The Health Record
Where does the Review of Systems go in the health record?
How do we determine Obesity?
With BMI, over 30
Name some types of eye screenings?
Snellen chart-vision, Red light reflex, six fields of cardinal gaze, corneal light reflex, cover/uncover test, fundoycopic exam
What is hemoptysis?
Coughing up blood
What sounds do you hear in a healthy abdomen during percussion?
tympanic sounds
What part of the SOAP note includes the physical exam?
Objective section
What is the difference between a vesicle and a bulla?
a bulla is greater than 1cm
How do we test for Nuchal rigidity?
Brudzinski sign and Kerning sign
What are you looking for when inspecting the chest wall?
Symmetry of movement, use of accessory muscles, structural abnormalities
What are the abdomen organs and their locations?
Right upper quad: Liver
Left upper quad: Spleen
Right lower quad: appendix
Where do you document the follow up for the patient in the health note (SOAP)?
In the Plan section
Honey-crusted lesion that is infectious, likely caused by Staph
Impetigo
How do we assess the ear differently in children than in adults?
Pull the pinna down and back as opposed to up and back
Where do we auscultate the apical pulse?
Fifth left intercostal space, mid-clavicular
How is the assessment of the abdomen different than any other system?
auscultation is second
What is included in the Assessment portion of the SOAP note?
Differential Diagnoses, rationales, possible testing to do, your interpretation of what is going on
What is the difference between delirium and dementia?
Delirium is episodic while dementia is progressive
Where is the sensory network of the eye located?
The retina
Where can we auscultate the aorta?
second right intercostal space at the right sternal border
What do we assess during bimanual exam?
ovaries, uterus, cervix, assess for abnormal lesions or growths
How should we document the chief complaint?
In the Subjective section, in quotations if possible
Main difference between anorexia and bulimia?
Anorexia causes malnutrition due to not eating, bulimia causes physical damage due to acid in emesis.
frontal, maxillary sinuses (ethmoid and sphenoid aren't palpated during exam)
Where can we hear vesicular breath sounds?
over healthy lung tissue
Colon Cancer risk factors?
family history, polyps, heart disease, obesity, other comorbidities