Advanced Health Assessment Study Guide 2025

What is included under each section of the SOAP note. - - • 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 rationale, medication, education Be able to recognize examples of objective data and subjective data. - - • 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". 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. - - • 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 conditions, 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. 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) - History of present illness: onset, location, duration, character, aggravating and Health Health 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 disorders, OBGYN. What is included in the general survey, when is it begun, what is assessed, and where within the SOAP note is it recorded? - -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 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 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 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 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. Fungal lesions - - o Usually classified according to anatomic location and can occur on nonhairy parts of the body (See next question for anatomical locations) Health Health o Can involve the stratum corneum, nails, or hair o Lesions very in appearance and may be papular, pustular, vesicular, erythematous, or scaling o Candidiasis, tinea, and pityriasis (tinea) versicolor are all listed under fungal infections so I listed page numbers for those also but this is all I could find on fungal lesions. Tinea pedis - -o Fungal eruption on the feet Tinea Barbae - -o Fungal eruption of the beard Tinea Cruris - -o Fungal eruption of the groin Tinea Corporis - -o Fungal eruption of the body How does candidiasis appear - - • Beefy-red, well demarcated plaques, often with scaling edge and satellite lesions (pinpoint papules) at the periphery with erosions and maceration in moist areas • Associated with mild to intense pruritus • Causative organism is usually Candida albicans. • Oral Thrush: White patches that bleed when you try to scrape them off • Diaper: Diaper rash: Groin area where diaper is worn. • Vaginal: Candida Vulvovaginitis: Thick, white, and curdy/cheesy discharge with vulvar pruritus. Labia are erythematous and edematous. What are the danger signs (ABCDE) associated with skin cancer? - -• Assymetry: One half of a mole or birthmark does not match the other • Borders: Edges are irregular, ragged, notched, or blurred. Pigment may be streaming from the border • Color: Color is not the same all over and may have differing shades of brown or black, sometimes with patches of red, white, or blue • Diameter: Diameter is 6 mm (about the size of a pencil eraser) • Evolution: Changes in existing pigmented lesions, particularly in a nonuniform, asymmetrical manner. Macules - - o Discrete flat change in color of skin o Usually 1.5 cm in diameter o Ex.: freckles, petechiae, measles, scarlet fever Papules - -o Discrete palpable elevation of skin o Firm circumscribed area o 1 cm in diameter o May be epidermal, dermal, or both o Ex. Elevated nevi, wart, seborrheic keratosis Petechiae - -o Red-purple nonblanchable discoloration of skin Health Health o 0.5 cm in diameter o Broken capillary blood vessels o Causes: intravascular defects, infection Senile lentigines - -Liver spots Seborrheic keratoses - -o Pigmented, raised, warty lesions that usually appear on the face or trunk. o Be careful to distinguish from actinic keratoses, which have malignant potential (they look similar). Which is the most serious skin condition if found? - -Petechia...can indicate thrombocytopenia, etc. What does "atopy" or "atopic" mean? - - • Pertaining to a hereditary tendency to experience immediate allergic reactions such as asthma or vasomotor rhinitis because of the presence of an antibody (atopic reagin) in the skin and sometimes the bloodstream. atopy [at′opē] , n What is normal capillary refill and what does prolongation suggest? - -• Normal capillary refill time is less than 2 seconds • Prolongation suggests that the system is compromised...peripheral arterial disease, hypovolemic shock, or hypothermia. • Refill will be much longer if circulatory compromise is severe. Cholasma - -o "Mask of pregnancy" o Found on the forehead, cheeks, bridge of the nose and chin o Blotchy in appearance and is usually symmetric o Found in pregnant women Linea nigra - -o Increase pigmentation of the linea alba o Extends from the symphysis pubis to the top of the fundus in the midline o Apparent in pregnant women Mongolian spots - -o Irregular areas o deep blue pigmentation o Usually in the sacral and gluteal regions o Seen predominantly in newborns of African, Native American, American Indian, Asian, or Latin descent. o Usually disappear in preschool years Striae - -o Stretch marks o May appear over the abdomen, thighs, and breasts during second trimester of pregnancy o Fade but never disappear Health Health Café au lait spots - -o Flat, evenly pigmented spots varying in color from light brown to dark brown or black in dark skin...coffee colored patches. o Larger than 5 mm in diameter o Present at birth or shortly thereafter o May be associated with neurofibromatosis or misc. other conditions including pulmonary stenosis, temporal lobe dysrhythmia, and tuberous sclerosis. How does a scarlatina rash present, and what diagnostic test is indicated when a patient presents with it? Hint...has to do with the throat - -o Macular erythema of the face (flushing), except around the mouth followed by a disseminated fine papular erythema (scarlatiniform), which may then desquamate. o Fine, mildly erythematous papules and sandpaper like rash found on the trunk o Rash begins in axillae, groin, and neck o The rash is intensified in the flexor folds (Pastia lines) o Associated symptoms are sore throat, malaise, fever, circumoral pallor, and a white or strawberry tongue o It's a systemic illness associated with (GABHS)...strep throat. o Diagnostic test is culture for group A Streptococcus Corns - -o Look for corns on pressure points o Flat or slightly elevated, circumscribed, painful lesions with a smooth, hard surface o Soft corns: caused by the pressure of a bony prominence against softer tissue (whitish thickenings commonly between 4th and 5th toes) o Hard corns: have a conical appearance and occur most often over bony prominences where pressure is exerted (shoe pressing on the interphalangeal joints of the toes) Calluses - -o Superficial area of hyperkeratosis o Usually occur on the weight bearing areas of the feet and on the palmar surface of the hands o Less well demarcated than corns and are usually not tender. Plantar warts - -Plantar warts are benign epithelial tumors generally caused by infection by human papilloma virus types 1, 2, 4, 60, or 63,[5] but have also been caused by types 57,[6] 65,[7] 66,[8] and 156.[9] These types are classified as clinical (visible symptoms). The virus attacks compromised skin through direct contact, entering through possibly tiny cuts and abrasions in the stratum corneum (outermost layer of skin). After infection, warts may not become visible for several weeks or months. Because of pressure on the sole of the foot or finger, the wart is pushed inward and a layer of hard skin may form over the wart. A plantar wart can be painful if left untreated. Ulcerations - -o Loss of epidermis and dermis o Concave o Varies in size Measles (rubeola) - -o The three Cs: cough, coryza (common cold), and conjunctivitis o Koplik spots are evident on buccal mucosa Health Health o Rash begins with spike of convalescent fever o Rash is centripetal (Moving or directed toward a center) in distribution, possibly becoming hemorrhagic in severe cases Rubella - -o Tender lymphadenopathy of postauricular and posterior occipital nodes o Maculopapular and confluent rash that is lacy and not pruritic o Rash lasts 3 days Pityriasis - -o Multiple, oval erythematous lesions with an inner fine circle of scale o Ovals line up along skin cleavage lines on trunk o Produces a Christmas tree like pattern Roseola - -o High fever for 3-4 days in infants and young children o As fever returns to normal, a diffuse maculopapular rash erupts Strawberry tongue - -Scarlet Fever Herald patch - -Pityriais (Tinea) Versicolor Koplik spots - -Measles Target lesions - -Erythema Multiforme