21. Fundamentals Of Diagnosis And Diagnostic Tests

Question 1

What is diagnosis?

Answer 1

The identification of the nature of an illness or other problem by examination of the symptoms

Question 2

What contributes to a diagnosis?

Answer 2

1. Observations
2. Patient history
3. Clinical experience and professional judgement
4. Physical examinations
5. Results of diagnostic tests

Question 3

What are the steps of history taking?

Answer 3

1. Introduction
2. PC: presenting complaints
3. HxPC: History of presenting complaint
4. PMHx: Past medical (and surgical) history
5. FHx: Family history
6. SHx: Social history
7. DHx: Drug history
8. System review

Question 4

What should you include in an introduction?

Answer 4

• Wash hands/don correct PPE
• Introduce yourself (name, job role)
• Identify you are speaking to the correct individual (name, address / dob)
• Purpose / permission: explain the purpose of the consultation / history taking
• Position: eye level with the patient, 1m away (2m to help with social distancing)

Question 5

What to ask about the presenting complaints?

Answer 5

Open questions:
- “What has brought you into hospital today?”
- “What can I help you with today?”
- “What seems to be the problem”

Question 6

What to ask when asking about history of the presenting complaint?

Answer 6

S: Site
O: Onset
C: Character
R: Radiation
A: Associated Symptoms
T: Time
E: Exacerbating or relieving factors
S: Severity

Question 7

What to ask when asking about past medical history?

Answer 7

MJ THREADS Ca

Myocardial infarction
Jaundice
Tuberculosis
Hypertension
Rheumatic fever
Epilepsy
Asthma
Diabetes
Stroke
Cancer

Question 8

What to ask when asking about family history?

Answer 8

Ask if any past family history of MJ THREADS Ca or anything else.

Question 9

What to ask when asking about social history?

Answer 9

smoking, job, marriage new activities, sports

Question 10

What to ask when asking about drug history?

Answer 10

Confirming name and dosage of all patients meds
Confirming compliance - how do they take it, when, do they take it as they should?
Allergies? What’s the nature of the reaction
Important to look for:
- Any side effects
- Drug/drug interactions
- Drug/patient interactions
- Drug/disease interactions
- Compliance

Question 11

What should be included in a systems review:

Answer 11

1. Cardiovascular
2. Respiratory
3. Gastrointestinal
4. Genitourinary
5. Neurological
6. Locomotor

Question 12

What is a differential diagnosis?

Answer 12

A list of possible conditions or diseases that could be causing the symptoms

Question 13

What is professional judgement and diagnosis?

Answer 13

“Professional judgement could be described as the use of accumulated knowledge and experience, in
order to make an informed decision.”
“It takes into account the law, ethical considerations and all other relevant factors related to the
surrounding circumstances.”

Question 14

What are the steps that go into professional judgement?

Answer 14

1. Identify the ethical dilemma / professional problem
2. Gather all the relevant information
3. Obtain advice from support services, seniors
4. Identify the possible options
5. Weight up the risk vs benefits and advantages and disadvantages of each options
6. Make a decision > must be able to justify it
7. Where appropriate or significant document your decision making process and reasoning