Health History and SOAP Documentation

lOMoARcPSD|46401444 Professor’s Exam 1 Review Guide: ____________________________________________________________________________________ Health History and SOAP documentation ● SOAP- subjective, objective, assessment, plan ● Old carts - onset, location, duration, characteristics, alleviating factors, aggravating factors, radiation or relieving pain, timing, severity HPI - history of present illness Acronyms to remember all components ● PQRST - precipitation, quality, radiation, severity, timing ● Client outcomes - character, location, impact, expectation, neglect, timing, other, understanding/beliefs, treatment, complementary, options, modulating, exposure, spirituality SOAP notes ● Subjective data is given from the patient, even ROS. ● Objective data is taken by the practitioner aka assessment. ● Past medical history means that it doesn't pertain to this visit. Even if the patient currently suffers from a comorbidity, it is past. Skin: Common Geriatric Lesions: ● Xerosis: Impaired keratinocyte formation, which results in abnormal epidermal cell turnover, is responsible for xerosis, the most common cause of itch in the elderly ● Stasis Dermatitis: Dry, itchy skin of the lower extremities warrants special evaluation for advancing vascular changes. Superficial varicose veins with the underlying vascular impediments of edema and pressure manifest as an eruption of the lower leg seen in stasis dermatitis. The inflamed, sometimes ulcerated skin of acute stasis dermatitis may be accompanied by the chronic changes of stasis dermatitis including hyperpigmentation, lichenification, and scars of healed ulcers. ● Rosacea: While not limited to the geriatric population, rosacea is an underdiagnosed and misdiagnosed inflammatory condition, which is chronic and progressive. The hallmark of rosacea in the geriatric population is in the bulky tissue (phymatous) and dilated telangiectatic vessels ● commonly seen after years of persistent redness and flushing. Another common variant of rosacea in the elderly is ocular rosacea, often overlooked in the ocular examination. Common Geriatric Skin Tumors: Eye Exam ● Eye Assessment - A good mnemonic for an eye history is to ask “RSVP” questions. If all answers are YES = urgent ophthalmology consult required. ○ Redness Sensitivity to light Vision Loss Pain ○ Any sudden loss of vision = ocular emergency ● Pupils ○ Arcus senilis - white or gray ring at corneal margin seen in older adults. Caused by fat deposits in the cornea or hyaline degeneration. See Photo Below. ○ ● Pterygium - Wedge-shaped and raised conjunctival growth, usually extending from nasal side. May be related to chronic irritation. Eyelids ○ Endotropion - inward turning of lid margin and lashes toward eye surface (incidence increases with age) ○ Exotropion - outward turning of the lid margin and lashes outward, away from eye (incidence increases with age) lOMoARcPSD|46401444 ○ ○ ● ● ● ● ● ● Eyelid malignancy - most common is basal cell carcinoma Hordeolum (Stye) and Chalazion - Cranial nerve III (oculomotor) is responsible for transmitting visual images to the brain Cranial nerve III (oculomotor), IV (trochlear), and VI (abducens) are responsible for the movements of the eye Vertical diplopia is caused by an issue with Cranial nerve IV while horizontal diplopia is caused by Cranial nerve VI Visual Acuity test: expressed as two numbers. The first number describes the patient’s distance from the chart (20 feet); the second describes the distance at which a normal eye can read print that a person with normal vision could read at 30 feet. The negative number documents the number of errors made by the patient. I.e. 20/30-1 Corneal Reflex test: Lightly touch the cornea with a wisp of cotton. The lids of both eyes will normally close when either eye is touched. Failure of both eyes to close indicated increased ICP which impairs the sensory branch (CN V) and motor branch (CN VII). Typically done on unconscious pts. Eyelid Eversion: If the pt complains of eye pain/foreign body sensation, evert the upper lid. Gently grasp upper eyelashes and pull downward. Place a cotton swab midway on the upper lid. Using slight pressure, evert lid over the applicator. Examine the lid for swelling, tenderness, and foreign bodies. See photo below: