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.

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

High levels of cholesterol make us prone to diseases such as hypertension. Total cholesterol in the blood should be at a level below 200 mg / dl.

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.

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.