Resumen

CORONA MARTINEZ, Luis  y  FONSECA HERNANDEZ, Mercedes. Medical Reasoning Stated in Patient’s Individual Records: a Reflection on the Diagnostic Discussion. Medisur [online]. 2011, vol.9, n.4, pp.327-333. ISSN 1727-897X.

Diagnostic discussion is the section of patients’ records that reflects the considerations on possible diseases. This paper is aimed at conducting an analysis of controversial issues in the three specific areas of diagnostic discussion: the discussion model, the use of complementary information and issues related to syndromic diagnosis. This author’s reflections on the written format of the discussion allow concluding that the traditional model (considering some diseases and ruling some others out) should be replaced by a model based on a probabilistic (qualitative) approach that evaluates several conditions as responsible for the patient’s pathological condition. Regarding the use of complementary information, the author supports the idea that there is no point in performing diagnostic discussions considering only clinical aspects. It is necessary to integrate consistently all the information existing at the time of the analysis to the medical reasoning. Clinical information should always be the starting point. In relation to the syndromic diagnosis, it is recognized that despite its unquestionable gnoseological function, in some situations it is entirely feasible and valid to go directly from the diagnosis of symptoms or major signs to the diagnosis of the disease.

Palabras clave : intelligence; clinical diagnosis; medical records.