health assessment complete health history

  1. symptom
    subjective sensation that the person feels from the disorder
  2. sign
    objective abnormality that you as the examiner could detect on physical examination or in lab reports
  3. PQRST
    • p=provacative or palliative (what brings it on, what makes it better, worse?)
    • q=quality or quantity
    • r=region or radiation
    • s=severity scale
    • t=timing (onset, duration, frequency)
    • u= understand the patients perception
  4. genogram
    a graphic family tree that uses symbols to depict the gender, relationship, and age of immediate blood related relatives in at lease 3 generations (grandparents, siblings, parents)
  5. self esteem/self concept
    education, financial status, value belief system
  6. biographical data
    name, nickname, address, phone #, patients names and #'s, age, dob, birth place, gender, race, ethnic origin, info about home
  7. source of history
    • -person providing info and relation to child
    • -your impression of the reliability of info
    • -any special circumstances (interpreter)
  8. nutritional history
    the younger the child the more detailed and specific the data should be.
  9. HEEADSSS for adolescents
    • H=home environment
    • E=education and employment
    • E=eating
    • A=activities drugs
    • S=sexuality
    • S=suicide or depression
    • S=safety from injury or violence
  10. mental disorder
    • apparent when a persons response is much greater than the expected reaction to a traumatic life event
    • -a significant behavioral or psychological pattern that is associated with distress or disability
  11. organic disorder
    die to brain disease of known specific organ cause
  12. psychiatric mental illness
    organic etiology has not yet been established ex. anxiety disorder
  13. assessment of mental status includes:
    consciousness, language, mood and affect, orientation, attention, memory, abstract reasoning, thought process, thought content, perceptions
  14. aging adult
    • -thought process is delayed and response time is slower
    • -recent memory is decreased
  15. 4 main categories of a mental exam
    appearance, behavior, cognition, and thought processes
  16. 4 unrelated works test
    • persons ability to lay down new memories.
    • -ask 10 and 30 minutes later the 4 words to see how memory works
  17. judgement
    when she or he can compare and evaluate the alternatives in a situation and reach an appropriate course of action
  18. perceptions
    consistently aware of reality
  19. GAD-7 test
    anxiety and depression score of 0-6 (0 being no anxiety)
  20. mini mental exam
    standard set of 11 questions (memory, orientation, time and place, naming, reading, copying, visuospatial orientation, writing, ability to follow a three state command)
  21. mental exam for children, what is the main problem
    omission, the child does not achieve a milestone you would expect
  22. denver II screening
    test that gives you a chance to interact directly with the young child to assess mental status. designed to detect developmental delays in infants and preschoolers within 4 functions: gross motor, language, fine motor, personal social skills. 125 items arranged in chronological order
  23. behavioral checklist
    • age 7-11, who have grown beyond the age of developmental milestones. can be given to the parent along with history
    • 5 major areas- mood, play, school, friends and family reactions
  24. mini cog
    • cognitive impairment tool for older adults
    • 3- item recall test and clock drawing test
  25. dysphonia
    • -voice disorder
    • -difficulty or discomfort in talking, with abnormal pitch or volume due to laryngeal disease. voice sounds hoarse or whispered, but articulation and language are intact
  26. dysarthria
    • -articulation disorder
    • -distorted speech sounds, speech may sound unintelligible, basic language, intact
  27. aphasia
    -true language disturbance, defect in word choice and grammar or defect in comprehension, defect is in higher integrative language processing
  28. 4 most common anxiety disorders
    generalized anxiety disorder, panic disorder, social anxiety disorder, ptsd
  29. global aphasia
    spontaneous speech is absent or reduced to a few stereotyped words or sounds, comprehension is absent or reduced to only the persons own name and a few select words, repetition, reading and writing are severely impaired, caused by a large lesion that damages most of language areas
  30. brocas aphasia
    expressive aphasia, person can understand language but cannot express himself or herself using language
  31. wernickes aphasia
    receptive aphasia, opposite of brocas, person can hear sounds and words but cannot relate them to previous experiences, speech can totally be incomprehensibile
  32. elation
    joy and optimism, overconfidence
  33. euphoria
    excessive well being, cheerful and elated
  34. ambivalence
    existence of opposing emotions toward an idea object or person
  35. lability
    rapid shift of emotion
  36. inappropriate effect
    affect clearly discordant with the content of the persons speech
  37. blocking
    sudden interruption in train of thought, unable to complete a sentence
  38. confabulation
    fabricates events to fill in memory gaps
  39. neologism
    coining a new word, invented word has no real meaning except for the person
  40. circumlocution
    round about expression, substituting a phrase when cannot think of name of object
  41. circumstantiality
    talks with excessive and unnecessary detail, delays reaching point
  42. loosening associations
    shifting from one topic to an unrelated topic
  43. flight of ideas
    abrupt change, rapid skipping from topic to topic
  44. word salad
    incoherent mixture of words, phrases, and sentences, illogical, disconnected, includes neologisms
  45. perseveration
    persistent repeating of verbal or motor response, even with varied stimuli
  46. echolalia
    imitation, repeats others words or phrases, often with mumbling mocking or mechanical tone
  47. clanging
    word choice based on sound, not meaning includes nonsense rhymes and puns
  48. phobia
    strong, persistent irrational fear of an object or situation
  49. hypochondriasis
    morbid worrying about his or her own health, feels sick with no actual basis for that assumption
  50. obsession
    unwanted, persistent thought or impulses
  51. compulsion
    unwanted repetitive, purposeful act, driven to do it
  52. delusions
    firm, fixed false beliefs, irrational
  53. hallucinations
    sensory perceptions for which there are no external stimuli
  54. illusion
    misperception of an actual existing stimulus
  55. schizophrenia
    delusions, hallucinations, disorganized speech, grossly disorganized, negative symptions
  56. AUDIT
    • detects less severe alcohol problems as well as alcohol abuse or dependence
    • covers 3 topics: alcohol consumption, drinking behavior or dependence, and adverse consequences
  57. CAGE
    • cutdown, annoyed, guilty, eye opener.
    • yes/no questions
    • tests for lifetime alcohol abuse and or dependence but does not establish past problem drinking with present drinking
  58. TWEAK
    • identify at risk drinking in women, especially pregnant women
    • tolerance, worry, eye opener, amnesia, kut down
  59. SMAST-G
    • for older adults who report social or regular drinking of any amount of alcohol.
    • 10 yes/ no questions
    • low risk is 0 or 1 point
  60. GTT
    drinking raises GTT, takes 4-5 weeks for levels to return to normal
  61. AST
    months of chronic drinking increases this
  62. MCV
    heavy alcohol drinking 4-8 weeks
  63. physical exam
    inspection, palpation, percussion and auscultation
  64. inspection
    general survey
  65. amplitude
    intensity-loud or soft
  66. pitch
    frequency-# of vibrations per sec
  67. general survey
    appearance, body structure, mobility, behavior
  68. mean arteriole pressure
    pressure forcing blood into the tissues, averaged over the cardiac cycle
  69. hypopituitary dwarfism
    dificiency in growth hormone in childhood results in retardation of growth below the 3rd percentile, delayed puberty, hypothyroidism, and adrenal insufficiency.
  70. gigantism
    excessive secretion of growth hormone by the anterior pituitary resulting in overgrowth of entire body
  71. acromegaly (hyperpituitarism)
    excessive secretion of growth hormone in adulthood, after normal completion of growth, causes overgrowth of bone in face, head, hands and feet, no change in height
  72. marfan syndrome
    connective tissue disorder, tall thin stature, long thin fingers, flexible joints, arm span greater than height
Card Set
health assessment complete health history