History & physical
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| 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
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| Define chief complaint. | reason for seeking care, in pt's own words (ie i have a sore throat)
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| 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
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| define MIIMASH. | it is Past Medical History (PMH)
stands for:
Medical Illnesses
Injuries
Immunizations
Medications
Allergies
Surgeries
Hospitalizations
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| define family history. | family history of disease, 1st & 2nd degree most important
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| 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)
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| 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
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| what is the review of systems(ROS)? | in full history, review of each body system to ensure completeness
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| 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
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| 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)
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| 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
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| what are the cardinal principles of the physical exam (PE)? | inspection
auscultation
percussion
palpation
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| describe inspection | seeking physical signs by observation. general & localized, depends on knowledge of DO, most productive
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| describe auscultation | listening w/and w/o stethoscope. pt's voice, breathing, coughing. w/stethoscope: heart, vessel, lung/breath, bowel sounds
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| describe percussion | surface of body is struck to emit sounds varying in intensity according to density of underlying tissue
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| 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
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| describe palpation and what can be evaluated with it. | use of tactile senses of fingertips: feel for tenderness, texture, temperature, tone, masses, etc..
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| 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)
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| 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
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| describe physical exam when pt is seated. | general appearance
vital signs
skin, hair, nails
HEENT
extremities
part of neurological & MSK exam
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| what is examined when pt is seated and exposed? | thorax and breasts
heart
lungs
part of structural and msk exam
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| what is examined when pt is supine? | vessels, pulses
precordium & supine cardiac exam
abdomen
parts of msk
external genitalia
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| what is examined when pt is standing? | spine
body type
parts of msk & neurologic exam
hernia/male genital
rectal
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| what is the assessment? | DDx, interpretation of data from H&P to decide what's wrong
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| what is the plan? (in SOAP note) | treatment: use of diagnostic resources, therapeutic procedures, referrals, pt education, f/u plan
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Created by:
mike7
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