Health ass final

SOAP Note

A structured format for medical documentation that includes Subjective, Objective, Assessment, and Plan sections.

OLDCARTS

An acronym used in medical history-taking that stands for Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Treatment, Symptoms.

Focused Exam

An exam that targets specific complaints or body systems, as opposed to a comprehensive exam.

Comprehensive Exam

A thorough examination that evaluates the overall health of a patient and includes a review of all body systems.

Pertinent Negatives

Symptoms or findings that are notably absent, which can help narrow down the diagnosis.

Physical Examination Techniques

Standard methods used to conduct an accurate and thorough physical exam of a patient.

5 As Framework

A structure used in motivational interviewing: Ask, Advise, Assess, Assist, Arrange.

Snellen Chart

A tool used for measuring visual acuity during an eye exam.

Lymph Node Locations

Common anatomical sites where lymph nodes can be palpated including cervical, axillary, and inguinal regions.

Thyroid Abnormalities

Physical signs that may indicate thyroid conditions, such as enlargement or nodules.

Ear Anatomy

The structural components of the ear including the outer, middle, and inner ear.

Weber Test

A test used to assess hearing where a tuning fork is placed on the center of the forehead.

Rinne Test

A hearing test comparing air conduction to bone conduction via tuning fork placement.

Epiglottitis Features

Signs of epiglottitis include sore throat, difficulty swallowing, fever, and stridor.

Allergic Rhinosinusitis

A condition characterized by nasal inflammation triggered by allergens.

Viral Rhinosinusitis

A common cold that causes nasal symptoms and is due to viral infection.

Bacterial Rhinosinusitis

Sinus infection characterized by nasal discharge and facial pain lasting longer than 10 days.

Oral Lesion Types

Different types of oral lesions include aphthous ulcers, candidiasis, and leukoplakia.

High Yield Questions for Hoarseness

Key questions to ask regarding onset, duration, and associated symptoms of hoarseness.

Grading Tonsillar Enlargement

A scale used to classify the size of tonsils on a scale of 1 to 4 from normal to touching the uvula.

Jugular Venous Pressure

A clinical measure used to assess right atrial pressure and fluid overload.

Ankle-Brachial Index

A comparison of blood pressure in the ankle to blood pressure in the arm to assess blood flow.

Allen Test

A test used to evaluate blood supply to the hand by assessing ulnar and radial arteries.

Grading Pulses

A method of assessing the strength of pulse, typically rated from 0 to 4.

Cranial Nerves

Twelve pairs of nerves that innervate the head, neck, and body, each tested through specific actions.

Kernig's Sign

A physical exam technique used to assess meningeal irritation by extending the leg at the knee.

Pronator Drift

A neurological test where a patient holds their arms out and drifts may indicate upper motor neuron lesions.

Abdominal Anatomy

The structural organization of organs within the abdominal cavity.

High Yield Questions for GI and Urinary Complaints

Essential history questions focusing on digestive and urinary symptoms.

Peritonitis Evaluation

Clinical assessment techniques to determine inflammation of the peritoneum.

Pap Smear

A procedure to collect cells from the cervix for cancer screening.

Female Anatomy

Anatomical structures of the female reproductive system.

Male Anatomy

Anatomical structures of the male reproductive system.

Testicular Findings

Common abnormalities seen during testicular examination that may indicate pathology.

ABCD-EFG Method

A system for evaluating skin lesions for potential malignancy based on asymmetry, border, color, diameter, evolving, flat, growing.

Terminology for Skin Lesions

Specific vocabulary used to describe features of skin lesions such as macules, papules, and plaques.

Subungal Melanoma vs. Melanonychia

Differentiation criteria for a type of skin cancer under nails versus harmless pigmentation.

Hair Loss Types

Different classifications of hair loss, such as alopecia areata and androgenetic alopecia.

High Yield Questions for Hair Loss

Key history questions concerning the onset and pattern of hair loss.

Peripheral Arterial Disease Features

Key symptoms of decreased blood flow to limbs, including pain with exertion.

Venous Insufficiency Features

Signs of inadequate venous return, including swelling and varicosities.

Lymphedema Identification

Physical findings associated with fluid accumulation in tissues due to lymphatic dysfunction.

Respiratory Conditions Characteristics

Common features of respiratory illnesses like asthma, COPD, and pneumonia.

Voice Testing Methods

Techniques used to assess quality and function of the voice, in normal and abnormal contexts.

Abnormal Pulmonary Exam Findings

Indicators from a lung examination that suggest potential respiratory issues.

Pulmonary Exam Conduct

Steps to perform a thorough examination of the respiratory system.

Types of Murmurs

Different heart sounds that indicate various heart conditions.

JVP Measurement

Technique used to assess the height of the jugular venous pulsations.