Clinical Assessment and Planning Quiz

Questions and Answers

What is the primary plausible diagnosis for the patient's symptoms of fatigue and dark stools?

Iron deficiency anemia (correct)

B12 deficiency anemia

Depression

Fibromyalgia

Which condition is considered a diagnostic possibility related to the presenting problem of fatigue?

Acute kidney injury

Chronic fatigue syndrome

Sleep apnea

Anemia of chronic disease (correct)

What must be documented if OMT is performed during the encounter?

Somatic Dysfunction (correct)

Physical examination findings

Only the medical history

Patient's lifestyle modifications

Which symptom is NOT typically associated with anemia in the assessment?

Severe headache Signup and view all the answers

In the assessment of the patient, which option does NOT qualify as a diagnostic possibility for fatigue?

Hypothyroidism Signup and view all the answers

What is the chief complaint of the patient in the sample SOAP note?

Head congestion Signup and view all the answers

Which medication is the patient taking for hypertension?

Lisinopril Signup and view all the answers

What must be included in an assessment for somatic dysfunction?

At least two diagnoses Signup and view all the answers

What symptom did the patient report that is associated with head congestion?

Purulent drainage Signup and view all the answers

Which ICD-10 code corresponds to lumbar somatic dysfunction?

M99.03 Signup and view all the answers

Which lifestyle modification did the patient previously make related to smoking?

Quit smoking Signup and view all the answers

What is a notable finding in the patient's family history?

Sister has type 2 diabetes Signup and view all the answers

When documenting somatic dysfunction, which of the following is an example of how it can be expressed?

Somatic dysfunction of the sacrum with R/R sacral torsion Signup and view all the answers

Which of the following components is NOT included in the physical exam options provided?

Neurological evaluation Signup and view all the answers

What should be included in the treatment section of a plan for a patient with somatic dysfunction?

OMT technique style and location Signup and view all the answers

Which area does the ICD-10 code M99.06 represent?

Lower extremity somatic dysfunction Signup and view all the answers

What does the patient's symptom rating of 7/10 indicate?

Severe pain Signup and view all the answers

Which referral type could be appropriate based on the patient's symptoms?

Pulmonologist Signup and view all the answers

What medications is the patient currently taking for hypertension and cardiovascular health?

Aspirin, lisinopril, and metoprolol Signup and view all the answers

What family history factor contributes to the patient’s risk for coronary artery disease?

Father and two brothers with coronary artery disease Signup and view all the answers

What was noted regarding the patient's social history?

No history of illicit drug use and 30 pack years of smoking Signup and view all the answers

Which symptom does the patient deny in the review of systems?

Syncope Signup and view all the answers

In the objective findings, what was observed about the heart during the examination?

Regular rhythm with no murmur Signup and view all the answers

Which of the following is included in the body areas/organ systems that should be assessed?

Cardiovascular and integumentary systems Signup and view all the answers

What osteopathic finding is relevant for the musculoskeletal system?

Anterior fibular head Signup and view all the answers

What is the appropriate approach when documenting objective findings in a medical examination?

Include observations and measurements only Signup and view all the answers

What should be included in the 'A' section of a SOAP note regarding the patient?

A ranking of possible etiologies for the patient's problem. Signup and view all the answers

Which of the following best describes what belongs in the 'S' section of a SOAP note?

The patient's chief complaint in their own words. Signup and view all the answers

What is the appropriate focus of the 'P' section in a SOAP note?

Outlining the plan for workup and treatment. Signup and view all the answers

In the HPI section, which format is recommended for presenting information?

Paragraph format using complete sentences. Signup and view all the answers

What symptom did Mr. John Jones report in the context of his headache?

Movement exacerbated the pain. Signup and view all the answers

Study Notes

SOAP Notes Overview

SOAP stands for Subjective, Objective, Assessment, and Plan; used for documenting patient encounters.

Subjective (S)

Includes patient identification, chief complaint (CC), and history of present illness (HPI).
Example: Mr. John Jones reports "the worst headache I've ever had," rated 9/10, with nausea and blurred vision.
Background details include past medical history (PMH), family history (FH), social history (SH), and review of systems (ROS).
PMH notable for hypertension and myocardial infarction; treated with ASA, lisinopril, and metoprolol.
Family has a history of coronary artery disease (CAD) and the patient has a significant smoking history.

Objective (O)

Includes observable measurements like vital signs, physical exam findings, and diagnostic results.
Vital signs and general appearance must be documented, such as patient being in distress.
Head-to-toe examination required, documenting pertinent positives/negatives for various systems (e.g., heart, lungs).
Osteopathic findings should be noted, including cranial and TART changes in the musculoskeletal system.

Assessment (A)

Must provide a differential diagnosis, ranking possible etiologies.
Key considerations in the case: severe headache, could indicate subarachnoid hemorrhage or other neurological issues.
Somatic dysfunction, if identified during examination, must be documented distinctly alongside the primary diagnosis.

Plan (P)

Details the next steps for workup and treatment including diagnostic tests (e.g., CBC, imaging).
Treatment plan may involve medication recommendations, OMT techniques, or referrals to specialists.
Education on health promotion practices including lifestyle changes such as smoking cessation.
Documentation must include any follow-up plans or the necessity for further physical examinations and labs.

Documentation Skills

Important to ensure that information in "S" and "O" logically leads to the conclusions in "A".
The "P" section should directly relate to the identified issues in "A", ensuring appropriate management strategies outlined.
Accurate documentation is crucial for continuity of care and billing/coding purposes (ICD-10 codes for somatic dysfunction provided).

Billing and Coding

Codes for specific somatic dysfunctions must be documented clearly (e.g., M99.00 for Head SD).
Important to differentiate areas of dysfunction and apply correct codes for billing purposes.

Key Tips

Use precise language and avoid ambiguity in documentation.
Maintain a clear structure to ensure the SOAP note is comprehensive and comprehensible for future providers.

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Description

This quiz assesses your ability to evaluate patient diagnoses and create effective treatment plans. You'll need to identify potential etiologies for symptoms and articulate a structured approach to preliminary workups and therapeutic interventions. Test your knowledge and skills in clinical reasoning and patient care.