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# What is suffocation?

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## Jul 14, 2010 ... Overview of Suffocation as a medical condition including introduction, prevalence, prognosis, profile, symptoms, diagnosis, misdiagnosis,

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Prognosis (Greek πρόγνωση - literally fore-knowing, foreseeing) is a medical term for predicting the likely outcome of one's current standing. When applied to large statistical populations, prognostic estimates can be very accurate: for example the statement "45% of patients with severe septic shock will die within 28 days" can be made with some confidence, because previous research found that this proportion of patients died. However, it is much harder to translate this into a prognosis for an individual patient: additional information is needed to determine whether a patient belongs to the 45% who will succumb, or to the 55% who survive. A complete prognosis includes the expected duration, the function, and a description of the course of the disease, such as progressive decline, intermittent crisis, or sudden, unpredictable crisis. Prognostic scoring is also used for cancer outcome predictions. A Manchester score is an indicator of prognosis in small-cell lung cancer. For Non-Hodgkin lymphoma, physicians have developed the International Prognostic Index to predict patient outcome. Other medical areas where prognostic indicators are used is in Drug-Induced Liver Injury (DILI) (Hy's law) and use of an exercise stress test as a prognostic indicator after myocardial infarction. Medical studies have demonstrated that most doctors are overly optimistic when giving prognostic information, that is, they tend to overstate how long a patient might live. For patients who are critically ill, particularly those in an intensive care unit, there are numerical prognostic scoring systems that are more accurate. The most famous of these is the APACHE II scale. However, this scale is most accurate when applied in the seven days prior to a patient's predicted death. Knowing the prognosis helps determine whether it makes more sense to attempt certain treatments or to withhold them, and thus plays an important role in end-of-life decisions. Estimators that are commonly used to describe prognoses include: For 19th century physicians, particularly those following the French school of medicine, the main aim of medicine was not to cure disease, but rather to give a medical diagnosis and achieve a satisfying prognosis of the patient's chances. Only several decades later did the focus of efforts in Western medicine shift to curing disease. Medical sign
Symptom
Syndrome Medical diagnosis
Differential diagnosis
Prognosis Acute
Chronic
Cure/Remission Disease
Eponymous disease
Acronym or abbreviation
A differential diagnosis (sometimes abbreviated DDx, ddx, DD, D/Dx, or ΔΔ) is a systematic diagnostic method used to identify the presence of an entity where multiple alternatives are possible (and the process may be termed differential diagnostic procedure), and may also refer to any of the included candidate alternatives (which may also be termed candidate condition). This method is essentially a process of elimination or at least of obtaining information that shrinks the "probabilities" of candidate conditions to negligible levels. The "probabilities" at issue are epistemic rather than ontological in that they are imaginative parameters in the mind of the diagnostician (or, for computerized or computer-assisted diagnosis, the software of the system), while in reality the target (such as a patient) either has a condition or not with an actual probability of either 0 or 100%. Differential diagnostic procedures are used by physicians, psychiatrists, and other trained medical professionals to diagnose the specific disease in a patient, or, at least, to eliminate any imminently life-threatening conditions. Differential diagnosis can be regarded as implementing aspects of the hypothetico-deductive method in the sense that the potential presence of candidate diseases or conditions can be viewed as hypotheses which are further processed as being true or false. There are various methods of performing a differential diagnostic procedure, but in general, it is based on the idea that one begins by considering the most common diagnosis first: a head cold versus meningitis, for example. As a reminder, medical students are taught the adage, "When you hear hoofbeats, look for horses, not zebras," which means look for the simplest, most common explanation first. Only after the simplest diagnosis has been ruled out should the clinician consider more complex or exotic diagnoses. Differential diagnosis has four steps. First, the physician should gather all information about the patient and create a symptoms list. The list can be in writing or in the physician's head, as long as he or she makes a list. Second, the physician should make a list of all possible causes (also termed "candidate conditions") of the symptoms. Again, this can be in writing or in the physician's head but it must be done. Third, the physician should prioritize the list by placing the most urgently dangerous possible cause of the symptoms at the top of the list. Fourth, the physician should rule out or treat the possible causes beginning with the most urgently dangerous condition and working his or her way down the list. "Rule out" practically means to use tests and other scientific methods to render a condition of clinically negligible probability of being the cause. In some cases, there will remain no diagnosis; this suggests the physician has made an error, or that the true diagnosis is unknown to medicine. Removing diagnoses from the list is done by making observations and using tests that should have different results, depending on which diagnosis is correct. Mnemonics are routinely taught to medical students to ensure that all possible pathological processes are considered, for example VINDICATE: There are several methods for performing a differential diagnostic procedure, and several variants among those in turn. Furthermore, a differential diagnostic procedure can be used concomitantly or switchingly with protocols, guidelines or other diagnostic procedures (such as pattern-recognition or using medical algorithms). For example, in case of medical emergency, there may not be enough time to do any detailed calculations or estimations of different probabilities, in which case the ABC protocol may be more appropriate. At a later, less acute, situation, there may be a switch to a more comprehensive differential diagnostic procedure. The differential diagnostic procedure may be easier in the finding of a pathognomonic sign or symptom, in which it is almost certain that the target condition is present, and in the absence of finding a sine qua non sign or symptom, in which case it is almost certain that the target condition is absent. In reality, however, the subjective probability of the presence of a condition is never exactly 100% or 0%, so in reality the procedure is usually aimed at specifying the various probabilities in order to form indications for further actions. One method of performing a differential diagnosis by epidemiology aims to estimate the probability of each candidate condition by comparing their probabilities to have occurred in the first place in the individual. It is based on probabilities related both to the presentation (such as pain) and probabilities of the various candidate conditions (such as diseases). The probability that a presentation or condition would have occurred in the first place in an individual is not same as the probability that the presentation or condition has occurred in the individual, because the presentation has occurred by 100% certainty in the individual. Yet, the contributive probability fractions of each condition are assumed to be the same, relatively: $\frac{P(Presentation~is~caused~by~condition~in~individual)}{P(Presentation~has~occurred~in~individual)} = \frac {P(Presentation~WHOIFPI~by~condition)}{P(Presentation~WHOIFPI)}$ , where: P(Presentation has occurred in individual) is 100% and can therefore be replaced by 1, and can be ignored since division by 1 does not make any difference: $P(Presentation~is~caused~by~condition~in~individual) = \frac {P(Presentation~WHOIFPI~by~condition)}{P(Presentation~WHOIFPI)}$ The total probability of the presentation to have occurred in the individual can be approximated as the sum of the individual candidate conditions: \begin{align} P(Presentation~WHOIFPI) = P(Presentation~WHOIFPI~by~condition~1) + \\ P(Presentation~WHOIFPI~by~condition~2) + \\ P(Presentation~WHOIFPI~by~condition~3) + etc \end{align} Also, the probability of the presentation to have been caused by any candidate condition is proportional to the probability of the condition, depending on what rate it causes the presentation: $P(Presentation~WHOIFPI~by~condition) = P(Condition~WHOIFPI) * r_{condition \rightarrow presentation}$ , where: The probability that a condition would have occurred in the first place in an individual is approximately equal to that of a population that is as similar to the individual as possible except for the current presentation, compensated where possible by relative risks given by known risk factor that distinguish the individual from the population: $P(Condition~WHOIFPI) \approx RR_condition * P(Condition~in~population)$ , where: The following table demonstrates how these relations can be made for a series of candidate conditions: One additional "candidate condition" is the instance of there being no abnormality, and the presentation is only a (usually relatively unlikely) appearance of a basically normal state. Its probability in the population (P(No abnormality in population)) is complementary to the sum of probabilities of "abnormal" candidate conditions. This example case is made to demonstrate how this method may be applied, but does not intend to be a guideline for handling similar cases in reality. Also, the example uses relatively specified numbers with sometimes several decimals, while in reality there are often simply rough estimations, such as of likelihoods being "very high", "high", "low" or "very low", but still using the general principles of the method. For an individual (who becomes the "patient" in this example), a blood test of, for example, serum calcium shows a result just above the standard reference range, which, by most definitions, classifies as hypercalcemia, which becomes the "presentation" in this case. A physician (who becomes the "diagnostician" in this example), who does not currently see the patient, gets to know about his finding. By practical reasons, the physician considers that there is enough test indication to have a look at the patient’s medical records. For simplicity, let’s say that the only information given in the medical records is a family history of primary hyperparathyroidism (here abbreviated as PH), which may explain the finding of hypercalcemia. For this patient, let’s say that the resultant hereditary risk factor is estimated to confer a relative risk of 10 (RRPH = 10). The physician considers that there is enough motivation to perform a differential diagnostic procedure for the finding of hypercalcemia. The main causes of hypercalcemia are primary hyperparathyroidism (PH) and cancer, so for simplicity, the list of candidate conditions that the physician could think of can be given as: The probability that primary hyperparathyroidism (PH) would have occurred in the first place in the individual (P(PH WHOIFPI)) can be calculated as follows:
Let’s say that the last blood test taken by the patient was half a year ago and was normal, and that the incidence of primary hyperparathyroidism in a general population that appropriately matches the individual (except for the presentation and mentioned heredity) is 1 in 4000 per year. Ignoring more detailed retrospective analyses (such as including speed of disease progress and lag time of medical diagnosis), the time-at-risk for having developed primary hyperparathyroidism can roughly be regarded as being the last half-year, because a previously developed hypercalcemia would probably have been caught up by the previous blood test. This corresponds to a probability of primary hyperparathyroidism (PH) in the population of: $P(PH~in~population) = 0.5~years * \frac{1}{4000~per~year} = \frac{1}{8000}$ With the relative risk conferred from the family history, the probability that primary hyperparathyroidism (PH) would have occurred in the first place in the individual given from the currently available information becomes: $P(PH~WHOIFPI) \approx \frac {1}{8000} * 10 = \frac {1}{800} = 0.00125 =$ Primary hyperparathyroidism can be assumed to cause hypercalcemia essentially 100% of the time (rPH &rarr hypercalcemia = 1), so this independently calculated probability of primary hyperparathyroidism (PH) can be assumed to be the same as the probability of being a cause of the presentation: \begin{align} P(Hypercalcemia~WHOIFPI~by~PH) = P(PH~WHOIFPI) * r_{PH \rightarrow hypercalcemia} = \\ 0.00125 * 1 = 0.00125 \end{align} For cancer, the same time-at-risk is assumed for simplicity, and let’s say that the incidence of cancer in the area is estimated at 1 in 250 per year, giving an population probability of cancer of: $P(cancer~in~population) = 0.5~years * \frac{1}{250~per~year} = \frac{1}{500}$ For simplicity, let’s say that any association between a family history of primary hyperparathyroidism and risk of cancer is ignored, so the relative risk for the individual to have contracted cancer in the first place is similar to that of the population (RRcancer = 1): $P(cancer~WHOIFPI) \approx \frac{1}{500} * 1 = \frac{1}{500} = 0.002$ However, hypercalcemia only occurs in, very approximately, 10% of cancers, (rcancer &rarr hypercalcemia = 0.1), so: \begin{align}P(Hypercalcemia~WHOIFPI~by~cancer) = \\ P(cancer~WHOIFPI) * r_{cancer \rightarrow hypercalcemia} = \\ 0.002 * 0.1 = 0.0002 \end{align} The probabilities that hypercalcemia would have occurred in the first place by other candidate conditions can be calculated in a similar manner. However, for simplicity, let’s say that the probability that any of these would have occurred in the first place is calculated to be 0.0005 in this example. For the instance of there being no disease, the corresponding probability in the population is complementary to the sum of probabilities for other conditions: \begin{align}P(no~disease~in~population) = 1 - P(PH~in~population) - \\ P(cancer~in~population) - P(other~conditions~in~population = 0.997 \end{align} The probability that the individual would be healthy in the first place can be assumed to be the same: $P(no~disease~WHOIFPI) = 0.997$ The rate at which the case of no abnormal condition still ends up in a measurement of serum calcium of being above the standard reference range (thereby classifying as hypercalcemia) is, by the definition of standard reference range, less than 2.5%. However, this probability can be further specified by considering how much the measurement deviates from the mean in the standard reference range. Let’s say that the serum calcium measurement was 1.30 mmol/L, which, with a standard reference range established at 1.05 to 1.25 mmol/L, corresponds to a standard score of 3 and a corresponding probability of 0.14% that such degree of hypercalcemia would have occurred in the first place in the case of no abnormality: $r_{no~disease \rightarrow hypercalcemia} = 0.0014$ Subsequently, the probability that hypercalemia would have resulted from no disease can be calculated as: \begin{align} P(Hypercalcemia~WHOIFPI~by~no~disease) = \\ P(no~disease~WHOIFPI) * r_{no~disease \rightarrow hypercalcemia} = \\ 0.997 * 0.0014 \approx 0.0014 \end{align} The probability that hypercalcemia would have occurred in the first place in the individual can thus be calculated as: \begin{align} P(hypercalcemia~WHOIFPI) = \\ P(hypercalcemia~WHOIFPI~by~PH) + P(hypercalcemia~WHOIFPI~by~cancer) + \\ P(hypercalcemia~WHOIFPI~by~other~conditions) + P(hypercalcemia~WHOIFPI~by~no~disease) = \\ 0.00125 + 0.0002 + 0.0005 + 0.0014 = 0.00335 \end{align} Subsequently, the probability that hypercalcemia is caused by primary hyperparathyroidism (PH) in the individual can be calculated as: \begin{align} P(hypercalcemia~is~caused~by~PH~in~individual) = \\ \frac {P(hypercalcemia~WHOIFPI~by~PH)}{P(hypercalcemia~WHOIFPI)} = \\ \frac {0.00125}{0.00335} = 0.373 = 37.3% \end{align} Similarly, the probability that hypercalcemia is caused by cancer in the individual can be calculated as: \begin{align} P(hypercalcemia~is~caused~by~cancer~in~individual) = \\ \frac {P(hypercalcemia~WHOIFPI~by~cancer)}{P(hypercalcemia~WHOIFPI)} = \\ \frac {0.0002}{0.00335} = 0.060 = 6.0% \end{align} , and for other candidate conditions: \begin{align} P(hypercalcemia~is~caused~by~other conditions~in~individual) = \\ \frac {P(hypercalcemia~WHOIFPI~by~other~conditions)}{P(hypercalcemia~WHOIFPI)} = \\ \frac {0.0005}{0.00335} = 0.149 = 14.9% \end{align} , and the probability that there actually is no disease: \begin{align} P(hypercalcemia~is~present~despite~no~disease~in~individual) = \\ \frac {P(hypercalcemia~WHOIFPI~by~no~disease)}{P(hypercalcemia~WHOIFPI)} = \\ \frac {0.0014}{0.00335} = 0.418= 41.8% \end{align} For clarification, these calculations are given as the table in the method description: Thus, this method estimates that the probabilities that the hypercalcemia is caused by primary hyperparathyroidism, cancer, other conditions or no disease at all are 37.3%, 6.0%, 14.9% and 41.8%, respectively, which may be used in estimating further test indications. This case is continued in the example of the method described in the next section. The procedure of differential diagnosis can become extremely complex if it would fully take additional tests and treatments into consideration. One method that is somewhat a tradeoff between being clinically perfect and being relatively simple to calculate is one that assigns two kinds of likelihood parameters for each disease or other condition that is included in the list of differential diagnoses; one independently calculated odds in favor of the condition, and one probability that is relative to the entire profile of conditions and their odds respectively. For each candidate condition, this method first estimates an independently calculated odds in favor, which initially corresponds to the probability that the individual would have developed the condition in the first place, as used in the previously mentioned method using epidemiology. If previously calculated as a probability, it can be converted to odds in favor by: $odds = \frac{probability}{1-probability}$ These independently calculated odds in favor, in the format of their value to one, are summed together in this method, and the resultant value is be used to estimate a profile-relative probability for each candidate condition, as follows: $PRP_{condition} \approx \frac {ICO_{condition}}{ICO_{all}}$ , where: The profile-relative probabilities correspond to the probabilities of each condition of causing the presentation (P(Presentation is caused by condition in individual)), and are more clinically useful than the individually calculated odds, similarly to that the probabilities of conditions having occurred are more clinically useful than that the conditions would have occurred in the first place as mentioned in the epidemiology-based method. Therefore, it is the profile-relative probabilities that are used for estimating the indications for further medical tests, treatments or other actions in this method. If there is an indication for a test, and it returns with a result, then the procedure is repeated by making new estimations of independently calculated odds for candidate conditions where they have likely changed, in turn likely resulting in a different sum of all independently calculated odds, and thereby different profile-relative probabilities. With different profile-relative probabilities, the indications for further tests, treatments or other actions have changed as well, and are therefore estimated anew, and so the procedure can be repeated until an end point where there no longer is any indication for currently performing further actions. Such an end point mainly occurs when one candidate condition becomes so certain that no test can be found that is powerful enough to change the relative probability-profile enough to motivate any current change in further actions. Tactics for reaching such an end point with as few tests as possible includes making tests with high specificity for conditions of already outstandingly high profile-relative probability, because the high likelihood ratio positive for such tests is very high, bringing all less likely conditions to relatively lower probabilities. Alternatively, tests with high sensitivity for competing candidate conditions, such tests have a high likelihood ratio negative, potentially bringing the probabilities for competing candidate conditions to negligible levels. If such negligible probabilities are achieved, these conditions can be decided to be ruled out, and the differential diagnostic procedure continues with only the remaining candidate conditions. Comparing to the previously mentioned epidemiology-based method, this method can be used with much more ease for including additional tests. However, this method is not so good at establishing initial probabilities, but can, on the other hand, be a good complementing method upon which to continue previously calculated probabilities from, for example, an epidemiology-based method. This example continues for the same patient as in the example for the epidemiology-based method. As with the previous example of epidemiology-based method, this example case is made to demonstrate how this method may be applied, but does not intend to be a guideline for handling similar cases in reality. Also, the example uses relatively specified numbers, while in reality there are often just rough estimations. The probabilities that the presentation would have occurred in the first place for each condition ("P(Presentation WHOIFPI by condition) can initially be set as the individually calculated probabilities, and the resultant probabilities of each condition of causing the presentation can initially be set as the profile relative probabilities: The condition of highest profile-relative probability (except “no disease”) is primary hyperparathyroidism (PH), but cancer is still of major concern, because if it is the actual causative condition for the hypercalcemia, then the choice of whether to treat or not likely means life or death for the patient, in effect potentially putting the indication at a similar level for further tests for both of these conditions. Here, let’s say that the physician considers the profile-relative probabilities of being of enough concern to indicate to send the patient a call for a doctor's visit, with an additional visit to the medical laboratory for an additional blood test complemented with further analyses, including parathyroid hormone for the suspicion of primary hyperparathyroidism. For simplicity, let’s say that the doctor first receives the result for the parathyroid hormone analysis, and that it showed a parathyroid hormone level that is elevated relatively to what would be expected by the calcium level. Such a constellation can be estimated to have a sensitivity of approximately 70% and a specificity of approximately 90% for primary hyperparathyroidism. This confers a likelihood ratio positive of 7 for primary hyperparathyroidism. The target value in this method is the independently calculated odds in favor of primary hyperparathyroidism, denoted Pre-CaP because it corresponds to before (Latin preposition prae means before) the calcium- and parathyroid hormone related test. $PreCaP~ICO_{PH} = \frac{PreCaP~ICP_{PH}}{1- (PreCaP~ICP_{PH})}$ , where: $ICO_{PH} = \frac{0.00125}{1- 0.00125} \approx 0.00125$ Here, the difference between odds and probability is negligible because the value is very low. The same can be done for the other candidate conditions, also resulting in negligible differences between odds and probabilities (although such differences can be substantial at higher values): With the likelihood ratio positive of 7 for the calcium- and parathyroid hormone related test, the post-test odds is calculated as: $PostCaP~ICO_{PH} = PreCaP~ICP_{PH} * LH+ = 0.00875$ , where: Subsequently, the sum of all independently calculated odds after the calcium- and parathyroid hormone related test becomes: $PostCaP~ICO_{all} = 0.00875 + 0.0002 + 0.0005 + 0.0014 = 0.01085$ The profile-relative probability for primary hyperparathyroidism (PH) after this test is calculated as: $PostCaP~PRP_{PH} \approx \frac {PostCaP~ICO_{PH}}{ PostCaP~ICO_{all}} = 0.806 = 80.6%$ , where: These are calculated similarly for the other conditions, but in this case with independently calculated post-test odds being same as pre-test odds, resulting as: These “new” percentages, including a profile-relative probability of 80% for primary hyperparathyroidism, underlie any indications for further tests, treatments or other actions. In this case, let's say that the physician continues the plan for the patient to attend a doctor's visit for further checkup, especially focused at primary hyperparathyroidism. A doctor's visit can, theoretically, be regarded as a series of tests, including both questions in a medical history and components of a physical examination, where the post-test probability of a previous test can be used as the pre-test probability of the next. The indications for choosing the next test is dynamically influenced by the results of previous tests. Let's say that the patient in this example is revealed to have depression, bone pain, joint pain and constipation of more severerity than what would be expected by the hypercalcemia itself, supporting the suspicion of primary hyperparathyroidism, and let's say that the likelihood ratios for the tests, when multiplied together, roughly results in a product of 10 for primary hyperparathyroidism. All the tests of the history and examination can concomitantly be used to estimate likelihood ratios for the presence of cancer, and let's say that the product of the likelihood ratios is estimated to be 3. Tests for other conditions were basically all negative, and let's say that the resultant probability after the history and examination becomes 0.0005. Continuing from the calcium- and parathyroid hormone related test, its post-test independently calculated odds are used as pre-test independently calculated odds for the medical history and physical examination (here abbreviated as H&E), with the ensuing calculations following the same overall pattern as the previous calcium- and parathyroid hormone related test: These profile relative probabilities after the history and examination may make the physician confident enough to plan the patient for surgery for a parathyroidectomy to resect the affected tissue. At this point, the profile-relative probability of "other conditions" is so low that the physician cannot think of any test for them that could make a difference that would be substantial enough to form an indication for such a test, and the physician thereby regards "other conditions" as ruled out, in this case not primarily by specific test for such other conditions that were negative, but rather by the absence of positive tests so far. For "cancer", the cutoff at which to confidently regard it as ruled out may be more stringent because of severe consequences of missing it, so the physician may consider that at least a histopathologic examination of the resected tissue is indicated. This case is continued in the example of Combinations in corresponding section below. The validity of both methods described above are dependent of inclusion of candidate conditions that are responsible for as large part as possible of the probability of having developed the condition, and it's clinically important to include those where relatively fast initiation of therapy is most likely to result in greatest benefit. The need to find more candidate conditions for inclusion increases with increasing severity of the presentation itself. For example, if the only presentation is a deviating laboratory parameter and all common harmful underlying conditions have been ruled out, then it may be acceptable to stop finding more candidate conditions, but this would much more likely be unacceptable if the presentation would have been severe pain. If two conditions appear as certain by their independently calculated probabilities, then there is a strong indication that the condition is a combination of the two, which can be added to the list of candidate conditions and be calculated independently for further evaluation. To continue the example used in independently and profile-relative probabilities, let's say that the ensuing surgery and histopathologic examination of the resected tissue confirms primary hyperparathyroidism, having a very high specificity, and let's say that it gives a likelihood ratio of 1000 in this case. However, let's also say that the histopathologic examination also showed a malignant pattern, and let's say that this pattern gives a likelihood ratio for cancer of 1000 as well. The resultant independently calculated odds in favor of primary hyperparathyroidism and cancer become 87.5 and 0.6, respectively, with profile-relative probabilities of 99.3% and 0.7%, respectively. However, at this point, the individually calculated odds in favor of cancer of 0.6, corresponding to an individually calculated probability of 37.5%, are high enough to consider that the patient actually has a combination of primary hyperparathyroidism and cancer, that is, in this case, parathyroid carcinoma. To evaluate its possibility by this method, the combination can be added to the list of candidate conditions, followed by processing by every relevant test performed so far. By an initial method by epidemiology, the incidence of parathyroid carcinoma is estimated at about 1 in 6 million people per year, giving a very low probability before taking any tests into consideration. Still, the probability that a non-malignant primary hyperparathyroidism would have occurred at the same time as an unrelated non-carcinoma cancer that presents with malignant cells in the parathyroid gland is calculated by multiplying the probabilities of the two, resulting in a negligible probability in comparison. So, focusing on parathyroid carcinoma, let's say that a review in regard to the subsequent blood tests, medical history, physical examination, surgery observations and histopathological examination result in rather high likelihood ratios, in turn resulting in a profile-relative probability high enough for an indication for making a confirmatory test for parathyroid cancer. In reality, the histopathologist may have recognized parathyroid carcinoma by pattern-recognition directly and, with or without specific tissue processing, may have given a certain diagnostic opinion of parathyroid carcinoma. Let's finally say that the diagnosis of parathyroid carcinoma resulted in an extended surgery that removed remaining malignant tissue before it had metastasized, and the patient lived happily ever after. Machine differential diagnosis is the use of computer software to partly or fully make a differential diagnosis. It may be regarded as an application of artificial intelligence. Many studies demonstrate improvement of quality of care and reduction of medical errors by using such decision support systems. Some of these systems are designed for a specific medical problem such as schizophrenia, Lyme disease or ventilator-associated pneumonia. Others such as ESAGIL, Iliad, QMR, DiagnosisPro, VisualDx, Isabel, and ZeroMD are designed to cover all major clinical and diagnostic findings to assist physicians with faster and more accurate diagnosis. However, these tools all still require advanced medical skills in order to rate the symptoms and choose additional tests to deduce the probabilities of different diagnoses. Thus, non-professionals still need to see a health care provider in order to get a proper diagnosis. The method of differential diagnosis was first suggested for use in the diagnosis of mental disorders by Emil Kraepelin. It is more systematic than the old-fashioned method of diagnosis by gestalt (impression).][ Differential diagnosis is also used more loosely, to refer simply to a list of the most common causes of a given symptom, to a list of disorders similar to a given disorder, or to such lists when they are annotated with advice on how to narrow the list down (the book French's Index of Differential Diagnosis, ISBN 0-340-81047-5, is an example). Thus, a differential diagnosis in this sense is medical information specially organized to aid in diagnosis. Methods similar to those of differential diagnostic processes in medicine are also is used by biological taxonomists to identify and classify organisms, living and extinct. For example, after finding an unknown species, there can first be a listing of all potential species, followed by ruling out of one by one until, optimally, only one potential choice remains. Medical sign
Symptom
Syndrome Medical diagnosis
Differential diagnosis
Prognosis Acute
Chronic
Cure/Remission Disease
Eponymous disease
Acronym or abbreviation CC  HPI (OPQRST)  ROS  Allergies/Medications  PMH/PSH/FH/SH
Lungs: Respiratory sounds
Heart: Precordium (Heart sounds, Apex beat)
In medicine, comorbidity is either the presence of one or more disorders (or diseases) in addition to a primary disease or disorder, or the effect of such additional disorders or diseases. In medicine, the term "comorbid" can be either medical condition(s) existing simultaneously but independently with another condition, —or it can indicate medical condition(s) in a patient that are related to another condition. In psychiatric diagnoses it has been argued in part that this "'use of imprecise language may lead to correspondingly imprecise thinking', [and] this usage of the term 'comorbidity' should probably be avoided." In medicine, comorbidity describes the effect of all other diseases an individual patient might have other than the primary disease of interest. Many tests attempt to standardize the "weight" or value of comorbid conditions, whether they are secondary or tertiary illnesses. Each test attempts to consolidate each individual comorbid condition into a single, predictive variable that measures mortality or other outcomes. Researchers have validated such tests because of their predictive value, but no one test is as yet recognized as a standard. The term "comorbid" has two definitions: The Charlson comorbidity index predicts the ten-year mortality for a patient who may have a range of comorbid conditions, such as heart disease, AIDS, or cancer (a total of 22 conditions). Each condition is assigned a score of 1, 2, 3, or 6, depending on the risk of dying associated with each one. Scores are summed to provide a total score to predict mortality. Many variations of the Charlson comorbidity index have been presented, including the Charlson/Deyo, Charlson/Romano, Charlson/Manitoba, and Charlson/D'Hoores comorbidity indices. Clinical conditions and associated scores are as follows: For a physician, this score is helpful in deciding how aggressively to treat a condition. For example, a patient may have cancer with comorbid heart disease and diabetes. These comorbidities may be so severe that the costs and risks of cancer treatment would outweigh its short-term benefit. Since patients often do not know how severe their conditions are, nurses were originally supposed to review a patient's chart and determine whether a particular condition was present in order to calculate the index. Subsequent studies have adapted the comorbidity index into a questionnaire for patients. The Elixhauser comorbidity measure was developed using administrative data from a statewide California inpatient database from all non-federal inpatient community hospital stays in California (n = 1,779,167). The Elixhauser comorbidity measure developed a list of 30 comorbidities relying on the ICD-9-CM coding manual. The comorbidities were not simplified as an index because each comorbidity affected outcomes (length of hospital stay, hospital changes, and mortality) differently among different patients groups. The comorbidities identified by the Elixhauser comorbidity measure are significantly associated with in-hospital mortality and include both acute and chronic conditions. Walraven et al. has derived and validated an Elixhauser comorbidity index that summarizes disease burden and can discriminate for in-hospital mortality. In addition, a systematic review and comparative analysis shows that among various comorbidities indices, Elixhauser index is a better predictor of the risk especially beyond 30 days of hospitalisation. Patients who are more seriously ill tend to require more hospital resources than patients who are less seriously ill, even though they are admitted to the hospital for the same reason. Recognizing this, the diagnosis-related group (DRG) manually splits certain DRGs based on the presence of secondary diagnoses for specific complications or comorbidities (CC). The same applies to Healthcare Resource Groups (HRGs) in the UK. In psychiatry, psychology and mental health counseling comorbidity refers to the presence of more than one diagnosis occurring in an individual at the same time. However, in psychiatric classification, comorbidity does not necessarily imply the presence of multiple diseases, but instead can reflect our current inability to supply a single diagnosis that accounts for all symptoms. On the DSM Axis I, Major Depressive Disorder is a very common comorbid disorder. The Axis II personality disorders are often criticized because their comorbidity rates are excessively high, approaching 60% in some cases, indicating to critics the possibility that these categories of mental illness are too imprecisely distinguished to be usefully valid for diagnostic purposes and, thus, for deciding how treatment resources should be allocated. The term 'comorbidity' was introduced in medicine by Feinstein (1970) to denote those cases in which a 'distinct additional clinical entity' occurred during the clinical course of a patient having an index disease. Although the term has recently become very fashionable in psychiatry, its use to indicate the concomitance of two or more psychiatric diagnoses is said to be incorrect because in most cases it is unclear whether the concomitant diagnoses actually reflect the presence of distinct clinical entities or refer to multiple manifestations of a single clinical entity. It has been argued that because "'the use of imprecise language may lead to correspondingly imprecise thinking', this usage of the term 'comorbidity' should probably be avoided". Due to its artifactual nature, psychiatric comorbidity has been considered as a Kuhnian anomaly leading the DSM to a scientific crisis and a comprehensive review on the matter considers comorbidity as an epistemological challenge to modern psychiatry. Many centuries ago the doctors propagated the viability of a complex approach in the diagnosis of disease and the treatment of the patient, however modern medicine, which boasts a wide range of diagnostic methods and variety of therapeutic procedures, stresses specification. This brought up a question: How to wholly evaluate the state of a patient who suffers from a number of diseases simultaneously, where to start from and which disease(s) require(s) primary and subsequent treatment? For many years this question stood out unanswered, until 1970, when a renowned American doctor epidemiologist and researcher, A.R. Feinstein, who had greatly influenced the methods of clinical diagnosis and particularly methods used in the field of clinical epidemiology, came out with the term of “comorbidity”. The appearance of comorbidity was demonstrated by Dr. Feinstein using the example of patients physically suffering from rheumatic fever, discovering the worst state of the patients, who simultaneously suffered from multiple diseases. In due course of time after its discovery, comorbidity was distinguished as a separate scientific-research discipline in many branches of medicine. Presently there is no agreed-upon terminology of comorbidity. Some authors bring forward different meanings of comorbidity and multi-morbidity, defining the former, as the presence of a number of diseases in a patient, connected to each other through proven pathogenetic mechanisms and the latter, as the presence of a number of diseases in a patient, not having any connection to each other through any of the proven till date pathogenetic mechanisms. Others affirm that multi-morbidity is the combination of a number of chronic or acute diseases and clinical symptoms in a person and do not stress the similarities or differences in their pathogenesis. However the principle clarification of the term was given by H. C. Kraemer and M. van den Akker, determining comorbidity as the combination in a patient of 2 or more chronic diseases (disorders), pathogenetically related to each other or coexisting in a single patient independent of each disease’s activity in the patient. Widespread study of physical and mental pathology found its place in psychiatry. I. Jensen (1975), J.H. Boyd (1984), W.C. Sanderson (1990), Y. L. Nuller (1993), D.L. Robins (1994), A. B. Smulevich (1997), C.R. Cloninger (2002) and other renowned psychiatrists devoted many years for the discovery of a number of comorbid conditions in patients suffering from most diverse psychiatric disorders. These very researchers developed the first models of comorbidity. Some of the models studied comorbidity as the presence in a person (patient) of more than one disorders (diseases) at a certain period of life, whereas the others elaborated the relative risk, for a person having one disease, of picking up other disorders.][ The influence of comorbidity on the clinical progression of the primary (basic) physical disorder, effectiveness of the medicinal therapy and immediate and long-term prognosis of the patients was researched by talented physicians and scientists of various medical fields in many countries across the globe. These scientists and physicians included: M.H. Kaplan (1974), T. Pincus (1986), M.E. Charlson (1987), F.G. Schellevis (1993), H.C.Kraemer (1995), M. van den Akker (1996), A. Grimby (1997), S. Greenfield (1999), M. Fortin (2004) & A. Vanasse (2004), C. Hudon (2005), L. B. Lazebnik (2005), A. L.Vertkin (2008), G.E. Caughey (2008), F. I. Belyaov (2009), L. A. Luchikhin (2010) and many others. Comorbidity is wide spread among the patients admitted at multidiscipline hospitals. During the phase of initial medical help, the patients having multiple diseases simultaneously are a norm rather than an exception. Prevention and treatment of chronic diseases declared by the World Health Organization, as a priority project for the second decade of the 20th century, are meant to better the quality of the global population. This is the reason for an overall tendency of large-scale epidemiological researches in different medical fields, carried-out using serious statistical data. In most of the carried-out, randomized, clinical researches the authors study patients with single refined pathology, making comorbidity an exclusive criterion. This is why it is hard to relate researches, directed towards the evaluation of the combination of ones or the other separate disorders, to works regarding the sole research of comorbidity. The absence of a single scientific approach to the evaluation of comorbidity leads to omissions in clinical practice. It is hard not to notice the absence of comorbidity in the taxonomy (systematics) of disease, presented in ICD-10.][ All the fundamental researches of medical documentation, directed towards the study of the spread of comorbidity and influence of its structure, were conducted till the 1990s. The sources of information, used by the researchers and scientists, working on the matter of comorbidity, were case histories, hospital records of patients and other medical documentation, kept by family doctors, insurance companies and even in the archives of patients in old houses. The listed methods of obtaining medical information are mainly based on clinical experience and qualification of the physicians, carrying out clinically, instrumentally and laboratorially confirmed diagnosis. This is why despite their competence, they are highly subjective. No analysis of the results of postmortem of deceased patients was carried out for any of the comorbidity researches. "It is the duty of the doctor to carry out autopsy of the patients they treat", said once professor M. Y. Mudrov. Autopsy allows you to exactly determine the structure of comorbidity and the direct cause of death of each patient independent of his/her age, gender and gender specific characteristics. Statistical data of comorbid pathology, based on these sections, are mainly devoid of subjectivism. The analysis of a decade long Australian research based on the study of patients having 6 widespread chronic diseases demonstrated that nearly half of the aged patients with arthritis also had hypertension, 20% had cardiac disorders and 14% had type 2 diabetes. More than 60% of asthmatic patients complained of concurrent arthritis, 20% complained of cardiac problems and 16% had type 2 diabetes. In aged patients with chronic nephatony the frequency of coronary heart diseases is 22% higher and new coronary events are 3.4 times higher as compared to patients without kidney function disorders. During the progression of ESRF, requiring substitutive therapy, the frequency of chronic forms of CHD is 24.8% and of cardiac accident is 8.7%. A Canadian research conducted upon 483 obesity patients, it was determined that spread of obesity related accompanying diseases was higher among females than males. The researchers discovered that nearly 75% of obesity patients had accompanying diseases, which mostly included dyslipidemia, hypertension and type 2 diabetes.It is to be noted that among the young obesity patients (from 18 to 29) more than two chronic diseases were found in 22% males and 43% females. Fibromyalgia is a condition which is comorbid with several others, including but not limited to; depression, anxiety, headache, irritable bowel syndrome, chronic fatigue syndrome, systemic lupus erythematosus, rheumatoid arthritis, migraine, and panic disorder. The number of comorbid diseases increases with age. Comorbidity increases by 10% in ages up to 19 years, up to 80% in people of ages 80 and older. According to data by M. Fortin, based on the analysis of 980 case histories, taken from daily practice of a family doctor, the spread of comorbidity is from 69% in young patients, up to 93% among middle aged people and up to 98% patients of older age groups. At the same time the number of chronic diseases varies from 2.8 in young patients and 6.4 among older patients. According to Russian data, based on the study of more than three thousand postmortem reports (n=3239) of patients of physical pathologies, admitted at multidisciplinary hospitals for the treatment of chronic disorders (average age 67.8 ± 11.6 years), the frequency of comorbidity is 94.2%. Doctors mostly come across a combination of two to three disorders, but in rare cases (up to 2.7%) a single patient carried a combination of 6–8 diseases simultaneously. The fourteen-year research conducted on 883 patients of idiopathic thrombocytopenic purpura (Werlhof disease), conducted in Great Britain, shows that the given disease is related to a wide range of physical pathologies. In the comorbid structure of these patients, most frequently present are malignant neoplasms, locomotorium disorders, skin and genitourinary system disorders, as well as haemorrhagic complications and other autoimmune diseases, the risk of whose progression during the first five years of the primary disease exceeds the limit of 5%. In a research conducted on 196 larynx cancer patients, it was determined that the survival rate of patients at various stages of cancer differs depending upon the presence or absence of comorbidity. At the first stage of cancer the survival rate in the presence of comorbidity is 17% and in its absence it is 83%, in the second stage of cancer the rate of survivability is 14% and 76%, in the third stage it is 28% and 66% and in the fourth stage of cancer it is 0% and 50% respectively. Overall the survivability rate of comorbid larynx cancer patients is 59% lower than the survivability rate of patients without comorbidity. Except for therapists and general physicians, the problem of comorbidity is also often faced by specialists. Regretfully they seldom pay attention to the coexistence of a whole range of disorders in a single patient and mostly conduct the treatment of specific to their specialization diseases. In current practice urologists, gynecologists, ENT specialists, eye specialists, surgeons and other specialists all too often mention only the diseases related to “own” field of specialization, passing on the discovery of other accompanying pathologies “under the control” of other specialists. It has become an unspoken rule for any specialized department to carry out consultations of the therapist, who feels obliged to carry out symptomatic analysis of the patient, as well as the to form the diagnostic and therapeutic concept, taking in view the potential risks for the patient and his long-term prognosis.][ Based on the available clinical and scientific data it is possible to conclude that comorbidity has a range of undoubted properties, which characterize it as a heterogeneous and often encountered event, which enhances the seriousness of the condition and worsens the patient’s prospects. The heterogeneous character of comorbidity is due to the wide range of reasons causing it. The factors responsible for the development of comorbidity can be chronic infections, inflammations, involutional and systematic metabolic changes, iatrogenesis, social status, ecology and genetic susceptibility. The division of comorbidity as per syndromal and nosological principles is mainly preliminary and inaccurate, however it allows us to understand that comorbidity can be connected to a singular cause or common mechanisms of pathogenesis of the conditions, which sometimes explains the similarity in their clinical aspects, which makes it difficult to differentiate between nosologies. There are a number of rules for the formulation of clinical diagnosis for comorbid patients, which must be followed by a practitioner. The main principle is to distinguish in diagnosis the primary and background diseases, as well as their complications and accompanying pathologies. There is no doubt in the significance of comorbidity, but how to evaluate (measure) it in a given patient? Patient S., 73 years, called an ambulance because of a sudden pressing pain in the chest. It was known from the case history that the patient suffered from CHD for many years. Such chest pains were experienced by her earlier as well, but they always disappeared after a few minutes of sublingual administration of organic nitrates. This time taking three tablets of nitroglycerine did not kill the pain. It was also known from the case history that the patient had twice suffered during the last ten years from myocardial infarction, as well as from Acute Cerebrovascular Event with sinistral hemiplegia more than 15 years ago. Apart from that the patient suffers from hypertension, type 2 diabetes with diabetic nephropathy, hysteromyoma, cholelithiasis, osteoporosis and varicose pedi-vein disease. It also came to knowledge that the patient regularly takes a number of antihypertensive drugs, urinatives and oral antihyperglycemic remedies, as well as statins, antiplatelet and nootropics. In the past the patient had undergone cholecystectomy due to cholelithiasis more than 20 years ago, as well as the extraction of crystalline tumor due to cataract of the right eye 4 years ago. The patient was admitted to cardiac intensive care unit at a general hospital diagnosed for acute transmural myocardial infarction. During the check-up moderate azotemia, mild erythronormoblastic anemia, proteinuria and lowering of left vascular ejection fraction were also identified. There are currently several generally accepted methods of evaluating (measuring) comorbidity: Analyzing the comorbid state of patient S, 73 years of age, using the most used international comorbidity assessment scales, a doctor would come across totally different evaluation. The uncertainty of these results would somewhat complicate the doctors judgment about the factual level of severity of the patient’s condition and would complicate the process of prescribing rational medicinal therapy for the identified disorders. Such problems are faced by doctors on everyday basis, despite all their knowledge about medical science. The main hurdle in the way of inducting comorbidity evaluation systems in broad based diagnostic-therapeutic process is their inconsistency and narrow focus. Despite the variety of methods of evaluation of comorbidity, the absence of a singular generally accepted method, devoid of the deficiencies of the available methods of its evaluation, causes disturbance. The absence of a unified instrument, developed on the basis of colossal international experience, as well as the methodology of its use does not allow comorbidity to become doctor “friendly”. At the same time due to the inconsistency in approach to the analysis of comorbid state and absence of components of comorbidity in medical universitycourses, the practitioner is unclear about its prognostic effect, which makes the generally available systems of associated pathology evaluation unreasoned and therefore un-needed as well. The effect of comorbid pathologies on clinical implications, diagnosis, prognosis and therapy of many diseases is polyhedral and patient-specific. The interrelation of the disease, age and drug pathomorphism greatly affect the clinical presentation and progress of the primary nosology, character and severity of the complications, worsens the patient’s life quality and limit or make difficult the remedial-diagnostic process. Comorbidity affects life prognosis and increases the chances of fatality. The presence of comorbid disorders increase bed days, disability, hinders rehabilitation, increases the number of complications after surgical procedures and enhances the chances of decline in aged people. The presence of comorbidity must be taken into account when selecting the algorithm of diagnosis and treatment plans for any given disease. It is important to enquire comorbid patients about the level of functional disorders and anatomic status of all the identified nosological forms (diseases). Whenever a new, as well as mildly notable symptom appears, it is necessary to conduct a deep examination to uncover its causes. It is also necessary to be remembered that comorbidity leads to polypragmasy, i.e. simultaneous prescription of a large number of medicines, which renders impossible the control over the effectiveness of the therapy, increases monetary expenses and therefore reduces compliance. At the same time, polypragmasy, especially in aged patients, renders possible the sudden development of local and systematic, unwanted medicinal side-effects. These side-effects are not always considered by the doctors, because they are considered as the appearance of comorbidity and as a result become the reason for the prescription of even more drugs, sealing-in the vicious circle. Simultaneous treatment of multiple disorders requires strict consideration of compatibility of drugs and detailed adherence of rules of rational drug therapy, based on E. M. Tareev’s principles, which state: “Each non-indicated drug is contraindicated”][ and B. E. Votchal said: “If the drug does not have any side-effects, one must think if there is any effect at all”.][
Diagnosis is the identification of the nature and cause of anything. Diagnosis is used in many different disciplines with variations in the use of logics, analytics, and experience to determine the cause and effect relationships. In systems engineering and computer science, diagnosis is typically used to determine the causes of symptoms, mitigations for problems and solutions to issues.
A symptom (from Greek σύμπτωμα, "accident, misfortune, that which befalls", from συμπίπτω, "I befall", from συν- "together, with" + πίπτω, "I fall") is a departure from normal function or feeling which is noticed by a patient, indicating the presence of disease or abnormality. A symptom is subjective, observed by the patient, and cannot be measured directly. The term is sometimes also applied to physiological states outside the context of disease, as for example when referring to "symptoms of pregnancy". Symptoms may be chronic, relapsing or remitting. Asymptomatic conditions also exist (e.g. subclinical infections and, sometimes, high blood pressure). Constitutional or general symptoms are those that are related to the systemic effects of a disease (e.g., fever, malaise, anorexia, and weight loss). They affect the entire body rather than a specific organ or location. The terms "chief complaint", "presenting symptom", "iatrotropic symptom", or "presenting complaint" are used to describe the initial concern which brings a patient to a doctor. The symptom that ultimately leads to a diagnosis is called a "cardinal symptom". Non-specific symptoms are those self-reported symptoms that do not indicate a specific disease process or involve an isolated body system. For example, fatigue is a feature of many acute and chronic medical conditions, whether physical or mental, and may be either a primary or secondary symptom. Fatigue is also a normal, healthy condition when experienced after exertion or at the end of a day. In describing mental disorders, especially schizophrenia, symptoms can be divided into positive and negative symptoms. Some symptoms occur in a wide range of disease processes, whereas other symptoms are fairly specific for a narrow range of illnesses. For example, a sudden loss of sight in one eye has a significantly smaller number of possible causes than nausea does. Some symptoms can be misleading to the patient or the medical practitioner caring for them. For example, inflammation of the gallbladder often gives rise to pain in the right shoulder, which may understandably lead the patient to attribute the pain to a non-abdominal cause such as muscle strain. A symptom can more simply be defined as any feature which is noticed by the patient. A sign is noticed by other people. It is not necessarily the nature of the sign or symptom which defines it, but who observes it. A feature might be a sign or a symptom, or both, depending on the observer(s). For example, a skin rash may be noticed by either a healthcare professional as a sign, or by the patient as a symptom. When it is noticed by both, then the feature is both a sign and a symptom. Some features, such as pain, can only be symptoms, because they cannot be directly observed by other people. Other features can only be signs, such as a blood cell count measured in a medical laboratory. Medical sign
Symptom
Syndrome Medical diagnosis
Differential diagnosis
Prognosis Acute
Chronic
Cure/Remission Disease
Eponymous disease
Acronym or abbreviation M: HRT anat/phys/devp noco/cong/tumr, sysi/epon, injr proc, drug (C1A/1B/1C/1D), blte M: VAS anat (a:h/u/t/a/l,v:h/u/t/a/l)/phys/devp/cell/prot noco/syva/cong/lyvd/tumr, sysi/epon, injr proc, drug (C2s+n/3/4/5/7/8/9) M: MYL cell/phys (coag, heme, immu, gran), csfs rbmg/mogr/tumr/hist, sysi/epon, btst drug (B1/2/3+5+6), btst, trns M: RES anat (n, x, l, c)/phys/devp noco (c, p)/cong/tumr, sysi/epon, injr proc, drug (R1/2/3/5/6/7) M: DIG anat (t, g, p)/phys/devp/enzy noco/cong/tumr, sysi/epon proc, drug (A2A/2B/3/4/5/6/7/14/16), blte M: INT, SF, LCT anat/phys/devp noco (i/b/d/q/u/r/p/m/k/v/f)/cong/tumr (n/e/d), sysi/epon proc, drug (D2/3/4/5/8/11) M: SKA anat/phys/devp noco/cong/tumr, sysi/epon proc, drug (D10) M: CNS anat (n/s/m/p/4/e/b/d/c/a/f/l/g)/phys/devp noco (m/d/e/h/v/s)/cong/tumr, sysi/epon, injr proc, drug (N1A/2AB/C/3/4/7A/B/C/D) M: PNS anat (h/r/t/c/b/l/s/a)/phys (r)/devp/prot/nttr/nttm/ntrp noco/auto/cong/tumr, sysi/epon, injr proc, drug (N1B) M: MUS, DF+DRCT anat (h/n, u, t/d, a/p, l)/phys/devp/hist noco (m, s, c)/cong (d)/tumr, sysi/epon, injr proc, drug (M1A/3) M: BON/CAR anat (c/f/k/f, u, t/p, l)/phys/devp/cell noco/cong/tumr, sysi/epon, injr proc, drug (M5) M: JNT anat (h/c, u, t, l)/phys noco (arth/defr/back/soft)/cong, sysi/epon, injr proc, drug (M01C, M4) M: URI anat/phys/devp/cell noco/acba/cong/tumr, sysi/epon, urte proc/itvp, drug (G4B), blte, urte M: PSO/PSI mepr dsrd (o, p, m, p, a, d, s), sysi/epon, spvo proc (eval/thrp), drug (N5A/5B/5C/6A/6B/6D) M: OLF anat, recp sysi - M: TST anat, phys sysi – M: PSO/PSI mepr dsrd (o, p, m, p, a, d, s), sysi/epon, spvo proc (eval/thrp), drug (N5A/5B/5C/6A/6B/6D) M: MOU anat/devp noco/cofa (c)/cogi/tumr, sysi proc (peri), drug (A1) M: END anat/phys/devp/horm noco (d)/cong/tumr, sysi/epon proc, drug (A10/H1/H2/H3/H5) M: NUT cof, enz, met noco, nuvi, sysi/epon, met drug (A8/11/12)
Medical diagnosis (often simply termed diagnosis) refers to both the process of attempting to determine or identify a possible disease or disorder (and diagnosis in this sense can also be termed (medical) diagnostic procedure), and to the opinion reached by this process (also being termed (medical) diagnostic opinion). From the point of view of statistics the diagnostic procedure involves classification tests. It is a major component of, for example, the procedure of a doctor's visit. The history of medical diagnosis began in earnest from the days of Imhotep in ancient Egypt and Hippocrates in ancient Greece. In Traditional Chinese Medicine, there are four diagnostic methods: inspection, auscultation-olfaction, interrogation, and palpation. A Babylonian medical textbook, the Diagnostic Handbook written by Esagil-kin-apli (fl. 1069-1046 BC), introduced the use of empiricism, logic and rationality in the diagnosis of an illness or disease. The book made use of logical rules in combining observed symptoms on the body of a patient with its diagnosis and prognosis. Esagil-kin-apli described the symptoms for many varieties of epilepsy and related ailments along with their diagnosis and prognosis. The plural of diagnosis is diagnoses, the verb is to diagnose, and a person who diagnoses is called a diagnostician. The word diagnosis is derived through Latin from the Greek word διαγιγνώσκει, meaning to discern or distinguish. This Greek word is formed from διά, meaning apart, and γιγνώσκειν, meaning to perceive. The practice of diagnosis continues to be dominated by theories set down in the early 20th century. Medical diagnosis or the actual process of making a diagnosis is a cognitive process. A clinician uses several sources of data and puts the pieces of the puzzle together to make a diagnostic impression. The initial diagnostic impression can be a broad term describing a category of diseases instead of a specific disease or condition. After the initial diagnostic impression, the clinician obtains follow up tests and procedures to get more data to support or reject the original diagnosis and will attempt to narrow it down to a more specific level. Diagnostic procedures are the specific tools that the clinicians use to narrow the diagnostic possibilities. A diagnosis, in the sense of diagnostic procedure, can be regarded as an attempt at classification of an individual's condition into separate and distinct categories that allow medical decisions about treatment and prognosis to be made. Subsequently, a diagnostic opinion is often described in terms of a disease or other condition, but in the case of a wrong diagnosis, the individual's actual disease or condition is not the same as the individual's diagnosis. A diagnostic procedure may be performed by various health care professionals such as a physician, physical therapist, optometrist, healthcare scientist, chiropractor, dentist, podiatrist, nurse practitioner, or physician assistant. This article uses diagnostician as any of these person categories. A diagnostic procedure (as well as the opinion reached thereby) does not necessarily involve elucidation of the etiology of the diseases or conditions of interest, that is, what caused the disease or condition. Such elucidation can be useful to optimize treatment, further specify the prognosis or prevent recurrence of the disease or condition in the future. However, a diagnosis can take many forms. It might be a matter of naming the disease, lesion, dysfunction or disability. It might be a management-naming or prognosis-naming exercise. It may indicate either degree of abnormality on a continuum or kind of abnormality in a classification. It’s influenced by non-medical factors such as power, ethics and financial incentives for patient or doctor. It can be a brief summation or an extensive formulation, even taking the form of a story or metaphor. It might be a means of communication such as a computer code through which it triggers payment, prescription, notification, information or advice. It might be pathogenic or salutogenic. It’s generally uncertain and provisional. The initial task is to detect a medical indication to perform a diagnostic procedure. Indications include: Even during an already ongoing diagnostic procedure, there can be an indication to perform another, separate, diagnostic procedure for another, potentially concomitant, disease or condition. This may occur as a result of an incidental finding of a sign unrelated to the parameter of interest, such as can occur in comprehensive tests such as radiological studies like magnetic resonance imaging or blood test panels that also include blood tests that are not relevant for the ongoing diagnosis. General components, which are present in a diagnostic procedure in most of the various available methods include: There are a number of methods or techniques that can be used in a diagnostic procedure, including performing a differential diagnosis or following medical algorithms. In reality, a diagnostic procedure may involve components of multiple methods. The method of differential diagnosis is based on finding as many candidate diseases or conditions as possible that can possibly cause the signs or symptoms, followed by a process of elimination or at least of rendering the entries more or less probable by further medical tests and other processing until, aiming to reach the point where only one candidate disease or condition remains as probable. The final result may also remain a list of possible conditions, ranked in order of probability or severity. The resultant diagnostic opinion by this method can be regarded more or less as a diagnosis of exclusion. Even if it doesn't result in a single probable disease or condition, it can at least rule out any imminently life-threatening conditions. Unless the provider is certain of the condition present, further medical tests, such as medical imaging, are performed or scheduled in part to confirm or disprove the diagnosis but also to document the patient's status and keep the patient's medical history up to date. If unexpected findings are made during this process, the initial hypothesis may be ruled out and the provider must then consider other hypotheses. In a pattern recognition method the provider uses experience to recognize a pattern of clinical characteristics. It is mainly based on certain symptoms or signs being associated with certain diseases or conditions, not necessarily involving the more cognitive processing involved in a differential diagnosis. This may be the primary method used in cases where diseases are "obvious", or the provider's experience may enable him or her to recognize the condition quickly. Theoretically, a certain pattern of signs or symptoms can be directly associated with a certain therapy, even without a definite decision regarding what is the actual disease, but such a compromise carries a substantial risk of missing a diagnosis which actually has a different therapy so it may be limited to cases where no diagnosis can be made. The term diagnostic criteria designates the specific combination of signs, symptoms, and test results that the clinician uses to attempt to determine the correct diagnosis. Some examples of diagnostic criteria are: Clinical decision support systems are interactive computer programs designed to assist health professionals with decision-making tasks. The clinician interacts with the software utilizing both the clinician’s knowledge and the software to make a better analysis of the patients data than either human or software could make on their own. Typically the system makes suggestions for the clinician to look through and the clinician picks useful information and removes erroneous suggestions. Other methods that can be used in performing a diagnostic procedure include: Once a diagnostic opinion has been reached, the provider is able to propose a management plan, which will include treatment as well as plans for follow-up. From this point on, in addition to treating the patient's condition, the provider can educate the patient about the etiology, progression, prognosis, other outcomes, and possible treatments of her or his ailments, as well as providing advice for maintaining health. A treatment plan is proposed which may include therapy and follow-up consultations and tests to monitor the condition and the progress of the treatment, if needed, usually according to the medical guidelines provided by the medical field on the treatment of the particular illness. Relevant information should be added to the medical record of the patient. A failure to respond to treatments that would normally work may indicate a need for review of the diagnosis. Sub-types of diagnoses include: Overdiagnosis is the diagnosis of "disease" that will never cause symptoms or death during a patient's lifetime. It is a problem because it turns people into patients unnecessarily and because it can lead to economic waste (overutilization) and treatments that may cause harm. Overdiagnosis occurs when a disease is diagnosed correctly, but the diagnosis is irrelevant. A correct diagnosis may be irrelevant because treatment for the disease is not available, not needed, or not wanted. Causes and factors of error in diagnosis are: When making a medical diagnosis, a lag time is a delay in time until a step towards diagnosis of a disease or condition is made. Types of lag times are mainly: Medical sign
Symptom
Syndrome Medical diagnosis
Differential diagnosis
Prognosis Acute
Chronic
Cure/Remission Disease
Eponymous disease
Acronym or abbreviation CC  HPI (OPQRST)  ROS  Allergies/Medications  PMH/PSH/FH/SH
Lungs: Respiratory sounds
Heart: Precordium (Heart sounds, Apex beat)
A diagnosis of exclusion (per exclusionem) is a diagnosis of a medical condition reached by a process of elimination, which may be necessary if presence cannot be established with complete confidence from examination or testing. Such elimination of other reasonable possibilities is a major component in performing a differential diagnosis. Perhaps the largest category of diagnosis by exclusion is seen among psychiatric disorders where the presence of physical or organic disease must be excluded as a pre-requisite for making a functional diagnosis. Diagnosis by exclusion tends to occur where scientific knowledge is scarce, specifically where the means to verify a diagnosis by an objective method is absent. As a specific diagnosis cannot be confirmed a fall back position is to exclude that group of known causes that may cause a similar clinical presentation. An example of such a diagnosis is "fever of unknown origin": to explain the cause of elevated temperature the most common causes of unexplained fever (infection, neoplasm, or collagen vascular disease) must be ruled out. Other examples include:
Nosology Health Medicine

Medical terminology is language that is used to accurately describe the human body and associated components, conditions, processes and process in a science-based manner. Some examples are: R.I.C.E., trapezius, and latissimus dorsi. It is to be used in the medical and nursing fields. This systematic approach to word building and term comprehension is based on the concept of: (1) word roots, (2) prefixes, and (3) suffixes. The 'rootword' is a term derived from a source language such as Greek or Latin and usually describes a body part. The prefix can be added in front of the term to modify the word root by giving additional information about the location of an organ, the number of parts, or time involved. Suffixes are attached to the end of a word root to add meaning such as condition, disease process, or procedure.

In the process of creating medical terminology, certain rules of language apply. These rules are part of language mechanics called linguistics. So, when a term is developed, some logical process is applied. The word root is developed to include a vowel sound following the term to add a smoothing action to the sound of the word when applying a suffix. The result is the formation of a new term with a vowel attached (word root + vowel) called a combining form. In English, the most common vowel used in the formation of the combining form is the letter -o-, added to the word root.

Medical diagnosis (often simply termed diagnosis) refers to both the process of attempting to determine or identify a possible disease or disorder (and diagnosis in this sense can also be termed (medical) diagnostic procedure), and to the opinion reached by this process (also being termed (medical) diagnostic opinion). From the point of view of statistics the diagnostic procedure involves classification tests. It is a major component of, for example, the procedure of a doctor's visit.

The history of medical diagnosis began in earnest from the days of Imhotep in ancient Egypt and Hippocrates in ancient Greece. In Traditional Chinese Medicine, there are four diagnostic methods: inspection, auscultation-olfaction, interrogation, and palpation. A Babylonian medical textbook, the Diagnostic Handbook written by Esagil-kin-apli (fl. 1069-1046 BC), introduced the use of empiricism, logic and rationality in the diagnosis of an illness or disease. The book made use of logical rules in combining observed symptoms on the body of a patient with its diagnosis and prognosis. Esagil-kin-apli described the symptoms for many varieties of epilepsy and related ailments along with their diagnosis and prognosis.hhdsjdkdjsa

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