ch 1-5 assessment exam - Google Docs

Menstrual regularity, bleeding patterns, menopausal symptoms, and dyspareunia.

Nervousness, tension, mood changes, depression, memory changes, suicidal ideation, and suicide plans or attempts.

Maintaining the privacy of patient information.

It helps to assess the characteristics of a patient's symptoms.

To document the presence or absence of common symptoms related to each major body system.

Using posture, gestures, and eye contact can encourage the patient to continue sharing their story.

Respect for Autonomy.

The ability to make an autonomous choice that clinicians should respect.

To prepare patients for what comes next and put them at ease.

By acknowledging their feelings and expressing understanding, such as saying, 'Your accident must have been terrifying.'

Adult illnesses with dates in medical, surgical, obstetric/gynecologic, and psychiatric categories, along with health maintenance practices, medications, and allergies.

Frequency, urgency, burning during urination, and blood in urine.

Eliciting and validating emotional content.

It shifted from a paternalistic relationship to a more collaborative one.

The principle that clinicians must obtain voluntary and informed authorization from patients before testing or treating them.

History of tobacco, alcohol, or recreational drug use, sexual history, educational level, family of origin, current household, personal interests, and lifestyle.

Moving from open-ended to focused questions, eliciting graded responses, and clarifying what the patient means.

Fever, chills, rash, anorexia, weight loss, or weakness.

Hereditary conditions and medical issues in close relatives, including age and health or cause of death of family members.

Usual weight, recent weight change, weakness, fatigue, or fever.

Swollen glands, goiter, lumps, pain, or stiffness in the neck.

Lifetime alcohol abuse and dependence alcohol use disorders (AUD).

They should be considered in contrast to acute symptoms.

Lumps, pain or discomfort, and nipple discharge.

By using brief transitional phrases like 'Now I’d like to ask some questions about your past health.'

Headaches, vision issues, ear problems, nasal issues, and throat conditions.

To act as a 'cultural navigator' who is neutral and trained in both languages and cultures.

Onset, Location, Duration, Aggravating or alleviating factors, Radiation, Timing, Setting.

A way to avoid stigmatizing language, e.g., saying 'person who uses drugs' instead of 'drug abuser.'

To facilitate, direct, and structure the interaction by attending to what the patient is communicating and connecting to their emotional state.

They can make the patient feel restricted and passive, leading to a significant loss of detail in their responses.

It helps patients understand the rationale behind recommendations and fosters trust.

To 'do no harm' and avoid causing harm to the patient.

The primary symptom or concern causing the patient to seek care.

Consciously acknowledge your discomfort.

Prioritize life-threatening conditions such as chest pain or difficulty breathing.

Intermittent leg pain, swelling, color changes in extremities, and past clots.

Encouraging them to ask questions and express their concerns.

Changes in mood, attention, speech, orientation, memory, insight, judgment, headache, dizziness, weakness, paralysis, numbness, tingling, tremors, or seizures.

Based on the exam type, e.g., seated for respiratory exam, supine for abdominal exam.

Onset, Precipitating and palliating factors, Quality, Region or radiation, Severity, Timing.

When the patient feels that problems have been fully understood and are being addressed.

It encourages the patient to elaborate on details and feelings, demonstrating careful listening.

Acting in the best interest of the patient.

Disclosing information beyond what is required by informed consent that may be relevant to patients.

To be nonjudgmental.

Trouble swallowing, heartburn, changes in bowel habits, and abdominal pain.

Hernias, discharge, testicular pain, and history of sexually transmitted infections.

Reveal those limits to the patient.

It lies at the heart of the patient interview and involves specific skills that enhance communication.

Identifying and acknowledging the patient’s feelings.

Concerns like fever or unexplained weight loss.

Cough, sputum characteristics, shortness of breath, wheezing, and pleuritic pain.

A technique to elicit more information without interrupting the flow of the patient’s story, showing sustained interest in their feelings.

Muscle or joint pain, stiffness, and any limitations in motion or activity.

Anemia, easy bruising, or bleeding.

Eye contact, facial expression, posture, head position, and interpersonal distance.

Chest pain, palpitations, orthopnea, paroxysmal nocturnal dyspnea, and edema.

It helps build rapport and assures patients that their care will continue.

Heat or cold intolerance, excessive sweating, thirst, hunger, or urine output.

To ensure accurate communication and avoid potential biases.

They may drift into thinking about their next question or possible diagnoses, losing focus on the patient's narrative.

Rashes, lumps, sores, itching, dryness, changes in color, hair or nails, and changes in size or color of moles.

Inspection → Palpation → Percussion → Auscultation.

By acknowledging their feelings, e.g., saying 'You seem upset today.'

C: Cut down on drinking, A: Annoyed by criticism of drinking, G: Guilty about drinking, E: Eye-opener (using alcohol first thing in the morning).

Treating patients fairly and distributing healthcare resources equitably.

HPI stands for History of Present Illness and amplifies the Chief Complaint.

Through hospital resources or contracted interpreter services.

It makes patients less apprehensive.