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Terms in this set (80)
What are the symptoms of intestinal Rushes of high-pitched, tinkling peristalsis,
obstruction? hyperactive bowel sounds, sudden onset of colicky
abdominal pain, vomiting, and obstipation.
What are the key signs of salpingitis Unilateral or bilateral tenderness on palpation in the
during a pelvic examination? lower abdomen, increased bowel sounds, pain with
lateral movement of the cervix and adnexal
palpation, chandelier sign, and tenderness during
menstruation.
What are the symptoms of acute Intermittent cramping, constipation, diarrhea, and a
diverticulitis? palpable mass in the left lower quadrant (LLQ).
What are the symptoms of Colicky pain that may progress to constant severe
ureterolithiasis? pain, lower abdominal pain radiating to the groin,
nausea/vomiting, abdominal distention, chills, fever,
costovertebral angle tenderness, and hematuria.
What characterizes acute nausea and Acute infection, ingestion of toxins, gastrointestinal
vomiting? obstruction or ischemia, new medication, pregnancy,
or head trauma/increased intracranial pressure.
What characterizes chronic nausea Persistence of symptoms for more than 1 month,
and vomiting? suggesting partial mechanical obstruction,
intracranial pathology, dysmotility, metabolic or
endocrine etiology, or psychological disturbance.
, What is the purpose of a To identify or rule out physical causes related to
comprehensive assessment for new patient concerns.
patients?
What is the focus of problem-focused To address specific concerns and assess symptoms
assessments for established patients? related to the body system.
What is the difference between Subjective data is reported by the patient (SELF),
subjective and objective data in while objective data is observed through physical
patient assessments? assessment and labs.
What is the significance of creating a It involves using clinical reasoning to distinguish
differential diagnosis? between two or more conditions that share similar
signs and symptoms.
What are pertinent negatives in Signs and symptoms that are NOT present but would
medical documentation? be expected, which can weaken a diagnosis.
What are pertinent positives in Signs and symptoms that are present and expected,
medical documentation? which support a diagnosis.
What is the first principle of good Ensure clear organization with headings,
documentation regarding indentations, and spacing.
organization?
How should the history of present In chronological order, starting with the current
illness (HPI) be arranged in episode and then providing relevant background
documentation? information.
What should be included in the Supporting evidence for each problem or diagnosis,
assessment section of detailing both positive and negative findings.
documentation?
Why is it important to describe To indicate that potential abnormalities were
pertinent negatives specifically? considered and ruled out, such as absence of injury
or bleeding disorders.