Primary Medical Care Subject

•Percussion involves tapping body parts to produce sound waves. •These sound waves or vibrations enable the underlying structures. Photo by Wanpen

Several types of sub techniques for performing percussion * Direct percussion : Lightly tap body part directly with fingers or hand. *Indirect or bimanual percussion : Tap finger(s) of dominant hand against finger of non-dominant hand, held against the body part. Then determines a hearing for a degree of sound propagates Photo by Wanpen Photo by Wanpen

Characteristic tones •The degree to which sound propagates is called Resonance. •Percussion produces characteristic tones Tympanic, Hyper-resonant, Resonant, Dull and Flat.

Tympanic •Tympanic sounds are hollow, high, drumlike sounds. •Tympani is normally heard over the stomach but is not a normal chest sound. •Tympanic sounds heard over the chest indicate excessive air in the chest, such as may occur with pneumothorax.

Resonant and Dull • Resonant sounds are low pitched, hollow sounds heard over normal lungs tissue. • A dull sound indicates the presence of a solid mass under the surface. Dull sounds are normally heard over dense areas such as the heart or liver. Dullness replaces resonance when fluid or solid tissue replaces air-containing lung tissues, such as occurs with pneumonia, pleural effusions, or tumors.

Characteristic tones •Hyper resonant Hyper Inflated Lungs Tissue •Resonant Normal Lungs Tissue •Dullness, Dull Liver •Flatness, Flat Bone

• Listening to body sounds, movement of air or fluid • Listen for sound intensity, pitch, duration, and frequency. • Amplification of sounds with stethoscope • Chestpiece has diaphragm and bell. อ.วนั เพญ็ แวววรี คปุ ต์

• Bell, rested lightly on skin, is best for low-frequency sounds (e.g., bruits, venous hums, third and fourth heart sounds); heavy pressure causes bell to function like a diaphragm. • Diaphragm is best for high-frequency sounds (e.g., breath sounds, friction rubs, bowel sounds). • Place warmed bell or diaphragm on exposed area. อ.วนั เพ็ญ แวววรี คปุ ต์

Topic Summary • Physical examination is the process of examining the patient's body to determine the presence or absence of physical problems. • The goal of the physical examination is to obtain valid information concerning the health of the patient. • There are four techniques used in physical examination and these are;- inspection, palpation, percussion and auscultation. Use your eye to see, your finger to feel, your ear to hear and your noses to smell

Thank You! Wanpen Waelveerakup, Email: [email protected] Ruffel Joy C. Manalo, Email: [email protected]

Wanpen Waelveerakup, RN, PhD Ruffel Joy C. Manalo, RN, MAN Faculty of Nursing, Nakhon Pathom Rajabhat University Thailand

Learning Objectives OF THE TOPIC After studying this topic, students will be able to ….  Describe the fundamental idea of a problem-oriented medical record.  Identify components on idea of the problem-oriented medical record.

1. Fundamental idea 2. Components

What is Problem Oriented Medical Record (POMR.)? •The problem-oriented medical record (POMR.) is a way of recording patient’s health information in a way that's easy for physicians to read and revise. POMR. is a comprehensive approach to recording and accessing patient’s medical data. Susan Chapman, 2016 Available from https://www.fortherecordmag.com/archives/0516p24.shtml

Fundamental Idea of POMR. •In 1968, the POMR. was developed and introduced by Dr. Lawrence Weed. •The POMR. gathers information from all members of the patient's care team in order to determine a diagnosis and create a treatment plan. So that •The POMR. help medical students and practitioners to function in a structured, rigorous way which facilitates their thinking and plan for patient treatment.

Fundamental Idea of POMR. • A patient who may require multiple treatment methods that must be adjusted over time wanted POMR. documenting on which patients with complex medical issues see more than one physician. • Moreover, the POMR. also helps nurse instructor to understand the student's idea in dealing with an assigned case.

2. The components of the POMR The basic components of the POMR are: 1. Data base – PT. history, physical examination and laboratory data 2. Problem lists 3. Initial plans 4. Daily progress notes 5. Discharge summary

COMPARISON BETWEEN POMR. AND NURSING PROCESS components POMR. components Nursing process components 1. Data base 1. Assessment 2. Problem lists 2. Analysis / Problem identification 3. Initial plan 3. Planning 4.Progress note 4. Implementation 5. Discharge summary 5. Evaluation

The database contains: •Subjective data : the patient’s medical history •Objective data : the physical examination & the laboratory test/s

2. Problem lists There are 2 types of problem lists :- 1. Obtained from various disorders/abnormalities noted in the initial data base : from any information which presented in CC., PI., Past H., Personal H., FM., neighborhood history, and ROS. ; from PE. ; from laboratory test results such as anemia, hematuria, ureteric stone, etc.

2. Problem lists There are 2 types of problem lists :- 2. Summarized data or analyzed and summarized as a diagnosis like; Hypertension, Tonsillitis, Peptic ulcer, Pulmonary tuberculosis, etc.

2. Problem lists Problems are either active or inactive. • An active problem is anything that requires management or further diagnostic workup. •An inactive problems are usually prior, resolved medical or surgical illnesses that are still important to remember.

3. Initial plan Planning the solution using SOAP drawing S = Subjective data O = Objective data A = Assessment/Analysis that includes differential diagnosis P = Plan (Plan for diagnosis, treatment, and patient’s health education)

P = Plan 1. Plan for diagnosis such as CBC, UA, Stool exam etc. 2. Plan for treatment 1) Specific treatment such as antibiotic, surgery, etc. 2) Supportive treatment/Symptomatic treatment such as medicine to relief pain or fever, antitussive, mucolytic etc. 3. Plan for patient education

4. Progress note •Means to record the tracking changes of patients based on the problem using SOAP drawing as in the initial plan. •Progress note should consist of -changes in symptoms and signs - laboratory results - the treatment result as planned - review of patient assessment /new problems - next treatment plan

5. Summary discharge •The summary discharge should include all active problems by using SOCP drawing. S = Subjective data O = Objective data C = Clinical course P = Plan (Plan for diagnosis, treatment, and patient health education)

5. Summary discharge •The subjective should include a brief review of the course of symptoms. •The objective should review the course of objective parameters. •The clinical course should review the course of curing/treatment. • The plan should include the probable course to follow and define end-points as a guide for further therapy.

topic Summary •POMR. is as a way to standardize the way physicians record and organize the patient information. • There are 5 components of POMR. These includes :- data base, problem lists, initial plans, daily progress note, and discharge summary. •The planning for solving patient’s problems using SOAP drawing while the summary using SOCP drawing.

Wanpen Waelveerakup, Email: [email protected] Ruffel Joy C. Manalo, Email: [email protected]

Wanpen Waelveerakup, RN, PhD Ruffel Joy C. Manalo, RN, MAN Faculty of Nursing Nakhon Pathom Rajabhat University

Learning Objectives OF THE TOPIC At the end of the topic, the students will be able to ….  Identify the common laboratory and diagnostic tests performed at Basic Medical Care level.  Determine the interpretation of laboratory test results.

The common laboratory tests are the following: 1. FBS, 2. UA, 3. CBC, 4. Sputum Ex., 5. Stool Ex. and the current epidemic diseases such as 6. Flu test, and 7. Covid-19 test

Define laboratory test  Also called “lab tests” and these are the tools that provide information about the patient condition.  Laboratory tests check a sample of PT. blood, urine, or body tissues.  A technician, doctor or practitioner analyzes the test samples to see if PT. results fall within the normal range.

WHAT IS THE IMPORTANCE OF LABORATORY TEST AND INTERPRETATION?  It is used as basic screening part of patient’s health condition.  It helps confirm a diagnosis or rule out a specific disease or condition  Monitors patient’s illness  Provide valuable information about the patient’s response to certain treatments  Check your overall health.

The results & meaning Reference range • Lab results are often shown as a set of numbers known as a reference range. • A reference range may also be called “normal values”. The lab results may also include one of these terms: •Negative or normal, which means the disease or substance being tested was not found •Positive or abnormal, which means the disease or substance was found •Inconclusive or uncertain, which means there wasn't enough information in the results to diagnose or rule out a disease.

The results & meaning • The lab results are graded such as Albumin / Proteinuria - Negative, Absent - Trace (10 to 20 mg/dL), - 1+ (30 mg/dL), - 2+ (100 mg/dL), - 3+ (300 mg/dL), or - 4+ ( 1,000 mg/dL) TIMOTHY S. LARSON, Concise Review for Primary-Care Physicians Evaluation of Proteinuria, (Mayo Clin Proc 1994; 69:1154-1158) available from https://www.mayoclinicproceedings.org/article/S0025-6196(12)65767-X/pdf

COMMON LABORATORY TESTS AND INTERPRETATION 1. Blood Sugar Test Purpose: to determine the blood glucose levels and effectiveness of insulin administration Specimen: fasting blood sugar or FBS (venous blood) capillary blood glucose or CBG (capillary blood)

COMMON LABORATORY TESTS AND INTERPRETATION 1. Blood Sugar Test Results and Interpretation FBS after meal < 180 mg/dl Normal Impaired fasting glucose values (IFG) Fasting Blood Sugar (FBS) < 100 mg/dl 100 – 125mg /dl  126 mg/dl indicates diabetes mellitus or DM Source: Clinical Practice Guidelines for Diabetes 2017, Thailand Capillary Blood Glucose 80 – 120 < 80 mg/dl may indicate (CBG) mg/dl hypoglycemia > 120 mg/dl may indicate hyperglycemia

COMMON LABORATORY TESTS AND INTERPRETATION 1. Blood Sugar Test  Hypoglycemia – also known as low blood sugar level that may result to symptoms like shakiness, loss of consciousness and confusion  Hyperglycemia – an elevated blood sugar level may indicate diabetes mellitus  Diabetes mellitus – also called “sugar diabetes” wherein a condition which the body is unable to regulate the use of glucose normally

COMMON LABORATORY TESTS AND INTERPRETATION 2. Urine Analysis (U/A) Purpose: to detect and manage a wide range of disorders, such as urinary tract infections, kidney disease and diabetes. Specimen: clean voided, midstream urine Normal values: pale yellow or clear

COMMON LABORATORY TESTS AND INTERPRETATION 2. Urine Analysis (U/A) (cont…) Specific gravity PH > Protein Normal value: 1.015 – 1.025 Normal values: 4.58– 8.0 Normal value: negative High specific gravity - may <8 may indicate acidity Trace: 1+ 2+ 3+ >4 may indicate alkalinity > 4+ damage to the kidneys indicate potassium deficiency Low- specific gravity - may indicate dehydration

COMMON LABORATORY TESTS AND INTERPRETATION 2. Urine Analysis (U/A) (cont…) Sugar/Glucose WBC RBC Normal value: negative Normal value: negative Normal value: negative 1+ + result may indicate 2+ + result may indicate urinary stones 3+ inflammation, infection 4+ such as cystitis or > glucosuria nephritis

COMMON LABORATORY TESTS AND INTERPRETATION 2. Urine Analysis (U/A) (cont…) Glycosuria – is a condition where a patient’s urine contains more sugar or glucose that may indicate diabetes or damage to the kidneys

COMMON LABORATORY TESTS AND INTERPRETATION 3. Complete Blood Count (CBC) and Differential Count1 Purpose: to measure many different parts and features of the blood Specimen: whole blood or venous blood Results and Interpretation White blood cell (WBC) Normal values Hematocrit (Hct) Hemoglobin (Hb) 4.6 – 10.2 k/ul Platelet count 37.7 -53.7 % 12.2 – 18.1 gm/dl 142 – 424 k/ul 1 cubic milliliter (K/uL)= x 1,000 cell

COMMON LABORATORY TESTS AND INTERPRETATION 3. Complete Blood Count (CBC) and Differential Count2 White blood cell (WBC) 4.6 – 10.2 or 5 – 10 , k/ul Normal values Neutrophils 55 – 70 % Eosinophils 1–4 % Basophils 0.5 – 1 % Lymphocytes 20 – 40 % Monocytes 2–8 % leukocytosis: an increase number of white cells (>10,000 cubic meter) may indicate current infection or inflammation leukopenia: a reduction in the number of white cells (,4,000 cubic meter) may indicate autoimmune disease or bone marrow failure phagocytosis: may happen when white cells engulf microorganisms, or foreign cells of the body.

COMMON LABORATORY TESTS AND INTERPRETATION 3. Complete Blood Count (CBC) and Differential Count3 Red blood cell (RBC) indices MCV Normal values MCH 80 – 94 µm3 27 – 31 pg (pictogram) MCHC 32 – 36 gm.%

COMMON LABORATORY TESTS AND INTERPRETATION 3. Complete Blood Count (CBC) and Differential Count4 Normal values Red blood cell count 4.6 – 6.2 x 106 /mm3 (RBC) 40 – 54 % Hematocrit (Hct) Hemoglobin (Hb) 13.3 – 18 % Platelet count 150 – 450 x 103/mm3 Increased: may indicate dehydration, pulmonary fibrosis Decreased: hemorrhage, anemia, pregnancy, dietary deficiency

COMMON LABORATORY TESTS AND INTERPRETATION 4. Stool Exam (fecal analysis) / Stool for occult blood test Purpose: to help diagnose certain conditions affecting the digestive tract Specimen: uncontaminated stool Normal values: negative

COMMON LABORATORY TESTS AND INTERPRETATION 5. Sputum Examination 5.1 Sputum gram stain 5.2 Sputum for Acid Fast Bacilli (AFB Test ) Purpose: for culture and sensitivity, effectiveness of TB treatment, lung infection Specimen: uncontaminated sputum early in the morning Normal values: negative : tuberculosis (TB)

COMMON LABORATORY TESTS AND INTERPRETATION 6. Rapid influenza diagnostic test, Flu Test Purpose: to inspect an infection caused by influenza virus A or B Specimen: nasal swab Normal values: negative