Questions and Answers
Lilly's _______ __________ for seeing the physician today is a sore throat.
chief complaint
What is a _____ _________?
final diagnosis
What does 'IBS vs. Gastroenteritis' listed under the impression represent?
differential diagnosis
_________ means pertaining to the operation of the mind by which we become aware of perceiving, thinking, and remembering.
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_________ is the relationship of harmony and accord that exists between the patient and the healthcare provider.
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Identify four important rules to remember when preparing the appropriate environment for patient interaction.
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List and describe the three processes of active listening.
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List and describe the six components of the medical history.
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List and define the three stages of the patient interview.
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What are four examples of therapeutic nonverbal behaviors that enhance communication?
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What type of question is 'How have you been feeling?'
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What type of question is 'Do you have a headache?'
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Study Notes
Patient Assessment Key Concepts
- Chief Complaint: Main reason for patient's visit, e.g., sore throat.
- Final Diagnosis: Conclusion reached after evaluating findings, tests, and results.
- Differential Diagnosis: Listing of conditions that might explain a patient's symptoms (e.g., "IBS vs. Gastroenteritis").
Cognitive and Rapport
- Cognitive: Refers to operations of the mind like perception, thought, and memory.
- Rapport: The harmonious relationship between the patient and healthcare provider.
Patient Interaction Environment
- Ensure privacy: Room should be clear for the duration of the interview.
- Prevent interruptions: Minimize distractions to maintain conversation flow.
- Comfortable surroundings: Conduct interviews with patient and provider at eye level to ease anxiety.
- Judicious note-taking: Focus primarily on the patient, minimizing distractions from note-taking.
Active Listening Skills
- Restatement: Paraphrasing patient’s words to confirm understanding (e.g., "You are saying...").
- Reflection: Summarizing main ideas while acknowledging patient's feelings, demonstrating empathetic listening.
- Clarification: Simplifying or summarizing thoughts and feelings to resolve confusion.
Components of Medical History
- Database: Demographics and initial findings.
- Chief complaint (CC): Reason for visit.
- Past Medical History (PH): Summary of previous health issues and treatments.
- Family History (FH): Health details of immediate family members.
- Social History (SH): Lifestyle factors including diet, hobbies, and substance use.
- Systems Review (SR): Comprehensive examination of body systems, progressing from head to toe.
Stages of Patient Interview
- Initiation: Introduction, verification of identity, and clarification of purpose.
- Body: Exploration of patient's healthcare needs and concerns using therapeutic communication.
- Closing: Summary of the visit, confirmation of expectations, and encouraging patient input.
Therapeutic Nonverbal Behaviors
- Leaning in: Shows interest in patient’s health history.
- Facing the patient: Maintains comfort and sensitivity.
- Eye contact: Essential for effective therapeutic communication.
- Open posture: Avoids crossing arms/legs to demonstrate engagement.
Question Types
- Open-ended Questions: Encourage detailed patient responses (e.g., "How have you been feeling?").
- Closed-ended Questions: Elicit specific responses (e.g., "Do you have a headache?").
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Description
This quiz explores key concepts in patient assessment, including chief complaints, final diagnoses, and differential diagnosis. It also covers vital communication skills such as cognitive understanding and building rapport, as well as creating a comfortable environment for patient interactions. Enhance your knowledge of effective patient assessment techniques.
