EM cervical practical

Question 1

olfaction

Answer 1

1. ask patient to inhale and exhale through each nostril separately to see if air transport works
2. tell patient to close there eyes
3. ask patient to inhale and exhale
4. on second inhale, hold the vial infront of the nostril being tested
5. ask if they smell something
6. ask if they can identify the smelll
7. repeat on other side

Question 2

H pattern

Answer 2

1. tell patient to follow your finger with there eyes and not there head
2. tell patient to let you know if they see double anytime during exam**
3. place finger 8-10 inches infront of the patients face
4. ask patient if they see two fingers and move further away until they see one image
5. then perfrom H pattern - left then up and down the back to middle, right then up and down then back to middle

Question 3

far visual acuity

Answer 3

1. have patient stand 20 feet away using snellen chart
2. instruct patient to cover one eye
3. instruct patient to read the lowest line
4. record visual acuity
5. repeat on other eye
6. repeat entire procedure without corrective lenses

Question 4

near visual acuity

Answer 4

1. have patient hold rosenbom chart 14 inches from face
2. instruct the patient to cover one eye
3. instruct the patient to read the lowest line
4. record visual acuity
5. repeat on other eye
6. repeat entire procedure without corrective lenses

Question 5

pupillary light reflex

Answer 5

direct

1. instruct patient to look and focus straight ahead on an object 6-10 ft away
2. use opthalamoscope
3. shine light in right eye
4. dr. observes constriction of right eye
5. shine light in left
6. dr. observes for constriction of left eye

indirect/ consensual

1. instruct patient to look and focus straight ahead on an object 6-10 ft away
2. use opthalamoscope
3. shine light on right temple and then rotate scope so light illuminates the pupil from the temporal field of view
4. dr observes constriction in the left eye
5. shine the light on the left temple and rotate scope so light illuminates the pupil from the temporal field of view
6. dr. observes constriction in the right eye

Question 6

crescent shadow

Answer 6

1. instruct patient to look and focus on object 6-10 ft away
2. use the opthalmoscope
3. dr. stands in front of patient to observe medial iris
4. shine the light on the right temple and rotate scope so light illuminates the iris from the temporal field of vision
5. dr. observes the medial portion of the right iris
6. shine the light on the left temple and rotate scope so light illuminates the iris from the temporal field of vision
7. dr. observes if medial portion of the left iris

Question 7

confrontation

Answer 7

1. evaluate the peripheral extent of visual field
2. instruct patient to focus on object 6-10 ft away
3. instruct patient to cover one eye
4. instruct patient to indicate or tell you when they see your fingers moving
5. then wiggle your fingers from superior, temporal, inferior, and nasal fields
6. retest in other eye

Question 8

corneal light reflection

Answer 8

1. use opthalmoscope
2. instruct patient to focus on the scope
3. dr. holds scope in front of patient so the circle of light reflects off both patients corneas at the same time
4. observe to see if the reflection comes off the same spot on both corneas

Question 9

accommodation

Answer 9

1. instruct patient to focus on object 20 ft away
2. hold pen with writing on it about 8-12 inches away
3. instruct patient to look at pen
4. dr. stands anterior and to side of patient so they can observe pupil constriction, eye convergence, and lens thickening
5. instruct patient to read the writing on the pen

Question 10

response to near vision

Answer 10

1. instruct patient to focus on object 20 feet away
2. hold pen about 8-12 inches away from patient
3. instruct patient to look at pen
4. dr. stands anterior and to the side of the patient so they can observe for pupil constriction and eye convergence

Question 11

convergence

Answer 11

1. dr. holds his finger 12-16 inches away from patients face
2. ask if patient sees one or two images
3. if patient sees two images, move your finger further away from patient
4. instruct the patient to follow your finger
5. dr. moves their finger to 4-6 inches from patients eyes
6. dr. observes for symmetry of eyes converging

Question 12

trigeminal sensation touch

Answer 12

1. instruct the patient to close their eyes
2. instruct the patient to tell you when they feel you touch them
3. dr. touches cottonball across the right V1,V2,V3
4. dr. touches cottonball across the left V1,V2,V3
5. instruct the patient to tell you and compare each side (same or different) as you touch each dermatome side to side
6. note any decrease in sensation

Question 13

trigeminal sensation sharp

Answer 13

1. break a cotton swab
2. show patient sharp and dull on forearm and ask if they understand the difference
3. instruct the patient to close their eyes
4. instruct patient to say sharp or dull when they feel something
5. dr. touches sharp end of swab over V1,V2,V3 on right
6. dr. touches sharp end of swab over V1,V2,V3 on left
7. dr. uses one dull touch per dermatome
8. instruct the patient to compare the sensation on each side and say same different as you touch each side with sharp
9. not nay decrease in sensation

Question 14

tempro mandibular evaluation

Answer 14

1. dr. palpates over the condyloid process of mandible on both sides
2. instruct the patient to slowly open and close the jaw
3. dr. observes for any deviation f the jaw
4. dr. palpates for any prominence of condyloid process of the mandible

Question 15

muscles of facial expression

Answer 15

1. tell patient that you are going to check the muscles of facial expression
2. instruct patient to raise eyebrows, close eyes tightly then open, pout/kiss, smile, frown, puff out your cheeks and doc adds over pressure to cheeks,
3. note any weaknesses

Question 16

Corneal reflex

Answer 16

1. use the pulp and hose
2. instruct the patient to look up and to the left
3. bring end of the hose to the lateral canthus of the right eye
4. depress the bulb and puff air over the right cornea
5. observe blink in both eyes
6. repeat on other side

Question 17

hearing screen

Answer 17

1. stand behind patient
2. scratch fingers on left, and can you hear this
3. scratch fingers on right, and can you hear this
4. compare on both sides, is it the same on both sides
5. tell me when the sound goes away
6. 20 inches away is normal

Question 18

weber and rhine test

Answer 18

1. weber using 512 hz tuning fork
2. dr strikes and places on top of head
3. dr asks if the sound is the same in both ears or is one ear better
4. rhine using 512hz tuning fork
5. dr strikes and places on mastoid ON THE SIDE WEBERS WAS LOUDER
6. ask patient if they heart it and have patient indicate when the sound goes away
7. dr counts time for how long patient hears it
8. when sound goes away, pull away from mastoid and ask patient if they hear it and have patient indicate when it goes away
9. dr counts time for how long the patient hears it

Question 19

gag reflex

Answer 19

1. need tongue blade and cotton swab
2. instruct patient to open mouth and stick out their tongue and extend head and neck backwards
3. place tongue blade on middle of tongue and push tongue down and anteriorly
4. take swab and approach mouth from in front of chin and swab the tonsils/posterior oropharyngeal wall
5. observe palate elevation on gag
6. repeat on other side**

Question 20

AHH palatal tenting

Answer 20

1. intone ahh
2. instruct patient to open mouth, tilt head back
3. place tongue blade on middle of tongue and push tongue down and anteriorly
4. instruct patient to say repetitive short ahhs
5. observe the palate elevate on both sides, look at the uvula, allow your peripheral vision to show symmetry in palatal tenting

Question 21

cranial nerve 11 strength upper trap

Answer 21

1. instruct patient to cross arms on chest
2. instruct patient to elevate shoulders
3. dr attempts to push them down
4. note any weaknesses

Question 22

cranial nerve 11 strength sternocleidomastoid

Answer 22

1. dr places their hand on the patients forehead
2. instruct the patient to flex their forehead while the doctor resisted the forward movement of the head
3. dr rotates patients head to the left
4. instruct the patient to resist the dr’s attempt to turn the patient to the right
5. note any weakness
6. repeat on other side

Question 23

cranial nerve 12 strength

Answer 23

1. instruct patient to open mouth
   2 observe tongue and look for any deviations
2. instruct the patient to push out their tongue and observe any deviations
3. instruct patient to move tongue to left and right
4. note any weaknesses

Question 24

physical exam of nose

Answer 24

1. observe for any deviations
2. observe any skin lesions
3. observe any secretions
4. palpate the nose for tenderness
5. instruct patient to obstruct nostril, inhale and exhale to observe for air flow
6. repeat on other side
7. attach otoscopic head on diagnostic kit and add specula
8. instruct patient to till their head up
9. instruct patient to breathe through there mouth
10. dr holds scope like a pencil horizantally
11. dr touches pinky to cheek of patient and enters the superior opening of the nostril
12. doctor looks through scope into nose (not up the nose)
13. observe for color of mucosa, wetness/dryness of mucosa, space between lower concha and the nasal spetum, growths, obstructions
14. repeat on other side

Question 25

physical exam of sinuses

Answer 25

1. percuss the frontal sinuses bilaterally asking any discomfort 2. percuss the maxillary sinuses bilaterally asking any discomfort 1. otoscopic head just under the supra orbital ridge in a darkened room to see air/fluid levels 2. repeat on other side 3. instruct patient to extend their head back and open mouth 4. otoscopic head just lateral to the lateral portion of the nose in a darkened room to see air/fluid levels 5. repeat on other side

Question 26

physical exam of mouth and throat

Answer 26

1. observe any cracks, vesicular lesions, or crusts on lips/mouth 2. instruct patient to tilt their head back and open mouth 3. wet a tongue depressor on patients tongue 4. place tongue blade inside patients cheek and inspect for lesions 5. inspect stentsons duct for inflammation or calcification 6. observe the soft palate for symmetry 7. repeat on other side 8. instruct patient to protrude tongue 9. observe for deviation 10. instruct patient to move tongue left and right 11. observe for deviation or symmtry

Question 27

fundoscopic exam

Answer 27

1. Set scope on white “0” in window on back side of scope head 2. Instruct patient to look at an object straight ahead of them 3. Dr. stands to patient’s right side with the lateral aspect of Dr.’s thigh against the lateral aspect of the patient’s thigh, Dr.’s right leg is forward of the left 4. Dr. holds scope like a pencil in right hand with index finger on the focus wheel 5. Dr places rubber strip on back of scope head against their right supraorbital ridge 6. Dr. brings arm holding scope into their side 7. Dr. places non-scope hand on top of the patient’s head 8. Dr. looks thru the scope with their right eye and visualizes patient’s right pupil from a 45 degree angle looking nasally 9. Dr. moves the scope by moving their body, NOT by moving the scope independently 10. Dr, observes for a red reflex that is clear 11. Dr. moves closer and closer to patient until their 5th digit touches the patient’s cheek 12. Dr. observes for a blood vessel on the nasal retina 13. Dr. moves to follow that blood vessel laterally to the optic disc 14. Dr. observes the optic disc for any swelling, increase cup to disc size, new vessel growth, vessel dilatation/constriction/leaks 15. Instruct the patient to look at the light (brings fovea into view) 16. Instruct the patient to look back 17. Dr. now observes for any non-transparent areas as dials out (into the green in window on back of scope head 18. Dr. “dials out” to visualize all the way out to the cornea 19. Dr. changes sides of patient, changes hand holding scope, and eye looking through the scope to repeat exam of the patient’s left eye.

Question 28

panoptic scope

Answer 28

1. Look thru the scope and focus on an object 8-10 feet away 2. Adjust light intensity to a low level 3. Dr holds scope so that their index finger is on the focus wheel 4. Dr holds scope so they can see the patient’s eye thru the scope 5. Dr puts hand on top of the patient’s head 6. Dr moves toward patient looking through the scope until their 5th digit contacts the patient’s cheek 7. Dr adjusts focus to visualize the optic disc 8. Dr observes the optic disc for any swelling 9. Dr observes the blood vessels at the disc for any increase or decrease of diameter 10. Dr observes for any new vessel growth around the optic disc 11. Dr instructs patient to look at the light 12. Dr quickly observes the foveal area for abnormality 13. Dr instructs patient to look back 14. Dr moves the focus wheel upwards while observing for any non-translucent areas in the eye 15. Dr moves away from the patient while still looking thru the scope until the cornea comes into clear focus 16. Repeat other side

Question 29

otoscopic exam

Answer 29

1. Dr instructs patient to sit at the end of the table 2. Dr palpates the tragus inquiring of the patient it there is any discomfort 3. Dr pulls auricle superior and posterior inquiring of the patient it there is any discomfort 4. Dr hold the scope like a pencil closer to the otoscopic head 5. Dr places their 5th digit on side of patient’s cheek and places the speculum superficially at the external auditory meatus 6. Dr grasps the auricle and pulls up and back 7. Dr looks thru the scope visualizing the canal as they move the speculum further into the auditory canal to visualize the tympanic membrane 8. Dr observes for any injection/inflammation/infection of the external drum or canal 9. Dr observes the drum for any air fluid lines suggesting fluid inside the drum 10. Dr observe the canal on the way out for any injection, lesions, or cerumen

Question 30

physical exam of head, neck, lymphatics

Answer 30

inspect 1. head position 2. toritcolis 3. face - facial features, shape, symmetry 4. skull - lesions, tenderness, scaliness 5. neck - symmetry, tracheal alignment, masses, fullness, venous distension palpation - skull - palpated for tenderness, swelling, depressions - temporal arteries - thickening/hardening - salivary glands - symmetry, alignment, tenderness - TMJ palpation - clicking - TMJ ROM - open distance, left to rigt distance, and a to p distance - lymph nodes - circular motion that is light for superficial nodes and deeper for deep nodes - head lymph nodes - occipital, postauricular, preauricular, parotid, tonsilar, submandibular, submental - neck lymph nodes - superficial cervical nodes at anterior border of scm, posterior cervical nodes at posterior border of trap, deep cervical nodes deep to scm, and supraclavicular area - trachea - palpate for deviation and tenderness by performing tracheal tug auscultation - using bell of stethoscope - subclavian artery -superior to clavicle and lateral to scm - carotid artery - posterior to trachea, anterior to scm, at the level of second cricoid cartilage below thyroid cartilage - orbits - instruct patient to close their eye

Question 31

physical exam of thyroid

Answer 31

inspection - neck is hyperextended and the patient swallows - dr observes elevation of the thyroid gland palpation - dr places fingers on anterior middle line of trachea below thyroid - instruct patient to swallow and palpate - dr stands behind patient - dr places his hands anterior to scm (lateral to trachea) and posterior to scm on same side - instruct patient to flex, laterally flex, rotate to the side of contact - instruct patient to swallow, palpating for harder structures - repeat on other side