The medical history or (medical) case history, also called 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 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 patient’s life are relevant to formulating a management plan for a psychiatric illness.
The information obtained in this way, together with the physical examination, enables the physician and other health professionals 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.
The first contact of the patient with the doctor begins a detailed and comprehensive conversation that must have all the essential aspects of the patient’s current condition, where the doctor has to take detailed information about the patient’s previous and joint diseases as well as possible previous surgeries. The interview was the first and perhaps most important step in order to establish trust between patients and doctors, which is perhaps the most important factor in successful treatment of the patient. The duration, intensity and constancy of the symptoms: they represent a very important information which physicians can easily specify the right path diagnostics. Experience and knowledge of doctors often unexplained, rectors, and non-specific symptoms related to quite some other organs can be directly linked to diseases of the upper digestive system. Only after taking detailed data on the symptomatology of the patient, can form an initial opinion, and set up a so-called differential diagnosis or referral. It is on the basis of conversations formed and diagnostic plan, which must be targeted, directed, and not turn into a “diagnostic” wandering or performing a large number of views and analysis without a clear plan and expediency.
In diseases of the foregut, the doctor must pay attention because the symptoms themselves have limited significance in diagnosing. So, symptomatology and clinical pictures provide only a way in which diagnostic and treatment needs to move, but they can never be sufficient for a definitive diagnosis and therapy in particular. The exception is the determination of the “empirical” therapies for suspected gastroesophageal reflux disease (GERD). With this approach a doctor for suspected GERD patients with heartburn overwrites taking specific drugs that reduce the secretion of stomach acid (proton pump inhibitors, PPIs). On the basis of therapeutic response to these medications, your doctor may suspect what kind of disorder is in place, and then continue treatment or access to further diagnosis.
- Medical History
- Abdominal Ultrasound
- Upper GI Series
- Upper GI Endoscopy
- Esophageal Manometry
- Esophageal 24-Hour pH Metry
- Esophageal 24-Hour pH Impedance
If you have more questions contact us: