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10 Cards in this Set

  • Front
  • Back

What is a Diagnosis?

-Entity


-Identification of nature and cause


-Lead up to: History,Physical Examination


-Differential/Provisional or Working Diagnosis Vs -Definitive Diagnosis.

What are the steps in the Diagnosis Process?

- Thorough History Taking


- Differential Diagnosis & Problems not to be missed


- Appropriate Regional Exam


- Working Diagnosis


- Construct management & Identify Prognosis


- Establish Definitive Diagnosis


- Revisit each as required

What are the Key Holistic Patient Assessments?

- Psychological - Feeling on Life? Greatest Joys? Happiest have been?




- Physiological - Expectations/Challenges/Higest Level of functioning? Meds?




- Social - Who they love/depend on and Vice Versa


- Environmental - live,work,safety,amenities/clean water?




- Service/Financial - How much need/recieve?


How much do they contribute? Reserves?(savings/friends)



What are some points about History Taking?

- Don't interrupt?


- Least expensive, most important!


- Open ended Questions.

1. What is a Medical Diagnosis?



- Imperfect information & uncertainty


- makes up 80% of info to make Diagnosis


- Dont do get unless plan to act on results


- Results unexpected? Repeat them!


- Diagnosis missed due to not looking rather than not knowing!

Clinical Information

- History incl collateral Hist & past Records.


- Physical exam & bed side testing.


e.g. Spirometry Testing/Xrays/MRI/Biopsy

Pain Assessment/ History = LODCTRRAPPA or SOCRATES

L - Location


O - Onset


D - Duration


C - Cause


T - Type


R - Radiation


R - Relieving Factors


A - Aggravating Faktors


P - Previous Episodes?


P - Previous History or Treatment?


Type/Response/Investigation


A - Associated Symptoms



What are the 7 Masquerades?

1 Depression


2 Drugs


3 Disease


4 Anemia


5 Thyroid Disorders


6 Spinal Dysfunction


7 UTI's

What are the 4 components of the Case History?

1 Personal Details




2 Presenting Complaint - LODCTRAPPA




3 Life Factors -Sleep/Exercise/Stress/Coffee/


Drugs/Family?




4 System Review - Varies from case to case. Further Questions and review may or may not be needed

Assessment & Diagnostic Process Summary

- HISTORY


- DDX


- EXAM/pntbm


- WORKING Diagnosis


- MANAGEMENT/prognosis


- DEFINITIVE DIAGNOSIS