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stereotype - ✔✔fixed image of any group that denies the potential of originality or
individuality within the group; Phase 1: categorization; phase 2: beliefs are used when
interacting with this person or group
RESPECT model - ✔✔Rapport
Empathy
Support
Partnership
Explanations
Cultural Competence
Trust
ROS - ✔✔review of systems; an inventory of specific body systems designed to
document current or past symptoms; not physical exam
problem list - ✔✔created after subjective and objective data has been organized; all
pertinent data and exam findings, illustrations, lab data, imaging studies, and prior
diagnoses are reviewed to develop problem list in form of running log with: problem
number, date of onset, description of problem, and date problem was resolved
Assessment (diagnosis) - ✔✔develop assessment for each of the problems in problem
list; most severe listed first; must be codable using ICD 10 codes; state whether
improving, worsening, or resolved; include differential diagnoses
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,plan - ✔✔diagnostics to be performed or ordered, therapeutic treatment plan with
rationale, and patient education
Pregnancy: PE & history taking - ✔✔include gravidity/parity, menstrual/OBGYN hx,
and how they are adjusting to pregnancy; include fundal height, fetal HR, pelvic
measurements, and uterine size in physical examinations
Older adults: PE & history taking - ✔✔add community and family support systems,
functional assessment; note skin lesions, baldness/thinning of hair, chest shape
changes, muscle mass/posture change, cognitive function, gait and balance
Tanner Stage - ✔✔puberty changes; a scale of physical development in children and
adolescents that measures development of primary and secondary sex characteristics
When are children considered dependable historians - ✔✔age 7
HEEADSSS - ✔✔Adolescent screening tool;
Home
Education and employment
Eating
Activities
Drugs
Sexuality
Suicide and depression
Safety
PACES - ✔✔adolescent screening tool;
Parents/peers
accidents/alcohol/drugs
Cigarettes
emotional issues
school/sexuality
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, CRAFFT - ✔✔6-item screen for alcohol or drugs in adolescents, 14-18
(C=car, R=relax, A=alone, F=forget, F= family or friends, T= trouble)
Infants: PE & history taking - ✔✔add birth hx, growth trajectory, developmental
milestones, diet (breast fed/formula fed), sleep injury prevention; include head
circumference, fontanels, molding, quality of cry, primitive reflexes, gross and fine
motor development, speech/language, cognitive, social/emotional
CAGE - ✔✔screening for alcoholism; cut down, annoyed, guilty, eye opener
HITS - ✔✔screening tool for domestic violence; (hurt-insult- threaten-scream)
partner violence screen - ✔✔Have you been hit, kicked, punched or otherwise hurt by
someone within the past year?
Do you feel safe in your current relationship?
Is there a partner from a previous relationship who is making you feel unsafe now?
FICA screening - ✔✔spirituality screening (faith/belief/meaning,
importance/influence, community, address/action in care)
5Ps sexual history - ✔✔-Partners
-Pregnancy prevention
-Protection STIs
-Practices
-Past hx STIs
transmission-based precautions - ✔✔second tier/ in addition to standard precautions
airborne: chickenpox, flu, covid, viral meningitis, measles
droplet: flu, covid, meningitis, RSV, rubella, pertussis, strep
contact: MDRO, mono, gonorrhea
pneumatic attachment of otoscope - ✔✔Used to assess the mobility of the Tympanic
Membrane.
diaphragm - ✔✔best transmits high pitched sounds (second heart sound)
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