Specialized Exams

Question 1

Transilluminate frontal sinuses

Answer 1

dim lights, place the light just below the brow, cup your hand over the light and look for a red glow. Do both sides.

Question 2

Transilluminate maxillary sinuses

Answer 2

dim lights, tilt head back, open mouth, place light just below eye on cheek bone. Red glow on hard palate indicates a normal airfilled sinus

Question 3

sinus percussion

Answer 3

tenderness, tell me if you have any discomfort, percuss frontal and maxillary sinuses

Question 4

temporal artery

Answer 4

palpate for normal palpations, feeling for abn tenderness or firmness, artery, then listen with bell for bruits

Question 5

visual fields

Answer 5

look at my nose and cover one eye, and point to the hand you see movement

Question 6

corneal reflex

Answer 6

cotton applicator, CN V, wisp to the eye, blink response

Question 7

cover-uncover test

Answer 7

checking for strabismus, done when corneal light reflection is asymmetrical. When I remove the card, I am looking for any motion of the covered eye. Do both eyes

Question 8

Weber

Answer 8

conductive vs sensory neuro hearing loss. Place tuning fork firmly on vertex of pts head on the midline. Ask pt is sound is heard equally. Sound will normally be heard equally on both sides.

Question 9

Rinne

Answer 9

helps determine if pt has a conductive or sensory neuro hearing loss, placed on mastoid process behind ear. Tell me when you cannot hear the sound any more. Then place tuning fork in front of ear canal. If pt can hear, air conduction is greater than bone conduction. This is a normal finding. “Say yes if you can hear, and say now when you can no longer hear. Then I will move it in front of your hear. Say yes if you can hear the sound, and now when you can no longer hear”

Question 10

Palpate anatomical snuffbox

Answer 10

checking for fracture of scaphoid

Question 11

Phalen’s test

Answer 11

checks carpal tunnel syndrome. Flex wrist, hold for 60 secs, numbness or tingling develop in hand, test is positive and suggests compression of median nerve.

Question 12

Tinnel’s sign

Answer 12

indication of carpal tunnel syndrome, extended slightly, percuss region of median nerve, if pt senses a tingling sensation in the hand and fingers in the distribution of the median nerve, the test is positive and suggests median nerve compression in the carpal tunnel

Question 13

Allen test

Answer 13

is conducted prior to drawing arterial blood gases from the radial artery. Used to assure patency of ulnar artery before radial artery puncture

Question 14

Consolidation

Answer 14

non gas in lungs, pulmonary edema, inflammatory exudate, pus, inhaled water, or blood (from bronchial tree or hemorrhage from a pulmonary artery). Pneumonia

Question 15

Tactile fremitus

Answer 15

when pts talks or makes other sounds, one can feel vibrations on the chest. These sounds can increase or decrease in certain disease states. Using the ulnar side of the hands, place them on the chest and ask pt to say “99.” Place hands where you would auscultate. Checking for symmetry. Decreased due to pleural effusion, increased in pneumonia

Question 16

Bronchophony

Answer 16

Is the sound a spoken voice makes when listening over large airways. Words are louder and clearer than when listening over peripheral airways. When broncohony is present in an area that is not over one of the main bronchi, consolidation of the lungs is suspected. “99”

Question 17

Egophony

Answer 17

sign of consolidation or fluid in lungs. Nasal quality. “E” sounds like ”A.” When you feel my stephescope, say “E.”

Question 18

Whispered pectoriloquy

Answer 18

is an exaggerated form of broncophony. When there is consolidation of the lungs, even a whispered sound may be lounder and easily heard with a stethescope. “whisper 99.” Decreased in pleural effusion, increased pneumonia

Question 19

Diaphragmatic excursion

Answer 19

sometimes it is important to see where the diaphragm is, and wheter it moves with inhalation or expiration. Exhale and hold it, percuss and mark with pen; then inhale and hold it, percuss and mark with pen. Usually 3-5cm. Can be reduced in some disease states.

Question 20

Respiratory expansion

Answer 20

determine how far the chest cavity expands during inhalation

Question 21

Auscultate heart

Answer 21

Ask patient to lean forward, exhale, and hold breath in expiration then auscultate at base with diaphragm. This brings the area closer to the chest wall. Best for listening for soft murmurs at the base, eg. Aortic regurgitation, aortic or pulmonic valves.

Question 22

Measure JVP

Answer 22

Exam table at 30 degrees, measure top level of venous impulse as number of cm above the sternal angle. Place ruler at the sternal angle, hold another ruler horizontally at the top of the JVP. Note how many cm this is above sternal angle. Add 5 cm to this number and the total is JVP. Normal is

Question 23

Hepatojugular reflux

Answer 23

A way to check for right sided fluid overload. Position the patient so that the upper level of the JV pulse is visible, then apply steady firm pressure to the region of the liver. Observe the upper level of JV pulse. If the JV pulse increases with this maneuver, it suggests volume overload.

Question 24

Percuss left border for cardiac dullness

Answer 24

To check heart size when PMI not palpable. With pt supine, percuss the ant chest wall at 5th intercostal space beginning with mid-axillary line and moving medially. When sound changes from resonant to dull, this is the left heart border. It can be recorded as the number of cm lateral to mid-clavicular line. Dullness detected to the left of the MCL suggests cardiomegally.

Question 25

Auscultate cardiac apex with bell:

Answer 25

(for low-pitched murmurs, S3, S4) with patient lying on left side

Question 26

Auscultate for bruits

Answer 26

renal arteries and iliac arteries

Question 27

check for ascites: shifting dullness test

Answer 27

With pt in supine position, percuss from midline and move lateral too flank. Note where percussion changes from tympanatic to dull. Then have pt roll onto his side and repeat. When free fluid is present, the level at which dullness appears shifts. This exam checks for excessive fluid or ascites. Free fluid within abd moves to dependent locations as pt changes location. Air filled loops of bowel rise to the superior parts of abd.

Question 28

check for ascites: fluid wave test

Answer 28

Stabilize mid-abd with hand, tap one side of abd and feel for transmitted impulse on the other side. When abdomen is distended, checking fluid wave will help you distinguish between dilated loops of bowel, fat and free fluid. Only fluid will transmit a pressure wave.

Question 29

obturator sign

Answer 29

With pt supine, flex hip and knee, and rotate leg internally at the hip. RLQ pain is positive sign. Appendicle irritation because internal obturator lies close to appendix.

Question 30

psoas sign

Answer 30

1. Flex right hip against resistance. 2. Have pt roll onto his left side. Stretch right leg back, check for RLQ pain. Iliopsoas muscle is close to appendix, so any maneuver that tenses or stretches this muscle may result in increased RLQ pain.

Question 31

rovsings sign

Answer 31

Press deeply in LLQ, then release your fingers quickly. Referred pain to RLQ is positive sign seen in acute appendicitis.

Question 32

murphys sign

Answer 32

Fist percussion of RUQ or pain with palpation on inspiration. Pain on inspiration is positive sign. Liver or gallbladder inflammation.

Question 33

abdominal reflexes

Answer 33

Use handle of reflex hammer to gently stroke away from umbilicus in all 4 quadrants. Observe for abd wall muscular contractions

Question 34

straight leg raise

Answer 34

Pt supine and leg straight, raise one leg off table and note angle to which it can be raised before pt complains of back or leg pain. At the apex, dorsiflex the foot and check for LBP or buttock pain. Sciatic nerve impingement

Question 35

bulge sign

Answer 35

Inspect the knee, gently palpate the knee for any gross effusion. Taking the back of the hand, sweep along medial and lateral knee and observe for fluid bulge. Tests for effusion of fluid in the knee.

Question 36

ballottement of patella

Answer 36

Slide one hand down pts distal thigh toward patella to move fluid from suprapatellar area, then push patella toward joint. If there is excessive joint fluid present, pressing on the patella will have a spongy feel.

Question 37

valgus stress test

Answer 37

Tests MCL, Flex knee about 15 degrees, stabilize lateral knee and apply pressure to ankle/foot. This tests the medial collateral ligament

Question 38

varus stress test

Answer 38

Tests LCL, Flex knee about 15 degrees, stabilize medial knee and apply pressure to ankle/foot. This tests the lateral collateral ligament.

Question 39

anterior drawer test

Answer 39

Test ACL, pt supine, knees bent 90 degrees, stabilize feet, both thumbs over tibial plateau, pull proximal tib/fib toward you. Note any laxity which would suggest tear of the anterior cruciate ligament

Question 40

posterior drawer test

Answer 40

As above, except push proximal tib/fib toward pt. Posterior pressure is placed at tibial plateau. Note any laxity which would suggest tear of posterior cruciate ligament

Question 41

mcmurrays test

Answer 41

Flex pt’s knee and with one hand palpate the joint line, hold the heel of the foot in your other hand with the ball of the foot on your wrist.
Lateral rotation of foot followed by extension of the leg tests the posterior horn of the medial meniscus.
Medial rotation of the foot followed by leg extension tests the posterior horn of the lateral meniscus.
-positive test with palpable click

Question 42

Lachmans test

Answer 42

Place the knee in the 15 degree flexion. Grasp distal femur with one hand and upper tibia with other. Move the femur back and tibia forward and estimate degree of forward excursion. This test is more sensitive than the Anterior Drawer Test for ACL tear.

Question 43

homans test

Answer 43

Dorsiflex foot and check for calf pain, positive if painful. Traditionally done to detect a DVT of calf. Fallen out of favor and is not very specific.

Question 44

ankle anterior drawer test

Answer 44

Stabilize distal tibia, grasp posterior calcaneus and pull forward, checking for ligamentous laxity. Positive drawer sign would suggest a tear or injury to the anterior talofibular ligament.

Question 45

rapid alternating movements

Answer 45

: Ask pt to rapidly pronate and supinate their hands, tapping their distal thigh. Inability to perform RAM is known as dysdiadochokinesia. This can be due to cerebellar ataxia.

Question 46

vibration

Answer 46

Place vibrating tuning fork on bony prominence

Question 47

proprioception

Answer 47

Gently hold finger or toe laterally and medially, and move it up or down, asking pt to describe the direction it is moving. Intact proprioception is a sign of normal primary sensory function.

Question 48

stereognosis

Answer 48

Ask pt to identify objects placed in his hand. Cortical sensory function test.

Question 49

two point discrimination

Answer 49

Use two ends of wooden ends of Q-tip to determine whether pt detects one or two items. Lesion in parietal cortex may impair normal two-point discrimination.

Question 50

extinction

Answer 50

Pt’s eyes closed, touch pt in same place on both sides of body, and ask whether pt detects one or two touches, and where pt was touched. Intact parietal lobe sensory function. If pt has a lesion in left parietal lobe, he may extinguish that sensation on the opposite side of the body when he is touched on both sides at the same time.

Question 51

graphethesia

Answer 51

Write a letter or number in palm of pts hand, identify it. Test if parietal lobe functioning.

Question 52

ankle clonus

Answer 52

When DTR is hyperactive, check for clonus. Clonus is the involuntary repetitive oscillation of the foot with alternating plantar flexion and dorsiflexion. Forcefully dorsiflex pt’s foot to see if it “beats” > 2 times, this suggests upper motor neuron disease.

Question 53

kernig

Answer 53

Straighten flexed knee  low back pain, Flex pt’s leg at hip and knee, then straighten leg. Back pain and resistance to straightening is positive Kernig’s sign. If finding is bilateral it strongly suggests meningeal irritation.

Question 54

brudzinski

Answer 54

Flex neck  flexion of hips and knees. Pt supine, flex pt’s neck, positive if hip and knee flexion occurs. Meningeal irritation will lead to positive Brudizinski sign.

Question 55

nuchal rigidity

Answer 55

Test for ease of neck flexion, extension and rotation