Health Assessment and SOAP Documentation

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Questions and Answers

What is the most common location for an acrochordon?

  • Neck (correct)
  • Glabella
  • Lateral surface of the helix
  • Vermillion border of the lip

What is a hallmark feature of a venous lake?

  • Soft compressible, pedunculated, or projectile
  • Painful, red to white nodule
  • Central umbilication
  • Compression collapses lesions (correct)

Which of the following is a differential diagnosis for sebaceous hyperplasia?

  • Blue nevus
  • Molluscum (correct)
  • Chondrodermatitis nodularis helicis
  • Pterygium

What is the meaning of the mnemonic 'RSVP' in eye assessment?

<p>Redness, Sensitivity, Vision, Pain (C)</p> Signup and view all the answers

What is Arcus senilis?

<p>A white or gray ring at the corneal margin (C)</p> Signup and view all the answers

What is the most common cause of itch in the elderly?

<p>Xerosis (C)</p> Signup and view all the answers

Which of the following is a hallmark feature of seborrheic keratosis?

<p>Stuck-on appearance, varying color and degrees of dryness (D)</p> Signup and view all the answers

What is the term for the chronic changes of stasis dermatitis, including hyperpigmentation, lichenification, and scars of healed ulcers?

<p>Post-inflammatory changes (A)</p> Signup and view all the answers

Which of the following is NOT a component of the SOAP documentation?

<p>Past Medical History (A)</p> Signup and view all the answers

Which acronym helps to remember all components of the history of present illness (HPI)?

<p>OLD CARTS (B)</p> Signup and view all the answers

Which of the following is NOT a component of the CLIENT OUTCOMES acronym?

<p>Treatment (B)</p> Signup and view all the answers

Which of these is a common variant of rosacea in the elderly?

<p>Ocular rosacea (C)</p> Signup and view all the answers

What is the hallmark feature of cherry angioma?

<p>Smooth, firm, deep red appearance (D)</p> Signup and view all the answers

What is the most common cause of eyelid malignancy?

<p>Basal cell carcinoma (A)</p> Signup and view all the answers

Which cranial nerve is responsible for transmitting visual images to the brain?

<p>Cranial nerve II (optic) (B)</p> Signup and view all the answers

What is the treatment for a hordeolum?

<p>Warm compresses and antibiotic eye drops (A)</p> Signup and view all the answers

What does the first number represent in a visual acuity test?

<p>The patient's distance from the chart (D)</p> Signup and view all the answers

Which cranial nerve is responsible for eye movements in the vertical plane?

<p>Cranial nerve IV (trochlear) (B)</p> Signup and view all the answers

What does a failure of both eyes to close during a corneal reflex test indicate?

<p>Increased intracranial pressure (C)</p> Signup and view all the answers

What is the purpose of fluorescein stain technique?

<p>To detect corneal abrasions or other corneal abnormalities (B)</p> Signup and view all the answers

What is the purpose of the cotton swab in eyelid eversion?

<p>To assist in everting the upper eyelid (B)</p> Signup and view all the answers

During the Weber test, what does a positive test result indicate?

<p>Air conduction is louder than bone conduction. (A)</p> Signup and view all the answers

How is the ear canal oriented in children under the age of three?

<p>Inward, forward, and upward (C)</p> Signup and view all the answers

What is the primary function of the inner ear?

<p>Conversion of sound waves into electrical signals (B)</p> Signup and view all the answers

Which of the following is NOT a potential cause of secondary otalgia?

<p>Middle ear infection (A)</p> Signup and view all the answers

What is the correct position of the tympanic membrane light reflex in the right ear?

<p>5 o'clock (C)</p> Signup and view all the answers

During the Romberg test, what does a positive result indicate?

<p>The patient has impaired balance and coordination. (A)</p> Signup and view all the answers

During the whisper test, what is considered a normal result?

<p>The patient gets 50% or more of the words correct. (D)</p> Signup and view all the answers

Which of the following is a characteristic of sensorineural hearing loss?

<p>Air conduction is equal to or less than half as long as bone conduction. (A)</p> Signup and view all the answers

What is a possible reason for a yellow-tinged tympanic membrane?

<p>Infection with pus (A)</p> Signup and view all the answers

What type of hearing loss might be indicated if a patient hears a tuning fork louder in one ear during a Weber test?

<p>Conductive hearing loss (B)</p> Signup and view all the answers

Which test compares air conduction to bone conduction?

<p>Rinne test (B)</p> Signup and view all the answers

What might be the reason for a patient's inability to stay still with their eyes closed during a Romberg test?

<p>Inner ear organ dysfunction (C)</p> Signup and view all the answers

What type of hearing loss might be caused by a lack of tympanic membrane flexibility?

<p>Conductive hearing loss (A)</p> Signup and view all the answers

What is the typical finding on a Rinne test for a patient with normal hearing?

<p>Air conduction is longer than bone conduction (B)</p> Signup and view all the answers

What is the desired finding in a Weber test?

<p>The tone is heard evenly in both ears (B)</p> Signup and view all the answers

What is the recommended order of assessment when examining a pediatric patient?

<p>External exam first, then internal exam (B)</p> Signup and view all the answers

What is a sign of conductive hearing loss during a Weber test?

<p>Sound is heard louder in one ear. (A)</p> Signup and view all the answers

Which of the following findings in the tympanic membrane is NOT an indicator of otitis media?

<p>Lack of tympanic membrane flexibility. (C)</p> Signup and view all the answers

Which cranial nerve is NOT involved in otalgia?

<p>Cranial Nerve XI (B)</p> Signup and view all the answers

A patient presents with a corneal abrasion. Which of the following is the recommended course of action?

<p>Remove foreign body if visible, flush with sterile saline, and monitor. (D)</p> Signup and view all the answers

A corneal light reflex test shows an imbalance in the reflected light. What is the next step?

<p>Perform a cover-uncover test to evaluate eye muscle movement. (B)</p> Signup and view all the answers

What finding in the ear canal is MOST likely to indicate otitis media?

<p>Erythema and swelling. (A)</p> Signup and view all the answers

Which of the following conditions can cause conductive hearing loss?

<p>All of the above (D)</p> Signup and view all the answers

What is the expected position of the tympanic membrane light reflex on the left ear?

<p>7 o'clock (B)</p> Signup and view all the answers

Flashcards

Acrochordon

Soft, compressible skin tags found on neck, axillary, groin, and eyelids.

Venous lake

Compressible lesions found on the vermillion border of the lip and ear.

Sebaceous hyperplasia

Soft, dome-shaped, pale yellow lesions with umbilication on the face.

Chondrodermatitis nodularis chronica helicis

Firm, painful nodule on the ear, red to white, 2-6 mm in size.

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RSVP eye assessment

Mnemonic for assessing eye history: Redness, Sensitivity to light, Vision loss, Pain.

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Endotropion

Inward turning of eyelid margin and lashes towards the eye surface.

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Exotropion

Outward turning of eyelid margin and lashes away from the eye.

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Hordeolum (Stye)

Bacterial infection causing a tender, swollen bump near an eyelash follicle.

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Chalazion

A blocked oil gland resulting in a firm, painless lump on the eyelid.

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Cranial Nerve III

Oculomotor nerve responsible for eye movements and transmitting visual images to the brain.

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Vertical Diplopia

Double vision caused by an issue with Cranial Nerve IV.

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Visual Acuity Test

Measures distance vision, expressed as two numbers (e.g., 20/30).

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Fluorescein Stain Technique

A method using dye to inspect cornea and conjunctiva under UV light.

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Air Conduction (AC)

Transmission of sound waves through the air to the ear canal.

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Bone Conduction (BC)

Transmission of sound through the bones of the skull directly to the inner ear.

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Positive Test Result

Occurs when air conduction is longer than bone conduction (AC > BC).

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Negative Test Result

Indicates conductive hearing loss when bone conduction is longer than air conduction (BC > AC).

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Sensorineural Hearing Loss

Condition where air conduction is equal to or less than half the bone conduction (AC ≤ 1/2 BC).

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Whisper Test

A test for hearing acuity asking the patient to repeat whispered words/numbers from two feet away.

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Romberg Test

A balance test where the patient stands with eyes closed to check inner ear function.

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Tympanic Membrane Light Reflex

Normal reflection seen in the anterior inferior quadrant of the tympanic membrane.

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Corneal Abrasion

A scratch or damage to the cornea causing pain and sensitivity.

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Corneal Light Reflex Test

Test to check symmetry of light reflections in pupils.

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Cover/Uncover Test

Identifies the weaker eye by observing eye movement when uncovered.

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Otalgia

Pain in the ear caused by infection, inflammation, or referred pain.

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Weber Test

Test to determine if hearing loss is conductive or sensorineural.

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Rinne Test

Compares air conduction to bone conduction in one ear at a time.

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Chronic Otitis Media

Long-term ear infection resulting in tympanic membrane changes.

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Opaque Tympanic Membrane

Indicates chronic otitis, repetitive perforations, or tympanosclerosis.

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Air Bubbles Behind Tympanic Membrane

Indicate acute otitis media and serous otitis.

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Yellow-Tinged Tympanic Membrane

Suggests infection with pus.

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Conductive Hearing Loss Causes

Lack of tympanic membrane flexibility can lead to this type of hearing loss.

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SOAP

An acronym for subjective, objective, assessment, plan in health documentation.

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HPI

History of present illness; details about the current health issue.

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Old Carts

A mnemonic for assessing pain: onset, location, duration, characteristics, alleviating/aggravating factors, radiation, timing, severity.

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Xerosis

Impaired skin condition in the elderly causing dry, itchy skin.

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Stasis Dermatitis

A skin condition characterized by dry, itchy skin due to vascular changes, particularly in the legs.

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Rosacea

A chronic inflammatory skin condition causing redness and sometimes thickening of the skin, often misdiagnosed.

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Seborrheic Keratosis

Non-cancerous skin growths with a stuck-on appearance, common on the face and trunk.

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Cherry Angioma

Common benign skin growths that appear as smooth, deep red spots, increasing with age.

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Study Notes

Health History and SOAP Documentation

  • SOAP stands for subjective, objective, assessment, and plan
  • Old carts: onset, location, duration, characteristics, alleviating factors, aggravating factors, radiation or relieving pain, timing, and severity
  • HPI: history of present illness
  • PQRST: precipitation, quality, radiation, severity, timing
  • Client outcomes: character, location, impact, expectation, neglect, timing, other, understanding/beliefs, treatment, complementary, options, modulating, exposure, and spirituality
  • SOAP notes: subjective data from the patient, including ROS, and objective data from the practitioner's assessment. Past medical history is not relevant to the current visit.

Common Geriatric Skin Lesions

  • Xerosis: abnormal epidermal cell turnover, causing dryness and itching in the elderly
  • Stasis dermatitis: dry, itchy, lower extremity skin, often with superficial varicose veins, causing edema and pressure. Inflamed skin may be ulcerated.

Common Geriatric Skin Tumors

  • Seborrheic keratosis: stuck-on appearance, varying color, waxy or pebbly surface. May be mistaken for other skin cancers.
  • Cherry angiomas (senile angiomas): smooth, firm, reddish spots, increasing with age.
  • Acrochordon (skin tags): soft, compressible, pedunculated or projectile.

Eye Exam

  • Eye assessment: "RSVP" (redness, sensitivity to light, vision loss, pain) questions. Any sudden vision loss is a medical emergency.
  • Pupils: Arcus senilis (ring of white or gray at corneal margin) in older adults, potentially due to fat deposits. Pterygium, a wedge-shaped growth of conjunctiva.
  • Eyelids: Endotropion and Exotropion may be observed.

Cranial Nerves

  • Cranial nerve III, IV, and VI are responsible for eye movements.
  • Vertical or horizontal diplopia may suggest issues with cranial nerve IV or VI respectively.
  • Ocular emergencies include sudden vision loss and significant eye pain.

Ear Exam

  • Outer ear includes the pinna and ear canal. Ear canal direction varies with age.
  • Middle ear includes the tympanic membrane, which transmits sound.
  • Inner ear consists of organs for hearing and balance.
  • Otalgia (ear pain) may be primary or secondary (e.g., dental or TMJ issues).
  • Hearing loss can be chronic or sudden.
  • Tympanic membrane light reflex should be seen in the anterior inferior quadrant, on the left at 7 and right at 5 o'clock.
  • Otitis media can sometimes be indicated by air bubbles behind tympanic membrane or yellow-tinged fluid.

Hearing Tests

  • Rinne test: comparing air conduction to bone conduction to check for conductive or sensorineural hearing loss.
  • Weber test: evaluates bone conduction differences between ears.
  • Whisper test: assessing hearing acuity at a distance.

Presbycusis and Other Hearing Issues

  • Presbycusis: gradual hearing loss due to nerve degeneration, it's common in adults.
  • Cerumen impaction: a possible cause of hearing loss.

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