UNIVERSIDAD TECNOLOGICA DE SANTIAGO

(UTESA)
Recinto Santo Domingo de Guzmán

Nombre: Alexandra

Apellido: Compère

Matrícula: 119 53 45

Asignatura: Ingles Técnico Medico

Sección: 003

Profesor: Edwin Emmanuel Reyes Ferrand

Fecha
03/10/2020
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.
We can also say is an investigation or analysis of the cause or nature of a condition,
situation, or problem diagnosis of engine trouble.
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. For example, a
correct diagnosis of infectious diseases usually requires both an examination of
the signs and symptoms, as well as the laboratory characteristics of the pathogen
involved.

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.

The medically relevant complaints reported by the patient or others familiar with the
patient are referred to as symptoms, in contrast with clinical signs, which are ascertained
by direct examination on the part of medical personnel. Most health encounters will result
in some form of history being taken. Medical histories vary in their depth and focus.

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, e.g diabetes or cardiac
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. Depending on the PC it may also be pertinent to find
out whether the patient drives, e.g. following an MI patient cannot drive for one month.
You should also ask the patient if they use any illegal substances, for example: cannabis,
cocaine, etc.
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.
The acronym is used to gain an insight into the patient's condition, and to allow the health
care provider to develop a plan for dealing with it.

 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?