Spring 2016 CAPE assessment

Question 1

Chief complaint (2)

Answer 1

Chief complaint, main health concerns

Question 2

HPI (2)

Answer 2

History of presenting illness, patient’s perspective of the illness

Question 3

Social History

Answer 3

addressing occupational, and recreational aspects of the patient’s personal life that have the potential to be clinically significant

Question 4

ROS General (4)

Answer 4

Weight loss or gain
Fatigue
Fever or chills
Weakness

Question 5

ROS Vision (5)

Answer 5

Vision Loss/Changes
Glasses or contacts
Pain
Redness
Blurry or double vision

Question 6

ROS Ears (4)

Answer 6

Decreased hearing
Ringing in ears
Earache
Drainage

Question 7

ROS Nose (5)

Answer 7

Stuffiness
Discharge
Itching
Nosebleeds
Sinus pain

Question 8

ROS Throat (4)

Answer 8

Sore throat
Hoarseness
Difficulty swallowing
Pain with swallowing

Question 9

ROS Neck (3)

Answer 9

Lumps
Swollen glands
Stiffness

Question 10

ROS Pulmonary (4)

Answer 10

Cough
Shortness of breath
Wheezing
Painful breathing

Question 11

ROS Cardiovascular (3)

Answer 11

Chest pain or discomfort
Palpitations
Fainting

Question 12

ROS GI (3)

Answer 12

Change in bowel habits
Constipation
Diarrhea

Question 13

ROS Urinary (2)

Answer 13

Urgency

Burning or pain

Question 14

ROS MSK (4)

Answer 14

Muscle or joint pain
Swelling of joints
Back pain
Stiffness

Question 15

ROS Neurologic (4)

Answer 15

Seizures
Numbness
Weakness
Fainting

Question 16

ROS Hematologic (2)

Answer 16

Ease of bruising

Ease of bleeding

Question 17

ROS Endocrine (3)

Answer 17

Change in appetite
Heat or cold intolerance
Sweating

Question 18

ROS Psychiatric (2)

Answer 18

Depression

Suicidal thoughts

Question 19

ROS Skin (3)

Answer 19

Rashes
Lumps
Dryness

Question 20

PE General (4)

Answer 20

General appearance
Heart rate (rate, rhythm, quality)
Blood pressure
Respiratory rate (measure and character)

Question 21

PE HEENT (6)

Answer 21

External inspection of eyes
Pupillary reaction to light
Inspect mouth and oral cavity (light, teeth, gums, mucous membranes, tongue)
Inspect posterior pharynx (palate, uvula, tonsils, pharynx)
Palpate lymph nodes (size, consistency, mobility, shape, tenderness, symmetry)
Palpate thyroid (size, shape symmetry, nodules, tenderness)

Question 22

PE Cardiac (5)

Answer 22

Inspect and palpate the precordium to assess apical point of maximal impulse
Auscultate cardiac sounds in four locations with diaphragm with the patient sitting or supine
Auscultate with bell at apex (in supine position)
Assess lower extremity edema bilaterally (compare side to side)
Palpate posterior tibial and dorsalis pedis pulses bilaterally (compare side to side)

Question 23

PE Pulmonary (3)

Answer 23

Inspect thorax (for size, shape, symmetry, and use of accessory muscles and retractions)
Percuss chest posteriorly (minimum 3 regions posteriorly comparing side to side)
Auscultate chest anteriorly and posteriorly (minimum 2 regions anteriorly and 3 regions posteriorly comparing side to side)

Question 24

PE Abdominal (4)

Answer 24

Inspect abdomen (expose the abdomen from sternum to pubis to assess skin, size, contour, symmetry)
Auscultate abdomen (in all four quadrants for 5-10 seconds each)
Palpate abdomen in four areas (both light and deep palpation)
Palpate liver

Question 25

PE Upper and lower MSK (2)

Answer 25

``` Inspect extremities (for alignment, symmetry, gross deformity) Inspect joints (for swelling, redness, or deformities for both the knees and hands bilaterally comparing side to side) ```

Question 26

PE Skin, Hair Nails (1)

Answer 26

Inspect skin (for color, lesions, moisture)