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Anamnesis

Also known as: Medical history, Case record

Anamnesis (Greek anámnēsis — recollection) is a basic method of clinical examination that involves obtaining information about a patient’s disease, living conditions, and individual characteristics through questioning. This is the fundamental and most informative stage of the diagnostic process.

This is not simply a collection of complaints, but a structured dialogue aimed at reconstructing the history of pathological process development. The quality of the medical history collected directly affects the accuracy of the preliminary diagnosis and the effectiveness of the entire subsequent examination.

Anamnesis structure

Clinical practice involves the systematic collection of information on key areas:

  • Anamnaesis morbi (anamnesis of the disease). A detailed chronology of the development of current symptoms, their nature, dynamics and previous treatment.
  • Anamnesis vitae (anamnaesis of life). Includes information about past diseases, surgeries, working conditions, bad habits and heredity (family history).
  • Special types of anamnesis. These include allergic, gynecological and epidemiological history, which are collected specifically depending on the situation.

Clinical Significance

The diagnostic value of anamnesis is enormous; it is believed that it allows correct diagnosis to be made in 70–80% of cases in general medical practice. A competently collected medical history allows forming an initial diagnostic hypothesis and drawing up a targeted plan for physical and instrumental examination.

In addition, the process of collecting medical history is key to establishing a trusting relationship between doctor and patient. This directly affects the patient’s adherence to treatment (compliance) and, ultimately, its outcome.

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