Term
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Definition
| Symptom- a subjective sensation that the person feels from the disorder. |
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Term
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Definition
| Sign- an objective abnormality that you as the examiner could detect on physical examination or in lab reports. |
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Term
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Definition
PQRSTU-mnemonic to help remember all the points of present health or history of present illness.
P: Provocative or Palliative: what bring it on? what where you doing when you first noticed it? what makes it better? worse?
Q: Quality or Quantity: how does it look, feel, sound? how intense/severe is it?
R: Region or Rationation: where is it? does it spread anywhere?
S: Severity Scale: how bad is it on a scale of 1-10, 10 beint the worst? is it getting better? worse? staying the same?
T: Timing:
Onset-exactly when did it first occur?
Duration-how long did it last?
Frequency- how often does it occur?
U: Understand Patient's Perception of the problem. what do you think it means? |
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Term
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Definition
Past Health:
1. childhood illnesses
2. accidents or injuries
3. serious or chronic illnesses
4. hospitalizations
5. operations
6. obstetric history
7. immunizations
8. last examination date
9. allergies
10. current meds (including OTC, herbal, illicit drugs, alcohol and birth control) |
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Term
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Definition
| Genogram- is a graphc family tree that uses symbols to depict gender, relationships, and age of immediate blood relatives in a least three generations, such as parents, grandparents, siblings. |
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Term
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Definition
Review of systems includes top to bottom:
skin
hair
head
eyes
ears
nose and sinuses
mouth and throat
neck
breast
axilla
respiratory system
cardiovascular
peripheral vascular
gastrointestinal
urinary system
male genitalia
female genitalia
sexual health
musculoskeletal system
neurological system
hematologic system
endocrine system |
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Term
| Functional Assessment (w. ADL's) |
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Definition
Functional assessment measures a person's self-care ability in the areas of general physical health or absence of illness; ADls such as bathing, dressing, toileting, walking; and instrumental activities of daily living (IADLS) or those needed for independent living such as housekeeping, cooking, shopping, laundry, self-concept, social relationships coping and home environment etc.
Functional assessment questions should be included in standard health history, provide data on the lifestyle and type of environment to which the person is accustomed and be asked later in the interview after you have had time to establish a rapport. |
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Term
| Functional Assessment includes (13) |
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Definition
Functional assessment includes:
-Self-esteem, Self-concept
-Activity/Exercise
-Sleep/Rest
-Nutrition/Elimination
-Interpersonal relationships/Resources
-Spiritual Resources
-Coping and Stress Management
-Personal Habits
-Alcohol
-Illicit or street drugs
- Environment/Hazards
-Intimate Partner Violence
-Occupational Health |
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Term
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Definition
| ask questions like how do you define health? what are your concerns? what do you expect from us? |
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Term
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Definition
Spiritual Resources:
Faith- got one?
Influence- of faith on perception of health
Community- involvement
Address- questions to incorporate persons spiritual values into health |
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Term
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Definition
Alcohol:
Cutting down (ever thought of...?)
Annoyed (ever annoyed by criticism of drinking?)
Guilty (ever guilty about drinking?)
Eye opener (ever drink in the AM?) |
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Term
| The HEEADSSS psychosocial interview assessment |
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Definition
Home
Environment and employment
Eating
Activities
Sexuality
Suicide or depression
Safety (savagery) |
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