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Book Details
Abstract
Learn the procedures and skills you need to succeed as a medical assistant! Clinical Procedures for Medical Assistants, 9th Edition provides clear, step-by-step instructions for common office procedures such as taking vital signs, collecting and processing lab specimens, preparing patients for examinations, and assisting with office surgeries. Written by expert educator Kathy Bonewit-West, this full-color edition covers the latest competencies and topics in today's medical assisting practice including emergency preparedness and the updated fecal occult blood testing procedure. The Evolve companion website includes videos of 84 procedures described in the book, preparing you to become a competent clinical medical assistant.
- Over 120 procedures are presented in a clear, illustrated, step-by-step format, with online videos showing 84 of the procedures in action.
- Chapter outlines and learning objectives prepare you for the skills and concepts you will be learning.
- What Would You Do? What Would You Not Do? case studies challenge you to apply your knowledge to realistic medical office situations — with a practitioner's response at the end of chapters.
- Putting It All Into Practice and Memories from Practicum boxes feature real medical assistants sharing personal, on-the-job experiences.
- Key Terms and Terminology Review help you master medical assisting terminology.
- Charting examples help you understand the process for charting your own procedures.
- Patient Teaching boxes prepare you for effective communication, with detailed instructions on how to answer questions and how to explain medical concepts and procedures.
- Student resources on the Evolve companion website offer a fun way to practice your medical assisting knowledge with animations, games such as Quiz Show and Road to Recovery, drag-and-drop exercises, Apply Your Knowledge exercises, matching exercises, and other interactive activities (blood pressure readings, determining height and weight, drawing up medication), as well as all video procedures and practicum activities.
- UPDATED fecal occult blood testing procedure includes new video demonstrating this procedure.
- UPDATED examples of medical assistants using an EHR are demonstrated in the video procedures, showing the use of electronic charting.
- Updated venipuncture photos show how to perform venipuncture.
- UPDATED content also includes topics such as the medical record, including HIPAA, electronic medical records, and advanced directives; emergency preparedness; the use of computer technology; medical asepsis; AIDS & hepatitis; latex glove allergies & non-latex gloves; vital signs including temporal artery thermometer, pulse oximetry, and the significance of pulse pressure; pediatrics including immunization information and IM injection theory; the colonoscopy; IV therapy; and the latest CLIA waived tests.
- All 84 procedure videos are now available on the Evolve companion website for convenient viewing
Table of Contents
Section Title | Page | Action | Price |
---|---|---|---|
Front cover | cover | ||
Evolve page | IFC2 | ||
End sheet iii | IFC3 | ||
Procedures | IFC4 | ||
Clinical Procedures for Medical Assistants, 9/e | i | ||
Copyright page | iv | ||
Reviewers | v | ||
Dedication | ix | ||
Preface | xi | ||
New Features in This Edition | xi | ||
Important Additions Include the Following: | xi | ||
Standard Pedagogical Features in This Edition | xi | ||
Extensive Supplemental Resources | xiii | ||
Procedural Videos | xiii | ||
Study Guide | xiii | ||
Evolve Resources | xiii | ||
Acknowledgments | xiv | ||
Clinical Procedure Icons | xvi | ||
Table of Contents | xvii | ||
1 The Medical Record | 1 | ||
Chapter Outline | 2 | ||
Key Terms | 2 | ||
Introduction to the Medical Record | 3 | ||
Components of the Medical Record | 3 | ||
Medical Office Administrative Documents | 3 | ||
Patient Registration Record | 3 | ||
Demographic Information | 3 | ||
Billing Information | 3 | ||
NPP Acknowledgment Form | 3 | ||
Correspondence | 3 | ||
Medical Office Clinical Documents | 4 | ||
Health History Report | 4 | ||
Physical Examination Report | 6 | ||
Progress Notes | 7 | ||
Medication Record | 7 | ||
Prescription and Over-the-Counter Medication Record Form | 7 | ||
Medication Administration Record Form | 7 | ||
Consultation Report | 8 | ||
Home Health Care Report | 8 | ||
Laboratory Documents | 8 | ||
Hematology | 8 | ||
Clinical Chemistry | 8 | ||
Immunology | 8 | ||
Urinalysis | 8 | ||
Microbiology | 8 | ||
Parasitology | 8 | ||
Cytology | 8 | ||
Histology | 8 | ||
Diagnostic Procedure Documents | 10 | ||
Electrocardiogram Report | 10 | ||
Holter Monitor Report | 10 | ||
Sigmoidoscopy Report | 10 | ||
Colonoscopy Report | 10 | ||
Spirometry Report | 10 | ||
Radiology Report | 10 | ||
Diagnostic Imaging Report | 11 | ||
Therapeutic Service Documents | 11 | ||
Physical Therapy | 11 | ||
Occupational Therapy | 11 | ||
Speech Therapy | 11 | ||
Hospital Documents | 11 | ||
History and Physical Report | 12 | ||
Operative Report | 15 | ||
Discharge Summary Report | 16 | ||
Pathology Report | 16 | ||
Emergency Department Report | 17 | ||
Consent Documents | 19 | ||
Consent to Treatment Form | 19 | ||
Release of Medical Information Form | 20 | ||
Mailed or Faxed Requests for Release of Medical Information | 20 | ||
Types of Medical Records | 24 | ||
Electronic Medical Record | 24 | ||
Advantages of the Electronic Medical Record | 24 | ||
Disadvantages of the Electronic Medical Record | 25 | ||
Medical Assistants’ Use of the EMR | 25 | ||
Functions Performed by the Medical Assistant | 25 | ||
Physicians’ Use of the EMR | 25 | ||
Medical Record Formats | 27 | ||
Source-Oriented Record | 27 | ||
Problem-Oriented Record | 27 | ||
Database | 27 | ||
Problem List | 28 | ||
Plan | 28 | ||
Progress Notes | 30 | ||
Preparing a Medical Record for a New Patient | 30 | ||
Medical Record Supplies | 31 | ||
File Folders | 31 | ||
Folder Labels | 32 | ||
Chart Dividers | 32 | ||
Taking a Health History | 32 | ||
Components of the Health History | 32 | ||
Identification Data | 32 | ||
Chief Complaint | 33 | ||
Recording Chief Complaints | 33 | ||
Correct Examples | 33 | ||
Incorrect Examples | 33 | ||
Present Illness | 33 | ||
Past History | 33 | ||
Family History | 37 | ||
Social History | 37 | ||
Review of Systems | 37 | ||
Charting in the Medical Record | 37 | ||
PPR Charting Guidelines | 37 | ||
Charting Progress Notes | 39 | ||
Charting Patient Symptoms | 39 | ||
Other Activities That Need to Be Charted | 39 | ||
Procedures | 39 | ||
Administration of Medication | 43 | ||
Specimen Collection | 43 | ||
Diagnostic Procedures and Laboratory Tests | 43 | ||
Results of Laboratory Tests | 43 | ||
Patient Instructions | 43 | ||
2 Medical Asepsis and the OSHA Standard | 50 | ||
Chapter Outline | 51 | ||
Key Terms | 51 | ||
Introduction to Medical Asepsis and the OSHA Standard | 51 | ||
Microorganisms and Medical Asepsis | 51 | ||
Growth Requirements for Microorganisms | 51 | ||
Infection Process Cycle | 52 | ||
Protective Mechanisms of the Body | 52 | ||
Medical Asepsis in the Medical Office | 52 | ||
Hand Hygiene | 52 | ||
Resident and Transient Flora | 53 | ||
Handwashing | 53 | ||
Antiseptic Handwashing | 54 | ||
Alcohol-Based Hand Rubs | 54 | ||
Infection Control | 54 | ||
Gloves | 54 | ||
Types of Gloves | 54 | ||
Glove Guidelines | 55 | ||
OSHA Bloodborne Pathogens Standard | 61 | ||
Purpose of the Standard | 61 | ||
Needlestick Safety and Prevention Act | 61 | ||
OSHA Terminology | 62 | ||
Components of the OSHA Standard | 62 | ||
Exposure Control Plan | 62 | ||
Labeling Requirements | 63 | ||
Communicating Hazards to Employees | 63 | ||
Record Keeping | 64 | ||
Control Measures | 64 | ||
Engineering Controls | 64 | ||
Safer Medical Devices | 65 | ||
Work Practice Controls | 65 | ||
Personal Protective Equipment | 66 | ||
Personal Protective Equipment Guidelines | 66 | ||
Housekeeping | 67 | ||
Hepatitis B Vaccination | 69 | ||
Universal Precautions | 69 | ||
Regulated Medical Waste | 69 | ||
Handling Regulated Medical Waste | 69 | ||
Disposal of Regulated Medical Waste | 71 | ||
Bloodborne Diseases | 71 | ||
Hepatitis B | 71 | ||
Postexposure Prophylaxis | 72 | ||
Acute Viral Hepatitis B | 72 | ||
Chronic Viral Hepatitis B | 72 | ||
Hepatitis C | 73 | ||
Other Forms of Viral Hepatitis | 73 | ||
Acquired Immune Deficiency Syndrome | 73 | ||
Stages of AIDS | 73 | ||
Stage 1: Acute HIV Infection | 73 | ||
Stage 2: Asymptomatic Period | 73 | ||
Stage 3: Symptomatic Period | 74 | ||
Stage 4: AIDS | 76 | ||
Transmission of AIDS | 78 | ||
3 Sterilization and Disinfection | 84 | ||
Chapter Outline | 85 | ||
Key Terms | 85 | ||
Introduction to Sterilization and Disinfection | 85 | ||
Definitions of Terms | 85 | ||
Hazard Communication Standard | 85 | ||
Hazard Communication Program | 86 | ||
Inventory of Hazardous Chemicals | 86 | ||
Labeling of Hazardous Chemicals | 86 | ||
Container Label Requirements | 87 | ||
Material Safety Data Sheets | 87 | ||
Material Safety Data Sheet Requirements | 87 | ||
Employee Information and Training | 89 | ||
Sanitization | 90 | ||
Sanitizing Instruments | 90 | ||
Cleaning Instruments | 90 | ||
Manual Method | 90 | ||
Ultrasound Method | 90 | ||
Guidelines for Sanitizing Instruments | 91 | ||
Disinfection | 95 | ||
Levels of Disinfection | 95 | ||
High-Level Disinfection | 95 | ||
Intermediate-Level Disinfection | 96 | ||
Low-Level Disinfection | 96 | ||
Types of Disinfectants | 96 | ||
Glutaraldehyde | 96 | ||
Alcohol | 96 | ||
Chlorine and Chlorine Compounds | 97 | ||
Phenolics | 97 | ||
Quaternary Ammonium Compounds | 97 | ||
Guidelines for Disinfection | 97 | ||
Sanitize Articles Before Disinfecting Them | 97 | ||
Observe Safety Precautions | 97 | ||
Properly Prepare and Use the Disinfectant | 97 | ||
Properly Store the Disinfectant | 97 | ||
Sterilization | 99 | ||
Sterilization Methods | 99 | ||
Autoclave | 100 | ||
Monitoring Program | 100 | ||
Sterilization Indicators | 100 | ||
Chemical Indicators | 100 | ||
Biologic Indicators | 101 | ||
Wrapping Articles | 103 | ||
Sterilization Paper | 103 | ||
Sterilization Pouches | 103 | ||
Muslin | 103 | ||
Operating the Autoclave | 106 | ||
Guidelines for Autoclave Operation | 106 | ||
Location of the Autoclave | 106 | ||
Filling the Water Reservoir | 107 | ||
Loading the Autoclave | 107 | ||
Timing the Load | 108 | ||
Drying the Load | 108 | ||
Handling and Storing Packs | 109 | ||
Maintaining the Autoclave | 109 | ||
Daily Maintenance | 109 | ||
Weekly Maintenance | 109 | ||
Monthly Maintenance | 109 | ||
Other Sterilization Methods | 109 | ||
Dry Heat Oven | 109 | ||
Ethylene Oxide Gas Sterilization | 110 | ||
Cold Sterilization | 110 | ||
Radiation | 110 | ||
Terminology Review | 115 | ||
On the Web | 115 | ||
4 Vital Signs | 116 | ||
Chapter Outline | 117 | ||
Key Terms | 117 | ||
Introduction to Vital Signs | 117 | ||
Temperature | 118 | ||
Regulation of Body Temperature | 118 | ||
Heat Production | 118 | ||
Heat Loss | 118 | ||
Body Temperature Range | 118 | ||
Alterations in Body Temperature | 118 | ||
Variations in Body Temperature | 118 | ||
Fever | 120 | ||
Stages of a Fever | 120 | ||
Assessment of Body Temperature | 120 | ||
Assessment Sites | 120 | ||
Oral Temperature | 121 | ||
Axillary Temperature | 121 | ||
Rectal Temperature | 121 | ||
Aural Temperature | 121 | ||
Forehead Temperature | 122 | ||
Types of Thermometers | 122 | ||
Electronic Thermometer | 122 | ||
Tympanic Membrane Thermometer | 122 | ||
Temporal Artery Thermometer | 122 | ||
Earlobe Temperature Measurement | 123 | ||
Care and Maintenance | 123 | ||
Chemical Thermometers | 125 | ||
Disposable Chemical Single-Use Thermometers | 125 | ||
Temperature-Sensitive Strips | 126 | ||
Pulse | 136 | ||
Mechanism of the Pulse | 136 | ||
Factors Affecting Pulse Rate | 136 | ||
Pulse Sites | 136 | ||
Radial | 136 | ||
Apical | 137 | ||
Brachial | 137 | ||
Ulnar | 137 | ||
Temporal | 137 | ||
Carotid | 138 | ||
Femoral | 138 | ||
Popliteal | 138 | ||
Posterior Tibial | 138 | ||
Dorsalis Pedis | 138 | ||
Assessment of Pulse | 138 | ||
Pulse Rate | 138 | ||
Pulse Rhythm and Volume | 138 | ||
Respiration | 139 | ||
Mechanism of Respiration | 139 | ||
Control of Respiration | 139 | ||
Assessment of Respiration | 140 | ||
Respiratory Rate | 140 | ||
Rhythm and Depth of Respiration | 141 | ||
Color of the Patient | 141 | ||
Respiratory Abnormalities | 141 | ||
Breath Sounds | 142 | ||
Pulse Oximetry | 142 | ||
Assessment of Oxygen Saturation | 142 | ||
Mechanism of Action | 142 | ||
Interpretation of Results | 143 | ||
Purpose of Pulse Oximetry | 143 | ||
Components of the Pulse Oximeter | 144 | ||
Monitor | 144 | ||
Probe | 144 | ||
Factors Affecting Pulse Oximetry | 145 | ||
Pulse Oximeter Care and Maintenance | 146 | ||
Blood Pressure | 151 | ||
Mechanism of Blood Pressure | 151 | ||
Interpretation of Blood Pressure | 151 | ||
Pulse Pressure | 151 | ||
Factors Affecting Blood Pressure | 151 | ||
Assessment of Blood Pressure: Manual Method | 152 | ||
Stethoscope | 152 | ||
Stethoscope Chest Piece | 152 | ||
Manual Sphygmomanometers | 152 | ||
Aneroid Sphygmomanometer | 152 | ||
Mercury Sphygmomanometer | 154 | ||
Cuff Sizes | 154 | ||
Korotkoff Sounds | 157 | ||
Assessment of Blood Pressure: Automatic Method | 160 | ||
Advantages | 160 | ||
Disadvantages | 161 | ||
5 The Physical Examination | 172 | ||
Chapter Outline | 173 | ||
Key Terms | 173 | ||
Introduction to the Physical Examination | 173 | ||
Definitions of Terms | 173 | ||
Preparation of the Examining Room | 174 | ||
Preparation of the Patient | 175 | ||
Measuring Weight and Height | 176 | ||
Body Mechanics | 185 | ||
Principles | 185 | ||
Application of Body Mechanics | 186 | ||
Standing | 186 | ||
Sitting | 186 | ||
Lifting | 186 | ||
Positioning and Draping | 187 | ||
Wheelchair Transfer | 196 | ||
Assessment of the Patient | 200 | ||
Inspection | 205 | ||
Palpation | 205 | ||
Percussion | 205 | ||
Auscultation | 205 | ||
Assisting the Physician | 206 | ||
6 Eye and Ear Assessment and Procedures | 213 | ||
Chapter Outline | 213 | ||
Key Terms | 213 | ||
Introduction to Eye and Ear Assessment | 214 | ||
The Eye | 214 | ||
Structure of the Eye | 214 | ||
Visual Acuity | 215 | ||
Assessment of Distance Visual Acuity (DVA) | 215 | ||
Conducting a Snellen Test | 216 | ||
Assessing Distance Visual Acuity in Preschool Children | 217 | ||
Assessment of Near Visual Acuity (NVA) | 217 | ||
Assessment of Color Vision | 218 | ||
Ishihara Test | 220 | ||
Eye Irrigation | 223 | ||
Eye Instillation | 223 | ||
The Ear | 228 | ||
Structure of the Ear | 228 | ||
Assessment of Hearing Acuity | 228 | ||
Types of Hearing Loss | 228 | ||
Hearing Acuity Tests | 229 | ||
Gross Screening Test | 229 | ||
Tuning Fork Tests | 229 | ||
Audiometry | 229 | ||
Tympanometry | 230 | ||
Ear Irrigation | 232 | ||
Ear Instillation | 233 | ||
7 Physical Agents to Promote Tissue Healing | 240 | ||
Chapter Outline | 240 | ||
Key Terms | 241 | ||
Introduction to Tissue Healing | 241 | ||
Local Application of Heat and Cold | 241 | ||
Factors Affecting the Application of Heat and Cold | 242 | ||
Heat | 242 | ||
Local Effects of Heat | 242 | ||
Purpose of Applying Heat | 242 | ||
Types of Heat Applications | 242 | ||
Heating Pad | 242 | ||
Hot Soak | 242 | ||
Hot Compress | 242 | ||
Chemical Hot Pack | 243 | ||
Cold | 243 | ||
Local Effects of Cold | 243 | ||
Purpose of Applying Cold | 244 | ||
Types of Cold Applications | 244 | ||
Ice Bag | 244 | ||
Cold Compress | 244 | ||
Chemical Cold Pack | 244 | ||
Casts | 251 | ||
Synthetic Casts | 251 | ||
Cast Application | 251 | ||
Precautions | 253 | ||
Guidelines for Cast Care | 253 | ||
Symptoms to Report | 254 | ||
Cast Removal | 254 | ||
Splints and Braces | 255 | ||
Ambulatory Aids | 256 | ||
Crutches | 256 | ||
Axillary Crutch Measurement | 257 | ||
Crutch Guidelines | 257 | ||
Crutch Gaits | 257 | ||
Canes | 257 | ||
Walkers | 258 | ||
8 The Gynecologic Examination and Prenatal Care | 267 | ||
Chapter Outline | 268 | ||
Key Terms | 268 | ||
Introduction to the Gynecologic Examination and Prenatal Care | 268 | ||
Gynecologic Examination | 268 | ||
Gynecology | 268 | ||
Terms Related to Gynecology | 269 | ||
Breast Examination | 269 | ||
Pelvic Examination | 271 | ||
Inspection of External Genitalia, Vagina, and Cervix | 271 | ||
Pap Test | 271 | ||
Patient Instructions | 273 | ||
Specimen Collection | 273 | ||
Vaginal Specimen | 273 | ||
Cervical Specimen | 273 | ||
Endocervical Specimen | 274 | ||
Preparation Methods | 274 | ||
Direct Smear | 274 | ||
Liquid-Based Preparation | 274 | ||
Cytology Request | 275 | ||
General Information | 275 | ||
Date and Time of Collection | 275 | ||
Collection Method | 275 | ||
Source of the Specimen | 275 | ||
Collection Technique | 275 | ||
Patient History | 275 | ||
Previous Treatment | 275 | ||
Evaluation of the Pap Specimen | 275 | ||
Maturation Index | 275 | ||
Cytology Report | 276 | ||
Bimanual Pelvic Examination | 278 | ||
Rectal-Vaginal Examination | 279 | ||
Vaginal Infections | 285 | ||
Trichomoniasis | 285 | ||
Candidiasis | 285 | ||
Chlamydia | 286 | ||
Gonorrhea | 287 | ||
Prenatal Care | 289 | ||
Obstetrics | 289 | ||
Obstetric Terminology | 289 | ||
Prenatal Visits | 290 | ||
First Prenatal Visit | 290 | ||
Prenatal Record | 290 | ||
Past Medical History | 291 | ||
Menstrual History | 292 | ||
Obstetric History | 293 | ||
Present Pregnancy History | 294 | ||
Interval Prenatal History | 295 | ||
Initial Prenatal Examination | 295 | ||
Purpose | 295 | ||
Preparation of the Patient | 296 | ||
Patient Education | 296 | ||
Laboratory Tests | 296 | ||
Urine Tests | 297 | ||
Urinalysis | 297 | ||
Swab Tests | 298 | ||
Pap Test | 298 | ||
Chlamydia and Gonorrhea | 298 | ||
Trichomoniasis and Candidiasis | 298 | ||
Group B Streptococcus | 298 | ||
Blood Tests | 298 | ||
Complete Blood Count | 298 | ||
Hemoglobin and Hematocrit | 298 | ||
Rh Factor and ABO Blood Type | 298 | ||
Glucose Challenge Test | 298 | ||
Syphilis Test | 299 | ||
Rubella Antibody Titer | 300 | ||
Rh Antibody Titer (On Rh-Negative Blood Specimens) | 300 | ||
Hepatitis B and Human Immunodeficiency Virus | 300 | ||
Return Prenatal Visits | 300 | ||
Fundal Height Measurement | 300 | ||
Fetal Heart Tones | 302 | ||
Vaginal Examination | 302 | ||
Special Tests and Procedures | 303 | ||
Multiple Marker Test | 303 | ||
Obstetric Ultrasound Scan | 303 | ||
Transabdominal Ultrasound Scan | 304 | ||
Endovaginal Ultrasound Scan | 305 | ||
Amniocentesis | 305 | ||
Fetal Heart Rate Monitoring | 306 | ||
Medical Assisting Responsibilities | 306 | ||
Six Weeks Postpartum Visit | 309 | ||
9 The Pediatric Examination | 319 | ||
Chapter Outline | 320 | ||
Key Terms | 320 | ||
Introduction to the Pediatric Examination | 320 | ||
Pediatric Office Visits | 320 | ||
Developing a Rapport | 321 | ||
Carrying the Infant | 322 | ||
Cradle Position | 322 | ||
Upright Position | 322 | ||
Growth Measurements | 323 | ||
Weight | 323 | ||
Length and Height | 323 | ||
Head and Chest Circumference | 323 | ||
Growth Charts | 325 | ||
Pediatric Blood Pressure Measurement | 333 | ||
Special Guidelines for Children | 333 | ||
Correct Cuff Size | 333 | ||
Cooperation of the Child | 333 | ||
Blood Pressure Classifications | 334 | ||
Collection of a Urine Specimen | 334 | ||
Pediatric Injections | 337 | ||
Types of Needles | 337 | ||
Intramuscular Injection Sites | 337 | ||
Immunizations | 338 | ||
National Childhood Vaccine Injury Act | 340 | ||
Newborn Screening Test | 342 | ||
10 Minor Office Surgery | 353 | ||
Chapter Outline | 354 | ||
Key Terms | 354 | ||
Introduction to Minor Office Surgery | 355 | ||
Surgical Asepsis | 356 | ||
Instruments Used in Minor Office Surgery | 356 | ||
Scalpels | 356 | ||
Scissors | 357 | ||
Forceps | 357 | ||
Miscellaneous Instruments | 357 | ||
Gynecologic Instruments | 358 | ||
Care of Surgical Instruments | 362 | ||
Commercially Prepared Sterile Packages | 362 | ||
Wounds | 368 | ||
Wound Healing | 368 | ||
Phases of Wound Healing | 369 | ||
Phase 1 | 369 | ||
Phase 2 | 369 | ||
Phase 3 | 369 | ||
Wound Drainage | 370 | ||
Sterile Dressing Change | 370 | ||
Sutures | 372 | ||
Types of Sutures | 372 | ||
Suture Size and Packaging | 374 | ||
Suture Needles | 374 | ||
Insertion of Sutures | 375 | ||
Suture Insertion Setup | 375 | ||
Items Placed to the Side of the Sterile Field | 375 | ||
Items Included on the Sterile Field | 375 | ||
Procedure: Suture Insertion | 376 | ||
Postoperative Instructions: Suture Insertion | 376 | ||
Suture Removal | 376 | ||
Surgical Skin Staples | 377 | ||
Adhesive Skin Closures | 379 | ||
Assisting with Minor Office Surgery | 384 | ||
Tray Setup | 384 | ||
Methods Used to Set Up a Sterile Tray | 384 | ||
Side Table | 384 | ||
Skin Preparation | 385 | ||
Shaving the Site | 385 | ||
Cleansing the Site | 385 | ||
Antiseptic Application | 385 | ||
Local Anesthetic | 385 | ||
Preparing the Anesthetic | 386 | ||
Assisting the Physician | 386 | ||
Medical Office Surgical Procedures | 392 | ||
Sebaceous Cyst Removal | 392 | ||
Sebaceous Cyst Setup | 393 | ||
Items Placed to the Side of the Sterile Field | 393 | ||
Items Included on the Sterile Field | 393 | ||
Procedure: Sebaceous Cyst Removal | 393 | ||
Postoperative Instructions: Sebaceous Cyst Removal | 394 | ||
Surgical Incision and Drainage of Localized Infections | 394 | ||
Incision and Drainage Setup | 394 | ||
Items Placed to the Side of the Sterile Field | 394 | ||
Items Included on the Sterile Field | 395 | ||
Procedure: Incision and Drainage | 395 | ||
Postoperative Instructions: Incision and Drainage | 395 | ||
Mole Removal | 395 | ||
Mole Shave Excision Setup | 397 | ||
11 Administration of Medication and Intravenous Therapy | 414 | ||
Chapter Outline | 415 | ||
Key Terms | 416 | ||
Introduction to the Administration of Medication | 416 | ||
Administering, Prescribing, and Dispensing Medication | 416 | ||
Legal Aspects | 416 | ||
Routes of Administration | 416 | ||
Drug References | 416 | ||
Food and Drug Administration | 416 | ||
Drug Nomenclature | 417 | ||
Classification of Drugs Based on Preparation | 420 | ||
Liquid Preparations | 420 | ||
Solid Preparations | 420 | ||
Classification of Drugs Based on Action | 421 | ||
Systems of Measurement for Medication | 433 | ||
Metric System | 433 | ||
Apothecary System | 434 | ||
Household System | 434 | ||
Converting Units of Measurement | 434 | ||
Controlled Drugs | 436 | ||
Prescription | 436 | ||
Parts of a Prescription | 437 | ||
Generic Prescribing | 440 | ||
Completing a Prescription Form | 441 | ||
EMR Prescription Program | 441 | ||
Medication Record | 442 | ||
Factors Affecting Drug Action | 445 | ||
Therapeutic Effect | 445 | ||
Age | 445 | ||
Route of Administration | 445 | ||
Size | 445 | ||
Time of Administration | 445 | ||
Tolerance | 445 | ||
Undesirable Effects of Drugs | 446 | ||
Adverse Reactions | 446 | ||
Drug Interactions | 446 | ||
Allergic Drug Reaction | 446 | ||
Idiosyncratic Reaction | 446 | ||
Guidelines for Preparation and Administration of Medication | 446 | ||
Oral Administration | 447 | ||
Parenteral Administration | 449 | ||
Parts of a Needle and Syringe | 449 | ||
Needle | 449 | ||
Syringe | 450 | ||
Safety-Engineered Syringes | 450 | ||
Preparation of Parenteral Medication | 451 | ||
Vials | 451 | ||
Ampules | 451 | ||
Prefilled Syringes | 452 | ||
Storage | 452 | ||
Reconstitution of Powdered Drugs | 452 | ||
Subcutaneous Injections | 453 | ||
Intramuscular Injections | 454 | ||
Intramuscular Injection Sites | 455 | ||
Dorsogluteal Site | 455 | ||
Deltoid Site | 455 | ||
Vastus Lateralis Site | 456 | ||
Ventrogluteal Site | 456 | ||
Z-Track Method | 457 | ||
Intradermal Injections | 467 | ||
Tuberculin Skin Testing | 468 | ||
Tuberculosis | 468 | ||
Purpose of Tuberculin Skin Testing | 468 | ||
Tuberculin Skin Test Reactions | 469 | ||
Mantoux Tuberculin Skin Test | 469 | ||
Guidelines for Administering a Mantoux TST | 471 | ||
Guidelines for Reading Mantoux TST Results | 471 | ||
Two-Step Tuberculin Skin Test | 472 | ||
Tuberculosis Blood Test | 473 | ||
Allergy Testing | 474 | ||
Allergy | 474 | ||
Allergic Reaction | 474 | ||
Diagnosis and Treatment | 475 | ||
Types of Allergy Tests | 477 | ||
Direct Skin Testing | 477 | ||
Quality Control | 477 | ||
Types of Direct Skin Tests | 477 | ||
Patch Testing | 477 | ||
Skin-Prick Testing | 478 | ||
Intradermal Skin Testing | 479 | ||
In Vitro Allergy Blood Testing | 480 | ||
Intravenous Therapy | 484 | ||
Advantages of Outpatient Intravenous Therapy | 484 | ||
Earlier Hospital Discharge | 484 | ||
Avoidance of Hospitalization | 484 | ||
Medical Office–Based Intravenous Therapy | 484 | ||
Indications for Outpatient Intravenous Therapy | 485 | ||
Scheduling the IV Therapy | 485 | ||
Medical Office Guidelines | 485 | ||
12 Cardiopulmonary Procedures | 491 | ||
Chapter Outline | 492 | ||
Key Terms | 493 | ||
Introduction to Electrocardiography | 493 | ||
Structure of the Heart | 493 | ||
Conduction System of the Heart | 494 | ||
Cardiac Cycle | 495 | ||
Waves | 495 | ||
Baseline, Segments, and Intervals | 496 | ||
Segments | 496 | ||
Intervals | 496 | ||
Electrocardiograph Paper | 496 | ||
Standardization of the Electrocardiograph | 497 | ||
Electrocardiograph Leads | 497 | ||
Electrodes | 498 | ||
Bipolar Leads | 499 | ||
Augmented Leads | 499 | ||
Chest Leads | 499 | ||
Paper Speed | 501 | ||
Patient Preparation | 502 | ||
Maintenance of the Electrocardiograph | 502 | ||
Electrocardiographic Capabilities | 502 | ||
Three-Channel Recording Capability | 502 | ||
Interpretive Electrocardiograph | 502 | ||
EMR Connectivity | 503 | ||
Teletransmission | 503 | ||
Artifacts | 503 | ||
Muscle Artifact | 504 | ||
Wandering Baseline Artifact | 506 | ||
60-Cycle Interference Artifact | 506 | ||
Interrupted Baseline Artifact | 506 | ||
Holter Monitor Electrocardiography | 509 | ||
Purpose | 510 | ||
Digital Holter Monitor | 510 | ||
Patient Preparation | 510 | ||
Electrode Placement | 510 | ||
Patient Diary | 511 | ||
Event Marker | 511 | ||
Evaluating Results | 512 | ||
Maintenance of the Holter Monitor | 512 | ||
Cardiac Dysrhythmias | 516 | ||
Premature Atrial Contraction | 516 | ||
Description | 516 | ||
13 Colon Procedures and Male Reproductive Health | 541 | ||
Chapter Outline | 541 | ||
Key Terms | 542 | ||
Introduction to Colon Procedures | 542 | ||
Structure of the Large Intestine | 542 | ||
Blood in the Stool | 542 | ||
Fecal Occult Blood Test | 542 | ||
Guaiac Slide Test | 542 | ||
Purpose | 543 | ||
Patient Preparation | 543 | ||
Quality Control | 544 | ||
Other Types of Stool Tests | 546 | ||
Fecal Immunochemical Test | 546 | ||
Fecal DNA Test | 547 | ||
Sigmoidoscopy | 551 | ||
Purpose | 551 | ||
Patient Preparation for Sigmoidoscopy | 552 | ||
Digital Rectal Examination | 552 | ||
Sigmoidoscope | 552 | ||
Procedure | 552 | ||
Colonoscopy | 553 | ||
Purpose | 553 | ||
Patient Preparation for Colonoscopy | 553 | ||
Procedure | 554 | ||
Introduction to Male Reproductive Health | 556 | ||
Prostate Cancer | 556 | ||
Prostate Cancer Screening | 557 | ||
Digital Rectal Examination | 557 | ||
Prostate-Specific Antigen Test | 557 | ||
Recommendations for Prostate Screening | 557 | ||
Testicular Self-Examination | 558 | ||
14 Radiology and Diagnostic Imaging | 562 | ||
Chapter Outline | 563 | ||
Key Terms | 563 | ||
Introduction to Radiology | 563 | ||
Contrast Media | 563 | ||
Fluoroscopy | 564 | ||
Positioning the Patient | 564 | ||
Specific Radiographic Examinations | 565 | ||
Mammography | 565 | ||
Bone Density Scan | 566 | ||
Gastrointestinal Series | 567 | ||
Upper Gastrointestinal Radiography | 567 | ||
Lower Gastrointestinal Radiography | 568 | ||
Intravenous Pyelography | 568 | ||
Other Types of Radiographs | 569 | ||
Introduction to Diagnostic Imaging | 569 | ||
Ultrasonography | 569 | ||
Patient Preparation | 570 | ||
Computed Tomography | 571 | ||
Patient Preparation | 571 | ||
Magnetic Resonance Imaging | 572 | ||
Patient Preparation | 573 | ||
Nuclear Medicine | 574 | ||
Bone Scans | 574 | ||
Nuclear Cardiac Stress Test | 574 | ||
Guidelines | 575 | ||
Digital Radiology | 575 | ||
15 Introduction to the Clinical Laboratory | 579 | ||
Chapter Outline | 580 | ||
Key Terms | 580 | ||
Introduction to the Clinical Laboratory | 580 | ||
Laboratory Tests | 581 | ||
Purpose of Laboratory Testing | 581 | ||
Types of Clinical Laboratories | 584 | ||
Physician’s Office Laboratory | 584 | ||
Physical Structure of the POL | 584 | ||
Outside Laboratories | 585 | ||
Laboratory Directory | 585 | ||
Collection and Testing Categories | 586 | ||
Laboratory Requests | 587 | ||
Purpose | 587 | ||
Parts of the Laboratory Request Form | 587 | ||
Laboratory Reports | 591 | ||
Laboratory Documents and the EMR | 594 | ||
Patient Preparation and Instructions | 595 | ||
Fasting | 595 | ||
Medication Restrictions | 596 | ||
Collecting, Handling, and Transporting Specimens | 597 | ||
Guidelines for Specimen Collection | 597 | ||
Clinical Laboratory Improvement Amendments | 604 | ||
Purpose of CLIA 1988 | 604 | ||
Categories of Laboratory Testing | 604 | ||
Requirements for Moderate-Complexity and High-Complexity Testing | 604 | ||
CLIA-Waived Laboratory Testing | 605 | ||
CLIA-Waived Testing Kits | 605 | ||
CLIA-Waived Automated Analyzers | 607 | ||
Quality Control | 607 | ||
Categories of Test Results | 611 | ||
Qualitative Test Results | 611 | ||
Quantitative Test Results | 611 | ||
Recording Test Results | 611 | ||
Laboratory Safety | 611 | ||
16 Urinalysis | 616 | ||
Chapter Outline | 616 | ||
Key Terms | 617 | ||
Structure and Function of the Urinary System | 617 | ||
Composition of Urine | 617 | ||
Terms Related to the Urinary System | 617 | ||
Collection of Urine | 617 | ||
Guidelines for Urine Collection | 618 | ||
Urine Specimen Collection Methods | 619 | ||
Random Specimen | 619 | ||
First-Voided Morning Specimen | 619 | ||
Clean-Catch Midstream Specimen | 619 | ||
Guidelines | 619 | ||
Twenty-Four–Hour Urine Specimen | 620 | ||
Analysis of Urine | 623 | ||
Physical Examination of Urine | 624 | ||
Color | 624 | ||
Appearance | 624 | ||
Odor | 624 | ||
Specific Gravity | 625 | ||
Chemical Examination of Urine | 625 | ||
Urine Testing Kits | 625 | ||
pH | 627 | ||
Glucose | 627 | ||
Protein | 627 | ||
Ketone | 627 | ||
Bilirubin | 627 | ||
Urobilinogen | 627 | ||
Blood | 628 | ||
Nitrite | 628 | ||
Leukocytes | 629 | ||
Reagent Strips | 629 | ||
Guidelines for Reagent Strip Urine Testing | 629 | ||
Quality Control Testing | 629 | ||
Urine Analyzer | 632 | ||
Microscopic Examination of Urine | 635 | ||
Red Blood Cells | 635 | ||
White Blood Cells | 644 | ||
Epithelial Cells | 644 | ||
Casts | 644 | ||
Crystals | 644 | ||
Miscellaneous Structures | 644 | ||
Rapid Urine Cultures | 647 | ||
Urine Pregnancy Testing | 647 | ||
Human Chorionic Gonadotropin | 647 | ||
Immunoassay Tests | 647 | ||
Guidelines for Urine Pregnancy Testing | 648 | ||
Serum Pregnancy Test | 648 | ||
17 Phlebotomy | 657 | ||
Chapter Outline | 657 | ||
Key Terms | 658 | ||
Introduction to Phlebotomy | 658 | ||
Venipuncture | 658 | ||
General Guidelines for Venipuncture | 659 | ||
Patient Preparation for Venipuncture | 659 | ||
Review Collection and Handling Requirements | 659 | ||
Identification of the Patient | 659 | ||
Assemble the Equipment and Supplies | 659 | ||
Reassuring the Patient | 661 | ||
Patient Position for Venipuncture | 661 | ||
Application of the Tourniquet | 662 | ||
Guidelines for Applying the Tourniquet | 662 | ||
Types of Tourniquets | 663 | ||
Rubber Tourniquet | 663 | ||
Procedure: Rubber Tourniquet | 663 | ||
Velcro-Closure Tourniquet | 663 | ||
Procedure: Velcro-Closure Tourniquet | 664 | ||
Site Selection for Venipuncture | 664 | ||
Guidelines for Site Selection | 664 | ||
Alternative Venipuncture Sites | 665 | ||
Types of Blood Specimens | 665 | ||
OSHA Safety Precautions | 666 | ||
Vacuum Tube Method of Venipuncture | 667 | ||
Needle | 667 | ||
Safety-Engineered Venipuncture Devices | 668 | ||
Plastic Holder | 669 | ||
Evacuated Tubes | 669 | ||
Additive Content of Evacuated Tubes | 670 | ||
Order of Draw for Multiple Tubes | 670 | ||
Evacuated Tube Guidelines | 671 | ||
Butterfly Method of Venipuncture | 678 | ||
Guidelines for the Butterfly Method | 678 | ||
Problems Encountered With Venipuncture | 685 | ||
Failure to Obtain Blood | 685 | ||
Inappropriate Puncture Sites | 686 | ||
Scarred and Sclerosed Veins | 686 | ||
Rolling Veins | 686 | ||
Collapsing Veins | 686 | ||
Premature Needle Withdrawal | 686 | ||
Hematoma | 686 | ||
Hemolysis | 686 | ||
Fainting | 686 | ||
Obtaining a Serum Specimen | 686 | ||
Serum | 686 | ||
Tube Selection | 687 | ||
Preparation of the Specimen | 687 | ||
Removal of Serum | 688 | ||
Serum Separator Tubes | 688 | ||
Obtaining a Plasma Specimen | 691 | ||
Plasma | 691 | ||
Tube Selection | 691 | ||
Preparation and Removal of the Specimen | 691 | ||
Plasma Separator Tube | 691 | ||
Skin Puncture | 691 | ||
Puncture Sites | 692 | ||
Skin Puncture Devices | 692 | ||
Disposable Semiautomatic Lancet | 692 | ||
Reusable Semiautomatic Lancet | 692 | ||
Microcollection Devices | 693 | ||
Capillary Tubes | 693 | ||
Microcollection Tubes | 693 | ||
Guidelines for Performing a Finger Puncture | 694 | ||
18 Hematology | 703 | ||
Chapter Outline | 703 | ||
Key Terms | 704 | ||
Introduction to Hematology | 704 | ||
Components and Functions of Blood | 706 | ||
Erythrocytes | 706 | ||
Leukocytes | 706 | ||
Thrombocytes | 708 | ||
Hemoglobin Determination | 708 | ||
Hematocrit | 709 | ||
White Blood Cell Count | 712 | ||
Red Blood Cell Count | 713 | ||
Red Blood Cell Indices | 713 | ||
MCV: Mean Corpuscular Volume | 713 | ||
MCH: Mean Corpuscular Hemoglobin | 713 | ||
MCHC: Mean Cell Hemoglobin Concentration | 713 | ||
RDW: Red Cell Distribution Width | 714 | ||
White Blood Cell Differential Count | 714 | ||
Automatic Method | 714 | ||
Manual Method | 714 | ||
Types of White Blood Cells | 715 | ||
Reference Range | 715 | ||
PT/INR | 718 | ||
Purpose | 718 | ||
Collection of the Specimen | 719 | ||
Performing a PT/INR Test | 721 | ||
PT/INR Home Testing | 721 | ||
19 Blood Chemistry and Immunology | 726 | ||
Chapter Outline | 726 | ||
Key Terms | 727 | ||
Introduction to Blood Chemistry and Immunology | 727 | ||
Blood Chemistry | 727 | ||
Collection of a Blood Chemistry Specimen | 727 | ||
Automated Blood Chemistry Analyzers | 727 | ||
Quality Control | 731 | ||
Calibration | 732 | ||
Controls | 732 | ||
Blood Glucose | 733 | ||
Blood Glucose Testing | 733 | ||
Fasting Blood Glucose Test | 733 | ||
Two-Hour Postprandial Blood Glucose Test | 734 | ||
Oral Glucose Tolerance Test | 734 | ||
Testing Requirements | 734 | ||
Side Effects | 734 | ||
Interpretation of Results | 734 | ||
Hypoglycemia | 735 | ||
Tests for Management of Diabetes | 735 | ||
Self-Monitoring of Blood Glucose | 735 | ||
Frequency of Testing | 737 | ||
Test Results | 737 | ||
Advantages | 737 | ||
Hemoglobin A1c Test | 738 | ||
Interpretation of Results | 738 | ||
Glucose Meters | 739 | ||
Reagent Test Strips | 739 | ||
Calibration Procedure | 739 | ||
Control Procedure | 740 | ||
Care and Maintenance | 740 | ||
Cholesterol | 744 | ||
HDL and LDL Cholesterol | 745 | ||
Cholesterol Testing | 745 | ||
Interpretation of Results | 746 | ||
Patient Preparation | 746 | ||
CLIA-Waived Cholesterol Analyzers | 746 | ||
Triglycerides | 747 | ||
Blood Urea Nitrogen | 748 | ||
Immunology | 748 | ||
Immunologic Tests | 748 | ||
Hepatitis Tests | 748 | ||
HIV Tests | 748 | ||
Syphilis Tests | 748 | ||
Mononucleosis Test | 748 | ||
Rheumatoid Factor | 748 | ||
Antistreptolysin O Test | 749 | ||
C-Reactive Protein | 749 | ||
Cold Agglutinins | 749 | ||
ABO and Rh Blood Typing | 749 | ||
Rh Antibody Titer | 749 | ||
Rapid Mononucleosis Testing | 749 | ||
Blood Typing | 751 | ||
Blood Antigens | 751 | ||
Blood Antibodies | 751 | ||
Rh Blood Group System | 752 | ||
Blood Antigen and Antibody Reactions | 752 | ||
Agglutination and Blood Typing | 753 | ||
20 Medical Microbiology | 758 | ||
Chapter Outline | 758 | ||
Key Terms | 759 | ||
Introduction to Microbiology | 759 | ||
Normal Flora | 759 | ||
Infection | 760 | ||
Stages of an Infectious Disease | 760 | ||
Microorganisms and Disease | 760 | ||
Bacteria | 760 | ||
Cocci | 761 | ||
Bacilli | 761 | ||
Spirilla | 761 | ||
Viruses | 761 | ||
Microscope | 762 | ||
Support System | 763 | ||
Frame | 763 | ||
Stage | 763 | ||
Light Source | 763 | ||
Condenser | 763 | ||
Diaphragm | 763 | ||
Adjustment Knobs | 763 | ||
Optical System | 764 | ||
Eyepiece | 764 | ||
Objective Lenses | 764 | ||
Focus | 764 | ||
Low and High Power | 764 | ||
Oil Immersion | 764 | ||
Care of the Microscope | 764 | ||
Microbiologic Specimen Collection | 767 | ||
Handling and Transporting Microbiologic Specimens | 768 | ||
Wound Specimens | 768 | ||
Collection and Transport Systems | 768 | ||
Microbial Cultures | 770 | ||
Streptococcus Testing | 771 | ||
Rapid Streptococcus Tests | 771 | ||
Hemolytic Reaction and Bacitracin Susceptibility Test | 771 | ||
Sensitivity Testing | 773 | ||
Microscopic Examination of Microorganisms | 773 | ||
Wet Mount Method | 774 | ||
Smears | 775 | ||
Gram Stain | 775 | ||
Prevention and Control of Infectious Diseases | 775 | ||
21 Emergency Medical Procedures | 781 | ||
Chapter Outline | 781 | ||
Key Terms | 782 | ||
Introduction to Emergency Medical Procedures | 782 | ||
Office Crash Cart | 782 | ||
Emergency Medical Services System | 782 | ||
First-Aid Kit | 784 | ||
OSHA Safety Precautions | 785 | ||
Guidelines for Providing Emergency Care | 785 | ||
Respiratory Distress | 786 | ||
Asthma | 786 | ||
Emphysema | 786 | ||
Hyperventilation | 787 | ||
Heart Attack | 787 | ||
Stroke | 787 | ||
Shock | 787 | ||
Hypovolemic Shock | 788 | ||
Cardiogenic Shock | 788 | ||
Neurogenic Shock | 788 | ||
Anaphylactic Shock | 788 | ||
Psychogenic Shock | 788 | ||
Bleeding | 789 | ||
External Bleeding | 789 | ||
Capillary Bleeding | 789 | ||
Venous Bleeding | 789 | ||
Arterial Bleeding | 789 | ||
Emergency Care for External Bleeding | 789 | ||
Nosebleeds | 790 | ||
Emergency Care for a Nosebleed | 790 | ||
Internal Bleeding | 792 | ||
Wounds | 792 | ||
Open Wounds | 792 | ||
Incisions and Lacerations | 792 | ||
Emergency Care for Incisions and Lacerations | 792 | ||
Minor Incisions and Lacerations | 792 | ||
Serious Incisions and Lacerations | 793 | ||
Punctures | 793 | ||
Emergency Care for Puncture Wounds | 793 | ||
Abrasions | 793 | ||
Emergency Care for Abrasions | 793 | ||
Closed Wounds | 793 | ||
Musculoskeletal Injuries | 793 | ||
Fracture | 793 | ||
Dislocation | 794 | ||
Sprain | 794 | ||
Strain | 795 | ||
Emergency Care for a Fracture | 795 | ||
Burns | 796 | ||
Superficial (First-Degree) Burn | 796 | ||
Partial-Thickness (Second-Degree) Burn | 796 | ||
Full-Thickness (Third-Degree) Burn | 796 | ||
Thermal Burns | 797 | ||
Emergency Care for Major Thermal Burns | 797 | ||
Emergency Care for Minor Thermal Burns | 797 | ||
Chemical Burns | 797 | ||
Seizures | 797 | ||
Emergency Care for Seizures | 798 | ||
Poisoning | 798 | ||
Ingested Poisons | 798 | ||
Emergency Care for Poisoning by Ingestion | 798 | ||
Inhaled Poisons | 799 | ||
Emergency Care for Inhaled Poisons | 799 | ||
Absorbed Poisons | 799 | ||
Emergency Care for Absorbed Poisons | 799 | ||
Injected Poisons | 799 | ||
Insect Stings | 799 | ||
Emergency Care for Insect Stings | 799 | ||
Spider Bites | 800 | ||
Emergency Care for Spider Bites | 800 | ||
Snakebites | 800 | ||
Emergency Care for Snakebites | 800 | ||
Animal Bites | 800 | ||
Emergency Care for Animal Bites | 801 | ||
Heat and Cold Exposure | 801 | ||
Heat Cramps | 801 | ||
Heat Exhaustion | 801 | ||
Heatstroke | 801 | ||
Frostbite | 802 | ||
Hypothermia | 802 | ||
Diabetic Emergencies | 802 | ||
Emergency Care in Diabetes | 803 | ||
Insulin Shock (Hypoglycemia) | 803 | ||
Diabetic Coma (Diabetic Ketoacidosis) | 803 | ||
Doubtful Situations | 804 | ||
Appendix A Medical Abbreviations | 808 | ||
Glossary | 816 | ||
Index | 826 | ||
A | 826 | ||
B | 827 | ||
C | 828 | ||
D | 829 | ||
E | 830 | ||
F | 831 | ||
G | 832 | ||
H | 832 | ||
I | 833 | ||
J | 833 | ||
K | 833 | ||
L | 834 | ||
M | 834 | ||
N | 835 | ||
O | 836 | ||
P | 836 | ||
Q | 838 | ||
R | 839 | ||
S | 839 | ||
T | 841 | ||
U | 842 | ||
V | 842 | ||
W | 843 | ||
X | 843 | ||
Y | 843 | ||
Z | 843 |