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1. Comprehensive *Chief Complaint
Adult *Hx of present illness
Assessment *Past medical
Sequence Hx *Past
surgical Hx
*Family Hx
*Social Hx
*Allergies
*Medications
*Review of Symptoms of System
*Physical Exam
*Assessment Steps
*Tx Plan
2. Objective Data what the health professional observes by inspecting,
palpating, percussing, and auscultating during the
physical examination
what the person says about himself or herself during
3. Subjective Data
history taking
4. Normal Findings findings that are within range
5. Abnormal findings that are outside of normal limits
Findings
The ability of a test to measure what it is intended to
6. Validity
measure
,7. Sensitivity indicates how likely it is to detect a condition when it
is actually present in a patient. A test with low
____________ can be thought of as being too cautious in
finding a positive result, meaning it will err on the side
of failing to identify a disease in a sick person.
8. Specificity the percentage of true negatives out of all subjects
who do not have a disease or condition. In other
words, it is the ability of the test or instrument to
obtain normal range or negative results for a person
who does not have a disease.
, 9. History Taking A step within the patient assessment
process that provides detail about the patient's chief
complaint and an account of the patient's signs and
symptoms.
*Ask open-ended questions and listen carefully to the
patient's story.
*Craft a thorough and systematic sequence to history
taking and physical examination.
*Keep an open mind toward both the patient and the
clinical data.
*Always include "the worst-case scenario" in your list
of possible explanations of the patient's problem,
and make sure it can be safely eliminated.
*Analyze any mistakes in data collection or interpretation.
*Confer with colleagues and review the pertinent
clinical literature to clarify uncertainties.
*Apply the principles of evaluating clinical evidence to
patient information and testing.
10. Psychopathology scientific study of psychological disorders
11. Pathophysiology the study of how disease processes affect the function
of the body
12. Interviewing - Se- The key to a thorough and accurate physical
examination is developing a systematic quencing sequence of
examination.
13. Order of Cardinal Inspection, palpation, percussion, and auscultation