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health history
healthy history, interviewing process
| Term | Definition |
|---|---|
| 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
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