Diagnosis
The
diagnosis is one of the fundamental tasks of physicians and the basis for an
effective therapy.
This
in itself is not an end but a means, and indispensable to establish the
appropriate treatment. Some people point out as the most
important
medical work, but despite this entails many difficulties when it is explained
and taught how to do.
It has been
argued that "in programs and curricula are not provided detailed
knowledge of how it performs diagnostic reasoning and empirically
seeing students learn what to do and copying of residents, specialists and
teachers.
Diagnosis
is based on analysis of insurance data.
The reasoning is valid only when resting on
accurate ideas and facts, but when these principles are not met the results are
always wrong.
The
validity of a deduction depends on the quality of the observations on which it
is based.
The
doctor-patient relationship: it is essential to obtain the information
need in the
diagnostic process. With a good doctor-patient relationship we provide comfort
and safety as well as better exposure of the patient symptoms and greater
cooperation on physical examination.
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They have exposed a group of principles needed
to establish a good relationship with the patient, among which are a good first
impression, good communication between physician and patient using all their
means, spend your time, show interest in patient's problem and never
undervalue, to meet patient expectations, maintaining trust and mutual respect,
treating it as you would wish them if we had the same health problem, etc..
You only
need to add some fundamental assumptions that we believe in the doctor-patient
relationship: put yourself in the patient, grasp his message, worry about him
as a person and not just sick, and make him understand that we will be
interested by it, we understand all his troubles, anxieties and sufferings,
being in full readiness to help in any way possible and never leave.
clinical history
The
history: it is the fundamental basis for the diagnosis of health problems
our
patients. 50 to 75% of diagnoses are made by the interrogation
They have
pointed out several of the principles of good interrogation.
among which mention may be made: let the patient be expressed freely and
spontaneously, correctly describe the reason for visit or chief complaint,
define all the symptoms of present illness, get the most semiografía
(description of) the conditions of onset of symptoms and how to start, sort
chronologically, the total duration of the clinical picture, evolution of
symptoms over time, the treatment they received, the current status of symptoms
at the time they serve, explore the psychosocial environment of the patient, as
well as the relationship of symptoms with situations involving family,
aspirations, etc..
detailed
description of symptoms guides us and allows us to
rule out a
large number of possibilities. We can quote that is not the same as saying that
a patient has chest pain substernal pain that describe the semiological
characteristics of anginal pain How many chances would have to consider and
rule in the first case?
These would be reduced to a few if we describe the symptom. The foregoing can
be applied to any symptom. We must remember that to question it is necessary to
know much.
Physical
examination: complements the interrogation, physical signs are trademarks ¨ ¨
objective
and verifiable disease and represent solid and indisputable facts.
Its meaning
is greater when confirmed functional or structural change and
suggested
by the history.
Its value
in diagnosis has been ratified by numerous studies. The principles of a good
physical exam are: having a set agenda anddifferent
symptoms (if the procedure is not systematic examination is easy to omit
details), respect the patient's modesty, privacy, and concentrate on the
examination of each separate thing, not all at once. It is important to perform
well each maneuver, the history should guide the physical examination, when you
have a suspected diagnosis, searching for all physical data that can produce
the disease. It should be a detailed description of each sign found to clearly
define where the sign is ambiguous or doubtful, and their inclusion as well.
The other
principle is that the physical examination should not be neutral, but be guided
by the anamnesis. What is not looking for is not, who does not know what you
are looking for does not understand what it finds. It's not just the technique
that determines the success for signs, but a mind prepared to realize them.
medical
history
The history
should be unique, integrated and cumulative for each patient in the hospital,
and there must be an effective clinical information retrieval.
The main
function of history is the care and allowing patients to call for different
computers. Other features include: teaching, allowing studies of research and
epidemiology, health care quality assessment, planning and health management
and use in legal cases in legal situations required Report high
- Data
related to the center.
- Name,
address, phone.
- Service
or Unit which produces the high.
- Optional
responsible discharge.
- Patient
identification data.
- Full
name.
- No. of
medical history.
- Date of
birth and sex.
- Data
refer to the care process.
- Date of
admission and discharge.
- Reason
for admission.
- State at
the time of discharge.
- Target.
- Main
diagnosis.
- Other
diagnoses (if applicable).
- Surgical
procedures and / or obstetrics.
- Other
significant procedures (if applicable).
- Clinical
Summary (history, physical examination,
complementary
investigations, clinical course and treatment recommendations).
physical examination
The patient
should feel comfortable.
1.-Temperature.
2.-Light →
especially for us to examine the oral cavity.
3.-Position
of the patient.
4.-Position
of the examiner should not feel → lower the patient.
5.-Consideration
→ the patient is a person who comes with a problem, we
must listen.
1.
inspection:
It begins
with the observation of the patient from the minute he enters the
query. No
physical contact, just watching things like the patient
for
example:
How to walk
the patient.
-Position.
Facial expression and gesture-→ What moves muscles in harmony?
-Color of the skin.
-Location, size and limits of disturbance as → changes
coloration,
increases in volume,.
palpation:
Should be
done with the fingertips in a gentle way. feeling
different
textures.
-Size - limits (corroborates what was observed during the inspection).
-Form - consistency.
-Sensitivity
-Temperature - turgor - moisture. -Turgor → ability of the skin to form the
pressure groove and is lost
with time.
With age, elasticity is lost turgor and delay the groove →
more time
to disappear.
-Crepitus - fluctuation - renitencia.
→ Crackling
noise-parchment. It occurs when there is cystic,
this
expands the table to which thins. Pressing the thinned table
crackles
.
percussion:
Commitment
is concerned when the periodontal ligament (vitality
ligament)
or making osteotomies (to see the quality of the bone:
hard or
soft).
By
percussion are obtained:
Vibrations audible and palpable, when percutimos chest →
obtain
various types of noise depending on the region (upper or
below) or
if the lung is healthy or sick.
-Noises striking the chest →
-Dullness →
solid masses (muscles).
-Loudness →
when air (collarbone).
-Bloat →
musical (hollow organs).
auscultation:
-It takes a
good stethoscope.
-In quiet
area.
-Ability to
focus examiner.
Normal-Hearing
→ 16 to 16000 cycles per second. But the average is
2000 cycles
per second.
laboratory tests
cholesterol
hematocrit
The percentage of cells and blood solutes. A low
percentage may be related to anemia and a high percentage with smoking or
dehydration.
Normal values are:
Female 37 to 51.
Men 40 to 58.
glucose
It measures the amount of sugar (glucose) in a blood
sample. Up to 100 milligrams per deciliter (mg / dL) are considered normal.
hemoglobin
Is the red cell protein. A low figure could be related
to anemia.
Normal values are:
Women 12 to 16
Men 14 to 19.
final diagnosis
the final diagnosis is the result of patient care,
based on studies that have in psychology, along with the experience obtained
over time in patient care, then I put the following lines, which apply or be
followed in the order you put them is not necessarily followed to the letter or
in that order.
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1.Conocer the basics of psychological diagnosis.
2.Identificar models representing the most common
diagnostic techniques.
3. Analyze the purpose and methods of diagnosis in the
professional field.
4.Describir mechanisms and processes related to key
areas of diagnosis.
5.Introducir strategies and techniques for efficient
and effective diagnostics.
6.Desarrollar skills for relevant reports from
diagnosis.
7.Aprender diagnostic tests applied in natural
settings, correct them and analyze them, to make reports, which you can discuss
with other colleagues in order to obtain different points of view and know how
you approached the target, which may lead to a cure patient.
