SOAP - Answers subjective, objective, assessment, plan
subjective - Answers what the patient tells you
objective - Answers Observable, measurable data. What can be seen or tested
Assessment - Answers Official diagnosis based on subjective and objective, test RESULTS
CC - Answers chief complaint
Five W's and H - Answers who, what, when, where, why, how
HPI - Answers history of present illness
PMI - Answers past medical illness
Medical history includes - Answers Chief complaint (cc), history of present illness (hpi), past
family and social history (pfsh) and review of systems (ros)
Family history includes - Answers Significant medical issues-anything that "runs in the family"-
among parents, children, grandparents, grandchildren (heart disease, cancer, diabetes, stroke)
non verbal behavior - Answers behavior that reveals a person's feelings without words, through
facial expressions, body language, and vocal cues
Why is non verbal behavior important - Answers May give clues for unspoken concerns
Vitals - Answers temperature, pulse, respiration, blood pressure
What is oxygen saturation called - Answers Pulse ox, O2 sats
anthropometric measurements - Answers height and weight
BMI - Answers body mass index (measurement of body fat based on height and weight)
Normal BMI - Answers Up to 30
BMR - Answers basal metabolic rate, minimum calories needed for basic function
gait - Answers How a person walks
What are some things to consider when instructing a patient to change into a gown? - Answers
Be specific, explain what the exam is for, how the gown needs to be worn, getting sheets to
cover patient, make sure patient understands directions
What can affect a person's temperature? - Answers Illness, stress, depression, anxiety, exercise,
age, gender, environment, time of day
, Pyrexia - Answers Fever of 102 or higher
hyperpyrexia - Answers Fever 105° and above
Normal oral temperature - Answers 98.6
Normal rectal temperature - Answers 99.6
Normal axillary temperature - Answers 97.6
Normal tympanic temperature - Answers 98.6
normal temporal temperature - Answers 98.6
Official start of fever - Answers 100.4
What can affect a person's pulse - Answers Anxiety, depression, stress, exercise, illness, time of
day, position, medication, body type, blood volume, alcohol, drugs
What are the characteristics of pulse - Answers rate, rhythm, volume
What artery is used most often for pulse rate - Answers radial
What pulse point is used on babies - Answers Apical preferred, or brachial
What would you expect for pulse rate on an athlete - Answers Lower, slower than normal
Normal adult pulse - Answers 60-100 bpm
Things that can affect a person's respirations - Answers Age, elevated body temperature, sleep
apnea, illness, knowing they are being watched
normal infant respiratory rate - Answers 20+ per minute
Normal child respiratory rate - Answers 18-20 per minute
normal adult respiratory rate - Answers 12-20 breaths per minute
What can affect a person's blood pressure - Answers Heart disease, age, activity, diet, alcohol,
tobacco use, family history, stress, body position
What happens if you use too large cuff for BP - Answers Lower than normal reading
What happens if you use too small of a cuff for BP - Answers Higher than normal reading
What artery is used to measure blood pressure? - Answers brachial artery
What phases of korotkoff sounds are recorded as blood pressure - Answers One and five
normal blood pressure - Answers 120/80