How to Diagnose an Illness

Begin the Investigation

"Misdiagnoses can cost lives" warns U.S. News and World Report. The evaluation of a patient begins with using your sight.The patient's physical appearance and reactions are major indicators of his or her condition. Investigate the patient's complaints of discomfort using careful observation and focused examination. Make a diagnosis based on your conclusions.

Instructions

Examine, Anayze, and Diagnose

1. 

   Conduct an Interview

   Interview the patient and determine what complaints about health have led him or her to seek treatment. Obtain information including patient allergies, chronic conditions, prescribed medications, history of illnesses, and history of alcohol or tobacco use.

2. 

   Physically Examine the Patient

   Perform a physical examination. The patient's "chief complaint" determines which area or body system will be examined, according to Clinical Medical Competency Handout. The order of the examination is determined by the patient's specific complaint.

3. 

   Analyze the Lab Results

   Consider which illnesses could cause your patient's symptoms, then narrow your choices in a process called the differential diagnosis.Order any lab tests that aid in narrowing the choices.Combine the lab test and examination results to determine the diagnosis.

Tips & Warnings

• Provide an accurate, legible record of the patient's examination and interview because the document may be used in legal proceedings, malpractice suits or to aid in recommending treatment at a later date.

• Include the following information in the medical record:

• Subjective observations - The patient's self-report of his condition

• Objective observations - Your measurements and observations from the examination

• Assessment - Your diagnosis and conclusions

• Plan - Next steps in the patient's care

• Remember that only a licensed physician can make a medical diagnosis that defines a disease or illness. (Resource 4, section "Nursing Diagnosis Vs. Medical Diagnosis")

• Ask questions about the diagnosis. "Physicians, even the most brilliant, makes a misdiagnosis or chooses the wrong therapy" on occasion according to "How Doctors Think." So the layman and physician both should question the diagnosis.(Reference 3, page 24, paragraph 1)

• Do not interrupt the patient as he describes his symptoms. The U.S. News warns patients that misdiagnosis often occurs if health care providers "interrupt you as you're describing your symptoms." (Reference 2, Paragraph 1)

• Before conducting the exam, ask the patient "if it is alright to perform the exam or to touch them. This keeps from alarming a patient or misinterpretation of an exam" counsels the Clinical Medical Competency Handbook. (Resource 1, page 8, first sentence).

• Don't order unnecessary lab tests. Also discuss the the tests and possible treatments with the patient. (Resource 1, page 9, paragraph 3,4)

References

• WD: What Does the Doctor Do in a Physical Examination
• US News and World Report: 6 Secrets to Getting the Right Diagnosis
• Google Books: How Doctors Think

Resources

• Edward Virginia College: Clinical Medical Competency Handout
• Web MD: Differential Diagnosis
• Nursing Link: Medical Record Keeping for Healthcare Providers
• NANDA: Nursing Diagnosis Frequently Asked Questions