The medical history or anamnesis of a patient is information gained by a physician 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. The medically relevant complaints reported by the patient or others familiar with the patient are referred to as symptoms, in contrast with clinical signs, which are ascertained by direct examination on the part of medical personnel. 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 his 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 patient’s 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, a provisional diagnosis may be formulated, and other possibilities (the differential diagnoses) may be added, listed in order of likelihood by convention. The treatment plan may then include further investigations to clarify the diagnosis.
Many Californians compromise their health because they do not think that disclosing their medical history at the dental office is that important, say officials from the California Dental Hygienists’ Association (CDHA), who warn that patients need to provide a full medical history to their oral care provider.
“When patients arrive at a dentist’s office, they often don’t take the medical history questionnaire very seriously,” says CDHA president Jean Honny. “But their answers can help us prevent complications.”
The daily regimen of aspirin is an example of what to disclose to your dentists, as patients should always list all medications they are taking to avoid complications during and following dental procedures. By disclosing one’s medical history, a person who had suffered a heart attack or stroke would be told that they should not have any elective dental work done for six months after the event.
The California Dental Hygienist Association (CDHA) has recently embarked on a campaign to inform people about the importance of providing a full medical history at a dental office. The CDHA has created an index card about the American Heart Association recommended pre-medication guidelines and blood pressure guidelines to give to the dental healthcare professionals and patients.