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NBCE Part IV study materials
NBCE Part IV study resources

NBCE Part IV practice questions

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Question 1Case History and Patient Interview

A patient's chief complaint is best recorded as:

  1. a complete list of every symptom the patient reports that day
  2. the patient's main reason for the visit, in their own words, with its duration Correct answer.
  3. the treatment plan agreed upon with the patient at the first visit
  4. the diagnosis reached after the physical examination is completed

Explanation

The chief complaint is a concise statement of the patient's primary reason for seeking care, ideally quoted in the patient's own words and accompanied by duration. It is recorded before the examination and diagnosis, and it is not a catalogue of every symptom or a treatment plan.

Question 2Case History and Patient Interview

In the OLDCARTS mnemonic used to structure the history of present illness, what does the letter "O" represent?

  1. Outcome
  2. Onset Correct answer.
  3. Observation
  4. Occupation

Explanation

OLDCARTS stands for Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Timing, and Severity. Onset describes when and how the symptom began, such as sudden versus gradual.

Question 3Case History and Patient Interview

Which item is properly documented under past medical history?

  1. the patient's current job and work station
  2. the quality and radiation of the current headache
  3. a prior diagnosis of type 2 diabetes mellitus Correct answer.
  4. the father's history of a stroke at age 62

Explanation

Past medical history records the patient's own previous illnesses, diagnoses, and conditions, including chronic diseases such as diabetes. Symptom detail belongs in the history of present illness, family illness in family history, and employment in social history.

Question 4Case History and Patient Interview

What is the primary purpose of the review of systems?

  1. to record the findings obtained during the physical examination
  2. to screen for symptoms in body systems other than the chief complaint Correct answer.
  3. to document the illnesses that run in the patient's family
  4. to determine the billing codes that will be submitted for the visit

Explanation

The review of systems is a systematic series of questions that screens each body system for symptoms the patient may not have volunteered. It can uncover associated complaints and occult disease that the chief complaint alone would not reveal.

Question 5Case History and Patient Interview

Which of the following is an open-ended question?

  1. "Tell me about the pain you have been having." Correct answer.
  2. "Does the pain travel into your leg?"
  3. "Did you take any pain medication today?"
  4. "Is the pain sharp or dull?"

Explanation

An open-ended question invites the patient to describe the problem in their own words and does not constrain the answer. Closed questions such as the others are useful later for confirming specific details but yield only brief, directed responses.

Question 6Case History and Patient Interview

A 54-year-old patient reports mid-back pain that awakens them from sleep and has been accompanied by 8 kg of unintentional weight loss. Which historical feature most strongly suggests serious underlying disease?

  1. Pain that is relieved by lying down
  2. Unintentional weight loss occurring with night pain Correct answer.
  3. Pain that began immediately after lifting a heavy box
  4. Pain that improves temporarily after an adjustment

Explanation

Constant night pain that wakes the patient, combined with unexplained weight loss, is a recognized red-flag constellation for malignancy or infection. The history should prompt further investigation or referral rather than routine conservative care alone.

Question 7Case History and Patient Interview

A patient with acute low back pain reports numbness in the perineum and new difficulty starting urination. What is the most appropriate next step?

  1. Begin lumbar manipulation and recheck the patient in two weeks
  2. Refer the patient immediately for emergency evaluation Correct answer.
  3. Reassure the patient that these symptoms are common with muscle strain
  4. Schedule a repeat chiropractic visit in 48 hours

Explanation

Saddle anesthesia with new bladder dysfunction suggests cauda equina syndrome, a surgical emergency. Urgent referral for imaging and decompression is required, and manual therapy must be deferred.

Question 8Case History and Patient Interview

A patient reports long-term use of oral prednisone for an autoimmune condition. Which additional history is most relevant before manual therapy is considered?

  1. The patient's childhood immunization record
  2. Corticosteroid dose, duration, and prior fracture history Correct answer.
  3. The patient's usual dietary and caffeine intake
  4. The family history of hypertension and stroke

Explanation

Prolonged corticosteroid use reduces bone density and raises the risk of insufficiency fracture, including vertebral fracture. Dose, duration, and any previous fragility fracture help gauge that risk before applying manual forces.

Question 9Case History and Patient Interview

Which element of the history best helps distinguish mechanical from non-mechanical spinal pain?

  1. The family history of chronic illness
  2. The pattern of aggravating and relieving factors Correct answer.
  3. The patient's current occupation and work station
  4. The date of the last general physical examination

Explanation

Mechanical pain characteristically varies with position, movement, and loading, so the pattern of what provokes and eases it is highly informative. Non-mechanical pain tends to be constant, unvarying, and unrelated to posture or activity.

Question 10Case History and Patient Interview

A patient describes pain radiating down the posterior leg as "burning and electric." This description most suggests which type of pain?

  1. Neuropathic pain Correct answer.
  2. Local muscular strain
  3. Visceral pain from an abdominal organ
  4. Somatic referred pain from a restricted joint

Explanation

Burning, electric, shooting, or lancinating qualities follow a dermatomal or nerve distribution and point to neuropathic mechanisms such as nerve root irritation. Somatic and muscular pain are more often described as aching, deep, or cramping.

Question 11Case History and Patient Interview

A 26-year-old man reports three months of morning back stiffness that improves with exercise. Which family history finding most increases suspicion for inflammatory spondyloarthritis?

  1. A father who had a myocardial infarction
  2. A mother with postmenopausal osteoporosis
  3. A first-degree relative with ankylosing spondylitis Correct answer.
  4. A sibling with type 1 diabetes mellitus

Explanation

Ankylosing spondylitis is strongly heritable, and a first-degree relative with the disease raises the pretest probability of axial spondyloarthritis in a young patient with inflammatory-type back pain. The other relatives' conditions do not carry this association.

Question 12Case History and Patient Interview

A patient who speaks limited English presents with low back pain. What is the most appropriate approach to the interview?

  1. Skip the history and move directly to the physical examination
  2. Proceed using gestures and simple words only
  3. Ask the patient's 12-year-old child to interpret the conversation
  4. Use a trained medical interpreter for the interview Correct answer.

Explanation

Accurate history-taking requires a qualified medical interpreter, ideally in person or by dedicated telephone or video service. Untrained interpreters, especially children, introduce errors and raise confidentiality and role concerns.

Question 13Case History and Patient Interview

Which item from the past history most changes the approach to manual therapy in a patient with neck pain?

  1. An appendectomy ten years ago
  2. Extraction of the wisdom teeth
  3. A prior cervical spinal fusion Correct answer.
  4. A tonsillectomy during childhood

Explanation

Previous cervical fusion alters segmental biomechanics and introduces hardware and adjacent-level stresses, so forces and techniques must be modified. Remote abdominal, throat, and dental procedures do not affect cervical manual therapy.

Question 14Case History and Patient Interview

A 40-year-old describes a headache that reached maximum intensity within seconds and is the worst headache of their life. What does this history most suggest?

  1. Migraine without aura
  2. Cervicogenic headache arising from the upper cervical spine
  3. Subarachnoid hemorrhage requiring emergency referral Correct answer.
  4. Tension-type headache related to emotional stress

Explanation

A thunderclap headache that peaks within seconds and is described as the worst ever is the classic presentation of subarachnoid hemorrhage. It requires immediate emergency evaluation, not office-based management.

Question 15Case History and Patient Interview

When taking a history from the parent of a 6-month-old infant with unexplained irritability, which component is most important to include?

  1. The infant's preferred sleeping position only
  2. The parents' current occupations
  3. Birth history and attainment of developmental milestones Correct answer.
  4. The family's dietary and religious practices

Explanation

In infants, birth events, prematurity, neonatal complications, and the timing of developmental milestones are central to interpreting irritability and neurological signs. Parental occupation and family practices are secondary to this core pediatric history.

Question 16Case History and Patient Interview

Before beginning the patient interview, the clinician should first:

  1. ask about the patient's insurance coverage and payment method
  2. perform the orthopedic tests to focus the questions
  3. introduce themselves and explain the purpose of the interview Correct answer.
  4. record the working diagnosis in the chart

Explanation

Opening the interview with an introduction and a clear statement of purpose establishes rapport, confirms the patient's identity, and sets expectations about confidentiality and time. Administrative and diagnostic tasks follow the history, not precede it.

Question 17Case History and Patient Interview

A patient reports leg pain that increases sharply with coughing or sneezing. Which interpretation of this historical detail is most accurate?

  1. It confirms a diagnosis of lumbar spinal stenosis
  2. It indicates that the pain is of visceral origin
  3. It reliably excludes nerve root involvement
  4. It suggests a discogenic or radicular source, since the pain responds to increased intrathecal pressure Correct answer.

Explanation

Valsalva maneuvers raise intrathecal and intra-abdominal pressure, which typically aggravates disc-related and radicular pain. Provocation with coughing is a supportive, not confirmatory, historical clue and does not exclude or establish any single diagnosis alone.

Question 18Case History and Patient Interview

An 82-year-old reports dizziness on standing. Which medication history is most relevant to this complaint?

  1. A recent course of oral antibiotics
  2. Use of sedatives or antihypertensive medication Correct answer.
  3. An influenza vaccination last autumn
  4. Daily use of a vitamin C supplement

Explanation

Sedatives and antihypertensives commonly cause orthostatic symptoms and contribute to falls in older adults. Reviewing these agents, along with dose timing, is central to evaluating postural dizziness.

Question 19Case History and Patient Interview

A patient with eight weeks of low back pain states, "I'm afraid to move because I might damage my spine," and has stopped working. Which historical domain do these findings belong to?

  1. Review of systems
  2. Psychosocial yellow flags Correct answer.
  3. Past surgical history
  4. Family history

Explanation

Fear-avoidance beliefs, catastrophizing, and work loss are psychosocial yellow flags that predict chronicity and poorer outcomes. Identifying them guides education and early referral for cognitive or behavioral support.

Question 20Case History and Patient Interview

A patient begins to cry while describing years of chronic pain. What is the most appropriate response?

  1. End the interview and reschedule for another day
  2. Assure the patient that the pain will soon resolve
  3. Redirect the conversation to the physical symptoms
  4. Acknowledge the emotion and pause before continuing Correct answer.

Explanation

Acknowledging distress and allowing a brief silence conveys empathy and encourages the patient to continue sharing relevant information. Hurried redirection, premature reassurance, or terminating the interview damages rapport and loses clinically useful detail.

Question 21Case History and Patient Interview

A patient reports about 90 minutes of morning stiffness that improves with activity, along with swelling in both hands. This pattern most suggests:

  1. An acute muscle strain
  2. Inflammatory arthropathy such as rheumatoid arthritis Correct answer.
  3. Osteoarthritis of the small joints
  4. Myofascial pain syndrome

Explanation

Morning stiffness lasting longer than roughly an hour, bilateral joint involvement, and improvement with use are hallmarks of inflammatory arthritis. Osteoarthritis typically produces brief stiffness that worsens with activity.

Question 22Case History and Patient Interview

Which item is documented in the allergy section of the history?

  1. Two cups of coffee consumed each morning
  2. Hives appearing after a dose of penicillin Correct answer.
  3. The patient's father has asthma
  4. A fractured wrist sustained in childhood

Explanation

The allergy section records adverse reactions to drugs, foods, latex, and environmental agents, including the type of reaction. Prior injuries, family illness, and dietary habits belong in other history sections.

Question 23Case History and Patient Interview

An older patient with known dementia gives inconsistent answers about a recent fall. What is the best approach to the history?

  1. Rely only on the patient's answers as the sole source
  2. Proceed to examination without attempting any history
  3. Obtain collateral history from a caregiver and review prior records Correct answer.
  4. Document that no history could be obtained and stop

Explanation

When cognition limits reliability, corroborating information from a caregiver who witnessed events, plus existing records, improves accuracy and safety. The patient should still be interviewed, but the account is supplemented rather than discarded.

Question 24Case History and Patient Interview

Which historical feature most supports a cervicogenic rather than a primary headache diagnosis?

  1. Bilateral band-like pressure tightness around the head
  2. Headache reproduced by sustained neck postures and neck movement Correct answer.
  3. A visual aura that precedes the onset of pain
  4. Throbbing pain accompanied by nausea and photophobia

Explanation

Cervicogenic headache is provoked by neck posture, movement, and palpation, and it typically lacks the migrainous features of nausea, photophobia, and aura. Reproducibility with cervical provocation is the key historical discriminator.

Question 25Case History and Patient Interview

Which question is the best way to close a patient interview?

  1. "Is there anything else you think I should know?" Correct answer.
  2. "You have told me everything, correct?"
  3. "Why did you not mention this sooner?"
  4. "Will your insurance cover today's visit?"

Explanation

An open closing invitation gives the patient a final chance to raise concerns and often uncovers important information that was withheld earlier. Confirming questions, criticism, and billing matters should not be used to end the clinical interview.

Question 26Case History and Patient Interview

Which component of the case history records the patient's own description of the problem that prompted the visit?

  1. Family history
  2. Chief complaint Correct answer.
  3. Review of systems
  4. Past medical history

Explanation

The chief complaint is the patient's stated reason for seeking care, ideally recorded in the patient's own words. It anchors the rest of the interview and focuses subsequent questioning.

Question 27Case History and Patient Interview

Which question is open-ended and most likely to encourage a full narrative response?

  1. Describe what the pain feels like. Correct answer.
  2. Is the pain worse at night?
  3. Does the pain radiate to the leg?
  4. When did the pain begin?

Explanation

Open-ended questions invite explanation rather than a yes-or-no or single-fact answer. Asking the patient to describe the pain encourages a broader, patient-centered response.

Question 28Case History and Patient Interview

Which item belongs in the social history?

  1. Surgical procedure dates
  2. Childhood immunization dates
  3. Occupation and tobacco use Correct answer.
  4. Current blood pressure

Explanation

The social history documents lifestyle, occupation, living situation, and substance use such as tobacco and alcohol. These factors can influence risk, treatment, and counseling.

Question 29Case History and Patient Interview

A patient reports two episodes of collapse. Which follow-up question best helps determine whether the episodes were true syncope?

  1. Did you have a headache afterward?
  2. Were you standing when it happened?
  3. Have you ever fainted before?
  4. Were you completely unconscious and did you recover fully? Correct answer.

Explanation

True syncope involves transient loss of consciousness with rapid onset, short duration, and complete recovery. Confirming complete unconsciousness and full recovery helps distinguish syncope from falls, seizures, or presyncope.

Question 30Case History and Patient Interview

A patient's history reveals daily alcohol use. Which additional detail most affects the clinical interpretation of this finding?

  1. Favorite type of beverage
  2. Age at first drink
  3. Family opinion of the drinking
  4. Quantity and pattern of use Correct answer.

Explanation

The amount, frequency, and pattern of alcohol use determine risk for withdrawal, organ injury, and interactions with treatment. Beverage preference or family opinion does not quantify exposure.

Question 31Case History and Patient Interview

An older adult reports a fall. Which historical detail most helps identify a cause?

  1. Whether there was a warning sensation or loss of consciousness Correct answer.
  2. Whether the patient was wearing shoes
  3. The time of day the fall occurred
  4. The type of flooring in the room

Explanation

A prodrome, palpitations, or loss of consciousness suggests a cardiovascular or neurologic cause rather than a simple mechanical trip. These features guide the need for further evaluation.

Question 32Case History and Patient Interview

A patient reports pain that began around the umbilicus and later localized to the right lower quadrant. This pattern most suggests which type of pain?

  1. Neuropathic pain from nerve irritation
  2. Psychogenic pain without tissue injury
  3. Referred somatic pain from a distant structure
  4. Visceral pain localizing to parietal peritoneum Correct answer.

Explanation

Early visceral pain is often poorly localized and midline, while later involvement of the parietal peritoneum produces sharper, localized pain. This migration is a classic historical pattern in acute appendicitis.

Question 33Case History and Patient Interview

A patient seeking workers' compensation describes pain that began after a lifting injury. Which interview approach is most appropriate?

  1. Record only findings related to the injury
  2. Ask about symptoms and function neutrally Correct answer.
  3. Postpone history taking until litigation ends
  4. Confront the patient about possible exaggeration

Explanation

Compensation or litigation status can influence reporting but does not justify adversarial questioning. A neutral, thorough history of symptoms and functional limitations preserves rapport and accuracy.

Question 34Case History and Patient Interview

A patient reports a headache and says light makes it worse. Which follow-up question best assesses associated symptoms?

  1. Does anyone in your family get headaches?
  2. Do you have nausea or vomiting with the headache? Correct answer.
  3. Have you had your vision checked?
  4. What is your occupation?

Explanation

Nausea and vomiting are associated symptoms that help classify headache syndromes, such as migraine. Occupational, vision, and family history questions are relevant but do not assess the current associated symptoms.

Question 35Physical Examination Procedures

When measuring blood pressure in an adult, the bladder of the cuff should encircle approximately what percentage of the upper arm circumference?

  1. About 80%
  2. About 100%
  3. About 60%
  4. About 40% Correct answer.

Explanation

The cuff bladder must be long enough to compress the brachial artery adequately. A bladder length of about 75% to 100% of arm circumference is recommended, with approximately 80% commonly cited as adequate. A cuff that is too small can produce falsely elevated readings.

Question 36Physical Examination Procedures

The radial pulse is best palpated at which location?

  1. Posterior to the medial malleolus
  2. Medial aspect of the wrist at the ulnar styloid
  3. Lateral aspect of the wrist near the radial styloid Correct answer.
  4. Anterior antecubital fossa medial to the biceps tendon

Explanation

The radial artery passes along the lateral aspect of the wrist near the radial styloid, where it is superficial and easily compressed. The ulnar artery is palpated on the medial wrist, while the brachial artery is in the antecubital fossa. The posterior tibial artery is palpated behind the medial malleolus.

Question 37Physical Examination Procedures

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

  1. 8 to 11 breaths per minute
  2. 4 to 8 breaths per minute
  3. 24 to 30 breaths per minute
  4. 12 to 20 breaths per minute Correct answer.

Explanation

A resting adult typically breathes about 12 to 20 times per minute. Rates below 12 are bradynea and rates above 20 are tachypnea in adults. The other listed ranges fall outside the usual adult normal range.

Question 38Physical Examination Procedures

Which temperature site generally yields a lower reading than the oral site in an adult?

  1. Tympanic
  2. Temporal artery
  3. Axillary Correct answer.
  4. Rectal

Explanation

Axillary temperature is typically lower than oral temperature because the thermometer is placed in a cooler surface area with less direct mucosal contact. Rectal temperature is generally higher than oral temperature. Tympanic and temporal artery readings are usually closer to core temperature.

Question 39Physical Examination Procedures

Which event marks the beginning of the stance phase in a normal gait cycle?

  1. Maximum knee flexion during swing
  2. Initial heel contact with the ground Correct answer.
  3. Toe-off of the contralateral foot
  4. Mid-swing of the ipsilateral limb

Explanation

The stance phase begins when the foot first contacts the ground, usually with the heel. It continues through weight acceptance and single-limb support until toe-off. Swing phase then begins as the foot leaves the ground.

Question 40Physical Examination Procedures

Pitting edema that leaves a 4-mm depression is graded as which level?

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

Explanation

Pitting edema is commonly graded by depth of the depression: 2 mm is 1+, 4 mm is 2+, 6 mm is 3+, and 8 mm is 4+. A 4-mm depression therefore corresponds to 2+ edema. The grade reflects the severity of interstitial fluid accumulation.

Question 41Physical Examination Procedures

Percussion over the normal gas-filled abdomen typically produces which sound?

  1. Flatness
  2. Resonance
  3. Tympany Correct answer.
  4. Dullness

Explanation

Gas-filled bowel and stomach produce a drum-like, high-pitched tympanic note on percussion. Dullness is heard over solid organs or fluid, and flatness is heard over very dense tissue such as muscle. Resonance is typical of normal air-filled lung.

Question 42Physical Examination Procedures

The diaphragm of the stethoscope is best suited for detecting which type of sound?

  1. Low-pitched murmurs
  2. High-pitched sounds Correct answer.
  3. Venous hums
  4. Third heart sounds

Explanation

The diaphragm filters out low-frequency vibrations and is used to hear high-pitched sounds such as breath sounds and bowel clicks. The bell is better for low-pitched sounds such as some heart murmurs and third heart sounds. Choosing the correct chest piece improves auscultatory accuracy.

Question 43Physical Examination Procedures

The first Korotkoff sound heard while deflating a blood pressure cuff corresponds to which pressure?

  1. Systolic pressure Correct answer.
  2. Diastolic pressure
  3. Pulse pressure
  4. Mean arterial pressure

Explanation

Korotkoff phase I is the first clear tapping sound heard as the cuff deflates and corresponds to systolic pressure. Diastolic pressure is typically recorded at phase V, when the sounds disappear. Pulse pressure and mean arterial pressure are calculated values, not direct Korotkoff endpoints.

Question 44Physical Examination Procedures

A pulse deficit is determined by comparing which two measurements?

  1. Resting and postexercise rates
  2. Radial and brachial rates
  3. Apical and radial rates Correct answer.
  4. Systolic and diastolic pressures

Explanation

A pulse deficit exists when the apical heart rate exceeds the peripheral radial rate, indicating that some ventricular contractions do not produce a palpable peripheral pulse. It is calculated by simultaneous apical and radial auscultation and palpation. This finding is classically associated with atrial fibrillation and other arrhythmias.

Question 45Physical Examination Procedures

A respiratory pattern characterized by gradually increasing then decreasing depth followed by apnea is called?

  1. Kussmaul respiration
  2. Cheyne-Stokes respiration Correct answer.
  3. Biot respiration
  4. Ataxic respiration

Explanation

Cheyne-Stokes respiration consists of cyclic crescendo-decrescendo breathing followed by periods of apnea. Biot respiration is irregular with abrupt pauses, and Kussmaul respiration is deep and rapid without apnea. Ataxic respiration is disorganized and irregular.

Question 46Physical Examination Procedures

Orthostatic vital signs are most appropriately obtained in which sequence?

  1. Supine, then standing at 1 to 3 minutes Correct answer.
  2. Seated, then supine after five minutes of rest
  3. Standing, then supine after ten minutes of rest
  4. Supine, then seated after ten minutes of rest

Explanation

Orthostatic vital signs are measured after the patient has rested supine and then assumes a standing position. Repeating blood pressure and pulse after 1 and 3 minutes of standing helps detect orthostatic hypotension. Comparing supine and standing values assesses the cardiovascular response to posture change.

Question 47Physical Examination Procedures

Which bedside test best assesses cranial nerve II?

  1. Pupillary light reflex only
  2. Visual acuity and fields Correct answer.
  3. Corneal and gag reflexes
  4. Facial sensation and taste

Explanation

Cranial nerve II is the optic nerve, so visual acuity and confrontation visual field testing directly assess its function. The pupillary light reflex involves both CN II and CN III and is not a test of vision alone. Facial sensation, taste, corneal reflex, and gag reflex assess other cranial nerves.

Question 48Physical Examination Procedures

A deep tendon reflex that is present but diminished compared with normal is graded as?

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

Explanation

Deep tendon reflexes are graded from 0 to 4+: 0 is absent, 1+ is diminished, 2+ is normal, 3+ is brisk, and 4+ is hyperactive with clonus. A reflex that is present but reduced therefore receives a grade of 1+. Grading helps localize neurologic dysfunction.

Question 49Physical Examination Procedures

The C6 dermatome is best tested by assessing sensation over which area?

  1. Medial arm and axilla
  2. Thumb and lateral forearm Correct answer.
  3. Little finger and medial forearm
  4. Middle finger and posterior forearm

Explanation

The C6 dermatome includes the thumb and lateral forearm. The C7 dermatome centers on the middle finger, and C8 includes the little finger and medial forearm. The medial arm and axilla are more characteristic of the T1 dermatome.

Question 50Physical Examination Procedures

A positive straight leg raise test for lumbar nerve root irritation is suggested by which finding?

  1. Hamstring tightness at 90 degrees of hip flexion
  2. Radicular pain at 30 to 70 degrees Correct answer.
  3. Increased pain with knee flexion
  4. Pain confined to the buttock

Explanation

A positive straight leg raise reproduces radicular pain in the lower extremity, usually between 30 and 70 degrees of hip flexion. Pain that is only in the buttock or that is caused by hamstring tightness at end range is less specific. The test is used to assess nerve root irritation, often from disc pathology.