ANAMNESIS SUMMARY

By: James Jeremia

General things to look out for in Anamnesis:
• The patient’s current situation and well being can be observed from
the moment the patient arrives at the door.

• Look for the patient’s posture, way of standing and sitting as he/she
enters and sits at the front of the examiner’s office.

• The patient’s face paints a general picture of the patient’s condition.

Fever
• Look for the onset, severity, and chronology of the fever. The
maximum temperature may determine the severity of the condition.
• Associated Symptoms such as coughs, runny noses, etc. may be the
key to finding the underlying issue.
• Ask for allergies, comorbidities, and chronic disease that are/aren’t
passable through bloodlines.
• Ask for vaccinations and the patient’s wellbeing.
• Some risk factors are tied to the environment and the travel habits or
history of the patient
Differential Diagnosis
• Autoimmune diseases
• SLE
• Allergic Reaction
• Food Poisoning
• Leukocytosis
• Infectious Diseases
• Viral Infection
• Bacterial Infection
• Fungal Infection (Immunocompromised)
• Parasitic Infection
Coughs and Runny Noses (Throat and Nasal
Problems)
• Ask if there is any secretions from the cough or nose. If yes ask for the color, consistency, how
much?, etc

• Ask if there is a fever accompanying the chief complaint

• Ask about allergy and asthma

• Ask if smoker, drug-user, or alcohol consumer

• Ask about environment in the home and travel history.

• Ask about any comorbidities and/or genetic diseases

• Ask about past medical history and chronic diseases

Differential Diagnosis
• COPD/Emphysema (Smoker’s lung)
• Deep Vein Thrombosis (Post-operative)
• Lung Cancer
• Lung Effusion
• Pleural Effusion
• Heart Failure
Shortness of Breath
• Keep in mind that a patient having SOB may not be able to participate
in anamnesis and require immediate treatment, and also keep in
mind about the person accompanying the patient, and if they are able
to provide information.
• Things to ask for:
Onset , Chronology, Aggravating and Relieving Factors,
History of genetic diseases, chronic diseases, and allergies
Habitual and Environmental factor, Tobacco and Alcohol use/abuse, and
Narcotic use.
Differential Diagnosis
• Asthma
• COPD/Emphysema
• Bronchitis
• Pleural Effusion
• Heart Disease
• Lung collapse
Diarrhea
• Ask for:
• Food intake, what you ate?, etc.
• Characteristics of the Diarrhea.
• Allergies
• Onset and Chronology
• Additional symptoms
• Dietary and excretory changes?
• Drastic body weight change?
• Environmental and Habitual Factors
• Family and Medical History
• Tobbacco, Alcohol, and Narcotic use?
Differential Diagnosis
• Food Poisoning
• Allergy
• Lactose Intolerance
• Bacterial Infection of the gut tract
• Imbalance of the gut flora
• Ulcers (Bloody Stool)
• Intussuception (Red Currant Jelly Stool)
Ear Pains
• Ask for:
Secretions? Onset? Chronology? Characteristic of said secretions?
Hearing loss? Additional/accompanying symptoms? Blood?
Histories of the patient? Any Object in Ear? Habit of picking ear?
Swimming? Location where he/she swam? Presence of Tinnitus?
Differential Diagnosis
• Otitis Media Accute/Chronic
• Otitis Interna Acute/Chronic
• Otitis Externa Acute/Chronic
• Object in Ear
• Sinusitis
• Perforated Ear Drum
THANK YOU!!