Medical findings

Medical findings encompass the aggregated physical and psychological observations made by a medical doctor when assessing patients. These observations arise from the direct examination using the physician's senses and basic medical tools, culminating in what are referred to as clinical findings. When the situation warrants, these findings may be verified or supplemented through additional diagnostic tests utilizing specialized medical equipment.

Distinction from Patient's Medical History

Medical findings specifically pertain to the intersubjective events identified by the physician, distinguishing them from the entirely subjective information contained in the patient's medical history.

Types of Documentation

Medical findings can be documented in a variety of manners, notably:

• Quantitative evidence: Data that can be numerically measured, e.g., "the cholesterol level is 220 mmol/L".
• Qualitative evidence: Descriptive data which does not rely on numeric measurement, e.g., "the consciousness is clouded".

Using a combination of these gathered medical findings, a physician can then derive their diagnosis, identifying the specific ailment or condition affecting the patient. Medical findings that do not align with these diagnoses are categorized as auxiliary medical findings, the symptoms of which may indicate other medical conditions.

Differentiation from Symptoms

While the terms are frequently used interchangeably in everyday language, medical findings and symptoms are distinct entities. During the validation of a medical finding, the empirical nature (observable characteristics) of the collected medical data is emphasized, underscoring the presence of a symptom indicative of a specific condition.

Role of the Doctor

The acquisition of medical findings represents one of the primary responsibilities of a medical doctor. It is through these findings that physicians can make informed decisions about diagnosis and treatment.

See Also

• Clinical diagnosis
• Medical history
• Medical examination
• Diagnostic test