Ch2 notes Flashcards
assessment
select and cluster relevant pieces of information, analyze their significance, and try to explain them logically using principles of biopsychosocial and biomedical sciences
plan
incorporates patient education, changes in medications, needed tests, referrals to other clinicians, and return visits for counseling and support
what are the three types of reasoning for clinical problem solving
pattern recognition, development of schemas, and application of relevant basic and clinical science
steps in clinical reasoning
- identify abnormal findings
- localize findings anatomically
- interpret findings in terms of probable process
- make hypothesis about the nature of the patient’s problem
- test the hypotheses and establish a working diagnosis
- develop a plan agreeable to the patient
pathophysiologic
derangements of biologic functions
psychopathologic
disorders of mood
what problems come first on the problem list?
the most active and serious problems
how does age play a factor in diagnosing?
young people are more likely to have a single disease, whereas older people tend to have multiple diseases
checklist for a clear and accurate record
- is the order clear?
- does the data included contribute directly to the assessment?
- are the pertinent negatives specifically described?
- are there overgeneralizations or omissions of important data?
- is there too much detail?
- are phrases and short words used appropriately? Is there unnecessary repetition of data?
- Is the written style succinct? are there excessive abbreviations?
- are diagrams and precise measurements included where appropriate?
- is the tone of the write-up neutral and professional?