Diagnosis:

Diagnosis is a word that has its etymological origin in the Greek and even more in the union of three words of that language. In particular, is a term that comprises thediagnostic code meaning "through" the word gnosis which is a synonym of "knowledge" and finally the suffix-tic which is defined as "relating to".

A diagnosis is something that, in the field of medicine, is linked to the diagnosis. This term, in turn, refers to diagnose: collect data to analyze and interpret, allowing evaluation of a certain condition.

Diagnosis is based on analysis of insurance data. The reasoning is valid only when resting on accurate ideas and facts,  but when these principles are not met the results are always wrong. The validity of a deduction depends on the quality of the observations on which it is based.

Given these principles, it is essential to present some basic premises upon which rests the medical diagnosis:

The doctor-patient relationship: it is essential to get the information we need in the diagnostic process. With a good doctor-patient relationship we provide comfort and safety as well as better exposure of the patient symptoms and greater cooperation on physical examination. 

They have exposed a group of principles needed to establish a good relationship with the patient, among those found, a good first impression, good communication between physician and patient using all its tracks, to dedicate the necessary time, show interest in the patient's problem and never undervalue, to meet patient expectations, maintaining trust and mutual respect, treating it as you would wish them if we had the same health problem, etc.. You only need to add some fundamental assumptions that we believe in the doctor-patient relationship: put yourself in the patient, grasp his message, worry about him as a person and not just sick, and make him understand that we will be interested by it, we understand all his troubles, anxieties and sufferings, being in full readiness to help in any way possible and never leave.

The history: it is the fundamental basis for the diagnosis of health problems of our patients. 50 to 75% of diagnoses are made ​​by the interrogation. 

They have pointed out several of the principles of good interrogation,  among which may include: allowing the patient to express freely and spontaneously, correctly describe the reason for visit or chief complaint, define all the symptoms of present illness to gain as semiografía (description of) the conditions of onset of symptoms and how to start, sort chronologically, the total duration of the clinical picture, evolution of symptoms over time, the treatment he has received, the current status of symptoms at the time they serve, explore the patient's psychosocial environment, as well as the relationship of symptoms with situations involving family, aspirations, etc..

Of all the principles outlined above we would say that because of its importance and the frequency of errors in their investigation, the correct description of the reason for consultation and the symptoms are, in our opinion, basic obtaining anamnesis. Without accurately interpret the patient's chief complaint, the whole exercise will not lead us further diagnosis on track.

Moreover, the detailed description of symptoms guides us and allows us to discard a large number of possibilities. We can quote that is not the same as saying that a patient has chest pain substernal pain that describe the semiological characteristics of anginal pain How many chances would have to consider and rule in the first case? These would be reduced to a few if we describe the symptom. The foregoing can be applied to any symptom. We must remember that to question it is necessary to know much, according to an old Arab proverb says.

Physical examination: complements the interrogation, physical signs are ¨ ¨ objective and verifiable marks of the disease and represent solid and indisputable facts. Its meaning is greater when confirmed functional or structural change already suggested by the history.  Its value in diagnosis has been ratified by numerous studies. 

The principles of a good physical exam are:  have a set order and the different symptoms (if the procedure is not systematic examination is easy to omit details), respect the patient's modesty, privacy, and concentrate on the examination of each separate thing, not all at once. It is important to perform well each maneuver, the history should guide the physical examination, when you have a suspected diagnosis, searching for all physical data that can produce the disease. It should be a detailed description of each sign found to clearly define where the sign is ambiguous or doubtful, and their inclusion as well. We will not tire of repeating the importance of detailed description of each sign found, it is not the same as saying that the patient has a mitral murmur, which describe the characteristics of the wind that can take us to the diagnosis of hand stenosis or mitral insufficiency.

The other principle is that the physical examination should not be neutral, but be guided by the anamnesis. What is not looking for is not, who does not know what you are looking for does not understand what it finds. It's not just the technique that determines the success for signs, but a mind prepared to realize them. Could cite many other statements and aphorisms that highlight the importance of the active search of the various clinical signs, guided by the anamnesis. We must also remember that history rather than an ordered list of symptoms and signs is a synthesis of facts and observations.

Medical record

The Medical Record (HC) is a forensic document which is characterized by objective and understandable by others, and not just because he writes, is part of clinical record and it records the information of the mother.

 

Basically the history now has two types of supports:

• Written paper: Includes a set of sheets or forms that are arranged in a folder. Can be individual or family.
• Computer through a variety of programs designed especially for programmers to the institutions or commercial offer. Is called electronic medical records stored in computers using software, usually with a program using ambulatory and inpatient another. The ready availability and timely all necessary information, their transport from one area to another to diagnostic decision making and / or therapeutic, make these systems a very useful weapon.

 

The usual order followed in the preparation of the interview is:

1.1 Personal Data

Personal data should be recorded at the head of the medical record. The name, address, telephone number, gender, age, occupation, race, nationality, religion, marital status, number of document and the name of the referring physician. Each of these data, which fit the patient, and cultural customs, provide information on their own medical use. The different incidences of diseases and etiologic agents according to age, sex (gender), race is clearly known. An example is the incidence of Ewing tumors in childhood and adult lung, breast in women. The incidence of Pneumococcus as a cause of meningitis in children, and Haemophilus influenzae in adults, endometrial cancer in women without sexual activity and cervical in sexually active. It should also mention the incidence of hemolytic anemia in Mediterranean populations, stomach cancer in Japanese, or illness or lifestyle groups and food, which guide the various religions. In turn, the patient will need during their illness spiritual support of their pastor, rabbi or pastor preacher, and therefore recognizing their religion can better manage the integrity of human beings.

 You must record the source of information, which may be the patient himself, or his representative.

1.2 Reasons for Consultation

It is the motive or reason (symptom, sign, syndrome, diagnosis or problem) that allows the patient to seek the advice of a doctor. This is what leads him to seek an interview with my health. Must be listed as the starter in the media release and in general, the terminology used by the patient. (Health check, fatigue, shortness of breath, etc.., Etc.). 

1.3 Present Illness

The disease now is the narrative of the reason for the consultation. In an orderly, logical, grammatically correct, will be described one by one the data mobilized to seek medical opinion. This should be developed with information provided as to which, by their absence, are important and contribute to the understanding of the different problems.

It should follow a logical sequence, and where possible be organized and focused on groups of symptoms and signs, problems. Write down the time of the appearance of data, marking the last time the patient felt well. 

It notes the information in chronological order, stating the dates on which data are incorporated. In long-term illness is useful to record the patient's age at different times of the disease.

A good practice is to use different paragraphs for each chronological period of the current illness, noting the time each of them. (One month prior to the consultation ...). Each symptom is described in regard to its inception, presenting features, evolution and progress, not leaving until all the information at the same, it was acquired.
This will follow two lines of description: The symptoms and signs, and the dates on which they occur

1.4 Personal history

This section of the interrogation should take note of all the episodes of his health suffered by the patient since birth. It should be a summary of previous admissions, but do not repeat information if it was included in the current disease. 

For every hospital record the dates of admission and discharge and a summary of the issues addressed in this episode. Findings emerged in this circumstance, operations, development, treatment results and final diagnoses, should be included. 

You should ask about the presence of allergies, reactions to drugs, foods such as milk and cereals, if you have had episodes that appear to hay fever, eczema, hives, or serum sickness. 

Take note, especially in children, or elderly, or patients who travel special areas of their immunization status, dates of application and responses to them. 
You must ask for infectious diseases such as lung disease, pleurisy, tuberculosis and so on. etc. Should be questioned about previous surgery, injury, trauma or other diseases of childhood or adulthood. 

You must ask for activities in mental institutions, social, corporate, military and so on., Etc.

1.5 Personal habits

This section provides information on customs (Travel) and habits such as sleep, regular diet, diuresis and catharsis, smoking, alcohol, drugs and self medication, use of seat belts, condoms in their sexual liaisons and sexual preferences. 

Always ask for aspirin, which is not considered drugs by the vulgar. You should also ask about levels of education and occupational history, with its factors also should ask about levels of education and occupational history, with its risk factors (asbestosis, lead, radiation. Etc.)

Of particular interest in the environment it inhabits, personal hygiene habits, knowledge of the insect, and other parasites. You must know the patient's psychological reaction to disease, or to the understanding of this and his attitude

1.6 Review of organ systems 

This section of the Medical Record is intended to supplement the information that may have been overlooked in the current disease. Symptoms and signs evaluated and should not be repeated. 

In the review of organ systems should be an order of questions, not to lose information. They are asked about symptoms and signs of skin, head, eyes, ears, nose, sinuses, oral cavity, throat, lymph, breast, cardiorespiratory, gastrointestinal, urogenital, endocrine, limbs, central and peripheral nervous system and hematopoietic systems. 

In women enter the age of onset of menstruation and breast development, periods, with duration and quality, and associated symptoms. Pregnancies, abortions and miscarriages unprovoked. Symptoms of menopause and hot flashes, nervousness, fatigue etc.

1.7 Family history

This section asks for all those diseases that may have a genetic or hereditary link with the patient. Should be questioned about parents, grandparents, siblings and children.This is developed more thoroughly if it suggests the patient's illness. For example on their sexual partners.Information about the couple that lives together and provides evidence of infectious psychosocial. If a family member died noting the age and cause.

Physical examination

 The physical examination is performed after the interrogation, following a methodological and must be implemented in full. That order is as follows: 

Inspection
Palpation
Percussion
Auscultation 

Gynecologic and Rectal Touch

Ophthalmoscopy and Otoscopy 

In practice, inspection and will start providing data since the start of the consultation. 

The findings from this study are normal or abnormal signs, or objective facts, health or disease markers, which may or may not confirm the suspect opened by the history. Sometimes the sign found is the only manifestation of disease, as an example worth a breast lump.

Physical examination is understood pedagogically as a skill, but it just fits, it is part of a line of knowledge, which can vary from patient to patient. The sound out a breath is a skill, but understanding what it means, its definition and clinical setting and alignment with the patient's case in question, query type, routine or emergency, due to defined query or " clear, "requires an adaptation to circumstances beyond the bounds of the required information or skills and knowledge of anatomy and pathophysiology. 

The findings or signs, normal as abnormal physical examination must be recorded or reported regularly. These may change or disappear, making it important to periodically repeat as many times as necessary. 

In the passing of the years the increase in the number, availability and accuracy of complementary laboratory tests have led to trust and rely on them for the solution and definition of clinical problems.

These studies are, of course, important, and in particular are based on screening programs for early diagnosis of various diseases. Most of these tests are not perfect and sometimes can sicken a healthy or detect disease. Therefore it is of utmost importance in evaluating the results, taking into consideration the limitations of these studies. Remember that they are impersonal, they have the possibility of technical errors, and interpretation, which certainly requires working with a quality controlled service.

 Imaging studies, with rays, echoes, radioactive isotopes, magnetism, endoscopy and conventional radiology, scintigraphy, ultrasound, Computed Tomography, MRI, Doppler, PET Scanner, tomography by multiple cuts (Multislice), endoscopy virtual diagnostic laparoscopy etc., etc., contribute to the study of the patient and provide important information to establish diagnosis, define the anatomy of the lesion, and further evolution.

 It should be emphasized that these studies should apply the same reservations as for the clinical laboratory. The sensitivity, specificity, prevalence and the cost of the procedure should be evaluated in relation to the information provided. It should also consider changes in the approach to follow, which accounts for the examination and have a clear reason to do so. The massive use of analysis does not relieve the physician of his responsibility to question and examine the patient and to recognize and observe as a whole. 

The cost-benefit studies that provide the results should be taken into account. 

The evidence-based medicine to their share of profit made ​​in recognition of the diagnostic value of the results or data 

The study classified as (a) is one in which the preponderance of data supporting this result is derived from level 1 studies, which cover all the criteria of evidence for such a study.

 The classified under (b) is one in which the preponderance of data supporting this result is derived from level 2 studies, which cover one of the criteria of evidence for this type of study. 

Those classified as (c) are that the preponderance of data supporting this result is derived from 3rd level studies, which have no standards of evidence for this type of study or are based on expert opinion supported by experience, or consensus of opinion and not proven with scientific method.

 One reason for consultation or a finding on physical examination as to guide the studies requested. In the case of an abnormal result on a patient presents no symptoms and no signs on the exam, must be repeated, the study to exclude an error. Repeated the abnormal result, clinical judgment indicate the action to take.

Laboratory tests
cholesterol
High levels of cholesterol make us prone to diseases such as hypertension. Total cholesterol in the blood should be at a level below 200 mg / dl.

 
Hematocrit
The percentage of cells and blood solutes. A low percentage may be related to anemia and a high percentage with smoking or dehydration.

 
Glucose
It measures the amount of sugar (glucose) in a blood sample. Up to 100 milligrams per deciliter (mg / dL) are considered normal.

 
Hemoglobin
Is the red cell protein. A low figure could be related to anemia.