Anamnesis example
When a medical history is taken, the doctor in charge of writing it must ask the patient certain questions in order to expose details related to their health, those that cannot be known through medical examinations.
The conversation that the doctor has with the patient and from which important information will be extracted is called anamnesis .
This is a talk that will be composed of very specific questions to find out the emotional state, family history, good and bad habits of the patient and more.
Anamnesis example
I. Affiliation data:
Name: MYPCH.D
Age: 29 years old
Date of Birth: 03/06/90
Place of birth: México DF
Grade of instruction: Secondary
Marital status: Single
Catolic religion
Separated parents
Lives with: Mother
Place of residence: XXXXXXXXXXX.
Interview date: 10/26/2018
Interviewer: Martínez, Alfredo
II. General remarks
Physical observation
29-year-old M.CH.D is of medium build and tall. It has a dark complexion and it has white spots, except for the face. His eyes are light brown, which denote vivacity. His hair is long, frizzy and black in color and some gray hair can be seen in it. His clothing was according to the season and the place where he was and in it denoted cleanliness and personal hygiene.
Behavioral observations
At the beginning of the evaluation, the examinee showed willingness to collaborate by being friendly and cheerful, reflecting this in her facial expression. During the interview, she developed and cooperated satisfactorily by answering the questions that were indicated, however, in some questions she was ashamed. At the end, he said goodbye kindly and cordially.
Observation of the environment
The interviews were conducted at night, at the home of the examinee, where good lighting and ventilation could be perceived.
III. Reason for consultation
Practices for the Health Psychology course
Current problem
The evaluated one reports that she has suffered from Vitiligo disease since she was 5 years old. He states that in those years, at the beginning of the disease, small spots began to appear on some parts of his body, but these were hardly noticeable, however, as time passed, more began to appear and thus became noticeable.
Family history
The evaluated is a native of Chiclayo. Her 50-year-old father is a taxi driver, he considers him an immature person and a womanizer, he does not live with her and the relationship between them is not good because she does not have much closeness with him. However, she states that I never physically punish her. Her 47-year-old mother is a housewife, she says that she is very understanding, simple, loving and refers to loving her a lot because she has known how to educate her siblings and herself. The evaluated mentions that her mother is the one who establishes the rules in her house, since she only lives with her.
Childhood
The patient claims to have been a shy, calm, respectful and obedient girl. He never threw tantrums. Born by natural childbirth, she received breastfeeding until the first year of age. Regarding food, he says he does not eat any type of vegetables and prefers the kid.
She claims to have been a healthy girl, far apart from her illness. He learned to walk at 1 to 6 m. He claims never to have wet the bed. At the age of 9 she had nightmares which produced great fear in her, her mother told her that they were only dreams that she did not give importance to and that she prayed when she went to sleep, that made her calm down.
VII. Education
The patient went to school for the first time at the age of 6 years. She states that she was afraid to go to school because she believed that her mother was going to abandon her, also because she did not know anyone and because she was afraid that they would make fun of her. However, when she got there, she established good friendships, which helped her adapt to the school environment. He missed the 4th year of primary school because he was not attending class due to the constant appointments he had with the dermatologist.
Accidents and illnesses
The evaluated woman states that she has not suffered any accident and that she suffers from vitiligo disease.
Sex life
The evaluated woman manifested having menstruated for the first time at the age of 10 years, being always irregular in her menstrual period. He mentions that he knew about the subject because his mother had explained it to him, so I take it as something normal.
XII. Habits and interests
The evaluated person states that in her free time she visits her maternal grandmother or her siblings together with her mother, or else talks with her friends.
Regarding religious beliefs, the evaluated one mentions being Catholic. She believes in God and shows that he gives meaning to her life and asks him to take care of her family and her.
XIV. Attitudes towards the problem
He is aware of the illness he has, he takes good care of himself, although he refers that sometimes it is inevitable to stress and think about what he is going through and feel sad about this.
Dreams
The evaluated one mentions that she does not suffer from any nightmares and sleeps peacefully.