Info

Figure 19-33 Chancre of primary syphilis. Figure 19-33 Chancre of primary syphilis. Figure 19-35 Common uterine positions. Figure 19-36 Sequelae of pelvic floor relaxation. A, Normal anatomy. B, Cystocele, which is a protrusion of the wall of the urinary bladder through the vagina. C, Rectocele, which is a protrusion of the rectal wall through the vagina. D, Uterine descent, which is a protrusion of the uterus through the vagina. Figure 19-37 Types of uterine bleeding. A, Normal 28-day cycle....

Signs and Symptoms in Deficiency States

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

Illustrative Case

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

Clinicopathologic Correlations

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

Ears

Pediatric Holding Otoscope

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

Impact of Musculoskeletal Disease on the Patient

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

Inspect the Penis

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

Syncope

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

Light Palpation

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...

General Considerations

The heart does not rest for more than a fraction of a second at a time. During a lifetime, it contracts more than 4 billion times. To support this active state, the coronary arteries supply more than 10 million liters of blood to the myocardium and more than 200 million liters to the systemic circulation. Cardiac output can vary under physiologic conditions from 3 to 30 L minute, and regional blood flow can vary by 200 . This wide range occurs without any loss of efficiency in the normal state....

Inspect the Lips

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

Wound Healing Scab

Wilk Scabies Ever Clear

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

Ancyclostoma Brazillienses Force Out Of The Skin

Neurotrophic Joint Xray Foot

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

Examination Vagina By Finger

Dick Vagina Cross Section View

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

The Adolescent Interview

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

The Rinne Test

Rinne Test

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

Change in Bowel Movements

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

Cyanosis

Differential Cyanosis

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

Neck

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

Mouth and Pharynx

Is there a cleft of the lip This may be to the left or the right of the midline and may be unilateral or bilateral. Is the philtrum well formed, with normal architecture Flattening of the philtrum is seen in infants with fetal alcohol syndrome. Test the sucking reflex. Put on a glove, and insert your index finger into the newborn's mouth. A strong sucking reflex should be present. The sucking reflex is usually strong by 34 weeks' gestation and disappears at 9 to 12...

Eyes

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

Skin Changes

Bico Viuva

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

The Weber Test

Weber Test

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

Impact of Deafness on the Patient

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

Secondary Survey

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

The Nervous System

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

Functional Anatomy of Birth

Right Occiput Posterior

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

Special Populations

Short Dick Syndrome

According to the National Health and Nutrition Examination Survey (NHANES) 2005-2006, 65.7 of adult Americans, representing nearly 100 million individuals, are classified as overweight or obese (defined as a BMI of 25 kg m2 or higher). Among the general population, 35 are considered overweight (BMI of 25 to 29.9), and 30.7 are considered obese (BMI of 30 or higher). Thus, obesity represents the most significant diet-related health problem encountered by health-care professionals. There are...

Bibliography

American Cancer Society Cancer Facts and Figures 2007. Atlanta, Ga American Cancer Society, 2007. Baldwin K, Ginsberg P, Harkaway RC Under-reporting of erectile dysfunction among men with unrelated urologic conditions. Int J Impot Res 15(2) 87, 2003. Bosl GJ, Bajorin DF, Sheinfeld J, et al Cancer of the testis. In DeVita VT Jr, Hellman S, Rosenberg SA (eds) Cancer Principles and Practice of Oncology, 7th ed. Philadelphia, Lippincott Williams & Wilkins, 2005. Brown JS, Bradley CS, Subak LL,...

Overriding Metopic Suture

Skull Anatomy Overriding Sutures

Examination of the head involves a thorough assessment of its shape, symmetry, and fontanelles. The skull may be molded, especially if the labor was prolonged and the head was engaged for a long period. The skull of a child born by cesarean section has a characteristic roundness. In the newborn, the sutures are frequently felt as ridges as a result of the overriding of the cranial bones by molding as the skull passes through the vaginal canal. Palpate the fontanelles, or ''soft spots.'' The...

Sample WriteUp of a Newborns History

This 2830-g female infant was born at 38 2 7 weeks to a 47-year-old G1 P0-0-0-0 mother by NSVD (normal spontaneous vaginal delivery) at 1 35 am on 1 16 2008. The pregnancy was complicated by chronic hypertension, for which the mother was treated with Aldomet (methyldopa). The mother is O+ and hepatitis B surface antigen, syphilis, HIV, and Chlamydia negative. Amniocentesis at 14 weeks revealed a 47,XX trisomy 21 karyotype. The mother continued the pregnancy, despite the amniocentesis results,...

Swollen Right Carotid Artery

Inspection Thyroid Gland

Cervical chain along the sternocleidomastoid muscle to feel for the superficial cervical chain hooking around the sternocleidomastoid muscle to feel for the deep cervical chain deep to the muscle into the anterior triangle region up to the jaw margin to feel for the tonsillar group along the jaw to feel the submaxillary chain to the tip of the jaw for the submental nodes and up to the anterior auricular chain in front of the ear. This sequence of examination is shown in Figure 9-9. Enlarged...

Palpate the Prostate Gland

The prostate gland lies anterior to the wall of the rectum. The size, surface, consistency, sensitivity, and shape of the prostate gland should be assessed. The prostate is a bilobed, heart-shaped structure approximately 1.5 inches (4 cm) in diameter. It is normally smooth and firm and has the consistency of a hard rubber ball. The apex of the heart shape points toward the anus. Identify the median sulcus and the lateral lobes. Note any masses, tenderness, and nodules. Only the lower apex...

Kayser Fleischer Ring

Kayser Fleischer Ring

Of the sclera with possible involvement of the cornea, uveal tract (i.e., iris, choroid, and ciliary body), or retina. Photophobia is common. Scleritis is usually related to a systemic disorder. It occurs much more commonly in patients with connective tissue disorders. It may be diffuse or localized and nodular. Nodular scleritis is marked by dark localized blue patches in the anterior portion of the sclera these are seen because the choroid is visible through the translucent sclera. The...

Visual Disturbance

Visual disturbances are common neurologic presenting symptoms. The most important symptoms are acute visual loss, chronic visual loss, and double vision. Ask any patient complaining of visual disturbances the following questions How long have you noticed these visual changes '' Is the visual loss associated with pain '' Did it occur suddenly '' ' 'Do you have a history of glaucoma '' Have you ever been told that you had a thyroid problem ' Do you have diabetes '' Acute painless visual loss is...

Traditional Chinese Medicine

There are many traditional medical practices. Of particular note are the Chinese, Ayurvedic, and Greek systems of healing. Owing to the limitations of space in this chapter, one traditional system of healing, Chinese medicine, which has influenced so many other systems, is considered. With more than 10 million people, the Asian and Pacific Islander group represents the third largest minority group in the United States. The Chinese approach to healing is a rich and complex tradition. It...

Structure and Physiology

Senile Loss Elasticity

This section covers some of the anatomic and physiologic changes that are attributed to aging, as well as some of the physical findings that result. There is atrophy of the epidermis, hair follicles, and sweat glands, which results in thinning skin. The skin becomes fragile and discolored. Wrinkling and dryness result from reduced skin turgor. In addition, the nails become thin and brittle, with marked ridging. There is decreased vascularity of the dermis, which contributes to prolonged healing...

Physical Examination

The equipment necessary for the examination of the abdomen and rectum consists of a stethoscope, gloves, lubricant, tissues, and occult blood testing card and Hemoccult developer. The patient should be lying flat in bed, and the abdomen should be fully exposed from the sternum to the knees. The arms should be at the sides, and the legs flat. Frequently, patients tend to place their arms behind their heads, which tightens the abdominal muscles and makes the examination more difficult. Placing a...

Rule Out Abdominal Bruits

Auscultation Abdomen Fig

The examiner places the diaphragm of the stethoscope in the midline of the patient's abdomen about 2 inches (5 cm) above the umbilicus and listens carefully for the presence of an aortic bruit. This technique is demonstrated in Figure 15-8. A renal bruit may be the only clue to renal artery stenosis. Auscultation should be performed about 2 inches (5 cm) above the umbilicus and 1 to 2 (2.5 to 5 cm) inches laterally to the right and to the left of midposition....

Inspect the Breasts

Inspection is first accomplished with the patient's arms at her side, as shown in Figure 16-10. Tell the patient, ''I am inspecting the breasts for any changes in the skin, contour, or symmetry.'' The breasts are inspected for size, shape, symmetry, contour, color, and edema. The nipples are inspected as to size, shape, inversion, eversion, or discharge. The nipples should be symmetric. Is any abnormal bulging present The skin of the breast is observed for edema. Edema of the skin of the breast...

Psychosocial and Spiritual History

The psychosocial history includes information on the education, life experiences, and personal relationships of the patient. This section should include the patient's lifestyle, other people living with the patient, schooling, military service, religious beliefs (in relation to the perceptions of health and treatment), and marital or significant-other relationships. You can start by asking one of the following questions ' 'Tell me a little about yourself your background, education, work,...

Palmar Crease Pallor

Herpes Simplex Rash Birth

Skin color in newborns is related partially to the amount of fat present. Preterm infants generally appear redder because they have less subcutaneous fat than do term infants. The newborn has vasomotor instability, and the color of the skin may vary greatly from moment to moment and from one area of the body to another. It is often noted that when the infant is lying on one side for a time, a sharp color demarcation appears The lower half of the body becomes red, and the upper half is pale....

Ruptur Thympanic Membran Cruris

This completes the basic musculoskeletal screening examination. The remainder of this section describes the symptoms and examination of specific joints. Any area must be inspected for evidence of swelling, atrophy, redness, and deformity, as well as palpated for swelling, muscle spasm, and local painful areas. The range of motion is assessed both actively and passively. Figure 20-35 Technique for evaluating the temporomandibular joint. Figure 20-35 Technique for evaluating the temporomandibular...

Inspect the Hard and Soft Palates

Petechiae Hard Palate

Inspect the rugae and vault shape of the palates. Also inspect the palates for ulceration and masses. Masses are usually minor salivary gland tumors, mostly malignant. Are any white plaques present Is the soft palate edematous Is the uvula in the midline Is the palate intact Figure 12-32 shows a severe cleft palate. Clefts of the palate and lips are distinct entities but are closely related embryologically, functionally, and genetically. The incidence of an isolated cleft palate is 1 per 1000...

Norwegian Scabies

Kaposi Sarcoma White Man Back

A month or longer may pass before the symptom of generalized pruritus develops. The diagnostic physical sign is the burrow, which is a serpiginous, palpable track about 1 cm in length that may end in a papule, nodule, or tiny vesicle. The adult female mite is present in the burrow. The extremely pruritic rash of scabies has a predilection for the web spaces of the fingers and toes, as well as the groin. The buttocks are also frequently involved, as are the genitals of men and the nipples of...

Pain

Pain is an infrequent symptom of neurologic disease, but it merits mention. Trigeminal neuralgia, also known as tic douloureux, is the occurrence of severe, jabbing pain lasting only seconds in the distribution of the maxillary or mandibular divisions of the trigeminal nerve (Fig. 21-10). It is frequently provoked by motion, touch, eating, or exposure to cold temperatures. Another cause of facial pain is the cluster headache, already discussed. Herpes zoster infection of a sensory nerve root,...

Sinus Disease Symptoms

The symptoms of sinus disease are similar to the symptoms of nasal disease. Fever, malaise, cough, nasal congestion, maxillary toothache, purulent nasal discharge, headache, and little improvement of symptoms with decongestants increase the likelihood of sinus disease. Pain, often made worse by bending forward, is an important symptom. Pain from localized sinus disease is usually present in the area overlying the involved sinus. The only exception is sphenoid sinus disease, which is felt...

Angular Cheilitis Early Hiv Symptom

Hiv Simptom Photos

Alteration of taste, gingival pain, malaise, fever, and halitosis. As the disease progresses, a whitish pseudomembrane develops along the gingival margins, with ulceration and blunting of the interdental papillae. Acute necrotizing gingivitis, pictured in Figure 12-57, may be an early feature of HIV infection. On August 6, 2008, the Centers for Disease Control and Prevention (CDC) released a new estimate of the annual number of new HIV infections (HIV incidence) in the United States, revealing...

Inspect the Facies

Moon Facies

Are the eyes sunken Is temporal wasting present These signs indicate wasting and poor nutrition. The skin around the mouth and oral mucosa may provide evidence of gastrointestinal disorders. Melanin deposition around and in the oral cavity, especially the buccal mucosa, Figure 17-8 Osler-Weber-Rendu syndrome. Figure 17-8 Osler-Weber-Rendu syndrome. suggests Peutz-Jeghers syndrome. Figure 12-12 shows the lips of a patient with the classic brown pigmentary changes of Peutz-Jeghers syndrome. This...

Roth Spot Fundus Photos

White Marks Choroid

Figure 10-99 Diabetic retinopathy with neovascularization of the disc, neovascularization elsewhere in the retina, preretinal hemorrhage, and fatty macular exudates. Figure 10-99 Diabetic retinopathy with neovascularization of the disc, neovascularization elsewhere in the retina, preretinal hemorrhage, and fatty macular exudates. Figure 10-101 Proliferative diabetic retinopathy. Note the lesions of panretinal photocoagulation. Figure 10-101 Proliferative diabetic retinopathy. Note the lesions...

Inspect the Tongue

White Tongue Normal Variant

Inspect the mucosa, and note any masses or ulceration. Is the tongue moist Ask the patient to stick out the tongue. A neuromuscular weakness may be present if the tongue cannot protrude in the midline or move rapidly in all directions. Are there any mass lesions on the sides or undersurface of the tongue Ask the patient to lift the tongue to the roof of the mouth so that the inferior aspect of the tongue can be inspected. In older individuals, the large veins on the ventral aspect of the tongue...

Palpitations

Palpitations are the uncomfortable sensations in the chest associated with a range of arrhythmias. Patients may describe palpitations as ''fluttering,'' ''skipped beats,'' ''pounding,'' Description ''Aching,'' ''dull,'' ''pressing,'' ''squeezing,'' ''viselike'' Precipitated by Effort, emotion, eating, cold Relieved by Rest, nitroglycerin Left inframammary, localized Right arm ''Sharp,'' ''shooting,'' cutting Excruciating Seconds, hours, days Respiration, posture, motion Nonspecific Description...

The Dying Patient

Few patients are as conscious of taking up a clinician's time as those who have less time remaining. Dying patients may initially have many questions, but as time goes by, they ask less and less of their health-care providers. Many health-care providers have a dread of death that is so intense that they behave irrationally. They avoid patients who are dying or those with incurable diseases. The emotional needs of the dying patients may be largely ignored. Many patients have a greater fear of...

Differential Diagnosis Genital Wart Scrotum

Condylomata Acuminata Man

Figure 18-33 Position of the examining finger in the inguinal canal. examine the patient's right side and the left index finger for the patient's left side. Try both techniques to see which one is more comfortable for you. If there is a large scrotal mass that appears opaque on transillumination, an indirect inguinal hernia may be present in the scrotum. Auscultation of the mass can be performed to determine whether bowel sounds are present in the scrotum, a useful sign in diagnosing an...

Inspect for Varicosities

Ask the patient to stand, and inspect the lower extremities for varicosities. Look at the area of the proximal femoral ring, as well as in the distal portion of the legs. Varicose veins in these locations may not have been visible when the patient was lying down. The patient in Figure 15-5 was a 37-year-old woman with severe right-sided heart failure. Notice the marked dilated and tortuous veins in the popliteal fossa. Also notice the increased pigmentation of the skin over the lower legs. *A...

Basic Principles of Geriatric Medicine

Whereas in the younger population the goal of medicine is to cure, the ultimate goal in the geriatric population is to preserve the patient's quality of life. The health-care professional must strive to maintain function and relieve the symptoms that can be relieved. This often involves moving from a doctor-patient relationship alone to a doctor-family or doctor-caregiver relationship. In the event of terminal illness, you should ensure as little mental and physical distress as possible and...

Classifications of Complementary and Alternative Medicine

The NCCAM has classified CAM therapies into five major but overlapping categories 3. Biologically based therapies 4. Manipulative and body-based methods *Policies of House of Delegates-I-95 H-480.973 BOT Rep. 15-A-94, Reaffirmed and Modified by Sub. Res. 514, I-95. Alternative medical systems are complete, complex systems of health-care practices that incorporate natural products, spiritual elements, diet, and other modalities. Some systems such as homeopathic medicine and naturopathic medicine...

Candy Cane Syndrome

Hyphema And Lense Dislocation

Mid-dilated pupil may be present with acute angle-closure glaucoma. Pupillary constriction, or miosis, occurs with ingestion of parasympathomimetic drugs, with inflammation of the iris, and with drug treatment for glaucoma. Many medications can cause anisocoria. It is therefore important to ascertain whether the patient has used any eye drops or has taken any medications. Pupillary abnormalities are often markers of neurologic disease. A condition known as Adie's tonic pupil is a pupil dilated...

Leaning Forward Maneuver Pancreatic Pain

Pain is probably the most important symptom of abdominal disease. Although abdominal neoplasia may be painless, most abdominal disease manifests itself with some amount of pain. Pain can result from mucosal irritation, smooth muscle spasm, peritoneal irritation, capsular swelling, or direct nerve stimulation. Abdominal pain necessitates speedy diagnosis and therapy. When a patient complains of abdominal pain, ask the following questions ''Has the pain changed its location since it started ''...

Inspect the Abdomen

Effect Abdomen Ascites Scar

The contour of the abdomen should be assessed. A scaphoid, or concave, abdomen may be associated with cachexia a protuberant abdomen may result from gaseous distention of the intestines, ascites, (splenomegaly lator), or obesity. When a patient with ascites stands, the fluid sinks into the lower abdomen when lying supine, the fluid bulges in the flanks. If a patient with ascites lies on the side, the fluid flows to the dependent lower side. A patient with a protuberant abdomen as a result of...

History of Present Illness and Debilitating Symptoms

The history of the present illness refers to the recent changes in health that led the patient to seek medical attention at this time. It describes the information relevant to the chief complaint. It should answer the questions of what, when, how, where, which, who, and why. Chronology is the most practical framework for organizing the history. It enables the interviewer to comprehend the sequential development of the underlying pathologic process. In this section, the interviewer gathers all...

Questioning

The secret of effective interviewing lies in the art of questioning. The wording of the question is often less important than the tone of voice used to ask it. In general, questions that stimulate the patient to talk freely are preferred. Open-ended questions are used to ask the patient for general information. This type of question is most useful in beginning the interview or for changing the topic to be discussed. An open-ended question allows the patient to tell his or her story...

Culture and Health

It is crucial for any health-care provider to have an appreciation for cross-cultural family values, language, norms, religion, and political ideology. An estimated 80 to 90 of all self-recognized episodes of illness are managed exclusively outside a formal health-care system. Traditional healers, mediums, self-help groups, and religious practitioners provide a substantial proportion of this health care. Within the United States, there are many culturally distinct groups. Even within these...

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Figure 28-1 Family tree of patient John Doe. A& W, alive and well Ca, cancer CHD, coronary heart disease. Chlor-Trimeton, for colds Aspirin, for headaches Multivitamins with iron, daily Father, 75, diabetes, broken hip Mother died, 64, stomach cancer Brother, 45, heart attack at age 40 Sister, 37, alive and well Son, 15, alive and well Wife, 41, alive and well There is no family history of congenital disease. No other history of diabetes or cardiac disease. No history of renal, hepatic, or...

The Written Physical Examination

Left Lower Abdominal Tenderness

After the examination has been completed, the examiner must be able to record objectively all the findings of inspection, palpation, percussion, and auscultation. Be precise in stating locations of abnormalities. Small drawings may be useful to describe a shape or location better. When describing the size of a finding, state the size in millimeters or centimeters rather than comparing it with a fruit or nut, for example, because these can vary greatly in size. It is best not to use most...

Inspect the Tympanic Membrane

Normal Tympanic Membrane Labeled

As the speculum is introduced farther into the canal in a downward and forward direction, the tympanic membrane is visualized. The tympanic membrane should appear as an intact, ovoid, semitransparent, pearly gray membrane at the end of the canal. The lower four fifths of the tympanic membrane is called the pars tensa the upper fifth, the pars flaccida. The handle of the malleus should be seen near the center of the pars tensa. From the lower end of the handle, there is frequently a bright...

Specific Cross Cultural Perspectives

In this section, some cross-cultural perspectives, including some common beliefs regarding health and illness, are examined. This section also discusses some strategies that can be applied to improving care of patients. The intention is to sensitize the reader to the vast differences among the major ethnic groups in the United States. It is beyond the scope of this book to include all ethnic groups the reader is referred to the Bibliography at the end of this chapter. A note about socioeconomic...

Tinea Cruris Cura

Fungal Infection Gluteal Cleft

Notice the rolled, well-defined margin. Figure 8-33 Basal cell carcinoma. Notice the rolled, well-defined margin. Figure 8-38 Acral-lentiginous melanoma. Figure 8-38 Acral-lentiginous melanoma. frequently in individuals who are exposed to constant sunlight, such as sailors and agricultural workers. Melanomas occur more often in rather fair-skinned individuals who experience brief, intense sun exposure, such as that occurring during vacations in the southern...

Inspect the Penis and Scrotum

Penis Syphilis

In the examination of the penis and scrotum, note the following Any lesions on the penis and penile edema Figure 18-11 shows ectopic sebaceous glands on the shaft of the penis. The glands appear as pinhead-sized, whitish-yellow papules. These are commonly seen in normal men on the corona, the inner foreskin, and the shaft of the penis. Their appearance is very similar to Fordyce's spots of the oral mucosa (see Fig. 12-18). Ectopic sebaceous glands also may be found in normal women on the labia...

Changes in Urine Flow

Changes in urine flow include frequency and incontinence. Urinary frequency is the most common symptom of the genitourologic system. Frequency is defined as passing urine more often than normal. Nocturia is urinary frequency at night. There are several causes of frequency decreased bladder size, bladder wall irritation, and increased urine volume. If an obstructed bladder cannot be completely emptied at each voiding, its effective capacity is diminished. The following questions, in addition to...

From the Sushruta Samhita ca 3000 bce

Penis Sup Dorsal Vein Cut Problems

Since the beginning of recorded history, the external genitalia and the urologic system have been of special interest to people. Kidney stones and urologic surgery were well described in antiquity. One of the earliest reported kidney stones was found in a young boy who lived about 7000 BCE. Circumcision is one of the oldest known surgical procedures in medicine. Male circumcision has been widely practiced as a religious rite since ancient times. An initiatory rite of Judaism, circumcision is...