The diagnosis

Medical diagnosis

 (often simply termed diagnosis) refers both to the process of attempting to determine or identify a possible disease or disorder (and diagnosis in this sense can also be termed (medical) diagnostic procedure), and to the opinion reached by this process (also being termed (medical) diagnostic opinion). From the point of view of statistics the diagnostic procedure involves classification tests. It is a major component of, for example, the procedure of a doctor's visit.


Medical diagnosis or the actual process of making a diagnosis is a cognitive process. A clinician uses several sources of data and puts the pieces of the puzzle together to make a diagnostic impression. The initial diagnostic impression can be a broad term describing a category of diseases instead of a specific disease or condition. After the initial diagnostic impression, the clinician obtains follow up tests and procedures to get more data to support or reject the original diagnosis and will attempt to narrow it down to a more specific level. Diagnostic procedures are the specific tools that the clinicians use to narrow the diagnostic possibilities.

The medical history

Or anamnesis of a patient is information gained by a physician by asking specific questions, either of the patient or of other people who know the person and can give suitable information (in this case, it is sometimes called heteroanamnesis), with the aim of obtaining information useful in formulating a diagnosis and providing medical care to the patient. The medically relevant complaints reported by the patient or others familiar with the patient are referred to as symptoms, in contrast with clinical signs, which are ascertained by direct examination on the part of medical personnel. Most health encounters will result in some form of history being taken. Medical histories vary in their depth and focus. For example, an ambulance paramedic would typically limit his history to important details, such as name, history of presenting complaint, allergies, etc. In contrast, a psychiatric history is frequently lengthy and in depth, as many details about the patient's life are relevant to formulating a management plan for a psychiatric illness.

The information obtained in this way, together with clinical examination, enables the physician to form a diagnosis and treatment plan. If a diagnosis cannot be made, a provisional diagnosis may be formulated, and other possibilities (thedifferential diagnoses) may be added, listed in order of likelihood by convention. The treatment plan may then include further investigations to clarify the diagnosis.

Physical examination

medical examination, or clinical examination (more popularly known as a check-up or medical) is the process by which a doctor investigates the body of apatient for signs of disease. It generally follows the taking of the medical history — an account of the symptoms as experienced by the patient. Together with the medical history, the physical examination aids in determining the correct diagnosis and devising the treatment plan. This data then becomes part of the medical record.

Although providers have varying approaches as to the sequence of body parts, a systematic examination generally starts at the head and finishes at the extremities. After the main organ systems have been investigated by inspection, palpation, percussion, and auscultation, specific tests may follow (such as a neurological investigation, orthopedic examination) or specific tests when a particular disease is suspected (e.g. eliciting Trousseau's sign in hypocalcemia).

With the clues obtained during the history and physical examination the healthcare provider can now formulate a differential diagnosis, a list of potential causes of the symptoms. Specific diagnostic tests (or occasionally empirical therapy) generally confirm the cause, or shed light on other, previously overlooked, causes.

While the format of examination as listed below is largely as taught and expected of students, a specialist will focus on their particular field and the nature of the problem described by the patient. Hence a cardiologist will not in routine practice undertake neurological parts of the examination other than noting that the patient is able to use all four limbs on entering the consultation room and during the consultation become aware of their hearing, eyesight and speech. Likewise an Orthopaedic surgeon will examine the affected joint, but may only briefly check the heart sounds and chest to ensure that there is not likely to be any contraindication to surgery raised by the anaesthetist. A primary care physician will also generally examine the male genitals but may leave the examination of the female genitalia to a gynecologist.

A complete physical examination includes evaluation of general patient appearance and specific organ systems. It is recorded in the medical record in a standard layout which facilitates others later reading the notes. In practice the vital signs of temperature examination, pulse and blood pressure are usually measured first.

Laboratory Tests

If you've ever had to give a tube of blood or a little cup of urine in your doctor's office, you've had a laboratory test. Laboratory tests check a sample of your blood, urine or body tissues. A technician or your doctor analyzes the test samples to see if your results fall within the normal range. The tests use a range because what is normal differs from person to person. Many factors affect test results. These include

• Your sex, age and race
• What you eat and drink
• Medicines you take
• How well you followed pre-test instructions

Your doctor may also compare your results to results from previous tests. Laboratory tests are often part of a routine checkup to look for changes in your health. They also help doctors diagnose medical conditions, plan or evaluate treatments, and monitor diseases.

Medicine In The Vocal Arts

Jamie Koufman, M.D

Reprinted from THE VISIBLE VOICE, The newsletter of the Center for Voice Disorders

Visit The Wake Forest University Baptist Medical Center website

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Abstract

Since President-elect Clinton first appeared on television with hoarseness, millions of Americans have become aware that voice disorders in public figures may have far-reaching implications. Indeed, a voice disorder in any professional vocalist may have emotional, social, professional, and even political consequences. While Mr. Clinton is not a vocalist per se, while he is president and therefore speaks for all of us, his voice is as important as that of any professional vocalist. This article addresses the medical care of vocal professionals who require prompt and effective treatment when a voice problem arises.

The causes of such voice disorders are often multifactorial, and may be both functional and organic in nature. Among the most common causes are upper respiratory infection, gastroesophageal reflux, muscle tension dysphonia, and the vocal abuse/misuse/overuse syndromes.

Medicine in the Vocal Arts is an emerging field devoted to the diagnosis, treatment, and prevention of voice disorders in professional voice users. Today, the multispecialty voice center has become an important clinical resource, and most patients with voice disorders can be treated.

INTRODUCTION

The voice is not an organ, but rather, the external phonatory output of the vocal tract. While this may seem obvious, it has important implications for all voice clinicians (laryngologist, speech language pathologist, voice teacher, voice coach, and voice scientist).

The vocal tract consists of four component systems:

1. The "Generator", which is the breath support provided by the lungs. A regulated breath stream is the principal force that drives the vibration of the vocal folds. Without air flowing through the larynx, the vocal folds can make no sound. Thus, the condition of the lungs and how efficiently the breath stream is utilized have a great influence on vocal function.
2. The "Vibrator", which is the larynx; specifically, the vocal folds themselves. The folds are actually little more than a vibrator. The richness of sound and the subtleties of articulation are the result of the "resonator" and the "articulator" above the larynx. Problems of the vibrator include all problems of the larynx and its supporting structures.
3. The "Resonator", which consists of the space above the larynx, and includes most of the pharynx. This resonating cavity gives the voice its harmonic overtones, its richness. (The trained opera singer is able to manipulate the resonator to produce resonance at 2,500 Hz, which allows the singer's voice to be heard above an entire orchestra.) Problems with the resonator are uncommon, although, for example, tonsillectomy in a singer may temporarily adversely alter the resonator.
4. The "Articulator", which is made up of the tongue, lips, cheeks, teeth, and palate. These structures shape the sound from below into words and other vocal gestures. Medical problems involving the articulator are uncommon; for the singer, most problems of the articulator are corrected by the voice coach or teacher.

The term voice disorder implies that the problem is laryngeal (within the vibrator); however, it is important to remember that the four component systems of the vocal tract interact in complex ways. For example, poor breath support often gives rise to muscle tension dysphonia (abnormal muscle tension in the larynx that alters the voice). It is also important to remember that the neural regulation of these systems is complex and involves many sensory, motor, and integrating pathways within the brain. In actuality, the vocal tract is the entire person, since any abnormality of the psyche or soma can give rise to an abnormality of the voice. The voice is therefore a measure of a person's overall sense of well-being.

Voice disorders are ubiquitous and may have a profound influence on a person's ability to communicate effectively; when they occur in professional vocalists, they may cause social, emotional, and professional hardship. Furthermore, just as professional athletes are prone to certain athletic (orthopedic) injuries, so too, are professional vocalists prone to specific injuries. Tennis players get tennis elbow; football players get knee injuries; and vocalists get voice disorders. The scheduling demands of successful vocalists (travel, rehearsal, promotion, performance), make it more likely for them to suffer a serious voice problem than for the average person. Consequences of a voice problem in a well-known performer can also include public scorn, loss of reputation, and loss of income. It is therefore not surprising that professional vocalists with voice problems usually arrive at a physician's office in a state of panic.

Who gets a voice disorder? And why? How are voice disorders treated? And how if possible, can they be prevented? The purpose of this article is: (1) to outline an approach to the management of these voice patients; and (2) to address specifically the more common voice problems of vocalists.

Approach To The Vocalist With A Voice Problem

Three somewhat distinct patient populations fall into the category of "professional vocalist," each with a somewhat different set of problems and demands. I call these three groups elite vocal performers, vocalists, and vocal professionals. An example of an elite vocal performer is the opera singer, in whom even the slightest aberration of voice may have dire consequences. Most other professional singers fall into the vocalist group, while actors, clergy, radio and television personalities fall into the vocal professional group. While all three levels of vocalists earn their living with their voices, the degree of "incapacity" in each varies with the vocal occupational demands and the severity of the voice disorder. Elite vocal performers seek medical attention for any and every acute condition that they perceive may have an effect on the voice, e.g., upper respiratory infection (a cold), allergy, etc. Other, less-demanding patients seek medical attention when the problem becomes more severe or chronic. Consequently, the voice clinician must take into account the vocal demands and needs of each patient. Table 1 lists (in decreasing order of frequency of occurrence) commonly encountered problems of vocal professionals.

Table 1: Common Problems of Professional Vocalists

·         Upper respiratory tract infection (URI, "cold," laryngitis)

·         Gastroesophageal reflux-related voice abnormalities

·         Overuse syndromes ("decompensation")

·         Vocal abuse syndrome

·         Misuse of the speaking voice

·         Environmental factors

·         Singing out of range

·         Substance abuse

·         Medications

The Spectrum Of Vocal Dysfunction

Traditional medical thinking has created a dichotomous model of disease, organic vs. functional. The term organic means, literally, "related to an organ"; thus, an organic condition is one that is usually associated with structural alteration(s) in the tissues of an organ, i.e., congenital, inflammatory, or other histopathologic changes. The term functional means "related to a function"; thus, a functional condition is the result of abuse or misuse of an anatomically intact organ or organ system. A functional abnormality is not primarily the result of a structural abnormality, although secondary histopathological alterations may be present. "Tennis elbow" is a good example of a functional condition from which secondary histologic changes may result. Likewise, organic conditions also may have a functional component.

Many voice disorders are multifactorial, and simultaneously both organic and functional. This is because compensatory alterations of vocal function occur in virtually every case. Furthermore, the compensatory component may obscure the underlying condition. Thus, the dichotomy between organic and functional appears to have little relevance to the understanding and management of voice disorders.

In approaching the diagnosis of each voice disorder patient, the clinician must therefore assess the degree of impairment related to the compensatory or functional component, as well as any organic problem. For example, a vocalist with viral laryngitis may present with "no voice" prior to a performance. When examined, the degree of vocal fold edema and inflammation may be mild, and abnormal laryngeal muscle tension (maladaptive compensation) may account for "most" of the loss of voice. While it may not be possible acutely to restore the voice to normal, with treatment, it is often possible to restore enough of the voice to permit the vocalist to perform a "modified program." Often successful treatment may take the combined efforts of the patient's otolaryngologist, speech ("voice") pathologist, voice coach, and manager. The effective management of chronic voice disorders, though somewhat different from the management of acute disorders, also requires a multidisciplinary team.

The Multidisciplinary Voice Center: Medicine In The Vocal Arts

In the U.S., within the last decade, a number of multidisciplinary voice centers have been established. Using new technology, these centers have focused the collaborative efforts of voice specialists on the diagnosis, treatment, and prevention of voice disorders. In addition, since the establishment of The National Institute on Deafness and Other Communication Disorders (NIDCD) in 1985, research in this area has increased. Today, most patients with voice disorders can be treated effectively; "arts medicine" has become a new subspecialty; and a national network of voice centers has been established.

At most voice centers, the core clinical unit consists of an otolaryngologist and a speech language pathologist; virtually every voice patient should be seen by both. The laryngologist is primarily responsible for the patient's overall care, but the speech pathologist is responsible for the diagnostic voice laboratory and for actually doing most of the speech/voice therapy. Videostroboscopy is performed by the laryngologist, and acoustical voice analysis by the speech pathologist; both are involved in the diagnosis and treatment of voice patients. The voice teacher is also involved in the "rehabilitation" of many singers.

When appropriate, patients are referred to the department of gastroenterology for ambulatory 24-hour double-probe pH monitoring, a diagnostic test for gastroesophageal reflux , which is a condition common in voice disorder patients. Occasionally, patients also are referred for evaluation to specialists and laboratories in other departments, including neurology, psychology, psychiatry, gastroenterology, gynecology, and internal medicine.

Clinical Assessment Of Voice Patients

With new voice patients, the laryngologist is usually the first member of the team to see the patient; then the speech pathologist should see the patient, on the same day if possible. (With return patients, this sequence is usually reversed.) The laryngologist takes a complete medical history and a "vocal history" (table 2); and the specific vocal complaint(s) must be elicited carefully (table 3). Next, an otolaryngologic examination is performed followed by videoendoscopy, including transnasal fiberoptic laryngoscopy and stroboscopy with a telescopic or optical rod. Ideally, the speech pathologist should be present during this phase of the examination. If he or she is not present, the videotaped examination can be reviewed later. At the very least, the otolaryngologist should communicate the findings and the presumed diagnosis to the speech pathologist.

Table 2: Elements of the Vocal History

• What are the patient's symptoms?
• What is(are) the vocal complaint(s)?
• Is there a history of vocal misuse or abuse?
• Does the patient have any respiratory symptoms?
• Does the patient have any gastroesophageal reflux symptoms?
• Is the patient under the care of a physician? For what reason?
• Is the patient taking any medications?
• Is there a history of substance abuse?
• What are the vocal needs of the patient?
• What is the practice/performance schedule?
• Are there any environmental factors that may be important?
• Has the patient had vocal training? If so, how much, when, and with whom?

Table 3: Common Vocal Complaints and Their Definitions

Aphonia	Loss of voice
Dysphonia	Abnormal voice; hoarseness
Odynophonia	Discomfort or pain associated with speaking or singing; also usually associated with abnormal laryngeal muscle tension
Vocal fatigue	Dysphonia(hoarseness) and/or dysphonia specifically associated with prolonged vocal usage
Voice break	A "momentary" pitch-specific dysphonia; a voice "crack"
Loss of range	A reduction in the pitch-range, usually a loss of a portion of the high range
Dysresonance	An abnormality of resonance

While the laryngologist is usually primarily responsible for the patient's overall medical management, the speech pathologist assumes several key responsibilities in this management: (1) baseline voice documentation, (2) acoustical voice analysis, (3) therapeutic manipulation (so-called "unloading"), (4) independent diagnosis, (5) performance of speech/voice therapy, and (6) determining dismissal criteria. Sometimes the speech pathologist assumes some of the functions of the laryngologist, and vice versa.

Before moving on to a discussion of treatment, two specific aspects of clinical voice assessment must be clarified. First, the laryngologist's examination should include both fiberoptic and telescopic laryngeal examination. The former method allows assessment of laryngeal function during connected speech and singing and across the dynamic and pitch ranges of the voice. This is important in assessing laryngeal biomechanics, particularly for identifying abnormal patterns of laryngeal muscle tension. Telescopic examination involves placing a rather large-bore instrument in the mouth so that during this examination, the patient can only phonate a vowel, e.g., /i/. Nevertheless, even though telescopic examination may significantly alter laryngeal biomechanics, the superior magnification and optics of this method allow optimal examination of the free edges of the vocal folds for lesions such as nodules, polyps, cysts, and hematomas. Thus, the two techniques are complementary, and both should be employed in the professional vocalist.

Second, the speech pathologist's role in "unloading" the patient may be crucial to accurate diagnosis and effective treatment. Unloading is the term used for voice therapy designed to remove any temporarily compensatory vocal behaviors. The details of unloading are beyond the scope of this paper; however, these are similar to the techniques of voice therapy for patients with functional, especially "hyperkinetic," voice disorders, such as the vocal abuse/misuse or nodule groups of patients. These therapeutic techniques include: (1) obtaining optimal breath support (efficient use of the breath stream); (2) softening the hardness of glottal attack (reducing the effort of initiating phonation); (3) reducing the rate of speaking; and (4) reducing laryngeal and neck muscle tension through digital manipulation and other relaxation methods.

As mentioned above, almost all patients with voice disorders have a functional or compensatory component that can readily be reversed in voice therapy. Through unloading of voice during evaluation, the processes of diagnosis and treatment become intertwined -- only when compensatory behaviors are removed can the voice clinician truly appreciate the true underlying glottal condition.

Common Problems Of Vocalists

Professional vocalists have some unique problems and risk factors for the development of voice difficulties. As a group, vocalists are often subjected to adverse working environments, e.g., smoke, dryness, dust, a high level of ambient noise, and inadequate amplification. These problems may contribute to "poor vocal hygiene," poor diet, and in some cases, substance abuse. In addition, successful vocalists may suffer from stressful schedules, anxiety, and fragmented -- sometimes inappropriate -- medical care. Table 4 lists some of the unique problems of vocal professionals, the most common of which are briefly addressed below.

Inflammatory Causes: "Laryngitis"

Infectious and noninfectious causes of laryngeal inflammation are among the most common reasons that professional vocalists seek medical attention. Often the patient will simply complain of "laryngitis," whether or not a specific cause is evident. Indeed, to the layman, the term laryngitis is mistakenly used as a synonym for hoarseness or dysphonia. From the voice clinician's point of view, laryngitis implies inflammation of the larynx, and the vocal abuse/misuse/overuse syndromes are separate entities. While tonsillitis, sinusitis, and allergy may occasionally involve the larynx and cause secondary laryngeal inflammation, by far the most common causes of true laryngitis are viral infection and gastroesophageal (laryngopharyngeal) reflux.