Advanced Health Assessment 2022 with
Complete Solutions
What is the name of the format commonly used to organize data obtained during the
history and physical examination? - ANSWER Problem-Oriented Medical Record
What are the components of a SOAP note? - ANSWER S = subjective
O = objective
A = assessment
P = plan
In which section of a SOAP note does the following information belong:
Patient's heart rate is 72 - ANSWER Objective
In which section of a SOAP note does the following information belong:
Patient's pain is not well controlled - ANSWER Subjective
In which section of a SOAP note does the following information belong:
Put patient on heparin for DVT prophylaxis - ANSWER Plan
In which section of a SOAP note does the following information belong:
Patient didn't sleep well last night - ANSWER Subjective
In which section of a SOAP note does the following information belong:
Patient's breath sounds are clear - ANSWER Objective
What is an example of a well formatted assessment/plan for a patient who come to your
office with high cholesterol and a UTI? - ANSWER 1. Hyperlipidemia
- On 7/8/18 total cholesterol 275
- Continue on atorvastatin 10 mg PO QD
- Counsel on healthy diet and exercise
- Recheck lipid panel in 3 months
2. Uncomplicated cystitis
- Today urine analysis positive for ketones,
nitrites, and leukocyte esterase
- Pt experiencing burning with urination
x2days
- Start on ciproflaxacin 250 mg PO Q12H x 3
days
- Follow up in 1 week
,Advanced Health Assessment 2022 with
Complete Solutions
In which section of a SOAP note does the following information belong:
Patient has a scar on his right lower abdomen - ANSWER Objective
In which section of a SOAP note does the following information belong:
Patient's had an MI - ANSWER Assessment
In which section of a SOAP note does the following information belong:
Schedule patient for psych evaluation - ANSWER Plan
What is a pertinent negative? - ANSWER The absence of a sign or symptom that can
help you rule out or rule in a diagnosis
How should you arrange your physical exam findings? - ANSWER Head to toe by body
system
What four actions should you think about doing when assessing every body system? -
ANSWER Inspect
Palpate
Percuss
Auscultate
When writing pertinent review of systems, what should go first? - ANSWER The
pertinent symptoms that your patient admits to.
For example:
"Patient admits fever, chills, and night sweats. Patient denies shortness of breath,
syncope, or chest pain"
Name the seven components of the Comprehensive Adult Health History. - ANSWER 1.
Identifying data/source/reliability
2. Chief complaint
3. History of present illness
4. Past medical history
5. Family history
6. Social history
7. Review of symptoms
What are the major components of the "past medical history?" - ANSWER Childhood
illnesses
,Advanced Health Assessment 2022 with
Complete Solutions
Adult illnesses (medical, surgical, OB, psychiatric)
Health maintenance (immunizations, screenings, safety)
What are the major components of the "social history?" - ANSWER Education
Family
Personal interests
Lifestyle
What is the best way to document a chief complaint? - ANSWER In the patient's own
words.
Ex: "pounding headache for 2 days"
What is the most important part when documenting a family tree diagram? - ANSWER A
key
What does it mean if a test is sensitive versus specific? - ANSWER Sensitivity =
"SnNout" sensitivity rules out
Specificity = "SpPin" specificity rules in
What is patient centered interviewing? - ANSWER Following the patient's lead to
understand their thoughts, ideas, concerns, and requests, without adding additional
information from the professional's perspective.
What is symptom-focused interviewing? - ANSWER The clinician takes charge of the
interview to meet his or her need to acquire details and data in order to identify the
disease.
What is the difference between disease and illness? - ANSWER Disease = the
explanation that the clinician brings to the symptoms
Illness = the way the patient experiences all aspects of the disease
What are the eight attributes you should know for every symptom? What is a good
mnemonic that can help you remember them? - ANSWER OLD CARTS:
O = Onset
L = Location
D = Duration
C = Character
A = Aggravating/alleviating factors
R = Radiation
, Advanced Health Assessment 2022 with
Complete Solutions
T = Timing
S = Severity
What is cultural competence? - ANSWER A set of attitudes, skills, behaviors, and
policies that enable organizations and staff to work effectively in cross- cultural
situations.
What would you want to include in a description of a breast mass? - ANSWER
Tenderness
Induration
Heat
Color
Size
Nipple discharge
Location
Consistency
Shape
Texture
Mobility
Where are the palpebral fissures? - ANSWER The space between the eyelids
Where are the nasolabial folds? What are the useful for? - ANSWER The skin folds that
run from the side of the nose to the corner of the mouth. Helpful for determining facial
symmetry.
What cranial nerves innervate the facial muscles? - ANSWER V and VII
42 y/o female presents to your office for a well visit. She tells you that her sister was just
diagnosed with a "thyroid problem" and she wants to know if she could have it to. What
questions do you want to ask her to develop her history of present illness? - ANSWER
Neck swelling?
Changes in hair, skin, nails?
Changes in mood or emotional stability?
Palpitations?
Changes in mensuration?
Changes in bowel habits?
Changes in temperature preference?
What parts of the face are ideal for checking symmetry of facial features? - ANSWER
Nasolabial folds
Palpebral fissures
Complete Solutions
What is the name of the format commonly used to organize data obtained during the
history and physical examination? - ANSWER Problem-Oriented Medical Record
What are the components of a SOAP note? - ANSWER S = subjective
O = objective
A = assessment
P = plan
In which section of a SOAP note does the following information belong:
Patient's heart rate is 72 - ANSWER Objective
In which section of a SOAP note does the following information belong:
Patient's pain is not well controlled - ANSWER Subjective
In which section of a SOAP note does the following information belong:
Put patient on heparin for DVT prophylaxis - ANSWER Plan
In which section of a SOAP note does the following information belong:
Patient didn't sleep well last night - ANSWER Subjective
In which section of a SOAP note does the following information belong:
Patient's breath sounds are clear - ANSWER Objective
What is an example of a well formatted assessment/plan for a patient who come to your
office with high cholesterol and a UTI? - ANSWER 1. Hyperlipidemia
- On 7/8/18 total cholesterol 275
- Continue on atorvastatin 10 mg PO QD
- Counsel on healthy diet and exercise
- Recheck lipid panel in 3 months
2. Uncomplicated cystitis
- Today urine analysis positive for ketones,
nitrites, and leukocyte esterase
- Pt experiencing burning with urination
x2days
- Start on ciproflaxacin 250 mg PO Q12H x 3
days
- Follow up in 1 week
,Advanced Health Assessment 2022 with
Complete Solutions
In which section of a SOAP note does the following information belong:
Patient has a scar on his right lower abdomen - ANSWER Objective
In which section of a SOAP note does the following information belong:
Patient's had an MI - ANSWER Assessment
In which section of a SOAP note does the following information belong:
Schedule patient for psych evaluation - ANSWER Plan
What is a pertinent negative? - ANSWER The absence of a sign or symptom that can
help you rule out or rule in a diagnosis
How should you arrange your physical exam findings? - ANSWER Head to toe by body
system
What four actions should you think about doing when assessing every body system? -
ANSWER Inspect
Palpate
Percuss
Auscultate
When writing pertinent review of systems, what should go first? - ANSWER The
pertinent symptoms that your patient admits to.
For example:
"Patient admits fever, chills, and night sweats. Patient denies shortness of breath,
syncope, or chest pain"
Name the seven components of the Comprehensive Adult Health History. - ANSWER 1.
Identifying data/source/reliability
2. Chief complaint
3. History of present illness
4. Past medical history
5. Family history
6. Social history
7. Review of symptoms
What are the major components of the "past medical history?" - ANSWER Childhood
illnesses
,Advanced Health Assessment 2022 with
Complete Solutions
Adult illnesses (medical, surgical, OB, psychiatric)
Health maintenance (immunizations, screenings, safety)
What are the major components of the "social history?" - ANSWER Education
Family
Personal interests
Lifestyle
What is the best way to document a chief complaint? - ANSWER In the patient's own
words.
Ex: "pounding headache for 2 days"
What is the most important part when documenting a family tree diagram? - ANSWER A
key
What does it mean if a test is sensitive versus specific? - ANSWER Sensitivity =
"SnNout" sensitivity rules out
Specificity = "SpPin" specificity rules in
What is patient centered interviewing? - ANSWER Following the patient's lead to
understand their thoughts, ideas, concerns, and requests, without adding additional
information from the professional's perspective.
What is symptom-focused interviewing? - ANSWER The clinician takes charge of the
interview to meet his or her need to acquire details and data in order to identify the
disease.
What is the difference between disease and illness? - ANSWER Disease = the
explanation that the clinician brings to the symptoms
Illness = the way the patient experiences all aspects of the disease
What are the eight attributes you should know for every symptom? What is a good
mnemonic that can help you remember them? - ANSWER OLD CARTS:
O = Onset
L = Location
D = Duration
C = Character
A = Aggravating/alleviating factors
R = Radiation
, Advanced Health Assessment 2022 with
Complete Solutions
T = Timing
S = Severity
What is cultural competence? - ANSWER A set of attitudes, skills, behaviors, and
policies that enable organizations and staff to work effectively in cross- cultural
situations.
What would you want to include in a description of a breast mass? - ANSWER
Tenderness
Induration
Heat
Color
Size
Nipple discharge
Location
Consistency
Shape
Texture
Mobility
Where are the palpebral fissures? - ANSWER The space between the eyelids
Where are the nasolabial folds? What are the useful for? - ANSWER The skin folds that
run from the side of the nose to the corner of the mouth. Helpful for determining facial
symmetry.
What cranial nerves innervate the facial muscles? - ANSWER V and VII
42 y/o female presents to your office for a well visit. She tells you that her sister was just
diagnosed with a "thyroid problem" and she wants to know if she could have it to. What
questions do you want to ask her to develop her history of present illness? - ANSWER
Neck swelling?
Changes in hair, skin, nails?
Changes in mood or emotional stability?
Palpitations?
Changes in mensuration?
Changes in bowel habits?
Changes in temperature preference?
What parts of the face are ideal for checking symmetry of facial features? - ANSWER
Nasolabial folds
Palpebral fissures
