WITH CORRECT ANSWERS
/. Subjective (SOAP note) - Answer-✅Information reported by the patient
Includes:
• Chief Complaint (CC)
• History of Present Illness (HPI)
• Review of Systems (ROS)
• Past Medical History
• Medications
• Allergies
• Family History
• Social History
• Sexual history
• Substance use
/.Objective (SOAP note) - Answer-✅Observed/measured findings
Includes:
• Vital signs
• Physical exam findings
• Lab results
• Diagnostic tests
/.Assessment (SOAP note) - Answer-✅• Medical diagnosis
• Differential diagnoses
• Clinical impression
/.Plan (SOAP note) - Answer-✅Treatment plan:
• Medications
• Labs
• Imaging
• Referrals
• Patient education
• Follow-up
/.Types of SOAP Notes - Answer-✅Comprehensive
Full history + full physical exam.
Used for:
,• New patient visits
• Annual exams
Focused
Problem-specific exam.
Used for:
• Follow-up
• Chronic disease management
Episodic
Single acute complaint.
Example:
• Sore throat
• Ear pain
/.HISTORY OF PRESENT ILLNESS (HPI) - Answer-✅OLDCARTS (onset-location-
duration-character-allieving/aggravating-time-severity)
/.SUBJECTIVE vs OBJECTIVE DATA - Answer-✅Subjective
Patient statements.
Example:
• "My chest hurts"
• "I feel dizzy"
• "I have a headache"
Objective
Clinician findings.
Example:
• BP 150/90
• Wheezing
• Rash on chest
/.SKILLED INTERVIEWING - Answer-✅Key components:
• Open-ended questions
• Active listening
• Empathy
• Clarification
• Cultural humility
,/.NEUROLOGICAL SYSTEM-CNS - Answer-✅Includes:
• Brain
• Spinal cord
Function:
• Processes information
• Controls movement
• Cognition
How to assess
• Mental status
• Orientation
• Speech
• Motor strength
• Sensory exam
• Reflexes
• Coordination
• Gait
• cranial nerves
/.NEUROLOGICAL SYSTEM-PNS - Answer-✅Includes:
• Peripheral nerves
• Sensory and motor nerves
Function:
• Communication between body and CNS
How to assess
• Sensation to light touch, pain, vibration
• Motor strength
• Reflexes
• Peripheral nerve tests like Phalen and Tinel
/.NEUROLOGICAL SYSTEM-ANS - Answer-✅Controls involuntary functions
Two divisions:
Sympathetic
Fight or flight
Effects:
• ↑ HR
• ↑ BP
• Dilated pupils
Parasympathetic
Rest and digest
, Effects:
• ↓ HR
• ↑ digestion
/.CRANIAL NERVES (HIGH-YIELD) - Answer-✅CNI- Olfactory
Smell
Identify odors
CNII- Optic
Vision
Snellen chart
CNIII- Oculomotor
Eye movement
PERRLA
CNIV- Trochlear
Eye movement
Look down/in
CNV- Trigeminal
Facial sensation
Clench jaw
CNVI- Abducens
Lateral eye movement
Look laterally
CNVII- Facial
Facial expression
Smile, frown
CNVIII- Vestibulocochlear
Hearing/balance
Whisper test
CNIX- Glossopharyngeal
Swallow
Gag reflex