History, SOAPS, DPR, Int medicine

Question 1

Components of comprehensive history (subjective)

Answer 1

• patient info
• CC
• HPI
• PMH
• meds, allergies, social history, family history
• ROS

Question 2

HPI Mnemonic - OLD CARTS

Answer 2

Onset
Location
Duration
Character/Quality
Alleviating/Aggravating
Radiating
Timing
Severity
Associated/Other symptoms

Question 3

SOAP note

Answer 3

Subjective (provided by patient) “symptoms”
Objective (provided by examiner/findings) “signs”
Assessment (diagnoses)
Plan (treatment and education)

Question 4

Objective

Answer 4

• Vitals, GA, heart, lungs, osteo, abdomen, neuro, other area pertinent to CC

Question 5

Assessment

Answer 5

• Diagnosis, 3 differentials, Correlation of osteopathic Somatic disfunctions, other problems that need to be addressed

Question 6

Plan

Answer 6

• tests, treatment, patient education, follow up

Question 7

CTA

Answer 7

clear to auscultation

Question 8

CVA

Answer 8

cerebrovascular accident

Question 9

c/o

Answer 9

complaining of

Question 10

CABG

Answer 10

coronary artery bypass graft

Question 11

CCU

Answer 11

cardiac care unit

Question 12

CHF

Answer 12

congestive heart failure

Question 13

COPD

Answer 13

coronary obstructive pulmonary disease

Question 14

CXR

Answer 14

chest xray

Question 15

DTR

Answer 15

deep tendon reflexes

Question 16

HEENT

Answer 16

head, eyes, ears, nose, throat

Question 17

HVLA

Answer 17

high velocity, low amplitude

Question 18

h/o

Answer 18

history of

Question 19

HTN

Answer 19

hypertension

Question 20

LMP

Answer 20

last menstrual period

Question 21

NKA

Answer 21

no known allergies/ NKDA

Question 22

NSR

Answer 22

normal sinus rythm

Question 23

po

Answer 23

orally

Question 24

PT/PTT

Answer 24

prothrombin time/pratial prothrombine time

Question 25

ROT

Answer 25

rotated

Question 26

RRR

Answer 26

regular rate and rhythm

Question 27

WNL

Answer 27

within normal limits

Question 28

yo

Answer 28

year-old

Question 29

what is a profession?

Answer 29

1. possession of a specialized body of knowledge | 2. a commitment to service`

Question 30

challenges to professionalism

Answer 30

commercialism, consumerism, beureaucratization, industrialization

Question 31

20 pack years

Answer 31

= 1 ppd for 20 years ...or 2 ppd for 10 years

Question 32

General ROS

Answer 32

- weight change, appetite change, fever, chills, fatigue, weakeness, general health, night sweats

Question 33

Skin ROS

Answer 33

itching, rashes, brusing, sores, discoloration, mole changes, changes in hair texture/loss, lumps, dry skin, color changes

Question 34

Head

Answer 34

headache

Question 35

Eyes

Answer 35

- glasses, vision changes, double vision, pain, redness, discharge, last eye exam

Question 36

Ears

Answer 36

ringing, changes in hearing, infections, discharge, pain, dizziness

Question 37

Nose

Answer 37

nosebleeds, congestion, sinus infections, polyps, injury, nasal obstruction

Question 38

Mouth/Throat

Answer 38

frequent sore throats, hoarseness, bleeding gums, voice changes, postnasal drip, sores in mouth, dental problems

Question 39

chest/pulmonary

Answer 39

cough, sputum, difficulty breathing/shortness of breath (dyspnea), coughing up blood (hemoptysis), chest pain with breathing (pelurisy), wheezing

Question 40

cardiac

Answer 40

chest pain, palpitations, exertional dyspnea, orthopnea (shortness of breath when lying flat), paroxysmal nocturnal dyspnea at rest, last EKG

Question 41

GI

Answer 41

nausea, vomiting, diarrhea, constipation, heartburn, blood in stool (hematochezia), melena, abdominal pain, change in appetite, rectal pain, hemorrhoids, food intolerance, hematemesis, dysphagia, odynophagia, jaundice

Question 42

Urinary

Answer 42

frequent urination, urgency, incontinence, dysuria, hesitancy, blood in urine, nocturia, flank pain, change in color/odor

Question 43

MSK

Answer 43

weakness, paralysis, joint stiffness/pain, joint swelling, limitation to movement, back pain, muscle cramps

Question 44

Neuro

Answer 44

fainting, dizziness, loss of consciousness, paralysis, memory changes, tremors, unsteady gait, disorientation, headaches

Question 45

Personal Zone

Answer 45

appropriate for interactions: 1.5-4 ft

Question 46

proper body language: SOLER

Answer 46

- positioned SQUARELY - OPEN posture - LEAN towards patient - EYE CONTACT - RELAXED

Question 47

constitutional symptoms

Answer 47

symptoms that commonly occur that are non-specific to a particular body system

Question 48

signs

Answer 48

- that what the examiner can see or feel

Question 49

DDX

Answer 49

hypothesis of problems

Question 50

nonverbal communication skills

Answer 50

- awareness: self and others - proximics: use of space - kinesics: use of body, eye contact, etc. - para linguistics: tone, rhythm, pace, volume, etc - reflect those of patient

Question 51

questioning

Answer 51

open ended --> direct --> forced

Question 52

marasmus

Answer 52

- stunted growth, extreme muscle wasting, loss of adipose with no peripheral edema --> combined energy and protein malnutrition

Question 53

Kwashiorkor

Answer 53

- marked by growth failure, peripheral edema, hair discoloration, hypoalbuminemia, and preservation of subcutaneous fat resulting from protein malnutrition.

Question 54

three major causes of death

Answer 54

ischemic heart disease, cerbrovascular disease, lower respiratory infections

Question 55

Three major infectious diseases

Answer 55

HIV, TB, Malaria