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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) Obtain Patient's Medical History
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 oth
(SID) Perform Diagnostic Procedures
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
(SID) Perform Physical Examination -- IPPA.
Adult Blood Pressure
140 / 90
Adult Pulse Rate
50 - 95
Adult Respiratory Rate
8 - 18
Child Blood Pressure
125 / 60
Child Pulse Rate
70 - 110
Child Respiratory Rate
18 - 30
Indentification of a disease; can be complicated but uses the same general steps as a diagnosis.
Clinical Diagnosis
Conclusion or decision based on a careful examination of relevant information.
Diagnosis
1) Subjective: Medical history. 2) Objective: Physical examination. 3) Assessment: Diagnosis, research and prognosis (probably outcome). 4) Plan: Treatment options, medications, etc.
Diagnostic Protocol (SOAP)
Failure to maintain homeostasis (homeostatic conditions).
Disease
Biological normality, such as temperature (98.6).
Homeostasis
Homeostatic Body Temperature
98.6
Infant Blood Pressure
90 / 50
Infant Pulse Rate
70 - 170
Infant Respiratory Rate
30 - 50
The invasion process of pathogens (inside the body).
Infection
Organisms attaching themselves to the body.
Infestation
Disease causing agent, such as bacterua or viruses.
Pathogen
The study of disease.
Pathology
The study of functional changes caused by disease.
Pathophysiology
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
Reasons for disease.
Physical manifestation of disease, such as swelling, cysts, broken bones, etc.
Sign
1) Obtain patient's medical history. 2) Perform physical examination. 3) (if necessary) Perform diagnostic procedures.
Steps in Diagnosis
Patient's perception of a change in normal body functions, such as nausea, malaise or pain.
Symptoms

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