GN.2012/GN.2031 Exam 1 Blueprint Flashcards

Health History, Documentation, and General qSurvey (Week 1)

  • SOAP Note Components

    • Health History (Subjective Data)

      • Patient Information: Includes full name, preferred name, pronouns, age, and other demographic identifiers.

      • Source of History and Reliability: Documentation of who is providing the information and whether the information is deemed trustworthy.

      • Chief Complaint (CC): The primary symptom or reason the patient is seeking care, documented in the patient’s own words.

      • History of Present Illness (HPI): Utilizes the OLDCARTS mnemonic to flesh out the chief complaint:

        • Onset: When the symptom started.

        • Location: Where the symptom is located.

        • Duration: How long the symptom lasts.

        • Character: The quality of the symptom (e.g., sharp, dull).

        • Aggravating/Alleviating Factors: What makes it worse or better.

        • Radiation: Does the pain move anywhere else.

        • Timing: When does it occur (e.g., constant, intermittent, at night).

        • Setting: Environmental factors or activities occurring when symptoms began.

        • Patient Perspective: Includes the patient's thoughts and feelings regarding the illness.

        • Pertinent Positives and Negatives: Presence or absence of symptoms related to differential diagnoses.

      • Medications: Must include name, dose (mgmg, ͰgͰg, etc.), route (PO, IV, etc.), and frequency (QD, BID, etc.).

      • Allergies: Includes drug, food, and environmental allergies; the specific reaction must always be documented.

      • Past Medical History (PMH): Includes childhood illnesses, adult medical conditions, surgical history, OBGYN history, psychiatric history, and health maintenance (immunizations and age-appropriate screenings); dates of events should be included.

      • Family History (FH): Outlines age and health status, or age and cause of death, for siblings, parents, and grandparents; specifically notes the presence or absence of hypertension, diabetes, or cancer.

      • Personal and Social History (PSH): History of tobacco, alcohol, or recreational drug use; sexual history; education level; family of origin; current household status; personal interests; and lifestyle.

      • Review of Systems (ROS): Subjective information organized system-by-system:

        • General: Chills, weight changes, weakness, fatigue, or fever.

        • Skin: Rashes, lumps, sores, itching, dryness, color changes; changes in hair/nails; change in mole size/color.

        • HEENT: Headaches, head injury, dizziness, lightheadedness; vision changes, corrective lenses, pain, redness, tearing, double/blurred vision, spots, flashing lights, glaucoma, cataracts; hearing loss, tinnitus, vertigo, earaches, infection, discharge, hearing aids; frequent colds, nasal stuffiness, discharge, itching, hay fever, nosebleeds, sinus trouble; teeth/gum condition, bleeding gums, dentures, sore tongue, dry mouth, frequent sore throats, hoarseness.

        • Neck: Swollen glands, goiter, pain, stiffness.

        • Breasts: Lumps, pain, discomfort, nipple discharge.

        • Respiratory: Cough, sputum, shortness of breath, wheezing, pain with deep breathing.

        • Cardiovascular: "Heart trouble," high blood pressure, rheumatic fever, murmurs, chest pain, palpitations, orthopnea (need for pillows at night), edema in hands/ankles/feet.

        • GI: Dysphagia (trouble swallowing), heartburn, appetite, nausea, bowel movements, stool color, change in habits, pain with defecation, rectal bleeding, constipation, diarrhea, abdominal pain, food intolerance, flatulence/belching, jaundice, liver/gallbladder trouble.

        • Peripheral Vascular: Intermittent claudication (leg pain with exertion), leg cramps, varicose veins, history of clots, swelling in calves/legs/feet, Raynaud’s (color change in fingertips/toes in cold), swelling with redness/tenderness.

        • Urinary: Frequency, polyuria, nocturia, urgency, dysuria (burning/pain), hematuria (blood in urine), infections, kidney/flank pain, stones, ureteral colic, suprapubic pain, hesitancy, dribbling.

        • Genitals (Male): Hernias, discharge/sores on penis, testicular pain/masses, scrotal swelling, history of STIs, sexual interest, function, satisfaction.

        • Genitals (Female): Menstrual regularity, frequency, duration, bleeding amount, intermenstrual/postcoital bleeding, dysmenorrhea, PMS, menopause symptoms, postmenopausal bleeding, discharge, sores, lumps, STIs, sexual interest, satisfaction, dyspareunia (pain during intercourse).

        • Musculoskeletal: Muscle/joint pain, stiffness, arthritis, gout, backache, neck/low back pain.

        • Psychiatric: Nervousness, tension, mood, depression, memory change, suicidal ideation/plans/attempts.

        • Neurologic: Changes in mood/attention/speech, orientation, memory, insight, judgment, headache, dizziness, vertigo, syncope (fainting), blackouts, weakness, paralysis, numbness, tingling (paresthesia), tremors, seizures.

        • Hematologic: Anemia, easy bruising or bleeding.

        • Endocrine: Heat/cold intolerance, excessive sweating, polydipsia (thirst), polyphagia (hunger), polyuria.

    • Physical Examination (Objective Data)

      • Inspection: Close observation of appearance, behavior, movements, mood, skin, symmetry, and gait.

      • Palpation: Tactile pressure using palmar fingers/finger pads to assess texture, lymph nodes, pulses, organ size, and joints.

      • Percussion: Tapping one finger against another on the body surface to generate sounds reflecting fluid, air, or organ size.

      • Auscultation: Using a stethoscope for heart, lung, and bowel sounds; focusing on pitch and intensity.

    • Plan

      • Detailed strategy for each problem identified in the assessment: diagnostic testing, medications, durable medical equipment, referrals, patient education, and follow-up.

  • Subjective vs. Objective Data

    • Subjective: What the patient says (Chief complaint through ROS). Examples: Chest pain, nausea.

    • Objective: What the clinician observes (Physical exam findings, Labs, Diagnostics). Examples: Tenderness on palpation, BP 135/80135/80, WBC count.

  • Assessment Types

    • Comprehensive Assessment: For new patients or annual physicals; includes complete health history and head-to-toe exam. Identifies hidden risks and establishes a baseline.

    • Focused Assessment: For established patients or urgent care (e.g., sore throat). Narrow and problem-oriented; limited to relevant history and exam components.

  • Constitutional Symptoms

    • Broad symptoms affecting multiple systems: Fatigue, weakness, fever, chills, night sweats, weight changes, pain.

Cognition, Behavior, and Mental Status; Nervous System (Week 2)

  • Cranial Nerves (CN): Functions and Examination

    • I - Olfactory: Sensory: Smell. Test: Occlude each nostril and test different smells.

    • II - Optic: Sensory: Vision. Test: Snellen chart for acuity, screen visual fields by confrontation, inspect fundi.

    • III - Oculomotor: Motor: Raise eyelids, most extraocular movements. Parasympathetic: Pupillary constriction, lens shape change.

    • IV - Trochlear: Motor: Downward, inward eye movement.

    • V - Trigeminal: Motor: Jaw opening, clenching, chewing. Sensory: Cornea, iris, lacrimal glands, forehead, nose, facial skin, teeth, tongue. Test: Palpate temporal/masseter muscles; sharp/dull test on forehead, cheek, jaw; corneal reflex (cotton touch results in blink).

    • VI - Abducens: Motor: Lateral eye movement.

    • VII - Facial: Motor: Facial expression muscles (except jaw), close eyelids, labial speech. Sensory: Taste (anterior 2/32/3 of tongue). Parasympathetic: Saliva and tears. Test: Symmetry during smile, frown, puffing cheeks, raising eyebrows, closing eyes tight.

    • VIII - Acoustic (Vestibulocochlear): Sensory: Hearing and equilibrium. Test: Hearing lateralization, air/bone conduction.

    • IX - Glossopharyngeal: Motor: Swallowing/phonation. Sensory: Nasopharynx, gag reflex, taste (posterior 1/31/3 of tongue). Parasympathetic: Salivary glands, carotid reflex.

    • X - Vagus: Sensory: Sensation behind ear. Parasympathetic: Digestive enzymes, peristalsis, involuntary reaction of heart/lungs/GI. Test (IX & X): Inspect palate movement during ‘ahh’, voice quality, swallowing, gag reflex.

    • XI - Spinal Accessory: Motor: Turn head, shrug shoulders. Test: Strength of shrug and head turn against resistance.

    • XII - Hypoglossal: Motor: Tongue movement (speech sounds l, t, d, n) and swallowing. Test: Protrude tongue, side-to-side movement, check for symmetry/atrophy.

  • Deep Tendon Reflexes (DTR)

    • Grading Scale:

      • 4+4+: Very brisk, hyperactive, with clonus (rhythmic oscillations).

      • 3+3+: Brisk; possibly but not necessarily disease-indicative.

      • 2+2+: Average; normal.

      • 1+1+: Diminished; low normal.

      • 00: No response.

    • Hyperactive Reflexes: Suggest CNS disease (associated with clonus).

    • Hypoactive Reflexes: Result from lost sensation, spinal segment damage, peripheral nerve damage, muscle disease, or substance abuse.

    • Specific Reflex Sites and Spinal Levels:

      • Bicep (C5–C6): Flexion of the arm at the elbow.

      • Triceps (C6–C7): Extension of the elbow.

      • Supinator/Brachioradialis (C5–C6): Flexion and supination of forearm.

      • Patellar (L2–L4): Extension or kicking of the leg.

      • Achilles (S1): Plantar flexion of the foot.

  • Motor System Exam

    • Muscle Strength Grade:

      • 00: No muscular contraction.

      • 11: Barely detectable flicker.

      • 22: Active movement with gravity eliminated.

      • 33: Active movement against gravity.

      • 44: Active movement against gravity and some resistance.

      • 55: Normal strength; active movement against full resistance.

    • Tone Abnormalities:

      • Spasticity: Rate-dependent hypertonia; "clasp-knife" resistance. Upper motor neuron lesion (e.g., Stroke).

      • Rigidity: Steady resistance throughout movement arc regardless of rate. "Lead-pipe" or "Cogwheel" (ratchet-like). Basal ganglia lesion (e.g., Parkinsonism).

      • Flaccidity (Hypotonia): Limbs are loose/floppy. Lower motor neuron lesion (e.g., Guillain–Barr syndrome).

  • Sensory System Exam

    • Tactile/Pain: Distinguish sharp vs. dull.

    • Vibration: Using tuning fork on DIP joint; patient identifies when buzz stops.

    • Proprioception: Move big toe up/down; patient identifies direction.

    • Discriminative Sensation:

      • Stereognosis: Identifying an object in hand (e.g., key).

      • Graphesthesia: Identifying a number traced on the palm.

      • Two-point Discrimination: Discerning two distinct points touching the skin.

  • Coordination, Station, and Gait

    • Cerebellum: Coordinates motor activity, posture, and equilibrium. Damage causes ataxia, nystagmus, or dysarthria.

    • Gait Patterns:

      • Spastic Hemiparesis: Affected leg stiff, foot drags or circumducts; arm flexed and adducted. (Corticospinal tract lesion).

      • Scissors Gait: Stiff gait, thighs cross forward on each other; short steps. (Common in cerebral palsy).

      • Steppage Gait: Hip/knee elevated high to lift plantar flexed foot; foot slap upon landing. (Foot drop).

      • Cerebellar Ataxia: Wide-based, staggering; heel stamps on ground.

      • Parkinsonian Gait: Stooped posture, body rigid, short shuffling steps, difficulty starting/stopping.

    • Tests:

      • Get Up & Go: Timed; > 15\text{--}20 seconds indicates fall risk.

      • Romberg Test: Stand feet together, eyes closed for 3030 seconds. Loss of balance is positive.

      • Pronator Drift: Arms forward, palms up, eyes closed. Downward drift or palm pronation is positive.

  • Mental Status Exam

    • Level of Consciousness (LOC):

      • Alert: Opens eyes, responds fully.

      • Lethargy: Appears drowsy, requires loud voice to wake, falls back asleep after responding.

      • Obtundation: Requires tactile stimulus; responds slowly/confused.

      • Stupor: Requires painful stimulus to arouse; verbal response slow/absent.

      • Coma: Unarousable; eyes closed.

    • Thought Process Abnormalities:

      • Blocking: Sudden interruption in speech.

      • Flight of Ideas: Accelerated speech with abrupt topic changes (loosely connected).

      • Incoherence: Incomprehensible "word salad."

      • Confabulation: Fabricating facts to fill memory gaps.

      • Echolalia: Repeating the words of others.

    • Screening Tools:

      • PHQ-2/PHQ-9: Depression screens (PHQ−9PHQ-9 score 20–2720–27 is severe).

      • GAD-7: Anxiety screen (15–2115–21 is severe).

      • Mini Cog: Word recall plus clock drawing (0–50–5 points).

      • MoCA: Montreal Cognitive Assessment (Normal ≥26≥ 26).

      • SLUMS: Normal is 27–3027–30 for high school education.

      • CAGE: Alcohol screening (22 positive answers suggest a problem).

      • AUDIT-PC: Alcohol intake screen (8–158–15 indicates increasing risk).

HEENOT: Head, Eyes, Ears, Nose, Oral, Throat (Week 3)

  • Lymph Nodes

    • Types of Findings:

      • Shotty: Small, non-tender nodes like BBs.

      • Fluctuant: Wavelike motion on palpation.

      • Matted: Group of nodes moving as a unit.

      • Malignancy Clues: Hard, fixed, painless nodes; Virchow Node (left supraclavicular) suggests thoracic/abdominal malignancy.

      • Inflammation Clues: Tender nodes.

  • Thyroid Gland Exam

    • Inspection: Use tangential lighting below cricoid cartilage; observe patient swallowing.

    • Palpation (Posterior/Anterior): Index fingers below cricoid; feel isthmus rise during swallow. Note size, nodules, or tenderness.

    • Bruit: Auscultate lateral lobes if enlarged.

  • Eye and Vision

    • Fundoscopic Exam: Use right eye/right hand for patient’s right eye. Identify red reflex, optic disc, and retina. Check for papilledema (disc swelling).

    • Refractory Errors:

      • Myopia: Nearsightedness.

      • Hyperopia: Farsightedness.

      • Presbyopia: Aging eye; loss of accommodation (begins after age 4040).

      • Astigmatism: Asymmetry in refractive power.

    • Acuity Interpretations: 20/4020/40 vision means a patient sees at 2020 feet what a normal eye sees at 4040 feet.

    • Lid Abnormalities:

      • Entropion/Ectropion: Margin turns in/out.

      • Hordeolum (Stye): Painful, red infection at margin.

      • Chalazion: Nontender nodule (blocked gland).

  • Ear and Hearing

    • Otoscopic Exam: Adult (auricle up and back); Child (auricle downward and backward).

    • Hearing Loss Types:

      • Conductive: Bypasses external/middle ear; Weber tests lateralize to impaired ear; Rinne test shows bone conduction ≥≥ air conduction.

      • Sensorineural: Involves cochlea/nerve; air conduction normally greater than bone conduction.

  • Oral Cavity

    • Findings: Herpes Simplex, Angioedema, exudative tonsillitis, Thrush.

    • Tongue: Geographic tongue, Black hairy tongue, Smooth tongue (atrophic glossitis).