The art of collecting a correct anamnesis is not easy. The reliability of complaints related by patients vary. Some patients forget to mention the most important symptoms while others dwell on unimportant and irrelevant details. The history will therefore be incomplete if the patient is allowed to tell the history of his illness by himself (unguided by the physician). It should be remembered that some patients may be shy and do not readily talk about some diseases (e.g. venereal) or harmful habits (alcoholism).
In order to collect information that might be actually important for a correct diagnosis, the physician should know the symptoms of the disease and the character of its progress. These are the subject matter of special Pathology and therapy of internal diseases. The physician must learn the
art of correct inquiring. The science of diagnostics concerns the art of the correct and systematic collecting of anamnestic data. The physician first collects general information about the patient: his name, age, place of birth, and occupation. Age is important in the development of some diseases, e.g. essential hypertension, atherosclerosis, and malignant tumours which commonly develop in the aged. Occupation and social status of the patient are often responsible for the onset of the disease (e.g.
poisoning, chills, etc.).
The next step is a systematic and thorough functional inquiry of the patient according to a predetermined scheme.
The Present Complaints
The main complaints of the patient should first be determined. If the patient complains of retrosternal pain, the character and exact location of this pain, its focus and intensity should be determined; the time of the onset, and possible causes that provoked the pain (strain, cough, taking food, etc.) should be established. The patient should be asked which remedies remove this pain. Other complaints should also be analysed. In pneumonia, for example, the patient would normally complain of weakness, high temperature, side pain (pleurodynia), and cough; he would note that the onset of the disease was marked a few days ago by a sudden chill and pricking in the side when coughing and breathing deeply.
The study of the main complaints can often lead the examiner to a conclusion concerning the general character of the disease, e.g. high body temperature would normally indicate an infectious process, cough and expectorated sputum indicate possible disease of the lungs. Knowledge of the exact time of the onset of the disease is informative of the character of the
disease (acute or chronic).
The inquiry should not be limited to these main points. So as not to omit any symptoms and determine the functional condition of all the organs (status functionalis) the patient should be questioned according to a specially outlined scheme. Changes in the patient's general state should be established (loss of weight, fever, weakness, oedema, headache). The condition of the respiratory system (cough, expectoration of sputum and blood, pain in the throat) should also be established. Next is the cardiovascular system (tachycardia, dyspnoea, heart pain, swelling of feet). Then follows the gastro-intestinal system (appetite, swallowing, vomiting,
epigastric pain, etc.).
The condition of the nervous system is established by asking the patient about his subjective condition, his sleep, irritability or indifferent attitude to the surroundings, weakness, excitement, headache, state of con-
Chapter 3. Methods of Clinical Examination
sciousness and the main senses. The patient should be asked about his conduct, responses to external stimuli, his attitude to work and his associates. This is necessary to establish the special properties of his higher nervous activity at the present time and in the past, and the type of his nervous system according to Pavlov's classification. The inquiry at this stage gives the physician information concerning the condition of various organs and systems of the patient (respiration, blood circulation, digestion, urinary function, motor function, nervous system, etc.).
History of the Present Disease
Exact answers should be obtained from the patient concerning the following aspects of his present disease (anamnesis morbi): (1) the time of the onset of the disease; (2) the character of the first symptoms; (3) the course of the disease; (4) examinations and their results, if any; (5) treatment, if any, and its efficacy. The answers to these questions may give the physician the necessary information on the present disease.
The history of the disease should include information concerning the onset of the disease and its development until the present. The patient's general condition before the disease should first be determined and the causes that might have provoked the disease established wherever possible. The patient should be questioned in detail about the first signs of the disease and the chronology of their development (dynamics), about relapses or exacerbations, remissions and their duration. If the patient was examined during an exacerbation of the disease by some other physician, the results should be studied. Excess verbosity of the patient should be prevented, because the results of the examinations and treatment only are important (therapy with cardiac glycosides, vasodilators, diuretics, antibiotics, hormones, etc.). Motives for hospitalization should also be determined (exacerbation of the disease, verification of the diagnosis, etc.).
The past history is often very important for establishing the character, the cause, and conditions for the onset of the disease. Anamnesis vitae is a history or a medical biography of the patient in every period of his life (infancy, childhood, adolescence, and maturity).
Collecting the anamnesis begins with the general biographical information. Birth place is important, because some diseases (e.g. endemic goitre) usually predominate in one locality and are not met in others. The age of the parents is also important. The patient should be asked if he was born at term, if there were other children in the family, if he was breast fed or ar-
Chapter 3. Methods of Clinical Examination
tificially; the age at which the patient began walking and talking is important, and the patient should inform the physician if he had marked signs of rickets during his childhood. This information is important to evaluate the patient's health at birth and during childhood. Conditions of life in childhood and adolescence and health during these periods of life are important information. It is necessary to find out if the patient's physical and mental development was not retarded and what was his progress at school. The time of sex maturity should be determined. Women should report the number of pregnancies and parturitions, and the course of labour.
Social conditions are important for the health of people. The patient should inform the physician on the conditions of his housing (separate apartment, hostel, country house, illumination, the presence of dampness, if any, hygienic conditions, etc.). The composition of the family is important: large or small family, their health, well-being, income, etc. Malnutrition is an important factor for the onset of some diseases. The patient should be asked if his diet is sufficiently rich in vegetables, fruits, etc. The way in which the patient spends his leisure time is also important. The patient should report on-the time he sleeps, rests, walks in the fresh air, and what sports and exercises he goes in for.
Unfavourable labour conditions and industrial hazards (some harmful dusts) are important, for they may cause bronchial asthma and chronic diseases of the bronchi and lungs. Strong noise, vibration, high ambient temperature, drafts, and cold (work in the open) can cause pathology. Industrial poisoning by mercuty, lead, carbon monoxide and other harmful agents, and also exposure to radiation (improper safety measures) may also cause disease. The working schedule is also important. Establishing whether there are unfavourable industrial factors helps the physician give recommendations for organization of the patient's work.
Past illnesses are also important. Some infectious diseases, such as measles or scarlet fever, do not recur because of acquired immunity, while other diseases, such as rheumatism or erysipelas, tend to recur. Rheumatism or diphtheria often provoke heart diseases. Nephropathy often develops after scarlet fever, and incompetence of heart valves often results from the previous endocarditis.
It should be remembered that the patient may not know about his past diseases. Therefore in dubious cases the physician should ask the patient whether he had certain symptoms by which a suspected past disease might manifest itself (e.g. prolonged fevers, swelling of and pain in the joints are characteristic of rheumatism, general oedema indicates kidney disease, attacks of right hypochondriac pain may be the cause of the gall bladder disease, etc.). Contacts with infectious patients are important, especially in the presence of epidemics (e.g. influenza).
Family history. Health of the parents, sisters or brothers is often informative. If some of the family have had tuberculosis, the other members of the family may also develop tuberculosis. Syphilis may be transmitted by an intrauterine route. By comparing the pathology of the patient with diseases of his relatives, the physician can make a conclusion on the role of hereditary factors in the development or origin of the disease.
Life of man is tightly connected with the environment, and pathology always depends on external effects. Harmful environmental factors may affect the patient's offspring: his children may be predisposed to some diseases. But this predisposition does not obligatory provoke the disease. Special conditions are usually required for the disease to develop, and if these special factors are absent the person will not develop the disease. Moreover, if conditions favour, the person may strengthen his health and eradicate the hereditary predisposition to an illness.
Hereditary or familial (genotypical) and non-hereditary (paratypical) diseases are distinguished. But this classification is only conventional. As genetics progresses it becomes more obvious that some diseases that would be considered to be resistant to the hereditary factors, are actually genotypical diseases. Internists mainly deal with diseases that are not usually transmitted to the offspring but merely predispose them to these diseases (e.g. essential hypertension, atherosclerosis, cholelithiasis, etc.). Under certain environmental conditions this predisposition may enable the person to develop the disease. It should be remembered that the inherited character may have varying expressivity, or hereditary disease may develop in one member of the family only, or it may be inherited by an offspring after several generations, or it may develop only in family members of one sex (e.g. only males develop haemophilia which is transmitted from a grandfather to a grandson through a healthy daughter). The onset of certain hereditary diseases is sometimes erroneously attributed to an external factor, which was actually only the stimulus that provoked the disease.
In order to establish the hereditary character of a disease, the familial factors should be first given a thorough clinico-genealogical analysis. For the sake of convenience, genealogical schemes should be made out, using the special conventional symbols.
According to the adopted terminology, the patient is called a proband. His brothers and sisters are given in the order of their birth, from left to right. The Roman numerals are used to designate (at the left) successive generations. Each member of the generation is designated by an Arabic numeral. Symbols designating the proband's relatives, who were affected by the same disease, are shaded. The diagram must include data concerning the disease occurring in both parental lines of the proband.
Three, main types of inheritance have been established. The first,
Chapter 3. Methods of Clinical Examination
autosomal-dominant type, is the most prevalent. It is characterized by full penetrance of the mutant gene. In this type of inheritance the disease is directly transmitted from both parents to their offspring with 50 per cent of both sexes being affected (Fig. 1). Those who do not inherit the mutant gene have normal offspring. If penetrance of the mutant gene is incomplete, the direct order of inheritance is more difficult to detect. Suspicion that an inherited disease is dominantly transmitted can be verified by analysis of the offspring from repeated marriages (affected children from each marriage). The direct order of inheritance occurs, for example, in subjects with anatomical abnormalities (of the internal organs included).
Heterozygotic carriage of the recessive gene in autosomal-recessive inheritance does not cause the disease, which only develops in homozygotic carriers (Fig. 2). A blood relationship between parents is often revealed in recessive inheritance (otherwise difficult to reveal). Many enzymopathies, certain diseases of the nervous system, etc. are often inherited by the autosome-recessive type.
Fig. 1. Familial genealogy with dominant inheritance.
1 female; 2-male; 3-sex unknown; 4-stillborn; 5-miscarriage; 6-proband; 7-wife and husband;
8-children; 9-monozygotic twins; 10-dizygotic twins; 11-sick; 12-suspected carriers of recessive
character; 13-children with malformations; 14-phenotypically healthy carrier of recessive character. The
exclamation mark is used to designate subjects observed by the physician.
Fig. 2. Familial genealogy in recessive inheritance (designations are the same as in Fig. 1).
In sex-linked inheritance the mutant genes are linked with the X chromosome. The disease transmitted by dominant inheritance develops equally in both sexes. In cases of recessive inheritance the disease develops only in males (the males have one X chromosome and one Y chromosome), and not in females (they have two X chromosomes and the characteristics of the mutant chromosome are suppressed by the healthy X chromosome). Inheritance of the disease linked with the X chromosome is transmitted to phenotypically healthy females, while only males are affected by the disease. Typical examples of such diseases are haemophilia and agamma-globulinaemia (congenital defect of the protein metabolism).
Methods of cytogenetic genetics of somatic cells and certain other methods that are more complicated than the genealogical one are now widely used in medicine. Genetic analysis ensures early diagnosis of inherited diseases, their rational prophylaxis, assessment of the risk of bearing a child with a genetic disease, and in some cases possible pathogenic therapy for inherited human disease (this trend in genetics is probably very promising).
Allergological anamnesis is very important. Some patients (and even healthy subjects) often develop a pathologically heightened (or an inverted) response of the immune system (allergy), and this factor is essential in the Pathogenesis of certain diseases of internal organs. It is necessary therefore to collect an allergological anamnesis, that is determine whether the patient or his relatives had allergic reactions to various foods, because strawberry, e8gs, canned crabs, and other foods may frequently act as allergen. Some Medicinal preparations, perfumes, pollen also do. Allergic reactions in man are quite varied: from vasomotor rhinitis, nettle rash or Quincke's oedema to anaphylactic shock.
Chapter 3. Methods of Clinical Examination