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Flashcards in Diagnostic & Treatment Deck (85):
1

Wilhelm Roentgen

X-ray (roentgenograms) scientists is credited with the discovery of x-ray.

2

Sanitization

Process of cleaning or freeing materials from dirt. (sanitization can be the first step in the process of preparing instruments for sterilization and includes cleaning grossly visible materials from the surface).

3

Sterilization

Is the method used for complete destruction of microorganisms and their spores.

4

Mensuration

Process of measuring.

5

Inspection

Is visualization

6

Palpation

Is examining through feel.

7

Percussion

Is resonance of sounds within the body.

8

Vital signs measurements

Temperature, Pluse, Respiration (TPR) and blood pressure (BP) are vital signs measurements.

9

Review Of System (ROS)

Questions regarding each of the major body systems and parts.

10

Medical chart-




- Is the chronological system for recording each patient's medical records.
- Purpose: To establish a database on each patient consisting of information concerning the patient's life, history, illness and treatment.

11

Medical chart- Chief complain (CC)

Chief complaint:
- Primary reason for seeking medical care.

12

Medical chart- Past medical history (PH/PMH)




Past medical history:
- This document may be prepared by the MA, provider, or patient. Questions relate to usual childhood disease (UCD), past illnesses, past surgeries, and current health status.

13

Medical chart- Family history (FH)

Family history:
- Includes details regarding the patient's parents and siblings such as health status, age and causes of death, hereditary disease, etc.

14

Medical chart- Present illness (PI)

Present illness:
- Details associated with the chief complaint.

15

Medical chart- Social history (SH)

Information regarding personal habits such as exercise, sleep, diet, alcohol/tobacco/drug use, sexual activity, hobbies, etc.

16

Medical chart- Occupational history (OH)

Occupational history:
- Information regarding the patient's employment.

17

Medical chart- Physical examination (PE)

Physical examination:
- A complete physical exam may be performed to assess the status of each body system. this documentation will serve as a base reference for future diagnosis and treatment.

18

Medical chart- Diagnostic and laboratory tests

Test results are usually arranged in reverse chronological order.

19

Medical chart- Consultation reports

Evaluations made by other practitioners at the request of the provider.

20

Medical chart- Correspondence

As related to the patient's care.

21

Medical chart- Providers notes

Notes written in the chart by the health care provider regarding a patient's diagnosis and treatment.

22

Medical chart- Termination summary

Documents that serve to identify discontinuation of care either by a consulting or primary provider.

23

Medical chart- Source



Medical data are characterized by it's source:
- Medical history
- Progress notes
- Diagnostic reports
- Correspondence.

24

Problem Oriented Medical Record (POMR)




Medical data are organized and identified according to disease, situation, or condition.
- Database
- Problem list
- Plans
- Progress notes

25

POMR- Database



Includes the patient's history, chief complaint, physical exam findings, and laboratory results. An additional page is prepared for each condition requiring diagnosis and treatment.

26

POMR- Problem list

Consist of physical, psychological, and social problems related to the condition. The chart may distinguish between short-and long-term problem lists.

27

POMR- Plans

Detailed description of diagnostic and treatment measures to include instruction, teaching and perhaps further evaluations.

28

POMR- Progress notes

Uses the SOAP approach.
- Subjective data
- Objective data
- Assessment (S + O)
- Plan (S + O + A)

29

POMR- Subjective data

Related to the patient's signs, symptoms and feelings as described by the patient.

30

POMR- Objective data

Determined by the providers examination and diagnostic tests.

31

POMR- Assessment


(S + O) Describing the providers impression of the problem and ultimately the diagnosis after considering the subjective and objective data.

32

POMR- Plan

(S + O + A) of action to solve the problem; may include treatment, medication, consultation, surgery, evaluations, etc.

33

Patient history

The history is a systematic process of recording relevant past medical data that affects the patient's medical care.

34

Content of the patient history-

- Demographic
- Personal habits
- Family history
- Past illness
- Review of systems (ROS)

35

Content of the patient history- Demographic

Name, date of birth, marital status, children, occupation, education, and social information.

36

Content of the patient history- Personal habits

To determine any correlation between the patient's health and lifestyle.

37

Content of the patient history- Family history

The patient is asked to identify the health habits, illnesses, and diseases of parents, siblings, and sometimes grandparents. Time and cause of death of family members may also be required.

38

Content of the patient history- Past patient illness

The patient will identify all past illnesses, disease, surgeries, injuries, childhood conditions, hospitalizations, drug sensitive and allergies.

39

Content of the patient history- Female patients

Will be asked questions concerning menses, pregnancies, and birth outcomes.

40

Content of the patient history- Review of System

ROS: Questions regarding each of the major body systems and parts.

41

Review of Systems- Cardiovascular systems

Palpitations, pain, blood pressure, edema, arrhythmia, etc

42

Review of Systems- Respiratory system

Shortness of breath (SOB), pain, irregulation, asthma, cough, allergies.

43

Review of System- Urinary system

Voiding habits, discharges, pain, frequency, odor, color, etc.

44

Review of System- Gastrointestinal system

Diet, weight, pain, indigestion, nausea, vomiting, bowel moment, hemorrhoids, etc.

45

Review of System- Menses

Interval, regularity, discharge, cramps, flow volume, etc.

46

Review of System- Neurological system

Vertigo, weakness, coordination, tremors, memory, concentration, etc.

47

Review of System- Musculoskeletal system

Pain, deformity, mobility, swelling, etc.

48

Regarding severe pain- P

P:
- Provoke: the patient to reveal what seems to cause the pain.

49

Regarding severe pain- Q

Q:
- Quality: of the pain should be elicited; stabbing, dull, throbbing, etc.

50

Regarding severe pain- R

R:
- Region: Where the pain is located.

51

Regarding severe pain- S

S:
- Signs and symptoms: that accompany the pain such as nausea, redness, swelling, etc.

52

Regarding severe pain- T

T:
- Time: of onset, frequency, and duration.

53

Asepsis and infection control- Handwashing

Handwashing:
- Appropriate handwashing is most important defense against disease transmission.

54

Asepsis and infection control- Sanitization

Sanitization:
- Process of cleaning or freeing materials especially instruments, from dirt. Requires scrubbing materials with brushes and detergents.
1. Detergents: wetting agents that mechanically remove bacteria, emulsify fats and oil. as well as dissolve high protein substance such as blood.
2. Ultrasound: Instruments may be placed in an ultrasonic bath containing a detergent solution. The ultrasonic bath is a device that passes sound waves through the liquid causing vibration which loosen contaminants, blood and dirt.
3. Antiseptic: Agents of sanitization used on the skin.

55

Asepsis and infection control- Disinfection

Disinfection:
- Process of removing infectious material from selected objects.
1. Chemical
2. Ultraviolet radiation
3. Desiccation
4. Boiling

56

Asepsis and infection control- Disinfection- Chemicals










Chemicals: Surface germicides used on inanimate materials that are sensitive to heat.
1. Soap: Mechanically removes some infectious material such as bacteria, but does not generally destroy them unless it contains a germicide.
2. Alcohol: Isopropyl alcohol is commonly used on skin as it has some germicide properties; iodine sometimes added for strength.
3. Acids: Phenol is an excellent germicidal.
4. Alkalies: 10% sodium hypolorite (bleach) is commonly used on laboratory surfaces and selected equipment.
5. Formaldehyde: 5% formalin is effective but requires thorough rinsing with water.

57

Asepsis and infection control- Disinfection- Ultraviolet radiation

Ultraviolet light has germicide effect on surfaces and airborne microbes, but has no penetrating power.

58

Asepsis and infection control- Disinfection Desiccation

Drying inhibits bacterial growth and is commonly used as a preservative; spores are highly resistant.

59

Asepsis and infection control- Disinfection- Boiling

Kills most bacteria, except some spore-forming bacterial and viruses.

60

Asepsis and infection control- Sterilization

Complete destruction of all microorganisms or infectious agent.
- Chemical: Agent such as glutaraldehyde may must be submerged for extended periods.
- Steam under pressure (autoclave): most common and effective means of sterilization.
- Gas: Special sterilization chamber that uses a sterilizing gas and sometimes pressure.
- Oven: Dry heat at a temperature and interval necessary to destroy all microorganisms.

61

Vital signs and anthropomety

Vital signs, also known as "cardinal signs" are measurements that indicate the state of health of the human body.

62

Vital signs and anthropomety- Factors affecting the body

- Age: infant = 97.7 to 99.5 F, 36.5 to 37.5 C
- Old age = below 97 F

1. Environment
2. Activity
3. Diurnal variation: normal variation throughout the day; lowest in the morning.
4. Emotional state

63

Vital signs and anthropomety- Temperature conversion formula

1. C to F: (C X 9 / 5) + 32 = F
- Example: 37 C x 9 / 5) + 32 = 66.6 + 32 = 98.6 F
2. F to C: (F - 32) x 5 / 9 = C
- Example: (102 F - 32) x 5 / 9 = 70 x 5 / 9 = 38.9 C

64

Vital signs and anthropometry- Normal temperatures

- Oral: 97 to 99 F, 36 to 37.8 C
- Rectal: one degree F higher than oral.
- Axillary: one degree F lower than oral.

65

Vital signs and anthropomety- Fever characteristics

1. Fever (pyrexia or hyperthermia) is a temperature over 100 F. it can be caused by infection, brain tumors, and hyperthyroidism. Untreated high fevers (105 F, 40.5 C) can cause brain damage or death.

66

Vital signs and anthropomety- Fever characteristics- Febrile

Febrile:
- Having a fever

67

Vital signs and anthropomety- Fever characteristics- Afebrile

Afebrile:
- Without a fever

68

Vital signs and anthropomety- Fever characteristics- Onset (invasion)

Onset (invasion):
- Period when fever began.

69

Vital signs and anthropomety- Fever characteristics- Continuous

Continuous:
- Relatively constant elevated temperature.

70

Vital signs and anthropomety- Fever characteristics- Defervescence

Defervescence:
- Fever subsides

71

Vital signs and anthropomety- Fever characteristics- Remittent

Remittent:
- Elevated fluctuation not returning to normal.

72

Vital signs and anthropomety- Fever characteristics- Subsiding

Subsiding:
- Phase during which temperature is returning to normal.

73

Vital signs and anthropomety- Fever characteristics- Lysis

Lysis:
- Gradual return of elevated temperature to normal.

74

Vital signs and anthropomety- Fever characteristics- Crises

Crises:
- Sudden return of elevated temperature to normal.

75

Vital signs and anthropomety- Fever characteristics

1. Fever
2. Febrile
3. Afebrile
4. Onset (invasion)
5. Continuous
6. Defervescence
7. Intermittent
8. Remittent
9. Subsiding
10. Lysis
11. Crises

76

Vital signs and anthropomety- Fever characteristics- Intermittent

Intermittent:
- Fluctuation between normal/subnormal and fever.

77

Vital signs and anthropomety- Pulse

Pulse:
- The rate and characteristics of the pulse provide clues as to the condition of the cardiovascular system.
- The pulse is defined as the wave of alternating expansion and relaxation of the arterial walls with each contraction of the left ventricle.

78

Vital signs and anthropomety- Factors affecting pulse

- Disease
- Age
- Physical activity
- Emotional status
- Medication

79

Vital signs and anthropomety- Pulse characteristics

- Rate: numbers of beats per unit time, usually a minuite.
1. Infants- 100 to 160/min
2. 1 to 7 yrs old- 80 to 120/min
3. 7 to 12 yrs old- 80 to 90/min
4. 12 yrs and older- 60 to 100/min
5. Elderly- 60 to 90/min
6. Athletes- 50 to 70/min
- Rhythm: Interval of time between beats (tempo)
- Volume: Force or strength of the pulse.
- Texture: Texture or strength of the arterial wall should be smooth and soft.

80

Vital signs and anthropomety- Pulse sites

1. Radial
2. Carotid
3. Brachial
4. Femoral
5. Temporal
6. Popliteal
7. Dorsalis pedis
8. Apical

81

Vital signs and anthropomety- Characteristics of respiration

- Normal rate:
1. Newborn- 30 to 80
2. 1 to 6 yrs- 20 to 40
3. 7 to 14 yrs- 15 to 25
4. Adults- 12 to 20
- Rhythm: Regular and even is normal. Respiratory rhythm is normally irregular in children.
- Depth: Air volume inhaled and exhaled.
- Audibility: Not easily audible except snoring.

82

Vital signs and anthropomety- Breathing patterns

1. Eupnea: normal breathing
2. Dyspnea: difficult/labored breathing
3. Apnea: Temporary cessation of breathing
4. Orthopnea: Difficulty breathing in positions other than upright.
5. Hyperpnea: increased depth of breathing
6. Tachypnea: Increased rate of breathing
7. Chyene-Strokes: Alternating periods of apnea and tachypnea.
8. Rales: Crackling, gurgling breathing sound caused by excretion in the bronchi.
9. Rhonchi: Rattling in the throats as in snoring.
10. Stertor: Laborious breathing as in snoring.

83

Vital signs and anthropomety- Blood pressure

- Blood pressure: indirectly measures the force of pressure that the blood exerts on the walls of the arteries.
1. Systole: The force of pressure exerted when the heart is contracting is called the systolic phase.
2. Diastole: Pressure exerted when the heart relaxes is called the diastolic phase.
*Expressed as a fraction: Systolic/diastolic

84

Vital signs and anthropomety- Normal values (average) blood pressure

1. Newborn- 50/30
2. 6 yrs- 95/62
3. 10 yrs- 100/65
4. 16 yrs- 118/75
5. Adult- 120/80
6. Elderly- 138/86
** Hypertension: High blood pressure- 140/90
** Hypotension: Low blood pressure- 90/60
** Orthostatic hypotension- temporary hypotension when one moves from a horizontal to vertical position.
** Pulse pressure- Difference between the systolic and diastolic pressure. Average is 40 mmHg with a sistolic:diastolic:pulse pressure ratio of 3:2:1.

85

Vital signs and anthropomety- Korotoff sounds

Korotoff: 5 phases of BP sounds.
- Phase 1: Faint tapping that increases in intensity.
- Phase 2: Sounds develop into squeaking quality.
- Phase 3: Crisp sounds that increase in volume (systolic reading).
- Phase 4: Sounds become muffled. If phase 4 is to be recorded as well: 120/110/80.
- Phase 5: Sounds disappear (diastolic reading).
** Repeated BP reading in the same arm will increase BP.