Once a patient is in the exam room, what is involved in making a diagnosis?

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Steven V. Gurland, MD
Internal Medicine
 Once the patient is in the exam room the health care provider needs to take a detailed history from the patient finding out  what the patients symptoms are, what organ systems are involved and  what if anything makes the symptoms better or worse.Important additional information is family history,recent travel or recent  exposure to ill contacts.All this information helps the provider focus the physical exam to the specific parts of the body that  may result in findings that lead to the diagnosis.In other  circumstances laboratory testing will be needed to confirm or exclude the suspected diagnosis.

After a triage nurse determines which patient to see first, the patient is brought into the examination room. There, an emergency-department nurse will obtains more detailed information about the patient's condition. The nurse will get the patient into a gown so he or she can be examined properly. Some early tests, such as a urine sample, might be taken right away.

Some emergency departments have been subdivided into different areas to better serve their patients. These areas can include a pediatric (children?s) ER, a chest-pain ER, a fast track (for more routine injuries and illnesses), trauma center (for severely injured patients) and an observation unit (for those patients who do not require hospital admission but do need prolonged treatment or several diagnostic tests).

Once the nurse has finished, the patient will see an emergency-medicine physician. That doctor gets a more detailed medical history including information about the present illness, any past medical problems, the family history, a social history and a complete review of all the patient?s body systems. The doctor then formulates a list of possible causes for the symptoms. This list is called a differential diagnosis. The patient's symptoms and physical examination will help the doctor to make a diagnosis. If this information is not adequate to determine the diagnosis, then diagnostic tests are required.

When the emergency doctor has all the information he can obtain, he will make a determination of the most likely diagnosis, usually from his differential diagnosis list.

He may decide instead that he doesn't have enough information to make a decision and may need more tests. Sometimes, at this point, the doctor might speak to a specialist (such as a surgeon) for more diagnostic help.

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Important: This content reflects information from various individuals and organizations and may offer alternative or opposing points of view. It should not be used for medical advice, diagnosis or treatment. As always, you should consult with your healthcare provider about your specific health needs.