CAPS I Midterm Exam

What is the first step in a clinician's approach to clinical ethical reasoning?

State the problem plainly.

What data categories should you gather and organize in clinical ethical reasoning?

Medical facts, medical goals, patient goals/preferences, and context.

After gathering data, what two questions must you ask in the clinician's approach?

Is the problem ethical? Is more information or dialogue needed?

Name three kinds of reasons you can use to support the best course of action in ethical reasoning.

Ethical principles, consequences (outcomes/utilitarian reasoning), and professional guidelines (including virtues and comparable cases).

What are the four Topics in the "Four Topics" approach?

Medical Indications, Patient Preferences, Quality of Life, Contextual Features.

What principle(s) do Medical Indications primarily address?

Beneficence and nonmaleficence.

What main principle does Patient Preferences address?

Respect for autonomy.

What issues are assessed under Quality of Life in the Four Topics?

Prospects with/without treatment, biases in evaluation, whether QOL judgments justify changing treatment plans, plans for comfort if forgoing life-sustaining treatment.

What kinds of issues belong to Contextual Features?

Conflicts of interest, family or third-party interests, confidentiality limits, financial/resource allocation, legal/religious/public health considerations, research/education implications.

Define moral pluralism and one key implication for clinical practice.

Moral pluralism is the fact that people disagree about foundational beliefs and sources of ethical authority; implication: clinicians need humility and respect in shared decision-making.

List the four basic principles of biomedical ethics.

Beneficence, Nonmaleficence, Respect for Autonomy, Justice.

How does a prima facie principle differ from an absolute principle?

A prima facie principle holds unless outweighed by stronger competing principles in a particular situation.

Give an example of a tension between beneficence and nonmaleficence.

Prescribing anticoagulation for atrial fibrillation (benefit of stroke prevention) vs increased bleeding risk (harm).

What is relational autonomy?

A view of autonomy that recognizes patients' decisions are often supported or shaped by relationships and may require help from others to exercise.

What is role fidelity and why is it important?

Role fidelity is prioritizing obligations specific to one's professional role (e.g., clinician's primary responsibility to individual patients); it supports a division of moral labor and fairness across roles.

Name three virtues expected of healthcare professionals.

Honesty, compassion, integrity (also benevolence, courage, temperance, fidelity to trust, practical wisdom).

How are principles and virtues related?

They are complementary: principles provide rules or duties; virtues shape the agent's character and motivation to apply principles well.

What is conscience in the clinical context?

A combination of moral reasoning, moral emotion, and moral motivation that orients a clinician to right and wrong and to the obligation to do good.

What is moral distress and one common cause in clinical training?

Moral distress is feeling constrained from doing what one believes is right; commonly caused by hierarchical pressures or institutional constraints.

What is utilitarian (consequentialist) reasoning in ethics?

An approach that judges actions by their consequences, aiming to maximize overall good (greatest good for the greatest number).

Name two challenges of consequence-based (utilitarian) reasoning.

Predicting all relevant consequences and avoiding sacrifice of individuals for the greater good without person-respecting justice.

Why must treatment decisions arise from goals-of-care discussions rather than focusing only on interventions?

Because overall goals (cure, prolong life, maintain function, comfort, achieve life goals) guide which interventions are appropriate and align care with patient values.

List the mnemonic CLFCLFC and what it stands for (goals of care).

Cure, Live longer, Function/quality/independence, Comfort, Life goals, Family support/caregiver support, Clarify diagnosis/prognosis.

Give three examples of specific, measurable treatment goals for chronic pain.

Increased ability to perform ADLs, fewer missed work days, attending a meaningful activity (e.g., going to a family event).

When a patient lacks capacity and has no surrogate, which Four Topics questions become most urgent?

Patient Preferences (prior expressed wishes), Quality of Life (best interests), Contextual Features (legal/ethical safeguards).

What steps should you follow when you suspect an ethical problem might instead be poor communication or interpersonal conflict?

Re-evaluate: check for poor communication, strained relationships, or incomplete exploration of medical alternatives before labeling it an ethical problem.

How should clinicians handle moral pluralism during shared decision-making?

With humility, respectfulness, patience, and willingness to explain reasons while listening to differing values.

What is the clinician's professional duty when institutional or population-level obligations conflict with individual patient care?

Recognize role-specific obligations, prioritize role fidelity (advocate for the patient in the clinical role), and escalate or consult when obligations conflict across roles.

State the primary learning objective of the ViSPULS module.

Accurately and efficiently assess vitals, pulses, and the lymphatic system as part of clinical reasoning for comprehensive care.

Name the four vital signs covered in the ViSPULS module.

Temperature, Pulse/Heart Rate, Respirations, Blood Pressure.

Before beginning the ViSPULS exam list three preparatory patient-centered actions.

Wash hands; introduce self and explain exam; ask if the patient wants a chaperone.

What trauma‑informed care principle is explicitly required before a sensitive exam?

Set the stage for a sensitive exam (explain process, obtain consent, signpost exposures).

When counting an irregular heart rate, how long should you measure the pulse?

Measure for a full 60 seconds.

For routine pulse measurement, what shortcut is typically used?

Count for 15 seconds and multiply by 4 to get beats per minute.

Give the pulse amplitude grading scale and what 2 and 0 mean.

4 = bounding; 3 = full; 2 = normal; 1 = diminished; 0 = absent.

Name six common peripheral pulse points to palpate bilaterally.

Carotid, Brachial, Radial, Femoral, Posterior tibial, Dorsalis pedis (also popliteal).

How should respirations ideally be counted?

By inspection for one minute, preferably without the patient knowing; or continue holding the wrist after pulse count to observe chest rise.

State patient positioning and preparatory steps for accurate seated blood pressure measurement.

Seated, rested 5 minutes, feet flat and uncrossed, back supported, arm bared and at heart level on hard surface, ask about recent caffeine/smoking/exercise.

What is the 80/40 rule for BP cuff sizing?

Bladder length ≈ 80% of arm circumference and bladder width ≥ 40% of arm circumference (or bladder width covers ~40% elbow-to-shoulder).

Describe how to estimate systolic pressure by palpation before auscultation.

Inflate cuff while palpating radial pulse, note the pressure where pulse disappears; use ~20-30 mm Hg above that for auscultatory measurement to avoid auscultatory gap error.

At what rate should you deflate the BP cuff during auscultation?

Gradually at about 2-3 mm Hg per second.

What Korotkoff phase indicates systolic pressure and which phase indicates diastolic (Phase 5 preferred)?

Systolic = Phase 1 (first two consecutive beats); Diastolic = Phase 5 (silence) or Phase 4 (muffling) if Phase 5 absent.

What is an auscultatory gap and why is it clinically important?

A transient disappearance of Korotkoff sounds between phases that can lead to underestimating systolic or overestimating diastolic pressure; avoidable by palpatory estimate first.

How is pulse pressure calculated and what typical range suggests normal?

Pulse pressure = Systolic − Diastolic; normal ≈ 30-40 mm Hg.

How many measurements/days are recommended before diagnosing hypertension?

Multiple measurements: typically 3 separate measurements on 3 separate days support diagnosis.

During peripheral pulse exam what simple test assesses peripheral perfusion and what is normal?

Capillary refill; normal < 2 seconds.

When assessing lower extremity edema, what is the pitting scale used?

1+ to 4+ with increasing mm of indentation (approx 2, 4, 6, 8 mm respectively).

Approximately how many lymph nodes are in the body and why are superficial nodes clinically useful?

Around 600; superficial nodes are accessible by inspection and palpation and give early clues to infection or malignancy.

Name at least five superficial lymph node chains to inspect on the head/neck and upper extremity.

Occipital, Postauricular, Preauricular, Submandibular, Submental, Anterior cervical, Posterior cervical, Supraclavicular, Axillary, Epitrochlear.

What three node characteristics raise concern for malignancy versus inflammation?

Hardness (firm → malignancy), non-tenderness/rapid painless enlargement (→ malignancy), matted nodes (→ possible malignancy or chronic TB/sarcoidosis).

What are "shotty" nodes and what clinical context is typical?

Small, firm, discrete nodes like buckshot; often benign or reactive (e.g., viral infections).

Why are palpable supraclavicular nodes considered especially concerning?

They are abnormal in adults and often indicate malignancy until proven otherwise.

Give three procedural or patient‑respect behaviors required throughout the ViSPULS exam.

Appropriate draping; signposting before exposure or palpation of neck/abdomen/groin/axilla; thank the patient afterward.

What should you always record when documenting blood pressure measurements?

Systolic and diastolic values, cuff size, arm used, and patient position (if not seated), and note repeat measurement if taken.

Summarize the ViSPULS exam flow in three bullets.

Repeat vitals (even if done by staff); assess pulses and capillary refill bilaterally; perform lymph node inspection and palpation in standard head/neck → axilla → groin sequence while maintaining draping and patient comfort.

What patient positioning is recommended for seated auscultation of heart sounds?

Patient seated upright, relaxed, properly draped, with exposure of the chest as needed and auscultation on skin.

Which four valve areas are routinely auscultated with the diaphragm?

Aortic (R 2nd ICS), Pulmonic (L 2nd ICS), Tricuspid (L 4th ICS parasternal), Mitral (apex, L 5th ICS MCL).

When and how is the bell used during the CV exam?

Use the bell at the apex in the left lateral decubitus position to accentuate low-frequency sounds like mitral stenosis and S3/S4.

How do you position the patient to accentuate aortic regurgitation during auscultation?

Have the patient lean forward, exhale and hold expiration; auscultate the left sternal border and right upper sternal border with the diaphragm.

What should you note systematically during heart auscultation?

Rate and rhythm, S1 and S2 characteristics, splitting, presence of S3/S4, extra sounds (snaps, clicks, rubs), murmurs with timing, pitch, intensity, location, and radiation.

How is the point of maximal impulse (PMI) inspected and palpated?

Inspect for visible PMI; palpate with finger pads at the apex to locate PMI and note displacement, size, and force.

What is a precordial lift/heave and what does it suggest?

A sustained outward impulse felt with fingertips indicating ventricular hypertrophy or increased chamber work.

How do you palpate for thrills and what do they indicate?

Use the ball of the hand or MCP joints to feel vibratory thrills over the chest; thrills suggest turbulent flow associated with high-grade murmurs.

List three observations to make on visual inspection of the chest and extremities.

Skin color, visible pulsations, venous distension, venous varicosities, ulcers, hair pattern, edema.

Which peripheral pulses should be palpated seated and which supine?

Seated: carotid (one at a time), brachial, radial, dorsalis pedis, posterior tibial. Supine: femoral, abdominal aorta (palpation), plus repeat peripheral pulses.

How should carotid artery auscultation be performed?

Auscultate each carotid separately with the bell while the patient briefly holds their breath to detect bruits.

What is capillary refill and the normal value?

Press nail or pulp until blanching, release and count time for color return; normal < 2 seconds.

Describe the pitting edema grading used in the CV exam.

1+ minimal; 2+ moderate (about 4 mm); 3+ deep (about 6 mm); 4+ very deep (about 8 mm).

How should a blood pressure-related CV exam consideration influence findings interpretation?

Recognize that BP varies with position (supine lower than sitting), cuff size matters, and repeat measurements are needed for hypertension diagnosis.

What key surface anatomy landmarks guide valve auscultation?

Suprasternal notch, sternal angle, R/L 2nd intercostal spaces, left sternal border, 4th-5th ICS, and midclavicular line for apex.

How do you grade murmur intensity and when is a thrill expected?

Grade I-VI: thrills are present starting at grade IV; I = barely audible, IV = loud with thrill, VI = audible without stethoscope contact.

What murmur timing and location suggest aortic stenosis?

Systolic, crescendo-decrescendo murmur best at R 2nd ICS, radiating to carotids.

What murmur pattern and radiation are characteristic of mitral regurgitation?

Holosystolic murmur best heard at the apex, often radiating to the left axilla.

Which maneuvers accentuate different murmurs: leaning forward, left lateral decubitus, Valsalva, handgrip?

Leaning forward (aortic regurgitation diastolic); left lateral decubitus (mitral stenosis, S3/S4); Valsalva/standing decrease venous return (most murmurs decrease, HCM increases with Valsalva); handgrip increases afterload (increases MR, AR, VSD murmurs; decreases AS).

What descriptors should you include when documenting a murmur?

Timing (systolic/diastolic), location of maximal intensity, radiation, pitch/quality, grade, and maneuvers affecting it.

Name three extra heart sounds and their usual clinical association.

S3 — rapid ventricular filling, can indicate volume overload/heart failure; S4 — atrial contraction against stiff ventricle, indicates decreased compliance; pericardial friction rub — pericarditis.

During peripheral vascular inspection, what findings suggest arterial insufficiency?

Cool skin, hair loss on the limb, thin shiny skin, ulcers with punched-out appearance, decreased or absent pulses.

During peripheral vascular inspection, what findings suggest venous disease?

Edema, varicosities, stasis dermatitis, venous ulcers (irregular margins), normal pulses.

When should you auscultate abdominal and peripheral arterial bruits?

When suspicious for vascular stenosis or aneurysm: abdominal aorta, renal arteries, common iliac, femoral arteries; auscultate with the bell.

What three documentation elements beyond findings should always be recorded after the CV exam?

Patient position during exam, presence/size of PMI/thrill, pulses graded and any bruits; note cuffs/measurements if BP assessed.

What are two red‑flag lymphatic/vascular findings that require urgent follow-up?

New displaced PMI with hypotension (possible cardiogenic shock or tamponade) and palpable supraclavicular lymph nodes (suggest malignancy until proven otherwise).

What inspection findings should you note when observing the chest and thorax?

Breathing rate/rhythm/depth/effort; chest shape (barrel chest, deformity); chest symmetry; skin and nail bed color (cyanosis); accessory muscle use, retractions; tracheal position; audible inspiratory/expiratory noises.

What is clubbing and what does it suggest?

Loss of the normal nailbed angle and thickening of distal fingers; associated with chronic hypoxia causes (lung cancer, CF, congenital heart disease, ILD).

How do you assess chest expansion and what does asymmetry suggest?

Place hands at the 10th ribs with thumbs at midline, ask deep breath and observe symmetry; unilateral decreased expansion suggests diaphragm weakness, lobar collapse/consolidation, or pleural disease.

How is tactile fremitus performed and what do increased vs decreased fremitus indicate?

Palpate with ulnar edge or MCPs while patient says "99"; increased fremitus → consolidation (pneumonia); decreased fremitus → pleural effusion, pneumothorax, or large airway obstruction/emphysema.

How many posterior percussion points are typical and what is normal diaphragmatic excursion?

Percuss ~5 paired posterior points (plus lateral/anterior as indicated); normal diaphragmatic excursion ≈ 3-5 cm.

Match percussion sounds to cause: dull, resonant, hyperresonant, tympanic.

Dull → consolidation or pleural effusion; Resonant → normal lung; Hyperresonant → emphysema or pneumothorax; Tympanic → large pneumothorax or gastric bubble.

During auscultation, which stethoscope piece and patient positions are used to best evaluate lungs?

Use the diaphragm on skin in pairs; patient seated upright for posterior/lateral/anterior listening; use special positions (lean forward) only as needed.

Name the normal breath sounds (type and where heard).

Vesicular — soft, low pitch, over most lung fields; Bronchovesicular — intermediate, near upper anterior and between scapulae; Bronchial — loud, high pitch, over manubrium or consolidated areas.

What are common adventitious lung sounds and their descriptions?

Crackles (rales) — high-pitched, discontinuous; Wheezes — musical, high-pitched continuous; Rhonchi — low-pitched, snoring/gurgling; Pleural friction rub — grating sound synchronous with respiration.

Describe bronchophony, whispered pectoriloquy, and egophony and what a positive result suggests.

Bronchophony: say "99" — increased clarity/loudness = consolidation. Whispered pectoriloquy: whisper "99" — increased clarity = consolidation. Egophony: say "eee" — hearing "ah" = consolidation at the exam site.

How do voice transmission tests (bronchophony/whispered pectoriloquy/egophony) alter with pleural effusion vs consolidation?

Consolidation → increased transmitted voice sounds (positive tests). Large pleural effusion → decreased transmission (negative tests) and dull percussion.

What combination of findings supports lobar pneumonia?

Increased tactile fremitus; dull percussion; bronchial or bronchovesicular breath sounds over the area; positive bronchophony/egophony/whispered pectoriloquy; ± crackles.

What physical findings suggest a pleural effusion?

Dull percussion with a standoff of dullness, decreased tactile fremitus, decreased/absent breath sounds over effusion, possible shifting dullness, reduced transmitted voice sounds.

What findings suggest pneumothorax on exam?

Hyperresonance to percussion, decreased or absent tactile fremitus, absent breath sounds over the affected area, possible tracheal deviation toward or away depending on tension, respiratory distress if large/tension.

How does a small pleural effusion differ from massive consolidation on the exam?

Small effusion: dullness, decreased fremitus, decreased breath sounds; Massive consolidation: dull percussion too but increased fremitus, bronchial breath sounds, positive voice tests, crackles.

What clues on inspection/palpation indicate respiratory distress requiring urgent attention?

Tachypnea, accessory muscle use, nasal flaring (especially in infants), marked retractions, altered mental status, cyanosis — these require immediate evaluation.

What are three red‑flag exam findings that should prompt urgent escalation?

New cyanosis or oxygen desaturation, severe asymmetric chest expansion with respiratory distress, signs of tension pneumothorax (severe dyspnea, hypotension, tracheal shift).

How do you interpret diaphragmatic excursion if you measure < 3 cm?

Reduced excursion suggests diaphragmatic dysfunction, pleural disease, subdiaphragmatic process, or shallow breathing — correlate with other findings and consider imaging.

What does EBCP stand for and what is its core meaning?

Evidence-Based Clinical Practice; incorporating scientific studies into patient care and appropriately evaluating evidence in clinical decision making.