test 3 Flashcards
how do you chart patient instructions
date time type of information provided patient signs form to indicate they got the instructions ma witnesses signature filed in chart
how to document specimen collection
date
time of collection
type of specimen
area from where it came
chart forms include:
- health history
- consent for treatment
- consent to use and disclose health information
- history and physical
- progress notes
- medication log
What are the four types of bones?
- long bones
- short bones
- flat bones
- sesamoid bones
what is an example of a long bone?
humerus
what is an example of a short bone?
carpal
what is an example of a flat bone?
skull
pelvis
scapula
what is an example of a sesamoid bone?
patella
Name the 9 types of joints
- synarthroses
- amphiarthroses
- diarthroses
- ball and socket
- condyle
- hinge
- gliding
- pivot
- saddle
what does synarthroses mean?
immoveable - skull
what does amphiarthroses mean?
slightly moveable - pelvic symphysis
what does diarthroses mean?
freely moveable - shoulder, elbow
tough, dense, fibrous bands of connective tissue that hold bones together
ligaments
strong, tough cords of dense connective tissue that usually attach muscle to bone
tendons
semi-smooth, dense, supporting connective tissue
cartilage
an exaggerated inward curvature of the spine
lordosis
treatment for lordosis
weight-loss
exercise
an abnormal outward curvature of the spine
kyphosis
treatment for kyphosis
exercise
spinal fusion
vertebroplasty
a lateral (sideways) curvature of the spine
scoliosis
treatment for scoliosis
exercise
back brace
fusion of the vertebrae
the breakdown and eventual loss of cartilage of one or more joints
osteoarthritis
causes of osteoarthritis
aging process
heredity
injury
chronic diseases; diabetes and obesity
signs of osteoarthritis
spur formation on fingers
degeneration of spinal vertebrae and pelvic joints
how do you treat osteoarthritis
reduce inflammation, minimize pain
an infectious bacterial disease spread by deer tick bites
lyme disease
any abnormal growth in the bone
bone tumor
3 types of bone tumors
- chondrogenic (from cartilage)
- osteogenic (from bone)
- fibrogenic ( from fibrous tissue)
the forcible displacement of a bone from its joint, causing loss of joint function
dislocation
treatment for dislocation
proper repositioning of joint within 30 minutes of the injury
caused by stress on the bones resulting from a traumatic insult to the musculoskeletal system, severe muscle spasm, or bone disease
fracture (broken bones)
general treatments for fracture
- depends on location, type, and severity and cause
- simple fracture of a long bone = reduction and immobilization
- compound fracture = cleaning, debriding, reduction, immobilization (bone came through the skin)
- internal fixation = open reduction (hip fracture)
an abnormal mass of tissue that results when cells divide more than they should or do not die when they should.
may be benign or malignant
also called a tumor
neoplasm
a localized area of enlargement of the inner portion of the metatarsophalangeal (MTP) joint at the base of the big toe
bunion
wearing footwear that is too tight
toes being squeezed too much
injured tendons, muscles, or other tissues resulting from overuse, overstretching, or excessive forcible stretching of the tissue beyond its functional capacity
strains
acute partial tears of a ligament
sprains
what are the parts of the physical exam?
health history
physical exam
tests
3 reasons why a physical exam is done
health maintenance disease prevention employment school military
what does a physical exam do?
to help determine the state of health, diagnosis, treatments and changes in patients under their care
scientific method of determining and identifying a patients condition through evaluation of the health history, PE, lab tests, and diagnostic test
final diagnosis
intermediate step in the determination of a final disgnosis
obtained through evaluation if health history and PE
WITHOUT lab and other tests
clinical diagnosis
two or more diseases may have similar symptoms
determines which disease is causing the symptoms so that a final diagnosis can be made
differential diagnosis
probable course and outcome of a patients condition and the patients prospects for recovery
prognosis
physical or behavioral condition that increases the probability that an individual will develop a particular condition
risk factor
name three risk factors
genetic factors
habits
environmental conditions
characterized by symptoms that have a rapid onset
acute illness
flu
characterized by symptoms that persist for more than 3 months
patient shows little change over time
chronic illness
diabetes
copd
a procedure performed to treat patients condition with the goal of eliminating it or promoting as much recovery as possible
therapeutic procedure
administration of medications
performed to assist in the diagnosis of a patients condition
diagnostic procedure
x-ray
stress test
MRI
the analysis and study of specimens obtained from patient to assist in diagnosis and treatment of disease
laboratory testing
biopsy
cultures
how do you identify the patient
by their name and date of birth
3 MA responsibilities
take vital signs
measure height and weight
explain purpose of exam and answer questions
reduce pt apprehension
process of measuring a patient
mensuration
change in which may be significant in:
diagnosis of patients condition
prescribing treatment
cardiac, diabetes, diet, hypertension
uses an upright scale balance
weight
divided into 50-lb increments
lower calibration
divided into pounds and quarter pounds
upper calibration lines
indicate pound increments
longer calibration
indicate quarter-pound and half-pound increments
shorter calibration lines
when weighing a patient measure to the….
nearest quarter pound
laying down on your back
examination of head, chest, abdomen
supine
laying on back
examination of back, extension of hip joint
prone
laying down with legs up on the table
examination of vagina and rectum, insertion of urinary catheters
dorsal recumbent
laying down with feet on stirups
used for pelvic, vaginal, and rectal exams
lithotomy
left-side laying
used to examine the vagina and rectum, to measure rectal temperature, administer an enema
sims
downward dog
examine the rectum, perform a protoscopic examination
knee-chest
sitting up with table/back support
examine upper body of patients with cardiovascular and respiratory problems
easier for patients to breathe in this postition
draw blood from patients who faint
fowlers
position at 90 degrees
hi fowlers
position at 45 degrees
semi fowler
extent of assessment during PE depends on
purpose of exam
patients condition
through assessment of all body systems
complete PE
patients who exhibit symptoms of illness:
do not require a complete PE
DR examines parts associated with symptoms
the process of observing a patient to detect signs of disease
inspection
3 kinds of inspection
color speech deformities skin conditions body movements anxiety level
the process of feeling with the hands to detect the signs of disease
helps verify data obtained from inspection
patients verbal and facial expressions are observed
palpation
2 types of palpation
light - determine areas of tenderness (finger tips)
deep- to examinee condition of organs (2 hands)
the process of tapping body and listening to the sounds produced to detect the signs of diease
percussion
used to determine-
size
density
location of organs
percussion
produce a dull sound
dense structures - liver
produce a hollow sound
empty or air filled structures - lungs
the process of listening with a stethoscope to the sounds produced within the body to detect the signs of disease
auscultation
utilization of the correct muscles to maintain proper balance, posture, and body alignment
body mechanics
spine consists of bones called
vertebrae
an infectious disease spread by deer tick bites
- flu-like symptoms
- fever, heachache, joint pain
- remove tick, oral antibiotics, bed rest
lymes dieases
a chronic disorder of uric acid metabloism, crystals develop within a joint causing arthritis
- high levels of uric acid in blood
- bed rest
- NSAIDS
gout
a condition characterized by loss of normal bone mass and density due to imbalance between breakdown of old bone tissue and manufacture of new bone
-asymptomatic until bone breaks
- increased intake in calcium and vitamin D
- estrogen replacement therapy
osteoporosis
a painful condition involving inflammation of the periosteum, the extensor muscles of the lower leg, and the surrounding tissues
- inflammation, edema, pain on inner aspect of tibia
- rest, applications of heat then ice
shin splints
3 types of muscles
cardiac
striated
-nonstriated
a chronic pain condition associated with stiffness and tenderness that affects muscles, tendons, and joints throughout the body. The cause is unknown.
- stress reduction
- physical activity
- medications
fibromyalgia
treatment of sprains and strains
- elevation and rest of affected limb
- immobilization with elastic bandage
- application of ice
- NSAIDS
what does RICE stand for and what is it used for
treatment of sprains and strains
- Rest
- Ice
- Compression
- Elevation
a painful condition involving inflammation of the periosteum, the extensor muscles of the lower leg, and the surrounding tissues
- inflammation, edema, pain on inner tibia
- rest, ice and heat
shin splints
caused by injury or laceration; involves the forearm, hand, calf, or foot. The severed ends snap away from each other
- immediate pain, inflammation, immobility
- tenorrhaphy - suturing of the two ends of the tendon
severed tendon
an inflammatory response at the bottom of the heel bone, generally caused by overuse
- pain on bottom of the foot
- ice, NSAIDS, heels pads, cortisone
plantar fasciitis
the four tendons of the rotator cuff, formed by the shoulder, partially surround the head of the humerus and stabilize it in the glenoid cavity of the socket.
rotator cuff
a stiff big toe that develops as a result of degeneration of the cartilage of the first metatarsophalangeal MTP joint
- unkown cause
- injury to the toe may cause this
rigid big toe
Hallus Rigidus
another word for bunion
hallus valgus
an abnormal mass of tissue that results when cells divide more than they should or do not die when they should. can sometimes be cancerous
neoplasm
infection resulting in erosion of tooth surfaces
dental caries
tooth decay
inflammation and swelling of the gums
gingivitis
destructive gum and bone disease around one or more of the teeth
periodontitis
specific angles of malposition and contact of the maxillary and mandibular teeth
malocclusion
a symptom complex related to inflammation, disease, or dysfunction of the temporomandibular joint
TMJ syndrome
a recurrent viral infection that affects the skin and mucous membranes
herpes simplex
cold sores
candidiasis of the oral mucosa, involving the mouth, tongue, plate, and gums
thrush
appears as white patchy leison or oral ulcer that wont heal
pain occurs late in the disease
oral cancer
what are 3 digestive distress signals
hiccup vomiting heartburn constipation nausea
are dilated submucosal veins that develop in patients with underlying portal hypertension and may result in serious upper GI bleeding
-usually dont survive
esophageal varices
inflammation and tissue injury of the esophagus
esophagitis
cancer of the esophagus
esophageal cancer
the clinical manifestations of regurgitation of stomach and duodenal contents into the esophagus
gastroesophageal reflux disease
GERD
severe consequence of GERD that replaces normal striated squamous epithelium of the distal esophagus with abnormal columnar epithelium
Barrett’s esophagus
sores or lesions in the mucous membrane of the stomach or upper intestinal tract
peptic ulcers
ulcers of the first part of the small intestine
duodenal ulcers
ulceration of the gastric mucosa of the stomach that follows chronic gastrics
gastric ulcers
inflammation of the appendix
- abdominal pain in lower right quadrant
- surgical removal
acute appendicitis
a defect in the diaphragm that permits segment of stomach to slide into thoracic cavity
- heart burn
- chest pain
- swallowing difficulty
hiatal hernia
a condition in which an organ protrudes through an abnormal opening in the abdominal wall
- lump or buldge
- groin pain
abdominal hernia
chronic inflammatory disorder of the gastrointestinal tract
crohns disease
ileitis
chronic inflammatory bowel disease affecting the mucosa and submucosa of the rectum and colon
ulcerative colitis
acute inflammation of the stomach and intestines
gastroenteritis
outpouches of mucosa penetrate weak points in muscular layer of large intestine
- mild discomfort
- irregular bowels
diverticulosis
trapped fecal matter causes inflammation of diverticula
- fever
- nausea
- pain
- changes in bowel function
diverticulitis
a cancer that arises in any part of the colon or rectum
- abdominal pain
- bloody stools
colorectal cancer
an irreversible chronic degenerative disease that results in the replacement of normal liver cells with hard, fibrous scar tissue
- nausea
- vomiting
- indigestion
cirrhosis of the liver
what is the most common blood borne infection in the US
Hep. C
primary tumor of the liver; usually arises in chronic liver disease setting
- weight loss
- ascites
- jaundice
hepatocellular carcinoma
condition in which there is abnormal presence of calculi that form in the bile
- pain
- nausea
- vomiting
- obstruction of the biliary duct by gallstones
cholelithiasis
gallstones
acute or chronic inflammation of the pancreas with variable involvement of adjacent or remote organs
- nausea
- vomitting
- sudden abdominal pain
- gallstones
- alcoholism
- biliary disease
pancreatitis
a neoplasm, usually an adenocarcinoma, that occurs more often in the head of the pancreas
- abdominal pain
- weight loss
- jaundice
- smoking
- obesity
- family hx
pancreatic cancer
a disorder of nutrition caused by primary deprivation of protein energy or secondary to deficiency diseases
- decreased/increased appetit
- emaciation or obesity
- diarrhea
- chronic illnesses
malnutrition
a group of disorders in which intestinal absorption of dietary nutrients is impaired
- impaired digestion
- defective mucosal cells in the small intestine
malabsorption syndrome
a disease of the small intestine characterized by malabsorption, gluten intolerance, and damage to the lining of the intestine
- weight loss
- anorexia
- diarrhea
- reaction to gluten
celiac disease
gluten enteropathy
an illness resulting from the ingestion of foods that contain bacterial or toxic substances
- sudden nausea, vomiting, and diarrhea
- contaminated foods
food poisoning
psychological disturbance in which self-imposed starvation and compulsion to be thin leads to denial of hunger
anorexia nervosa
behavioral disorder characterized by recurring episodes of binge eating followed by self-induced vomiting and purging
bulimia
3 common symptoms of musculoskeletal disorders
- joint stiffness, pain, inflammation
- weight loss
- fever
- loss of motion, immobility
3 osteoporosis medications and treatments
- reduced bone mass
- fractures common
- lack of calcium
- accelerated by menopause
inflammation of joints
accompanied by pain, swelling, bony changes in joint
osteoarthritis
treat rheumatoid conditions by reducing body’s autoimmune response to its own tissues
rheumatoid arthritis
what are the 3 drug classes
NSAIDS - non-steroidal anti-inflammatory drugs
DMARDs - disease modifying antiheumatic drugs
glucocorticosteriods
NSAIDS
- provide rapid relief of symptoms but do not prevent progression of disease
- cause gastric bleeding and irritation
- Asprin
reduce inflammation
available in oral medications and injections
glucocorticosteroids
treatments of joint diseases
DMARDs
gold salts
miscellaneous
associated with hyperuricemia, a high level of uric acid
most often affects big toe, ankle, instep, knee, and elbow
-prevent attack
-end the attack
-decrease complications
gouty arthritis
result of involuntary contractions, must be treated according to cause
spams
hypertonicity of muscles resulting from neurologic disorders or trauma
spasticity
relieve muscle injuries and spasms
depress central nervous system
can cause physical dependency
skeletal muscle relaxants
what causes muscle spasticity
muscle stimulation from spinal cord or brain
progressive and incurable; characterized by skeletal muscle weakness and fatigue
-caused by loss of acetylcholine treatment
myasthenia gravis
painful syndrome causing chronic pain in muscles and soft tissues
- aching, stiffness, fatigue, depression
- NSAIDS
- physical therapy
fibromyalgia
what other things do you chart in a patients file other than their medications, etc
missed or canceled appointments
telephone calls from pt
medication refills
changes in medication dosage by physician
information is to be entered at the time of occurrence and not later
due course
what needs to happen to the chart when it is a work related injury
a new chart needs to be made
who owns the medical record
the physician
what part of the medical record does the patient own
the information
what does HIPAA stand for
health insurance portability and accountability act
always chart what about the patient when they received treatment
their condition before the treatment and how they tolerated it and left the office
how do you correct an error in the MR
draw a line through it
write error above
write correction above
date and initial beside it
what are 3 common allergies
shellfish
latex
iodine
how long do you have to keep a file of an inactive patient
7 years
what are the components of the health history
chief complaint present illness past history family history social history
patients reason for seeking care
-symptom causing them the most trouble
chief complaint
expansion of the CC
full description of the pts current illness
present illness
past medical status of the patient
assists physician in providing optimal care
past history
review of health status of patients blood relatives
family history
information on patients lifestyle
health habits and living environment
social history
how does the MA chart procedures
date, time, type of procedures, outcome, patient reaction
how to chart administration of medication
date time name of medication how it was given dosage
