APA EYES/SOAP Note Flashcards
What goes in S of Soap Note
Subjective: Demographics Chief complaint HPI-OLDCART PH (allergies, meds, PMH, surg hx, social hx) ROS “Who is my patient?”
What goes in O of Soap Note
Objective:
VS
Exam by systems (same systems as ROS)
Diagnostic results obtained during visit
What goes in A of SOAP note?
Assessment:
Differential Dx
Primary Dx w/ any Evidence based support (guidelines)
Supporting Dx
What goes in P of SOAP Note?
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
How are Strep & Mono Similar?
Throat pain, general illness and fever. Exudative tonsils.
How are strep & mono different
Strep- anterior lymphadenopathy, Centor criteria >4, age is a big factor.
Mono- posterior lymphadenopathy, profound fatigue, spleenic enlargement. EBV or CMV
What is a Chalazian?
A subacute/chronic painless stye- present greater that 3 weeks. Usually staph/strep
Tx: refer to optho for I&D
What is a Hordeolum?
An acute stye- painful, self-limiting
Tx: warm compress/ abx ointment & monitor
Usually SA/MRSA. Tobramycin eye oint.
What does OLDCART Stand for?
Onset Location duration Characteristics Aggrevating factors Relieving factors Treatment
Where does OLDCART go in the SOAP Note?
HPI
What areas does the Consensus Model address?
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)
What 3 roles are considered Advance Practice?
NP (CNP)
CRNA
CNM
What is required to be conidered an APRN?
Minimum masters
Certification by board
Licensure by governing state
What is primary prevention & an example?
Preventing the issue before it happens.
Ex: Immunizations
Safety education
Disease prevention
What is secondary prevention & example?
Efforts early to minimize impact of disease
Detect early, preclinical state
Ex: screening tests, ASA w/ hx MI, BP checks, blood sugar checks
What is tertiary prevention & example?
Minimizing negative disease induced outcomes in established disease
Ex: adjusting therapies to reduce end organ impact.
Seen as failure of primary prevention.
What is important education for the patient with bacterial conjunctivitis?
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
What are the characteristics of diabetic retinopathy?
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
What are characteristics of macular degeneration?
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
What are the characteristics of corneal abrasion?
Feeling of FB- relieved w/ tetracaine
Dye concentrates around abrasion
Tx: abx gtts preventative & DT prophylaxis
How does scabies present?
severe itching worse at nightime
Burrows and hole- linear papular rash
Tx: Permetherine & Antihistamines
What are characteristics of herpes zoster?
Painful vesicular rash
Follows dermatomes
Unilateral
Tx acyclovir/valacyclovir
What is the causative organism in impentigo?
SA and strep
What are defining characteristics of impentigo?
Superficial vesiculopustular infection
Honeycomb perioral crusted lesion
SA & strep most common
Tx bactroban ointment or keflex if systemic
When documenting PH- what goes in social history?
Occupation
Substance use
Sexual hx
Home environment
What are the symptoms and differentiation between allergic, viral and bacterial conjuctivitis
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
What are the characteristics of HSV 1 & 2
HSV 1- oral HSB 2- genitial Can have either in each location Tx acyclovir & valacyclovir Only painful STI genital lesion
What are the characteristics of gluacoma
Optic nerve damage from elecated IOP Acute (Closed) Angle IOP 40-80 Sudden onset loss of vision Open Angle IOP 20-40 Insiduous
What are cataracts
Protein acculuation in lens causing cloudy vision
