Diagnosis, Ch. 1
Terms
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- Diagnosis
- 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.
- Homeostasis
- Biological normality, such as temperature (98.6).
- Pathogen
- Disease causing agent, such as bacterua or viruses.
- Disease
- Failure to maintain homeostasis (homeostatic conditins).
- Infection
- The invasion process of pathogens (inside the body).
- Infestation
- 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).
- Pathology
- The study of disease.
- Pathophysiology
- The study of functional changes caused by disease.
- Symptoms
- Patient's perception of a change in normal body functions, such as nausea, malaise or pain.
- Sign
- 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
- 98.6
- 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.