Chapter 7:
Diagnosis and
Treatment; Surgery
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Chapter Objectives
 Main components of a patient history.
 Main methods used in patient examination.
 Nine imaging techniques.
 Possible forms of treatment.
 Theories of alternative & complementary medicine and some
healing practices used in these fields.
■ Staging and grading as they apply to cancer.
■ Basic terms for to medical examination, diagnosis & treatment.
■ Roots and suffixes pertaining to diagnosis and surgery.
■ Symbols and abbreviations used in diagnosis & treatment.
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Key Terms
anesthesia
Loss of the ability to feel pain, as by administration of a drug
auscultation
Listening for sounds within the body, usually within the chest or
abdomen
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
Use of chemicals to treat disease. The term is often applied specifically
to the treatment of cancer with chemicals.
diagnosis
The process of determining the cause and nature of an illness
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
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Key Terms (cont’d)
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
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Key Terms (cont’d)
ophthalmoscope
An instrument for examining the interior of the eye
otoscope
Instrument used to examine the ears
palliative
Providing relief but not cure; a treatment that provides such relief
palpation
Examining by placing the hands or fingers on the surface of the body to
determine characteristics such as texture, temperature, movement, and
consistency
percussion
Tapping the body lightly but sharply to assess the condition of the
underlying tissue by the sounds obtained
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;
roentgenography (rent-ge-NOG-ra-fē)
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Key Terms (cont’d)
remission
A lessening of disease symptoms; the period during which this
decrease occurs or the period when no sign of a disease exists
sign
Objective evidence of disease that can be observed or tested;
examples are fever, rash, high blood pressure, and blood or urine
abnormalities; an objective symptom.
sphygmomanometer
Blood pressure apparatus or blood pressure cuff; 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
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Key Terms (cont’d)
suture
To unite parts by stitching them together; also the thread or other
material used in that process or the seam formed by surgical stitching
(suffix -rhaphy)
symptom
Any evidence of disease; sometimes limited to subjective evidence of
disease, as experienced by the individual, such as pain, dizziness,
and weakness
therapy
Treatment; intervention
vital signs
Measurements that reflect basic functions necessary to maintain life
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Key Terms
Alternative and Complementary Medicine
acupuncture
An ancient Chinese method of 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 method for learning control of involuntary physiologic responses
by using electronic devices to monitor bodily changes and feeding
this information back to a person
chiropractic
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. (From Greek cheir, meaning “hand”)
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Key Terms
Alternative and Complementary Medicine
(cont’d)
holistic health care
Practice of treating a person as a whole entity with physical,
emotional, social, and spiritual needs. It stresses comprehensive
care, involvement in one's own care, and the maintenance of good
health rather than the treatment of disease.
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”)
massage
Manipulation of the body or portion of the body to calm, relieve
tension, increase circulation, and stimulate muscles
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Key Terms
Alternative and Complementary Medicine
(cont’d)
meditation
Process of clearing the mind by concentrating on the inner self while
controlling breathing and perhaps repeating a word or phrase
(mantra)
naturopathy
A therapeutic philosophy of 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
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. Osteopaths use standard medical practices for
diagnosis and treatment but stress the identification and correction of
faulty body structure (from oste/o, meaning “bone,” and path,
meaning “disease”).
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Supplementary Terms
Symptoms
clubbing
Enlargement of the ends of the fingers and toes because of soft-tissue
growth of 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
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Supplementary Terms
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, therapy, and research
radiology
The branch of medicine that uses radiation, such as x-rays, in the
diagnosis and treatment of disease; a specialist in this field is a
radiologist.
radionuclide
A substance that gives off radiation; used for diagnosis and
treatment; also called radioisotope or radiopharmaceutical
speculum
An instrument for examining a canal
syndrome
A group of signs and symptoms that together characterize a disease
condition
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Supplementary Terms
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
irrigation
Flushing of a tube, cavity, or area with a fluid
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
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Supplementary Terms
Surgery
drain
Device for allowing matter to escape from a wound or cavity; common
types include Penrose (cigarette), T-tube, Jackson–Pratt (J-P), and
Hemovac
ligature
A tie or bandage; the process of binding or tying (also called ligation)
resection
Partial excision of a structure
stapling
In surgery, the joining of tissue by using wire staples that are pushed
through the tissue and then bent
surgeon
One who specializes in surgery
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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
HIPAA
Health Insurance Portability and Accountability Act
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Abbreviations
History and Physical Examination (cont’d)
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
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Abbreviations
History and Physical Examination (cont’d)
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
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Abbreviations
History and Physical Examination (cont’d)
TPR
Temperature, pulse, respiration
VS
Vital signs
WD
Well developed
WNL
Within normal limits
w/o
Without
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Abbreviations
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
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Abbreviations
Diagnosis and Treatment (cont’d)
EBL
Estimated blood loss
ICU
Intensive care unit
I&D
Incision and drainage
MET
Metastasis
MRI
Magnetic resonance imaging
NCCAM
National Center for Complementary and Alternative Medicine
NS, N/S
Normal saline
NSS
Normal saline solution
PCA
Patient-controlled analgesia
PET
Positron emission tomography
PICC
Peripherally inserted central catheter
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Abbreviations
Diagnosis and Treatment (cont’d)
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
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Abbreviations
Views for Radiography
AP
Anteroposterior
LL
Left lateral
PA
Posteroanterior
RL
Right lateral
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Abbreviation Orders
AMA
Against medical advice
NPO
Nothing by mouth (Latin, non per os)
AMB
Ambulatory
OOB
Out of bed
BRP
Bathroom privileges
QNS
Quantity not sufficient
CBR
Complete bed rest
QS
Quantity sufficient
DNR
Do not resuscitate
STAT
Immediately
KVO
Keep vein open
TKO
To keep open
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Diagnosis
■ Determination of nature and cause of illness
■ Starts with patient history
– Description of symptoms
– Past medical history
– Family, social history as relevant
■ Physical examination follows
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Physical Examination
■ Inspection
– Visual examination
■ Palpation
– Touching body surface with hands, fingers
■ Percussion
– Tapping body and listening to sounds made
■ Auscultation
– Using a stethoscope to listen to body sounds
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Vital Signs
■ Temperature
■ Pulse rate
– Measured in beats per minute
■ Respiration
– Measured in breaths per minute
■ Blood pressure
– Systolic recorded when heart contracting
– Diastolic recorded when heart relaxing
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Examination Tools
■ Ophthalmoscope
– For examining eyes
■ Otoscope
– For examining ears
■ Hammer
– For testing reflexes
■ Sphygmomanometer (blood pressure cuff)
– For testing blood pressure
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Examination Procedures
■ Endoscope
– Examines body cavities
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Examination Procedures (cont’d)
■ Biopsy
– Removal of tissue for microscopic examination
– Specimens obtained by:
■ Needle withdrawal
■ Small punch
■ Endoscopy
■ Surgical removal
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Imaging Techniques
■ Used to produce visual images of body
■ Most common is Radiography (X-rays)
– Best at showing dense tissues
– Soft tissues enhanced by contrast mediums
■ Other methods:
– Sound waves
– Radioactive isotopes
– Radio waves
– Magnetic fields
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Treatment
■ Determined if appropriate by diagnosis
■ May consist as any combination of:
–
Counselling
–
Drugs
–
Surgery
–
Radiation
–
Physical therapy
–
Occupational therapy
–
Psychiatric treatment
■ Followed up done with Prognosis (prediction of outcome
of disease)
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Surgery
■ One method of treating disease by manual operations
■ Usually done by cutting an incision into skin
■ Anesthesia dulls pain
■ Incision sealed after surgery with sutures, adhesive
stripes, staples, skin glue
■ Operations now performed with laser
■ Some procedures require cautery
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Purpose of Surgery
■ Treatment
–
Excision of diseased or abnormal tissue
–
Also can repair wounds or correct problems
■ Diagnosis
–
Remove tissue for lab biopsy
■ Restoration
–
To compensate for lost function
■ Relief
–
Palliative treatment (therapy to provide relief, not intended as
cure)
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Surgical Instruments
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Alternative and Complementary Medicine
■ Disease causes have shifted
■ People looking to other philosophies and cultures
■ Other philosophies include:
– Osteopathy
– Naturopathy
– Homeopathy
– Chiropractic
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Alternative and Complementary Medicine
(cont’d)
■ Other treatments include: acupuncture, biofeedback,
massage, meditation, herbal remedies, nutritional
counselling
■ Holistic health care emphasizes treating individual as
whole with emotional, social, and spiritual needs in
addition to physical
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Roots for Physical Forces
Root
Meaning
Example
Definition of Example
aer/o
air, gas
aerobic
pertaining to or requiring air (oxygen)
bar/o
pressure
barometer
instrument used to measure pressure
chrom/o,
color, stain chromatic
chromat/o
having color
chron/o
time
chronologic
arranged according to the time of
occurrence
cry/o
cold
cryoprobe
instrument used to apply extreme cold
electro/o
electricity
electrolysis
decomposition of a substance by means of
electric current
erg/o
work
synergistic
working together with increased effect, such
as certain drugs in combination
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Roots for Physical Forces (cont’d)
Root
Meaning
Example
Definition of Example
phon/o
sound, voice
phonograph
instrument used to reproduce
sound
phot/o
light
photoreaction
response to light
radi/o
radiation, x-ray
radiology
study and use of radiation
son/o
sound
sonogram
record obtained by use of
ultrasound
therm/o
heat, temperature
hypothermia
abnormally low body temperature
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Suffixes for Diagnosis
Suffix
Meaning
Example
Definition of Example
-graph
instrument for
recording data
polygraph
instrument used to record
many physiologic responses
simultaneously; lie detector
-graphy
act of recording
data*
echography
recording data obtained by
ultrasound
-gram†
a record of data
electrocardiogram record of the heart's electrical
activity
*This ending is often used to mean not only the recording of data but also the evaluation and
interpretation of the data.
†A picture taken simply using x-rays is called a radiograph. When special techniques are
used to image an organ or region with x-rays, the ending -gram is used with the root for that
area, as in urogram (urinary tract), angiogram (blood vessels), and mammogram (breast).
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Suffixes for Diagnosis (cont’d)
Suffix
Meaning
Example
Definition of Example
-meter
instrument for
measuring
calorimeter
instrument for measuring the
caloric energy of food
-metry
measurement of
audiometry
measurement of hearing
(audi/o)
-scope
instrument for
viewing or
examining
bronchoscope
instrument for examining the
bronchi (breathing passages)
-scopy
examination of
celioscopy
examination of the abdominal
cavity (celi/o)
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Suffixes for Surgery
Suffix
Meaning
Example
Definition of Example
-centesis
puncture, tap
arthrocentesis
puncture of a joint (arthr/o)
-desis
binding, fusion
pleurodesis
binding of the pleura
(membranes around the
lungs)
-ectomy
excision, surgical
removal
hepatectomy
excision of liver tissue
(hepat/o)
-pexy
surgical fixation
hysteropexy
surgical fixation of the uterus
(hyster/o)
-plasty
plastic repair,
plastic surgery,
reconstruction
rhinoplasty
plastic surgery of the nose
(rhin/o)
-rhaphy
surgical repair,
suture
herniorrhaphy
surgical repair of a hernia
(herni/o)
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Suffixes for Surgery (cont’d)
Suffix
Meaning
Example
Definition of Example
-stomy
surgical creation tracheostomy
of an opening
creation of an opening into the
trachea (trache/o)
-tome
instrument for
incising (cutting)
microtome
instrument for cutting thin
sections of tissue for
microscopic study
-tomy
incision, cutting
laparotomy
surgical incision of the
abdomen (lapar/o)
-tripsy
crushing
neurotripsy
crushing of a nerve (neur/o)
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Cancer
■ Several methods to diagnose
– Physical examination
– Biopsy
– Imaging
– Laboratory tests
■ Two methods to classify:
– Grading
■ Based on histologic changes seen through
microscope
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Cancer (cont’d)
– Staging
■ Procedure for seeing how far tumor has spread
■ Treatment may involve surgery, radiation therapy,
chemotherapy, immunotherapy, hormone therapy
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Pretest
1. Determination of a disease's nature cause is called:
(a) prognosis
(b) diagnosis
(c) titration
(d) admission
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Pretest
1. Determination of a disease's nature cause is called:
(a) prognosis
(b) diagnosis
(c) titration
(d) admission
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Pretest
2. Measurements of the basic functions needed to maintain
life, such as breathing and pulse, together are called:
(a) respiration
(b) health signs
(c) vital signs
(d) etiology
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Pretest
2. Measurements of the basic functions needed to maintain
life, such as breathing and pulse, together are called:
(a) respiration
(b) health signs
(c) vital signs
(d) etiology
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Pretest
3. The two phases recorded when measuring blood
pressure are:
(a) systolic and sinoatrial
(b) diastolic and symbiotic
(c) superior and inferior
(d) systolic and diastolic
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Pretest
3. The two phases recorded when measuring blood
pressure are:
(a) systolic and sinoatrial
(b) diastolic and symbiotic
(c) superior and inferior
(d) systolic and diastolic
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Pretest
4. A simple device for listening to sounds within the body
is a:
(a) cystoscope
(b) speculum
(c) barometer
(d) stethosocope
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Pretest
4. A simple device for listening to sounds within the body
is a:
(a) cystoscope
(b) speculum
(c) barometer
(d) stethosocope
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Pretest
5. Removal of tissue for microscopic study is a(n):
(a) biopsy
(b) aeration
(c) endoscopy
(d) CT scan
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Pretest
5. Removal of tissue for microscopic study is a(n):
(a) biopsy
(b) aeration
(c) endoscopy
(d) CT scan
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Pretest
6. Prediction of a disease’s outcome is a(n):
(a) evidence
(b) prognosis
(c) history
(d) therapy
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Pretest
6. Prediction of a disease’s outcome is a(n):
(a) evidence
(b) prognosis
(c) history
(d) therapy
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Pretest
7. A process used to evaluate the severity of cancer is:
(a) radiation
(b) staging
(c) laparoscopy
(d) endoscopy
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Pretest
7. A process used to evaluate the severity of cancer is:
(a) radiation
(b) staging
(c) laparoscopy
(d) endoscopy
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Pretest
8. A process used to evaluate the severity of cancer is:
(a) therapy of the appendix
(b) measurement of the appendix
(c) imaging of the appendix
(d) surgical removal of the appendix
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Pretest
8. A process used to evaluate the severity of cancer is:
(a) therapy of the appendix
(b) measurement of the appendix
(c) imaging of the appendix
(d) surgical removal of the appendix
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Pretest
9. A tracheotomy is:
(a) surgical incision of the trachea
(b) placement of a tracheal tube
(c) removal of a tracheal tube
(d) removal of the trachea
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Pretest
9. A tracheotomy is:
(a) surgical incision of the trachea
(b) placement of a tracheal tube
(c) removal of a tracheal tube
(d) removal of the trachea
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