Arriving at a complete clinical diagnosis of a patient is one of the most important fundamentals a medical student can learn, and it is not as easy as relating a list of symptoms to a condition or disease. That is why we offer you some key tips to keep in mind below.
1. Listen to the patient’s ailments
This is, without a doubt, the cornerstone of the clinical diagnostic process, the key reason why the patient seeks medical help. Sometimes it is simple but the human being is complex. So, as a medical professional, you should ideally explore the patient’s ideas, concerns, and expectations.
2. Listen to the medical history to create a clinical diagnosis
The past can sometimes point to the present. This can help rule out a possibility. For example, a patient with pain in the right lower quadrant of the abdomen may not have appendicitis if the appendix has already been removed.
3. Listen to medication history
According to the National Institute for Health and Clinical Excellence (NICE) in the United Kingdom, it is estimated that between 6 and 7% of hospital admissions are due to adverse drug relationships. As these are not reported it is likely to be even more, this does not include the expected side effects of the medication.
4. Listen to caregivers to create the clinical diagnosis
Caregivers will have invaluable insight into the patient’s problems and behavior. They are indispensable when it comes to certain presentations, such as blackouts, where an eyewitness account is essential, or if the patient has a poor memory for reasons such as dementia or delirium.
5. Listen to health professionals to create the clinical diagnosis
Whether they are nurses, assistants, therapists or anyone who has been in contact with their patient. People vary in how they report signs and symptoms. Some exaggerate, others downplay their symptoms, and others are dead on. Unfortunately, it is not always known in which fields they are found. Instead, a health professional should be able to dispassionately and accurately record any signs or symptoms to assist you in your search for a clinical diagnosis.