Health History and SOAP Documentation

A structured method for documenting patient information: Subjective, Objective, Assessment, Plan.

History of Present Illness; details about a patient's current health issue.

Aids in gathering health history: Onset, Location, Duration, Characteristics, Alleviating factors, Aggravating factors, Radiation, Timing, Severity.

An acronym for assessing pain: Precipitation, Quality, Radiation, Severity, Timing.

Dry skin condition in the elderly due to impaired epidermal cell turnover.

Skin condition in lower extremities due to vascular changes and edema; presents as dry, itchy skin.

A common skin tumor in the elderly; appears as a stuck-on, waxy growth on the face and trunk.

Smooth, firm, deep red spots on the trunk, increasing with age; known as senile angioma.

A soft, compressible skin tag found on the neck, axillary, groin, and eyelids.

A bluish lesion on the vermillion border of the lip or ear that collapses when compressed.

Soft, dome-shaped, pale yellow lesions with central umbilication found on the face, especially glabella.

A painful, firm nodule located on the helix with a size of 2 to 6 mm.

A white or gray ring seen at the corneal margin in older adults due to fat deposits.

Air conduction (AC) should be louder than bone conduction (BC) in a healthy ear; AC > BC indicates normal hearing.

A positive hearing test indicates AC is longer than BC, ideally twice as long, showing normal hearing function.

Indicated when BC is louder or longer than AC; suggests problems in the outer/middle ear.

Occurs when AC is equal to or less than half the length of BC, indicating inner ear issues.

A basic acuity test that checks hearing sensitivity; passing is getting 50% or more words correct.

A test for balance and inner ear function where a patient stands still with eyes closed to assess swaying.

Normal light reflex seen in the tympanic membrane at specific positions: left at 7 o'clock, right at 5 o'clock.

Ear pain that can be primary (from infection) or secondary (from other causes like TMJ or sinus issues).

Fluorescent green areas indicating corneal abrasion.

Test where patients focus on a light to check pupil symmetry.

Determines the weaker eye by observing movement after covering.

Outer, middle, and inner ear responsible for hearing and balance.

Reflection seen at specific positions indicating normal ear health.

Tests bone conduction by placing a tuning fork on the forehead.

Compares air conduction to bone conduction for one ear.

Indicates chronic otitis without perforation or tympanosclerosis.

Indicate acute otitis media or serous otitis.

May indicate infection with pus.

Earwax build-up causing hearing loss; common in older adults.

Inward turning of the eyelid margin and lashes towards the eye surface, often increasing with age.

Outward turning of the eyelid margin and lashes away from the eye, commonly occurs with age.

A bacterial infection resulting in tenderness, swelling, usually near an eyelash follicle.

A firm, painless lump caused by a blocked oil gland, typically above the eyelashes.

The oculomotor nerve responsible for transmitting visual images and eye movements.

Double vision caused by dysfunction of Cranial Nerve IV (trochlear).

A test expressed as two numbers representing distance from the chart and normal vision distance.

A test checking the response of eyelids closing when touching the cornea, indicating nerve function.