====== Medical history ======

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see [[Discharge report]]
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===== Past medical history =====

[[Past medical history]].

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The medical [[history]], [[case history]], or [[anamnesis]] of a [[patient]] is a set [[information]] gained by a [[physician]] by asking specific [[question]]s, either of the patient or of other people who know the person and can give suitable information, to obtain information useful in formulating a [[diagnosis]] and providing medical [[care]] to the patient. The medically relevant complaints reported by the patient or others familiar with the patient are referred to as [[symptom]]s, in contrast with clinical [[sign]]s, which are ascertained by direct examination on the part of medical personnel. Most health encounters will result in some form of history being taken. Medical histories vary in their depth and focus. For example, an ambulance paramedic would typically limit their history to important details, such as name, history of presenting complaint, allergies, etc. In contrast, a psychiatric history is frequently lengthy and in depth, as many details about the patient's life are relevant to formulating a management plan for a psychiatric illness.
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The information obtained in this way, together with the [[physical examination]], enables the physician and other health professionals to form a diagnosis and treatment plan. If a diagnosis cannot be made, a provisional diagnosis may be formulated, and other possibilities (the differential diagnoses) may be added, listed in order of likelihood by convention. The treatment plan may then include further investigations to clarify the diagnosis.

===== Best prompts for a Neurosurgical Medical history =====

When crafting prompts for a neurosurgical medical history, it’s important to gather both detailed clinical and personal information that can guide diagnostic and treatment decisions. Below are a few sample prompts:

Chief Complaint and Symptom Onset

"Please describe the main issue or symptom that brought you in today. When did these symptoms first appear, and how have they changed over time?"

Pain and Discomfort

"Do you experience any pain, and if so, can you describe the type of pain (sharp, dull, throbbing, etc.)? On a scale of 1 to 10, how severe is the pain, and does it radiate to other areas of your body?"

Neurological Symptoms

"Have you noticed any numbness, weakness, or tingling sensations? Do these sensations occur in specific areas, and if so, which ones?"

Functional Impact

"How are your symptoms affecting your daily activities or ability to function? Are you able to perform tasks like walking, driving, or working?"

History of Trauma or Injury

"Have you experienced any head trauma, neck injury, or other physical events that could be relevant to your current symptoms?"

Medical and Surgical History

"Do you have any previous history of neurological issues (such as seizures, strokes, or previous surgeries)? Please describe any prior surgeries or treatments related to your condition."

Family History

"Is there a history of neurological diseases in your family, such as brain tumors, epilepsy, or degenerative conditions like Parkinson's disease?"

Medications

"Please list any medications you are currently taking, including any over-the-counter drugs or supplements. Have you recently started or stopped any medications?"

Risk Factors

"Do you have any known risk factors for neurological conditions, such as smoking, high blood pressure, diabetes, or a history of heart disease?"

Psychosocial Impact

"Have your symptoms impacted your mood or emotional well-being? Do you feel anxious, depressed, or stressed due to your condition?"

Previous Diagnostic Tests

"Have you undergone any imaging or diagnostic tests such as MRI, CT scan, or EEG? What were the findings from these tests?"

Current and Past Treatments

"What treatments or therapies have you tried for your condition (e.g., medications, physical therapy, injections)? Were any of these treatments helpful?"

Follow-up and Monitoring

"How often do you follow up with a neurosurgeon or neurologist for your condition? Are there any upcoming appointments or tests you are scheduled for?"