Health History and SOAP Documentation Quiz

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Questions and Answers

Which of the following is a hallmark feature of a venous lake?

  • Single, firm, painful, and red to white nodule
  • Soft, compressible, and pedunculated
  • 1-2 mm soft, dome-shaped, pale yellow with central umbilication
  • Compression collapses lesions (correct)

What is the differential diagnosis for chondrodermatitis nodularis chronica helicis?

  • Blue nevus, malignant melanoma, tattoo
  • Actinic keratosis, keratoacanthoma (correct)
  • Seborrheic keratosis, dermal nevi, warts
  • Basal cell carcinoma, HSV, Molluscum

Which of the following is a common location for acrochordon?

  • Face, glabella
  • Vermillion border of lip, ear
  • Neck, axillary, groin, eyelids (correct)
  • Lateral surface of the helix, antihelix

What is the main characteristic of sebaceous hyperplasia?

<p>1-2 mm soft, dome-shaped, pale yellow with central umbilication (B)</p> Signup and view all the answers

What is the mnemonic used to remember the key questions to ask for an eye history?

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

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

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

If someone experiences an inability to move their eye downward, which cranial nerve is likely affected?

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

What type of diplopia (double vision) is associated with an issue in Cranial nerve VI (abducens)?

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

In the context of the Fluorescein Stain Technique, what is the purpose of using UV light after applying the stain?

<p>To enhance the visibility of corneal abrasions or foreign bodies (D)</p> Signup and view all the answers

Which condition is characterized by a firm, painless lump above the eyelashes on the upper lid?

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

In the context of eyelid assessment, what does 'everting the upper lid' refer to?

<p>Turning the eyelid outward to examine the inner surface (D)</p> Signup and view all the answers

In a visual acuity test, what does the second number in the fraction (e.g., 20/30) represent?

<p>The distance at which a person with normal vision can read the same line of print (D)</p> Signup and view all the answers

What is the purpose of the Corneal Reflex test?

<p>To evaluate the function of the sensory and motor branches of cranial nerves V and VII (B)</p> Signup and view all the answers

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

<p>Procedure (D)</p> Signup and view all the answers

What does the acronym PQRST stand for in the context of pain evaluation?

<p>Precipitation, Quality, Radiation, Severity, Timing (B)</p> Signup and view all the answers

Which of the following is the most common cause of itch in the elderly?

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

Which skin condition is characterized by dry, itchy skin of the lower extremities and may indicate advancing vascular changes?

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

What are the hallmark features of seborrheic keratosis?

<p>Stuck-on appearance, varying color, waxy surface (B)</p> Signup and view all the answers

Which of the following is NOT a common variant of rosacea in the elderly?

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

Which of these is considered subjective data in a SOAP note?

<p>Patient's description of pain (C)</p> Signup and view all the answers

Which of the following is a common characteristic of cherry angiomas (senile angiomas)?

<p>They are small, red, and smooth (C)</p> Signup and view all the answers

What does a corneal abrasion indicate when areas of stain uptake appear fluorescent bright green?

<p>That there is a foreign body in the eye (B)</p> Signup and view all the answers

Which direction should the ear be pulled when examining the ear of a child under the age of three?

<p>Downward, outward, and backward (D)</p> Signup and view all the answers

What does an opaque tympanic membrane indicate?

<p>Chronic otitis without perforation or tympanosclerosis (A)</p> Signup and view all the answers

How is conductive hearing loss indicated in the Weber test?

<p>Sound is heard louder in the affected ear (D)</p> Signup and view all the answers

What should be observed in the tympanic membrane's light reflex?

<p>It should appear in the anterior inferior quadrant (B)</p> Signup and view all the answers

What does the cover-uncover test assess?

<p>Muscle coordination of the eyes (A)</p> Signup and view all the answers

What does the presence of air bubbles behind the tympanic membrane indicate?

<p>Acute otitis media or serous otitis (C)</p> Signup and view all the answers

What does it indicate if air conduction is louder than bone conduction in a hearing test?

<p>Normal hearing (A), Positive test result (C)</p> Signup and view all the answers

What is the primary role of the ear's outer structure?

<p>Protect the ear canal from debris (B)</p> Signup and view all the answers

In which scenario would the whisper test be repeated with a louder sound?

<p>When a patient hears no words correctly (A), When a patient repeats 50% of the words correctly (C)</p> Signup and view all the answers

During the Romberg test, what signifies a positive outcome?

<p>Ability to stay still with eyes closed (B)</p> Signup and view all the answers

How should the ear of a child under three years be examined?

<p>Pull downward, outward, and backward (D)</p> Signup and view all the answers

What does the presence of otalgia indicate?

<p>Possible inflammation or infection of the ear (B)</p> Signup and view all the answers

What is the significance of the tympanic membrane light reflex location?

<p>Indicates a possible ear infection (B)</p> Signup and view all the answers

What is indicated if air conduction is equal to or less than half as long as bone conduction?

<p>Sensorineural hearing loss (C)</p> Signup and view all the answers

What does an opaque tympanic membrane typically indicate?

<p>Tympanosclerosis (B), Chronic otitis without perforation (C)</p> Signup and view all the answers

What anatomical structures are part of the outer ear?

<p>Pinna and ear canal (B)</p> Signup and view all the answers

During a Weber test, if the sound is louder in one ear, this typically indicates what type of hearing loss?

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

What indicates a positive Rinne test result?

<p>Air conduction is twice as long as bone conduction (B)</p> Signup and view all the answers

What does a whisper test result showing less than 50% correct responses indicate?

<p>Either conductive or sensorineural hearing loss (A)</p> Signup and view all the answers

Presbycusis is characterized by which of the following?

<p>Gradual hearing loss due to nerve degeneration (B)</p> Signup and view all the answers

A yellow-tinged tympanic membrane can indicate what condition?

<p>An infection with pus (C)</p> Signup and view all the answers

What does a Romberg test primarily assess?

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

What is cerumen impaction commonly associated with?

<p>Persistent or sudden hearing loss (C)</p> Signup and view all the answers

Which cranial nerve is responsible for controlling the movement of the tongue?

<p>Cranial Nerve XII (Hypoglossal) (A)</p> Signup and view all the answers

Which cranial nerve is tested by having the patient follow a penlight through six cardinal fields of gaze?

<p>Cranial Nerve VI (Abducens) (C)</p> Signup and view all the answers

Which cranial nerve is responsible for the sense of taste on the anterior two-thirds of the tongue?

<p>Cranial Nerve VII (Facial) (D)</p> Signup and view all the answers

A patient presents with difficulty swallowing. Which two cranial nerves might be involved in this issue?

<p>Cranial Nerve IX (Glossopharyngeal) and Cranial Nerve X (Vagus) (A)</p> Signup and view all the answers

Which cranial nerve is tested by asking the patient to smile, close their eyes tightly, and raise their eyebrows?

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

Flashcards

Acrochordon

Soft, compressible skin tags found in areas like neck and groin.

Venous lake

A compressible lesion located at the lip's vermillion border or ear.

Sebaceous hyperplasia

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

Chondrodermatitis nodularis chronica helicis

A painful nodule on the ear's helix, red to white, firm.

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Eye Exam RSVP mnemonic

Questions that indicate urgent eye assessment: Redness, Sensitivity, Vision loss, Pain.

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SOAP Documentation

A method for documenting a patient's health record consisting of Subjective, Objective, Assessment, and Plan components.

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Old CARTS

An acronym used in health history to assess pain, covering Onset, Location, Duration, Characteristics, Alleviating factors, Aggravating factors, Radiation or relieving pain, Timing, and Severity.

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HPI

History of Present Illness; a detailed account of a patient's current health problem.

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PQRST

A mnemonic for assessing pain: Precipitation, Quality, Radiation, Severity, Timing.

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Subjective Data

Information given by the patient, including their personal experience and complaints.

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Xerosis

The most common cause of itch in the elderly, characterized by impaired skin moisture and disrupted skin cell turnover.

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Stasis Dermatitis

A condition causing dry, itchy skin in the lower extremities due to vascular changes, often evident with varicose veins and edema.

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Seborrheic Keratosis

A common skin tumor in the elderly, presenting as a stuck-on appearance, varying colors, and a waxy surface, typically located on the face and trunk.

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Endotropion

Inward turning of eyelid margin and lashes toward the eye.

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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 tenderness and swelling near an eyelash follicle.

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Chalazion

A blocked oil gland causing a firm, painless lump above eyelashes.

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Cranial Nerve III

Oculomotor nerve responsible for eye movements and visual transmission.

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Cranial Nerve IV

Trochlear nerve, involved in vertical eye movement; issues cause diplopia.

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Visual Acuity Test

Measures distance vision expressed as a fraction (e.g., 20/30).

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Fluorescein Stain Technique

Used to inspect eye's cornea and conjunctiva for issues after applying stain.

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Air Conduction (AC)

The transmission of sound through the air to the inner ear.

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Opaque Tympanic Membrane

Indicates chronic otitis without perforation or tympanosclerosis.

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Air Bubbles in Tympanic Membrane

Can indicate acute otitis media or serous otitis.

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Bone Conduction (BC)

The transmission of sound through the bones of the skull to the inner ear.

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Yellow Tinged Tympanic Membrane

Suggests infection with pus present.

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Positive Hearing Test

Result where air conduction is louder than bone conduction (AC > BC).

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Conductive Hearing Loss

Condition where BC is louder than AC (BC > AC).

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Conductive Hearing Loss Cause

Can occur from lack of tympanic membrane flexibility.

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Sensorineural Hearing Loss

Occurs when AC is equal to or less than half of BC.

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Weber Test

Tests bone conduction by placing a fork on the forehead.

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Whisper Test

Tests hearing acuity by whispering words from 2 feet away.

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Rinne Test

Compares air conduction to bone conduction in one ear.

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Romberg Test

Assesses balance; patient stands with eyes closed and arms at their side.

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Whisper Test

Tests hearing acuity by whispering words from a distance.

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Romberg Test

Assesses inner ear function by balancing with eyes closed.

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Tympanic Membrane Light Reflex

Normal light reflection seen in the tympanic membrane, indicating health.

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Corneal Abrasion

A scratch or damage on the cornea, indicated by fluorescent green stain uptake.

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Corneal Light Reflex Test

A test to check symmetrical light reflection in pupils; an imbalance prompts further testing.

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Cover/Uncover Test

A test to determine weak eye by observing movement after covering and uncovering each eye.

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Otalgia

Ear pain which can be primary (from infection) or secondary (from conditions like TMJ).

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Tympanic Membrane Reflex

Normal light reflex should be seen at specific quadrants (left 7 o'clock, right 5 o'clock).

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Acute Otitis Media

Infection characterized by air bubbles and frequently occurs behind the tympanic membrane.

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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, expectations, neglect, timing, other, understanding/beliefs, treatment, complementary options, modulating factors, exposure, and spirituality

SOAP Notes

  • Subjective data comes from the patient, including ROS (review of systems)
  • Objective data is the assessment from the practitioner

Past Medical History

  • Past medical history is not relevant to the current visit, even if the patient has a comorbidity.

Common Geriatric Skin Lesions

  • Xerosis: impaired keratinocyte formation, resulting in abnormal epidermal cell turnover, causing itching in the elderly.
  • Stasis Dermatitis: dry, itchy skin in the lower extremities, often caused by advancing vascular changes; superficial varicose veins with underlying impediments lead to edema/pressure causing eruption in the lower leg. Inflammation and ulceration in acute stages may be chronic.

Common Geriatric Skin Tumors

  • Seborrheic Keratosis: stuck-on appearance, varying color, dryness, waxy, pebbly/verrucous surface. Differentiation from malignant melanoma, lentigo, wart, and actinic keratosis is crucial.
  • Cherry Angioma (senile angioma): smooth, firm, deep red, numerous, increasing with age. Differentiation from petechiae is important.
  • Other common geriatric skin tumors include: Acrochordon (skin tags) which are soft compressible, potentially pedunculated or projectile. Also venous lakes as well as sebaceous hyperplasia, which manifests as pale yellow, dome-shaped lesions commonly on the face and glabella, 1-2 mm in size, often with a central umbilication.

Other Skin Conditions

  • Rosacea: an underdiagnosed inflammatory skin condition that is chronic and progressive and can present with persistent redness, flushing, and dilated telangiectatic vessels, particularly in the geriatric population. Ocular rosacea is a common, overlooked variant in the elderly.

Acronyms

  • PQRST: Precipitation, Quality, Radiation, Severity, Timing

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