Exam 1 Physical Diagnosis Objectives
From Iusmicm
(Difference between revisions)
(Created page with '===Chapter 1=== # Apply the guidelines for using a medical interpreter when a medical interpreter is needed for a patient interview. # Define the “rule of 5 vowels” and use t…') |
|||
Line 1: | Line 1: | ||
+ | *Note, much borrowed from generous, previous IUSM medical students. | ||
+ | |||
===Chapter 1=== | ===Chapter 1=== | ||
- | + | *Apply the guidelines for using a medical interpreter when a medical interpreter is needed for a patient interview. | |
- | + | **need to be trained in med. Terminology | |
- | + | **same sex and age as patient | |
- | + | **establish an approach with interpreter before talking to patient | |
- | + | **speak and look at patient | |
- | + | **do not expect word for word translation | |
- | + | **ask interpreter about patient fears and expectations | |
- | + | **use short questions | |
- | + | **use simple language | |
+ | **keep explanations brief | ||
+ | **avoid using "if", "would" and "could" questions and statements | ||
+ | **avoid idiomatic expressions | ||
+ | |||
+ | *Define the “rule of 5 vowels” and use the 5 vowels in a patient interview. | ||
+ | **AEIOU: audition, evaluation, inquiry, observation, understanding | ||
+ | **audition: listen to story | ||
+ | **evaluation: determine what is relevant | ||
+ | **inquiry: ask appropriate questions | ||
+ | **observation: importance of non-verbal communication | ||
+ | **understanding: show empathy and signs that you understand and care | ||
+ | |||
+ | *Recognize the difference between a “symptom” and a “sign”. | ||
+ | **A symptom is what a pt feels. | ||
+ | **A sign is what a physician detects. | ||
+ | |||
+ | *Select the appropriate terminology and questions to begin a medical interview. | ||
+ | **Greet with your name, ask their name, make eye contact, shake hands, smile, state your purpose and intent. | ||
+ | |||
+ | *Apply the use of open-ended questions when conducting a medial interview. | ||
+ | **Start with open ended questions, focus down with direct questions. | ||
+ | |||
+ | *Apply the use of direct questions when conducting a patient interview. | ||
+ | **ROS should be demarked with a transition statement explaining that you're not looking for simple yes or no answers. | ||
+ | **Follow positive ROS responses with open ended and OPQRST questions. | ||
+ | |||
+ | *Discriminate patient symptoms using the O-P-Q-R-S-T mnemonic. | ||
+ | **OPQRST: | ||
+ | ***onset (time, activity); | ||
+ | ***provoke / palliate (what makes it worse or better); | ||
+ | ***quality (characteristics like blurry, sharp, burning, deep, etc.); | ||
+ | ***radiation (does the symptom occur anywhere else or associate with any other symptom); | ||
+ | ***severity (1-10); | ||
+ | ***timeline | ||
+ | **CLOSER: | ||
+ | ***characteristics (quality, severity) | ||
+ | ***location (and radiation) | ||
+ | ***onset (and duration) | ||
+ | ***symptoms associated | ||
+ | ***exacerbating factors | ||
+ | ***relieving factors | ||
+ | |||
+ | *Discriminate which questions to avoid and not use when interviewing a patient. | ||
+ | **Avoid rapid-fire questions; "have you lost or gained weight or had any nausea or vomitting?" | ||
+ | **Avoid medical jargon; "where you tachypnic when the pain started?" | ||
+ | **Avoid leading or biased questions; "you don't have any heart problems do you?" | ||
+ | |||
+ | *Describe the parts of the medical history and include each part when writing a medical history. | ||
+ | **Chief complaint | ||
+ | **History of Present Illness | ||
+ | **Past Medical History | ||
+ | **Social History | ||
+ | **Family History | ||
+ | **Psychosocial and Spiritual History | ||
+ | **Sexual and Reproductive History | ||
+ | **Review of Systems | ||
===Chapter 2=== | ===Chapter 2=== | ||
- | + | *Describe the various responses to illness in a patient. | |
- | + | **There are several major responses to illness, including: anxiety, depression, denial, projection, and regression. | |
- | + | **Anxiety: characterized by uneasiness and a sense of impending danger | |
- | + | **Depression: a chronic state of lowered mood | |
- | + | ***The most common reaction to illness and perhaps the most overlooked. | |
- | + | ***20% of pts with major illnesses express depression (especially cancer pts). | |
- | + | ***Noted by brief answers, slow speech, and low volume. | |
- | + | ***Thoughts are negative, with lots of (perceived) inadequacy, defeat, and worthlessness. | |
- | + | **Denial: acting and thinking a part of reality is not true. | |
- | + | ***Recall that denial is a defense mechanism used to guard against an inner tension that causes anxiety. Denial prevents the turmoil from producing overt anxiety. | |
- | + | ***The more acute the illness, the less room for denial; the more insidious the illness, the more denial. | |
- | + | ***May need to interview a reliable informant when denial is so severe accurate answers cannot be secured. | |
- | + | **Projection: perceiving one's own emotions in another being | |
- | + | ***Recall that projection is a defense mechanism that guards against an inner tension and manifests as the pt perceiving their own emotion in the interviewer (fear, anger, for example). | |
- | + | ***A danger for the Doctor-Pt relationship. | |
- | + | **Regression: an unconscious return to an earlier stage of physical or emotional development in which the pt was free from the demands of disease and was often gratified. | |
- | + | ***Regression is a defense mechanism. | |
- | + | ||
- | + | *Describe the variety of patient types and how to approach them during an interview. | |
- | + | **Silent | |
- | + | ***Characteristics: shy, insecure, easily embarrassed normally or silent from fear of illness. May be depressed. | |
- | + | ***Approach: Use directed questions, not open-ended. | |
+ | **Over-talkative | ||
+ | ***Characteristics: | ||
+ | ***Approach: use courteous interruption followed by another direct question. Avoid open-ended questions. | ||
+ | **Seductive: | ||
+ | ***Characteristics: many have personality disorder and have fantasy of intimacy with doctor. | ||
+ | ***Approach: Keep empathy and reassurance to minimum. Keep professional distance. | ||
+ | **Angry | ||
+ | ***Approach: Realize reactions are to illness and not personal. Confront about anger and allow to vent, proceed slow, avoid interpretations and ask questions about present illness. | ||
+ | **Paranoid | ||
+ | ***Characteristics: Reassurance tends to be threatening. | ||
+ | ***Approach: Complete questioning and don’t try to convince about false ideations. Avoid any anger. | ||
+ | **Insatiable | ||
+ | ***Character: never satisfied. | ||
+ | ***Approach: Handle with firm, noncondescending approach. Use definite closing statement. | ||
+ | **Ingratiating | ||
+ | ***Character: attempts to please interviewer. | ||
+ | ***Approach: Try to give “right” answer. Stress importance of accuracy | ||
+ | **Aggressive | ||
+ | ***Character: often has personality disorder, easily irritated and can fly into rage. | ||
+ | ***Approach: Stay away from provoking anxiety early and establish rapport. | ||
+ | **Help-rejecting | ||
+ | ***Character: seen many experts and no one can figure out what is wrong. Return saying suggestions didn’t work. New symptoms appear after one goes away. Blame “illness” for disappointments. | ||
+ | ***Approach: Use strong emotional support and gentile reasoning | ||
+ | **Demanding | ||
+ | ***Character: Use intimidation and guilt to force others to take care of them. See self as neglected, may have outburst of anger and have power struggle with doctor. | ||
+ | ***Approach: Provide firm boundaries, elicit and set clear expectations. | ||
+ | **Compulsive | ||
+ | ***Character: concerned about every detail, use projection | ||
+ | ***Approach: Provide detailed and specific info in a straight forward way | ||
+ | **Dependent | ||
+ | ***Character: finds life hard without help. Need to care for closely, but they can take advantage of doctors by demanding time. | ||
+ | ***Approach: Be direct about limits without leaving rejected. | ||
+ | **Masochistic | ||
+ | ***Character: go thru life suffering mentally, but don’t seek physical abuse or pain. Feel they self-sacrifice and handle illness well, but may feel threatened by recovery. | ||
+ | ***Approach: Don’t promise cures, attend to all aspects of illness. | ||
+ | **Borderline | ||
+ | ***Character: personality disorder with instability, splitting, impulsiveness and unstable moods. Are always afraid, but may mask with anger. | ||
+ | ***Approach: Use lots of reassuring words. | ||
+ | |||
+ | *Describe how disease can influence the type of patient response. | ||
+ | **Disabled | ||
+ | ***Theme is mistrust of healthcare; response is assurance. | ||
+ | ***Sort out emotional problems for physical ones. | ||
+ | ***Smile and nice words help them cooperate. | ||
+ | ***Don’t like their routines changed. | ||
+ | ***If hearing impaired sit in front so they can read your lips or speak louder, write things down if needed. | ||
+ | ***If vision impaired: occasionally touch patient’s arm so they know where you are. Avoid non-verbals. | ||
+ | ***Developmentally delayed need guardian to give history. | ||
+ | **Cancer | ||
+ | ***-5 major concerns: loss of control, pain, alienation, mutilation and mortality. | ||
+ | ***Doctor may be afraid of patient’s questions about death and patient feels rejected. | ||
+ | ***Doctor needs to recognize their limitations. | ||
+ | ***Allow patient to vent and promote dialogue. | ||
+ | **AIDS | ||
+ | ***Fearful for life and being stigmatized which may result in delay of seeking care. | ||
+ | ***Denial is important and may fear doctors. | ||
+ | ***Fear worsened by anxiety of health care workers who care for them. | ||
+ | ***Unsympathetic rejection of AIDS patients leading to anxiety, hostility and depression. | ||
+ | ***Be supportive with out false sense of hope. | ||
+ | ***Give facts and make sure staff is educated. | ||
+ | **Dyphasic | ||
+ | ***Impairment of speech and can’t arrange words correctly. | ||
+ | ***Always assume patient is aware if talking with them in the room. | ||
+ | ***Give patient pen and paper and or ask yes / no questions. | ||
+ | **Psychotic | ||
+ | ***Impaired reality testing abilities and can’t communicate effectively. | ||
+ | ***May have hallucinations and delusions. | ||
+ | ***Remain calm and get assistance if violent episode. | ||
+ | ***May have Munchausen’s and be malingerers. | ||
+ | ***Many self injure. | ||
+ | **Demented or Delirious | ||
+ | ***Demented are more confused out of their environment especially at night ("sundowning"). | ||
+ | ***Fear is common. Be sensitive and allay their fears. Avoid question that may seem threatening to them. | ||
+ | ***Need mental status exam. | ||
+ | ***History may not reliable. | ||
+ | **Acutely Ill | ||
+ | ***Need concise history and physical. | ||
+ | ***May need to interview while doing exam. | ||
+ | ***Finish interview after stable. | ||
+ | **Surgical | ||
+ | ***Frightened even if calm appearance. | ||
+ | ***Feel helpless and out of control. | ||
+ | ***Lack of communication from surgeon makes worse. | ||
+ | ***Depression if loss of body part. | ||
+ | ***Allow time to release tension and feelings of loss during interview | ||
+ | **Alcoholic | ||
+ | ***Feel castigated and alone. Alcohol is only friend. | ||
+ | ***Often ready to talk and may have low self esteem. | ||
+ | ***May be self destructive. May have fears of sexual inadequacy or homosexuality. | ||
+ | **Psychosomatic | ||
+ | ***Psychological problems create physical ailments. | ||
+ | ***May be unaware of emotional distress. | ||
+ | ***Identify disorder, teach patient to cope with psych problems. | ||
+ | ***Somatization is unconscious and patients are really suffering. Acknowledge their suffering is real. Never say problem is in your head. | ||
+ | ***Use open ended questions to get insight. | ||
+ | **Dying | ||
+ | ***Conscious of taking up doctor’s time and will start asking fewer questions. | ||
+ | ***Don’t avoid dying patients because of own fears. | ||
+ | ***Many fear process of dying more than death. | ||
+ | ***May have anger or guilt or resentment. | ||
+ | ***Envy healthy and deny imminent death. | ||
+ | ***May deny disease even when asked directly. | ||
+ | ***Most reach acceptance which may include apathy and withdraw. | ||
+ | ***Dying patient needs to talk to someone. | ||
+ | ***Appropriate response to an expression of grief may be period of silence. | ||
===Chapter 7=== | ===Chapter 7=== |
Revision as of 21:08, 28 September 2011
- Note, much borrowed from generous, previous IUSM medical students.
Contents |
Chapter 1
- Apply the guidelines for using a medical interpreter when a medical interpreter is needed for a patient interview.
- need to be trained in med. Terminology
- same sex and age as patient
- establish an approach with interpreter before talking to patient
- speak and look at patient
- do not expect word for word translation
- ask interpreter about patient fears and expectations
- use short questions
- use simple language
- keep explanations brief
- avoid using "if", "would" and "could" questions and statements
- avoid idiomatic expressions
- Define the “rule of 5 vowels” and use the 5 vowels in a patient interview.
- AEIOU: audition, evaluation, inquiry, observation, understanding
- audition: listen to story
- evaluation: determine what is relevant
- inquiry: ask appropriate questions
- observation: importance of non-verbal communication
- understanding: show empathy and signs that you understand and care
- Recognize the difference between a “symptom” and a “sign”.
- A symptom is what a pt feels.
- A sign is what a physician detects.
- Select the appropriate terminology and questions to begin a medical interview.
- Greet with your name, ask their name, make eye contact, shake hands, smile, state your purpose and intent.
- Apply the use of open-ended questions when conducting a medial interview.
- Start with open ended questions, focus down with direct questions.
- Apply the use of direct questions when conducting a patient interview.
- ROS should be demarked with a transition statement explaining that you're not looking for simple yes or no answers.
- Follow positive ROS responses with open ended and OPQRST questions.
- Discriminate patient symptoms using the O-P-Q-R-S-T mnemonic.
- OPQRST:
- onset (time, activity);
- provoke / palliate (what makes it worse or better);
- quality (characteristics like blurry, sharp, burning, deep, etc.);
- radiation (does the symptom occur anywhere else or associate with any other symptom);
- severity (1-10);
- timeline
- CLOSER:
- characteristics (quality, severity)
- location (and radiation)
- onset (and duration)
- symptoms associated
- exacerbating factors
- relieving factors
- OPQRST:
- Discriminate which questions to avoid and not use when interviewing a patient.
- Avoid rapid-fire questions; "have you lost or gained weight or had any nausea or vomitting?"
- Avoid medical jargon; "where you tachypnic when the pain started?"
- Avoid leading or biased questions; "you don't have any heart problems do you?"
- Describe the parts of the medical history and include each part when writing a medical history.
- Chief complaint
- History of Present Illness
- Past Medical History
- Social History
- Family History
- Psychosocial and Spiritual History
- Sexual and Reproductive History
- Review of Systems
Chapter 2
- Describe the various responses to illness in a patient.
- There are several major responses to illness, including: anxiety, depression, denial, projection, and regression.
- Anxiety: characterized by uneasiness and a sense of impending danger
- Depression: a chronic state of lowered mood
- The most common reaction to illness and perhaps the most overlooked.
- 20% of pts with major illnesses express depression (especially cancer pts).
- Noted by brief answers, slow speech, and low volume.
- Thoughts are negative, with lots of (perceived) inadequacy, defeat, and worthlessness.
- Denial: acting and thinking a part of reality is not true.
- Recall that denial is a defense mechanism used to guard against an inner tension that causes anxiety. Denial prevents the turmoil from producing overt anxiety.
- The more acute the illness, the less room for denial; the more insidious the illness, the more denial.
- May need to interview a reliable informant when denial is so severe accurate answers cannot be secured.
- Projection: perceiving one's own emotions in another being
- Recall that projection is a defense mechanism that guards against an inner tension and manifests as the pt perceiving their own emotion in the interviewer (fear, anger, for example).
- A danger for the Doctor-Pt relationship.
- Regression: an unconscious return to an earlier stage of physical or emotional development in which the pt was free from the demands of disease and was often gratified.
- Regression is a defense mechanism.
- Describe the variety of patient types and how to approach them during an interview.
- Silent
- Characteristics: shy, insecure, easily embarrassed normally or silent from fear of illness. May be depressed.
- Approach: Use directed questions, not open-ended.
- Over-talkative
- Characteristics:
- Approach: use courteous interruption followed by another direct question. Avoid open-ended questions.
- Seductive:
- Characteristics: many have personality disorder and have fantasy of intimacy with doctor.
- Approach: Keep empathy and reassurance to minimum. Keep professional distance.
- Angry
- Approach: Realize reactions are to illness and not personal. Confront about anger and allow to vent, proceed slow, avoid interpretations and ask questions about present illness.
- Paranoid
- Characteristics: Reassurance tends to be threatening.
- Approach: Complete questioning and don’t try to convince about false ideations. Avoid any anger.
- Insatiable
- Character: never satisfied.
- Approach: Handle with firm, noncondescending approach. Use definite closing statement.
- Ingratiating
- Character: attempts to please interviewer.
- Approach: Try to give “right” answer. Stress importance of accuracy
- Aggressive
- Character: often has personality disorder, easily irritated and can fly into rage.
- Approach: Stay away from provoking anxiety early and establish rapport.
- Help-rejecting
- Character: seen many experts and no one can figure out what is wrong. Return saying suggestions didn’t work. New symptoms appear after one goes away. Blame “illness” for disappointments.
- Approach: Use strong emotional support and gentile reasoning
- Demanding
- Character: Use intimidation and guilt to force others to take care of them. See self as neglected, may have outburst of anger and have power struggle with doctor.
- Approach: Provide firm boundaries, elicit and set clear expectations.
- Compulsive
- Character: concerned about every detail, use projection
- Approach: Provide detailed and specific info in a straight forward way
- Dependent
- Character: finds life hard without help. Need to care for closely, but they can take advantage of doctors by demanding time.
- Approach: Be direct about limits without leaving rejected.
- Masochistic
- Character: go thru life suffering mentally, but don’t seek physical abuse or pain. Feel they self-sacrifice and handle illness well, but may feel threatened by recovery.
- Approach: Don’t promise cures, attend to all aspects of illness.
- Borderline
- Character: personality disorder with instability, splitting, impulsiveness and unstable moods. Are always afraid, but may mask with anger.
- Approach: Use lots of reassuring words.
- Silent
- Describe how disease can influence the type of patient response.
- Disabled
- Theme is mistrust of healthcare; response is assurance.
- Sort out emotional problems for physical ones.
- Smile and nice words help them cooperate.
- Don’t like their routines changed.
- If hearing impaired sit in front so they can read your lips or speak louder, write things down if needed.
- If vision impaired: occasionally touch patient’s arm so they know where you are. Avoid non-verbals.
- Developmentally delayed need guardian to give history.
- Cancer
- -5 major concerns: loss of control, pain, alienation, mutilation and mortality.
- Doctor may be afraid of patient’s questions about death and patient feels rejected.
- Doctor needs to recognize their limitations.
- Allow patient to vent and promote dialogue.
- AIDS
- Fearful for life and being stigmatized which may result in delay of seeking care.
- Denial is important and may fear doctors.
- Fear worsened by anxiety of health care workers who care for them.
- Unsympathetic rejection of AIDS patients leading to anxiety, hostility and depression.
- Be supportive with out false sense of hope.
- Give facts and make sure staff is educated.
- Dyphasic
- Impairment of speech and can’t arrange words correctly.
- Always assume patient is aware if talking with them in the room.
- Give patient pen and paper and or ask yes / no questions.
- Psychotic
- Impaired reality testing abilities and can’t communicate effectively.
- May have hallucinations and delusions.
- Remain calm and get assistance if violent episode.
- May have Munchausen’s and be malingerers.
- Many self injure.
- Demented or Delirious
- Demented are more confused out of their environment especially at night ("sundowning").
- Fear is common. Be sensitive and allay their fears. Avoid question that may seem threatening to them.
- Need mental status exam.
- History may not reliable.
- Acutely Ill
- Need concise history and physical.
- May need to interview while doing exam.
- Finish interview after stable.
- Surgical
- Frightened even if calm appearance.
- Feel helpless and out of control.
- Lack of communication from surgeon makes worse.
- Depression if loss of body part.
- Allow time to release tension and feelings of loss during interview
- Alcoholic
- Feel castigated and alone. Alcohol is only friend.
- Often ready to talk and may have low self esteem.
- May be self destructive. May have fears of sexual inadequacy or homosexuality.
- Psychosomatic
- Psychological problems create physical ailments.
- May be unaware of emotional distress.
- Identify disorder, teach patient to cope with psych problems.
- Somatization is unconscious and patients are really suffering. Acknowledge their suffering is real. Never say problem is in your head.
- Use open ended questions to get insight.
- Dying
- Conscious of taking up doctor’s time and will start asking fewer questions.
- Don’t avoid dying patients because of own fears.
- Many fear process of dying more than death.
- May have anger or guilt or resentment.
- Envy healthy and deny imminent death.
- May deny disease even when asked directly.
- Most reach acceptance which may include apathy and withdraw.
- Dying patient needs to talk to someone.
- Appropriate response to an expression of grief may be period of silence.
- Disabled
Chapter 7
- Describe the “Four Principles of Physical Examination”, their importance, and clinical application.
- Describe what the examiner should observe while taking a history and how to apply clinically when evaluating a patient.
- Apply the “preparations for the physical examination” clinically when evaluating a patient.
- Discriminate which comments to refrain from when performing the physical examination.
- Apply the precautionary guidelines for health-care workers from the CDC and OSHA and how to apply them when examining a patient.
Chapter 9
- Describe and recognize common symptoms of diseases involving the neck: neck mass and neck stiffness.
- Interpret the signs and symptoms of diseases involving the neck: neck mass and neck stiffness.
- Apply the components of the physical exam of the neck to a patient.
- Clinically correlate the symptoms and physical findings for the following disease processes: hyperthyroidism, hypothyroidism, thyroid nodules.
- Using the symptoms and/or physical exam findings pertaining to the neck, generate a diagnosis and a differential diagnosis.
Chapter 10
- Describe the actions and innervations of the eye and extraocular muscles.
- Identify the major symptoms of eye disease.
- Interpret the symptoms of the major diseases of the eye and apply them clinically to a patient: loss of vision, eye pain, diplopia, tearing or dryness, discharge, and redness.
- Apply the components of the physical examination of the eye to a patient.
- Clinically correlate the symptoms and physical exam findings pertaining to the eye for the following disease processes: visual field defect, red eye (acute conjunctivitis, acute iritis, narrow-angle glaucoma, and corneal abrasion), diabetes, hypertension, and papilledema.
- Give a differential diagnosis based on symptoms and/or physical exam findings pertaining to the eye.
Chapter 11
Ear
- Describe the structure and innervations of the ear.
- Identify the major symptoms of ear disease and how these symptoms can identify diseases involving the ear: hearing loss, vertigo, tinnitus, otorrhea, otalgia, and itching.
- Interpret the symptoms of diseases of the ear and apply them clinically to a patient.
- Apply the components of the physical exam of the ear to a patient.
- Clinically correlate the symptoms and physical exam findings pertaining to the ear for the following disease processes: conductive and sensorineural hearing loss, otitis media. Serous otitis media, otitis externa, and vertigo.
- Generate a diagnosis and/or differential diagnosis based on symptoms and/or physical exam findings of the ear.
Nose
- Describe the structure of the nose.
- Illustrate how the major symptoms of nose diseases are used to identify nose diseases.
- Interpret the symptoms related to the nose and apply them clinically to a patient.
- Apply the components of the physical exam of the nose to a patient.
- Clinically correlate the symptoms and physical exam findings pertaining to the nose for the following disease processes: allergic rhinitis, sinusitis, and nonallergic rhinitis.
- Generate a diagnosis and/or differential diagnosis based on symptoms and/or physical exam findings of the nose.
Chapter 13
- Describe the topographical landmarks of the chest and utilize that knowledge to describe physical findings of the chest.
- Recognize the main symptoms of pulmonary disease and how these symptoms can identify disease.
- Interpret the symptoms of pulmonary disease and apply them clinically to a patient.
- Apply the components of the physical exam of the chest to a patient.
- Clinically correlate the symptoms and physical exam findings pertaining to the chest:
- Pulmonary Edema
- Pneumothorax
- Asthma
- Pneumonia
- Emphysema
- Pulmonary Embolism
- Pleural Effusion
- Generate a diagnosis and/or differential diagnosis based on symptoms and/or physical exam findings of the chest.
Chapter 17
- Describe the topographical landmarks of the abdomen and utilize that knowledge to describe physical findings of the abdomen.
- Recognize where abdominal structures are located by topographical quadrants of the abdomen.
- Recognize the main symptoms of abdominal disease and how these symptoms can identify disease.
- Interpret the symptoms of abdominal disease and apply them clinically to a patient.
- Apply the components of the physical examination of the abdomen to a patient.
- Clinically correlate the symptoms and physical exam findings pertaining to the abdomen.
- Generate a diagnosis and/or differential diagnosis based on symptoms and/or physical exam findings.