1
Q
What are the four elements required in every patient encounter documentation?
A
History, Physical, Assessment, and Plan.
2
Q
What is the standard documentation format for organizing the medical history, assessment, and plan?
A
The SOAP note (Subjective, Objective, Assessment, Plan).
3
Q
Name the three main components of the Subjective (‘S’) section of a SOAP note.
A
Data told by the patient: Chief Complaint, Present Illness, and Review of Systems (symptoms).
4
Q
What type of information belongs in the Objective (‘O’) section of the note?
A
Findings detected by the examiner: Physical exam findings, signs, labs, and images.
5
Q
When is a Comprehensive visit required versus a Focused visit?
A
Comprehensive: For new patients to establish a baseline and fundamental information. Focused: For established patients, addressing specific concerns.
6
Q
What essential safety procedure must be performed before any patient contact?
A
Observe Standard Universal Precautions and practice thorough hand hygiene to prevent blood-borne pathogen transmission.
7
Q
What is a crucial goal to establish before entering the patient’s room?
A
Set interview goals (e.g., new complaint, follow-up) and aim to balance them with the patient’s goals.
8
Q
What are the first steps in greeting the patient and establishing rapport?
A
Greet by name, introduce yourself (as a medical student working with an attending), confirm name/DOB, and address confidentiality.
9
Q
After greeting, what must you establish before diving into the history?
A
The Agenda: Identify all patient concerns and your goals at the start, especially with multiple complaints.
10
Q
How should the Chief Complaint be documented?
A
Using the patient’s own words (e.g., ‘My stomach hurts and I feel awful’).
11
Q
What is the sequence of the three open-ended questions used to invite the patient’s story?
A
- ‘What brings you here to the office today?’ 2. ‘Can you tell me more about that?’ 3. ‘Is there anything else you would like to discuss today?’.
12
Q
What is a high-stakes error to avoid when first listening to the patient’s story?
A
Interrupting the patient. Listen actively and use continuers (e.g., nodding, ‘Go on’).
13
Q
What four elements must you explore to understand the patient’s perspective?
A
Feelings (fears/concerns), Ideas about the problem, Effect on their life, and Expectations of the disease/care.
14
Q
What acronym is used to ensure a complete understanding of a symptom in the Present Illness (PI)?
A
OLDCAARTS: Onset, Location, Duration, Character, Aggravating/Alleviating Factors, Radiation, Timing, Setting.
15
Q
What details must be documented for all medications (prescribed, OTC, supplements)?
A
Name, dose, route, and frequency of use.
16
Q
List the 3 types of allergies you should ask the patient during history taking.
A
Drugs
Food
Environmental
Always ask about reactions.
17
Q
What is essential to document alongside any reported allergy (e.g., PCN)?
A
Always specify the type of reaction (e.g., PCN/Rash).
18
Q
What are the four cardinal techniques used in the physical examination?
A
Inspection, Palpation, Percussion, and Auscultation.
19
Q
What type of questioning should be avoided, as it minimizes response accuracy and introduces bias?
A
Leading questions (e.g., ‘You don’t have any blood in your stools, do you?’).
Assumption questions (“When did you stop drinking?”)
Embedded Info questions (“Does the pain radiate down your leg, suggesting sciatica?”)
Forced-choice questions (“Is your pain a stabbing pain or a burning pain?”)
20
Q
What common communication error should be avoided when the patient expresses worry?
A
Premature or generic reassurance (e.g., ‘Don’t worry, everything will be all right’), as it blocks further disclosure.
21
Q
How do you achieve effective reassurance?
A
Instill confidence by providing competent, thorough care (history/exam) and conveying that the problem is understood and manageable.
22
Q
What is the last procedural step before ending the visit?
A
Signal the approaching end and allow time for final questions (e.g., ‘We need to stop now. Do you have any questions?’).
23
Q
How can you effectively elicit patient questions about the plan?
A
Invite questions at multiple points, not just at the end. Use encouraging phrases like, “What questions does that bring up for you?” instead of a simple “Do you have any questions?”.
24
Q
How should a clinician manage shifting from one topic (like PI) to another (like Past History)?
A
Use summarization and inform the patient of the topic shift to help them feel at ease (e.g., ‘Now I’d like to ask about your family history…’).
25
What is 'unconditional positive regard' in the context of an interview?
Respecting the patient's autonomy and assuming they are doing their best, regardless of their circumstances.
26
What does the acronym WWFF represent in a General Review of Systems (ROS)?
Unexplained Weight Change, Weakness, Fatigue, and Fever
27
How must a healthcare provider differentiate between fatigue and weakness?
Fatigue is a nonspecific sense of weariness or loss of energy; Weakness denotes a loss of muscle power and is distinct from fatigue
28
What vital calculation must be included when recording height and weight?
Body Mass Index (BMI)
## Footnote
The metric formula is weight (kg) / (height (m))²
29
According to ACC/AHA 2017 guidelines, what defines Hypertension Stage 1?
Systolic 130–139 mmHg OR Diastolic 80–89 mmHg
30
What is a critical preparation step a patient must follow before accurate Blood Pressure (BP) measurement?
The patient must avoid smoking or caffeinated beverages for 30 minutes before the exam
31
How is the correct BP cuff size determined?
The cuff bladder width should be approximately 40% of the arm's circumference, and the length should be about 80% of the circumference
32
Describe the method for estimating systolic pressure using palpation.
Palpate the radial pulse, inflate the cuff until the pulse is gone, slowly deflate, and the point the pulse returns is the estimated systolic pressure. Add 30 mmHg to this value for the estimated systolic pressure
33
What is the Auscultatory Gap, and why is it crucial to identify?
A silent interval where Korotkoff sounds temporarily disappear between systolic and diastolic pressures; failing to recognize this may lead to underestimating systolic pressure
34
What are the diagnostic criteria for Orthostatic Hypotension?
A drop in Systolic BP (SBP) by ≥ 20 mmHg or a drop in Diastolic BP (DBP) by 10 mmHg within 3 minutes of standing
35
How long should you count the Heart Rate (Pulse) if the rhythm is regular?
Count for 15 seconds and multiply by 4
36
What temperature defines a fever?
**100.4°F (38°C) +**
37
What mnemonic should be used to ensure all essential attributes of a patient's pain symptom are assessed?
OLD CAARTS
## Footnote
Onset (When did it start?)
Location (Where exactly is the pain?)
Duration (How long does it last/has it been going on?)
Character/Quality (What does the pain feel like—sharp, dull, throbbing?)
Aggravating factors (What makes it worse?)
Alleviating factors (What makes it better?)
Radiation (Does the pain spread or move anywhere?)
Timing/Temporal Pattern (When does it occur—morning, night, intermittent?)
Severity (How bad is the pain, usually on a 1-10 scale?)
38
What is Neuropathic Pain and how is it often described?
Pain arising from a lesion or disease affecting the somatosensory system. Often described as burning, lancinating, or shock-like
39
What is the preferred method for routine hand cleaning in most clinical situations?
Alcohol-based hand sanitizer (hand rub)
40
List three specific circumstances requiring hand washing with soap and water instead of alcohol-based hand sanitizer.
* When hands are visibly soiled
* After caring for a person with known or suspected infectious diarrhea
* After known or suspected exposure to spores (e.g., C. difficile outbreaks)
41
What is the recommended duration for the entire hand washing procedure (soap and water)?
40–60 seconds
42
What is the recommended duration for the entire alcohol-based hand rub procedure?
20–30 seconds
43
What is a critical rule regarding glove use between patients?
Do not wear the same pair of gloves for the care of more than one patient
44
What is the required length for natural fingernail tips for healthcare workers?
Natural nail tips should be kept to ¼ inch in length
45
What is the systematic approach for examining both the anterior and posterior thorax?
| (the cardinal rules)
Inspect, Palpate, Percuss, and Auscultate.
46
List the five key symptoms you must inquire about regarding the thorax and lungs.
* Chest pain
* Dyspnea (shortness of breath)
* Wheezing
* Cough
* Hemoptysis (blood-streaked sputum)
47
Where does the trachea bifurcate posteriorly and what spinous process marks the location?
At the T4 spinous process (anteriorly at the sternal angle).
48
What position is optimal for examining both the posterior and anterior thorax?
The Sitting position is excellent for both; the supine position is best for the anterior thorax.
49
What is the specific technique for testing posterior Chest Expansion?
Place your thumbs at the level of the 10th ribs, creating a loose fold, and observe the thumbs moving apart symmetrically during inhalation.
50
What finding is suggested when Tactile Fremitus is increased over a lung field?
Consolidation (like pneumonia) due to enhanced vibrations transmitted through solid tissue.
51
When percussing, which part of the hand must strike the pleximeter finger?
The tip of the plexor finger (not the pad) must quickly strike the pleximeter finger over the DIP joint.
52
What specific breathing instruction must be given to the patient prior to auscultation?
Ask the patient to take deep, quiet breaths through an open mouth to prevent noisy breathing from interfering with assessment.
53
What sound note is expected when percussing over a healthy lung?
Resonance (Loud, low pitch, long duration).
54
What sound (quality: drum-like, high pitch) might be heard over a pneumothorax?
Tympany.
55
What chest deformity (seen in COPD) has an increased AP diameter, impairing inspiration/expiration volume?
Barrel Chest.
56
How does the duration of inspiration relate to expiration in normal Vesicular sounds?
Inspiration is longer than expiration, with soft intensity.
57
If you hear 'A' instead of 'E' when testing voice sounds, what is this specific finding?
Egophony.
58
Why are positive transmitted voice sounds (Bronchophony, Egophony, Whispered Pectoriloquy) clinically important?
They suggest airways blocked by inflammation or secretions (consolidation).
59
What is the critical distinction between Rhonchi and Crackles (Rales)?
Rhonchi are continuous (snoring quality), while Crackles are discontinuous (fine or coarse).
60
What coarse, grating sound is caused by friction between inflamed parietal and visceral pleura?
Pleural friction rub.
61
What must you accommodate when examining the anterior thorax of a female patient?
You must negotiate around the bra to properly examine the anterior thorax.
62
When percussing for diaphragmatic excursion, how do you determine the level of the diaphragm?
Percuss from resonant lung sound down to the dullness of the diaphragm during quiet respiration.
63
What are the four essential elements that make up every patient encounter?
History, Physical, Assessment, and Plan.
64
What does the acronym SOAP stand for in documentation, and which part contains the physical exam findings?
Subjective, Objective, Assessment, Plan. The Objective section contains physical findings, signs, and labs/images.
65
What is the scope of a Comprehensive Visit?
It is for new patients, providing fundamental information, strengthening rapport, establishing a baseline, and promoting health.
66
What is the required safety step that must be observed before patient contact?
Always observe Standard Universal Precautions (including protective gear as needed) and practice thorough hand hygiene.
67
How must you introduce yourself during the Greeting and Rapport phase?
1. Greet by name & introduce self/position.
2. Confirm Name & DOB.
3. **Ask how they prefer to be addressed**.
4. Address confidentiality.
## Footnote
"Ask how they prefer to be addressed (e.g., Mr. Smith, John?)"
68
What is the critical first step in establishing the visit's agenda?
Identify all patient concerns and the interviewer's goals at the beginning of the visit using open-ended questions.
69
What three essential open-ended questions should you use to invite the patient's story (Chief Complaint)?
* 'What brings you here to the office today?'
* 'Can you tell me more about that?'
* 'Is there anything else you would like to discuss today?'.
70
What four domains (F.I.E.S.) must be explored to understand the patient's perspective?
* Feelings (fears/concerns)
* Ideas about the problem
* Effect of the problem on their life
* Expectations of the care.
71
List the Seven Attributes of a Symptom used to clarify the Present Illness (PI).
* Onset
* Location
* Duration
* Character
* Aggravating/Alleviating Factors
* Radiation
* Timing
* Setting (OLDCAARTS).
72
Why should you avoid asking a leading question, such as 'You don't have any blood in your stools, do you?'?
It minimizes bias and avoids generating a potentially false negative.
73
Why is using premature or generic reassurance (e.g., 'Don't worry, everything will be all right') discouraged?
It can block further disclosures from the patient. Effective reassurance must be competent and follow a thorough assessment.
74
What is the purpose of Echoing during the interview?
To prompt further factual or emotional detail by repeating the patient's last few words.
75
What should be done before shifting topics during the interview?
Use a smooth transition (e.g., 'Now I'd like to ask about your family history...') to help the patient feel at ease.
76
What are the four Cardinal Techniques of Examination in order?
* Inspection
* Palpation
* Percussion
* Auscultation.
77
When documenting medications, what specific information must be included beyond the name of the drug?
**Name**, **dose**, **route**, and **frequency** of use (including OTCs, supplements, and herbals).
78
During history taking, the Health Maintenance section includes? Provide examples.
**Immunizations** (as applicable: Influenza, Tdap, COVID-19, Shingles, etc.)
**Screening tests** (as applicable: mammograms, pap smears, colonoscopies, LDCT, bone density tests, vision/hearing tests, blood glucose test, BP checks, cholesterol checks)
79
What specific data points must be gathered for living and deceased first/second-degree relatives?
* For living relatives: age, health status, and chronic conditions.
* For deceased: age and cause of death.
80
What 3 important parameters you should document regarding patient's **personal and social history**? What are the other 2?
**Tobacco**: Document status (current, former, never) and quantity in **pack-years** (Packs Per Day x Years Smoked).
**Alcohol**: Screen with the **CAGE** questionnaire if applicable. Quantify use in drinks per day/week.
**Illicit/Recreational Drugs**: Ask specifically about drug types (marijuana, cocaine, opioids, etc.), frequency, and route of use (IV, inhalation).
Other two: **Occupation** (current/previous jobs), **Religious affiliation**
81
What are the components of the CAGE questionnaire used for screening alcohol use?
* Cut down
* Annoyed
* Guilty
* Eye-opener.
82
What is a negative nonverbal cue that should be avoided?
Disapproval, impatience, or condescension in your posture, gestures, eye contact, or tone.
83
How do you perform the Bulge Sign to detect minor knee effusions?
Press above the knee to displace fluid down, stroke down the medial aspect to force fluid laterally, then tap the knee and watch for a fluid wave.
84
How do you confirm a major knee effusion using the Balloon Sign?
Compress the suprapatellar pouch and feel for fluid entering the spaces next to the patella as you place the thumb/index finger on either side of the patella.
85
What is the required positioning and simultaneous motion for the high-yield Lachman Test?
Position the knee in 15 degrees flexion/external rotation, then simultaneously move the tibia forward and the femur back.
86
When testing the MCL using the Abduction (Valgus) Stress Test, how must the examiner apply force?
Stabilize the lateral knee (femur) and pull laterally at the medial ankle, pushing medially on the knee to open the medial joint line.
87
What specific stress is required for the medial meniscus portion of the McMurray Test?
Apply valgus stress (push on the lateral side), externally rotate the leg, and slowly extend it; a click/pop suggests a posterior medial meniscus tear.
88
What is the positive sign in the Anterior Drawer Test?
A forward jerk showing the contours of the tibia when the examiner draws the tibia forward with the hips/knees flexed 90 degrees.
89
What critical step ensures an accurate measure of Hip Abduction ROM?
Stabilize the pelvis by pressing down on the opposite Anterior Superior Iliac Spine (ASIS) with one hand.
90
What is the key procedural step for palpating the painful Trochanteric bursa?
The patient should be resting on one side with the hip flexed and internally rotated.
91
What is the pitfall/normal finding regarding knee flexion during the gait cycle?
The knee should be flexed throughout the stance phase (60% of walking cycle), except specifically at heel strike.
92
How is the Supraspinatus strength specifically tested using the Empty Can Test?
The patient elevates their arms against resistance with their thumbs pointing down.
93
What function does the Apley Scratch Test evaluate?
Overall shoulder rotation and ROM (by testing abduction/external rotation, and adduction/internal rotation).
94
What is a positive finding in the Drop Arm Test?
The arm drops around 90° abduction after being held at 90°, suggesting a tear in the rotator cuff, often the Supraspinatus.
95
How do you test the strength of the Infraspinatus and Teres Minor?
The patient rotates their forearm laterally against resistance.
96
Differentiate Articular from Non-Articular disorders based on pain and ROM limitations.
**Articular**: **Deep, diffuse pain** and **limits Active & Passive ROM**.
**Non-Articular**: **Focal tenderness** and **preserves Passive ROM**.
97
What finding in the Straight Leg Raising (SLR) Test is a strong confirmation of radicular pain?
A Positive Crossed SLR, defined as pain in the affected leg when the opposite, unaffected leg is raised.
98
When assessing for warmth (a sign of inflammation), what technique is required?
Use the backs of your fingers to compare the temperature with the contralateral (opposite) side.
99
Which ankle joints are tested by Inversion/Eversion of the heel versus the forefoot?
Heel movement tests the Subtalar (Talocalcaneal) Joint; Forefoot movement tests the Transverse Tarsal Joint.
100
What is an essential high-yield normal documentation statement for a Musculoskeletal Physical Exam (PE)?
Full ROM in all joints. No evidence (Ø) of joint pains, swelling, effusion, or contractures. Ø evidence of muscle atrophy or tenderness.
101
What is the patient setup for an abdominal exam?
Patient lies flat and supine; physician stands to the right
## Footnote
A pillow is permitted for the patient's head.
102
What is the purpose of draping during the abdominal exam?
Expose the anterior thorax; drape to the iliac crest and gown to the chest
## Footnote
This is to preserve patient dignity.
103
What components should be inspected during an abdominal exam?
Check for scars, striae, dilated veins, rashes, lesions, umbilicus inflammation/herniation, contour, peristalsis, pulsations
## Footnote
This is part of general inspection.
104
How should the abdominal contour be evaluated?
Note if the contour is flat, rounded, protuberant, or concave
## Footnote
This is important for inspection.
105
What is the efficiency protocol for bowel sound auscultation?
Listen in all four quadrants; if bowel sounds are heard in the RLQ, no need to listen in the other quadrants
## Footnote
This helps streamline the examination process.
106
Where should abdominal bruit auscultation be performed?
Over the abdominal aorta, renal arteries, common iliacs, and femoral arteries
## Footnote
Listen bilaterally for murmur-like sounds (bruits).
107
What is the general method for abdominal percussion?
Perform in all four quadrants; note areas of normal tympany and abnormal dullness
## Footnote
Tympany and dullness can indicate different conditions.
108
What is the normal vertical span of the liver?
6–12 cm
## Footnote
This is measured by percussion along the midclavicular line.
109
How is the spleen size assessed via Traube Space?
Percuss Traube Space; **normal** finding is **tympany**; **absence of dullness** suggests no enlargement
## Footnote
This space is between the costal margin and lung edge.
110
What is the splenic percussion sign?
Percuss last intercostal space along anterior axillary line; absence of dullness suggests no enlargement
## Footnote
This is assessed while the patient takes a deep breath.
111
What is the abdominal palpation sequencing rule?
Ask the patient to identify areas of tenderness and examine those areas **last**
## Footnote
This helps minimize discomfort for the patient.
112
Describe the technique for light palpation.
Use a light, gentle, dipping motion with flat fingers to assess superficial tenderness
## Footnote
This technique is important for evaluating superficial tenderness.
113
What is the technique for deep palpation?
Use firm, slow, constant deep pressure often utilizing two hands
## Footnote
This helps identify pulsations or masses.
114
What are the characteristics of normal liver palpation?
Edge should be soft, smooth, sharp, and non-tender
## Footnote
Palpation is done below the costal margin while the patient takes a deep breath.
115
What is the normal finding during spleen palpation?
The spleen is normally not palpable
## Footnote
This is assessed by pressing towards the spleen during a deep breath.
116
What is the normal width of the aorta upon palpation?
About 3 cm
## Footnote
Palpation is done 2–3 cm lateral of the midline to feel pulsations.
117
What is the technique for kidney palpation?
Use the left hand under the lower ribs to lift and the right hand to palpate deeply
## Footnote
The patient is asked to breathe in/out to feel the right kidney slide.
118
What is the finding for left kidney palpation?
The left kidney is normally not palpable
## Footnote
This is considered a normal finding.
119
How is costovertebral angle (CVA) tenderness assessed?
Firmly strike the CVA with the ulnar surface of a fist over a supported hand; should not be tender
## Footnote
This test is done bilaterally and can indicate conditions like pyelonephritis.
120
What are the high-yield GI ROS categories?
Inquire about nausea, vomiting, dysphagia, GERD, abdominal pain, constipation, diarrhea, change in stool caliber
## Footnote
Includes specifics like melena and BRPR.
121
What abbreviations document a benign abdomen on physical exam?
**NT, ND, Soft, Ø RG, Ø HSM, Ø Bruits, Ø CVAT**
## Footnote
NT = non-tender
ND = non-distended
Ø RG = no rebound or guarding
Ø HSM = no hepatosplenomegaly
Ø CVAT = no CVA tenderness/kidney tenderness
122
What are the two core components of the 'Assessment' in a patient note?
1. **Working Diagnosis:** The single most likely diagnosis.
2. **Differential Diagnosis:** A prioritized list of other possible diagnoses, typically ordered from most to least likely.
## Footnote
**Crucially, after presenting options, get patient input into the plan** (e.g., "Does that sound like a reasonable plan to you?", "Do you have a preference between physical therapy or a home exercise plan?")."
123
For each diagnosis, what are the three essential components of the 'Plan'?
**Diagnostics** (labs, imaging, procedures), **Therapeutics** (medications, physical therapy, counseling), and **Education** (patient instructions, red flags, follow-up timeline).
124
PMH Components (4) "COPS"
* **C**hildhood Illnesses
* **O**B/Gyn (if female)
* **P**sychiatric History
* **S**urgical
125
When documenting a Surgical History, what four details are essential for each procedure?
Name of **procedure**, **date** (or year), **indication** (why it was done), and any significant **complications**.
126
In an OB/GYN history, what does the acronym GPA stand for?
**Gravida** (total # of pregnancies), **Para** (births > 20 wks), and **Abortus** (pregnancies lost before 20 wks).
127
What is the single most important question to ask in an OB/GYN history for a female of reproductive age?
**The first day of their Last Menstrual Period (LMP).**
128
What are the key symptoms to ask about in a **Skin** Review of Systems?
**Rashes**, lumps, sores, **itching** (pruritus), dryness, changes in **color**, changes in **hair** or **nails**, or changes in the size or color of **moles**.
129
What are the key symptoms to ask about in a **Respiratory** Review of Systems?
**Cough**, **sputum** (noting color and quantity), **hemoptysis** (coughing up blood), **dyspnea** (shortness of breath), **wheezing**, and **pleurisy** (pleuritic chest pain).
130
What are the key symptoms to ask about in a **Cardiovascular** Review of Systems?
**Chest pain** or discomfort, **palpitations**, **dyspnea**, **orthopnea** (shortness of breath when lying flat), **paroxysmal nocturnal dyspnea** (PND), and **edema** (swelling).
131
What are the key symptoms to ask about in a comprehensive Gastrointestinal ROS?
Trouble or pain with swallowing (**dysphagia/odynophagia**), **heartburn**, change in **appetite**, **nausea/vomiting**, abdominal **pain**, change in **bowel movements**, rectal bleeding (**hematochezia**) or black/tarry stools (**melena**), and **jaundice**.
132
What are the key symptoms to ask about in a **Musculoskeletal** Review of Systems?
Muscle or joint **pain**, **stiffness**, **swelling**, redness, weakness, or **limited range of motion**. Also ask about systemic features like **fever** or **rash** associated with joint pain.
133
What is a key principle of language use when sharing information with a patient?
**Avoid medical jargon**. Use simple, understandable language. If a medical term must be used, explain it immediately (e.g., "We'll check for any edema, which is just a medical term for swelling.").
134
Besides medication, what alternative or holistic management options should be discussed in the Plan?
**Activity modifications**, **R.I.C.E.** (Rest, Ice, Compression, Elevation), stretching, dietary changes, and relevant **over-the-counter supportive therapies**.
135
What are the three essential elements of a warm and professional closing?
(1) **Thank the patient**
(2) **Offer a personal goodbye** (e.g., "It was a pleasure meeting you, Mr. Smith")
(3) **Offer a handshake** (if culturally appropriate).
136
What are the **determinants of Cardiac Output (CO)**?
* Heart rate
* Stroke volume
* Preload
* Myocardial contractility
* Afterload
## Footnote
CO is calculated as the product of heart rate and stroke volume, fundamentally regulated by these factors.
137
The **Heart Conduction System Components** consist of which elements?
* Sinus node
* AV node
* Bundle of His
* Left bundle branch
* Right bundle branch
## Footnote
This system is crucial for the regulation of heart rhythm and is associated with arrhythmias.
138
Define **Preload**.
The load that stretches the cardiac muscle prior to contraction
## Footnote
It is equivalent to the volume of blood in the right ventricle at the end of diastole.
139
What factors can **modify Preload**?
* Increased by inspiration
* Increased by exercising muscles
* Decreased by exhalation
* Decreased by pooling of blood in the venous system
## Footnote
These changes are influenced by the respiratory cycle.
140
How is **Myocardial Contractility** controlled?
* Increases with sympathetic stimulation
* Decreases if myocardial blood flow or oxygenation is impaired
## Footnote
This reflects the muscle's ability to shorten when loaded.
141
What is the **Afterload Mechanism**?
Vascular resistance against which the ventricles must contract
## Footnote
It is determined by the tone of the aorta walls, large arteries, and peripheral vascular tree.
142
What is the definition of **Palpitations**?
An unpleasant awareness of the heartbeat
## Footnote
Clinical queries must determine rhythm (regular/irregular), duration, and if heartbeats are rapid.
143
Define **Dyspnea**.
| (bonus: orthopnea?)
Uncomfortable awareness of breathing
## Footnote
Orthopnea is dyspnea when lying down, relieved by sitting up or using pillows.
144
What is **Paroxysmal Nocturnal Dyspnea (PND)**?
Episodes of sudden dyspnea and orthopnea that awaken the patient from sleep
## Footnote
Often associated with wheezing or coughing and may recur nightly.
145
What is the significance of **Edema Assessment**?
Increased fluid in interstitial tissue spaces manifesting as swelling
## Footnote
Clinicians must specifically ask the patient about swelling.
146
Differentiate between **Thrills** and **Bruits**.
* Thrills: palpable humming vibrations
* Bruits: murmur-like sounds detected via auscultation
## Footnote
Both are associated with turbulent flow.
147
What are the **Standard Cardiac Exam Positions**?
* Supine (head at 30 degrees)
* Left lateral decubitus
* Supine (head 30 degrees)
* Sitting/leaning forward after full exhalation
## Footnote
This sequence is important for auscultation maneuvers.
148
What should be documented when inspecting the **Apical Impulse**?
* Diameter
* Location
* Amplitude
* Duration
## Footnote
This is crucial for assessing the left ventricle.
149
What is the **Heart Sound Correlation** at the apex and base?
* S1 is louder than S2 at the apex
* S2 is louder than S1 at the base
## Footnote
This correlation is important for timing in physical exams.
150
When does **Systole** occur?
| (auscultation definition)
Between S1 and S2
## Footnote
Diastole occurs between S2 and the subsequent S1.
151
Identify the **Aortic Auscultation Landmark**.
Right 2nd interspace
## Footnote
This is the anatomical landmark for assessing the aortic valve.
152
Identify the **Pulmonic Auscultation Landmark**.
Left 2nd interspace
## Footnote
This is the anatomical landmark for assessing the pulmonic valve.
153
Identify the **Mitral Auscultation Landmark**.
Apex (left ventricular area)
## Footnote
This is the anatomical landmark for assessing the mitral valve.
154
Identify the **Tricuspid Auscultation Landmark**.
Lower left sternal border
## Footnote
This is the anatomical landmark for assessing the tricuspid valve.
155
What is the typical location of the **Apical Impulse**?
Near the Midclavicular line at the 5th interspace
## Footnote
This is important for assessing the point of maximal impulse (PMI).
156
What characterizes a **Grade 4 Murmur**?
Loud murmur accompanied by a palpable thrill
## Footnote
This indicates significant valvular lesions.
157
What characterizes a **Grade 6 Murmur**?
Very loud murmur associated with a thrill, audible even when the stethoscope is completely off the chest
## Footnote
This suggests severe disease.
158
What is **Physiological S2 Splitting**?
S2 normally splits into its components, A2 and P2, during inspiration
## Footnote
This is a normal finding during the respiratory cycle.
159
What is the **Etiology of Heart Murmurs**?
Longer duration than heart sounds, resulting from blood flow through a stenotic valve or from regurgitation/insufficiency
## Footnote
This is associated with valvular stenosis.
160
What parameters should be assessed in **Carotid Pulse Assessment**?
* Pulse amplitude
* Contour (speed of upstroke/downstroke, duration of summit)
* Variations in amplitude
## Footnote
These characteristics provide insight into cardiovascular health.
161
What is the purpose of the **Left Lateral Decubitus Maneuver**?
To accentuate extra sounds S3 and S4 and murmurs such as Mitral Stenosis
## Footnote
This position is crucial for detailed cardiac examination.
162
What is the purpose of the **Sitting/Leaning Forward Maneuver**?
To best assess murmurs like Aortic Regurgitation
## Footnote
Typically performed after full exhalation.
163
How are **Systolic Murmurs** classified?
* Midsystolic
* Pansystolic (holosystolic)
* Late systolic patterns
## Footnote
This classification is important for diagnosis.
164
How are **Diastolic Murmurs** classified?
* Early diastolic
* Middiastolic
* Late diastolic (presystolic) patterns
## Footnote
This classification aids in identifying underlying conditions.
165
What is the **first step** in executing specific cardiac physical exam techniques?
Use the bell first at the apex for low-pitched sounds (S3/S4/MS)
## Footnote
This technique is crucial for accurately detecting low-frequency sounds.
166
What should you document during a **carotid assessment**?
* Contour profile
* Speed of upstroke/downstroke
* Duration of the summit
## Footnote
This detailed assessment is essential for understanding pulse wave characteristics.
167
What technique should be used for **differential palpation** of the carotid arteries?
* Use finger pads lightly for soft extra sounds (S3/S4)
* Apply firmer pressure for S1/S2
* Use the ball of the hand firmly for thrills
## Footnote
This technique helps in identifying thrills and heaves effectively.
168
Where should you listen with the **auscultation tool** for low-frequency sounds?
At the apex with the bell
## Footnote
For other areas, use the diaphragm at the tricuspid area and all sites.
169
What are the key components of **comprehensive murmur characterization**?
* Pitch (high, medium, low)
* Quality (blowing, harsh, rumbling, musical)
* Location
* Radiation
## Footnote
These elements are critical for valvular assessment.
170
What should be inspected in the **precordium**?
* Anterior chest
* 2nd interspaces
* Right ventricle
* Left ventricle (apical impulse)
## Footnote
Inspection should precede palpation for thorough assessment.
171
What details should be documented when assessing the **apical impulse**?
* Diameter
* Location
* Amplitude
* Duration
## Footnote
This documentation is important for evaluating the left ventricle's function.
Normal Finding Example: *Cardiovascular: Regular rate and rhythm. Normal S1, S2. No murmurs, rubs, or gallops. The apical impulse is noted at the **location** of the 5th intercostal space, left midclavicular line. It is approximately 2 cm in **diameter**, has a brisk, non-forceful **amplitude**, and a brief **duration** (occupying the first half of systole).*
172
Mnemonic: "2245 APT. M"
173
What must be printed at the bottom of every SOAP note?
**Student Name and Identifier**
"Kevin Xie, OMS-I, PCOM"
174
What is a TART finding?
Tissue Texture Change
Asymmetry
Restriction of Motion
Tenderness.
175
What is an example of a documentable OMM structural finding?
"Increased paravertebral muscle tone at T3-T5 on the right." (Note: "No TART" is unacceptable per the criteria).
176
What is the required format for the HPI vs. other subjective sections?
**HPI** must be in **paragraph form**.
All other subjective sections (**PMH, PSH, FH, SH, ROS**) should be **bulleted lists with headers**.
177
How should the ROS related to the chief complaint be documented?
As "**Pertinent Positives**" and "**Pertinent Negatives**."
178
What should be documented under the "Gen:"(General) heading in the PE?
**Alertness, orientation, and any apparent distres**s. (e.g., "A&Ox3, in no apparent distress")
179
What standard phrase is used to document a normal heart exam?
**RRR, S1S2 present. No murmurs, rubs, or gallops.**
180
What are the 4 components of the neck exam? "RLTT"
1. **ROM** (flexion, extension, rotation, lateral bending)
2. **Lymphadenopathy** (anterior and posterior nodes)
3. **Thyroid** (palpation)
4. **Trachea** (position).
181
What is "specific empathy"?
**Connecting** the patient's **illness** directly to their **life**. (e.g., "Walking on crutches must be tricky for a Kindergarten teacher") vs. **generic empathy** ("That must be difficult").
182
What "practical aspects" of an illness should you ask about?
How the illness affects their: **Home life, personal life, work, family members, or finances**.
183
For ECG readings, what are the 9 questions to determine before arriving to a complete interpretation?
1) Is there a P wave before *every* QRS?
2) Is the P wave *upright*?
3) Are the R to R *regular*?
4) What is the rate?
5) What is the PR interval?
6) What is the QRS interval
7) Is there a T wave *after* the QRS?
8) What is the QT interval?
9) Is there any ST segment *abnormality*?
## Footnote
Each small box is 0.04s; one big box is 0.2s
184
What is the correct sequence for examining the **carotid arteries**, and why?
**Auscultate first**, then **palpate**.
## Footnote
Palpating first may dislodge a plaque or induce syncope, and performing it before auscultation can artificially create bruit-like sounds.
185
What is the standard **grading scale** for arterial pulses (0-3+)?
* **0:** Absent
* **1+:** Diminished, weaker than expected
* **2+:** Brisk, expected (Normal)
* **3+:** Bounding/Increased
## Footnote
This scale helps assess the strength of arterial pulses.
186
During a cardiac exam, what specifically does the **'Left Lateral Decubitus'** position assess, and which part of the stethoscope should be used?
**Point of Maximal Impulse (PMI)** and **Mitral valve** sounds.
*Tool:* Use the **Bell** of the stethoscope.
## Footnote
This position enhances the detection of certain heart sounds.
187
Which cardiac murmurs are enhanced when the patient is sitting up, leaning forward, after full exhalation?
**Aortic Regurgitation** (and friction rubs).
*Location:* Listen at the Left Lower Sternal Border (LLSB) and Apex.
## Footnote
This position helps in better auscultation of specific murmurs.
188
What are the anatomical landmarks for auscultating the **4 main heart valves** (APTM)?
* **Aortic:** Right 2nd intercostal space
* **Pulmonic:** Left 2nd intercostal space
* **Tricuspid:** Left lower sternal border (4th/5th ICS)
* **Mitral:** Apex (Left 5th ICS, mid-clavicular line)
## Footnote
Knowing these landmarks is essential for accurate auscultation.
189
What is the clinical definition of **'Tactile Fremitus'**?
Palpable vibrations transmitted through the bronchopulmonary tree to the chest wall when the patient speaks.
## Footnote
Increased fremitus suggests consolidation (e.g., pneumonia); decreased suggests air/fluid in pleural space (e.g., pneumothorax, effusion).
190
How many **percussion/auscultation 'pairs'** are typically required for a complete **Posterior Thorax** exam?
**7 pairs** (14 spots total).
## Footnote
This method involves comparing side-to-side in a ladder pattern.
191
How many **percussion/auscultation 'pairs'** are typically required for a complete **Anterior Thorax** exam?
**6 pairs**.
## Footnote
This ensures coverage of the apices and lateral fields.
192
What is a **'Bruit'** (abdominal context)?
A murmur-like sound of vascular origin heard on auscultation.
## Footnote
Typically caused by turbulent blood flow through a narrowed (stenotic) vessel.
193
Which **4 distinct vascular areas** must be auscultated during an abdominal exam for bruits?
* **Aorta** (midline, superior to umbilicus)
* **Renal arteries** (bilateral, lateral to aorta)
* **Iliac arteries** (bilateral, inferior to umbilicus)
* **Femoral arteries** (bilateral, in groin crease)
## Footnote
This ensures thorough assessment of vascular health.
194
What is the normal vertical span of the **liver** at the mid-clavicular line?
**6–12 cm.**
## Footnote
This measurement is important for assessing liver size and potential enlargement.
195
What are the two primary techniques for **palpating the liver**?
* **Standard:** Left hand behind lower ribs to lift; Right hand palpates RUQ.
* **Hooking Technique:** Both hands hooked under the costal margin from above.
## Footnote
These techniques help in accurately assessing liver size and tenderness.
196
What are the two **percussion techniques** used to assess for **Splenomegaly**?
* **Traube’s Space:** Percuss the left lower anterior chest wall; it should remain **tympanic**.
* **Splenic Percussion Sign:** Percuss the lowest interspace in the left anterior axillary line; it should remain **tympanic** during deep inspiration.
## Footnote
A positive sign indicates a shift to **dullness, suggesting splenomegaly.**
197
What are the **3 critical 'Professionalism' failures** that result in automatic point deductions during a practical?
* **Unprofessional Behavior** (-10 pts)
* **Equipment not present** (-10 pts)
* **Not dressed as directed** (-5 pts)
## Footnote
These failures are explicitly outlined in the rubric.
198
What is the most common **forgotten step** during a practical skills exam that is required for full credit?
**Verbalizing the exam.**
## Footnote
You must explain what you are doing while you are doing it, e.g., 'I am now palpating the carotid artery for contour and amplitude.'
199
For the **PCS Practical Pulmonary Exam**, how many pairs of percussion/auscultation points are required for the **Anterior thorax**?
6 pairs
## Footnote
This is part of the examination process to assess lung function.
200
For the **PCS Practical Pulmonary Exam**, how many pairs of percussion/auscultation points are required for the **Posterior thorax**?
7 pairs
## Footnote
This is part of the examination process to assess lung function.
201
What is the specific **patient angle** required for inspecting the precordium and auscultating the **Tricuspid area** during the Cardiovascular exam?
Supine at 30 degrees
## Footnote
This angle helps in better visualization and auscultation of heart sounds.
202
Define **Fremitus**.
Palpable vibrations transmitted through the bronchopulmonary tree to the chest wall
## Footnote
Fremitus is assessed during a physical examination to evaluate lung conditions.
203
What should you verbalize when palpating the precordium (chest wall over heart) to confirm it is normal?
"No heaves, lifts, or thrills palpated."
204
How do you verbalize a normal Neck/Vascular exam (often done with Heart)?
"Trachea is midline. No Jugular Venous Distension (JVD). No carotid bruits auscultated."
205
What is the "4-point" verbalization for a benign Abdominal Inspection & Auscultation?
"Abdomen is **non-distended**. **Bowel** **sounds** **are** **normoactive** in all four quadrants. **No** **bruits** noted over the aorta or renal arteries."
206
How do you verbalize a normal Abdominal Palpation?
## Footnote
Hint: Indicates absence of pain and abnormal findings during examination.
"Abdomen is Soft and Non-Tender (NT). No guarding or rebound. No hepatosplenomegaly (HSM) or masses palpated."
207
What do you say to the facilitator/evaluator after performing the Costovertebral Angle (CVA) thump?
"Negative CVA tenderness bilaterally."
208
How do you verbalize a normal lung expansion during a physical exam?
"Chest expansion is symmetric."
209
How do you verbalize a normal tactile fremitus of the lungs during a physical exam?
"Tactile fremitus is symmetric and normal."
210
How do you verbalize PMI (Point of Maximal Impulse) location during a heart physical examination?
"PMI is **palpable** at the 5th intercostal space, mid-clavicular line, and is **non-displaced**."
211
What is the standard "buzzword" phrase for a normal Lung Auscultation?
"Lungs are **Clear to Auscultation (CTA**) bilaterally. No wheezes, rales, or rhonchi."
212
What "peripheral" verbalizations should be included with a Cardiac exam?
"**Capillary refill is < 2 seconds** in upper and lower extremities. **No pitting edema** noted to the mid-shin."
213
How do you verbalize a normal Abdominal Aorta palpation?
"Aortic pulsation is **non-expansile** and estimated to be **< 3 cm** in width."
214
How do you verbalize the finding for Radial Pulses?
"Radial pulses are **2+ and symmetric** bilaterally."
215
How do you verbalize the palpation of the Carotid Arteries?
"Carotid upstrokes are **brisk** and **normal in amplitude**."
216
[Endotracheal Intubation]
trachea
217
What are the **initial assessment steps** for an unconscious patient?
* Identify ID/Role
* Decontaminate hands
* Confirm unconsciousness
* Check carotid pulse (30-50 bpm)
* Check for agonal respirations (<2/min)
## Footnote
Performing steps out of sequence or omitting distress assessment can lead to critical errors.
218
What is the correct **ventilation rate** using a Bag Valve Mask (BVM) prior to intubation?
Provide a 1-second inspiration once every 6 seconds
## Footnote
Ventilating too rapidly or failing to assure a face seal can compromise patient safety.
219
How should the **Endotracheal (ET) tube cuff** be prepared?
* Inflate pilot balloon with 10 ml to check integrity
* Withdraw air
* Leave the charged syringe attached
## Footnote
Removing the syringe before the procedure is complete can lead to complications.
220
What is the correct **positioning for the stylet** within the ET tube?
Insert stylet (hockey stick/30-degree curve) ensuring it does not pass the 'Murphy' eye hole
## Footnote
Allowing the stylet to extend past the tip of the tube can cause injury.
221
Which hand must hold the **laryngoscope**?
The laryngoscope must be held in the left hand
## Footnote
Using the laryngoscope in the right hand is a critical failure.
222
Where is the tip of the **Macintosh (curved) blade** placed?
The tip is placed in the vallecula
## Footnote
Lifting the epiglottis directly is a technique for the Miller blade.
223
What is the correct **lifting vector** for the laryngoscope?
Lift in the direction of the handle (vertical 10:00 angle)
## Footnote
Rocking back on the upper incisors/teeth can lead to injury.
224
How far should the **ET tube** be advanced relative to the vocal cords?
Stop advancing when the proximal cuff is about 1 cm below the cords
## Footnote
Advancing too deep can lead to endobronchial intubation or too shallow can cause inadequate ventilation.
225
What is the **sequence immediately after placing the ET tube**?
* Remove laryngoscope
* Remove stylet
* Inflate balloon with 10cc air
* Remove syringe
* Maintain manual control
## Footnote
Releasing manual control of the tube before it is secured can lead to displacement.
226
How is proper **tube placement verified**?
* Check CO2 (capnograph)
* Listen for absence of epigastric sounds
* Listen for breath sounds at 4 anterior sites
## Footnote
Failing to auscultate the epigastrium to rule out esophageal intubation can result in inadequate ventilation.
227
What constitutes a **'Critical Failure'** in the intubation skill exam?
* Failure of 3 attempts
* Using laryngoscope in right hand
* Failure to ventilate successfully
* Prolonged apnea
228
What are the **risks associated with endotracheal intubation**?
* Trauma to teeth/cords
* Infection (VAP)
* Failed intubation
* Tracheal stenosis
* Barotrauma
## Footnote
Overlooking potential for accidental extubation or esophageal placement can lead to serious complications.
229
[Endotracheal Intubation] What is the mandatory verbalization for team safety before starting the procedure?
Verbalize "Placing PPE in place" for all airway team members.
## Footnote
Donning your own gear but failing to verbalize safety for the room.
230
[Endotracheal Intubation] How must you verbalize the equipment preparation phase?
Explicitly verbalize "Oxygen" and "Suction" (or "Checking Suction").
## Footnote
Touching the equipment without announcing its readiness.
231
[Endotracheal Intubation] What specific phrase must be stated upon inserting the laryngoscope and seeing anatomy?
"I visualize vocal cords."
## Footnote
Attempting to insert the tube before declaring you have a clear view.
232
[Endotracheal Intubation] What exact verbalization is required as you advance the ET tube?
"I’m visualizing endotracheal tube passing through vocal cords."
## Footnote
Advancing the tube silently, implying a potential blind insertion.
233
[Endotracheal Intubation] How do you verbalize the confirmation of CO2?
"I am checking for CO2 on the capnograph" or "I am looking for the color change indicating carbon dioxide."
## Footnote
Looking at the monitor without announcing what you are interpreting.
234
[Endotracheal Intubation] What are the Critical Failures that result in an automatic fail?
* Failure of 3 attempts
* Using laryngoscope in the RIGHT hand
* Failure to ventilate successfully
* Prolonged apnea
## Footnote
Switching hands during a difficult lift.
235
[Endotracheal Intubation] What is the correct sequence for preparing the ET tube cuff (balloon)?
Inflate with 10ml to check integrity, withdraw air, and leave the charged (10ml) syringe attached.
## Footnote
Removing the syringe before the tube is placed, wasting time re-attaching it later.
236
[Endotracheal Intubation] Where is the Stylet positioned relative to the tube tip?
Ensure stylet does not pass the "Murphy" eye hole; stop at the proximal cuff.
## Footnote
Allowing the stylet to protrude past the tip, causing tracheal trauma.
237
[Endotracheal Intubation] What is the correct lifting vector for the laryngoscope handle?
Lift in the direction of the handle (vertical 10:00 angle).
## Footnote
Rocking back on the upper incisors/teeth.
238
[Endotracheal Intubation] Where must the tip of the Macintosh (curved) blade be placed?
In the vallecula.
## Footnote
Placing the tip under the epiglottis (incorrect for Mac, correct for Miller).
239
[Endotracheal Intubation] How far do you advance the ET tube?
Stop advancing when the proximal cuff is about 1 cm below the vocal cords.
## Footnote
"Mainstemming" the tube (advancing too deep into the right bronchus).
240
[Endotracheal Intubation] What is the immediate sequence after the tube is in the trachea?
* Remove laryngoscope
* Remove stylet
* Inflate balloon
* Remove syringe
* Maintain manual control
## Footnote
Inflating the balloon while the stylet is still inside.
241
[Endotracheal Intubation] What is the auscultation sequence for verifying placement?
Listen for ABSENCE of sounds over epigastrium first, then listen for breath sounds at 4 anterior sites.
## Footnote
Auscultating lungs first and missing esophageal intubation sounds.
242
[Endotracheal Intubation] What are the initial vital signs to assess in the unconscious patient scenario?
* Carotid pulse (30-50 bpm)
* Agonal respirations (<2/min)
## Footnote
Failing to identify agonal breathing as a sign of cardiac arrest/distress.
243
[Endotracheal Intubation] What is the target ventilation rate with the BVM?
One breath (1 second inspiration) every 6 seconds.
## Footnote
Hyperventilating the patient (bagging too fast).
244
What is the critical rule regarding **equipment readiness** for the lab or exam room?
Verify your battery charge before entering the lab or exam room
## Footnote
A 'dead' otoscope/ophthalmoscope is a useless one.
245
When inserting anything into a patient's ear or nose, how should you **brace your hand**?
Your hand must be braced against the patient's face
## Footnote
This prevents injury if the patient moves.
246
What does the **oral exam** involve beyond just looking at teeth?
Grasp the tongue with gauze to visualize lateral borders and palpate the floor of the mouth
## Footnote
This area is a high-risk cancer zone.
247
Why is it important to **know the normals** when identifying pathology?
You cannot identify pathology if you don't know what a normal node feels like
## Footnote
Normal nodes are typically mobile, soft, and discrete.
248
[HEENT Skills Lab] What specific equipment must you ensure is ready before the lab begins?
A diagnostic kit that is charged and a tuning fork
## Footnote
Bringing a diagnostic kit with dead batteries is a pitfall.
249
What is the correct technique for holding the **otoscope** during the ear exam?
Hold the handle like a pencil/pen and brace your hand against the patient's cheek/face
## Footnote
Holding it incorrectly risks injury if the patient moves.
250
How do you straighten the **ear canal** for an adult otoscopic exam?
Pull the auricle upward, backward, and slightly away from the head
## Footnote
Pulling down is a pediatric technique and may not be effective.
251
What landmark do you look for on the **tympanic membrane** to ensure proper orientation?
The cone of light (fans anteriorly and downward from the umbo)
## Footnote
Confusing the pars flaccida with a perforation is a common pitfall.
252
How is the **'Tug Test'** performed and what does pain indicate?
Move the auricle up and down and press on the tragus; pain suggests otitis externa
## Footnote
Pain on manipulation does not indicate otitis media.
253
What is the correct placement for the **tuning fork** during the Weber test?
Firmly on the top of the patient's head (vertex) or mid-forehead
## Footnote
Placing it off-midline or not pressing firmly enough can lead to inaccurate results.
254
What is the normal finding for the **Rinne test**?
Air Conduction (AC) should be heard longer/better than Bone Conduction (BC) (AC > BC)
## Footnote
Documenting BC > AC indicates conductive hearing loss.
255
How do you perform the test for **CN X (Vagus)** elevation?
Ask the patient to say 'Ah' or yawn; observe the soft palate rise symmetrically and uvula remain midline
## Footnote
Failing to use a tongue blade if the view is obstructed can lead to missed observations.
256
What is the critical maneuver for **palpating the thyroid gland**?
Ask the patient to swallow (sip water) and feel the gland rise under your fingers
## Footnote
Palpating too high or forgetting to have the patient swallow can lead to errors.
257
What is the proper technique for examining the **lateral margins of the tongue**?
Grasp the tip of the tongue with gauze, pull it to the side, and inspect/palpate the lateral margin
## Footnote
Just asking the patient to stick their tongue out misses lateral cancers.
258
What is the specific order of **palpation for the head/neck lymph nodes**?
Preauricular -> Posterior Auricular -> Occipital -> Tonsillar -> Submandibular -> Submental -> Superficial Cervical -> Posterior Cervical -> Deep Cervical -> Supraclavicular
## Footnote
Skipping a group or palpating randomly can lead to missed findings.
259
How do you assess the **frontal sinuses**?
Press up on the frontal sinuses from under the bony brows
## Footnote
Avoid pressing on the forehead to prevent discomfort.
260
What is the correct insertion angle for the **nasal speculum**?
Direct the speculum posteriorly, then upward in small steps
## Footnote
Avoid touching the nasal septum to prevent pain or bleeding.
261
If a **supraclavicular lymph node** is palpable, what must you suspect?
Malignancy (metastasis from thoracic or abdominal malignancy), especially on the left
## Footnote
This is known as Virchow's node.
262
What is the technique to visualize the **posterior pharynx** if the tongue obstructs the view?
Press a tongue blade firmly down on the midpoint of the arched tongue
## Footnote
Avoid pressing too far back to prevent gagging.
263
What three specific actions must be performed on the **Skull**?
* Inspect (size, contour)
* Inspect (deformities, lumps)
* Palpate (tenderness, depressions, step-offs)
## Footnote
These actions are essential for a thorough examination of the skull.
264
When inspecting the **Hair**, what three characteristics must be verbalized?
* Quantity
* Distribution
* Texture
## Footnote
These characteristics help assess the health and condition of the hair.
265
What specific facial features are you inspecting for during the **Face** portion of the exam?
* Expression
* Contours
* Asymmetry
* Involuntary movements
* Edema
* Masses
## Footnote
These features provide insights into the patient's health and emotional state.
266
What **three specific bony landmarks** on the tympanic membrane must be identified/verbalized?
* The Umbo
* The Handle of the Malleus
* The Short Process of the Malleus
## Footnote
Identifying these landmarks is crucial for assessing ear health.
267
Distinguish the **Pars Flaccida** from the **Pars Tensa**.
* Pars Flaccida: The small portion of the eardrum above the short process
* Pars Tensa: The remainder (majority) of the eardrum
## Footnote
Understanding these parts is important for diagnosing ear conditions.
268
What other sinus set must be palpated, and where?
Maxillary Sinuses. Press up on the maxillary sinuses (cheeks) from under the bony zygomatic arches.
## Footnote
Palpating these sinuses helps assess for sinusitis or other conditions.
269
What **two internal structures** are listed on the checklist to identify during the internal nasal exam?
* The Septum
* The Inferior Turbinates
## Footnote
Identifying these structures is essential for a complete nasal examination.
270
What are the **Wharton ducts** and where do you find them?
The ducts of the **submandibular glands**. They open on papillae that lie on each side of the lingual frenulum (under the tongue).
## Footnote
These ducts are important for saliva drainage.
271
What are the **Stensen ducts** and where do you find them?
The ducts of the **parotid glands**. They open onto the buccal mucosa near the upper second molar.
## Footnote
These ducts are significant for understanding salivary gland function.
272
Besides the uvula, what specific pharyngeal structures are also required for inspection?
* Soft palate
* Anterior and posterior pillars
* Tonsils
* Posterior Pharynx
## Footnote
Inspecting these structures is crucial for evaluating throat health.
273
How do you test **Cranial Nerve XII (Hypoglossal)** during the mouth exam?
Ask the patient to stick out their tongue. Inspect for symmetry (it should be midline).
## Footnote
This test assesses the function of the hypoglossal nerve.
274
What are the lymph notes below the clavicle called?
The **Infraclavicular** nodes.
## Footnote
These nodes are important for assessing lymphatic drainage.
275
What is the correct **Posterior Approach** technique for palpating the thyroid?
* Stand behind the patient
* Have patient flex neck slightly forward
* Place fingers of both hands just below the cricoid cartilage
* Ask patient to sip and swallow water
* Feel for the isthmus rising
* Displace trachea to right/left to palpate lobes
## Footnote
This technique ensures accurate palpation of the thyroid gland.
276
When inspecting the **Trachea**, what pathology are you specifically checking for?
**Deviation** from the midline.
## Footnote
Deviation may suggest pneumothorax, large effusion, or mass.
277
Verbalize a normal **Nose/Sinus** exam findings.
"Nasal mucosa pink, septum midline; no sinus tenderness."
## Footnote
This statement indicates a healthy nasal and sinus condition.
278
Verbalize a normal **Mouth/Throat** exam.
"Oral mucosa pink, dentition good, tongue midline, tonsils absent/1+, pharynx without exudates or erythema."
## Footnote
This reflects a healthy oral and throat examination.
279
Verbalize a normal **Neck/Thyroid** exam.
"Trachea midline. Neck supple; thyroid isthmus palpable, lobes not felt. No cervical lymphadenopathy."
## Footnote
This indicates a normal neck and thyroid examination.
280
What is the **critical failure** regarding the otoscope and patient safety?
Failing to **brace** your hand against the patient's face to prevent injury if they move.
## Footnote
This is essential for ensuring patient safety during the examination.
281
What must be done **before** whispering during the Whispered Voice Test?
You must **exhale a full breath** before whispering.
## Footnote
This ensures a quiet voice for accurate testing.
282
In a **Snellen visual acuity test**, what does a score of 20/40 indicate?
The patient sees at 20 feet what a person with normal vision sees at 40 feet.
## Footnote
This score reflects the patient's visual clarity compared to standard vision.
283
What is the **cutoff rule** for determining visual acuity on a specific Snellen line?
If the patient makes **two mistakes** on a line, move to the line above to determine their acuity.
## Footnote
This rule helps ensure accurate assessment of visual acuity.
284
What is the correct distance for testing **near vision** using a pocket visual acuity card?
14 inches from the nose.
## Footnote
This distance is standard for assessing near visual acuity.
285
What is the proper starting position for the examiner's hands during the **confrontation visual field test**?
Behind the patient's ears (behind the visual field), moving forward into view.
## Footnote
This position allows for an accurate assessment of peripheral vision.
286
What are the specific distance parameters for the **EOM 'H-test'** and the **Convergence test**?
* **EOM:** Finger approximately **2 feet** away.
* **Convergence:** Move finger towards the nose to about **5 inches** away.
## Footnote
These distances are critical for evaluating eye movement and convergence.
287
What is the **'Right-Right-Right' rule** for the fundoscopic exam?
Hold the ophthalmoscope in the **Right** hand, use your **Right** eye, to examine the patient's **Right** eye (and vice-versa for the left).
## Footnote
This rule helps maintain proper alignment during the examination.
288
What is the correct approach angle and distance to identify the **Red Reflex**?
Approach from **15 degrees off-center**, starting **1 to 2 feet** (arm's length) away.
## Footnote
This technique is essential for assessing the health of the retina.
289
How do **retinal arteries** differ in appearance from **retinal veins** on fundoscopy?
* **Arteries:** Light red (smaller).
* **Veins:** Dark red (larger).
## Footnote
This distinction is important for evaluating vascular health in the eye.
290
What is the normal size ratio of the **central physiologic cup** to the optic disc?
The cup is typically **half the diameter** of the optic disc.
## Footnote
This ratio is used to assess for conditions like glaucoma.
291
What specific instruction allows visualization of the **fovea/macula**?
Ask the patient to **look directly at the light**.
## Footnote
This helps in examining the central part of the retina.
292
What type of words must be used during the **Whispered Voice Test**?
**Two-syllable** distinct words (e.g., 'Baseball', '94').
## Footnote
This ensures clarity in assessing auditory function.
293
Where should the **tongue blade** be placed to view the pharynx without inducing the gag reflex?
On the **anterior two-thirds** of the tongue (pressing down, not backward).
## Footnote
This technique minimizes discomfort while allowing for a clear view.
294
What inspection technique assists in visualizing the **thyroid isthmus** during a swallow?
Using **tangential lighting** (shining light down from above the chin).
## Footnote
This method enhances visibility of the thyroid during examination.
295
What are the specific landmarks for the **Superficial, Deep, and Posterior Cervical lymph nodes** relative to the **Sternocleidomastoid (SCM)**?
* **Superficial:** Over the surface of the SCM.
* **Deep:** Under the SCM.
* **Posterior:** Behind the SCM.
## Footnote
Knowing these landmarks is crucial for accurate lymph node examination.
296
What are the **five specific symptoms/signs** to ask about during the **Neck Review of Systems (ROS)**?
* Swollen glands
* Goiter
* Lumps
* Pain
* Stiffness
## Footnote
These symptoms are important for assessing potential neck-related health issues.
297
What is the first step upon **entry** during a physical exam?
Immediate hand sanitizer
## Footnote
Do not skip this step.
298
What should you say when introducing yourself as a **Student Doctor**?
| (As a role of the Physical Examiner in a SP Lab)
"Hello, I'm Student Doctor [Name]. I'll be conducting your physical exam today."
## Footnote
Verify Name/DOB.
299
What should you verbalize regarding the **vitals** observed upon entering the exam room?
"I see your vitals were taken at the door and they are stable."
## Footnote
Do not pick up the BP cuff.
300
What does **HEENT** stand for in a physical exam?
* Head
* Ears
* Nose
* Throat
* Neck
## Footnote
This section covers the examination of these areas.
301
What should you verbalize after inspecting the **head**?
"Normocephalic, atraumatic. Hair distribution normal."
## Footnote
This is part of the head inspection process.
302
How should you hold the **otoscope** during ear examination?
Like a pencil, bracing your pinky/hand against the patient's cheek
## Footnote
Pull the ear Up, Back, and Out before inserting the speculum.
303
What should you verbalize after examining the **ears**?
"Canals clear, Tympanic Membranes pearly gray."
## Footnote
This indicates a normal ear examination.
304
What should you verbalize after examining the **nose**?
"Mucosa pink, septum midline."
## Footnote
This is part of the nasal examination process.
305
What action should you take when examining the **throat**?
Ask patient to open mouth, use light, press tongue down with blade
## Footnote
Ask patient to say "Ah" during the examination.
306
What should you verbalize after examining the **throat**?
"Uvula rises midline, no exudates."
## Footnote
This indicates a normal throat examination.
307
What technique is used to **palpate** the neck?
Use pads of fingers to palpate lymph node chains and trachea
## Footnote
Ensure the trachea is midline and check for thyroid movement.
308
What should you verbalize after palpating the **neck**?
"Trachea midline, no lymphadenopathy, thyroid moves freely."
## Footnote
This indicates a normal neck examination.
309
What is the setup for the **thorax and lungs** examination?
Ask patient to sit up, expose the back
## Footnote
Gown should be down to the waist.
310
What should you instruct the patient during the **lung auscultation**?
"Please take deep breaths through an open mouth every time my stethoscope touches you."
## Footnote
This ensures proper lung sounds are heard.
311
What should you verbalize after auscultating the **lungs**?
"Lungs clear to auscultation bilaterally. No wheezes, rales, or rhonchi."
## Footnote
This indicates normal lung sounds.
312
What is the **setup** for the cardiovascular examination?
Patient supine, head at 30 degrees
## Footnote
If the table adjusts, ensure proper positioning.
313
What is the **Z Pattern** for cardiovascular auscultation?
* Aortic: Right 2nd intercostal space
* Pulmonic: Left 2nd intercostal space
* Tricuspid: Left Lower Sternal Border
* Mitral: 5th intercostal space, Mid-clavicular line
## Footnote
This pattern helps locate heart sounds.
314
What should you verbalize after examining the **heart**?
"Regular rate and rhythm. S1 and S2 normal. No murmurs, gallops, or rubs."
## Footnote
This indicates a normal heart examination.
315
What should you do before leaving the exam room or completing the physical exam?
Sanitize hands
## Footnote
This is crucial for hygiene.
316
What are the highlights to report during the **oral presentation** following a **HEENT + Heart/Lungs PE**?
* Vitals were stable
* HEENT was normocephalic, atraumatic. Pharynx clear
* Lungs clear to auscultation anteriorly and posteriorly
* Heart was regular rate and rhythm, no murmurs
## Footnote
Note any pertinent positives if observed.
317
What is the **'Right-Right-Right' rule** for Fundoscopic examination?
Hold the ophthalmoscope in your **Right** hand, use your **Right** eye, to examine the patient's **Right** eye.
318
What is the specific technique to test for the **Red Reflex**?
Shine the light from **arms length away (1-2 feet)** at an angle of **15 degrees off center**.
319
How do you verbalize a **normal finding** for the Optic Disc?
"Disc margins are sharp; cup-to-disc ratio is 1:2 (or 0.5)."
320
What is the correct technique for **palpating the Thyroid gland** (Posterior Approach)?
Place hands below the cricoid cartilage, ask patient to **flex neck slightly forward**, and **swallow (sip water)** to feel the isthmus rise.
321
When inspecting the trachea, what is the critical pathology to rule out?
Tracheal Deviation (deviation from midline).
322
How do you assess **Cranial Nerve V (Trigeminal) Motor function**?
Palpate the **masseter and temporal muscles** while the patient clenches their jaw.
323
How do you assess **Cranial Nerve V (Trigeminal) Sensory function**?
Test light touch (cotton) and pain (sharp/dull) in all three divisions (Opthalmic, Maxillary, Mandibular) bilaterally.
324
What does a unilateral absence of the **gag reflex** indicate?
A lesion of **Cranial Nerve IX (Glossopharyngeal)** or **X (Vagus)**.
325
How do you test **Cranial Nerve XI (Spinal Accessory)**?
Inspect trapezius for atrophy; assess strength by asking patient to **shrug shoulders against resistance** and **turn head against resistance** (SCM).
326
How is **Cranial Nerve XII (Hypoglossal)** assessed?
Ask patient to protrude tongue; look for deviation. Tongue deviates **toward** the side of the lesion.
327
What is **Grade 5 Muscle Strength**?
Active movement against **full resistance** without fatigue (Normal).
328
What is **Grade 3 Muscle Strength**?
Active movement against **gravity only**.
329
What constitutes a **positive Pronator Drift**?
With eyes closed/arms supinated: One forearm **pronates** or drifts **downward**.
330
Which spinal levels are tested by the **Biceps Reflex**?
**C5 and C6**.
331
Which spinal levels are tested by the **Triceps Reflex**?
**C6 and C7**.
332
Which spinal levels are tested by the **Patellar (Knee) Reflex**?
**L2, L3, L4**.
333
Which spinal levels are tested by the **Achilles (Ankle) Reflex**?
**S1**.
334
What is the **Grading Scale for Deep Tendon Reflexes (DTRs)**?
0: Absent
1+: Diminished
2+: Average (Normal)
3+: Brisker than average
4+: Hyperactive (with Clonus)
335
What is a **positive Babinski Response** and what does it indicate?
Dorsiflexion of the great toe with fanning of other toes. Indicates **Central Nervous System (CNS) / Corticospinal tract** lesion.
336
What is the **Brudzinski Sign**?
Flexion of the hips and knees in response to **passive flexion of the neck**.
337
What does a **Snellen visual acuity score** of 20/40 indicate?
The patient sees at **20 feet** what a person with normal vision sees at **40 feet**.
## Footnote
The larger the bottom number, the worse the vision.
338
What is the **Cutoff Rule** for determining acuity on a Snellen line?
If the patient makes **two mistakes** on a line, move to the line **above** to determine their acuity.
## Footnote
Always test one eye at a time, then both.
339
What is the correct technique for testing **Visual Fields by Confrontation**?
Place hands **behind the patient's ears** (out of view) and wiggle fingers while moving them forward into the central vision.
## Footnote
Test all quadrants. If a defect is found, test each eye individually.
340
When performing the **H-Test** for EOMs, what specific pathology are you checking for at the lateral extremes?
**Nystagmus** (rhythmic oscillation of the eyes).
## Footnote
A few beats can be normal; sustained nystagmus is abnormal.
341
Ptosis (drooping eyelid) indicates a palsy of which **Cranial Nerve**?
**Cranial Nerve III (Oculomotor)**.
## Footnote
CN III controls the levator palpebrae superioris.
342
What does the **Romberg Test** specifically evaluate? (Hint: It is NOT primarily a cerebellar test)
It tests **Position Sense** (Posterior Columns).
## Footnote
The patient stands with feet together, eyes open (vision compensates), then **eyes closed**. Loss of balance with eyes closed is a Positive Romberg.
343
How do you perform the test for **Dysdiadochokinesia** (Rapid Alternating Movements)?
Ask patient to strike thigh with palm/back of hand rapidly, OR tap index finger against thumb joint rapidly.
## Footnote
Observe for speed, rhythm, and smoothness. Slow/clumsy movements suggest **Cerebellar disease**.
344
What is **Stereognosis**?
The ability to identify a common object (e.g., key, coin) by feeling it with **eyes closed**.
## Footnote
Tests discriminative sensation (Cortex).
345
What is **Graphesthesia**?
The ability to identify a **number drawn on the palm** with a blunt object while eyes are closed.
## Footnote
Used when motor impairment prevents holding an object (Stereognosis).
346
What is the proper technique for testing **vibration sense**?
Place a **128 Hz** tuning fork on the **distal interphalangeal joint** (finger/toe).
## Footnote
If distal sensation is impaired, move proximally to bony prominences (wrist/ankle).
347
What is the **Kernig Sign**?
Pain elicited when the hip and knee are flexed, and the examiner attempts to **straighten (extend) the knee**.
## Footnote
Bilateral pain suggests Meningeal inflammation (Meningitis).
348
What is the **Reinforcement** (Jendrassik) technique for reflexes?
If reflexes are absent:
* Upper Extremity: Clench teeth.
* Lower Extremity: Lock fingers and pull hands against each other.
## Footnote
This uses isometric contraction to distract/facilitate the reflex arc.
349
What constitutes a positive **Asterixis** ('Stop Traffic') sign?
Sudden, non-rhythmic flexion/flapping of the hands when arms are extended and wrists dorsiflexed.
## Footnote
Indicates Metabolic Encephalopathy (e.g., liver failure).
350
What does **Winging of the Scapula** indicate?
Weakness of the **Serratus Anterior** muscle (Long Thoracic Nerve injury).
## Footnote
Test by having patient push against a wall.
351
What does '**Tandem Walking**' test?
Walking heel-to-toe in a straight line. Tests **Cerebellar function** and position sense.
## Footnote
This may reveal ataxia not obvious during normal gait.
352
What is the specific technique to locate the **Red Reflex**?
Shine the light from **arms length away (1-2 feet)** at an angle of **15 degrees off center**.
## Footnote
Place your free hand on the patient's forehead/brow to steady yourself.
353
How do you stabilize yourself when moving closer during a **fundoscopic exam**?
Place your thumb on the patient's eyebrow and extend your fingers to rest against the patient's **cheek/face**.
## Footnote
This acts as a 'bumper' to prevent hitting the patient.
354
What is the specific motion for the **'H-Test'** (EOMs) to check for nystagmus?
Pause at the **extreme lateral** and **upward/downward** positions.
## Footnote
A few beats of nystagmus can be normal; sustained is abnormal.
355
How do you test for **Convergence**?
Move your finger toward the bridge of the patient's nose, stopping about **5 inches (or 6 cm)** away.
## Footnote
Watch for the eyes to cross (converge) and pupils to constrict.
356
What is the setup for the **Posterior Approach** thyroid exam?
Stand behind the patient, place fingers below the cricoid cartilage, and ask the patient to **flex their neck slightly forward**.
## Footnote
Flexing relaxes the SCM muscles, making palpation easier.
357
What critical action must the patient perform to make the thyroid **isthmus palpable**?
The patient must **swallow (sip water)**.
## Footnote
You feel for the isthmus rising under your fingers.
358
How do you palpate the **lateral lobes** of the thyroid?
Displace the trachea to the right with one hand, and palpate the right lobe with the other hand (and vice versa).
## Footnote
Note size, shape, and consistency (nodules).
359
How do you test the **Motor** function of CN V (Trigeminal)?
Palpate the **temporal and masseter muscles** while asking the patient to **clench their teeth**.
## Footnote
Note the strength of muscle contraction.
360
What is the correct technique for the **Corneal Reflex**?
Ask patient to look up and away; lightly touch the **cornea** (not eyelashes) with a wisp of cotton.
## Footnote
Tests CN V (Sensory) and CN VII (Motor blink).
361
How do you test CN XI (Spinal Accessory) strength?
Ask patient to **shrug shoulders** against resistance (Trapezius) and **turn head** against resistance (SCM).
## Footnote
362
How do you test CN XII (Hypoglossal)?
Ask patient to **protrude tongue** (check for deviation) and push tongue against the **cheek** against resistance.
## Footnote
Tongue deviates TOWARD the side of the lesion.
363
What is the correct strike technique for a **reflex hammer**?
Use a **rapid wrist movement** to strike the tendon briskly; let the hammer swing freely in an arc.
## Footnote
Do not 'push' the hammer; use the weight of the head.
364
How do you perform **Reinforcement** (Jendrassik maneuver) for lower extremity reflexes?
Ask the patient to **lock their fingers** and pull one hand against the other.
## Footnote
This distracts the nervous system to facilitate the reflex.
365
What is the specific technique for the **Babinski** (Plantar) response?
Stroke the lateral sole from the **heel to the ball of the foot**, curving medially across the ball.
## Footnote
Normal = Toe flexion (curling). Abnormal = Big toe extends (up), others fan.
366
How do you test for **Pronator Drift**?
Patient stands with eyes closed, arms extended, palms up (supinated) for **20-30 seconds**. Tap the arms briskly downward.
## Footnote
Positive drift = arm pronates and drops. Indicates Corticospinal tract lesion.
367
How is **Rapid Alternating Movements (RAM)** tested in the upper extremity?
Patient strikes thigh with palm, then back of hand, repeating rapidly; OR taps index finger against thumb joint rapidly.
## Footnote
Slow/clumsy movement = Dysdiadochokinesia (Cerebellar disease).
368
How do you test **Vibration Sense**?
Place a **128 Hz** tuning fork on the **distal interphalangeal (DIP) joint** of the finger or toe.
## Footnote
Ask what they feel and when it stops.
369
How do you test **Proprioception** (Position Sense) in the toe?
Grasp the great toe by the **sides** (not top/bottom), move it up or down, and ask the patient to identify the direction with eyes closed.
## Footnote
370
How is the **Romberg Test** performed correctly?
Patient stands feet together, eyes open first, then **eyes closed** for 20-30 seconds.
## Footnote
Loss of balance with eyes closed = Positive Romberg (Posterior Column/Sensory Ataxia).
371
How do you perform the **Brudzinski Sign** test?
With patient supine, **flex the neck forward** until chin touches chest.
## Footnote
Positive = Involuntary flexion of hips and knees (Meningitis).
372
How do you perform the **Kernig Sign** test?
Flex the patient's hip and knee, then attempt to **straighten (extend) the knee**.
## Footnote
Positive = Pain and resistance (bilateral suggests Meningitis).
373
What are the **5 Components** of **Mental Status** that must be evaluated?
* Appearance and Behavior
* Speech and Language
* Mood
* Thoughts and Perceptions
* Cognition
## Footnote
These components provide a comprehensive assessment of a patient's mental state.
374
How do you test **Cognition/Attention** using the **'Serial 7s'** or **'World'** test?
Ask the patient to **subtract 7 from 100** backward (100, 93, 86...) OR spell the word **'WORLD'** backward.
## Footnote
These tests assess the patient's attention and cognitive processing.
375
How do you assess **Abstract Thinking** (Higher Cognitive Function)?
Ask the patient to interpret a **proverb** (e.g., 'Don't count your chickens before they hatch') or ask how two objects are **alike** (e.g., Apple and Pear).
## Footnote
This evaluates the patient's ability to think abstractly and make connections.
376
During the fundoscopic exam, why would you turn the diopter wheel to **+10** (Green numbers)?
To inspect the **anterior structures** of the eye (cornea, lens, iris).
## Footnote
Return to **0** to view the fundus/retina.
377
What is the specific technique for inspecting the **Iris**?
Shine a light **temporally** (from the side) across the iris.
## Footnote
Note its normal flat shape and check for shadows (which suggest narrow angles).
378
How do you test **Deep Cervical** lymph nodes differently than **Superficial Cervical** nodes?
You must palpate **UNDER** the Sternocleidomastoid (SCM) muscle for Deep nodes, whereas Superficial nodes are **OVER** the SCM.
## Footnote
Posterior nodes are *behind* the SCM.
379
What is the correct technique for testing **Tone** in the upper extremity?
Support the patient's arm and put the shoulder, elbow, and wrist through a **moderate range of motion** (passive stretch).
## Footnote
If resistance is felt, determine if it is spasticity (varies) or rigidity (constant).
380
What specific muscle groups does the **Shallow Knee Bend** test?
**Proximal muscles** of the leg: Extensors of the hip and Quadriceps (extensors of the knee).
## Footnote
Perform on one leg, then the other.
381
What does **Hopping in place** test?
Proximal and distal muscle strength, **position sense**, and **cerebellar function**.
## Footnote
This test evaluates overall motor function and balance.
382
If a patient has distal sensory loss, what is the efficiency rule for testing?
Move **proximally** until the sensation returns to normal.
## Footnote
If distal sensation (fingers/toes) is intact, you generally do not need to test proximally.
383
When testing **Temperature** sensation, what materials should be used?
Test tubes filled with **hot and cold liquid**.
## Footnote
Ask the patient to identify 'Hot' or 'Cold' with eyes closed.
384
What are the specific definitions for **Muscle Strength Grades** 0, 1, 2, and 4?
* **0:** No muscular contraction detected.
* **1:** A barely detectable flicker or trace of contraction.
* **2:** Active movement with **gravity eliminated** (planar motion).
* **4:** Active movement against gravity with **some** resistance.
## Footnote
(Note: Grades 3 and 5 on separate card in this deck).
385
Which spinal levels are tested by **Hip Flexion**?
**L2** (Iliposoas)
## Footnote
386
Which spinal levels are tested by **Knee Extension**?
**L3** (Quadriceps)
## Footnote
387
Which spinal levels are tested by **Ankle Dorsiflexion** and **Great Toe Extension**?
**L5** (Tibialis Anterior / Extensor Hallucis Longus)
## Footnote
388
Which spinal levels are tested by **Ankle Plantar Flexion**?
**S1** (Gastrocnemius/Soleus)
## Footnote
(Tip: Also tested by walking on toes).
389
Distinguish **Spasticity** from **Rigidity** when assessing Muscle Tone.
* **Spasticity:** Increased resistance that varies, often worse at the extremes of motion.
* **Rigidity:** Constant resistance throughout the range of motion (often called "lead pipe" rigidity)
## Footnote
390
What is the technique for testing **Ankle Clonus**?
Support the knee in a partly flexed position. Dorsiflex and plantarflex the foot a few times to relax it, then **sharply dorsiflex** the foot and maintain the pressure. Look and feel for rhythmic oscillations.
## Footnote
391
How do you perform the **Abdominal Reflex** test and what levels are involved?
Briskly stroke each side of the abdomen (above and below umbilicus) toward the umbilicus.
* **Upper:** T8, T9, T10.
* **Lower:** T10, T11, T12.
## Footnote
(Normal response: Muscle contraction and umbilicus deviates toward stimulus).
392
What is **Extinction** in sensory testing?
The ability to perceive two simultaneous touch stimuli on corresponding areas of the body (e.g., both thighs).
## Footnote
(Abnormality: Patient feels only one side, suggesting a contralateral parietal cortex lesion).
393
When performing the **Whispered Voice Test**, what specific "distraction" technique is required?
You must rub the tragus or move your finger in the **opposite** ear while whispering into the test ear to prevent "listening over."
## Footnote
394
What are the **3 types of Gait** you must test during the Screening Neuro Exam?
1. **Regular walking** (observe posture, balance, arm swing).
2. **Tandem walking** (Heel-to-toe).
3. **Heel and Toe walking** (Tests L5 and S1 strength specifically).
## Footnote
395
What is the standard time limit goal for the **Screening Neuro Exam**?
5 minutes or less.
## Footnote
396
Why do we perform the **Pronator Drift** test (eyes closed, palms up)?
It tests the **Corticospinal Tract**
## Footnote
The 'drift' indicates a contralateral lesion in the corticospinal tract. If the arm bounces or overshoots when tapped, that suggests Cerebellar incoordination.
397
What specific systems does **Heel-to-Toe (Tandem) Walking** evaluate?
* Cerebellar
* Vestibular
* Intoxication
## Footnote
It forces the patient to rely on balance, revealing ataxia not obvious during normal gait.
398
Why do we test **Rapid Alternating Movements** (hand flip or finger tap)?
To detect **Dysdiadochokinesia**, a sign of **Cerebellar disease**
## Footnote
In disease, movements are slow, irregular, and clumsy.
399
What does the **Romberg Test** actually assess?
**Position Sense (Posterior Columns)**
## Footnote
The patient stands well with eyes open because vision compensates. Losing balance only when eyes are closed confirms the sensory loss.
400
What does **Winged Scapula** indicate when a patient pushes against a wall?
Weakness of the **Serratus Anterior** muscle
## Footnote
This suggests injury to the **Long Thoracic Nerve**.
401
What is the clinical significance of **Asterixis** ('Stop Traffic' sign)?
It helps identify **Metabolic Encephalopathy**
## Footnote
Look for non-rhythmic flapping of the hands.
402
What is the mandatory command sequence for testing **Mental Status (Registration/Memory)**?
"I am going to say three words. I want you to repeat them now and remember them for later: **Table, Flower, Hamburger**."
## Footnote
You must ask them to recall these 3 objects at the end of the exam.
403
How do you verbalize the command for **CN V (Sensory) Light Touch**?
"I’m going to touch you with this cotton wisp. Please close your eyes and say **'Yes'** every time you feel it."
## Footnote
This ensures the patient is aware of the sensation being tested.
404
What instruction ensures a valid **Finger-to-Nose** test?
"Touch my finger, then touch your nose. **Move fast.**"
## Footnote
You must move your finger to different spots to fully extend their arm.
405
What is the precise instruction for **Graphesthesia**?
"Keep your eyes closed. I am going to draw a number in your palm. Tell me what it is."
## Footnote
This tests the patient's ability to recognize shapes drawn on their skin.
406
What is the standard 'Normal' documentation phrase for **Motor**?
"Good muscle bulk and tone. Strength **5/5 bilaterally** in upper and lower extremities."
## Footnote
This indicates normal muscle strength and tone.
407
What is the standard 'Normal' documentation phrase for **Sensory**?
"Pinprick, light touch, position, and vibration **intact bilaterally** throughout upper and lower extremities."
## Footnote
This confirms normal sensory function.
408
How do you document a normal **Gait/Cerebellar** exam?
"Gait fluid with normal base. **No cerebellar signs**. **Ø Romberg** test."
## Footnote
This indicates normal coordination and balance.
409
When documenting **Reflexes**, what is the specific notation for a normal exam with down-going toes?
"+2 bilaterally in UEs and LEs with **plantar reflexes down-going**."
## Footnote
This indicates normal reflex responses.
410
What standard ROS (Review of Systems) negative intro should be used for Neuro?
"Denies dizziness, seizures, syncope, weakness, or numbness."
## Footnote
This provides a clear overview of the patient's neurological status.
411
What is the **Jendrassik Maneuver** (Reinforcement) and when do you use it?
A technique used if reflexes are symmetrically diminished or absent
## Footnote
* Upper Extremities: Ask patient to clench their teeth.
* Lower Extremities: Ask patient to lock fingers and pull hands against each other.
412
How do you distinguish **Spasticity** from **Rigidity** during passive tone testing?
* Spasticity: Increased resistance that **varies**.
* Rigidity: Constant resistance throughout the range of motion.
## Footnote
Spasticity is often worse at the extremes of motion.
413
What is the **Cutoff Rule** for visual acuity on the Snellen chart?
If the patient makes **two mistakes** on a line, move to the line **above**.
## Footnote
This helps determine their acuity accurately.
414
To visualize the **Macula/Fovea** during fundoscopy, what specific instruction must you give?
"Look directly at the light."
## Footnote
This may cause brief discomfort.
415
What is the **'Right-Right-Right' Rule** for ophthalmoscopy?
Hold the scope in your **Right** hand, use your **Right** eye, to examine the patient's **Right** eye.
## Footnote
This ensures proper alignment and focus during the examination.
416
What is the high-level order of operations for the **5-minute Screening Neuro Exam**?
* Mental Status
* Cranial Nerves
* Motor System
* Coordination
* Sensory
* Reflexes
* Stance
* Gait
## Footnote
This sequence is essential to prevent 'islands of understanding' during the exam.
417
When does the **Mental Status** exam actually begin?
The moment you meet the patient
## Footnote
You assess Appearance, Behavior, and Speech during the history taking, before touching the patient.
418
What is the efficient 'top-down' sequence for the **Cranial Nerve (CN)** portion of the screening exam?
* Eyes: Visual Fields (II), Pupils (II, III), EOMs (III, IV, VI)
* Face (Sensory/Motor): Light touch V1/V2/V3 (V), Smile/Puff cheeks (VII)
* Mouth/Throat: Tongue protrusion (XII), 'Ah'/Gag (IX, X)
* Neck/Shoulders: Shrug shoulders (XI)
* Ears: Whisper test (VIII)
## Footnote
This sequence ensures a systematic approach to cranial nerve assessment.
419
Where does **CN V (Trigeminal) Motor** testing fit in the sequence?
It is often paired with the Face inspection/palpation
## Footnote
Palpate temporal/masseter muscles while patient clenches teeth before doing the sensory (cotton wisp) test.
420
What is the correct order for assessing the **Motor System** (Tone vs. Strength)?
* Inspection: Check for bulk/atrophy/fasciculations first
* Tone: Passive Range of Motion (PROM) to check for rigidity/spasticity
* Strength: Active resistance testing (graded 0-5)
## Footnote
This order helps in accurately assessing motor function.
421
What is the efficient sequence for **Upper Extremity (UE) Strength** testing?
* Shoulder Abduction (Deltoid)
* Elbow Flexion/Extension (Biceps/Triceps)
* Wrist Extension/Flexion
* Hand Grip (Squeeze fingers)
* Finger Abduction/Opposition
## Footnote
The sequence follows a proximal to distal approach.
422
What is the 'Efficiency Rule' pattern for **Sensory** testing?
* Distal to Proximal: Start at fingers/toes
* Symmetric: Always compare Left vs. Right immediately
* Modality Grouping: Do all 'Sharp/Dull' first, then switch tools for 'Vibration' or 'Light Touch'
## Footnote
This pattern enhances the effectiveness of sensory assessment.
423
What is the anatomical sequence for **Deep Tendon Reflexes (DTRs)**?
* Biceps (C5-6)
* Triceps (C6-7)
* Brachioradialis (C5-6)
* Patellar (L2-4)
* Achilles (S1)
* Plantar/Babinski (L5, S1)
## Footnote
Always do the Plantar/Babinski reflex last as it is noxious.
424
What is the sequence for **Coordination** testing (Upper vs. Lower)?
* RAM (Rapid Alternating Movements): Hands on thighs (flip-flop) or Finger tapping
* Point-to-Point: Finger-to-Nose (Upper Extremity)
* Heel-to-Shin: (Lower Extremity - done while supine or seated)
## Footnote
This sequence is crucial for assessing coordination effectively.
425
Which two tests require the patient to **stand still** before they start walking?
* Romberg Test: Feet together, eyes open, then eyes closed (30 secs)
* Pronator Drift: Arms out, palms up, eyes closed (tap arms down)
## Footnote
Perform these before the Gait exam to ensure safety/balance.
426
What is the 3-step sequence for the **Gait** exam?
* Regular Walk: Observe posture, arm swing, and balance
* Tandem Walk: Heel-to-toe (stress test for ataxia)
* Heel & Toe Walking: Walk on heels (L5), then walk on toes (S1)
## Footnote
This sequence assesses various aspects of gait and balance.
427
What is the very last step of the exam/visit before leaving the room?
**Sanitize Hands**
## Footnote
Also, thank the patient before exiting.
428
# Peripheral IV Placement Skill
ID self (2)
Introduces self
Identifies title
429
# Peripheral IV Placement Skill
ID patient (2)
Name
DOB
430
# Peripheral IV Placement Skill
Inform patient of procedure (7)
Discussion of:
indication
contraindication
risks
benefits
alternatives
Ask for questions
Obtain verbal consent
431
# Peripheral IV Placement Skill
Gather equipment (name each) (9)
IV catheter
Saline lock
Saline flush
Tape
Polyurethane dressing present
Tourniquet
4x4 or 2x2
Gloves
Alcohol Prep
432
# Peripheral IV Placement Skill
Prepare equipment (2)
Prime saline lock
Tear tape (3 pieces)
433
# Peripheral IV Placement Skill
Procedure Part 1 - Right Before Cannulation (7)
1. Wash hands
2. Gloves
3. Immobilize extremity and locate vein
4. Tourniquet 3-5 in from insertion point
5. Palpate vein
6. Clean w/ alcohol prep circular inside-out 30s
7. Grasps skin taut to stabilize vein w/ non-dominant hand
434
# Peripheral IV Placement Skill
Procedure Part 2 - Cannulation onwards (10)
1. Cannulates vein w/ IV needle bevel up
2. Verbalize seeing flash
3. Advance catheter over the needle while not moving the needle
4. Apply pressure to advanced catheter and safely remove needle
5. Remove tourniquet
6. Attach primed saline lock to cath; attach saline syringe to saline lock
7. aspirate for blood; flush cath w/ saline
8. verbalize (3): no resistance, patient no pain with flush, no evidence of vessel infiltration
9. remove syringe
10. secure saline lock with dressing (3 tapes) and dispose needle in sharps container
PCOM DO (2025-)
flashcards
Decks in class (100)
# Cards
-
Medical Roots and Affixes695
-
PCS434
-
CBFM Week 1184
-
CBFM Week 2173
-
CBFM Week 3204
-
CBFM Week 4116
-
CBFM Week 5170
-
CBFM Week 6241
-
CBFM Week 7238
-
OPP-1 Week 1168
-
OPP-1 Week 275
-
OPP-1 Week 386
-
OPP-1 Week 424
-
OPP-1 Week 524
-
OPP-1 Week 668
-
MSK Week 1454
-
MSK Week 2441
-
MSK Week 3231
-
MSK Week 4120
-
MSK Anatomy Practical 2237
-
CP (Histology)106
-
CP (Gross Anatomy)81
-
CP Week 168
-
CP Week 2269
-
CP Week 3387
-
CP Week 438
-
REGI (Histology)187
-
REGI (Gross Anatomy)166
-
REGI Week 1298
-
REGI Week 2163
-
REGI Week 3379
-
REGI Week 4285
-
OPP-2 Week 146
-
OPP-2 Week 2117
-
OPP-2 Week 331
-
OPP-2 Week 419
-
OPP-2 Week 520
-
OPP-2 Week 631
-
OPP-2 Week 718
-
OPP-2 Week 826
-
OPP-2 Week 9-10111
-
OPP-2 Week 1173
-
OPP-2 Week 1269
-
OPP-2 Week 1368
-
OPP-2 Week 1452
-
OPP-2 Week 1559
-
OPP-2 Week 16 (Review)39
-
FRGM (Histology)238
-
FRGM (Gross Anatomy)242
-
FRGM Week 1369
-
FRGM Week 2155
-
HEENT (Gross Anatomy)352
-
HEENT Week 1431
-
HEENT Week 2393
-
HEENT Week 3359
-
HEENT Week 4163
-
I&I Week 1399
-
I&I Week 2284
-
I&I Week 3258
-
I&I Week 4177
-
I&I Week 5167
-
I&I Week 6282
-
I&I Week 7269
-
I&I Week 8469
-
I&I Week 9736
-
I&I Final Exam Review485
-
HDT Week 1233
-
HDT Week 2197
-
HDT Week 3313
-
HDT Week 4236
-
HDT Week 5199
-
HDT Week 6409
-
HDT Week 7352
-
HDT Week 9405
-
HDT Week 100
-
HDT Final Exam Review1
-
OPP-3 Week 173
-
OPP-3 Week 1 Lab20
-
OPP-3 Week 266
-
OPP-3 Week 2 Lab41
-
OPP-3 Week 357
-
OPP-3 Week 3 Lab41
-
OPP-3 Week 494
-
OPP-3 Week 4 Lab1
-
OPP-3 Week 550
-
OPP-3 Week 5 Lab39
-
OPP-3 Week 712
-
OPP-3 Week 7 Lab20
-
OPP-3 Week 829
-
OPP-3 Week 8 Lab28
-
OPP-3 Week 928
-
OPP-3 Week 9 Lab19
-
OPP-3 Week 1035
-
OPP-3 Week 10 Lab33
-
OPP-3 Week 1257
-
OPP-3 Week 12 Lab35
-
OPP-3 Week 135
-
OPP-3 Week 14 (Final Review)116
