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healthy history, interviewing process

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