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ICM > OPE Review > Flashcards

OPE Review Flashcards

1
Q

Everything you need to say for:

Introduction

A
  1. Hello (shake patient’s hand), my name is ____. I am a 1st year medical student and a member of the team caring for you today.
  2. May I have your name and date of birth?
  3. How would you like me to address you?
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2
Q

Everything you need to say for:

CC

Chief Complaint

A
  1. How can I help you?
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3
Q

Everything you need to say for:

HPI

History of Present Illness

A
  1. Onset - when and how did this problem start?
  2. Location - where is the problem located?
  3. Duration - how long does an episode last?
  4. Character - can you describe your problem in more detail?
  5. Circumstances - what were you doing when it started?
  6. Aggravating - is there anything that makes this worse?
  7. Attributions - what do you think might be causing it?
  8. Relieving - is there anything that makes this better?
  9. Timing - is there a particular time of day when your problem comes on or is more severe?
  10. Severity - how severe is your problem?
  11. Associated - are you having any other problems aside from the ones you have told me about so far?
  12. Progression - is this problem getting better or worse over time?

OLD CCAARTS AP

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4
Q

Everything you need to say for:

Allergies

A
  1. Are you allergic to any medications?
  2. Are you allergice to any foods?
  3. Are you allergic to any environmental agents?
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5
Q

Everything you need to say for:

Medications

A
  1. What medications do you take?
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6
Q

Everything you need to say for:

Supplements

A
  1. What supplements do you take?
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7
Q

Everything you need to say for:

Immunizations

A
  1. What immunizations have you had and when were they given?
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8
Q

Everything you need to say for:

PMH

Past Medical History

A
  1. Do you have any ongoing medical problems?
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9
Q

Everything you need to say for:

PSH

Past Surgical History

A
  1. What surgeries have you had?
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10
Q

Everything you need to say for:

SH

Social History

A
  1. Where do you live?
  2. With whom do you live?
  3. What is your diet?
  4. Are you exposed to any hazardous materials or conditions at work or home?
  5. What type of exercise do you get?
  6. How is your sleep?
  7. Do you drink?
  8. Do you smoke?
  9. Do you use recreational substances?
  10. Do you have a religious affiliation?
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11
Q

Everything you need to say for:

FH

Family History

A
  1. Are there any medical problems that run your family (parents, siblings, children)?
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12
Q

Everything you need to say for:

ROS (Eyes)

Review of Systems - Eyes

A
  1. Any problems with your vision?
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13
Q

Everything you need to say for:

ROS (HENT)

Review of Systems - HENT

A
  1. Any problems with your hearing?
  2. Any nasal stuffiness or discharge?
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14
Q

Everything you need to say for:

ROS (Mouth and Throat)

Review of Systems - Mouth and Throat

A
  1. Any problems with your mouth such as pain, sores, spots, swelling, lumps, or dryness?
  2. Any problems with your throat such as pain, sores, spots, swelling, lumps, dryness, or hoarseness?
  3. Any problems with your tongue such as pain, sores, spots, swelling, lumps, or dryness?
  4. Any problems with your teeth such as pain or sores?
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15
Q

Everything you need to say for:

ROS (Neuro/Psychiatric)

Review of Systems - Neuro/Psychiatric

A
  1. Do you have any concerns about your mental health such as excessive sadness, memory difficulties, difficulty sleeping, etc?
  2. Do you have any problems with dizziness?
  3. Do you have any problems with headaches?
  4. Any problems with movement?
  5. Any problems with abnormal sensation?
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16
Q

Everything you need to say for:

ROS (Neck)

Review of Systems - Neck

A
  1. Any stiffness, lumps, or pain in your neck?
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17
Q

Everything you need to say for:

ROS (Respiratory)

Review of Systems - Respiratory

A
  1. Any shortness of breath?
  2. Any cough?
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18
Q

Everything you need to say for:

ROS (CV)

Review of Systems - CV

A
  1. Any chest discomfort?
  2. Any chest fluttering?
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19
Q

Everything you need to say for:

ROS (PV/Lymph)

Review of Systems - PV/Lymph

A
  1. Any swelling in your arms or legs?
  2. Any pain in your arms or legs?
  3. Any discoloration in your arms or legs?
20
Q

Everything you need to say for:

ROS (GI)

Review of Systems - GI

A
  1. Any problems with eating such as swallowing, nausea, vomiting, etc?
  2. Any abdominal discomfort?
  3. Any problems with bowel habits?
21
Q

Everything you need to say for:

ROS (Breasts)

Review of Systems - Breasts

A
  1. Any skin changes in the breasts?
  2. Any lumps in the breast?
  3. Any nipple discharge from the breasts?
22
Q

Everything you need to say for:

ROS (GU)

Review of Systems - GU

Non-gender specific

A
  1. Any problems or changes with your urination?
  2. Any problems with your sex life?
  3. Any problems with sexually transmitted diseases?
  4. Any genital discomfort?
  5. Any genital masses?
23
Q

Everything you need to say for:

ROS (GU)

Review of Systems - GU

Female Specific

A
  1. Are you currently pregnant?
  2. Are you currently breast feeding?
  3. Any problems with your menstrual cycle?
24
Q

Everything you need to say for:

ROS (Skin)

Review of Systems - Skin

A
  1. Any changes with your skin?
  2. Any changes with your hair?
  3. Any changes with your nails?
  4. Any discolorations?
  5. Any lumps?
  6. Any rashes?
25
Q

Everything you need to say for:

ROS (Musculoskeletal)

Review of Systems - Musculoskeletal

A
  1. Any discomfort or problems with your extremities?
  2. Any problems in your neck or back such as stiffness, lumps, or pain?
26
Q

Exam for:

Eyes

A
  1. Perform visual field exam by confrontation - each eye tested individually in at least four quadrants
  2. Test direct and consensual pupillary reactions bilaterally
  3. Examine the function of the extraocular muscles - eyes tested in six positions of gaze including accomodation
  4. Perform a fundoscopic exam
27
Q

Exam for:

CN V

A
  1. Assess function of temporalis muscles bilaterally - patient must bite down with examiner palpating muscle belly
  2. Assess function of masseter muscles bilaterally - patient must bite down with examiner palpating muscle belly
  3. Assess sensation in the forehead bilaterally - patient must have eyes closed and say (or point) where they are being touched
  4. Assess sensation in cheeks bilaterally - patient must have eyes closed and say (or point) where they are being touched
  5. Assess sensation in the jaw bilaterally - patient must have eyes closed and say (or point) where they are being touched
28
Q

Exam for:

CN VII

A
  1. Assess the function of the muscles of facial expression bilaterally - must assess some component of upper and lower portions of face
29
Q

Exam for:

Ears

A
  1. Perform otoscopy - must assess both ears. MUST PULL EAR UP AND BACK.
30
Q

Exam for:

Nose

A
  1. Inspect the nose and assess for nasal obstruction - alternately block nostrils and ask patient to sniff
  2. Use the otoscope to examine the interior of the nose - must assess both nares
31
Q

Exam for:

Mouth

A
  1. Inspect the lips, teeth, oral mucosa, tongue, and pharynx - must assess under the tongue and pull buccal mucosa away from teeth bilaterally using a light source and tongue blade
32
Q

Exam for:

Pharynx

A
  1. Assess movements of soft palate - have patient stick out tongue and say “ah” using tongue blade
33
Q

Exam for:

CN XI

A
  1. Assess function of SCM muscle - have patient turn head against resistance left and right
  2. Assess function of trapezius muscle -** have patient shrug shoulders against resistance**
34
Q

Exam for:

Lymph Nodes

A
  1. Palpate for the lymph nodes of the head -** exam must include palpation of the submental, submandibular, tonsillar, pre-auricular, post-auricular, and occipital nodes. **
  2. Palpate for the lymph nodes of the neck - exam must include palpation of the SCM and pre- and post-SCM areas of the neck
  3. Palpate for the lymph nodes of the supraclavicular area bilaterally

YOU MUST USE PRESS-AND-CIRCLE TECHNIQUE FOR ALL THREE

35
Q

Exam for:

Thyroid

A
  1. Palpate the thyroid - patient does not need to swallow. PALPATING HANDS MUST BE IN CORRECT LOCATION.
36
Q

Exam for:

Chest

A
  1. Percuss posterior chest - must include three positions bilaterally and examine side-to-side
  2. Auscultate posterior chest - must include three positions bilaterally and examine side-to-side
  3. Percuss anterior chest - must include one position bilaterally and examine side-to-side
  4. Auscultate anterior chest - must include one position bilaterally and examine side-to-side

MUST USE HAMMER TECHNIQUE FOR PERCUSSIOn

37
Q

Exam for:

Heart

A
  1. Auscultate S1 and S2 in A listening post
  2. Auscultate S1 and S2 in P listening post
  3. Auscultate S1 and S2 in T listening post
  4. Auscultate S1 and S2 in M listening post

Only use of diaphragm required

38
Q

Exam for:

Abdomen

A
  1. Perform light palpation of the abdomen
  2. Perform deep palpation of the abdomen

Must include all four quadrants

39
Q

Exam for:

Extremity Muscles

A
  1. Generally assess muscle strength of bilateral biceps
  2. Generally assess muscle strength of bilateral triceps
  3. Generally assess muscle strength of bilateral deltoids
  4. Generally assess muscle strength of bilateral quadriceps
  5. Generally assess muscle strenght of bilateral gastrocs
40
Q

Exam for:

Spine

A
  1. Perform segmental motion testing of cervical, thoracic, and lumbar spines bilaterally. Must assess cervical motion using head and thoracic and lumbar motion using shoulder.
41
Q

Exam for:

Pulses

A
  1. Palpate the radial pulses bilaterally
  2. Palpate the dorsalis pedis or the posterior tibial pulses bilaterally
42
Q

Exam for:

Edema

A
  1. Palpate the lower extremities for edema
43
Q

Exam for:

Cerebellum

A
  1. Generally assess normal gait
  2. Generally assess tandem walking
44
Q

Exam for:

Temperature

A
  1. Assess temperature sensation in four extremities bilaterally - use cooled and warmed tuning forks to test temperature sensation. patient must have eyes closed and say (or point) where they are being touched and whether sensation is warm or cold. Must only test one location at a time.
45
Q

Exam for:

Vibration

A
  1. Assess vibration sensation in four extremities - use tuning fork with and without vibration. patient must have eyes closed and say (or point) where they are being touched and whether sensation is vibratory or not. must only test only location at a time.
46
Q

Exam for:

General

A
  1. Washed hands prior to exam. Soap and water or hand sanitizer OK
  2. Appropriate draping technique was utilized.

ICM (8 decks)

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