Treatments & Therapies

Findings – treatment, effect and risks

Finding

Medical jargon refers to the result of a medical examination on a patient as a finding . This area includes psychological exploration, physical examination as well as laboratory and medical device examinations.

What is the finding?

The medical term “findings” refers both to holistic examination results and to sub-areas. A finding constellation exists when several findings are determined. On the basis of this constellation of findings, the attending physician makes the diagnosis , taking the anamnesis into account.

The anamnesis survey includes asking the patient about their health history, living conditions, any allergies that may be present , current symptoms and determination of the genetic risk constellation. The findings are written down in a medical findings report.

The findings report summarizes qualitative and quantitative statements. A qualitative statement is made, for example, if the patient’s finding for a bronchial disease is negative ” bronchi free”. A quantitative statement is, for example, the determination of the cholesterol value “total cholesterol 200 mg/dl”.

Function, effect & goals

In the case of certain complaints and illnesses, detailed examinations are indicated. Specialists carry out these examinations because general practitioners often do not have the opportunity to carry them out in the surgery.These examinations are carried out, for example, as further examinations in the event of an initial suspicion of a tumor disease . A histological and a laboratory examination are necessary, which are carried out by specialists, radiologists and pathologists . These examinations can be, for example, microscopic examinations of sampling. Laboratory findings include examination results of urine , blood and other bodily fluids.

In almost all medical fields, it is not possible to assess the health situation of patients without laboratory findings. The results of this laboratory examination enable the doctors to make a final assessment of the state of health and determine effective therapy options. In order to clarify the abnormalities and symptoms in the patient, the general practitioner refers the patient to a specialist using a referral slip. The result of the medical examination is the finding.

In many cases, this only comes a week or two later. It will be sent to the family doctor. The general practitioner then discusses the results with the patient, explains the results of the results and discusses the specialist doctor’s suggestions for further action. The histological finding provides information about the microscopic analysis of a commercial sample, a pathological finding names the pathological change in a tissue sample. Causal findings unrelated to the primary disease are referred to as incidental findings.

Incidental findings appear during the main examination without the attending physician having specifically searched for them beforehand. A finding is positive if the examination confirms the initial suspicion. If a patient is examined for cancer and it turns out during the examination that a malignant tumor is present, the cancer finding is positive. The finding is negative if the examination does not confirm the initial suspicion and the patient is tumor-free. Medical jargon uses these two terms differently than everyday language. People associate the word “positive” with something positive, but the positive finding warns that the patient’s state of health is developing unfavorably and something conspicuous has been found.

People associate the word “negative” with unpleasant situations, but in the case of a negative finding they have reason to be friends, because it means that the initial suspicion is not confirmed and the suspected illness is not present. If the doctor diagnoses a patient with AIDS , he is “HIV-positive”, if the disease is not present, he is “HIV-negative”. The distinction from the term “symptom” is that the finding describes the empirical character of documented characteristics, i.e. the collection of information, while the symptom emphasizes the appearance of the characteristic as an indication of a disease.

However, a report of findings can prove to be a closed book for affected patients, since most people do not understand the medical terminology. They perceive them as difficult to understand, both subjectively and in terms of technical language. Since this technical language is part of everyday work for medical professionals, they often do not take into account that their patients do not understand it in most cases.

Even if doctors are able to explain the findings to their patients in a way that is easy to understand, they may forget what was said in their excitement and are then left alone with their findings and the incomprehensible technical language. There is a great need for easy-to-understand explanations in the report. Laypersons need a “translation” of medical jargon, because language that is easy to understand calms many patients and makes even complex and disturbing findings easier to bear.

Risks, side effects & dangers

This discrepancy has now also been discovered by science and is trying to remedy the situation. In the 2014/2015 winter semester, the University of Dresden celebrated a Germany-wide premiere with the elective “What’s the matter with me?”.

The project at the TU Dresden was funded by the University Medicine Foundation, and the concept was conceived by medical students. The elective pursues the goal of practical and improved communication between doctors and patients. First course evaluations show significantly improved communication skills with a high practical relevance. An expansion of this offer to other universities in Germany is planned.

The creation and documentation of a finding is one of the most important medical duties with regard to proof of performance in billing issues and in the event of legal disputes. Main complaints, accompanying complaints and initial suspicion lead to a suspected diagnosis, which leads to the targeted assessment of findings and the working diagnosis. The subsequent treatment and therapy of the disease are based on the findings.

Structured documentation of findings supports cooperation and communication between the doctors, patients, institutions and clinics involved. The development of telemedicine sustainably supports this structured approach. Standardized findings are easier to compare and the course of the disease easier to assess. The risk of misunderstandings between the doctors involved is largely eliminated. According to § 630 of the German Civil Code, the Patient Rights Act obliges physicians to keep a patient file with all relevant findings and information.

Lisa Newlon
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Hello! I am Lisa Newlon, and I am a medical writer and researcher with over 10 years of experience in the healthcare industry. I have a Master’s degree in Medicine, and my deep understanding of medical terminology, practices, and procedures has made me a trusted source of information in the medical world.