Subjective Section of SOAP data
Chief complaint
History of present illness
Past medical history
Medications
Allergies
Last menstrual period for women
Family and social history
Nutritional assessment
Review of systems
Objective SOAP data
Data and information obtained by the examiner with his eyes, ears, and hands
Laboratory findings and diagnostic test results obtained at the time of the examination or immediately afterwards
Comprehensive history and PE
Patient presents for an annual physical examination or is a new patient
Focused hx and PE
Focused, or episodic, health history and physical examination
Patient is presenting to the healthcare provider for a specific problem
Components of PMH
Previous or current illnesses
Hospitalizations/surgeries
Injuries
Immunizations
Medications
Allergies
Transfusions/transfusion reactions
Results of any screening examinations
Documentation strategies to avoid legal problems
What was taught or explained
To whom it was told
If the patient/family stated they understood the information presented
The format (written and/or verbal instructions)
PE Face and head
Inspect skin characteristics
Inspect and palpate scalp and hair
Inspect face for appearance, expression, symmetry of structure and features, and movements
Ask the patient to raise his eyebrows, frown, smile, and open eyes against resistance
Evaluate sensa
PE Neck
Palpate the lymph nodes in the neck area
Palpate carotid pulses one at a time
Determine the position of the trachea
Palpate thyroid
Auscultate carotid arteries and thyroid for bruits
PE posterior chest and back
Inspect skin for lesions
Note thoracic configuration
Palpate the spine
Percuss the kidneys
Assess the lungs
PE lungs
Evaluate thoracic expansion
Palpate tactile fremitus
Percuss the chest
Determine diaphragmatic excursion
Auscultate the posterior thoracic cage; note breath sounds
Functional assessment of elderly pt
Determine the ability of the elderly to deal with the daily demands of life
Establish a management plan for the elderly patient
Decide on the level of instruction to provide
Determine the ability of the patient to comply with the management plan
Ability t
Functions or cerebral cortex
General movement
Visceral functions
Perception
Behavior
Integration of these functions
Temporal lobe
Perception and interpretation of sounds
Comprehension of written and spoken language (Wernicke speech area)
Integration of sensations, behavior, and personality
Functions of frontal lobe
Voluntary skeletal movement and speech formation (Broca's area)
Emotions, affect, drive, and awareness of self
parietal lobe
Processing of sensory data (visual, tactile, gustatory, olfactory, auditory)
Comprehension of written language
Proprioception
occipital lobe
Processing vision
Providing interpretation of visual input
limbic system
Hippocampus
Memory
Amygdala
Confusion, fear, anger
Cingulate gyrus
Attentive behavior and sexual activity
Septal area, medial forebrain bundle
Pleasure
Hypothalamus
Connections to ANS, limbic system, and endocrine system
Common CC r/t mental health d/o
Fatigue / Sleep disturbances
Mood/emotional alterations
Weight loss or gain
Cognitive difficulties
Personality changes
Delusions or hallucinations
Screening for depression, what does it entail, meaning of scores
Patient health questionnaire
-little interest in doing things
-feeling down, depressed and hopeless
Score of 3 or more positive
DSM 5 dx for depression
Use SIGECAPS
4 symptoms plus either depressed mood or anhedonia (absence of pleasure) for at least 2 weeks to diagnose major depression
2 symptoms plus depressed mood for 2 years to diagnoses dysthymia
Acronym for assessment of depression
SIGECAPS
Sleep: How well do you sleep?
Interest: How is your interest in hobbies?
Guilt: Do you feel very guilty about anything?
Energy: Do you feel like you have enough energy to do things you like and need?
Concentration: How is your concentration to st
risk factors/signs of suicide
History of suicide attempts and depression
Family history of suicide
Acute overuse of alcohol or other CNS depressants
Severe hopelessness and/or helplessness
Attraction to death
Losses or separation
Serious medical condition (perceived or real)
Age, such
dx bipolar
Manic episode includes at least 1 week of irritable or elevated mood plus 3 of the 7 DIGFAST
Generalized anxiety disorder
Excessive anxiety and worry about a number of topics on most days for at least 6 months
Difficulty controlling worry
Anxiety and worry associated with three or more of following on most days for at least 6 months:
Restless, feeling tense and "keyed up"
Be
acronym for bipolar
symptoms for at least 1 week
Distractibility - inability to concentrate on specific tasks and work projects
Indiscretion - over-involvement in pleasurable activities (money spending?)
Grandiosity - unfounded claims of superiority and authority
Flight of i
Acronym for domestic abuse
S: Stress in relationship, is it safe with your partner?
A: What happens when your partner is angry? Are you afraid at times? Have you been abused?
F: What financial resources do you need? Is a firearm present at home? What do friends and family know of y
bipolar screening
Ask: Are you ever so happy or full of energy that friends or family tell you that you talk too fast or are hyperactive?
Often overlooked, especially when patient presents in depressed mood phase; prescription for antidepressant drug alone without a mood s
Dermis composition
Composed of a thin upper layer, the papillary dermis, and a thicker lower layer, the reticular dermis
Levels of consciousness
Alert - awake and spontaneous
Confused - decreased attention span and memory; answers questions inappropriately
Lethargy - drowsy; falls asleep easily; when aroused answers appropriately
Delirium - confused with disordered perceptions, decreased attention
functions of the skin
Preventing fluid loss
Barrier to invading organisms
Relaying sensations (touch, temperature, pain)
Regulating body temperature and blood pressure
Synthesizing vitamin D
Excreting sweat, urea, and lactic acid
epidermis
Outermost, avascular layer of the skin composed of four to five layers
Subcutaneous layer
Composed of fat and connective tissues
eccrine glands
regulate body temperature through water secretion and evaporation
appocrine glands
release clear and odorless secretions under cholinergic and hormonal control
Skin cancer risk factors
Men over age 50
Blue or green eyes
Blonde or red hair
Family history of skin cancer
Personal history of skin cancer
Continuous exposure to sun at work or play
Light skin that burns, freckles, or easily gets red
Certain types and larger number of moles
macule
< 1 cm in diameter, flat, nonpalpable, circumscribed, discolored
Patch
>1 cm in diameter, flat, nonpalpable, irregular shape, discolored
papule
papule
<1 cm in diameter, raised, palpable, firm
nodule
>1 cm, raised, solid
plaque
>1 cm, raised, superficial flat topped, rough
tumor
large nodule
vesicle
<1 cm superficially raised, filled with serous fluid
macule
papule
patch
nodule
plaque
tumor
vesicle
bulla
>1 cm vesicle
bulla
pustule
raised, superficial, filled with cloudy, purulent fluid
pustule
wheal
raised, irregular area of edema, solid, transient variable size
wheal
...
wheal
cyst
raised, circumscribed, encapsulated with a wall and lumen and filled with liquid or semisolid
cyst
scale
irregular formation of exfoliated, keratinized cells, irregular shape and size
Scale skin lesion
crust
dried serum, blood or exudate, slightly elevated
crust skin lesion
lichenification
thickened epidermis with accentuated skin lines caused by rubbing
Lichenification
scar
thin or thick fibrous tissue, following dermal injury
fissure
linear break in skin through epidermis and dermis
excorification
hollowed-out area of all or portion of epidermis with depressed appearance
Excoriation
erosion
localized loss of epidermis, heals without scaring
erosion lesion
ulcer
loss of epidermis and dermis, variations in size
atrophy
depression resulting from loss of epidermis and/or dermis
burrow
: a narrow, elevated channel produced by a parasite
Telangiectasia:
superficial dilated blood vessel
petichiae
<1.0 cm circumscribed deposit of blood
purpura
>1.0 cm circumscribed deposit of blood
Allergic contact dermatitis
Vesicles, edema, extreme pruritis
Location: exposure site usually hands, forearms, face, tops of feet
Atopic dermatitis
Ooozing, severe pruritis, redness, scale Flexor in children, extensor in adults
Nummular Dermatitis
Location: extremities and trunk
sharply demarcated annular plaques with ezematous inflammation
Stasis dermatitis
Ezematous rash with fissuring, chronic venous stasis, discoloration
Location: legs with varicosities dilated veins and edema
Diaper area dermatitis
Red base with satelite pustules fringe base with moist scale
Location: infant buttocks/gentials, areas in contact with diaper
Erythema nodosum
often bilateral, poorly defined, red, nodule-like swelling over shins
cysts
circumscribed lesion with wall and lumen that is filled with fluid or solid
Dermatofibroma
solitary, dome-shaped, fixed, pink to brown; lateral pressure causes dimpling
grannuloma annulare
asymptomatic, flesh-colored or red papules that progress to annular ring without scale
grannuloma annulare
dermatofibroma
Acne
comedones and inflammatory papules, pustules, and nodules
boils
red, hard, tender, then fluctuant (moves when pushed)
hidradenitis
inflammatory subcutaneous nodules, perforate, drain, and form sinus with healing
Pyogenic granuloma
friable vascular papule arising at site of previous trauma
Hyperplasia- verruca 1) Location 2)PE findings
elbows hands and knees epidermal proliferation single multiple or confluent
Malignant diseases of the skin
Basal cell carcinoma
Squamous cell carcinoma
Melanoma
Paget's disease
Cutaneous T-cell lymphoma
Kaposi's sarcoma
Metastasis to the skin
five functions of interview and health hx
Initial bond between provider and patient
Foundation for subsequent clinical decision-making
Legal record of subjective and objective data
Documentation required for third-party reimbursement
Element in the peer review process for evaluation of clinical p
Describe subjective data
Information provided during the health history based on patient's perception
Less quantifiable and open to multiple interpretations
Describe objective data
Measurable and verifiable
E.g., test results and physical examination findings
Characteristics of sound provider patient relationship
Autonomy and self-determination of patient
Knowledge as the key to patient empowerment
Ongoing partnership built on mutual trust and respect
Keys to providing culturally competent care
Obtaining knowledge of the beliefs, values, and practices of the patient populations being served
Using cross-cultural theoretical models
Applying relevant research findings
Valuing ethnically diverse patients as teachers of their culture
Reflecting on th
Barriers to sound patient-provider relationship
Initial encounters with patients who are angry or hostile
Two Patient Syndrome
Adverse clinical phenomena
Unexpected fetal loss
Chronic pain that is unresponsive to treatment
Terminal diagnosis
Elements of comprehensive Health hx
Patient identifiers
Reliability
Chief complaint (CC)
History of present illness (HPI)
Past medical history (PMI)
Family history (FH)
Social history (SH)
Review of systems (ROS)
elements of a focused health hx
Identifying data
Chief complaint
History of present illness
Data from patient's past medical, family, and social history pertinent to the chief complaint
Problem-oriented review of systems
CLIENT OUTCOMES Pneumonic
includes ethnocultural considerations into data gathering
Character of symptoms
Location
Impact of symptoms on life
Expectation (of care giving process)
Neglect or abuse
Timing (onset,duration, frequency)
Other symptoms
Understanding/beliefs about cx of i
Describe percussion
establishes qualities such as location, size, density, and reflex. Can be direct or indirect
Direct:use finger/hand to directly strike area
Indirect: one hand on area, second hand strikes first hand
Sounds described as tympnic, hyper-resonant, resonant, d
PE considerations for pregnant pts
empty bladder prior to PE
side-laying position supine only if necessary
PE considerations for neonates
look carefully before touching
begin with head, fontanels, extremities, abdomen, rest
invasive procedures always last
PE considerations for Peds
May be unpredictable, consider developmental levels
Allow parent on exam table with pt
Establish relaxed environment, allow pt.s to touch equipment
PE considerations for geriatric pts
May have difficulty assuming positions
Use patience, reaction and senses may take longer
don't forget functional assessment
lobes of brain and functions
Frontal lobe: voluntary musculoskeletal movement, speech formation (Broca's area), areas of emotion, drive, self awareness
Parietal lobe: Sensory data processing, proprioception, comprehensin of written language
Temporal Lobe: Wernicke speech area, integr
Common chief complaints related to mental health disorders
sleep, mood, emotional disturbances, weight fluctuation, cognitive difficulties, personality changes, delusions, hallucinations
functions of integumentary system
preventing fluid loss
provides barrier to organisms
relays sensations (pain/temp)
regulated body temp and pain
synthezises vitamin D
excretes sweat, urea, and lactic acid
Where are keratinocytes found?
in the basal layer (stratum germinativum) of the epithelium
Layers of the epidermis
stratum corneum, stratum lucidum, stratum granulosum, stratum spinosum, stratum basale
What does the structure of hair include?
follicle, shaft, sebaceous gland, and arrector pili muscle
Describe and give and example of a lesion that is nummular
Coin-shaped, nummlar ezema
Describe and give and example of a lesion that is annular
cirular or ring shaped, tinea corporis
Describe and give and example of a lesion that is linear
line formation, coupe de sabre
Describe and give and example of a lesion that is arciform
arch-shaped, drug reaction
Describe and give and example of a lesion that is grouped
occuring close together, herpes zoster
Describe and give and example of a lesion that is gyrate
convoluted shape, creeping eruption
Define seborrhea
Dandruff, found on head and trunk sites of sebaceous gland rich skin
Define pityriasis rosea
papulosquamous disease, follows natural skin lines of trunk, 3-4 cm oval at onset with numerous smaller plaques
Impetigo
on face, neck, extremities. Thin, erythematous bullous vesicles or pustules that heal with honey colored crust
herpes zoster
dermatomal distribution of thoracic, cranial, trigeminal, lumbar, and sacral nerves. Erythematous papules and plaques followed by erosive blisters
dyshidrosis
symmetrical on palms, fingers, toes, soles. Sudden eruption of highly pruritic that are deep-seeded with clear fluid followed by ring of scale and peeling
erythema multiform minor
surfaces of extremities and oral mucosa. target lesions with well defined border and three zones of color
erythema multiform major
widespread trunk and mucosa. raised, flat, macules and papules two color zones with poorly defined border extensive eruption epidermal detachment and systemic symptoms
List nodules
erythema nodosum, dermatofibroma, granuloma annulare, cysts
List inflammatory disorders of the skin
Acne, boil, hidradenitis, pyogenic granuloma
List hyperplasic lesions of the skin
Verruca, molluscum, corn, epidermal cyst, xanthelasma, skin tag
List benign neoplasias
seborrheic kertosis, mole, lipoma, deratofibroma, keliod, hemangioma, neurofibroma
List premalignant diseases of skin
actinic keratosis, keratoacanthoma, dysplasic nevus
list malignant skin conditions
basal cell carcinoma, squamous cell carcinoma, melanoma, pagets, cutaneous T cell lymphoma, kaposi sarcoma, mets to skin
Method to evaluate pigmented lesions
ABCDE
Asymmetry
Border irregularity
Color variegation
Diameter
Elevation or Enlargement
What viral skin infections are caused by HPV?
Verruca Vulgaris (black dots of thrombosed capillaries)
Verruca plantaris (numerous small warts may fuse into mosaic surface)
Verruca Plana(due to trauma, linear or grouped flat topped pustules)
Describe common fungal skin infections
Tinea pedis (fungal toe/foot infection)
Tinea capitis (hair shaft)
Tinea corporis (non-hairy extremities and trunk)
Tinea versicolor (finely scaling hypo&hyperpigmented flat plaques on trunk, neck, arms, shoulders)
cutaneous candidiasis (bright erythema w
Describe skin infestations
pediculosis (shared bedding/clothing)
pubic louse
Ticks (female feeds, engorges, drops off @ 1-2 weeks)
scabies (severe nightime pruritis, highly contagious, cross antigenicity with house dustmites)
List acne subtypes
Acne Mechanica (mechanical pressure over skin)
Steroid Acne (oral steroids)
Drug-induced (steroids, antiepilepytics)
Ace neonatorum (large sebaceous glands stimulated by maternal androgens)
Acne excorie (self manipulation)
acne cosmetica (inflammatory pap
Common benign geriatric skin tumors
seborrheic keratosis (waxy, pebbly, stuck on appearance)
Cherry angioma (smooth firm, red, inc with age)
Skin tag/acrochordon
Venous lake (border of lip/ear, compression collapse lesion)
Sebaceous hyperplasia (face, soft, dome shaped pale yellow with cent
Common chief complaints of eye
Pain
Foreign body sensation
Red eye
Vision loss/change
Sclera
white portion of the eye, muscles insert into sclera
cornea
transparent, smooth tissue that covers pupil and iris; sensory nerves; allows light transmission through lens to retina
Iris
circular disc containing pigment that gives eye color
Pupil
black appearing aperture that allows light to enter the eye
Anterior chamber
filled with aqueous humor (fluid continuously produced by ciliary body)
Lense
refracts and focuses light onto the retina; muscles of iris control pupillary size
Cilliary Body
muscles control thickness of lens (allow near/far focus)
Choroid
tissue between sclera and retina; blood vessels
Retina
rods and cones in retina translate light into electrical impulses; optic nerve carries these to the brain where the image is interpreted
Possible ocular disease assoc with diabetes?
Diabetci retinopathy, vascular d/o
Possible ocular disease assoc with HTN
ocular hemorrhage
Possible ocular disease assoc with HA
Papilledema (increased intracranial pressure)
Glaucoma (inc intraocular pressure)
Possible ocular disease assoc with Nystagmus (congenital)
hydrocephalus, dicephalic tumors, medication toxicity, Arnold-chiari malformation, brain tumor/anomaly
Possible ocular disease assoc with Nystagmus (acquired)
Blindness, multiple sclerosis, peripheral vestibular disease, cerebellar/brain stem disease, drug use
Equipment needed for eye exam
Snellen eye chart or E chart
Hand-held near-vision screener (Rosenbaum or Jaeger)
Cover card (opaque)
Penlight
Ophthalmoscope
Color vision plates�Ishihara or Hardy-Rand-Ritter (optional)
Allen figures
How to test visual aquity
test central vision with Snellen eye chart (tests optic nerve). Position patient 20 feet from chart. Cover one eye with card and read smallest line possible. First number describes distance (20 feet), the second number describes distance at which normal e
what is legal blindness
20/200
How to test extra ocular movements
test 6 cardinal directions of gaze; "follow my finger without moving your head" - make an H
Congenital ptosis (droopy eyelids); can be seen with third nerve palsy and myasthenia gravis
Early pterygium (tissue growth form periphery toward cornea); common develops in response to chronic irritation of the cornea such as wind.
Arcus senilis (white opaque ring around the limbus); common in elderly; sign of hyperlipidemia if patient is under 40.
Hyphema (blood in the anterior chamber) - result of trauma or surgery.
describe the red reflex
by light illuminating the retina
How to examine a corneal reflex
usually done in unconscious patients; lightly touch cornea with wisp of cotton; failure of both eyes to close indicates increased intracranial pressure which impairs CN V (sensory) and CNVII (motor)
When does a fetuses eye form
at 8 weeks gestation
Discuss the visual acuity of an infant
Acuity if 20/200
peripheral vision nearly fully formed at birth
Central vision develops later
Young eyes are more spherical, making vision myopic in pediatric pts
Discuss vision at 2-3 months of age
Begins to have voluntary control over eye muscles
Lacrimal ducts begin carrying tears into nasal meatus
When can an infant distinguish colors?
8 months
Discuss vision at 9 months of age
The eyes are able to perceive a single image, reflecting the eye muscle's ability to coordinate
When is adult visual acuity developed
age 6
What pediatric patients should be referred to an ophthalmologist?
Children with a family history of amblyopia, "lazy-eye," or "crossed eyes"
Children who are developmentally delayed or who have cerebral palsy
amblyopia
Eye exam with peditric pts
Assess red reflux
Assess ocular mobility by having the child follow a brightly colored object or toy
After 6 months of age, perform the cover-uncover test
Begin visual acuity screening after age 3
Assess binocular vision (stereoacuity)
Describe cover/uncover eye exam
patient looks straight at an object; cover one eye with opaque card; assess uncovered eye's position noting any deviation from steady, fixed gaze; remove card and asses uncovered eye for movement (should not move; if moves it is the weaker eye, refer)
Geriatric eye exam considerations
Observe changes in the external structure of the eye
Graying of eyebrows and eyelashes
Loss of tone; decreased elasticity of eyelid muscles
Note corneal reflexes may be decreased or absent
Assess visual acuity for older adults
Perform routine ophthalmosco
Describe functions of the ear
Interpreting and identifying sound
Detecting the direction of sound
Identifying the intensity and time lag between hearing the sound in one ear and then the other ear
Maintaining equilibrium
Describe the anatomy of the ear canal
- part of external ear; about 1 inch long; extends inward, forward and downward after age 3; before age 3 points upward. So when doing an exam, need to straighten the ear canal.
how should one position the ear for an exam for 1)Adults and 2) children
When using otoscope, in older children and adults, straighten ear canal by pulling the pinna upward outward and backward
For children under 3, pull downward, outward, and backward