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VFMH Virtual Family Medical History
The medical history or anamnesis of a patient is information gained by a
physician or other healthcare professional 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. This kind of information is called the symptoms, in
contrast with clinical signs, which are ascertained by direct examination. 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 their 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 patients 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 then a provisional diagnosis may be formulated, and other
possibilities (the differential diagnosis) may be added, by convention listed in
order of likelihood. The treatment plan may then include further investigations
to try and clarify the diagnosis.
Process
A physician typically asks questions to obtain the following information about
the patient:
Identification and demographics: The name, age, height, weight.
The "chief complaint (CC)" — the major health problem or concern, and its time
course.
History of present illless (HOPI) - details about the complaints enumerated in
the CC.
History of past illness (HPI)(including major illnesses, any previous
surgery/operations, any current ongoing illness, eg diabetes)
Review of systems(ROS) Systematic questioning about different organ systems
Family diseases
Childhood diseases
Social history- including living arrangements, occupation, drug use (including
tobacco, alcohol, other recreational drug use), recent foreign travel and
exposure to environmental pathogens through recreational activities or pets.
Regular medications (including those prescribed by doctors, and others obtained
over the counter or alternative medicine)
Allergies
Sex life, obstetric/gynecological history and so on as appropriate.
History-taking may be comprehensive history taking (a fixed and extensive set of
questions are asked, as practised only by medical students) or iterative
hypothesis testing (questions are limited and adapted to rule in or out likely
diagnoses based on information already obtained, as practised by busy
clinicians). Computerised history-taking could be an integral part of clinical
decision support systems.
Review of systems
Whatever system a specific condition may seem restricted to, it may be
reasonable to review all the other systems in a comprehensive history. A review
of system (ROS) should cover these 14 subheadings according to the legal billing
policies in the US:
Constitutional symptoms (e.g., fever, weight loss)
Eyes
Ears, nose, mouth, and throat
Cardiovascular
Respiratory
Gastrointestinal
Genitourinary
Musculoskeletal
Integumentary
Neurological
Psychiatric
Endocrine
Hematologic/lymphatic
Allergic/immunologic
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