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University of New England
Physician Assistant Program
LIVE ANATOMY
Each region of the human body in PAC500 Anatomy will be first introduced in LIVE anatomy. This is done to better assist
students in transferring understanding of the human body into a clinical setting. LIVE anatomy will allow students an
opportunity to bridge the gap between the living anatomy of their peers and the dead anatomy in the cadaver lab. This approach
to learning about the human body will require some different strategies in addition to the ones used in a traditional course in
human anatomy. At the same time, it helps students to develop an appreciation of the importance and relevance of human
anatomy to the clinical setting.
It is critical that the introduction to a body region be on a living person, not from a lecture, text or the lab. In these sessions,
the focus will be on introducing specific anatomy and palpating relevant landmarks. Students will be learning the specifics of
the clinical examination in their clinical assessment course. Following LIVE anatomy and clinical assessment, students will
again study the anatomy, this time in the cadaver lab. During this time, students will study structures in more detail and they will
be investigating deeper within the body. This will not only reinforce the clinical anatomy students have already learned, but also
enables them to enter the cadaver lab having some experience for how they are going to use anatomy in the assessment of
patients.
There will be a handout for each LIVE anatomy session that will include those items for which students will be held
responsible on the LIVE anatomy exam. This exam will be given at the end of the course and LIVE anatomy will count 10% of
the overall anatomy course grade. Students will be tested in pairs in an oral practical format. One student will function as the
physician assistant and the other will function as the patient. An examiner will ask the student PA to point out certain
anatomical/clinical landmarks and will be graded on their responses. The students will then change roles and the examiner will
ask the new student PA a different set of questions.
Keep one thing in mind: The purpose of this LIVE anatomy course is to optimize student’s utilization of anatomic
knowledge in a clinical setting. This is not meant to be a clinical anatomy course. We will not be embellishing anatomy with
clinical correlations. That should happen naturally as students go through this course and the clinical assessment course.
References
Cross (2006) Live Anatomy Handouts, University of New England, unpublished
Montagu (1986) Touching: The Human Significance of Skin (3rd Ed.) Harper & Row
Moore and Dalley (2006) Clinically Oriented Anatomy (5th Ed.) Lippincott, Williams and Wilkins
Moore and Agur (2007) Essential Clinical Anatomy (3rd Ed.) Lippincott, Williams and Wilkins –
Source for all images, unless otherwise noted
Nolan (2003) Clinical Applications of Human Anatomy: A Laboratory Guide, Slack Incorporated
Protocol for LIVE anatomy
Wear comfortable, loose fitting clothing that allows for direct visualization and palpation by student peers.
The best option is to wear shorts and a T-shirt/tank top.
Be sure to bring Moore’s Essential Clinical Anatomy to the LIVE anatomy session.
It has most of the pictures needed and/or referred to in this manual.
Students will be working in groups of 2-4 that will be randomly assigned each day.
The group assignments expose the students to the maximum number of types and personalities.
This increases the amount of anatomical variation to which students are exposed.
All students should act as both patient and student PA.
Be sure to wash your hands before examining each other.
The sinks with soap and water are located one the South end of the lab – use them EVERY session.
Inform your partners of any open wounds or lesions that should be avoided during lab exercises.
Work on your partner to find the structures, NOT on yourself.
Treat each other with respect. Honor the boundaries that your partner possesses.
These boundaries may be quite different from one person to another.
Ask before you go too far!
It is very important to communicate with each other openly and honestly during examinations.
If you feel your partner is being too rough, tell him/her.
Treating each other in this respectful fashion during live anatomy will help ensure that you will treat your patients
similarly.
If you are uncomfortable being examined by a particular person speak to an instructor.
Racial, sexual, or religious bias and all forms of bigotry will NOT be tolerated.
See student handbook for university policies for further information
http://www.une.edu/studentlife/handbook/pdf/studenthandbook.pdf
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01: Introduction to Palpation and Skin
Discussion of sense of touch and tactility
Palpation practice (inanimate objects)
Palpate various objects in the bags/boxes and describe the "qualities" of those objects. Rather than just identification,
students should be using adjectives like; hard, soft, squishy, smooth, bumpy, malleable, round, square, triangular, brittle, sharp,
serrated, etc.). Students may also describe unknown objects by sight and/or by smell. Students should write down observations
on the supplied unknown sheet, as this will provide a record of
participation.
Be sure to WASH your hands before examining each other
Skin examination
The skin is the largest organ. It is made up of two layers, the epidermis (superficial) and the dermis (deep). These layers lie
superficial to the underlying fascia, which is made up of loose connective tissue and fat. The skin serves three primary
functions:
Protection (from mechanical injury, from invasion of foreign objects, from fluid loss)
Thermoregulation (through sweat and blood vessel diameter regulation)
Sensation (most notably touch, pain, heat and cold)
When examining the skin, notice that hair quantity and hair patterns vary markedly from one part of the body to another.
Look for direction of hair, amount of hair and types and length of hair.
Notice that the thickness of the skin and its sensitivity varies greatly from one body region to another. This sensitivity is
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related to the thickness of the epidermis and to the density of the nerve endings in a given part of the body (see homunculus
above). Some of the most sensitive regions include the lips, fingertips, tongue and external genitalia. The weight bearing
portions of the soles of the feet are particularly insensitive to light touch because of the thickness of the epidermis.
Notice creases in the skin around mobile body parts. These are related to the function of the underlying joints. Notice the
particularly complex system of creases on the palms. This is a direct result of the sophisticated movements that makes the
human hand unique among the primates. Look at the fingertips and notice the patterns of small ridges on the skin. These are
the fingerprints (dermatoglyphics). Take note of the lines (cleavage, tension) on the skin surface reflecting the underlying
connective tissue components of the skin. These are important in making incisions. Scarring is minimized if incisions are made
parallel to these tension lines.
Take note of any abnormal marks on the skin. Look for scars, tattoos, body piercings, open lesions, etc. Also look for any
warts, moles and freckles or any other discolorations such as "birthmarks".
Notice that in some regions of the skin large veins can be easily visualized. These are especially prominent on the back of
the hand and the anterior aspect of the forearm. On the legs these superficial veins may become distended and tortuous (due to
incompetent valves) and are referred to as varicose veins. Other common sites for varicose veins are at the knees, within the
scrotum, and at the inferior end of the esophagus.
Examine at the fingernails and toenails. These are outgrowths from the skin.
Von Frey Hairs (optional - as time permits)
Take some of the Von Frey hairs and test your partner for 2-point discrimination and detection threshold. The test subject
should not look at the area of skin that is being tested.
Lightly touch the two probes simultaneously to the back of the hand of your partner. Ask your partner if he/she felt one or
two pressure points. If your partner reported one point, spread the tips of the probes a bit further apart, then touch the back of
the partner's hand again. If your partner reported 2 points, push the tips a bit closer together, and test again. Measure the
minimal distance at which your partner reports two points. Skin receptors NOT uniformly distributed around the body. Some
places, such as the fingers and lips, have more touch receptors than other parts of the body, such as the back. This is one reason
why people are more sensitive to touch on their fingers and face than on their backs.
To test the detection threshold of someone, have your partner close his/her eyes. Touch the Von Frey hair to different places
on his/her skin until the “hair” just bends. It is important to press hard enough to just bend the hair. The size of the hair is
calibrated for specific force application and additional force will not be transferred to the patient. Ask your partner if they felt
anything. Change the size of the Von Frey hair and see if your partner can still detect the stimulus. Determine at which point
your partner can no longer detect the stimulus.
The Von Frey concept is based on the principle that a hair pressed against the skin will increase in force applied until it
bends. After bending, the increasing proximity of the probe to the skin will not increase the force applied. After the initial
deflection, the force is fairly constant or declines. This physical fact is used to make a stimulator that can be hand applied, yet
delivers a consistent and reproducible force, even though the hand could not. The force applied is a property of the hair
thickness and material composition.
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After the monofilament contacts the skin at 90°, the probe should be advanced an additional 1/8”. The resulting flexural
bow should be about ¼” from vertical. The more deflection will result in decreased and variable force.
The kit includes 20 hairs of graded sizes, with known clinical significance (see chart below). The set of 20 Von Frey hairs
based on the Semmes Weinstein set of 20 with near logarithmic increase in physical force applied and hence a linear increase in
perceived force applied. This kit is designed for diagnosing pathologies of crude touch sensation in humans or animals. The
Semmes Weinstein addition to that concept (the graded set linear scale of perceived intensity) has a long and successful clinical
record of diagnosing both hypo- and hyper-aesthesia. The probes fold under to a protected position when not in use.
Site
Fingers
Upper
Lip
Threshold
Distance
2-3 mm
5 mm
Cheek
6 mm
Nose
Palm
Forehead
Foot
Belly
Forearm
Upper
arm
Back
Shoulder
Thigh
Calf
7 mm
10 mm
15 mm
20 mm
30 mm
35 mm
http://www.myneurolab.com/myneurolab/mnl_products_detail.asp?idproduct=337500&catdesc=Animal+Function+%28P
harmacology+or+Neurology%29&CatThreeID=708&CatOneID=7&subcatdesc=Tactile+Sensitivity&idsubcategory=38
39 mm
39
41
42
45
mm
mm
mm
mm
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02: Upper Extremity
Be sure to WASH your hands before examining each other.
With your partner seated comfortably and the back and shoulders exposed, take a few moments to palpate the structures of
the shoulder girdle. Most of the bones of the upper extremity offer a palpable surface enabling the examiner to identify specific
structures. The bones of the shoulder girdle are the clavicle and scapula. The muscles of the shoulder girdle are those with one
attachment on a shoulder girdle bone and the other attachment on the trunk.
Follow the clavicle from its lateral end to medial end. This bone is concave laterally and convex medially. Between the
elevated medial ends of the clavicle is the jugular notch (suprasternal notch).
Palpate the sternoclavicular joint. Determine how the clavicle shifts during elevation and depression of the shoulder, as well
as protraction and retraction of the shoulder. Palpate the acromioclavicular
joint. The lateral end of the clavicle often raises higher then the acromion.
Determine how the clavicle shifts during flexion/extension of the arm as well
as protraction/retraction and elevation/depression of the shoulder. Feel the
motion in this joint as you passively abduct and rotate the humerus.
Anteriorly, identify the pectoral muscles. The sternal head of pectoralis
major attaches to the sternum and humerus while the clavicular head of
pectoralis major attaches to the clavicle and to the humerus. Palpate this muscle
near its sternal and clavicular attachment where the two heads can sometimes
be identified. Abduct your partner’s arm to about 120 degrees and note the
thick lateral portion of pectoralis
major. Note that this area of the
pectoralis muscle can be quite
sensitive to touch. Deep inside the
deltopectoral (CP- claviculopectoral
triangle - clavicle, anterior head of
deltoid and clavicular head of
pectoralis
major),
palpate the
coracoid process of the scapula. In
the female, the inferior portion of
the pectoralis major is covered by
breast tissue. Palpation of the entire
muscle in the male is readily
performed. Before leaving this area,
palpate the anterior border of the
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axilla. Identify the anterior axillary fold made by
pectoralis major.
Palpate the borders the muscles of the shoulder
girdle, namely the superior and inferior borders of
trapezius, superior and inferior borders of the
rhomboids (deep to trapezius), inferior border of
teres major and borders of latissimus dorsi.
Palpate the borders of the scapula. The medial
border is the most easily identified. The superior
and lateral borders will be more difficult to palpate
because of the overlying musculature. The superior
border of the scapula will be the most difficult. Next
palpate the inferior angle of the scapula. A
horizontal line interconnecting the right and left
inferior angle of the scapula would intersect the
vertebral column at T7 vertebral level. Palpate the
spine of the scapula running in a superolateral
direction from the upper third of the vertebral
border. The scapular spine starts medially at the
level of T3 vertebra. The spine of the scapula ends
with a large bony prominence (acromion) that
articulates with the lateral end of the clavicle. When
serratus anterior is paralyzed, the medial border of
the scapula moves away from the thoracic wall
giving the appearance of a “winged” scapula.
Next identify the large deltoid muscle that forms the rounded
contour of the shoulder. This muscle overlies the distal ends of the
muscles making up the rotator cuff. Deltoid has three distinct bellies,
with each serving different functions. The middle head is the largest
and is the strongest humeral abductor. The anterior and posterior
heads assist in humeral flexion and extension respectively, especially
when the arm is abducted to 90 degrees (horizontal flexion and
extension). Identify these three heads by having your partner abduct,
flex and extend his/her humerus against your resistance. Deep
palpation through the anterior part of middle deltoid, inferior to the
acromion is necessary to feel the greater tubercle of the humerus.
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The lesser tubercle of the humerus may be palpated through the anterior deltoid, inferior to the coracoid process of the
scapula. Arm rotation helps to identify the lesser tubercle of the humerus. Between the tubercles, locate the intertubercular
groove of the humerus. Before leaving this area, palpate the posterior border of the axilla. Latissimus dorsi and teres major
muscles make the posterior axillary fold. Moving down to the arm (brachium) notice two large muscle masses, one anterior and
one posterior, separated by the cutaneous lateral and medial bicipital grooves. These cutaneous grooves are not the same
structures as the bicipital groove of the humerus.
Posterior are three heads of the triceps brachii that
extend the arm and the forearm. Anterior, the biceps
brachii and brachialis (deep to biceps brachii) make up
most of the muscle mass. Note that the biceps brachii is the
strongest supinator of the forearm and the brachialis is the
strongest flexor of the forearm. This point is important for
remembering the distal attachments/insertion of these
muscles. Have the partner look away from his/her arm and
identify the difference between the biceps brachii and
brachialis. To demonstrate the biceps brachii, have your
partner attempt to supinate his/her flexed forearm against
resistance. To demonstrate the brachialis have him/her
attempt to flex the pronated forearm against resistance. It
helps to be able to recognize the biceps brachii tendon and
palpate on either side of it to find brachialis.
At the elbow, three prominent bony
landmarks can be palpated: the medial
epicondyle of the humerus, the lateral
epicondyle of the humerus and the olecranon
process of the ulna. These three landmarks
form a straight line when the forearm is
extended at the elbow and a triangle when
the forearm is flexed. The medial epicondyle
is the site of common attachment of the wrist
and finger flexors. Just proximal to the
medial epicondyle of the humerus is the medial supracondylar ridge, another site of flexor muscle attachment. The lateral
epicondyle/supracondylar ridge is the site of common attachment of the wrist and finger extensors. One muscle of this group
(brachioradialis) acts a forearm flexor rather than a forearm extensor. This muscle makes the large lateral mass in the anterior
forearm. Confirm the flexor and extensor attachments by having your partner flex and extend his/her wrist against resistance.
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Locate the cubital fossa. This space is located between the brachioradialis (distal/lateral) and pronator teres (distal/medial).
The other border of the cubital fossa is an imaginary line between the medial and lateral epicondyles of the humerus. The biceps
brachii tendon and biceps brachii aponeurosis are located in this space. Just distal to the lateral epicondyle of the humerus
palpate the head of the radius. This can be done easily by having your partner alternatively supinate and pronate his/her
forearm.
Moving down to the wrist, first palpate the prominent distal ends of the radius and ulna. There are styloid processes at the
end of each bone. Confirm that the styloid process of the radius extends further distally than that of the ulna. Palpate the head
of the ulna and locate the pisiform bone. The pisiform bone is the distal attachment of the flexor carpi ulnaris muscle and can be
moved from side to side when the hand is relaxed. The hook of the hamate can be palpated with deep pressure in the medal
palm, approximately 1cm distal and lateral to pisiform. Have your
partner flex his/her wrist while holding the little finger and thumb
together. On the anterior aspect of the wrist palpate the following
four muscle tendons (from lateral to medial): flexor carpi radialis
tendon, palmaris longus tendon, flexor digitorum superficialis
tendon, and flexor carpi ulnaris tendon. In approximately 13% of the
population, the palmaris longus tendon is absent. This absence may
be either bilateral (right and left) or unilateral (one side only).
The anatomical snuffbox lies to the radial side and dorsal on the
hand between the thumb and index finger. By extending your thumb
and at the same time hyperextending your wrist, identify the three
tendons that form the boundaries of this anatomical snuffbox (or
brevis sandwich). They are the abductor pollicis longus and extensor
pollicis brevis in a lateral/anterior position and the extensor pollicis
longus medial/posterior position. Sometimes a fracture of the
scaphoid presents itself as point
tenderness on the floor of the
anatomical
snuffbox.
This
relatively common injury can
occur after falling backwards upon
an extended and abducted wrist, as
might happen when ice-skating.
With the fist clenched and the
wrist extended against resistance,
locate the extensor carpi radialis
longus just dorsal to the distal end
of the radius. This is obscured by
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the extensor pollicis longus if the thumb is extended simultaneously. Moving medially locate the tendons of the extensor
digitorum and extensor digiti minimi. This can be accomplished by having your partner wiggle his/her fingers. Note that there
are two tendons associated with the second digit (index finger). The lateral tendon (closer to thumb) belongs to extensor
digitorum and the medial tendon belongs to extensor indicis.
On the palm note the two large muscle masses. These are the thenar and hypothenar eminences associated with the thumb
and little finger respectively. One important nerve is located at a specific site on the thenar eminence. The recurrent median
nerve lies very superficial in the center of this mass. An innocuous superficial wound to the thenar eminence must be carefully
examined to ensure that the nerve is intact. Be sure to test thumb function (flex, abduct, oppose thumb). The fact that this nerve
is often overlooked has led to the nickname the “million dollar nerve”. Place your partner’s ring finger on his/her thenar
eminence to locate the approximate site of the recurrent median nerve.
On the dorsum of the hand, palpate the dorsal interossei lying between the metacarpals. Having your partner abduct his/her
fingers against resistance to facilitate this. There are no muscle bellies between the phalanges, only tendons. The muscle bellies
lie between the metacarpals. The heads of the metacarpals form the knuckles, with the 3rd metacarpal head being most
prominent.
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03: Arteries, Veins, Nerves and Tendons of the Upper Extremity
Be sure to WASH your hands before examining each other.
Arteries
In the upper limb, the primary arteries are the subclavian, axillary, brachial, radial and ulnar. You will attempt to locate the
subclavian artery in the neck in a later session. The axillary artery is the continuation of the subclavian as it passes beyond the
border of the clavicle/1st rib. You cannot easily feel for this pulse.
The brachial artery is the direct continuation of the axillary as it passes inferior
to the lower border of the teres major. Its pulse can be felt medial to biceps brachii
(see picture). It often helps to palpate deep to the belly of biceps brachii and
superficial to the brachialis to find this artery. The brachial pulse can also be felt in
the floor of the cubital fossa, just medial to the bicipital tendon and just superior to
the medial epicondyle of the humerus. Find the brachial pulse in your partner.
In the cubital fossa the brachial artery bifurcates into the radial and ulnar
arteries, which run down the anterior aspect of the forearm on the lateral and medial
sides respectively. In about 2% of the population, a superficial ulnar artery occurs
superficial to the bicipital tendon (and to the bicipital aponeurosis). It can be easily
confused for a vein, with potentially disastrous results. Always check for pulsating
"veins" when performing venipunctures in this region. In addition, about 10% of
the population has a superficial radial artery. This is not usually a problem in
venipuncture as arterial pulsations are easily detected.
The radial and ulnar arteries go on to form the superficial and deep palmar
arterial arches within the hand. Both arteries contribute to each arch, but the ulnar
artery is the primary artery of the superficial arch and the radial artery the primary
artery of the deep arch. In your clinical assessment course, you will learn to do the
Allen's test to check for the competency of each of these arteries. This becomes
critical in preparation for hand surgery where the blood supply to the hand may be
compromised.
The radial pulse may easily be felt on the distal aspect of the forearm just lateral
to the tendon of the flexor carpi radialis (towards thumb). Remember that flexor
carpi radialis is the most conspicuous lateral tendon on the anterior aspect of the
forearm. It also helps to remember that radial side = thumb side = lateral side of the
forearm. In some individuals, the radial artery may be able to be palpated in the
anatomical snuffbox. This anatomical landmark is located at the base of the thumb on the side and is bounded by the tendons of
the abductor pollicis longus and extensor pollicis brevis on the anterior/lateral side and by the tendon of the extensor pollicis
longus on the posterior/medial side.
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To find the ulnar pulse, feel for the tendons the distal aspect of the forearm just medial (towards pinkie) to the tendon of the
flexor carpi ulnaris. Remember that flexor carpi ulnaris is the most conspicuous medial tendon on the anterior aspect of the
forearm. Flexor carpi ulnaris inserts into the hook of the hamate, pisiform and the 5th metacarpal.
Veins
The veins of each extremity can be divided into superficial and deep
veins. We will only be concerned with the superficial veins in LIVE
anatomy, but keep in mind that the two systems have multiple
interconnections. The deep veins run parallel to the arteries and are usually
found as a pair of veins on either side of the artery. Superficial veins do not
necessarily follow the same course are the arteries. Generally speaking, there
are very few superficial arteries associated with the extremities.
On the dorsum of the hand note the dorsal venous network (rete). Emerging from the lateral
aspect of this network and running along the lateral aspect of the forearm and arm is the cephalic
vein. This large vein empties into the axillary vein just medial to the anterior head of the deltoid,
deep within the deltopectoral triangle. It may be absent unilaterally (or bilaterally) and its size and
branching varies greatly. This vein is substantially larger in athletes. Find this vein on your partner
Emerging from the medial aspect of the dorsal venous network is the basilic vein. This vein
runs along the medial aspect of the forearm and empties into the brachial vein about 1/3 the way up
the arm. Find this vein on your partner. In the cubital fossa, the median cubital vein connects the
basilic and cephalic veins and is a common site of venipuncture. The pattern found here varies
greatly from person to person. Remember that in this region you need to be on alert for the presence of superficial arteries.
Running distal to the median cubital vein is the median antebrachial vein of the forearm. There may be several of these median
antebrachial veins. These represent other sites for venipuncture.
Choose a prominent vein on the forearm or hand of your partner and occlude (compress) it with one of your fingers. With a
finger (or thumb) from your other hand, push the blood in the vein proximally toward the heart, thus emptying the vein. When
you release the PROXIMAL digit the blood will backfill (flow distal – away from heart) to a specific point in the vein and then
stop. Remember that veins have valves to ensure that venous blood flows only in one direction.
Lymphatics
The lymphatic system is an extensive and dense network of vessels that return interstitial fluids to the cardiovascular system.
The lymphatics drain extra-cellular fluid, blood plasma and cellular debris from the periphery back into the venous circulation.
Lymphatic vessels are similar to veins, in that they have valves for one-way flow and have relatively weak walls. Lymph drains
centrally either through superficial vessels (for skin) or deep vessels (running along arteries and veins) towards the
brachiocephalic veins. At regular intervals, superficial lymph drains to deep lymph vessels. This lymphatic fluid is filtered along
the way by lymph nodes. These nodes vary greatly in size and are located superficial and deep on the body. The superficial
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lymph nodes can be examined by palpation. Since their size and numbers vary widely from person to person, it is common not
to be able to palpate normal lymph nodes. However if they are inflamed (fighting infection) or "hot" (metastasizing cancer) they
are readily palpable. Lymph nodes are named for the body regions in which they are located.
Lymph from the hand and forearm flows centrally
into cubital lymph nodes, located in the medial aspect of
the cubital fossa. From the cubital lymph nodes, most
lymph flows centrally into the axillary nodes. These
axillary nodes are divided into five groups (brachial,
subscapular, pectoral, central and apical/subclavian).
You may be able to GENTLY palpate two of these
groups. The pectoral axillary nodes can sometimes be
compressed against the lateral aspect of the thoracic wall
high up in the axilla, near the anterior axillary fold. The
subscapular axillary nodes can sometimes be palpated
about midway up the posterior axillary fold. The
brachial axillary nodes, pectoral axillary nodes and
subscapular axillary nodes all drain into the central
axillary nodes, which in turn drain into the
apical/subclavian axillary nodes.
From the subclavian lymph nodes, lymph continues
to drain centrally towards either the thoracic duct (left)
or the lymphatic duct (right). Both of these ducts drain
lymph directly into the brachiocephalic veins.
An
alternative route of lymph flow runs from the
deltopectoral nodes (located in the deltopectoral
triangle) to the subclavian axillary lymph nodes, where
it joins normal lymph flow to the brachiocephalic veins.
Peripheral nerves
The olecranon is often referred to as the "funny bone", defined by the feeling you get when you bang the elbow and
surrounding structures on a hard surface. The funny feeling is due hitting the ulnar nerve that lies just posterior the medial
epicondyle of the humerus, adjacent to the olecranon of the ulna. GENTLY feel for this large ulnar nerve as it passes posterior
to the medial epicondyle of the humerus.
Accidents can compromise the ulnar nerve and other inferior components of the brachial plexus. Typically, this is an
uncommon result when the upper limb is forcefully abducted from the torso. Damage to the ulnar nerve results in contraction of
the internal hand muscles and the characteristic “clawhand”.
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It is more likely that injuries to the upper extremity will affect the superior parts of the brachial plexus, including the
axillary, musculocutaneous and radial nerves. Typically this is a result injury between the neck and the shoulder. The upper limb
takes on the characteristic position of medial rotation, adduction of the shoulder and extension of the elbow. This is called the
“waiter’s tip position”. Damage specifically to the radial nerve results in “wrist drop”, a clinical sign indicative of paralyzed
forearm extensor muscles. The hand and fingers are unable to extend and are more strongly affected by gravity.
Median nerve injury
(benediction harnd)
Ulnar nerve injury (claw hand)
Disagree with Moore, p435,468
Locate the median nerve as it passes deep to, and just lateral (radial) to, the tendon of the palmaris longus. Injections into
the carpal tunnel are done about one finger medial (ulnar) to the tendon of the palmaris longus. Discuss why is it important to
determine if your partner has palmaris longus in this case. In addition, relocate the recurrent branch of the median nerve and
discuss its function.
Tendons
Locate the following tendons and the position of the appropriate joints for testing reflexes. If there is difficulty palpating any
of the following tendons, have your partner gently contract the appropriate muscle against resistance.
With your partner seated, have partner place his/her palm down on his/her thigh.
Palpate the bicipital tendon in the cubital fossa.
Hold partner’s flexed forearm across and against his/her chest.
Palpate the triceps tendon just above the olecranon.
Partially pronate the forearm and palpate the tendon of the brachioradialis.
(two fingerbreadths proximal to the radial styloid process)
Locate both tendons of the index finger. The tendon of extensor indicis is medial (closer to pinkie) and the lateral tendon is
one of the tendons of extensor digitorum. While holding partner’s hand, palpate the extensor tendons to the other digits. Follow
the tendons and muscles back to their origin on the lateral epicondyle of the humerus. This common proximal attachment of the
forearm extensors will become inflamed and produce pain radiating down the posterior forearm with repeated forceful flexion
and extension of the hand at the wrist joint. The common name for this condition is tennis elbow, indicative of repetitive use of
the superficial extensor muscles of the forearm.
Review the tendons bordering the anatomical snuffbox, including abductor pollicis longus, extensor pollicis brevis and
extensor pollicis longus. Determine the difference between the tendons of abductor pollicis longus and extensor pollicis brevis.
14
04: REXLAXATION PROCEDURES 1
Be sure to WASH your hands before working with each other.
Suboccipital Hold
The suboccipital muscle group is relatively easy to find. It lies just inferior the base of the skull, in a line from ear to ear.
While the entire muscle group responds positively to pressure in most cases, there is some variation in quality from one location
to another along the muscle attachments.
You will hold the following position with your partner for approximately 20 minutes. Although any position may be
relatively comfortable at the start, correct positioning is critical to last the entire exercise. You should sit comfortably upright
and rest your forearms on the elevated table. Your elbows should be just at the edge of the table and in a position to bear some
of your own weight.
Have your partner lay down face up (supine) on the table, in such a way that you can maintain your position. It is very likely
that his/her feet will hang off the end of the table. Reach under the base of his/her skull and press GENTLY upwards with your
fingertips. Most people will be able to tolerate strong pressure here. Start slowly! Tell your partner when you are going to start
moving or when you need to put down his/her head. Do NOT drop his/her head suddenly! Your fingers should be placed so that
the two distal phalanges of all 4 medial digits are near vertical. Your partner’s head should be suspended off of the palms of
your hands.
Only the weight of the head furnishes the pressure in this situation, keeping your partner in control at all times. The pressure
exerted is your partner’s choice. When doing this exercise too forcefully, the head will have a tendency to roll away from the
fingertips. If you are in the correct position, the only chin will elevate. If you're too high the forehead will elevate. Make sure
you are inferior to the nuchal lines of the skull.
The exact center of the neck is the one spot where you might not get a positive reaction. There is a small hollow there, right
at the top of the spine, below the base of the skull. To some people, pressure on this spot — which is not actually even muscular
— will be enjoyable. To others, it feels too vulnerable, yet there is no danger. Some people can learn to love it, if they feel
comfortable enough. They might prefer pressure on the thick bands of muscle on either side of the center, or they might prefer it
more laterally just behind the mastoid process. Your partner’s preference might be in the thinner insertions/distal attachments of
the tissue, more on the actual skull, or deeper into the muscle bellies inferior to the nuchal lines. Beware! Your partner won’t
want you to stop. After 20 minutes, tell your partner that you are going to GENTLY put down his/her head. Change positions
with your partner and have him/her go through the same suboccipital hold procedure.
It’s a bit tricky to effectively massage your own suboccipital muscles without a tool. Try using a tennis ball. To some extent
you can roll back and forth on that and get some satisfaction.
References:
http://vancouvermassage.ca/articles/spot-01.php
http://www.healingpeople.com/index.php?option=com_content&task=view&id=598&Itemid=136
http://headache.homepainrelief.com/Head&NeckInstructions%20.htm
15
05: Lower Extremity
Be sure to WASH your hands before examining each other.
Start with your partner standing up, facing you. Palpate his/her iliac crest (hip bone) and the iliac tubercle. The anterior 1/3
of the crest can be easily palpated because it is subcutaneous. The iliac tubercle can be palpated just anterior and lateral to the
highest point on the iliac crest. A horizontal line interconnecting the iliac tubercles (supracristal plane) would cross the vertebral
column at L4 intervertebral disc.
Palpate the anterior superior iliac spine (ASIS) at the anterior end of the iliac crest. The muscle belly of the tensor fascia lata
(TF) lies between the iliac tubercle and the ASIS. Locate this muscle belly. This is one of two potentially safe intra-muscular
injection sites in the gluteal region. An injection here is very unlikely to damage a vital structure.
Palpate the posterior iliac crest and locate the posterior superior iliac spine (PSIS). These can be found on the lower part of
the back and underlie the two conspicuous "dimples". These dimples also mark the superior margin of the sacroiliac joint. Just
medial and inferior to the PSIS is the superior aspect of the sacroiliac joints. In anatomical position, the anterior inferior iliac
spine (AIIS) is on the same vertical plane as the pubic symphysis and on the same horizontal plane as the PSIS. The other safe
injection site in the gluteal region is the superior lateral quadrant of the buttocks. The other three quadrants are unsafe because
of underlying structures. Look for the sciatic
nerve and gluteal blood vessels deep to the
gluteus maximus in the gross lab.
Have your partner lie on his/her side and
rotate his/her thigh medially/laterally while
you palpate the very large greater trochanter
of the femur. This bony prominence should
be located just proximal to the widest part of
the thigh. On the anterior aspect of the thigh,
note the large muscle mass made up of the
quadriceps femoris. Palpate quadriceps
femoris and pay particular attention to the
16
distally located vastus medialis (VM). Instruct your partner to contract his/her quadriceps femoris muscles to extend the leg at
the knee as you palpate vastus medialis. Identify the action of this muscle on the patella (P) and patellar ligament (PL). See if
you can trace the sartorius (S) as it runs from the ASIS medially and inferiorly to attach to the anterior/medial aspect of the tibia
just inferior to the knee joint. This muscle will only be readily identified in very muscular and/or thin individuals.
Another large muscle mass in the thigh that is located medially is the adductor group (AD). This muscle group can be
readily defined by adducting the thigh against resistance. The large muscle mass in the posterior aspect of the thigh is principally
made up of the hamstrings. This muscle group both flexes the leg at the knee and extends the thigh at the hip. Have your
partner lie face down with his/her knee flexed to 90 degrees. At the lower part of the thigh you can identify the
semimembranosus and semitendinosus medially and the long and short heads of the biceps femoris laterally. As your partner
contracts the hamstrings against resistance, identify these muscles as they define the superior/medial and superior/lateral borders
of the popliteal fossa in the back of the knee. Inspect and palpate the inferior borders of the popliteal fossa. These muscles are
the medial and lateral heads of gastrocnemius. When examining the knee and popliteal fossa, be careful not to apply too much
pressure to the structures of the popliteal fossa. Look for the sciatic, common fibular, and tibial nerves plus the popliteal artery
and vein in the popliteal fossa in the gross lab.Spend some time examining the knee. The femoral epicondyles are subcutaneous
and can be easily palpated when the knee is flexed or extended. The adductor tubercle, a small bony prominence for the
insertion of adductor magnus, may be felt at the superior margin of the medial epicondyle of the femur. Anteriorly, note the
17
patella (kneecap). With the leg extended and relaxed, move the patella medially and laterally. Locate the patellar base and apex
as well as the medial and lateral margins of the patella. Note the patellar ligament’s inferior attachment to the tibial tuberosity,
just proximal to the anterior tibial crest.
The medial and lateral tibial condyles can be palpated anteriorly at the sides of the patellar ligament, especially when the
knee is flexed. On the lateral aspect of the knee and slightly distal, locate the fibular head and neck. The common fibular
(peroneal) nerve lies subcutaneous on the fibular neck. Attempt to palpate the lateral collateral ligament of the knee. This is
readily done if you have your partner cross one leg over the other (ankle on knee). It runs from the inferior aspect of the femur to
the fibular head and feels very cordlike. The medial collateral ligament is not as easily palpated, as it is thinner and flatter and
attached to the medial meniscus.
Drawing your attention to the leg, examine the anterior muscle group. These muscles are the dorsiflexors of the foot (toe
extensors). They are very strong, as their primary function is to "lower" the body weight through the foot and ankle during gait.
The large posterior muscle mass plantarflexes (toe flexors) the foot at the ankle and produces the push-off power during gait.
The two largest and superficial muscles of this group are the gastrocnemius and soleus (triceps surae). These muscles come
together inferiorly to form the calcaneal tendon or Achilles’ tendon. Palpate this structure.
Move to the lateral aspect of the leg and palpate the small lateral group of muscles. These muscles fibularis (peroneus)
longus and fibularis (peroneus) brevis are the everters of the foot. Examine the ankle. Palpate the medial and lateral malleoli.
Note that the lateral malleolus extends further distally and more posteriorly than the tip of the medial malleolus. Just inferior and
posterior to the lateral malleolus palpate the tendons of the fibularis longus and fibularis brevis. Ask your partner to evert (point
sole laterally) his/her foot as you palpate these fibularis tendons.
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The dorsiflexor and plantarflexor tendons are held in
place by their overlying retinacula. These connective tissue
sleeves often tear following repeated inversion sprains (by
far the most common ankle sprains) and the tendons can be
felt pulling away from the ankle and lateral malleolus. Reexamine the calcaneal tendon. Understand that the ankle
joint (the tibiotalar joint) allows for dorsiflexion and
plantarflexion whereas the motions of inversion and
eversion take place at the transverse tarsal (subtalar) and
tarso-metatarsal joints. Passively move your partner’s foot
in these planes while palpating the joints of the ankle with
your other hand. Keep in mind that the motions of the foot
and ankle are very complex and rotate about three axes:
vertical, horizontal and transverse. Palpate the calcaneus.
The calcaneal tuberosity is posterior and very prominent.
Heel spurs are often associated with the calcaneus at the
point were the plantar ligaments attach to it (anterior). The calcaneal tuberosity is not readily palpable, but you can look for it
on the skeletons in the lab.
Examine the foot. On the lateral aspect of the dorsum note the muscle mass. It lies about two fingerbreadths anterior to the
lateral malleolus. This is the bellies of extensor digitorum brevis and extensor hallucis brevis. Just superficial to this muscle
mass, locate the tendons of extensor digitorum longus which run from the lateral anterior leg to the lateral digits. Usually there is
a fibularis (peroneus) tertius that arises from the lateral side of extensor digitorum longus. Fibularis tertius’ tendon inserts into
the base (tuberosity) of the 5th metatarsal. On the medial side of the anterior leg and dorsal foot, locate the tendons of tibialis
anterior (medial) and extensor hallucis longus (lateral). Tibialis anterior inserts into the navicular and medial cuneiform bones
and extensor hallucis longus inserts into the first digit.
Turning your attention to the sole of the foot, note the medial and lateral muscles masses that are similar to the thenar and
hypothenar groups in the hand. The skin on the sole is very thick and relatively insensitive compared to the skin of the hand.
Remember that there is all of the same musculature in the foot as in the hand, and if required to do so from birth one can
perform all hand functions with the feet. Inspect the transverse and longitudinal arches of the foot. Have your partner stand on
the floor with his/her feet about 8 inches apart, toes parallel and pointed forward.
Inspect the toes and note their natural position. Determine if your partner has any hammertoes (permanent flexion of one of
the interphalangeal joints of the toe). Identify if your partner has hallux valgus (deviate 1st digit toward lateral side of foot) or
hallux varus (deviation of 1st digit medially away from 2nd digit). One surgical technique replace an amputated thumb utilizes the
second toe. Notice that the second toe is more appropriate (size) than the big toe for this purpose. During gait, the second toe is
less important mechanically than the big toe. Ask your partner to abduct his/her toes and attempt to palpate the dorsal interossei
between the metatarsals.
19
06: Tendons, Nerves and Vasculature of the Lower Extremity
Be sure to WASH your hands before examining each other.
Arteries:
The major arteries of the lower extremity are the femoral, deep femoral (profunda femoris), popliteal, anterior tibial,
posterior tibial and fibular (peroneal) arteries. The deep femoral, anterior tibial and fibular arterial pulsations cannot be easily
palpated, but you should be able to locate all other pulses.
The femoral pulse can be felt just below the inguinal ligament. Use your right hand on your partner’s right inguinal
ligament. Place your index finger on the pubic tubercle and your thumb on the anterior superior iliac spine. Approach this artery
from the lateral aspect of the thigh and palpate half way between the anterior superior iliac spine and the pubic symphysis.
The popliteal pulse can be felt posterior to the knee, deep to the musculature. Have the partner lie prone (face down) and
passively flex his/her leg prior to palpating the pulse. The pulse is most easily felt in the inferior part of the popliteal fossa in the
midline. On occasion, this pulse can be very difficult to palpate. The popliteal artery, a continuation of the femoral artery,
bifurcates into the anterior and posterior tibial arteries just below the knee.
The pulse of the posterior tibial artery can be felt as it passes posterior the medial malleolus at the ankle. Palpate ½ way
between the posterior border of the medial malleolus and the medial border of the calcaneal tendon. The artery lies deep to the
flexor retinaculum and the retinaculum must be relaxed by inverting the foot, to feel the pulse. Failure to do so may lead to an
inability to feel the posterior tibial pulse.
The dorsal artery of the foot (dorsalis pedis) is the direct continuation of the anterior tibial artery. Have your partner slightly
dorsiflex his/her foot as you attempt to find the artery. The dorsalis pedis pulse can be palpated between the tendons of the
20
extensor hallucis longus and extensor digitorum longus on the top of the foot. Some healthy individuals have a congenitally nonpalpable dorsalis pedis pulse.
Veins:
The two major superficial veins are the greater and lesser saphenous veins. These are the equivalent to the upper limb
cephalic and basilic veins. The greater saphenous can be seen to originate anterior to the medial malleolus and runs up the
medial aspect of the leg and thigh (along inseam) to join the femoral vein in the femoral triangle below the inguinal
ligament. The great saphenous vein is often harvested to use for arterial grafts within the coronary circulation.
The lesser saphenous begins posterior to the lateral malleolus and runs up the lateral and then posterior aspect of the leg
and empties into the popliteal vein within the popliteal fossa. The superficial veins of the lower extremity are often the sites
of varicosities. Varicose veins have incompetent valves and thus run a very tortuous path. In some cases they can be quite
painful.
To locate a valve within a vein, place your fingers on a large easily defined vein and occlude it. With a finger (or thumb)
from your other hand, push the blood in the vein proximally toward the heart, thus emptying the vein. When you release the
PROXIMAL digit the blood will backfill (flow distal – away from heart) to a specific point in the vein and then stop (valve).
Remember that veins have valves to ensure that venous blood flows only in one direction.
21
Lymphatics:
Lymphatic vessels drain extra-cellular fluid, blood plasma and cellular debris from the periphery back into the venous
circulation. The lymph drains centrally either through superficial vessels (for skin) or deep vessels (running along arteries and
veins) towards the femoral veins. Lymph nodes are named for the body regions in which they are located. Inflamed superficial
lymph nodes can be examined by palpation, but it is common not to be able to palpate normal lymph nodes.
The first group of lymph nodes that is palpable in the lower limb is the popliteal group. These nodes are located in the
popliteal fossa. GENTLY palpate the popliteal fossa, keeping in mind the important arteries, veins and nerves in this region.
The popliteal lymph nodes drain to the inguinal group of lymph nodes. These are major lymph nodes draining the lower limb.
The inguinal lymph nodes are divided into four groups, 3 superficial groups and 1 deep group. You will only attempt to palpate
superficial nodes.
Just inferior to the inguinal ligament (index finger on pubic tubercle, thumb on ASIS), are the superolateral and
superomedial inguinal lymph nodes. The inferior inguinal lymph nodes are located slightly inferior to the superomedial inguinal
nodes along the great saphenous vein. GENTLY palpate these nodes on your partner. The deep inguinal nodes are located deep
to the inguinal ligament and cannot be palpated.
Nerves:
You will be locating only 1 peripheral nerve in this session and then working on identifying the innervation fields of other
nerves in preparation for the neurological exam.
On the lateral aspect of the knee and slightly distal, locate the fibular head and neck. The common fibular (peroneal) nerve
lies superficial to the fibular neck. See if you can gently palpate this nerve as it crosses the fibular neck. Given this location, it is
the most commonly injured nerve in the human body. Severance of the common fibular nerve results in the loss of dorsiflexion
of the foot at the ankle (footdrop). To compensate for this, individuals may adopt a waddling gate, a swing-out gait or a steppage
gait to keep the toes from dragging on the ground. The braking action of normal gait is lost and the resulting foot-slapping
action of heelstrike produces a distinctive “clop”.
The femoral nerve innervates the anterolateral thigh and lies subcutaneous, just distal to the inguinal ligament. It maintains a
position lateral to the femoral artery, just outside of the femoral sheath in the femoral triangle (FT borders – sartorius, adductor
longus and inguinal ligament). The obturator nerve that innervates the medal thigh lies deep to some of the adductor muscles.
The divisions of the sciatic nerve that innervate the posterior thigh lie deep to the hamstring muscles. Neither the obturator nor
sciatic nerve can be palpated. The sciatic nerve branches into the tibial and common fibular nerves. The tibial nerve innervates
the posterior leg, lies deep to gastrocnemius and cannot be palpated.
The common fibular nerve branches into the deep and superficial fibular nerve. The superficial fibular nerve innervates
the lateral leg and the deep fibular nerve innervates the anterior leg. The deep fibular nerve stretches down to the dorsal foot and
goes on to innervate the skin between the first and second toes. The deep fibular nerve is not palpable at any point.
22
Tendons / Ligaments:
Have your partner stand and palpate his/her patellar ligament
(tendon) just inferior to the patella. With the leg extended, the
ligament should be fairly loose and able to be passively moved
medial/lateral.
Have your partner sit down and ask him/her to flex his/her leg at
the knee. Support his/her knee with the other knee and re-examine
the patellar ligament. This is a site and anatomical configuration
commonly used to test reflexes. If the patella does not track properly,
it frequently will dislocate laterally.
Attempt to palpate the lateral collateral ligament of the knee.
This is readily done if you have your partner cross one leg over the
other (ankle to knee). The lateral collateral ligament runs from the
inferior aspect of the femur to the fibular head and feels very
cordlike.
The medial collateral ligament is not as easily palpated, as it is thinner and flatter and attached to the medial meniscus. This
fact is the reason that the medial meniscus is often damaged following blows to the lateral fixed knee. The three structures torn
in such injuries are the ACL (anterior cruciate ligament), medial meniscus and medial collateral ligament (these represent the so
called “unhappy triad”).
With your partner still seated, have him/her dorsiflex his/her foot as you palpate the calcaneal tendon posterior to the ankle.
Have your partner lie supine on the examination table, with his/her head supported on the table and his/her feet extending
off the table as necessary. Slide your partner’s foot towards his/her buttock until the knee is flexed at 90°. Keep your partner’s
foot supported on the examination table. Grasp your partner’s flexed leg with both hands just below the knee joint. GENTLY
pull the tibia away from the buttock while keeping your partner’s foot immobile. This is the anterior drawer test that determines
the functionality of the anterior cruciate ligament. You should not perceive any motion at the proximal end of the tibia with this
test.
While still holding onto your partner’s leg, GENTLY push the tibia towards the buttock while keeping your partner’s foot
immobile on the examination table. This is the posterior drawer test that determines the functionality of the posterior cruciate
ligament. Again, you should not perceive any motion of the proximal end of the tibia with this test.
In the gross lab, we will cut the cruciate ligaments on the knee of one of our cadavers so that you can see the positive
anterior / posterior drawer test.
23
07: Back
Be sure to WASH your hands before examining each other.
Start the back examination by inspecting the midline of the back, from the
skull to the superior sacrum. Make note of any lateral deviation from midline.
Attempt to palpate the spinous processes of C7, spines of T1-T12 vertebrae and
the spines of L1-L5 vertebrae. Note the different shapes and angles of the spinous
processes in different regions. The inferior direction of the thoracic spinous
processes can be closely studied on the skeletons in the gross lab. Two landmarks
that can help to orient are:
1
- The inferior angle of the scapula is at the approximate level of T7 vertebra
(or T6 spinous process).
2
- A plane connecting the iliac crests lies at L4 vertebral level (supracristal
plane), the site for lumbar puncture.
Inspect the spine from a lateral view and note any irregular curves in the
spine. There should be anterior curvatures (convex) at the neck (cervical lordosis)
and lower back (lumbar lordosis). There should be posterior curvatures (concave)
at the thorax (thoracic kyphosis) and sacrum (sacral kyphosis). Abnormalities
include missing regional curves, exaggerated curves in the thoracic (humpback /
dowager’s hump) or lumbar (hollow back) regions, and/or lateral curvature
(scoliosis).
Locate the vertebra prominens (usually the spinous process of C7 vertebra,
sometimes T1 vertebra spinous process). This may be done more easily if your
partner is sitting in a relaxed slouched position. After placing your fingers on the
two vertebrae (C7, T1), GENTLY rotate your partner’s
neck to the left and to the right. The spinous process of
C7 vertebra will move, the spinous process of T1 vertebra
will not. You may confirm this identification by passively
flexing and extending your partner’s head with motion at
C7 vertebra and no motion at T1 vertebra.
The T1 vertebra maintains its position due to its
attachment to the first rib. Superior to C7 vertebra, the
nuchal ligament obscures the spinous processes of most
of the other cervical vertebrae within the nuchal groove of
the neck. Try to locate the spines of C6 vertebra and C2
vertebra in the posterior neck.
24
The vertebral column is stabilized by a variety of intervertebral
ligaments, thereby restricting its motion. You will not be able to palpate
these ligaments, but visualizing their location will help to understand the
motion of the vertebral column. There are anterior and posterior
longitudinal ligaments on either side of the vertebral bodies. There are
also interlaminar, intertransverse, interspinous and supraspinous
ligaments connecting adjacent vertebrae. During extreme flexion or
extension of the vertebral column, these ligaments may become
compromised. Whiplash injuries happen with sudden, forceful extension
of the neck and tearing of the anterior longitudinal ligament.
Review the attachments of the trapezius. Have your partner shrug
his/her shoulders against resistance to demonstrate this muscle. Review
the attachments of the rhomboid muscles. Have your partner retract
his/her scapula as you palpate from the medial
border of the scapula and the vertebral spines.
Remember, when serratus anterior is
paralyzed, the medial border of the scapula
moves away from the thoracic wall giving the
appearance of a “winged” scapula. Review the
attachments of the latissimus dorsi. Have your
partner push his/her elbow posterior and medial
against resistance to demonstrate this muscle.
Starting at the top of the thoracic spine,
palpate bilaterally and get a sense for the
variation in thickness and extent of the
paravertebral musculature (erector spinae,
transversospinalis) that runs from the base of
the skull to the pelvic girdle. Locate the three
parts of the erector spinae: spinalis (medial),
longissimus and iliocostalis (lateral) on either
side of the vertebral column. The posterior
median furrow separates these muscles. Have
your partner extend his/her spine and note that
these muscles contract bilaterally. Have your
partner (ipsi-) lateral flex (side bend) his/her
back and notice unilateral (same side)
25
contraction. Palpate deep to the erector spinae muscles to locate the transverse thoracic processes and the angle of the ribs, if
possible (in thin partners).
Palpate the sacrum and some of its
landmarks. Palpate the spinous process of L5
and then move your fingers inferiorly until
you feel the spinous process of S1. Relocate
the dimples over the posterior superior iliac
spines. Locate the S2 sacral spinous process
in the midline between these dimples. This
location is the inferior limit of the
cerebrospinal fluid lumbar cistern.
Cerebrospinal fluid can be the site of
bacterial
infection
(meningitis)
or
cardiovascular leakage (blood in CSF). It can
also be used to detect a neurological
electrolyte imbalance. There is a blood brain
barrier
that
actively
protects
the
cerebrospinal fluid and it is difficult to obtain samples from inside the skull. Luckily, the subarachnoid space in the brain is
continuous with the subarachnoid space in the vertebral column. To obtain a sample of cerebrospinal fluid, a needle is used to
puncture the dura and arachnoid of the lumbar cistern. The needle is inserted between the spines of either L3/L4 or L4/L5
vertebrae. There is little danger of injury to the spinal nerves at this level and there is no danger to the spinal cord. The spinal
cord ends at L2 vertebrae and only the spinal nerve roots continue inferiorly as cauda equina. Anesthetic can be injected at these
sites to have a direct effect on the lumbar and sacral spinal nerve roots. Anesthetic injected into the lumbar cistern will have a
greater effect if injected subarachnoid rather than epidural. The amount of anesthetic and the position of the patient will also
play a large role in the action of the drug.
Spinal taps can also be used to treat slipped (herniated)
discs, typically in the lumbar region. Because of the size and
location of the posterior longitudinal ligament, protrusion of
the nucleus pulposus usually occurs in a posterolateral
direction. This tends to be the exact location of the spinal
nerve exit from the vertebral canal at each vertebral level. The
gelatinous nucleus pulposus compresses the spinal nerve and
a perception of pain is experienced.
26
08: LIVE ANATOMY REVIEW
Student Supplied Review Questions for Self-Study
Review previous handouts for answers
What is the largest human organ?
Locate the popliteal fossa.
Where is the anterior superior iliac spine?
What are the three elbow bony prominences?
Find the medial epicondyle of the humerus.
Locate the strongest forearm flexor.
What muscles make up the shoulder girdle?
Where is the medial border of the scapula?
What uses the medial epicondyle of the humerus as a common
attachment?
Where are dermatoglyphics located?
Palpate the inferior angle of the scapula.
Palpate soleus.
Name three functions of skin.
Where is the cubital fossa?
Where is the common fibular nerve best palpated?
Name and locate the strongest supinator.
What structural fracture causes pain in the anatomical snuffbox?
Locate the ulnar groove of the humerus.
Palpate extensor pollicis longus.
Outline trapezius.
Locate the spine of the scapula.
Locate pectoralis major.
Where is the posterior superior iliac spine?
Palpate the palmaris longus tendon.
Palpate extensor digiti minimi tendon.
Palpate the insertion of semitendinosus.
Localize the brachial pulse.
Locate the common attachment of wrist and hand extensors.
What is the common site of attachment for the wrist and finger
flexors?
Where are subscapular lymph nodes palpated?
Locate the fibular collateral ligament of the knee.
Outline the rhomboids.
Trace the boundaries of sartorius.
What nerve runs posterior to the medial epicondyle of the
humerus?
Which tendons make up the anatomical snuffbox?
Palpate the lateral border of the scapula.
Which of the two styloid processes of the wrist extend further?
What is the strongest humeral abductor?
Where are the supratrochlear lymph nodes located?
Locate the dorsalis pedis pulse.
Where would you palpate the calcaneal tendon?
Where is the thenar region?
What are the attachments of the long and short heads of biceps
femoris?
Palpate the acromion process.
Where is the acromioclavicular joint?
Palpate the calcaneal tuberosity.
Palpate flexor carpi radialis tendon.
Where is the vertebral border of the scapula located?
Which nerve is nicknamed the million-dollar nerve?
What is the location of the million-dollar nerve?
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09: Complementary and Alternative Medicine (CAM)
Today’s session is intended as a brief introduction to complementary and alternative forms of healthcare. Practices that are
now deemed "alternative" were considered standard medical practices for thousands of years previously. Some of these therapies
have been extensively researched and others have not. Currently, over 2500 references for complementary and alternative
medicine can be found in literature searches, including the research journals Science and Nature.
While conventional health care is still thought by many to be the primary option for treating an illness, many people
throughout the world still seek alternative medical solutions to their physical ailments. Much of this acceptance has been
prompted by a worldwide crisis in terms of quality health care. Prohibitively expensive conventional medical care has prompted
people to seek alternative means to cure their ailments. People suffering from chronic conditions or life-threatening diseases will
often seek out alternative treatment when they have exhausted all the possibilities that conventional care has to offer.
To give some background how these forms of medicine have performed in the past, an outbreak of cholera in Ohio in 1849
proved complementary and alternative medicine validity when only 3% of homeopathic patients died compared with a mortality
rate of 40-70% for those treated with conventional (heroic/allopathic) methods. In 1879, New Orleans homeopathic medical
practitioners treated yellow fever with a mortality rate of 5.6% while the conventional treatment (heroic/allopathic) yielded a
16% mortality rate.
Most alternative medicine practices fall outside the spectrum of conventional allopathic medicine. Some of the
complementary and alternative medicine practices are briefly explained below:
Acupuncture: Involves stimulating certain acupoints on a person's body to relieve pain, promote healing and overall well-being.
Allopathic Medicine: Advocates making use of all measures that have proven to be effective in the treatment of disease.
Chiropractic Medicine: Uses spine manipulation and adjustments as a way of treating health conditions.
Heroic Medicine: Inexact medicine using extreme measures to “cure” patients, including bloodletting and amputation.
This was the precursor of the allopathic medicine in practice today.
Holistic Medicine: Treats both the mind and the body as whole, rather than individual parts.
Homeopathic Medicine: A system of natural remedies used to treat disease.
Iridology: The study of the iris of the eye in order to diagnose illness or disease.
Massage Therapy: The manipulation of soft tissue in the body to relieve and prevent pain, stress, and muscle spasm.
Naturopathic Medicine: Focuses on the body's inherent healing powers and works to restore and maintain overall health.
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REFLEXOLOGY
Be sure to WASH your hands before examining each other
We are going to focus on reflexology, as novice reflexologists are not likely to injure their partners during these exercises.
Reflexology has been around for the past five thousand years. It has roots in China, but evidence has been found indicating that
reflexology was also used in Egypt as far back as 2300 B.C.
Many people seek reflexology for relaxation and to improve their health and well-being. It is thought that by pressing points
on the feet, impulses are sent through “pathways” to certain areas of the body, increasing energy and health in those areas. It is
believed that there is a "vital energy" that is circulating between organs of the human body that penetrates into every living cell.
During treatments, patients may even feel tingling sensations in the parts of the body to which the impulses are being sent. If
someone has a problem in a particular organ, a reflexologist will press on the corresponding reflex zone and the person will
experience pain. This pain is claimed to originate from the deposition of crystals in the reflex zone and, with massage, these
crystalline structures can be broken down and the pain relieved. Reflexology is thought to help anxiety, asthma and allergies,
chronic pain, diarrhea and constipation, high blood pressure, migraine headaches, premenstrual syndrome (PMS), skin
problems, and stress. In Great Britain, reflexology is covered as part of the National Health Service. In Switzerland, nurses use
reflexology with terminally ill cancer patients to reduce pain.
For the most of the part, the reflexology massage is pleasant and soothing. There may be discomfort in some places that is
an indication of congestion or imbalance in a corresponding part of the body. Reflexology can help relax your partner and is
believed to stimulate the body's healing mechanisms. Massage reflex points on your partner’s feet, hands and /or ears to see if
you can find tender spots and note problem areas. Use the following reflexology charts to explore your partner’s feet, hands
and/or ears. A course of treatment varies in length depending on the need of the body, but in this case you will spend about 20
minutes for the session and then change roles. As you are changing roles, talk with each other about the treatment. Ask your
partner if she/he ever had a problem with the structure that is reflexively related to the tender spot you located. Were there points
of pain? Was there any body tingling during the treatment? Does either of these correspond to any known conditions?
Reflexologists use a combination of foot, hand and ear reflexology to obtain the most accurate results. Most scientists and
medical professionals consider reflexology to be a pseudo-science, offering no more benefits than ordinary massage. They claim
there are no reliable scientific studies proving its effectiveness as a medical treatment, or that there is any form of link between
specific areas of the feet and the various organs of the body. Furthermore, the 'crystalline structures' rationale is not sustained by
current understanding of physiology. There is no scientific evidence that healing can be achieved by it or that the claimed
"energies" and their supposed pathways through the body even exist.
Prominent skeptic Stephen Barrett, M.D., contends there is no scientific support for any of the theories of Reflexology.
He refers to several scientific studies that have shown Reflexology is no better than random chance detecting medical problems.
In "Reflexology: A Closer Look", Dr. Barrett concludes "Reflexology is based on an absurd theory... Claims that reflexology is
effective for diagnosing or treating disease should be ignored. Such claims could lead to delay of necessary medical care..."
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30
http://www.crystalinks.com/reflexology.html
http://www.lww.com/product/?FWC20L
http://www.quackwatch.org/01QuackeryRelatedTopics/reflex.html
http://www.lww.com/product/?FWC20L
http://www.crystalinks.com/reflexology.html
http://aboutreflexology.com/charts.htm
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10: Eye and Eye Adnexa
Be sure to WASH your hands before examining each other
To start, instruct your partner to look straight ahead and focus on a fixed object in the distance (about 20 feet away). Inspect
the position of the eye in the orbit. Note if the visual axes are parallel and if the eyes are held steady.
Notice that there are three prominent features on the surface of the eyeball, the sclera, the iris and the pupil. Inspect the
opaque sclera and note the color of the tissue. You may be able to see numerous small blood vessels throughout the sclera. Note
if the obvious vessels are engorged or dilated. The cornea is a thick clear structure overlying the iris and pupil. The limbus is the
site where the sclera meets the cornea. A very thin layer of cells covers much of the sclera and passes back into the orbit and is
reflected up (and down) onto the deep surfaces of the eyelids. This transparent layer of cells is the conjunctiva. It has its bulbar
(eyeball) attachment at the limbus.
Inspect the colored iris and note the color variation from periphery to center, and from eye to eye. In the center of the iris,
you can see the black pupil through which light enters the eye. Inspect the pupil and determine if the pupils of both eyes match
in size and shape. The pupils should remain stable as long as the light levels remain stable. Muscles attached to the iris control
the diameter of the pupil and alter the amount of light entering the eye. Deep to the iris and pupil lies a thick clear lens. Muscles
attached to the suspensory ligaments of the lens contract to change its shape, allowing you to focus on nearby objects
(accommodation).
32
Use a pen light in a darkened area of the room to check pupillary reflexes. Quickly illuminate only one eye (right) without
illuminating the other (left) eye. Observe the pupillary constriction in each eye and confirm that they match in response. Shift to
the other side and do the same procedure for the left eye. Again observe the pupillary constriction in each eye.
Extra-ocular muscle function is evaluated by observing eye movement produced by isolated eye muscles. Positioning of the
eye so that individual muscles can only act on a single axis (perpendicular) of motion is critical to test the muscles. There are six
extra-ocular muscles that move the eye: superior rectus, inferior rectus, medial rectus, lateral rectus, superior oblique, and inferior
oblique. The rectus muscles shift gaze in the direction of the muscle name (superior rectus shifts gaze superior). The oblique
muscles shift gaze in the opposite direction of the muscle name, especially when the gaze is adducted (medial shift).
One
or more of the extra-ocular muscles may be paralyzed with head injury or problems with the brainstem. No matter the cause, the
result will be double vision (diplopia). Complete oculomotor nerve lesion affects most of the extra-ocular muscles, including the
muscles of the upper eyelid and the pupil. The pupil would be fully dilated, depressed and abducted. A lesion of the abducent
nerve results in paralysis of the lateral rectus muscle. This time, correct pupillary elevation and dilation would be maintained
although the pupil would be fully adducted.
33
Eye adnexa refers to the accessory structures of the visual system. You will need your partner’s help in order to see all of the
following structures. Ask for your partner to pull out his/her own eyelid and to move his/her eyes around in the orbital cavity to
improve your view.
First inspect the upper and lower eyelids (palpebrae). They are separated from one another by the palpebral fissure and
contact each other at the medial and lateral canthi (corners). Notice that there are hairs (eyelashes) emerging from each eyelid. A
small sebaceous gland (ciliary gland) for the eyelashes is associated with each eyelid. Inflammation of the ciliary gland results in
a sty on the edge of the eyelid. There is also a dense connective tissue band (tarsal plate) that supports the superior eyelid. Within
the plate, there are additional glands. These tarsal glands make an oily secretion that prevents the eyelids from sticking together
and prevents the lacrimal fluid from leaking out of the eye. Eyelid paralysis is the result of lesion of one of two cranial nerves,
either the oculomotor nerve (upper eyelid) or the facial nerve (lower eyelid). In either case, the eyelid droops (ptosis) in response
to decreased muscle tone.
The lacrimal gland sits in the upper lateral portion of the orbit. This gland is responsible for the majority of tears that are
secreted. The tears protect the eyeball surface from desiccation and microbial invasion. The tears run across the eyeball from
superior lateral to inferior medial where they collect in the lacrimal lake. From there, tears run into the nose via the nasolacrimal
duct.
Focusing your attention on the medial aspect of the orbit, locate a small fleshy mass. This is the lacrimal caruncle.
Protruding just lateral and deep to the lacrimal caruncle, find the plica semilunaris. Have your patient slowly look laterally and
the plica semilunaris will appear to emerge out from under the caruncle. Both of these structures provide connective tissue and
bony attachment for the conjunctiva. The lacrimal caruncle and the plica semilunaris lie on the floor of the space referred to as
the lacrimal lake, the portion of the orbit where tears collect.
Just lateral to the lacrimal lake locate a small elevation on the upper and lower eyelid. These are the lacrimal papillae. Atop
each papilla there is a small opening, the lacrimal punctum. The lacrimal puncta lead to the lacrimal canaliculi. These structures
drain tears into the lacrimal sac, which in turn drains inferiorly through the nasolacrimal duct into the inferior meatus of the nasal
cavity.
34
11: Neck
Be sure to WASH your hands before examining each other
Start by having your partner sit comfortably facing you. Inspect his/her neck from the body of the mandible to the superior
border of the clavicle. A very thin muscle (platysma), attached to the skin, covers this entire area. Locate the large
sternocleidomastoid (SCM) muscle that divides the neck into two spaces, anterior triangle and posterior triangle. The external
jugular vein runs superficial to sternocleidomastoid. Try to locate this superficial vein that tends to be prominent in singers and
other musicians. Ask your partner to take a deep breath and hold it to assist in your location of this vein.
Sternocleidomastoid runs from the medial
end of the clavicle and manubrium superiorly to
insert just posterior to the ear on the mastoid
process of the temporal bone.
Palpate the
margins of this muscle. Ask your partner to
rotate his/her head to one side and slightly
elevate his/her chin.
Examine the contralateral (opposite side)
sternocleidomastoid while your partner’s head
is rotated and locate the space between
clavicular and sternal heads of sternocleidomastoid. This space is called the lesser supraclavicular triangle and is a site of
internal jugular vein puncture (cannulation for diagnosis).
The anterior triangle of the neck uses sternocleidomastoid, the mandible and the midline of the neck as its boundaries.
Inside the anterior triangle are another 4 triangles of the neck, each with specific boundaries and contents that can be clinically
important.
35
The submandibular “triangle” is located just inferior to the mandible and is
bounded by the anterior and posterior digastric muscles as well as the mandible. This
space contains the submandibular gland and the facial artery.
The submental triangle is located inferior to the chin (mental protuberance) and
is bounded by the anterior digastric, hyoid bone and midline of the neck. This is the
site of the submental lymph nodes, which you are unlikely to palpate.
The muscular triangle is located directly inferior to the submental triangle. It is
bounded by the midline of the neck, sternocleidomastoid and omohyoid. It contains
the laryngeal and thyroid structures of the neck.
The carotid triangle is located inferior to the angle of the mandible. It is bounded by sternocleidomastoid, posterior digastric
and omohyoid. This triangle is relatively easy to locate, as it is the location of the strong carotid pulse. GENTLY palpate your
partner’s carotid pulse. Located in very close proximity to the common carotid artery are the vagus nerve (CN X) and the carotid
sinus, both of which help to regulate heart rate. Stimulation of this area can have a depressive effect on heart rate, which is one
possible treatment for heart fibrillation. Remember those complementary and alternative medical (CAM) procedures. This one
definitely has an effect! The common carotid artery bifurcates (splits) into the external and internal carotid arteries in the carotid
triangle, specifically at C4 vertebral level. Palpate the angle of the mandible and feel for the internal carotid pulse, just deep to
the ramus of the mandible. The internal carotid artery pulse may be difficult to locate at this site.
While your partner is still seated, move to a position behind him/her. Be careful here and be sure to tell your partner
what you are going to do! Palpate the angle of the mandible again and your fingers anteriorly along the body of the mandible
towards the mental protuberance. Once there, move your fingers inferiorly from the mandible to GENTLY palpate the hyoid
bone. This bone sits at the posterior part of the submandibular angle. Attempt to palpate it bilaterally and move it around. Have
your patient swallow to facilitate finding the hyoid. By pushing GENTLY on one side, the greater and lesser horns of the hyoid
can be palpated on the contralateral side.
There are a number of structures to be palpated in the midline of the anterior triangle. Move your fingers inferiorly from
the hyoid bone to GENTLY palpate the thyroid notch on the midline (very conspicuous in men) on the superior border of the
thyroid cartilage (at the level of C5 vertebra). Locate the intervening thyrohyoid membrane and move inferior to the laryngeal
prominence (Adam’s apple). Have your partner swallow again and confirm that the thyroid cartilage moves as the hyoid bone
moves. This cartilage is one of several sexually dimorphic structures in humans.
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Run your finger inferiorly along the thyroid cartilage until you come to a
gap between it and the next structure. The floor of this “gap” is made up of the
cricothyroid membrane. The next inferior rigid structure is the cricoid cartilage.
Slide your fingers inferior to the cricoid cartilage and GENTLY palpate the trachea
in the suprasternal notch. Tracheal rings 2-4 are covered over by the thyroid
isthmus just anterior to the trachea. If you are having difficulty palpating the
tracheal rings, have your partner swallow again to move the laryngeal structures.
You may feel the thyroid isthmus move during swallowing. The thyroid isthmus is
the site of tracheotomy (temporary) and tracheostomy (permanent) incisions.
Palpate the thyroid gland with the two lobes on either side of the trachea. This may
be difficult due to the infra-hyoid muscles covering the lateral lobes of the thyroid
gland. With the posterior approach, you can usually feel the posterior margin of the
lateral lobes of the thyroid gland, deep to the thin infrahyoid muscles.
Lymphatics of the neck are located throughout the neck triangles and surrounding sternocleidomastoid. The retroauricular
(mastoid) lymph nodes are located just posterior to the ear (auricle) and the parotid lymph nodes are located just anterior to the
ear. Both of these nodes drain into the superficial cervical nodes, overlying the sternocleidomastoid about 1/3 inferior to its
mastoid attachment. The superficial cervical nodes drain into the superior deep cervical nodes (deep to sternocleidomastoid).
The superior deep cervical nodes drain into the inferior deep cervical nodes. The submental lymph nodes drain into the
submandibular lymph nodes and subsequently drain into the inferior deep cervical (jugulo-omohyoid) nodes. Once lymph is in
the inferior deep cervical lymph nodes, it drains into either the lymphatic duct (right) or the thoracic duct (left) to reach the
37
subclavian veins. The supraclavicular lymph nodes, present just lateral to the clavicular attachment of the sternocleidomastoid,
also drain into either the thoracic or lymphatic duct.
Palpate along the anterior margin of the sternocleidomastoid from the manubrium to the mastoid process of the temporal
bone. Also palpate along the inferior margins of the mandible from the auricle (ear) to the mental protuberance. Feel for any of
the lymph nodes. Sometimes superior deep cervical nodes can be felt just anterior to the anterior margin of the
sternocleidomastoid and inferior to parotid or submandibular nodes. Remember, it is common not to be able to palpate normal
lymph nodes.
Next, palpate the external occipital protuberance and move your fingers inferior along the nuchal ligament to vertebra
prominens. Palpate the superior portion of the trapezius running from the superior nuchal line of the occipital bone to superior
scapular spine. The anterior margin of the trapezius, the posterior margin of the sternocleidomastoid and the clavicle form the
posterior triangle. The posterior triangle can be divided into two smaller triangles, with each with specific boundaries and
contents that can be clinically important.
The occipital triangle has sternocleidomastoid, trapezius and omohyoid as its boundaries. Several large nerves are
located within this triangle, including the spinal accessory nerve (CN XI) and the ventral rami of the brachial plexus.
The
greater
supraclavicular
triangle
has
omohyoid,
sternocleidomastoid and the superior border of the clavicle as its
boundaries. This triangle is separated from the lesser supraclavicular
triangle by the clavicular head of sternocleidomastoid. The greater
supraclavicular triangle is the site where the subclavian pulse can be felt
just deep to the superior border of the clavicle. This is also the site of
venipuncture for central line placement for prolonged cardiovascular
procedures. The pleura of the lungs and the subclavian artery are in
danger of puncture in this tight space.
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12: Ear, Nose & Mouth
Be sure to WASH your hands before examining each other
The ear is made up of three parts: external ear, middle ear, and inner ear. You will examine the external ear on each other
and the middle and inner ear as models in the gross anatomy lab. The external ear is made up of the auricle (pinna) and external
auditory canal. The auricle is the elastic cartilage, conch shell-shaped structure on the lateral head.
With your partner comfortably seated and facing you, examine your partner’s auricle to determine if both ears are
symmetrical. Palpate the entire pinna and confirm that it is made up primarily of firm elastic cartilage covered with skin. The
earlobe (lobule) also contains some subcutaneous fat. The prominent outer rim of the ear is the helix. Just anterior to the helix,
within the pinna, is the antihelix. The scapha separates the helix from the antihelix and the cymba separates the antihelix from
the external auditory meatus. The tragus is another prominent feature of the external ear that overlies the entrance (anterior) to
the external auditory canal. All of these folds together make the concha of the ear. Other structures that can be harder to see on
everyone are the anti-tragus (inferior to the tragus) and the auricular (Darwin’s) tubercle (if present). The auricular tubercle is a
thickening of the helix at the junction of the upper and middle third of the ridge that comes in a variety of shapes. There are
three muscles that move our ears, the anterior auricular, superior auricular and posterior auricular muscles. Some people can
even use these muscles to voluntarily wiggle their ears. Give it a try!
http://www.emedmag.com/html/pre/dia/11_03.asp
http://pinna.hawkelibrary.com/anatomicalvariations/1_9_R
The middle and internal ear cannot be viewed externally. An otoscope would assist you in viewing the tympanic membrane
and looking for signs of middle ear infection or torn membranes. Middle ear infections tend to be the result of blockage of the
pharyngeotympanic (Eustachian/auditory) tube. Swelling of the mucous membrane or an infection of the nasopharynx (or
adenoid/pharyngeal tonsil) will result in blocked drainage from the air-filled middle ear. In turn, this leads to middle ear
infection (otitis media) and swelling of the tympanic membrane. This painful condition causes the alteration of vibrations and
affects hearing (muffled sound).
Lesions of some cranial nerves can also affect hearing. Paralysis of stapedius, due to loss of facial nerve (CN VII)
innervation, results in excessively acute hearing. The paralyzed muscle no longer modulates the oscillations of the ossicle
(stapes) and all subsequent sounds are effectively amplified.
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Examine your partner’s nose. The external features include the tip, alar nasi (broad wings extending from the tip), nasal
septum and the anterior naris (opening, nostril) that leads to the nasal cavity. The upper lip has a prominent groove called the
philtrum. Inspect this nasolabial fold and check for symmetry in both depth and definition.
The first part of the nasal cavity is the vestibule and it is lined with skin rather than mucosa. Similar to most skin
throughout the body, it contains hair. The nose serves several functions including: olfaction, respiration, and filtration for
inhaled particulate matter, humidification and warming of inspired air, plus the drainage site of various secretions.
Note the location of the paranasal sinuses. The paranasal sinuses include the frontal, ethmoid, sphenoid and maxillary
sinuses. These air filled cavities are lined with mucosa and most effectively drain inferiorly into the nasal cavity. The maxillary
sinuses are the exception, with a small superomedial drain (ostium) that is non-functioning in anatomical position. Even small
amounts of congestion can block this drain and result in a maxillary sinus infection. The resulting pressure and pain are
transmitted through the trigeminal nerve (CN V2). On the CT, note the upper molar teeth in close proximity to the maxillary
sinuses. Any molar pathology can easily pass into these spaces as well.
With your partner comfortably seated and facing you, examine your partner’s temporomandibular joint. Place your fingers
anterior to the tragus to feel for the mandibular condyle. Ask your partner to open and close his/her mouth as you examine the
joint bilaterally. You should be able to feel the anterior gliding motion when your partner fully opens his/her mouth and the
posterior glide when closing his/her mouth. Ask your partner to clench and unclench their teeth as you palpate immediately
superior and anterior to the angle of the mandible and the temporal fossa (above zygomatic arch).
40
The masseter muscle can be palpated at the edge of the mandible as the muscle overlying the ramus. The temporalis muscle
is palpated in the temporal fossa superior to the zygomatic arch. Both of these muscles work together to elevate the mandible
and close the mouth. Determine if the muscles move symmetrically while closing and opening the mouth.
Next, inspect the margins of the mouth. Notice that the lips are muscular folds that surround the opening into the oral cavity.
Notice the dramatic change in the color and texture of the lip skin as it approaches the mouth. The skin becomes thinner and
hairless on the lips and this is referred to as the vermillion border. The mouth is made up of several sensitive regions (remember
homunculus), some of which you will need your partner’s assistance to view. Before we go any further, can you find Cupid’s
bow? The closed lips resemble a compound bow (for arrows) lying on its back.
Ask your partner to open his/her lips and expose the gums (gingivae) and teeth. There are supposed to be 32 teeth in the
adult, but dental surgery often decreases that number. Count the teeth that are exposed in your partner. Notice the edge of the
gums are scalloped in appearance and had numerous interdental papillae. Ask your partner to gently reflect his/her lower lip and
notice the rich vascular mucosa. On the internal surface of both the upper and lower lips there is a mucosal fold in the midline,
the labial frenulum. Ask your partner to pull their lips out and down (and up) to show this attachment.
Inspect your partner’s tongue while it is relaxed on the floor of the oral cavity. Determine if it is symmetrical from side to
side in regards to muscle mass. Have your partner stick out his/her tongue and note the numerous papillae on the dorsal surface.
Some of these papillae will look like small white dots on the red surface of the tongue. When your partner protrudes his/her
tongue, note if it deflects to one side. Examine the undersurface of the tongue. You should easily observe the prominent lingual
frenulum on the midline. Notice that on either side of the frenulum there is a prominent vein located just deep to the mucosa.
These are the deep lingual veins. They can be used as a site of rapid drug ingestion due to the thin mucosa and rich vascular
supply. Typically this is the site for life saving vasodilator (nitroglycerin) pills.
Near the inferior attachment of the lingual frenulum, notice two papillae just lateral of midline. The submandibular salivary
ducts open into these papillae. Ask your partner to imagine biting into a very sour lemon and see whether or not there is saliva
secreted through these openings. Next, show your partner a slice of lemon and squeeze a few drops into your own mouth.
41
Observe if this affects the saliva secretion of the submandibular glands. Finally, take a slice of lemon and place a small drop of
lemon juice into your partner’s mouth. Again see how this affects the saliva secretion of the submandibular glands. The paired
submandibular glands can be palpated just medial to the
mandible, overlying tense extrinsic tongue muscles. Ask
your partner to press his/her tongue against the back of
the upper incisors and then palpate these glands against
the internal mandibular body (about 1/3 posterior). You
can palpate your own sublingual glands by dragging
your tongue down the posterior surface of your lower
medial incisors and then move your tongue to one side
or the other over the floor of your mouth. Each gland
will feel round and firm and sometimes quite
asymmetrical in size. Finally, palpate the parotid glands.
These paired salivary glands lie posterior to the ramus
of the mandible and are superficial.
Ask your partner to open his/her mouth widely and
examine the posterior oral cavity. Look at the back of
the mouth and locate the uvula (the thing that hangs
down). Determine that the position of the uvula is
midline when at rest. Ask your partner to say
“AAAHHH”. Watch how the position of the uvula
shifts in response to phonation and respiration. Inspect
the lateral walls of the oropharynx and observe where
the soft palate reaches the pharynx and tongue. Notice
the two prominent folds (anterior/posterior pillars).
They are also called the palatoglossal (anterior) and
palatopharyngeal (posterior) folds/arches. In the space between the anterior and posterior arches, you should be able to see the
palatine tonsils between these two pillars. Be sure to ask your partner if he/she had his/her tonsils removed if you can’t find the
them between the pillars.
Nerve blocks for dental surgery can be performed in a variety of locations, depending upon which zones of the oral cavity
require the work. Between the 2nd and 3rd upper molars, the greater palatine nerve (CN V2) emerges to innervate the posterior
hard palate, the mucosa and the posterior on the ipsilateral (same) side. A nasopalatine nerve (CN V2) block, with an injection
just posterior to the upper incisors, results in anesthesia of the anterior hard palate, mucosa and the anterior incisors and canine
teeth on both sides. An inferior alveolar nerve block requires an injection of part of the mandibular division of the trigeminal
nerve (CN V3). The dentist feels for the lingula of the mandible on the internal surface of the ramus and injects near that site. All
of the ipsilateral mandibular teeth are anesthetized well as the mucosa, mandible and skin of the mental region of the face.
42
13: Head & Face
Be sure to WASH your hands before examining each other
Begin with the head examination by
comparing its position to the neck. Have your
partner sit in a comfortable position facing you.
The head should be on the midline and be held
steady. Palpate for the following landmarks on the
head: external occipital protuberance, glabella,
nasion, zygomatic arch, mental protuberance,
angle of the mandible and mastoid process of the
temporal bone. These are sites of bony sutures or
muscular attachment. Try to recall which muscles
are attached at each location. Inspect the skin of
the forehead and the location of the eyebrows.
Ensure that the structures are symmetrical. Ask
your partner to raise their eyebrows and watch for
uneven motion. Examine the palpebral fissures
and determine if they are symmetrical and evenly
open (check the height with a ruler). The upper
eyelid (palpebrae) should not cover the pupil and
in some individuals it does not cover any part of
the iris. The eye should be centrally located within
the orbit with uniform amount of sclera on either
side of the iris. Ask your partner to perform the following motions: close his/her eyes
tightly, smile, purse lips, frown. All motions should be symmetrical. Inspect the face for
uniformity of color and note if one location of the face (right, left, forehead, upper jaw,
lower jaw) is flushed or especially dry/clammy.
Bell’s Palsy is a condition in which the facial nerve (CN VII) is injured and the
ipsilateral facial muscles become paralyzed. This condition may be due to an infection of
the parotid gland. The facial nerve passes through the encapsulated gland on its way to the
facial muscles. The affected facial area appears to droop, including the eyebrow, upper
eyelid and corner of the mouth. Because the eyelids do not close tightly, tears often leak
from the orbit. The person is not able to eat effectively because he/she is unable to keep
the cheek tight against the teeth. Affected individuals will have altered speech and a
tendency to wipe at the tears and saliva that leak due to inadequate seals.
43
Try to GENTLY palpate the infraorbital nerve as it passes out of the skull, onto the maxilla. Locate this nerve by placing a
finger on your partner’s zygomatic process at the anterior end. Slowly shift medially to the face, inferior to the orbit. Move
approximately one fingerbreadth medial and inferior to the anterior part of the zygomatic arch. At this point your finger should
overlay the infraorbital nerve (CN V2) and the infraorbital foramen of the maxilla. Be careful. Too much pressure on this point
is painful! You may also be able to locate the smaller supraorbital (CN V1) and mental (CN V3) nerves using a similar method.
From the zygomatic arch, move medially and superior to the orbit to find the supraorbital nerve. Move along the body of the
mandible to just lateral to the mental protuberance to find the mental nerve. Both the supraorbital and mental nerves are
substantially smaller than the infraorbital nerve and are less likely to cause the extreme pain response.
Attempt to locate some of the terminal
branches of the external carotid artery. The
superficial temporal artery and some of its
branches can be located in the temporal fossa,
anterior to the ear and superior to the zygomatic
arch. The main artery is located just anterior to
the tragus of the external ear. This is the pulse
point that anesthesiologists use to monitor
patients. Some branches of the superficial
temporal artery can be felt at the origin /
superior (distal) attachment of temporalis, just
superior to pterion of the skull. This is a
potentially dangerous area for arteries. Blows to
the head can rupture the middle meningeal
artery (deep to pterion) and lead to intracranial
44
hemorrhage. Left untreated, this arterial bleed can result in death within a few hours.
Palpate the facial artery pulse as it passes over the mandibular base just anterior to the insertion of masseter. Occlusion of
this artery has little major consequence due to the large anastomosis with nearby vessels.
Lymphatics of the head are named based upon location or nearby structures. Lymph from the scalp drains either through the
occipital (posterior), retroauricular/mastoid (lateral) or parotid (anterior) lymph nodes. Lymph from the face drains through the
buccal (upper jaw), submental (anterior lower jaw) and submandibular (posterior lower jaw) lymph nodes. From each of these
subcutaneous lymph nodes, lymph drains into the superficial cervical nodes and then into the superior deep cervical nodes, lying
deep to sternocleidomastoid. The superior deep cervical nodes drain into the inferior deep cervical nodes and from there it
drains into either the lymphatic duct (right) or the thoracic duct (left) to reach the subclavian veins. Of all these nodes, the
submental node tends to be one of the most active. It is one that often “heats up” in association with cancer of the tongue.
Next session: We will be working on thoracic structures.
Please wear clothing that allows for direct visualization and palpation.
The ideal option is a tank top.
45
14: Respiratory Thorax
Be sure to WASH your hands before examining each other
While you obviously cannot directly examine the lungs by palpation, you can listen to them through the chest wall.
Therefore, it is important to know the precise location of the lungs and other organs, as they would be projected onto the
thoracic wall. Start with your partner seated comfortably facing you. Inspect the sternum and note if it is flat, indented or bowed
out. Examine the suprasternal (jugular) notch and confirm that it is located at T2 vertebral level. Examine the sternoclavicular
joints and palpate the medial end of the clavicle as you move the joint through its range of motion.
Locate the sternal angle (of Louis – T4 vertebral level – also the level of the tracheal bifurcation/carina) on your partner,
between the manubrium and the body of the sternum. Move your finger laterally until you find the second rib. The space below
rib 2 is the second intercostal space, as these spaces are numbered according to the rib located superiorly. Next palpate the
xiphoid process at the inferior most part of the sternum. The xiphoid becomes calcified with age and that may lead to “unusual”
bumps. The lower margin of the fifth rib is at the level of the xiphisternal joint (T9 vertebral level). Locate the rest of the ribs
and intercostal spaces through palpation on your partner. It is more easily done on thinner partners, but it should still be possible
in all partners. Combine groups as necessary.
The first rib lies inferior to the clavicle can only be indirectly palpated posterior to the clavicle (midclavicular).
Occasionally, cervical ribs increase the number of ribs in the thorax (1%). They are clinically significant as they may compress
the inferior trunk of the brachial plexus and the subclavian vessels. Relocate the second rib and "walk down" the ribs and
intercostal spaces with your fingers. Move slightly laterally as you descend as the ribs are quite close together at the sternum.
The first seven (true) ribs articulate directly with the sternum using their costal cartilages. Palpate the inferior margin of the ribs
close to the sternum to feel for the costal cartilage. This cartilage contributes to the elasticity of the ribcage. It starts to calcify
with age, leading to a more rigid thorax and decreased respiratory capacity. Ribs 8-10 (false ribs) articulate with the costal
46
cartilage of rib seven. Ribs 11-12 are unattached to the sternum and called floating ribs. The tip of rib 11 can be GENTLY
palpated anteriorly, while the tip of rib 12 can best be GENLTY palpated from the back.
Have your partner lie face down on the examination table and attempt to palpate the
ribs posteriorly. Locate rib 12 and then “walk up” the ribs and intercostal spaces moving
superolateral. Next, palpate the spinous processes of the vertebrae. Start by locating the
spinous process of C7 (vertebrae prominens – moves with neck rotation and flexion).
Count superior and inferior to locate as many vertebrae as you can. Look at a skeleton to
appreciate the relationship of the ribs between the thoracic vertebrae and the sternum. The
ribs attach at a higher point on the thoracic vertebrae than they seem to attach anteriorly on
the sternum. Also, realize that these vertebral levels are different than the dermatome
levels.
Locate the triangle of auscultation. The inferior lateral border of the trapezius, the
superior lateral border of the latissimus dorsi and the medial border of the scapula
(rhomboid major) bound this space. The floor of the triangle of auscultation is made by the
6th intercostal space between ribs 6 & 7. Have your partner slump forward while in a
sitting position that will enlarge this space and allow for less muffled lung sounds.
Imaginary vertical lines are clinically important to help locate structures throughout the thorax. These lines divide the thorax
into identifiable regions. Starting anteriorly find the anterior median (midsternal) line on the anterior midline. It runs from the
jugular notch through the umbilicus toward the pubic symphysis. Close to this line tends to be the location of the cardiac valves
of the heart. The midclavicular line, that divides the clavicle into equal lengths, runs just lateral to the rectus abdominus muscles
of the abdomen (semilunar lines) and divides the inguinal ligament in half. Close to the midclavicular lines are the location of
the breast tissue. The anterior axillary line is a vertical line dropped from the anterior axillary fold, made by pectoralis major.
This represents the anterior wall of the armpit. The midaxillary line divides the armpit into anterior and posterior halves using a
vertical line dropped from the apex of the axilla. This line is also used to define the inferior extent of the lungs and pleura in the
47
lateral thorax. The posterior axillary line represents the posterior axillary fold of the armpit and is made by latissimus dorsi and
teres major. A vertical line dropped from the posterior axillary fold limits this space. The scapular lines run along the medial
border of the scapula and continue as a vertical line dropped from the inferior angle of the scapula. The scapular lines tend to
closely parallel the midclavicular lines. The posterior median (midvertebral) line is on the posterior midline.
With you partner seated comfortably in front of you and his/her
hands resting on his/her thighs, observe your partner’s quiet
breathing. Determine which part of the breathing cycle takes longer
(inhalation/exhalation) as you count the respiratory rate. Place your
hands on your partner’s chest in anterior and posterior positions.
Note the deflection of the ribs during respiration during quiet
breathing. Ask your partner to breathe deeply for a few breaths and
again note the rib deflection. Move your hands to the right and left
false ribs (ribs 8-10) and monitor his/her breathing. Note the
transverse deflection of the ribs, especially during deep breathing.
Surface projections of the pleural spaces and the lungs reflect the
differences on the left and right. The pleural
reflections along the midclavicular line extend to
rib 8, along the midaxillary line they extend to rib
10 and along the scapular line the reflections
extend to rib 12. Along the sternum and costal
cartilage, the pleural reflections run parallel to one
another from rib 1 to rib 4.
48
Inferior to rib 4, the left pleura is deflected further left because of the
heart, but it is not until rib 6 that the right pleural reflection is deflected
further right. The parietal pleura is extremely sensitive to pain that will be
referred to the thoracic or abdominal wall. Irritation to the mediastinal pleura
may be referred to the root of the neck and shoulder due to the phrenic nerve.
The lung boundaries match the pleural reflections along the sternum and
costal cartilage (rib 6 on right, rib 4 on left), but they do not match along the
bodies of the ribs. The lung boundaries along the midclavicular line extend
only down to rib 6, along the midaxillary line to rib 8 and the scapular line to
rib 10.
Entry of air (or blood, intercellular fluid or lymph) into the pleural cavity results in a pneumothorax. (hemo-, hydro-,
chylo-) and subsequent collapsed lung. The surface tension adhering the parietal and visceral pleura is compromised and the
lung collapses on its own due to inherent elasticity. Care needs to be taken resolving these pleural issues because of the location
of the intercostal and collateral intercostal nerves and vessels. Needles should be inserted in the center of the intercostal space
(rather along a rib) to assure the preservation of the innervation and blood supply.
The arrowheads in Panel A show the position of the collapsed lung.
In Panel B, the arrowheads indicate the re-inflated lung and the position of the
chest tube.
Tariq, Sadaf (2006)
NEJM 354 (19): 2046
Next session: We will continue working on thoracic structures.
Please wear clothing that allows for direct visualization and palpation.
The ideal option is a tank top.
49
15: Cardiovascular Thorax
Be sure to WASH your hands before examining each other
While you obviously cannot directly examine the heart by palpation, you can listen to it’s valves and feel it’s beat through
the thoracic wall. It is important to know the precise location of the heart and its valves to fully evaluate the heart. Have your
partner sit comfortably in front of you and review the thoracic landmarks that were used to examine the lungs. Locate the
sternoclavicular joints, suprasternal notch, sternal angle, xiphoid process, xiphisternal joint, true ribs 2-6 and intercostal spaces
2-5. Relocate the imaginary vertical lines defining regions of the thorax: anterior median (midsternal), midclavicular, anterior
axillary lines.
Locate the heart as projected onto the anterior
chest wall. Outline the heart on your partner
using the washable markers provided. The
superior border of the heart lies posterior to the
sternum. Find the inferior margin of costal
cartilage 2 on the left and the inferior margin of
costal cartilage 2 on the right. A line drawn
across the sternum at this level represents the
superior border of the heart.
The right border of the heart is made up
entirely by the right atrium. The superior vena
cava runs down the right side of the sternum to
the 2nd costal cartilage where it enters the right
atrium. The right atrial border then continues
down to the 6th costal cartilage to the point where
the inferior vena cava
enters from below. Draw
the right border of the
atrium lies just lateral to
the lateral border of the
sternum with a slight
curve to the right between
the 2nd and 6th costal
cartilage.
The inferior border of
the heart rests on the
50
thoracic diaphragm. Draw it as it runs from the right 6th costal cartilage, posterior to the sternum to the left 5th intercostal space
on the midclavicular line. This left position is the apex of the left ventricle.
The left border of the heart completes the outline of the heat by connecting the superior and inferior borders of the heart. It
runs from the left 5th intercostal space on the midclavicular line to the 2nd costal cartilage on the left sternum border.
Identify and mark the locations of the 4 heart valves. The aortic valve is located posterior to the sternum along the anterior
median line at the level of the 3rd intercostal space. Superior and slightly to the left, the pulmonary valve is located at the 3rd
sternochondral junction posterior to the left border of the sternum. The triscupid valve is located posterior to the sternum at the
5th sternochondral joint along the anterior median line of the thorax. The bicuspid (mitral) valve is located posterior to the left
border of the sternum at the 4th sternochondral joint.
Bijl, van den Brink (2005)
NEJM 353(7): 712
Now, appreciate the differences
between the anatomic locations of
the heart valves and where to place a
stethoscope when listening to heart
sounds.
These do not match the
regions where you would hear the
heart sounds because the valves are
protected by the sternum. Bone is
extremely difficult through which to
hear. The aortic valve is best heard
in the 2nd intercostal space on the
right side of the sternum. The
pulmonary valve is best heard
directly across the sternum in the left
2nd intercostal space adjacent to the
sternum.
The
tricuspid
valve
(between right heart chambers) can
be heard in the LEFT 5th intercostal
space along the border of the
sternum. The bicuspid (mitral) valve
is best heard at the apex of the heart.
This is located that the 5th intercostal space on the left
midclavicular line.
Next locate the great vessels as projected onto the
anterior chest wall. The aortic arch lies posterior to the
sternal angle on the left border of the sternum. Just
inferior to the aortic arch, and slightly to the left, lies
51
the pulmonary trunk (arteries). About 1-2 fingers lateral to the sternum, these 2 major vessels form the aortic and pulmonary
“knuckles” of the radiograph. Just below the “knuckles”, a small portion of the left atrium appears in the 3rd intercostal space
and posterior to the 4th rib. The remainder of the left border of the heart is made up of the left ventricle. The right border of the
heart can be seen posterior to the sternum as a slight bulge in the 4th and 5th intercostal space on the right.
Finally, check your partner’s heart rate. You
could use any of the upper or lower extremity
pulse points that we have already located in the
body. You can also find an apical heartbeat to
determine the heart rate. The apical heartbeat is
located in either the 4th or 5th intercostal space
on near the left midclavicular line of the thorax.
The heart is innervated with autonomic nerves
to maintain a normal heart rate. The heart is
insensitive to touch, temperature or sharp pain,
but pain due to ischemia can be felt
instantaneously. This pain information is not
transmitted through the autonomic motor nerves. Instead, the heart refers pain to the thoracic wall through the intercostal nerves
(primarily left). Pain may be perceived in left thoracic areas or in the left upper extremity due to those left intercostal nerves
joining the spinal cord between T1-T5 spinal levels. If you think back to your dermatome map, these spinal nerve levels
correspond with the thorax and upper extremity.
As a final thought, be careful if your examination gives
you the exact opposite results from what you expect. Leads on
electrocardiograms may be mixed or images may be
mislabeled. On occasion, the thorax is where the error lies.
During development, the heart is supposed to take up a
position on the left side of the thorax. Occasionally, it resides
on the right and the individual will have right-sided heart
sounds. Individuals can live completely normal lives with
dextrocardia (right heart) or situs inversus (inverted location).
These conditions usually only come to light as other clinical
issues need to be addressed.
Next session:
We will continue working on abdominal structures.
Please wear clothing to allow for visualization.
Spigelman (1994)
The ideal option is a tank top.
NEJM 330(9): 606
52
16: Abdomen
Be sure to WASH your hands before examining each other
Abdominal exams are an important and challenging component of the physical exam. Start with your partner lying
comfortably in a supine position. Inspect the anterior abdominal wall and observe if it is flat, distended, scarred, bruised or if
there are dilated veins present. Inspect the umbilicus (at L3/L4 intervertebral disc level) on the anterior median line. Note if the
umbilicus is off-center, inverted or everted. Remember that the dermatome that innervates this level is the T10 spinal nerve. Ask
your partner to cross his/her arms over his/her chest and then lift his/her shoulders off the table. Determine if it is possible to see
the lateral border of the rectus abdominus muscles (semilunar lines) and the tendinous insertions of the rectus muscle near the
umbilicus.
Note the locations of important abdominal landmarks used to lay out the lines necessary for reference. Palpate the xiphoid
process of the sternum and note its location. Remember this process may be calcified in older individuals. From this point, trace
(with your finger) the margins of the infrasternal angle and move laterally along the costal margin on either side. Palpate the
inferior margin of rib 10 and follow it to the midaxillary line. Palpate the iliac crests and the anterior superior iliac spine (ASIS)
to locate the inguinal ligament. Remember that the inguinal ligament connects to the anterior superior iliac spine and the pubic
tubercle. The inguinal groove is a skin crease that lies just superficial to the inguinal ligament.
The anterior abdominal wall can be divided into either 4 quadrants or 9 regions using a series of vertical and horizontal
lines that intersect at identifiable anatomical landmarks. These two clinical reference systems used for locating organs relative to
the abdominal wall. On one partner, draw the two lines of the 4-quadrant system using the washable markers provided. On the
other partner, draw the 4 lines of the 9-region system. Representations of different organ systems will be drawn on each student
using the lines and other anatomical landmarks are reference points.
The 4-quadrant system requires two lines intersecting at the umbilicus. Locate the xiphoid process and the umbilicus and
draw a vertical anterior median line/plane (AML/P) to connect these structures with a line that extends towards the pubic
symphysis (on pelvic midline). A horizontal transverse umbilical line/plane (TUL/P) intersects the umbilicus as it extends from
the right midaxillary line to the left midaxillary line. These lines define the right upper quadrant (RUQ), left upper quadrant
(LUQ), right lower quadrant (RLQ), and left lower quadrant (LLQ).
53
The right upper quadrant is the location of the liver, gall bladder, duodenum, right kidney, head of the pancreas and the
hepatic (right) colic flexure. The left upper quadrant contains the stomach, spleen, left kidney, body of the pancreas and the
splenic (left) colic flexure. The lower right quadrant is the location of the appendix, cecum, right ovary, right ureter and
ascending colon. The lower left quadrant contains the left ovary, left ureter, descending/sigmoid colons.
The 9-region system requires 2 additional lines to create smaller spaces. We are going to stick with bony landmarks to
locate the next lines, but additional vertical and horizontal lines are based upon soft structures in the abdomen. On the unmarked partner, locate the center point of the clavicle and the center point of the inguinal ligament (inguinal groove). Draw a
vertical line between both of these locations on the right and the left sides of the abdomen to represent the midclavicular
(midinguinal) lines/planes. Approximately 1 inch medial to the midclavicular lines are the semilunar lines, made by the lateral
margin of rectus abdominis. These semilunar lines can be used as the vertical lines/planes of the 9-region system as well (see
Netter 268 – no need to mark).
The first of the horizontal lines is the subcostal line/plane (SCL/P) that runs from the lowest extent of the 10th costal
cartilage on the right to the lowest extent of the 10th costal cartilage on the left. Draw in the subcostal line and confirm that it
aligns with L2/L3 intervertebral disc. Just about 1 inch above this line lies the transpyloric line/plane (TUL/P) that runs through
the center of the pyloric canal (of the stomach) and the inferior border of the costal cartilage of rib 8 (see Netter 268 – no need to
mark). Another way to locate the transplyoric line/plane is to make a horizontal line
½ way between the xiphisternal joint and the umbilicus at the L1 vertebral level.
The second horizontal line is the transtubercular line/plane (TTL/P) that interconnects the right and left iliac tubercles (L5
vertebral level). Draw this line approximately 1 inch below the transtubercular line/plane is the interspinous line/plane. This
horizontal line runs between the anterior superior iliac spines and may be used in place of the intertubercular line/plane (see
Netter 268 – no need to mark).
No matter which of the two horizontal lines (subcostal/transpyloric and transtubercular/interspinous) are chosen, the
resulting 9 regions will be smaller than the 4 quadrants, yet still contain specific organs. The right/left hypochondriac regions are
54
located deep to the ribcage. In between them is the epigastric region in the intrasternal angle. The middle regions are arranged so
that the right/left lumbar (flank) regions on either side of the umbilical region. The inferior regions are named for the inguinal
ligament (right/left inguinal or groin) and the hypogastric (suprapubic) region centrally located.
Locate the abdominal organs in either the 9-region or 4-quadrant system. You are only going to draw some of the organs
in the outlined spaces. Draw the stomach and kidneys or the liver, pancreas and spleen on your partner.
STOMACH
Outline the boundaries of
the
stomach
in
the
left
hypochondriac, epigastric and
umbilical
regions
of
the
abdomen (mostly in upper left
quadrant).
The
orifice/sphincter
cardinal
(entry
to
stomach) lies posterior to the
left 6th costal cartilage at
T10/T11 intervertebral disc.
The fundus of the stomach extends slightly superior, deep to the left rib 5. The greater curvature of the stomach runs from the
fundus to the left 10th costal cartilage and through the superior parts of the umbilical region in the infrasternal angle (inferior to
the subcostal line). The pyloric part of the stomach sits at the L1 vertebral level, just inferior to the transpyloric line. The pyloric
sphincter crosses to the right side of the abdomen, exactly on the transpyloric line (L1 vertebral level).
KIDNEYS
Outline the boundaries of
both kidneys in the right/left
lumbar (flank) regions. This
can be done from the anterior,
but it will help to locate the
organs
from
a
posterior
direction. Ask your partner to
prone and locate the kidneys
deep to ribs 11-12. The left
kidney (2x3inches) is centered
on the junction between the
transpyloric line and the left scapular line. The hilum of the kidney and the renal arteries are located at L2 vertebral level. The
abdominal aorta bifurcates about 2 inches below this level at L4 vertebra. The right kidney sits mostly below the transpyloric
line on the right scapular line. It is approximately the same size as the other, but it is located about 1 inch (2.5cm) below the
55
level of the left kidney. In thin partners, the right kidney will descend during deep inspiration. Ask your partner to take a deep
breath and determine if you can feel a firm, smooth, rounded mass shifting inferiorly on your partner. As your partner exhales,
the right kidney will shift back into its normal position.
PANCREAS/SPLEEN
Outline the borders of the spleen in the left
hypochondriac region. The spleen is about the size of the
kidneys (2x3inches) with the long axis parallel to ribs 9-11
along the posterior abdominal wall. It is rarely palpable
unless it is enlarged due to infection.
The pancreas lies along the transpyloric line. The tail
extends to the left hypochondriac region near the hilum of
the spleen. The head of the pancreas sits below the
transpyloric line at the L2 vertebral level in the umbilical
region, just to the right of the anterior median line. No pancreatic
structures are palpable.
LIVER
The liver occupies most of the upper right quadrant and spills
over to the left side of the abdomen. It sits inferior to the
diaphragm and deep to ribs 7-11 on the right. The inferior border
of the liver follows the costal margin on the right at the axillary
lines. As the liver extends towards the left, it fills the infrasternal
angle through the Epigastric regions and reaches the left
midclavicular line. Ask your partner to inspire deeply to try to palpate the
liver as it moves. Just inferior to the right costal margin/cartilage,
throughout the upper right quadrant, you should be able to palpate a
smooth, firm edge to the liver as it descends during inspiration.
As a final exercise, locate and mark McBurney’s point on all
partners. This point is superficial to the appendix and a likely site of
emergency abdominal access for acute inflammation of the appendix.
Start by tracing a line (with your finger) between the right anterior
superior iliac spine and the umbilicus (spinoumbilical line). Where the
transtubercular line/plane crosses the right midclavicular line/plane is the
site of McBurney’s point. This point is 2/3 of the distance from the
umbilicus to the ASIS along the spinoumbilical line and is the site of
maximum abdominal tenderness due to appendicitis.
56
17: Referred Pain
The presumption that pain originates at the site of that stimulus is usually correct, but this may not always be the case. Often
the cause of pain is at the exact location that pain is perceived. This is somatic pain and it is described as sharp, cutting, fast and
easily localized. For example, knee pain usually comes from the knee itself, whether it is skinned in a fall, the articular cartilage
wears away through disease or the meniscus tears due to external forces.
But, at times, knee pain comes from a healthy knee. It may really be hip pain that is perceived at the knee or poor mechanics
in the foot that lead to knee pain. This can be nearly as sharp and quick, although it may be harder to localize. When pain is
perceived in a location other than the site of painful stimulus, it is called referred pain. It's defined as pain from a malfunctioning
or diseased area of the body, perceived in another area, often far from the origin. Referred pain is quite common.
Abdominopelvic organs are a common source of referred pain. In these situations, the pain perception is not like somatic
pain. Visceral pain is described as vague, hard to localize, deep-seated and dull. In the case where abdominal pain is referred to
another area, it can be difficult to determine the original location of the pain stimulus. Often visceral pain will be experienced as
somatic pain at a distant site distant away from the affected organ. For example, myocardial ischemia is often referred to the
upper left chest wall, down the inside of the left arm and forearm. It may also extend to the left side of the head.
Somatic pain transmissions are sent by the nervous system indicating to the brain that a specific area hurts. The reasons for
referred pain are not completely known, yet somehow related is the fact that when there's pain in these (and other!) areas and
action must be taken. Referred pain may indicate a problem that is not so obvious. Any of the following situations should be
treated as emergency situations: sudden, sharp abdominal pain; chest, neck or shoulder pain; swollen and tender abdominal
regions. Although less critical, the following should also be treated by a physician: recurrent, persistent or increasing abdominal
pain, especially when accompanied by shortness of breath, dizziness, bleeding, vomiting or a high fever.
Abdominal pain has the unusual ability to travel along nerves and emerge at sites strangely distant from the source of the
problem. Pain related to gallbladder inflammation can spread through the right phrenic nerve to the right thorax and right
shoulder/arm. Pain from the spleen can spread through the left phrenic nerve to the left shoulder and neck. Pain from a pancreas
disorder may radiate posteriorly between the shoulder blades. Pain from the throat may be perceived in the middle ear.
57
Specific Examples of Referred Pain
http://www.mayoclinic.com/health/abdominal-pain/DG00013
Umbilical pain
Pain near the umbilicus can be related to a small intestine disorder or an inflammation of your appendix.
(appendicitis)
Epigastric pain
Pain associated with stomach disorders (Gastro Esophageal Reflux Disease - GERD, peptic ulcer, esophageal hiatal hernia) is
perceived here. Persistent pain in this area may also signal a problem with your upper small intestine (duodenum), pancreas or
gallbladder.
Left Hypochondriac pain
It's uncommon to experience pain here, although it suggests colon, stomach, spleen or pancreas problems.
Right Hyopchondriac pain
Intense pain in this region is often related to inflammation of the gallbladder (gallstones, cancer). The pain may extend to the
center of the abdomen and/or penetrate to the back. Occasionally, an inflamed pancreas (pancreatitis) or duodenum can cause
pain in this area as well.
Suprapubic (Hypogastric) pain
Pain that spreads to either side may signify a colon disorder (irritable bowel syndrome). For women, pain in this area may also
indicate a urinary tract infection or pelvic inflammatory disease.
Left Inguinal pain
Pain here most often suggests a problem in the lower colon, where food waste is expelled. Possible causes include inflammatory
bowel syndrome, Crohn’s disease or an infection in the colon known as diverticulitis.
Right Inguinal pain
Inflammation of the colon may cause pain in your lower right abdomen. The pain of appendicitis initially will be spread over the
entire lower right quadrant. Eventually it usually localizes to McBurney’s point on the spinoumbilical line at the union of the
right midclavicular and transtubercular lines. If the appendix gets clogged or obstructed, it may become inflamed. Without
treatment, an infected appendix can burst and cause a serious infection (peritonitis). Appendicitis may also cause nausea,
vomiting, loss of appetite, fever, and the urge to defecate.
Other organs also refer visceral pain to somatic regions. The heart refers pain to the left shoulder/arm, the lungs refer pain to
the thoracic wall and diaphragm and the brain refers pain to the meninges.
58
After amputation of a limb, an amputee continues to have an awareness of the limb and to experience sensations from it.
These phantom limb sensations are also present in children born without a limb, suggesting that perception of our limbs is 'hardwired' into our brain and that sensations from the limbs become mapped onto these brain networks as we develop. If phantom
limb sensations are normal then so is
Another pain phenomenon that is difficult to describe is trigger points. Trigger points are concentrated fascicles inside a
larger muscle that often are the sites of acute trauma or repetitive injury. Examples of these injuries would include holding a
telephone receiver between the ear and shoulder; prolonged bending over a table; sitting in chairs with poor back support,
improper height of arm rests; and moving boxes using improper body mechanics. Acute sports injuries (e.g., tennis elbow),
surgical scars, and tissues under tension frequently found after spinal surgery and hip replacement may also predispose a patient
to the development of trigger points.
Trigger points produce local somatic pain and may refer pain in a specific pattern. Typically, trigger points involve the
postural muscles of the neck, back and pelvis. Palpation of a sensitive bundle of muscle fiber, firmer than normal, is usually
associated with a trigger point. Palpation of the trigger point will elicit pain directly over the affected area and/or cause radiation
of pain outward in concentric circles from that site. The area of perceived pain is usually much larger than the actual site of
stimulation. Referred pain is an important characteristic of a trigger point. It differentiates a trigger point from a tender point,
which is associated with pain at the site of palpation only. Tender points are not associated with referred pain and occur in the
insertion zone of muscles, not in taut bands in the muscle belly.
Localization of a trigger point is based on the individual’s sense of feel, assisted by his/her partner’s expressions of pain.
Palpation of a trigger point will elicit pain over the palpated muscle and/or cause radiation of pain toward the zone of reference
in addition to a twitch (withdrawal) response. The commonly encountered locations of trigger points and their pain reference
zones are consistent.
A
B
C
Examples of the three directions in which trigger points (Xs) may refer pain (dark): (A) Peripheral projection of pain from
suboccipital and infraspinatus trigger points. (B) Mostly central projection of pain from biceps brachii trigger points with
some pain in the region of the distal tendinous attachment of the muscle. (C) Local pain from a trigger point in the serratus
posterior inferior muscle.
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For trigger points in the acute stage of formation (before additional pathologic changes develop), effective treatment may be
delivered through manual methods. The goal of manual therapy is to train the patient to effectively self-manage the pain and
dysfunction. However, manual methods are more likely to require several treatments and the benefits may not be as fully
apparent for a day or two when compared with injections. The patient should be placed in a comfortable or recumbent position
to produce muscle relaxation.
Be sure to WASH your hands before examining each other
Have your partner partner lie prone on the examination table. Working in the locations indicated, try to locate a trigger point
in one of the large postural muscles of the back. Use alternating pressure between two fingers to confirm the location of the
palpable nodule of the trigger/tender point. As the trigger/tender point is palpated, ask your partner to describe the sensation. If
it’s painful, have him/her describe the exact location of the pain to determine if it is being referred to a different location. There
are normally about 20 tender/trigger points in the body. Determine how many of these points your partner has.
Some studies have found that injection with lidocaine has been shown to be effective in patients who have symptomatic
active trigger points that produce a twitch (withdrawal) response to pressure and create a pattern of referred pain. Stretching the
affected muscle group immediately after injection further increases the
efficacy of trigger point therapy. An injectable solution of 1% lidocaine or
1% procaine is usually used. Several other substances, including diclofenac
(Voltaren), botulinum toxin type A (Botox), and corticosteroids, have been
used in trigger-point injections. It is important to remember that these
substances have been associated with significant myotoxicity. We will not
be injecting our partners today.
Most frequent locations of myofascial trigger points
http://www.aafp.org/afp/20020215/653.html
Cross-sectional schematic drawing of flat palpation to localize and hold
the trigger point.
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18: Head / Neck, Thorax and Abdomen TAP Review
Student Supplied Review Questions for Self-Study
Point to the tragus.
Palpate the submandibular glands.
Where is the lacrimal punctum?
Where is kidney pain usually felt?
Palpate the three heads of the sterno-cleidomastoid muscle.
Palpate the zygomatic arch.
Point to the alar nasi.
Which lymph node “heats-up” due to lung cancer?
Where would you find palpebrae?
Locate the caruncle.
Palpate the maxillary sinus.
Where is the subcostal plane?
Where is the mental region?
Point to where the gall bladder refers pain.
Where is the conjunctiva?
Where is a common site of varicosities in men?
Palpate the thyroid gland.
Locate the triangle of auscultation.
Where is the anterior pillar?
Stomach problems my refer pain to which region?
Where is Darwin’s tubercle?
Why are the first seven ribs known as true ribs?
Gently palpate the hyoid bone.
Point to the helix.
Where is plica semilunaris?
Outline the anterior triangle.
Locate the canthus.
Which pulse can be felt in the anterior triangle?
Point to the philtrum.
Locate the parotid gland.
Locate the lacrimal gland.
What makes the borders of the posterior triangle?
Where is the vermillion border?
What is the function of the lens muscles?
Gently palpate the suprathyroid notch.
Locate the uvula.
What vessel is located near the ear?
What structure carries tears to the nose?
Where is the limbus?
What structure lies just posterior to the tonsils?
What is the sclera?
What is the function of the lacrimal punctum?
What borders the hypochondriac region (lines)?
What structures are located at T4 vertebral level?
Where is McBurney’s point?
Where is the xiphisternal joint?
Locate the epigastric region.
Why are ribs 8-10 known as false ribs?
At which level is the angle of the scapula?
Locate the 7 vertical thoracic lines.
Where would you listen to the aortic valve?
How floating ribs exist in a normal human?
What is the importance of the angle of Louis?
Where would you listen to the pulmonary valve?
Which lines describe the 9 abdominal regions?
Locate the manubrium.
Where is the suprasternal notch?
Where is an enlarged liver palpated?
Which lines divide the abdomen into 4 quadrants?
Where is the transplyoric plane?
Where does the diaphragm refer pain?
Where is the angle of Louis?
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