MA 201 Screening

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Shutrbug20
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74124
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MA 201 Screening
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2011-03-20 23:48:49
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  1. Screening
    • The process of obtaining info from patient to determine medical condition (Chief Complaint C.C.)
    • Has replaced word Triage
  2. Triage
    • French word for sort
    • Developed by the military
    • Used to help prioritize by injury
  3. Triage Order
    • 1. Breathing is most important, then most severe injured (chest pain, severe bleeding, poisoning, etc)
    • 2. Next less severe (major / multi fractures, 2nd burns, back injury, severe eye injury)
    • 3. All others saved for last
  4. Subjective
    • Information received from patient they feel, not measureable
    • (Pain, dizziness, itchy)
  5. Objective
    • Measureable by any other person
    • (Swelling, bruising, rash, vital signs)
  6. SOAP
    • Used by Dr's to obtain patient info during visit
    • Subjective, Objective (MA does)
    • Assessment, Plan (Dr does)
  7. 11 Factors Influencing Screening
    • Privacy, Biases, Relaxed Atmosphere
    • Non-verbals, Understands, Patient Talking
    • Listening Skills, Patient non-verbals
    • Open ?'s, Focus Interview, Summary
  8. History of Present Illness (HPI)
    • Self treatment, effects of treatment
    • Other symptoms of CC
    • What helps / aggrivates
  9. LASTSAQ
    • Location
    • Association
    • Setting
    • Timing
    • Severity
    • Alleviation / Aggrivation
    • Quality
  10. Medication
    • All current medications
    • All over the counter drugs
    • All suppliments
    • All vitimins
    • All home remedies
  11. NKDA
    No Known Drug Allergies
  12. Genogram
    • A diagram of family and their diseases
    • Both sides
  13. Present Illness
    PI
  14. Over The Counter
    • OTC
    • Meds, vitimins, suppliments
  15. Review of Body Systems
    • ROS
    • Helps patient remember previous illness / symptoms
  16. PH
    Past History
  17. PMH
    Past Medical History
  18. UCHD
    Usual Childhood Disease
  19. FH
    Family History
  20. Mensuration
    To measure
  21. Initial Measurements / Vital Signs
    Become baseline for new patients
  22. 4 Vital Signs
    • Temperature
    • Pulse
    • Respiration
    • Blood Pressure
    • (TPR & BP)
  23. Temperature
    • Condition's that affect include
    • Metabolism, time of day, amount of activity
  24. Above Normal Temperature
    Febrile
  25. No High Temperature
    Afebrile
  26. Normal Temperature
    97.6-99.6
  27. Below Normal Temperature
    • Subnormal
    • Hypothermia
    • Collapse will occur at 96.0deg
    • Death at 93.0deg
  28. Axillary Temperature
    • -1deg from normal Oral
    • 97.6
  29. Rectal Temperature
    • +1deg from normal Oral
    • 99.6
  30. Fever Temp Ranges
    • Slight --------99.6-101.0
    • Moderate ---101.0-102.0
    • Severe ------102.0-104.0
    • Dangerous -104.0-105.0
    • Fatal over ---106.0
  31. 5 Types Thermometers
    • 1. Disposable (avoids cross contam)
    • 2. Digital (quick and easy)
    • 3. Electronic (quick and easy)
    • 4. Tympanic (no mucous concerns) BEST
    • 5. Temporal (no mucous)
  32. When Temp from Other Than Oral
    • 98.6
    • (R) for Rectal
    • (Ax) for Axillary
    • (TA) for Temporal Artery
    • (T or TC) for Tympanic / Tympanic Core
  33. Formula Conversion
    C = F-32 / 1.8

    F = (C * 1.8) + 32
  34. Known Temps
    • Freezing ----------32F ----0C
    • Body Temp -------98.6F --37C
    • Pasteurization --145F ---63C
    • Boiling ------------212F ---100C
    • Sterilization ------250F ---121C
  35. Tachycardia
    • Constant pulse rate over 100
    • Means Fast / High
  36. Bradycardia
    • Constant pulse rate below 60
    • Means Low / Slow
  37. Apex
    Left 5th intercostal space in line with middle of left clavical
  38. Counting Respiration
    Improtant patient unaware of counting / measuring (can scew reading)
  39. 3 Types Respiration
    • Normal
    • Shallow
    • Deep
  40. 2 Types Rhythm
    • Regular
    • Irregular
  41. Apnea
    Lack of breathing
  42. Adult Normal Resp Rate
    16-20 per minute
  43. Maintain Blood Pressure
    • The heart (pump)
    • The Brain (controls autonomic nervous system)
  44. Blood Pressure Phases
    • Contraction - Systole (max pressure)
    • Relax / Fill - Diastole (least pressure)
  45. Blood Pressure Classifications
    • Normal ---------------------<120 / <80
    • Prehypertension ----------120-139 / 80-89
    • Stage 1 Hypertension ---140-159 / 90-99
    • Stage 2 Hypertension ------->160 / >100
  46. Hypotension
    Blood pressure below 90/60
  47. Phrenic Nerve
    Controlls Diaphram
  48. Inhalation
    Flatens Diaphram
  49. Exhalation
    Domes Diaphram
  50. Sphygmomanometer
    Blood Pressure Cuff, gauge
  51. Types Sphygmomanometer
    • 1. Aneroid (dial)
    • 2. Digital
    • 3. Mercury
    • 4. Wall Mount
  52. 12 Examination Positions
    • 1. Anatomical - standing, arms to side, palms forward
    • 2. Horizontal Recumbant / Supine - on back flat
    • 3. Dorsal Recumbant - on back, knees bent
    • 4. Prone - on stomach, head turned to one side
    • 5. Sim's - on stomach, to side, knee bent (sleeping) rectal exam
    • 6. Knee Chest - on knees, face on bed
    • 7. Fowler's - sitting at end of table
    • 8. High Fowler's - sitting, 90deg
    • 9. Lithotomy - pap test, stirrups
    • 10. Trendelenburg - shock, head down, on back, feet up
    • 11. Jacknife - in chair, leaned back
    • 12. Proctological - like knee chest, in special chair
  53. NPO
    • Non-per-os
    • Nothing by mouth
  54. CPE
    Complete Physical Exam
  55. H&P
    History and Physical
  56. PE
    Physical Exam
  57. 6 Techniques Evaluate Patient
    • 1. Inspection - sight
    • 2. Palpation - touch
    • 3. Percussion - tapping
    • 4. Auscultation - listening
    • 5. Mensuration - measure
    • 6. Manipulation - movement of joints
    • 6a. Passive - Dr moves
    • 6b. Active - Patient moves
  58. PERRLA
    • Pupils
    • Equil
    • Round
    • Responds to light
    • Accommedations
  59. TSE
    Testicular self exam
  60. Acute
    Within 72 hours
  61. Chronic
    More than 6 months
  62. Child under 3 Years Old
    • Measure lying down
    • Push gently on knees to straighten
  63. Child Over 3 Years Old
    Can stand and measure as normal
  64. Papanicolaou (pap)
    Cytologic screening test to detect cervical cancer
  65. When Pap Due
    • 3yrs after start sex or by 21yrs old
    • every year or 2 with liquid-based pap
  66. EDD
    • Estimated day/date of delivery
    • Nagele Rule
  67. Premature
    Born before 37 weeks

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