Medical Terminology: SOAP Notes Exam Guide With Questions And Well Elaborated Correct Answers/2024.

Subjective - correct answer symptoms in the patients own words Subjective - correct answer pertinent past medical history, surgical history, family history, social history along with current medications and allergies Subjective - correct answer includes:onset, location, duration;character or symptoms;alleviating/aggravating factors; radiation of pain/symptoms; temporal pattern(time of day, all day);associated symptoms Objective - correct answer vital signs Objective - correct answer findings from physical examinations:posture, bruising, abnormalities Objective - correct answer results from tests, labs, ones performed Objective - correct answer measurements, age, weight Assessment - correct answer summary of the patient with main symptoms Assessment - correct answer differential diagnosis Assessment - correct answer list of other possible diagnosis Assessment - correct answer problems the patient has Plan - correct answer diagnostic plan,treatment plan Plan - correct answer patient education Plan - correct answer address each item in differential diagnosis Plan - correct answer timing for further review or follow-up Plan - correct answer may be grouped with assesment Objective - correct answer x-ray shows plural effusion Subjective - correct answer current medications patient taking tylenol, insulin Subjective - correct answer patient quote:"I can't lie down to sleep and my chest feels heavy" Objective - correct answer visible signs:bilateral lower extremities edema, breathing appears labored Subjective - correct answer Reason for patients visit:dyspnea and angina for the last 3 days Objective - correct answer electrocardiogram shows mild bradycardia Assessment - correct answer Diagnosis;congestive heart failure, poorly controlled diabetes Plan - correct answer Tests needed:repeat electrocardiogram, CBC Subjective - correct answer Previously diagnosed with diabetes and rheumatoid arthritis Plan - correct answer needs referral to endocrinologist Plan - correct answer Drugs needed: anti arrhythmic, diuretic and anticoagulant Objective - correct answer Patient is 78 years old, female Objective - correct answer Blood pressure 130/85, pulse:65; respirations 14;temperature 99.1 Subjective - correct answer family history of breast cancer, heart disease and stroke Plan - correct answer sputum sample needed Subjective - correct answer current complaints:polyuria, polydipsia, dyspnea, angina Objective - correct answer echocardiogram showed cardiomegaly Objective - correct answer