Jan. 10th, 2013

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Cameron lesion--an ulcer within a hiatal hernia. Usually asymptomatic, can cause anemia. Caused by ischemia and trauma from diaphragm? Especially seen in large hiatal hernias.
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Why do doctors make you say ah? How do you breathe for different parts of the exam? Things people never ask, but seem not to know for a medical exam.

Eyes--'follow the finger' Watch my finger, moving just your eyes, not your head. This shows muscle/nerve coordination between the two eyes. It's actually making sure the third, fourth, and sixth cranial nerves are functioning well.  'Focus on a distant point while I shine a light in your eyes'. This checks the second cranial nerve, to be sure that the pupils constrict and dilate normally. Then I may get right in your face, to look at the optic nerve in the retina, aka the blind spot. Since this connects directly to the brain, it can show if there is any unusual pressure in the brain.

Mouth--'say ah'. This lifts the soft palate (the back of the mouth) and allows me to see the tonsils and back of mouth more clearly. Either a yawn or a vocalized 'ah' will open the mouth. Saying 'ng' or some other nasal sound does not do it, and usually means the tongue is up, protecting the back of the mouth (in which case I may pull out a tongue depressor). You can practice this at home, or with the right light (sun in front or behind) in your car's rearview mirror.

Neck--'swallow'  This helps me feel the thyroid, and distinguish it from neck muscles. Yes, it's hard to swallow on command, especially repeatedly.
Also, if the doctor has the stethoscope over your neck, to listen to your arteries or your thyroid, it's a bad time to vocalize anything. The stethoscope is right over the vocal cords, and sounds get extremely magnified, to the point of pain. I've ripped off my stethoscope and thrown it to the ground on occasion when someone says 'what' at that point. Please be kind, be quiet during a throat exam.

Lungs--'deep breaths' To best hear what's going on in the lungs, I like a lot of air flow, and less noise from the nasal passages or vocal cords. This means breathe through the mouth, not the nose, both inhalation and exhalation. And not a slow yoga breath, more of a active breath in and out.

Heart--'breathe regularly' Some doctors want to listen to the lungs in the front, in which case they would ask for another two deep breaths. Otherwise it's on to the heart, and we mostly don't want you to hyperventilate. Yes, it's hard to breathe 'normal' when you are thinking about it.

Abdomen--'deep breath into the abdomen' I remember in choir in middle school, they tried to tell us to breathe into the abdomen when singing, and it was years before I understood what the heck the choirmasters meant. There are two large sets of muscles that you use to breathe--the rib muscles, and the diaphragm (which is the horizontal muscle between the chest and the abdomen). If you move your chest when you breathe, you are using the former, and you feel the air up higher in your lungs. With the diaphragm your stomach moves out a bit, your shoulders stay about the same, and the air goes deep into the bottom of the lungs. It's good for singing because you can get more air in. For abdominal exams, it will push the liver and spleen out a bit from under the protective ribs so we can feel them. You can practice the different types of breathing--put one hand on your breastbone, another on your belly button, and try breathing so one moves, then the other moves.

Hernia exam (men)--'cough' Turn your head to the side, so you don't cough your germs on top of the poor doctor. Either side is okay; you can switch left and right or stay on the same side, the neck position doesn't change the hernia exam. Coughing again pushes on your organs, this time the intestines. If you have a hernia, I can feel the intestines pushing down into the scrotal sac. 'Push like you're having a bowel movement' does the same thing, and can be used to check for hernia in the abdomen or uterine prolapse in the vagina.

Tendon reflexes--hitting the knee with the hammer activates the nerve/muscle pathway in the quadriceps. We're mostly looking that the two sides are equal, and not excessive. Many people have no visible or palpable reaction to the hammer test. We can also check a similar reflex on other tendons, such as the biceps in the elbow, the base of the thumb, or the Achilles behind the heel.

Those are the major ones. Others, like the Babinski test, the Romberg, the Rinne, are more specialized, and instructions are usually given.

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