ADVANCED HEALTH ASSESSMENT EXAM: A+ GRADED GUIDE
WITH THE LATEST KEY QUESTIONS AND ANSWERS.
Subjective Section of SOAP data
Chief complaint
History of present illness
Past medical history
Medications
Allergies
Last menstrual period for women
Family and social history
Nutritional assessment
Review of systems
Objective SOAP data
Data and information obtained by the examiner with his eyes, ears, and hands
Laboratory findings and diagnostic test results obtained at the time of the examination
or immediately afterwards
Comprehensive history and PE
Patient presents for an annual physical examination or is a new patient
Focused hx and PE
Focused, or episodic, health history and physical examination
Patient is presenting to the healthcare provider for a specific problem
Components of PMH
Previous or current illnesses
Hospitalizations/surgeries
Injuries
Immunizations
Medications
Allergies
Transfusions/transfusion reactions
Results of any screening examinations
,Documentation strategies to avoid legal problems
What was taught or explained
To whom it was told
If the patient/family stated they understood the information presented
The format (written and/or verbal instructions)
PE Face and head
Inspect skin characteristics
Inspect and palpate scalp and hair
Inspect face for appearance, expression, symmetry of structure and features, and
movements
Ask the patient to raise his eyebrows, frown, smile, and open eyes against resistance
Evaluate sensation awareness of the forehead, cheeks, and jaw on each side of the
face (CN V)
Palpate the masseter and temporal muscles
PE Neck
Palpate the lymph nodes in the neck area
Palpate carotid pulses one at a time
Determine the position of the trachea
Palpate thyroid
Auscultate carotid arteries and thyroid for bruits
PE posterior chest and back
Inspect skin for lesions
Note thoracic configuration
Palpate the spine
Percuss the kidneys
Assess the lungs
PE lungs
Evaluate thoracic expansion
Palpate tactile fremitus
Percuss the chest
, Determine diaphragmatic excursion
Auscultate the posterior thoracic cage; note breath sounds
Functional assessment of elderly pt
Determine the ability of the elderly to deal with the daily demands of life
Establish a management plan for the elderly patient
Decide on the level of instruction to provide
Determine the ability of the patient to comply with the management plan
Ability to perform basic activities of daily living (ADL)
Ability to perform instrumental ADL
Mobility (use of cane, walker, wheelchair)
Communication, speech, hearing acuity
Safety
Medication status
Mental status and mood impairment
Functions or cerebral cortex
General movement
Visceral functions
Perception
Behavior
Integration of these functions
Temporal lobe
Perception and interpretation of sounds
Comprehension of written and spoken language (Wernicke speech area)
Integration of sensations, behavior, and personality
Functions of frontal lobe
Voluntary skeletal movement and speech formation (Broca's area)
Emotions, affect, drive, and awareness of self
parietal lobe
Processing of sensory data (visual, tactile, gustatory, olfactory, auditory)
Comprehension of written language
Proprioception
WITH THE LATEST KEY QUESTIONS AND ANSWERS.
Subjective Section of SOAP data
Chief complaint
History of present illness
Past medical history
Medications
Allergies
Last menstrual period for women
Family and social history
Nutritional assessment
Review of systems
Objective SOAP data
Data and information obtained by the examiner with his eyes, ears, and hands
Laboratory findings and diagnostic test results obtained at the time of the examination
or immediately afterwards
Comprehensive history and PE
Patient presents for an annual physical examination or is a new patient
Focused hx and PE
Focused, or episodic, health history and physical examination
Patient is presenting to the healthcare provider for a specific problem
Components of PMH
Previous or current illnesses
Hospitalizations/surgeries
Injuries
Immunizations
Medications
Allergies
Transfusions/transfusion reactions
Results of any screening examinations
,Documentation strategies to avoid legal problems
What was taught or explained
To whom it was told
If the patient/family stated they understood the information presented
The format (written and/or verbal instructions)
PE Face and head
Inspect skin characteristics
Inspect and palpate scalp and hair
Inspect face for appearance, expression, symmetry of structure and features, and
movements
Ask the patient to raise his eyebrows, frown, smile, and open eyes against resistance
Evaluate sensation awareness of the forehead, cheeks, and jaw on each side of the
face (CN V)
Palpate the masseter and temporal muscles
PE Neck
Palpate the lymph nodes in the neck area
Palpate carotid pulses one at a time
Determine the position of the trachea
Palpate thyroid
Auscultate carotid arteries and thyroid for bruits
PE posterior chest and back
Inspect skin for lesions
Note thoracic configuration
Palpate the spine
Percuss the kidneys
Assess the lungs
PE lungs
Evaluate thoracic expansion
Palpate tactile fremitus
Percuss the chest
, Determine diaphragmatic excursion
Auscultate the posterior thoracic cage; note breath sounds
Functional assessment of elderly pt
Determine the ability of the elderly to deal with the daily demands of life
Establish a management plan for the elderly patient
Decide on the level of instruction to provide
Determine the ability of the patient to comply with the management plan
Ability to perform basic activities of daily living (ADL)
Ability to perform instrumental ADL
Mobility (use of cane, walker, wheelchair)
Communication, speech, hearing acuity
Safety
Medication status
Mental status and mood impairment
Functions or cerebral cortex
General movement
Visceral functions
Perception
Behavior
Integration of these functions
Temporal lobe
Perception and interpretation of sounds
Comprehension of written and spoken language (Wernicke speech area)
Integration of sensations, behavior, and personality
Functions of frontal lobe
Voluntary skeletal movement and speech formation (Broca's area)
Emotions, affect, drive, and awareness of self
parietal lobe
Processing of sensory data (visual, tactile, gustatory, olfactory, auditory)
Comprehension of written language
Proprioception
