Intro to Med Diagnostic Process Slides

Pieces of diagnostic process

Symptoms, signs, diagnostic tests, diagnosis, and treatment and management

Steps of the diagnostic process

Gather information, analyze the information, and make judgements and decisions

How do you set the stage of an exam

Establish a rapport, introduce yourself properly, and provide the purpose of visit

Steps of subjective exam

Chief complaint, HPI, past medical history (allergies and medications), personal and social history, and family history

Chief complaint is?

Main reason for patients visit

HPI is?

History of present illness (7 factors)

The first factor is?

Setting

The second factor is?

Chronology

The third factor is?

Location

The fourth factor is?

Quality

The fifth factor is?

Quantity

The sixth factor is?

Aggravating/Alleviating factors

The seventh factor is?

Associated manifestations

Setting (In HPI) is?

Where the patient started having symptoms and what he was doing at the time

Chronology (In HPI) is?

The story of the chief complaint and how it has changed or developed

Location (In HPI) is?

Where the symptoms are located

Quality (In HPI) is?

How they describe the symptoms

Quantity (In HPI) is?

Numerical value of complaint

Aggravating/Alleviating factors (In HPI) is?

What makes symptoms worse or better

Associated manifestations (In HPI) is?

Other complaints and symptoms patient denies

Name the four physical examinations for normal visit

Inspection, palpation, percussion, and auscultation

In what order do the 4 physical examination go when it is an abdominal examination?

Inspection, auscultation, percussion, and palpation

Objective things are?

What you see, hear, feel, and smell

Subjective things are?

What the patient tells you

What are the vital signs? (no abbreviations)

Pulse, respiratory rate, temperature, blood pressure, height, weight, and body mass index

What are the vital sings? (with abbreviations)

P, R, T, BP, Ht, Wt, and BMI

Why do we order diagnostic testing?

To support, confirm, and rule out

What are the steps of analysis of information

Patients history, PE and testing, interpretation, possible causes, further questions, and diagnosis

Assessment is?

What is wrong with patient

Plan is?

What are we going to do for the patient