B A T E S' Pocket Guide to
Physical
Examination
AND History Taking
ERRNVPHGLFRVRUJ
B A T E S ' Pocket Guide to
Physical
Examination
AND History Taking
EIGHTH EDITIO N
Lynn S. Bickley, MD, FACP
Clinical Professor of Internal Medicine
School of Medicine
University of New Mexico
Albuquerque, New Mexico
Peter G. Szilagyi, MD, MPH
Professor of Pediatrics and Executive Vice-Chair
Department of Pediatrics
University of California at Los Angeles (UCLA)
Los Angeles, California
Gu est Edit or
Richard M. Hoffman, MD, MPH, FACP
Professor of Internal Medicine and Epidemiology
Director, Division of General Internal Medicine
University of Iowa Carver College of Medicine
Iowa City, Iowa
ERRNVPHGLFRVRUJ
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Eighth Edition
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Library of Congress Cataloging-in-Publication Data
Names: Bickley, Lynn S., author. | Szilagyi, Peter G., author. | Hoffman,
Richard M., editor. | Abridgement of (expression): Bickley, Lynn S. Bates’
guide to physical examination and history-taking. 12th ed.
Title: Bates’ pocket guide to physical examination and history taking / Lynn
S. Bickley, Peter G. Szilagyi ; guest editor, Richard M. Hoffman.
Other titles: Pocket guide to physical examination and history taking
Description: Eighth edition. | Philadelphia : Wolters Kluwer, [2017] |
Abridgement of: Bates’ guide to physical examination and history-taking. /
Lynn S. Bickley, Peter G. Szilagyi. Twelfth edition. [2017]. | Includes
bibliographical references and index.
Identifiers: LCCN 2016030575 | ISBN 9781496338488 (alk. paper)
Subjects: | MESH: Physical Examination–methods | Medical History
Taking–methods | Handbooks
Classification: LCC RC76 | NLM WB 39 | DDC 616.07/54–dc23
LC record available at https://lccn.loc.gov/2016030575
This work is provided “as is,” and the publisher disclaims any and all warranties, express or
implied, including any warranties as to accuracy, comprehensiveness, or currency of the content
of this work.
This work is no substitute for individual patient assessment based upon healthcare professionals’
examination of each patient and consideration of, among other things, age, weight, gender, current
or prior medical conditions, medication history, laboratory data and other factors unique to the
patient. The publisher does not provide medical advice or guidance and this work is merely a
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Given continuous, rapid advances in medical science and health information, independent
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We would like to dedicate this book to all our
students, tr ainees, and mentees who have
taught us the tr ue value of both
the science and the
ar t of medicine.
Faculty Reviewers
J. D. Bartleson Jr., MD
Amit Garg, MD
Associate Professor of Neurology
Mayo Clinic
Rochester, Minnesota
Dermatologist
Northwell Health Physician Partners
Manhasset, New York
John D. Bartlett, MD
Catherine F. Gracey, MD
Assistant Clinical Professor of
Ophthalmology
Jules Stein Eye Institute
David Geffen School of Medicine
Los Angeles, California
Associate Professor
Department of Medicine
School of Medicine and Dentistry
University of Rochester Medical
Center
Rochester, New York
Amy E. Blatt, MD
Assistant Professor
Department of Medicine
School of Medicine and Dentistry
University of Rochester Medical Center
Rochester, New York
Adam Brodsky, MD
Associate Professor
Medical Director
Geriatric Psychiatry Services
Department of Psychiatry and
Behavioral Sciences
School of Medicine
University of New Mexico Psychiatric
Center & Sandoval Regional
Medical Center
Albuquerque, New Mexico
Thomas M. Carroll, MD, PhD
Assistant Professor
Department of Medicine
School of Medicine and Dentistry
University of Rochester Medical Center
Rochester, New York
Adam J. Doyle, MD
Assistant Professor
Department of Surgery
School of Medicine and Dentistry
University of Rochester Medical Center
Rochester, New York
vi
Carla Herman, MD, MPH
Chief
Division of Geriatrics and Palliative
Medicine
Professor
Department of Internal Medicine
School of Medicine
University of New Mexico
Albuquerque, New Mexico
William C. Hulbert, MD
Professor
Department of Urology
School of Medicine and Dentistry
University of Rochester Medical Center
Rochester, New York
Mark Landig, OD
Department of Ophthalmology
Jules Stein Eye Institute
David Geffen School of Medicine
Los Angeles, California
Helen R. Levey, DO, MPH
PGY5 Resident
School of Medicine and Dentistry
University of Rochester Medical
Center
Rochester, New York
Fa c ulty Re vie we rs
Patrick McCleskey, MD
Scott A. Vogelgesang, MD
Dermatologist
Oakland Medical Center
Oakland, California
Director
Division of Immunology
Clinical Professor
Department of Internal Medicine–
Immunology
University of Iowa Carver College
of Medicine
Iowa City, Iowa
Jeanne H. S. O’Brien, MD
Associate Professor
Department of Urology
School of Medicine and Dentistry
University of Rochester Medical Center
Rochester, New York
Alec B. O’Connor, MD, MPH
Director, Internal Medicine
Associate Professor
Department of Medicine
School of Medicine and Dentistry
University of Rochester Medical Center
Rochester, New York
A. Andrew Rudmann, MD
Associate Professor
Department of Medicine
University of Rochester Medical Center
School of Medicine and Dentistry
Rochester, New York
Moira A. Szilagyi, MD, PhD
Brian P. Watkins, MD
Surgeon
Genesee Surgical Associates
Rochester, New York
Paula Zozzaro-Smith, DO
Fellow of Maternal-Fetal Medicine
Department of Obstetrics and
Gynecology
The University of Rochester
Rochester, New York
S TU D EN T REVIEWERS
Ayala Danzig
University of Rochester School of
Medicine and Dentistry
Professor of Pediatrics
University of California at Los Angeles
(UCLA)
Los Angeles, California
Benjamin Edmonds
Loralei Lacina Thornburg, MD
University of Rochester School of
Medicine and Dentistry
Associate Professor
Department of Obstetrics and
Gynecology
School of Medicine and Dentistry
University of Rochester Medical Center
Rochester, New York
University of Central Florida College
of Medicine
Nicholas P. N. Goldstein
vii
Preface
Bates’ Pocket Guide to Physical Examination and History Taking, eighth edition, is a concise, portable text, with new chapters on assessing clinical
evidence and examination of the skin, hair, and nails, that:
■ Recommends how to sequence the physical examination and document
■
■
■
■
■
an accurate written record.
Clari es assessment of clinical evidence.
Describes how to interview the patient and take the health history.
Details and illustrates the steps of each of the regional physical examinations.
Reminds students of common, normal, and abnormal physical ndings.
Provides visual aids and comparative tables to guide recognition of
common and selected ndings.
There are several ways to use the Pocket Guide:
■ To review and remember the content of a health history.
■ To review and rehearse the techniques of examination. This can be
done while learning a single section and again while combining the
approaches to several body systems or regions into an integrated
examination (see Chapter 1).
■ To review common variations of normal and selected abnormalities.
Observations are keener and more precise when the examiner knows
what to look, listen, and feel for.
■ To look up special techniques as the need arises. Maneuvers such as
The Timed Get Up and Go test are included in the Special Techniques
section in each chapter.
■ To look up additional information about possible ndings, including
abnormalities and standards of normal.
The Pocket Guide is not intended to serve as a primary text for learning the
skills of history taking or physical examination. Its detail is too brief. It is
intended instead as an aid for student recall of the regional examinations
and examinations for special populations and as a convenient, brief, and
portable reference.
viii
Contents
Faculty Reviewers
Preface viii
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Index
vi
1
2
3
4
Foundations for Clinical Proficiency
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Behavior and Mental Status
Evaluating Clinical Evidence
1
27
Interviewing and the Health History
41
Beginning the Physical Examination: General Survey,
Vital Signs, and Pain 59
The Skin, Hair, and Nails
77
89
The Head and Neck 115
The Thorax and Lungs
145
The Cardiovascular System
The Breasts and Axillae
The Abdomen
167
187
199
The Peripheral Vascular System
Male Genitalia and Hernias
Female Genitalia
219
233
247
The Anus, Rectum, and Prostate
The Musculoskeletal System
The Nervous System
265
275
311
Assessing Children: Infancy through Adolescence
The Pregnant Woman
The Older Adult
349
383
399
423
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ix
1
C H A P T E R
Foundations for Clinical
Proficiency
This chapter provides a road map to clinical pro ciency in two critical
areas: the health history and the physical examination.
For adults, the comprehensive history includes Identifying Data and
Source of the History, Chief Complaint(s), Present Illness, Past History,
Family History, Personal and Social History, and Review of Systems. New
patients in the of ce or hospital merit a comprehensive health history;
however, in many situations, a more exible focused, or problem-oriented,
interview is appropriate. The components of the comprehensive health
history structure the patient’s story and the format of your written record,
but the order shown below should not dictate the sequence of the interview.
The interview is more uid and should follow the patient’s leads and cues,
as described in Chapter 3.
O v e r v ie w : C o m p o n e n t s o f t h e A d u lt H e a lt h H is t o r y
Id e n t if y in g D a t a
●
●
●
Re lia b ilit y
●
C h ie f C o m p la in t (s )
●
P r e s e n t Illn e s s
●
●
●
●
Identifying d t —such s ge, gender, occu tion,
rit l st tus
Source of the history—usu lly the tient, but c n
be f ily e ber or friend, letter of referr l, or
the clinic l record
If
ro ri te, est blish source of referr l bec use
written re ort
y be needed
V ries ccording to the tient’s e ory, trust, nd
ood
The one or ore sy to s or concerns c using the
tient to seek c re
A lifies the Chief Co l int; describes how e ch
sy to develo ed
Includes tient’s thoughts nd feelings bout the
illness
Pulls in relev nt ortions of the Review of Syste s,
c lled “ ertinent ositives nd neg tives” (see . 3)
M y include edic tions, llergies, h bits of s oking nd lcohol, which frequently re ertinent to
the resent illness
(continued )
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2
Ba te s ’ Poc ke t Guide to Phys ic a l Exa mina tion a nd His tory Ta king
O v e r v ie w : C o m p o n e n t s o f t h e A d u lt
H e a lt h H is t o r y (Continued )
P a s t His t o ry
●
●
●
Fa m ily His t o ry
●
●
P e r s o n a l a n d S o c ia l
His t o ry
●
Re v ie w o f S y s t e m s
●
Lists childhood illnesses
Lists dult illnesses with d tes for t le st four
c tegories: edic l, surgic l, obstetric/gynecologic,
nd sychi tric
Includes he lth
inten nce r ctices such s
i
uniz tions, screening tests, lifestyle issues, nd
ho e s fety
Outlines or di gr s ge nd he lth, or ge nd
c use of de th, of siblings, rents, nd gr nd rents
Docu ents resence or bsence of s ecific illnesses
in f ily, such s hy ertension, coron ry rtery
dise se, etc.
Describes educ tion l level, f ily of origin, current
household, erson l interests, nd lifestyle
Docu ents resence or bsence of co
on
sy to s rel ted to e ch
jor body syste
Decide if your assessment will be comprehensive or focused. Be sure to
distinguish subjective from objective data.
S u b je c t ive D a t a
O b je c t ive D a t a
Wh t the
Wh t you detect during the ex in tion, l bor tory infor tion, nd
test d t
All hysic l ex in tion findings, or
signs
tient tells you
The sy to s nd history, fro
Chief Co l int through Review
of Syste s
The Comprehensive Adult
Health History
As you elicit the adult health history, be sure to include the following: date
and time of history; identifying data, which include age, gender, marital
status, and occupation; and reliability, which re ects the quality of information the patient provides.
C h ie f C o m p la in t (s )
Quote the patient’s own words. “My stomach hurts and I feel awful”; or
“I have come for my regular check-up.”
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Chapter 1 | Foundations for Clinical Proficiency
3
P r e s e n t Illn e s s
This section is a complete, clear, and chronologic account of the problems
prompting the patient to seek care. It should include the problem’s onset, the
setting in which it has developed, its manifestations, and any treatments.
Every principal symptom should be well characterized, with descriptions
of the seven features listed below and pertinent positives and negatives from
relevant areas of the Review of Systems that help clarify the differential
diagnosis.
T h e S e v e n A t t r ib u t e s o f E v e r y S y m p t o m
●
●
●
●
●
●
●
Loc tion
Qu lity
Qu ntity or severity
Ti ing, including onset, dur tion, nd frequency
Setting in which it occurs
Aggr v ting nd relieving f ctors
Associ ted
nifest tions
In addition, list medications, including name, dose, route, and frequency
of use; allergies, including speci c reactions to each medication; tobacco use;
and alcohol and drug use.
P a s t H is t o r y
List childhood illnesses, then list adult illnesses in each of four areas:
■ Medical (e.g., diabetes, hypertension, hepatitis, asthma, HIV), with dates
of onset; also information about hospitalizations with dates; number and
gender of sexual partners; risky sexual practices
■ Surgical (dates, indications, and types of operations)
■ Obstetric/gynecologic (obstetric history, menstrual history, birth control,
and sexual function)
■ Psychiatric (illness and time frame, diagnoses, hospitalizations, and
treatments)
Also discuss Health Maintenance, including immunizations, such as tetanus,
pertussis, diphtheria, polio, measles, rubella, mumps, in uenza, varicella,
hepatitis B virus (HBV), human papillomavirus (HPV), Haemophilus
in uenzae type B, pneumococcal vaccine, and herpes zoster vaccine; and
screening tests, such as tuberculin tests, Pap smears, mammograms, stool
tests for occult blood, colonoscopy, and cholesterol tests, together with the
results and the dates they were last performed.
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Ba te s ’ Poc ke t Guide to Phys ic a l Exa mina tion a nd His tory Ta king
F a m ily H is t o r y
Outline or diagram the age and health, or age and cause of death, of each
immediate relative, including grandparents, parents, siblings, children, and
grandchildren. Record the following conditions as either present or absent
in the family: hypertension, coronary artery disease, elevated cholesterol
levels, stroke, diabetes, thyroid or renal disease, cancer (specify type),
arthritis, tuberculosis, asthma or lung disease, headache, seizure disorder,
mental illness, suicide, alcohol or drug addiction, and allergies, as well as
conditions that the patient reports.
P e r s o n a l a n d S o c ia l H is t o r y
Include occupation and the last year of schooling; home situation and
signi cant others; sources of stress, both recent and long term; important
life experiences, such as military service; leisure activities; religious
af liation and spiritual beliefs; and activities of daily living (ADLs). Also
include lifestyle habits such as exercise and diet, safety measures, and
alternative health care practices.
R e v ie w o f S y s t e m s (R O S )
These “yes/no” questions go from “head to toe” and conclude the
interview. Selected sections can also clarify the Chief Complaint;
for example, the respiratory ROS helps characterize the symptom of
cough. Start with a fairly general question. This allows you to shift
to more speci c questions about systems that may be of concern. For
example, “How are your ears and hearing?” “How about your lungs and
breathing?” “Any trouble with your heart?” “How is your digestion?”
The Review of Systems questions may uncover problems that the patient
overlooked. Remember to move major health events to the Present Illness or
Past History in your write-up.
Some clinicians do the Review of Systems during the physical examination. If the patient has only a few symptoms, this combination
can be efficient but may disrupt the flow of both the history and the
examination.
Ge n e ra l. Usual weight, recent weight change, clothing that ts more
tightly or loosely than before; weakness, fatigue, fever.
S k in . Rashes, lumps, sores, itching, dryness, color change; changes in
hair or nails; changes in size or color of moles.
He a d , Eye s , Ea r s , No s e , Th ro a t (HEENT). Head: Headache, head
injury, dizziness, lightheadedness. Eyes: Vision, glasses or contact lenses,
last examination, pain, redness, excessive tearing, double or blurred vision,
ERRNVPHGLFRVRUJ
Chapter 1 | Foundations for Clinical Proficiency
5
spots, specks, ashing lights, glaucoma, cataracts. Ears: Hearing, tinnitus, vertigo, earache, infection, discharge. If hearing is decreased, use or
nonuse of hearing aid. Nose and sinuses: Frequent colds, nasal stuf ness,
discharge or itching, hay fever, nosebleeds, sinus trouble. Throat (or
mouth and pharynx): Condition of teeth and gums; bleeding gums;
dentures, if any, and how they t; last dental examination; sore tongue;
dry mouth; frequent sore throats; hoarseness.
Ne c k . Lumps, “swollen glands,” goiter, pain, stiffness.
Bre a s t s . Lumps, pain or discomfort, nipple discharge, self-examination
practices.
Re s p ira t o ry. Cough, sputum (color, quantity), hemoptysis, dyspnea,
wheezing, pleurisy, last chest x-ray. You may wish to include asthma, bronchitis, emphysema, pneumonia, and tuberculosis.
Ca rd io va s c u la r. “Heart trouble,” hypertension, rheumatic fever, heart
murmurs, chest pain or discomfort, palpitations, dyspnea, orthopnea,
paroxysmal nocturnal dyspnea, edema, past electrocardiographic or other
cardiovascular tests.
Ga s t ro in t e s t in a l. Trouble swallowing, heartburn, appetite, nausea.
Bowel movements, color and size of stools, change in bowel habits, rectal
bleeding or black or tarry stools, hemorrhoids, constipation, diarrhea.
Abdominal pain, food intolerance, excessive belching or passing of gas.
Jaundice, liver or gallbladder trouble, hepatitis.
P e r ip h e r a l Va s c u la r. Intermittent claudication; leg cramps;
varicose veins; past clots in veins; swelling in calves, legs, or feet; color
change in ngertips or toes during cold weather; swelling with redness
or tenderness.
Urin a ry. Frequency of urination, polyuria, nocturia, urgency, burning
or pain on urination, hematuria, urinary infections, kidney stones, incontinence; in males, reduced caliber or force of urinary stream, hesitancy,
dribbling.
G e n it a l. Male: Hernias, discharge from or sores on penis, testicular
pain or masses, history of sexually transmitted infections (STIs) and
treatments, testicular self-examination practices. Sexual habits, interest,
function, satisfaction, birth control methods, condom use, problems.
Concerns about HIV infection. Female: Age at menarche; regularity, frequency, and duration of periods; amount of bleeding, bleeding
between periods or after intercourse, last menstrual period; dysmenorrhea, premenstrual tension. Age at menopause, menopausal symptoms,
postmenopausal bleeding. In patients born before 1971, exposure to
ERRNVPHGLFRVRUJ
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Ba te s ’ Poc ke t Guide to Phys ic a l Exa mina tion a nd His tory Ta king
diethylstilbestrol (DES) from maternal use during pregnancy. Vaginal
discharge, itching, sores, lumps, STIs and treatments. Number of pregnancies, number and type of deliveries, number of abortions (spontaneous and induced), complications of pregnancy, birth control methods.
Sexual preference, interest, function, satisfaction, problems (including
dyspareunia). Concerns about HIV infection.
M u s c u lo s k e le t a l. Muscle or joint pain, stiffness, arthritis, gout,
backache. If present, describe location of affected joints or muscles, any
swelling, redness, pain, tenderness, stiffness, weakness, or limitation of
motion or activity; include timing of symptoms (e.g., morning or evening),
duration, and any history of trauma. Neck or low back pain. Joint pain
with systemic features such as fever, chills, rash, anorexia, weight loss, or
weakness.
P s yc h ia t ric . Nervousness; tension; mood, including depression, memory change, suicide attempts, if relevant.
Ne u ro lo g ic . Changes in mood, attention, or speech; changes in orientation, memory, insight, or judgment; headache, dizziness, vertigo; fainting,
blackouts, seizures, weakness, paralysis, numbness or loss of sensation,
tingling or “pins and needles,” tremors or other involuntary movements,
seizures.
He m a t o lo g ic . Anemia, easy bruising or bleeding, past transfusions,
transfusion reactions.
En d o c rin e . “Thyroid trouble,” heat or cold intolerance, excessive sweating,
excessive thirst or hunger, polyuria, change in glove or shoe size.
The Comprehensive
Physical Examination
Conduct a comprehensive physical examination on most new patients or
patients being admitted to the hospital. For more problem-oriented, or
focused, assessments, the presenting complaints will dictate which segments
you elect to perform.
■ The key to a thorough and accurate physical examination is a systematic
sequence of examination. With effort and practice, you will acquire your
own routine sequence. This book recommends examining from the
patient’s right side.
■ Apply the techniques of inspection, palpation, auscultation, and percus-
sion to each body region, but be sensitive to the whole patient.
ERRNVPHGLFRVRUJ
Chapter 1 | Foundations for Clinical Proficiency
7
■ Minimize the number of times you ask the patient to change position from
supine to sitting, or standing to lying supine.
■ For an overview of the physical examination, study the sequence that
follows. Note that clinicians vary in where they place different segments,
especially for the musculoskeletal and nervous systems.
B e g in n in g t h e E x a m in a t io n :
S e t t in g t h e S t a g e
Take the following steps to prepare for the physical examination.
S t e p s in P r e p a r in g f o r t h e P h y s ic a l E x a m in a t io n
1.
2.
3.
4.
5.
6.
Reflect on your
ro ch to the tient.
Adjust the lighting nd the environ ent.
Check your equi ent.
M ke the tient co fort ble.
Observe st nd rd nd univers l rec utions.
Choose the sequence, sco e, nd ositioning of ex
in tion.
Think through your approach, your professional demeanor, and how to
make the patient comfortable and relaxed. Always wash your hands in the
patient’s presence before beginning the examination.
Re e c t o n Yo u r A p p r o a c h t o t h e P a t ie n t . Identify yourself as
a student. Try to appear calm, organized, and competent, even if you feel
differently. If you forget to do part of the examination, this is not uncommon, especially at rst! Simply examine that area out of sequence, but
smoothly.
A d ju s t Lig h t in g a n d t h e En v ir o n m e n t . Adjust the bed to
a convenient height (be sure to lower it when nished!). Ask the
patient to move toward you if this makes it easier to do your physical
examination. Good lighting and a quiet environment are important.
Tangential lighting is optimal for structures such as the jugular venous
pulse, the thyroid gland, and the apical impulse of the heart. It throws
contours, elevations, and depressions, whether moving or stationary,
into sharper relief.
Ch e c k Yo u r Eq u ip m e n t . Be sure your stethoscope, re ex hammer,
and other equipment are readily at hand.
M a k e t h e P a t ie n t C o m fo r t a b le . Show concern for privacy and
modesty.
ERRNVPHGLFRVRUJ
8
Ba te s ’ Poc ke t Guide to Phys ic a l Exa mina tion a nd His tory Ta king
■ Close nearby doors and draw curtains before beginning.
■ Acquire the art of draping the patient with the gown or draw sheet as you
learn each examination segment in future chapters. Your goal is to visualize
one body area at a time.
■ As you proceed, keep the patient informed, especially when you antic-
ipate embarrassment or discomfort, as when checking for the femoral
pulse. Also try to gauge how much the patient wants to know.
■ Make sure your instructions to the patient at each step are courteous
and clear.
■ Watch the patient’s facial expression and even ask “Is it okay?” as you
move through the examination.
When you have nished, tell the patient your general impressions and
what to expect next. Lower the bed to avoid risk of falls and raise the
bedrails if needed. As you leave, clean your equipment, dispose of waste
materials, and wash your hands.
S t a n d a r d a n d M RS A P r e c a u t io n s . Observe standard and
universal precautions. Use rigorous handwashing before and after
all patient contact and, whenever indicated, personal protective
equipment (gloves; gowns; and mouth, nose, and eye protection);
safe injection practices; safe handling of contaminated equipment or
surfaces; respiratory hygiene and cough etiquette; patient isolation
criteria; and precautions relating to equipment, toys, solid surfaces,
and laundry handling.
Un ive r s a l P re c a u t io n s . Universal precautions are a set of precautions
designed to prevent transmission of HIV, HBV, and other bloodborne pathogens when providing rst aid or health care. The following uids are considered potentially infectious: all blood and other body uids containing visible
blood, semen, and vaginal secretions; and cerebrospinal, synovial, pleural,
peritoneal, pericardial, and amniotic uids. Protective barriers include
gloves, gowns, aprons, masks, and protective eyewear. All health care workers should observe the important precautions for safe injections and prevention of injury from needlesticks, scalpels, and other sharp instruments and
devices. Report to your health service immediately if such injury occurs.
C h o o s e t h e S e q u e n c e , S c o p e , a n d P o s it io n in g o f t h e
Ex a m in a t io n . The sequence of the examination should
■ maximize the patient’s comfort
■ avoid unnecessary changes in position, and
■ enhance the clinician’s ef ciency.
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Chapter 1 | Foundations for Clinical Proficiency
T h e P h y s ic a l E x a m in a t io n : S u g g e s t e d
S e q u e n c e a n d P o s it io n in g
●
●
●
●
●
●
●
●
●
●
●
Gener l survey
Vit l signs
Skin: u er torso, nterior nd
osterior
He d nd neck, including
thyroid nd ly h nodes
Optional: Nervous syste
( ent l st tus, cr ni l
nerves, u er extre ity otor
strength, bulk, tone, cerebell r
function)
Thor x nd lungs
Bre sts
Musculoskelet l s indic ted:
u er extre ities
C rdiov scul r, including
jugul r venous ressure (JVP),
c rotid u strokes nd bruits,
oint of xi l i ulse (PMI),
S1, S2, ur urs, extr sounds
C rdiov scul r, for S3 nd
ur ur of itr l stenosis
C rdiov scul r, for ur ur
of ortic insufficiency
●
●
●
●
●
●
●
●
●
●
●
●
Optional: thor x nd lungs—
nterior
Bre sts nd xill e
Abdo en
Peri her l v scul r
Optional: skin—lower torso
nd extre ities
Nervous syste : lower
extre ity otor strength,
bulk, tone, sens tion;
reflexes; B binski reflex
Musculoskelet l, s indic ted
Optional: skin, nterior
nd ost erior
Optional: nervous syste ,
including g it
Optional: usculoskelet l,
co rehensive
Women: elvic nd rect l
ex in tion
Men: rost te nd rect l
ex in tion
Key to the Symbols for the Patient’s Position
Sitting
Lying su ine
Lying su ine, with he d of bed r ised
3 degrees
St nding
S
e, t urned
rt ly t o left side
Sitting, le ning forw rd
Lying su ine, with hi s flexed,
bducted, nd extern lly rot ted,
nd knees flexed (lithoto y
osition)
Lying on the left side (left l ter l
decubitus)
Each symbol pertains until a new one appears. Two symbols separated by a slash indicate either or both
positions.
Choose whether to do a comprehensive or focused examination. In general,
move from “head to toe.” An important goal as a student is to develop
your own sequence with these principles in mind.
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Ba te s ’ Poc ke t Guide to Phys ic a l Exa mina tion a nd His tory Ta king
Examine the patient from the patient’s right side. Note that the right side
is more reliable to estimate jugular venous pressure from the right, the
palpating hand rests more comfortably on the apical impulse, the right
kidney is more frequently palpable than the left, and examining tables
are frequently positioned to accommodate a right-handed approach.
To examine the supine patient, you can examine the head, neck, and anterior chest. Then roll the patient onto each side to listen to the lungs, examine the back, and inspect the skin. Roll the patient back and nish the rest
of the examination with the patient again supine.
T h e P h y s ic a l E x a m in a t io n : H e a d t o T o e
Ge n e ra l S u r ve y. Continue this survey throughout the patient visit.
Observe general state of health, height, build, and sexual development.
Note posture, motor activity, and gait; dress, grooming, and personal
hygiene; and any odors of the body or breath. Watch facial expressions
and note manner, affect, and reactions to persons and things in the environment. Listen to the patient’s manner of speaking and note the state of
awareness or level of consciousness.
Vit a l S ig n s . Ask the patient to sit on the edge of the bed or examining
table, unless this position is contraindicated. Stand in front of the patient,
moving to either side as needed. Measure the blood pressure. Count pulse
and respiratory rate. If indicated, measure body temperature.
S k in . Observe the face. Identify any lesions, noting their location, distribution, arrangement, type, and color. Inspect and palpate the hair and
nails. Study the patient’s hands. Continue to assess the skin as you examine
the other body regions.
HEENT. Head: Examine the hair, scalp, skull, and face. Eyes: Check
visual acuity and screen the visual elds. Note position and alignment of
the eyes. Observe the eyelids. Inspect the sclera and conjunctiva of each
eye. With oblique lighting, inspect each cornea, iris, and lens. Assess
extraocular movements. Darken the room to promote pupillary dilation
and visibility of the fundi. Compare the pupils, and test their reactions to
light. With an ophthalmoscope, inspect the ocular fundi. Ears: Inspect the
auricles, canals, and drums. Check auditory acuity. If acuity is diminished,
check lateralization (Weber test) and compare air and bone conduction
(Rinne test). Nose and sinuses: Examine the external nose; using a light
and nasal speculum, inspect nasal mucosa, septum, and turbinates. Palpate
for tenderness of the frontal and maxillary sinuses. Throat (or mouth and
pharynx): Inspect the lips, oral mucosa, gums, teeth, tongue, palate, tonsils, and pharynx. You may wish to assess the cranial nerves at this point in
the examination.
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Ne c k . Move behind the sitting patient to feel the thyroid gland and to
examine the back, posterior thorax, and lungs. Inspect and palpate the
cervical lymph nodes. Note any masses or unusual pulsations in the neck.
Feel for any deviation of the trachea. Observe sound and effort of the
patient’s breathing. Inspect and palpate the thyroid gland.
Ba c k . Inspect and palpate the spine and muscles.
P o s t e rio r Th o ra x a n d Lu n g s . Inspect and palpate the spine and
muscles of the upper back. Inspect, palpate, and percuss the chest. Identify the level of diaphragmatic dullness on each side. Listen to the breath
sounds; identify any adventitious (or added) sounds, and, if indicated,
listen to transmitted voice sounds (see p. 151).
Bre a s t s , Axilla e , a n d Ep it ro ch le a r No d e s . The patient is still sitting.
Move to the front again. In a woman, inspect the breasts with patient’s
arms relaxed, then elevated, and then with her hands pressed on her hips.
In either sex, inspect the axillae and feel for the axillary nodes; feel for the
epitrochlear nodes.
A N o t e o n t h e M u s c u lo s k e le t a l S y s t e m . By now, you have made
preliminary observations of the musculoskeletal system, including the
hands, the upper back, and, in women, the shoulders’ range of motion
(ROM). Use these observations to decide whether a full musculoskeletal
examination is warranted: With the patient still sitting, examine the hands,
arms, shoulders, neck, and temporomandibular joints. Inspect and palpate the joints and check their ROM. (You may choose to examine upper
extremity muscle bulk, tone, strength, and re exes at this time, or you may
decide to wait until later.)
Palpate the breasts, while continuing your inspection.
An t e rio r Th o ra x a n d Lu n g s . The patient position is supine. Ask
the patient to lie down. Stand at the right side of the patient’s bed. Inspect,
palpate, and percuss the chest. Listen to the breath sounds, any adventitious sounds, and, if indicated, transmitted voice sounds.
Ca rd io va s c u la r S ys t e m . Elevate head of bed to about 30 degrees,
adjusting as necessary to see the jugular venous pulsations. Observe the
jugular venous pulsations, and measure the jugular venous pressure in relation to the sternal angle. Inspect and palpate the carotid pulsations. Listen
for carotid bruits.
/
Ask the patient to roll partly onto the left side while you listen at the
apex. Then have the patient roll back to supine while you listen to the rest of
the heart. Ask the patient to sit, lean forward, and exhale while you listen for
the murmur of aortic regurgitation. Inspect and palpate the precordium.
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Ba te s ’ Poc ke t Guide to Phys ic a l Exa mina tion a nd His tory Ta king
Note the location, diameter, amplitude, and duration of the apical
impulse. Listen at the apex and the lower sternal border with the bell of a
stethoscope. Listen at each auscultatory area with the diaphragm. Listen
for S1 and S2 and for physiologic splitting of S2. Listen for any abnormal
heart sounds or murmurs.
Ab d o m e n . Lower the head of the bed to the at position. The
patient should be supine. Inspect, auscultate, and percuss. Palpate lightly,
then deeply. Assess the liver and spleen by percussion and then palpation.
Try to feel the kidneys; palpate the aorta and its pulsations. If you suspect
kidney infection, percuss posteriorly over the costovertebral angles.
/ P e rip h e ra l Va s c u la r S ys t e m . With the patient supine, palpate
the femoral pulses and, if indicated, popliteal pulses. Palpate the inguinal
lymph nodes. Inspect for edema, discoloration, or ulcers in the lower
extremities. Palpate for pitting edema. With the patient standing, inspect for
varicose veins.
/ Lo w e r Ext re m it ie s . Examine the legs, assessing the peripheral
vascular, musculoskeletal, and nervous systems while the patient is still supine.
Each of these systems can be further assessed when the patient stands.
/
Ne r vo u s S ys t e m . The patient is sitting or supine. The examination of the nervous system can also be divided into the upper extremity
examination (when the patient is still sitting) and the lower extremity
examination (when the patient is supine) after examination of the peripheral nervous system.
M e n t a l S t a t u s . If indicated and not done during the interview, assess ori-
entation, mood, thought process, thought content, abnormal perceptions,
insight and judgment, memory and attention, information and vocabulary,
calculating abilities, abstract thinking, and constructional ability.
C r a n ia l N e r ve s . If not already examined, check sense of smell, fun-
duscopic examination, strength of the temporal and masseter muscles,
corneal reflexes, facial movements, gag reflex, strength of the trapezia and
sternocleidomastoid muscles, and protrusion of tongue.
M o t o r S y s t e m . Muscle bulk, tone, and strength of major muscle groups.
Cerebellar function: rapid alternating movements (RAMs), point-to-point
movements such as finger to nose (F → N) and heel to shin (H → S); gait.
Observe patient’s gait and ability to walk heel to toe, on toes, and on heels;
to hop in place; and to do shallow knee bends. Do a Romberg test; check
for pronator drift.
S e n s o ry S ys t e m . Pain, temperature, light touch, vibrations, and discrimina-
tion. Compare right and left sides and distal with proximal areas on the limbs.
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13
Re f le xe s . Include biceps, triceps, brachioradialis, patellar, Achilles
deep tendon reflexes; also plantar reflexes or Babinski reflex (see
pp. 327–328).
Ad d it io n a l Exa m in a t io n s . The rectal and genital examinations are
often performed at the end of the physical examination.
/ M a le G e n it a lia a n d He r n ia s . Examine the penis and scrotal
contents. Check for hernias.
Re c t a l Ex a m in a t io n in M e n . The patient is lying on his left side for
the rectal examination. Inspect the sacrococcygeal and perianal areas.
Palpate the anal canal, rectum, and prostate. (If the patient cannot stand,
examine the genitalia before doing the rectal examination.)
G e n it a l a n d Re c t a l Ex a m in a t io n in Wo m e n . The patient is
supine in the lithotomy position. Sit during the examination with the
speculum, then stand during bimanual examination of uterus, adnexa,
and rectum. Examine the external genitalia, vagina, and cervix. Obtain
a Pap smear. Palpate the uterus and adnexa. Do a bimanual and rectal
examination.
Clinical Reasoning,
Assessment, and Plan
Using sound clinical reasoning, you must now analyze your ndings and
identify the patient’s problems. You must share your impressions with the
patient and document your ndings in the patient’s record in a succinct
legible format that communicates the patient’s story and physical ndings,
and the rationale for your assessment and plan, to other members of the
health care team. As you make clinical decisions, you will turn to clinical
evidence, calling on your knowledge of sensitivity, speci city, predictive
value, and the analytical tools detailed in Chapter 2, Evaluating Clinical
Evidence.
The comprehensive health history and physical examination form the
foundation of your clinical Assessment. The Plan is often wide-ranging
and incorporates patient education, changes in medications, needed
tests, referrals to other clinicians, and return visits for counseling
and support. A successful Plan includes the patient’s responses to the
problems identi ed and to the interventions that you recommend. It
requires good interpersonal skills and sensitivity to the patient’s goals,
economic means, competing responsibilities, and family structure and
dynamics.
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Ba te s ’ Poc ke t Guide to Phys ic a l Exa mina tion a nd His tory Ta king
C lin ic a l R e a s o n in g a n d A s s e s s m e n t
Because assessment takes place in the clinician’s mind, the process of
clinical reasoning may seem opaque and even mysterious to beginning
students. Study the steps described below. Focus on determining “What
explains this patient’s concerns?” and “What are the ndings, problems,
and diagnoses?”
S t e p s f o r Id e n t if y in g P r o b le m s a n d M a k in g D ia g n o s e s
1.
2.
3.
4.
5.
6.
7.
Identify bnor l findings.
Loc lize findings n to ic lly.
Cluster the clinic l findings.
Se rch for the rob ble c use of the findings.
Cluster the clinic l d t .
Gener te hy otheses bout the c uses of the tient’s roble s.
Test the hy otheses nd est blish working di gnosis.
Id e n t ify Ab n o rm a l Fin d in g s . Make a list of the patient’s symptoms,
the signs you observed during the physical examination, and any laboratory reports available to you.
Lo c a lize Th e s e Fin d in g s An a t o m ic a lly. Often this step is straightforward. The symptom of scratchy throat and the sign of an erythematous
in amed posterior pharynx, for example, clearly localize the problem to
the pharynx. A complaint of headache leads you quickly to the structures
of the skull and brain. Other symptoms, however, may present greater
dif culty. Chest pain, for example, can originate in the coronary arteries,
the stomach and esophagus, or the muscles and bones of the thorax. If the
pain is exertional and relieved by rest, either the heart or the musculoskeletal components of the chest wall may be involved. If the patient notes
pain only when carrying groceries with the left arm, the musculoskeletal
system becomes the likely culprit.
When localizing ndings, be as speci c as your data allow; however, you
may have to settle for a body region, such as the chest, or a body system,
such as the musculoskeletal system. On the other hand, you may be able
to de ne the exact structure involved, such as the left pectoral muscle.
Some symptoms and signs are constitutional and cannot be localized, such
as fatigue or fever, but are useful in the next set of steps.
Clu s t e r t h e Clin ic a l Fin d in g s . Several clinical characteristics may help.
■ Patient age: The patient’s age may help; younger adults are more likely
to have a single disease, whereas older adults tend to have multiple
diseases.
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15
■ Timing of symptoms: The timing of symptoms is often useful. For example, an
episode of pharyngitis 6 weeks ago is probably unrelated to the fever, chills,
pleuritic chest pain, and cough that prompted an of ce visit today. To use
timing effectively, you need to know the natural history of various diseases
and conditions. A yellow penile discharge followed 3 weeks later by a
painless penile ulcer suggests two problems: gonorrhea and primary syphilis.
■ Involvement of different body systems: If symptoms and signs occur in a
single system, one disease may explain them. Problems in different,
apparently unrelated, systems often require more than one explanation.
For example, you might decide to group a patient’s high blood pressure
and sustained apical impulse together with ame-shaped retinal hemorrhages, place them in the cardiovascular system, and label the constellation “hypertensive cardiovascular disease with hypertensive retinopathy.”
■ Multisystem conditions: With experience, you will become increasingly
adept at recognizing multisystem conditions and building plausible explanations that link manifestations that are seemingly unrelated. To explain
cough, hemoptysis, and weight loss in a 60-year-old plumber who has
smoked cigarettes for 40 years, you would rank lung cancer high in
your differential diagnosis. You might support your diagnosis with your
observation of the patient’s cyanotic nailbeds.
■ Key questions: You can also ask a series of key questions that may steer
your thinking in one direction and allow you to temporarily ignore
the others. For example, you may ask what produces and relieves the
patient’s chest pain. If the answer is exercise and rest, you can focus on
the cardiovascular and musculoskeletal systems and set the gastrointestinal (GI) system aside. If the pain is epigastric, you can logically focus
on the GI tract. A series of discriminating questions helps you analyze
the clinical data and reach logical explanations.
S e a rc h fo r t h e P ro b a b le Ca u s e o f t h e Fin d in g s . Patient complaints often stem from a pathologic process involving diseases of a body
system or structure. These processes are commonly classi ed as congenital,
in ammatory or infectious, immunologic, neoplastic, metabolic, nutritional,
degenerative, vascular, traumatic, and toxic.
Other problems are pathophysiologic, re ecting derangements of biologic
functions, such as heart failure or migraine headache. Still other problems
are psychopathologic, such as disorders of mood like depression or headache
as an expression of a somatic symptom disorder.
Ge n e ra t e Hyp o t h e s e s Ab o u t t h e Ca u s e s o f t h e P a t ie n t ’s
P ro b le m . Draw on the full range of your knowledge and experience,
and read widely. By consulting the clinical literature, you embark on the
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Ba te s ’ Poc ke t Guide to Phys ic a l Exa mina tion a nd His tory Ta king
lifelong goal of evidence-based decision making and clinical practice. The
following steps may help.
S t e p s f o r G e n e r a t in g C lin ic a l H y p o t h e s e s
1.
2.
3.
4.
5.
Select the ost s ecific nd critic l findings to su ort your hy othesis.
M tch your findings g inst ll the conditions th t c n roduce the .
Eli in te the di gnostic ossibilities th t f il to ex l in the findings.
Weigh the co eting ossibilities nd select the ost likely di gnosis.
Give s eci l ttention to otenti lly life-thre tening conditions.
Te s t Yo u r Hyp o t h e s e s . You are likely to need further history, additional maneuvers on physical examination, or laboratory studies or x-rays
to con rm or rule out your tentative diagnosis or to clarify which diagnosis
is most likely.
Es t a b lis h a Wo r k in g D ia g n o s is . Establish a working de nition
of the problem at the highest level of explicitness and certainty that the
data allow. You may be limited to a symptom, such as “tension headache,
cause unknown.” At other times, you can de ne a problem more speci cally based on its anatomy, disease process, or cause. Routinely listing
Health Maintenance helps you track several important health concerns
more effectively: immunizations, screening tests such as mammograms
or colonoscopies, instructions regarding nutrition and breast or testicular
self-examinations, recommendations about exercise or use of seat belts,
and responses to important life events.
U s e S h a r e d D e c is io n -M a k in g
t o D e v e lo p a P la n
Identify and record a Plan for each patient problem. Specify the next steps
for each problem, ranging from tests and procedures to subspecialty consultations to new or changed medications to arranging a family meeting.
It is critical to not only obtain patient agreement but to have the patient
participate in the decision making whenever possible.
The Quality Clinical Record:
The Case of Mrs. N.
The clinical record serves a dual purpose—it re ects your analysis of the
patient’s health status, and it documents the unique features of the patient’s
history, examination, laboratory and test results, assessment, and plan in a
formal written format. In a well-constructed record, each problem in the
Assessment is listed in order of priority with an explanation of supporting
ERRNVPHGLFRVRUJ
Chapter 1 | Foundations for Clinical Proficiency
17
ndings and a differential diagnosis, followed by a Plan for addressing that
problem.
Compose the clinical record as soon after seeing the patient as possible,
before your ndings fade from memory, and follow the tips below for a
quality patient record.
T ip s f o r E n s u r in g Q u a lit y P a t ie n t D a t a
●
●
●
●
●
●
●
Ask o en-ended questions nd listen c refully to the tient’s story.
Cr ft thorough nd syste tic sequence to history t king nd hysic l
ex in tion.
Kee n o en ind tow rd both the tient nd the clinic l d t .
Alw ys include “the worst-c se scen rio” in your list of ossible ex l n tions
of the tient’s roble , nd
ke sure it c n be s fely eli in ted.
An lyze ny ist kes in d t collection or inter ret tion.
Confer with colle gues nd review the ertinent clinic l liter ture to cl rify
uncert inties.
A ly the rinci les of ev lu ting clinic l evidence to tient infor tion
nd testing.
Study the case of Mrs. N. and scrutinize the history, physical examination,
assessment, and plan. Note the standard format of the clinical record.
Th e C a s e o f M r s . N .
HEALTH HISTORY
8/25/ 16 11: am
Mrs. N. is le s nt, 54-ye r-old widowed s leswo
New Mexico.
Referral. None
Source and Reliability. Self-referred; see s reli ble.
n residing in Es
nol ,
Chief Complaint
“My he d ches.”
Present Illness
Mrs. N. re orts incre sing roble s with front l he d ches over the st 3 onths.
These re usu lly bifront l, throbbing, nd ild to oder tely severe. She h s
issed work on sever l occ sions bec use of ssoci ted n use nd vo iting.
He d ches now ver ge once week, usu lly rel ted to stress, nd l st 4 to
6 hours. They re relieved by slee nd utting d
towel over her forehe d.
There is little relief fro
s irin. There re no ssoci ted visu l ch nges, otorsensory deficits, or resthesi s.
She h d he d ches with n use nd vo iting beginning t ge 15 ye rs. These
recurred throughout her id-2 s, then decre sed to one every 2 or 3 onths
nd l ost dis
e red.
(continued )
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Ba te s ’ Poc ke t Guide to Phys ic a l Exa mina tion a nd His tory Ta king
Th e C a s e o f M r s . N .
(Continued)
The tient re orts incre sed ressure t work fro
de nding su ervisor;
she is lso worried bout her d ughter (see Personal and Social History). She
thinks her he d ches
y be like those in the st, but w nts to be sure
bec use her other h d he d che just before she died of stroke. She is
concerned bec use her he d ches interfere with her work nd
ke her
irrit ble with her f ily. She e ts three e ls d y nd drinks three cu s of
coffee d y nd te t night.
Medications. Acet ino hen, 1 to 2 t blets every 4 to 6 hours s needed. “W ter
ill” in the st for nkle swelling, none recently.
Allergies. A icillin c uses r sh.
Tobacco. About 1 ck of cig rettes er d y since ge 18 (36 ck-ye rs).
Alcohol/drugs. Wine on r re occ sions. No illicit drugs.
Past History
Childhood Illnesses: Me sles, chicken ox. No sc rlet fever or rheu t ic
fever.
Adult Illnesses: Medical: Pyelone hritis, 1998, with fever nd right fl nk in;
tre ted with
icillin; develo ed gener lized r sh with itching sever l d ys
l ter. Re orts x-r ys were nor l; no recurrence of infection. Surgical: Tonsillecto y, ge 6;
endecto y, ge 13. Sutures for l cer tion, 2 1, fter ste ing
on gl ss. Ob/ Gyn: 3–3– –3, with nor l v gin l deliveries. Three living children.
Men rche ge 12. L st enses 6 onths go. Little interest in sex, nd not sexully ctive. No concerns bout HIV infection. Psychiatric: None.
Health Maintenance: Immunizations: Or l olio v ccine, ye r uncert in; tet nus
shots × 2, 1982, followed with booster 1 ye r l ter; flu v ccine, 2
, no re ction.
Screening tests: L st P s e r, 2 14, nor l. No
ogr s to d te.
Family History
The f ily history is de icted below.
Tra in a ccide nt
S troke , va ricos e
67 ve ins , he a da che s
43
High
blood
pre s s ure 67
Infa ncy
58
Migra ine
he a da che s
Indica te s pa tie nt
54
He a rt
a tta ck
He a da che s
33
31
De ce a s e d ma le
De ce a s e d fe ma le
27
Living ma le
Living fe ma le
(continued )
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Chapter 1 | Foundations for Clinical Proficiency
Th e C a s e o f M r s . N .
19
(Continued)
OR, ltern tively: F ther died t ge 43 ye rs in tr in ccident. Mother died t
ge 67 ye rs fro stroke; h d v ricose veins, he d ches.
One brother, ge 61 ye rs, with hy ertension, otherwise well; one brother,
ge 58 ye rs, well exce t for ild rthritis; one sister, died in inf ncy of
unknown c use.
Husb nd died t ge 54 of he rt tt ck
D ughter, ge 33 ye rs, with igr ine he d ches, otherwise well; son, ge
31 ye rs, with he d ches; son, ge 27 ye rs, well.
No f ily history of di betes, tuberculosis, he rt or kidney dise se, c ncer,
ne i , e ile sy, or ent l illness.
Personal and Social History
Born nd r ised in L s Cruces, finished high school, rried t ge 19 ye rs.
Worked s s les clerk for 2 ye rs, then oved with husb nd to Es nol , h d
three children. Returned to work 15 ye rs go to i rove f ily fin nces. Children ll rried. Four ye rs go Mr. N. died suddenly of he rt tt ck, le ving
little s vings. Mrs. N. h s oved to s ll
rt ent to be ne r d ughter,
Is bel. Is bel’s husb nd, John, is de loyed overse s. Mrs. N.’s
rt ent is now
h ven for Is bel nd her two children, Kevin, ge 6 ye rs, nd Luci , ge 3 ye rs.
Mrs. N. feels res onsible for hel ing the ; she feels tense nd nervous but
denies de ression. She h s friends but r rely discusses f ily roble s: “I’d
r ther kee the to yself. I don’t like gossi .” No church or other org niz tion l su ort. She is ty ic lly u t 7: am, works 9: am to 5:3 pm, nd e ts
dinner lone.
Exercise and diet. Gets little exercise. Diet high in c rbohydr tes.
Safety measures. Uses se t belt regul rly. Uses sunblock. Medic t ions ke t
in n unlocked edicine c binet . Cle ning solut ions in unlocked c binet
below sink. Mr. N’s shotgun nd box of shells in unlocked closet u st irs.
Review of Systems
General: H s g ined 1 lb in the st 4 ye rs.
Skin: No r shes or other ch nges.
Head, Eyes, Ears, Nose, Throat (HEENT): See Present Illness. Head: No history
of he d injury. Eyes: Re ding gl sses for 5 ye rs, l st checked 1 ye r go. No
sy to s. Ears: He ring good. No tinnitus, vertigo, infections. Nose, sinuses:
Occ sion l ild cold. No h y fever, sinus trouble. Throat (or mouth and pharynx): So e bleeding of gu s recently. L st dent l visit 2 ye rs go. Occ sion l
c nker sore.
Neck: No lu s, goiter, in. No swollen gl nds.
Breasts: No lu s, in, disch rge. Does bre st self-ex in tion s or dic lly.
Respiratory: No cough, wheezing, shortness of bre th. L st chest x-r y, 1986,
St. M ry’s Hos it l; unre rk ble.
Cardiovascular: No known he rt dise se or high blood ressure; l st blood
ressure t ken in 2 7. No dys ne , ortho ne , chest in, l it tions. H s
never h d n electroc rdiogr
(ECG).
(continued )
ERRNVPHGLFRVRUJ
20
Ba te s ’ Poc ke t Guide to Phys ic a l Exa mina tion a nd His tory Ta king
Th e C a s e o f M r s . N .
(Continued)
Gastrointestinal: A etite good; no n use , vo iting, indigestion. Bowel oveent bout once d ily, though so eti es h s h rd stools for 2 to 3 d ys when
es eci lly tense; no di rrhe or bleeding. No in, j undice, g llbl dder or liver
roble s.
Urinary: No frequency, dysuri , he turi , or recent fl nk in; nocturi × 1,
l rge volu e. Occ sion lly loses urine when coughing.
Genital: No v gin l or elvic infections. No dys reuni .
Peripheral vascular: V ricose veins
e red in both legs during first regn ncy.
For 1 ye rs, h s h d swollen nkles fter rolonged st nding; we rs light el stic su ort hose; tried “w ter ill” 5 onths go, but it didn’t hel
uch; no
history of hlebitis or leg in.
Musculoskelet al: Mild low b ck ches, oft en t t he end of the workd y; no
r di tion int o the legs; used to do b ck exercises but not now. No ot her joint
in.
Psychiatric: No history of de ression or tre t ent for sychi tric disorders.
(See lso Present Illness nd Personal and Social History.)
Neurologic: No f inting, seizures, otor or sensory loss. Me ory good.
Hematologic: Exce t for bleeding gu s, no e sy bleeding. No ne i .
Endocrine: No known thyroid disorders or he t or cold intoler nce. No sy to s
or history of di betes.
PHYSICAL EXAMINATION
Mrs. N. is short , overweight , iddle- ged wo n, who is ni t ed nd
res onds quickly t o quest ions. She is so ewh t t ense, wit h oist , cold
h nds. Her h ir is well groo ed. Her color is good, nd she lies fl t without
disco fort .
Vital signs: Ht (without shoes) 157 c (5′2″). Wt (dressed) 65 kg (143 lb). BMI 26.
BP 164/98 right r , su ine; 16 /96 left r , su ine; 152/ 88 right r , su ine
with wide cuff. He rt r te (HR) 88 nd regul r. Res ir tory r te (RR) 18. Te er ture (or l) 98.6°F.
Skin: P l s cold nd oist, but color good. Sc ttered cherry ngio s over
u er trunk. N ils without clubbing, cy nosis.
Head, Eyes, Ears, Nose, Throat (HEENT): Head: H ir of ver ge texture. Sc l
without lesions, nor oce h lic/ tr u tic (NC/AT). Eyes: Vision 2 /3 in e ch
eye. Visu l fields full by confront tion. Conjunctiv ink; scler white. Pu ils
4
constricting to 2
, round, regul r, equ lly re ctive to light. Extr ocul r
ove ents int ct. Disc rgins sh r , without he orrh ges, exud tes. No
rteriol r n rrowing or A-V nicking. Ears: W x rti lly obscures right ty
nic
e br ne (TM); left c n l cle r, TM with good cone of light. Acuity good to
whis ered voice. Weber idline. AC > BC. Nose: Mucos ink, se tu
idline.
No sinus tenderness. Mouth: Or l ucos ink. Sever l interdent l
ill e red,
slightly swollen. Dentition good. Tongue idline, with 3 × 4
sh llow white
ulcer on red b se on undersurf ce ne r ti ; tender but not indur ted. Tonsils
bsent. Ph rynx without exud tes.
(continued )
ERRNVPHGLFRVRUJ
Chapter 1 | Foundations for Clinical Proficiency
Th e C a s e o f M r s . N .
21
(Continued)
Neck: Neck su le. Tr che
idline. Thyroid isth us b rely l ble, lobes
not felt.
Lymph nodes: S ll (<1 c ), soft, nontender, nd obile tonsill r nd osterior
cervic l nodes bil ter lly. No xill ry or e itrochle r nodes. Sever l s ll
inguin l nodes bil ter lly, soft nd nontender.
Thorax and lungs: Thor x sy
etric with good excursion. Lungs reson nt.
Bre th sounds vesicul r with no dded sounds. Di hr g s descend 4 c
bil ter lly.
Cardiovascular: Jugul r venous ressure 1 c
bove the stern l ngle, with
he d of ex ining t ble r ised to 3 º. C rotid u strokes brisk, without bruits.
A ic l i ulse discrete nd t
ing, b rely l ble in the 5th left inters ce,
8 c l ter l to the idstern l line. Good S1, S2; no S3 or S4 . A II/ VI ediu itched idsystolic ur ur t the lower left stern l border. No di stolic
ur urs.
Breasts: Pendulous, sy
etric. No
sses; ni les without disch rge.
Abdomen: Protuber nt. Well-he led sc r, right lower qu dr nt. Bowel sounds
ctive. No tenderness or
sses. Liver s n 7 c in right idcl vicul r line;
edge s ooth, l ble 1 c below right cost l rgin (RCM). S leen nd
kidneys not felt. No costovertebr l ngle tenderness (CVAT).
Genitalia: Extern l genit li without lesions. Mild cystocele t introitus on
str ining. V gin l ucos ink. Cervix ink, rous, nd without disch rge.
Uterus nterior, idline, s ooth, not enl rged. Adnex not l ted due to
obesity nd oor rel x tion. No cervic l or dnex l tenderness. P s e r
t ken. Rectov gin l w ll int ct.
Rectal: Rect l v ult without
sses. Stool brown, neg tive for fec l blood.
Extremities: W r
nd without ede . C lves su le, nontender.
Peripheral vascular: Tr ce ede
t both nkles. Moder te v ricosities of s henous veins both in lower extre ities. No st sis ig ent tion or ulcers. Pulses
(2+ = brisk, or nor l):
Ra d ia l
Fe m o r a l
P o p lit e a l
D o r s a lis P e d is
P o s t e r io r Tib ia l
RT
2+
2+
2+
2+
2+
LT
2+
2+
2+
Absent
2+
Musculoskeletal: No joint defor ities. Good r nge of otion in h nds, wrists,
elbows, shoulders, s ine, hi s, knees, nkles.
Neurologic: Mental Status: Tense, but lert nd coo er tive. Thought coherent.
Oriented to erson, l ce, nd ti e. Cranial nerves: II to XII int ct.
Motor: Good uscle bulk nd tone. Strength 5/5 throughout. Cerebellar: R id
ltern ting ove ents (RAMs), oint-to- oint ove ents int ct. G it st ble,
fluid. Sensory: Pin rick, light touch, osition sense, vibr tion, nd stereognosis
int ct. Ro berg neg tive.
(continued )
ERRNVPHGLFRVRUJ
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Ba te s ’ Poc ke t Guide to Phys ic a l Exa mina tion a nd His tory Ta king
Th e C a s e o f M r s . N .
(Continued)
Reflexes:
Bic e p s Tr ic e p s
Bra c h io ra d ia lis P a t e lla r Ac h ille s P la n t a r
RT
2+
2+
2+
2+
1+
↓
LT
2+
2+
2+
2+/2+
1+
↓
++
++
++
++
+ + +_+ +_+ + +
++ ++
OR
++
++
+
+
ASSESSMENT AND PLAN
1. Migraine headaches. A 54-ye r-old wo n with igr ine he d ches since
childhood, with throbbing v scul r ttern nd frequent n use nd vo iting. He d ches re ssoci ted with stress nd relieved by slee nd cold
co resses. There is no
illede , nd there re no otor or sensory
deficits on the neurologic ex in tion. The differenti l di gnosis includes
tension he d che, lso ssoci ted with stress, but there is no relief with
ss ge, nd the in is ore throbbing th n ching. There re no fever,
stiff neck, or foc l findings to suggest eningitis, nd the lifelong recurrent
ttern
kes sub r chnoid he orrh ge unlikely (usu lly described s “the
worst he d che of y life”).
Pl n:
● Discuss fe tures of
igr ine versus tension he d ches.
● Discuss biofeedb ck nd stress
n ge ent.
● Advise
tient to void c ffeine, including coffee, col s, nd other
c rbon ted bever ges.
● St rt nonsteroid l nti-infl
tory drugs (NSAIDs) for he d che, s
needed.
● If needed next visit, begin ro hyl ctic
edic tion if he d ches re
occurring ore th n 2 d ys week or 8 d ys
onth.
2. Elevat ed blood pressure. Systolic hy ertension is resent . M y be rel ted
to nxiety fro first visit. No evidence of end-org n d
ge to retin or
he rt .
Pl n:
● Discuss st nd rds for ssessing blood ressure; check BP in 1 onth.
● Recheck systolic
ur ur.
● Check b sic
et bolic nel; review urin lysis.
● Discuss weight reduction nd exercise rogr
s (see #4).
● Reduce s lt int ke.
3. Cystocele with occasional stress incontinence. Cystocele on elvic ex in tion, rob bly rel ted to bl dder rel x tion. P tient is eri eno us l.
Incontinence re orted with coughing, suggesting lter tion in bl dder neck
n to y. No dysuri , fever, fl nk in. Not t king ny contributing edic tions. Usu lly involves s ll ounts of urine, no dribbling, so doubt urge
or overflow incontinence.
(continued )
ERRNVPHGLFRVRUJ
Chapter 1 | Foundations for Clinical Proficiency
Th e C a s e o f M r s . N .
4.
5.
6.
7.
8.
9.
10.
11.
23
(Continued )
Pl n:
● Ex l in c use of stress incontinence.
● Review urin lysis.
● Reco
end Kegel exercises.
● Consider to ic l estrogen cre
to v gin during next visit if no i rove ent.
Overweight . P tient 5′2″, weighs 143 lbs. BMI is 26.
Pl n:
● Ex lore diet history, sk
tient to kee food int ke di ry.
● Ex lore
otiv tion to lose weight, set t rget for weight loss by next visit.
● Schedule visit with dietiti n.
● Discuss exercise rogr
, s ecific lly, w lking 3 inutes ost d ys week.
Family stress. Son-in-l w de loyed, r rely t ho e; d ughter nd gr ndchildren often t tient’s ho e, le ding to tensions in these rel tionshi s.
P tient lso h s fin nci l constr ints. Stress currently situ tion l. No
current evidence of jor de ression.
Pl n:
● Ex lore
tient’s views on str tegies to co e with stress.
● Ex lore sources of su
ort, including Al-Anon for d ughter nd fin nci l
counseling for tient.
● Continue to
onitor for de ression.
Occasional musculoskelet al low back pain. Usu lly with rolonged st nding. No history of tr u
or otor vehicle ccident. P in does not r di te;
no tenderness or otor-sensory deficits on ex in tion. Doubt disc or
nerve root co ression, troch nteric bursitis, s croiliitis.
Pl n:
● Review benefits of weight loss nd exercises to strengthen low b ck
uscles.
Tobacco abuse. 1 ck er d y for 36 ye rs.
Pl n:
● Check e k flow or FEV1/ FVC on office s iro etry.
● Give strong w rning to sto s oking.
● Offer referr l to tob cco cess tion rogr
.
● Offer
tch, current tre t ent to enh nce bstinence.
Varicose veins, lower extremities. No co l ints currently.
History of right pyelonephritis, 1998.
Ampicillin allergy. Develo ed r sh but no other llergic re ction.
Health maintenance. L st P s e r 2 14; h s never h d
ogr .
Pl n:
● Schedule
ogr .
● P
s e r sent tod y.
● Provide three c rds to test for fec l blood; next visit, discuss screening
colonosco y.
● Suggest dent l c re for
ild gingivitis.
● Advise
tient to ove edic tions nd c ustic cle ning gents to
locked c binet bove shoulder height . Urge tient to ove gun nd
c rtridges to locked gun c binet.
ERRNVPHGLFRVRUJ
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Ba te s ’ Poc ke t Guide to Phys ic a l Exa mina tion a nd His tory Ta king
T h e Im p o r t a n c e o f t h e P r o b le m Lis t
After you complete the clinical record, it is good clinical practice to generate a Problem List that summarizes the patient’s problems that can be placed
in the front of the of ce or hospital chart. List the most active and serious
problems rst, and record their date of onset. Some clinicians make separate
lists for active or inactive problems; others make one list in order of priority. A sample Problem List for Mrs. N. is provided below.
P r o b le m Lis t : T h e C a s e o f M r s . N .
Da t e En t e r e d
8/25/ 16
P ro b le m No .
1
2
3
4
5
6
7
8
9
1
11
P ro b le m
Migr ine he d ches
Elev ted blood ressure
Cystocele wit h occ sion l st ress
incontinence
Overweight
F ily stress
Low b ck in
Tob cco buse since ge 18 ye rs
V ricose veins
History of right yelone hritis 1998
Allergy to
icillin
He lth
inten nce
Recording Your Findings
A clear, well-organized clinical record is one of the most important
adjuncts to patient care. Think especially about the order and readability of
the record and the amount of detail needed. Use the following checklist to
make sure your record is informative and easy to follow.
C h e c k lis t t o E n s u r e a Q u a lit y C lin ic a l R e c o r d
Is the Order Clear?
Order is i er tive. M ke sure th t re ders c n e sily find s ecific oints of
infor tion. Kee the subjective ite s of the history, for ex
le, in the history;
do not let the str y into the hysic l ex in tion. Did you:
●
●
●
M ke the he dings cle r?
Accent your org niz tion with indent tions nd s cing?
Arr nge the Present Illness in chronologic order, st rting with the current
e isode, then filling in relev nt b ckground infor tion?
(continued )
ERRNVPHGLFRVRUJ
Chapter 1 | Foundations for Clinical Proficiency
C h e c k lis t t o E n s u r e a Q u a lit y C lin ic a l R e c o r d
25
(Continued)
Do the Data Included Contribute Directly to the Assessment?
S ell out the su orting evidence, both ositive nd neg tive, for e ch roble
or di gnosis. M ke sure there is sufficient det il to su ort your differenti l
di gnosis nd l n.
Are Pertinent Negatives Speci cally Described?
Often ortions of the history or ex in tion suggest th t n bnor lity ight
exist or develo in th t re . For ex
le, for the tient with not ble bruises,
record the “ ertinent neg tives,” such s the bsence of injury or violence,
f ili l bleeding disorders, or edic tions or nutrition l deficits th t ight
le d to bruising. For the tient who is de ressed but not suicid l, recording
both f cts is i ort nt. In the tient with tr nsient ood swing, on the other
h nd, co
ent on suicide is unnecess ry.
Are There Overgeneralizations or Omissions of Important Data?
Remember that data not recorded are data lost. No tter how vividly you c n rec ll
clinic l det ils tod y, you will rob bly not re e ber the in few onths. The
hr se “neurologic ex neg tive,” even in your own h ndwriting, y le ve you
wondering in few onths’ ti e, “Did I re lly check the reflexes?”
Is There Too Much Detail?
Is there excess infor tion or redund ncy? Is i ort nt infor t ion buried
in
ss of det il, to be discovered by only t he ost ersistent re der?
M ke your descri tions concise. “Cervix ink nd s oot h” indic tes you s w
no redness, ulcers, nodules,
sses, cyst s, or ot her sus icious lesions, but
t his descri t ion is short er nd ore e sily re d. You c n o it uni ort nt
struct ures even though you ex ined t he , such s nor l eyebrows nd
eyel shes.
Omit most of your negative findings unless they rel te directly to the
tient’s co l ints or s ecific exclusions in your differenti l di gnosis. Instead,
concentrate on major negative findings such s “no he rt ur urs.”
Is the Written Style Succinct? Are Phrases, Short Words, and Abbreviations
Used Appropriately? Is Data Unnecessarily Repeated?
O it re etitive introductory hr ses such s “The tient re orts no . . .”
bec use re ders ssu e the tient is the source of the history unless otherwise s ecified.
●
●
Using words or brief hr ses inste d of whole sentences is co
on, but
bbrevi tions nd sy bols should be used only if they re re dily understood.
Use shorter words when ossible such s “felt” for “ l ted” or “he rd” for
“ uscult ted.” O it unnecess ry words, such s those in rentheses in the
ex
les below. For ex
le, “Cervix is ink (in color).” “Lungs re reson nt
(to ercussion).”
Describe wh t you observed, not wh t you did. “O tic discs seen” is less
infor tive th n “disc rgins sh r .”
(continued )
ERRNVPHGLFRVRUJ
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Ba te s ’ Poc ke t Guide to Phys ic a l Exa mina tion a nd His tory Ta king
C h e c k lis t t o E n s u r e a Q u a lit y C lin ic a l R e c o r d
(Continued)
Are Diagrams and Precise Measurements Included Where Appropriate?
Di gr s dd gre tly to the cl rity of the record.
To ensure ccur te ev lu tions nd future co
in centi eters, not in fruits, nuts, or veget bles.
●
●
risons,
ke
e sure ents
“1 × 1 c ly h node” versus “ e -sized ly h node . . .”
Or “2 × 2 c
ss on the left lobe of the rost te” versus “w lnut-sized
rost te
ss.”
Is the Tone of the Write-up Neutral and Professional?
It is i ort nt to be objective. Hostile or dis
roving co
ents h ve no l ce
in the tient’s record. Never use infl
tory or de e ning words or unctu tion.
Co
ents such s “P tient DRUNK nd LATE TO CLINIC AGAIN!!” re
un rofession l nd set b d ex
le for other clinici ns re ding the ch rt.
They lso ight rove difficult to defend in leg l setting.
ERRNVPHGLFRVRUJ
2
C H A P T E R
Evaluating Clinical
Evidence
Excellence in clinical care requires integrating clinical expertise, patient
preferences, and the best available clinical evidence. Carefully study the
clear descriptions of how the history and physical examination can be
viewed as diagnostic tests; how to assess the accuracy of laboratory tests,
radiographic imaging, and diagnostic procedures; and how to evaluate
clinical research studies and disease prevention guidelines.
Throughout the regional examination chapters, you will nd evidencebased recommendations for health promotion interventions, especially
screening and prevention. These recommendations are also based on
evidence from the clinical literature that can be evaluated according to
criteria presented in this chapter.
The History and Physical
Examination as Diagnostic Tests
The process of diagnostic reasoning begins with the history. As you learn
about your patient, you will start to develop a differential diagnosis. You will
assign probabilities to the various diagnoses that correspond to how likely
you consider them to be explanations for your patient’s problem. As you
approach clinical problems, your goal is to determine whether you need to
perform additional testing (Fig. 2-1).
Pro bability o f Diag no s is
0%
Te s t
Thre s hold
P roba bility be low
te s t thre s hold; no
te s ting wa rra nte d
Tre a tme nt
Thre s hold 100%
P roba bility be twe e n
te s t a nd tre a tme nt thre s hold;
furthe r te s ting re quire d
P roba bility a bove
tre a tme nt thre s hold;
te s ting comple te d;
tre a tme nt comme nce s
Fig ure 2-1 Probability revis ions . (Adapte d w ith pe rm is s ion from Guyatt G, Re nnie
D, Me ade M, e t al. Us e rs’ Guide s to the Me dical Lite rature . 2nd e d. New York, NY:
McGraw-Hill Com pany; 2008; Chapte r 14, Figure 14–2.)
ERRNVPHGLFRVRUJ
27
28
Ba te s ’ Poc ke t Guide to Phys ic a l Exa mina tion a nd His tory Ta king
If your probability for a disease based on your history and examination is
very high (i.e., exceeds the treatment threshold), then you can move ahead
and initiate treatment. Conversely, if your probability for a disease is very
low (i.e., below the test threshold), then you do not need further testing.
The area between the test and treatment thresholds represents clinical
uncertainty, and you need further testing to revise probabilities and guide
your clinical management.
Evaluating Diagnostic Tests
Two concepts in evaluating diagnostic tests are the validity of the ndings
and the reproducibility of the test results.
V a lid it y
Does the test provide valid results and accurately identify whether
the patient has a disease? This involves comparing the test against
a gold standard—the best measure of whether a patient has disease.
This could be a biopsy, a structured psychiatric examination, or a
colonoscopy.
The 2 × 2 table is the basic format for evaluating the performance characteristics of a diagnostic test, which means how much the test results
revise probabilities for disease.
There are two columns—patients with disease present and patients with
disease absent. These categorizations are based on the gold standard test.
The two rows correspond to positive and negative test results. The four cells
(a, b, c, d) correspond to true positives, false positives, false negatives, and
true negatives, respectively.
S e t t in g u p t h e 2 ë 2 T a b le
G o ld S t a n d a r d :
Dis e a s e P r e s e n t
G o ld S t a n d a r d :
D is e a s e A b s e n t
True ositive
b
F lse ositive
c
F lse neg tive
d
True neg tive
Te s t p o s it ive
Te s t n e g a t ive
S e n s it ivit y a n d S p e c i c it y. The rst test statistics to estimate are
sensitivity and speci city.
ERRNVPHGLFRVRUJ
Chapter 2 | Evaluating Clinical Evidence
29
S e n s it iv it y a n d S p e c if ic it y
●
●
●
Sensitivity is the rob bility th t
erson with dise se h s ositive test.
This is re resented s / ( + c) in the dise se resent colu n of the 2 × 2
t ble. Sensitivity is lso known s the true ositive r te.
Specificity is the rob bility th t nondise sed erson h s neg tive test,
re resented s d/ (b + d) in the dise se bsent colu n of the 2 × 2 t ble. S ecificity is lso known s the true neg tive r te.
Examples. An ex
le of these st tistics would be the rob bility th t s lenoeg ly (see Ch ter 11, . 21 ) is ssoci ted with ercussion dullness below
the left cost l rgin (sensitivity). Conversely, the rob bility th t
tient
without s leno eg ly will h ve ercussion dullness is the f lse- ositive r te
(1 − s ecificity) for this hysic l neuver.
A negative result from a test with a high sensitivity (i.e., a very low falsenegative rate) usually excludes disease. This is represented by the acronym
SnNOUT—a Sensitive test with a Negative result rules OUT disease. Conversely, a positive result in a test with high speci city (e.g., a very low falsepositive rate) usually indicates disease. This is represented by the acronym
SpPIN—a Speci c test with a Positive result rules IN disease.
P o s it ive a n d Ne g a t ive P re d ic t ive Va lu e s . To determine the probability that a patient actually has disease based on a test result that is either
positive or negative, calculate positive and negative predictive values.
P o s it iv e a n d N e g a t iv e P r e d ic t iv e V a lu e s
●
●
The positive predictive value (PPV) is the rob bility th t
erson with
ositive test h s dise se, re resented s / ( + b) fro the test ositive row
in the 2 × 2 t ble.
An ex
le of this st tistic is found in rost te c ncer screening (see
Ch ter 15, . 266), where
n with PSA v lue gre ter th n 4. ng/ L
h s only 3 % rob bility of h ving rost te c ncer found on bio sy.
The negative predictive value (NPV) is the rob bility th t
erson with
neg tive test does not h ve dise se, re resented s d/ (c + d) in the test
neg tive row in 2 × 2 t ble.
An ex
le is: A ong en with PSA level of 4. ng/ L or below, 85% re
found to be c ncer-free on bio sy.
P re va le n c e o f Dis e a s e . Predictive value statistics vary substantially
according to the prevalence of disease (i.e., the proportion of patients in
the disease present column), which is based on the characteristics of the
patient population and the clinical setting. The box below shows a 2 × 2
table where both the sensitivity and speci city of the diagnostic test are
90% and the prevalence is 10%. The positive predictive value calculated
ERRNVPHGLFRVRUJ
30
Ba te s ’ Poc ke t Guide to Phys ic a l Exa mina tion a nd His tory Ta king
from the test positive row of the table would be 90/180 = 50%. This means
that half of the people with a positive test have disease.
P r e d ic t iv e V a lu e s : P r e v a le n c e o f 1 0 % w it h
S e n s it iv it y a n d S p e c if ic it y = 9 0 %
D is e a s e P r e s e n t
D is e a s e A b s e n t
b
Te s t p o s it ive
Te s t n e g a t ive
To t a l
To t a l
9
9
18
c
1
d
81
82
1
9
1,
Sensitivity = a/(a + c) = 90/100 or 90%; speci city = d/(b + d) = 810/900 = 90%
Positive predictive value = a/(a + b) = 90/180 = 50%
However, if the sensitivity and speci city remained the same, but prevalence
was only 1%, then the cells would look very different.
P r e d ic t iv e V a lu e s : P r e v a le n c e o f 1 % w it h S e n s it iv it y
a n d S p e c if ic it y = 9 0 %
Dis e a s e P r e s e n t
D is e a s e A b s e n t
To t a l
9
b
99
1 8
c
1
d
891
892
1
99
Te s t p o s it ive
Te s t n e g a t ive
To t a l
1,
Sensitivity = a/(a + c) = 9/10 or 90%; speci city = d/(b + d) = 891/990 = 90%
Positive predictive value = a/(a + b) = 9/108 = 8.3%
Lik e lih o o d Ra t io s . To evaluate the performance of a diagnostic test
that can account for the varying disease prevalence observed in different
patient populations, you can use likelihood ratio statistics, de ned as the
probability of obtaining a given test result in a diseased patient divided by
the probability of obtaining a given test result in a nondiseased patient.
The likelihood ratio tells us how much a test result changes the pre-test
disease probability (prevalence) to the post-test disease probability.
The likelihood ratio for a positive test is the ratio of getting a positive test result in
a diseased person divided by the probability of getting a positive test result in
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Chapter 2 | Evaluating Clinical Evidence
31
a nondiseased person. The 2 × 2 table shows that this is the same as saying the
ratio of the true positive rate (sensitivity) over the false-positive rate (1 − specicity). A higher value (much >1) indicates that a positive test is much more
likely to be coming from a diseased person than from a nondiseased person,
increasing our con dence that a person with a positive result has disease.
The likelihood ratio for a negative test is the ratio of the probability of getting
a negative test result in a diseased person divided by the probability of
getting a negative test result in a nondiseased person. The 2 × 2 table
shows that this is the same as saying the ratio of the false-negative rate
(1 − sensitivity) divided by the true negative rate (speci city). A lower
value (much <1) indicates that the negative test is much more likely to be
coming from a nondiseased person than from a diseased person, increasing
our con dence that a person with a negative result does not have disease.
In t e r p r e t in g Lik e lih o o d R a t io s
Lik e lih o o d Ra t io s a
Eff e c t o n P r e - t o P o s t -t e s t P ro b a b ilit y
LRs > 1
LRs 5–1
LRs 2–5
LRs 1–2
Gener te l rge ch nges
Gener te oder te ch nges
Gener te s ll (so eti es i ort nt) ch nges
Alter the rob bility to s ll degree (r rely
i ort nt)
or < .1
or .1– .2
nd .5– .2
nd .5–1
Likelihood ratios >1 re ssoci ted with ositive results nd n incre sed rob bility for
dise se. Likelihood ratios <1 re ssoci ted with neg tive results nd decre sed rob bility of dise se. A test with likelihood ratio of 1 rovides no ddition l infor tion bout
the rob bility of dise se.
a
Ba ye s Th e o re m . One way to use likelihood ratios to revise probabilities
for disease is with the Bayes theorem. This theorem requires converting the
estimated prevalence (pre-test probability) to odds using the equation:
Pre-test odds = pre-test probability/(1 − pre-test probability)
The pre-test odds are multiplied by the likelihood ratio to estimate the
post-test odds using the following equation:
Post-test odds = Pre-test odds × likelihood ratio
The post-test odds are then converted to a probability using the equation:
Post-test probability = post-test odds/(1 + post-test odds)
Fa g a n No m o g ra m . If you are more comfortable thinking in terms of
probability of having disease, then the Fagan nomogram may be an easier
way for you to use likelihood ratios (Fig. 2-2). With this nomogram, you
read the pre-test probabilities from the line on the left, then take a straight
edge and draw a line from the pre-test probability through the likelihood
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Ba te s ’ Poc ke t Guide to Phys ic a l Exa mina tion a nd His tory Ta king
0.1
99
0.2
98
0.5
95
1
2000
1000
90
500
2
5
10
20
200
100
80
50
5
20
10
70
5
40
60
50
2
30
1
30
0.5
40
60
0.2
0.1
0.05
70
0.02
0
80
0.01
.0
0.005
00
50
90
95
20
10
5
2
0.002
02
0.001
0.0005
5
1
0.5
98
0.2
99
0.1
Pre -te s t
Pro bability (%)
Like liho o d
Ratio
Po s t-te s t
Pro bability (%)
Fig ure 2-2 Fagan nom ogram . (Adapte d w ith pe rm is s ion from Fagan TJ. Le tte r:
nom ogram for Baye s the ore m . N Engl J Me d. 1975;293:257.)
ratio in the middle line, and then read the post-test probability on the line
on the right.
Figure 2.2 shows how the Fagan nomogram displays probability revisions.
In this example, the diagnostic test has a sensitivity of 90% and speci city of 91%. With a pre-test probability (prevalence) of 1%, a positive test
result (blue line) leads to a post-test probability of 9%. A negative test
result (red line) leads to a post-test probability of 0.1%.
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Chapter 2 | Evaluating Clinical Evidence
33
R e p r o d u c ib ilit y
Ka p p a S c o re . Two clinicians examining a patient may not always agree
upon the presence of a given nding. Understanding whether there is
agreement well beyond chance is important in knowing whether the nding is useful enough to support clinical decision making. The kappa score
measures the amount of agreement that occurs beyond chance. The box
shows how to interpret Kappa values.
In t e r p r e t in g K a p p a V a lu e s
Va lu e o f Ka p p a
S t r e n g t h o f Ag r e e m e n t
< .2
.21– .4
.41– .6
.61– .8
.81–1.
Poor
F ir
Moder te
Good
Excellent
For example, although clinicians agree 75% of the time that a patient has
an abnormal physical nding, the expected agreement based on chance is
50%. This means that the potential agreement beyond chance is 50% and
the actual observer agreement beyond chance is 25%. The kappa level is
then 25%/50% = 0.5, which indicates moderate agreement.
P re c is io n . In the context of reproducibility, precision refers to being able
to apply the same test to the same unchanged person and obtain the same
results. Precision is often used when referring to laboratory tests. A statistical test used to characterize precision is the coef cient of variation, de ned
as the standard deviation divided by the mean value. Lower values indicate
greater precision.
Health Promotion
Throughout the book you will nd health promotion sections that make
recommendations for primary prevention (interventions designed to prevent
disease) as well as secondary prevention (screening tests designed to nd
disease or disease processes at an early, asymptomatic stage). The rationale
for secondary prevention is that treatment for early-stage disease is often
more effective than treatment for later-stage disease. We highlight guidelines from professional organizations that are evidence-based, such as those
of the U.S. Preventive Services Task Force (USPSTF) that consider the
quality of the evidence and the strength of the recommendation to either
provide or withhold the intervention. The strongest health promotion recommendations are based on results from randomized controlled trials (or
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Ba te s ’ Poc ke t Guide to Phys ic a l Exa mina tion a nd His tory Ta king
S ys te ma tic
Re vie ws
Ra ndomize d
Control Tria ls
Cohort S tudie s
Ca s e -Control S tudie s
Ca s e S e rie s , Ca s e Re ports
Editoria ls , Expe rt Opinion
Figure 2-3 Evidence pyramid. (Adapted with permission from Sackett DL, Straus
SE, Richardson WS, et al. Evidence-Based Medicine: How to Practice and Teach EBM.
2nd ed. Edinburgh: Churchill Livingstone; 2000.)
syntheses of multiple such trials) of therapy or prevention. When searching for evidence-based information, you should select the highest level of
available evidence (Fig. 2-3).
Critical Appraisal
Learn the process of critically appraising the clinical literature in order
to interpret new studies and guidelines as they appear throughout your
professional career. The Evidence-Based Working Group, which consists of
experts in epidemiology, has created a rigorous and standardized approach
for evaluating studies that has been applied to a wide range of clinical
topics, including therapeutic and prevention trials, diagnostic tests, metaanalysis, cost-effectiveness analyses, and practice guidelines. This approach
asks three basic questions:
1. Are the results valid (can you believe them)?
2. What are the results (magnitude and precision)?
3. How can you apply the results to patient care?
U n d e r s t a n d in g B ia s
When evaluating study results, it is important to have a thorough understanding of bias. The key sources of bias in clinical research are selection
bias, performance bias, detection bias, and attrition bias.
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T y p e s o f B ia s e s A f f e c t in g E v id e n c e
S e le c t io n Bia s
●
●
●
Occurs when co
rison grou s h ve syste tic differences in their b seline
ch r cteristics th t c n ffect the outco e of the study
Cre tes roble s in inter reting observed differences in outco es bec use they
could result fro the interventions or the b seline differences between grou s
R ndo ly lloc ting subjects to the intervention is the best
ro ch to
ini izing this bi s
P e r fo r m a n c e Bia s
●
●
●
Occurs when there re syste tic differences in the c re received between
co
rison grou s (other th n the intervention)
Cre tes roble s in inter reting outco e differences
Blinding subjects nd roviders to the intervention is the best
ro ch to
ini izing this bi s
D e t e c t io n Bia s
●
●
Occurs when there re syste tic differences in efforts to di gnose or
scert in n outco e
Blinding outco es ssessors (ensuring th t they re un w re of the intervention received by the subject) is the best
ro ch to ini izing this bi s
A t t r it io n Bia s
●
●
●
Occurs when there re syste tic differences in the co
rison grou s in
the nu ber of subjects who do not co lete the study
F iling to ccount for these differences c n le d to incorrectly esti ting the
effectiveness of n intervention
Using n intention-to-tre t n lysis, where ll n lyses consider ll subjects
who were ssigned to co
rison grou , reg rdless of whether they
received or co leted the intervention, c n ini ize this bi s
R e s u lt s
As s e s s in g P e rfo rm a n c e o f a Tre a t m e n t o r P re ve n t io n In t e rve n t io n . The statistics used to characterize the performance of a treatment
or prevention intervention include relative risks, relative risk differences (can
be a reduction or increase, re ecting bene t or harm), absolute risk differences (can be a reduction or increase, re ecting bene t or harm), numbers
needed to treat, and numbers needed to harm.
2 ë 2 T a b le s f o r E v a lu a t in g S t u d ie s
o f T r e a t m e n t o r P r e v e n t io n
Eve n t O c c u r r e d
Ex eri ent l grou
Control grou
c
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To t a l
b
+b
d
c+d
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Ba te s ’ Poc ke t Guide to Phys ic a l Exa mina tion a nd His tory Ta king
Calculating these performance statistics from the 2 × 2 table begins with
determining probabilities for outcomes.
■ The probability that an intervention subject had the outcome is
described by a/(a + b) from row 1 (experimental group); this also called
the experimental event rate (EER).
■ The probability that a control subject had the outcome is c/(c + d) from
row 2 (control group), or the control event rate (CER).
■ The relative risk, the probability of an outcome in the intervention
group compared to the probability of an outcome in the control group,
is expressed as the EER/CER.
■ The relative risk difference is de ned as |CER − EER|/CER × 100% or
100% − the relative risk, which describes the proportion of baseline risk
is reduced/increased by the therapy.
■ The absolute risk difference, the difference in outcome rates between
the comparisons groups, is expressed by the |CER − EER|.
■ The reciprocal of the absolute risk difference (reported as a fraction) is
the number of subjects who need to be treated over a speci c period of
time to prevent one outcome. If the intervention actually increases the
risk for a bad outcome, then this statistic becomes the number needed
to harm.
In many studies these calculations are used to measure treatment effectiveness between control and treatment interventions comparing medications,
procedures, or diagnostic tests.
G e n e r a liz a b ilit y
To make this determination, you need to rst look at the demographics
of the study subjects (e.g., age, gender, race/ethnicity, socioeconomic
status, clinical conditions). Then, you need to determine: Are the study
demographics applicable to your patient? Is the intervention feasible in
your clinical setting? And, most importantly, is the range of potential bene ts and harm of the intervention acceptable for your patient?
G u id e lin e R e c o m m e n d a t io n s
There are many approaches for rating the strength of recommendations
and we will discuss several grading systems. Review the rating systems in
Tables 2-1 to 2-3 (pp. 37–40).
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Chapter 2 | Evaluating Clinical Evidence
37
Aids to Interpretation
Table 2-1 U.S . P r e ve n t ive S e r v ic e s Ta s k Fo r c e
Ra t in g s : Gra d e De f in it io n s a n d
Im p lic a t io n s fo r P r a c t ic e
Gra d e
S u g g e s t io n s
fo r P ra c t ic e
D e f in it io n
A
The USPSTF recommends the service.
There is high certainty that the net
benefit is substantial.
Offer or provide this
service.
B
The USPSTF recommends the service. Offer or provide this
There is high certainty that the net
service.
benefit is moderate or there is moderate
certainty that the net benefit is
moderate to substantial.
C
The USPSTF recommends selectively
offering or providing this service to
individual patients based on
professional judgment and patient
preferences. There is at least moderate
certainty that the net benefit is small.
Offer or provide this
service for selected
patients depending
on individual
circumstances.
D
The USPSTF recommends against the
service. There is moderate or high
certainty that the service has no net
benefit or that the harms outweigh the
benefits.
Discourage the use of
this service.
I
The USPSTF concludes that the current
evidence is insufficient to assess the
balance of benefits and harms of the
service. Evidence is lacking, of poor
quality, or conflicting, and the balance
of benefits and harms cannot be
determined.
If the service is
offered, patients
should understand the
uncertainty about the
balance of benefits
and harms.
The USPSTF de nes certainty as the “likelihood that the USPSTF assessment of the net bene t
of a preventive service is correct.” The net bene t is de ned as bene t minus harm of the
preventive service as implemented in a general, primary care population.
Source: Grade De nitions. U.S. Preventive Services Task Force. October 2014. http://www.
uspreventiveservicestaskforce.org/Page/Name/grade-de nitions.
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Ba te s ’ Poc ke t Guide to Phys ic a l Exa mina tion a nd His tory Ta king
Table 2-2 U.S . P re ve n t ive S e r vic e s Ta s k Fo rc e Le ve ls
o f Ce r t a in t y Re g a rd in g Be n e f it
Le ve l o f
C e r t a in t y
D e s c r ip t io n
High
The available evidence usually includes consistent
results from well-designed, well-conducted studies in
representative primary care populations. These studies
assess the effects of the preventive service on health
outcomes. This conclusion is therefore unlikely to be
strongly affected by the results of future studies.
Moderate
The available evidence is sufficient to determine the
effects of the preventive service on health outcomes,
but confidence in the estimate is constrained by such
factors as:
■
■
■
■
The number, size, or quality of individual studies.
Inconsistency of findings across individual studies.
Limited generalizability of findings to routine primary
care practice.
Lack of coherence in the chain of evidence.
As more information becomes available, the magnitude
or direction of the observed effect could change, and
this change may be large enough to alter the conclusion.
Low
The available evidence is insufficient to assess effects on
health outcomes. Evidence is insufficient because of:
■
■
■
■
■
■
The limited number or size of studies.
Important flaws in study design or methods.
Inconsistency of findings across individual studies.
Gaps in the chain of evidence.
Findings not generalizable to routine primary care
practice.
Lack of information on important health outcomes.
More information may allow estimation of effects on
health outcomes.
Source: Update on Methods: Estimating Certainty and Magnitude of Net Bene t. U.S. Preventive Services Task Force. February 2014: http://www.uspreventiveservicestaskforce.org/Page/
Name/update-on-methods-estimating-certainty-and-magnitude-of-net-bene t.
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Chapter 2 | Evaluating Clinical Evidence
39
Table 2-3 Am e ric a n Co lle g e o f Ch e s t P h ys ic ia n s :
Gra d in g Re c o m m e n d a t io n s
Gra d e o f
Be n e f it v s .
Re c o m m e n d a t io n / Ris k a n d
D e s c r ip t io n
Bu r d e n s
M e t h o d o lo g ic
Q u a lit y o f
S u p p o r t in g
Ev id e n c e
Im p lic a t io n s
1A/Strong
recommendation;
high-quality
evidence
Benefits
clearly
outweigh
risk and
burdens, or
vice versa
RCTs without
important
limitations or
overwhelming
evidence from
observational
studies
Strong
recommendation;
can apply to most
patients in most
circumstances
without reservation
1B/Strong
recommendation;
moderate-quality
evidence
Benefits
clearly
outweigh
risk and
burdens, or
vice versa
RCTs with
important
limitations
(inconsistent
results, methodologic flaws,
indirect, or
imprecise) or
exceptionally
strong evidence
from observational studies
Strong recommendation; can apply
to most patients
in most circumstances without
reservation
1C/Strong
recommendation;
low-quality or
very low-quality
evidence
Benefits
clearly
outweigh
risk and
burdens, or
vice versa
Observational
studies or case
series
Strong
recommendation
but may change
when higher-quality
evidence becomes
available
2A/Weak
recommendation;
high-quality
evidence
Benefits
closely
balanced
with risk
and burdens
RCTs without
important
limitations or
overwhelming
evidence from
observational
studies
Weak
recommendation;
best action may
differ depending
on circumstances
or patients’ societal
values
(table continues on page 40)
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Ba te s ’ Poc ke t Guide to Phys ic a l Exa mina tion a nd His tory Ta king
Table 2-3 Am e ric a n Co lle g e o f Ch e s t P h ys ic ia n s :
Gra d in g Re c o m m e n d a t io n s (continued )
Gra d e o f
Be n e f it v s .
Re c o m m e n d a t io n / Ris k a n d
D e s c r ip t io n
Bu r d e n s
M e t h o d o lo g ic
Q u a lit y o f
S u p p o r t in g
Ev id e n c e
Im p lic a t io n s
2B/Weak
recommendation;
moderate-quality
evidence
Benefits
closely
balanced
with risk
and burdens
RCTs with
important
limitations
(inconsistent
results,
methodologic
flaws, indirect,
or imprecise) or
exceptionally
strong evidence
from
observational
studies
2C/Weak
recommendation;
low-quality or
very low-quality
evidence
Uncertainty Observational
in the estistudies or case
mates of
series
benefits, risks,
and burden;
benefits, risks,
and burdens
may be closely
balanced
Weak recommendation; best action
may differ depending on circumstances or patients’
societal values
Very weak
recommendation;
other alternatives
may be equally
reasonable
Source: Guyatt G, Gutterman D, Baumann MH, et al. Grading strength of recommendations and
quality of evidence in clinical guidelines: report from an American college of chest physicians
task force. Chest. 2006;129(1):174.
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3
C H A P T E R
Interviewing and the
Health History
The health history is a conversation with a purpose. In social conversation, you express your own needs and interests with responsibility
only for yourself. The primary goal of the clinician–patient interview
is to listen and improve the well-being of the patient through a trusting and supportive relationship. The interviewing process differs signi cantly from the format for the health history presented in Chapter 1.
Both are fundamental to your work with patients but serve different
purposes.
■ The interviewing process that generates the patient’s story is fluid
and requires empathy, effective communication, and the relational
skills to respond to patient cues, feelings, and concerns. It is
“open-ended,” drawing on a range of techniques that affirm and
empower the patient—active listening, guided questioning, nonverbal affirmation, empathic responses, validation, reassurance,
summarization, and partnering. These techniques are especially
pertinent to eliciting the patient’s chief concerns and the History
of the Present Illness.
■ The health history format is a structured framework for organizing
patient information into written or verbal form. This format focuses
your attention on the speci c kinds of information you need to obtain,
facilitates clinical reasoning, and clari es communication of patient
concerns, diagnoses, and plans to other health care providers involved
in the patient’s care. More “clinician-centered” closed-ended yes/no
questions are more pertinent to the Past History, the Family History, the
Personal and Social History, and, most closed-ended of all, the Review
of Systems.
For new patients in the of ce, hospital, or long-term care setting,
you will do a comprehensive health history, described for adults in
Chapter 1. For patients who seek care for a speci c complaint, such
as painful urination, a more limited interview, tailored to that speci c
problem—sometimes called a focused or problem-oriented history—may
be indicated.
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Ba te s ’ Poc ke t Guide to Phys ic a l Exa mina tion a nd His tory Ta king
The Fundamentals of
Skilled Interviewing
Skilled interviewing requires the use of speci c learnable techniques
perfected over a lifetime. Practice these techniques and nd ways to
be observed or recorded so that you can receive feedback on your
progress.
Ac t ive Lis t e n in g . This requires listening closely to what the patient
is communicating, being aware of the patient’s emotional state, and using
verbal and nonverbal skills to encourage the patient to continue and
expand both concerns and fears.
Em p a t h ic Re s p o n s e s . Patients may express—with or without
words—feelings they have not consciously acknowledged. Empathic
responses are vital to patient rapport and convey that you experience
some of the patient’s suffering. To express empathy, you must rst recognize
the patient’s feelings. Elicit these feelings rather than assume how the
patient feels.
Respond with understanding and acceptance. Responses may be as simple
as “I understand,” “That sounds upsetting,” or “You seem sad.” Empathy
also may be nonverbal—for example, placing your hand on the patient’s
arm if the patient is crying.
Gu id e d Qu e s t io n in g . It is important to adapt your questioning to the
patient’s verbal and nonverbal cues.
T e c h n iq u e s o f G u id e d Q u e s t io n in g
●
●
●
●
●
●
●
Moving fro o en-ended to focused questions
Using questioning th t elicits gr ded res onse
Asking series of questions, one t ti e
Offering ulti le choices for nswers
Cl rifying wh t the tient e ns
Encour ging with continuers
Using echoing
Proceed from the general to the speci c. Directed questions should not be leading
questions that call for a “yes” or “no” answer: not “Did your stools look like
tar?” but “Please describe your stools.”
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Chapter 3 | Interviewing and the Health History
43
Ask questions that require a graded response rather than a single
answer. “What physical activity do you do that makes you short of
breath?” is better than “Do you get short of breath climbing stairs?” Be
sure to ask one question at a time. Try “Do you have any of the following
problems?” Be sure to pause and establish eye contact as you list each
problem.
Sometimes patients seem unable to describe symptoms. Offer multiplechoice answers.
For patients using words that are ambiguous, request clari cation, as in
“Tell me exactly what you meant by ‘the u.’”
Posture, actions, or words encourage the patient to say more but do
not specify the topic. Nod your head or remain silent. Lean forward,
make eye contact, and use continuers like “Mm-hmm,” “Go on,” or “I’m
listening.”
Repetition and echoing of the patient’s words encourage the patient to
express both factual details and feelings.
No n ve rb a l Co m m u n ic a t io n . Being sensitive to nonverbal messages
allows you to both “read the patient” more effectively and send messages of
your own. Pay close attention to eye contact, facial expression, posture, head
position and movement such as shaking or nodding, interpersonal distance,
and placement of the arms or legs, such as crossed, neutral, or open. Physical contact (like placing your hand on the patient’s arm) can convey empathy
or help the patient gain control of feelings. You also can mirror the patient’s
paralanguage, or qualities of speech such as pacing, tone, and volume, to
increase rapport. Be sensitive to cultural variations in uses and meanings of
nonverbal behaviors.
Va lid a t io n . An important way to make a patient feel accepted is to
provide verbal support that legitimizes or validates the patient’s emotional
experience.
Re a s s u ra n c e . Avoid premature or false reassurance. Such reassurance may block further disclosures, especially if the patient feels that
exposing anxiety is a weakness. The first step to effective reassurance is
identifying and accepting the patient’s feelings without offering reassurance
at that moment.
P a r t n e rin g . Express your desire to work with patients in an ongoing
way. Reassure patients that regardless of what happens with their disease,
as their provider, you are committed to a continuing partnership. Even in
your role as a student, such support makes a big difference.
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Ba te s ’ Poc ke t Guide to Phys ic a l Exa mina tion a nd His tory Ta king
S u m m a riza t io n . Giving a capsule summary lets the patient know
that you have been listening carefully. It also clari es what you know and
what you don’t know. Summarization allows you to organize your clinical
reasoning and to convey your thinking to the patient, which makes the
relationship more collaborative.
Tra n s it io n s . Tell patients when you are changing directions during the
interview. This gives patients a greater sense of control.
Em p o w e rin g t h e P a t ie n t . The clinician–patient relationship is
inherently unequal. Patients have many reasons to feel vulnerable:
pain, worry, feeling overwhelmed with the health care system, lack of
familiarity with the clinical evaluation process. Differences of gender,
ethnicity, race, or class may also create power differentials. Ultimately,
patients must be empowered to take care of themselves and follow
through on your advice. Review the principles below.
E m p o w e r in g t h e P a t ie n t : T e c h n iq u e s f o r S h a r in g P o w e r
●
●
●
●
●
●
●
Evoke the tient’s ers ective.
Convey interest in the erson, not just the roble .
Follow the tient’s le d.
Elicit nd v lid te e otion l content.
Sh re infor tion with the tient, es eci lly t tr nsition oints during the
visit.
M ke your clinic l re soning tr ns rent to the tient.
Reve l the li its of your knowledge.
The Sequence and Context
of the Interview
P r e p a r a t io n , S e q u e n c e , a n d
C u lt u r a l C o n t e x t
Interviewing patients to elicit their health history requires planning.
■ Review the clinical record. Before seeing the patient, review the clini-
cal record or chart. It often provides valuable information about past
diagnoses and treatments; however, data may be incomplete or even
disagree with what you learn from the patient, so be open to developing
new approaches or ideas.
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Chapter 3 | Interviewing and the Health History
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■ Set goals for the interview. Clarify your goals for the interview. A
clinician must balance provider-centered goals with patient-centered
goals. The clinician’s task is to balance these multiple agendas.
■ Review your clinical behavior and appearance. Consciously or
not, you send messages through your behavior. Posture, gestures,
eye contact, and tone of voice all can express interest, attention,
acceptance, and understanding. The skilled interviewer is calm and
unhurried, even when time is limited. Reactions that betray disapproval, embarrassment, impatience, or boredom block communication. Patients nd cleanliness, neatness, conservative dress, and a
name tag reassuring.
■ Adjust the environment. Always consider the patient’s privacy. Pull
shut any bedside curtains. Suggest moving to an empty room rather
than having a conversation that can be overheard.
T h e S e q u e n c e o f t h e In t e r v ie w
In general, an interview moves through several stages. Throughout this
sequence, as the clinician, you must always stay attuned to the patient’s
feelings, help the patient express them, respond to their content, and validate their signi cance.
■ Greet the patient and establish rapport. Greet the patient by name
and introduce yourself, giving your name. If possible, shake hands.
If this is the rst contact, explain your role, including your status as
a student and how you will be involved in the patient’s care. Using
a title to address the patient (e.g., Mr. O’Neil, Ms. Wu) is always
best. Avoid rst names unless you have speci c permission from
the patient.
Whenever visitors are present, maintain con dentiality. Let the patient
decide if visitors or family members should remain in the room, and
ask for the patient’s permission before conducting the interview in front
of them.
Attend to the patient’s comfort. Ask how he or she is feeling and if you
are coming at a convenient time. Look for signs of discomfort, such
as frequent changes of position or facial expressions that show pain or
anxiety. Arranging the bed may make the patient more comfortable.
Consider the best way to arrange the room. Choose a distance that facilitates conversation and good eye contact. Try to sit at eye level with the
patient. Move any physical barriers between you and the patient, such
as desks or bedside tables, out of the way.
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Give the patient your undivided attention. Spend enough time on small
talk to put the patient at ease. If necessary, jot down short phrases, speci c dates, or words rather than trying to put them into a nal format.
Maintain good eye contact, especially when using the electronic clinical
record. Whenever the patient is talking about sensitive or disturbing
material, put down your pen.
■ Establish an agenda. It is important to identify both your own and the
patient’s issues at the beginning of the encounter. Often, you may need to
focus the interview by asking the patient which problem is most pressing.
For example, “Do you have some special concerns today? Which one are
you most concerned about?” Some patients may not have a speci c complaint or problem. It is still important to start with the patient’s story.
■ Invite the patient’s story. Encourage patients to tell their own stories,
using their own words. Begin with open-ended questions that allow
full freedom of response: “Tell me more about…” Avoid questions that
restrict the patient to a minimally informative “yes” or “no” answer.
Listen to the patient’s answers without interrupting.
Train yourself to follow the patient’s leads. Use verbal and nonverbal cues
that prompt patients to recount their stories spontaneously. Use continuers, especially at the outset, such as nodding your head and using
phrases such as “Uh huh,” “Go on,” and “I see.”
■ Explore the patient’s perspective. The disease/illness model helps you
understand the difference between your perspective and the patient’s
perspective. In this model, disease is the explanation that the clinician
uses to organize symptoms that lead to a clinical diagnosis. Illness is a
construct that explains how the patient experiences the disease, including its effects on relationships, function, and sense of well-being. The
health history interview needs to include both of these views of reality.
Learning how patients perceive illness means asking patient-centered
questions in the four domains listed below, which follow the mnemonic
“FIFE”—Feelings, Ideas, effect on Function, and Expectations. This is
crucial to patient satisfaction, effective health care, and patient followthrough.
E x p lo r in g t h e P a t ie n t ’s P e r s p e c t iv e (F -I-F -E )
●
●
●
●
The tient’s Feelings, including fe rs or concerns, bout the roble
The tient’s Ide s bout the n ture nd the c use of the roble
The effect of the roble on the tient’s life nd Function
The tient’s Ex ect tions of the dise se, of the clinici n, or of he lth c re,
often b sed on rior erson l or f ily ex eriences
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Chapter 3 | Interviewing and the Health History
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■ Identify and respond to the patient’s emotional cues. Patients offer
various clues to their concerns that may be direct or indirect, verbal or
nonverbal; they may express them as ideas or emotions. Acknowledging
and responding to these clues help build rapport, expand the clinician’s
understanding of the illness, and improve patient satisfaction. Clues to
the patient’s perspective on illness are provided in the box below.
C lu e s t o t h e P a t ie n t ’s P e r s p e c t iv e o n Illn e s s
●
●
●
●
●
●
Direct st te ent(s) by the tient of ex l n tions, e otions, ex ect tions,
nd effects of the illness
Ex ression of feelings bout the illness without n ing the illness
Atte ts to ex l in or underst nd sy to s
S eech clues (e.g., re etition, rolonged reflective uses)
Sh ring erson l story
Beh vior l clues indic tive of unidentified concerns, diss tisf ction, or un et
needs such s reluct nce to cce t reco
end tions, seeking second o inion, or e rly
oint ent
Source: L ng F, Floyd MR, Beine KL. Clues to tients’ ex l n tions nd concerns bout their
illnesses: c ll for ctive listening. Arch Fam Med. 2
;9(3):222–227.
■ Expand and clarify the patient’s story. Each symptom has attributes
that must be clari ed, including context, associations, and chronology,
especially for pain. It is critical to understand fully every symptom’s
essential characteristics. Always elicit the seven features of every symptom.
To pursue the seven attributes, two mnemonics may help:
■
OLD CARTS, or Onset, Location, Duration, Character,
Aggravating/Alleviating Factors, Radiation, and Timing; and
■
OPQRST, or Onset, Palliating/Provoking Factors, Quality, Radiation,
Site, and Timing
T h e S e v e n A t t r ib u t e s o f a S y m p t o m
1. Location. Where is it? Does it r di te?
2. Quality. Wh t is it like?
3. Quantity or severity. How b d is it? (For in, sk for r ting on sc le of 1
to 1 .)
4. Timing. When did (does) it st rt? How long did (does) it l st? How often did
(does) it occur?
5. Onset (setting in which symptom occurs). Include environ ent l f ctors,
erson l ctivities, e otion l re ctions, or other circu st nces th t
y
h ve contributed to the illness.
6. Remitting or exacerbating factors. Does nything
ke it better or worse?
7. Associated manifestations. H ve you noticed nything else th t cco
nies it?
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Use language that is understandable and appropriate to the patient. Technical
language confuses patients and blocks communication. Whenever possible, repeat back the patient’s words and expressions as the history unfolds,
to af rm the patient’s experience as you clarify what he or she means.
Facilitate the patient’s story by using different types of questions and the
techniques of skilled interviewing on pp. 42–44. Often you will need
to use directed questions (see pp. 42–43) that ask for speci c information
the patient has not already offered. In general, an interview moves back and
forth from open-ended questions to increasingly focused questions and then on to
another open-ended question, returning the lead in the interview to the patient.
Establishing the sequence and time course of the patient’s symptoms is
important. Encourage a chronologic account by asking such questions
as “What then?” or “What happened next?”
■ Generate and test diagnostic hypotheses. As you listen to the patient’s
concerns, you will generate and test diagnostic hypotheses about which disease process might be present. Identifying all the features of each symptom is fundamental to recognizing patterns of disease and to generating
the differential diagnosis. It is important to fully esh out the patient’s story.
This avoids the common trap of premature closure, or shutting down the
patient’s story too quickly, which can lead to errors in diagnosis.
It is helpful to visualize the process of evoking a full description of each
symptom(s) as “the cone” (Fig. 3-1). Each symptom has its own “cone,”
which becomes a paragraph in the History of Present Illness in the written record.
Firs t, ope n-e nde d que s tions to
he a r “the s tory of the s ymptom”
in the pa tie nt’s own words
The n more s pe cific que s tions to
e licit “the s e ve n fe a ture s of e ve ry
s ymptom”
Fina lly, the ye s -no que s tions or
“pe rtine nt pos itive s a nd ne ga tive s ”
from the re le va nt s e ction of the
re vie w of s ys te ms
Fig ure 3-1 Gathe r patie nt inform ation.
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Chapter 3 | Interviewing and the Health History
49
■ Share the treatment plan. Learning about the disease and conceptual-
izing the illness give you and the patient the basis for planning further
evaluation (physical examination, laboratory tests, consultations, etc.).
Shared decision-making involves a three-step process: introducing
choices and describing options, using patient decision support tools
when available; exploring patient preferences; and moving to a decision,
checking that the patient is ready to make a decision and offering more
time if needed. Motivational interviewing may help the patient achieve
desired behavior changes.
T h e G u id in g S t y le o f M o t iv a t io n a l In t e r v ie w in g
●
●
●
“Ask” o en-ended questions—invite the tient to consider how nd why
they ight ch nge
“Listen” to underst nd your tient’s ex erience—“c ture” their ccount
with brief su
ries or reflective listening st te ents such s “quitting
s oking feels beyond you t the o ent”; these ex ress e
thy, encourge the tient to el bor te, nd re often the best w y to res ond to resist nce
“Infor ”—by sking er ission to rovide infor tion, nd then sking wh t
the i lic tions ight be for the tient.
Source: Quoted directly fro
ing. BMJ. 2 1 ;34 :1242.
Rollnick S, Butler CC, Kinnersly P, et l. Motiv tion l Interview-
■ Close the interview and visit. Make sure the patient fully understands
the plans you have developed together. You can say, “We need to stop
now. Do you have any questions about what we’ve covered?” Review
future evaluation, treatments, and follow-up. Give the patient a chance
to ask any nal questions. Ask the patient to “teach back” the plan of
care to you in his or her own words.
■ Take time for self-re ection. As clinicians, we encounter a wide variety
of people, each one unique. Because we bring our own values, assumptions, and biases to every encounter, we must look inward to clarify how
our expectations and reactions may affect what we hear and how we
behave. Self-re ection brings a deepening personal awareness to our work
with patients and is one of the most rewarding aspects of providing patient care.
T h e C u lt u r a l C o n t e x t o f t h e In t e r v ie w
Cu lt u ra l Hu m ilit y—a Ch a n g in g P a ra d ig m . As you provide care
for an ever-expanding and diverse group of patients, it is important to
understand how culture shapes not just the patient’s beliefs, but your own.
Culture is a system of shared ideas, rules, and meanings that in uences
how we view the world, experience it emotionally, and behave in relation
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Ba te s ’ Poc ke t Guide to Phys ic a l Exa mina tion a nd His tory Ta king
to other people. This de nition of culture is broader than the term ethnicity.
The in uence of culture is not limited to minority groups—it is relevant
to everyone, including the culture of clinicians and their training. Cultural
competence commonly is viewed as: “a set of attitudes, skills, behaviors,
and policies that enable organizations and staff to work effectively in crosscultural situations. It re ects the ability to acquire and use knowledge of
the health-related bene ts, attitudes, practices, and communication patterns of clients and their families to improve services, strengthen programs,
increase community participation, and close the gaps in health status
among diverse population groups.”
Clinicians are increasingly challenged to adopt cultural humility, a “process
that requires humility as individuals continually engage in self-re ection
and self-critique as lifelong learners and re ective practitioners.” This process includes “the dif cult work of examining cultural beliefs and cultural
systems of both patients and providers to locate the points of cultural dissonance or synergy that contribute to patients’ health outcomes.” It calls
for clinicians to “bring into check the power imbalances that exist in the
dynamics of (clinician)–patient communication” and maintain mutually
respectful and dynamic partnerships with patients and communities. The
following three-point framework will help you.
T h e T h r e e D im e n s io n s o f C u lt u r a l H u m ilit y
1. Self-awareness. Le rn bout your own bi ses; we ll h ve the .
2. Respectful communication. Work to eli in te ssu tions bout wh t is
“nor l.” Le rn directly fro your tients; they re the ex erts on their
culture nd illness.
3. Collaborative partnerships. Build your tient rel tionshi s on res ect nd
utu lly cce t ble l ns.
Advanced Interviewing
In t e r v ie w in g t h e C h a lle n g in g P a t ie n t
Always remember the importance of listening to the patient and clarifying
the patient’s agenda.
S ile n t P a t ie n t . Silence has many meanings. Watch closely for nonverbal cues such as dif culty controlling emotions. You may need to shift your
inquiry to symptoms of depression or begin an exploratory mental status
examination. Silence may be the patient’s response to how you are asking
questions. Are you asking too many direct questions? Have you offended
the patient?
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Chapter 3 | Interviewing and the Health History
51
Co n fu s in g P a t ie n t . Some patients have multiple symptoms or a somatization disorder. Focus on the context of the symptoms and guide the
interview into a psychosocial assessment. At other times, you may be frustrated or confused. The history is vague and dif cult to understand, and
patients may describe symptoms in bizarre terms. Try to learn more about
the unusual symptoms. Watch for delirium in acutely ill or intoxicated
patients and for dementia in the elderly. When you suspect a psychiatric or
neurologic disorder, shift to a mental status examination, focusing on level
of consciousness, orientation, and memory.
Pa t ie n t w it h Alt e re d Co g n it io n . Some patients cannot provide their
own histories because of delirium, dementia, or other conditions. Others
cannot relate certain parts of the history. In such cases, determine whether
the patient has decision-making capacity, or the ability to understand information related to health, to make clinical choices based on reason and a consistent set of values, and to declare preferences about treatments. Capacity is
a clinical designation and can be assessed by clinicians, whereas competence
is a legal designation and can only be decided by a court. If a patient lacks
capacity to make a health care decision, then identify the health care proxy
or the agent with power of attorney for health care. If the patient had not
identi ed a surrogate decision maker, then that role may shift to a spouse or
family member. It is critical to remember that decision-making capacity is both
“temporal and situational.” It can uctuate depending on the condition of
the patient and the complexity of the decision involved. Many patients with
psychiatric or cognitive de cits still retain the ability to make decisions.
E le m e n t s o f D e c is io n -M a k in g C a p a c it y
P tients
ust h ve the bility to:
1. Underst nd the relev nt infor tion bout ro osed di gnostic tests or
tre t ent,
2. A reci te their situ tion (including their underlying v lues nd current
clinic l situ tion),
3. Use re son to
ke decision, nd
4. Co
unic te their choice.
Source: Sessu s LL, Ze brzusk H, J ckson JL. Does this
c city? JAMA. 2 11;3 6:42 .
tient h ve
edic l decision-
king
For patients with capacity, obtain their consent before talking about their
health with others. Consider dividing the interview into two segments—one
with the patient and the other with both the patient and a second informant.
Also learn the tenets of the Health Insurance Portability and Accountability Act
(HIPAA) passed by Congress in 1996, which sets strict standards for disclosure for both institutions and providers when sharing patient information.
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For patients with impaired capacity, nd a surrogate informant or decision
maker to assist with the history. Check whether the patient has a durable
power of attorney for health care or a health care proxy. If not, in many cases,
a spouse or family member can represent the patient’s wishes.
Ta lk a t ive P a t ie n t . Several techniques are helpful. For the rst 5 or
10 minutes, listen closely. Does the patient seem obsessively detailed or
unduly anxious? Is there a ight of ideas or disorganized thought process? Try to focus on what seems most important to the patient. “You’ve
described many concerns. Let’s focus on the hip pain rst. Can you tell me
what it feels like?” Or you can ask, “What is your #1 concern today?”
Cryin g P a t ie n t . Usually crying is therapeutic, as is quiet acceptance of
the patient’s distress. Make a facilitating or supportive remark like “I’m glad
that you were able to express your feelings.”
An g ry o r Dis ru p t ive P a t ie n t . Many patients have reasons to be
angry: they are ill, they have suffered a loss, they lack accustomed control
over their own lives, and they feel relatively powerless. They may direct
this anger toward you. Accept angry feelings from patients and allow them to
express such emotions without getting angry in return. Validate their feelings
without agreeing with their reasons. “I understand that you felt very frustrated by the long wait and answering the same questions over and over.”
Some angry patients become hostile and disruptive. Before approaching
them, alert security. Stay calm, appear accepting, and avoid being challenging. Keep your posture relaxed and nonthreatening. Once you have established rapport, gently suggest moving to a different location.
P a t ie n t w it h a La n g u a g e Ba rrie r. If the patient speaks a different
language, make every effort to nd a trained interpreter. The ideal interpreter is a neutral, objective person trained in both languages and cultures.
Avoid using family members or friends: con dentiality may be violated. As
you work with the interpreter, make questions clear, short, and simple. Speak
directly to the patient. Bilingual written questionnaires are valuable.
G u id e lin e s f o r W o r k in g w it h a n
In t e r p r e t e r : “ IN T E R P R E T ”
I
N
T
Introductions: M ke sure to introduce ll the individu ls in the roo . During
the introduction, include infor tion s to the roles individu ls will l y.
Note Goals: Note the go ls of the interview. Wh t is the di gnosis? Wh t
will the tre t ent ent il? Will there be ny follow-u ?
Transparency: Let the tient know th t everything s id will be inter reted
throughout the session.
(continued )
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53
G u id e lin e s f o r W o r k in g w it h a n
In t e r p r e t e r : “ IN T E R P R E T ” (Continued)
E
R
P
R
E
T
Ethics: Use qu lified inter reters (not f ily e bers or children) when
conducting n interview. Qu lified inter reters llow the tient to
int in utono y nd
ke infor ed decisions bout his or her c re.
Respect Beliefs: Li ited English Proficient (LEP) tients
y h ve cultur l
beliefs th t need to be t ken into ccount s well. The inter reter
y be
ble to serve s cultur l broker nd hel ex l in ny cultur l beliefs th t
y exist.
Patient Focus: The tient should re in the focus of the encounter. Providers should inter ct with the tient nd not the inter reter. M ke sure
to sk nd ddress ny questions the tient
y h ve rior to ending the
encounter. If you don’t h ve tr ined inter reters on st ff, the tient
y
not be ble to c ll in with questions.
Ret ain Cont rol: It is i ort nt s the rovider th t you re in in control
of the inter ction nd not let the tient or the inter reter t ke over the
convers tion.
Explain: Use si le l ngu ge nd short sentences when working with n
inter reter. This will ensure th t co
r ble words c n be found in the
second l ngu ge nd th t ll the infor tion c n be conveyed cle rly.
Thanks: Th nk the inter reter nd the tient for their ti e. On the ch rt,
note th t the tient needs n inter reter nd who served s n inter reter
this ti e.
Source: U.S. De rt ent of He lt h nd Hu n Services. Int er ret Tool: working wit h
int er ret ers in cult ur l set t ings. Av il ble t ht t s:www.t hinkcult ur lhe lt h.hhs.gov/
dfs/ Int er ret Tool. df. Accessed M y 3, 2 16.
P a t ie n t w it h Lo w Lit e r a c y o r Lo w He a lt h Lit e r a c y. Assess the
ability to read. Some patients may try to hide their reading problems.
Ask the patient to read whatever instructions you have written. Simply
handing the patient written material upside down to see if the patient
turns it around may settle the question. Assess health literacy, or the skills
to function effectively in the health care system: interpreting documents,
reading labels and medication instructions, and speaking and listening
effectively.
P a t ie n t w it h He a r in g Lo s s . Find out the patient’s preferred
method of communicating. Patients may use American Sign Language,
a unique language with its own syntax, or various other communication forms combining signs and speech. Determine whether the patient
identi es with the Deaf or Hearing culture. Handwritten questions and
answers may be the best solution. When patients have partial hearing impairment or can read lips, face them directly, in good light. If the
patient has a unilateral hearing loss, sit on the hearing side. If the patient
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has a hearing aid, make sure it is working. Eliminate background noise
such as television.
P a t ie n t w it h Im p a ire d Vis io n . Shake hands to establish contact and
explain who you are and why you are there. If the room is unfamiliar, orient the patient to the surroundings.
P a t ie n t w it h Lim it e d In t e llig e n c e . Patients of moderately limited
intelligence usually can give adequate histories. Pay special attention to the
patient’s schooling and ability to function independently. How far has the
patient gone in school? If he or she didn’t nish, why not? Assess simple
calculations, vocabulary, memory, and abstract thinking. For patients with
severe mental retardation, obtain the history from the family or caregivers.
Avoid “talking down” or using condescending behavior. The sexual history
is equally important and often overlooked.
P a t ie n t w it h P e r s o n a l P ro b le m s . Patients may ask you for advice
about personal problems outside the range of health. Letting the patient
talk through the problem is usually more valuable and therapeutic than
any answer you could give.
S e d u c t ive P a t ie n t . The emotional and physical intimacy of the clinician–patient relationship may lead to sexual feelings. If you become aware
of such feelings, accept them as a normal human response, and bring them
to the conscious level so they will not affect your behavior. Denying these
feelings makes it more likely that you will act inappropriately. Any sexual
contact or romantic relationship with patients is unethical; keep your
relationship with the patient within professional bounds and seek help if
you need it.
S e n s it iv e T o p ic s
G u id e lin e s f o r B r o a c h in g S e n s it iv e T o p ic s
●
●
●
●
The single ost i ort nt rule is to be nonjudg ent l. Your role is to le rn
fro the tient nd hel the tient chieve better he lth. Acce t nce is
the best w y to re ch this go l.
Ex l in why you need to know cert in infor tion. This
kes tients less
rehensive. For ex
le, s y to tients, “Bec use sexu l r ctices ut
eo le t risk for cert in dise ses, I sk ll of y tients the following
questions.”
Find o ening questions for sensitive to ics nd le rn the s ecific kinds of
infor tion needed for your sh red ssess ent nd l n.
Consciously cknowledge wh tever disco fort you re feeling. Denying your
disco fort
y le d you to void the to ic ltogether.
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Th e S e xu a l His t o ry. You can introduce questions about sexual function and practices at multiple points in a patient’s history. An orienting
sentence or two is often helpful. “Now I’d like to ask you some questions
about your sexual health and practices” or “I routinely ask all patients
about their sexual function.”
T h e S e x u a l H is t o r y : S a m p le Q u e s t io n s
●
●
●
●
“When w s the l st ti e you h d inti te hysic l cont ct with so eone?”
“Did th t cont ct include sexu l intercourse?” The ter “sexu lly ctive” c n
be
biguous. P tients h ve been known to re ly, “No, I just lie there.”
“Do you h ve sex with en, wo en, or both?” P tients
y h ve s e-sex
rtners yet not consider the selves g y, lesbi n, or bisexu l. So e g y nd
lesbi n tients h ve h d o osite-sex rtners.
“How
ny sexu l rtners h ve you h d in t he l st 6 onths? In the l st
5 ye rs? In your lifeti e?” These quest ions
ke it e sy for t he t ient to
cknowledge ult i le rtners. Ask, “H ve you h d ny new rt ners in
t he st 6 ont hs?” If tients question why this infor t ion is i ort nt , ex l in t h t new rt ners or ult i le rtners over lifeti e c n
r ise t he risk for STIs. Ask bout routine use of condo s. “How often do
you use condo s?” is n o en-ended question th t does not resu e n
nswer.
It is i ort nt to sk ll tients, “Do you h ve ny concerns bout HIV infection or AIDS?” since infection c n occur in the bsence of risk f ctors.
Me n t a l He a lt h His t o ry. Cultural constructs of mental illness vary
widely, causing marked differences in acceptance and attitudes. Ask openended questions initially: “Have you ever had any problem with emotional
or mental illnesses?” Then move to more speci c questions: “Have you
ever visited a counselor or psychotherapist?” “Have you taken medication for
emotional issues?” “Have you or a family member ever been hospitalized for
a mental health problem?”
Be sensitive to reports of mood changes or symptoms such as fatigue,
tearfulness, appetite or weight changes, insomnia, and vague somatic complaints. Two validated screening questions are: “Over the past 2 weeks, have
you felt down, depressed, or hopeless?” and “Over the past 2 weeks, have
you felt little interest or pleasure in doing things?” Ask about thoughts of
suicide: “Have you ever thought about hurting yourself or ending your life?”
Evaluate severity.
Many patients with schizophrenia or other psychotic disorders can function in the community and tell you about their diagnoses, symptoms, hospitalizations, and medications. Investigate their symptoms and assess any
effects on mood or daily activities.
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Ba te s ’ Poc ke t Guide to Phys ic a l Exa mina tion a nd His tory Ta king
Alc o h o l a n d P re s c rip t io n a n d Illic it Dru g s . Clinicians should
routinely ask about current and past use of alcohol or drugs, patterns of
use, and family history. Be familiar with the de nitions below:
A d d ic t io n , P h y s ic a l D e p e n d e n c e , a n d T o le r a n c e
Tolerance: A st t e of d t tion in which ex osure t o drug induces
ch nges th t result in di inut ion of one or ore of t he drug’s effects
over t i e.
Physical Dependence: A st te of d t tion th t is
nifested by drug cl sss ecific withdr w l syndro e th t c n be roduced by bru t cess tion,
r id dose reduction, decre sing blood level of the drug, nd/or d inistr tion of n nt gonist.
Addiction: A ri ry, chronic, neurobiologic dise se, with genetic, sychosoci l, nd environ ent l f ctors influencing its develo ent nd
nifest tions. It is ch r cterized by beh viors th t include one or ore of the
following: i
ired control over drug use, co ulsive use, continued use
des ite h r , nd cr ving.
Source: A eric n P in Society. Definitions Rel ted to the Use of O ioids for the Tre t ent
of P in. A consensus st te ent fro the A eric n Ac de y of P in Medicine, the A eric n P in Society, nd the A eric n Society of Addiction Medicine, 2 1. Av il ble t
htt :/ / www. s .org/docs/ ublicy- olicy-st te ents/ 1o ioid-definitions-consensus2– 11. df?sfvrsn= . Accessed M y 3, 2 16.
A lc o h o l. For assessing alcohol intake, “What do you like to drink?” or
“Tell me about your use of alcohol” are good opening questions that avoid
the easy yes or no response. The most widely used screening questions
are the CAGE questions about Cutting down, Annoyance when criticized,
Guilty feelings, and Eye-openers. Two or more affirmative answers to the
CAGE questions suggest alcoholism. The CAGE Questionnaire is readily
available online.
Also ask about blackouts (loss of memory for events during drinking),
seizures, accidents or injuries while drinking, job loss, marital con ict, or
legal problems. Ask speci cally about drinking while driving or operating
machinery.
P r e s c r ip t io n a n d Illic it D r u g s . Questions about drugs are similar.
“How much marijuana do you use? Cocaine? Heroin? Amphetamines?”
(Ask about each one by name.) “How about prescription drugs such
as sleeping pills?” “Diet pills?” “Painkillers?” Use the CAGE questions
but relate them to drug use. With adolescents, it may be helpful to ask
about substance use by friends or family members rst. “A lot of young
people are using drugs these days. How about at your school? Your
friends?”
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57
In t im a t e P a r t n e r Vio le n c e a n d Do m e s t ic Vio le n c e . Many
authorities recommend routine screening of all female and older adult
patients for domestic violence. Start with general “normalizing” questions:
“Because abuse is common in many women’s lives, I’ve begun to ask about
it routinely.” “Are there times in your relationships that you feel unsafe or
afraid?” “Have you ever been hit, kicked, punched, or hurt by someone
you know?”
C lu e s t o P h y s ic a l a n d S e x u a l A b u s e
●
●
●
●
●
●
●
●
●
●
●
Injuries th t re unex l ined, see inconsistent with the tient’s story, re
conce led by the tient, or c use e b rr ss ent
Del y in getting tre t ent for tr u
History of re e ted injuries or “ ccidents”
Presence of lcohol or drug buse in tient or rtner
P rtner tries to do in te the visit, will not le ve the roo , or see s unusully nxious or solicitous
Pregn ncy t young ge; ulti le rtners
Re e ted v gin l infections nd STIs
Difficulty w lking or sitting due to genit l/ n l in
V gin l l cer tions or bruises
Fe r of the elvic ex in tion or hysic l cont ct
Fe r of le ving the ex in tion roo
De a t h a n d t h e Dyin g P a t ie n t . Work through your own feelings with
the help of reading and discussion. Kübler-Ross has described ve stages
in our response to loss or the anticipatory grief of impending death: denial
and isolation, anger, bargaining, depression or sadness, and acceptance.
These stages may occur sequentially or overlap in different combinations.
Dying patients rarely want to talk about their illnesses all the time, nor do
they wish to con de in everyone they meet. Give them opportunities to
talk and then listen receptively, but be supportive if they prefer to stay at a
social level.
Understanding the patient’s wishes about treatment at the end of life is an
important clinician responsibility. Even if discussions of death and dying
are dif cult, you must learn to ask speci c questions. Ask about Do Not
Resuscitate (DNR) status. Find out about the patient’s frame of reference.
“What experiences have you had with the death of a close friend or relative?” “What do you know about cardiopulmonary resuscitation (CPR)?”
Assure patients that relieving pain and taking care of their other spiritual
and physical needs will be a priority. Encourage any adult, but especially
the elderly or chronically ill, to establish a health care proxy, an individual
who can act for the patient in life-threatening situations.
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Ba te s ’ Poc ke t Guide to Phys ic a l Exa mina tion a nd His tory Ta king
Ethics and Professionalism
Clinical ethics come into play in almost every patient interaction. Fundamental maxims are as follows:
B u ild in g B lo c k s o f P r o f e s s io n a l E t h ic s in P a t ie n t C a r e
●
●
●
●
Nonmaleficence or primum non nocere, co
only st ted s, “First, do no
h r .”
Beneficence, or the dictu th t the clinici n needs to “do good” for the
tient. As clinici ns, our res onsibility is to lw ys ct in the best interest of
the tient.
Autonomy, whereby infor ed tients h ve the right to deter ine wh t is in
their own best interest.
Confidentiality, e ning th t we re oblig ted not to tell others wh t we
le rn fro our tients. Note th t so e fr eworks osit Justice s the
fourth critic l rinci le, n ely th t ll tients be tre ted f irly with equit ble distribution of he lth c re resources.
The Tavistock Principles guide behavior in health care for both individuals
and institutions.
T h e T a v is t o c k P r in c ip le s
Rights: Peo le h ve right to he lth nd he lth c re.
Balance: C re of individu l tients is centr l, but the he lth of o ul tions is
lso our concern.
Comprehensiveness: In ddition to tre ting illness, we h ve n oblig tion to e se
suffering, ini ize dis bility, revent dise se, nd ro ote he lth.
Cooperation: He lth c re succeeds only if we coo er te with those we serve,
e ch other, nd those in other sectors.
Improvement: I roving he lth c re is serious nd continuing res onsibility.
Safety: Do no h r .
Openness: Being o en, honest, nd trustworthy is vit l in he lth c re.
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C H A P T E R
Beginning the Physical
Examination: General
Survey, Vital Signs, and Pain
The Health History
C o m m o n o r C o n c e r n in g S y m p t o m s
●
●
●
●
F tigue nd we kness
Fever, chills, nd night swe ts
Weight ch nge
P in
Fa t ig u e a n d We a k n e s s . Fatigue is a nonspeci c symptom with many
causes. Use open-ended questions to explore the attributes of the patient’s
fatigue, and encourage the patient to fully describe what he or she is
experiencing.
Weakness differs from fatigue. It denotes a demonstrable loss of muscle
power and will be discussed later with other neurologic symptoms.
Fe ve r, Ch ills , a n d Nig h t S w e a t s . Ask about fever if the patient has
an acute or chronic illness. Find out whether the patient has used a thermometer to measure the temperature. Distinguish between feeling cold and
a shaking chill, with shivering throughout the body and chattering of teeth.
Night sweats raise concerns about tuberculosis or malignancy.
Focus your questions on the timing of the illness and its associated
symptoms. Become familiar with patterns of infectious diseases that
may affect your patient. Inquire about travel, contact with sick people,
or other unusual exposures. Be sure to inquire about medications, as
they may cause fever. In contrast, recent ingestion of aspirin, acetaminophen, corticosteroids, and nonsteroidal anti-in ammatory drugs
may mask fever.
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Ba te s ’ Poc ke t Guide to Phys ic a l Exa mina tion a nd His tory Ta king
We ig h t Ch a n g e . Good opening questions include “How often do you
check your weight?” and “How is it compared to a year ago?”
■ Weight gain occurs when caloric intake exceeds caloric expenditure over
time. It also may re ect abnormal accumulation of body uids.
■ Weight loss has many causes: decreased food intake, dysphagia, vomit-
ing, and insuf cient supplies of food; defective absorption of nutrients;
increased metabolic requirements; and loss of nutrients through the
urine, feces, or injured skin. Also consider chronic illnesses, malignancy,
and abuse of alcohol, cocaine, amphetamines, or opiates, or withdrawal
from marijuana. Be alert for signs of malnutrition.
P a in . Each year, approximately 100 million Americans report chronic
pain, often underassessed. Adopt the comprehensive approach found
on pp. 69–71.
Health Promotion and Counseling:
Evidence and Recommendations
Im p o r t a n t T o p ic s f o r H e a lt h P r o m o t io n
a n d C o u n s e lin g
●
●
●
O ti l weight, nutrition, nd diet
Blood ressure nd diet ry sodiu
Exercise
Op t im a l We ig h t , Nu t rit io n , a n d Die t . Nearly 69% of U.S. adults
are overweight (BMI ≥25 to 29 kg/m2) or obese (BMI ≥30 kg/m2). Obesity
has increased in every segment of the population. More than 80% of
people with type 2 diabetes and roughly 20% of those with hypertension
or elevated cholesterol levels are overweight or obese. Increasing obesity
in children contributes to rising rates of childhood diabetes. Reducing
weight by even 5% to 10% can improve blood pressure, lipid levels, and
glucose tolerance, and reduce the risk of diabetes and hypertension. Diet
recommendations hinge on assessment of the patient’s motivation and
readiness to lose weight and individual risk factors.
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61
F o u r S t e p s t o P r o m o t e O p t im a l W e ig h t
a n d N u t r it io n
1. Me sure BMI nd w ist circu ference; dults with BMI ≥25 kg/ 2, en with
w ist circu ferences >4 inches, nd wo en with w ist circu ferences
>35 inches re t incre sed risk for he rt dise se nd obesity-rel ted dise ses.
R tios > .95 in en nd > .85 in wo en re considered elev ted. Deter ine
ddition l risk f ctors for c rdiov scul r dise ses, including s oking, high
blood ressure, high cholesterol, hysic l in ctivity, nd f ily history.
2. Assess diet ry int ke.
3. Assess the tient’s otiv tion to ch nge.
4. Provide counseling bout nutrition nd exercise.
Review the 2010 dietary guidelines of the U.S. Department of Agriculture
and counsel patients to turn to its helpful MyPlate icon and website.
Blo o d P re s s u re a n d Die t a ry S o d iu m . The Institute of Medicine
(IOM) recommends a maximum daily dietary intake of 2,300 mg of
sodium for adults to reduce risk of hypertension. Advise patients to read
the Nutrition Facts panel on food labels to help them adhere to the
2,300-mg/day guideline and to consider adopting the well-investigated
Dietary Approaches to Stop Hypertension, or DASH Eating Plan (see Table
4-1, Patients with Hypertension: Recommended Changes in Diet, p. 72).
Exe rc is e . Adults should do at least 150 minutes (2 hours and 30 minutes) of moderate-intensity cardiorespiratory activity, for example, walking briskly at a pace of 3 to 4.5 miles per hour, each week. Alternatively,
adults can engage in vigorous-intensity aerobic activity, such as jogging or
running, for 75 minutes (1 hour and 15 minutes) each week. Patients can
increase exercise by such simple measures as parking further away from
their place of work or using stairs instead of elevators.
Techniques of Examination
EXAMINATIO N TECHNIQ UES
P O SSIBLE FIN DIN G S
G e ne ra l S urve y
Ap p a re n t S t a t e o f He a lt h
Acutely or chronically ill, frail, robust,
vigorous
Le ve l o f Co n s c io u s n e s s . Is the
patient awake, alert, and interactive?
If not, promptly assess level of
consciousness (see p. 332)
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Ba te s ’ Poc ke t Guide to Phys ic a l Exa mina tion a nd His tory Ta king
EXAMINATIO N TECHNIQ UES
P O SSIBLE FIN DIN G S
S ig n s o f Dis t re s s
■ Cardiac or respiratory distress
Clutching the chest, pallor, diaphoresis;
labored breathing, wheezing, cough
■ Pain
Wincing, sweating, protecting painful
area
■ Anxiety or depression
Anxious face, fidgety movements, cold
and moist palms; inexpressive or flat
affect, poor eye contact, psychomotor
slowing
S k in C o lo r a n d O b v io u s
Le s io n s . See Chapter 6, The Skin,
Hair, and Nails, for details.
Pallor, cyanosis, jaundice, rashes, bruises
Dre s s , Gro o m in g , a n d Pe rs o n a l
Hyg ie n e
■ How is the patient dressed? Is
Body p iercing or tattoos can b e
associated with alcohol and drug use.
the clothing suitable for the
temperature and weather? Is
it clean and appropriate to the
setting?
■ Note patient’s hair, ngernails,
These may be clues to the patient’s
personality, mood, lifestyle, and
self-regard.
and use of make-up.
Fa c ia l Exp re s s io n . Watch for
eye contact. Is it natural? Sustained
and unblinking? Averted quickly?
Absent?
Stare of hyperthyroidism; flat or sad
affect of depression. Decreased eye
contact may be cultural or may suggest
anxiety, fear, or sadness.
Od o r s o f Bo d y a n d Bre a t h .
Odors can be important diagnostic
clues.
Breat h od or of alcohol, acetone
(d iab etes), uremia, or liver failure.
Fruit y od or of d iab etes. (Never assume
that alcohol on a p at ient ’s b reat h
exp lains changes in mental status or
neurologic find ings.)
Po s t u re , Ga it , a n d Mo t o r
Ac t ivit y
Preference to sit up in left-sided heart
failure and to lean forward with arms
braced in chronic obstructive pulmonary
disease (COPD).
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Chapter 4 | Beginning the Physical Examination: General Survey, Vital Signs, and Pain
EXAMINATIO N TECHNIQ UES
63
P O SSIBLE FIN DIN G S
H e ig h t a n d W e ig h t
He ig h t . Measure the patient’s height
in stocking feet. Note the build—
muscular or deconditioned, tall or
short. Observe the body proportions.
Short stature in Turner syndrome;
elongated arms in Marfan syndrome;
loss of height in osteoporosis.
We ig h t . Is the patient emaciated?
Plump? If obese, is there central or
dispersed distribution of fat? Weigh
the patient with shoes off.
Obesity (BMI ≥30 kg/m 2) increases risk of
diabetes, heart disease, stroke, hypertension, osteoarthritis, sleep apnea syndrome, and some forms of cancer.
Calculate the body mass index
(BMI), which incorporates
estimated but more accurate
measurements of body fat than
weight alone.
M e t h o d s t o C a lc u la t e B o d y M a s s In d e x (B M I)
U n it o f M e a s u r e
M e t h o d o f C a lc u la t io n
Weight in pounds, height in inches
(1) St nd rd BMI Ch rt
(2) Weight (lb ) × 7 a
Height (inches)
Weight in kilograms, height in
meters squared
(3) Weight (kg)
Height ( 2)
Either unit of measure
(4) “BMI C lcul tor” t htt :/ / www.nhlbi.
nih.gov/ he lth/educ tion l/ lose_wt/
BMI/ b ic lc.ht
Sever l org niz tions use 7 4.5, but the v ri tion in BMI is negligible. Conversion for ul s:
2.2 lb = 1 kg; 1 inch = 2.54 c ; 1 c = 1 .
Source: N tion l Institutes of He lth–N tion l He rt, Lung, nd Blood Institute: C lcul te
Your Body M ss Index. Av il ble t: htt :/ / www.nhlbi.nih.gov/ he lth/educ tion l/ lose_
wt/ BMI/ b ic lc.ht . Accessed J nu ry 21, 2 15.
a
If the BMI is above 25, engage the patient in a 24-hour dietary recall and
compare the intake of food groups and number of servings per day with
current recommendations. Or, choose a screening tool and provide appropriate counseling or referral (see Table 4-2, Nutrition Screening, p. 73, and
Table 4-3, Nutrition Counseling, p. 74).
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Ba te s ’ Poc ke t Guide to Phys ic a l Exa mina tion a nd His tory Ta king
If the BMI falls below 17, be concerned about possible anorexia nervosa,
bulimia, or other medical conditions (see Table 4-4, Eating Disorders and
Excessively Low BMI, p. 75).
T h e V it a l S ig n s : B lo o d P r e s s u r e , H e a r t R a t e ,
R e s p ir a t o r y R a t e , a n d T e m p e r a t u r e
Blo o d P re s s u re
M e t h o d s f o r M e a s u r in g Blo o d P r e s s u r e . Office screening with
manual and automated cuffs remains common, but elevated readings
increasingly require confirmation with home and ambulatory monitoring,
which are more predictive of cardiovascular disease and end-organ
damage than manual and automated measurements in the office. Automated ambulatory blood pressure monitoring measures blood pressure
at preset intervals over 24 to 48 hours, usually every 15 to 20 minutes
during the day and 30 to 60 minutes during the night. Be familiar with
these different methods of blood pressure measurement and their varying
criteria for hypertension.
Ty p e s o f Hy p e r t e n s io n . Three types of hypertension are especially
important to recognize, described below. Suspicion of these entities and
assessing the effects of treatment are indications for ambulatory blood
pressure monitoring.
T y p e s o f H y p e r t e n s io n
White coat hypertension
(isolated clinic hypertension)
Masked hypertension
Blood ressure ≥14 /9 in edic l settings nd e n w ke
bul tory
re dings <135/ 85.
Re orted in u to 2 % of tients with
elev ted office blood ressure
C rries nor l to slightly incre sed c rdiov scul r risk nd does not require
tre t ent; ttributed to conditioned
nxiety res onse
Blood ressure <14 /9 , but n elev ted
d yti e blood ressure of >135/ 85 on
ho e or
bul tory testing
Re orted in n esti ted 1 % to 3 % of
the gener l o ul tion
If unt re t ed, it incre ses risk of c rdiov scul r dise se nd end-org n
d
ge
(continued )
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T y p e s o f H y p e r t e n s io n
Nocturnal hypertension
65
(Continued)
Physiologic blood ressure “di ing”
occurs in ost tients s they shift
fro w kefulness to slee
A nocturn l f ll of <1 % of d yti e v lues
is ssoci ted with oor c rdiov scul r
outco es nd c n only be identified on
24-hour
bul tory blood ressure
onitoring
Two other tterns h ve oor c rdiov scul r outco es, nocturn l rising ttern
nd
rked nocturn l f ll of >2 % of
d yti e v lues
S e le c t in g t h e C o r r e c t S iz e B lo o d P r e s s u r e C u f f
It is i ort nt for clinici ns nd tients to use cuff th t fits the
Follow the guidelines outlined here for selecting the correct size:
●
●
●
tient’s r .
Width of the infl t ble bl dder of the cuff should be bout 4 % of u er r
circu ference ( bout 12 to 14 c in the ver ge dult).
Length of the infl t ble bl dder should be bout 8 % of u er r circu ference ( l ost long enough to encircle the r ).
The st nd rd cuff is 12 × 23 c ,
ro ri t e for r circu ferences u t o
28 c .
S t e p s t o E n s u r e A c c u r a t e B lo o d
P re s s u re M e a s u re m e n t
1. The t ient should void s oking or drinking c ffein t ed bever ges
for 3
inut es before t he blood ressure is t ken nd rest for t le st
5 inut es.
2. M ke sure the ex ining roo is quiet nd co fort bly w r .
3. M ke sure the r selected is free of clothing. There should be no rteriovenous
fistul s for di lysis, sc rring fro
rior br chi l rtery cutdowns, or signs of
ly hede
(seen fter xill ry node dissection or r di tion ther y).
4. P l te the br chi l rtery to confir th t it h s vi ble ulse.
5. Position the r so th t the br chi l rtery, t the ntecubit l cre se, is
at heart level—roughly level with the 4th inters ce t its junction with the
sternu .
6. If the tient is se ted, rest the r on t ble little bove the tient’s
w ist; if st nding, try to su ort the tient’s r
t the idchest level.
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M e a s u r in g B lo o d P r e s s u r e
●
●
●
●
●
●
●
●
●
Center the infl t ble bl dder over the br chi l rtery. The lower border of the
cuff should be bout 2.5 c bove the ntecubit l cre se. Secure the cuff
snugly. Position the tient’s r so th t it is slightly flexed t the elbow.
To deter ine how high to r ise the cuff ressure, first esti te the systolic
ressure by l tion. As you feel the r di l rtery with the fingers of one
h nd, r idly infl te the cuff until the r di l ulse dis
e rs. Re d this ressure on the
no eter nd dd 3
Hg to it. Use of this su
s the t rget
for subsequent infl tions revents disco fort fro unnecess rily high cuff
ressures. It lso voids the occ sion l error c used by n uscult tory
g — silent interv l between the systolic nd di stolic ressures.
Defl te the cuff ro tly.
Now l ce the bell of stethosco e lightly over the br chi l rtery, t king c re
to ke n ir se l with its full ri . Bec use the sounds to be he rd (Korotkoff
sounds) re rel tively low in itch, they re he rd better with the bell.
Infl te the cuff r idly g in to the level just deter ined, nd then defl te it
slowly, t r te of bout 2 to 3
Hg er second. Note the level t which you
he r the sounds of t le st two consecutive be ts. This is the systolic pressure.
Continue to lower the ressure slowly. The dis
e r nce oint, usu lly only
few
Hg below the uffling oint, is the best esti te of diastolic pressure.
Re d both the systolic nd di stolic levels to the ne rest 2
Hg. W it 2 or
ore inutes nd re e t. Aver ge your re dings. If the first two re dings
differ by ore th n 5
Hg, t ke ddition l re dings.
T ke blood ressure in both r s t le st once.
In tients t king ntihy ertensive edic tions or with history of f inting,
ostur l dizziness, or ossible de letion of blood volu e, t ke the blood
ressure in two ositions—su ine nd st nding (unless contr indic ted).
A f ll in systolic ressure of 2
Hg or ore within 3 inutes fter st nding u , es eci lly when cco
nied by sy to s, indic tes orthostatic
(postural) hypotension.
In 2013, the Joint National Committee on Detection, Evaluation, and
Treatment of High Blood Pressure ( JNC) updated the classi cation of
systolic blood pressure (SBP) and diastolic blood pressure (DBP).
J N C 8 B lo o d P r e s s u r e C la s s if ic a t io n f o r A d u lt s
C a t e g o ry
Nor l
Prehy ertension
St ge 1 hy ertension
Ages ≥18 to <6 ye rs;
di betes or ren l dise se
Age ≥6 ye rsa
St ge 2 hy ertension
S y s t o lic (m m Hg )
D ia s t o lic (m m Hg )
<12
12 –139
<8
8 –89
14 —159
9 —99
15 –159
≥16
9 –99
≥1
The A eric n Society of Hy ertension r ises this cutoff to ge ≥8 ye rs.
a
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67
When the systolic and diastolic levels fall in different categories, use the
higher category. For example, 170/92 mm Hg is Stage 2 hypertension;
135/100 mm Hg is Stage 1 hypertension. In isolated systolic hypertension,
SBP is ≥140 mm Hg, and DBP is <90 mm Hg.
He a r t Ra t e . The radial pulse is
used commonly to count the heart
rate. With the pads of your index
and middle ngers, compress the
radial artery until you detect a
maximal pulsation (Fig. 4-1). If the
rhythm is regular, count the rate
for 15 seconds and multiply by 4.
If the rate is unusually fast or slow,
count it for 60 seconds. When the
rhythm is irregular, evaluate the
rate by auscultation at the cardiac
apex (the apical pulse).
EXAMINATIO N TECHNIQ UES
Fig ure 4-1 Palpate the radial puls e .
P O SSIBLE FIN DIN G S
Rh yt h m . Palpate the radial
pulse. Check the rhythm again by
listening with your stethoscope
at the cardiac apex. Is the rhythm
regular or irregular? If irregular, try
to identify a pattern: (1) Do early
beats appear in a basically regular
rhythm? (2) Does the irregularity
vary consistently with respiration?
(3) Is the rhythm totally irregular?
Palpation of an irregularly irregular
rhythm reliably indicates atrial fibrillation.
For all irregular patterns, an ECG is
needed to identify the arrhythmia.
Re s p ira t o ry Ra t e a n d Rhyt h m .
Observe the rate, rhythm, depth, and
effort of breathing. Count the number
of respirations in 1 minute either
by visual inspection or by subtly
listening over the patient’s trachea
with your stethoscope during
examination of the head and neck
or chest. Normally, adults take 14
to 20 breaths per minute in a quiet,
regular pattern.
See Table 8-4, p. 162, Abnormalities in
Rate and Rhythm of Breathing.
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EXAMINATIO N TECHNIQ UES
P O SSIBLE FIN DIN G S
Te m p e ra t u re . Average oral temperature, usually 37°C (98.6°F),
uctuates considerably from the
early morning to the late afternoon
or evening. Rectal temperatures are
higher than oral temperatures by
about 0.4 to 0.5°C (0.7 to 0.9°F)
but also vary. Axillary temperatures
are lower than oral temperatures
by approximately 1°C but take
5 to 10 minutes to register and are
considered less accurate than other
measurements.
Tympanic membrane temperatures
can be more variable than oral or
rectal temperatures. Studies suggest that in adults, oral and temporal artery temperatures correlate
more closely with the pulmonary
artery temperature, but are about
0.5°C lower.
Fever or pyrexia refers to an elevated
body temperature. Hyperpyrexia refers to
extreme elevation in temperature, above
41.1°C (106°F), while hypothermia refers
to an abnormally low temperature, below
35°C (95°F) rectally.
Causes of fever includ e infection,
trauma (such as surgery or crush
injuries), malignancy, b lood d isord ers
(such as acute hemolyt ic anemia), d rug
react ions, and immune d isord ers such
as collagen vascular d isease.
The chief cause of hypothermia is
exp osure to cold. Other causes include
reduced movement as in paralysis,
interference with vasoconstriction as
from sepsis or excess alcohol, starvation,
hypothyroidism, and hypoglycemia.
Older adults are especially susceptib le
to hypothermia and also less likely to
develop fever.
Oral temperatures: Choose either
glass or electronic thermometer.
■ Glass thermometer: Shake the ther-
mometer down to 35°C (96°F) or
below, insert it under the tongue,
instruct the patient to close both
lips, and wait 3 to 5 minutes.
Then read the thermometer,
reinsert for 1 minute, and read it
again. Avoid breakage.
■ Electronic thermometer: Carefully
place the disposable cover over
the probe and insert the thermometer under the tongue for
about 10 seconds.
Rectal temperatures: Position the
patient on one side with the hip
exed. Select a rectal thermometer
with a stubby tip, lubricate it, and
Taking rectal temperatures is common
practice in unresponsive patients or
those at risk for biting down on the
thermometer.
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EXAMINATIO N TECHNIQ UES
69
P O SSIBLE FIN DIN G S
insert it about 3 to 4 cm
(1½ inches) into the anal canal,
in a direction pointing to the umbilicus. Remove it after 3 minutes,
then read. Alternatively, use an
electronic thermometer after lubricating the probe cover. Wait about
10 seconds for the digital temperature recording to appear.
Tympanic membrane temperature:
Make sure the external auditory
canal is free of cerumen. Position
the probe in the canal. Wait 2 to
3 seconds until the digital reading
appears. This method measures
core body temperature, which is
higher than the normal oral temperature by approximately 0.8°C
(11.4°F).
Temporal artery temperature:
Place the probe against the center
of the forehead, depress the infrared scanning button, and brush the
device across the forehead, down
the cheek, and behind an earlobe.
Read the display, which records
the highest measure temperature.
Industry information suggests that
combined forehead and behindthe-ear contact is more accurate
than scanning only the forehead.
A c u t e a n d C h r o n ic P a in
The experience of pain is complex and multifactorial. It involves sensory,
emotional, and cognitive processing but may lack a speci c physical
etiology.
Chronic pain is de ned in several ways: pain not associated with cancer or
other clinical conditions that persists for more than 3 to 6 months; pain
lasting more than 1 month beyond the course of an acute illness or injury;
or pain recurring at intervals of months or years. Chronic noncancer pain
affects 5% to 33% of patients in primary care settings.
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Adopt a multidisciplinary measurement-based approach to assessing pain,
carefully listening to the patient’s story, and any contributing factors. Pursue
the seven features of pain, as you would with any symptom. Accept the
patient’s self-report, which experts state is the most reliable indicator of pain.
Location: Ask the patient to point to the pain. Lay terms may not be speci c enough to localize the site of origin.
Severity: Use a consistent method to determine severity. Three scales are
common: the Visual Analog Scale, and two scales using ratings from 1 to
10—the Numeric Rating Scale and the Faces Pain Scale.
Co n t rib u t in g Fa c t o r s . Be sure to ask about any treatments that the
patient has tried, including medications, physical therapy, and alternative medicines. A comprehensive medication history helps you to identify
drugs that interact with analgesics and reduce their ef cacy.
Identify any comorbid conditions such as arthritis, diabetes, HIV/AIDS,
substance abuse, sickle cell disease, or psychiatric disorders. These can
signi cantly affect the patient’s experience of pain.
He a lt h Dis p a rit ie s . Be aware of the well-documented health disparities in pain treatment and delivery of care, which range from lower use of
analgesics in emergency rooms for African-American and Hispanic patients
to disparities in use of analgesics for cancer, postoperative, and low back
pain. Clinician stereotypes, language barriers, and unconscious clinician
biases in decision making all contribute to these disparities. Critique your
own communication style, seek information and best practice standards,
and improve your techniques of patient education and empowerment.
P a in Ma n a g e m e n t . Managing pain is a complex clinical challenge.
Experts recommend a stepped-care approach, with an emphasis on measurement and tracking tools to follow responses to treatment and referrals
to specialists, summarized below.
M a n a g in g C h r o n ic P a in : S t e p s f o r
M e a s u r e m e n t -B a s e d C a r e
Step 1: Measure pain intensity and pain interference. A v lid ted 2-ite questionn ire is v il ble for ri ry c re sking tients to r te in in the st
onth nd interference with d ily ctivities on sc le of 1 to 1 .
Step 2: Measure mood. Tre t ble de ression, nxiety, nd osttr u tic stress
disorder (PTSD) frequently cco
ny chronic in. The PHQ-4 is
4-ite questionn ire for detecting nxiety nd de ression. The Pri ry
C re-PTSD is 4-question screen for PTSD.
(continued )
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Chapter 4 | Beginning the Physical Examination: General Survey, Vital Signs, and Pain
71
M a n a g in g C h r o n ic P a in : S t e p s f o r
M e a s u r e m e n t -B a s e d C a r e (Continued)
Step 3: Measure the effect of pain on sleep. O ioid doses correl te with slee disordered bre thing nd slee
ne .
Step 4: Me sure risk of co-occurring subst nce buse, esti ted t 18% to 3 %.
Step 5: Measure the opioid dose nd c lcul te the o ioid dose equiv lency using
v il ble web-b sed c lcul tors.
Source: T uben D. Chronic in
n ge ent: e sure ent-b sed ste ed c re solutions.
P in: Clinic l U d tes. Intern tion l Associ tion for the Study of P in. Dece ber 2 12.
Av il ble t htt :/ / www.i s - in.org/ Public tionsNews/ NewsletterIssue.
s x?Ite Nu ber=2 64. Accessed J nu ry 28, 2 15.
Recording Your Findings
Record the vital signs taken at the time of your examination. They are
preferable to those taken earlier in the day by other providers. (Common
abbreviations for blood pressure, heart rate, and respiratory rate are selfexplanatory.)
R e c o r d in g t h e P h y s ic a l E x a m in a t io n —G e n e r a l
S u r v e y a n d V it a l S ig n s
“Mrs. Scott is young, he lthye ring wo n, well-groo ed, fit, nd in
good s irits. Height is 5′4″, weight 135 lb, BP 12 / 8 , HR 72 nd regul r, RR 16,
te er ture 37.5°C.”
OR
● “Mr. Jones is n elderly
n who looks le nd chronic lly ill. He is lert,
with good eye cont ct, but c nnot s e k ore th n two or three words t
ti e bec use of shortness of bre th. He h s intercost l uscle retr ction
when bre thing nd sits u right in bed. He is thin, with diffuse uscle w sting. Height is 6′2″, weight 175 lb, BP 16 /95, HR 1 8 nd irregul r, RR 32 nd
l bored, te er ture 1 1.2°F.” (These findings suggest COPD exacerbation.)
●
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Ba te s ’ Poc ke t Guide to Phys ic a l Exa mina tion a nd His tory Ta king
Aids to Interpretation
Table 4-1 Pa t ie n t s w it h Hyp e rt e n s io n :
Re c o m m e n d e d Ch a n g e s in Die t
D ie t a ry C h a n g e
Fo o d S o u r c e
Increase foods high
in potassium
Baked white or sweet potatoes, white beans, beet
greens, soybeans, spinach, lentils, kidney beans
Yogurt
Tomato paste, juice, puree, and sauce
Bananas, plantains, many dried fruits, orange juice
Decrease foods high
in sodium
Canned foods (soups, tuna fish)
Pretzels, potato chips, pizza, pickles, olives
Many processed foods (frozen dinners, ketchup,
mustard)
Batter-fried foods
Table salt, including for cooking
Source: Adapted from: U.S. Department of Agriculture and U.S. Department of Health and
Human Services. Dietary Guidelines for Americans, 2010. Washington, D.C.: U.S. Government Printing Of ce; 2010; Choose MyPlate.gov. Available at http://www.choosemyplate.gov/
index.html. Accessed December 15, 2014; Of ce of Dietary Supplements, National Institutes
of Health. Dietary Supplement Fact Sheets: Calcium; Vitamin D. Available at http://ods.
od.nih.gov/factsheets/list-all/. Accessed December 15, 2014.
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Chapter 4 | Beginning the Physical Examination: General Survey, Vital Signs, and Pain
73
Table 4-2 Nu t rit io n S c re e n in g
Mini Nutritiona l As s e s s me nt
MNA®
La s t name :
S ex:
Firs t name:
Age :
Weight, kg:
He ight, cm:
Da te :
Complete the s cre e n by filling in the boxe s with the a ppropria te numbe rs . Tota l the numbe rs for the final scre ening s core.
S cre e ning
A Has fo o d intake de cline d o ve r the pas t 3 mo nths due to lo s s o f appetite , dig e s tive pro ble ms , c hewing o r
s wallo wing diffic ultie s ?
0 = s e ve re de cre as e in food inta ke
1 = mode rate decrea s e in food intake
2 = no decre as e in food inta ke
B Weig ht lo s s during the las t 3 months
0 = weight los s grea te r tha n 3 kg (6.6 lbs )
1 = doe s not know
2 = weight los s be twe en 1 a nd 3 kg (2.2 and 6.6 lbs )
3 = no weight los s
C Mo bility
0 = bed or chair bound
1 = a ble to ge t out of be d / cha ir but does not go out
2 = goe s out
D Has s uffe re d ps yc ho lo g ic al s tres s o r acute dis e as e in the pas t 3 mo nths ?
0 = ye s
2 = no
E Neuro ps ycho lo g ic al pro ble ms
0 = s e vere dementia or de pre ss ion
1 = mild dementia
2 = no ps ychologica l problems
F1 Bo dy Mas s Inde x (BMI) (weig ht in kg ) / (heig ht in m)2
0 = BMI le ss than 19
1 = BMI 19 to le ss tha n 21
2 = BMI 21 to les s tha n 23
3 = BMI 23 or grea te r
IF BMI IS NOT AVAILABLE, REP LACE QUES TION F1 WITH QUES TION F2.
DO NOT ANSWER QUES TION F2 IF QUES TION F1 IS ALREADY COMP LETED.
F2 Calf circ umfere nc e (CC) in cm
0 = CC le ss tha n 31
3 = CC 31 or grea te r
S cre e ning s core (ma x. 14 points )
12 - 14 po ints : Norma l nutritional s tatus
8 - 11 po ints : At risk of ma lnutrition
0 - 7 po ints : Malnouris he d
Source: Vellas B, Villars H, Abellan G, et al. Overview of the MNA—Its history and challenges. J
Nutr Health Aging. 2006;10:456.
Rubenstein LZ, Harker JO, Salva A, et al. Screening for undernutrition in geriatric practice:
developing the short-form mini nutritional assessment (MNA-SF). J Gerontol A Biol Sci Med
Sci. 2001;56(6):M366.
Guigoz Y. The Mini-Nutritional Assessment (MNA) Review of the Literature—What does it tell
us? J Nutr Health Aging. 2006;10:466.
Kaiser MJ, Bauer JM, Ramsch C, et al. Validation of the Mini Nutritional Assessment Short-Form
(MNA-SF): a practical tool for identi cation of nutritional status. J Nutr Health Aging. 2009;
13:782.
®Société des Produits Nestlé, S.A., Vevey, Switzerland, Trademark Owners
©Nestlé, 1994, Revision 2009. N67200 12/99 10M
For more information: www.mna-elderly.com
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Ba te s ’ Poc ke t Guide to Phys ic a l Exa mina tion a nd His tory Ta king
Table 4-3 Nu t rit io n Co u n s e lin g : S o u rc e s o f N u t r i e n t s
N u t r ie n t
Fo o d S o u r c e
C a lc iu m
Dairy foods such as milk, natural cheeses, and yogurt
Calcium-fortified cereals, fruit juice, soy milk, and tofu
Dark green leafy vegetables like collard, turnip, and
mustard greens; bok choy
Sardines
Iro n
Lean meat, dark turkey meat, liver
Clams, mussels, oysters, sardines, anchovies
Iron-fortified cereals
Enriched and whole grain bread
Spinach, peas, lentils, turnip greens, and artichokes
Dried prunes and raisins
Fo la t e
Cooked dried beans and peas
Oranges, orange juice
Liver
Spinach, mustard greens
Black-eyed peas, lentils, okra, chickpeas, peanuts
Folate-fortified cereals
Vit a m in D
Vitamin D–fortified milk, orange juice, and cereals
Cod liver oil; swordfish, salmon, herring, mackerel,
tuna, trout
Egg yolk
Mushrooms
Source: Adapted from U.S. Department of Agriculture and U.S. Department of Health and
Human Services. Dietary Guidelines for Americans, 2010. Washington, D.C.: U.S. Government Printing Of ce; 2010; Choose MyPlate.gov. Available at http://www.choosemyplate.gov/
index.html. Accessed December 15, 2014; Of ce of Dietary Supplements, National Institutes
of Health. Dietary Supplement Fact Sheets: Calcium; Vitamin D. Available at http://ods.
od.nih.gov/factsheets/list-all/. Accessed December 15, 2014.
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75
Table 4-4 Ea t in g Dis o rd e r s a n d Exc e s s ive ly Lo w BMI
A n o r e x ia N e r vo s a
Bu lim ia N e r vo s a
Refusal to maintain minimally normal
body weight (or BMI above 17.5 kg/m2)
Repeated binge eating followed
by self-induced vomiting,
misuse of laxatives, diuretics, or
other medications; fasting; or
excessive exercise
Fear of appearing fat
Frequently starving but in denial;
lacking insight
Often brought in by family members
May present as failure to make expected
weight gains in childhood or adolescence,
amenorrhea in women, loss of libido or
potency in men
Often with normal weight
Overeating at least twice a week
during 3-month period; large
amounts of food consumed in
short period ( 2 hrs)
Preoccupation with eating;
Associated with depressive symptoms
such as depressed mood, irritability, social craving and compulsion to eat;
lack of control over eating;
withdrawal, insomnia, decreased libido
alternating with periods of
Additional features supporting
starvation
diagnosis: self-induced vomiting or
purging, excessive exercise, use of appetite Dread of fatness but may be
obese
suppressants and/or diuretics
Subtypes of
Biologic complications
■
■
■
■
Neuroendocrine changes: amenorrhea,
hormonal alterations
Cardiovascular disorders: bradycardia,
hypotension, dysrhythmias,
cardiomyopathy
Metabolic disorders: hypokalemia,
hypochloremic metabolic alkalosis,
increased BUN, edema
Other: dry skin, dental caries, delayed
gastric emptying, constipation,
anemia, osteoporosis
Purging: bulimic episodes
accompanied by self-induced
vomiting or use of laxatives,
diuretics, or enemas
■ Nonpurging: bulimic episodes
accompanied by compensatory
behavior such as fasting,
exercise without purging
Biologic complications; see
changes listed for anorexia
nervosa.
■
Sources: World Health Organization. The ICD-10 Classi cation of Mental and Behavioral Disorders:
Diagnostic Criteria for Research. Geneva: World Health Organization, 1993; American Psychiatric Association. DSM-IV-TR: Diagnostic and Statistical Manual of Mental Disorders. 4th ed.
Text Revision. Washington, DC: American Psychiatric Association, 2000. Halmi KA: Eating
disorders: In: Kaplan HI, Sadock BJ, eds. Comprehensive Textbook of Psychiatry, 7th ed.
Philadelphia, PA: Lippincott Williams & Wilkins, 1663–1676, 2000. Mehler PS. Bulimia
nervosa. N Engl J Med. 2003;349(9):875–880.
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5
C H A P T E R
Behavior and
Mental Status
Clinicians are uniquely poised to detect clues to mental illness and
harmful behavior through empathic listening and close observation.
Nonetheless, these clues are often missed. Recognizing mental illness is
especially important given its signi cant prevalence and morbidity, the
high likelihood that it is treatable, the shortage of psychiatrists, and the
increasing importance of primary care clinicians as the rst to encounter
the patient’s distress. The prevalence of mental health disorders in U.S.
adults in 2012 was 18%, affecting 43.7 million people; yet, only 41%
received treatment. Even for those receiving care, adherence to treatment
guidelines in primary care of ces is <50% and disproportionately lower
for ethnic minorities.
Mental health disorders are commonly masked by other clinical conditions. Look for the interaction of anxiety and depression in patients
with substance abuse, termed “dual diagnosis,” because both must be
treated for the patient to achieve optimal function. Watch for underlying psychiatric conditions in “dif cult encounters” and patients with
unexplained symptoms. Explore the outlook of patients with chronic
illness, a group that is especially vulnerable to depression and anxiety.
Nearly half of those with any single mental disorder meet the criteria
for one or more additional disorders, with severity strongly related to
comorbidity.
Approximately 5% of somatic symptoms are acute, triggering immediate
evaluation. Another 70% to 75% are minor or self-limited and resolve
in 6 weeks. Nevertheless, approximately 25% of patients have persisting and recurrent symptoms that elude assessment and fail to improve.
Overall, 30% of symptoms are medically unexplained, masking anxiety,
depression, or even somatoform disorders (see Table 5-1, Somatoform
Disorders: Types and Approach to Symptoms, p. 87). Depression and
anxiety are highly correlated with substance abuse, for example, and
clinicians are advised to look for overlap in these conditions. “Dif cult
patients” are frequently those with multiple unexplained symptoms and
underlying psychiatric conditions that are amenable to therapy. Without
better “dual diagnosis,” patient health, function, and quality of life are
at risk.
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Ba te s ’ Poc ke t Guide to Phys ic a l Exa mina tion a nd His tory Ta king
M e n t a l H e a lt h D is o r d e r s a n d U n e x p la in e d
S y m p t o m s in P r im a r y C a r e S e t t in g s
M e n t a l D is o r d e r s in P r im a ry C a r e
●
●
A roxi tely 2 % of ri ry c re out tients h ve ent l disorders, but
5 % to 75% of these disorders re undetected nd untre ted.
Prev lence of ent l disorders in ri ry c re settings is roughly:
● Anxiety—2 %
● Mood disorders including dysthy
i , de ressive, nd bi ol r
disorders—25%
● De ression—1 %
● So
tofor disorders—1 % to 15%
● Alcohol nd subst nce buse—15% to 2 %
Ex p la in e d a n d U n e x p la in e d S y m p t o m s
●
●
●
Physic l sy to s ccount for
roxi tely 5 % of office visits.
Roughly one third of hysic l sy to s re unex l ined; in 2 % to 25% of
tients, hysic l sy to s beco e chronic or recurring.
In tients with unexplained symptoms, t he rev lence of de ression nd
nxiet y exceeds 5 % nd incre ses wit h the t ot l nu ber of re ort ed
hysic l sy t o s
king det ection nd “du l di gnosis” i ort nt
clinic l go ls.
C o m m o n Fu n c t io n a l S y n d ro m e s
●
●
●
Co-occurrence r tes for common functional syndromes such s irrit ble bowel
syndro e, fibro y lgi , chronic f tigue, te oro ndibul r joint disorder,
nd ulti le che ic l sensitivity re ch 3 % to 9 %, de ending on the disorders co
red.
The rev lence of symptom overlap is high in the co
on function l syndro es: n ely, co l ints of f tigue, slee disturb nce, usculoskelet l
in, he d che, nd g strointestin l roble s.
The co
on function l syndro es lso overl in r tes of function l i
irent, sychi tric co orbidity, nd res onse to cognitive nd ntide ress nt
ther y.
Pe rs o n a lit y Dis o rd e rs . Dif cult patients may have personality disorders resulting in problematic of ce behaviors that escape diagnosis.
The DSM-5 characterizes these disorders as “an enduring pattern of
inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and in exible, has an
onset in adolescence or early adulthood, is stable over time, and leads
to distress or impairment.” These patients have dysfunctional interpersonal coping styles that disrupt and destabilize their relationships, including those with health care providers.
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Chapter 5 | Behavior and Mental Status
79
For unexplained conditions lasting beyond 6 weeks, experts recommend
brief screening questions with high sensitivity and speci city, followed by
more detailed investigation when indicated due to high rates of coexisting
depression and anxiety.
Me n t a l He a lt h S c re e n in g . Unexplained conditions lasting more than
6 weeks are increasingly recognized as chronic disorders that should
prompt screening for depression, anxiety, or both. Because screening
all patients is time consuming and expensive, experts recommend a
two-tiered approach: brief screening questions with high sensitivity and
speci city for patients at risk, followed by more detailed investigation
when indicated.
P a t ie n t Id e n t if ie r s f o r M e n t a l H e a lt h S c r e e n in g
●
●
●
●
●
●
●
●
●
●
Medic lly unex l ined hysic l sy to s— ore th n h lf h ve de ressive
or nxiety disorder
Multi le hysic l or so tic sy to s or “high sy to count”
High severity of the resenting so tic sy to
Chronic in
Sy to s for ore th n 6 weeks
Physici n r ting s “difficult encounter”
Recent stress
Low self-r ting of over ll he lth
High use of he lth c re services
Subst nce buse
The Health History
C o m m o n o r C o n c e r n in g S y m p t o m s
●
●
●
●
Ch nges in ttention, ood, or s eech
Ch nges in insight, orient tion, or e ory
Anxiety, nic, ritu listic beh vior, nd hobi s
Deliriu or de enti
Your assessment of mental status begins with the patient’s rst words. As
you gather the health history, you will quickly observe the patient’s level
of alertness and orientation, mood, attention, and memory. You will learn
about the patient’s insight and judgment, as well as any recurring or unusual
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thoughts or perceptions. For some, you will need to conduct a more formal
evaluation of mental status.
Many of the terms used to describe the mental status examination are familiar
to you from social conversation. Take the time to learn their precise meanings
in the context of the formal evaluation of mental status (see below).
T e r m in o lo g y : T h e M e n t a l S t a t u s E x a m in a t io n
Le ve l o f
C o n s c io u s n e s s
A le r t n e s s o r S t a t e o f Aw a r e n e s s o f t h e
En v iro n m e n t
Attention
The bility to focus or concentr te over ti e on one
t sk or ctivity
The rocess of registering or recording infor tion.
Recent or short-ter
e ory covers inutes,
hours, or d ys; re ote or long-ter
e ory refers
to interv ls of ye rs.
Aw reness of erson l identity, l ce, nd ti e;
requires both e ory nd ttention
Sensory w reness of objects in the environ ent nd
their interrel tionshi s; lso refers to intern l sti uli (e.g., dre s)
The logic, coherence, nd relev nce of the tient's
thoughts, or how eo le think
Wh t the tient thinks bout, including level of
insight nd judg ent
Aw reness th t sy to s or disturbed beh viors re
nor l or bnor l
Process of co
ring nd ev lu ting ltern tives;
reflects v lues th t
y or
y not be b sed on
re lity nd soci l conventions or nor s
An observ ble, usu lly e isodic, feeling tone
ex ressed through voice, f ci l ex ression, nd
de e nor
A ore sust ined e otion th t
y color erson's
view of the world ( ffect is to ood s we ther is to
cli te)
A co lex sy bolic syste for ex ressing, receiving,
nd co rehending words; essenti l for ssessing
other ent l functions
Assessed by voc bul ry, fund of infor tion, bstr ct
thinking, c lcul tions, construction of objects with
two or three di ensions
Memory
Orientation
Perceptions
Thought processes
Thought content
Insight
Judgment
Affect
Mood
Language
Higher cognitive
functions
Assess level of consciousness, general appearance and mood, and ability to
pay attention, remember, understand, and speak.
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Chapter 5 | Behavior and Mental Status
81
Assess the patient’s responses to illness and life circumstances, which
often tell you about his or her insight and judgment. Test orientation and
memory.
Explore any unusual thoughts, preoccupations, beliefs, or perceptions
as they arise during the interview (see Table 20-2, Delirium and
Dementia, pp. 418–419).
Health Promotion and Counseling:
Evidence and Recommendations
Im p o r t a n t T o p ic s f o r H e a lt h P r o m o t io n
a n d C o u n s e lin g
●
●
Screening for de ression nd suicid lity
Screening for subst nce use disorders, including lcohol nd rescri tion
drugs
M o o d D is o r d e r s a n d D e p r e s s io n . Depressive and bipolar disorders affect over 9% of the U.S. population. About 16 million adult Americans, or almost 7%, have major depression, often with coexisting anxiety
disorders and substance abuse. Depression is nearly twice as common in
women as men, and frequently accompanies chronic clinical illness, yet
is frequently underdiagnosed. Look closely for early clues of depression
in primary care settings such as low self-esteem, loss of pleasure in daily
activities (anhedonia), sleep disorders, and dif culty concentrating or
making decisions.
Failure to diagnose depression can have fatal consequences—suicide
rates in patients with major depression are eight times higher than in the
general population. Ask, “Over the past 2 weeks, have you felt down,
depressed, or hopeless?” and “Over the past 2 weeks, have you felt little
interest or pleasure in doing things?”
S u ic id e . Suicide ranks as the 10th leading cause of death in the United
States, accounting for nearly 40,000 deaths annually, and is the second
leading cause of death among 15- to 24-year olds. Suicide rates are highest
among those ages 45 to 54 years, followed by elderly adults ≥age 85 years.
Men have suicide rates nearly four times higher than women, though
women are three times more likely to attempt suicide. Risk factors include
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suicidal or homicidal ideation, intent, or plan; access to the means for suicide; current symptoms of psychosis or severe anxiety; any history of psychiatric illness (especially linked to a hospital admission); substance abuse;
personality disorder; and prior history or family history of suicide. Patients
at high risk should be referred immediately for psychiatric evaluation and
possible hospitalization.
S u b s t a n c e U s e D is o r d e r s , In c lu d in g A lc o h o l a n d
P r e s c r ip t io n D r u g s . The overlap of substance abuse and mental
health disorders is extensive. The 2013 National Survey on Drug Use and
Health showed that 23% of the U.S. population ages 12 years or older
(60.1 million people) reported binge drinking, and over 6% reported
heavy drinking. Over 24 million Americans, or 9.4% of the population, reported use of an illicit drug during the month before the survey,
including nearly 20 million marijuana users, 1.6 million cocaine users,
and 6.5 million users of prescription drugs for nonmedical indications.
Prescription drug abuse now kills more people than illicit substances.
Because screening for alcohol and drug use is part of every patient history, review the screening questions recommended in Chapter 3, Interviewing and the Health History.
Techniques of Examination
T h e M e n t a l S t a t u s E x a m in a t io n
●
●
●
●
●
A e r nce nd beh vior
S eech nd l ngu ge
Mood
Thoughts nd erce tions
Cognition, including e ory, ttention, infor tion nd voc bul ry, c lcul tions, bstr ct thinking, nd construction l bility
Observe the patient’s mental status throughout your interaction.
Test speci c functions if indicated during the interview or physical
examination. The Mental Status Examination consists of ve components: appearance and behavior; speech and language; mood; thoughts and
perceptions; and cognitive function.
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EXAMINATIO N TECHNIQ UES
83
P O SSIBLE FIN DIN G S
A p p e a r a n c e a n d B e h a v io r
Assess the following:
■ Level of Consciousness. Observe
alertness and response to verbal
and tactile stimuli.
■ Posture and Motor Behavior. Observe
pace, range, character, and appropriateness of movements.
■ Dress, Grooming, and Personal
Normal consciousness, lethargy,
obtundation, stupor, coma (see
pp. 331–332)
Restlessness, agitation, bizarre postures,
immobility, involuntary movements
Fastidiousness, neglect
Hygiene
■ Facial Expressions. Assess during
rest and interaction.
■ Manner, Affect, and Relation to
People and Things
Anxiety, depression, elation, anger, and
facial immobility of parkinsonism
An g e r, h ost ilit y, su sp iciou sn e ss, or
e vasiven e ss in p at ie n t s wit h pa ra noia ;
t h e elat ion an d eu p h o ria o f ma nia ;
t h e flat affe ct an d re m ot e n e ss o f
schizophrenia ; t h e ap at hy an d d u lle d
affect of d e p re ssion an d dementia
S p e e c h a n d La n g u a g e
Note quantity, rate, loudness,
clarity, and fluency of speech.
If indicated, test for aphasia. A
person who can write a correct
sentence does not have aphasia.
Ap h asia, d ysp h on ia, d ysart h ria,
ch an g e s wit h m ood d isord e rs
T e s t in g f o r A p h a s ia
Wo r d C o m p r e h e n s io n
Re p e t it io n
N a m in g
Re a d in g C o m p r e h e n s io n
Wr it in g
Ask tient to follow one-st ge co
nd, such
s “Point to your nose.” Try two-st ge co nd: “Point to your outh, then your knee.”
Ask tient to re e t
hr se of one-syll ble
words (the ost difficult re etition t sk): “No
ifs, nds, or buts.”
Ask tient to n e the rts of w tch.
Ask tient to re d
r gr h loud.
Ask tient to write sentence.
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EXAMINATIO N TECHNIQ UES
P O SSIBLE FIN DIN G S
M ood
Ask about the patient’s spirits. Note
nature, intensity, duration, and
stability of any abnormal mood. If
indicated, assess risk of suicide.
Happiness, elation, depression, anxiety,
anger, indifference
T h o u g h t a n d P e r c e p t io n s
Thought Processes. Assess logic, relevance, organization, and coherence.
Derailments, flight of ideas, incoherence,
confabulation, blocking
Thought Content. Ask about and
explore any unusual or unpleasant
thoughts.
Obsessions, compulsions, delusions,
feelings of unreality
Perceptions. Ask about any unusual
perceptions (e.g., seeing or hearing
things).
Illusions, hallucinations
Insight and Judgment. Assess
patient’s insight into the illness and
level of judgment used in making
decisions or plans.
Recognition or denial of mental cause
of symptoms; bizarre, imp ulsive, or
unrealistic judgment
C o g n it iv e F u n c t io n s
If indicated, assess:
Orientation to time, place, and person
Disorientation
Attention
■ Digit span—ability to repeat a
series of numbers forward and
then backward
Poor performance of digit span, serial 7s,
and spelling backward are common in
dementia and delirium but have other
causes, too.
■ Serial 7s—ability to subtract 7
repeatedly, starting with 100
■ Spelling backward of a ve-letter
word, such as W-O-R-L-D
Remote Memory (e.g., birthdays,
anniversaries, social security number, schools, jobs, wars)
Impaired in late stages of dementia
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Chapter 5 | Behavior and Mental Status
EXAMINATIO N TECHNIQ UES
Recent Memory (e.g., events of the day)
New Learning Ability—ability to
repeat three or four words after a
few minutes of unrelated activity
85
P O SSIBLE FIN DIN G S
Recent memory and new learning ability
impaired in dementia, delirium, and
amnestic disorders
H ig h e r C o g n it iv e F u n c t io n s
If indicated, assess:
Information and Vocabulary. Note
range and depth of patient’s
information, complexity of ideas
expressed, and vocabulary used.
For the fund of information, ask
names of presidents, other political
gures, or large cities.
These attributes reflect intelligence,
education, and cultural background.
They are limited by mental retardation
but are fairly well preserved in early
dementia.
Calculating Abilities, such as addition, subtraction, and multiplication
Poor calculation in mental retardation
and dementia
Abstract Thinking—ability to respond
abstractly to questions about
Concrete resp onses (observab le details
rather than concepts) are common in
mental retardation, dementia, and
delirium. Responses are sometimes
b izarre in schizophrenia.
■ The meaning of proverbs, such as
“A stitch in time saves nine.”
■ The similarities of beings or
things, such as a cat and a
mouse or a piano and a violin
Constructional Ability. Ask patient:
■ To copy gures such as circle,
Imp aired ability common in dementia
and with parietal lobe damage
cross, diamond, and box, and
two intersecting pentagons, or
■ To draw a clock face with num-
bers and hands
S p e c ia l T e c h n iq u e
Min i-Me n t a l S t a t e Exa m in a t io n (MMS E). This brief test is useful
in screening for cognitive dysfunction and dementia and following their
course over time. For more detailed information regarding the MMSE, contact the Publisher, Psychological Assessment Resources, Inc., 16204 North
Florida Avenue, Lutz, Florida 33549. Some sample questions are given on
the next page.
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M M S E S a m p le It e m s
Orient ation to Time
Registration
Naming
Reading
“Wh t is the d te?”
“Listen c refully. I
going to s y three words.
You s y the b ck fter I sto . Re dy? Here they
re . . . APPLE ( use), PENNY( use), TABLE ( use).
Now re e t those words b ck to e.” (Re e t u
to five ti es, but score only the first tri l.)
“Wh t is this?” (Point to encil or en.)
“Ple se re d this nd do wh t it s ys.” (Show
ex inee the words on the sti ulus for .)
CLOSE YOUR EYES
Re roduced by s eci l er ission of the Publisher, Psychologic l Assess ent Resources,
Inc., 162 4 North Florid Avenue, Lutz, Florid 33549, fro the Mini Ment l St te Ex in tion, by M rsh l Folstein nd Sus n Folstein, Co yright 1975, 1998, 2 1 by Mini Ment l
LLC, Inc. Published 2 1 by Psychologic l Assess ent Resources, Inc. Further re roduction is rohibited without er ission of PAR, Inc. The MMSE c n be urch sed fro PAR,
Inc. by c lling (813) 968–3 3.
Recording Your Findings
R e c o r d in g t h e B e h a v io r a n d M e n t a l
S t a t u s E x a m in a t io n
“Mental Status: The tient is lert, well-groo ed, nd cheerful. S eech is fluent
nd words re cle r. Thought rocesses re coherent, insight is good. The
tient is oriented to erson, l ce, nd ti e. Seri l 7s ccur te; recent nd
re ote e ory int ct. C lcul tions int ct.”
OR
“Mental Status: The tient
e rs s d nd f tigued; clothes re wrinkled.
S eech is slow nd words re u bled. Thought rocesses re coherent, but
insight into current life reverses is li ited. The tient is oriented to erson,
l ce, nd ti e. Digit s n, seri l 7s, nd c lcul tions ccur te, but res onses
del yed. Clock dr wing is good.” (These findings suggest depression.)
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87
Aids to Interpretation
Table 5-1
S o m a t o fo rm Dis o rd e r s :
Typ e s a n d Ap p ro a ch t o S ym p t o m s
Ty p e o f D is o r d e r
D ia g n o s t ic Fe a t u r e s
Somatic symptom
disorder
Somatic symptoms are either very distressing or
result in significant disruption of functioning, as
well as excessive and disproportionate thoughts,
feelings, and behaviors related to those
symptoms. Symptoms should be specific if with
predominant pain.
Illness anxiety
disorder
Preoccupation with having or acquiring a serious
illness where somatic symptoms, if present, are
only mild in intensity.
Conversion disorder
Syndrome of symptoms of deficits mimicking
neurologic or clinical illness in which
psychological factors are judged to be of
etiologic importance.
Psychological factors
affecting other clinical
conditions
Presence of one or more clinically significant
psychological or behavioral factors that adversely
affect a clinical condition by increasing the risk
for suffering, death, or disability
Factitious disorder
Falsification of physical or psychological signs or
symptoms, or induction of injury or disease,
associated with identified deception. The individual
presents himself or herself as ill, impaired, or injured
even in the absence of external rewards.
O t h e r Re la t e d D is o r d e r s o r Be h a v io r s
Body dysmorphic
disorder
Preoccupation with one or more perceived defects
or flaws in physical appearance that are not
observable or appear only slight to others
Dissociative disorder
Disruption of and/or discontinuity in the normal
integration of consciousness, memory, identity,
emotion, perception, body representation, motor
control, and behavior
Note to readers: Regarding tables in past editions on mood, anxiety, and psychotic disorders,
per current DSM-5 copyright, readers are referred to the DSM-5 for further diagnostic
information.
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6
C H A P T E R
The Skin, Hair, and Nails
This edition provides a helpful new approach that features careful history
taking; thorough inspection and palpation of benign and suspicious lesions
to better detect the three major skin cancers–basal cell carcinoma, squamous
cell carcinoma, and melanoma; focused techniques for assessing changes in
the hair and nails; accurate use of terminology to describe your ndings;
and visual familiarity with important common benign and malignant skin
conditions.
The Health History
C o m m o n o r C o n c e r n in g S y m p t o m s
●
●
●
Growths
R sh
H ir loss
Gro w t h s . Ask about any new growths or rashes: “Have you noticed any
changes in your skin? . . . your hair? . . . your nails?” “Have you had any
rashes? . . . sores? . . . lumps? . . . itching?” Pursue the personal and family
history of skin cancer and note the type, location, and date of occurrence.
Ask about regular self-skin examination and use of sunscreen.
Ra s h e s . Ask about itching, the
most important symptom when
assessing rashes. Does itching
precede the rash or follow the
rash? For itchy rashes, ask about
seasonal allergies with itching and
watery eyes, asthma, and atopic
dermatitis. Can the patient sleep
all night or does itching wake up
the patient?
Causes of generalized itching, without
apparent rash, include dry skin; pregnancy; uremia; jaundice; lymphomas
and leukemia; drug reactions; and, less
commonly, polycythemia vera and
thyroid disease.
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Ha ir Lo s s o r Na il Ch a n g e s .
Ask if there is hair thinning or
hair shedding and, if so, where. If
shedding, does the hair come out
at the roots or break along the hair
shafts? Be familiar with common
nail changes such as onychomycosis, habit tic deformity, and
melanonychia, shown in Table 6-8,
pp. 113–114.
Hair shedding at the roots is common in
telogen effluvium and alopecia areata.
Hair breaks along the shaft suggest
damage from hair care or tinea ca pitis.
Health Promotion and Counseling:
Evidence and Recommendations
Im p o r t a n t T o p ic s f o r H e a lt h P r o m o t io n
a n d C o u n s e lin g
●
●
Skin c ncer revention
Skin c ncer screening
S k in Ca n c e r P re ve n t io n . Skin cancers affect an estimated one in ve
Americans during their lifetime. The most common skin cancer is BCC,
followed by SCC, and melanoma.
M e la n o m a . Although it is the least common skin cancer, melanoma is
the most lethal due to its high rate of metastasis and high mortality at
advanced stages, causing over 70% of skin cancer deaths. The incidence of
melanoma has the most rapid increase of any cancer and is now the fifth
most frequently diagnosed cancer in men and the seventh most frequently
diagnosed in women.
Use of the Melanoma Risk Assessment Tool developed by the National
Cancer Institute, available at http://www.cancer.gov/melanomarisktool/
to assess an individual’s 5-year risk of melanoma based on geographic
location, gender, race, age, history of blistering sunburns, complexion,
number and size of moles, freckling, and sun damage.
Avo id in g U lt r a v io le t Ra d ia t io n a n d Ta n n in g Be d s . Increasing
lifetime sun exposure correlates directly with increasing risk of skin cancer. Intermittent sun exposure appears to be more harmful than chronic
exposure. The best defense against skin cancers is to avoid ultraviolet
radiation exposure by limiting time in the sun, avoiding midday sun, using
sunscreen, and wearing sun-protective clothing with long sleeves and
hats with wide brims. Advise patients to avoid indoor tanning, especially
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Chapter 6 | The Skin, Hair, and Nails
91
children, teens, and young adults. Use of indoor tanning beds, especially
before age 35 years, increases risk of melanoma by as much as 75%. In 2009,
the International Agency for Research on Cancer classified ultraviolet-emitting
tanning devices as “carcinogenic to humans.”
Re g u la r U s e o f S u n s c r e e n P r e ve n t s S k in C a n c e r. A landmark
study in 2011 demonstrated that the regular use of sunscreen decreases the
incidence of melanoma. Advise patients to use at least sun-protective factor (SPF) 30 and broad-spectrum protection. For water exposure, patients
should use water-resistant sunscreens.
S k in Ca n c e r S c re e n in g . Although the USPSTF found insuf cient
evidence (grade I) to recommend routine skin cancer screening, it does
advise clinicians to “remain alert for skin lesions with malignant features”
during routine physical examinations and reference the ABCDE criteria.
The American Cancer Society (ACS) and the AAD recommend full-body
examinations for patients over age 50 years or at high risk, because melanoma can appear in any location. High-risk patients are those with a
personal or family history of multiple or dysplastic nevi or previous melanoma. Both new and changing nevi should be closely examined, as at least
half of melanomas arise de novo from isolated melanocytes rather than
pre-existing nevi.
S c r e e n in g fo r M e la n o m a : Th e A BC D Es . Clinicians should apply the
ABCDE-EFG method when screening moles for melanoma (this does not
apply for nonmelanocytic lesions like seborrheic keratoses). The sensitivity
of this tool for detecting melanoma ranges from 43% to 97%, and specificity from 36% to 100%; diagnostic accuracy depends on how many criteria
are used to define abnormality.
T h e A B C D E R u le
If two or ore of the ABCDE criteri re resent, risk of el no
incre ses
nd bio sy should be considered. So e h ve suggested dding EFG to hel
detect ggressive nodul r el no s.
M e la n o m a
Be n ig n N e v u s
Asymmetry
Of one side of ole co red to the other
(continued )
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T h e A B C D E R u le
(Continued)
M e la n o m a
Be n ig n N e v u s
Border irregularity
Es eci lly if r gged,
notched, or blurred
Color variations a
More th n two colors,
es eci lly blue-bl ck, white
(loss of ig ent due to
regression), or red (infl tory re ction to bnor l
cells)
Diameter >6 mmb
A roxi tely the size
of encil er ser
Evolving c
Or ch nging r idly in size,
sy to s, or or hology
●
●
●
Elev ted
Fir to l tion
Growing rogressively over sever l weeks
With the exce tion of ho ogeneous blue color in blue nevus, blue or bl ck color within
l rger ig ented lesion is es eci lly concerning for el no .
b
E rly el no s
y be <6
, nd
ny benign lesions re >6
.
c
Evolution, or ch nge, is the ost sensitive of these criteri . A reli ble history of ch nge
y
ro t bio sy of benigne ring lesion.
a
P a t ie n t S c r e e n in g : Th e S e lf -S k in Ex a m in a t io n . The AAD and the
ACS recommend regular self-skin examination. Instruct patients with risk
factors for skin cancer and melanoma, especially those with a history of
high sun exposure, prior or family history of melanoma, and ≥50 moles or
>5 to 10 atypical moles, to perform regular self-skin examinations.
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93
Techniques of Examination
EXAMINATIO N TECHNIQ UES
P O SSIBLE FIN DIN G S
F u ll-B o d y a n d In t e g r a t e d S k in E x a m in a t io n s
Perform a full-body skin examination in the context of the overall
physical examination. Inspect and
palpate all skin lesions, focusing on
key features that help distinguish
if lesions are benign or suspicious
for malignancy. Are they raised,
at, or uid- lled? Are they rough
or smooth? What about color? Is
the lesion pink or brown? Measure
the size. Is the size changing? Learn
to describe each lesion accurately,
using the terminology speci ed
below. Changing moles, a history
of skin cancer, and other risk factors all warrant a full-body skin
examination.
See Tab le s 6-1 t o 6-5, p p. 100–108,
for exam p le s of p rim ary le sion s (flat ,
raised , an d flu id -fille d ; p u st u les,
fu ru n cle s, n od u le s, cyst s, wh e als, an d
b u rrows); an d rou g h , p in k, an d b rown
le sion s.
Even during routine examinations, you can pursue an integrated skin examination as you examine areas on the head and neck, arms and hands, and
over the back as you listen to the lungs that are already easily accessible.
Integrating the skin examination into the physical examination and routinely recording your ndings as part of the general write-up saves time
and contributes to earlier detection of skin cancers, when they are easier to
treat. Systemic illnesses also have many associated skin ndings.
P r e p a r in g f o r t h e E x a m in a t io n
Make sure there is good overhead ambient lighting or natural light from
windows. Add a strong light source if the room is dark. You will also
need a small ruler or tape measure and a small magnifying glass to help
you document important features of skin lesions, such as size, shape,
color, and texture. Dermoscopy provides cross-polarized or unpolarized
light to visualize patterns of pigmentation or vascular structures and
improves the sensitivity and speci city of differentiating melanomas from
benign lesions.
Ask the patient to change into a gown with the opening in the back and
clothes removed except for underwear. Before beginning the examination,
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cleanse your hands thoroughly. It is important for you to palpate lesions
for texture, rmness, and scaliness.
Im p o r t a n t Te r m s fo r D e s c r ib in g S k in Le s io n s . It is important
to use speci c terminology. Good descriptions include each of the following
elements: type of primary lesion, number, size, shape, color, texture,
location, and con guration.
D e s c r ib in g S k in F in d in g s
Primary lesions are flat or raised.
●
●
●
Flat: You c nnot l te the lesion with your eyes closed.
● Macule: Lesion is fl t
nd <1 c .
● Patch: Lesion is fl t
nd >1 c .
Raised: You c n l te the lesion with eyes closed.
● Papule: Lesion is r ised, <1 c
, nd not fluid-filled.
● Plaque: Lesion is r ised, >1 c
, but not fluid-filled.
● Vesicle: Lesion is r ised, <1 c
, nd filled with fluid.
● Bulla: Lesion is r ised, >1 c
, nd fluid-filled.
Other primary lesions include erosions, ulcers, nodules, ecchy oses,
etechi e, nd l ble ur ur .
Number: Lesions c n be solit ry or ulti le. If ulti le, record how
ny.
Also consider esti ting the tot l nu ber of the ty e of lesion you re
describing.
Size: Me sure with ruler in illi eters or centi eters. For ov l lesions, e sure in the long xis then er endicul r to the xis.
Shape: So e good words to le rn re “circul r,” “ov l,” “ nnul r” (ring-like,
with centr l cle ring), “nu
ul r” (coin-like, no centr l cle ring), nd
“ olygon l.”
Color: Be cre tive. Refer to color wheel if needed. There re
ny sh des of
brown, but you c n st rt with t n, light brown, nd d rk brown.
●
●
Use “skin-colored” when
ro ri te.
For red lesions or r shes, bl nch the
lesion by ressing it fir ly with your
finger or gl ss slide to see if the
redness te or rily lightens then
refills.
Texture: P l te the lesion to see if it
is s ooth, fleshy, verrucous, w rty, or
sc ly (fine, ker totic, or gre sy sc le).
Blanching lesions are erythematous and
suggest inflammation. Nonblanching
lesions, petechiae, purpura, and vascular
structures are red, purple, and
violaceous but not erythematous.
See Table 6-6, Vascular and Purpuric
Lesions of the Skin, pp. 109–110.
Scaling can be greasy, like seborrheic
dermatitis or seborrheic keratoses, dry
and fine like tinea pedis, or hard and
keratotic like actinic keratoses or SCC.
(continued )
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EXAMINATIO N TECHNIQ UES
D e s c r ib in g S k in F in d in g s
95
P O SSIBLE FIN DIN G S
(Continued )
Location: Be s s ecific s ossible. For single lesions, e sure their dist nce
fro other l nd rks (e.g., 1 c l ter l to left or l co
issure).
Configuration: Describing
often very hel ful.
tterns is
For ore infor tion nd ddition l
illustr tions of e ch of these ele ents,
Le rnDer is free nd very hel ful
website.
Te c h n iq u e s o f Exa m in a t io n —
P a t ie n t S e a t e d . Choose one of
two patient positions for performing the full-body skin examination.
The patient can be seated or lie
supine then prone. Plan to examine
the skin in the same order every time,
so you are less likely to skip part of
the examination.
Examples are herpes zoster with unilateral and dermatomal vesicles; herpes
simplex, with grouped vesicles or pustules on an erythematous base; tinea
pedis with annular lesions; and poison
ivy allergic contact dermatitis with linear
lesions.
Fig ure 6-1 Part the hair on the s calp.
Stand in front of the patient and
adjust the table to a comfortable
height. Start by examining the hair
and scalp (Fig. 6-1).
Alopecia, or hair loss, can be diffuse, patchy,
or total. Male and female pattern hair loss
are normal with aging. Focal patches may
be lost suddenly in alopecia areata. Refer
scarring alopecia to a dermatologist.
Sparse hair is seen in hypothyroidism; ne, silky hair in hyperthyroidism.
See Table 6-7, Hair Loss, pp. 111–112.
Inspect the head and neck, including the forehead; eyes including
eyelids, conjunctivae, sclerae, eyelashes, and eyebrows; nose, cheeks,
lips, oral cavity, and chin; and
anterior neck (Figs. 6-2 to 6-4).
Look for signs of basal cell carcinoma on
the face. See Table 6-4, Pink Lesions: Basal
Cell Carcinoma and Its Mimics, p. 106.
Move the gown to see each area.
Ask permission rst.
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EXAMINATIO N TECHNIQ UES
P O SSIBLE FIN DIN G S
Fig ure 6-2 Ins pe ct the fore he ad.
Fig ure 6-3 Ins pe ct the face , eye s ,
and e ars .
Fig ure 6-4 Ins pe ct the ante rior ne ck.
Inspect the shoulders, arms, and
hands (Fig. 6-5). Inspect and
palpate the ngernails. Note their
color, shape, and any lesions.
See Table 6-8, Findings in or near the
Nails, pp. 113–114.
Inspect the chest and abdomen
(Fig. 6-6). Lower or raise the gown
to expose these areas and cover up
when you are nished.
Fig ure 6-5 Ins pe ct the arm s , hands ,
Fig ure 6-6 Ins pe ct the che s t and
and nails .
abdom e n.
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EXAMINATIO N TECHNIQ UES
97
P O SSIBLE FIN DIN G S
Inspect the thighs and lower legs
(Fig. 6-7). Inspect and palpate the
toenails, and inspect the soles and
between the toes (Fig. 6-8).
Fig ure 6-7 Ins pe ct the thighs and
Fig ure 6-8 Ins pe ct the s ole s of the
lowe r le gs .
fe e t and be twe e n the toe s .
Ask the patient to stand so that you
inspect the lower back and posterior
legs (Fig. 6-9). If needed, uncover the
buttocks. Examination of the breasts
and genitalia may be saved for last.
Te ch n iq u e s o f Exa m in a t io n —P a t ie n t S u p in e a n d
P ro n e . Some clinicians prefer
this positioning for more thorough
examinations (Fig. 6-10). With the
patient supine, inspect the scalp,
face, and anterior neck; the shoulders,
arms, and hands; the chest and abdomen; anterior thighs; and lower legs,
feet, and, if appropriate, the genitalia.
Ask permission when moving the
gown to expose different areas, and
let the patient know which areas
you will be examining next.
Ask the patient to turn over to the
prone position, lying face down.
Look at the posterior scalp, posterior neck, back, posterior thighs, legs,
soles of the feet, and buttocks (if
appropriate).
Fig ure 6-9 Ins pe ct the back, buttocks ,
and pos te rior le gs .
Fig ure 6-10 Ins pe ct the s calp, arm s ,
hands , che s t, abdom e n, ante rior and
pos te rior thighs , and fe e t.
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Ba te s ’ Poc ke t Guide to Phys ic a l Exa mina tion a nd His tory Ta king
EXAMINATIO N TECHNIQ UES
P O SSIBLE FIN DIN G S
S p e c ia l T e c h n iq u e s
Th e P a t ie n t S e lf -S k in Ex a m in a t io n . The patient will need a fulllength mirror, a hand-held mirror, and a well-lit room that provides privacy.
Teach the patient the ABCDE-EFG method for assessing moles. Help them
and to identify melanomas by looking at photographs of benign and malignant nevi on easy-to-access websites, handouts, or tables in this chapter.
Ex a m in in g t h e P a t ie n t w it h
Ha ir Lo s s . Examine the hair to
determine the overall pattern of
hair loss or hair thinning. Inspect
the scalp for erythema, scaling,
pustules, tenderness, bogginess,
and scarring. Look at the width of
the hair part in various sections
of the scalp. For shedding from
the roots, perform a hair pull test
by gently grasping 50 to 60 hairs
with your thumb and index and
middle ngers, pulling rmly
away from the scalp (Fig. 6-11).
If all the hairs have telogen bulbs,
the most likely diagnosis is telogen
ef uvium. For fragility, perform the
tug test by holding a group of hairs
in one hand, pulling along the hair
shafts with the other (Fig. 6-12); if
any hairs break, it is abnormal.
Possible internal causes of diffuse
nonscarring hair shedding in young
women are iron-deficiency anemia and
hyper- or hypothyroidism.
Fig ure 6-11 Hair pull te s t.
Fig ure 6-12 Tug te s t.
Eva lu a t in g t h e Be d b o u n d
P a t ie n t . People con ned to bed,
especially when they are emaciated,
elderly, or neurologically impaired,
are particularly susceptible to pressure sores. Carefully inspect the skin
that overlies the sacrum, buttocks,
greater trochanters, knees, and
heels. Roll the patient onto one
side to see the low back and gluteal
area best.
Local redness of the skin warns of
impending necrosis, although some
deep pressure sores develop without
antecedent redness. Inspect closely for
skin breaks and ulcers.
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99
Recording Your Findings
As stated on p. 94, use speci c terms to describe skin lesions and rashes,
including number of lesions, size, color, shape, texture, location, con guration, and whether a primary lesion.
R e c o r d in g t h e S k in , H a ir , a n d N a ils E x a m in a t io n
“Skin w r
nd dry. N ils without clubbing or cy nosis. A roxi tely 2
brown, round
cules on u er b ck, chest, nd r s, re ll sy
etric in igent tion, none sus icious. No r sh, etechi e, or ecchy oses.” (These findings
suggest normal nevi and perfusion without any rashes or suspicious lesions.)
OR
“Sc ttered stuck-on verrucous l ques on b ck nd bdo en. Over 3 s ll
round brown
cules with sy
etric ig ent tion on b ck, chest, nd r s.
Single 1.2 × 1.6 c sy
etric d rk brown nd bl ck l que with erythe tous,
uneven border, on left u er r .” (These findings suggest normal seborrheic keratoses and benign nevi, but also a possible malignant melanoma.)
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Aids to Interpretation
Table 6-1 De s c rib in g P rim a ry S k in Le s io n s :
Fla t , Ra is e d , a n d Flu id -Fille d
Describe skin lesions accurately, including number, size, color, texture,
shape, primary lesion, location, and configuration. This table identifies
common primary skin lesions and includes classic descriptions of each
lesion with the diagnosis in italics.
Fla t s p o t s : If you run your finger over the lesion but do not feel the
lesion, the lesion is flat. If a flat spot is small (<1 cm), it is a macule. If a
flat spot is larger (>1 cm), it is a patch.
Macules (flat, small)
Multiple 3–8-mm erythematous
confluent round macules on chest, back,
and arms; morbilliform drug eruption
Patches (flat, large)
Bilaterally symmetric erythematous
patches on central cheeks and eyebrows,
some with overlying greasy scale;
seborrheic dermatitis
Large confluent completely depigmented
patches on dorsal hands and distal
forearms; vitiligo
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Chapter 6 | The Skin, Hair, and Nails
Table 6-1
101
De s c rib in g P rim a ry S k in Le s io n s :
Fla t , Ra is e d , a n d Flu id -Fille d (continued )
Ra is e d s p o t s : If you run your finger over the lesion and it is palpable
above the skin, it is raised. If a raised spot is small (<1 cm), it is a papule.
If a raised spot is larger (>1 cm), it is a plaque.
Papules (raised, small)
Multiple 2–4-mm soft, fleshy skincolored to light brown papules on lateral
neck and axillae in skin folds; skin tags
Scattered erythematous round drop-like,
flat-topped well-circumscribed scaling
papules and plaques on trunk; guttate
psoriasis
Plaques (raised, large)
Scattered erythematous to bright pink
well-circumscribed flat-topped plaques
on extensor knees and elbows, with
overlying silvery scale; plaque psoriasis
Multiple round coin-like eczematous
plaques on arms, legs, and abdomen,
with overlying dried transudate crust;
nummular dermatitis
(table continues on page 102)
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Ba te s ’ Poc ke t Guide to Phys ic a l Exa mina tion a nd His tory Ta king
Table 6-1
De s c rib in g P rim a ry S k in Le s io n s :
Fla t , Ra is e d , a n d Flu id -Fille d (continued )
Flu id -f ille d le s io n s : If the lesion is raised, filled with fluid, and small
(<1 cm), it is a vesicle. If a fluid-filled spot is larger (>1 cm), it is a bulla.
Vesicles (fluid-filled, small)
Multiple 2–4-mm vesicles and pustules
on erythematous base, grouped together
on left neck; herpes simplex virus
Bullae (fluid-filled, large)
Several tense bullae on lower legs; insect
bites
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Chapter 6 | The Skin, Hair, and Nails
103
Table 6-2 Ad d it io n a l P rim a ry Le s io n s : P u s t u le s ,
Fu ru n c le s , No d u le s , Cys t s , Wh e a ls , Bu rro w s
Pustule: Small palpable collection of neutrophils or keratin that appears white
15–20 pustules and acneiform papules on
buccal and parotid cheeks bilaterally; acne
vulgaris
Furuncle: Inflamed hair follicle; multiple furuncles together form a carbuncle
Two large (2-cm) furuncles on forehead,
without fluctuance; furunculosis (Note:
fluctuant deep infections are abscesses)
Nodule: Larger and deeper than a papule
Solitary blue-brown 1.2-cm firm nodule
with positive dimple sign and
hyperpigmented rim on left lateral thigh;
dermatofibroma
Solitary 4-cm pink and brown scar-like
nodule on central chest at site of previous
trauma; keloid
(table continues on page 104)
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Ba te s ’ Poc ke t Guide to Phys ic a l Exa mina tion a nd His tory Ta king
Table 6-2
Ad d it io n a l P rim a ry Le s io n s : P u s t u le s ,
Fu ru n c le s , No d u le s , Cys t s , Wh e a ls ,
Bu rro w s (continued )
Subcutaneous mass/cyst: Whether mobile or fixed, cysts are encapsulated
collections of fluid or semisolid
Three 6–8-mm mobile subcutaneous cysts
on vertex scalp, that on excision reveal
pearly white balls; pilar cysts
Solitary 9-cm mobile rubbery subcutaneous
mass on left temple; lipoma
Wheal: Area of localized dermal edema that evanesces (comes and goes)
within a period of 1–2 days; this is the essential primary lesion of urticaria
Many variably sized (1–10-cm) wheals on
lateral neck, shoulders, abdomen, arms, and
legs; urticaria
Burrow: Small linear or serpiginous pathways in the epidermis created by
the scabies mite
Multiple small (3–6-mm) erythematous
papules on abdomen, buttocks, scrotum,
and shaft and head of penis, with four
burrows noted on interdigital web spaces;
scabies
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Chapter 6 | The Skin, Hair, and Nails
105
Table 6-3 Ro u g h Le s io n s : Ac t in ic Ke ra t o s e s
a n d S q u a m o u s Ce ll Ca rc in o m a
Patients commonly report feeling rough lesions. Many are benign, like
seborrheic keratoses or warts, but squamous cell carcinoma (SCC) and its
precursor actinic keratosis can also feel rough or keratotic.
Ac t in ic k e r a t o s is
■
■
Often easier to feel than to see
Superficial keratotic papules that
“come and go,” on sun-damaged
skin
Wa r t s
■
■
■
Usually skin-colored to pink, texture
more verrucous than keratotic
May be filiform
Often have hemorrhagic punctate
that can be seen with a magnifying
glass or dermatoscope
S q u a m o u s c e ll c a r c in o m a
■
■
■
Keratoacanthomas are SCCs that arise
rapidly and have a crateriform center
Often have a smooth but firm border
SCCs can become quite large if left
untreated (Note: highest sites of
metastasis are the scalp, lips, and ears)
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Ba te s ’ Poc ke t Guide to Phys ic a l Exa mina tion a nd His tory Ta king
Table 6-4 P in k Le s io n s : Ba s a l Ce ll Ca rc in o m a
a n d it s Mim ic s
Basal cell carcinoma (BCC) is the most common cancer in the world.
Fortunately, it rarely spreads to other parts of the body. Nonetheless, it can
invade and destroy local tissues, causing significant morbidity to the eye,
nose, or brain.
Ba s a l C e ll C a r c in o m a
S u p e r f ic ia l b a s a l c e ll c a r c in o m a
■
■
Pink patch that does not heal
May have focal scaling
N o d u la r b a s a l c e ll c a r c in o m a
■
■
■
Pink papule, often with translucent
or pearly appearance and overlying
telangiectasias
May have focal pigmentation
Dermoscopy shows arborizing
vessels, focal pigment globules, and
other specific patterns
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Chapter 6 | The Skin, Hair, and Nails
107
Table 6-5 Bro w n Le s io n s : Me la n o m a a n d It s Mim ic s
Most patients have brown spots on their body surface. Although these are
usually freckles, benign nevi, solar lentigines, or seborrheic keratoses, you and
the patient must look closely for any that stand out as a possible melanoma.
With enough practice, when you see a melanoma, it will stick out as the “ugly
duckling.” Review the ABCDE rule and photographs on pp. 91–92.
M e la n o m a
M im ic s
A m e la n o t ic m e la n o m a
S k in t a g s o r in t ra d e rm a l n e vi
■
■
Usually in very fair-skinned
people
Evolution or rapid change is
the most important feature,
because variegation or dark
pigment is missing in this type
■
■
■
M e la n o m a in s it u
■
■
On sun-exposed or sunprotected skin
Look for ABCDE features
Soft and fleshy
Often around neck, axillae, or
back
Sessile nevi may have a hint of
brown pigmentation
S o la r le n t ig o
■
■
On sun-exposed skin
Light brown and uniform in
color but may be asymmetric
(table continues on page 108)
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Ba te s ’ Poc ke t Guide to Phys ic a l Exa mina tion a nd His tory Ta king
Table 6-5
Bro w n Le s io n s : Me la n o m a a n d
It s Mim ic s (continued )
M e la n o m a
M im ic s
M e la n o m a
D y s p la s t ic n e v u s
■
■
May arise de novo or in existing
nevi and exhibits ABCDEs
Patients with many dysplastic
nevi have increased risk of
melanoma
M e la n o m a
■
■
May have variegated color
(browns, red)
Has melanocytic features on
dermoscopy
M e la n o m a
■
May be uniform in color but
asymmetric; key feature is
rapid change or evolution
■
■
May have macular base and
papular central “fried egg”
component
Compare to the patient’s other
nevi and monitor changes
In f la m e d s e b o rrh e ic k e ra t o s is
■
■
Can sometimes mimic a
melanoma if it has an
erythematous base
Dermoscopy helps the trained
eye distinguish these
S e b o r r h e ic k e r a t o s is
■
Stuck-on and verrucous, may be
darkly pigmented
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Chapter 6 | The Skin, Hair, and Nails
109
Table 6-6 Va s c u la r a n d P u rp u ric Le s io n s o f t h e S k in
Le s io n s
Fe a t u r e s : A p p e a r a n c e ,
D is t r ib u t io n , S ig n if ic a n c e
C h e r ry A n g io m a
■
■
■
Bright or ruby red, may become
purplish with age; 1–3 mm; round,
flat, sometimes raised; may be
surrounded by a pale halo
Found on trunk or extremities
Not significant; increase in size and
number with aging
S p id e r A n g io m a a
■
■
■
Fiery red; very small to 2 cm;
central body, sometimes raised,
radiating with erythema
Face, neck, arms, and upper trunk,
but almost never below the waist
Seen in liver disease, pregnancy,
vitamin B deficiency; normal in
some people
S p id e r Ve in a
■
■
■
Bluish; varies from very small to
several inches; may resemble a
spider or be linear, irregular, or
cascading
Most often on the legs, near veins;
also on anterior chest
Often accompanies increased
pressure in the superficial veins, as
in varicose veins
(table continues on page 110)
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Ba te s ’ Poc ke t Guide to Phys ic a l Exa mina tion a nd His tory Ta king
Table 6-6
Va s c u la r a n d P u rp u ric Le s io n s
o f t h e S k in (continued )
Le s io n s
Fe a t u r e s : A p p e a r a n c e ,
D is t r ib u t io n , S ig n if ic a n c e
P e t e c h ia /P u r p u r a
■
■
■
Deep red or reddish purple; fades
over time; 1–3 mm or larger;
rounded, sometimes irregular, flat
Varied distribution
Seen if blood outside the vessels;
may suggest a bleeding disorder or,
if petechiae, emboli to skin
Ec c h y m o s is
■
■
■
Purple or purplish blue, fading to
green, yellow, and brown over time;
larger than petechiae; rounded,
oval, or irregular
Varied distribution
Seen if blood outside the vessels;
often secondary to bruising or
trauma; also seen in bleeding
disorders
These are telangiectasias, or dilated small vessels that look red or bluish.
Sources of photos: Spider Angioma—Marks R. Skin Disease in Old Age. Philadelphia, PA: JB Lippincott; 1987; Petechia/Purpura—Kelley WN. Textbook of Internal Medicine. Philadelphia, PA:
JB Lippincott; 1989.
a
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Chapter 6 | The Skin, Hair, and Nails
111
Table 6-7 Ha ir Lo s s
G e n e r a lize d o r D iff u s e Ha ir Lo s s
In men, look for frontal hairline regression and thinning on the posterior
vertex; in women look for thinning that spreads from the crown down
without hairline regression.
Male pattern hair loss (MPHL)
Female pattern hair loss (FPHL)
Te lo g e n Eff lu v iu m a n d A n a g e n Eff lu v iu m
In telogen effluvium overall the patient’s scalp and hair distribution appear
normal, but a positive hair pull test reveals most hairs have telogen bulbs.
In anagen effluvium there is diffuse hair loss from the roots. The hair pull
test shows few if any hairs with telogen bulbs.
Normal hair part width in
telogen effluvium
Positive hair pull test in telogen
effluvium showing all hairs have
telogen bulbs
Anagen effluvium
(table continues on page 112)
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Ba te s ’ Poc ke t Guide to Phys ic a l Exa mina tion a nd His tory Ta king
Table 6-7 Ha ir Lo s s (continued )
Fo c a l Ha ir Lo s s
A lo p e c ia A r e a t a
There is sudden onset of clearly demarcated, usually localized, round or
oval patches of hair loss leaving smooth skin without hairs, in children
and young adults. There is no visible scaling or erythema.
Tin e a C a p it is (“ Rin g w o r m ” )
There are round scaling patches of alopecia, usually caused by Trichophyton
tonsurans from humans, and less commonly, Microsporum canis from dogs
or cats.
References: For a complete guide to evaluation of hair loss, review Mubki T, Rucnicka L,
Olszewska M, et al. Evaluation and diagnosis of the hair loss patient. J Am Acad Dermatol.
2014;71:415.
a
See also Hair Loss Help. Hair loss classi cations. Available at http://www.hairlosshelp.com/
hair_loss_research/hair_loss_charts.cfm. Accessed February 13, 2015.
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Chapter 6 | The Skin, Hair, and Nails
113
Table 6-8 Fin d in g s in o r n e a r t h e Na ils
P a ro n yc h ia
A superficial infection of the proximal
and lateral nail folds adjacent to the nail
plate. The nail folds are often red,
swollen, and tender. Represents the most
common infection of the hand, usually
from Staphylococcus aureus or
Streptococcus. Creates a felon if it extends
into the pulp space of the finger.
C lu b b in g o f t h e Fin g e r s
Clinically a bulbous swelling of the soft
tissue at the nail base, with loss of the
normal angle between the nail and the
proximal nail fold. The angle increases
to 180 degrees or more, and the nail
bed feels spongy or floating. The
mechanism is still unknown. Seen in
congenital heart disease, interstitial lung
disease and lung cancer, inflammatory
bowel diseases, and malignancies.
Ha b it Tic D e fo r m it y
There is depression of the central nail
with a “Christmas tree” appearance from
small horizontal depressions, resulting
from repetitive trauma from rubbing the
index finger over the thumb or vice
versa.
M e la n o n yc h ia
Caused by increased pigmentation in
the nail matrix, leading to a streak as
the nail grows out. This may be a
normal ethnic variation if found in
multiple nails. A wide streak, especially
if growing or irregular, could represent a
subungual melanoma.
(table continues on page 114)
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Table 6-8 Fin d in g s in o r n e a r t h e Na ils (continued )
O n yc h o ly s is
A painless separation of the whitened
opaque nail plate from the pinker
translucent nail bed.
O n yc h o m yc o s is
The most common cause of nail
thickening and subungual debris is
onychomycosis, most often from the
dermatophyte Trichophyton rubrum.
Te r ry N a ils
Nail plate turns white with a groundglass appearance, a distal band of
reddish brown, and obliteration of the
lunula. Seen in liver disease, usually
cirrhosis, heart failure, and diabetes.
Sources of photos: Clubbing of the Fingers, Paronychia, Onycholysis, Terry Nails—Habif TP. Clinical
Dermatology: A Color Guide to Diagnosis and Therapy. 2nd ed. St. Louis, MO: CV Mosby; 1990.
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7
C H A P T E R
The Head and Neck
The Health History
C o m m o n o r C o n c e r n in g S y m p t o m s
●
●
●
●
●
●
●
●
●
●
He d che
Ch nge in vision: blurred vision, loss of vision, flo ters, fl shing lights
Eye in, redness, or te ring
Double vision (di lo i )
He ring loss, e r che, ringing in the e rs (tinnitus)
Dizziness nd vertigo
Nosebleed (e ist xis)
Sore thro t, ho rseness
Swollen gl nds
Goiter
Th e He a d
Headache is a common symptom
that always requires careful evaluation because a small fraction of
headaches arise from life-threatening
conditions. Elicit a full description
of the headache and all seven
attributes of the patient’s pain
(see p. 3).
See Table 7-1, Primary Headaches, p. 128,
and Table 7-2, Secondary Headaches,
pp. 129–131. Tension and migraine headaches are the most common recurring
headaches.
Is the headache one sided or bilateral? Severe with sudden onset, like
a thunderclap? Steady or throbbing? Continuous or comes and
goes? Ask the patient to point to the
area of pain or discomfort. Assess
chronologic pattern and severity.
Tension headaches often arise in the
temporal areas; cluster headaches may
be retro-orbital.
Changing or progressively severe headaches increase the likelihood of tumor,
a bscess, or other mass lesion. Extremely
severe headaches suggest subara chnoid
hemorrhage or meningitis.
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H e a d a c h e W a r n in g S ig n s f o r Im m e d ia t e In v e s t ig a t io n
●
●
●
●
●
●
●
●
●
●
●
Progressively frequent or severe over 3- onth eriod
Sudden onset like “thundercl ” or “the worst he d che of y life”
New onset fter ge 5 ye rs
Aggr v ted or relieved by ch nge in osition
Preci it ted by V ls lv
neuver
Associ ted sy to s of fever, night swe ts, or weight loss
Presence of c ncer, HIV infection, or regn ncy
Ch nge in ttern fro
st he d ches
L ck of si il r he d che in the st
Recent he d tr u
Associ ted
illede , neck stiffness, or foc l neurologic deficits
■ Ask about associated symptoms,
such as nausea and vomiting,
and neurologic symptoms, such
as change in vision or motorsensory de cits.
■ Ask if coughing, sneezing, or
changing the position of the
head affects (better, worse, or
none) the headache.
■ Ask about family history.
Visual aura or scintillating scotomas may
accompany migraine. Nausea and vomiting are common with migraine but also
occur with brain tumor and subarachnoid
hemorrhage.
Such maneuvers may increase pain from
brain tumor and acute sinusitis.
Family history is often positive in
patients with migraine.
Th e Ey e s
Ask “How is your vision?” If the
patient reports a change in vision,
pursue the related details:
Gradual blurring, often from refractive
errors; also occurs in hyperglycemia.
■ Is the problem worse during
Difficulty with close work suggests
hyperopia (farsightedness) or presbyopia
(aging vision); difficulty with distances
suggests myopia (nearsightedness).
close work or at distances?
■ Is the onset sudden or gradual?
Sudden visual loss suggests retinal
detachment, vitreous hemorrhage, or
occlusion of the central retinal artery.
■ Is there blurring of the entire
Slow central loss occurs in nuclea r ca ta ra ct and ma cula r degenera tion; p erip heral loss in advanced open-a ngle
gla ucoma ; one -sid ed loss in hemia nopsia and q uadrantic defects (p. 132).
eld of vision or only parts? Is
blurring central, peripheral, or
only on one side?
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Chapter 7 | The Head and Neck
■ Has the patient seen lights ash-
ing across the eld of vision?
Vitreous oaters?
117
These symptoms suggest detachment of
vitreous from the retina. Prompt eye
consultation is indicated.
Ask about pain in or around the
eyes, redness, and excessive tearing
or watering.
Eye pain in acute glaucoma and optic
neuritis.
Check for diplopia, or double
vision.
Diplopia in brainstem or cerebellum
lesions, also from weakness or paralysis
of one or more extraocular muscles.
Th e Ea r s
Ask “How is your hearing?”
Does the patient have special dif culty understanding people as they
talk? Does a noisy environment
make a difference?
Sensorineura l loss (inner ear) leads to
difficulty understanding speech, often
complaining that others mumble; noisy
environments worsen hearing. In conductive loss (external or middle ear),
noisy environments may help.
For complaints of earache, or
pain in the ear, ask about associated fever, sore throat, cough,
and concurrent upper respiratory
infection.
Consider otitis externa if pain in the ear
canal; otitis media if pain associated with
respiratory infection.
Tinnitus is an internal musical ringing or rushing or roaring noise,
often unexplained.
When associated with hearing loss
and vertigo, tinnitus suggests Ménière
disease.
Ask about vertigo, the perception
that the patient or the environment
is rotating or spinning.
Vertigo in labrynthitis (inner ear), CN VII
lesions, brainstem lesions
T h e N o s e a n d S in u s e s
Rhinorrhea, or drainage from the
nose, frequently accompanies nasal
congestion. Ask further about sneezing, watery eyes, throat discomfort,
and itching in the eyes, nose, and
throat.
Causes include viral infections, allergic
rhinitis (“hay fever”), and vasomotor
rhinitis. Itching favors an allergic cause.
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For epistaxis, or bleeding from
the nose, identify the source
carefully—is bleeding actually
from the nose, or has the patient
coughed up or vomited blood?
Assess the site of bleeding, its
severity, and associated symptoms.
Local causes of epistaxis include trauma
(especially nose -picking), inflammation,
drying and crusting of the nasal mucosa,
tumors, and foreign bodies. Anticoagulants, NSAIDs, and coagulopathies may
contribute.
Th e M o u t h , Th r o a t , a n d N e c k
Sore throat or pharyngitis is a frequent complaint. Ask about fever,
swollen glands, and any associated
cough.
Fever, pharyngeal exudates, and
anterior cervical lymphadenopathy,
especially without cough, suggest
streptococcal pha ryngitis, or “strep
throat”(p. 142).
Hoarseness may arise from overuse
of the voice, allergies, smoking, or
inhaled irritants.
If present more than 2 weeks, refer for
laryngoscopy; consider hypothyroidism,
reflux, vocal cord nodules, head and neck
cancers, thyroid masses, and neurologic
disorders (Parkinson disease, amyotrophic
lateral sclerosis, or myasthenia gravis).
Assess thyroid function. Ask about
goiter, temperature intolerance,
and sweating.
With goiter, thyroid function may
be increased, decreased, or normal.
Cold intolerance in hypothyroidism; heat
intolerance, palpitations, and involuntary weight loss in hyperthyroidism
Health Promotion and Counseling:
Evidence and Recommendations
Im p o r t a n t T o p ic s f o r H e a lt h P r o m o t io n a n d C o u n s e lin g
●
●
●
Loss of vision: c t r cts,
He ring loss
Or l he lth
cul r degener tion, gl uco
Disorders of vision shift with age. Healthy young adults generally have
refractive errors. Older adults have refractive errors, cataracts, macular
degeneration, and glaucoma. Glaucoma is the leading cause of blindness
in African Americans and the U.S. population overall. Glaucoma causes
gradual vision loss, with damage to the optic nerve, loss of visual elds,
beginning usually at the periphery, and pallor and increasing size of the
optic cup (enlarging to more than half the diameter of the optic disc).
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More than a third of adults older than 65 years have detectable hearing
de cits. Questionnaires and handheld audioscopes work well for periodic
screening.
Be sure to promote oral health: 19% of children aged 2 to 19 years have
untreated cavities, and about 5% of adults aged 40 to 59 years and 25% of
those older than age 60 years have no teeth at all. Inspect the oral cavity
for decayed or loose teeth, in ammation of the gingiva, signs of periodontal disease (bleeding, pus, receding gums, and bad breath), and oral cancers. Counsel patients to use uoride-containing toothpastes, brush, oss,
and seek dental care at least annually.
Techniques of Examination
EXAMINATIO N TECHNIQ UES
P O SSIBLE FIN DIN G S
Th e He a d
Examine the:
■ Hair, including quantity,
Coarse and sparse in hypothyroidism,
fine in hyperthyroidism
distribution, and texture
■ Scalp, including lumps or
Pilar cysts, psoriasis, seborrheic dermatitis, pigmented nevi
lesions
■ Skull, including size and
Hydrocephalus, skull depression from
trauma
contour
■ Face, including symmetry and
facial expression
■ Skin, including color, texture,
Facial paralysis; flat affect of depression,
moods such as anger, sadness
Pale, fine, hirsute, acne, skin cancer
hair distribution, and lesions
Th e Ey e s
Test visual acuity in each eye with
a Snellen wall chart or handheld
card.
Vision of 20/200 means that at 20 feet,
the patient can read print that a person
with normal vision could read at
200 feet.
Assess visual elds by confrontation with the static nger wiggle
test and the kinetic red target test, if
indicated (Fig. 7-1).
Hemianopsia, quadrantic defects in
cerebrovascular accidents (CVAs). See
Table 7-3, Visual Field Defects, p. 132.
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EXAMINATIO N TECHNIQ UES
P O SSIBLE FIN DIN G S
Fig ure 7-1 Static finge r w iggle te s t.
Inspect the:
See Table 7-4, Physical Findings in and
Around the Eye, pp. 133–134.
■ Position and alignment of eyes
Exophthalmos, strabismus
■ Eyebrows
Seborrheic dermatitis
■ Eyelids
Sty, chalazion, ectropion, ptosis, xanthe lasma, blepharitis
■ Lacrimal apparatus
Swollen lacrimal sac, excessive tearing
■ Conjunctiva and sclera
Red eye, conjunctivitis, jaundice, episcleritis
■ Cornea, iris, and lens
Cataract, crescentic shadow of acute
angle glaucoma
Inspect pupils for:
■ Size, shape, and symmetry
Miosis, mydriasis, anisocoria
■ Reactions to light, direct and
Absent in paralysis of CN III
consensual
■ The near reaction, namely pupil-
lary constriction with gaze shift
to near object; note the accompanying convergence of the eyes
and accommodation of the lens
(becomes more convex)
(Fig. 7-2)
Constriction slows in tonic (Adie) pupil
and is absent in Argyll Robertson pupils
of syphilis; poor convergence in hyperthyroidism
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121
P O SSIBLE FIN DIN G S
Fig ure 7-2 The pupils cons trict w he n the focus s hifts to a clos e obje ct.
Assess the extraocular muscles by
observing:
■ The symmetry of corneal re ec-
tions from a midline light
■ The six cardinal directions of
Cranial nerve palsy, strabismus, nystagmus, lid lag of hyperthyroidism
gaze (Fig. 7-3)
S upe rior
re ctus (III)
La te ra l
re ctus
(VI)
Infe rior
re ctus (III)
Asymmetric reflection if deviation in
ocular alignment
Infe rior
oblique (III)
S upe rior
re ctus (III)
Me dia l
re ctus (III)
La te ra l
re ctus
(VI)
S upe rior
oblique (IV)
Infe rior
re ctus (III)
Fig ure 7-3 The s ix cardinal dire ctions of gaze .
Inspect the fundi with an ophthalmoscope.
S t e p s f o r U s in g t h e O p h t h a lm o s c o p e
●
D rken the roo . Switch on the o hth l osco e light nd turn the lens disc
until you see the l rge round be
of white light.* Shine the light on the b ck
of your h nd to check the ty e of light, its desired brightness, nd the electric l ch rge of the o hth l osco e.
*So e clinici ns like to use the l rge round be
for l rge u ils, nd the
s ll round be
for s ll u ils. The other be s re r rely hel ful. The
slit-like be
is so eti es used to ssess elev tions or conc vities in the
retin , the green (or red-free) be
to detect s ll red lesions, nd the grid
to
ke e sure ents. Ignore the l st three lights nd r ctice with the
l rge or s ll round white be .
(continued )
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EXAMINATIO N TECHNIQ UES
P O SSIBLE FIN DIN G S
S t e p s f o r U s in g t h e O p h t h a lm o s c o p e
●
●
●
●
●
(Continued )
Turn the lens disc to the 0 dio ter. (A dio ter is unit th t e sures the
ower of lens to converge or diverge light.) At this dio ter, the lens neither
converges nor diverges light. Kee your finger on the edge of the lens disc so
you c n turn the disc to focus the lens when you ex ine the fundus.
Hold the o hth l osco e in your right hand and use your right eye to ex ine
the patient’s right eye; hold it in your left hand and use your left eye to examine
the patient’s left eye. This kee s you fro bu ing the tient’s nose nd gives
you ore obility nd closer r nge for visu lizing the fundus. With r ctice,
you will beco e ccusto ed to using your nondo in nt eye.
Hold the o hth l osco e fir ly br ced g inst the edi l s ect of your
bony orbit, with the h ndle tilted l ter lly t bout 2 -degree sl nt fro the
vertic l. Check to
ke sure you c n see cle rly through the erture. Instruct
the patient to look slightly u nd over your shoulder at a point directly ahead on
the wall.
Pl ce yourself bout 15 inches w y fro the tient nd t n ngle 15-degree
lateral to the patient’s line of vision. Shine the light be
on the u il nd look
for the or nge glow in the u il—
the red reflex. Note ny o cities
interru ting the red reflex.
Now place the thumb of your other
hand across the patient’s eyebrow,
which ste dies your ex ining
h nd. Kee ing the light be
focused on the red reflex, ove in
with the o hth l osco e on the
15-degree ngle tow rd the u il
until you re very close to it,
l ost touching the tient’s
eyel shes nd the thu b of your
other h nd.
Inspect the fundi for the following:
■ Red re ex
Cataracts, artificial eye
■ Optic disc (Fig. 7-4)
Papilledema, glaucomatous cupping,
optic atrophy. See Table 7-5, Abnormalities
of the Optic Disc, p. 135, and Table 7-6,
Ocular Fundi: Diabetic Retinopathy, p. 136.
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EXAMINATIO N TECHNIQ UES
123
P O SSIBLE FIN DIN G S
Arte ry
Ve in
Optic dis c
Ma cula
P hys iologic cup
Fig ure 7-4 The optic dis c.
■ Arteries, veins, and AV
AV nicking, copper wiring in hypertensive changes
crossings
■ Adjacent retina (note any
Hemorrhages, exudates, cotton-wool
patches, microaneurysms, pigmentation
lesions)
■ Macular area
Macular degeneration
■ Anterior structures
Vitreous floaters, cataracts
T ip s f o r E x a m in in g t h e O p t ic D is c a n d R e t in a
●
●
●
●
Locate the optic disc. Look for the round yellowish-or nge structure.
Now, bring the optic disc into sharp focus by djusting the lens of your o hth losco e.
Inspect the optic disc. Note the following fe tures:
● The sharpness or clarity of the disc outline
● The color of the disc
● The size of the central physiologic cup ( n enl rged cu
suggests chronic
o en- ngle gl uco )
● Venous pulsations in the retin l veins s they e
erge fro the centr l ortion of the disc (loss of venous uls tions fro elev ted intr cr ni l ressure
y occur in he d tr u , eningitis)
Inspect the retina. Distinguish rteries fro veins b sed on the fe tures listed below.
Color
Size
Light Reflex (reflection)
●
●
●
A r t e r ie s
Ve in s
Light red
S ller (2/3 to 3/4 the
di eter of veins)
Bright
D rk red
L rger
Follow the vessels peripherally in each of four directions.
Ins ect the fovea nd surrounding macula. M cul r
degener tion ty es include dry atrophic ( ore co on but less severe) nd wet exudative (neov scul r). Undigested cellul r debris, c lled drusen, y
be h rd or soft.
Assess for ny papilledema fro incre sed intr cr ni l
ressure le ding to swelling of the o tic nerve he d.
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EXAMINATIO N TECHNIQ UES
P O SSIBLE FIN DIN G S
Th e Ea r s
Examine on each side:
Th e Au ric le . Inspect the auricle.
Keloid, epidermoid cyst
If you suspect otitis:
■ Move the auricle up and down,
Pain in otitis externa (“the tug test”)
and press on the tragus.
■ Press rmly behind the ear.
Possible tenderness in otitis media and
mastoiditis
Ea r Ca n a l a n d Dru m . Pull the
auricle up, back, and slightly out.
Inspect, through an otoscope with
speculum:
■ The canal
Cerumen; swelling and erythema in otitis externa
■ The eardrum (Fig. 7-5)
Red bulging drum in acute otitis media;
serous otitis media, tympanosclerosis,
perforations. See Table 7-7, Abnormalities of the Eardrum, p. 137.
Pa rs fla ccida
S hort proce s s of ma lle us
Incus
Ha ndle of ma lle us
Pa rs te ns a
Umbo
Cone of light
Fig ure 7-5 Anatomy of m iddle and inne r e ar.
He a rin g . “Do you feel you have a
hearing loss or dif culty hearing?”
is a sensitive screening question.
Assess auditory acuity to spoken
or whispered voice or with a handheld audiometer.
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EXAMINATIO N TECHNIQ UES
125
P O SSIBLE FIN DIN G S
If hearing is diminished, use a
512-Hz tuning fork to:
■ Test lateralization (Weber test),
but only in patients with unilateral hearing loss. Place vibrating
and tuning fork on vertex of
skull and check hearing.
■ Compare air and bone conduction
(Rinne test). Place vibrating and
tuning fork on mastoid bone,
then remove and check hearing.
In unilateral conductive hearing loss,
sound is heard in (lateralized to) the
impaired ear. See Table 7-8, Patterns of
Hearing Loss, p. 138.
In conductive hearing loss, sound is heard
through bone longer than through air
(BC = AC or BC > AC). In sensorineural
hearing loss, sound is heard longer
through air (AC > BC).
T h e N o s e a n d S in u s e s
Inspect the external nose.
Inspect, through a speculum, the:
■ Nasal mucosa that covers the
septum and turbinates, noting
its color and any swelling
Swollen and red in viral rhinitis, swollen
and pale in allergic rhinitis; polyps
(Fig. 7-6); ulcer from cocaine use
Fig ure 7-6 Nas al polyps .
■ Nasal septum for position and
Deviation, perforation
integrity
Palpate the frontal and maxillary
sinuses.
Tender in acute sinusitis
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EXAMINATIO N TECHNIQ UES
P O SSIBLE FIN DIN G S
Th e M o u t h a n d P h a r y n x
Inspect the:
■ Lips
Cyanosis, pallor, cheilosis. See also
Table 7-9, Abnormalities of the Lips, p. 139.
■ Oral mucosa
Aphthous ulcers (canker sores)
■ Gums
Gingivitis, periodontal disease
■ Teeth
Dental caries, tooth loss
■ Roof of the mouth
Torus palatinus (benign)
■ Tongue, including:
See Table 7-10, Abnormalities of the
Tongue, pp. 140–141.
■
Papillae
Glossitis
■
Symmetry
Deviation to one side from paralysis of
CN XII from CVA
■
Any lesions
Erythroplakia, leukoplakia (precancerous);
squamous cell or other carcinomas
■ Floor of the mouth
Lesions suspicious for cancer
■ Pharynx, including:
See Table 7-11, Abnormalities of the
Pharynx, p. 142.
■
Color or any exudate
Pharyngitis
■
Presence and size of tonsils
Exudates, tonsillitis, peritonsillar abscess
■
Symmetry of the soft palate as
patient says “ah”
Soft palate fails to rise, uvula deviates to
opposite side in CN X paralysis from CVA.
Th e N e c k
Inspect the neck.
Scars, masses, torticollis
Palpate super cial and deep anterior, posterior cervical, and supraclavicular lymph nodes.
Cervical lymphadenopathy from HIV or
AIDS, infectious mononucleosis, lymphoma, leukemia, and sarcoidosis.
Enlarged supraclavicular node from
possible abdominal malignancy
Inspect and palpate the position of
the trachea.
Deviated trachea from neck mass or
pneumothorax
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EXAMINATIO N TECHNIQ UES
127
P O SSIBLE FIN DIN G S
Inspect the thyroid gland:
■ At rest
Goiter, nodules. See Table 7-12, Abnormalities of the Thyroid Gland, p. 143.
■ As patient swallows water
From behind patient, palpate
the thyroid gland, including the
isthmus, and rst one then
the opposite lobe:
Goiter, nodules, tenderness of thyroiditis
■ At rest
■ As patient swallows water
(Fig. 7-7)
Fig ure 7-7 Thyroid gland w ith goite r
w hile s w allow ing.
Alternative Examination Sequence—After examining the thyroid gland, you
may proceed to musculoskeletal examination of the neck and upper back
and check for costovertebral angle tenderness.
Recording Your Findings
R e c o r d in g t h e H e a d , E y e s , E a r s , N o s e , a n d
T h r o a t (H E E N T ) E x a m in a t io n
Head—The skull is nor oce h lic/ tr u tic. Front l b lding. Eyes—Visu l cuity 2 / 1 bil ter lly. Scler white; conjunctiv injected. Pu ils constrict fro
3 to 2
, equ lly round nd re ctive to light nd cco
od tion. Disc rgins
sh r ; no he orrh ges or exud tes. Arteriol r-to-venous r tio (AV r tio) 2:4; no
AV nicking. Ears—Acuity di inished to whis ered voice; int ct to s oken voice.
TMs cle r. Nose—Mucos swollen with erythe
nd cle r dr in ge. Se tu
idline. Tender over
xill ry sinuses. Throat—Or l ucos ink, dent l c ries
in lower ol rs, h rynx erythe tous, no exud tes.
Neck—Tr che
idline. Neck su le; thyroid isth us idline, lobes l ble but not enl rged.
Lymph Nodes—Sub ndibul r nd nterior cervic l ly h nodes tender, 1 ×
1 c , rubbery nd obile; no osterior cervic l, e itrochle r, xill ry, or inguin l
ly h deno thy.
(These findings suggest myopia and mild arteriolar narrowing as well as upper
respiratory infection.)
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Aids to Interpretation
Table 7-1 P rim a ry He a d a ch e s
P ro b le m
Co m m o n
C h a r a c t e r is t ic s
Te n s io n
Location: variable
A s s o c ia t e d S y m p t o m s ,
P ro vo k in g a n d
Re lie v in g Fa c t o r s
Quality: pressing or
tightening pain; mild-tomoderate intensity
Onset: gradual
Duration: minutes to days
Mig ra in e
■
■
■
With aura
Without
aura
Variants
Location: unilateral in
70%; bifrontal or global
in 30%
Quality: throbbing or
aching, variable in severity
Onset: fairly rapid, peaks
in 1–2 hours
Duration: 4–72 hours
Sometimes photophobia,
phonophobia; nausea absent
↑ by sustained muscle
tension, as in driving or
typing
↓ possibly by massage,
relaxation
Nausea, vomiting,
photophobia, phonophobia,
visual auras (flickering zigzagging lines), motor auras
affecting hand or arm, sensory
auras (numbness, tingling
usually precede headache)
↑ by alcohol, certain foods,
tension, noise, bright light.
More common premenstrually
↓ by quiet dark room, sleep
Clu s te r
Location: unilateral,
usually behind or around
the eye
Lacrimation, rhinorrhea,
miosis, ptosis, eyelid edema,
conjunctival infection
Quality: deep,
continuous, severe
↑ sensitivity to alcohol during
some episodes
Onset: abrupt, peaks
within minutes
Duration: up to 3 hours
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Table 7-2 S e c o n d a ry He a d a ch e s
P ro b le m
Co m m o n
C h a r a c t e r is t ic s
As s o c ia t e d S ym p t o m s ,
P ro vo k in g a n d
Re lie vin g Fa c t o r s
An a lge s ic
Re b o u n d
Location: previous
headache pattern
Depends on prior headache
pattern
Quality: variable
↑ by fever, carbon monoxide,
hypoxia, withdrawal of
caffeine, other headache
triggers
Onset: variable
Duration: depends on
prior headache pattern
He a d a ch e s
fro m Eye
Dis o rd e rs
Errors of
Refraction
(farsightedness
and astigmatism,
but not
nearsightedness)
Acute Glaucoma
↓ —depends on cause
Eye fatigue, “sandy” sensation
Location: around and
over the eyes; may radiate in eyes, redness of the
conjunctiva
to the occipital area
Quality: steady,
aching, dull
Onset: gradual
Duration: variable
Location: in and
around one eye
Quality: steady,
aching, often severe
Onset: often rapid
↑ by prolonged use of the
eyes, particularly for close
work
↓ by resting the eyes
Diminished vision,
sometimes nausea and
vomiting
↑ —sometimes by drops that
dilate the pupils
Duration: variable, may
depend on treatment
He a d a ch e fro m
S in u s it is
Location: usually above Local tenderness, nasal
congestion, tooth pain,
eye (frontal sinus) or
discharge, and fever
over maxillary sinus
Quality: aching or
throbbing, variable in
severity; consider
possible migraine
↑ by coughing, sneezing, or
jarring the head
↓ by nasal decongestants,
antibiotics
Onset: variable
Duration: often several
hours at a time, recurring
over days or longer
(table continues on page 130)
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Table 7-2 S e c o n d a ry He a d a ch e s (continued )
P ro b le m
Co m m o n
C h a r a c t e r is t ic s
Me n in g it is
Location: generalized
Quality: steady or
throbbing, very severe
Onset: fairly rapid
Duration: variable,
usually days
S u b a ra ch n o id
He m o rrh a ge —
“ Th u n d e rcla p
He a d a ch e”
Location: generalized
Quality: severe, “the
worst of my life”
Onset: usually abrupt;
prodromal symptoms
may occur
As s o c ia t e d S ym p t o m s ,
P ro vo k in g a n d
Re lie vin g Fa c t o r s
Fever, stiff neck,
photophobia, change in
mental status
Can ↓ from immediate
antibiotics until viral versus
bacterial cause identified
Nausea, vomiting, possibly
loss of consciousness, neck
pain
↑ rebleeding, ↑ intracranial
pressure, cerebral edema
↓ by subspecialty treatments
Duration: variable,
usually days
Bra in Tu m o r
Location: varies with
the location of the
tumor
↑ by coughing, rebleeding,
↑ intracranial pressure,
cerebral edema
Quality: aching, steady, ↓ by subspecialty treatments
variable in intensity
Onset: variable
Duration: often brief
Gia n t Ce ll
(Te m p o ra l)
Arte rit is
Location: near the
involved artery, often
the temporal, also the
occipital; age related
Quality: throbbing,
generalized, persistent,
often severe
Onset: gradual or rapid
Duration: variable
Tenderness of the adjacent
scalp; fever (in 50%),
fatigue, weight loss; new
headache ( 60%), jaw
claudication ( 50%), visual
loss or blindness ( 15–
20%), polymyalgia
rheumatica ( 50%)
↑ by movement of neck and
shoulders
Often ↓ by steroids
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Table 7-2 S e c o n d a ry He a d a ch e s (continued )
P ro b le m
Co m m o n
C h a r a c t e r is t ic s
As s o c ia t e d S ym p t o m s ,
P ro vo k in g a n d
Re lie vin g Fa c t o r s
Postconcussion
Headache
Location: often but not Drowsiness, poor
always localized to the concentration, confusion,
memory loss, blurred vision,
injured area
dizziness, irritability,
Quality: generalized,
restlessness, fatigue
dull, aching, constant
↑ by mental and physical
Onset: within hours to
exertion, straining, stooping,
1–2 days of the injury
emotional excitement,
Duration: weeks,
alcohol
months, or even years
↓ by rest
Cra n ia l
Ne u ra lg ia s :
Trige m in a l
Ne u ra lg ia
(CN V)
Location: cheek, jaws,
lips, or gums;
trigeminal nerve
divisions 2 and 3 >1
Quality: shocklike,
stabbing, burning,
severe
Onset: abrupt,
paroxysmal
Exhaustion from recurrent
pain
↑ by touching certain areas
of the lower face or mouth;
chewing, talking, brushing
teeth
↓ by medication; neurovascular
decompression
Duration: each jab lasts
seconds but recurs at
intervals of seconds or
minutes
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Table 7-3 Vis u a l Fie ld De fe c t s
Altitudinal (horizontal) defect,
usually resulting from a vascular
lesion of the retina
Unilateral blindness, from a lesion
of the retina or optic nerve
Bitemporal hemianopsia, from a
lesion at the optic chiasm
Homonymous hemianopsia, from
a lesion of the optic tract or optic
radiation on the side contralateral to
the blind area
Homonymous quadrantic defect,
from a partial lesion of the optic
radiation on the side contralateral to
the blind area
Left
Right
(from patient’s viewpoint)
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133
Table 7-4 P h ys ic a l Fin d in g s in a n d Aro u n d t h e Eye
Eye lid s
Ptosis. A drooping upper eyelid that
narrows the palpebral fissure from a muscle
or nerve disorder
Ectropion. Outward turning of the margin
of the lower lid, exposing the palpebral
conjunctiva
Entropion. Inward turning of the lid
margin, causing irritation of the cornea or
conjunctiva
Lid retraction and exophthalmos. A
wide-eyed stare suggests hyperthyroidism.
Note the rim of sclera between the upper
lid and the iris. Retracted lids and “lid lag”
when eyes move from up to down
markedly increase the likelihood of
hyperthyroidism, especially when
accompanied by fine tremor, moist skin,
and heart rate >90 beats per minute.
Exophthalmos describes protrusion of the
eyeball, a common feature of Graves
ophthalmopathy, triggered by autoreactive
T lymphocytes
(table continues on page 134)
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Table 7-4 P h ys ic a l Fin d in g s in a n d Aro u n d
t h e Eye (continued )
In a n d A ro u n d t h e Eye
Pinguecula. Harmless yellowish nodule in
the bulbar conjunctiva on either side of the
iris; associated with aging
Episcleritis. A localized ocular redness
from inflammation of the episcleral vessels.
Seen in rheumatoid arthritis, Sjögren
syndrome, and herpes zoster
Sty. A pimple-like infection around a hair
follicle near the lid margin, usually from
Staphylococcus aureus
Chalazion. A beady nodule in either eyelid
caused by a chronically inflamed
meibomian gland
Xanthelasma. Yellowish plaque seen in
lipid disorders. Half of affected patients
have hyperlipidemia; also common in
primary biliary cirrhosis
Blepharitis. Chronic inflammation of the
eyelids at the base of the hair follicles, often
from S. aureus. Also a scaling seborrheic
variant
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135
Table 7-5 Ab n o rm a lit ie s o f t h e Op t ic Dis c
No rm a l
P ro c e s s
Ap p e a ra n c e
Tiny disc vessels
give normal
color to the disc
Disc is yellowish
orange to creamy pink
Disc vessels are tiny
Disc margins are sharp
(except perhaps
nasally)
P a p ille d e m a
Venous stasis
leads to
engorgement
and swelling
Disc is pink, hyperemic
Disc vessels are more
visible, more numerous,
and curve over the
borders of the disc
Disc is swollen, with
margins blurred
G la u c o m a t o u s
C u p p in g
Increased
pressure within
the eye leads to
increased cupping
(backward
depression of the
disc) and atrophy
The base of the
enlarged cup is pale
O p t ic A t ro p h y
Death of optic
nerve fibers leads
to loss of the tiny
disc vessels
Disc is white
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136
Ba te s ’ Poc ke t Guide to Phys ic a l Exa mina tion a nd His tory Ta king
Table 7-6 Oc u la r Fu n d i: Dia b e t ic Re t in o p a t h y
N o n p ro lif e r a t ive
Re t in o p a t h y,
M o d e r a t e ly S e ve r e
Note tiny red dots or microaneurysms,
also the ring of hard exudates (white
spots) located superotemporally.
Retinal thickening or edema in the
area of hard exudates can impair
visual acuity if it extends to center of
macula. Detection requires specialized
stereoscopic examination
N o n p ro lif e r a t ive
Re t in o p a t h y, S e ve r e
In superior temporal quadrant, note
large retinal hemorrhage between two
cotton-wool patches, beading of the
retinal vein just above, and tiny
tortuous retinal vessels above the
superior temporal artery, termed
intraretinal microvascular abnormalities
P ro lif e r a t ive Re t in o p a t h y,
w it h N e o va s c u la r iz a t io n
Note new preretinal vessels arising on
disc and extending across disc
margins. Visual acuity is still normal,
but the risk of severe visual loss is
high. Photocoagulation can reduce
this risk by >50%
P ro lif e r a t ive Re t in o p a t h y,
Ad va n c e d
Same eye as above, but 2 years later and
without treatment. Neovascularization
has increased, now with fibrous
proliferations, distortion of the macula,
and reduced visual acuity
Source of photos: Nonproliferative Retinopathy, Moderately Severe; Proliferative Retinopathy,
With Neovascularization; Nonproliferative Retinopathy, Severe; Proliferative Retinopathy,
Advanced—Early Treatment Diabetic Retinopathy Study Research Group. Courtesy of MF
Davis, MD, University of Wisconsin, Madison. Source: Frank RB. Diabetic retinopathy.
N Engl J Med 2004;350:48.
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137
Table 7-7 Ab n o rm a lit ie s o f t h e Ea rd ru m
P e r fo r a t io n
Hole in the eardrum that may be central
or marginal
Usually from otitis media or trauma
Ty m p a n o s c le ro s is
A chalky white patch
Scarring process of the middle ear from
otitis media with deposition of hyaline
and calcium and phosphate crystals in
the eardrum and middle ear. When
severe, it may entrap the ossicles and
cause conductive hearing loss
S e ro u s Eff u s io n
Amber fluid behind the eardrum, with
or without air bubbles
Associated with viral upper respiratory
infections or sudden changes in
atmospheric pressure (diving, flying)
Ac u t e O t it is M e d ia
w it h P u r u le n t Eff u s io n
Red, bulging drum, loss of landmarks
Painful hemorrhagic vesicles appear on
the tympanic membrane and/or ear
canal causing earache, blood-tinged
discharge from the ear, and conductive
hearing loss. Seen in mycoplasma and
viral infections and bacterial otitis media
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Table 7-8 P a t t e rn s o f He a rin g Lo s s
C o n d u c t ive Lo s s
S e n s o r in e u r a l Lo s s
Im p a ir e d
U n d e r s t a n d in g
o f Wo r d s
Minor
Often troublesome
Eff e c t s
Noisy environment
may improve hearing
Noisy environment
worsens hearing
Voice remains soft
since cochlear nerve
intact
Voice may be loud due
to nerve damage
U s u a l Ag e o f
On s e t
Childhood, young
adulthood
Middle and later years
Ea r C a n a l a n d
Dru m
Often a visible
abnormality
Problem not visible
We b e r Te s t (in
U n ila t e r a l
He a r in g Lo s s )
Lateralizes to the
impaired ear
Lateralizes to the good
ear
Rin n e Te s t
BC ≥ AC
AC > BC
C a u s e s In c lu d e
Plugged ear canal,
otitis media, immobile
or perforated drum,
otosclerosis, foreign
body
Sustained loud noise,
drugs, inner ear
infections, trauma,
hereditary disorder,
aging, acoustic neuroma
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139
Table 7-9 Ab n o rm a lit ie s o f t h e Lip s
Angular cheilitis. Softening and cracking of
the angles of the mouth
Herpes simplex. Painful vesicles, followed
by crusting; also called cold sore or fever
blister
Angioedema. Diffuse, tense, subcutaneous
swelling, usually allergic in cause
Hereditary hemorrhagic telangiectasia.
Small red spots. Autosomal dominant
disorder causing vascular fragility and
arteriovascular malformations (AVMs),
including in the brain and lungs. Associated
bleeding in nose and GI tract
Peutz–Jeghers syndrome. Brown spots of
the lips and buccal mucosa, significant
because of associated intestinal polyposis
and high risk of GI cancer
Syphilitic chancre. A firm lesion that
ulcerates and may crust
Carcinoma of the lip. A thickened plaque
or irregular nodule that may ulcerate or
crust; malignant
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Table 7-10 Ab n o rm a lit ie s o f t h e To n g u e
Geographic tongue. Scattered areas in
which the papillae are lost, giving a maplike appearance; benign
Hairy tongue. Results from elongated
papillae that may look yellowish, brown, or
black; benign
Fissured tongue. May appear with aging;
benign
Smooth tongue. Results from loss of
papillae; seen in deficiency of riboflavin,
niacin, folic acid, vitamin B12, pyridoxine,
or iron, and treatment with chemotherapy
Candidiasis. May show a thick, white coat,
which, when scraped off, leaves a raw red
surface; tongue may also be red; antibiotics,
corticosteroids, AIDS may predispose
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141
Table 7-10 Ab n o rm a lit ie s o f t h e To n g u e (continued )
Hairy leukoplakia. White raised, feathery
areas, usually on sides of tongue. Seen in
HIV/AIDS
Varicose veins. Dark round spots in the
undersurface of the tongue, associated with
aging; also called caviar lesions
Aphthous ulcer (canker sore). Painful,
small, whitish ulcer with a red halo; heals
in 7–10 days
Mucous patch of syphilis. Slightly raised,
oval lesion, covered by a grayish membrane
Carcinoma of the tongue or floor of the
mouth. Malignancy should be considered
in any nodule or nonhealing ulcer at the
base or edges of the mouth
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Table 7-11 Ab n o rm a lit ie s o f t h e P h a ryn x
Pharyngitis, mild to moderate.
Note redness and vascularity of the
pillars and uvula
Pharyngitis, diffuse. Note redness
is diffuse and intense. Cause may be
viral or, if patient has fever, bacterial.
If patient has no fever, exudate, or
cervical lymphadenopathy, viral
infection is more likely
Exudative pharyngitis. A sore red
throat with patches of white exudate
on the tonsils is associated with
streptococcal pharyngitis and some
viral illnesses
Diphtheria. An acute infection
caused by Corynebacterium
diphtheriae. The throat is dull red,
and a gray exudate appears on the
uvula, pharynx, and tongue
Koplik spots. These small white
specks that resemble grains of salt
on a red background are an early
sign of measles
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Table 7-12 Ab n o rm a lit ie s o f t h e Th yro id Gla n d
Diffuse enlargement. May result
from Graves disease, Hashimoto
thyroiditis, endemic goiter (iodine
deficiency), or sporadic goiter
Multinodular goiter. An
enlargement with two or more
identifiable nodules, usually
metabolic in cause
Single nodule. May result from a
cyst, a benign tumor, or cancer of
the thyroid, or may be one
palpable nodule in a clinically
unrecognized multinodular goiter
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8
C H A P T E R
The Thorax and Lungs
The Health History
C o m m o n o r C o n c e r n in g S y m p t o m s
●
●
●
●
●
●
Chest in
Shortness of bre th (dys ne )
Wheezing
Cough
Blood-stre ked s utu (he o tysis)
D yti e slee iness or snoring nd disordered slee
Complaints of chest pain or chest discomfort raise the specter of heart disease
but often arise from conditions in the thorax and lungs. For this important
symptom, keep the possible causes below in mind. Also see Table 8-1, Chest
Pain, pp. 155–156.
S o u r c e s o f C h e s t P a in a n d R e la t e d C a u s e s
The
yoc rdiu
Angina pectoris, myocardial infarction,
myocarditis
The eric rdiu
Pericarditis
The ort
Aortic dissection
The tr che nd l rge bronchi
Bronchitis
The riet l leur
Pericarditis, pneumonia, pneumothorax,
pleural effusion, pulmonary embolus
The chest w ll, including the usculo- Costochondritis, herpes zoster
skelet l nd neurologic syste s
The eso h gus
Gastroesophageal reflux disease, esophageal spasm, esophageal tear
Extr thor cic structures such s the
Cervical arthritis, biliary colic, gastritis
neck, g llbl dder, nd sto ch
For patients who are short of breath, focus on pulmonary complaints:
■ Dyspnea and wheezing
See Table 8-2, Dyspnea, pp. 157–158.
■ Cough and hemoptysis
See Table 8-3, Cough and Hemoptysis,
pp. 159–161.
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Ba te s ’ Poc ke t Guide to Phys ic a l Exa mina tion a nd His tory Ta king
■ Daytime sleepiness or snoring
and disordered sleep
Snoring, witnessed apneas ≥10 seconds,
awakening with a choking sensation, or
morning headache point to obstructive
sleep apnea.
Health Promotion and Counseling:
Evidence and Recommendations
Im p o r t a n t T o p ic s f o r H e a lt h P r o m o t io n a n d C o u n s e lin g
●
●
●
Tob cco cess tion
Lung c ncer
I
uniz tions—influenz
nd stre tococc l neu oni v ccines
Despite declines in smoking over the past several decades, 19% of Americans still smoke. Regularly counsel all adults, pregnant women, parents,
and adolescents who smoke to stop. Use “the ve As” and the Stages of
Change Model to assess readiness to quit.
A s s e s s in g R e a d in e s s t o Q u it S m o k in g :
B r ie f In t e r v e n t io n s M o d e ls
5 As Mo d e l
S t a g e s o f Ch a n g e Mo d e l
Ask bout tob cco use
Advise to quit
Precontemplation—“I don’t w nt to quit.”
Contemplation—“I
concerned but not
re dy to quit now.”
Preparation—“I
re dy to quit.”
Assess willingness to
quit tte t
Assist in quit tte t
Arrange follow-u
ke
Action—“I just quit.”
Maintenance—“I quit 6
onths go.”
Counsel patients to never smoke or quit smoking. The U.S. Preventive
Services Task Force recommends annual low-dose computed tomography
(LDCT) screening for current smokers (or those who have quit within the
last 15 years) ages 55 to 79 years (grade B recommendation).
Provide u shots to everyone age 6 months or older and especially to those
with chronic pulmonary conditions, nursing home residents, household
contacts, and health care personnel.
Recommend pneumococcal vaccine to adults 65 years and older, smokers
between the ages of 16 and 64 years, and those with increased risk of
pneumococcal infection.
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147
Techniques of Examination
EXAMINATIO N TECHNIQ UES
P O SSIBLE FIN DIN G S
In it ia l In s p e c t io n o f T h o r a x
Supra s ternal notch
2nd rib
Manubrium
of s ternum
2nd rib
inters pace
2nd cos tal
ca rtilage
Sternal
angle
Body of
s ternum
Xyphoid
proces s
Cos toc hondral
junctions
Cos tal angle
Fig ure 8-1 Che s t wall anatomy.
Inspect the thorax (Fig. 8-1) and its
respiratory movements for signs of
distress and note:
■ Facial color
Cyanosis and pallor in lips and oral
mucosa signal hypoxia.
■ Rate, rhythm, depth, and effort
Tachypnea, hyperpnea, Cheyne –Stokes
breathing. Normally 14 to 20 breaths/
minute in adults. See Table 8-4 Abnormalities in Rate and Rhythm of Breathing, p. 162.
of breathing
■ Inspiratory retraction of the
supraclavicular areas
■ Inspiratory contraction of the
Occurs in chronic obstructive pulmonary
disease (COPD), asthma, upper airway
obstruction
Indicates severe breathing difficulty
sternocleidomastoids
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Ba te s ’ Poc ke t Guide to Phys ic a l Exa mina tion a nd His tory Ta king
EXAMINATIO N TECHNIQ UES
P O SSIBLE FIN DIN G S
If distress, auscultate the neck and
lungs for:
■ Stridor
Stridor in upper airway obstruction from
foreign body or epiglottitis
■ Wheezes
Expiratory wheezing in asthma and
COPD
Observe shape of patient’s chest.
Normal or barrel chest (see Table 8-5,
Deformities of the Thorax, pp. 163–164)
T h e P o s t e r io r C h e s t
Inspect the chest for:
■ Deformities or asymmetry
Kyphoscoliosis
■ Abnormal inspiratory retraction
Retraction in asthma, COPD, upper airway obstruction
of the interspaces
■ Impairment or unilateral lag in
respiratory movement
Disease of the underlying lung or pleura,
phrenic nerve palsy
Palpate the chest for:
■ Tender areas
Fractured ribs
■ Assessment of visible abnor-
Masses, sinus tracts
malities
■ Chest expansion (Fig. 8-2)
Impairment, both sides in COPD and
restrictive lung disease; unilateral
decrease or delay in chronic fibrosis of
the underlying lung or pleura, pleural
effusion, lobar pneumonia, pleural pain
with associated splinting, unilateral
bronchial obstruction, and paralysis of
the hemidiaphragm
Fig ure 8-2 As s e s s lung expans ion.
■ Tactile fremitus as the patient
says “aa” or “blue moon”
Decreased or absent fremitus when
transmission of vibrations to the chest is
impeded by a thick chest wall, obstructed
bronchus, COPD, or pleural effusion,
fibrosis, air (pneumothorax), or an infiltrating tumor.
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Chapter 8 | The Thorax and Lungs
EXAMINATIO N TECHNIQ UES
149
P O SSIBLE FIN DIN G S
Asymmetric decreased fremitus in unilateral pleural effusion, pneumothorax,
or neoplasm; asymmetric increased
fremitus occurs in unilateral pneumonia,
which increases transmission through
consolidated tissue.
Percuss the chest, comparing one
side with the other at each level,
using the side-to-side “ladder
pattern,” as shown in Figures 8-3
and 8-4.
6
7
1
1
2
2
3
3
4
4
5
5
Dullness when fluid or solid tissue
replaces normally air-filled lung; hyperresonance in emphysema or pneumothorax
6
7
Fig ure 8-3 Pe rcus s and aus cultate in
Fig ure 8-4 Strike the plexim e te r
a “ ladde r” patte rn.
finge r w ith the right m iddle finge r.
P e r c u s s io n N o t e s a n d T h e ir C h a r a c t e r is t ic s
Re la t ive In t e n s it y,
P it c h , a n d D u r a t io n
Ex a m p le s
Flat
Dull
Resonant
Soft/ high/short
Mediu / ediu / ediu
Loud/ low/ long
Hyperresonant
Tympanitic
Louder/ lower/ longer
Loud/ high (ti bre is usic l)
Percuss level of diaphragmatic
dullness on each side and estimate
diaphragmatic descent after patient
takes full inspiration (Fig. 8-5).
L rge leur l effusion
Lob r neu oni
He lthy lung, si le chronic
bronchitis
E hyse , neu othor x
L rge neu othor x
Pleural effusion or a paralyzed diaphragm
raises level of dullness.
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EXAMINATIO N TECHNIQ UES
P O SSIBLE FIN DIN G S
Loca tion
a nd s e que nce
of pe rcus s ion
Re s ona nt
Leve l of
dia phra gm
Dull
Figure 8-5 Identify the extent of diaphragmatic excursion.
Auscultate the chest with stethoscope in the “ladder” pattern, again
comparing sides.
See Table 8-6, Physical Findings in
Selected Chest Disorders, p. 165.
■ Evaluate the breath sounds.
Vesicular, bronchovesicular, or bronchial
breath sounds; decreased breath sounds
from decreased airflow.
■ Note any adventitious (added)
Crackles (fine and coarse) and continuous sounds (wheezes and rhonchi)
sounds.
Observe qualities of breath sound,
timing in the respiratory cycle,
and location on the chest wall. Do
they clear with deep breathing or
coughing?
Clearing after cough suggests atelectasis.
C h a r a c t e r is t ic s o f B r e a t h S o u n d s
D u r a t io n
In t e n s it y a n d P it c h
o f Ex p ir a t o ry S o u n d
Ex a m p le
Lo c a t io n s
Ins > Ex
Soft/ low
Most of the lungs
Bronchovesicular Ins = Ex
Mediu / ediu
Bronchial
Ex > Ins
Loud/ high
1st nd 2nd inters ces, intersc ul r re
Over the
nubriu
Tracheal
Ins = Ex
Very loud/ high
Vesicular
Over the tr che
Dur tion is indic ted by the length of the line, intensity by the width of the line, nd itch by
the slo e of the line.
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Chapter 8 | The Thorax and Lungs
EXAMINATIO N TECHNIQ UES
151
P O SSIBLE FIN DIN G S
A d v e n t it io u s o r A d d e d B r e a t h S o u n d s
C r a c k le s (o r Ra le s )
Wh e e ze s a n d Rh o n c h i
Disco ntinuo us
Co ntinuo us
●
Inter ittent, nonmusical, nd
brief
●
●
Like dots in ti e
Fine crackles: soft, high- itched
( 65 Hz), very brief (5–1 s)
●
Coarse crackles: so ewh t louder,
lower in itch ( 35 Hz), brief
(15–3
s)
●
●
●
●
Sinusoid l, musical, rolonged (but
not necess rily ersisting throughout
the res ir tory cycle)
Like d shes in ti e
Wheezes: rel tively high- itched
(≥4 Hz) with hissing or shrill
qu lity (>8
s)
Rhonchi: rel tively low- itched
(15 –2 Hz) with snoring qu lity
(>8
s)
Source: Loudon R, Mur hy LH. Lung sounds. Am Rev Respir Dis. 1994;13 :663; Boh d n A,
Izbicki G, Kr
n SS. Fund ent ls of lung uscult tion. N Engl J Med. 2 14;37 :744.
Assess transmitted voice sounds
and bronchial breath sounds heard
in abnormal places. Ask patient to:
■ Say “ninety-nine” and “ee.”
Bronchophony if sounds become louder;
egophony if “ee”to “A”change from
lobar consolidation
■ Whisper “ninety-nine” or
Whispered pectoriloquy if whispered
sounds transmit louder and more
clearly
“one-two-three.”
T r a n s m it t e d V o ic e S o u n d s
Th ro u g h N o r m a lly A ir-Fille d Lu n g
Th ro u g h A ir le s s Lu n g a
Usu lly cco
nied by vesicul r
bre th sounds nd nor l t ctile
fre itus
S oken words uffled nd indistinct
Usu lly cco
nied by bronchi l or
bronchovesicul r bre th sounds
nd incre sed t ctile fre itus
S oken words louder, cle rer
(bronchophony)
S oken “ee” he rd s “ y” (egophony)
Whis ered words louder, cle rer
(whispered pectoriloquy)
S oken “ee” he rd s “ee”
Whis ered words f int nd indistinct,
if he rd t ll
As in lob r neu oni
a
nd tow rd the to of l rge leur l effusion.
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EXAMINATIO N TECHNIQ UES
P O SSIBLE FIN DIN G S
Alternative Examination Sequence—While the patient is still sitting, you
may inspect the breasts and examine the axillary and epitrochlear lymph
nodes, and examine the temporomandibular joint and the musculoskeletal
system of the upper extremities.
T h e A n t e r io r C h e s t
Mids te rna l
line
Ante rior
a xilla ry
line
Midclavicula r
line
Mida xilla ry
line
Ante rior
a xilla ry
line
Fig ure 8-6 Mids te rnal and m idclavicu-
Pos te rior
a xilla ry
line
lar line s .
Fig ure 8-7 Ante rior, pos te rior, and
m idaxillary line s .
Inspect the chest (Figs. 8-6 and
8-7) for:
■ Deformities or asymmetry
Pectus excavatum
■ Intercostal retraction
From obstructed airways
■ Impaired or lagging respiratory
Disease of the underlying lung or pleura,
phrenic nerve palsy
movement
Palpate the chest for:
■ Tender areas
Tender pectoral muscles, costochondritis
■ Assessment of visible abnor-
Flail chest
malities
■ Respiratory expansion
■ Tactile fremitus
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Chapter 8 | The Thorax and Lungs
EXAMINATIO N TECHNIQ UES
Percuss the chest in the areas illustrated in Figure 8-8.
1
5
6
P O SSIBLE FIN DIN G S
Normal cardiac dullness may disappear
in emphysema.
1
2
2
3
3
4
153
4
5
6
Fig ure 8-8 Palate and pe rcus s in a
“ ladde r” patte rn.
Auscultate the chest. Assess breath
sounds, adventitious sounds, and if
indicated transmitted voice sounds.
S p e c ia l T e c h n iq u e s
Clin ic a l As s e s s m e n t o f
P u lm o n a ry Fu n c t io n . Walk
with patient down the hall or up
a ight of stairs. Observe the rate,
effort, and sound of breathing, and
inquire about symptoms. Or learn
to do a standardized “6-minute walk
test.”
Fo rc e d Exp ira t o ry
Tim e . Ask the patient to take a
deep breath in and then breathe
out as quickly and completely as
possible, with mouth open. Listen
over trachea with diaphragm of
stethoscope, and time audible expiration. Try to get three consistent
readings, allowing rests as needed.
Older adults walking 8 feet in <3 seconds
are less likely to be disabled than those
taking >5 to 6 seconds.
Patients age ≥60 years with a forced
expiratory time of ≥9 seconds are four
times more likely to have COPD.
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Recording Your Findings
R e c o r d in g t h e T h o r a x a n d Lu n g s E x a m in a t io n
“Thor x is sy
etric with good ex nsion. Lungs reson nt. Bre th sounds
vesicul r; no r les, wheezes, or rhonchi. Di hr g s descend 4 c bil ter lly.”
OR
“Thor x sy
etric with oder te ky hosis nd incre sed ntero osterior (AP)
di eter, decre sed ex nsion. Lungs re hy erreson nt. Bre th sounds dist nt
with del yed ex ir tory h se nd sc ttered ex ir tory wheezes. Fre itus
decre sed; no broncho hony, ego hony, or whis ered ectoriloquy. Di hr g s
descend 2 c bil ter lly.” (These findings suggest COPD.)
ERRNVPHGLFRVRUJ
Chapter 8 | The Thorax and Lungs
155
Aids to Interpretation
Table 8-1 Ch e s t P a in
Q u a lit y, S e ve r it y, Tim in g ,
a n d A s s o c ia t e d S y m p t o m s
P ro b le m a n d Lo c a t io n
C a r d io va s c u la r
An g in a Pe cto ris
■
Retrosternal or across the anterior
chest, sometimes radiating to the
shoulders, arms, neck, lower jaw,
or upper abdomen
■
■
■
Myo ca rd ia l In fa rctio n
■
Same as in angina
■
■
■
Pe rica rd itis
■
Retrosternal or Precordial: May
radiate to the tip of the shoulder
and to the neck
■
■
■
■
Dis s e ctin g Ao rtic An e u rys m
■
Anterior chest, radiating to the
neck, back, or abdomen
■
■
■
Pressing, squeezing, tight,
heavy, occasionally burning
Mild to moderate severity,
sometimes perceived as
discomfort rather than pain
Usually 1–3 min but up to
10 min; prolonged episodes up
to 20 min
Sometimes with dyspnea,
nausea, swelling
Same as in angina
Often but not always a severe
pain
20 min to several hours
Associated with nausea,
vomiting, sweating, weakness
Sharp, knifelike quality
Often severe
Persistent timing
Relieved by leaning forward
Seen in autoimmune disorders,
postmyocardial infarction, viral
infection, chest irradiation
Ripping, tearing quality
Very severe
Abrupt onset, early peak,
persistent for hours or more
Associated syncope, hemiplegia,
paraplegia
(table continues on page 156)
ERRNVPHGLFRVRUJ
156
Ba te s ’ Poc ke t Guide to Phys ic a l Exa mina tion a nd His tory Ta king
Table 8-1 Ch e s t P a in (continued )
P ro b le m a n d Lo c a t io n
Q u a lit y, S e ve r it y, Tim in g ,
a n d A s s o c ia t e d S y m p t o m s
P u lm o n a ry
Ple u ritic Pa in
■
Chest wall overlying the process
■
■
■
Sharp, knifelike quality
Often severe
Persistent timing
Associated symptoms of the
underlying illness (often
pneumonia, pulmonary
embolism)
G a s t ro in t e s t in a l a n d O t h e r
Ga s tro in te s tin a l Re flu x Dis e a s e
■
Retrosternal, may radiate to the
back
■
■
■
Diffu s e Es o p h a g e a l S p a s m
■
Retrosternal, may radiate to the
back, arms, and jaw
■
■
■
Ch e s t Wa ll Pa in ,
Co s to ch o n d ritis
■
Often below the left breast or
along the costal cartilages; also
elsewhere
■
An xie ty, Pa n ic Dis o rd e r
■
■
■
■
■
Burning quality, may be
squeezing
Mild to severe
Variable timing
Associated with regurgitation,
dysphagia; also cough,
laryngitis, asthma
Usually squeezing quality
Mild to severe
Variable timing
Associated dysphagia
Stabbing, sticking, or dull
aching quality
Variable severity
Fleeting timing, hours or days
Often with local tenderness
Pain may be stabbing, sticking,
or dull, aching
Can mimic angina
Associated with breathlessness,
palpitations, weakness, anxiety
ERRNVPHGLFRVRUJ
Chapter 8 | The Thorax and Lungs
157
Table 8-2 Dys p n e a
P ro vo k in g /Re lie v in g
Fa c t o r s ; A s s o c ia t e d
Sym p t o m s
P ro b le m
Tim in g
Le ft -S id e d He a r t
Fa ilu r e (Left Ventricular
Failure or Mitral Stenosis)
Dyspnea may
progress slowly
or suddenly, as
in acute
pulmonary
edema
↑ by exertion, lying
down
Chronic
productive
cough followed
by slowly
progressive
dyspnea
↑ by exertion, inhaled
irritants, respiratory
infections
C h ro n ic Bro n c h it is
(may be seen with COPD)
↓ by rest, sitting up,
though dyspnea may
become persistent
Associated Symptoms:
Often cough, orthopnea,
paroxysmal nocturnal
dyspnea; sometimes
wheezing
↓ by expectoration, rest
though dyspnea may
become persistent
Associated Symptoms:
Chronic productive
cough, recurrent
respiratory infections;
wheezing possible
C h ro n ic O b s t r u c t ive
P u lm o n a ry D is e a s e
(CO P D )
Slowly
progressive;
relatively mild
cough later
↑ by exertion
↓ by rest, though
dyspnea may become
persistent
Associated Symptoms:
Cough with scant mucoid
sputum
(table continues on page 158)
ERRNVPHGLFRVRUJ
158
Ba te s ’ Poc ke t Guide to Phys ic a l Exa mina tion a nd His tory Ta king
Table 8-2 Dys p n e a (continued )
P ro vo k in g /Re lie v in g
Fa c t o r s ; A s s o c ia t e d
S ym p t o m s
P ro b le m
Tim in g
As t h m a
Acute episodes,
then symptomfree periods;
nocturnal
episodes
common
↑ by allergens, irritants,
respiratory infections,
exercise, emotion
Diffu s e In t e r s t it ia l
Lu n g Dis e a s e s
(Sarcoidosis, Neoplasms,
Asbestosis, Idiopathic
Pulmonary Fibrosis)
Progressive;
varies in rate of
development
depending on
cause
↑ by exertion
P n e u m o n ia
Acute illness;
timing varies
with causative
agent
Associated Symptoms:
Pleuritic pain, cough,
sputum, fever, though
not necessarily present
Spontaneous
P n e u m o t h o ra x
Sudden onset of
dyspnea
Associated Symptoms:
Pleuritic pain, cough
Ac u t e P u lm o n a ry
Em b o lis m
Sudden onset of
dyspnea
Associated Symptoms:
Often none; retrosternal
oppressive pain if
massive occlusion;
pleuritic pain, cough,
syncope, hemoptysis,
and/or unilateral leg
swelling and pain from
instigating deep vein
thrombosis; anxiety
↓ by separation from
aggravating factors
Associated Symptoms:
Wheezing, cough,
tightness in chest
↓ by rest, though
dyspnea may become
persistent
Associated Symptoms:
Often weakness, fatigue;
cough less common than
in other lung diseases
ERRNVPHGLFRVRUJ
Chapter 8 | The Thorax and Lungs
159
Table 8-3 Co u g h a n d He m o p t ys is
P ro b le m
C o u g h , S p u t u m , A s s o c ia t e d
S y m p t o m s , a n d S e t t in g
Ac u t e In f la m m a t io n
La ryn g itis
Cough and Sputum: Dry, or with variable
amounts of sputum
Associated Symptoms and Setting: Acute,
fairly minor illness with hoarseness.
Associated with viral nasopharyngitis
Acu te Bro n ch itis
Cough and Sputum: Dry or productive of
sputum
Associated Symptoms and Setting: An acute,
often viral illness, with burning retrosternal
discomfort
Myco p la s m a a n d Vira l
Pn e u m o n ia s
Cough and Sputum: Dry and hacking often
with mucoid sputum
Associated Symptoms and Setting: Acute
febrile illness, often with malaise,
headache, and possibly dyspnea
Ba cte ria l Pn e u m o n ia s
Cough and Sputum: Sputum is mucoid or
purulent; may be blood-streaked, diffusely
pinkish, or rusty
Associated Symptoms and Setting: Acute
illness with chills, often high fever,
dyspnea, and chest pain. Commonly from
Streptococcus pneumonia, Haemophilus
influenza, Moraxella catarrhalis; Klebsiella in
alcoholism
C h ro n ic In f la m m a t io n
Po s tn a s a l Drip
Cough and Sputum: Chronic cough with
mucoid or mucopurulent sputum
Associated Symptoms and Setting: Repeated
attempts to clear the throat. Postnasal drip,
discharge in posterior pharynx. Associated
with chronic rhinitis, with or without
sinusitis
(table continues on page 160)
ERRNVPHGLFRVRUJ
160
Ba te s ’ Poc ke t Guide to Phys ic a l Exa mina tion a nd His tory Ta king
Table 8-3 Co u g h a n d He m o p t ys is (continued )
P ro b le m
C o u g h , S p u t u m , A s s o c ia t e d
S y m p t o m s , a n d S e t t in g
Ch ro n ic Bro n ch itis
Cough: Chronic
Sputum: Mucoid to purulent; may be
blood-streaked or even bloody
Associated Symptoms and Setting: Often long
history of cigarette smoking. Recurrent
superimposed infections; often wheezing
and dyspnea
Bro n ch ie cta s is
Cough and Sputum: Chronic cough; sputum
mucoid to purulent, may be bloodstreaked or even bloody
Associated Symptoms and Setting: Recurrent
bronchopulmonary infections common;
sinusitis may coexist
Pu lm o n a ry
Tu b e rcu lo s is
Cough and Sputum: Dry, mucoid or
purulent; may be blood-streaked or bloody
Associated Symptoms and Setting: Early, no
symptoms. Later, anorexia, weight loss,
fatigue, fever, and night sweats
Lu n g Ab s ce s s
Cough and Sputum: Sputum purulent and
foul-smelling; may be bloody
Associated Symptoms and Setting: Often from
aspiration pneumonia from oral anaerobes
and poor dental hygiene; often with
dysphagia, impaired consciousness
As th m a
Cough and Sputum: Thick and mucoid,
especially near end of an attack
Associated Symptoms and Setting: Episodic
wheezing and dyspnea, but cough may
occur alone. Often a history of allergy
ERRNVPHGLFRVRUJ
Chapter 8 | The Thorax and Lungs
161
Table 8-3 Co u g h a n d He m o p t ys is (continued )
P ro b le m
C o u g h , S p u t u m , A s s o c ia t e d
S y m p t o m s , a n d S e t t in g
Ga s tro e s o p h a g e a l
Re flu x
Cough and Sputum: Chronic cough,
especially at night or early morning
Associated Symptoms and Setting: Wheezing,
especially at night (often mistaken for
asthma), early morning hoarseness,
repeated attempts to clear throat. Often
with history of heartburn and regurgitation
N e o p la s m
Cough: Dry to productive
Lu n g Ca n ce r
Sputum and Cough: Cough, dry to
productive; sputum may be blood-streaked
or bloody
Associated symptoms and setting: Commonly
with dyspnea, weight loss, and history of
tobacco abuse
C a r d io va s c u la r D is o r d e r s
Le ft Ve n tricu la r Fa ilu re
o r Mitra l S te n o s is
Cough and Sputum: Cough often dry,
especially on exertion or at night. Sputum
may progress to pink and frothy, as in
pulmonary edema, or to frank hemoptysis
Associated Symptoms and Setting: Dyspnea,
orthopnea, paroxysmal nocturnal dyspnea.
Pu lm o n a ry Em b o lis m
Cough and Sputum: Dry cough, at times
with hemoptysis
Associated Symptoms and Setting: Tachypnea,
chest or pleuritic pain, dyspnea, fever,
syncope, anxiety; factors that predispose to
deep venous thrombosis
Irrita tin g Pa rticle s ,
Ch e m ica ls , o r Ga s e s
Cough and Sputum: Variable. May be a
latent period between exposure and
symptoms
Associated Symptoms and Setting: Exposure to
irritants; eye, nose, and throat symptoms
ERRNVPHGLFRVRUJ
162
Ba te s ’ Poc ke t Guide to Phys ic a l Exa mina tion a nd His tory Ta king
Table 8-4 Ab n o rm a lit ie s in Ra t e a n d
Rh yt h m o f Bre a t h in g
Inspira tion Expira tion
No rm al. In adults, 14–20 per min; in
infants, up to 44 per min.
Rapid Shallow Breathing (Tachypnea).
Many causes, including salicylate
intoxication, restrictive lung disease, pleuritic
chest pain, and an elevated diaphragm.
Rapid Deep Breathing (Hyperpnea,
Hyperventilation). Many causes,
including exercise, anxiety, metabolic
acidosis, brainstem injury. Kussmaul
breathing, due to metabolic acidosis, is
deep, but rate may be fast, slow, or normal.
Slow Breathing (Bradypnea). May be
secondary to diabetic coma, drug-induced
respiratory depression.
Hype rpne a
Apne a
Cheyne –S to ke s Bre athing .
Rhythmically alternating periods of
hyperpnea and apnea. In infants and the
aged, may be normal during sleep; also
accompanies brain damage, heart failure,
uremia, drug-induced respiratory depression.
Ataxic (Biot) Bre athing. Unpredictable
irregularity of depth and rate. Causes
include meningitis, respiratory depression,
and brain injury.
S ighs
P rolonge d e xpira tion
S ig hing Bre athing . Breathing
punctuated by frequent sighs. When
associated with other symptoms, it
suggests the hyperventilation syndrome.
Occasional sighs are normal.
Obs tructive Bre athing . In obstructive
lung disease, expiration is prolonged
due to narrowed airways increase the
resistance to air flow. Causes include
asthma, chronic bronchitis, and COPD.
ERRNVPHGLFRVRUJ
Chapter 8 | The Thorax and Lungs
163
Table 8-5 De fo rm it ie s o f t h e Th o ra x
C ro s s -S e c t io n o f Th o r a x
N o r m a l Ad u lt
The thorax is wider than it is
deep; lateral diameter is greater
than anteroposterior (AP)
diameter.
Ba r r e l C h e s t
Has increased AP diameter,
seen in normal infants and
normal aging; also in COPD.
Tr a u m a t ic Fla il C h e s t
If multiple ribs are fractured,
can see paradoxical movements
of the thorax. Descent of the
diaphragm decreases
intrathoracic pressure on
inspiration. The injured area
may cave inward; on
expiration, it moves outward.
Expiration
Ins piration
Fu n n e l C h e s t
(Pe ctu s Exca va tu m )
Depression in the lower portion
of the sternum. Related
compression of the heart and
great vessels may cause
murmurs.
(table continues on page 164)
ERRNVPHGLFRVRUJ
164
Ba te s ’ Poc ke t Guide to Phys ic a l Exa mina tion a nd His tory Ta king
Table 8-5 De fo rm it ie s o f t h e Th o ra x (continued )
C ro s s -S e c t io n o f Th o r a x
P ig e o n C h e s t
(Pe ctu s Ca rin a tu m )
Sternum is displaced anteriorly,
increasing the AP diameter;
costal cartilages adjacent to the
protruding sternum are
depressed.
Anteriorly
dis placed s ternum
Depres s ed
cos ta l cartilages
Th o r a c ic Ky p h o s c o lio s is
Abnormal spinal curvatures and
vertebral rotation deform the
chest, making interpretation of
lung findings difficult.
Sp inal convexity to the right
(patient be nding forward)
Rib s clos e
together
ERRNVPHGLFRVRUJ
Ribs
widely
s eparated
ERRNVPHGLFRVRUJ
165
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ERRNVPHGLFRVRUJ
9
C H A P T E R
The Cardiovascular
System
The Health History
C o m m o n o r C o n c e r n in g S y m p t o m s
●
●
●
●
●
Chest in
P l it tions
Shortness of bre th: dys ne , ortho ne , or
Swelling or ede
F inting (synco e)
roxys
l nocturn l dys ne
As you assess reports of chest pain or discomfort, keep serious adverse
events in mind, such as angina pectoris, myocardial infarction, or even
a dissecting aortic aneurysm. Ask about any palpitations, shortness of
breath from orthopnea or paroxysmal nocturnal dyspnea (PND),
swelling from edema, and fainting. Be systematic as you think through
the range of possible cardiac, pulmonary, and extrathoracic etiologies.
Know the presentations of chest pain, dyspnea, wheezing, cough, and even
hemoptysis, because these symptoms can be cardiac as well as pulmonary
in origin. Also, when assessing cardiac symptoms, it is important to
quantify the patient’s baseline level of activity compared to the symptomatic
episode.
C o m m o n C a r d ia c S y m p t o m s
●
●
●
Chest pain refers to cl ssic exertion l in, ressure, or disco fort in the
chest, shoulder, b ck, neck, or r in ngin ectoris, occurs in 18% of
tients with cute MI; ty ic l descri tors lso re co
on, such s
cr
ing, grinding, ricking or, r rely, tooth or j w in.
Palpitations re n un le s nt w reness of the he rtbe t.
Shortness of breath
y re resent dys ne , ortho ne , or PND.
● Dyspnea is n unco
fort ble w reness of bre thing th t is in
ro ri te
for given level of exertion.
(continued )
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168
Ba te s ’ Poc ke t Guide to Phys ic a l Exa mina tion a nd His tory Ta king
C o m m o n C a r d ia c S y m p t o m s
(Continued )
Orthopnea is dys ne th t occurs when the tient is lying down nd
i roves when the tient sits u . It suggests left ventricular heart
failure or mitral stenosis; it lso
y cco
ny obstructive pulmonary
disease.
● PND describes e isodes of sudden dys ne
nd ortho ne th t w ken the
tient fro slee , usu lly 1 to 2 hours fter going to bed, ro ting the
tient to sit u , st nd u , or go to window for ir.
Edema refers to the ccu ul tion of excessive fluid in the interstiti l tissue
s ces; it
e rs s swelling. Dependent edema
e rs in the feet nd lower
legs when sitting or in the s cru when bedridden.
Fainting (“bl cking out”) or syncope, is tr nsient loss of consciousness
followed by recovery.
●
●
●
Health Promotion and Counseling:
Evidence and Recommendations
Im p o r t a n t T o p ic s f o r H e a lt h P r o m o t io n
a n d C o u n s e lin g
●
●
●
S eci l o ul tions t risk
Screening for c rdiov scul r risk f ctors
● Step 1: Screen for glob l risk f ctors
● Step 2: C lcul te 1 -ye r nd lifeti
e c rdiov scul r dise se (CVD) risk
using n online c lcul tor
● Step 3: Tr ck individu l risk f ctors—hy ertension, di betes, dysli ide
i s,
et bolic syndro e, s oking, f ily history, nd obesity
Pro oting lifestyle ch nges nd risk f ctor odific tion
CVD, which consists primarily of hypertension (the vast majority of
diagnoses), coronary heart disease (CHD), heart failure, and stroke, affects
nearly 84 million U.S. adults. CVD is the leading cause of death for both
men and women in the United States. Primary prevention, in those without
evidence of CVD, and secondary prevention, in those with known cardiovascular events, remain important clinical priorities. Provide education
and counseling to promote optimal levels of blood pressure, cholesterol,
weight, exercise, and smoking cessation and to reduce risk factors for
CVD and stroke.
The American Heart Association recommends important goals for ideal
cardiovascular health.
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169
A H A 2 0 2 0 G o a ls f o r Id e a l C a r d io v a s c u la r H e a lt h
1. Tot l cholesterol <2
g/dL
(untre ted)
2. Le n body ss
3. BP <12 / <8 (untre ted)
4. F sting glucose <1
g/dL
(untre ted)
5. Abstinence fro s oking
6. Physic l ctivity go l: ≥15
in/ wk
oder te intensity, ≥75 in/ wk
vigorous intensity, or co bin tion
7. He lthy diet
S p e c ia l P o p u la t io n s a t R is k
Virtually no U.S. adults have optimal health behaviors for all seven goals.
Women and African Americans are groups at especially high risk.
S c r e e n in g f o r C a r d io v a s c u la r R is k F a c t o r s
S t e p 1 : S c re e n fo r Glo b a l Ris k Fa c t o r s . Begin routine screening at
age 20 for combined individual risk factors or “global” risk of CVD and any
family history or premature heart disease, de ned as onset at age <55 years
in rst-degree male relatives and <60 years in rst-degree female relatives.
See the recommended screening intervals listed below.
M a jo r C a r d io v a s c u la r R is k F a c t o r s a n d
S c r e e n in g F r e q u e n c y
Ris k Fa c t o r
S c r e e n in g Fr e q u e n c y
F
U d te regul rly
ily history of
re ture CVD
Cig rette s oking
Poor diet
Physic l in ctivity
Obesity, es eci lly
centr l di osity
Hy ertension
Dysli ide i s
Go a l
At e ch visit
At e ch visit
Cess tion
I roved over ll e ting
ttern
At e ch visit
3
inutes oder te
intensity d ily
At e ch visit
BMI 2 –25 kg/ 2; w ist
circu ference:
≤4 inches for en,
≤35 inches for wo en
At e ch visit
<14 /9 for dults <6 ye rs,
dults >6 ye rs with
di betes or chronic kidney
dise se; <15 /9 for ll
other dults ≥6 ye rs
Every 5 ye rs if low risk
Initi te st tin ther y if eetEvery 2 ye rs if strong risk
ing ACC/AHA guidelines
(continued )
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Ba te s ’ Poc ke t Guide to Phys ic a l Exa mina tion a nd His tory Ta king
M a jo r C a r d io v a s c u la r R is k F a c t o r s a n d
S c r e e n in g F r e q u e n c y (Continued )
Ris k Fa c t o r
S c r e e n in g Fr e q u e n c y
Go a l
Di betes
Every 3 ye rs (if nor l)
beginning t ge
45 ye rs; ore frequently t ny ge
if risk f ctors
At e ch visit
Prevent/del y di betes for
those with HbA1c of
5.7–6.4%
Pulse
Identify nd tre t tri l
fibrill tion
Sources: see . 186.
S t e p 2 : Ca lc u la t e 10 -ye a r a n d Lo n g -Te rm CVD Ris k Us in g
On lin e Ca lc u la t o r s . Use the CVD risk calculators to establish 10-year
and lifetime risk for ages 40 to 79 years. The most recent ACC/AHA
Cholesterol Guideline provides a new risk-assessment calculator.
C V D R is k C a lc u la t o r s
●
●
htt :/ / y. eric nhe rt.org/cvriskc lcul tor
htt :/ / www. cc.org/ tools- nd- r ctice-su ort/ obile-resources/
fe tures/2 13- revention-guidelines- scvd-risk-esti tor?w_n v=S.
S t e p 3 : Tra ck In d ivid u a l Ris k Fa c t o rs —Hyp e rt e n s io n , Dia b e t e s ,
Dys lip id e m ia s , Me t a b o lic S yn d ro m e , S m o k in g , Fa m ily His t o ry,
a n d Ob e s it y
Hy p e r t e n s io n . The U.S. Preventive Services Task Force recommends
screening all people age ≥18 years for high blood pressure. Use the blood
pressure classification of the Seventh Report of the Joint National Committee
on Prevention, Detection, Evaluation, and Treatment of High Blood
Pressure ( JNC 7).
B lo o d P r e s s u r e C la s s if ic a t io n f o r A d u lt s —J N C 7 ,
A m e r ic a n S o c ie t y o f H y p e r t e n s io n
C a t e g o ry
Nor l
Prehy ertension
St ge 1 hy ertension
Age ≥18 to <6 ye rs
Age ≥6 ye rsa
S y s t o lic (m m Hg )
D ia s t o lic (m m Hg )
<12
12 –139
<8
8 –89
14 –159
15 –159
9 –99
9 –99
(continued )
ERRNVPHGLFRVRUJ
Chapter 9 | The Cardiovascular System
171
B lo o d P r e s s u r e C la s s if ic a t io n f o r A d u lt s —J N C 7 ,
A m e r ic a n S o c ie t y o f H y p e r t e n s io n (Continued )
C a t e g o ry
S y s t o lic (m m Hg )
St ge 2 hy ertension
If di betes or ren l dise se
(including ge ≥6 ye rs)
≥16
<14
D ia s t o lic (m m Hg )
≥1
<9
The A eric n Society of Hy ertension r ises this cutoff to ge ≥8 ye rs.
Sources: Weber MA, Schiffrin EL, White WB, et l. Clinic l r ctice guidelines for the
n geent of hy ertension in the co
unity: st te ent by the A eric n Society of Hy ertension nd the Intern tion l Society of Hy ertension. J Clin Hypertens. 2 14;16:14; Chob ni n
AV, B kris GL, Bl ck HR, et l. The Seventh Re ort of the Joint N tion l Co
ittee on Prevention, Detection, Ev lu tion, nd Tre t ent of High Blood Pressure—The JNC 7 Re ort.
JAMA. 2 3;289:256 . Av il ble t htt :/ / www.nhlbi.nih.gov/ he lth- ro/guidelines/
current/ .
a
D ia b e t e s . Use the screening and diagnostic criteria below.
A m e r ic a n D ia b e t e s A s s o c ia t io n 2 0 1 5 :
C la s s if ic a t io n a n d D ia g n o s is o f D ia b e t e s
S c r e e n in g C r it e r ia
Healthy adults with no risk factors: begin t ge 45 ye rs, re e t t 3-ye r interv ls
Adults with BMI ≥25 kg/ m 2 and additional risk factors:
● Physic l in ctivity
● First-degree rel tive with di betes
● Me
bers of high-risk ethnic o ul tion—Afric n A eric n, His nic/
L tino A eric n, Asi n A eric n, P cific Isl nder
● Mothers of inf nts ≥4. 8 kg (9 lb) t birth or di gnosed with GDM
● Hy ertension ≥14 /9
Hg or on ther y for hy ertension
● HDL cholesterol <35
g/dL nd/or triglycerides >25
g/dL
● Wo en with olycystic ov ry syndro e
● HbA1c ≥5.7%, i
ired glucose toler nce, or i
ired f sting glucose on
revious testing
● Other conditions ssoci ted with insulin resist nce such s severe obesity,
c nthosis nigric ns
● History of CVD
D ia g n o s t ic C r it e r ia
D ia b e t e s a
P r e d ia b e t e s
HbA1c
F sting l s
occ sions)
≥6.5%
≥126 g/dL
5.7%–6.4%
1 –125 g/dL
glucose (on t le st 2
(continued )
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Ba te s ’ Poc ke t Guide to Phys ic a l Exa mina tion a nd His tory Ta king
A m e r ic a n D ia b e t e s A s s o c ia t io n 2 0 1 5 :
C la s s if ic a t io n a n d D ia g n o s is o f D ia b e t e s
(Continued )
Dia g n o s t ic C r it e r ia
D ia b e t e s a
P r e d ia b e t e s
2-Hour l s
glucose (or l glucose
toler nce test)
R ndo glucose if cl ssic sy to s
≥2
g/dL
14 –199
≥2
g/dL
g/dL
In the bsence of cl ssic sy to s, n bnor l test ust be re e ted to confir the di gnosis.
However, if two different tests re both bnor l then no ddition l testing is necess ry.
Source: A eric n Di betes Associ tion. Cl ssific tion nd di gnosis of di betes. Diabetes Care.
2 15;38(Su l):S8.
a
D y s lip id e m ia s . LDL is the primary target of cholesterol-lowering therapy.
The USPSTF has issued a grade A recommendation for routine lipid
screening for all men of age >35 years and women >45 years who are at
increased risk for CHD; and a grade B recommendation to screen for lipid
disorders beginning at age 20 years for men and women who have diabetes, hypertension, obesity, tobacco use, noncoronary atherosclerosis, or
family history of early CVD. In 2014 the ACC/AHA published “a guideline
on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults.” Use the CVD risk calculator to establish 10-year risk and
lifetime gender and race-speci c risks for CHD and stroke events to guide
statin use for primary prevention (ACC/AHA Risk Calculator: http://tools.
cardiosource.org/ASCVD-Risk-Estimator). The most recent ACC/AHA Cholesterol Guideline provides evidence-based recommendations for initiating
statin therapy based on high, moderately high, and low risk level.
A T P III G u id e lin e s : 1 0 -Y e a r R is k a n d LD L G o a ls
1 0 -Ye a r Ris k
C a t e g o ry
LD L G o a l
(m g /d L)
C o n s id e r D r u g Th e r a p y if LD L
(m g /d L)
High risk (>2 %)
<1
Optional goal:
<7
<13
Optional goal:
<1
<13
<16
>1
(<1 : consider drug o tions, including
further 3 %–4 % reduction in LDL)
≥13
1 –129: consider drug o tions to
chieve go l of <1
≥16
>19
(16 –189: drug ther y optional)
Moder tely high risk
(1 %–2 %)
Moder te risk (<1 %)
Lower risk ( –1 risk
f ctor)
Source: Ad ted fro N tion l Cholesterol Educ tion P nel Re ort. I lic tions of recent
clinic l tri ls for the N tion l Cholesterol Educ tion Progr
Adult Tre t ent P nel III
Guidelines. Grundy SM, Clee n JI, Merz NB, et l., for the Coordin ting Co
ittee of
the N tion l Cholesterol Educ tion Progr . Circulation. 2 4;119:227–239.
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Chapter 9 | The Cardiovascular System
173
M e t a b o lic S y n d ro m e . The metabolic syndrome consists of a cluster of
risk factors which confer and increased risk of both CVD and diabetes. In
2009, the International Diabetes Association and other societies harmonized diagnostic criteria as the presence of three or more of the ve risk
factors listed below.
M e t a b o lic S y n d r o m e : 2 0 0 9 D ia g n o s t ic C r it e r ia
Waist circumference
Fasting plasma glucose
HDL cholesterol
Triglycerides
Blood pressure
Men ≥1 2 c , wo en ≥88 c
≥1
g/dL or being tre ted for elev ted glucose
Men <4
g/dL, wo en <5
g/dL, or being tre ted
≥15
g/dL, or being tre ted
≥13 / ≥85, or being tre ted
Source: Alberti K, Eckel RH, Grundy SM, et l. H r onizing the et bolic syndro e: joint
interi st te ent of the Intern l Di betes Feder tion T sk Force on E ide iology nd
Prevention; N tion l He rt, Lung nd Blood Institute; A eric n He rt Associ tion; World
He rt Feder tion; Intern l Atherosclerosis Society; nd Intern l Associ tion for the Study
of Obesity. Circulation. 2 9;12 :162 –1645.
O t h e r Ris k Fa c t o r s : S m o k in g , Fa m ily His t o ry, a n d O b e s it y. Smoking
increases the risk of CHD and stroke by two- to fourfold compared to nonsmokers or past smokers who quit >10 years previously; about 14% of U.S.
cardiovascular deaths are attributed to smoking annually. Among adults, 13%
report a family history of heart attack or angina before age 50 years. Along
with a family history of premature revascularization, this risk factor is associated with about a 50% increased lifetime risk for CHD and for CVD mortality.
Obesity, or BMI over 30 kg/m2, contributed to 112,000 excess adult deaths
compared to those of normal weight, and was associated with 13% of CVD
deaths in 2004.
P r o m o t in g Lif e s t y le C h a n g e a n d R is k F a c t o r
M o d if ic a t io n
Motivating behavior change is challenging, but it is an essential clinical
skill for promoting risk factor reduction. Encourage the ACC/AHA recommendations below.
Lif e s t y le M o d if ic a t io n s f o r C a r d io v a s c u la r H e a lt h
●
●
●
O ti l weight, or BMI of 18.5–24.9 kg/ 2
Int ke of <6 g of sodiu chloride or 2.3 g of sodiu
er d y
Regul r erobic exercise such s brisk w lking three to four ti es week,
ver ging 4
inutes er session
(continued )
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Ba te s ’ Poc ke t Guide to Phys ic a l Exa mina tion a nd His tory Ta king
Lif e s t y le M o d if ic a t io n s f o r C a r d io v a s c u la r H e a lt h
●
(Continued )
Moder te lcohol consu tion er d y of ≤2 drinks for en nd ≤1 drink for
wo en (2 drinks = 1 oz eth nol, 24 oz beer, 1 oz wine, or 2–3 oz whiskey)
Diet rich in fruits, veget bles, whole gr ins, nd low-f t d iry roducts with
reduced int ke of s tur ted nd tot l f t, sweets, nd red e ts.
Source: Eckel RH, J kicic JM, Ard JD, et l. 2 13 AHA/ACC guideline on lifestyle
n ge ent
to reduce c rdiov scul r risk: re ort of the A eric n College of C rdiology/A eric n
He rt Associ tion T sk Force on Pr ctice Guidelines. Circulation. 2 14;129:S76.
Techniques of Examination
EXAMINATIO N TECHNIQ UES
P O SSIBLE FIN DIN G S
H e a r t R a t e a n d B lo o d P r e s s u r e
If not already done, count the
radial or apical pulse.
Estimate systolic blood pressure by
palpation and add 30 mm Hg. Use
this sum as the target for further
cuff in ations.
This step helps you to detect an
auscultatory gap and avoid recording
an inappropriately low systolic blood
pressure.
Measure blood pressure with a
sphygmomanometer. If indicated,
recheck it.
Orthostatic (postural) hypotension
within 3 minutes of position change from
supine to standing is SBP↓ ≥20 mm Hg;
HR↑ ≥20 beats/min.
J u g u la r V e in s
Jugular venous pulsations: In the
right internal jugular vein identify
their highest point in the neck.
Start with head of the bed at 30
degrees; adjust the head of the bed
as necessary, giving consideration
to volume status.
Jugular venous pressure ( JVP)—
Measure the vertical distance
between this highest point and the
sternal angle, normally <3 to 4 cm
(Fig. 9-1).
Elevated JVP in right-sided heart failure;
decreased JVP in hypovolemia from
dehydration or gastrointestinal
bleeding.
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Chapter 9 | The Cardiovascular System
EXAMINATIO N TECHNIQ UES
175
P O SSIBLE FIN DIN G S
Fig ure 9-1 Me as ure the he ight of
the J VP.
Study the waves of venous pulsation. Note the a wave of atrial contraction and the v wave of venous
lling.
Abnormally prominent a waves in tricuspid stenosis, pulmonary hypertension,
and pulmonic stenosis; absent a waves
in atrial fibrillation. Increased v waves in
tricuspid regurgitation, atrial septal
defects, and constrictive pericarditis.
C a r o t id P u ls e
Palpate the amplitude and contour
of the carotid upstroke.
A delayed upstroke in aortic stenosis;
a bounding upstroke in aortic
insufficiency.
P u ls u s Alt e rn a n s . Palpate for
alteration in carotid pulse amplitude. Lower pressure of blood
pressure cuff slowly to systolic level
while you listen with your stethoscope over the brachial artery.
Alternating amplitude of pulse or
sudden doubling of Korotkoff sounds
indicates pulsus alternans—a sign of left
ventricular heart failure.
P a r a d o x ic a l P u ls e . Lower
pressure of BP cuff slowly and
note two pressure levels: (1) where
Korotkoff sounds are rst heard and
(2) where they rst persist through
the respiratory cycle. These levels
are normally not more than 3 to
4 mm Hg apart.
A drop of >10 mm Hg during inspiration
signifies a paradoxical pulse. Consider
obstructive pulmonary disease, asthma,
COPD, pericardial tamponade, or constrictive pericarditis.
Listen for bruits.
Carotid bruits suggest atherosclerotic
narrowing and increase stroke risk.
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Ba te s ’ Poc ke t Guide to Phys ic a l Exa mina tion a nd His tory Ta king
EXAMINATIO N TECHNIQ UES
Th e H e a r t
S e q u e n c e o f t h e C a r d ia c E x a m in a t io n
P a t ie n t P o s it io n
Ex a m in a t io n
Supine, with the
head elevated
30 degrees
After ex ining the JVP nd c rotid ulse, ins ect nd
l te the recordiu : the 2nd right nd left
inters ces; the right ventricle; nd the left ventricle,
including the ic l i ulse (di eter, loc tion,
litude, dur tion).
P l te the ic l i ulse to ssess its di eter.
Listen t the ex with the bell of the stethosco e.
Listen t the six re s with the diaphragm then the bell:
the 2nd right nd left inters ces, down the left stern l
border to the 4th nd 5th inters ces, nd cross to the
ex (see . 177). As indic ted, listen t the lower right
stern l border for right-sided ur urs nd sounds, often
ccentu ted with ins ir tion, with the diaphragm nd
bell.
Listen down the left stern l border nd t the ex with the
diaphragm for the soft decrescendo ur ur of ortic
insufficiency.
Left lateral
decubitus
Supine, with the
head elevated
30 degrees
Sitting, leaning
forward, after
full exhalation
In s p e c t io n a n d P a lp a t io n .
Inspect and palpate the anterior
chest for heaves, lifts, or thrills.
Inspect and palpate the apical
impulse (Fig. 9-2). Turn patient to
left as necessary. Note:
Fig ure 9-2 Palpate the apical im puls e .
■ Location of impulse
Displaced to left in pregnancy.
■ Diameter
Increased diameter, amplitude, and
duration in left ventricular dilatation from
heart failure or ischemic cardiomyopathy.
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177
EXAMINATIO N TECHNIQ UES
P O SSIBLE FIN DIN G S
■ Amplitude—usually tapping
Sustained in left ventricular hypertrophy;
diffuse in CHF.
■ Duration
Feel for a right ventricular impulse
in left parasternal and epigastric
areas.
Prominent impulses suggest right ventricular enlargement.
Palpate left and right second interspaces close to sternum. Note any
thrills in these areas.
Pulsations of great vessels; accentuated
S2; thrills of aortic or pulmonic stenosis.
Au s c u lt a t io n . Listen to the
heart by “inching” your stethoscope
from the base to the apex (or apex
to base) in the areas illustrated in
Figure 9-3.
Le ft 2nd
inte rs pac e —
P ulmonic a re a
Rig ht 2nd
inte rs pac e —
Aortic a re a
Rig ht
ve ntric ular
are a—
Le ft s te rna l
borde r
Epiga s tric
(s ubxiphoid)
Le ft
ve ntric ular
are a—Apex
Fig ure 9-3 Aus cultate the he art from
the bas e to the apex.
Use the diaphragm to detect the
relatively high-pitched sounds like
S1, S2.
Also murmurs of aortic and mitral regurgitation, pericardial friction rubs.
Use the bell for low-pitched sounds at
the lower left sternal border and apex.
S3, S4, murmur of mitral stenosis.
Listen at each area for:
See Table 9-1, Heart Sounds, p. 181;
Table 9-2, Variations in the First Heart
Sound—S1, p. 182; Table 9-3, Variations
in the Second Heart Sound—S2 During
Inspiration and Expiration, pp. 183–184.
■ S1
■ S2. Is splitting normal in left
2nd and 3rd interspaces?
Physiologic (inspiratory) or pathologic
(expiratory) splitting
■ Extra sounds in systole
Systolic clicks
■ Extra sounds in diastole
S3, S4
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Ba te s ’ Poc ke t Guide to Phys ic a l Exa mina tion a nd His tory Ta king
EXAMINATIO N TECHNIQ UES
P O SSIBLE FIN DIN G S
■ Systolic murmurs
Midsystolic, pansystolic, late systolic
murmurs
■ Diastolic murmurs
Early, mid-, or late diastolic murmurs
Use two maneuvers as needed to
help identify the murmurs of mitral
stenosis and aortic regurgitation.
Listen at the apex with patient
turned toward left side for lowpitched sounds (Fig. 9-4).
Left-sided S3, and diastolic murmur of
mitral stenosis.
Fig ure 9-4 Lis te n at the apex for lowpitche d s ounds .
Listen down the left sternal
border to the apex as patient sits,
leaning forward, with breath held
after exhalation (Fig. 9-5).
Diastolic decrescendo murmur of aortic
regurgitation.
Fig ure 9-5 Lis te n at the lowe r le ft
s te rnal borde r for aortic ins ufficie ncy.
As s e s s in g a n d De s c rib in g
Mu rm u r s . Identify, if murmurs are
present, their:
■ Timing in the cardiac cycle
See Table 9-4, Heart Murmurs, p. 185.
(systole, diastole). It is helpful to
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Chapter 9 | The Cardiovascular System
EXAMINATIO N TECHNIQ UES
179
P O SSIBLE FIN DIN G S
palpate the carotid upstroke while
listening to any murmur—murmurs occurring simultaneously
with the upstroke are systolic.
■ Shape
Plateau, crescendo, decrescendo
A crescendo–decrescendo murmur first
rises in intensity, then falls (e.g., aortic
stenosis).
S1
S2
A plateau murmur has the same intensity
throughout (e.g., mitral regurgitation).
S1
S2
A crescendo murmur grows louder (e.g.,
mitral stenosis).
S2
S1
A decrescendo murmur grows softer (e.g.,
aortic regurgitation).
S2
S1
■ Location of maximal intensity
Murmurs loudest at the base are often
aortic; at the a pex, they are often mitral.
■ Radiation
■ Pitch
High, medium, low
■ Quality
Blowing, harsh, musical, rumbling
■ Intensity on a six-point scale (see
“Gradations of Murmurs” below)
G r a d a t io n s o f M u r m u r s
Gra d e
D e s c r ip t io n
Grade 1 Very f int, he rd only fter listener h s “tuned in”; y not be he rd in
ll ositions
Grade 2 Quiet, but he rd i
edi tely fter l cing the stethosco e on the chest
Grade 3 Moder tely loud
Grade 4 Loud, with palpable thrill
Grade 5 Very loud, with thrill. M y be he rd when the stethosco e is rtly off
the chest
Grade 6 Very loud, with thrill. M y be he rd with stethosco e entirely off the chest
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EXAMINATIO N TECHNIQ UES
P O SSIBLE FIN DIN G S
S p e c ia l T e c h n iq u e s
Aid s t o Id e n t ify S ys t o lic Mu rm u r s
Va ls a lva M a n e u ve r. Ask patient
to strain down.
In suspected mitral valve prolapse
(MVP), listen to the timing of click
and murmur.
Ventricular filling decreases, the systolic
click of MVP is earlier, and the murmur
lengthens.
To distinguish aortic stenosis (AS)
from hypertrophic cardiomyopathy
(HCM), listen to the intensity of the
murmur.
In AS, the murmur decreases; in HCM, it
often increases.
/
S q u a t t in g a n d S t a n d in g . In
suspected MVP, listen for the click
and murmur in both positions.
Try to distinguish AS from HCM
by listening to the murmur in both
positions.
Squatting increases ventricular filling
and delays the click and murmur.
Standing reverses the changes.
Squatting increases murmur of AS and
decreases murmur of HCM. Standing
reverses the changes.
Recording Your Findings
R e c o r d in g t h e C a r d io v a s c u la r E x a m in a t io n
“The jugul r venous ulse is 3 c bove the stern l ngle with the he d of the
bed elev ted to 3 degrees. C rotid u strokes re brisk, without bruits. The
oint of xi l i ulse (PMI) is t
ing, 7 c l ter l to the idstern l line in
the 5th intercost l s ce. Cris S1 nd S2. At the b se, S2 is gre ter th n S1 nd
hysiologic lly s lit, with A2 > P2. At the ex, S1 is gre ter th n S2 nd const nt.
No ur urs or extr sounds.”
OR
“The JVP is 5 c bove the stern l ngle with the he d of the bed elev ted to
5 degrees. C rotid u strokes re brisk; bruit is he rd over the left c rotid
rtery. The PMI is diffuse, 3 c in di eter, l ted t the nterior xill ry line
in the 5th nd 6th intercost l s ces. S1 nd S2 re soft. S3 resent t the ex.
High- itched, h rsh 2/ 6 holosystolic ur ur best he rd t the ex, r di ting
to the xill . No S4 or di stolic ur urs.” (These findings suggest CHF with
possible left carotid stenosis and mitral regurgitation.)
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Chapter 9 | The Cardiovascular System
181
Aids to Interpretation
Table 9-1 He a r t S o u n d s
S 1 E1
S 2 OS S 3
S ys tole
S4 S1
Dia s tole
Fin d in g
P o s s ib le C a u s e s
S1 accentuated
Tachycardia, states of high cardiac
output; mitral stenosis
S 1 d im in is h e d
First-degree heart block; reduced left
ventricular contractility; immobile
mitral valve, as in mitral regurgitation
S y s t o lic c lic k (s )
Mitral valve prolapse (as in E1 above)
S 2 a c c e n t u a t e d in r ig h t
2 n d in t e r s p a c e
Systemic hypertension, dilated aortic
root
S 2 d im in is h e d o r a b s e n t
in r ig h t 2 n d in t e r s p a c e
Immobile aortic valve, as in calcific
aortic stenosis
P2 accentuated
Pulmonary hypertension, dilated
pulmonary artery, atrial septal defect
P 2 d im in is h e d o r a b s e n t
Aging, pulmonic stenosis
O p e n in g s n a p
Mitral stenosis
S3
Physiologic (usually in children and
young adults); volume overload of
ventricle, as in mitral regurgitation or
heart failure
S4
Excellent physical conditioning (trained
athletes); resistance to ventricular filling
because of decreased compliance, left
ventricular hypertrophy from pressure
overload, as in hypertensive heart
disease or aortic stenosis
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Ba te s ’ Poc ke t Guide to Phys ic a l Exa mina tion a nd His tory Ta king
Table 9-2 Va ria t io n s in t h e Fir s t He a r t S o u n d —S 1
N o r m a l Va r ia t io n s
S1
S1 is softer than S2 at the base (right and
left 2nd interspaces).
S2
S1 is often but not always louder than S2 at
the apex.
S1
S2
Ac c e n t u a t e d S 1
S1
S2
Occurs in first-degree heart block, calcified
mitral valve of mitral regurgitation, and
↓ left ventricular contractility in heart
failure or coronary heart disease.
D im in is h e d S 1
S1
S2
S1 varies in complete heart block and
any totally irregular rhythm (e.g., atrial
fibrillation).
Va ry in g S 1
S1 S2
S1 S2
S p lit S 1
S1
Occurs in (1) tachycardia, rhythms with
a short PR interval, and high cardiac
output states (e.g., exercise, anemia,
hyperthyroidism), and (2) mitral stenosis.
S2
Normally heard along the lower left sternal
border if audible tricuspid component. If
S1 sounds split at apex, consider an S4, an
aortic ejection sound, an early systolic click,
right bundle branch block, and premature
ventricular contractions.
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Chapter 9 | The Cardiovascular System
183
Table 9-3 Va ria t io n s in t h e S e c o n d He a r t S o u n d —
S 2 Du rin g In s p ira t io n a n d Exp ira t io n
P h y s io lo g ic S p lit t in g
A2
S1
P2
S2
S1
S2
Heard in the 2nd or 3rd left interspace: the pulmonic component of S2 is
usually too faint to be heard at the apex or aortic area, where S2 is single
and derived from aortic valve closure alone. Accentuated by inspiration;
usually disappears on exertion.
P a t h o lo g ic S p lit t in g
S1
S2
S1
S2
Wide splitting of S2 persists throughout respiration; arises from delayed
closure of the pulmonic valve (e.g., by pulmonic stenosis or right bundle
branch block); also from early closure of the aortic valve, as in mitral
regurgitation.
Fixe d S p lit t in g
S1
S2
S1
S2
Does not vary with respiration, as in atrial septal defect, right ventricular
failure.
(table continues on page 184)
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Ba te s ’ Poc ke t Guide to Phys ic a l Exa mina tion a nd His tory Ta king
Table 9-3 Va ria t io n s in t h e S e c o n d He a rt S o u n d —
S 2 Durin g Ins pira tion a n d Exp ira t io n (continued )
P a r a d o x ic a l o r Re ve r s e d S p lit t in g
P2
S1
S2
S1
A2
S2
Appears on expiration and disappears on inspiration. Closure of the
aortic valve is abnormally delayed, so A2 follows P2 on expiration, as in
left bundle branch block.
Mo re o n A2 a n d P 2
Increased Intensity of A2, 2nd Right Interspace (where only A2 can
usually be heard) occurs in systemic hypertension because of the
increased ejection pressure. It also occurs when the aortic root is dilated,
probably because the aortic valve is then closer to the chest wall.
Decreased or Absent A2, 2nd Right Interspace is noted in calcific
aortic stenosis because of immobility of the valve. If A2 is inaudible, no
splitting is heard.
Increased Intensity of P2. When P2 is equal to or louder than A2,
pulmonary hypertension may be suspected. Other causes include a
dilated pulmonary artery and an atrial septal defect. When a split S2 is
heard widely, even at the apex and the right base, P2 is accentuated.
Decreased or Absent P2 is most commonly due to the increased
anteroposterior diameter of the chest associated with aging. It can also
result from pulmonic stenosis. If P2 is inaudible, no splitting is heard.
ERRNVPHGLFRVRUJ
Chapter 9 | The Cardiovascular System
185
Table 9-4 He a r t Mu rm u r s
Lik e ly C a u s e s
Innocent murmurs (no valve abnormality)
M id s y s t o lic
S1
Physiologic murmurs (from ↑ flow across
a semilunar valve, as in pregnancy, fever,
anemia)
S2
Aortic stenosis
Murmurs that mimic aortic stenosis—
aortic sclerosis, bicuspid aortic valve,
dilated aorta, and pathologically ↑ systolic
flow across aortic valve
Hypertrophic cardiomyopathy
Pulmonic stenosis
Mitral regurgitation
P a n s y s t o lic
Tricuspid regurgitation
S1
Ventricular septal defect
S2
Mitral valve prolapse, often with click (C)
La t e S y s t o lic
S1
C
S2
Aortic regurgitation
Ea r ly D ia s t o lic
S1
S2
S1
M id d ia s t o lic a n d
P r e s y s t o lic
S1
S 2 OS
Mitral stenosis—note opening snap (OS)
S1
C o n t in u o u s M u r m u r s
and Sounds
S1
S1
S1
S2
S2
S2
S1
Patent ductus arteriosus—harsh,
machinery-like
S1
Pericardial friction rub—a scratchy sound
with 1–3 components
S1
Venous hum—continuous, above
midclavicles, loudest in diastole
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Ba te s ’ Poc ke t Guide to Phys ic a l Exa mina tion a nd His tory Ta king
S o u r c e s fo r M a jo r C a r d io va s c u la r Ris k Fa c t o r s a n d S c r e e n in g
Fr e q u e n c y Bo x o n p . 1 7 0
Sources: Ad ted fro : Goff DC, Jr., Lloyd-Jones DM, Bennett G, et l. 2 13 ACC/AHA guideline on the ssess ent of c rdiov scul r risk: re ort of the A eric n College of C rdiology/A eric n He rt Associ tion T sk Force on Pr ctice Guidelines. J Am Coll Cardiol.
2 14;63(25 Pt B):2935; Stone NJ, Robinson JG, Lichtenstein AH, et l. 2 13 ACC/AHA guideline on the tre t ent of blood cholesterol to reduce therosclerotic c rdiov scul r risk in
dults: re ort of the A eric n College of C rdiology/A eric n He rt Associ tion T sk
Force on Pr ctice Guidelines. Circulation. 2 14;129:S1; J es PA, O ril S, C rter BL, et l.
2 14 evidence-b sed guideline for the
n ge ent of high blood ressure in dults:
re ort fro the nel e bers
ointed to the Eighth Joint N tion l Co
ittee (JNC 8).
JAMA. 2 14;311:5 7; Meschi JF, Bushnell C, Boden-Alb l B, et l. Guidelines for the riry revention of stroke: st te ent for he lthc re rofession ls fro the A eric n
He rt Associ tion/A eric n Stroke Associ tion. Stroke. 2 14;45:3754; Fl ck JM, Sic DA,
B kris G, et l. M n ge ent of high blood ressure in Bl cks: n u d te of the Intern tion l Society on Hy ertension in Bl cks consensus st te ent. Hypertension. 2 1 ;56:78 ;
A eric n Di betes A. Executive su
ry: St nd rds of edic l c re in di betes—2 14.
Diabetes Care. 2 14;37 Su l 1:S5.
ERRNVPHGLFRVRUJ
10
C H A P T E R
The Breasts and Axillae
The Health History
C o m m o n o r C o n c e r n in g S y m p t o m s
●
●
●
Bre st lu
or
ss
Bre st in or disco fort
Ni le disch rge
Ask, “Do you examine your breasts?” . . . “How often?” Ask about any
discomfort, pain, or lumps in the breasts. Also ask about any discharge
from the nipples, change in breast contour, dimpling, swelling, or
puckering of the skin over the breasts.
Health Promotion and Counseling:
Evidence and Recommendations
Im p o r t a n t T o p ic s f o r H e a lt h P r o m o t io n
a n d C o u n s e lin g
●
●
●
P l ble
sses of the bre st
Assessing risk of bre st c ncer
Bre st c ncer screening
Pa lp a b le Ma s s e s o f t h e Bre a s t . Breast masses show marked variation in
etiology, from broadenomas and cysts seen in younger women, to abscess
or mastitis, to primary breast cancer. All breast masses warrant careful evaluation, and de nitive diagnostic measures should be pursued.
ERRNVPHGLFRVRUJ
187
188
Ba te s ’ Poc ke t Guide to Phys ic a l Exa mina tion a nd His tory Ta king
P a lp a b le M a s s e s o f t h e B r e a s t
Ag e
C o m m o n Le s io n
C h a r a c t e r is t ic s
15–25
Fibro deno
25–5
Cysts
Usu lly s ooth, rubbery, round,
obile, nontender
Usu lly soft to fir , round,
obile; often tender
Nodul r, ro e-like
Irregul r, fir , y be obile or
fixed to surrounding tissue
As bove
Fibrocystic ch nges
C ncer
Over 5
Pregn ncy/
l ct tion
C ncer until roven otherwise
L ct ting deno s, cysts,
stitis, nd c ncer
As bove
Ad ted fro Schultz MZ, W rd BA, Reiss M. Bre st dise ses. In: Noble J, Greene HL,
Levinson W, et l. (eds). Primary Care Medicine. 2nd ed. St. Louis: MO; 1996; Venet L, Str x P,
Venet W, et l. Adequ cies nd in dequ cies of bre st ex in tions by hysici ns in
ss
screenings. Cancer. 1971;28(6):1546–1551.
As s e s s in g Ris k o f Bre a s t Ca n c e r. About 50% of affected women have
no known predisposing risk factors; however, selected risk factors are well
established.
B r e a s t C a n c e r R is k F a c t o r s
Nonmodifiable risk factors:
● Age ( ost i
ort nt)
● F
ily history of bre st nd ov ri n
c ncers
● Inherited genetic
ut tions
● Person l history of bre st c ncer or
lobul r c rcino
in situ
● High levels of endogenous hor ones
● Bre st tissue density
● Prolifer tive lesions with ty i on
bre st bio sy
● Dur tion of uno
osed estrogen
ex osure rel ted to e rly en rche
● Age of first full-ter
regn ncy
● L te
eno use
Bre st density on
ogr s
(co
nds incre sing i ort nce
s strong inde endent risk f ctor)
● History of r di tion to the chest
● History of diethylstilbestrol (DES)
ex osure
Modifiable risk factors:
● Bre stfeeding for <1 ye r
● Post
eno us l obesity
● Use of hor one re l ce
ent
ther y (HRT)
● Cig rette s oking
● Alcohol ingestion
● Physic l in ctivity
● Ty e of contr ce tion
●
See also Table 10-1, Breast Cancer in Women: Factors That Increase Relative
Risk, p. 196.
Use the Breast Cancer Risk Assessment Tool of the National Cancer Institute (http://www.cancer.gov/bcrisktool) or other available clinical models,
such as the Gail model, to individualize risk factor assessment for your
patients. Ask women beginning in their 20s about any family history of
breast or ovarian cancer, or both, on the maternal or paternal side, to help
ERRNVPHGLFRVRUJ
Chapter 10 | The Breasts and Axillae
189
assess risk of BRCA1 or BRCA2 gene mutation. (See http://bcb.dfci.harvard.
edu/bayesmendel/software.php.)
Bre a s t Ca n c e r S c re e n in g . Mammography combined with the CBE are
the most common screening modalities; however, recommendations from
professional groups vary about how to screen, when to start screening, and
screening intervals, as shown in the table below. Clinicians should be well
informed as they counsel individual patients, particularly as more evidence
emerges to guide risk-based screening.
B r e a s t C a n c e r S c r e e n in g R e c o m m e n d a t io n s
Ma m m o g ra p hy
U.S. Preventive
Services T sk
Force—
ver ge-risk
wo en (2 16)
C lin ic a l Br e a s t
Ex a m in a t io n
Br e a s t S e lf Ex a m in a t io n
Reco
ends
≥4 ye rs—
5 –74 ye rs—
g inst
insufficient
bienni lly
● <5 ye rs—
te ching BSE
evidence to
ssess ddiindividu lize
tion l benefits
screening b sed
nd h r s of
on tient-s ecific
CBE beyond
f ctors
screening
● ≥75 ye rs—insuffiogr hy
cient evidence to
reco
end
● 4 –45 ye rs—
A eric n C ncer
Not reco
ended Not reco
ended
Society— ver gedue to l ck of
due to l ck of
o tion l nnu l
risk wo en (2 15)
evidence
evidence
screening
showing cle r
showing cle r
● 45–54 ye rs—
benefit
benefit
nnu l screening
● ≥55 ye rs—bienni l
screening with
o tion to continue
nnu l screens
● Continue screening
if good he lth nd
life ex ect ncy
≥1 ye rs
A eric n College of ≥4 ye rs— nnu lly ● 2 –39 ye rs—
Encour ges
Obstetrici ns nd
bre st selfevery 1–3 ye rs
Gynecologists
● ≥4 ye rs—
w reness
nnu lly
●
Sources: U.S. Preventive Services T sk Force. Bre st C ncer: Screening. J nu ry 2 16. At
htt :/ / www.us reventiveservicest skforce.org/ P ge/ Docu ent/ U d teSu
ryFin l/
bre st-c ncer-screening1?ds=1&s=BREAST CANCER. Accessed 2.11.16; Oeffinger KC,
Fonth
ETH, Etzioni R, et l. Bre st c ncer screening for wo en t ver ge risk 2 15
guideline u d te fro the A eric n C ncer Society. JAMA. 2 15;314:15 . See lso htt :/ /
www.c ncer.org/c ncer/ bre stc ncer/ oreinfor tion/ bre stc ncere rlydetection/
bre st-c ncer-e rly-detection- cs-recs. Accessed Nove ber 14, 2 15.
A eric n College of Obstetrici ns nd Gynecologists. Pr ctice bulletin No. 122: bre st
c ncer screening. Obstet Gynecol. 2 11;118(2 t 1):372.
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Ba te s ’ Poc ke t Guide to Phys ic a l Exa mina tion a nd His tory Ta king
Techniques of Examination
EXAMINATIO N TECHNIQ UES
P O SSIBLE FIN DIN G S
T h e F e m a le B r e a s t
Inspect the breasts in four positions, identifying the quadrant
where changes appear (Figs. 10-1
through 10-5).
12
Ta il of
S pe nce
Uppe r
oute r
qua dra nt
9
3
Lowe r
oute r
qua dra nt
Uppe r
inne r
qua dra nt
Lowe r
inne r
qua dra nt
6
Fig ure 10-1 Bre as t quadrants .
Fig ure 10-2 Ins pe ct w ith arm s at
Fig ure 10-3 Ins pe ct w ith arm s ove r
s ide s .
he ad.
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Chapter 10 | The Breasts and Axillae
EXAMINATIO N TECHNIQ UES
191
P O SSIBLE FIN DIN G S
Fig ure 10-4 Ins pe ct w ith hands
Fig ure 10-5 Ins pe ct w hile le aning
pre s s e d agains t hips .
forward.
Note:
■ Size and symmetry
See Table 10-2, Visible Signs of Breast
Cancer, pp. 197–198.
■ Contour
Flattening, dimpling suspicious for
malignancy
■ Appearance of the skin
Edema (peau d’orange) in breast cancer
Inspect the nipples.
■ Compare their size, shape, and
Inversion, retraction, deviation
direction of pointing.
■ Note any rashes, ulcerations, or
Paget disease of the nipple, galactorrhea
discharge.
Palpate the breasts, including
augmented breasts. Breast tissue
should be attened and the patient
supine.
Use a vertical strip pattern (currently the best validated technique)
or a circular or wedge pattern. Palpate in small, concentric circles.
For the lateral portion of the breast,
ask the patient to roll onto the
opposite hip, place her hand on
her forehead, but keep shoulders
pressed against the bed or examining table (Fig. 10-6).
Fig ure 10-6 Ve rtical s trip patte rn—
late ral bre as t.
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Ba te s ’ Poc ke t Guide to Phys ic a l Exa mina tion a nd His tory Ta king
EXAMINATIO N TECHNIQ UES
P O SSIBLE FIN DIN G S
For the medial portion of the breast,
ask the patient to lie with her
shoulders at against the bed or
examining table, place her hand
at her neck, and lift up her elbow
until it is even with her shoulder
(Fig. 10-7).
Fig ure 10-7 Ve rtical s trip patte rn—
m e dial bre as t.
Palpate a rectangular area extending from the clavicle to the inframammary fold, and from the midsternal line to the posterior axillary
line and well into the axilla for the
tail of Spence.
Note:
■ Consistency
Physiologic nodularity
■ Tenderness
Infection, premenstrual tenderness
■ Nodules. If present, note
Cyst, fibroadenoma, cancer
location, size, shape, consistency,
delimitation, tenderness, and
mobility.
Palpate each nipple.
Thickening in cancer
Compress the areola in a spokelike pattern around the nipple.
Watch for discharge.
Type and source of discharge may be
identified.
Palpate and inspect along the
incision lines of mastectomy.
Local recurrences of breast cancer
/
T h e M a le B r e a s t
Inspect and palpate the nipple and
areola.
Gynecomastia, mass suspicious for
cancer, fat
ERRNVPHGLFRVRUJ
Chapter 10 | The Breasts and Axillae
EXAMINATIO N TECHNIQ UES
P O SSIBLE FIN DIN G S
A x illa e
Inspect for rashes, infection, and
pigmentation.
Hidradenitis suppurativa, acanthosis
nigricans
Palpate the axillary nodes,
including the central, pectoral,
lateral, and subscapular groups
(Figs. 10-8).
Lymphadenopathy
Fig ure 10-8 Palpate the le ft axilla.
S p e c ia l T e c h n iq u e
/
In s t ru c t io n s fo r t h e
Bre a s t S e lf-Exa m in a t io n . For
interested or high-risk patients,
instruct the patient about how to
perform the BSE.
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194
Ba te s ’ Poc ke t Guide to Phys ic a l Exa mina tion a nd His tory Ta king
P a t ie n t In s t r u c t io n s f o r t h e B r e a s t S e lf -E x a m in a t io n
(B S E )—A m e r ic a n C a n c e r S o c ie t y
Ly in g S u p in e
1. Lie down with illow under your
right shoulder. Pl ce your right r
behind your he d.
2. Use the finger ds of the three
iddle fingers on your left h nd to
feel for lu s in the right bre st.
The finger ds re the to third of
e ch finger. M ke overl
ing,
di e-sized circul r otions to feel
the bre st tissue.
3. A ly three levels of ressure in
e ch s ot: light, ediu , nd fir ,
using fir er ressure for tissue
closest to the chest nd ribs. A fir
ridge in the lower curve of e ch
bre st is nor l. If you’re not sure
how h rd to ress, t lk with your
he lth c re rovider, or try to co y
the w y the doctor or nurse does it.
4. Ex ine the bre st in n u - nddown or “stri ” ttern. St rt t n
i gin ry str ight line under the
r , oving u nd down cross
the entire bre st, fro the ribs to
the coll rbone, until you re ch the
iddle of the chest bone (the sternu ). Re e ber how your bre st
feels fro
onth to onth.
5. Re e t the ex in tion on your
left bre st, using the finger ds of
the right h nd.
6. If you find ny sses, lu s, or
skin ch nges, see your clinici n
right w y.
(continued )
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Chapter 10 | The Breasts and Axillae
195
P a t ie n t In s t r u c t io n s f o r t h e B r e a s t S e lf -E x a m in a t io n
(B S E )—A m e r ic a n C a n c e r S o c ie t y (Continued )
S t a n d in g
1. While st nding in front of
irror
with your h nds ressing fir ly
down on your hi s, look t your
bre sts for ny ch nges of size,
sh e, contour, or di ling, or redness or sc liness of the ni le or
bre st skin. (The ressing down on
the hi s osition contr cts the
chest w ll uscles nd enh nces
ny bre st ch nges.)
2. Ex ine e ch under r while sitting u or st nding nd with your
r only slightly r ised so you c n
e sily feel in this re . R ising your
r str ight u tightens the tissue
in this re nd
kes it h rder to
ex ine.
Ad ted fro the A eric n C ncer Society. A eric n C ncer Society. Bre st w reness nd
self-ex . U d ted A ril 9, 2 15. Av il ble t htt :/ / www.c ncer.org/c ncer/ bre stc ncer/
oreinfor tion/ bre stc ncere rlydetection/ bre st-c ncer-e rly-detection- cs-recs-bse.
Accessed M y 7, 2 15.
Recording Your Findings
R e c o r d in g t h e B r e a s t s a n d A x illa e E x a m in a t io n
“Bre sts sy
etric nd s ooth, without
sses. Ni les without disch rge.”
(Axill ry deno thy usu lly included fter Neck in section on Ly h Nodes.)
OR
“Bre sts endulous with diffuse fibrocystic ch nges. Single fir 1 × 1 c
ss,
obile nd nontender, with overlying e u d’or nge
e r nce in right bre st,
u er outer qu dr nt t 11 o’clock, 2 c fro the ni le.” (These findings suggest
possible breast cancer.)
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Aids to Interpretation
Table 10-1 Fa c t o r s Th a t In c re a s e t h e Re la t ive
Ris k fo r Bre a s t Ca n c e r in Wo m e n
Re la t ive
Ris k
Fa c t o r
>4.0
■
■
■
■
■
■
■
2.1–4.0
■
■
■
■
1.1–2.0
■
■
■
■
■
■
■
■
■
■
■
■
■
■
■
■
■
Age (65+ vs. <65 years, although risk increases across all ages until
age 80)
Biopsy-confirmed atypical hyperplasia
Certain inherited genetic mutations for breast cancer
(BRCA1 and/or BRCA2)
Ductal carcinoma in situ
Lobular carcinoma in situ
Personal history of early-onset (<40 years) breast cancer
Two or more first-degree relatives with breast cancer diagnosed at
an early age
High endogenous estrogen or testosterone levels (postmenopausal)
High-dose radiation to chest
Mammographically extremely dense (>50%) breasts compared to
less dense (11%–25%)
One first-degree relative with breast cancer
Alcohol consumption
Ashkenazi Jewish heritage
Diethylstilbestrol exposure
Early menarche (<12 years)
Height ( >5 feet 3 inches)
High socioeconomic status
Late age at first full-term pregnancy (>30 years)
Late menopause (>55 years)
Mammographically dense (26%–50%) breasts compared to less
dense (11%–25%)
Non-atypical ductal hyperplasia or fibroadenoma
Never breastfed a child
No full-term pregnancies
Obesity (postmenopausal)/adult weight gain
Personal history of breast cancer (40+ years)
Personal history of endometrium, ovary, or colon cancer
Recent and long-term use of menopausal hormone therapy
containing estrogen and progestin
Recent oral contraceptive use
Source: American Cancer Society. Facts & Figures 2015–2016. Atlanta: American Cancer Society
Inc, 2015. Available at http://www.cancer.org/acs/groups/content/@research/documents/
document/acspc-046381.pdf. Accessed May 1, 2015.
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197
Table 10-2 Vis ib le S ig n s o f Bre a s t Ca n c e r
Re t r a c t io n S ig n s
Fibrosis from breast cancer, fat necrosis,
and mammary duct ectasia can produce
the three retraction signs illustrated here.
Ca nce r
Dimpling
Re tra cte d
nipple
S kin Dim p lin g
Ab n o rm a l Co n to u rs
Look for any variation in the normal
convexity of each breast, and compare
one side with the other.
Nip p le Re tra ctio n a n d De via tio n
A retracted nipple is flattened or pulled
inward and may be broadened and
thickened. Typically the nipple deviates
toward the underlying cancer.
(table continues on page 198)
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Table 10-2 Vis ib le S ig n s o f Bre a s t Ca n c e r (continued )
Ed e m a o f t h e S k in
From lymphatic blockade, appearing as
thickened skin with enlarged pores—the
so-called peau d’orange (orange peel)
sign.
P a g e t D is e a s e o f t h e N ip p le
An uncommon form of breast cancer
that usually starts as a scaly, eczema-like
lesion that may weep, crust, or erode. A
breast mass may be present. Suspect
Paget disease in any persisting dermatitis
of the nipple and areola.
De rma titis of
a re ola
Eros ion of
nipple
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11
C H A P T E R
The Abdomen
The Health History
C o m m o n o r C o n c e r n in g S y m p t o m s
G a s t ro in t e s t in a l D is o r d e r s
●
●
●
●
●
●
U r in a ry a n d Re n a l D is o r d e r s
Abdo in l in, cute nd chronic
Indigestion, n use , vo iting
including blood (hematemesis), loss
of
etite (anorexia), e rly s tiety
Difficulty sw llowing (dysphagia)
nd/or inful sw llowing
(odynophagia)
Ch nge in bowel function
Di rrhe , consti tion
J undice
●
●
●
●
●
●
●
Su r ubic in
Difficulty urin ting (dysuria),
urgency, or frequency
Hesit ncy, decre sed stre
in
les
Excessive urin tion (polyuria) or
excess urin tion t night (nocturia)
Urin ry incontinence
Blood in the urine (hematuria)
Fl nk in nd ureter l colic
M e c h a n is m s o f A b d o m in a l P a in
Be familiar with three broad
categories:
Visceral pain—occurs when hollow abdominal organs such as the
intestine or biliary tree contract
unusually forcefully or are distended or stretched.
Visceral pain in the right upper quadrant
(RUQ) from liver distention against its
capsule from the various causes of
hepatitis, including alcoholic hepatitis
■ May be dif cult to localize
■ Varies in quality; may be gnaw-
ing, burning, cramping, or
aching
■ When severe, may be associated
with sweating, pallor, nausea,
vomiting, restlessness.
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Parietal pain—from in ammation
of the parietal peritoneum.
Visceral periumbilical pain in early acute
appendicitis from distention of inflamed
appendix gradually changes to parietal
pain in the right lower quadrant (RLQ)
from inflammation of the adjacent
parietal peritoneum.
■ Steady, aching
■ Usually more severe
■ Usually more precisely localized
over the involved structure than
visceral pain
Referred pain—occurs in more
distant sites innervated at approximately the same spinal levels as the
disordered structure.
Pain of duodenal or pancreatic origin
may be referred to the back; pain from
the biliary tree —to the right shoulder or
right posterior chest.
Pain from the chest, spine, or
pelvis may be referred to the
abdomen.
Pain from pleurisy or acute myocardial
infarction may be referred to the epigastric area.
T h e G a s t r o in t e s t in a l T r a c t
Ask patients to describe the pain in
their own words, especially timing
of the pain (acute or chronic); then
ask them to point to the pain.
In emergency rooms, up to 45% of
patients have nonspecific pain, but
15% to 30% need surgery, usually for
appendicitis, intestinal obstruction, or
cholecystitis.
Pursue important details:
“Where does the pain start?”
“Does it radiate or travel?”
“What is the pain like?”
“How severe is it?”
“How about on a scale of 1 to 10?”
“What makes it better or worse?”
Doubling over with cramping colicky
pain signals a renal stone. Sudden
knife -like epigastric pain often radiating
to the back is typical of pancreatitis.
Elicit any symptoms associated with
the pain, such as fever or chills; ask
about their sequence.
Epigastric pain occurs with gastroesophageal reflux disease (GERD), pancreatitis,
and perforated ulcers. RUQ and upper
abdominal pain are common in cholecystitis and cholangitis.
Up p e r Ab d o m in a l P a in , Dis c o m fo r t , o r He a r t b u rn . Ask
about chronic or recurrent upper
abdominal discomfort, or dyspepsia.
Related symptoms include bloating,
nausea, upper abdominal fullness,
and heartburn. Is there:
ERRNVPHGLFRVRUJ
Chapter 11 | The Abdomen
■ Bloating from excessive gas,
especially with frequent belching, abdominal distention, or
atus, the passage of gas by
rectum
■ Unpleasant abdominal fullness
after normal meals or early
satiety, the inability to eat a full
meal
■ Heartburn, dysphagia, or regur-
gitation?
Lo w e r Ab d o m in a l P a in o r
Dis c o m fo r t —Ac u t e a n d
Ch ro n ic . If acute, is the pain
sharp and continuous or intermittent and cramping?
201
Bloating may occur with lactose intolerance, inflammatory bowel disease, or
ovarian cancer; belching results from
aerophagia, or swallowing air.
Consider diabetic gastroparesis, anticholinergic drugs, gastric outlet obstruction,
gastric cancer. Early satiety may signify
hepatitis.
Suggests GERD. Up to 90% of patients
with asthma have GERD-like symptoms.
If patient fails empiric therapy, is age
>55 years, or has “alarm symptoms”
(dysphagia, pain with swallowing or
odynophagia, recurrent vomiting,
gastro intestinal bleeding, risk factors
for gastric cancer, or palpable mass),
endoscopy is warranted.
RLQ pain, or pain migrating from
periumbilical region in appendicitis; in
women with RLQ pain, possible pelvic
inflammatory disease, ectopic pregnancy,
ruptured ovarian follicle
Left lower quadrant (LLQ) pain in diverticulitis, diffuse abdominal pain with
abdominal distention, hyperactive
bowel sounds, and tenderness on palpation in small or large bowel obstruction;
pain with absent bowel sounds, rigidity,
percussion tenderness, and guarding in
peritonitis
If chronic, is there a change in
bowel habits? Alternating diarrhea
and constipation?
Colon ca ncer; irritable bowel syndrome
Ab d o m in a l Pa in w it h
As s o c ia t e d GI S ym p t o m s
■ Nausea, vomiting, loss of
appetite (anorexia)
Pregnancy, diabetic ketoacidosis, adre nal insufficiency, hypercalcemia, uremia,
liver disease. Induced vomiting without
nausea in anorexia/bulimia.
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■ Regurgitation
GERD, esophageal stricture, and
esophageal cancer
■ Coffee ground emesis
Esophageal or gastric varices, Mallory–
Weiss tears, peptic ulcer disease
(hematemesis)
Ot h e r GI S ym p t o m s
■ Dif culty swallowing
If solids and liquids, neuromuscular
disorders affecting motility. If only
solids, consider structural conditions like
Zenker diverticulum, Scha tzki ring,
stricture, neoplasm.
(dysphagia)
■ Painful swallowing
Radiation; caustic ingestion, infection
from cytomegalovirus, herpes simplex,
HIV, esophageal ulceration from aspirin
or NSAIDs
(odynophagia)
■ Diarrhea, acute (<2 weeks)
Acute infection (viral, salmonella,
shigella, etc.); chronic in Crohn disease,
ulcerative colitis; oily diarrhea
(steatorrhea)—in pancreatic insufficiency.
See Table 11-1, Diarrhea, pp. 214–215.
and chronic
■ Constipation
Medications, especially anticholinergic
agents and opioids; colon cancer, diabetes,
hypothyroidism, hypercalcemia, multiple
sclerosis, Parkinson disease
■ Black tarry stools (melena)
GI bleed
■ Jaundice from increased levels of
bilirubin: Intrahepatic jaundice
can be hepatocellular, from
damage to the hepatocytes, or
cholestatic, from impaired
excretion caused by damaged
hepatocytes or intrahepatic bile
ducts
Impaired excretion of conjugated
bilirubin in viral hepatitis, cirrhosis,
primary biliary cirrhosis, drug-induced
cholestasis
Extrahepatic jaundice arises from
obstructed extrahepatic bile
ducts, commonly the cystic and
common bile ducts
Common bile duct obstruction from
gallstones or pancreatic, cholangio-, or
duodenal carcinoma
Ask about the color of the urine
and stool.
Dark urine from increased conjugated
bilirubin excreted in urine (hepa titis);
acholic clay-colored stool when bilirubin
excretion into intestine is obstructed
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Chapter 11 | The Abdomen
203
R is k F a c t o r s f o r Liv e r D is e a s e
●
●
●
●
●
Hepatitis: Tr vel or e ls in re s of oor s nit tion, ingestion of cont in ted w ter or foodstuffs (hepatitis A); renter l or ucous e br ne
ex osure to infectious body fluids such s blood, seru , se en, nd s liv ,
es eci lly through sexu l cont ct with n infected rtner or use of sh red
needles for injection drug use (hepatitis B); illicit injection drug use or blood
tr nsfusion (hepatitis C)
Alcoholic hepatitis or alcoholic cirrhosis (screen tients c refully bout lcohol
use)
Toxic liver damage fro
edic tions, industri l solvents, environ ent l
toxins, or so e nesthetic gents
Gallbladder disease or surgery th t
y result in extr he tic bili ry
obstruction
Hereditary disorders in the F ily History
T h e U r in a r y T r a c t
Ask about pain on urination, usually
a burning sensation, sometimes
termed dysuria (also refers to
dif culty voiding).
Bladder infection (cystitis)
Also seen in urethritis, urinary tract
infections, bladder stones, tumors, and,
in men, acute prostatitis. In women,
internal burning in urethritis, external
burning in vulvova ginitis
Is there:
■ Urgency, an unusually intense
May lead to urge incontinence
and immediate desire to void
■ Urinary frequency, or abnormally
Urinary tract infection
frequent voiding
■ Fever or chills; blood in the
Urinary tract infection
urine
■ Any pain in the abdomen, ank,
or back
■ In men, hesitancy in starting the
Dull, steady pain in pyelonephritis;
severe colicky pain in ureteral
obstruction from renal stone
Prostatitis, urethritis
urine stream, straining to void,
reduced caliber and force of the
urine stream, or dribbling as they
complete voiding.
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Ba te s ’ Poc ke t Guide to Phys ic a l Exa mina tion a nd His tory Ta king
Assess any:
■ Polyuria, a signi cant increase in
Diabetes mellitus, diabetes insipidus
24-hour urine volume
■ Nocturia, urinary frequency at
Bladder obstruction
night
■ Urinary incontinence, involuntary
loss of urine:
See Table 11-2, Urinary Incontinence,
pp. 216–217.
■
From coughing, sneezing,
lifting
Stress incontinence (poor urethral
sphincter tone)
■
From urge to void
Urge incontinence (detrusor overactivity)
■
From bladder fullness with
leaking but incomplete
emptying
Overflow incontinence (anatomic
obstruction, impaired neural innervation to bladder)
Health Promotion and Counseling:
Evidence and Recommendations
Im p o r t a n t T o p ic s f o r H e a lt h P r o m o t io n a n d C o u n s e lin g
●
●
●
Screening for lcohol buse
Vir l he titis: risk f ctors, v ccines, nd screening
Screening for colorect l c ncer
S c re e n in g fo r Alc o h o l Ab u s e . Use the four CAGE questions (see Chapter 3, p. 56) to screen all adults in primary care settings, adolescents, and
pregnant women for risky or hazardous alcohol use. Focus on detection,
counseling, and, for signi cant impairment, speci c treatment recommendations. Brief counseling interventions have been shown to reduce
alcohol consumption by 13% to 34% over 6 to 12 months.
S c r e e n in g f o r P r o b le m D r in k in g
Standard Drink Equivalents: 1 st nd rd drink is equiv lent to 12 oz of regul r
beer or wine cooler, 8 oz of lt liquor, 5 oz of wine, or 1.5 oz of 8 - roof s irits
Initial Screening Question: “How ny ti es in the st ye r h ve you h d 4
or ore drinks d y (wo en), or 5 or ore drinks d y ( en)?”
(continued )
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Chapter 11 | The Abdomen
S c r e e n in g f o r P r o b le m D r in k in g
205
(Continued)
D e f in it io n s o f D r in k in g Le ve ls fo r Ad u lt s —N a t io n a l In s t it u t e o f
A lc o h o l Ab u s e a n d A lc o h o lis m
Wo m e n
Moder te drinking
Uns fe drinking levels (incre sed risk for
develo ing n lcohol use disorder)a
Binge drinkingb
Me n
≤1 drink/d
≤2 drinks/d
>3 drinks/d nd
>4 drinks/d nd
>7 drinks/ wk
>14 drinks/ wk
≥4 drinks on one ≥5 drinks on one
occ sion
occ sion
Pregn nt wo en nd those with he lth roble s th t could be worsened by drinking should
not drink ny lcohol.
b
Brings blood lcohol level to . 8 g%, usu lly within 2 hours.
a
Vira l He p a t it is : Ris k Fa c t o r s , S c re e n in g , a n d Va c c in a t io n . Protective
measures against infectious hepatitis include counseling about transmission.
■ Hepatitis A: Transmission is fecal–oral. Illness occurs approximately
30 days after exposure. Advise hand washing with soap and water after
bathroom use or changing diapers and before preparing or eating food.
Diluted bleach can be used to clean environmental surfaces.
C D C R e c o m m e n d a t io n s f o r H e p a t it is A V a c c in a t io n
●
●
●
All children t ge 1 ye r
Individu ls with chronic liver dise se
Grou s t incre sed risk of cquiring HAV: tr velers to re s with high
ende ic r tes of infection, en who h ve sex with en, injection nd illicit
drug users, individu ls working with nonhu n ri tes, nd ersons who
h ve clotting-f ctor disorders
The v ccine lone
ende ic re s.
y be d inistered t ny ti e before tr veling to
■ Hepatitis B: Transmission occurs during contact with infected body
uids, such as blood, semen, saliva, and vaginal secretions. Infection
increases risk of fulminant hepatitis, chronic infection, and subsequent
cirrhosis and hepatocellular carcinoma. Provide counseling and serologic
screening for patients at risk.
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Ba te s ’ Poc ke t Guide to Phys ic a l Exa mina tion a nd His tory Ta king
C D C R e c o m m e n d a t io n s f o r H e p a t it is B V a c c in a t io n :
H ig h -R is k G r o u p s a n d S e t t in g s
●
●
●
●
Sexual contacts, including sex rtners of he titis B surf ce ntigen- ositive
ersons, eo le with ore th n one sex rtner in the rior 6 onths, eo le
seeking ev lu tion nd tre t ent for sexu lly tr ns itted infections, nd
en who h ve sex with en
People with percutaneous or mucosal exposure to blood, including injection drug
users, household cont cts of ntigen- ositive ersons, residents nd st ff of
f cilities for the develo ent lly dis bled, he lth c re workers, nd eo le
on di lysis
Others, including tr velers to ende ic re s, eo le with chronic liver
dise se nd HIV infection, nd eo le seeking rotection fro he titis B
infection
All adults in high-risk settings, such s sexu lly tr ns itted infection (STI)
clinics, HIV testing nd tre t ent rogr s, drug- buse tre t ent rogr s
nd rogr s for injection drug users, correction l f cilities, rogr s for
en h ving sex with en, chronic he odi lysis f cilities nd end-st ge
ren l dise se rogr s, nd f cilities for eo le with develo ent l
dis bilities
■ Hepatitis C: Hepatitis C, now the most common form of hepatitis, is
spread by blood exposure and injection drug use. There is no vaccination for hepatitis C, so prevention targets counseling to avoid risk factors.
Serologic screening should be recommended for high-risk groups.
S c re e n in g fo r Co lo re c t a l Ca n c e r. Adopt the 2008 recommendations of
the U.S. Preventive Services Task Force, listed below.
S c r e e n in g f o r C o lo r e c t a l C a n c e r
Assess Risk: Begin screening t ge 2 ye rs. If high risk, refer for ore co lex
n ge ent. If ver ge risk t ge 5 (high-risk conditions bsent), offer the
screening o tions listed.
●
●
Common high-risk conditions (25% of colorect l c ncers)
● Person l history of colorect l c ncer or deno
● First-degree rel tive with colorect l c ncer or deno
tous oly s
● Person l history of bre st, ov ri n, or endo
etri l c ncer
● Person l history of ulcer tive or Crohn colitis
Heredit ary high-risk conditions (6% of colorect l c ncers)
● F
ili l deno tous oly osis
● Heredit ry non oly osis colorect l c ncer
(continued )
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Chapter 11 | The Abdomen
S c r e e n in g f o r C o lo r e c t a l C a n c e r
207
(Continued)
Screening recommendations
● Adults age 50 to 75 years—o tions
● High-sensitivity fec l occult blood testing (FOBT) nnu lly
● Sig
oidosco y every 5 ye rs with FOBT every 3 ye rs
● Screening colonosco y every 1 ye rs
● Adults age 76 to 85 years—do not screen routinely, s g in in life-ye rs is
s ll co
red to colonosco y risks, nd screening benefits not seen for
7 ye rs; use individu l decision
king if screening for the first ti e
● Adults older than age 85—do not screen, s “co
eting c uses of ort lity
reclude
ort lity benefit th t outweighs h r s”
Techniques of Examination
EXAMINATIO N TECHNIQ UES
P O SSIBLE FIN DIN G S
Th e A b d o m e n
Inspect the abdomen,
including:
■ Skin
Scars, striae, veins, ecchymoses (in intraor retroperitoneal hemorrhages)
■ Umbilicus
Hernia, inflammation
■ Contours for shape, symmetry,
Bulging flanks of ascites, suprapubic
bulge, large liver or spleen, tumors
enlarged organs or masses
■ Any peristaltic waves
Increased in GI obstruction
■ Any pulsations
Increased in aortic aneurysm
Auscultate the abdomen for:
■ Bowel sounds
Increased or decreased motility
■ Bruits
Bruit of renal artery stenosis
■ Friction rubs
Liver tumor, splenic infarct
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Ba te s ’ Poc ke t Guide to Phys ic a l Exa mina tion a nd His tory Ta king
EXAMINATIO N TECHNIQ UES
P O SSIBLE FIN DIN G S
B o w e l S o u n d s a n d B r u it s
Ch a n g e
S e e n w it h
Incre sed bowel sounds
Di rrhe
E rly intestin l obstruction
Adyn ic ileus
Peritonitis
Intestin l fluid
Air under tension in dil ted bowel
Intestin l obstruction
Decre sed, then bsent bowel sounds
High- itched tinkling bowel sounds
High- itched rushing bowel sounds
with cr
ing
He tic bruit
C rcino
of the liver
Alcoholic he titis
P rti l obstruction of the ort or
ren l, ili c or fe or l rteries
Arteri l bruits
Aorta
Re na l a rte ry
Ilia c a rte ry
Fe mora l a rte ry
Percuss the abdomen for patterns
of tympany and dullness.
Ascites, GI obstruction, pregnant uterus,
ovarian tumor
Palpate all quadrants of the
abdomen:
■ Lightly for guarding, rebound,
See Table 11-3, Abdominal Tenderness,
p. 217. “Acute abdomen”or peritonitis if:
and tenderness (Fig. 11-1)
Firm, board-like abdominal wall—
suggests peritoneal inflammation.
Guarding if the patient flinches,
grimaces, or reports pain during
palpation.
Fig ure 11-1 Be gin w ith light palpation
of the abdom e n.
Rebound tenderness from peritoneal
inflammation; pain is greater when
you withdraw your hand than when
you press down. Press slowly on a tender area, then quickly “let go.”
ERRNVPHGLFRVRUJ
Chapter 11 | The Abdomen
EXAMINATIO N TECHNIQ UES
■ Deeply for masses or tenderness
(Fig. 11-2)
209
P O SSIBLE FIN DIN G S
Tumors, a distended viscus
Abdominal masses may be: physiologic
(pregnant uterus), inflammatory (diverticulitis), vascular (an AAA), neoplastic
(colon cancer), or obstructive (a distended bladder or dilated loop of bowel).
Fig ure 11-2 Us e two hands for
de e p palpation.
T h e Liv e r
Percuss span of liver dullness
in the midclavicular line (MCL),
Figure 11-3.
4–8 cm in
mids te rna l
line
6–12 cm
in right
midcla vicula r
line
Increased dullness in hepatomegaly
from acute hepatitis, heart failure;
decreased dullness in cirrhosis
Norma l
live r
s pa ns
Fig ure 11-3 Me as ure the live r s pan.
Feel the liver edge, if possible, as
patient breathes in.
Firm edge of cirrhosis
Starting well below the costal margin, measure distance of the liver
edge from the costal margin in the
MCL (Fig. 11-4).
Increased distance in hepatomegaly—
may be missed (as in Fig. 11-5) by
starting palpation too high in the RUQ
Fig ure 11-4 Palpate the live r e dge .
Fig ure 11-5 Palpating firs t at the cos tal
m argin m ay m is s the live r e dge .
Note any tenderness or masses.
Tender liver of hepatitis or heart failure;
tumor mass
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EXAMINATIO N TECHNIQ UES
P O SSIBLE FIN DIN G S
T h e S p le e n
Percuss across left lower anterior chest (Traube space), noting
change from tympany to dullness.
Palpate the spleen with the
patient supine then lying on the
right side with legs exed at hips
and knees (Fig. 11-6).
Splenomegaly
Figure 11-6 Spleen tip (purple) palpable
below costal margin.
T h e Kid n e y s
Try to palpate each kidney
(Fig. 11-7).
Enlargement from cysts, cancer,
hydronephrosis
Fig ure 11-7 Palpate e ach kidney.
Check for costovertebral angle
(CVA) tenderness (Fig. 11-8).
Tender in pyelonephritis
Fig ure 11-8 Pe rcus s for cos tove rte bral
angle te nde rne s s .
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Chapter 11 | The Abdomen
EXAMINATIO N TECHNIQ UES
211
P O SSIBLE FIN DIN G S
Th e A o r t a
Palpate the aorta’s pulsations
(Fig. 11-9). In older people, estimate its width.
Periumbilical mass with expansile pulsations ≥3 cm in diameter in abdominal
aortic aneurysm. Assess further due to
risk of rupture.
Fig ure 11-9 Palpate on both s ide s of
the aorta.
A s s e s s in g A s c it e s
/
Palpate for shifting dullness. Map areas of tympany and
dullness with patient supine, then
lying on side (Fig. 11-10).
Ascitic fluid usually shifts to dependent
side, changing the margin of dullness
(Fig. 11-11).
Tympa ny
Tympa ny
Dullne s s
S hifting
dullne s s
Fig ure 11-10 Pe rcus s outw ard to m ap
Fig ure 11-11 Pe rcus s for s hifting dull-
dullne s s from as cite s .
ne s s (he re patie nt turne d to right s ide ).
Check for a uid wave
(Fig. 11-12). Ask patient or an
assistant to press edges of both
hands into midline of abdomen.
Tap one side and feel for a wave
transmitted to the other side.
A palpable wave suggests but does not
prove ascites.
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EXAMINATIO N TECHNIQ UES
P O SSIBLE FIN DIN G S
Fig ure 11-13 Ballotte the live r.
Fig ure 11-12 Te s t for a fluid wave .
Ballotte an organ or mass in
an ascitic abdomen. Place your
stiffened and straightened ngers
on the abdomen, brie y jab them
toward the structure, and try to
touch its surface.
Your hand, quickly displacing the fluid,
stops abruptly as it touches the solid
surface (Fig. 11-13).
A s s e s s in g P o s s ib le A p p e n d ic it is
Ask:
In classic appendicitis:
“Where did the pain begin?”
Near the umbilicus
“Where is it now?”
RLQ
Ask patient to cough. “Where does
it hurt?”
RLQ at “the McBurney point”
Palpate for local tenderness.
RLQ tenderness
Palpate for muscular rigidity.
RLQ rigidity
Perform a rectal examination and,
in women, a pelvic examination
(see Chapters 14 and 15).
Local tenderness, especially if appendix
is retrocecal
■ Rovsing sign: Press deeply and
Pain in the right lower quadrant during
left-sided pressure suggests appendicitis
(a positive Rovsing sign).
evenly in the left lower quadrant. Then quickly withdraw
your ngers.
ERRNVPHGLFRVRUJ
Chapter 11 | The Abdomen
EXAMINATIO N TECHNIQ UES
■ Psoas sign: Place your hand just
above the patient’s right knee.
Ask the patient to raise that
thigh against your hand. Or, ask
the patient to turn onto the left
side. Then extend the patient’s
right leg at the hip to stretch the
psoas muscle.
■ Obturator sign: Flex the patient’s
right thigh at the hip, with the
knee bent, and rotate the leg
internally at the hip, which
stretches the internal obturator
muscle.
213
P O SSIBLE FIN DIN G S
Pain from irritation of the psoas muscle
suggests an inflamed appendix (a positive
psoas sign).
Right hypogastric pain in a positive
obturator sign, suggesting irritation of
the obturator muscle by an inflamed
appendix.
A s s e s s in g P o s s ib le A c u t e C h o le c y s t it is
Auscultate, percuss, and palpate
the abdomen for tenderness.
Bowel sounds may be active or
decreased; tympany may increase with
an ileus: Assess any RUQ tenderness.
Assess for the Murphy sign. Hook
your thumb under the right costal
margin at edge of rectus muscle,
and ask patient to take a deep
breath.
Sharp tenderness and a sudden stop in
inspiratory effort constitute a positive
Murphy sign.
Recording Your Findings
R e c o r d in g t h e A b d o m in a l E x a m in a t io n
“Abdo en is rotuber nt with ctive bowel sounds. It is soft nd nontender; no
l ble
sses or he tos leno eg ly. Liver s n is 7 c nd in the right
MCL; edge is s ooth nd l ble 1 c below the right cost l rgin. S leen
nd kidneys not felt. No CVA tenderness.”
OR
“Abdo en is fl t. No bowel sounds he rd. It is fir
nd bo rd-like, with
incre sed tenderness, gu rding, nd rebound in the right idqu dr nt. Liver
ercusses to 7 c in the MCL; edge not felt. S leen nd kidneys not felt. No lble
ss. No CVA tenderness.” (These findings suggest peritonitis from possible
appendicitis; see pp. 212–213.)
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Ba te s ’ Poc ke t Guide to Phys ic a l Exa mina tion a nd His tory Ta king
Aids to Interpretation
Table 11-1 Dia rrh e a
P ro b le m /P ro c e s s
C h a r a c t e r is t ic s o f S t o o l
Ac u t e D ia r r h e a
Se cre to ry In fe ctio n (noninflam m atory)
Infection by viruses; preformed
bacterial toxins such as Staphylococcus
aureus, Clostridium perfringens,
toxigenic Escherichia coli; Vibrio
cholerae, Cryptosporidium, Giardia
lamblia, rotavirus
Watery, without blood, pus,
or mucus
In fla m m a to ry In fe ctio n
Colonization or invasion of intestinal
mucosa as in nontyphoid Salmonella,
Shigella, Yersinia, Campylobacter,
enteropathic E. coli, Entamoeba
histolytica, Clostridium difficile
Loose to watery, often with
blood, pus, or mucus
D r u g -In d u c e d D ia r r h e a
Action of many drugs, such as
magnesium-containing antacids,
antibiotics, antineoplastic agents, and
laxatives
Loose to watery
C h ro n ic D ia r r h e a (ê 3 0 d a y s )
Dia rrh e a l Syn d ro m e s
■
■
Irritable bowel syndrome: A disorder
of bowel motility with alternating
diarrhea and constipation
Cancer of the sigmoid colon: Partial
obstruction by a malignant
neoplasm
Loose; may show mucus but
no blood. Small, hard stools
with constipation
May be blood-streaked
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Chapter 11 | The Abdomen
215
Table 11-1 Dia rrh e a (continued )
P ro b le m /P ro c e s s
C h a r a c t e r is t ic s o f S t o o l
In fla m m a to ry Bo w e l Dis e a s e
■
■
Ulcerative colitis: inflammation and
ulceration of the mucosa and
submucosa of the rectum and colon
Crohn disease of the small bowel
(regional enteritis) or colon
(granulomatous colitis): chronic
inflammation of the bowel wall,
typically involving the terminal
ileum, proximal colon, or both
Soft to watery, often
containing blood
Small, soft to loose or watery,
usually free of gross blood
(enteritis) or with less
bleeding than ulcerative
colitis (colitis)
Vo lu m in o u s Dia rrh e a s
■
■
■
Malabsorption syndrome: Defective
absorption of fat, including fatsoluble vitamins, with steatorrhea
(excessive excretion of fat) as in
pancreatic insufficiency, bile salt
deficiency, bacterial overgrowth
Osmotic Diarrheas
■ Lactose intolerance: Deficiency in
intestinal lactase
■ Abuse of osmotic purgatives:
Laxative habit, often surreptitious
Secretory diarrheas from bacterial
infection, secreting villous adenoma,
fat or bile salt malabsorption,
hormone-mediated conditions
(gastrin in Zollinger–Ellison
syndrome, vasoactive intestinal
peptide): Process is variable.
Typically bulky, soft, light
yellow to gray, mushy, greasy
or oily, and sometimes frothy;
particularly foul-smelling;
usually floats in the toilet
Watery diarrhea of large volume
Watery diarrhea of large volume
Watery diarrhea of large volume
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Table 11-2 Urin a ry In c o n t in e n c e
P ro b le m
M e c h a n is m s
S t r e s s In c o n t in e n c e : Urethral
■
sphincter weakened. Transient
increases in intra-abdominal
pressure raise bladder pressure to
levels exceeding urethral resistance.
Leads to voiding small amounts
during laughing, coughing, and
sneezing.
■
U r g e In c o n t in e n c e : Detrusor
contractions are stronger than
normal and overcome normal
urethral resistance. Bladder is
typically small. Results in voiding
moderate amounts, urgency,
frequency, and nocturia.
■
■
■
O ve r f lo w In c o n t in e n c e :
■
Detrusor contractions are
insufficient to overcome urethral
resistance. Bladder is typically
large, even after an effort to void,
leading to continuous dribbling.
■
■
In women, weakness of the
pelvic floor with inadequate
muscular support of the bladder
and proximal urethra and a
change in the angle between the
bladder and the urethra from
childbirth, surgery, and local
conditions affecting the internal
urethral sphincter, such as
postmenopausal atrophy of the
mucosa and urethral infection
In men, prostatic surgery
Decreased cortical inhibition
of detrusor contractions, as in
stroke, brain tumor, dementia,
and lesions of the spinal cord
above the sacral level
Hyperexcitability of sensory
pathways, as in bladder
infection, tumor, and fecal
impaction
Deconditioning of voiding
reflexes, caused by frequent
voluntary voiding at low
bladder volumes
Obstruction of the bladder
outlet, as by benign prostatic
hyperplasia or tumor
Weakness of detrusor muscle
associated with peripheral
nerve disease at the sacral level
Impaired bladder sensation
that interrupts the reflex arc,
as in diabetic neuropathy
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Chapter 11 | The Abdomen
217
Table 11-2 Urin a ry In c o n t in e n c e (continued )
P ro b le m
M e c h a n is m s
Fu n c t io n a l In c o n t in e n c e :
■
Problems in mobility from
weakness, arthritis, poor vision,
other conditions; environmental
factors such as unfamiliar setting,
distant bathroom facilities, bed
rails, physical restraints
■
Sedatives, tranquilizers,
anticholinergics, sympathetic
blockers, potent diuretics
Inability to get to the toilet in time
because of impaired health or
environmental conditions
In c o n t in e n c e S e c o n d a ry
t o M e d ic a t io n s : Drugs may
contribute to any type of
incontinence listed.
Table 11-3 Ab d o m in a l Te n d e rn e s s
Vis c e r a l Te n d e r n e s s
P e r it o n e a l Te n d e r n e s s
Enla rge d
live r
Norma l
a orta
Norma l
ce cum
Norma l
or
s pa s tic
s igmoid
colon
Dive rticulitis
Appe ndicitis
Chole cys titis
Te n d e r n e s s f ro m D is e a s e in t h e C h e s t a n d P e lv is
Acu te Ple u ris y
Acu te Sa lp in g itis
Unila te ra l or
bila te ra l, uppe r
or lowe r a bdome n
ERRNVPHGLFRVRUJ
ERRNVPHGLFRVRUJ
12
C H A P T E R
The Peripheral
Vascular System
The Health History
C o m m o n o r C o n c e r n in g S y m p t o m s
●
●
●
●
●
●
●
Abdo in l, fl nk, or b ck in
P in in the r s or legs
Exercise-induced in (inter ittent cl udic tion)
Cold, nu bness, llor in the legs; h ir loss
Swelling in c lves, legs, or feet
Color ch nge in fingerti s or toes in cold we ther
Swelling with redness or tenderness
Ask about abdominal, ank, or
back pain, especially in older male
smokers.
An expanding abdominal aortic aneurysm
(AAA) may compress arteries or ureters.
Ask about any pain in the arms
and legs.
Cold-induced digital ischemic change
with blanching then cyanosis then rubor
in Raynaud phenomenon or disease
Is there intermittent claudication,
exercise-induced pain that is
absent at rest, makes the patient
stop exertion, and abates within
about 10 minutes? Ask “Have you
ever had any pain or cramping in
your legs when you walk or exercise?” “How far can you walk without stopping to rest?” and “Does
pain improve with rest?”
Peripheral arteria l disea se (PAD) can
cause symptomatic limb ischemia with
exertion; distinguish this from the
neurogenic pain of spinal stenosis, which
produces leg pain with exertion, often
reduced by leaning forward (stretching
the spinal cord in the narrowed vertebral
canal) and less readily relieved by rest.
Ask also about coldness, numbness,
or pallor in legs or feet or hair loss
over the anterior tibial surfaces.
Hair loss over the anterior tibiae in PAD.
“Dry”or brown–black ulcers from gangrene may ensue.
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220
Ba te s ’ Poc ke t Guide to Phys ic a l Exa mina tion a nd His tory Ta king
Because patients have few symptoms, identify risk factors—
tobacco abuse, hypertension,
diabetes, hyperlipidemia, and
coronary artery disease—and
PAD warning signs.
Only 10% to 30% of affected patients
have the classic symptoms of exertional
calf pain relieved by rest.
P e r ip h e r a l A r t e r ia l D is e a s e “ W a r n in g S ig n s ”
●
●
●
F tigue, ching, nu bness, or in
Symptom location suggests the site of
th t li its w lking or exertion in the arterial ischemia:
legs; if resent, identify the loc tion.
aortoiliac
Ask lso bout erectile dysfunction.
iliac–pudendal
Any oorly he ling or nonhe ling
common femoral or aortoiliac
wounds of the legs or feet
superficia l femoral
Any in resent when t rest in the
popliteal
tibial or peroneal
lower leg or foot nd ch nges when
st nding or su ine
●
Abdo in l in fter e ls nd
ssoci ted “food fe r” nd weight
loss
These symptoms suggest intestinal
ischemia of the celiac or superior or
inferior mesenteric arteries.
●
Any first-degree rel tives with n
AAA
Prevalence of AAAs in first-degree
relatives is 15% to 28%.
Ask about swelling of feet and legs,
or any ulcers on lower legs, often
near the ankles from peripheral
vascular disease.
Calf swelling in deep venous thrombosis
(DVT); hyperpigmentation, edema, and
possible cyanosis, especially when legs
are dependent, in venous stasis ulcers;
swelling with redness and tenderness in
cellulitis.
Health Promotion and Counseling:
Evidence and Recommendations
Im p o r t a n t T o p ic s f o r H e a lt h P r o m o t io n
a n d C o u n s e lin g
●
●
●
●
Screening for eri her l rteri l dise se
The nkle–br chi l index
Screening for ren l rtery dise se
Screening for bdo in l ortic neurys
ERRNVPHGLFRVRUJ
Chapter 12 | The Peripheral Vascular System
221
S c re e n in g fo r P e rip h e ra l Ar t e ria l Dis e a s e . PAD prevalence increases with age, ranging from around 5% before age 50 years to 15%
to 20% in persons aged 80 years and older. Cardiovascular risk factors,
particularly smoking and diabetes, increase risk: An estimated 40% to
60% of PAD patients have coexisting coronary artery disease and/or cerebral artery disease, and the presence of PAD signi cantly increases risk
of cardiovascular events. Most patients with PAD have either no symptoms
or a range of nonspeci c leg symptoms, such as aching, cramping, numbness,
or fatigue.
R is k F a c t o r s f o r Lo w e r -E x t r e m it y P e r ip h e r a l
A r t e r ia l D is e a s e
●
●
●
●
Age ≥65 ye rs
Age ≥5 ye rs with history of di betes or s oking
Leg sy to s with exertion
Nonhe ling wounds
Th e An k le –Bra c h ia l In d e x. To diagnose PAD, use the ankle–brachial
index (ABI), which is reliable, reproducible, noninvasive, easy to perform in the of ce, and highly speci c. The ABI is the ratio of blood
pressure measurements in the foot and arm; values <0.9 are considered
abnormal.
A wide range of interventions reduces both onset and progression of PAD,
including: supervised exercise programs; tobacco cessation; treatment of
hyperlipidemia; optimal control of diabetes and hypertension; use of antiplatelet agents; meticulous foot care and well- tting shoes, particularly for
diabetic patients; and revascularization.
S c re e n in g fo r Re n a l Art e ry Dis e a s e . The American College of Cardiology and the American Heart Association recommend renal artery disease
(RAS) screening with duplex ultrasonography, magnetic resonance angiography, or computed tomographic angiography in patients with the conditions
listed in the box below.
C o n d it io n s S u s p ic io u s f o r R e n a l A r t e r y D is e a s e
●
●
●
Onset of hy ertension t ge ≤3 ye rs
Onset of severe hy ertension t ge ≥55 ye rs
Acceler ted (sudden nd ersistent worsening of reviously controlled
hy ertension), resist nt (not controlled with three drugs), or
lign nt
hy ertension (evidence of cute end-org n d
ge)
(continued )
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C o n d it io n s S u s p ic io u s f o r R e n a l A r t e r y D is e a s e
●
●
●
(Continued )
New worsening of ren l function or worsening function fter use of n
ngiotensin-converting enzy e inhibitor or n ngiotensin-rece tor blocking
gent
An unex l ined s ll kidney or size discre ncy of >1.5 c between the two
kidneys
Sudden unex l ined ul on ry ede , es eci lly in the setting of worsening
ren l function
S c re e n in g fo r Ab d o m in a l Ao rt ic An e u rys m . An AAA is present when
the infrarenal aortic diameter exceeds 3 cm. Rupture and mortality rates
dramatically increase for AAAs exceeding 5.5 cm in diameter. Additional
risk factors are smoking, age older than 65 years, family history, coronary
artery disease, PAD, hypertension, and elevated cholesterol level. Because
symptoms are rare, and screening is now shown to reduce mortality by
50% over 13 to 15 years, the U.S. Preventive Services Task Force recommends one-time screening by ultrasound in men between 65 and 75 years
of age with a history of “ever smoking,” de ned as more than 100 cigarettes
in a lifetime.
Techniques of Examination
EXAMINATIO N TECHNIQ UES
P O SSIBLE FIN DIN G S
A rm s
Inspect for:
■ Size and symmetry, any swelling
Lymphedema, venous obstruction
■ Venous pattern
Visible venous collaterals, swelling,
edema, and discoloration signal upperextremity DVT.
■ Color and texture of skin and
Sharply demarcated pallor of the fingers
in Raynaud disease
nails
Palpate and grade the pulses:
G r a d in g A r t e r ia l P u ls e s
3+
2+
1+
Bounding
Brisk, expect ed (normal)
Di inished, we ker th n ex ected
Absent, un ble to l te
ERRNVPHGLFRVRUJ
Chapter 12 | The Peripheral Vascular System
EXAMINATIO N TECHNIQ UES
■ Radial (Fig. 12-1)
223
P O SSIBLE FIN DIN G S
Bounding radial, carotid, and femoral
pulses in aortic regurgita tion
Lost in thromboangiitis obliterans or
acute arterial occlusion
Fig ure 12-1 Palpate the radial puls e .
■ Brachial (Fig. 12-2)
Fig ure 12-2 Palpate the brachial puls e .
Feel for the epitrochlear nodes.
Lymphadenopathy from local or distal
infection, lymphoma, or human immunodeficiency virus (HIV)
Abdom en
Auscultate for aortic, renal, and
femoral bruits.
Palpate and estimate the width of
the abdominal aorta between your
two ngers (see p. 211).
Pulsatile mass, AAA if width ≥4 cm.
Palpate the super cial inguinal nodes
(Fig. 12-3). Note size, consistency,
discreteness, and any tenderness.
Lymphadenopathy in genital infections,
lymphoma, AIDS
■ Horizontal group
■ Vertical group
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Ba te s ’ Poc ke t Guide to Phys ic a l Exa mina tion a nd His tory Ta king
EXAMINATIO N TECHNIQ UES
P O SSIBLE FIN DIN G S
Horizontal group
Femoral vein
Femoral artery
Great
s aphenous vein
Vertical group
Fig ure 12-3 Supe rficial inguinal lym ph node s .
Le g s
Inspect for:
See Table 12-1, Chronic Insufficiency of
Arteries and Veins, p. 228, and Table 12-2,
Common Ulcers of the Feet and Ankles,
p. 229.
■ Size and symmetry, any swelling
Venous insufficiency, lymphedema; DVT.
Calf asymmetry >3 cm (measure 10 cm
below tibial tuberosity) doubles the risk
of DVT.
in thigh or calf
■ Venous pattern
Varicose veins
■ Color and texture of skin
Pallor, rubor, cyanosis; erythema,
warmth in cellulitis, thrombophlebitis;
pigmentation, ulcers of the feet in PAD
■ Hair distribution, temperature
Atrophic hairless cool skin in PAD
Palpate and grade the pulses:
Loss of pulses in acute arterial occlusion
and arteriosclerosis obliterans
■ Femoral
■ Popliteal (Fig. 12-4)
Figure 12-4 Palpate the popliteal pulse.
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Chapter 12 | The Peripheral Vascular System
EXAMINATIO N TECHNIQ UES
■ Dorsalis pedis and posterior
tibial (Figs. 12-5 and 12-6)
225
P O SSIBLE FIN DIN G S
Absent pedal pulses with normal
femoral and popliteal pulses make PAD
highly likely. Confirm with the ABI (see
Table 12-3, Using the Ankle –Brachial
Index, pp. 230–231).
Fig ure 12-5 Palpate the dors alis pe dis
puls e .
Fig ure 12-6 Palpate the poste rior
tibial puls e .
Palpate for pitting edema.
Dependent edema, heart failure, hypoalbuminemia, nephrotic syndrome
Palpate the calves.
Possible cord and tenderness in DVT
(not always present)
Ask patient to stand, and reinspect
the venous pattern.
Varicose veins
S p e c ia l T e c h n iq u e s
Eva lu a t in g Ar t e ria l S u p p ly
t o t h e Ha n d . Feel ulnar pulse, if
possible. Perform an Allen test.
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Ba te s ’ Poc ke t Guide to Phys ic a l Exa mina tion a nd His tory Ta king
EXAMINATIO N TECHNIQ UES
P O SSIBLE FIN DIN G S
1. Ask the patient to make a tight
st, palm up. Occlude both
radial and ulnar arteries with
your thumb (Fig. 12-7).
2. Ask the patient to open hand
into a relaxed, slightly exed
position (Fig. 12-8).
Fig ure 12-7 Com pre s s the radial and
Fig ure 12-8 Pallor w he n hand re laxe d.
ulnar arte rie s .
3. Release your pressure over one
artery. Palm should ush within
3 to 5 seconds (Fig. 12-9).
4. Repeat, releasing other artery.
Persisting pallor of palm indicates
occlusion of the released artery or
its distal branches (Fig. 12-10).
Fig ure 12-9 Palm ar flus hing—Alle n
Fig ure 12-10 Palm ar pallor—Alle n
te s t ne gative .
te s t pos itive .
/ Po s t u ra l Co lo r
Ch a n g e s o f Ch ro n ic Ar t e ria l
In s u f c ie n c y. Raise both legs to
60 degrees for about 1 minute.
Then ask patient to sit up with legs
dangling down. Note time required
for (1) return of pinkness (normally 10 seconds) and (2) lling of
veins on feet and ankles (normally
about 15 seconds).
Marked pallor of feet on elevation,
delayed color return and venous filling,
and rubor of dependent feet suggest
arterial insufficiency.
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Chapter 12 | The Peripheral Vascular System
227
Recording Your Findings
R e c o r d in g t h e P e r ip h e r a l V a s c u la r S y s t e m E x a m in a t io n
“Extre ities re w r
nd without ede . No v ricosities or st sis ch nges.
C lves re su le nd nontender. No fe or l or bdo in l bruits. Br chi l,
r di l, fe or l, o lite l, dors lis edis (DP), nd osterior tibi l (PT) ulses re
2+ nd sy
etric.”
OR
“Extre ities re le below the idc lf, with not ble h ir loss. Rubor noted
when legs de endent but no ede
or ulcer tion. Bil ter l fe or l bruits; no
bdo in l bruits he rd. Br chi l nd r di l ulses 2+; fe or l, o lite l, DP, nd
PT ulses 1+.” Altern tively, ulses c n be recorded s below. (These findings
suggest atherosclerotic PAD.)
RT
LT
Ra d ia l
Br a c h ia l
Fe m o r a l
P o p lit e a l
D o r s a lis
P e d is
2+
2+
2+
2+
1+
1+
1+
1+
1+
1+
ERRNVPHGLFRVRUJ
P o s t e r io r
Tib ia l
1+
1+
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Ba te s ’ Poc ke t Guide to Phys ic a l Exa mina tion a nd His tory Ta king
Aids to Interpretation
Table 12-1 Ch ro n ic In s u ffic ie n c y o f Art e rie s a n d Ve in s
C o n d it io n
C h a r a c t e r is t ic s
C h ro n ic A r t e r ia l In s u ff ic ie n c y
Intermittent claudication
progressing to pain at rest.
Decreased or absent pulses.
Pale, especially on elevation;
dusky red on dependency. Cool.
Absent or mild edema, which
may develop on lowering the leg
to relieve pain. Thin, shiny,
atrophic skin; hair loss over foot
and toes; thickened, ridged
nails. Possible ulceration on toes
or points of trauma on feet.
Potential for gangrene.
Rubor
Is che mic ulce r
C h ro n ic Ve n o u s In s u ff ic ie n c y
No pain to aching pain on
dependency. Normal pulses,
though may be hard to feel
because of edema. Color normal
or cyanotic on dependency;
petechiae or brown pigment
may develop. Often marked
edema. Stasis dermatitis,
possible thickening of skin, and
narrowing of leg as scarring
develops. Potential ulceration at
sides of ankles. No gangrene.
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Chapter 12 | The Peripheral Vascular System
229
Table 12-2 Co m m o n Ulc e r s o f t h e Fe e t a n d An k le s
U lc e r
C h a r a c t e r is t ic s
A r t e r ia l In s u ff ic ie n c y
Located on toes, feet, or possible
areas of trauma. No callus or
excess pigment. May be atrophic.
Pain often severe, unless masked
by neuropathy. Possible gangrene.
Decreased pulses, trophic changes,
pallor of foot on elevation, dusky
rubor on dependency.
C h ro n ic Ve n o u s In s u ff ic ie n c y
Located on inner or outer ankle.
Pigmented, sometimes fibrotic.
Pain not severe. No gangrene.
Edema, pigmentation, stasis
dermatitis, and possibly cyanosis
of feet on dependency.
N e u ro p a t h ic U lc e r
Located on pressure points in
areas with diminished sensation,
as in diabetic neuropathy. Skin
calloused. No pain (which may
cause ulcer to go unnoticed).
Usually no gangrene. Decreased
sensation, absent ankle jerks.
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Table 12-3
Us in g t h e An k le –Bra ch ia l In d e x
In s t r u c t io n s fo r M e a s u r in g t h e A n k le –Br a c h ia l In d e x (A BI)
1. Patient should rest supine in a warm room for at least 10 min before
testing.
Dopple r
Bra chia l a rte ry
2. Place blood pressure cuffs on both arms and ankles as illustrated, then
apply ultrasound gel over brachial, dorsalis pedis, and posterior tibial
arteries.
3. Measure systolic pressures in the arms
■ Use vascular Doppler to locate brachial pulse
■ Inflate cuff 20 mm Hg above last audible pulse
■ Deflate cuff slowly and record pressure at which pulse becomes
audible
■ Obtain 2 measures in each arm and record the average as the
brachial pressure in that arm
Dors a lis pe dis
(DP ) a rte ry
Dopple r
Dopple r
P os te rior
tibia l (P T)
a rte ry
4. Measure systolic pressures in ankles
■ Use vascular Doppler to locate dorsalis pedis pulse
■ Inflate cuff 20 mm Hg above last audible pulse
■ Deflate cuff slowly and record pressure at which pulse becomes
audible
■ Obtain 2 measures in each ankle and record the average as the
dorsalis pedis pressure in that leg
■ Repeat above steps for posterior tibial arteries
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Chapter 12 | The Peripheral Vascular System
231
Table 12-3 Us in g t h e An k le –Bra ch ia l In d e x (continued )
5. Calculate ABI
Right ABI =
Left ABI =
highest right average ankle pressure (DP or PT)
highest average arm pressure (right or left)
highest left average ankle pressure (DP or PT)
highest average arm pressure (right or left)
In t e r p r e t a t io n o f A n k le –Br a c h ia l In d e x
An kle –Bra ch ia l In d e x Re s u lt
Clin ica l In te rp re ta tio n
>0.90 (with a range of 0.90 to 1.30)
Normal lower-extremity
blood flow
<0.89 to >0.60
Mild PAD
<0.59 to >0.40
Moderate PAD
<0.39
Severe PAD
Source: Wilson JF, Laine C, Goldman D. In the clinic: peripheral arterial disease. Ann Int Med.
2007;146(5):ITC3.
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C H A P T E R
Male Genitalia
and Hernias
The Health History
C o m m o n o r C o n c e r n in g S y m p t o m s
●
●
●
●
Sexu l he lth
Penile disch rge or lesions
Scrot l in, swelling, or lesions
Sexu lly tr ns itted infections (STIs)
S e xu a l He a lt h . Explain your concern for the patient’s sexual health.
Pose questions in a neutral and nonjudgmental way.
■ “Are you currently dating, sexually active, or in a relationship?” “How
would you identify your sexual orientation?” Continue with “How
would you describe your gender identity?”
■ “How is your current relationship?” “Are you satis ed with your rela-
tionship and your sexual activity?” “What about your ability to perform
sexually?”
To assess libido, or desire: “How is
your desire for sex?”
Decreased libido from depression,
endocrine dysfunction, or side effects
of medications.
For the arousal phase: “Can you
achieve and maintain an erection?”
Erectile d ysfunct ion from p sychogenic
causes, esp ecially if early morning
erection is p reserved ; also from
d ecreased testosterone, d ecreased
b lood flow in hyp ogast ric arterial
system, imp aired neural innervation,
d iab etes.
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Ba te s ’ Poc ke t Guide to Phys ic a l Exa mina tion a nd His tory Ta king
If ejaculation is premature or early:
“About how long does intercourse
last?” “Do you climax too soon?”
For reduced or absent ejaculation:
“Do you nd that you cannot have
orgasm even though you can have
an erection?” “Does the problem
involve the pleasurable sensation of
orgasm, the ejaculation of seminal
uid, or both?”
Premature ejaculation is common,
especially in young men. Less common is
reduced or absent ejaculation affecting
middle -aged or older men. Consider
medications, surgery, neurologic deficits,
or lack of androgen. Lack of orgasm with
intact ejaculation is usually psychogenic.
P e n ile Dis c h a rg e o r Le s io n s ,
S c ro t a l S w e llin g o r P a in ,
S TIs a n d HIV. To assess possible
infection from STIs, ask about any
discharge from the penis.
Penile discharge in gonococcal (usually
yellow) and nongonococcal (clear or
white) urethritis.
Inquire about sores or growths on
the penis and any pain or swelling
in the scrotum.
See Table 13-1, Abnormalities of the Penis
and Scrotum, p. 241, and Table 13-2,
Sexually Transmitted Infections of Male
Genitalia, pp. 242–243.
STIs may involve other parts of the
body. Ask about practices of oral
and anal sex and any related sore
throat, oral itching or pain,
diarrhea, or rectal bleeding.
Rash in disseminated gonococcal
infection.
Ask “Do you have any concerns
about HIV infection?” and discuss
the need for universal testing for
HIV.
Health Promotion and Counseling:
Evidence and Recommendations
Im p o r t a n t T o p ic s f o r H e a lt h P r o m o t io n a n d C o u n s e lin g
●
●
●
Screening for STIs nd HPV
Screening for HIV infection nd AIDS; counseling bout sexu l r ctices
Screening for testicul r c ncer; testicul r self-ex in tion
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Chapter 13 | Male Genitalia and Hernias
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S c re e n in g fo r S TIs a n d HP V. Focus on patient education about STIs
and HPV, early detection of infection during history taking and physical
examination, and identi cation and treatment of infected partners. Identify the patient’s sexual orientation, the number of sexual partners in the
past month, and any history of STIs. Also query use of alcohol and drugs,
particularly injection drugs. Counsel patients at risk about limiting the
number of partners, using condoms, and establishing regular medical care
for treatment. Correct use of male condoms is highly effective in preventing
the transmission of STIs, HPV, and HIV.
Routine HPV vaccination is recommended in males age 11 or 12 years and
through age 21 years if not vaccinated previously (age 26 years if immunocompromised or having sex with other men). The vaccine can prevent
HPV-related diseases in males (genital warts, anal cancer, and penile cancer)
and possibly reduce HPV transmission to female sex partners and lower
the risk of oropharyngeal cancers.
S c re e n in g fo r HIV In fe c t io n a n d AIDS . The USPSTF recommends
HIV screening for all adolescents and adults from age 15 to 65 years and
all pregnant women. At least annual testing is recommended for high-risk
groups (including adolescents younger than 15 years and older adults),
de ned as men with male sex partners, individuals with multiple sexual
partners, past or present injection-drug users, persons who exchange sex
for money or drugs, and sex partners of persons who are HIV-infected,
bisexual, or injection-drug users. The presence of any STI, or requests for
STI testing, warrants testing for coinfection with HIV.
Patient counseling should be interactive and combine information about
general risk reduction with personalized messages based on the patient’s
personal risk behaviors.
S c r e e n in g fo r Te s t ic u la r Ca n c e r ; Te s t ic u la r S e lf -Exa m in a t io n .
Testicular cancer is rare but highly treatable when detected early. It is the
most commonly diagnosed cancer in white men ages 20 to 34 years. Risk
factors are white ethnicity, family history, HIV infection, and a history of
cryptorchidism. The American Cancer Society encourages men, especially
those between 15 and 35 years of age, to perform monthly testicular
self-examinations.
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Techniques of Examination
EXAMINATIO N TECHNIQ UES
P O SSIBLE FIN DIN G S
M a le G e n it a lia
Wear gloves to examine the male
genitalia (Fig. 13-1). The patient
may be standing or supine.
Vas
deferens
Blood
ves s els
Corpus
cavernos um
Corpus
s pongios um
Urethra
S eminal
ves icle
Ejaculatory
duct
Bulb of
the penis
Corona
Glans
Prepuce
Urethral
meatus
Epididymis
S crotum
Tunica vaginalis
Spermatic cord
Tes tis
Fig ure 13-1 Anatomy of m ale ge nitalia.
/
Th e Pe n is
Inspect the:
■ Development of the penis and
Sexual maturation, lice
the skin and hair at its base
■ Prepuce (if present, retract the
Phimosis, cancer
foreskin)
■ Glans
Ba lanitis, chancre, herpes, wa rts, ca ncer
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Chapter 13 | Male Genitalia and Hernias
EXAMINATIO N TECHNIQ UES
■ Urethral meatus (compress the
237
P O SSIBLE FIN DIN G S
Hypospadias, discharge of urethritis
glans to inspect the meatus for
discharge)
Palpate:
■ Any visible lesions
Chancre, cancer
■ The shaft
Urethral stricture or cancer
Th e S c ro t u m a n d It s Co n t e n t s
Inspect:
■ Skin of scrotum
Rashes
■ Contours of scrotum
Hernia, hydrocele, cryptorchidism
■ Inguinal areas
Fungal infection
Palpate each:
■ Testis (Fig. 13-2), noting any:
See Table 13-3, Abnormalities of the
Testis, p. 244.
■
Lumps
Testicular carcinoma
■
Tenderness
Acute epididymitis, acute orchitis, torsion of the spermatic cord, strangulated
inguinal hernia.
Fig ure 13-2 Palpate the te s tis and
e pididym is .
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Ba te s ’ Poc ke t Guide to Phys ic a l Exa mina tion a nd His tory Ta king
EXAMINATIO N TECHNIQ UES
P O SSIBLE FIN DIN G S
■ Epididymis
Epididymitis, cyst
■ Spermatic cord and adjacent
Varicocele if multiple tortuous veins;
cystic structure may be a hydrocele
areas (Fig. 13-3)
See Table 13-4, Abnormalities of the
Epididymis and Spermatic Cord, p. 245.
Fig ure 13-3 Palpate the s pe rm atic
cord.
H e r n ia s
Patient is usually standing.
See Table 13-5, Hernias in the Groin,
p. 246.
Inspect inguinal and femoral areas
as patient strains down.
Inguinal and femoral hernias
Palpate external inguinal ring
through scrotal skin and ask
patient to strain down (Fig. 13-4).
Indirect and direct inguinal hernias
Inguina l
liga me nt
Exte rna l
inguina l
ring
Fig ure 13-4 Invaginate the s crotum .
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S p e c ia l T e c h n iq u e
P a t ie n t In s t r u c t io n s f o r t h e T e s t ic u la r S e lf -E x a m in a t io n
This ex in tion is best erfor ed fter w r b th or shower. This w y the
scrot l skin is w r
nd rel xed. It is best to do the test while st nding.
●
●
St nding in front of
irror, check for ny swelling on the skin of the scrotu .
With the enis out of the w y, gently feel your scrot l s c to loc te testicle.
Ex ine e ch testicle se r tely.
As noted by the A eric n C ncer Society, “It’s nor l for one testicle to be
slightly l rger th n the other, nd for one to h ng lower th n the other. You
should lso know th t e ch nor l testicle h s s ll, coiled tube (e ididyis) th t c n feel like s ll bu
on the u er or iddle outer side of the
testicle. Nor l testicles lso h ve blood vessels, su orting tissues, nd
tubes th t c rry s er . So e en
y confuse these with bnor l lu s
t first. If you h ve ny concerns, sk your doctor or clinici n.”
●
●
Use one h nd to st bilize the testicle. Using the fingers nd thu b of your
other h nd, fir ly but gently feel or roll the testicle between your fingers.
Feel the entire surf ce. Find the e ididy is. This is soft, tube-like structure
t the b ck of the testicle th t collects nd c rries s er , nd is not n bnorl lu . Check the other testicle nd e ididy is the s e w y.
If you find h rd lu , n bsent or enl rged testicle,
inful swollen scrotu , or ny other differences th t do not see nor l, do not w it. See your
he lth c re rovider right w y.
Sources: A eric n C ncer Society. Testicul r self-ex . U d ted J nu ry 21, 2 15. Av il ble t
htt :/ / www.c ncer.org/c ncer/ testicul rc ncer/ oreinfor tion/doih vetesticul rc ncer/
do-i-h ve-testicul r-c ncer-self-ex . Accessed M y 13, 2 15; U.S. N tion l Libr ry of
Medicine, N tion l Institutes of He lth. MedlinePlus—Testicul r self-ex . U d ted
Dece ber 27, 2 13. Av il ble t htt :/ / www.nl .nih.gov/ edline lus/ency/ rticle/
39 9.ht . Accessed M y 13, 2 15.
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Ba te s ’ Poc ke t Guide to Phys ic a l Exa mina tion a nd His tory Ta king
Recording Your Findings
R e c o r d in g t h e M a le G e n it a lia a n d H e r n ia E x a m in a t io n
“Circu cised
le. No enile disch rge or lesions. No scrot l swelling or
discolor tion. Testes descended bil ter lly, s ooth, without
sses. E ididy is
nontender. No inguin l or fe or l herni s.”
OR
“Uncircu cised
le; re uce e sily retr ctible. No enile disch rge or lesions.
No scrot l swelling or discolor tion. Testes descended bil ter lly; right testicle
s ooth; 1 × 1 c fir nodule on left l ter l testicle. It is fixed nd nontender.
E ididy is nontender. No inguin l or fe or l herni s.” (These findings are
suspicious for testicular carcinoma, the most common form of cancer in men
between ages 15 and 35 years).
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Chapter 13 | Male Genitalia and Hernias
241
Aids to Interpretation
Table 13-1 Ab n o rm a lit ie s o f t h e P e n is a n d S c ro t u m
Hy p o s p a d ia s
S c ro t a l Ed e m a
A congenital displacement of the
urethral meatus to the inferior surface
of the penis. A groove extends from the
actual urethral meatus to its normal
location on the tip of the glans.
Pitting edema may make the
scrotal skin taut; seen in heart
failure or nephrotic syndrome.
Finge rs ca n
ge t a bove
ma s s
P e y ro n ie D is e a s e
Hyd ro c e le
Palpable, nontender, hard plaques are
found just beneath the skin, usually
along the dorsum of the penis. The
patient complains of crooked, painful
erections.
A nontender, fluid-filled mass
within the tunica vaginalis. It
transilluminates, and the
examining fingers can get above
the mass within the scrotum.
Finge rs ca nnot
ge t a bove
ma s s
C a r c in o m a o f t h e P e n is
S c ro t a l He r n ia
An indurated nodule or ulcer that is
usually nontender. Limited almost
completely to men who are not
circumcised, it may be masked by the
prepuce. Any persistent penile sore is
suspicious.
Usually an indirect inguinal
hernia that comes through the
external inguinal ring, so the
examining fingers cannot get
above it within the scrotum.
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Ba te s ’ Poc ke t Guide to Phys ic a l Exa mina tion a nd His tory Ta king
Table 13-2 S e xu a lly Tra n s m it t e d In fe c t io n s
o f Ma le Ge n it a lia
G e n it a l He r p e s S im p le x
G e n it a l Wa r t s (C o n d y lo m a t a
Ac u m in a t a )
■
■
■
■
■
■
Appearance: Single or multiple
papules or plaques of variable
shapes; may be round,
acuminate (or pointed), or thin
and slender. May be raised, flat,
or cauliflower-like (verrucous).
Causative organism: Human
papillomavirus (HPV), usually
from subtypes 6, 11; carcinogenic
subtypes rare, approximately
5%–10% of all anogenital warts.
Incubation: Weeks to months;
infected contact may have no
visible warts.
Can arise on penis, scrotum,
groin, thighs, anus; usually
asymptomatic, occasionally
cause itching and pain.
May disappear without
treatment.
■
■
■
■
Appearance: Small scattered or
grouped vesicles, 1–3 mm in
size, on glans or shaft of penis.
Appear as erosions if vesicular
membrane breaks.
Causative organism: Usually
Herpes simplex virus 2 (90%),
a double-stranded DNA virus.
Incubation: 2–7 days after
exposure.
Primary episode may be
asymptomatic; recurrence
usually less painful, of shorter
duration.
Associated with fever, malaise,
headache, arthralgias; local pain
and edema, lymphadenopathy.
Need to distinguish from
genital herpes zoster (usually
in older patients with
dermatomal distribution);
candidiasis.
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Table 13-2 S e xu a lly Tra n s m it t e d In fe c t io n s
o f Ma le Ge n it a lia (continued )
P r im a ry S y p h ilis
■
■
■
■
■
■
C h a n c ro id
Appearance: Small red papule
that becomes a chancre, or
painless erosion up to 2 cm
in diameter. Base of chancre
is clean, red, smooth, and
glistening; borders are raised
and indurated. Chancre heals
within 3–8 weeks.
Causative organism: Treponema
pallidum, a spirochete.
Incubation: 9–90 days after
exposure.
May develop inguinal
lymphadenopathy within 7 days;
lymph nodes are rubbery,
nontender, mobile.
20%–30% of patients develop
secondary syphilis while chancre
still present (suggests coinfection
with HIV).
Distinguish from: genital herpes
simplex, chancroid, granuloma
inguinale from Klebsiella
granulomatis (rare in the United
States; four variants, so difficult
to identify).
■
■
■
■
■
Appearance: Red papule or
pustule initially, then forms a
painful deep ulcer with ragged
nonindurated margins;
contains necrotic exudate, has
a friable base.
Causative organism: Haemophilus
ducreyi, an anaerobic bacillus.
Incubation: 3–7 days after
exposure.
Painful inguinal adenopathy;
suppurative bobos in 25% of
patients.
Need to distinguish from:
primary syphilis; genital herpes
simplex; lymphogranuloma
venereum, granuloma inguinale
from Klebsiella granulomatis
(both rare in the United States).
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Table 13-3 Ab n o rm a lit ie s o f t h e Te s t is
C ry p t o r c h id is m
S m a ll Te s t is
Ac u t e O r c h it is
Testis is atrophied and
may lie in the inguinal
canal or the abdomen,
resulting in an unfilled
scrotum. As above,
there is no palpable left
testis or epididymis.
Cryptorchidism
markedly raises the
risk for testicular
cancer.
In adults, testicular
length is usually
≤3.5 cm. Small, firm
testes seen in
Klinefelter syndrome,
usually ≤2 cm.
Small, soft testes
suggesting atrophy
seen in cirrhosis,
myotonic dystrophy,
use of estrogens, and
hypopituitarism;
may also follow
orchitis.
The testis is acutely
inflamed, painful,
tender, and swollen.
It may be difficult to
distinguish from the
epididymis. The
scrotum may be
reddened. Seen in
mumps and other
viral infections;
usually unilateral.
Ea rly
Tu m o r o f t h e Te s t is
Usually appears as a painless
nodule. Any nodule within the
testis warrants investigation for
malignancy.
La te
As a testicular neoplasm grows
and spreads, it may seem to
replace the entire organ. The
testicle characteristically feels
heavier than normal.
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245
Table 13-4 Ab n o rm a lit ie s o f t h e Ep id id ym is
a n d S p e rm a t ic Co rd
Ac u t e Ep id id y m it is
An acutely inflamed epididymis is
tender and swollen and may be
difficult to distinguish from the
testis. The scrotum may be reddened
and the vas deferens inflamed. It
occurs chiefly in adults. Coexisting
urinary tract infection or prostatitis
supports the diagnosis.
S p e r m a t o c e le a n d Cy s t
o f t h e Ep id id y m is
A painless, movable cystic mass
just above the testis suggests a
spermatocele or an epididymal
cyst. Both transilluminate. The
former contains sperm, and the
latter does not, but they are
clinically indistinguishable.
Va r ic o c e le o f t h e
S p e r m a t ic C o r d
To r s io n o f t h e
S p e r m a t ic C o r d
Varicocele refers to varicose veins
of the spermatic cord, usually
found on the left. It feels like a soft
“bag of worms” separate from the
testis, and slowly collapses when
the scrotum is elevated in the
supine patient.
Twisting of the testicle on its
spermatic cord produces an
acutely painful and swollen organ
that is retracted upward in the
scrotum, which becomes red
and edematous. There is no
associated urinary infection.
It is a surgical emergency because
of obstructed circulation.
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Ba te s ’ Poc ke t Guide to Phys ic a l Exa mina tion a nd His tory Ta king
Table 13-5 He rn ia s in t h e Gro in
In d ir e c t In g u in a l
Most common hernia at all ages, both sexes.
Originates above inguinal ligament and often
passes into scrotum. May touch examiner’s
fingertip in inguinal canal.
D ir e c t In g u in a l
Less common than indirect hernia, usually
occurs in men older than 40 years. Originates
above inguinal ligament near external inguinal
ring and rarely enters scrotum. May bulge
anteriorly, touching side of examiner’s finger.
Fe m o r a l
Least common hernia, more common in
women than in men. Originates below
inguinal ligament, more lateral than inguinal
hernia. Never enters scrotum.
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C H A P T E R
Female Genitalia
The Health History
Com m on Conce rns
●
●
●
●
●
●
Men rche, enstru tion, eno use, ost eno
Pregn ncy
Vulvov gin l sy to s
Sexu l he lth
Pelvic in— cute nd chronic
Sexu lly tr ns itted infections (STIs)
us l bleeding
Me n a rc h e , Me n s t ru a t io n ,
Me n o p a u s e , P o s t m e n o p a u s a l Ble e d in g ; P re g n a n c y.
For the menstrual history, ask when
menstrual periods began (age at
menarche).
When did her last menstrual
period (LMP) start, and the one
prior menstrual period (PMP)?
What is the interval between periods, from the rst day of one to the
rst day of the next? Are menses
regular or irregular? How long do
they last? How heavy is the ow?
Changes in the interval between periods
can signal possible pregnancy or menstrual irregularities.
Amenorrhea is the absence of
periods. Failure to begin periods
is primary amenorrhea, whereas
cessation of established periods is
secondary amenorrhea.
Secondary amenorrhea from pregnancy,
lactation, menopause; low body weight
from conditions of malnutrition,
a norexia nervosa, stress, chronic illness,
and hypothalamic–pituitary–ovarian
dysfunction
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In amenorrhea from pregnancy, common early symptoms are tenderness, tingling, or increased size of
breasts; urinary frequency; nausea
and vomiting; easy fatigability; and
feelings that the baby is moving
(usually noted at about 20 weeks).
Amenorrhea followed by heavy bleeding
in threatened abortion or dysfunctional
uterine bleeding
Dysmenorrhea, or painful menses,
is common.
Primary dysmenorrhea from increased
prostaglandin production; secondary
dysmenorrhea from endometriosis, a denomyosis, pelvic infla mmatory disease,
and endometrial polyps
Menopause, the absence of menses
for 12 consecutive months, usually
occurs between 48 and 55 years.
Associated symptoms include hot
ashes, ushing, sweating, and
sleep disturbances.
Postmenopausa l bleeding, or bleeding
occurring 6 months after cessation of
menses, from endometrial cancer, hormone replacement therapy (HRT), or
uterine or cervical polyps
Vu lvo va g in a l S ym p t o m s . For
vaginal discharge and local itching,
inquire about amount, color, consistency, and odor of discharge.
See Table 14-1, Lesions of the Vulva,
pp. 258–259; and Table 14-2, Vaginal
Discharge, p. 260.
S e xu a l He a lt h . Ask neutral
questions about sexual orientation
and gender identity: “Are you currently dating, sexually active, or in
a relationship?” “How would you
identify your sexual orientation?”
Then, “How would you describe
your gender identity?” and “Do you
use protection such as birth control
or condoms? . . . Has anyone ever
tried to touch or have sex with you
without your consent?”
To assess sexual health, be nonjudgmental. Ask “How is sex for
you?” “Are you having any problems with sex? This includes sexual
intercourse and anal and oral sex.”
Or, “Are you satis ed with your sex
life as it is now?”
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249
Direct questions help you assess
desire, arousal, and orgasm.
“Do you have an interest in (appetite for) sex?” “Do you get sexually
aroused?” “Are you able to reach
climax?”
Ask also about dyspareunia, or discomfort or pain during intercourse.
Superficial pain suggests local inflammation, atrophic vaginitis, or inadequate
lubrication; deeper pain may result from
pelvic disorders or pressure on a normal
ovary.
P e lvic P a in . Assess acute and
chronic (>6 months) pelvic pain.
Acute pelvic pain in PID, ruptured ovarian cyst, appendicitis; ectopic pregnancy; also mittelschmerz, ruptured
ovarian cyst, tubo-ovarian abscess.
Chronic pelvic pain in endometriosis,
PID, adenosis and fibroids, history of
sexual abuse; pelvic floor spasm.
S e xu a lly Tra n s m it t e d In fe c t io n . Identify sexual preference
(male, female, or both) and the
number of sexual partners in the
previous month. Ask if the patient
has concerns about HIV infection,
desires HIV testing, or has current
or past partners at risk.
In women, some STIs do not produce
symptoms, but do increase the risk of
infertility.
Health Promotion and Counseling:
Evidence and Recommendations
Im p o r t a n t T o p ic s f o r H e a lt h P r o m o t io n
a n d C o u n s e lin g
●
●
●
●
●
Cervic l c ncer screening
Ov ri n c ncer
STIs nd HIV infection
O tions for f ily l nning
Meno use nd hor one re l ce ent ther
y
Ce r vic a l Ca n c e r S c re e n in g . In 2012, ve major societies released
common guidelines for cervical cancer screening.
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C u r r e n t C e r v ic a l C a n c e r S c r e e n in g G u id e lin e s f o r
A v e r a g e -R is k W o m e n a : U S P S T F , A C S / A S C C P / A S C P ,
a nd ACOG
Va r ia b le
Re c o m m e n d a t io n
Age t which to begin screening
Screening ethod nd interv l
21 ye rs
Ages 21–65 ye rs: cytology every 3 ye rs
OR
Ages 21–29 ye rs: cytology every 3 ye rs
Ages 3 –65 ye rs: cytology lus HPV testing (for high-risk or oncogenic HPV
ty es) every 5 ye rs
Age >65 ye rs, ssu ing three consecutive
neg tive results on cytology or two consecutive neg tive results on cytology
lus HPV testing within 1 ye rs before
cess tion of screening, with the ost
recent test erfor ed within 5 ye rs
Not reco
ended
Age t which to end screening
Screening fter hysterecto y
with re ov l of the cervix
USPSTF, U.S. Preventive Services T sk Force; ACS/ASCCP/ASCP, A eric n C ncer Society/
A eric n Society for Col osco y nd Cervic l P thology/A eric n Society for Clinic l
P thology; ACOG, A eric n College of Obstetrici ns nd Gynecologists; HPV, hu n
illo virus.
a
Definition of Average Risk: No history of high-gr de, rec ncerous cervic l lesion (cervic l
intr e itheli l neo l si gr de 2 or
ore severe lesion) or cervic l c ncer; not i
unoco ro ised (including being HIV-infected); nd no in utero ex osure to diethylstilbestrol.
Source: S w y GF, Kul sing
S, Denberg T, et l. Cervic l c ncer screening in ver ge-risk
wo en: best r ctice dvice fro the Clinic l Guidelines Co
ittee of the A eric n
College of Physici ns. Ann Intern Med. 2 15;162:851.
The most important risk factor for cervical cancer is HPV infection from
HPV strains 16, 18, 6, or 11. The three-dose HPV vaccination series prevents HPV infection from the strains when given before sexual exposure
at age 11 years. The vaccine is also recommended for unvaccinated and
immunocompromised girls and women up to age 26 years.
Ova ria n Ca n c e r. There are no effective screening tests to date. Risk
factors include family history of breast or ovarian cancer and BRCA1 or
BRCA2 mutation. Watch for the nonspeci c symptoms of new abdominal
distention, abdominal bloating, and urinary frequency.
S TIs a n d HIV In fe c t io n . Assess risk factors by taking a careful sexual
history and counseling patients about spread of disease and ways to reduce
high-risk practices. Chlamydia trachomatis is the most commonly reported
STI in the United States and the most common STI in women. The CDC
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Chapter 14 | Female Genitalia
251
and the USPSTF strongly recommend screening for STIs as summarized in
the box below.
C D C S T D a n d H IV S c r e e n in g R e c o m m e n d a t io n s 2 0 1 4
●
●
●
●
●
Chl ydi nd gonorrhe screening nnu lly for ll sexu lly ctive wo en
ges <25 ye rs nd older wo en with risk f ctors such s new or ulti le sex
rtners, or sex rtner infected with n STD.
Chl ydi , sy hilis, he titis B, nd HIV screening for ll regn nt wo en
nd gonorrhe screening for t-risk regn nt wo en st rting e rly in regn ncy, with re e t testing s needed to rotect the he lth of others nd
their inf nts.
Chl ydi , gonorrhe , nd sy hilis screening t le st once ye r for ll sexully ctive g y, bisexu l, nd other MSM. MSM who h ve ulti le or nonyous rtners should be screened ore frequently for STDs (i.e., t 3- to
6- onth interv ls).
HIV testing t le st once for ll dults nd dolescents fro
ges 13–64 ye rs.
HIV testing t le st once ye r for nyone h ving uns fe sex or using injection drug equi ent. Sexu lly ctive g y nd bisexu l en
y benefit fro
testing every 3–6 onths.
Source: Centers for Dise se Control nd Prevention. Sexu lly tr ns itted dise ses. STD nd
HIV screening reco
end tions. U d ted Dece ber 16, 2 14. Av il ble t htt :/ / www.
cdc.gov/std/ revention/screeningreccs.ht . Accessed M y 2 , 2 15.
Op t io n s fo r Fa m ily P la n n in g . More than half of U.S. pregnancies are
unintended. Counsel women, particularly adolescents, about the timing of
ovulation, midway in the regular menstrual cycle. Discuss methods for contraception and their effectiveness.
O p t io n s f o r F a m ily P la n n in g
Me t h o d s
Ty p e s o f C o n t r a c e p t io n
Natural
Fertility w reness/ eriodic bstinence,
withdr w l, l ct tion
M le condo , fe le condo , di hr g ,
cervic l c , s onge
Intr uterine device, subder l i l nt of
levonorgestrel
S er icide, or l contr ce tives (estrogen nd
rogesterone; rogestin only), estrogen/
rogesterone inject bles nd tch, horon l v gin l contr ce tive ring, e ergency
contr ce tion
Tub l lig tion; tr nscervic l steriliz tion;
v secto y
Barrier
Implantable
Pharmacologic/ hormonal
Surgery (permanent)
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Me n o p a u s e a n d Ho rm o n e Re p la c e m e n t Th e ra p y. Be familiar
with the psychological and physiologic changes of menopause. Help the
patient to weigh the risks of HRT, including increased risk of stroke, pulmonary embolism, and breast cancer.
Techniques of Examination
T ip s f o r t h e S u c c e s s f u l P e lv ic E x a m in a t io n
Th e P a t ie n t
●
●
●
Avoids intercourse, douching, or use of v gin l su ositories for 24–48 hours
before ex in tion
E ties bl dder before
ex in tion
Lies su ine, with he d nd
shoulders elev ted, r s t
sides or folded cross chest
to enh nce eye cont ct nd
reduce tightening of bdo in l uscles
Th e Ex a m in e r
●
●
●
●
●
●
●
●
Obt ins er ission; selects ch erone
Ex l ins e ch ste of the ex in tion in
dv nce
Dr es tient fro
id bdo en to
knees; de resses dr e between knees to
rovide eye cont ct with tient
Avoids unex ected or sudden ove ents
Chooses s eculu th t is the correct size
W r s s eculu with t w ter
Monitors co fort of the ex in tion by
w tching the tient’s f ce
Uses excellent but gentle technique, es eci lly when inserting the s eculu
Male examiners should be accompanied by female chaperones. Female
examiners should be assisted whenever possible.
EXAMINATIO N TECHNIQ UES
P O SSIBLE FIN DIN G S
E x t e r n a l G e n it a lia
Observe pubic hair to assess
sexual maturity.
Normal or delayed puberty
Examine the external genitalia
(Fig. 14-1).
See Table 14-1, Lesions of the Vulva,
pp. 258–259.
■ Labia minora
Ulceration in herpes simplex, syphilitic
chancre; inflammation in Bartholin cyst
■ Clitoris
Enlarged in masculinization
■ Urethral ori ce
Urethral ca runcle or prolapse; tenderness
in interstitial cystitis
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EXAMINATIO N TECHNIQ UES
253
P O SSIBLE FIN DIN G S
Mons pubis
La bia ma jora
P re puce
La bia minora
Clitoris
Ure thra l
me a tus
Hyme n
Va gina
Ope ning of
pa ra ure thra l
(S ke ne ) gla nd
Ve s tibule
Ope ning of
Ba rtholin
gla nd
Introitus
Pe rine um
Anus
Fig ure 14-1 Exte rnal fe m ale ge nitalia.
■ Introitus
Imperforate hymen
Milk the urethra for discharge if
indicated.
Discharge of urethritis
In t e r n a l G e n it a lia a n d P a p S m e a r
Locate the cervix with a gloved and
water-lubricated index nger.
Assess support of vaginal outlet by
asking patient to strain down.
Cystocele, cystourethrocele, rectocele
Enlarge the introitus by pressing its
posterior margin downward.
Insert a water-lubricated speculum
of suitable size. Start with speculum held obliquely (Fig. 14-2),
then rotate to horizontal position
for full insertion (Fig. 14-3).
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EXAMINATIO N TECHNIQ UES
Fig ure 14-2 Entry angle .
P O SSIBLE FIN DIN G S
Fig ure 14-3 Care fully ins e rt the
s pe culum to full le ngth.
Open the speculum gently and
inspect cervix:
■ Position
Cervix faces forward if uterus is retroverted.
■ Color
Purplish in pregnancy
■ Shape of the cervical os
Oval (normal) or slit-like or transverse os
from delivery; raised, friable, or lobed
wart-like lesions in condylomata or cervical cancer (see Table 14-3, Abnormalities of the Cervix, p. 261)
(Fig. 14-4); epithelial surface
(squamous–columnar epithelial
junction)
Columna r e pithe lium
Exte rna l os of
the ce rvix
S qua mocolumna r junction
Tra ns forma tion
zone
S qua mous e pithe lium
Fig ure 14-4 Ce rvical e pithe lial s urface .
■ Any discharge or bleeding
Discharge from os in mucopurulent cervicitis from Chlamydia or gonorrhea (see
Table 14-2, Vaginal Discharge, p. 260)
■ Any ulcers, nodules, or masses
Herpes, polyp, cancer
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Chapter 14 | Female Genitalia
255
EXAMINATIO N TECHNIQ UES
P O SSIBLE FIN DIN G S
Obtain specimens for cytology
(Pap smears) with:
Early cancer before it is clinically evident
■ An endocervical broom
(Fig. 14-5) or brush with scraper
(except in pregnant women),
to collect both squamous and
columnar cells
■ Or, if the woman is pregnant,
use a cotton-tipped applicator
moistened with water
Inspect the vaginal mucosa as you
withdraw the speculum.
Fig ure 14-5 Endoce rvical broom .
Bluish color and deep rugae in pregnancy; vaginal cancer (rare); vaginal discharge from infection from Candida,
Trichomonas vaginalis, bacterial vaginosis
(see Table 14-2, Vaginal Discharge, p. 260)
Palpate, by means of a bimanual
examination (Fig. 14-6):
■ The cervix and fornices
Pain on moving cervix in PID
■ The uterus
Pregnancy, myomas; soft isthmus in
early pregnancy (see Table 14-4,
Positions of the Uterus and Uterine
Myomas, p. 262)
■ Right and left adnexa (ovaries)
Ovarian cysts or masses, salpingitis, PID,
tubal pregnancy
Fig ure 14-6 Palpate the ce rvix,
ute rus , and adnexa.
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EXAMINATIO N TECHNIQ UES
P O SSIBLE FIN DIN G S
Assess strength of pelvic muscles.
With your vaginal ngers clear of
the cervix, ask patient to tighten
her muscles around your ngers as
hard and long as she can.
/
When indicated, perform a rectovaginal examination
as shown in Figure 14-7 to palpate
a retroverted uterus, uterosacral
ligaments, cul-de-sac, and adnexa
or screen for colorectal cancer in
women 50 years or older (see
p. 269).
H e r n ia s
A firm squeeze that compresses your
fingers, moves them up and inward, and
lasts more than 3 seconds is full strength
(see Table 14-5, Relaxations of the Pelvic
Floor, p. 263).
Retroverted
uterus
Fig ure 14-7 Exam ine the re ctovaginal
Ask the woman to strain down, as
you palpate for a bulge in:
are a.
■ The femoral canal
Femoral hernia
■ The labia majora up to just
Indirect inguinal hernia
lateral to the pubic tubercle
S p e c ia l T e c h n iq u e
As s e s s in g Ure t h rit is . Insert your
index nger into the vagina and
milk the urethra gently outward
from the inside (Fig. 14-8). Note
any discharge.
Discharge in C. trachomatis and Neisseria
gonorrhoeae infection
Fig ure 14-8 Milk the ure thra if
indicate d.
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Chapter 14 | Female Genitalia
257
Recording Your Findings
R e c o r d in g t h e F e m a le G e n it a lia E x a m in a t io n
“No inguin l deno thy. Extern l genit li without erythe , lesions, or
sses. V gin l ucos ink. Cervix rous, ink, nd without disch rge.
Uterus nterior, idline, s ooth, nd not enl rged. No dnex l tenderness. P
s e r obt ined. Rectov gin l w ll int ct. Rect l v ult without
sses. Stool
brown nd He occult neg tive.”
OR
“Bil ter l shotty inguin l deno thy. Extern l genit li without erythe
or
lesions. V gin l ucos nd cervix co ted with thin, white ho ogeneous
disch rge with ild fishy odor. After sw bbing cervix, no disch rge visible in
cervic l os. Uterus idline; no dnex l sses. Rect l v ult without
sses.
Stool brown nd He occult neg tive.” (These findings suggest bacterial vaginosis.)
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Aids to Interpretation
Table 14-1 Le s io n s o f t h e Vu lva
Ep id e r m o id Cy s t
Cys tic
nodule
in s kin
Ve n e r e a l Wa r t (C o n d y lo m a
Ac u m in a t u m )
A small, firm, round cystic
nodule in the labia suggests an
epidermoid cyst. They are
yellowish in color. Look for the
dark punctum marking the
blocked opening of the gland.
Warty lesions on the labia and
within the vestibule suggest
condyloma acuminata from
infection with human
papillomavirus.
Wa rts
Shallow, small, painful ulcers on
red bases suggest a herpes
infection. Initial infection may be
extensive, as illustrated here.
Recurrent infections are usually
confined to a small local patch.
G e n it a l He r p e s
S ha llow
ulce rs
on re d
ba s e s
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259
Table 14-1 Le s io n s o f t h e Vu lva (continued )
S y p h ilit ic C h a n c r e
A firm, painless ulcer suggests
the chancre of primary syphilis.
Because most chancres in women
develop internally, they often go
undetected.
S e c o n d a ry S y p h ilis
(C o n d y lo m a La t u m )
Slightly raised, round or oval
flat-topped papules covered by a
gray exudate suggest condylomata
lata, a manifestation of secondary
syphilis. They are contagious.
Fla t,
gra y
pa pule s
C a r c in o m a o f t h e Vu lva
An ulcerated or raised red vulvar
lesion in an elderly woman may
indicate vulvar carcinoma.
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Ba te s ’ Poc ke t Guide to Phys ic a l Exa mina tion a nd His tory Ta king
Table 14-2 Va g in a l Dis ch a rg e
Note: Accurate diagnosis depends on laboratory assessment and
cultures.
Tr ic h o m o n a s va g in it is
Dis charg e : Yellowish green,
often profuse, may be
malodorous
Othe r Sym pto m s : Itching,
vaginal soreness, dyspareunia
Vulva: May be red
Vag ina: May be normal or red,
with red spots, petechiae
Laboratory Assessment: Saline
wet mount for trichomonads
C a n d id a va g in it is
Dis charge : White, curdy, often
thick, not malodorous
Othe r Sym pto m s : Itching,
vaginal soreness, external
dysuria, dyspareunia
Vulva: Often red and swollen
Vag ina: Often red with white
patches of discharge
Labo rato ry As s e s s m e nt:
KOH preparation for branching
hyphae
Ba c t e r ia l va g in o s is
Lactoba cilli
Dis charg e : Gray or white,
thin, homogeneous, scant,
malodorous
Othe r Sym pto m s : Fishy
genital odor
Vulva: Usually normal
Vag ina: Usually normal
Laboratory Assessment: Saline
wet mount for “clue cells,” “whiff
test” with KOH for fishy odor
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Chapter 14 | Female Genitalia
261
Table 14-3 Ab n o rm a lit ie s o f t h e Ce r vix
En d o c e r v ic a l p o ly p . A bright
red, smooth mass that protrudes
from the os suggests a polyp. It
bleeds easily.
M u c o p u r u le n t c e r v ic it is . A
yellowish exudate emerging from
the cervical os suggests infection
from Chlamydia, gonorrhea (often
asymptomatic), or herpes.
C a r c in o m a o f t h e c e r v ix .
An irregular hard mass suggests
carcinoma from HPV infection.
Early lesions are best detected by
pap smear and HPV screening,
followed by colposcopy.
Columna r
e pithe lium
Colla r
Va gina l
a de nos is
Fe t a l e x p o s u r e t o d ie t h y ls t ilb e s t ro l (D ES ). Several
changes may occur: a collar of
tissue around the cervix,
columnar epithelium that covers
the cervix or extends to the
vaginal wall (then termed vaginal
adenosis), and, rarely, carcinoma
of the vagina.
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Table 14-4 P o s it io n s o f t h e Ut e ru s a n d
Ut e rin e Myo m a s
A n a n t e ve r t e d u t e r u s lies in a forward
position at roughly a right angle to the
vagina. This is the most common position.
Anteflexion—a forward flexion of the uterine
body in relation to the cervix—often
coexists.
A r e t ro ve r t e d u t e r u s is tilted posteriorly
with its cervix facing anteriorly.
A r e t ro f le xe d u t e r u s has a posterior tilt
that involves the uterine body but not the
cervix. A uterus that is retroflexed or
retroverted may be felt only through the
rectal wall; some cannot be felt at all.
A m yo m a o f t h e u t e r u s is a very
common benign tumor that feels firm and
often irregular. There may be more than one.
A myoma on the posterior surface of the
uterus may be mistaken for a retrodisplaced
uterus; one on the anterior surface may be
mistaken for an anteverted uterus.
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263
Table 14-5 Re la xa t io n s o f t h e P e lvic Flo o r
When the pelvic floor is weakened, various structures may become
displaced. These displacements are seen best when the patient strains
down.
A c y s t o c e le is a bulge of the anterior
wall of the upper part of the vagina,
together with the urinary bladder above it.
A c y s t o u r e t h ro c e le involves both the
bladder and the urethra as they bulge into
the anterior vaginal wall throughout most
of its extent.
A r e c t o c e le is a bulge of the posterior
vaginal wall, together with a portion of the
rectum.
A p ro la p s e d u t e r u s has descended
down the vaginal canal. There are three
degrees of severity: first, still within
the vagina (as illustrated); second, with
the cervix at the introitus; and third,
with the cervix outside the introitus.
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15
C H A P T E R
The Anus, Rectum,
and Prostate
The Health History
C o m m o n o r C o n c e r n in g S y m p t o m s
●
●
●
●
●
●
●
Ch nge in bowel h bits
Blood in the stool
P in with defec tion; rect l bleeding or tenderness
An l w rts or fissures
We k stre
of urine
Burning with urin tion
Blood in urine
Ask about any change in bowel
habits or stool size or caliber, and
any diarrhea or constipation. Is there
any blood in the stool, or dark tarry
stools? Any mucus in the stool?
Pencil-like stool or blood in stool in colon
cancer; dark tarry stools if polyps, carcinoma, gastrointestinal bleeding; mucus
in villous adenoma, inflammatory bowel
disease (IBD), or irritable bowel
syndrome (IBS)
Any pain with defecation, or rectal
bleeding or tenderness?
Hemorrhoids; proctitis from sexually
transmitted infections (STIs)
Any anal warts, ssures, or ulcerations?
Human papillomavirus (HPV), condylomata
lata in secondary syphilis; fissures in Crohn
disease, proctitis from receptive anal
intercourse, ulcerations of herpes simplex,
or chancres of primary syphilis
In men, is there dif culty starting the
urine stream or holding back urine?
Is the ow weak? What about frequent urination, especially at night?
Or pain or burning when passing
urine? Any blood in the urine or
semen or pain with ejaculation? Is
there frequent pain or stiffness in the
lower back, hips, or upper thighs?
These symptoms suggest urethral
obstruction from benign prostatic hyperplasia (BPH) or prostate ca ncer, especially
in men age ≥70 years. The American
Urological Association (AUA) Symptom
Index helps quantify BPH severity (see
Table 15-1, BPH Symptom Score Index:
American Urological Association (AUA),
p. 271).
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Health Promotion and Counseling:
Evidence and Recommendations
Im p o r t a n t T o p ic s f o r H e a lt h P r o m o t io n a n d C o u n s e lin g
●
●
●
Prost te c ncer screening
Colorect l c ncer screening
Counseling for sexu lly tr ns itted infections
P ro s t a t e Ca n c e r S c re e n in g . Prostate cancer is the leading nonskin
cancer diagnosed in the United States and the second leading cause of
death in men. Risk factors are age, family history of prostate cancer, and
African American ethnicity.
Screening methods such as prostate-speci c antigen (PSA) test and the
digital rectal examination (DRE) are not highly accurate, which complicates
decisions about screening men without symptoms.
Th e P S A . PSA screening remains controversial, so warrants shared
decision making about risks and benefits and patient preferences. About
12% of men have a PSA screening test above 4 ng/mL, but only 30% of these
men have prostate cancer on biopsy. At 4 ng/mL, PSA sensitivity is 21%
and specificity is 91%. See recommendations of major societies below.
P r o s t a t e C a n c e r S c r e e n in g G u id e lin e s
A m e r ic a n
U ro lo g ic a l
A s s o c ia t io n
Sh red decision
king
Age to begin
offering
screening
Aver ge-risk
High-risk
Age to sto
offering
screening
Screening tests
Yes
4 ye rs
4 ye rs
Life
ex ect ncy
<1 ye rs
PSA
DRE (o tion l)
A m e r ic a n
C a n c e r S o c ie t y
Yes (consider
using decision
id)
5 ye rs
4 –45 ye rs
Life ex ect ncy
<1 ye rs
PSA
DRE (o tion l)
U n it e d S t a t e s
P r e ve n t ive S e r v ic e s
Ta s k Fo r c e
Yes (when tient
requests screening)
No reco
end tion
No reco
end tion
No reco
end tion
(continued )
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Chapter 15 | The Anus, Rectum, and Prostate
P r o s t a t e C a n c e r S c r e e n in g G u id e lin e s
A m e r ic a n
U ro lo g ic a l
A s s o c ia t io n
Frequency of
screening
Bio sy referr l
criteri
Annu l
Am e r ic a n
C a n c e r S o c ie t y
Annu l (bienni l
when PSA
<2.5 ng/ L)
PSA ≥4 ng/ L
Abnor l DRE
Individu lized risk
ssess ent for
PSA levels
2.5–4 ng/ L
267
(Continued )
U n it e d S t a t e s
P r e ve n t ive S e r v ic e s
Ta s k Fo r c e
No reco
end tion
No reco
end tion
Abbrevi tions: PSA, rost te-s ecific ntigen; DRE, digit l rect l ex
in tion.
Th e D RE. reaches only the posterior and lateral surfaces of the prostate,
missing findings in the anterior and central areas. DRE sensitivity for
prostate cancers is only 59%.
Encourage men with symptomatic disorders such as incomplete emptying
of the bladder, urinary frequency or urgency, weak or intermittent stream
or straining to initiate ow, hematuria, nocturia, or even bony pains in the
pelvis to seek evaluation and treatment early.
C o lo r e c t a l C a n c e r S c r e e n in g . In 2008, screening recommendations
were revised to promote more aggressive surveillance:
■ Clinicians should rst identify whether patients are at average or
increased risk, ideally by age 20 years. High-risk factors include a
personal history of colorectal neoplasia or long-standing IBD—or a
family history of colorectal neoplasia, including hereditary syndromes.
People at increased risk should undergo colonoscopy at intervals
ranging from 3 to 5 years.
■ Average-risk patients 50 years or older should be offered a range of
screening options to increase compliance: annual screening with highsensitivity fecal occult blood tests (including guaiac-based Hemoccult
tests and fecal immunochemical tests), colonoscopy every 10 years, or
sigmoidoscopy every 5 years (which can be combined with highsensitivity fecal occult blood testing performed every 3 years).
Co u n s e lin g fo r S TIs . Anal intercourse increases risk for HIV and STIs.
Promote abstinence from high-risk behaviors, use of condoms, vaccination
for hepatitis B and HPV, and good hygiene.
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Techniques of Examination
EXAMINATIO N TECHNIQ UES
P O SSIBLE FIN DIN G S
Wear gloves to examine the
anus, rectum, and prostate
(Fig. 15-1).
Bla dde r
P e ritone a l
re fle ction
Va lve of
Hous ton
S e mina l
ve s icle
Re ctum
Anore cta l
junction
Ana l ca na l
Ure thra
P ros ta te
Fig ure 15-1 Anus and re ctum —s agittal view.
M a le
Position the patient on his side, or
standing leaning forward over the
examining table and hips exed
(Fig. 15-2).
Figure 15-2 Position the patie nt on the
le ft side .
Inspect the:
■ Sacrococcygeal area
Pilonidal cyst or sinus
■ Perianal area
Hemorrhoids, warts, herpes, chancre,
cancer, fissures from proctitis, STIs, or
Crohn disease, fistula from anorectal
abscess
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EXAMINATIO N TECHNIQ UES
269
P O SSIBLE FIN DIN G S
Palpate the anal canal and rectum
with a lubricated and gloved nger.
Palpate the:
Lax sphincter tone in some neurologic
disorders; tightness in proctitis
■ Walls of the rectum
Cancer of the rectum, polyps
■ Prostate gland, as shown in
Prostate nodule or cancer (Fig. 15-4);
BPH; tenderness in prostatitis
Figure 15-3, including median
sulcus
Fig ure 15-3 Palpate the pros tate
Fig ure 15-4 Re ctal cance r.
gland.
Try to palpate above the prostate
for irregularities or tenderness, if
indicated.
/
See Table 15-2, Abnormalities on Rectal
Examination, pp. 272–273.
F e m a le
The patient is usually in the
lithotomy position or lying on
her side.
Rectal shelf of peritoneal metastases;
tenderness of inflammation
Inspect the anus.
Hemorrhoids
Palpate the anal canal and rectum.
Rectal cancer, normal uterine cervix or
tampon (felt through the rectal wall)
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Recording Your Findings
R e c o r d in g t h e A n u s , R e c t u m , a n d
P r o s t a t e E x a m in a t io n
“No erirect l lesions or fissures. Extern l s hincter tone int ct. Rect l v ult
without
sses. Prost te s ooth nd nontender with l ble edi n sulcus.
(Or in fe le, uterine cervix nontender.) Stool brown nd He occult neg tive.”
OR
“Perirect l re infl ed; no ulcer tions, w rts, or disch rge. C nnot ex ine
extern l s hincter, rect l v ult, or rost te bec use of s s of extern l s hincter
nd rked infl
tion nd tenderness of n l c n l.” (These findings suggest
proctitis from infectious cause.)
OR
“No erirect l lesions or fissures. Extern l s hincter tone int ct. Rect l v ult
without
sses. Left l ter l rost te lobe with 1 × 1 c fir h rd nodule; right
l ter l lobe s ooth; edi l sulcus is obscured. Stool brown nd He occult
neg tive.” (These findings are suspicious for prostate cancer.)
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Aids to Interpretation
Table 15-1 BP H S ym p t o m S c o re In d e x: Am e ric a n
Uro lo g ic a l As s o c ia t io n (AUA)
Score or ask the patient to score each of the questions below on a scale
of 1 to 5, with 0 = not at all, 1 = less than 1 time in 5, 2 = less than half
the time, 3 = about half the time, 4 = more than half the time, and 5 =
almost always.
Higher scores (maximum 35) indicate more severe symptoms; scores ≤7 are
considered mild and generally do not warrant treatment.
PA RT A
S c o re
1. Incomplete emptying: Over the past month, how often
have you had a sensation of not emptying your bladder
completely after you finished urinating?
2. Frequency: Over the past month, how often have you had
to urinate again <2 hours after you finished urinating?
3. Intermittency: Over the past month, how often have you
stopped and started again several times when you urinated?
4. Urgency: Over the past month, how often have you
found it difficult to postpone urination?
5. Weak stream: Over the past month, how often have you
had a weak urinary stream?
6. Straining: Over the past month, how often have you had
to push or strain to begin urination?
PART A TOTAL SCORE
For Part B, 0 = none, 1 = 1 time, 2 = 2 times, 3 = 3 times, 4 = 4 times,
5 = 5 times.
PA RT B
S c o re
7. Nocturia: Over the past month, how many times did you
most typically get up to urinate from the time you went to
bed at night until the time you got up in the morning?
(Score 0 to 5 times on night)
TOTAL PARTS A and B (maximum 35)
Adapted from: Madsen FA, Burskewitz RC. Clinical manifestations of benign prostatic hyperplasia.
Urol Clin North Am. 1995;22:291.
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Table 15-2 Ab n o rm a lit ie s o n Re c t a l Exa m in a t io n
Ex t e r n a l He m o r r h o id s
(Th ro m b o s e d ). Dilated
hemorrhoidal veins that originate
below the pectinate line, covered
with skin; a tender, swollen, bluish
ovoid mass is visible at the anal
margin.
A n a l Fis s u r e . Painful longitudinal
oval ulceration usually in posterior
midline with swollen sentinel tag
just below it.
S e ntine l ta g
Fis s ure
A n o r e c t a l Fis t u la . An
inflammatory tract or tube opening
inside the anus or rectum and also
onto the perianal area or into
another viscus.
Ope ning
Fis tula
P o ly p s o f t h e Re c t u m . A soft
mass that may or may not be on a
stalk; may not be palpable.
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Chapter 15 | The Anus, Rectum, and Prostate
Table 15-2 Ab n o rm a lit ie s o n Re c t a l
Exa m in a t io n (continued )
Be n ig n P ro s t a t ic Hy p e r p la s ia .
An enlarged, nontender, smooth,
firm but slightly elastic prostate
gland; can cause symptoms without
palpable enlargement.
Ac u t e P ro s t a t it is . A prostate that
is very tender, swollen, and firm
because of acute infection.
C a n c e r o f t h e P ro s t a t e . A hard
area in the prostate that may or may
not feel nodular.
C a n c e r o f t h e Re c t u m . Firm,
nodular, rolled edge of an ulcerated
cancer.
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16
C H A P T E R
The Musculoskeletal
System
Fundamentals for Assessing Joints
Musculoskeletal disorders are the leading primary diagnosis during of ce
visits in the United States. Your rst goal is to assess four key features of
the patient’s complaint. Is the joint problem:
■ Articular or extra-articular;
■ Acute (usually <6 weeks) or chronic (usually >12 weeks);
■ In ammatory or nonin ammatory; and
■ Localized (monoarticular) or diffuse (polyarticular)?
Assessing joints requires knowledge of each joint’s structure and function.
Learn the surface landmarks and underlying anatomy of each of the major
joints. Use the descriptive terms below.
J o in t A n a t o m y —Im p o r t a n t T e r m s
●
●
Articular structures include the joint capsule nd articular cartilage, the
synovium nd synovial fluid, intra-articular ligaments, nd juxta-articular bone.
Articul r c rtil ge is co osed of coll gen
trix cont ining ch rged ions
nd w ter, llowing the c rtil ge to ch nge sh e in res onse to ressure or
lo d, cting s cushion for underlying bone. Synovi l fluid rovides nutrition
to the dj cent rel tively v scul r rticul r c rtil ge.
Extra-articular structures include eri rticul r lig ents, tendons, burs e,
uscle, f sci , bone, nerve, nd overlying skin.
● Ligaments re ro e-like bundles of coll gen fibrils th t connect bone to bone.
● Tendons re coll gen fibers connecting
uscle to bone.
● Bursae re
ouches of synovi l fluid th t cushion the ove ent of tendons
nd uscles over bone or other joint structures.
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Age also provides clues to causes of joint pain.
C o m m o n C a u s e s o f J o in t P a in b y A g e
Ag e <6 0 Ye a r s
●
●
●
●
Ag e >6 0 Ye a r s
Re etitive str in or overuse syndro es (tendinitis, bursitis)
Cryst lline rthritis (gout; cryst lline
yro hos h te de osition dise se
[CPPD])
Rheu toid rthritis (RA), sori tic
rthritis nd re ctive (Reiter) rthritis
(in infl
tory bowel dise se [IBD])
Infectious rthritis fro gonorrhe ,
Ly e dise se, or vir l or b cteri l
infections
●
Osteo rthritis (OA)
Osteo orotic fr cture
Gout nd seudogout
●
Poly y lgi rheu
●
Se tic b cteri l rthritis
●
●
tic (PMR)
Review the three primary types of joint articulation—synovial, cartilaginous, and brous—and the varying degrees of movement each type allows.
Note that joint anatomy determines its function and range of motion.
T y p e s o f J o in t s
S y n o v ia l J o in t s
●
●
●
●
●
Bone
Liga me nt
S ynovia l
me mbra ne
J oint
s pa ce
J oint
ca ps ule
S ynovia l
cavity
Articula r
ca rtila ge
Freely ov ble within li its of
surrounding lig ents
Se r ted by articular cartilage
nd synovial cavity
Lubric ted by synovi l fluid
Surrounded by joint c sule
Example: knee, shoulder
C a r t ila g in o u s J o in t s
●
●
●
●
Ve rte bra l
body
Slightly ov ble
Cont in fibroc rtil ginous discs
th t se r te the bony surf ces
H ve centr l nucleus pulposus of
discs th t cushions bony cont ct
Example: vertebr l bodies
Nucle us
pulpos us
of the dis c
Disc
Liga me nt
Fib ro u s J o in t s
●
●
●
●
No
reci ble ove ent
Consist of fibrous tissue or c rtil ge
L ck joint c vity
Example: skull sutures
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Chapter 16 | The Musculoskeletal System
277
Review the types of synovial joints and their associated features as well.
T y p e s o f S y n o v ia l J o in t s
S p h e ro id a l (b a ll a n d s o c k e t )
Articul r sh e: Convex surf ce in conc ve
c vity
Move ent: Wide-r nging flexion, extension,
bduction, dduction, rot tion,
circu duction
Ex
le: Shoulder, hi
Hin g e
Articul r sh e: Fl t, l n r
Move ent: Motion in one l ne; flexion,
extension
Ex
le: Inter h l nge l joints of h nd nd
foot; elbow
C o n d y la r
Articul r sh e: Convex or conc ve
Move ent: Move ent of two rticul ting
surf ces, not dissoci ble
Ex
le: Knee; te oro ndibul r joint
The Health History
C o m m o n o r C o n c e r n in g S y m p t o m s
●
●
●
●
Joint in: rticul r or extr - rticul r, cute or chronic, infl
noninfl
tory, loc lized or diffuse
Joint in: ssoci ted constitution l sy to s nd syste ic
fro other org n syste s
Neck in
Low b ck in
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278
Ba te s ’ Poc ke t Guide to Phys ic a l Exa mina tion a nd His tory Ta king
Assess the seven features of any joint pain (see p. 47).
T ip s f o r A s s e s s in g J o in t P a in
●
●
●
Ask the tient to “ oint to the in.” This
y s ve consider ble ti e
bec use
ny tients h ve trouble in ointing in loc tion in words.
Cl rify nd record when the in st rted nd the ech nis of injury, rticul rly if there is history of tr u .
Deter ine whether the in is rticul r or extr - rticul r, cute or chronic,
infl
tory or noninfl
tory, nd loc lized ( ono rticul r) or diffuse
( oly rticul r).
J o in t Pa in
A r t ic u la r o r Ex t r a -a r t ic u la r.
See Table 16-1, Patterns of Pain in and
Around the Joints, p. 304.
Ask “Do you have any pains in
your joints?” Ask the patient to
point to the pain. If localized and
involving only one joint, it is
monoarticular.
Consider trauma, monoarticular arthritis, tendinitis, or bursitis. Hip pain near
the greater trochanter suggests
trochanteric bursitis.
If polyarticular, does it migrate from
joint to joint, or steadily spread
from one joint to multiple joint
involvement? Is the involvement
symmetric?
Migratory pattern in rheumatic fever or
gonococcal arthritis; progressive and
symmetric pattern in rheumatoid arthritis
If pain is extra-articular, are there
generalized “aches and pains”
(myalgia if in muscles, arthralgia
if in joints with no evidence of
arthritis)?
Bursitis if inflammation of bursae; tendinitis if in tendons, and tenosynovitis
if in tendon sheaths; also sprains from
stretching or tearing of ligaments
Ask if there is decreased joint
movement or stiffness.
In articular pain, decreased active and
passive range of motion and morning
stiffness (“gelling”); in nonarticular joint
pain, periarticular tenderness and only
passive range of motion intact
Ac u t e o r C h ro n ic . Acute joint
Severe pain of rapid onset in red swollen
joint in acute septic arthritis or crystalline arthritis (gout; CPPD). In children,
osteomyelitis in bone contiguous to a
joint.
pain typically lasts up to 6 weeks;
chronic pain lasts >12 weeks. Assess
the timing, quality, and severity of
joint symptoms.
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Chapter 16 | The Musculoskeletal System
279
If from trauma, what was the mechanism of injury or series of events
that caused the joint pain? Furthermore, what aggravates or relieves
the pain? What are the effects of
exercise, rest, and treatment?
See Table 16-1, Patterns of Pain in and
Around the Joints, p. 304.
In f la m m a t o ry o r N o n in f la m m a t o ry. Is the problem inflamma-
If inflammatory, consider infectious
causes (Neisseria gonorrhoeae or Mycobacterium tuberculosis), crystal-induced
(gout, pseudogout), immune -related
(RA, SLE), reactive (rheumatic fever, reactive arthritis), or idiopathic arthritis. If
noninflammatory, consider trauma
(rotator cuff tear), repetitive use
(bursitis, tendinitis), OA, fibromyalgia.
tory or noninflammatory? Is there
fever, chills, tenderness, warmth,
or redness?
Assess any stiffness or limitations
of motion.
Morning stiffness that gradually
improves with activity in inflammatory
disorders like RA and PMR; intermittent
stiffness and gelling in OA
Lo c a liz e d o r D iff u s e . Ask the
Monoarticular arthritis in traumatic,
crystalline, or septic arthritis; oligoarticular arthritis gonorrhea or rheumatic
fever, connective tissue disease, and OA;
polyarthritis if may be viral or inflammatory from RA, SLE, or psoriasis
patient to point to the joints that
are painful to determine if joint
pain is be monoarticular, oligoarticular involving two to four joints,
or polyarticular.
J o in t P a in : A s s o c ia t e d
C o n s t it u t io n a l S y m p t o m s
a n d S y s t e m ic M a n if e s t a t io n s f ro m O t h e r O r g a n
S y s t e m s . Assess constitutional
symptoms such as fever, chills, rash,
fatigue, anorexia, weight loss, and
weakness.
Common in RA, SLE, PMR, and other
inflammatory arthritides. High fever and
chills suggest an infectious cause.
Ne c k P a in . Ask about location,
radiation into the shoulders or
arms, arm or leg weakness, bladder
or bowel dysfunction.
C7 or C6 spinal nerve compression from
foraminal impingement more common
than disc herniation. See Table 16-2,
Pains in the Neck, p. 305.
If the patient reports neck trauma,
common in motor vehicle accidents, ask about neck tenderness
and consider clinical decision rules
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that identify risk of cervical cord
injury (NEXUS criteria and
Canadian C-Spine Rule).
Lo w Ba c k P a in . There are
numerous clinical guidelines, but
most categorize low back pain into
three groups: nonspeci c (>90%),
nerve root entrapment with radiculopathy or spinal stenosis ( 5%),
and pain from a speci c underlying
disease (1% to 2%). Ask, “Do you
have any pains in your back?” and
“Is the pain in the midline over the
vertebrae, or off midline?”
See Table 16-3, Low Back Pain, pp. 306–
307. Midline back pa in in vertebral collapse, disc herniation, epidural abscess,
spinal cord compression, or spinal cord
metastases. Pain off the midline in muscle strain, sacroiliitis, trochanteric bursitis, sciatica, hip arthritis, renal conditions
such as pyelonephritis or renal stones
If the pain radiates into the legs,
ask about any associated numbness, tingling, or weakness. Ask
about history of trauma.
Scia tica if radicular gluteal and posterior
leg pain in the S1 distribution that
increases with cough or Valsalva
Check for bladder or bowel dysfunction.
Present in cauda equina syndrome from
S2–S4 tumor or disc herniation, especially if “saddle anesthesia”from perianal
numbness
Elicit any “red ags” for serious
underlying systemic disease.
R e d F la g s f o r Lo w B a c k P a in f r o m
U n d e r ly in g S y s t e m ic D is e a s e
●
●
●
●
●
●
●
●
●
●
Age <2 ye rs or >5 ye rs
History of c ncer
Unex l ined weight loss, fever, or decline in gener l he lth
P in l sting ore th n 1 onth or not res onding to tre t ent
P in t night or resent t rest
History of intr venous drug use, ddiction, or i
unosu ression
Presence of ctive infection or hu n i
unodeficiency virus (HIV) infection
Long-ter steroid ther y
S ddle nesthesi , bl dder or bowel incontinence
Neurologic sy to s or rogressive neurologic deficit
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281
Health Promotion and Counseling:
Evidence and Recommendations
Im p o r t a n t T o p ic s f o r H e a lt h P r o m o t io n
a n d C o u n s e lin g
●
●
●
●
Nutrition, weight, nd hysic l ctivity
Low b ck in
Osteo orosis: risk f ctors, screening, nd ssessing fr cture risk
Tre ting osteo orosis nd reventing f lls
Nu t rit io n , We ig h t , a n d P h ys ic a l Ac t ivit y. Good nutrition supplies the calcium and vitamin D needed for bone mineralization and bone
density, with supplements advised in selected age groups. Optimal weight
reduces excess mechanical stress on weight-bearing joints like the hips and
knees. Exercise helps maintain bone mass and improves outlook and stress
management.
P h y s ic a l A c t iv it y G u id e lin e s f o r A m e r ic a n s
●
●
At le st 2 hours nd 3
inutes week of oder te-intensity, or 1 hour
nd 15 inutes week of vigorous-intensity, aerobic physical activity, or n
equiv lent co bin tion
Moder te- or high-intensity muscle-strengthening activity th t involves ll jor
uscle grou s on 2 or ore d ys week
Lo w Ba ck P a in . The estimated lifetime prevalence of low back pain in
the U.S. population is over 80%. Most patients with acute low back pain
get better within 6 weeks; for patients with nonspeci c symptoms, clinical
guidelines emphasize reassurance, staying active, analgesics, muscle relaxants, and spinal manipulation therapy. About 10% to 15% of these patients
develop chronic symptoms, often associated with long-term disability. Poor
outcomes are linked to inappropriate beliefs about low back pain as a serious clinical condition, maladaptive pain-coping behaviors (avoiding work,
movement, or other activities for fear of causing back damage), multiple
nonorganic physical examination ndings, psychiatric disorders, poor
general health, high levels of baseline functional impairment, and low
work satisfaction.
O s t e o p o ro s is : Ris k Fa c t o r s , S c re e n in g , a n d As s e s s in g
Fra c t u r e Ris k . Osteoporosis is a major public health threat and a
common U.S. health problem—9% of adults over age 50 years have
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osteoporosis at the femoral neck or lumbar spine, including 16% of
women and 4% of men. Half of all postmenopausal women sustain an
osteoporosis-related fracture during their lifetime; 25% develop vertebral
deformities, and 15% suffer hip fractures that increase risk of chronic pain,
disability, loss of independence, and increased mortality.
The U.S. Preventive Services Task Force (USPSTF) gives a grade B recommendation supporting osteoporosis screening for women age ≥65 years
and for younger women whose 10-year fracture risk equals or exceeds that
of an average-risk 65-year-old white woman.
R is k F a c t o r s f o r O s t e o p o r o s is
●
●
●
●
●
●
●
●
Post eno us l st tus in wo en
Age ≥5 ye rs
Prior fr gility fr cture
Low body ss index
Low diet ry c lciu
Vit in D deficiency
Tob cco nd excessive lcohol use
F ily history of fr cture in firstdegree rel tive, rticul rly with
history of fr gility fr cture
●
●
Clinic l conditions such s thyrotoxicosis, celi c s rue, IBD, cirrhosis, chronic ren l dise se, org n
tr ns l nt tion, di betes, HIV,
hy ogon dis , ulti le yelo ,
norexi nervos , nd rheu tologic nd utoi
une disorders
Medic tions such s or l nd
high-dose inh led corticosteroids,
ntico gul nts (long-ter use),
ro t se inhibitors for bre st
c ncer, ethotrex te, selected
ntiseizure edic tions, i
unosu ressive gents, roton- u
inhibitors (long-ter use), nd
ntigon d l ther y for rost te
c ncer
■ Use the country-speci c FRAX calculator to assess fracture risk. If risk
is >9.3% for any fracture and >3% for hip fracture, bone density screening is warranted. The website for the FRAX Calculator for Assessing
Fracture Risk for the United States is http://www.shef.ac.uk/FRAX/tool.
jsp?country=9.
■ Use the World Health Organization scoring criteria to determine bone
density.
W o r ld H e a lt h O r g a n iz a t io n B o n e D e n s it y C r it e r ia
Osteoporosis: T score <−2.5 (>2.5 st nd rd devi tions below the
young dult white wo en)
Osteopenia: T score between −1.
dult e n)
e n for
nd −2.5 (1. to 2.5 SDs below the young
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Tre a t in g Os t e o p o ro s is a n d P re ve n t in g Fa lls . Learn the therapeutic uses of agents that inhibit bone resorption: calcium and vitamin D;
antiresorptive agents such as bisphosphonates, selective estrogen-receptor
modulators (SERMs), calcitonin, and postmenopausal estrogen; and
anabolic agents such as PTH.
More than one in three adults over age 65 years falls each year. Risk factors
for falls include increasing age, impaired gait and balance, postural hypotension, loss of strength, medication use, comorbid illness, depression,
cognitive impairment, and visual de cits.
The USPSTF gives a grade B recommendation for providing exercise or
physical therapy and/or vitamin D supplementation to prevent falls among
at-risk community-dwelling adults age ≥65 years. Effective exercise interventions target balance, gait, and strength training. Urge patients to correct
poor lighting, dark or steep stairs, chairs at awkward heights, slippery or
irregular surfaces, and ill- tting shoes. Scrutinize any medications affecting
balance, especially benzodiazepines, vasodilators, and diuretics.
Techniques of Examination
S t e p s f o r E x a m in in g t h e J o in t s
1. Ins ect for joint sy
etry, lign ent, bony defor ities, nd swelling
2. Ins ect nd l te surrounding tissues for skin ch nges, nodules, uscle
tro hy, tenderness
3. Assess r nge of otion nd
neuvers to test joint function nd st bility nd
the integrity of lig ents, tendons, burs e, es eci lly if in or tr u
4. Assess ny re s of infl
tion, es eci lly tenderness, swelling, w r th,
redness
Inspect and palpate any joints with signs of in ammation.
T h e F o u r S ig n s o f In f la m m a t io n
●
●
Swelling. P l ble swelling
y involve: (1) the synovi l e br ne, which c n
feel boggy or doughy; (2) effusion fro excess synovi l fluid within the joint
s ce; or (3) soft tissue structures, such s burs e, tendons, nd tendon
she ths.
Warmth. Use the b cks of your fingers to co
re the involved joint with its
un ffected contr l ter l joint, or with ne rby tissues if both joints re involved.
(continued )
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T h e F o u r S ig n s o f In f la m m a t io n
●
●
(Continued)
Redness. Redness of the overlying skin is the le st co
on sign of infl
tion ne r the joints nd is usu lly seen in ore su erfici l joints like fingers,
toes, nd knees.
Pain or tenderness. Try to identify the s ecific n to ic structure th t is tender.
EXAMINATIO N TECHNIQ UES
P O SSIBLE FIN DIN G S
T e m p o r o m a n d ib u la r J o in t
Inspect the temporomandibular
joint (TMJ) for swelling or redness.
Palpate the TMJ as the patient
opens and closes the mouth
(Fig. 16-1).
Palpate the muscles of mastication:
the masseters, temporal muscles, and
pterygoid muscles.
Fig ure 16-1 Palpate the TMJ.
S h o u ld e r s
Inspect the contour of the shoulders and shoulder girdles from
front and back.
Muscle atrophy; anterior or posterior
dislocation of humeral head; scoliosis if
shoulder heights asymmetric
See Table 16-4, Painful Shoulders, p. 308.
Palpate:
■ The clavicle from the sternocla-
“Step -offs”if fracture from trauma
vicular joint to the acromioclavicular joint (Fig. 16-2)
■ The bicipital tendon
Fig ure 16-2 Palpate the bicipital
groove and te ndon.
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■ The subacromial and subdeltoid
bursae after lifting arm posteriorly (Fig. 16-3)
S uba cromia l burs a
285
P O SSIBLE FIN DIN G S
Subacromial or subdeltoid bursitis; tenderness over the SITS (Supraspinatus,
Infraspinatus, Teres minor, and Subscap ularis) muscle insertions and difficulty
abducting the arm above shoulder level
occurs in sprains, tears, tendon rupture
of rotator cuff.
Rota tor cuff
Fig ure 16-3 Palpate the s ubacrom ial
burs a.
Assess range of motion.
■ Flexion—“Raise your arm in
front of you and overhead.”
■ Extension—“Move your arms
behind you.”
Intact glenohumeral motion if patient
raises arms to shoulder level, palms
facing down
Intact scapulothoracic motion if patient
raises arms an additional 60 degrees,
palms facing up
■ Abduction—“Raise your arms
out to the side and overhead.”
■ Adduction—“Cross your arm in
Acromioclavicular joint arthritis
front of your body, keeping the
arm straight.”
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■ External and internal rotation
P O SSIBLE FIN DIN G S
Shoulder arthritis
(Figs. 16-4 and 16-5)
Fig ure 16-4 Te s t abduction and
Fig ure 16-5 Te s t adduction and
exte rnal rotation.
inte rnal rotation.
Perform ve maneuvers to assess
the “SITS” muscles of the rotator
cuff and the bicipital tendon.
Pain or inability to perform these
maneuvers in rotator cuff sprains,
tendinitis, rupture
F iv e M a n e u v e r s f o r S IT S M u s c le A s s e s s m e n t
P a in P ro vo c a t io n Te s t
180º
Painful arc test (Fig. 16-6). Fully
dduct the tient’s r fro
to
18 degrees.
120º
No pa in
S uba cromia l
pa in
90ºº
S uba cromia l
pa in
60º
No pa in
0º
Fig ure 16-6 Painful arc te s t.
(continued )
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P O SSIBLE FIN DIN G S
F iv e M a n e u v e r s f o r S IT S M u s c le A s s e s s m e n t
(Continued)
S t r e n g t h Te s t s
●
External rotation lag test (Fig. 16-7).
With the tient’s r flexed to
9 degrees with l u , rot te
the r into full extern l rot tion.
9900 º
90º
fle
llee xio
io
on
200 º
a bduction
n
Fig ure 16-7 Inte rnal rotation lag te s t.
●
Internal rotation lag test (Fig. 16-8).
Ask the tient to l ce the dorsu
of the h nd on the low b ck with
the elbow flexed to 9 degrees.
Then you lift the h nd off the b ck,
which further intern lly rot tes the
shoulder. Ask the tient to kee
the h nd in this osition.
90
90º
fle xion
xion
Fig ure 16-8 Exte rnal rotation lag te st.
●
Drop-arm test (Fig. 16-9). Ask the
tient to fully bduct the r to
shoulder level, u to 9 degrees,
nd lower it slowly. Note th t
bduction bove shoulder level,
fro 9 to 12 degrees, reflects
ction of the deltoid uscle.
Fig ure 16-9 Drop arm te s t.
C o m p o s it e Te s t
External rotation resistance test
(Fig. 16-10). Ask the tient to dduct
nd flex the r to 9 degrees, with
the thu bs turned u . St bilize the
elbow with one h nd nd
ly ressure roxi l to the tient’s wrist
s the tient resses the wrist outw rd in extern l rot tion.
Fig ure 16-10 Exte rnal rotation
re s is tance te s t.
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P O SSIBLE FIN DIN G S
E lb o w s
Inspect and palpate:
■ Olecranon process
Olecranon bursitis; posterior dislocation
from direct trauma or supracondylar
fracture
■ Medial and lateral epicondyles
Tenderness distal to epicondyle in epicondylitis (medial → “tennis elbow”;
lateral → “pitcher’s elbow”)
■ Extensor surface of the ulna
Rheumatoid nodules
■ Grooves between the epicon-
Tender in arthritis
dyles and the olecranon
Ask patient to:
o˚
■ Flex and extend elbows
■ Turn forearms and palms up and
down (supination and pronation), as shown in Figure 16-11
S upina tion
P rona tion
Fig ure 16-11 Elbow s upination and
pronation.
W r is t s a n d H a n d s
Inspect:
■ Movement of the wrist ( exion,
Guarded movement in injury
extension, ulnar and medial
deviation), hands, and ngers
■ Contours of wrists, hands, and
ngers
■ Contours of palms
Asymmetric DIP, PIP deformities in OA;
symmetric deformities in PIP, MCP, wrist
joints in RA; swelling in arthritis, ganglia;
impaired alignment of fingers in flexor
tendon damage; flexion contractures in
Dupuytren contractures
Thenar atrophy in median nerve compression (carpal tunnel syndrome);
hypothenar atrophy in ulnar nerve
compression
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289
P O SSIBLE FIN DIN G S
Palpate:
■ Wrist joints (Fig. 16-12)
Swelling and tenderness in rheuma toid
a rthritis, gonococcal infection of joint or
extensor tendon sheaths
Fig ure 16-12 Palpate the
w ris t joint.
■ Distal radius and ulna
Tenderness over ulnar styloid in Colles
fracture
■ “Anatomic snuffbox,” the hollow
Tenderness suggests scaphoid fracture.
Tenderness over extensor and abductor
tendons in de Quervain tenosynovitis.
space distal to the radial styloid
bone; thumb extensor and
abductor tendons (Fig. 16-13).
Fig ure 16-13 Palpate the
anatom ic s nuffbox.
■ Metacarpophalangeal joints
Swelling in rheumatoid arthritis
(Fig. 16-14)
Fig ure 16-14 Palpate the
MCP joints .
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P O SSIBLE FIN DIN G S
■ Proximal and distal interphalan-
geal joint
Proximal nodules in RA; Bouchard (PIP)
and Heberden (DIP) nodes in OA
Assess range of motion:
■ Wrists: Flexion, extension,
Arthritis, tenosynovitis
adduction (radial deviation),
abduction (lateral deviation)
■ Fingers: Flexions, extension,
Trigger finger, Dupuytren contracture
abduction/adduction (spread
ngers apart and back)
■ Thumbs (Figs. 16-15 to 16-18)
Fig ure 16-15 Flexion.
Fig ure 16-16 Exte ns ion.
Fig ure 16-17 Abduction and adduction.
Figure 16-18 Opposition.
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P O SSIBLE FIN DIN G S
Perform selected maneuvers.
■ Hand grip strength (Fig. 16-19)
■ Thumb movement (Fig. 16-20)
Te ndon
Fig ure 16-19 Te s t grip s tre ngth.
Decreased grip strength if weakness of
finger flexors or intrinsic hand muscles
Fig ure 16-20 Te s t thum b function.
Pain if de Quervain tenosynovitis
■ Carpal tunnel testing
■
Thumb adduction (Fig. 16-21)
Fig ure 16-21 Te s t thum b abduction.
Weakness of abductor pollicis longus is
specific to the median nerve.
■
Tinel sign: Tap lightly over
median nerve at volar wrist
(Fig. 16-22)
Fig ure 16-22 Te s t Tine l s ign.
Aching, tingling, and numbness in
second, third, and fourth fingers is a
positive Tinel sign.
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■
P O SSIBLE FIN DIN G S
Phalen sign: Patient exes
wrists for 60 seconds
(Fig. 16-23)
Aching, tingling, and numbness in second, third, and fourth volar fingers is a
positive Phalen sign.
Fig ure 16-23 Te s t Phale n s ign.
S p in e
Inspect spine from the side and
back, noting any abnormal
curvatures.
Kyphosis, scoliosis, lordosis, gibbus, list
curvatures
Look for asymmetric heights of
shoulders, iliac crests, or buttocks.
Scoliosis, pelvic tilt, unequal leg length
Identify and palpate (Fig. 16-24):
S pinous proce s s
of L5 ve rte bra
Pa rave rte bra l
mus cle s
Inte rve rte bra l
joint be twe e n
L5 a nd s a crum
S a croilia c
notch
Pos te riors upe rior
ilia c s pine
S cia tic
ne rve
S a croilia c
joint
Is chia l tube ros ity
a nd s ite of
is chia l burs a
Fig ure 16-24 Palpate the bony landm arks and m us cle s of the back.
■ Spinous processes of each
vertebra
Tender if trauma, infection; “step -offs”in
spondylolisthesis, fracture
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P O SSIBLE FIN DIN G S
■ Sacroiliac joints
Sacroiliitis, ankylosing spondylitis
■ Paravertebral muscles, if painful
Paravertebral muscle spasm in abnormal
posture, degenerative and inflammatory
muscle disorders, overuse
■ Sciatic nerve (midway between
Herniated disc or nerve root compression
greater trochanter and ischial
tuberosity), Figure 16-25
S cia tic ne rve
Gre a te r trocha nte r
Is chia l tube ros ity
Fig ure 16-25 Palpate the s ciatic
ne rve .
Test the range of motion in the
neck and spine in: exion, extension, rotation, and lateral bending.
Decreased mobility in arthritis
H ip s
Inspect gait (Fig. 16-26) for:
He els trike
Foot flat
Mids ta nce
Fig ure 16-26 The s tance phas e of gait.
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P O SSIBLE FIN DIN G S
■ Stance (see Fig. 16-26) and swing
(foot moves forward, does not
bear weight)
■ Width of base (usually 2 to
Most problems arise during the weightbearing stance phase.
Cerebellar disease or foot problems if
wide base; impaired shift of pelvis in
arthritis, hip dislocation, abductor weakness; disrupted gait if poor knee flexion
4 inches from heel to heel),
shift of pelvis, exion of knee
Palpate:
■ Bony landmarks: anterior—iliac
crest and tubercle, anteriorsuperior iliac spine, greater
trochanter, pubic tubercle;
posterior—posterior-superior
iliac spine, greater trochanter,
ischial tuberosity, sacroiliac joint
■ Along the inguinal ligament.
Bulges in inguinal hernia, aneurysm
Identify the Nerve–Artery–
Vein–Empty space–Lymph
node (NAVEL).
■ The trochanteric bursa, on the
Focal tenderness in trocha nteric bursitis,
often described by patients as “low back
pain”
greater trochanter of the femur
(Fig. 16-27)
Trocha nte ric burs a
Is chioglute a l burs a
Fig ure 16-27 Trochante ric and is chioglute al burs ae .
■ The ischiogluteal bursa, super -
cial to the ischial tuberosity
Tender in bursitis (“weaver’s bottom”)
from prolonged sitting
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P O SSIBLE FIN DIN G S
Check range of motion, including:
■ Flexion—“Bend your knee and
pull it against your abdomen.”
(Fig. 16-28)
Flexion of opposite leg suggests
deformity of that hip.
Fig ure 16-28 Hip flexion and flatte ning
of lum bar lordosis .
■ Extension (Fig. 16-29)
Painful in iliopsoas abscess
Fig ure 16-29 Abduct the le g.
■ Abduction and adduction
Restricted in hip arthritis
■ Internal and external rotation
Restricted in hip arthritis
(Fig. 16-30)
Fig ure 16-30 Te st inte rnal and exte rnal
rotation of the hip.
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P O SSIBLE FIN DIN G S
Kn e e s
Identify the medial (Fig. 16-31)
and lateral structures of the knee.
Me dia l fe mora l
condyle
Adductor tube rcle
Pa te lla r te ndon
Me dia l tibia l
pla te a u
Me dia l fe mora l
e picondyle
Me dia l colla te ra l
liga me nt
Ans e rine burs a
Tibia l tube ros ity
Fig ure 16-31 Me dial com partm e nt of the kne e .
Inspect:
■ Gait for knee extension at heel
strike, exion during all other
phases of swing and stance
Stumbling or “giving way”during heel
strike in qua driceps weakness or abnormal patellar tracking
■ Alignment of knees
Bowlegs, knock-knees; flexion contractures in limb paralysis or hamstring
tightness.
■ Contours of knees, including
Quadriceps atrophy with patellofemoral
disorder; swelling over the patella in
prepatellar bursitis (housemaid’s knee),
over the tibial tubercle in infrapatellar or
if more medial anserine bursitis
any atrophy of the quadriceps
muscles
Inspect and palpate:
See Table 16-5, Painful Knees,
pp. 309–310.
■ The tibiofemoral joint—with
knees exed, including:
■
Joint line—place thumbs
on either side of the patellar
tendon.
Irregular, bony ridges in osteoarthritis.
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P O SSIBLE FIN DIN G S
■
Medial and lateral meniscus
Tenderness if meniscus tear
■
Medial and lateral collateral
ligaments
Tenderness if MCL tear (LCL injuries less
common)
■ The patellofemoral compart-
ment:
■
Patella
Swelling over the patella in prepatellar
bursitis (“housemaid’s knee”)
■
Palpate the patellar tendon
and ask patient to extend
the leg.
Tenderness or inability to extend the leg
in partial or complete tear of the patellar
tendon
■
Press the patella against the
underlying femur.
Pain, crepitus, and a history of knee pain
in patellofemoral disorder
■
Push patella distally and
ask patient to tighten knee
against table.
Pain during contraction of quadriceps in
chondroma lacia
■ Also:
■
Suprapatellar pouch
Swelling in synovitis and arthritis
■
Infrapatellar spaces (hollow
areas adjacent to patella)
Swelling in arthritis
■
Medial tibial condyle
Swelling in pes anserine bursitis
■
Popliteal surface
Popliteal or Baker cyst
Assess any effusions.
■ Bulge sign (minor effusions):
Compress the suprapatellar
pouch, stroke downward on
medial surface (Fig. 16-32),
apply pressure to force uid to
lateral surface (Fig. 16-33), and
then tap knee behind lateral
margin of patella (Fig. 16-34).
A fluid wave returning to the medial
surface after a lateral tap confirms an
effusion—a positive “bulge sign.”
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Fig ure 16-33 Apply m e dial pre s s ure .
Fig ure 16-32 Milk dow nward.
Fig ure 16-34 Tap and w atch for fluid w ave .
■ Balloon sign (major effusions):
A palpable fluid wave is a positive sign.
Compress suprapatellar pouch
with one hand; with thumb and
nger of other hand, feel for
uid entering the spaces next to
the patella (Fig. 16-35).
Fig ure 16-35 Te s t for the balloon
s ign.
■ Ballotte the patella (major effu-
Visible wave is a positive sign.
sion): Push the patella sharply
against the femur; watch for uid
returning to the suprapatellar
space.
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P O SSIBLE FIN DIN G S
Assess range of motion: exion,
extension, internal and external
rotation.
Use maneuvers to assess menisci
and ligaments.
■ Medial meniscus and lateral
meniscus—McMurray test
(Fig. 16-36): With the patient
supine, grasp the heel and
ex the knee. Cup your other
hand over the knee joint with
ngers and thumb along the
medial joint line. From the heel,
externally rotate the lower leg,
then push on the lateral side
to apply a valgus stress on the
medial side of the joint. Slowly
extend the lower leg in external
rotation.
The same maneuver with internal rotation stresses the lateral
meniscus.
■ Medial collateral ligament
(Fig. 16-37): With knee slightly
exed, push medially against
lateral surface of knee with
one hand and pull laterally at
the ankle with the other hand
(abduction or valgus stress).
Click or pop along the medial joint with
valgus stress, external rotation, and leg
extension in tear of posterior medial
meniscus.
Fig ure 16-36 McMurray te s t.
Pain or a gap in the medial joint line
points to a partial or complete MCL tear.
Fig ure 16-37 Me dial collate ral ligam e nt te s t.
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■ Lateral collateral ligament (LCL)
(Fig. 16-38): With knee slightly
exed, push laterally along
medial surface of knee with one
hand and pull medially at the
ankle with the other hand (an
adduction or varus stress).
P O SSIBLE FIN DIN G S
Pain or a gap in the lateral joint line
points to a partial or complete LCL tear.
Fig ure 16-38 Late ral collate ral ligam e nt te s t.
■ Anterior cruciate ligament (ACL)
(Fig. 16-39): (1) With knee
exed, place thumbs on medial
and lateral joint line and place
ngers on hamstring insertions.
Pull tibia forward, observe
if tibia slides forward “like a
drawer.” Compare to opposite
knee.
Forward slide of proximal tibia is a positive a nterior drawer sign in ACL laxity or
tear.
Fig ure 16-39 Ante rior cruciate ligam e nt te s t.
(2) Lachman test (Fig. 16-40):
Grasp the distal femur with
one hand and the proximal
tibia with the other (place the
thumb on the joint line). Move
the femur forward and the tibia
back.
Significant forward excursion of tibia in
ACL tear
Fig ure 16-40 Lachm an te s t.
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■ Posterior cruciate ligament
301
P O SSIBLE FIN DIN G S
Isolated PCL tears are rare.
(PCL): Posterior drawer sign
(Fig. 16-41): Position patient and
hands as in the ACL test. Push
the tibia posteriorly and observe
for posterior movement, like a
drawer sliding posteriorly.
Fig ure 16-41 Pos te rior cruciate ligam e nt te s t (pos te rior drawe r s ign).
A n k le s a n d F e e t
Inspect ankles and feet.
Hallux valgus, corns, calluses
Palpate:
■ Ankle joint
Tender joint in arthritis
■ Ankle ligaments: medial-deltoid;
Tenderness in sprain: lateral ligaments
weaker, making inversion injuries (ankle
bows outward, heel bows inward) more
common
lateral-anterior and posterior
talo bular, calcaneo bular
■ Achilles tendon
Rheumatoid nodules, tenderness in
tendinitis
■ Compress the metatarsophalan-
Tenderness in arthritis, Morton neuroma
third and fourth MTP joints; inflammation of first MTP joint in gout
geal joints; then palpate each joint
between the thumb and fore nger (Figs. 16-42 and 16-43).
Fig ure 16-42 Palpate the MTP joints .
Fig ure 16-43 Palpate the m e tatars al
he ads .
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P O SSIBLE FIN DIN G S
Assess range of motion.
■ Dorsi ex and plantar ex the
Arthritic joint often painful when moved
in any direction; sprain, when injured
ligament is stretched.
ankle (tibiotalar joint).
■ Stabilize the ankle and
Ankle sprain
invert (Fig. 16-44) and evert
(Fig. 16-45) the heel (subtalar
or talocalcaneal joint).
Fig ure 16-45 Eve rt the he e l.
Fig ure 16-44 Inve rt the he e l.
■ Stabilize the heel and invert
Trauma, arthritis
(Fig. 16-46) and evert
(Fig. 16-47) the forefoot
(transverse tarsal joints).
Fig ure 16-47 Eve rt the fore foot.
Fig ure 16-46 Inve rt the fore foot.
■ Move proximal phalanx of each
toe up and down (metatarsophalangeal joints).
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P O SSIBLE FIN DIN G S
S p e c ia l T e c h n iq u e s
Me a s u rin g Le g Le n g t h .
Patient’s legs should be aligned
symmetrically. With a tape, measure distance from anterior-superior iliac spine to medial malleolus.
Tape should cross knee medially.
Unequal leg length may be the cause of
scoliosis.
/
Me a s u rin g Ra n g e o f
Mo t io n . To measure range of
motion precisely, a simple pocket
goniometer is needed. Estimates
may be made visually. Movement
in the elbow at the right is limited
to range indicated by red lines
(Fig. 16-48).
A flexion deformity of 45 degrees
and further flexion to 90 degrees
(45 degrees → 90 degrees)
160 ˚
90 ˚
45 ˚
0˚
Figure 16-48 Degrees of elbow flexion.
Recording Your Findings
R e c o r d in g t h e M u s c u lo s k e le t a l S y s t e m
E x a m in a t io n
“Full r nge of otion in ll joints. No evidence of swelling or defor ity.”
OR
“Full r nge of otion in ll joints. H nd with degener tive ch nges of Heberden
nodes t the dist l inter h l nge l joints, Bouch rd nodes t roxi l inter h l nge l joints. Mild in with flexion, extension, nd rot tion of both hi s. Full
r nge of otion in the knees, with oder te cre itus; no effusion but boggy
synoviu
nd osteo hytes long the tibiofe or l joint line bil ter lly. Both feet
with h llux v lgus t the first et t rso h l nge l joints.” (These findings suggest osteoarthritis.)
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Table 16-1 P a t t e rn s o f P a in in a n d Aro u n d
t h e J o in t s
Rh e u m a t o id
A r t h r it is
O s t e o a r t h r it is
(D e g e n e r a t ive J o in t
D is e a s e , o r D J D )
P ro c e s s
Chronic inflammation
of synovial membranes
with secondary erosion
of adjacent cartilage
and bone, damage to
ligaments and tendons
Degeneration and
progressive loss of cartilage
within joints, damage
to underlying bone,
formation of new bone at
margins of cartilage
Co m m o n
Lo c a t io n s
Hands (proximal
interphalangeal and
metacarpophalangeal
joints), feet
(metatarsophalangeal
joints), wrists, knees,
elbows, ankles
Knees, hips, hands (distal,
sometimes proximal
interphalangeal joints),
cervical and lumbar spine,
and wrists (first
carpometacarpal joint);
also joints previously
injured or diseased
Pa tt e rn o f
S p re a d
Symmetrically additive:
progresses to other joints;
persists in initial ones
Additive; however,
sometimes only one joint
affected
On s e t
Usually insidious
Usually insidious
P ro g r e s s io n
and
D u r a t io n
Often chronic, with
remissions and
exacerbations
Slowly progressive, with
exacerbations after overuse
A s s o c ia t e d
S ym p t o m s
Frequent swelling of
synovial tissue in joints
or tendon sheaths; also
subcutaneous nodules
Small joint effusions may
be present, especially in
knees; also bony
enlargement
Tender, often warm but
seldom red
Tender, seldom warm or
red
Prominent stiffness,
often for >1 hour in
mornings
Frequent but brief stiffness
in the morning
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Table 16-2 P a in s in t h e Ne ck
Pa tt e rn s
P h y s ic a l S ig n s
M e c h a n ic a l N e c k P a in
Aching pain in the cervical paraspinal
muscles and ligaments with
associated muscle spasm, stiffness,
and tightness in the upper back and
shoulder, lasting up to 6 weeks. No
associated radiation, paresthesias, or
weakness. Headache may be present.
Local muscle tenderness, pain on
movement. No neurologic deficits.
Possible trigger points in
fibromyalgia. Torticollis if
prolonged abnormal neck posture
and muscle spasm.
M e c h a n ic a l N e c k P a in —
Wh ip la s h
Also mechanical neck pain with
aching paracervical pain and stiffness,
often beginning the day after injury.
Occipital headache, dizziness,
malaise, and fatigue may be present.
Chronic whiplash syndrome if
symptoms last more than 6 months,
present in 20–40% of injuries.
Localized paracervical tenderness,
decreased neck range of motion,
perceived weakness of the upper
extremities. Causes of cervical
cord compression such as fracture,
herniation, head injury, or altered
consciousness are excluded.
C e r v ic a l Ra d ic u lo p a t h y —
f ro m n e r ve ro o t c o m p r e s s io n
Sharp burning or tingling pain in the
neck and one arm, with associated
paresthesias and weakness. Sensory
symptoms often in myotomal
pattern, deep in muscle, rather than
dermatomal pattern.
C7 nerve root affected most often
(45–60%), with weakness in triceps
and finger flexors and extensors.
C6 nerve root involvement also
common, with weakness in biceps,
brachioradialis, wrist extensors.
C e r v ic a l M ye lo p a t h y —f ro m
c e r v ic a l c o r d c o m p r e s s io n
Neck pain with bilateral weakness
and paresthesias in both upper and
lower extremities, often with
urinary frequency. Hand clumsiness,
palmar paresthesias, and gait
changes may be subtle. Neck flexion
often exacerbates symptoms.
Hyperreflexia; clonus at the wrist,
knee, or ankle; extensor plantar
reflexes (positive Babinski signs);
and gait disturbances. May also see
Lhermitte sign: neck flexion with
resulting sensation of electrical
shock radiating down the spine.
Confirmation of cervical myelopathy
warrants neck immobilization and
neurosurgical evaluation.
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Table 16-3 Lo w Ba ck P a in
Pa tt e rn s
P h y s ic a l S ig n s
M e c h a n ic a l Lo w Ba c k P a in
Aching pain in lumbosacral area;
may radiate into lower leg, along
L5 or S1 dermatomes. Usually
acute, work related, in age group
30 to 50 years; no underlying
pathology
Paraspinal muscle or facet
tenderness, muscle spasm or pain
with back movement, loss of
normal lumbar lordosis but no
motor or sensory loss or reflex
abnormalities. In osteoporosis,
check for thoracic kyphosis,
percussion tenderness over a
spinous process, or fractures in the
thoracic spine or hip.
S c ia t ic a (Ra d ic u la r Lo w
Ba c k P a in )
Usually from disc herniation;
more rarely from nerve root
compression, primary or metastatic
tumor
Disc herniation most likely if calf
wasting, weak ankle dorsiflexion,
absent ankle jerk, positive crossed
straight-leg raise (pain in affected
leg when healthy leg tested);
negative straight-leg raise makes
diagnosis highly unlikely.
Lu m b a r S p in a l S t e n o s is
Pseudoclaudication pain in the
back or legs that improves with
rest, forward lumbar flexion. Pain
vague but usually bilateral, with
paresthesias in one or both legs;
usually from arthritic narrowing of
spinal canal
Posture may be flexed forward
with lower extremity weakness and
hyporeflexia; straight-leg raise
usually negative
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Table 16-3 Lo w Ba ck P a in (continued )
Pa tt e rn s
P h y s ic a l S ig n s
C h ro n ic Ba c k S t iff n e s s
Consider ankylosing spondylitis in
inflammatory polyarthritis, most
common in men younger than
40 years. Diffuse idiopathic skeletal
hyperostosis (DISH) affects men
more than women, usually age
older than 50 years.
Loss of the normal lumbar
lordosis, muscle spasm, limited
anterior and lateral flexion;
improves with exercise. Lateral
immobility of the spine, especially
thoracic segment
N o c t u r n a l Ba c k P a in ,
U n r e lie ve d b y Re s t
Consider metastasis to spine from
cancer of the prostate, breast, lung,
thyroid, and kidney, and multiple
myeloma.
Findings vary with the source.
Local vertebral tenderness may be
present.
P a in Re f e r r e d f ro m t h e
A b d o m e n o r P e lv is
Usually a deep, aching pain, the
level of which varies with the
source ( 2% of low back pain)
Spinal movements are not painful
and range of motion is not affected.
Look for signs of the primary
disorder, such as peptic ulcer,
pancreatitis, dissecting aortic
aneurysm.
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Table 16-4 P a in fu l S h o u ld e r s
Ac ro m io c la v ic u la r A r t h r it is
Tenderness over the
acromioclavicular joint, especially
with adduction of the arm across the
chest. Pain often increases with
shrugging the shoulders, due to
movement of scapula.
S u b a c ro m ia l a n d
S u b d e lt o id Bu r s it is
Pain over anterior-superior aspect of
shoulder, particularly when raising
the arm overhead. Tenderness
common anterolateral to the
acromion, in hollow recess formed
by the acromiohumeral sulcus. Often
seen in overuse syndromes.
Ro t a t o r C u ff Te n d in it is
Tenderness over the rotator cuff,
when elbow passively lifted
posteriorly or with five maneuvers
(pp. 286–287).
Bic ip it a l Te n d in it is
Tenderness over the long head of the
biceps when rolled in the bicipital
groove or when flexed arm is
supinated against resistance suggests
bicipital tendinitis.
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Table 16-5 P a in fu l Kn e e s
Arthritis . Degenerative arthritis usually
occurs after age 50; associated with
obesity. Often with medial joint line
tenderness, palpable osteophytes,
bowleg appearance, suprapatellar
bursae and joint effusion. Systemic
involvement, swelling, and
subcutaneous nodules in rheumatoid
arthritis.
Burs itis . Inflammation
and thickening of bursa
seen in repetitive motion
Iliotibia l
and overuse syndromes.
ba nd
Can involve prepatellar
bursa (“housemaid’s
knee”), pes anserine bursa
medially (runners, osteoarthritis),
iliotibial band laterally (over lateral
femoral condyle), especially in runners.
P re pa te lla r
burs a
Pes
a ns e rine
Pate llo fe m o ral ins tability. During
flexion and extension of knee, due to
subluxation and/or malalignment,
patella tracks laterally instead of
centrally in trochlear groove of femoral
condyle. Inspect or palpate for lateral
motion with leg extension. May lead to
chondromalacia, osteoarthritis.
P a te lla
move s up
a nd la te ra l
Le g e xte nds
a nd foot
ra is e s
La te ra l
me nis cus
Me dia l
me nis cus
torn
Me nis cal te ar. Commonly arises from
twisting injury of knee; in older patients
may be degenerative, often with
clicking, popping, or locking sensation.
Check for tenderness along joint line
over medial or lateral meniscus and for
effusion. May have associated tears of
medial collateral of anterior cruciate
ligaments.
(table continues on page 310)
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Table 16-5 P a in fu l Kn e e s (continued )
Ante rior
crucia te
liga me nt
torn
Me dia l
colla te ra l
liga me nt
torn
Ba ke r
cys t
P os te rior kne e
Ante rio r cruciate te ar o r s prain.
In twisting injuries of the knee, often
with popping sensation, immediate
swelling, pain with flexion/extension,
difficulty walking, and sensation of
knee “giving way.” Check for anterior
drawer sign, swelling of hemarthrosis,
injuries to medial meniscus or medial
collateral ligament. Consider evaluation
by an orthopedic surgeon.
Co llate ral ligam e nt s prain o r te ar.
From force applied to medial or lateral
surface of knee (valgus or varus stress),
producing localized swelling, pain,
stiffness. Patients able to walk but
may develop an effusion. Check for
tenderness over affected ligament and
ligamentous laxity during valgus or
varus stress.
Bake r cys t. Cystic swelling palpable
on the medial surface of the popliteal
fossa, prompting complaints of aching
or fullness behind the knee. Inspect,
palpate for swelling adjacent to medial
hamstring tendons. If present, suggests
involvement of posterior horn of medial
meniscus. In rheumatoid arthritis, cyst
may expand into calf or ankle.
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17
C H A P T E R
The Nervous System
Fundamentals for Assessing
the Nervous System
A pproa ch to A s s e s s m e nt
The history and neurologic examination respond to four guiding questions.
These questions are not answered separately, but iteratively as you learn
about the patient during the interview and establish your neurologic ndings. To acquire the skills of nervous system examination, it is important to
test your physical ndings against those of your teachers and neurologists
to re ne your clinical expertise.
G u id in g Q u e s t io n s f o r E x a m in a t io n o f t h e
N e rvous S y s te m
●
●
●
●
Does the tient h ve neurologic dise se?
If so, wh t is the loc liz tion of the lesion or lesions? Are your findings
sy
etric?
Wh t is the tho hysiology of bnor l findings?
Wh t is the reli in ry differenti l di gnosis?
C e n t r a l a n d P e r ip h e r a l N e r v o u s S y s t e m s
Ce n t ra l Ne r vo u s S ys t e m . The central nervous system (CNS) consists
of the brain and spinal cord.
Th e Br a in . The brain has four regions: the cerebrum, the diencephalon,
the brainstem, and the cerebellum (Fig. 17-1). Each cerebral hemisphere is
subdivided into frontal, parietal, temporal, and occipital lobes. The brain
consists of gray matter and myelinated neuronal axons, or white matter.
Important structures include the basal ganglia, the thalamus, the hypothalamus, the brainstem (midbrain, pons, and medulla), which connects the
cortex with the spinal cord, the reticular activating (arousal) system linked to
consciousness, and the cerebellum.
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Frontal lobe
Pa rieta l lobe
Oc cipital lobe
Diencephalon
Pituitary gland
Midbrain
Brains tem
Ce rebellum
Pons
Me dulla
Fig ure 17-1 Right half of the brain, m e dial view.
S p in a l C o r d . The spinal cord extends from the medulla to the first or
second lumbar vertebrae. The spinal cord:
■ is divided into ve segments: cervical (C1–C8), thoracic (T1–T12),
lumbar (L1–L5), sacral (S1–S5), and coccygeal. Its roots fan out like a
horse’s tail at L1–L2, the cauda equina.
■ contains important motor and sensory nerve pathways that exit and
enter the cord via anterior and posterior nerve roots and spinal and
peripheral nerves.
■ mediates the monosynaptic muscle stretch re exes.
P e rip h e ra l Ne r vo u s S ys t e m . The peripheral nervous system consists
of the 12 pairs of cranial nerves and the spinal and peripheral nerves. Most
peripheral nerves contain both motor and sensory bers.
C r a n ia l N e r ve s . The twelve pairs of cranial nerves (CNs) emerge from
the cranial vault through skull foramina and canals to structures in the head
and neck. Some are limited to general motor and/or sensory functions,
whereas others are specialized, serving smell, vision, or hearing (I, II, VIII).
P e r ip h e r a l N e r ve s . Thirty-one pairs of nerves carry impulses to and
from the cord: 8 cervical, 12 thoracic, 5 lumbar, 5 sacral, and 1 coccygeal.
Each nerve has an anterior (ventral) root containing motor fibers, and a
posterior (dorsal) root containing sensory fibers. These merge to form a
short (<5 mm) spinal nerve. Spinal nerve fibers commingle with similar
fibers in plexuses outside the cord—from these emerge peripheral nerves.
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The Health History
C o m m o n o r C o n c e r n in g S y m p t o m s
●
●
●
●
●
●
●
He d che
Dizziness or vertigo
We kness (gener lized, roxi l, or dist l)
Nu bness, bnor l or lost sens tions
F inting or bl cking out (ne r-synco e nd synco e)
Seizures
Tre ors or involunt ry ove ents
He a d a c h e . Ask about location,
severity, duration, and any associated
symptoms, such as visual changes,
weakness, or loss of sensation.
Always elicit unusual headache
warning signs, such as sudden onset
“like a thunderclap,” onset after age
50 years, and associated symptoms
such as fever and stiff neck, which
warrant examination for papilledema
and focal neurologic signs.
See Table 7-1, Primary Headaches,
p. 128, and Table 7-2, Secondary Headaches, pp. 129–131. Subarachnoid hemorrhage may evoke “the worst headache
of my life.”Dull headache especially on
awakening and in the same location,
especially when affected by examination
maneuvers, may arise from mass lesions
like a brain tumor or abscess.
Dizzin e s s o r Ve rt ig o . Dizziness
or vertigo can have many meanings. Is the patient lightheaded or
feeling faint (presyncope)? Is there
unsteady gait from disequilibrium
or ataxia, or true vertigo, a perception that the room is spinning or
rotating?
Lightheadedness in palpitations; nearsyncope from vasovagal stimulation, low
blood pressure, febrile illness, and others; vertigo in benign positional vertigo,
Ménière disease, brainstem tumor
Are any medications contributing
to dizziness?
Are associated symptoms present,
such as double vision (diplopia),
dif culty forming words (dysarthria), or dif culty with gait
or balance (ataxia)? Is there any
weakness?
Diplopia, dysarthria, ataxia in vertebrobasilar transient ischemic a ttack (TIA) or
stroke
See Table 17-1, Types of Stroke, pp. 335–
336, and Table 17-2, Disorders of Speech,
pp. 347–348.
Weakness or paralysis in TIA or stroke
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We a k n e s s . Distinguish proximal
from distal weakness. For proximal
weakness, ask about combing hair,
reaching for things on a high shelf,
dif culty getting out of a chair or
taking a high step up.
Bilateral proximal limb weakness with
intact sensation in myopathies from
alcohol, drugs like glucocorticoids, and
inflammatory muscle disorders like
polymyositis and dermatomyositis
For distal weakness, ask about hand
movements such as opening a jar
or can or using hand tools (e.g.,
scissors, pliers, screwdriver). Ask
about frequent tripping.
Bilateral predominantly distal weakness,
often with sensory loss, in polyneuropathy, as in diabetes
S e n s o ry Lo s s . Is there any loss
of sensation or altered sensation
such as tingling or pins and needles
without an obvious stimulus (paresthesias)? Dysesthesias, or disordered sensations in response to a
stimulus, may last longer than the
stimulus itself.
Consider: paresthesias in hands and
around the mouth in hyperventilation;
local nerve compression or “entrap ment,”seen in hand numbness from
median, ulnar, or radial nerve disorders;
nerve root compression with dermatomal sensory loss from vertebral bone
spurs or herniated discs; or central
lesions from stroke or multiple sclerosis.
S yn c o p e . “Have you ever fainted
or passed out?” leads to discussion
of any loss of consciousness (syncope).
Syncope is complete but temporary loss
of consciousness from decreased cerebral
blood flow, commonly called fainting.
Get a complete description of the
event including setting and triggers, any warning signs, position
(standing, sitting, lying down), and
duration. What brought on the episode? Could voices be heard while
passing out and coming to? How
rapid was recovery? Were onset
and offset slow or fast?
Young people with emotional stress and
warning symptoms of flushing, warmth,
or nausea may have vasodepressor (or
vasovagal) syncope of slow onset, slow
offset.
In myasthenia gravis, weakness is asymmetric and gets worse with effort
(fatigability), and often has bulbar
symptoms such as diplopia, ptosis,
dysarthria, and dysphagia.
Consider:
vasovagal syncope, postural tachycardia syndrome, carotid sinus syncope,
and orthostatic hypotension
tachycardia and bradyarrhythmias,
often with syncope of sudden onset
and offset
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Also ask if anyone observed the
episode. What did the patient look
like before, during, and after the
episode? Was there any seizure-like
movement of the arms or legs?
Any incontinence of the bladder
or bowel?
S e izu re . A seizure is a sudden
excessive electrical discharge from
cortical neurons, and may be
symptomatic, with an identi able
cause, or idiopathic. Elicit a careful
history.
Tre m o r s o r In vo lu n t a ry
Mo ve m e n t s . Ask about any
tremor, shaking, or body movements that the patient is unable
to control. Does the tremor occur
at rest? Get worse with voluntary
intentional movement or with
sustained postures?
315
Tonic–clonic motor activity, incontinence, and postictal state
seizures. Unlike in syncope, tongue
biting or bruising of limbs may occur.
may be loss of consciousness or abnormal feelings, thought processes, and
sensations, including smells, as well as
abnormal movements.
head trauma; alcohol, cocaine, and other
insults from low or high glucose or low
calcium or sodium; acute stroke; and
meningitis or encephalitis.
Low-frequency unilateral resting tremor,
rigidity, and bradykinesia in Parkinson
disease.
Essential tremors if high-frequency,
bilateral, upper extremity tremors that
occur with both limb movement and
sustained posture and subside when the
limb is relaxed.
Health Promotion and Counseling:
Evidence and Recommendations
Im p o r t a n t T o p ic s f o r H e a lt h P r o m o t io n
a n d C o u n s e lin g
●
●
●
●
●
Preventing stroke nd tr nsient ische ic tt ck (TIA)
C rotid rtery screening
Reducing risk of eri her l neuro thy
Her es zoster v ccin tion
Detecting the “three Ds”: deliriu , de enti , nd de ression
P re ve n t in g S t ro k e o r TIA. Cerebrovascular disease is the fourth
leading cause of death in the United States. Stroke is a sudden neurologic
de cit caused by cerebrovascular ischemia (87%) or hemorrhage (13%).
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Hemorrhagic strokes may be intracerebral (10% of all strokes) or subarachnoid (3% of all strokes). Decreased vascular perfusion results in sudden
focal but transient brain dysfunction in TIA, or in permanent neurologic
de cits in stroke, as determined by neurodiagnostic imaging. Detecting
TIAs is important—in the rst 3 months after a TIA, subsequent stroke
occurs in approximately 15% of patients.
A H A / A S A S t r o k e W a r n in g S ig n s a n d S y m p t o m s
F
A
S
T
Face Drooping—Does one side of the f ce droo or is it nu b? Ask the
erson to s ile. Is the erson’s s ile uneven?
Arm Weakness—Is one r we k or nu b? Ask the erson to r ise both
r s. Does one r drift downw rd?
Speech Difficulty—Is s eech slurred? Is the erson un ble to s e k or
h rd to underst nd? Ask the erson to re e t si le sentence, like
“The sky is blue.” Is the sentence re e ted correctly?
Time to call 9-1-1—If so eone shows ny of these sy to s, even if the
sy to s go w y, c ll 9-1-1 nd get the erson to the hos it l i
editely. Check the ti e so you’ll know when the first sy to s
e red.
Beyond FAST: Other i
●
●
●
●
●
ort nt sy
to s
Sudden nu bness or we kness of the leg, r , or f ce
Sudden confusion or trouble underst nding
Sudden trouble seeing in one or both eyes
Sudden trouble w lking, dizziness, loss of b l nce or coordin tion
Sudden severe he d che with no known c use
AHA, A eric n He rt Associ tion; ASA, A eric n Stroke Associ tion.
Primary prevention of stroke requires aggressive management of risk factors
and patient education.
■ Target modi able risk factors: hypertension, smoking, dyslipidemia,
excess weight, diabetes, poor diet and nutrition, physical inactivity, and
alcohol use.
■ Address disease-speci c risk factors: atrial brillation, carotid artery
disease, and sleep apnea.
Ca ro t id Ar t e ry S c re e n in g . Screen symptomatic patients with duplex
ultrasound. The U.S. Preventive Services Task Force recommends against
screening asymptomatic patients in the general population.
Re d u c in g Ris k o f P e rip h e ra l Ne u ro p a t h y. In diabetics, promote
optimal glucose control to reduce risk of sensorimotor polyneuropathy,
autonomic dysfunction, mononeuritis multiplex, or diabetic neuropathy.
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Examine diabetics regularly for neuropathy, including testing pinprick
sensation, ankle re exes, vibration perception (with a 128-Hz tuning fork)
and plantar light touch sensation (with a Semmes-Weinstein mono lament), as well as checking for skin breakdown, poor circulation, and
musculoskeletal abnormalities.
He rp e s Zo s t e r Va c c in a t io n . The herpes zoster vaccine reduces the
short-term risks for zoster and postherpetic neuralgia in adults ≥50 years.
The Advisory Committee on Immunization Practices (ACIP) currently
recommends routinely offering onetime vaccination for adults ≥60 years;
the vaccine is FDA-approved for adults ≥50 years.
De t e c t in g t h e “ Th re e Ds ” : De liriu m , De m e n t ia , a n d
De p re s s io n . Delirium is an acute confusional state marked by sudden
onset, uctuating course, inattention and changes in the level of consciousness; it is often undetected. Learn to use the Confusional Assessment
Method (CAM) algorithm.
T h e C o n f u s io n A s s e s s m e n t M e t h o d (C A M )
D ia g n o s t ic A lg o r it h m
1. Acute ch nge in ent l st tus nd fluctu ting course
● Is there evidence of n cute ch nge in cognition fro
b seline?
● Does the
bnor l beh vior fluctu te during the d y?
2. In ttention
● Does the
tient h ve difficulty focusing ttention?
3. Disorg nized thinking
● Does the
tient h ve r bling or irrelev nt convers tions, uncle r or
illogic l flow of ide s, or un redict ble switching fro subject to subject?
4. Abnor l level of consciousness
● Is the
tient nything besides lert—hy er lert, leth rgic, stu orous, or
co tose?
Di gnosing deliriu
requires fe tures 1 nd 2 nd either 3 or 4.
Dementia is best assessed by the Mini-Mental State examination and the
Mini-Cog (see Chapter 20, Table 20-3, p. 420), but may be dif cult to
distinguish from benign forgetfulness and mild cognitive impairment.
Depression is common in individuals with signi cant medical conditions.
Ask the well-validated screening questions: “Have you been feeling down,
depressed, or hopeless (depressed mood)?” and, “Have you felt little
interest or pleasure in doing things (anhedonia)?”
See also Chapter 20, The Older Adult, pp. 405–406, and Table 20-2,
Delirium and Dementia, pp. 418–419.
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Techniques of Examination
C r a n ia l N e r v e s a n d F u n c t io n
No .
C r a n ia l N e r ve
Fu n c t io n
I
II
III
Olf ctory
O tic
Oculo otor
IV
V
Trochle r
Trige in l
VI
VII
Abducens
F ci l
VIII
Acoustic
IX
Glosso h rynge l
X
V gus
XI
S in l ccessory
XII
Hy ogloss l
Sense of s ell
Vision
Pu ill ry constriction, o ening the eye (lid elev tion),
ost extr ocul r ove ents
Downw rd, intern l rot tion of the eye
Motor—te or l nd
sseter uscles (j w clenching), l ter l terygoids (l ter l j w ove ent)
Sensory—f ci l; the nerve h s three divisions:
(1) o hth l ic, (2) xill ry, nd (3) ndibul r
L ter l devi tion of the eye
Motor—f ci l ove ents, including those of f ci l
ex ression, closing the eye, closing the outh
Sensory—t ste for s lty, sweet, sour, nd bitter
subst nces on nterior two thirds of tongue;
sens tion fro the e r
He ring (cochle r division) nd b l nce (vestibul r
division)
Motor— h rynx
Sensory— osterior ortions of the e rdru
nd e r
c n l, the h rynx, nd the osterior tongue,
including t ste (s lty, sweet, sour, bitter)
Motor— l te, h rynx, nd l rynx
Sensory— h rynx nd l rynx
Motor—sternocleido stoid; u er ortion of the
tr ezius
Motor—tongue
EXAMINATIO N TECHNIQ UES
P O SSIBLE FIN DIN G S
C r a n ia l N e r v e s
CN I (Olfa c t o ry). Test sense of
smell on each side.
Loss of smell in sinus conditions, head
trauma, smoking, aging, cocaine use,
Parkinson disease
CN II (Op t ic ). Assess visual
acuity.
Blindness
Check visual elds.
Hemianopsia
Inspect optic discs.
Papilledema, optic atrophy, glaucoma
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EXAMINATIO N TECHNIQ UES
319
P O SSIBLE FIN DIN G S
CN II, III (Op t ic a n d Oc u lo m o t o r). Test pupillary reactions to
light. If abnormal, test reactions to
near effort.
Blindness, CN III paralysis, tonic pupils;
Horner syndrome may affect light
reactions
CN III, IV, VI (Oc u lo m o t o r,
Tro c h le a r, a n d Ab d u c e n s ).
Assess extraocular movements.
Strabismus and binocular diplopia in CN
III, IV, and VI neuropathy; diplopia in eye
muscle disorders from myasthenia gravis, trauma, thyroid ophthalmopathy,
and internuclear ophthalmoplegia;
nystagmus
CN V (Trig e m in a l). Palpate the
contractions of temporal and masseter muscles. Test pain and light
touch sensations on face in
(1) ophthalmic, (2) maxillary, and
(3) mandibular zones (Fig. 17-2).
Motor or sensory loss from lesions of CN V
or its higher motor pathways.
(1)
C2
(2)
(3)
Figure 17-2 Te st for facial sensory loss.
Test corneal re exes (Fig. 17-3).
Fig ure 17-3 Te s t the corne al re flex.
CN VII (Fa c ia l). Ask patient to
raise both eyebrows, frown, close
eyes tightly, show teeth, smile, and
puff out cheeks.
Weakness from lesion of peripheral
nerve, as in Bell palsy, or of CNS, as in a
stroke. See Table 17-3, Types of Facial
Paralysis, p. 339.
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CN VIII (Ac o u s t ic ). Test hearing
of whispered voice. If decreased:
■ Test for lateralization if unilateral
hearing loss (Weber test).
In unilateral sensorineural loss, sound is
heard in the good ear where AC > BC.
affected ear where BC > AC. See p. 125.
■ Compare air and bone conduction
(Rinne test).
CN IX, X (Glo s s o p h a ryn g e a l
a n d Va g u s ). Observe any
dif culty swallowing.
In sensorineural hearing loss, sound is
heard longer through air than bone
(AC > BC). In conductive loss sound is
heard through bone longer than air
(BC = AC or BC > AC). See p. 125.
A weakened palate or pharynx impairs
swallowing.
Listen to the voice.
Hoarseness in vocal cord paralysis; nasal
voice in paralysis of palate
Watch soft palate rise with “ah.”
Deviated uvula, palatal paralysis in CVA
Test gag re ex on each side.
Absent reflex is often normal.
CN XI (S p in a l Ac c e s s o ry).
Trapezius muscles. Assess muscles for
bulk, involuntary movements, and
strength of shoulder shrug
(Fig. 17-4).
Atrophy, fasciculations, weakness
Fig ure 17-4 Te s t trape zius s tre ngth.
Sternocleidomastoid muscles. Assess
strength as head turns against your
hand.
Weakness of sternocleidomastoid muscle when head turns to opposite side
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CN XII (Hyp o g lo s s a l). Listen
to patient’s articulation.
Dysarthria from damage to CN X or CN XII
Inspect the resting tongue.
Atrophy, fasciculations in ALS, polio
Inspect the protruded tongue.
In a unilateral cortical lesion, the protruded tongue deviates away from the
side of cortical lesion; in CN XII lesion,
tongue deviates to the weak side.
/
Th e M o t o r
System
See Table 17-4, Motor Disorders, p. 340.
Bo d y P o s it io n . Observe the
patient’s body position during
movement and at rest.
Hemiplegia in stroke
In vo lu n t a ry Mo ve m e n t s . If
present, observe location, quality, rate, rhythm, amplitude, and
setting.
Tremors, fasciculations, tics, chorea,
athetosis, oral–facial dyskinesias. See
Table 17-5, Involuntary Movements,
p. 341.
Mu s c le Bu lk a n d To n e . Inspect
muscle contours.
Atrophy of bulk. See Table 17-6, Disorders of Muscle Tone, p. 342.
Assess resistance to passive stretch
of arms and legs.
Spasticity, rigidity, flaccidity of tone
Mu s c le S t re n g t h . Test and grade the major muscle groups, with the
examiner trying to overcome the strength of the patient’s resistance.
Is the pattern focal, from a lower motor neuron lesion in peripheral nerve
or nerve root? Is there unilateral paralysis from an upper motor neuron
cortical or subcortical lesion? Is there a symmetric distal weakness from
polyneuropathy, or proximal weakness from myopathy?
G r a d in g M u s c le S t r e n g t h
Gra d e
1
2
3
4
5
D e s c r ip t io n
No uscul r contr ction detected
A b rely detect ble tr ce of contr ction
Active ove ent with gr vity eli in ted
Active ove ent g inst gr vity
Active ove ent g inst gr vity nd so e resist nce
Active movement against full resistance (normal)
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■ Flexion (C5, C6)—biceps and
brachioradialis and extension
(C6, C7, C8)—triceps at the
elbow
■ Wrist extension (C6, C7, C8,
Peripheral radial nerve damage; central
stroke or multiple sclerosis if hemiplegia
radial nerve)—extensor carpi
radialis longus and brevis
■ Grip (C7, C8, T1)
Weak grip in cervical radiculopathy, de
Quervain tenosynovitis, carpal tunnel
syndrome
■ Finger abduction (C8, T1, ulnar
Weak in ulnar nerve disorders
nerve) (Fig. 17-5)
Fig ure 17-5 Te s t finge r abduction.
■ Thumb opposition (C8, T1)—
Weak in carpal tunnel syndrome
median nerve (Fig. 17-6)
Fig ure 17-6 Te st oppos ition of the
thum b.
■
Trunk— exion extension,
lateral bending
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■
323
P O SSIBLE FIN DIN G S
/
Hip exion (L2, L3,
L4)—iliopsoas (Fig. 17-7)
■ Hip extension (S1)—gluteus
maximus
■ Hip adduction (L2, L3, L4)—
adductors
■ Hip abduction (L4, L5, S1)—
Fig ure 17-7 Te s t hip flexion.
gluteus medius and minimus
■ Knee extension (L2, L3, L4)—
quadriceps
■ Knee exion (L4, L5, S1, S2)—
hamstrings
■ Ankle dorsi exion (L4, L5)—
tibialis anterior
■ Ankle plantar exion (S1)—
gastrocnemius, soleus
Co o rd in a t io n . Test rapid alternating movements in hands (tap
ngers), arms, and legs (tap foot)
(Fig. 17-8)
Clumsy, slow movements in cerebellar
disease
Fig ure 17-8 Te s t rapid alte rnating arm
m ove m e nt.
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Point-to-point movements in arms
and legs— nger-to-nose, heel-toshin
Clumsy, unsteady movements in
cerebellar disease
G a it . Ask patient to:
■ Walk away, turn, and come back
CVA, cerebellar ataxia, parkinsonism,
or loss of position sense may affect
performance.
■ Walk heel-to-toe
Ataxia
■ Walk on toes, then on heels
Corticospinal tract injury
■ Hop in place on each foot; do
Proximal hip girdle weakness increases
risk of falls.
one-leg shallow knee bends.
Substitute rising from a chair
and climbing on a stool for hops
and bends as indicated.
Stance
■ Do a Romberg test (a sensory
Loss of balance when eyes are closed is a
positive Romberg test, suggesting poor
position sense.
test of stance). Ask patient to
stand with feet together and
eyes open, then closed for
20 to 30 seconds. Mild swaying
may occur. Stand close by to
prevent falls.
■ Inspect for a pronator drift as
Flexion and pronation at elbow and
downward drift of arm from contra lateral corticospinal tract lesion (Fig. 17-10)
patient holds arms forward,
with eyes closed, for 20 to
30 seconds (Fig. 17-9).
Fig ure 17-10 Pos itive te s t for pronator
Fig ure 17-9 Te s t for pronator drift.
drift.
Ask patient to keep arms up and
tap them downward. A smooth
return to position is normal.
Weakness, incoordination, poor position
sense
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P O SSIBLE FIN DIN G S
/
Th e S e n s o r y S y s t e m
Use an object like a sharp pin or
stick portion of a broken cotton
swab to test sharp and dull sensation; compare symmetric areas on the
A hemisensory loss pattern suggests a
contralateral cortical lesion.
two sides of the body. Do not reuse
the object on another patient.
Compare proximal and distal areas
of arms and legs for pain, temperature, and touch sensation. Scatter
stimuli to sample most dermatomes
and major peripheral nerves.
“Glove-and-stocking”loss of peripheral
neuropathy, often seen in alcoholism
and diabetes
Map any area of abnormal
response, including dermatomes,
if present.
Dermatomal sensory loss in herpes
See Table 17-7, Dermatomes, pp. 343–
344.
Assess response to the following
stimuli, with the patient’s eyes
closed.
■ Pain. Use the sharp end of a pin
Analgesia, hypalgesia, hyperalgesia
or other suitable tool. The dull
end serves as a control.
■ Temperature (if indicated). Use
test tubes with hot and cold
water, or other objects of suitable temperature.
■ Light touch. Use a ne wisp of
Temperature and pain sensation usually
correlate.
Anesthesia, hyperesthesia
cotton.
Test for vibration and proprioception
(joint position sense). If responses
are abnormal, test more proximally.
Vibration and position senses, both
carried in the posterior columns,
often correlate.
Loss of vibration and position senses in
peripheral neuropathy from diabetes or
alcoholism and in posterior column disease from tertiary syphilis or vitamin B12
deficiency
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■ Vibration. Use a 128-Hz tuning
fork, held on a bony prominence
at the ankle and wrist (Fig. 7-11).
Fig ure 17-11 Te s t vibration s e ns e .
■ Proprioception (joint position
sense). Holding patient’s nger or
big toe by its sides, move it up
or down (Fig. 17-12).
Fig ure 17-12 Te s t proprioce ption.
Assess discriminative sensations:
■ Stereognosis. Ask for identi ca-
Lesions in the posterior columns or
sensory cortex impair stereognosis,
number identification, and two-point
discrimination.
tion of a common object placed
in patient’s hand.
■ Number identi cation (graphes-
thesia). Draw a number on
patient’s palm with blunt end
of a pen and ask the patient to
identify the number.
■ Two-point discrimination (Fig. 17-13).
Use two pins of the sides of a
paper clip to nd minimal distance on pad of patient’s nger at
which two points can be distinguished (normally <5 mm).
Fig ure 17-13 Te s t two-point dis crim ination.
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■ Point localization. Touch skin
brie y, and ask patient to open
both eyes and identify the place
touched.
327
P O SSIBLE FIN DIN G S
A lesion in the sensory cortex may
lateral side and cause contralateral
extinction of the touch sensation.
■ Extinction. Simultaneously touch
opposite, corresponding areas
of the body; ask whether the
patient feels one touch or two.
/
R e f le x e s
Hold the re ex hammer loosely
between your thumb and index nger so that it swings freely in an arc
within the limits set by your palm
and other ngers. Use the common
grading system below.
Hyperactive deep tendon reflexes,
absent abdominal reflexes, and a
positive Babinski response in upper
motor neuron lesions.
G r a d in g R e f le x e s
Gra d e
4+
3+
2+
1+
D e s c r ip t io n
Hy er ctive (clonus ust be resent)
Brisker th n ver ge, not necess rily bnor
Average, normal
Di inished, low nor l
No res onse
Biceps (C5, C6) (Fig. 17-14)
l
Triceps (C6, C7) (Fig. 17-15)
Fig ure 17-14 Bice ps re flex—patie nt
s itting.
Fig ure 17-15 Trice ps re flex—patie nt
s itting.
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Brachioradialis (C5, C6)
(Fig. 17-16)
P O SSIBLE FIN DIN G S
/
Quadriceps (patellar)
(L2, L3, L4) (Fig. 17-17)
Fig ure 17-17 Quadrice ps (pate llar)
re flex.
Fig ure 17-16 Brachioradialis re flex.
Achilles (ankle) (S1) (Fig. 17-18)
Check for clonus if re exes seem
hyperactive (Fig. 17-19).
Fig ure 17-18 Achille s re flex—patie nt
Fig ure 17-19 Te s t for ankle clonus .
s itting.
Ankle jerks symmetrically, decreased or
absent in peripheral polyneuropathy;
slowed ankle jerk in hypothyroidism.
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P O SSIBLE FIN DIN G S
C u t a n e o u s o r S u p e r f ic ia l S t im u la t io n
R e f le x e s
Abdominal re exes (upper T8,
T9, T10; lower T10, T11, T12)
(Fig. 17-20)
May be absent in both central and
peripheral nerve disorders
Fig ure 17-20 Te s t the abdom inal
re flexe s .
Plantar response (L5, S1), normally
exor (Fig. 17-21)
Babinski extensor response (big toe
fans up) from corticospinal tract lesion
(Fig. 17-22)
Fig ure 17-21 Te s t the plantar
Fig ure 17-22 Babins ki re s pons e
re s pons e .
(abnorm al).
Anal re ex. With a dull object,
stroke outward from anus in four
quadrants. Watch for anal
contraction.
Loss of reflex suggests cauda equina
lesion at the S2, S3, S4 level.
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S p e c ia l T e c h n iq u e s
M e n in g e a l S ig n s . Make
sure there is no injury or fracture
to the cervical vertebrae or cervical
cord. This often requires radiologic
evaluation. With patient supine,
ex head and neck toward chest.
Note resistance or pain, and watch
for exion of hips and knees
(Brudzinski sign).
Inflammation in the subarachnoid space
causes resistance to movement that
stretches the spinal nerves (neck flex-
Flex one of patient’s legs at hip
and knee, then straighten knee
(Fig. 17-23). Note resistance or
pain (Kernig sign).
A compressed lumbosacral nerve root
also causes pain on straightening the
knee of the raised leg.
and the sciatic nerve (Kernig sign).
signs in meningitis ranges from 5% to
60%.
Fig ure 17-23 Te s t for Ke rnig s ign.
Lu m b o s a c ra l Ra d ic u lo p a t h y: S t ra ig h t -Le g Ra is e . With
patient supine, raise relaxed and
straightened leg, exing the leg at
the hip. Then dorsi ex the foot
(Fig. 17-24).
Pain radiating into the ipsilateral leg is a
positive straight-leg test for lumbosacral
radiculopathy. Foot dorsiflexion can
further increase leg pain in lumbosacral
radiculopathy, sciatic neuropathy, or
both. Increased pain when the contralateral healthy leg is raised is a positive
crossed straight-leg raise sign.
Fig ure 17-24 Te s t the s traight-le g
rais e .
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P O SSIBLE FIN DIN G S
As t e rixis . Ask patient to hold
both arms forward, with hands
cocked up and ngers spread, like
“stopping traf c.” Watch for 1 to
2 minutes.
Sudden brief flexions in liver disease,
uremia and hypercapnia.
Win g in g o f t h e S c a p u la .
Ask patient to push against the
wall of your hand with a partially
straightened arm (Fig. 17-25).
Inspect scapula. It should stay
close to the chest wall.
Winging of scapula away from chest wall
suggests weakness of the serratus anterior muscle, seen in muscular dystrophy or
injury to long thoracic nerve (Fig. 17-26).
Figure 17-25 Test for scapular winging.
Figure 17-26 Positive scapular w inging.
Th e S t u p o ro u s o r Co m a t o s e
Pa t ie n t
Assess ABCs (airway, breathing,
and circulation).
See Table 17-8, Metabolic and Structural
Coma, p. 345, Table 17-9, Glasgow Coma
Scale, p. 346, and Table 17-10, Pupils in
Comatose Patients, p. 347.
■ Take pulse, blood pressure, and
rectal temperature.
■ Establish level of consciousness
Lethargy, obtundation, stupor, coma
with escalating stimuli.
However, do not dilate pupils, and
do not ex patient’s neck if any
suspicion of cervical cord injury.
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P O SSIBLE FIN DIN G S
Le v e ls o f C o n s c io u s n e s s
Ale rtne s s
Le thargy
Obtundatio n
S tupo r
Co m a
P tient is w ke nd w re of self nd environ ent. When
s oken to in nor l voice, tient looks t you nd
res onds fully nd
ro ri tely to sti uli.
When s oken to in loud voice, tient
e rs drowsy but
o ens eyes nd looks t you, res onds to questions, nd
then f lls slee .
When sh ken gently, tient o ens eyes nd looks t you
but res onds slowly nd is so ewh t confused. Alertness
nd interest in environ ent re decre sed.
P tient rouses fro slee only fter inful sti uli. Verb l
res onses re slow or bsent. P tient l ses into unres onsiveness when sti ulus sto s. P tient h s ini l
w reness of self or environ ent.
Des ite re e ted inful sti uli, tient re ins un rousble with eyes closed. No evident res onse to inner need
or extern l sti uli is shown.
N e u r o lo g ic E x a m in a t io n
Conduct neurologic examination,
looking for asymmetric ndings.
Observe:
■ Breathing pattern
Cheyne –Stokes, ataxic breathing
■ Pupils
Asymmetrical pupils and loss of the light
reaction in structural lesions from stroke,
abscess, or tumor
■ Ocular movements
Deviation to affected side in hemispheric stroke
Check for the oculocephalic re ex
(doll’s eye movements), as shown
in Figure 17-27. Holding upper
eyelids open, turn head quickly to
each side, and then ex and extend
patient’s neck. This patient’s head
will be turned to her right.
In a comatose patient with an int a ct
b ra in st em, the eyes move in the
opposite direction, in this case to her
left (doll’s eye movements) as in
Figure 17-28.
Very deep coma or a lesion in the midbrain or pons abolishes this reflex, so
eyes do not move.
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P O SSIBLE FIN DIN G S
Fig ure 17-27 Te s t the oculoce phalic
Fig ure 17-28 Oculoce phalic re flex
re flex.
intact.
Note posture of body.
Decorticate rigidity, decerebrate rigidity,
flaccid hemiplegia
Test for accid paralysis.
■ Hold forearms vertically; note
wrist positions.
■ From 12 to 18 inches above bed,
A flaccid arm drops more rapidly.
drop each arm.
■ Support both knees in a some-
The flaccid leg drops more rapidly.
what exed position, and then
extend each knee and let leg
drop to the bed.
■ From a similar starting position,
release both legs.
A flaccid leg falls into extension and
external rotation.
Complete the neurologic and
general physical examination.
Recording Your Findings
R e c o r d in g t h e N e r v o u s S y s t e m E x a m in a t io n
“Mental Status: Alert, rel xed, nd coo er tive. Thought rocess coherent.
Oriented to erson, l ce, nd ti e. Det iled cognitive testing deferred. Cranial
Nerves: I—not tested; II through XII int ct. Motor: Good uscle bulk nd tone.
(continued )
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R e c o r d in g t h e N e r v o u s S y s t e m E x a m in a t io n
(Continued)
Strength 5/5 throughout. Cerebellar: R id ltern ting ove ents (RAMs),
finger-to-nose (F→N), heel-to-shin (H→S) int ct. G it with nor l b se.
Ro berg— int ins b l nce with eyes closed. No ron tor drift. Sensory:
Pin rick, light touch, osition, nd vibr tion int ct. Reflexes: 2+ nd sy
etric
with l nt r reflexes downgoing.”
OR
“Mental Status: The tient is lert nd tries to nswer questions but h s
difficulty finding words. Cranial Nerves: I—not tested; II—visu l cuity int ct;
visu l fields full; III, IV, VI—extr ocul r ove ents int ct; V otor—te or l
nd
sseter strength int ct, sensory corne l reflexes resent; VII otor—
ro inent right f ci l droo nd fl ttening of right n sol bi l fold, left f ci l
ove ents int ct, sensory—t ste not tested; VIII—he ring int ct bil ter lly to
whis ered voice; IX, X—g g int ct; XI—strength of sternocleido stoid nd
tr ezius uscles 5/5; XII—tongue idline. Motor: strength in right bice s,
trice s, ilio so s, glute ls, qu drice s, h string, nd nkle flexor nd extensor
uscles 3/5 with good bulk but incre sed tone nd s sticity; strength in co r ble uscle grou s on the left 5/5 with good bulk nd tone. G it—un ble to
test. Cerebell r—un ble to test on right due to right r
nd leg we kness;
RAMs, F→N, H→S int ct on left. Ro berg—un ble to test due to right leg
we kness. Right ron tor drift resent. Sensory: decre sed sens tion to in rick
over right f ce, r , nd leg; int ct on the left. Stereognosis nd two- oint
discri in tion not tested. Reflexes (c n record in two w ys):
(These findings suggest left hemispheric CVA in distribution of the left middle cerebral artery, with right-sided hemiparesis.)
RT
LT
Bic e p s
Tr ic e p s
Br a c h
Kn e e
An k le
Pl
4+
2+
4+
2+
4+
2+
4+
2+
4+
1+
↑
↓
OR
R
4+
4+
4+
4+
2+
4+
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2+
2+
2+
Chapter 17 | The Nervous System
335
Aids to Interpretation
Table 17-1 Typ e s o f S t ro k e
C lin ic a l Fe a t u r e s a n d Va s c u la r Te r r it o r ie s o f S t ro k e
Assessment of stroke requires careful history taking and a detailed
physical examination. Focus on three fundamental questions: What brain
area and related vascular territory explain the patient’s findings? Is the stroke
ischemic or hemorrhagic? If ischemic, is the mechanism thrombosis or embolus?
This brief overview is intended to prompt further study and practice.
La te ra l
ve ntrica l
Body of
ca uda te
Ante rior ce re bra l
a rte ry
Inte rna l
ca ps ule
Ante rior choroida l
a rte ry
Middle ce re bra l
a rte ry
P uta me n
Tha la mus
Globus
pa llidus
Pos te rior ce re bra l
a rte ry
Uncus
P re fronta l a re a
P rima ry
a uditory cortex
P re motor a re a
Auditory
a s s ocia tion a re a
P rima ry motor
cortex
S e ns ory s pe e ch
(We rnike ) a re a
Motor s pe e ch
(Broca ) a re a
Re a ding compre he ns ion a re a
P rima ry s oma tic
s e ns ory cortex
Vis ua l a s s ocia tion
a re a
S oma tic s e ns ory
a s s ocia tion a re a
Vis ua l cortex
Ta s te a re a
M a jo r C lin ic a l Fe a t u r e s
Va s c u la r Te r r it o ry
Contralateral leg weakness
Anterior circulation—anterior cerebral
artery (ACA)
Includes stem of circle of Willis
connecting internal carotid artery to
ACA, and the segment distal to ACA
and its anterior choroidal branch
(table continues on page 336)
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Table 17-1 Typ e s o f S t ro k e (continued )
Clin ic a l Fe a t u re s a n d Va s c u la r Te rrit o rie s o f S t ro k e (c o n t in u e d )
M a jo r C lin ic a l Fe a t u r e s
Va s c u la r Te r r it o ry
Contralateral face, arm > leg
weakness, sensory loss, field
cut, aphasia (left MCA) or
neglect, apraxia (right MCA)
Anterior circulation—middle cerebral
artery (MCA)
Contralateral motor or
sensory deficit without
cortical signs
Subcortical circulation—lenticulostriate
deep penetrating branches of MCA
Contralateral field cut
Posterior circulation—posterior
cerebral artery (PCA)
Largest vascular bed for stroke
Small vessel subcortical lacunar infarcts
in internal capsule, thalamus, or
brainstem. Four common syndromes:
pure motor hemiparesis; pure sensory
hemianesthesia; ataxic hemiparesis;
clumsy hand—dysarthria syndrome
Includes paired vertebral arteries, the
basilar artery, paired posterior cerebral
arteries. Bilateral PCA infarction
causes cortical blindness but
preserved pupillary light reaction.
Dysphagia, dysarthria, tongue/
palate deviation and/or ataxia
with crossed sensory/motor
deficits ( = ipsilateral face with
contralateral body)
Posterior circulation—brainstem,
vertebral, or basilar artery branches
Oculomotor deficits and/or
ataxia with crossed sensory/
motor deficits
Posterior circulation—basilar artery
Complete basilar artery occlusion—
“locked-in syndrome” with intact
consciousness but inability to speak
and quadriplegia
Source: Adapted from American College of Physicians. Stroke, in Neurology. Medical Knowledge
Self-Assessment Program (MKSAP) 14. Philadelphia, PA: American College of Physicians;
2006:52.
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Table 17-2 Dis o rd e r s o f S p e e ch
Disorders of speech fall into three groups affecting: (1) phonation of
the voice, (2) the articulation of words, and (3) the production and
comprehension of language.
■
Aphonia refers to a loss of voice that accompanies disease affecting
the larynx or its nerve supply. Dysphonia refers to less severe
impairment in the volume, quality, or pitch of the voice. For
example, a person may be hoarse or only able to speak in a whisper.
Causes include laryngitis, laryngeal tumors, and unilateral vocal
cord paralysis (CN X).
■
Dysarthria refers to a defect in the muscular control of the speech
apparatus (lips, tongue, palate, or pharynx). Words may be nasal,
slurred, or indistinct, but the central symbolic aspect of language
remains intact. Causes include motor lesions of the central or
peripheral nervous system, parkinsonism, and cerebellar disease.
■
Aphasia refers to a disorder in producing or understanding language.
It is often caused by lesions in the dominant cerebral hemisphere,
usually the left.
(table continues on page 338)
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Table 17-2 Dis o rd e r s o f S p e e ch (continued )
Compared below are two common types of aphasia: (1) Wernicke, a
fluent (receptive) aphasia, and (2) Broca, a nonfluent (or expressive)
aphasia. There are other less common kinds of aphasia, which are
distinguished by differing responses on the specific tests listed.
Neurologic consultation is usually indicated.
We r n ic k e A p h a s ia
Bro c a A p h a s ia
Q u a lit ie s o f
Spontaneous
S p e e ch
Fluent; often rapid,
voluble, and effortless.
Inflection and
articulation are good,
but sentences lack
meaning and words
are malformed
(paraphasias) or
invented (neologisms).
Speech may be totally
incomprehensible.
Nonfluent; slow, with
few words and
laborious effort.
Inflection and
articulation are
impaired but words
are meaningful, with
nouns, transitive
verbs, and important
adjectives. Small
grammatical words
are often dropped.
Wo r d
C o m p r e h e n s io n
Impaired
Fair to good
Re p e t it io n
Impaired
Impaired
N a m in g
Impaired
Impaired, though the
patient recognizes
objects
Re a d in g
C o m p r e h e n s io n
Impaired
Fair to good
Wr it in g
Impaired
Impaired
Lo c a t io n o f
Le s io n
Posterior superior
temporal lobe
Posterior inferior
frontal lobe
Although it is important to recognize aphasia early in your encounter
with a patient, integrate this information with your neurologic
examination as you generate your differential diagnosis.
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Table 17-3 Typ e s o f Fa c ia l P a ra lys is
Distinguish peripheral from central lesions of CN VII by closely
observing movements of the upper face. Because of innervation from both
hemispheres, the upper facial movements are preserved in central lesions.
C N VII—P e r ip h e r a l Le s io n
C N VII—C e n t r a l Le s io n
Peripheral nerve damage to CN VII
paralyzes the entire right side of
the face, including the forehead.
Motor
cortex
Motor c orte x
CN VII
c e ntral
le s io n
CN VII
pe riphe ral
le s io n
Syna ps es
in the pons
Syna ps es in
the pons
Facia l
ne rve
Facial ne rve
Clo s ing Eye s
Clo s ing Eye s
Eye does
not clos e;
e yeba ll rolls up
Eye clos es ;
pe rha ps with
s light we aknes s
Flat nas olabial
fold
Flat na s ola bia l
fold
Rais ing Eye bro w s
Fore he ad
not wrinkled;
e yebrow not rais ed
Rais ing Eye bro w s
Smiling
Paralys is of
lower fac e
Forehea d wrinkle d;
eye brow rais ed
Smiling
Para lys is of
lower fa ce
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Table 17-4 Mo t o r Dis o rd e r s
P e r ip h e r a l
N e r vo u s
Sys t e m
D is o r d e r
Ce n t ra l
N e r vo u s
S ys t e m
D is o r d e r a
P a r k in s o n is m
(Ba s a l
G a n g lia
D is o r d e r )
In vo lu n t a ry
m o ve m e n t s
Often
fascicu lations
No fasciculations
Resting tremors
Intention
tremors
M u s c le
b u lk
Atrophy
Normal or
mild
atrophy
(disuse)
Normal
Normal
M u s c le
tone
Decreased or
absent
Increased,
spastic
Increased, rigid
Decreased
M u s c le
s t re n g t h
Decreased or
lost
Decreased
or lost
Normal or
slightly decreased
Normal or
slightly
decreased
C o o r d in a t io n
Unimpaired,
though
limited by
weakness
Slowed and
limited by
weakness
Good, though
slowed and often
tremulous
Impaired,
ataxic
De e p te n d o n
Decreased or
absent
Increased
Normal or
decreased
Normal or
decreased
Pla n ta r
Flexor or
absent
Extensor
Flexor
Flexor
Ab d o m in a ls
Absent
Absent
Normal
Normal
C e r e b e lla r
D is o r d e r
Re f le xe s
a
Upper motor neuron.
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Table 17-5 In vo lu n t a ry Mo ve m e n t s
Re s ting s tatic tre m o rs . Fine,
“pill-rolling” tremor seen at rest, usually
disappear with movement; seen in basal
ganglia disorders like Parkinson disease.
Po s tural tre m o r. Seen when
maintaining active posture; in anxiety,
hyperthyroidism; also familial. From
basal ganglia disorder.
Inte ntio n tre m o r. Seen with
intentional movement, absent at rest; in
cerebellar disorders, including multiple
sclerosis
Fas ciculations . Fine, rapid flickering of
muscle bundles in lower motor neuron
disorders.
Cho re a. Brief, rapid, irregular, jerky;
face, head, arms, or hands (e.g.,
Huntington disease)
Athe to s is . Slow, twisting, writhing;
face, distal limbs, often with associated
spasticity (e.g., cerebral palsy)
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Table 17-6 Dis o rd e r s o f Mu s c le To n e
S p a s t ic it y
Rig id it y
Lo catio n. Upper motor neuron or
corticospinal tract systems.
Lo catio n. Basal ganglia system
De s criptio n. Increased muscle
tone (hypertonia) that is ratedependent. Tone is greater when
passive movement is rapid, and
less when passive movement is
slow. Tone is also greater at the
extremes of the movement arc.
During rapid passive movement,
initial hypertonia may give way
suddenly as the limb relaxes. This
spastic “catch” and relaxation is
known as “clasp-knife” resistance.
De s criptio n. Increased resistance
that persists throughout the
movement arc, independent of
rate of movement, is called leadpipe rigidity. With flexion and
extension of the wrist or forearm,
a superimposed ratchet-like
jerkiness is called cogwheel rigidity.
Co m m o n Caus e . Stroke,
especially late or chronic stage
Co m m o n Caus e . Parkinsonism
Fla c c id it y
P a r a t o n ia
Lo catio n. Lower motor neuron at
any point from the anterior horn
cell to the peripheral nerves
Lo catio n. Both hemispheres,
usually in the frontal lobes
De s criptio n. Loss of muscle tone
(hypotonia), causing the limb to be
loose or floppy. The affected limbs
may be hyperextensible or even
flail-like.
De s criptio n. Sudden changes
in tone with passive range of
motion. Sudden loss of tone that
increases the ease of motion is
called mitgehen (moving with).
Sudden increase in tone making
motion more difficult is called
gegenhalten (holding against).
Co m m o n Caus e . Guillain–
Barré syndrome; also initial phase
of spinal cord injury (spinal shock)
or stroke
Co m m o n Caus e . Dementia
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343
Table 17-7 De rm a t o m e s
C2
C3 Front of ne ck
C3
C4
T2
T3
C5
C5
T4
T4 Nipple s
T5
T6
T7
T8
T9
C6
T1
T1
C6
T10
T10 Umbilicus
T11
L1 Inguina l
T12
L1
L2
C8
L2
C8
C7
C7
S 2,3
L3
L3
C8 Ring a nd
little finge rs
L4
L4
L4 Kne e
L5
S1
L5
S1
L5 Ante rior
a nkle a nd foot
Dermatomes Innervated by Posterior Roots
(table continues on page 344)
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Table 17-7 De rm a t o m e s (continued )
C2
C5
C6
C7
C8
C3
C3 Ba ck of ne ck
T1
C4
T2
T3
T4
T5
T6
T7
T8
T9
T10
T11
T12
L1
L2
L3
L4
L5
S1
S2
C5
C6
T1
C5
C6
T1
S3
S4
C6
Thumb
S5
C8
C8
C7
C7
C8 Ring a nd
little finge rs
S 5 Pe ria na l
S1
S2
S2
S1
L4, L5, S 1
Pos te rior a nkle
a nd foot
L4
L4
L5
L5
Dermatomes Innervated by Posterior Roots
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Table 17-8 Me t a b o lic a n d S t ru c t u ra l Co m a
To x ic –M e t a b o lic
S t ru c t u ra l
P a t h o p h y s io lo g y
Arousal centers poisoned or
critical substrates depleted
Lesion destroys or compresses
brainstem arousal areas, either
directly or secondary to more
distant expanding mass lesions.
C lin ic a l Fe a t u r e s
■
Re s p ira to ry p a tte rn . If
regular, may be normal or
hyperventilation. If irregular,
usually Cheyne–Stokes
Re s p ira to ry p a tte rn . Irregular,
especially Cheyne–Stokes or
ataxic breathing. Also with
selected stereotypical patterns like
“apneustic” respiration (peak
inspiratory arrest) or central
hyperventilation.
■
Pu p illa ry s ize a n d re a ct io n .
Equal, reactive to light. If
pinpoint from opiates or
cholinergics, you may need a
magnifying glass to see the
reaction.
Pu p illa ry s ize a n d re a ct io n .
Unequal or unreactive to light
(fixed)
May be unreactive if fixed and
dilated from anticholinergics or
hypothermia
■
Le ve l o f co n s cio u s n e s s .
Changes after pupils change
Midposition, fixed—suggests
midbrain compression
Dilated, fixed—suggests
compression of CN III from
herniation
Le ve l o f co n s cio u s n e s s .
Changes before pupils change
Ex a m p le s o f C a u s e
Uremia, hyperglycemia
Epidural, subdural, or
intracerebral hemorrhage
Alcohol, drugs, liver failure
Hypothyroidism, hypoglycemia
Anoxia, ischemia
Meningitis, encephalitis
Hyperthermia, hypothermia
Cerebral infarct or embolus
Tumor, abscess
Brainstem infarct, tumor, or
hemorrhage
Cerebellar infarct, hemorrhage,
tumor, or abscess
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Table 17-9 Gla s g o w Co m a S c a le
Ac t iv it y
S c o re
Eye O p e n in g
None
1 = Even to supraorbital pressure
To pain
2 = Pain from sternum/limb/
supraorbital pressure
To speech
3 = Nonspecific response, not
necessarily to command
Spontaneous
4 = Eyes open, not necessarily aware
M o t o r Re s p o n s e
None
1 = To any pain; limbs remain flaccid
Extension
2 = Shoulder adducted and shoulder
and forearm internally rotated
Flexor response
3 = Withdrawal response or
assumption of hemiplegic
posture
Withdrawal
4 = Arm withdraws to pain, shoulder
abducts
Localizes pain
5 = Arm attempts to remove
supraorbital/chest pressure
Obeys commands
6 = Follows simple commands
Ve r b a l Re s p o n s e
None
1 = No verbalization of any type
Incomprehensible
2 = Moans/groans, no speech
Inappropriate
3 = Intelligible, no sustained
sentences
Confused
4 = Converses but confused,
disoriented
Oriented
5 = Converses and is oriented
TOTAL (3–15)a
Interpretation: Patients with scores of 3–8 usually are considered to be in a coma.
Source: Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical
scale. Lancet. 1974;304(7872):81.
a
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347
Table 17-10 P u p ils in Co m a t o s e P a t ie n t s
S m a ll o r P in p o in t P u p ils
Bilaterally small pupils (1–2.5 mm)
suggest (1) damage to the sympathetic
pathways in the hypothalamus or
(2) metabolic encephalopathy (a
diffuse failure of cerebral function
from drugs and other causes). Light
reactions are usually normal.
Pinpoint pupils (<1 mm) suggest (1) a
hemorrhage in the pons or (2) the
effects of morphine, heroin, or other
narcotics. Use a magnifying glass to
see the light reactions.
M id p o s it io n Fixe d P u p ils
Midposition or slightly dilated pupils
(4–6 mm) and fixed to light suggest
damage in the midbrain.
La r g e P u p ils
Bilaterally fixed and dilated pupils in
severe anoxia with sympathomimetic
effects, may be seen with cardiac
arrest. They also result from atropinelike agents, phenothiazines, or
tricyclic antidepressants.
O n e La r g e P u p il
One fixed and dilated pupil warns of
herniation of the temporal lobe, causing
compression of the oculomotor nerve
and midbrain. Also seen in diabetes
with CN III infarction.
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18
C H A P T E R
Assessing Children:
Infancy through Adolescence
Child Development
Children display tremendous variations in physical, cognitive, and social
development compared with adults.
K e y P r in c ip le s o f C h ild D e v e lo p m e n t
●
●
●
●
Child develo ent roceeds long redict ble thw y.
The r nge of nor l develo ent is wide.
V rious hysic l, sychologic l, soci l, nd environ ent l f ctors, s well s
dise ses, c n ffect child develo ent nd he lth.
The child’s develo ent l level ffects how you conduct the history nd
hysic l ex in tion.
The Health History
The child’s history follows the same outline as the adult’s history, with
certain additions presented here.
Id e n t if y in g D a t a
Record date and place of birth, nickname, and rst and last names of
parents.
C h ie f C o m p la in t s
Determine if they are the concerns of the child, the parent(s), a schoolteacher, or some other person.
P r e s e n t Illn e s s
Determine how each family member responds to the child’s symptoms, why
he or she is concerned, and impact on the child’s functioning.
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H is t o r y
Bir t h His t o ry. This is especially important when neurologic or developmental problems are present. Get hospital records if necessary.
■ Prenatal—maternal health: medications; tobacco, drug, and alcohol use;
weight gain; duration of pregnancy
■ Natal—nature of labor and delivery, birth weight, Apgar scores at 1 and
5 minutes
■ Neonatal—resuscitation efforts, cyanosis, jaundice, infections, bonding
Fe e d in g His t o ry. This is particularly important with either undernutrition or obesity.
■ Breast-feeding—frequency and duration of feeds, dif culties, timing
and method of weaning
■ Bottle-feeding—type; amount; frequency; vomiting; colic; diarrhea
■ Vitamins, iron, and uoride supplements; introduction of solid foods
■ Eating habits—types and amounts of food eaten, parental attitudes and
responses to feeding problems
Gro w t h a n d De ve lo p m e n t a l His t o ry. This is particularly important
with delayed growth or development and behavioral disturbances.
■ Physical growth—weight and height at all ages; head circumference at
birth and younger than 2 years; periods of slow or rapid growth; BMI
after age 2 years
■ Developmental milestones, speech development, performance in
preschool and school
■ Social development—day and night sleeping patterns; toilet training;
habitual behaviors; discipline problems; school behavior; relationships
with family and peers; social risks such as poverty, food insecurity and
adverse experiences
C u r r e n t H e a lt h S t a t u s
Alle rg ie s . Pay particular attention to history of eczema, urticaria,
perennial allergic rhinitis, asthma, food intolerance, insect hypersensitivity,
and recurrent wheezing.
Im m u n iza t io n s . Include dates given and any untoward reactions.
S c r e e n in g Te s t s . These vary according to the child’s medical and social
conditions. Include newborn screening results, anemia screening, blood
lead, sickle cell disease, vision, hearing, developmental screening, and
others (e.g., tuberculosis).
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351
Health Promotion and Counseling:
Evidence and Recommendations
For the most up-to-date Bright Futures recommendations for preventive
health care, see https://www.aap.org/en-us/Documents/periodicity_
schedule.pdf. Each child and family is unique; therefore, such recommendations are designed for the care of children who are receiving competent
parenting, have no manifestation of any important health problems, and
are growing and developing in satisfactory fashion.
1. Age-appropriate developmental achievement of the child
■
Physical (maturation, growth, puberty)
■
Motor (gross and ne motor skills)
■
Cognitive (milestones, language, school performance)
■
Emotional (self-regulation, self-ef cacy, self-esteem, independence)
■
Social (social competence, self-responsibility, integration with family
and community)
2. Health supervision visits (per health supervision schedule)
■
Periodic assessment of medical and oral health
■
Adjustment of frequency for children or families with special needs
3. Integration of physical examination ndings
4. Immunizations
5. Screening procedures
6. Anticipatory guidance
■
Healthy habits
■
Nutrition and healthy eating
■
Emotional and mental health
■
Oral health
■
Safety and prevention of injury
■
Sexual development and sexuality
■
Self-responsibility and ef cacy and self-esteem
■
Family relationships (interactions, strengths, supports)
■
Prevention or recognition of illness
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■
Prevention of risky behaviors and addictions
■
School and vocation
■
Peer relationships
■
Community interactions
7. Partnership between health provider, child, and family
Techniques of Examination
S e q u e n c e o f E x a m in a t io n
The sequence of ex
level.
●
●
in tion v ries ccording to the child’s ge nd co fort
For inf nts nd young children, perform nondisturbing maneuvers early and
potentially distressing maneuvers toward the end. For ex
le, l te the he d
nd neck nd uscult te the he rt nd lungs e rly; ex ine the e rs nd
outh nd l te the bdo en ne r the end. If the child re orts in in n
re , ex ine th t rt l st.
For older children nd dolescents, use the s e sequence s with dults,
exce t ex ine the ost inful re s l st.
Assessing Newborns
EXAMINATIO N TECHNIQ UES
P O SSIBLE FIN DIN G S
Im m e d ia t e A s s e s s m e n t a t B ir t h
Listen to the anterior thorax with
your stethoscope. Palpate the abdomen. Inspect the head, face, oral
cavity, extremities, genitalia, and
perineum.
Ap g a r S c o re . Score each newborn according to the following
table, at 1 and 5 minutes after birth,
according to the 3-point scale (0, 1,
or 2) for each component.
If the 5-minute score is 8 or more, proceed to a more complete examination.
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353
T h e A p g a r S c o r in g S y s t e m
A s s ig n e d S c o r e
C lin ic a l S ig n
0
1
2
Heart rate
Respiratory
effort
Muscle tone
Absent
Absent
>1
Good; strong
Reflex
irritabilitya
Color
No res onses
<1
Slow nd
irregul r
So e flexion of
the r s nd
legs
Gri ce
Fl ccid
Blue,
le
1-M in u t e A p g a r S c o r e
8–1
5–7
–4
Pink body, blue
extre ities
Active
ove ent
Crying vigorously,
sneeze, or cough
Pink ll over
5 -M in u t e A p g a r S c o r e
Nor l
8–1
So e nervous sys–7
te de ression
Severe de ression,
requiring i
edite resuscit tion
Nor l
High risk for subsequent centr l nervous syste
nd
other org n syste dysfunction
Re ction to suction of n res with bulb syringe.
a
Ge s t a t io n a l Ag e a n d Bir t h We ig h t . Classify newborns according
to their gestational age and birth weight (see Table 18-1, Classi cation of
Newborn’s Level of Maturity, p. 373).
C la s s if ic a t io n b y G e s t a t io n a l A g e a n d B ir t h W e ig h t
G e s t a t io n a l Ag e
C la s s if ic a t io n
Ge s t a t io n a l Ag e
Preterm
Late preterm
Term
Postterm
<34 wks
34–36 wks
37–42 wks
>42 wks
Bir t h We ig h t
C la s s if ic a t io n
We ig h t
Extremely low birth weight
Very low birth weight
Low birth weight
Normal birth weight
<1,
<1,5
<2,5
≥2,5
g
g
g
g
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EXAMINATIO N TECHNIQ UES
P O SSIBLE FIN DIN G S
N e w b o r n C la s s if ic a t io n s
C a t e g o ry
Ab b r e v ia t io n
Small for gestational age
Appropriate for gestational age
Large for gestational age
SGA
AGA
LGA
P e r c e n t ile
<1 th
1 –9 th
>9 th
A s s e s s m e n t S e v e r a l H o u r s A f t e r B ir t h
During the rst day of life,
newborns should have a comprehensive examination following
the technique outlined under
“Infants.” Wait until 1 or 2 hours
after a feeding, when the newborn
is more responsive. Ask parents to
remain.
Observe the baby’s color, size,
body proportions, nutritional
status, posture, respirations,
and movements of the head and
extremities.
Most newborns are bowlegged, reflecting their curled up intrauterine position.
Inspect the newborn’s umbilical cord
to detect abnormalities. Normally,
there are two thick-walled umbilical arteries and one larger but
thin-walled umbilical vein, which
is usually located at the 12-o’clock
position.
A single umbilical artery may be associated with congenital anomalies. Umbilical hernia s in infants are from a defect in
the abdominal wall.
The neurologic screening examination of all newborns should include
assessment of mental status, gross
and ne motor function, tone, cry,
deep tendon re exes, and primitive
re exes.
Signs of severe neurologic disease
include extreme irritability; persistent
asymmetry of posture or extension of
extremities; constant turning of head to
one side; marked extension of head,
neck, and extremities (opisthotonus);
severe flaccidity; and limited pain
response.
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EXAMINATIO N TECHNIQ UES
355
P O SSIBLE FIN DIN G S
Assessing Infants
M e n t a l a n d P h y s ic a l S t a t u s
Observe the parents’ affect when
talking about the baby and their
manner of holding, moving, and
dressing the baby. Observe a breast
or bottle-feeding. Determine attainment of developmental milestones,
optimally using a standardized
developmental screening test.
Common causes of developmental delay
include abnormalities in embryonic
development, hereditary and genetic
disorders, environmental and social
problems, other pregnancy or perinatal
problems, childhood diseases such as
infection (e.g., meningitis), trauma, and
severe chronic disease.
G e ne ra l S urve y
Growth, re ected in increases in
height and weight within expected
limits, is an excellent indicator of
health during infancy and childhood. Deviations from normal may
be early indications of an underlying problem. To assess growth,
compare a child’s parameters with
respect to:
Fa ilure to thrive is a condition reflecting
significantly low weight gain (e.g., below
2nd percentile) for gestational-age corrected age and sex. Causes can be environmental or psychosocial, or various
gastrointestinal, neurologic, cardiac,
endocrine, renal, and other diseases.
■ Normal values according to age
Measures above the 97th or below the
3rd percentile, or recent rises or falls
from prior levels, require investigation.
and sex
■ Prior readings to assess trends
He ig h t a n d We ig h t . Plot each
child’s height and weight on standard growth charts to determine
progress.
Reduced growth in height may indicate
endocrine disease, other causes of short
stature, or, if weight is also low, other
chronic diseases.
He a d Circ u m fe re n c e . Determine head circumference at every
physical examination during the
rst 2 years (Fig. 18-1).
Premature closure of the sutures or
microcephaly may cause small head size.
Hydrocephalus, subdural hematoma, or,
rarely, brain tumor or inherited syndromes may cause an abnormally large
head size.
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P O SSIBLE FIN DIN G S
Fig ure 18-1 He ad circum fe re nce is a
vital m e tric during e arly childhood.
V it a l S ig n s
Blo o d P re s s u re . Measure
blood pressure at least once during
infancy. Although the hand-held
method is shown in Figure 18-2,
the most easily used measure of
systolic blood pressure in infants
and young children is obtained
with the Doppler method.
Fig ure 18-2 Practice is re quire d to
accurate ly m e as ure blood pre s s ure in
e arly childhood.
C a u s e s o f S u s t a in e d H y p e r t e n s io n in C h ild r e n
Ne w b o r n
M id d le C h ild h o o d
Ren l rtery dise se (stenosis,
thro bosis)
Congenit l ren l lfor tions
Co rct tion of the ort
Pri
In f a n c y a n d Ea r ly C h ild h o o d
Ad o le s c e n c e
Ren l renchy l or rtery dise se
Co rct tion of the ort
Pri ry hy ertension
Ren l renchy l dise se
Drug induced
ry hy ertension
Ren l renchy l or rteri l dise se
Co rct tion of the ort
P u ls e . The heart rate is quite
variable and will increase markedly
with excitement, crying, or anxiety.
Therefore, measure the pulse when
the infant or child is quiet.
Tachycardia (>180–200 beats per minute) usually indicates paroxysma l supraventricular tachycardia . Bradycardia may
result from serious underlying disease.
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Re s p ira t o ry Ra t e . The respiratory rate has a very wide range and
is more responsive to illness, exercise, and emotion than in adults.
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Respiratory diseases such as bronchiolitis
or pneumonia may cause rapid respirations (up to 80 to 90 breaths per minute),
and increased work of breathing. Peaceful
tachypnea (without increased work of
breathing) may be a sign of cardiac failure.
T h e S k in
Assess:
■ Texture and appearance
Cutis marmorata
■ Vasomotor changes
Acrocyanosis; cyanotic congenital heart
disease
■ Pigmentation (e.g., Mongolian
Café-au-lait spots
spots)
■ Hair (e.g., lanugo)
Midline hair tuft on back
■ Common skin conditions (e.g.,
Herpes simplex
milia, erythema toxicum)
■ Color
Jaundice can be from hemolytic disease.
■ Turgor
Dehydration
Th e He a d
Examine sutures and fontanelles
carefully (Fig. 18-3).
Ante rior fonta ne lle
Pos te rior fonta ne lle
La mbdoida l s uture
S a gitta l
s uture
Corona l
s uture
Head small with microcephaly, enlarged
with hydrocephaly; fontanelles full and
tense with meningitis, closed with microcephaly, separated with increa sed intracranial pressure (hydrocephaly, subdural
hematoma, and brain tumor)
Swelling from subperiosteal hemorrhage (cephalohematoma) does not
cross suture lines; swelling from bleeding associated with a fracture does.
Me topic
s uture
Fig ure 18-3 Suture s and fontane lle s .
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Check the face for symmetry.
Examine for an overall impression
of the facies; comparing with the
faces of the parents is helpful.
Abnormal facies occurs in a child with a
constellation of facial features that
appear abnormal. A variety of syndromes can cause abnormal facies (see
box below for evaluation). Examples
include Down syndrome and fetal alcohol
syndrome.
P e a r ls t o E v a lu a t e P o t e n t ia lly A b n o r m a l F a c ie s
C refully review the history, es eci lly the family history, pregnancy, nd perinatal
history.
Note bnor lities of growth/develo ent or dys or hic so tic fe tures.
Me sure nd lot ercentiles, es eci lly of head circumference, height, nd
weight.
Consider the three ech nis s of f ci l dys or hogenesis:
● Defor
tions fro intr uterine constr int
● Disru tions fro
niotic b nds or fet l tissue
● M lfor
tions fro intrinsic bnor lity (either f ce/ he d or br in)
Ex ine rents nd siblings (si il rity y be re ssuring but ight lso oint
to f ili l disorder).
Deter ine whether f ci l fe tures fit recogniz ble syndro e. Co
re
g inst references, ictures, t bles, nd d t b ses.
Th e Ey e s
Newborns and young infants may
look at your face and follow a
bright light if you catch them while
alert. Examine the red re ex.
Nystagmus, strabismus
Leukocoria is a white papillary reflex
(instead of the normal red papillary
reflex). It can be a sign of a rare tumor
called retinoblastoma.
Normal visual milestones are as
follows:
V is u a l M ile s t o n e s o f In f a n c y
Birth
1 month
1½–2 months
3 months
12 months
Blinks, y reg rd f ce
Fixes on objects
Coordin ted eye ove ents
Eyes converge, b by re ches
Acuity round 2 / 6 –2 / 8
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P O SSIBLE FIN DIN G S
Th e Ea r s
Check position, shape, and features.
Small, deformed or low-set auricles may
indicate associated congenital defects,
especially renal disease.
S ig n s T h a t a n In f a n t C a n H e a r
Ag e
S ig n s
0–2 months
St rtle res onse nd blink to sudden noise
C l ing down with soothing voice or usic
Ch nge in body ove ents in res onse to sound
Ch nge in f ci l ex ression to f ili r sounds
Turning eyes nd he d to sound
Turning to listen to voices nd convers tion
A ro ri te l ngu ge develo ent
2–3 months
3–4 months
6–7 months
Th e N o s e
Test patency of the nasal passages
by occluding alternately each
nostril while holding the infant’s
mouth closed.
With choanal atresia , the baby cannot
breathe if one nostril is occluded.
Th e M o u t h a n d P h a r y n x
Inspect (with a tongue blade and
ashlight) and palpate.
Supernumerary teeth, Epstein pearls
You may see a whitish covering on
the tongue. If this coating is from
milk, you can easily remove it by
scraping or wiping it away.
Ora l candidiasis (thrush)
Vesicles in the mouth can be caused
by enteroviral infections and herpes
simplex virus infections.
Th e N e c k
Palpate the lymph nodes, and
assess for any additional masses
(e.g., congenital cysts), as shown in
Figure 18-4.
Lymphadenopathy is usually from viral or
bacterial infections.
Other neck masses include malignancy,
branchia l cleft or thyroglossa l duct cysts,
and peria uricular cysts and sinuses.
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Prea uric ula r c ys t
Parotid nodes
Epide rmoid c ys t
Oc cipital node
J uguloga s tric
nod e
Re troa uric ular
(ma s toid ) nodes
Sub mandibular
nod e
Sup erior de ep
c ervica l nodes
Midd le de ep
c ervica l nodes
Sub mental
nod e
Pos te rior
c ervica l nodes
Thyroglos s al
duct c ys t
Cys tic hygroma
2nd branc hial
cle ft c ys t
Supra clavicular
node
Inferior d eep
c ervic al node s
Ante rior
ce rvic al node s
Fig ure 18-4 Node s and cys ts of the he ad
and ne ck.
T h e T h o r a x a n d Lu n g s
Carefully assess respirations and
breathing pattern.
Apnea
Do not rush to the stethoscope, but
observe the patient carefully rst.
Upper respiratory infections may cause
nasal flaring.
E x a m in a t io n o f t h e Lu n g s in In f a n t s —B e f o r e
Y o u T o u c h t h e C h ild !
As s e s s m e n t
P o s s ib le Fin d in g s
Ex p la n a t io n
General appearance
In bility to feed or s ile
L ck of consol bility
Respiratory rate
T chy ne
Color
Nasal component of
breathing
P llor or cy nosis
N s l fl ring (enl rge ent
of both n s l o enings
during ins ir tion)
Lower respiratory infections
(e.g., bronchiolitis, pneumonia) re co
on in inf nts.
C rdi c or res ir tory dise se
(e.g., neu oni )
C rdi c or ul on ry dise se
U er or lower res ir tory
infection
(continued )
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P O SSIBLE FIN DIN G S
E x a m in a t io n o f t h e Lu n g s in In f a n t s —B e f o r e
Y o u T o u c h t h e C h ild ! (Continued)
As s e s s m e n t
P o s s ib le Fin d in g s
Ex p la n a t io n
Audible breath
sounds
Grunting (re etitive, short
ex ir tory sound)
Wheezing ( usic l ex ir tory sound)
Stridor (high- itched,
ins ir tory noise)
Obstruction (l ck of bre th
sounds)
N s l fl ring
Grunting
Retr ctions (chest
indr wing):
Su r cl vicul r ( otion
of soft tissue bove
cl vicles)
Intercost l (indr wing of
the skin between ribs)
Substern l ( t xi hoid
rocess)
Subcost l (just below
the cost l rgin)
Lower res ir tory dise se
Work of breathing
Asth
or bronchiolitis
Crou , e iglottitis, b cteri l
tr cheitis
Foreign body
In inf nts, bnor l work of
bre thing co bined with
bnor l findings on uscult tion is the best finding
for ruling in pneumonia.
Auscultate the chest, and try to distinguish upper airway from lower
airway sounds.
D is t in g u is h in g U p p e r A ir w a y f r o m Lo w e r
A ir w a y S o u n d s
Te c h n iq u e
U p p e r A ir w a y
Lo w e r A ir w a y
Compare sounds from
nose/ stethoscope
Listen to harshness of
sounds
Note symmetry (left/right)
Compare sounds at different locations (higher or
lower)
Inspiratory vs. expiratory
S
Often different
sounds
V ri ble
e sounds
H rsh nd loud
Sy
etric
Sounds louder s stethosco e is oved u
chest
Al ost lw ys ins ir tory
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Often sy
etric
Sounds louder lower
in chest
Often h s ex ir tory
h se
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Th e H e a r t
In s p e c t io n . Observe carefully
for any cyanosis. The best body
part to assess cyanosis is the tongue
or inside of the mouth.
At birth: Tra nsposition of the great arteries; pulmonary valve atresia or stenosis
P a lp a t io n . Palpate the peripheral
pulses. The point of maximal impulse
(PMI) is not always palpable in
infants. Thrills are palpable when
enough turbulence is within the
heart or great vessels.
No or diminished femoral pulses suggest
coarcta tion of the aorta. Weak or thready,
difficult-to-feel pulses may reflect myocardia l dysfunction and heart fa ilure.
Au s c u lt a t io n . Heart rhythm is
evaluated more easily in infants by
listening to the heart than by feeling the peripheral pulses.
The most common dysrhythmia in children is paroxysmal supra ventricular
tachyca rdia.
Evaluate S1 and S2 carefully. They
are normally crisp with intermittent splitting of S1 and S2 (fused in
expiration).
A louder-than-normal pulmonic component suggests pulmonary hypertension.
Persistent splitting of S2 may indicate
atrial septal defect.
Listen for heart murmurs. Two
common benign systolic murmurs are from a closing ductus
or peripheral pulmonary ow
murmur.
Most infants with cardiac pathology
have signs beyond heart murmurs.
Within a few days of birth: The above;
also total anomalous pulmonary venous
return, hypopla stic left heart
Th e B r e a s t s
The breasts of males and females
may be enlarged for months
after birth as a result of maternal
estrogen.
Th e A b d o m e n
You will nd it easy to palpate an
infant’s abdomen, because infants
like being touched. Palpate the
liver and spleen and assess for
hepatosplenomegaly.
Abnormal abdominal masses can be
associated with kidney, bladder, or
bowel tumors. In pyloric stenosis, deep
palpation in the right upper quadrant or
midline can reveal an “olive,”or a 2-cm
firm pyloric mass.
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P O SSIBLE FIN DIN G S
M a le G e n it a lia
Inspect with the infant supine. The
foreskin of a newborn is nonretractable at birth or just enough to
visualize the urethral meatus.
Common scrotal masses are hydroceles
and inguinal hernias.
In 3% of infants, one or both testes
cannot be felt in the scrotum or
inguinal canal. Try to milk the testes into the scrotum.
Inability to palpate testes, even with
maneuvers, indicates undescended
testicles.
F e m a le G e n it a lia
In females, genitalia may be prominent for several months after birth
from the effects of maternal estrogen.
Ambiguous genita lia involves masculinization of the female external genitalia.
T h e M u s c u lo s k e le t a l S y s t e m
Examine the extremities by inspection and palpation to detect congenital abnormalities, particularly in the
hands, spine, hips, legs, and feet.
Skin tags, remnants of digits, polydactyly
(extra fingers), or syndactyly (webbed
fingers) are congenital defects. Fracture
of the cla vicle can occur during a difficult
delivery.
Examine the hips carefully at each
visit for signs of dislocation. There
are two major techniques: one to
test for a posteriorly dislocated hip
(Ortolani test), as shown in Figure 18-5, and the other to test for
the ability to sublux or dislocate
an intact but unstable hip (Barlow
test), as shown in Figure 18-6.
Congenital hip dysplasia may have a
positive Ortolani or Barlow test, particularly during the first 3 months of age.
With a hip dysplasia , you feel a “clunk.”
Fig ure 18-5 Ortolani te s t, ove rhe ad
Fig ure 18-6 Barlow te s t, ove rhe ad
view.
view.
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P O SSIBLE FIN DIN G S
Some normal infants exhibit twisting or torsion of the tibia inwardly
or outwardly on its longitudinal
axis.
Pathologic tibial torsion occurs only in
association with deformities of the feet or
hips.
Th e N e r v o u s S y s t e m
Evaluate the developing central
nervous system by assessing infantile automatisms, called primitive
re exes.
Suspect a neurologic or developmenta l
abnormality if primitive reflexes are
absent at appropriate age, present longer than normal, asymmetric, or associated with posturing or twitching.
Neurologic abnormalities in
infants often present as developmental abnormalities such
as failure to do age-appropriate
tasks.
Hypotonia can be a sign of a variety of
neurologic abnormalities.
Assessing Children (1 to 10 Years)
T ip s f o r In t e r v ie w in g C h ild r e n
●
●
●
●
●
Establish rapport. Refer to children by n e nd eet the on their own
level. M int in eye cont ct t their level (e.g., sit on the floor if needed). P rtici te in l y nd t lk bout their interests.
Work with families. Ask si le, o en-ended questions such s “Are you sick?
Tell e bout it,” followed by ore s ecific questions. Once the rent h s
st rted the convers tion, direct questions b ck to the child. Also observe how
rents inter ct with the child.
Identify multiple agendas. Your job is to discover s
ny ers ectives nd
gend s s ossible.
Use the family as the key resource. View rents s ex erts in the c re of
their child nd you s their consult nt.
Note hidden agendas. As with dults, the chief co l int
y not rel te to
the re l re son the rent h s brought the child to see you.
The following discussion focuses on those re s of the co rehensive hysic l
ex in tion th t re different for children th n for inf nts nd for dults.
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P O SSIBLE FIN DIN G S
M e n t a l a n d P h y s ic a l S t a t u s
In children age 1 to 5 years, observe
the degree of sickness or wellness,
mood, nutritional state, speech,
cry, facial expression, and developmental skills. Note parent–child
interaction, including separation
tolerance, affection, and response
to discipline.
This overall examination can uncover evidence of chronic disease, developmental
delay, social or environmental disorders,
and family problems.
In children 6 to 10 years, determine
orientation to time and place,
factual knowledge, and language
and number skills. Observe motor
skills used in writing, tying laces,
buttoning, cutting, and drawing.
Observing children performing tasks can
reveal signs of inattentiveness or impulsivity, which may indicate attention deficit disorder.
Bo d y Ma s s In d e x fo r Ag e .
Age- and sex-speci c charts are
now available to assess body mass
index (BMI) in children.
Underweight is <5th percentile, at risk
of overweight is ≥85th percentile, and
overweight is ≥95th percentile.
Blo o d P re s s u re . Hypertension
during childhood is more common
than previously thought. Recognizing, con rming, and appropriately
managing it is important. Blood
pressure readings should be part of
the physical examination of every
child older than 2 years (see Table
18-2, Hypertension in Childhood,
p. 374). Proper cuff size is essential
for accurate determination of blood
pressure in children.
The most frequent “cause”of elevated
blood pressure in children is probably an
improperly performed examination, often
from an incorrect cuff size.
Causes of sustained hypertension in
childhood include renal disease, coarctation of the aorta, and primary hypertension. Hypertension is often related to
childhood obesity.
Th e Ey e s
Test visual acuity in each eye and
determine whether the gaze is
conjugate or symmetric.
Any difference in visual acuity between
eyes is abnormal.
Myopia or hyperopia often present in
school-aged children.
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S p e c ia l T e c h n iq u e
The corneal light re ex test
(Fig. 18-7) and the cover–uncover
test (Fig. 18-8) are particularly
useful in young children.
Strabismus can lead to a mblyopia.
Fig ure 18-7 Corne al light re flex te s t.
Fig ure 18-8 Cove r–uncove r te s t.
V is u a l A c u it y
Ag e
Vis u a l Ac u it y
3 months
12 months
Younger than 4 years
4 years and older
Eyes converge, b by re ches
2 / 6 –2 / 8
2 /4
2 /3
Th e Ea r s
Examine the ear canal and drum.
There are two positions for the child
(lying down or sitting), and also two
ways to hold the otoscope, as shown
in Figures 18-9 and 18-10.
Pain on movement of the pinna occurs
with otitis externa.
Fig ure 18-9 Ge ntly holding the child’s
Fig ure 18-10 Ge ntly pulling up on the
arm s re duce s re actions to the otoscope .
auricle give s a be tte r otos cope view
w ith m any childre n.
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EXAMINATIO N TECHNIQ UES
■ Insert the speculum, obtaining a
proper seal.
P n e u m a t ic Ot o s c o p e . Learn
to use a pneumatic otoscope to
improve accuracy of diagnosis of
otitis media. When air is introduced into the normal ear canal,
the tympanic membrane and its
light re ex move inward. When air
is removed, the tympanic membrane moves outward toward you.
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P O SSIBLE FIN DIN G S
Acute otitis media involves a red and
bulging tympanic membrane.
Diminished movement of tymp anic
membrane with a cute otitis media ;
no movement with otitis media with
effusion.
Th e M o u t h a n d P h a r y n x
For anxious or young children,
leave this examination toward
the end. The best technique for a
tongue blade is to push down and
pull slightly forward toward you
while the child says “ah.” Do not
place the blade too far posteriorly,
eliciting a gag re ex.
A common cause of a strawberry tongue,
red uvula, and pharyngeal exudate is
streptococcal pharyngitis.
Examine the teeth for the timing
and sequence of eruption, number,
character, condition, and position.
Abnormalities of the enamel may reflect
local or general disease.
Carefully inspect the inside of
the upper teeth, as shown in
Figure 18-11.
Nursing bottle ca ries; denta l caries; staining of the teeth, which may be intrinsic or
extrinsic
Dental ca ries are the most common
health problem of children and are
particularly prevalent in impoverished
children.
Fig ure 18-11 Lift the lip to che ck for
de ntal carie s .
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Look for abnormalities of tooth
position.
Malocclusion
Note the size, position, symmetry,
and appearance of the tonsils.
Peritonsillar a bscess
Th e H e a r t
A challenging aspect to cardiac
examination of children is evaluation of heart murmurs, particularly
distinguishing common benign
murmurs from unusual or pathologic ones. Most children have one
or more functional, or benign, heart
murmurs at some point in time
(Fig. 18-12).
See Table 18-3, Characteristics of Pathologic Heart Murmurs, pp. 375–376.
Venous hum
Carotid
bruit
Pulmonary
flow
Still’s
murmur
Fig ure 18-12 Location of be nign he art m urm urs in
childre n.
Th e A b d o m e n
Most children are ticklish when
you rst place your hand on their
abdomens for palpation. This reaction tends to disappear, particularly
if you distract the child.
A pathologically enlarged liver in children usually is palpable more than 2 cm
below the costal margin, has a round,
firm edge, and often is tender.
A common condition of childhood that
can occasionally cause a protuberant
abdomen is constipation.
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P O SSIBLE FIN DIN G S
M a le G e n it a lia
There is an art to palpation of the
young boy’s scrotum and testes,
because many have an active cremasteric re ex causing the testes to
retract upward into the inguinal
canal and appear undescended. A
useful technique is to have the boy
sit cross-legged on the examining
table.
In precocious puberty, the penis and testes are enlarged, with signs of pubertal
changes.
A painful testicle requires rapid treatment and may indicate torsion.
Inguinal hernias in older boys present as
they do in adult men.
F e m a le G e n it a lia
Use a calm, gentle approach,
including a developmentally appropriate explanation.
Examine the genitalia in an ef cient and systematic manner. The
normal hymen can have various
con gurations (Fig. 18-13).
Vaginal discha rge in early childhood can
result from perinea l irritation (e.g., from
bubble baths, soaps), foreign body, va ginitis, or sexually tra nsmitted infections
from sexual abuse. Va ginal bleeding,
a brasions, or signs of trauma to the
external genitalia can result from sexua l
a buse (see Table 18-7, Physical Signs of
Sexual Abuse, p. 381).
Fig ure 18-13 Se parate labia to as s e s s
ge nital s tructure s .
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T h e M u s c u lo s k e le t a l S y s t e m
Abnormalities of the upper extremities are rare in the absence of injury.
To assess the lower extremities,
observe the child standing and
walking barefoot, and ask the child
to touch the toes, rise from sitting,
run a short distance, and pick up
objects. You will detect most abnormalities by watching carefully.
A screening musculoskeletal examination for children participating in sports
can detect injuries or abnormalities that
may result in problems during athletics.
Extreme bowing or unilateral bowing
may be from pathologic causes such as
rickets or tibia vara (Blount disease).
Th e N e r v o u s S y s t e m
Beyond infancy, the neurologic
examination includes the components evaluated in adults. Again,
combine the neurologic and developmental assessments. You can
turn this into a game with the child
to assess optimal development and
neurologic performance.
Delayed language or cognitive skills can
be due to neurologic disease as well as
developmental disorders.
Soft neurologic signs can suggest minor
developmental abnormalities.
Assessing Adolescents
The key to successfully examining teens is a comfortable, con dential environment that makes the examination relaxed and informative. Adolescents
are more likely to open up when the interview focuses on them rather than
on their problems.
Consider the patient’s cognitive and social development when deciding
issues of privacy, parental involvement, and con dentiality. Explain to
both teens and parents that the purpose of con dentiality is to improve
health care, not keep secrets. Your goal is to help adolescents bring their
concerns or questions to their parents. Never make con dentiality unlimited, however. Always state to teens explicitly that you may need to act on
information that makes you concerned about safety.
The physical examination of the adolescent is similar to that of the adult.
Keep in mind issues particularly relevant to teens, such as puberty, growth,
development, family and peer relationships, sexuality, decision making,
and risk behaviors. For more details on speci c techniques of examination, the reader should refer to the corresponding chapter for the regional
examination of interest or concern. Following are special areas to highlight
when examining adolescents.
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Chapter 18 | Assessing Children: Infancy through Adolescence
EXAMINATIO N TECHNIQ UES
371
P O SSIBLE FIN DIN G S
Th e B r e a s t s
Assess normal maturational
development.
See Table 18-4, Sex Maturity Ratings in
Girls: Breasts, p. 377.
S p e c ia l T e c h n iq u e
Te s t in g fo r S c o lio s is . Inspect
any child who can stand for scoliosis. Make sure the child bends
forward with the knees straight
(Adams bend test). Evaluate any
asymmetry in positioning or gait. If
you detect scoliosis, use a scoliometer to test for the degree of scoliosis
(Fig. 18-14).
Fig ure 18-14 Me as ure and re cord
s colios is w ith a s coliom e te r.
M a le a n d F e m a le G e n it a lia
An important goal when examining adolescent males and females is
to assign a sexual maturity rating,
regardless of chronologic age.
See Table 18-5, Sex Maturity Ratings in
Boys, pp. 378–379, and Table 18-6, Sex
Maturity Ratings in Girls: Pubic Hair,
p. 380.
Recording Your Findings
The format of the pediatric medical record is the same as that of the adult.
Thus, although the sequence of the physical examination may vary, convert
your written ndings back to the traditional format.
R e c o r d in g t h e P h y s ic a l E x a m in a t io n —
T h e P e d ia t r ic P a t ie n t
Bri n is chubby, ctive, nd energetic toddler. He l ys with the reflex h er, retending it is truck. He
e rs closely bonded with his other, looking t her occ sion lly for co fort. She see s concerned th t Bri n will bre k
so ething. His clothes re cle n.
(continued )
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Ba te s ’ Poc ke t Guide to Phys ic a l Exa mina tion a nd His tory Ta king
R e c o r d in g t h e P h y s ic a l E x a m in a t io n —
T h e P e d ia t r ic P a t ie n t (Continued )
Vit a l S ig n s . Ht 9 c
(9 th ercentile). Wt 16 kg (>95th ercentile). BMI 19.8
(>95th ercentile). He d circu ference 5 c (75th ercentile). BP 1 8/58.
He rt r te 9 nd regul r. Res ir tory r te 3 ; v ries with ctivity. Te er ture
(e r) 37.5°C. Obviously no in.
S k in . Nor
l exce t for bruises on legs, nd
surf ce of elbows.
tchy, dry skin over extern l
HEEN T. Head: Nor oce h lic; no lesions. Eyes: Difficult to ex
ine bec use he
won’t sit still. Sy
etric with nor l extr ocul r ove ents. Pu ils 4 to 5
constricting. Discs difficult to visu lize; no he orrh ges noted. Ears: Nor l
inn ; no extern l bnor lities. Nor l extern l c n ls nd ty
nic e br nes (TMs). Nose: Nor l n res; se tu
idline. Mouth: Sever l d rkened
teeth on inside surf ce of u er incisors. One cle r c vity on u er right incisor.
Tongue nor l. Cobblestoning of osterior h rynx; no exud tes. Tonsils l rge
but dequ te g (1.5 c ) between the .
N e c k . Su
le,
idline tr che , no thyroid
l ble.
Ly m p h N o d e s . E sily
l ble (1.5 to 2 c ) tonsill r ly h nodes bil ter lly.
S ll ( .5 c ) nodes in inguin l c n l bil ter lly. All ly h nodes obile nd
nontender.
Lu n g s . Good ex
nsion. No t chy ne or dys ne . Congestion udible, but
see s to be u er irw y (louder ne r outh, sy
etric). No rhonchi, r les,
or wheezes. Cle r to uscult tion.
C a r d io va s c u la r. PMI in 4th or 5th inters
ce nd idstern l line. Nor l S1
nd S2. No ur urs or bnor l he rt sounds. Nor l fe or l ulses; dors lis
edis ulses l ble bil ter lly.
Br e a s t s . Nor
l, with so e f t under both.
A b d o m e n . Protuber nt but soft; no
below right cost l
l ble.
sses or tenderness. Liver s n 2 c
rgin (RCM) nd not tender. S leen nd kidneys not
G e n it a lia . T nner I circu cised enis; no ubic h ir, lesions, or disch rge.
Testes descended, difficult to
Nor l scrotu both sides.
M u s c u lo s k e le t a l. Nor
l te bec use of ctive cre
l r nge of otion of u
nd ll joints. S ine str ight. G it nor l.
steric reflex.
er nd lower extre ities
N e u ro lo g ic . Mental Status: H
y, coo er tive child. Developmental:
Gross otor—Ju s nd throws objects. Fine otor—I it tes vertic l line.
L ngu ge—Does not co bine words; single words only, three to four noted
during ex in tion. Person l–soci l—W shes f ce, brushes teeth, nd uts on
shirt. Over ll—Nor l, exce t for l ngu ge, which
e rs del yed. Cranial
Nerves: Int ct, lthough sever l difficult to elicit. Cerebellar: Nor l g it; good
b l nce. Deep tendon reflexes (DTRs): Nor l nd sy
etric throughout with
downgoing toes. Sensory: Deferred.
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Chapter 18 | Assessing Children: Infancy through Adolescence
373
Aids to Interpretation
Table 18-1 Cla s s if ic a t io n o f Ne w b o rn ’s
Le ve l o f Ma t u rit y
Intraute rine Gro wth Curve s
5
4.5
90%
4
La rge for ge s ta tiona l a ge
Appropria te
for ge s ta tiona l a ge
3
10%
2.5
S ma ll for
ge s ta tiona l a ge
B
i
r
t
h
W
e
i
g
h
t
(
k
g
)
3.5
2
A
B
1.5
1
0.5
25
27
29
31
33 35 37 39
We e ks of Ge s ta tion
P re ma ture
Te rm
41
43
45
Pos tma ture
Weight Small for Gestational Age (SGA) = Birth weight <10th percentile
on the intrauterine growth curve
Weight Appropriate for Gestational Age (AGA) = Birth weight within
the 10th and 90th percentiles on the intrauterine growth curve
Weight Large for Gestational Age (LGA) = Birth weight >90th percentile
on the intrauterine growth curve
Level of intrauterine growth based on birth weight and gestational age of liveborn, single, white
infants. Point A represents a premature infant, while point B indicates an infant of similar
birth weight who is mature but small for gestational age; the growth curves are representative
of the 10th and 90th percentiles for all of the newborns in the sampling.
Adapted from Sweet YA. Classi cation of the low-birth-weight infant. In: Klaus MH, Fanaroff AA.
Care of the High-Risk Neonate, 3rd ed. Philadelphia, PA: WB Saunders; 1986. Reproduced with
permission.
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Ba te s ’ Poc ke t Guide to Phys ic a l Exa mina tion a nd His tory Ta king
Table 18-2 Hyp e r t e n s io n in Ch ild h o o d
Hypertension can start in childhood. Although young children with
elevated blood pressure are more likely to have a renal, cardiac, or
endocrine cause older children and adolescents with hypertension are
most likely to have primary or essential hypertension. Hypertension is
often related to obesity.
This child developed hypertension before adolescence, and it “tracked”
into adulthood. Children tend to remain in the same percentile for blood
pressure as they grow. This tracking of blood pressure continues into
adulthood, supporting the concept that adult essential hypertension
begins during childhood.
The consequences of untreated hypertension can be severe.
S
y
s
t
o
l
i
c
B
l
o
o
d
P
r
e
s
s
u
r
e
Boys S ys tolic Blood P re s s ure 95% Pe rce ntile
150
145
140
135
130
125
120
115
110
105
100
95
90
0
1
2
S ys tolic 5%
3
4
5
6
7
8 9 10 11 12 13 14 15 16 17
Age (Ye a rs )
S ys tolic 50%
S ys tolic 95%
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Chapter 18 | Assessing Children: Infancy through Adolescence
375
Table 18-3 Ch a ra c t e ris t ic s o f P a t h o lo g ic
He a r t Mu rm u r s
C o n g e n it a l D e f e c t
C h a r a c t e r is t ic s o f M u r m u r
P u lm o n a ry Va lve S t e n o s is
Location. Upper left sternal border
Mild
Radiation. In mild degrees of
stenosis, the murmur may be heard
over the course of the pulmonary
arteries in the lung fields.
S1
A2
P2
Intensity. Increases in intensity and
duration as the degree of
obstruction increases
Quality. Ejection, peaking later in
systole as the obstruction increases
Se ve re
S1
A2
P2
Location. Midsternum, upper right
sternal border
Ao r t ic Va lve S t e n o s is
S1
A2
P2
Radiation. To the carotid arteries
and suprasternal notch; may also
be a thrill
Intensity. Varies, louder with
increasingly severe obstruction
Quality. An ejection, often harsh,
systolic murmur
Te t r a lo g y o f Fa llo t
General. Variable cyanosis,
increasing with activity
With Pu lm o n ic S te n o s is
Location. Mid to upper left sternal
border. If pulmonary atresia, there
is no systolic murmur but the
continuous murmur of ductus
arteriosus flow at upper left sternal
border or in the back.
With Pu lm o n ic Atre s ia
Radiation. Little, to upper left sternal
border, occasionally to lung fields
S1
A2
S1
Intensity. Usually grade III–IV
Quality. Midpeaking, systolic
ejection murmur
(table continues on page 376)
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Ba te s ’ Poc ke t Guide to Phys ic a l Exa mina tion a nd His tory Ta king
Table 18-3 Ch a ra c t e ris t ic s o f P a t h o lo g ic
He a r t Mu rm u r s (continued )
C o n g e n it a l D e f e c t
C h a r a c t e r is t ic s o f M u r m u r
Tr a n s p o s it io n o f t h e
G r e a t A r t e r ie s
General. Intense generalized
cyanosis
Location. No characteristic murmur.
If present, it may reflect an
associated defect such as VSD.
Radiation and quality. Depends on
associated abnormalities
Ve n t r ic u la r S e p t a l D e f e c t
Location. Lower left sternal border
S m a ll to Mo d e ra te
Radiation. Little
S1
A2
P2
Intensity. Variable, only partially
determined by the size of the
shunt. Small shunts with a highpressure gradient may have very
loud murmurs. Large defects with
elevated pulmonary vascular
resistance may have no murmur.
Grade II–IV/VI, with a thrill if
grade IV/VI or higher.
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Chapter 18 | Assessing Children: Infancy through Adolescence
377
Table 18-4 S e x Ma t u rit y Ra t in g s in Girls : Bre a s t s
Stage 1
Preadolescent—elevation of nipple only
Stage 2
Stage 3
Breast bud stage. Elevation of
breast and nipple as a small
mound; enlargement of areolar
diameter
Further enlargement and
elevation of breast and areola,
with no separation of the
contours
Stage 4
Stage 5
Projection of areola and nipple to
form a secondary mound above the
level of the breast
Mature stage; projection of nipple
only. Areola has receded to
general contour of the breast
(although may continue to form
a secondary mound).
Photos reprinted, with permission from the American Academy of Pediatrics, Assessment of
Sexual Maturity Stages in Girls, 1995.
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Ba te s ’ Poc ke t Guide to Phys ic a l Exa mina tion a nd His tory Ta king
Table 18-5 S e x Ma t u rit y Ra t in g s in Bo ys
In assigning SMRs in boys, observe each of the three characteristics
separately. Record two separate ratings: pubic hair and genital. If the
penis and testes differ in their stages, average the two into a single figure
for the genital rating.
Stage 1
Pubic Hair: Preadolescent—no pubic hair
except for the fine body hair (vellus hair)
similar to that on the abdomen
Genitalia
■
Stage 2
Penis, Testes, and Scrotum:
Preadolescent—same size and
proportions as in childhood
Pubic Hair: Sparse growth of long, slightly
pigmented, downy hair, straight or only
slightly curled, chiefly at the base of the
penis
Genitalia
■
■
Stage 3
Penis: Slight to no enlargement
Testes and Scrotum: Testes larger;
scrotum larger, somewhat reddened, and
altered in texture
Pubic Hair: Darker, coarser, curlier hair
spreading sparsely over the pubic symphysis
Genitalia
■
■
Penis: Larger, especially in length
Testes and Scrotum: Further enlarged
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Chapter 18 | Assessing Children: Infancy through Adolescence
379
Table 18-5 S e x Ma t u rit y Ra t in g s in Bo ys (continued )
Stage 4
Pubic Hair: Coarse and curly hair, as in the
adult; area covered greater than in stage 3
but less than adult and not yet on thighs
Genitalia
■
■
Stage 5
Penis: Further enlarged in length and
breadth, with development of the glans
Testes and Scrotum: Further enlarged;
scrotal skin darkened
Pubic Hair: Hair adult quantity and quality,
spread to the medial surfaces of the thighs
but not up over the abdomen
Genitalia
■
■
Penis: Adult in size and shape
Testes and Scrotum: Adult in size and
shape
Photos reprinted from Pediatric Endocrinology and Growth, 2nd ed., Wales & Wit, 2003, with
permission from Elsevier.
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Ba te s ’ Poc ke t Guide to Phys ic a l Exa mina tion a nd His tory Ta king
Table 18-6 S e x Ma t u rit y Ra t in g s in Girls : P u b ic Ha ir
Stage 1
Preadolescent—no pubic hair except for
the fine body hair (vellus hair) similar to
that on the abdomen
Stage 2
Sparse growth of long, slightly pigmented,
downy hair, straight or only slightly
curled, chiefly along the labia
Stage 3
Darker, coarser, curlier hair, spreading
sparsely over the pubic symphysis
Stage 4
Coarse and curly hair as in adults; area
covered greater than in stage 3 but not as
great as in the adult and not yet including
the thighs
Stage 5
Hair adult in quantity and quality, spread
on the medial surfaces of the thighs but
not up over the abdomen
Photos reprinted, with permission from the American Academy of Pediatrics, Assessment of Sexual
Maturity Stages in Girls, 1995.
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Chapter 18 | Assessing Children: Infancy through Adolescence
381
Table 18-7 P h ys ic a l S ig n s o f S e xu a l Ab u s e
P h y s ic a l S ig n s Th a t M a y In d ic a t e S e x u a l A b u s e in
C h ild r e n a
1. Marked and immediate dilatation of the anus in knee–chest position,
with no constipation, stool in the vault, or neurologic disorders
2. Hymenal notch or cleft that extends >50% of the inferior hymenal rim
(confirmed in knee–chest position)
3. Condyloma acuminata in a child older than 3 years
4. Bruising, abrasions, lacerations, or bite marks of labia or perihymenal
tissue
5. Herpes of the anogenital area beyond the neonatal period
6. Purulent or malodorous vaginal discharge in a young girl (all discharges
should be cultured and viewed under a microscope for evidence of a
sexually transmitted infection)
P h y s ic a l S ig n s Th a t S t ro n g ly S u g g e s t S e x u a l A b u s e in
C h ild r e n a
1. Lacerations, ecchymoses, and newly healed scars of the hymen or the
posterior fourchette
2. No hymenal tissue from 3 to 9 o’clock (confirmed in various positions)
3. Healed hymenal transections, especially between 3 and 9 o’clock
(complete cleft)
4. Perianal lacerations extending to external sphincter
A sexual abuse expert must evaluate a child with concerning physical
signs for a complete history and sexual abuse examination.
a
Any physical sign must be evaluated in light of the entire history, other parts of the physical
examination, and laboratory data.
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19
C H A P T E R
The Pregnant Woman
The Health History
Com m on Conce rns
●
●
●
Initi l ren t l history
● Confir
tion of regn ncy
● Sy
to s of regn ncy
● Concerns bout
nd ttitudes tow rd the regn ncy
● Current he lth nd
st edic l history
● P st obstetric history
● Risk f ctors for
tern l nd fet l he lth
● F
ily history of tient nd f ther of the newborn
● Pl ns for bre stfeeding
● Pl ns for
ost rtu contr ce tion
Gest tion l ge nd ex ected d te of delivery
Subsequent ren t l visits
In it ia l P re n a t a l Vis it . Focus the initial prenatal visit on the health status
of the mother and fetus. Con rm the pregnancy and estimate gestational
age, develop a plan for continuing care, and counsel the mother about her
expectations and concerns. At the end of the visit, reaf rm your commitment to the patient’s health and any ongoing concerns, review your ndings, and discuss any questions or tests or screenings that are needed. Ask
about the following topics:
■ Con rmation of pregnancy. Has the patient had a con rmatory urine
pregnancy test, and when? When was her last menstrual period (LMP)?
Has an ultrasound been done to establish dates? Explain that serum
pregnancy tests are rarely required to con rm pregnancy.
■ Symptoms of pregnancy. Has the patient had absence of menses, breast
fullness or tenderness, nausea or vomiting, fatigue, and urinary frequency? Explain that serum or urine testing for beta human chorionic
gonadotropin (HCG) offers the best con rmation of pregnancy.
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384
Ba te s ’ Poc ke t Guide to Phys ic a l Exa mina tion a nd His tory Ta king
■ Maternal concerns and attitudes. Review the mother’s feelings about
the pregnancy and whether she plans to continue to term. Ask about
any fears and about support from the father. Respect diverse family
structures, such as extended family support, single motherhood, or
pregnancy conceived by sperm donation with or without a partner of
either gender.
■ Current health and past medical history. Does the patient have any
acute or chronic medical concerns, past or present? Pay particular
attention to issues that affect pregnancy, such as abdominal surgeries,
hypertension, diabetes, cardiac conditions including any that were
surgically corrected in childhood, asthma, hypercoagulability states
involving lupus or anticardiolipin antibodies, mental health disorders
including postpartum depression, HIV, sexually transmitted infections,
abnormal Pap smears, and exposure to diethylstilbestrol (DES) in utero.
■ Past obstetric history. Ask about prior pregnancies and outcomes. Has she
had any complications during past pregnancies? Were there any complications during labor and delivery such as large babies (fetal macrosomia),
fetal distress, or emergency interventions? Were deliveries by vaginal
delivery, assisted delivery (vacuum or forceps), or cesarean section?
■ Risk factors for maternal and fetal health. Does the patient use tobacco,
alcohol, or illicit drugs? Does she take any medications, over-thecounter drugs, or herbal prescriptions? Does she have any toxic exposures at work, home, or otherwise? Is her nutritional intake adequate,
or is she at risk from obesity? Does she have an adequate social support
network and income? Is there unusual stress at home or work? Is there
any history of physical abuse or domestic violence?
■ Family history of chronic illnesses or genetically transmitted diseases:
sickle cell anemia, cystic brosis, muscular dystrophy, and others.
■ Plans for breastfeeding. Education and encouragement during pregnancy
increase adoption and duration of breastfeeding.
■ Plans for postpartum contraception. Initiate this discussion early, as
postpartum contraception reduces the risk of unintended pregnancy
and shortened interpregnancy intervals, which are linked to adverse
pregnancy outcomes.
Ge s t a t io n a l Ag e a n d Exp e c t e d Da t e o f De live ry. Accurate dating is best done early and contributes to appropriate management of the
pregnancy. Dating establishes the timeframe for reassuring the patient about
normal progress, establishing paternity, timing screening tests, tracking fetal
growth, and effectively triaging preterm and postdated labor.
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Chapter 19 | The Pregnant Woman
385
D e t e r m in in g G e s t a t io n a l A g e a n d t h e
E x p e c t e d D a t e o f D e liv e r y
●
●
●
●
Gestational age. Count the nu ber of weeks nd d ys fro the first d y of
the LMP. Counting this menstrual age fro the LMP– lthough biologic lly distinct fro the d te of conce tion, is the st nd rd e ns of c lcul ting fet l
ge, yielding n ver ge regn ncy length of 4 weeks. If the ctu l d te of
conce tion is known ( s with in vitro fertiliz tion), conce tion ge which is
2 weeks less th n the enstru l ge c n be used to c lcul te enstru l ge
(i.e., corrected or djusted LMP d ting) to est blish d ting.
Expected date of delivery (EDD). The ex ected d te of delivery is 4 weeks
fro the first d te of the LMP. Using the Naegele rule, the EDD c n be esti ted
by t king the LMP, dding 7 d ys, subtr cting 3 onths, nd dding 1ye r.
Tools for calculations. Pregn ncy wheels nd online c lcul tors re co
only
used to c lcul te the EDD, but they should be checked for ccur cy.
Limitations on pregnancy dating. P tient rec ll of the LMP is highly v ri ble.
The LMP c n lso be bi sed by hor on l contr ce tives, enstru l irregul rities, or v ri tions in ovul tion th t result in ty ic l cycle lengths. Check LMP
d ting g inst hysic l ex in tion
rkers such s fund l height, cl rifying
discre ncies g inst ultr sound ev lu tion.
S u b s e q u e n t P re n a t a l Vis it s . During subsequent visits, assess interim
changes in the health status of the mother and fetus, review speci c physical examination ndings related to the pregnancy, and provide counseling
and timely preventive screenings. Obstetric visits traditionally follow a
set schedule: monthly until 28 gestational weeks, then biweekly until
36 weeks, then weekly until delivery. Update and document the history at
every visit, especially fetal movement, contractions, leakage of uids and
vaginal bleeding. At every visit, assess: vital signs (especially blood pressure and weight), fundal height, veri cation of FHR, and fetal position and
activity. At each visit, test the urine for infection and protein.
Health Promotion and Counseling:
Evidence and Recommendations
Im p o r t a n t T o p ic s f o r H e a lt h P r o m o t io n
a n d C o u n s e lin g
●
●
●
●
●
●
●
Nutrition
Weight g in
I
uniz tions
Exercise
Subst nce buse
Inti te rtner violence
Pren t l l bor tory screenings
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Ba te s ’ Poc ke t Guide to Phys ic a l Exa mina tion a nd His tory Ta king
Nu t rit io n a n d We ig h t Ga in . Evaluate nutritional status, especially
inadequate nutrition and obesity.
■ Assess diet history; measurement of height, weight, and body mass
index (BMI); and a hematocrit. Prescribe needed vitamin and mineral
supplements.
■ To help prevent listeriosis, encourage pregnant patients to avoid:
unpasteurized milk and foods made with unpasteurized milk; raw and
undercooked seafood, eggs, and meat; refrigerated paté, meat spreads,
and smoked salmon; and hot dogs, luncheon meats, and cold cuts
unless served steaming hot.
■ Recommend two servings a week of selected sh low in mercury and
shell sh.
■ Make a nutritional plan tailored to the patient’s BMI. Use the Pregnancy
Weight Gain Calculator and Super Tracker at the user-friendly ChooseMyPlate.gov website (http://www.choosemyplate.gov/pregnancy-weightgain-calculator). This calculator displays the daily recommended intake
of each of the ve food groups for each trimester, based on height,
prepregnancy weight, due date, and levels of weekly exercise.
Monitor weight gain at each visit, with the results plotted on a graph,
using the updated recommendations below.
R e c o m m e n d a t io n s f o r T o t a l a n d R a t e o f W e ig h t G a in
D u r in g P r e g n a n c y , b y P r e p r e g n a n c y B M I, 2 0 0 9
P re p re g n a n c y
BM Ia
Underweight, or <18.5
Nor l weight, or 18.5–24.9
Overweight, or 25. –29.9
Obese, or ≥3 .
To t a l We ig h t
G a in (Ra n g e
in lb s )
28–4
25–35
15–25
11–2
Ra t e s o f We ig h t G a in b
2 n d a n d 3 r d Tr im e s t e r s
(lb s /w k )
1
1
.6
.5
M e a n Ra n g e
1. –1.3
.8–1.
.5– .7
.4– .6
To c lcul te BMI, go to C lcul te Your Body M ss Index, N tion l He rt, Lung, nd Blood
Institute t htt :/ / www.nhlbi.nih.gov/ he lth/educ tion l/ lose_wt/ BMI/ b ic lc.ht .
b
C lcul tions ssu e 1.1–4.4 lbs-weight g in in the first tri ester.
Source: R s ussen KM, Y ktine AL (eds.) nd Institute of Medicine. Committee to Re-examine
IOM Pregnancy Weight Guidelines. Weight gain during pregnancy: re-examining the guidelines.
W shington, DC: N tion l Ac de ies Press, 2 9. Av il ble t htt :/ / www.ncbi.nl .nih.
gov/ books/ NBK32799/ t ble/su
ry.t1/ ?re ort = objectonly. Accessed Se te ber 4, 2 15.
a
Im m u n iza t io n s . Administer Tdap during each pregnancy, ideally at 27
to 36 weeks of gestation, regardless of the prior immunization history, and
to caretakers in direct contact with the infant. Give inactivated in uenza
vaccination in any trimester during the in uenza season.
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387
S a f e a n d U n s a f e V a c c in e s d u r in g P r e g n a n c y
S a f e d u r in g P r e g n a n c y
●
●
●
●
N o t S a f e d u r in g P r e g n a n c y
Pneu ococc l olys cch ride
Meningococc l olys cch ride nd
conjug te
He titis A
He titis B
●
●
●
Me sles/ u
Polio
V ricell
s/rubell
All women should have rubella titers drawn during pregnancy and be
immunized after birth if found to be nonimmune. Check Rh(D) and antibody typing at the rst prenatal visit, at 28 weeks, and at delivery. Anti-D
immunoglobulin should be given to all Rh-negative women at 28 weeks’
gestation and again within 3 days of delivery to prevent sensitization if the
infant is Rh-D positive.
Exe rc is e . Recommend ≥30 minutes of moderate exercise on most days
of the week unless there are contraindications. Women initiating exercise
during pregnancy should be cautious and consider programs developed
speci cally for pregnant women. Water-based exercises can temporarily
help alleviate musculoskeletal aches, but immersion in hot water should be
avoided. After the rst trimester, women should avoid exercise in the supine
position, which compresses the inferior vena cava and can cause dizziness
and decreased placental blood ow. Because the center of gravity shifts in the
third trimester, advise against exercises that cause loss of balance. Contact
sports or activities that risk abdominal trauma are contraindicated throughout pregnancy. Pregnant women also should avoid overheating, dehydration,
and any exertion that causes notable fatigue or discomfort.
S u b s t a n c e Ab u s e . Promote abstinence as the immediate goal during
pregnancy. Pursue universal screening in a neutral manner for:
■ Tobacco. Tobacco use accounts for up to 20% of all low-birth-weight
babies. It doubles the risk of placenta previa, placental abruption, and
preterm labor and increases risk of spontaneous abortion, fetal death,
and fetal digit anomalies. Cessation is the goal, but any decrease in use
is favorable.
■ Alcohol. Fetal alcohol syndrome is the leading cause of preventable men-
tal retardation in the United States. The American Congress of Obstetricians and Gynecologists (ACOG) strongly recommends that women
abstain throughout pregnancy.
■ Illicit drugs including narcotics. Women with addictions should be
referred for treatment immediately and counseled and screened for
hepatitis C and HIV.
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■ Abuse of prescription drugs. Ask about commonly abused prescription
drugs, including narcotics, stimulants, benzodiazepines.
In t im a t e P a r t n e r Vio le n c e . Pregnancy is a time of increased risk from
intimate partner violence ranging from verbal to physical abuse or from mild
to severe physical abuse. Up to one in ve women experiences some form
of abuse during pregnancy, contributing to delayed prenatal care, low infant
birth weight, or even murder of the mother and fetus. ACOG recommends
universal screening of all women for domestic violence at the rst prenatal
visit and at least once each trimester. For a direct nonjudgmental approach,
ACOG recommends the statement and simple questions listed below.
A C O G S c r e e n in g A p p r o a c h f o r In t im a t e
P a r t n e r V io le n c e
Initial Statement: “Bec use violence is so co
on in
ny wo en’s lives nd
bec use there is hel v il ble for wo en being bused, I now sk every tient
bout do estic violence.”
Screening Questions:
1. “Within the st ye r—or since you h ve been regn nt—h ve you been hit,
sl
ed, kicked or otherwise hysic lly hurt by so eone?”
2. “Are you in rel tionshi with erson who thre tens or hysic lly hurts you?”
3. “H s nyone forced you to h ve sexu l ctivities th t
de you feel
unco fort ble?”
Source: A eric n Congress of Obstetrici ns nd Gynecologists. Screening tools–do estic
violence. Av il ble t htt :/ / www. cog.org/About-ACOG/ACOG-De rt ents/ ViolenceAg inst-Wo en/ Screening-Tools–Do estic-Violence. Accessed Se te ber 2, 2 15.
Watch for nonverbal clues of abuse such as frequent last-minute appointment changes, unusual behavior during visits, partners who refuse to leave
the patient alone during the visit, and bruises or other injuries. Once the
patient acknowledges abuse, ask about the best way for you to help her.
Respect limits she places on sharing information, with the caveat that if
children are involved, you may be required to report harmful behaviors
to the authorities. Maintain an updated list of shelters, counseling centers,
hotline numbers, and other trusted local referrals. Plan future appointments
at more frequent intervals. Perform as thorough a physical examination as
the patient permits, and document all injuries on a body diagram.
N a t io n a l D o m e s t ic V io le n c e H o t lin e
●
●
●
Website: www.thehotline.org
1–8 –799-SAFE (7233)
TTY for he ring i
ired: 1–8
–787–3224
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P re n a t a l La b o ra t o ry S c re e n in g s . Initially include blood type and
Rh, antibody screen, complete blood count—especially hematocrit and
platelet count, rubella titer, syphilis test, hepatitis B surface antigen, HIV,
STI screen for gonorrhea and chlamydia, and urinalysis with culture.
Scheduled screenings include an oral glucose tolerance test for gestational
diabetes around 24 weeks; a vaginal swab for group B streptococcus
between 35 to 37 weeks’ gestation; and for obese pregnant patients, a
glucose tolerance in the rst trimester. Pursue additional tests related to
the mother’s risk factors, such as screening for aneuploidy, Tay–Sachs, or
other genetic diseases, or amniocentesis.
Techniques of Examination
P r e p a r in g f o r t h e E x a m in a t io n
Be res onsive to the tient’s co fort nd riv cy, s well s her individu l nd
cultur l sensitivities. During the initi l visit, t ke the history while she is
clothed. Ask her to we r her gown with the o ening in front to e se the ex in tion of both bre sts nd the regn nt bdo en.
Positioning
● The se
isitting osition with the knees bent (see . 391) ffords the ost
co fort nd rotects bdo in l org ns nd vessels fro the weight of the
gr vid uterus.
● Avoid rolonged eriods of lying on the b ck. M ke your bdo in l
l tion
efficient nd ccur te.
● The elvic ex
in tion lso should be rel tively quick.
Equipment
● Gynecologic speculum and lubrication: Bec use of v gin l w ll rel x tion during
regn ncy, l rger-th n-usu l s eculu
y be needed.
● Sampling materials: The cervic l brush
y c use bleeding, so the “broo ”
s
ling device is referred during regn ncy. Use ddition l sw bs if
needed to screen for sexu lly tr ns itted infections, grou B stre , nd wet
ount re r tions.
● Tape measure: Use
l stic or
er t e e sure to ssess the size of the
uterus fter 2 gest tion l weeks.
● Doppler fetal heart rate monitor and gel: A
ly “Do ler” or “Do tone” to the
gr vid bdo en to ssess fet l he rt r te fter 1 weeks of gest tion.
H e ig h t , W e ig h t , a n d V it a l S ig n s
Observe the general health, emotional state, nutritional status, and coordination as the pregnant woman comes into the room.
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Measure height and weight. Calculate
the BMI with standard tables, using
19 to 25 as normal for the prepregnant state.
Weight loss of more than 5% in excessive
vomiting, or hyperemesis
Measure blood pressure at every visit.
In midpregnancy, it may be lower
than in the nonpregnant state.
H y p e r t e n s io n in P r e g n a n c y
●
●
●
Gestational hypertension: Systolic blood ressure (SBP) >14 or di stolic
blood ressure (DBP) >9 first docu ented fter 2 weeks, without roteinuri or reecl
si , th t resolves by 12 weeks’ ost rtu .
Chronic hypertension: SBP >14 or DBP >9 th t red tes regn ncy.
Preeclampsia: SBP ≥14 or DBP ≥9 fter 2 weeks on two occ sions t le st
4 hours
rt in wo n with reviously nor l BP or BP ≥16 / 11 confir ed
within inutes and roteinuri ≥3
g/24 hours, rotein:cre tinine ≥ .3, or
di stick 1+; or new onset hy ertension without roteinuri nd ny of the following: thro bocyto eni ( l telets <1 ,
/ µL), i
ired liver function
(liver tr ns in se levels ore th n twice nor l), new ren l insufficiency
(cre tinine >1.1 g/dL or doubles in the bsence of ren l dise se), ul on ry
ede , or new onset cerebr l or visu l sy to s.
He a d a n d N e c k
■ Face. Inspect for the mask of
pregnancy, chloasma, or irregular
brownish patches around the
forehead and cheeks, across
the bridge of the nose, or along
the jaw.
Facial edema after 20 weeks in possible
preeclampsia
■ Hair
Hair loss should not be attributed to
pregnancy.
■ Eyes. Note the conjunctival
Anemia of pregnancy may cause conjunctival pallor.
color.
■ Nose, including nasal congestion
Nosebleeds are more common during
pregnancy. Erosion of nasal septum if
use of intranasal cocaine.
■ Mouth
Gingival enlargement common
■ Thyroid gland. Inspect and
Thyroid enlargement, goiters, and nodules are abnormal and should be investigated.
palpate. Modest symmetric
enlargement is common.
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391
P O SSIBLE FIN DIN G S
T h o r a x a n d Lu n g s
Inspect the thorax for contours.
Observe the pattern of breathing.
Auscultate the lungs.
Respiratory alkalosis in later trimesters.
Increased respiratory rate, cough, rales,
or respiratory distress in infection,
asthma, pulmonary embolus, peripartum cardiomyopathy.
He a rt
Palpate the apical impulse.
Impulse may be rotated upward and to
the left toward the 4th intercostal space
by the enlarging uterus.
Auscultate the heart. A venous
hum and systolic or continuous
mammary souf e (see p. 185) are
common.
Murmurs may signal anemia; new diastolic murmurs should be investigated.
If signs of heart failure, consider peripartum cardiomyopathy.
Bre a s ts
Inspect the breasts and nipples for
symmetry and color. Venous pattern, darkened nipples and areolae,
and prominent Montgomery glands
are normal.
Inverted nipples at the time of birth may
hamper breastfeeding.
Palpate for masses. Tender nodular
breasts are normal.
Focal tenderness in mastitis. Investigate
any new discrete masses.
Compress each nipple between
your index nger and thumb.
This may express colostrum from the
nipples; investigate if abnormal bloody
or purulent discharge.
Abdom en
Place the pregnant woman in a
semisitting position with her knees
exed (Fig. 19-1).
Fig ure 19-1 The s e m is itting pos ition.
■ Inspect any scars or striae, the
shape and contour of the abdomen, and the fundal height.
Purplish striae and linea nigra are
normal.
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EXAMINATIO N TECHNIQ UES
P O SSIBLE FIN DIN G S
■ Assess the shape and contour
to estimate pregnancy size
(Fig. 19-2).
36
32
28
24
wks
wks
wks
wks
20 wks
16 wks
12–14 wks
■ Palpate for:
Fig ure 19-2 Grow th patte rns of the
■
Organs and masses
ute rine fundus by we e ks of pre gnancy.
■
Fetal movements, usually
detected after 24 weeks
Ultrasound confirmation of fetal health
and movement may be needed.
■
Uterine contractility
■
Irregular contractions after
12 weeks or after palpation
during the third trimester
Prior to 37 weeks, regular uterine
contractions or bleeding are abnormal,
suggesting preterm labor.
■
If woman is >20 weeks pregnant, measure fundal height
with a tape measure from the
top of the symphysis pubis to
the top of the uterine fundus.
After 20 weeks, measurement
in centimeters should roughly
equal the weeks of gestation.
If fundal height is more than 4 cm higher
than expected, consider multiple gestation, a large fetus, extra amniotic fluid,
or uterine leiomyoma. If more than 4 cm
lower, consider low level of amniotic
fluid, missed abortion, transverse lie,
growth retardation, or fetal anomaly.
■ Auscultate the fetal heart tones,
noting rate (FHR), location, and
rhythm. A Doptone detects the
FHR after 10 weeks. The FHR
is audible with a fetoscope after
18 weeks.
■
Lack of an audible FHR may indicate
pregnancy of fewer weeks than
expected, fetal demise, or false
pregnancy. If unable to locate the FHR,
investigate with formal ultrasound.
Location. From 10 to 18 weeks,
the FHR is in the midline of the
lower abdomen; later depends
on fetal position. Use modi ed
Leopold’s maneuvers to palpate
the fetal head and back and
identify where to listen.
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P O SSIBLE FIN DIN G S
■
Rate. The rate usually is
120 to 160 beats per minute.
After 32 to 34 weeks, the
FHR should increase with
fetal movement.
Sustained dips in FHR, or “decelerations,”
always warrant investigation, at least by
formal FHR monitoring.
■
Rhythm. In the third trimester,
expect a variance of 10 to
15 beats per minute (BPM)
over 1 to 2 minutes.
Lack of beat-to-beat variability late in
pregnancy warrants investigation with
an FHR monitor.
G e n it a lia , A n u s , a n d R e c t u m
Inspect the external genitalia.
Parous relaxation of the introitus, labial
varicosities, enlargement of the labia
and clitoris, scars from an episiotomy or
perineal lacerations
Palpate Bartholin and Skene glands.
Check for a cystocele or rectocele.
Bartholin cyst
Examine the internal genitalia.
S p e c u lu m Exa m in a t io n
■ Inspect the cervix for color,
shape, and healed lacerations.
■ Perform a Pap smear, if
Purplish color of pregnancy; lacerations
from prior deliveries, cervical erosion,
erythema, discharge, or irritation in
cervicitis and STIs
Specimens may be needed for diagnosis
of vaginal or cervical infection
indicated.
■ Inspect the vaginal walls.
Bluish or violet color, deep rugae,
leukorrhea in normal pregnancy; vaginal
discharge in candidiasis and bacterial
vaginosis (can affect pregnancy outcome)
Bim a n u a l Exa m in a t io n . Insert
two lubricated ngers into introitus, palmar side down, with
slight pressure downward on the
perineum. Slide the ngers into the
posterior vaginal vault. Maintaining
downward pressure, gently turn
the ngers palmar side up.
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EXAMINATIO N TECHNIQ UES
P O SSIBLE FIN DIN G S
■ Assess the cervical os and degree
of effacement. Place your nger
gently in the os, and then sweep
it around the surface of the cervix.
■ Estimate the length of the cervix.
Closed external os if nulliparous; os
open to size of fingertip if multiparous
Prior to 34 to 36 weeks, cervix should
retain normal length of ≥3 cm. Effacement
prior to 37 weeks in preterm labor.
Palpate the lateral surface from
the cervical tip to the lateral
fornix.
■ Palpate the uterus for size, shape,
consistency, and position.
■ Estimate uterine size. With your
Hegar sign, or early softening of the
isthmus; pear-shaped uterus up to
8 weeks, then globular
An irregularly shaped uterus suggests
uterine myomata or a bicornua te uterus,
two distinct uterine cavities separated
by a septum.
internal ngers placed at either
side of cervix, palmar surfaces
upward, gently lift the uterus
toward the abdominal hand.
Capture the fundal portion of
the uterus between your two
hands and gently estimate size.
■ Palpate the left and right adnexa.
Early in pregnancy, it is important to rule
out tubal (ectopic) pregnancy.
■ Evaluate pelvic oor strength
as you withdraw the examining
ngers.
■ Inspect the anus. Rectal and
Hemorrhoids may engorge later in
pregnancy.
rectovaginal examinations are
usually not indicated.
E x t r e m it ie s
Inspect the legs for varicose veins.
Varicose veins may worsen during
pregnancy.
Palpate the hands and legs for
edema.
Watch for swelling of preeclampsia or
deep venous thrombosis.
Check knee and ankle deep tendon
re exes.
Hyperreflexia may signal preeclampsia.
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395
P O SSIBLE FIN DIN G S
S p e c ia l T e c h n iq u e s
Le o p o ld Ma n e u ve rs
Identify:
■ The upper and lower fetal poles,
namely, the proximal and distal
fetal parts
Common deviations include breech
presentation (fetal buttocks present at
the outlet of the maternal pelvis) and
absence of the presenting part well
down into the maternal pelvis at term.
■ The maternal side where the
fetal back is located
■ The descent of the presenting
part into the maternal pelvis
■ The extent of exion of the fetal
head
■ Estimated fetal weight and size
Fir s t Ma n e u ve r (Up p e r Fe t a l
P o le ). Stand at the woman’s side,
facing her head. Keep the ngers
of both examining hands together.
Palpate gently with the ngertips
to determine what part of the fetus
is in the upper pole of the uterine
fundus (Fig. 19-3).
Fig ure 19-3 Palpate uppe r fe tal pole .
S e c o n d Ma n e u ve r (S id e s o f
t h e Ma t e rn a l Ab d o m e n ). Place
one hand on each side of the
woman’s abdomen, capturing the
fetal body between them (Fig. 19-4).
Steady the uterus with one hand
and palpate the fetus with the other,
looking for the back on one side
and extremities on the other.
Fig ure 19-4 Palpate fe tal back and
extre m itie s .
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EXAMINATIO N TECHNIQ UES
P O SSIBLE FIN DIN G S
Th ird Ma n e u ve r (Lo w e r
Fe t a l P o le a n d De s c e n t
in t o P e lvis ). Face the woman’s
feet. Palpate the area just above
the symphysis pubis (Fig. 19-5).
Note whether the hands diverge
with downward pressure or stay
together to learn if the presenting
part of the fetus, head or buttocks,
is descending into the pelvic inlet.
Fig ure 19-5 Palpate lowe r fe tal pole .
Fo u r t h Ma n e u ve r (Fle xio n o f
t h e Fe t a l He a d ). This maneuver
assesses the exion or extension of
the fetal head, presuming that the
fetal head is the presenting part in
the pelvis. Still facing the woman’s
feet, with your hands positioned
on either side of the gravid uterus
as in the third maneuver, identify the fetal front and back sides
(Fig. 19-6). Using one hand at a
time, slide your ngers down each
side of the fetal body until you
reach the “cephalic prominence,”
that is, where the fetal brow or
occiput juts out.
Fig ure 19-6 Palpate for the ce phalic
prom ine nce .
Recording Your Findings
Pregnant women are described in terms of number of pregnancies
(Gravida, or “G”) and labors (Para, or “P”) they have experienced. Parity
is further broken down into term deliveries, preterm deliveries, abortions
(spontaneous abortions and terminated pregnancies), and living children,
(which yields the mnemonic “TPAL”).
■ For example, a woman who has had two prior children and is pregnant
with her third pregnancy would be referred to simply as “G3P2.”
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Chapter 19 | The Pregnant Woman
397
■ A woman with two spontaneous losses prior to 20 weeks’ gestation,
three living children who delivered at term, and a current pregnancy,
would be referred to as “G6P3023.”
■ One common error is to assign a multiple pregnancy, for example,
twins, as a count of two for either gravity or parity. In practice, each
pregnancy receives only one count in any of the categories regardless of
the number of fetuses, except for living children, when all are counted.
So, designate a rst pregnancy with twins delivered at term as G1P1002.
Typically, the write-up follows a standard order: age, Gs and Ps, weeks of
gestation, means of determining gestational age (ultrasound vs. LMP), followed by chief complaint, chief pregnancy complications, then important
history and examination ndings, as below.
R e c o r d in g t h e P h y s ic a l E x a m in a t io n —T h e
P re gna nt W om a n
“32-ye r-old G3,P11 2 t 18 weeks’ gest tion s deter ined by LMP resents to
est blish ren t l c re. P tient endorses fet l ove ent; denies contr ctions,
v gin l bleeding, nd le k ge of fluids. On extern l ex in tion, low tr nsverse
ces re n sc r is evident; fundus is l ble just below u bilicus. On intern l
ex in tion, cervix is o en to fingerti t the extern l os but closed t the
intern l os; cervix is 3 c long; uterus enl rged to size consistent with 18-week
gest tion. S eculu ex in tion shows leukorrhe with ositive Ch dwick
sign. FHT by Do ler re between 14 nd 145 BPM.” (This describes a healthy
woman at 18 weeks’ gestation.)
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20
C H A P T E R
The Older Adult
Older Americans now number more than 43 million people and are expected
to reach 80 million by 2040, over 20% of the population. Life span at birth
is currently 81 years for women and 76 years for men. The “demographic
imperative” is to maximize not only life span but also “health span” so that
older adults maintain full function for as long as possible, enjoying rich and
active lives in their homes and communities. This entails a focus on healthy
or “successful” aging; understanding and mobilizing family, social, and
community supports; skills directed to functional assessment, “the sixth vital
sign”; and promoting long-term health and safety.
The aging population displays marked heterogeneity. Investigators distinguish “usual” aging, with its complex of diseases and impairments, from
optimal aging. Optimal aging occurs in those people who escape debilitating disease entirely and maintain healthy lives late into their 80s and 90s.
Studies of centenarians show that genes account for approximately 20%
of the probability of living to 100, with healthy lifestyles accounting for
approximately 20% to 30%.
T h e G e r ia t r ic A p p r o a c h f o r P r im a r y C a r e
1. Le rn to quickly identify fr il elderly tients; they re ost vulner ble to
dverse outco es nd ost benefit fro
holistic geri tric
ro ch.
2. Look for co
on geri tric syndro es, including f lls, deliriu /cognitive
i
ir ent, function l de endence, nd urin ry incontinence in every
tient.
3. Le rn bout efficient ssess ent tools for geri trics nd geri tric
syndro es nd te ch clinic l st ff to d inister the when ossible.
4. Be f ili r with co
unity resources, such s f ll revention rogr s,
PACE rogr s, nd senior centers.
5. T ke into ccount
tient’s go ls, life ex ect ncy, nd function l st tus
before considering ny test or rocedure.
6. Review dv nced directives nd go ls of c re eriodic lly.
7. Be knowledge ble bout the Beers Criteri ( J Am Geriatr Soc. 2 12;6 :616);
use the to identify otenti lly in
ro ri te edic tions in the elderly
nd infor
eriodic co rehensive edic tion review.
8. Ado t n evidence-b sed
ro ch to he lth screening, es eci lly in the
fr il elderly.
(continued )
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T h e G e r ia t r ic A p p r o a c h f o r P r im a r y C a r e
(Continued)
9. W tch c refully for ood disorders in the fr il elderly nd consider using
geri tric-s ecific screening tools, such s the five-ite Geri tric De ression Sc le.
10. Provide c regiver su ort when ossible.
Source: C rlson C, Merel SE, Yuk w M. Geri tric syndro es nd geri tric ssess ent for
the gener list. Med Clin N Am. 2 15:99:263; Ad ted fro A eric n Geri trics Society
2 12 Beers Criteri U d te Ex ert P nel. A eric n Geri trics Society u d ted Beers
criteri for otenti lly in
ro ri te edic tion use in older dults. J Am Geriatr Soc.
2 12;6 :616; nd Hoyl MT, Alessi CA, H rker JO, et l. Develo ent nd testing of
five-ite version of the geri tric de ression sc le. J Am Geriatr Soc. 1999;47:873.
The Health History
A p p r o a c h t o t h e O ld e r A d u lt
As you talk with older adults, convey respect, patience, and cultural
awareness. Be sure to address patients by their last name.
Ad ju s t in g t h e O f c e En v iro n m e n t . Make sure the of ce is neither
too cool nor too warm. Face the patient directly, sitting at eye level. A well-lit
room allows the older adult to see your facial expressions and gestures.
More than 50% of older adults have hearing de cits. Free the room of
distractions or noise. Consider using a “pocket talker,” a microphone that
ampli es your voice and connects to an earpiece inserted by the patient.
Chairs with higher seating and a wide stool with a handrail leading up to
the examining table help patients with quadriceps weakness.
S h a p in g t h e Co n t e n t a n d P a c e o f t h e Vis it . Older people often
reminisce. Listen to this process of life review to gain important insights
and help patients as they work through painful feelings or recapture joys
and accomplishments. Balance the need to assess complex problems with
the patient’s endurance and possible fatigue. Consider dividing the initial
assessment into two visits.
Elic it in g S ym p t o m s in t h e Old e r Ad u lt . Older patients may
overestimate their health even when increasing disease and disability are
apparent. To reduce the risk of late recognition and delayed intervention,
adopt more directed questions or health screening tools. Consult with family
members and caretakers.
Acute illnesses present differently in older adults. Be sensitive to unusual
presentations of myocardial infarction and thyroid disease. Older patients
with infections are less likely to have fever.
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401
Recognize the symptom clusters of different geriatric syndromes, characterized by interacting clusters of symptoms that lead to functional decline, for
example, falls, dizziness, depression, urinary incontinence, and functional
impairment. Searching for the usual “unifying diagnosis” may pertain to
fewer than 50% of older adults.
Although cognitive impairment may alter the patient’s history, most older
adults even with mild cognitive impairment can provide suf cient history
to reveal current disorders. Use simple sentences with prompts to trigger
necessary information. If impairments are more severe, con rm symptoms
with family members or caregivers.
Ad d re s s in g Cu lt u ra l Dim e n s io n s o f Ag in g
G e r ia t r ic D iv e r s it y —N o w a n d in 2 0 5 0
●
●
●
●
Hispanic Americans over ge 65 will incre se fro 2.7 illion in 2 1 , or 6.9%
of older dults, to 17.5 illion in 2 5 , or 19.8% of the older o ul tion.
African American older dults will incre se fro 3.4 illion (8.5%), to
1 .5 illion in 2 5 (11.9%).
Asian Americans nd other ethnic grou s, lthough s ller in nu ber currently,
will incre se fro 1.4 illion to 7.5 illion, or fro 3.4% to 8.5%.
Non-Hispanic whites will incre se fro 32.2 illion to 58.5 illion in 2 5 , but
will dro s ercent ge of the older o ul tion fro 8 % to 58.5%.
Source: Feder l Inter gency Foru on Aging Rel ted St tistics. Older A eric ns 2 12, Key
Indic tors of Well Being. Indic tor 2, R ci l nd Ethnic Co osition, . 86. Feder l Intergency Foru on Aging-Rel ted St tistics. W shington, DC: U.S. Govern ent Printing
Office. June 2 12. Av il ble t htt :/ / gingst ts.gov/ gingst tsdotnet/ M in_Site/
D t /2 12_Docu ents/ Docs/ EntireCh rtbook. df. Accessed August 11, 2 15.
Cultural differences affect the epidemiology of illness and mental health,
acculturation, the speci c concerns of the elderly, the potential for misdiagnosis, and disparities in health outcomes. Review the components of
self-awareness needed for cultural responsiveness, discussed in Chapter 3
(pp. 49–50). Ask about spiritual advisors and native healers. Cultural
values particularly affect decisions about the end of life. Elders, family, and
even an extended community group may make these decisions with or for
the older patient.
Com m on Conce rns
●
●
●
●
Activities of d ily living
Instru ent l ctivities of d ily
living
Medic tions
Acute nd ersistent in
●
●
●
●
S oking nd lcohol
Nutrition
Fr ilty
Adv nce directives nd
c re
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Place symptoms in the context of your overall functional assessment, always
focusing on helping the older adult to maintain optimal well-being and
level of function.
Ac t ivit ie s o f Da ily Livin g . Daily activities provide an important
baseline for future evaluations. Ask, “Tell me about your typical day” or
“Tell me about your day yesterday.” Then move to a greater level of detail:
“You got up at 8 AM? How is it getting out of bed?”
A c t iv it ie s o f D a ily Liv in g a n d
In s t r u m e n t a l A c t iv it ie s o f D a ily Liv in g
P h y s ic a l Ac t iv it ie s o f
Da ily Liv in g (A D Ls )
In s t r u m e n t a l Ac t iv it ie s o f
Da ily Liv in g (IA D Ls )
B thing
Dressing
Toileting
Tr nsferring
Continence
Feeding
Using the tele hone
Sho ing
Pre ring food
Housekee ing
L undry
Tr ns ort tion
T king edicine
M n ging oney
Me d ic a t io n s . Adults older than 65 take approximately 30% of all prescriptions. Almost 40% take ve or more prescription drugs daily. Older
adults have more than 50% of all reported adverse drug reactions. Take a
thorough medication history, including name, dose, frequency, and indication for each drug. Explore all components of polypharmacy, including
concurrent use of multiple drugs, underuse, inappropriate use, and nonadherence. Ask about use of over-the-counter medications, vitamin and
nutrition supplements, and mood-altering drugs. Medications are the most
common modi able risk factor associated with falls. “Start low, go slow”
when prescribing doses.
Ac u t e a n d P e r s is t e n t P a in . Pain and associated complaints account
for 80% of clinician visits, usually for musculoskeletal complaints like
back and joint pain. Older patients are less likely to report pain, leading to
undue suffering, depression, social isolation, physical disability, and loss of
function.
Inquire about pain each time you meet with the older patient. Ask speci cally, “Are you having any pain right now? How about over the past
week?” Unidimensional scales such as the Visual Analog Scale, graphic
pictures, and the Verbal 0–10 Scale have all been validated and are easiest
to use.
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C h a r a c t e r is t ic s o f A c u t e a n d P e r s is t e n t P a in
Ac u t e P a in
P e r s is t e n t P a in
Distinct onset
Obvious thology
L sts ore th n 3 onths
Often ssoci ted with sychologic l or function l
i
ir ent
Short dur tion
C n fluctu te in ch r cter nd intensity over ti e
Co
on c uses: ostsurgic l, Co
on c uses: rthritis, c ncer, cl udic tion,
tr u , he d che
leg cr
s, neuro thy, r diculo thy
Source: Reuben DB, Herr KA, P c l JT, et l. Geriatrics at Your Fingertips: 2004. 6th ed. M lden,
MA: Bl ckwell Publishing, for the A eric n Geri trics Society; 2 4:149.
S m o k in g a n d Alc o h o l. At each visit, advise elderly smokers to quit.
From 10% to 15% of older patients in primary care practices have problem
drinking. Rates of detection and treatment are low. Screen all older adults
for excess alcohol use, which contributes to drug interactions and worsens
comorbid illnesses. Use the CAGE questions to uncover problem drinking
(see p. 56), and watch for clues of excess consumption such as memory
loss, depression, and self-neglect.
Nu t rit io n . Taking a diet history and using rapid screening tools (p. 73)
are especially important in older adults.
Fra ilt y. The prevalence of this multifactorial syndrome is 4% to 59%.
Screen for three key features and pursue related interventions: weight loss
of more than 5% over 3 years, inability to do ve chair stands, and selfreported exhaustion.
Ad va n c e Dire c t ive s a n d P a llia t ive Ca re . Initiate these discussions
before serious illness develops. Advance care planning involves providing
information, invoking the patient’s preferences, identifying surrogate
decision makers, and conveying empathy and support. Use clear, simple
language. Clarify preferences related to “Do Not Resuscitate” orders specifying life support measures “if the heart or lungs were to stop or give out.”
Seek a written health care proxy or durable power of attorney for health
care, “someone who can make decisions re ecting your wishes in case of
confusion or emergency.” Discuss these decisions in the of ce rather than
in the pressured environments of the emergency room or hospital.
When needed, provide palliative care “to relieve suffering and improve
the quality of life for patients with advanced illnesses and their families
through speci c knowledge and skills, including communication with
patients and family members; management of pain and other symptoms;
psychosocial, spiritual, and bereavement support; and coordination of an
array of clinical and social services.”
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Health Promotion and Counseling:
Evidence and Recommendations
Im p o r t a n t T o p ic s f o r H e a lt h P r o m o t io n
a n d C o u n s e lin g
●
●
●
●
When to screen
C ncer screening
De ression, de enti , nd cognitive i
Elder istre t ent nd buse
ir ent
Wh e n t o S c re e n . As the life span for older adults extends into the
80s, base screening decisions on the older adult’s individual health and
functional status, including presence of comorbidity, rather than age alone.
The American Geriatrics Society recommends a ve-step approach: assess
patient preferences, interpret the available evidence, estimate prognosis,
consider treatment feasibility, and optimize therapies and care plans. If life
expectancy is short, adopt treatments that bene t the patient in the time
that remains. Defer screening if it overburdens the older adults who have
multiple clinical problems, shortened life expectancy, or dementia.
■ Screen for age-related changes in vision and hearing. These are included
in the 10-Minute Geriatric Screener (p. 407).
■ Recommend aerobic exercise, such as brisk walking for 150 minutes
every week and graded resistance training in major muscle groups to
increase strength.
■ Promote household safety. Correct poor lighting, chairs at awkward
heights, slippery or irregular surfaces, and environmental hazards.
■ Immunizations. Recommend vaccination for in uenza; pneumonia, both
PPSV23 and PCV13; herpes zoster (shingles); and tetanus/diphtheria
and pertussis (Tdap and Td). Consult the updated annual guidelines and
contraindications provided by the CDC at http://www.cdc.gov/vaccines.
Ca n c e r S c re e n in g . Cancer screening can be controversial because of
limited evidence about adults older than age 70 to 80. The U.S. Preventive
Services Task Force (USPSTF) guidelines are summarized below.
S c r e e n in g R e c o m m e n d a t io n s f o r O ld e r A d u lt s :
U . S . P r e v e n t iv e S e r v ic e s T a s k F o r c e
●
Breast cancer (2016): Reco
ends
ogr hy every 2 ye rs for wo en
ges 5 to 74 nd cites insufficient evidence for screening wo en ges ≥75 ye rs.
(continued )
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S c r e e n in g R e c o m m e n d a t io n s f o r O ld e r A d u lt s :
U . S . P r e v e n t iv e S e r v ic e s T a s k F o r c e (Continued)
●
●
●
●
●
Cervical cancer (2012): Reco
ends g inst routine screening for wo en
over ge 65 if they h ve h d dequ te recent screening with nor l P s e rs
nd re not otherwise t high risk for cervic l c ncer, b sed on f ir evidence.
Colorectal cancer (2008): Reco
ends screening with colonosco y every
1 ye rs, sig oidosco y every 5 ye rs with high-sensitivity fec l occult blood
tests (FOBTs) every 3 ye rs, or FOBTs every ye r beginning ge 5 ye rs
through ge 75 ye rs. Reco
ends g inst routine screening for dults ges
76 to 85 ye rs, due to oder te cert inty th t the net benefit is s ll.
Prostate cancer (2012): Reco
ends g inst rost te-s ecific ntigenb sed screening for rost te c ncer in en of ll ges due to evidence th t
ex ected h r s re gre ter th n ex ected benefits.
Lung cancer (2013): For dults ges 55 to 8 ye rs with 3 - ck/ ye r s oking history, nd those who currently s oke or h ve quit within the st
15 ye rs, reco
ends nnu l screening with low-dose co uted to ogr hy.
Screening should be discontinued once erson h s not s oked for 15 ye rs
or develo s he lth roble th t subst nti lly li its life ex ect ncy or the
bility or willingness to h ve cur tive lung surgery.
Skin cancer (2009; updated in 2015): St tes th t evidence is insufficient to
b l nce the benefits nd h r s of whole-body skin ex in tion.
De p re s s io n , De m e n t ia , a n d Co g n it ive Im p a irm e n t . Depression
affects 5% to 7% of community-dwelling older adults and approximately
10% of older men and 18% of older women, but is often undiagnosed. Use
the two validated screening questions in Chapter 5 on pp. 85–86.
Dementia is “an acquired condition that is characterized by a decline in at
least two cognitive domains (e.g., loss of memory, attention, language, or
visuospatial or executive functioning) that is severe enough to affect social or
occupational functioning.” Alzheimer disease (AD), the predominant form,
affects 11% of Americans over age 65 years; over two thirds are women.
Probable AD, based on DSM-5 criteria, consists of evidence of a causative
genetic mutation from family history or genetic testing, or the presence of
cognitive decline in two or more cognitive domains, with all three of the
following features:
■ Clear evidence of a decline in memory and learning and at least one
other cognitive domain (as described for dementia above);
■ Steady progressive decline in cognition without extended plateaus; and
■ No evidence of mixed etiology from other neurodegenerative, cerebro-
vascular, mental, or systemic disease.
Most dementias represent AD (50% to 85%) or vascular multi-infarct
dementia (10% to 20%). Other dementias include frontotemporal
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dementia, dementia with Lewy bodies, Parkinson disease with dementia,
and dementia of mixed etiology.
The spectrum of cognitive decline includes:
■ Age-related cognitive decline: with occasional mild forgetfulness, dif-
culty remembering names, and mildly reduced concentration but
preservation of daily function.
■ Mild cognitive impairment (MCI): Daily function is preserved, but there is
evidence of modest cognitive decline in one or more cognitive domains
(complex attention, executive function, learning and memory, language,
perceptual-motor, or social cognition) based on objective tasks, as
reported by the patient, an informant, or the clinician or on clinical
testing. Alertness and attention is preserved (unlike delirium).
Use recommended screening tests for dementia such as the Mini-Cog and
the Montreal Cognitive Assessment (MoCA). See Table 20-3, p. 420, and
Table 20-4, p. 421.
Eld e r Mis t re a t m e n t a n d Ab u s e . Screen older patients for possible
elder mistreatment, which includes abuse, neglect, exploitation, and abandonment. Prevalence ranges from 5% to 10% of older adults; however,
many cases remain undetected.
Techniques of Examination
Assessment of the older adult departs from the traditional history and
physical examination. Enhanced interviewing, emphasis on daily function
and the key topics described above, and functional assessment are
especially important.
A s s e s s in g F u n c t io n a l S t a t u s :
T h e “ S ix t h V it a l S ig n ”
As s e s s in g Fu n c t io n a l Ab ilit y. Functional status is the ability to perform tasks and ful ll social roles associated with daily living across a wide
range of complexity. The 10-Minute Geriatric Screener is brief, has high
interrater agreement, and can be used easily by of ce staff. It covers the
three important domains: physical, cognitive, and psychosocial function
and addresses key sensory modalities and urinary incontinence, an often
unreported problem. Mnemonics that help students assess incontinence
are: DIAPERS (Delirium, Infection, Atrophic urethritis/vaginitis, Pharmaceuticals, Excess urine output from conditions like hyperglycemia or heart
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failure, Restricted mobility, and Stool impaction) and DDRRIIPP (Delirium,
Drug side effects, Retention of feces, Restricted mobility, Infection of urine,
In ammation, Polyuria, and Psychogenic).
1 0 -M in u t e G e r ia t r ic S c r e e n e r
P ro b le m a n d S c r e e n in g M e a s u r e
P o s it ive S c r e e n
Vision: Two P rts:
Ask: “Do you h ve difficulty driving, or w tching
television, or re ding, or doing ny of your d ily
ctivities bec use of your eyesight?”
If yes, then: Test e ch eye with Snellen ch rt while
tient we rs corrective lenses (if
lic ble).
Hearing: Use udiosco e set t 4 dB. Test he ring
using 1,
nd 2,
Hz.
Yes to question nd
in bility to re d
>2 /4 on Snellen
ch rt
Leg mobility: Ti e the tient fter instructing:
“Rise fro the ch ir. W lk 2 feet briskly, turn,
w lk b ck to the ch ir, nd sit down.”
Urinary incontinence: Two P rts:
Ask: “In the l st ye r, h ve you ever lost your
urine nd gotten wet?”
If yes, then sk: “H ve you lost urine on t le st
6 se r te d tes?”
Nutrition/ weight loss: Two rts:
Ask: “H ve you lost 1 lb over the st 6 onths
without trying to do so?”
Weigh the tient.
Memory: Three-ite rec ll
In bility to he r 1,
or
2,
Hz in both e rs
or either of these
frequencies in one e r
Un ble to co lete t sk
in 15 seconds
Yes to both questions
Yes to the question or
weight <1 lb
Un ble to re e ber ll
three ite s fter
1 inute
Yes to the question
Depression: Ask: “Do you often feel s d or
de ressed?”
Physical disability: Six questions:
No to ny of the
“Are you ble to . . . :
questions
● “Do strenuous ctivities like f st w lking or
bicycling?”
● “Do he vy work round the house like w shing
windows, w lls, or floors?”
● “Go sho
ing for groceries or clothes?”
● “Get to l ces out of w lking dist nce?”
● “B the, either
s onge b th, tub b th, or shower?”
● “Dress, like utting on
shirt, buttoning nd
zi ing, or utting on shoes?”
Source: More AA, Siu AL. Screening for co
on roble s in
bul tory elderly: clinic l
confir tion of screening instru ent. Am J Med. 1996;1 :438.
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Fu r t h e r A s s e s s m e n t fo r P r e ve n t in g Fa lls . Compelling evidence
links falls, a multifactorial geriatric syndrome, to fatal and nonfatal injuries, mortality, and burgeoning clinical costs that exceed $34 billion
annually. One in three older adults falls each year. Falls are the most
common cause of traumatic brain injury in older adults and cause 95%
of hip fractures.
The American Geriatrics Society, the British Geriatrics Society, and the
CDC’s Injury Center has launched the STEADI (Stopping Elderly Accidents,
Deaths, and Injuries) falls prevention toolkit to help primary care providers better assess, treat, and refer patients at risk. Also see Figure 20-1.
S T E A D I F a lls P r e v e n t io n A lg o r it h m : K e y F e a t u r e s
f o r C lin ic a l P r a c t ic e
●
●
●
●
●
●
●
Screen all co
unity-dwelling older dults bout risk for f lls.
Encour ge all older tients to ursue g it nd b l nce exercise.
Do g it, strength, nd b l nce ssess ent with the Ti ed Get U nd Go
test in tients who screen ositive.
Str tify tients ccording to low, oder te, nd high risk.
Identify high-risk older adults, n ely, those with g it, strength, or b l nce
roble
nd t le st one f ll with n injury.
In high-risk older adults, conduct
ultif ctori l risk ssess ent, including:
● review of the St y Inde endent brochure;
●
f lls history nd edic tion review;
●
hysic l ex in tion including ssess ent of visu l cuity, ostur l hy otension, cognitive screen, ins ection of the feet nd use of footwe r, nd
use of obility ids;
● function l ssess
ent; nd
● environ
ent l or ho e s fety ssess ent.
I le ent individu lized interventions, including hysic l ther y nd
follow-u in 3 d ys.
EXAMINATIO N TECHNIQ UES
P O SSIBLE FIN DIN G S
P h y s ic a l E x a m in a t io n
o f t h e O ld e r A d u lt
Vit a l S ig n s . Measure blood
pressure, checking for increased
systolic blood pressure (SBP) and
widened pulse pressure (PP),
de ned as SBP minus diastolic
blood pressure (DBP).
Isolated systolic hypertension (SBP ≥140)
after age 50 years and PP ≥60 increase
risk of stroke, renal failure, and heart
disease.
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Chapter 20 | The Older Adult
409
Pa tie nt c ompletes S tay
Indep endent brochure
Sc re e n fo r falls and/o r fall ris k
Pa tie nt a ns we rs YES to a ny key
ques tion:
)
s t (optional)
medications
Vitamin D +/– calcium
L
o
w
R
i
i
s
k
H
i
e nhanc e func tional
mobility & improve
s tre ngth & ba la nc e
fall ris k reduction
beha viors
es s
barriers to
adhe re nc e
g
Vita min D +/– ca lc ium
Fo llo w up with HIGH
RISK patie nt within
30 days
re p la n
h
inc luding:
- Pos tura l
dizzine s s /pos tural
hyp ote ns ion
- Medica tion review
- Cognitive s cree n
- Fee t & footwea r
- Us e of mobility a id s
- Vis ual ac uity c he ck
HIGH RISK
Individualize d fall
inte rve ntio ns
R
Co nduc t
multifac to rial
ris k as s e s s me nt
S tay
Inde pende nt
brochure
No injury
i
Injury
0 falls
s
1 fa ll
k
≥2 falls
improve gait,
strength & balance
or
refer to a community
fall prevention
program
R
e
t
Gait, s trength or balanc e problem
s
MODERATE RISK
Individualize d fall
inte rve ntio ns
M
(re commended)
o
No gait,
s tre ngth, or
ba lance
problems *
d
Evaluate g ait, s tre ng th &
balanc e
e
YES to any ke y ques tion
k
Vitamin D +/– calcium
ength &
cise
cise
or fall prevention
program
r
- Were you injur
LOW RISK
Individualize d fall
inte rve ntio ns
a
NO to all
key
ques tions
hypotens ion
s
Addres s foot
p roblems
Optimize vis ion
Optimize home
s afety
ans ition to
cis e
progra m whe n patient
is read y
*For thes e patients , c ons ider additional ris k as s es s ment (e.g. medica tion review,
cognitive s cree n, s yncope)
Fig ure 20-1 STEADI algo rithm . Source : Ce nte rs for Dis e as e Control and
Preve ntion. National Ce nte r for Injury Preve ntion and Control. STEADI—Stopping
Elde rly Accide nts , De aths and Injurie s . Available at http://w w w.cdc.gov/s te adi/pdf/
algorithm _2015–04-a.pdf. Acce s s e d Augus t 23, 2015.
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EXAMINATIO N TECHNIQ UES
P O SSIBLE FIN DIN G S
For adults ages ≥60 years, the
JNC8 recommends blood pressure
targets of ≤150/90 but notes that
if treatment results in SBP <140
and is “well tolerated and without
adverse effects to health or quality
of life, treatment does not need to
be adjusted.”
Assess the patient for orthostatic
hypotension, de ned as a drop in
SBP of ≥20 mm Hg or DBP of
≥10 mm Hg or HR increase of
≥20 BPM, within 3 minutes of
standing. Measure in two positions:
supine after the patient rests for up
to 10 minutes, then within 2 to
3 minutes after standing up.
Orthostatic hypotension occurs in 10% to
20% of older adults and in up to 30% of
frail nursing home residents, especially
when they first arise in the morning.
Watch for lightheadedness, weakness,
unsteadiness, visual blurring, and, in
20% to 30% of patients, syncope.
Measure heart rate, respiratory
rate, and temperature. Check the
apical heart rate to help detect
arrhythmias in older adults. Use
thermometers accurate for lower
temperatures.
Respiratory rate ≥25 breaths per minute
indicates lower respiratory infection or
possible CHF or COPD.
Weight and height are especially
important and needed for calculation of the BMI (p. 63). Weight
should be measured at every visit.
Obtain oxygen saturation using a
pulse oximeter.
Low weight is a key indicator of poor
nutrition.
S k in . Note physiologic changes
of aging, such as thinning, loss
of elastic tissue and turgor, and
wrinkling.
Dry, flaky, rough, and often itchy
Inspect the extensor surface of the
hands and forearms.
White depigmented patches (pseudoscars); well-demarcated, vividly purple
macules or patches that may fade after
several weeks (actinic purpura)
Assess medications and causes such as
autonomic disorders, diabetes, prolonged
bed rest, volume depletion, amyloidosis,
postprandial state, and cardiovascular
disorders.
Hypothermia is more common in elderly
patients.
Undernutrition in depression, alcoholism, cognitive impairment, malignancy,
chronic organ failure (cardiac, renal,
pulmonary), medication use, poor
dentition, social isolation, and poverty
Benign comedones, or blackheads, on
the cheeks or around the eyes; cherry
angiomas (p. 113); and seborrheic
keratoses (p. 112)
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Chapter 20 | The Older Adult
EXAMINATIO N TECHNIQ UES
411
P O SSIBLE FIN DIN G S
Look for changes from sun exposure: actinic lentigines, or “liver
spots,” and actinic keratoses, supercial attened papules covered by
a dry scale (p. 108).
Distinguish such lesions from a basal cell
carcinoma and squamous cell carcinoma
(p. 108). Dark, raised, asymmetric lesions
with irregular borders are suspicious for
melanoma
Inspect for painful vesicular lesions
in a dermatomal distribution.
Herpes zoster from reactivation of latent
varicella-zoster virus in the dorsal root
ganglia
In older bedbound patients, especially when emaciated or neurologically impaired, inspect for damage
or ulceration.
Pressure sores if obliteration of arteriolar
and capillary blood flow to the skin or
shear forces with movement across
sheets or lifting upright incorrectly
HEENT. Inspect the eyelids, the
bony orbit, and the eye.
Senile ptosis arising from weakening of
the levator palpebrae, relaxation of the
skin, and increased weight of the upper
eyelid
Ectropion or entropion of lower lids
(p. 133)
Yellowing of the sclera and arcus senilis,
a benign whitish ring around the limbus
Test visual acuity, using a pocket
Snellen chart or wall-mounted
chart.
More than 40 million Americans have
refractive errors—presbyopia.
Examine the lenses and fundi.
Cataracts, glaucoma, and macular
degeneration all increase with aging.
Inspect each lens for opacities.
Ca taracts are the world’s leading cause
of blindness.
Assess the cup-to-disc ratio,
usually ≤1:2.
Increased cup -to-disc ratio suggests
open-angle glaucoma and possible loss
of peripheral and central vision, and
blindness. Prevalence is three to four
times higher in African Americans.
Inspect the fundi for colloid bodies
causing alterations in pigmentation
called drusen. These may be hard
and sharply de ned, or soft and
con uent with altered pigmentation.
Macular degeneration causes poor
central vision and blindness: types
include dry atrophic (more common
but less severe) and wet exudative (or
neovascular).
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EXAMINATIO N TECHNIQ UES
P O SSIBLE FIN DIN G S
Test hearing by the whispered
voice test (see p. 124) or audioscope. Inspect ear canals for
cerumen.
Removing cerumen often quickly
improves hearing.
Examine the oral cavity for odor,
appearance of the gingival mucosa,
any caries, mobility of the teeth,
and quantity of saliva.
Malodor in poor oral hygiene, periodontitis, or caries
Inspect for lesions on mucosal
surfaces. Ask patient to remove
dentures so you can check gums
for denture sores.
Dental plaque and cavitation if caries.
Increased tooth mobility; risk of tooth
aspiration
Gingivitis if periodontal disease
Decreased salivation from medications,
radiation, Sjögren syndrome, or dehydration
Oral tumors, usually on lateral borders of
tongue and floor of mouth
Th o ra x a n d Lu n g s . Percuss
and auscultate the lungs. Note
subtle signs of changes in pulmonary function.
Increased anteroposterior diameter,
purse -lipped breathing, and dyspnea
with talking or minimal exertion in
chronic obstructive pulmona ry disease
Ca rd io va s c u la r S ys t e m . Review
blood pressure and heart rate.
Isolated systolic hypertension and a
widened pulse pressure are cardiac risk
factors. Search for left ventricular
hypertrophy (LVH).
Inspect the jugular venous pulsation ( JVP), palpate the carotid
upstrokes, and listen for any
overlying carotid bruits.
A tortuous atherosclerotic aorta can raise
pressure in the left jugular veins by
impairing drainage into right atrium.
Assess the point of maximal
impulse (PMI), and then heart
sounds.
Sustained PMI is found in LVH,
hypertension, and aortic stenosis;
diffuse PMI in heart failure (see p. 180).
Carotid bruits in possible ca rotid
stenosis.
In older adults, S3 in dilatation of the left
ventricle from heart failure or cardiomyopathy; S4 in hypertension
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Chapter 20 | The Older Adult
EXAMINATIO N TECHNIQ UES
Listen for cardiac murmurs in all six
listening areas (see p. 185). Describe
timing, shape, location of maximal
intensity, radiation, intensity, pitch,
and quality of each murmur.
413
P O SSIBLE FIN DIN G S
A systolic crescendo–decrescendo
murmur in the second right interspace
in aortic sclerosis or aortic stenosis. Both
carry increased risk of cardiovascular
disease and death.
A harsh holosystolic murmur at the
apex suggests mitral regurgitation,
common in older adults.
Bre a s t s a n d Axilla e . Palpate
the breasts carefully for lumps or
masses.
Possible breast cancer
Ab d o m e n . Listen for bruits
over the aorta, renal arteries, and
femoral arteries.
Bruits in atherosclerotic vascular disease
Inspect the upper abdomen;
palpate to the left of the midline
for aortic pulsations.
Widened aorta of ≥3 cm and pulsatile
mass in abdominal aortic a neurysm.
P e rip h e ra l Va s c u la r S ys t e m .
Auscultate the abdomen for aortic,
renal, femoral artery bruits.
Bruits over these vessels in atherosclerotic disease.
Palpate pulses.
Diminished or absent pulses in a rterial
occlusion. Confirm with an office
ankle –brachial index (see pp. 230–231).
Fe m a le Ge n it a lia a n d P e lvic
Exa m in a t io n . Take special care
to explain the steps of examination
and allow time for careful positioning. For the woman with arthritis
or spinal deformities who cannot
ex her hips or knees, an assistant
can gently raise and support the
legs, or help the woman into the
left lateral position.
Inspect the vulva for changes
related to menopause; identify any
labial masses. Bluish swellings may
be varicosities.
Benign masses include condylomata,
fibromas, leiomyomas, and sebaceous
cysts. Bulging of the anterior vaginal
wall below the urethra in urethrocele
Erythema with satellite lesions in Candida
infection; erythema with ulceration or a
necrotic center in vulvar carcinoma.
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Ba te s ’ Poc ke t Guide to Phys ic a l Exa mina tion a nd His tory Ta king
EXAMINATIO N TECHNIQ UES
P O SSIBLE FIN DIN G S
Inspect the urethra for caruncles,
or prolapse of eshy erythematous
mucosal tissue at the urethral meatus.
Clitoral enlargement in androgenproducing tumors or use of androgen
creams
S p e c u lu m Ex a m in a t io n . Inspect
Estrogen-stimulated cervical mucus with
ferning in use of hormone replacement
therapy, endometrial hyperplasia , and
estrogen-producing tumors; lichen
sclerosus
vaginal walls, which may be
atrophic, and cervix.
If indicated, obtain endocervical
cells for the Pap smear. Use a blind
swab if the atrophic vagina is too
small.
Removing speculum, ask patient to
bear down.
Uterine prolapse, cystocele, urethrocele,
or rectocele.
Perform the bimanual examination.
Note any uterine retroversion, retroflexion, porolapse, or myomas (fibroids)
Mobility of cervix restricted if inflammation, malignancy, or surgical adhesion
Palpable ovaries in ovarian cancer.
Perform the rectovaginal examination if indicated.
Enlarged, fixed, or irregular uterus if
adhesions or malignancy. Rectal masses
in colon ca ncer.
Ma le Ge n it a lia a n d P ro s t a t e .
Examine the penis; retract foreskin
if present. Examine the scrotum,
testes, and epididymis.
Smegma, penile cancer, and scrotal
hydroceles
Do a rectal examination.
Rectal masses in colon cancer. Prosta te
hyperplasia if enlargement; prostate
cancer if nodules or masses.
Mu s c u lo s k e le t a l S ys t e m .
Screen general range of motion
and gait. Conduct timed “get up
and go” test.
Review examination techniques for
individual joints in Chapter 16,
Musculoskeletal System.
If joint deformity, de cits in mobility, or pain with movement, conduct
a more thorough examination.
Degenerative joint changes in osteoarthritis; joint inflammation in rheumatoid
or gouty arthritis. See Tables 16-1 to 16-4,
pp. 304–308.
See Table 20-1, Timed Get Up and Go
Test, p. 417.
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Chapter 20 | The Older Adult
EXAMINATIO N TECHNIQ UES
415
P O SSIBLE FIN DIN G S
Ne r vo u s S ys t e m . Review
results of 10-Minute Geriatric
Screener, p. 407. Pursue further
examination if any de cits. Focus
especially on memory and affect.
Distinguish delirium from depression
and dementia. See Table 20-2, Delirium
and Dementia, pp. 418–419 and
Table 20-3, Screening for Dementia:
The Mini-Cog, p. 420. Table 20-4,
Montreal Cognitive Assessment, p. 421.
Assess gait and balance, particularly standing balance; timed 8-foot
walk; stride characteristics like
width, pace, and length of stride;
and careful turning.
Abnormalities of gait and balance,
especially widening of base, slowing and
lengthening of stride, and difficulty
turning, are correlated with risk of falls.
Although neurologic abnormalities
are common in older adults, their
prevalence without identi able
disease increases with age, ranging
from 30% to 50%.
Physiologic changes of aging: unequal
pupil size, decreased arm swing and
spontaneous movements, increased leg
rigidity and abnormal gait, presence of
the snout and grasp reflexes, and
decreased toe vibratory sense.
Assess any tremor, rigidity, bradykinesia, micrographia, shuf ing
gait, and dif culty turning in bed,
opening jars, and rising from a
chair.
In Parkinson disease, tremor is slow
frequency and at rest, with a “pill-rolling”
quality, aggravated by stress and
inhibited during sleep or movement.
Essential tremor is often bilateral,
symmetric, with positive family history,
and diminished by alcohol.
Recording Your Findings
As you read through this physical examination, you will notice some atypical
ndings. Test yourself to see if you can interpret these ndings in the context
of all you have learned about the examination of the older adult.
R e c o r d in g t h e P h y s ic a l E x a m in a t io n —T h e O ld e r A d u lt
Mr. J is n older dult who
e rs he lthy but underweight, with good uscle
bulk. He is lert nd inter ctive, with good rec ll of his life history. He is
cco
nied by his son.
Vital Signs: Ht (without shoes) 16 c (5′). Wt (dressed) 65 kg (143 lb). BMI 28.
BP 145/ 88 right r , su ine; 154/94 left r , su ine. He rt r te (HR) 98 nd
regul r. Res ir tory r te (RR) 18. Te er ture (or l) 98.6°F.
(continued )
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Ba te s ’ Poc ke t Guide to Phys ic a l Exa mina tion a nd His tory Ta king
R e c o r d in g t h e P h y s ic a l E x a m in a t io n —
T h e O ld e r A d u lt (Continued)
10-Minute Geriatric Screener: (see . 4 7)
Vision: P tient re orts difficulty re ding. Visu l cuity 2 / 6 on Snellen ch rt.
Needs further ev lu tion for gl sses nd ossibly he ring id.
Hearing: C nnot he r whis ered voice in either e r. C nnot he r 1,
2,
Hz with udiosco e in either e r.
or
Leg Mobility: C n w lk 2 feet briskly, turn, w lk b ck to ch ir, nd sit down in
14 seconds.
Urinary Incontinence: H s lost urine nd gotten wet on 2 se
r te d ys.
Needs further ev lu tion for incontinence, including “DIAPER” ssess ent
(see . 4 6), rost te ex in tion, nd ostvoid residu l, which is nor lly
≤5
L (requires bl dder c theteriz tion).
Nutrition: H s lost 15 lb over the
st 6
onths without trying.
Needs nutrition l screen (see . 73).
Memory: C n re e ber three ite s fter 1 inute.
Depression: Does not often feel s d or de ressed.
Physical Disability: C n w lk f st but c nnot ride bicycle. C n do oder te
but not he vy work round the house. C n go sho ing for groceries or
clothes. C n get to l ces out of w lking dist nce. C n b the e ch d y
without difficulty. C n dress, including buttoning nd zi ing, nd c n ut
on shoes.
Consider exercise regi en with strength tr ining.
Physical Examination: C refully describe your findings for e ch relev nt
seg ent of the eri her l ex in tion, using ter inology found in the
“Recording Your Findings” sections of the rior ch ters.
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Chapter 20 | The Older Adult
417
Aids to Interpretation
Table 20-1 Tim e d Ge t Up a n d Go Te s t
Performed with patient wearing regular footwear, using usual walking
aid if needed, and sitting back in a chair with armrest.
On the word, “Go,” the patient is asked to do the following:
1.
2.
3.
4.
5.
Stand up from the arm chair
Walk 3 m (in a line)
Turn
Walk back to chair
Sit down
Time the second effort.
Observe patient for postural stability, steppage, stride length, and sway.
S c o r in g :
1. Normal: completes task in <10 seconds
2. Abnormal: completes task in >20 seconds
Low scores correlate with good functional independence; high scores
correlate with poor functional independence and higher risk of falls.
Reproduced from: Get-up and Go Test. In: Mathias S, Nayak USL, Isaacs B. “Balance in elderly
patient” The “Get Up and Go” Test. Arch Phys Med Rehabil. 1986;67:387; Podsiadlo D,
Richardson S. The Timed “Up and Go”: A test of basic functional mobility for frail elderly
persons. J Am Geriatr Soc. 1991;39:142.
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418
Ba te s ’ Poc ke t Guide to Phys ic a l Exa mina tion a nd His tory Ta king
Table 20-2 De liriu m a n d De m e n t ia
D e lir iu m
D e m e n t ia
On s e t
Acute
Insidious
Co u rs e
Fluctuating, with lucid
intervals; worse at night
Slowly progressive
Du ra tio n
Hours to weeks
Months to years
S le e p /Wa ke Cycle
Always disrupted
Sleep fragmented
Ge n e ra l Clin ica l
Illn e s s o r Dru g
Toxicity
Either or both present
Often absent,
especially in
Alzheimer disease
Le ve l o f
Co n s cio u s n e s s
Disturbed. Person less
clearly aware of the
environment and less
able to focus, sustain, or
shift attention
Usually normal until
late in the course of
the illness
Be h a vio r
Activity often
abnormally decreased
(somnolence) or
increased (agitation,
hypervigilance)
Normal to slow;
may become
inappropriate
S p e e ch
May be hesitant, slow
or rapid, incoherent
Difficulty in finding
words, aphasia
Mo o d
Fluctuating, labile, from
fearful or irritable to
normal or depressed
Often flat, depressed
Th o u g h t Pro ce s s e s
Disorganized, may be
incoherent
Impoverished.
Speech gives little
information
Th o u g h t Co n te n t
Delusions common,
often transient
Delusions may occur
Pe rce p tio n s
Illusions, hallucinations,
most often visual
Hallucinations may
occur.
C lin ic a l Fe a t u r e s
Me n t a l S t a t u s
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Chapter 20 | The Older Adult
419
Table 20-2 De liriu m a n d De m e n t ia (continued )
D e lir iu m
D e m e n t ia
J udgm ent
Impaired, often to a
varying degree
Increasingly
impaired over the
course of the illness
Orie n ta tio n
Usually disoriented,
especially for time. A
known place may seem
unfamiliar.
Fairly well
maintained, but
becomes impaired in
the later stages of
illness
Atte n tio n
Fluctuates. Person
easily distracted, unable
to concentrate on
selected tasks
Usually unaffected
until late in the
illness
Me m o ry
Immediate and recent
memory impaired
Recent memory and
new learning
especially impaired
Ex a m p le s o f C a u s e
Delirium tremens (due
to withdrawal from
alcohol)
Reversible: Vitamin
B12 deficiency,
thyroid disorders
Uremia
Acute hepatic failure
Acute cerebral vasculitis
Atropine poisoning
ERRNVPHGLFRVRUJ
Irreversible:
Alzheimer disease,
vascular dementia
(from multiple
infarcts), dementia
due to head trauma
420
Ba te s ’ Poc ke t Guide to Phys ic a l Exa mina tion a nd His tory Ta king
Table 20-3 S c re e n in g fo r De m e n t ia : Th e Min i-Co g
Ad m in is t r a t io n
The test is administered as follows:
1. Instruct the patient to listen carefully to and remember three
unrelated words and then to repeat the words.
2. Instruct the patient to draw the face of a clock, either on a blank
sheet of paper or on a sheet with the clock circle already drawn on
the page. After the patient puts the numbers on the clock face, ask
him or her to draw the hands of the clock to read a specific time.
3. Ask the patient to repeat the three previously stated words.
S c o r in g
Word Recall: Give 1 point for each recalled word without cueing after
doing the clock drawing test (CDT).
Patients recalling none of the three words are classified as demented
(Score = 0). Patients recalling all three words are classified as nondemented
(Score = 3). Patients with intermediate word recall of one to two words
are classified based on the CDT (Abnormal = demented; Normal =
nondemented).
Clock Draw: The CDT is considered normal if all numbers are present in
the correct sequence and position, and the hands readably display the
requested time. Scoring is 2 (normal) or 0 (abnormal).
Total Score (0–5 points): Score <3 has been validated for dementia.
MINI-COG
3-Ite m Re ca ll = 0
3-Ite m Re ca ll = 1–2
DEMENTED
CDT Abnorma l
3-Ite m Re ca ll = 3
NONDEMENTED
CDT Norma l
From Borson S, Scanlan J, Brush M, et al. The Mini-Cog: a cognitive “vital signs” measure for
dementia screening in multi-lingual elderly. Int J Geriatr Psychiatry. 2000;15(11):1021.
Copyright John Wiley & Sons Limited. Reproduced with permission.
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Chapter 20 | The Older Adult
421
Table 20-4 S c re e n in g fo r De m e n t ia : Th e Mo n t re a l
Co g n it ive As s e s s m e n t (Mo CA)
NAME:
Education:
Sex:
VISUOSPATIAL / EXECUTIVE
E
D
Draw Clock (Ten past eight)
Copy
cube
SCORE
(3 points)
A
3
End
Date of birth:
DATE:
1
2
B
Begin
4
5
C
[ ]
[ ]
[ ]
[ ]
Contour
[ ]
Numbers
/5
Hands
NAMING
[ ]
[ ]
MEMORY
ROSE
Read list of words, subject must repeat them.
Do 2 trials, even if 1st trial is successful.
Do a recall after 5 minutes.
ATTENTION
[ ]
CHAIR
SPOON
HOUSE
RED
No
p o in t s
1st trial
2nd trial
Read list of digits (1 digit /sec.).
/3
[ ] 3 2 7 45
[ ] 2 7 4
Subject has to repeat them in the forward order
Subject has to repeat them inthe backward order
/2
Read list of letters. The subject must point with his nger at each letter C. No points if ≥ 2 errors.
[ ] FBCAMNCCJKLBCFCKDECCJAMOFA
[ ] 95
Serial 7 subtraction starting at 100
[ ] 86
[ ] 76
[ ] 65
[ ] 45
4 or 5 correct subtractions: 3 pts, 2 or 3 correct: 2pts, 1 correct: 1pt, 0 correct: 0pt
LANGUAGE
Repeat : I only know that Judy is the one to help today. [ ]
The cat always hid under the couch when dogs were in the room. [ ]
Fluency / Name maximum number of words in one minute that begin with the letter F
ABSTRACTION
DELAYED RECALL
Similarity between e.g. banana - orange = fruit
Has to recall words
WITH NO CUE
Optional
ORIENTATION
ROSE
[ ]
CHAIR
[ ]
[ ] train - bicyle
SPOON
[ ]
[ ]
(N ≥ 11 words)
/1
/2
Points for
UNCUED
recall only
RED
[ ]
/3
/2
[ ] watch - ruler
HOUSE
[ ]
/1
/5
Category cue
Multiple choice cue
[ ] Date
[ ] Month
[ ] Year
[ ] Day
[ ] Place
Normal ≥ 26 / 30
Administered by:
[ ] City
TOTAL
Add 1 point if ≤ 12 yr edu
Source: © Z. Nasreddine MD. Reproduced with permission. Copies are available at
www.mocatest.org.
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ERRNVPHGLFRVRUJ
Index
Note: Page numbers followed by “b,” “f,” and “t” indicate boxed material, gure, and
end-of-chapter tables, respectively.
A
ABCDE criteria, for skin cancer
screening, 91, 91b–92b
Abdomen
auscultation, 207, 208b
in children, 368
concerning symptoms, 199b
examination of, 12, 207–213, 223, 224f
health history, 199–204
health promotion and counseling,
204–207
in infants, 362
inspection, 207
older adults and, 413
pain in (see Abdominal pain)
palpation, 208–209, 208f, 209f
percussion, 208
during pregnancy, 391–393
recording ndings, 213
Abdominal aortic aneurysm (AAA), 219
in older adults, 413
screening for, 222
Abdominal fullness, 201
Abdominal masses, 209
Abdominal pain, 199b
with associated GI symptoms, 201–202
lower, 201
patterns and mechanisms of, 199–200
upper, 200–201
Abdominal re exes, 329, 329f
Abdominal tenderness, 217t
Abducens nerve, 318b, 319
Abscess, 103t
headache and, 115
lung, 160t
peritonsillar, 368
Abstract thinking, 85
Abuse
elder, 406
illicit drugs, 56
physical, 57b
prescription drugs, 56, 82, 388
sexual, 57b, 369, 381t
Acne vulgaris, 103t
Acoustic nerve, 318b, 320
Acromioclavicular arthritis, 308t
Actinic keratosis, 105t, 410
Actinic lentigines, 410
Actinic purpura, 410
Active listening, 42
Activities of daily living (ADLs), 402,
402b
Acute otitis media, with purulent
effusion, 137t
Adams bend test, 371
Addiction, 56b
Adolescents, 370
breasts, examination of, 371
genitalia, examination of, 371
Adult illnesses, in health history, 3
Advance directives, 403
Adventitious breath sounds, 151b
Advisory Committee on Immunization
Practices (ACIP), 314
Aerobic activity, 61
Affect, 83
de ned, 80b
African-American, 70, 118, 169, 170.
266, 401,411
Alcohol use/abuse, 56
in health history, 3
health promotion and counseling for,
82, 204, 204b–205b
older adults and, 403
during pregnancy, 387
Allen test, 225–226, 225f, 226f
Allergic rhinitis, 117
Allergies, in health history, 3
Alopecia areata, 112t
Altitudinal (horizontal) defect (visual
eld defect), 132t
Alzheimer disease (AD), 405–406
Ambiguous genitalia, 363
Amelanotic melanoma, 107t
Amenorrhea, 248
primary, 248
secondary, 248
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423
424
Inde x
American Cancer Society (ACS), 91
on Breast Self-Examination (BSE),
189b, 193, 194b–195b
American College of Chest Physicians,
grading recommendations, 39t–40t
American Geriatrics Society, 404
American Heart Association, goals for
ideal cardiovascular health, 169b
American Sign Language, 53
American Urological Association (AUA)
Symptom Index, 265, 271t
Anagen ef uvium, 111t
Anal ssure, 272t
Analgesic rebound headache, 129t
Anal re ex, 329
Anatomic snuffbox, 289, 289f
Androgen-producing tumors, 413
Anemia of pregnancy, 390
Angina pectoris, 155t
Angioedema, 139t
Angry patient, 52
Angular cheilitis, 139t
Ankle–brachial index (ABI), 221
interpretation of, 231t
measurement of, 230t–231t
Ankle clonus, 328, 328f
Ankles, examination of, 301–302
Anorectal stula, 272t
Anorexia nervosa, 72t
Ante exion, 262t
Anterior cruciate ligament test, 300, 300f
Anterior cruciate tear/sprain, 310t
Anus
concerning symptoms, 265b
examination of, 268–269, 268f
health history, 265
during pregnancy, 394
recording ndings, 270
Anxiety, panic disorder, 156t
Aorta, assessment of, 211, 211f
Aortic aneurysm, dissecting, 155t
Aortic stenosis (AS), 180
Aortic valve stenosis, 375t
Apgar score, 352, 353b
Aphasia, 83, 337t–338t
testing for, 83b
Aphonia, 337t
Aphthous ulcer, 141t
Appearance, assessment of, 83
Appendicitis, 212–213
Appropriate for gestational age (AGA),
354t, 373t
Arcus senilis, 411
Arms, examination of, 222–223
Arterial insuf ciency, chronic, 226,
228t, 229t
Arterial pulses, grading of, 222b
Arthritis, knee, 309t
Articular structures, joint, 275b
Asbestosis, 158t
Ascites, assessment of, 211–212, 211f, 212f
Ascitic uid, 211, 211f
Asian-American, 171, 401
Assessment, 13. See also speci c topics
clinical reasoning and, 14–16
of mental status, 79–80 (see also
Mental status)
Asterixis, 331
Asthma, 158t, 160t, 165t
Ataxia, 313
Ataxic (Biot) breathing, 162t
Atelectasis, 165t
Atherosclerotic disease, 413
Atrial brillation, 67
Atrial septal defect, 362
Attention
assessment of, 84
de ned, 80b
in delirium and dementia, 419t
Attention de cit disorder, 365
Attrition bias, 35b
Auricle, examination of, 124
Automated ambulatory blood pressure
monitoring, 64
Autonomy, 58b
Axillae
examination of, 11, 193, 193f
recording ndings, 195
Axillary temperature, 68
B
Babinski response, 329, 329f
Back, in physical examination, 11
Back pain
low, 280, 306t–307t (see also Low
back pain)
midline, 280
nocturnal, 307t
Back stiffness, chronic, 307t
Bacterial pneumonias, 159t
Bacterial vaginosis, 260t
Baker cyst, 310t
Balance, in older adults, assessment
of, 415
Balloon sign, 298, 298f
Barlow test, 363, 363f
Barrel chest, 163t
Basal cell carcinoma (BCC), 106t
nodular, 106t
super cial, 106t
Basal ganglia disorder, 340t
Bayes theorem, 31
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Inde x
Bedbound patient, evaluation of, 98
Behavior
assessment of, 83
in delirium and dementia, 418t
Bene cence, 58b
Benign prostatic hyperplasia, 265, 273t
Bias, in clinical research, 34, 35b
Bicipital tendinitis, 308t
Bilingual written questionnaires, 52
Bimanual examination, 255, 255f,
393–394, 414
Birth history, child, 350
Bitemporal hemianopsia, 132t
Bleeding, postmenopausal, 248
Blepharitis, 134t
Blindness, unilateral, 132t
Bloating, 201
Blood pressure, 64–67.
See also Hypertension
in children, 365
cuff size, selection of, 65b
diastolic, 66b
in infants, 356
measurement of, 64, 66b, 174
during pregnancy, 390
recording of, steps in, 65b
systolic, 66b
Blount disease, 370
Body dysmorphic disorder, 87t
Body mass index (BMI), 63–64, 365
calculation of, 63b
and cardiovascular disease, 173
excessively low, 72t
obesity and, 63
Bone density criteria, by WHO, 282b
Bowel sounds, 207, 208b
BPH symptom score index, 265, 271t
Brachial pulse, 223f
Bradypnea, 162t
Brain, 311, 312f
Brain tumor, and headache, 130t
Breast cancer
relative risk factor, 196t
retraction signs, 197t
risk factor assessment, 188
screening, 189, 189b
visible signs of, 197t–198t
Breast Cancer Risk Assessment Tool, 188
Breasts
in adolescents, 371
concerning symptoms, 187b
development of, 377t
examination of, 11, 190–192
female, 190–192, 190f–192f
health history, 187
health promotion and counseling,
187–189
425
in infants, 362
male, 192
in older adults, 413
palpable masses of, 187, 188b
during pregnancy, 391
recording ndings, 195
in review of systems, 5
Breast Self-Examination (BSE), 189b,
193, 194b–195b
Breathing
abnormal, 162t
normal, 162t
rapid deep, 162t
rapid shallow, 162t
slow, 162t
Breath odor, 62
Breath sounds
adventitious (added), 151b
characteristics of, 150b
evaluation of, 150
Breech presentation, 395
Broca aphasia, 337t–338t
Bronchiectasis, 160t
Bronchiolitis, 357
Bronchitis
acute, 159t
chronic, 157t, 160t, 165t
Brown lesions, 107t–108t
Brudzinski sign, 330
Bruits, 207, 208b, 413
Bulge sign, 297, 298f
Bulimia nervosa, 72t
Bullae, 102t
Burrow, 104t
Bursae, 275b
Bursitis, knee, 309t
C
CAGE Questionnaire, 56, 204, 403
Calcium, food sources of, 74t
Calculating abilities, assessment of, 85
Cancer
breast (see Breast cancer)
colorectal, 206, 206b–207b
lung, 158t
ovarian, 250
prostate, 265–267, 266b–247b, 273t
rectum, 273t
screening for, 404–405
sigmoid colon, 214t
skin, 90–92
testicular, 235
Candida vaginitis, 260t
Candidiasis, 140t
Canker sore, 141t
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426
Inde x
Carbuncle, 103t
Carcinoma
of cervix, 261t
of lip, 139t
of penis, 241t
of tongue/ oor of mouth, 141t
of vulva, 259t
Cardiac failure, 357
Cardiopulmonary resuscitation
(CPR), 57
Cardiovascular disease (CVD), 168
and chest pain, 155t
lifestyle change and risk factor
modi cation, 173b–174b
primary prevention, 168
risk calculators, 170, 170b
risk factors and screening frequency,
169b–170b
screening for, 169–173
secondary prevention, 168
Cardiovascular system
common cardiac symptoms,
167b–168b
concerning symptoms, 167b
examination of, 174–180
health history, 167
health promotion and counseling,
168–174
in older adults, 412–413
in physical examination, 11–12
recording ndings, 180
in review of systems, 5
Carotid artery screening, 316
Carotid bruits, 175, 412
Carotid pulse, 175
Carpal tunnel syndrome, 288
Carpal tunnel testing, 291
Caruncles, 413
Cataracts, 411
Cauda equina syndrome, 280
Caviar lesions, 141t
Central nervous system (CNS), 311
brain, 311, 312f
disorder, 340t
spinal cord, 312
Cephalic prominence, 396
Cephalohematoma, 357
Cerebellar disorder, 340t
Cerebellar function, examination
of, 12
Cerebrovascular disease, 316
Cervical myelopathy, 305t
Cervical radiculopathy, 305t
Cervix
abnormalities of, 261t
inspection of, 253–254, 254f
during pregnancy, 393–394
Chalazion, 134t
Chancroid, 243t
Cherry angioma, 109t
Chest
examination of, 147–153
palpation of, 152
Chest pain, 155t–156t, 167b
sources of, 145b
Chest wall, 147f
Chest wall pain, costochondritis, 156t
Cheyne–Stokes breathing, 162t
Chief complaint(s), 1b, 2
Childhood
hypertension in, 374t
Childhood illnesses, in health history, 3
Children
adolescents, 370–371
blood pressure in, 365
development, principles of, 349n
ear in, 366–367, 366f
examination of, sequence of, 352b
eyes in, 365–366
health history, 349–350
health promotion and counseling,
351–352
heart, 368
hypertension in, 374t
infants, 355–364
interviewing, 364b
mental and physical status, 365
mouth and pharynx in, 367–368
newborns, 352–354
overweight, 365
recording ndings, 371–372
sexual abuse in, 381t
sustained hypertension in, 356b
1 to 10 years children, 364–370
underweight, 365
Chill, 59
Chlamydia trachomatis, 250
Choanal atresia, 359
Cholecystitis, 213
Chorea, 341t
Chronic bronchitis, 157t
Chronic obstructive pulmonary disease
(COPD), 157t, 165t, 412
Clasp-knife resistance, 342t
Clinical reasoning, and assessment,
13–16, 14b
abnormal ndings identi cation, 14
clustering clinical ndings, 14–15
generating clinical hypotheses,
15–16, 16b
localizing ndings, 14
probable cause of ndings, 15
testing hypotheses, 16
working diagnosis, 16
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Clinical record
checklist for, 24b–26b
purpose of, 16
reviewing of, 44
standard format of, example of, 17b–23b
tips for quality patient record, 17b
Clinician–patient interview, 41. See also
Interviewing
Clubbing of ngers, 113t
Cluster headache, 128t
Cognitive functions
assessment of, 84–85
de ned, 80b
Cogwheel rigidity, 342t
Coldness, in legs/feet, 219
Cold sore, 139t
Collaborative partnerships, 50b
Collateral ligament tear/sprain, 310t
Colorectal cancer
prevention of, 267
screening for, 206, 206b–207b
Coma, 331
metabolic, 345t
structural, 345t
Comfort, patient, 45
Communication
nonverbal, 43
respectful, 50b
Condoms, male, 235
Conductive loss, 117
Condyloma latum, 259t
Condylomata acuminata. See Genital warts
Con dentiality, 45, 58b
Confusing patient, 51
Confusional Assessment Method (CAM)
algorithm, 314b
Congenital hip dysplasia, 363
Consciousness, level of, 332b
assessment of, 61, 83
de ned, 80b
in delirium and dementia, 418t
Consciousness, loss of, 314
Constipation, 202, 368
Constructional ability, assessment of, 85
Conversion disorder, 87t
Coordination, 323–324
Corneal light re ex test, 366, 366f
Corneal re exes, 319, 319f
Corynebacterium diphtheriae, 142t
Costovertebral angle (CVA) tenderness,
210, 210f
Cough, 159t–161t
Cover–uncover test, 366, 366f
Crackles, 151b
Cranial nerves (CNs), 312
examination of, 12, 318–321
functions of, 318b
427
Cranial neuralgias, 131t
Critical appraisal, 34–36
bias in clinical research, 34, 35b
generalizability, 36
guideline recommendations, 36,
37t–40t
treatment/prevention intervention,
performance of, 35–36
Crohn disease, 215t
Crying patient, 52
Cryptorchidism, 244t
Cues
emotional, 47
verbal and nonverbal, 46
Cultural competence, 50
Cultural humility, 50, 50b
Culture, 49–50
Cup-to-disc ratio, 411
CVD risk calculator, 170b, 172
Cyst
Baker, 310t
epidermoid, 258t
of epididymis, 245t
pilar, 104t
Cystocele, 263t
Cystourethrocele, 263t
D
Death, interviewing about issues
related to, 57
Decision-making capacity, 51, 51b
Decision-making, shared, 49
Delirium, 314, 418t–419t
clinical features, 418t
mental status, 418t–419t
screening for, 421t
Dementia, 83, 314, 405,
418t–419t
clinical features, 418t
mental status, 418t–419t
screening for, 420t
Dental caries, 367
Denture sores, 412
Depression, 314
health promotion and counseling
for, 81
older adults and, 405
Dermato broma, 103t
Dermatomes, 343t–344t
Dermoscopy, 93
Detection bias, 35b
Developmental delay, causes of, 355
Diabetes, classi cation and diagnosis
of, 171b–172b
Diagnostic hypotheses, 48
ERRNVPHGLFRVRUJ
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Inde x
Diagnostic tests, evaluation of, 28
reproducibility of test results, 33
validity of ndings, 28–32
Diarrhea, 202, 214t–215t
acute, 214t
chronic, 214t–215t
drug-induced, 214t
Diastolic blood pressure, 66b
Dietary Approaches to Stop
Hypertension (DASH) eating
plan, 61
Diet, hypertension and, 75t
Differential diagnosis, 27, 48
Dif cult patients, 77
Diffuse esophageal spasm, 156t
Diffuse interstitial lung diseases, 158t
Digital rectal examination (DRE),
267
Digit span, 84
Diphtheria, 142t
Diplopia, 117, 313
Direct inguinal hernia, 246t
Disc herniation, and back pain, 306t
Discriminative sensations, 326
Disease/illness model, 46
Disruptive patient, 52
Dissecting aortic aneurysm, chest pain
in, 155t
Dissociative disorder, 87t
Distal weakness, 314
Distress, signs of, 62
Dizziness, 313
Doll’s eye movements. See
Oculocephalic re ex
Domestic violence, 57
Do Not Resuscitate (DNR) status, 57
Dorsalis pedis pulse, 225f
Down syndrome, 358
Dress, patient, 62, 83
Dribbling, continuous, 216t
Drop-arm test, 287b
Drug use, in health history, 3
Drusen, 411
Dual diagnosis, 77
Durable power of attorney for health
care, 52
Dysarthria, 313, 337t
Dysesthesias, 314
Dyslipidemias, 172, 172b
Dysmenorrhea, 248
Dyspareunia, 249
Dyspepsia, 200
Dysphagia, 199b, 201, 202
Dysphonia, 337t
Dysplastic nevus, 108t
Dyspnea, 157t–158t, 167b
Dysuria, 203
E
Earache, 117
Eardrum
abnormalities of, 137t
examination of, 124, 124f
Ear(s)
in children, 366–367, 366f
concerning symptoms, 115b
examination of, 124–125
health history, 117
health promotion and counseling,
119
in infants, 359
Eating disorders, and low body mass
index, 72t
Ecchymosis, 110t
Ectopic pregnancy, 394
Ectropion, 133t
Edema, 168b
Ejaculation, premature, 234
Elbows, examination of, 288
Elder mistreatment, 406
Electronic thermometer, 68
Empathic responses, 42
Empowerment, patient, 44, 44b
Endocervical polyp, 261t
Endocrine system, in review of
systems, 6
Entropion, 133t
Environment, for examination, 7
Epidermoid cyst, 258t
Epididymal cyst, 245t
Epididymis
abnormalities of, 245t
examination of, 238
Epididymitis, acute, 245t
Episcleritis, 134t
Epistaxis, 118
Epitrochlear nodes, 223
inspection of, 11
Erectile dysfunction, 233
Essential tremor, 415
Ethics, professionalism and, 58, 58b
Evidence-based information, 34, 34f
Evidence-Based Working Group, 34
Exercise
health promotion and counseling
for, 61
during pregnancy, 387
Exercise-induced pain, 219
Exophthalmos, 133t
Expected date of delivery (EDD), 385b
Expressions, facial, 62, 83
External hemorrhoids, 272t
External rotation lag test, 287b
External rotation resistance test, 287b
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Extra-articular structures, joint, 275b
Extraocular muscles, assessment
of, 121
Extremities, 12
Extremities, during pregnancy, 394
Exudative pharyngitis, 142t
Eye disorders, headache from, 129t
Eye(s)
in children, 365–366
concerning symptoms, 115b
examination of, 119–123
health history, 116–117
health promotion and counseling,
118
in infants, 358, 358b
physical ndings, 133t–134t
during pregnancy, 390
F
Face
expressions of, 62, 83
in infants, 358, 358b
during pregnancy, 390
Faces Pain Scale, 70
Facial nerve, 318b, 319
Facial paralysis, 339t
Facies, abnormal, 358, 358b
Factitious disorder, 87t
Fagan nomogram, 31–32, 32f
Failure to thrive, 355
Fainting, 168b, 314
Falls, in older adults, 283, 407–409,
408b, 409f
STEADI falls prevention toolkit,
408b, 409f
Family history, 2b, 4
of breast and ovarian cancers, 188
Family planning
counseling on, 251
methods, 251b
Fasciculations, 341t
Fatigue, 59
Feeding history, child, 350
Feet, examination of, 301–302
Female genitalia
in children, 369
common concerns, 247b
examination of, 13, 252–256
external, 252–253, 253f
health history, 247–249
health promotion and counseling,
249–252
in infants, 363
internal, 253–254, 254f
older adults, examination in, 413
429
recording ndings, 257
in review of systems, 5–6
Femoral hernia, 246t
Fetal alcohol syndrome, 358, 387
Fetal exposure to diethylstilbestrol
(DES), 261t
Fetal heart rate (FHR), 392–393
Fetal movements, 392
Fever, 59, 68
causes of, 68
Fever blister, 139t
Fibromyalgia, 305t
FIFE (mnemonic), 46
Fissured tongue, 140t
Flaccidity, 342t
Flat spots (skin lesions), 100t
Fluid- lled lesions, 102t
Folate, food sources of, 74t
Fontanelles, 357, 357f
Forced expiratory time, 153
Fracture of clavicle, 363
Frailty, older adults, 403
FRAX calculator for assessing fracture
risk, 282
Functional incontinence, 217t
Functional status, of older adults, 406,
406b–407b
Fundal height, 392
Funnel chest, 163t
Furuncle, 103t
Furunculosis, 103t
G
Gail model (breast cancer risk
assessment), 188
Gait
examination of, 62, 293f, 323
older adults, examination in, 415
Gastroesophageal re ux, 161t, 201
Gastrointestinal re ux disease, and
chest pain, 156t
Gastrointestinal system
disorders related to, 199b
pain related to, 200–201
in review of systems, 5
symptoms related to, 201–202
Gaze, cardinal directions of, 121, 121f
Gegenhalten, 342t
General survey
in infants, 355
in physical examination, 10, 61–62
recording ndings, 71b
in review of systems, 4
Genital herpes, 258t
Genital herpes simplex, 242t
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430
Inde x
Genitalia. See also Female genitalia;
Male genitalia
examination of, 13
during pregnancy, 393–394
in review of systems, 5–6
Genital warts, 242t
Geographic tongue, 140t
Gestational age, 385
Gestational hypertension, 390b
Get Up and Go test, 417t, 418t–419t
Giant cell arteritis, and headache, 130t
Glasgow Coma Scale, 346t
Glass thermometer, 68
Glaucoma, 118, 411
acute, 129t
open-angle, 116, 411
Glaucomatous cupping, 135t
Glossopharyngeal nerve, 318b, 320
Goiter, multinodular, 143t
Gonorrhea, 251b, 254, 256, 261t
Grooming, patient, 62, 83
Growth and developmental history,
children, 350
Guided questioning, 42–43, 42b
Gums, inspection of, 126
Guttate psoriasis, 101t
Gynecomastia, 192
H
Habit tic deformity, 113t
Hair, examination of, 94f, 95, 98, 98f
Hair loss, 90, 98
female pattern, 111t
focal, 112t
generalized/diffuse, 111t
male pattern, 111t
Hair pull test, 98, 98f
Hairy leukoplakia, 141t
Hairy tongue, 140t
Hand, arterial supply to, 225–226,
225f, 226f
Hand grip strength, 291, 291f
Hands, examination of, 288–292
Head
concerning symptoms, 115b
examination of, 119
health history, 115–116
in infants, 357, 357f
during pregnancy, 390
Headache, 115, 313
from eye disorders, 129t
primary, 128t
secondary, 129t–131t
from sinusitis, 129t
warning signs, 116b
Head circumference, in infants, 355, 356f
Head, eyes, ears, nose, throat (HEENT)
examination of, 10
older adults and, 411–412
recording ndings, 127
in review of systems, 4–5
Health care proxy, 52, 57
Health disparities, 70
Health history, 2–6, 41
chief complaint(s), 2
components of, 1b–2b
concerning symptoms, 59–60
family history, 4
interviewing and, 41–58
past history, 3
personal and social history, 4
present illness, 3
review of systems, 4–6
Health Insurance Portability and
Accountability Act (HIPAA), 51
Health literacy, 53
Health maintenance, 3, 16
Health promotion, 33–34, 34f
Health promotion and counseling
abdominal aortic aneurysm
screening, 222
alcohol abuse, 82, 204, 204b–205b
ankle–brachial index, 221
breast cancer risk assessment, 188
breast cancer screening, 189, 189b
breast masses, 187, 188b
cardiovascular risk factors, screening
for, 169–173
carotid artery screening, 316
cervical cancer screening, 249–250, 250b
colorectal cancer, 206, 206b–207b, 267
delirium, dementia, and depression
detection, 317
depression, 81
diet, 60
exercise, 61, 387
family planning options, 251, 251b
hearing de cits, 119
herpes zoster vaccination, 317
HIV/AIDS screening, 235
hormone replacement therapy, 252
immunizations, 386–387, 387b
intimate partner violence, 388, 388b
lifestyle modi cations for
cardiovascular health, 173b–174b
low back pain, 281
lung cancer, 146
menopause, 252
mood disorders, 81
nutrition, 61, 61b, 73t, 74t, 281, 386
older adults, 404–406
optimal weight, 60, 61b
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oral health, 119
osteoporosis, 281–283
ovarian cancer, 250
peripheral arterial disease, screening
for, 221, 221b
peripheral neuropathy risk
prevention, 316–317
physical activity, 281, 281b
pneumococcal vaccine, 146
prenatal laboratory screenings, 389
prescription drug abuse, 82
prostate cancer, 266–267
renal artery disease screening, 221,
221b–222b
skin cancer, 90–92
STIs and HIV infection screening,
250–251, 251b, 267
stroke prevention, 316
substance abuse, 82, 387–388
suicide risk, 81–82
testicular cancer, 235
testicular self-examination, 235
tobacco cessation, 146, 146b
viral hepatitis, 205–206
vision disorders, 118
weight gain during pregnancy, 386, 386b
weight, optimal, 281
Health, state of, in general survey, 61
Hearing, assessment of, 124–125
Hearing loss
conductive, 125, 138t
sensorineural, 125, 138t
Heart
auscultation, 177–178, 177f, 178f
in children, 368
in infants, 362
inspection and palpation, 176–177, 176f
murmurs, 178–180, 185t
during pregnancy, 391
sequence of examination, 176b
Heart failure, left, 157t, 165t
Heart murmurs, 185t. See also Murmurs
Heart rate, 67, 174
Heart sounds, 181t
rst, variations in, 182t
second, variations in, 183t–184t
Hegar sign, 394
Height
in infants, 355
measurement of, 63, 390
older adults and, 410
Hematologic questions, in review of
systems, 6
Hemianopsia, 116
Hemoptysis, 159t–161t
Hepatitis A, 205, 205b
Hepatitis B, 205, 206b
431
Hepatitis C, 206
Hereditary hemorrhagic telangiectasia,
139t
Hernias
direct inguinal, 246t
examination for, 13
examination of, 238, 238f
femoral, 246t
indirect inguinal, 246t
recording ndings, 240
Herpes simplex virus, 102t
Herpes zoster, 411
Herpes zoster vaccine, 314
Hips, examination of, 293–295
Hispanic, 70,171b, 401
HIV/AIDS, screening for, 235
Hoarseness, 118
Homonymous hemianopsia, 132t
Homonymous quadrantic defect, 132t
Hormone replacement therapy (HRT), 252
Housemaid’s knee, 297
HPV infection, and cervical cancer, 250
Hydrocele, 241t, 363
Hyperlipidemia, 134t
Hyperopia, 116
in school-aged children, 365
Hyperpnea, 162t
Hyperpyrexia, 68
Hypertension, 64. See also Blood pressure
in childhood, 374t
chronic, 390b
dietary guidelines, 75t
in pregnancy, 390b
screening for, 170
types of, 64b–65b
Hyperthyroidism, 118
Hypertonia, 342t
Hyperventilation, 162t
Hypoglossal nerve, 318b, 321
Hypospadias, 241t
Hypothermia, 68
Hypothyroidism, 118
Hypotonia, 342t, 364
I
Idiopathic pulmonary brosis, 158t
Iliotibial band, 309t
Illicit drug use, 56, 82
during pregnancy, 387
Illness anxiety disorder, 87t
Illness, patient’s perspective on, 46, 47b
Immunizations
in health history, 3
older adults and, 404
during pregnancy, 386–387, 387b
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Inde x
Indirect inguinal hernia, 246t
Infantile automatisms, 364
Infants, assessment of
abdomen, 362
blood pressure, 356
breasts, 362
ear, 359
eyes, 358, 358b
face, 358, 358b
female genitalia, 363
general survey, 355
head, 357, 357f
head circumference, 355, 356f
heart, 362
height and weight, 355
male genitalia, 363
mental and physical status, 355
mouth and pharynx, 359
musculoskeletal system, 363–364, 363f
neck, 359, 360f
nervous system, 364
nose, 359
skin, 357
thorax and lungs, 360, 360b–361b
upper airway vs. lower airway
sounds, 361b
vital signs, 356–357
In ammatory bowel disease, 215t
Information, patient, 85
Inguinal hernias, 363
in older boys, 369
Inguinal nodes, super cial, 223, 224f
Insect bites, 102t
Insight, patient, 80b, 84
Institute of Medicine (IOM), 61
Instrumental activities of daily living
(IADLs), 402b
Intention tremor, 341t
Intermittent claudication, 219
Internal rotation lag test, 287b
Interpreter, working with, 52b–53b
Interviewer, behavior and appearance, 45
Interviewing, 41
advanced, 50–57
challenging patient, 50–54
cultural context of, 49–50
ethics and professionalism, 58, 58b
focused/ problem-oriented history, 41
goals for, 45
and health history, 41–58
open-ended, 41
patient’s perspective in, 46, 46b
preparation for, 44–45
sensitive topics, 54–57
sequence for, 45–49
skilled, 42–44
techniques for, 42–44
Intimate partner violence, 57, 388,
388b
Involuntary movements, 315, 341t
Iron, food sources of, 74t
Irritable bowel syndrome, 214t
Irritating particles/chemicals, and
cough, 161t
Ischiogluteal bursa, 294, 294f
Isolated clinic hypertension. See White
coat hypertension
Itching
rashes and, 89
vaginal, 248
J
Jaundice, 202
extrahepatic, 202
intrahepatic, 202
Joint pain
acute or chronic, 278–279
articular or extra-articular, 278
assessment of, tips for, 278b
constitutional symptoms with, 279
in ammatory or nonin ammatory, 279
localized or diffuse, 279
monoarticular, 278
polyarticular, 278
Joints
aging, effect of, 276, 276b
anatomy, terminology related to, 275b
cartilaginous, 276b
examination of, steps in, 283b
brous, 276b
in ammation, signs of, 283b–284b
pain in, 304t (see also Joint pain)
problem, 275
synovial, 276b, 277b
Judgment
in delirium and dementia, 419t
patient, 80b, 84
Jugular venous pressure ( JVP), 174, 175f
Jugular venous pulsations, 174
K
Kappa score, 33
Keloid, 103t
Kernig sign, 330, 330f
Kidneys, examination of, 210, 210f
Kinetic red target test, 119
Klinefelter syndrome, 244t
Knee
examination of, 296–301, 296f
pain in, 309t–310t
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Inde x
Koplik spots, 142t
Korotkoff sounds, 66b
433
in infants, 360, 360b–361b
in older adults, 412
in physical examination, 11
during pregnancy, 391
recording ndings, 154
Lymphadenopathy, 359
L
Lachman test, 300, 300f
Language
barrier, 52
de ned, 80b
Large for gestational age (LGA), 354t, 373t
Laryngitis, 159t
Lateral collateral ligament test, 300, 300f
Leadpipe rigidity, 342t
Left ventricular heart failure, 157t, 161t
Left ventricular hypertrophy (LVH), 412
Leg length, measurement of, 303
Legs, examination of, 12, 224–225,
224f, 225f
Leopold maneuvers, 395–396
Lesions
skin, 62
vulva, 258t–259t
Leukocoria, 358
Lhermitte sign, 305t
Libido, assessment of, 233
Lid retraction, 133t
Lifestyle habits, in health history, 4
Lifestyle modi cations, for
cardiovascular health, 173b–174b
Ligaments, 275b
Lighting, for examination, 7
Likelihood ratio, 30
interpretation of, 31
for negative test, 31
for positive test, 30–31
Lipoma, 104t
Lips
abnormalities of, 139t
inspection of, 126
Listening, active, 42
Liver, examination of, 209–210, 209f
Lobar obstruction, 165t
Low back pain, 280, 280b, 306t–307t
health promotion and counseling, 281
red ags for, 280b
Lower extremities, in physical
examination, 12
Lumbar spinal stenosis, 306t
Lumbosacral radiculopathy, 330
Lung abscess, 160t
Lung cancer, 158t, 161t
Lungs
concerning symptoms, 145b
examination of, 147–153
health history, 145–146
health promotion and counseling, 146
M
Macular degeneration, 116, 123b, 411
Macules, 100t
Malabsorption syndrome, 215t
Male genitalia, 378t–379t
anatomy of, 236f
in children, 369
concerning symptoms, 233b
examination of, 13, 236–239
health history, 233–234
health promotion and counseling,
234–235
in infants, 363
older adults, examination in, 414
recording ndings, 240
in review of systems, 5
sexually transmitted infections of,
242t–243t
Mammography, 189, 189b
Mania, 83
Masked hypertension, 64b
McMurray test, 299, 299f
Mechanical neck pain, 305t
Medial collateral ligament test, 299, 299f
Medications, in health history, 3
Melanoma, 90, 411
ABCDE-EFG method for, 91,
91b–92b
incidence of, 90
and mimics, 107t–108t
prevention of, 90–91
risk factors for, 90–91
screening for, 91
Melanoma in situ, 107t
Melanoma Risk Assessment Tool, 90
Melanonychia, 113t
Melena (black tarry stools), 202
Memory
de ned, 80b
in delirium and dementia, 419t
Ménière disease, 117
Meningeal signs, 330
Meningitis, and headache, 130t
Meniscal tear, 309t
Menopause, 248, 252
Mental health disorders, 77, 78b, 87t
personality disorders, 78
and unexplained symptoms, 77, 78b, 79
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434
Inde x
Mental health history, 55
Mental illness, 77. See also Mental status
Mental status
assessment of, 12
behavior and, 77–88
examination of, 82–86 (see also
Mental Status Examination)
health history, 79–81
health promotion and counseling, 81–82
recording ndings, 86
screening, 79, 79b
unexplained symptoms and, 77, 78b
Mental Status Examination, 82, 82b
appearance and behavior, 83
cognitive function, 84–85
mood, 84
speech and language, 83, 83b
thoughts and perceptions, 84
Metabolic syndrome, 173, 173b
Metacarpophalangeal joints, 289, 289f
Metatarsophalangeal joints, 301, 301f
Migraine, 116
with aura, 128t
without aura, 128t
Mini-Cog, 420t
Mini-Mental State Examination
(MMSE), 85, 86b, 314
Mitgehen, 342t
Mitral regurgitation, 413
Mitral stenosis, 157t, 161t
Mitral valve prolapse (MVP), 180
Montreal Cognitive Assessment (MoCA),
421t
Mood
assessment of, 84
de ned, 80b
in delirium and dementia, 418t
disorders, 81
Morbilliform drug eruption, 100t
Morning stiffness, 279
Motivational interviewing, 49, 49b
Motor behavior, assessment of, 83
Motor disorders, 340t
Motor system, examination of, 12, 62,
321–324
Mouth
in children, 367–368
concerning symptoms, 115b
examination of, 126
health history, 118
health promotion and counseling, 119
in infants, 359
inspection of, 126
MRSA precautions, 7
Mucopurulent cervicitis, 261t
Mucous patch of syphilis, 141t
Multinodular goiter, 143t
Murmurs, 178–179
aortic, 179
in children, 368
crescendo, 179
crescendo–decrescendo, 178
decrescendo, 179
gradations of, 179b
in older adults, 413
pathologic, 375t–376t
plateau, 179
Murphy sign, 213
Muscle strength
grading of, 321b
testing of, 321–323
Muscle tone, disorders of, 342t
Musculoskeletal disorders, 275
Musculoskeletal system, 275
in children, 370
concerning symptoms, 277b
examination of, 283–303
health history, 277–280
health promotion and counseling,
281–283
in infants, 363–364, 363f
joints, assessment of, 275–277
in older adults, 414
in physical examination, 11
recording ndings, 303
in review of systems, 6
Mycoplasma, 159t
Myocardial infarction, chest pain in, 155t
Myoma of uterus, 262t
Myopia, 116, 365
N
Nails
changes in, 90
ndings, 113t–114t
National Survey on Drug Use and
Health, 82
Natural frequencies, 32
Neck
concerning symptoms, 115b
examination of, 126–127
health history, 118
in infants, 359, 360f
pain in, 279–280, 305t
in physical examination, 11
during pregnancy, 390
in review of systems, 5
Negative predictive value (NPV), 29b
Nervous system, 311–312
central, 311–312
in children, 370
concerning symptoms, 313b
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examination of, 12, 318–333
guiding questions for examination
of, 311b
health history, 313–315
health promotion and counseling,
315–317
in infants, 364
older adults, examination in, 415
peripheral, 312
recording ndings, 333–334
Neurologic abnormalities, in older
adults, 415
Neurologic examination, 332–333
Neurologic questions, in review of
systems, 6
Neuropathic ulcer, 229t
Newborn
Apgar scoring system, 352, 353b
assessment after some time, 354
bowlegged, 354
classi cations, 354b
gestational age and birth weight,
353, 353b
immediate assessment, 352–353
level of maturity, 373t
neurologic screening of, 354
umbilical cord, 354
New learning ability, assessment of, 85
Night sweats, 59
Nocturia, 204
Nocturnal back pain, 307t
Nocturnal hypertension, 65b
Nodule, 103t
Nonmale cence, 58b
Nonproliferative retinopathy
moderately severe, 136t
severe, 136t
Nonverbal communication, 43
Nose
concerning symptoms, 115b
examination of, 125
health history, 117–118
in infants, 359
during pregnancy, 390
Nosebleeds, 390
Number identi cation, 326
Numbness, in legs/feet, 219
Numeric Rating Scale, 70
Nummular dermatitis, 101, 101f
Nutrients, sources of, 74t
Nutrition
health promotion and counseling for,
61, 61b
older adults and, 403
during pregnancy, 386
screening checklist, 73t
sources of nutrients, 74t
435
O
Obesity, 60
body mass index and, 63
and cardiovascular disease, 173
childhood, 365
Obturator sign (appendicitis), 213
Oculocephalic re ex, 332, 333f
Oculomotor nerve, 318b, 319
Odors, body and breath, 62
Odynophagia, 199b, 202
Older adults, 399–400
activities of daily living, 402, 402b
approach to, 400–403
common concerns, 401b
cultural dimensions, 401, 401b
delirium and dementia, 418t–419t
eliciting symptoms in, 400–401
examination of, 408–415
falls prevention in, 283, 407–409,
408b, 409f
health history, 400–403
health promotion and counseling,
404–406
hearing de cits in, 119
hypothermia in, 68
medications and, 402
Mini-Cog, 420t
10-Minute Geriatric Screener, 406,
406b–407b
mistreatment and abuse, 406
Montreal Cognitive Assessment
(MoCA), 421t
pain in, 402, 403b
primary care, approach for,
399b–400b
recording ndings, 415–416
vision disorders in, 118
Olfactory nerve, 318, 318b
Onycholysis, 114t
Onychomycosis, 114t
Open-ended questions, 46
Ophthalmoscope, use of, 121b–122b
Optic atrophy, 135t
Optic disc
abnormalities of, 135t
examination of, 123, 123b
Optic nerve, 318, 318b, 319
Oral candidiasis (thrush), 359
Oral mucosa, inspection of, 126
Orchitis, acute, 244t
Orientation
assessment of, 84
de ned, 80b
in delirium and dementia, 419t
Orthopnea, 168b
Orthostatic hypotension, 410
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Inde x
Orthostatic (postural) hypotension,
66b, 174
Ortolani test, 363, 363f
Osmotic diarrheas, 215t
Osteoarthritis, 304t
Osteopenia, 282b
Osteoporosis
bone density criteria, 282b
falls prevention, 283
health promotion and counseling,
281–283
risk factors for, 282b
treatment of, 283
Otitis externa, 117, 366
Otitis media, 117, 367
Ovarian cancer, 250
Over ow incontinence, 204, 216t
P
Paget disease of nipple, 198t
Pain, 60, 69
assessment of, 69–70
chronic, 69, 70b–71b
contributing factors, 70
health disparities in treatment of, 70
in knee, 309t–310t
location of, 70
management of, 70, 70b–71b
in neck, 305t
in older adults, 402, 403b
severity of, 70
in shoulder, 308t
on urination, 203
Painful arc test, 286b
Pain provocation test, 286b
Palliative care, 403
Pallor, in legs/feet, 219, 226
Palpitations, 167b
Papilledema, 135t
Pap smear, 393
specimens for, 255, 255f
Papules, 101t
Paradoxical pulse, 175
Paranoia, 83
Paratonia, 342t
Paresthesias, 314
Parietal pain (abdomen), 200
Parkinsonism, 340t
Paronychia, 113t
Paroxysmal nocturnal dyspnea (PND),
168b
Paroxysmal supraventricular
tachycardia, 356, 362
Partnerships, collaborative, 50b
Past history, 2b, 3
Patches (skin), 100t
Patellofemoral instability, 309t
Patent ductus arteriosus, 177–178,
177f, 178f, 185t
Patient
with altered cognition, 51–52
angry, 52
bedbound, 98
confusing, 51
crying, 52
disruptive, 52
dying, 57
empowerment of, 44, 44b
with hearing loss, 53–54
with impaired vision, 54
with language barrier, 52, 52b–53b
with limited intelligence, 54
with low literacy, 53
partnering with, 43
with personal problems, 54
seductive, 54
silent, 50
talkative, 52
Patient care, ethics in, 58b
Peau d’orange sign (breast cancer),
198t
Pectus carinatum, 164t
Pectus excavatum, 163t
Pelvic examination, 252
in older adults, 413–414
Pelvic oor, relaxations of, 263t
Pelvic pain, 249
Penile discharge, 234
Penis
abnormalities of, 234, 241t
examination of, 236–237
Perceptions
assessment of, 84
de ned, 80b
in delirium and dementia, 418t
Percussion notes, 149b
Perforation, eardrum, 137t
Performance bias, 35b
Pericarditis, chest pain in, 155t
Perineal irritation, 369
Peripheral arterial disease (PAD), 219
risk factors for, 221b
screening for, 221, 221b
warning signs, 220b
Peripheral nerves, 312
Peripheral nervous system, 312
disorder, 340t
Peripheral neuropathy risk, prevention
of, 316–317
Peripheral vascular system
concerning symptoms, 219b
examination of, 12, 222–226
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health history, 219–220
health promotion and counseling,
220–222
older adults and, 413
recording ndings, 227
in review of systems, 5
Personal history, 2b, 4
Personal hygiene, 62, 83
Personality disorders, 78
Pes anserine bursa, 309t
Petechia/purpura, 110t
Peutz–Jeghers syndrome, 139t
Peyronie disease, 241t
Phalen sign, 292, 292f
Pharyngitis, 118, 142t
Pharynx
abnormalities of, 142t
examination of, 126
in infants, 359
Physical abuse, 57b
Physical activity, guidelines for, 281, 281b
Physical contact, 43
Physical dependence, 56b
Physical examination, 6–13
approach for, 7
beginning of, 7–10
comprehensive vs. focused, 9
general survey in, 61–62
health promotion and counseling in,
60–61
patient positioning for, 9b, 10
preparation for, 7b
recording ndings, 71, 71b
sequence of, 8, 9b
standard and universal precautions in, 7
Pigeon chest, 164t
Pilar cysts, 104t
Pinguecula, 134t
Pink lesions, 106t
Plan, 13, 16
Plantar response, 329, 329f
Plaque psoriasis, 101t
Plaques, 101t
Pleural effusion, 165t
Pleuritic pain, 156t
Pneumatic otoscope, 367
Pneumococcal vaccine, 146
Pneumonia, 158t, 357
Pneumothorax, 165t
Point of maximal impulse (PMI), 412
Polydactyly, 363
Polyps of rectum, 272t
Polyuria, 204
Popliteal pulse, 224f
Positive predictive value (PPV), 29b
Postconcussion headache, 131t
Posterior cruciate ligament test, 301, 301f
437
Posterior drawer sign, 301, 301f
Posterior tibial pulse, 225f
Postmenopausal bleeding, 248
Postnasal drip, 159t
Posture, assessment of, 62, 83
Precision, 33
Precocious puberty, 369
Predictive value
negative, 29b
positive, 29b
Preeclampsia, 390b, 394
Pregnancy
common concerns, 383b
con rmation of, 383
examination in, 389–396
expected date of delivery, 385b
gestational age, 385b
health history, 383–385
health promotion and counseling,
385–389
hypertension in, 390b
maternal concerns and attitudes,
384
obstetric visits, 385
postpartum contraception, plans
for, 384
preparation for examination, 389b
recording ndings, 396–397
risk factors for maternal and fetal
health, 384
symptoms of, 383
Pregnancy Weight Gain Calculator, 386
Premature closure, 48
Premature ejaculation, 234
Prepatellar bursa, 309t
Presbyopia, 116, 411
Prescription drugs
abuse of, 56, 82
during pregnancy, 388
Present illness, 1b, 3
Pressure sores, 98, 411
Presyncope, 313
Preterm labor, 392
Prevalence of disease, 29–30
Primary biliary cirrhosis, 134t
Primary prevention, 33
Primitive re exes, 364
Primum non nocere, 58b
Probability revisions, 27–28, 27f
Problem List, 24
Professionalism, and ethics, 58, 58b
Prolapsed uterus, 263t
Proliferative retinopathy
advanced, 136t
with neovascularization, 136t
Pronator drift, test for, 324, 324f
Proprioception, test for, 326, 326f
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Inde x
Prostate
cancer of, 273t
concerning symptoms, 265b
examination of, 268–269
health history, 265
recording ndings, 270
Prostate cancer, 265, 266
risk factors, 266
screening for, 266–267, 266b–247b
Prostate-speci c antigen (PSA) test, 266
Prostatitis, acute, 273t
Proximal weakness, 314
Pseudoclaudication pain, in back, 306t
Psoas sign (appendicitis), 213
Psychiatric questions
in review of systems, 6
Ptosis, 133t
Pubic hair, 378t–380t
Pulmonary disease, chest pain in, 156t
Pulmonary embolism, 158t, 161t
Pulmonary brosis, idiopathic, 158t
Pulmonary function, clinical assessment
of, 153
Pulmonary hypertension, 362
Pulmonary tuberculosis, 160t
Pulmonary valve stenosis, 375t
Pulse, in infants, 356
Pulsus alternans, 175
Pupils
in comatose patients, 347t
inspection of, 120, 121f
large, 347t
midposition xed, 347t
one xed and dilated, 347t
pinpoint, 347t
small, 347t
Pustules, 103t
Pyloric stenosis, 362
Pyrexia. See Fever
R
Race and ethnicity
cultural ethnicity, 49–50
diabetic risk factors, 171
geriatric diversity, 401b, 401–402
prostate cancer risk factors, 266
testicular cancer risk factors, 235
Radial pulse, 67, 67f, 223, 223f
irregular rhythm, 67
regular rhythm, 67
Radicular low back pain, 306t
Raised spots (skin), 101t
Range of motion
ngers, 290
hip, 295, 295f
measurement of, 303
shoulder, 285–286
thumbs, 290f
wrists, 290
Rashes, 89
Reassurance, 43
Rebound tenderness, 208
Recent memory, assessment of, 85
Rectal examination
in men, 13
in women, 13
Rectal temperature, 68
measurement of, 68–69
Rectocele, 263t
Rectovaginal examination, 256, 256f
Rectum
abnormalities of, 272t–273t
cancer of, 273t
concerning symptoms, 265b
examination of, 268–269, 268f
health promotion and counseling,
266–267
recording ndings, 270
Red re ex, 121f, 122b
Referred pain (abdomen), 200
Re exes, 327
abdominal, 329, 329f
Achilles, 328f
biceps, 327f
brachioradialis, 328f
examination of, 13
grading, 327b
quadriceps (patellar), 328f
triceps, 327f
Remnants of digits, 363
Remote memory, assessment of, 84
Renal artery disease (RAD), 221b–222b
screening for, 221b
Reproducibility, test, 33
Respiratory rate
in infants, 357
and rhythm., 67
Respiratory system, 5
Responses, empathic, 42
Resting static tremors, 341t
Retina, examination of, 123, 123b
Retinoblastoma, 358
Retinopathy
nonproliferative, 136t
proliferative, 136t
Review of systems (ROS), 2b, 4–6
Rheumatoid arthritis, 304t
Rhinorrhea, 117
Rhonchi, 151b
Rigidity, 342t
Ringworm, 112t
Rinne test, 125, 320
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Romberg test, 12, 324
Rotator cuff tendinitis, 308t
Rough lesions (skin), 105t
Rovsing sign (appendicitis), 212
S
Sarcoidosis, 158t
Scabies, 104t
Scapular winging, 331, 331f
Schizophrenia, 83
Sciatica, 306t
Sciatic nerve, 293, 293f
Scoliometer, 371
Scoliosis, testing for, 371, 371f
Screening
for abdominal aortic aneurysm, 222
for breast cancer, 189, 189b
for cancer, 404–405
for cardiovascular disease, 169–173
for cervical cancer, 249–250, 250b
for colorectal cancer, 206, 206b–207b
for delirium, 421t
for dementia, 406, 420t
for high blood pressure, 170
for HIV/AIDS, 235
for intimate partner violence, 388, 388b
lipid, 172
mental health, 79, 79b
in older adults, 404
for peripheral arterial disease, 221, 221b
for problem drinking, 204b–205b
for renal artery disease, 221
for STIs and HPV, 235
Screening tests, in health history, 3
Scrotal edema, 241t
Scrotal hernia, 241t
Scrotum
abnormalities of, 234, 241t
examination of, 237
Seborrheic dermatitis, 100t
Seborrheic keratosis, 108t
in amed, 108t
Secondary prevention, 33
Secondary syphilis, 259t
Secretory diarrheas, 215t
Seductive patient, 53
Seizure, 315
Selection bias, 35b
Self-awareness, 50b
Self-re ection, 49
Self-skin examination, 92, 98
Senile ptosis, 411
Sensitivity, 29b
Sensorineural loss, 117
Sensory loss, 314
439
Sensory system
assessment of, 324–327
examination of, 12–13
Serial 7s, 84
Serous effusion, 137t
Sex maturity ratings, in boys,
378t–379t
Sex maturity ratings, in girls
breast, 377t
pubic hair, 380t
Sexual abuse, 57b, 369
physical signs of, 381t
Sexual health
female, 248–249
male, 233–234
Sexual history, 55, 55b
Sexually transmitted infections
of male genitalia, 234, 242t–243t
screening for, 235
in women, 249
Shortness of breath, 167b
Shoulder
examination of, 284–287
pain in, 308t
Sighing breathing, 162t
Silent patient, 50
Sinuses
concerning symptoms, 115b
examination of, 125
health history, 117–118
Sinusitis, headache from, 129t
SITS muscle (rotator cuff) assessment,
286, 286b–287b
Skin, 89–114
color of, 62
description of ndings, terms for, 94,
94b–95b
examination of, 10, 93–98
health history, 89
health promotion and counseling
for, 90–92
in infants, 357
lesions of, 62, 100t–110t
older adults and, 410–411
preparation for examination, 93–94
recording ndings, 99
in review of systems, 2b, 4–6
seated position, examination in,
95–97, 95f–97f
supine and prone position,
examination in, 97, 97f
Skin cancer
health promotion and counseling
for, 90–92
prevention, 90–91
screening, 91, 91b–92b
self-skin examination, 92, 98
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Inde x
Skin lesions. See also speci c lesion
assessment of, 62
brown, 107t–108t
description of, 94, 94b–95b
pink, 106t
primary, 100t–102t, 103t–104t
rough, 105t
vascular and purpuric, 109t–110t
Skin tags, 101t, 107t, 363
Small for gestational age (SGA), 354t, 373t
Smoking
and cardiovascular disease, 173
older adults and, 403
readiness for cessation, 146, 146b
Smooth tongue, 140t
SnNOUT mnemonic, 29
Social history, 2b, 4
Sodium, dietary, 61
Solar lentigo, 107t
Somatic symptom disorder, 87t
Sore throat, 118
Spasticity, 342t
Speci city, 29b
Speculum examination, 393, 414
Speech
assessment of, 83
in delirium and dementia, 418t
disorders of, 337t–338t
Spelling backward, 84
Spermatic cord
abnormalities of, 245t
examination of, 238, 238f
torsion of, 245t
varicocele of, 245t
Spermatocele, 245t
Spider angioma, 109t
Spider vein, 109t
Spinal accessory nerve, 318b, 320
Spinal cord, 312
Spinal nerve, 312
Spinal stenosis, 219
Spine, examination of, 292–293
Spleen, examination of, 210, 210f
Spontaneous pneumothorax, 158t
SpPIN mnemonic, 29
Squamous cell carcinoma (SCC), 105t
Stance, 324
Standard precautions, 7
Static nger wiggle test, 119, 120f
Stereognosis, 326
Sternocleidomastoid muscles,
assessment of, 320
Stool, color of, 202
Straight-leg raise, 306t, 330, 330f
Streptococcal pharyngitis, 118, 367
Stress incontinence, 204, 216t
Stridor, 148
Stroke
prevention of, 316
risk factors management, 316
types of, 335t–336t
warning signs and symptoms, 316b
Sty, 134t
Subacromial/subdeltoid bursitis, 285,
308t
Subarachnoid hemorrhage, and
headache, 130t
Subcutaneous mass/cyst, 104t
Substance abuse, 82
Subungual melanoma, 113t
Suicide risk, 81–82
Summarization, 44
Sun exposure, and skin cancer cancer,
90–91
Sunscreen, use of, 91
Sutures, 357
Swelling of feet and legs, 220
Symptom, seven attributes of, 3, 3b, 47, 47b
Syncope, 168b, 314–315
Syndactyly, 363
Syphilis
primary, 243t
secondary, 259t
Syphilitic chancre, 139t, 259t
Systems review, 2b, 4–6
Systolic blood pressure, 66b
Systolic murmurs, identi cation, 180
T
Tachypnea, 162t
Tactile fremitus, 148
Talkative patient, 52
Tanning beds, and melanoma risk, 91
Tavistock Principles, 58, 58b
Telogen ef uvium, 98, 111t
Temperature
axillary, 68
measurement of, 68–69
oral, 68
rectal, 68–69
temporal artery, 69
tympanic membrane, 68, 69
Temporal artery temperature,
measurement of, 69
Temporomandibular joint (TMJ), 284, 284f
Tendons, 275b
Tension headache, 115, 128t
Terry nails, 114t
Testicular cancer, 235
Testicular self-examination, 235, 239b
Testis
abnormalities of, 244t
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examination of, 237, 237f
small, 244t
Tetralogy of Fallot, 375t
Thoracic kyphoscoliosis, 164t
Thorax
concerning symptoms, 145b
deformities of, 163t–164t
examination of, 147–153
health history, 145–146
health promotion and counseling, 146
in infants, 360, 360b–361b
normal, 163t
in older adults, 412
in physical examination, 11
during pregnancy, 391
recording ndings, 154
Thought content
assessment of, 84
in delirium and dementia, 418t
patient, 80b
Thought processes
assessment of, 84
in delirium and dementia, 418t
patient, 80b
Thrills, 362
Throat
concerning symptoms, 115b
health history, 118
Thumb abduction, 291, 291f
Thunderclap headache, 130t
Thyroid gland
abnormalities of, 143t
diffuse enlargement, 143t
examination of, 127
with goiter while swallowing, 127f
during pregnancy, 390
Thyroid nodule (single), 143t
Tibial torsion, 364
Tinea capitis, 112t
Tinel sign, 291, 291f
Tinnitus, 117
Tobacco use
in health history, 3
during pregnancy, 387
Tolerance, 56b
Tongue
abnormalities of, 140t–141t
inspection of, 126
Torsion of spermatic cord, 245t
Torticollis, 305t
Tortuous atherosclerotic aorta, 412
Transient ischemic attack (TIA), 313.
See also Stroke
Transitions, 44
Transposition of great arteries, 376t
Trapezius muscles, assessment of, 320,
320f
441
Traumatic ail chest, 163t
Treatment plan, sharing of, 48–49
Tremors, 315, 415
Trichomonas vaginitis, 260t
Trichophyton rubrum, 114t
Trigeminal nerve, 318b, 319, 319f
Trochanteric bursa, 294, 294f
Trochlear nerve, 318b, 319
Tug test, 98, 98f
Tumor of testis, 244t
Two-point discrimination, 326, 326f
Tympanic membrane temperature, 68
measurement of, 69
Tympanosclerosis, 137t
U
Ulcerative colitis, 215t
Ulcers of feet and ankles, 229t
Ultraviolet radiation exposure,
avoidance of, 90
Umbilical hernias, in infants, 354
Undescended testicles, 363
Unilateral blindness, 132t
Universal precautions, 7
Urethritis, assessment of, 256, 256f
Urge incontinence, 204, 216t
Urgency, urinary, 203
Urinary frequency, 203
Urinary incontinence, 204, 216t–217t
functional, 217t
over ow, 216t
secondary to medications, 217t
stress, 216t
urge, 216t
Urinary system
in review of systems, 5
symptoms related to, 203–204
Urine, color of, 202
Urticaria, 104t
U.S. Preventive Services Task Force
(USPSTF), 33
abdominal aortic aneurysm screening,
222
breast cancer screening, 189b
cancer screening in older adults, 399
carotid artery screening
cervical cancer screening, 250b
colorectal cancer screening, 206b
grade de nitions and implications for
practice, 37t
hypertension screening, 170
levels of certainty, 38t
low-dose computed tomography
screening, 146
osteoporosis screening, 282
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Inde x
Uterus
anteverted, 262t
bicornuate, 394
myoma of, 262t
palpation of, 255, 255f
during pregnancy, 394
prolapsed, 263t
retro exed, 262t
retroverted, 256, 256f, 262t
Vital signs
in infants, 356–357
in older adults, 408–410
in physical examination, 10,
64–69
recording ndings, 71b
Vitamin D, food sources of, 74t
Vitiligo, 100t
Vocabulary, patient, 85
Voice sounds, transmitted, 151b
Voluminous diarrheas, 215t
Vulva, lesions of, 258t–259t
Vulvar carcinoma, 259t
V
Vaccination. See also Immunizations
hepatitis A, 205b
hepatitis B, 206b
HPV, 235
Vaginal adenosis, 261t
Vaginal discharge, 248, 260t, 369
Vagus nerve, 318b, 320
Validation, 43
Validity, test, 28–32
Valsalva maneuver, 180
Varicocele of spermatic cord, 245t
Varicose veins (tongue), 141t
Vasomotor rhinitis, 117
Venereal wart, 258t
Venous insuf ciency, chronic, 228t, 229t
Ventricular heart failure, left, 157t, 161t
Ventricular septal defect, 376t
Verbal support, 43
Vertigo, 117, 313
Vesicles, 102t
Vibration sense, testing of, 325
Violence
domestic, 57
intimate partner, 57
Viral hepatitis, health promotion and
counseling for, 205–206
Viral pneumonias, 159t
Visceral pain (abdomen), 199
Visual Analog Scale, 70, 402
Visual eld defects, 132t
Visual loss
central, 116
one-sided loss, 116
peripheral loss, 116
sudden, 116
W
6-minute walk test, 153
Warts, 105t
Weakness, 59, 314
distal, 314
proximal, 314
Weber test, 125, 320
Weight
change in, 60
gain, 60
in infants, 355
loss, 60
measurement of, 63
older adults and, 410
optimal, 60, 61b
during pregnancy, 390
Weight gain, during pregnancy, 386,
386b
Wernicke aphasia, 337t–338t
Wheal, 104t
Wheezes, 148, 151b
Whiplash syndrome, 305t
White coat hypertension, 64b
Winging of scapula, 331, 331f
World Health Organization, bone
density criteria, 282b
Wrists, examination of, 288–290
X
Xanthelasma, 134t
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