PE Skills 2008 Describe and define the purpose of tangential lighting? (Mosbys 6th ed p.

55, Moores Physical Exam Skills lecture slide 10) An indirect light source used to see contour and variations in the body surface What is meant by the General Survey? What is being assessed? (Moores Physical Exam Skills lecture slide 3) Its when you generally inspect the patient as they come in to the office, or when you first walk into the room and start talking to them. You can note their age, if they have any deformities or disabilities, note their posture, if theyre dressed appropriately for the weather, their hygiene, how they speak to you, how theyre breathing, if they look you in the eye, their gait as they walk, their movements, how their skin looks, etc. What are considered vital signs and how do you measure them? (Mosbys 6th ed p. 61) Pulse, respiration, blood pressure, and temperature. Pulse may be palpated and counted in one minute, respirations are counted by inspection in one minute, blood pressure is taken using a blood pressure cuff (sphygmomanometer) and stethoscope and is systolic/diastolic, and temperature is measured with a thermometer and normal temperature is 98.6. Know normal values for each. Why is it important to take blood pressures in two arms and two positions? Which is routinely highter: blood pressure sitting or supine? Blood pressure measured in R arm or L arm? (Mosbys 6th ed p. 475-476) Because the readings between the arms may vary by as much as 10 mm Hg and tend to be higher in the right arm, and the higher reading should be accepted as closest to the patients blood pressure. Pressures taken when the patient is supine tend to be lower than those taken when the patient is sitting. The preferred position for monitoring blood pressure is with the patient seated. Explain the differences between temperatures from oral, tympanic, axillary and rectal. (Mosbys 6th ed p. 61 and 62) Oral is in the mouth, tympanic is in the ear, axillary is under the armpit, and rectal is in the rectum. Rectal, oral, and axillary temperatures can be taken using equipment that contains an electronic sensing probe. The same equipment can be used for all three because the probe is covered by a disposable sheath that is discarded after being used. Temperatures obtained using a tympanic thermometer vary from those obtained by oral or rectal routes. With very young infants, traditional routes of measurement may be more accurate than tympanic, but in other situations like with children in an outpatient setting, tympanic is preferred. Although tympanic thermometers are simple to use, accurate measurement depends on correct technique. Tympanic thermometers use infrared technology. Ear temperature reflects body temperature b/c the

tympanic membrane shares its blood supply with the hypothalamus in the brain. Infrared axillary thermometers for neonates are available and may be more accurate for newborns b/c axillary measurements correlate well with their core temp. b/c of their small body mass and uniform skin blood flow. What is the frequency of the tuning fork used to detect vibratory sensation? (reference pg 79) Exam skills Objective 13 Answer: 128 Hz What is the frequency of the tuning fork used to detect auditory function? (reference pg 79) Answer: 512 Hz (Hint: Try each fork on yourself and see which one is best for each. You wont forget the experience.) What BMI is considered overweight? (reference pg 146) Exam skills Obj 15 Answer: 25-29.9 Know numbers for underweight, normal, obese and morbidly obese What do you call a star-shaped lesion when describing the shape/arrangement? (reference pg 189) Obj 3 integument Answer: Stellate What is an elevated firm, and rough lesion with a flat top surface greater than 1 cm in diameter? (reference ps183) Answer: A plaque Know macule, papule, patch, plaque, pustule, vesicle, bulla, nodule, tumor, cyst, wheal. Know telangiectasia, petechia, eccymosis, angioma (spider, cherry and capillary hem-). Know scale, lichenification, keloid, scar, excoriation, fissure, erosion, ulcer, crust, and atrophy. Be able to characterize lesions based on their morphology: refer to Table 8-6, page 189. For nails, look at page 193, Figure 8-15 and understand what causes the different abnormalities depicted on this page. The nail base angle should measure 160 degrees. Any angle greater than 180 degrees is considered to be ___________. Pg 192 ANS: clubbing.

The sudden onset of pigment deposits or bands (in the nails of Caucasians) may be indicative of ___________? Pg 191 ANS: melanoma Nail pitting is most commonly associated with this condition? Pg 192 ANS: psoriasis This type of vascular skin lesion is characterized by red-purple nonblanchable discolorations less than .5 cm in diameter, and are caused by intravascular defects or infection? Pg 180 ANS: Petechiae This type of vascular skin lesion is indicative of vascular wall destruction, trauma, or vasculitis, and produces red-purple non-blanchable discoloration of variable size? Pg 180 ANS: ecchymoses What are you feeling for upon palpation of the hair? texture (look in the book for more answers. This is only one of several answers!) What is the Schamroth technique test for? Pg 194 clubbing of the nails What type of disease is usually present when pitting occurs in the finger nails? - Psoriasis What is the term for absence of the nail? Anonychia (Look up other terms ending in nychia) Name three diseases that clubbing of the finger nails are associated with. resp, cv, cirrhosis, colitis, and thyroid (which is the most common of these?? Look it up!) This is commonly known in laymans terms as a bruise. A: Ecchymosis Generally associated with increased volume in the blood, these pinpoint non-blanchable areas appear on the upper chest during a normal pregnancy.

A: petechiae This idopathetic vascular anomaly is painless, blanchable, and contains spider-like legs. It can be, although its not always, attributed to liver disease. A: spider petechiae Skin turgor in newborns is generally assessed where? A: the chest What does the term tenting refer to? A: poor skin turgor where the skin stays elevated after being pinched In reference to the 9 regions of the abdomen, which region is the location of the appendix? (p 534) Right Inguinal region What are 3 things that could cause abdominal distension? (p 535) (Fat, fluid, feces, fetus, flatus, fibroid, full bladder, false pregnancy, fatal tumor, over forty) Describe the venous pattern that is seen on the abdomen in portal hypertension. (p 535) Veins radiating from umbilicus, called caput medusa When a patient is in the supine position, how would you describe their belly that is rounded outward with a protruding belly button? (p 535) Fully rounded (or distended) belly with everted umbilicus (I prefer to reserve the term distended for the abdomen that is filled with fluid and/or gas rather that one that is obese or just heavy) What sign is testing for weak hip abductor muscles while the patient is standing on one leg? Reference: Mosby, 6th ed, pg 734 Answer: Trendelenburg test When performing the Patrick test, at what 2 points on the patient is the clinician applying force while the hip is in external rotation? Reference: The Musculoskeletal Exam presentation on 8/11/08 by Tina Moore, PA-C Answer: knee of the hip that is in external rotation and the ASIS of the opposite extended leg. The Barlow and Ortolani maneuvers, which tests for hip dislocation, should be performed at all well child checks until what age of the child? Reference: Mosby, 6th ed, pg 736

Answer: age 1 Where should the examiner be standing in relation to the infant when checking for the Allis sign? Reference: Mosby, 6th ed, pg 737 Answer: at the infants feet looking up toward their head Upon evaluation of a patients spine, the curve of the lumbar spine should be? Reference: Mosby, 6th ed, pg 708 Answer: concave; they have a lordotic curve to their spine Which of these is not a sub-category that is tested in the Folsteins Mini-Mental Status Exam? Objective 3: See slide 8-10 of neuro slides. A. Orientation B. Registration C. Cognition D. Language E. Recall Answer: C-Cognition What is the maximum score for the MMSE test? Objective 3: See slide 10 of neuro slides A. 30 B. 40 C. 100 D. 50 Answer: A What are the maximum and minimum score for the Glasgow Coma Scale? Objective 3: Pg. 97 of Mosbys 6th edition A. 30 : 0 B. 20 : 1

C. 15 : 3 D. 10 : 2 E. 100 : 0 Answer:C-15:3 _________ is a clinical syndrome of failing memory and cognitive impairment, behavioral abnormalities, and personality changes resulting in a CHRONIC progressive deterioration of the brain. (Classic signs include memory impairment, disturbances of executive functioning, and impairment in social and occupational functioning). Objectives 4: Pg. 103 in Mosbys 6th edition A. Delirium Tremens B. Mania C. Depression D. Dementia E. Confusion Answer:D- Dementia _________ is a severe, persistent, psychotic disorder that is a neuroanatomic and neurochemical in abnormality; it may be either genetically or environmentally induced and typically has an adolescent or early adult onset. Objectives 4: Pg. 104 in A. Mosbys 6th edition B. Schizophrenia C. Autism D. Alzheimers E. Vascular Dementia Answer: B-Schizophrenia A bunion that forms due to an inflamed bursa over the medial aspect of the 1st metartasal head is called: Hallux Valgus

Stretching or partial tear of a muscle or tendon is: Sprain What is the laymans term for pes planus? Flat foot Bony overgrowths in the DIP joints that are hard and non-tender and more commonly associated with osteoarthritis are called: Heberden nodes (Bony overgrowths in the PIP joints that are more common to rheumatoid arthritis patients are called Bouchard nodes). Dowagers hump is associated with which portion of the spine? Is this a kyphotic, scoliotic, or lordotic curvature? Answer: thoracic area, excessive kyphotic curve Are widely placed feet expected in a normal gait pattern? No (this can be a tabetic, cerebellar ataxia or sensory ataxia pattern. Refer to Table 22-4, pg 784) Name four ways to assess gait: Walk in a straight line (tandem walk), heel walking, toe walking, heel to toe walking

When walking in a normal gait pattern, should the patients heel or toe strike the floor first? Heel hits first Should the patients eyes be opened or closed while checking for sensory function? Obj 11: Closed

How would you grade a deep tendon reflex with a sluggish, diminished response? Obj 12: 1+ Describe a pronator drift noted on the Romberg Test and what is it indicative of. Not listed in book; refer to Neuro II Power Point

While in the Romberg position (pt standing with feet together and eyes closed), have patient raise both arm straight in front and raised to 90* with arms supinated. If one arm drifts away from the other, it is termed pronator drift and is a soft sign for CVA. Describe Parkinsonian gait, appearance, posture, and mentation. The patients posture is stooped and the body is held rigid; steps are short and shuffling with hesitation on starting and difficulty stopping. They have a pill-rolling, resting tremor, a masked facial expression. Drooling may be present. They have a slowed mental process and are more prone to dementia. Describe dystonia. pg784 Dystonia is jerky, dancing movements that appear nondirectional., What is the term for a persons gait when the hip and knee are elevated excessively high to lift the plantar flexed foot off the ground; the foot is brought down to the floor with a slap, and the patient is unable to walk on the heels? pg 784 Steppage What are ways to test for cortical (pertaining to the cortical level of the brain) sensory function? Pg 787 stereognosis, two-point discrimination, extinction phenomenon, graphesthesia, and point location. How do you test the cremasteric reflex and what is the expected response? Mosby, 6th ed, pg 652 & 789 Answer: The cremasteric reflex is tested in males by stroking the inner thigh, (book says) proximal to distal (I have always tested by stroking distal to proximal?) , and watching for the testicle and scrotum to rise on the stroked side. In what direction does the great toe move if the Babinski sign is said to be present in a 21 year old and what does it mean if the sign is present? Reference: Mosby, 6th ed, pg 789 Answer: The great toe dorsiflexes (goes up) when scraping the bottom of the foot (from the lateral aspect of the heel to the little toe the across the metatarsal pad toward the great toe). This is a sign of damage to the pyramidal tract (corticospinal portion) of the upper motor neuron system in the medulla oblongata in individuals older than two years of age. In individuals +/- 2 years old it is normal for the great toe to go up (dorsiflex), i.e, the Babinski to be present. The normal response in an individual older than 2 is for the great toe to go down (plantar flex), i.e, Babinski to be absent. The other toes may or may not fan. Either is OK. It is best not to use the term Babinski positive or negative as it is confusing. State instead Babinski: great toe

downgoing or great toe upgoing.

Upon physical exam of a patient, you notice a rhythmic uncontrollable flapping movement of dorsiflexion and plantar flexion of the ankle after you briskly dorsiflex the foot with the patient in the seated position. This finding is called: CLONUS This finding may indicate: Reference: Mosby, 6th ed, pg 790 A. Stroke *** B. Upper motor neuron disease **** C. Normal response (not the answer) D. Previous head injury ****** E. Brain tumor ******

This deep tendon reflex causes contraction of the quadriceps muscle and extension of the lower leg. What is the reflex and what would be the expected response? Reference: Mosby, 6th ed, pg 790 A. Achilles Reflex;0 B. Achilles Reflex; 1 C. Patellar Reflex; 0 D. Patellar Reflex; 2 Answer:D.- Patellar Reflex;2 What spinal nerve level is this deep tendon reflex testing? Mosby, Table 22-7 pg 789 L2, 3, 4 The lower abdominal superficial reflex is associated with what spinal level? Reference: Mosby, 6th ed, pg 789 A. T7,T8,T9 B. T10 and T11

C. T12, L1,L2 D. All of the above Answer:B.- T10 and T11 Which deep tendon reflex is associated with C6, C7, and C8? Reference: Mosby, 6th ed, pg 789 A. Biceps reflex B. Triceps reflex C. Brachioradial reflex D. Shoulder reflex Answer: B.-Triceps reflex What is the grade for a sluggish or diminished deep tendon reflex? A .0 B. 1+ C. 2+ D. 3+ Answer: B. 1+ Mosby, pg 790, Table 22-8 What is CORRECT about the technique for the monofilament test ? A. With the patients eyes open apply the monofilament in a random pattern in several sites on the plantar surface. B. The monofilament should be applied to each site in less than 1.5 seconds C. When the filament bends, adequate pressure is applied D. Test also over calluses or broken skin Answer:C.-When the filament bends, adequate pressure is applied

Which one of these is NOT a positive Babinski sign? A. Hyperactive deep tendon reflex B. Toes up going C. Hyporactive deep tendon reflex D. Abdominal reflex Answer: C.-Hyporactive deep tendon reflex Which one of these tests is NOT used to recognize meningeal irritation? A. Kernig Sign B. Thompson Sign C. Brudzinski Answer: B.-Thompson Sign Which primitive infants reflex shows the presence of flexion of the hips and knees and lifting of the foot as if stepping up on the table? A. Plantar B. Moro C. Palmar D. Placing Answer: D.- Placing

Which cranial nerve is tested for hearing? Mosby pg 333 the acoustic or vestibulocochlear nerve, CN VIII What is conductive hearing loss? Mosby pg 334 sound transmission impaired through the external or middle ear What is sensorineural hearing loss? Mosby pg 334

hearing loss that results from a defect in the inner ear leading to distortion of sound and misinterpretation of speech What is the primary characteristic to look for upon inspecting and palpating the skull and scalp in the older child and adult? p.262 - the skull should be symmetric and smooth with indistinguishable bones and the scalp should be without tenderness, swelling, and it should be mobile What are the main items to look for when inspecting facial features? p. 262 - shape and symmetry

Which of the following cranial nerves is responsible for sensation to the cornea? Objective 4: (pg. 291) A. CN II B. CN III C. CN V D. CN VII Answer: C Which cranial nerve is responsible for moving the eye laterally? Page 293 Answer: VI - Abducens What is the expected respiratory rate of an adult? Mosbys, ed 6th, p373 Answer: 12 to 20 breaths per minute The dorsal curvature of the thoracic spine is called? Mosbys, ed 6th, p 397 Answer: kyphosis Excessive kyphosis such as that seen in the elderly is termed GIBBUS. Mosby, pg 397 Which is not a feature, warning sign or risk factor associated with malignant skin lesions? Pg 213 A. An open sore that bleeds, oozes, or crusts and does not heal in 3 weeks or more.

B. A reddish patch or irritated area, frequently occurring on the chest, shoulders, arms, or legs. C. A scarlike area that is white and has clearly defined edges. D. A pink growth with a slightly elevated rolled border and a crusted indentation in the center. Answer: C The range of motion associated with hinge joint is? Pg 694 A. Motion limited to flexion and extension in a single plane B. Motion limited to rotation C. Motion in 2 planes at right angles to each other, but no axial rotation. D. Widest range in motion in all planes Answer: A The instruments that can be used in examination of the musculoskeletal system are? (select 2) Pg 704 Reflex hammer BP cuff Tape measure Opthalmoscope Which is not the normal range of motion for cervical joints is? Pg 709 Extension of 55 degrees, and flexion of 45 degrees Right and left lateral bending of 40 degrees Right and left lateral bending of 70 degrees Left and Right rotation of 70 degrees Of The Following Vital Signs, Which One Is Not Within Acceptable Limits With Respect To The Cardiovascular Exam (In A Normal Healthy Adult)? Cardiovascular Objective #2

Pages 477,470, 375 Bp: 115/75 Pulse: 45 Bpm ** (termed bradycardia) Respirations: 14/Min Answer: Bp: 115/75 (this answer is incorrect, this is an excellent blood pressure!) What is the loudest, highest pitch sound heard upon percussion? A: Tympany p. 57 What surface of the hand is used to palpate for vibration? A: Ulnar p. 57 What surface of the hand is used to palpate for body temperature? A: Dorsum p.57 Generally, when is auscultation performed? A: Last p. 59

Which type of vision does the Snellen chart test? A: Far p. 72 If a patient has 20/40 vision, what does that mean? A: That the pt sees at 20 feet what an individual with normal vision sees at 40 feet p. 72 The nail base angle should measure 160 degrees. Any angle greater than 180 degrees is considered to be ___________. ANS: clubbing. Pg 192 The sudden onset of pigment deposits or bands (in the nails of Caucasians) may be indicative of ___________? ANS: melanoma Pg 191

Nail pitting is most commonly associated with this condition? ANS: psoriasis Pg 192 This type of vascular skin lesion is characterized by red-purple nonblanchable discolorations less than .5 cm in diameter, and is caused by intravascular defects or infection? ANS: Petechiae Pg 180

This type of vascular skin lesion is indicative of vascular wall destruction, trauma, or vasculitis, and produces red-purple non-blanchable discoloration of variable size? ANS: ecchymoses Pg 180 What are the 9 Ss mnemonic to remember features used to describe a lump? (Mosbys Guide to PE, pg 244) A: Size, Shape, Surface characteristics, Site, Symptoms, Softness, Squeezability, Spread, Sensations What are 3 breast changes associated with lactation?

Breasts become full & tense Engorgement (hard, warm, enlarged, shiny, painful) Clogged milk ducts (tender spot on the breast that may feel lumpy & hot) Irritation (redness, tenderness) that may lead to cracking

(Mosbys Guide to PE, pg 495, 512) What are 3 normal breast changes in a pregnant female? (Mosbys Guide to PE, pg 495, 512)

Breasts enlarge 2-3x their pre-pregnancy size Tissue becomes looser & softer Areolae become darker and more erectile Montgomery tubercles often develop Mammary vascularization increases (veins become visible as blue network beneath skin) Sensation of fullness with tingling/tenderness Coarse nodularity

A patient who is drowsy and falls asleep quickly; however, once aroused, responds appropriately to questions could be described as: (Reference: Mosby, p92) a.Confused b.Delirious c.Lethargic (Answer:C) A patient who is neither awake nor aware and may respond to painful stimuli with decerebrate posturing could be described as: (Reference: Mosby, p 92) a. Confused b. Delirious c. Stuporous d. Comatose (Answer:D) The 3 behaviors assessed using the Glasgow Coma Scale includes: (Reference: Mosby, p97)
Eye Opening Response Verbal Response Motor Response

The maximum score achievable on the Glasgow Coma Scale is: (Reference: Mosby, p97) a. 10 b. 15 c. 20 d. 24 (Answer:B) What Cranial Nerve (when intact) allows a person to puff up their cheeks? (Reference: Mosby, p764)
CN VII Facial

What Cranial Nerve (when intact) is responsible for hearing and equilibrium? (Reference: Mosby, p764)
CN VIII Vestibulocochlear (Acoustic)

What Cranial Nerve (when intact) is responsible for taste on the posterior 1/3 of the tongue? (Reference: Mosby, p764)
CN IX Glossopharyngeal

Name the areas you can palpate a pulse? Temporal, Radial, brachial, carotid, femoral, popliteal, dorsalis pedis, posterior tibialis. If an arterial pulse was determined to be full or increased, it would charted as? +3 pulse If an artery was partially occluded, what could be a finding with your auscultatory exam? A bruit What is the the normal capillary refill time as determined by pressure followed by release over the nail bed? <2 sec You found pitting edema over the lower anterior shin of your patient to be 6mm, you would chart this finding as? plus three (3+) pitting edema Describe 3 anatomical changes with pregnancy. Softening and cyanosis of the cervix, increase in blood volume, linea alba becomes darker, enlarged breats, etc. What is the darkened line along linea alba during pregnancy? ppt slide #6) Linea nigra

What is the physical sign that causes bluish color of the cervix, vagina and vulva at 8 to 12 weeks gestation? (p.614) Chadwicks sign Describe the 2 points used to measure fundal height. (ppt slide #19) Symphysis pubis to superior fundus What maneuver would you use to determine fetal head position? (ppt slide# 24) Leopold maneuver Identify the purpose of the corneal light reflex (Hirschberg test) . The corneal light reflex is used to test the balance of the extraocular eye muscles. Describe how to test accommodation and convergence. FIRST HAVE THE PATIENT LOOK AT AN OBJECT IN THE FAR DISTANCE, THEN HAVE THEM LOOK AT AN OBJECT (such as a pen or your finger) AT A DISTANCE OF ABOUT 2 FEET FROM THEIR EYES. NOTE HOW THE PUPILS CONSTRICT AND THE EYES CONVERGE TO LOOK AT THE NEAR OBJECT. Identify the six cardinal fields of vision as used to test extraocular eye muscles. 1) Lateral, 2) Medial, 3) Superior, 4) Inferior, 5) obliques superior and medial, and 6) obliques - Inferior and medial Identify which muscle controls each direction of extraocular movement. Lateral Rectus moves eyes laterally (LR6) Medial Rectus moves eyes medially (III) Inferior Rectus Moves eyes inferiorly and laterally (III) Superior Rectus moves eyes superiorly and laterally (III) Inferior Oblique moves eyes superiorly and medially (III) Superior Oblique (SO4) What does strength 5/5 mean?

A: The scale of muscle strength ranges from 0-5, 0 having no contractility and 5 having full strength against resistance.

What is the normal deviation of the cervical spinal cord? Slide #16 on MS ppt A: concave Describe and demonstrate the following tests and/or signs used to evaluate the upper extremity: Tinel, Phalen, Finkelstein, Neer, and Hawkins, and state what a positive test/sign may signify. What does the Neer test check? Slide #30 on MS ppt A: it checks the integrity of the rotator cuff, specifically the supraspinatus muscle During the Hawkins test, do you internally rotate or externally rotate the pts shoulder? Slide #29 on MS ppt A: Internally rotate What test checks for DeQuervians tenosynovitis? Slide #59 on MS ppt A: Finkelsteins