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Advanced Health Assessment FOR REVISION USE
comprehensive and latest
1.What is the name of the format commonly used to organize data ob- tained during the history and physical examination?: Problem-Oriented Medical Record 2.What are the components of a SOAP note?: S = subjective O = objective A = assessment P = plan 3.In which section of a SOAP note does the following information belong: Patient's heart rate is 72: Objective 4.In which section of a SOAP note does the following information belong: Patient's pain is not well controlled: Subjective 5.In which section of a SOAP note does the following information belong: Put patient on heparin for DVT prophylaxis: Plan 6.In which section of a SOAP note does the following information belong: Patient didn't sleep well last night: Subjective 7.In which section of a SOAP note does the following information belong: Patient's breath sounds are clear: Objective 8.What is an example of a well formatted assessment/plan for a patient who come to your office with high cholesterol and a UTI?: 1. Hyperlipidemia
- On 7/8/18 total cholesterol 275
- Continue on atorvastatin 10 mg PO QD
- Counsel on healthy diet and exercise
- Recheck lipid panel in 3 months
2 / 77 2.Uncomplicated cystitis
- Today urine analysis positive for ketones, nitrites, and leukocyte esterase
- Pt experiencing burning with urination x2days
- Start on ciproflaxacin 250 mg PO Q12H x 3 days
- Follow up in 1 week
4 / 77 history?": Childhood illnesses Adult illnesses (medical, surgical, OB, psychiatric) Health maintenance (immunizations, screenings, safety) 18.What are the major components of the "social history?": Education Family
5 / 77 Personal interests Lifestyle 19.What is the best way to document a chief complaint?: In the patient's own words. Ex: "pounding headache for 2 days"
- What is the most important part when documenting a family tree diagram?- : A key 21.What does it mean if a test is sensitive versus specific?: Sensitivity = "SnNout" sensitivity rules out Specificity = "SpPin" specificity rules in 22.What is patient centered interviewing?: Following the patient's lead to un- derstand their thoughts, ideas, concerns, and requests, without adding additional information from the professional's perspective. 23.What is symptom-focused interviewing?: The clinician takes charge of the interview to meet his or her need to acquire details and data in order to identify the disease. 24.What is the difference between disease and illness?: Disease = the expla- nation that the clinician brings to the symptoms Illness = the way the patient experiences all aspects of the disease 25.What are the eight attributes you should know for every symptom? What is a good mnemonic that can help you remember them?: OLD CARTS: O = Onset L = Location D = Duration C = Character A = Aggravating/alleviating factors R = Radiation T = Timing S = Severity
7 / 77 Heat Colo r Size Nipple discharge Location Consistency Shape Textur e Mobilit y 28.Where are the palpebral fissures?: The space between the eyelids 29.Where are the nasolabial folds? What are the useful for?: The skin folds that run from the side of the nose to the corner of the mouth. Helpful for determining facial symmetry. 30.What cranial nerves innervate the facial muscles?: V and VII
- 42 y/o female presents to your office for a well visit. She tells you that her sister was just diagnosed with a "thyroid problem" and she wants to know if she could have it to. What questions do you want to ask her to develop her history of present illness?: Neck swelling? Changes in hair, skin, nails? Changes in mood or emotional stability? Palpitations? Changes in mensuration? Changes in bowel habits? Changes in temperature preference? 32.What parts of the face are ideal for checking symmetry of facial features?- : Nasolabial folds Palpebral fissures 33.Where is the temporal artery located?: Between the top of the ear and the eye.
8 / 77 34.What is it called when you percuss the masseter muscle on the side of the face and it twitches? When would you test this?: Chvostek sign When checking for hypocalcemia
- What is a bruit? What does it sound like?: A "whooshing" over a vessel formed by turbulent flow of blood through a partially obstructed vessel. 36.How does the skin contribute to blood pressure regulation?: Through con- striction of skin blood vessels. 37.Your four year old patient presents with an intracranial bruit. What is your course of action?: Nothing, that is common
10 / 77 inspiration. What is this called? What is it indicative of?: Tracheal tugging Indicative of an aortic aneurysm 49.What is the anatomy of the thyroid?:
there are kull. What 11 / 77 50.How do you preform a thyroid exam?: First inspect for size, shape, nodules, enlargement, asymmetry Watch patient swallow Stand behind patient and palpate lobes with the tips of your fingers as they swallow Displace the trachea to the right and to the left and feel the lobes of the thyroid If enlarged, auscultate for bruits 51.What are the two major autoimmune thyroid disorders?: Graves - hyperthy- roid Hashimoto - hypothyroid 52.Thyroglossal duct versus branchial cleft cysts?: Thyroglossal - anterior neck by the thyroid gland Branchial - lateral neck 53.Describe fetal thyroid functioning. What does a large thyroid in a pregnant woman usually indicate?: The fetal thyroid doesn't become functional until the second trimester so the mother supplies the thyroid hormone. An enlarged thyroid means that mom probably isn't getting enough iodine 54.What is choasma?: Also called melasma - dark discolored patches. A "mask of pregnancy." 55.When should the fontanels close?: Posterior - 1-2 months Anterior - 9-18 months 56.Your newborn patient presents with a neural tube defect where protrusions of the brain and membranes through openings in the s is this?: Encephalocele
13 / 77 Terminal = coarse, thicker, pigmented hair 68.What are hair cells formed by?: Epidermal cells which invaginate into the dermal layers 69.What are the parts of the nail?:
14 / 77 70.What is the nail formed by?: Epidermal cells get converted to hard plates of keratin 71.What systemic problems do you want to ask about when interviewing a patient with a skin/hair/nails complaint?: Thyroid of liver disorder Autoimmune diseases Malnutrition Skin disorders Congenital anomalies 72.What do you want to know about a patient's family who presents with a skin/hair/nail problem?: Dermatologic diseases Allergic diseases like asthma Hair loss of coloration patterns 73.What eight components must be observed and documented when you are performing a skin exam?: 1. color 2.vascularity 3.temperature 4.texture 5.turgor 6.mobility 7.moisture 8.lesions 74.What is the Woods Lamp used for?: It uses fluorescent light to detect bacterial or fungal skin infections, detect pigment disorders, or determine corneal abrasion 75.How do you determine turgor and mobility during your skin exam?: Pinch resilient skin 76.How should you be testing temperature on your skin exam?: Using the dorsal surface of your hands/finger, test symmetrically 77.How do you document "normal" skin texture?: "Smooth, soft, and even" 78.What parts of the body are absent of eccrine glands?: Lips,
16 / 77 81.Define primary versus secondary skin lesions.: Primary - initial spontaneous manifestations of a pathologic process Secondary - result from later evolution or external trauma to a primary lesion 82.What are the major characteristic you should be examining/documenting for a skin lesion?: Size Shape Color Textur e Elevation/ Depression Attachment Exudates Configuration Location/distributi on 83.In what ways can a skin lesion be attached to the base?: With a stalk (pedunculated) Without a stalk (sessile) 84.What is a arciform configured skin lesion?: Bow-shaped 85.Macule: flat, colored spot on the skin 86.Papule: small, solid, raised lesion on surface of the skin 87.Nodule: solid, raised clump of skin cells 88.Patch: a flat, discolored area on the skin larger than 1 cm
the surface of 17 / 77 89.Plaque: a solid mass greater than 1 cm in diameter and limited to the skin 90.Tumor: mass of rapidly dividing cells that can damage surrounding tissue
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- Furuncle versus carbuncle?: Infectious boil usually filled with staph aureus that originates in the hair follicle. Carbuncle is bigger involving more hair follicles.
- Herpes simplex versus herpes zoster?: Simplex is genital or oral warts Zoster is the shingles rash
- Name the fungal infection based on the location: 1. Athlete's foot 2. Jock itch 3. Ringworm (body) 4. Ringworm (scalp) 5. Nails: 1. Tinea pedis 2.Tinea cruris 3.Tinea corporis 4.Tinea capitis 5.Onychomycosis
- Your 6 y/o male patient presents with a itchy rash on his hands and feet. His mom tells you he came home from school one day with the itching. On physical exam you see a linear bites between his fingers and toes. What is your diagnosis? Treatment?: Scabies Treat with permethrin, kwell, or lindane
- What is the medical term for lice?: Pediculosis
- Your patient presents with eczema. What other two disease processes is he at increased risk for? What is this triad called?: Atopy - eczema, asthma, and allergies
- What is the medical term for eczema?: Atopic dermatitis
- What surfaces are normally affected by eczema/atopic dermatitis?: Flex- ural surfaces
- Cherry angioma:
tion, such n exam on an oration in 20 / 77
- What is lichenification of the skin?: Thickening from chronic irrita as eczema
- 4 y/o male presents to your office with a rash above the lips and round the nose. Mom tells you it used to be a bunch of little "boils" but now it looks to you as if it crusted over like a honey-colored plaque. What is the likely diagnosis? What bacteria is likely the source?: Impetigo Staph aureus or group A strep
- What widespread macular papular rash is caused by a type IV hyper- sensitivity reaction associated with medications like penicillins, sulfonamids, barbituates, salicylates, and some infectious processes? What is a severe and life threatening form?: Erythema multiforme Steven-Johnson Syndrome (and Toxic Epidermal Necrolysis)
- You are performing a skin exam on a patient with rheumatoid arthritis.You notice an erythematous, sharply demarcated rash with silvery white scales on the back of both his elbows. He tells you that he's seen the rash before, it comes and goes, and he's noticed it on his scalp before too. What is this?: Psoriasis
- What do you want to look for when you are preforming a ski obese, diabetic, patient?: Acanthosis nigrans - dark, velvety discol body folds and creases
- What are the three major types of skin cancer?: 1. Basal cell carcinoma 2.Squamous cell carcinoma 3.Melanoma
- Your patient presents to your office with pearly white, non-healing lesion on his nose. He is a landscaper. What is the likely diagnosis? What is the prognosis?: Basal cell carcinoma Good prognosis, most common type of skin cancer and very rarely metastasizes
