Diagnosis Flashcards
1
Q
Diagnosis
A
- Observation
- Patient history
- Physical examination
- Results of diagnostic tests
- Clinical experience and professional judgement
2
Q
History taking
A
- Introduction
- Presenting complaint
- History of the presenting complaint
- Past medical (and surgical) history
- Family history
- Social history - Occupational could be COPD miner
- Drug history
- Sytemic review
3
Q
Introduction
A
- Wash hands
- Introduce yourself
- Identify your speaking to correct indavidual
- Purpose and eye level 1 meter away
4
Q
Presenting complaint
A
- Active listening
- Open body language
- Building rapport
- Letting the patient speak
5
Q
SOCRATES
A
- Site
- Onset
- Character
- Radiation
- Accociated symptoms
- Time
- Exacebated
- sever
6
Q
Past Medical history
A
- Any risk factors associated may link to condition
7
Q
M J T H R E A D S
A
- Myocardial infarction
- Jaundice, tuberculosis
- Hypertension
- Rheumatic fever
- Epilepsy
- Asthma
- Diabetes
- Stroke.
8
Q
Family History
A
- Relatives that have had heart conditions
- Hay fever and eczema
- May be genetically related
9
Q
Social History
A
- Travel been to area with high risk area
- Alcohol intak calculation and smoking per pack calculation
- Asbestos or coal mine dust causing respiratory conditions
10
Q
Drug History
A
- Side effects
- Drug interection and patient interaction
- Drug disease interaction and complience
- Rash more likely allergic reaction compared to just upset stomach
11
Q
Systems review
A
- Cardiovascular
- Respiratory
- Gastrointestinal
- Genitourinary
- Neurological
- Locomotor
12
Q
Differential diagnosis
A
- A list of possible conditions or diseases that could be causing the symptoms
- List of causes plan used to differentiate
13
Q
Professional judgement
A
- 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
14
Q
Steps of professional judgement
A
- Identify the ethical dilemma
- Gather all the relevant information
- Obtain advice from support services, seniors
- Identify the possible options
- Weight up the risk vs benefits and advantages and disasvantages of each options
- Make a decision - must be able to justify it
- Where appropriate or significant document your decision making process and reasoning
15
Q
Diagnostic tests - Blood pressure
A
- Routine observation in hospital
- Routine as part of BP medication check
- High BP = headache
- Low BP = light headed, falls
16
Q
Diagnostic tests – Heart Rate
A
- Routine observation in hospital
- Dizziness
- Fainting / light headed
- Palpitations
- Measure pulse for 30s
17
Q
Diagnostic tests – Respiratory rate
A
- Number of breaths / min
- Count the number of times the patients chest rises in 60 seconds 2 x 30s
- Routine observation in hospital, Shortness of breath
Respiratory assessment
18
Q
Diagnostic tests - Temperature
A
- Use of multiple thermometers
- Could possibly be an infection
19
Q
Diagnostic tests- Oxygen levels
A
- Health patient O2 sat: >95%
- Respiratory conditions (COPD): 88 – 92%
- Shines two types of light through your finger (one red light, one infra-red light)
- Red blood cells absorbtion of infered light allow red light to pass through high oxygen
- Red blood cell with low oxygen absorb read light and infered pass through
20
Q
Diagnostic tests – Ear examination
A
- Not routinely used
- Dizziness / ringing / crackling sound in ear
Ear infection - Hearing assessment: hearing loss / changes in hearing
21
Q
Diagnostic tests- BMI
A
BMI = Weight (kgs)/[Height (m)]2
- Weight loss clinic
- Diabetes or cardiovascular clinic high BMI is a risk factor
22
Q
Blood sugar monitoring
Continuous glucose monitoring
A
devices fitted under the patients skin which they can scan using smart phone to check BMs
23
Q
Blood glucose monitoring
A
- Single use blood tests used to check BMs where patient pricks finger, collects blood and runs the test
- Diabetic patients
- Patients who have collapsed
- Recurrent urinary tract infections
24
Q
Diagnostic Tests – Peak Flow
A
- Take a deep breath in
- Blow as hard and fast as you can into the peak flow meter = Peak Expiratory Flow (PEF)
- Plot on the chart to see where your PEF score sits
- Respiratory conditions such as asthma identification
25
Throat Swabs
- Sore throat test and treat service
- Patients with sore throat can have a throat swab undertaken by a community pharmacist;
- Bacterial: antibiotics provided OTC
- Viral: self help advice
26
Urine Dip testing
- Urinary tract infection service
- Allows urine to be tested to look for infection markers provided if needed
- Also can highlight excessive glucose, blood which may warrant further investigation and referral
27
Pregnancy testing
- HIV
- Chlamydia / gonorrhoea
- Syphilis
- Tend to be provided in community pharmacy (charge) and sent to be tested and patient contacted by external company
