I write this down just trying to remember my lecture today about how do we write a good anamnesis
What is The Concept?
Concept while doing anamnesis in patient is consist of:
- Fundamental four
- Sacred seven
For example:
Case: Ana, 3 years old baby girl has been diarrhea for 2 days ago.
How Many Type?
There are two type of anamnesis based on sources
1. Heteroanamnesis or Aloanamnesis, particulary for infant or incompatible children.
2. Autoanamnesis by asking directly to sick children and give the chief complain.
There are two type of anamnesis based on sources
1. Heteroanamnesis or Aloanamnesis, particulary for infant or incompatible children.
2. Autoanamnesis by asking directly to sick children and give the chief complain.
What is The Concept?
Concept while doing anamnesis in patient is consist of:
- Fundamental four
- Sacred seven
Fundamental Four
We should ask the patients or their family this related information because we can make a good diagnose or refer to another specialist.
1. Present Illness
To write present illness, we have to pit chief complains in it. Chief complain is complains that made patient come to seek doctor help.
For example, we can write the chief complain such as: palpitation, headache, fever, paralyze, tinnitus, chest pain, insomnia, etc.
Make sure you write one chief complain and explore them properly by using sacred seven.
2. (related) Past Health History
- Child birth (weight, needed resusitation or not, cry or not, child bearing).
- Growth development (rough motoric development, fine motoric development, language and speech, social adaptation).
- Vaccine history.
- Past (related) illness.
- Nutrition history.
There are so many. disease that related to past health history. For example, TBC (tuberculose) in children is one kind of disease that may not reach full remission. It is caused by bacteria Mycobacterium tuberculose have a latent phase make it able to appear whenever it wants. Existence of bacteria or other infectious agent is caused by other past health history too, such as child birth, growth development, vaccine history and nutrition. They all are related to the immunity of the patient.
3. Family Health History
We should ask "Is there infectious disease spread on patient's family?" or "Is there hereditary illness do exist in patient's family?" If we've done asked them about family health history, we can consider causal factor or maybe modifying or comorbid factor of the illness.
4. Personal/Social History
We may ask about interaction of patient's family member each other. Is there any problem? Because we can consider child abuse or neglect might happen to patient.
Sacred Seven
Sacred Seven is part of present illness status. Scared seven has an important role to make a good decision in given medicine. It is consist of:
- Location
- Quality
- Quantity
- chronology
- Severity
- Onset
- Modifying factor
- Associated symptoms
We should ask the patients or their family this related information because we can make a good diagnose or refer to another specialist.
1. Present Illness
To write present illness, we have to pit chief complains in it. Chief complain is complains that made patient come to seek doctor help.
For example, we can write the chief complain such as: palpitation, headache, fever, paralyze, tinnitus, chest pain, insomnia, etc.
Make sure you write one chief complain and explore them properly by using sacred seven.
2. (related) Past Health History
- Child birth (weight, needed resusitation or not, cry or not, child bearing).
- Growth development (rough motoric development, fine motoric development, language and speech, social adaptation).
- Vaccine history.
- Past (related) illness.
- Nutrition history.
There are so many. disease that related to past health history. For example, TBC (tuberculose) in children is one kind of disease that may not reach full remission. It is caused by bacteria Mycobacterium tuberculose have a latent phase make it able to appear whenever it wants. Existence of bacteria or other infectious agent is caused by other past health history too, such as child birth, growth development, vaccine history and nutrition. They all are related to the immunity of the patient.
3. Family Health History
We should ask "Is there infectious disease spread on patient's family?" or "Is there hereditary illness do exist in patient's family?" If we've done asked them about family health history, we can consider causal factor or maybe modifying or comorbid factor of the illness.
4. Personal/Social History
We may ask about interaction of patient's family member each other. Is there any problem? Because we can consider child abuse or neglect might happen to patient.
Sacred Seven
Sacred Seven is part of present illness status. Scared seven has an important role to make a good decision in given medicine. It is consist of:
- Location
- Quality
- Quantity
- chronology
- Severity
- Onset
- Modifying factor
- Associated symptoms
For example:
Case: Ana, 3 years old baby girl has been diarrhea for 2 days ago.
How to explore sacred seven from this patient?
We should ask:
- Location: bowel.
- Onset. If It had gone for more than 14 days, it may caused by chronic diarrhea and can cause severe dehydration.
- Quality including consistency, color of feces, with or without blood or mucous.
- Quantity: how many times she's been diarrhea in a day (interval per xxx hours)
- Chronology including medication history and defect in patient (cry a lot and cyanosis)
- Modifying factor such as tenesmus
- Associated symptoms such vomit, fever etc
We should ask:
- Location: bowel.
- Onset. If It had gone for more than 14 days, it may caused by chronic diarrhea and can cause severe dehydration.
- Quality including consistency, color of feces, with or without blood or mucous.
- Quantity: how many times she's been diarrhea in a day (interval per xxx hours)
- Chronology including medication history and defect in patient (cry a lot and cyanosis)
- Modifying factor such as tenesmus
- Associated symptoms such vomit, fever etc
Okay then. That's all I can tell you. Hope this writing give you some important information!
