ANAMNESIS – TIMES AND SEQUENCES

Each medical record is already appropriately prepared for the collection of an Anamnesis in all its components according to defined times and sequences. However, be careful not to reduce the Anamnesis to a mere questionnaire, even if an appropriate synthesis must be privileged in the drafting.

In some healthcare settings, computerized electronic medical records are already in place or being tested, complete with terminological aids and international codes, which, however, however perfectly elaborated, will hardly be able to completely replace a complete and exhaustive transcription of what the interviewee declared.

Often, those who conduct the interview and collect the anamnesis in a traditional way rely on unlikely abbreviations that are sometimes difficult to interpret. In fact, there are some that have now become part of the traditional medical lexicon, such as: FVT, which stands for tactile vocal fremitus or SCP which stands for Clear Pulmonary Sound, all clinical findings that I will explain later.

Some others, which I will in fact mention and explain so as not to overlook anything in this excursus, are, in my opinion, very original and in any case amusing. For example, I have always found it laughable that the Interviewee's Relatives and Children, being, thank God, apparently in good health, are sometimes labeled as ABS or as if, being equipped with the now famous anti-lock braking system supplied with many of our cars, they enjoyed a safer management of the soles of their shoes, provided they were made of rubber.

The four phases that traditionally make up an Anamnesis are: Family Anamnesis, Physiological Anamnesis, Remote Pathological Anamnesis and Proximate Pathological Anamnesis. By visiting the various hospitalization departments, you will notice how the clinical records of surgical environments require more succinct anamnesis than what happens for medical environments.

However, this is easily understandable if one takes into account the fact that usually patients who are admitted to surgery have already passed through emergency departments (DEA), diagnostic day hospitals or outpatient services where a diagnosis has already been made and therefore they are admitted to carry out appropriate preparation for an operation (cardiological, anesthesiological, etc.) to which they will have to undergo and which has most likely already been scheduled.

In the medical environment, the diagnosis is usually built starting from one or more symptoms that the patient manifests and that must be appropriately investigated through the planning, often completely de novo, of an instrumental diagnostic procedure. All this clearly ignores the non-deferrable urgency for which the patient is destined for immediate surgical or interventional cardiological or resuscitation treatment, coming from a code labeled as red at the triage carried out at the DEA.

But let's go back to our patient hospitalised for a deferrable emergency (i.e. one which allows time to plan a diagnosis and suitable treatment) or elective (i.e. within the scope of a specific programme).

In educating students to conduct a correct interview for the scholastic collection of anamnesis in all its sequences, a not at all negligible detail is often omitted. It is clear that the first phase of the anamnesis is the family one which involves as the first question to ask the patient information about the Father and the Mother.

Now, imagine a young doctor in training who, after having correctly introduced himself to a patient who is writhing in pain because, for example, he is suffering from biliary colic, or to an eighty-year-old hospitalized for a disease of old age, first asks the question: "Are your father and mother alive and in good health?": the fate is certainly that of being sent at the very least "to hell".

The first questions, which are not included in the Medical Records forms, to ask a newly admitted patient are: “How do you feel?” “Are you suffering from something at the moment that I can help you with?” and then, calmly and quietly: “What is the reason for your hospitalization?”

The Patient expects these questions and obviously does not understand your primary interest in his Father, Mother or Grandfather, which however, as we will see, has in a certain sense no importance.

In some medical records there is a space called “Clinical Summary” which obviously refers to the Reason for Hospitalization determined by the latest events which will then be part of the description of the Proximate Pathological History.

I recommend filling it out at the beginning, before any other section of the Folder.