Inspect the Eyes

The presence of yellowish plaques on the eyelids, called xanthelasma, should raise the suspicion of an underlying hyperlipoproteinemia, even though this lesion is less specific than the xanthoma. Xanthelasma in a patient with hypercholesterolemia is shown in Figure 14-18. Examination of the eyes may reveal an arcus senilis. An arcus (see Figs. 10-53 and 10-54) seen in a patient younger than 40 years should raise the suspicion of hypercholesterolemia. Opacities in the cornea may be evidence for...

Auditory Acuity Testing

Testing for auditory acuity is the next part of the physical examination. The easiest method of testing for a gross hearing loss is for the examiner to occlude one external canal by pressing inward on the tragus and to speak softly into the other ear. The examiner should hide his or her mouth to prevent lip reading by the patient. The examiner should whisper words such as ''park,'' ''dark,'' or ''daydream'' in the nonoccluded ear and determine whether the patient can hear them. This procedure...

Sleep Apnea

The sleep apnea syndrome is a potentially disabling condition characterized by excessive daytime fatigue or sleepiness, disruptive snoring, episodes of upper airway obstruction during sleep, and nocturnal hypoxemia. During sleep, the pharynx repeatedly collapses. The patient *Splinting means making the chest muscles rigid to avoid motion of that part of the chest. struggles to breathe against the closed airway, which results in hypoxemia. The patient eventually awakens from sleep the posterior...

Snoring

An important problem often associated with heavy snoring is obstructive sleep apnea. Many affected patients are overweight and have a history of excessive daytime sleepiness. A bed partner may describe the patient as at first sleeping quietly then a transition occurs to louder snoring, followed by a period of cessation of snoring, during which time the patient becomes restless, has gasping motions, and appears to be struggling for breath. This period is terminated...

The Patient with Cancer

The patient with cancer has five major concerns loss of control, pain, alienation, mutilation, and mortality. Loss of control makes this patient feel helpless. The knowledge of something growing uncontrolled within a patient's body creates frustration, fear, and anger. Suffering with pain is one of the most feared aspects of cancer. The feeling of alienation stems from the reactions of people around the patient. Fears of mutilation are common among patients with cancer. The fear of being...

Screening Guidelines for Early Detection of Cancer of the Breast

The National Cancer Institute recommends that women begin receiving screening mammograms every 1 to 2 years starting at 40 years of age and every year once they reach 50 years of age, continuing for as long as a woman is in good health. Screening mammography involves taking low-dose radiographs from two views of each breast, typically from above (craniocaudal view) and from an oblique or angled position (mediolateral-oblique view). Mammography can detect approximately 85 of breast cancers. If...

Bibliography

Adelman RD, Greene MG, Charon R Issues in physician-elderly patient interaction. Ageing Soc 11 127, 1991. Adler G The physician and the hypochondriacal patient. N Engl J Med 304 1394, 1981. American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders, 3rd ed. Washington, DC, American Psychiatric Press, 1980. Cassem NH, Hackett TP Psychological aspects of myocardial infarction. Med Clin North Am 61 711, 1977. Catalano RA, Kessell ER, McConnell W, et al Psychiatric...

Description of Lesions

If a skin lesion is found, it should be classified as a primary or secondary lesion, and its shape and distribution should be described. Primary lesions arise from normal skin. They result from anatomic changes in the epidermis, dermis, or subcutaneous tissue. The primary lesion is the most characteristic lesion of the skin disorder. Secondary lesions result from changes in the primary lesion. They develop during the course of the cutaneous disease. The first step in identifying a skin disorder...

Diagnostic Reasoning from Signs and Symptoms

Unfortunately, decisions in medicine can rarely be made with 100 certainty. Probability weights the decision. Only if the cluster of symptoms, signs, and test results is unequivocal can the clinician be certain of a diagnosis. This does not occur often. How, then, can the clinician make the ''best'' decision best in light of current knowledge and research Laboratory tests immediately come to mind. But signs and symptoms obtained from the patient's history and physical examination perform the...

Dyspnea

The subjective sensation of ''shortness of breath'' is dyspnea. Dyspnea is an important manifestation of cardiopulmonary disease, although it is found in other states such as neurologic, metabolic, and psychologic conditions. It is important to differentiate dyspnea from the objective finding of tachypnea, or rapid breathing. A patient may be observed to be breathing rapidly while stating that he or she is not short of breath. The converse is also true a patient may be breathing slowly but have...

Dysuria

Pain on urination, called dysuria, is frequently described as ''burning.'' Dysuria is evidence of inflammation of the lower urinary tract. The patient may describe discomfort in the penis or in the suprapubic area. Dysuria also implies difficulty in urination. This may result from external meatal stenosis or from a urethral stricture. Painful urination is usually associated with urinary frequency and urgency. When the patient describes pain or difficulty in urination, ask the following...

Evaluate General Appearance

The general appearance of the patient often furnishes valuable information as to the nature of the condition. Patients with renal or biliary colic writhe in bed. They squirm constantly and can find no comfortable position. In contrast, patients with peritonitis, who have intense pain on movement, characteristically remain still in bed because any slight motion worsens the pain. They may be lying in bed with their knees drawn up to help relax the abdominal muscles and reduce intra-abdominal...

Examination of the Newborn

When examining the newborn, you are trying to answer three questions 1. How well is this infant making the transition to extrauterine life 2. Is there any evidence of birth trauma 3. Does this infant have any evidence of congenital malformations The newborn is assessed in the delivery room immediately after birth to determine the integrity of the cardiopulmonary system. The infant is dried with a towel and placed on a warming table, where the initial examination is conducted. Gloves are worn...

Eye Pain

Eye pain may result from a variety of causes. Ask the patient the following questions ''Can you describe the pain ''Did the pain come on suddenly '' ''Does the light bother your eye '' ''Do you have pain when you blink '' ''Do you have the sensation of something in the eye '' Do you have headaches '' ''Do you have pain on movement of the eye '' ''Do you have pain over the brow on the same side '' ''Do you wear contact lenses '' Pain may be experienced as ''burning,'' aching, throbbing,...

Gait Disturbance

Gait disturbances may occur for a variety of reasons. Gait may be changed by local pain in the foot, pain in a joint, claudication of the hip or leg, bone disease, vestibular problems, and extrapyramidal disorders. Interruption of the corticospinal tracts in the cerebrum after a stroke produces a spastic weakness in the contralateral leg. The foot is dragged, and the whole leg appears stiff and extended. Lesions in the spinal cord may produce a spastic paralysis affecting both legs. The gait is...

General Considerations

In the United States, the National Cancer Institute estimates that one of every eight women (approximately 12.5 ) will develop breast cancer during her lifetime. Among the malignant diseases in women, breast cancer is the most common to develop and is the second most common cancer cause of death. In 2007, it accounted for 31 of new cancer cases in American women, and 15 of cancer deaths there were 180,510 new cases of invasive breast cancer (stages I to IV) and 40,910 related deaths in the...

Genital Rashes

They may be confusing to identify and are often difficult to treat. Some rashes may occur exclusively on the genitalia others, which are typically found on other parts of the body, have an atypical appearance when present on the genitalia. The skin over the genitalia is thin and moist, so typical dry scaliness may not be present. The most common inflammatory reaction affecting the male genitalia is psoriasis. The patient develops bright red, well-defined,...

Info

Figure 20-22 Range of motion at the lumbar spine. A, Flexion and extension. B, Rotation. C, Lateral extension. ''What kinds of medications have you taken to relieve the pain '' ''Have you noticed that the pain changes according to the weather '' ''Do you have any difficulty putting on your shoes or coat '' ''Does the pain ever awaken you from sleep '' ''Does the pain shoot to another part of your body '' ''Have you noticed that the pain moves from one joint to another '' ''Has there been any...

Inspect the Buccal Mucosa

The patient should be asked to open the mouth widely. The mouth should be illuminated with a light source. The buccal mucosa must be evaluated for any lesions or color changes, and the buccal cavity is inspected for any evidence of asymmetry or areas of injection (dilated vessels, usually indicative of inflammation). The buccal mucosa, teeth, and gingivae are easily evaluated by using a tongue depressor to retract the cheek away from the gums, as shown in Figure 12-14. The examiner should...

Inspect the External Meatus

The examiner should note the position of the external urethral meatus. It should be central on the glans. To inspect the meatus, the examiner places his or her hands on either side of the glans penis and opens the meatus. The technique for examining the meatus is demonstrated in Figure 18-20. The meatus should be observed for any discharge, warts, and stenosis. Figure 18-21 shows a patient with meatal condylomata acuminata. On occasion, the urethral meatus opens on the ventral surface of the...

Inspect the Facies

Abnormalities of the heart may also be associated with peculiarities of the face and head. Supravalvular aortic stenosis, a congenital problem, occurs in association with widely set eyes, strabismus, low-set ears, an upturned nose, and hypoplasia of the mandible. Moon facies and widely spaced eyes are suggestive of pulmonic stenosis. Expressionless facies with puffy eyelids and loss of the outer third of the eyebrow is seen in hypothyroidism. Affected individuals may have a cardiomyopathy. The...

Inspect the Gingivae

Normal gingivae are stippled, pink, and firm. Does the gingival tissue completely occupy the interdental space Are the roots of the teeth visible, indicating recession of the periodontal tissue Is there pus or blood along the gingival margin Are the gingivae swollen Is there Figure 12-19 Angiokeratomas of the buccal mucosa. Figure 12-20 Erythroplakia of the gingiva (right). evidence of bleeding Is gingival inflammation present Is abnormal coloration present Erythroplakia is an area of mucous...

Inspect the Skin

Inspect the skin and sclera for jaundice. Whenever possible, the patient should be evaluated for jaundice in natural light because incandescent light frequently masks the existence of icterus. Jaundice becomes apparent when the serum bilirubin level exceeds 2.5 mg dL in adults or 6 mg dL in neonates. Figure 17-5 shows a patient with jaundice. Notice the scleral icterus as well as the yellow discoloration of the skin. Hyperbilirubinemia can also result in intense generalized pruritus. Inspect...

Inspect the Superficial Veins

The venous pattern of the abdomen is usually barely perceptible. If it is visible in the normal individual, the drainage of the lower two thirds of the abdomen is downward. In the presence of vena caval obstruction, superficial veins may dilate, and the veins drain cephalad (toward the head). In patients with portal hypertension, the dilated veins appear to radiate from the Figure 17-13 Ascites with umbilical hernia. Figure 17-13 Ascites with umbilical hernia.

Inspect the Tonsils

Tonsillar enlargement results from infection or tumor. In chronic tonsillar infection, the deep tonsillar crypts may contain cheeselike debris. Figure 12-41 shows enormous tonsillar enlargement, known as ''kissing tonsils.'' Figure 12-42 depicts massive tonsillar enlargement in a patient with infectious mononucleosis the cheeselike deposit in the tonsillar crypts is visible. Is a pseudomembranous patch or membrane present over the tonsils A membrane is associated with...

Liver Palpation

To perform palpation of the liver, place your left hand posteriorly between the patient's right 12th rib and the iliac crest, lateral to the paraspinal muscles. Place your right hand in the patient's right upper quadrant parallel and lateral to the rectus muscles and below the area of liver dullness. The patient is instructed to take a deep breath as you press inward and upward with your right hand and pull upward with your left hand. You may feel the liver edge slipping over the fingertips of...

Mass or Swelling

During self-examination, a patient may discover a breast mass. Ask the following questions ''When did you first notice the lump '' ''Have you noticed that the mass changes in size during your menstrual periods '' ''Is the mass tender '' ''Have you ever noticed a mass in your breast before '' ''Have you noticed any skin changes on the breast '' ''Have you had any recent injury to the breast '' ''Is there any nipple discharge nipple retraction '' ''Do you have breast implants '' If yes, ' 'What...

Mouth and Pharynx

The evaluation of the mouth and pharynx is usually the last part of the examination of the small child. Inspect the lips for any lesions and color. Tell the child, ''Open your mouth. I am going to count your teeth.'' Inspect the teeth for number and caries. The first lower molars erupt at about 1 year of age. These are followed by Figure 24-42 A, Milk caries. B, Periapical abcesses secondary to carious destruction. Figure 24-42 A, Milk caries. B, Periapical abcesses secondary to carious...

Musculoskeletal Examination

The purpose of the musculoskeletal examination of the newborn is to detect gross abnormalities. The appearance of the extremities at birth usually reflects the positioning of the child within the uterus, known as intrauterine packing. Inspect the extremities and digits. Are all four extremities and 20 digits present Polydactyly, the presence of one or more extra digits, is fairly common. It may be inherited as an autosomal dominant trait or may be part of a more complex multiple malformation...

Nausea and Vomiting

Vomiting may be caused by severe irritation of the peritoneum resulting from the perforation of an abdominal organ from obstruction of the bile duct, ureter, or intestine or from toxins. Vomiting resulting from a perforation is rarely massive. Obstruction of the bile duct or other tube produces stretching of the muscular wall, resulting in episodic vomiting that occurs at the height of the pain. Intestinal obstruction prevents the intestinal contents from passing distally consequently, vomiting...

Neck Mass

Diagnosis Neck Masses

The most common symptom is a lump or swelling in the neck. Once a patient complains of a neck lump, ask the following questions ''When did you first notice the lump '' ''Does it hurt '' ''Have you had any ear infections Infections in your mouth '' ''Has there been hoarseness associated with the mass '' ''Is there a family history of thyroid cancer '' ' 'Is there a history of prior neck or thyroid gland radiation '' Figure 9-5 Lymph nodes of the neck and their drainage. If there is associated...

Neck Stiffness

Stiffness of the neck is usually caused by spasm of the cervical muscles and is commonly the cause of tension headache. The sudden occurrence of stiff neck, fever, and headache should raise suspicion of possible meningeal irritation. Neck pain may be associated with *A thyroglossal cyst may arise anywhere along the route of the thyroid gland's descent from the foramen cecum of the tongue to its adult location in the neck. See Figure 24-41. The thyroid gland is a painless, mobile structure that...

Neuromuscular Maturity

Figure 24-3 Ballard Clinical Assessment. (Reprinted with permission from Ballard J, Novak K, Driver M A simplified score for assessment of fetal maturation of newly born infants. J Pediatr 95 769, 1979.) Following are some notes on techniques for assessing the neurologic criteria Posture Observed with infant quiet and in supine position. Score 0, arms and legs extended 1, beginning of flexion of hips and knees, arms extended 2, stronger flexion of legs, arms extended 3, arms slightly flexed,...

Nutrition

Nutrition is central to the child's well-being. Getting a complete nutritional history not only helps you monitor the child's health but may also help you make the diagnosis of an acute problem. Ask the following questions ' 'Is the child being breast-fed '' If yes, ' 'How often For how long at each feeding Is vitamin D or supplemental fluoride being given '' ''How many ounces of formula is the baby given a day What kind of formula do you feed How do you prepare it '' ''When did you introduce...

Occupational and Environmental History

The occupational and environmental history concerns exposure to potential disease-producing substances or environments. Occupational exposures account for an estimated 50,000 to 70,000 deaths annually in the United States. More than 350,000 new cases of occupational disease are recognized each year. These diseases can involve every organ system. Because they often mimic other diseases, occupational diseases may be incorrectly ascribed to some other cause. One of the important barriers to the...

Palpate the Abdominal Aorta

AAAs kill approximately 10,000 people in the United States each year. Many of these deaths could be prevented if the patients were aware of the presence of this defect. Once the defect is recognized, the rate of operative mortality for a nonruptured aneurysm is less than 5 , and after operation, the survival rate equals that of the general population. An AAA that ruptures carries a mortality rate of nearly 90 . Even among patients who reach the operating room alive, the surgical mortality rate...

Palpate the Epididymis and Vas Deferens

Next, locate and palpate the epididymis on the posterior aspect of the testicle. The head and tail should be carefully palpated for tenderness, nodularity, and masses. The spermatic cord is palpated from the epididymis up to the external abdominal ring. The patient is asked to elevate his penis gently. If the penis is elevated too much, the scrotal skin is reduced, and the examination is more difficult. Hold the scrotum in the midline by placing both your thumbs in front of and both your index...

Palpate the External Ear Structures

Palpate the pinna for tenderness, swelling, or nodules. If pain is elicited by pulling up and down on the pinna or by pressing in on the tragus, an infection of the external canal is probably present. Inspect the posterior auricular region for scars or swelling. Apply pressure to the mastoid tip, which should be painless. Tenderness may indicate a suppurative process of the mastoid bone. Figure 11-11 Squamous cell carcinoma (on the right) and malignant melanoma (on the left) of lobule. Figure...

Palpate the Popliteal Pulse

The popliteal artery is often difficult to assess. Each artery is evaluated separately. While the patient is lying on the back, the examiner's thumbs are placed on the patella, and the remaining fingers of both hands are pressed in the popliteal fossa medial to the lateral biceps femoris tendon, as demonstrated in Figure 15-11. The examiner should hold the leg in a mild degree of flexion. The patient should not be asked to elevate the leg, because this tightens the muscles and makes it more...

Past Medical History

The past medical history consists of the overall assessment of the patient's health before the present illness. It includes all of the following General state of health Past illnesses Injuries Complementary and alternative therapies As an introduction to the past medical history, the interviewer may ask, ''How has your health been in the past '' If the patient does not elaborate about specific illnesses but says only ''Excellent'' or ''Fair,'' for example, the interviewer might ask, ''What does...

Percuss the Liver

The upper border of the liver is percussed in the right midclavicular line, starting in the mid-chest. As the chest is percussed downward, the resonant note of the chest becomes dull as the liver is reached. As percussion continues still further, this dull note becomes tympanic because the percussion is now over the colon. The upper and lower borders of the liver should be no more than 4 inches (10 cm) apart. The technique is illustrated in Figure 17-17. There are several problems with...

Preface to the Sixth Edition

Textbook of Physical Diagnosis History and Examination has been written for students of health care who are learning to communicate effectively with patients, to examine patients, and to assess their medical problems. Although 20 years have passed since the publication of the first edition, this text still offers a unique approach to physical diagnosis. By discussing pathophysiology of disease and emphasizing the humanistic element of health care, I attempt to show the importance of the...

Primary Survey

Cardiopulmonary Resuscitation Survey It should not be assumed that any patient who is not obviously interacting with his or her environment is simply sleeping. For the purpose of this approach, the patient is in cardiopul-monary arrest until it is proved otherwise. As you approach the patient, observe the patient closely, looking for spontaneous breathing or movements. If these are not discernible, stimulate the patient by talking loudly to him or her. If necessary, shout ''ARE YOU OKAY ''...

Putting the History and Physical Examination Together

Until this point, this book has dealt separately with the history and the physical examination. Chapters 1 to 6 give an in-depth analysis of history-taking techniques. Chapters 7 to 21 discuss the many elements of the physical examination, and Chapter 22 suggests an approach to performing the complete physical examination and its write-up. Chapters 23 to 26 cover the evaluation of specific patients. Chapter 27 discusses data gathering and data analysis. This chapter suggests how the history and...

Rectal Bleeding

Rectal bleeding may be manifested by bright red blood, blood mixed with stool, or black, tarry stools. Bright red blood per rectum, also known as hematochezia, can occur from colonic tumors, diverticular disease, or ulcerative colitis. Blood mixed with stool can be the result of ulcerative colitis, diverticular disease, tumors, or hemorrhoids. Ask the patient who describes rectal bleeding the following questions How long have you noticed bright red blood in your stools '' Is the blood mixed...

Regression

Regression is a common defense mechanism by which the patient with extreme anxiety attempts unconsciously to return to earlier, more desirable stages of development. During these periods, the individual enjoyed full gratification and freedom from anxiety. Regressed patients become dependent on others and free themselves from the complex problems that have created their anxiety. For example, consider a middle-aged married man who has recently been told that he has inoperable lung cancer that has...

Responses to Illness

Health is characterized by a state of well-being, enthusiasm, and energetic pursuit of life's goals. Illness is characterized by feelings of discomfort, helplessness, and a diminished interest in the future. Once patients recognize that they are ill and possibly face their own mortality, a series of emotional reactions occurs, including anxiety, fear, depression, denial, projection, regression, anger, frustration, withdrawal, and an exaggeration of symptoms. These psychological reactions are...

Review of Specific Symptoms

The main symptoms of disease of the skin, hair, and nails are the following Rash or skin lesion Changes in skin color Itching (pruritus) Changes in hair Changes in nails There are some important points to clarify when a patient is interviewed about a new rash or skin lesion. The specific time of onset and location of the rash or skin lesion are critical. A careful description of the first lesions and any changes is vital. The patient with a rash or skin lesion should be asked the following...

Review of Systems and Examination of the Young Child

A child 1 to 5 years of age is becoming verbal and, if in pain, can tell you where it hurts. They may start to report nausea, sore throat, chest pain, fatigue, or headache. Note that headache in a preschool child is unusual and probably indicates a serious intracranial pathologic process. Other questions to add to the infants' review of systems include questions about snoring and loss of bowel or bladder control in a child who has been toilet trained. Most children have achieved daytime control...

Rule Out Orthostatic Hypotension

After the patient has been recumbent for at least 5 minutes, measure the baseline blood pressure and pulse. Then have the patient stand, and repeat the measurements immediately. Orthostatic hypotension is defined as a drop in systolic blood pressure of 20 mm Hg or more, in association with the development of symptoms such as dizziness or syncope, when Figure 14-21 Technique for blood pressure assessment by auscultation. Figure 14-21 Technique for blood pressure assessment by auscultation.

Sensory Function Basic Principles

The sensory examination consists of testing for the following Vibration sense Proprioception Discriminative sensations (two-point discrimination, stereognosis, graphesthesia, and point localization) In a patient without any symptoms or signs of neurologic disease, the examination for sensory function can be performed by quickly assessing the presence of normal sensation on the distal fingers and toes. The examiner can choose to test for light touch, pain, and vibration sense. If these are...

Skin

The examination of the skin is the same for children as for adults. Careful descriptions of the numerous rashes seen in this age group are paramount for diagnosis. There are many exanthematous diseases of childhood. These rashes may consist of macules, papules, vesicles, pustules, or petechiae. (A summary of important viral and bacterial exanthems is given in Table 24-6 at the end of the chapter.) Impetigo is one of the most common skin conditions of children in this age group. It is a highly...

Statureforage and Weightforage percentiles

Published May 30, 2000 (modified 11 21 00). SOURCE Developed by the National Center for Health Statistics in the National Center for Chronic Disease Prevention and http www.cdc.gov growthcharts collaboration with Health Promotio(n2000). Figure 24-25 B, NCHS percentiles for girls. Published May 30, 2000 (modified 11 21 00). SOURCE Developed by the National Center for Health Statistics in the National Center for Chronic Disease Prevention and http www.cdc.gov growthcharts collaboration with...

Structure and Physiology

The external landmarks of the eye are shown in Figure 10-1, and the cross-sectional anatomy of the eye is shown in Figure 10-2. The eyelids and eyelashes protect the eyes. The eyelids cover the globe and lubricate its surface. The meibomian glands, which are modified sebaceous glands in the eyelids, secrete an oily lubricating substance to retard evaporation. The openings of these glands are at the lid margins. The orbicularis oculi muscle encircles the lids and is responsible for their...

Test Motor Function

Ask the patient to open the mouth and stick out the tongue. Normally, the tongue is protruded and lies in the midline. This is demonstrated in Figure 21-20. Deviation of the tongue to either side is abnormal. Because the tongue muscles push rather than pull, weakness of one side results in the tongue's being pushed by the normal side to the side of the lesion. In Figure 21-21, notice the marked scalloping of the tongue's surface. The patient has a chronic neurologic disease known as amyotrophic...

The Acutely Ill Patient

Ther is no thing more precious here than tyme. The objective of this chapter is to provide a practical approach to acutely ill patients. The emphasis is on diagnosis, not on therapy. In the assessment of acutely ill patients, time is a critical factor. Unlike the assessment of stable patients, the evaluation of acutely ill patients involves not achieving a specific diagnosis but rather identifying a pathophysiologic abnormality that may be identical for several diagnoses. In the evaluation of...

The Male Breast

Gynecomastia is the enlargement of one or both breasts in a man. It often occurs at puberty, occurs with aging, or is drug-related. Figure 16-21 shows a 90-year-old man who was treated with diethylstilbestrol for carcinoma of the prostate and developed gynecomastia. Carcinoma of the breast affects approximately 1000 men per year in the United States. More than 300 men per year die of metastatic breast cancer. The average age at the time of diagnosis is 59 years. The most common clinical...

The Oral Cavity

The physical examination of the oral cavity includes inspection and palpation of the following structures Floor of the mouth Hard and soft palates Salivary glands Twelfth cranial nerve Sit or stand directly in front of the patient, who should be seated. The patient's face should be well illuminated. Work systematically from front to back so that no areas are omitted. Put on a pair of gloves when palpating any structure in the mouth. When any lesion is found, note its consistency and tenderness....

The Pediatric Emergency

When assessing an acutely ill child, always consider the similarities and differences between the pediatric age group and adult patients approach the pediatric emergency as you would an emergency in an adult, but recognize the smaller size of the patient and the difference in the physiologic responses to acute illness and injury. The primary assessment of a child is the same as that of an adult. The most dangerous life-threatening pediatric emergency is respiratory distress. Respiratory...

The Pharynx Inspect the Pharynx

Examination of the pharynx is limited to inspection. To visualize the palate and oropharynx adequately, the examiner usually must use a tongue depressor. The patient is asked to open the mouth widely, stick out the tongue, and breathe slowly through the mouth. On occasion, leaving the tongue in the floor of the mouth provides better visibility. The examiner should hold the tongue depressor in the right hand and a light source in the left. The tongue blade should be placed on the middle third of...

The Rational Clinical Examination Additional References

Akshay B, Thavendiranathan P, Detsky AS Does this patient have hearing impairment JAMA 295 416-428, 2006. Anand SS, Wells PS, Hunt D, et al Does this patient have deep vein thrombosis JAMA 279 1094-1099, 1998. Anderson MR, Klink K, Cohrssen A Evaluation of vaginal complaints. JAMA 291 1368-1379, 2004. Attia J, Hatala R, Cook DJ, et al Does this adult patient have acute meningitis JAMA 282 175-181, 1999. Barton MB, Harris R, Fletcher SW Does this patient have breast cancer The screening clinical...

Transilluminate Scrotal Masses

If a scrotal mass is detected, transillumination is necessary. In a darkened room, a light source is applied to the side of scrotal enlargement. Vascular structures, tumors, blood, hernias, and normal testicles appear opaque on transillumination. Transmission of the light as a red glow indicates a serous fluid-containing cavity, such as a hydrocele or a spermatocele. A hydrocele is an abnormal collection of clear fluid in the tunica vaginalis. The testicle is contained within this cystic mass,...

Ulceration

Oral ulcerative lesions are common and may be manifestations of local or systemic disease of immunogenic, infectious, malignant, or traumatic origin. The patient's history is important because it indicates whether the lesions are acute or chronic, single or multiple, and primary or recurrent. Oral pain is frequently related to ulceration of the lips or tongue. Cancer is not the most common cause of oral cavity ulceration, but it must always be considered. When a patient complains of ulceration,...

Use a Nasal Speculum

If a nasal speculum is used, the instrument is held in the examiner's left hand, and the speculum is introduced into the patient's nostril in a vertical position (blades facing up and down). The speculum should not rest on the nasal septum. The blades are inserted about 1 cm into the vestibule, and the patient's neck should be slightly extended. The examiner's left index finger is placed on the ala of the patient's nose to anchor the upper blade of the speculum while the examiner's right hand...

Wheezing

Wheezing is an abnormally high-pitched noise resulting from a partially obstructed airway. It is usually present during expiration when slight bronchoconstriction occurs. Bronchospasm, mucosal edema, loss of elastic support, and tortuosity of the airways are the usual causes. Asthma causes bronchospasm, which results in the wheezing associated with this condition. Obstruction by intraluminal material, such as aspirated foreign bodies or secretions, is another important cause of wheezing. A...

Examination

The cervical spine can be examined with the patient seated. You should inspect the cervical spine from the front, back, and sides for deformity and unusual posture. Test range of motion of the cervical spine. Palpate the paravertebral muscles for tenderness and spasm. The thoracolumbar spine is examined with the patient standing in front of you. Inspect the spine for deformity or swelling. Inspect the spine from the side for abnormal curvature. Test ranges of motion. Palpate the paravertebral...

Zd

Figure 1C-67 Assessing the depth of the anterior chamber. dominant condition, often with incomplete expression, in which there is increased length of the long bones ocular complications include dislocation, or subluxation, of the lens, usually superiorly and nasally. Figure 10-70 shows a subluxated lens secondary to Marfan's syndrome. This is the pupil of the patient's left eye. Note the lower edge of the lens and the attached zonules that are apparent from the 3 o'clock to 7 o'clock positions...

External Examination Inspect the Nose

The external examination consists of inspection of the nose for any swelling, trauma, or congenital anomalies. Is the nose straight Does a deviation involve the upper, bony portion or the lower, cartilaginous portion Inspect the external nares. Are they symmetric Test the patency of each nostril. Occlude one nostril by gently placing a finger across the opening. Ask the patient to sniff. Do not compress the contralateral nostril by aggressive pressure. Any swelling or deformity should be...

Bone Spicule Retina Differential

Figure 10-141 shows a giant retinal tear. A large area of bare choroid is visible through the break. Retinitis pigmentosa is a very rare, genetically determined degenerative disease of the retina with an onset from the ages of 6 and 12 years. It is more common in boys than in girls and is almost always bilateral. Night blindness is the first symptom, followed by a gradually progressive constriction of the peripheral fields and eventually blurred vision. Evaluation of the retina reveals the very...

Review of Systems

The review of systems summarizes in terms of body systems all the symptoms that may have been overlooked in the history of the present illness or in the medical history. By reviewing the list of possible symptoms in an orderly manner, the interviewer can specifically check each system and uncover additional symptoms of ''unrelated'' illnesses not yet discussed. The review of systems is best organized from the head down to the extremities, and the questions can be asked while the physical...

Rule Out Ascites

On patients in whom ascites is thought to be present, a special percussion test for shifting dullness may be performed. While the patient is lying on the back, the examiner determines the borders of tympany and dullness. The area of tympany is present above the area of dullness and is caused by gas in the bowel that is floating on top of the ascites. The patient is then asked to turn on the side, and the examiner again determines the borders of the percussion notes. If ascites is present,...

Impact of Infertility on the Patient

The problem of infertility is not new. From ancient times, cultures have practiced fertility rites to ensure the continuation of their people. Many societies considered a woman's worth in terms of her ability to have children. The ''barren woman'' was frequently banished. The average time it takes for a woman to conceive is 4 to 5 months. The American Fertility Society defines infertility as the inability to conceive ''after one year of regular coitus without contraception.'' During this time,...

Inspection

Does the patient hold the head erect Is there any asymmetry of the facial structure Is the head in proportion to the rest of the body Inspect the scalp for lesions. Describe the hair. Are any masses present If so, describe their size, consistency, and symmetry. Figure 24-41 depicts a child with a midline thyroglossal duct cyst. This cyst results from failure of obliteration of the embryologic tract, along which the thyroid descends from the base of the tongue...

Signs and Symptoms in Deficiency States

Protein-calorie (kwashiorkor) (see Fig. 5-5) Extensive dermatitis (common on parts of body exposed to sunlight or mechanical trauma often bilateral and symmetric) Glossitis Stomatitis induration of skin Pigmentation on pressure points Skin fissuring Atrophic skin changes Scaling of skin Seborrheic dermatitis, especially in the nasolabial region, around the eyes, behind the ears, and on the scrotum Ocular manifestations Defective collagen formation Ecchymoses Subperiosteal hematomas Follicular...

Illustrative Case

Now consider as an example the case of Mr. Roger Stern. Mr. Stern is a 29-year-old man who has come to the emergency room with a chief complaint of ''diarrhea and abdominal pain.'' What possible diagnoses are you thinking about What pathologic conditions may be involved Acute problems Chronic problems Some possibilities include genetic disorders, infectious diseases, diseases of immunity, neoplastic diseases, environmental problems, nutritional pathologic processes, vascular disorders, or...

Clinicopathologic Correlations

In addition to the normal breath sounds discussed, other lung sounds may be produced in abnormal clinical states. These abnormal sounds heard during auscultation are called adventitious sounds. Adventitious sounds include the following Crackles are short, discontinuous, nonmusical sounds heard mostly during inspiration. Also known as rales or crepitation, crackles are caused by the opening of collapsed distal airways and alveoli. A sudden equalization of pressure seems to result in a crackle....

Ears

Pediatric Holding Otoscope

Otoscopy is one of the most difficult skills to learn to perform in infants and toddlers, and it is also one of the most important because these are the ages when otitis media is most prevalent. The child can either be placed prone on the examination table or held by a parent. Figure 24-35 demonstrates how to position the child in the parent's lap. To examine the ear, use one hand to pull the pinna out, back, and up* as your other hand holds the otoscope firmly your hands should be braced...

Impact of Musculoskeletal Disease on the Patient

Musculoskeletal diseases have an enormous impact on the lives of patients and their families. The perturbation of a patient's personal life and restriction of activities as a result of disability are frequently more catastrophic than the muscle or joint pain itself. Diseases of the musculoskeletal system range from minor aches and pains to severe crippling disorders, often associated with premature death. Rheumatoid arthritis is a crippling disorder that strikes many patients in the prime of...

Inspect the Penis

If the patient is not circumcised, the foreskin should be retracted. Some examiners ask the patient to retract it himself others prefer to determine the tightness of the foreskin. The cheesy, white material under the foreskin is smegma and is normal. Phimosis is the condition in which the foreskin cannot be retracted, and it prevents adequate examination of the glans. Because the glans also cannot be cleaned, smegma builds up, leading to possible inflammation of the glans and prepuce...

Syncope

Fainting, or syncope, is the transient loss of consciousness that results from inadequate cerebral perfusion. Ask patients what they mean by ''fainting'' or ''dizziness.'' Syncope may have cardiac or noncardiac causes. When a patient describes fainting, ask the following questions ' 'What were you doing just before you fainted '' ''Have you had recurrent fainting spells '' If so, ' 'How often do you have these attacks '' Was the fainting sudden '' Did you lose consciousness '' ''In what...

Light Palpation

Images Palpation

Light palpation is used to detect tenderness and areas of muscular spasm or rigidity. The examiner should systematically palpate the entire abdomen by using the flat part of his or her right hand or the pads of the fingers, not the fingertips. The fingers should be together, and sudden jabs are to be avoided. The hand should be lifted from area to area instead of sliding over the abdominal wall. Light palpation is demonstrated in Figure 17-20. With patients who are ticklish, it may be useful to...

Basilar Skull Fracture Raccoon Eyes

Basilar Skull Fracture

Zoster ophthalmicus at different stages of evolution (fresh and crusted vesicles) in the ophthalmic division of the trigeminal nerve. Treatment with antivirals can dramatically reduce the symptoms. Is orbital pigmentation present Orbital pigmentation, also known as raccoon eyes, is an important sign of a basilar skull fracture. This discoloration is caused by extravasated blood from the fracture of the base of the brain. This is an important sign to recognize, especially in an unconscious...

Inspect the Lips

Inspect the lips for localized or generalized swellings, and assess the patient's ability to open the mouth. Assess the color of the lips. Is cyanosis present Are there any lesions on the lips If a lesion is detected, palpate it to characterize its texture and consistency. Figure 12-10 depicts the mouth of a patient with multiple herpetic ulcers, commonly known as cold sores, or herpes simplex labialis, on the lips and external nares. Figure 12-11 depicts multiple telangiectatic lesions on the...

Wound Healing Scab

Wilk Scabies Ever Clear

Figure 15-16 Close-up of a necrobiosis lipoidica diabeticorum lesion. Figure 15-16 Close-up of a necrobiosis lipoidica diabeticorum lesion. Figure 15-17 Deep vein thrombosis, left leg. Table 15-2 Precipitating Factors in Thromboembolism Secondary to venous thrombosis, inflammation around the vein may result. Erythema, warmth, and fever then occur, and thrombophlebitis is present. In many cases, the examiner can palpate this tender, indurated vein in the groin or medial thigh. This is commonly...

Ancyclostoma Brazillienses Force Out Of The Skin

Neurotrophic Joint Xray Foot

Figure 20-69 A, Exostosis at the metatarsocuneiform joint. B, X-ray film of the affected metatarsocuneiform joint. Figure 20-69 A, Exostosis at the metatarsocuneiform joint. B, X-ray film of the affected metatarsocuneiform joint. Approximately 30 of patients with diabetes mellitus have disease-related dermatologic problems. Neurotrophic foot ulcers are very common in diabetic patients. Figure 20-72 shows bilateral neurotrophic ulcers. Painless plantar ulcers heal slowly after apparently...

Examination Vagina By Finger

Dick Vagina Cross Section View

The speculum is introduced to full depth. When it is inserted completely, the speculum is rotated to the horizontal position, with the handle now pointing downward, and is opened slowly. With the bills open, the vaginal walls and cervix can be visualized. The cervix should rest within the bills of the speculum. This is demonstrated in Figure 19-21 and diagrammed in Figure 19-22. To keep the speculum open, the set screw can be tightened. If the cervix is not immediately seen, gently turn the...

The Adolescent Interview

The adolescent interview can present a number of special challenges, as well as its own special delights. Adolescents, aged 13 to 22 years, make up 15 of the U.S. population. Too old to be considered children but too young to be considered adults, adolescents may avoid health care because they do not feel comfortable either at the pediatrician's office or at an internist's office. On the other hand, mortality rates are almost five times higher among 15- to 24-year-olds than among 5- to...

The Rinne Test

Rinne Test

In the Rinne test, air conduction is compared with bone conduction. Each ear is tested separately. Strike a 512-Hz tuning fork and place its handle on the mastoid tip near the external auditory meatus. Ask the patient whether he or she hears the sound and to indicate when he or she no longer hears it. When the patient can no longer hear the sound, place the tines of the vibrating tuning fork in front of the external auditory meatus of the same ear, and ask the patient whether he or she can...

Change in Bowel Movements

Take a careful history of bowel habits. A change in bowel movements necessitates further elaboration. Ask these questions of the patient with acute onset of diarrhea ''How long have you had the diarrhea '' ''How many bowel movements do you have a day '' ''Did the diarrhea start suddenly '' ''Did the diarrhea begin after a meal '' If yes, ' 'What did you eat '' ''Are the stools watery bloody malodorous '' ''Is the diarrhea associated with abdominal pain loss of appetite nausea vomiting '' The...

Cyanosis

Differential Cyanosis

Cyanosis is also discussed in Chapter 13, The Chest. The important questions regarding cyanosis are indicated in that chapter. On occasion, cyanosis is noted only in the lower extremities. This is termed differential cyanosis. It is related to a right-to-left shunt through a patent ductus arteriosus (PDA). In a right-to-left shunt resulting from pulmonary hypertension, blood in the pulmonary artery crosses the PDA, which is located below the level of the carotid and left subclavian arteries...

Neck

The neck of a newborn appears relatively short. Is the neck symmetric with regard to the midline Rotate the infant's head. Normally, the infant's head should be easily rotated to either side so that the chin can touch either shoulder. Torticollis is a condition in which the head is tilted to one side while the chin is rotated to the other shoulder. In the newborn, a hematoma of the sternocleidomastoid muscle as a result of a birth injury may produce this condition. Palpate for a mass in the...

Eyes

Several attempts to evaluate the eyes of the newborn may be necessary. Eyelid edema related to the birth process, medications, or infection makes this part of the examination difficult. Inspect the eyes for symmetry. The eyes should be the same size and should be at the same depth in the orbits. Bulging eyes may be a sign of congenital glaucoma. Microcornea may result from congenital rubella. Assess whether the eyes are normal distance from one another. If there is a concern about the eyes...

Genitalia

Inspect the external genitalia for ambiguity. In the term male infant, the scrotum is relatively large and rugate. The foreskin of the penis is tight and adherent to the glans penis. Inspect the glans for the location of the external urethral meatus. Hypospadias is a condition in which the meatus is located in an abnormal ventral position, anywhere from the lower glans of the penis to the scrotum. It is important to detect hypospadias in the neonatal period because it represents a...

Skin Changes

Bico Viuva

In addition to the skin changes of the breast already discussed, hyperpigmentation is common, especially in women with dark hair and a dark complexion. The linea alba darkens to become the linea nigra, as shown in Figure 23-7A. Areas prone to friction (e.g., medial thighs, axilla) also tend to darken. New pigmentation on the face, called chloasma, also commonly develops on the cheeks, forehead, nose, and chin. These skin changes are caused by the presence of high levels of ovarian, placental,...

Normal Optic Disc

Normal Optic Disc

Figure 10-74 Photograph of the retinas of the right (A) and left (B) eyes. Careful assessment of the optic fundus is important for several reasons. The optic fundus is the only area where the blood vessels can be seen in vivo it can provide an excellent picture of the state of the vasculature of other organs. In addition, the optic fundus is frequently involved with manifestations of systemic disease such as AIDS, infective endocarditis, hypertension, and diabetes a thorough evaluation of the...

The Weber Test

Weber Test

In the Weber test, bone conduction is compared in both ears, and the examiner determines whether monaural impairment is neural or conductive in origin. Stand in front of the patient and place a vibrating 512-Hz tuning fork firmly against the center of the patient's forehead. Ask the patient to indicate whether he or she hears or feels the sound in the right ear, in the left ear, or in the middle of the forehead. Hearing the sound, or feeling the vibration, in the middle is the normal response....

Impact of Deafness on the Patient

The ear is the sensory organ of hearing. Audition is one of the main avenues of communication. Any disturbance in the reception of sound waves by the external ear or the transmission of electrical impulses to the brain may result in an abnormal interpretation of language. It is estimated that there are more than 15 million persons in the United States with some degree of hearing loss that interferes with their ability to understand speech. About half of these individuals, 7.2 million, have...

Secondary Survey

Medical Log Rolling

In the secondary survey, document a history from the patient, the patient's relatives, emergency department personnel, or bystanders. The secondary survey is a systematic method for determining whether other conditions or injuries are present and necessitate attention. This survey consists of a rapid interview, a check of the vital signs, and a focused physical examination. The mnemonic AMPLE can be helpful in gathering pertinent information M medications currently being taken E events...

The Nervous System

As the debility increases and the influence of the will over the muscles fades, the tremulous agitation becomes more vehement. It now seldom leaves him for a moment but even when exhausted nature seizes a small portion of sleep, the motion becomes so violent as not only to shake the bed-hangings, but even the floor and sashes of the room. The chin is now almost immovably bent down upon the sternum. The slops with which he is attempted to be fed, with the saliva, are continually trickling from...

Functional Anatomy of Birth

Right Occiput Posterior

The pelvic cavity is bounded above by the plane of the brim (the inner sacral promontory to the upper and inner borders of the symphysis pubis), below by the plane of the outlet (the lower and inner borders of the symphysis pubis to the end of the sacrum or coccyx), posteriorly by Figure 23-2 Types of fetal positions. the sacrum, laterally by the sacrosciatic ligaments and ischial bones, and anteriorly by the pubic rami. The birth canal, through which the infant is delivered, may be thought of...