Flashcards in Diagnostic & Treatment Deck (85):
X-ray (roentgenograms) scientists is credited with the discovery of x-ray.
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).
Is the method used for complete destruction of microorganisms and their spores.
Process of measuring.
Is examining through feel.
Is resonance of sounds within the body.
Vital signs measurements
Temperature, Pluse, Respiration (TPR) and blood pressure (BP) are vital signs measurements.
Review Of System (ROS)
Questions regarding each of the major body systems and parts.
- 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.
Medical chart- Chief complain (CC)
- Primary reason for seeking medical care.
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.
Medical chart- Family history (FH)
- Includes details regarding the patient's parents and siblings such as health status, age and causes of death, hereditary disease, etc.
Medical chart- Present illness (PI)
- Details associated with the chief complaint.
Medical chart- Social history (SH)
Information regarding personal habits such as exercise, sleep, diet, alcohol/tobacco/drug use, sexual activity, hobbies, etc.
Medical chart- Occupational history (OH)
- Information regarding the patient's employment.
Medical chart- Physical examination (PE)
- 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.
Medical chart- Diagnostic and laboratory tests
Test results are usually arranged in reverse chronological order.
Medical chart- Consultation reports
Evaluations made by other practitioners at the request of the provider.
Medical chart- Correspondence
As related to the patient's care.
Medical chart- Providers notes
Notes written in the chart by the health care provider regarding a patient's diagnosis and treatment.
Medical chart- Termination summary
Documents that serve to identify discontinuation of care either by a consulting or primary provider.
Medical chart- Source
Medical data are characterized by it's source:
- Medical history
- Progress notes
- Diagnostic reports
Problem Oriented Medical Record (POMR)
Medical data are organized and identified according to disease, situation, or condition.
- Problem list
- Progress notes
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.
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.
Detailed description of diagnostic and treatment measures to include instruction, teaching and perhaps further evaluations.
POMR- Progress notes
Uses the SOAP approach.
- Subjective data
- Objective data
- Assessment (S + O)
- Plan (S + O + A)
POMR- Subjective data
Related to the patient's signs, symptoms and feelings as described by the patient.
POMR- Objective data
Determined by the providers examination and diagnostic tests.
(S + O) Describing the providers impression of the problem and ultimately the diagnosis after considering the subjective and objective data.
(S + O + A) of action to solve the problem; may include treatment, medication, consultation, surgery, evaluations, etc.
The history is a systematic process of recording relevant past medical data that affects the patient's medical care.
Content of the patient history-
- Personal habits
- Family history
- Past illness
- Review of systems (ROS)
Content of the patient history- Demographic
Name, date of birth, marital status, children, occupation, education, and social information.
Content of the patient history- Personal habits
To determine any correlation between the patient's health and lifestyle.
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.
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.
Content of the patient history- Female patients
Will be asked questions concerning menses, pregnancies, and birth outcomes.
Content of the patient history- Review of System
ROS: Questions regarding each of the major body systems and parts.
Review of Systems- Cardiovascular systems
Palpitations, pain, blood pressure, edema, arrhythmia, etc
Review of Systems- Respiratory system
Shortness of breath (SOB), pain, irregulation, asthma, cough, allergies.
Review of System- Urinary system
Voiding habits, discharges, pain, frequency, odor, color, etc.
Review of System- Gastrointestinal system
Diet, weight, pain, indigestion, nausea, vomiting, bowel moment, hemorrhoids, etc.
Review of System- Menses
Interval, regularity, discharge, cramps, flow volume, etc.
Review of System- Neurological system
Vertigo, weakness, coordination, tremors, memory, concentration, etc.
Review of System- Musculoskeletal system
Pain, deformity, mobility, swelling, etc.
Regarding severe pain- P
- Provoke: the patient to reveal what seems to cause the pain.
Regarding severe pain- Q
- Quality: of the pain should be elicited; stabbing, dull, throbbing, etc.
Regarding severe pain- R
- Region: Where the pain is located.
Regarding severe pain- S
- Signs and symptoms: that accompany the pain such as nausea, redness, swelling, etc.
Regarding severe pain- T
- Time: of onset, frequency, and duration.
Asepsis and infection control- Handwashing
- Appropriate handwashing is most important defense against disease transmission.
Asepsis and infection control- 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.
Asepsis and infection control- Disinfection
- Process of removing infectious material from selected objects.
2. Ultraviolet radiation
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.
Asepsis and infection control- Disinfection- Ultraviolet radiation
Ultraviolet light has germicide effect on surfaces and airborne microbes, but has no penetrating power.
Asepsis and infection control- Disinfection Desiccation
Drying inhibits bacterial growth and is commonly used as a preservative; spores are highly resistant.
Asepsis and infection control- Disinfection- Boiling
Kills most bacteria, except some spore-forming bacterial and viruses.
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.
Vital signs and anthropomety
Vital signs, also known as "cardinal signs" are measurements that indicate the state of health of the human body.
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
3. Diurnal variation: normal variation throughout the day; lowest in the morning.
4. Emotional state
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
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.
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.
Vital signs and anthropomety- Fever characteristics- Febrile
- Having a fever
Vital signs and anthropomety- Fever characteristics- Afebrile
- Without a fever
Vital signs and anthropomety- Fever characteristics- Onset (invasion)
- Period when fever began.
Vital signs and anthropomety- Fever characteristics- Continuous
- Relatively constant elevated temperature.
Vital signs and anthropomety- Fever characteristics- Defervescence
- Fever subsides
Vital signs and anthropomety- Fever characteristics- Remittent
- Elevated fluctuation not returning to normal.
Vital signs and anthropomety- Fever characteristics- Subsiding
- Phase during which temperature is returning to normal.
Vital signs and anthropomety- Fever characteristics- Lysis
- Gradual return of elevated temperature to normal.
Vital signs and anthropomety- Fever characteristics- Crises
- Sudden return of elevated temperature to normal.
Vital signs and anthropomety- Fever characteristics
4. Onset (invasion)
Vital signs and anthropomety- Fever characteristics- Intermittent
- Fluctuation between normal/subnormal and fever.
Vital signs and anthropomety- 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.
Vital signs and anthropomety- Factors affecting pulse
- Physical activity
- Emotional status
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.
Vital signs and anthropomety- Pulse sites
7. Dorsalis pedis
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.
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.
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
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.