TDP Week 4 – Accurate Answers To All Questions
What the patient tells you - the history component.
S in SOAP
Components Subjective:
Chief complaint (CC)
History of Present Illness (HPI)
Past Medical History (PMH)
Past Surgical History (PSH)
Medications (Meds)
Allergies (All)
Social History (SH)
Family History (FH)
Review of Systems (ROS) Correct Answer - Subjective (S)
What you the doctor observes/measures
O in SOAP
Components of Objective:
Physical Exam
Vital Signs, Height, Weight, BMI (Vitals are always first)
General
HEENT: Head, Eyes, Ears, Nose, Throat Cardiovascular
Pulmonary
Abdomen
Genital-Urinary
Neurologic
Psych
Musculoskeletal
Skin
,OMMLabs, Imaging, other test resultsObjective Correct Answer -
Objective (O)
Your goal is to visualize one area of the body at a time to preserve
patient's modesty Correct Answer - Tips of Draping
General Survey: A head-to-toe assessment and observation of a
patient which includes the patient's appearance and demeanor.
***This is done/observed within the first few minutes ofmeeting a
patient***
Components of a General Survey
Apparent State of Health
Level of consciousness
Signs of Distress
Skin Color
Grooming/Personal Hygiene/OdorFacial Expressions
Posture/Gait/Motor Activity Correct Answer - General Survey
Alert: If patient is awake and alert you would document that patient
is alert.
Oriented: - this has 4 components: Person, Time, Place, andSituation.
1. Person - to assess for this can ask "What is yourname?" or "What
is your date of birth?"
2. Time - to assess for this can ask "what is today's date?" or "What
is the year?" or "What is the month?"
3. Place - to assess for this can ask "Where are you?" or "What kind
of building is this?" or "What city are you in ?"
4. Situation -to assess for thi Correct Answer - Orientation
In front of or front Correct Answer - Anterior
, In behind of or behind Correct Answer - Posterior
Towards the front of the body Correct Answer - Ventral
Towards the back of the body Correct Answer - Dorsal
Further or away from the trunk or the point of origin of the body
Correct Answer - Distal
Closer or towards the trunk or the point of origin of the body
Correct Answer - Proximal
Midline of the body Correct Answer - Median
Towards the median Correct Answer - Medial
Away from the median Correct Answer - Lateral
Towards the top of the head Correct Answer - Superior
Towards the feet Correct Answer - Inferior
Towards the head Correct Answer - Cranial (Cephalic)
Towards the tail Correct Answer - Caudal
Towards the surface, superficial Correct Answer - External
Away from the surface, deep Correct Answer - Internal
Nearer to the surface Correct Answer - Superficial
Farther from the surface Correct Answer - Deep
What the patient tells you - the history component.
S in SOAP
Components Subjective:
Chief complaint (CC)
History of Present Illness (HPI)
Past Medical History (PMH)
Past Surgical History (PSH)
Medications (Meds)
Allergies (All)
Social History (SH)
Family History (FH)
Review of Systems (ROS) Correct Answer - Subjective (S)
What you the doctor observes/measures
O in SOAP
Components of Objective:
Physical Exam
Vital Signs, Height, Weight, BMI (Vitals are always first)
General
HEENT: Head, Eyes, Ears, Nose, Throat Cardiovascular
Pulmonary
Abdomen
Genital-Urinary
Neurologic
Psych
Musculoskeletal
Skin
,OMMLabs, Imaging, other test resultsObjective Correct Answer -
Objective (O)
Your goal is to visualize one area of the body at a time to preserve
patient's modesty Correct Answer - Tips of Draping
General Survey: A head-to-toe assessment and observation of a
patient which includes the patient's appearance and demeanor.
***This is done/observed within the first few minutes ofmeeting a
patient***
Components of a General Survey
Apparent State of Health
Level of consciousness
Signs of Distress
Skin Color
Grooming/Personal Hygiene/OdorFacial Expressions
Posture/Gait/Motor Activity Correct Answer - General Survey
Alert: If patient is awake and alert you would document that patient
is alert.
Oriented: - this has 4 components: Person, Time, Place, andSituation.
1. Person - to assess for this can ask "What is yourname?" or "What
is your date of birth?"
2. Time - to assess for this can ask "what is today's date?" or "What
is the year?" or "What is the month?"
3. Place - to assess for this can ask "Where are you?" or "What kind
of building is this?" or "What city are you in ?"
4. Situation -to assess for thi Correct Answer - Orientation
In front of or front Correct Answer - Anterior
, In behind of or behind Correct Answer - Posterior
Towards the front of the body Correct Answer - Ventral
Towards the back of the body Correct Answer - Dorsal
Further or away from the trunk or the point of origin of the body
Correct Answer - Distal
Closer or towards the trunk or the point of origin of the body
Correct Answer - Proximal
Midline of the body Correct Answer - Median
Towards the median Correct Answer - Medial
Away from the median Correct Answer - Lateral
Towards the top of the head Correct Answer - Superior
Towards the feet Correct Answer - Inferior
Towards the head Correct Answer - Cranial (Cephalic)
Towards the tail Correct Answer - Caudal
Towards the surface, superficial Correct Answer - External
Away from the surface, deep Correct Answer - Internal
Nearer to the surface Correct Answer - Superficial
Farther from the surface Correct Answer - Deep
