. And if they occur in an unfavorable environmentally, region or infection, this will help the doctor quickly determine the diagnosis and identify the impact of negative factors (stress, chemicals, etc.) on the body of the individual. The doctor will be primarily interested in information that is in any way related to the development of the disease. For example, work in harmful production reduces the stability of an individual’s body and significantly weakens the immune system. Thus, the history of life allows us to evaluate the individual characteristics of the body, which is undoubtedly important for the choice of treatment methods and prevention of complications.