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Foundations 607

History & physical

QuestionAnswer
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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