chapter 28

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chapter 28
2012-09-18 23:03:52
chapter 28

chapter 28
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  1. biophysical
    the science of applying physcial laws and theeories of biologic problems
  2. cognitive
    pertaining to the operation of the mind, the process by which we become aware of perceiving , thinking and remembering
  3. congruence
    agreement, the state that occurs when verbal expression of the message mathces the sender's nonverbal body language
  4. familial
    occuring in or affecting members of a family more than would be expected by chance
  5. present illness
    the chief compaint, written in chronologic sequence with dates of onset
  6. psychosocial
    peraining to a combination of psychological and social factors
  7. rapport
    a relationship of harmony and accord between the patient and the healthcare professional
  8. signs
    . objective findings determined by a clinician such as a fever, hypertenision or rash

    . something that can be measured , inspected ( to see), palpated(touch), auscultated or manipulated(move)
  9. symptoms
    . subjective complaints reported by the patient such as pain or visual disturbances , nausea, dizziness

    • . patients complaints regarding how he or she feels
    • . measures pain on scale of 1 to 10
    • . cardinal symptoms are those most helpful in diagnosis
  10. holistic care
    . includes assessing the patient's health status with physcial, cognitive, psychosocial and behavioral data

    . the whole patient
  11. PMH
    • past medical history
    • . previous health
    • . usual childhood diseases, allergies, surgeries , accidents and immunization record
  12. FH
    family history
  13. SH
    • social history
    • . lifestyle
    • . occupation
    • . hobbies
    • . education
  14. ROS
    • review of systems
    • . help detect conditions other than those covered under the present illness
  15. empathy
    . is the key to creating a caring therapeutic environment

    . requires those in healthcare services to examine their own values, beliefs , and actions
  16. listening must be an active process in a therapeutic relationship such as
    • . restatement
    • . reflection
    • . clarification
  17. nonverbal communication
    . approximately 90% of patient interactions occur through nonverbal language

    . successful patient interaction has congruent verbal and nonverbal messages.
  18. preparing the appropriate environment
    • . ensure privacy
    • . refuse interruptions
    • . prepare comfortable surroundings
    • . take judicious notes
  19. open-ended questions
    . gives the patient the opportunity to provide additional information

    • . " what brings you to the doctor?"
    • . " how have you been getting along?"
    • . " you mentioned having dizzy spells. tell more about that
  20. closed-ended questions
    . asked for specific information that can be answered with only a few words

    • .  do you have a headache?
    • . what is your birthdate?
    • . have you ever broke a bone?
  21. interviewing the patient contract between the medical assistant and patient three parts
    • . initiation or introduction
    • . the body
    • . the closing
  22. interview barriers
    • . providing unwarranted assurance
    • . giving advice
    • . using medical terminolgy
    • . asking leading questions
    • . talking too much
    • . using defense mechanisms
  23. POMR
    promblem-oriented medical record

    • . logical sequence to recording
    • . database
    • . problem list
    • . plan
    • . progress notes
    • . use SOAPE format to define the patient's health problems
  24. s
    • . subjcetive data
    • . chief complaint in patients words
  25. o
    • . objective data
    • . anything that is observed or measurable
  26. a
    • . assessement
    • . physician's tentative diagnosis
  27. p
    • . plan of care
    • . physician documents how health problem will be managed
  28. e
    • . evaluation
    • . assessment of treatment outcome
  29. new diagnosis is called
    differentiated diagnosis
  30. database
    the record of patient name, address, date of birth, insurance information, personal data , history, physical exam, and initial laboratory findings
  31. progress notes should include
    • . the purpose of the visits written as chief complaint
    • . vital signs
    • . pain report 1 to 10
  32. denial
    the patient completely rejects the information

    .  I couldn't possible have breast cancer. you must mistaken
  33. suppression
    the patient is consciously aware of the infromation or feeling but refuses to admit it

    . I don't think the test is accurate. my mammogrames are always normal
  34. reaction formation
    the patient expresses her feelings as the opposite of what she really feels

    . I appreciate your trying to help me but I just can't come to the hospital that day
  35. projection
    the patient accuses someone else of having the feeling that she has

    . you don't have to lose your temper about this
  36. rationalization
    the patient comes up with varous explanations to justify her response

    . I think the results are wrong I didn't follow the directions for the test like I should have besides there's no history of breast cancer in my family
  37. undoing
    the patient tries to reverse a negative feeling by doing something that indicated the opposite feeling

    . don't worry dear i'm not upset with for telling me about this
  38. regression
    the paitent reverts to an old usually immature behavior to ventilate her feelings

    . I can't possibly schedule a procedure without discussing this with my mother
  39. sublimation
    the patient redirects her negative feelings into a socially productive activity

    . becoming a member of local support group
  40. cardinal symptoms
    symptoms of the greatest significanace in identifying a disease

    • . crushing chest pain
    • . difficulty breathing
  41. SOMR
    . source-oriented medical record organizes patient data into specific sections

    . filed in reverse chronologic order with the most recent report or progress note on top
  42. EMR
    • . electronic medical record
    • . use passwords
  43. patient education
    the perfect time to initiate patient education is during the initial patient interview
  44. kubler-ross 5 stages of dying
    Denial "This is not happening to me.
  45. Anger: "How dare God do this to me."
    • Bargaining: "Just let me live to see my son graduate."
    • Depression: "I can't bear to face going through this, putting my family through this."
    •  Acceptance: "I'm ready, I don't want to struggle anymore."