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Clin Tech Phys Ex

The three parts to the complete patient examination health history, physical examination, laboratory and diagnostic tests
Why the patient examination is done results are used by physician to determine the patient's general state of health, to arrive at a diagnosis and prescribe treatment and to observe any change in a patient's illness after treatment has been instituted
final diagnosis often called the diagnosis, refers to the scientific method of determining and identifying a patient's condition through the evaluation of the health history, the physical examination, laboratory tests, and diagnostic procedures
why a final diagnosis is important provides a logical basis for treatment and prognosis
clinical diagnosis intermediate step in the determination of a final diagnosis, obtained through the evaluation of the health history and the physical examination without the benefit of laboratory or diagnostic tests
differential diagnosis two or more diseases may have similar symptoms
prognosis the probable course and outcome of a patient's condition and the patient's prospects for recovery
risk factor physical or behavioral condition that increases the probability that an individual will develop a particular condition
the presence of a risk factor for a certain disease means what? does not mean that the disease will develop
acute illness characterized by symptoms that have a rapid onset, usually severe and intense, and subside after a relatively short time
chronic illness characterized by symptoms that persist for more than three months and show little change over a long time
therapeutic procedure performed to treat a patient's condition with the goal of eliminating it or promoting as much recovery as possible
examples of therapeutic procedures administration of medication, ear and eye irrigations, and thereapeutic ultrasound
diagnostic procedure performed to assist in the diagnosis of a patient's condition
examples of diagnostic procedures electrocardiography, x-ray examination, and sigmoidoscopy
laboratory testing analysis and study of specimens obtained from patients to assist in diagnosing and treating disease
proper prepartion of the patient taking vital signs and measures weight and height, explain purpose of exam and offer answers, address patient by his/her name of choice, adopt a friendly and supportive attitude, speak clearly, distinctly, and slowly
why should a patient be asked to empty his/her bladder before the examination? it makes the examination easier and is more comfortable for the patient, if a urine specimen is needed, the patient is requested to void
how to address disrobing be specific so the patient understands what items of clothing to remove and where to place them
what should the disrobing facility be like? comfortable and provide privacy, have a place for the patient to sit to make it easier to remove clothing, instructions for putting on the exam gown and for locating the gown opening reduce patient confusion
what should be done if the patient will have trouble undressing? assistance should be offered, elderly and disabled patients sometimes have difficulty removing clothing
medical records should be made available for whom? the physician to review
where should medical record be placed? in a designated location, such as a chart holder on the front of the examining room door so that the patient-identifiable information is not visible due to HIPAA
the process of measuring the patient mensuration
a change in weight may be significant how? in the diagnosis of a patient's condition and in prescribing the course of treatment
who should be weighed at regular intervals? underweight and overweight patients who follow a diet therapy program to determine progress
prenatal patients are weighed how often? during each prenatal visit to assist in the assessment of fetal development and mother's health
an adult's weight is usually measured when? each office visit
an adult's height is measured when? only during the first visit or during a complete physical examination
children are weighed and measured during when? each office visit to observe their pattern of growth and to calculate medication dosage
guildeines for measuring weight and height
many patients are self conscious about having weight measured and prefer it where? in private, be careful not to make weight-sensitive comments during the procedure
this is especially important for who? patients with weight control problems such as obesity and eating disorders
balance the scale before measuring weight
assist the patient make sure to assist the patient on and off the scale platform
obtain an accurate weight always ask the patient to remove his/her shoes, measure weight with the patient in normal clothing, ask the patient to remove heavy outer clothing, such as a sweater or a jacket
interpret the calibration markings accurately the lower calibration bar is divided into 50-pound increments, the upper calibration bar is divided into pounds and quarter pounds
interpreting body weight
the two common methods to interpret body weight are? weight in relation to standard tables and calculation of the BMI
interpreting body weight is the what? BMI- body mass index
BMI expresses what? correlation of an individual's weight to his/her height
BMI is not used for whom? trained atheletes
method for calculating BMI 1) multiply weight in pounds by 703, 2) divide this number by your height in inches, 3) divide this amount again by your height in inches and round off to the nearest whole number
BMI Interpretations Below 18.5 = Underweight, 18.5-24.9 = Healthy weight, 25-29.9 = Overweight, 30-39.9 = Obesity, 40 or more = Morbid obesity
Assessment of the patient includes Inspection, palpation, percussion, auscultation
Inspection observation of the patient for any signs of disease, and of the four assessment techniques, one most frequently used
Areas assessed through inspection patient's color, speech, deformities, skin condition, body contour and symmetry, orientation to the surroundings, body movements, and anxiety level
Palpation examination of the body using the sense of touch, often helps verify data obtained by inspection
why physician uses palpation determine the placement and size of organs, presence of lumps, the existence of pain, swelling, or tenderness
what are 2 examples of palpation? examining breasts and taking pulse
Percussion involves tapping the patient with the fingers and listening to the sounds produced to determine the size, density, and location of organs
Auscultation involves listening with a stethoscope to the sounds produced within the body
Ausculatation is used for? to listen to the heart and lungs or to measure blood pressure
Assisting the physician- helping the patient change positions for the physician's examination of different parts of the body, handing the physician instruments and supplies, reassuring the patient to reduce apprehension
once examination is complete? assist the patient off the eamining table and provide additional information if needed, such as scheduling return visit or patient education to promote wellness
Ophthalmoscope an instrument for examining the interior of the eye
Otoscope an instrument for examining the external ear canal and tympanic membrane
Speculum an instrument for opening a body orifice or cavity for viewing
Correct positioning of the patient facilitates what? the examination by permitting better access to the part being examined or treated
Basic positions used in medical office? sitting, supine, prone, dorsal recumbent, lithotomy, Sims, knee-chest, and Fowler's
Position used depends on what? type of examination or procedure to be performed
when positioning a patient explain the position to the patient and assist the patient in attaining it, it is important to take the patient's endurance and degree of wellness into consideration when positioning a patient
why is the patient draped during positioning? to provide for modesty, comfort and warmth, only the part to be examined should be exposed
patient gowns and drapes are made of? usually paper but may also be made of cloth
Created by: melmobax
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