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NBCE Part III study materials
NBCE Part III study resources

NBCE Part III practice questions

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Question 1Patient History and Interviewing

On the initial intake form, the chief complaint should be recorded as:

  1. the patient's primary reason for the visit, in their own words Correct answer.
  2. a summary of the family history relevant to the patient's current illness
  3. the chiropractor's initial diagnostic impression recorded after the examination
  4. a complete inventory of every symptom the patient has experienced in the past year

Explanation

The chief complaint is a concise statement, ideally in the patient's own words, of the main reason for the encounter. It anchors the rest of the history and is not a diagnosis, a symptom inventory, or a family history summary.

Question 2Patient History and Interviewing

Which of the following is an example of an open-ended question?

  1. Have you taken ibuprofen today?
  2. Does your pain radiate into the leg?
  3. How would you describe the pain? Correct answer.
  4. Is the pain worse at night?

Explanation

Open-ended questions invite a narrative answer and cannot be satisfied with yes or no, which encourages the patient to describe the problem in their own words. The remaining items are closed questions that restrict the response.

Question 3Patient History and Interviewing

The review of systems is designed to:

  1. confirm the appropriate billing codes before the patient leaves the office
  2. document the patient's insurance carrier and preferred pharmacy
  3. screen systematically for symptoms in organ systems not yet discussed Correct answer.
  4. replace the physical examination when the schedule is running behind

Explanation

The review of systems is a structured screen of symptoms organized by organ system, capturing problems the patient has not volunteered. It complements rather than replaces the physical examination and is unrelated to billing or pharmacy data.

Question 4Patient History and Interviewing

Which historical finding most strongly warrants urgent medical referral?

  1. Stiffness that lasts for about 15 minutes after rising in the morning
  2. Tenderness reproduced by light palpation of the paraspinal muscles
  3. Weight loss of 10 kg in 3 months without trying Correct answer.
  4. Pain that is relieved by lying down

Explanation

Unintentional weight loss is a constitutional red flag that may signal malignancy, chronic infection, or endocrine disease and calls for prompt medical evaluation. Positional pain relief and reproducible soft-tissue tenderness are common mechanical findings.

Question 5Patient History and Interviewing

Which item belongs in the social history?

  1. The date of the patient's last tetanus booster
  2. Tobacco, alcohol, and recreational drug use Correct answer.
  3. The age and health status of the patient's parents and siblings
  4. The patient's prior hospitalizations and surgical procedures

Explanation

Social history covers lifestyle and environmental factors such as tobacco, alcohol, drug use, occupation, and living situation. Relatives' health, immunizations, and prior surgeries belong to family history, preventive care, and past medical history respectively.

Question 6Patient History and Interviewing

Which finding belongs in the past medical history rather than the history of present illness?

  1. The pain is described as sharp and is rated 7 out of 10
  2. The pain began after lifting a heavy box two days ago
  3. A diagnosis of type 2 diabetes made 8 years ago Correct answer.
  4. The pain is worse when the patient bends forward in the morning

Explanation

The past medical history records prior and ongoing conditions that exist independently of the current complaint. Onset, character, severity, and aggravating factors of the presenting pain all belong to the history of present illness.

Question 7Patient History and Interviewing

A 52-year-old patient reports that her mother and older sister both developed breast cancer before age 45. The most appropriate action is to:

  1. document the history and recommend she discuss screening with her primary care provider Correct answer.
  2. order breast imaging in the chiropractic office before treatment
  3. record the information and note that family history does not influence the management of musculoskeletal complaints
  4. reassure the patient that these cancers are unrelated to her presentation

Explanation

A strong family history of early-onset breast cancer is clinically meaningful even when the presenting complaint is musculoskeletal, and the appropriate response is documentation plus encouragement of appropriate medical screening. Ordering imaging or dismissing the finding both fall outside the chiropractor's role.

Question 8Patient History and Interviewing

A patient reports taking warfarin. Which aspect of the encounter is most directly affected?

  1. The patient's ability to lie prone on the treatment table for long periods
  2. The frequency of follow-up radiographs
  3. The bleeding risk associated with soft-tissue and needling procedures Correct answer.
  4. The need for a chaperone during the interview

Explanation

Warfarin is an anticoagulant, so manual soft-tissue work, instrument-assisted techniques, and needling carry an increased risk of bruising or hematoma. Positioning tolerance and imaging frequency are not the primary concerns raised by anticoagulation.

Question 9Patient History and Interviewing

Which question best assesses the quality of a patient's pain?

  1. What makes the pain better or worse?
  2. When did you first notice this pain?
  3. How long does the pain last each time it occurs?
  4. What does the pain feel like? Correct answer.

Explanation

Quality refers to the character of the sensation, such as sharp, dull, burning, or aching, and is elicited by asking what the pain feels like. Timing, duration, and modifying factors address other dimensions of the pain history.

Question 10Patient History and Interviewing

During the interview a patient pauses and looks at the floor. Which response best demonstrates active listening?

  1. Let me explain why your back pain is probably mechanical.
  2. You seem upset. Tell me more about that. Correct answer.
  3. I think we should move on to your past surgeries now.
  4. Many patients feel that way, so don't worry about it.

Explanation

Active listening involves noticing nonverbal cues and reflecting the patient's emotional state back to them, which invites further disclosure. Changing the subject, minimizing the feeling, or lecturing all shut down the patient's narrative.

Question 11Patient History and Interviewing

Which statement is an example of an empathic response?

  1. If you would just do your exercises, you would feel better.
  2. That sounds exhausting. It makes sense that you are frustrated. Correct answer.
  3. At least your pain isn't as bad as some patients I see.
  4. I know exactly how you feel because I have back pain too.

Explanation

Empathy names the patient's experience and conveys understanding without judgment or comparison. Comparing, advising prematurely, or claiming identical experience shifts the focus away from the patient.

Question 12Patient History and Interviewing

A 16-year-old presents with her mother, who asks to remain in the room during the history. The best approach is to:

  1. ask the mother to leave without explaining why
  2. state the office policy and offer the teen time alone Correct answer.
  3. conduct the entire interview with the mother present and omit sensitive questions
  4. refuse the request so the teen can speak freely

Explanation

Adolescent visits commonly use a structured approach in which the guardian is included for part of the visit and the teen is offered confidential time for sensitive questions. Explaining the policy respects both parties, whereas skipping sensitive topics or abruptly excluding the parent compromises the history.

Question 13Patient History and Interviewing

A patient who speaks limited English arrives with her adult son, who offers to interpret. The preferred approach is to:

  1. use a qualified medical interpreter rather than the son Correct answer.
  2. speak slowly and loudly and use hand gestures instead of an interpreter
  3. accept the son's help because it is faster and the patient trusts him
  4. postpone all history taking until the patient learns English

Explanation

Trained medical interpreters improve accuracy and reduce errors in interpretation, whereas family members may edit content, especially on sensitive topics. Postponing care or relying on gestures compromises the history and is not acceptable practice.

Question 14Patient History and Interviewing

Which approach is recommended when screening for intimate partner violence?

  1. Avoid the topic unless the patient has visible bruises.
  2. Ask directly in private with a nonjudgmental statement. Correct answer.
  3. Ask only if the patient brings up the subject first.
  4. Ask the partner to confirm the patient's answers.

Explanation

Screening is most effective when conducted privately, directly, and without judgment, using a routine question rather than waiting for the patient to disclose. Involving the partner or restricting screening to visible injury misses many cases and may jeopardize safety.

Question 15Patient History and Interviewing

The CAGE questionnaire is used to screen for:

  1. nicotine dependence in adolescent patients
  2. problem alcohol use Correct answer.
  3. cognitive impairment after head trauma
  4. major depressive disorder in older adults

Explanation

The CAGE instrument consists of four questions about cutting down, annoyance by criticism, guilt, and eye-openers, and is a brief screen for problem drinking. Depression, cognition, and nicotine use are assessed with other tools.

Question 16Patient History and Interviewing

An 82-year-old patient brings a bag of 11 medications from three prescribers. Which action is most important during the history?

  1. Defer the medication list to the next visit to save time
  2. Assume all listed medications are necessary and record them as given
  3. Reconcile the list for duplication and interactions Correct answer.
  4. Ask the patient to choose which medications seem most important

Explanation

Older adults frequently experience polypharmacy, and the history is the point at which duplicated agents and potentially interacting drugs are identified. Assuming, deferring, or asking the patient to prioritize medications defeats the purpose of medication reconciliation.

Question 17Patient History and Interviewing

When taking a history for an infant with a new concern, which information is most useful?

  1. Prenatal course, birth history, and feeding patterns Correct answer.
  2. The parents' insurance coverage and preferred pharmacy
  3. The parents' own childhood illnesses and school performance
  4. The infant's favorite toys and daily routine at daycare

Explanation

Perinatal and feeding information identifies risk factors such as prematurity, birth complications, and inadequate intake that directly shape the clinical picture in infants. Daycare preferences, coverage details, and parents' childhood history are not primary contributors.

Question 18Patient History and Interviewing

Which element is part of the history of present illness?

  1. The date of the patient's last dental examination
  2. The ages and health of the patient's siblings
  3. Aggravating and relieving factors Correct answer.
  4. The patient's marital status and living situation

Explanation

The history of present illness characterizes the current complaint with elements such as onset, location, quality, severity, timing, and modifying factors. Marital status is social history, siblings' health is family history, and dental visits are past history.

Question 19Patient History and Interviewing

A patient with chronic widespread pain lists symptoms across many body systems and has had multiple normal workups. Which interviewing approach is most appropriate?

  1. Acknowledge distress while keeping a structured, consistent interview Correct answer.
  2. End the visit early and refer the patient to a different chiropractor
  3. Confront the patient with the belief that the symptoms are not real
  4. Order another full round of imaging to search for a missed cause

Explanation

Patients with symptom amplification benefit from a consistent, structured interview combined with validation of their distress, which maintains the relationship while allowing focused assessment. Repeated unfocused testing, confrontation, or abrupt referral tends to escalate the cycle.

Question 20Patient History and Interviewing

A patient reports new saddle anesthesia and difficulty initiating urination. The correct action is to:

  1. Schedule a routine follow-up visit in two weeks
  2. Begin lumbar traction and reassess in three days
  3. Arrange emergency evaluation immediately Correct answer.
  4. Reassure the patient that these symptoms are common with low back pain

Explanation

Saddle anesthesia with new urinary difficulty suggests cauda equina syndrome, a surgical emergency requiring immediate evaluation. Delaying care, treating with traction, or reassuring the patient risks permanent neurologic deficit.

Question 21Patient History and Interviewing

The PHQ-2 is used to:

  1. measure functional disability from neck pain
  2. grade the severity of acute postsurgical pain
  3. screen for depressed mood and anhedonia Correct answer.
  4. assess the patient's readiness to quit smoking

Explanation

The PHQ-2 asks about depressed mood and loss of interest over the past two weeks and serves as a brief initial screen for depression. Pain grading, readiness to change, and functional disability each require different instruments.

Question 22Patient History and Interviewing

Before beginning care, the informed consent discussion should include:

  1. the fee schedule and the patient's insurance deductible
  2. the chiropractor's malpractice carrier and license number
  3. the names of all staff members who will be involved in care
  4. the risks, benefits, and reasonable alternatives to care Correct answer.

Explanation

Informed consent requires that the patient understand the nature of the proposed care, its risks and expected benefits, and the reasonable alternatives, including declining care. Financial and administrative details are handled separately and do not constitute the consent discussion.

Question 23Patient History and Interviewing

When a patient reports an allergy, the record should include:

  1. the name of the prescribing physician only
  2. the cost of the medication to the patient
  3. the pharmacy where the drug was dispensed
  4. the specific reaction and its severity Correct answer.

Explanation

An allergy entry must include the agent and the nature and severity of the reaction so that future prescribing decisions can distinguish true allergy from intolerance. Prescriber, pharmacy, and cost data do not describe the reaction itself.

Question 24Patient History and Interviewing

Which technique best confirms that a patient understands the plan discussed during the interview?

  1. Provide a printed handout and assume it was read
  2. Ask, 'Do you have any questions?' at the end of the visit
  3. Ask the patient to repeat the plan back Correct answer.
  4. Repeat the instructions several times in the same words

Explanation

Techniques such as teach-back, in which the patient restates the plan, reveal actual comprehension rather than polite agreement. Asking whether there are questions, handing out a sheet, or pure repetition do not verify understanding.

Question 25Physical Examination Procedures

Which sequence lists the correct order of the four core abdominal examination techniques?

  1. Palpation, percussion, auscultation, inspection
  2. Inspection, auscultation, percussion, palpation Correct answer.
  3. Inspection, palpation, percussion, auscultation
  4. Auscultation, inspection, palpation, percussion

Explanation

Inspection is always performed first because it establishes baseline appearance before the abdomen is disturbed. Auscultation follows inspection because percussion and palpation alter bowel motility and can artificially change bowel sound frequency. Percussion and palpation are therefore reserved for the end of the sequence.

Question 26Physical Examination Procedures

What is the normal span of liver dullness in the midclavicular line of an adult?

  1. 16 to 20 cm
  2. 12 to 16 cm
  3. 2 to 4 cm
  4. 6 to 12 cm Correct answer.

Explanation

Percussion of the liver in the midclavicular line normally yields a span of roughly 6 to 12 cm in adults. A span exceeding this range suggests hepatomegaly or downward displacement of the organ. The span is measured between the upper border of dullness in the chest and the lower border in the abdomen.

Question 27Physical Examination Procedures

The patellar tendon reflex is used most directly to assess which nerve root?

  1. C7
  2. C5
  3. L4 Correct answer.
  4. S1

Explanation

The knee jerk is mediated primarily by the L4 root through the femoral nerve. Biceps and brachioradialis reflexes assess C5-C6, the triceps reflex assesses C7, and the Achilles reflex assesses S1-S2. Matching a reflex to its root level allows localization of a radiculopathy.

Question 28Physical Examination Procedures

Tactile fremitus is increased over which of the following conditions on chest examination?

  1. Lobar consolidation Correct answer.
  2. Hyperinflated lung from emphysema
  3. Pleural effusion
  4. Pneumothorax

Explanation

Fremitus is generated by sound transmission through the airways to the chest wall and is enhanced when lung tissue becomes solid, as in lobar consolidation. Air or fluid in the pleural space and hyperinflation both act as insulators that reduce transmission. This is why fremitus is diminished with effusion, pneumothorax, and emphysema.

Question 29Physical Examination Procedures

Which finding defines orthostatic hypotension when vital signs are taken in the supine and standing positions?

  1. Systolic fall ≥20 mmHg or diastolic fall ≥10 mmHg within 3 minutes Correct answer.
  2. Systolic rise ≥20 mmHg on standing
  3. Systolic fall ≥10 mmHg or diastolic fall ≥5 mmHg within 3 minutes of quiet standing
  4. Pulse rise ≥30 beats per minute on standing

Explanation

Orthostatic hypotension is defined by a sustained drop of at least 20 mmHg systolic or at least 10 mmHg diastolic on assuming the upright posture. Measurements are compared with the supine baseline and are typically taken at one and three minutes. A compensatory pulse rise may accompany the drop but is not itself the diagnostic criterion.

Question 30Physical Examination Procedures

Where is the point of maximal impulse normally located on precordial palpation of an adult?

  1. Third intercostal space at the left sternal border
  2. Left sixth intercostal space at the anterior axillary line
  3. Fifth intercostal space at the left midclavicular line Correct answer.
  4. Second intercostal space at the right sternal border

Explanation

The apical impulse is produced by the left ventricle and is normally felt in the fifth intercostal space at the left midclavicular line. It is best appreciated with the patient supine or in the left lateral decubitus position. Displacement laterally or inferiorly suggests ventricular enlargement.

Question 31Physical Examination Procedures

Pulsus paradoxus is defined as which of the following?

  1. Alternating strong and weak pulses
  2. Systolic rise >10 mmHg on inspiration
  3. Two beats for every cardiac cycle
  4. Systolic decline >10 mmHg on inspiration Correct answer.

Explanation

A normal inspiratory decline in systolic pressure is under 10 mmHg; a decline exceeding 10 mmHg is termed pulsus paradoxus. It reflects exaggerated ventricular interdependence and is classically seen in cardiac tamponade and severe obstructive airway disease. The cuff is deflated slowly to detect the first and last Korotkoff sounds during the respiratory cycle.

Question 32Physical Examination Procedures

Which respiratory rate range is considered normal for a resting adult?

  1. 12 to 20 breaths per minute Correct answer.
  2. 4 to 8 breaths per minute
  3. 24 to 30 breaths per minute
  4. 8 to 12 breaths per minute

Explanation

Normal adult resting respiratory rate is approximately 12 to 20 breaths per minute. Rates below 12 suggest bradypnea from sedation, neurologic depression, or metabolic derangement. Rates above 20 suggest tachypnea from pulmonary, cardiac, or metabolic causes.

Question 33Physical Examination Procedures

A positive Rovsing sign is best described as which finding?

  1. Right lower quadrant pain elicited by palpating the left lower quadrant Correct answer.
  2. Right lower quadrant pain elicited by extending the right hip with the patient on the left side
  3. Periumbilical pain that increases when the patient coughs
  4. Inspiratory arrest during deep palpation beneath the right costal margin

Explanation

Rovsing sign refers to pain felt in the right lower quadrant when the left lower quadrant is palpated. The maneuver displaces colonic gas and fluid toward the inflamed appendix and peritoneum. It supports a diagnosis of acute appendicitis.

Question 34Physical Examination Procedures

Which finding constitutes a positive Murphy sign?

  1. Pain with internal rotation of the flexed right hip
  2. Rebound tenderness in the left lower quadrant
  3. Inspiratory arrest during deep palpation below the right costal margin Correct answer.
  4. Pain in the right lower quadrant when the left lower quadrant is palpated

Explanation

Murphy sign is elicited by hooking the fingers beneath the right costal margin and asking the patient to take a deep breath. The descending gallbladder contacts the examiner's hand and produces pain that halts inspiration. It suggests acute cholecystitis.

Question 35Physical Examination Procedures

A patient lying on the left side reports sharp right lower quadrant pain when the examiner passively extends the right hip. This finding is termed which sign?

  1. Pain in the right lower quadrant when the left lower quadrant is palpated
  2. Pain at the costovertebral angle with percussion
  3. Pain when the right hip is extended with the patient on the left side Correct answer.
  4. Pain with internal rotation of the flexed right hip

Explanation

This maneuver stretches the iliopsoas muscle, and reproduction of pain is the psoas sign. It suggests an inflammatory process adjacent to the muscle, classically retrocecal appendicitis. The response is pain in the right lower quadrant rather than in the hip joint itself.

Question 36Physical Examination Procedures

A pitting depression 8 mm deep that persists for 2 to 5 minutes corresponds to which grade of edema?

  1. 4+ Correct answer.
  2. 2+
  3. 1+
  4. 3+

Explanation

Pitting edema is graded by depth and duration of the depression. Grade 1+ is about 2 mm with rapid rebound, 2+ is 4 mm lasting 10 to 15 seconds, 3+ is 6 mm lasting 1 to 2 minutes, and 4+ is 8 mm lasting 2 to 5 minutes. The deepest and most sustained pitting therefore corresponds to 4+.

Question 37Physical Examination Procedures

How is costovertebral angle tenderness elicited during the physical examination?

  1. Percussion with the ulnar edge of the fist over the 12th rib angle Correct answer.
  2. Ballottement of the flank with the patient in the supine position
  3. Deep palpation of both lower abdominal quadrants simultaneously
  4. Auscultation over the renal arteries in the epigastrium during systole

Explanation

The examiner places one hand over the costovertebral angle, formed by the 12th rib and the vertebral column, and strikes it with the ulnar edge of the other fist. Reproduction of tenderness suggests renal inflammation such as pyelonephritis or nephrolithiasis. The patient is usually seated or standing so the back is accessible.

Question 38Physical Examination Procedures

A patient with left-sided hearing loss hears the Weber tone louder in the left ear. This result indicates which condition?

  1. Sensorineural hearing loss in the right ear
  2. Conductive hearing loss in the left ear Correct answer.
  3. Sensorineural hearing loss in the left ear
  4. Normal hearing bilaterally

Explanation

In the Weber test the vibrating fork is placed on the midline of the skull. Sound lateralizes to the ear with conductive loss because ambient masking is reduced, and away from the ear with sensorineural loss. Lateralization to the symptomatic ear therefore indicates a conductive deficit on that side.

Question 39Physical Examination Procedures

During a Rinne test the patient hears the tuning fork by bone conduction longer than by air conduction in the right ear. This result indicates which condition?

  1. An invalid test requiring a different tuning fork
  2. Conductive hearing loss in the right ear Correct answer.
  3. Sensorineural hearing loss in the right ear
  4. Normal hearing in the right ear

Explanation

In normal hearing and in sensorineural loss, air conduction exceeds bone conduction, giving a positive Rinne. When bone conduction is heard longer than air conduction, the Rinne is negative and indicates a conductive loss in that ear. The finding reflects impaired transmission of airborne sound through the external or middle ear.

Question 40Physical Examination Procedures

Which response is a positive Babinski sign in an adult?

  1. Plantar flexion of all toes
  2. Flexion of the great toe only
  3. Dorsiflexion of the great toe with fanning of the other toes Correct answer.
  4. Rhythmic dorsiflexion and plantar flexion of the foot

Explanation

The normal adult plantar response is flexion of the toes. Extension of the great toe with fanning of the remaining toes constitutes a positive Babinski sign. This indicates corticospinal tract dysfunction and is normal only in infants before myelination is complete.

Question 41Physical Examination Procedures

A patient sways and loses balance only when standing with feet together and eyes closed, while the same stance with eyes open is stable. This finding most likely reflects which problem?

  1. A corticospinal tract lesion producing spasticity
  2. A cerebellar hemispheric lesion
  3. Loss of proprioceptive input from the posterior columns Correct answer.
  4. Vestibular hypofunction

Explanation

The Romberg test isolates proprioceptive input by removing visual compensation. Marked instability that appears only with the eyes closed indicates impaired position sense, as in posterior column disease or severe peripheral neuropathy. A positive Romberg is not a cerebellar sign.

Question 42Physical Examination Procedures

Which finding represents a positive Kernig sign?

  1. Pain in the ipsilateral buttock when the hip is extended
  2. Flexion of the hips and knees when the neck is flexed
  3. Pain and resistance when the knee is extended with the hip flexed Correct answer.
  4. Pain in the opposite hip when the flexed knee is internally rotated

Explanation

With the patient supine, the hip is flexed to 90 degrees and the knee is then passively extended. Resistance to extension or pain in the hamstrings and low back is a positive Kernig sign. It reflects meningeal irritation and is assessed along with nuchal rigidity and Brudzinski sign.

Question 43Physical Examination Procedures

Which finding during a straight leg raise test suggests nerve root irritation?

  1. Pain in the buttock that occurs at 20 degrees of elevation
  2. Pain in the anterior thigh relieved by ankle dorsiflexion
  3. Radicular pain reproduced between 30 and 70 degrees of elevation Correct answer.
  4. Hamstring tightness reproduced only beyond 90 degrees

Explanation

In a symptomatic patient, reproduction of radiating leg pain at 30 to 70 degrees of passive elevation is consistent with lower lumbar nerve root irritation. Pain that occurs with dorsiflexion of the ankle at the point of discomfort further supports the finding. Discomfort outside this arc is usually due to hamstring tightness or other structures.

Question 44Physical Examination Procedures

The modified Allen test is performed before radial artery cannulation primarily to do which of the following?

  1. Detect compression of the brachial plexus
  2. Measure capillary refill in the fingertips
  3. Confirm collateral circulation through the ulnar artery Correct answer.
  4. Assess median nerve function in the carpal tunnel

Explanation

The examiner compresses both the radial and ulnar arteries while the patient clenches the fist, then releases only the ulnar artery. Return of color within about 5 to 15 seconds indicates adequate ulnar collateral flow. This ensures the hand remains perfused if the radial artery is cannulated or sacrificed.

Question 45Physical Examination Procedures

An auscultatory gap detected during blood pressure measurement is best described as which of the following?

  1. A systolic pressure difference between the two arms
  2. The interval between the first and second heart sounds
  3. An inspiratory fall in systolic pressure greater than 10 mmHg
  4. Disappearance of Korotkoff sounds between phase I and phase II Correct answer.

Explanation

An auscultatory gap is a silent interval after the initial Korotkoff sounds in which sounds transiently disappear before returning. It is seen in some hypertensive patients and can cause underestimation of systolic pressure if the cuff is not inflated high enough. Palpating the radial pulse to estimate inflation pressure helps avoid this error.

Question 46Physical Examination Procedures

Which condition most typically produces paradoxical (reversed) splitting of the second heart sound?

  1. Right bundle branch block
  2. Left bundle branch block Correct answer.
  3. Atrial septal defect
  4. Mitral stenosis

Explanation

Paradoxical splitting occurs when closure of the pulmonic valve is delayed enough that the order of valve closure reverses. Left bundle branch block delays left ventricular depolarization and aortic valve closure, so splitting appears on expiration and disappears on inspiration. This is the reverse of the normal respiratory pattern.

Question 47Physical Examination Procedures

A positive Castell sign (splenic percussion sign) consists of which finding?

  1. Tympany over the left lower chest that disappears on inspiration
  2. Dullness over the left lower chest that disappears on inspiration
  3. Dullness in the lowest left intercostal space that persists during inspiration Correct answer.
  4. A fluid wave transmitted across the abdomen

Explanation

The lowest left intercostal space in the anterior axillary line is percussed during quiet breathing and then during inspiration. Persistence of dullness on inspiration suggests the spleen has enlarged and displaced the resonant air-filled stomach and colon. Normally tympany replaces dullness as the lung expands and the diaphragm descends.

Question 48Physical Examination Procedures

Egophony is considered present when which of the following occurs during chest auscultation?

  1. 'Ee' is heard more clearly and loudly than normal
  2. 'Ee' is heard as 'ay' over the area being tested Correct answer.
  3. '99' becomes louder over the base of the lung
  4. Whispered words are heard distinctly over the lower lobes

Explanation

Egophony is tested by asking the patient to repeat a long 'ee' sound while the examiner auscultates. When the sound is transmitted as 'ay', increased resonance from consolidated lung is present. The other voice tests, bronchophony and whispered pectoriloquy, involve increased loudness or clarity rather than a change in vowel quality.

Question 49Physical Examination Procedures

Which finding best indicates an upper motor neuron rather than a lower motor neuron cause of facial weakness?

  1. Weakness of the entire half of the face including the forehead
  2. Loss of taste over the anterior two-thirds of the tongue
  3. Weakness of the lower face with sparing of the forehead Correct answer.
  4. Ipsilateral loss of the corneal reflex

Explanation

The upper facial muscles receive bilateral corticobulbar input, so a unilateral upper motor neuron lesion spares the forehead and eye closure. The lower facial muscles receive mainly contralateral input and are therefore weakened. Lower motor neuron (peripheral facial nerve) lesions paralyze the entire ipsilateral face.

Question 50Physical Examination Procedures

During a knee-jerk reflex examination, the patient's leg extends with a brisk but normal contraction. Which deep tendon reflex grade does this represent?

  1. 1+
  2. 0
  3. 2+ Correct answer.
  4. 3+

Explanation

Deep tendon reflexes are graded on a 0 to 4+ scale: 0 is absent, 1+ is diminished, 2+ is normal, 3+ is exaggerated without clonus, and 4+ is exaggerated with clonus. A brisk contraction with normal limb movement is recorded as 2+.