Advanced Health Assessment
and Diagnostic Reasoning |
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Terms in this set (195)
Subjective Data Things the pt tells you
What your seeing, observing, or
Objective data
examining
The chief Patient's own words
compliant
should use the
____
, -OLDCARTS (onset, location,
duration, characteristics,
History of
aggravating/alleviating, radiation,
present illness
timing, severity)
nomics
-OPQRST (onset, provocation,
quality, radiation, severity, timing)
Concerning -Changes in weight
health history -Fatigue or weakness
findings -Fever, chills, and night sweats
-Rapid or gradual - rapid changes
Concerning over a few days suggest changes
health history in fluid, not tissue
findings: -Weight gain: nutrition vs. medical
changes in causes
weight -Weight loss: medical vs.
psychosocial causes
Concerning Medical vs. psychosocial
health history
findings:
fatigue and
weakness
A sense of weariness or loss of
Fatigue
energy
, A demonstrable loss of muscle
Weakness
muscle power
Concerning -Ask about exposure to illness or
health history any recent travel
findings: fever, -Some medications may cause
chills, and night elevated temperature
sweats
-Nociceptive (somatic)
-Neuropathic
What are the
-Idiopathic
types of pain?
-Psychogenic
-Chronic
-Damage to tissue or viscera but
sensory nerves intact
Nociceptive
-Described as dull, pressing,
(somatic)
pulling, throbbing, boring,
spasmodic, or colicky
-Direct trauma to the peripheral
or central nervous system
Neuropathic -Described as shock like,
stabbing, burning, pins and
needles
, Idiopathic No identifiable etiology
Related to factors that influence
the patient's report of pain
(psychiatric conditions,
Psychogenic
personality and coping style,
cultural norms, social support
systems)
-Not due to cancer or illness
lasting > 3-6 months
-Lasting > 1 month beyond the
ChronicN
course of an illness
-Recurring at intervals over
months or years
All notes -Date of encounter
should start -Patient name (age is also
with the important)
following -Informant and reliability
documentation:
-Subjective
-Objective
SOAP format
-Assessment
-Plan
and Diagnostic Reasoning |
Complete Questions and Correct
Answers | Newest Exam | Verified
Answers | Just Released
Save
Terms in this set (195)
Subjective Data Things the pt tells you
What your seeing, observing, or
Objective data
examining
The chief Patient's own words
compliant
should use the
____
, -OLDCARTS (onset, location,
duration, characteristics,
History of
aggravating/alleviating, radiation,
present illness
timing, severity)
nomics
-OPQRST (onset, provocation,
quality, radiation, severity, timing)
Concerning -Changes in weight
health history -Fatigue or weakness
findings -Fever, chills, and night sweats
-Rapid or gradual - rapid changes
Concerning over a few days suggest changes
health history in fluid, not tissue
findings: -Weight gain: nutrition vs. medical
changes in causes
weight -Weight loss: medical vs.
psychosocial causes
Concerning Medical vs. psychosocial
health history
findings:
fatigue and
weakness
A sense of weariness or loss of
Fatigue
energy
, A demonstrable loss of muscle
Weakness
muscle power
Concerning -Ask about exposure to illness or
health history any recent travel
findings: fever, -Some medications may cause
chills, and night elevated temperature
sweats
-Nociceptive (somatic)
-Neuropathic
What are the
-Idiopathic
types of pain?
-Psychogenic
-Chronic
-Damage to tissue or viscera but
sensory nerves intact
Nociceptive
-Described as dull, pressing,
(somatic)
pulling, throbbing, boring,
spasmodic, or colicky
-Direct trauma to the peripheral
or central nervous system
Neuropathic -Described as shock like,
stabbing, burning, pins and
needles
, Idiopathic No identifiable etiology
Related to factors that influence
the patient's report of pain
(psychiatric conditions,
Psychogenic
personality and coping style,
cultural norms, social support
systems)
-Not due to cancer or illness
lasting > 3-6 months
-Lasting > 1 month beyond the
ChronicN
course of an illness
-Recurring at intervals over
months or years
All notes -Date of encounter
should start -Patient name (age is also
with the important)
following -Informant and reliability
documentation:
-Subjective
-Objective
SOAP format
-Assessment
-Plan
