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25 Cards in this Set
- Front
- Back
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What are the pathologic process involving disease?`
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Congenital, inflammatory or infectious, immunologic, neoplastic, metabolic, nutritional, degenerative, vascular, traumatic, and toxic
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What does the assessment and plan include?
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includes the pt's responses to the problems identified and to your diagnostic and therapeutic plans.
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What doew a good plan requires?
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Good interpersonal skills and sensitivity to the pt's goals, economic means, competing responsibilities, and family structure and dynamics.
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Why keep a patient's record?
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It facilitates clinical thinking, promotes communication and coordination among the many professionals caring for you pt, and documents the pt's problems and management for medicolegal purposes.
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What are the steps in clinical reasoning for diagnosing?
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Identify abnormal findings
Localize findings anatomically Interpret findings in terms of probable process Make hypotheses about the nature of the pt's problem Test the hypotheses and establish a working diagnosis Develop a plan agreeable to the patient |
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What are the steps for clinical decision making?
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Select the most specific and critical findings to support you hypothesis
Match your findings against all the conditions you know that can produce them Eliminate the diagnostic possibilities that fail to explain the findings Weigh the competing possibilities and select the most likely dx Give special attention to potentially life-threatening and treatable conditions |
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What does the general survey involve?
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An overview of the pt's built or habitus, HT, WT, and general state of health during the initial encounter
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What is reliability?
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indicates how well repeated measurments of the same relatively stable phenomenon will give the same result, also known as precision. May be measured for one observer or more than one observer.
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What is validity?
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Indicates how closely a given observation agrees with "the true state of affairs," or the best possible measure of reality.
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What is sensitivity?
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Identifies the proportion of people who test positive in a group of people known to have the disease or condition, or the proportion of people who are true positives compared with the total number of people who actually have the disease.
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What is specificity?
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Identifies the proportion of people who test negative in a group of people known to be w/o a given disease, or the proportion of people who are "true negatives" compared with the total number of people w/o the disease.
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What is predictive value?
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Indicates how well a given symptom, sign, or test result- either positive or negative- predicts the presence or absence of disease.
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What is a positive predictive value?
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Is the probability of disease in a patient with a positive (abnormal) test, or the proportion of "true positives" out of the total population tested.
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What is a negative predictive value?
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Is the probability of not having the condition or disease when the test is negative, or normal, or the proportion of "true negatives" out of the total population tested.
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What is the difference b/t disease and illness?
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Illness can be defined as how the pt experiences symptoms
Disease is the explanation that the clinician brings to the symptoms. |
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What are the 7 attributes of a symptom?
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OLD CARTS
Onset Location Duration Contributing characteristics Alleviating/Agravating factors Radiation Timing Setting |
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What are the OPQRST of a symptom? (attributes)
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OPQRST
Onset Prevention Quality Radiation Severity Time |
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What is the ROS format?
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General, Skin, HEENT, Neck, Breasts, Respiratory, Cardiovascular, Gastrointestinal, Urinary, Genital, Peripheral vascular, Musculoskeletal, Psychiatric, Neurologic, Hematologic, Endocrine
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What is MME and when is it used?
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It is mini mental examination that is done if a pt is not oriented to time and place
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What are the 6 domain patient centerd questions that help us learn about the pt's perception of illness?
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The pt's thoughts about hte nature and the cause of the problem
The pt's feelings, especially fears, about the probem The pt's expectations fo the clinician and health care The effect of the problem on the pt's life Prior personal or family experiences that are similar Therapeutic approaches the pt has already tried |
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What is the CAGE questinair and what does CAGE stands for?
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it is a screening tool for alcoholism
Cut down Annoyed Guilty Eye-opener |
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What are clues to possible physical abuse?
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If injuries are unexplained, seem inconsistent with the pt's story, are concealed by the pt, or cause embarrassment
If the pt has delayed getting treatment for trauma if there is a past history of repeated injuries or "accidents" If the pt or person close to the pt has a hx of alcohol/drug If the partner tries to dominate the interview, will not leave the room, or seems unusually anxious or solicitous |
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What are the stages of loss?
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Denial and asolation, anger, bargaining, depression or sadness, and acceptance
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What are the 3 demensions of cultureal competence?
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Self-awareness
Respectful communication Collaborative partnerships (pg 55) |
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What are the principles of Tavistock?
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Rights
Balance Comprehensiveness Cooperation Improvement Safety Openness (pg 60) |
