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SWC W1 Vitals Heep

Western Clinical Sciences, SOAP and VItals, Heep, Bastyr

What does SOAP stand for?: S:// Subjective: Interview/Health History O:// Objective: Physical Exam A:// Assessment: Differential Diagnoses, Working Diagnosis P:// Plan: Today’s treatment, case management
What do you include for Subjective Health History? Date (& time) Time of visit should be documented in urgent/emergent situations Identifying Data age, gender, occupation, marital status… Source of History Patient, family member, friend Source of referral network, reports Chief Complaint/Present
Describe Chief Complaint: One or more symptoms or concerns causing the patient to seek care
Do you make a diagnosis during chief complaint? Do not make a diagnosis here! Use patient’s own words. Seen in chart as “CC”
Describe Seven Attributes: Also known as “history of present illness (HPI)” Amplifies chief complaint Location Quality Quantity/severity Timing: Onset, duration, frequency Aggravation/Alleviation Setting Associated Symptoms or OLD CART / OPQRST
Describe OLDCART: OLD CART: onset, location, duration, character, aggravating/alleviating factors, radiation, timing
Describe OPQRST :OPQRST: onset, palliating/provoking factors, quality, radiation,
When do you review the Medications and supplements list? Medications and supplements list reviewed every visit. If they bring in a list, review it with patient, sign and date it, and put in chart with the visit
What do you include with past medical history? Childhood illnesses Surgeries Hospitalizations Immunization Adult illness
Describe Adult Illnesses: Medical – medical conditions past and present Surgical – include dates OB/GYN Psychiatric
What constitutes Family History? Cause of death of family members Focus on specific illnesses in the family such as: DM HTN CVD
Describe Personal and Social History: Personal and Social history Education, Employment, hobbies Relationships, social support Exercise, diet
Describe Objective: Objective= Physical Exam Tongue and Pulse
Describe Assessment: Assessment= Diagnosis (Dx) Differential Diagnoses (DDx)
Describe Plan: Plan for treatment and Follow up plan
What must every page include? Every page must include: Name of patient DOB Date of service Practitioner name
Is a SOAP chart a legal document? yes. it is a Legal document
How do you correct mistakes? Strikethrough mistakes only – no erasing, scratching out. Initial any changes!
Do you sign every chart? YES! Sign and date at the end of each chart.
What Vitals do you take? Height Weight HR BP Respiratory Rate Temperature
How do you take Height? Height in cm or inch. Should be measured from back of heel to the highest point of head – back straight against wall. For kids: lie supine on table, mark head and heel, then measure distance between marks.
How do you take Weight? Tare Weight in Kg or lbs Remove heavy shoes and clothing beforehand
Describe BMI? Body mass index (BMI), based on age height and weight, does not take muscle mass into account. Normal: 18.5-24.9 Underweight, < 18.5 Overweight: 25-29 Obese: ≥ 30 --Class 1: 30- 34.9 
--Class 2: 35- 39.9
Extreme obesity: ≥ 40 Bates 10th ed. page 10
What is the formula to calculate BMI: Formula to calculate BMI: Multiply weight (in lbs) by 700 Divide the result by height (in inches) Divide the result by height (in inches) The final number would be the BMI
What two factors are important about Heart Rate? Rate and Rhythm
Describe Rate: Rate = bpm Normals: Adults 60-100 bpm Adult Males: about 72 bpm Adult Females: 76 to 80 bpm Elderly: 50 to 65 bpm Newborns: up to 140 Children: about 90 bpm
Describe different types of heart rhythm: Rhythm: regular, irregular, r-ir, ir-ir.
Where do you measure heart rate? Palpate both sides. Measured at the radial, carotid or femoral
What do you observe with Respiratory Rate? Observe rate, rhythm, depth, effort of breathing Indirect measurement Normal: 12- 18 rpm Even, unlabored, respiratory distress (using accessory respiratory muscles)… 30 secs x 2 = respiratory rate.
Where do you take temperature? Places to take temperature: Oral / Rectal / Axillary / Tympanic membrane
What is average body temperature? Average body temperature is about 98.6º F (or 37º C). Temperature varies from 1 to 2º F (.5 to 1º Celsius) throughout the day. Temperature is usually low in the morning and increases during the day, going up in the late afternoon or evening.
What is the most accurate temperatures from best to worst? Rectal>Oral>Axillary
Define Fever: Fever/Pyrexia; Above Normal body temperature
Define hyperpyrexia: Hyperpyrexia is a fever ≥106º F (41.1º C);
Define Hypothermia: Hypothermia is body temperature ≤ 95º F (35º C) (rectal).
What does the BP reflect? Blood pressure (BP) is the pressure exerted by circulating blood upon the walls of blood vessels, and is one of the principal vital signs.
Define Systolic Blood Pressure: Systolic Blood Pressure is the maximum amount of pressure exerted by the heart on the arteries.
Define Diastolic Blood Pressure: Diastolic Blood Pressure is the minimum amount of blood pressure held in the arteries.
What organs are affected by high BP? Organs with more capillaries are effected first. Eyes: Retinopathy Kidneys: Nephropathy Heart: Cardiomyopathy Brain: Stroke
What is normal blood pressure? <Systolic 120 / diastolic <180
What is prehypertension blood pressure? Systolic 120-139 / diastolic 80-89
What is Stage 1 hypertension? systolic 140-159 / diastolic 90-99
What is Stage 2 hypertension? systolic > 160 / diastolic > 100
What we use to measure BP? Proper blood pressure cuff (Sphygmomanometer) Stethoscope
Where do we measure it? Brachial artery and Popliteal artery
How do we measure it? Listen to Korotkoff sounds (turbulent and laminar flow) Use the bell of your stethoscope
Describe Orthostatic hypotension Hypotension of blood pressure when a person stands up. BP and HR measured after sitting/supine for 10 minutes, then within 2 minutes of standing
What is normal Orthostatic blood pressure? Normal orthostatic pressure shows no change or slight drop in systolic, slight increase in diastolic
What bp shows Orthostatic Hypotension? Sys drops ≥ 20 mm Hg or Dias drops ≥ 10 mm Hg
Describe accompanied symptoms of orthostatic hypotension: Accompanied symptoms: dizziness, faintness or lightheadedness which appear only on standing, and which are caused by low blood pressure
Causes of Orthostatic Hypotension} Cardiogenic factors Low Blood volume Adrenal insufficiency Neurogenic
Describe Cardiogenic factors of Orthostatic Hypotension Cardiogenic factors: not able to increase heart rate.
Describe Low Blood Volume factors of Orthostatic Hypotension Low Blood volume: (anemia, dehydration)
Describe Adrenal insufficiency factors of Orthostatic Hypotension Adrenal insufficiency: (adrenal glands not able to produce chemicals necessary to increase heart rate and blood pressure.)
Describe Neurogenic factors of Orthostatic Hypotension Neurogenic: (inability of the nervous system to signal change in BP, Parkinson’s, Diabetes)
Created by: bastyr41