Full name : Anne Sandy Gilles ID: 119 52 90 Section: 003

Investigate all about the diagnosis. What's a diagnosis?

The diagnosis is the process of identifying a disease, condition, or injury from its signs and
symptoms. A health history, physical exam, and tests, such as blood tests, imaging tests, and
biopsies, may be used to help make a diagnosis.
The definition of a diagnosis is the process of finding out what is causing symptoms, a disease or
injury in a patient and the opinion reached based on the process.
Investigate the different types of diagnosis. Write it. A, B, C, D...

A. CLINICAL diagnosis: A diagnosis made on the basis of reported medical signs and
symptoms, rather than diagnostic tests.

B. Laboratory diagnosis: A diagnosis based significantly on laboratory reports or test results,

rather than the physical examination of the patient.

C. Radiology diagnosis: A diagnosis based primarily on the results from medical imaging
studies. Magnetic resonating imaging (MRI) is common radiological diagnoses.

D. Prenatal diagnosis: Diagnosis work done before birth Example: sonography

E. Diagnosis of exclusion: A medical condition whose presence cannot be established with

complete confidence from either examination or testing.

F. Dual diagnosis : The diagnosis of two related, but separate, medical conditions

G. Self-diagnosis: The diagnosis of two related, but separate, medical conditions Examples:
headaches, menstrual cramps, and head lice.

What's a medical history and when taking a medical history?

The medical history, case history, or anamnesis is information gained by a physician by asking
specific questions, either of the patient or of other people who know the person and can give
suitable information, with the aim of obtaining information useful in formulating a diagnosis and
providing medical care to the patient.

When you understand and document an individual's medical history, you help to assure that you
and the individual's health care providers provide the most appropriate and effective treatment
and support for the individual's illnesses and health conditions so that they maintain the best
possible health.
Write and define the steps for taking a patient's history into the correct order.

1-Introductory”Small Talk
Introduce yourself, identify your patient and gain consent to speak with them.

2-Chief Complaint
This is what the patient tells you is wrong, for example: chest pain.

3-History of Present Condition

Gain as much information you can about the specific complaint.

4-Past Medical History

Gather information about a patients other medical problems 

5-Medication
At this point it is a good idea to find out if the patient has any allergies.

6-Family History
Gather some information about the patient’s family history
Find out if there are any genetic conditions within the family, for example: polycystic kidney
disease.

7-Social History

This is the opportunity to find out a bit more about the patient’s background. Remember to ask
about smoking and alcohol.

Investigate all about the Socrates mnemonic. 

SOCRATES is a mnemonic acronym used by emergency medical services, doctors, nurses and
other health professionals to evaluate the nature of pain that a patient is experiencing.

 Site: Where exactly is the pain?

 Onset: When did it start, was it constant/intermittent, gradual/ sudden?

 Character: What is the pain like e.g. sharp, burning, and tight?

 Radiation: Does it radiate/move anywhere?

 Associations: Is there anything else associated with the pain, e.g. sweating, vomiting.

 Time course: Does it follow any time pattern, how long did it last?

 Exacerbating / relieving factors: Does anything make it better or worse?

 Severity: How severe is the pain, consider using the 1-10 scale?