Physical Exam Videos

Dartmouth Medical School has a fabulous resource for the physical exam that includes video sections for each part of the exam as well as an explanation of why you are doing things (always helpful!).

Doctoring: Year 1

Doctoring: Year 2

Example video

Dermatology Tutorials

Dermatology. You either love it or hate it. I haven't found many people in between. I hate it. Most everything looks like eczema to me (especially in pediatrics). Some people just have a gift for rash recognition... like interior designers that can talk a length about the difference between egg shell, cream, and off.  ...It all looks white to me.

I found a great Dermatology site put together by The Univ of Wisconsin-Madison with tutorials and excellent descriptions of macules/papules/etc. I love this site because it is SIMPLE - just enough information for me to intelligibly answer my friends' questions about "this strange rash" that just appeared on their stomach - but not enough for me to become a dermatology expert. Perfect.

This is the main menu for the Tutorials.

There is a description as well as several pictures that can be enlarged by clicking on them.

Unique Cardiac Sound App for iPhone

Cardiac sounds.... as I've said before... not my strong suit... so I have been on the hunt for some great iPhone apps to help me pass the time and learn a bit in the process. After all, you can't become good at murmur auscultation by reading a book. I was recently introduced to the Blaufuss Sound Builder. This app is has some great features. I found myself playing with it for hours (rather than studying!).

1. It allows you to listen to a murmur on a patient and then listen to the app and customize the app's sounds to match that of the patient's. Not sure if it is systolic or diastolic? Click on each and then ask yourself which one sounds like your patient. As advertised, you can "You can also compare/contrast sounds that are easily confused: holosystolic vs mid systolic, murmurs, and extra sounds near the 1st and 2nd heart sounds."

2. As I show in the screen shots below, once you find the combo of heart sounds that you are looking for you can hit Dx for the predicted diagnosis or a differential list (super helpful)!

3. If you need some extra information... you can select the side arrow in blue and more information is available (screen shot below).

4. The initial download of the app is free - but you get only a few of the sounds included. For full use of the application it is $9.99 - but honestly worth it. I've downloaded and tried 10-15 heart sound apps and ended up deleting them 2 days later because they weren't very helpful. This is definitely a keeper. 

You can select any combination of heart sounds to hear together. By adding them 1 at a time I found it MUCH easier to pick them out.

You can see how the "Early diastolic" tab is selected because it is yellow. Then select the blue Dx circle  to  get the differential diagnosis list.

The differential list of Early systolic murmurs. (There is more if you scroll.)

More information on Aortic Regurgitation 

Disclaimer: I received this app for free as a tester, but do not receive any compensation for future purchases.

'Tis the Season for Giving...

Northeastern has a great clinical rotation collaboration with the Shattuck hospital in MA. They offer several great rotations in in-patient medicine and ambulatory care to our students. The patient population consists of mostly uninsured, homeless, or immigrant patients without other options of healthcare. The Shattuck has a great volunteer service that collects clothing donations and distributes them to in-need patients. Our PA classes (1st and 2nd year) decided that it would be great to create an annual clothing drive around the holiday season as a "Thank you" for providing us with such great rotations as well as help out the patient population in a small way.

This year was the 1st Annual Shattuck Clothing Drive! What is your program doing to give back during the holidays? 'Tis the season for giving.

Fluid Management Simulation

I found the coolest fluid management site. It allows you to replace loss fluids with the "correct" fluids as well as control loss (hemorrhage, urine, etc). They also have other great simulations such as a "Post-Op Cardiac Patient in the ICU" and "Weaning From Cardio-Pulm Bypass" --This simulation will cover the process of weaning a patient from cardio-pulmonary bypass following completion of the surgery.

Hats off to Toronto General Hospital!

Cardiac Auscultation

Michael Chizner, MD wrote a great article in July 2008 on the lost art of listening to the heart called: Cardiac Auscultation: Rediscovering the Lost Art - It is great. Listening for murmurs is a difficult skill to master. I have worked with several seasoned PAs and MDs that still claim that they don't have a good handle on murmurs. Personally, I am terrible at it. I can tell you it is abnormal and I can tell you what the text book systolic or diastolic murmurs should sound like.... but hearing a heart beating at 80 bpm and picking out and correctly naming a murmur.... I'm definitely not there yet.

If you have access to your school's library- you should have access to free journal articles. Just do a quick search for the title and author. Below is a snippet from the article.

TABLE 1. Proper cardiac auscultatory technique

● Room should be quiet

● Time heart sounds and murmurs by “inching” technique (or by palpation of carotid artery

or apical impulse)

● The bell of the stethoscope is best for low-frequency sounds and murmurs (eg, S4 and S3

gallops, diastolic rumbles)

● The diaphragm of the stethoscope is best for high-frequency sounds and murmurs (eg,

aortic regurgitation)

● Listen with bell lightly applied at cardiac apex, with patient turned to left lateral decubitus

position, for S4and S3 gallops and/or diastolic rumble of mitral stenosis

● Listen with diaphragm firmly applied over the left sternal border with patient sitting

forward, during held expiration for diastolic blowing murmur of aortic regurgitation and/or

pericardial friction rub

● Listen individually to S1 and S2

— Are both S1 and S2 present?

— Is either sound loud, normal, or faint? Does splitting of S2 widen, remain “fixed,” or

reverse with inspiration?

● Listen for extra sounds in systole (eg, mitral clicks, aortic or pulmonic ejection sounds)

or diastole (eg, S4 and S3 gallops, pericardial knock sound, mitral opening snap, “tumor

plop”)

● Listen for murmurs

— Systolic (early, mid, late, holosystolic)

— Diastolic

— Continuous

— Where is the murmur heard and radiate?

— Does the murmur change with body position, respiration, certain maneuvers (eg,

Valsalva)

Listen for pericardial friction rubs or prosthetic valve sounds

(Reproduced with permission from Chizner MA. Clinical Cardiology Made Ridiculously Simple, 2nd edition. Miami, FL: MedMaster, Inc., 2007.) 






Picture: http://www.medcomrn.com/cgi-bin/mc/sectionpreview?8a9dQUaN;VIDM259B-T;620

Neurological Exam

Just wanted to take a quick second to say thank you to all the people who have visited my blog and participated through email and comments. The blog just hit 6,000 views! Keep the requests coming and I will do my best to deliver the subject matter. I had a question about the resources for the general neurological exam... this is the site that I use because it is pretty comprehensive and it is to-the-point (my 2 favorite qualities).

The Neurological Exam

Snippets:

Cranial Nerves

Observation

• Ptosis (III)
• Facial Droop or Asymmetry (VII)
• Hoarse Voice (X)
• Articulation of Words (V, VII, X, XII)
• Abnormal Eye Position (III, IV, VI)
• Abnormal or Asymmetrical Pupils (II, III)

Manual Muscles Testing

Test the following:

1. Flexion at the elbow (C5, C6, biceps)
2. Extension at the elbow (C6, C7, C8, triceps)
3. Extension at the wrist (C6, C7, C8, radial nerve)
4. Squeeze two of your fingers as hard as possible ("grip," C7, C8, T1) [10]
5. Finger abduction (C8, T1, ulnar nerve)
6. Oppostion of the thumb (C8, T1, median nerve)
7. Flexion at the hip (L2, L3, L4, iliopsoas)
8. Adduction at the hips (L2, L3, L4, adductors)
9. Abduction at the hips (L4, L5, S1, gluteus medius and minimus)
10. Extension at the hips (S1, gluteus maximus) [12]
11. Extension at the knee (L2, L3, L4, quadriceps) [10]
12. Flexion at the knee (L4, L5, S1, S2, hamstrings)
13. Dorsiflexion at the ankle (L4, L5)
14. Plantar flexion (S1) [12]