COMLEX Level 3 cheat sheet

Four core tenets: body is a unit; structure and function are reciprocally interrelated; body possesses self-regulatory mechanisms; rational treatment is based on these principles.

Somatic dysfunction (ICD-10 M99.0x) requires TART: Tissue texture change, Asymmetry, Restriction of motion, Tenderness - all four needed for the diagnosis.

Direct technique engages the restrictive barrier and moves toward it (HVLA, muscle energy, articulatory); indirect technique moves away from the barrier (counterstrain, functional, balanced ligamentous tension).

HVLA is relatively contraindicated with osteomyelitis, metastatic bone disease, fracture, severe osteoporosis, and unstable cervical spine; caution with anticoagulation and Down syndrome (atlantoaxial instability).

Muscle energy uses patient-initiated isometric or isotonic contraction against operator counterforce, typically 3–5 seconds with 3–5 repetitions, followed by reassessment.

Counterstrain places the region in a position of ease (tender point reduced ≥70%) and holds 90 seconds, then returns slowly to neutral.

Visceral and lymphatic techniques target fascial and fluid balance; lymphatic pump is avoided in acute infection with fever, DVT, and decompensated heart failure.

Cranial motion is described as a primary respiratory mechanism with a normal rate of about 10–14 cycles per minute in adults.

Cervical HVLA: screen for vertebral artery insufficiency, avoid end-range rotation-plus-extension, and use the locked-jaw or similar position to limit rotation.

Universal precautions apply to all body fluids; needlestick with hollow-bore contaminated needle: wash, report immediately, and start HIV PEP within hours (ideally <2 hours) after source testing.

Informed consent requires capacity, disclosure of risks/benefits/alternatives, comprehension, and voluntariness; documented refusal by a capacitated adult is binding.

Suture removal timing: face 4–5 days, scalp/trunk 7–10 days, extremities 10–14 days, over joints 14 days.

Joint aspiration: avoid if overlying cellulitis; send cell count with differential, crystals, Gram stain, culture; septic joint typically shows >50,000 WBC/µL with >75% neutrophils.

Lumbar puncture opening pressure normal 10–20 cm H2O; traumatic tap shows decreasing RBCs across tubes and a clearing supernatant.

Adult basic life support: compressions 100–120/min at 5–6 cm depth, ratio 30:2 single rescuer, minimize interruptions to <10 seconds.

Anaphylaxis: IM epinephrine 0.3–0.5 mg (1:1000) into the anterolateral thigh, repeated every 5–15 minutes as needed; antihistamines and steroids are adjuncts only.

Perioperative risk: stop warfarin about 5 days before elective surgery; metformin is typically held 48 hours if contrast or renal risk is present.

Central line placement: ultrasound guidance, Trendelenburg for internal jugular, confirm tip at cavoatrial junction, and rule out pneumothorax before use.

Chest pain with ST elevation: activate reperfusion immediately; door-to-balloon goal ≤90 minutes for primary PCI, or fibrinolysis within 30 minutes if PCI is unavailable.

Acute ischemic stroke: noncontrast CT first to exclude hemorrhage; IV alteplase within 4.5 hours of last known well; thrombectomy up to 24 hours in selected large-vessel occlusion.

Diabetic ketoacidosis: isotonic fluids first, insulin infusion after potassium is ≥3.3 mEq/L, and add dextrose when glucose falls below ~200–250 mg/dL.

Hyperkalemia with ECG changes: IV calcium gluconate first for membrane stabilization, then insulin/glucose, albuterol, and dialysis if refractory.

Sepsis bundle: cultures before antibiotics, broad-spectrum antibiotics within 1 hour for septic shock, 30 mL/kg crystalloid for hypotension or lactate ≥4.

Community-acquired pneumonia severity: CURB-65 (confusion, urea >7 mmol/L, respiratory rate ≥30, BP low, age ≥65) guides inpatient versus outpatient disposition.

Thyroid storm: beta-blocker, thionamide (PTU preferred), iodine at least 1 hour after thionamide, plus glucocorticoid.

Acute pancreatitis: diagnosis needs 2 of 3 - characteristic pain, lipase >3× upper limit, or imaging findings; early aggressive fluids and enteral nutrition when tolerated.

Pediatric dehydration: 20 mL/kg isotonic bolus for shock; maintenance with isotonic fluid, and correct sodium slowly (≤10 mEq/L per 24 hours) to avoid cerebral edema.

Autosomal dominant: vertical transmission, male-to-male possible; autosomal recessive: horizontal pattern, consanguinity increases risk; X-linked recessive: no male-to-male transmission, carrier females.

Hardy-Weinberg: p + q = 1 and p² + 2pq + q² = 1; carrier frequency for an autosomal recessive disease is 2pq.

Cardiac output = heart rate × stroke volume; mean arterial pressure ≈ diastolic + 1/3(systolic − diastolic); Fick principle: CO = VO2 / (CaO2 − CvO2).

Renal clearance C = (U × V) / P; inulin clearance equals GFR; PAH clearance approximates renal plasma flow.

Oxygen content = 1.34 × Hb × SaO2 + (0.003 × PaO2); a right shift of the oxyhemoglobin curve (↑CO2, ↑H+, ↑temperature, ↑2,3-BPG) releases oxygen.

Starling forces: net filtration = (Pc − Pi) − σ(πc − πi); low oncotic pressure or high hydrostatic pressure produces edema.

Antibiotic targets: 30S ribosome (aminoglycosides, tetracyclines), 50S (macrolides, chloramphenicol, clindamycin), cell wall transpeptidase (beta-lactams), DNA gyrase (fluoroquinolones).

Virchow triad: stasis, endothelial injury, hypercoagulability - the framework for venous thromboembolism risk.

Acid-base stepwise: check pH, then PaCO2, then calculate compensation; anion gap = Na − (Cl + HCO3), normal 8–12 mEq/L; delta-delta compares gap rise to bicarbonate fall.

PICO frames a clinical question: Population, Intervention, Comparison, Outcome - the first step before searching evidence.

Evidence hierarchy from strongest: systematic reviews/meta-analyses, randomized controlled trials, cohort, case-control, case series, expert opinion.

Sensitivity = TP/(TP+FN); specificity = TN/(TN+FP); a highly sensitive test is best for ruling out (SnNout), a highly specific test for ruling in (SpPin).

Positive likelihood ratio = sensitivity/(1 − specificity); negative LR = (1 − sensitivity)/specificity; LR >10 or <0.1 meaningfully shifts probability.

Number needed to treat = 1/absolute risk reduction; NNH = 1/absolute risk increase.

Relative risk comes from cohort studies; odds ratio approximates RR only when the outcome is rare (<10%).

Publication bias is assessed with a funnel plot; heterogeneity in meta-analysis is quantified by I² (I² >50% suggests substantial heterogeneity).

Quality improvement uses PDSA cycles and measures structure, process, and outcome; run charts and statistical process control distinguish signal from common-cause variation.

Maintenance of certification and CME require documented self-assessment and practice improvement activities, not just lecture attendance.

SPIKES protocol for breaking bad news: Setting, Perception, Invitation, Knowledge, Emotions/empathy, Strategy and summary.

Teach-back confirms comprehension: the patient restates the plan in their own words; a correct restatement is the check, not a yes/no question.

Ask-tell-ask elicits the patient's agenda before giving information, then verifies understanding afterward.

Chunk-and-check delivers information in small segments with comprehension checks between segments.

Motivational interviewing uses open questions, affirmations, reflections, and summaries (OARS) and rolls with resistance rather than arguing.

LEARN model for cross-cultural communication: Listen, Explain, Acknowledge, Recommend, Negotiate.

Health literacy red flags include missed appointments, medication errors, and forms filled out incorrectly; plain-language materials should target about a 6th-grade reading level.

Interpreters must be trained medical interpreters, not family members, for informed consent and sensitive discussions; document interpreter use.

Shared decision-making requires discussing options, benefits, harms, and patient values, then confirming the patient's preference.

The AOA Code of Ethics addresses patient welfare, patient autonomy, social justice, competence, and confidentiality; the patient's welfare is the primary obligation.

Informed refusal by a capacitated adult is ethically and legally binding; document capacity assessment and the discussion of risks.

HIPAA permits disclosure without authorization for treatment, payment, operations, and specific public-health or legal exceptions; minimum necessary applies.

Mandatory reporting examples: suspected child or elder abuse, certain communicable diseases, gunshot wounds in many jurisdictions, and impaired drivers in some states.

Conflict of interest requires disclosure and recusal; gifts from industry that could influence judgment should be declined or reported per institutional policy.

Impairment in a colleague: the duty is to protect patients and report through the appropriate channel (program director, physician health program) rather than to investigate personally.

Futile or non-beneficial treatment may be limited with due process; the ethical obligation is to disclose, involve palliative care, and follow institutional and state law.

Boundary violations include dual relationships; sexual contact with a current patient is always prohibited.

Research ethics: IRB approval before enrollment, and the Declaration of Helsinki governs human-subject protections.

Medicare Part A covers hospital and skilled nursing facility care; Part B covers outpatient and physician services; Part D covers outpatient prescriptions.

Medicaid is jointly funded by federal and state governments with state-set eligibility and benefits; CHIP covers children in families above Medicaid thresholds.

HEDIS measures quality at the health-plan level; the CMS Star Rating uses similar measures for Medicare Advantage.

ACOs in the Medicare Shared Savings Program accept accountability for a population's total cost and quality; shared savings are earned by beating benchmarks.

Never events (wrong-site surgery, retained foreign body, transfusion of the wrong blood type) are non-reimbursable under CMS policy.

Hospital readmission within 30 days for specified conditions triggers the Hospital Readmissions Reduction Program penalty.

Patient-centered medical home principles: accessible, continuous, coordinated, comprehensive, and team-based care with emphasis on quality and safety.

Root cause analysis follows a bad outcome; failure mode and effects analysis is prospective; both are system-level, not individual-blame, tools.

Cost-effectiveness is expressed as cost per quality-adjusted life-year (QALY); the incremental cost-effectiveness ratio compares two strategies.