module 4 hx and physical exam

Question 1

recording info

Answer 1

organize
synthesize
record the data 
record the problems identified 
record the plan of care

Question 2

SOAP

Answer 2

Subjective
Objective
Assessment
Plan

Question 3

OLDCARTS

Answer 3

Onset
Location
Duration
Character: when/how
Aggravating/associated factors
Relieving factors
Temporal factors: time of day, consistent? 
Severity of symptoms: able to work/ADL

Question 4

Objective data

Answer 4

resulting from direct observation: see, hear, touch

relate findings to processes of inspection, palpation, auscultation, and percussion

Question 5

objective data location

Answer 5

topographic and anatomic landmarks

Question 6

objective data organs, masses, lesions

Answer 6

texture or consistency
size
shape or configuration
mobility 
tenderness
induration heat
color
location 
other: oozing, bleeding, discharge, scab formation, scarring, excoriation

Question 7

Problem oriented medical record

Answer 7

format for collecting and recording your thoughts
assists with critical thinking and clinical decision making
- Comprehensive health hx
- complete physical exam
- problem list
- assessment and plan
- baseline and problem-directed labs/imaging
- progress notes

Question 8

problem list

Answer 8

create running log with

• problem number
• date of onset
• description of the problem
• date problem resolved

Question 9

assessment

Answer 9

composed of

• interpretations and conclusions
• their rational
• diagnostic strategy
• present and anticipated problems
• needs of ongoing as well as future care

Question 10

assessment for each problem on list

Answer 10

diagnosis with rationale
if dx can not be made differential diagnoses are prioritized
also includes anticipated potential problems
- complicatoins
- progression of disease
- sequelae
Dx tests performed
tx plan
pt education
referrals
target dates for re-evaluating results of plan