The anamnesis (medical history) represents an important component in the diagnosis of traumatic brain injury. If the patient is unresponsive himself or herself, the discussion is with family members/contact persons.
Family history
Social anamnesis
Current anamnesis/systemic anamnesis (somatic and psychological complaints).
- Can you describe the mechanism of the accident?
- For car accidents: describe (extraneous history: interviewing people involved in the accident or witnesses).
- Type of vehicle damage?
- Crash height?
- Were you or the patient unconscious?
- At the time of the accident?
- Later?
- Do you or the patient suffer from headaches, dizziness?
- Are you or the patient nauseous, have you/has he/she vomited?
- How long have these symptoms been present?
- Have you noticed any other symptoms/injuries?
Vegetative anamnesis incl. nutritional anamnesis.
- Do you drink alcohol at an increased rate? If so, what drink(s) and how many glasses of it per day?
- Do you use drugs? If yes, which drugs and how often per day or per week?
Self history incl. medication history.
- Pre-existing conditions
- Operations
- Radiotherapy
- Allergies
- Drug history (clustered intracranial hemorrhage(bleeding inside the skull – even in mild TBI) under clopidogrel).
- Environmental history
Medication history
- Acetylcholinesterase inhibitors (donezepil, galantamine, rivastigmine).
- Alpha-sympatholytics (phenoxybenzamine).
- Antiarrhythmics
- Class Ib antiarrhythmics (lidocaine).
- Anticoagulants
- Hypnotics
- Muscle relaxants
- Benzodiazepines (tetrazepam)
- Opiates
- Sedatives
- Triptans (sumatriptan)
Environmental history including intoxications (poisonings).
- Intoxications by:
- Alkaloids
- Alcohol
- Hypnotics (sleeping pills)
- Carbon monoxide
- Hydrocarbons (aliphatic, aromatic)
- Opiates (painkillers such as morphine)
- Sedatives (tranquilizers)
- Hydrogen cyanide/potassium cyanide
