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health history

healthy history, interviewing process

TermDefinition
CAGE questionnaire for discussing use of alcohol - cutting down, annoyance by criticism, guilty, eye openers
functional assessment questions concerning ability to take care of one's daily needs that are a part of the review of systems
personal and social history work, marriage, sexual and spiritual experiences, pt's use of alcohol, tobacco, and drugs
review of systems identifies presence or absence of health related issues in each body system
symptom analysis questions specifying the onset, location, duration, intensity, characteristics, and aggravating and alleviating factors
TACE questionnaire for discussing alcohol - how many drinks does it Take to make you feel high, Annoyance by criticism, cutting down, eye openers
CRAFFT screening tool for alcohol and substance abuse for adolescents -
HITS screening tool for domestic violence - Hurt physically, Insult, Threaten, Scream or curse
5 Ps of sexual history Partners, Practices, Protection for STIs, Past history of STIs, Prevention of pregnancy
4 Cs of communication courtesy, comfort, connection, confirmation
confusion inappropriate response to question
lethargy drowsy - falls asleep quickly - once aroused responds appropriately
delirium confusion with disordered perceptions and decreased attention span - marked anxiety with marked motor and sensory excitement - inappropriate reactions to stimuli - acute
stupor arousable for short periods to visual, verbal, or painful stimuli - simple motor or moaning responses to stimuli - slow responses
coma neither awake nor aware - may have decerebrate posturing to painful stimuli
apraxia inability to complete task unrelated to paralysis or lack of grasp - may indicate cerebral disorder
affect emotional response or feeling
analogy figure of speech wherein objects or concepts are compared
anxiety group of disorders with marked apprehension or fear that causes significant interference with personal, social, and occupational functioning
aphasia speech disorder that can be receptive (understanding language) or expressive (speaking language) - may indicate cerebral disorder
broca area associated with speech formation
cerebral cortex part of the brain that houses higher mental functions and is responsible for perception and behavior
cerebrum lobe of the brain primarily responsible for mental status
cognitive pertaining to mental processes of memory, judgement, and reasoning - cognitive impairment is characterized by a loss of memory, confusion, and inappropriate affect
coherence pt's intentions or perceptions should be clearly conveyed to you
comprehension capacity of the mind to understand - demonstrated by an ability to follow simple instructions
concussion alteration in mental status resulting from a blow to the head or neck
dementia chronic, slowly progressive disorder of failing memory, cognitive impairment, behavioral abnormalities, and personality changes that often begins after 60 yo
depression mood disorder in which feelings of sadness, loss, anger, or frustration interfere with everyday life for an extended period of time
dysarthria motor speech disorder defect associated with many conditions of the nervous system such as stroke, inebriation, cerebral palsy, and Parkinson's
dysphonia disorder of voice volume, quality, or pitch
glasgow coma scale coma scale used to assess function of cerebral cortex and brainstem and to quantify consciousness
hallucination sensory experience not due to external stimulus
insults events in the brain such as trauma, infection, or chemical imbalance can damage brain cells that may result in serious permanent dysfunction in mental status
intellectual disability developmental, cognitive, or intellectual deficit with accompanying deficits in adaptive behavior, academic performance, adaptive functioning that begins before 18 yo - previously called mental retardation
judgement ability to reason
limbic referring to system that mediates patterns of behavior that determine survival such as mating, aggression, fear and affection
mania persistently elevated, expansive, euphoric or irritable and agitated mood lasting longer than 1 wk - one phase of the bipolar psychiatric disorder
mini mental state exam brief standardized screening tool used to assess cognitive function and to detect changes over time
parietal lobe of the brain primarily responsible for processing sensory data
schizophrenia severe persistent psychotic syndrome that relapses throughout life
temporal lobe of the brain responsible for perception and interpretation of sounds
wernicke area of temporal lobe that permits comprehension of spoken and written language
Created by: stephanie.gage