SUMMARY

Subjective

Which component of the SOAP framework includes history taking and lifestyle vital signs?

Objective

Which component of the SOAP framework includes Physical Examination findings?

Assessment

Which component of the SOAP framework includes the problem list and primary impression?

Plan

Which component of the SOAP framework includes diagnostic and therapeutic plans?

Nutrition and physical activity

What are two examples of lifestyle vital signs documented in the Subjective section?

Laboratory and imaging results

In the SOAP flow, where are objective test results documented?

Biomedical and psychosocial

What two categories of problems are included in the Assessment problem list?

Patient education and supportive plans

Besides diagnostic and therapeutic plans, what two components are part of the Plan?

Onset

In the OLDCAARTS framework, what does the O stand for?

When did the pain start?

What is the example question for the Onset component of OLDCAARTS?

Location

In the OLDCAARTS framework, what does the L stand for?

Where exactly do you feel it?

What is a key question for the Location component of OLDCAARTS?

Can you point to it?

What is a physical instruction used to determine Location in OLDCAARTS?

Duration

In the OLDCAARTS framework, what does the D stand for?

How long does it last?

What is the primary question for the Duration component of OLDCAARTS?

Constant or intermittent

What are the two common descriptors for Duration in OLDCAARTS?

Character

In the OLDCAARTS framework, what does the C stand for?

Sharp, colicky, crampy, or heavy

What are four descriptors for the Character of a symptom?

Aggravating Factors

In the OLDCAARTS framework, what does the first A stand for?

Movement, certain foods, or positions

What are three factors often explored as Aggravating Factors?

Alleviating Factors

In the OLDCAARTS framework, what does the second A stand for?

Medications or positions

What are two common factors explored as Alleviating Factors?

Associated Symptoms

In the OLDCAARTS framework, what does the third A stand for?

Nausea, vomiting, and fever

What are three examples of Associated Symptoms?

Changes in bowel or urinary habits

What specific bodily changes are explored in Associated Symptoms?

Radiation

In the OLDCAARTS framework, what does the R stand for?

Does the pain move to other areas?

What is the key question for assessing Radiation?

Back or shoulder

What are two common examples of areas where pain might radiate?

Timing

In the OLDCAARTS framework, what does the T stand for?

Relation to meals, time of day, or menstrual cycle

What three factors are assessed regarding symptom Timing?

Severity

In the OLDCAARTS framework, what does the S stand for?

Function

The Severity of a symptom often relates to the patient's what?

Patient is unable to go to work

What is an example description of symptom Severity?

Independent

What is the dependency status of an adult patient?

Family-dependent

What is the dependency status of a pediatric patient?

Stable physiology

What is the physiological state of an adult compared to a child?

Rapid physiologic change

What is the physiological state of a child?

Mature immunity

What is the state of immunity in an adult?

Developing immunity

What is the state of immunity in a child?

Children

Which patient group is more vulnerable to infections?

Fixed anatomy

What is the state of adult anatomy in terms of growth?

Growing anatomy

What is the state of pediatric anatomy?

Provide their own history

Who typically provides the medical history for an adult?

Parents and child

Whose engagement is required for a pediatric history?

Disease-centered

What is the clinical approach for an adult patient?

Development-centered

What is the clinical approach for a pediatric patient?

On the parent's lap

How should an infant be examined for security?

Observe first

What is the initial strategy when approaching a toddler?

Become comfortable

What must a toddler do before the clinician touches them?

Play and distraction

What two strategies are best for preschoolers?

Least invasive first

In what order should exams be performed on a preschooler?

Simple and honest

How should procedures be explained to a school-age child?

Directly and privately

How should a clinician speak to an adolescent?

Privacy and confidentiality

What two ethical concepts must be respected with adolescents?

Underweight

What is the BMI classification for a WHO score less than 18.5?

Normal

What is the BMI classification for a WHO score of 18.5 to 24.9?

Overweight

What is the BMI classification for a WHO score of 25.0 to 29.9?

Obesity

What is the BMI classification for a WHO score of 30.0 or greater?

Underweight

What is the WHO-APP classification for a BMI less than 18.5?

Normal

What is the WHO-APP classification for a BMI of 18.5 to 22.9?

Overweight

What is the WHO-APP classification for a BMI of 23.0 to 24.9?

Obesity

What is the WHO-APP classification for a BMI of 25.0 or greater?

Asian-Pacific

What population do the WHO-APP cut-offs target?

kg/m2

What are the units for Body Mass Index?

Gravida

In the GTPAL score, what does the G stand for?

Total number of pregnancies

What is the definition of Gravida?

Includes current pregnancy

Does Gravida include the current pregnancy?

Regardless of outcome

What is the rule for pregnancy outcomes in Gravida?

Parity

In the GTPAL score, what does the P stand for?

Reached viable gestational age

What is the requirement for a pregnancy to be counted in Parity?

Greater than 20 weeks

What is the specific gestational age for viability in Parity?

Term

In the GTPAL score, what does the T stand for?

37 weeks or more

At what gestational age is an infant delivery considered Term?

Preterm

In the GTPAL score, what does the second P stand for?

Between 20 and 36 weeks

What is the gestational age range for Preterm delivery?

Abortion

In the GTPAL score, what does the A stand for?

Miscarriages or elective abortions

What two types of events are counted under Abortion?

Less than 20 weeks

Before what gestational age must a pregnancy end to be an Abortion?

Living

In the GTPAL score, what does the L stand for?

Children currently living

What does the Living component of the OB score measure?

Home

In the HEEADSSSS framework, what does the H stand for?

Living situation and family relationships

What are focus areas for the Home domain?

Household rules

What is an interview focus regarding family dynamics in the Home domain?

Education

In the HEEADSSSS framework, what does the first E stand for?

School performance and learning problems

What are two school-related focus areas in Education?

Future goals

What is a long-term focus area in the Education domain?

Eating

In the HEEADSSSS framework, what does the second E stand for?

Diet habits and body image

What are two focus areas for the Eating domain?

Exercise frequency

Besides diet, what is assessed in the Eating domain?

Activities

In the HEEADSSSS framework, what does the A stand for?

Hobbies and peer groups

What are two social focus areas in Activities?

Social media and gadget use

What modern activity is screened in the Activities domain?

Drugs

In the HEEADSSSS framework, what does the D stand for?

Tobacco, alcohol, or prohibited substances

What three types of substances are screened in the Drugs domain?

Personal and peer use

Whose drug use should be explored with the adolescent?

Sexuality

In the HEEADSSSS framework, what does the first S stand for?

Relationships and identity

What are two core focus areas of the Sexuality domain?

Uncomfortable touching

What safety concern is explored in the Sexuality domain?

Suicide

In the HEEADSSSS framework, what does the second S stand for?

Mood and depression symptoms

What two mental health indicators are part of the Suicide domain?