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Glossary of Interviewing, Health History, Physical Exam

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Interviewing is a converstation...
with a purpose.
Two types of an interview are____________ health history and _____________ oriented history.
Comprehensive & Problem
Things to consider when getting ready for the interview...
self reflection and awareness, review the patient record, set goals, environment.
To establish rapport in an interview always...
look at patient, assure privacy, acknowledge visitors, use appropriate titles.
What are you always thinking about during every step from the very beginning of the interview?
Differential diagnosis.
Techniques to use in interview include...
transitional statements, summarization, reassurance, validation, echoing, non-verbals, adaptave questioning, directive questioning from general to specific
The Health History helps you do what things?
Focus the patient assessment, determines next steps, guides physical exam and additional testing.
Health History Components include: Identification Data, Chief Complaint, Source and Reliability and...
Present Health Status, History of Present Illness, Past Medical History, Medications, Allergies,
Health Habits,
Social and Family History, ROS.
Review of Systems
Top
Head-Neck, HEENT- or eyes, ears, nose, sinueses, mouth, teeth, throat and pharynx.
Review of Systems
Middle
Breasts, Respiratory, cardiovascular
Review of Systems
Bottom
GI,GU
Review of Systems, General
Musculoskeletal
Peripheral Vascular
Skin
Neurologic
Endocrine
Psychiatric
Hematologic
Constitutional
Physical Exam's two key points are to________& procede from ____to ___, Utilizing the four techniques of ______,_____,____, & _____.
minimize position changes,
head to toe.

Inspection, Palpation, Percussion, Auscultation
Ballottement is?
Palpation of area while moving from one quadrant to another keeping contact on skin surface. Can be deep or light pressure.
What is 90% of the diagnosis?
The History.

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