Medical Diagnosis Fundamentals & Clinical History Taking
Core Medical Diagnostic Concepts
Sign
A visible or measurable manifestation of a disease.
Syndrome
A collection of signs and symptoms that occur together, characteristic of a specific condition, regardless of the underlying cause.
Diagnosis
The identification of the nature of an illness or other problem by examination of the symptoms and signs. It involves understanding the anatomical and physiological changes caused by a morbid agent.
Nosological Diagnosis
Assigns the specific name given in pathology to the clinical picture being studied.
Differential Diagnosis
The process of distinguishing between two or more conditions which share similar signs or symptoms. It involves systematically comparing and contrasting potential diseases through hypothesis testing, laboratory investigations, and clinical findings to identify the actual cause of the patient’s symptoms.
Symptomatic Diagnosis
Focuses on identifying the disease based primarily on the list of symptoms presented.
Etiologic Diagnosis
Determines the specific cause or origin of a disease.
Prognosis
A prediction of the likely course and outcome of a disease. It is formulated based on the natural history of the disorder, the patient’s current condition, treatment options, clinical experience, and known facts about the disease.
Comprehensive Diagnosis
An overall assessment integrating various diagnostic findings (nosological, etiological, differential, symptomatic, etc.) to provide a complete picture of the patient’s condition, including the affected systems or areas (territory) where the disease evolves.
Understanding the Clinical History
Definition of Clinical History
The clinical history is a detailed narrative of events in a patient’s life that are important for their mental and physical health. It is a specialized written document where the physician records a story based on facts provided by the patient or an informant. Various aspects are included only after careful assessment by the physician, who uses knowledge about the natural history of diseases to ensure relevant details are captured and the sequence of events is established.
Purpose of Clinical History Taking
Key objectives include obtaining precise quantitative descriptions, ensuring accurate chronologies of events, and thoroughly investigating symptoms.
Structure of the Clinical History
While minor variations exist between institutions, the components of the clinical history generally follow a standard sequence:
- Identification Sheet: Basic patient demographics.
- Family History (Heredofamilial): Health status of relatives, focusing on hereditary conditions.
- Non-Pathological Personal History: Lifestyle, habits, social background, occupation, etc.
- Pathological Personal History: Past illnesses, surgeries, hospitalizations, allergies, medications.
- Obstetric/Gynecological History: Relevant reproductive history for female patients.
- Androgenic History: Relevant reproductive and sexual health history for male patients.
- History of Present Illness: A detailed chronological account of the current problem.
- Review of Systems: Systematic inquiry about symptoms related to each body system.
- Physical Examination: Objective assessment of the patient’s physical state.
- Special Investigations: Results from laboratory tests, imaging studies, etc.
Components of the Identification Sheet
- Full Name: Record the complete name, usually with the surname placed first, followed by a comma and then the given names.
- Age and Date of Birth: Note the patient’s age in years and their full date of birth. The date of birth helps distinguish between patients with the same name.
- Sex: Record the patient’s sex. While usually obvious, in cases of intersexuality, it may suffice to record the gender the patient identifies with.
- Current Address and Telephone Number: Essential contact information.
- Place of Origin and Previous Residence: This information can be useful for assessing potential environmental exposures, endemic diseases, or understanding the social impact of the illness.
Physical Examination Components
A systematic physical assessment typically includes evaluation of the following:
- General Appearance: Overall impression of the patient’s health, consciousness, and distress level.
- Vital Signs: Temperature, pulse rate, respiration rate, blood pressure, and sometimes oxygen saturation.
- Somatometry: Body measurements such as height, weight, and Body Mass Index (BMI).
- Head: Examination of the skull, scalp, eyes, ears, nose, mouth, and face.
- Neck: Assessment of lymph nodes, thyroid gland, carotid arteries, jugular veins, and range of motion.
- Chest: Examination of the lungs (auscultation, percussion) and heart (auscultation).
- Abdomen: Inspection, auscultation, percussion, and palpation of abdominal organs.
- Extremities (Tips): Examination of arms and legs for pulses, edema, skin changes, joint mobility, and neurological function.
- Genital Examination: Assessment of external genitalia as indicated.
- Anus and Rectum: Examination as indicated, often including a digital rectal exam.