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SOAP NOTE KADIN Flashcards

(62 cards)

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1
Q

NLDOCAT

A

Nature
Location
Duration
Onset
Course
Aggravated
Treatment

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2
Q

Nature

A

Do you have burning, tingling, shooting, or numbness pain?

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3
Q

Location

A

Can you point with one finger where it hurts?

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4
Q

Duration

A

Months, weeks, days?

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5
Q

Onset

A

Did this happen gradually or all at once?

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6
Q

Course

A

Getting better or worse? Radiating to other parts of body?

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7
Q

Aggravated

A

What makes it worse? Walking, certain shoes, resting?

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8
Q

Treatment

A

What have you tried to make it better?

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9
Q

Does he have any fever, chills, nausea, or vomiting? Shortness of breath? Any trauma? If trauma, know when last time he ate

A
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10
Q

Temperature

A

36.5-37.6 C

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11
Q

Objective:
VITALS

A
  1. Temperature
  2. Heart Rate
  3. Respiratory Rate
  4. Blood Pressure
  5. Pulse Oximetry
  6. Pain Scale
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12
Q

Heart Rate

A

80-100 beats/min

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13
Q

Respiratory Rate

A

12-22 breaths/min

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14
Q

Blood Pressure

A

100-160 mmHg systolic

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15
Q

Pulse Oximetry

A

95-100 SpO2

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16
Q

Pain Scale

A

scale of 1-10

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17
Q

General Exam

A

Awake, alert, oriented
Well groomed
dressing are dry and intact. No strikethrough

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18
Q

Neurologic

A

Light touch
Vibratory
Sharp/dull
Proprioception
Deep Reflexes
Superficial Reflexes
SW

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19
Q

Light touch

A

10g Semmes Weinstein Monofilament (5.07)

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20
Q

Vibratory

A

128 Hz Tuning Fork

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21
Q

Sharp/dull

A

the blunt end and sharp end of a swab stick

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22
Q

Proprioception

A

move hallux up or down in space

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23
Q

Deep Achilles

A

Achilles (L5-S2) and Patellar (L2-L4) with a reflex hammer

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24
Q

Superficial Relflexes

A

Babinski sign with a curved stroke of the reflex hammer

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25
SW
10/10
26
Vascular
Pulses Doppler Ultrasound Capillary refill Digital hair Varicosities Edema Skin temperature
27
Pulses
Dorsalis Pedis (DP) and Posterior Tibialis (PT) palpable
28
Doppler Ultrasound
Mono-, Bi-, Triphasic
29
Capillary refill
<3 seconds or >3 seconds
30
Digital hair
(+/-) presents (hair in toes=good blood flow)
31
Varicosities
(+/-) presents
32
Edema
pitting edema vs non- 1+ minima, 2+ moderate, 3+ severe
33
Skin temperature
is cold/warm to the touch Hot: inflammation or infection Warm: normal healthy Cold: poor blood flow
34
Muscular
Foot type Digital deformity Range of Motion (ROM) Muscle Strength Equines Biomechanics
35
Foot type
pes cavus, pes rectus, pes planus
36
Digital deformity
bunion, claw toe, hammer toe, mallet toe, hallux limitus. Amputations
37
Range of Motion (ROM)
Adequate ROM to MTPK, STJ, and AJ without crepitus, slight pain at end of range of motion
38
Muscle strength
5/5 on all quadrants
39
Equines
Gastroc equinus Gastroc-soleus equinus Pseudoequinus
40
Biomechanics
Gait analyses WB vs non-
41
Dermatological: Nails Onychauxis
thickened, long nail
42
Dermatological: Nails Onycholysis
separated nail
43
Dermatological: Nails Onychocrytosis
ingrown nail
44
Dermatological: Nails Onychogryphosis
ram's horn nail
45
Dermatological: Nails Onychomycosis
fungal nail
46
Dermatological: Skin
No hyperkeratotic lesions, verruca tissue, foreign body Mild edema, erythema but no open lesions abrasion, or interdigital maceration No varicosities, telangiectasias, pigmented lesion, or venous stasis Adequate fat padding to the plantar aspect of the foot
47
Ulcer
Length x width x depth Location? Granular or fibrotic base? Roofing/undermining? Tracking? Tunneling? Macerated or hypertrophic border? Probes to a bone? Sanguineous or serious drainage? Periwound erythema or edema? Malodor present? Type: decubitus, ischemic, venous, neuropathic ulcer/
48
LABS
CBC BMP PT/INR Culture Gram stain Liver function
49
CBC (complete blood count)
is a blood test that measures many different parts and features of your blood
50
BMP (basic metabolic panel)
is a test that measures eight different substances in your blood. It provides important information about your body's chemical balance and metabolism
51
PT/INR (prothrombin time test with an international normalized ratio)
A prothrombin time (PT) test measures how many seconds it takes for a clot to form in a blood sample
52
Culture
laboratory test to check for bacteria or other germs in a blood sample
53
Gram Stain
identify the cause of a bacterial infection
54
Liver function
blood tests that can provide information about how your liver is working
55
Radiographs
3 views of foot, 3 views of ankle x-ray
56
CT scan (Computerized Tomography Scan)
diagnostic imaging procedure that uses a combination of X-rays and computer technology to produce images of the inside of the body
57
MRI (Magnetic Resonance Imaging)
medical imaging technique used in radiology to form pictures of the anatomy and the physiological processes inside the body
58
MRA (Magnetic Resonance Angiogram)
type of MRI that looks specifically at the body's blood vessels
59
Ultrasound
A procedure that uses high-energy sound waves to look at tissues and organs inside the body
60
Assessment: Comorbidities
DMII HTN Afib RA Anemia Smoker
61
Assessment: Think diagnosis or differential diagnosis
Hammertoes, ankle fracture, neuropathic ulcer
62
Plan
Educate patient Medication dispensed New exams (labs or x-ray) Weight bearing status: WB, non-WB, or partial-WB Pt. will return to clinic in ____ weeks

Medical Assistant (1 decks)

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