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29 Cards in this Set

  • Front
  • Back
pertaining to the science dealing with the application of physical methods and theories to biological problems.
chief complaint
the reason the patient is seeking medical care
pertaining to the operation of the mind process by which we become aware of perceiving, thinking and remembering
the verbal expression of the message matches the sender's nonverbal body language
concise technical description of the cause, nature, or manifestations of a condition or problem
Initial diagnosis
physician's temporary impression, sometimes called a "working diagnosis"
Differentiated diagnosis
comparison of two or more diseases with similar signs and symptoms
final diagnosis
conclusion physician reaches after evaluating all findings, including lab and other test results
occurring in or affecting members of a family more than would be expected by chance
present illness
the chief complaint, written in chronological sequence, with dates of onset
pertaining to a combination of psychological and social factors
relationship of harmony and accord between the patient and the healthcare professional
Medical history components
Database - name, address, DOB, etc
Past med. history - pts previous health
Family history - pt's mother, father - their health, cause and age of death
Social history - lifestyle, hobbies
System's reviews - general health
active listening techniques
restatement - "you are saying..."
reflection - "you sound frustrated about..."
clarification - "explain to me about..."
non-verbal communication observations

Breathing patterns
rapid respirations, sighing, shallow, thoracic breathing
non-verbal communication observations

Eye Patterns
no eye contact, side to side movement, looking down at hands
open ended questions
asking for general information (How are you feeling today?)
closed questions
asking for specific information (Do you have a headache?)
Communication techniques

Open ended questions
encourages pt to respond in a comfortable manner
communication techniques

direct questions
ask for specific information, usually reply is a yes or no
communication tecniques

nonverbally communicates your interest in the patient
communication techniques

communicates your acceptance of the patient, nonverbally
communication techniques

establishing guidelines
helps the patient to know what is expected
communication techniques

shows the importance of the patient's role
communication techniques

checks your interpretation of the patient's message for validation
communication techniques

shows the importance of the pt's feelings
communication techniques

helps the patient to separate relevant from irrelevant material
Subjective findings
Symptoms - perceptible only to the patient
objective findings
signs - perceptible to a person other than the patient