ECOS II Midterm Practice

Questions (PART 1)
 DISCLAIMER:
If there are discrepancies between our
slides and what was presented to you in
lecture/lab, please refer to your lecture
and lab slides.

For clarifications on specific questions, please

reach out to the tutor who wrote the question.
Lecture Questions
Approach to Differential
Diagnosis
Lauren Cheng & Joanna Yuen
1. What are the 5 Osteopathic models that help you
develop a broad differential diagnosis?
1. What are the 5 Osteopathic models that help you
develop a broad differential diagnosis?

- Biomechanical
- Neurologic
- Respiratory-circulatory
- Metabolic-Energetic-Immune
- Biopsychosocial/Behavioral

Explanation/answer on slide 20 of the lecture.

2. What does the acronym VINDICATE stand for?
2. What does the acronym VINDICATE stand for?

- Vascular
- Inflammatory
- Neoplastic
- Degenerative/Deficiency
- Idiopathic/Intoxication
- Congenital
- Autoimmune/Allergic
- Traumatic
- Endocrine

Explanation/answer on slide 20 of the lecture.

3. A 30 year old female presents to the clinic complaining of low back pain that
she describes as sharp and shooting. She states the pain began when she was
lifting boxes for her move to a new apartment. She states the pain is constant
and radiates to her left great toe. She has tried Ibuprofen, but states that it
hasn’t helped much. Straining and lifting has made the pain worse. The patient
has a history of smoking 1 ppd/10 years and has a mother and father that are
alive and have HTN. Which of the diagnoses below would be classified as a
secondary diagnosis for this patient?

a. Herniated disc
b. History of smoking
c. Somatic dysfunction of lumbar region
d. Sciatica
 3. A 30 year old female presents to the clinic complaining of low back pain that
she describes as sharp and shooting. She states the pain began when she was
lifting boxes for her move to a new apartment. She states the pain is constant
and radiates to her left great toe. She has tried Ibuprofen, but states that it
hasn’t helped much. Straining and lifting has made the pain worse. The patient
has a history of smoking 1 ppd/10 years and has a mother and father that are
alive and have HTN. Which of the diagnoses below would be classified as a
secondary diagnosis for this patient?
a. Herniated disc
b. History of smoking (family history of HTN would have counted as well if it was included as a choice)
c. Somatic dysfunction of lumbar region
d. Sciatica

A secondary diagnosis is any chronic, ongoing, or new diagnosis. Examples would include a history of smoking, history of
HTN, family history of colon cancer, something found on the physical exam such as a heart murmur etc.
4. What is the correct way to write a somatic
dysfunction in the assessment section of the SOAP
note?
a. T7 E Rotated R Sidebent R
b. Hypertonic paraspinal muscles T1-T5
c. Somatic dysfunction of cervical region
d. Somatic dysfunction of the knee
e. Somatic dysfunction of the supraspinatus muscle
4. What is the correct way to write a somatic
dysfunction in the assessment section of the SOAP
note?
a. T7 E Rotated R Sidebent R
b. Hypertonic paraspinal muscles T1-T5
c. Somatic dysfunction of cervical region
d. Somatic dysfunction of the knee
e. Somatic dysfunction of the supraspinatus muscle

Somatic dysfunction must be written by region. Ex’s (head, cervical, thoracic, rib cage, lumbar, upper
extremity, lower extremity, abdomen)
5. Which of the choices below would fall under the
Respiratory-Circulatory Osteopathic model?
a. Scoliosis
b. Vertebral artery occlusion
c. Cauda equina
d. Somatic dysfunction of the thoracic region
e. Depression
f. Myeloma
5. Which of the choices below would fall under the
Respiratory-Circulatory Osteopathic model?
a. Scoliosis
b. Vertebral artery occlusion
c. Cauda equina
d. Somatic dysfunction of the thoracic region
e. Depression
f. Myeloma

Vertebral artery occlusion disrupts circulation. Scoliosis, somatic dysfunctions, and myeloma fall under
biomechanical, cauda equina falls under neurologic, and depression falls under
biopsychosocial/behavioral.
Feel free to reach out to me if you have any
questions. Good luck on your studying!

lauren.cheng@kansascity.edu
1. Pt is a cis-gender male who presents to clinic c/o sharp, stabbing
lumbar back that is felt down his left leg. He also reports reduced
sensation around the buttock and bowel and bladder incontinence.
Which of the 5 osteopathic models would their diagnosis likely fall
under?

a) Biomechanical
b) Biopsychosocial/Behavioral
c) Neurologic
d) Respiratory-Circulatory
e) Metabolic-Energy-Immune
1. Pt is a cis-gender male who presents to clinic c/o sharp, stabbing
lumbar back that is felt down his left leg. He also reports reduced
sensation around the buttock and bowel and bladder incontinence.
Which of the 5 osteopathic models would their diagnosis likely fall
under?

a) Biomechanical
b) Biopsychosocial/Behavioral
c) Neurologic
d) Respiratory-Circulatory
e) Metabolic-Energy-Immune
2. Pt presents with low back pain. What steps would you use to rule
in/rule out differential diagnoses?

a) CC → ROS → Diagnostic testing

b) Diagnostic testing
c) History then physical
d) Physical then diagnostic testing
e) CC/demographic → HPI/ROS/history → Physical/Diagnostic testing
f) Physical exam
2. Pt presents with low back pain. What steps would you use to rule
in/rule out differential diagnoses?

a) CC → ROS → Diagnostic testing

b) Diagnostic testing
c) History then physical
d) Physical then diagnostic testing
e) CC/demographic → HPI/ROS/history → Physical/Diagnostic
testing
f) Physical exam
3. Which of the following does NOT show proper nomenclature
when documenting an OSE in a SOAP note?

a) Right hypertonic upper trapezius muscle

b) Cervical lymphatic congestion
c) T5-9 NRlSr
d) Knee pain
3. Which of the following does NOT show proper nomenclature
when documenting an OSE in a SOAP note?

a) Right hypertonic upper trapezius muscle

b) Cervical lymphatic congestion
c) T5-9 NRlSr
d) Knee pain
Refer to specific examples here. If the link doesn’t work, go to your
ECOS II homepage, click on ‘Helpful documents’, search and open
‘ECOS 2 SOAP Note OSE Documentation Examples’ to view,
4. True or False: There does not need to be a treatment plan
documented for a secondary diagnosis when writing a SOAP
note.

a) True
b) False
4. True or False: There does not need to be a treatment plan
documented for a secondary diagnosis when writing a SOAP
note.

a) True
b) False
5. Which of the following diagnoses do not belong under the the
Metabolic-Energetic-Immune framework of the 5 Osteopathic
Models?

a) Scoliosis
b) Nephrolithiasis
c) Herpes zoster
d) Irritable bowel disease
e) Ankylosing spondylitis
5. Which of the following diagnoses do not belong under the the
Metabolic-Energetic-Immune framework of the 5 Osteopathic
Models?

a) Scoliosis
b) Nephrolithiasis
c) Herpes zoster
d) Irritable bowel disease
e) Ankylosing spondylitis
Email me with any questions!
Good luck on the exam :)

Joanna Yuen
joanna.yuen@kansascity.edu
Lymphatics

Allison Melnick & Rebecca Roberts

1. Which of the following is NOT considered
organized lymphatic tissues/organs?
a. Spleen
b. Thyroid
c. Thymus
d. Liver
e. Appendix
1. Which of the following is NOT considered
organized lymphatic tissues/organs?
a. Spleen
b. Thyroid
c. Thymus
d. Liver
e. Appendix
2. One of the lymphatic system’s role is to aid in
nutrition. Absorption of which of the following
macronutrients is dependent on the lymphatic
system?
a. Carbohydrates
b. Protein
c. Fat
d. All of the above
2. One of the lymphatic system’s role is to aid in
nutrition. Absorption of which of the following
macronutrients is dependent on the lymphatic
system?
a. Carbohydrates
b. Protein
c. Fat
d. All of the above
3. Which of the following tissues contains lymphatic
vessels?
a. Epidermis
b. Endomysium of muscle
c. Cartilage
d. Bone marrow
e. Dermis
3. Which of the following tissues contains lymphatic
vessels?
a. Epidermis
b. Endomysium of muscle
c. Cartilage
d. Bone marrow
e. Dermis
4. The right lymphatic duct originates from the
cisterna chyli as a dilation at L1-2 level.
a. True
b. False
4. The right lymphatic duct originates from the
cisterna chyli as a dilation at L1-2 level.
a. True
b. False
5. If the left supraclavicular lymph node is found to
be swollen, indurated, non-painful, and fixed on
examination, what would your main concern be?
a. Infection
b. Malignancy
c. Somatic dysfunction
d. This is a normal finding
5. If the left supraclavicular lymph node is found to
be swollen, indurated, non-painful, and fixed on
examination, what would your main concern be?
a. Infection
b. Malignancy
c. Somatic dysfunction
d. This is a normal finding
GOOD LUCK!

Let me know if you have any questions or need any clarification! My email is
allison.melnick@kansascity.edu
Lymph fluid will move through this part of the lymphatic
system immediately after draining into the collecting
vessels:
A. Terminal lymphatics

B. Lymph nodes

C. Venous system

D. Afferent lymph vessels

E. Efferent lymph vessels

Lymph fluid will move through this part of the lymphatic
system immediately after draining into the collecting
vessels:
A. Terminal lymphatics

B. Lymph nodes

C. Venous system

D. Afferent lymph vessels

E. Efferent lymph vessels

A 52 yo female patient presents with complaint of left arm swelling. Her
history is significant for metastatic breast cancer for which she underwent
successful mastectomy with lymph node removal four weeks ago. Which
lymphatic trunk is most likely affected?
A. Lumbar

B. Jugular

C. Subclavian

D. Bronchomediastinal

E. Intestinal
A 52 yo female patient presents with complaint of left arm swelling. Her
history is significant for metastatic breast cancer for which she underwent
successful mastectomy with lymph node removal four weeks ago. Which
lymphatic trunk is most likely affected?
A. Lumbar

B. Jugular

C. Subclavian

D. Bronchomediastinal

E. Intestinal
Which of the following is an accurate description of the
spleen?

A. Located in the right upper abdominal quadrant

B. Serves as the maturation site for T-cells

C. Nonessential in adult immune function

D. Largest single mass of lymphoid tissue

E. Normally palpable on physical exam

Which of the following is an accurate description of the
spleen?

A. Located in the right upper abdominal quadrant - liver

B. Serves as the maturation site for T-cells - thymus

C. Nonessential in adult immune function - tonsils, thymus (may have little function)

D. Largest single mass of lymphoid tissue

E. Normally palpable on physical exam - liver

Refer to lecture slides for appendix
and GALT
A 73 yo male patient presents to your clinic with an upper respiratory
infection for the last week. You decide to treat him with lymphatic OMT to
alleviate his symptoms. Which of the following general approaches would
be the most appropriate first step in treating this patient?
A. Maximize diaphragmatic functions

B. Mobilize target tissue fluids

C. Open pathways to remove restriction to flow

D. Increase pressure differentials

E. Prep region of somatic dysfunction with MFR

A 73 yo male patient presents to your clinic with an upper respiratory
infection for the last week. You decide to treat him with lymphatic OMT to
alleviate his symptoms. Which of the following general approaches would
be the most appropriate first step in treating this patient?
A. Maximize diaphragmatic functions

B. Mobilize target tissue fluids

C. Open pathways to remove restriction to flow

D. Increase pressure differentials

E. Prep region of somatic dysfunction with MFR

Which of the following clinical conditions would produce an
absolute contraindication for lymphatic OMT?

A. COPD

B. Cancer

C. Pregnancy

D. Chronic infection

E. Anuria
Which of the following clinical conditions would produce an
absolute contraindication for lymphatic OMT?

A. COPD

B. Cancer

C. Pregnancy

D. Chronic infection

E. Anuria
Good luck on the exam! Please email me with any questions or concerns at
rebecca.roberts@kansascity.edu
Approach to Endocrine
Complaint 1
Sanjana Janumpally

Natasha Subbarao
A patient comes in for a wellness visit, and you are concerned he may be
diabetic due to increased polydipsia and polyuria. You let him know you
want to order a HbA1c. He asks what the HbA1c measures. You let him
know that the HbA1c is which of the following?

A. It measures the average blood insulin for the past 3 months

B. It measures the average blood glucose levels for the past 3 months
C. It measures the average blood glucose levels after an overnight fast
D. It measures the average blood glucose levels at the time of the test taken
A patient comes in for a wellness visit, and you are concerned he may be
diabetic due to increased polydipsia and polyuria. You let him know you
want to order a HbA1c. He asks what the HbA1c measures. You let him
know that the HbA1c is which of the following?

A. It measures the average blood insulin for the past 3 months

B. It measures the average blood glucose levels for the past 3 months
C. It measures the average blood glucose levels after an overnight fast
D. It measures the average blood glucose levels at the time of the test taken
You diagnosed a patient with diabetes mellitus recently. How
often should you check the HbA1c?

A. 4 months initially, then 8 months when it is stable

B. 6 months initially, then 3 months when it is stable
C. 3 months initially, then 6 months when it is stable
D. 6 months initially, then 12 months when it is stable
You diagnosed a patient with diabetes mellitus recently. How
often should you check the HbA1c?

A. 4 months initially, then 8 months when it is stable

B. 6 months initially, then 3 months when it is stable
C. 3 months initially, then 6 months when it is stable
D. 6 months initially, then 12 months when it is stable
A 45-year-old man comes to the physician because of a 4-month history of increased
urinary frequency. He wakes up several times a night to urinate and feels fatigued
during the day. Physical examination shows patches of velvety hyperpigmentation in
the axillae and on the posterior neck. Laboratory evaluation in this patient is most likely
to show which of the following findings?

A) Random glucose = 179

B) HbA1c = 6.3%
C) Fasting glucose = 122
D) 2-hour glucose = 210 on oral glucose tolerance test
A 45-year-old man comes to the physician because of a 4-month history of increased
urinary frequency. He wakes up several times a night to urinate and feels fatigued
during the day. Physical examination shows patches of velvety hyperpigmentation in
the axillae and on the posterior neck. Laboratory evaluation in this patient is most likely
to show which of the following findings?

A) Random glucose = 179

B) HbA1c = 6.3%
C) Fasting glucose = 122
D) 2-hour glucose = 210 on oral glucose tolerance test
A 24-year-old male comes to the physician for his follow-up visit
regarding his Type 1 diabetes mellitus. The physician notes that
his glucose levels have been well controlled, but he would like
to evaluate for one of the following autoimmune conditions:

A. Lupus
B. Multiple sclerosis
C. Autoimmune thyroiditis
D. Rheumatoid arthritis
A 24-year-old male comes to the physician for his follow-up visit
regarding his Type 1 diabetes mellitus. The physician notes that
his glucose levels have been well controlled, but he would like
to evaluate for one of the following autoimmune conditions:

A. Lupus
B. Multiple sclerosis
C. Autoimmune thyroiditis
D. Rheumatoid arthritis
A 18-year-old male comes into the clinic with adrenergic
symptoms. Which of the following is one of the symptoms?

A. Paresthesias
B. Tremor
C. Sweating
D. Hunger
A 18-year-old male comes into the clinic with adrenergic
symptoms. Which of the following is one of the symptoms?

A. Paresthesias
B. Tremor
C. Sweating
D. Hunger
Good luck! Please reach out with any questions

sanjana.janumpally@kansascity.edu
1. A 43 year old female patient presents to your office complaining of blurry vision for
the last 2 days. On the ROS, she states she has lost about 7 lbs recently and has been
urinating more frequently. You find her HBA1C to be above 6.5%. As part of your
physical exam you should inspect which of the following in particular:

a. Fingers of the hands

b. Spine
c. Foot
d. Knee
A 43 year old female patient presents to your office complaining of blurry vision for the last
2 days. On the ROS, she states she has lost about 7 lbs recently and has been urinating more
frequently. You find her HBA1C to be above 6.5%. As part of your physical exam you should
inspect which of the following:

a. Fingers of the hands

b. Spine
c. Foot
d. Knee
2. A 17 year old diabetic male patient is brought in by his mother
after he was found unresponsive in his room. When assessing his
mental status, he is unable to tell you where he is. The first thing
you should consider as part of your differential is:
a. Trauma - The patient must have hit his head.
b. Hypoglycemia - The patient must have taken too much insulin.
c. Drug Overdose
d. Hypertension
A 17 year old diabetic male patient is brought in by his mother after
he was found unresponsive in his room. When assessing his mental
status, he is unable to tell you where he is. The first thing you
should consider as part of your differential is:
a. Trauma - The patient must have hit his head.
b. Hypoglycemia - The patient must have taken too much insulin.
c. Drug Overdose
d. Hypertension
3. A 30 year old female patient presents to your office trying to
establish care. You note her BMI to be 28. She also has a blood
pressure of 151/91. On physical exam you note a black velvety
band of skin on the back of her neck. This finding is known as:
a. Dermal Candidiasis
b. Skin ulceration
c. Acanthosis Nigricans
d. Melanoma
A 30 year old female patient presents to your office trying to
establish care. You note her BMI to be 28. She also has a blood
pressure of 151/91. On physical exam you note a black velvety
band of skin on the back of her neck. This finding is known as:
a. Dermal Candidiasis
b. Skin ulceration
c. Acanthosis Nigricans
d. Melanoma
4. A 67 year old male patient is brought to the ER via EMS after family
members noticed he had been feeling weak and fatigued. His caretakers
also noticed that he had been drinking a lot of water and urinating more
frequently. As a result of this dehydration, you expect to find the following
on exam:
a. Decreased skin turgor
b. Decreased tendon reflexes
c. Decreased heart rate
d. Increased blood pressure
A 67 year old male patient is brought to the ER via EMS after family
members noticed he had been feeling weak and fatigued. His caretakers
also noticed that he had been drinking a lot of water and urinating more
frequently. As a result of this dehydration, you expect to find the following
on exam:
a. Decreased skin turgor
b. Decreased tendon reflexes
c. Decreased heart rate
d. Increased blood pressure
5. A 27 year old male patient presents for wellness check. He states he has not
been to a doctor in 5 years. He also notes recently he has been feeling more
thirsty and urinating more frequently. You order a HbA1C. Which one of the
following criteria is not necessary to make a diagnosis of diabetes:
a. Central Obesity - a waistline of greater than 40 inches
b. Fasting glucose greater than 100
c. Capillary refill time
d. Blood pressure greater than 130/85
5. A 27 year old male patient presents for wellness check. He states he has not
been to a doctor in 5 years. He also notes recently he has been feeling more
thirsty and urinating more frequently. You order a HbA1C. Which one of the
following criteria is not necessary to make a diagnosis of diabetes:
a. Central Obesity - a waistline of greater than 40 inches
b. Fasting glucose greater than 100
c. Capillary refill time
d. Blood pressure greater than 130/85
Good luck! Please feel free to email me with any
questions at natasha.subbarao@kansascity.edu
Approach to Endocrine
Complaint 2
Parker Howe

Rose Beranek
A 40 y/o woman presents to your office with complaints of 3
months of worsening fatigue and cold intolerance.
Examination of the neck shows a nontender enlarged and firm
thyroid. Based on these presenting symptoms and history,
which is the most likely diagnosis?
a. Hashimoto’s Thyroiditis
b. Myocardial Infarction
c. Diabetes Mellitus Type 2
d. Grave’s Disease
A 40 y/o woman presents to your office with complaints of 3
months of worsening fatigue and cold intolerance.
Examination of the neck shows a nontender enlarged and firm
thyroid. Based on these presenting symptoms and history,
which is the most likely diagnosis?
a. Hashimoto’s Thyroiditis
(Explanation on next slide)
b. Myocardial Infarction
c. Diabetes Mellitus Type 2
d. Grave’s Disease
A 37 y/o woman presents to a physician after a 4 month history of fatigue
and a 15 pound weight loss. On physical exam, the physician notes that the
patient appears to have “bulging eyes” and tachycardia. Suspecting the
cause of these symptoms to be Grave’s Disease, the physician orders labs.
What finding in the table would the physician most likely expect to see if
the patient does in fact have Grave’s disease?

a. A
b. B TSH T3/T4
c. C A ↑ ↓ ↑= higher than normal
d. D
↓= lower than normal
B ↓ ↓

C ↓ ↑

D ↑ ↑
A 37 y/o woman presents to a physician after a 4 month history of fatigue
and a 15 pound weight loss. On physical exam, the physician notes that the
patient appears to have “bulging eyes” and tachycardia. Suspecting the
cause of these symptoms to be Grave’s Disease, the physician orders labs.
What finding in the table would the physician most likely expect to see if
the patient does in fact have Grave’s disease?

a. A
b. B TSH T3/T4
c. C (Explanation on ↑= higher than normal
A ↑ ↓
next slide)
↓= lower than normal
d. D B ↓ ↓

C ↓ ↑

D ↑ ↑
A medical student is evaluating a 50 year old male patient. When a blood
pressure cuff is inflated on the patient’s left arm, the patient experiences a
muscular spasm and contraction in their left wrist. This astute student
recognizes this clinical sign as an indication that the patient likely has low
levels of calcium. What is this clinical sign called?

a. Lhermitte’s Phenomenon
b. Brudzinski’s Sign
c. Chvostek’s Sign
d. Trousseau’s Sign
A medical student is evaluating a 50 year old male patient. When a blood
pressure cuff is inflated on the patient’s left arm, the patient experiences a
muscular spasm and contraction in their left wrist. This astute student
recognizes this clinical sign as an indication that the patient likely has low
levels of calcium. What is this clinical sign called?
a. Lhermitte’s Phenomenon
b. Brudzinski’s Sign
c. Chvostek’s Sign
d. Trousseau’s Sign
A 57 y/o male patient with inflammatory bowel disease is
treated with glucocorticoids to help him manage his disease
symptoms. The patient presents today with complains of
weight gain in his abdomen, easy bruising, purple abdominal
striae, and depression. Recognizing that these symptoms may
be side effects of this patients glucocorticoid prescription,
what name could the physician use to describe this
constellation of symptoms?

a. Iatrogenic Hypercortisolism
b. Iatrogenic Hypocortisolism
c. Iatrogenic Hyperthyroidism
d. Iatrogenic Hyperparathyroidism
A 57 y/o male patient with inflammatory bowel disease is
treated with glucocorticoids to help him manage his disease
symptoms. The patient presents today with complains of
weight gain in his abdomen, easy bruising, purple abdominal
striae, and depression. Recognizing that these symptoms may
be side effects of this patients glucocorticoid prescription,
what name could the physician use to describe this
constellation of symptoms?
a. Iatrogenic Hypercortisolism (explanation on next
slide)
b. Iatrogenic Hypocortisolism
c. Iatrogenic Hyperthyroidism
d. Iatrogenic Hyperparathyroidism
A 45 y/o women presents to a physician complaining of
fatigue, unexplained weight loss, and abdominal pain. On
questioning, the patient admits to having intense salt cravings
recently. On physical exam, the patients blood pressure is
90/50, and there are areas of intense skin hyperpigmentation.
What is the most likely diagnosis?

a. Type 2 diabetes
b. Addison’s Disease
c. Meniere’s Disease
d. Hypothyroidism
A 45 y/o women presents to a physician complaining of
fatigue, unexplained weight loss, and abdominal pain. On
questioning, the patient admits to having intense salt cravings
recently. On physical exam, the patients blood pressure is
90/50, and there are areas of intense skin hyperpigmentation.
What is the most likely diagnosis?

a. Type 2 diabetes
b. Addison’s Disease (explanation on next slide)
c. Meniere’s Disease
d. Hypothyroidism
Best of luck on your exam! Please reach out should you have
any questions: parker.howe@kansascity.edu
Which of the follow is not one of the 3 main
mechanisms of endocrine pathology?
A. Hormone excess
B. Hormone deficiency
C. Hormone resistance
D. Hormone breakdown
Which of the follow is not one of the 3 main
mechanisms of endocrine pathology?
A. Hormone excess
B. Hormone deficiency
C. Hormone resistance
D. Hormone breakdown
A 62 year old male patient is brought to the ED by his wife. The patient’s wife tell you that
the patient hasn’t been acting like himself for the past few days, and the patient seems
confused as to where he is. She says that the reason she brought him is because he has
been in extraordinary pain the past few hours and that there was some blood in his urine. As
you go to grab and ultrasound machine the patient leans over and vomits all over the floor.
You order some labs to confirm the diagnosis. What is your top differential diagnosis?

A. Appendicitis
B. Dehydration secondary to blood loss
C. Primary hyperparathyroidism
D. Food poisoning
E. Pancreatitis
A 62 year old male patient is brought to the ED by his wife. The patient’s wife tell you that
the patient hasn’t been acting like himself for the past few days, and the patient seems
confused as to where he is. She says that the reason she brought him is because he has
been in extraordinary pain the past few hours and that there was some blood in his urine. As
you go to grab and ultrasound machine the patient leans over and vomits all over the floor.
You order some labs to confirm the diagnosis. What is your top differential diagnosis?

A. Appendicitis
B. Dehydration secondary to blood loss
C. Primary hyperparathyroidism
D. Food poisoning
E. Pancreatitis

See next slide for explanation

“Painful bones, renal stones, abdominal groans, and psychic moans” is a key phrase to remember for
primary hyperparathyroidism.

Renal stones: Patients will often present with some of the worst pain of their life as the stones pass
through ureters. In the urine you may see fragments of stones and you often times will see blood.

Painful bones: Osteoporosis, osteitis fibrosis cystica, etc. Our patient did not have this presentation.

Abdominal moans: This can be pain, nausea, vomiting, diarrhea, etc. Our patient presented with
vomiting.

Psychic moans: Any number of psychiatric disorders. Depression, anxiety, confusion, stupor, coma, etc.
Our patient presenting with a change in personality/behavior and confusion.

Some of the other answer choices can present in similar ways as our patient did, but try to keep in mind
that constellation of symptoms you can see in hyperparathyroidism to help narrow down your
diagnosis!
Which of the following is true about calcium and
parathyroid hormone? (Select all that apply)
A. Increased parathyroid hormone increases serum calcium
B. Increased parathyroid hormone decreases serum calcium
C. Increased calcium decreased parathyroid hormone
D. Decreased calcium increases parathyroid hormone
E. Increased calcium increases parathyroid hormone
F. Decreased calcium decreases parathyroid hormone
Which of the following is true about calcium and
parathyroid hormone? (Select all that apply)
A. Increased parathyroid hormone increases serum calcium
B. Increased parathyroid hormone decreases serum calcium
C. Increased calcium decreased parathyroid hormone
D. Decreased calcium increases parathyroid hormone
E. Increased calcium increases parathyroid hormone
F. Decreased calcium decreases parathyroid hormone

PTH helps control calcium regulation. If calcium levels are low, PTH will be released in order to increase
calcium levels. If calcium levels are too high, PTH release will be turned off so that calcium levels will
drop.
A 35 year old female presents to your office complaining of dizziness and fatigue. She notices that
it happens more often when she stands up after sitting or laying down. When you inquire about her
diet and water intake, she states that she drinks close to 64 oz of water each day. She says that she
usually eats well but recently she’s been craving fast food, especially extra crispy and extra salty
fries from McDonald’s. You draw some blood work from her and send it off to get analyzed. When it
comes back, you are surprised to note that her sodium and glucose levels are low, and you are
concerned about her high potassium levels. What is a likely diagnosis for your patient?

A. Diabetes mellitus
B. Dehydration
C. Hyperthyroidism
D. Pregnancy
E. Adrenal insufficiency
A 35 year old female presents to your office complaining of dizziness and fatigue. She notices that
it happens more often when she stands up after sitting or laying down. When you inquire about her
diet and water intake, she states that she drinks close to 64 oz of water each day. She says that she
usually eats well but recently she’s been craving fast food, especially extra crispy and extra salty
fries from McDonald’s. You draw some blood work from her and send it off to get analyzed. When it
comes back, you are surprised to note that her sodium and glucose levels are low, and you are
concerned about her high potassium levels. What is a likely diagnosis for your patient?

A. Diabetes mellitus- Glucose would be high,

polyuria, polydipsia, polyphagia
B. Dehydration- Drinking sufficient water but
could check mucus membranes, skin turgor, etc
C. Hyperthyroidism- Heat intolerance, weight loss,
tachycardia, hyperactivity, etc
D. Pregnancy- Possible for further workup but
symptoms fit other cause better
E. Adrenal insufficiency
Which of the following are all signs of
hypothyroidism?
A. Hyperreflexia, tachycardia, change in menses, weight loss
B. Alopecia, dry skin, edema, change in menses
C. Fatigue, dry skin, feeling hot, weight gain
D. Constipation, palpitations, eyelid retraction
E. Goiter, change in menses, weight gain, irritability
Which of the following are all signs of
hypothyroidism?
A. Hyperreflexia, tachycardia, change in menses, weight loss
B. Alopecia, dry skin, edema, change in menses
C. Fatigue, dry skin, feeling hot, weight gain
D. Constipation, palpitations, eyelid retraction
E. Goiter, change in menses, weight gain, irritability

Hypothyroidism: Fatigue, weakness, dry skin, feeling cold, hair loss, constipation, weight gain, change in
menses, dry coarse cool skin, myxedema, alopecia, edema, hyporeflexia

Hyperthyroidism: Hyperactivity,irritability, heat intolerance, palpitations, weight loss w increased

appetite, decreased menses, tachycardia, tremor, goiter, warm moist skin, eyelid retraction,
,hyperreflexia
Please reach out if you have any questions!

Rose Beranek

rosemary.beranek@kansascity.edu
Approach to ENT Complaint

Lauren Cheng & Rebecca Roberts

1. Which of the choices below are hearing tests that
can be done in an ENT exam?
a. Whisper pectoriloquy
b. Finger Rub test
c. Whisper test
d. Romberg test
e. Finger-to-nose test
1. Which of the choices below are hearing tests that
can be done in an ENT exam?
a. Whisper pectoriloquy
b. Finger Rub test
c. Whisper test
d. Romberg test
e. Finger-to-nose test
2. Which of the choices below raises suspicion for a
bacterial sinusitis?
a. Double sickening
b. Tonsillar exudate
c. Absence of cough
d. Conjunctivitis
e. Hoarseness
2. Which of the choices below raises suspicion for a
bacterial sinusitis?
a. Double sickening
b. Tonsillar exudate
c. Absence of cough
d. Conjunctivitis
e. Hoarseness
3. Patient presents with a bulging and red tympanic
membrane. Their tympanic membrane also has
reduced mobility. Which of the choices below is the
most likely diagnosis?
a. Serous Otitis Media
b. Normal TM
c. Acute Otitis Media
d. Otosclerosis
e. Otitis Externa
3. Patient presents with a bulging and red tympanic
membrane. Their tympanic membrane also has
reduced mobility. Which of the choices below is the
most likely diagnosis?
a. Serous Otitis Media
b. Normal TM
c. Acute Otitis Media
d. Otosclerosis
e. Otitis Externa
4. Which of the choices below describes a progressive
hearing loss associated with abnormal bone growth
around the stapes bone?
a. Otitis Externa
b. Otosclerosis
c. Acute suppurative Otitis Media
d. Multiple sclerosis
e. Meniere disease
4. Which of the choices below describes a progressive
hearing loss associated with abnormal bone growth
around the stapes bone?
a. Otitis Externa
b. Otosclerosis
c. Acute suppurative Otitis Media
d. Multiple sclerosis
e. Meniere disease
5. Which of the choices below is a cause of
conductive hearing loss and what would be the
corresponding findings on a Rinne test?
a. Meniere Disease; Bone conduction > air conduction
b. Cerumen impaction; Lateralizes to the affected size
c. Middle ear fluid; Bone conduction > air conduction
d. Ototoxic drugs; Lateralizes to the side opposite the affected ear
e. Hereditary; Air conduction > bone conduction
5. Which of the choices below is a cause of conductive hearing loss and what
would be the corresponding finding on a Rinne test?
a. Meniere Disease; Bone conduction > air conduction
b. Cerumen impaction; Lateralizes to the affected size
c. Middle ear fluid; Bone conduction > air conduction
d. Ototoxic drugs; Lateralizes to the side opposite the affected ear
e. Hereditary; Air conduction > bone conduction
Feel free to email me if you have any questions. Good
luck studying!

lauren.cheng@kansascity.edu
Which of the following is NOT a structure you would need
to evaluate during an ENT exam?
A. Lymph nodes

B. Gingiva

C. Turbinates

D. Thyroid

E. Esophagus
Which of the following is NOT a structure you would need
to evaluate during an ENT exam?
A. Lymph nodes

B. Gingiva

C. Turbinates

D. Thyroid

E. Esophagus
Of the following symptoms, which would most indicate a
bacterial pharyngitis?
A. Hearing loss

B. Coryza

C. Conjunctivitis

D. Tonsillar exudate

E. Low-grade fever
Of the following symptoms, which would most indicate a
bacterial pharyngitis?
A. Hearing loss

B. Coryza

C. Conjunctivitis

D. Tonsillar exudate

E. Low-grade fever
A 34yo patient presents complaining that they are having a harder time hearing in the last few
weeks than they used to. As part of your ENT exam, you perform the Weber-Rinne test. The test
finds that when the tuning fork is placed on the top of the head, it’s heard better in the right ear.
Further testing reveals that the patient hears the tuning fork longer when held in the air next to the
ear on the left side, while the tuning fork is heard longer against the bone of the mastoid process on
the right ear. These findings would suggest which most likely etiology?
A. Trauma

B. Meniere disease

C. Excessive movement of the ossicles

D. Ototoxic drugs

E. Hereditary hearing loss

A 34yo patient presents complaining that they are having a harder time hearing in the last few
weeks than they used to. As part of your ENT exam, you perform the Weber-Rinne test. The test
finds that when the tuning fork is placed on the top of the head, it’s heard better in the right ear.
Further testing reveals that the patient hears the tuning fork longer when held in the air next to the
ear on the left side, while the tuning fork is heard longer against the bone of the mastoid process on
the right ear. These findings would suggest which most likely etiology?
A. Trauma

B. Meniere disease

C. Excessive movement of the ossicles

D. Ototoxic drugs

E. Hereditary hearing loss

A 12yo male patient presents with rapid onset of sore throat and difficulty speaking. The patient
appears very sick on general inspection. Physical exam reveals a high fever and drooling. A lateral
neck x-ray confirms the most likely diagnosis of:

A. Croup

B. Rhinosinusitis

C. Bacterial pharyngitis

D. Epiglottitis

E. Bacterial sinusitis
A 12yo male patient presents with rapid onset of sore throat and difficulty speaking. The patient
appears very sick on general inspection. Physical exam reveals a high fever and drooling. A lateral
neck x-ray confirms the most likely diagnosis of:

A. Croup

B. Rhinosinusitis

C. Bacterial pharyngitis

D. Epiglottitis

E. Bacterial sinusitis
A patient presents complaining of dizziness for the last two months. Based on their history, you
suspect Meniere’s disease. What information, if included in their history, would support this
diagnosis?

A. They are over 60 years old

B. Performing the Dix-Hallpike maneuver reproduced their symptoms

C. Dizziness is triggered by changes in position

D. They had a recent sinus infection

E. Associated with fluctuating hearing loss

A patient presents complaining of dizziness for the last two months. Based on their history, you
suspect Meniere’s disease. What information, if included in their history, would support this
diagnosis?

A. They are over 60 years old

B. Performing the Dix-Hallpike maneuver reproduced their symptoms

C. Dizziness is triggered by changes in position

D. They had a recent sinus infection

E. Associated with fluctuating hearing loss

Good luck on the exam! Please email me with any questions or concerns at
rebecca.roberts@kansascity.edu
Autonomics/Chapman
Points
Sahaam Mirza
Angad Salh
A patient comes in with a complaint of pain in a very specific spot on
their leg. The patient describes this pain as very sharp (10/10) when it
first started but now has become more manageable (2/10). What
aspect of the nociceptive theory of facilitation is this an example of?

A - Habituation
B - Sensitization
C - Facilitation
D - Desensitization
A patient comes in with a complaint of pain in a very specific spot on
their leg. The patient describes this pain as very sharp (10/10) when it
first started but now has become more manageable (2/10). What
aspect of the nociceptive theory of facilitation is this an example of?

A - Habituation -- The process of decreasing response of a neural pathway with a continuous stimulation
B - Sensitization
C - Facilitation
D - Desensitization
The AOA definition of facilitation is maintenance of a pool of neurons
in a state of subthreshold excitation.” Which one of the answer choices
does not contribute to maintenance of facilitation?

A - Sustained increase in afferent input

B -Aberrant patterns of afferent input
C - Changes within the participating neurons themselves
D - None of these contribute to maintenance of facilitation
E- All of these contribute to maintenance of facilitation
The AOA definition of facilitation is maintenance of a pool of neurons
in a state of subthreshold excitation.” Which one of the answer choices
does not contribute to maintenance of facilitation?

A - Sustained increase in afferent input

B -Aberrant patterns of afferent input
C - Changes within the participating neurons themselves
D - None of these contribute to maintenance of facilitation
E- All of these contribute to maintenance of facilitation
An infant sees a burning hot stove and as any logical and curious would,
she puts her hand on the stove. The baby immediately pulls her hands
away and starts crying. What reflex caused her to pull her hand away?

A- Somatosomatic
B - Somatovisceral
C - Viscerovisceral
D - Viscerosomatic
An infant sees a burning hot stove and as any logical and curious would,
she puts her hand on the stove. Realizing it is burning hot the baby
immediately pulls her hands away and starts crying. What reflex is this?

A- Somatosomatic
B - Somatovisceral
C - Viscerovisceral
D - Viscerosomatic
A 27 year old non-binary patient comes in with complaint of a
feeling of food getting stuck in their stomach when they got
their flu vaccine. What kind of reflex is this?

A - somatogastric
B - somatoadrenal
C - Somatocardiac
D - viscerovisceral
A 27 year old non-binary patient comes in with complaint of a
feeling of food getting stuck in their stomach when they got
their flu vaccine. What kind of reflex is this?

A - somatogastric
B - somatoadrenal
C - Somatocardiac
D - viscerovisceral

The pain from the site of injection, caused

the peristalsis of the intestines to
stop.
What spinal cord level supplies sympathetic innervation to the
Upper esophagus?

A - T5-T10
B - T1-T4
C - C4-C5
D - T9-T11
What spinal cord level supplies sympathetic innervation to the
Upper esophagus?

A - T5-T10
B - T1-T4
C - C4-C5
D - T9-T11

Look on slides 40-47 of this lecture for all the viscerosomatic reflex spinal levels!!!!
Email me with questions if you have any!

Angad.salh@kansascity.edu
A 50 year old female comes into clinic who complains that her
heart rate will rise when she has pain in her knee due to
inflammation. As an astute medical student, you recognize this
as what kind of reflex?

a. Somatoadrenal reflex
b. Somatocardiac reflex
c. Somatogastric reflex
d. Sympathetic reflex
A 50 year old female comes into clinic who complains that her
heart rate will rise when she has pain in her right knee due to
inflammation (which has been a chronic condition). As an
astute medical student, you recognize this as what kind of
reflex?

a. Somatoadrenal reflex
b. Somatocardiac reflex -> BP and HR are increased
when a noxious stimulus
c. Somatogastric reflex
d. Sympathetic reflex
A 70 year old man who has a history of smoking a pack per day
for 50 years comes into clinic with chronic cough. He states
that there are spots of blood when he coughs, especially in the
mornings. You perform a TART screen and find paraspinal
hypertonicity. Which vertebral levels are you most likely to find
this for the sympathetics?

a. T1-T7
b. T1-T6
c. T5-T10
d. T2-T7
A 70 year old man who has a history of smoking a pack per day
for 50 years comes into clinic with chronic cough. He states
that there are spots of blood when he coughs, especially in the
mornings. You perform a TART screen and find paraspinal
hypertonicity. Which vertebral levels are you most likely to find
this for the sympathetics?

a. T1-T7 -> The sympathetics reflex levels for the lungs are from T1-T7. Make sure to have
these down as they show up on almost all ECOS tests.
b. T1-T6 -> Heart
c. T5-T10 -> Adrenal Glands
d. T2-T7 -> Upper Extremities
Who was the first person to describe the Chapmans Points?

a. Frank Chapman
b. Dr. Zaremski
c. Irvin Korr
d. Stedman Denslow
e. Charles Owens
Who was the first person to describe the Chapmans Points?

a. Frank Chapman
b. Dr. Zaremski
c. Irvin Korr
d. Stedman Denslow
e. Charles Owens
A 60 year old male comes in with chest pain and claims that
there is a radiating pain in his left arm. Where would you
expect to find an Anterior Chapman Point?

a. Umbilicus
b. 8 ICS on the right
c. Near the ASIS
d. 2nd ICS on the left
A 60 year old male comes in with chest pain and claims that
there is a radiating pain in his left arm. Where would you
expect to find an Anterior Chapman Point?

a. Umbilicus -> Bladder

b. 8 ICS on the right -> Small Intestine
c. Near the ASIS
d. 2nd ICS on the left -> Heart
A 70 year old women comes in with chronic cough. She states
that she been smoking a pack per day since she was 20. You
suspect she could have lung cancer. Where would you expect
to see a Chapman's point?

a. One inch to the right and one inch superior of the umbilicus
b. 3 ICS
c. 6 ICS on the right
d. Tip of Rib 12 on the right
A 70 year old women comes in with chronic cough. She states
that she been smoking a pack per day since she was 20. You
suspect she could have lung cancer. Where would you expect
to see a Chapman's point?

a. One inch to the right and one inch superior of the umbilicus -> Kidney
b. 3 ICS -> Lung
c. 6 ICS on the right -> Stomach peristalsis
d. Tip of Rib 12 on the right -> Appendix
Good luck!

Contact me if you have questions:

Sahaam.mirza@kansascity.edu
Lab Questions
Lymphatics Lab

Elizabeth Straus

Rose Beranek
A 54 year old male presents to your office complaining of fever,
headache, rhinorrhea, and fatigue. You decide to perform a
lymphatic treatment on the patient. What would be your first
step?
a. Evaluate and treat craniocervical and thoracolumbar myofascial pathways
b. Open the thoracic inlet
c. Perform rib raising
d. Mobilize target tissues
A 54 year old male presents to your office complaining of fever,
headache, rhinorrhea, and fatigue. You decide to perform a
lymphatic treatment on the patient. What would be your first
step?
a. Evaluate and treat craniocervical and thoracolumbar myofascial pathways- this would be
your second step
b. Open the thoracic inlet- always, always open the thoracic inlet first!!
c. Perform rib raising
d. Mobilize target tissues- you could do this after opening the inet and the second step
The same 54 year old male from the previous question, after a
thorough PMH was obtained, reveals he was previously
diagnosed with COPD 5 years prior. Which of the following
treatments would be contraindicated in this patient?
a. Abdominal pump
b. Rib raising
c. Tapotement
d. Thoracic Pump
The same 54 year old male from the previous question, after a
thorough PMH was obtained, reveals he was previously
diagnosed with COPD 5 years prior. Which of the following
treatments would be contraindicated in this patient?
a. Abdominal pump
b. Rib raising
c. Tapotement
d. Thoracic Pump- remember, it is just the
vacuum associated with the COPD risk
You decide to perform a lymphatic exam on a patient. After
opening the thoracic inlet, you evaluate the central
myofascial pathways. If the patient has a compensated Zink
pattern, which of the following patterns would be correct?
a. R/L/R/L
b. R/R/L/L
c. L/L/R/R
d. L/R/L/R
You decide to perform a lymphatic exam on a patient. After
opening the thoracic inlet, you evaluate the central
myofascial pathways. If the patient has a compensated Zink
pattern, which of the following patterns would be correct?
a. R/L/R/L
b. R/R/L/L
c. L/L/R/R
d. L/R/L/R

Bonus question: which one is the most common?

L/R/L/R. This question may seem easy, but it’s very important to know and understand Zink patterns
A 24 year old nonbinary college student comes to your office
complaining of fever, a sore throat, and a “fullness” of their head. You
believe the patient is suffering from an upper respiratory infection. You
open the thoracic inlet and treat the myofascial pathways. You decide
next to perform a thoracic pump. Which of the following correctly
describes the steps for this treatment?
a. The patient should be supine, with the physician at the head of the bed. Physician should apply a
rhythmic pumping at the end of exhalation at a rate of 120x/min.
b. The patient should be supine, with the physician at the head of the bed. Physician should apply a
rhythmic pumping at the end of inhalation at a rate of 20-30x/min.
c. The patient should be supine, with the physician at the head of the bed. Physician should apply a
rhythmic pumping at the end of inhalation at a rate of 120x/min.
d. The patient should be supine, with the physician at the head of the bed. Physician should apply a
rhythmic pumping at the end of exhalation at a rate of 20-30x/min.
A 24 year old nonbinary college student comes to your office
complaining of fever, a sore throat, and a “fullness” of their head. You
believe the patient is suffering from an upper respiratory infection. You
open the thoracic inlet and treat the myofascial pathways. You decide
next to perform a thoracic pump. Which of the following correctly
describes the steps for this treatment?
a. The patient should be supine, with the physician at the head of the bed. Physician should apply
a rhythmic pumping at the end of exhalation at a rate of 120x/min.
b. The patient should be supine, with the physician at the head of the bed. Physician should apply a
rhythmic pumping at the end of inhalation at a rate of 20-30x/min.
c. The patient should be supine, with the physician at the head of the bed. Physician should apply a
rhythmic pumping at the end of inhalation at a rate of 120x/min.
d. The patient should be supine, with the physician at the head of the bed. Physician should apply a
rhythmic pumping at the end of exhalation at a rate of 20-30x/min.
 a. The patient should be supine, with the physician at the head of the bed. Physician should apply
a a rhythmic pumping at the end of exhalation at a rate of 120x/min.

It’s very important to be extra aware of the rates of all of the different pumps. The thoracic pump is
during exhalation and NOT inhalation.

Bonus question: which pump is the slowest at 20-30x/min?

Abdominal pump!
Which of the following is NOT considered a principle of
treatment when considering the lymphatics?
a. Open pathways to remove restriction flow
b. Mobilize targeted tissues
c. Evaluate central myofascial pathways
d. Increase pressure differentials or transmit motion
 Which of the following is NOT considered a principle of
treatment when considering the lymphatics?
a. Open pathways to remove restriction flow
b. Mobilize targeted tissues
c. Evaluate central myofascial pathways- this is a principle of DIAGNOSIS. There are four
principles of diagnosis and four principles of treatment. Know them and know the correct order
of both.
d. Increase pressure differentials or transmit motion
Email me if you have any questions and good luck this semester!

elizabeth.straus@kansascity.edu
Which of the following is not the name of a junction
where you screen for lymphatic OMT?
A. Craniocervical
B. Cervicothoracic
C. Thoracolumbar
D. Lumbosacral
Which of the following is not the name of a junction
where you screen for lymphatic OMT?
A. Craniocervical
B. Cervicothoracic
C. Thoracolumbar
D. Lumbosacral

The last region of lumbar OMT screening is the lumbopelvic region. This is an important distinction
because you screen on the posterolateral portion of the innominates instead of posteriorly on the
sacrum.
When describing lymphatic OMT, which statement is
correct?
A. Treating lymphatics requires a direct technique that can use MET. It requires the physician to
move the fascia into the restrictive barrier.
B. Treating lymphatics requires an indirect technique that can use BLT. It requires the physician to
move the fascia away from the restrictive barrier and into a position of ease.
C. Treating lymphatics can utilize either an indirect or direct technique and can utilize MFR, ST, or
ART. This may vary between patients or be due to physician preference.
D. Treating lymphatics is a direct technique that uses HVLA. You want to force the lymphatic fluid
into the restrictive barrier in order to optimize flow.
When describing lymphatic OMT, which statement is
correct?
A. Treating lymphatics requires a direct technique that can use MET. It requires the physician to
move the fascia into the restrictive barrier.
B. Treating lymphatics requires an indirect technique that can use BLT. It requires the physician to
move the fascia away from the restrictive barrier and into a position of ease.
C. Treating lymphatics can utilize either an indirect or direct technique and can utilize MFR, ST, or
ART. This may vary between patients or be due to physician preference.
D. Treating lymphatics is a direct technique that uses HVLA. You want to force the lymphatic fluid
into the restrictive barrier in order to optimize flow.

Lymphatic OMT is a myofascial release technique that can utilize either direct or indirect motion
using MFR, ST, or ART.. The physician can also choose to use additional release enhancing
maneuvers.
Which of the following is an incorrect step in doming
the thoracic diaphragm in lymphatic OMT?
A. Place thumbs inferior to the xiphoid process with thumbs facing cephalad
B. On exhalation, push thumbs posteriorly and superiorly
C. At the end of every exhalation, release thumbs and allow the patient to full inhale
D. Repeat 3-5 times until effective treatment
Which of the following is an incorrect step in doming
the thoracic diaphragm in lymphatic OMT?
A. Place thumbs inferior to the xiphoid process
with thumbs facing cephalad
B. On exhalation, push thumbs posteriorly and
superiorly
C. Release thumbs and allow the patient to
full inhale
D. Repeat 3-5 times until effective treatment

You don’t want to release your thumbs. As

the patient inhales you want to resist
inhalation
Which of the following is not a regional collection
site for lymph node drainage?
A. Achilles region
B. Antecubital fossa
C. Inguinal region
D. Popliteal space
E. Posterior axillary fold
Which of the following is not a regional collection
site for lymph node drainage?
A. Achilles region
B. Antecubital fossa
C. Inguinal region
D. Popliteal space
E. Posterior axillary fold

See next slide for description

Don’t forget some of these less common
regions! We all know to check head and neck,
supraclavicular, and epigastric regions for
lymph nodes.

Don’t forget about collecting regions in the

upper and lower extremities. Lymph will
collect here before draining into more major
collecting ducts.

The lower extremities and the upper left half

of the body will drain into the cisterna chyli to
the thoracic duct while the right upper half of
the body, heart, and most of the lungs will
drain into the right thoracic duct
What does rib raising do?

A. Help normalize the sympathetic nervous system

B. Helps to “turn on” the sympathetic nervous system
C. Helps to “turn off” the sympathetic nervous system
D. Help normalize the parasympathetic nervous system
E. Helps to “turn on” the parasympathetic nervous system
F. Helps to “turn off” the parasympathetic nervous system
What does rib raising do?

A. Help normalize the sympathetic nervous system

B. Helps to “turn on” the sympathetic nervous system
C. Helps to “turn off” the sympathetic nervous system
D. Help normalize the parasympathetic nervous system
E. Helps to “turn on” the parasympathetic nervous system
F. Helps to “turn off” the parasympathetic nervous system

It’s important to understand that techniques like rib raising or sacral rocking don’t “turn on” or
“turn off” either part of the nervous system. These techniques try to help bring things back to a
baseline or normal tone. That’s to say: If you perform rib raising and it calms down sympathetic
tone, that doesn’t mean that you’re amping up parasympathetic tone at the same time.
Feel free to reach out if you have any questions or
need further clarification!

Rose Beranek

rosemary.beranek@kansascity.edu
Cervical HVLA Lab

Sam Heywood and Allison Melnick

1. Your great aunt Sally comes to you asking about her neck feeling tight. Since you learned
cervical HVLA recently you want to do some neck cracking. You do your TART screen of the
cervical region and find C5 F RlSl. You notice that the rotation has a much harder endpoint. What
is your treatment position?

A. C5 F RrSl

B. C5 F RlSr

C. C5 F RrSr

D. C5 E RrSl

E. C5 E RlSr

F. C5 E RrSr
1. Your great aunt Sally comes to you asking about her neck feeling tight. Since you learned
cervical HVLA recently you want to do some neck cracking. You do your TART screen of the
cervical region and find C5 F RlSl. You notice that the rotation has a much harder endpoint. What
is your treatment position?

A. C5 F RrSl

B. C5 F RlSr

C. C5 F RrSr

D. C5 E RrSl

E. C5 E RlSr

F. C5 E RrSr Since this is a rotation emphasis, the

patient is placed in the restrictive barrier of
rotation, while placing side-bending in the
position of ease
2. Your Uncle Doug is so impressed with how you treated Aunt Sally that he eagerly pushes her
away and sits on your OMM table. His neck has also been hurting him near the skull. You do your
TART screen and you diagnose him as OA F RrSl. What is the correct HVLA thrust direction?

A. Medially, Anteriorly, Superiorly

B. Laterally, Anteriorly, Superiorly

C. Medially, Posteriorly, Inferiorly

D. Laterally, Posteriorly, Inferiorly

2. Your Uncle Doug is so impressed with how you treated Aunt Sally that he eagerly pushes her
away and sits on your OMM table. His neck has also been hurting him near the skull. You do your
TART screen and you diagnose him as OA F RrSl. What is the correct HVLA thrust direction?

A. Medially, Anteriorly, Superiorly

B. Laterally, Anteriorly, Superiorly

C. Medially, Posteriorly, Inferiorly

D. Laterally, Posteriorly, Inferiorly

Remember this is all one fluid motion

3. Cousin Larry is flabbergasted as to how much you’ve learned so far in medical school. Surprisingly
his neck is hurting too. As you perform your TART screen you notice that C3 has a hard end feel on the
right and doesn’t like to go into extension. What is your diagnosis?

A. C3 E RlSl

B. C3 F RrSr

C. C3 E RlSr

D. C3 F RlSl
3. Cousin Larry is flabbergasted as to how much you’ve learned so far in medical school. Surprisingly
his neck is hurting too. As you perform your TART screen you notice that C3 has a hard end feel on the
right and prefers flexion. What is your diagnosis?

A. C3 E RlSl

B. C3 F RrSr - flexion since it likes to go into that direction, and with a hard end feel on the right C3 is
rotated to the right. You can assume that side-bending will be to the right as well.

C. C3 E RlSr

D. C3 F RlSl
4. Match the correct letter to the Step number for HVLA technique.

1. A. Diagnose SD correctly

2. B. Release enhancing maneuver

3. C. Return patient to neutral

4. D. Localize to the segment

5. E. Corrective force

6. F. Reassess

7. G. Soft tissue preparation

8. H. Accumulate forces
4. Match the correct letter to the Step number for HVLA technique.

1. A A. Diagnose SD correctly

2. G B. Release enhancing maneuver

3. D C. Return patient to neutral

4. B D. Localize to the segment

5. H E. Corrective force

6. E F. Reassess

7. C G. Soft tissue preparation

8. F H. Accumulate forces
5. Where should the lateral thrust be directed towards when treating a C2 somatic dysfunction with
HVLA?

A. Straight across the cervical region

B. Superiorly toward the cranium

C. Towards the eye

D. Down toward the opposite shoulder

5. Where should the lateral thrust be directed towards when treating a C2 somatic dysfunction with
HVLA?

A. Straight across the cervical region

B. Superiorly toward the cranium

C. Towards the eye

D. Down toward the opposite shoulder

You will do great!
Email me if you
have any questions
Sam Heywood

samuel.heywood@kansascity.edu
1. You have been practicing your cervical HVLA techniques in
lab and feel confident you can use your skills to help
alleviate your roommates neck pain. What will you do first
after correctly diagnosing the somatic dysfunction?
a. Localize the segment and engage the restrictive barrier
b. Ask the patient to breathe and relax
c. Perform a direct techniche, such as muscle energy
d. Soft tissue preparation, such as MFR
1. You have been practicing your cervical HVLA techniques in
lab and feel confident you can use your skills to help
alleviate your roommates neck pain. What will you do first
after correctly diagnosing the somatic dysfunction?
a. Localize the segment and engage the restrictive barrier
b. Ask the patient to breathe and relax
c. Perform a direct techniche, such as muscle energy
d. Soft tissue preparation, such as MFR
2. When determining an AA diagnosis, which of the
following is correct?
a. Grasp head with fingertips contacting the nuchal ridge
b. Fully flex the C-spine
c. Fully extend the C-spine
d. Sidebend head bilaterally assessing range of motion and freedom
2. When determining an AA diagnosis, which of the
following is correct?
a. Grasp head with fingertips contacting the nuchal ridge
b. Fully flex the C-spine
c. Fully extend the C-spine
d. Sidebend head bilaterally assessing range of motion
and freedom
3. When diagnosing your lab partner’s somatic dysfunction, you find that
C4 prefers extension and does not rotate to the left easily. Once you have
performed a soft tissue preparation, you localize the segment. If you are
treating with a rotation emphasis, what will your treatment position be?
a. F, SrRl
b. E, SrRl
c. F, SlRr
d. E, SrRl
3. When diagnosing your lab partner’s somatic dysfunction, you find that
C4 prefers extension and does not rotate to the left easily. Once you have
performed a soft tissue preparation, you localize the segment. If you are
treating with a rotation emphasis, what will your treatment position be?
a. F, SrRl
b. E, SrRl
c. F, SlRr
d. E, SrRl
4. Where should the rotational thrust be directed
when treating a C7 somatic dysfunction with HVLA?
a. Toward the eye
b. Straight across the cervical region
c. Down toward opposite shoulder
d. Inferiorly toward the thoracic spine
4. Where should the rotational thrust be directed
when treating a C7 somatic dysfunction with HVLA?
a. Toward the eye
b. Straight across the cervical region
c. Down toward opposite shoulder
d. Inferiorly toward the thoracic spine
5. When applying the corrective force in cervical
HVLA, it is important to have the patient take an extra
breath right before.
a. True
b. False
5. When applying the corrective force in cervical
HVLA, it is important to have the patient take an extra
breath right before.
a. True
b. False
GOOD LUCK!

Let me know if you have any questions or need any clarification! My email is
allison.melnick@kansascity.edu