PATP Quiz 1 Flashcards
Language of Diagnosis
Findings
Signs
Symptoms
Findings: Pieces of info about the patient that have been gathered by asking questions and reviewing forms, observing, and examining structures, performing diagnostic tests, and consulting physicians.
Signs: Findings discovered by the clinician during an examination.
Symptoms: Findings that are apparent to the patient, usually because the findings are causing a problem.
WNL vs NSF
WNL: Within Normal Limits
NSF: No Significant Findings
Getting a PATIENT HISTORY through:
Questionnaires and forms
Patient Interview -
- Open ended and Closed ended Q’s
Demographic Information:
Name Phone # Address Email SSN Insurance Info Emergency Contact Physician’s Name
Chief Compalaint (CC)
Always in the Patient’s Own Words!
History of Present Illness (HPI)
List of Symptoms Timeline (Onset, duration) What elicits symptoms Pain Scale Location Progress Desired Outcome
General Health History
May Affect:
Treatment
Patient Management
Outcomes
Effective Interviewing:
Make Eye Contact Ask Open-Ended Q’s Explain Rationale Be Objective/Unbiased Pay Attention and Listen Watch Non-Verbal Cues Summarize and confirm accuracy at end
What is General Health History?
Review of past and present illnesses What? When? Why? Outcome? Maybe Who? Maybe Where?
What to list for General Health History?
Medications (Prescription, Herbals) What Why Dosage Duration Past History Allergies To What Symptoms When Testing
Psychosocial History?
Social, Emotional, Behavioral
Occupation, Habits, Financial Resources, Lifestyle
Priorities, Expectations, Motivations,
Attitude toward dentistry
Oral Health History
Last Dental Care Frequency of Care Nature of previous dental care Timing of previous dental care Specialty care received Experiences during previous care
Physical Examination?
Posture and Gait Exposed Skin Surfaces Cognition and Mental Acuity Speech and Ability to Communicate Vital Signs
Physical Examination
Patient Posture and Gait
Mobility
Disability
Affect
Physical Examination
Exposed Skin Surfaces
Color
Lesions
Moistness
Hair and Nails
Physical Examination
Vital Signs
Heart Rate/Rhythm Blood Pressure Temperature Respiratory Rate Height/Weight
Why do you take blood pressure and heart rate?
Be able to discuss:
Identification of patients who might be at risk during procedures
Identification of patients for whom we should be careful with
Epinephrine
Patient Positioning during Blood Pressure Measurement?
Comfortably Seated
Legs Uncrossed
Back and Arm Supported
Arm bare without constrictions from clothing
Middle of cuff at level of midpoint of sternum
Put at ease
Blood Pressure Measurement Inflation/Deflation
Be sure the cuff is completely deflated before applying
Inflate to 30 mmHg above the point that the radial pulse disappears
Record the readings of the first and last sounds (Systolic and diastolic)
Look over ASA Classifications
Look over ASA Classifications