PRE-CLINICAL CLERKSHIP, YEAR 1

Physical Examination

Session One A

Vital Signs

Cheryl A. Walters, M.D.
(VH Dissector Pro Images: Lawrence Rizzolo, Ph.D.)

1. Learning Objectives

2. Student Prep

Vital Signs

Read pp. 413-416, Chapter 14 The Heart (Blood Pressure Assessment, The Arterial Pulse) and pp. 374-376, Chapter 13 The Chest (Assess the Respiratory Rate and Pattern)

Inspection:Outlineon yourself or partner the cubital fossa, biceps tendon, brachial artery pulse, and radial artery pulse. On this left arm the tendon and artery are exposed when the skin is removed. On the right cubital fossa, the antecubital vein obsures the tendon and artery until it is removed. Note the brachial artery (pulse point), just medial to the biceps tendon in the antecubital fossa.

Palpation: Practice palpating the radial pulse in each arm. Place the pads of your index and middle fingers on the flexor surface of the wrist laterally and palpate for rate and rhythm for at least 15 secs. (multiply by 4 for rate/min). Pay attention to the defining features of rate and rhythm. Normal pulse is 60 to100 beats/min and regular in a healthy adult at rest and symmetrical in both arms. (Palpation of the radial pulse is an accurate assessment of the heart rate for most regular rhythms. In irregular rhythms, such as atrial fibrillation, auscultation of the heart is required for an accurate assessment of heart rate.)Outlineon yourself or partner the cubital fossa, biceps tendon, brachial artery pulse, and radial artery pulse.

 

Session One B

Nose, Oral Cavity, and Neck

  1. Learning Objectives
  1. Student Prep

Cervical Triangles

The anterior cervical triangle is bounded by the anterior midline, mandible, and sternocleidomastoid muscle. The posterior cervical triangle (and rotate to 70 degrees) is bounded by the sternocleidomastoid muscle, clavicle, and trapezius muscle.

Software: Microsoft Office 

Lymph Nodes (superficial right and deep; superficial left and deep) (preauricular, postauricular, occipital, posterior cervical, submandibular, submental, tonsillar, anterior cervical, superficial cervical, supraclavicular)

      3.Clinical Anatomical Landmarks

Nose

External Structures                                           Internal Structures

Software: Microsoft Office

Maps for Palpation or Transillumination of Paranasal Sinuses

Use ctrl-P or apple-P to see the plane of section; move the plane superiorly and inferiorly to explore the dimension of each sinus.

1-frontal  (just below the superior orbital rim)

2-ethmoidal (palpation only)

3-maxillary (just below the inferior orbital rim)

Oral Cavity (lips, tongue, circumvallate papillae, floor of the mouth, lingual frenulum, puncta of Wharton’s ducts, buccal mucosa, upper and lower  buccal sulci, puncta of Stensen’s ducts, gingivae, teeth, hard palate, soft palate, oropharynx, uvula, palatine tonsils)

                

    The openings, or puncta, of Wharton’s ducts from the submandibular gland are seen in the floor of the mouth on either side of the lingual frenulum. The punctum of Stensen’s duct from the parotid gland is seen in the buccal mucosa at the level of the second maxillary molar.    The giant, or circumvallate,  papillae may be seen on the posterior aspect, or base, of the tongue.                           

                         

 

Cervical Vertebrae

There are seven cervical vertebrae. To eyeball where C7 is, have your partner flex his/her neck. The most prominent vertebral body is C7 (vertebra prominens).

 Landmarks along the Anterior Midline of the Neck: Landmarks 1; Landmarks 2

 

Software: Microsoft Office

                             

 

The hyoid bone may be palpated in the anterior midline between the mandible and thyroid cartilage at the level of C3. The laryngeal prominence of the thyroid cartilage may be observed on inspection as the Adam’s apple. The cricoid cartilage, the junction of the larynx and trachea, may be palpated inferior to the laryngeal prominence at the level of C6. The isthmus of the thyroid is about 3 cm inferiorly and overlying the 2nd through 4th tracheal rings. It extends about 1.25 cm on either side of the anterior midline. The right and left lobes of the thyroid may be palpated laterally. The apices are at the middle of the laminae of the thyroid cartilage. The inferior rings of the trachea are palpable in the midline at the suprasternal notch.