About this post: Determining
What is the Diagnosis?
What is wrong with the patient? What causes the symptoms? Once the diagnosis is made, is this is a definite diagnosis or is there some uncertainty? Are there multiple facets to this condition? Are there other conditions that influence the condition?
How do doctors establish a diagnosis?
To establish a diagnosis, three distinctive “medical tools” are used by all doctors.
- Interview: What is the patient able to tell the doctor regarding the symptoms of the condition? This is called the history taking or Anamnesis. Information gathered this way is invaluable in making an accurate diagnosis. (Discussed in this Blog)
- Physical Examination: During the physical examination, signs are detected by the examiner that add information towards the diagnosis. (Discussed in the following Blog)
- Further tests: Sometimes it is necessary to request special investigations, like X-Rays, to confirm the diagnosis. (Discussed in the following Blog)
The information gained, using these tools together, supportive the doctor in coming to an informed and hopefully accurate decision. In addition, if a patient does does not respond to the management of a particular diagnosis in the expected way, it may be necessary to reconsider the diagnosis and revisit the above process repeatedly, in order to come to the correct diagnosis.
If, on interpreting the information gathered, more than one possible diagnosis exists, a list of possible causes for the condition will be made, in descending order of probability. This is called a differential diagnosis.
Your Consultation, and making sense of the symptoms to establish the diagnosis:
The first of the consultation is when you and your doctor will discuss your medical history. This is also known as the Anamneses. You, as the patient, inform the doctor about the reason for the visit. The symptoms will be taken note of. The doctors will then ask specific, pointed questions regarding the complaint. During proper history taking, it becomes clear, precisely what you are complaining about.
In some instances, it is immediately clear what is wrong with you. For example, a patient with a hemiplegia has a particular stance, posture and walk. Even upon entering the door of the surgery, the doctor will know the patient has a hemiplegia. This is called a spot diagnosis.
A patient with an acute disc lesion, causing severe, agonizing radiculopathy, (which is pain down one leg because of significant pressure on a nerve in the spine) will present an expression of pain. The posture during standing and walking will be slightly flexed forward and toward the side of the pain. The leg will be used sparingly and will be kept slightly flexed at the hip and knee on the affected side. Again, a spot diagnosis may be possible in some instances.
History taking is a skill that medical students are taught from the moment they enter their clinical years. However, patients do not often have the opportunity to practice for this part of the consultation.
Preparing for your doctor’s visit, thinking about your symptoms beforehand.
It is helpful to think about your complaint in advance to enable you to answer the questions your doctor will ask you regarding your medical condition.
For patients with back pain and / or leg pain some of the relevant questions could include:
- For how long have you had this complaint?
- Did it start slowly, progressively, or suddenly; after an injury or specific movement or lifting or sporting activity?
- Is it getting better, staying more or less the same or getting worse?
- Is it continuous or does it come and go, allowing pain-free periods?
Regarding specific pain characteristics, questions could include:
- What does it feel like to you: is it a sharp pain; or stabbing; maybe burning; a pressure or pulling sensation; is the pain pulsating?
- For pain in your leg, added variations could include: the sensation of pins and needles; numbness; tingling or a combination of any of the abovementioned sensations.
Regarding your pain intensity, questions include:
- Various methods to determine the intensity of pain exist, however, all are inherently subjective and related to the individual patient’s interpretation. Probably the most commonly used way a practitioner would grade pain would be the “Visual Analogue Scale” (VAS). The patient grades the pain by choosing a number between 1-10 in order to express their perception regarding the intensity of their pain.
- Various alternatives do exist and may be used to assist your doctor, including for instance the Oswestry Disability Index.
How do activities influence your pain? What do you do to improve the pain when you are on your own?
- Does movement and stretching help to alleviate the pain? Alternatively: does resting; lying down; supporting your legs with pillows, help to relieve the pain? Does applying heat or ice packs help? What happens to your pain with activities like: bending; stooping; picking up; carrying items; walking; standing; sitting; sleeping?
- You will probably be asked about: your walking distance; for how long you can sit at a time, and for how long you can stand? A good way of preparing for these questions would be to consider: your most recents activities at home or at work; thinking about how you were influenced during a day at the office, or when you went shopping.
What would your normal activity pattern pattern look like, before the pain started, and what does it look like now that the pain is influencing your daily program:
- What sporting and leisure time activities did you participate in and how have these been influenced by the symptoms? How has your working day been influenced? Have you been able to do your normal work or have you been put on sick leave? If you are on sick leave, how do you spend your time at present?
- Many patients would be expected to manage quite heavy manual labour. The statement often made by patients that “I have to lift and carry heavy items all day long” is seldom correct or helpful. It is worth the effort to be honest about the true nature of the work that is performed, and the practitioner would find it helpful to grade the expected load that is dealt with by specifics like: “ I lift weights between 5 and 15 kg roughly 30 to 40 times a day, having to carry them for about 10 meters before alternatively placing them on the floor, at waist level or above my head for roughly 3 to 4 hours a day.”
A helpful functional evaluation will give the practitioner the information on how aggressive the diagnostics and management plan should be.
Your honest interpretation of three scenarios helps this understanding:
- How is your quality of life impacted by your complaints? Interpret how you see yourself enjoying life?
- Do you manage the activities of daily living (ADL), e.g. dressing yourself, washing and performing the daily necessary ablutions?
- Is your ability to function normally at work influenced, and therefore your ability to generate an income by working jeopardised?
Also read “part two regarding Diagnosis“
Credit Featured Image: Albert_Anker_-_Schlafendes_Mädchen_auf_einer_Holzbank.jpg