CSAA practice EXAMS

CSA: 3/24/2025 8:00AM

HPI
ROS
PMH
PSH
ALL
MED
SH
- Diet
- Exercise
- Work
FH
HPI: OLDCAARTS
- Onset
- Location
- Character
- Duration
- Aggravating
- Associated s/s
- Alleviating
- Radiation
- Timing
- Severity
:
ROS: at least two findings from 10 separate systems:
G! Some Nurses provide Excellent Enteral Medical Care, Really AmazinG
1. General: Fatigue? Fever? Weight loss?
2. Skin: rashes? Bruising?
3. Nuero: headache? Dizziness?
4. PSYC: anxiety? Change in mood?
5. EENT: blurred vision? Nasal discharge?
6. Endocrine: heat intolerance? Cold intolerance?
7. MSK: muscle cramps? Joint pain?
8. CARDIO: Chest pain? Edema (sweelling feet)? Orthopean? (SOB when
lying down)
9. RESP: SOB? Cough?
10. GI/Abdominal: abdominal pain?
11. GU: pain urinating? Blood in urine?

-----------------------------
● Objective
● Vitals(just include everything)
● GEN: NAD; appears in pain
● Physical Exam
○ Expanded of One system
○ Basic exams for remaining systems
●
:
 ● PHYSICAL EXAM : Some Nurses Provide Excellent Enternal Medical
Care, Really AMazing
●
● Skin
○ ROS: rashes? Bruising?
○ Basic exam:
■ Skin Inspection: inspected anterior and posterior UPPER
extremities b/l
● ‘No rashes b/l UE and LE’
■ Skin palpation:
csa com2 ● ‘B/l UE and LE skin warm and dry’
○ EXPANDED
■ draping
■ Scalp: have them tilt head forward, move hair in organized
pattern
■ Anterior: inspected skin of anterior chest and abdomen
● Have pt lie down for abdomen and drape them
accordingly
■ Posterior: inspected skin on back
■ [standing]
■ Extremities INSPECTION: inspect anterior and posterior LE
and UE b/l + SOLES OF FEET
■ Extremities PALPATION: palpate anterior and poster UE and
LE b/l and soles of feet
■ Nails: inspect pt’s finger and toenails b/l
● Nuerological
○ ROS:
■ NEURO: headache? Dizziness?
■ PSYC: anxiety? Change in mood?
○ Basic
■ Mental status:
● What’s your name?
● Where are you?
● What year is it?
● Can you explain why you are here?
■ CN 2-12:
● CN 2,3,4,6
:
 ○ Check pupillary rxn
○ EOM
● CN 5,7,8
○ Facial sensation
○ Smile and frown
○ Hearing rubbing test
Edit with the Docs app
● CN 9, 10, 11, 12
Make tweaks, leave comments, and share with
○ Ask patient to ask ahh - assess uvula
others to edit at the same time.
○ Shrug shoulder w resistance
○ Stick tongue out
NO THANKS GET THE APP
■ DTR: (UE and LE)
● Triceps and patella DTR
■ Sensation: tested 3 upper and 3 lower dermatoes w light
touch sensatio b/l
○ C6,C7,C8
○ L4,L5, S1
○ Expanded
● Mental status
● CN 12-12
● Strength
○ Elbow flexion, elbow extension and shoulder
abduction b/l
○ Kne flexion, knee extension and hip abduction
b/l
● DTR: triceps and patella
● Sensation: tested 3 upper and 3 lower w light touch +
virbratory sensation
● Cerebellar : assessed Finger to nose cerebellar test
● Gait: assessed at least 2 forms of gait
○ Casual and tandem (tippy toe walking)
● Special test:
○ Nuchal rigiditiy - meningitis
● EENT
○ ROS: blurred vision? Nasal discharge?
○ Basic: EEnOL
■ Eyes - inspect eyes b/l w patient looking up, down, L/R
■ Ears - pull ear up and poster and inspect inside ears
■ nOSE
■ Oral cavity - use tongue blade and light to assess posterior
pharynx
:
 ■ Lymph nodes: paplate posterior auricular and occipital lymph
nodes.
○ Expanded: EENOOTLSS
■ Eye: inspect eyes b/l with pt looking up, down, left and right
■ Ear: inspected inside ears b/l
■ Nose: using different speculum than ear, inspect nose b/l
■ Oral 1: check teeth, gingiva and tongue using tongue blade
b/l [Lower upper and lower lip]
■ Oral 2: check posterior pharnyz and tonsils use tongue blase
and light
■ Thyroid: palpate thyroid b/l
■ Lymph node: palate 3 sets of lymph nodes b/l - posterior
auricular, occipital and submandubular lymph nodes
■ Sinuses - assessed for tenderness of 2 sinuses
● Frontal - above and below eye brows
● Ethmoid - nextto nose
■ Special test
● Finger rub test (negative)
● Endocrine
○ ROS: heat intolerance? Cold intolerance?
○ Basic:
■ Palpated thyroid b/l
○ Expanded → SETS-NSD
■ Scalp: inspected pt scalp
■ Eyes: inspected eye b/l, looking up, down and left/right
■ Thyroid: palpates thyroid b/l
■ Skin: inspected upper extremity including interdigital area
■ Nails: inspect finger and toenails b/l
■ Strength: tested at-least 3 ROM of UE or lower b/l
● Elbow flexion, elbow extension and shoulder abduction
b/l
■ DTR: tested one reflex upper or lower
● Triceps
● MSK
○ ROS: muscle cramps? Joint pain?
○ Basic
■ STRENGTH Tested 3 ROM of either upper OR LE
● UE: elbow flexion, elbow extension, shoulder
abduction
● LE: knee extension, knee flexion and hip abduction
■ EXPANDED UE/LE
● Inspection: inspect entire relevant joint
:
 ● Palpation: palapte entire relevant joint
● ROM: test all ROM
● Strength: TESTED ALL ROM STRENGTHS
● DTR: one reflex ue or le
● Sensation:3 dermatomes light touch ue or lw
● Vasculature: cap refill <2 sec of ue or le
○ Radial pulse or dorsalis pedis
● Special test:
○ Shoulder: painful arc test
○ Wrist: tinel test
○ Elbow: phalens test
○ Hip: Straight leg test
○ Knee: Anterior drawer test
○ Ankle: Inversion test
■ Expanded thoracolumbar
● Inspection: have patient stand up and look at their back
● Palpation: PSIS, iliac crest, rib 12 - palpate in this
region
● ROM: SB, flex, rt, extent
● Strength: Hip abducted, knee flexion and extenstion b/l
● Sensation: LE 3 dermatomes light touch - L4, L5, S1
● Vasculature: cap refill LE or dorsalis pedis pulse b/l
● Special test: Straight leg test
● Cardiovascular
○ ROS: chest pressure? Chest pain? Orthopenea?
○ BASIC:
■ draping
■ Cardiac auscultation - auscultated 4 cardiac posts w
diaphragm
■ Vasculature -UE and LE
○ Expanded - DIP AJCCVS
■ Draping
■ Inspect anterior chest b/l
■ Palpate anterior chest b/l
■ Ausculatte: listen to 4 posts(APTM) w diaphragm &
then do reverse with Bell of stethoscope
■ JVD - put them at 30 degrees and have them look to their
left
■ Carotid ausculatation - have them hold their breath and
listen w BELL
■ Carotid pulse -
:
 ■ Vasculature - upper and lower
■ Special test: Peripheral edema
○ Respiratory
■ ROS: SOB? Cough?
■ Basic
● Resp status
● DRAPING
● Resp ascultation: ausculatd 2 anterior and 4
posterior
○ Have patient breath in and out while mouth is
open.
○ Ladder-like pattern.
■ Expanded: DR. LIPPAC
● Draping
● Resp status
● Lips and fingers
● Inspection - anterior chest b/l
● Palpation - palpates anterior chest b/l
● Percussion- percussed chest wall, 4 anterior, 6
posterior ladder-like pattern
● Auscultation: auscultated w diaphragm 2 anterior, 1
right lateral, and 4 posterior listening posts w
diaphragm in ladder-like pattern while patient
provides one full breath.
● Special test: Tactile fermitus

○
○ Abdominal
■ GI/abdomina: abd pain? n/v?
■ GU: pain w urination? Blood in urine
■ Basic
● Draping
● Abdominal inspection
:
 ● Auscultation: listen to all 4 quadrants w diaphragm.
● Abdominal palpation: palpated abdomen in all 4
quadrants + epigastric + suprapubic lightly and
deeply.
■ Expanded:
● Drape
● Inspect
● Bowel sounds - all four quadrants w diaphragm
● Auscultate arteries: abdominal aorta and b/l renal
arteries w bell.
● Percussion: percussed - all 4 quadrants (2 strikes
per quadrant
● Liver size: precise liver
○ starts in RLQ and percuss until the tympany shifts to dullness
(reach bone) and then moves superiorly downwards until
resonance of lung is replaced by the dullness of liver = measure
between those two points
● Palpation: light and deep in all 4 quadrants,
epigrastric and suprapubic.
● Rigifitiy? Guardian? rebound?
● Special test: Rovsking;s test

○
● OSE:

○
○ Assess for SD → find 3 TART, evaluate w movement
■ MSK
● UE: R/L paraspinal hypertonicity of t2-t7
● LE: R/L paraspinal hypetonciity of T11-L2
● Thoracolumbar: L3 F SrRr
○ Right/LEFT paraspinal hypertonicity T1-T7
:
 ○

○
● Diagnostics
:
 ○
○ (will be included)
Assessment

- Primary diagnisis: rewrite c/c

- Secondary diagnosis: from PMH or labs #1
- Secondary diagnosis #2
- SD of __ region
Plan
:
 -

-
- Primary diagnosis:
-
-
- Secondary diagnosis
- Plan for OMT to ___ using __ once stable

-
- Disposition: Admit to telemetry

Return 10-15 min

Admit them upstairs

Abdominal
- Tums
- Ct SCA
Smoking
:
 - Smoking cessation
T1DB
- Continue metformin

SOAP NOTE TEMPLATE

SUBJECTIVE:
HPI: Pt is a ___ y/o F/M presenting with c/c.
- Onset, Location, Duration, Characterized, Aggravating, Associated
s.s, Alleviated w, Radiation, Timing, Pain scale
ROS (documents 2 from 10 systems): ‘G, Some Nurses Provide Excellent
Enternal Medical Care, Really Awesome!’
- General: fatigue? Weight loss?
- Skin: bruises? Rashes
- Neuro: dizziness? Headache?
- Psych: mood changes? Anxiety?
- EENT: nasal discharge? Blurry vision
- Endocrine: heat intolerance? Cold intolerance?
- Msk: joint pain? Muscle spasms?
- Cardio: chest pain/pressure? Edema (swelling of feet)?
- Resp: SOB? Cough?
- Abdominal: abdominal pain? n/v?

PMH:
- No PMH, no prior hospitalization
- Current ___, hospitalized for __
PSH:
- Surgical history or ‘none’
ALL:
:
 - Meds
(rxn)
- Food (rxn)
- Environment (rxn)
MEDS
- Prescribed (dose, frequency)
- OTC (dose, frequency)
- Multivitamins/ supplements (frequency ‘daily or weekly’)
SH
- Diet/exercise
- Occupation
- Alcohol (current _ drinks, times/weekly; past __, never alcohol use)
- Tobacco use (current 2 ppd x 2 yr; past 2 ppd x 2 yr; never smoked)
- Recreational drugs (current, previous, or never)
FH
- M( ), D () , Siblings (healthy)

----------
OBJECTIVE:
General: NAD or appears distressed
VITALS: rewrite everything
1. Skin
a. Basic: “No rashes or redness of anterior and posterior UE b/l
on inspection. B/l UE and LE skin warm and dry.”
b. Expanded:
i. Scalp skin intact
ii. No lesions over the anterior chest or abdomen b/l
iii. No lesions over back b/l
iv. No rash or redness over anterior and poster UE and LE
b/l.
v. Skin warm and dry over anterior and posterior UE and
LE b/l upon palpation.
vi. UE and LE nails in good repair b/l
2. Nuero
:
 a. Basic: A&O x4; CN 2-12 intact b/l; triceps and patella DTR
2+ b/l; C6-C8, L4, L5, S1 UE and LE dermatomes intact to light
Touch b/l
b. Expanded:
i. A&O x4
ii. CN 2-12 intact b/l
iii. Elbow flexion, elbow extension, shoulder abduction 5/5
b/l & knee flexion, knee extension and hip abduction 5/5
b/l
iv. Triceps and patella DTR 2+ b/l
v. C6-C8, L4, L5, S1 UE, and LE dermatomes intact to
light and vibratory touch b/l
vi. Finger-to-nose test intact b/l
vii. Normal casual and tandem (heel-to-toe) walking gait b/l
viii. Special test: Negative Nuchal Rigidity Test
ix. OSE: R T1-T4 Paraspinal hypertonciity
3. EENT
a. Basic (EENOL): pupils intact b/l; TMs intact without bulging
b/l; nares patent b/l; no cobble stoning notes in posterior
pharynx; no palpable nodes in occipital or post-auricular
lymph.
b. Expanded (EENOOTLS):
i. Pupils intact b/l
ii. TMs intact without bulging b/l
iii. Nares patent b/l
iv. Tongue midline, no dental caries b/l
v. No cobble stoning in posterior pharynx b/l
vi. Thyroid symmetric, nontender
vii. no palpable nodes in occipital, submandibular or post-
auricular lymph.
viii. No sinus tenderness notes b/l to frontal and maxilallary
ix. Special test: Finger rub test negative b/l
4. Endocrine
a. Basic: Thyroid symmetric, non-tender
b. Expanded (SETS-SND):
:
 i. Scalp skin intact
ii. Pupils intact b/l
iii. Thyroid symmetric, non-tender
iv. No lesions or rashes of UE skin b/l on inspection
v. Elbow flexion, elbow extension, and shoulder abd 5/5 b/l
vi. UE and lE nails in good repair b/l
vii. Triceps DTR 2+ b/l
5. MSK
a. Basic (3 ROM strength): Elbow flexion, elbow extension, and
shoulder abduction 5/5 strength b/l OR knee flexion, knee
extension, hip abduction 5/5 strength b/l
b. Expanded (IPSS RVD):
i. Inspection: no rash over __ region b/l.
ii. Palpation: no bony deformities of __ region b/l
iii. ROM: __region full ROM intact
iv. Strength (all ROM):
v. DTR: Triceps/Patella 2+ DTR b/l
vi. Sensation: C6-C8 UE dermatoses intact to light touch
OR l4,l5,s1 LE dermatoes intact to light tough b/l
vii. Vasculature: LE/UE cap refill <2 sec b/l or radial pulse/
dorsalis pedis pulse 2+ b/l
viii. Special Test (complete b/l)
1. Cervical: pos/neg neck compression test
2. Thoracolumbar: straight leg test
3. Shoulder: painful arc test
4. Elbow: Tinel test
5. Wrist: Phalen’s test
6. Hip: FABER
7. Knee: Anterior Drawer’s test
8. Ankle: Inversion test
ix. OSE:
1. UE: R T2 - T7 paraspinal hypertonicity
2. LE: R T11- L2 paraspinal hypertonicity
6. Cardio
:
 a. Basic (draping, auscultation, vasc): RRR and no murmurs and
radial and dorsalis pedis pulse 2+ b/l
b. Expanded (DIP ACJCVS)
i. Chest wall skin intact, symmetric
ii. Normal chest wall motion b/l
iii. RRR, no murmurs
iv. No caroid bruits noted b/l and no JVD
v. Carotid pulse 2+ b/l
vi. Radial and dorsalis pulse 2+ b/l
vii. Special test: post/ neg LE pitting edema present b/l
viii. OSE: R T1-T6 paraspinal hypertoncity
7. Respiratory
a. Basic (DRA): not in tripod position, CTAB
b. Expanded (DR LIPPAS):
i. Not in tripod position
ii. No cyanosis of lips nor clubbing of the fingers
iii. No barrel chest notes
iv. Chest wall non-tender b/l
v. No hyper resonance notes b/l
vi. CTAB
vii. Special test: neg/pos tactile fremitus test
viii. OSE: R T1-T7 paraspinal hypertoncity
8. Abdominal
a. Basic (drape, inspect, bowel sounds, palpate): no abdominal
distention, normal BSX4, no masses and NTTP in all 4 quadrats,
suprapubic, and epigastric on light and deep palpation.
b. Expanded:
i. No abdominal distention on inspection
ii. Normal BSX4
iii. No bruit over the abdominal aorta or renal arteries b/l
iv. Tympatic in all 4 quadrants
v. No hepatomegaly
vi. No masses present, NTTP in all 4 quadrants, suprapubic
and pigastric.
vii. No rigidity, rebound, or guardian
:
 viii. Special
test: Neg/pos rovskins test
ix. OSE: R T5-10 paraspinal hypertoncity

OSE: “Due to the pain you're experiencing and because your in an osteopathic medicine
clinic, we do perform osteopathic manipulative treatment that i think might relieve some of
that pain. I first would need to screen to be able to localize where the pain is and to make
sure you qualified for the treatment. If you are interested, would it be okay if i screen your
back, and then if you are qualified my attending can complete the treatment when you are
more stable? Does that sound good?

○
● Diagnostics: rewrite what the note says

------
ASSESSMENT
:
 - Primary diagnosis
- Secondary diagnosis #1
- Secondary diagnosis #2
- SD to __ region

----
PLAN
- Primary diagnosis:
- TWO THINGS
- Secondary diagnosis
- Two things
- Plan for OMT to ___ using __ once stable
- Disposition: Admit to telemetry

Closing statement:
“ I am going to give this information to the attending, we will be back in 10 -15 min so that
we can have time to review everything carefully and come back to give you an update with
the best treatment plant for you. Any questions?”
: