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25 Cards in this Set

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What are the pathologic process involving disease?`
Congenital, inflammatory or infectious, immunologic, neoplastic, metabolic, nutritional, degenerative, vascular, traumatic, and toxic
What does the assessment and plan include?
includes the pt's responses to the problems identified and to your diagnostic and therapeutic plans.
What doew a good plan requires?
Good interpersonal skills and sensitivity to the pt's goals, economic means, competing responsibilities, and family structure and dynamics.
Why keep a patient's record?
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.
What are the steps in clinical reasoning for diagnosing?
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
What are the steps for clinical decision making?
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
What does the general survey involve?
An overview of the pt's built or habitus, HT, WT, and general state of health during the initial encounter
What is reliability?
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.
What is validity?
Indicates how closely a given observation agrees with "the true state of affairs," or the best possible measure of reality.
What is sensitivity?
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.
What is specificity?
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.
What is predictive value?
Indicates how well a given symptom, sign, or test result- either positive or negative- predicts the presence or absence of disease.
What is a positive predictive value?
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.
What is a negative predictive value?
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.
What is the difference b/t disease and illness?
Illness can be defined as how the pt experiences symptoms
Disease is the explanation that the clinician brings to the symptoms.
What are the 7 attributes of a symptom?
OLD CARTS
Onset
Location
Duration
Contributing characteristics
Alleviating/Agravating factors
Radiation
Timing
Setting
What are the OPQRST of a symptom? (attributes)
OPQRST
Onset
Prevention
Quality
Radiation
Severity
Time
What is the ROS format?
General, Skin, HEENT, Neck, Breasts, Respiratory, Cardiovascular, Gastrointestinal, Urinary, Genital, Peripheral vascular, Musculoskeletal, Psychiatric, Neurologic, Hematologic, Endocrine
What is MME and when is it used?
It is mini mental examination that is done if a pt is not oriented to time and place
What are the 6 domain patient centerd questions that help us learn about the pt's perception of illness?
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
What is the CAGE questinair and what does CAGE stands for?
it is a screening tool for alcoholism
Cut down
Annoyed
Guilty
Eye-opener
What are clues to possible physical abuse?
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
What are the stages of loss?
Denial and asolation, anger, bargaining, depression or sadness, and acceptance
What are the 3 demensions of cultureal competence?
Self-awareness
Respectful communication
Collaborative partnerships
(pg 55)
What are the principles of Tavistock?
Rights
Balance
Comprehensiveness
Cooperation
Improvement
Safety
Openness
(pg 60)