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29 Cards in this Set
- Front
- Back
Biophysical
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pertaining to the science dealing with the application of physical methods and theories to biological problems.
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chief complaint
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the reason the patient is seeking medical care
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cognitive
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pertaining to the operation of the mind process by which we become aware of perceiving, thinking and remembering
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congruence
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the verbal expression of the message matches the sender's nonverbal body language
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diagnosis
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concise technical description of the cause, nature, or manifestations of a condition or problem
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Initial diagnosis
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physician's temporary impression, sometimes called a "working diagnosis"
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Differentiated diagnosis
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comparison of two or more diseases with similar signs and symptoms
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final diagnosis
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conclusion physician reaches after evaluating all findings, including lab and other test results
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familial
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occurring in or affecting members of a family more than would be expected by chance
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present illness
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the chief complaint, written in chronological sequence, with dates of onset
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psychosocial
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pertaining to a combination of psychological and social factors
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rapport
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relationship of harmony and accord between the patient and the healthcare professional
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Medical history components
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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 |
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active listening techniques
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restatement - "you are saying..."
reflection - "you sound frustrated about..." clarification - "explain to me about..." |
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non-verbal communication observations
Breathing patterns |
rapid respirations, sighing, shallow, thoracic breathing
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non-verbal communication observations
Eye Patterns |
no eye contact, side to side movement, looking down at hands
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open ended questions
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asking for general information (How are you feeling today?)
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closed questions
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asking for specific information (Do you have a headache?)
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Communication techniques
Open ended questions |
encourages pt to respond in a comfortable manner
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communication techniques
direct questions |
ask for specific information, usually reply is a yes or no
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communication tecniques
listening |
nonverbally communicates your interest in the patient
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communication techniques
silence |
communicates your acceptance of the patient, nonverbally
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communication techniques
establishing guidelines |
helps the patient to know what is expected
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communication techniques
acknowledgement |
shows the importance of the patient's role
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communication techniques
restating |
checks your interpretation of the patient's message for validation
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communication techniques
reflecting |
shows the importance of the pt's feelings
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communication techniques
summarizing |
helps the patient to separate relevant from irrelevant material
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Subjective findings
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Symptoms - perceptible only to the patient
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objective findings
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signs - perceptible to a person other than the patient
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