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 Chief, Division of General Pediatrics University of Rochester School of Medicine and Dentistry Rochester, New York
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7th Edition
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins. Copyright © 2009 by Wolters Kluwer Health | Lippincott Williams & Wilkins. Copyright © 2007, 2004, 2000 by Lippincott Williams & Wilkins. Copyright © 1995, 1991 by J. B. Lippincott Company. All rights reserved. This book is protected by copyright. No part of this book may be reproduced or transmitted in any form or by any means, including as photocopies or scanned-in or other electronic copies, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews. Materials appear- ing in this book prepared by individuals as part of their official duties as U.S. government employees are not covered by the above-mentioned copyright. To request permission, please contact Lippincott Williams & Wilkins at Two Commerce Square, 2001 Market Street, Philadelphia PA 19103, via email at [email protected] or via website at lww.com (products and services).
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Library of Congress Cataloging-in-Publication Data
Bickley, Lynn S. Bates’ pocket guide to physical examination and history taking / Lynn S. Bickley, Peter G. Szilagyi. — 7th ed. p. ; cm. Pocket guide to physical examination and history taking Abridgement of: Bates’ guide to physical examination and history-taking. 11th ed. / Lynn S. Bickley, Peter G. Szilagyi. c2013.
Includes bibliographical references and index. Summary: “This concise pocket-sized guide presents the classic Bates approach to physical exami- nation and history taking in a quick-reference outline format. It contains all the critical information needed to obtain a clinically meaningful health history and to conduct a thorough physical assessment. Fully revised and updated, the Seventh Edition will help health professionals elicit relevant facts from the patient’s history, review examination procedures, highlight common findings, learn special assess- ment techniques, and sharpen interpretive skills.The book features a vibrant full-color art program and an easy-to-follow two-column format with step-by-step examination techniques on the left and abnormalities with differential diagnoses on the right.”—Provided by publisher.
ISBN 978-1-4511-7322-2 (pbk. : alk. paper) I. Bates, Barbara, 1928-2002. II. Szilagyi, Peter G. III. Bickley, Lynn S. Bates’ guide to physical examination and history-taking. IV. Title. V. Title: Pocket guide to physical examination and history taking.
[DNLM: 1. Physical Examination—methods—Handbooks. 2. Medical History Taking— methods—Handbooks. WB 39] 616.07′51—dc23 2012030529
Care has been taken to confirm the accuracy of the information presented and to describe gener- ally accepted practices. However, the authors, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make no warranty, expressed or implied, with respect to the currency, completeness, or accuracy of the contents of the publication. Application of this information in a particular situation remains the professional responsibility of the practitioner; the clinical treatments described and recommended may not be con- sidered absolute and universal recommendations. The authors, editors, and publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accordance with the current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any change in indications and dosage and for added warn- ings and precautions. This is particularly important when the recommended agent is a new or infre- quently employed drug. Some drugs and medical devices presented in this publication have Food and Drug Administration (FDA) clearance for limited use in restricted research settings. It is the responsi- bility of the health care provider to ascertain the FDA status of each drug or device planned for use in his or her clinical practice.
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To Randolph B. Schiffer, for lifelong care and support, and to students world-wide committed to clinical excellence.
I n t r o d u c t i o n
The Pocket Guide to Physical Examination and History Taking, 7th edition is a concise, portable text that: ● Describes how to interview the patient and take the health history. ● Provides an illustrated review of the physical examination. ● Reminds students of common, normal, and abnormal physical
findings. ● Describes special techniques of assessment that students may need in
specific instances. ● Provides succinct aids to interpretation of selected findings.
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 Chap. 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 sections in each chapter.
● To look up additional information about possible findings, including abnormalities and standards of normal.
The Pocket Guide is not intended to serve as a primary text for learn- ing the skills of history taking or physical examination. Its detail is too brief for these purposes. It is intended instead as an aid for student review and recall and as a convenient, brief, and portable reference.
vii
C o n t e n t s
1 Overview: Physical Examination and History Taking 1
2 Clinical Reasoning, Assessment, and Recording Your Findings 15
3 Interviewing and the Health History 31 4 Beginning the Physical Examination: General
Survey, Vital Signs, and Pain 49
5 Behavior and Mental Status 67 6 The Skin, Hair, and Nails 83 7 The Head and Neck 99 8 The Thorax and Lungs 127 9 The Cardiovascular System 147 10 The Breasts and Axillae 167 11 The Abdomen 179 12 The Peripheral Vascular System 199 13 Male Genitalia and Hernias 211 14 Female Genitalia 225 15 The Anus, Rectum, and Prostate 241 16 The Musculoskeletal System 251 17 The Nervous System 285 18 Assessing Children: Infancy Through
Adolescence 323
19 The Pregnant Woman 359 20 The Older Adult 373
Index 395
ix
1
C H A P T E R
1Overview: Physical Examination and
History Taking
This chapter provides a road map to clinical proficiency 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 office or hospital merit a comprehensive health history; however, in many situations, a more flexible 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 fluid and should follow the patient’s leads and cues, as described in Chapter 3.
Over view: Components of the Adult Health History
Identifying Data ◗ Identifying data—such as age, gender, occupation, marital status
◗ Source of the history—usually the patient, but can be a family member or friend, letter of referral, or the
medical record
◗ If appropriate, establish source of referral because a written report may be needed
Reliability ◗ Varies according to the patient’s memory, trust, and mood
Chief Complaint(s) ◗ The one or more symptoms or concerns causing the patient to seek care
(continued)
2 Bates’ Pocket Guide to Physical Examination and History Taking
Be sure to distinguish subjective from objective data. Decide if your assessment will be comprehensive or focused.
Over view: Components of the Adult Health History (continued)
Present Illness ◗ Amplifies the Chief Complaint; describes how each symptom developed
◗ Includes patient’s thoughts and feelings about the
illness
◗ Pulls in relevant portions of the Review of Systems, called “pertinent positives and negatives” (see p. 3)
◗ May include medications, allergies, habits of smoking and alcohol, which frequently are pertinent to the present illness
Past History ◗ Lists childhood illnesses ◗ Lists adult illnesses with dates for at least four
categories: medical, surgical, obstetric/gynecologic,
and psychiatric
◗ Includes health maintenance practices such as
immunizations, screening tests, lifestyle issues, and
home safety
Family History ◗ Outlines or diagrams age and health, or age and cause of death, of siblings, parents, and grandparents
◗ Documents presence or absence of specific illnesses
in family, such as hypertension, coronary artery
disease, etc.
Personal and Social History
◗ Describes educational level, family of origin, current
household, personal interests, and lifestyle
Review of Systems ◗ Documents presence or absence of common symp- toms related to each major body system
Subjective Data Objective Data
What the patient tells you What you detect during the examination
The history, from Chief Complaint
through Review of Systems
All physical examination findings
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 reflects the quality of information the patient provides.
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Chapter 1 | Overview: Physical Examination and History Taking 3
CHIEF COMPLAINT(S)
Quote the patient’s own words. “My stomach hurts and I feel awful”; or “I have come for my regular check-up.”
PRESENT ILLNESS
This section is a complete, clear, and chronologic account of the prob- lems prompting the patient to seek care. It should include the prob- lem’s onset, the setting in which it has developed, its manifestations, and any treatments.
Every principal symptom should be well characterized, with descrip- tions 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.
The Seven Attributes of Every Symptom
◗ Location
◗ Quality
◗ Quantity or severity
◗ Timing, including onset, duration, and frequency
◗ Setting in which it occurs
◗ Aggravating and relieving factors
◗ Associated manifestations
In addition, list medications, including name, dose, route, and frequency of use; allergies, including specific reactions to each medication; tobacco use; and alcohol and drug use.
HISTORY
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)
4 Bates’ Pocket Guide to Physical Examination and History Taking
● 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, influenza, varicella, hepatitis B, Haemophilus influenzae type b, pneumococcal vaccine, and herpes zoster vaccine; and screening tests, such as tuber- culin tests, Pap smears, mammograms, stool tests, for occult blood colonoscopy, and cholesterol tests, together with the results and the dates they were last performed.
FAMILY HISTORY
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, ele- vated 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.
PERSONAL AND SOCIAL HISTORY
Include occupation and the last year of schooling; home situation and significant others; sources of stress, both recent and long term; impor- tant life experiences, such as military service; leisure activities; religious affiliation 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.
REVIEW OF SYSTEMS (ROS)
These “yes/no” questions go from “head to toe” and conclude the inter- view. 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 specific ques- tions about systems that may be of concern. For example, “How are your ears and hearing?” “How about your lungs and breathing?” “Any trouble
Chapter 1 | Overview: Physical Examination and History Taking 5
with your heart?” “How is your digestion?” The Review of Systems ques- tions 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.
General. Usual weight, recent weight change, clothing that fits more tightly or loosely than before; weakness, fatigue, fever.
Skin. Rashes, lumps, sores, itching, dryness, color change; changes in hair or nails; changes in size or color of moles.
Head, Eyes, Ears, Nose, Throat (HEENT). Head: Headache, head injury, dizziness, lightheadedness. Eyes: Vision, glasses or contact lenses, last examination, pain, redness, excessive tearing, double or blurred vision, spots, specks, flashing lights, glaucoma, cataracts. Ears: Hearing, tinnitus, vertigo, earache, infection, discharge. If hear- ing is decreased, use or nonuse of hearing aid. Nose and sinuses: Fre- quent colds, nasal stuffiness, 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 fit; last dental examination; sore tongue; dry mouth; frequent sore throats; hoarseness.
Neck. Lumps, “swollen glands,” goiter, pain, stiffness.
Breasts. Lumps, pain or discomfort, nipple discharge, self-examination practices.
Respiratory. Cough, sputum (color, quantity), hemoptysis, dyspnea, wheezing, pleurisy, last chest x-ray. You may wish to include asthma, bronchitis, emphysema, pneumonia, and tuberculosis.
Cardiovascular. “Heart trouble,” hypertension, rheumatic fever, heart murmurs, chest pain or discomfort, palpitations, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, edema, past electrocardio- graphic or other cardiovascular tests.
Gastrointestinal. 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.
6 Bates’ Pocket Guide to Physical Examination and History Taking
Peripheral Vascular. Intermittent claudication; leg cramps; varicose veins; past clots in veins; swelling in calves, legs, or feet; color change in fingertips or toes during cold weather; swelling with redness or tenderness.
Urinary. Frequency of urination, polyuria, nocturia, urgency, burn- ing or pain on urination, hematuria, urinary infections, kidney stones, incontinence; in males, reduced caliber or force of urinary stream, hesitancy, dribbling.
Genital. Male: Hernias, discharge from or sores on penis, testicu- lar pain or masses, history of sexually transmitted infections (STIs) or diseases (STDs) 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, meno- pausal symptoms, postmenopausal bleeding. In patients born before 1971, exposure to diethylstilbestrol (DES) from maternal use during pregnancy. Vaginal discharge, itching, sores, lumps, STIs and treat- ments. 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.
Musculoskeletal. 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 limita- tion of motion or activity; include timing of symptoms (e.g., morn- ing 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.
Psychiatric. Nervousness; tension; mood, including depression, memory change, suicide attempts, if relevant.
Neurologic. Changes in mood, attention, or speech; changes in ori- entation, 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.
Hematologic. Anemia, easy bruising or bleeding, past transfusions, transfusion reactions.
Chapter 1 | Overview: Physical Examination and History Taking 7
Endocrine. “Thyroid trouble,” heat or cold intolerance, excessive sweating, excessive thirst or hunger, polyuria, change in glove or shoe size.
The Physical Examination: Approach and Overview
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 sys- tematic sequence of examination. With effort and practice, you will acquire your own routine sequence. This book recommends exam- ining from the patient’s right side.
● Apply the techniques of inspection, palpation, auscultation, and per- cussion to each body region, but be sensitive to the whole patient.
● 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.
BEGINNING THE EXAMINATION: SET TING THE STAGE
Take the following steps to prepare for the physical examination.
Preparing for the Physical Examination
◗ Reflect on your approach to the patient.
◗ Adjust the lighting and the environment.
◗ Make the patient comfortable.
◗ Determine the scope of the examination.
◗ Choose the sequence of the examination.
◗ Observe the correct examining position (the patient’s right side) and handedness.
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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.
8 Bates’ Pocket Guide to Physical Examination and History Taking
The Physical Examination: Suggested Sequence and Positioning
◗ General survey
◗ Vital signs
◗ Skin: upper torso, anterior and
posterior
◗ Head and neck, including
thyroid and lymph nodes
◗ Optional: Nervous system (mental status, cranial
nerves, upper extremity motor
strength, bulk, tone, cerebellar
function)
◗ Thorax and lungs
◗ Breasts
◗ Musculoskeletal as indicated:
upper extremities
◗ Cardiovascular, including JVP,
carotid upstrokes and bruits,
PMI, etc.
◗ Cardiovascular, for S3 and
murmur of mitral stenosis
◗ Nervous system: lower
extremity motor strength,
bulk, tone, sensation;
reflexes; Babinskis
◗ Musculoskeletal, as indicated
◗ Optional: Skin, anterior and posterior
◗ Optional: Nervous system, including gait
◗ Optional: Musculoskeletal, comprehensive
◗ Women: Pelvic and rectal examination
◗ Men: Prostate and rectal examination
◗ Cardiovascular, for murmur of
aortic insufficiency
◗ Optional: Thorax and lungs— anterior
◗ Breasts and axillae
◗ Abdomen
◗ Peripheral vascular; Optional: Skin—lower torso and
extremities
Key to the Symbols for the Patient’s Position
Sitting
Lying supine, with head
of bed raised 30 degrees
Same, turned partly to
left side
Standing
Lying supine, with hips flexed,
abducted, and externally rotated,
and knees flexed (lithotomy
position)
Lying on the left side (left lateral
decubitus)
Sitting, leaning forward
Lying supine
Each symbol pertains until a new one appears. Two symbols separated by a slash
indicate either or both positions.
Chapter 1 | Overview: Physical Examination and History Taking 9
Reflect on Your Approach to the Patient. 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 first! Simply examine that area out of sequence, but smoothly.
Adjust Lighting and the Environment. Adjust the bed to a convenient height (be sure to lower it when finished!). 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.
Make the Patient Comfortable. Show concern for privacy and modesty.
● 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 finished, 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.
Determine the Scope of the Examination. Comprehensive or Focused? Choose whether to do a comprehensive or focused examination.
10 Bates’ Pocket Guide to Physical Examination and History Taking
Choose the Sequence of the Examination. The sequence of the examination should
● maximize the patient’s comfort
● avoid unnecessary changes in position, and
● enhance the clinician’s efficiency.
In general, move from “head to toe.” An important goal as a student is to develop your own sequence with these principles in mind. See Chapter 1 of the textbook for a suggested examination sequence.
Observe the Correct Examining Position and Handedness. Examine the patient from the patient’s right side. Note that it 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 finish the rest of the examination with the patient again supine.
The Comprehensive Adult Physical Examination
General Survey. Continue this survey throughout the patient visit. Observe general state of health, height, build, and sexual develop- ment. 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.
Vital Signs. Ask the patient to sit on the edge of the bed or exam- ining 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.
Skin. 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.
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Chapter 1 | Overview: Physical Examination and History Taking 11
HEENT. Darken the room to promote pupillary dilation and vis- ibility of the fundi. Head: Examine the hair, scalp, skull, and face. Eyes: Check visual acuity and screen the visual fields. 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. Compare the pupils, and test their reactions to light. Assess extraocular movements. 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.)
Neck. 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.
Back. Inspect and palpate the spine and muscles.
Posterior Thorax and Lungs. 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. 133).
Breasts, Axillae, and Epitrochlear Nodes. The patient is still sit- ting. 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 Note on the Musculoskeletal System. By now, you have made pre- liminary 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.
12 Bates’ Pocket Guide to Physical Examination and History Taking
(You may choose to examine upper extremity muscle bulk, tone, strength, and reflexes at this time, or you may decide to wait until later.)
Palpate the breasts, while continuing your inspection.
Anterior Thorax and Lungs. 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.
Cardiovascular System. Elevate head of bed to about 30 degrees, adjusting as necessary to see the jugular venous pulsa- tions. 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. 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 ausculta- tory area with the diaphragm. Listen for S1 and S2 and for physiologic splitting of S2. Listen for any abnormal heart sounds or murmurs.
Abdomen. Lower the head of the bed to the flat 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.
/ Peripheral Vascular System. 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.
/ Lower Extremities. Examine the legs, assessing the three systems (see next page) while the patient is still supine. Each of these systems can be further assessed when the patient stands.
/ Nervous System. The patient is sitting or supine. The exami- nation of the nervous system can also be divided into the upper extremity
Chapter 1 | Overview: Physical Examination and History Taking 13
examination (when the patient is still sitting) and the lower extremity examination (when the patient is supine) after examination of the peripheral nervous system.
Mental Status. If indicated and not done during the interview, assess orientation, mood, thought process, thought content, abnormal per- ceptions, insight and judgment, memory and attention, information and vocabulary, calculating abilities, abstract thinking, and construc- tional ability.
Cranial Nerves. 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 sternomastoid muscles, and protrusion of tongue.
Motor System. 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.
Sensory System. Pain, temperature, light touch, vibrations, and discrimination. Compare right and left sides and distal with proximal areas on the limbs.
Reflexes. Include biceps, triceps, brachioradialis, patellar, Achilles deep tendon reflexes; also plantar reflexes or Babinski reflex (see pp. 301–303).
Additional Examinations. The rectal and genital examinations are often performed at the end of the physical examination.
/ Male Genitalia and Hernias. Examine the penis and scrotal contents. Check for hernias.
Rectal Examination in Men. 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 can- not stand, examine the genitalia before doing the rectal examination.)
Genital and Rectal Examination in Women. The patient is supine in the lithotomy position. Sit during the examination with the speculum, then stand during bimanual examination of uterus,
14 Bates’ Pocket Guide to Physical Examination and History Taking
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.
Standard and Universal Precautions
The Centers for Disease Control and Prevention (CDC) have issued several guidelines to protect patients and examiners from the spread of infectious disease. All clinicians examining patients are well advised to study and observe these precautions at the CDC Web sites. Advi- sories for standard and methicillin-resistant Staphylococcus aureus (MRSA) precautions and for universal precautions are briefly sum- marized below.
● Standard and MRSA precautions: Standard precautions are based on the principle that all blood, body fluids, secretions, excretions except sweat, nonintact skin, and mucous membranes may contain trans- missible infectious agents. These practices apply to all patients in any setting. They include hand hygiene; when to use gloves, gowns, and mouth, nose, and eye protection; respiratory hygiene and cough eti- quette; patient isolation criteria; precautions relating to equipment, toys and solid surfaces, and handling of laundry; and safe needle- injection practices.
Be sure to wash your hands before and after examining the patient. This will show your concern for the patient’s welfare and display your awareness of a critical component of patient safety. Antimicro- bial fast-drying soaps are often within easy reach. Change your white coat frequently, because cuffs can become damp and smudged and transmit bacteria.
● Universal precautions: Universal precautions are a set of precautions designed to prevent transmission of HIV, hepatitis B virus (HBV), and other blood-borne pathogens when providing first aid or health care. The following fluids are considered potentially infectious: all blood and other body fluids containing visible blood, semen, and vaginal secretions; and cerebrospinal, synovial, pleural, peritoneal, pericardial, and amniotic fluids. 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.
SSStaannddarrd anndd UUnivveerssal Prrecaautioonss
15
C H A P T E R
2Clinical Reasoning, Assessment, and
Recording Your Findings
Assessment and Plan: the Process of Clinical Reasoning
Because assessment takes place in the clinician’s mind, the process of clinical reasoning often seems inaccessible to beginning students. As an active learner, ask your teachers and clinicians to elaborate on the fine points of their clinical reasoning and decision making.
As you gain experience, your clinical reasoning will begin at the outset of the patient encounter, not at the end. Listed below are principles underlying the process of clinical reasoning and certain explicit steps to help guide your thinking.
Identifying Problems and Making Diagnoses: Steps in Clinical Reasoning
◗ Identify abnormal findings. Make a list of the patient’s symptoms, the signs you observed during the physical examination, and available laboratory reports.
◗ Localize these findings anatomically. The symptom of a scratchy throat and the sign of an erythematous inflamed pharynx, for example, clearly localize
the problem to the pharynx. Some symptoms and signs, such as fatigue or
fever, cannot be localized but are useful in the next steps.
◗ Interpret the findings in terms of the probable process. There are a number of pathologic processes, including congenital, inflammatory or infectious, immunologic, neoplastic, metabolic, nutritional, degenerative,
vascular, traumatic, and toxic. Other problems are pathophysiologic, reflect- ing derangements of biologic functions, such as heart failure. Still other
problems are psychopathologic, such as headache as an expression of a somatization disorder.
(continued)
AAAssseessssmmeeentt aanndd PPllaan:: thhhe Proooceess off CCCliniiccaal Reeeassooniinggg
16 Bates’ Pocket Guide to Physical Examination and History Taking
The Case of Mrs. N
Now study the case of Mrs. N. Scrutinize the findings recorded, apply your clinical reasoning, and analyze the assessment and plan.
◗ Make hypotheses about the nature of the patient’s problems. Draw on your knowledge, experience, and reading about patterns of abnormali-
ties and diseases. By consulting the clinical literature, you embark on
the lifelong goal of evidence-based decision making. The following steps should help:
1. Select the most specific and critical findings to support your hypothesis.
2. Match your findings against all the conditions you know that can produce them.
3. Eliminate the diagnostic possibilities that fail to explain the findings. 4. Weigh the competing possibilities and select the most likely diagnosis. 5. Give special attention to potentially life-threatening and treatable
conditions. One rule of thumb is always to include “ the worst-case scenario” in your list of differential diagnoses and make sure you have ruled out that possibility based on your findings and patient
assessment.
◗ Test your hypotheses. You may need further history, additional maneuvers on physical examination, or laboratory studies or x-rays to confirm or to rule
out your tentative diagnosis or to clarify which possible diagnosis is most
likely.
◗ Establish a working diagnosis. Make this 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 define a prob-
lem explicitly in terms of its structure, process, and cause, such as “bacterial
meningitis, pneumococcal.” Routinely listing Health Maintenance helps you track several important health concerns more effectively: immunizations,
screening measures (e.g., mammograms, prostate examinations), instruc-
tions regarding nutrition and breast or testicular self-examinations, recom-
mendations about exercise or use of seat belts, and responses to important
life events.
◗ Develop a plan agreeable to the patient. Identify and record a Plan for each patient problem, ranging from tests to confirm or further evaluate a diagno-
sis; to consultations for subspecialty evaluation; to additions, deletions, or
changes in medication; or to arranging a family meeting.
Identifying Problems and Making Diagnoses: Steps in Clinical Reasoning (continued)
TTThee CCCaasee oof MMrss. NN
Chapter 2 | Clinical Reasoning, Assessment, and Recording Your Findings 17
Health History
8/25/12 11:00 am
Mrs. N is a pleasant, 54-year-old widowed saleswoman residing in Espanola,
New Mexico.
Referral. None Source and Reliability. Self-referred; seems reliable.
Chief Complaint: “My head aches.”
Present Illness: For about 3 months, Mrs. N has had increasing problems with frontal headaches. These are usually bifrontal, throbbing, and mild to moder-
ately severe. She has missed work on several occasions because of associated
nausea and vomiting. Headaches now average once a week, usually are related
to stress, and last 4 to 6 hours. They are relieved by sleep and putting a damp
towel over the forehead. There is little relief from aspirin. No associated visual
changes, motor-sensory deficits, or paresthesias.
“Sick headaches” with nausea and vomiting began at age 15, recurred
throughout her mid-20s, then decreased to one every 2 or 3 months and
almost disappeared.
The patient reports increased pressure at work from a new and demanding
boss; she is also worried about her daughter (see Personal and Social History). She thinks her headaches may be like those in the past but wants to be sure,
because her mother died following a stroke. She is concerned that they inter-
fere with her work and make her irritable with her family. She eats three meals
a day and drinks three cups of coffee a day and tea at night.
Medications. Aspirin, 1 to 2 tablets every 4 to 6 hours as needed. “Water pill” in the past for ankle swelling, none recently.
*Allergies. Ampicillin causes rash. Tobacco. About 1 pack of cigarettes per day since age 18 (36 pack-years). Alcohol/drugs. Wine on rare occasions. No illicit drugs.
Past History
Childhood Illnesses. Measles, chickenpox. No scarlet fever or rheumatic fever. Adult Illnesses. Medical: Pyelonephritis, 1998, with fever and right flank pain; treated with ampicillin; developed generalized rash with itching
several days later. Reports x-rays were normal; no recurrence of infection.
Surgical: Tonsillectomy, age 6; appendectomy, age 13. Sutures for laceration, 2001, after stepping on glass. Ob/Gyn: 3-3-0-3, with normal vaginal deliver- ies. Three living children. Menarche age 12. Last menses 6 months ago. Little
interest in sex, and not sexually active. No concerns about HIV infection.
Psychiatric: None. Health Maintenance. Immunizations: Oral polio vaccine, year uncertain; tetanus shots × 2, 1991, followed with booster 1 year later; flu vaccine, 2000, no reaction. Screening tests: Last Pap smear, 2008, normal. No mammograms to date.
*You may wish to add an asterisk or underline important points.
(continued)
18 Bates’ Pocket Guide to Physical Examination and History Taking
Family History
Train accident Stroke, varicose veins, headaches
43 67
High blood
pressure
Heart attack
Infancy 67 58 54
33 31 27
Headaches Migraine headaches
Indicates patient
Deceased male
Deceased female
Living male
Living female
OR Father died at age 43 in train accident. Mother died at age 67 from stroke; had
varicose veins, headaches.
One brother, 61, with hypertension, otherwise well; second brother, 58, well
except for mild arthritis; one sister, died in infancy of unknown cause.
Husband died at age 54 of heart attack.
Daughter, 33, with migraine headaches, otherwise well; son, 31, with head-
aches; son, 27, well.
No family history of diabetes, tuberculosis, heart or kidney disease, cancer,
anemia, epilepsy, or mental illness.
Personal and Social History: Born and raised in Las Cruces, finished high school, married at age 19. Worked as sales clerk for 2 years, then moved with
husband to Amarillo, had 3 children. Returned to work 15 years ago because of
financial pressures. Children all married. Four years ago, Mr. N died suddenly
of a heart attack, leaving little savings. Mrs. N has moved to small apartment
to be near her daughter, Isabel. Isabel’s husband, John, has an alcohol problem.
Mrs. N’s apartment now a haven for Isabel and her 2 children, Kevin, 6 years,
and Lucia, 3 years. Mrs. N feels responsible for helping them; feels tense and
nervous but denies depression. She has friends but rarely discusses family
problems: “I’d rather keep them to myself. I don’t like gossip.” No church or
other organizational support. She is typically up at 7:00 a.m., works 9:00 to
5:30, eats dinner alone.
Exercise and diet. Gets little exercise. Diet high in carbohydrates. Safety measures. Uses seat belt regularly. Uses sunblock. Medications kept in an unlocked medicine cabinet. Cleaning solutions in unlocked cabinet
below sink. Mr. N’s shotgun and box of shells in unlocked closet upstairs.
(continued)
Chapter 2 | Clinical Reasoning, Assessment, and Recording Your Findings 19
Review of Systems
General. *Has gained about 10 lbs in the past 4 years. Skin. No rashes or other changes. Head, Eyes, Ears, Nose, Throat (HEENT). See Present Illness. No history of head injury. Eyes: Reading glasses for 5 years, last checked 1 year ago. No symptoms. Ears: Hearing good. No tinnitus, vertigo, infections. Nose, sinuses: Occasional mild cold. No hay fever, sinus trouble. *Throat (or mouth and pharynx): Some bleeding of gums recently. Last dental visit 2 years ago. Occasional canker sore.
Neck. No lumps, goiter, pain. No swollen glands. Breasts. No lumps, pain, discharge. Does breast self-exam sporadically. Respiratory. No cough, wheezing, shortness of breath. Last chest x-ray, 1986, St. Vincent’s Hospital; unremarkable.
Cardiovascular. No known heart disease or high blood pressure; last blood pressure taken in 2006. No dyspnea, orthopnea, chest pain, palpitations. Has
never had an electrocardiogram (ECG).
Gastrointestinal. Appetite good; no nausea, vomiting, indigestion. Bowel movement about once daily, *though sometimes has hard stools for 2 to 3 days
when especially tense; no diarrhea or bleeding. No pain, jaundice, gallbladder
or liver problems.
Urinary. No frequency, dysuria, hematuria, or recent flank pain; nocturia × 1, large volume. *Occasionally loses some urine when coughs hard.
Genital. No vaginal or pelvic infections. No dyspareunia. Peripheral Vascular. Varicose veins appeared in both legs during first preg- nancy. For 10 years, has had swollen ankles after prolonged standing; wears
light elastic pantyhose; tried “water pill” 5 months ago, but it didn’t help much;
no history of phlebitis or leg pain.
Musculoskeletal. Mild, aching, low back pain, often after a long day’s work; no radiation down the legs; used to do back exercises but not now. No other
joint pain.
Psychiatric. No history of depression or treatment for psychiatric disorders. See also Present Illness and Personal and Social History. Neurologic. No fainting, seizures, motor or sensory loss. Memory good. Hematologic. Except for bleeding gums, no easy bleeding. No anemia. Endocrine. No known thyroid trouble, temperature intolerance. Sweating average. No symptoms or history of diabetes.
Physical Examination
Mrs. N is a short, overweight, middle-aged woman, who is animated and
responds quickly to questions. She is somewhat tense, with moist, cold
hands. Her hair is well-groomed. Her color is good, and she lies flat without
discomfort.
Vital Signs. Ht (without shoes) 157 cm (5′2″ ). Wt (dressed) 65 kg (143 lb). BMI 26. BP 164/98 right arm, supine; 160/96 left arm, supine; 152/88 right arm,
supine with wide cuff. Heart rate (HR) 88 and regular. Respiratory rate (RR) 18.
Temperature (oral) 98.6°F.
(continued)
20 Bates’ Pocket Guide to Physical Examination and History Taking
Skin. Palms cold and moist, but color good. Scattered cherry angiomas over upper trunk. Nails without clubbing, cyanosis.
Head, Eyes, Ears, Nose, Throat (HEENT). Head: Hair of average texture. Scalp without lesions, normocephalic/atraumatic (NC/AT). Eyes: Vision 20/30 in each eye. Visual fields full by confrontation. Conjunctiva pink; sclera white.
Pupils 4 mm constricting to 2 mm, round, regular, equally reactive to light.
Extraocular movements intact. Disc margins sharp, without hemorrhages,
exudates. No arteriolar narrowing or A-V nicking. Ears: Wax partially obscures right tympanic membrane (TM); left canal clear, TM with good cone of light. Acu-
ity good to whispered voice. Weber midline. AC > BC. Nose: Mucosa pink, septum midline. No sinus tenderness. Mouth: Oral mucosa pink. Several interdental papillae red, slightly swollen. Dentition good. Tongue midline, with 3 × 4 mm shallow white ulcer on red base on undersurface near tip; tender but not indu-
rated. Tonsils absent. Pharynx without exudates.
Neck. Neck supple. Trachea midline. Thyroid isthmus barely palpable, lobes not felt. Lymph Nodes. Small (<1 cm), soft, nontender, and mobile tonsillar and poste- rior cervical nodes bilaterally. No axillary or epitrochlear nodes. Several small
inguinal nodes bilaterally, soft and nontender.
Thorax and Lungs. Thorax symmetric with good excursion. Lungs resonant. Breath sounds vesicular with no added sounds. Diaphragms descend 4 cm bilaterally.
Cardiovascular. Jugular venous pressure 1 cm above the sternal angle, with head of examining table raised to 30°. Carotid upstrokes brisk, without bruits.
Apical impulse discrete and tapping, barely palpable in the 5th left interspace,
8 cm lateral to the midsternal line. Good S1, S2; no S3 or S4. A II/VI medium-
pitched midsystolic murmur at the 2nd right interspace; does not radiate to
the neck. No diastolic murmurs.
Breasts. Pendulous, symmetric. No masses; nipples without discharge. Abdomen. Protuberant. Well-healed scar, right lower quadrant. Bowel sounds active. No tenderness or masses. Liver span 7 cm in right midclavicular
line; edge smooth, palpable 1 cm below right costal margin (RCM). Spleen and
kidneys not felt. No costovertebral angle tenderness (CVAT).
Genitalia. External genitalia without lesions. Mild cystocele at introitus on straining. Vaginal mucosa pink. Cervix pink, parous, and without discharge.
Uterus anterior, midline, smooth, not enlarged. Adnexa not palpated due to
obesity and poor relaxation. No cervical or adnexal tenderness. Pap smear
taken. Rectovaginal wall intact.
Rectal. Rectal vault without masses. Stool brown, negative for occult blood. Extremities. Warm and without edema. Calves supple, nontender. Peripheral Vascular. Trace edema at both ankles. Moderate varicosities of saphenous veins in both lower extremities. No stasis pigmentation or ulcers.
Pulses (2+ = brisk, or normal):
Radial Femoral Popliteal Dorsalis Pedis Posterior Tibial
RT 2+ 2+ 2+ 2+ 2+ LT 2+ 2+ 2+ 2+ 2+
(continued)
Chapter 2 | Clinical Reasoning, Assessment, and Recording Your Findings 21
Musculoskeletal. No joint deformities. Good range of motion in hands, wrists, elbows, shoulders, spine, hips, knees, ankles.
Neurologic. Mental Status: Tense but alert and cooperative. Thought coher- ent. Oriented to person, place, and time. Cranial Nerves: II–XII intact. Motor: Good muscle bulk and tone. Strength 5/5 throughout (see p. 295 for grading system). Cerebellar: Rapid alternating movements (RAMs), point- to-point movements intact. Gait stable, fluid. Sensory: Pinprick, light touch, position sense, vibration, and stereognosis intact. Romberg negative.
Reflexes:
Biceps Triceps Brachioradialis Patellar Achilles Plantar
RT 2+ 2+ 2+ 2+ 1+ ↓ LT 2+ 2+ 2+ 2+/2+ 1+ ↓
OR
Laboratory Data
None Currently. See Plan.
Assessment and Plan
1. Migraine headaches. A 54-year-old woman with migraine headaches since childhood, with a throbbing vascular pattern and frequent nausea
and vomiting. Headaches are associated with stress and relieved by sleep
and cold compresses. There is no papilledema, and there are no motor or
sensory deficits on the neurologic examination. The differential diagnosis
includes tension headache, also associated with stress, but there is no
relief with massage, and the pain is more throbbing than aching. There are
no fever, stiff neck, or focal findings to suggest meningitis, and the lifelong
recurrent pattern makes subarachnoid hemorrhage unlikely (usually
described as “the worst headache of my life”).
(continued)
++ ++
++ ++
++
++ ++ ++ ++
++++
++
+ +
_ _
22 Bates’ Pocket Guide to Physical Examination and History Taking
Assessment and Plan (continued)
Plan: ◗ Discuss features of migraine vs. tension headaches.
◗ Discuss biofeedback and stress management.
◗ Advise patient to avoid caffeine, including coffee, colas, and other caf-
feinated beverages.
◗ Start NSAIDs for headache, as needed.
◗ If needed next visit, begin prophylactic medication, because patient is
having more than three migraines per month.
2. Elevated blood pressure. Systolic hypertension is present. May be related to anxiety from first visit. No evidence of end-organ damage to retina or
heart.
Plan: ◗ Discuss standards for assessing blood pressure.
◗ Recheck blood pressure in 1 month.
◗ Check basic metabolic panel; review urinalysis.
◗ Introduce weight reduction and/or exercise programs (see #4).
◗ Reduce salt intake.
3. Cystocele with occasional stress incontinence. Cystocele on pelvic exami- nation, probably related to bladder relaxation. Patient is perimenopausal.
Incontinence reported with coughing, suggesting alteration in bladder neck
anatomy. No dysuria, fever, flank pain. Not taking any contributing medica-
tions. Usually involves small amounts of urine, no dribbling, so doubt urge
or overflow incontinence.
Plan: ◗ Explain cause of stress incontinence.
◗ Review urinalysis.
◗ Recommend Kegel exercises.
◗ Consider topical estrogen cream to vagina next visit if no improvement.
4. Overweight. Patient 5′2″, weighs 143 lb. BMI is ∼26. Plan: ◗ Explore diet history; ask patient to keep food intake diary.
◗ Explore motivation to lose weight; set target for weight loss by next
visit.
◗ Schedule visit with dietitian.
◗ Discuss exercise program, specifically, walking 30 minutes most days
each week.
5. Family stress. Son-in-law with alcohol problem; daughter and grand- children seeking refuge in patient’s apartment, leading to tensions in
these relationships. Patient also has financial constraints. Stress currently
situational. No evidence of major depression at present.
Plan: ◗ Explore patient’s views on strategies to cope with stress.
◗ Explore sources of support, including Al-Anon for daughter and financial
counseling for patient.
◗ Continue to monitor for depression. (continued)
Chapter 2 | Clinical Reasoning, Assessment, and Recording Your Findings 23
Assessment and Plan (continued)
6. Occasional musculoskeletal low back pain. Usually with prolonged standing. No history of trauma or motor vehicle accident. Pain does not
radiate; no tenderness or motor-sensory deficits on examination. Doubt
disc or nerve root compression, trochanteric bursitis, sacroiliitis.
Plan: ◗ Review benefits of weight loss and exercises to strengthen low back
muscles.
7. Tobacco abuse. 1 pack per day for 36 years. Plan: ◗ Check peak flow or FEV1/FVC on office spirometry.
◗ Give strong warning to stop smoking.
◗ Offer referral to tobacco cessation program.
◗ Offer patch, current treatment to enhance abstinence.
8. Varicose veins, lower extremities. No complaints currently. 9. History of right pyelonephritis, 1998. 10. Ampicillin allergy. Developed rash but no other allergic reaction. 11. Health maintenance. Last Pap smear 2004; has never had a mammogram.
Plan: ◗ Teach patient breast self-examination; schedule mammogram.
◗ Schedule Pap smear next visit.
◗ Provide three stool guaiac cards; next visit discuss screening colonoscopy.
◗ Suggest dental care for mild gingivitis.
◗ Advise patient to move medications, caustic cleaning agents, gun and
ammunition to locked cabinet—if possible, above shoulder height.
Approaching the Challenges of Clinical Data
As you can see from the case of Mrs. N, organizing the patient’s clini- cal data poses several challenges. The following guidelines will help you address these challenges.
● Clustering data into single vs. multiple problems. The patient’s age may help. Young people are more likely to have a single disease, while older people tend to have multiple diseases. The timing of symptoms is often useful. For example, an episode of pharyngitis 6 weeks ago probably is unrelated to fever, chills, pleuritic chest pain, and cough that prompt an office visit today.
If symptoms and signs are in a single system, one disease may explain them. Problems in different, apparently unrelated systems often require more than one explanation. Again, knowledge of dis- ease patterns is necessary.
AAAppprrrooacchhhing tthhe CCChhallleenggess off Cliniiccal DData
24 Bates’ Pocket Guide to Physical Examination and History Taking
Some diseases involve multisystem conditions. To explain cough, hemoptysis, and weight loss in a 60-year-old plumber who has smoked cigarettes for 40 years, you probably even now would rank lung cancer high in your list of differential diagnoses.
● Sifting through an extensive array of data. Try to tease out sepa- rate clusters of observations and analyze one cluster at a time. You also can ask a series of key questions that may steer your thinking in one direction. 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 system aside.
● Assessing the quality of the data. To avoid errors in interpreting clinical information, acquire the habits of skilled clinicians, summa- rized below.
Tips for Ensuring the Quality of Patient Data
◗ Ask open-ended questions and listen carefully and patiently to the patient’s
story.
◗ Craft a thorough and systematic sequence to history taking and physical
examination.
◗ Keep an open mind toward the patient and the data.
◗ Always include “the worst-case scenario” in your list of possible
explanations of the patient’s problem, and make sure it can be safely
eliminated.
◗ Analyze any mistakes in data collection or interpretation.
◗ Confer with colleagues and review the pertinent medical literature to clarify
uncertainties.
◗ Apply principles of data analysis to patient information and testing.
● Improving your assessment of clinical data and laboratory tests. Apply several key principles for selecting and using clinical data and tests: reliability, validity, sensitivity, specificity, and predictive value. Learn to apply these principles to your clinical findings and the tests you order.
● Displaying clinical data. To use these principles, it is important to display the data in the 2 × 2 format diagrammed on page 32. Always using this format will ensure the accuracy of your calculations of sensitivity, specificity, and predictive value.
Chapter 2 | Clinical Reasoning, Assessment, and Recording Your Findings 25
Principles of Test Selection and Use
Reliability: The reproducibility of a measurement. It indicates how well repeated measurements of the same relatively stable phenomenon will give
the same result, also known as precision. Reliability may be measured for one
observer or more observers.
Example. If on several occasions one clinician consistently percusses the same span of a patient’s liver dullness, intraobserver reliability is good. If, on the other hand, several observers find quite different spans of liver
dullness on the same patient, interobserver reliability is poor.
Validity: The closeness with which a measurement reflects the true value of an object. It indicates how closely a given observation agrees with “the true
state of affairs,” or the best possible measure of reality.
Example. Blood pressure measurements by mercury-based sphygmoma- nometers are less valid than intra-arterial pressure tracings.
Sensitivity: Identifies the proportion of people who test positive in a group of people known to have the disease or condition, or the proportion of people
who are true positives compared with the total number of people who actu- ally have the disease. When the observation or test is negative in people who
have the disease, the result is termed false negative. Good observations or tests have a sensitivity of more than 90% and when negative help “rule out” disease because false negatives are few. Such observations or tests are especially useful for screening.
Example. The sensitivity of Homan’s sign in the diagnosis of deep venous thrombosis (DVT) of the calf is 50%. In other words, compared with a
group of patients with DVT confirmed by venous ultrasound, a much bet-
ter test, only 50% will have a positive Homan’s sign, so this sign, if absent,
is not helpful, because 50% of patients may have DVT.
Specificity: Identifies the proportion of people who test negative in a group known to be without a given disease or condition, or the proportion of people who are true negatives compared with the total number of people without the disease. When the observation or test is positive in people without the
disease, the result is termed false positive. Good observations or tests have a specificity of more than 90% and help “rule in” disease, because the test is rarely positive when disease is absent, and false positives are few.
Example: The specificity of serum amylase in patients with possible acute pancreatitis is 70%. In other words, of 100 patients without pancreatitis,
70% will have a normal serum amylase; in 30%, the serum amylase will be
falsely elevated.
Predictive value: Indicates how well a given symptom, sign, or test result— either positive or negative—predicts the presence or absence of disease.
Positive predictive value is the probability of disease in a patient with a posi- tive (abnormal) test, or the proportion of “true positives” out of the total
population with the disease. Negative predictive value is the probability of not having the condition or disease when the test is negative (normal), or
(continued)
26 Bates’ Pocket Guide to Physical Examination and History Taking
Principles of Test Selection and Use (continued)
the proportion of “true negatives” out of the total population without the
disease.
Examples. In a group of women with palpable breast nodules in a cancer screening program, the proportion with confirmed breast cancer would con-
stitute the positive predictive value of palpable breast nodules for diagnosing breast cancer. In a group of women without palpable breast nodules in a
cancer screening program, the proportion without confirmed breast cancer
constitutes the negative predictive value of absence of breast nodules.
Sensitivity, specificity, and predictive values are illustrated in a 2 × 2 table, as shown below in an example of 200 people, half of whom have the disease in
question. In this example, the disease prevalence of 50% is much higher than
in most clinical situations. Because the positive predictive value increases with
prevalence, its calculated value here is unusually high.
Negative predictive value = = × 100 = 94.7% d
c + d
90
90 + 5
Specificity = = × 100 = 90% d
b + d
90
90 + 10
Sensitivity =
Observation
Disease
Present Absent
100 total persons with the disease
100 total persons without the disease
200 total persons
95
true-positive observations
95
false-positive observations
105
total positive observations
95
total negative observations
90
true-negative observations
5
false-negative observations
+
–
= × 100 = 95% a
a + c
95
95 + 5
Positive predictive value = = × 100 = 90.5% a
a + b
95
95 + 10
a b
c d
Likelihood ratio (LR): Conveys the odds that a finding occurs in a patient with the condition compared with a patient without the condition. When the LR is
>1.0, the probability of the condition goes up; when the LR is < 1.0, the prob- ability of the condition goes down.
(continued)
Chapter 2 | Clinical Reasoning, Assessment, and Recording Your Findings 27
Principles of Test Selection and Use (continued)
◗ A positive LR =
◗ A negative LR =
Example. The LR of a subarachnoid hemorrhage (SAH) is 10 if neck stiffness is present and 0.4 if neck stiffness is absent. The odds of SAH are 10 times
higher if neck stiffness is present compared with patients without SAH.
When neck stiffness is absent, the odds the patient has SAH are reduced
by a factor of 0.4.
For example, suppose the pre-test probability of SAH in the patient is 25% or a
pre-test odds of 1:3. If the patient has neck stiffness, the post-test probability
is revised upward by the LR to 77% (post-test odds of 10.3). If there is no neck
stiffness, the post-test probability is revised downward by the negative LR to
12% (post-test odds of 4:30).
(1 – sensitivity) specificity
sensitivity (1 – specificity)
Organizing the Patient Record
A clear, well-organized clinical record is one of the most important adjuncts to your patient care. Think about the order and readability of the record and the amount of detail needed. Use the following check- list to make sure your record is clear, informative, and easy to follow.
OOOrggaannizzinnng thhe Paattieennt RRReccorrdd
Checklist for a Clear Patient Record
Is the order clear?
Order is imperative. Make sure that future readers, including you, can find
specific points of information easily. Keep the subjective items of the history, for example, in the history; do not let them stray into the physical examina-
tion. Did you . . .
◗ Make the headings clear?
◗ Accent your organization with indentations and spacing?
◗ Arrange the Present Illness in chronologic order, starting with the current episode, then filling in relevant background information?
Do the data included contribute directly to the assessment?
Spell out the supporting data—both positive and negative—for every problem
or diagnosis that you identify. (continued)
28 Bates’ Pocket Guide to Physical Examination and History Taking
Checklist for a Clear Patient Record (continued)
(continued)
Are pertinent negatives specifically described?
Often portions of the history or examination suggest a potential or actual
abnormality.
Examples. For the patient with notable bruises, record the “pertinent nega- tives,” such as the absence of injury or violence, familial bleeding disorders,
or medications or nutritional deficits that might lead to bruising.
For the patient who is depressed but not suicidal, record both facts. In the
patient with a transient mood swing, on the other hand, a comment on suicide
is unnecessary.
Are there overgeneralizations or omissions of important data?
Remember that data not recorded are data lost. No matter how vividly you can recall selected details today, you probably will not remember them in a few months.
The phrase “neurologic exam negative,” even in your own handwriting, may leave
you wondering in a few months’ time, “Did I really do the sensory exam?”
Is there too much detail?
Avoid burying important information in a mass of excessive detail, to be dis-
covered by only the most persistent reader. Omit most negative findings unless they relate directly to the patient’s complaints or to specific exclusions in your
diagnostic assessment. Do not list abnormalities that you did not observe. Instead, concentrate on a few major ones, such as “no heart murmurs,” and try to describe structures concisely and positively.
Examples. “Cervix pink and smooth” indicates you saw no redness, ulcers, nodules, masses, cysts, or other suspicious lesions, but the description is
shorter and much more readable.
You can omit certain body structures even though you examined them, such as
normal eyebrows and eyelashes.
Are phrases and short words used appropriately? Is there unnecessary repetition of data?
Omit unnecessary words, such as those in parentheses in the examples below.
This saves valuable time and space.
Examples. “Cervix is pink (in color).” “Lungs are resonant (to percussion).” “Liver is tender (to palpation).” “Both (right and left) ears with cerumen.”
“II/VI systolic ejection murmur (audible).” “Thorax symmetric (bilaterally).”
Omit repetitive introductory phrases such as “The patient reports no . . . ,” be-
cause readers assume the patient is the source of the history unless otherwise
specified.
Use short words instead of longer, fancier ones when they mean the same
thing, such as “felt” for “palpated” or “heard” for “auscultated.”
Describe what you observed, not what you did. “Optic discs seen” is less informative than “disc margins sharp,” even if it marks your first glimpse as an
examiner!
Chapter 2 | Clinical Reasoning, Assessment, and Recording Your Findings 29
Checklist for a Clear Patient Record (continued)
Is the written style succinct? Is there excessive use of abbreviations? Records are scientific and legal documents, so they should be clear and
understandable. Using words and brief phrases instead of whole sentences
is common, but abbreviations and symbols should be used only if they are
readily understood. Likewise, an overly elegant style is less appealing than a
concise summary.
Be sure your record is legible; otherwise, all that you have recorded is
worthless to your readers.
Are diagrams and precise measurements included where appropriate?
Diagrams add greatly to the clarity of the record.
Examples. Study the examples below:
To ensure accurate evaluations and future comparisons, make measure-
ments in centimeters, not in fruits, nuts, or vegetables.
Example. “1 × 1 cm lymph node” vs. “a pea-sized lymph node . . .” Or “2 × 2 cm mass on the left lobe of the prostate” vs. “a walnut-sized pros- tate mass.”
Is the tone of the write-up neutral and professional?
It is important to be objective. Hostile, moralizing, or disapproving comments
have no place in the patient’s record. Never use words, penmanship, or punc-
tuation that are inflammatory or demeaning.
Example. Comments such as “Patient DRUNK and LATE TO CLINIC AGAIN!!” are unprofessional and set a bad example for other providers reading the
chart. They also might prove difficult to defend in a legal setting.
30 Bates’ Pocket Guide to Physical Examination and History Taking
After you have completed your assessment and written record, you will find it helpful to generate a Problem List that summarizes the patient’s problems for the front of the office or hospital chart. A sample Problem List for Mrs. N is provided below.
Sample Problem List
Date Entered Problem No. Problem
8/30/12 1 Migraine headaches
2 Elevated blood pressure
3 Cystocele with occasional stress
incontinence
4 Overweight
5 Family stress
6 Low back pain
7 Tobacco abuse
8 Varicose veins
9 History of right pyelonephritis
10 Allergy to ampicillin
11 Health maintenance
31
C H A P T E R
3Interviewing and the Health History
The health history is a conversation with a purpose. In social conversa- tion, 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 significantly 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 affirma- tion, empathic responses, validation, reassurance, 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 specific kinds of information you need to obtain, facilitates clinical reasoning, and clarifies 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 Medical History, the Family History, the Personal and Social History, and, most closed-ended of all, the Review of Systems.
For new patients in the office, 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 specific complaint, such as painful urination, a more limited interview, tailored to that specific problem—sometimes called a focused or problem-oriented history—may be indicated.
32 Bates’ Pocket Guide to Physical Examination and History Taking
The Fundamentals of Skilled Interviewing
Skilled interviewing requires the use of specific learnable techniques perfected over a lifetime. Practice these techniques and find ways to be observed or recorded so that you can receive feedback on your progress.
Active Listening. 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.
Empathic Responses. Patients may express—with or without words—feelings they have not consciously acknowledged. Emphatic responses are vital to patient rapport and healing and convey that you experience some of the patient’s suffering. To express empathy, you must first 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.
Guided Questioning. It is important to adapt your questioning to the patient’s verbal and nonverbal cues.
Types of Guided Questioning
◗ Moving from open-ended to focused questions
◗ Using questioning that elicits a graded response
◗ Asking a series of questions, one at a time
◗ Offering multiple choices for answers
◗ Clarifying what the patient means
◗ Encouraging with continuers
◗ Using echoing
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Proceed from the general to the specific. 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.”
Ask questions that require a graded response rather than a single answer. “What physical activity do you do that makes you short of
Chapter 3 | Interviewing and the Health History 33
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 fol- lowing problems?” Be sure to pause and establish eye contact as you list each problem.
Sometimes patients seem unable to describe symptoms. Offer multiple-choice answers.
For patients using words that are ambiguous, request clarification, as in “Tell me exactly what you meant by ‘the flu.’”
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.
Nonverbal Communication. Being sensitive to nonverbal mes- sages allows you to both “read the patient” more effectively and send messages of your own. Pay close attention to eye contact, facial expres- sion, posture, head position and movement such as shaking or nod- ding, 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 quali- ties of speech such as pacing, tone, and volume, to increase rapport. Be sensitive to cultural variations in uses and meanings of nonverbal behaviors.
Validation. An important way to make a patient feel accepted is to provide verbal support that legitimizes or validates the patient’s emotional experience.
Reassurance. Avoid premature or false reassurance. Such reassur- ance 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 reassur- ance at that moment.
Partnering. Express your desire to work with patients in an on- going way. Reassure patients that regardless of what happens with their disease, as their provider, you are committed to a continuing
34 Bates’ Pocket Guide to Physical Examination and History Taking
partnership. Even in your role as a student, such support can make a big difference.
Summarization. Giving a capsule summary lets the patient know that you have been listening carefully. It also clarifies 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.
Transitions. Tell patients when you are changing directions during the interview. This gives patients a greater sense of control.
Empowering the Patient. 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 famil- iarity with the clinical evaluation process. Differences of gender, ethnic- ity, race, or class may also create power differentials. Ultimately, patients must be empowered to take care of themselves and feel confident about following through on your advice. Review the principles below.
Empowering the Patient: Principles of Sharing Power
◗ Evoke the patient’s perspective.
◗ Convey interest in the person, not just the problem.
◗ Follow the patient’s lead.
◗ Elicit and validate emotional content.
◗ Share information with the patient, especially at transition points during
the visit.
◗ Make your clinical reasoning transparent to the patient.
◗ Reveal the limits of your knowledge.
The Sequence and Context of the Interview
PREPARATION
Interviewing patients to elicit their health history requires planning.
● Review the medical record. Before seeing the patient, review the medical record or chart. It often provides valuable information about past diagnoses and treatments; however, data may be incom- plete 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 35
● 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 disap- proval, embarrassment, impatience, or boredom block communica- tion. Patients find 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.
THE SEQUENCE OF THE INTERVIEW
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 vali- date their significance.
● 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 first 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 first names unless you have specific permission from the patient.
Whenever visitors are present, maintain confidentiality. 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.
36 Bates’ Pocket Guide to Physical Examination and History Taking
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.
Give the patient your undivided attention. Spend enough time on small talk to put the patient at ease. If necessary, jot down short phrases, specific dates, or words rather than trying to put them into a final format. Maintain good eye contact, and 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 specific complaint or problem. It is still important to start with the patient’s story.
● Invite the patient’s story. As you probe the patient’s concern, 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 brings to the symptoms. It is the way that the clinician organizes what he or she learns from the patient into a coherent picture that leads to a clinical diagnosis and treatment plan. Illness can be defined as how the patient experiences symp- toms. 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
Chapter 3 | Interviewing and the Health History 37
mnemonic “FIFE”—Feelings, Ideas, effect on Function, and Expec- tations. This is crucial to patient satisfaction, effective health care, and patient follow-through.
Exploring the Patient’s Perspective (F-I-F-E)
◗ The patient’s Feelings, including fears or concerns, about the problem ◗ The patient’s Ideas about the nature and the cause of the problem ◗ The effect of the problem on the patient’s life and Function ◗ The patient’s Expectations of the disease, of the clinician, or of health care, often based on prior personal or family experiences
Clues to the Patient’s Perspective on Illness
◗ Direct statement(s) by the patient of explanations, emotions, expectations,
and effects of the illness
◗ Expression of feelings about the illness without naming the illness
◗ Attempts to explain or understand symptoms
◗ Speech clues (e.g., repetition, prolonged reflective pauses)
◗ Sharing a personal story
◗ Behavioral clues indicative of unidentified concerns, dissatisfaction, or
unmet needs such as reluctance to accept recommendations, seeking a
second opinion, or early appointment
Source: Lang F, Floyd MR, Beine KL. Clues to patients’ explanations and concerns about
their illnesses: a call for active listening. Arch Fam Med 2000;9(3):222–227.
● 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.
● Expand and clarify the patient’s story. Each symptom has attri- butes that must be clarified, 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.
38 Bates’ Pocket Guide to Physical Examination and History Taking
The Seven Attributes of a Symptom
1. Location. Where is it? Does it radiate? 2. Quality. What is it like? 3. Quantity or severity. How bad is it? (For pain, ask for a rating on a scale of
1 to 10.)
4. Timing. When did (does) it start? How long did (does) it last? How often did (does) it occur?
5. Setting in which it occurs. Include environmental factors, personal activities, emotional reactions, or other circumstances that may have contributed to
the illness.
6. Remitting or exacerbating factors. Does anything make it better or worse?
7. Associated manifestations. Have you noticed anything else that accompanies it?
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, Radia- tion, Site, and Timing
Use language that is understandable and appropriate to the patient. Technical language confuses patients and blocks communication. Whenever possible, use the patient’s words, making sure you clarify their meaning.
Facilitate the patient’s story by using different types of questions and the techniques of skilled interviewing on pp. 32–34. Often you will need to use directed questions (see p. 32) that ask for spe- cific information the patient has not already offered. In general, the patient interview moves back and forth from an open-ended question to a directed question and then on to another open-ended question.
Establishing the sequence and time course of the patient’s symptoms is important. You can encourage a chronologic account by asking such questions as “What then?” or “What happened next?”
Some students visualize the process of evoking a full description of the symptom as “the cone”, as shown on the following page.
Chapter 3 | Interviewing and the Health History 39
First, open-ended questions to hear “the story of the symptom” in the patient’s own words
Then more specific questions to elicit “the seven features of every symptom”
Finally, the yes-no questions or “pertinent positives and negatives” from the relevant section of the review of systems
Each symptom has its own “cone,” which becomes a paragraph in the History of Present Illness in the written record.
● Generate and test diagnostic hypotheses. As you listen to the patient’s concerns, you will begin to generate hypotheses about what disease process might be the cause. Identifying the various attributes of the patient’s symptoms and pursuing specific details are funda- mental to recognizing patterns of disease and differentiating one disease from another.
● Share the treatment plan. Learning about the disease and concep- tualizing the illness give you and the patient the basis for planning further evaluation (physical examination, laboratory tests, consul- tations, etc.). Motivational interviewing techniques may help the patient achieve desired behavior changes.
● Close the interview. 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 final questions. Ask the patient to repeat the plan back to you.
● Take time for self-reflection. 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-reflection brings a deepening personal awareness to our work with patients and is one of the most rewarding aspects of providing patient care.
40 Bates’ Pocket Guide to Physical Examination and History Taking
THE CULTURAL CONTEXT OF THE INTERVIEW
Cultural Humility—A Changing Paradigm. 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 influences how we view the world, experience it emotionally, and behave in relation to other people. This definition of culture is broader than the term ethnicity. The influence 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 orga- nizations and staff to work effectively in cross-cultural situations. It reflects the ability to acquire and use knowledge of the health-related benefits, 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- reflection and self-critique as lifelong learners and reflective practitioners.” This process includes “the difficult work of examining cultural beliefs and cultural systems of both patients and providers to locate the points of cul- tural 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 commu- nities. The following three-point framework will help you.
● Self-awareness. As clinicians, we face the task of bringing our own values and biases to a conscious level. Values are the standards we use to measure our own and others’ beliefs and behaviors. Biases are the attitudes or feelings that we attach to perceived differences, for example, the way an individual relates to time, which can be a cul- turally determined phenomenon. Are you always on time—a posi- tive value in the dominant Western culture? Or do you tend to run a little late? How do you feel about people whose habits are opposite to yours? Think about the role of physical appearance. Do you con- sider yourself thin, midsize, or heavy? How do you feel about people who have different weights?
● Respectful Communication. Maintain an open, respectful, and inquiring attitude. “What did you hope to get from this visit?” If
Chapter 3 | Interviewing and the Health History 41
you have established rapport and trust, patients will be willing to teach you. Be ready to acknowledge your ignorance or bias. “I mis- takenly made assumptions about you that are not right. I apologize. Would you be willing to tell me more about yourself and your future goals?”
Learn about different cultures: do pertinent reading; go to movies that are made in different countries; learn about different consumer health agendas.
● Collaborative Partnerships. Communication based on trust, respect, and a willingness to re-examine assumptions helps allow patients to express concerns that run counter to the dominant culture. You, the clinician, must be willing to listen to and validate these emotions, and not let your own feelings prevent you from exploring painful areas. You also must be willing to re-examine your beliefs.
Advanced Interviewing
CHALLENGING PATIENTS
Always remember the importance of listening to the patient and clarify- ing the patient’s agenda.
Silent Patient. Silence has many meanings and purposes. Watch closely for nonverbal cues such as difficulty 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?
Confusing Patient. 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 baffled, frustrated, or confused. The history is vague and difficult 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, orien- tation, and memory.
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42 Bates’ Pocket Guide to Physical Examination and History Taking
Patient With Altered Capacity. 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, deter- mine whether the patient has decision-making capacity, or the ability to understand information related to health, to make medical choices based on reason and a consistent set of values, and to declare prefer- ences about treatments. Many patients with psychiatric or cognitive deficits still retain the ability to make decisions.
For patients with capacity, obtain their consent before talking about their health with others. Maintain confidentiality and clarify what you can discuss with others. They may offer surprising and important information. 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. These can be found at www.hhs. gov/ocr/hipaa/.
For patients with impaired capacity, find 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.
Talkative Patient. Several techniques are helpful. For the first 5 or 10 minutes, listen closely. Does the patient seem obsessively detailed or unduly anxious? Is there a flight of ideas or disorganized thought pro- cess? Try to focus on what seems most important to the patient. “You’ve described many concerns. Let’s focus on the hip pain first. Can you tell me what it feels like?” Or you can ask, “What is your #1 concern today?”
Crying Patient. 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.”
Angry or Disruptive Patient. 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
Chapter 3 | Interviewing and the Health History 43
the same questions over and over.” Some angry patients become hostile and disruptive. Before approaching them, alert security. It is important to 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.
Patient With a Language Barrier. The ideal interpreter is a neu- tral, objective person trained in both languages and cultures. Avoid using family members or friends as interpreters: confidentiality may be violated. As you begin working with the interpreter, make questions clear, short, and simple. Speak directly to the patient. Bilingual written questionnaires are valuable.
Guidelines for Working With an Interpreter: “INTERPRET ”
I Introductions: Make sure to introduce all the individuals in the room. During the introduction, include information as to the roles individuals
will play.
N Note Goals: Note the goals of the interview. What is the diagnosis? What will the treatment entail? Will there be any follow-up?
T Transparency: Let the patient know that everything said will be inter- preted throughout the session.
E Ethics: Use qualified interpreters (not family members or children) when conducting an interview. Qualified interpreters allow the patient to main-
tain autonomy and make informed decisions about his or her care.
R Respect Beliefs: Limited English Proficient (LEP) patients may have cul- tural beliefs that need to be taken into account as well. The interpreter
may be able to serve as a cultural broker and help explain any cultural
beliefs that may exist.
P Patient Focus: The patient should remain the focus of the encounter. Providers should interact with the patient and not the interpreter.
Make sure to ask and address any questions the patient may have prior
to ending the encounter. If you don’t have trained interpreters on staff,
the patient may not be able to call in with questions.
R Retain Control: It is important as the provider that you remain in con- trol of the interaction and not let the patient or the interpreter take
over the conversation.
E Explain: Use simple language and short sentences when working with an interpreter. This will ensure that comparable words can be found in the
second language and that all the information can be conveyed clearly.
T Thanks: Thank the interpreter and the patient for their time. On the chart, note that the patient needs an interpreter and who served as an
interpreter this time.
Source: U.S. Department of Health and Human Services. Interpret Tool: working with
interpreters in cultural settings. Available at https: www.thinkculturalhealth.hhs.gov/pdfs/
InterpretTool.pdf. Accessed June 6, 2012.
44 Bates’ Pocket Guide to Physical Examination and History Taking
Patient With Low Literacy or Low Health Literacy. 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.
Patient With Hearing Loss. Find out the patient’s preferred method of communicating. Patients may use American Sign Lan- guage, a unique language with its own syntax, or various other com- munication forms combining signs and speech. Determine whether the patient identifies 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 hear- ing side. If the patient has a hearing aid, make sure it is working. Eliminate background noise such as television.
Patient With Impaired Vision. Shake hands to establish contact and explain who you are and why you are there. If the room is unfa- miliar, orient the patient to the surroundings.
Patient With Limited Intelligence. 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 finish, 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 condescend- ing behavior. The sexual history is equally important and often over- looked.
Patient With Personal Problems. 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 thera- peutic than any answer you could give.
Seductive Patient. 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
Chapter 3 | Interviewing and the Health History 45
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.
SENSITIVE TOPICS
The Sexual History. You can introduce questions about sexual function and practices at multiple points in a patient’s history. An ori- enting 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.”
● “When was the last time you had intimate physical contact with someone?” “Did that contact include sexual intercourse?”
● “Do you have sex with men, women, or both?” The health implications of heterosexual, homosexual, or bisexual experiences are significant.
● “How many sexual partners have you had in the last 6 months?” “In the last 5 years?” “In your lifetime?”
● Because no explicit risk factors may be present, it is important to ask all patients “Do you have any concerns about HIV or AIDS?” Also ask about routine use of condoms.
Mental Health History. Cultural constructs of mental illness vary widely, causing marked differences in acceptance and attitudes. Ask open-ended questions initially: “Have you ever had any problem with emotional or mental illnesses?” Then move to more specific questions: “Have you ever visited a counselor or psychotherapist?” “Have you taken medication for emotional issues?” “Have you or a family mem- ber 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 opening 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 func- tion in the community and tell you about their diagnoses, symptoms,
46 Bates’ Pocket Guide to Physical Examination and History Taking
hospitalizations, and medications. Investigate their symptoms and assess any effects on mood or daily activities.
Alcohol and Prescription and Illicit Drugs. Clinicians should routinely ask about current and past use of alcohol or drugs, patterns of use, and family history. Be familiar with the definitions below:
● Tolerance: A state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more of the drug’s effects over time.
● Physical Dependence: A state of adaptation that is manifested by a drug class–specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist.
● Addiction: A primary, chronic, neurobiologic disease with genetic, psychosocial, and environmental factors influencing its development and manifestations. It is characterized by behaviors that include one or more of the following: impaired control over drug use, compul- sive use, continued use despite harm, and craving.
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 affirma- tive 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 conflict, or legal problems. Ask specifically about drinking while driving or operating machinery.
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 first. “A lot of young people are using drugs these days. How about at your school? Your friends?”
Chapter 3 | Interviewing and the Health History 47
Intimate Partner Violence and Domestic Violence. Many authorities recommend routine screening of all female and older adult patients for domestic violence. Start with general “normalizing” ques- tions: “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?”
Clues to Physical and Sexual Abuse
◗ Injuries that are unexplained, seem inconsistent with the patient’s story, are
concealed by the patient, or cause embarrassment
◗ Delay in getting treatment for trauma
◗ History of repeated injuries or “accidents”
◗ If the patient or a person close to the patient has a history of alcohol or drug
abuse
◗ Partner tries to dominate the visit, will not leave the room, or seems unusu-
ally anxious or solicitous
◗ Pregnancy at a young age; multiple partners
◗ Repeated STIs; vaginal lacerations or bruises
◗ Fear of the pelvic examination or leaving the examination room
Death and the Dying Patient. Work through your own feelings with the help of reading and discussion. Kübler-Ross has described five 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 confide 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 difficult, you must learn to ask specific 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 cardiopul- monary 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.
48 Bates’ Pocket Guide to Physical Examination and History Taking
Ethics and Professionalism
Medical ethics come into play in almost every patient interaction. Fundamental maxims are as follows:
● Nonmaleficence or primum non nocere, commonly stated as “First, do no harm”
● Beneficence, or the dictum that the clinician needs to “do good” for the patient. As clinicians, our actions need to be motivated by what is in the patient’s best interest.
● Autonomy, whereby patients have the right to determine what is in their own best interest
● Confidentiality, meaning that we are obligated not to tell others what we learn from our patients
The Tavistock Principles guide behavior in health care for both individuals and institutions.
The Tavistock Principles
Rights: People have a right to health and health care. Balance: Care of individual patients is central, but the health of populations is
also our concern.
Comprehensiveness: In addition to treating illness, we have an obligation to ease suffering, minimize disability, prevent disease, and promote health.
Cooperation: Health care succeeds only if we cooperate with those we serve, each other, and those in other sectors.
Improvement: Improving health care is a serious and continuing responsibility. Safety: Do no harm. Openness: Being open, honest, and trustworthy is vital in health care.
EEEthhicccs annddd PProoofeesssiioonaaliiismm
49
C H A P T E R
4Beginning the Physical Examination: General
Survey, Vital Signs, and Pain
The Health History
Fatigue and Weakness. Fatigue is a nonspecific 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.
Fever, Chills, and Night Sweats. 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 subjective chilliness 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,
Common or Concerning Symptoms
◗ Fatigue and weakness
◗ Fever, chills, night sweats
◗ Changes in weight
◗ Pain
50 Bates’ Pocket Guide to Physical Examination and History Taking
or other unusual exposures. Be sure to inquire about medications, as they may cause fever. In contrast, recent ingestion of aspirin, acet- aminophen, corticosteroids, and nonsteroidal anti-inflammatory drugs may mask it.
Weight Changes. 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 expen- diture over time. It also may reflect abnormal accumulation of body fluids.
● Weight loss has many causes: decreased food intake, dysphagia, vomiting, and insufficient supplies of food; defective absorption of nutrients; increased metabolic requirements; and loss of nutrients through the urine, feces, or injured skin. Be alert for signs of malnutrition.
Pain. Approximately 70 million Americans report persisting or intermittent pain, often underassessed. Adopt the comprehensive approach found on p. 59.
Health Promotion and Counseling: Evidence and Recommendations HHHeealltthh PPrroommoootioonn andd CCCouunsselingg: EEEviideenncce aannd Reecooommmmeeenddattionns
Important Topics for Health Promotion and Counseling
Optimal Weight, Nutrition, and Diet. Less than half of U.S. adults maintain a healthy weight (BMI ≥19 but <25). Obesity has increased in every segment of the population. More than 85% of people with type 2 diabetes and roughly 20% of those with hyper- tension or elevated cholesterol levels are overweight or obese. Increasing obesity in children contributes to rising rates of child- hood diabetes. Diet recommendations hinge on assessment of the patient’s motivation and readiness to lose weight and individual risk
◗ Optimal weight, nutrition, and diet
◗ Exercise
Chapter 4 | Beginning the Physical Examination 51
factors. Experts urge that everyone restrict salt intake to a half tea- spoon a day. General national guidelines recommend:
● A 10% weight reduction over 6 months, or a decrease of 300 to 500 kcal/day, for people with BMIs between 27 and 35
● A weight loss goal of ½ to 1 pound per week because more rapid weight loss does not lead to better results at 1 year
Exercise. Thirty minutes of moderate activity (defined as walking 2 miles in 30 minutes, or its equivalent, on most days of the week) is recommended. 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 ExaminationTTTecchhnniiquees offf EExaammminnatttionn
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
GENERAL SURVEY
Apparent State of Health Acutely or chronically ill, frail, robust, vigorous
Level of Consciousness. Is the patient awake, alert, and interactive?
If not, promptly assess level of
consciousness (see p. 305)
Signs of Distress ● Cardiac or respiratory distress
● Pain
● Anxiety or depression
Clutching the chest, pallor, diapho-
resis; labored breathing, wheezing,
cough
Wincing, sweating, protecting
painful area
Anxious face, fidgety movements, cold
and moist palms; inexpressive or flat
affect, poor eye contact, psychomotor
slowing
Skin Color and Obvious Lesions. See Chapter 6, The Skin, Hair, and Nails, for details.
Pallor, cyanosis, jaundice, rashes,
bruises
52 Bates’ Pocket Guide to Physical Examination and History Taking
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
Dress, Grooming, and Personal Hygiene
● Is the patient wearing any unusual jewelry? Where? Is there any body piercing or tattoo?
● Note patient’s hair, fingernails, and use of cosmetics.
Risk of hepatitis C
Facial Expression. 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.
Odors of Body and Breath. Odors can be important diagnostic clues.
Breath odor of alcohol, acetone,
uremia, or liver failure. Fruity odor
of diabetes. (Never assume that
alcohol on a patient’s breath explains
changes in mental status or neuro-
logic findings.)
Posture, Gait, and Motor Activity
Preference to sit up in left-sided heart
failure and to lean forward with arms
braced in chronic obstructive pulmonary
disease (COPD)
HEIGHT AND WEIGHT
Height. Measure the patient’s height in stocking feet. Note the build—muscular or decondi- tioned, tall or short. Observe the body proportions.
Short stature in Turner’s syndrome; elon-
gated arms in Marfan’s syndrome; loss of
height in osteoporosis
Weight. Is the patient emaci- ated? Plump? If obese, is there central or dispersed distribution of fat? Weigh the patient with shoes off.
More than 50% of U.S. adults are
overweight (BMI >25); nearly 25% are obese (BMI >30). These excesses are proven risk factors for diabetes, heart
disease, stroke, hypertension, osteo-
arthritis, sleep apnea syndrome, and
some forms of cancer.
Methods to Calculate BMI
Unit of Measure Method of Calculation
◗ Weight in pounds, height in inches
◗ Weight in kilograms, height in meters squared
◗ Either
1. Body Mass Index Chart (see p. 54)
2.
3.
4. BMI Calculator at Web site www.nhlbisupport.com/bmi
*Several organizations use 704.5, but the variation in BMI is negligible. Conversion formu-
las: 2.2 lb = 1 kg; 1.0 inch = 2.54 cm; 100 cm = 1 meter
Source: National Institutes of Health–National Heart, Lung and Blood Institute. Body Mass
Index Calculator. Available at: www.nhlbisupport.com/bmi. Accessed June 25, 2011.
Weight (lbs) × 700* Height (inches) Height (inches)
⎛ ⎝⎜
⎞ ⎠⎟
Weight (kg) Height (m2)
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.
If the BMI falls below 17, be concerned about possible anorexia nervosa, bulimia, or other medical conditions (see Table 4-1, Eating Disorders and Excessively Low BMI, p. 61).
If the BMI is ≤35, measure the waist circumference just above the hip bones. The patient may have excess body fat if the waist measures ≥40 inches for men.
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
Calculate the body mass index (BMI), which incorporates estimated but more accurate measurements of body fat than weight alone.
Chapter 4 | Beginning the Physical Examination 53
54 Bates’ Pocket Guide to Physical Examination and History Taking
BMI Char t
Normal Overweight Obese
BMI 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35
Height (inches) Body Weight (pounds)
58 91 96 100 105 110 115 119 124 129 134 138 143 148 153 158 162 167
59 94 99 104 109 114 119 124 128 133 138 143 148 153 158 163 168 173
60 97 102 107 112 118 123 128 133 138 143 148 153 158 163 168 174 179
61 100 105 111 116 122 127 132 137 143 148 153 158 164 169 174 180 185
62 104 109 115 120 126 131 136 142 147 153 158 164 169 175 180 185 191
63 107 113 118 124 130 135 141 145 152 158 163 169 174 180 185 191 197
64 110 116 122 128 134 140 145 151 157 163 169 174 180 185 192 197 204
65 114 120 126 132 138 144 150 156 162 168 174 180 186 192 198 204 210
66 118 124 130 136 142 148 155 161 167 173 179 186 192 198 204 210 216
67 121 127 134 140 146 153 159 166 172 178 185 191 198 204 211 217 223
68 125 131 138 144 151 158 164 171 177 184 190 197 203 210 216 223 230
69 128 135 142 149 155 162 169 176 182 189 196 203 209 216 223 230 236
70 132 139 146 153 160 167 174 181 188 189 196 203 209 216 223 230 236
71 136 143 150 157 165 172 179 186 193 200 208 215 222 229 236 243 250
72 140 147 154 162 169 177 184 191 199 206 213 221 228 235 242 250 258
73 144 151 159 166 174 182 189 197 204 212 219 227 235 242 250 257 265
74 148 155 163 171 179 186 194 202 210 218 225 233 241 249 256 264 272
75 152 160 168 176 184 192 200 208 216 224 232 240 248 256 264 272 279
76 156 164 172 180 189 197 205 213 221 230 238 246 254 263 271 279 287
Source: National Heart, Lung, and Blood Institute, National Institutes of Health. Body Mass Index
Table. Available at: www.nhlbi.nih.gov/guidelines/obesity/bmi_tbl.pdf. Accessed June 25, 2011.
THE VITAL SIGNS: BLOOD PRESSURE, HEART RATE, RESPIRATORY RATE, AND TEMPERATURE
Blood Pressure. To measure blood pressure accurately, choose a cuff of appropriate size and ensure careful technique.
Selecting the Correct Blood Pressure Cuff
◗ Width of the inflatable bladder of the cuff should be about 40% of upper arm
circumference (about 12–14 cm in the average adult).
◗ Length of inflatable bladder should be about 80% of upper arm circumference
(almost long enough to encircle the arm)
E XA M I N AT I O N T E C H N I Q U E S
Measuring Blood Pressure
◗ Center the inflatable bladder over the brachial artery. The lower border of
the cuff should be about 2.5 cm above the antecubital crease. Secure the cuff
snugly. Position the patient’s arm so that it is slightly flexed at the elbow.
◗ To determine how high to raise the cuff pressure, first estimate the systolic
pressure by palpation. As you feel the radial artery with the fingers of one
hand, rapidly inflate the cuff until the radial pulse disappears. Read this pres-
sure on the manometer and add 30 mm Hg to it. Use of this sum as the tar-
get for subsequent inflations prevents discomfort from unnecessarily high
cuff pressures. It also avoids the occasional error caused by an auscultatory
gap—a silent interval between the systolic and diastolic pressures.
◗ Deflate the cuff promptly.
◗ Now place the bell of a stethoscope lightly over the brachial artery, taking care
to make an air seal with its full rim. Because the sounds to be heard (Korotkoff sounds) are relatively low in pitch, they are heard better with the bell.
◗ Inflate the cuff rapidly again to the level just determined, and then deflate it
slowly, at a rate of about 2 to 3 mm Hg per second. Note the level at which you
hear the sounds of at least two consecutive beats. This is the systolic pressure. ◗ Continue to lower the pressure slowly. The disappearance point, usually only a
few mm Hg below the muffling point, is the best estimate of diastolic pressure. ◗ Read both the systolic and diastolic levels to the nearest 2 mm Hg. Wait 2 or
more minutes and repeat. Average your readings. If the first two readings
differ by more than 5 mm Hg, take additional readings.
◗ Take blood pressure in both arms at least once.
◗ In patients taking antihypertensive medications or with a history of fainting,
postural dizziness, or possible depletion of blood volume, take the blood
pressure in two positions—supine and standing (unless contraindicated). A
fall in systolic pressure of 20 mm Hg or more, especially when accompanied
by symptoms, indicates orthostatic (postural) hypotension.
Chapter 4 | Beginning the Physical Examination 55
Steps to Ensure Accurate Blood Pressure Recordings
◗ Ideally, ask the patient to avoid smoking or drinking caffeinated beverages for
30 minutes before the blood pressure is taken and to rest for at least 5 minutes.
◗ Make sure the examining room is quiet and comfortably warm.
◗ Make sure the arm selected is free of clothing. There should be no arterio- venous fistulas for dialysis, scarring from prior brachial artery cutdowns,
or signs of lymphedema (seen after axillary node dissection or radiation
therapy).
◗ Palpate the brachial artery to confirm that it has a viable pulse.
◗ Position the arm so that the brachial artery, at the antecubital crease, is at heart level—roughly level with the 4th interspace at its junction with the sternum.
◗ If the patient is seated, rest the arm on a table a little above the patient’s
waist; if standing, try to support the patient’s arm at the midchest level.
E XA M I N AT I O N T E C H N I Q U E S
56 Bates’ Pocket Guide to Physical Examination and History Taking
In 2003, the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (JNC) categorized four levels of systolic blood pressure (SBP) and diastolic blood pressure (DBP).
JNC VII Blood Pressure Classification for Adults
Category Systolic (mm Hg) Diastolic (mm Hg)
Normal <120 <80
Prehypertension 120–139 80–89
Stage 1 Hypertension 140–159 90–99
Stage 2 Hypertension ≥160 ≥100
If Diabetes or Renal Disease <130 <80
When the systolic and diastolic levels fall in different categories, use the higher category. For example, 170/92 mm Hg is Stage 2 hyper- tension; 135/100 mm Hg is Stage 1 hypertension. In isolated systolic hypertension, systolic blood pressure is ≥140 mm Hg, and diastolic blood pressure is <90 mm Hg.
Heart Rate. The radial pulse is used commonly to assess heart rate. With the pads of your index and middle fingers, compress the radial artery until you detect a maximal pulsa- tion. 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 car- diac apex (the apical pulse).
E XA M I N AT I O N T E C H N I Q U E S
Chapter 4 | Beginning the Physical Examination 57
Rhythm. Feel the radial pulse. Check the rhythm again by lis- tening 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 fibrilla- tion. For all irregular patterns, an ECG is needed to identify the arrhythmia.
Respiratory Rate and Rhythm. 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 tra- chea with your stethoscope dur- ing examination of the head and neck or chest. Normally, adults take 14 to 20 breaths per min- ute in a quiet, regular pattern.
See Table 4-5, p. 65, Abnormalities in
Rate and Rhythm of Breathing.
Temperature. Average oral temperature, usually 37°C (98.6°F), fluctuates considerably from the early morning to the late afternoon or evening. Rectal tem- peratures are higher than oral tem- peratures by about 0.4 to 0.5°C (0.7 to 0.9°F) but also vary.
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 include infection, trauma (such as surgery or crush injuries),
malignancy, blood disorders (such as
acute hemolytic anemia), drug reactions,
and immune disorders such as collagen
vascular disease.
The chief cause of hypothermia is expo- sure to cold. Other predisposing causes
include reduced movement as in paraly-
sis, interference with vasoconstriction as
from sepsis or excess alcohol, starvation,
hypothyroidism, and hypoglycemia.
Older adults are especially susceptible
to hypothermia and also less likely to
develop fever.
In contrast, axillary temperatures are lower than oral temperatures by approximately 1° but take 5 to 10 minutes to register and are considered less accurate than other measurements.
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
58 Bates’ Pocket Guide to Physical Examination and History Taking
Oral temperatures: Choose either glass or electronic thermometer.
● Glass thermometer: Shake the thermometer 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 : Care- fully place the disposable cover over the probe and insert the thermometer under the tongue for about 10 seconds.
Tympanic membrane tem- perature: Make sure the external auditory canal is free of cerumen. Position the probe in the canal. Wait 2 to 3 seconds until the dig- ital reading appears. This method measures core body temperature, which is higher than the normal oral temperature by approxi- mately 0.8°C (11.4°F).
Rectal temperatures: Ask the patient to lie on one side with the hip flexed. Select a rectal ther- mometer with a stubby tip, lubri- cate it, and insert it about 3 cm to 4 cm (1½ inches) into the anal canal, in a direction pointing to the umbilicus. Remove it after 3 min- utes, then read. Alternatively, use an electronic thermometer after lubricating the probe cover. Wait about 10 seconds for the digital temperature recording to appear.
Taking rectal temperatures is common
practice in unresponsive patients at risk
for biting down on the thermometer.
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
ACUTE AND CHRONIC PAIN
The experience of pain is complex and multifactorial. It involves sensory, emotional, and cognitive processing but may lack a specific physical etiology.
Chronic pain is defined in several ways: pain not associated with cancer or other medical 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.
Adopt a comprehensive approach, carefully listening to the patient’s description of the many features of pain and contributing factors. Accept the 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 specific 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.
Associated Features. Ask the patient to describe the pain and how it started. Pursue the seven features of pain, as you would with any symptom.
Attempted Treatments, Medications, Related Illnesses, and Impact on Daily Activities. 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 efficacy.
Identify any comorbid conditions such as arthritis, diabetes, HIV/AIDS, substance abuse, sickle cell disease, or psychiatric disorders. These can significantly affect the patient’s experience of pain.
Health Disparities. Be aware of the well-documented health dis- parities 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,
Chapter 4 | Beginning the Physical Examination 59
E XA M I N AT I O N T E C H N I Q U E S
60 Bates’ Pocket Guide to Physical Examination and History Taking
postoperative, and low back pain. Clinician stereotypes, language bar- riers, 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.
Pain Management. Monitor the effectiveness of pain interven- tions, especially narcotics, by assessing the “four As”: Analgesia, Activities of daily living, Adverse effects, and Aberrant drug-related behaviors. Risk of death from overdose of opioids rise four- to eight- fold for doses above 100 mg/day.
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. (Com- mon abbreviations for blood pressure, heart rate, and respiratory rate are self-explanatory.)
Recording the Physical Examination—General Sur vey and Vital Signs
◗ “Mrs. Scott is a young, healthy-appearing woman, well-groomed, fit, and in
good spirits. Height is 5′4″, weight 135 lb, BP 120/80, HR 72 and regular, RR 16, temperature 37.5°C.”
OR ◗ “Mr. Jones is an elderly man who looks pale and chronically ill. He is alert,
with good eye contact, but cannot speak more than two or three words at
a time because of shortness of breath. He has intercostal muscle retraction
when breathing and sits upright in bed. He is thin, with diffuse muscle wast-
ing. Height is 6′2″, weight 175 lbs, BP 160/95, HR 108 and irregular, RR 32 and labored, temperature 101.2°F.” (Suggests COPD exacerbation.)
RRReccoorddinnggg YYouuur FinnddinngssYY
E XA M I N AT I O N T E C H N I Q U E S
Aids to InterpretationAAAiddss ttoo Inntterrpprreetaattioonn
Eating Disorders and Excessively Low BMITable 4-1
Anorexia Nervosa Bulimia Nervosa
Refusal to maintain minimally normal body weight (or BMI above 17.5 kg/m2)
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
Associated with depressive symptoms such as depressed mood, irritability, social withdrawal, insomnia, decreased libido
Additional features supporting diagnosis: self-induced vomiting or purging, excessive exercise, use of appetite suppressants and/or diuretics
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
Repeated binge eating followed by self-induced vomiting, misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise
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; craving and compulsion to eat; lack of control over eating; alternating with periods of starvation
Dread of fatness but may be obese
Subtypes of ● 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 Classification 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: Lippincott Williams & Wilkins, 1663–1676, 2000. Mehler PS. Bulimia nervosa. N Engl J Med 2003;349(9):875–880.
Chapter 4 | Beginning the Physical Examination 61
62 Bates’ Pocket Guide to Physical Examination and History Taking
Table 4-2 Nutrition Screening Checklist
I have an illness or condition that made me change the kind and/or amount of food I eat.
Yes (2 pts) _________
I eat fewer than 2 meals per day. Yes (3 pts) _________
I eat few fruits or vegetables, or milk products.
Yes (2 pts) _________
I have 3 or more drinks of beer, liquor, or wine almost every day.
Yes (2 pts) _________
I have tooth or mouth problems that make it hard for me to eat.
Yes (2 pts) _________
I don’t always have enough money to buy the food I need.
Yes (4 pts) _________
I eat alone most of the time. Yes (1 pt) _________
I take 3 or more different prescribed or over-the-counter drugs each day.
Yes (1 pt) _________
Without wanting to, I have lost or gained 10 pounds in the last 6 months.
Yes (2 pts) _________
I am not always physically able to shop, cook, and/or feed myself.
Yes (2 pts) _________
TOTAL _________
Instructions: Check “yes” for each condition that applies, then total the nutritional score. For total scores between 3 and 5 points (moderate risk) or ≥6 points (high risk), further evaluation is needed (especially for the elderly).
Source: American Academy of Family Physicians. The Nutrition Screening Initiative. Available at: www.aafp.org/PreBuilt/NSI_DETERMINE.pdf. Accessed January 23, 2008.
Table 4-3 Nutrition Counseling: Sources of Nutrients
Nutrient Food Source
Calcium 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
Iron Lean meat, dark turkey meat, liver Clams, mussels, oysters, sardines, anchovies Iron-fortified cereals Enriched and whole grain bread Spinach, peas, lentil, turnip greens, peas, and
artichokes Dried prunes and raisins
Folate Cooked dried beans and peas Oranges, orange juice Liver Black-eyed peas, lentils, okra, chick peas, peanuts Folate-fortified cereals
Vitamin D Vitamin D–fortified milk Cod liver oil; salmon, mackerel, tuna Egg yolks, butter, margarine Vitamin D–fortified cereals
Source: Adapted from: Dietary Guidelines Committee, 2000 Report. Nutrition and Your Health: Dietary Guidelines for Americans. Washington, DC: Agricultural Research Service, U.S. Department of Agriculture, 2000; Choose MyPlate.gov. Available at http://www.choosemyplate.gov/index.html. Accessed June 24, 2011; Office of Dietary Supplements, National Institutes of Health. Dietary Supplement Fact Sheets: Calcium; Vitamin D. At http://ods.od.nih.gov/factsheets/list-all/. Accessed June 24, 2011.
Chapter 4 | Beginning the Physical Examination 63
64 Bates’ Pocket Guide to Physical Examination and History Taking
Table 4-4
Patients With Hypertension: Recommended Changes in Diet
Dietary Change Food Source
Increase foods high in potassium
Baked white or sweet potatoes White beans, beet greens, soybeans, spinach,
lentils, kidney beans Bananas, plantains, many dried fruits, orange
juice Tomato sauce, juice, and paste
Decrease foods high in sodium
Canned foods (soups, tuna fish) Pretzels, potato chips, pickles, olives
Many processed foods (frozen dinners, ketchup, mustard)
Batter-fried foods Table salt, including for cooking
Source: Adapted from Dietary Guidelines Committee. 2000 Report. Nutrition and Your Health: Dietary Guidelines for Americans. Washington, DC: Agricultural Research Service, U.S. Department of Agriculture, 2000. Choose MyPlate.gov. Available at http://www.choosemyplate.gov/index.html. Accessed June 24, 2011; Office of Dietary Supplements, National Institutes of Health. Dietary Supplement Fact Sheets: Calcium; Vitamin D. At http://ods.od.nih.gov/factsheets/list-all/. Accessed June 24, 2011.
Table 4-5
Abnormalities in Rate and Rhythm of Breathing
Normal. In adults, 14–20 per min; in infants, up to 44 per min.
Rapid Shallow Breathing (Tachypnea). Many causes, including restrictive lung disease, pleural 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, increased intracranial pressure.
Cheyne-Stokes Breathing. 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’s) Breathing. Unpredictable irregularity of depth and rate. Causes include brain damage and respiratory depression.
Sighing Breathing. Breathing punctuated by frequent sighs. When associated with other symptoms, it suggests the hyperventilation syndrome. Occasional sighs are normal.
Chapter 4 | Beginning the Physical Examination 65
67
C H A P T E R
5Behavior and Mental Status Empathic listening, careful observation, and skilled history tak- ing help patients to reveal their deepest concerns and experiences. Clinicians often miss clues to trauma, mental illness, and harmful dysfunctional behaviors. The prevalence of mental health disorders in the U.S. population is 30%, yet only approximately 20% of affected patients receive treatment. Even for patients who obtain care, evi- dence suggests that adherence to treatment guidelines in primary care offices is <50%.
Often, patients have health symptoms that mirror medical illnesses. Thirty percent of symptoms last more than 6 weeks and are “medically unexplained,” masking anxiety, depression, or even somatoform disorders. See Table 5-1, Somatoform Disorders: Types and Approach, pp. 76–78. Depression and anxiety are highly correlated with substance abuse, for example, and clinicians are advised to look for overlap in these conditions. “Difficult 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.
Mental Health Disorders and Unexplained Symptoms in Primary Care Settings
Mental Health Disorders in Primary Care
◗ Approximately 20% of primary care outpatients have mental disorders, but
up to 50% to 75% of these disorders are undetected and untreated.
◗ Prevalence of mental disorders in primary care settings is roughly:
◗ Anxiety—20%
◗ Mood disorders including dysthymia, depressive, and bipolar
disorders—25%
◗ Depression—10%
◗ Somatoform disorder—10% to 15%
◗ Alcohol and substance abuse—15% to 20%
(continued)
68 Bates’ Pocket Guide to Physical Examination and History Taking
For unexplained conditions lasting beyond 6 weeks, experts recom- mend brief screening questions with high sensitivity and specificity, followed by more detailed investigation when indicated due to high rates of coexisting depression and anxiety.
Mental Health Disorders and Unexplained Symptoms in Primary Care Settings (continued)
Explained and Unexplained Symptoms
◗ Physical symptoms account for approximately 50% of office visits.
◗ Roughly one-third of physical symptoms are unexplained; in 20% to 25% of
patients, physical symptoms become chronic or recurring.
◗ In patients with unexplained symptoms, the prevalence of depression and anxiety exceeds 50% and increases with the total number of reported physical
symptoms, making detection and “dual diagnosis” important clinical goals.
Common Functional Syndromes
◗ Co-occurrence rates for common functional syndromes such as irritable bowel syndrome, fibromyalgia, chronic fatigue, temporomandibular joint disorder,
and multiple chemical sensitivity reach 30% to 90%, depending on the dis-
orders compared.
◗ The prevalence of symptom overlap is high in the common functional syn- dromes: namely, complaints of fatigue, sleep disturbance, musculoskeletal
pain, headache, and gastrointestinal problems.
◗ The common functional syndromes also overlap in rates of functional
impairment, psychiatric comorbidity, and response to cognitive and
antidepressant therapy.
Patient Identifiers for Mental Health Screening
◗ Medically unexplained physical symptoms—more than half have a depressive
or anxiety disorder
◗ Multiple physical or somatic symptoms or “high symptom count”
◗ High severity of the presenting somatic symptom
◗ Chronic pain
◗ Symptoms for more than 6 weeks
◗ Physician rating as a “difficult encounter”
◗ Recent stress
◗ Low self-rating of overall health
◗ High use of health care services
◗ Substance abuse
Chapter 5 | Behavior and Mental Status 69
The Health History
Common or Concerning Symptoms
◗ Changes in attention, mood, or speech
◗ Changes in insight, orientation, or memory
◗ Anxiety, panic, ritualistic behavior, and phobias
◗ Delirium or dementia
Your assessment of mental status begins with the patient’s first 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 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).
TTThee HHeeaaltth HHiisstoryy
Terminology: The Mental Status Examination
Level of Consciousness Alertness or State of Awareness of the Environment
Attention The ability to focus or concentrate over time on one task or activity
Memory The process of registering or recording information. Recent or short-term memory covers minutes, hours, or days; remote or long-term memory refers to intervals of years.
Orientation Awareness of personal identity, place, and time; requires both memory and attention
Perceptions Sensory awareness of objects in the environment and their in- terrelationships; also refers to internal stimuli (e.g., dreams)
Thought processes
The logic, coherence, and relevance of the patient’s
thoughts, or how people think Thought content What the patient thinks about, including level of insight
and judgment
Insight Awareness that symptoms or disturbed behaviors are normal or abnormal
Judgment Process of comparing and evaluating alternatives; reflects values that may or may not be based on
reality and social conventions or norms
(continued)
70 Bates’ Pocket Guide to Physical Examination and History Taking
Assess level of consciousness, general appear- ance and mood, and ability to pay attention, remember, understand, and speak.
See Table 5-2, Disorders of
Mood, pp. 78–79.
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, preoccupa- tions, beliefs, or perceptions as they arise during the interview.
See Table 5-3, Anxiety Disor-
ders, pp. 80–81, and Table 5-4,
Selected Psychotic Disorders,
p. 82.
All patients with documented or suspected brain lesions, psychiatric symptoms, or reports from family members of vague or changed behavioral symptoms need further systematic assessment.
See Table 20-2, Delirium and
Dementia, pp. 391–392.
Terminology: The Mental Status Examination (continued)
Level of Consciousness Alertness or State of Awareness of the Environment
Affect An observable, usually episodic, feeling tone expressed through voice, facial expression, and demeanor
Mood A more sustained emotion that may color a person’s view of the world (affect is to mood as weather is to climate)
Language A complex symbolic system for expressing, receiving, and comprehending words; essential for assessing other
mental functions
Higher cognitive functions
Assessed by vocabulary, fund of information, abstract
thinking, calculations, construction of objects with two
or three dimensions
Mood Disorders and Depression. Lifetime prevalence of major depression meeting formal diagnostic criteria in the United States is approximately 7%. Primary care providers fail to diagnose major
Important Topics for Health Promotion and Counseling
◗ Screening for depression and suicidality
◗ Screening for alcohol, prescription drug, and substance abuse
Health Promotion and Counseling: Evidence and Recommendations
Chapter 5 | Behavior and Mental Status 71
depression in up to 50% of affected patients, often missing early clues such as low self-esteem, anhedonia (lack of pleasure in daily activities), sleep disorders, and difficulty 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?”
Suicide. Suicide rates are highest among men 75 years and older and are increasing among teenagers and young adults. More than half of patients committing suicide have visited their physicians in the prior month. More than 90% of suicide deaths occur in patients with depression or other mental health disorders or substance abuse. Risk factors include 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 admis- sion); substance abuse; personality disorder; and prior history or family history of suicide. Patients with these risk factors should be immediately referred for psychiatric care and possibly hospitalization.
Alcohol, Prescription Drug, and Substance Abuse. The comor- bidity of alcohol and substance abuse with mental health disorders and suicide are extensive. Alcohol, tobacco, and illicit drugs account for more illness, deaths, and disabilities than any other preventable condi- tion. Lifetime prevalence of alcohol and illicit drug use in the United States is 13% and 3%. In recent U.S. surveys, 8% of those 12 years or older, or 19 million people, reported use of illicit drugs in the prior 30 days. An estimated 3% are dependent on or abuse illicit drugs; of these, 60% use marijuana. 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
The Mental Status Examination
◗ Appearance and behavior
◗ Speech and language
◗ Mood
◗ Thoughts and perceptions
◗ Cognition, including memory, attention, information and vocabulary,
calculations, abstract thinking, and constructional ability
72 Bates’ Pocket Guide to Physical Examination and History Taking
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
Observe patient’s mental status throughout your interaction. Test specific functions if indicated during the interview or physical examination.
APPEARANCE AND BEHAVIOR
Assess the following: ● Level of Consciousness. Observe alertness and response to verbal and tactile stimuli.
Normal consciousness, lethargy,
obtundation, stupor, coma (see
p. 304–305)
● Posture and Motor Behavior. Observe pace, range, character, and appropriateness of movements.
Restlessness, agitation, bizarre
postures, immobility, involuntary
movements
● Dress, Grooming, and Personal Hygiene
Fastidiousness, neglect
● Facial Expressions. Assess during rest and interaction.
Anxiety, depression, elation, anger,
responses to imaginary people or
objects, withdrawal
● Manner, Affect, and Relation to People and Things
SPEECH AND LANGUAGE
Note quantity, rate, loudness, clarity, and fluency of speech. If indicated, test for aphasia.
Aphasia, dysphonia, dysarthria,
changes with mood disorders
Testing for Aphasia
Word Comprehension Ask patient to follow a one-stage command, such as “Point to your nose.” Try a two-stage
command: “Point to your mouth, then your
knee.”
Repetition Ask patient to repeat a phrase of one-syllable words (the most difficult repetition task):
“No ifs, ands, or buts.”
Naming Ask patient to name the parts of a watch. Reading Comprehension Ask patient to read a paragraph aloud. Writing Ask patient to write a sentence.
Chapter 5 | Behavior and Mental Status 73
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
MOOD
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
THOUGHT AND PERCEPTIONS
Thought Processes. Assess logic, rel- evance, organization, and coherence.
Derailments, flight of ideas, incoher-
ence, 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,
impulsive, or unrealistic judgment
COGNITIVE FUNCTIONS
If indicated, assess:
Orientation to time, place, and person Disorientation
Attention
● Digit span—ability to repeat a series of numbers forward and then backward
● Serial 7s—ability to subtract 7 repeatedly, starting with 100
● Spelling backward of a five-letter word, such as W-O-R-L-D
Poor performance of digit span,
serial 7s, and spelling backward are
common in dementia and delirium
but have other causes, too.
Remote Memory (e.g., birthdays, anniversaries, social security number, schools, jobs, wars)
Impaired in late stages of dementia
74 Bates’ Pocket Guide to Physical Examination and History Taking
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
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
Recent memory and new learning
ability impaired in dementia, delir-
ium, and amnestic disorders
HIGHER COGNITIVE FUNCTIONS
If indicated, assess:
Information and Vocabulary. Note range and depth of patient’s informa- tion, complexity of ideas expressed, and vocabulary used. For the fund of information, ask names of presidents, other political figures, or large cities.
These attributes reflect intelligence,
education, and cultural background.
They are limited by mental retarda-
tion but are fairly well preserved in
early dementia.
Calculating Abilities, such as addi- tion, subtraction, and multiplication
Poor calculation in mental
retardation and dementia
Abstract Thinking—ability to respond abstractly to questions about
● 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
Concrete responses (observable
details rather than concepts) are
common in mental retardation,
dementia, and delirium. Responses
are sometimes bizarre in schizo-
phrenia.
Constructional Ability. Ask patient: Impaired ability common in demen- tia and with parietal lobe damage
● To copy figures such as circle, cross, diamond, and box, and two intersecting pentagons, or
● To draw a clock face with numbers and hands
SPECIAL TECHNIQUE
Mini-Mental State Examination (MMSE). 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.
Chapter 5 | Behavior and Mental Status 75
MMSE Sample Items
Orientation to Time “What is the date?”
Registration “Listen carefully; I am going to say three words. You say them back after I
stop. Ready? Here they are . . .
HOUSE (pause), CAR (pause), LAKE (pause). Now repeat those words back o
me.” [Repeat up to five times, but score only the first trial.]
Naming “What is this?” [Point to a pencil or pen.]
Reading “Please read this and do what it says.” [Show examinee the words on the
stimulus form.]
CLOSE YOUR EYES
Reproduced by special permission of the Publisher, Psychological Assessment Resources,
Inc., 16204 North Florida Avenue, Lutz, FL 33549, from the Mini Mental State Examination,
by Marshal Folstein and Susan Folstein, Copyright 1975, 1998, 2001 by Mini Mental LLC, Inc.
Published 2001 by Psychological Assessment Resources, Inc. Further reproduction is
prohibited without permission of PAR, Inc. The MMSE can be purchased from PAR, Inc.
Recording Your FindingsRRReccoorddinnggg YYouuur Finnddinngss
Recording Behavior and Mental Status
“Mental Status: The patient is alert, well-groomed, and cheerful. Speech is fluent and words are clear. Thought processes are coherent, insight is good.
The patient is oriented to person, place, and time. Serial 7s accurate; recent
and remote memory intact. Calculations intact.”
OR “Mental Status: The patient appears sad and fatigued; clothes are wrinkled. Speech is slow and words are mumbled. Thought processes are coherent, but
insight into current life reverses is limited. The patient is oriented to person,
place, and time. Digit span, serial 7s, and calculations accurate, but responses
delayed. Clock drawing is good.” (Suggests depression)
E XA M I N AT I O N T E C H N I Q U E S
76 Bates’ Pocket Guide to Physical Examination and History Taking
Aids to InterpretationAAAiddss ttoo IInntterrpprreetaattioonn
Somatoform Disorders: Types and Approach to SymptomsTable 5-1
Types of Somatoform Disorders Somatoform Disorders*
Disorder Features
Somatization disorder
Chronic multisystem disorder characterized by complaints of pain, gastrointestinal and sexual dysfunction, and pseudoneurologic symptoms. Onset is usually early in life, and psychosocial and vocational achievements are limited.
Conversion disorder Syndrome of symptoms of deficits mimicking neurologic or medical illness in which psychological factors are judged to be of etiologic importance
Pain disorder Clinical syndrome characterized predominantly by pain in which psychological factors are judged to be of etiologic importance
Hypochondriasis Chronic preoccupation with the idea of having a serious disease. The preoccupation is usually poorly amenable to reassurance
Body dysmorphic disorder
Preoccupation with an imagined or exaggerated defect in physical appearance
Other Somatoform-like Disorders
Factitious disorder Intentional production or feigning of physical or psychological signs when external reinforcers (e.g., avoidance of responsibility, financial gain) are not clearly present
Malingering Intentional production or feigning of physical or psychological signs when external reinforcers (e.g., avoidance of responsibility, financial gain) are present
Dissociative disorders
Disruptions of consciousness, memory, identity, or perception judged to be due to psychological factors
Approach to Somatic and Unexplained Symptoms
Stepped Care Approach to Somatic Symptoms in Primary Care†
Is the somatic symptom likely to be . . . Clinician action might be . . .
Acutely serious? (<5% of cases)
Expedited diagnostic workup
Minor/self-limited? (70%–75% of cases)
Address patient expectations Symptom-specific therapy Follow-up in 2–6 weeks
Chapter 5 | Behavior and Mental Status 77
Is the somatic symptom likely to be . . . Clinician action might be . . .
Chronic or recurrent? (20%– 25% of cases)
Screen for depression and anxiety
Caused or aggravated by a depressive or anxiety disorder?
Antidepressant therapy and/or cognitive–behavioral therapy (CBT)
Due to a functional somatic syndrome?
Syndrome-specific therapy Antidepressant therapy and/or CBT
Persistent and medically unexplained?
Regular, time-limited clinic visits Consider mental health referral Symptom management strategies, if evidence-based
(e.g., behavioral treatments, pain self-management programs, pain or other specialty clinics, complementary and alternative medicine)
Rehabilitative rather than disability approach
Management Guidelines for Patients With Medically Unexplained Symptoms‡
General Aspects Show empathy and understanding for the complaints and frustrating experiences the patient has had so far (e.g., explain that medically unexplained symptoms are common).
Develop a good patient–physician relationship; try to be the “coordinator” of diagnostic procedures and care.
Diagnosis Explore not only the history of complaints and former treatments, but any impairment, anxiety, and psychosocial issues.
Use screeners and self-report questionnaires to enhance detection; use symptom diaries to assess course and factors influencing symptoms.
When the patient presents with a new symptom, examine the relevant organ system.
Provide the results of investigations to give clear reassurance that there is no serious physical disease.
Avoid unnecessary diagnostic tests or surgical procedures. Treatment Provide regularly scheduled visits (e.g., every 4–6
weeks), especially in the case of a history of very frequent healthcare utilization.
Explain that treatment is coping, not curing (when pathology cannot be found or does not explain degree of complaints).
Somatoform Disorders: Types and Approach to Symptoms (continued)Table 5-1
(continued)
78 Bates’ Pocket Guide to Physical Examination and History Taking
Is the somatic symptom likely to be . . . Clinician action might be . . .
Referral Suggest coping strategies like regular physical activity, relaxation, distraction.
If referral is necessary to start psychotherapy or psychopharmacotherapy, prepare the patient for the treatment and provide reassurance that you will continue to be the patient’s doctor.
Sources: *Schiffer RB. Psychiatric disorders in medical practice. In: Goldman L, Ausiello D, eds. Cecil Textbook of Medicine. 22nd ed. Philadelphia: Saunders 2004, pp. 2628–2639; †Kroenke K. Patients presenting with somatic complaints: epidemiology, psychiatric comorbidity, and management. Int J Methods Psychiatr Res 2003;12(1):34–43. ‡Reif W, Martin A, Rauh E, et al. Evaluation of general practitioners’ training: how to manage patients with unexplained physical symptoms. Psychosomatics 2006;47(4):304–311.
Somatoform Disorders: Types and Approach to Symptoms (continued)Table 5-1
Disorders of MoodTable 5-2
Major Depressive Episode Manic Episode
At least five of the symptoms listed below (including one of the first two) must be present during the same 2-week period; they must represent a change from the person’s previous state.
● Depressed mood (may be an irritable mood in children and adolescents) most of the day, nearly every day
● Markedly diminished interest or pleasure in almost all activities most of the day, nearly every day
● Significant weight gain or loss (not dieting) or increased or decreased appetite nearly every day
A distinct period of abnormally and persistently elevated, expansive, or irritable mood must be present for at least a week (any duration if hospitalization is necessary). During this time, at least three of the symptoms listed below have been persistent and significant. (Four symptoms are required if the mood is only irritable.)
● Inflated self-esteem or grandiosity ● Decreased need for sleep (feels rested after sleeping 3 hours)
● More talkative than usual or pressure to keep talking
Chapter 5 | Behavior and Mental Status 79
Disorders of Mood (continued)Table 5-2
Major Depressive Episode Manic Episode ● Insomnia or hypersomnia nearly every day
● Psychomotor agitation or retardation nearly every day
● Fatigue or loss of energy nearly every day
● Feelings of worthlessness or inappropriate guilt nearly every day
● Inability to think or concentrate or indecisiveness nearly every day
● Recurrent thoughts of death or suicide, or a specific plan for or attempt at suicide
The symptoms cause significant distress or impair social, occupational, or other important functions. In severe cases, hallucinations and delusions may occur.
● Flight of ideas or racing thoughts ● Distractibility ● Increased goal-directed activity (either socially at work or school, or sexually) or psychomotor agitation
● Excessive involvement in pleasurable high-risk activities (buying sprees, foolish business ventures, sexual indiscretions)
The disturbance is severe enough to impair social or occupational functions or relationships. It may necessitate hospitalization for the protection of self or others. In severe cases, hallucinations and delusions may occur.
Mixed Episode Hypomanic Episode
A mixed episode, which must last at least 1 week, meets the criteria for both major and manic depressive episodes.
The mood and symptoms resemble those in a manic episode but are less impairing, do not require hospitalization, do not include hallucinations or delusions, and have a shorter minimum duration—4 days.
Dysthymic Disorder Cyclothymic Episode
A depressed mood and symptoms for most of the day, for more days than not, over at least 2 years (1 year in children and adolescents). Freedom from symptoms lasts no more than 2 months at a time.
Numerous periods of hypomanic and depressive symptoms that last for at least 2 years (1 year in children and adolescents). Freedom from symptoms lasts no more than 2 months at a time.
Tables 5-2 to 5-4 are based, with permission, on the Diagnostic and Statistical Manual of Mental Disorders, 4th ed., Text Revision [DSM IV-TR]. Washington, DC: American Psychiatric Association, 2000. For further details and criteria, the reader should consult this manual, its successor, or comprehensive textbooks of psychiatry.
80 Bates’ Pocket Guide to Physical Examination and History Taking
Anxiety DisordersTable 5-3
Panic Disorder. Recurrent, unexpected panic attacks, at least one of which has been followed by a month or more of persistent concern about further attacks, worry over their implications or consequences, or a significant change in behavior in relation to the attacks.
A panic attack is a discrete period of intense fear or discomfort that develops abruptly and peaks within 10 minutes. It involves at least four of the following symptoms: (1) palpitations, pounding heart, or accelerated heart rate; (2) sweating; (3) trembling or shaking; (4) shortness of breath or a sense of smothering; (5) a feeling of choking; (6) chest pain or discomfort; (7) nausea or abdominal distress; (8) feeling dizzy, unsteady, lightheaded, or faint; (9) feelings of unreality or depersonalization; (10) fear of losing control or going crazy; (11) fear of dying; (12) paresthesias (numbness or tingling); and (13) chills or hot flushes.
Agoraphobia. Anxiety about being in places or situations where escape may be difficult or embarrassing or help for sudden symptoms unavailable. Such situations are avoided, require a companion, or cause marked anxiety.
Specific Phobia. A marked, persistent, and excessive or unreasonable fear that is cued by the presence or anticipation of a specific object or situation, such as dogs, injections, or flying. The person recognizes the fear as excessive or unreasonable, but exposure to the cue provokes immediate anxiety. Avoidance or fear impairs the person’s normal routine, occupational or academic functioning, or social activities or relationships.
Social Phobia. A marked, persistent fear of one or more social or performance situations that involve exposure to unfamiliar people or to scrutiny by others. Those afflicted fear that they will act in embarrassing or humiliating ways, as by showing their anxiety. Exposure creates anxiety and possibly a panic attack, and the person avoids precipitating situations. He or she recognizes the fear as excessive or unreasonable. Normal functioning, social activities, or relationships are impaired.
Chapter 5 | Behavior and Mental Status 81
Anxiety Disorders (continued)Table 5-3
Obsessive–Compulsive Disorder. Obsessions or compulsions that cause marked anxiety or distress. Although recognized as excessive or unreasonable, they are time-consuming and interfere with the person’s normal routine and relationships.
Acute Stress Disorder. Exposure to a traumatic event that involved actual or threatened death or serious injury to self or others, leading to intense fear, helplessness, or horror. During or immediately after this event, the person has at least three dissociative symptoms: (1) a subjective sense of numbing, detachment, or absence of emotional responsiveness; (2) a reduced awareness of surroundings, as in a daze; (3) feelings of unreality; (4) feelings of depersonalization; and (5) amnesia for an important part of the event. The event is persistently reexperienced, as in thoughts, images, dreams, illusions, and flashbacks. The person is anxious, shows increased arousal, and avoids stimuli that evoke memories of the event. Causes marked distress or impairs social, occupational, or other important functions. Symptoms occur within 4 weeks of the event and last from 2 days to 4 weeks.
Posttraumatic Stress Disorder. The event, fearful response, and persistent reexperiencing of the traumatic event resemble acute stress disorder. Hallucinations may occur. The person has increased arousal, tries to avoid stimuli related to the trauma, and has numbing of general responsiveness. Causes marked distress and impaired social or occupational function, and lasts for more than a month.
Generalized Anxiety Disorder. Lacks a specific traumatic event or focus for concern. Excessive anxiety and worry are hard to control and generalize to a number of events or activities. At least three of the following symptoms are associated: (1) feeling restless, keyed up, or on edge; (2) being easily fatigued; (3) difficulty in concentrating or mind going blank; (4) irritability; (5) muscle tension; and (6) difficulty in falling or staying asleep, or restless, unsatisfying sleep. Causes significant distress or impairs daily function.
82 Bates’ Pocket Guide to Physical Examination and History Taking
Selected Psychotic DisordersTable 5-4
Schizophrenia. Impairs major functioning at work or school, in interpersonal relations, or in self-care. Performance of one or more of these functions must decrease for a significant time to a level markedly below prior achievement. Person displays at least two of the following for a significant part of 1 month: (1) delusions; (2) hallucinations; (3) disorganized speech; (4) grossly disorganized or catatonic behavior; and (5) negative symptoms such as a flat affect, alogia (lack of content in speech), or avolition (lack of interest, drive, and ability to set and pursue goals). Continuous signs of the disturbance must persist for at least 6 months.
Subtypes of this disorder include paranoid, disorganized, and catatonic schizophrenia.
Schizophreniform Disorder. Symptoms are similar to those of schizophrenia but last <6 months. Functional impairment need not be present.
Schizoaffective Disorder. Features both a major mood disturbance and schizophrenia. Mood disturbance (depressive, manic, or mixed) present during most of the illness and must, for a time, be concurrent with symptoms of schizophrenia and demonstrate delusions or hallucinations for at least 2 weeks without prominent mood symptoms.
Delusional Disorder. Nonbizarre delusions involve situations in real life, such as having a disease, and persists for at least a month. Functioning is not markedly impaired and behavior is not obviously odd or bizarre. Symptoms of schizophrenia, except for tactile and olfactory hallucinations, are not present.
Brief Psychotic Disorder. At least one of the following psychotic symptoms must be present: delusions, hallucinations, disordered speech such as frequent derailment or incoherence, or grossly disorganized or catatonic behavior. Disturbance lasts ≥1 day but <1 month, and person returns to prior functional level.
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C H A P T E R
6The Skin, Hair, and Nails The Health History
Common or Concerning Symptoms
◗ Hair loss
◗ Rash
◗ Growths
Health Promotion and Counseling: Evidence and Recommendations
Important Topics for Health Promotion and Counseling
◗ Skin cancers: types and risk factors
◗ Avoidance of excessive sun exposure
Counsel patients to avoid unnecessary sun exposure, tanning beds, and sunlamps and to use sunscreen with at least SPF-15. It is helpful to show patients pictures of basal cell carcinomas, squamous cell carci- nomas and melanomas (pp. 94–95).
Teach the ABCDE screen for dysplastic nevi/melanomas: Asymmetry, irregular Borders, variation in Color, Diameter ≥6 mm, and Evolution or change in size, symptoms, or morphology. Survey skin at 3-year intervals for patients 20 to 40 years of age and annually for patients older than 40 years. For those older than age 50 or with dysplastic nevi or history of melanoma, encourage monthly self-examination and do regular clinical screening.
84 Bates’ Pocket Guide to Physical Examination and History Taking
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
SKIN Examine the entire skin surface under good lighting.
Inspect and palpate any growths.
Note: ● Color
● Moisture
● Temperature
● Texture
● Mobility—ease with which a fold of skin can be moved
● Turgor—speed with which the fold returns into place
Cyanosis, jaundice, carotenemia,
changes in melanin
Dry, oily
Cool, warm
Smooth, rough
Decreased if edema
Decreased if dehydration
Note any lesions and their: ● Anatomical location and distribution
● Patterns and shapes
● Type
● Color
Generalized, localized
Linear, clustered, dermatomal
Macule, papule, pustule, bulla, tumor
Red, white, brown, heliotrope
Techniques of Examination
Chapter 6 | The Skin, Hair, and Nails 85
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
HAIR
Inspect and palpate the hair.
Note: ● Quantity
● Distribution
● Texture
Thin, thick
Patchy or total alopecia
Fine, coarse
NAILS
Inspect and palpate the fingernails and toenails.
Note: ● Color
● Shape
● Any lesions
Cyanosis, pallor
Clubbing
Paronychia, onycholysis
Recording the Physical Examination—The Skin
Recording Your Findings
“Color pink. Skin warm and moist. Nails without clubbing or cyanosis. No
suspicious nevi, rash, petechiae, or ecchymoses.”
86 Bates’ Pocket Guide to Physical Examination and History Taking
Aids to Interpretation
Color/Mechanism Selected Causes
Brown: Increased melanin (greater than a person’s genetic norm)
Sun exposure Pregnancy (melasma) Addison’s disease
Blue (cyanosis): Increased deoxyhemoglobin
from hypoxia: ● Peripheral ● Central (arterial)
Anxiety or cold environment Heart or lung disease
Abnormal hemoglobin Methemoglobinemia, sulfhemoglobinemia
Red: Increased visibility of oxyhemoglobin from:
● Dilated superficial blood vessels or increased blood flow in skin
● Decreased use of oxygen in skin
Fever, blushing, alcohol intake, local inflammation
Cold exposure (e.g., cold ears)
Yellow: Increased bilirubin of jaundice
(sclera looks yellow)
Carotenemia (sclera does not look yellow)
Liver disease, hemolysis of red blood cells
Increased carotene intake from yellow fruits and vegetables
Pale: Decreased melanin
Decreased visibility of oxyhemoglobin from:
● Decreased blood flow to skin ● Decreased amount of oxyhemoglobin
Edema (may mask skin pigments)
Albinism, vitiligo, tinea versicolor
Syncope or shock Anemia
Nephrotic syndrome
Color Changes in the SkinTable 6-1
Chapter 6 | The Skin, Hair, and Nails 87
Primary Skin LesionsTable 6-2
Flat, Nonpalpable Lesions With Changes in Skin Color
Macule—Small flat spot, up to 1.0 cm
Examples: ● Hemangioma ● Vitiligo
Patch—Flat spot, 1.0 cm or larger Example: Café-au-lait spot
Palpable Elevations: Solid Bumps
Papule—Up to 1.0 cm Example: An elevated nevus
(continued)
88 Bates’ Pocket Guide to Physical Examination and History Taking
Table 6-2 Primary Skin Lesions (continued)
Plaque—Elevated superficial lesion 1.0 cm or larger, often formed by coalescence of papules
Example: Psoriasis
Nodule—Knot-like lesion larger than 0.5 cm, deeper and more firm than a papule
Example: Dermatofibroma
Cyst—Nodule filled with expressible material, either liquid or semisolid
Example: Epidermal inclusion cyst
Wheal—A somewhat irregular, relatively transient, superficial area of localized skin edema
Examples: Mosquito bite, hives (urticaria)
Chapter 6 | The Skin, Hair, and Nails 89
Table 6-2 Primary Skin Lesions (continued)
Palpable Elevations With Fluid-Filled Cavities
Vesicle—Up to 1.0 cm; filled with serous fluid
Example: Herpes simplex
Example: Herpes zoster
Bulla—1.0 cm or larger; filled with serous fluid
Example: Insect bite
Example: Insect bite
Pustule—Filled with pus (yellow proteinaceous fluid filled with neutrophils)
Example: Acne
(continued)
90 Bates’ Pocket Guide to Physical Examination and History Taking
Table 6-2 Primary Skin Lesions (continued)
Example: Small pox
Burrow—A minute, slightly raised tunnel in the epidermis, commonly found on the finger webs and on the sides of the fingers. It looks like a short (5–15 mm), linear or curved gray line and may end in a tiny vesicle. With a magnifying lens, look for the burrow of the mite that causes scabies.
Example: Scabies
Table 6-3 Secondary Skin Lesions
May arise from primary lesions, overtreatment, excess scratching
Scale—A thin flake of dead, exfoliated epidermis
Example: Ichthyosis vulgaris
Example: Dry skin
Chapter 6 | The Skin, Hair, and Nails 91
Table 6-3 Secondary Skin Lesions (continued)
Crust—The dried residue of skin exudates such as serum, pus, or blood
Example: Impetigo
Lichenification—Visible and palpable thickening of the epidermis and roughening of the skin with increased visibility of the normal skin furrows (often from chronic rubbing)
Example: Neurodermatitis
Scars—Increased connective tissue that arises from injury or disease
Example: Hypertrophic scar from steroid injections
Keloids—Hypertrophic scarring that extends beyond the borders of the initiating injury
Example: Keloid—ear lobe
Sources of photos: Hemangioma, Café-au-Lait Spot, Elevated Nevus, Psoriasis [bottom], Dermatofibroma, Herpes Simplex, Insect Bite [bottom], Impetigo, Lichenification—Hall JC. Sauer’s Manual of Skin Diseases, 9th ed. Philadelphia: Lippincott Williams & Wilkins, 2006; Vitiligo, Psoriasis [top], Epidermal Inclusion Cyst, Urticaria, Insect Bite [top], Acne, Ichthyosis, Psoriasis, Acne Scar, Keloids— Goodheart HP. Goodheart’s Photoguide of Common Skin Disorders: Diagnosis and Management, 2nd ed. Philadelphia: Lippincott Williams & Wilkins, 2003; Small Pox—Ostler HB, Mailbach HI, Hoke AW, Schwab IR. Diseases of the Eye and Skin: A Color Atlas. Philadelphia: Lippincott Williams & Wilkins, 2004.
92 Bates’ Pocket Guide to Physical Examination and History Taking
Table 6-4 Secondary Skin Lesions—Depressed
Erosion—Nonscarring loss of the superficial epidermis; surface is moist but does not bleed
Example: Aphthous stomatitis, moist area after the rupture of a vesicle, as in chickenpox
Excoriation—Linear or punctate erosions caused by scratching
Example: Cat scratches
Fissure—A linear crack in the skin, often resulting from excessive dryness
Example: Athlete’s foot
Ulcer—A deeper loss of epidermis and dermis; may bleed and scar
Examples: Stasis ulcer of venous insufficiency, syphilitic chancre
Sources of photos: Erosion, Excoriation, Fissure—Goodheart HP. Goodheart’s Photoguide of Common Skin Disorders: Diagnosis and Management, 2nd ed. Philadelphia: Lippincott Williams & Wilkins, 2003; Ulcer—Hall JC. Sauer’s Manual of Skin Diseases, 9th ed. Philadelphia: Lippincott Williams & Wilkins, 2006.
Chapter 6 | The Skin, Hair, and Nails 93
Table 6-5 Vascular and Purpuric Lesions of the Skin
Lesion Features: Appearance; Distribution; Significance
Cherry Angioma ● 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
Spider Angioma ● 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
Spider Vein ● 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
Petechia/Purpura ● 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
(continued)
94 Bates’ Pocket Guide to Physical Examination and History Taking
Table 6-5 Vascular and Purpuric Lesions of the Skin (continued)
Lesion Features: Appearance; Distribution; Significance
Ecchymosis ● 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
Table 6-6 Skin Tumors
Actinic Keratoses Superficial, flattened papules covered by a dry scale. Often multiple; may be round or irregular; pink, tan, or grayish. Appear on sun- exposed skin of older, fair-skinned persons. Considered dysplastic or precancerous: 1 out of 1,000 per year develop into squamous cell carcinoma (look for continued growth, induration, redness at the base, and ulceration). Typically on face and hands.
Seborrheic Keratoses Common, benign, whitish-yellowish to brown, raised papules or plaques that feel slightly greasy, velvety or warty; have a “stuck-on” appearance. Typically multiple and symmetrical, distributed on the trunk of older people, also on the face and elsewhere. In blacks, may appear as small, deeply pigmented papules on cheeks and temples (dermatosis papulosa nigra).
Chapter 6 | The Skin, Hair, and Nails 95
Table 6-6 Skin Tumors (continued)
Basal Cell Carcinoma Though malignant, grows slowly and almost never metastasizes. Most common in fair-skinned adults 40 years or older; usually on the face. Initial translucent red macule or papule may develop a depressed center and firm elevated border. Telangiectatic vessels often visible.
Squamous Cell Carcinoma Usually on sun-exposed skin of fair-skinned adults 60 years or older. May develop in an actinic keratosis. Usually grows more quickly than a basal cell carcinoma, is firmer, and looks redder. The face and the dorsum of the hand are often affected.
Kaposi’s Sarcoma in AIDS May appear in many forms: macules, papules, plaques, or nodules almost anywhere on the body. Lesions are often multiple and may involve internal structures.
Sources of photos: Basal Cell Carcinoma: Rapini R. Squamous Cell Carcinoma, Actinic Keratosis, and Seborrheic Keratosis—Hall JC. Sauer’s Manual of Skin Diseases, 9th ed. Philadelphia: Lippincott Williams & Wilkins, 2006; Kaposi’s Sarcoma in AIDS— DeVita VT Jr, Hellman S, Rosenberg SA [eds]. AIDS: Etiology, Diagnosis, Treatment, and Prevention. Philadelphia: JB Lippincott, 1985.
96 Bates’ Pocket Guide to Physical Examination and History Taking
Table 6-7 Benign and Malignant Nevi
Benign
Diameter <6 mm Symmetric; regular borders; even in color
Malignant Melanoma: “ABCDE”
Asymmetric
Borders irregular
Color varied Diameter >6 mm Evolution or change in size, symptoms or
morphology
Courtesy of American Cancer Society; American Academy of Dermatology.
Chapter 6 | The Skin, Hair, and Nails 97
Table 6-8 Hair Loss
Alopecia Areata Clearly demarcated round or oval patches of hair loss, usually affecting young adults and children. There is no visible scaling or inflammation.
Trichotillomania Hair loss from pulling, plucking, or twisting hair. Hair shafts are broken and of varying lengths. More common in children, often in settings of family or psychosocial stress.
Tinea Capitis (“Ringworm”) Round scaling patches of alopecia. Hairs are broken off close to the surface of the scalp. Usually caused by fungal infection from Trichophyton tonsurans from humans, microsporum canis from dogs or cats. Mimics seborrheic dermatitis.
Sources of photos: Alopecia Areata [top], Trichotillomania [top]—Hall JC. Sauer’s Manual of Skin Diseases, 9th ed. Philadelphia: Lippincott Williams & Wilkins, 2006; Alopecia Areata [bottom], Tinea Capitis—Goodheart HP. Goodheart’s Photoguide of Common Skin Disorders: Diagnosis and Management, 2nd ed. Philadelphia: Lippincott Williams & Wilkins, 2003; Trichotillomania [bottom]—Ostler HB, Mailbach HI, Hoke AW, Schwab IR. Diseases of the Eye and Skin: A Color Atlas. Philadelphia: Lippincott Williams & Wilkins, 2004.
98 Bates’ Pocket Guide to Physical Examination and History Taking
Table 6-9 Findings in or Near the Nails
Clubbing Dorsal phalanx rounded and bulbous; convexity of nail plate increased. Angle between plate and proximal nail fold increased to 180° or more. Proximal nail folds feel spongy. Many causes, including chronic hypoxia and lung cancer.
Paronychia Inflammation of proximal and lateral nail folds, acute or chronic. Folds red, swollen, may be tender.
Onycholysis Painless separation of nail plate from nail bed, starting distally. Many causes.
Terry’s Nails Whitish with a distal band of reddish brown. Seen in aging and some chronic diseases.
Leukonychia White spots caused by trauma. They grow out with nail(s).
Transverse White Lines
Curved white lines similar to curve of lunula. They follow an illness and grow out with nails.
99
C H A P T E R
7The Head and Neck The Health History
Common or Concerning Symptoms
THE HEAD
Headache is a common symp- tom that always requires careful evaluation because a small frac- tion 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. 111, and Table 7-2, Secondary Head-
aches, pp. 112–114. Tension and migraine headaches are the most common recurring headaches.
Is the headache one-sided or bilateral? 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 head-
aches increase the likelihood of tumor, abscess, or other mass lesion. Extremely severe headaches suggest subarachnoid hemorrhage or meningitis.
TTThee HHeeaaltth HHiisstoryy
◗ Nosebleed, or epistaxis
◗ Sore throat, hoarseness
◗ Swollen glands
◗ Goiter
◗ Headache
◗ Change in vision
◗ Double vision, or diplopia
◗ Hearing loss, earache, tinnitus
◗ Vertigo
100 Bates’ Pocket Guide to Physical Examination and History Taking
● Ask about associated symptoms, such as nausea and vomiting, and neurologic symptoms such as change in vision or motor- sensory deficits.
Visual aura or scintillating scotomas may
accompany migraine. Nausea and vomit- ing are common with migraine but also
occur with brain tumor and subarachnoid hemorrhage.
● Ask if coughing, sneezing, or changing the position of the head affects (better, worse, or none) the headache.
Such maneuvers may increase pain from
brain tumor and acute sinusitis.
● Ask about family history. Family history is often positive in patients with migraine.
THE EYES
Ask “How is your vision?” If the patient reports a change in vision, pursue the related details:
Gradual blurring, often from refractive
errors; also in hyperglycemia.
● Is the onset sudden or gradual?
Sudden visual loss suggests retinal detachment, vitreous hemorrhage, or occlusion of the central retinal artery.
● Is the problem worse during close work or at distances?
Difficulty with close work suggests hyper- opia (farsightedness) or presbyopia (aging vision); difficulty with distances suggests
myopia (nearsightedness).
● Is there blurring of the entire field of vision or only parts? Is blurring central, peripheral, or only on one side?
Slow central loss occurs in nuclear cataract and macular degeneration; peripheral loss in advanced open-angle glaucoma; one-sided loss in hemianopsia and quadrantic defects (p. 115).
Headache Warning Signs
◗ Progressively frequent or severe over a 3-month period
◗ Sudden onset like a “thunderclap” or “the worst headache of my life”
◗ New onset after age 50 years
◗ Aggravated or relieved by change in position
◗ Precipitated by Valsalva maneuver
◗ Associated symptoms of fever, night sweats, or weight loss
◗ Presence of cancer, HIV infection, or pregnancy
◗ Recent head trauma
◗ Associated papilledema, neck stiffness, or focal neurologic deficits
Chapter 7 | The Head and Neck 101
● Has the patient seen lights flashing across the field of vision? Vitreous floaters?
These symptoms suggest detachment
of vitreous from retina. Prompt eye
consultation is indicated.
Ask about pain in or around the eyes, redness, and excessive tear- ing 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.
THE EARS
Ask “How is your hearing?” See Table 7-8, Patterns of Hearing Loss, p. 121.
Does the patient have special difficulty understanding people as they talk? Does a noisy envi- ronment make a difference?
Sensorineural loss leads to difficulty understanding speech, often complain-
ing that others mumble; noisy environ-
ments worsen hearing. In conductive loss, noisy environments may help.
For complaints of earache, or pain in the ear, ask about associated fever, sore throat, cough, and con- current 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’s disease.
Ask about vertigo, the percep- tion that the patient or the envi- ronment is rotating or spinning.
Vertigo in labrynthitis (inner ear), CN VII
lesions, brainstem lesions
THE NOSE AND SINUSES
Rhinorrhea, or drainage from the nose, frequently accom- panies 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.
102 Bates’ Pocket Guide to Physical Examination and History Taking
For epistaxis, or bleeding from the nose, identify the source carefully—is bleeding 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. Anticoagu-
lants, NSAIDs, and coagulopathies may
contribute.
THE MOUTH, THROAT, AND NECK
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 pharyngitis, or “strep throat” (p. 125).
Hoarseness may arise from over- use of the voice, allergies, smok- ing, or inhaled irritants.
Also present in viral laryngitis, hypo- thyroidism, laryngeal disease, or when
extrapharyngeal lesions press on the
laryngeal nerves
Assess thyroid function. Ask about goiter, temperature intol- erance, and sweating.
With goiter, thyroid function may be
increased, decreased, or normal. Cold
intolerance in hypothyroidism; heat intolerance, palpitations, and involun-
tary weight loss in hyperthyroidism
Important Topics for Health Promotion and Counseling
Disorders of vision shift with age. Healthy young adults generally have refractive errors. Up to 25% of adults older than 65 years have refractive errors; cataracts, macular degeneration, and glaucoma also become more prevalent. Glaucoma is the leading cause of blindness in African Americans and the second leading cause of blindness overall. Glaucoma causes gradual vision loss, with damage to the optic nerve, loss of visual fields, beginning usually at the periphery, and pallor
Health Promotion and Counseling: Evidence and Recommendations
◗ Loss of vision: cataracts, macular degeneration, glaucoma
◗ Hearing loss
◗ Oral health
Chapter 7 | The Head and Neck 103
and increasing size of the optic cup (enlarging to more than half the diameter of the optic disc).
More than a third of adults older than 65 years have detectable hear- ing deficits. Questionnaires and handheld audioscopes work well for periodic screening.
Be sure to promote oral health: Up to half of all children 5 to 17 years of age have one to eight cavities, and the average U.S. adult has 10 to 17 decayed, missing, or filled teeth. More than half of all adults older than 65 years have no teeth! Inspect the oral cavity for decayed or loose teeth, inflammation of the gingiva, and signs of periodontal dis- ease (bleeding, pus, receding gums, and bad breath). Counsel patients to use fluoride-containing toothpastes, brush, floss, and seek dental care at least annually.
Techniques of Examination
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
THE HEAD
Examine the:
● Hair, including quantity, distribution, and texture
● Scalp, including lumps or lesions
● Skull, including size and con- tour
● Face, including symmetry and facial expression
● Skin, including color, texture, hair distribution, and lesions
Coarse and sparse in hypothyroidsm, fine in hyperthyroidism
Pilar cysts, psoriasis, pigmented nevi
Hydrocephalus, skull depression from trauma
Facial paralysis; flat affect of depression,
moods such as anger, sadness
Pale, fine, hirsute, acne, skin cancer
THE EYES
Test visual acuity in each eye. Diminished acuity
Assess visual fields, if indicated. Hemianopsia, quadrantic defects in cerebrovascular accidents (CVAs). See
Table 7-3, Visual Field Defects, p. 115.
TTTecchhnniquees offf EExaammminnatttionn
104 Bates’ Pocket Guide to Physical Examination and History Taking
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
Inspect the: See Table 7-4, Physical Findings In and Around the Eye, pp. 116–117.
● Position and alignment of eyes
● Eyebrows
● Eyelids
● Lacrimal apparatus
● Conjunctiva and sclera
● Cornea, iris, and lens
Exophthalmos, strabismus
Seborrheic dermatitis
Sty, chalazion, ectropion, ptosis,
xanthelasma
Swollen lacrimal sac
Red eye, conjunctivitis, jaundice,
episcleritis
Corneal opacity, cataract
Examine pupils for: ● Size, shape, and symmetry
● Reactions to light, direct and consensual
● The near reaction: pupillary constriction with gaze shift to near objection; with con- vergence and accommodation (lens becomes more convex)
Miosis, mydriasis, anisocoria
Absent in paralysis of CN III
Useful in tonic (Adie’s) versus Argyll
Robertson pupils: constriction slows in
tonic pupil; absent in Argyll Robertson
pupils of syphilis; poor convergence in
hyperthyroidism
THE NEAR REACTION
Assess the extraocular muscles by observing:
● The corneal reflections from a midline light
● The six cardinal directions of gaze
Asymmetric reflection if deviation in
ocular alignment
Cranial nerve palsy, strabismus, nystag-
mus, lid lag of hyperthyroidism
Chapter 7 | The Head and Neck 105
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
Superior rectus (III)
Lateral rectus
(VI)
Inferior rectus (III)
Superior rectus (III)
Lateral rectus (VI)
Inferior rectus (III)
Superior oblique (IV)
Medial rectus (III)
Inferior oblique (III)
Inspect the fundi with an ophthalmoscope.
Inspect the fundi for the following:
● Red reflex
● Optic disc
Cataracts, artificial eye
Papilledema, glaucomatous cupping,
optic atrophy. See Table 7-5, Abnormali-
ties of the Optic Disc, p. 118, and Table 7-6,
Ocular Fundi: Diabetic Retinopathy, p. 119.
Tips for Using the Ophthalmoscope
◗ Darken the room. Turn the lens disc to the large round beam of white light.
Lower the brightness of the light beam to make the examination more com- fortable for the patient.
◗ Turn the lens disc to the 0 diopter (a diopter measures the power of a lens to
converge or diverge light).
◗ Hold the ophthalmoscope in your right hand and use your right eye to exam- ine the patient’s right eye; hold it in your left hand and use your left eye to examine the patient’s left eye to avoid bumping the patient’s nose.
◗ Brace the ophthalmoscope firmly against the medial aspect of your bony
orbit, with the handle tilted laterally at about a 20-degree slant from the
vertical. Instruct the patient to look slightly up and over your shoulder at a
point directly ahead on the wall.
◗ Place yourself about 15 inches away from the patient and at an angle 15 degrees lateral to the patient’s line of vision. Look for the orange glow in the pupil—the red reflex. Note any opacities interrupting the red reflex. No red reflex suggests an opacity of the lens (cataract) or possibly the vitreous.
◗ Place the thumb of your other hand across the patient’s eyebrow. Keeping the
light beam focused on the red reflex, move in at a 15-degree angle toward the
pupil until you almost touch the patient’s eyelashes. Adjust the position of
your ophthalmoscope and angle of vision as a unit until you see the fundus.
106 Bates’ Pocket Guide to Physical Examination and History Taking
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
Artery
Vein
Optic disc
Physiologic cupMacula
● Arteries, veins, and AV crossings
● Adjacent retina (note any lesions)
AV nicking, copper wiring in
hypertensive changes
Hemorrhages, exudates, cotton-wool
patches, microaneurysms, pigmentation
● Macular area
● Anterior structures
Macular degeneration
Vitreous floaters, cataracts
Tips for Examining the Optic Disc and Retina
◗ Locate the optic disc. Look for the round yellowish-orange structure. ◗ Now, bring the optic disc into sharp focus by adjusting the lens of your ophthalmoscope.
◗ Inspect the optic disc. Note the following features: ◗ The sharpness or clarity of the disc outline ◗ The color of the disc ◗ The size of the central physiologic cup (an enlarged cup suggests chronic open-angle glaucoma)
◗ Venous pulsations in the retinal veins as they emerge from the central por- tion of the disc (loss of venous pulsations from elevated intracranial pres-
sure may occur in head trauma, meningitis)
◗ Inspect the retina. Distinguish arteries from veins based on the features listed below.
Arteries Veins
Color Light red Dark red
Size Smaller (2⁄3 to 3⁄4 the diam- eter of veins)
Larger
Light Reflex (reflection) Bright Inconspicuous or absent
(continued)
Chapter 7 | The Head and Neck 107
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
Tips for Examining the Optic Disc and Retina (continued)
◗ Follow the vessels peripherally in each of four directions. ◗ Inspect the fovea and surrounding macula. Macular degeneration types include dry atrophic (more common but less severe) and wet exudative (neo- vascular). Undigested cellular debris, called drusen, may be hard or soft.
◗ Assess for any papilledema from increased intracranial pressure
leading to swelling of the optic
nerve head.
PAPILLEDEMA
THE EARS
Examine on each side:
The Auricle
Inspect the auricle. Keloid, epidermoid cyst
If you suspect otitis:
● Move the auricle up and down, and press on the tragus.
● Press firmly behind the ear.
Pain in otitis externa (“the tug test”)
Possible tenderness in otitis media and
mastoiditis
Ear Canal and Drum
Pull the auricle up, back, and slightly out. Inspect, through an otoscope speculum:
● The canal
● The eardrum
Cerumen; swelling and erythema in
otitis externa
Red bulging drum in acute otitis media;
serous otitis media, tympanosclerosis,
perforations. See Table 7-7, Abnormalities
of the Eardrum, p. 120.
108 Bates’ Pocket Guide to Physical Examination and History Taking
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
Short process of malleus
Handle of malleus
Cone of light
Umbo Pars tensa
Incus
Pars flaccida
Hearing
Assess auditory acuity to whispered or spoken voice.
If hearing is diminished, use a 512-Hz tuning fork to:
● Test lateralization (Weber test). Place vibrating and tuning fork on vertex of skull and check hearing.
● Compare air and bone con- duction (Rinne test). Place vibrating and tuning fork on mastoid bone, then remove and check hearing.
These tests help distinguish between
sensorineural and conduction hearing
loss.
See Table 7-8, Patterns of Hearing Loss,
p. 121.
THE NOSE AND SINUSES
Inspect the external nose.
Inspect, through a speculum, the:
● Nasal mucosa that covers the septum and turbinates, noting its color and any swelling
● Nasal septum for position and integrity
Swollen and red in viral rhinitis, swollen
and pale in allergic rhinitis; polyps; ulcer
from cocaine use
Deviation, perforation
Palpate the frontal and maxillary sinuses.
Tender in acute sinusitis
Chapter 7 | The Head and Neck 109
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
THE MOUTH AND PHARYNX
Inspect the:
● Lips
● Oral mucosa
● Gums
● Teeth
● Roof of the mouth
● Tongue, including:
● Papillae
● Symmetry
● Any lesions
● Floor of the mouth
● Pharynx, including:
● Color or any exudate
● Presence and size of tonsils
● Symmetry of the soft palate as patient says “ah”
Cyanosis, pallor, cheilosis. See also Table
7-9, Abnormalities of the Lips, p. 122.
Aphthous ulcers (canker sores)
Gingivitis, periodontal disease
Dental caries, tooth loss
Torus palatinus
See Table 7-10, Abnormalities of the
Tongue, pp. 123–124.
Glossitis
Deviation to one side from paralysis of
CN XII from CVA
Cancer
Cancer
See Table 7-11, Abnormalities of the
Pharynx, p. 125.
Pharyngitis
Exudates, tonsillitis, peritonsillar abscess
Soft palate fails to rise in paralysis of
CN X from CVA
THE NECK
Inspect the neck. Scars, masses, torticollis
Palpate the lymph nodes. Cervical lymphadenopathy from inflam- mation, malignancy, HIV
110 Bates’ Pocket Guide to Physical Examination and History Taking
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
Inspect and palpate the position of the trachea.
Deviated trachea from neck mass or
pneumothorax
Inspect the thyroid gland:
● At rest
● As patient swallows water
Goiter, nodules. See Table 7-12, Abnor-
malities of the Thyroid Gland, p. 126.
From behind patient, palpate the thyroid gland, including the isthmus and the lateral lobes:
Goiter, nodules, tenderness of thyroiditis
● At rest
● As patient swallows water
Alternate Sequence. After examining the thyroid gland from behind the patient, you may proceed to musculoskeletal examination of the neck and upper back and check for costovertebral angle tenderness.
Recording the Physical Examination—The Head, Eyes, Ears, Nose, and Throat (HEENT)
HEENT: Head—The skull is normocephalic/atraumatic (NC/AT). Hair with aver- age texture. Eyes—Visual acuity 20/20 bilaterally. Sclera white; conjunctiva pink. Pupils constrict 4 mm to 2 mm, equally round and reactive to light and
accommodations. Disc margins sharp; no hemorrhages or exudates; no arte-
riolar narrowing. Ears—Acuity good to whispered voice. Tympanic membranes (TMs) with good cone of light. Weber midline. AC > BC. Nose—Nasal mucosa pink, septum midline; no sinus tenderness. Throat (or Mouth)—Oral mucosa pink; dentition good; pharynx without exudates. Neck—Trachea midline. Neck supple; thyroid isthmus palpable, lobes not felt. Lymph Nodes—No cervical, axillary, epitrochlear, inguinal adenopathy.
Recording Your FindingsRRReccoorddinnggg YYouuur Finnddinngss
Chapter 7 | The Head and Neck 111
Aids to InterpretationAAAiddss ttoo IInntterrpprreetaattioonn
Table 7-1 Primary Headaches
Problem Common Characteristics
Associated Symptoms, With Provoking and Relieving Factors
Tension Location: Variable Quality: Pressing or
tightening pain; mild to moderate intensity
Onset: Gradual Duration: Minutes
to days
Sometimes photophobia, phonophobia; nausea absent
↑ by sustained muscle tension, as in driving or typing
↓ possibly by massage, relaxation
Migraine ● 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 hr
Duration: 4–72 hr
Nausea, vomiting, photophobia, phonophobia, visual auras (flickering zig-zagging 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
Cluster Location: Unilateral, usually behind or around the eye
Quality: Deep, continuous, severe
Onset: Abrupt, peaks within minutes
Duration: Up to 3 hr
Lacrimation, rhinorrhea, miosis, ptosis, eyelid edema, conjunctival infection
↑ sensitivity to alcohol during some episodes
112 Bates’ Pocket Guide to Physical Examination and History Taking
Table 7-2 Secondary Headaches
Problem Common Characteristics
Associated Symptoms, With Provoking and Relieving Factors
Analgesic Rebound
Location: Previous headache pattern
Quality: Variable Onset: Variable Duration: Depends on
prior headache pattern
Depends on prior headache pattern
↑ by fever, carbon monoxide, hypoxia, withdrawal of caffeine, other headache triggers
↓ —depends on cause
Headaches From Eye Disorders Errors of Refraction (farsighted ness and astigmatism, but not near - sightedness)
Location: Around and over the eyes; may radiate to the occipital area
Quality: Steady, aching, dull
Onset: Gradual Duration: Variable
Eye fatigue, “sandy” sensation in eyes, redness of the conjunctiva
↑ by prolonged use of the eyes, particularly for close work
↓ by rest of the eyes
Acute Glaucoma Location: In and around one eye
Quality: Steady, aching, often severe
Onset: Often rapid Duration: Variable, may
depend on treatment
Diminished vision, sometimes nausea and vomiting
↑ —sometimes by drops that dilate the pupils
Headache From Sinusitis
Location: Usually above eye (frontal sinus) or over maxillary sinus
Quality: Aching or throbbing, variable in severity; consider possible migraine
Onset: Variable Duration: Often several
hours at a time, recurring over days or longer
Local tenderness, nasal congestion, tooth pain, discharge, and fever
↑ by coughing, sneezing, or jarring the head
↓ by nasal decongestants, antibiotics
Chapter 7 | The Head and Neck 113
Problem Common Characteristics
Associated Symptoms, With Provoking and Relieving Factors
Meningitis Location: Generalized Quality: Steady or
throbbing, very severe Onset: Fairly rapid Duration: Variable,
usually days
Fever, stiff neck
Subarachnoid Hemorrhage
Location: Generalized Quality: Severe, “the
worst of my life” Onset: Usually abrupt;
prodromal symptoms may occur
Duration: Variable, usually days
Nausea, vomiting, possibly loss of consciousness, neck pain
Brain Tumor Location: Varies with the location of the tumor
Quality: Aching, steady, variable in intensity
Onset: Variable Duration: Often brief
↑ by coughing, sneezing, or sudden movements of the head
Cranial Neuralgias: Trigeminal Neuralgia (CN V)
Location: Cheek, jaws, lips, or gums; trigeminal nerve divisions 2 and 3 > 1
Quality: Shocklike, stabbing, burning, severe
Onset: Abrupt, paroxysmal
Duration: Each jab lasts seconds but recurs at intervals of seconds or minutes
Exhaustion from recurrent pain
↑ by touching certain areas of the lower face or mouth; chewing, talking, brushing teeth
Table 7-2 Secondary Headaches (continued)
(continued)
114 Bates’ Pocket Guide to Physical Examination and History Taking
Problem Common Characteristics
Associated Symptoms, With Provoking and Relieving Factors
Giant Cell (Temporal) Arteritis
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
Postconcu ssion Headache
Location: Injured area, but not necessarily
Quality: Generalized, dull, aching, constant
Onset: Within hours to 1–2 days of the injury
Duration: Weeks, months, or even years
Poor concentration, problems with memory, vertigo, irritability, restlessness, fatigue
↑ by mental and physical exertion, straining, stooping, emotional excitement, alcohol
↓ by rest
Table 7-2 Secondary Headaches (continued)
Chapter 7 | The Head and Neck 115
Table 7-3 Visual Field Defects
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)
116 Bates’ Pocket Guide to Physical Examination and History Taking
Table 7-4 Physical Findings in and Around the Eye
Eyelids
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.
Chapter 7 | The Head and Neck 117
In and Around the 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
Sty. A pimplelike infection around a hair follicle near the lid margin
Chalazion. A beady nodule in either eyelid caused by a chronically inflamed meibomian gland
Xanthelasma. Yellowish plaque seen in lipid disorders
Inflammation of the Lacrimal Sac (Dacryocystitis). From inflammation or obstruction of the lacrimal duct
Table 7-4
Physical Findings in and Around the Eye (continued)
118 Bates’ Pocket Guide to Physical Examination and History Taking
Table 7-5 Abnormalities of the Optic Disc
Process Appearance
Normal 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).
Papilledema 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.
Glaucomatous Cupping
Increased pressure within the eye leads to increased cupping (backward depression of the disc) and atrophy.
The base of the enlarged cup is pale.
Optic Atrophy Death of optic nerve fibers leads to loss of the tiny disc vessels.
Disc is white. Disc vessels are absent.
Chapter 7 | The Head and Neck 119
Table 7-6 Ocular Fundi: Diabetic Retinopathy
Nonproliferative Retinopathy, Moderately Severe
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.
Nonproliferative Retinopathy, Severe
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.
Proliferative Retinopathy, With Neovascularization
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%.
Proliferative Retinopathy, Advanced
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;350:48–58.
120 Bates’ Pocket Guide to Physical Examination and History Taking
Table 7-7 Abnormalities of the Eardrum
Perforation Hole in the eardrum that may be central or marginal
Usually from otitis media or trauma
Tympanosclerosis A chalky white patch Scar of an old otitis media; of little or no
clinical consequence
Serous Effusion Amber fluid behind the eardrum, with or without air bubbles
Associated with viral upper respiratory infections or sudden changes in atmospheric pressure (diving, flying)
Acute Otitis Media With Purulent Effusion
Red, bulging drum, loss of landmarks Associated with bacterial infection
Chapter 7 | The Head and Neck 121
Table 7-8 Patterns of Hearing Loss
Conductive Loss Sensorineural Loss
Impaired Understanding of Words
Minor Often troublesome
Effect of Noisy Environment
May help Increases the hearing difficulty
Usual Age of Onset
Childhood, young adulthood
Middle and later years
Ear Canal and Drum
Often a visible abnormality
Problem not visible
Weber Test (in Unilateral Hearing Loss)
Lateralizes to the impaired ear
Lateralizes to the good ear
Rinne Test BC ≥ AC AC > BC
Causes Include 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
122 Bates’ Pocket Guide to Physical Examination and History Taking
Table 7-9 Abnormalities of the Lips
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. Red spots, significant because of associated bleeding from nose and GI tract
Peutz-Jeghers syndrome. Brown spots of the lips and buccal mucosa, significant because of their association with intestinal polyposis
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
Chapter 7 | The Head and Neck 123
Table 7-10 Abnormalities of the Tongue
Geographic tongue. Scattered areas in which the papillae are lost, giving a maplike appearance; harmless
Hairy tongue. Results from elongated papillae that may look yellowish, brown, or black; harmless
Fissured tongue. May appear with aging; harmless
Smooth tongue. Results from loss of papillae, caused by vitamin B or iron deficiency or possibly 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
Hairy leukoplakia. White raised, feathery areas, usually on sides of tongue. Seen in HIV/AIDS
(continued)
124 Bates’ Pocket Guide to Physical Examination and History Taking
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. A malignancy that should be considered in any nodule or nonhealing ulcer at the base or edges of the mouth
Table 7-10 Abnormalities of the Tongue (continued)
Chapter 7 | The Head and Neck 125
Table 7-11 Abnormalities of the Pharynx
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’s spots. These small white specks that resemble grains of salt on a red background are an early sign of measles.
126 Bates’ Pocket Guide to Physical Examination and History Taking
Table 7-12 Abnormalities of the Thyroid Gland
Diffuse enlargement. May result from Graves’ disease, Hashimoto’s 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
127
C H A P T E R
8The Thorax and Lungs The Health History
● The myocardium
● The pericardium
● The aorta
● The trachea and large bronchi
● The parietal pleura
● The chest wall, including the musculoskeletal system and skin
● The esophagus
● Extrathoracic structures such as the neck, gallbladder, stomach
Angina pectoris, myocardial infarction
Pericarditis
Dissecting aortic aneurysm
Bronchitis
Pericarditis, pneumonia
Costochondritis, herpes zoster
Reflux esophagitis, esophageal spasm
Cervical arthritis, biliary colic, gastritis
Common or Concerning Symptoms
◗ Chest pain
◗ Shortness of breath (dyspnea)
◗ Wheezing
◗ Cough
◗ Blood-streaked sputum (hemoptysis)
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. 137–138.
128 Bates’ Pocket Guide to Physical Examination and History Taking
For patients who are short of breath, focus on such pulmonary complaints as:
● dyspnea and wheezing
● cough and hemoptysis
See Table 8-2, Dyspnea, pp. 139–140.
See Table 8-3, Cough and Hemoptysis,
pp. 141–143.
Health Promotion and Counseling: Evidence and Recommendations
Despite declines in smoking over the past several decades, 21% of Americans still smoke. Regularly counsel all adults, pregnant women, parents, and adolescents who smoke to stop. Include “the five As” and assess readiness to quit, using the Stages of Change Model.
Provide flu 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.
Assessing Readiness to Quit Smoking: Brief Inter ventions Models
5 As Model Stages of Change Model
Ask about tobacco use Precontemplation—“I don’t want to quit.”
Advise to quit Contemplation—“I am concerned but not ready to quit now.”
Assess willingness to make a quit attempt
Preparation—“I am ready to quit.”
Assist in quit attempt Action—“I just quit.” Arrange follow-up Maintenance—“I quit 6 months ago.”
Chapter 8 | The Thorax and Lungs 129
Techniques of Examination
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
SURVEY OF THORAX
Manubrium of sternum
Body of sternum
Xyphoid process
Costal angle Costochondral junctions
Suprasternal notch
Sternal angle
2nd costal cartilage
Cardiac notch of left lung
2nd rib
2nd rib interspace
Inspect the thorax and its respiratory movements.
Note: ● Rate, rhythm, depth, and effort of breathing
● Inspiratory retraction of the supraclavicular areas
● Inspiratory contraction of the sternomastoids
Tachypnea, hyperpnea, Cheyne–
Stokes breathing
Occurs in chronic obstructive pulmo-
nary disease (COPD), asthma, upper
airway obstruction
Indicates severe breathing difficulty
Observe shape of patient’s chest. Normal or barrel chest (see Table 8-4, Deformities of the Thorax, pp. 144–145)
Listen to patient’s breathing for:
● Rate and rhythm of breathing
● Stridor
● Wheezes
14–16 breaths/minute in adults (see
Chapter 4, pp. 57, 65)
Stridor in upper airway obstruction
from foreign body or epiglottitis
Expiratory wheezing in asthma and
COPD
130 Bates’ Pocket Guide to Physical Examination and History Taking
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
THE POSTERIOR CHEST
Inspect the chest for: ● Deformities or asymmetry
● Abnormal inspiratory retrac- tion of the interspaces
● Impairment or unilateral lag in respiratory movement
Kyphoscoliosis
Retraction in airway obstruction
Disease of the underlying lung or
pleura, phrenic nerve palsy
Palpate the chest for: ● Tender areas
● Assessment of visible abnor- malities
● Chest expansion
● Tactile fremitus as the patient says “aa” or “blue moon”
Fractured ribs
Masses, sinus tracts
Impairment, both sides in COPD and
restrictive lung disease
Local or generalized decrease or
increase
Chapter 8 | The Thorax and Lungs 131
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
Percuss the chest in the areas illustrated, comparing one side with the other at each level, using the side-to-side “ladder pattern.”
Dullness when fluid or solid tissue replaces normally air-filled lung;
hyperresonance in emphysema or pneumothorax
1
2
3
4
5
1
2
3
4
5
6 6
7 7
Percuss level of diaphragmatic dullness on each side and esti- mate diaphragmatic descent after patient takes full inspiration.
Pleural effusion or a paralyzed diaphragm raises level of dullness.
Resonant
Level of diaphragm
Dull
Location and sequence of percussion
Percussion Notes and Their Characteristics
Relative Intensity, Pitch, and Duration
Examples
Flat Soft/high/short Large pleural effusion Dull Medium/medium/medium Lobar pneumonia Resonant Loud/low/long Normal lung, simple
chronic bronchitis
Hyperresonant Louder/lower/longer Emphysema, pneumothorax Tympanitic Loud/high (timbre is musical) Large pneumothorax
132 Bates’ Pocket Guide to Physical Examination and History Taking
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
Listen to chest with stethoscope in the “ladder” pattern, again comparing sides.
See Table 8-5, Physical Findings in
Selected Chest Disorders, p. 146.
● Evaluate the breath sounds.
● Note any adventitious (added) sounds.
Vesicular, bronchovesicular, or bron-
chial breath sounds; decreased breath
sounds from decreased airflow
Crackles (fine and coarse) and continuous
sounds (wheezes and rhonchi)
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 atelec-
tasis
Characteristics of Breath Sounds
Duration
Intensity and Pitch of Expiratory Sound
Example Locations
Vesicular Insp > Exp Soft/low Most of the lungs
Bronchovesicular Insp = Exp Medium/medium 1st and 2nd interspaces, in-
terscapular area
Bronchial Exp > Insp Loud/high Over the manu- brium
Tracheal Insp = Exp Very loud/high Over the trachea
Duration is indicated by the length of the line, intensity by the width of the line, and pitch
by the slope of the line.
Chapter 8 | The Thorax and Lungs 133
Adventitious or Added Breath Sounds
Crackles (or Rales) Wheezes and Rhonchi
◗ Discontinuous ◗ Intermittent, nonmusical,
and brief
◗ Like dots in time
◗ Fine crackles: Soft, high- pitched, very brief (5–10 msec)
◗ Coarse crackles: Somewhat louder, lower in pitch, brief
(20–30 msec)
◗ Continuous ◗ ≥250 msec, musical, prolonged (but not necessarily persisting throughout the
respiratory cycle)
◗ Like dashes in time
◗ Wheezes: Relatively high-pitched (≥400 Hz) with hissing or shrill quality
◗ Rhonchi: Relatively low-pitched (≤200 Hz) with snoring quality
Transmitted Voice Sounds
Through Normally Air-Filled Lung Through Airless Lung*
Usually accompanied by vesicular
breath sounds and normal tactile
fremitus
Usually accompanied by bronchial
or bronchovesicular breath sounds
and increased tactile fremitus
Spoken words muffled and indistinct Spoken words louder, clearer
(bronchophony) Spoken “ee” heard as “ee” Spoken “ee” heard as “ay” (egophony) Whispered words faint and indistinct,
if heard at all
Whispered words louder, clearer
(whispered pectoriloquy)
*As in lobar pneumonia and toward the top of a large pleural effusion
Assess transmitted voice sounds, bronchial breath sounds heard in abnormal places. Ask patient to:
● Say “ninety-nine” and “ee.”
● Whisper “ninety-nine” or “one- two-three.”
Bronchophony if sounds become
louder; egophony if “ee” to “A”
change to lobar consolidation
Whispered pectoriloquy
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
134 Bates’ Pocket Guide to Physical Examination and History Taking
Alternate 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.
THE ANTERIOR CHEST
Midsternal line
Midclavicular line
Anterior axillary line
Anterior axillary line
Posterior axillary line
Midaxillary line
Inspect the chest for: ● Deformities or asymmetry
● Intercostal retraction
● Impaired or lagging respiratory movement
Pectus excavatum
From obstructed airways
Disease of the underlying lung or
pleura, phrenic nerve palsy
Palpate the chest for: ● Tender areas
● Assessment of visible abnormalities
● Respiratory expansion
● Tactile fremitus
Tender pectoral muscles,
costochondritis
Flail chest
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
ANTERIOR VIEW RIGHT ANTERIOR
OBLIQUE VIEW
Chapter 8 | The Thorax and Lungs 135
Percuss the chest in the areas illustrated.
11
22
33
44 55
66
Normal cardiac dullness may disap-
pear in emphysema.
Listen to the chest with stetho- scope. Note:
● Breath sounds
● Adventitious sounds
● If indicated, transmitted voice sounds
SPECIAL TECHNIQUES
CLINICAL ASSESSMENT OF PULMONARY FUNCTION
Walk with patient down the hall or up a flight of stairs. Observe the rate, effort, and sound of breath- ing, and inquire about symptoms. Or do a “6-minute walk test.”
Older adults walking 8 feet in <3 seconds are less likely to be disabled
than those taking >5 to 6 seconds.
FORCED EXPIRATORY TIME
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 stetho- scope, and time audible expiration. Try to get three consistent read- ings, allowing rests as needed.
If the patient understands and cooper-
ates well, a forced expiratory time of
6 to 8 seconds strongly suggests COPD.
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
136 Bates’ Pocket Guide to Physical Examination and History Taking
Recording Your Findings
Recording the Physical Examination—The Thorax and Lungs
“Thorax is symmetric with good expansion. Lungs resonant. Breath sounds
vesicular; no rales, wheezes, or rhonchi. Diaphragms descend 4 cm bilaterally.”
OR “Thorax symmetric with moderate kyphosis and increased anteroposterior
(AP) diameter, decreased expansion. Lungs are hyperresonant. Breath sounds
distant with delayed expiratory phase and scattered expiratory wheezes.
Fremitus decreased; no bronchophony, egophony, or whispered pectoriloquy.
Diaphragms descend 2 cm bilaterally.” (Suggests COPD)
Chapter 8 | The Thorax and Lungs 137
Table 8-1 Chest Pain
Problem and Location Quality, Severity, Timing, and Associated Symptoms
Cardiovascular
Angina Pectoris Retrosternal or across the
anterior chest, sometimes radiating to the shoulders, arms, neck, lower jaw, or upper 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
Myocardial Infarction
Same as in angina
● Same as in angina ● Often but not always a severe pain ● 20 min to several hours ● Associated with nausea, vomiting, sweating, weakness
Pericarditis Precordial: May radiate to the
tip of the shoulder and to the neck
● Sharp, knifelike quality ● Often severe ● Persistent timing ● Symptoms of the underlying illness; relieved by leaning forward
Retrosternal ● Crushing quality ● Severe ● Persistent timing ● Symptoms of the underlying illness
Dissecting Aortic Aneurysm Anterior chest, radiating to the
neck, back, or abdomen
● Ripping, tearing quality ● Very severe ● Abrupt onset, early peak, persistent for hours or more
● Associated syncope, hemiplegia, paraplegia
Aids to Interpretation
(continued)
138 Bates’ Pocket Guide to Physical Examination and History Taking
Table 8-1 Chest Pain (continued)
Problem and Location Quality, Severity, Timing, and Associated Symptoms
Pulmonary
Tracheobronchitis Upper sternal or on either
side of the sternum
● Burning qualtiy ● Mild to moderate severity ● Variable timing ● Associated cough
Pleural Pain Chest wall overlying the
process
● Sharp, knifelike quality ● Often severe ● Persistent timing ● Associated symptoms of the underlying illness
Gastrointestinal and Other
Reflex Esophagitis Retrosternal, may radiate to
the back
● Burning quality, may be squeezing ● Mild to severe ● Variable timing ● Associated with regurgitation, dysphagia
Diffuse Esophageal Spasm Retrosternal, may radiate to
the back, arms, and jaw
● Usually squeezing quality ● Mild to severe ● Variable timing ● Associated dysphagia
Chest Wall Pain Often below the left breast or
along the costal cartilages; also elsewhere
● Stabbing, sticking, or dull aching quality
● Variable severity ● Fleeting timing, hours or days ● Often with local tenderness
Anxiety ● Pain may be sharp, intense, or severe
● Can mimic angina ● Associated with stress of anxiety
Chapter 8 | The Thorax and Lungs 139
Table 8-2 Dyspnea
Problem Timing Provoking and Relieving Factors
Left-Sided Heart Failure (left ventricular failure or mitral stenosis)
Dyspnea may progress slowly or suddenly, as in acute pulmonary edema
↑ by exertion, lying down ↓ by rest, sitting up, though
dyspnea may become persistent
Associated Symptoms: Often cough, orthopnea, paroxysmal nocturnal dyspnea; sometimes wheezing
Chronic Bronchitis (may be seen with COPD)
Chronic productive cough followed by slowly progressive dyspnea
↑ by exertion, inhaled irritants, respiratory infections
↓ by expectoration, rest though dyspnea may become persistent
Associated Symptoms: Chronic productive cough, recurrent respiratory infections; wheezing possible
Chronic Obstructive Pulmonary Disease (COPD)
Slowly progressive; relatively mild cough later
↑ by exertion ↓ by rest, though dyspnea
may become persistent Associated Symptoms: Cough
with scant mucoid sputum
Asthma Acute episodes, then symptom- free periods; nocturnal episodes common
↑ by allergens, irritants, respiratory infections, exercise, emotion
↓ by separation from aggravating factors
Associated Symptoms: Wheezing, cough, tightness in chest
(continued)
140 Bates’ Pocket Guide to Physical Examination and History Taking
Table 8-2 Dyspnea (continued)
Problem Timing Provoking and Relieving Factors
Acute Pulmonary Embolism
Sudden onset of dyspnea
Associated Symptoms: Often none; retrosternal oppressive pain if occlusion is massive; pleuritic pain, cough, and hemoptysis may follow an embolism if pulmonary infarction ensues; symptoms of anxiety
Pneumonia Acute illness; timing varies with causative agent
Associated Symptoms: Pleuritic pain, cough, sputum, fever, though not necessarily present
Diffuse Interstitial Lung Diseases (sarcoidosis, neoplasms, asbestosis, idiopathic pulmonary fibrosis)
Progressive; varies in rate of development depending on cause
↑ by exertion ↓ by rest, though dyspnea
may become persistent Associated Symptoms: Often
weakness, fatigue; cough less common than in other lung diseases
Spontaneous Pneumothorax
Sudden onset of dyspnea
Associated Symptoms: Pleuritic pain, cough
Chapter 8 | The Thorax and Lungs 141
(continued)
Table 8-3 Cough and Hemoptysis
Problem Cough, Sputum, Associated Symptoms, and Setting
Acute Inflammation
Laryngitis Cough and Sputum: Dry, or with variable amounts of sputum
Associated Symptoms and Setting: Acute, fairly minor illness with hoarseness. May be associated with viral nasopharyngitis
Tracheobronchitis Cough and Sputum: Dry or productive of sputum
Associated Symptoms and Setting: An acute, often viral illness, with burning retrosternal discomfort
Mycoplasma and Viral Pneumonias
Cough: Dry and hacking Sputum: Often mucoid Associated Symptoms and Setting: An
acute febrile illness, often with malaise, headache, and possibly dyspnea
Bacterial Pneumonias Cough and Sputum: With pneumococcal infection, mucoid or purulent; may be blood streaked, diffusely pinkish, or rusty. With Klebsiella, similar to pneumococcal, or sticky red and jellylike.
Associated Symptoms and Setting: An acute illness with chills, high fever, dyspnea, and chest pain; often preceded by acute upper respiratory infection. Klebsiella often in older alcoholic men.
Chronic Inflammation
Postnasal Drip Cough: Chronic Sputum: Mucoid or mucopurulent Associated Symptoms and Setting: Repeated
attempts to clear the throat. Postnasal drip, discharge in posterior pharynx. Associated with chronic rhinitis, with or without sinusitis
142 Bates’ Pocket Guide to Physical Examination and History Taking
Table 8-3 Cough and Hemoptysis (continued)
Problem Cough, Sputum, Associated Symptoms, and Setting
Chronic Bronchitis 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.
Bronchiectasis Cough: Chronic Sputum: Purulent, often copious and foul
smelling; may be blood-streaked or bloody
Associated Symptoms and Setting: Recurrent bronchopulmonary infections common; sinusitis may coexist
Pulmonary Tuberculosis 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.
Lung Abscess Cough and Sputum: Purulent and foul smelling; may be bloody
Associated Symptoms and Setting: A febrile illness. Often poor dental hygiene and a prior episode of impaired consciousness
Asthma 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
Chapter 8 | The Thorax and Lungs 143
Table 8-3 Cough and Hemoptysis (continued)
Problem Cough, Sputum, Associated Symptoms, and Setting
Gastroesophageal Reflux
Cough and Sputum: Chronic, 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
Neoplasm Cough: Dry to productive
Cancer of the Lung Sputum: May be blood-streaked or bloody Associated Symptoms and Setting: Usually a
long history of cigarette smoking
Cardiovascular Disorders
Left Ventricular Failure or Mitral Stenosis
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
Pulmonary Emboli Cough: Dry to productive Sputum: May be dark, bright red, or mixed
with blood Associated Symptoms and Setting: Dyspnea,
anxiety, chest pain, fever; factors that predispose to deep venous thrombosis
Irritating Particles, Chemicals, or Gases
Cough and Sputum: Variable. There may be a latent period between exposure and symptoms.
Associated Symptoms and Setting: Exposure to irritants; eye, nose, and throat symptoms
144 Bates’ Pocket Guide to Physical Examination and History Taking
Table 8-4 Deformities of the Thorax
Cross-Section of Thorax
Normal Adult
The thorax is wider than it is deep; lateral diameter is greater than anteroposterior (AP) diameter.
Barrel Chest
Has increased AP diameter, seen in normal infants and normal aging; also in COPD.
Traumatic Flail Chest
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
Inspiration
Funnel Chest (Pectus Excavatum)
Depression in the lower portion of the sternum. Related compression of the heart and great vessels may cause murmurs.
Chapter 8 | The Thorax and Lungs 145
Table 8-4 Deformities of the Thorax (continued)
Cross-Section of Thorax Pigeon Chest
(Pectus Carinatum)
Depressed costal cartilages
Anteriorly displaced sternum
Sternum is displaced anteriorly, increasing the AP diameter; costal cartilages adjacent to the protruding sternum are depressed.
Thoracic Kyphoscoliosis Spinal convexity to the right (patient bending forward)
Ribs widely
separated
Ribs close together
Abnormal spinal curvatures and vertebral rotation deform the chest, making interpretation of lung findings difficult.
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147
C H A P T E R
9The Cardiovascular System The Health History
Common or Concerning Symptoms
◗ Chest pain
◗ Palpitations
◗ Shortness of breath: dyspnea, orthopnea, or paroxysmal nocturnal dyspnea
◗ Swelling or edema
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 also about any associated palpitations, orthopnea, paroxysmal nocturnal dyspnea (PND), and edema.
● Palpitations are an unpleasant awareness of the heartbeat.
● Shortness of breath may represent dyspnea, orthopnea, or PND.
● Dyspnea is an uncomfortable awareness of breathing that is inap- propriate for a given level of exertion.
● Orthopnea is dyspnea that occurs when the patient is lying down and improves when the patient sits up. It suggests left ventricular heart failure or mitral stenosis; it also may accompany obstructive pulmonary disease.
● PND describes episodes of sudden dyspnea and orthopnea that awaken the patient from sleep, usually 1 to 2 hours after going to bed, prompt- ing the patient to sit up, stand up, or go to a window for air.
● Edema refers to the accumulation of excessive fluid in the interstitial tissue spaces; it appears as swelling. Dependent edema appears in the feet and lower legs when sitting or in the sacrum when bedridden.
148 Bates’ Pocket Guide to Physical Examination and History Taking
Health Promotion and Counseling:
Evidence and Recommendations
Important Topics for Health Promotion and Counseling
HHHeealltthh PPrroommoootioonn andd CCCouunsselingg:
EEEviideenncce aannd Reecooommmmeeenddattionns
◗ Screening for cardiovascular risk factors
◗ Step 1: Screen for global risk factors ◗ Step 2: Calculate 10-year and long-term CVD risk using online calculators ◗ Step 3: Track individual risk factors—hypertension, diabetes, dyslipidemias, metabolic syndrome, smoking, family history and obesity
◗ Promoting lifestyle modification and risk factor reduction
Cardiovascular disease is the leading cause of death for both men and women in the United States. Primary prevention, in those without evidence of cardiovascular disease, and secondary prevention, in those with known cardiovascular events (e.g., myocardial infarction, heart failure), remain important clinical priorities. Use education and coun- seling to help your patients maintain optimal levels of blood pressure, cholesterol, weight, and exercise and to reduce risk factors for cardio- vascular disease and stroke.
The American Heart Association recommends a new goal for 2020, “ideal cardiovascular health,” namely:
● Total cholesterol <200 mg/dL (untreated)
● Lean body mass
● BP <120/<80 (untreated)
● Fasting glucose <100 mg/dL (untreated)
● Abstinence from smoking
● Physical activity goal: ≥150 min/wk moderate intensity, ≥75 min/wk vigorous intensity, or combination
● Healthy diet
Only 3% of U.S. adults have optimal health behaviors for all 7 goals. Women and African Americans have emerged as groups at especially high risk.
CVD Screening Steps Step 1: Screen for Global Risk Factors. Begin routine screening at age 20 for combined individual risk factors or “global” risk of CVD
Chapter 9 | The Cardiovascular System 149
and any family history or premature heart disease. See the recom- mended screening intervals listed below.
Major Cardiovascular Risk Factors and Screening Frequency
Risk Factor Screening Frequency Goal
Family history of
premature CVD
(at age <55 years in first-degree male
relatives and <65 years in first-degree
female relatives)
Update regularly
Cigarette smoking At each visit Cessation
Poor diet At each visit Improved overall eating
pattern
Physical inactivity At each visit 30 min moderate intensity
daily
Obesity, especially
central adiposity
At each visit BMI 20–25 kg/m2; waist
circumference 40 inches in
men, ≤35 inches in women Hypertension At each visit <140/90
<135/85 if African American with HTN and without end-
organ or CVD
<130/80 if diabetes or African American with HTN
and end-organ or CVD
<125/75 if renal disease Dyslipidemias Every 5 years if low risk
Every 2 years if risk
factors
See ATP III guidelines
Diabetes Every 3 years beginning
at age 45
More frequently at any
age if risk factors
HgA1C ≥6.5%, at risk if 5.7%–6.4%
Pulse At each visit Identify and treat atrial
fibrillation
Source: Adapted from: Pearson TA, Blair SN, Daniels SR et al. AHA Guidelines for Primary
Prevention of Cardiovascular Disease and Stroke: 2002Update. Consensus Panel Guide
to Com prehensive Risk Reduction for Adult Patients without Coronary or Other Ath-
erosclerotic Vascular Diseases. Circulation 2002;106:388–391; Flack JM, Sica DA, Bakris
G et al. Management of high blood pressure in blacks. An update of the International
Society on Hypertension in Blacks Consensus Statement. Hypertension 2010;56:780–800;
American Diabetes Association. Standards of medical care in diabetes–2011. Diabetes Care
2001;34:S1–S61.
150 Bates’ Pocket Guide to Physical Examination and History Taking
Step 2: Calculate 10-year and Long-Term CVD Risk Using Online Calculators. For Step 2, assemble risk factor data and calculate mul- tivariable global risk assessment. This is easily accomplished by access- ing well-validated online calculators that provide 10-year CVD risk assessments that can also be used to guide treatment of dyslipidemias.
● Framingham 10-year and 30-year risk calculator: http://www.framing hamheartstudy.org/risk/gencardio.html
● Stroke risk calculator (Cleveland Clinic): http://my.clevelandclinic. org/p2/stroke-risk-calculator.aspx
Step 3: Track Individual Risk Factors–Hypertension, Diabetes, Dyslipidemias, Metabolic Syndrome, Obesity, Smoking, and Family History.
Hypertension. The U.S. Preventive Services Task Force recom- mends screening all people 18 years or older 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).
JNC 7: Classification and Management of Blood Pressure for Adults
Normal <120/80 mm Hg Prehypertension 120–139/80–89 mm Hg
Stage 1 Hypertension 140–159/90–99 mm Hg
Stage 2 Hypertension >160/>100 mm Hg If diabetes or kidney disease <130/80 mm Hg
Diabetes. Use the screening and diagnostic criteria below.
American Diabetes Association 2011: Criteria for Diabetes Screening and Diagnosis
Screening Criteria
Healthy adults with no risk factors: Begin at age 45 years, repeat at 3 year intervals
Adults with BMI ≥25 kg/m2 and additional risk factors: ◗ Physical inactivity
◗ First-degree relative with diabetes (continued)
Chapter 9 | The Cardiovascular System 151
Dyslipidemias. LDL is the primary target of cholesterol-lowering therapy. Ten-year risk categories are as follows:
● High risk (10-year CVD risk >20%): established CVD and CHD risk equivalents
● Moderately high risk (10-year CVD risk 10% to 20%): multiple or ≥2 risk factors
● Low risk (10-year CVD risk <10%): 0 to 1 risk factor
For high-risk people, the recommended LDL goal is <70 mg/dL and intensive lipid therapy is a therapeutic option.
◗ Members of a high-risk ethnic population–African American, Latino American,
Asian American, Pacific Islander
◗ Mothers of infants ≥9 lb or diagnosed with GDM ◗ Hypertension ≥140/90 mm Hg or on therapy for hypertension ◗ HDL cholesterol <35 mg/dL and/or triglycerides >250 mg/dL ◗ Women with polycystic ovary syndrome
◗ A1C ≥5.7%, impaired glucose tolerance, or impaired fasting glucose on previous testing
◗ Other conditions associated with insulin resistance such as severe obesity,
acanthosis nigricans
◗ History of cardiovascular disease
Diagnostic Criteria Diabetes Prediabetes
A1C ≤6.5% 5.7%–6.4% Fasting plasma glucose (on at least
2 occasions)
≥126 mg/dL 100–125 mg/dL
2-hour plasma glucose (oral
tolerance test)
≥200 mg/dL 140–199 mg/dL
Random glucose if classic
symptoms
≥200 mg/dL
American Diabetes Association 2011: Criteria for Diabetes Screening and Diagnosis (continued)
152 Bates’ Pocket Guide to Physical Examination and History Taking
The Metabolic Syndrome. 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 five risk factors listed below.
ATP III Guidelines: 10-Year Risk and LDL Goals
10-Year Risk Category
LDL Goal (mg/dL)
Consider Drug Therapy if LDL (mg/dL)
High risk (>20%) <100 Optional
goal: <70
>100 (<100: consider drug options, including further 30%–40%
reduction in LDL)
Moderately high
risk (10%–20%)
<130 Optional goal: <100
≥130 100–129: consider drug options to
achieve goal of <100 Moderate risk
(<10%) <130 ≥160
Lower risk (0–1
risk factor)
<160 >190 (160–189: drug therapy optional)
Source: Adapted from National Cholesterol Education Panel Report. Implications of recent
clinical trials for the National Cholesterol Education Program Adult Treatment Panel III
Guidelines. Grundy SM, Cleeman JI, Merz NB, et al., for the Coordinating Committee of the
National Cholesterol Education Program. Circulation 2004;119:227–239.
Metabolic Syndrome: 2009 Diagnostic Criteria
Waist circumference Men ≥102 cm, women ≥88 cm Fasting plasma glucose ≥100 mg/dL or being treated for elevated
glucose
HDL cholesterol Men <40 mg/dL, women <50 mg/dL, or being treated
Triglycerides ≥150 mg/dL, or being treated Blood pressure ≥130/≥85, or being treated
Source: Alberti K, Eckel RH, Grundy SM et al. Harmonizing the metabolic syndrome: a joint
interim statement of the Internal Diabetes Federation Task Force on Epidemiology and
Prevention; National Heart, Lung and Blood Institute; American Heart Association; World
Heart Federation; Internal Atherosclerosis Society; and Internal Association for the Study
of Obesity. Circulation 2009;120:1620–1645.
Chapter 9 | The Cardiovascular System 153
Other Risk Factors: Smoking, Family History, and Obesity. In adult smokers, 33% of deaths are related to CVD. Smoking increases the risk of coronary heart disease by two- to fourfold. Among adults, 13% report a family history of heart attack before age 50, which roughly doubles the risk the risk of heart attack. Obesity, or BMI more than 30, contributed to 112,000 excess adult deaths compared to normal weight in recent data and was associated with 13% of CVD deaths in 2004.
Promoting Lifestyle Modification and Risk Factor Reduction. The JNC 7 and AHA encourage well-studied effective lifestyle modifica- tion and risk interventions to prevent hypertension, CHD, and stroke.
Lifestyle Modifications for Cardiovascular Health
◗ Optimal weight (BMI of 18.5–24.9 kg/m2)
◗ Salt intake <½ teaspoon or 1500 mg/day of sodium ◗ Regular aerobic exercise (e.g., brisk walking) for at least 30 min/day, most
days of the week
◗ Moderate alcohol consumption of 2 or fewer drinks per day for men and
1 drink or fewer per day for women
◗ Diet rich in fruits, vegetables, and low-fat dairy products with reduced
saturated and total fat
◗ Dietary intake of >3,500 mg of potassium ◗ Optimal blood pressure control (see p. 150)
◗ Lipid management
◗ Diabetes management so that fasting glucose level is <100 mg/dL and HgA1C is <7%
◗ Complete smoking cessation
◗ Conversion of atrial fibrillation to normal sinus rhythm or, if chronic,
anticoagulation
Techniques of Examination
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
HEART RATE AND BLOOD PRESSURE
If not already done, measure 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 inflations.
This step helps you to detect an ausculta-
tory gap and avoid recording an inappro-
priately low systolic blood pressure.
TTTecchhnniiquees offf EExaammminnatttionn
154 Bates’ Pocket Guide to Physical Examination and History Taking
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
Measure blood pressure with a sphygmomanometer. If indi- cated, recheck it.
Orthostatic (postural) hypotension
with position change from supine to
standing, SBP↓ ≥20 mm Hg; HR↑ ≥20 beats/min
JUGULAR VEINS
Identify jugular venous pulsa- tions and their highest point in the neck. Start with head of the bed at 30 degrees; adjust angle of the bed as necessary.
Study the waves of venous pul- sation. Note the a wave of atrial contraction and the v wave of venous filling.
Absent a waves in atrial fibrillation; prom- inent v waves in tricuspid regurgitation
Measure jugular venous pressure (JVP)—the vertical distance between this highest point and the sternal angle, normally <3 to 4 cm.
Elevated JVP in right-sided heart fail-
ure; decreased JVP in hypovolemia
from dehydration or gastrointestinal
bleeding
CAROTID PULSE
Assess the amplitude and con- tour of the carotid upstroke.
A delayed upstroke in aortic stenosis; a bounding upstroke in aortic insufficiency
Check for variations in pulse amplitude.
See pulsus alternans and paradoxical
pulse, p. 159
Listen for bruits. Carotid bruits suggest atherosclerotic narrowing and increase stroke risk.
Chapter 9 | The Cardiovascular System 155
INSPECTION AND PALPATION
Inspect and palpate the anterior chest for heaves, lifts, or thrills.
Identify the apical impulse. Turn patient to left as necessary. Note:
● Location of impulse
● Diameter
● Amplitude—usually tapping
● Duration
Displaced to left in pregnancy
Increased diameter, amplitude, and
duration in left ventricular dilatation
from congestive heart failure (CHF) or ischemic cardiomyopathy
Sustained in left ventricular hypertro- phy; diffuse in CHF
Sequence of the Cardiac Examination
Patient Position Examination
Supine, with the head
elevated 30 degrees
Inspect and palpate the precordium: the 2nd
interspaces; the right ventricle; and the left
ventricle, including the apical impulse (diameter,
location, amplitude, duration).
Left lateral decubitus Palpate the apical impulse if not previously de-
tected. Listen at the apex with the bell of the stethoscope for low-pitched extra sounds (S3, open- ing snap, diastolic rumble of mitral stenosis).
Supine, with the head
elevated 30 degrees
Listen at the 2nd right and left interspaces, along
the left sternal border, and across to the apex
with the diaphragm. Listen with the bell at the right sternal border for
tricuspid murmurs and sounds.
Sitting, leaning
forward, after full
exhalation
Listen along the left sternal border and at the apex
for the soft decrescendo diastolic murmur of
aortic insufficiency.
THE HEART
E XA M I N AT I O N T E C H N I Q U E S P OS S I B L E F I N D I N G S
156 Bates’ Pocket Guide to Physical Examination and History Taking
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
AUSCULTATION
Listen to heart by “inching” your stethoscope from the base to the apex (or apex to base) in the areas illustrated.
Apex—left ventricular area
Right 2nd interspace— aortic area
Left 2nd interspace— pulmonic area
Epigastric (subxiphoid)
Left sternal border—right ventricular area
Use the diaphragm in the areas illustrated above for 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. 161; Table 9-2, Variations in the First Heart
Sound—S1, p. 162; Table 9-3, Variations in
the Second Heart Sound—S2, pp. 163–164.
● S1
● S2. Is splitting normal in left 2nd and 3rd interspaces?
● Extra sounds in systole
● Extra sounds in diastole
● Systolic murmurs
● Diastolic murmurs
Physiologic (inspiratory) or pathologic
(expiratory) splitting
Systolic clicks
S3, S4
Midsystolic, pansystolic, late systolic
murmurs
Early, mid-, or late diastolic murmurs
E XA M I N AT I O N T E C H N I Q U E S P OS S I B L E F I N D I N G S
Chapter 9 | The Cardiovascular System 157
ASSESSING AND DESCRIBING MURMURS
Identify, if murmurs are present, their:
● Timing in the cardiac cycle (systole, diastole). It is help- ful to palpate the carotid upstroke while listening to any murmur—murmurs occur- ring simultaneously with the upstroke are systolic.
● Shape
S2S1
S2S1
S2 S1
S2 S1
● Location of maximal intensity
● Radiation
● Pitch
● Quality
● Intensity on a 6-point scale
See Table 9-4, Heart Murmurs, p. 165.
Plateau, crescendo, decrescendo
A crescendo–decrescendo murmur first rises in intensity, then falls (e.g., aortic
stenosis).
A plateau murmur has the same intensity throughout (e.g., mitral
regurgitation).
A crescendo murmur grows louder (e.g., mitral stenosis).
A decrescendo murmur grows softer (e.g., aortic regurgitation).
Murmurs loudest at the base are often aortic; at the apex, they are often mitral.
High, medium, low
Blowing, harsh, musical, rumbling
See “Gradations of Murmurs” on next page.
Listen at the apex with patient turned toward left side for low-pitched sounds.
Left-sided S3, and diastolic murmur of
mitral stenosis
E XA M I N AT I O N T E C H N I Q U E S P OS S I B L E F I N D I N G S
158 Bates’ Pocket Guide to Physical Examination and History Taking
Listen down left sternal border to the apex as patient sits, leaning forward, with breath held after exhalation.
Diastolic decrescendo murmur of aortic regurgitation
Gradations of Murmurs
Grade Description
Grade 1 Very faint, heard only after listener has “tuned in”; may not be heard in all positions
Grade 2 Quiet, but heard immediately after placing the stetho- scope on the chest
Grade 3 Moderately loud Grade 4 Loud, with palpable thrill Grade 5 Very loud, with thrill. May be heard when the stetho-
scope is partly off the chest
Grade 6 Very loud, with thrill. May be heard with stethoscope entirely off the chest
E XA M I N AT I O N T E C H N I Q U E S P OS S I B L E F I N D I N G S
Chapter 9 | The Cardiovascular System 159
SPECIAL TECHNIQUES
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
PULSUS ALTERNANS
Feel pulse for alternation in ampli- tude. Lower pressure of blood pressure cuff slowly to systolic level while you listen with stetho- scope over brachial artery.
Alternating amplitude of pulse or
sudden doubling of Korotkoff sounds
indicates pulsus alternans—a sign of left ventricular heart failure.
PARADOXICAL PULSE
Lower pressure of blood pres- sure cuff slowly and note two pressure levels: (1) where Korotkoff sounds are first heard and (2) where they first 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 inspira- tion signifies a paradoxical pulse. Con-
sider obstructive pulmonary disease,
pericardial tamponade, or constrictive
pericarditis.
AIDS TO IDENTIFY SYSTOLIC MURMURS
Valsalva Maneuver 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 (HC), listen to the intensity of the murmur.
In AS, the murmur decreases; in HC, it
often increases.
/ Squatting and Standing In suspected MVP, listen for the click and murmur in both positions.
Squatting increases ventricular fill-
ing and delays the click and murmur.
Standing reverses the changes.
Try to distinguish AS from HC by listening to the murmur in both positions.
Squatting increases murmur of AS and
decreases murmur of HC. Standing
reverses the changes.
160 Bates’ Pocket Guide to Physical Examination and History Taking
Recording Your FindingsRRReccoorddinnggg YYouuur Finnddinngss
Recording the Physical Examination—The Cardiovascular Examination
“The jugular venous pulse (JVP) is 3 cm above the sternal angle with the head
of the bed elevated to 30 degrees. Carotid upstrokes are brisk, without bruits.
The point of maximal impulse (PMI) is tapping, 7 cm lateral to the midsternal
line in the 5th intercostal space. Crisp S1 and S2. At the base, S2 is greater than
S1 and physiologically split, with A2 > P2. At the apex, S1 is greater than S2 and constant. No murmurs or extra sounds.”
OR “The JVP is 5 cm above the sternal angle with the head of the bed elevated to
50 degrees. Carotid upstrokes are brisk; a bruit is heard over the left carotid
artery. The PMI is diffuse, 3 cm in diameter, palpated at the anterior axillary
line in the 5th and 6th intercostal spaces. S1 and S2 are soft. S3 present at the
apex. High-pitched, harsh 2/6 holosystolic murmur best heard at the apex,
radiating to the axilla. No S4 or diastolic murmurs.” (Suggests CHF with possible left carotid stenosis and mitral regurgitation.)
Chapter 9 | The Cardiovascular System 161
Table 9-1 Heart Sounds
Systole Diastole
S1 S3S2OS S1E1 S4
Finding Possible Causes
S1 accentuated Tachycardia, states of high cardiac output; mitral stenosis
S1 diminished First-degree heart block; reduced left ventricular contractility; immobile mitral valve, as in mitral regurgitation
Systolic clicks(s) Mitral valve prolapse (as in E1 above)
S2 accentuated in right 2nd interspace
Systemic hypertension, dilated aortic root
S2 diminished or absent in right 2nd interspace
Immobile aortic valve, as in calcific aortic stenosis
P2 accentuated Pulmonary hypertension, dilated pulmonary artery, atrial septal defect
P2 diminished or absent Aging, pulmonic stenosis
Opening snap 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
Aids to Interpretation
162 Bates’ Pocket Guide to Physical Examination and History Taking
Table 9-2 Variations in the First Heart Sound—S1
Normal Variations
S1 S2
S1 is softer than S2 at the base (right and left 2nd interspaces).
S1 S2
S1 is often but not always louder than S2 at the apex.
Accentuated S1
S1 S2
Occurs in (1) tachycardia, rhythms with a short PR interval, and high cardiac output states (e.g., exercise, anemia, hyperthyroidism), and (2) mitral stenosis.
Diminished S1
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.
Varying S1
S1 S2 S1 S2
S1 varies in complete heart block and any totally irregular rhythm (e.g., atrial fibrillation).
Split S1
S1 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.
Chapter 9 | The Cardiovascular System 163
Table 9-3 Variations in the Second Heart Sound—S2 During Inspiration and Expiration
Physiologic Splitting
S1 S2S1 S2
A2 P2
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.
Pathologic Splitting
S1 S2S1 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.
Fixed Splitting
S1 S2S1 S2
Does not vary with respiration, as in atrial septal defect, right ventricular failure.
(continued)
164 Bates’ Pocket Guide to Physical Examination and History Taking
Paradoxical or Reversed Splitting
S1 S2 S1 S2
P2 A2
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.
More on A2 and P2 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.
Table 9-3
Variations in the Second Heart Sound—S2 During Inspiration and Expiration (continued )
Chapter 9 | The Cardiovascular System 165
Table 9-4 Heart Murmurs
Likely Causes
Midsystolic
S1 S2
Innocent murmurs (no valve abnormality) Physiologic murmurs (from ↑ flow across
a semilunar valve, as in pregnancy, fever, anemia)
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
Pansystolic
S1 S2
Mitral regurgitation Tricuspid regurgitation Ventricular septal defect
Late Systolic
S1 S2C
Mitral valve prolapse, often with click (C)
Early Diastolic
S1 S1S2
Aortic regurgitation
Middiastolic and Presystolic
S1 S1S2 OS
Mitral stenosis—note opening snap (OS)
Continuous Murmurs and Sounds
S1 S2 S1
S1 S2 S1
S1 S2 S1
Patent ductus arteriosus—harsh, machinery- like
Pericardial friction rub—a scratchy sound with 1–3 components
Venous hum—continuous, above midclavicles, loudest in diastole
167
C H A P T E R
10The Breasts and Axillae
Ask, “Do you examine your breasts?” . . . “How often?” Ask about any discomfort, pain, or lumps in the breasts. Also ask about any dis- charge from the nipples, change in breast contour, dimpling, swelling, or puckering of the skin over the breasts.
The Health History
Common or Concerning Symptoms
◗ Breast lump or mass
◗ Breast pain or discomfort
◗ Nipple discharge
Health Promotion and Counseling: Evidence and Recommendations
Important Topics for Health Promotion and Counseling
◗ Palpable masses of the breast
◗ Assessing risk of breast cancer
◗ Breast cancer screening
◗ Breast self-examination (BSE)
Palpable Masses of the Breast. Breast masses show marked variation in etiology, from fibroadenomas and cysts seen in younger women, to abscess or mastitis, to primary breast cancer. All breast masses warrant careful evaluation, and definitive diagnostic measures should be pursued.
168 Bates’ Pocket Guide to Physical Examination and History Taking
Palpable Masses of the Breast
Age Common Lesion Characteristics
15–25 Fibroadenoma Usually smooth, rubbery, round,
mobile, nontender
25–50 Cysts Usually soft to firm, round, mo-
bile; often tender
Fibrocystic changes Nodular, ropelike
Cancer Irregular, firm, may be mobile or
fixed to surrounding tissue
Over 50 Cancer until proven
otherwise
As above
Pregnancy/
lactation
Lactating adenomas, cysts,
mastitis, and cancer
As above
Adapted from Schultz MZ, Ward BA, Reiss M. Breast diseases. In: Noble J, Greene HL,
Levinson W, et al., eds: Primary Care Medicine, 2nd ed. St. Louis: Mosby, 1996. See also
Venet L, Strax P, Venet W, et al. Adequacies and inadequacies of breast examinations by
physicians in mass screenings. Cancer 1971;28(6):1546–1551.
Assessing Risk of Breast Cancer. Although 70% of affected women have no known predisposing factors, selected risk factors are well established. 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 assess risk of BRCA1 or BRCA2 gene mutation. (See http: astor.som.jhmi.edu/Bayesmendel/brcapro. html). See also Table 10-1, Breast Cancer in Women: Factors That Increase Relative Risk, p. 175.
Breast Cancer Screening. The American Cancer Society recom- mendations, listed below, vary slightly from those of the U.S. Preven- tive Services Task Force.
● Yearly mammography for women 40 years of age and older. For women at increased risk, many clinicians advise initiating screening mammography between ages 30 and 40, then every 2 to 3 years until 50 years of age.
Chapter 10 | The Breasts and Axillae 169
● Clinical breast examination (CBE) by a health care professional every 3 years for women between 20 and 39 years of age, and annually after 40 years of age
● Regular breast self-examination (BSE), in conjunction with mam- mography and CBE, to help promote health awareness
Techniques of Examination
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
Subclavian vein Subclavian lymph nodes
Axillary vein Axillary lymph nodes
Axillary tail of breast
Fat
Serratus anterior
Pectoralis major
Areola
Upper inner
Upper outer
Lower outer
Lower innerGland lobules
THE FEMALE BREAST
Inspect the breasts in four positions.
Note: ● Size and symmetry See Table 10-2, Visible Signs of Breast
Cancer, pp. 176–177, development,
asymmetry.
● Contour Flattening, dimpling
170 Bates’ Pocket Guide to Physical Examination and History Taking
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
● Appearance of the skin Edema (peau d’orange) in breast cancer
ARMS AT SIDES ARMS OVER HEAD
HANDS PRESSED AGAINST HIPS LEANING FORWARD
Inspect the nipples. ● Compare their size, shape, and direction of pointing.
Inversion, retraction, deviation
● Note any rashes, ulcerations, or discharge.
Paget’s disease of the nipple,
galactorrhea
Palpate the breasts, includ- ing augmented breasts. Breast tissue should be flattened and the patient supine. Palpate a rectangular area extending from the clavicle to the inframam- mary fold, and from the midsternal line to the posterior axillary line and well into the axilla for the tail of Spence.
Chapter 10 | The Breasts and Axillae 171
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
Note:
● Consistency Physiologic nodularity
● Tenderness Infection, premenstrual tenderness
● Nodules. If present, note location, size, shape, consis- tency, delimitation, tenderness, and mobility.
Cyst, fibroadenoma, cancer
Use 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.
● For the medial portion of the breast, ask the patient to lie with her shoulders flat against the bed or examining table, place her hand at her neck, and lift up her elbow until it is even with her shoulder.
Palpate each nipple. Thickening in cancer
Palpate and inspect along the incision lines of mastectomy.
Local recurrences of breast cancer
172 Bates’ Pocket Guide to Physical Examination and History Taking
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
THE MALE BREAST / Inspect and palpate the
nipple and areola. Gynecomastia, mass suspicious for
cancer, fat
AXILLAE
Inspect for rashes, infection, and pigmentation.
Hidradenitis suppurativa, acanthosis
nigricans
Palpate the axillary nodes, including the central, pectoral, lateral, and subscapular groups.
Lymphadenopathy
Lateral
Central (deep within axilla)
Subscapular (posterior)
Pectoral (anterior)
Supraclavicular
Infraclavicular
ARROWS INDICATE DIRECTION OF LYMPH FLOW
SPECIAL TECHNIQUE
BREAST DISCHARGE
Compress the areola in a spokelike pattern around the nipple. Watch for discharge.
Type and source of discharge may be
identified.
Chapter 10 | The Breasts and Axillae 173
/ BREAST SELF-EXAMINATION
Patient Instructions for the Breast Self-Examination (BSE)
Supine
1. Lie down with a pillow under your right shoulder. Place your
right arm behind your head.
2. Use the finger pads of the three middle fingers on your left hand
to feel for lumps in the right
breast. The finger pads are the
top third of each finger.
3. Press firmly enough to know how your breast feels. A firm
ridge in the lower curve of each
breast is normal. If you’re not
sure how hard to press, talk with
your health care provider, or try
to copy the way the doctor or
nurse does it.
4. Press firmly on the breast in an up-and-down or “strip” pattern.
You can also use a circular or
wedge pattern, but be sure to
use the same pattern every
time. Check the entire breast
area, and remember how your
breast feels from month to
month.
5. Repeat the examination on your left breast, using the finger pads
of the right hand.
6. If you find any changes, see your doctor right away.
(continued)
174 Bates’ Pocket Guide to Physical Examination and History Taking
Patient Instructions for the Breast Self-Examination (BSE) (continued)
Standing
1. While standing in front of a mirror with your hands
pressing firmly down on your
hips, look at your breasts for
any changes of size, shape,
contour, or dimpling, or redness
or scaliness of the nipple or
breast skin. (The pressing down
on the hips position contracts
the chest wall muscles and
enhances any breast changes.)
2. Examine each underarm while sitting up or standing and with
your arm only slightly raised so
you can easily feel in this area.
Raising your arm straight up
tightens the tissue in this area
and makes it harder to examine.
Adapted from the American Cancer Society, updated September 2010. Available at http://
www.cancer.org/Cancer/BreastCancer/MoreInformation/BreastCancerEarlyDetection/
breast-cancer-early-detection-a-c-s-recs-b-s-e. Accessed December 3, 2010.
Recording Your Findings
Recording the Physical Examination— Breasts and Axillae
“Breasts symmetric and smooth, without masses. Nipples without discharge.”
(Axillary adenopathy usually included after Neck in section on Lymph Nodes;
see p. 123.)
OR “Breasts pendulous with diffuse fibrocystic changes. Single firm 1 × 1 cm mass, mobile and nontender, with overlying peau d’orange appearance in right
breast, upper outer quadrant at 11 o’clock, 2 cm from the nipple.” (Suggests possible breast cancer.)
Chapter 10 | The Breasts and Axillae 175
Aids to Interpretation
Breast Cancer in Women: Factors That Increase Relative RiskTable 10-1
Relative Risk Factor
>4.0 ● Female ● Age (65+ versus <65 years, although risk increases across all ages until age 80)
● Certain inherited genetic mutations for breast cancer (BRCA1 and/or BRCA2)
● Two or more first-degree relatives with breast cancer diagnosed at an early age
● Personal history of breast cancer ● High breast tissue density ● Biopsy-confirmed atypical hyperplasia
2.1–4.0 ● One first-degree relative with breast cancer
● High-dose radiation to chest ● High bone density (postmenopausal)
1.1–2.0
Factors that affect circulating hormones
● Late age at first full-term pregnancy (>30 years)
● Early menarche (<12 years) ● Late menopause (>55 years) ● No full-term pregnancies ● Never breast-fed a child ● Recent oral contraceptive use ● Recent and long-term use of hormone replacement therapy
● Obesity (postmenopausal)
Other factors ● Personal history of endometrium, ovary, or colon cancer
● Alcohol consumption ● Height (tall) ● High socioeconomic status ● Jewish heritage
Source: American Cancer Society. Breast Cancer Facts and Figures 2009–2010, p. 11. Available at: www.cancer.org/acs/groups/content/cnho/documents/document/ f861009final90809pdf.pdf. Accessed July 31, 2012.
176 Bates’ Pocket Guide to Physical Examination and History Taking
Visible Signs of Breast CancerTable 10-2
Retraction Signs
Fibrosis from breast cancer produces retraction signs: dimpling, changes in contour, and retraction or deviation of the nipple. Other causes of retraction include fat necrosis and mammary duct ectasia.
Cancer
Dimpling
Retracted nipple
Skin Dimpling
Abnormal Contours Look for any variation in the normal
convexity of each breast, and compare one side with the other.
Nipple Retraction and Deviation A retracted nipple is flattened or
pulled inward. It may also be broadened and feel thickened. The nipple may deviate, or point in a different direction, typically toward the underlying cancer.
Chapter 10 | The Breasts and Axillae 177
Visible Signs of Breast Cancer (continued)Table 10-2
Edema of the Skin
From lymphatic blockade, appearing as thickened skin with enlarged pores—the so-called peau d’orange (orange peel) sign.
Paget’s Disease of the Nipple
An uncommon form of breast cancer that usually starts as a scaly, eczemalike lesion. The skin may also weep, crust, or erode. A breast mass may be present. Suspect Paget’s disease in any persisting dermatitis of the nipple and areola.
Dermatitis of areola
Erosion of nipple
179
C H A P T E R
11The Abdomen The Health History
Common or Concerning Symptoms
Gastrointestinal Disorders Urinary and Renal Disorders
◗ Abdominal pain, acute and chronic
◗ Indigestion, nausea, vomiting includ-
ing blood, loss of appetite, early
satiety
◗ Dysphagia and/or odynophagia
◗ Change in bowel function
◗ Diarrhea, constipation
◗ Jaundice
◗ Suprapubic pain
◗ Dysuria, urgency, or frequency
◗ Hesitancy, decreased stream
in males
◗ Polyuria or nocturia
◗ Urinary incontinence
◗ Hematuria
◗ Kidney or flank pain
◗ Ureteral colic
PATTERNS AND MECHANISMS OF ABDOMINAL PAIN
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 disten-
tion against its capsule in alcoholic hepatitis
● May be difficult to localize
● Varies in quality; may be gnawing, burning, cramping, or aching
180 Bates’ Pocket Guide to Physical Examination and History Taking
● When severe, may be associated with sweating, pallor, nausea, vomiting, restlessness.
Parietal pain—from inflammation of the parietal peritoneum.
● Steady, aching
● Usually more severe
● Usually more precisely localized over the involved structure than visceral pain
Visceral periumbilical pain in early acute appendicitis from distention of inflamed appendix gradually
changes to parietal pain in the right
lower quadrant (RLQ) from inflam-
mation of the adjacent parietal
peritoneum.
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 myocar- dial infarction may be referred to the upper abdomen.
THE GASTROINTESTINAL TRACT
Ask patients to describe the abdominal pain in their own words, especially timing of the pain (acute or chronic); then ask them to point to the pain.
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?”
Chapter 11 | The Abdomen 181
Elicit any symptoms associated with the pain, such as fever or chills; ask their sequence.
Upper Abdominal Pain, Discomfort, or Heartburn. Ask about chronic or recurrent upper abdominal discomfort, or dyspepsia. Related symptoms include bloating, nausea, upper abdominal fullness, and heartburn.
Find out just what your patient means. Possibilities include:
● Bloating from excessive gas, especially with frequent belching, abdominal distention, or flatus, the passage of gas by rectum
● Nausea and vomiting
● Unpleasant abdominal fullness after normal meals or early satiety, the inability to eat a full meal
● Heartburn
Consider diabetic gastroparesis,
anticholinergic drugs, gastric outlet
obstruction, gastric cancer. Early
satiety may signify hepatitis.
Suggests gastroesophageal reflux disease (GERD)
Lower Abdominal Pain or Discomfort—Acute and Chronic. If acute, is the pain sharp and continuous or intermittent and cramping?
Right lower quadrant (RLQ) pain,
or pain migrating from perium-
bilical region in appendicitis; in women with RLQ pain, possible
pelvic inflammatory disease, ectopic pregnancy
Left lower quadrant (LLQ) pain in
diverticulitis
182 Bates’ Pocket Guide to Physical Examination and History Taking
If chronic, is there a change in bowel habits? Alternating diarrhea and constipation?
Colon cancer; irritable bowel syndrome
Other GI Symptoms ● Anorexia
● Dysphagia or difficulty swallowing
Liver disease, pregnancy, diabetic
ketoacidosis, adrenal insufficiency,
uremia, anorexia nervosa
If solids and liquids, neuro-
muscular disorders affecting
motility. If only solids, consider
structural conditions like Zenker’s
diverticulum, Schatzki’s ring, stric-
ture, neoplasm
● Odynophagia, or painful swallowing
● Diarrhea, acute (<2 weeks) and chronic
● Constipation
● Melena, or black tarry stools
● Jaundice from increased levels of bilirubin: Intrahepatic jaundice can be hepatocellular, from damage to the hepatocytes, or cholestatic, from impaired excretion caused by dam- aged hepatocytes or intrahepatic bile ducts
Radiation; caustic ingestion,
infection from cytomegalovirus, herpes simplex, HIV
Acute infection (viral, salmonella,
shigella, etc.); chronic in Crohn’s disease, ulcerative colitis; oily diarrhea (steatorrhea)—in pancre- atic insufficiency. See Table 11-1,
Diarrhea, pp. 194–195.
Medications, especially anticho-
linergic agents and opioids; colon cancer
GI bleed
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
Chapter 11 | The Abdomen 183
Ask about the color of the urine and stool.
Dark urine from increased conju-
gated bilirubin excreted in urine;
acholic clay-colored stool when
excretion of bilirubin into intestine
is obstructed
Risk Factors for Liver Disease
◗ Hepatitis A: Travel or meals in areas with poor sanitation, ingestion of con- taminated water or foodstuffs
◗ Hepatitis B: Parenteral or mucous membrane exposure to infectious body fluids such as blood, serum, semen, and saliva, especially through sexual contact
with an infected partner or use of shared needles for injection drug use
◗ Hepatitis C: Illicit intravenous drug use or blood transfusion ◗ Alcoholic hepatitis or alcoholic cirrhosis: Interview the patient carefully about alcohol use
◗ Toxic liver damage from medications, industrial solvents, environmental toxins or some anesthetic agents
◗ Extrahepatic biliary obstruction that may result from gallbladder disease or surgery
◗ Hereditary disorders reported in the Family History
THE URINARY TRACT
Ask about pain on urination, usually a burning sensation, some- times termed dysuria (also refers to difficulty voiding).
Bladder infection
Also, consider bladder stones,
foreign bodies, tumors, and acute prostatitis. In women, internal burn- ing in urethritis, external burning in vulvovaginitis
Other associated symptoms include: ● Urgency, an unusually intense and immediate desire to void
● Urinary frequency, or abnormally frequent voiding
● Fever or chills; blood in the urine
● Any pain in the abdomen, flank, or back
May lead to urge incontinence
Dull, steady pain in pyelonephritis; severe colicky pain in ureteral
obstruction from renal stone
184 Bates’ Pocket Guide to Physical Examination and History Taking
In men, hesitancy in starting the urine stream, straining to void, reduced caliber and force of the urine stream, or dribbling as they complete voiding.
Prostatitis, urethritis
Assess any: ● Polyuria, a significant increase in 24-hour urine volume
● Nocturia, urinary frequency at night
● Urinary incontinence, involuntary loss of urine:
● From coughing, sneezing, lifting
● From urge to void
● From bladder fullness with leaking but incomplete emptying
Diabetes mellitus, diabetes insipidus
Bladder obstruction
See Table 11-2, Urinary Inconti-
nence, pp. 196–197.
Stress incontinence (poor urethral sphincter tone)
Urge incontinence (detrusor over- activity)
Overflow incontinence (anatomic obstruction, impaired neural
innervation to bladder)
Health Promotion and Counseling: Evidence and Recommendations
Important Topics for Health Promotion and Counseling
◗ Screening for alcohol abuse
◗ Risk factors for hepatitis A, B, and C
◗ Screening for colon cancer
Alcohol Abuse. Assessing use of alcohol is an important clinician responsibility. Focus on detection, counseling, and, for significant impairment, specific treatment recommendations. Use the four CAGE questions to screen for alcohol dependence or abuse in all adolescents and adults, including pregnant women (see Chapter 3, p. 46). Brief
HHHeealltthh PPrroommoootioonn andd CCCouunsselingg: EEEviideenncce aannd Reecooommmmeeenddattionns
Chapter 11 | The Abdomen 185
counseling interventions have been shown to reduce alcohol con- sumption by 13% to 34% over 6 to 12 months.
Hepatitis. Protective measures against infectious hepatitis include counseling about transmission:
● Hepatitis A: Transmission is fecal–oral. Illness occurs approximately 30 days after exposure. Hepatitis A vaccine is recommended for chil- dren after age 1 and groups at risk: travelers to endemic areas; food handlers; military personnel; caretakers of children; Native Americans and Alaska Natives; selected health care, sanitation, and laboratory workers; homosexual men; and injection drug users.
● Hepatitis B: Transmission occurs during contact with infected body fluids, such as blood, semen, saliva, and vaginal secretions. Infec- tion increases risk of fulminant hepatitis, chronic infection, and sub- sequent cirrhosis and hepatocellular carcinoma. Provide counseling and serologic screening for patients at risk. Hepatitis B vaccine is recommended for infants at birth and groups at risk: all young adults not previously immunized, injection drug users and their sexual partners, people at risk for sexually transmitted infections, travelers to endemic areas, recipients of blood products as in hemo- dialysis, and health care workers with frequent exposure to blood products. Many of these groups also should be screened for HIV infection, especially pregnant women at their first prenatal visit.
● Hepatitis C: Hepatitis C, now the most common form, is spread by blood exposure and is associated with injection drug use. No vaccine is available.
Colorectal Cancer. The U.S. Preventive Services Task Force made the recommendations below in 2008.
Screening for Colorectal Cancer
Assess Risk: Begin screening at age 20 years. If high risk, refer for more com- plex management. If average risk at age 50 (high-risk conditions absent), offer
the screening options listed.
◗ Common high-risk conditions (25% of colorectal cancers) ◗ Personal history of colorectal cancer or adenoma
◗ First-degree relative with colorectal cancer or adenomatous polyps
◗ Personal history of breast, ovarian, or endometrial cancer
◗ Personal history of ulcerative or Crohn’s colitis
(continued)
186 Bates’ Pocket Guide to Physical Examination and History Taking
Detection rates for colorectal cancer and insertion depths of colon- oscopy are roughly as follows: 25% to 30% at 20 cm; 50% to 55% at 35 cm; 40% to 65% at 40 cm to 50 cm. Full colonoscopy or air con- trast barium enema detects 80% to 95% of colorectal cancers.
Techniques of Examination
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
THE ABDOMEN
Inspect the abdomen, including:
● Skin
● Umbilicus
● Contours for shape, symmetry, enlarged organs or masses
● Any peristaltic waves
● Any pulsations
Scars, striae, veins, ecchymoses (in intra-
or retroperitoneal hemorrhages)
Hernia, inflammation
Bulging flanks of ascites, suprapubic
bulge, large liver or spleen, tumors
Increase in GI obstruction
Increased in aortic aneurysm
Screening for Colorectal Cancer (continued)
◗ Hereditary high-risk conditions (6% of colorectal cancers) ◗ Familial adenomatous polyposis
◗ Hereditary nonpolyposis colorectal cancer
Screening recommendations—U.S. Preventive Services Task Force 2008 ◗ Adults age 50 to 75 years—options
◗ High-sensitivity fecal occult blood testing (FOBT) annually
◗ Sigmoidoscopy every 5 years with FOBT every 3 years
◗ Screening colonoscopy every 10 years
◗ Adults age 76 to 85 years—do not screen routinely, as gain in life-years is small compared to colonoscopy risks, and screening benefits not seen for
7 years; use individual decision making if screening for the first time
◗ Adults older than age 85—do not screen, as “competing causes of mortality preclude a mortality benefit that outweighs harms”
TTTecchnniiquees offf EExaammminnattionn
Chapter 11 | The Abdomen 187
Bowel Sounds and Bruits
Change Seen With
Increased bowel sounds Diarrhea
Early intestinal obstruction
Decreased, then absent bowel sounds Adynamic ileus
Peritonitis
High-pitched tinkling bowel sounds Intestinal fluid
Air under tension in a dilated bowel
High-pitched rushing bowel sounds
with cramping
Intestinal obstruction
Hepatic bruit Carcinoma of the liver
Alcoholic hepatitis
Arterial bruits Partial obstruction of the aorta or
renal, iliac or femoral arteries
Aorta
Renal artery
Iliac artery
Femoral artery
Percuss the abdomen for patterns of tympany and dullness.
Ascites, GI obstruction, pregnant uterus,
ovarian tumor
Palpate all quadrants of the abdomen:
See Table 11-3, Abdominal Tenderness,
p. 197.
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
Auscultate the abdomen for:
● Bowel sounds
● Bruits
● Friction rubs
Increased or decreased motility
Bruit of renal artery stenosis
Liver tumor, splenic infarct
188 Bates’ Pocket Guide to Physical Examination and History Taking
● Lightly for guarding, rebound, and tenderness
“Acute abdomen” or peritonitis if:
• Firm, boardlike abdominal wall— suggests peritoneal inflammation.
• Guarding if the patient flinches, grimaces, or reports pain during
palpation.
• 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.”
● Deeply for masses or tenderness
Tumors, a distended viscus
THE LIVER
Percuss span of liver dullness in the midclavicular line (MCL).
Hepatomegaly
4–8 cm in midsternal line
6–12 cm in right midclavicular line
Normal liver spans
Feel the liver edge, if possible, as patient breathes in.
Firm edge of cirrhosis
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
Chapter 11 | The Abdomen 189
Measure its distance from the costal margin in the MCL.
Increased in hepatomegaly—may be
missed (as below) by starting palpation
too high in the RUQ
Note any tenderness or masses. Tender liver of hepatitis or heart failure; tumor mass
THE SPLEEN
Percuss across left lower anterior chest, noting change from tym- pany to dullness.
Try to feel spleen with the patient:
Splenomegaly
● Supine
● Lying on the right side with legs flexed at hips and knees
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
190 Bates’ Pocket Guide to Physical Examination and History Taking
THE KIDNEYS
Try to palpate each kidney. Enlargement from cysts, cancer, hydronephrosis
Check for costovertebral angle (CVA) tenderness.
Tender in pyelonephritis
THE AORTA
Palpate the aorta’s pulsa- tions. In older people, estimate its width.
Periumbilical mass with expansile pulsa-
tions ≥3 cm in diameter in abdominal aortic aneurysm. Assess further due to risk of rupture.
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
Chapter 11 | The Abdomen 191
ASSESSING ASCITES
/ Palpate for shifting dullness. Map areas of tympany and dullness with patient supine, then lying on side (see below).
Ascitic fluid usually shifts to dependent
side, changing the margin of dullness
(see below)
Tympany
Dullness
Tympany
Shifting dullness
Check for a fluid wave. 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.
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
192 Bates’ Pocket Guide to Physical Examination and History Taking
Ballotte an organ or mass in an ascitic abdomen. Place your stiffened and straightened fingers on the abdomen, briefly 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.
ASSESSING POSSIBLE APPENDICITIS Ask: In classic appendicitis:
“Where did the pain begin?” Near the umbilicus
“Where is it now?” Right lower quadrant (RLQ)
Ask patient to cough. “Where does it hurt?”
RLQ at “McBurney’s point”
Palpate for local tenderness. RLQ tenderness
Palpate for muscular rigidity. RLQ rigidity
Perform a rectal examination and, in women, a pelvic examina- tion (see Chapters 14 and 15).
Local tenderness, especially if appendix
is retrocecal
● Rovsing’s sign: Press deeply and evenly in the left lower quadrant. Then quickly with- draw your fingers.
Pain in the right lower quadrant during left-sided pressure suggests appendici- tis (a positive Rovsing’s sign).
● 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.
Pain from irritation of the psoas muscle
suggests an inflamed appendix (a posi- tive psoas sign).
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
Chapter 11 | The Abdomen 193
● 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.
Right hypogastric pain in a positive obturator sign, suggesting irritation of
the obturator muscle by an inflamed
appendix.
ASSESSING POSSIBLE ACUTE CHOLECYSTITIS
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 Murphy’s 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’s sign.
Recording Your Findings
Recording the Physical Examination—The Abdomen
“Abdomen is protuberant with active bowel sounds. It is soft and nontender;
no palpable masses or hepatosplenomegaly. Liver span is 7 cm and in the right
MCL; edge is smooth and palpable 1 cm below the right costal margin. Spleen
and kidneys not felt. No CVA tenderness.”
OR “Abdomen is flat. No bowel sounds heard. It is firm and boardlike, with in-
creased tenderness, guarding, and rebound in the right midquadrant. Liver
percusses to 7 cm in the MCL; edge not felt. Spleen and kidneys not felt. No
palpable mass. No CVA tenderness.” (Suggests peritonitis from possible appendi- citis; see pp. 192–193.)
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
RRReccoorddinnggg YYouuur Finnddinngss
194 Bates’ Pocket Guide to Physical Examination and History Taking
Aids to InterpretationAAAiddss ttoo IInntterrpprreetaattioonn
DiarrheaTable 11-1
Problem/Process Characteristics of Stool
Acute Diarrhea
Secretory Infections (noninflammatory) Infection by viruses; preformed
bacterial toxins such as Staphylococcus aureus, Clostridium perfringens, toxigenic Escherichia coli; Vibrio cholerae, Cryptosporidium, Giardia lamblia
Watery, without blood, pus, or mucus
Inflammatory Infections Colonization or invasion
of intestinal mucosa as in nontyphoid Salmonella, Shigella, Yersinia, Campylobacter, enteropathic E. coli, Entamoeba histolytica
Loose to watery, often with blood, pus, or mucus
Drug-Induced Diarrhea
Action of many drugs, such as magnesium-containing antacids, antibiotics, antineoplastic agents, and laxatives
Loose to watery
Chronic Diarrhea ( 30 days)
Diarrheal Syndromes ● 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
Chapter 11 | The Abdomen 195
Problem/Process Characteristics of Stool
Inflammatory Bowel Disease ● Ulcerative colitis: inflammation and ulceration of the mucosa and submucosa of the rectum and colon
● Crohn’s 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)
Voluminous Diarrheas ● Malabsorption syndrome: Defective absorption of fat, including fat-soluble 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
Diarrhea (continued)Table 11-1
196 Bates’ Pocket Guide to Physical Examination and History Taking
Urinary IncontinenceTable 11-2
Problem Mechanisms
Stress Incontinence: 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.
● 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
Urge Incontinence: Detrusor contractions are stronger than normal and overcome normal urethral resistance. Bladder is typically small. Results in voiding moderate amounts, urgency, frequency, and nocturia.
● 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
Overflow Incontinence: Detrusor contractions are insufficient to overcome urethral resistance. Bladder is typically large, even after an effort to void, leading to continuous dribbling.
● 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
Chapter 11 | The Abdomen 197
Urinary Incontinence (continued)Table 11-2
Problem Mechanisms
Functional Incontinence: Inability to get to the toilet in time because of impaired health or environmental conditions
● Problems in mobility from weakness, arthritis, poor vision, other conditions; environmental factors such as unfamiliar setting, distant bathroom facilities, bed rails, physical restraints
Incontinence Secondary to Medications: Drugs may contribute to any type of incontinence listed.
● Sedatives, tranquilizers, anticholinergics, sympathetic blockers, potent diuretics
Abdominal TendernessTable 11-3
Visceral Tenderness Peritoneal Tenderness
Enlarged liver
Normal cecum
Normal aorta
Normal or spastic sigmoid colon
Diverticulitis
Appendicitis Cholecystitis
Tenderness From Disease in the Chest and Pelvis
Acute Pleurisy Acute Salpingitis
Unilateral or bilateral, upper or lower abdomen
199
C H A P T E R
12The Peripheral Vascular System
Ask about abdominal, flank, or back pain, especially in older male smokers.
An expanding abdominal aortic aneu-
rysm (AAA) may compress arteries or
ureters.
Ask about any pain in the arms and legs.
Is there intermittent claudica- tion, 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 cramp- ing in your legs when you walk or exercise?” “How far can you walk without stopping to rest?” and “Does pain improve with rest?”
Peripheral arterial disease (PAD) can cause symptomatic limb ischemia with exer-
tion; distinguish this from spinal stenosis, which produces leg pain with exertion
often reduced by leaning forward
(stretching the spinal cord in the nar-
rowed 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 gan-
grene may ensue.
The Health History
◗ Abdominal, flank, or back pain
◗ Pain in the arms or legs
◗ Intermittent claudication
◗ Cold, numbness, pallor in the legs; hair loss
◗ Color change in fingertips or toes in cold weather
◗ Swelling in calves, legs, or feet
◗ Swelling with redness or tenderness
Common or Concerning Symptoms
200 Bates’ Pocket Guide to Physical Examination and History Taking
Because patients have few symptoms, identify risk factors— tobacco abuse, hypertension, diabetes, hyperlipidemia, and history of myocardial infarction or stroke.
Only approximately 10% to 30% of
affected patients have the classic symp-
toms of exertional calf pain relieved
by rest.
“Do your fingertips or toes ever change color in cold weather or when you handle cold objects?”
Digital ischemic changes from arte-
rial spasm cause blanching, followed
by cyanosis and then rubor with cold
exposure and rewarming in Raynaud’s phenomenon or disease
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 thrombo-
sis; hyperpigmentation, edema, and
possible cyanosis, especially when legs
are dependent, in venous stasis ulcers; swelling with redness and tenderness
in cellulitis
◗ Screening for peripheral arterial disease (PAD); the ankle–brachial index
◗ Screening for renal artery disease
◗ Screening for abdominal aortic aneurysm
Screening for Peripheral Arterial Disease (PAD). PAD involves the femoral and popliteal arteries most commonly, followed by the tibial and peroneal arteries. PAD affects from 12% to 29% of community populations; despite significant association with cardio- vascular and cerebrovascular disease, PAD often is underdiagnosed in office practices. Most patients with PAD have either no symptoms or a range of nonspecific leg symptoms, such as aching, cramping, numb- ness, or fatigue.
Health Promotion and Counseling: Evidence and Recommendations
Important Topics for Health Promotion and Counseling
Chapter 12 | The Peripheral Vascular System 201
Screen patients for PAD risk factors, such as tobacco abuse, elevated cholesterol, diabetes, age older than 70 years, hypertension, or athero- sclerotic coronary, carotid, or renal artery disease. Pursue aggressive risk factor intervention. Consider use of the ankle–brachial index (ABI), a highly accurate test for detecting stenoses of 50% or more in major vessels of the legs (see pp. 209–210).
A wide range of interventions reduces both onset and progression of PAD, including meticulous foot care and well-fitting shoes, tobacco cessation, treatment of hyperlipidemia, optimal control and treatment of diabetes and hypertension, use of antiplatelet agents, graded exer- cise, and surgical revascularization. Patients with ABIs in the lowest category have a 20% to 25% annual risk of death.
Screening for Renal Ar ter y Disease. The American College of Cardiology and the American Heart Association recommend diagnostic studies for renal artery disease, usually beginning with ultrasound, in patients with hypertension before age 30 years; severe hypertension (see p. 56) after age 55 years; accelerated, resistant, or malignant hypertension; new worsening of renal func- tion or worsening after use of an angiotensin-converting enzyme inhibitor or an angiotensin-receptor blocking agent; an unex- plained small kidney; or sudden unexplained pulmonary edema, especially in the setting of worsening renal function. Symptoms arise from these conditions rather than directly from atherosclerotic changes in the renal artery.
Screening for Abdominal Aor tic Aneurysm (AAA). An AAA is present when the infrarenal aortic diameter exceeds 3.0 cm. Rup- ture and mortality rates dramatically increase for AAAs exceeding 5.5 cm in diameter. The strongest risk factor for rupture is excess aortic 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 approximately 40%, 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,” defined as more than 100 cigarettes in a lifetime.
202 Bates’ Pocket Guide to Physical Examination and History Taking
● Radial Bounding radial, carotid, and femoral pulses in aortic regurgitation
Lost in thromboangiitis obliterans or acute arterial occlusion
● Brachial
Techniques of Examination
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
ARMS
Inspect for:
● Size and symmetry, any swelling
● Venous pattern
● Color and texture of skin and nails
Lymphedema, venous obstruction
Venous obstruction
Raynaud’s disease
Palpate and grade the pulses:
Grading Ar terial Pulses
3+ Bounding 2+ Brisk, expected (normal) 1+ Diminished, weaker than expected 0 Absent, unable to palpate
Chapter 12 | The Peripheral Vascular System 203
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
Feel for the epitrochlear nodes. Lymphadenopathy from local cut, infection
ABDOMEN
Palpate and estimate the width of the abdominal aorta between your two fingers. (See p. 190)
Pulsatile mass, AAA if width ≥4 cm.
LEGS
Inspect for: See Table 12-1, Chronic Insufficiency
of Arteries and Veins, p. 207, and Table
12-2, Common Ulcers of the Feet and
Ankles, p. 208.
● Size and symmetry, any swell- ing in thigh or calf
● Venous pattern
● Color and texture of skin
● Hair distribution, temperature
Venous insufficiency, lymphedema;
deep venous thrombosis
Varicose veins
Pallor, rubor, cyanosis; erythema,
warmth in cellulitis, thrombophlebitis
Loss hair and coldness in arterial
insufficiency
Palpate the inguinal lymph nodes: Lymphadenopathy in genital infections, lymphoma, AIDs
● Horizontal group
● Vertical group
Vertical group
Great saphenous vein
Femoral vein
femoral arteryHorizontal group
204 Bates’ Pocket Guide to Physical Examination and History Taking
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
Palpate and grade the pulses: Loss of pulses in acute arterial occlu- sion and arteriosclerosis obliterans
● Femoral
● Popliteal
● Dorsalis pedis
● Posterior tibial
Check for pitting edema.
See Table 12-3, Using the Ankle-Brachial
Index, p. 209–210.
Dependent edema, heart failure, hypo-
albuminemia, nephrotic syndrome
Palpate the calves. Tenderness in deep venous thrombosis (though tenderness often not present)
Ask patient to stand, and rein- spect the venous pattern.
Varicose veins
Chapter 12 | The Peripheral Vascular System 205
SPECIAL TECHNIQUES
EVALUATING ARTERIAL SUPPLY TO THE HAND
Persisting pallor of palm indicates
occlusion of the released artery or its
distal branches.
Feel ulnar pulse, if possible. Perform an Allen test.
1. Ask the patient to make a tight fist, palm up. Occlude both radial and ulnar arteries with your thumb.
2. Ask the patient to open hand into a relaxed, slightly flexed position.
3. Release your pressure over one artery. Palm should flush within 3 to 5 seconds.
4. Repeat, releasing other artery.
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206 Bates’ Pocket Guide to Physical Examination and History Taking
Recording Your Findings
Recording the Physical Examination—The Peripheral Vascular System
“Extremities are warm and without edema. No varicosities or stasis changes.
Calves are supple and nontender. No femoral or abdominal bruits. Brachial,
radial, femoral, popliteal, dorsalis pedis (DP), and posterior tibial (PT) pulses
are 2+ and symmetric.” OR “Extremities are pale below the midcalf, with notable hair loss. Rubor noted
when legs dependent but no edema or ulceration. Bilateral femoral bruits; no
abdominal bruits heard. Brachial and radial pulses 2+; femoral, popliteal, DP, and PT pulses 1+.” (Alternatively, pulses can be recorded as below.) Suggests atherosclerotic PAD.
Radial Brachial Femoral Popliteal Dorsalis
Pedis Posterior
Tibial
RT 2+ 2+ 1+ 1+ 1+ 1+ LT 2+ 2+ 1+ 1+ 1+ 1+
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
POSTURAL COLOR CHANGES OF CHRONIC ARTERIAL INSUFFICIENCY
Marked pallor of feet on elevation,
delayed color return and venous filling,
and rubor of dependent feet suggest
arterial insufficiency.
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) filling of veins on feet and ankles (normally about 15 seconds).
Chapter 12 | The Peripheral Vascular System 207
Aids to InterpretationAAAiddss ttoo IInntterrpprreetaattioonn
Chronic Insufficiency of Arteries and VeinsTable 12-1
Condition Characteristics
Chronic Arterial Insufficiency
Rubor
Ischemic ulcer
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 gangrene.
Chronic Venous Insufficiency 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.
208 Bates’ Pocket Guide to Physical Examination and History Taking
Common Ulcers of the Feet and AnklesTable 12-2
Ulcer Characteristics
Arterial Insufficiency 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.
Chronic Venous Insufficiency 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.
Neuropathic Ulcer 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.
Chapter 12 | The Peripheral Vascular System 209
Using the Ankle–Brachial Index Table 12-3
Instructions for Measuring the Ankle–Brachial Index (ABI)
1. Patient should rest supine in a warm room for at least 10 minutes before testing.
Doppler
Brachial artery
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
Doppler
Doppler
Dorsalis pedis (DP) artery
Posterior tibial (PT)
artery
(continued)
210 Bates’ Pocket Guide to Physical Examination and History Taking
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 5. Calculate ABI
Right ABI =
Left ABI =
Interpretation of Ankle–Brachial Index
Ankle–Brachial Index Result Clinical Interpretation >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):ITC3-1.
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)
Using the Ankle–Brachial Index (continued)Table 12-3
211
C H A P T E R
13Male Genitalia and Hernias
The Health History
Common or Concerning Symptoms
◗ Sexual orientation and sexual response
◗ Penile discharge or lesions
◗ Scrotal pain, swelling, or lesions
◗ Sexually transmitted infections (STIs)
Cavity of tunica vaginalis
Scrotum Testis
Epididymis
Spermatic cord
Ejaculatory duct
Seminal vesicle
Prepuce
Urethral meatus
Glans
Corona
Corpus spongiosum
Corpus cavernosum
Blood vessels
Vas deferens
Urethra
212 Bates’ Pocket Guide to Physical Examination and History Taking
Explain your concern for the patient’s sexual health. Pose questions in a neutral and nonjudgmental way.
● “What is your relationship status? Tell me about your sexual preference.”
● “How is sexual function for you?” “Are you satisfied with your sexual life?” “What about your ability to perform sexu- ally?”
To assess libido, or desire: “Have you maintained an interest in sex?”
Decreased libido from depression,
endocrine dysfunction, or side effects
of medications
For the arousal phase: “Can you achieve and maintain an erection?”
Erectile dysfunction from psychogenic
causes, especially if early morning
erection is preserved; also from
decreased testosterone, decreased
blood flow in hypogastric arterial
system, impaired neural innervation,
diabetes
If ejaculation is premature or early: “About how long does intercourse last?” “Do you climax too soon?” For reduced or absent ejaculation: “Do you find 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 fluid, or both?”
Premature ejaculation is common,
especially in young men. Less common
is reduced or absent ejaculation affect-
ing middle-aged or older men. Consider
medications, surgery, neurologic
deficits, or lack of androgen. Lack of
orgasm with intact ejaculation is usually
psychogenic.
Chapter 13 | Male Genitalia and Hernias 213
To assess possible infection from sexually transmitted infections (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. 218, and Table
13-2, Sexually Transmitted Infections of
Male Genitalia, pp. 219–220.
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
Prevention of STIs and HIV Infection. Focus on patient educa- tion about STIs and HIV, early detection of infection during history taking and physical examination, and identification and treatment of infected partners. Identify the patient’s sexual orientation, the num- ber 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 of STIs and HIV infection.
Counseling and testing for HIV are recommended for: all people at increased risk for infection with HIV, STIs, or both; men with male
Health Promotion and Counseling: Evidence and Recommendations
Important Topics for Health Promotion and Counseling
◗ Prevention of STIs and HIV
◗ Screening for testicular cancer; testicular self-examination
214 Bates’ Pocket Guide to Physical Examination and History Taking
partners; past or present injection drug users; men and women hav- ing unprotected sex with multiple partners; sex workers; any past or present partners of people with HIV infection, bisexual practices, or injection drug use; and patients with a history of transfusion between 1978 and 1985.
Testicular Self-Examination. Encourage men, especially those between 15 and 35 years of age, to perform monthly testicular self-examinations. Testicular cancer strikes men ages 15 to 34, especially those with a positive family history or cyptorchidism (see p. 221).
Techniques of Examination
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
MALE GENITALIA
Wear gloves. The patient may be standing or supine.
/ THE PENIS
Inspect the:
● Development of the penis and the skin and hair at its base
● Prepuce
● Glans
● Urethral meatus
Sexual maturation, lice
Phimosis
Balanitis, chancre, herpes, warts, cancer
Hypospadias, discharge of urethritis
Palpate:
● Any visible lesions
● The shaft
Chancre, cancer
Urethral stricture or cancer
Chapter 13 | Male Genitalia and Hernias 215
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
THE SCROTUM AND ITS CONTENTS
Inspect:
● Contours of scrotum
● Skin of scrotum
Hernia, hydrocele, cryptorchidism
Rashes
Palpate each:
● Testis, noting any:
● Lumps
● Tenderness
● Epididymis
● Spermatic cord and adjacent areas
See Table 13-3, Abnormalities of the
Testis, p. 221.
Testicular carcinoma
Orchitis, torsion of the spermatic cord,
strangulated inguinal hernia
Epididymitis, cyst
Varicocele if multiple tortuous veins;
cystic structure may be a hydrocele
See Table 13-4, Abnormalities of the
Epididymis and Spermatic Cord, p. 222.
216 Bates’ Pocket Guide to Physical Examination and History Taking
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
HERNIAS
Patient is usually standing. See Table 13-5, Hernias in the Groin, p. 223.
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.
Indirect and direct inguinal hernias
Inguinal ligament
External inguinal ring
SPECIAL TECHNIQUE
Patient Instructions for the Testicular Self-Examination
This examination is best performed after a warm bath or shower. The heat
relaxes the scrotum and makes it easier to find anything unusual.
◗ Standing in front of a mirror, check for any swelling on the skin of the scrotum.
◗ With the penis out of the way, examine each testicle separately.
◗ Cup the testicle between your thumbs and forefingers with both hands and
roll it gently between the thumbs and fingers. One testicle may be larger
than the other; that’s normal, but be concerned about any lump or area of
pain.
(continued)
Chapter 13 | Male Genitalia and Hernias 217
Recording the Physical Examination—Male Genitalia and Hernias
“Circumcised male. No penile discharge or lesions. No scrotal swelling or dis-
coloration. Testes descended bilaterally, smooth, without masses. Epididymis
nontender. No inguinal or femoral hernias.”
OR “Uncircumcised male; prepuce easily retractible. No penile discharge or lesions.
No scrotal swelling or discoloration. Testes descended bilaterally; right testicle
smooth; 1 × 1 cm firm nodule on left lateral testicle. It is fixed and nontender. Epididymis nontender. No inguinal or femoral hernias.” (Suspicious for testicular carcinoma, the most common form of cancer in men between 15 and 35 years of age.)
Recording Your FindingsRRReccoorddinnggg YYouuur Finnddinngss
Patient Instructions for the Testicular Self-Examination (continued)
◗ Find the epididymis. This is a soft, tubelike structure at the back of the
testicle that collects and carries sperm, not an abnormal lump.
◗ If you find any lump, don’t wait.
See your doctor. The lump may just
be an infection, but if it is cancer,
it will spread unless stopped by
treatment.
Source: Medline Plus. U.S. National Library of Medicine and National Institutes of Health.
Medical Encyclopedia—Testicular self-examination. Available at www.nlm.nih.gov/medlineplus/
ency/article/003909.htm. Accessed December 19, 2010.
E XA M I N AT I O N T E C H N I Q U E S
218 Bates’ Pocket Guide to Physical Examination and History Taking
Aids to InterpretationAAAiddss ttoo IInntterrpprreetaattioonn
Hypospadias Scrotal Edema 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.
Peyronie’s Disease
Fingers can get above mass
Hydrocele 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.
Carcinoma of the Penis
Fingers cannot get above mass
Scrotal Hernia 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.
Abnormalities of the Penis and ScrotumTable 13-1
Chapter 13 | Male Genitalia and Hernias 219
Sexually Transmitted Infections of Male GenitaliaTable 13-2
Genital Warts (condylomata acuminata)
● 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 cauliflowerlike (verrucous).
● Causative organism: Human papillomavirus (HPV), usually from subtypes 6, 11; carcinogenic subtypes rare, approximately 5% to 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.
Genital Herpes Simplex ● Appearance: Small scattered or grouped vesicles, 1 to 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 to 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.
(continued)
220 Bates’ Pocket Guide to Physical Examination and History Taking
Primary Syphilis ● 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 to 8 weeks.
● Causative organism: Treponema pallidum, a spirochete.
● Incubation: 9 to 90 days after exposure.
● May develop inguinal lymphadenopathy within 7 days; lymph nodes are rubbery, nontender, mobile.
● 20% to 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; 4 variants, so difficult to identify).
Chancroid ● 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 to 7 days after exposure.
● Painful inguinal adenopathy; suppurative bobos in 25% of patients.
● Need to distinguish from: primary syphilis; genital herpes simplex; lymphomogranuloma venereum, granuloma inguinale from Klebsiella granulomatis (both rare in the United States).
Sexually Transmitted Infections of Male Genitalia (continued)Table 13-2
Chapter 13 | Male Genitalia and Hernias 221
Abnormalities of the TestesTable 13-3
Cryptorchidism 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.
Small Testis In adults, testicular length is usually ≤3.5 cm. Small, firm testes seen in Klinefelter’s syndrome, usually ≤2 cm. Small, soft testes suggesting atrophy seen in cirrhosis, myotonic dystrophy, use of estrogens, and hypopituitarism; may also follow orchitis.
Acute 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.
Early
Tumor of the Testis Usually appears as a painless nodule. Any nodule within the testis warrants investigation for malignancy.
Late
As a testicular neoplasm grows and spreads, it may seem to replace the entire organ. The testicle characteristically feels heavier than normal.
222 Bates’ Pocket Guide to Physical Examination and History Taking
Abnormalities of the Epididymis and Spermatic CordTable 13-4
Acute Epididymitis 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.
Spermatocele and Cyst of the Epididymis 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.
Varicocele of the Spermatic Cord 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.
Torsion of the Spermatic Cord 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.
Chapter 13 | Male Genitalia and Hernias 223
Hernias in the Groin Table 13-5
Indirect Inguinal 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.
Direct Inguinal 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.
Femoral Least common hernia, more common in women than in men. Originates below inguinal ligament, more lateral than inguinal hernia. Never enters scrotum.
225
C H A P T E R
14Female Genitalia
Common Concerns
◗ Menarche, menstruation, menopause, postmenopausal bleeding
◗ Pregnancy
◗ Vulvovaginal symptoms
◗ Sexual preference and sexual response
◗ Pelvic pain—acute and chronic
◗ Sexually transmitted infections (STIs)
Mons pubis
Prepuce
Clitoris
Urethral meatus
Opening of paraurethral (Skene's) gland
Vestibule
Introitus
Perineum
Labia majora
Labia minora
Hymen
Vagina
Opening of Bartholin's gland
Anus
The Health History
For the menstrual history, ask when menstrual periods began (age at menarche).
Changes in the interval between peri-
ods can signal possible pregnancy or
menstrual irregularities.
226 Bates’ Pocket Guide to Physical Examination and History Taking
When did her last menstrual period (LMP) start, and the one prior menstrual period (PMP)? What is the interval between periods, from the first day of one to the first day of the next? Are menses regular or irregular? How long do they last? How heavy is the flow?
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 bleed- ing in threatened abortion or dysfunc-
tional uterine bleeding
Dysmenorrhea, or painful menses, is common.
Primary dysmenorrhea from increased
prostaglandin production; secondary
dysmenorrhea from endometriosis, pelvic inflammatory disease, and endometrial polyps
Amenorrhea is the absence of periods. Failure to begin periods is primary amenorrhea, whereas cessation of established periods is secondary amenorrhea.
Secondary amenorrhea from low
body weight is seen in malnutrition,
anorexia nervosa, stress, chronic illness, and hypothalamic–pituitary–ovarian
dysfunction.
Menopause, the absence of menses for 12 consecutive months, usually occurs between 48 and 55 years. Associated symptoms include hot flashes, flushing, sweating, and sleep disturbances.
Postmenopausal bleeding, or bleeding occurring 6 months after menses have
stopped, suggests endometrial cancer,
hormone replacement therapy, or
uterine or cervical polyps.
For vaginal discharge and local itching, inquire about amount, color, consistency, and odor of discharge.
See Table 14-1, Lesions of the Vulva,
pp. 233–234; and Table 14-2, Vaginal
Discharge, p. 235.
Chapter 14 | Female Genitalia 227
Ask, “Tell me about your sexual preferences. Are your partners men, women or do you have partners of both sexes?”
To assess sexual function, start with general nonjudgmental questions like “How is sex for you?” or “Are you having any problems with sex?”
Direct questions help you assess each phase of the sexual response: desire, arousal, and orgasm.
Ask also about dyspareunia, or discomfort or pain during intercourse.
Superficial pain suggests local inflam-
mation, atrophic vaginitis, or inad-
equate lubrication; deeper pain may
result from pelvic disorders or pressure
on a normal ovary.
For sexually transmitted infections (STIs) and diseases, 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.
Important Topics for Health Promotion and Counseling
◗ Cervical cancer screening; Pap smear and HPV infection
◗ Ovarian cancer: symptoms and risk factors
◗ STIs and HIV
◗ Options for family planning
◗ Menopause and hormone replacement therapy
Health Promotion and Counseling: Evidence and Recommendations
228 Bates’ Pocket Guide to Physical Examination and History Taking
New Pap Smear Screening Guidelines. Observe the new Pap smear guidelines from the American College of Obstetricians and Gynecologists (ACOG) in 2012 based on scientific advances related to the biology of human papillomavirus (HPV) infection.
● First screening: Begin screening at age 21
● Women ages 21–29: ● Screen every 3 years if normal pap smears ● Screen more frequently in patients with positive Pap or at high risk of positive HPV test; HIV infection; immunosuppression; DES exposure in utero; prior history of cervical cancer
● Women ages 30–65: Screen every 3 years with cytology if 3 con- secutive normal Pap smears, no history of CIN 2 or CIN 3, and no high-risk factors; or with cytology and HPV testing every 5 years.
● Women with hysterectomy: Discontinue routine screening if hys- terectomy for benign indications and no history of high-grade CIN. If hysterectomy for CIN 2, CIN 3, or cancer and cervix removed, screen annually for 20 years
● Women ages >65: Discontinue screening if ≥3 negative pap smears in a row and no abnormal Pap smears for 20 years
The most important risk factor for cervical cancer is HPV infection from HPV strains 16, 18, 6, or 11. The HPV vaccine prevents HPV infection from the strains when given before sexual exposure at age 11.
Ovarian Cancer. There are no effective screening tests to date. Risk factors include family history of breast or ovarian cancer and BRCA1 or BRCA2 mutation.
STIs and HIV Infection. For STIs and HIV, assess risk factors by taking a careful sexual history and counseling patients about spread of disease and ways to reduce high-risk practices. Test women younger than 26 years and pregnant women for Chlamydia; in women at increased risk and pregnant women, test for gonor- rhea, syphilis, and HIV. In 2006, the CDC recommended universal screening for HIV for those ages 13 to 64 because infection occurs in many without known risk factors.
Chapter 14 | Female Genitalia 229
Options for Family Planning. More than half of U.S. pregnancies are unintended. Counsel women, particularly adolescents, about the timing of ovulation, which occurs midway in the regular menstrual cycle. Discuss methods for contraception and their effectiveness: natural (peri- odic abstinence, withdrawal, lactation); barrier (condom, diaphragm, cervical cap); implantable (intrauterine device, subdermal implant); pharmacologic (spermicide, oral contraceptives, subdermal implant of levonorgestrel, estrogen/progesterone injectables and patch, vaginal ring); and surgical (tubal ligation, transcervical sterilization).
Menopause and Hormone Replacement Therapy (HRT). Be famil- iar with the psychological and physiologic changes of menopause. Help the patient to weigh the risks of hormone replacement therapy (HRT), including increased risk of stroke, pulmonary embolism, and breast can- cer. One to 2 years of HRT may be indicated for menopausal symptoms.
Techniques of Examination
Tips for the Successful Pelvic Examination
The Patient The Examiner
◗ Avoids intercourse, douching, or
use of vaginal suppositories for 24
to 48 hours before examination
◗ Empties bladder before examination
◗ Lies supine, with head and shoul-
ders elevated, arms at sides or
folded across chest to enhance eye
contact and reduce tightening of
abdominal muscles
◗ Obtains permission; selects chap-
erone
◗ Explains each step of the examina-
tion in advance
◗ Drapes patient from midabdomen
to knees; depresses drape between
knees to provide eye contact with
patient
◗ Avoids unexpected or sudden
movements
◗ Chooses a speculum that is the
correct size
◗ Warms speculum with tap water
◗ Monitors comfort of the examina-
tion by watching the patient’s face
◗ Uses excellent but gentle tech-
nique, especially when inserting
the speculum
TTTecchhnniiquees offf EExaammminnatttionn
Male examiners should be accompanied by female chaperones. Female examiners should be assisted whenever possible.
230 Bates’ Pocket Guide to Physical Examination and History Taking
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
EXTERNAL GENITALIA
Observe pubic hair to assess sexual maturity.
Normal or delayed puberty
Examine the external genitalia.
● Labia minora
● Clitoris
● Urethral orifice
● Introitus
Ulceration in herpes simplex, syphiliti chancre; inflammation in Bartholin’s cyst
Enlarged in masculinization
Urethral caruncle or prolapse; tenderness in interstitial cystitis
Imperforate hymen
Milk the urethra for discharge, if indicated.
Discharge of urethritis
INTERNAL GENITALIA AND PAP SMEAR
Locate the cervix with a gloved and water-lubricated index finger.
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, then rotate to horizontal position for full insertion.
ENTRY ANGLE ANGLE AT FULL INSERTION
Chapter 14 | Female Genitalia 231
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
Open the speculum and inspect cervix.
See Table 14-3, Shapes of the Cervical
Os, p. 236, and Table 14-4, Abnormalities
of the Cervix, p. 237.
Observe:
● Position
● Color
● Epithelial surface
Cervix faces forward if uterus is
retroverted.
Purplish in pregnancy
Squamous and columnar epithelium
External os of the cervix
Transformation zone
Columnar epithelium
Squamocolumnar junction
Squamous epithelium
● Any discharge or bleeding
● Any ulcers, nodules, or masses
Discharge from os in mucopurulent cer-
vicitis from Chlamydia or gonorrhea
Herpes, polyp, cancer
Obtain specimens for cytology (Pap smears) with:
Early cancer before it is clinically
evident
● An endocervical broom 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.
Bluish color and deep rugae in preg-
nancy; vaginal cancer
232 Bates’ Pocket Guide to Physical Examination and History Taking
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
Palpate, by means of a bimanual examination:
● The cervix and fornices
● The uterus
● Right and left adnexa (ovaries)
Pain on moving cervix in pelvic inflam- matory disease
Pregnancy, myomas; soft isthmus in
early pregnancy
Ovarian cysts or masses, salpingitis, PID,
tubal pregnancy
Assess strength of pelvic muscles. With your vaginal fingers clear of the cervix, ask patient to tighten her muscles around your fingers as hard and long as she can.
A firm squeeze that compresses your
fingers, moves them up and inward,
and lasts more than 3 seconds is full
strength.
/ Perform a rectovaginal examination 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. 245).
Retroverted uterus
SPECIAL TECHNIQUE
HERNIAS
Ask the woman to strain down, as you palpate for a bulge in:
● The femoral canal
● The labia majora up to just lateral to the pubic tubercle
Femoral hernia
Indirect inguinal hernia
Chapter 14 | Female Genitalia 233
Recording Your FindingsRRReccoorddinnggg YYouuur Finnddinngss
Recording the Physical Examination—Female Genitalia
“No inguinal adenopathy. External genitalia without erythema, lesions, or
masses. Vaginal mucosa pink. Cervix parous, pink, and without discharge.
Uterus anterior, midline, smooth, and not enlarged. No adnexal tenderness.
Pap smear obtained. Rectovaginal wall intact. Rectal vault without masses.
Stool brown and Hemoccult negative.”
OR “Bilateral shotty inguinal adenopathy. External genitalia without erythema
or lesions. Vaginal mucosa and cervix coated with thin, white homogenous
discharge with mild fishy odor. After swabbing cervix, no discharge visible in
cervical os. Uterus midline; no adnexal masses. Rectal vault without masses.
Stool brown and Hemoccult negative.” (Suggests bacterial vaginosis.)
Aids to InterpretationAAAiddss ttoo IInntterrpprreetaattioonn
Lesions of the VulvaTable 14-1
Epidermoid Cyst
Cystic nodule in skin
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.
Venereal Wart (Condyloma Acuminatum)
Warts
Warty lesions on the labia and within the vestibule suggest condylomata acuminata from infection with human papillomavirus.
(continued)
E XA M I N AT I O N T E C H N I Q U E S
234 Bates’ Pocket Guide to Physical Examination and History Taking
Lesions of the Vulva (continued)Table 14-1
Genital Herpes
Shallow ulcers on red bases
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.
Syphilitic Chancre A firm, painless ulcer suggests the chancre of primary syphilis. Because most chancres in women develop internally, they often go undetected.
Secondary Syphilis (Condyloma Latum)
Flat, gray papules
Slightly raised, round or oval flat- topped papules covered by a gray exudate suggest condylomata lata, a manifestation of secondary syphilis. They are contagious.
Carcinoma of the Vulva An ulcerated or raised red vulvar lesion in an elderly woman may indicate vulvar carcinoma.
Chapter 14 | Female Genitalia 235
Vaginal DischargeTable 14-2
Note: Accurate diagnosis depends on laboratory assessment and cultures.
Trichomonas vaginitis Discharge: Yellowish green, often profuse, may be malodorous
Other Symptoms: Itching, vaginal soreness, dyspareunia
Vulva: May be red Vagina: May be normal or red, with red
spots, petechiae Laboratory Assessment: Saline wet
mount for trichomonads
Candida vaginitis Discharge: White, curdy, often thick, not malodorous
Other Symptoms: Itching, vaginal soreness, external dysuria, dyspareunia
Vulva: Often red and swollen Vagina: Often red with white patches of
discharge Laboratory Assessment: KOH
preparation for branching hyphae
Bacterial vaginosis Discharge: Gray or white, thin, homogeneous, scant, malodorous
Other Symptoms: Fishy genital odor Vulva: Usually normal Vagina: Usually normal Laboratory Assessment: Saline wet
mount for “clue cells,” “whiff test” with KOH for fishy odor
236 Bates’ Pocket Guide to Physical Examination and History Taking
Shapes of the Cervical OsTable 14-3
Normal Variations
Oval Slitlike
Lacerations
Unilateral Transverse Bilateral Transverse
Stellate
Chapter 14 | Female Genitalia 237
Abnormalities of the CervixTable 14-4
Endocervical polyp. A bright red, smooth mass that protrudes from the os suggests a polyp. It bleeds easily.
Mucopurulent cervicitis. A yellowish exudate emerging from the cervical os suggests infection from Chlamydia, gonorrhea (often asymptomatic), or herpes.
Carcinoma of the cervix. An irregular, hard mass suggests cancer. Early lesions are best detected by colposcopy following abnormal Pap smear from of high risk of HPV.
Vaginal adenosis
Columnar epithelium
Collar
Fetal exposure to diethylstilbestrol (DES). 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.
238 Bates’ Pocket Guide to Physical Examination and History Taking
Relaxations of the Pelvic FloorTable 14-5
When the pelvic floor is weakened, various structures may become displaced. These displacements are seen best when the patient strains down.
A cystocele is a bulge of the anterior wall of the upper part of the vagina, together with the urinary bladder above it.
A cystourethrocele involves both the blad- der and the urethra as they bulge into the anterior vaginal wall throughout most of its extent.
A rectocele is a bulge of the posterior vaginal wall, together with a portion of the rectum.
A prolapsed uterus 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.
Chapter 14 | Female Genitalia 239
Positions of the Uterus and Uterine MyomasTable 14-6
An anteverted uterus 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 retroverted uterus is tilted posteriorly with its cervix facing anteriorly.
A retroflexed uterus 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 myoma of the uterus 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 retrodis- placed uterus; one on the anterior surface may be mistaken for an anteverted uterus.
241
C H A P T E R
15The Anus, Rectum, and Prostate
The Health History
Common or Concerning Symptoms
◗ Change in bowel habits
◗ Blood in the stool
◗ Pain with defecation; rectal bleeding or tenderness
◗ Anal warts or fissures
◗ Weak stream of urine
◗ Burning with urination
Valve of Houston
Peritoneal reflection
Rectum
Prostate
Anorectal junction
Anal canalUrethra
Bladder
242 Bates’ Pocket Guide to Physical Examination and History Taking
Ask about any change in bowel habits, diarrhea, or constipation. Is there any blood in the stool, or dark tarry stools?
Pencil-like stool or blood in stool in
colon cancer; dark tarry stools in gastrointestinal bleeding
Any pain with defecation, or rectal bleeding or tenderness?
Hemorrhoids; proctitis from STIs
Any anal warts or fissures? Human papillomavirus (HPV), condy- lomata lata in secondary syphilis; fissures in proctitis, Crohn’s disease
In men, is there difficulty starting the urine stream or holding back urine? Is the flow weak? What about frequent urination, espe- cially 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 can- cer, especially in men age ≥70. The American Urological Association
(AUA) Symptom Index helps quantify
BPH severity (see Table 15-1, BPH
Score Index: American Urological
Association (AUA), pp. 246–247).
Screening for Prostate Cancer. Prostate cancer is the leading cancer diagnosed in U.S. men and the second leading cause of death. Risk factors are age, family history of prostate cancer, and African American ethnicity.
Screening methods such as the digital rectal examination (DRE) and the prostate-specific antigen (PSA) test are not highly accurate, which complicates decisions about screening men without symptoms.
● The DRE reaches only the posterior and lateral surfaces of the pros- tate, missing 25% to 35% of tumors in other areas. Sensitivity of the
Important Topics for Health Promotion and Counseling
◗ Screening for prostate cancer
◗ Screening for colorectal cancer
◗ Counseling for sexually transmitted infections (STIs)
Health Promotion and Counseling: Evidence and Recommendations
Chapter 15 | The Anus, Rectum, and Prostate 243
DRE for prostate cancer is low, 59%, and the rate of false positives is high.
● The PSA. PSA testing is controversial. The PSA can be elevated in benign conditions like hyperplasia, prostatitis, ejaculation, and urinary retention. Its detection rate for prostate cancer is about 28% to 35% in asymptomatic men. It does not distinguish small-volume indo- lent cancers from aggressive life-threatening disease. Discussion and shared decision making are warranted. Several groups recommend annual combined screening with PSA and DRE for men older than 50 years and for African Americans and men older than 40 years with a positive family history. Studies of baseline PSA testing at age 40, and reducing the threshold for biopsy from 4.0 ng/mL to 2.5 ng/mL are inconclusive.
For symptomatic prostate disorders, the clinician’s role is more straight- forward. Men with incomplete emptying of the bladder, urinary fre- quency or urgency, weak or intermittent stream or straining to initiate flow, hematuria, nocturia, or even bony pains in the pelvis should be encouraged to seek evaluation and treatment early.
Screening for Colorectal Cancer. In 2008, screening recommen- dations were revised to promote more aggressive surveillance:
● Clinicians should first identify whether patients are at average or increased risk, ideally by age 20 years, but earlier if the patient has inflammatory bowel disease or a family history of familial adenoma- tous polyposis.
● Average-risk patients 50 years or older should be offered a range of screening options to increase compliance: annual screening with high-sensitivity fecal occult blood tests (FOBTs); flexible sigmoidos- copy every 5 years, with annual high-sensitivity FOBT every 3 years; or colonoscopy every 10 years.
● People at increased risk should undergo colonoscopy at intervals ranging from 3 to 5 years.
Clinicians should also use the 6-sample fecal occult blood test. Avoid single-sample FOBT and DRE, which have inadequate detection rates.
Counseling for STIs. Anal intercourse increases risk for HIV and STIs. Promote abstinence, use of condoms, and good hygiene.
244 Bates’ Pocket Guide to Physical Examination and History Taking
Techniques of Examination
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
Wear gloves.
MALE
Position the patient on his side, or standing leaning forward over the examining table and hips flexed.
Inspect the:
● Sacrococcygeal area
● Perianal area
Pilonidal cyst or sinus
Hemorrhoids, warts, herpes, chancre,
cancer, fissures from proctitis or Crohn’s disease
Palpate the anal canal and rectum with a lubricated and gloved finger. Feel the:
Lax sphincter tone in some neurologic
disorders; tightness in proctitis
● Walls of the rectum
● Prostate gland, as shown below, including median sulcus
Cancer of the rectum, polyps
Prostate nodule or cancer; BPH;
tenderness in prostatitis
TTTecchhnniiquees offf EExaammminnatttionn
Chapter 15 | The Anus, Rectum, and Prostate 245
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
Try to feel above the prostate for irregularities or tenderness, if indicated.
See Table 15-2, Abnormalities on Rectal
Examination, pp. 248–249.
/ FEMALE
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)
Recording Your Findings
Recording the Physical Examination—The Anus, Rectum, and Prostate
“No perirectal lesions or fissures. External sphincter tone intact. Rectal vault
without masses. Prostate smooth and nontender with palpable median sul-
cus. (Or in a female, uterine cervix nontender.) Stool brown and Hemoccult
negative.”
OR “Perirectal area inflamed; no ulcerations, warts, or discharge. Cannot exam-
ine external sphincter, rectal vault, or prostate because of spasm of external
sphincter and marked inflammation and tenderness of anal canal.” (Raises concern of proctitis from infectious cause.) OR “No perirectal lesions or fissures. External sphincter tone intact. Rectal vault
without masses. Left lateral prostate lobe with 1 × 1 cm firm hard nodule; right lateral lobe smooth; medial sulcus is obscured. Stool brown and Hemoccult
negative.” (Raises concern of prostate cancer.)
RRReccoorddinnggg YYouuur Finnddinngss
246 Bates’ Pocket Guide to Physical Examination and History Taking
Aids to InterpretationAAAidds ttoo Inntterrpprreetaattioonn
BPH Symptom Score Index: American Urological Association (AUA)Table 15-1
Score or ask the patient to score each of the questions below on a scale of 1 to 5.
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
5 = Almost always
Higher scores (maximum 35) indicate more severe symptoms; scores ≤7 are considered mild and generally do not warrant treatment.
PART A Score
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. Inter-mittency: 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 ————
Chapter 15 | The Anus, Rectum, and Prostate 247
Score or ask the patient to score each of the questions below on a scale of 1 to 5.
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
5 = Almost always
Higher scores (maximum 35) indicate more severe symptoms; scores ≤7 are considered mild and generally do not warrant treatment.
PART B Score
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;22:291–298.
BPH Symptom Score Index: American Urological Association (AUA) (continued)Table 15-1
248 Bates’ Pocket Guide to Physical Examination and History Taking
Abnormalities on Rectal ExaminationTable 15-2
External Hemorrhoids (Thrombosed). Dilated hemorrhoidal veins that originate below the pectinate line, covered with skin; a tender, swollen, bluish ovoid mass is visible at the anal margin
Polyps of the Rectum. A soft mass that may or may not be on a stalk; may not be palpable
Benign Prostatic Hyperplasia. An enlarged, nontender, smooth, firm but slightly elastic prostate gland; can cause symptoms without palpable enlargement
Acute Prostatitis. A prostate that is very tender, swollen, and firm because of acute infection
Chapter 15 | The Anus, Rectum, and Prostate 249
Abnormalities on Rectal Examination (continued)Table 15-2
Cancer of the Prostate. A hard area in the prostate that may or may not feel nodular
Cancer of the Rectum. Firm, nodular, rolled edge of an ulcerated cancer
251
C H A P T E R
16The Musculoskeletal System
Fundamentals for Assessing Joints
Assessing joints requires knowledge of their structure and function. Learn the surface landmarks and underlying anatomy of each major joint. Be familiar with the following terms:
● Articular structures include the joint capsule and articular cartilage, synovium and synovial fluid, intra-articular ligaments, and juxta- articular bone.
● Extra-articular structures include periarticular ligaments, tendons, bursae, muscle, fascia, bone, nerve, and overlying skin.
● Ligaments are the ropelike bundles of collagen fibrils that connect bone to bone.
● Tendons are collagen fibers that connect muscle to bone.
● Bursae are pouches of synovial fluid that cushion the movement of tendons and muscles over bone or other joint structures.
Review the three primary types of joint articulation—synovial, car- tilaginous, and fibrous—and the varying degrees of movement each type allows.
252 Bates’ Pocket Guide to Physical Examination and History Taking
Review the types of synovial joints and their associated features as well.
Note that joint structure determines joint function and range of motion.
Joints
Synovial Joints
◗ Freely movable within limits of
surrounding ligaments
◗ Separated by articular cartilage and a synovial cavity
◗ Lubricated by synovial fluid
◗ Surrounded by a joint capsule
◗ Example: knee, shoulder
Cartilaginous Joints
◗ Slightly movable
◗ Contain fibrocartilaginous discs
that separate the bony surfaces
◗ Have a central nucleus pulposus of discs that cushions bony
contact
◗ Example: vertebral bodies
Fibrous Joints
◗ No appreciable movement
◗ Consist of fibrous tissue or
cartilage
◗ Lack a joint cavity
◗ Example: skull sutures
FIBROUS
Vertebral body
Nucleus pulposus of the disc
Disc
Ligament
CARTILAGINOUS
Bone
Synovial membrane
Articular cartilage
Synovial cavity
Ligament
Joint space Joint capsule
SYNOVIAL
Chapter 16 | The Musculoskeletal System 253
Synovial Joints
Type of Joint Articular Shape Movement Example
Spheroidal (ball and
socket)
Convex surface
in concave
cavity
Wide-ranging
flexion,
extension,
abduction,
adduction,
rotation, cir-
cumduction
Shoulder, hip
Hinge Flat, planar Motion in one plane;
flexion,
extension
Interphalan-
geal joints
of hand and
foot; elbow
Condylar Convex or concave
Movement
of two ar-
ticulating
surfaces, not
dissociable
Knee;
temporo-
mandibular
joint
The Health History
Common or Concerning Symptoms
◗ Low back pain
◗ Neck pain
◗ Monoarticular or polyarticular joint pain
◗ Inflammatory or infectious joint pain
◗ Joint pain with systemic features such as fever, chills, rash, anorexia, weight
loss, and weakness
◗ Joint pain with symptoms from other organ systems
TTThee HHeeaaltth HHiisstoryy
254 Bates’ Pocket Guide to Physical Examination and History Taking
Assess the seven features of any joint pain (see p. 38).
Tips for Assessing Joint Pain
◗ Ask the patient to “point to the pain.” This may save considerable time, because the patient’s verbal description is often imprecise.
◗ Clarify and record the onset of pain and the mechanism of injury, particularly if there is a history of trauma.
◗ Determine whether the pain is localized or diffuse, acute or chronic, inflamma- tory or noninflammatory.
Low Back Pain. Ask, “Any pains in your back?” Low back pain is the second most common reason for office visits. Ask if the pain is in the midline over the vertebrae, or off midline. If the pain radiates into the legs, ask about any associ- ated numbness, tingling, or weak- ness. Ask about history of trauma.
See Table 16-1, Low Back Pain, pp.
277–278. Causes of midline back pain include vertebral collapse, disc hernia-
tion, epidural abscess, spinal cord com-
pression, or spinal cord metastases.
Pain off the midline in muscle strain, sacroiliitis, trochanteric bursitis, sciat-
ica, hip arthritis, renal conditions such
as pyelonephritis or renal stones
Check for bladder or bowel dysfunction.
Present in cauda equine syndrome from S2–4 tumor or disc herniation,
especially if “saddle anesthesia” from
perianal numbness
Neck Pain. 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, pp. 279–280.
Joint Pain. Proceed with “Do you have any pain in your joints?”
See Table 16-3, Patterns of Pain in and
Around the Joints, p. 281.
Ask the patient to point to the pain. If localized and involving only one joint, it is monoarticular.
Consider trauma, monoarticular arthri-
tis, tendonitis, 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
Chapter 16 | The Musculoskeletal System 255
Ask if pain is extra-articular (bones, muscles, and tissues around the joint, such as the tendons, bursae, or even overlying skin). Are there generalized “aches and pains” (myalgia if in muscles, arthralgia if in joints with no evidence of arthritis)?
Bursitis if inflammation of bursae; ten- donitis if in tendons, and tenosynovitis if in tendon sheaths; also sprains from stretching or tearing of ligaments
Assess the timing, quality, and severity of joint symptoms. 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?
Severe pain of rapid onset in a red,
swollen joint in acute septic arthritis or gout
Is the problem inflammatory or noninflammatory? Is there tenderness, warmth, or redness?
Fever, chills, warmth, redness in septic arthritis; also consider gout or rheumatic fever
Is the pain articular in origin, with swelling, stiffness, or decreased range of motion?
Pain, swelling, loss of active and
passive motion, “locking,” deformity
in articular joint pain; loss of active but not passive motion, tenderness
outside the joint, no deformity in
nonarticular pain
Assess any limitations of motion. Transient stiffness after limited activity in degenerative arthritis; prolonged stiffness in rheumatoid arthritis, fibromyalgia, polymyalgia rheumatica
Ask about any systemic symptoms such as fever, chills, rash, anorexia, weight loss, and weakness.
Common in rheumatoid arthritis, sys- temic lupus erythematosus, polymyalgia rheumatica, and other inflammatory arthritides. High fever and chills sug-
gest an infectious cause.
256 Bates’ Pocket Guide to Physical Examination and History Taking
Health Promotion and Counseling: Evidence and Recommendations
Nutrition, Weight, and Physical Activity. Advise patients that a healthy lifestyle conveys direct benefits to the skeleton. Good nutrition supplies the calcium needed for bone mineralization and bone density. 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.
Profiling Low Back Pain. The low back is especially vulnerable, most notably at L5–S1, where the sacral vertebrae make a sharp pos- terior angle. Approximately 60% to 80% of the population experiences low back pain at least once. Current evidence supports active exercise with minimal bed rest and delay of back-specific exercise while pain is acute; cognitive-behavioral counseling; and occupational interventions targeting graded exercise and early return to modified work. Depres- sion is a major predictor of new low back pain, warranting prompt treatment of psychiatric comorbidities.
Osteoporosis Screening and Prevention. Osteoporosis is a major public health threat for postmenopausal women and some men. The U.S. Preventive Services Task Force recommends routine bone density screening for women 65 years or older and earlier for those with the risk factors on next page.
HHHeealltthh PPrroommoootioonn andd CCCouunsselingg: EEEviideenncce aannd Reecooommmmeeenddattionns
Important Topics for Health Promotion and Counseling
◗ Nutrition, weight, and physical activity
◗ Profiling low back pain
◗ Osteoporosis: screening and prevention
◗ Preventing falls
Chapter 16 | The Musculoskeletal System 257
Use the country-specific FRAX calculator to assess fracture risk. If risk is >9.3% for any fracture and >3% for hip fracture, bone density screen- ing is warranted. The Web site 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. A 10% drop in bone density, equivalent to 1.0 standard deviation, is associated with a 20% increase in risk of fracture.
Risk Factors for Osteoporosis and Fracture
◗ Prior fragility fracture
◗ Postmenopausal status in white women
◗ Age ≥50 years ◗ Weight ≤70 kg (154 lb) ◗ Lower dietary calcium
◗ Vitamin D deficiency
◗ Tobacco and alcohol use
◗ Family history of fracture in a first-degree relative
◗ Use of corticosteroids
◗ Medical conditions such as thyrotoxicosis, celiac sprue, chronic renal
disease, organ transplantation, diabetes, HIV, primary or secondary
hypogonadism, multiple myeloma, and anorexia nervosa
◗ Medications such as aromatase inhibitors for breast cancer, methotrexate,
selected antiseizure medications, immunosuppressive agents, and anti-
gonadal therapy
◗ Inflammatory disorders of the musculoskeletal, pulmonary, or gastrointestinal
systems, including rheumatoid arthritis
Several agents inhibit bone resorption: calcium, vitamin D, and anti- resorptive agents such as bisphosphonates, selective estrogen-receptor modulators (SERMs), and calcitonin. Learn the therapeutic uses of these agents and exercise.
World Health Organization Bone Density Criteria
Osteoporosis: T score <−2.5 (>2.5 standard deviations below the mean for young adult white women)
Osteopenia: T score −2.5 to 1.5 (1.0 to 2.5 standard deviations below the mean for young adult white women)
258 Bates’ Pocket Guide to Physical Examination and History Taking
Preventing Falls. Falls are the leading cause of nonfatal injuries and account for a dramatic rise in death rates after 65 years of age. Risk factors include unstable gait, imbalanced posture, reduced strength, cognitive loss and dementia, deficits in vision and proprioception, and osteoporosis. Urge patients to correct poor lighting, dark or steep stairs, chairs at awkward heights, slippery or irregular surfaces, and ill- fitting shoes. Scrutinize any medications affecting balance, especially benzodiazepines, vasodilators, and diuretics.
Techniques of Examination
Approach to Individual Joint Examination
Inspect the joints and surrounding tissues as you do the various regional
examinations.
Identify joints with changes in structure and function, carefully assessing for:
◗ Symmetry of involvement—one or both sides of the body; one joint or
several
◗ Deformity or malalignment of bones
◗ Changes in surrounding soft tissue—skin changes, subcutaneous nodules,
muscle atrophy, crepitus
◗ Limitations in range of motion and maneuvers, ligamentous laxity
◗ Changes in muscle strength
Note signs of inflammation and arthritis: swelling, warmth, tenderness,
redness.
TTTecchhnniiquees offf EExaammminnatttionn
Recommended Dietary Intakes of Calcium and Vitamin D for Adults (Institute of Medicine 2010)
Age Group Calcium (elemental)
mg/day Vitamin D
IU/day
19–50
50–71
Women
Men
≥71
1,000
1,200
1,000
1,200
600
600
600
800
Source: Ross AC, Manson JE, Abrams SA, et al. The 2011 report on dietary reference intakes
for calcium and vitamin D from the Institute of Medicine: what clinicians need to know. J
Endocrinol Metab 2011;96:53–58.
Chapter 16 | The Musculoskeletal System 259
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
TEMPOROMANDIBULAR JOINT (TMJ)
Inspect the TMJ for swelling or redness.
Palpate the TMJ as the patient opens and closes the mouth.
Palpate the muscles of mastica- tion: the masseters, temporal muscles, and pterygoid muscles.
SHOULDERS
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. 282.
Palpate: ● The clavicle from the sterno- clavicular joint to the acro- mioclavicular joint
“Step-offs” if fracture from trauma
● The bicipital tendon Subacromial bursa
Rotator cuff
● The subacromial and sub- deltoid bursae after lifting arm posteriorly
Subacromial or subdeltoid bursitis
260 Bates’ Pocket Guide to Physical Examination and History Taking
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
Assess range of motion. ● Flexion—“Raise your arm in front of you and overhead.”
● Extension—“Move your arms behind you.”
● Abduction—“Raise your arms out to the side and overhead.”
● Adduction—“Cross your arm in front of your body, keeping the arm straight.”
● External and internal rotation
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
Acromioclavicular joint arthritis
Shoulder arthritis
TESTS ABDUCTION AND EXTERNAL ROTATION
TESTS ADDUCTION AND INTERNAL ROTATION
Perform maneuvers to assess the “SITS” muscles and tendons of the rotator cuff—supraspinatus, infra- spinatus, teres minor, subscapu- laris, and the bicipital tendon.
● “Empty can test” for supraspinatus strength
Weakness in rotator cuff tear
Chapter 16 | The Musculoskeletal System 261
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
● Infraspinatus strength
● Forearm supination
● “Drop arm” test
Weakness in rotator cuff tear or bicipital tendonitis
Pain in rotator cuff tear
If patient cannot hold arm fully
abducted at shoulder level, possible
rotator cuff tear
262 Bates’ Pocket Guide to Physical Examination and History Taking
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
ELBOWS
Inspect and palpate:
● Olecranon process
● Medial and lateral epicondyles
● Extensor surface of the ulna
● Grooves between the epicondyles and the olecranon
Olecranon bursitis; posterior disloca-
tion from direct trauma or supracon-
dylar fracture
Tenderness distal to epicondyle in
epicondylitis (medial → “tennis elbow”; lateral → “pitcher’s elbow”)
Rheumatoid nodules
Tender in arthritis
Ask patient to: o˚
Supination Pronation
● Flex and extend elbows
● Turn palms up and down (supination and pronation)
WRISTS AND HANDS
Inspect:
● Movement of the wrist (flexion, extension, ulnar and medial deviation), hands, and fingers
● Contours of wrists, hands, and fingers
● Contours of palms
Guarded movement in injury
Deformities in rheumatoid and degen- erative arthritis; swelling in arthritis, ganglia; impaired alignment of fingers
in flexor tendon damage; flexion con-
tractures in Dupuytren’s contractures
Thenar atrophy in median nerve
compression (carpal tunnel syndrome); hypothenar atrophy in ulnar nerve
compression
Chapter 16 | The Musculoskeletal System 263
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
Palpate:
● Wrist joints
● Distal radius and ulna
● “Anatomic snuffbox,” the hol- low space distal to the radial styloid bone; thumb extensor and abductor tendons.
● Metacarpophalangeal joint
Swelling and tenderness in rheumatoid arthritis, gonococcal infection of joint or extensor tendon sheaths
Tenderness over ulnar styloid in
Colles’ fracture
Tenderness suggests scaphoid frac- ture. Tenderness over extensor and abductor tendons in de Quervain’s
tenosynovitis.
Swelling in rheumatoid arthritis
264 Bates’ Pocket Guide to Physical Examination and History Taking
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
● Proximal and distal interpha- langeal joint
Proximal nodules in rheumatoid
arthritis (Bouchard’s nodes), distal nodules in osteoarthritis (Heberden’s nodes)
Assess range of motion:
● Wrists: Flexion, extension, adduction (radial deviation), abduction (lateral deviation)
● Fingers: Flexions, extension, abduction/adduction (spread fingers apart and back)
● Thumbs
Arthritis, tenosynovitis
Trigger finger, Dupuytren’s
contracture
FLEXION EXTENSION
ABDUCTION AND ADDUCTION OPPOSITION
Chapter 16 | The Musculoskeletal System 265
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
Perform selected maneuvers.
● Hand grip strength
Decreased grip strength if weakness
of finger flexors or intrinsic hand
muscles
● Carpal tunnel testing
● Thumb adduction
Weakness of abductor pollicis longus is
specific to median nerve.
● Thumb movement
Tendon
Pain if de Quervain’s tenosynovitis
● Tinel’s sign: Tap lightly over median nerve at volar wrist
Aching, tingling, and numbness in
second, third, and fourth fingers is a
positive Tinel’s sign.
266 Bates’ Pocket Guide to Physical Examination and History Taking
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
● Phalen’s sign: Patient flexes wrists for 60 seconds
Aching, tingling, and numbness in sec-
ond, third, and fourth volar fingers is a
positive Phalen’s sign.
SPINE
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 but- tocks.
Scoliosis, pelvic tilt, unequal leg length
Paravertebral muscles
Spinous process of L5 vertebra
Ischial tuberosity and site of ischial bursa
Posterior superior iliac spine
Sacroiliac joint
Sacroiliac notch
Sciatic nerve
Intervertebral joint between L5 and sacrum
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E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
Identify and palpate:
● Spinous processes of each vertebra
● Sacroiliac joints
● Paravertebral muscles, if painful
● Sciatic nerve (midway between greater trochanter and ischial tuberosity)
Tender if trauma, infection; “step-offs”
in spondylolisthesis, fracture
Sacroiliitis, ankylosing spondylitis
Paravertebral muscle spasm in abnor-
mal posture, degenerative and inflam-
matory muscle disorders, overuse
Herniated disc or nerve root
compression
Sciatic nerve Greater trochanter
Ischial tuberosity
Test the range of motion in the neck and spine in: flexion, extension, rotation, and lateral bending.
Decreased mobility in arthritis
HIPS
Inspect gait for:
● Stance (see below) and swing (foot moves forward, does not bear weight)
Most problems arise during the
weight-bearing stance phase.
Heelstrike Foot flat Midstance Push-off
PHASES OF GAIT: STANCE (RIGHT LEG) AND SWING (LEFT LEG)
268 Bates’ Pocket Guide to Physical Examination and History Taking
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
● Width of base (usually 2 to 4 inches from heel to heel), shift of pelvis, flexion of knee
Cerebellar disease or foot problems
if wide base; impaired shift of pelvis
in arthritis, hip dislocation, abductor
weakness; disrupted gait if poor knee
flexion
Palpate:
● Along the inguinal ligament
● The trochanteric bursa, on the greater trochanter of the femur
● The ischiogluteal bursa, super- ficial to the ischial tuberosity
Trochanteric bursa
Ischiogluteal bursa
TROCHANTERIC AND
ISCHIOGLUTEAL BURSA
Bulges in inguinal hernia, aneurysm
Focal tenderness in trochanteric bursitis, often described by patients as “low
back pain”
Tender in bursitis (“weaver’s bottom”)
from prolonged sitting
Check range of motion, including:
● Flexion—“Bend your knee and pull it against your abdomen.”
Flexion of opposite leg suggests
deformity of that hip.
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E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
● Extension
● Abduction and adduction
● Internal and external rotation
Painful in iliopsoas abscess
Restricted in hip arthritis
Restricted in hip arthritis
KNEES
Review the structures of the knee.
Medial femoral condyle
Medial femoral epicondyle
Patellar tendon
Medial tibial plateau
Tibial tuberosity
Adductor tubercle
Medial collateral ligament
Pes anserine bursa
270 Bates’ Pocket Guide to Physical Examination and History Taking
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
Inspect:
● Gait for knee extension at heel strike, flexion during all other phases of swing and stance
● Alignment of knees
● Contours of knees, including any atrophy of the quadriceps muscles
Stumbling or “giving way” during heel
strike in quadriceps weakness or abnor- mal patellar tracking
Bowlegs, knock-knees; flexion contrac-
tures in limb paralysis or hamstring
tightness
Quadriceps atrophy with patellofemoral disorder
Inspect and palpate: See Table 16-5, Painful Knees, pp. 283–284.
● The tibiofemoral joint—with knees flexed, including:
● Joint line—place thumbs on either side of the patellar tendon.
Irregular, bony ridges in osteoarthritis.
● Medial and lateral meniscus
● Medial and lateral collateral ligaments
Tenderness if meniscus tear
Tenderness if MCL tear (LCL injuries
less common)
● The patellofemoral compart- ment:
● Patella
● Palpate the patellar tendon and ask patient to extend the leg.
● Press the patella against the underlying femur.
● Push patella distally and ask patient to tighten knee against table.
Swelling over the patella in prepatellar
bursitis (“housemaid’s knee”)
Tenderness or inability to extend the
leg in partial or complete tear of the
patellar tendon
Pain, crepitus, and a history of knee
pain in patellofemoral disorder
Pain during contraction of quadriceps
in chondromalacia
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● Also:
● Suprapatellar pouch
● Infrapatellar spaces (hollow areas adjacent to patella)
● Medial tibial condyle
● Popliteal surface
Swelling in synovitis and arthritis
Swelling in arthritis
Swelling in pes anserine bursitis
Popliteal or Baker’s cyst
Assess any effusions.
● Bulge sign (minor effusions): Compress the suprapatellar pouch, stroke downward on medial surface, apply pres- sure to force fluid to lateral surface, and then tap knee behind lateral margin of patella.
A fluid wave returning to the medial
surface after a lateral tap confirms an
effusion—a positive “bulge sign.”
Tap and watch for fluid wave
Apply medial pressure
Milk downward
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E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
● Balloon sign (major effusions): Compress suprapatellar pouch with one hand; with thumb and finger of other hand, feel for fluid entering the spaces next to the patella.
● Ballotte the patella (major effusion): Push the patella sharply against the femur; watch for fluid returning to the suprapatellar space.
A palpable fluid wave is a positive sign.
Visible wave is a positive sign.
Assess range of motion: flexion, extension, internal and external rotation.
Use maneuvers to assess menisci and ligaments.
● Medial meniscus and lateral meniscus—McMurray test:
With the patient supine, grasp the heel and flex the knee. Cup your other hand over the knee joint with fingers 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.
Click or pop along the medial joint
with valgus stress, external rotation,
and leg extension in tear of posterior
medial meniscus.
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E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
● Medial collateral ligament: With knee slightly flexed, push medially against lateral surface of knee with one hand and pull laterally at the ankle with the other hand (abduc- tion or valgus stress).
● Lateral collateral ligament (LCL): With knee slightly flexed, 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).
Pain or a gap in the medial joint line
points to a partial or complete MCL
tear.
Pain or a gap in the lateral joint line
points to a partial or complete LCL
tear.
● Anterior cruciate ligament (ACL): (1) With knee flexed, place thumbs on medial and lateral joint line and place fin- gers on hamstring insertions. Pull tibia forward, observe if tibia slides forward “like a drawer.” Compare to oppo- site knee.
Forward slide of proximal tibia is a
positive anterior drawer sign in ACL laxity or tear.
(2) Lachman test: 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
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E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
● Posterior cruciate ligament (PCL): Posterior drawer sign: Position patient and hands as in the ACL test. Push the tibia posteriorly and observe for posterior movement, like a drawer sliding posteriorly.
Isolated PCL tears are rare.
ANKLES AND FEET
Inspect ankles and feet. Hallux valgus, corns, calluses
Palpate:
● Ankle joint
● Ankle ligaments: medial- deltoid; lateral-anterior and posterior talofibular, calca- neofibular
Tender joint in arthritis
Tenderness in sprain: lateral ligaments
weaker, inversion injuries (ankle bows
outward) more common
● Achilles tendon
● Compress the metatarsopha- langeal joints; then palpate each joint between the thumb and forefinger.
Rheumatoid nodules, tenderness in
tendonitis
Tenderness in arthritis, Morton’s
neuroma third and fourth MTP joints;
inflammation of first MTP joint in gout
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E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
Assess range of motion.
● Dorsiflex and plantar flex the ankle (tibiotalar joint).
● Stabilize the ankle and invert and evert the heel (subtalar or talocalcaneal joint).
Arthritic joint often painful when
moved in any direction; sprain, when
injured ligament is stretched
Ankle sprain
INVERSION EVERSION
● Stabilize the heel and invert and evert the forefoot (transverse tarsal joints).
Trauma, arthritis
INVERSION EVERSION
● Move proximal phalanx of each toe up and down (meta- tarsophalangeal joints).
276 Bates’ Pocket Guide to Physical Examination and History Taking
SPECIAL TECHNIQUES
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
Measuring Leg Length. 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.
Measuring Range of Motion. 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 indi- cated by red lines.
A flexion deformity of 45 degrees
and further flexion to 90 degrees
(45 degrees → 90 degrees)
0˚
45˚
90˚
160˚
Recording Your FindingsRRReccoorddinnggg YYouuur Finnddinngss
Recording the Physical Examination—The Musculoskeletal System
“Full range of motion in all joints. No evidence of swelling or deformity.”
OR “Full range of motion in all joints. Hand with degenerative changes of He-
berden’s nodes at the distal interphalangeal joints, Bouchard’s nodes at
proximal interphalangeal joints. Mild pain with flexion, extension, and rota-
tion of both hips. Full range of motion in the knees, with moderate crepitus;
no effusion but boggy synovium and osteophytes along the tibiofemoral joint
line bilaterally. Both feet with hallux valgus at the first metatarsophalangeal
joints.” (Suggests osteoarthritis.)
Chapter 16 | The Musculoskeletal System 277
Aids to Interpretation
Table 16-1
Patterns Physical Signs
Mechanical Low Back Pain 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.
Sciatica (Radicular Low Back Pain) 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.
Lumbar Spinal Stenosis 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
Low Back Pain
(continued)
278 Bates’ Pocket Guide to Physical Examination and History Taking
Patterns Physical Signs
Chronic Back Stiffness 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
Nocturnal Back Pain, Unrelieved by Rest 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.
Pain Referred from the Abdomen or Pelvis 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.
Table 16-1 Low Back Pain (continued)
Chapter 16 | The Musculoskeletal System 279
Table 16-2 Pains in the Neck
Patterns Physical Signs
Mechanical Neck Pain 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.
Mechanical Neck Pain—Whiplash 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% to 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.
Cervical Radiculopathy—from nerve root compression 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.
(continued)
280 Bates’ Pocket Guide to Physical Examination and History Taking
Patterns Physical Signs
Cervical Myelopathy—from cervical cord compression 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’s sign: neck flexion with resulting sensation of electrical shock radiating down the spine. Confirmation of cervical myelopathy warrants neck immobilization and neurosurgical evaluation.
Table 16-2 Pains in the Neck (continued)
Chapter 16 | The Musculoskeletal System 281
Table 16-3 Patterns of Pain in and Around the Joints
Rheumatoid Arthritis
Osteoarthritis (Degenerative Joint Disease, or DJD)
Process 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
Common Locations
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
Pattern of Spread
Symmetrically additive: progresses to other joints; persists in initial ones
Additive; however, sometimes only one joint affected
Onset Usually insidious Usually insidious
Progression and Duration
Often chronic, with remissions and exacerbations
Slowly progressive, with exacerbations after overuse
Associated Symptoms
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
282 Bates’ Pocket Guide to Physical Examination and History Taking
Table 16-4 Painful Shoulders
Acromioclavicular Arthritis 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.
Subacromial and Subdeltoid Bursitis
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.
Rotator Cuff Tendinitis Tenderness over the rotator cuff, when elbow passively lifted posteriorly or with “drop-arm” maneuver.
Bicipital Tendinitis 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.
Chapter 16 | The Musculoskeletal System 283
Table 16-5 Painful Knees
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.
Prepatellar bursa
Pes anserine
Iliotibial band
Bursitis. Inflam- mation and thickening of bursa seen in repetitive motion and overuse syndromes. Can involve prepatellar
bursa (“housemaid’s knee”), pes anserine bursa medially (runners, osteoarthritis), iliotibial band laterally (over lateral femoral condyle), especially in runners.
Patella moves up
and lateral
Leg extends and foot
raises
Patellofemoral instability. 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.
Lateral meniscus
Medial meniscus torn
Meniscal tear. 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.
(continued)
284 Bates’ Pocket Guide to Physical Examination and History Taking
Anterior cruciate ligament torn
Anterior cruciate tear or sprain. 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.
Medial collateral ligament torn
Collateral ligament sprain or tear. 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.
Baker’s cyst
Posterior knee
Baker’s cyst. 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.
Painful Knees (continued)Table 16-5
285
C H A P T E R
17The Nervous System Fundamentals for Assessing the Nervous System
The central nervous system (CNS) consists of the brain and spinal cord. 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 fibers.
CENTRAL NERVOUS SYSTEM
The Brain ● Gray matter, or aggregations of neuronal cell bodies; rims the sur- faces of the cerebral hemispheres, forming the cerebral cortex
● White matter, or neuronal axons coated with myelin, allowing nerve impulses to travel more rapidly
● Basal ganglia, which affect movement
● Thalamus, which processes and relays sensory impulses to the cerebral cortex
● Hypothalamus, which maintains homeostasis and regulates tem- perature, heart rate, and blood pressure; affects endocrine system, and governs emotional behaviors such as anger and sex drive; and contains hormones that act directly on the pituitary gland
● Brainstem, which connects the upper part of the brain with the spinal cord and has three sections: midbrain, pons, and medulla
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286 Bates’ Pocket Guide to Physical Examination and History Taking
● Reticular activating (arousal) system, in the diencephalon and upper brainstem; activation linked to consciousness
● Cerebellum, at the base of the brain, which coordinates all movement and helps maintain the body upright in space
The Spinal Cord ● A cylindrical mass of nerve tissue encased within the bony vertebral column, extending from medulla to first or second lumbar vertebra
● 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 reflex activity of the deep tendon (or spinal nerve) reflexes
● Divided into five segments: cervical (C1–8), thoracic (T1–12), lumbar (L1–5), sacral (S1–5), and coccygeal
● Roots fan out like a horse’s tail at L1–2, the cauda equina
PERIPHERAL NERVOUS SYSTEM
The Cranial Nerves ● Cranial nerves I and II are actually fiber tracts emerging from the brain.
● Cranial nerves III through XII arise from the diencephalon and brainstem.
The Peripheral Nerves ● 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.
Chapter 17 | The Nervous System 287
● 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.
The Health History
Common or Concerning Symptoms
◗ Headache
◗ Dizziness or vertigo
◗ Generalized, proximal, or distal weakness
◗ Numbness, abnormal or lost sensations
◗ Loss of consciousness, syncope, or near-syncope
◗ Seizures
◗ Tremors or involuntary movements
Headache: ask about location, severity, duration, and any associated symptoms, such as visual changes, weakness, or loss of sensation. Ask if coughing, sneezing, or sudden movements of the head affect the headache.
See Table 7-1, Primary Headaches, p. 111,
and Table 7-2, Secondary Headaches,
pp. 112–113. Subarachnoid hemorrhage may evoke “the worst headache of my
life.” Dull headache affected by maneu-
vers, especially on awakening and in the
same location are seen in mass lesions
such as brain tumors
Dizziness can have many mean- ings. Is the patient lightheaded or feeling faint (presyncope)? Is there unsteady gait from dis- equilibrium or ataxia, or true vertigo, a perception that the room is spinning or rotating?
Are any medications contribut- ing to dizziness?
Lightheadedness in palpitations; near-
syncope from vasovagal stimulation,
low blood pressure, febrile illness, and
others; vertigo in benign positional ver-
tigo, Ménière’s disease, brainstem tumor
288 Bates’ Pocket Guide to Physical Examination and History Taking
Are associated symptoms pres- ent, such as double vision (dip- lopia), difficulty forming words (dysarthria), or difficulty with gait or balance (ataxia)? Is there any weakness?
Diplopia, dysarthria, ataxia in vertebro-
basilar transient ischemic attack (TIA) or stroke
See Table 17-1, Types of Stroke,
pp. 308–311
Weakness or paralysis in TIA or stroke
Distinguish proximal from distal weakness. For proximal weakness, ask about combing hair, reach- ing for things on a high shelf, difficulty getting out of a chair or taking a high step up. 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 proximal weakness in myo- pathy; bilateral, predominantly distal weakness in polyneuropathy; weak- ness worsened by repeated effort and
improved by rest in myasthenia gravis
Is there any loss of sensation, difficulty moving a limb, or altered sensation such as tingling or pins and needles? Peculiar sensations without an obvious stimulus (paresthesias)? Dysesthe- sias, or disordered sensations in response to a stimulus, may last longer than the stimulus itself.
Loss of sensation, paresthesias, and
dysesthesias in brain and spinal cord
lesions; also in disorders of peripheral
sensory roots and nerves; paresthesias
in hands and around mouth in hyper-
ventilation
Synope: “Have you ever fainted or passed out?” leads to discussion of any loss of consciousness (syncope).
Syncope if sudden but temporary loss of consciousness from decreased cerebral
blood flow, commonly called fainting.
Get a complete description of the event. What brought on the episode? Were there any warn- ing symptoms? Was the patient standing, sitting, or lying down when it began? How long did it last? 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. Cardiac syncope from dysrhyth- mias, more common in older patients,
often with sudden onset, sudden offset.
Chapter 17 | The Nervous System 289
Also ask if anyone observed the episode. What did the patient look like before, during, and after the episode? Was there any seizurelike movement of the arms or legs? Any incontinence of the bladder or bowel?
Tonic–clonic motor activity, inconti-
nence, and postictal state in generalized seizures. Unlike syncope, injury such as tongue biting or bruising of limbs may
occur.
A seizure is a paroxysmal dis- order caused by sudden exces- sive electrical discharge in the cerebral cortex or its underlying structures.
Depending on the type of seizure, there
may be loss of consciousness or abnor-
mal feelings, thought processes, and
sensations, including smells, as well as
abnormal movements.
Health Promotion and Counseling: Evidence and Recommendations
Important Topics for Health Promotion and Counseling
◗ Preventing stroke or transient ischemic attack (TIA)
◗ Preventing risk of peripheral neuropathy
◗ Preventing the “three Ds”: delirium, dementia, and depression
Preventing Stroke or TIA. Cerebrovascular disease is the third leading cause of death in the United States. Decreased vascular perfu- sion results in sudden focal but transient brain dysfunction in TIA, or in permanent neurological deficits in stroke, as determined by neurodiagnostic imaging.
Counsel patients about the warning signs of stroke: sudden numbness or weakness of the face, arm, or leg; sudden confusion or trouble speaking or understanding; sudden difficulty walking, dizziness, or loss of balance or coordination; sudden trouble seeing in one or both eyes; or sudden severe headache. Detecting TIAs is important—in the first 3 months after a TIA, subsequent stroke occurs in approximately 15% of patients.
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290 Bates’ Pocket Guide to Physical Examination and History Taking
Primary prevention of stroke requires aggressive management of risk factors and patient education. Risk factors include smoking, excess weight, hypertension, dyslipidemia, heavy alcohol use, physical inactiv- ity, obesity, and diabetes. Blood pressure should be ≤140/90 mm Hg and ≤130/80 mm Hg for those with diabetes or renal disease with proteinuria. Lipid-lowering agents may reduce risk of stroke. Urge patients to replace saturated and transunsaturated fats, found in dairy products, meat, and stick margarine, with polyunsaturated and unhy- drogenated monosaturated fats, found in soybeans, liquid margarine, and fish oils. Or recommend increased intake of fruits, vegetables, and fiber. Encourage regular exercise, optimal body weight, and moderate intake of alcohol. Aim for optimal blood glucose levels, approximately 100 mg/dL for patients with diabetes.
Preventing Risk of Peripheral Neuropathy. In diabetics, pro- mote optimal glucose control to reduce risk of sensorimotor polyneu- ropathy, autonomic dysfunction, mononeuritis multiplex, or diabetic neuropathy.
Preventing the “Three Ds”: Delirium, Dementia, and Depression Delirium is an acute confusional state marked by sudden onset, fluctu- ating course, inattention and changes in the level of consciousness; it is often undetected. Learn to use the Confusional Assessment Method (CAM) algorithm.
Dementia is best assessed by the Mini-Mental State examination and the Mini-Cog, but may be difficult to distinquish from benign forget- fulness and mild cognitive impairment.
Depression is common in individuals with significant medical conditions. See screening questions on p. 45, Chapter 3. See also Chapter 20, The Older Adult, pp. 378–379, and Table 20-2, Delirium and Dementia, pp. 391–392, and Table 20-3, Screening for Dementia: The Mini-Cog, p. 393.
Chapter 17 | The Nervous System 291
Techniques of ExaminationTTTecchhnniiquees offf TT Exaammminnatttionn
Cranial Ner ves and Function
No. Cranial Nerve Function
I Olfactory Sense of smell
II Optic Vision
III Oculomotor Pupillary constriction, opening the eye (lid
elevation), and most extraocular movements
IV Trochlear Downward, internal rotation of the eye
V Trigeminal Motor—temporal and masseter muscles (jaw clenching), also lateral pterygoid’s (lateral jaw
movement)
Sensory—facial. The nerve has three divisions: (1) ophthalmic, (2) maxillary, and (3) man-
dibular.
VI Abducens Lateral deviation of the eye
VII Facial Motor—facial movements, including those of facial expression, closing the eye, and closing
the mouth
Sensory—taste for salty, sweet, sour, and bitter substances on the anterior two-thirds of the
tongue
VIII Acoustic Hearing (cochlear division) and balance (ves-
tibular division)
IX Glossopharyngeal Motor—pharynx Sensory—posterior portions of the eardrum and
ear canal, the pharynx, and the posterior tongue,
including taste (salty, sweet, sour, bitter)
X Vagus Motor—palate, pharynx, and larynx Sensory—pharynx and larynx
XI Spinal accessory Motor—the sternomastoid and upper portion of the trapezius
XII Hypoglossal Motor—tongue
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CRANIAL NERVES
CN I (OLFACTORY)
Test sense of smell on each side. Loss in frontal lobe lesions
CN II (OPTIC)
Assess visual acuity. Blindness
Check visual fields. Hemianopsia
Inspect optic discs. Papilledema, optic atrophy
CN II, III (OPTIC AND OCULOMOTOR)
Test pupillary reactions to light. If abnormal, test reactions to near effort.
Blindness, CN III paralysis, tonic pupils;
Horner’s syndrome may affect light
reactions
CN III, IV, VI (OCULOMOTOR, TROCHLEAR, AND ABDUCENS)
Assess extraocular movements. Strabismus from paralysis of CN III, IV, or VI; nystagmus, intranuclear opthal-
moplegia
CN V (TRIGEMINAL) Test pain and light touch sensations on face in (1) ophthalmic, (2) maxillary and (3) mandibular zones.
(1)
(2)
(3)
C2
CN V—SENSORY
Chapter 17 | The Nervous System 293
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Feel the contractions of temporal and masseter muscles.
Motor or sensory loss from lesions of
CN V or its higher motor pathways
TEMPORAL MUSCLES MASSETER MUSCLES
Check corneal reflexes.
CN VII (FACIAL)
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’s palsy, or of CNS, as in
a stroke. See Table 17-2, Facial Paraly-
sis, p. 312.
CN VIII (ACOUSTIC)
Assess hearing of whispered voice. If decreased:
● Test for lateralization (Weber test).
● Compare air and bone conduction (Rinne test).
Sensorineural loss causes lateralization
to affected ear where AC > BC. Con- duction loss causes lateralization to
affected ear and BC > AC. See p. 108.
See p. 108.
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E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
CN IX, X (GLOSSOPHARYNGEAL AND VAGUS)
Observe any difficulty swallowing.
A weakened palate or pharynx impairs
swallowing.
Listen to the voice. Hoarseness or nasality
Watch soft palate rise with “ah.” Palatal paralysis in CVA
Test gag reflex on each side. Absent reflex is often normal.
CN XI (SPINAL ACCESSORY)
Trapezius Muscles. Assess muscles for bulk, involuntary movements, and strength of shoulder shrug.
Atrophy, fasciculations, weakness
Sternomastoid Muscles. Assess strength as head turns against your hand.
Weakness of sternomastoid muscle
when head turns to opposite side
CN XII (HYPOGLOSSAL)
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. Deviation to weak side in contralateral CVA
THE MOTOR SYSTEM
See Table 17-3, Motor Disorders, p. 313.
BODY POSITION
Observe the patient’s body position during movement and at rest.
Hemiplegia in stroke
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INVOLUNTARY MOVEMENTS
If present, observe location, quality, rate, rhythm, amplitude, and setting.
Tremors, fasciculations, tics, chorea,
athetosis, oral–facial dyskinesias. See
Table 17-4, Involuntary Movements,
pp. 314–315.
MUSCLE BULK AND TONE
Inspect muscle contours. Atrophy of bulk. See Table 17-5, Disorders of Muscle Tone, p. 316.
Assess resistance to passive stretch of arms and legs.
Spasticity, rigidity, flaccidity of tone
MUSCLE STRENGTH
Test and grade the major muscle groups, with the examiner providing resistance.
Grading Muscle Strength
Grade Description
0 No muscular contraction detected
1 A barely detectable trace of contraction
2 Active movement with gravity eliminated
3 Active movement against gravity
4 Active movement against gravity and some resistance
5 Active movement against full resistance (normal)
Look for a pattern if any detectable weakness. It may suggest a lower motor neuron lesion affecting a peripheral nerve or nerve root. Weakness of one side of body suggests an upper motor neuron lesion. A polyneuropathy causes symmetric distal weakness, and a myopathy usually causes proximal weakness. Weakness that worsens with repeated effort and improves with rest suggests myasthenia gravis.
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● Elbow flexion (C5, C6)—biceps
● Elbow extension (C6, C7, C8)—triceps
● Wrist extension (C6, C7, C8)—radial nerve
● Grip (C7, C8, T1)
● Finger abduction (C8, T1)—ulnar nerve
● Thumb opposition (C8, T1)—median nerve
● Trunk—flexion extension, lateral bending
● Hip flexion (L2, L3, L4)—iliopsoas
Peripheral radial nerve damage; central
stroke or multiple sclerosis if hemiplegia
Weak grip in cervical radiculopathy, de Quervain’s tenosynovitis, carpal tunnel syndrome
Weak in ulnar nerve disorders
Weak in Carpal tunnel syndrome
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● Hip extension (S1)—gluteus maximus
● Hip adduction (L2, L3, L4)—adductors
● Hip abduction (L4, L5, S1)— gluteus medius and minimus
● Knee extension (L2, L3, L4)—quadriceps
● Knee flexion (L4, L5, S1, S2)—hamstrings
● Ankle dorsiflexion (L4, L5)
● Ankle plantar flexion (S1)
COORDINATION
Check rapid alternating movements in arms and legs (tap foot)
Clumsy, slow movements in cerebellar
disease
Point-to-point movements in arms and legs–finger to nose, heel to shin
Clumsy, unsteady movements in
cerebellar disease
Gait. Ask patient to: ● Walk away, turn, and come back
CVA, cerebellar ataxia, parkinsonism,
or loss of position sense may affect
performance.
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● Walk heel to toe
● Walk on toes, then on heels
● Hop in place on each foot; do one-legged shallow knee bends. Substitute rising from a chair and climbing on a stool for hops and bends as indicated.
Ataxia
Corticospinal tract injury
Proximal hip girdle weakness increases
risk of falls.
Stance ● Do a Romberg test (a sensory 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.
● Look for a pronator drift as patient holds arms forward, with eyes closed, for 20 to 30 seconds.
Loss of balance when eyes are closed is a
positive Romberg test, suggesting poor position sense.
Flexion and pronation at elbow and
downward drift of arm from contra- lateral corticospinal tract lesion
Ask patient to keep arms up and tap them downward. A smooth return to position is normal.
Weakness, incoordination, poor position
sense
THE SENSORY SYSTEM
Use an object like a broken cotton swab to test sharp and dull sensation; compare symmetric areas on the two sides of the body. Do not reuse the object on another patient.
A hemisensory loss pattern suggests a
contralateral cortical lesion.
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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
See Table 17-6, Dermatones, pp.
317–318.
Map any area of abnormal response, including dermatomes, if present.
Dermatomal sensory loss in herpes zoster, nerve root compression.
Assess response to the following stimuli, with the patient’s eyes closed.
● Pain. Use the sharp end of a pin 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 suit- able temperature.
● Light touch. Use a fine wisp of cotton.
Analgesia, hypalgesia, hyperalgesia
Temperature and pain sensation usually
correlate.
Anesthesia, hyperesthesia
Check for vibration and position senses. If responses are abnormal, test more proximally
Loss of vibration and position senses in
peripheral neuropathy from diabetes
or alcoholism and in posterior column
disease from syphilis or vitamin B12
deficiency
● Vibration and position. Vibra- tion: Use a 128-Hz tuning fork, held on a bony promi- nence. Vibration and position senses, both carried in the pos- terior columns, often correlate.
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● Position. Holding patient’s finger or big toe by its sides, move it up or down.
Assess discriminative sensations:
● Stereognosis. Ask for identifi- cation of a common object placed in patient’s hand.
● Number identification (graphesthesia). Draw a num- ber on patient’s palm with blunt end of a pen and ask the patient to identify the number.
Lesions in the posterior columns or
sensory cortex impair stereognosis,
number identification, and two-point
discrimination.
● Two-point discrimination. Use two pins of the sides of a paper clip to find minimal distance on pad of patient’s finger at which two points can be distin- guished (normally <5 mm).
Chapter 17 | The Nervous System 301
REFLEXES
Grading Reflexes
Grade Description
4+ Hyperactive (clonus must be present) 3+ Brisker than average, not necessarily abnormal 2+ Average, normal 1+ Diminished, low normal 0 No response
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● Point localization. Touch skin briefly, and ask patient to open both eyes and identify the place touched.
A lesion in the sensory cortex may
impair point localization on the contra-
lateral side and cause extinction of the
touch sensation.
● Extinction. Simultaneously touch opposite, corresponding areas of the body; ask whether the patient feels one touch or two.
Biceps (C5, C6) Triceps (C6, C7)
Hyperactive deep tendon reflexes, absent abdominal reflexes, and a positive
Babinski response in upper motor neuron lesions
302 Bates’ Pocket Guide to Physical Examination and History Taking
Supinator (brachioradialis) (C5, C6)
Knee (L2, L3, L4)
Ankle (S1) Check for clonus if reflexes seem hyperactive.
Ankle jerks symmetrically, decreased or absent in peripheral polyneuropathy;
slowed ankle jerk in hypothyroidism.
CUTANEOUS STIMULATION REFLEXES
Abdominal reflexes (upper T8, T9, T10; lower T10, T11, T12)
May be absent with upper or lower
neuron lesions
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Plantar response (L5, S1), normally flexor
Babinski extensor response (big toe
fans up) from corticospinal tract lesion
Anal Reflex. With a dull object, stroke outward from anus in four quadrants. Watch for anal contraction.
Loss of reflex suggests cauda equina
lesion at the S2–3–4 level.
SPECIAL TECHNIQUES
Meningeal Signs. With patient supine, flex head and neck toward chest. Note resistance or pain, and watch for flexion of hips and knees (Brudzinski’s sign).
Meningeal irritation in the subarachnoid
space may cause resistance or pain on
flexion during both maneuvers.
Flex one of patient’s legs at hip and knee, then straighten knee. Note resistance or pain (Kernig’s sign).
A compressed lumbosacral nerve root
also causes pain on straightening the
knee of the raised leg.
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Lumbosacral Radiculopathy: Straight-Leg Raise.
With patient supine, raise relaxed and straightened leg, flexing the leg at the hip. Then dorsiflex the foot.
Pain and muscle weakness if herniated
disc; ipsilateral calf wasting and weak
ankle dorsiflexion may also be present.
Asterixis. Ask patient to hold both arms forward, with hands cocked up and fingers spread. Watch for 1 to 2 minutes.
Sudden brief flexions in liver disease,
uremia and hypercapnia.
Winging of the Scapula. Ask patient to push against the wall of your hand with a par- tially straightened arm. Inspect scapula. It should stay close to the chest wall.
Winging of scapula away from chest wall
suggests weakness of the serratus ante-
rior muscle, seen in muscular dystrophy
or injury to long thoracic nerve.
The Stuporous or Comatose Patient.
Assess ABCs (airway, breathing, and circulation).
See Table 17-7, Metabolic and Structural
Coma, p. 319, Table 17-8, Glascow Coma
Scale, p. 320, and Table 17-9, Pupils in
Comatose Patients, p. 321.
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● Take pulse, blood pressure, and rectal temperature.
● Establish level of conscious- ness with escalating stimuli.
Lethargy, obtundation, stupor, coma
However, don’t dilate pupils, and don’t flex patient’s neck if any suspicion of cervical cord injury.
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
Levels of Consciousness
Alertness Patient is awake and aware of self and environ- ment. When spoken to in a normal voice, patient
looks at you and responds fully and appropriately
to stimuli.
Lethargy When spoken to in a loud voice, patient appears drowsy but opens eyes and looks at you, re-
sponds to questions, and then falls asleep.
Obtundation When shaken gently, patient opens eyes and looks at you but responds slowly and is somewhat
confused. Alertness and interest in environment
are decreased.
Stupor Patient arouses from sleep only after painful stim- uli. Verbal responses are slow or absent. Patient
lapses into unresponsiveness when stimulus
stops. Patient has minimal awareness of self or
environment.
Coma Despite repeated painful stimuli, patient remains unarousable with eyes closed. No evident re-
sponse to inner need or external stimuli is shown.
● Conduct neurological examina- tion, looking for asymmetric findings.
NEUROLOGIC EXAMINATION
Observe:
● Breathing pattern
● Pupils
● Ocular movements
Cheyne-Stokes, ataxic breathing
Asymmetric if structural lesions or brain
herniation
Deviation to affected side in hemispheric
stroke
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Check for the oculocephalic reflex (doll’s eye movements). Holding upper eyelids open, turn head quickly to each side, and then flex and extend patient’s neck. This patient’s head will be turned to her right.
In a comatose patient with an intact brainstem, the eyes move in the oppo- site direction, in this case to her left
(doll’s eye movements) as below.
Very deep coma or a lesion in the mid-
brain or pons abolishes this reflex, so
eyes do not move.
Note posture of body. Decorticate rigidity, decerebrate rigidity, flaccid hemiplegia
Test for flaccid paralysis.
● Hold forearms vertically; note wrist positions.
● From 12 to 18 inches above bed, drop each arm.
● Support both knees in a some- what flexed position, and then extend each knee and let leg drop to the bed.
● From a similar starting position, release both legs.
A flaccid hand droops to the horizontal.
A flaccid arm drops more rapidly.
The flaccid leg drops more rapidly.
A flaccid leg falls into extension and
external rotation.
Complete the neurologic and general physical examination.
Chapter 17 | The Nervous System 307
Recording Your Findings
Recording the Examination—The Nervous System
“Mental Status: Alert, relaxed, and cooperative. Thought process coherent. Oriented to person, place, and time. Detailed cognitive testing deferred.
Cranial Nerves: I—not tested; II through XII intact. Motor: Good muscle bulk and tone. Strength 5/5 throughout. Cerebellar: Rapid alternating movements (RAMs), finger-to-nose (F→N), heel-to-shin (H→ S) intact. Gait with nor- mal base. Romberg—maintains balance with eyes closed. No pronator drift.
Sensory: Pinprick, light touch, position, and vibration intact. Reflexes: 2+ and symmetric with plantar reflexes downgoing.”
OR “Mental Status: The patient is alert and tries to answer questions but has dif- ficulty finding words. Cranial Nerves: I—not tested; II—visual acuity intact; visual fields full; III, IV, VI—extraocular movements intact; V motor—temporal
and masseter strength intact, sensory corneal reflexes present; VII motor—
prominent right facial droop and flattening of right nasolabial fold, left facial
movements intact, sensory—taste not tested; VIII—hearing intact bilaterally
to whispered voice; IX, X—gag intact; XI—strength of sternomastoid and
trapezius muscles 5/5; XII—tongue midline. Motor: strength in right biceps, triceps, iliopsoas, gluteals, quadriceps, hamstring, and ankle flexor and exten-
sor muscles 3/5 with good bulk but increased tone and spasticity; strength
in comparable muscle groups on the left 5/5 with good bulk and tone. Gait—
unable to test. Cerebellar—unable to test on right due to right arm and leg
weakness; RAMs, F→N, H→S intact on left. Romberg—unable to test due to right leg weakness. Right pronator drift present. Sensory: decreased sensation to pinprick over right face, arm, and leg; intact on the left. Stereognosis and
two-point discrimination not tested. Reflexes (can record in two ways):
Suggests left hemispheric CVA in distribution of the left middle cerebral artery, with right sided hemiparesis.
Biceps Triceps Brach Knee Ankle Pl
RT 2+ 2+ 2+ 2+ 2+ ↓ OR
LT 2+ 2+ 2+ 2+ 1+ ↓
R L
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Aids to Interpretation
Types of StrokeTable 17-1
Assessing patients with stroke involves 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 thrombus or embolus?
Stroke is a medical emergency, and timing is of the essence. Answers to these questions are critical to patient outcomes and use of antithrombotic therapies.
In acute ischemic stroke, ischemic brain injury begins with a central core of very low perfusion and often irreversible cell death. This core is surrounded by an ischemic penumbra of metabolically disturbed cells that are still potentially viable, depending on restoration of blood flow and duration of ischemia. Because most irreversible damage occurs in the first 3 to 6 hours after onset of symptoms, therapies targeted to the initial 3-hour window achieve the best outcomes, with recovery in up to 50% of patients in some studies.
Understanding the pathophysiology of stroke takes dedication, expert supervision to improve techniques of neurological examination, and perseverance. This brief overview is intended to prompt further study and practice.
Chapter 17 | The Nervous System 309
Types of Stroke (continued)Table 17-1
Body of caudate
Internal capsule
Putamen
Globus pallidus
Uncus
Thalamus
Anterior cerebral artery
Middle cerebral artery
Posterior cerebral artery
Anterior choroidal artery
Lateral ventrical
Prefrontal area
Premotor area
Primary motor cortex
Primary somatic sensory cortex
Somatic sensory association area
Taste area
Primary auditory cortex
Auditory association area
Sensory speech (Wernike's) area
Reading compre- hension area
Visual association area
Visual cortex
Motor speech (Broca's) area
(continued)
310 Bates’ Pocket Guide to Physical Examination and History Taking
Types of Stroke (continued)Table 17-1
Clinical Features and Vascular Territories of Stroke
Major Clinical Features Vascular Territory
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
Contralateral face, arm > leg weakness, sensory loss, field cut, aphasia (left MCA) or neglect, apraxia (right MCA)
Anterior circulation—middle cerebral artery (MCA)
Largest vascular bed for stroke
Contralateral motor or sensory deficit without cortical signs
Subcortical circulation—lenticulostriate deep penetrating branches of MCA
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
Contralateral field cut Posterior circulation—posterior cerebral artery (PCA)
Includes paired vertebral arteries, the basilar artery, paired posterior cerebral arteries. Bilateral PCA infarction causes cortical blindness but preserved pupillary light reaction.
Chapter 17 | The Nervous System 311
Types of Stroke (continued)Table 17-1
Clinical Features and Vascular Territories of Stroke (continued) Major Clinical Features Vascular Territory
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: American College of Physicians, 2006. pp. 52–68.
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Facial ParalysisTable 17-2
Distinguish peripheral from central lesions of CN VII by closely observing movements of the upper face. Because of innervation from both hemispheres, the movements are preserved in central lesions.
Lesion of Peripheral Nervous System
Lesion of Central Nervous System
Side of face affected
Same side as the lesion
Side opposite the lesion
Upper face Unable to wrinkle forehead, raise eyebrow, close eye
Movements normal or slightly weak
Lower face Unable to smile, show teeth
Same
Common cause Bell’s palsy (injury to CN VII)
CVA
Motor cortex
CN VII peripheral
lesion
Synapses in the pons
Facial nerve
Motor cortex
CN VII central lesion
Synapses in the pons
Facial nerve
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Motor DisordersTable 17-3
Peripheral Nervous System Disorder
Central Nervous System Disorder*
Parkinsonism (Basal Ganglia Disorder)
Cerebellar Disorder
Involuntary movements
Often fascicu- lations
No fascicu- lations
Resting tremors
Intention tremors
Muscle bulk
Atrophy Normal or mild atrophy (disuse)
Normal Normal
Muscle tone Decreased or absent
Increased, spastic
Increased, rigid
Decreased
Muscle strength
Decreased or lost
Decreased or lost
Normal or slightly decreased
Normal or slightly decreased
Coordina- tion
Unimpaired, though limited by weakness
Slowed and limited by weakness
Good, though slowed and often tremulous
Impaired, ataxic
Reflexes Deep tendon Decreased
or absent Increased Normal or
decreased Normal or decreased
Plantar Flexor or absent
Extensor Flexor Flexor
Abdominals Absent Absent Normal Normal
* Upper motor neuron.
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Involuntary MovementsTable 17-4
Resting static tremors. Fine, “pin- rolling” tremor seen at rest, usually disappear with movement; seen in basal ganglia disorders like Parkinson’s disease.
Postural tremor. Seen when maintaining active posture; in anxiety, hyperthyroidism; also familial. From basal ganglia disorder.
Intention tremor. Seen with intentional movement, absent at rest; in cerebellar disorders, including multiple sclerosis
Fasciculations. Fine, rapid flickering of muscle bundles in lower motor neuron disorders.
Chorea. Brief, rapid, irregular, jerky; face, head, arms, or hands (e.g., Huntington’s disease)
Athetosis. Slow, twisting, writhing; face, distal limbs, often with associated spasticity (e.g., cerebral palsy)
Chapter 17 | The Nervous System 315
Involuntary Movements (continued)Table 17-4
Oral-facial dyskinesias. Rhythmic, repetitive, bizarre movements of face, mouth. Tardive dyskinesias with prolonged use of psychotropic drugs such as phenothiazines
Tics. Brief, irregular, repetitive, coordinated movements (e.g., winking, shrugging); in Tourette’s syndrome, users of phenothiazines, amphetamines
Dystonia. Grotesque, twisted postures, often in trunk or, as shown, in neck (spasmodic torticollis)
316 Bates’ Pocket Guide to Physical Examination and History Taking
Table 17-5 Disorders of Muscle Tone
Spasticity Rigidity
Location. Upper motor neuron or corticospinal tract systems.
Location. Basal ganglia system
Description. Increased muscle tone (hypertonia) that is rate- dependent. 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.
Description. Increased resistance that persists throughout the movement arc, independent of rate of movement, is called lead-pipe rigidity. With flexion and extension of the wrist or forearm, a superimposed rachetlike jerkiness is called cogwheel rigidity.
Common Cause. Stroke, especially late or chronic stage
Common Cause. Parkinsonism
Flaccidity Paratonia
Location. Lower motor neuron at any point from the anterior horn cell to the peripheral nerves
Location. Both hemispheres, usually in the frontal lobes
Description. Loss of muscle tone (hypotonia), causing the limb to be loose or floppy. The affected limbs may be hyperextensible or even flaillike.
Description. 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).
Common Cause. Guillain–Barré syndrome; also initial phase of spinal cord injury (spinal shock) or stroke
Common Cause. Dementia
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Table 17-6 Dermatomes
C3 Front of neck
C4
C5 C5
C6 C6
C7 C7
C8 C8
T1 T1
T2
T3
T4
T5
T6
T7 T8 T9
T10
T11
T12
S1 S1
S2,3
L1 L2 L2
L3 L3
L4 L4
L5 L5
C8 Ring and little fingers
L4 Knee
L1 Inguinal
L5 Anterior ankle and foot
T4 Nipples
T10 Umbilicus
C2
C3
CN V
DERMATOMES INNERVATED BY POSTERIOR ROOTS (continued)
318 Bates’ Pocket Guide to Physical Examination and History Taking
Dermatomes (continued)Table 17-6
C2
C3C3 Back of neck
C4
C5
C5C5
C6
C6C6
C6 Thumb
C7
C7C7
C8
C8C8
T1
T1T1
T2
T3 T4 T5 T6 T7 T8 T9
T10 T11 T12
S1
S1S1
S2
S2S2
S3 S4
S5
L1 L2 L3 L4
L4L4
L4, L5, S1 Posterior ankle
and foot
L5
L5L5
C8 Ring and little fingersS5 Perianal
DERMATOMES INNERVATED BY POSTERIOR ROOTS
Chapter 17 | The Nervous System 319
Table 17-7 Metabolic and Structural Coma
Toxic–Metabolic Structural
Pathophysiology Arousal centers poisoned or
critical substrates depleted Lesion destroys or compresses
brainstem arousal areas, either directly or secondary to more distant expanding mass lesions.
Clinical Features ● Respiratory pattern. If regular, may be normal or hyperventilation. If irregular, usually Cheyne-Stokes
Respiratory pattern. Irregular, especially Cheyne-Stokes or ataxic breathing. Also with selected stereotypical patterns like “apneustic” respiration (peak inspiratory arrest) or central hyperventilation.
● Pupillary size and reaction. Equal, reactive to light. If pinpoint from opiates or cholinergics, you may need a magnifying glass to see the reaction.
May be unreactive if fixed and dilated from anticholinergics or hypothermia
Pupillary size and reaction. Unequal or unreactive to light (fixed)
Midposition, fixed—suggests midbrain compression
Dilated, fixed—suggests com- pression of CN III from herniation
● Level of consciousness. Changes after pupils change
Level of consciousness. Changes before pupils change
Examples of Cause Examples of Cause Uremia, hyperglycemia Epidural, subdural, or
intracerebral hemorrhage Alcohol, drugs, liver failure Cerebral infarct or embolus Hypothyroidism, hypoglycemia Tumor, abscess Anoxia, ischemia Meningitis, encephalitis Brainstem infarct, tumor, or
hemorrhage Hyperthermia, hypothermia Cerebellar infarct, hemorrhage,
tumor, or abscess
320 Bates’ Pocket Guide to Physical Examination and History Taking
Activity Score
Eye Opening
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
___________
Motor Response
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 __________
Verbal Response
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)*
*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):81–84.
Table 17-8 Glasgow Coma Scale
Chapter 17 | The Nervous System 321
Table 17-9 Pupils in Comatose Patients
Small or Pinpoint Pupils 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.
Midposition Fixed Pupils Midposition or slightly dilated pupils (4–6 mm) and fixed to light suggest damage in the midbrain.
Large Pupils 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.
One Large Pupil 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.
323
C H A P T E R
18Assessing Children: Infancy Through Adolescence
Child Development
Children display tremendous variations in physical, cognitive, and social development compared with adults.
CCChilddd DDeevveeloopppmmennt
Key Principles of Child Development
◗ Child development proceeds along a predictable pathway marked by devel-
opmental milestones.
◗ The range of normal development is wide. Children mature at different rates.
◗ Various physical, psychological, social, and environmental factors, as well as
diseases, can affect child development and health. For example, chronic dis-
eases, child abuse, and poverty can contribute to detectable physical abnor-
malities and influence the rate and course of developmental advancement.
◗ The child’s developmental level affects how you conduct the medical history
and physical examination.
The Health History
The child’s history follows the same outline as the adult’s history, with certain additions presented here.
Identifying Data. Record date and place of birth, nickname, and first names of parents (and last name of each, if different).
Chief Complaints. Determine if they are the concerns of the child, the parent(s), a schoolteacher, or some other person.
Present Illness. Determine how each family member responds to the child’s symptoms, why he or she is concerned, and whether the illness may provide for the child any secondary gain.
324 Bates’ Pocket Guide to Physical Examination and History Taking
History Birth History. This is especially important when neurologic or devel- opmental 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
Feeding History. This is particularly important with either under- nutrition or obesity.
● Breast-feeding—frequency and duration of feeds, difficulties, timing and method of weaning
● Bottle-feeding—type; amount; frequency; vomiting; colic; diarrhea
● Vitamins, iron, and fluoride supplements; introduction of solid foods
● Eating habits—types and amounts of food eaten, parental attitudes and responses to feeding problems
Growth and Developmental History. 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
● Developmental milestones—ages child held head up, rolled over, sat, stood, walked, and talked
● 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
Chapter 18 | Assessing Children: Infancy Through Adolescence 325
Current Health Status Allergies. Pay particular attention to history of eczema, urticaria, perennial allergic rhinitis, asthma, food intolerance, insect hyper- sensitivity, and recurrent wheezing.
Immunizations. Include dates given and any untoward reactions.
Screening Tests. These are likely to 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).
Health Promotion and Counseling: Evidence and Recommendations
1. Age-appropriate developmental achievement of the child ● Physical (maturation, growth, puberty) ● Motor (gross and fine motor skills) ● Cognitive (milestones, language, school performance) ● Emotional (self-efficacy, self-esteem, independence, morality) ● 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 findings 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 efficacy ● Family relationships (interactions, strengths, supports) ● Prevention or recognition of illness ● Prevention of risky behaviors and addictions ● School and vocation ● Peer relationships ● Community interactions
7. Partnership between health provider, child, and family
326 Bates’ Pocket Guide to Physical Examination and History Taking
Assessing Newborns
Sequence of Examination
The sequence of examination varies according to the child’s age and comfort
level.
◗ For infants and young children, perform nondisturbing maneuvers early and potentially distressing maneuvers toward the end. For example, palpate the head and neck and auscultate the heart and lungs early; examine the ears
and mouth and palpate the abdomen near the end. If the child reports pain
in an area, examine that part last.
◗ For older children and adolescents, use the same sequence as with adults,
except examine the most painful areas last.
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
IMMEDIATE ASSESSMENT AT BIRTH
Listen to the anterior thorax with your stethoscope. Palpate the abdomen. Inspect the head, face, oral cavity, extremities, genitalia, and perineum.
Apgar Score. 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, pro-
ceed to a more complete examination.
Techniques of Examination
Chapter 18 | Assessing Children: Infancy Through Adolescence 327
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
The Apgar Scoring System
Assigned Score
Clinical Sign 0 1 2
Heart rate Absent <100 >100 Respiratory
effort
Absent Slow and irregular Good; strong
Muscle tone Flaccid Some flexion of the
arms and legs
Active
movement Reflex
irritability*
No responses Grimace Crying vigor-
ously, sneeze,
or cough Color Blue, pale Pink body, blue
extremities
Pink all over
1-Minute Apgar Score 5-Minute Apgar Score
8–10 Normal 8–10 Normal 5–7
0–4
Some nervous
system
depression
Severe depres-
sion, requir-
ing immediate
resuscitation
0–7 High risk for
subsequent
central ner-
vous system
and other
organ system
dysfunction
*Reaction to suction of nares with bulb syringe.
Gestational Age and Birth Weight. Classify newborns according to their gestational age and birth weight.
Classification by Gestational Age and Bir th Weight
Gestational Age
Classification Gestational Age
◗ Preterm
◗ Term
◗ Postterm
<37 wks (<259th day) 37–42 wks
>42 wks (>294th day)
Birth Weight
Classification Weight
◗ Extremely low birth weight
◗ Very low birth weight
◗ Low birth weight
◗ Normal birth weight
<1,000 g <1,500 g <2,500 g ≥2,500 g
328 Bates’ Pocket Guide to Physical Examination and History Taking
Assessment Several Hours After Birth
During the first 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 respon- sive. 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 asso- ciated with congenital anomalies.
Umbilical hernias 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 fine motor function, tone, cry, deep tendon reflexes, and primitive reflexes.
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.
AAAssseessssmmeeentt SSeevverraall HHouuurss Afftteer BBirtthh
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
Newborn Classifications
Category Abbreviation Percentile
Small for gestational age SGA <10th Appropriate for gestational age AGA 10–90th
Large for gestational age LGA >90th
Chapter 18 | Assessing Children: Infancy Through Adolescence 329
Assessing InfantsAAAssseessssinnggg Innfaaannts
MENTAL AND PHYSICAL STATUS
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, environ-
mental and social problems, other
pregnancy or perinatal problems,
childhood diseases such as infec-
tion (e.g., meningitis), trauma, and
severe chronic disease.
GENERAL SURVEY
Growth, reflected 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:
Failure 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 gastrointes-
tinal, neurologic, cardiac, endocrine,
renal, and other diseases.
● Normal values according to age and sex
● Prior readings to assess trends
Measures above the 97th or below
the 3rd percentile, or recent rises
or falls from prior levels, require
investigation.
Height and Weight. Plot each child’s height and weight on standard growth charts to determine progress.
Reduced growth in height may indi-
cate endocrine disease, other causes of short stature, or, if weight is also low, other chronic diseases.
Head Circumference. Determine head circumference at every physical examination during the first 2 years.
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.
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
330 Bates’ Pocket Guide to Physical Examination and History Taking
VITAL SIGNS
Blood Pressure. Measure blood pressure at least once during infancy. Although the hand-held method is shown here, the most easily used measure of systolic blood pressure in infants and young children is obtained with the Doppler method.
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
Causes of Sustained Hyper tension in Children
Newborn Middle Childhood
Renal artery disease (stenosis,
thrombosis)
Congenital renal malformations
Coarctation of the aorta
Primary hypertension
Renal parenchymal or arterial disease
Coarctation of the aorta
Infancy and Early Childhood Adolescence
Renal parenchymal or artery disease
Coarctation of the aorta
Primary hypertension
Renal parenchymal disease
Drug induced
Pulse. 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 paroxysmal supraventricular tachycardia. Bradycar- dia may result from serious underlying
disease.
Respiratory Rate. The respiratory rate has a very wide range and is more responsive to illness, exercise, and emotion than in adults.
Respiratory diseases such as bronchi- olitis or pneumonia may cause rapid respirations (up to 80–90 breaths
per minute), and increased work of breathing.
Chapter 18 | Assessing Children: Infancy Through Adolescence 331
THE SKIN
Assess:
● Texture and appearance
● Vasomotor changes
● Pigmentation (e.g., Mongolian spots)
● Hair (e.g., lanugo)
● Common skin conditions (e.g., milia, erythema toxicum)
● Color
● Turgor
Cutis marmorata
Acrocyanosis; cyanotic congenital heart disease
Café-au-lait spots
Midline hair tuft on back
Herpes simplex
Jaundice can be from hemolytic disease.
Dehydration
THE HEAD
Examine sutures and fontanelles carefully. Anterior fontanelle
Posterior fontanelle
Lambdoidal suture
Sagittal suture
Coronal suture
Metopic suture
Head small with microcephaly, enlarged with hydrocephaly; fontanelles full and tense with meningitis, closed with microcephaly, separated with increased intracranial pressure (hydrocephaly, subdural hematoma, and brain tumor)
Swelling from subperiosteal hemor-
rhage (cephalohematoma) does not
cross suture lines; swelling from
bleeding associated with a fracture
does.
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 table below for evaluation).
Examples include Down syndrome and fetal alcohol syndrome.
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332 Bates’ Pocket Guide to Physical Examination and History Taking
THE EYES
Newborns and young infants may look at your face and follow a bright light if you catch them while alert. Normal visual mile- stones are as follows:
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.
THE EARS
Check position, shape, and features.
Small, deformed or low-set auricles
may indicate associated congenital defects, especially renal disease.
Pearls to Evaluate Potentially Abnormal Facies
Carefully review the history, especially the family history, pregnancy, and perinatal history.
Note abnormalities, especially of growth, development, or dysmorphic somatic features.
Measure and plot percentiles, especially of head circumference, height, and weight.
Consider the three mechanisms of facial dysmorphogenesis:
◗ Deformations from intrauterine constraint
◗ Disruptions from amniotic bands or fetal tissue
◗ Malformations from an intrinsic abnormality (either face/head or brain)
Examine parents and siblings (similarity may be reassuring but might point to
a familial disorder).
Determine whether facial features fit a recognizable syndrome. Compare
against references, pictures, tables, and databases.
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
Visual Milestones of Infancy
Birth Blinks, may regard face
1 month Fixes on objects
1½–2 months Coordinated eye movements
3 months Eyes converge, baby reaches
12 months Acuity around 20/50
Chapter 18 | Assessing Children: Infancy Through Adolescence 333
Signs That an Infant Can Hear
Age Signs
0–2 months Startle response and blink to a sudden noise
Calming down with soothing voice or music
2–3 months Change in body movements in response to sound
Change in facial expression to familiar sounds
3–4 months Turning eyes and head to sound
6–7 months Turning to listen to voices and conversation
THE NOSE
Test patency of the nasal pas- sages by occluding alternately each nostril while holding the infant’s mouth closed.
With choanal atresia, the baby cannot breathe if one nostril is occluded.
THE MOUTH AND PHARYNX
Inspect (with a tongue blade and flashlight) and palpate.
Supernumerary teeth, Epstein’s 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.
Oral candidiasis (thrush)
Vesicles in the mouth can be caused by
enteroviral infections and herpes simplex virus infections.
THE NECK
Palpate the lymph nodes, and assess for any additional masses (e.g., congenital cysts).
Lymphadenopathy is usually from viral or bacterial infections.
Other neck masses include malignancy, branchial cleft or thyroglossal duct cysts, and periauricular cysts and sinuses.
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
Jugulogastric node
Epidermoid cyst
Submandibular node
Submental node
Cystic hygroma
Thyroglossal duct cyst
Parotid nodes
Occipital node
Retroauricular (mastoid) nodes
Superior deep cervical nodes
Middle deep cervical nodes
Posterior cervical nodes
2nd branchial cleft cyst
Supraclavicular node
Inferior deep cervical nodes
Anterior cervical nodes
334 Bates’ Pocket Guide to Physical Examination and History Taking
THE THORAX AND LUNGS
Carefully assess respirations and breathing pattern.
Apnea
Do not rush to the stethoscope, but observe the patient care- fully first.
Upper respiratory infections may cause nasal flaring.
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
Examination of the Lungs in Infants—Before You Touch the Child!
Assessment Possible Findings Explanation
General
appearance
Inability to feed or smile
Lack of consolability
Lower respiratory infections below the
vocal cords (e.g., bron- chiolitis, pneumonia) are common in infants.
Respiratory
rate
Tachypnea Cardiac or respiratory
disease
Color Pallor or cyanosis Cardiac or pulmonary disease
Nasal
component of
breathing
Nasal flaring
(enlargement of both
nasal openings during
inspiration)
Upper or lower
respiratory infection
Audible
breath sounds
Grunting (repetitive, short
expiratory sound)
Wheezing (musical
expiratory sound)
Stridor (high-pitched,
inspiratory noise)
Obstruction (lack of
breath sounds)
Acute stridor is a potentially serious condition with
causes such as laryngo- tracheobronchitis (croup), epiglottitis, bacterial tracheitis, foreign body, vascular ring
Work of
breathing
Nasal flaring
Grunting
Retractions (chest
indrawing):
Supraclavicular
(motion of soft tissue
above clavicles)
Intercostal (indraw
ing of the skin
between ribs)
Subcostal (just below
the costal margin)
In infants, abnormal
work of breathing com-
bined with abnormal
findings on ausculta-
tion is the best finding
for ruling in pneumonia.
Chapter 18 | Assessing Children: Infancy Through Adolescence 335
Distinguishing Upper Air way From Lower Air way Sounds
Technique Upper Airway Lower Airway
Compare sounds from
nose/stethoscope
Same sounds Often different
sounds
Listen to harshness of
sounds
Harsh and loud Variable
Note symmetry
(left/right)
Symmetric Often asymmetric
Compare sounds at
different locations
(higher or lower)
Sounds louder as
stethoscope is
moved up chest
Sounds louder
lower in chest
Inspiratory vs. expiratory Almost always
inspiratory
Often has expiratory
phase
THE HEART
Inspection. Observe care- fully for any cyanosis. The best body part to assess cyanosis is the tongue or inside of the mouth.
At birth: Transposition of the great arteries; pulmonary valve atresia or stenosis
Within a few days of birth: The above;
also total anomalous pulmonary venous return, hypoplastic left heart
Palpation. Palpate the periph- eral pulses. The point of maximal impulse (PMI) is not always palpable in infants. Thrills are palpable when enough turbu- lence is within the heart or great vessels.
No or diminished femoral pulses sug-
gest coarctation of the aorta. Weak or thready, difficult-to-feel pulses may
reflect myocardial dysfunction and heart failure.
Auscultation. 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 supraventricular tachycardia.
Heart Sounds. Evaluate S1 and S2 carefully. They are normally crisp.
A louder-than-normal pulmonic compo-
nent suggests pulmonary hypertension. Persistent splitting of S2 may indicate
atrial septal defect.
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
336 Bates’ Pocket Guide to Physical Examination and History Taking
THE BREASTS
The breasts of males and females may be enlarged for months after birth as a result of maternal estrogen, and even engorged for 1 to 2 weeks with a white liquid.
THE ABDOMEN
You will find it easy to palpate an infant’s abdomen, because infants like being touched. Palpate the liver and spleen and assess for hepatosplenomagaly.
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.
MALE GENITALIA
Inspect with the infant supine. Common scrotal masses are hydroceles and inguinal hernias.
In 3% of infants, one or both tes- tes 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.
FEMALE GENITALIA
In females, genitalia may be prominent for several months after birth from the effects of maternal estrogen.
Ambiguous genitalia involves masculin- ization of the female external genitalia.
THE MUSCULOSKELETAL SYSTEM
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 clavicle can occur during a difficult delivery.
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Chapter 18 | Assessing Children: Infancy Through Adolescence 337
Examine the hips carefully at each visit for signs of dislocation. There are two major techniques: one to test for a posteriorly dis- located hip (Ortolani test) and the other to test for the ability to sublux or dislocate an intact but unstable hip (Barlow test).
Congenital hip dysplasia may have a
positive Ortolani or Barlow test, particu-
larly during the first 3 months of age.
With a hip dysplasia, you feel a “clunk.”
ORTOLANI TEST BARLOW TEST
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.
THE NERVOUS SYSTEM
Evaluate the developing central nervous system by assessing infantile automatisms, called primitive reflexes.
Suspect a neurologic or developmental abnormality if primitive reflexes are absent at appropriate age, present lon-
ger than normal, asymmetric, or associ-
ated with posturing or twitching.
Neurologic and developmental abnor-
malities often co-exist. Hypotonia can be a sign of a variety of neurologic
abnormalities.
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338 Bates’ Pocket Guide to Physical Examination and History Taking
Assessing Children (1 to 10 Years)
Tips for Interviewing Children
MENTAL AND PHYSICAL STATUS
In children 1 to 5 years, observe the degree of sickness or well- ness, mood, nutritional state, speech, cry, facial expression, and developmental skills. Note parent–child interaction, includ- ing separation tolerance, affec- tion, and response to discipline.
This overall examination can uncover
evidence of chronic disease, developmen- tal delay, social or environmental disor- ders, 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.
Body Mass Index for Age. Age- and sex-specific 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.
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
◗ Establish rapport. Refer to children by name and meet them on their own level. Maintain eye contact at their level (e.g., sit on the floor if needed).
Participate in play and talk about their interests.
◗ Work with families. Ask simple, open-ended questions such as “Are you sick? Tell me about it,” followed by more specific questions. Once the par-
ent has started the conversation, direct questions back to the child. Also
observe how parents interact with the child.
◗ Identify multiple agendas. Your job is to discover as many perspectives and agendas as possible.
◗ Use the family as the key resource. View parents as experts in the care of their child and you as their consultant.
◗ Note hidden agendas. As with adults, the chief complaint may not relate to the real reason the parent has brought the child to see you.
The following discussion focuses on those areas of the comprehensive physical
examination that are different for children than for infants and for adults.
Chapter 18 | Assessing Children: Infancy Through Adolescence 339
BLOOD PRESSURE
Hypertension during childhood is more common than previously thought. Recognizing, confirm- ing, and appropriately managing it is important. Blood pressure readings should be part of the physical examination of every child older than 2 years. 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 child- hood include renal disease, coarctation
of the aorta, and primary hypertension.
Hypertension is often related to child- hood obesity.
THE EYES
Test visual acuity in each eye and determine whether the gaze is conjugate or symmetric.
Strabismus can lead to amblyopia
Myopia or hyperopia often present in school-aged children.
SPECIAL TECHNIQUE
The corneal light reflex test (left) and the cover–uncover test (right) are particularly use- ful in young children.
Any difference in visual acuity between eyes is abnormal.
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340 Bates’ Pocket Guide to Physical Examination and History Taking
THE EARS
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 illustrated.
Pain on movement of the pinna occurs
with otitis externa.
Pneumatic Otoscope. Learn to use a pneumatic oto- scope to improve accuracy of diagnosis of otitis media.
● Insert the speculum, obtain- ing a proper seal.
Acute otitis media involves a red and bulging tympanic membrane.
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
Visual Acuity
Age Visual Acuity
3 months Eyes converge, baby reaches
12 months ∼20/200 Younger than 4 years 20/40
4 years and older 20/30
Chapter 18 | Assessing Children: Infancy Through Adolescence 341
● When air is introduced into the normal ear canal, the tym- panic membrane and its light reflex move inward. When air is removed, the tympanic membrane moves outward toward you.
Diminished movement of tympanic
membrane with acute otitis media; no movement with otitis media with effusion.
THE MOUTH AND PHARYNX
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 reflex.
A common cause of a strawberry tongue,
red uvula, and pharyngeal exudate is
streptococcal pharyngitis.
Examine the teeth for the tim- ing 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.
Nursing bottle caries; dental caries; stain- ing of the teeth, which may be intrinsic or extrinsic
Dental caries are the most common health problem of children and are
particularly prevalent in impoverished
children.
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
342 Bates’ Pocket Guide to Physical Examination and History Taking
Look for abnormalities of tooth position.
Malocclusion
Note the size, position, sym- metry, and appearance of the tonsils.
Peritonsillar abscess
THE HEART
A challenging aspect to car- diac examination of children is evaluation of heart murmurs, particularly distinguishing com- mon benign murmurs from unusual or pathologic ones. Most children have one or more functional, or benign, heart murmurs at some point in time (see below).
See Table 18-4, Characteristics of
Pathologic Heart Murmurs, pp. 351–352.
Still's
Carotid bruit
Venous hum
Pulmonary flow
Location of Benign Heart Murmurs in Children
THE ABDOMEN
Most children are ticklish when you first place your hand on their abdomens for palpation. This reaction tends to disap- pear, particularly if you distract the child.
A pathologically enlarged liver in chil-
dren usually is palpable more than 2 cm
below the costal margin, has a round,
firm edge, and often is tender.
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
Chapter 18 | Assessing Children: Infancy Through Adolescence 343
MALE GENITALIA
There is an art to palpation of the young boy’s scrotum and testes, because many have an active cremasteric reflex caus- ing 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 tes- tes are enlarged, with signs of pubertal
changes.
A painful testicle requires rapid treat-
ment and may indicate torsion.
Inguinal hernias in older boys present as they do in adult men.
FEMALE GENITALIA
Use a calm, gentle approach, including a developmentally appropriate explanation.
Examine the genitalia in an efficient and systematic manner. The normal hymen can have various configurations.
Vaginal discharge in early childhood can result from perineal irritation (e.g., from bubble baths, soaps), foreign body, vaginitis, or sexually transmitted infections from sexual abuse. Vaginal bleeding, abrasions, or signs of trauma to the external genitalia can result from
sexual abuse.
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
344 Bates’ Pocket Guide to Physical Examination and History Taking
THE MUSCULOSKELETAL SYSTEM
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 sit- ting, run a short distance, and pick up objects. You will detect most abnormalities by watching carefully.
A screening musculoskeletal examina-
tion for children participating in sports
can detect injuries or abnormalities that
may result in problems during athletics.
THE NERVOUS SYSTEM
Beyond infancy, the neurologic examination includes the com- ponents 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 neurological signs can suggest
minor developmental abnormalities.
Assessing Adolescents
The key to successfully examining teens is a comfortable, confidential 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 confidentiality. Explain to both teens and parents that the purpose of confidentiality is to improve health care, not keep secrets. Your goal is to help adoles- cents bring their concerns or questions to their parents. Never make confidentiality unlimited, however. Always state to teens explicitly that you may need to act on information that makes you concerned about safety.
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
AAAssseessssinnggg AAdoooleescceents
Chapter 18 | Assessing Children: Infancy Through Adolescence 345
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 specific tech- niques 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.
THE BREASTS
Assess normal maturational development.
See Table 18-5, Sex Maturity Ratings in
Girls: Breasts, p. 353.
SPECIAL TECHNIQUE
Testing for Scoliosis. Inspect any child who can stand for sco- liosis. 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 scolio meter to test for the degree of scoliosis.
MALE AND FEMALE GENITALIA
An important goal when examin- ing adolescent males and females is to assign a sexual maturity rating, regardless of chronologic age.
See Table 18-6, Sex Maturity Ratings in
Boys, pp. 354–355, and Table 18-7, Sex
Maturity Ratings in Girls: Pubic Hair,
p. 356.
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
346 Bates’ Pocket Guide to Physical Examination and History Taking
Recording the Physical Examination— The Pediatric Patient
Brian is a chubby, active, and energetic toddler. He plays with the reflex ham-
mer, pretending it is a truck. He appears closely bonded with his mother, look-
ing at her occasionally for comfort. She seems concerned that Brian will break
something. His clothes are clean.
Vital Signs. Ht 90 cm (90th percentile). Wt 16 kg (>95th percentile). BMI 19.8 (>95th percentile). Head circumference 50 cm (75th percentile). BP 108/58. Heart rate 90 and regular. Respiratory rate 30; varies with activity. Tempera-
ture (ear) 37.5°C. Obviously no pain.
Skin. Normal except for bruises on legs, and patchy, dry skin over external surface of elbows.
HEENT. Head: Normocephalic; no lesions. Eyes: Difficult to examine because he won’t sit still. Symmetric with normal extraocular movements. Pupils 4 to
5 mm constricting. Discs difficult to visualize; no hemorrhages noted. Ears: Normal pinna; no external abnormalities. Normal external canals and tym-
panic membranes (TMs). Nose: Normal nares; septum midline. Mouth: Several darkened teeth on inside surface of upper incisors. One clear cavity on upper
right incisor. Tongue normal. Cobblestoning of posterior pharynx; no exudates.
Tonsils large but adequate gap (1.5 cm) between them.
Neck. Supple, midline trachea, no thyroid palpable.
Lymph Nodes. Easily palpable (1.5 to 2 cm) tonsillar lymph nodes bilaterally. Small (0.5 cm) nodes in inguinal canal bilaterally. All lymph nodes mobile and
nontender.
Lungs. Good expansion. No tachypnea or dyspnea. Congestion audible, but seems to be upper airway (louder near mouth, symmetric). No rhonchi, rales,
or wheezes. Clear to auscultation.
Cardiovascular. PMI in 4th or 5th interspace and midsternal line. Normal S1 and S2. No murmurs or abnormal heart sounds. Normal femoral pulses;
dorsalis pedis pulses palpable bilaterally.
(continued)
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 findings back to the traditional format.
E XA M I N AT I O N T E C H N I Q U E S
Chapter 18 | Assessing Children: Infancy Through Adolescence 347
Breasts. Normal, with some fat under both.
Abdomen. Protuberant but soft; no masses or tenderness. Liver span 2 cm below right costal margin (RCM) and not tender. Spleen and kidneys not palpable.
Genitalia. Tanner I circumcised penis; no pubic hair, lesions, or discharge. Testes descended, difficult to palpate because of active cremasteric reflex.
Normal scrotum both sides.
Musculoskeletal. Normal range of motion of upper and lower extremities and all joints. Spine straight. Gait normal.
Neurologic. Mental Status: Happy, cooperative child. Developmental: Gross motor—Jumps and throws objects. Fine motor—Imitates vertical line. Lan-
guage—Does not combine words; single words only, three to four noted during
examination. Personal–social—Washes face, brushes teeth, and puts on shirt.
Overall—Normal, except for language, which appears delayed. Cranial Nerves: Intact, althwough several difficult to elicit. Cerebellar: Normal gait; good bal- ance. Deep tendon reflexes (DTRs): Normal and symmetric throughout with downgoing toes. Sensory: Deferred.
E XA M I N AT I O N T E C H N I Q U E S
348 Bates’ Pocket Guide to Physical Examination and History Taking
Classification of Newborn’s Level of MaturityTable 18-1
25 27 29 31 33 35 37 39 41 43 45
5
4.5
4
3.5
3
2.5
2
1.5
1
0.5
90%
10%
B ir
th W
e ig
h t (k
g )
Weeks of Gestation
Large for gestational age
Appropriate for gestational age
Small for gestational age
Premature Term Postmature
A B
Intrauterine Growth Curves
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. Classification of the low-birth-weight infant. In: Klaus MH, Fanaroff AA. Care of the High-Risk Neonate, 3rd ed. Philadelphia: WB Saunders, 1986. Reproduced with permission.
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350 Bates’ Pocket Guide to Physical Examination and History Taking
Hypertension in ChildhoodTable 18-3
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.
90
0 1 2 3 4 5 6 7 8 9
Age
Girls Systolic Blood Pressure 95% Percentile
10 11 12 13 14 15 16 17
120
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to lic
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o d P
re ss
u re
95
100
105
110
115
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130
135
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120
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Chapter 18 | Assessing Children: Infancy Through Adolescence 351
Characteristics of Pathologic Heart MurmursTable 18-4
Congenital Defect Characteristics of Murmur
Pulmonary Valve Stenosis Location. Upper left sternal border
Radiation. In mild degrees of stenosis, the murmur may be heard over the course of the pulmonary arteries in the lung fields.
Mild
S1 A2 P2
Moderate
S1 A2 P2
Intensity. Increases in intensity and duration as the degree of obstruction increases
Severe
S1 A2 P2
Quality. Ejection, peaking later in systole as the obstruction increases
Aortic Valve Stenosis
S1 A2 P2
Location. Midsternum, upper right sternal border
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
Tetralogy of Fallot General. Variable cyanosis, increasing with activity
With Pulmonic Stenosis 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.
(continued)
352 Bates’ Pocket Guide to Physical Examination and History Taking
Characteristics of Pathologic Heart Murmurs (continued)
Congenital Defect Characteristics of Murmur
With Pulmonic Atresia S1 A2 S1
Radiation. Little, to upper left sternal border, occasionally to lung fields
Intensity. Usually grade III–IV Quality. Midpeaking, systolic
ejection murmur
Transposition of the Great Arteries
General. Intense generalized cyanosis
Location. No characteristic murmur. If a murmur is present, it may reflect an associated defect such as VSD or patent ductus arteriosus.
Radiation. Depends on associated abnormalities
Quality. Depends on associated abnormalities
Ventricular Septal Defect Location. Lower left sternal border
Small to Moderate
S1 A2 P2
Radiation. Little Intensity. Variable, only partially
determined by the size of the shunt. Small shunts with a high pressure 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.
Table 18-4
Chapter 18 | Assessing Children: Infancy Through Adolescence 353
Sex Maturity Ratings in Girls: BreastsTable 18-5
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 in some normal individuals areola continues to form a secondary mound).
Photos reprinted, with permission from the American Academy of Pediatrics, Assessment of Sexual Maturity Stages in Girls, 1995.
Table 18-6 Sex Maturity Ratings in Boys
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
Stage 2
Stage 3
Pubic Hair: Preadolescent—no pubic hair except for the fine body hair (vellus hair) similar to that on the abdomen
Genitalia
• Penis: Preadolescent—same size and proportions as in childhood
• 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
• 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
354 Bates’ Pocket Guide to Physical Examination and History Taking
Table 18-6 Sex Maturity Ratings in Boys (continued)
Stage 4
Stage 5
Pubic Hair: Coarse and curly hair, as in the adult; area covered greater than in stage 3 but not as great as in the adult and not yet including the thighs
Genitalia
• 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.
Chapter 18 | Assessing Children: Infancy Through Adolescence 355
356 Bates’ Pocket Guide to Physical Examination and History Taking
Sex Maturity Ratings in Girls: Pubic HairTable 18-7
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.
Chapter 18 | Assessing Children: Infancy Through Adolescence 357
Physical Signs of Sexual AbuseTable 18-8
Physical Signs That May Indicate Sexual Abuse in Children*
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)
Physical Signs That Strongly Suggest Sexual Abuse in Children*
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.
*Any physical sign must be evaluated in light of the entire history, other parts of the physical examination, and laboratory data.
359
C H A P T E R
19The Pregnant Woman
Focus the initial prenatal visit on confirming the pregnancy, assessing the health status of the mother and any risks for complications, and counseling to ensure a healthy pregnancy. Ask about the following topics:
● Confirmation of pregnancy. Has the patient had a confirmatory 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 confirm pregnancy.
● Symptoms of pregnancy. absence of menses, breast fullness or tender- ness, nausea or vomiting, fatigue, and urinary frequency. Explain that serum or urine testing for beta human chorionic gonadotropin (HCG) offers the best confirmation of pregnancy.
● 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.
The Health History
Common Concerns
◗ Initial prenatal history
◗ Confirmation of pregnancy
◗ Symptoms of pregnancy
◗ Concerns about and attitudes toward the pregnancy
◗ Current health and past medical history
◗ Past obstetric history
◗ Risk factors for maternal and fetal health
◗ Family history
◗ Plans for breast-feeding
◗ Determining gestational age and expected date of delivery
360 Bates’ Pocket Guide to Physical Examination and History Taking
● 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 surger- ies, 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 transmit- ted infections, abnormal Pap smears, and exposure to diethylstilbes- trol (DES) in utero.
● Past obstetric history. Ask about prior pregnancies and outcomes. Has she had any complications during past pregnancies, including labor and delivery? Has she had a premature or growth-retarded infant, or a baby large for gestational age? Has there been a prior fetal demise?
● Risk factors for maternal and fetal health. Does the patient use tobacco, alcohol, or illicit drugs? Does she take any medications, over-the-counter 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 for problems stemming from obe- sity? Does she have an adequate social support network and income sources? Are there unusual sources of 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 fibrosis, muscular dystrophy, and others.
● Plans for breast-feeding. Education and encouragement during preg- nancy are recommended.
Gestational age and expected date of delivery.
● Gestational age. Count the number of weeks and days from the first day of the LMP. Counting this menstrual age from the LMP– although biologically distinct from the date of conception, it is the standard means of calculating fetal age, yielding an average preg- nancy length of 40 weeks. Rarely, the actual date of conception is known (as with in vitro fertilization.) In these cases, use a conception age, which is 2 weeks less than the menstrual age. However, this number should never be used to make clinical judgements that rely on the menstrual age for standards of care.
● Expected date of delivery (EDD). The expected date of delivery is 40 weeks from the first date of the LMP. Using Naegele’s rule, the EDD
Chapter 19 | The Pregnant Woman 361
can be estimated by taking the LMP, adding 7 days, subtracting 3 months and adding 1 year.
● Tools for calculations. Pregnancy wheels and online calculators are commonly used to expedite these calculations, but they should be checked for accuracy.
● Limitations on pregnancy dating. Patient recall of the LMP is highly variable. The LMP can also be biased by hormonal contraceptives or lengthly menstrual cycles. Check LMP dating against physical exam markers such as fundal height, clarifying discrepancies against ultrasound evaluation.
Subsequent Prenatal Visits. Obstetric visits traditionally follow a set schedule: monthly until 30 gestational weeks, then biweekly until 36 weeks, then weekly until delivery. Update and document the his- tory at every visit, especially fetal movement, contractions, leakage of fluids and vaginal bleeding. At every visit, assess: vital signs (especially blood pressure and weight), fundal height, verification of FHR, and fetal position and activity.
Nutrition and Weight Gain. Evaluate nutritional status during the first prenatal visit, including: diet history; measurement of height, weight, and body mass index (BMI); and a hematocrit. Prescribe needed vitamin and mineral supplements. Develop a nutrition plan appropriate to cultural preferences, typically three balanced meals each day, including 300 additional kcal plus prenatal supplements. Caution against excess amounts of vitamin A, which can become toxic; fish with mercury exposure such as sharks, swordfish, or even canned tuna; unpasteurized dairy products; and undercooked meats.
Health Promotion and Counseling: Evidence and Recommendations
◗ Nutrition
◗ Weight gain
◗ Exercise
◗ Substance abuse
◗ Domestic violence
◗ Prenatal laboratory screenings
◗ Immunizations
Important Topics for Health Promotion and Counseling
362 Bates’ Pocket Guide to Physical Examination and History Taking
Weigh the woman at each visit, with the results plotted on a graph, using the updated recommendations below.
Exercise. Recommend 30 minutes of moderate exercise or more on most days of the week unless contraindications exist. Women initiating exercise during pregnancy should consider programs developed specifi- cally for pregnant women. Immersion in hot water should be avoided. After the first trimester, women should avoid exercise in the supine position, which can compress the inferior vena cava, resulting in dizzi- ness and decreased placental blood flow. In the third trimester, advise against exercises that may cause loss of balance. Contact sports or activ- ities that risk abdominal trauma are unwise in all trimesters. Pregnant woman should avoid overheating, dehydration, and any exertion that causes notable fatigue or discomfort.
Substances of Abuse. Promote abstinence as the immediate goal during pregnancy. Pursue universal screening in a neutral manner for:
● Tobacco. Tobacco use accounts for a third of all low-birth-weight babies and many poor pregnancy outcomes, including placental
Recommendations for Total and Rate of Weight Gain During Pregnancy, by Prepregnancy BMI, 2009
Prepregnancy BMI
BMI*
Total Weight Gain (lbs)
Rates of Weight Gain†
2nd and 3rd Trimester (lbs/wk)
Underweight <18.5 28–40 1 (1–1.3)
Normal weight 18.5–24.9 25–35 1
(0.8–1)
Overweight 25–29.9 15–25 0.6
(0.5–0.7)
Obese (includes
all classes)
≥30 11–20 0.5 (0.4–0.6)
∗To calculate BMI, go to www.nhlbisupport.com/bmi. †Calculations assume a 0.5–2 kg (1.1–4.4 lbs) weight gain in the first trimester (based on
Siega-Riz et al., 1994; Abrams et al., 1995; Carmichael et al., 1997)
Source: Rasmussen KM, Yaktine AL (eds) and Institute of Medicine. Committee to Reex-
amine IOM Pregnancy Weight Guidelines. Weight gain during pregnancy: re-examing the
guidelines. Washington, DC: National Academics Press, 2009. (Available at http://www.
iom.edu/Reports/2009/Weight-Gain-During-Pregnancy-Reexamining-the-Guidelines.aspx.)
Accessed February 26, 2011.
Chapter 19 | The Pregnant Woman 363
abruption and preterm labor. Cessation is the goal, but any decrease in usage is favorable.
● Alcohol. Fetal alcohol syndrome is the leading cause of preventable mental retardation in the United States. Abstinence is widely recom- mended throughout pregnancy.
● Illicit drugs including narcotics. Women with addictions should be referred for treatment immediately and counseled and screened for hepatitis C and HIV.
● Prescription drugs. Ask about commonly abused prescription drugs, including narcotics, stimulants, benzodiazepines.
Domestic Violence. Pregnancy is a time when risk of intimate part- ner violence increases. Up to one in five women experience some form of abuse during pregnancy. Pursue universal screening of all pregnant women without regard to socioeconomic status. Ask, “Since you’ve been pregnant, have you been slapped or otherwise physically hurt by anyone?” Nonverbal clues include frequent changes in appoint- ments at the last minute, unusual behavior during visits, partners that refuse to leave the patient alone, and bruises or other injuries. When abuse becomes apparent, ask the patient how you might best help her. Respect limits she places on sharing information. Maintain an updated list of shelters, counseling centers, hotline numbers and other trusted local referrals. Plan future appointments at accelerated intervals. Com- plete a thorough physical exam as much as she permits and document all injuries on a body diagram.
National Domestic Violence Hotline
◗ Web site: www.thehotline.org
◗ 1-800-799-SAFE (7233)
◗ TTY for hearing impaired: 1-800-787-3224
Prenatal Laboratory Screenings. Initially include blood type and Rh, antibody screen, complete blood count—especially hemato- crit and platelet count, rubella titer, syphilis test, hepatitis B surface antigen, HIV, STI screen for gonorrhea and chlamydia and urinalysis with culture. Timed screenings include an oral glucose tolerance test for gestational diabetes around 24 weeks, and a vaginal swab for group B streptococcus between 35 to 37 weeks’ gestation. Pursue additional tests related to the mother’s risk factors, such as screening for aneuploidy,
364 Bates’ Pocket Guide to Physical Examination and History Taking
screening for Tay-Sachs or other genetic diseases, amniocentesis, or checking for infectious diseases such as hepatitis C.
Immunizations. As indicated, give tetanus and influenza vaccinations in the second or third trimester. The following vaccines are safe dur- ing pregnancy: pneumococcal, meningococcal, and hepatitis B. The following vaccines are NOT safe during pregnancy: measles/mumps/ rubella, polio, varicella. However, all women should have rubella titers drawn during pregnancy and be immunized after birth if non- immune. Rho (D) immunoglobulin, or RhoGAM, should be given to all Rh-negative women at 28 weeks’ gestation and again within 3 days of delivery to prevent sensitization to an Rh-positive infant.
Techniques of Examination
Preparing for the Examination
Show respect for the woman’s comfort and privacy, as well as for her individual
needs and sensitivities. Ask her to wear her gown with the opening in front to
ease the examination of both breasts and the pregnant abdomen.
Positioning ◗ The semisitting position with the knees bent (see p. 366) affords the most
comfort and protects abdominal organs and vessels from the weight of the
gravid uterus.
◗ Avoid prolonged periods of lying on the back. Make your abdominal palpa-
tion efficient and accurate.
◗ The pelvic examination also should be relatively quick.
Equipment ◗ Gynecologic speculum and lubrication: Because of vaginal wall relaxation during pregnancy, a larger-than-usual speculum may be needed.
◗ Sampling materials: The cervical brush may cause bleeding, so the Ayre wooden spatula or “broom” sampling device is preferred during pregnancy.
Additional swabs may be needed to screen for sexually transmitted infections,
group B strep, and wet mount
preparations.
◗ Tape measure: Use a plastic or paper tape measure to assess the
size of the uterus after 20 gesta-
tional weeks.
◗ Doppler fetal heart rate monitor and gel: Apply a “Doppler” or “Doptone” to the gravid belly
to assess fetal heart rate after
10 weeks of gestation.
Chapter 19 | The Pregnant Woman 365
HEIGHT, WEIGHT, AND VITAL SIGNS
Observe the general health, emotional state, nutritional status, and coordination as the pregnant woman comes into the room.
HEAD AND NECK
● Face. Check for the mask of pregnancy, chloasma, or irregular brownish patches around the fore- head and cheeks, across the bridge of the nose, or along the jaw.
● Hair
● Eyes. Note the conjunctival color.
● Nose, including nasal congestion
● Mouth
● Thyroid gland. Inspect and palpate. Modest symmetric enlargement is common.
Facial edema after 20 weeks in gesta-
tional hypertension
Hair loss should not be attributed to
pregnancy.
Anemia of pregnancy may cause
conjunctival pallor.
Nosebleeds are more common
during pregnancy. Erosion of nasal
septum if use of intranasal cocaine.
Gingival enlargement common
Significant enlargement is abnormal
and should be investigated.
Measure the height and weight. Calculate BMI. First-trimester weight loss should not exceed 5% of prepartum weight.
Weight loss of more than 5% in
excessive vomiting, or hyperemesis
Measure the blood pressure at every visit. In midpregnancy, it may be lower than in the nonpregnant state.
Gestational hypertension: if systolic blood pressure (SBP) ≥140 mm Hg and diastolic blood pressure (DBP)
≥90 mm Hg, first occurring after week 20 and without proteinuria
Chronic hypertension: if SBP ≥140 mm Hg and DBP ≥90 mm Hg prior to pregnancy, before week 20, and after
12 weeks postpartum
Preeclampsia: if SBP ≥140 mm Hg and DBP ≥90 mm Hg after week 20 and with proteinuria
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THORAX AND LUNGS
Inspect the thorax for contours. Observe the pattern of breathing. Auscultate the lungs.
Respiratory alkalosis in later tri-
mesters. Elevated respiratory rate
in infection, pulmonary embolism,
peripartum cardiomyopathy.
HEART
Palpate the apical impulse. Impulse may be higher than normal in the fourth intercostal space because
of transverse and leftward rotation of
the heart from the higher diaphragm.
Auscultate the heart. A venous hum and systolic or continuous mammary souffle (see p. 165) are common.
Murmurs may signal anemia; new
diastolic murmurs should be inves-
tigated. If signs of heart failure, con-
sider peripartum cardiomyopathy.
BREASTS
Inspect the breasts and nipples for symmetry and color.
The venous pattern may be marked,
the nipples and areolae are dark, and
Montgomery’s glands are prominent.
Palpate for masses. During pregnancy, breasts are tender and nodular; focal tenderness in
mastitis. Investigate any new discrete masses.
Compress each nipple between your index finger and thumb.
This may express colostrum from
the nipples; investigate if abnormal
bloody or purulent discharge.
ABDOMEN
Place the pregnant woman in a semisitting position with her knees flexed.
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● Inspect any scars or striae, the shape and contour of the abdomen, and the fundal height.
● Assess the shape and contour to estimate pregnancy size.
● Palpate for: ● Organs and masses ● Fetal movements, usually detected after 24 weeks
● Uterine contractility
Purplish striae and linea nigra are
normal.
36 wks 32 wks 28 wks 24 wks
16 wks
20–22 wks
12–14 wks
EXPECTED HEIGHT OF UTERINE FUNDUS OF PREGNANCY
Ultrasound confirmation of fetal health
and movement may be needed.
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 preg- nant, 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.
● 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.
If fundal height is more than 4 cm
higher than expected, consider mul-
tiple gestation, a large fetus, extra
amniotic fluid, or uterine leiomyoma.
If more than 4 cm lower, consider low
level of amniotic fluid, missed abor-
tion, transverse lie, growth retarda-
tion, or fetal anomaly.
Lack of an audible FHR may indicate
pregnancy of fewer weeks than
expected, fetal demise, or false
pregnancy.
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● Location. From 10 to 18 weeks, the FHR is in the midline of the lower abdomen; later depends on fetal position. Use modified Leopold’s maneuvers to palpate the fetal head and back and identify where to listen.
● Rate. The rate usually is 120 to 160 beats per minute. After 32 to 34 weeks, the FHR should increase with fetal movement.
An FHR that drops noticeably near
term with fetal movement could
indicate poor placental circulation.
● Rhythm. In the third trimes- ter, 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.
GENITALIA, ANUS, AND RECTUM
Inspect the external genitalia. Parous relaxation of the introitus, labial varicosities, enlargement of the
labia and clitoris, scars from an episi- otomy or perineal lacerations
Palpate Bartholin’s and Skene’s glands. Check for a cystocele or rectocele.
Bartholin’s cyst
Examine the internal genitalia.
Speculum Examination
● Inspect the cervix for color, shape, and healed lacerations.
Purplish color of pregnancy; lacera-
tions from prior deliveries
● Perform a Pap smear, if indicated.
Specimens may be needed for diag-
nosis of vaginal or cervical infection
● Inspect the vaginal walls. Bluish or violet color, deep rugae, leu- korrhea in normal pregnancy; vaginal
irritation, itching, and discharge in
infection
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Bimanual Examination
Insert two lubricated fingers into introitus, palmar side down, with slight pressure downward on the perineum. Slide fingers into the posterior vaginal vault. Maintain- ing downward pressure, gently turn fingers palmar side up.
● Assess cervical os and degree of effacement. Place your finger gently in the os, and then sweep it around the surface of the cervix.
● Estimate the length of the cervix. 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 internal fingers 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.
● Evaluate pelvic floor strength as you withdraw the examining fingers.
● Inspect the anus. Rectal and rectovaginal examinations are usually not indicated.
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.
Hegar’s 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 bicornuate uterus, two distinct uterine cavities separated by a septum.
Early in pregnancy, it is important to
rule out tubal (ectopic) pregnancy.
Hemorrhoids may engorge later in
pregnancy.
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EXTREMITIES
Inspect the legs for varicose veins.
Palpate the hands and legs for edema.
Watch for swelling of preeclampsia or deep venous thrombosis.
Check knee and ankle deep tendon reflexes.
Hyperreflexia may signal preeclampsia.
SPECIAL TECHNIQUES
LEOPOLD’S MANEUVERS
To identify: ● The upper and lower fetal poles, namely, the proximal and distal fetal parts
● The maternal side where the fetal back is located
● The descent of the presenting part into the maternal pelvis
● The extent of flexion of the fetal head
● Estimated fetal weight and size
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.
FIRST MANEUVER (Upper Fetal Pole)
Stand at the woman’s side, facing her head. Keep the fingers of both examining hands together. Pal- pate gently with the fingertips to determine what part of the fetus is in the upper pole of the uterine fundus.
Chapter 19 | The Pregnant Woman 371
SECOND MANEUVER (Sides of the Maternal Abdomen)
Place one hand on each side of the woman’s abdomen, aiming to capture the body of the fetus between them. Use one hand to steady the uterus and the other to palpate the fetus. Look for the back on one side and the extremi- ties on the other.
THIRD MANEUVER (Lower Fetal Pole and Descent into Pelvis)
Face the woman’s feet. Palpate the area just above the symphysis pubis. 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.
FOURTH MANEUVER (Flexion of the fetal head)
This maneuver assesses the flexion 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. Using one hand at a time, slide your fingers down each side of the fetal body until you reach the “cephalic prom- inence,” that is, where the fetal brow or occiput juts out.
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Recording Your Findings
Recording the Physical Examination—The Pregnant Woman
“32-year-old G3,P1102 at 18 weeks’ gestation as determined by LMP presents to
establish prenatal care. Patient endorses fetal movement; denies contractions,
vaginal bleeding, and leakage of fluids. On external exam, low transverse cesar-
ean scar is evident; fundus is palpable just below umbilicus. On internal exam,
cervix is open to fingertip at the external os but closed at the internal os; cervix
is 3 cm long; uterus enlarged to size consistent with 18-week gestation. Specu-
lum exam shows leucorrhea with positive Chadwick’s sign. FHT by Doppler are
between 140 and 145 BPM.” Describes healthy woman at 18 weeks’ gestation.
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373
C H A P T E R
20The Older Adult Older adults now number more than 39 million in the United States, growing to 88 million by 2050. Life span at birth is currently 84 years for women and 82 years for men. The “demographic imperative” is to maximize not only life span but also “health span” for older adults so that seniors maintain full function for as long as possible, enjoying rich and active lives in their homes and communities.
● Assessing the older adult 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 the older adult’s long-term health and safety.
● The aging population displays marked heterogeneity. Investigators distinguish “usual” aging, with its complex of diseases and impair- ments, 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%.
The Health History
APPROACH TO THE PATIENT
As you talk with older adults, convey respect, patience, and cultural awareness. Be sure to address patients by their last name.
Adjusting the Office Environment. Make sure the office 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 deficits. Free the room of distractions or noise. Consider using a “pocket talker,” a microphone
374 Bates’ Pocket Guide to Physical Examination and History Taking
that amplifies your voice and connects to an earpiece inserted by the patient. Chairs with higher seating and a wide stool with a handrail lead- ing up to the examining table help patients with quadriceps weakness.
Shaping the Content and Pace of the Visit. 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 endur- ance and possible fatigue. Consider dividing the initial assessment into two visits.
Eliciting Symptoms in the Older Adult. Older patients may over- estimate healthiness even when increasing disease and disability are apparent. To reduce the risk of late recognition and delayed interven- tion, adopt more directed questions or health screening tools. Consult with family members and caretakers.
Acute illnesses present differently in older adults than in younger age groups. Be sensitive to changes in presentation of myocardial infarc- tion and thyroid disease. Older patients with infections are less likely to have fever.
Recognize the symptom clusters typical of different geriatric syn- dromes, notable interacting clusters of symptoms, for example, falls, dizziness, depression, urinary incontinence, and functional impair- ment. Searching for the usual “unifying diagnosis” may pertain to fewer than 50% of older adults.
Cognitive impairment may affect the patient’s history. Even elders with mild cognitive impairment, however, can provide sufficient history to reveal concurrent disorders. Use simple sentences with prompts to trigger necessary information. If impairments are more severe, confirm symptoms with family members or caregivers.
Addressing Cultural Dimensions of Aging. By 2050, the older adult population will increase by 230%, and the minority older adult population by 510%. Cultural differences affect the epidemiology of illness and mental health, acculturation, the specific concerns of the elderly, the potential for misdiagnosis, and disparities in health out- comes. Review the components of self-awareness needed for cultural responsiveness, discussed in Chapter 3 (pp. 40–41). Ask about spiritual advisors and native healers. Cultural values particularly affect decisions
Chapter 20 | The Older Adult 375
about the end of life. Elders, family, and even an extended community group may make these decisions with or for the older patient.
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.
Activities of Daily Living. Daily activities provide an important baseline for the future. You might say “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?”
COMMON CONCERNS
Activities of Daily Living and Instrumental Activities of Daily Living
Physical Activities of Daily Living (ADLs)
Instrumental Activities of Daily Living (IADLs)
Bathing Using the telephone
Dressing Shopping
Toileting Preparing food
Transferring Housekeeping
Continence Laundry
Feeding Transportation
Taking medicine
Managing money
Medications. Adults older than 65 take approximately 30% of all prescriptions. Roughly 30% take more than eight prescribed drugs each day! Take a thorough medication history, including name, dose, frequency, and indication for each drug. Explore all components of
◗ Activities of daily living
◗ Instrumental activities of daily living
◗ Medications
◗ Smoking and alcohol
◗ Acute and persistent pain
◗ Nutrition
◗ Frailty
◗ Advance directives and palliative care
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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 modifiable risk factor associated with falls.
Smoking and Alcohol. At each visit, advise elderly smokers to quit. An estimated 2% to 20% of older adults have alcohol-related problems. This percentage is expected to rise as the population ages in com- ing decades. Despite the prevalence of alcohol problems among the elderly, rates of detection and treatment are low. Use the CAGE ques- tions to uncover problem drinking (see p. 46), which contributes to drug interactions and worsens comorbid illnesses.
Acute and Persistent Pain. 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, lead- ing to undue suffering, depression, social isolation, physical disability, and loss of function.
Inquire about pain each time you meet with the older patient. Ask specifically, “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.
Characteristics of Acute and Persistent Pain
Acute Pain Persistent Pain
Distinct onset Lasts more than 3 months
Obvious pathology Often associated with psychological or
functional impairment
Short duration Can fluctuate in character and intensity
over time
Common causes: postsurgical,
trauma, headache
Common causes: arthritis, cancer, clau-
dication, leg cramps, neuropathy,
radiculopathy
Source: Reuben DB, Herr KA, Pacala JT, et al. Geriatrics at Your Fingertips: 2004, 6th ed.
Malden, MA: Blackwell Publishing, for the American Geriatrics Society, 2004:149.
Nutrition. Taking a diet history and using the Rapid Screen for Dietary Intake and the Nutrition Screening Checklist (p. 62) are especially important in older adults.
Chapter 20 | The Older Adult 377
Frailty. The prevalence of this multifactorial syndrome related to declines in physiologic reserves, muscle mass, energy and exercise capacity is 4% to 22%. Pursue related interventions.
Advance Directives and Palliative Care. Initiate these discus- sions before serious illness develops. Advance care planning involves providing information, invoking the patient’s preferences, identify- ing proxy decision makers, and conveying empathy and support. Use clear, simple language. Ask about preferences relating to writ- ten “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 reflecting your wishes in case of confusion or emergency.” Include these discussions in office settings rather than the uncertain and stressful environment of emergency or acute care.
The goal of palliative care is “to relieve suffering and improve the quality of life for patients with advanced illnesses and their families through specific 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 medical and social services.”
Health Promotion and Counseling: Evidence and Recommendations
Important Topics for Health Promotion and Counseling in the Older Adult
◗ When to screen
◗ Cancer screening
◗ Depression, dementia, and cognitive impairment
◗ Elder mistreatment and abuse
When to Screen. As the life span for older adults extends into the 80s, new issues for screening emerge. In general, base screening deci- sions on each older person’s particular circumstances, rather than on age alone. Consider life expectancy, time interval until benefit from screening accrues, and patient preference. The American Geriatrics Society recommends that if life expectancy is short, give priority
378 Bates’ Pocket Guide to Physical Examination and History Taking
to treating conditions that will benefit the patient in the time that remains.
● Screen for age-related changes in vision and hearing. These are included in the 10-Minute Geriatric Screener (pp. 380–381).
● Recommend regular aerobic exercise, resistance training to increase strength, and balance exercise like tai chi.
● Immunizations. Include the pneumococcal vaccine once after age 65, annual influenza vaccinations, Td boosters every 10 years, and the herpes zoster vaccine.
● Promote household safety. Correct poor lighting, chairs at awk- ward heights, slippery or irregular surfaces, and environmental hazards.
Cancer Screening. 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:
● Breast cancer (2009): Mammography every 2 years between ages 50 and 74; insufficient evidence thereafter.
● Cervical cancer (2003): Routine screening up to age 65 if low risk.
● Colorectal cancer (2008): Colonoscopy every 10 years, beginning at age 50; This examination is difficult for many older patients, sigmoidoscopy every 5 years with high-sensitivity fecal occult blood tests (FOBTs) every 3 years, or FOBTs every year ages 50 to 75.
● Prostate cancer (2008): Insufficient evidence to declare recommen- dation.
● Skin cancer (2006), lung cancer (2004): Insufficient evidence. American Geriatrics Society recommends checking for skin and oral cancers in high-risk patients.
Depression, Dementia, and Cognitive Impairment. Depression affects 10% of older men and 18% of older women. Use the two screening questions in Chapter 5 p. 68.
Chapter 20 | The Older Adult 379
Dementia is “an acquired syndrome of decline in memory and at least one other cognitive domain such as language, visuospatial, or executive function sufficient to interfere with social or occupational functioning.” It affects 13% of Americans over age 65. Prominent features include:
● Normal alertness but short-term memory deficits and subtle lan- guage errors.
● Visuospatial perceptual difficulties and loss of orientation to place.
● Changes in executive function, or ability to perform sequential tasks.
● In later stages, impaired judgment, aphasia, apraxia and loss of ADLs.
Most dementias represent Alzheimer’s disease (50% to 85%) or vascu- lar multi-infarct dementia (10% to 20%). Dementia often has a slow, insidious onset. The early stages of mild cognitive impairment may be detected only on neurocognitive testing. Watch for family complaints of new or unusual behaviors. Investigate contributing factors such as medications, depression, metabolic abnormalities, or other medical and psychiatric conditions.
Elder Mistreatment and Abuse. Screen older patients for possible elder mistreatment, which includes abuse, neglect, exploitation, and abandonment. Prevalence is approximately 1% to 10% of the older population; however, many more cases may remain undetected.
Techniques of Examination
Assessment of the older adult departs from the traditional format of the history and physical examination. Enhanced interviewing, empha- sis on daily function and key topics related to elder health, and func- tional assessment are especially important.
ASSESSING FUNCTIONAL STATUS: THE “SIXTH VITAL SIGN”
Assessing Functional Ability. Functional status is the ability to perform tasks and fulfill social roles associated with daily living across
TTTecchhnniiquees offf Exaammminnatttionn
380 Bates’ Pocket Guide to Physical Examination and History Taking
a wide range of complexity. Several performance-based assessment instruments are available. The screening tool below is brief, has high inter-rater agreement, and can be used easily by office staff. It covers the three important domains of geriatric assessment: physical, cognitive, and psychosocial function. It addresses key sensory modalities and urinary incontinence, an often unreported problem that greatly affects social interactions and self-esteem in the elderly. One mnemonic that helps students assess incontinence is DIAPERS: Delirium, Infection, Atrophic urethritis/vaginitis, Pharmaceuticals, Excess urine output (e.g., due to heart failure, hyperglycemia), Restricted mobility, Stool impaction.
10-Minute Geriatric Screener
Problem and Screening Measure Positive Screen
Vision: Two Parts: Ask: “Do you have difficulty driving, or
watching television, or reading, or doing
any of your daily activities because of
your eyesight?
Yes to question and inability
to read >20/40 on Snellen chart
If yes, then: Test each eye with Snellen chart
while patient wears corrective lenses (if
applicable).
Hearing: Use audioscope set at 40 dB. Test hearing using 1,000 and 2,000 Hz.
Inability to hear 1,000 or
2,000 Hz in both ears or
either of these frequencies
in one ear
Leg mobility: Time the patient after in- structing: “Rise from the chair. Walk 20
feet briskly, turn, walk back to the chair,
and sit down.”
Unable to complete task in
15 seconds
Urinary incontinence: Two Parts: Ask: “In the last year, have you ever lost
your urine and gotten wet?”
Yes to both questions
If yes, then ask: “Have you lost urine on at
least 6 separate dates?”
Nutrition/weight loss: Two parts: Ask: “Have you lost 10 lbs over the past
6 months without trying to do so?”
Weigh the patient.
Yes to the question or weight
<100 lbs
(continued)
Chapter 20 | The Older Adult 381
10-Minute Geriatric Screener (continued)
Problem and Screening Measure Positive Screen
Memory: Three-item recall Unable to remember all three items after 1 minute
Depression: Ask: “Do you often feel sad or depressed?”
Yes to the question
Physical disability: Six questions: “Are you able to. . . :
No to any of the questions
◗ “Do strenuous activities like fast walking
or bicycling?”
◗ “Do heavy work around the house like
washing windows, walls, or floors?”
◗ “Go shopping for groceries or clothes?”
◗ “Get to places out of walking distance?”
◗ “Bathe, either a sponge bath, tub bath, or
shower?”
◗ “Dress, like putting on a shirt, buttoning
and zipping, or putting on shoes?”
Source: More AA, Siu AL. Screening for common problems in ambulatory elderly: clinical
confirmation of a screening instrument. Am J Med 1996;100:438–440.
Further Assessment for Preventing Falls. Each year approximately 35% to 40% of healthy community-dwelling older adults experience falls. Incidence rates in nursing homes and hospitals are almost three times higher, with related injuries in approximately 25%.
The American Geriatrics Society (AGS) recommends risk factor assess- ment for falls during routine primary care visits, with more intensive assessment in high-risk groups—those with first or recurrent falls, nurs- ing home residents, and those prone to fall-related injuries. Assess how the fall occurred, seeking details from any witnesses, and identify risk factors, medical comorbidities, functional status, and environmen- tal risks. Couple your assessment with interventions for prevention, including gait and balance training and exercise to strengthen muscles, vitamin D supplementation, reduction of home hazards, discontinu- ation of psychotropic medication, and multifactorial assessment with targeted interventions. The AGS recommendations are provided on the next page.
382 Bates’ Pocket Guide to Physical Examination and History Taking
1. Obtain relevant medical history, physical examination, cognitive and functional assessment.
2. Determine multifactorial fall risk: a. History of falls b. Medications c. Gait, balance, and mobility d. Visual acuity e. Other neurological impairments f. Muscle strength g. Heart rate and rhythm h. Postural hypotension i. Feet and footwear j. Environmental hazards
Initiate multifactorial/multicomponent intervention to address identified risk(s) and prevent falls:
1. Minimize medications 2. Provide individually tailored exercise program 3. Treat vision impairment (including cataract) 4. Manage postural hypotension 5. Manage heart rate and rhythm abnormalities 6. Supplement vitamin D 7. Manage foot and footwear problems 8. Modify the home environment 9. Provide education and information
Any indication for additional intervention?
Reassess periodically
Older person encounters health care provider
Prevention of Falls in Older Persons Living in the Community
Screen for fall(s) or risk for falling:
1. Two or more falls in prior 12 months? 2. Presents with acute fall? 3. Difficulty with walking or balance?
Answers yes to any screening questions
Does the person report a single fall in the past 12 months?
Are abnormalities in gait or unsteadiness identified?
No
No
No
No
Yes
Yes
Yes
Evaluate gait and balance
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
PHYSICAL EXAMINATION OF THE OLDER ADULT
Vital Signs. Measure blood pressure, checking for increased systolic blood pressure (SBP) and widened pulse pressure (PP), defined as SBP minus dia- stolic blood pressure (DBP).
Isolated systolic hypertension (SBP ≥140) after age 50 triples the risk of coronary
heart disease in men. PP ≥60 is a risk fac- tor for cardiovascular and renal disease
and stroke.
Source: Panel on Prevention of Falls in Older Persons, American Geriatrics Society and British Geriatrics Society. Summary of the Updated American Geriatrics Society/British Geriatrics Society. Clinical Practice guideline for prevention of falls in older persons, 2010. J Am Geriatr Soc 59:148–157, 2011. Also at http://www. americangeriatrics.org/files/documents/health_care_pros/JAGS.Falls.Guidelines.pdf. Accessed January 24, 2011. See also U.S. Preventive Services Task Force. Interventions to Prevent Falls in Older Adults, Topic Page. December 2010. At http://www. uspreventiveservicestaskforce.org/uspstf/uspsfalls.htm. Accessed January 24, 2011.
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
Review the JNC 7 categories of hypertension to guide early detection and treatment.
Assess the patient for orthostatic hypotension, defined 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 posi- tions: 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.
Assess for medications, autonomic disor-
ders, diabetes, prolonged bedrest, blood
loss, and cardiovascular disorders.
Measure heart rate, respira- tory rate, and temperature. The apical heart rate may yield more information about arrhythmias in older patients. Use thermometers accurate for lower temperatures.
Respiratory rate ≥25 breaths per minute indicates lower respiratory infection or
possible CHF or COPD.
Hypothermia is more common in elderly
patients.
Weight and height are especially important and needed for calcula- tion of the body mass index (p. 53). Weight should be mea- sured at every visit. Obtain oxygen saturation using a pulse oximeter.
Low weight is a key indicator of poor
nutrition.
Undernutrition in depression, alcohol-
ism, cognitive impairment, malignancy,
chronic organ failure (cardiac, renal, pul-
monary), medication use, social isolation,
and poverty
Skin. Note physiologic changes of aging, such as thin- ning, loss of elastic tissue and turgor, and wrinkling.
Dry, flaky, rough, and often itchy
Check the extensor surface of the hands and forearms.
White depigmented patches (pseudos- cars); well-demarcated, vividly purple macules or patches that may fade after
several weeks (actinic purpura)
Look for changes from sun exposure. There may be actinic lentigines, or “liver spots,” and actinic keratoses, superficial flat- tened papules covered by a dry scale (p. 94).
Distinguish such lesions from a basal cell carcinoma and squamous cell carcinoma (p. 95). Dark, raised, asymmetric lesion
with irregular borders is suspicious for
melanoma
Chapter 20 | The Older Adult 383
384 Bates’ Pocket Guide to Physical Examination and History Taking
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
Inspect for the benign com- edones, or blackheads, on the cheeks or around the eyes; cherry angiomas (p. 93); and seborrheic keratoses, (p. 94).
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. 116)
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 degen- eration all increase with aging.
Inspect each lens for opacities. Cataracts 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 defined, or soft and confluent 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).
Chapter 20 | The Older Adult 385
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Test hearing by the whispered voice (see p. 108) or audio- scope. Inspect ear canals for cerumen.
Removing cerumen often quickly
improves hearing.
Examine the oral cavity for odor, appearance of the gingi- val mucosa, any caries, mobility of the teeth, and quantity of saliva.
Malodor in poor oral hygiene, periodon- titis, or caries
Gingivitis if periodontal disease
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
Decreased salivation from medications,
radiation, Sjögren’s syndrome, or dehy-
dration
Oral tumors, usually on lateral borders of tongue and floor of mouth
Thorax and 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 pulmonary disease
Cardiovascular System. Review blood pressure and heart rate.
Isolated systolic hypertension and a
widened pulse pressure are cardiac risk
factors. Search for left ventricular hyper- trophy (LVH).
Inspect the jugular venous pulsa- tion (JVP), palpating 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.
Carotid bruits in possible carotid stenosis.
Assess the point of maximal impulse (PMI), and then heart sounds.
Sustained PMI is found in LVH; diffuse
PMI is found within heart failure (see
p. 155).
In older adults, S3 in dilatation of the left
ventricle from heart failure or cardiomy-
opathy; S4 in hypertension
386 Bates’ Pocket Guide to Physical Examination and History Taking
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
Listen for cardiac murmurs in all areas (see p. 157). Describe timing, shape, location of maximal intensity, radiation, intensity, pitch, and quality of each murmur.
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, also com- mon in the elderly.
For systolic murmurs over the clavicle, check for delay between the brachial and radial pulses.
Delay during simultaneous palpation
(but not compression) of brachial and
radial pulses in aortic stenosis.
Breasts and Axillae. Palpate the breasts carefully for lumps or masses.
Possible breast cancer
Abdomen 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 and pulsatile mass may
be found in abdominal aortic aneurysm.
Female Genitalia and Pelvic Examination. Take special care to explain the steps of the examination and allow time for careful positioning. For the woman with arthritis or spinal deformities who cannot flex 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 swell- ings may be varicosities.
Benign masses include condylomata,
fibromas, leiomyomas, and sebaceous
cysts.
Bulging of the anterior vaginal wall
below the urethra in urethrocele
Inspect the urethra for caruncles, or prolapse of fleshy erythema- tous mucosal tissue at the urethral meatus.
Clitoral enlargement in androgen- producing tumors or use of androgen creams
Chapter 20 | The Older Adult 387
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Speculum Examination. Inspect vaginal walls, which may be atrophic, and cervix.
Estrogen-stimulated cervical mucus with
ferning in use of hormone replacement
therapy, endometrial hyperplasia, and estrogen-producing tumors
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 examina- tion.
See Table 14-6, Positions of the Uterus,
and Uterine Myomas, p. 239.
Mobility of cervix restricted if inflam-
mation, 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 cancer.
Male Genitalia and Prostate. 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. Prostate hyperplasia if enlargement; prostate cancer if nodules or masses.
Peripheral Vascular System. Auscultate the abdomen for aortic, renal, femoral artery bruits.
Bruits over these vessels in atheroscle- rotic disease.
Palpate pulses. Diminished or absent pulses in arterial occlusion. Confirm with an office ankle– brachial index (see pp. 209–210).
388 Bates’ Pocket Guide to Physical Examination and History Taking
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
Musculoskeletal System. Screen general range of motion and gait. Conduct timed “get up and go” test.
If joint deformity, deficits in mobility, or pain with move- ment, conduct a more thorough examination.
Review examination techniques for indi-
vidual joints in Chapter 16, Musculosk-
elatal System. See Table 20-1, Timed Get
Up and Go Test, p. 390.
Degenerative joint changes in osteoar- thritis; joint inflammation in rheumatoid or gouty arthritis. See Tables 16-1 to 16-4, pp. 277–282.
Nervous System. Refer to results of 10-Minute Geriatric Screener, pp. 380–381. Pursue further examination if any defi- cits. Focus especially on memory and affect.
Learn to distinguish delirium from
depression and dementia. See Table
20-2, Delirium and Dementia, pp.
391–392 and Table 20-3, Screening for
Dementia: The Mini-Cog, p. 393.
Assess gait and balance, particu- larly 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 turn-
ing, are correlated with risk of falls.
Although neurologic abnormali- ties are common in older adults, their prevalence without identifi- 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, bra- dykinesia, micrographia, shuf- fling gait, and difficulty turning in bed, opening jars, and rising from a chair.
Seen in Parkinson’s 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, sym- metric, with positive family history, and
diminished by alcohol
Chapter 20 | The Older Adult 389
E XA M I N AT I O N T E C H N I Q U E S
Mr. J is an older adult who appears healthy but underweight, with good muscle
bulk. He is alert and interactive, with good recall of his life history. He is ac-
companied by his son.
Vital Signs: Ht (without shoes) 160 cm (5 ′). Wt (dressed) 65 kg (143 lb). BMI 28. BP 145/88 right arm, supine; 154/94 left arm, supine. Heart rate (HR) 98 and
regular. Respiratory rate (RR) 18. Temperature (oral) 98.6°F. 10-Minute Geriatric Screener: (see pp. 380–381)
Vision: Patient reports difficulty reading. Visual acuity 20/60 on Snellen chart.
Needs further evaluation for glasses and possibly hearing aid.
Hearing: Cannot hear whispered voice in either ear. Cannot hear 1,000 or 2,000 Hz with audioscope in either ear.
Leg Mobility: Can walk 20 feet briskly, turn, walk back to chair, and sit down in 14 seconds.
Urinary Incontinence: Has lost urine and gotten wet on 20 separate days.
Needs further evaluation for incontinence, including “DIAPER” assessment
(see p. 380), prostate examination, and postvoid residual, which is normally
≤50 mL (requires bladder catheterization). Nutrition: Has lost 15 lbs over the past 6 months without trying.
Needs nutritional screen (see p. 62).
Memory: Can remember three items after 1 minute.
Depression: Does not often feel sad or depressed.
Physical Disability: Can walk fast but cannot ride a bicycle. Can do moderate but not heavy work around the house. Can go shopping for groceries or clothes.
Can get to places out of walking distance. Can bathe each day without diffi-
culty. Can dress, including buttoning and zipping, and can put on shoes.
Consider exercise regimen with strength training.
Physical Examination: Record the vital signs and weight. Carefully describe your findings for each relevant segment of the peripheral examination,
using terminology found in the “Recording Your Findings” sections of the
prior chapters.
Recording Your Findings
As you read through this physical examination, you will notice some atypical findings. Test yourself to see if you can interpret these findings in the context of all you have learned about the examination of the older adult.
Recording the Physical Examination— The Older Adult
390 Bates’ Pocket Guide to Physical Examination and History Taking
Aids to InterpretationAAAiddss ttoo Inntterrpprreetaattioonn
Timed Get Up and Go TestTable 20-1
Performed with patient wearing regular footwear, using usual walking aid if needed, and sitting back in a chair with arm rest.
On the word, “Go,” the patient is asked to do the following:
1. Stand up from the arm chair 2. Walk 3 meters (in a line) 3. Turn 4. Walk back to chair 5. Sit down
Time the second effort.
Observe patient for postural stability, steppage, stride length, and sway.
Scoring: ● Normal: completes task in <10 seconds ● 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– 389; Podsiadlo D, Richardson S. The Timed “Up and Go”: A test of basic functional mobility for frail elderly persons. J Am Geriatr Soc 1991;39:142–148.
Chapter 20 | The Older Adult 391
Table 20-2 Delirium and Dementia
Delirium Dementia
Clinical Features Onset Acute Insidious
Course Fluctuating, with lucid intervals; worse at night
Slowly progressive
Duration Hours to weeks Months to years
Sleep/Wake Cycle Always disrupted Sleep fragmented
General Medical Illness or Drug Toxicity
Either or both present
Often absent, especially in Alzheimer’s disease
Mental Status Level of
Consciousness 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
Behavior Activity often abnormally decreased (somnolence) or increased (agitation, hypervigilance)
Normal to slow; may become inappropriate
Speech May be hesitant, slow or rapid, incoherent
Difficulty in finding words, aphasia
Mood Fluctuating, labile, from fearful or irritable to normal or depressed
Often flat, depressed
Thought Processes Disorganized, may be incoherent
Impoverished. Speech gives little information
(continued)
392 Bates’ Pocket Guide to Physical Examination and History Taking
Delirium Dementia
Thought Content Delusions common, often transient
Delusions may occur
Perceptions Illusions, hallucinations, most often visual
Hallucinations may occur.
Judgment Impaired, often to a varying degree
Increasingly impaired over the course of the illness
Orientation Usually disoriented, especially for time. A known place may seem unfamiliar.
Fairly well maintained, but becomes impaired in the later stages of illness
Attention Fluctuates. Person easily distracted, unable to concentrate on selected tasks
Usually unaffected until late in the illness
Memory Immediate and recent memory impaired
Recent memory and new learning especially impaired
Examples of Cause Delirium tremens (due to withdrawal from alcohol)
Uremia Acute hepatic failure Acute cerebral
vasculitis Atropine poisoning
Reversible: Vitamin B12 deficiency, thyroid disorders
Irreversible: Alzheimer’s disease, vascular dementia (from multiple infarcts), dementia due to head trauma
Table 20-2 Delirium and Dementia (continued)
Chapter 20 | The Older Adult 393
Table 20-3 Screening for Dementia: The Mini-Cog
Administration The test is administered as follows:
1. Instruct the patient to listen carefully to and remember 3 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 3 previously stated words.
Scoring Give 1 point for each recalled word after the clock drawing test
(CDC) distractor.
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 1–2 words are classified based on the CDT (Abnormal = demented; Normal = nondemented).
Note: The CDT is considered normal if all numbers are present in the correct sequence and position, and the hands readably display the requested time.
3-Item Recall = 1-2
NONDEMENTEDDEMENTED
CDT Abnormal CDT Normal
MINI-COG
3-Item Recall = 33-Item Recall = 0
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): 1021–1027. Copyright John Wiley & Sons Limited. Reproduced with permission.
395
Page numbers followed by “b” indicate boxed material; those followed by “t” indicate end-of-chapter tables.
A ABCDE screening, 83, 96t Abdomen, 179–193
in children, 336, 342 concerning symptoms, 179–184 examination of, 12, 186–193 fullness of, 181 health history, 179–184 health promotion and counseling,
184–186 in older adults, 386 pain or tenderness, 179–182, 197t during pregnancy, 366–368 recording findings, 193b
Abdominal aortic aneurysm, 190, 199, 201, 203, 386
Abdominal fullness, 181 Abdominal reflexes, 302, 313t Abducens nerve, 291b, 292 Abscess
of brain, 99 lung, 142t peritonsillar, 109, 342
Abstract thinking, 74 Abuse
of alcohol, 71, 184–185 of drugs, 46, 71, 363 intimate partner, 47, 47b, 363,
363b of older adults, 379 during pregnancy, 363, 363b sexual, in children, 343, 357t
Acoustic nerve, 291b, 293 Acquired immunodeficiency
syndrome (AIDS). See also HIV infection
Kaposi’s sarcoma, 95t Acromioclavicular arthritis, 282t Actinic keratoses, 94t, 383 Actinic lentigines, 383 Actinic purpura, 383
Activities of daily living (ADLs), 375, 375b
Acute stress disorder, 81t Adam’s bend test, 345 Adnexa (ovaries), 228, 232, 369, 387 Adolescents
examination of, 344–346 hypertension in, 330b, 350t recommended preventative care
for, 349t sexual maturity ratings in,
353t–356t Advance directive, 377 Adventitious breath sounds, 132,
133b, 135 Agoraphobia, 80t Airway, upper vs. lower, 335b Alcohol abuse, 71, 184–185 Alcohol use
CAGE questionnaire for, 46, 184 interviewing about, 46 in older adults, 376 during pregnancy, 363
Allen test, 205 Allergic rhinitis, 101 Allergies, 3, 101, 325 Alopecia areata, 97t Alzheimer’s disease, 379 Amblyopia, 339 Amenorrhea, 226 Anal reflex, 303 Analgesic rebound headache, 112t Anatomic snuffbox, 263 Androgen-producing tumors, 386 Angina pectoris, 137t, 147 Angioedema, 122t Angioma
cherry, 93t, 384 spider, 93t
Angular cheilitis, 122t Ankle jerks, 302 Ankle reflex, 302
I n d e x
396 Index
Ankle–brachial index, 209t–210t Ankles
examination of, 274–275, 297 ulcers of, 208t
Anorexia, 182 Anorexia nervosa, 61t, 226 Anterior cruciate ligament,
273, 284t Anterior drawer sign, 273 Anteverted uterus, 239t Anticipatory guidance, 325–326 Anus, during pregnancy, 369 Anxiety disorders, 80t–81t Aorta
abdominal aortic aneurysm, 190, 199, 201, 203, 386
coarctation of the, 335 dissecting aneurysm, 137t, 147 examination of, 190 tortuous atherosclerotic, 385
Aortic insufficiency, 154, 155b, 202 Aortic regurgitation, 156–158 Aortic sclerosis, 386 Aortic stenosis, 154, 156–157, 159,
351t, 386 Apgar score, 326, 327b Aphasia, assessment for, 72b Aphthous ulcer, 124t Apical impulse
assessment of, 56, 155–156 in children, 335 in older adults, 385 during pregnancy, 366
Apnea, 334 Appearance, assessment of, 72 Appendicitis, 180, 181, 197t
assessment for, 192–193 Arcus senilis, 384 Argyll Robertson pupil, 104 Arms
examination of, 202–203 flaccid, 306
Arousal, 212 Arousal system, 286 Arrhythmias, 57, 161t–164t, 330 Arterial insufficiency, 206, 207t–208t Arterial occlusion, 202, 204, 387 Arteriosclerosis obliterans, 204 Arthralgia, 255 Arthritis
acromioclavicular, 282t acute septic, 255 in ankles and feet, 274–275 degenerative (osteoarthritis), 255,
262, 281t, 388
gonococcal, 254, 263 gouty, 388 of hip, 269 knee, 270–271, 283t patterns of pain in, 281t rheumatoid, 254–55, 262–263,
281t, 388 Articular structures, 251 Asbestosis, 140t Ascites, assessment of, 191–192 Assessment, 15–23
clinical reasoning in, 15–16 comprehensive vs. focused, 1, 9, 31 organizing data, 23–24 recording, 27b–29b test selection for, 25b–27b tips for, 24b
Asterixis, 304 Asthma, 139t, 142t, 146t Ataxia, 288 Ataxic breathing, 65t Atelectasis, 132 Atherosclerotic disease, 387 Athetosis, 314t Atrial fibrillation, 57, 154 Atrial septal defect, 335 Attention
assessment of, 73, 392t defined, 69b
Attention deficit disorder, 338 Auricle, examination of, 107 Auscultation
of abdomen, 187, 187b of chest, 132, 132b, 135 of fetal heart, 367–368 of heart, 156–158, 158b of infant heart, 335
Axillae examination of, 11, 172 in older adults, 386
Axillary temperature, 57
B Babinski response, 303 Back
examination of, 11 stiffness of, 278t
Back pain, low, 254, 256, 277t–278t Bacterial vaginitis, 235t Baker’s cyst, 271, 284t Balance, 388, 390t Balanitis, 214 Balloon sign, 272
Index 397
Ballotte, patella, 272 Barlow test, 337 Barrel chest, 144t Bartholin’s gland, 225, 368 Basal cell carcinoma, 95t, 383 Basal ganglia, 285 Basal ganglia disorder, 313t Behavior
assessment of, 72 in delirium and dementia, 391t in older adults, 390t
Bell’s palsy, 293, 312t Benign prostatic hyperplasia (BPH),
242, 246t–247t, 248t–249t, 387 Biceps reflex, 301 Bicipital tendinitis, 282t Biliary obstruction, 183b Bimanual examination, 232, 369, 387 Biot’s breathing, 65t Birth history, 324 Bitemporal hemianopsia, 115t Bladder, disorders of, 183–184,
196t–197t Bleeding
gastrointestinal, 242 from nose, 102 postmenopausal, 226 sputum and, 141t–143t subarachnoid, 99–100, 113t, 287 uterine, 226 vitreous, 100
Blood, in stool, 182 Blood pressure
assessment of, 54–56, 153–154 in children, 330, 339 classifications for, 56b, 150b cuff size, 54b high. See Hypertension low, 154, 383 measuring, 55b in older adults, 382–383, 385 during pregnancy, 365 tips for accurate, 55b
Blood pressure cuff, sizing, 54b Body mass index (BMI), 52–54
calculation of, 53b chart for, 54b in children, 338 excessively low, 61t for obesity, 52 during pregnancy, 362b
Bone density, criteria for, 257b Bouchard’s nodes, 264 Bowel sounds, 187b Bowlegged, 328
Brachial pulse, 202 Brachioradialis reflex, 302 Brain
abscess of, 99 tumors of, 99–100, 113t
Brainstem, 285 Breast self-examination (BSE), 169,
173b–174b Breastfeeding, 360 Breasts, 167–175
in adolescents, 345, 353t anatomy of, 169 cancer of, 167–169, 168b,
175t–177t, 378 concerning symptoms, 167–169 cysts of, 168b, 171 discharge from, 172 examination of, 11, 169–172 health history, 167–169 in infants, 336 male, 172 masses of, 167, 168b in older adults, 386 during pregnancy, 366 recording findings, 174b in review of systems, 5 sexual maturity ratings for, 353t
Breath odor, 52 Breath sounds, 132, 132b, 135
adventitious, 132, 133b, 135 Breathing
abnormal, 65t assessment of, 57, 129 in children, 330 in comatose patient, 319t effort of, 57 normal, 57, 65t in older adults, 383 shortness of breath, 128, 147
Breech presentation, 370 Brief psychotic disorder, 82t Bronchial breath sounds, 132b Bronchiectasis, 142t Bronchiolitis, 330 Bronchitis, chronic, 139t,
142t, 146t Bronchophony, 133, 133b Bronchovesicular breath sounds,
132b Brudzinski’s sign, 303 Bruits
abdominal, 187b, 386 carotid, 154
Bulge sign, 271 Bulimia nervosa, 61t
398 Index
Bulla, 89t Burrow, 90t Bursa, 251 Bursitis, 255
in hip, 268 in knee, 270–271, 283t olecranon, 262 in shoulder, 259, 282t
C CAGE questionnaire, 46, 184 Calcium
food sources of, 63t recommended dietary intake for,
258b Calf swelling, 200 Cancer
breast, 167–169, 168b, 175t–177t, 378
cervical, 228, 237t, 378 colorectal, 182, 185b–186b, 194t,
242, 378, 387 lip, 122t ovarian, 228, 387 penis, 218t prostate, 242, 249t, 378, 387 rectal, 249t screening in older adults, 378 skin, 95t, 378, 383 testicular, 221t tongue, 124t vulvar, 234t
Candidiasis in infants, 333 oral, 124t, 333 tongue, 123t vaginitis, 235t
Canker sore, 124t Capacity, altered, 42 Carcinoma
basal cell, 95t, 383 cervical, 237t of lip, 122t of penis, 218t squamous cell, 95t, 383 of tongue, 124t of vulva, 234t
Cardiac examination, 155–159 auscultation, 156–159 heart sounds, 156 in infants, 335 inspection and palpation, 155–156 murmurs, 157–159, 158b
during pregnancy, 366 sequence for, 155b
Cardiac syncope, 288 Cardinal directions of gaze, 104–105 Cardiomyopathy, 155
hypertrophic, 159 peripartum, 366
Cardiovascular disease major risk factors for, 149b screening for, 148–153
Cardiovascular system, 147–160 cardiac examination, 155–159 concerning symptoms, 147 examination of, 12, 153–159 health history, 147 health promotion and counseling,
148–153 in older adults, 385–386 during pregnancy, 366 recording findings, 160b in review of systems, 5
Carotid bruits, 154 Carotid pulse, 154 Carotid stenosis, 385 Carpal tunnel syndrome, 262,
265–266, 296 Cartilaginous joints, 252b Caruncles, 386 Cataracts, 100, 102, 384 Cauda equina, 286 Cauda equine syndrome, 254 Cellulitis, 200, 203 Central nervous system, 285–286
disorders of, 313t Cerebellar disorders, 297, 313t Cerebellum, 286 Cerebrovascular accident (CVA), 103 Cervical myelopathy, 280t Cervical radiculopathy, 279t, 296 Cervicitis, 237t Cervix
abnormalities of, 237t cancer of, 228, 237t, 378 examination of, 231 during pregnancy, 369 shapes of Os, 236t
Chalazion, 117t Chancre
female genitalia, 234t lip, 122t male genitalia, 214, 220t
Cheilitis, angular, 122t Cherry angioma, 93t, 384 Chest. See Thorax (chest) Chest pain, 127, 137t–138t, 147
Index 399
Chest wall pain, 138t Cheyne-Stokes breathing, 65t Chief complaint, 1b, 3, 323 Childhood illnesses, 3–4 Children. See also Adolescents
development of, 323b, 324–325 examination of, 338–344 health history, 323–326 health promotion and counseling,
325–326 heart murmurs in, 335, 342,
351t–352t hypertension in, 330b, 339, 350t infants, 329–337 interviewing, 338b newborns, 326–328 recommended preventative care
for, 349t recording findings, 346b–347b sexual abuse in, 343, 357t sexual maturity ratings in, 353t–356t
Chills, 49 Chloasma, 365 Choanal atresia, 333 Cholecystitis, 193 Chondromalacia, 270 Chorea, 314t Chronic obstructive pulmonary
disease (COPD), 135, 139t, 146t, 385
Chronic pain, defined, 59 Cirrhosis, 182, 183b Clavicle fracture, 336 Clinical breast examination (CBE), 169 Clinical reasoning, 15–16. See also
Assessment Clinician
behavior and appearance, 35 self-reflection of, 39
Clitoris, 230 Clubbing, 98t Cluster headache, 99, 111t Coarctation of the aorta, 335 Cognitive function
assessment of, 73 higher, 70b, 74
Cognitive impairment, 290b mild, 379 in older adults, 378–379
Cogwheel rigidity, 316t Collaborative partnerships, 41 Colles’ fracture, 263 Colonoscopy, 243 Colorectal cancer, 182, 185b–186b,
194t, 242, 243, 378, 387
Coma, 305 Glasgow Coma Scale, 320t structural, 319t toxic-metabolic, 319t
Comatose patient assessment of, 304–306 pupils in, 305–306, 319t, 321t
Comedones, 384 Communication
nonverbal, 33 respectful, 40–41
Comprehensive health history. See Health history
Concussion, headache due to, 114t Conductive hearing loss, 101, 121t,
293 Condylar joints, 253b Condyloma acuminatum, 233t Condyloma latum, 234t Condylomata acuminata, 219t Congestive heart failure, 335. See also
Heart failure Consciousness, level of, 305b
assessment of, 51, 72 in comatose patient, 319t defined, 69b in delirium and dementia, 391t loss of, 288
Constipation, 182 Constructional ability, assessment of, 74 Coordination, 297–298, 313t Corneal light reflex, 339 Corneal reflexes, 104, 293 Corticospinal lesion, 298 Costovertebral angle, 190 Cough, 141t–143t Crackles, 133b Cranial nerves, 286
assessment of, 292–294 examination of, 13 functions of, 291b
Cranial neuralgias, 113t Crohn’s disease, 182, 195t, 242, 244 Crossed straight-leg raise, 277 Croup, 334b Crust, skin, 91t Cryptorchidism, 215, 221t Cultural competence, defined, 40 Cultural considerations
health disparities in pain management, 59–60
in older adults, 374–375 patient with language barrier, 43,
43b working with interpreter, 43b
400 Index
Cultural humility, 40–41 Culture, defined, 40 Cutaneous stimulation reflexes,
302–3 Cyanosis, 86t Cyclothymic episode, 79t Cystocele, 230, 238t, 368 Cystourethrocele, 230, 238t Cysts, 88t
Baker’s, 271 breast, 168b, 171 congenital, 333 epidermoid, 233t periauricular, 333 pilar, 103 pilonidal, 244 thyroglossal duct, 333
Cytomegalovirus, 182
D Dacryocystitis, 117t Data
identifying, 323 organizing, 23–24 subjective vs. objective, 2b
Death, interviewing about issues related to, 47
Decerebrate rigidity, 306 Decorticate rigidity, 306 Deep tendon reflexes, 301, 313t Deep venous thrombosis, 204 Degenerative joint disease, 255, 262,
281t, 388 Delirium, 290b, 391t–392t Delusional disorder, 82t Dementia, 290b
in older adults, 378–379 screening for, 393t vs. delirium, 391t–392t
Dental caries, 341 Dependent edema, 147 Depression, 290b
health promotion and counseling for, 70–71
low back pain and, 256 in older adults, 378–379
de Quervain’s tenosynovitis, 263, 265, 296
Dermatomes, 317t–318t Development, child, 323b,
324–325 Developmental delay/abnormality,
329, 338, 344
Diabetes in cardiovascular disease, 149b screening for, 150b–151b
Diabetes insipidus, 184 Diabetes mellitus, 184 Diabetic retinopathy, 119t Diarrhea, 182, 194t–196t Diet
health promotion and counseling for, 50–51, 256
in older adults, 376 during pregnancy, 361 recommendations for hypertension,
64t screening checklist, 62t sources of nutrients, 63t
Diethylstilbestrol (DES), 237t Diffuse esophageal spasm, 138t Digital rectal examination, 242–243 Diphtheria, 125t Diplopia, 101, 288 Discharge
breast, 172 penile, 213 vaginal, 226, 235t, 343
Discriminative sensations, 300 Disease, defined, 36 Disease/illness model, defined, 36 Dissecting aortic aneurysm, 137t, 147 Distal weakness, 288 Distress, signs of, 51 Diverticulitis, 181, 197t Dizziness, 287 Do Not Resuscitate (DNR), 47, 377 Doll’s eye movements, 306 Domestic violence, 47, 47b, 363, 363b Doppler method, blood pressure, 330 Dorsalis pedis pulse, 204 Down’s syndrome, 331 Drawer sign
anterior, 273 posterior, 274
Dress, patient, 52, 72 Drug abuse, 46, 71, 363 Drug use
allergies and, 3 diarrhea related to, 194t health history, 3, 46 in older adults, 375–376 during pregnancy, 363 prescription abuse, 46 urinary incontinence related to, 197t
Drusen, 384 Dullness, percussion notes, 131b, 135 Dupuytren’s contracture, 262, 264
Index 401
Durable medical power of attorney, 42
Dying patient, 47 Dysarthria, 288 Dyskinesia, oral-facial, 315t Dyslipidemia
in cardiovascular disease, 149b classification of, 151 in metabolic syndrome, 152b screening for, 151, 152b treatment of, 152b
Dysmenorrhea, 226 Dyspareunia, 227 Dyspepsia, 181 Dysphagia, 182 Dyspnea, 139t–140t, 147 Dysrhythmias, 57, 161t–164t,
330 Dysthymic disorder, 79t Dystonia, 315t Dysuria, 183
E Ear canal, 107 Earache, 101 Eardrum, 107–108, 120t Ears
in children, 340 examination of, 11, 107 health history of, 101 in infants, 332, 333b in older adults, 385 pain in, 101 recording findings, 110b in review of systems, 5
Eating disorders, 61t, 226 Ecchymosis, 94t Echoing, 33 Ectopic pregnancy, 181, 369 Ectropion, 116t Edema, 147
dependent, 147 pitting, 204 during pregnancy, 370
Effusion of knee, 271–272 pleural, 131, 146t
Egophony, 133, 133b Ejaculation, 212 Elbow, 262, 296 Elder mistreatment, 379 Elderly patients. See Older adults Empathetic response, 32
Empowerment, patient, 34, 34b Endocervical broom, 231 Endocervical polyp, 237t Endocrine system, 6 Endometrial hyperplasia, 387 Endometriosis, 226 Enteroviral infections, 333 Entropion, 116t Environment for examination, 9, 35,
373–374 Epidermoid cyst, 233t Epididymis, 215, 222t Epididymitis, 222t Episcleritis, 117t Episiotomy, 368 Epistaxis, 102 Epitrochlear lymph nodes, 11, 203 Epstein’s pearls, 333 Erectile dysfunction, 212 Erosion, skin, 92t Esophageal spasm, diffuse, 138t Esophagitis, reflex, 138t Estrogen-producing tumors, 387 Ethics, professionalism and, 48, 48b Excoriation, 92t Exercise
health promotion and counseling for, 51, 256
during pregnancy, 362 Exophthalmos, 116t Expected date of delivery (EDD),
360–361 Expressions, facial, 52, 72 Extinction, sensation, 301 Extra-articular structures, 251 Extraocular muscles, 101 Extremities, lower. See also specific
structures examination of, 12, 370
Eyelid abnormalities of, 116t–117t in older adults, 384 retraction, 116t
Eyes abnormalities of, 116t–117t in children, 339–340 in comatose patient, 305–306 disorders of, 112t examination of, 11, 103–104 health history of, 100–101 in infants, 332, 332b in older adults, 384 during pregnancy, 365 recording findings, 110b in review of systems, 5
402 Index
F Face
expressions of, 52, 72 of infants, 331, 332b paralysis of, 103, 312t during pregnancy, 365
Facial nerve, 291b, 293 Failure to thrive, 329 Fainting, 288 Fall prevention, 258, 381–382 Fallot, tetralogy of, 351t–352t Family history, 2b, 4, 149b, 153, 360 Family planning, 229 Fasciculations, 314t Fatigue, 49 Fecal occult blood test (FOBT), 243 Feeding history, 324 Feet
swelling of, 200 ulcers of, 208t
Female genital examination, 225–232 anatomical considerations, 225 concerning symptoms, 225–227 examination techniques, 13–14,
229–232, 229b health history, 225–227 health promotion and counseling,
227–229 recording findings, 233b sexually transmitted infections
(STIs) in, 227–228, 231 Female genitalia
in adolescents, 345 in children, 343 examination of, 13–14 in infants, 336 in older adults, 386–387 during pregnancy, 368–369 in review of systems, 6 sexual maturity ratings for, 356t
Femoral hernia, 216, 223t, 232 Femoral pulse, 204 Fetal alcohol syndrome, 331, 363 Fetal heart rate (FHR), 367–368 Fever, 49, 57 Fibroadenoma, of breast, 168b, 171 Fibromyalgia, 255, 279t Fibrous joints, 252b Fingernails, 85, 98t Fingers, 264, 296 Fissure, 92t Fissured tongue, 123t Flaccid paralysis, 306 Flaccidity, 316t
Flail chest, 144t Flat percussion note, 131b Flu shots, 128 Folate, food sources of, 63t Fontanelles, 331 Forced expiratory time, 135 Forgetfulness, 290b Fracture
clavicle, 259, 336 Colles’, 263 osteoporosis and, 257b scaphoid, 263
Frailty, 377 Functional assessment, 375 Functional status, 379–380 Fundal height, 367 Funnel chest, 144t
G Gait
assessment of, 52, 267–268, 297–298 in older adults, 388, 390t
Gastroesophageal reflux disease (GERD), 181
Gastrointestinal reflux, 143t Gastrointestinal system
bleeding, 242 chest pain and, 138t pain related to, 180–183 in review of systems, 5 symptoms related to, 182–183
Gaze, cardinal directions of, 104–105 Gegenhalten, 316t General survey
in infants, 329–330 in physical examination, 10,
51–52 recording findings, 60 in review of systems, 5
Generalized anxiety disorder, 81t Genital herpes, 219t, 234t Genital warts, 219t, 233t Genitalia
ambiguous, 336 examination of, 13–14 female, 225. See also Female genital
examination male, 211. See also Male genital
examination in review of systems, 6
Geographic tongue, 123t Geriatric competencies, minimum,
391t–393t
Index 403
Geriatric Screener, 10-Minute, 378, 380b–381b
Geriatric syndromes, 374 Gestational age, 327b, 328b, 348t,
360–361 Gestational hypertension, 365b “Get Up and Go” test, 388, 390t Giant cell arteritis, 114t Gingivitis, 385 Glasgow Coma Scale, 320t Glaucoma
acute, 101, 112t health promotion and counseling
for, 102–103 open-angle, 100, 384
Glaucomatous cupping, 118t Glossopharyngeal nerve, 291b, 294 Goiter, 102, 110, 126t Gonococcal arthritis, 254, 263 Gout, 255, 388 Gray matter, 285 Great arteries, transposition of the,
335, 352t Grip strength, hand, 265 Growth, of child, 324 Guarding, abdominal, 188 Gums, 109
H Hair
examination of, 85 loss of, 97t, 199 pubic, 354t–356t
Hairy leukoplakia, 123t Hairy tongue, 123t Hand
arterial supply to, 205 flaccid, 306 grip strength of, 265
Head, 99–102 circumference of, 329 examination of, 11, 103–111 health history, 99–102 health promotion and counseling,
102–103 in infants, 331 in older adults, 384–385 during pregnancy, 365 recording findings, 110b in review of systems, 5
Headache, 99, 287 cluster, 99, 111t migraine, 100, 111t
primary, 111t red flags for, 100b secondary, 112t–114t tension, 99, 111t
Health care proxy, 42, 47 Health disparities
in cardiovascular screening and risk factors, 149
in diabetes screening and diagnosis, 151
in pain management, 59–60 in osteoporosis risk factors,
256–257 in risk of prostate cancer, 242–243
Health history, 2–7, 2b in children, 323–326 components of, 1b–2b comprehensive vs. focused, 1, 9, 31 concerning symptoms, 49–50 interview and, 31–48 in older adults, 373–377 prenatal, 359–361
Health Insurance Portability and Accountability Act (HIPAA), 42
Health maintenance, 4 Health promotion and counseling,
227–229 abdominal aortic aneurysm, 201 alcohol abuse, 71, 184–185 cardiovascular disease screening,
148–153 cervical cancer screening, 228 in children, 325–326 colorectal cancer, 185b–186b colorectal cancer screening, 243 depression, 70–71 diet, 50–51, 62t, 63t, 256 exercise, 51, 256 fall prevention, 258 family planning, 229 flu shots, 128 hearing loss, 103 hepatitis prevention, 185 low back pain, 256 for menopause, 229 nutrition, 50–51, 62t, 63t, 256 in older adults, 377–379, 391t optimal weight, 50–51 oral health, 103 osteoporosis, 256–257, 257b–258b ovarian cancer screening, 228 peripheral neuropathy, 290 peripheral vascular disease, 200–201 pneumococcal vaccine, 128 during pregnancy, 361–364
404 Index
Health promotion and counseling (continued)
prostate cancer screening, 242–243 renal artery disease, 201 sexually transmitted infections
(STIs) prevention, 213–214, 228 skin cancer screening, 83 smoking cessation, 128b stroke prevention, 289–290 substance abuse, 71 suicide risk, 71 testicular self-examination, 214 vision loss, 102–103
Health supervision visits, 325 Hearing
assessment of, 108, 121t in infants, 333b in older adults, 385
Hearing loss, 293 conductive, 101, 121t health promotion and counseling,
103 sensorineural, 101, 121t
Heart. See also Cardiovascular system examination of. See Cardiac
examination in infants, 335 in older adults, 385–386 during pregnancy, 366
Heart failure congestive, 335 left ventricular, 139t, 143t, 146t,
147, 155, 159 Heart murmurs
assessment of, 156–158 causes of, 165t in children, 335, 342, 351t–352t grading of, 158b in older adults, 386 during pregnancy, 366 systolic murmur identification, 159
Heart rate assessment of, 56–57, 153 fetal, 367–368 in older adults, 383
Heart rhythm, 57, 161t–164t, 330 Heart sounds
assessment of, 156, 161t–164t in infants, 335
Heartburn, 181 Heberden’s nodes, 264 HEENT (head, ears, eyes, nose, and
throat), 99–102 examination of, 11, 103–110 health history, 99–102
health promotion and counseling, 102–103
in older adults, 384–385 recording findings, 110b in review of systems, 5
Height assessment of, 52 in infants, 329 in older adults, 383
Hematoma, subdural, 329 Hemianopsia, 103, 115t Hemoptysis, 141t–143t Hemorrhage
subarachnoid, 99–100, 113t, 287
vitreous, 100 Hemorrhagic telangiectasia,
hereditary, 122t Hemorrhoids, 249t, 369 Hepatitis, 181, 182
alcoholic, 179, 183b prevention of, 185 types of, 183b, 185
Hepatomegaly, 188–189, 342 Hereditary hemorrhagic
telangiectasia, 122t Hernia
in children, 328, 336, 343 in female, 232 femoral, 216, 223t, 232 indirect vs. direct, 216, 223t inguinal, 216, 232, 336, 343 scrotal, 218t umbilical, 328
Herpes simplex female genital, 234t in infants, 333 lip, 122t male genital, 219t
Herpes zoster, 384 Higher cognitive functions, defined,
70b Hinge joints, 253b Hip dysplasia, congenital, 337 Hips, examination of, 267–268,
296–297 History. See Health history HIV infection
female genital examination, 228 male genital examination, 213–214
Hoarseness, 102 Homonymous hemianopsia, 115t Hormone replacement therapy
(HRT), 229 Housemaid’s knee, 270, 283t
Index 405
Human immunodeficiency virus (HIV). See HIV infection
Human papillomavirus (HPV), 219t, 242
Hydrocele, 215, 218t, 336 Hydrocephalus, 103, 329 Hymen, imperforate, 230 Hyperglycemia, 100 Hyperopia, 100 Hyperpnea, 65t Hyperpyrexia, defined, 57 Hyperresonance, 131, 131b Hypertension
in cardiovascular disease, 149b in children, 330b, 339, 350t classification of, 56b, 150b dietary recommendations for, 64t gestational, 365b isolated systolic, 56, 382 during pregnancy, 365, 365b pulmonary, 335 screening for, 150
Hyperthyroidism, 102, 103 Hypertonia, 316t Hypoglossal nerve, 291b, 294 Hypomanic episode, 79t Hypoplastic left heart, 335 Hypospadias, 214, 218t Hypotension, orthostatic, 154, 383 Hypothalamus, 285 Hypothermia
causes of, 57 defined, 57
Hypothesis, generating, 38–39 Hypothyroidism, 102 Hypotonia, 316t, 337 Hypovolemia, 154
I Illicit drug abuse, 71, 363 Illness, defined, 36 Immunizations, 4, 325
in older adults, 378 during pregnancy, 364
Imperforate hymen, 230 Impulse, point of maximal, 56,
155–156, 335, 366, 385 Incontinence, urinary, types of, 184,
196t–197t Infantile automatisms, 337 Infants
assessment of, 329–337 head circumference, 329
hypertension in, 330b maturity classification for, 348t recommended preventative care
for, 349t Infection
diarrhea related to, 194t sexually transmitted. See Sexually
transmitted infections (STIs) Inflammatory bowel disease (IBD),
194t, 195t Inguinal hernia, 216, 232, 336, 343 Inguinal lymph nodes, 203 Insight, patient, 69b, 73 Intention tremor, 314t Intercourse, pain with, 227 Intermittent claudication, 199, 207t Interpreter, working with, 43b Interviewing, 31–48
children, 338b comprehensive vs. focused, 1, 9, 31 cultural humility in, 40–41 ethics and professionalism, 48, 48b format of, 31 patient with hearing loss, 44 patient with vision loss, 44 patient’s perspective in, 37, 37b preparation for, 34–35 sensitive topics, 45–47 sequence for, 35–39 specific situations, 41–45 techniques for, 32–34
Intimate partner abuse, 47, 47b Intracranial pressure, increased, 331 Introitus, 230 Involuntary movements, 295, 313t,
314t–315t Iron, food sources of, 63t Irritable bowel syndrome, 182 Ischiogluteal bursa, 268 Isolated systolic hypertension, 56, 382
J Jaundice, 86t, 182 Joint pain, 281t
assessment of, 254–255, 254b monoarticular, 254 polyarticular, 254
Joints. See also specific joint concerning symptoms, 253–255 examination of, 258–275, 258b recording findings, 276b stiffness, 255 types of, 252b–253b
406 Index
Judgment, patient, 70b, 73, 392t Jugular veins, 154 Jugular venous pressure, 154 Jugular venous pulsations, 154,
385
K Kaposi’s sarcoma, 95t Keloid, 91t Keratoses
actinic, 94t seborrheic, 94t
Kernig’s sign, 303 Kidneys, examination of, 190 Klinefelter’s syndrome, 221t Knee
anatomical considerations, 269 examination of, 269–274, 297 painful, 283t–284t
Knee reflex, 302 Koplik’s spots, 125t Korotkoff sounds, 159 Kussmaul breathing, 65t Kyphoscoliosis, thoracic, 145t
L Labia, 230 Labor, preterm, 367 Labyrinthitis, 101 Lachman test, 273 Language, 70b, 72 Language barrier, 43, 43b Laryngitis, 141t Laryngotracheobronchitis, 334b Last period start (LMP), 226 Lateral collateral ligament, 273,
284t Lateral meniscus, 272, 283t Lead-pipe rigidity, 316t Left ventricular heart failure, 139t,
143t, 146t, 147, 155, 159 Left ventricular hypertrophy, 155, 385 Legs
coldness, numbness, pallor on, 199
examination of, 203–204 flaccid, 306 hair loss on, 199 length measurement, 276 peripheral vascular disease and,
199–200, 203–204, 207t–210t swelling of, 200
Leopold’s maneuvers, 368, 370–371
Lesions brainstem, 101 corticospinal, 298 skin, 51, 87t–94t upper motor neuron, 301
Lethargy, 305 Leukocoria, 332 Leukonychia, 98t Leukoplakia, hairy, 123t Level of consciousness, 305b, 319t,
391t Lhermitte’s sign, 280t Libido, 212 Lichenification, 91t Lifestyle, in cardiovascular disease,
153, 153b Ligaments, 251
knee, 273–274, 284t Light reflex, 106b Lighting, 9 Likelihood ratio, 26b–27b Lips, 109, 122t Listening, active, 32 Literacy, low, 44 Liver
enlarged, 188–189, 342 examination of, 188–189 normal, 188 risk factors for disease, 183b
Lumbar spinal stenosis, 277t Lumbosacral radiculopathy, 304 Lungs
abscess of, 143t anterior, 12 cancer of, 140t, 143t concerning symptoms, 127–128 disorders of, 137t–140t, 146t examination of, 129–135 health history, 127–128 health promotion and counseling,
128 in infants, 334, 334b–335b in older adults, 385 posterior, 11 during pregnancy, 366 recording findings, 136b
Lymph nodes axillae, 172 cervical, 109 epitrochlear, 203 in infants, 333 inguinal, 203
Lymphadenopathy, 203, 333
Index 407
M Macular degeneration, 100, 102, 384 Macule, 87t Major depressive episode, 78t–79t Malabsorption syndrome, 195t Male genital examination, 211–217
anatomical considerations, 211 concerning symptoms, 211–213 examination techniques, 13, 214–217 health history, 211–213 recording findings, 217b sexually transmitted infections
(STIs) in, 213–214, 219t–220t testicular self-examination, 214
Male genitalia in adolescents, 345 in children, 343 examination of, 13 in infants, 336 in older adults, 387 in review of systems, 6 sexual maturity ratings for,
354t–355t Malignant melanoma, 96t Malocclusion, 342 Malodor, 385 Mammography, 168 Manic episode, 78t– 79t Masseter muscles, 259, 293 Maximal impulse, point of, 56,
155–156, 335, 366, 385 McBurney’s point, 192 McMurray test, 272 Medial collateral ligament, 273, 284t Medial meniscus, 272, 283t Melanoma, 96t, 383 Melena, 182 Memory
defined, 69b in delirium and dementia, 394t recent, 74 remote, 73
Ménière’s disease, 101 Meningeal signs, 303 Meningitis, 99, 113t, 303, 331 Meniscus of knee, 272, 283t Menopause, 226, 229 Menstrual history, 225 Mental health history, 45–46 Mental health screening, red flags
for, 68b Mental status, 67–82
in children, 338 concerning symptoms, 69
disorders of, 76t–82t examination of, 13, 71–75, 71b health history, 69–70 health promotion and counseling,
70–71 in infants, 329 recording findings, 75b red flags for mental health
screening, 68b unexplained symptoms and, 67,
67b–68b Metabolic syndrome, 152, 152b Methicillin-resistant Staphylococcus
aureus (MRSA) precautions, 14 Microcephaly, 331 Migraine headache, 100, 111t Mini-Cog exam, 290b, 393t Mini-Mental State Examination
(MMSE), 74, 75b Mitgehen, 316t Mitral regurgitation, 156–157, 386 Mitral stenosis, 139t, 143t, 147,
155b, 156–157 Mitral valve prolapse, 159 Mixed episode, 79t Mood
assessment of, 73, 391t defined, 70b disorders of, 78t–79t
Motor system (motor activity) assessment of, 13, 52, 72, 294–98 disorders of, 313t
Mouth abnormalities of, 122t–124t assessment of, 109 cancers of, 122t, 124t candidiasis of, 124t, 333 in children, 341–342 health history of, 102 in infants, 333 in older adults, 385 during pregnancy, 365
Movements, involuntary, 295, 313t, 314t–315t
MRSA precautions, 14 Multiple sclerosis, 296 Murmurs. See Heart murmurs Murphy’s sign, 193 Muscle bulk, 295, 313t Muscle strength
assessment of, 295–297, 295b in motor system disorders, 313t
Muscle tone, 313t assessment of, 295 disorders of, 316t
408 Index
Musculoskeletal system, 251–276 abnormalities of, 277t–281t in children, 344 concerning symptoms, 253–255 examination of, 11–12, 258–275,
258b health history, 253–255 health promotion and counseling,
256–258 in infants, 336–337 joint assessment, 251, 252b–253b in older adults, 388 recording findings, 276b in review of systems, 6
Myalgia, 255 Myasthenia gravis, 288, 295 Mycoplasma, 141t Myelopathy, cervical, 280t Myocardial infarction, 137t, 147, 180 Myoma, of uterus, 239t Myopathy, 288, 295 Myopia, 100 Myxedema, 103
N Naegele’s rule, 360–361 Nails
abnormalities of, 98t examination of, 85
Nasal congestion, 101 Nausea, 181 Near reaction, pupillary, 104 Neck
examination of, 11, 109–110 health history, 102 in infants, 333 pain in, 254, 279t–280t during pregnancy, 365 in review of systems, 5
Negative predictive value, 26b Nerves
cranial, 13, 286, 291b, 292–294 peripheral, 286–287 spinal, 287
Nervous system, 285–307 central, 285–286 in children, 344 concerning symptoms, 287–289 examination of, 12–13 health promotion and counseling,
289–290 in older adults, 388 peripheral, 286–387
recording findings, 307b in review of systems, 6
Neuralgias, cranial, 113t Neurologic screening, in newborns,
328 Neuropathic ulcers, 208t Neuropathy, peripheral, 290 Nevi, ABCDE screening for, 83, 96t Newborns
Apgar score, 326, 327b assessment of, 326–328 birth weight, 327b classification of, 327b–328b, 348t head circumference, 329 hypertension in, 330b
Night sweats, 49 Nipple
discharge of, 172 inspection of, 170 Paget’s disease of, 170, 177t retraction or deviation, 170, 176t
Nocturia, 184 Nose
assessment of, 108 bleeding from, 365 examination of, 11 health history of, 101–102 in infants, 333 in older adults, 384–385 during pregnancy, 365 recording findings, 110b in review of systems, 5
Numbness, 199 Nursing bottle caries, 341 Nutrients, sources of, 63t Nutrition
health promotion and counseling for, 50–51, 256
in older adults, 376 during pregnancy, 361 screening checklist, 62t sources of nutrients, 63t
Nystagmus, 332
O Obesity
body mass index (BMI) for, 52 in cardiovascular disease, 149b during pregnancy, 362b
Objective data, 2b Obsessive-compulsive disorder, 81t Obstetric history, 360 Obstructive pulmonary disease, 147
Index 409
Obtundation, 305 Obturator sign, 192 Occlusion, arterial, 202, 204, 387 Oculocephalic reflex, 306 Oculomotor nerve, 291b, 292 Odor, body and breath, 52 Odynophagia, 182 OLD CARTS mnemonics, 38 Older adults, 373–389
abuse of, 379 cancer screening in, 378 concerning symptoms, 375–377 cultural considerations, 374–375 delirium and dementia, 391t–392t examination of, 379–388 fall prevention in, 381–382 health history, 373–389, 373–377 health promotion and counseling,
377–379 Mini-Cog exam, 393t recording findings, 389b
Olfactory nerve, 291b, 292 Onycholysis, 98t Open-angle glaucoma, 100, 384 Ophthalmoscope, 105b OPQRST mnemonics, 38 Optic disc
abnormalities of, 118t examination of, 105–106,
106b–107b Optic nerve, 291b, 292 Optic neuritis, 101 Oral health, health promotion and
counseling, 103 Oral mucosa, 109 Oral temperature, 57–58 Oral-facial dyskinesias, 315t Orchitis, 221t Orgasm, 212 Orientation
assessment of, 73, 392t defined, 69b
Orthopnea, 147 Orthostatic hypotension, 154, 383 Ortolani test, 337 Osteoarthritis, 255, 262, 281t,
388 Osteopenia, 257b Osteoporosis, 256–257, 257b–258b Otitis externa, 101, 340 Otitis media, 101, 120t, 340–341 Ovaries
cancer of, 228, 387 examination of, 232, 369
Ovulation, 229
P Paget’s disease, of nipple, 170, 177t Pain
abdominal, 179–182, 197t acute, 376, 376b in arms and legs, 199 assessment of, 59–60 chest, 127, 137t–138t, 147 chronic, 59 in health history, 50 joint, 254–255, 254b, 281t knee, 283t–284t low back, 254, 256, 277t–278t neck, 254, 279t–280t in older adults, 376 persistent, 376, 376b sensation of, 299 shoulder, 282t
Pain management, 60 health disparities in, 59–60
Palliative care, 377 Pallor, 199 Palpitations, 147 Panic attack, 80t Panic disorder, 80t Pap smear, 230–231, 368, 387 Papilledema, 118t Papule, 87t Paradoxical pulse, 159 Paralysis
of face, 312t flaccid, 306
Paratonia, 316t Parietal pain, 180 Parkinsonism, 313t Paronychia, 98t Paroxysmal nocturnal dyspnea
(PND), 147 Paroxysmal supraventricular
tachycardia, 330, 335 Partnering with patient, 33–34 Partnerships, collaborative, 41 Patch, skin, 87t Patellofemoral compartment, 270 Patellofemoral disorder, 270, 283t Patient
with altered capacity, 42 angry or disruptive, 42–43 comfort of, 9 confusing, 41 crying, 42 dying, 47 empowerment of, 34, 34b with impaired hearing, 44
410 Index
Patient (continued) with impaired vision, 44 with language barrier, 43, 43b with limited intelligence, 44 with low literacy, 44 with personal problems, 44 perspective, 37, 37b positioning of, 8b, 10 seductive, 44–45 silent, 41 talkative, 42
Peau d’orange, 170, 177t Pectus carinatum (pigeon chest), 145t Pectus excavatum (funnel chest), 144t Pediatrics. See Children Pelvic examination, 229–232, 229b
in older adults, 386–387 during pregnancy, 368–369
Pelvic floor, 238t, 369 Pelvic inflammatory disease (PID),
181, 226, 232 Pelvic muscles, 232 Penis
abnormalities of, 218t cancer of, 218t in children and adolescents,
354t–355t discharge from, 213 examination of, 214
Perceptions, patient, 69b, 73, 392t Percussion, chest, 131, 131b, 135 Perforation, eardrum, 120t Pericardial friction, 156 Pericarditis, 137t, 159 Peripheral nerves, 286–287 Peripheral nervous system, 286–287,
313t Peripheral neuropathy, 290 Peripheral vascular disease, 200–201 Peripheral vascular system, 199–206
concerning symptoms, 199–200 disorders of, 199–201, 207t–208t examination of, 12, 202–206 health history, 199–200 health promotion and counseling,
200–201 in older adults, 387 recording findings, 206b in review of systems, 6
Peritonsillar abscess, 109, 342 Personal history, 2b, 4 Personal hygiene, 52, 72 Pes anserine bursitis, 271, 283t Petechia, 93t Peutz-Jeghers syndrome, 122t
Phalen’s sign, 266 Pharyngitis, 125t
streptococcal, 102, 341 Pharynx
abnormalities of, 125t in children, 341 examination of, 11, 102, 109 in infants, 333 in older adults, 384–385
Phimosis, 214 Phobias, types of, 80t Physical activity, 51, 256 Physical examination, 7–14
approach to, 7 in children, 338–344 general survey in, 51–52 health history in, 49–50 health promotion and counseling
in, 50–51 of older adults, 379–388 pain in, 59–60 patient positioning for, 8b, 10 during pregnancy, 364–371,
364b preparation for, 7b recording findings, 60 sequence for, 8b, 10 standard and universal precautions
in, 14 vital signs, 54–58
Physical status in children, 338 in infants, 329
Pigeon chest, 145t Pilar cyst, 103 Pilonidal cyst, 244 Pinguecula, 117t Plantar reflex, 303, 313t Plaque, skin, 88t Pleural effusion, 131, 146t Pleural pain, 138t Pleurisy, 180, 197t Pneumatic otoscope, 340 Pneumococcal vaccine, 128 Pneumonia, 140t–141t, 330, 334b Pneumothorax, 140t, 146t Point localization, 301 Point of maximal impulse, 385
assessment of, 56, 155–156 in children, 335 in older adults, 385 during pregnancy, 366
Polydactyly, 336 Polymyalgia rheumatica, 255 Polyneuropathy, 288, 295
Index 411
Polyps endocervical, 237t of rectum, 249t
Polyuria, 184 Popliteal cyst, 271, 284t Popliteal pulse, 204 Position sensation, 299–300 Positive predictive value, 26b Postconcussion headache, 114t Posterior cruciate ligament, 274 Posterior drawer sign, 274 Posterior tibial pulse, 204 Postictal state, 289 Postmenopausal bleeding, 226 Postnasal drip, 141t Posttraumatic stress disorder, 81t Postural hypotension, 154, 383 Postural tremor, 314t Posture, assessment of, 52, 72 Potassium, food sources of, 64t Precocious puberty, 343 Predictive value, 25b–26b
negative, 26b positive, 26b
Preeclampsia, 365b, 370 Pregnancy
amenorrhea due to, 226 concerning symptoms, 359–361 ectopic, 181, 369 examination during, 364–371, 364b family planning and, 229 health promotion and counseling,
361–364 hypertension during, 365b prenatal laboratory screenings,
363–364 recording findings, 372b symptoms of, 226
Premature ejaculation, 212 Prenatal visit
initial, 359–360 subsequent, 361
Prepatellar bursitis, 270, 283t Presbyopia, 100, 384 Prescription drug use. See Drug use Present illness, 2b, 3, 3b, 323 Pressure sores, 384 Presyncope, 287 Prevention
primary, 148 secondary, 148
Primary prevention, 148 Primitive reflexes, 337 Problem list, 30b Proctitis, 244
Professionalism, and ethics, 48, 48b Pronator drift, 298 Prostate
benign prostatic hyperplasia, 242, 246t–247t, 248t–249t
cancer of, 242–243, 249t, 378, 387 concerning symptoms, 241–242 examination of, 244–245 in older adults, 387 recording findings, 245
Prostate-specific antigen (PSA), 242–243
Prostatitis, 183–184, 249t Proximal weakness, 288 Pseudoscars, 383 Psoas sign, 192 Psoriasis, 88t, 103 Psychiatric disorders. See Mental status Psychotic disorders, 82t Pterygoid muscles, 259 Ptosis, 116t
senile, 384 Puberty
delayed, 230 precocious, 343
Pubic hair, 354t–356t Pulmonary embolism, 140t, 143t Pulmonary fibrosis, 140t Pulmonary function, assessment of,
135 Pulmonary tuberculosis, 142t Pulmonary valve atresia, 335 Pulmonary valve stenosis, 156, 335 Pulse
apical, 56, 155 brachial, 202 carotid, 154 in children, 330 dorsalis pedis, 204 femoral, 204 grading of, 202b in older adults, 386 paradoxical, 159 popliteal, 204 posterior tibial, 204 pulsus alternans, 159 radial, 56, 202
Pulse pressure, 382 Pulsus alternans, 159 Pupils
Argyll Robertson, 104 in comatose patient, 305–306,
319t, 321t examination of, 104 near reaction, 104
412 Index
Purpura, 93t Pustule, 89t Pyelonephritis, 183 Pyloric stenosis, 336 Pyrexia, defined, 57
Q Questioning
guided, 32–33, 32b open-ended, 36, 39
R Radial pulse, 56, 202 Radiculopathy
cervical, 279t, 296 lumbosacral, 304
Rales, 133b Range of motion (ROM)
ankle, 275 elbow, 262 hip, 268–269 measuring, 276 shoulder, 260 spine, 267 wrist and hands, 262, 264
Rapport, 35 Raynaud’s disease, 200, 202 Reasoning, clinical, 15–16 Reassurance, 33 Rebound tenderness, 188 Record, patient
checklist for, 27b–29b organizing, 27b–30b
Rectal examination, 13–14 in female, 245 in male, 244–245 in older adults, 387 during pregnancy, 369
Rectal thermometer, 58 Rectocele, 230, 238t, 368 Rectovaginal examination, 232,
387 Rectum
abnormalities of, 249t cancer of, 249t concerning symptoms, 241–242 examination of, 244–245 health history, 241–242 recording findings, 245
Red reflex, 105 Referred pain, 180, 278t Reflex esophagitis, 138t
Reflexes assessment of, 13, 301–303 corneal light, 339 cutaneous stimulation, 302–303 grading of, 301b in infants, 337 in motor system disorders, 313t during pregnancy, 370 primitive, 337
Reliability, 25b Renal artery disease, 201 Resonant percussion note, 131b Respiratory infection, upper, 334 Respiratory rate
abnormal, 65t assessment of, 57, 129 in children, 330 in comatose patient, 319t normal, 57, 65t in older adults, 383
Respiratory rhythm abnormal, 65t assessment of, 57, 129
Respiratory system, 127–136 anterior thorax, 12, 134–135 concerning symptoms, 127–128 disorders of, 137t–140t,
144t–146t examination of, 129–135 health history, 127–128 health promotion and counseling,
128 posterior thorax, 11, 130–134 recording findings, 136b in review of systems, 5
Reticular activating system, 286 Retina, examination of, 106b–107b Retinal detachment, 100–101 Retinoblastoma, 332 Retinopathy, diabetic, 119t Retroflexed uterus, 239t Retroverted uterus, 239t Review of systems, 2b, 4–7 Rheumatic fever, 254 Rheumatoid arthritis, 254–255,
262–263, 281t, 388 Rhinitis, 101 Rhinorrhea, 101 Rhonchi, 133b Right ventricular enlargement,
156 Rigidity, 316t Ringworm, 97t Rinne test, 108, 121t, 293 Romberg test, 298
Index 413
Rotator cuff, 259–260 tear, 260–261 tendinitis, 282t
Rovsing’s sign, 192
S Sacroiliitis, 254 Safety, 378 Salpingitis, 197t Sarcoidosis, 140t Sarcoma, Kaposi’s, 95t Scabies, 90t Scale, skin, 90t Scaphoid fracture, 263 Scapula, winging of, 304 Scar, 91t Schizoaffective disorder, 82t Schizophrenia, 82t Schizophreniform disorder, 82t Sciatica, 277t Scoliometer, 345 Scoliosis, assessment of, 345 Screening
for breast cancer, 168–169 for cardiovascular disease, 148–153 for cervical cancer, 228 in children, 325 for colorectal cancer, 243 for diabetes, 150b–151b for dyslipidemia, 151, 152b for hypertension, 150 in older adults, 377–378 for ovarian cancer, 228 prenatal laboratory, 363–364 for prostate cancer, 242–243 for skin cancer, 83, 96t
Scrotum abnormalities of, 218t edema of, 218t examination of, 215 in hernia, 218t
Seborrheic keratoses, 94t, 384 Secondary prevention, 148 Seizure, 289 Self-awareness, 40 Self-care capacity, in older adults, 390t Self-examination
breast, 169, 173b–174b testicular, 214, 216b–217b
Senile ptosis, 384 Sensitivity, statistical, 25b–26b Sensorineural hearing loss, 101, 121t,
293
Sensory system, assessment of, 13, 298–301
Serous effusion, 120t Sexual abuse, in children, 343, 357t Sexual history, 45 Sexual maturity ratings, in
adolescents, 353t–356t Sexually transmitted infections (STIs)
counseling for, 213–214, 228, 243 in females, 227–228, 231 in males, 213–214, 219t–220t
Short stature, 329 Shortness of breath, 128, 147 Shoulder
examination of, 259–261 painful, 282t
Signing breathing, 65t Sinuses
assessment of, 11, 108 health history of, 101–102 in review of systems, 5
Sinusitis, 112t Skene’s gland, 225, 368 Skin, 83–98
cancer of, 83, 94t–96t, 378 color of, 51, 86t concerning symptoms, 83 examination of, 10, 84–85 health promotion and counseling
for, 83 in infants, 331 lesions of, 51, 87t–94t nevi, 83, 96t in older adults, 383–384 recording findings, 85 in review of systems, 5 tags, 336
Skin cancer ABCDE screening for, 83, 96t in older adults, 378 types of, 95t–96t
Skin lesions assessment of, 51 primary, 87t–90t secondary, 90t–92t vascular and purpuric, 93t–94t
Smoking in cardiovascular disease, 153 in older adults, 376 during pregnancy, 362–363 readiness for cessation, 128b
Sneezing, 101 Social development, 324 Social history, 2b, 4 Social phobia, 80t
414 Index
Sodium, food sources of, 64t Somatoform disorders, 76t–78t Spasticity, 316t Specificity, statistical, 25b–26b Speculum examination, 230–231,
368 Speech
aphasia, 72b assessment of, 72 in delirium and dementia, 391t development of, 324
Spermatic cord, 215, 222t Spermatocele, 222t Spheroidal joints, 253b Spider angioma, 93t Spider vein, 93t Spinal accessory nerve, 291b, 294 Spinal cord, 286 Spinal nerve, 287 Spinal stenosis, 199
lumbar, 277t Spine, examination of, 266–267 Spleen, examination of, 189 Splenomegaly, 189 Spontaneous pneumothorax, 140t Sprains, 255, 274–275, 284t Squamous cell carcinoma, 95t, 383 Stance, assessment of, 298 Standard precautions, 14 Steatorrhea, 182 Stereognosis, 300 Sternomastoid muscles, 294 Stiffness
back, 278t joint, 255
Stool, 182–183 Strabismus, 332, 339 Straight leg rise, 304 Strep throat, 102 Stress disorder, acute, 81t Stridor, 129, 334b Stroke
face paralysis in, 312t prevention of, 289–290 types of, 308t–309t vascular territories of, 310t–311t
Structural coma, 319t Stupor, 305 Sty, 117t Subacromial bursitis, 282t Subarachnoid hemorrhage, 99–100,
113t, 287 Subdeltoid bursitis, 282t Subdural hematoma, 329 Subjective data, 2b
Substance abuse, 46, 71, 363 Subtalar joint, 275 Suicide risk, 71 Summarization, 34 Supernumerary teeth, 333 Supinator reflex, 302 Sutures, cranial, 331 Swallowing, 182 Swelling
of feet, 200 of infant head, 331 joint, 255 of legs, 200
Symptoms seven attributes of, 3b, 38b unexplained and mental status, 67,
67b–68b Syncope, 288 Syndactyly, 336 Synovial joints, 252b–253b Syphilis
female genital, 234t lip, 122t male genital, 220t primary, 220t, 234t secondary, 234t tongue, 124t
Systemic lupus erythematosus (SLE), 255
Systems review, 2b, 4–7 Systolic hypertension, isolated, 56,
382 Systolic murmur, 159
T Tachycardia, paroxysmal
supraventricular, 330 Tachypnea, 65t Tactile fremitus, 130 Talocalcaneal joint, 275 Tangential lighting, 9 Tavistock principles, 48b Teeth, 109
in children, 341–342 supernumerary, 333
Telangiectasia, hereditary hemorrhagic, 122t
Temperature, body, assessment of, 57–58
Temperature sensation, 299 Temporal muscles, 259, 293 Temporomandibular joint,
examination of, 259
Index 415
Tendonitis, 255 of shoulder, 282t
Tendons, 251 10-Minute Geriatric Screener, 378,
380b–381b Tenosynovitis, 264 Tension headache, 99, 111t Terry’s nails, 98t Testes
abnormalities of, 221t cancer of, 221t examination of, 215 sexual maturity ratings, 354t–355t small, 221t undescended, 336
Testicular self-examination, 214, 216b–217b
Tetralogy of Fallot, 351t–352t Thalamus, 285 Thermometers, 58 Thorax (chest), 127–136
anterior, 12, 134–135 concerning symptoms, 127–128 deformities of, 144t–145t disorders of, 137t–140t,
144t–146t examination of, 129–135 health history, 127–128 health promotion and counseling,
128 in infants, 334, 334b–335b in older adults, 385 posterior, 11, 130–134 during pregnancy, 366 recording findings, 136b
Thought content assessment of, 73, 392t defined, 69b
Thought processes assessment of, 73, 391t defined, 69b
Throat abnormalities of, 125t in children, 333, 341–342 examination of, 11, 102, 109 health history, 102 in older adults, 384–385 recording findings, 110b in review of systems, 5 sore, 102, 125t
Thromboangiitis obliterans, 202 Thrombophlebitis, 203 Thrush, 333 Thumbs, examination of,
264–265
Thyroid gland abnormalities of, 126t examination of, 110 in health history, 102 during pregnancy, 365
TIA (transient ischemic attack), 288, 289
Tibia, torsion of the, 337 Tibial pulse, posterior, 204 Tibiofemoral joint, 270 Tibiotalar joint, 275 Tics, 315t Tinea capitis, 97t Tinnitus, 101 Tinsel’s sign, 265 Tobacco use. See Smoking Tongue
abnormalities of, 123t–124t assessment of, 109 in children, 333, 341
Tonsillitis, 109 Tonsils, 109, 342 Torsion of spermatic cord, 222t Torsion of the tibia, 337 Torticollis, 279t Tortuous atherosclerotic aorta,
385 Total anomalous pulmonary venous
return, 335 Touch sensation, 299 Toxic-metabolic coma, 319t Tracheal breath sounds, 132b Tracheobronchitis, 138t, 141t Transient ischemic attack (TIA),
288, 289 Transmitted voice sounds, 133,
133b Transposition of the great arteries,
335, 352t Transverse tarsal joint, 275 Trapezius muscles, 294 Traumatic flail chest, 144t Tremors, 314t
essential, 388 in older adults, 388
Triceps reflex, 301 Trichomonas vaginitis, 235t Trichotillomania, 97t Tricuspid regurgitation, 154 Trigeminal nerve, 291b, 292–293 Trigeminal neuralgia, 113t Trigger finger, 264 Trochanteric bursa, 268 Tuberculosis, pulmonary, 142t Tug test, 107
416 Index
Tumors androgen-producing, 386 of brain, 99–100, 113t estrogen-producing, 387 skin, 94t–95t of testis, 321t
Turgor, skin, 84, 331 Two-point discrimination, 300 Tympanic membrane temperature, 58 Tympanic percussion note, 131b Tympanosclerosis, 120t
U Ulcerative colitis, 195t Ulcers
aphthous, 124t arterial insufficiency, 208t of feet and ankles, 208t neuropathic, 208t of skin, 92t, 384 venous insufficiency, 208t
Umbilical cord, 328 Umbilical hernia, 328 Universal precautions, 14 Upper motor neuron lesion, 301 Urethral caruncle, 230 Urethral orifice, 230 Urethritis, 183–184, 213, 230 Urinary frequency, 183 Urinary incontinence, types of, 184,
196t–197t Urinary system
concerning symptoms, 179b examination of, 183–184 in review of systems, 6
Urinary urgency, 183 Urination, 183–184 Urine, 183 Uterus
bicornuate, 369 examination of, 232 myoma of, 239t positions of, 239t during pregnancy, 367, 369 prolapsed, 238t
V Vagina
adenosis of, 237t discharge from, 226, 235t, 343 examination of, 231–232
Vaginitis, 235t, 343
Vaginosis, 235t Vagus nerve, 291b, 294 Validation, 33 Validity, test, 25b Valsalva maneuver, 159 Values, defined, 40 Varicocele, 215, 222t Varicose veins, 204, 370 Vasovagal (vasodepressor) syncope,
288 Veins
jugular, 154 spider, 93t varicose, 124t, 204, 370
Venereal warts, 219t, 233t Venous insufficiency, 207t–208t Venous stasis ulcers, 200 Ventricular heart failure, left, 139t,
143t, 146t, 147, 155, 159 Ventricular hypertrophy
left, 155, 385 right, 156
Ventricular septal defect, 352t Vertigo, 101, 287 Vesicle, 89t Vesicular breath sounds, 132b Vibration sensation, 299–300 Visceral pain, 179 Vision
in children, 339, 340b disorders of, 102–103, 112t, 115t headaches and, 112t health promotion and counseling
for, 102–103 in infants, 332, 332b interviewing patient with
impairment, 44 in older adults, 384
Visual field defects, 115t Vital signs
assessment of, 10, 54–58 blood pressure, 54–56 in children, 330, 339 functional status, 379–380 heart rate and rhythm, 56–57 in older adults, 382–383 during pregnancy, 365 recording findings, 60 respiratory rate and rhythm, 57 temperature, 57–58
Vitamin D food sources of, 63t recommended dietary intake for,
258b Vitreous floaters, 101
Index 417
Vitreous hemorrhage, 100 Vocabulary, assessment of, 74 Voice sounds, transmitted, 133, 133b Vomiting, 181 Vulva, 233t–234t Vulvovaginitis, 183
W Warts, genital, 219t, 233t Weakness, 49, 288 Weaver’s bottom, 268 Weber test, 108, 121t, 293 Weight
assessment of, 52–53 body mass index (BMI) and, 52–54 changes in, 50
in children, 338 health history, 50 in infants, 329 in older adults, 383 optimal, 50–51 during pregnancy, 361, 362b
Wheal, 88t Wheezes, 129, 133b Whiplash, 279t Whispered pectoriloquy, 133, 133b White matter, 285 Winging of scapula, 304 Wrist, 262, 264, 296
X Xanthelasma, 117t
- Bates' Pocket Guide to Physical Examination and History Taking
- Half Title Page
- Title Page
- Copyright
- Dedication
- Introduction
- Contents
- Chapter 1: Overview: Physical Examination and History Taking
- The Comprehensive Adult Health History
- CHIEF COMPLAINT(S)
- PRESENT ILLNESS
- HISTORY
- FAMILY HISTORY
- PERSONAL AND SOCIAL HISTORY
- REVIEW OF SYSTEMS (ROS)
- The Physical Examination: Approach and Overview
- BEGINNING THE EXAMINATION: SETTING THE STAGE
- The Comprehensive Adult Physical Examination
- Standard and Universal Precautions
- Chapter 2: Clinical Reasoning, Assessment, and Recording Your Findings
- Assessment and Plan: the Process of Clinical Reasoning
- The Case of Mrs. N
- Approaching the Challenges of Clinical Data
- Organizing the Patient Record
- Chapter 3: Interviewing and the Health History
- The Fundamentals of Skilled Interviewing
- The Sequence and Context of the Interview
- PREPARATION
- THE SEQUENCE OF THE INTERVIEW
- THE CULTURAL CONTEXT OF THE INTERVIEW
- Advanced Interviewing
- CHALLENGING PATIENTS
- SENSITIVE TOPICS
- Ethics and Professionalism
- Chapter 4: Beginning the Physical Examination: General Survey, Vital Signs, and Pain
- The Health History
- Health Promotion and Counseling: Evidence and Recommendations
- Techniques of Examination
- THE VITAL SIGNS: BLOOD PRESSURE, HEART RATE, RESPIRATORY RATE, AND TEMPERATURE
- ACUTE AND CHRONIC PAIN
- Recording Your Findings
- Aids to Interpretation
- Chapter 5: Behavior and Mental Status
- The Health History
- Health Promotion and Counseling: Evidence and Recommendations
- Techniques of Examination
- SPECIAL TECHNIQUE
- Recording Your Findings
- Aids to Interpretation
- Chapter 6: The Skin, Hair, and Nails
- The Health History
- Health Promotion and Counseling: Evidence and Recommendations
- Techniques of Examination
- Recording Your Findings
- Aids to Interpretation
- Chapter 7: The Head and Neck
- The Health History
- Health Promotion and Counseling: Evidence and Recommendations
- Techniques of Examination
- Recording Your Findings
- Aids to Interpretation
- Chapter 8: The Thorax and Lungs
- The Health History
- Health Promotion and Counseling: Evidence and Recommendations
- Techniques of Examination
- SPECIAL TECHNIQUES
- Recording Your Findings
- Aids to Interpretation
- Chapter 9: The Cardiovascular System
- The Health History
- Health Promotion and Counseling: Evidence and Recommendations
- Techniques of Examination
- SPECIAL TECHNIQUES
- Recording Your Findings
- Aids to Interpretation
- Chapter 10: The Breasts and Axillae
- The Health History
- Health Promotion and Counseling: Evidence and Recommendations
- Techniques of Examination
- SPECIAL TECHNIQUE
- Recording Your Findings
- Aids to Interpretation
- Chapter 11: The Abdomen
- The Health History
- Health Promotion and Counseling: Evidence and Recommendations
- Techniques of Examination
- Recording Your Findings
- Aids to Interpretation
- Chapter 12: The Peripheral Vascular System
- The Health History
- Health Promotion and Counseling: Evidence and Recommendations
- Techniques of Examination
- SPECIAL TECHNIQUES
- Recording Your Findings
- Aids to Interpretation
- Chapter 13: Male Genitalia and Hernias
- The Health History
- Health Promotion and Counseling: Evidence and Recommendations
- Techniques of Examination
- SPECIAL TECHNIQUE
- Recording Your Findings
- Aids to Interpretation
- Chapter 14: Female Genitalia
- The Health History
- Health Promotion and Counseling: Evidence and Recommendations
- Techniques of Examination
- SPECIAL TECHNIQUE
- Recording Your Findings
- Aids to Interpretation
- Chapter 15: The Anus, Rectum, and Prostate
- The Health History
- Health Promotion and Counseling: Evidence and Recommendations
- Techniques of Examination
- Recording Your Findings
- Aids to Interpretation
- Chapter 16: The Musculoskeletal System
- Fundamentals for Assessing Joints
- The Health History
- Health Promotion and Counseling: Evidence and Recommendations
- Techniques of Examination
- SPECIAL TECHNIQUES
- Recording Your Findings
- Aids to Interpretation
- Chapter 17: The Nervous System
- Fundamentals for Assessing the Nervous System
- CENTRAL NERVOUS SYSTEM
- PERIPHERAL NERVOUS SYSTEM
- The Health History
- Health Promotion and Counseling: Evidence and Recommendations
- Techniques of Examination
- SPECIAL TECHNIQUES
- Recording Your Findings
- Aids to Interpretation
- Chapter 18: Assessing Children: Infancy Through Adolescence
- Child Development
- The Health History
- Health Promotion and Counseling: Evidence and Recommendations
- Techniques of Examination
- Assessing Newborns
- Assessment Several Hours After Birth
- Assessing Infants
- Assessing Children (1 to 10 Years)
- SPECIAL TECHNIQUE
- Assessing Adolescents
- SPECIAL TECHNIQUE
- Recording Your Findings
- Aids to Interpretation
- Chapter 19: The Pregnant Woman
- The Health History
- Health Promotion and Counseling: Evidence and Recommendations
- Techniques of Examination
- SPECIAL TECHNIQUES
- Recording Your Findings
- Chapter 20: The Older Adult
- The Health History
- APPROACH TO THE PATIENT
- COMMON CONCERNS
- Health Promotion and Counseling: Evidence and Recommendations
- Techniques of Examination
- ASSESSING FUNCTIONAL STATUS: THE “SIXTH VITAL SIGN”
- Recording Your Findings
- Aids to Interpretation
- Index
<Project 1>
User Interface Design
<Version>
<Date>
<Your Name>
Table of Contents
1. Introduction 1
1.1 Purpose 1
1.2 Scope 1
1.3 Reference Document 1
1.4 Terms, Abbreviations and acronyms 1
2. Graphical Interface Design 1
2.1 <Module 1> 1
2.1.1 <Screen 1> 1
2.1.2 <Screen 2> 1
2.2 <Module 2> 2
2.2.1 <Screen 3> 2
2.2.2 <Screen 4> 2
<Project 1>
User Interface Design Document Page 2
1. Introduction
1.1 Purpose
Give a brief description of the purpose of this document.
Please note: All areas of the document that include words between < > are implied that they will be replaces with the appropriate terms. For example, replace <Project 1> with the name of the project.
1.2 Scope
Define the scope of the interface design. This could include the application or modules within the application.
1.3 Reference Document
If there are any document reference, include requirement documents, reference them there.
1.4 Terms, Abbreviations and acronyms
If this domain has any special terms, abbreviations or anonyms, list them here with their definitions.
2. Graphical Interface Design
Logically decompose your application’s UI into logical units. For last applications this might be modules of the application. For very small programs this might simple be screens. This will be organized on the 2.x level of the document. You may copy and paste to get as many 2.x subsections of the template as you need.
2.1 <Module 1>
Rename <Module 1> to be the logical name of this module. For each screen create a 2.x.y level of the document. You may copy and paste to get as many 2.x.y subsections of the template as you need.
2.1.1 <Screen 1>
Screen Name: Give a logical name for the screen.
Image: Put an image of the screen.
Internal UI functionality: Explain all relevant internal UI functionality. Include images with parts of screens if needed. For example, if the user clicks a specific button a drop-box gets populated. This example is functionality internal to the screen that is relevant to UI.
External UI functionality: Explain all relevant external UI functionality. This includes UI features that interact with application functionality outside for the screen. For example, when the user clicks a specific button another window opens.
2.1.2 <Screen 2>
Screen Name:
Image:
Internal UI functionality:
External UI functionality:
2.2 <Module 2>
2.2.1 <Screen 3>
Screen Name:
Image:
Internal UI functionality:
External UI functionality:
2.2.2 <Screen 4>
Screen Name:
Image:
Internal UI functionality:
External UI functionality:
Description
In your job you are to build the Maryland State Police Vehicle of Interest user interface, your first assignment will be to create a design document for the desktop part of the application. This will be used by users at the headquarters. Make sure to review the Vehicles of Interest Introduction and requirements document that outlines the major features of the application
Vehicles of Interest Background information.
You are employed in the Information Technology department of the Maryland State Police. Your department is working on modernizing law enforcement duties.
You have been assigned to a project called Vehicles of Interest (VOI). There are many reasons that law enforcement might be interested in identifying a Maryland registered vehicle. Some of the reasons are:
Silver Alert – vehicle is associated to a missing elderly person.
Amber Alert – vehicle is associated to a missing child.
Stolen – vehicle has been report stolen.
Arrest Warrant – the owner of the vehicle has an active arrest warrant.
After the program is deployed there might be additional reasons that need to be added.
Group of users.
There are three general groups of users that all have special user interface needs.
Headquarters – User’s at the police headquarters receive all information about what vehicles are of interest to the police department. They will need to perform all functions of the system. They are centrally located at the headquarters and would like a desktop application.
Police Departments from other States – Sometimes police departments from other states want to check (ie read-only) the vehicle list. This often happens after they arrest someone. This will be from their police station, which could be anywhere in the United States. They would like a web interface.
Maryland State Troopers – Maryland State Troopers need access (ie read-only) to the list during traffic stops. They would like a mobile interface.
High Level Requirements:
Here is a list of high level requirements for this project.
The system shall track the reason for interest. This will start with values and descripts shown in the table above (Silver Alert, Amber Alert, etc). Headquarters can add, edit and delete this reason. For reason for interest, it contains data for the reason and a description of the reason.
The system shall track the vehicles of interest. Headquarters can add, edit and delete from this list. Police Departments from other States and Maryland State Troopers can read the list. For vehicle of interest, it contains data for license plate number, make, model, color, year manufactured, owners name and owners’ phone. Sometimes we don’t know the year, color and owner’s information; so, they are optional fields.
The Headquarters users also have to keep up-to-date the list of vehicle makes and model.
You should not build any type of login screen(s) or implement roles. You can assume that will be done by another developer once you have finished
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