Recording is the result of the brief given by the patient with the patients language about the disease can travel and all things associated with the disease, from the beginning until the time the information is.
Anamnesis very important because the diagnosis can be 90% with vertical anamnessis only.
Anamnesis usually have identity information (name, sex, age, occupation), history of disease, prior history of disease, family, customs, and must have information about each of the 5 symptoms presented by patients;
1. the pain
2. What pain? Sliced?
3. when it occurred, whether recurring?
4. factors that aggravate the disease
5. symptoms related
6. treatment
For example;
The patient pain, asked where the pain? Pain in the stomach up. Right, middle, or left? Left. I feel the pain? Acute as in the hair-pin. Occurrence since when, what repeatedly? Has been approximately 1 year, relapse?, every morning and night. If you feel sick after eating or not? Often have to eat? When food is acute, especially when the late eat. Do you often nausea? Yes, it's sour. Have you ever been treated before? Already. Where you examination? Doctors in X. What medicine? Do not remember. It's what? Such as candy mints. Are there any other? Yes. How many kinds? Three kinds. What color? The mint, white round, the other blue and white round small. How many times each medication that you drink in a day? There are 3 times and 2 times. Are there any changes after drinking drug? There are, but only briefly. How long you have been drinking the medicine? 1 this week already.
So writing anamnesis; (reports)
Female, 35 years, with complaints on the left colic, acute as in hair-pin, since ± 1 years ago, the recurrence morning and night, especially when eating late, accompanied by nausea and feeling of acid tongue, was obtained with treatment 3,
2 types of drug-shaped white tablet, one taste mints and 1 blue tablet, but relapse again.
Abdominal Pain
14 years ago
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