DCP - Cranial nerve examination
All together with my colleagues CD and JH we decided to practise the cranial nerves examination. CD had a go first. I have realised that her approach is different to mine one. She followed the order of cranial nerves and examined each one in consecutive order. I felt that that her approach wasn’t one for me to copy for a future as I have been practising the CN examination by dividing the examination to 4 groups as eyes, face, mouth and hearing plus balance.
As I never practised with the above lot before, it was good to hear the comments and tips how to improve the CN examination procedure. JH recommended to me to ask the patient to use their hand with the base of the thumb fitting into the base of the nose so during the pupil reflex examination no light gets through the gap between the hand and nose. We discussed the need for olfactory examination and the discrepancies in the literature. We have concluded that perhaps asking the patient questions regarding the recent changes in the smell perception should be sufficient enough.
We have identified few questions we could not answer. These were:
- oculomotor muscles exact action and innervation.
- Taste perception of the tongue – distribution and innervation
- Nystagmus – what types and which area affected, and what exactly do we look for.
- Balance problems – how to test them, which areas do we test and how do they present.
The presentation on the above problems will follow as to prove that the identified areas of lack of knowledge were looked into and revised and understood.
As I never practised with the above lot before, it was good to hear the comments and tips how to improve the CN examination procedure. JH recommended to me to ask the patient to use their hand with the base of the thumb fitting into the base of the nose so during the pupil reflex examination no light gets through the gap between the hand and nose. We discussed the need for olfactory examination and the discrepancies in the literature. We have concluded that perhaps asking the patient questions regarding the recent changes in the smell perception should be sufficient enough.
We have identified few questions we could not answer. These were:
- oculomotor muscles exact action and innervation.
- Taste perception of the tongue – distribution and innervation
- Nystagmus – what types and which area affected, and what exactly do we look for.
- Balance problems – how to test them, which areas do we test and how do they present.
The presentation on the above problems will follow as to prove that the identified areas of lack of knowledge were looked into and revised and understood.
DCP practice - Blood pressure taking
Today we had a new group of the first years observing and as I had no patients I took two students with me to the treatment room and practised with them taking the blood pressure. I taught both of them how to do it, what to listen for and what the measured numbers meant. It was good revision for me to go through the procedure in a step by step logical approach and explaining why am feeling for radial pulse, where to listen with the stethoscope to the brachial artery, what is considered normal and high blood pressure, why to take the BP from both sides.....
DCP practice - respiratory, CVS and cranial nerves examination
Today in my study group with LJ and SJ we practiced the clinical examination of the CNs, CVS and respiratory system. It went quite well but slowly. We talked through the details we would be looking for and what do these details mean. the picture of SJ and LJ below shows the CVS examination and picture of myself and SJ performing CNs examination.
DCP practice with 3rd years in the clinic
Today the clinic was very quiet so we used the spare time to practice some DPC. With colleague MG we went through the CVS exam and with some 3rd years through the cranial nerves examination. The 3rd years are only in the process of learning the skill of the examination of the CNs so they were asking quite a lot of questions relating to as why would you do some testing so the brains were working on the first day back in the clinic. I have learnt something new too, as RR explained to me that during the hearing examination for which we use the tuning fork, the fork needs to be facing towards the examinar in the U shape so the vibrations created travel directly to the ear of the patient and not in front and back to him/her.
DCP practice with study group - Cranial nerves examination
We have done today the thorough CN examination in the study group when we also done a lot of questioning on common lesions of specific cranial nerves, differentiation between upper and lower motor neuron injuries etc. We have realised that the knowledge of the head and neck anatomy from the 2nd year is blurry and we decided to have session next week no tuesday when we go through all the CNs and their point of origin and pathway so we can better understand the possible injuries. However I was quite pleasantly surprised about how much I could remember but all of us had some weak areas where we were not so sure about the details. I think revising this area will be very interesting.
DCP practice with LJ - complete neurological exam
As SJ is sick today only with LJ we went in a detail over whole neurological examination. We included CNs, tests for cerebellar ataxia and parkinson's disease, whole body neurological examination. LJ had some new ways of testing for pain when he used pin prick on the sternum and asked the Pt is it was sharp of blunt. then he was comparing left and right side of the UEx and LEx but pricking the skin on the larger area on the multiple occasion. also we discussed testing of the vibration that is needed only in the tiptoes and fingertips to start with. We also discussed the MS presentation in which dorsal columns carrying vibration and proprioception would be affected but most likely the spinothalamic tract would be preserved (as unmyelinated).
Abdominal examination - study group DCP practice
today we went through the abdominal exam. it is on of those we do not perform in clinic on the regular basis so our ability to smoothly perform it is somewhat below the standard expected. we talked about the history of the patient that would prompt us to do abdominal examination: pain in the abdomen, nausea, vomiting, difficulty to swallow, bleeding, distension of the abdomen, bloating, weight change, change in toilet habits.
We would observe for general appearance - demeanour, belching. Hands - for temperature, sweating, colour, dupuytrens contracture, spiner naevi + asterixitis (due to liver disfunction). Nails would be observed for luekonychia, koilonychia, brown colour, sphincter haemorrhage, clubbing. Feet for pitting oedema, temperature and colour. Face for colour and also eyes, mouth, tongue for the usual signs of disease. We would check chest for gyneacomastia and spiner naevi (more than 5 above nipples and on the arms means either pregnancy, chronic liver disease, hyperthyroidism, RA, viral hepatitis). Check the abdomen for scars, striae, bruised umbilicus, distension, varicose veins, caput medusa and engorged superficial veins.
Palpation of supraclavicular lymph nodes , specially left that drain abdomen, each quadrant for any lumps or masses or tenderness, liver for displacement due to hyperinflated lungs, Reidels lobe, hepatomegaly, atrophy. Spleen for spleenomegaly. Gallbladder - murphy's point. Appendix Mc Burny's point. Balloting of the kidneys is difficult and we do not seem to be able to perform it successfully. Pulses: aorta (between xiphoid process and umbilicus for aneurysm), femoral and radiofemoral for delay. Percussion of the liver, spleen and ascites. Auscultation of the GIT - borborygma, bruit (renal femoral and liver), rub of the liver and spleen if capsule inflamed.
while discussing the jaundice we could not remember exact processes of the jaundice. these were revised and the handout from LJ is in my LPA file and below too:
We would observe for general appearance - demeanour, belching. Hands - for temperature, sweating, colour, dupuytrens contracture, spiner naevi + asterixitis (due to liver disfunction). Nails would be observed for luekonychia, koilonychia, brown colour, sphincter haemorrhage, clubbing. Feet for pitting oedema, temperature and colour. Face for colour and also eyes, mouth, tongue for the usual signs of disease. We would check chest for gyneacomastia and spiner naevi (more than 5 above nipples and on the arms means either pregnancy, chronic liver disease, hyperthyroidism, RA, viral hepatitis). Check the abdomen for scars, striae, bruised umbilicus, distension, varicose veins, caput medusa and engorged superficial veins.
Palpation of supraclavicular lymph nodes , specially left that drain abdomen, each quadrant for any lumps or masses or tenderness, liver for displacement due to hyperinflated lungs, Reidels lobe, hepatomegaly, atrophy. Spleen for spleenomegaly. Gallbladder - murphy's point. Appendix Mc Burny's point. Balloting of the kidneys is difficult and we do not seem to be able to perform it successfully. Pulses: aorta (between xiphoid process and umbilicus for aneurysm), femoral and radiofemoral for delay. Percussion of the liver, spleen and ascites. Auscultation of the GIT - borborygma, bruit (renal femoral and liver), rub of the liver and spleen if capsule inflamed.
while discussing the jaundice we could not remember exact processes of the jaundice. these were revised and the handout from LJ is in my LPA file and below too: