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Medical Assistant > SOAP NOTE KADIN > Flashcards

SOAP NOTE KADIN Flashcards

1
Q

NLDOCAT

A

Nature
Location
Duration
Onset
Course
Aggravated
Treatment

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2
Q

Nature

A

Do you have burning, tingling, shooting, or numbness pain?

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3
Q

Location

A

Can you point with one finger where it hurts?

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4
Q

Duration

A

Months, weeks, days?

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5
Q

Onset

A

Did this happen gradually or all at once?

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6
Q

Course

A

Getting better or worse? Radiating to other parts of body?

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7
Q

Aggravated

A

What makes it worse? Walking, certain shoes, resting?

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8
Q

Treatment

A

What have you tried to make it better?

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9
Q

Does he have any fever, chills, nausea, or vomiting? Shortness of breath? Any trauma? If trauma, know when last time he ate

A
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10
Q

Temperature

A

36.5-37.6 C

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11
Q

Objective:
VITALS

A
  1. Temperature
  2. Heart Rate
  3. Respiratory Rate
  4. Blood Pressure
  5. Pulse Oximetry
  6. Pain Scale
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12
Q

Heart Rate

A

80-100 beats/min

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13
Q

Respiratory Rate

A

12-22 breaths/min

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14
Q

Blood Pressure

A

100-160 mmHg systolic

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15
Q

Pulse Oximetry

A

95-100 SpO2

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16
Q

Pain Scale

A

scale of 1-10

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17
Q

General Exam

A

Awake, alert, oriented
Well groomed
dressing are dry and intact. No strikethrough

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18
Q

Neurologic

A

Light touch
Vibratory
Sharp/dull
Proprioception
Deep Reflexes
Superficial Reflexes
SW

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19
Q

Light touch

A

10g Semmes Weinstein Monofilament (5.07)

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20
Q

Vibratory

A

128 Hz Tuning Fork

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21
Q

Sharp/dull

A

the blunt end and sharp end of a swab stick

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22
Q

Proprioception

A

move hallux up or down in space

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23
Q

Deep Achilles

A

Achilles (L5-S2) and Patellar (L2-L4) with a reflex hammer

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24
Q

Superficial Relflexes

A

Babinski sign with a curved stroke of the reflex hammer

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25
Q

SW

26
Q

Vascular

A

Pulses
Doppler Ultrasound
Capillary refill
Digital hair
Varicosities
Edema
Skin temperature

27
Q

Pulses

A

Dorsalis Pedis (DP) and Posterior Tibialis (PT) palpable

28
Q

Doppler Ultrasound

A

Mono-, Bi-, Triphasic

29
Q

Capillary refill

A

<3 seconds or >3 seconds

30
Q

Digital hair

A

(+/-) presents (hair in toes=good blood flow)

31
Q

Varicosities

A

(+/-) presents

32
Q

Edema

A

pitting edema vs non-
1+ minima, 2+ moderate, 3+ severe

33
Q

Skin temperature

A

is cold/warm to the touch
Hot: inflammation or infection
Warm: normal healthy
Cold: poor blood flow

34
Q

Muscular

A

Foot type
Digital deformity
Range of Motion (ROM)
Muscle Strength
Equines
Biomechanics

35
Q

Foot type

A

pes cavus, pes rectus, pes planus

36
Q

Digital deformity

A

bunion, claw toe, hammer toe, mallet toe, hallux limitus. Amputations

37
Q

Range of Motion (ROM)

A

Adequate ROM to MTPK, STJ, and AJ without crepitus, slight pain at end of range of motion

38
Q

Muscle strength

A

5/5 on all quadrants

39
Q

Equines

A

Gastroc equinus
Gastroc-soleus equinus
Pseudoequinus

40
Q

Biomechanics

A

Gait analyses
WB vs non-

41
Q

Dermatological: Nails
Onychauxis

A

thickened, long nail

42
Q

Dermatological: Nails
Onycholysis

A

separated nail

43
Q

Dermatological: Nails
Onychocrytosis

A

ingrown nail

44
Q

Dermatological: Nails
Onychogryphosis

A

ram’s horn nail

45
Q

Dermatological: Nails
Onychomycosis

A

fungal nail

46
Q

Dermatological: Skin

A

No hyperkeratotic lesions, verruca tissue, foreign body
Mild edema, erythema but no open lesions abrasion, or interdigital maceration
No varicosities, telangiectasias, pigmented lesion, or venous stasis
Adequate fat padding to the plantar aspect of the foot

47
Q

Ulcer

A

Length x width x depth
Location?
Granular or fibrotic base?
Roofing/undermining?
Tracking? Tunneling? Macerated or hypertrophic border?
Probes to a bone?
Sanguineous or serious drainage?
Periwound erythema or edema?
Malodor present?
Type: decubitus, ischemic, venous, neuropathic ulcer/

48
Q

LABS

A

CBC
BMP
PT/INR
Culture
Gram stain
Liver function

49
Q

CBC (complete blood count)

A

is a blood test that measures many different parts and features of your blood

50
Q

BMP (basic metabolic panel)

A

is a test that measures eight different substances in your blood. It provides important information about your body’s chemical balance and metabolism

51
Q

PT/INR (prothrombin time test with an international normalized ratio)

A

A prothrombin time (PT) test measures how many seconds it takes for a clot to form in a blood sample

52
Q

Culture

A

laboratory test to check for bacteria or other germs in a blood sample

53
Q

Gram Stain

A

identify the cause of a bacterial infection

54
Q

Liver function

A

blood tests that can provide information about how your liver is working

55
Q

Radiographs

A

3 views of foot, 3 views of ankle x-ray

56
Q

CT scan (Computerized Tomography Scan)

A

diagnostic imaging procedure that uses a combination of X-rays and computer technology to produce images of the inside of the body

57
Q

MRI (Magnetic Resonance Imaging)

A

medical imaging technique used in radiology to form pictures of the anatomy and the physiological processes inside the body

58
Q

MRA (Magnetic Resonance Angiogram)

A

type of MRI that looks specifically at the body’s blood vessels

59
Q

Ultrasound

A

A procedure that uses high-energy sound waves to look at tissues and organs inside the body

60
Q

Assessment:
Comorbidities

A

DMII
HTN
Afib
RA
Anemia
Smoker

61
Q

Assessment:
Think diagnosis or differential diagnosis

A

Hammertoes, ankle fracture, neuropathic ulcer

62
Q

Plan

A

Educate patient
Medication dispensed
New exams (labs or x-ray)
Weight bearing status: WB, non-WB, or partial-WB
Pt. will return to clinic in ____ weeks

Medical Assistant (1 decks)

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