INFORMATIC SUPPORT TO MEDICAL DIAGNOSIS - GENERAL INFORMATION OBTAINED FROM A FIRST STRUCTURED CONTACT WITH THE PATIENT

BACKGROUND: The methods and characteristics of clinical data gathered at the initial steps of development of a computerized system to aid me dical diagnosis are reported. The objectives of the study were as foll ows: to describe the overall method and to set a framework for develop ing an intellectual model of the medical diagnosic procedure. MATERIAL AND METHODS: A structured medical interview and physical examination using an informatic program running on PC compatible portable computer s were completed in a sample 1,238 patients attending the outpatient c linics of our institution. Data obtained were compared with informatio n in the patient's medical record taking as reference pattern the reco rd of physicians in charge of the patients. Diagnosis were codified ac cording to WHO International Classification of Diseases (ICD-9-CM). RE SULTS: The distribution of symptoms and signs corresponding to the dif ferent organs and systems was analized. Each subdivision afforded a ra nge of 1.3 to 3.9 abnormal findings per patient. A total of 3,571 diag noses were codified for the whole group 1,238 patients with a mean (st andard deviation) of 3 (2) diagnoses per patient (range 0-12). The dis tribution of diagnostic groups varied depending on the consideration o f the main diagnosis or the concomitant diagnoses that defined the pat ient's clinical context. The most frequent main diagnoses included tum ors, cardiovascular diseases, gastrointestinal disorders, and genitour inary tract diseases. CONCLUSIONS: As shown by results obtained in a s ample of 1,238 patients, there is a very complex situation in clinical practice due to the simultaneous ocurrence of several clinical patter ns. This finding should be taken into account when developing clinical decision making support systems, The use of a structured medical inte rview or a structured and standard medical visit may be an adequate to ol to clarify this matter and to contribute to standardization of clin ical concepts and situations.