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10 Cards in this Set

  • Front
  • Back

What is a Diagnosis?


-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?


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/


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

Assessment & Diagnostic Process Summary



- EXAM/pntbm

- WORKING Diagnosis

- MANAGEMENT/prognosis