Midterm Prep

Question 1

What are the differences between comprehensive and focused assessment?

Answer 1

Comprehensive - for new patients, provides fundamental and personalized knowledge

Focused - established patient, address focused concerns

Question 2

What are the

differences between subjective and objective data?

Answer 2

Subjective - what patient tells you

Objective - what you detect during examination

Question 3

How chief is complaint recorded on the health history?

Answer 3

Quote patient’s words

Question 4

What information is recorded in present illness, and In personal and social history?

Answer 4

Present illness - symptoms of chief complaint, thoughts and feelings, pertinent positive and negatives

Personal and social history - education level, family of origin, current household, personal interests, lifestyle

Question 5

What are the seven attributes of a patient’s symptom?

Answer 5

location, quality, quantity/severity, timing, setting, relieving/exacerbating factors, associated manifestations

Question 6

Define tangential lighting. What are the structures which can be optimally inspected by tangential lighting?

Answer 6

Tangential lighting is when the light strikes the illuminated surface at a very low angle.

neck (thyroid, veins), skin, eye

Question 7

What are the four cardinal techniques of physical examination?

Answer 7

Inspection
Palpation
Percussion
Auscultation

Question 8

How are palpation and percussion performed?

How do you obtain a louder percussion note?

Answer 8

palpation - tactile pressure from palmar fingers or finger pads
percussion - strike plexor finger against pleximeter finger

apply more pressure with pleximeter finger

Question 9

What are the 5 “A”s related to tobacco cessation counseling?

Answer 9

Ask
Advice
Assess
Assist
Arrange for follow up

Question 10

What are the general techniques in examination of the chest?

Answer 10

examine posterior thorax while patient is sitting and arms folded across the chest, hands resting on opposite shoulder

examine anterior thorax with patient supine

compare one side of thorax with other

Question 11

What are the features will you look for when inspecting the posterior chest? What are the
causes of abnormal retraction of interspaces of the chest? .

Answer 11

shape of chest and the way it moves

severe asthma, COPD, upper airway obstruction

Question 12

How will you test for chest expansion and vocal fremitus on posterior thorax? On which side
vocal fremitus may be more prominent?

Answer 12

Chest expansion - place thumbs at level of 10th rib with fingers loosely grasping and parallel to lateral rib cage; watch distance between the thumbs as they move apart during inspiration

Fremitus - Apply ball or ulnar surface of hand to thorax. Ask patient to repeat “ninety-nine”

Fremitus may be more prominent on right side since the right light receives more air

Question 13

How can you identify rib fracture?

Answer 13

press on the sternum and spine simultaneously; an

increase in the local pain distant from your hand suggests rib fracture

Question 14

What is the normal location of heart dullness on percussion?

Answer 14

left of the sternum from 3rd to 5th interspaces

Question 15

What are the 5 types of percussion notes? Give examples of location and pathologic examples
of each. Which percussion note would you obtain over the gastric bubble?

Answer 15

flatness - soft, high pitch, short; e.g. thigh, large pleural effusion
dullness - medium intensity, pitch, duration; e.g. liver, lobar pneumonia
resonance - loud, low pitch, long duration; e.g. healthy lung, simple chronic bronchitis
hyperresonance - very loud, low pitch, longer duration; e.g none, COPD, pneumothorax
tympany - loud, high pitch; e.g. gastric air bubble or puffed out cheek, large pneumothorax

Question 16

How will you determine diaphragmatic dullness? What are the causes of abnormally high
levels of dullness?

Answer 16

Holding pleximeter above and parallel to expected level of dullness, percuss downward in progressive steps until dullness clearly replaces resonance

pleural effusion, atelectasis, phrenic nerve paralysis

Question 17

What is the normal length of diaphragmatic excursion?

Answer 17

3-5.5cm

Question 18

What are the 4 types of normal breath sounds? Describe their character and location where each is usually heard.

Answer 18

Vesicular - soft, low pitch; over most of lungs
Bronchial - louder and higher pitch; over manubrium
Bronchovesicular - medium pitch, intensity; over 1st and 2nd interspaces
Tracheal - very loud, harsh sounds; over trachea or neck

Question 19

What are the adventitious sounds that can be heard in the chest? What are their causes?

Answer 19

crackles - pneumonia, fibrosis, early CHF
wheezes - asthma, COPD, bronchitis
rhonchi - secretions in large airways

Question 20

How can you determine that an adventitious sound is due to inspissated secretion? Give examples.

Answer 20

clearing of crackles, wheezes or rhonchi after coughing or position change, e.g. bronchitis, atelectasis

Question 21

How will you determine the size of the liver by percussion of the anterior chest? Wnat is the
normal liver span on different lines? How does COPD affect the position of the liver?

Answer 21

Start a level below umbilicus and percuss along midclavicular line until liver dullness

Start at nipple line and percuss down toward liver dullness

Midclavicular line: normally 6-12cm.
Midsternal line: normally 4-8cm.

A lung affected by COPD often displaces the upper border of the liver downward. It also lowers the level of diaphragmatic dullness posteriorly.

Question 22

Describe barrel chest, funnel chest, and pigeon chest.

Answer 22

Barrel chest: Increased anteroposterior
diameter ofthe chest found in COPD.

Funnel chest: Depression in the lower portion of the
sternum causing compression of the heart and great vessels.
Pigeon chest: The sternum is
displaced anteriorly, increasing the anteroposterior diameter. The costal cartilages adjacent to the
protruding sternum are depressed.

Question 23

How will you test visual acuity?

Answer 23

Visual acuity is tested with a Snellen eye chart with the patient 20’ from the chart.

Near vision is tested with special cards held 14” from the patient’s face.

Question 24

How visual fields are screened and tested? Which visual field will you start screening?

Answer 24

Visual fields by confrontation is used to test visual field by holding the patient’s gaze and bringing your
wiggling finger in from 2’ to each side until they can see them, then superior-lateral, then inferio-lateral.

Question 25

How the extraocular movements are tested?

Answer 25

Extraocular movements are tested by asking the patient to follow your finger with their eyes only as you
move your finger in a wide H pattern.

Question 26

How ear canal is examined by otoscope? Which way will you pull the auricle?

Answer 26

Grasp the auricle and firmly but gently pull it upward, backward, and slightly away from the head

Question 27

How is hearing status (auditory acuity) tested? In whisper test, at what distance should you stand?

Answer 27

To assess hearing, test one ear at a time. Stand 2 feet behind the seated patient.
Occlude the non-test ear of the patient with your finger and gently rub the tragus in a circular motion to
prevent transfer of sound to that ear.
And now, tell me what I’m saying.
Exhale fully to ensure a quiet voice, and test the open ear by softly whispering a combination of three
numbers and letters.

Question 28

How will you interpret Weber and Rinne test in determining air and bone conduction defects?

Answer 28

Weber - lateralization of sound to impaired ear - suspect unilateral conductive hearing loss
Rinne - compare time or air vs. bone conduction - suspect conductive loss if bone is => air conduction

Question 29

How the frontal and maxillary sinuses are palpated?

Answer 29

Press up on frontal sinus from under bony brows

Press up on maxillary sinus

Question 30

How will you examine the thyroid gland? Learn the entire procedure?

Answer 30

Ask patient to flex neck slightly
Place finger of both hands w/ index finger just below cricoid cartilage
Ask patient to sip and swallow water. Feel for thyroid isthmus rising up under your finger pads.

Question 31

How will you test for nasolacrimal duct obstruction (Dacbryocystitis)?

Answer 31

Press on the lower lid close to the medial canthus, just inside the rim of the bony orbit. This compresses the lacrimal sac. Discharge of mucopurulent fluid from the puncta suggests obstruction.

Question 32

How will you examine the pupil? What are the characters of pupils you will look for?

Answer 32

Light reaction - consensual reaction of opposite eye to light

Near reaction - pupillary constriction

Question 33

What are the types of skin cancers?

Answer 33

Basal Cell Carcinoma
Comprises 80% of skin cancers
Shiny and translucent with telangiectic vessels, they grow slowly and rarely metastasize

Squamous Cell Carcinoma
Comprises 16% of skin cancers
Crusted, scaly, and ulcerated, they can metastasize

Melanoma
Comprises 4% of skin cancers
Rapidly increasing in frequency, they spread rapidly

Question 34

Describe ABCDE used for screening moles for possible melanoma

Answer 34

▪ A for asymmetry
▪ B for irregular borders, especially ragged, notched, or blurred
▪ C for variation or change in color, especially blue or black
▪ D for diameter ≥6 mm or different from other moles, especially changing, itching, or
bleeding
▪ E for elevation or enlargement

Question 35

What are the risk factors for-melanoma?

Answer 35

HARMM Risk Factors for Melanoma
▪ History of previous melanoma
▪ Age over 50
▪ Regular dermatologist absent
▪ Mole changing
▪ Male gender

Question 36

What are the causes of skin dryness and of oiliness? What are the causes of skin roughness and of velvety texture?

Answer 36

Dryness can occur in hypothyroidism; oiliness can occur with acne.

Skin roughness also occur in hypothyroidism, but velvety texture could be hyperthyroidism.

Question 37

What are the causes of hair loss? How will you distinguish between them?

Answer 37

Alopecia areata will show clearly demarcated oval or round patches of hair loss with no inflammation.

Trichotillomania will show patches with broken hair shafts of varying lengths.

Tinea capitis (ringworm) will show patches with all of the hair broken off close to the scalp.

Question 38

What is koilonychias? What is its cause?

Answer 38

Koilonychias are spoon-like depressions in the nails associated with iron deficiency anemia

Question 39

What causes tinea versicolor? How does it look like?

Answer 39

Tinea versicolor is caused by a superficial fungal infection of the skin. It looks like hypopigmented,
slightly scaly macules on the trunk, neck, and upper arms.

Question 40

Define paronychia, clubbing of finger nails, and pitting of nails.

Answer 40

Paronychia is red, swollen, and tender nail beds due to a superficial infection of the proximal and lateral
nail folds.

Clubbing of finger nails is a bulbous swelling of the soft tissue at the nail base diagnosed by a nail angle
of greater than 180 degrees seen when placing the same nail of each hand against each other (showing no
space in between). This is caused by increased blood flow due to hypoxia.

Nail pitting show defects in the nail plate often associated with psoriasis.

Question 41

How will you classify overweight and obesity by BMI? How will you calculate BMI?

Answer 41

(Weight lbs x 700) / (height” x height”)

▪ Underweight: < 18.5
▪ Normal: 18.5-24.9
▪ Overweight: 25.0-29.9
▪ Obesity I: 30.0-34.9
▪ Obesity II: 35.0-39.9
▪ Obesity III (extreme obesity): ≥ 40

Question 42

Can slight reduction of weight improve BP and other risk factors? What are the recommended
rate of optimum weight loss per week and over 6 months?

Answer 42

Even reducing weight by 5% to 10% can improve blood pressure, lipid levels, and glucose tolerance and
reduce the risk of diabetes or hypertension.

A weight loss goal of ½ to 1 pound per week is recommended because more rapid weight loss does not lead to better results at 1 year. A 10% weight reduction over 6 months is recommended, or a decrease of 300 to 500 kcal/day, for people with BMIs between 27 and 35.

Question 43

How will you classify blood pressure?

Answer 43

Normal: < 120 (systolic) / < 80 (diastolic)
▪ Prehypertension: 120-139 / 80-89
▪ Hypertension (Stage 1): 140-159 / 90-99
▪ Hypertension (Stage 2): ≥ 160 / ≥ 100

Question 44

What is the ideal way to measure the blood pressure?

Answer 44

Patient seated with upper arm at level of the heart. Width of the inflatable bladder of the cuff should be about 40% of upper arm circumference (about 12-
14 cm in the average adult). Length of the inflatable bladder should be about 80% of upper arm
circumference (almost long enough to encircle the arm).

Question 45

What is the normal heart rate in adults?

Answer 45

Normal rate is between 50-90 beats per minutes;

Question 46

What is the normal respiratory rate in adults?

Answer 46

Normal respiration

rate is between 12 and 20 breaths per minute

Question 47

What are the normal oral, rectal, and tympanic membrane temperatures?

Answer 47

oral (average 98.6°F)
rectal (average 99.4°F)
tympanic membrane (average 100.0°F).