P2 (CHAPTER 7)

medical diagnosis - the determination of the nature and cause of an illness

physical examination - includes a review of all systems and observation of any signs of illness

Practitioners use the following techniques in performing physicals:

• Inspection - visual examination

• Palpation - touching the surface of the body with the hands or fingers

• Percussion - tapping the body and listening to the sounds produced

• Auscultation - listening to body sounds with a stethoscope

vital signs (VS) - measurements that reflect basic functions necessary to maintain life; includes:

• Temperature (T)

• Pulse rate, measured in beats per minute (bpm)

• Respiration rate (R), measured in breaths per minute.

• blood pressure (BP), measured in millimeters mercury (mm Hg) and recorded when the heart is contracting (systolic pressure) and relaxing (diastolic pressure)

imaging techniques - the use of various physical forces to produce visual images of the body

imaging techniques:

• cineradiography - making of a motion picture of successive images appearing on a fluoroscopic screen

  • a radiology technique that records a series of images of moving objects in a short amount of time

• computed tomography - use of a computer to generate an image from a large number of x-rays passed at different angles through the body; a three-dimensional picture of a cross-section of the body is obtained; reveals more about soft tissues than does simple radiography

  • a noninvasive imaging procedure that uses X-rays to create detailed pictures of the inside of the body

• fluoroscopy - use of x-rays to examine deep structures; the shadows cast by x-rays passed through the body are observed on a fluorescent screen; the device used is called a fluoroscope

  • a medical imaging technique that uses X-rays to create a video of the inside of the body in real time

• magnetic resonance imaging (MRI) - production of images through the use of a magnetic field and radio waves; the characteristics of soft tissue are revealed by differences in molecular properties; eliminates the need for x-rays and contrast media

  • a non-invasive medical imaging technique that uses radio waves and a strong magnet to create detailed pictures of the body's internal structures

• positron emission tomography (PET) - production of sectional body images by administration of a natural substance, such as glucose, labeled with a positron-emitting isotope; the rays subsequently emitted are interpreted by computer to show the internal distribution of the substance administered; used to follow blood flow through an organ and to measure metabolic activity within an organ, such as the brain, under different conditions

  • a medical imaging procedure that uses a radioactive tracer to create pictures of the inside of the body

• radiography - rays passed through the body to make a visual record (radiograph) of internal structures on specially sensitized film

• scintigraphy - production of an image of the distribution of radioactivity in tissues after internal administration of a radioactive substance (radionuclide)

  • a nuclear medicine imaging technique that uses a radioactive substance to create pictures of the inside of the body. It's also known as a gamma scan or radionuclide scanning.

  • the images are obtained with a scintillation camera

  • the record produced is a scintiscan

• single photon emission computed tomography (SPECT) - scintigraphic technique that permits visualization of the cross-sectional distribution of a radioisotope

  • a nuclear medicine imaging test that uses gamma rays to create 3D images of internal organs

• ultrasonography - generation of a visual image from the echoes of high-frequency sound waves traveling back from different tissues; also called sonography and echography

surgical instruments:

• bougie - slender, flexible instrument for exploring and dilating tubes

• cannula - tube enclosing a trocar that allows escape of fluid or air after removal of the trocar

• clamp - instrument used to compress tissue

• curet (curette) - spoon-shaped instrument for removing material from the wall of a cavity or other surface

• elevator - instrument for lifting tissue or bone

• forceps - instrument for holding or extracting

• gigli saw - flexible wire saw

• hemostat - small clamp for stopping blood flow from a vessel

• rasp - surgical file

• retractor - instrument used to maintain exposure by separating a wound and holding back organs or tissues

• rongeur - gouge forceps

• scalpel - surgical knife with a sharp blade

• scissors - a cutting instrument with two opposing blades

• sound - instrument for exploring a cavity or canal

• trocar - sharp pointed instrument contained in a cannula used to puncture a cavity

key terms:

• anesthesia - Loss of the ability to feel pain, as by administration of a drug

• biopsy - Removal of a small amount of tissue for microscopic examination

• cautery - Destruction of tissue by a damaging agent, such as a harmful chemical, heat, or electric current (electrocautery); cauterization

• chemotherapy - The use of chemicals to treat disease

• endoscope - An instrument for examining the inside of an organ or cavity through a body opening or small incision; most endoscopes use fiberoptics for viewing

• excision - Removal by cutting (suffix -ectomy)

• fixation - Holding or fastening a structure in a fixed position (suffix -pexy)

• grading - A method for evaluating a tumor based on microscopic examination of the cells

• immunotherapy - Treatment that involves stimulation or suppression of the immune system, either specifically or nonspecifically

• incision - A cut, as for surgery; also the act of cutting (suffix -tomy)

• inspection - Visual examination of the body

• laser - A device that transforms light into a beam of intense heat and power; used for surgery and diagnosis

• opthalmoscope - An instrument for examining the interior of the eye

• otoscope - Instrument used to examine the ears

• palliative - a treatment that provides relief but not cure

• prognosis - Prediction of the course and outcome of a disease

• radiography - Use of x-rays passed through the body to make a visual record (radiograph) of internal structures on specially sensitized film

• radionuclide - A substance that gives off radiation; used for diagnosis and treatment; also called radioisotope or radiopharmaceutical

• remission - A lessening of the symptoms of a disease; the period during which this decrease occurs or the period when no sign of a disease exists

• sign - An objective evidence of disease that can be observed or tested

• sphygmomanometer - instrument for measuring blood pressure

  • pressure is read in millimeters of mercury (mm Hg) when the heart is contracting (systolic pressure) and when the heart is relaxing (diastolic pressure) and is reported as systolic/diastolic

• staging - The process of classifying malignant tumors for diagnosis, treatment, and prognosis

• stethoscope - An instrument used for listening to sounds produced within the body (from the Greek root steth/o, meaning “chest”)

• surgery - A method for treating disease or injury by manual operations

• suture - To unite parts by stitching them together; (suffix -rhaphy)

• symptom - indicators of disease that the patient is experiencing

• therapy - Treatment; intervention

alternative and complementary medicine:

• acupuncture - inserting thin needles into the body at specific points to relieve pain, induce anesthesia, or promote healing

  • similar effects can be obtained by using firm finger pressure at the surface of the body in the technique of acupressure

• biofeedback - a mind-body technique that uses instruments to help you control certain bodily functions

  • A method for learning control of involuntary physiologic responses by using electronic devices to monitor bodily changes and feed this information back to a person

• chiropractic - manually adjusting the spine and other parts of the body

  • (from Greek cheir, meaning “hand”)

  • A science that stresses the condition of the nervous system in diagnosis and treatment of disease; often, the spine is manipulated to correct misalignment; most patients consult for musculoskeletal pain and headaches

• homeopathy - A philosophy of treating disease by administering drugs in highly diluted form along with promoting healthy life habits and a healthy environment

  • (from home/o, meaning “same,” and path, meaning “disease”)

• naturopathy - helping people to heal themselves by developing healthy lifestyles, naturopaths may use some of the methods of conventional medicine

  • (from nature and path/o, meaning “disease”)

• osteopathy - treatment of medical disorders through manipulation and massage of the bones, joints, and muscles.

  • (from oste/o, meaning “bone,” and path, meaning “disease”)

  • A system of therapy based on the theory that the body can overcome disease when it has normal structure, a favorable environment, and proper nutrition

roots for physical forces:

• aer/o - air, gas

  • aerobic - requiring air (oxygen)

• bar/o - pressure

  • barotrauma - injury caused by pressure

• chrom/o, chromat/o - color, stain

  • achromatous - lacking color

• chron/o - time

  • synchronous - occurring at the same time

• cry/o - cold

  • cryoprobe - instrument used to apply extreme cold

• electr/o - electricity

  • electrolysis - destruction (-lysis) by means of electric current

• erg/o - work

  • synergistic - working together with increased effect, such as certain drugs in combination

• phon/o - sound, voice

  • phonograph - instrument used to reproduce sound

• phot/o - light

  • photography - using light to record an image on light-sensitive paper

• radi/o - radiation, x-ray

  • radioactive - giving off radiation

• son/o - sound

  • ultrasonic - pertaining to high-frequency sound waves (beyond human hearing)

• therm/o - heat, temperature

  • hypothermia - abnormally low body temperature

asynchronous - not occurring at the same time

hypobaric - pertaining to decreased pressure

chromophilic - attracting color (stain)

hyperthermia - abnormally high body temperature

radiology - study and use of radiation

cryalgesia - pain caused by cold

phonetics - the study of sound

electroconvulsive - causing convulsions by means of electricity

ultrasonography - a method of diagnosis that uses sound or ultrasound

barometer - an instrument used to measure pressure

photoreaction - a response to light

suffixes for diagnosis:

• -graph - instrument for recording data

  • polygraph - instrument used to record many physiologic responses simultaneously; lie detector

• -graphy - act of recording data

  • radiography - obtaining pictures using x-rays

• -gram - a record of data

  • sonogram - record obtained by use of ultrasound (ultrasonography)

• -meter - instrument for measuring

  • audiometer - instrument for measuring hearing (audi/o)

• -metry - measurement of

  • ergometry - measurement of work done

• -scope - instrument for viewing or examining

  • endoscope - instrument for viewing the inside of an organ or cavity

• -scopy - examination of

  • laparoscopy - examination of the abdomen through the abdominal wall (lapar/o)

audiometry - measurement of hearing

microscope - instrument for examining very small objects

phonogram - a record of sound

echography - producing images by use of ultrasound

thermometer - instrument for measuring temperature

calorimeter - instrument for measuring the energy content of food

electroencephalogram - record of the brain’s electrical activity

bronchoscopy - endoscopic examination of breathing passages

celioscope - instrument for examining the abdominal cavity

chronometer - instrument for measuring time

suffixes for surgery:

• -centesis - puncture, tap

  • thoracentesis - puncture of the chest

• -desis - binding, fusion

  • pleurodesis - binding of the pleural membranes (around the lungs)

• -ectomy - excision, surgical removal

  • hysterectomy - excision of the uterus (hyster/o)

• -pexy - surgical fixation

  • cystopexy - surgical fixation of the bladder (cyst/o)

• -plasty - plastic repair, plastic surgery, reconstruction

  • rhinoplatsy - plastic surgery of the nose

• -rhapy - surgical repair, suture

  • herniorrhaphy - surgical repair of a hernia (herni/o)

• -stomy - surgical creation of an opening

  • colostomy - creation of an opening into the colon

• -tome - instrument for incising (cutting)

  • microtome - instrument for cutting thin sections of tissue for microscopic study

• -tomy - incision, cutting

  • tracheotomy - surgical incision of the trachea

• -tripsy - crushing

  • lithotripsy - crushing of a stone

laparotomy - surgical incision of the abdomen

neurotripsy - crushing of a nerve

mammoplasty - plastic surgery of the breast

arthrocentesis - puncture of a joint

adenoctomy - excision of a gland

arthrodesis - fusion of a joint

arthrotomy - incision of a joint

arthroplasty - plastic repair of a joint

arthrotome - instrument for incising a joint

hepatorrhaphy - surgical repair of the liver

hepatotomy - incision of the liver

hepatectomy - excision of liver tissue

hepatopexy - surgical fixation of the liver

tracheostomy - creation of an opening in the trachea

gastrotomy - incision into the stomach

dermatome - an instrument for cutting skin

symptoms:

• clubbing - Enlargement of the ends of the fingers and toes because of growth of the soft tissue around the nails; seen in a variety of diseases, especially lung and heart diseases

• colic - Acute abdominal pain associated with smooth muscle spasms

• cyanosis - Bluish discoloration of the skin due to lack of oxygen

• diaphoresis - Profuse sweating

• malaise - A feeling of discomfort or uneasiness, often indicative of infection

• nocturnal - Pertaining to or occurring at night (roots noct/i and nyct/o mean “night”)

• pallor - Paleness; lack of color

• prodrome - A symptom indicating an approaching disease

• sequela - A lasting effect of a disease (plural, sequelae)

• syncope - A temporary loss of consciousness because of inadequate blood flow to the brain; fainting

diagnosis:

• alpha-fetoprotein (AFP) - A fetal protein that appears in the blood of adults with certain types of cancer

• bruit - A sound, usually abnormal, heard in auscultation

• facies - The expression or appearance of the face

• febrile - Pertaining to fever

• nuclear medicine - The branch of medicine concerned with the use of radioactive substances (radionuclides) for diagnosis

• speculum - An instrument for examining a canal

• syndrome - A group of signs and symptoms that together characterize a disease condition

treatment:

• catheter - A thin tube that can be passed into the body; used to remove fluids from or introduce fluids into a body cavity

• clysis - The introduction of fluid into the body, other than orally, as into the rectum or abdominal cavity; also refers to the solution thus used

• lavage - The washing out of a cavity; irrigation

• normal saline solution (NSS) - A salt (NaCl) solution compatible with living cells; also called physiologic saline solution (PSS)

• paracentesis - Puncture of a cavity for removal of fluid

• prophylaxis - Prevention of disease

surgery:

• drain - Device for allowing matter to escape from a wound or cavity

• ligature - A tie or bandage; the process of binding or tying (also called ligation)

• resection - Partial excision of a structure

• stapling - the joining of tissue by using wire staples that are pushed through the tissue and then bent

• surgeon - One who specializes in surgery

ABBREVIATIONS:

History and Physical Examination

ADL - Activities of daily living

BP - Blood pressure

bpm - Beats per minute

C - Celsius (centigrade)

CC - Chief complaint

c/o - Complains of

EOMI - Extraocular muscles intact

ETOH - Alcohol (ethyl alcohol)

F - Fahrenheit

HEENT - Head, eyes, ears, nose, and throat

h/o - History of

H & P - History and physical

HPI - History of present illness

HR - Heart rate

Hx - History

I & O - Intake and output

IPPA - Inspection, palpation, percussion, auscultation

IVDA - Intravenous drug abuse

NAD - No apparent distress

NKDA - No known drug allergies

P - Pulse

PE - Physical examination

PE(R)RLA - Pupils equal (regular) react to light and accommodation

PMH - Past medical history

pt - Patient

R - Respiration

R/O - Rule out

ROS - Review of systems

T - Temperature

TPR - Temperature, pulse, respiration

VS - Vital signs

WD - Well developed

WNL - Within normal limits

w/o - Without

PET - Positron emission tomography

PICC - Peripherally inserted central catheter

postop - Postoperative

preop - Preoperative

PSS - Physiologic saline solution

RATx - Radiation therapy

Rx - Drug, prescription, therapy

SPECT - Single photon emission computed tomography

TNM - (Primary) tumor, (regional lymph) nodes, (distant) metastases

UV - Ultraviolet

Views for Radiography

AP - Anteroposterior

LL - Left lateral

PA - Posteroanterior

RL - Right lateral

Diagnosis and Treatment

ABC - Aspiration biopsy cytology

AFP - Alpha-fetoprotein

BS - Bowel sounds

bx - Biopsy

CAM - Complementary and alternative medicine

Ci - Curie (unit of radioactivity)

C & S - Culture and (drug) sensitivity (of bacteria)

CT - Computed tomography

D/C, dc - Discontinue, discharge

Dx - Diagnosis

EBL - Estimated blood loss

ICU - Intensive care unit

I & D - Incision and drainage

MET - Metastasis

MRI - Magnetic resonance imaging

NSS - Normal saline solution

PCA - Patient-controlled analgesia

Orders

AMA - Against medical advice

AMB - Ambulatory

BRP - Bathroom privileges

CBR - Complete bed rest

DNR - Do not resuscitate

KVO - Keep vein open

NPO - Nothing by mouth (Latin, non per os)

OOB - Out of bed

QNS - Quantity not sufficient

QS - Quantity sufficient

STAT - Immediately

TKO - To keep open