Patient Clues
A patient says, “My stomach hurts.”
Is this a SIGN or SYMPTOM?
Symptom
What does the O in OLDCARTS stand for?
Onset
Tremor for 2 years, unchanged.
Acute or Chronic?
Chronic
PRIORITY answers which question?
WHEN or WHO?
WHEN care/attention is needed.
In SOAP, what does A stand for?
Assessment
The MA measures a temperature of 102.4°F.
Is this SUBJECTIVE or OBJECTIVE?
Objective
Patient: “My head hurts.”
Ask ONE question to determine severity.
“How severe is the pain?” / “Rate your pain from 0–10.”
New facial weakness started 20 minutes ago.
Acute or Chronic?
Acute
REFERRAL answers which question?
WHEN or WHO?
WHO may provide additional care.
Where does this information belong?
Patient reports, “My headache is 7/10.”
Subjective or Objective?
Subjective
The MA observes that the patient's left ankle is visibly swollen.
Classify it TWO ways:
Sign or Symptom?
Subjective or Objective?
Sing and objective
Patient: “My left foot is tingling.”
Ask THREE useful follow-up questions.
Possible answers:
A patient with ADHD needs a medication refill.
They have 3 pills left and no new symptoms.
Routine/time-sensitive or emergency?
Routine / Time-sensitive
A patient has difficulty swallowing after a neurological illness.
Which professional may be involved?
A. Neurology
B. SLP
C. OT
D. Psychiatry
B — Speech-Language Pathology (SLP)
Where does this information belong?
MA measures temperature: 100.8°F.
Subjective or Objective?
Objective
The patient says:
“My left hand feels numb.”
Classify it TWO ways.
Symptom and subjective
Patient: “I've been dizzy.”
Which question is MOST useful for understanding when/how it happens?
A. What's your favorite food?
B. Does it happen when you stand up?
C. Are you married?
D. What pharmacy do you use?
B — Does it happen when you stand up?
A patient has had headaches for 3 months, but they have become more frequent during the last 2 weeks.
What is most important?
A. The problem is chronic, so nothing changed
B. The patient's age
C. The change in the pattern
D. The patient's insurance
C — Change in the pattern
After a brain injury, a patient speaks clearly but has problems with:
Which specialist may be involved?
Neuropsychology
Which is the BEST documentation?
A. Patient is acting weird.
B. Patient seems really confused.
C. Patient asked, “Why am I here?” three times.
D. Patient probably has dementia.
C
A daughter says:
“My father has mild memory problems, but today he suddenly doesn't know where he is.”
Identify TWO important patient clues.
Sudden/ accute confusion or disorientation
Change from the patient's usual baseline
Patient: “My right hand feels numb.”
Your team has 30 seconds.
Give FOUR important questions the MA should ask.
onset, exact location, duration, characteristics, severity if appropriate, weakness, ability to move hand/arm, speech changes, facial changes, previous episodes, injury, associated symptoms, whether symptoms are changing/spreading.
A patient suddenly develops:
The patient asks for an appointment this afternoon.
What should the MA recognize?
Possible emergency requiring immediate escalation/emergency protocol.
A patient with MS has difficulty:
Which professional may help with these functional activities?
What is the MA's role?
Occupational Therapy (OT)
Help coordinate an authorized referral/care, communicate information, and document appropriately—not independently decide treatment.
BAD NOTE:
“Patient acting weird today. Daughter says dementia is really bad. He seems worse. Told doctor. Probably needs neurology.”
IDENTIFY AT LEAST 3 PROBLEMS