chapter 28

the science of applying physcial laws and theeories of biologic problems

pertaining to the operation of the mind, the process by which we become aware of perceiving , thinking and remembering

agreement, the state that occurs when verbal expression of the message mathces the sender's nonverbal body language

occuring in or affecting members of a family more than would be expected by chance

the chief compaint, written in chronologic sequence with dates of onset

peraining to a combination of psychological and social factors

a relationship of harmony and accord between the patient and the healthcare professional

. 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)

. 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

. includes assessing the patient's health status with physcial, cognitive, psychosocial and behavioral data

. the whole patient

• past medical history
• . previous health
• . usual childhood diseases, allergies, surgeries , accidents and immunization record

family history

• social history
• . lifestyle
• . occupation
• . hobbies
• . education

• review of systems
• . help detect conditions other than those covered under the present illness

. is the key to creating a caring therapeutic environment

. requires those in healthcare services to examine their own values, beliefs , and actions

• . restatement
• . reflection
• . clarification

. approximately 90% of patient interactions occur through nonverbal language

. successful patient interaction has congruent verbal and nonverbal messages.

• . ensure privacy
• . refuse interruptions
• . prepare comfortable surroundings
• . take judicious notes

. 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

. 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?

• . initiation or introduction
• . the body
• . the closing

• . providing unwarranted assurance
• . giving advice
• . using medical terminolgy
• . asking leading questions
• . talking too much
• . using defense mechanisms

promblem-oriented medical record

• . logical sequence to recording
• . database
• . problem list
• . plan
• . progress notes
• . use SOAPE format to define the patient's health problems

• . subjcetive data
• . chief complaint in patients words

• . objective data
• . anything that is observed or measurable

• . assessement
• . physician's tentative diagnosis

• . plan of care
• . physician documents how health problem will be managed

• . evaluation
• . assessment of treatment outcome

differentiated diagnosis

the record of patient name, address, date of birth, insurance information, personal data , history, physical exam, and initial laboratory findings

• . the purpose of the visits written as chief complaint
• . vital signs
• . pain report 1 to 10

the patient completely rejects the information

.  I couldn't possible have breast cancer. you must mistaken

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

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

the patient accuses someone else of having the feeling that she has

. you don't have to lose your temper about this

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

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

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

the patient redirects her negative feelings into a socially productive activity

. becoming a member of local support group

symptoms of the greatest significanace in identifying a disease

• . crushing chest pain
• . difficulty breathing

. 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

• . electronic medical record
• . use passwords

the perfect time to initiate patient education is during the initial patient interview

Denial "This is not happening to me.

• 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."