Must Memorize

Question 1

What are the seven cardinal features of a symptom?

Answer 1

Onset: when did this start?
Location: where is the symptom located?
Duration: how long does the symptom last?
Characteristics: what does the symptom feel like?
Aggravation/alleviation: Does anything make it better or worse?
Radiation/relieving: Does it spread? What relieves it?
Time: When does the symptom occur (daily/weekly)
Severity: how intense is the symptom?

Question 2

What are the sections of a SOAP?

Answer 2

• Subjective
• Objective
• Assessment
• Plan

Question 3

What are the sections of a subjective?

Answer 3

• Chief complaint: quote pt when possible
• History of present illness: (HPI) introductory statement, OLDCARTS, pertinent + & -
• Past medical history (PMH or PH)
• Family history: (FH) - parents, siblings, children, grandparents (age, condition, age of death & cause)
• Social History (SH): marital, occupation/edu, living arrangements, religion, personal interest, family origin, sexual orientation/habits, tobacco/alcohol/drug use
• Review of system:

Question 4

What is an order for the review of systems?

Answer 4

• General: weight change, orientation, activity, fever, chills, fatigue, sweats
• Skin: color change, pallor, rash, wound
• Hematologic: bruising, adenopathy, gum bleeding, would healing delay, recurrent infection
• Musculoskeletal: joints ROM, swelling, pain, redness/warmth
• Neurologic; dizzy, facial asymmetry, headaches, numbness, seizures, speech difficulty, syncope tremors, weakness
• HEENT: change hearing, vision, smell, taste or pain/discomfort in ears, eyes, nose, throat, sinuses, headaches, discharge, change voice
• Psychiatric: depressive mood, anxiety, affective/personality disorders, sleep disturbances, suicidal thoughts/ideation, homicidal thoughts/ideations, hallucinations, delusions, substance abuse
• Neck: swelling, restricted movement
• Endocrine: heat/cold intolerance, excessive thirst/hunger
• Breasts: change skin/tissue
• Respiratory: dyspnea, cough, hemoptysis, orthopnea
• Cardiovascular: chest pain w/ or w/o exertion, chest wall pain, venous change swelling feet/hands
• GI: change appetite, difficult chew/swallow, nausea, vomiting, diarrhea, constipation, cramping, bloating, indigestion, blood in stool, hemorrhoids
• Urinary: pain w/ urination, hesitancy, frequency hematuria
• Genital: irregular/painful menses, vaginal pain/discharge, dyspareunia, penile discharge, testicular/scrotal pain/swelling