Advanced Health Assessment Study Guide (copied from
maria_nuon_rafae)
1. What is included under each section of the SOAP note Ans: • Include date,
name, occupation, marital status, source of information, reliability, referral source
• Subjective data- the information including the absence or presence of pertinent
symptoms that the patient tells you. Chief complaint, HPI, medications, allergies,
tobacco, alcohol, drugs, past medical history, family and social history, review of
systems that are pertinent
• Objective data- your direct observations from what you see, hear, smell, and touch.
ROS (same as from subjective data), vital signs, height and weight
• Assessment- your interpretations and conclusions, your rationale, the diagnostic
possibilities, present and anticipated problems
• Plan- diagnostic testing, therapeutic modalities, need for consultation, and ratio-
nale, medication, education
2. Be able to recognize examples of objective data and subjective data Ans:
• Subjective data- information the patient tells you, quality or character of pain,
also absence of symptoms, "denies n/v/d", "sharp abdominal pain", "feels tired"
• Objective data- what you can directly see, touch, hear, and measure, physical
findings from inspection, palpation, auscultation, and percussion, examples: vital
signs, "distended abdomen with tenderness", "vaginal discharge", "wheezing on
inspiration".
3. What are the components of the health history (chief complaint, present
illness, past history, family history, ROS, functional history, etc.) and what
is included under each section Ans: • Chief complaint- brief description of
,patients reason for seeking care
• History of present illness- description of problem; OLDCARTS
• Past medical history- surgeries, illnesses, injuries, immunizations, medications,
allergies, emotional status, recent lab tests
• Family history-pedigree of 3 generations with medical problems (HTN, DM, CA)
• Review of systems- General, skin, head, neck, EENT, chest, lungs, breasts,
vasculature, GI, GU, diet, endocrine, musculoskeletal, neuro, psych
• Functional history/Personal and social history- cultural background, home condi-
tions, occupation, environment of work/school/home, health habits (diet, exercise,
smoking, alcohol, drugs), any handicap or disability, exposure to chemicals, sexual
health, concerns about costs or health coverage.
4. After someone presents with a complaint, what is the next step in the health
assessment process? (Hint...what do you do prior to initiating the physical
exam) Ans: History of present illness: onset, location, duration, character,
aggravating and associated factors, relieving factors, temporal factors, and severity:
medications, allergies
THEN
,Past medical history: hospitalizations, surgeries, childhood illnesses, adult illnesses,
serious injuries, immunizations, medications, allergies, transfusions, mood disor-
ders, OBGYN.
5. What is included in the general survey, when is it begun, what is assessed,
and where within the SOAP note is it recorded Ans: General survey is the first
part of the Review of Symptoms. Can include symptoms such as fever, chills, fatigue,
weight loss. An example could be: "Patient is an alert, young woman, sitting
comfortably on the examination table". You could assess this as soon as you see
the patient with observation. Seidel 801 and General Survey Notes under
Interviewing and health history
6. Herpetic lesions: o Primary infection is grouped vesicles on an erythematous
base at the site of inoculation
o Can occur anywhere on body but most common areas are genitals and
thighs...mouth, lips, and chin.
o Regional lymphadenopathy
o May be preceded by a prodrome of tingling, itching, burning, or tenderness at site
7. Psoriasis: o Well-demarcated, ham-colored plaques and papules with silvery
scale
o Chronic recurrent pruritis is common
o Favors elbows, knees, and scalp...intertriginous areas may involve nails
o Not contagious
8. Impetigo: o Vesicular infection
o Honey-colored crusts and erosions
o Can be seen on the face and any area of body with aminor wound...especially
excoriated lesions
, o Very contagious
9. Allergic (atopic) skin reactions: o Contact dermatitis (inflammatory reaction to
poison ivy, etc.): Papulovesicular or bullous eruption surrounded by erythema
o Weeping of exudates...noncontagious
o Moderate to intense pruritus
o Not sure if this also includes eczema, psoriasis, and seborrheic dermatitis?? They
are found on same pages.
10. Fungal lesions: o Usually classified according to anatomic location and can
occur on nonhairy parts of the body (See next question for anatomical locations)
o Can involve the stratum corneum, nails, or hair
o Lesions very in appearance and may be papular, pustular, vesicular, erythema-
tous, or scaling
o Candidiasis, tinea, and pityriasis (tinea) versicolor are all listed under fungal
maria_nuon_rafae)
1. What is included under each section of the SOAP note Ans: • Include date,
name, occupation, marital status, source of information, reliability, referral source
• Subjective data- the information including the absence or presence of pertinent
symptoms that the patient tells you. Chief complaint, HPI, medications, allergies,
tobacco, alcohol, drugs, past medical history, family and social history, review of
systems that are pertinent
• Objective data- your direct observations from what you see, hear, smell, and touch.
ROS (same as from subjective data), vital signs, height and weight
• Assessment- your interpretations and conclusions, your rationale, the diagnostic
possibilities, present and anticipated problems
• Plan- diagnostic testing, therapeutic modalities, need for consultation, and ratio-
nale, medication, education
2. Be able to recognize examples of objective data and subjective data Ans:
• Subjective data- information the patient tells you, quality or character of pain,
also absence of symptoms, "denies n/v/d", "sharp abdominal pain", "feels tired"
• Objective data- what you can directly see, touch, hear, and measure, physical
findings from inspection, palpation, auscultation, and percussion, examples: vital
signs, "distended abdomen with tenderness", "vaginal discharge", "wheezing on
inspiration".
3. What are the components of the health history (chief complaint, present
illness, past history, family history, ROS, functional history, etc.) and what
is included under each section Ans: • Chief complaint- brief description of
,patients reason for seeking care
• History of present illness- description of problem; OLDCARTS
• Past medical history- surgeries, illnesses, injuries, immunizations, medications,
allergies, emotional status, recent lab tests
• Family history-pedigree of 3 generations with medical problems (HTN, DM, CA)
• Review of systems- General, skin, head, neck, EENT, chest, lungs, breasts,
vasculature, GI, GU, diet, endocrine, musculoskeletal, neuro, psych
• Functional history/Personal and social history- cultural background, home condi-
tions, occupation, environment of work/school/home, health habits (diet, exercise,
smoking, alcohol, drugs), any handicap or disability, exposure to chemicals, sexual
health, concerns about costs or health coverage.
4. After someone presents with a complaint, what is the next step in the health
assessment process? (Hint...what do you do prior to initiating the physical
exam) Ans: History of present illness: onset, location, duration, character,
aggravating and associated factors, relieving factors, temporal factors, and severity:
medications, allergies
THEN
,Past medical history: hospitalizations, surgeries, childhood illnesses, adult illnesses,
serious injuries, immunizations, medications, allergies, transfusions, mood disor-
ders, OBGYN.
5. What is included in the general survey, when is it begun, what is assessed,
and where within the SOAP note is it recorded Ans: General survey is the first
part of the Review of Symptoms. Can include symptoms such as fever, chills, fatigue,
weight loss. An example could be: "Patient is an alert, young woman, sitting
comfortably on the examination table". You could assess this as soon as you see
the patient with observation. Seidel 801 and General Survey Notes under
Interviewing and health history
6. Herpetic lesions: o Primary infection is grouped vesicles on an erythematous
base at the site of inoculation
o Can occur anywhere on body but most common areas are genitals and
thighs...mouth, lips, and chin.
o Regional lymphadenopathy
o May be preceded by a prodrome of tingling, itching, burning, or tenderness at site
7. Psoriasis: o Well-demarcated, ham-colored plaques and papules with silvery
scale
o Chronic recurrent pruritis is common
o Favors elbows, knees, and scalp...intertriginous areas may involve nails
o Not contagious
8. Impetigo: o Vesicular infection
o Honey-colored crusts and erosions
o Can be seen on the face and any area of body with aminor wound...especially
excoriated lesions
, o Very contagious
9. Allergic (atopic) skin reactions: o Contact dermatitis (inflammatory reaction to
poison ivy, etc.): Papulovesicular or bullous eruption surrounded by erythema
o Weeping of exudates...noncontagious
o Moderate to intense pruritus
o Not sure if this also includes eczema, psoriasis, and seborrheic dermatitis?? They
are found on same pages.
10. Fungal lesions: o Usually classified according to anatomic location and can
occur on nonhairy parts of the body (See next question for anatomical locations)
o Can involve the stratum corneum, nails, or hair
o Lesions very in appearance and may be papular, pustular, vesicular, erythema-
tous, or scaling
o Candidiasis, tinea, and pityriasis (tinea) versicolor are all listed under fungal
