Practicum (mid term)

Question 1

First steps

Answer 1

Introduce self & wash hands

Question 2

SKIN

Answer 2

Inspects exposed skin: examine face, neck, arms, hands, legs and soles of feet

Inspect nail beds: nail bed inspection for capillary refill and integrity

Question 3

HEAD

Answer 3

Inspect & palpate the skull:

parts the hair from frontal to occipital region

pays special attention to area behind ears, hairline, and crown of head

occipital glands at base of skull

palpates temporal arteries

palpates temporomandibular joint with 2 fingertips just anterior to the tragus of ear.

ask patient to open and close mouth

Question 4

Face

Answer 4

palpates facial bones: frontal, zygomatic, mandible

palpates sinuses:

frontal: thumbs pressed up under body ridge of eyebrow on each side of nose
maxillary: thumb or index finger under the zygomatic process

Clench teeth

Wrinkle forehead

Smile

Stick out tongue and move right to left

Puff out cheeks

Squeeze eye tightly shut with eyes closed and test muscular strength by trying to open

Question 5

EYES part 1

Answer 5

Inspects eyelids, eyelashes, palpebral folds, sclera, conjunctiva, iris, eyebrow alignment

Palpate lacrimal glands, ducts

Evaluate pupil size: direct penlight at nasal bridge from about 30cm and observe for light symmetrically in both eyes

Test pupillary response: direct and consensual. Use penlight and have patient look into distance

Test alignment: patient to look at distant object and then at object 10cm from bridge of nose; watch for pupillary constriction with near effect

Question 6

EYES part 2

Answer 6

Test for ocular muscle function:

Corneal reflex: check with tissue. Etc

Extraocular muscle movements: hold patient chin and instruct patient to watch finger movement thru six cardinal fields of gaze. CN III, IV, & VI)

Performs opthalmoscopic examination

Starts with lens on O setting and large aperture

Holds opthalmoscope in hand corresponding to the eye examined; maintain finger on lens selector dial
throughout exam

Stabilizes patient head

Attempts to visualize: red reflex, lens, disc, cup margins, vessels, retinal surface

Question 7

EARS part 1

Answer 7

Inspect ears for size, shape, symmetry, position

Palpates: auricle, mastoid area, push tragus for tenderness, pull gently on each lobe

Evaluates auditory acuity for whispered voice test (CN VIII)

Question 8

EARS part 2

Answer 8

Evaluate Weber test (CN VIII)

Evaluate Rinne test (CN VIII)

Otoscope Examination:

Tilts patient’s head toward opposite shoulder

Pulls patient’s auricle upward and back

Attempts to visualize canals, tympanic membranes for color, position, landmarks, integrity, deformities, inflammation

Question 9

NOSE

Answer 9

Inspects external position of nose for deviation

Palpates nasal skeleton from nasal bridge to tip of the nose

Assess patency of nares: instruct patient to occlude each nares separately and breathe in and out with mouth closes

Inspect nasal turbinates

Question 10

MOUTH

Answer 10

Inspects lips with mouth closed

Inspects oral mucosa with penlight and tongue blade with patient’s mouth open

Buccal mucosa, gingiva, teeth, Stensen’s and Wharton’s ducts, hard and soft palate, tonsils

Asks patient to touch tip of tongue to palate

Ask patient to extend tongue and move tongue side to side (CN XII) and observe lateral borders of tongue for lesions

Tests glossopharyngeal and vagus nerve function (CN IX, X)

Inspects posterior pharynx

Instructs patient to say “ah” and observes uvula movement, palantine arch rise

Test gag reflex

Question 11

NECK

Answer 11

• Inspect neck: Instruct patient to slightly hyperextend and swallow; check for jugular vein distention

Palpate trachea for midline: thumb and forefinger along each side of trachea in lower portion of neck

Palpates all head and neck lymph nodes

Preauricular, postauricular, tonsillar, submandibular, submental, superficial cervical, deep cervical, posterior cervical, supraclavicular

Question 12

Neck 2

Answer 12

Palpate thyroid gland using posterior approach:

Locate landmarks: hyoid bone, thyroid cartilage, cricoid cartilage

Place two fingers on each hand on sides of trachea just below cricoid

Ask patient to swallow feeling for movement of isthmus

Using right hand, displace trachea to left and palpate
for main body of left thyroid

Question 13

CHEST AND LUNGS part 1

Answer 13

STAND BEHIND PATIENT AND EXPOSE BACK

Inspect posterior chest wall for symmetry, movement with breathing

Simultaneously palpates posterior chess wall with ball of hand

Simultaneously palpates for tactile fremitus using palmar surface of hand and patient saying “99” repeatedly

Question 14

CHEST AND LUNGS part 2

Answer 14

Thumbs at 10th rib on each side spinal column & fingers on lateral thorax

Symmetrically percuss posterior lungs: superior, inferior, medial and lateral

Symmetrically auscultate posterior lung fields: superior, inferior, medial and lateral

Question 15

CHEST AND LUNGS part 3

Answer 15

MOVE IN FRONT OF PATIENT

Inspect anterior chest wall

Auscultate breath sounds on anterior chest

Question 16

CARDIOVASCULAR AND PERIPHERAL VASCULAR part 1

Answer 16

Auscultate with diaphragm with patient leaning slightly forward: (detects aortic regurgitation murmurs)

Left sternal border

Mitral area

Question 17

CARDIOVASCULAR AND PERIPHERAL VASCULAR part 2

Answer 17

ASSIST PATIENT TO SUPINE POSITION

Palpate: Apex, left sternal border, base left, base right, right sternal border, epigastrium

Auscultate with diaphragm following areas: Aortic, pulmonic, second pulmonic, tricuspid, mitral

Auscultate with bell following areas: Aortic, pulmonic, second pulmonic, tricuspid, mitral

Auscultate mitral area with patient in left lateral recumbent position with bell and patient holding breath (brings out S3, S4 and mitral murmurs)

Question 18

CARDIOVASCULAR AND PERIPHERAL VASCULAR part 3

Answer 18

Inspect neck for JVD, place patient 30- 45 degree angle

Inspects neck for carotid pulsations

Palpates carotids one at a time

Auscultates carotid arteries with bell

Question 19

CARDIOVASCULAR AND PERIPHERAL VASCULAR part 4

Answer 19

Auscultates vascular sounds with bell of stethoscope: Aortic, renal, iliac, femoral

Palpates Brachial, radial, femoral, popliteal, dorsalis pedal, posterior tibial

Question 20

ABDOMEN 1

Answer 20

Inspect abdomen: have patient cough to note pulsations/masses

Auscultate with diaphragm all 4 quadrants of abdomen

Percuss all 4 quadrants of abdomen

Question 21

ABDOMEN 2

Answer 21

Spleen :)

Percuss under the left rib for tympany

additional-
Percuss for splenic sign:
o Locate lowest interspace in left anterior axillary line
o Percuss for tympany
o Instruct patient to take deep breath and hold
o Percuss for tympany (with splenic enlargement sound turns to dullness)

Question 22

ABDOMEN 3

Answer 22

Palpates abdomen: light and then deep in all 4 quadrants

Question 23

ABDOMEN 4

Answer 23

Gallbladder :)

Murphy’s sign: ask patient to take deep breath and palpate deeply on RUQ under rib cage. (sign for inflamed gallbladder)

Question 24

ABDOMEN 5

Answer 24

Appendix :)
Blumberg sign at McBurney’s point:
o Correctly identify landmarks (1/3 between bone and umbilicus)
o Hold hand at 90 degree angle to abdomen with fingers extended
o Press gently and deeply into RLQ (pain suggest appendicitis)
o Rebound tenderness – ask if pain increases when hand removed

Question 25

ABDOMEN 6

Answer 25

Liver :)
Palpate liver edge:
o Place left hand under patient’s 11th and 12th rib
o Place right hand on abdomen with fingers pointing toward head
o Ask patient to take deep inspiration & expiration to relax abdomen
o Place right hand deeply in and under rib cage
o Ask patient to take another deep inspiration and feel for rib edge

Question 26

Musculoskeletal 1

Answer 26

Inspect muscle mass

Palpate and compare arm and leg muscles

Question 27

Musculoskeletal 2

Answer 27

Hip :)

Hip Flex with leg extended
Hip Flex with leg flexed 
Hip Abduction
Hip Adduction 
Internal Rotate with knee bent
External Rotate with knee bent  
Raise each leg with resistance

Question 28

Musculoskeletal 3

Answer 28

Knee :)

Stability (check for anterior and posterior Draw sign); anterior and posterior cruciate ligament

Assess for fluid of the knee (pressure on quads and tap patella)

Question 29

Musculoskeletal 4

Answer 29

Neck :)

Sit the patient up
Flex 
Extend
Left bend
Right bend
Left rotate
Right rotate

Question 30

Musculoskeletal 5

Answer 30

Foot and Ankle :)

o	Dorsiflexion (toes up)
o	Plantar flexion (toes down) 
o	Inversion (sole in)
o	Eversion (sole out)
o	Abduction
o	Adduction

Question 31

Neurological

Answer 31

Test sensory function – sharp and dull sensation (use broken cotton swab)
o Distal sites – at least 2 (e.g. finger and toe)
o Scalp
o Chin
o Cheeks

Question 32

Neurological 2

Answer 32

• Test vibratory sensation of each wrist (radial bone) and ankles
• Assess position sense: ask patient to close eyes and ask to identify which way you are moving several fingers (up or down)

Question 33

Neurological

Answer 33

• Test stereogenosis
  o Patient closes eyes
  o Place different object in each hand of patient and ask to identify
• Test graphesthesia
  o Instruct patient to close eyes
  o Write a different number in each of patient’s hands and ask to identify

Question 34

Neurological

Answer 34

• Test fine motor function, coordination and position of upper extremities by asking patient to Touch nose with alternating finger
• Test fine motor function, coordination and position of lower extremities by asking the patient to Alternately and rapidly cross leg over opposite leg

Question 35

Neurological

Answer 35

• Test deep tendon reflexes,

o Biceps

o Patellar

Question 36

Neurological

Answer 36

Shoulder :)

Stand up

o	Shoulder shrug
o	Flexion – elbows straight
o	Extension – elbows straight
o	Abduction – elbows straight
o	Adduction – elbows straight – across chest
o	Internal rotation – elbows bent 
o	External rotation – elbows bent

Repeat each step while adding resistance

Question 37

Neurological

Answer 37

Spine :)

STAND BEHIND PATIENT
- Inspect alignment and palpate spine: (maintain one hand on patient’s waist)
o Ask patient to bend forward and palpate spinous processes (assess for scoliosis/lordosis/kyphosis)
- Active ROM Upper trunk: (maintain hands on patient’s waist)
o Lateral bending left
o Lateral bending right
o Rotation left
o Rotation right

Question 38

Neurological

Answer 38

• Observe gait

o Active ROM for hip – extend right leg out front and then behind patient and repeat with left.

• Test proprioception and cerebellar function by asking patient to Walk heel to toe