Wiki User
∙ 12y agochief complaint
Wiki User
∙ 12y agoThe diagnosis remains uncertain because of the mildness of the patient's symptoms, the absence of a family history of the syndrome, and other variables. These borderline conditions are sometimes referred to as marfanoid syndromes.
The Present Chief Complaint tells about the major reason which resulted in the admission of a patient in a hospital or to visit a doctor. The History Of presenting complaint includes all the reasons that aggravated the present illness. It includes the past history of the present complaint.
The reason for the encounter is a history element because it provides context and background information about why the individual is seeking medical attention. It helps the healthcare provider understand the patient's current symptoms, concerns, and medical history to make an accurate diagnosis and treatment plan.
"Rule out" is another term for differential diagnosis. The differential is a list of possible conditions that could explain the patient's symptoms. Through continued history, exam, and lab/imaging studies, the clinician narrows the differential to come to a diagnosis. When reading "rule out" in a medical narrative, you can replace the phrase with the words "make sure it's not." So the phrase "chest pain, rule out myocardial infarction" can be read as "chest pain, make sure it's not a heart attack." differential diagnosis.
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Chief Complaint
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Clinical Diagnosis
Clinical Diagnosis
A clinical diagnosis is one based on observations during the history and physical. It doesn't involve laboratory or imaging to make the diagnosis.
History does not record the diagnosis.