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...

Abdomen

The examination of the abdomen is often one of the earlier parts of the examination of a young child because this requires no instruments other than the stethoscope and is usually painless. An anxious child 2 or 3 years of age can be examined in the parent's lap By leaning back in the chair, the parent acts as the examining table, with the supine child semireclined against the parent's chest and abdomen. An adequate abdominal examination on a child may require repeated ''visits'' to that part...

Abnormalities of Splitting of the Second Heart Sound

Normal physiologic splitting of S2 was discussed in the section The Cardiac Cycle. This section deals with abnormalities of splitting. Any condition that delays right ventricular systole, either electrically or mechanically, delays P2 and produces a widened splitting of S2. Right ventricular emptying is delayed by a right bundle branch block or pulmonic stenosis. The pulmonic component of S2 is delayed during both inspiration and expiration, and wide splitting of S2 occurs. Any condition that...

Ankle and Foot Symptoms

The ankle is a hinge joint between the lower end of the tibia and the talus. Although symptoms in the ankle and foot usually have a local cause, they can also be secondary to systemic disorders. Symptoms may include pain, swelling, and deformities. The patient's only complaint may be uneven shoe wear. Patients with flatfoot wear down their soles on the medial side extending to the tip of the shoe. The outer portion of the heel is also worn out early. Scuff marks are usually present on the...

Art Science and Observation

This is one of the most important chapters of the book, because it considers the methods and concepts of evaluating the signs and symptoms involved in diagnostic reasoning. The previous chapters discuss the ''science'' of medicine by explaining the techniques for interviewing and performing the physical examination. The ability to make the ''best'' decision in the presence of uncertainty is the ''art'' of medicine. But there are rules and standards for the practice of this art, and these are...

Assess the Respiratory Rate and Pattern

When assessing respiratory rate, never ask the patient to breathe ''normally.'' Individuals voluntarily change their breathing patterns and rates once they are aware that respiration is being assessed. A better way is, after taking the radial pulse, to direct your eyes to the patient's chest and evaluate respirations while still holding the patient's wrist. The patient is unaware that you are no longer taking the pulse, and voluntary changes in breathing rate will not occur. Counting the number...

Auscultate the Carotid Artery

Femoral Pulse Auscultation

Auscultation for carotid bruits* is performed by placing the diaphragm of the stethoscope over the patient's carotid artery while the patient is lying supine. This is demonstrated in Figure 15-7. The patient's head should be slightly elevated on a pillow and turned slightly away from the carotid artery being evaluated. It is often helpful to ask the patient to hold his or her breath during the auscultation. Normally, either nothing or transmitted heart sounds are heard. After one carotid artery...

Basic Physiology of Reproduction

When semen is deposited in the vagina, sperm travel through the cervix and uterus and into the fallopian tubes, where fertilization may occur if an ovum is present. The majority of sperm deposited in the vagina die within 1 to 2 hours because of the normal acidic environment. The sperm are aided in their travel into the fallopian tubes by uterine and tubal contractions and favorable mucous conditions. The fertilized ovum, or zygote, remains in the fallopian tube for about 3 days. While in the...

Basic Principles

Good communication skills are the foundation of excellent medical care. Even with the exciting new technology that has appeared since 2000, communicative behavior is still paramount in the care of patients. Studies have shown that good communication improves health outcomes by resolving symptoms and reducing patients' psychological distress and anxiety. Technologic medicine cannot substitute for words and behavior in serving the ill. The quality of patient care depends greatly on the skills of...

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...

Blood Pressure

Arterial blood pressure is the lateral pressure exerted by a column of blood against the arterial wall. It is the result of cardiac output and peripheral vascular resistance. Blood pressure depends on the volume of blood ejected, its velocity, the distensibility of the arterial wall, the viscosity of the blood, and the pressure within the vessel after the last ejection. Systolic blood pressure is the peak pressure in the arteries. It is regulated by the stroke volume and the compliance of the...

Blood Pressure Assessment The Principles

Blood pressure can be measured directly with an intra-arterial catheter or indirectly with a sphygmomanometer. The sphygmomanometer consists of an inflatable rubber bladder within a cloth cover, a rubber bulb to inflate the bladder, and a manometer to measure the pressure in the bladder. Indirect measurement of blood pressure involves the auscultatory detection of the appearance and disappearance of the Korotkoff sounds over the compressed artery. Korotkoff sounds are low-pitched sounds...

Breast Self Examination

Women should be encouraged to perform breast self-examination monthly starting at age 20 years. It is important for a woman to learn what is normal and about the changes in her breasts that occur with her menstrual cycle. Familiarity with breast tissue makes it easier for the woman to notice any changes in the breast from month to month. Advise the woman that the best time to perform breast self-examination is 2 to 3 days to a week after the end of her menstrual period. At this time the breasts...

Chief Complaint

The chief complaint is the patient's brief statement explaining why he or she sought medical attention. It is the answer to the question, ''What is the medical problem that brought you to the hospital '' In the written history, it is frequently a quoted statement of the patient, such as ''Chestpain for the past 5 hours.'' ''Terrible nausea and vomiting for 2 days.'' ''Headache for the last week, on and off.'' ''Routine examination for school.'' Patients sometimes use medical terms. The...

Concluding Thoughts

Health-care professionals cannot be expected to know everything about each culture rather, it is important that they know it is important to keep in mind cultural considerations in the treatment process and the doctor-patient relationship. This chapter has introduced the healthcare provider to some aspects of several diverse cultures. Ideally, the clinician can be better prepared for the challenges of caring for patients in this multicultural society. Aday LA At Risk in America The Health and...

Cranial Nerve I Olfactory

The olfactory nerve supplies nerve endings to the superior nasal concha and upper one third of the nasal septum. The olfactory nerve is not routinely tested. However, in any patient with a suspected frontal lobe disorder, the olfactory nerve should be evaluated. Table 21-1 Cranial Nerves Cranial Nerve Eye movements papillary constriction accommodation General sensation of face, scalp, and teeth chewing movements Taste general sensation of palate and external ear lacrimal gland and submandibular...

Deep Palpation

Deep palpation is used to determine organ size, as well as the presence of abnormal abdominal masses. In deep palpation, the examiner places the flat portion of his or her right hand on the patient's abdomen, and his or her left hand is placed over the right hand. The fingertips of the left hand exert the pressure, while the right hand should appreciate any tactile stimulation. Pressure should be applied to the abdomen gently but steadily. The technique of deep palpation is demonstrated in...

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...

Determine the Jugular Wave Forms

To visualize the jugular wave forms, the patient should lie flat without a pillow so that his or her neck is not flexed and does not interfere with the pulsations. The patient's trunk should be at approximately 25 to the horizontal. The higher the venous pressure is, the greater the elevation that is required the lower the pressure, the lower the elevation needed. The patient's head should be turned slightly to the right and slightly down to relax the right sternocleidomastoid muscle. Standing...

Determine the Mobility of the Tympanic Membrane

If there is a question of middle ear infection, pneumatic otoscopy should be performed. This technique requires the use of a speculum large enough to fit snugly into the external canal to establish a closed air chamber between the canal and the interior of the otoscopic head. A rubber squeeze bulb is attached to the otoscopic head. By squeezing the bulb, the examiner can increase the air pressure in the canal. Pneumatic otoscopy must be performed gently, and the patient should be informed that...

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...

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,...

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...

Ears

Is any discharge present Purulent discharge may be related to bacterial infection. Eczema may cause flaking and cracking behind the ears. A bloody discharge may be caused by irritation, injury, a foreign body, or a basilar skull fracture. Use the otoscope to inspect the external canal and tympanic membrane. A cooperative 2- to 3-year-old child may be either sitting or lying prone on the examination table with the head turned to one side. An uncooperative child can be held upright or prone in a...

Emboli

Thrombus formation results from stasis and hypercoagulability. It appears, however, that venous stasis is the most important cause of thrombus formation. Bed rest, congestive heart failure, obesity, pregnancy, recent extended travel on airplanes, and oral contraceptives have been linked to thrombus formation and emboli. Symptoms secondary to emboli can include shortness of breath from pulmonary emboli abdominal pain from splenic, intestinal, or renal artery...

Evaluate Diaphragmatic Movement

Percussion is also used to detect diaphragmatic movement. The patient is asked to take a deep breath and hold it. Percussion at the right lung base helps determine the lowest area of resonance, which represents the lowest level of the diaphragm. Below this level is dullness from the liver. The patient is then instructed to exhale as much as possible, and the percussion is repeated. With expiration, the lung contracts, the liver moves up, and the same area becomes dull that is, the level of...

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

The examination of the knee is performed with the patient standing and lying on the back. While the patient is standing, any varus or valgus deformity should be noted. Is there wasting of the quadriceps muscle Is there swelling of the knee An early sign of knee joint swelling is loss of the slight depressions on the lateral sides of the patella. Inspect for swelling in the popliteal fossa. A Baker's cyst in the popliteal fossa may be responsible for swelling in the popliteal fossa, causing calf...

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 Lymphatic System

Physical signs of lymphatic system disease include the following Lymph nodes should be described as painless or tender and as single or matted. Generalized lymphadenopathy and localized lymphadenopathy are suggestive of different diagnoses. Generalized lymphadenopathy is the presence of palpable lymph nodes in three or more lymph node chains. Lymphoma, leukemia, collagen vascular disorders, and systemic bacterial, viral, and protozoal infections may be responsible. Localized lymphadenopathy is...

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,...

Format of the History

The information obtained by the interviewer is organized into a comprehensive statement about the patient's health. Traditionally, the history has been obtained by using a disease-oriented approach emphasizing the disease process that prompted the patient to seek medical advice. For example, a patient may present with shortness of breath the interview would be conducted to ascertain the pathologic causes of the shortness of breath. An alternative approach to obtaining the history is a...

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...

General Suggestions

It is important to determine the medications that a patient is taking, because many drugs have deleterious effects on the eye. Some antimalarial, antituberculous, antiglaucoma, and anti-inflammatory drugs can cause eye disorders. A thorough family history reveals familial disease tendencies such as glaucoma, cataracts, retinal degeneration, strabismus, or corneal dystrophies. There are many specific symptoms related to eye disease. The common visual, nonvisual but painful, and nonvisual and...

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 Lie Supine with Bed Flat

Auscultate abdomen for bowel sounds, one quadrant. 5. Auscultate abdomen for bruits, both sides. 6. Palpate abdomen lightly, all quadrants. 7. Palpate abdomen deeply, all quadrants. 8. Percuss abdomen, all quadrants. 11. Test superficial abdominal reflex (see Chapter 21, The Nervous System). 12. Check for rebound tenderness. 13. Check for hepatic tenderness. 14. Evaluate hepatojugular reflux (see Chapter 14, The Heart). 18. Check for shifting dullness if ascites is suspected. Pulses (Chapter...

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...

Head

All the chains (as indicated in Chapter 9, The Head and Neck) must be examined. Small (0.75- to 1.5-inch 2- to 4-mm ), movable, nontender, discrete nodes are commonly found. Warm, tender nodes are usually indicative of infection. Palpate the sutures in the 1- to 3-year-old child. Check for the fontanelles. The posterior fontanelle frequently closes soon after the neonatal period. The anterior fontanelle may close as early as 8 months of age or may remain open until 2...

Health Care Proxy

A health-care proxy form is an extremely important document that every patient should have in order to serve as protection of his or her wishes at a time when he or she might be incapacitated. A health-care proxy is a person who is appointed to make decisions on behalf of the patient if the patient is unable to do so. This health-care proxy is anyone whom the patient designates as someone he or she trusts for example, a family member or close friend. Once this health-care proxy is designated,...

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...

History of Previous Pregnancies

A history of traumatic or second trimester fetal loss increases the possibility of cervical injury and subsequent incompetence of the cervix, an often preventable cause of second trimester miscarriage. A history of premature delivery (newborn's weight < 2500 g) or immature delivery (< 1000 g) increases the probability of recurrent early delivery. These patients require particularly close surveillance. A history of unexplained pregnancy loss in the third trimester should alert the clinician...

Impact of a Voice Disorder on the Patient

Phonation is the process of sound production by the interaction of airflow through the glottis and the opening and closing of the vocal cords of the larynx. Voice loudness is proportional to the air pressure below the glottis pitch is related to this pressure and to the length of the vocal cords. Voice quality may change when there is interference with the vocal cords or pharyngeal cavity vibration (i.e., resonance). A voice disorder may be related to an enlarged vocal cord, a laryngeal mass,...

Impact of Head and Neck Disease on the Patient

The concept of body image is important. The head and neck are the most visible portions of the body. The shape of the eyes, mouth, face, and nose is very important to people. Many dislike their body image and want to change it by cosmetic surgery. Others require cosmetic surgery to repair alterations caused by trauma. Still others suffer from disfiguring head and neck cancer and need to undergo surgical procedures for the removal of these lesions. Many of these procedures are themselves...

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...

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 Canal

Gently insert the speculum and inspect the external canal. The external auditory canal is 24 mm long in the adult and is the only skin-lined, blind-ended canal in the body. The canal follows a tortuous course from the external meatus to the tympanic membrane. The techniques previously described are used to straighten the canal. There should be no evidence of redness, swelling, or tenderness, which indicates inflammation. The walls of the canal should be free of foreign bodies, scaliness, and...

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 Neck

Is the patient's breathing aided by the action of the accessory muscles Use of the accessory muscles is one of the earliest signs of airway obstruction. In respiratory distress, the trapezius and sternocleidomastoid muscles contract during inspiration. The accessory muscles assist in ventilation they raise the clavicle and anterior chest to increase the lung volume and produce an increased negative intrathoracic pressure. This results in retraction of the supraclavicular fossae and intercostal...

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...

Inspection

*The total cholesterol concentration for an adult is normally lower than 220 mg dL. in plasma triglyceride concentrations, usually to levels greater than 1500 mg dL.* These lesions developed in this patient after excessive alcohol consumption his serum triglyceride concentrations exceeded 2000 mg dL. The lesions, frequently found on the abdomen, buttocks, elbows, knees, and back, are small (1 to 3 mm in diameter), yellowish papules on an erythem-atous base. With reduction in the level of...

Internal Examination

The key to the internal examination is proper positioning of the head. Ask the patient to hold his or her head back. Place your left hand firmly on top of the patient's head, and use your left thumb to elevate the tip of the patient's nose. In this manner, change the position of the patient's head to visualize the intranasal structures. Use a light source to illuminate the internal structures. This technique is shown in Figure 11-21. Inspect the position of the septum to the lateral cartilages...

Interview of Mr John

John Doe, the He is a white man, interviewer enters patient, is lying comfortably in a two-bed room in St. Catherine's Hospital. is slightly obese, and is in his mid-40s. Mr. Doe is watching television. The the room, wearing a white coat. (Interviewer smiles and extends hand for a firm handshake) Good morning, I'm Susan Smith, a second-year medical student. Are you Mr. Doe (Pause interviewer watches for response) I've been asked to interview and examine you today. (Patient smiles, appearing...

Jaundice

The presence of jaundice (icterus) must alert the examiner that there is either liver parenchymal disease or an obstruction to bile flow. The presence of icterus, or jaundice, results from a decreased excretion of conjugated bilirubin into the bile. This can result from intrahepatic biliary obstruction, known as medical jaundice, or from extrahepatic biliary obstruction, known as surgical jaundice. In any patient with icterus, the examiner should search for clues by asking the following...

Jugular Venous Pulse

The jugular venous pulse provides direct information about the pressures in the right side of the heart because the jugular system is in direct continuity with the right atrium. During diastole, when the tricuspid valve is open, the jugular veins are continuous with the right ventricle as well. If there is no stenotic lesion at the pulmonic or mitral valves, the right ventricle indirectly monitors the pressures in the left atrium and left ventricle. The most common cause of right-sided heart...

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...

Loss of Consciousness

Loss of consciousness syncope may result from cardiovascular or neurologic causes. The cardiovascular causes are discussed in Chapter 14, The Heart, and Chapter 15, The Peripheral Vascular System. The term blackout is commonly used, but it may mean different conditions to the patient and the interviewer. Any patient who uses this term should be asked to clarify its meaning. The patient may be referring to an actual loss of consciousness, a dimming of vision, or a decreased awareness of the...

Loss of Vision

When a patient complains of loss of vision, the following two questions must be asked ''Did the loss of vision occur suddenly '' ''Is the eye painful '' It is extremely important to ascertain the acuteness of the loss of vision and the presence or absence of pain. Sudden, painless loss of vision may result from a retinal vascular occlusion or a retinal detachment. Sudden, painful loss of vision occurs in attacks of acute narrow-angle glaucoma. Gradual, painless loss of vision commonly occurs in...

Mark H Swartz Md Facp

I wish to acknowledge all of my professional colleagues and friends who have supported and guided me in writing this Sixth Edition. I express my heartfelt thanks to the following people, without whose assistance I could not have brought this book to a reality To all my teachers, students, and patients who have taught me so much about medicine. Special thanks to the following people who have helped in reviewing chapters for this edition Former Director of Statistics and Research Consulting and...

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 examination of the mouth and pharynx is the last part of the examination in this age group. The child should be seated on the parent's lap, with the parent holding the child's head. It is usually possible to examine a crying infant without using the tongue depressor. A frightened Figure 24-37 Ear specula designed to facilitate pneumatic otoscopy. A comfortable but tight seal in the ear canal is important for insufflation to be effective. Both of these reusable specula have the same internal...

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

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,...

Nipple Discharge

Nipple discharge is not a common symptom, but it should always raise the suspicion of breast disease, especially if the discharge occurs spontaneously. Any patient who describes a nipple discharge should be asked the following questions ' 'What is the color of the discharge '' ''Do you have a discharge from both breasts '' ''When did you first notice the discharge '' ''Is the discharge related to your menstrual cycle '' ''When was your last menstrual cycle '' ''Is the discharge associated with...

Nose

Is flaring of the nostrils present Flaring occurs in any type of respiratory distress. Inspect the tip of the nose. Is there a permanent transverse crease near the lower part of the nose directing the tip upward This is commonly seen in allergy sufferers. This unmistakable sign is caused by the allergic salute using a palm or an extended forefinger to rub the nose upward and outward. Elevate the tip of the nose and inspect the nasal mucosa. Are secretions present Purulent...

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...

Ocular Movements

Ocular movements are effected by the contraction and relaxation of the extraocular muscles. This results in simultaneous movement of the eyes up or down or from side to side, as well as in convergence. Alignment of the eyes is seen by observing the location of reflected light on the cornea. The penlight should be held directly in front of the patient. If the patient is looking straight ahead into the distance, the light reflex should be in the center of each cornea. If the light falls in the...

Palpate for Inguinal Hernias

To palpate for inguinal hernias, the examiner places his or her right index finger in the patient's scrotum above the left testis and invaginates the scrotal skin. There should be Figure 18-27 Varicocele. Figure 18-28 Hydrocele. Figure 18-27 Varicocele. Figure 18-28 Hydrocele. Figure 18-29 Transilluminated hydrocele. Figure 18-30 Cross section of a hydrocele, illustrating its anatomy. Figure 18-30 Cross section of a hydrocele, illustrating its anatomy. sufficient scrotal skin to reach the...

Palpate for Localized Motion

The patient should now lie down so that all four main cardiac areas can be palpated. The examiner uses his or her fingertips to assess any localized motion. This technique is demonstrated in Figure 14-28. The presence of a systolic impulse in the second intercostal space to the left of the sternum is suspect for pulmonary hypertension. This impulse is caused by the closure of the pulmonic valve under increased pressure. The presence of this impulse is suggestive of a dilated pulmonary artery,...

Palpate the Brachial Pulse

Because the brachial pulse is stronger than the digital pulses, the examiner may use his or her thumbs to palpate the patient's brachial pulses. The brachial artery can be felt medially just under the belly or tendon of the biceps muscle. With the examiner still standing in front of the patient, both brachial arteries can be palpated simultaneously. The examiner's left hand holds the patient's right arm, and the examiner's right hand holds the patient's left arm. Once the examiner's thumbs feel...

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 Floor of the Mouth

The floor of the mouth should be examined by bimanual palpation. This is performed by placing one finger under the tongue and another finger under the chin to assess any thickening or masses. Whenever palpating in a patient's mouth, the examiner should hold the patient's cheeks, as shown in Figure 12-31. This is done as a precaution in case the patient suddenly tries to speak or bite down on the examiner's finger. The examiner's right index finger is placed under the tongue the left thumb and...

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

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...

Palpate the Rectal Walls

The lateral, posterior, and anterior walls of the rectum are palpated. To palpate the lateral walls, rotate your digit along the sides of the patient's rectum, as shown in Figure 17-36. The ischial spines, coccyx, and lower sacrum can be felt easily. Palpate the walls for polyps, which may be sessile (attached by a base) or pedunculated (attached by a stalk). Any irregularities or undue tenderness should be noted. The only way to examine the entire circumference of the rectal wall fully is to...

Palpate the Testes

Use both hands to grasp the patient's testicle gently. While your left hand holds the superior and inferior poles of the testicle, your right hand palpates the anterior and posterior surfaces. The technique for palpation of the testicle is demonstrated in Figure 18-25. Note the size, shape, and consistency of each testicle. No tenderness or nodularity should be present. Normal testicles have a firm, rubbery consistency. The size and consistency of one

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...