ࡱ> hjg#` Ibjbj\.\. *N>D>Df8<|H4 RHTHTHTHTHTHTH${JhLxH!w @ !!xHHD$D$D$!RHD$!RHD$D$n*C"F ՜b:F"|2D ~FH0HRDM" M@"FM"F\ " D$ ! xHxH#v H!!!! SMALL GROUP SESSION 21 February 27th or March 1st Groups 1 to 12: Abdominal Pain Case and Abdominal Examination Workshop/OSCE Review Readings for this week: Complete the abdominal exam module on the POM-1 web-site. Review other OSCEs that you have learned in your small group Optional:  HYPERLINK "http://medicine.ucsd.edu/clinicalmed/abdomen.htm" http://medicine.ucsd.edu/clinicalmed/abdomen.htm Mentors: Bring pads, cleaning supplies, gowns, and hand washing gel. Prepare by: Wearing clothing that will allow for examination of the abdomen: two-piece outfits; bringing your stethoscope. A group member should bring anatomy text or notes and atlas. Session Overview Section 1. Touch base Section 2. Abdominal pain case Section 3. Abdominal examination Section 4. Review and practice other OSCEs Section 5. Evaluation Part 1. Touch base (20 minutes) Regale each other with stories of adventure and recreation! Part 2. Case discussion (60 minutes) Objectives: To apply knowledge of abdominal anatomy to a patient with abdominal pain. To better understand the anatomy of the abdomen To relate historical and physical exam findings to abdominal organs and their disorders. Logistics: A student interviews the mentor, who plays the patient in the case. Then mentors hand out the case for discussion. Pick a scribe to record discussion, and then choose learning objectives. We suggest that you write findings or questions in several columns: History Physical findings Anatomy Issues (physician, patient, ethical) Diagnostic possibilities Laboratory and test findings, if any Part 3. Examination of the abdomen (60 minutes) Goals: To learn how to examine a patients abdomen. Objectives: To learn the following aspects of the abdominal exam Inspection: for distension, scars, hernias, asymmetry, etc. Auscultation: (before you touch the abdomen): For normal bowel sounds: in all four quadrants For bruits: over the aorta, renal arteries and iliac arteries Percussion: Of the liver: estimate liver size by percussing up from the abdomen and down from the chest, both at the right midclavicular line Of the spleen: look for enlarged spleen by percussing just above the lowest rib in the left anterior axillary line, first at rest, then in the same location while patient takes and holds a deep breath Of all four quadrants, listening for changes in pitch or quality Palpation: Of liver edge by deep palpation, starting low in the abdomen and moving up to the right costal margin at the midaxillary line For enlarged spleen, holding rib cage up from below with your left hand while pressing inward with the right hand, starting at the left lower quadrant For aortic pulsation, using palmar surface of fingers of both hands, or thumb and forefinger of one hand in the upper abdomen, just left of midline For masses and tenderness: once lightly and once deeply Percussion of kidneys for CVA tenderness: just under the lowest rib posteriorly on both sides Part 4: OSCE Practice (30 minutes) You should have some time today to practice some of the OSCEs you have already learned. These include the upper and lower extremity exam and the cardiac exam. Pick one or two of these and review them and practice them. Part 5: Evaluation (5 minutes) How did this small group go? What could it make it work better in the future? Physical Examination Objective Structured Clinical Examination (OSCE) Abdominal Examination Checklist A = Attempted Satisfactory B = Attempted Below Satisfactory C = Did Not Attempt Procedure A B C Comments INSPECTION: Ex inspects abdomen for color, contour, symmetry, movement, scars. (Ex states what they are inspecting for.)AUSCULTATION: Ex listens to ALL FOUR QUADRANTS of the abdomen: right upper, left upper, right lower, and left lower. Ex MUST auscultate before palpating or percussing. Ex listens to the AORTIC artery (located in the middle of the abdomen above the umbilicus), the RENAL arteries (located above the umbilicus),and the ILIAC arteries (located below the umbilicus bilaterally)3. LIVER PERCUSSION: Ex begins percussing the liver in the right midclavicular line at the level between the lower right chest and the umbilicus and proceeds superiorly. Then, Ex begins in the right midclavicular line over the lung and proceeds inferiorly. 4. SPLEEN PERCUSSION: Ex percusses just above lowest rib on the left anterior axillary line and then repeats while Pt holds a deep breath.5. GENERAL PALPATION: Ex first palpates all four quadrants and the epigastrium LIGHTLY while using the palmar surface of the fingers to identify any masses or areas of tenderness. 6. DEEP PALPATION: Ex palpates all four quadrants and the epigastrium more DEEPLY while using the palmar surface of the fingers.7. LIVER - RIGHT COSTAL MARGIN: Ex places his/her hand on the lower right quadrant of Pts abdomen and gently presses in and upward. Ex asks Pt to take a deep breath and then exhale while Ex moves his/her hand upward toward the right. 8. SPLEEN - LEFT COSTAL MARGIN: Ex places his/her left hand around Pts left lower rib cage and gently presses upwards against back. Exs right hand is placed below the left costal margin and pressed inward toward the spleen. Ex should start in the lower left quadrant and work up towards the upper left quadrant.9. AORTIC PULSE: Ex uses opposing thumb and finger or palmar surface of fingers and palpates the aortic pulsation located in the upper abdomen slightly to the left of midline.10. CVA TENDERNESS: Ex uses his/her fist and percusses the kidneys just under the lowest rib posteriorly on both sides.      PAGE  PAGE 1 (University of Virginia 2007  FILENAME \p O:\Practice of Medicine1\2006-2007\Spring Sessions\Final versions\Session 21\SESSION 21A abdominal case and exam_Student_spring 2007_Nov 17.doc "#%02345E{  % & ƹ񝍀scSA"jhoOJQJU\^JaJh h,OJQJ\^JaJh h-nOJQJ\^JaJh-nOJQJ\^JaJhSJOJQJ\^JaJh hSJOJQJ\^JaJh hSJ5OJQJ^JaJhoOJQJ^JaJh^q5OJQJ^JaJh^qhSJOJQJ^JaJh^qh^qH*OJQJ^JaJh^qOJQJ^JaJh hSJOJQJ^JaJ45 `  & F gd  & F `^`` ^`gdSJ & F gd $a$gd^qgdSJfH& 2 b d e f ^ _ ʸ|sgWJ;Wh hSJOJQJ^JaJh 5OJQJ^JaJh hSJ5OJQJ^JaJh hSJ5\aJh hSJaJh hSJ\aJh hSJOJQJ\^JaJh h,OJQJ\^JaJ#h{ho0JOJQJ\^JaJ"jhoOJQJU\^JaJ.jh{hoOJQJU\^JaJhx@hoOJQJ\^JaJhoOJQJ\^JaJ_ ` 9 : C D T U h i k t u c ĸЌp`ЌNEh hSJaJ"h hSJ5OJQJ\^JaJh^qh^qOJQJ\^JaJhSJ5OJQJ\^JaJh^qOJQJ\^JaJh hSJOJQJ\^JaJh 5OJQJ^JaJh h^qOJQJ^JaJh^qOJQJ^JaJhSJOJQJ^JaJh hSJ5OJQJ^JaJh hSJOJQJ^JaJh h#(5OJQJ^JaJ  : ; R S T u 1 2 c  & Fgd  & F^$a$$a$   > ? .STUV= & F & F 5$7$8$9DH$c k VWX{|} >KMks}`ҲwwgwwwZh^q5OJQJ^JaJh hSJ>*OJQJ^JaJ"h hSJ5OJQJ\^JaJh^qOJQJ^JaJh^qhSJ5OJQJ^JaJh^qOJQJ\^JaJh hSJOJQJ\^JaJh h=5OJQJ^JaJh hSJ5OJQJ^JaJh hSJOJQJ^JaJh h OJQJ^JaJ#=>lh1rs~'_` & F 80`0gd~B@gd^q & F  & F & F & F^ & F & Fh^h!423Hz ʸʉzlX@l/jh hSJ5OJQJU^JmHnHu&h hSJ5OJQJ^JmHnHuh hSJ5OJQJ^Jh h OJQJ^JaJh hSJ6OJQJ^JaJh h#(OJQJ^JaJh hSJOJQJ\^JaJ"h hSJ5OJQJ\^JaJh hSJOJQJ^JaJh^qOJQJ^JaJh^qOJQJ^Jh^qh^qOJQJ^Jh^q2Hyz $If & F h$Ifgd~B@$a$^ & F 80`0gd~B@G{qkeeee$If$If  & F$Ifkd9$$Iflr.&2  h h h    4 la!"#$%{uoooo$If$Ifkd$$Iflr.&2  h h h    4 la !&  ',./^cdfgijlmoprsyzթ՚՚xplplplplb\b h=0Jjh=0JUh~B@jh~B@U"h hSJ5OJQJ\^JaJh hSJ5CJOJQJ^Jh hSJCJOJQJ^J/jh hSJ5OJQJU^JmHnHu&h hSJ5OJQJ^JmHnHuh hSJOJQJ^JaJh hSJOJQJ^Jh hSJ5OJQJ^J$%&{uoooo$If$Ifkd$$Iflr.&2 hhh  4 lap{uuoooo$If$Ifkd$$Iflr.&2 hhh  4 la{qkkkk$If xx$Ifkd$$Iflr.&2 hhh  4 la'()*+{qkkkk$If xx$Ifkd$$Iflr.&2 hhh  4 la+,{uoooo$If$Ifkdy$$Iflr.&2 hhh  4 la^_`ab{uoooo$If$IfkdR$$Iflr.&2 hhh  4 labcdfhiklnoqr{{usqqqqqqqqh&`#$^kd9$$Iflr.&2  h h h    4 la z{}~CDEGHIȵyufh hSJOJQJ^JaJh~B@h\XCJ aJ mHnHuh h=CJ aJ jh h=CJ UaJ (h\Xh=5B*CJ OJQJ^Jph$h\Xh\X5B*OJQJ^Jph jh\Xh=5jh=0JU*h+0JmHnHu*jh=0JUh= h=0J{|}EFGHIh]h&`#$h]h (/ =!"#$% 9DyK 1http://medicine.ucsd.edu/clinicalmed/abdomen.htmyK bhttp://medicine.ucsd.edu/clinicalmed/abdomen.htm$$If!vh525h5h5h5#v2#vh#v:V l525h5/  /  / / /  /  4$$If!vh525h5h5h5#v2#vh#v:V l525h5/  /  / / /  /  4$$If!vh525h5h5h5#v2#vh#v:V l525h5/  /  / / / /  4$$If!vh525h5h5h5#v2#vh#v:V l525h5/  / / / / / /  4$$If!vh525h5h5h5#v2#vh#v:V l525h5/  / / / / / /  4$$If!vh525h5h5h5#v2#vh#v:V l525h5/  / / / / / /  4$$If!vh525h5h5h5#v2#vh#v:V l525h5/  /  / / / /  4$$If!vh525h5h5h5#v2#vh#v:V l525h5/  / / / / / /  4$$If!vh525h5h5h5#v2#vh#v:V l525h5/  /  / / / /  /  4<@< NormalCJ_HmH sH tH F@F Heading 1$$@&a$ 5OJQJ@@@ Heading 2$@& 5OJQJ@@@ Heading 3$@& >*OJQJDA@D Default Paragraph FontVi@V  Table Normal :V 44 la (k@(No List JB@J Body Text xx5CJOJPJQJDP@D Body Text 25OJQJ\^JB'B Comment ReferenceCJaJD@"D  Comment TextCJOJPJQJ4@24 Header  !4 @B4 Footer  !.)@Q. Page Number6U@a6 Hyperlink >*B*phFVqF FollowedHyperlink >*B*ph`d IN45` :;RSTu12c>?.STUV=>lh1 r s ~ ' _ ` 2 H y z G!"#$%&p'()*+,^_`abcdfhiklnoqr{|}EFGJ00000505051 051 051 050505050505052 052 05050505000000000000000000000 00 0 00000000000000 00 00 00 00 00 0000000000& 00' 0( 0( 00) 0+ 0+ 0+ 00, 0- 0- 0- 0- 0000000 3 0 3 0 0000000H 00z 0(0  0 0 0 0 0 0  0 0 0 0 0 0 0  0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0000000000000000000 & _ c zI% =%+b{I !"#$&H%eIX  ?M!!8 @N (  VB   C D"VB   C D"B S  ?I * *t a atrs Tr] JJ9*urn:schemas-microsoft-com:office:smarttagsplace8*urn:schemas-microsoft-com:office:smarttagsCity  39 " effhhiiklnoqrz}DGJeffhhiiklnoqrz}DJ;G]t.W_`s ~ oGeffhhiiklnoqrDGJeffhhiiklnoqrz}DJ 6j4"4 b.nJ*) x*fBv.`&V4mf/[8@[UD4QVlK#iz.NvFk@PV|0Zn h88^8`OJQJo(hHh^`OJQJ^Jo(hHoh  ^ `OJQJo(hHh  ^ `OJQJo(hHhxx^x`OJQJ^Jo(hHohHH^H`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh ^`OJQJo( pp^p`OJQJo(o @ @ ^@ `OJQJo( ^`OJQJo( ^`OJQJo(o ^`OJQJo( ^`OJQJo( PP^P`OJQJo(o   ^ `OJQJo(h ^`OJQJo(h ^`OJQJo(oh pp^p`OJQJo(h @ @ ^@ `OJQJo(h ^`OJQJo(oh ^`OJQJo(h ^`OJQJo(h ^`OJQJo(oh PP^P`OJQJo(hh^h`o(.^`o(.h^`OJQJo(hHpLp^p`L.@ @ ^@ `.^`.L^`L.^`.^`.PLP^P`L.h 88^8`OJQJo(oh ^`OJQJo(oh   ^ `OJQJo(h   ^ `OJQJo(h xx^x`OJQJo(oh HH^H`OJQJo(h ^`OJQJo(h ^`OJQJo(oh ^`OJQJo(h ^`OJQJo(h ^`OJQJo(oh pp^p`OJQJo(h @ @ ^@ `OJQJo(h ^`OJQJo(oh ^`OJQJo(h ^`OJQJo(h ^`OJQJo(oh PP^P`OJQJo(h 88^8`OJQJo(oh ^`OJQJo(oh   ^ `OJQJo(h   ^ `OJQJo(h xx^x`OJQJo(oh HH^H`OJQJo(h ^`OJQJo(h ^`OJQJo(oh ^`OJQJo(h ^`OJQJo(h ^`OJQJo(oh pp^p`OJQJo(h @ @ ^@ `OJQJo(h ^`OJQJo(oh ^`OJQJo(h ^`OJQJo(h ^`OJQJo(oh PP^P`OJQJo(h88^8`OJQJo(hHh^`OJQJ^Jo(hHoh  ^ `OJQJo(hHh  ^ `OJQJo(hHhxx^x`OJQJ^Jo(hHohHH^H`OJQJo(hHh^`OJQJo(hHh^`OJQJ^Jo(hHoh^`OJQJo(hHh ^`OJQJo(h ^`OJQJo(oh pp^p`OJQJo(h @ @ ^@ `OJQJo(h ^`OJQJo(oh ^`OJQJo(h ^`OJQJo(h ^`OJQJo(oh PP^P`OJQJo(h 88^8`OJQJo(oh ^`OJQJo(oh   ^ `OJQJo(h   ^ `OJQJo(h xx^x`OJQJo(oh HH^H`OJQJo(h ^`OJQJo(h ^`OJQJo(oh ^`OJQJo(88^8`OJQJo(hHhh^h`OJQJ^Jo(hHo88^8`OJQJo(hH^`OJQJo(hH  ^ `OJQJ^Jo(hHo  ^ `OJQJo(hHxx^x`OJQJo(hHHH^H`OJQJ^Jo(hHo^`OJQJo(hH x*)#i&V4v.@[U/[8BJFk4 K4QV6jV|                                                                                                             g$h%#(=~B@SJ\X-noKv.Pv+,^q !"#$%&'()*+,^_`abceJ@  Ip@UnknownGz Times New Roman5Symbol3& z ArialABook Antiqua3z Times?5 z Courier New;Wingdings"0hDfDf W (W (!4d[[* 2QHX?-n2 7WEEK 10  Tuesday, October 31, or Thursday, Nov 1, 2000 John GazewoodHSCS@         Oh+'0 ,8 X d p |8WEEK 10 Tuesday, October 31, or Thursday, Nov 1, 2000John Gazewood Normal.dotHSCS2Microsoft Office Word@@恢@h(a:@h(a:W՜.+,D՜.+,d  hp|  ( [ 8WEEK 10 Tuesday, October 31, or Thursday, Nov 1, 2000 Title 8@ _PID_HLINKSA1http://medicine.ucsd.edu/clinicalmed/abdomen.htm  !"#$%&')*+,-./123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVXYZ[\]^`abcdefiRoot Entry FPb:kData (1Table0MWordDocument*NSummaryInformation(WDocumentSummaryInformation8_CompObjq  FMicrosoft Office Word Document MSWordDocWord.Document.89q