Midterm Flashcards
explanation proposed for a patients problems
diagnosis
a diagnosis is based on…(3)
symptoms
signs
laboratory
IPPA for physical exam
Inspection
Palpation
Percussion
Auscultation
Diagnostic terms (5)
- differential
- tentative/working
- admitting
- final/discharge
- preoperative and postoperative
differential
not sure; could be one of several diseases
tentative
H&P done before lab/test results
“rule out”
still a possibility
admitting
newly admitted to hospital
final/discharge
end of encounter
preoperative/postoperative
Operations
choice of dx. influenced by…
third-party payers
etiology
cause of disorder, syndrome, or disease
secondary etiology
something other than the main organ involved
organic
problem in tissues or organs is visible
functional
no disease is visible
symptoms
get details
signs
verbal report
history is usually obtained by….
a series of questions
other ways to get a dx
- overlapping content
- thorough h&p
- dictated in short, clipped phrases
- may seem to jump around
- technical words may replace laymen’s terms
source of history
questioning the patient
family
previous charts
consultation with other HCPs
symptoms of history (10)
- quality
- intensity
- onset
- duration
- indeterminacy
- location
- radiation
- inciting/aggravating or alleviating factors
- prior episodes of similar pain
- associated symptom
most important part of history
HPI
statement of patients presenting problem
chief complaint
“the heart” the medical history
CC is followed by detains in HPI as to why they sought help