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Foundations 607
History & physical
| Question | Answer |
|---|---|
| what is SOAP? and what do the different parts consist of? | Subjective: -chief complaint -history of present illness -MIIMASH -family history -SHORES -review of systems Objective: -vital signs -head to toe physical exam Assessment Plan |
| Define chief complaint. | reason for seeking care, in pt's own words (ie i have a sore throat) |
| define history of present illness (HPI), what mnemonic is used? | OLDCARTS = HPI Onset Location Duration Character Associated/Aggravating factors Relieving factors Temporal factors Severity of symptoms |
| define MIIMASH. | it is Past Medical History (PMH) stands for: Medical Illnesses Injuries Immunizations Medications Allergies Surgeries Hospitalizations |
| define family history. | family history of disease, 1st & 2nd degree most important |
| what is a 1st degree of relationship vs 2nd degree? | 1st- shares 1/2 DNA (parent, sibling, or child) 2nd- share 1/4 DNA (uncle/aunt, grandparent, niece/nephew, grandchild, or half-sibling) |
| define SHORES | social history Safety of relationships Habits: tobacco, alcohol, drugs, diet, exercise, sleep (not judging) Occupation Religion Environment Sexual history (make sure situation appropriate |
| what is the review of systems(ROS)? | in full history, review of each body system to ensure completeness |
| what are the different parts of the ROS? | general head eyes ears nose/sinuses mouth/throat/neck cardiac respiratory GI urinary breasts female skin vascular MSK neuro heme endocrine psychiatric |
| when should a complete history be taken vs a focused? | full given to new pt's & focused given either to returning pt's or if there is a risk to life & limb (trauma, acute illness) |
| what does a focused history & physical (H&P) do? | concentrates on presenting problem and/or most urgent need, SOAP note can be used for full & focused |
| what are the cardinal principles of the physical exam (PE)? | inspection auscultation percussion palpation |
| describe inspection | seeking physical signs by observation. general & localized, depends on knowledge of DO, most productive |
| describe auscultation | listening w/and w/o stethoscope. pt's voice, breathing, coughing. w/stethoscope: heart, vessel, lung/breath, bowel sounds |
| describe percussion | surface of body is struck to emit sounds varying in intensity according to density of underlying tissue |
| why is percussion used? | to locate lung bases, ascites (fluid in peritoneal cavity), map out organ size.. can be almost as effective as a sonigram |
| describe palpation and what can be evaluated with it. | use of tactile senses of fingertips: feel for tenderness, texture, temperature, tone, masses, etc.. |
| how can you use your smell to examine pt? | smell their breath (acetone, alcohol, infection), sputum (foul smell may mean abscess), vomitus (fecal odor), urine (ammonia smell may indicate fermentation) |
| give an overview of the physical exam | divided by system, adjust for pt position (don't make pt sit, stand, lie down constantly), discuss findings as you go, reinforce good behavior |
| describe physical exam when pt is seated. | general appearance vital signs skin, hair, nails HEENT extremities part of neurological & MSK exam |
| what is examined when pt is seated and exposed? | thorax and breasts heart lungs part of structural and msk exam |
| what is examined when pt is supine? | vessels, pulses precordium & supine cardiac exam abdomen parts of msk external genitalia |
| what is examined when pt is standing? | spine body type parts of msk & neurologic exam hernia/male genital rectal |
| what is the assessment? | DDx, interpretation of data from H&P to decide what's wrong |
| what is the plan? (in SOAP note) | treatment: use of diagnostic resources, therapeutic procedures, referrals, pt education, f/u plan |
Created by:
mike7
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