Anamnesis is the process by which a health professional obtains information from the patient. This is achieved through an interview in which he finds out what hurts the patient, the symptoms he has had, or the family history, for example. Through this evaluation, the doctor can make a diagnosis to treat the disease, so it is an essential tool in the medical process.
Are you thinking of studying a specialization in the health field? In that case, you may be interested in taking the Master in Clinical Neuropsychology from Esneca Business School. Through this training, you will learn aspects related to memory, language,e, and attention. You will also learn about the biological processes that trigger neurological disorders and the clinical data for diagnosis, that is, the anamnesis.
What is anamnesis and what is it for?
Anamnesis is the process of obtaining information from a patient. This refers to the set of data collected in a person’s medical history as part of their medical evaluation and to define a diagnosis. In this medical examination, it is important that communication between doctor and patient is fluid and that the latter feels comfortable and confident to facilitate the collection of clinical information. During the initial interview, the healthcare professional selects all the data that he or she considers relevant to defining an adequate diagnosis. Likewise, the specialist must detect possible weak points in the patient; aspects that make him or her uncomfortable or that he or she seems to omit. The latter is much more important when we enter the field of neuropsychology, but it should not be overlooked in other fields of medicine. Collecting all of the patient’s information allows for the creation of a clinical history that provides detailed information about each person. From there, it is easier to make a correct diagnosis and offer the best treatment for each type of ailment, pathology, or, disease.
How to perform an anamnesis
To conduct a good medical interview or anamnesis, the professional must determine which data he or she wants to obtain as a priority. He or she begins by asking for personal data and those that attracted the patient to the consultation and continues by requesting information that may be relevant.
Preparation
In the preparation phase, the specialist reviews the patient’s medical history to understand his or her background and be able to conduct the interview accurately and in an optimal environment.
Reception
The first contact should be made in a friendly and personalized manner. A proper reception should convey professionalism, offer good treatment,t and, generate confidence in the patient.
Development
At this point, we must focus on the patient’s condition. The health professional is concerned about how the patient is and delves into the relevant aspects of obtaining a diagnosis or offering treatment.
Closing
Finally, the professional focuses on the cause of the consultation, and hthe patient’sconcerns, and tries to understand his or her position, as well as emphasize the consequences that this has on his or her environment.
What is asked in an anamnesis?
During a medical interview, several types of data are collected. The main ones that are usually asked beforehand are personal data: name, age, sex, occupation, marital status, etc. If you are going with someone, some of these questions are also asked of the person accompanying you.
But, apart from the typical personal data, what other information is taken into account in this type of interview?
The current disease
The health professional collects data relating to the illness or disease that the patient suffers from. To carry out a clinical examination, the professional must take into account the patient’s condition, whether it has progressed, or whether the patient has taken any medication to mitigate its effects. The different episodes or incidents that led the patient to ask for help must also be taken into account.
The medical history
A medical record is a document that contains all the medical data about a person. It collects the information necessary to provide adequate medical care, so it is important to record the most significant diagnoses, hospitalizations, and interventions.
Personal background
The medical professional investigates which diseases, pathologies,o r previous alterations influence the patient’s current state.
Family history
Many diseases have genetic components. The predisposition to suffer from them or the effects they have on each person also have genetic components. For this reason, having a family history offers the health professional the necessary information to make a diagnosis.
At this point, the patient’s habits and social relationships are analyzed. Interaction styles are also taken into account, how he or she relates to others, what support he or she has throughout the therapeutic process, and whether he or she has suffered any exceptional and relevant episodes in his or her life. This will serve to create context and obtain a global vision of the individual’s situation.
Guidelines for performing a clinical examination
When carrying out the medical interview, we must take into account a series of considerations to carry it out satisfactorily.
Assess the extent and depth of the anamnesis.
An overly exhaustive and lengthy examination can be counterproductive. The patient may feel uncomfortable and reduce information, or may even lose interest in receiving help. We must consider how to approach the interview and not dwell too much on those aspects in which we detect that the patient does not feel comfortable or safe.
The patient may not know what is wrong with him.
Sometimes, the patient may not be clear about what is happening to him or her exactly and the information he or she provides may be modified. It is very common for the patient to not have an exact idea of what his or her problem is, especially about psychological disorders, but also in many other areas of health. We must be prepared and have the right questions to explore the presence of possible symptoms that he or she has not noticed, or to which he or she has not given special importance. For example, psychological symptoms and mood changes that, a priori, the patient has not related to the presence of any pathology or disease.
Respect ethical boundaries
A medical interview aims to obtain data and to do so it is necessary to ask a large number of questions. However, these must be asked discreetly and respectfully. The patient has every right to maintain his or her privacy and can keep certain aspects to himself or herself. When asking these questions, we must limit ourselves exclusively to the context of the disease and the exploration of possible symptoms, causes, or lifestylechangese that have caused it, but we must refrain from personal assessments or intimate questions unrelated to the case.
