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Gen Med Eval

Section one of gen med

OSHA BBP standards, barriers, disinfection
PPE required by NCAA must cover immmunizations, allergies, illness, CV, neuro, musculoskeletal
Stages of Prevention Primary, secondayr tertiary
Primary Stage of prevention Goals:reduce risk factors Intervention:nutrition, exercise, monitoring environmental risks, prevention and educational programs
Secondary Stages of Prevention Goals:early detection, early intervention, inhibit proliferation Intervention:regular medical checkups, self-examination, early medical treatment
Tertiary Stage of Prevention Goal:limit established disease Intervention:medical treatment, supporitve and restorative
HIPAA Health Information Poprtability and Accountability ACt Implemented in 2003 Protects Patient Privacy-control over who and how their info is disclosed, full access to their health records
General Medical Evaluation History, Systemic Review, Physical Exam, Assessment, Plan
History Cheif Complaint, Current Medication, vitamins, supplements, past medical hisotry, current health status, family health history, past med history, current med history, family health history
systemic review all systems are review, begins w. a gen assessment(height weight etc) continue system by stystem starting with skin, work head to toe
Systems in a systemic review Skin, HEENT, lymphatic, GI, endocrine, male/female, chest/lungs, CV, hematology, genitourinary, musculoskeletal, mental
skin appearance and color
HEENT head, eyes, ears, nose and throat HA, seizures, syncope, contacts, tinnitus,vertigo, irritation
lymphatic swelling, pitting edema
GI heart burn, vomit, diarrhea, constipation
Endocrine temperature, tolerance
Male/female breast pain, swelling, lumps, LMP
Chest/lungs SOB, dyspnea, night sweats, sputum
Cardiovascular chest pain, exertional SOB
Hematology easily bruise
Genitourinary frequency, volume, color, dysuria
General survey-physical exam observe current state of health
physical exam-vital signs height and weight, bp, pulse rate and rythem respiration rate, temp
height and weight body comp, BMI
BP stephoscope, sphgnomanometer, size, procedure, normal levels, position
pulse rate and rythme location(radial, brachial, carotid, popliteal, post tib dorsal pedal), active c resting measurements, normal bradycardia, tachycardia
respiration rate normal level 12 per min, symmetry of movement
temp normal values, sites of taking temp, most accurate fever
evaluation tools stethoscope, opthalmoscope, otoscope, tuning fork, snellen eye chart
diagnostic test imaging, lab(urinalysis0-ph, RBC, WBC, glucose, specific gravity, protien)(CBC-RBC, WBC, hemoglobin, hematocrit)
Evaluation techniques neurological testing, palpation, percussion, ausculation
neurological testing-eval techniques dermatomes, myotomes, DTR
palpation-evaluation techniques light- 1cm deep-4cm
percussion direct:ulnar aspect of fist indirect:finger and hand Tone:air/lungs-loud, fluid(less loud, solid-soft
Auscultaion high pitch:bowl, lung, normal heart(diaphram) low pitch:heart murmers(bell)
diagnosis regers to the specific injury, illness, disease or condition a patient has, as determined by medical examination
differential diagnosis the identification of several conditions that might have similar clinical presentations, reqruies referral to doc for further lab or imaging studies for clarification of diagnosis
clinical decision making-the ats diagnosis may lead to actions such as first aid, emergency transport, treatment and rehab, reassessment, modification of activity, referral to other health care specialists
RED FLAGS constant p!, heart palpitations, fainting, night pain or sweats, visual problems, unexplained weight loss, severe shortness of breath, recurrent nausea or comiting, difficult or painful urination, blood in urine or stool, excessive malaise or fatigue
Created by: jwebst1