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Diagnosis has been described as both a process and a classification scheme, or a “pre-existing set of categories agreed upon by the medical profession to designate a specific condition” (Jutel, 2009). When a diagnosis is accurate and made in a timely manner, a patient has the best opportunity for a positive health outcome because clinical decision making will be tailored to a correct understanding of the patient’s health problem (Holmboe and Durning, 2014).
The working diagnosis may be either a list of potential diagnoses (a differential diagnosis) or a single potential diagnosis. OVERVIEW OF THE DIAGNOSTIC PROCESS To help frame and organize its work, the committee developed a conceptual model to illustrate the diagnostic process (see Figure 2-1). Simple tools for understanding risks: From innumeracy to insight. The committee concluded that the diagnostic process is a complex, patient-centered, collaborative activity that involves information gathering and clinical reasoning with the goal of determining a patient’s health problem. Don’t be a thief—save your grade, use Bib Me™ and give credit to those who deserve it!As the Syrian Arab Red Crescent and the International Committee of the Red Cross (ICRC) resumed this morning evacuations from besieged neighbourhoods in eastern Aleppo, the United Nations reported that it has received authorization to send 20 international and national staff to the city to play a critical role in the monitoring and the response.Once a patient seeks health care, there is an iterative process of information gathering, information integration and interpretation, and determining a working diagnosis.
Performing a clinical history and interview, conducting a physical exam, performing diagnostic testing, and referring or consulting with other clinicians are all ways of accumulating information that may be relevant to understanding a patient’s health problem.
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Typically, clinicians will consider more than one diagnostic hypothesis or possibility as an explanation of the patient’s symptoms and will refine this list as further information is obtained in the diagnostic process.
The working diagnosis should be shared with the patient, including an explanation of the degree of uncertainty associated with a working diagnosis.
2 The Diagnostic Process This chapter provides an overview of diagnosis in health care, including the committee’s conceptual model of the diagnostic process and a review of clinical reasoning.