HealthDiseases and Conditions

History of Neurology for Students

The history of the disease for neurology is established for each patient who is in the department of the appropriate profile. In this document, you can find full information about how a disease started, flowed and was treatable.

Main sections

As for the components, here the history of the disease in neurology is not much different from the general therapy. It includes the following sections:

  • Passport;
  • Section of diagnoses;
  • Primary examination by a doctor;
  • Diaries of periodic observation;
  • Consultations of medical specialists;
  • Results of diagnostic studies;
  • Dispensary part;
  • Discharge epicrisis.

As a result, the scheme of the history of the disease according to neurology is identical to that found in the main medical documentation of the departments of other profiles.

Passport part

Any medical history of neurology begins with this section. Here, full information is provided on who was hospitalized and how to contact the patient's relatives in the event of such a need. In addition, the passport office always indicates who the patient was sent to the hospital.

Section of diagnoses

Here there is enough useful information. In this section, there are data on the diagnosis with which the patient was delivered or referred to the department. In addition, there is immediately information about what kind of diagnosis was exhibited to the patient in the receiving ward of the medical institution. After the patient entered a department, he should be exposed to a certain diagnosis. Currently, this doctor is given 3 days. Any medical history of neurology in this section also contains a final diagnosis. He is exposed immediately before discharge from the hospital.

Initial examination by a doctor

This section describes the patient's first contact with his or her attending physician. It indicates information about what complaints the person received, what happened to him before hospitalization, whether he is allergic to certain medications, and also data on the results of a general examination of the patient's main organs and systems. In this case, the doctor's primary visit to the patient can occur in conjunction with the head of the department.

About diaries of observation

In most hospitals they are filled daily. That is, the doctor after the conducted detour leaves a record of how the patient feels and what the dynamics of the pathological process are. In the diary, the complaints of a person must be indicated, as well as the results of his objective examination. The case history of pediatric neurology, like any other that fills in the child, always includes daily observations. In the event that the patient has not reached the age of one, then, besides the main diary left by the treating doctor, there should also be a record of the doctor on duty, since such a small child must also be supervised by a specialist for the night.

Consultations

In this section, consultant doctors leave information about their observations of the patient. Most often, a consultation is required if the person has a concomitant pathology, which differs in its profile from the department where it is on treatment. As doctors-advisers can act as narrow experts, and doctors of a wide profile.

Diagnostic section

Naturally, every history of the disease in neurology, as well as in any other specialty, contains the results of the conducted studies. They collect them in one place so that the doctor can visually track the dynamics of changes in the basic parameters of the patient's organism. This is very conducive to the promptest exposure of an accurate diagnosis, and hence the appointment of a rational course of treatment.

The dispensary part

This section assumes the patient's passage of several specialist consultants of different profiles. The dispensary part in many respects echoes with the advisory, however there are no detailed records. In this section, specialist doctors only indicate a small amount of general information, as well as all diagnoses.

Write epicrisis

This part is a brief retelling of the entire medical history. At present, it is usually simply pasted into a medical card, as the extracts are not most often written by hand, but are typed on a computer. As a result, one discharge epicrisis is given to the person on hands, and the second is intended for a case history.

About neurological pathology

It is worth noting that this branch of medicine is one of the main. She is studying various pathologies, one way or another related to the nervous system. The most common diseases that a neurologist has to deal with in a hospital are osteochondrosis, epilepsy and strokes.

The history of the disease in neurology: epilepsy

With this pathology, it will be noted that a person entered the hospital after an epileptic attack. At the time of arrival at the hospital, there is little to worry about, if, of course, he did not hurt himself unconscious.

According to such a history of the disease, it can be seen that during the diagnosis the patient was referred to an electroencephalogram. This study is necessary for recording the electrical potentials of the brain. If the patient does have epilepsy, certain deviations will be detected during this study. Treatment of such pathology is based on a long-term intake of drugs prescribed by a neurologist. Any violations in taking drugs may be accompanied by new epileptic seizures.

Case histories of neurology: osteochondrosis

With such a disease, the patient can enter the hospital as planned, and in connection with the emergence of severe pain in a certain department of the spine. This history of the disease will contain information that a person complains of soreness in one area or another, which 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 indicated that as a result of carrying out the X-ray of this or that part of the spine, certain deviations in the structure of the vertebrae and intervertebral cartilages were detected. According to the medical history, it will be seen that in the course of treatment in the hospital, anesthetics were used, as well as drugs that improve blood circulation. In addition, the recommendations will necessarily note that people do not forget 1-2 times a year to take medicines from the group of chondroprotectors courses of 1-1.5 months.

About strokes

Hemorrhage in the brain is one of the most dangerous pathologies. Complaints about paresis and paralysis of the extremities, change or absence of speech, contain any such case history from neurology. The stroke is extremely difficult to treat. In the case of this pathology, doctors try, first of all, to minimize the affected area as much as possible . Most nerve cells can not be restored. In any such case history, you can find recommendations for a visit to a particular rehabilitation center. Only there a person has the opportunity to restore the basic disturbed functions of his body.

Similar articles

 

 

 

 

Trending Now

 

 

 

 

Newest

Copyright © 2018 en.birmiss.com. Theme powered by WordPress.