Diagnostic Tests and Procedures in Medical Examinations
Classified in Medicine & Health
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Diagnostic Tests and Procedures
Scanning and Recording (Tests Diagnosed Tics)
Clinical History is the initial interview with the doctor, where a thorough and systematic interrogation is conducted about the patient's history, current state, and finally completed with a physical exam and follow-up on their evolution.
All information is documented to form the clinical history, including surgical operations and procedures performed.
The clinical history comprises the following parts:
- Interrogation or Amnesis
- Physical Examination
- Tracking the Evolution of the Patient
1. Interrogation (Amnesis)
Personal History (of the patient): Name, age, marital status, address, etc.
Family History (Clinical): Information about relatives, including their health status, diseases, and causes of death.
Personal History (from childhood): Immunizations, allergies, interventions, etc.
Present Illness: Addressing three key questions:
- What is the problem?
- Since when has it been present?
- What do they attribute it to?
Data Collection: Researching signs and symptoms that may indicate pathology.
2. Physical Examination
Observing signs and symptoms to guide the diagnosis. The physical examination includes:
- Inspection
- Palpation
- Percussion
- Auscultation
Inspection: Observing the patient, analyzing their age, morphological and functional alterations.
Palpation: Using one or both hands to palpate different body parts to locate potential pain points or organic abnormalities (e.g., the size of some organs).
Percussion: Striking different parts or areas of the body with fingers to produce different sounds.
- Dull sound: When percussing areas that have no air.
- Tympanic sound: Results from vibration and air, heard in the stomach and intestine.
Auscultation: Listening to physiological or pathological sounds within the body, important for exploring lung and heart sounds, intestinal sounds, and the fetus during gestation.