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Diagnosis, Ch. 1


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Conclusion or decision based on a careful examination of relevant information.
Steps of Diagnosis
1) Make an observation about a condition. 2) Compare observations with available data. 3) Determine probable nature of problem.
Clinical Diagnosis
Indentification of a disease; can be complicated but uses the same general steps as a diagnosis.
Biological normality, such as temperature (98.6).
Disease causing agent, such as bacterua or viruses.
Failure to maintain homeostasis (homeostatic conditins).
The invasion process of pathogens (inside the body).
Organisms attaching themselves to the body.
Reasons for disease.
1) Genetics (sickle cell anemia). 2) Loss of normal regulatory control (autoimmune disorder). 3) Degeneration of body systems due to aging. 4) Trauma / toxins / enviromental hazards (wreck / poison / air pollution). 5) Nutrition (defincies in certain vitamins)(anemia).
The study of disease.
The study of functional changes caused by disease.
Patient's perception of a change in normal body functions, such as nausea, malaise or pain.
Physical manifestation of disease, such as swelling, cysts, broken bones, etc.
Steps in Diagnosis
1) Obtain patient's medical history. 2) Perform physical examination. 3) (if necessary) Perform diagnostic procedures.
(SID) Obtain Patient's Medical History
1) Chief Complaint ("Why are you here today?) 2) History of current illness ("Has this happened before?"); chronic or acute. 3) Review of systems.
(SID) Perform Physical Examination -- IPPA.
1) Inspection: height, weight, posture, patterns of movement (gait). 2) Palpation: feel for tender spots, prospective tumors and pulse. 3) Percussion: tapping with fingers, listening for changes in sound. 4) Auscultation: using stethoscope to listen to the sounds or changes in the sounds.
Homeostatic Body Temperature
Infant Blood Pressure
90 / 50
Child Blood Pressure
125 / 60
Adult Blood Pressure
140 / 90
Infant Respiratory Rate
30 - 50
Child Respiratory Rate
18 - 30
Adult Respiratory Rate
8 - 18
Infant Pulse Rate
70 - 170
Child Pulse Rate
70 - 110
Adult Pulse Rate
50 - 95
(SID) Perform Diagnostic Procedures
1) Two catagories of diagnostic tests. A) Tests performed on the individual within a hospital, such as scans, x-rays, mammographies, E.C.G., stress tests, skin tests, etc. B) Tests performed in a clinical laboratory on tissue samples, body fluids or other materials collected from the body (sending samples to the lab), such as blood, urine or biopsies.
Diagnostic Protocol (SOAP)
1) Subjective: Medical history. 2) Objective: Physical examination. 3) Assessment: Diagnosis, research and prognosis (probably outcome). 4) Plan: Treatment options, medications, etc.

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