EYES/EARS, NOSE AND THROAT (OJOS, OREJAS, NARIZ, Y GARGANTA)

S.O.A.PSocial and Medical IntakeGlobal Medical Training @ UCLASarah Kim & Kevin LloydS.O.A.PSUBJECTIVEOBJECTIVEASSESMENTPLAN

SUBJECTIVE: Patient InfoFirst, introduce yourself!

Obtain basic info

Past medical history (PMH)

Social life

Chief complaint (secondary complaint)

Vitals (objective)TemperaturePulse RateBlood Pressure

-Remember, your speech, posture and body language can greatly affect the interview.-Open-ended questions; Let the patient be as descriptive as possible. -If more than one issue addressed, explore EACH one individually using the follow-up questions described in the next slide-

3SUBJECTIVE: Present IllnessHistory of present illness (HPI):OnsetLocationDurationCharacteristicsAggravating factorsRelieving factorsSeverity

OBJECTIVE: Physical ExamInspection/ObservationGeneral, eyes, ears/nose/throat (ENT), cardiovascular (CV), respiratory, gastrointestinal, muscular, skin, neurology, psychology AuscultationPalpationPercussion

5ASSESSMENT/PLANDiscussion of caseAssessmentPreliminary diagnosis presented to attending physiciansPlan/TreatmentPrescribe medicationPREVENTATIVE ADVICE!RxDoctors prescription