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  • 1. MEDEX Northwest Physician Assistant Training Program Technical Skills II Winter Quarter 2003 Course Chairs: Don Coerver, PA-C, MA Yakima Coordinator: Wayne Clark, ARNP Seattle Coordinator: Monica Morrison, PA-C School of Medicine University of Washington
  • 2. Table of Contents Course Description and Grading 2 Reading List 3 Slit Lamp Examination 4 Abdominal X-Ray Interpretation 5 Interpretation of Orthopedic Radiographs 6 Electrocardiogram I 7 Electrocardiogram II 8 Splinting and Casting Workshop 9 Examination of the Hand/Wrist 10 Hand/Wrist Focus Sheet 11 Hand/Wrist Check List 14 Venipuncture 17 Intro to Microscopy, Peripheral Blood Smear, 18 KOH and Wet Preps 2
  • 3. Course Description and Grading Outline Technical Skills II I. Course Description This course will expose you to specific diagnostic procedures and skills utilized in a primary care setting with the focus on mastery of these skills. The emphasis is in “hands- on” experiences; electrocardiogram interpretation parts I and II, x-ray interpretation of the abdomen and orthopedic radiology of the extremities, slit lamp examinations skills in ophthalmology, casting & splinting techniques, venipuncture and microscopy with peripheral blood smear, KOH & wet prep interpretation. The course, where needed, will utilize manikins or models to demonstrate normal and pathologic conditions seen in a primary care practice. Course requirements include satisfactory attendance of all class and clinical sessions, completion of assigned readings, write-ups, and written examinations. In addition, you are expected to demonstrate the various skills taught in class. II. Grading Tests A mixture of Objective Standardized Clinical Examinations (OSCE) and objective testing will be utilized. Passing grade for objective based testing will be 80%, with OSCE testing points being included in the mid-term and final Adult Medicine examinations. Each test will carry equal weight for the overall course grade. Students must pass each test in order to pass the course. Tutoring and retesting will be required for any failed exam. Failure to pass the course will result in academic probation. Professional Conduct In addition to content knowledge, professional behaviors and attitudes will be considered when final grades are awarded. Attendance, participation in class discussions, courtesy to and consideration for speakers and fellow students are markers of professional behavior and attitudes. This will account for 10% of the course grade. Grading Table % of grade Quizzes: 60% Abdominal Xrays 10% Orthopedic Xrays 10% ECG I 10% 3
  • 4. ECG II 10% Examination of the Hand 10% Microscopy/Smears/Wet Preps 10% Objective Standardized Clinical Examinations (OSCE) 30% Midterm: 15 % Final: 15% Professional Conduct 10% Total: 100% III. Required Textbooks Aehlert, B. ECG’s Made Easy. 2nd ed. (Mosby, 2002). Balleweg, R. Physician Assistant, 2nd ed., 1999. Dehn R, Asprey D. Clinical Procedures for Physician Assistants. (WB Saunders, 2002). Green, W, Essentials of Musculoskeletal Care, 2nd ed. (AAOS, 2001). Pagana K, Pagana T. Manual of Diagnostic and Laboratory Tests. 2nd ed. (Mosby, 2002). Squire LF, Noveline RA. Fundamentals of Radiology. 4th ed. (Harvard Press, 1998). Swartz, M. Textbook of Physical Diagnosis: History and Examination. 4th ed. (WB Saunders, 2002). Tintinalli, J, et al: Emergency Medicine: A Comprehensive Study Guide, 5th ed., (McGraw Hill), 2000. IV. Optional textbooks; Dubin, D, Rapid Interpretation of EKGs,.6th ed., (COVER, 2002). Hoppenfeld, S, Physical Examination of the Extremities, (Appleton-Century-Crofts, 1976). Ravel, R, Clinical Laboratory Medicine, 6th ed., (Mosby, 1995). Reider, B. The Orthopedic Physical Examination, (WB Saunders, 1999). V. Web Sites EKG Websites www.theMDsite.com/ www.ecglibrary.com/ecghome.html www.mdchoice.com/ekg/ekg.asp Radiology Web Sites www.rad.washington.edu/teachingfiles www.indyrad.iupui.edu/rtf/index VI. Reserve List 4
  • 5. The following books are provided as supplemental material for those interested, as well as the required texts. They are available in the Spokane and Yakima site libraries, and in Seattle, on reserve at the Health Sciences Library under course #MEDEX 453. Bates, B. A Guide to Physical Examination and History Taking, 7th ed. DeGowin and DeGowin. Diagnostic Examination, 6th ed., 1993. Kraytman, M. The Complete Patient History, 2nd ed., 1991. Seidel, H. Mosby’s Guide to Physical Examination, 2nd ed., 1991. Snell, R. Clinical Anatomy for Medical Students. 5
  • 6. Slit Lamp Examination Workshop Required Reading: Swartz, Chap. 9 Goal: Be able to perform a basic slit lamp examination. Objectives: 1. Be familiar with patient education needed in regards to the slit lamp examination. 2. Be able to name and explain the use of various components of the slit lamp. 3. Given an eye mannequin, be able to describe normal and abnormal findings. 6
  • 7. Radiology Workshop: Abdominal X-Ray Interpretation Required Reading: Squire, Chaps. 11,12,14 Goal: Be able to perform a basic interpretation of an abdominal x-ray series. Objectives: 1. Identify which views are included in an “acute abdominal series” and what each one detects. 2. Identify the patient in whom plain films are needed. 3. In the abdominal series, describe and recognize a. abnormal gas collections b. gas patterns c. calcifications 7
  • 8. Interpretation of Orthopedic Radiographs: Upper and Lower Extremities Required Reading: Squire, Chap 15 Goal: Learn the basic fundamentals of describing and interpreting plain x-rays of extremity trauma and other orthopedic pathology. Objectives: 1. Know the minimum number of x-rays views needed for adequate interpretation of extremity trauma. 2. Be able to list other views appropriate for the following anatomic areas: a. ankle-mortise view b. knee- notch and sunrise views c. hand –navicular/scaphoid views d. shoulder-axillary view or “Y” view (tangential lateral) 3. Given an x-ray, be able to describe a fracture using these criteria: a. anatomic location b. orientation c. degree of displacement/ separation d. shortening e. angulation f. rotational deformity 4. Given a diagram or x-ray of a pediatric fracture, be able to describe the pattern of injury according to the Salter-Harris classification system. 8
  • 9. Electrocardiogram I Required Reading: Dehn, Chap 10 Aehlert Chaps 3,4 Goal: Be able to identify basic rhythm disturbances. Objectives: If given an ECG, be able to: 1. Identify the following sinus rhythms: a. Normal sinus rhythm b. Sinus Bradycardia c. Sinus Tachycardia d. Sinus Arrhythmia 2. Differentiate atrial flutter and fibrillation. 3. Identify supraventricular tachycardias. 9
  • 10. Electrocardiograms II Required Reading: Aehlert Chaps 5,6,7, Goal: Be able to identify more complex dysrhythmias. Objectives: If given an ECG, be able to: 1. Identify junctional dysrhythmias. 2. Differentiate premature ventricular contractions (PVCs), ventricular tachycardia, and ventricular fibrillation. 3. Identify the characteristics distinct to first, second and third degree atrioventricular (AV) blocks . 10
  • 11. Splinting and Casting Workshop Required Reading: Dehn, Chap 21 Tintinelli, Chap 259 Goal: Exposure to and practice the rudimentary skills in applying and removing casts and splints to upper and lower extremities. Although the workshops will use fiberglass, you should be aware that many emergency and orthopedic physicians and physician assistants prefer to use plaster, especially for splinting. Although it is messy and requires more time to use and to harden, it is superior for customizing and molding a precise fit. Objectives: 1. Describe the rational for casting or splinting an extremity. 2. Be able to explain why the joint above and below a fracture site should be immobilized. 3. Describe a potential complication of casting an acutely injured extremity 4. Describe iatrogenic conditions that can be caused by casting. 5. Explain how long the splint should be for the following injured areas: a. elbow b. ankle c. mid-shaft of the radius/ulna d. mid-shaft of the tibia/fibula 6. Review the various splints shown in Tintinalli on pages 1748-51, as you will be required to fabricate some of them in the workshops using fiberglass. 7. List the similarities and differences between plaster of paris and fiberglass casting materials. 11
  • 12. 8. Explain or demonstrate splinting techniques for the: a. elbow b. forearm c. ankle d. mid-shaft tibia/fibula e. hand (include; the “intrinsic plus” position or “position of function” splinting) 9. Apply and remove at least one upper and lower extremity cast and splint 12
  • 13. Examination of the Hand / Wrist Required Reading: Green, Chap 204 Optional Reading: Reider Chap 4 Goal: To be able to perform a focused hand exam. Objective: 1. Identify normal and abnormal findings on a hand exam. 2. Demonstrate competency by being able to perform a hand exam as taught in class. 3. Demonstrate competency by being able to perform tests specific to pathologic conditions found in the hand. 13
  • 14. Musculoskeletal Branching Exam – Hand and Wrist Exam maneuver Focus I. Introduction States name and purpose. States would wash hands. II. General Appearance Observes patient for habitus, posture, level of comfort, signs of distress. III. Vital Signs* (verbalize only) A. Takes or verifies temperature B. Palpates radial pulse bilat. Checks pulses distally C. Counts radial pulse (15 seconds) in trauma D. Counts respirations E. Takes blood pressure R. arm IV. Patient preparation: Patient sitting with both hands and wrists adequately exposed. V. Inspection: Compare both Hands/Wrists A. Dorsal 1. Phalanges/nails Swelling, pitting 2. Metacarpal Muscle atrophy ,bony deformity 3. Carpals synovitis, extensor tendon rupture 4. The “attitude”of the hand “position of function” B. Volar 1. Thenar Muscles atrophy, median nerve innervation 2. Hypothenar Muscles atrophy, ulnar nerve innervation 3. Palmar fascia Dupuytren’s contracture VI. Palpation: Distal to proximal. Compare both hands/wrists A. Dorsal 1. Phalanges DIP/PIP swelling, tenderness, deformity (mallet finger) 2. Metacarpals (especially 1st MCP & 1st CMC jts) arthritis/ulnar collateral ligament injury, fracture 14
  • 15. 3. Carpals 4. Base of 1st metcarpal-trapezium arthritis 5. Anatomic snuffbox-scaphoid fracture 6. Base of 3rd metacarpal-capitate arthritis/fracture 7. Distal to ulnar styloid-triquetrum, trauma triangular fibrocartilage complex B. Volar 1. Phalanges ganglion, nodules 2. Metacarpals tenderness over flexor tendons 3. Carpals a. ulnar styloid-pisiform border of the carpal tunnel/tenderness b. radial styloid-scaphoid border of the carpal tunnel/tenderness VII. Range of Motion A. Phalanges(DIP/PIP) 1. Active* a. abduction interossi atrophy b. adduction nerve damage c. flexion mal-rotation/tendon injury d. extension tendon injury e. thumb opposition nerve damage f. thumb extension nerve/tendon damage 2. Passive (checked when active ROM is impaired)* a. flexion Dupuytren’s contrature b. extension arthritis/trauma B. Metacarpals (MCP) 1. Active* a. extension fracture/tendon damage b. flexion fracture/arthritis 2. Passive (checked when active ROM is impaired)* a. flexion arthritis b. extension contracture C. Carpals/Wrist 1. Active * a. extension (dorsi-flexion) tendon damage b. flexion (palmar flexion) trauma/nerve damage c. radial and ulnar deviation trauma/arthritis 2. Passive (checked when active ROM is impaired) * a. extension 15
  • 16. b. flexion VIII. Neurological Exam A. Muscle strength* (bilat.) 1. Phalanges/metacarpals a. hold PIP in extension and flex DIP (Flexor digitorum profundus) tendon rupture/nerve damage b. flex PIP while other fingers in extension tendon rupture/ median (flexor digitorum sublimes) nerve damage c. phalanges adduction/abduction ulnar nerve d. Opponens strength weakness (adduct thumb against resistance) e. grip strength weak intrinsic muscles 2. Carpals/wrist a. flexion (palmar flexion) C7 b. extension (dorsi-flexion) C6/radial nerve palsy B. Sensory: two point discrimination/ bilat.* Decreased sensation 1. Thumb, dorsal aspect (C6) radial nerve 2. Middle finger, palmer aspect (C7) median nerve 3. Little finger, palmer aspect (C8) ulnar nerve C. Vascular: 1. Radial pulse 2. Capillary refill IX. Special Tests * (Unless otherwise indicated, do tests on 1 side only.) A. Finklestein test 1. Flex and ulnarly deviate the wrist Pain at the dorsoradial 2. Push the thumb into flexion aspect of the wrist B. De Quervain’s tenosynovitis. Grind Test Pain will be elicited if the 1. Push down on the dorsum of the base of the patient has 1st CMC 1st metacarpal arthritis 2. While holding this joint in place, push the metacarpal proximally C. Ulnar Collateral Ligament Test Laxity indicates an ulnar 1. Place thumb MCP joint in full flexion collateral ligament tear 2. While stabilizing MCP, abduct (push away) thumb away from the index finger 3. Compare both thumbs 16
  • 17. D. Phalen’s Test for Carpal tunnel syndrome Positive if symptoms 1. Compress the dorums of both hands together reproduced - pain in the with the wrists flexed at 90* thumb, index and long 2. Hold this position for 1 minute fingers (median nerve distribution) X. State would perform the following if Hand/Wrist exam is negative:* Referred pain A. Shoulder exam B. C-spine * may do in any order 17
  • 18. MEDEX Northwest Student: Hand/Wrist Exam Evaluator: Date: Musculoskeletal Branching Exam – Hand and Wrist Check List Total Points (to pass) Subtract 2 point for each item omitted, poor technique (partial points may be awarded) Subtract 1point for out of sequence, each minute overtime Time Limit: 15 minutes (including special tests) Out of Poor Omitted Sequence Techni que I. Introduction States name and purpose States would wash hands II. General Appearance Observes patient for habitus, posture, level of comfort, signs of distress III. Vital Signs* (verbalize) A. Takes or verifies temperature B. Palpates radial pulse bilat. C. Counts radial pulse (15 seconds) D. Counts respirations E. Takes blood pressure R. arm IV. Patient Preparation: Pt. Sitting with both hands/wrists adequately exposed V. Inspection: Compare both Hands/Wrists A. Dorsal 1. Phalanges/nails 2. Metacarpal 3. Carpals 4. The “attitude”of the hand B. Volar 1. Thenar Muscles 2. Hypothenar Muscles 3. Palmar fascia VI. Palpation: Distal to proximal. 18
  • 19. Compare both hands/wrists A. Dorsal 1. Phalanges 2. Metacarpals (especially 1st MCP & 1st CMC jts) 3. Carpals 4. Base of 1st metcarpal-trapezium 5. Anatomic snuffbox-scaphoid 6. Base of 3rd metacarpal-capitate 7. Distal to ulnar styloid-triquetrum, triangular fibrocartilage complex 7. Distal to ulnar styloid- triquetr um, triangul ar fibrocart ilage complex B. Volar 1. Phalanges 2. Metacarpals 3. Carpals a. ulnar styloid-pisiform b. radial styloid-scaphoid VII. Range of Motion A. Phalanges(DIP/PIP) 1. Active* a. abduction interossi atrophy b. adduction nerve damage c. flexion mal-rotation/tendon injury d. extension tendon injury e. thumb opposition nerve damage f. thumb extension 19
  • 20. nerve/tendon damage 2. Passive (check when active ROM is impaired)* a. flexion Dupuytren’s contrature b. extension B. Metacarpals (MCP) 1. Active* a. extension b. flexion 2. Passive (check when active ROM is impaired)* a. flexion b. extension C. Carpals/Wrist 1. Active * a. extension (dorsi-flexion) b. flexion (palmar flexion) c. radial and ulnar deviation 2. Passive (check when active ROM is impaired) * a. extension b. flexion 20
  • 21. VIII. Neurovascular Exam A. Muscle strength* (bilat.) 1. Phalanges/metacarpals a. hold PIP in extension and flex DIP (Flexor digitorum profundus) b. flex PIP while other fingers in extension (flexor digitorum sublimes) c. phalanges adduction/abduction d. Opponens strength (adduct thumb against resistance) e. grip strength 2. Carpals/wrist a. flexion (palmar flexion) b. extension (dorsi-flexion) B. Sensory: two point discrimination/ bilat.* 1. Thumb, dorsal aspect (C6) 2. Middle finger, palmer aspect (C7) 3. Little finger, palmer aspect (C8) C. Vascular: 1. Radial pulse 2. Capillary refill IX. Special Tests * (Unless otherwise indicated, do tests on 1 side only.) A. Finklestein test 1. Flex and ulnarly deviate the wrist 2. Push the thumb into flexion B. De Quervain’s tenosynovitis. Grind Test 1. Push down on the dorsum of the base of the 1st metacarpal 2. While holding this joint in place, push the metacarpal proximally C. Ulnar Collateral Ligament Test 1. Place thumb MCP joint in full flexion 2. While stabilizing MCP, abduct (push away) thumb away from the index finger 3. Compare both thumbs 21
  • 22. D. Phalen’s Test for Carpal tunnel syndrome 1. Compress the dorums of both hands together with the wrists flexed at 90* 2. Hold this position for 1 minute X. State would perform the following if Wrist/Hand exam is negative:* A. Shoulder exam B. C-spine * may do in any order 22
  • 23. Venipuncture Required Reading: Dehn Chap 5 Pagana, Chap 7, p.671 Goal: Obtain a venous sample of blood while observing standard precautions and with minimal risk to the patient. Objectives: 1. Be able to describe the appropriate anatomy and physiology associated with a venipuncture. 2. Describe the indications, contraindications and rationale for performing a venipuncture. 3. Demonstrate competency in obtaining a venous blood specimen. 23
  • 24. Introduction to Microscopy and Peripheral Blood Smear, KOH & Wet Prep Workshop Required Reading: Pagana, Chap 7, p.671 Goal: To become familiar with the optical microscope. Objectives: 1. Be able to demonstrate the process needed to make a peripheral blood smear. 2. Be able to describe white and red cell morphology. 3. If given a peripheral blood smear, be able to perform basic interpretation of white and red cell morphology. 4. Be able to describe the process needed to make a KOH or Wet Preparation. 5. Given a KOH or wet prep, be able to identify associated pathological conditions. 24

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