The Apprentice Doctor® - How To Examine Patients

Welcome to The Apprentice Doctor™ e-book course!

Reading this e-book will bring you one step closer to an exciting and respected career in medicine! This e-book contains a wealth of medical information and numerous practical projects. These practical projects will ensure the retention of the knowledge for years and years. This is indeed the secret why medical students seem to grasp and retain such an enormous amount of information with apparent ease – they apply their knowledge daily! In order to complete the practical projects contained in this e-book, you will need a number of medical instruments. Most of these instruments can be acquired at your nearest pharmacy, or you can purchase them from the ‘Shop’ page at www.TheApprenticeDoctor.com. You should also consider investing in The Apprentice Doctor™ Standard kit. All the instruments you will need, as well as the interactive CD-ROM which contains the sound clips, video clip, animations etc… are included in this package.

VERY IMPORTANT NOTE: Your integrity, as well as international copyright laws, requires that you do not make illegal copies of this e-book. And then there’s just me, asking you not to! Thank you for respecting this! Anton

THE APPRENTICE DOCTOR™ COURSE INDEX · INTRODUCTION

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· DISCLAIMER

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· README PRO

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· BASIC PRINCIPLES OF EXAMINATION

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1. SOUND: A BIOMEDICAL PERSPECTIVE

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2. THE EAR AND HEARING

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3. LIGHT: A BIOMEDICAL PERSPECTIVE

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4. THE EYE AND VISION

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5. MEDICAL INSTRUMENTS

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6. THE EXAMINATION OF A PATIENT

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· B. THE HUMAN BODY

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1. THE COVERING SYSTEM

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2. THE SKELETAL SYSTEM

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3. THE MUSCULAR SYSTEM

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4. THE NERVOUS SYSTEM

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5. THE ENDOCRINE SYSTEM

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6. THE CARDIOVASCULAR SYSTEM

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7. THE LYMPHATIC SYSTEM

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8. THE RESPIRATORY SYSTEM

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9. THE DIGESTIVE SYSTEM

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10. THE URINARY SYSTEM

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11. THE REPRODUCTIVE SYSTEM

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· PROJECT 00 – 41

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· A CAREER IN MEDICINE

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· SUPPLEMENT ON HIV AND AIDS

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· OTHER INFECTIOUS DISEASES

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· GLOSSARY

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· ADDENDUMS 1–4

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The Apprentice Doctor™ E–book First published by: Multimed Media c.c. E-mail: [email protected] Copyright © Multimed Media c.c. 2005 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form, or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior permission of the author. This manual is sold subject to the condition that it shall not, by way of trade or otherwise, be lent, re-sold, rented out or otherwise circulated without the author’s prior consent in any form of binding or cover other than that in which it is published and without a similar condition including this condition being imposed upon the subsequent purchaser.

INTRODUCTION

Congratulations on your decision to choose this exciting medical course! This program will: • Give a young mind a glimpse into the fascinating world of medicine • Enable a person to examine and explore the wonderful human body, using some of the instruments used by the family doctor on a daily basis • Promote the concept of taking responsibility for one’s own health • Introduce a person to some basic medical examination skills • Demonstrate how a doctor examines certain parts of the human body • Interactively help a person to learn the meaning of a number of medical terms • Supply information on the structure and functioning of the human body • Supply information about some of the medical instruments used by the family doctor • This program will stimulate a young person’s curiosity, and this could very well lead to choosing an exciting career in one of the numerous fields of modern medicine The Apprentice Doctor™ course is intended mainly for scholars and students; however adult participants have also been amazed at their newly gained medical knowledge, insights and skills! A PERSONAL NOTE TO THE APPRENTICE DOCTOR, FROM YOUR INSTRUCTOR DOCTOR With the various projects contained in this program, you will be able to use your general and special senses, just like your doctor, to examine the human body. You can examine your own body, or with the guidance of a responsible adult (preferably a parent or teacher), you may examine somebody else. You are most likely going to examine a perfectly healthy body. Remember that, just like your doctor, you first need to learn about normality, before you will be able to recognize abnormality. Only by repeatedly examining the normal situation will you be able to start recognizing the abnormal. The proverb, “practice makes perfect,” is especially true in this regard. Should you suspect any abnormality during self-examination, inform your parent or legal guardian. An examination by a professionally qualified person (doctor or dentist) is recommended. NEVER embarrass somebody else or allow yourself to become embarrassed during an examination. ALWAYS respect yourself and other people. I trust that you will learn a lot about the amazing human body, that you will find the various projects interesting, and that you will gain some understanding of the basic approach used in a medical examination.

DISCLAIMER

The producer or supplier of this application does not: • Offer any warranty regarding the accuracy or correctness of any information contained in this application; 1

• Assume any responsibility for any damage or consequential damage related in any way to the information, instrumentation or items contained in this product/application or as a result of the use thereof. The user takes full and exclusive responsibility for the safe application of any information contained in this application. The user also takes full and exclusive responsibility for all safety aspects related in any way to the use of any instrument or item supplied with this application. This exclusive responsibility applies equally to the user or to any person or persons being supervised by the user. No warranties are offered on the functional status or fitness for a specific application of any information, instrument, or item supplied in this application. The supplier accepts no responsibility for the malfunction of any instrument or item. The supplier disclaims all liability for any direct or indirect damages – specific or consequential – related in any way to the information and instrumentation or any item contained in this application. All practical exercises are performed exclusively at the user’s own risk. The producer or supplier of this application disclaims any responsibility for any medical emergencies, medical problems, or any other problems whatsoever, which may arise while using any instrument or item or applying any information supplied with this application. The use of the instruments, items and information supplied in this application is conditional upon the acceptance of this disclaimer, as well as the following three conditions: 1. I have read and understand the disclaimer. 2. I undertake to read the READ ME PRO document before starting the practical projects. 3. I understand that all material contained in The Apprentice Doctor™ course is protected by international copyright laws. For further information on copyright, see “copyright information.”

READ ME PRO (Read Me file before starting the practical exercises)

G E N E R A L G U I D E L I N E S R E G A R D I N G M E D I C A L E X A M I N AT I O N P R O J E C T S The projects consist of a variety of practical exercises aimed at teaching the student (pupil) some basic principles pertaining to the medical examination of a person. The projects are primarily intended as educational tools and NOT as medical diagnostic exercises. Most of the projects entail the examination of a part or an aspect of the human body and are intended primarily as self-examination exercises, although the majority of the projects are also suitable for examining another person. This should not present any problems within a family unit under the supervision or with the participation of the parent(s) (or legal equivalent). The projects may be useful as practical sessions to supplement the biology curriculum, or as a specialist interest group consisting of students (learners) who may consider pursuing a medical career. In a group situation the following guidelines apply: • Proper guidance and supervision of a responsible teacher is essential. • Keep groups in a same-sex environment – a girls’ group with a female teacher, and a boys’ group with a male teacher – doing the projects in separate locations. • Practice a policy of “no embarrassment” using volunteers. • Apply an approach of minimal exposure of the body within the requirements of the specific project. Always keep “anatomically sensitive” areas covered with clothing. NOTE Participants, particularly in their puberty or adolescent years, may feel “overly embarrassed” regarding the exposure of their bodies (e.g. chest or abdominal areas). Avoid pressure on an individual to participate in a specific project. As an alternative, consider some projects as home exercises. • Legal consent by the parents or legal guardian of students taking part in the projects is required. • The teacher/supervisor and all participants in the practical sessions should sign a “confidentiality form.” • Should any abnormalities be suspected during the performance of a practical session, the parent or legal guardian will be advised by the teacher/supervisor to seek professional medical advice. 2

I M P O R TA N T N O T E R E G A R D I N G S T E R I L I T Y A N D A S E P T I C T E C H N I Q U E : Body fluids, e.g. saliva, sweat, tears and nasal discharge, normally contain numerous microorganisms. Some of these may be the cause of various diseases. The examination of another person, especially projects where body fluids may touch the examiner’s hands or instruments, requires: • The application of strict rules regarding sterility and aseptic technique. • Supervision by a suitably qualified person familiar with sterility and aseptic techniques and taking responsibility for applying these techniques. IMPORTANT: THE PURCHASER TAKES FULL RESPONSIBILITY FOR THE ABOVE OR ANY C O N S E Q U E N C E S F O R N O T A P P LY I N G T H E S E P O I N T S ( s e e d i s c l a i m e r ) . RECOMMENDATIONS REGARDING STERILITY AND ASEPSIS: Remember the following rules apply with any examination (including self examination): • Wash your hands thoroughly with soap and water before and after an examination. • Use disposable items, e.g. gloves, tongue depressors and masks, ONCE ONLY. • Get into the good habit of wearing gloves and a mask when performing an examination. Wearing gloves is optional when performing a self-examination but compulsory when examining another person. • Items touching body fluids must be disposable and must be discarded after use. • Equipment, e.g. your examination light, is not allowed to touch body fluids. • If any equipment accidentally is contaminated with a body fluid such as saliva, ensure that the equipment used (e.g. examination light) is thoroughly cleaned with gauze and an antiseptic solution. PROJECT 00 - A TECHNIQUE FOR PROPER HAND WASHING The Apprentice Doctor™ course requires a number of medical instruments and items in order to complete a variety of exciting practical projects: • One interactive CD-ROM • A medical file • A stethoscope • A penlight examination torch • An eye test chart • Various other medical charts • Surgical marker pen and ruler • Tongue depressors • A pair of examination gloves • Antiseptic swabs • Face masks • A blood pressure meter (sphygmomanometer) • A digital thermometer • A magnifying examination light • An otoscope • A reflex hammer • Urine test strips

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You can order any of these medical instruments and items listed above from our Online Shop at the following website: http://www.theapprenticedoctor.com/ ; alternatively most of these products should be available at your pharmacy. We strongly recommend that you invest in The Apprentice Doctor™ Standard Kit which will permit you to complete the majority of the practical projects or The Apprentice Doctor ™ plus Kit, which contains the complete set of instruments and items that is required to complete all the practical projects in this course, packed in an attractive doctor’s case! These kits are also available from our Online Shop at http://www.theapprenticedoctor.com/. RECOMMENDATIONS ON HOW TO WORK YOUR WAY THROUGH THE APPRENTICE DOCTOR™ COURSE: In order to gain the maximum benefit from The Apprentice Doctor™ course, the following guidelines should be followed: • It is essential that you study the READ ME PRO document before starting with any of the practical Projects. This document will offer detailed guidelines regarding the practical Projects. Specifically start with Project 00 and Project 0 before proceeding with any of the other practical projects. • Work your way systematically through the Basic Principles of Examination before proceeding with the Human Body section. Study the lectures found throughout The Apprentice Doctor™ course before proceeding with the practical Projects associated with that specific lecture. Proceed with the practical Projects only once the information provided in the basic lectures is well understood. • For more information on a specific subject, click on some of the Internet Links provided throughout the course. These will launch your Internet browser and take you to the relevant Web sites. • Ensure that you become acquainted with all of the medical terms listed alphabetically in the Medical Glossary. • Visit The Apprentice Doctor™ Web site for information on exciting new developments and upgrades. • Please direct all technical and medical questions as well as inquiries regarding orders and products to the e-mail address provided: [email protected] You have now concluded your first lecture and are ready to begin with your second practical project of The Apprentice Doctor™ course. PROJECT 0 - OPEN A MEDICAL FILE 4

The Basic Principles of a Medical Examination SOUND: A BIOMEDICAL PERSPECTIVE Sound is energy in the form of a wave created by vibrating objects. It travels through media such as air, water, or solid materials from one location to another. Sound stimulates the sense of hearing by transferring its energy to sensitive structures in the ear. Sound, in the form of speech, is a means of conveying information. When people speak, the vibrations of their vocal cords are used to transmit sound waves through the medium of air to the ears of others, whose brains then interpret these sounds.

Sound Waves Vibrations, which generate sounds, may be slow or rapid. The rate of vibration, and the fluctuations in the sound wave to which it gives rise, is referred to as the frequency, or the number of vibrations occurring in one second. The scientific unit of frequency is Hertz (or Hz). 1 vibration per second = 1 Hertz. The human ear can detect a wide range of frequencies, ranging between approximately 80 vibrations per second to 18,000 vibrations per second (80 Hertz to 18,000 Hertz). Dogs can detect frequencies as high as 45,000 Hertz, cats as high as 85,000 Hertz and dolphins as high as 200,000 Hertz! The sensations or perceptions of different frequencies of sounds are commonly referred to as the pitch. A high-pitched sound corresponds to a high frequency, and a low-pitched sound to a low frequency.

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Audible sound is sound that can be detected by the human ear. For sound to be audible, it must fall within the detectable frequency range of human hearing. In addition to this, sound must be loud enough to be audible. The human body has ways and means of telling someone that it is healthy or that it has a problem. One of these methods of communication is audible sound. Doctors use a stethoscope to pick up sounds from the body and to transfer these sounds to their ears. Parts of the body that may produce sound Some of the organs of the human body cause vibrations when they do their work. Some of these vibrations are audible and communicate information about their state. One can listen to these sounds with a stethoscope and thereby gather information about the well-being of the body. These sounds can also be transferred to a computer. This information can be graphically displayed, digitally analyzed, recorded or stored as a graphic or sound file, and transmitted to another computer via a network or via the Internet. One can, for instance, send the sound file via e-mail to one’s family doctor and ask for an opinion. The family doctor can also forward the sound file via e-mail to a specialist for an expert opinion! Percussion is the production of sound by striking or tapping an object or a part of the body. A doctor can use a finger to tap (percuss) an area of a patient’s body. The sound produced by this percussion offers information about the condition of the internal organs of the body. PROJECT 1 - THE QUALITIES OF SOUND PROJECT 2 - AN INTRODUCTION TO PERCUSSION 6

THE EAR AND HEARING The ear is a special sense organ and is equipped with specialized structures to receive sound signals, and to convert these signals into nerve impulses. These impulses are perceived as hearing. The human ear can pick up sound vibrations from ±80 Hertz to 18,000 Hertz.

In addition, the ear has other specialized structures involved in perceiving position and movement. These structures are important in maintaining the body’s balance (equilibrium). The external ear (auricle) is concerned mainly with receiving sound waves and directing these waves into the ear canal leading to the ear drum (tympanic membrane). The middle ear houses three small bones – the hammer (malleus), the anvil (incus) and the stirrup (stapes). Sound is amplified and transferred from the eardrum to the inner ear by these bones. The inner ear contains the cochlea. The cochlea is a very special structure with the ability to convert sound vibrations into nerve impulses. The inner ear also contains three semicircular canals. This structure is concerned with balance. A doctor uses an otoscope to examine the external ear canal, the eardrum and the middle ear.

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PROJECT 3 - MEDICAL SOUND SAMPLES PROJECT 4 - EXAMINE THE EXTERNAL EAR 8

LIGHT: A BIOMEDICAL PERSPECTIVE Light is a specific form of energy with the ability to stimulate the sense of sight. Light is a special form of wave belonging to a group of waves called electromagnetic waves. Radio waves, transmitting signals from the radio station to a radio receiver and x-rays, used by doctors to obtain images of a patient’s bone structure, also belong to this group of electromagnetic waves.

Visible light includes a spectrum of colors as seen in a rainbow. These colors are red, orange, yellow, green, blue, indigo and violet. White light consists of a combination of these seven colors. Black is the absence of all these seven colors. Primary colors consist of any three colors of light, which when combined appear as white light. Red, green and blue light, when mixed together, will produce white light and are therefore considered primary colors. Red and green light makes yellow, red and blue light makes magenta and blue and green light makes cyan. A doctor uses the special sense of sight to gather information from the patient’s body. The medical term used for this process is called inspection. Light waves carry information about the appearance – form, structure, dimensions and color of the area being inspected. The doctor’s knowledge of the normal appearance of all the different areas of the human body helps him/her to recognize abnormalities. He/she may use an examination light or another type of light source to inspect certain areas in more detail.

PROJECT 5.1 - MIXING COLORS OF LIGHT PROJECT 5.2 INSPECT THE COLOR OF THE MUCOUS MEMBRANES 9

THE EYE AND VISION The eye is a very special sense organ, which is able to capture light energy from the environment, to form a focused image, and to convert this image into nerve impulses. This process is called vision. At this stage one needs to learn about the basic structures of the eye.

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The eyeball works in a similar fashion to a camera. Both have: 1. A protective outside “housing.” 2. A system for “bending” light by lenses (the scientific name for this is refraction). 3. A mechanism to regulate the amount of light received. 4. A light-sensitive layer (film/membrane).

The eye has a sensitive nerve reflex system with the purpose of regulating the size of the pupil. If the pupil is small, just a little light is allowed into the eye. If the pupil is large, more light is allowed into the eye. This process is called the pupil-light reflex. This reflex protects the nerve cells of the retina from damage by an excessive amount of light energy. In the dark or in dim light, the pupil will dilate (become large). Sharp or intense light will cause the pupil to contract (become small). A sudden fright will also change the size of the pupil for some time. Certain medicines may cause the pupil to increase or decrease in size.

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In some people, one or both eyes may be unable to focus a sharp image on the retina. An ophthalmologist can check the ability of an eye to focus. Inability of an eye to focus sharply may be corrected using lens-shaped glasses or contact lenses. The ophthalmic surgeon may also be able to correct the problem with laser surgery to the cornea. Visual acuity can be measured using various methods. A Snellen test chart is often used to measure distance visual acuity. Two specialized cells in the retina convert light into nerve impulses. These cells are the rods and the cones. The rods help to see shades of gray in dim light. The cones help to see different colors. There are three types of cones – red-sensitive cones, green-sensitive cones and blue-sensitive cones. Inability to distinguish between different colors is called color blindness.

The retina has a small spot where rods and cones are absent. This is called the blind spot. The blind spot makes it necessary for instance, to look at least twice to the left and twice to the right before crossing a road. The reason for this is simply that the oncoming vehicle may be “hidden” in one’s blind spot when one looks the first time.

PROJECT 6 - EXAMINE THE EYE PROJECT 7 - THE SNELLEN TEST PROJECT 8 - THE BLIND SPOT

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BASIC MEDICAL EXAMINATION INSTRUMENTS AND ITEMS Let’s discuss some of the common medical instruments and items used by healthcare professionals on a daily basis. 1. The Stethoscope A French physician René Théophile Laënnec who worked in Paris at the beginning of the 19th century designed the first stethoscope. He was exploring the idea of listening to body sounds but could not hear much by pressing his ear against someone’s chest. Two children playing by tapping and listening at the two ends of a long piece of wood gave him the idea. He designed the first stethoscope – a wooden tube about 1 foot long with a bell shaped opening at one end. The first stethoscope was shaped like a trumpet. The wider opening was placed against the chest of the patient, and the doctor listened through the smaller opening at the other end. Doctors occasionally still use this old-design stethoscope to check the heartbeat of an unborn baby.

The Modern Stethoscope The modern stethoscope consists of two earpieces at the end of two metal tubes, connected by flexible rubber tubes to a chest piece. The chest piece consists of a metal bell and a diaphragm (some stethoscopes have only the diaphragm part). The bell is best for listening to low-pitched sounds, and the diaphragm for identifying high-pitched sounds.

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2. The Blood Pressure Meter (Sphygmomanometer) The sphygmomanometer is a device used to measure blood pressure. It consists of the following: • The cuff • Rubber inflatable bladder covered by a material covering and Velcro strip • Pressure meter • Rubber tubing • Bulb-like pump • Pressure release valve.

A Sphygmomanometer works as follows: By pumping up the rubber bladder with air when it is wrapped around the arm, the air becomes compressed. The compressed air directly compresses the main artery of the arm. The blood in the artery flows under pressure due to the pumping action of the heart. The pulsating blood in the artery “pushes” against the compressed air in the cuff around the arm and the air transfers this force to the meter. A doctor measures blood pressure by observing the meter on the sphygmomanometer, while simultaneously listening with a stethoscope to the changing sounds produced by the blood flow in the compressed artery in the arm. 14

3a

3b

3. Examination Light Good lighting is a basic requirement when examining any region of the human body. An examination light consists of a power supply (e.g. batteries), a special light bulb and a switch mechanism. An examination room requires good general lighting. In addition to this, an examination light increases the amount of light in the area being inspected. A magnifying examination light (3a) also increases the detail of the area being inspected by enlarging the area. The penlight examination set (3b) consists of a penlight as well as a special extension (speculum) for examining the ear. This converts the penlight into a simple otoscope. 4. Reflex Hammer

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A reflex hammer consists of a handle with a plastic or a rubber head. This instrument is designed to exert a momentary force on the tendon part of a muscle. 5. Digital Thermometer

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1

Disposable Items

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A thermometer (temperature meter) is designed to measure temperature. The digital thermometer is a battery-operated device that electronically measures the temperature and displays it digitally. It is accurate to within one tenth of a degree Celsius. In order to maintain a high level of aseptic technique, special thermometer covers or sleeves are supplied with the set. It is recommended that the thermometer be covered every time someone’s temperature is measured. Do not use the digital thermometer to measure rectal temperature.

Disposable Items 1. Urinary Test Strips Urinary test strips are plastic strips impregnated with various chemical indicators that change color when reacting with chemical substances in urine. One can estimate the levels of certain chemicals in urine by comparing the color of a test strip with a standard color chart. 2. Surgical Marker And Ruler Surgeons use a surgical marker and ruler to plan certain surgical procedures. Structural landmarks or planned incision lines are carefully measured and marked. The ink used in the surgical marker is washable, biodegradable, and will not cause a tattoo to form.

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3. Face Mask

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During talking, coughing and sneezing small droplets of saliva or nasal secretions form. These droplets contain numerous microorganisms. Healthcare professionals use face masks as a barrier to limit the spread of these potentially harmful microorganisms. A face mask also protects the healthcare professional from potentially harmful body secretions, e.g. blood, and has the additional benefit of limiting bad odors, e.g. a dentist or a patient with bad breath. 4 4. Tongue Depressor A tongue depressor is a flat, disposable item made from plastic or wood with dimensions of about 15 x 2 x 0.1 cm (6 x 3/4 x 1/32 inches). Healthcare personnel use tongue depressors to facilitate the examination of the mouth and throat by retracting or depressing structures, e.g. the tongue and cheeks. 5 5. Examination Gloves Examination gloves serve as a two-way barrier to reduce the risk of transferring potentially harmful microorganisms between patient and doctor or other healthcare workers. A thorough washing and drying of the hands with soap and water is essential before putting on examination gloves. Different sized hands require specific sized gloves. 6

6. Antiseptic Swabs These swabs are small (5 x 5 cm or 2 x 2 inches) squares saturated with 70% medical alcohol and packed in sterile packages. Alcohol weakens or kills microorganisms and thereby reduces the risk of causing an infection. A doctor or professional nurse will clean the skin with an antiseptic swab before piercing it with a needle.

WARNINGS 1. Use your medical instruments and disposable items only along the guidelines of the various practical projects. 2. The use of the instruments and disposable items supplied in this kit is strictly intended for educational purposes only, and not for any medical application whatsoever. 3. If you are allergic to latex, DO NOT use the gloves supplied in this medical kit. Ask your pharmacist to supply you with latex free – e.g. silicone gloves. 4. Do not use the alcohol swabs close to the eyes. Keep alcohol from getting into the eyes at all costs.

PROJECT 9 - THE STETHOSCOPE AND SPHYGMOMANOMETER – ASSEMBLY AND CARE PROJECT 10 - THE STETHOSCOPE – FAMILIARIZE

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THE EXAMINATION OF A PATIENT During a consultation, a doctor follows a certain basic approach to find out which disease is causing the patient’s symptoms. This process is called examination. Establishing the cause of a problem or disease is called diagnosis. A doctor usually starts the process of diagnosis by asking questions. First, he/she will need to know the reason for the visit or the patient’s main complaint. The doctor will now ask more questions in order to establish the finer details of the problem. He/she will also ask questions about the patient’s current and previous state of health. When the doctor feels satisfied that sufficient information has been gathered, the physical examination will begin. During the physical examination, the doctor will use all senses to help gather more relevant information about the problem. The general senses of touch, temperature and pressure, as well as the special senses of vision, hearing and smell all contribute to giving the doctor more information about the patient. During the physical examination, the doctor uses the special sense of vision to inspect the body. Special instruments may be used to help with the process of inspection. An ophthalmoscope is used to inspect the structures of the eye and an otoscope (auriscope) is used for the inspection of the ear. The doctor will rely on the general senses of touch, temperature and pressure to gather further information. The medical term for gathering information by touching a patient is called palpation. Depending on the problem, the doctor may systematically tap with his/her finger(s) while listening to the quality and intensity of the sounds produced by the tapping. This process of tapping and listening is called percussion. A stethoscope will give the doctor information about sounds originating from inside the human body. The medical term for listening to these sounds is auscultation. The special sense of hearing is used during the process of percussion and auscultation. The doctor may not purposely smell the patient from head to toe, but during the examination he/she may become aware of a smell or odor. The smell may supply the doctor with additional information. Certain problems have a characteristic odor emanating from the infected area, for instance bad breath, which is called halitosis. The special sense of smell may also give the doctor a hint as to the abuse of certain substances (for example alcohol). Before modern scientific methods became available, doctors had to use their special sense of taste to help them in the diagnostic process of certain diseases. One of the signs of diabetes is too much glucose in the urine, thus giving these patients’ urine a sweet taste! In modern times, however, we have special chemical tests to analyze the amount of glucose in urine. After the physical examination, the doctor may still need additional information and will then request one or more special investigations. Blood tests and x-rays are examples of such special investigations. Having gathered sufficient information about the patient through questioning, the physical examination and doing special investigations, the doctor will go on to formulate a diagnosis and will then discuss the findings with the patient. He/she will also supply the patient with relevant information and help the patient to make decisions about the management or treatment of the problem or disease. PROJECT 11 - THE STRUCTURAL ARRANGEMENT OF THE BODY/ PROJECT 12 - SUBDIVISIONS OF THE CHEST/ PROJECT 13 - SUBDIVISIONS OF THE ABDOMEN/ PROJECT 14 - A PERCUSSION MODEL OF THE CHEST/ PROJECT 15 - TECHNIQUE FOR MEDICAL PERCUSSION/ PROJECT 16 - EXAMINATION BY PERCUSSION 17

The Human Body The basic building blocks of the human body are cells. Cells differ in function and structure. Tissue consists of groups of similar cells. Examples are nerve tissue, muscle tissue and bone tissue. An organ is made up of different tissues. The lungs, the heart and the brain are examples of organs. Groups of organs form systems. The heart and blood vessels form the “cardiovascular system” and all the bones of the body form the “skeletal system.”

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Tissue (Groups of Similar Cells) The body is usually divided into 11 systems. They are: • The skin (dermatological) system • The bone (skeletal) system • The muscle (muscular) system • The nerve (nervous) system • The heart and blood vessel (cardiovascular) system

• The hormonal (endocrine) system • The lymphatic system • The breathing (respiratory) system • The digestive (gastrointestinal) system • The urinary system • The reproductive system.

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THE COVERING (SKIN) SYSTEM The skin is the single largest organ of the human body. Skin consists of an outer layer of cells called the epidermis, a middle layer called the dermis, and at a still deeper level, the subcutaneous layer. The skin together with its accessory structures (the hair and nails as well as associated tissue, e.g. glands, muscles and nerves) make up the covering (integument) system. Skin helps to guard and maintain the integrity of the body’s internal environment. It protects us against physical injury, chemical injury and harmful microorganisms as well as against harmful ultraviolet radiation from the sun. Skin helps to regulate the body’s temperature. It also supplies the nervous system with information about the external environment. Skin is an external organ and is therefore readily visible and can be examined with ease. The skin, the hair and the nails can give a doctor a wealth of information about the state of health of the body. In the same way it can provide the doctor with information on disease processes occurring in the body. A thorough physical examination always includes an examination of the patient’s skin, nails and hair.

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PROJECT 17 - EXAMINE THE SKIN PROJECT 18 - EXAMINE THE NAILS PROJECT 19 - EXAMINE THE HAIR 21

THE SKELETAL SYSTEM

A total of 206 different bones make up the adult human skeleton. The bony framework of the body provides support to the soft tissue. The skeletal system, together with the muscular system, makes movement possible.

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Bone tissue serves as a storehouse for minerals such as calcium. The production of blood cells occurs in red bone marrow found within the internal areas of many bones. Bones range tremendously in shape and form. Long bones support the muscles of the arms and legs. Short bones are found in places like the hands and feet. The vertebrae (the building blocks of the spine) are irregular and the bones of the skull are flat in shape. PROJECT 20 - THE BONY LANDMARKS OF THE BODY

Cartilage

Cartilage is a flexible type of tissue. It covers the rounded end of long bones. Cartilage helps with smooth movement where bones move against each other. It also helps to absorb the shock of strong forces occurring during physical activities. Cartilage is also found in the larynx, the trachea, the nose and ears as well as where the ribs connect with the sternum.

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Joints Where two bones connect, a joint is formed. Three types of joints are found in the human body: 1. Joints that allow no movement. The sutures between the different bones of the skull are examples of this. 2. Joints that allow slight movement, for example the joints between the vertebrae of the spine. 3. Joints that allow free movement. Examples of these joints are the shoulder joint, the elbow joint, the hip joint and the knee joint as well as the left and right jaw joints.

Most movable joints operate quite smoothly and softly due to a lubricating liquid formed in the joint cavity, reminiscent of how oil can be used to take care of a squeaking door hinge. Sometimes a joint may make a noise during movement. Although normal on occasion, this may in some instances be an indication of a joint problem. A stethoscope is sometimes used to listen to these noises and may offer the doctor some clues as to the nature of the problem in the joint.

PROJECT 21 - JOINT SOUNDS 24

THE MUSCULAR SYSTEM

Three main types of muscle tissue are found in the human body: 1. Skeletal muscle 2. Cardiac muscle 3. Smooth muscle

Skeletal Muscle These muscles can be contracted or relaxed at will. Most of the muscles in the human body are made up of skeletal muscle tissue. Examples are the muscles of the arms, legs and tongue. Skeletal muscles give us the ability to move. They help to maintain body posture. The skeletal muscles use a lot of energy and produce a lot of heat. This helps to maintain normal body temperature (an average of 37ºC/98.4ºF).

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PROJECT 22 - BODY TEMPERATURE PROJECT 23 - THE MUSCLES OF THE BODY 26

Cardiac Muscle This type of muscle is found in the heart. Cardiac muscle maintains blood circulation. Cardiac muscle has a much higher endurance level than skeletal muscle. For example, if one were to squeeze a rubber ball 70 times a minute, one’s hand would get tired very quickly. The cardiac muscle of the heart contracts about 70 times a minute all day long, every day of a person’s life. Cardiac muscle has been designed to utilize energy with “super” efficiency. The heart muscle rests only momentarily between each heartbeat. The physically fit person’s heart beats somewhat slower, allowing the heart a longer rest period between heartbeats.

PROJECT 24 - THE HEART RATE Smooth Muscle This type of muscle is found in the internal organs (viscera). Some of the organs containing smooth muscle are the intestines, the walls of the blood vessels, the urinary bladder, and parts of the male and female reproductive systems as well as the walls of the air passages. Smooth muscle helps to maintain normal blood pressure, move food along the gastrointestinal system, and assists in moving a baby from the uterus to the outside world during the birthing process.

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THE NERVOUS SYSTEM The body needs as much information as possible about its external (outside) environment, as well as information about its internal (inside) environment. This information needs to be analyzed, interpreted and followed up by appropriate actions in order to survive and procreate (reproduce) successfully. The nervous system is a very complex system performing these functions. It can be subdivided into (i) the central nervous system consisting of the brain and spinal cord and (ii) the peripheral nervous system consisting of the nerve highways that run throughout the body.

The peripheral nerves carry information between the body and the central nervous system. Some nerves carry information towards the central nervous system. These nerves are called sensory nerves. Other nerves carry signals towards the muscles – these nerves are called motor nerves. Autonomic nerves send and receive nerve impulses of an involuntary nature. These nerves regulate the internal organs of the body and control other involuntary functions, for example the pupil light reflex.

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A computer has: (i) input devices, e.g. keyboard and mouse; (ii) a central processor and associated memory devices; and (iii) output devices, e.g. the screen and printer. The nervous system functions similarly to a computer. The input devices of a computer are equivalent to the sensory receptors and sensory nerves of the nervous system. The equivalent of the central processor is the central nervous system (brain and spinal cord). The equivalent of the output devices are the motor nerves and associated structures.

The nervous system generally functions in the following manner: Step 1: Information gathering Step 2: Sensory nerves Step 3: Processing of information by the central nervous system (Brain and spinal cord) Step 4: Motor nerves Step 5: Response (Reaction)

Let’s focus on each of these functions: 1. Gathering information The nervous system is equipped with a range of general and special receptors with the ability to convert information about the body’s internal and external environments into nerve impulses. General senses are touch, pressure, vibration, position, temperature and pain. Receptors for these senses are distributed throughout the body. Special senses are smell, vision, taste, balance and hearing. Receptors for these senses are located in specialized sense organs.

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2. Processing of information The brain weighs about 3 pounds and is made up of about 100 billion nerve cells (neurons). The brain receives information and analyzes and interprets this information. It may take action or store the information for later use in its immensely large memory banks. The brain is the center of conscious awareness of yourself, of your body and of your environment. The higher functions of personality, character, intelligence and emotions are seated in the brain.

3. Response to information received The brain may respond by sending out nerve impulses to skeletal muscles, smooth muscles, cardiac muscles, or to glands. The response may be expressed as: 1. Speech, 2. Purposeful behavior in performing tasks, 3. Complex behavior as an expression of character and personality, 4. Reaction in emergency situations (flight or fight response), and 5. Regulation of body functions.

The Spinal Cord The spinal cord is part of the central nervous system, and has two main functions: 1. It contains nerve fibers carrying information from the peripheral sensory nerves to the brain, and from the brain to the peripheral motor nerves. 2. It is the center of numerous neural reflex systems. An example of a spinal reflex is when you accidentally touch a hot plate on a stove. Your arm muscles will jerk away your finger even before you become consciously aware of the pain caused by the heat.

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PROJECT 25 - THE PUPIL-LIGHT REFLEX PROJECT 26 - THE FACIAL NERVE PROJECT 27 - SPINAL NERVE REFLEXES

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THE ENDOCRINE SYSTEM The efficient functioning of a family, a company, an organization, or a school requires effective communication between individuals in the group. In a similar way, effective communication between the individual cells of the human body is essential for normal functioning, and potentially for survival and procreation. Two body systems are involved in the process of communication between cells – the nervous system and the endocrine system.

The nervous system uses electrical impulses along nerve fibers for communication. The endocrine system uses chemical mediators called hormones for communication. These hormones are produced by various endocrine glands in different locations within the human body. Hormones are secreted into the blood stream and reach specific "target" cells in other tissues. In essence, hormones are chemical messengers. Hormones play an important role in growth and regulate almost all the biochemical processes occurring in the human body to some extent. The endocrine system influences all other body systems directly or indirectly and plays an important role in all the different aspects of procreation.

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One of the endocrine hormones secreted by the pancreas is insulin. Insulin prevents blood levels of glucose from reaching abnormally high levels. Cells require energy to function and use glucose as “fuel” to produce this energy. Too little glucose in the blood will cause a short supply of fuel to cells. The nerve cells of the brain are especially vulnerable to a shortage of glucose and may suffer irreparable damage should this occur. Too much glucose in the blood will disturb the normal balance of chemical reactions occurring in the body, causing a variety of problems. The kidneys have the ability to retain glucose molecules circulating in the blood stream and to prevent glucose from ending up in the urine as waste. If the blood levels of glucose get too high, the kidneys will be unable to retain the glucose molecules in the blood, and some glucose will “spill over” to the urine for elimination as waste. A systematic examination of all the systems of the human body followed by special tests will help the doctor to evaluate the endocrine system. Hormone levels may be normal, too high, or even absent, causing a variety of signs and symptoms.

Table 1 contains a list of some of the endocrine glands, the hormones they secrete, and some functions of these hormones.

PROJECT 28 - GROWTH CHART * PROJECT 40 - URINALYSIS 33

TABLE 1. Endocrine Glands and the Hormones they produce Endocrine Glands

Hormone/s

Hypothalamus

Various hormones control the pituitary gland.

Pituitary gland

Various hormones stimulate the release of hormones by various other endocrine glands.

Thyroid gland

Thyroxin stimulates the energy metabolism of all cells.

Parathyroid glands

Parathyroid hormone increases blood calcium levels.

Adrenal glands (cortex)

Various hormones regulate metabolism, the body’s fluid and electrolyte balance, and the immune system.

Adrenal glands (medulla)

Adrenalin levels increase during stressful situations.

Pancreas

Insulin and glucagon regulate blood glucose levels.

Ovaries

Estrogen promotes the development of female sexual characteristics.

Testes

Testosterone promotes the development of male sexual characteristics.

Thymus

Thymosin helps with the development of cells of the immune system.

Placenta

Various hormones regulate certain aspects of pregnancy.

Pineal gland

Melatonin is involved in the body’s “internal clock.”

Heart

An atrial hormone helps to regulate the body’s fluid and electrolyte balance. 34

THE CARDIOVASCULAR SYSTEM Blood transports oxygen (O2) and nutrients to the tissues in the human body. It also carries waste chemicals like carbon dioxide (CO2) away from the tissues. To fulfill this purpose, blood needs to move through the different blood vessels all the time. Blood circulates through these blood vessels continuously, carrying nutrients to and waste products away from the tissues in the body. Blood cannot circulate by itself.

A pump is needed to cause the blood to circulate, and the heart is this very special pump. In fact, the heart is a double pump in a single structural unit. The left side of the heart receives oxygen-rich blood from the lungs and pumps this blood to the tissues and organs of the body. The right side of the heart receives oxygen-depleted (oxygen-poor) blood from the tissues and organs and pumps it to the lungs, where the blood picks up fresh oxygen. Arteries carry blood away from the heart and veins carry blood back to the heart. Capillaries are microscopic vessels allowing blood to flow from the arteries to the veins. Capillaries allow the exchange of oxygen, nutrients, carbon dioxide and waste products across their walls. At this stage one needs to study the structure (anatomy) of the heart. The left side and the right side of the heart each have a smaller chamber or atrium, and a bigger chamber or ventricle. At the entrance and exit of the ventricle is a valve. These valves allow blood to flow in one direction only. These valves open and close as the pressure in the heart changes due to contractions of the heart muscle. The heart of a healthy young adult contracts and relaxes about 72 times per minute.

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Heart Sounds The closure of the heart valves is mainly responsible for the heart sounds, just as the sudden closure of a door causes a sound. Irregular (turbulent) blood flow may also cause vibrations and therefore sounds. Irregular blood flow occurs when blood “rushes” into large chambers (ventricles) from the smaller chambers (atria).

Normally two distinct sounds can be heard when a stethoscope is placed over the heart area on the front wall of the chest. These sounds are rhythmical, repetitive, and commonly described as “lubdup.” The first sound (lub) is caused by vibrations due to the sudden closure of the valves at the entrance to the ventricles, and the second sound (dup) is caused by vibrations due to the sudden closure of the valves at the exit from the ventricles. A short period of silence (pause) occurs between the “lub” and “dup” sounds, and a somewhat longer pause occurs after the first “lub-dup” sound and the next “lub-dup” sound. Occasionally, a faint third and a fourth heart sound may be audible. These sounds associated with irregular (turbulent) blood flow are very faint and often undetectable. Irregular blood flow (turbulent flow) may be caused by a leaking valve at the entrance or exit of one or both ventricles. A valve not opening completely may also cause turbulent blood flow. The blood then “struggles” to flow through the incompletely opened and therefore partially obstructed heart valve. Abnormal heart sounds are caused mainly by defective heart valves (heart valves that do not shut or open properly). A doctor can diagnose these problems by using a stethoscope. Sometimes special tests may be necessary to confirm these conditions or to evaluate the extent of the problem. PROJECT 29 - TURBULENCE IN THE FLOW OF A LIQUID PROJECT 30 - HEART SOUNDS PROJECT 31 - BLOOD PRESSURE PROJECT 24 - THE HEART RATE (see Muscular System) 36

THE LYMPHATIC SYSTEM A country needs a well-organized defense force to protect its citizens against hostile forces outside its borders. In the same way, the body has a well-organized defense system called the immune system. The “soldiers” of this system are cells called lymphocytes. Many organs contain large numbers of these lymphocytes including the lymphatic system, the tonsils, the thymus, the spleen and red bone marrow. The lymphatic system consists of a network of lymph vessels distributed throughout the body as well as a special fluid called lymph. The lymph vessels converge towards nodular structures called lymph nodes. Eventually the large lymph vessels empty their contents into the bloodstream.

The lymphatic system is involved in: 1. The production of lymphocytes. 2. Drainage of excess body fluids. 3. The transport of certain fatty substances from the tissue and digestive tract to the bloodstream. During a routine examination a doctor will examine the lymph nodes in a specific area by means of palpation. He may also examine the spleen (palpation) and the tonsils (inspection). 37

Blood tests may reveal the number and percentage of lymphocytes in a specific amount of blood. This offers the doctor considerable diagnostic information. Normally lymph nodes are small and soft. Enlarged lymph nodes may be the body’s normal response to fight off foreign microorganisms. Sometimes enlarged lymph nodes may be an indication of a disease process occurring in the body. The family doctor should professionally assess enlarged tonsils, lymph nodes, or spleen.

PROJECT 32 - THE BODY’S LYMPH NODES * PROJECT 36 - EXAMINE THE ORAL CAVITY (SPECIFICALLY THE TONSILS) * PROJECT 39 - EXAMINE THE ABDOMEN (SPECIFICALLY THE SPLEEN) 38

THE RESPIRATORY SYSTEM The body needs oxygen to sustain the life of each individual cell in the body. The organs for breathing are designed for conveying oxygen molecules from the air to the lungs and then to transfer these molecules to the blood. Simultaneously, a waste gas called carbon dioxide (CO2) is transferred from the blood to the lungs and then moved out of the body into the atmosphere. This process of oxygen supply to the blood and removal of carbon dioxide from the blood is called “gas exchange.” The respiratory system needs to ensure that oxygen-rich air is available in the lungs and that carbon dioxide-rich air is removed from the lungs on a continuous basis. “Fresh” air is moved into the lungs, and “stale” air is removed from the lungs during the process of respiration (breathing).

The number of times a person breathes in and out in one minute is called the respiratory rate. A normal healthy adult at rest breathes in and out 11 to 14 times per minute (respiratory rate of 1114 on average during periods of rest). The respiratory rate in children ranges from 18–20, and in babies from 30-40 during rest. The rate of respiration increases dramatically during physical activity and decreases during sleep. The respiratory system consists of two parts. The upper respiratory system consisting of the nose and associated structures as well as the throat (pharynx) and associated structures.

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These passageways help to filter, warm and humidify (dampen) the air on its way to the lungs. The lower respiratory system consists of the voice box (larynx), the air pipe (trachea), the bronchial tree (a network of smaller air passageways) and the lungs. Oxygen is transferred from the air to the blood via the small blood vessels in the lungs within very small air spaces called “alveoli.” The mouth may occasionally become involved as part of the upper breathing system. When your body needs a lot of oxygen as for example during physical activity or if the nasal passages are blocked, breathing will occur partially or totally through the mouth. The respiratory system is involved in the special sense of smell via special nerves in the nasal cavity. The movement of air through the breathing passage may cause vibrations, and therefore sounds. A healthy respiratory system will cause normal breathing sounds. Various diseases of the airways and lungs may cause abnormal breathing sounds. These sounds may be described as wheezes (sounds with a musical character), crackles (bubbling or clicking sounds) and rubbing (creaking or leathery) sounds. 40

Listening to the lungs gives considerable information about the condition of the respiratory system. When one uses one’s voice, vibrations can be felt by the sense of touch (palpation) when the palm of the hand is placed over the chest (lung) area. The voice box (larynx) is designed to produce special vibrations. Together with the rest of the respiratory system, it produces sounds (voice) for speaking and singing as well as non-verbal communication, e.g. laughing and crying. Of course one will easily be able to pick up these sounds using a stethoscope. One can graphically analyze these sounds using a suitable audio computer program. Voice recognition software utilizes this process.

PROJECT 33 - THE RESPIRATORY RATE PROJECT 34 - RESPIRATORY SOUNDS PROJECT 35 - BREATHING MOVEMENTS

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THE DIGESTIVE SYSTEM The cells of the human body need water and chemical substances (nutrients) to stay alive. Cells use these nutrients as building blocks for various cell structures. They also need nutrients to sustain the various chemical processes (reactions) occurring in the cell. The digestive system is designed to act as the source from which nutrients are conveyed to the cells of the body. The digestive process involves the following: • Eating (ingestion), • Mechanical processing (chewing and movement of the food along the digestive canal), • Chemical breakdown of food (digestion), • Absorption of nutrients, and • Excretion of waste products.

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MOUTH The mouth can be considered the entrance to the digestive (gastrointestinal) system. The mouth can on occasion help to transport oxygen-rich air to the lungs (for example during yawning). The mouth helps with pronunciation and articulation of sounds when speaking. The special organ of taste is situated in the lining of the mouth – mainly in the tongue. The structures in the mouth picking up the taste sensation are called taste buds. Some areas of the tongue specialize in specific taste sensations. The teeth are used for chewing the food. In this process, food is ground into small pieces and mixed with saliva. In the final stages of chewing, food is formed into a small ball called a “bolus” by the muscles of the cheek and tongue. During swallowing, the food bolus moves from the mouth to the throat into the tube connecting the throat to the stomach, called the “esophagus.” Baby teeth consist of 5 teeth on both sides of the upper and lower jaws – a total of 20 teeth. Adult (permanent) teeth consist of a total of 8 teeth on both sides of the upper and lower jaws – a total of 32 teeth. A tooth develops in the jaw and then moves through the gums into the mouth. This process of a tooth moving towards and appearing in the mouth is called “eruption.” The jaws may be too small to accommodate all the permanent teeth. The permanent teeth may erupt in a crowded situation. Alternatively, the jaws may be left with residual spaces after having accommodated all the teeth. In some people, the teeth may erupt fairly straight, but the upper and lower jaws may not fit properly onto each other. A specialist dentist called an orthodontist can correct and treat these conditions by means of braces.

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PROJECT 36 - EXAMINE THE ORAL CAVITY PROJECT 37 - TASTE LABORATORY

Digestion Various processes in the digestive canal may cause vibrations that can be picked up by a stethoscope. Obviously the chewing and mixing of the food with saliva in the mouth causes a fair amount of sound. In western culture, chewing with your mouth closed to minimize these sounds is considered good manners. Swallowing food or liquid also causes a fair amount of vibration that can be heard as sounds. The movement of food along the stomach and intestines is another source of sound. The action of the muscles of the intestines moving the food material is called “peristalsis.” The chemical processes involved in digestion may form various gases as by-products. Movement of gas causes sounds (sometimes loud enough to cause some embarrassment). These sounds can be picked up by a stethoscope and can inform a doctor about what is happening in the digestive tract. The medical term used for intestinal gas is “flatus.”

PROJECT 38 - GASTROINTESTINAL SOUNDS PROJECT 39 - EXAMINE THE ABDOMEN 44

THE URINARY SYSTEM After a meal has been digested and assimilated, our bodies utilize the useful nutrients. The waste products need to be disposed of. The urinary system performs this duty effectively while at the same time conserving water and other valuable substances. The urinary system consists of two kidneys, two ureters, the urinary bladder and the urethra. The kidneys remove waste products from the bloodstream and produce urine. A system of tubes as well as the urinary bladder help to transport, store and then eliminate the urine. The process of eliminating urine from the body is called urination. The medical term for this is micturition. Various disease processes may involve the urinary system. An examination of the urinary system includes a physical examination followed by specific special investigations, if indicated. Chemical analysis and microscopic examination of urine in the laboratory gives a wealth of information about the state of health of the urinary system as well as other systems of the body.

PROJECT 40 - URINALYSIS 45

THE REPRODUCTIVE SYSTEM The male reproductive system consists of the testes, a duct system, supporting sex glands and the external genital organs – the scrotum and penis. The male organs produce, store and eventually introduce sperm-containing semen into the female reproductive tract. The female reproductive system consists of the ovaries, the fallopian tubes, the uterus and vagina, as well as the external genitals called the clitoris and vulva.

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The female reproductive system produces ova, receives the sperm-containing semen, and then allows fertilization to take place. This is then followed by the development of a fetus, birth and the production of milk (lactation) after birth. Malfunctioning of either the male or the female reproductive system may cause a woman to be unable to become pregnant. This condition is called infertility. A doctor can examine the reproductive systems and may require a variety of tests in order to find the cause of the infertility. Highly specialized techniques are available to help infertile couples to have babies. Numerous disease processes may affect the reproductive systems. Certain diseases may be transmitted by sexual contact with another person. AIDS (acquired immunodeficiency syndrome) is a fatal disease caused by the human immunodeficiency virus (HIV). This virus is readily transmitted by sexual contact with another person. Having a single faithful sexual partner for life can prevent sexually transmittable diseases.

PROJECT 41 - HEART SOUNDS: UNBORN BABY SUPPLEMENT ON HIV-AIDS

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The Apprentice Doctor™ Standard kit

If you’re serious about a career in medicine, I highly recommend that you invest in The Apprentice Doctor™ Standard kit. On interactive CD-ROM… Various sections packed with medical knowledge, 45 clearly explained step-by-step practical projects, a disease fact file, and much more! Numerous animations illustrate the body’s normal functions while video clips illustrate how a qualified doctor performs and explains various medical examinations. Sound clips illustrate the normal and abnormal sounds a body makes. These are skills you will need as a medical professional, whether it be a doctor, nurse, therapist, or specialist surgeon. Real medical instruments are included in the package. In addition to this knowledge-packed, interactive CD-ROM, you get real, genuine medical instruments, such as a stethoscope, examination light, surgical marker and ruler, masks, gloves, alcohol swabs, eye-test and growth charts and tongue depressors, to complete the practical projects on the CD! If you’re serious about a career in medicine, you need to invest in The Apprentice Doctor ™ Standard package! Click on this link: www.TheApprenticeDoctor.com

J.A.D. PROJECTS INDEX PROJECT 00 PROJECT 0 PROJECT 1 PROJECT 2 PROJECT 3 PROJECT 4 PROJECT 5.1 PROJECT 5.2 PROJECT 6 PROJECT 7 PROJECT 8 PROJECT 9 PROJECT 10 PROJECT 11 PROJECT 12 PROJECT 13 PROJECT 14 PROJECT 15 PROJECT 16 PROJECT 17 PROJECT 18 PROJECT 19 PROJECT 20 PROJECT 21 PROJECT 22 PROJECT 23 PROJECT 24 PROJECT 25 PROJECT 26 PROJECT 27 PROJECT 28 PROJECT 29 PROJECT 30 PROJECT 31 PROJECT 32 PROJECT 33 PROJECT 34 PROJECT 35 PROJECT 36 PROJECT 37 PROJECT 38 PROJECT 39 PROJECT 40 PROJECT 41

A TECHNIQUE FOR PROPER HAND WASHING OPEN A MEDICAL FILE THE QUALITIES OF SOUND AN INTRODUCTION TO PERCUSSION MEDICAL SOUND SAMPLES EXAMINE THE EXTERNAL EAR MIXING COLORS OF LIGHT INSPECT THE COLOR OF THE MUCOUS MEMBRANES EXAMINE THE EYE THE SNELLEN TEST THE BLIND SPOT THE STETHOSCOPE AND SPHYGMOMANOMETER – ASSEMBLY AND CARE THE STETHOSCOPE – FAMILIARIZE THE STRUCTURAL ARRANGEMENT OF THE BODY SUBDIVISIONS OF THE CHEST SUBDIVISIONS OF THE ABDOMEN A PERCUSSION MODEL OF THE CHEST TECHNIQUE FOR MEDICAL PERCUSSION EXAMINATION BY PERCUSSION EXAMINE THE SKIN EXAMINE THE NAILS EXAMINE THE HAIR THE BONY LANDMARKS OF THE BODY JOINT SOUNDS BODY TEMPERATURE THE MUSCLES OF THE BODY THE HEART RATE THE PUPIL-LIGHT REFLEX THE FACIAL NERVE SPINAL NERVE REFLEXES GROWTH CHART TURBULENCE IN THE FLOW OF A LIQUID HEART SOUNDS BLOOD PRESSURE THE BODY’S LYMPH NODES THE RESPIRATORY RATE RESPIRATORY SOUNDS BREATHING MOVEMENTS EXAMINE THE ORAL CAVITY TASTE LABORATORY GASTROINTESTINAL SOUNDS EXAMINE THE ABDOMEN URINALYSIS HEART SOUNDS: AN UNBORN BABY

48 51 53 53 55 55 58 58 60 62 64 65 67 68 73 75 77 79 80 82 85 87 90 93 94 95 99 101 103 104 107 109 110 112 115 116 117 119 120 122 124 125 128 130

IMPORTANT NOTE Read the medical disclaimer as well as the “READ ME PRO” documents before proceeding with any of the practical projects in The Apprentice Doctor™ course.

PROJECT 00 - A TECHNIQUE FOR PROPER HAND WASHING How to cleanse your hands hygienically before examining a patient.

INFORMATION • The simple act of hand washing is probably the single most important way to reduce the transfer of harmful microorganisms from one person to another. • For hand washing to be effective in avoiding or reducing the transfer of harmful microorganisms, adherence to a proper technique is of utmost importance. • The following infection control measures are essential in a hospital environment: 1. Washing hands before and after examining/touching a patient, 2. Wearing clean/sterile gloves during an examination 3. Sterilization of all surgical instruments, and 4. Proper discarding of all disposable items after use. • Hand washing is also important for reasons of personal hygiene, e.g. the washing of hands after using the bathroom as well as before meals. • Staff working in the food and restaurant industries require a high level of hygiene including a protocol regarding hand washing to avoid the contamination of food with dangerous microorganisms. SETTING: The bathroom or any room with a suitable faucet and sink for washing hands. REQUIREMENTS: • A nail clipper or nail care set. • Soap (antiseptic or regular soap). Liquid soap is preferable but a bar of soap will also do. • A clean towel. Disposable paper towels are preferable.

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NOTE: 1. Hand washing can be subdivided into the following important steps: • Wet • Soap • Rinse • Dry 2. Hands should be washed for at least 1 minute but preferable 2 minutes to be effective. 3. A healthcare worker’s nails should ALWAYS be kept neat, short and hygienically clean! STEP 1 Turn on the faucet and adjust to a moderate stream of water. Wet both hands up to the wrists. STEP 2 Apply soap to the hands until you have a rich foamy lather. Spread the soap lather over the complete surface of both hands up the wrist. STEP 3 3.1 Rub the hands, palm to palm in an up and down as well as a circular motion. 3.2 Rub the right palm over the back of the left hand, then the left palm over the back of the right hand. 3.3 Wash the hands palm to palm again, but now with the fingers interlaced. 3.4 Rub the interlocked fingers against the palm of the opposing hand. 3.5 Perform rotational rubbing of the right thumb clasped in the palm of the left hand and vice versa. 3.6 Wash the tips of the fingers with rotational motions in the palm of the opposing hand.

1

2

3.1a

3.1b

3.2

3.3

3.4

3.5

3.6

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STEP 4 Rinse the hands well. Allow running water to flow over the hands. The water should run from fingertips to the palms and then towards the wrists. Ensure that all soap is rinsed off properly and then turn off the faucet.

4.1

4.2

4.3

STEP 5 Dry the hands thoroughly starting at the fingers then the palms and back of the hands and lastly the wrist areas. If you intend to perform a clinical examination, put on a pair of clean gloves.

5.1

5.2

5.3

5.4

HINTS: • Frequent washing of hands will remove the skin’s natural surface oils, making it scabby and rough. To reduce this tendency, wash the hands in cool rather than hot water. • The frequent use of a moisturizing hand lotion will assist in keeping the hands feeling smooth and comfortable. POINTS OF INTEREST • Worldwide, hand transmitted diseases are the cause of many thousands of deaths every year. • A number of waterless alcohol-based hand sanitizers are available on the market. These agents appear to be an effective alternative for routine decontamination of hands. 50

• Surgeons and operating room staff use a special technique called “surgical scrubbing” before a surgical operation. This technique is similar to the above described technique with the following main differences: 1. Surgical scrubbing requires scrubbing the nails with a sterile brush. 2. It requires more time (between 3 and 5 minutes). 3. The wash area extends from the nails up to just above the elbows. • Extensive brushing of the skin of the hands and arms is not only unnecessary but in fact abrades the skin making it easier for bacteria to reestablish, which is why scrubbing is limited to the nails.

PROJECT 0 - OPEN A MEDICAL FILE Record general information, take a medical history, and collect clinical information from a patient.

INFORMATION Most medical practitioners choose medicine as a career because they are interested in people. They often take a personal interest in their patients, and therefore need to establish a doctor-patient relationship starting with the very first visit. In the process of establishing this relationship, the doctor will need to gather some information such as: • General Information • This is usually of a personal and social nature like your name, address, occupation and so on. • Medical History The doctor needs information about the patient’s present and past state of health, including the use of medicines, previous operations and family members with medical conditions. • Presenting Complaint In short this is the reason why a patient made the appointment to consult with his/her doctor. The doctor will ask questions about the nature, severity, duration, frequency and other specifics regarding this complaint. In an effort to gather some of the basic information mentioned above, many doctors will ask the patient to record these details on the front page of a patient file. The patient’s medical file is intended to serve as a recording system for all information of a medical nature. REQUIREMENTS: • A pen or a pencil • An Apprentice Doctor™ medical file* *Available from our Online Shop or as part of The Apprentice Doctor™ Standard or Plus kits. See an example of The Apprentice Doctor™ medical file in Addendum 1 at the end of this book. You may print this example and use it in this project. FOLLOW THESE STEPS: STEP 1 Familiarize yourself with The Apprentice Doctor™ medical file (see Addendum 1). STEP 2 Use The Apprentice Doctor™ medical file (or the example in Addendum 1), and complete all your own information on the front page. STEP 3 If you answered yes to any of the questions in the medical questionnaire, expand with more detail on page 2 about the condition(s) or illness(es). 51

STEP 4 Make notes regarding the presenting complaint. • You may have a real complaint. • Use a fictitious complaint, or • Simply write down “routine examination.” STEP 5 Get acquainted with the middle pages of the medical file. Space is provided on The Apprentice Doctor™ medical file for making notes on your findings when doing Project 1 to Project 41. The page with diagrams of outlines of the body is provided for this purpose as well. Add extra pages if you need more space for clinical notes. Keep these pages inside The Apprentice Doctor™ medical file. STEP 6 Record the successful completion of a project on the back page of The Apprentice Doctor™ medical file (preferably with a signature from a person in a supervising capacity). STEP 7 Open a new medical file for each new patient taking part in the practical exercises. Follow the same basic sequence as in Steps 2-6 above: • Ask them to complete the front page of their clinical file. • Study the medical questionnaire, ask for more information, and record it on the second page of the file. • Record the presenting complaint. • Make notes on your clinical findings during and after an examination on the middle pages of the medical file. • Record the successful completion of a project on the back page of The Apprentice Doctor™ medical file (preferably with a signature from a person in a supervising capacity).

POINTS OF INTEREST • Gathering information about the patient is usually referred to as “taking a history.” • History-taking is an essential skill that doctors use in the process of diagnosing a disease or condition. • A thorough history can go a long way in avoiding serious problems, for example: 1. If a doctor knows that the patient is allergic to a specific drug, the doctor will refrain from prescribing this drug and thereby avoid serious complications or even a patient’s death. IMPORTANT NOTE: The patient files contain confidential information. Always keep these files in a safe place or ask your parent(s) or teacher to keep them in a secure area.

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PROJECT 1 - THE QUALITIES OF SOUND Explore some of the characteristics of sound waves.

INFORMATION The pure tones produced by a violin in the hands of a master; the noise heard during rush hour traffic; the voice of a friend talking to you; and a bird singing peacefully are all examples of sound waves. Each has its own set of unique characteristics, e.g. pitch, intensity and quality. ONLY AVAILABLE ON *CD-ROM!! *Available from our Online Shop or as part of The Apprentice Doctor™ Standard or Plus kits. Go to: http://www.theapprenticedoctor.com/ for further details.

PROJECT 2 - AN INTRODUCTION TO PERCUSSION Acquire a basic understanding of percussion principles.

INFORMATION In an orchestra, the drums and cymbals are called percussion instruments, because they make sounds when you hit (percuss) them with your hand or with an instrument such as a drumstick. Medically, percussion is the examination of a patient by gently striking or tapping a part of the patient’s body with the fingers or an instrument. A doctor uses the special sense of hearing to listen to the quality of sound produced when using percussion over some areas of the body. This gives the doctor some idea of the contents inside some of the body cavities. We use percussion in our daily lives to find out what is inside containers. If you want to know if a tin is filled with your favorite cookies, you do not have to open the tin. By simply knocking on it with one of your hands, you will be able to get an idea of what is happening on the inside by the quality of the sound produced. A “hollow” sound will indicate that the tin is probably empty. A more solid sound will indicate that the tin is filled, to some degree, with cookies. Here are some things you can do to prove the value of percussion. PROJECT 2.1 YOU WILL NEED: • 3 glasses of identical shape and form • A teaspoon FOLLOW THESE STEPS: STEP 1 • Fill the first glass with water almost to the top. • Fill the second glass halfway up with water. • Leave the third glass completely empty.

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STEP 2 Use the teaspoon to tap each glass lightly on the sides. Caution: Do not tap too forcefully. Do you notice the difference in the quality of the sound? Will you be able to judge which glass is which – even if you look away and somebody else taps the glasses? Listen closely to the pitch of the sound. The empty glass vibrates faster when tapped, producing a higher frequency sound compared to the other glasses. The full glass vibrates slower when tapped, producing a lower frequency sound.

PROJECT 2.2 YOU WILL NEED: • Three empty tins with lids. FOLLOW THESE STEPS: STEP 1 Place the three tins on a table. STEP2 Ask someone else to fill one or two tins with an object or with some substance. Ensure that you are unaware which tins are filled and which tins are empty. STEP 3 Try to differentiate between the empty and the filled tins by using percussion (tapping) exclusively as the only tool of investigation.

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POINTS OF INTEREST • The difference in the pitch (or frequency) of the sound tells us something about the inside of a hollow container (a glass in Project 2a and a tin in Project 2b). • Did you notice another quality of sound when you tapped the empty glass and empty tins compared to tapping full containers? The empty glass and tins had a “hollow” sound. This is caused by sound waves bouncing back and forth on the inside of the container’s surface. The scientific name for this is reverberation. Reverberation increases with the amount of air (or any gas) filling the inside of a hollow container, as opposed to the comparative absence of air in a full container which produces a duller sound. (See the diagram on the previous page.)

PROJECT 3 - MEDICAL SOUND SAMPLES Listen to a variety of sounds related to the world of medicine.

INFORMATION The siren of an ambulance transporting an injured patient warns other road users to give right of way to the ambulance. Sound plays an important role in the world of medicine. A doctor listens to body sounds with a stethoscope to assist in making a diagnosis. An anesthetist listens intently to the sounds produced by the medical monitoring equipment in order to assess the condition of the anaesthetized patient during surgery. An alarm will warn if the heart rate, for instance, increases or decreases beyond predetermined values. STEP 1 Simply click the “Play” button to start one of the medical sound samples and click the “Stop” button to stop the sound. ONLY AVAILABLE ON *CD-ROM!! *Available from our Online Shop or as part of The Apprentice Doctor™ Standard or Plus kits.

PROJECT 4 - EXAMINE THE EXTERNAL EAR Identify the normal structures of the external ear.

INFORMATION The external ear consists of the auricle (pinna) and the ear canal. The pinna of the ear helps to collect sound waves and to direct them into the ear. The ear canal is about 24 mm long and transfers sound waves from the pinna to the eardrum. Wax glands secrete wax into the ear canal. The wax is yellowish in color with an unpleasant smell. Earwax helps to protect the eardrum against drying out. The unpleasant smell may help to repel insects. An excessive accumulation of earwax may partially block the ear canal and impair hearing somewhat.

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SETTING: Steps 1 & 3 - A room with good lighting. Step 4 - A slightly darkened room. REQUIREMENTS: Step 2 and 3: • Penlight examination light or • A magnifying examination light* Step 4: • Mini Otoscope* *Order from our Online Shop; alternatively these products are available at most pharmacies.

STEP 1 Use the penlight examination light (available in The Apprentice Doctor™ Standard kit) or a magnifying examination light to perform “Steps 2” and “Step 3” of this project. Convert the penlight examination light to a mini otoscope by attaching the otoscope extension (speculum) to the tip of the penlight to perform “Step 4”. An otoscope is available only in The Apprentice Doctor™ Plus kit. STEP 2 Study the diagram of the pinna. Inspect your own ear in a mirror or inspect the ear of another person. Identify all the structures noted on the diagram. Examine the ear regarding dimensions (large, small, or average). Do you note any abnormalities in structure or form such as “bat ears”? STEP 3 Manipulate the pinna of the ear between your fingers. Fold the pinna to the front and allow it to return to its normal form spontaneously. Do you notice the non-rigid and elastic properties of the pinna? The pinna is composed of a “framework” of elastic cartilage covered by a thin layer of skin.

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STEP 4 Examine the ear canal of another person using the magnifying examination light and the penlight converted into an otoscope. You can pull gently on the pinna to inspect the ear canal. Pulling the pinna backwards may help you to examine the deeper parts of the ear canal. Do you notice any earwax? Do you notice any potatoes growing? The ear canal of an adult may have some hair, especially in its outer one third, obscuring the deeper parts of the canal. The ear canal curves slightly forward and inward. If the ear canal is clean and clear, you should be able to see the eardrum. Can you see the adjacent auditory bone, the malleus (hammer) attached to the inner surface of the eardrum? WARNING: Do not put any objects or material into the ear canal. This may cause damage to the paper-thin eardrum (It is only 0.1 mm thick). STEP 5 Darken the room somewhat by closing the curtains and switching off the lights. Place the examination light right behind the pinna of the ear. Examine the light shining through the skin and cartilage of the ear. Do you notice any small blood vessels in the skin of the ear? Do you notice the reddish tone to the light? This is caused by the red color of the blood flowing in the vessels supplying the skin of the ear. A special instrument called a Pulse Oximeter can analyze this transilluminated light and thereby determine the blood’s oxygen saturation level. STEP 6 Wash the plastic otoscope extension with soap and water. Dry it with a clean paper towel. Clean up and replace the instruments in The Apprentice Doctor™ case (available from our Online Shop). POINTS OF INTEREST • A doctor or Ear, Nose & Throat specialist uses an otoscope to examine the ear canal and the tympanic membrane. • Excessive amounts of earwax may have to be removed professionally. Special instruments can be used for this purpose. Alternatively, the wax can be removed by rinsing the ear canal with lukewarm water from a syringe. • A difference in air pressure between the inner and outer sides of the eardrum will cause a feeling of blocked ears. This may happen when descending suddenly like traveling downhill or descending in an airplane before landing. • The eustachian tube connects the middle ear with the upper respiratory system. This tube is opened by swallowing and helps to keep the air pressure equal on both sides of the eardrum. 57

PROJECT 5.1 - MIXING COLORS OF LIGHT Create new colors by mixing the primary colors of light.

INFORMATION Two different systems of primary colors exist: 1. Pigment primary colors. When you mix different colors of paint or coloring pencils, for instance, blue and yellow produces green. Blue and red produces purple and red and yellow produces orange. 2. Primary colors of light. This project demonstrates what happens when you mix the primary colors of light (red, blue and green). STEP 1 Simply click on one of the primary color buttons to switch on a red, green, or blue light. STEP 2 Carefully observe the new colors created by simultaneously switching on two or more colors of light. ONLY AVAILABLE ON *CD-ROM!! *Available from our Online Shop or as part of The Apprentice Doctor™ Standard or Plus kits.

PROJECT 5.2 - INSPECT THE COLOR OF THE MUCOUS MEMBRANES Discover the diagnostic value of inspecting the color of mucous membrane linings.

INFORMATION · Mucous membranes line the inner body surfaces that open to the exterior. Examples are the lining of the oral cavity, the lining of the nasal cavity and airways and the lining of the eyelids (conjunctiva). Mucous membrane linings have small glands that secrete a “slippery” fluid keeping the linings moist. · The mucous membranes are usually fairly thin with the underlying blood-rich fibrous tissue visible due to its semi-transparent characteristics. · Inspection of the mucous membranes allows the examiner to get a good idea of the color of the underlying blood, which may reveal a number of possible abnormalities. · In darker pigmented races, pigmented cells (melanocytes) may cause a brownish/purplish/bluish color to the lining, often in a spotted or patchy fashion. SETTING A room with good lighting – preferably natural light. REQUIREMENTS · An examination light* · Gloves* (if examining another person) · A mirror (for self-examination) · Tongue depressor* *Order from our Online Shop; alternatively these products are available at most pharmacies. 58

IMPORTANT NOTE: This exercise is limited to inspection. Examine the mucous membrane of the mouth (cheeks, tongue, palate and inside of the lips). Do NOT touch mucous membranes with your finger or with the examination light. STEP 1 Wash your hands thoroughly, dry, and put on gloves. Position yourself in front of a mirror. STEP 2 Study the color diagram demonstrating the possible colors of mucous membranes.

STEP 3 Examine the mucous membrane of your mouth by inspection with special reference to the color. Compare the color of your mucous membrane with the colors illustrated in the diagram. Is the lining of your oral cavity a healthy pink? If you suspect any abnormalities, consult your family doctor. A blood test may be necessary to exclude any abnormalities like anemia or jaundice.

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STEP 4 Wash your hands, put on new gloves, and inspect the mucous membranes of another person (see note before STEP 1). PLEASE NOTE: The colors on the diagram may vary according to the specific settings on the computer as well as the settings, type and quality of the monitor. POINTS OF INTEREST · The simple act of inspecting a patient’s mucous membranes is a powerful diagnostic tool enabling the examiner to make a provisional diagnosis of a number of serious medical conditions and diseases! · An irregular white patch on the oral mucous membrane of a smoker may indicate the initial stages of cancer developing in this area. · The mucous membrane of the eye called the conjunctiva is quite thin and usually void of racial pigmentation. This makes the conjunctiva an exceptionally suitable site for inspecting the mucous membranes. The examiner places the index finger on the lower eyelid and then gently moves the finger downwards thus exposing the conjunctiva by everting the lower lid. Special care is always necessary when performing any examination in or around the eye! · A complete clinical examination always includes a thorough inspection of the patient’s mucous membranes.

PROJECT 6 - EXAMINE THE EYE Identify the normal structures of the eye.

INFORMATION The eyeball is situated in the protective, hollow, bony eye socket of the skull. The eyeball houses an optical lens system whereby light is focused and projected on light-sensitive receptors in the retina. Two movable eyelids protect the eyeball from injury, dust and drying out. Movement of the eyeball is controlled by a set of six muscles. SETTING: Ensure that you use a room with good lighting. YOU WILL NEED: • An examination light* (preferably a magnifying examination light) • A hand or desktop mirror * Order fromour Online Shop; alternatively this product is available at most pharmacies. STEP 1 Position yourself comfortably in front of the mirror when performing self-examination. To examine another person, stand in front of this person facing him/her, armed with an examination light. If it is a tall person, perform the examination with this person in the seated position. STEP 2 Study the picture of a normal eye.

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NOTE OF CAUTION: Be careful! Do not let anything touch the inside of the eye.

STEP 3 Identify all the different structures of the eye being examined. Use the penlight and magnifying examination light to inspect the different structures of the eye in more detail. HINT: If the protective blink reflex (open-close-open movement of the eyelids) makes it difficult to examine the eye, the eyelids may be gently kept in the open position by finger retraction as indicated in the picture.

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STEP 4 Compare the left and right eyes regarding the various structures, dimensions, colors and blood vessels. STEP 5 With the necessary care and supervision examine somebody else’s eye. PLEASE NOTE: • Always wash your hands and put on a new pair of gloves each time you examine a different person. POINTS OF INTEREST • The membrane lining the inside of the eyelids and covering the white area of the eye (sclera) is called the conjunctiva. • Blood vessels are normally visible over the sclera of the eye. Too many blood vessels over this area may indicate inflammation or infection of the conjunctiva (conjunctivitis). • Blood vessels are normally absent over the iris and pupil areas of the eye. • The color of the iris may vary in different individuals (but rarely between the two eyes of the same individual). The color of the iris may be variable shades of blue, green, or brown. • Tears, produced by the tear glands, protect the eyes by keeping them moist, and they help to lubricate the movement of the eyelids. Tears are normally produced in small amounts but increase when the eyes are irritated, for example, by cutting an onion or when crying. Excess tears drain via small canals situated on the eyelids to the lacrimal sac, and from here into the nose. 61

PROJECT 7 - THE SNELLEN TEST Perform a distance visual acuity test using a Snellen test chart.

INFORMATION Some people can see very well at a distance. For instance they are able to read a car’s registration number from a distance. Some students need to sit in the front of the classroom to be able to read the teacher’s writing. The distance visual acuity test is designed to measure objectively a person’s sharpness of vision at varying distances. Note: Normal font is used for distance in the metric system. The equivalent distance in feet follows in brackets. SETTING: You will need a room with a distance of more than 6 meters (20 feet) available and with good general lighting. REQUIREMENTS: • A Snellen test chart* • Double-sided tape (or similar product to temporarily stick the test chart to a wall) * Available from our Online Shop. An example of a Snellen eye test chart is available as Addendum 2 at the end of this book. This chart once printed can be used for this project. STEP 1 Examine the Snellen chart. It consists of rows of letters in different sizes. The chart has letters printed on both sides. On the right-hand side of each row of letters a number is printed. On one side the numbers range from 1 to 21. Use this side if you measure distance in meters. On the other side the numbers range from 4 to 70. Use this side if you measure distance in feet. STEP 2 Fix the chart on a wall with double-sided tape or a similar substance at eye level (the level of the eyes when standing upright).

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STEP 3 Measure 6 meters (20 feet) from the wall at a right angle to the wall. Place an object such as a ruler or piece of string indicating this 6-meter (20-foot) mark. STEP 4 Test the right eye while covering the left eye with the left hand. Read the rows of letters starting at the top, then the second row, followed by the third row and so on. A number is printed on the Snellen test chart to the right side of each row of letters. Make a note of the number in line with the row of letters that you are able to read without making mistakes. STEP 5 Test the left eye in the same manner. STEP 6 Record your distance visual acuity on the inside of The Apprentice Doctor™ medical file. (Change the “6” in The Apprentice Doctor™ medical file to “20” if you use feet for measuring distance rather than meters). Write the number noted in STEP 4 below the “6” (“20”) of STEP 3. Distance visual acuity is recorded as two numbers written one over the other. Example: Right eye: 6 (20) 15 (50)

Left eye: 6 (20) 4.5 (15)

EXPLANATORY NOTE: Looking at the above example of the right eye of the patient, the number above the line is 6 (20). This number refers to the distance between the person being tested and the test chart “6 meters” (20 feet). See Step 3. The number below the line is 15 (50). This figure indicates the last row of letters the patient had been able to read without making a mistake, and signifies the distance at which a person with normal eyesight would be able to read that same row. STEP 7 Test the distance visual acuity of other people. POINTS OF INTEREST • The distance visual acuity should be done without glasses or contact lenses, if applicable. The Snellen test should be normal or better than normal if glasses or contact lenses are used. • Examples of values and their meaning: 1. Normal vision 6/6 (20/20). 2. Subnormal vision, but still allowed to drive a car: 6/9 – 6/12 (20/30 – 20/40). 3. Legally blind 3/60 (10/200). Such an individual will be unable to read a letter 9 cm (3.5 inches) high from a distance of 3 meters (10 feet), while a normally sighted person will be able to recognize this letter at a distance of 60 meters (200 feet). Arrange for an eye evaluation by a professional person if the Snellen test is less than normal for one or both eyes: 6/6 (20/20). Periodic testing of the eyes and vision is advisable, even if the Snellen test is normal or better than normal.

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PROJECT 8 - THE BLIND SPOT Demonstrate the existence of the so-called “physiological blind spot.”

INFORMATION The retina is the light-sensitive layer on the inside at the back of the eye. It has two special spots: • The macula. This is the area of maximum visual sharpness. • The optic disc. In this area, light-sensitive cells are absent. Light perception is not possible here, and it is therefore also known as the “blind spot.” SETTING: Normal room environment. YOU WILL NEED: • A blank piece of paper or cardboard of 10 x 12.5 cm (4 x 5 inches), and • The surgical marker, a pen or a pencil and a ruler. STEP 1 Make a “blind spot test diagram.” Use the surgical marker to make about a 3mm (1/8-inch) diameter circular dot and star 5 cm (2 inches) apart on the piece of paper or cardboard (see diagram).

STEP 2 Take the diagram, keeping the dot and the star horizontally on the same level. STEP 3 Close the left eye. STEP 4 Hold the diagram about 25 cm (10 inches) in front of the right eye, with the dot in front of the right eye. The star should be on the right side and the dot should be on the left side. STEP 5 Fix the vision of the right eye on the dot (stare at the dot with the right eye). STEP 6 Vary the distance between the diagram and the right eye by slowly moving it closer to the right eye - to ±10cm (4 inches) and then further away from this eye again. 64

You will notice the star “disappears” at a certain distance and then (magically) reappears again. STEP 7 Demonstrate the blind spot of the left eye by swapping “left” and “right” in Step 2 to Step 6. POINTS OF INTEREST • The blind spot represents the area at the back of the eye where the nerves conducting nerve impulses for vision leave the retina of the eye to go to the brain. • The blind spot rarely causes problems in people with vision in both eyes, because the blind spot of the left eye does not coincide with the blind spot of the right eye in the field of vision. • A person who is blind in one eye finds the blind spot much more of a nuisance.

PROJECT 9 - THE STETHOSCOPE AND SPHYGMOMANOMETER – ASSEMBLY AND CARE How to assemble and care for the stethoscope and sphygmomanometer.

INFORMATION A stethoscope is an instrument designed to capture low-frequency sound signals and to transfer them with minimal loss of character and loudness to an examiner’s ear. A sphygmomanometer (blood pressure meter) is an instrument designed to register the upper and lower limits of pressure in an artery. REQUIREMENTS: An unassembled stethoscope* packed in its box * Order from our Online Shop; alternatively this product is available at most pharmacies. ASSEMBLE THE STETHOSCOPE: STEP 1 O p e n t h e b o x m a r k e d “ s t e t h o s c o p e ” a n d i d e n t i f y t h e d i ff e r e n t c o m p o n e n ts . The following components are supplied: • A metal tube with earpieces attached • Y-shaped plastic tubing • A chest piece STEP 2 Adjust both earpieces ±15°–20° forward.

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STEP 3 Connect the plastic tubing to the metal tubing as well as to the chest piece as indicated in the diagram. STEP 4 Test the stethoscope by placing the earpieces angled slightly forward into the ear canals while tapping on the diaphragm of the chest piece with a finger.

NOTE: You may adjust the spring tension somewhat if necessary. To reduce the spring tension: Bend open the connector between the two earpiece tubes. To increase the spring tension: Bend closed the connector between the two earpiece tubes. HOW TO TAKE CARE OF AND MAINTAIN THE STETHOSCOPE NOTE: • Do not immerse the stethoscope in any liquid! • Be careful not to kink or over-extend the plastic tubing. • Avoid extremes of heat and cold as well as solvents and oils. • Do not leave in direct sunlight for extended periods of time. • Ear tubes, tubing and chest piece may be cleaned with a damp cloth using a mild soapy solution, or alternatively use alcohol, e.g. alcohol swabs. • Clean the earpieces before and after giving it to another person to use. • Clean the diaphragm of the chest piece with an alcohol swab after an examination and before examining another person. With proper care, the stethoscope should last many years. A pharmacist will be able to replace an old or worn stethoscope.

WARNING: Keep the stethoscope out of the hands of babies and toddlers as this may present a choking hazard! 66

MAINTENANCE OF THE SPHYGMOMANOMETER With proper care and maintenance, the blood pressure kit will provide years of satisfactory service. The basic rules are: • Do not drop or jar. • Never inflate beyond 300 mmHg. • Never leave the cuffs in the sun for prolonged periods! • Never touch the cuff fabric or parts with a sharp instrument, since this could cause damage! • Always deflate cuff completely before storage. • Do not dismantle the apparatus under any circumstances. • Store complete apparatus in the storage bag provided to keep all the parts clean. • Store at room temperature. The instrument may withstand exposure to temperatures ranging from -20°C to 70°C (-4°F to 200°F). CLEANING INSTRUCTIONS • Remove the bladder first, and wipe the Velcro, bladder and tubes with a damp cloth. The cuff can be washed with soap and cold water, but ensure that the cuff is rinsed with clean water before letting it to air-dry. • Sterilization is not necessary, since the parts do not come into direct contact with any of the patient’s body secretions.

PROJECT 10 - THE STETHOSCOPE – FAMILIARIZE Familiarize yourself with the stethoscope as an instrument for picking up sound waves. INFORMATION A stethoscope is most commonly used to pick up low-frequency sounds emanating from the body. The stethoscope can pick up sounds originating from various other sources as well. SETTING: A room with a solid door. YOU WILL NEED: • The stethoscope* (make sure that it is correctly assembled as described in Project 9) • A portable radio/tape/CD-player or stereo. * Order from our Online Shop; alternatively this product is available at most pharmacies. STEP 1 Switch on the radio/tape/CD-player and listen to music (not too loud and not too soft). STEP 2 Put the stethoscope’s earpieces into your ears. The earpieces should be angled slightly forward to follow the natural direction of the external ear canal. STEP 3 Hold the stethoscope’s diaphragm about 15 cm (6 inches) in front of the speaker with the diaphragm facing the speaker. Listen to the volume and quality of the sound.

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STEP 4 Press the diaphragm of the stethoscope flat against the speaker. Compare the volume and the quality of the sound with the sound in Step 3. • Note that the stethoscope picks up sound with a low pitch (low frequency) somewhat preferentially. For instance, when listening to music, the drums and bass guitar will be heard the loudest. STEP 5 Increase the volume of the music, go out of the room and close the door. Listen to the music by placing the diaphragm of the stethoscope flat onto the outside surface of the door. • The stethoscope can be a useful instrument in the hands of a detective or spy. Does this give you some interesting ideas?

PROJECT 11 - THE STRUCTURAL ARRANGEMENT OF THE BODY Explore the structural arrangement of the body by inspection and palpation.

INFORMATION The body can be subdivided into the following “units”: • The head and neck • The upper extremities (arms and hands) • The lower extremities (legs and feet) • The torso (the body without the head, neck, or upper and lower extremities) The head contains one and the torso two of the three body cavities.

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BODY CAVITIES: Body cavities serve as a protective environment for important organs. The brain is enclosed and protected by the bony brain case (cranial cavity). The chest (thoracic) cavity houses the heart and two lungs. The abdominal cavity contains mainly organs of the gastrointestinal, urinary and reproductive systems. NOTE: This project is primarily intended as a self-examination exercise.

SETTING: • The privacy of your home or room. • A large mirror (enabling you to see the whole body in the mirror). • Well-lit area. CLOTHING: No clothes or minimal clothing (privacy essential). REQUIREMENTS: 1. A pair of clean gloves* (optional in self-examination). 2. A full-length mirror will be useful. * Order from our Online Shop; alternatively this product is available at most pharmacies. FOLLOW THESE STEPS: STEP 1 Study the diagrams demonstrating the structural arrangement of the body. STEP 2 Position yourself in front of the mirror in the standing position facing the mirror. With the help of the illustration, examine the body by inspection. Observe the general appearance, the form and contour, the texture and the color of the area being inspected. START WITH THE HEAD: Draw an imaginary line (or a real line with a washable marker pen) starting at the eyebrow backwards past the outer ear canal to the back of the head. 69

This line divides the head into “an upper two thirds” representing the brain case (cranium) and “a lower one third” representing the face. Take a minute to inspect the familiar structures of the face – the eyes, the nose, the lips, the cheeks and the chin.

INSPECT THE NECK: Swallow once or twice and see if you are able to see the movement of the voice box (larynx) during swallowing. The voice box (larynx) is in the midline on the front side of the upper third of the neck.

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INSPECT THE UPPER EXTREMITIES: The arms are attached to the torso at the shoulder joint. The arms move at three joints – the shoulder, elbow and wrist joints. Inspect the fingers, each moving at three joints as well. Inspect the lower extremities. The legs are attached to the torso at the hip joint. The legs move at three joints – the hip, the knee and the ankle. Inspect the feet and the toes. NOW INSPECT THE TORSO: Identify the nipples. The slightly darker area around the nipple is known as the “areola.” Identify the navel (umbilicus). The umbilicus is slightly sunken in most people. The naval string (umbilical cord) was connected to the body at the umbilicus of the unborn baby. Raise the arm above the head and inspect the armpit (axilla). Do you see the prominence of the collarbone? (The scientific name is the “clavicle”). If you are skinny, you should be able to see the outline of some of the ribs of the ribcage. On the sides of the hips observe the outline of the upper edge of the hipbone. Visualize the two body cavities of the torso. The chest (thoracic) cavity occupies roughly the upper one third of the torso and the abdominal cavity the lower two thirds.

STEP 3 Use the illustration to examine the body by touch (palpation). Take note of the form, consistency and temperature as well as possible tenderness of the area being palpated. Start with the head. With the fingertips, gently feel the hard bony cranial cavity. Feel the soft tissue of the face as well as the underlying bony framework. Touch the lower border of the jawbone. Place your hand flat over the front surface of the neck. Swallow to feel the larynx move in the midline upper neck area. Touch the muscles of the neck and the vertebrae in the midline at the back of the neck. Touch the muscles and bones of the upper and lower extremities.

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Place the palm of your hands over the breast area and feel the muscles of the chest. Tense your front abdominal muscles while pressing inwards with your fingers. Follow the outline of the collarbone (clavicle) with your hands. Can you feel the ribs? Run your fingers down from the collarbone (clavicle) just next to the breastbone on either the left or the right side, until you reach the lower end of the rib cage. Try to count the ribs. Identify the spaces between the ribs. Press down in the middle of the front chest area and feel for the breastbone. Follow the breastbone to its upper and lower ends with your fingers. Do you feel the V-shaped notch formed at the upper margin of the breastbone between the left and right collarbones?

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POINTS OF INTEREST • A doctor uses knowledge of the surface structures and bony landmarks to identify the position of the deeper structures and organs of the body. • The dimension of the chest cavity increases during inspiration as the diaphragm displaces the abdominal organs downwards. • The ribcage protects not only the contents of the chest cavity but also the contents of the upper abdominal organs – the liver and the spleen. • The oral cavity (mouth) and the nasal cavity are regarded as passages rather than body cavities. The mouth acts as a passage for food and the nose as a passage for air.

PROJECT 12 - SUBDIVISIONS OF THE CHEST Imaginary lines are used to subdivide the chest into different regions facilitating the visualization of the underlying organs.

INFORMATION 1. SUBDIVISION OF THE CHEST AREA: a. The midline of the chest. This line is an imaginary vertical line in the middle of the chest separating the left and right sides of the chest. b. The left and right “mid-clavicular” lines. These vertical lines start in the middle of the collar bone (clavicle) and divide the left and right sides of the chest into two halves. These lines usually run just inside the nipples. c. The “mid-axillary” lines of the chest. These lines are vertical lines starting in the middle of the armpit (axilla) and run down on the left and right sides of the chest. SETTING: Steps 1 - 3 - A well-lit room. Step 4 - At your computer.

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CLOTHING: • Exposure of the chest area is required. • Comfortable clothing. A t-shirt and short pants are suggested. REQUIREMENTS: • A clean pair of gloves* • A skin marker pen* • A large mirror • Picture of the model (print Addendum 3 at the end of this book) * Order from our Online Shop; alternatively these products are available at most pharmacies. STEP 1 Use a pen, pencil, or the surgical marker to indicate the position of the following lines on the picture of the model (see Addendum 3): The midline of the chest The mid-clavicular line The mid-axillary line

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1b

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STEP 2 Indicate the position of these lines on your own body. Mark these lines with a skin marker pen on your own body. STEP 3 Indicate the subdivisions of the chest on the chest of another person using the marker pen. STEP 4 Study the picture showing the chest in relation to the deeper structures and organs of the chest cavity. Note the position of the heart and the lungs in relation to the surface landmarks of the chest. POINTS OF INTEREST • The heart occupies the middle chest area behind the solid breastbone and between the lungs. • The heart is positioned slightly more to the left side of the chest cavity especially the lower part of the heart. • The ribcage helps to protect heart and lungs while at the same time allowing for movement of the chest during breathing. • The tip of the left ventricle of the heart is close to the front surface of the left chest wall near the left mid-clavicular line on the level of the space between the 5th and 6th ribs. The area corresponds to the space between subsequent ribs just below the left nipple of the male breast. A stethoscope in this area can readily pick up the sounds produced by the pumping action of the heart.

PROJECT 13 - SUBDIVISIONS OF THE ABDOMEN Imaginary lines are used to subdivide the abdomen into different regions facilitating the visualization of the underlying organs.

INFORMATION The abdominal area can be subdivided into 4 quarters or quadrants. A left and right upper quadrant, and a left and right lower quadrant are produced when an imaginary cross is placed over the umbilicus (navel). The horizontal and vertical lines of the cross meet at the umbilicus. SETTING: Steps 1 - 3 - A well-lit room. Step 4 - At the computer. CLOTHING: • Exposure of the abdominal area is required. • Comfortable clothing. A t-shirt and short pants are suggested. REQUIREMENTS: • A clean pair of gloves* • A surgical marker pen* • A large mirror • Picture of the model (print Addendum 3 at the end of this book) * Order from our Online Shop; alternatively these products are available at most pharmacies.

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STEP 1 Use a pen or pencil or the surgical marker to divide the abdomen on the picture of the model (see Addendum 3) into four quadrants. Indicate the position of the: · Left upper quadrant · Left lower quadrant · Right upper quadrant · Right lower quadrant

STEP 2 Identify these four quadrants on your body by dividing your abdomen into these four quadrants. You can use the surgical marker pen for this purpose.

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STEP 3 Divide the abdomen of another person into four quadrants with the surgical marker pen. STEP4 Study the picture showing the abdomen in relation to the deeper structures and organs of the chest and abdominal cavity. Note the position of the abdominal organs in relation to the surface landmarks of the abdomen.

POINTS OF INTEREST • The liver is positioned mainly in the right upper quadrant of the abdomen. • The stomach is situated mainly in the upper left quadrant of the abdomen. The spleen is also positioned in this quadrant. • The appendix (an “excess” piece of intestine commonly removed by surgeons due to infection) is situated in the right lower quadrant of the abdomen. • The lower part of the abdominal cavity is called the pelvic cavity. The urinary bladder is situated in the middle front area of this cavity.

PROJECT 14 - A PERCUSSION MODEL OF THE CHEST Build a simple percussion model of the chest.

INFORMATION A model serves to demonstrate basic principles. It also offers the student (learner) the opportunity for practicing and attaining a comfortable level of skill before examining a real person. YOU WILL NEED: • Two large (about a half gallon) plastic containers • One smaller (about a quart) plastic container (Empty milk or cool drink bottles can be used) • Wrapping tape • Teaspoon 77

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TAKE THE FOLLOWING STEPS: STEP 1 Fill the small plastic bottle with water. Replace and tighten the cap. Make sure the larger bottles are empty. Do not replace the caps of these bottles. STEP 2 Tape the 3 bottles together as in the diagram. STEP 3 Consider the similarities of these plastic bottles with the human chest cavity.

STEP4 Tap the bottles alternatively using a teaspoon. STEP5 Knock each bottle a number of times using one of your fingers in a hammer-like manner. Did you notice a difference in the quality of sounds produced? Can you hear the “clear” or “hollow” sound produced by tapping the larger empty bottles? Can you hear the “dull” or “solid” sound produced when you tap the smaller bottle filled with fluid? The two empty bottles represent the lungs filled with air, and the bottle filled with water represents the heart filled with blood.

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PROJECT 15 - TECHNIQUE FOR MEDICAL PERCUSSION You can use your hands as percussion instruments when medically examining a person’s body.

INFORMATION Medical percussion is a science and an art in which the examiner uses his/her hands as well as his/her ears to gather information from a person’s body. PRACTICE THE TECHNIQUE OF MEDICAL PERCUSSION BY FOLLOWING THESE STEPS: 1. Place the left hand palm down flat on the top of a table surface (or on top of an empty tin). 2. Make sure the fingers are slightly spread apart. 3. Firmly push the middle finger of the left hand against the table or tin. 4. Bend the fingers of the right hand slightly down with the middle finger slightly lower. 5. Use this middle finger of the right hand as a hammer and strike it firmly by way of a tapping motion in the mid-section of the middle finger of the left hand. 1

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HINTS: • Make sure that the right (hammer) hand moves mainly at the wrist and not at the elbow when making the tapping movements. • Tap with the tip of the middle finger of the right hand. • Make sure that the tapping is causing a distinct noise. • This technique may take quite a bit of practice to master. • Ask for help if you do not succeed. • Some people (e.g. left handed people) may find it more comfortable to use the left hand for the hammer effect. • Listen closely to the sound produced. Listen to the pitch and quality of the sound. • Explore different types of surfaces using this technique (for example, the wall, the refrigerator, a cabinet and different types of containers). • Listen closely to all the different types of sounds produced when percussed. Describe these different sounds in your own words. When you feel comfortable about your percussion technique, you are ready for the next project. 79

PROJECT 16 - EXAMINATION BY PERCUSSION Perform a simple examination of the chest and abdomen by percussion.

INFORMATION NOTE: Successful completion of Project 15 is essential before starting with Project 16. Percussion is usually performed over body cavities. The chest and the abdomen are body cavities. Some regions within these cavities may be filled mainly with gas such as a healthy lung. Other areas may contain mainly fluid like the urinary bladder (when it is full), and other areas may be occupied by solid tissue such as the liver, producing different sounds when percussion is performed over these regions. SETTING: A well-lit room, preferably close to the computer. CLOTHING: Thin clothing, for example a t-shirt. Ideally, exposure of the chest and abdominal areas is required. REQUIREMENTS: • A pair of clean gloves* • Skin marker pen* • A pen or a pencil * Order from our Online Shop; alternatively these products are available at most pharmacies. STEP 1 Study Diagram 1 showing a body map with recommended areas for performing percussion over the front of the chest and abdomen. Make spot markings in equivalent areas on your own body (you may need some help from another person) or on a test subject’s body with the surgical marker.

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STEP 2 • Examine your own body by percussing the previously marked areas as indicated on the diagram. • Perform percussion, taking your time, while listening carefully to the sounds produced. Work systematically – start at the top left side and work towards the right side while progressing downwards. • Use a pen or pencil to indicate the character of the sound produced when percussing the different areas over the chest and abdomen. Use the pictures of the model marked “Project 16” for this purpose. Write an “H” at all the markings producing a hollow sound and an “S” at all the markings producing a solid sound.

STEP 3 Study Diagram 2, showing the normal percussion map of the human body in relation to the internal organs. Compare the percussion map made during your examination with this map. • Can you identify the position of some of the internal organs on yourself or the person being examined? • Did you perceive a difference in the quality of the hollow sound produced over the lungs compared to the hollow sound produced over the intestines? STEP 4 Use the technique of medical percussion to examine the chest and abdomen of another person (repeat Steps 1-3). 81

PLEASE NOTE: • Always wash your hands and put on a new pair of gloves each time you examine a different person. • You are probably examining a perfectly healthy body. A variety of abnormalities and diseases may produce abnormal percussion maps. • Do not perform percussion on the biology teacher’s cranial cavity – you may hear a disturbingly hollow sound! POINTS OF INTEREST • In the chest cavity, percussion will produce a solid sound over the heart and large blood vessels, and a hollow sound over the lungs. • Percussion over the abdominal cavity will produce a hollow sound except over the liver in the right upper quadrant, the spleen (only if enlarged) towards the side of the left upper quadrant, and the over-full bladder in the mid-lower quadrants. In these regions a solid sound will be produced. • The hollow sound produced by percussion over the abdominal cavity has a special character called “tympanic.” • Reverberation and resonance are mainly responsible for the quality of sound produced when percussion is performed over the body cavities.

PROJECT 17 - EXAMINE THE SKIN Examine the skin by inspection and palpation. INFORMATION The skin is easy to examine due to its accessible exterior position. Normal skin varies tremendously in color and texture from person to person as well as from one area to another area on the body of the same person. 82

Skin color is mainly the result of the appearance of the tissue under the epithelium of the skin, the thickness of the skin and the amount of pigment in the skin. The natural (brownish) pigment present in the outer layer (epithelium) of the skin of most people is melanin. Cells called melanocytes produce melanin. Albinism is a condition where melanin is absent in the skin. Exposure of the skin to ultra-violet rays of the sun will cause an increase in the amount of melanin pigment, making the skin somewhat darker (more brown). Skin exposed to ultraviolet rays of the sun over a period of many years causes acceleration of the aging process. The skin then looses its elasticity and it becomes excessively wrinkled. SETTING: A room with good general lighting, preferably natural light. REQUIREMENTS: • A mirror • An examination light* (preferably a magnifying examination light) • Gloves* * Order from our Online Shop; alternatively these products are available at most pharmacies. PLEASE NOTE: The examination of the skin involves examining all the skin of a person’s body. For the purpose of this exercise, we will only examine specific areas. STEP 1 Wash and dry your hands, then put on a pair of examination gloves. STEP 2 Inspect the skin of the face. Take note of the general appearance, the color and texture of the skin. Inspect the forehead, the eyelids, the ears, the neck, the nose and the chin. Observe the variation in appearance, color and texture of the skin in all these different areas. Do you see any pigmented spots in any of the above areas? Do you observe any other spots or pimples? Use the examination light to inspect certain areas in more detail.

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STEP 3 In all the above areas, first touch the skin, then move the skin with your fingers over the underlying tissue. Lastly, gently pinch and roll the skin between your fingers. Use your thumb and middle or index fingers. Do you notice any difference in the texture of the skin in the different areas? STEP 4 Examine the skin of the arms and hands by careful inspection. Observe the appearance, color, texture and presence or absence of hair. Observe the fine grooves at the tips of the fingers. This gives each person a unique fingerprint. Inspect the fingerprints in more detail with the magnifier examination light. STEP 5 Examine the skin of the arm and hands by palpation as described in Step 3 above. STEP 6 Place one hand around the upper arm and grip firmly around the arm. This partially closes the veins of the arms making them somewhat more prominent and easier to identify. Do you notice any veins beneath the skin? In people with light complexions, the veins may shine slightly bluish through the skin. Touch one of the veins with your finger and push lightly down. Blood flow in the veins does not cause pulsations. Pulsations are only present in arteries. STEP 7 Press a finger, the nose, or forehead against the mirror and observe the slightly oily residue on the mirror. This substance is called sebum and is secreted by the sebaceous glands of the skin. Sebum protects and keeps skin supple. Sebum is the body’s natural skin lotion!

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STEP 8 Examine the skin of another person. NOTE: Wash your hands and use a clean pair of gloves each time you examine a different person. STEP 9 Clean the mirror, discard the gloves and wash your hands. Replace the items of the set that you have used. POINTS OF INTEREST • In general, a brown color in the skin is caused by melanin pigment. This may be general, e.g. dark complexions in ethnic groups, or localized (a small pigmented spot). A freckle is a small spot caused by an increase in melanin pigment in the epithelium. A mole (nevus) is caused by an increase in the number of melanocytes in or just below the epithelial layer of the skin. N.B. IMPORTANT NOTE: • Any pigmented spot showing an increase in size, a change in dimensions, a change in color, becoming raised or more prominent or causing an itch, should be examined by a doctor or dermatologist (specialist skin doctor). • A red color is generally caused by blood vessels filled with oxygen rich blood visible through the skin. This may be normal in light complexioned skin, e.g. the red of the lips, or it may be abnormal, e.g. a red birth mark (the medical term for this is a hemangioma). • Blue is generally a result of veins full of oxygen-depleted blood visible through the skin. Doctors often use the veins on the back of the hand or the inside of the arm to inject or infuse medication into the bloodstream. • Skin rich in elastic fibers moves freely and stretches easily, e.g. the skin around the eyes. Skin rich in firm fibers moves less freely and stretches with difficulty, e.g. the skin in the forehead area. The most common firm fibers are called collagen fibers. • Any variation beyond the normal limits of appearance, color, texture, or temperature of the skin may be an indication of a skin disease. It may also be a sign of a disease process affecting one of the other systems of the body.

PROJECT 18 - EXAMINE THE NAILS Examine the nails by inspection.

INFORMATION The nails mainly have a protective function in human beings. In the animal kingdom they serve various other functions such as defense as in cats and digging as in moles. The examination of the nails is an important part of the general examination of a patient. The nails may reveal many secrets about the well-being of the body. Melanin pigment is essentially absent in the nail bed area. Nails are semi-transparent. The nail beds may therefore be considered as “windows” to the blood stream. Hemoglobin is a protein–iron molecule with the ability to carry oxygen. Hemoglobin is contained in the red blood cells. Blood saturated with oxygen is bright red in color and blood depleted in oxygen is dark red or bluish in color. SETTING: A room with good general lighting, preferably natural light. 85

REQUIREMENTS: • An examination light* (preferably a magnifying examination light) • Gloves* (if examining another person) * Order from our Online Shop; alternatively these products are available at most pharmacies. PLEASE NOTE: A thorough inspection of all the nails of the fingers and feet is recommended. For the purpose of this exercise, only the fingernails need be examined. STEP 1 Inspect the nails one by one regarding general appearance. Identify the normal structures of the nail by comparing the nail being examined with the nail on the diagram. Do you observe any irregularities on the surface of the nail? Is there any evidence of nail biting? STEP 2 Inspect each nail from above, and then from the side. Inspect the form of the nail as well as the form of the tip of the finger. STEP 3 Observe the nail plate and nail bed of each nail in detail. Use the examination light for this purpose. Do you see any spots on the nail plate? Do you see any spots in the nail bed? Pay special attention to the color of the nail beds. 1

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STEP 4 With one fingernail press firmly down on the nail bed of another finger and then suddenly release the pressure. Did you notice the pink of the nail bed going white on applying pressure and returning to pink on releasing the pressure? This process is called “blanching,” and is caused by blood being pressed out of the small blood vessels in the nail bed and then filling up again. STEP 5 Examine the nails of another person by repeating Steps 1 to 4. NOTE: Wash your hands and use a new pair of gloves each time you examine a different person. STEP 6 Clean up and replace the items used in The Apprentice Doctor™ case. POINTS OF INTEREST • Nail biting often points to an anxious personality. • Irregularities on the surface of the nail plate may be caused by previous injury to the nail bed or a history of a serious illness. • Small white spots on the nail plate are often caused by minor injury to the nail bed and not by a shortage of calcium, as is a common perception. 86

• Small purplish spots in the nail bed may indicate minute blood clots and may be caused by injury. It may also be an indication of infection inside the heart. • Spoon shaped nails may be caused by a shortage of iron over a long period of time. • The tips of the fingers may resemble drumsticks (the medical term is “clubbing”). This may be caused by various problems usually of the respiratory and cardio-vascular systems. • The nail beds may have an abnormal color. Examples are: 1. Pale pink – this may be caused by a shortage of hemoglobin in the blood. The medical term is “anemia.” 2. Bluish – oxygen-depleted blood may cause this color change. The medical term is “cyanosis.” 3. Yellowish brown – if the discoloration is restricted to one or two fingers consider possible nicotine staining caused by heavy smoking.

PROJECT 19 - EXAMINE THE HAIR Examine the hair by inspection.

INFORMATION Hair may differ in color, in form (e.g. straight or curly) in thickness, and in length. Hair is found over most parts of the body. Exceptions are the palms of the hands and the soles of the feet. The growth of hair changes during and after puberty (see diagram of hair distribution of male and female after puberty). Hair grows in phases. On the scalp, an active growth phase lasts for 3-5 years. This phase is followed by a rest phase lasting about 3 months. At the end of the resting phase, the hair is shed, and new hair starts to grow in a new active growth phase. The scalp contains about 100,000 hairs. On average, 85,000 will be actively growing, 15,000 hair follicles will be resting, and up to 100 hairs may be shed from the scalp each day.

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SETTING: A room with good general lighting, preferably natural light. REQUIREMENTS: • An examination light* (preferably a magnifying examination light) • Gloves* (if examining another person) • A hair brush (not supplied in the set) • A mirror (for self examination) * Order from our Online Shop; alternatively these products are available at most pharmacies. STEP 1 Examine the hair of the scalp, the eyebrows and the eyelashes. Observe the difference in character and thickness of the hair in these different areas. Take note of the color of the hair. Inspect the scalp. You may (surprisingly) find hair lice or nits (small white rounded lice eggs) in well-kept and clean hair! Do you observe any areas of hair loss over the scalp area? NOTE: If you examine an adult male’s scalp, this may be quite normal. This is called “baldness”! The medical term for hair loss is “alopecia.”

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STEP 2 Make sure that you have a clean brush without any hair stuck to the bristles. STEP 3 Brush the hair of the scalp and inspect the bristles. Take some of the shed hair filaments, and place them on a contrasting background. • Black, brown, or red hair can be placed on a white background and white (blonde or gray) hair on a dark background. STEP 4 Use the examination light to examine the hair in more detail. First identify the hair shaft then identify the root of the hair. A white bulb like prominence over the root confirms that the hair is in the end resting phase and was about to be shed. Observe the contours of the hair. Is it straight or curly? Is it uniform in thickness or does the thickness vary somewhat? STEP 5 Examine the hair of another person. NOTE: Wash your hands and use a clean pair of gloves every time you examine a different person. STEP 6 Clean up and replace used items in the set.

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POINTS OF INTEREST • The distribution of hair on the body is closely linked to the hormonal system. An unexplained increase or decrease in the body hair or an abnormal change in the hair distribution over the body may be caused by an abnormality in the hormonal system. • Hair color comes from the natural pigment “melanin.” The melanin-producing cells, the “melanocytes” may stop producing melanin. This is usually age related. Hair without melanin pigment is gray in color. • Inflammation of the upper layers of the skin of the scalp will cause scales to form. The common name for scales on the scalp is dandruff. Anti-dandruff shampoo used regularly will usually control this condition. • Lice infections of the scalp often occur as outbreaks in schools. Lice infections of the scalp can be cured by special anti-lice shampoo. Remember to follow the instructions carefully. • The average scalp has 100 000 hairs on it. Blondes have the most hair, followed by brunettes and lastly redheads. 89

• Your hair grows about 12 mm per month and a single strand of hair lives for up to seven years. • If you never cut your hair, it will grow to a length of approximately 107 cm (43 inches) before falling out. • The combined strength of a head of hair can support the equivalent of ±100 people.

PROJECT 20 - THE BONY LANDMARKS OF THE BODY Learn the position of the bony landmarks on the body.

INFORMATION Note: You need to study the bones of the skeletal system in the chapter on the skeletal system before doing Project 20. The bones of the body form a rigid supportive and protective framework for the soft tissues of the body. Some bones are covered by a lot of soft tissue in an area distant from the skin surface. Other bones or parts of bones are superficially situated close to the surface of the skin. These bony areas are easily identified by palpation and are considered bony landmarks. SETTING: Steps 1 and 2: at the computer. Steps 3 and 4: a room with good light. Self-examination: the privacy of your own room. CLOTHING: • Self-examination: no clothing or minimal clothing (privacy essential). • Examine someone else. Most of the bony landmarks can be palpated through thin clothes such as t-shirt and short pants.

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REQUIREMENTS: 1. A pair of clean gloves* 2. A full-length mirror will be useful * Order from our Online Shop; alternatively this product is available at most pharmacies. STEP 1 Study the diagram of the human skeleton showing some of the bony landmarks of the body. STEP 2 Study the surface structure of the human body indicating the position of some of the bony landmarks. STEP 3 By inspection, see if you can identify as many of these landmarks as possible using the figures supplied in Step 1 and 2. (A full-length mirror will be helpful to inspect certain bony landmarks during self-examination). STEP 4 Wash your hands, dry and put on gloves (optional with self-examination). • Use the figures in Steps 1 and 2 to facilitate the examination.

BY PALPATION, FEEL: • The flat bones of the skull just under the scalp. • The rim of the eye socket. • The nasal bones over the bridge of the nose. • Feel the lower border of the jaw bone (mandible). • Touch the collar bone (clavicle). • Feel for the highest point of the shoulder. This is the “acromion process” of the shoulder bone (scapula). • Palpate the ribs and the breast bone. • Touch the prominences in the midline of the back. These are the spinous processes of the vertebrae. • Put your hands on the hips and feel the hipbones. • At the lower end of the humerus, touch the inner and outer prominences. 91

• At the lower end of the forearm, touch the inner prominence of the ulna and the outer prominence of the radius. • Palpate the bones of the hands and fingers. • On the lower extremities, palpate the knee cap (patella). • The front border of the shinbone (tibia). • Touch the inner prominence of the tibia and the outer prominence of the fibula. • Palpate the bones of the feet and toes. Attempt to identify as many bony landmarks as possible.

POINTS OF INTEREST • The inner prominence of the humerus protects a nerve called the ulnar nerve passing by on its way to the forearm. Occasionally, this nerve may be bumped, causing a “shock” in the arm. This area is sometimes referred to as the “funny bone.” • An orthopedic surgeon specializes in abnormalities, diseases and injuries of muscles, bones and joints. • A physiotherapist often treats diseases, deformities, or injuries of muscles, bones and joints by massage, heat, cold, exercises and other modalities like laser and ultrasound. • Surgeons and other health professionals use these bony landmarks as reference points to identify other structures of the body. Identification of the bony landmarks offers valuable information when dealing with an injured patient. 92

PROJECT 21 - JOINT SOUNDS Listen to a joint with a stethoscope.

INFORMATION Most joints move smoothly and quietly but occasionally a joint may produce a noise during movement. Such a noise may be normal but on occasion it may be an indication of a problem in the joint. The jaw joint in some people produces a clicking noise on opening and/or closing the mouth. YOU WILL NEED: 1. Your stethoscope* 2. The skin marker pen* * Order from our Online Shop; alternatively these products are available at most pharmacies. FOLLOW THESE STEPS: STEP 1 Locate the jaw joints by placing the index fingers just in front of the ears. Open and close the jaw a couple of times. Feel the head of the jawbone move in this area. (You may wish to mark this area with your surgical marker). STEP 2 Place the stethoscope correctly in the ear canals and place the diaphragm over the previously identified area. Open and close the jaw a couple of times. Listen to both the left and the right jaw joints. STEP 3 Use the stethoscope to listen to the jaw joints of someone else. • Do you hear any sounds? • Describe the sounds in your own words. REMEMBER TO: • Wash your hands and put on clean gloves before examining another person. • Ensure the hygienic care of the stethoscope. Your dentist will be able to assess the jaw joint professionally and offer information and advice.

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PROJECT 22 - BODY TEMPERATURE A quick and accurate way to measure the body’s temperature.

INFORMATION. Note: The digital thermometer is mercury-free and therefore safe to use. The body has various mechanisms to maintain its temperature within narrow limits at an average body temperature of 37°C or 98.4°F. Heat is produced as a result of chemical reactions occurring in cells throughout the body. The circulating blood ensures a fairly even distribution of this heat. Excess heat is released into the environment via the skin. Evaporation of sweat from the skin surface accelerates this process and helps in cooling the body. REQUIREMENTS: · A digital thermometer* · A disposable thermometer cover* · A pair of clean gloves* · An alcohol swab* * Order from our Online Shop; alternatively these products are available at most pharmacies. FOLLOW THESE STEPS: STEP 1 Wash your hands and put on clean gloves. STEP 2 Cover the sensor tip of the thermometer with a disposable thermometer cover. STEP 3 Press the on/off button of the thermometer. STEP 4 Place the probe well under the test subject’s tongue, keep the mouth closed, and begin measuring. (The measurement process takes about 2 minutes. After measuring the °C/°F will stop flashing, and the alarm signal will sound for about 4 seconds. The thermometer is now displaying the test subject’s body temperature). STEP 5 Remove the disposable thermometer cover and discard. Wipe only the probe area of the thermometer with a damp cloth, then disinfect with an alcohol swab. WARNING: Never immerse the thermometer in any liquid or allow a liquid to enter the inside of the thermometer. STEP 6 Switch the thermometer off by pressing the on/off button. (The thermometer will switch off automatically after 10 minutes if not switched off manually). POINTS OF INTEREST • The body’s temperature may be slightly lower if measured in the morning. • A pregnant woman’s body temperature is generally ± 1°C (±1.9°F) higher than normal. • The temperature of the skin is somewhat cooler than the temperature of the internal organs. • A sustained increase of the body’s temperature above the normal level (fever) is an indication of some disease process affecting the body, and the patient should be professionally examined by a medical doctor. 94

PROJECT 23 - THE MUSCLES OF THE BODY Learn the position of some of the muscles of the body.

INFORMATION The skeletal muscles close to the skin surface are usually easily identifiable by inspection and palpation. As a general rule, the muscles in males are better defined than in females. The skeletal muscles of people who exercise regularly are better defined compared to physically inactive people. Body builders pursue the development of well-defined skeletal muscles as an organized sport. Some of the muscles of the body will be named by their scientific (medical) names. Attempt to memorize as many of these names as you can. SETTING: Steps 1, 2 and 5: at the computer. Steps 3 and 4: a room with good light. Self-examination: the privacy of your own room. CLOTHING: • Self-examination: no clothing or minimal clothing (privacy essential). • Examine someone else: a male volunteer in short pants or boxer shorts is recommended. REQUIREMENTS: • A pair of clean gloves* • A full-length mirror will be useful * Order from our Online Shop; alternatively this product is available at most pharmacies.

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STEP 1 Study the diagrams showing the muscular system. STEP 2 Study the muscles demonstrated on the photographs of these body builders. HINTS: (When performing Steps 3 and 4.) • Tighten specific muscles to facilitate the examination by inspection and palpation. A full-length mirror will be helpful to inspect certain muscles or muscle groups during self-examination. STEP 3 By inspection, try to identify as many of these muscles on your own body or on the body of someone else using the illustrations in Step 1. 96

STEP 4 Wash your hands, dry, and put on gloves (optional with self-examination). Examine some of the muscles by palpation: • Touch the facial and jaw muscles. • Palpate the muscles of the neck and shoulder. • Do you notice any tender spots or nodules in some of these muscles? • Palpate the muscles of the chest, abdomen and back. • Place your hand over the buttock region. The buttock muscle (the gluteus maximus muscle) is the largest muscle of the human body. • Palpate the muscles of the arms and legs.

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STEP 5 Attempt to identify as many muscles as possible in the following photographs of body builders.

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POINTS OF INTEREST • Tender areas in muscles may be caused by previous injury. • Tender areas in the jaw, neck and shoulder muscles are often due to stress-related muscle spasm. • Massaging these muscles using body or skin lotion may help to relieve these painful symptoms. • Stress may cause muscle spasm in the jaw muscles especially during night time. This will cause nightly clenching and “grinding.” A dentist will be able to examine and treat this problem.

PROJECT 24 – THE HEART RATE How to determine a person’s heart rate.

IINFORMATION The heart normally contracts 70-80 times in one minute during rest. The heart rate is the number of times the heart contracts in a one-minute time period. Every time the heart contracts, pressure waves occur in the arteries supplying oxygen-rich blood to the tissues of the body. These pressure waves can be palpated (felt with the sense of touch by an observer) where arteries close to the body’s surface run over bony or firm structures. REQUIREMENTS: • A stopwatch or timer that measures in seconds • A surgical marker pen* * Order from our Online Shop; alternatively this product is available at most pharmacies. STEP 1 See if you can identify the pulse point on the wrist. HINT: Use the middle three fingers to feel for a pulse. Do not feel with the thumb as you may in fact be feeling the small artery pulsating in your own thumb! NOTE: The pulse point of the wrist is situated on the thumb’s side of the wrist as indicated in the picture. STEP 2 Gently press down with the middle 3 fingers in this area. You may have to move the position of these fingers slightly over the specific area before feeling the pulse. HINT: Do not press too hard as this may block the artery and stop the pulsations. Some practice may be necessary before you will be able to identify a clear pulse.

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STEP 3 Count the number of beats in one minute. This number is the pulse rate and equals the heart rate for the specific person. Alternatively you may count the number of beats in half a minute, and then multiply this number by two to get the pulse rate. Also take note of the following: • The forcefulness of each individual beat, e.g. a weak pulse or a strong pulse. • Is the pulse regular or irregular? • Make notes on your findings! STEP 4 See if you can identify some of the other pulse points of the body as indicated in the following diagram:

VARIOUS PULSE POINTS OF THE BODY Do not be too concerned if you are not able to identify all these pulse points. A thorough knowledge of the anatomy (structure) of the human body is required to identify successfully the position of all these points. STEP 5 Investigate the influence of the following on the pulse rate: 1. Physical exercise such as jogging or jumping up and down for 2-3 minutes; 2. Listening to soft, calm, classical music; 3. Listening to fast, loud, rock music; 4. Watching different types of movies or TV programs; 5. Different times of the day; 6. Being stressed, e.g. taking exams; and 7. Being relaxed such as socializing with friends. Record the pulse rate in as many of the above circumstances as possible. STEP 6 Practice by checking the pulse rate of other people (using the wrist pulse point). 100

REMEMBER: The pulse rate varies with age, for example, the normal pulse rate during rest for: • A newborn infant is 140 beats per minute; • A 3 year old is 100 beats per minute; • An 11 year old is 80 beats per minute; • An adult is 70–72 beats per minute. The pulse rate varies with physical fitness. A fit person will have a lower pulse rate compared to the average pulse rate. Generally, strong emotions increase the pulse rate, e.g. happiness, fear, anger, etc. • The pulse rate decreases during sleep. • An increase in the pulse rate is generally the body’s attempt to increase the supply of oxygen-rich blood to the tissues of the body. • Various medications, abnormalities and diseases may cause variations in the pulse rate.

WARNING Do not press too hard to find a pulse in the neck! This may cause fainting!

PROJECT 25 - THE PUPIL–LIGHT REFLEX Elicit the pupil-light reflex of an eye.

INFORMATION The pupil-light reflex gives information to an examiner about: • Sensory and motor nerves supplying the eye, • Certain brain functions, • Various structures of the eye, and • The use or abuse of certain medications. SETTING: A semi-dark room is recommended. It is advisable to allow the eyes to get used to the semi-dark environment for 5-10 minutes before starting the examination. YOU WILL NEED: • A penlight or a magnifying examination light* • A hand or desktop mirror (only necessary for self-examination) * Order from our Online Shop; alternatively this product is available at most pharmacies. STEP 1 Position yourself comfortably in front of the mirror when performing a self-examination. To examine another person, stand in front of this person facing him/her and use an examination light. If it is a tall person, perform the examination with this person in the seated position. STEP 2 Position and hold the examination light 10–15cm (4–6 inches) in front of the left or right eye. NOTE OF CAUTION Be careful! Do not let anything touch the inside of the eye. 101

STEP 3 Switch the examination light on and off for a moment. Observe the size of the pupil. • What happens to the eye being tested when the light is switched on? • What happens when the light is switched off? • What happens to the pupil of the other eye? • Make short notes on your findings.

POINTS OF INTEREST • Normally the pupils are more or less equal in size. When light is directed at one pupil it decreases in size (constricts) thus limiting the amount of light entering the eye. When light is directed away from the pupil it increases in size (dilates), thereby increasing the amount of light entering the eye. • The reaction of the eye being tested is called the “direct light reflex.” • The pupil of the other eye also constricts when shining light into the eye being tested. This is the “consensual light reflex.” • Some doctors use the abbreviation “PEARL” when testing the pupil light reflex. This is short for Pupils Equal And Reactive to Light. Are the pupils of your eyes “PEARL”? • If you test the pupil light reflex of a dead or “brain dead” person, the pupils will both be dilated and fixed (no constriction reaction whatsoever).

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PROJECT 26 - THE FACIAL NERVE Examine the motor function of the facial nerve.

INFORMATION A number of different nerves in the head and neck area carry nerve impulses from special and general sense organs to the brain. They also carry nerve impulses from the brain to muscles and glands in this region. One of the nerves is called the facial nerve. A number of muscles are found in the head area. An example is the muscles around the eyeball, which make movement of the eyeball in different directions possible. Another group of muscles help with the movement of the lower jaw in the chewing process. A very special group of muscles makes facial expression possible. The facial skin is “draped” over these muscles. Movement of these muscles causes movement of the overlying facial skin. This makes facial expressions possible. Facial expressions reveal a person’s mood and emotions. Actors know how to use and control these muscles when acting. The facial nerve supplies the muscles of facial expressions with innervation. SETTING: Room with good light. REQUIREMENTS: • A mirror (for self-examination). STEP 1 Divide the face in the mid-line with an imaginary vertical line. Inspect the left and the right halves for any asymmetry. STEP 2 Look at the picture of the facial muscles. See if you can move some of these muscles at will. STEP 3 Test some of these muscles with specific actions. 1. Raise the eyebrows. 2. Frown. 3. Close the eyes tightly. 4. Smile. 5. Show the teeth. 6. Whistle. 7. Blow up the cheeks, and then press air out of the lips by pushing with a finger on the cheek.

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STEP 4 Simulate specific emotions. Try to: Look happy, Look sad, Look surprised, Look fearful, Look puzzled. Simulate other emotions that come to mind. Observe the muscles of facial expression helping you to create the facial appearance associated with these different emotions. NOTE: If you like this exercise, you may have some talent for acting! POINTS OF INTEREST • Various disease processes may affect the normal function of the facial nerve. • Weakness of the facial muscles will cause the affected side to “hang” or droop. • Such a person will find it difficult to keep the saliva in the mouth from flowing over the lip on the affected side, and complete closure of the eye may be impossible on the affected side. An eye ointment will be necessary to keep the membranes covering the eyeball from drying out especially when sleeping.

PROJECT 27 - SPINAL NERVE REFLEXES Elicit some spinal nerve reflexes.

INFORMATION Spinal nerve reflexes consist of the following components: 1. Nerve receptors in the body, e.g. skin, muscles and tendons. 2. Sensory nerve fibers conducting impulses to the spinal cord. 3. Processing of the impulses in the spinal cord. 4. A motor nerve conducting nerve impulses from the spinal cord to a muscle or a group of muscles. 104

Spinal nerve reflexes occur primarily in the spinal cord. Nerve impulses from the brain may modify (increase or decrease) a reflex. To test a spinal nerve reflex, you will need another person. Testing a spinal nerve reflex on yourself is very difficult as the brain will anticipate the stimulus and inhibit the reflex. If you test this reflex, try to “surprise” the test subject with the stimulus like a tap on a tendon. Spinal nerve reflexes involving the muscles of the body may be active thus modifying movement during physical activity. Passive spinal reflexes help the muscles to maintain normal body posture.

PROJECT 27.1 - KNEE-JERK REFLEX YOU WILL NEED: • A patellar hammer* • The surgical marker* • A volunteer test person wearing clothes with the knees are exposed. * Order from our Online Shop; alternatively these products are available at most pharmacies. SETTING: A room with a high chair or bed. A person should be able to sit with feet hanging freely and not touching the floor. STEP 1 Place the test subject on the bed or chair with both feet hanging freely. The entire upper leg must be supported by the bed or chair. Ensure that the knees do not touch each other. STEP 2 Choose either the left or the right leg, and feel with your finger for the softer area on the front of the lower leg below the kneecap (patella). Mark this area with the surgical marker. STEP 3 Ask the test person to keep their eyes closed. Aim well for the marked area, and firmly tap this point with a patellar hammer. Observe the forward movement of the lower leg and foot immediately after the tap.

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HINTS: • Do not stand in front of the leg being tapped! • Do not tap too hard or too softly. The exact amount of force needed may require a bit of practice. • If you have difficulty eliciting this knee–jerk reflex, ask the test person to make a tight fist on the same side during the test. 105

STEP 4 Allocate a value to the reflex. -: Reflex is absent +: Slight ++: Normal +++: Hyperactive Make a note of these values in The Apprentice Doctor™ medical file. STEP 5 • Test the knee-jerk reflex of the other leg. • Ask the test person to elicit your knee-jerk reflex. POINTS OF INTEREST • Reflexes vary considerably from individual to individual. The complete absence of a reflex or an overly excessive reflex may be an indication of an abnormality within the muscular or neural systems. • The knee-jerk reflex is called a tendon reflex. A tap on the tendon of the upper leg muscle causes the muscle to stretch. Receptors in this muscle send nerve impulses to the spinal cord followed by the activation of motor nerves. The spinal cord then sends nerve impulses to the upper leg muscles “telling” them to contract. This contraction causes the lower leg to move forward. 1. Numerous other reflexes help to maintain order in the body. Examples of other reflexes are the pupil-light reflex and the eye-blink reflex (corneal reflex). 2. Reflexes play important roles in: · Swallowing; · Micturition (releasing urine from the bladder); · Defecation (excretion of waste products from the anus); and · Sexual functions.

PROJECT 27.2 - THE PLANTAR REFLEX Plantar refers to the sole (bottom) of the feet.

REQUIREMENTS: • An object with a sharpish edge like the handle of the patellar hammer or a key* • A volunteer test person with bare feet * Order from our Online Shop; alternatively these products are available at most pharmacies. SETTING: You will need a room with a bed. STEP 1 Ask the test subject to lie flat on the back. STEP 2 Position yourself at the subject’s feet with the soles of the feet clearly visible. Identify the outer edge of the sole of one of the feet. You may wish to mark this area with the surgical marker pen. STEP 3 Ask the test subject to relax the muscles of the legs, then stimulate the area identified in Step 2 with a gentle but definite scratching with the patellar hammer’s handle or a key. Start at the heel end and moving towards the small toe. 106

• Observe the toes curling downwards. The ankle may bend upwards, and with strong stimulation, the leg will be withdrawn.

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STEP 4 Allocate a value to the reflex as in Step 4 in Project 27.1, and make a note of this in The Apprentice Doctor™ medical file. STEP 5 • Test the plantar reflex of the other foot. • Swap roles. Ask the test subject to elicit your plantar reflex. POINTS OF INTEREST • The plantar reflex may vary considerably from person to person in normal subjects. Abnormal responses to the stimulus may be an indication of damage to the central nervous system. • An abnormal plantar reflex in children under the age of one year may be quite normal at this stage of development!

WARNING: DO NOT USE BABIES AS TEST SUBJECTS!

PROJECT 28 - GROWTH CHART Record a person’s height and weight on a graph.

INFORMATION Growth implies an increase in length as well as an increase in weight. The hormones of the endocrine system are directly involved in the process of growth. One of the endocrine glands, the pituitary gland, secretes growth hormone. Growth hormone’s primary function is the promotion of the growth process. Most of the endocrine hormones influence growth and body weight directly or indirectly. (To learn more about the endocrine glands, the hormones they produce and their functions, refer to the table: “Hormones of the Human Body”. To follow your growth you need to keep a record of your height (stature) and your weight over a period of time. 107

REQUIREMENTS: • An accurate bathroom scale • Measuring tape • A pen or pencil • A growth chart (print Addendum 4 at the end of this book) STEP 1 Measure your weight by placing the bathroom scale on a level, firm surface. NOTE: Remove all excess clothing. A good time to measure your weight is just after having a bath or a shower and before dressing yourself. Weigh yourself at equivalent times of the day, e.g. mornings before breakfast. Make a note of your weight. STEP 2 Measure your height in bare feet. Stand upright with your back against a wall (or a doorjamb). STEP 3 Ask someone to place a ruler horizontally flat on your head touching the wall or doorjamb and to make a tiny marking next to the ruler on the wall (or doorjamb). STEP 4 Measure the distance from the floor up to the level of the small mark made in Step 3. Make a note of this number. STEP 5 With pen or a pencil, plot the previously noted figures on the two graphs supplied in The Apprentice Doctor™ medical file. 1. Weight–to–age graph (a separate graph for boys and girls). 2. Height–to–age graph (a separate graph for boys and girls). Do your values fall within the normal limits indicated on the graphs (between the upper and the lower lines)? NOTE • Keep a monthly record of your weight and length by completing these three graphs over an extended period of time. Compare your figures with the normal range of values provided on the graphs. • Create a growth chart for your brother or sister (under 20 years of age!). • Don’t bother measuring your parent’s weight and height. They will feel badly about seeing their weight increase and their height decrease as they get older! POINTS OF INTEREST • Normal height and weight vary considerably from individual to individual. Important factors influencing this are: 1. Genetic factors (height and body shape of your parents); 2. Nutritional factors - a healthy balanced diet will promote normal growth while prolonged starvon will retard growth. 3. Race. • Your ideal weight should be interpreted in light of your bone structure or “frame.” Bone structure (frame) is somewhat arbitrarily classified into small, medium and large. • Growth from babyhood to adulthood is a somewhat fluctuating process. Some time periods are associated with an increase in growth activity and are called growth spurts. A professional opinion by a doctor or pediatrician for height and weight figures falling outside of the normal limits is recommended.

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PROJECT 29 - TURBULENCE IN THE FLOW OF A LIQUID A liquid such as water flows quietly when it flows evenly, while irregular flow produces sounds. INFORMATION A river normally flows quietly, but rapids and waterfalls are quite noisy. You can demonstrate this difference between the even flow and the irregular flow of water in a garden. SETTING: In a garden. YOU WILL NEED: • The garden hose • The stethoscope* * Order from our Online Shop; alternatively these products are available at most pharmacies. STEP 1 Connect the hose to a faucet, turn on the faucet, and let the water flow freely in the garden. STEP 2 Go to the middle section of the hose, pick up the hose, and listen to the water flowing. STEP 3 Twist the hose somewhat, and listen to the sound produced by the turbulent flow of the water. Then untwist the hose and listen to the sound disappearing. STEP 4 Place the earpieces of the stethoscope in your ears, and hold the diaphragm on the hose in the region of the twist with one of your hands. STEP 5 Twist and untwist the hose using your other hand while carefully listening to the changing sounds produced by the flow of the water.

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STEP 6 Turn off the faucet when finished. POINTS OF INTEREST • Occasionally, turbulent flow of blood through the heart may produce sound waves. • The closing action of heart valves is the main source of heart sounds. 109

PROJECT 30 - HEART SOUNDS Listen to heart sounds with a stethoscope.

INFORMATION The sounds produced by the pumping action of the heart offer a wealth of information about the condition of the heart. Despite various other modalities, the modern stethoscope remains the routine instrument for assessing the heart sounds by doctors and other health professionals. SETTING: A quiet environment (turn off the radio, music, TV, etc.). CLOTHING: • Exposure of the chest area is required • Although not ideal, the exercise can be performed on a person wearing thin material clothing such as a t-shirt. YOU WILL NEED: • The stethoscope* • A pair of gloves* * Order from our Online Shop; alternatively these products are available at most pharmacies. STEP 1 Review Project 12. Identify the landmarks over the front of the chest as well as the position of the heart in relation to these landmarks. STEP 2 Study the picture indicating the areas where you should listen to the heart sounds. Heart sounds can be picked up over most of the front chest area. They are louder in the center of the chest between the left and right middle chest lines and often loudest over the tip of the left side of the heart.

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STEP 3 Wash your hands, dry thoroughly, put on examination gloves. STEP 4 Put the earpiece of the stethoscope, facing slightly forward, into your ears. • Start listening to the front of the chest using the picture(s) as a guide. • Be patient. Take your time. Remember, practice makes perfect. • Breathe normally (slowly and controlled). Do not hold your breath. • Place the diaphragm of the stethoscope gently down, ensuring that the full surface of the diaphragm makes contact with the skin. • Eliminate any distracting noises such as music, people talking, etc. • Avoid unnecessary movement of the diaphragm over the skin. • Keep the stethoscope in one position for 15-30 seconds before moving it to another position. • In each position listen attentively to the lub-dup …… lub-dup …… lub-dup sounds. • Do you hear any sounds in between the lub and the dup? • Do you hear any sounds in between one lub-dup sound and the next lub-dup sound? • Do you notice any change in the loudness and character of the lub-dup sounds when the stethoscope is placed in different positions over the front chest surface? REMEMBER: Make notes about your findings.

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STEP 5 With the necessary guidance from a responsible adult, you can listen to somebody else’s heart sounds. PLEASE NOTE: • Always wash your hands and use a new pair of gloves each time you examine a different person. • Ensure the hygienic care of the stethoscope. (See section “Assembly – Care of Stethoscope”) POINTS OF INTEREST • The doctor can listen to specific heart valves in more detail by moving the position of the stethoscope over the front chest surface. • Abnormal heart sounds are called heart murmurs. Although some heart murmurs may be innocent, other murmurs may be caused by abnormalities such as defective heart valves.

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PROJECT 31 - BLOOD PRESSURE Learn how to measure a person’s blood pressure.

INFORMATION The heart is an amazing pump. It works reliably for decades, and it safely pumps blood, a very specialized liquid. The blood vessels are special pipes. They take the output from the pump and distribute it throughout the body. A blood pressure gauge serves as a simple way to measure the performance of the pump and the pipes. There are two numbers in a blood pressure reading: systolic and diastolic. For example, a typical reading might be 120/80. When the doctor puts the cuff around the arm and pumps it up, what he/she is doing is cutting off the blood flow with the pressure exerted by the cuff. As the pressure in the cuff is released, blood starts flowing again and the doctor can hear the flow in the stethoscope. The number at which blood starts flowing (120) is the measure of the maximum output pressure of the heart (systolic reading). The doctor continues releasing the pressure on the cuff and listens until there is no sound. That number (80) indicates the pressure in the system when the heart is relaxed (diastolic reading). If the numbers are too high, it means that the heart has to work too hard because of restrictions in the pipes. Certain hormones like adrenaline (which is released when you are under stress) cause certain blood vessels to constrict, and this increases the blood pressure. If a person is under constant stress, the blood pressure goes up, and it means that the heart has to work harder. Other things that can increase the blood pressure include deposits in the pipes and a loss of elasticity as the blood vessels age. The blood pressure can be measured at various sites on the human body using a number of different methods. The unit for measuring blood pressure is “mmHg.” This refers to the height (in millimeters) of displacement of a column of mercury (chemical symbol: Hg). This project will explain how to take a blood pressure reading in the upper arm area. SETTING: A well-lit room with a comfortable chair. YOU WILL NEED: • The sphygmomanometer (a blood pressure cuff and meter)* • The stethoscope* • The marking pen and ruler* • A pair of gloves* * Order from our Online Shop; alternatively these products are available at most pharmacies. FOLLOW THESE STEPS: STEP 1 Remove all clothing on the arm where the blood pressure will be measured. STEP 2 Identify the following structures of the upper arm. 2.1 Palpate the muscle on the front aspect of the upper arm (biceps muscle). 2.2 At the inner side of the elbow joint, feel the tendon of this muscle using the thumb and index finger. 2.3 Mark the position of this tendon with the marking pen. To the inner side of this tendon (towards the body), press down with the middle three fingers. Try to identify the pulsating main artery of the arm (brachial artery). Mark the position of this artery with the marking pen. 2.4 Measure 1’’ above the elbow, and mark this position on the arm with a straight line. 112

WARNING • Measuring the blood pressure will temporarily stop the flow of oxygen-rich blood to the arm due to the blood pressure cuff. An extended period of no blood supply to the arm will cause damage to the tissue in the arm area. This damage may be irreversible. • Restrict attempts to measure the blood pressure to 15 minutes. Wait at least an hour before attempting again. • Do not keep the cuff inflated for more than 20 seconds before starting the deflation process. • Adult supervision is essential.

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STEP 3 It is very important that the person whose blood pressure is being taken is relaxed and sitting comfortably. Keep the arm being measured at heart level. Rest the extended arm on a flat surface such as a desk with the left palm facing upwards. Keep the arm still. STEP 4 Place the cuff 2–3 cm (1 inch) above the elbow on the line marked in Step 2 as indicated in the picture. Ensure that the marking on the cuff corresponds to the markings on the arm. STEP 5 Close the air valve on the bulb by turning the screw clockwise. Do not tighten it too much. Place the diaphragm of the stethoscope over the main artery of the arm between the cuff and the elbow joint. Place the earpieces of the stethoscope (angled slightly forward) into your ear canals. STEP 6 Repeatedly squeeze the inflation bulb with the hand at a steady rate until the needle on the gauge points to 30 mmHg above the person’s normal upper systolic-pressure value. If you do not know this value, inflate to 200 mmHg. STEP 7 Slowly open the air valve by turning the screw counter-clockwise while holding the chest piece of the stethoscope over the brachial artery. A proper deflation rate is vital for an accurate reading, so you should practice to attain a recommended deflation rate of 2-3ÊmmHg per second or drop down two marks on the pressure gauge for each heartbeat. You should not keep the cuff inflated for longer than necessary. As the cuff begins to deflate you must listen carefully with the stethoscope. Note the reading on the gauge as soon as you hear the faint, rhythmic tapping or thumping sounds. This is the systolic (upper) blood pressure reading. Listen carefully and familiarize yourself with the pulse sound. STEP 8 Allow the pressure to continue dropping at the same deflation rate. When the diastolic (lower) blood pressure value is reached, the thumping sound stops. Deflate the cuff valve completely. Remove the cuff from the arm and stethoscope from your ears. If you struggle or are unsure, check this procedure with a medical doctor.

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STEP 9 Repeat the measurement on more than one occasion. Do not forget to record the readings and the time of the day after you finish measuring. A convenient time is first thing in the morning or just before the evening meal. Record the readings in this format: Systolic pressure --------------------- mmHg Diastolic pressure OTHER SUGGESTIONS: • With the necessary supervision of a responsible adult you may measure the blood pressure of other people. • Remember to wash your hands and put on a clean pair of gloves. • Investigate the influence of the following on the blood pressure of a person: 1. The time of the day, 2. Physical activity, and 3. Emotional state of mind. NOTE: It may not be a good idea to measure the blood pressure of your parent(s) when they are upset with you! POINTS OF INTEREST • Various factors influence the blood pressure reading including: 1. The state of health of the cardiovascular system 2. Physical activity 3. Emotions 4. Daily and seasonal rhythms 5. The position of the body 6. Various hormones 7. Various medications • Normal blood pressure values vary according to age 1. Shortly after birth 80/45 mmHg 2. Age 4 years 100/65 mmHg 3. Adult 120/80 mmHg 4. Needs investigation by a medical doctor: more than 140/90 mmHg • Repeated blood pressure readings are of more medical value than a single reading. • High blood pressure can cause the heart to fail (from having to work too hard), or it can cause the kidneys to fail (from too much pressure).

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PROJECT 32 - THE BODY’S LYMPH NODES Examine some of the accessible lymph glands of the body.

INFORMATION Lymph glands are distributed throughout the body. Some of these glands are close to the body’s surface and can be palpated with ease when enlarged. Some lymph glands are situated deep within body cavities and may need special investigations to be assessed properly. Radiographs, CAT scans and ultrasound investigations may be useful for this purpose. NOTE: Omit the examination of the lymph glands in the groin area when examining the lymph glands of someone else. SETTING: Steps 1 and 2 - at your computer. Steps 3 and 4 - a room with good light. A full-length mirror will be useful. CLOTHING: • Self-examination: no clothing or minimal under clothing (privacy essential). • Examine someone else: a volunteer in a t-shirt and short pants or boxer shorts. YOU WILL NEED: • A pair of clean gloves* * Order from our Online Shop; alternatively this product is available at most pharmacies. STEP 1 Study the diagram showing the distribution of lymph glands, which can be examined by palpation due to their proximity to the skin. STEP 2 Study the surface structure of the human body indicating the position of some of the lymph glands accessible to examination by palpation. STEP 3 In front of the mirror, inspect the lymph glands in all the areas demonstrated in the diagram for visible swelling. STEP 4 Wash and dry your hands thoroughly and put on gloves (optional with self examination). Examine the lymph glands demonstrated in the diagram by palpation. Gently move (slide) your fingers over the skin of the area under examination. STEP 5 Examine the lymph glands of somebody else, excluding the lymph glands in the groin area, by inspection and palpation. HINTS: • Examine one side at a time. • Compare the left and right sides with each other. • Make notes about the size, position and consistency of a gland (or group of glands). Be aware of any tenderness in the area. 115

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POINTS OF INTEREST • Lymph glands are structurally organized into “groups” and “chains.” • Swollen lymph glands are usually associated with infection within the drainage area of the specific group of lymph glands. • More serious disease processes in the body may occasionally cause swollen lymph glands, e.g. cancer and HIV disease. See supplement on HIV-AIDS. IMPORTANT NOTE: A doctor should assess any swollen lymph glands professionally.

PROJECT 33 - THE RESPIRATORY RATE How slowly or fast does a person breathe?

INFORMATION The respiratory rate is the number of breaths (inhalation and exhalation cycles) occurring in a given one-minute time period. It varies according to the body’s oxygen requirements, for example: • The level of physical activity. • Emotional state. • Various disease processes. REQUIREMENTS: • A stopwatch or timer that measures in seconds. STEP 1 Place the palm of your hand over the lower mid-chest or upper mid-abdominal area. STEP 2 Count the number of times the hand moves back and forth during a one minute time period. STEP 3 Make a note of this number. Also take note of the “depth” of respiration, for example, shallow or deep breathing. Is the breathing regular or irregular? Does the breathing occur through the nose, the mouth, or both of these passages? Make notes about the above as well as of any peculiarities. 116

STEP 4 Investigate the influence of the following on the respiratory rate: Measure the respiratory rate: 1. After physical exercise. 2. At different times of the day. 3. During certain emotions such as fear, anger, excitement, etc. STEP 5 Check the respiratory rate of other people. POINTS OF INTEREST • The resting respiratory rate of 1. A newborn baby is 30–40 breaths per minute; 2. An adult is 12–16 breaths per minute. • Physical exercise will increase the respiratory rate. • Strong emotions generally increase the respiratory rate. • Breathing during rest normally occurs through the nose. • Some medications, abnormalities and diseases will influence the tempo of respiration (respiratory rate). In general, an increase in the respiratory rate is the body’s attempt to increase the oxygen supply to the various tissues and organs of the body.

PROJECT 34 - RESPIRATORY SOUNDS Listening to respiratory sounds with a stethoscope.

INFORMATION Breath sounds have both intensity (loudness) and quality. Breath sounds as well as voice sounds are transmitted through the tissues of the respiratory system (bronchi and lungs) to the skin surface of the chest, where they can be picked up with a stethoscope. SETTING: A quiet environment (switch off the radio, stereo, TV, etc.) CLOTHING: • Exposure of the chest area is required. • Although not ideal, the exercise can be performed on a person wearing thin material clothing. YOU WILL NEED: • The stethoscope* • A pair of gloves* * Order from our Online Shop; alternatively these products are available at most pharmacies. FOLLOW THESE STEPS: STEP 1 Review Project 12. Take note of the position of the lungs in the chest cavity. 117

STEP 2 Study the picture indicating the areas where you should listen to the lungs.

STEP 3 Wash and dry your hands thoroughly and put on a pair of gloves. Remove any clothing over the chest area. STEP 4 Put the earpieces of the stethoscope facing slightly forward into your ears. Start listening to the lungs, and follow the sequence as indicated in the diagram. Begin with the front of the chest, then the sides, and lastly the back. NOTE: You may need help from somebody else to hold the stethoscope when going through the back positions. Breathe deeply in and out through the mouth. • Compare the breathing sounds on the left side to the breathing sounds on the right side of the chest over similar positions. Take note of the quality as well as the volume (loudness) of the sounds. • Listen to the breath sound while whispering, for example, whisper “ninety-nine.” • Be patient. Take your time. A doctor learns to evaluate these sounds by listening to numerous patients over many years. • Do any sounds seem musical at all? This may be a “wheeze.” • Do you hear any “bubbling” or “clicking” noises? These may be “crackles.” STEP 5 With the necessary guidance from a responsible adult, you can listen to somebody else’s breathing sounds. PLEASE NOTE: • Always wash your hands and use a new pair of gloves each time you examine a different person. • Ensure the hygienic care of the stethoscope. 118

WARNING Do not breathe in and out deeply for more than 2 minutes at a time. Take a break for at least 5 minutes before the next session. Breathing in and out deeply for too long may cause dizziness or fainting! • Do you hear any rubbing sounds? This may be a “friction rub”. • “Wheezes”, “crackles” and “friction rubs” are considered abnormal sounds.

POINTS OF INTEREST • Breathing sounds are produced by an irregular flow of air through the larger airways (air pipes and voice box). • Abnormal breathing sounds give the doctor information about the type of respiratory disease, the extent of the disease process, as well as the location of the problem or disease. Diseases like bronchitis and pneumonia produce fairly characteristic breathing sounds. • Some lung diseases may not produce any abnormal sounds in the early stages such as lung tuberculosis (TB). • Smoking causes damage to the fragile lining of the respiratory system. It causes the respiratory system to become more prone to a number of diseases. Smoking is considered the main cause of lung cancer.

WARNING SMOKING IS A VERY UNHEALTHY HABIT!

PROJECT 35 - BREATHING MOVEMENTS This simple exercise will demonstrate two muscle groups involved in the breathing process.

INFORMATION Breathing normally occurs automatically and without any conscious effort, although it may be consciously controlled or modified to some extent. For example, you may be able to hold your breath for a period of time, but eventually your brain will override any conscious control, and breathing will resume again. The nervous and muscular systems help the respiratory system to do its work. FOLLOW THESE STEPS: STEP 1 • Place your left hand over the lower left front, and your right hand over the lower right front part of your chest. • Feel the movement of your hands when you breathe. Make a conscious effort to move the chest during breathing. • See your hands move forward and slightly away from each other as the lungs expand and the volume of the chest cavity increases.

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STEP 2 • Place one of your hands on the front area of your stomach (abdomen). • Make a conscious effort to move the abdomen during breathing. • Observe your hand moving forward and backwards. POINTS OF INTEREST • Breathing causing expansion of the chest cavity is called costal breathing, and occurs as a result of the contraction and relaxation of the inter-rib muscles (situated in between the ribs). • Movement of the abdomen while breathing is called diaphragmatic breathing and is caused by the contraction and relaxation of the main muscle for breathing – the diaphragm. • The diaphragm separates the chest and the abdominal cavities. • A broken back may cause paralysis to the inter-rib muscles. Such a person will still be able to maintain spontaneous breathing by using the diaphragm muscle. • A broken neck may cause paralysis to both the inter-rib and diaphragm muscles. Such a person will need assistance from a respirator for breathing.

PROJECT 36 – EXAMINE THE ORAL CAVITY Identify the normal structures of the oral cavity.

INFORMATION Inspection of the mouth by a doctor or dentist forms a routine part of the physical examination of a patient. The mouth is the entrance to the inside of the body and more specifically to the digestive system. The mouth reveals information about the inside of the body and therefore about the patient’s state of health. SETTING: A well-lit room. YOU WILL NEED: • An examination light (preferably a magnifying examination light)* • A clean wooden tongue depressor* • Antiseptic swabs* (A square gauze swab and an antiseptic solution may be used as an alternative) • A hand or tabletop mirror • A pair of gloves* * Order from our Online Shop; alternatively these products are available at most pharmacies. 120

TAKE THE FOLLOWING STEPS: STEP 1 Study the structure of the oral cavity in the diagram. STEP 2 Wash your hands thoroughly with soap and water. Dry your hands with a paper towel or clean hand towel, and put on a pair of clean gloves. Step 3 Self-examination: Position yourself comfortably in front of a mirror and open your mouth. Examine the mouth: 1. Take your time; do not rush. 2. Use the examination light to inspect specific areas in more detail. 3. Make use of the wooden tongue depressor to move the lips, cheeks, and tongue out of the way to reveal all the different areas of the mouth. 4. Identify all the different structures in the mouth by comparing them with the illustration. 5. Start at the lips and work your way systematically towards the back of the mouth. 6. Observe the color, form and dimensions of each area or structure being inspected.

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STEP 4 Observe the small projections on the surface of the tongue. The numerous small finger-like projections are called the filiform papillae and the slightly larger mushroom-like projections are called the fungiform papillae. Identify under the tongue: • The attachment of the tongue to the floor of the mouth called the “lingual frenulum”. • The sublingual fold and papillae – the openings of the ducts of the salivary glands are situated here. Do you see saliva flowing from these areas? Saliva keeps the lining of the mouth moist and healthy, it adds moisture to food during the chewing process, and it contains chemicals involved in the digestive process. STEP 5 Examine the teeth using the diagrams displaying the primary (baby) and permanent (adult) teeth. NOTE: • Most people under the age of 6 will still have their primary teeth. • Between ages 6 and 13 years, a person will probably have some primary teeth and some permanent teeth in the mouth (mixed dentition stage). • After the age of 13, all the permanent teeth should be visible in the mouth (if space allows, wisdom teeth may appear in the mouth only after the age of 16). Identify all the different types of teeth – incisors, canines, premolars and molars. Do you see any fillings (restorations of the teeth)? Are your teeth well aligned? Do you see any obvious cavities?

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NOTE: Cavities may range from a small, discolored spot on a tooth to an obvious hole or defect on a tooth. A cavity may be present between teeth where it will not be visible. A dentist needs to examine these areas using x-rays. STEP 6 Identify the structures at the back of the mouth. HINT: Use the tongue depressor to push the tongue down at the back. • Try not to elicit a “gag” reflex – this may cause vomiting. • Saying a long “Aaa…h” sound facilitates the inspection of this area. Can you see the tonsils? If you are unable to identify the tonsils, remember that a doctor or an Ear, Nose and Throat Surgeon may have removed them previously. The tonsils are part of the body’s lymphatic system. Are you able to identify the soft palate and the small tongue (uvula)? Can you see the wall at the back of the throat? ON COMPLETION OF THE EXAMINATION: • If saliva touched the examination light: 1. Wipe the examination light with an antiseptic swab. 2. Wipe off any excess moisture with a dry paper towel, and replace in The Apprentice Doctor™ case. • Discard the used gauze swab, gloves. and tongue depressor • Wash your hands thoroughly with soap and water

PROJECT 37 - TASTE LABORATORY Produce a “taste map” of the tongue. INFORMATION Traditionally, there are four different primary taste sensations, namely: sweet, salty, sour and bitter. Certain areas of the tongue are particularly more sensitive to one of these four basic tastes. A doctor may need to test the sensation of taste during a detailed examination of the nerves in the head area. SETTING: The kitchen. YOU WILL NEED THE FOLLOWING: • Four small containers. • Four Q-Tips/Ear buds. • Something sweet such as sugar or honey. Mix 1 teaspoon of sugar with 2 teaspoons of water in a small container. • Something sour such as vinegar or lemon juice. Place 2 teaspoons into a small container. • Something salty such as table salt. Mix ½ a teaspoon table salt with 2 teaspoons of water in a small container. • Something bitter such as unsweetened cocoa powder (available in most supermarkets). Mix ½ a teaspoon of cocoa powder with 2 teaspoons of boiling water in a small container. Allow to cool. 122

FOLLOW THESE STEPS: STEP 1 Wash your hands and put on clean gloves. STEP 2 Place the 4 small containers with the 4 basic taste substances on a table or bench. Place an unused Q-Tip in each of these 4 containers. STEP 3 Saturate one end of the Q-Tip in the container with the sweet solution and wipe it over different areas of the tongue. Apply the mixture to the back, the middle area, the sides, and then the tip of the tongue. Can you decide which area responds most intensely to sweet taste stimulus?

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STEP 4 Rinse the mouth thoroughly with clean water and wait for 2-3 minutes. STEP 5 Repeat Steps 2, 3 and 4 using the “sour,” then the “salty,” and lastly the “bitter” solutions. Ensure that you use a clean, unused Q-Tip in each of these four solutions. STEP 6 Indicate which areas of the tongue respond more intensely to the 4 specific primary tastes. Please do so on a taste map (map of the tongue). STEP 7 Compare your map with the taste map in the picture.

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POINTS OF INTEREST 1. Physiologists believe that they have identified at least two other primary taste sensations, namely “water” and “umami.” Water has a flavor of its own, and umami may be described as a “meaty” or “meat gravy” taste. 2. Different tastes are produced mainly by a combination of the primary taste sensations. 3. Although the tongue is considered the main organ of taste, other structures such as the palate and front structures of the throat also contribute significantly to taste sensations.

PROJECT 38 - GASTROINTESTINAL SOUNDS Listen to gastrointestinal sounds with a stethoscope.

INFORMATION The sounds produced by the gastrointestinal system may vary quite a bit according to: • The time of the day, • Meals, • Types of food, • Diseases in the abdominal cavity, and • Abdominal surgery. SETTING: A quiet environment (Switch off the radio, stereo, TV, etc.) CLOTHING: • Exposure of the abdominal area is required. • Although not ideal, the exercise can be performed on a person wearing thin material clothing.

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YOU WILL NEED: • The stethoscope* • A pair of gloves* * Order from our Online Shop; alternatively these products are available at most pharmacies. STEP 1 Review Project 13. Refresh your memory about the surface landmarks over the abdominal area. STEP 2 Wash your hands, dry thoroughly and put on clean gloves. Remove clothing over the abdominal area. STEP 3 Put the diaphragm of the stethoscope just to the right side of the navel (umbilicus). • Listen for 2-3 minutes in this position. • Can you hear any bowel sounds? • Do you hear “gurgling” noises? These noises have a low to medium pitch. • Do you hear any “tinkling” noises? Tinkling is a high-pitched noise. STEP 4 With guidance from a responsible adult, listen to the intestinal sounds of somebody else. PLEASE NOTE: • Always wash your hands and put on a new pair of gloves each time you examine a different person. • Ensure the hygienic care of the stethoscope.

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POINTS OF INTEREST • Movement of food and gas in the small and large bowel causes bowel sounds. • After surgery in the abdominal area, bowel sounds may be absent for a period of time. • Bowel sounds increase somewhat after meals. Obstruction of the intestines may cause bowel sounds to become excessive.

PROJECT 39 - EXAMINE THE ABDOMEN Principles of examining the abdomen by inspection and palpation.

INFORMATION The abdomen is the largest of the body cavities and contains a large part of the gastrointestinal system, two large glands associated with the gastrointestinal system – the liver and the pancreas – as well as the left and right kidney and the spleen. The kidneys are part of the urinary system and the spleen is considered part of the lymphatic system. 125

The abdominal cavity is subdivided into the larger upper true abdominal cavity and the smaller lower pelvic cavity. The pelvic cavity contains mainly organs of the urinary system such as the urinary bladder as well as organs of the reproductive system such as the womb (uterus). The roof of the pelvic cavity is the floor of the abdominal cavity. The roof of the abdominal cavity is the diaphragm. The diaphragm constitutes the floor of the chest cavity. A thorough examination of the abdomen is an important part of a physical examination by a doctor. SETTING: • A warm room with good light. • A bed with a firm mattress (alternatively, a floor with a soft carpet may be used). YOU WILL NEED: • Examination gloves* (and a mask if you wish) • The magnifying or penlight examination light* * Order from our Online Shop; alternatively these products are available at most pharmacies. CLOTHING: • Exposure of the abdominal area is required. • Comfortable clothing such as a t-shirt and short pants or boxer shorts is recommended. When a doctor examines the abdomen, exposure of the entire abdomen is required. For the purpose of the exercise, only the part of the abdomen exposed above the pants and below the chest is required. FOLLOW THESE STEPS: STEP 1 Wash your hands in warm water and put on examination gloves. Position the test subject comfortably on his/her back on a bed and expose the abdomen as indicated in the illustration. STEP 2 Closely inspect the abdomen from above. Take special note of the following: • General shape • Symmetry • Do you consider the abdomen “full” or is it “sunken” in shape? In the abdomen, the medical term for “full” is “distended.” Do you notice any movement of the abdominal wall? Use the examination light and shine it across the abdomen. This will help you to recognize subtle movement in the abdomen. Inspect the navel (umbilicus). Is it inverted (like a dimple) or somewhat prominent?

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STEP 3 Inspect the skin over the abdomen. Use the examination light to examine certain areas in more detail. Do you notice any spots or any variation in normal skin color such as pigmented areas? Do you notice any lines? • Slightly raised lines with a bluish hue are probably superficial veins. • White or pink “wrinkled” lines could be stretch marks. This could have been caused by pregnancy for instance. • A scar from a previous operation may be white or pink in color and is usually linear or slightly curved. Stitch marks may be noted as a line of little “dots” on both sides of the incision line. STEP 4 Gently palpate by placing the palm of the hand flat on the abdominal wall starting in the left lower quadrant. Press gently downwards with the hand, systematically palpating this quadrant. Palpate the right lower quadrant systematically in the same manner, then the right upper quadrant, and lastly the left upper quadrant. HINT: Visualize the four quadrants of the abdomen. Keep in mind the normal structures found in each quadrant. STEP 5 Vary the depth of palpation and reexamine the four quadrants. PLEASE NOTE: • DO NOT USE EXCESSIVE FORCE. • Ensure that the palm of the hand is in continuous contact with the abdominal wall. • Use the whole hand to palpate – emphasize pressure with the fingers slightly bent, but avoid pressing down too forcefully with the fingertips. • Ensure that the muscles of the abdominal wall are relaxed: 1. Ask the test subject to relax! 2. Palpate mainly during deep inspiration (breathing in). • Make sure that the room is warm, including your hands as examiner. Can you feel any nodules or masses during the examination? Do you feel any pulsations? Is there any tenderness in any of the four abdominal quadrants?

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POINTS OF INTEREST • The edge of a normal liver may be palpated just below the lower edge of the rib cage in the right upper quadrant of the abdomen. • A normal sized spleen cannot be felt when examining the left upper quadrant of the abdomen. Only a significantly enlarged spleen can be felt during palpation. • As a general statement, the abdomen should be soft and not tender when examined by gentle palpation. Certain abdominal organs and occasionally abdominal contents such as feces are palpable with examination by deep palpation. • Fullness of the abdomen may be caused by one of 5 words starting with an “F”: 1. Fat, 2. Fluid, 3. Flatus (intestinal gas), 4. Feces (bowel contents), or 5. Fetus (unborn baby in womb). REMINDER: Make notes on your findings. A medical doctor should professionally examine tenderness of the abdomen as well as abdominal masses felt with palpation.

PROJECT 40 - URINALYSIS Analyze some of the chemicals in a sample of urine.

INFORMATION Your medical kit contains urinary test strips (dipsticks) impregnated with specific chemicals. These chemicals undergo a change in color when reacting with certain chemicals in urine. The dipsticks supplied may be able to detect the levels of one or more of the following substances: • Glucose Glucose is absent in the urine normally. The most common cause for glucose in the urine is too high levels of glucose in the blood. • Ketones Ketones are chemicals produced when the body utilizes fat rather than glucose as “fuel” for its energy requirements. A high level of ketones in the urine is an indication that the normal mechanisms of the body to regulate chemical reactions are out of control. • Leukocytes Leukocyte esterase is a chemical found in certain white blood cells, and its presence in urine is a sign of inflammation. Bacterial infection is the most common reason for a positive leukocyte esterase test. • Protein Minute amounts of protein in the urine may be normal. Increased amounts of protein in the urine may be a sign of kidney infection. Strenuous exercise will also cause an increase in the amount of protein in the urine. • Blood The indicator on the dipstick detects the oxygen-carrying protein hemoglobin. Blood in the urine (hematuria) may be caused by an infection of or injury to one of the components of the urinary system.

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SETTING: • The bathroom or toilet. • Good light. YOU WILL NEED: • Examination gloves* • Urinary test strips (dipsticks)* • A watch or timer that measures in seconds • A clean, dry, preferably disposable container * Order from our Online Shop; alternatively these products are available at most pharmacies. NOTE: The reagent strips expire after a period of time. Make a note the expiry date of the strips and do not use after this date as you may register an inaccurate reading! STEP 1 Collect a fresh urine specimen in a clean, dry container. Inspect the appearance and color of the urine. Normal urine is clear yellowish to amber in color. Certain drugs and foods may change the color of urine. Blood in the urine may be bright red or dark red-brown in color. Urine with a cloudy appearance may be due to a bacterial infection of the urinary tract. STEP 2 Remove a dipstick from the container, and replace the lid immediately. STEP 3 Hold the plastic end of the strip – do not touch the test area. Dip the test area of the strip into the urine and remove immediately. Wipe off excess urine on the rim of the container, and begin timing.

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STEP 4 After 60 seconds, compare the colors of the dipstick with the color scales on the label of the dipstick container. STEP 5 Record the results on the graph of your projects notebook. POINTS OF INTEREST • Urinalysis offers a convenient and quick screening test to the doctor to assist him/her to diagnose certain diseases or abnormalities. • A shortage of the hormone insulin will cause a rise in the blood glucose level. • When glucose levels in the blood are too high, a patient is diagnosed as having diabetes. • Abnormal levels of any of the chemicals tested for in the urine should be brought to the attention of your medical doctor for further investigation. 129

PROJECT 41 - HEART SOUNDS: UNBORN BABY Use a stethoscope to listen to the fetal heartbeat.

NOTE: If you are lucky enough to have a close family member who is 6-9 months pregnant, you will be able to proceed with this project. The apprentice doctor should be familiar and comfortable with the use of a stethoscope. Complete Projects 10, 21, 30, 34 and 38 before embarking on Project 41. INFORMATION The sound produced by the fetal heart is quite soft and needs to travel some distance before one can pick up the sound with a stethoscope. The sound is audible only in the later stages of pregnancy and when the unborn baby is lying with the back close to the mother’s front abdominal wall. Although a regular stethoscope can pick up the sound produced by the heartbeat of a fetus, a doctor may prefer to use a special fetal stethoscope to listen to the unborn baby’s heartbeat more clearly. See chapter on the stethoscope. YOU WILL NEED: • The stethoscope* * Order from our Online Shop; alternatively this product is available at most pharmacies. SETTING: • The privacy of a bedroom • A quiet environment STEP 1 The best area to listen to the fetal heartbeat is 3–7 cm (1–3 inches) below the umbilicus on the front abdominal wall of the pregnant mother. Place the diaphragm of the stethoscope in this region (or ask the pregnant person to place it over this area for you). STEP 2 Put the earpieces of the stethoscope facing slightly forward into your ears. STEP 3 LISTEN INTENTLY: • Be patient. Take your time. • Ensure that the diaphragm of the stethoscope is positioned facing firmly down, with the full surface of the diaphragm making skin contact. • Eliminate distracting noises. • Avoid unnecessary movement of the diaphragm over the skin. • Keep the stethoscope still in one position for 15–30 seconds before moving it to another position. • Vary the position of the diaphragm somewhat – up, down, to the left and to the right. • In each position, listen for a faint but fast heartbeat. The normal heart rate of a fetus ranges between 120-160 beats per minute. • If you are not successful, try again on another occasion. The position of the unborn baby may be more favorable next time! 130

A CAREER IN THE FIELD OF MEDICINE And now…your exciting future! Congratulations! By completing The Apprentice Doctor™ basic medical course, you have gained a reasonable degree of knowledge and skills in some of the many examinations that a general medical doctor performs on a daily basis. If you enjoyed The Apprentice Doctor™ basic medical course and the practical projects, you may wish to pursue this further by training to become a medical doctor or alternatively pursue a career in one of the many branches of healthcare and medicine. A strong desire to become a medical doctor is an absolute prerequisite for success. Other attributes required are: • Love and respect for human beings, • Respect for life, and • A keen interest in the structure and functioning of the human body. Do not be put off by a tendency towards fainting, nausea, or an aversion for blood or injured people. Over a period of time you will get used to it without the tendency to react negatively! Recommended school subjects include mathematics, science and biology. Most medical schools have strict selection criteria in place, with good results in especially mathematics and science counting in your favor for selection. In many countries across the world, a premedical science degree is required before an application for entrance into medical school will be considered. Ensure that you get information on the selection requirements as well as the necessary application forms in enough time from the medical school where you intend to pursue your studies. It is wise to apply for selection at a number of medical schools at the same time in order to widen your options. You will be wise to consider some of the many other careers in the field of healthcare/medicine before making a final career choice. So go ahead, become a good diagnostician and a successful doctor or healthcare worker of your choice!

Follow your dreams… and never give up!! http://www.multimedmedia.com/ http://www.usd.edu/biol/biocareers/health-related/ http://www.bc.edu/offices/careers/careers/careerfields/health/#explore

WARNING: The law prohibits unregistered/unlicensed persons from selling medical skills/services to other people. This course is intended to kindle an interest in medicine/healthcare as a career but does not qualify you to any degree as a healthcare professional of any sort.

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The Apprentice Doctor™ – SUPPLEMENT ON HIV AND AIDS What are HIV and AIDS? HIV is the abbreviation for “Human Immunodeficiency Virus.” HIV disease is the disease process occurring when the human immunodeficiency virus attacks part of the lymphatic system of the body called the immune system. The immune system defends the body against attacks from disease-forming microorganisms like bacteria, viruses, fungi and parasites. HIV progressively damages this system and consequently the body becomes unable to fight infections caused by these agents. HIV disease progresses commonly without causing any symptoms. If symptoms occur, they are usually mild and may include one or more of the following: • Swollen lymph glands in the neck, armpit and groin • Fever • Headaches • Fatigue • Muscle aches. AIDS is the abbreviation for “Acquired ImmunoDeficiency Syndrome” and is the term used in advanced HIV disease when more advanced symptoms are found. The symptoms may include one or more of the following: • Rapid unexplained loss of more than 10 pounds of weight • Long periods of diarrhea • Recurrent fevers and night sweats • Swelling and hardening of lymph glands • A continuous deep dry cough • A thick whitish coating of the tongue or mouth • Recurrent vaginal yeast infections • Chronic inflammatory disease of the pelvic cavity • Recurrent skin rashes or attacks of shingles • Periods of extreme fatigue, headaches and/or dizziness • The appearance of discolored purplish growths on the skin or mucous membranes • Unexplained bleeding from the gums or from any other body opening • Unexplained numbness of any area of the body, or paralysis of any muscle or group of muscles • A change in personality, mental deterioration, or an altered state of consciousness The cause of AIDS The causative agent of AIDS is the human immunodeficiency virus (HIV), transmitted when a body fluid such as blood, semen, breast milk and vaginal fluids of an infected person enters the body of an uninfected person. This may happen: • In the majority of cases during sexual encounters with an infected person; • Sharing needle or syringes with an infected person when injecting illegal drugs; • Accidental needle pricks or cuts when healthcare professionals treat HIV infected patients; • The transfer of HIV from an infected mother to her unborn child; or • Receiving a blood transfusion or blood product donated by an infected person. As a result of vigorous screening and testing by blood transfusion services, this is indeed an extremely rare occurrence. Please note: • HIV is not transmitted by casual contact such as kissing, hugging and sharing silverware, glasses, or mugs. • HIV cannot be contracted by donating blood.

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How to avoid HIV infection. One hundred percent effective measures are: • Abstaining from sexual intercourse. • Have sexual intercourse with a single faithful sexual partner for life • Refrain from injecting illegal drugs. The use of male or female condoms when having sexual intercourse will significantly reduce the risk, but is not guaranteed to prevent infection with HIV. Healthcare professionals should be extremely careful when treating HIV-infected patients especially when using any sharp objects such as scalpels and needles. Barrier techniques like single or double gloving, the wearing of masks, as well as protective glasses or visors should be utilized when performing surgery on a patient with HIV disease. Accidental injuries with infected sharp objects do occasionally occur. A combination of anti-HIV drugs started as soon as possible after the accident can prevent the development of HIV infection in the majority of cases. A number of anti-HIV drugs are effective in reducing the chances of transferring HIV from an infected mother to her unborn baby. How to find out if I am, or if my sexual partner is infected with HIV. A blood sample is required. Testing is the only way to tell if you are infected or not. The result may be: 1. HIV-negative. This means that at the time of the test, no sign of HIV infection could be detected, and that the person is probably uninfected. A follow-up blood test after about 3 months is required to confirm the HIV-negative status as it may take up to 3 months for the blood test to become positive following exposure to the virus. Consider a person who has been exposed to HIV as HIV-positive until proven otherwise! 2. HIV-positive. This means that infection has already occurred. Any primary healthcare clinic or hospital will be able to arrange for the necessary testing free of charge. What to do if your test indicates that you are HIV-positive: • Realize that this is not the end of your life! You do have many years ahead of you to continue pursuing your dreams. Medical science is advancing and treatment is becoming more and more effective. • Do not make any harsh or rash decisions - continue with your normal life. • Do not terminate your studies and do not resign from your job. The doctor informing you about your blood results should: • Offer you some advice on the management and treatment of the disease as well as providing information about preventing further spread of the HIV disease. • Answer your immediate questions. • Offer treatment if you are experiencing any symptoms. • Arrange for counseling by a qualified AIDS counselor. Make a list of questions to discuss with the AIDS counselor. Important notes: It is now your responsibility to: • Ensure that you do not engage in * unprotected sexual intercourse as you may be spreading the disease. • Inform your sexual partner(s) of your HIV status. He/she has the right to know! • Encourage your sexual partner(s) to have an HIV test in order to ascertain their HIV status. • Increase your knowledge and awareness of AIDS and share this knowledge with other people. 133

Remember: * In some countries or states passing on HIV knowingly to another person is illegal with severe penalties that may be enforced. * With the consent of your informed sexual partner, use a condom during sexual intercourse without any exceptions. Condoms are available free of charge in some locations. Knowledge of the causes of AIDS and educating as many people as possible in the prevention of this disease are the only really effective weapons to counteract the progress of this terrible disease. Share your knowledge with as many people as possible and help fight the battle against AIDS! For more information: National AIDS hotline (Centers for Disease Control): 1-800-342-AIDS; your local Health Department; or visit these Web sites: http://www.thebody.com http://www.hivan.org.za http://www.medicalmailbox.com/infectious diseases.htm http://www.mayoclinic.com/findinformation/diseasesandconditions/index.cfm

Other infectious diseases

Learn more about all a variety of infectious diseases by visiting the following Web sites: http://www.medicalmailbox.com/infectious diseases.htm http://www.mayoclinic.com/findinformation/diseasesandconditions/index.cfm

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GLOSSARY Abdomen The body cavity below the chest cavity, separated from the chest cavity by the diaphragm muscle. Abdominal Pertaining to the abdomen (belly). Acoustic nerve The nerve conducting nerve impulses of hearing from the cochlea of the ear to the brain. Acoustics The science of sound. Acromion process Part of the shoulder bone forming the tip of the shoulder. Adrenal glands Endocrine glands situated above the kidneys. AIDS A fatal disease caused by a virus with the ability to slowly destroy part of a person's immune system. Albinism A condition in which melanin (coloring pigment) is absent. Albino A person having an inborn absence of melanin (coloring pigment) from the skin, hair, etc. Alimentary Pertaining to the function of nutrition. Alopecia Complete or partial loss of hair/baldness. Alveolar duct Airway branching from the smallest bronchioles. Alveolar sac Alveolar ducts end in several minute sacs resembling a cluster of grapes. Alveoli Very small air sacs in the lung. Amniotic sac Membranous bag containing fluid in which a baby floats in the uterus. Amplitude Maximum extent of vibration of a wave, e.g. a sound wave. Anemia The shortage of hemoglobin in the blood. Anesthetic General anesthetic: absence of sensation or feeling in the whole body. Local anesthetic: absence of sensation or feeling in a limited area of the body. Analyze Examine the detailed constitution of a substance. Anatomically Relating to bodily structure. Anatomist One who deals with the science relating to the structure of the body. Anatomy Body structure./The study of the form and arrangement of body parts. Anterior Located to the front. Antiseptic Chemical used to destroy microbes. Anus External opening at the end of the gastrointestinal tract. Aorta The main artery transporting oxygen-rich blood from the heart to the body. Aortic Pertaining to the aorta. Aortic valve The heart valve situated at the exit of the left ventricle. Appendix A short worm-like tube attached to the large intestine. Arteriole Small artery. Artery A vessel that conveys blood away from the heart. Articular Pertaining to a joint. Articular cartilage Tough smooth tissue covering the moving surfaces of joints./Gristle. Articulation Speaking, utterance. Aseptic Being relatively free from microorganisms such as bacteria, obtained by sterilization or antiseptics. Asymmetry Absence of symmetry. (See symmetry). Atom Smallest particle of a chemical element. Atrium One of two upper and smaller chambers of the heart. Attrition Gradual loss of enamel from teeth due to friction. Audible Able to be heard. Auditory Pertaining to the sense of hearing. Auricle External ear./Ear-shaped. Auriscope An instrument for examining the inside of the ear. Auscultation Listening to body sounds for diagnostic purposes. Autonomic nerves Nerves that send and receive impulses not directly controlled by the mind or will, mainly concerned with the regulation of internal organs. Autonomic nerves Nerves that send and receive impulses not directly controlled by the mind or will, mainly concerned with the regulation of internal organs. Axilla Armpit. Axon Nerve cell process or filament that transmits impulses away from the nerve cell body. Bacilli (single: Bacillus) A large group of rod-like bacteria. Bacteria (single: Bacterium) Microorganisms of a fairly primitive form, responsible for causing numerous diseases. Barium A substance used to outline the digestive tract when taking X-rays. Basophils A specific type of white blood cell with a granular cytoplasm having an affinity for basic stains. Biceps A muscle with two heads in front of the humerus (bone of the upper arm). 135

Bicuspid valve The heart valve situated between the left atrium and left ventricle. (Mitral valve). Bile A bitter greenish-brown thick fluid, secreted by the liver and stored in the gallbladder. Biochemical substances Chemical substances that relate to life. Biomedical Pertaining to the sciences of life and medicine. Biopsy Removing and examining a portion of living tissue for diagnostic purposes. Bipolar cells Cells having two poles. Blastocyst A hollow cluster of cells, representing a very early stage in the development of an embryo. Blind spot A small blind area in the field of vision. Blood The liquid circulating in the cardiovascular system of the body. Blood platelets See platelets. Blood pressure Pressure of blood in the major arteries. Blood vessels Tubes through which blood circulates through the body. Bolus A small ball of chewed food. Bone Rigid hard tissue making up the skeleton. Bone shaft The rod-like part of a long bone. Brachial Pertaining to the arm. Brachial artery Main artery of the arm. Brain The part of the central nervous system enclosed by the skull. Brain stem The connecting part of the brain between the cerebrum and the spinal cord. Bronchi Two tubes into which the trachea divides at its lower end. Bronchial tree Subdivisions of the bronchi after they enter the lungs, resembling the branching of a tree. Bronchiole The minute subdivision of the bronchi. Bronchus The main air pipe of a lung. Buccal Pertaining to the mouth or inside of the cheek. Caesarean section A surgical operation to deliver an infant usually at a late stage of pregnancy. Calcaneus The largest bone in the foot, the heel-bone. Calcification The formation of calcium crystals in tissue. Canine An eye tooth. Canthus The angle at either end of the opening between the eyelids. Capillary Minute hair-like blood vessels transporting blood from arterioles to venules. Cardiac muscle Muscle found in the heart. Cardiovascular system The heart and blood vessels. Carotid artery Artery in the neck carrying blood to the head. Carpal Pertaining to the wrist. Cartilage Tough smooth tissue covering the moving surfaces of joints. Gristle. CAT scan A computerized X-ray technique that produces cross-sectional images of the body. Cell A microscopic living unit enclosed by a membrane. Cementum Bony substance covering the root area of a tooth. Central nervous system The brain and spinal cord. Centrioles A pair of cylinder-like structures in a cell concerned with cell division. Cerebellum Part of the brain occupying the back part of the floor of the skull. Cerebrum The largest and top part of the brain. Cervical Referring to the neck region. Cervix Neck of the uterus. Cheek Side of the face. Chemical Relating to the science of elements and compounds. Choroid The middle coat (layer) of the eye. Cilia Hair-like projections/eyelashes. Ciliary body The muscles encircling the lens of the eye for focusing. Clavicle Collarbone. Clinical Pertaining to the “bed-side” examination of a patient for signs and symptoms of disease. Clitoris A small, sensitive protrusion at the front of the vulva. Coccyx The lower end of the backbone below the sacrum. Cochlea A structure in the inner ear, resembling the shape of a garden snail, which converts sound vibrations into nerve impulses. Collagen fibers Firm skin fibers that do not stretch freely. Colon The large intestine. Compact bone Solid, dense bone. Concha Shell-shaped structure, e.g. bony projections into the nasal cavity and hollow area of the external ear. 136

Condom A thin rubber sheath placed over the penis before sexual intercourse. Condyle Rounded end of a bone. Cone A type of light sensitive receptor in the retina stimulated by light and specialized for color vision. Conjunctiva The delicate membrane covering the inside of the eyelids and the front of the eye. Conjunctivitis Inflammation of the eyelids. Connective tissue The packaging material of the body, separating, protecting and supporting the various organs. Cornea Circular transparent layer at the front of the eye through which the pupil and iris can be seen. Coronal suture The immovable joint between the frontal and parietal bones of the skull. Coronary artery The arteries supplying blood to the heart muscle. Cortex The outer layer of a gland or organ. Corticosteroids A group of hormones formed in the cortex of the adrenal glands. Costal breathing Breathing causing movement over the chest area as a result of the contraction and relaxation of the inter-rib muscles. Cranial Pertaining to the skull. Cranium Part of the skull enclosing the brain. Cricoid cartilage The uppermost ring of cartilage around the trachea. Curettage Scooping out the contents of a cavity or cleaning using a scraping action. Cusp A peak (tip) or prominence of a tooth. Cutaneous Relating to the skin. Cuticle Skin fold over the root of the nail. Cyanosis Bluish complexion due to a lack of oxygen in the blood. Cytoplasm The jelly-like structure of a cell in which the nucleus is supported. D & C Dilatation and curettage. The inner lining of the uterus is peeled or scraped off during this gynecological procedure. Deltoid Large triangular muscle forming rounding of the shoulder. Dendrite A nerve cell process or filament transmitting nerve impulses towards the nerve cell body. Dentine Hard dense tissue forming the main part of teeth. Dentition The characteristic arrangement of the teeth of a person. Dermatologist Skin specialist. Dermis The layer of the skin below the epidermis containing fibrous tissue, blood vessels, nerves and sweat glands. Diabetes A condition in which the concentration of glucose in the blood is raised because of a deficiency (or absence) in the production of insulin. Diagnose The identification of a disease from signs and symptoms noted during the examination of a patient. Diagnosis The science and art of recognizing a disease by studying the symptoms it presents. Diagnostic Assisting in diagnosis. Diagnostician One who has studied the art of interpreting and evaluating a patient's symptoms. Diaphragm The dome-shaped muscular portion between the chest cavity above and the abdominal cavity below. Diaphragm The part of the stethoscope that is held against the body of the patient. Diaphragmatic breathing Breathing causing movement over the abdominal area as a result of the contraction and relaxation of the diaphragm muscle. Diarrhea The frequent passage of soft, watery feces. Diastole Relaxation phase of the heart muscle during which the heart chambers fill with blood. Diastolic Pertaining to diastole. Diastolic blood pressure The lowest pressure value of blood in the main arteries during the relaxation phase of the heart. Digestive system The body system concerned with taking in food, processing food and excretion of waste products. Digital Displayed by digits. Dilate Widening or stretching. Drugs Natural or synthetic chemicals that can alter the way that the body works, can be used to treat diseases. Ductus deferens A tube with a thick smooth muscular wall carrying sperm from the testis to the urethra. Ear Specialized organ for hearing and balance. Elastic fibers Flexible and stretchable fibers found in connective tissue in certain parts of the body. Electromagnetic waves A spectrum of waves including radio waves, light waves, X-rays, etc. Elimination Expel/get rid of. Ellipse Oval in shape. Ellipsoidal Resembling an oval shape or form. 137

Emanating Coming forth./Proceed from. Embryo The term used to describe the developing baby from the time of fertilization to the end of the eighth week of development in the uterus. Enamel The extremely hard substance covering the crown area of a tooth. Endocrine glands Ductless glands which release their product (a hormone) into the blood-stream. Endocrine system A system of ductless glands secreting hormones. Endoplasmic reticulum Network of microscopic tubes and vesicles in the cytoplasm. Enema Introduction of fluid via the anus. Enzyme A chemical substance produced by living cells that promotes chemical reactions. Eosin A red acidic dye used to stain cells for the purpose of microscopic examination. Eosinophil A type of white blood cell, containing granules staining readily with eosin. Epidermis The outer layer of the cells of the skin. Epiglottis A thin leaf-shaped flap at the root of the tongue covering the windpipe during swallowing. Epithelial layer Outer layer of the skin. Epithelium The outer layer of skin and mucous membranes. Equilibrium Balance. Eruption The process of a tooth moving through the gums into the mouth. Erythrocyte Red blood cell. Esophagus The tube or “pipe” connecting the throat to the stomach. Ethmoid bone Small bone of the skull, forming the roof of the nose. Eustachian tube The canal connecting the throat and the middle ear. Extensor muscles Muscles producing a straightening motion (extension). External Referring to the outside or surface of the body. Extremities Limbs (arms or legs). Eye Specialized organ for sight. Eyebrow Strip of hair over the upper part of the eye socket. Eyelash Hair situated at the free end of the eyelids. Eyelid Either of two muscular skin folds covering the exposed parts of the eyeball when in the closed position. Familiarization Make well known. Fatigue Tiredness. Feces Waste material discharged from the gastrointestinal tract./Bowel contents. Femoral Pertaining to the femur. Femur The thighbone. (The longest and strongest bone in the body). Fertilization The process by which the sperm and ovum unite. Fertilize The union of male and female reproductive cells. Fester Collection or formation of pus in an abscess or ulcer. Fiber A thread-like cell or structure. Fibrous Consisting of microscopic fibers. Fibrous tissue Tissue rich in microscopic fibers. Fibula The long thin bone of the lower leg to the outer side of the tibia. Filament A thread-like structure. Filiform papilla A fine hair-like projection. Fimbriae A fringe-like structure/frond-like structures. Flatus Intestinal gas. Flexor muscles Muscles producing a bending motion (flexion). Fetal Pertaining to fetus. Fetus Unborn baby in womb. Follicle Small sac-shaped cavity, e.g. hair follicle, tooth follicle and ovarian follicle. Foramen A hole or opening in bone. Frenulum (frenum) The membrane that attaches the tongue to the mouth floor. Frequency The number of beats, cycles, or vibrations per time unit, e.g. seconds or minutes. Frontal bone The bone forming the forehead. Frontalis Muscle over the forehead. Fungi Simple parasitic plant organisms. Fungiform papilla A small mushroom-shaped projection. Gall A bitter greenish-brown thick fluid secreted by the liver and stored in the gallbladder. Gallbladder A small bag attached to the under-side of the liver serving as a temporary storing area for bile. Ganglion A collection of nerve cells. Gastrocnemius Largest muscle of the calf.

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Gastrointestinal system The tube-like structure starting at the mouth, including the stomach, small and large bowel, and ending at the anus. Gastrointestinal tract The tube-like structure starting at the mouth, including the stomach, small and large bowel, and ending at the anus. Genital Pertaining to the external reproductive organs. Gingiva The gum. Gland A structure secreting fluid and/or chemical substances. Gliding To move in a smooth motion from one position to another. Glottis Entrance to the main airway from the pharynx. Glottis The gap between the vocal cords. Gluteus maximus Buttock muscle (largest muscle in the body). Golgi complex (apparatus) Small elongated sacs stacked on one another, packing biochemical substances into small pockets (globules). Gum The firm connective tissue over the tooth-bearing areas of the upper and lower jaws. Gynecological Pertaining to gynecology, the medicine and surgery of the female reproductive system. Hemangioma A red, blood-rich birth mark. Hematuria Blood in the urine. Hemoglobin The red substance contained in red blood cells/an iron molecule with the ability to carry oxygen. Hair bulb A small cap-shaped structure at the root end of a hair. Hair follicle A small sac from which a hair grows. Hair root Embedded portion of a hair. Hair shaft The long slender stem growing out of the skin. Halitosis Bad breath. Hamstring muscles The group of muscles at the back of the thigh. Heart A hollow muscular organ situated in the chest cavity between the lungs, which pumps blood through the cardiovascular system. Heart murmur An abnormal heart sound that is heard before, between, or after the normal lub-dup sounds. Helix Curved fold that forms the rim of the external ear. Hertz (Hz.) Unit for measuring the frequency or the number of vibrations per second of waves, e.g. sound waves. HIV Human immunodeficiency virus. HIV-negative A laboratory test which is unable to detect infection with the human immunodeficiency virus. HIV-positive A laboratory test which is able to detect infection with the human immunodeficiency virus. Hormone A substance secreted into the bloodstream by one organ to regulate the function of other organs. Humerus The bone of the upper arm that lies between the elbow and shoulder joints. Humidify Dampen, make moist. Hypertension Blood pressure that is higher than normal. Hypotension Blood pressure that is lower than normal. Hypothalamus The part of the brain just above the pituitary, regulating the endocrine system. Ilium Upper part of the hipbone. Immune system The defense system of the body. Implantation Attachment of the embryo to the lining of its mother's uterus. Impotent Inability to perform the sexual act. Incisors The four front cutting teeth of the upper and lower jaws. Incus The anvil; one of the three small bones in the middle ear. Infection The transmission of disease-forming microorganisms to the body, their entry into, and multiplication in the body. Inferior Lower. Infertility Inability to become pregnant. Inflammation The response of tissue to injury characterized by pain and swelling. Insulin A hormone formed in the pancreas regulating the glucose levels in the blood. Integument system The covering system consisting of the skin, hair and nails. Intestinal Pertaining to the intestine. Intestine The tubular part of the digestive system beyond the stomach. Involuntary Performed without exercise of a person's will. Iris The colored part of the eyeball seen through the cornea. Jaw One of the bones in which teeth are set. Joint The structure found where two bones meet. Ketones Chemical substances formed during the combustion of fat in the body. Kidneys A pair of large excretory glands at the back of the abdomen, concerned primarily with the regulation of the amount of water in the body. 139

Labium A lip-like structure. Labium majora/minora Outer and inner skin folds of the vulva. Labor The process by which a pregnant woman delivers her baby. Labor pain Painful contractions of the uterus just before or during the birth process. Lacrimal Pertaining to tears. Lacrimal caruncle A small reddish, fleshy eminence on the inner aspect of the eye containing glands. Lambdoidal suture The immovable joint between the parietal and occipital bones. Larynx The voice-box/the organ situated at the upper end of the trachea containing the vocal cords. Lateral At the side. Latissimus dorsi Broad flat muscle on the side of the spine. Left atrium Chamber of the heart receiving oxygen-rich blood from the lungs. Left ventricle Chamber of the heart pumping oxygen rich blood to the body. Leukocytes White blood cells. Ligaments Strong tough fibrous bands between two bones at a joint. Limb Referring to an arm or a leg. Lingual Pertaining to the tongue. Lingual frenum The fold of membrane which passes from the under surface of the tongue to the floor of the mouth. Lip The upper and lower structures surrounding the mouth opening. Liver The largest gland in the body, occupying the upper right part of the abdominal cavity with multiple diverse functions. Lobule Small roundish, flattish structure, e.g. the lower part of the external ear. Lower (inferior) vena cava The large vein which receives blood from the trunk and the lower extremities and empties into the right atrium. Lumbar The region between the ribs and the pelvis. Lung One of two organs of respiration. Lunula The semi-half-moon, pale area at the root of the nail. Lymph Fluid contained within the lymphatic vessels of the body. Lymph nodes Small bean-like bodies filtering lymph fluid. Lymph vessels Thin-walled tubular structures carrying lymph from the tissue spaces towards the circulatory system. Lymphatic system A network of thin-walled vessels containing lymph. Lymphocyte A kind of white blood cell (leukocyte). Lysosome A number of particles on the outside of the cell nucleus that contain enzymes capable of breaking down biochemical substances. Macula A flat spot. Malleolus One of the two bony prominences of the ankle. Malleus The hammer; one of the three small bones in the middle ear. Malnutrition A deficiency of essential components of a proper diet. Mandible The lower jawbone. Marrow The soft pulpy substance contained in the cavity/cavities within bones. Masseter Muscle of mastication on the side of the jaw. Mastication Chew/grind food with teeth. Mastoid process Conical prominence on the temporal bone behind the ear. Maxilla The upper jaw. Medical staff Personnel employed in medical services by institutions. Medulla The central zone of a gland or organ. Medullary space Marrow cavity within a bone. Meiosis Division of the nucleus of a cell resulting in two daughter nuclei having half the number of chromosomes as the parent nucleus. Melanin A dark brown to black pigment found in various areas of the body, e.g. skin, hair, the retina of the eye. Melanocytes Cells that produce melanin. Melatonin A hormone formed by the pineal gland, regulating the body's day-night rhythms. Meniscus A lens-shaped structure (convex on the one side, concave on the other side). Mentalis Muscle over the chin. Mentum Pertaining to the chin. Metabolism The sum of all the biochemical processes occurring in the body. Microbe See “microorganism.” Microbiological Pertaining to the study of microbes (microorganisms). 140

Microorganism A living creature too small to be seen with the naked eye. Microscope An optical instrument containing lenses to enlarge very small objects. Microscopic So small that a microscope is required to see this. Micturition Passing urine. Mid-axillary Middle of the armpit. Mid-clavicular Middle of the collarbone. Mitochondrion Small body in the protoplasm concerned with supplying energy to a cell. Mitosis Division of the nucleus of a cell resulting in two daughter nuclei having the same number of chromosomes as the parent nucleus. Molars Teeth serving to grind. Molecule A collection of atoms chemically bonded together. Molecule A group of atoms held together by forces called chemical bonds/the most fundamental structural unit of a substance. Monocyte A large white blood cell. Morbid Indicative of disease. Morula A solid group of cells formed by the division of a fertilized egg cell. Motor nerve A nerve cell that transmits nerve impulses from the brain and spinal cord to muscles and glands. Mucus A thick “slippery” fluid, formed on the surface of lining membranes. Mucous membrane Membranes lining body surfaces opening to the exterior, e.g. the nose and mouth. Muscle A specialized tissue with the ability to contract, making movement possible. Muscular system The muscles of the body. Mycobacterium A group of rod-like bacteria resembling fungi. Nail body The horny or rigid part of the finger or toenail. Nail root The part of the nail underneath the cuticle. Nasal Pertaining to the nose. Nasal cavity The hollow area inside the nose. Nasalis Muscle over the nose. Nerve A bundle or “cable” of conducting fibers. Nerve fiber An axon or dendrite projecting from the cell body of a neuron (nerve cell). Nerve plexus A network of nerves. Nerve stem A large group of nerve fibers. Nervous system The body’s rapid information gathering, processing and response system consisting of the brain, spinal cord and peripheral nerves. Neural Pertaining to nerves/the nervous system. Neural reflex Involuntary response to a stimulus due to nerve impulses. Neuron A nerve cell. Neutrophils White blood cells that stain readily with neutral dyes. Nevus A spot on the skin consisting of a group of pigmented cells (also known as a mole). Nitrates Salts of nitrous acid, used to dilate blood vessels e.g. the coronary arteries. Nodule A small prominence or swelling. Nose Organ of breathing and smell. Nuclei Plural of nucleus. Nucleolus Spherical body in the nucleus of a cell. Nucleus The inner part of a cell, essential for growth, nourishment and reproduction. Obstructed Blocked. Occipital Referring to the back of the skull/head. Occipitalis The muscle at the back of the skull/head. Olecranon The bony process of the ulna forming the tip of the elbow. Ophthalmologist One who has studied the science which deals with the structure, function and diseases of the eye. Ophthalmoscope An instrument for examining the interior parts of the eye. Optic Pertaining to sight. Optic disc The point where the optic nerve enters the eyeball. Oral Pertaining to the mouth. Oral cavity Mouth. Orbicularis oculi Circular muscle around the eye. Orbicularis oris Circular muscle around the mouth. Orbit The bony socket (hollow) containing the eyeball. Orbital fat Fat contained within the eye socket. Organ A distinct structure in the body serving a particular function. 141

Orthodontist A specialist dentist trained to correct the misalignment of teeth and jaws. Orthopedic Relating to abnormalities and injuries of bone muscles and joints. Ossicles Small bones contained in the middle ear. Otoscope An instrument used to examine the ear. Outpatient A patient visiting a hospital but not admitted to a bed. Oval window A small opening covered by a membrane separating the middle ear from the inner ear, accommodating the footplate of the stapes. Ovarian follicle A name for immature egg cells contained in a small sac-like structure. Ovary The female reproductive gland producing egg cells and female hormones./A gland situated on either side of the womb. Ovulation The release of an ovum (egg cell) from a mature follicle. Ovum The female reproductive cell (egg cell) capable of developing into a new individual when fertilized by sperm. Pain receptors Nerve receptors converting harmful stimuli to nerve impulses perceived as pain. Palate The roof of the mouth. Palpation The act of examining by touch using the hand(s). Pancreas A dual endocrine and gastrointestinal gland secreting insulin into the blood stream and digestive juices into the small bowel. Papilla A minute elevated bulge or prominence./A minute projection from the surface of a tissue. Parasite An organism living in or on the body deriving all its nutrients from the body but provides no benefits in return. Parathyroid gland One of four small glands behind or embedded in the thyroid gland. Parietal The side of the cranium or brain case./Pertaining to the wall of a body cavity. Patella The kneecap. Patellar hammer An examination instrument used to test tendon reflexes. Pectoralis Breast muscle. Pelvic cavity The lower part of the abdominal cavity. Pelvis A firm ring of bone composed of the lower backbone and the two hipbones. Penis Male urinary and copulatory organ. Percussion Striking or tapping an object./The act of examining by striking or tapping a part of the body. Periodontal membrane The fibrous joint between a tooth and its bony socket. Periosteum The membrane covering a bone. Peripheral Towards the surface of the body. Peripheral nerves Nerves connecting the central nervous system (brain and spinal cord) to all parts of the body. Peristalsis The rhythmic contraction of the muscles of the intestines propelling its contents. Perspective A broad view or frame of reference. Perspiration A weak salty, watery solution secreted by glands in the skin./Sweat. Phalanges The small bones of the fingers. Pharynx The cavity to the back of the nose and mouth. The throat. Physiology Study of the function of living organisms and their parts. Pigment A compound with a characteristic color. Pigment cells Cells with the ability to produce melanin. Pineal gland Endocrine gland situated in the center of the brain producing melatonin. Pinna The external ear./The part of the ear which is external to the head. Pituitary The pea-shaped endocrine gland lying in a depression of the sphenoid bone just below the brain. Pivot To turn or rotate on a short pin or shaft. Placenta A fleshy mass of tissue attached to the wall of the pregnant uterus; organ of nutrition for the fetus. Plantar Pertaining to the sole of the foot. Plasma membrane The structure that separates the cell contents from the tissue fluids. Platelets Small fragments of cytoplasm circulating in the bloodstream, playing an important role in the clotting process. Plexus A network of nerves or veins. Popliteal Behind the knee. Posterior Located behind. Postoperative The period after an operation. Premolars The permanent teeth behind the canines and to the front of the molars. (Bicuspid teeth). Procreation The process of creating offspring./Reproduction of a living creature. Prostate Male reproductive gland around the neck of the bladder secreting substances that nourish sperm. Protoplasm The jelly-like, semi-transparent material forming the main constituent of most living cells. 142

Protoplasmic Pertaining to protoplasm. Protozoa Single-cell animal organisms. Pubic symphysis The joint of the left and right pubic bones in the midline. Pubis The joint of the left and right pubic bones in the midline. Pulmonary Pertaining to the lungs. Pulmonary arteries The arteries that carry oxygen-depleted blood from the heart to the lungs. Pulmonary valve The heart valve situated at the exit of the right ventricle. Pulp The innermost part of a tooth consisting of loose fibrous tissue, fine blood vessels and nerves. Pulse Pressure- wave in an artery, corresponding with the heart beat. Pulse oximeter An instrument that measures the oxygen saturation level of the blood by non-invasive means. Pupil Circular opening in the center of the iris through which light reaches the back of the eye. Pus A thick yellow or greenish fluid found in abscesses and on inflamed surfaces. Quadriceps Large muscle at the front of the thigh with four heads. Radius The bone on the outer side of the forearm. Receptor A minute organ at the end of a sensory nerve capable of responding to a particular kind of stimulus, e.g. touch, heat, pressure, etc. Rectum The last twenty centimeters (seven inches) of the large bowel, terminating in the anal canal. Rectus abdominus Straight muscle at the front of the abdomen. Red bone marrow Tissue found in spaces of certain bones responsible for the formation of blood cells. Red corpuscle A red blood cell. Reflex An involuntary response to a stimulus. Refraction The "bending" of light by lenses. Reproductive system The system dealing with procreation. Resonance The vibration of an object activated by waves originating from another object. Respiration The exchange of gases between air and blood. Respirator A medical apparatus designed to assist or take over the breathing function of an injured, paralyzed, or unconscious patient. Respiratory rate The number of breaths (inhalation and exhalation cycles) occurring in a given one-minute time period. Respiratory system Pertaining to the lungs, airways and breathing. Retina The inner light-sensitive lining at the back of the eye. Reverberate The bouncing or reflection of sound waves against the inner walls of a room, the inside surfaces of a container, or a body cavity. Rhythmical Regular beats or sounds. Rib One of twelve pairs of curved flat bones protecting the organs of the chest cavity. Rib cage The structure formed by the twelve pairs of ribs, the sternum and the vertebrae in the thoracic region. Ribosomes Very small spherical structures within a cell concerned with protein synthesis. Right atrium Chamber of the heart receiving oxygen-depleted blood from the body. Right ventricle Chamber of the heart pumping oxygen-depleted blood to the lungs. Rods A type of light-sensitive receptor in the retina responsible for night vision. Round window A membranous opening in the bony part of the inner ear just below the oval window. Sacrum The continuation of the backbone below the lumbar vertebrae. Saliva The secretion of the salivary glands./Spittle. Salivary glands Glands that secrete saliva. Sartorius Long slender muscle crossing the thigh obliquely in front. Saturation The level of absorption of a substance into another substance. Scapula Shoulder bone. Schwann cell Outer covering and insulating layer around nerve fibers. Sciatic Referring to the principal nerve of the lower limb, the sciatic nerve. Sclera The white area or shell of the eye. Scotoma A blind spot in the field of vision. Scrotum A sac-like pouch (loose bag of skin) containing the testes. Sebaceous glands The skin glands that secrete an oily substance called sebum. Sebum The fatty secretion of the skin's sebaceous glands. Secreting The process of producing and releasing fluid or chemical substances from a gland. Secretions Body fluids. Seizure The sudden loss of the ability to feel or move due to a blockage or rupture of a brain artery. Semen Male reproductive fluid. Semicircular canals Three canals located in the inner ear, involved in the special sense of balance. Semicircular ducts Three canals located in the inner ear, involved in the special sense of balance. 143

Seminal vesicles A pair of male reproductive glands contributing to the composition of semen. Sensory nerve A nerve cell transmitting nerve impulses towards the central nervous system. Serratus anterior Large muscle arising from the side of the ribs drawing the shoulder forwards. Sesamoid Bone formed in a tendon./Shaped like a sesame seed. Sexual Pertaining to aspects of reproduction. Shingles Painful inflammation of the skin with the eruption of numerous blisters in a specific region, caused by the chickenpox virus. Sign An objective indication that something is wrong as found by an examiner. Sinus A recess or cavity found in some of the bones of the skull. Skeletal muscle Muscles that can be controlled at will, e.g. muscles of the arms and legs. Skeletal system The rigid bony framework of the body/the skeleton. Smooth muscle Involuntary muscle found in the internal organs. Socket A hollow area, e.g. eye socket. Soleus Muscle at the back of the tibia (shin bone). Solvent Substance capable of dissolving something. Sound Sensation experienced in the ear caused by vibrations of air. Sound propagation The transmission of acoustic energy through a medium via a sound wave. Spasm An intense muscle contraction. Sperm The male reproductive cell/male reproductive fluid. Sphenoid A wedge-shaped bone at the base of the skull. Sphenoidal Pertaining to the sphenoid bone of the skull. Sphygmomanometer An instrument for measuring blood pressure. Spinal cord The continuation of the brain below the skull. Spleen A large lymphatic organ in the left upper quadrant of the abdominal cavity. Among other functions it filters blood. Spongy bone Porous, soft bone. Speculum Lighted tube-like instrument to inspect body openings or body cavities. Sputum Mucus coughed from the air passages. Stapes The stirrup: one of the three small bones in the middle ear. Sterile Free from microorganisms. Sternomastoid A muscle on the side of the neck. Sternum The breastbone. Stethoscope An instrument for listening to body sounds. Stomach An expansion of the gastrointestinal tract between the esophagus and the small intestine. Structural The way something is put together. Subcutaneous The tissue layer of the skin below the dermis. Sublingual fold A ridge-like fold in the floor of the mouth. Superior Upper (higher). Suture The fibrous joint of the bones of the skull./Surgical stitching material. Sweat A weak, salty, watery solution secreted by glands in the skin./Perspiration. Symmetry Two or more parts exactly similar in size, shape and position relative to a dividing point or line. Symphysis pubis The junction of the left and right pubic bones. Symptom A subjective indication that something is wrong as reported by the patient. Synovial fluid The lubricating fluid secreted by the synovial membrane. Synovial membrane The membrane lining the capsule of a joint. System A number of distinct organs of the body with the same purpose (common function). Systole Contraction of the heart muscle; the active phase of the heart cycle when blood is pumped into the arteries. Systolic Pertaining to systole. Systolic blood pressure The highest pressure value of blood in the main arteries during the contraction phase of the heart. Tarsal bones The seven bones forming the base of the foot. Temple The side of the skull (head). Temporal Referring to the side of the skull (temple) area. Temporalis Referring to the muscle on the side of the skull (temple) area. Tendon A firm white fibrous cord joining a muscle to bone. Terminal illness A disease ending in the death of a patient. Testes The male reproductive glands producing sperm and male hormones. Testis One of two glands contained in the scrotum. Thermometer An instrument for measuring the body temperature. 144

Thoracic Pertaining to the chest cavity (thorax). Thorax Chest cavity. Thymus An endocrine gland lying behind the upper breastbone. An important part of the body's immune system. Thyroid cartilage The shell of the larynx. Thyroid gland An endocrine gland situated in front and below the cartilage of the larynx. Tibia The shin bone./The main bone of the lower leg. Tibialis Muscle to the front of the tibia (shin bone). Tissue A collection of similar cells. Tongue Muscular organ of eating and speech. Tonsil A mass of lymphoid tissue at either side of the back of the mouth. Tooth A shell of dentine, enamel covering the crown area, and cementum over the root area. Torso Trunk or body without the head and limbs. Trachea The windpipe. Tragus Small projection of cartilage covered by skin immediately to the front of the external ear canal. Transilluminate Passing strong light through an object in order to inspect. Trapezius Large triangular muscle of the back. Trauma A wound./Damage to a part of a person's body or emotions. Triceps brachii Muscle with three heads to the back of the humerus (bone of the upper arm). Tricuspid valve The heart valve situated between the right atrium and right ventricle. Tuberculosis An infection caused by Mycobacterium tuberculosis, most commonly involving the lungs, but most other organs may be affected. Tumor A swelling, especially referring to swellings caused by the abnormal growth of cells or tissue. Turbulence Stormy/disorderly (flow). Turbulent Noisy, irregular. Tympanic membrane Ear drum. Ulna Bone on the inner side of the forearm. Umbilical cord Cord-like structure connecting the placenta to the unborn baby. Umbilicus The navel. Upper (superior) vena cava Large vein which receives blood from the head, chest and upper extremities and empties into the right atrium. Ureter Tube passing from kidney to urinary bladder. Urethra Tube carrying urine away from the urinary bladder. Urinary bladder A muscular sac serving as a temporary storage space for urine. Urinary system The system dealing with the formation and excretion of urine – the kidneys, ureters, urinary bladder and urethra. Urine Amber-colored watery fluid that is excreted by the kidneys. Uterine tube Duct that transports egg cells (ova) from the ovary to the uterus. Uterus Womb, the muscular baby-holding bag lying in the female pelvic cavity. Uvula Small tongue. A tongue-like projection at the back of the soft palate. Vagina The birth canal, tube from the uterus to the vulva. Valve A structure that ensures the flow of a liquid, e.g. blood in one direction only. Valve incompetence A leaking valve. Valve stenosis Narrowing of a valve opening or a valve with restricted flow. Vein A vessel that conveys blood towards the heart. Vena cava One of two large veins opening into the right atrium. Ventricle The strongly muscled lower and larger chambers (cavities) of the heart. Venule Small vein. Vertebrae Small bones forming the vertebral column (spine). Vesicle A small blister or sac. Vestibule A small space or cavity, e.g. vestibule of the inner ear. Virus A group of extremely small infectious agents causing a variety of diseases. Viscera The internal organs. Visual acuity Sharpness and clearness of vision. Vitreous chamber The cavity (hollow) inside the eyeball behind the lens. Vitreous humor The jelly-like transparent substance in the eye to the back of the lens. Vocal Pertaining to voice. Vocal cords Folds of lining membrane of the larynx with the ability to produce voice. Voluntary Performed under the control of a person's will. Vulva External female reproductive organs. 145

Wave length Distance between equivalent points of two successive sound waves. Wisdom teeth The last or farthest back molar teeth of the permanent dentition. Yeast Fungi proliferating as single cells. Yellow marrow Tissue found within spaces of certain bones consisting mainly of fatty tissue. Zygoma Cheekbone. Zygomatic Referring to the cheekbone. Zygote Cell produced by the fusion of an ovum and a sperm (fertilized ovum).

The next pages include Addendums 1-4, set out in the following list: Addendum 1 Example of The Apprentice Doctor™ medical file: 1. Front 2. Inner Left 3. Inner Right 4. Back Addendum 2 The Snellen eye test chart: 5. Snellen test chart (feet) 6. Metric Snellen test chart (meter) Addendum 3 Pictures of the models – projects 12 and 13: 7. Model 1 8. Model 2 Addendum 4 Growth charts: 9. Male growth chart 10. Female growth chart

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PATIENT DETAILS Surname: ……..……………............………………… Name: …….………………………… Title: ……..………………………...........……….……. Initials: …….………………………... Age: …..………………………............………... Date of Birth: ….………………………….. Address: ….……………………………............………………………………………………… Tel No.: …………………………………………............………………………………………...

FAMILY DOCTOR Name: ……..………………....…….………… Tel No.: …….…………………………….......

DENTIST Name: ……..………………....…….………… Tel No.: …….…………………………….......

MEDICAL HISTORY

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NO

Have you been a patient in a hospital during the past 2 years? …………………………. Have you been under the care of a physician during the past 2 years? ………………… Have you taken any kind of medicine or drugs during the past year? …………………... Are you allergic to penicillin, or to any other drugs or medicine? ………………………… Have you ever had any excessive bleeding requiring special treatment? ………………. Do you suffer from any illnesses? …………………………………………...…….………… Have you ever had any other serious illnesses?……………………………………..…….. (Woman) Are you pregnant?………………………………………………………….……….

Presenting complaint ….…..………………………...............…….………………….................…………

Reviewed by ……..…………………...........…………… Signature ……..................…………………..

DATE

COMMENT

DATE

PROJECT NO

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