A neurological medical history is entered for each patient in the department of the corresponding profile. In this document, you can find complete information about how a disease started, progressed and responded to treatment.
Main sections
As for the components, here the history of the disease in neurology is not much different from the general therapeutic. It includes the following sections:
- passport;
- section of diagnoses;
- initial examination by a doctor;
- diaries of periodic monitoring;
- consultations of medical specialists;
- diagnostic test results;
- dispensary part;
- discharge epicrisis.
As a result, the scheme of the medical history in neurology is identical to that found in the main medical documentation of departments of other profiles.
Passport part
Any neurological medical history begins with this section. It provides complete information about exactly who was hospitalized and how to contact the patient's relatives in case of such a need. In addition, the passport section always indicates who exactly sent the patient to the hospital.
Diagnosis Section
Here is some pretty useful information. This section contains data on the diagnosis with which the patient was delivered or referred to the department. In addition, there is information about what kind of diagnosis the patient was placed in the emergency room of a medical institution. After the patient has been admitted to a particular department, he must be given a definitive diagnosis. Currently, the doctor is given 3 days for this. Any neurological medical history in this section also contains a final diagnosis. It is exposed immediately before the patient’s discharge from the hospital.
Initial examination by a doctor
This section describes the patient’s first contact with their healthcare provider. It contains information on what complaints the person received, what happened to him before hospitalization, whether he has an allergy to certain drugs, as well as data on the results of a general examination of the main organs and systems of the patient. In this case, the initial visit to the patient by the doctor may occur in conjunction with the head of the department.
About Observation Diaries
In most hospitals, they are filled daily. That is, the doctor after the round, leaves a record of how the patient feels and what is the dynamics of the pathological process. The diary must indicate the person’s complaints, as well as the results of his objective examination. The case history of pediatric neurology, like any other, filled out on a child, always includes daily observations. If the patient is less than one year old, then, in addition to the main diary left by the treating doctor, there should also be notes of the doctor on duty, since such a small child should also remain under the supervision of a specialist for the night.
Consultations
In this section, medical consultants leave information about their observations of the patient. Most often, consultation is required if a person has a concomitant pathology that differs in profile from the department where he is being treated. Consulting doctors can be both narrow specialists and general practitioners.
Diagnostic Section
Naturally, each medical history in neurology, as in any other specialty, contains the results of the studies. They are collected in one place so that the doctor can visually trace the dynamics of changes in the main indicators of the patient’s body activity. This is very conducive to an early accurate diagnosis, and therefore the appointment of a rational course of treatment.
Dispensary part
This section assumes that the patient undergoes several specialist consultants of various profiles. The dispensary part has much in common with the advisory, however, there are no detailed records here. In this section, specialist doctors indicate only a small amount of general information, as well as all diagnoses.
Prescribed Epicrisis
This part is a brief retelling of the entire medical history. Currently, it is usually simply pasted into a medical card, since extracts are now most often not written by hand, but typed on a computer. As a result, one discharge epicrisis is issued to a person in his arms, and the second is intended for a medical history.
About neurological pathology
It is worth noting that this branch of medicine is one of the main ones. She is engaged in the study of a variety of pathologies, one way or another connected with the nervous system. The most common diseases that a neurologist has to deal with in a hospital are osteochondrosis, epilepsy and strokes.
Neurological medical history: epilepsy
With this pathology, it will be noted that the person was admitted to the hospital after an epileptic attack. At the same time, at the time of his arrival to the hospital, he had little to worry about, unless, of course, in an unconscious state he didn’t harm himself.
According to such a medical history, it is clear that during the diagnosis of the patient they were sent for an electroencephalogram. This study is necessary to record the electrical potentials of the brain. If the patient does have epilepsy, then certain abnormalities will be detected during this study. The treatment of such a pathology is based on long-term use of drugs prescribed by a neurologist. Any disturbances in the administration of drugs may be accompanied by new epileptic seizures.
Case Studies in Neurology: Osteochondrosis
With such a disease, the patient can be admitted to the hospital both planned and in connection with the occurrence of severe pain in a particular section of the spine. This medical history will contain information that a person complains of pain in a particular area that arises and intensifies when the body is in a certain position for a sufficiently long time or when performing any physical work associated with a serious load.
In the diagnostic part, it will be mandatory to indicate that as a result of radiography of a particular part of the spine, certain deviations in the structure of the vertebrae and intervertebral cartilage were revealed. According to the medical history, it will be seen that during the treatment in the hospital painkillers were used, as well as drugs that improve blood circulation. In addition, the recommendations will necessarily indicate that a person does not forget to take medicines from the group of chondroprotectors, courses of 1-1.5 months, 1-2 times a year.
About strokes
Brain hemorrhage is one of the most dangerous pathologies. Complaints about paresis and paralysis of the limbs, change or lack of speech contains any such medical history of neurology. In this case, stroke is extremely difficult to treat. In the case of this pathology, doctors are trying, first of all, to minimize the affected area. Restore most of the nerve cells fails. In any such medical history, you can find recommendations on the patient visiting a rehabilitation center. Only there does a person have the opportunity to restore the basic disturbed functions of his body.