3

BM 340 Clinical Skills Notes

Course Overview

  • Title: Clinical Skills: Western Biomedicine Exam

  • Instructor(s):

    • Miriam Janove, DPT

    • Adapted from coursework by Geoffrey Bender, ND, LAc, EAMP and Jutta Von Stieglitz, MD, FAAP

Week 2: Examination Focus Areas

  • Regions:

    • Thorax & Lungs

    • Abdomen

    • Eyes

    • Ears

    • Nose

    • Throat

    • Cranial Nerves

Thoracic Expansion

  • Procedure for Assessing Thoracic Expansion:

    1. Set hands on posterior thorax, inferior to scapulae during exhale.

    2. Allow hands to move with the thorax during inhalation.

  • Normal Range: 2 to 5 inches.

  • Observation: Symmetry in movement during thoracic expansion.

Lung Auscultation

  • Equipment Used: Diaphragm of the stethoscope.

  • Stethoscope Variations:

    • If stethoscope has two sides:

    • Small end = bell

    • Large end = diaphragm

    • If stethoscope has only one side:

    • Press firmly for diaphragm

    • Press lightly for bell.

  • Normal Breath Sounds by Location:

    • Vesicular sounds:

    • Soft, low-pitched heard over most lung areas.

    • Bronchovesicular sounds:

    • Intermediate pitch heard in the central areas.

    • Bronchial sounds:

    • High-pitched, heard primarily over the trachea.

Abnormal Lung Sounds

  • Terminology for Adventitious Sounds:

    • Crackles/Rales: Popping sound; indicates fluid in alveoli.

    • Wheezes: Whistle or hissing sound; indicates narrowed airways.

    • Rhonchi: Snore/moan quality; indicates secretions in large airways.

    • Stridor: High-pitched squeak; indicates narrowed airway.

    • Pleural Friction Rub: Crunch or creak sound; indicates inflammation of pleura.

    • Transmitted Voice Sounds (if pneumonia or pleural effusion suspected):

    • Egophony: E sounds like A (“eeee”).

    • Bronchophony: Words are clearer when spoken (“ninety-nine”).

    • Whispered Pectoriloquy: Whispering “1-2-3” produces loud sound.

  • Resources: Additional learning material can be found on Practical Clinical Skills website.

Anterior Thorax Anatomy

  • Structures Identified in the Anterior Thorax:

    • Manubrium, Body, Angle of Louis, True ribs (vertebrosternal), Vertebrochondral ribs, Floating ribs.

    • Muscles: Sternocleidomastoid, Deltoid, Pectoralis major, Subclavius, Pectoralis minor, Coracobrachialis, Serratus anterior.

    • Sternum and its Xiphoid process.

    • Costal cartilage.

    • Humerus.

Lung Percussion

  • Procedure:

    1. Use the middle finger of one hand to press into the intercostal space, ensuring no other parts touch the patient.

    2. Tap the palpating finger twice with the tip of the other hand’s finger at a perpendicular angle.

  • Results Interpretation:

    • Resonant: Indicates normal air-filled lung.

    • Dull: Indicates presence of fluid or tissue.

Anterior Chest Percussion Map

  • Percussion findings are mapped for anatomical regions of the chest to guide diagnosis based on sound resonance.

Abdominal Exam Procedures

  • Examination Order:

    1. Inspect

    2. Auscultate

    3. Percuss

    4. Palpate

  • Palpation and Percussion for Liver:

    • Liver size should range 6-12 cm in the right midclavicular line.

    • Check for Abdominal Aortic Aneurysm (AAA).

  • Palpation of Inguinal Lymph Nodes:

    • Typical size in adults is 0.5-2 cm.

    • Obtain patient consent, locate inguinal ligament from ASIS to pubic tubercle, palpate inferior and lateral to genitals.

Appendicitis Indicators

  • Symptoms of Acute Abdomen:

    • Sudden onset of pain; usually high fever.

    • McBurney’s Point: Found 1/3 the distance from ASIS to umbilicus.

    • Positive Signs:

    • Rebound tenderness: pain upon release of pressure.

    • Guarding: rigidity of abdomen.

    • Rovsing's Sign: Press in the left lower quadrant, release to observe referred pain in the right lower quadrant.

Referred Pain Mechanism

  • Referred Pain:

    • Local pain that is perceived in another area, masquerading pain from different origins.

    • Viscero-somatic pain: Organ pain felt in other parts of the body; a classic example is shoulder pain in a 40-year-old individual assigned female at birth, caused by gallbladder issues.

The Head and Neck Examination

  • Areas Examined:

    • Neck, Head, Eyes, Ears, Nose and Paranasal sinuses.

The Neck Examination Procedures

  • Inspect and palpate cervical and submandibular lymph nodes.

  • Palpate clavicle and AC (acromioclavicular) joints.

  • Observe symmetry of trachea.

Thyroid Gland Examination

  • Start at the Adam's apple and move down to thyroid isthmus.

  • Check lobes for symmetry and look for nodules or hard points.

  • The parathyroid glands are located on the posterior side of the thyroid gland.

Head Examination Procedures

  • Observe shape, size, symmetry of facial bones.

  • Palpate for abnormalities such as bumps, depressions, tenderness.

  • Examine hair and scalp for texture, thinning, alopecia, flaking, scalp rashes, or lesions.

Eye Examination Procedures

  • Inspect eyelid position, conjunctiva, and sclera.

  • Test pupillary reflexes to light and accommodation.

  • Assess eye movements and extraocular movements (EOMs).

  • Screen visual fields; refer for dilated/retinal exams every 1-2 years for maintenance.

Pupillary Reaction Testing (PERRLA)

  • Components:

    • Pupil Equality: Both pupils should be of the same size.

    • Roundness: Both pupils should be round.

    • Reactivity to Light: Both pupils constrict when exposed to light.

    • Accommodation: Constriction of pupils and convergence follows finger towards the nose.

Visual Fields Assessment

  • Observe for visual field deficits, noting any presence of hemianopia.

  • Video resources available for further learning about visual field evaluation.

Extraocular Muscle Movement Assessment

  • Draw a wide 'H' for the patient to follow with their eyes.

  • Convergence testing should occur within 6-10 cm of visual focus; failure to converge at >12 cm indicates insufficiency.

  • Video tutorials available for EOM testing procedures.

Retinal Examination Details

  • Observe for the fovea and macula.

  • Assess retinal arteries for conditions such as nicks, breakage, or hemorrhages.

  • Look at optic cup and disk for abnormalities.

Ear Examination Procedures

  • Inspect and palpate external ears and mastoid processes.

  • Conduct an otoscopic examination for the external auditory canal and tympanic membrane condition.

  • Refer for audiology if diminished hearing is suspected.

Otoscopic Exam Findings

  • Check for:

    • Redness, bulging, or inflammation of the tympanic membrane.

    • Presence of discharge.

    • Verify ossicles: incus and malleus for proper function.

External Nose and Sinuses Examination

  • Examine the external nose.

  • Palpate for tenderness of frontal and maxillary sinuses.

Cranial Nerves Overview

  • Total: 12 pairs arise from the brain (cerebrum and brain stem).

  • Part of the peripheral nervous system.

  • Functions include:

    • Sensory: touch, sight, smell, hearing.

    • Motor: muscle movement in the face.

    • Autonomic: regulating heart rate, pupil response.

Cranial Nerves Functions

  • I - Olfactory Nerve: Sensory - Sense of smell.

  • II - Optic Nerve: Sensory - Sense of sight/vision.

  • III - Oculomotor Nerve: Motor - Extraocular movements.

  • IV - Trochlear Nerve: Motor - Extraocular movements.

  • V - Trigeminal Nerve: Both - Sensation & motor for face.

  • VI - Abducens Nerve: Motor - Extraocular movements.

  • VII - Facial Nerve: Both - Facial expression & taste in the anterior tongue.

  • VIII - Auditory/Vestibulocochlear Nerve: Sensory - Cochlear (hearing) & vestibular (balance).

  • IX - Glossopharyngeal Nerve: Both - Taste sensation in posterior tongue & swallowing.

  • X - Vagus Nerve: Both - Controls several autonomic actions (heart rate, gastrointestinal function).

  • XI - Accessory Nerve: Motor - Shoulder shrug (innervates sternocleidomastoid and trapezius).

  • XII - Hypoglossal Nerve: Motor - Tongue movements.

  • Mnemonic: “Some Say Marry Money; But My Brother Says Big Brains Matter More.”

Cranial Nerve Testing Protocols

  1. Olfactory Nerve (I): Test using familiar, non-irritating scents (coffee, mint).

  2. Optic Nerve (II): Conduct visual acuity tests; assess visual fields.

  3. Oculomotor Nerve (III): Check extraocular movements.

  4. Trochlear Nerve (IV): Check extraocular movements.

  5. Trigeminal Nerve (V): Test for clenching jaw & sensations on forehead, cheek, chin.

  6. Abducens Nerve (VI): Check extraocular movements.

  7. Facial Nerve (VII): Check for symmetry in facial expressions (raise eyebrows, puff cheeks, etc.).

  8. Vestibulocochlear Nerve (VIII): Whisper numbers in one ear while covering the other ear.

  9. Glossopharyngeal Nerve (IX): Say “Ahhhh” to check soft palate symmetry.

  10. Vagus Nerve (X): Evaluate swallowing.

  11. Accessory Nerve (XI): Check shoulder shrug strength.

  12. Hypoglossal Nerve (XII): Request the patient stick their tongue out and observe for symmetry.

Upper Limb Tension Testing Procedures

  • Median Nerve Test: Examining response through shoulder and arm positioning. Steps:

    1. Position shoulder at 90 degrees abduction.

    2. Keep elbow flexed and the wrist in neutral position.

    3. Extend the shoulder to neutral.

    4. Extend wrist and fingers.

    5. Externally rotate the shoulder, extend the elbow.

    6. Side bend neck away from the side being tested.

  • Radial Nerve Test: Adjust positioning to assess radial nerve response through shoulder depression and internal rotation.

  • Ulnar Nerve Test: Check flexibility and proper response by following precise movements, ensuring extension, supination, flexion, and shoulder abduction.

  • Testing Considerations: Each nerve's function and responses should be tested under varying positions to evaluate their integrity and function effectively.

References

  • Various online resources, videos, and additional reading materials are suggested throughout the notes for visual aids and further understanding of clinical skills and procedures involved in examinations.