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10 Cards in this Set
- Front
- Back
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What is a Diagnosis? |
-Entity -Identification of nature and cause -Lead up to: History,Physical Examination -Differential/Provisional or Working Diagnosis Vs -Definitive Diagnosis. |
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What are the steps in the Diagnosis Process? |
- Thorough History Taking - Differential Diagnosis & Problems not to be missed - Appropriate Regional Exam - Working Diagnosis - Construct management & Identify Prognosis - Establish Definitive Diagnosis - Revisit each as required |
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What are the Key Holistic Patient Assessments? |
- Psychological - Feeling on Life? Greatest Joys? Happiest have been? - Physiological - Expectations/Challenges/Higest Level of functioning? Meds? - Social - Who they love/depend on and Vice Versa - Environmental - live,work,safety,amenities/clean water? - Service/Financial - How much need/recieve? How much do they contribute? Reserves?(savings/friends) |
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What are some points about History Taking? |
- Don't interrupt? - Least expensive, most important! - Open ended Questions. |
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1. What is a Medical Diagnosis? |
- Imperfect information & uncertainty - makes up 80% of info to make Diagnosis - Dont do get unless plan to act on results - Results unexpected? Repeat them! - Diagnosis missed due to not looking rather than not knowing! |
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Clinical Information |
- History incl collateral Hist & past Records. - Physical exam & bed side testing. e.g. Spirometry Testing/Xrays/MRI/Biopsy |
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Pain Assessment/ History = LODCTRRAPPA or SOCRATES |
L - Location O - Onset D - Duration C - Cause T - Type R - Radiation R - Relieving Factors A - Aggravating Faktors P - Previous Episodes? P - Previous History or Treatment? Type/Response/Investigation A - Associated Symptoms |
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What are the 7 Masquerades? |
1 Depression 2 Drugs 3 Disease 4 Anemia 5 Thyroid Disorders 6 Spinal Dysfunction 7 UTI's |
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What are the 4 components of the Case History? |
1 Personal Details 2 Presenting Complaint - LODCTRAPPA 3 Life Factors -Sleep/Exercise/Stress/Coffee/ Drugs/Family? 4 System Review - Varies from case to case. Further Questions and review may or may not be needed |
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Assessment & Diagnostic Process Summary |
- HISTORY - DDX - EXAM/pntbm - WORKING Diagnosis - MANAGEMENT/prognosis - DEFINITIVE DIAGNOSIS |
