Health Assessment Final Part 1
Study online at https://quizlet.com/_947vnf
1. Symptoms: What patient tells you
Subjective Data
2. Signs: What you examine (5 senses)
Objective data
3. Order of SOAP note: Chief Complaint
Differential Dx
HPI
ROS
PMH
FH
SH
Objective
Assessment/Diagnosis
Plan
4. Chief complaint: age, race/ethnicity, gender, timing
5. HPI: OLDCARTS
6. ROS episodic visit: focused hx, assess only sx that are pertinent to CC and each differential dx
7. ROS comprehensive exam: Each body system reviewed in head-to order
8. PMH: allergies, medications, chronic illnesses, hospitalizations, surgery, females, health promotion/screening
9. FH: genetic factors, not sick contacts
10. SH: social factors or risks specific to CC and differentials
11. Objective on SOAP note: physical exam findings
12. Assessment: confirm/refute each sx and sign of each DD
provide dx
13. Plan: rx, labs, patient education, health promotion (USPSTF and Immunizations)
14. Male symbol: square
15. female symbol: circle
16. pregnancy: triangle
17. death: square with x
18. primary prevention: legislation laws
immunizations
diet, exercise
, Health Assessment Final Part 1
Study online at https://quizlet.com/_947vnf
19. secondary prevention: mammogram, colonoscopy, low-dose lung CT
modifiable lifestyle change after dx
20. tertiary prevention: cardiac rehab
support groups
vocational rehab
21. Name Bones of skull: OPTS to Forehead
Occipital
Parietal
Temporal
Sphenoid
Frontal
Sagittal Suture (side to side)
Coronal Suture (frontal and parietal bones)
Zygomatic bone/arch
Nasal bone
Maxilla
Mandible
TMJ
22. Palpebral fissure
Nasolabial fold:
23. Philtrum: above upper lip
24. Vermilion border: edge of lips and skin
25. FAS facial characteristics: small eye openings
smooth philtrum
thin upper lip
26. Sinuses: frontal maxillary ehtmoid sphenoid:
, Health Assessment Final Part 1
Study online at https://quizlet.com/_947vnf
27. function of sinuses: lighten weight of head
give resonance to voice
respiratory moisture
28. Sinuses we palpate?: Frontal and maxillary
29. What turbinate can we not see?: Superior. we can see the inferior and middle
30. Reason why you lay babies down with bottle and it comes out ears?: Opening of
Eustachian tube in oropharynx
Also GERD running straight up into middle ear and give middle ear effusion
31. taste buds: vallate papillae
32. Salivary glands: Wharton's and sublingual duct
33. Parotid gland: Stenson's duct (gives us saliva)
34. Parotid and submandibular glands and duct:
35. Normal sinus transillimunation: (press otoscope against sinus)
Sinus appears hollow and the light shines through giving a reddish glow
36. Abnormal Sinus transillimunation: opaque, dull
37. Tight Frenulum: Ankyloglossia
38. epiglottis: flap that closes over airway so we dont aspirate while talking
39. Adam's Apple: thyroid cartilage
40. size of each lobe of thyroid: 4-5 cm or less
joined by isthmus
41. What is isthmus?: joining of two lobes of thyroid gland
42. Top to bottom neck anatomy: Hyoid bone
Thyroid cartilage
Cricoid Cartilage
Thyroid gland surrounding with isthmus in middle
43. What to do if thyroid gland is enlarged: auscultate
44. What lymph node specifically needs further inspection and why?: Supraclavicular
because drain chest
Study online at https://quizlet.com/_947vnf
1. Symptoms: What patient tells you
Subjective Data
2. Signs: What you examine (5 senses)
Objective data
3. Order of SOAP note: Chief Complaint
Differential Dx
HPI
ROS
PMH
FH
SH
Objective
Assessment/Diagnosis
Plan
4. Chief complaint: age, race/ethnicity, gender, timing
5. HPI: OLDCARTS
6. ROS episodic visit: focused hx, assess only sx that are pertinent to CC and each differential dx
7. ROS comprehensive exam: Each body system reviewed in head-to order
8. PMH: allergies, medications, chronic illnesses, hospitalizations, surgery, females, health promotion/screening
9. FH: genetic factors, not sick contacts
10. SH: social factors or risks specific to CC and differentials
11. Objective on SOAP note: physical exam findings
12. Assessment: confirm/refute each sx and sign of each DD
provide dx
13. Plan: rx, labs, patient education, health promotion (USPSTF and Immunizations)
14. Male symbol: square
15. female symbol: circle
16. pregnancy: triangle
17. death: square with x
18. primary prevention: legislation laws
immunizations
diet, exercise
, Health Assessment Final Part 1
Study online at https://quizlet.com/_947vnf
19. secondary prevention: mammogram, colonoscopy, low-dose lung CT
modifiable lifestyle change after dx
20. tertiary prevention: cardiac rehab
support groups
vocational rehab
21. Name Bones of skull: OPTS to Forehead
Occipital
Parietal
Temporal
Sphenoid
Frontal
Sagittal Suture (side to side)
Coronal Suture (frontal and parietal bones)
Zygomatic bone/arch
Nasal bone
Maxilla
Mandible
TMJ
22. Palpebral fissure
Nasolabial fold:
23. Philtrum: above upper lip
24. Vermilion border: edge of lips and skin
25. FAS facial characteristics: small eye openings
smooth philtrum
thin upper lip
26. Sinuses: frontal maxillary ehtmoid sphenoid:
, Health Assessment Final Part 1
Study online at https://quizlet.com/_947vnf
27. function of sinuses: lighten weight of head
give resonance to voice
respiratory moisture
28. Sinuses we palpate?: Frontal and maxillary
29. What turbinate can we not see?: Superior. we can see the inferior and middle
30. Reason why you lay babies down with bottle and it comes out ears?: Opening of
Eustachian tube in oropharynx
Also GERD running straight up into middle ear and give middle ear effusion
31. taste buds: vallate papillae
32. Salivary glands: Wharton's and sublingual duct
33. Parotid gland: Stenson's duct (gives us saliva)
34. Parotid and submandibular glands and duct:
35. Normal sinus transillimunation: (press otoscope against sinus)
Sinus appears hollow and the light shines through giving a reddish glow
36. Abnormal Sinus transillimunation: opaque, dull
37. Tight Frenulum: Ankyloglossia
38. epiglottis: flap that closes over airway so we dont aspirate while talking
39. Adam's Apple: thyroid cartilage
40. size of each lobe of thyroid: 4-5 cm or less
joined by isthmus
41. What is isthmus?: joining of two lobes of thyroid gland
42. Top to bottom neck anatomy: Hyoid bone
Thyroid cartilage
Cricoid Cartilage
Thyroid gland surrounding with isthmus in middle
43. What to do if thyroid gland is enlarged: auscultate
44. What lymph node specifically needs further inspection and why?: Supraclavicular
because drain chest
