Anamnesis is a medical history of a patient. According to J.

Gleadle (2003), the purpose

of history taking/anamnesis is to develop knowledge about the patient’s problems and to
generate a differential diagnosis.

Dhani Redhono, Wachid Putranto, Veronika Ika Budiastuti (2012) argued that in a
process of anamnesis, the ability to structure the interview (structuring the consultation), the
ability to establish a relationship / connection to patients (building the relationship) and the
ability to establish rapport and ability to structure the interview should always be used
(appropriately) at each stage of the doctor-patient communication. It must be run in parallel at
the time of the interview.

The Calgary-Cambridge Guides Framework For The Medical Consultation

Kurtz, Silverman, Benson and Draper (2003)
The history taking should be guided by the Fundamental Four are looking for data through

1. Recent medical problems

2. Past medical history, drugs, and allergies

3. Family Health History

4. Social and Economic History

Before doing further anamnesis a doctor must introduce him/herself and ask about the patient’s
identity including age, sex, race, marital status, religion and occupation. (Redhono, Putranto and
Ika, 2012)

To do an introduction, a doctor must always be polite, respectful and clear. A doctor must
consider about the privacy, language, and relatives that the patient has. Remember that the
patient is the most important person in the room. Ensure that there is privacy. Ask if the patient
has troubles about understanding language and wishes for a chaperone to be present during the
examination. (Gleadle, 2003)

1 . Recent Medical Problems

This includes the chief complaint and history continued . The main complaint is a complaint that
makes a person comes to the health services for help . After the main complaints , anamnesis
followed systematically by using the seven sacred history , namely

1 . Location ( where ? Spread or not ? )

2 . Onset and chronological ( when did it happen ? How long ? )

3 . Quantity complaints ( mild or severe , how often ? )

4 . Quality complaints ( taste like? )

5 . The factors that aggravate the complaint .

6 . The factors which alleviate complaints .

7 . Systems analysis that accompanies any major complaints .

In the logic of history taking to note are as follows :

1 . Systematic approach , so keep in mind : Fundamental Four & Sacred Seven .

2 . Start thinking which organs are affected but do not think about what diseases that the patient
has.

3 . Anamnesis using interpersonal skills that required knowledge sociology , psychology and
anthropology .

2 . Past history of disease

This section is important to record in detail all previous medical problems and their treatment. It
is also useful to record this information in chronological order.

Asked is there any similar pain sufferers ever before , if and when it happens and how many
times and have been given any medication , as well as search for the relevant disease with the
current situation and chronic diseases ( hypertension , diabetes mellitus , etc. ) ,

Drug history

 What medication is patient taking?

 What medication is prescribed?
 What drugs do they have taken?
 What medication have they been intolerant of and why?

Allergies

The patient should be asked if they are allergic to anything. They should be aked
specifically whether they are allergic to any antibiotics including penicillint.

A doctor should ask about other allergies too, such as foodstuffs, bee or wasp stings. A doctor
may ask about their reaction about that, for example nausea, rash, anaphylatic shock, etc.

Smoking and Alcohol

3 . Family history of disease

This history is used to find whether there is a hereditary disease of the family ( diabetes mellitus ,
hypertension , tumors , etc. ) or a history of infectious diseases .

It is important to establish the diseases that have affected relatives given the strong genetic
contribution to many diseases. A doctor can ask if there are any illnesses that ‘run’ in the family.
(Gleadle, 2003)

4 . Social and economic history

Social history is about understanding the patient’s background, because the patient’s problem
may generated by their surroundings, pets, jobs, house, etc. (Gleadle, 2003)

This is to determine the social status of the patient , which includes education , employment
weddings , the habit of many ( sleep patterns , drinking alcohol or smoking , medications , sexual
activity , financial resources , health insurance and trust ).

A doctor may ask about travel history, it is to consider that a patient can be contaminated by
virus or bacteria that spreads in the other country.

According to J. Gleadle (2003), to do an anamnesis, we must consider about how the patient
presents complaints and how the doctor should behaveAccording to J. Gleadle (2003), there is a
graph about history about presenting complaint

The history of presenting complaint is the most important part of the history and examination. It
usually provides the most important information in arriving at a differential diagnosis but also
provides vital insight into the features of the complaints that the patient gives the greatest
importance to. (Gleadle, 2003). First, a doctor must let the patient talk without intteruption. This
may be initiated by asking them an open question. In this section, the doctor must adopt an open
posture, lean towards patient, actively listen, nod, verbally encourage to show that the doctor is
listening to the patient.

Then a doctor must write and record about the patient which may help to generate a differential
diagnosis. Summarize and present the patient’s actual words to show that the doctor understands
and has emphaty towards the patient
If the doctor assumes that the information is not complete yet, the doctor can ask an open
question such as tell me more about ……, and ask about more details about something relevant.
And the doctor must remember to always focus on the main problem.

History of Presenting Complaint. Gleadle, 2003.

Besides that, Kurtz, Silverman, Benson and Draper (2003) made a framework about medical
consultation.

They divided a medical consultation into 4 parts.

1. Initiating the Session

This session includes preparation, introduction, and asks about the patient’s complaints.
2. Gathering Information
In this part, a doctor should dig deeper about the patient. A doctor must ask about past
medical history, drugs, allergies, habbits, family, and social history
3. Explanation and Planning
In this session, a doctor must summarize what patient already said and discuss about what
should a doctor do to a patient (a shared decision-making)
 4. Closing the Session
In this final session, a doctor can give an end summary, make a contract, and final check
the patient.

Basically, anamnesis is a medical history of patient. The skill of history taking is very important
for a doctor. Because, anamnesis provides the most important information in arriving at a
differential diagnosis but also provides vital insight into the features of the complaints that the
patient gives the greatest importance to (Gleadle, 2003).

Literature Review

Gleadle, J., 2003. History and Examination at a Glance.Chichester: Wiley-Blackwell. Page 10-
16

Kurtz, S., Silverman, J., Benson, J. and Draper, J., 2003. Marrying Content and Process in
Clinical Method Teaching: Enhancing the Calgary-Cambridge Guides. Academic Medicine,
78(8), pp.802-809.

Sebelas Maret University, 2012. History Taking-Anamnesis. [pdf] Surakarta: Faculty of

Medicine Sebelas Maret University. Available at: <fk.uns.ac.id/static/file/Manual_Semester_II-
2012.pdf> [Accessed 1 November 2013]