Structure and Physiology

The mammary glands are the distinguishing feature of all mammals. Human breasts are conical in form and are often unequal in size. The breast extends from the level of the second or third rib to the level of the sixth or seventh rib, from the sternal edge to the anterior axillary line. The tail of the breast extends into the axilla and tends to be thicker than the other breast areas. This upper outer quadrant contains the greatest bulk of mammary tissue and is frequently the site of neoplasia....

Growth and Development

Ask about the child's pattern of growth. As is discussed later, the height, weight, and head circumference of children should be plotted on appropriate growth curves. Has the child's growth been consistent, or has he or she crossed percentile lines on the growth chart Is the mother concerned about her child's growth *The typical ampicillin rash occurs about 7 to 8 days after the drug is started and is not considered a penicillin allergy. The normal newborn can take 15 to 20 ounces a day. Ask,...

Info

Onychomycosis is an infection in which fungal organisms invade the nail bed and is the most common nail disorder. It accounts for nearly 50 of all nail problems. Its prevalence in the general population ranges from 2 to 14 . This infection causes progressive changes in the color, structure, and texture of the nail. It rarely resolves spontaneously, and, even with treatment, it may take months to years to clear. Figures 8-115 and 8-116 show examples of distal and lateral...

The Neck

Thyroid Sternocleidomastoid

The neck is divided by the sternocleidomastoid muscle into the anterior, or medial, triangle and the posterior, or lateral, triangle. These are illustrated in Figure 9-3. The sternocleidomastoid is a strong muscle that serves to raise the sternum during respiration. The sternocleidomastoid has two heads The sternal head arises from the manubrium sterni, and the clavicular head originates on the sternal end of the clavicle. The two heads unite and insert on the lateral aspect of the mastoid...

Clinicopathologic Correlations

The signs of an acute arterial occlusion are the five Ps pain, pallor, paresthesia, paralysis, and pulselessness. Chronic progressive small vessel disease is characteristic of diabetes mellitus. It is commonly observed that arterial pulses are present despite gangrene in the extremity. Figure 15-14 depicts dry gangrene of the toes in a diabetic patient. Diabetes has been associated with many skin disorders. The cutaneous hallmark of diabetes is a waxy, yellow or reddish-brown, sharply...

William Harvey 15781657

Records of obstetrics and gynecology date back to the time of Hippocrates in 400 bce. He was probably the first physician to describe midwifery, menstruation, sterility, symptoms of pregnancy, and puerperal (the period after labor) infections. Most of the early gynecologic history stems from Soranus in the second century ce. His works included chapters on anatomy, menstruation, fertility, signs of pregnancy, labor, care of the infant, dysmenorrhea (painful menstruation), uterine hemorrhage, and...

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...

General Considerations

Most people are fortunate to hear the sounds of music, noise, and, above all, speech. Sometimes ''silence is golden,'' but silence can be golden only when a person can choose not to hear. Although normal children are born with the apparatus necessary to produce speech, they are not born with speech. The ear and brain integrate and process sound, enabling the child to learn to imitate it. If sound cannot be heard, it cannot be imitated. Sounds will not become words words will not become...

Review of Specific Symptoms

The major symptoms of ear disease are the following Vertigo Tinnitus Otorrhea Otalgia Itching Hearing loss may be unilateral or bilateral and may develop slowly or occur suddenly. For any patient with a hearing loss, ask the following questions Is the hearing loss in one ear '' For how long have you been aware of a loss of hearing '' ''Was the loss sudden '' ''Is there a family history of hearing loss '' ''What type of work do you do ''''What other work have you done '' ''What types of hobbies...

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...

The Geriatric History

The main components of the medical history are basically the same for geriatric patients as for younger patients, except for the chief complaint and the family history. With the exception of a family history of Alzheimer's disease, the family history is less important for geriatric patients than for younger patients. For example, the fact that a family member died of a myocardial infarction at 60 years of age is relatively unimportant for a patient who is already in his or her 80s. It is also...

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...

Inspect the External Ear Structures

A small dimple in front of the tragus is usually a remnant of the first branchial arch. Inspect the external ear for deformities, nodules, inflammation, or lesions. The presence of tophi is a highly specific but nonsensitive sign of gout. Tophi are deposits of uric acid crystals. They appear as hard nodules in the helix or antihelix. In rare cases, a white discharge may be seen in association with them. A ''cauliflower ear'' is a pinna that is gnarled as a result of repeated trauma. Figure...

Inspect the Teeth

There are 32 teeth in the full adult dentition. Is the dentition appropriate for the patient's age The teeth should be inspected for caries and malocclusion. Are the teeth clean, especially around the gum line Is there discoloration of the teeth Is there tooth loss Inspection of the teeth often provides insight into the patient's attitude toward general hygiene. Are the teeth aligned properly Ask the patient to bite normally while you retract the buccal mucosa with a tongue depressor. How many...

Auscultate the Anterior Chest

Auscultation of the anterior chest is performed in the supraclavicular fossae, the axillae, and the anterior chest interspaces, as illustrated in Figure 13-22. The techniques of auscultation have already been discussed. The breath sounds of one side are compared with the breath sounds heard in the corresponding position on the other side. Table 13-6 Timing of Common Inspiratory Crackles Congestive heart failure Obstructive lung disease Interstitial fibrosis

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...

Cranial Nerve X Vagus

The vagus nerve supplies parasympathetic fibers to the viscera of the chest and abdomen motor fibers to the pharynx and larynx and sensory fibers to the external ear canal, the meninges of the posterior cranial fossa, the pharynx, the larynx, and the viscera of the body cavities above the pelvis. Figure 21-18 Technique for evaluating the spinal accessory nerve. Figure 21-19 Alternative technique for evaluating the spinal accessory Figure 21-19 Alternative technique for evaluating the spinal...

Description of Lesions

Esquema Paisatge Les Coves

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...

Disease Illness and Health

The terms disease and illness are often used interchangeably. Medical sociologists and cultural anthropologists, however, make a distinction. The word disease refers to a disorder in which there is a change from normal in the body's structure or function, involving one or more organs of the body. Illness is the subjective distress felt by the patient and by those close to the patient, rather than the actual state of ill health. The patient's culture often determines how the patient interprets,...

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...

Ethical Challenges

Since the mid-1960s, there has been an increased awareness of and interest in medical ethics. With the first human heart transplant operation by Dr. Christiaan Barnard in 1967, the U.S. Supreme Court's declaration in 1973 that state laws prohibiting abortion were unconstitutional, and the controversy in 1975 over removing the respirator from a patient with irreversible brain damage in the case of Karen Ann Quinlan, modern medical ethics was born. Touching on three key issues organ...

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 Infant

Infants 1 week to 6 months of age can be examined on the examination table with a parent standing nearby. It may be easier to perform part of the examination while the infant is in the parent's arms or lap. Infants 6 months to 1 year of age are best examined on the parent's lap. The examiner should also be seated, at the child's level. The more difficult portions of the examination, such as the evaluation of the pharynx and the otoscopic examination, should be performed last. To listen to the...

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,...

Fecal Occult Blood Test

Twitsquinten Blake

The examining digit should be inspected. The color of the fecal material should be noted. The fecal material should be placed on the fecal occult blood test (FOBT) card and examined with the Hemoccult developer. The guaiac or benzidine test detects occult blood. If blood is present, a chemical reaction results in a blue coloration on the card. The reaction is graded by the intensity of the blue color, from light blue (trace blood) to dark blue (4+ positive). Although the examination for...

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 Assessment

As mentioned before, there are a variety of ways of measuring temperature in a child older than 6 months. The heart rate of a child aged 1 to 5 years ranges from 80 to 140 beats per minute the average rate is 100. The respiratory rate varies from 24 to 40 breaths per minute at 1 year of age and decreases to 20 to 24 by 5 years of age. Blood pressure assessment by auscultation is usually possible with children at least 3 to 4 years of age and should be performed on all children. Inform the child...

Genital Rashes

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,...

Have Male Patient Turn Around and Bend over

Inspect anus while patient strains. 6. Test stool for occult blood. Help Female Patient to Lithotomy Position Female Genitalia (Chapter 19, Female Genitalia) Help Female Patient to Lithotomy Position Female Genitalia (Chapter 19, Female Genitalia) Inspect labia minora, clitoris, urethral meatus, and introitus Inspect area of Bartholin's glands, both sides.

Have Patient Turn and Sit with Legs Dangling off Side of Bed Vital Signs

Palpate radial pulse for rate and regularity (see Chapter 15, The Peripheral Vascular System). 2. Determine respiratory rate and pattern (see Chapter 13, The Chest). Face (Chapters 8, The Skin, and 9, The Head and Neck) 1. Assess visual acuity, both eyes. 2. Check visual fields, both eyes. 3. Determine eye alignment, both eyes. 4. Test extraocular muscle function, both eyes. 5. Check pupillary response to light, both eyes. 7. Inspect external eye structures, both eyes. 8. Perform...

Historical Considerations

The eyes are the human windows to the world. Most of the sensory input to the brain is through the eyes. For centuries, the eye has been considered the essence of the person, representing the I. In mythology and the writings of ancient times, the eye is an organ associated with mystical powers. The eye has long been associated with mythical gods. In ancient Egypt, the eye was the symbol of the Great Goddess. The Eye of Horus was believed to protect against all evil and to ensure success. The...

Impact of Cardiac Disease on the Patient

Patients with cardiac disease are intensely fearful. Once cardiac disease has been diagnosed, a series of reactions occurs. Fear, depression, and anxiety are the outcomes. The patients, who were totally asymptomatic until their episode of ''sudden death'' resulting from a coronary occlusion, are scared. They were resuscitated the first time will an episode happen again When During recovery in the hospital, they are afraid to leave the intensive care unit for fear that ''no one will be...

Initial Comprehensive Evaluation

There are three main goals to the initial evaluation 1. Determine the health of the mother and fetus. 2. Determine the gestational age of the fetus. 3. Initiate a plan for continuing care. The physical examination must include the following Determination of height and weight Assessment of blood pressure Inspection of the teeth and gums Palpation of the thyroid gland Auscultation of the heart and lungs Examination of the breasts and nipples Examination of the legs for varicosities and edema...

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.

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...

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...

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...

Neurologic Examination

Careful inspection is the most important aspect of the neonatal neurologic examination. The inspection should include the following Symmetry of extremities Spontaneous movements Facial expressions and symmetry Eye movements and symmetry Notice the position of the newborn. Is hyperextension of the neck present This sign is frequently found in infants with severe meningeal or brain-stem irritation. What is the position of the thumb The cerebral thumb sign is the finding of the thumb curled under...

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...

Pain In Buttocks Hips And Cal When Walking

Pain is the principal symptom of atherosclerosis. Whenever a patient complains of pain in the calf, arch of the foot, thighs, hips, or buttocks while walking, peripheral vascular disease of the arteries must be considered. The symptom of pain in the lower extremity during exercise is called intermittent claudication. The site of the pain is always distal to the occlusive disease. As the disease progresses, pain at rest occurs. This is often severe and is aggravated by cool temperatures and...

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 Penis

Palpate the shaft from the glans to the base of the penis. The presence of scars, ulcers, nodules, induration, and signs of inflammation must be noted. To palpate the corpora cavernosa, hold the penis between the fingers of both your hands and use your index fingers to note any induration. Figure 18-22 illustrates the method of palpation of the shaft of the penis. The presence of nontender induration or fibrotic areas under the skin of the shaft is suggestive of Peyronie's disease. Patients...

Palpate the Point of Maximum Impulse

The examiner should stand on the right side of the patient, with the bed at a level comfortable for the examiner. Palpation for the PMI is most easily performed with the patient in a sitting position. Only the examiner's fingertips should be applied to the patient's chest in the fifth intercostal space, midclavicular line, because they are the most sensitive for assessing localized motion. The PMI should be noted. This technique is demonstrated in Figure 14-27. If the apical impulse is not...

Palpate the Popliteal Pulse

Femoral Artery Palpation

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...

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...

Physical Examination

No special equipment is necessary for the examination of the musculoskeletal system. The purpose of the internist's musculoskeletal examination is as a screening examination to indicate or exclude functional impairment of the musculoskeletal system. The examination should take only a few minutes and should be part of the routine examination of all patients. If an abnormality is noted or if the patient has specific symptoms referable to a particular joint, a more detailed examination of that...

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...

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...

Red Urine

Red urine is often indicative of hematuria, or blood in the urine. However, there are many causes of red urine, and it should not automatically be assumed that red urine indicates bleeding. Vegetable dyes, drugs such as phenazopyridine (Pyridium), and excessive ingestion of beets can cause red urine. When it is determined that the urine is red as a result of the presence of blood, the hematuria is termed gross hematuria. Hematuria may be the first symptom of serious disease of the urinary...

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 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.

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

Thoracic Cutaneous Hemangioma

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...

Subsequent Antenatal Examinations

Subsequent antenatal examinations are important for screening for impaired fetal growth, malpresentation, anemia, preeclampsia, and other problems. In the absence of specific complaints by the patient or of abnormal findings on the initial examination or initial laboratory and sonographic studies, only a few parts of the physical examination just outlined are routinely performed during each visit. These include weight, blood pressure, and examination of the abdomen. This section concerns the...

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 Borderline Patient

Borderline patients are defined as individuals with a personality disorder who have an instability in their personal relationships, engage in impulsive behavior, and have unstable moods. Intense, fluctuating emotions of love and hate are typical of borderline patients. They need emotional support because they are constantly threatened by people and circumstances. It is often very difficult to develop a good doctor-patient relationship with borderline patients because the swings of affect are...

The Larynx

The larynx is located at the superior margin of the trachea and below the hyoid bone, which is located at the base of the tongue. The larynx is at the level of the fourth to sixth cervical vertebrae. The larynx functions as a guard against the entrance of solids and liquids into the trachea, as well as being the organ of voice production. The epiglottis is attached above the larynx. The function of the epiglottis is generally believed to be protection of the airway during swallowing. The body...

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 Pediatric History

The pediatric history, like the adult history, is obtained before the examination is performed. During this period, the child can get accustomed to the clinician. Unlike the adult history, however, much of the pediatric history is taken from the parent or guardian. If the child is old enough, interview the child as well. Good communication with the child is the key to a successful work-up, just as with an adult. An infant communicates by crying and, in so doing, indicates that something is...

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...

The Technique

The patient is told that a rectal examination will now be performed. The examiner should tell the patient that a lubricant that will feel cool will be used, and this will be followed by the sensation of having to move the bowels the patient should be assured that he will not do so. The examiner lubricates the right gloved index finger and places the left hand on the patient's buttocks. As the left hand spreads the patient's buttocks, the examiner's right index finger is gently placed on the...

Transilluminate Scrotal Masses

Testicular Atrophy Images

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...

Writing Up the Physical Examination

Listed here are examples of the write-up for the examination of the head, neck, and The head is normocephalic without evidence of trauma. The neck is supple, with full range of motion. No adenopathy is present in the neck. The thyroid is nontender and is not enlarged. No thyroid nodules are felt. The head is normocephalic and atraumatic. There is a 2-cm, rubbery, nontender mass in the superficial cervical chain on the left side. The mass is freely mobile and is not fixed to the skin or...

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...

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

Spicule The Bone

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

Where The Hyoid Bone Figure

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

Nail Beading And Hypothyroidism

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...

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

Images Infantigo

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...