Advanced Physical Examination Learning Objectives
Note: Page numbers correspond to Bates 9th Edition
The Skin and Nails (Ch 5):
1. Be able to describe and recognize vascular skin lesions, i.e. spider angioma, cherry angioma and
purpuric skin lesions, i.e. petechia/purpura, ecchymosis (141).
Spider Angioma
Spider Vein
Fiery red
Bluish
From very small to 2cm
Variable, from
very small to
several inches
Variable; may
resemble a spider
or be linear,
ireegular,
cascading
Color
Size
Shape
Pulsatility
Effect of
Pressure
Distribution
Central body, sometimes
raised, surrounded by
erythema and radiating
legs
Often demonstrable in the
body of the spider, when
pressure w/ a glass slide
is applied
Pressure on the body
causes blanching of the
spider
Face, neck, arms, and
upper trunk;
Liver disease, pregnancy,
vitamin B deficiency
Significance
absent
Diffuse pressure
causes blanching
Legs, near veins;
anterior chest
Often
accompanies
increased
pressure n the
superficial veins,
as in varicose
veins
Cherry
Angioma
Bright or
ruby red;
may become
brownish w/
age
1-3mm
Rounded,
flat or
sometimes
raised, may
be
surrounded
by a pale
halo
Absent
Partial
blanching,
esp. if
pressure
applied to
the edge of
a pinpoint
Trunk,
extremeties
None;
increase in
size and
numbers w/
aging
Petechia/Purpura
Ecchymosis
Deep red or reddish
pimple, fading away
over time
Purple or purplish
blue, fading to green,
yellow, and brown
with time
Petechia 1-3mm;
purpura, larger
Variable, larger than
petechiae
Rounded,
sometimes irregular,
flat
Variable (rounded,
oval, irregular); may
have a central
subcutaneous flat
nodule (hematoma)
Absent
Absent
None
None
Variable
Variable
Blood outside the
vessels; may
suggest a bleeding
disorder or, if
petechiae, emboli to
skin
Blood outside the
vessels; often
secondary to
bruising or trauma;
also seen in bleeding
disorders
2. Identify a macule, papule, erosion, crust, scar, ulcer, fissure, vesicle, splinter hemorrhages, and
clubbing (see photographs in Tables 5-9 & 5-13, pp144-145).
 Macule- a small patch or spot, not elevated above or depressed below the skin surface
 Papule- small circumscribed elevation on the skin
 Clubbing
o distal phalanx rounded and bulbous, nail plate convex; angle between plate and proximal nail
fold increases to 180o or more
o proximal nail fold feels spongy or floating when palpated
The Head and Neck (Ch 6):
1. Be able to recognize the following facies: acromegaly, myxedema, Cushing’s syndrome, nephrotic
syndrome, Parkinson’s disease (211)
 Acromegaly
o Due to increase in growth hormone that produces enlargement of both bone and soft
tissues
o Head elongated with bony prominence of the forehead, nose and lower jaw (soft tissues
of nose, lips, and ears may also enlarge)
o Facial features generally coarsened
 Myxedema
 Due to severe hypothyroidism
 Dull, puffy facies
 Edema pronounced around eyes, does not pit with pressure
 Hair and eyebrows dry, coarse, and thinned; skin Is dry
 Cushing’s
 Due to increased adrenal hormone production
 Round moon-face with red cheeks
 Excessive hair growth  mustache, sideburn, chin
 Nephrotic
 Face edematous and pale; swelling appears around eyes first thing in the morning (may
be so severe that eyes become slit-like)
 Parkinson’s
 Decreased facial mobility blunts expression (mask-like), decreased blinking
 Neck and trunk tend to flex forward, gives appearance that patient is staring in their peer
upward
 Skin may become oily, drooling may occur
2. Understand the lesions of visual pathways and their corresponding visual field defects, i.e. bitemporal
hemianopsia, left homonymous hemianopsia, etc (176).
Defect
Horizontal Defect
Blind Right Eye (A)
Bitemporal Hemianopsia
(optic chiasm) – (B)
Left Homonymous
Hemianopsia (right optic
tract) – (C)
Homonymous Left
Superior Quadrantic
Defect (right optic
radiation, partial) – (D)
Left Homonymous
Hemianopsia (right optic
radiation) – (E)
What is it?
Occlusion of a branch of central retinal artery may
produce horizontal (altitudinal) defect
Lesion of optic nerve (of the eye itself) produces
unilateral blindness
Lesion at optic chiasm may involve only the fibers
crossing over to the opposite side, producing visual
loss in temporal half of each field
Lesion in optic tract interrupts fibers originating on
same side of both eyes
What does it look like?
Not pictured, see pp212
See figure below
Partial lesion of optic radiation may involve only a
portion of the nerve fibers
Complete interruption of fibers in the optic radiation
produces defect similar to that produced by lesion of
optic tract
3. Recognize ptosis, exophthalmos, sty, and xanthelasma (for photographs see pg213-214).




Ptosis
o Drooping of the upper eyelid
o Causes: myasthenia gravis, CNIII damage, damaged to sympathetic supply (Horner’s)
Exophthalmos
o Eyeball protrudes forward, may have associated edema and conjunctival injection
o Graves’ Disease (hyperthyroidism)  unilateral or bilateral
o Unilateral exophthalmos also caused by tumor or inflammation in the orbit
Sty (Acute Hordeolum)
o Painful, tender, red infection at the margin of the eyelid (looks like pimple or boil)
Xanthelasma (may accompany lipid disorders)
o Slightly raised, yellowish, well-circumscribed plaques in the skin
o Appear along nasal portions of one or both eyelids
4. Understand the differential diagnosis of the red eye, i.e. conjunctivitis, iritis, corneal injury, etc. pg215
Conjunctivitis
Pattern of
Redness
Conjunctival
injections: diffuse
diliatation of
conjunctival
vessels with
redness that
tends to be
maximal
peripherally
Pain
Mild discomfort
rather than pain
Vision
Ocular
Discharge
Not affected
except for
temporary mild
blurring due to
discharge
Watery, mucoid,
or mucopurulent
Corneal
Injury/Infection
Subconjunctival Hemorrhage
Leakage of blood outside of the
vessels, producing a homogenous
sharply demarcated red area that
fades over days to yellow and then
disappears
Moderate to
severe, superficial
Moderate,
aching,
deep
Severe,
aching,
deep
Absent
Usually
decreased
Decreased
Decreased
Not affected
Watery or
purulent
Absent
Absent
Absent
Dilated,
fixed
Not affected
Steamy,
cloudy
Clear
Acute
increase in
intraocular
pressure –
emergency!
Often none; may results from
trauma, bleeding disorders, or
sudden increase in venous
pressure, as from cough
Pupil
Not affected
Cornea
Clear
Varies
Significance
Glaucoma
Cliary infection: dilation of deeper vessels that
are visible as radiating vessels or a reddish
violet flush around the limbus; eye may also
be diffusely red;
Not affected
unless iritis
develops
Bacterial, viral;
allergy; irritation
Acute Iritis
Abrasions; viral,
bacterial;
May be
small and,
with time,
irregular
Clear or
slightly
clouded
Many
ocular and
systemic
disorders
5. Be able to recognize Argyll Robertson pupil and Horner’s Syndrome (217).
 Argyll Robertson pupil
o Small, irregular pupils that do not react to light, but react to near effort
o Most often, but not always, caused by CNS Syphilis

Horner’s Syndrome
o Small pupil on affected side, reacts briskly to light and near effort
o Ptosis of ipsilateral eyelid
o Loss of sweating on forehead ipsilaterally
o Congenital Horner’s: affected iris lighter (heterochromia)
6. Be able to recognize papilledema, optic atrophy, a-v nicking, deep retinal hemorrhages (dot or blot
hemorrhages), soft exudates (cotton wool spots), and neovascularization (for photographs see 220225).
 Papilledema
o Engorgement and swelling of disc vessels (more numerous, curve over borders of disc)
o Disc swollen w/ margins blurred, physiologic cup not visible
o Due to venous stasis
 Optic atrophy
o Loss of the tiny disc vessels, disc is white
o Due to death of optic nerve fibers
 A-V nicking (Concealment)
o Vein appears to stop abruptly on either side of an artery
 Deep retinal hemorrhage (dot/blot hemorrhages)
o Small, rounded, slightly irregular red spots
o Due to diabetes mellitus
o Vessels may grow into vitreous to cause retinal detachment or hemorrhage  vision loss
 Soft exudates (Cotton-wool patches)
o White or grayish ovoid lesions with irregular borders
o Moderate in size, but smaller than the disc
o Due to infracted nerve fibers from hypertension
 Neovascularization
o More numerous, torturous, and narrower than other blood vessels in the area
o Form disorderly-looking red arcades
o Due to late, proliferative diabetic retinopathy
7. Be able to recognize and differentiate between acute otitis media, serous effusion, bullous myringitis,
and otitis externa (for photographs see pg229).
 AOM
o Eardrum reddened, losing its landmarks, and bulges laterally (toward examiner’s eye)
o Sx: earache, fever, hearing loss, no pain in tragus and auricle
o Caused by bacterial infection
 Serous Effusion
o Serous fluid accumulates behind eardrum b/c eustachian tube cannot equalize pressures
in middle ear with that of outside ear
o Sx: amber fluid behind eardrum is characteristic (may see air bubbles), fullness and
popping sensations in the ear, mild conduction problems, some pain
o Caused by viral upper respiratory infections or changes in atm pressure
 Bullous Myringitis
o Viral infection characterized by painful hemorrhagic vesicles on the tympanic membrane,
ear canal, or both
o Sx: earache, blood-tinged discharge from ear, conductive hearing loss
 Otitis Externa
o Ear canal often swollen, narrowed, moist, pale, and tender (may be reddened)
o Moving the auricle and pressing the tragus cause pain
o Chronic OE  skin of canal often thickened, red, and itchy
8. Know how to evaluate air and bone conduction, i.e. Weber and Rinne tests
Weber
Rinne
Causes
How to…
Place base of lightly vibrating
tuning fork on top of patient’s
head or mid-forehead
Conductive
Loss
Sound lateralizes to impaired
ear; since this ear is not
distracted by room noise, can
detect vibrations better than
normal (lateralization
disappears in an absolutely
quite room)
Sensorineural
Loss
Sound lateralizes to the good
ear; impaired inner ear or
cochlear nerve less able to
transmit impulses
Place base of lightly
vibrating tuning fork on the
mastoid bone behind the
ear, at the level of the ear
canal
Bone conduction lasts
longer than or is equal to
air conduction  while air
conduction through the
external or middle ear is
impaired, vibrations
through bone bypass the
problem to reach the
cochlea
Air conduction last longer
than bone conduction 
inner ear or cochlear
nerve less able to transmit
impulses regardless of
how the vibration reaches
the cochlea
N/A
Obstruction of ear
canal, otitis media,
perforated eardrum,
otosclerosis
Sustained exposure to
loud noise, drugs,
infections of inner ear,
trauma, tumors,
congenital and
hereditary disorders,
aging (presbycusis)
9. Know the techniques of examining the sinuses (193, 202).
 Palpation
 Transillumination
o reddish glow indicates normal air-filled sinuses
o absence of glow indicates thickened mucosa or secretions
 Frontal  place light source under each brow, close to nose  shield light with
hand and look for glow transmitted through sinuses
 Maxillary  have patient tilt head back and open mouth wide, with light shined
from just below the inner aspect of each eye  observe glow through hard palate
10. Be able to identify the following lip lesions: herpes simplex, angular chelitis, angioedema and
carcinoma (for photographs see 230-231).
 HSV
o Recurrent and painful vesicular eruptions of the lips and surrounding skin
o Small cluster of vesicles  eruption  formation of yellow-brown crusts  healing w/in
10-14 days
 Angular chelitis
o Softening of skin at angles of mouth  fissuring
o Due to nutritional deficiency or over-closure of mouth (e.g., no teeth, ill-fitting dentures)
o Secondary infection w/ candida w/ saliva
 Angioedema
o Diffuse, non-pitting, tense swelling of dermis and subcutaneous tissue
o Develops rapidly  disappears over hours to days
o Typically allergic in nature, but does not itch
 Carcinoma
o Scaly plaque, ulcer w/ or w/out a crust, or nodular lesion; affects lower lip
o Risk factors: fair skin, sun exposure
11. Be able to identify and differentiate pharyngitis, large normal tonsils, cranial nerve X paralysis, cranial
nerve XII lesion (for photographs see 232).
 Pharyngitis
o Redness, vascularity of varying degrees
o Sx: scratchy, sore throat; fever, exudate, enlargement of cervical nodes w/ Group A Strep
and EBV infection
 Large (Normal) Tonsils


o Protrude medially beyond pillars, even toward midline
o Common in children
CN X Paralysis
o Soft palate fails to rise, contralateral deviation of
o Uvula
CN XII Lesion
o Ipsilateral protrusion of tongue
12. Be able to locate the thyroid gland and to identify diffuse enlargement, multinodular goiter and a
single nodule (239, pictures are switched though).
 Diffuse enlargement
o Enlargement includes isthmus and lateral lobes, w/out discreetly palpable nodules
o Causes: Graves’, Hashimoto’s thyroiditis, endemic goiter (iodine deficiency)
 Multinodular goiter
o Enlarged thyroid containing two or more identifiable nodules
o Multiple nodules usually suggests metabolic rather than neoplastic process
 Single nodule
o May be cyst, benign tumor, or one nodule w/in a multinodular gland
o Hardness, fixation to surrounding tissues, enlarged cervical nodes increase chances
of malignancy
13. Know the locations of all superficial lymph nodes (196; SCM=sterno-mastoid).
 Pre-auricular  in front of the ear
 Posterior auricular  superficial to the mastoid process
 Occipital  at the base of the skull posteriorly
 Tonsillar  at the angle of the mandible
 Submandibular  midway between angle and tip of mandible; smaller and smoother than the
lobulated submandibular gland (against which they lie)
 Submental  midline, few cm behind the tip of the mandible
 Superficial cervical  superficial to the SCM
 Posterior cervical  along anterior edge of trapezius
 Deep cervical  deep to the SCM, often inaccessible to examination
 Supraclavicular  deep in the angle formed by the clavicle and SCM
Thorax and Lungs (Ch 7):
1. Be able to perform the techniques of examining the thorax and lungs, i.e. Where to listen for the RML,
LUL, etc. (refer to relevant materials on physical examination of thorax and lungs)
2. Be able to define the following terms: egophony, bronchophony, whispered pectoriloquy (240)

In the consolidated lung, filled with fluid, RBCs, WBCs:
o Egophony  spoken “ee” heard as “ay”
o
o
Bronchophony  spone words louder, clearer
Whispered pectoriloquy  whispered words louder and clearer
3. Be able to identify adventitious sounds and the accompanying pathophysiologic state, i.e. wheezes
and asthma (narrowed bronchi) (Table 7-6, 275).
 Crackles
o Result from a series of tiny explosions when small airways (deflated during expiration)
pop open during inspiration (as in interstitial lung disease, CHF) OR
o Result from air bubbles flowing through secretions or lightly closed airways (“coarse
crackles”)
i. Late inspiratory  fine, fairly profuse, persist from breath to breath; appear at
bases of lungs, and then spread upward as condition worsens, shifting to
dependent positions with changes in posture; CHF, interstitial lung disease
ii. Early inspiratory  chronic bronchitis, asthma
iii. Mid inspiratory, expiratory  found in bronchiectasis, but not diagnostic
 Wheezes
o Results when air flows rapidly through bronchi narrowed to the point of closure
o Heard in asthma, chronic bronchitis, COPD, CHF/cardiac asthma
 Rhonchi
o Low-pitched wheezes
o Suggestive of secretions in the larger airways
 Stridor
o A wheeze that is predominantly or entirely INSPIRATORY
o Results from partial obstruction of the larynx or trachea
 Pleural Rub
o Creaking sounds resulting from the rubbing of inflamed or roughened surfaces against
each other, delayed by increased friction
o Acoustically resemble crackles
 Mediastinal Crunch (Hamman’s Sign)
o Series of precordial crackles synchronous with heart beat, not with respiration
o Due to mediastinal emphysema
Cardiovascular System (Ch 8):
1. Be able to perform the techniques of examining the heart, jugular venous pressure, and blood
pressure (refer to relevant physical examination materials (302-320).
2. Be familiar with the terms widened pulse pressure, pulsus alternans, pulsus paradoxus (paradoxical
pulse) (119).
 Wide pulse pressure
o Large difference between systolic and diastolic blood pressures
o Indicated decreased arterial compliance, arterial injury
 Pulsus alternans
o alternating pulse amplitude, usually associated with left-sided heart failure;
o best felt in the radial or femoral arteries
o may be accentuated by upright positioning, usually accompanied by S3 heart sound
 Pulsus paradoxus
o Pulse varies in amplitude with respirations
o Typical w/ cardiac tamponade, constrictive pericarditis, obstructive lung disease
3. Be familiar with the murmurs aortic stenosis, aortic regurgitation, mitral stenosis, and mitral
regurgitation. Understand the special maneuvers to identify systolic murmurs, i.e. Valsalva maneuver
or squatting/standing (291-94).
Systolic
Aortic Stenosis
Mechanism
Immobile valve impairs blood flow across
it, causing turbulence
Murmur
Mid-systolic
Mitral
regurgitation
Diastolic
Aortic
Regurgitation
Mitral Stenosis
Valsalva
Maneuver
Standing
(Strain)
Squatting
(Release)
Failure of MV to close fully
Pan/holo-systolic
Mechanism
Murmur
Failure of AV to close fully
Early decrescendo
Failure of valve to open sufficiently
Rumbling in mid or late diastole
Cardiovascular Effect
Decreased LV volume from
decreased venous return
to heart
Decreased vascular tone
(decreased arterial
pressure and peripheral
vascular resistance)
Increased left ventricular
volume
Increased vascular tone
Effect on Systolic Sounds and Murmurs
Mitral Valve
Hypertrophic
Aortic Stenosis
Prolapse
Cardiomyopathy
Increase prolapse
Increased outflow
Decreased blood volume
of valve  click
obstruction 
ejected into aorta 
moves earlier in
increased intensity decreased intensity of
systolic and
of murmur
murmur
murmur lengthens
and gains intensity
Decreased
prolapse  delay
of click, murmur
shortens and loses
intensity
Decreased outflow
obstruction 
decreased
intensity of
murmur
Increased blood volume
ejected into aorta 
increased intensity of
murmur
The Breasts (Ch 9):
1. Be able to perform the techniques of examining the breasts.
 INSPECTION
o Patient should be sitting; disrobed to waist. Inspect breast (and nipples) for skin changes,
symmetry, contours, and retraction in 4 views: arms at side, arms over head, arms
pressed against hips, and leaning forward. Teen girls’ breasts assessed according to
Tanner stages (779).
o Arms at Sides
 Skin appearance
 Color – redness from infection or inflammatory carcinoma
 Thickening and prominent pores suggest breast cancer
 Size and symmetry (differences are normal)
 Contour
 Look for changes such as masses, dimpling, flattening
 Flattening of normally convex breast suggests cancer
 Characteristics of the nipples, including size, shape, direction they point, rashes,
ulcerations, discharges
 Asymmetry of directions suggests cancer; rash or ulceration in Paget’s
disease
o Arms over Head; Hands Pressed Against Hops; Leaning Forward
 Dimpling or retraction suggestive of cancer or occasionally associated
with benign lesions such as posttraumatic fat necrosis or mammary duct
ectasia

PALPATION
o Best performed when breast tissue flattened – patient supine.
o Palpate rectangular area extending from clavicle to infra-mammary fold or bra line and
from midsternal line to posterior axillary line and into axilla for the tail of the breast.
o Thorough exam takes 3 minutes per breast.
o Use fingerpads of 2nd, 3rd, 4th finger, keeping fingers slightly flexed. Be systematic.

Circular or wedge pattern can be used, but vertical strip pattern currently best validated
technique for detecting breast masses.
o Palpate in small, concentric circles at each point, applying light, medium, deep pressure,
pressing more firmly to reach deeper tissues of larger breasts. Exam should cover entire
breast, including periphery, tail, axilla. Do not mistake normal rib for hard breast
mass.
o To examine lateral portion of breast, patient should roll on opposite hip, placing hand on
forehead, keeping shoulders pressed against bed or exam table. This flattens breast
tissue.
 Begin palpation in axilla, moving in straight line down to bra line, then move
fingers medially and palpate in vertical strip up the chest to clavicle. Continue in
vertical overlapping strips until nipple reached, then reposition patient to flatten
medial portion of the breast. Nodules in tail of breast sometimes mistaken for
axillary lymph nodes and vice versa.
o To examine medial portion of breast, ask patient to lie with shoulders flat against bed,
placing hand at neck and lifting elbow until it is even with shoulder.
 Palpate in straight line down from nipple to bra line, then back to clavicle,
continuing in vertical overlapping xtrips to midsternum.
o Examine breast tissue for
 Consistency – varies widely. Physiologic nodularity sometimes present,
increasing before menses. There may be firm transverse ridge of compressed
tissue along lower margin of breast, especially large ones. This is normal
inframammary ridge, not a tumor. Tender cords suggest mammary duct ectasia,
benign but sometimes painful dilation of ducts with surrounding inflammation and
sometimes masses.
 Tenderness – can be premenstrual
 Nodules – qualitatively different from rest of breast; called a dominant mass,
reflecting pathology requiring mammogram, aspiration or biopsy. Characteristics:
 Location (by quadrant or clock, cm from nipple), size in cm
 Shape – round or cystic, disclike, or irregular in contour
 Consistency – soft, firm, hard
 Delimitation – well circumscribed or not
 Mobility in relation to skin, pectoral fascia, chest wall.
 Cysts, inflamed areas, some cancers may be tender
 Try to move mass while patient relaxes arm and then while hand pressed
against hip. Mobile mass that becomes fixed when arm relaxes is
attached to ribs and intercostals muscles; if fixed when hand pressed
against hip, it’s attached to pectoral fascia.
NIPPLES
o Palpate each nipple, noting elasticity
o Thickening or loss of elasticity – possible cancer.

MALE BREAST
o Inspect nipple and areola for nodules, swelling or ulceration.
o Palpate areola and breast tissue for nodules.
o If breast enlarged, distinguish between soft fatty enlargement of obesity and firm disc of
glandular enlargement – gynecomastia, attributed to imbalance of estrogens and
androgens and sometimes drug-related.
o Hard, irregular, eccentric, or ulcerating nodule is not gynecomastia, but suggests breast
cancer.

AXILLAE: Sitting position preferable to patient lying down for examination.
o INSPECTION
 Rash – deodorant-induced or other
 Infection – sweat gland infection (hidradenitis suppurativa)
 Unusual pigmentation – deeply pigmented, velvety axillary skin suggests
acanthosis nigricans, a form of which is associated with internal malignancy
o

PALPATION
 To examine left axilla, ask patient to relax with left arm down. Help by supporting
left wrist or hand with your left hand. Cup together fingers of your right hand and
reach as high as possible toward apex of axilla. Warn patient that this may feel
uncomfortable. Your fingers should be behind pec muscles, pointing toward
midclavicle. Press fingers in toward chest wall and slide downward, trying to feel
central nodes against chest wall (most palpable of axillary nodes). One or more
soft small (< 1 cm) nontender nodes frequently palpable. Enlarged axillary nodes
from infection of hand or arm, recent immunizations or skin tests in arm, or part
of generalized lymphadenopathy. Check epitrochlear and other groups of lymph
nodes.
 Nodes larger than 1 cm suggest malignancy.
 Use left hand to examine right axilla.
 If central nodes feel large, hard, tender, or if there is suspicious lesion in
drainage areas for axillary nodes, feel for other groups of axillary lymph nodes –
pectoral, lateral, subscapular nodes. Also feel for infra and supraclavicular
nodes.
Special Techniques
o Assess for spontaneous nipple discharge, especially if there is prior hx. Try to determine
origin by compressing areola with index finger placed in radial positions around nipple.
Watch for discharge from duct openings on nipple surface. Note color, consistency,
quantity, location. Milky discharge unrelated to prior pregnancy and lactation called
nonpuerperal galactorrhea – leading causes are hormonal and pharmacologic.
o Take special care with exam of mastectomy patient (likewise women with breast
augmentation or reconstruction), inspecting mastectomy scar and axilla for masses,
nodularity. Note changes in color, signs of inflammation. Lymphedema may be present in
axilla or upper arm from impaired lymph drainage after surgery. Palpate gently along scar
using 2 or 3 fingers in circular motion, paying special attention to upper outer quadrant
and axilla.
2. Be comfortable with the three most common kinds of breast masses, fibroadenoma, cysts, and
cancer. (357)
Fibroadenoma
Cysts
Cancer
15-25, usually puberty
30-50, regress after
30-90, most common
Usual Age
And young
menopause except
over 50 (middle age,
adulthood, to 55
With estrogen tx
ellderly)
Usually single; may
Usually single; may
Number
Single or multi
coexist with other
be multi
nodules
Round, disc-like or
Shape
Round
Irregular or stellate
lobular
May be soft, usually
Solid to firm, usually
Consistency
Firm or hard
firm
elastic
Delineation
Well delineated
Well delineated
Not clearly
May be fixed to skin
Mobility
Very mobile
Mobile
or underlying tissues
Tenderness
Usually non-tender
Often tender
Usually non-tender
Retraction Signs
absent
Absent
May be present
3. Recognize the visible signs of breast cancer, i.e. skin dimpling, nipple retraction, peau d’orange. (356)
a. Retraction signs
o Mechanism – breast cancer causes fibrosis (scar tissue) as it advances. Shortening of
fibrotic tissue causes retraction signs but other causes include fat necrosis, mammary
duct ectasia.
b. Skin dimpling
o Look for this sign with patient’s arm at rest, during special positioning and on moving or
compressing breast.
Abnormal contours
o Look for variation in normal convexity, comparing one side of each breast with the other.
Special positioning may be useful.
d. Nipple retraction and deviation
o Flattened or pulled inward or may be broadened and feel thickened.
o When involvement is radially asymmetric, nipple may deviate, i.e., point in different
direction from its normal counterpart, typically toward underlying cancer
e. Edema of the skin (Peau d’orange)
o Produced by lymphatic blockade; appears as thickened skin with enlarged pores
o Often seen 1st in lower portion of breast or areola
f. Paget’s Disease of the nipple
o Uncommon form of breast cancer that usually starts as scaly, eczema-like lesion. Skin
may also weep, crust, erode; breast mass may be present
o Suspect Paget’s in any persisting dermatitis of the nipple and areola
c.
The Abdomen (Ch 10):
1. Be able to identify structures in each quadrant and how to examine for them.
 Refer to relevant physical examination materials
2. Be able to perform the techniques for examining the liver, spleen, and kidneys (374-386).
3. Know the significance of absent and/or increased bowel sounds, guarding, and rebound
tenderness.
 Bowel Sounds
Increased  diarrhea, early intestinal obstruction
Decreased, then absent  adynamic ileus, peritonitis
High-pitched  intestinal fluid or air under tension in a dilated bowel
 Rushes of sound with abdominal pain  intestinal obstruction
Guarding
o Muscle rigidity ensues when trying to examine patient to protect area in pain
Rebound Tenderness
o Press fingers in firmly and slowly, and quickly withdraw them
o More pain when you let go than when you are pressing in  peritoneal inflammation
o
o
o


4. Know how to examine for ascites (387-388).
 Ascetic fluid seeks the lowest point in the abdomen
 Produces bulging flanks dull to percussion, umbilicus may protrude
 Turn patient on one side to detect shift in position of fluid level
 See UCSD’s website: http://medicine.ucsd.edu/clinicalmed/abdomen.htm
5. Know the clinical presentation (both history and physical exam findings) of common abdominal
diseases: acute appendicitis, acute cholecystitis, acute diverticulitis, acute pancreatitis
Problem
Process
Location
Quality
Timing
Aggravating
Factors
Acute
pancreatitis
Acute inflammation
of pancreas
Epigastric; may
radiate to back
or other parts
of abdomen;
may be poorly
localized
Usually
steady
Acute
onset,
persistent
pain
Lying supine
Acute
cholecystitis
Inflammation of
gallbladder, usually
from obstruction of
cystic duct by
gallstones
RUQ or upper
abdominal;
may radiate to
right scapular
area
Steady,
aching
Jarring, deep
breathing
Acute
diverticulitis
Acute inflammation
of colonic
diverticulum, saclike
mucosal outpouching thru
colonic muscle
Acute inflammation
of appendix with
distention or
obstruction
LLQ
May be
cramping
at first, but
becomes
steady
Gradual
onset;
course
longer
than in
biliary
colic
Often a
gradual
onset
Poorly localized
peri-umbilical
pain followed
usually by
RLQ pain
Mild but
increasing,
possibly
cramping;
Steady
and more
sever
lasts
roughly 46 hr;
depends
on
interventio
n
movement or
cough
Acute
appendicitis
Alleviating
Factors
Leaning
forward with
trunk flexed
Associated
Symptoms
& Settings
Nausea,
vomiting,
abdominal
distention,
fever; often
hx of
previous
attacks and
alcoholic
abuse or
gallstones
Anorexia,
nausea,
vomiting,
fever
Fever,
constipation
; perhaps
intial brief
diarrhea
if it subsides
temporarily,
suspect
perforation
Anorexia,
nausea,
possibly
vomiting,
which
typically
follow onset
of pain; low
fever
Male Genitalia and Hernias (Ch 11): UCSD: http://medicine.ucsd.edu/clinicalmed/genital.htm
1. Know what organs can be felt in the examination of the penis and scrotum and inguinal canal (416420
2. Be familiar with the abnormalities of the male genitalia: hydrocele, acute epididymitis, varicocele,
torsion of the spermatic cord (424-425)
 Hydrocele
o nontender, fluid-filled mass within tunica vaginalis; transilluminates and
examining fingers can get above the mass within scrotum
 Acute epididymitis
o Tender and swollen, may be difficult to distinguish from the testis; scrotum may
be reddened, and vas deferens inflamed; occurs chiefly in adults; coexisting uti
or prostatitis supports dx
 Varicocele
o Varicose veins of spermatic cord, usually found on the left; feels like “soft bag of
worms” separate from testis, slowly collapsing when scrotum elevated in supine
patient; infertility may be associated.
 Torsion of spermatic cord
o Torsion or twisting of the testicle on its spermatic cord produces acutely painful,
tender, and swollen organ that is retracted upward in scrotum, which becomes
red and edematous; no assoc. uti; torsion most common in teens and is surgical
emergency because of obstructed circulation.
3.
Be able to identify the following abnormalities of the penis: hypospadias, venereal warts, and genital
herpes (442)
 Hypospadias
o congenital displacement of urethral meatus to inferior surface of penis; groove extends
from actual urethral meatus to its normal location on tip of glans
 Venereal warts (condyloma acuminatum)
o result of HPV infection; are rapidly growing excrescences that are moist and often
malodorous.
 Genital herpes
o cluster of small vesicles, followed by shallow, painful, nonindurated ulcers on red bases,
suggesting herpes simplex infection; lesions may occur anywhere on penis; usually fewer
lesions when infection recurs.
4.
Be able to differentiate between an indirect hernia, direct hernia, and a femoral hernia (427)
Frequency
Age and Sex
Point of Origin
Course
With examining
finger in inguinal
canal during
straining or cough
Inguinal
Indirect
Direct
Most common, all
Less common
ages, both sexes
Often in children, may
Usually in men over
be in adults
age 40, rare in women
Above inguinal
Above inguinal
ligament, near its
ligament, close to the
midpoint (internal
pubic tubercle (near
inguinal ring)
external inguinal ring)
Often into scrotum
Hernia comes down
inguinal canal and
touches fingertip
Female Genitalia (Ch 12):
Rarely into scrotum
Hernia bulges
anteriorly and pushes
side of finger forward
Femoral
Least common
More common in women than men
Below inguinal ligament; appears
more lateral than inguinal hernia
and may be hard to differentiate
from lymph nodes
Never into scrotum
Inguinal canal empty
1. Know the anatomy of the external genitalia (please refer to anatomy 429-430).
2. Be familiar with common causes of adnexal masses: ovarian cysts, pelvic inflammatory disease,
ruptured tubal pregnancy (Table 12-9, 457)
 Ovarian Cysts and tumors
o Cysts tend to be smooth and compressible, non-tender; smaller mobile cysts in young
women usually benign and disappear following the next menstrual period
o Tumors more solid and nodular, non-tender
 Ruptured Tubal Pregnancy
o Blood spills into peritoneal cavity, causing severe abdominal pain and tenderness
o Unilateral mass, guarding, rebound tenderness on physical exam
o Hemorrhage may induce faintness, syncope, nausea, vomiting, tachycardia, shock
 PID
o Most often a result of sexually transmitted infection (Niesseria gonorrhea, Chlamydia
trachomatis, etc.) of the fallopian tubes (salpingitis) or of the tubes and ovaries (salpingooophoritis)  also may result from infection following delivery or gynecologic surgery
o Acute disease  tender bilateral adnexal masses, pain w/ movement of cervix
o Complications: tuboovarian abscess or infertility
3. Understand the various abnormalities and positions of the uterus: myomas, uterine prolapse (Table
12-8, 456-457).
 Myomas (Fibroids)
o Common, benign tumors of the uterus; may be single or multiple, vary in size
o Firm, irregular nodules in continuity with uterine surface
o
 Prolapse
o Results from weakness of supporting structures of the pelvic floor
o Often associated with cystocele or rectocele
o Uterus progressively becomes retroverted and descends down into the vaginal canal to
the outside
o First-degree (cervix well w/in vagina) versus second-degree (at the introitus)
 Retroversion
o Tilting backward of the entire uterus
o Cervix faces forward and uterus not palpable by the abdominal hand
 Retroflexion
o Backward angulation of the body of uterus in relation to the cervix
o Body of uterus may be palpable through posterior fornix or through the rectum
4. Know the following terms: cystocele, cystourethrocele, rectocele (Table 12-2, 451).
 Cystocele  bulge of the anterior vaginal wall (upper 2/3) together with the bladder above it;
results from weaked supporting tissues
 Cystourethrocele  entire anterior vaginal wall, along with bladder and urethra, are involved in
the bulge of tissue
 Rectocele  herniation of the rectum into the posterior wall of the vagina; results from weakness
or defect in the endopevic fascia
The Anus, Rectum, and Prostate (Ch 13):
1. Know the anatomy of the area (459-467) and what can be felt during an examination in both the male
and female.
 Males
o Inspection of sacrococcygeal and perianal areas (lumps, ulcers, inflammation, rashes or
excoriations)
o Examination of anus and rectum (sphincter tone, tenderness, induration, irregularities or
nodules)
o Examination of posterior surface of prostate gland (normally rubbery and non-tender,
median sulcus felt between lateral lobes)

Females
o Examine in the lithotomy position (if post-pelvic exam) or laterally to gain a better view
o Cervix is felt through the anterior rectal wall
2. Have an understanding of the abnormalities of the anus and rectum: external hemorrhoids, rectal
prolapse, anal fissure, pilonidal cyst (Table 13-1, pp470-471)
 Anorectal Fistula
o Inflammatory tract or tube that opens at one end into the anus or rectum and at the other
end onto the skin surface (or another viscus, e.g., vagina)
 External hemorrhoids
o Dilated hemorrhoidal veins originating below pectinate line and covered with skin
o Thrombosis of veins causes acute local pain inc by defecation and sitting
o Tender, swollen, bluish ovoid mass visible at the anal margin
 Rectal Prolapse
o Happens with straining on bowel movement
o Rectal mucosa appears as a doughnut or rosette of red tissue
 Anal Fissue
o Painful oval ulceration of the anal canal , most commonly found in the midline posteriorly
o May be associated with a “sentinel” skin tag just below it
o Anal sphincter may be spastic, making examination painful
 Pilonidal Cyst (common)
o Located in midline superficial to the coccyx or lower sacrum
o Clinically identified by the opening of a sinus tract
o May exhibit a tuft of hair or be surrounded by a halo of erythema
o Generally asymptomatic except for drainage, may be complicated by abscess and/or
infection
 Rectal shelf
o Widespread peritoneal metastases may cause firm to hard nodular “shelf”
o In women, shelf develops in the rectouterine pouch (behind cervix and uterus)
The Peripheral Vascular System (Ch 14):
1. Know the signs and symptoms of arterial insufficiency and chronic venous insufficiency (494).
Pain
Chronic Arterial Insufficiency
Intermittent claudication, progressing to pain at
rest
Pulses
Decreased or absent
Color
Pale, esp. on elevation; dusky red on dependency
Temperature
Cool
Absent or mild; may develop as the patient tries to
relieve rest pain by lowering the leg
Edema
Skin
Changes
Trophic changes: thin, shiny, atrophic skin; loss of
hair over the foot and toes; nails thickened and
rigid
Ulceration
If present, involves toes or points of trauma on feet
Gangrene
May develop
Chronic venous insufficiency
None to an aching pain on dependency
Normal, though may be difficult to feel
through edema
Normal, or cyanotic on dependency;
petechiae and then brown pigmentation
appear w/ chronicity
Normal
Present; often marked
Often brown pigmentation around the ankle,
stasis dermatitis, and possible thickening of
the skin and narrowing of the leg as scarring
develops
If present, develops at sides of ankle,
especially medially
Does not develop
2. Know the areas of lymph nodes that should be examined and what areas they drain (476-477).
 Cervical nodes (170)
 Axillary nodes (339)


o Central nodes post frequently palpable
o Receive drainage from pectoral, subscapular, and lateral nodes
o Drains all areas of the arm except for those drained by epitrochlear nodes
Epitrochlear nodes
o Medial surface of the arm 3cm above the elbow
o Drains ulnar surface of the forearm and hand, little and ring fingers, adjacent surface of
the middle finger
Superficial Inguinal Nodes
o Horizontal group
 High in the anterior thigh below the inguinal ligament
 Drains superficial portions of lower abdomen and buttock, external genitalia, anal
canal, and lower vagina
o Vertical group
 Cluster near upper part of saphenous vein
 Drains area drained by the great saphenous vein
3. Be able to examine for edema and the different characteristics of pitting edema, chronic venous
insufficiency, and lymphedema (496).
Pitting Edema
Chronic Venous
Insufficiency
Lymphadema
Nature of
Edema
Soft, pits on pressure
Soft, pits on pressure, later
may become brawny (hard)
Soft in early stages, then
becomes indurated, hard, nonpitting
Skin Thickening
Absent
Ulceration
Pigmentation
Edema of Foot
Bilaterality
Absent
Absent
Present
Always
Inc interstitial fluid from: legs
dependent from prolonged
standing/sitting  inc hydrostatic
pressure In veins, capillaries, CHF
 decreased cardiac output  low
albumin, decreased intra-vascular
colloid oncotic pressure; drugs
Examples/
Mechanisms
May be present, especially
near ankle
Common
Common
Often present
Occasionally
Chronic obstruction or
valvular incompetence of
the deep veins
Becomes marked
Rare
Absent
Present, including toes
Often
Lymph channels obstructed by
tumor, fibrosis, inflammation;
also from axillary node
dissection, radiation
The Musculoskeletal System (Ch 15): UCSD: http://medicine.ucsd.edu/clinicalmed/Joints.html
1. Be able to describe range of motion and maneuvers: flexion, extension, abduction, adduction, rotation
(516).
2. Be able to describe supination (turn up the palms), pronation (turn down palms) of hand and
inversion and eversion of the foot/ankle (554 for figures).
3. Know the classic swellings and deformities of the hands seen in osteoarthritis, rheumatoid arthritis,
and Dupuytren’s contracture (Table 15-6, p567-569).
 Osteoarthritis (degenerative joint disease)
o Nodules on dorsolateral aspects of DIP joints (Heberden’s nodes) due to bony
overgrowth.
o Usually hard and painless, affecting middle-aged or elderly, often but not always assoc.
w/ arthritic changes in other joints. Sometimes flexion and deviation deformities.
o Similar nodules on PIP joints (Bouchard’s nodes) less common. MCP joints spared.
 Rheumatoid Arthritis
o Acute – tender, painful, stiff joints. Symmetric involvement on both sides of body typical.

PIP, MCP, wrist joints frequently affected; DIP joints rarely so. Often patients have
fusiform or spindle-shaped swelling of PIP joints.
o Chronic – chronic swelling and thickening of MCP and PIP joints. ROM limited and
fingers deviate ulnarly. Interosseous muscles atrophy. Fingers may show “swan neck”
deformities (hyperextension of PIP joints with fixed flexion of DIP joints). Less common is
boutonniere deformity (persistent flexion of PIP with hyperextension of DIP).
o Rheumatoid nodules may accompany either acute or chronic stage.
Dupuytren’s contracture – 1st sign is thickened plaque overlying flexor tendon of ring finger and
possibly little finger at distal palmar crease. Subsequently skin in this area puckers and thickened
fibrotic cord develops between palm and finger. Flexion contracture of fingers may gradually
ensue.
4. Be able to describe the techniques for examining the knee: Anterior Drawer Sign, Lachman Test,
McMurray Test (550-551)
 ACL
o Anterior Drawer Sign – with patient supine, hips flexed and knees flexed to 90 degrees
and feet flat on table, cup your hands around the knee with the thumbs on medial and
lateral joint line and fingers on medial and lateral insertions of the hamstrings. Draw tibia
forward and observe if it slides forward (like a drawer) from under femur. Compare the
degree of forward movement with that of opposite knee. Few degrees of forward
movement normal if equally present on opposite side. Forward jerk showing contours of
upper tibia is positive anterior drawer sign suggesting a tear of ACL.
o Lachman Test – place knee in 15 degrees of flexion and external rotation. Grasp distal
femur with one hand and upper tibia with the other. With thumb of tibial hand on joint line,
simultaneously move tibia forward and femur back. Estimate degree of forward
excursion. Significant forward excursion = ACL tear.
 Medial meniscus and lateral meniscus
o McMurray Test – if click felt or heard at joint line during flexion and extension of knee, or
if tenderness is noted along joint line, further assess meniscus for posterior tear.
o With patient supine, grasp heel and flex the knee. Cup your other hand over the knee
joint with fingers and thumb along the medial and lateral joint line. From the heel, rotate
the lower leg internally and externally. Then push on the lateral side to apply a valgus
stress on the medial side of the joint. At the same time, rotate leg externally and slowly
extend it. A click or pop along medial joint with valgus stress, external rotation, and leg
extension suggests probable tear of posterior medial meniscus.
5. Know Phalen’s test, Tinel’s sign, and what a positive straight leg raise means (555-556).
 Phalen’s test
o Hold patient’s wrists in acute flexion for 60s; alternatively, ask patient to press backs of
both hands together to form right angles  these maneuvers compress median nerve.
o If numbness and tingling develop over the distribution of the median nerve (e.g., the
palmar surface of the thumb, and the index, middle, and part of the ring fingers), the sign
is positive, suggesting carpal tunnel syndrome.
 Tinel’s sign
o Percuss lightly over course of median nerve in carpal tunnel at palmar-forearm crease of
wrist (see Bates figure p.555)
o Tingling or electric sensations in distribution of median nerve constitutes positive test for
carpal tunnel syndrome
 Positive straight leg raise
o For low back pain with radiation into the leg.
o Patient should be supine. Raise patient’s relaxed and straightened leg until pain occurs.
Then dorsiflex foot. Record degree of elevation at which pain occurs, quality, distribution
of pain, effects of dorsiflexion
o Tightness and mild discomfort of hamstrings are common with this maneuver and do not
indicate radicular pain (L5 or S1)
o Sharp pain radiating from back down the leg (increased on dorsiflexion of foot) suggests
tension on or compression of nerve roots, often caused by herniated lumbar disc.
Increased pain in affected leg when opposite leg raised strongly confirms radicular pain
and constitutes positive crossed straight leg-raising sign
The Nervous System (Ch 17):
1. Know the segmental levels of the deep tendon reflexes (634-637).
 Ankle reflex – S1 (primarily)
 Knee reflex – L2,3,4
 Supinator – C5,6
 Biceps reflex – C5,6
 Triceps reflex – C6,7
2. Be familiar with the zero to five scale of muscle strength (619).
 0 – No muscular contraction detected
 1 – A barley detectable flicker or trace of contraction
 2 – Active movement of the body part with gravity eliminated
 3 – Active movement against gravity
 4 – Active movement against gravity and some resistance
 5 – Active movement against full resistance without evident fatigue (normal muscle strength)
3. Be able to perform the techniques for examining the cranial nerves (611-616).
 CN I
o nasal patency (loss of smell: nasal disease, head trauma, smoking, aging, cocaine)
 CN II
o Visual Acuity (optic atrophy, papilledema)
o Confrontation (extinction  lesion in parietal cortex)
o Pupillary reactions to light
 CN III, IV, VI
o Extraocular movements in 6 cardinal directions
o Nystagmus Ptosis
 CN V
o Motor
i. Palpate masseter muscles, with patient’s teeth clenched
o Sensory
i. Pain, temperature, light touch
ii. Corneal Reflex (observe blinking in reaction to this stimulus)
 CN VII (Note weakness of asymmetry in the following)
o Raise eyebrows
o Smile/Frown (unilateral facial paralysis  mouth droops)
o Puff out both cheeks
o Show both upper and lower teeth
o Close eyes tightly so that you cannot open them to test muscle strength
 CN VIII
o Hearing  lateralization and air/bone conduction
 CN IX, X
o Voice  hoarseness? Vocal cord paralysis; nasal voice? Paralysis of the palate
o Movements of soft palate and pharynx  palate fails to rise with bilateral lesion of X;
unilateral rise of palate and uvula deviation toward normal side with unilateral lesion
o Gag reflex  unilateral absence? Lesion of IX or X
 CN XI
o Observe for atrophy or fasciculations (fine, flickering, irregular movements in small
groups of muscle fibers)  indicative of peripheral nerve disorder
o Supine patient w/ bilateral weakness of SCM has difficulty raising head off pillow
 CN XII
o Observe for atrophy or fasciculations (fine, flickering, irregular movements in small
groups of muscle fibers)  indicative of peripheral nerve disorder (ALS, polio)
o
o
Disorders of speech
Cortical Lesions  Tongue deviation toward contralateral side
4. Be able to perform the techniques: Romberg sign, pronator drift (629).
 Romberg Sign
o Patient should stand with feet together and eyes open, then close both eyes for 20-30s
without support (note ability to maintain upright posture, minimal swaying is normal)
o Positive Rhomberg sign – patient can maintain balance with eyes open, but have a loss
of balance with eyes closed
o Cerebellar ataxia – patient has difficulty standing with feet together whether the eyes are
open or closed
 Pronator Drift
o Patient should stand for 20-30s with both arms straight forward, palms up, with eyes
closed
o Pronation of one forearm suggests a contralateral lesion of the corticospinal tract; may
also be accompanies by downward drift of the arm with flexion of fingers and elbow
Mental Status (Ch 16):
1. Be able to identify the various levels of consciousness: alertness, lethargy, obtundation, stupor, coma
(Table, p.634)
 Alertness
o address patient in normal tone of voice. Alert patient opens eyes, looks at you and
responds appropriately.
 Lethargy
o speak to patient in loud voice. Lethargic patient appears drowsy but opens eyes, looks at
you, responds to questions, then falls asleep.
 Obtundation
o shake patient as if to awakening a sleeper. Obtunded patient opens eyes, looks at you,
but responds slowly and is somewhat confused. Alertness and interest in environment
decreased.
 Stupor
o stuporous patient arouses from sleep only after painful stimuli. Slow or absent verbal
responses. Patient lapses into unresponsive state when stimuli removed. Minimal
awareness of self or environment.
 Coma
o comatose patient unarousable, eyes closed. No evident response to inner need or
external stimuli.
2. Know how to evaluate speech and language and how to test for aphasia (p580 Table 16-2, p.591)
 Note quantity, rate, loudness, articulation, fluency.
 2 kinds of aphasia –
o Wernicke’s (fluent, receptive; posterior superior temporal lobe) – all domains
impaired.
o Broca’s (non-fluent, expressive; posterior influent frontal lobe) – word and reading
comprehension fair to good; other domains impaired (including patient recognizing
objects but unable to name them).
 Testing for Aphasia
o Word comprehension – ask patient to follow 1-stage (“point to nose”) then 2-stage
command (“point to mouth and knee”).
o Repetition – ask patient to repeat phrase of monosyllabic words (“no ifs ands or
buts”)
o Naming – ask patient to name parts of a watch.
 Reading comprehension – ask patient to read paragraph aloud
 Writing – ask patient to write a sentence
 Consider deficiencies in vision, hearing, intelligence, and education on performance of tests.
A person who can write a correct sentence does not have aphasia.
3. Recognize abnormalities in thought process, i.e. flight of ideas, neologisms, confabulation, etc. and
thought content, i.e. phobias, delusions, obsessions (582)
 Thought Process
o Circumstantiality – indirection and delay in reaching point b/c of unnecessary detail,
although components of description meaningfully connected (obsessional people but
also applies to people without mental disorder).
o Derailment (loosening of associations) – person shifts from one subject to others
unrelated or obliquely related without realizing subjects not meaningfully related;
ideas slip off track between clauses, not within them (in schizophrenics, manics,
other psychotics).
o Flight of ideas – almost continuous flow of rapid speech with changes of topic;
changes based on understandable associations, plays on words, distracting stimuli,
but ideas do not progress to sensible conversation (manics)
o Neologisms – invented or distorted words or words with new or highly idiosyncratic
meanings (schizos, psychotics, aphasics)
o Incoherence – largely incomprehensible speech b/c of illogic, lack of meaningful
connections, etc; shift in meaning within clauses; flight of ideas may produce
incoherence (typically schizos)
o Blocking – sudden interruption of speech in midsentence or before completion of
idea; attributed to loss of train of thought (schizos but also in normal people)
o Confabulation – fabrication of facts or events in response to questions, to fill in gaps
in impaired memory (amnesiacs)
o Perseveration – persistent repetition of words words or ideas ideas (schizos, other
psychos)
o Echolalia – repeating other people’s words or phrases (manics and schizos)
o Clanging – speech wherein a person chooses a word based on sound rather than
meaning, as in rhyming or punning. “Look at my eyes and nose, wise eyes rosy
nose…the ayes have it!” (schizos, manics)
 Thought Content
o Compulsions, obsessions, phobias, anxieties often associated with neuroses (anxiety
disorders)
o Delusions and feelings of unreality or depersonalization more often associated with
psychotic disorders such as schizophrenia. Delusions may also occur in delirium,
severe mood disorders, dementia.
4. Know how to administer tests of memory and attention (584-585).
 Attention: serial 7’s; spell W-O-R-L-D backwards
 Remote memory: inquire about birthdays, anniversaries, names of schools attended, etc
 Recent memory: the day’s weather, medications taken, but NOT what had for breakfast (unless
can be verified)
 New learning ability: give the patient 3 or 4 words to repeat – “table, flower, green, hamburger.”
ask patient to repeat the words so that you know information has been heard and registered.
Proceed to other parts of exam. After 3-5 minutes ask patient to repeat words.