UNIVERSIDAD TECNOLOGICA DE SANTIAGO

(UTESA)
Recinto Santo Domingo de Guzmán

Nombre: Anastania

Apellido: Charlestin

Matrícula: 219 3696

Asignatura: Ingles Técnico Medico

Sección: 003

Profesor: Edwin Emmanuel Reyes Ferrand

Santo Domingo
02/10/2020
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.
The art or act of identifying a disease from its signs and symptoms
The decision reached by diagnosis the doctor's 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 medical signs and

reported symptoms, rather than diagnostic tests. patient

B. Laboratory diagnosis: A diagnosis based significantly on laboratory reports

or test results, rather than the physical examination of the patient. For
instance, a proper diagnosis of infectious diseases usually requires both an
examination of signs and symptoms, as well as 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.
 For example, an ambulance paramedic would typically limit their history to
important details, such as name, history of presenting complaint, allergies, etc.
In contrast, a psychiatric history is frequently lengthy and in depth, as many details
about the patient's life are relevant to formulating a management plan for a
psychiatric illness.

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.
Should you wish to take notes as you proceed, ask the patients permission to do so.

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
Find out what medications the patient is taking, including dosage and how often they
are taking them, for example: once-a-day, twice-a-day, etc.
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.

Also find out who lives with the patient. You may find that they are the carer for an
elderly parent or a child and your duty would be to ensure that they are not
neglected should your patient be admitted/remain in hospital.
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?