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APN1 > APA EYES/SOAP Note > Flashcards

APA EYES/SOAP Note Flashcards

1
Q

What goes in S of Soap Note

A 
Subjective:
Demographics
Chief complaint
HPI-OLDCART
PH (allergies, meds, PMH, surg hx, social hx)
ROS
“Who is my patient?”
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2
Q

What goes in O of Soap Note

A

Objective:
VS
Exam by systems (same systems as ROS)
Diagnostic results obtained during visit

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3
Q

What goes in A of SOAP note?

A

Assessment:
Differential Dx
Primary Dx w/ any Evidence based support (guidelines)
Supporting Dx

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4
Q

What goes in P of SOAP Note?

A 
Plan=Treatment
Rx w/ dose and rationale
Non-pharma treament (lifestyle, diet)
Further w/u orders
Referrals
Follow up & next visit
Evidence based here as well
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5
Q

How are Strep & Mono Similar?

A

Throat pain, general illness and fever. Exudative tonsils.

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6
Q

How are strep & mono different

A

Strep- anterior lymphadenopathy, Centor criteria >4, age is a big factor.
Mono- posterior lymphadenopathy, profound fatigue, spleenic enlargement. EBV or CMV

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7
Q

What is a Chalazian?

A

A subacute/chronic painless stye- present greater that 3 weeks. Usually staph/strep
Tx: refer to optho for I&D

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8
Q

What is a Hordeolum?

A

An acute stye- painful, self-limiting
Tx: warm compress/ abx ointment & monitor
Usually SA/MRSA. Tobramycin eye oint.

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9
Q

What does OLDCART Stand for?

A 
Onset
Location
duration
Characteristics
Aggrevating factors
Relieving factors
Treatment
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10
Q

Where does OLDCART go in the SOAP Note?

A

HPI

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11
Q

What areas does the Consensus Model address?

A 
L- licensure
A- accreditation
C- certification
E- education
Pyramid: BASE: APRN to Role to Population Foci to Specialty
Minumum Masters degree
Focus on direct pt care
Population foci
Roles & titles to be used. The 4 roles (CNP, CNS, CNM, CRNA)
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12
Q

What 3 roles are considered Advance Practice?

A

NP (CNP)
CRNA
CNM

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13
Q

What is required to be conidered an APRN?

A

Minimum masters
Certification by board
Licensure by governing state

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14
Q

What is primary prevention & an example?

A

Preventing the issue before it happens.
Ex: Immunizations
Safety education
Disease prevention

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15
Q

What is secondary prevention & example?

A

Efforts early to minimize impact of disease
Detect early, preclinical state
Ex: screening tests, ASA w/ hx MI, BP checks, blood sugar checks

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16
Q

What is tertiary prevention & example?

A

Minimizing negative disease induced outcomes in established disease
Ex: adjusting therapies to reduce end organ impact.
Seen as failure of primary prevention.

17
Q

What is important education for the patient with bacterial conjunctivitis?

A

Education: secretions infectious for 48 hrs past start of abx. hand washing to prevent spread of infection, avoid touching eyes and do not share towels/cloths
Severe purulence could be gonoccal and needs immediate referral

18
Q

What are the characteristics of diabetic retinopathy?

A

Most common complication DM
due to duration of elevated BS
Annual eye exams to early dx and intervene
Always refer (curtain over eye for acute)
Sx: Floaters & Spots rt vitrial hemorrahge in back of eye
Exam: Fundal exam w/ macular edema, hard exudate, angiogenesis of smaller new vessels
3 Stages: Background, preproliferative, proliferative

19
Q

What are characteristics of macular degeneration?

A

Loss of central vision
Leading cause of vision loss >60yo
Dry- slow progressive atrophy & retinal degeneration
Wet- Age related, new blood vessels under retina in macula- sudden distoriation or loss central vision
Risk: Smoking, CVD, Fm Hx
Annual Amsler Grid screening

20
Q

What are the characteristics of corneal abrasion?

A

Feeling of FB- relieved w/ tetracaine
Dye concentrates around abrasion
Tx: abx gtts preventative & DT prophylaxis

21
Q

How does scabies present?

A

severe itching worse at nightime
Burrows and hole- linear papular rash
Tx: Permetherine & Antihistamines

22
Q

What are characteristics of herpes zoster?

A

Painful vesicular rash
Follows dermatomes
Unilateral
Tx acyclovir/valacyclovir

23
Q

What is the causative organism in impentigo?

A

SA and strep

24
Q

What are defining characteristics of impentigo?

A

Superficial vesiculopustular infection
Honeycomb perioral crusted lesion
SA & strep most common
Tx bactroban ointment or keflex if systemic

25
Q

When documenting PH- what goes in social history?

A

Occupation
Substance use
Sexual hx
Home environment

26
Q

What are the symptoms and differentiation between allergic, viral and bacterial conjuctivitis

A

None have photophobia
Allergic: c/o itching & burning, Bilateral, watery discharge
Viral: c/o ithcing, Bilateral, pale yellow mucousy discharge, moderate & diffuse conjunctival abnormalities
Bacterial: c/o sandy/gritty sensation, starts unilateralthick purulent drng, crusts in am, heavy conjunctival abnormalities

27
Q

What are the characteristics of HSV 1 & 2

A 
HSV 1- oral
HSB 2- genitial 
Can have either in each location
Tx acyclovir & valacyclovir
Only painful STI genital lesion
28
Q

What are the characteristics of gluacoma

A 
Optic nerve damage from elecated IOP
Acute (Closed) Angle
IOP 40-80
Sudden onset loss of vision
Open Angle
IOP 20-40
Insiduous
29
Q

What are cataracts

A

Protein acculuation in lens causing cloudy vision

APN1 (10 decks)

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