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CAPS II FInal > Prompts > Flashcards

Prompts Flashcards

(116 cards)

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1
Q

Assess freestyle gait for rhythm, symmetry of movement in legs and arms.

A

Assessed spring of the gait and swing of the arms- start in exam room and if abnormal, took patient out to
common area to provide a longer distance for walking.

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2
Q

Assess toe walking

A

Had patient walk away from examiner on toes while observing elevation of heels

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3
Q

Assess heel walking

A

Had patient walk toward examiner on heels while observing elevation of toes

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4
Q

Assess tandem gait

A

Explained test to the patient (example: walk heel-to-toe). Stood close to patient to provide support if needed

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5
Q

Perform Romberg test

A

Asked patient to stand with feet together and arms at sides.
Asked patient to close eyes to assess balance.
Stood close to patient to prevent a fal

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6
Q

Assess upper extremity drift

A

Observed outstretched upper extremities for drift. Test is performed by extending arms with palms facing up and
eyes closed.

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7
Q

CN I

A

Tested sense of smell by identifying mild fragrance in each nostril (may use any item with recognizable odor)

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8
Q

CN II - visual acuity

A

Tested visual acuity in each eye using pocket vision card (test is performed by holding card 14 inches from
patient and asking patient to read the smallest line and moving up or down the lines until patient can read a full
line in the smallest possible print. Each eye should be tested independently by closing the other eye)

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9
Q

CN II - visual field

A

Screened visual fields (test is performed with the examiner standing or sitting about 3 feet from patient, with
examiner and patient eyes at same level. One eye is examined at a time by covering the other eye, by presenting
a varied number of fingers (0, 1, or 2) to the patient in each of the four quadrants and asking the patient to
count (add) the fingers).

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10
Q

CN II - pupillary reaction

A

Tested direct and consensual pupillary reaction to light (room lights should be dimmed, may cup the eye with
hand to prevent light from going into the other eye)

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11
Q

CN II - movement

A

Performed the swinging light test (room lights should be dimmed). May cup the eye with hand to prevent light
from going into the other eye.

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12
Q

CN III, IV, VI

A

Observed all extraocular movements (examiner moves finger or light into the 6 cardinal positions and asks the
patient to follow the movement with the eyes. The 6 cardinal positions are: up and right, straight right, down
and right, up and left, straight left, and down and left). Observed eyelids.

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13
Q

CN V - pain sensation

A

Tested the three divisions for pain sensation - using a sharp object, with patient’s eyes open or closed:

  • Tested sensation on forehead, cheek, and chin on both sides
  • Asked if patient feels the object on each side
  • Asked patient to compare the sensation between the 2 sides
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14
Q

CN V - light sensation

A

Tested the three divisions for light touch - using a tissue or a cotton tip, with patient’s eyes closed.

  • Tested sensation on forehead, cheek, and chin on both sides
  • Asked if patient feels the object on each side
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15
Q

CN V - motor

A

Tested contraction of masseter

  • Asked patient to clench teeth or bite
  • Asked patient to move jaw side to side
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16
Q

CN VII

A

Observed motor function and tone in musculature of face.
Had patient raise eyebrows. Had patient squeeze eyes shut.
Had patient grimace to show teeth.
Had patient puff out cheeks and pushed on each cheek with 1 finger to deflate it.

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17
Q

CN VIII - finger friction or whisper

A

Screened hearing using finger friction or whisper on both sides (hand should be behind the field of vision).

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18
Q

CN VIII - Rhinne test

A

Performed the Rinne test on both sides (examiner taps the tines of the tuning fork, places the base of the fork on the
mastoid bone and asks the patient to report when he/she stops hearing the vibration (bone conduction). Then
examiner places the still vibrating fork 1-2 cm from the ear and asks the patient to report when he/she stops hearing
the vibrations (air conduction). Duration of air conduction should be longer than that of bone conduction

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19
Q

CN VIII - Weber test

A

Performed the Weber test (examiner taps the tines of the tuning fork, places the base of the fork on the midline of the
patient’s head and asks the patient to report if he/she hears the vibrating sound equally in both ears or if it is better in
one ear. The bones of the skull will transmit the sound which then should be heard equally in both ears.

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20
Q

CN IX and X

A

Observed elevation of palate by asking patient to say “Ahh.”
Performed gag reflex on both sides using a cotton swab to touch back of palate on each side (may use a tongue
depressor to move tongue out of the way if needed).

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21
Q

. CN XI

A

Tested rotation of patient’s head against resistance. Tested shoulder shrug against resistance.

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22
Q

CN XII

A

Observed tongue for atrophy and fasciculations (twitching) while at rest inside the mouth. Observed midline
protrusion of tongue. Tested tongue strength by asking patient to push tongue against the inside of cheek while
applying resistance on the outside of the cheek - both sides should be tested.

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23
Q

Assess upper extremity functional muscle groups for bulk, atrophy and fasciculations

A

Observed and compared deltoids on both sides.
Observed and compared biceps on both sides.
Observed and compared pectoralis on both sides.

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24
Q

Assess lower extremity functional muscle groups for bulk, atrophy and fasciculations

A

Observed and compared calves on both sides.

Observed and compared quadriceps on both sides.

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25
Assess muscle tone.
Asked patient to relax completely. Passively moved the arms to check for spasticity or rigidity (both sides). Passively moved the legs to check for spasticity or rigidity (both sides).
26
Grade muscle strength in the hands, both sides.
Asked patient to squeeze 2 fingers with each hand and pulled fingers out (distal muscles). Asked patient to spread fingers and tried to push them together (distal)
27
Grade muscle strength in the arms, both sides.
Asked patient to extend arms to the sides with elbows bent, pushed down on the elbows and asked patient to resist (proximal). Asked patient to flex elbow against resistance (proximal). Asked patient to extend elbow against resistance (proximal)
28
Grade muscle strength in the feet, both sides.
Asked patient to dorsiflex (move foot up) ankle against resistance (distal). Asked patient to plantar flex (point toes) ankle against resistance (distal).
29
Grade muscle strength in the legs, both sides.
Asked patient to lift knee up while sitting against resistance (proximal). Asked patient to extend bent knee against resistance (proximal).
30
Assess pain sensation on lower extremities - both sides
Using a sharp object, agreed with patient on how sharp should feel by touching skin with object. Touched top of foot on each side and asked patient to compare the 2 sides. Touched shin on each side and asked patient to compare the 2 sides. On each side separately: touched foot then shin moving distal to proximal and asked patient for any changes in sensation as object moved up
31
Assess pain sensation on upper extremities - both sides
Using a sharp object, touched dorsum of hand on each side and asked patient to compare the 2 sides. Touched forearm on each side and asked patient to compare the 2 sides. On each side separately: touched hand then forearm moving distal to proximal and asked patient for any changes in sensation as object moved up
32
Assess light touch on lower extremities - both sides
Using a cotton tip or tissue, agreed with patient on how light touch should feel by touching skin with object. Asked patient to close eyes. Touched top of foot on each side and asked patient if he/she can feel it. Touched shin on each side and asked patient if he/she can feel it. On each side separately: touched foot then shin moving distal to proximal and asked patient for any changes in sensation as object moved up
33
. Assess light touch on upper extremities - both sides (patient's eyes closed).
Touched dorsum of hand on each side using a cotton tip or tissue and asked patient if he/she can feel it. Touched forearm on each side and asked patient if he/she can feel it. On each side separately: touched hand then forearm moving distal to proximal and asked patient for any changes in sensation as object moved up
34
Assess position sense in both feet
Asked patient to close eyes. Separated big toe from other toes and grasped it on the sides. Moved the toe up and down several times in a random fashion while asking the patient to describe the direction of movement
35
Assess position sense in both hands
Asked patient to close eyes. Separated index finger and grasped it on the sides. Moved finger up and down several times in a random fashion while asking patient to describe the direction of movement
36
Assess vibration sense in toes - both sides
In big toe: Tapped the tines of tuning fork and placed it on the joint below the nail, while examiner’s finger is on the other side of the toe. Tested duration of time patient felt the vibration and compared it to examiner’s sensation in the finger that is on the toe
37
Assess vibration sense in fingers - both sides
In index finger: Tapped the tines of tuning fork and placed it on the joint below the nail, while examiner’s finger is on the other side of the finger. Tested duration of time patient felt the vibration and compared it to examiner’s sensation
38
Brachioradialis deep tendon reflex - both sides
n/a
39
Biceps deep tendon reflex - both sides
n/a
40
Triceps deep tendon reflex - both sides
patient’s hands on hips
41
Patellar deep tendon reflex - both sides
n/a
42
Achilles deep tendon reflex - both sides
gently dorsiflex the foot
43
Babinski reflex - both sides
Rubbed bottom of foot, back to front, lateral to slightly medial
44
Test rapid alternating movements in upper extremities - both sides (one side at a time)
Asked patient to extend arm and fully turn hand up and down fast
45
Test rapid alternating movements in lower extremities - both sides (one side at a time)
Can be done by asking patient to rapidly tap his/her toes on the floor.
46
Test fine finger movements - both sides
Asked patient to touch each finger against thumb.
47
Test finger-to-nose bilaterally - both sides
Explained or showed test to patient. | Moved finger as patient performed the test.
48
Test heel-to-shin bilaterally
Patient should be lying down.
49
Test visual acuity
Examined one eye at a time by covering the other eye (with glasses on if patient wears glasses). Used near vision chart correctly- 14 inches away from patient. Recorded visual acuity for each eye.
50
Examine peripheral vision
xaminer and patient should be at eye level. Examiner should be about 3 feet from patient. Examined one eye at a time while covering the other eye. Counting fingers test - Presented a varied number of fingers to the patient in each of four quadrants.
51
Inspect orbits and eyelids
Visually inspected orbits and eyelids from front and side
52
Examine the conjunctiva, sclera and lacrimal apparatus
n/a
53
Examine the cornea
Held a penlight close to the cornea and slowly move it around while keeping the beam pointed toward the center of the cornea
54
Examine the pupils
Inspected the pupils for shape, symmetry and size. Dimmed the room lights to observe the pupils’ response to light. Examined direct reaction of each pupil to light. Examined consensual reaction of each pupil to light. Performed the swinging flashlight test. Examined pupillary reaction to accommodation.
55
Examine the extraocular muscles
Tested ocular alignment: examiner stood 2 feet from patient and shined a light toward the eyes (in the midline) while the patient was looking at a distant target. The examiner observed for symmetry of the light reflection on the corneas. Tested conjugate eye movement: Examiner moved finger or light into the 6 cardinal positions and asked the patient to follow the movement with the eyes. The 6 cardinal positions are: up and right, straight right, down and right, up and left, straight left, and down and left. At end examiner brought finger or light toward the patient’s nose to check for convergence and accommodation.
56
Prepare the room and patient for the funduscopic examination
Dimmed the room light. Asked patient to remove glasses (contact lenses OK). Examiner can remove glasses or keep them on. Asked patient to look at the opposite corner or other specific distant location
57
Demonstrate proper use of the ophthalmoscope.
Held the ophthalmoscope appropriately: in the right hand while examining the patient's right eye and in the left hand while examining the patient's left eye. Index finger on the side wheel
58
Check for red reflex.
- diopters in the lens | - standing 12 inches away from the patient
59
Visualize the retina
Moved closer to the patient and focused the ophthalmoscope to visualize the retina
60
Visualize the optic disk, retinal vessels, and macula
Examined the optic disc (examiner should approach the patient from about 15 or 20 degrees lateral to the center to view the nasal side of the fundus). Examined the retinal vessels in all 4 quadrants. Examined the macula: moved toward the middle in order to see the macula that is located lateral (to the outside) to the disc - examiner may ask the patient to stare directly at the light of the ophthalmoscope in order to view the macula (this test should be done last).
61
Observe head and face for symmetry, involuntary movements, and general features
n/a
62
Inspect the scalp for lesions and hair patterns
n/a
63
Palpate scalp to identify areas of tenderness and deformity
Palpated scalp systematically from front to back using rotary movements
64
Palpate the temporomandibular joint - both sides
n/a
65
Palpate the parotid and submandibular salivary glands
Palpated the parotid and submandibular salivary glands looking for asymmetry, pain, and/or enlargement.
66
Inspect the neck for symmetry and swelling or masses
n/a
67
Examine range of motion of the neck
Examined the range of motion of the neck by asking the patient to flex, extend, and rotate the neck and to laterally flex it to each side
68
Palpate the bony and cartilaginous structures of the neck
n/a
69
Palpate lymph nodes bilaterally
Examiner bent patient’s head slightly forward or to the side to ease taut tissue and make underlying structures more accessible, used pads of fingers to palpate, and applied steady gentle pressure.
70
Examine preauricular, postauricular and occipital lymph nodes
Examined preauricular nodes: just in front of the ear - both sides. Examined postauricular nodes: over mastoid process - both sides. Examined occipital nodes: over mastoid process on both sides.
71
Examine parotid, retropharyngeal, submandibular and submental lymph nodes
Examined parotid and retropharyngeal (tonsillar) nodes: angle of mandible - both sides. Examined submandibular nodes: halfway between angle and tip of mandible - both sides. Examined submental nodes: midline behind the tip of the mandible - both sides
72
Examine supraclavicular, superficial, deep, and posterior cervical lymph nodes
Examined superficial nodes: at the SCM on both sides. Examined posterior cervical nodes: anterior border of the trapezius muscle on both sides. Examined cervical nodes deep in the SCM: probe gently around the muscle on both sides. Examined superclavicular nodes: probe deeply in the area formed by the clavicle and the SCM on both sides
73
Examine axillary lymph nodes bilaterally
probed deeply with relaxed or supported arm
74
Inspect the thyroid gland
Asked patient to slightly extend neck. Asked the patient to swallow while observing the thyroid move up and down (provided patient with cup of water if hard to swallow).
75
Palpate the thyroid gland
Sat or stood behind patient. Positioned 2-3 fingers of each hand on each side of the trachea about 3 cm below the thyroid cartilage (at the base of the neck). Felt the isthmus. Felt both the right and left lobes of the thyroid.
76
Inspect the external ear
Inspected the position, color, and shape of the auricles. Inspected the external auditory canal for discharge. Looked behind the ear for any skin lesions or nodules.
77
Palpate the auricles - both sides
Palpated the auricles for tenderness and masses.
78
Inspect the mastoid area for redness and swelling
n/a
79
Palpate the mastoid process
n/a
80
Perform the otoscopic examination
Examiner placed a disposable speculum on the end of the scope, selecting the largest speculum that fit in the patient’s ear. Examiner held the scope in the right hand to examine the patient’s right ear and in the left hand to examine the patient’s left ear (demonstrated control of the otoscope). Inserted the scope correctly with the handle either pointed directly downward or angled up and towards the patient's forehead. Placed the tip of the speculum in the opening of the external canal under direct vision. Gently grasped the top of the patient's ear and pulled up and backwards to straighten out the canal, allowing easier passage of the scope. Slowly advanced the otoscope without causing pain to the patient.
81
Perform whispered voice or rubbing fingers test - both sides
n/a
82
Perform Rinne test - both sides
Examiner tapped the tines of a tuning fork, placed the base of the fork on the mastoid bone and asked the patient to report when he/she stopped hearing the vibration (bone conduction). Examiner then placed the still vibrating fork 1-2 cm from the patient's ear and asked the patient to report when he/she stopped hearing the vibrations (air conduction). Duration of air conduction should be longer than that of bone conduction.
83
Perform Weber test
Examiner tapped the tines of a tuning fork, placing the base of the fork on the midline of the patient's head and asked the patient to report if he/she hears the vibrating sound equally in both ears or if it is better in one ear. The bones of the skull will transmit the sound, which should then be heard equally in both ears.
84
Inspect the nose
Inspected the anterior and inferior surfaces of the nose.
85
Palpate the nose
Palpated the bridge and soft tissues of the nose.
86
Assess the patency of the nasal passages
Compared patency of each nasal passage by pressing on each nasal ala in turn and asking the patient to breathe in
87
Examine the nasal cavity
Asked patient to tilt head back, and pushed slightly on the tip of the nose with the thumb. Placed the end of the speculum into the nostril under direct vision. Stabilized the otoscope without causing patient discomfort while looking at the nasal cavity through the viewing window
88
Examine the sinuses
Palpated the maxillary sinuses by pushing under the bony ridge on each side of the nose. Palpated the frontal sinuses on both sides
89
Examine the lips, teeth, and gums
Inspected the lips with the patient’s mouth closed, looking for symmetry, swelling, and lesions or masses. Asked patient to clench teeth and smile and observed the occlusion of the teeth. Inspected the teeth. Inspected the gums (asked patient to remove dentures if applicable). Palpated the gums and lips with gloved hand.
90
Palpate the gums and lips with gloved hand
n/a
91
Examine the oral mucosa
Asked the patient to open his/her mouth and inspected the oral mucosa (may use a tongue blade to move tissues; may use otoscope or penlight as a source of light). Inspected the dorsum of the tongue for swelling, color and lesions. Asked patient to touch the tip of tongue to the roof of the mouth and inspected the ventral surface of the tongue and the roof of the mouth for swelling or lesions.
92
Examine the tongue
Wrapped the tongue with a piece of gauze and gently moved it to each side, inspecting the borders
93
Palpate the tongue and floor of the mouth
Palpated the tongue and floor of the mouth for masses.
94
Evaluate CN XII
Asked patient to stick tongue out to evaluate CN XII.
95
Inspect the palate and uvula
Asked patient to tilt head back and inspected the palate and uvula. Asked patient to say “Ahh” to observe the oropharynx and tonsils and to assess the movement of the soft palate and uvula (may need to place a tongue blade on the back of the tongue and press it down to visualize).
96
Assess general skin health
Inspected overall skin color, skin type, obvious lesions or disease processes. Can do this while greeting and talking to patient to give a general overview inspection.
97
Assess skin turgor and texture
Palpated the skin of anterior of one forearm to assess turgor (pinch skin and see how it goes back to normal), texture (touch and palpate to assess) and laxity (notice any sagging of skin which may also require palpation and/or squeezing).
98
Assess skin moisture and temperature
Palpated skin for moisture and temperature (using dorsal fingers and hand) and noted regional variation by touching several places on arms.
99
Examine the scalp and hair
Inspected and palpated skin of scalp and hair (should also note hair loss and/or distribution). Deliberately moved hair aside to inspect scalp about every 2 inches
100
Examine skin of the ears and behind ears
Inspected and palpated skin of ears and behind ears
101
Examine skin of the face
Inspected and palpated skin of face.
102
Examine skin of the neck
Inspected and palpated skin of neck (may use hand lens).
103
Examine oral mucosa and conjunctiva
Inspected oral mucosa and conjunctiva with use of penlight, noting lesions or variations in pigment. Asked patient to open mouth wide with tongue inside mouth; asked patient to lift tongue to the roof of mouth. Asked patient to stick tongue out to ensure inspection of all surfaces of tongue, including the sides.
104
Examine skin of both arms and axillae
Inspected and palpated skin of both arms and axillae
105
Examine skin of hands
Inspected and palpated skin of both hands (including palms)
106
Examine the fingernails
Inspected all fingernails of both hands for anatomy, symmetry, thickness, luster, clubbing, signs of trauma, texture, color, and overall hygiene.
107
Assess capillary refill of fingers
One finger on each hand is sufficient.
108
Examine the skin of the back
Inspected and palpated skin of back. May have to lift bra straps to get close inspection.
109
Examine skin of the chest
Inspected and palpated skin of chest. May have to move body hair to get close inspection. May have to lift bra straps to get close inspection
110
. Examine skin of the abdomen
Inspected and palpated skin of the abdomen. May have to move body hair to get close inspection.
111
Examine skin of the anterior legs
Inspected and palpated skin of the anterior legs. May have to move body hair to get close inspection.
112
Examine skin of the anterior feet and toes
Inspected and palpated skin of both anterior feet and toes (including looking between toes)
113
Examine the toenails
Inspected all toenails of both feet for anatomy, symmetry, thickness, luster, clubbing, signs of trauma, texture, color, and overall hygiene.
114
Assess capillary refill of toes
one toe on each foot is sufficient
115
Examine the skin of the torso back and posterior legs
Inspected and palpated skin of torso back and posterior legs. May have to move body hair to get close inspection.
116
Examine the skin of the plantar (soles) of the feet
Examine the skin of the plantar (soles) of the feet

CAPS II FInal (2 decks)

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