Internal Diseases · MU Sofia

Practical · 1. Anamnesis — general rules; parts;

Covers the general rules for taking a patient history, including open questioning, active listening, building rapport and involving the patient, followed by a five-point plan for ending the consultation. It then sets out the parts of the history: identification, chief complaint, history of present illness, past medical, family, and personal and social history, and a review of systems. The note includes a picture of a framework for building the history of the present illness.

Inside: 6 sections · 1 labelled picture · 13 flashcards · 4 min

Topic 59 of 88 in the MU Sofia syllabus for Internal Diseases (Dental Medicine, Year 4). The free AceMed note covers it in 6 sections, about 587 words (4 min of reading), with 13 flashcards.

In this note

  1. Anamnesis — general rules; parts
  2. General rules
  3. Gathering Information
  4. Building the Relationship
  5. Ending the Consultation – The 5-Point Plan
  6. Parts

Gathering Information

1. Explore the Patient’s Problems

  • Start with open-ended questions, then follow up with clarifying closed questions.
  • Encourage the patient to tell the full story from when symptoms first started.
  • Active listening is essential:
  • Maintain eye contact.
  • Use non-verbal communication (nodding, body orientation).
  • Tailor questions to what the patient is saying.
  • Reflect back and summarize periodically to show understanding.
  • Allow pauses to give the patient space to talk more.

Building the Relationship

1. Develop Rapport

  • Be non-judgmental.
  • Show empathy – acknowledge feelings and struggles.
  • Be supportive and respectful.
  • Approach embarrassing or sensitive topics sensitively.

2. Involve the Patient

  • Share your clinical thinking (e.g., “I’m asking this to understand better…”).
  • Explain why certain questions are asked.
  • During examination:
  • Ask for permission.
  • Explain the steps of the exam.

3. Respond to Patient’s Needs

  • If the patient appears to be in pain, distress, or discomfort – acknowledge and act accordingly.
  • Avoid continuing as if nothing is wrong.

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