Fundamentals of Diagnosis & Diagnostic tests Flashcards
What is a diagnosis?
the identification of the nature of an illness or other problem by examination of the symptoms.
WHAT CONTRIBUTES TO DIAGNOSIS?
- Observations
- Physical examination
- Results of diagnostic tests
- Clinical experience & Profession judgement
- Patient history
History taking:
split -
Information gathering”
Split into 8 stages:
a) Introduction
b) PC: Presenting complaint
c) HxPC: History of the presenting complaint
d) PMHx: Past medical (and surgical) history
e) FHx: Family history
f) SHx: Social history
g) DHx: Drug history
h) Allergies
i) System review
History taking - a) intro
opening consultation: W I I P P
What should we include here?
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)
History taking - b) presenting complaint (PC)
Why has the patient come to see you?
Open questions:
“What has brought you into hospital today?”
“What can I help you with today?”
Points to remember from your communication skills workshop
Active listening
Open body language
Building rapport
Letting the patient speak
History taking - c) (HxPC) presenting complaint
Details relating to the presenting complaint
These questions depend on the presenting complaint or body system being affected
History taking - d) Past Medical / Surgical History (PMHx)
Identifying what underlying conditions and surgical procedures the patient has had
Why?
Risk factors associated with PC
e.g. Type II diabetes heart attack risk
Open questions:
“Do you have any medical conditions”
“Have you ever had surgery”
Useful to cross match the PMHx and DHx:
History taking - e) Family History (FHx)
This tends to relate to the presenting complaint (PC)
E.g. Cardiovascular PC
1st degree relatives having hx of heart attacks?
E.g. Hay fever / asthma / eczema
History taking - f) Social hisorty (SHx)
smoking, alcohol, recreational drugs, accommodation and living arrangements, marital status, baseline functioning, occupation, pets and hobbies.
History taking - g) Drug history (DHx)
- name and dose of med
- does patients actually take it
why is f) drug history important?
Side-effects / Adverse drug reactions
Drug – drug interaction
Drug – patient interaction
Drug – disease interaction
Compliance
allergies - nature of the reaction
How do they take their medication?
Does anyone help them?
Nomad box?
Carers?
History taking - h) Systems review
Specific questions relating to all body systems:
1. Cardiovascular
2. Respiratory
3. Gastrointestinal
4. Genitourinary
5. Neurological
6. Locomotor
What is Differential diagnosis?
“ A list of possible conditions or diseases that could be causing the symptoms”
- A plan will then be made to help differentiate between the potential causes e.g. tests needed, treatment required
When a patient presents with a set of symptoms, the practitioner will develop a list of possible causes > differential diagnosis
The list of potential causes will be based off the facts they have obtained from:
Patients history
Observations
Physical examination
Diagnostic tests
Professional Judgement and Diagnosis
“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.”
importance of Professional Judgement and Diagnosis?
Needed day to day when working as a pharmacist in all sectors
Part of the decision making process
Easy concept to understand but often exercising professional judgement takes consideration
