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ICM Exam 1 > Week 1 - SOAP > Flashcards

Week 1 - SOAP Flashcards

1
Q

History

A

Subjective

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2
Q

Physical

A

Objective

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3
Q

Diagnosis

A

Assessment

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4
Q

Treatment

A

Plan

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5
Q

What 5 things do we put in a SOAP note that is not part of CHAMPS For Real?

A
  1. Date and Time of visit
  2. Identifying data
  3. Immunizations
  4. Vitals
  5. Exam of specific body areas/systems
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6
Q

Is CHAMPS For Real and the other 3 things subjective or objective?

A

Subjective

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7
Q

What 3 things are in the Objective portion?

A
  1. Vitals
  2. Exam of specific body areas/systems
  3. Test results
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8
Q

2 things with CC

A
  1. Problem

2. Duration

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9
Q

4 things with Allergies

A
  1. Food
  2. Drugs
  3. Environment
  4. Reaction
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10
Q

5 things with Medications

A
  1. Medication
  2. Milligrams (how much?)
  3. Pills (how many, 1 tab, 1/2 tab?)
  4. Route
  5. Schedule
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11
Q

4 things with PMH

A
  1. Significant problems
  2. When diagnosed
  3. Treatment
  4. Status
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12
Q

4 things with PSH

A
  1. Surgeries or injuries
  2. When
  3. Why
  4. Status
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13
Q

2 things with Immunizations

A
  1. What

2. When

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14
Q

4 things with Alcohol, Smoking, and Drugs

A
  1. What do they drink/use
  2. How much do they drink/use
  3. How long have they been drinking/using
  4. If not, when did you stop?
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15
Q

4 things with FH

A
  1. 1st degree relatives
  2. Alive or dead
  3. Ages
  4. Problems
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16
Q

6 things with Vitals

A
  1. BMI
  2. Pulse
  3. BP
  4. RR
  5. Temp
  6. O2 Sat
17
Q

3 things we put in Assessment

A
  1. Pertinent positive and negatives for today’s visit
  2. Differential and lead diagnosis w/ BRIEF supporting defense or lack thereof
  3. “Other” problem list
18
Q

What 4 thins do we put in Plan

A
  1. Patient education
  2. Additional diagnostics (if any)
  3. Therapy recommendations
  4. Follow-up plans
19
Q

Does temp fluctuate? What may it be in the early morning or late evening?

A

Yes; possibly 96.4 in morning, 99.1 in evening

20
Q

What 2 things are higher in temp than oral? By how much?

A
  1. Rectal (0.7-0.9)

2. Tympanic (0.8-1.4)

21
Q

What is lower than oral temp? By how much?

A

Axillary (1 degree)

22
Q

How long does it take to get axillary temps? How is its accuracy considered?

A

5-10 minutes; less accurate

23
Q

What is the chief cause of decreased temp?

A

Exposure to cold

24
Q

What 3 things could cause decreased heat production?

A
  1. Reduced movement as in paralysis
  2. Starvation
  3. Hypothyroidism
25
Q

What could cause increased heat loss?

A

Interference with vasoconstriction

ICM Exam 1 (7 decks)

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