Today was an exciting day, my first time dabbling with the physical examination. Today’s practice was the head, neck, and eye exam. My partner Lisa and I awkwardly took turns trying vital signs and probing the standardized patient. We are both the giggly, shy type, and with a ‘patient’ there watching and hearing our conversation probably sounded a little funny.
Vital signs: I think I have blood pressure down. Taking the heart rate and breathing rate is still a little tough, because you have to watch the time and count. I looked down at my watch, only to realize I don’t have a second hand because a Paul Frank monkey face IS the rotating second hand. Breathing rate is tougher to count because you have to be discrete and pretend to take a pulse in order to avoid the patient breathing faster or harder. I was watching the chest and holding the shoulders, but I couldn’t just keep doing that indefinitely. In the end I just estimated 5 breaths in a 15 second span.
Head and Neck: There’s a lot of touching here, and I feel weird touching people in general. That includes hugging, punching, rubbing, patting, massaging, holding,… but the social gal that I am, I do it all anyway. First, I had to touch the scalp, without gloves, to feel for bumps or abnormalities. In my head, I was thinking, “Uh, what if there’s lice? Dandruff? Head oils?” Next, I had to feel the lymph nodes in the neck region for hard lumps or tenderness: superficial and deep cervical, submandibular, submental, and auricular (by the ears). The thyroid gland is also palpated with both hands, and you can feel it when the patient swallows fluid. The cricoid cartilage is a little protuberance in the neck right near the thyroid gland itself. That’s the part that makes you feel like puking if you palpate it too much, at least for me…
Nose, Ears, Mouth: Yes, I looked in the nose today with the otoscope. I also think I saw the tiny tympanic membrane of the ear. The mouth is an adventure in itself. We didn’t have what I call a ‘popsicle stick,’ so we made way with a wooden Q-tip. I was poking around with this puny stick to take a look at the gums, teeth, buccal mucosa, tongue, and palates. The patient said she has a small mouth and it’s hard for her tongue to come out completely. That’s why I couldn’t see the uvula and the back of the pharynx. Oo poops.
The ear exam was horrendous. I rubbed my fingers at her ears, and she only heard on one side. Woops, one of my hands was drier than the other I guess. Then when I whispered a number in each ear, she heard fine. We had issues with the stupid tuning fork for the Weber and Rinne tests. I banged it to get it vibrating, and the patient was not hearing properly. Take the Rinne test. You get the fork vibrating and place the tip at the mastoid process behind the ear. Once the patient stops hearing the sound, you move the fork in front of the ear. This tests air conduction versus bone conduction, with the former always louder (in front of the ear). In our case, we were not banging the fork hard enough on our palms, so the patient was not hearing anything behind the ear, at the bone. Let’s say we got our palms banged up with this metal fork before we finally got the test down.
Finally, Eyes: I had to keep in mind that I was shining light into someone’s eye, possibly her retinas. Everyone was reminded not to get too carried away with ourselves during the eye exam. With the ophthalmascope, we took turns testing the pupillary light reflex, direct (one eye) and consensual (both eyes) responses, which involves the ciliary muscles innervated by the oculomotor nerve. Then we had to look IN the eye, for the blood vessels coming out of the optic disc. I only got as far as seeing some red liney things, so no optic disc just yet. Double poops…
And of course, for the standardized patient, everything is normal. Nothing abnormal was felt, otherwise, that would be a big nasty problem. It’s the practice that counts.