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BatesPocketGuidetoPhysicalExaminationandHistoryTaking8thEdition.pdf

Physical Examination AND History Taking

B A T E S' Pocket Guide to

E I G H T H E D I T I O N

Lynn S. Bickley, MD, FACP Clinical Professor of Internal Medicine School of Medicine University of New Mexico Albuquerque, New Mexico

Peter G. Szilagyi, MD, MPH Professor of Pediatrics and Executive Vice-Chair Department of Pediatrics University of California at Los Angeles (UCLA) Los Angeles, California

Guest Edit or

Richard M. Hoffman, MD, MPH, FACP Professor of Internal Medicine and Epidemiology Director, Division of General Internal Medicine University of Iowa Carver College of Medicine Iowa City, Iowa

Physical Examination AND History Taking

B A T E S' Pocket Guide to

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Eighth Edition

Copyright © 2013, 2009 by Wolters Kluwer Health | Lippincott Williams & Wilkins. Copyright © 2007, 2004, 2000 by Lippincott Williams & Wilkins. Copyright © 1995, 1991 by J. B. Lippincott Company. All rights reserved. This book is protected by copyright. No part of this book may be reproduced or transmitted in any form or by any means, including as photocopies or scanned-in or other electronic copies, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews. Materials appearing in this book prepared by individuals as part of their official duties as U.S. government employees are not covered by the above-mentioned copyright. To request permission, please contact Wolters Kluwer at Two Commerce Square, 2001 Market Street, Philadelphia, PA 19103, via email at [email protected], or via our website at lww.com (products and services).

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Library of Congress Cataloging-in-Publication Data Names: Bickley, Lynn S., author. | Szilagyi, Peter G., author. | Hoffman, Richard M., editor. | Abridgement of (expression): Bickley, Lynn S. Bates’ guide to physical examination and history-taking. 12th ed. Title: Bates’ pocket guide to physical examination and history taking / Lynn S. Bickley, Peter G. Szilagyi ; guest editor, Richard M. Hoffman. Other titles: Pocket guide to physical examination and history taking Description: Eighth edition. | Philadelphia : Wolters Kluwer, [2017] | Abridgement of: Bates’ guide to physical examination and history-taking. / Lynn S. Bickley, Peter G. Szilagyi. Twelfth edition. [2017]. | Includes bibliographical references and index. Identifiers: LCCN 2016030575 | ISBN 9781496338488 (alk. paper) Subjects: | MESH: Physical Examination–methods | Medical History Taking–methods | Handbooks Classification: LCC RC76 | NLM WB 39 | DDC 616.07/54–dc23 LC record available at https://lccn.loc.gov/2016030575

This work is provided “as is,” and the publisher disclaims any and all warranties, express or implied, including any warranties as to accuracy, comprehensiveness, or currency of the content of this work.

This work is no substitute for individual patient assessment based upon healthcare professionals’ examination of each patient and consideration of, among other things, age, weight, gender, current or prior medical conditions, medication history, laboratory data and other factors unique to the patient. The publisher does not provide medical advice or guidance and this work is merely a reference tool. Healthcare professionals, and not the publisher, are solely responsible for the use of this work including all medical judgments and for any resulting diagnosis and treatments.

Given continuous, rapid advances in medical science and health information, independent professional verification of medical diagnoses, indications, appropriate pharmaceutical selections and dosages, and treatment options should be made and healthcare professionals should consult a variety of sources. When prescribing medication, healthcare professionals are advised to consult the product information sheet (the manufacturer’s package insert) accompanying each drug to verify, among other things, conditions of use, warnings and side effects and identify any changes in dosage schedule or contraindications, particularly if the medication to be administered is new, infrequently used or has a narrow therapeutic range. To the maximum extent permitted under applicable law, no responsibility is assumed by the publisher for any injury and/or damage to persons or property, as a matter of products liability, negligence law or otherwise, or from any reference to or use by any person of this work.

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We would like to dedicate this book to all our

students, trainees, and mentees who have

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ar t of medicine.

Faculty Reviewers

J. D. Bartleson Jr., MD Associate Professor of Neurology Mayo Clinic Rochester, Minnesota

John D. Bartlett, MD Assistant Clinical Professor of

Ophthalmology Jules Stein Eye Institute David Geffen School of Medicine Los Angeles, California

Amy E. Blatt, MD Assistant Professor Department of Medicine School of Medicine and Dentistry University of Rochester Medical Center Rochester, New York

Adam Brodsky, MD Associate Professor Medical Director Geriatric Psychiatry Services Department of Psychiatry and

Behavioral Sciences School of Medicine University of New Mexico Psychiatric

Center & Sandoval Regional Medical Center

Albuquerque, New Mexico

Thomas M. Carroll, MD, PhD Assistant Professor Department of Medicine School of Medicine and Dentistry University of Rochester Medical Center Rochester, New York

Adam J. Doyle, MD Assistant Professor Department of Surgery School of Medicine and Dentistry University of Rochester Medical Center Rochester, New York

Amit Garg, MD Dermatologist Northwell Health Physician Partners Manhasset, New York

Catherine F. Gracey, MD Associate Professor Department of Medicine School of Medicine and Dentistry University of Rochester Medical

Center Rochester, New York

Carla Herman, MD, MPH Chief Division of Geriatrics and Palliative

Medicine Professor Department of Internal Medicine School of Medicine University of New Mexico Albuquerque, New Mexico

William C. Hulbert, MD Professor Department of Urology School of Medicine and Dentistry University of Rochester Medical Center Rochester, New York

Mark Landig, OD Department of Ophthalmology Jules Stein Eye Institute David Geffen School of Medicine Los Angeles, California

Helen R. Levey, DO, MPH PGY5 Resident School of Medicine and Dentistry University of Rochester Medical

Center Rochester, New York

Faculty Reviewers vii

Patrick McCleskey, MD Dermatologist Oakland Medical Center Oakland, California

Jeanne H. S. O’Brien, MD Associate Professor Department of Urology School of Medicine and Dentistry University of Rochester Medical Center Rochester, New York

Alec B. O’Connor, MD, MPH Director, Internal Medicine Associate Professor Department of Medicine School of Medicine and Dentistry University of Rochester Medical Center Rochester, New York

A. Andrew Rudmann, MD Associate Professor Department of Medicine University of Rochester Medical Center School of Medicine and Dentistry Rochester, New York

Moira A. Szilagyi, MD, PhD Professor of Pediatrics University of California at Los Angeles

(UCLA) Los Angeles, California

Loralei Lacina Thornburg, MD Associate Professor Department of Obstetrics and

Gynecology School of Medicine and Dentistry University of Rochester Medical Center Rochester, New York

Scott A. Vogelgesang, MD Director Division of Immunology Clinical Professor Department of Internal Medicine–

Immunology University of Iowa Carver College

of Medicine Iowa City, Iowa

Brian P. Watkins, MD Surgeon Genesee Surgical Associates Rochester, New York

Paula Zozzaro-Smith, DO Fellow of Maternal-Fetal Medicine Department of Obstetrics and

Gynecology The University of Rochester Rochester, New York

S TUD EN T REVIEWERS

Ayala Danzig University of Rochester School of

Medicine and Dentistry

Benjamin Edmonds University of Central Florida College

of Medicine

Nicholas P. N. Goldstein University of Rochester School of

Medicine and Dentistry

viii

Preface

Bates’ Pocket Guide to Physical Examination and History Taking, eighth edi- tion, is a concise, portable text, with new chapters on assessing clinical evidence and examination of the skin, hair, and nails, that:

■ Recommends how to sequence the physical examination and document an accurate written record.

■ Clari es assessment of clinical evidence. ■ Describes how to interview the patient and take the health history. ■ Details and illustrates the steps of each of the regional physical examina- tions.

■ Reminds students of common, normal, and abnormal physical ndings. ■ Provides visual aids and comparative tables to guide recognition of common and selected ndings.

There are several ways to use the Pocket Guide: ■ To review and remember the content of a health history. ■ To review and rehearse the techniques of examination. This can be done while learning a single section and again while combining the approaches to several body systems or regions into an integrated examination (see Chapter 1).

■ To review common variations of normal and selected abnormalities. Observations are keener and more precise when the examiner knows what to look, listen, and feel for.

■ To look up special techniques as the need arises. Maneuvers such as The Timed Get Up and Go test are included in the Special Techniques section in each chapter.

■ To look up additional information about possible ndings, including abnormalities and standards of normal.

The Pocket Guide is not intended to serve as a primary text for learning the skills of history taking or physical examination. Its detail is too brief. It is intended instead as an aid for student recall of the regional examinations and examinations for special populations and as a convenient, brief, and portable reference.

Contents

Faculty Reviewers vi Preface viii

C H A P T E R 1 Foundations for Clinical Proficiency 1

C H A P T E R 2 Evaluating Clinical Evidence 27

C H A P T E R 3 Interviewing and the Health History 41

C H A P T E R 4 Beginning the Physical Examination: General Survey, Vital Signs, and Pain 59

C H A P T E R 5 Behavior and Mental Status 77

C H A P T E R 6 The Skin, Hair, and Nails 89

C H A P T E R 7 The Head and Neck 115

C H A P T E R 8 The Thorax and Lungs 145

C H A P T E R 9 The Cardiovascular System 167

C H A P T E R 10 The Breasts and Axillae 187

C H A P T E R 11 The Abdomen 199

C H A P T E R 12 The Peripheral Vascular System 219

C H A P T E R 13 Male Genitalia and Hernias 233

C H A P T E R 14 Female Genitalia 247

C H A P T E R 15 The Anus, Rectum, and Prostate 265

C H A P T E R 16 The Musculoskeletal System 275

C H A P T E R 17 The Nervous System 311

C H A P T E R 18 Assessing Children: Infancy through Adolescence 349

C H A P T E R 19 The Pregnant Woman 383

C H A P T E R 2 0 The Older Adult 399

Index 423

C H A P T E R

1Foundations for Clinical Proficiency

This chapter provides a road map to clinical pro ciency in two critical areas: the health history and the physical examination.

For adults, the comprehensive history includes Identifying Data and Source of the History, Chief Complaint(s), Present Illness, Past History, Family History, Personal and Social History, and Review of Systems. New patients in the of ce or hospital merit a comprehensive health history; however, in many situations, a more exible focused, or problem-oriented, interview is appropriate. The components of the comprehensive health history structure the patient’s story and the format of your written record, but the order shown below should not dictate the sequence of the interview. The interview is more uid and should follow the patient’s leads and cues, as described in Chapter 3.

O v e r v ie w : C o m p o n e n t s o f t h e A d u lt H e a lt h H is t o r y

Id e n t ify in g Da t a ● Identifying d t —such s ge, gender, occu tion, rit l st tus

● Source of the history—usu lly the tient , but c n be f ily e ber or friend, letter of referr l, or the clinic l record

● If ro ri te, est blish source of referr l bec use written re ort y be needed

Re lia b ilit y ● V ries ccording to the tient’s e ory, trust, nd ood

Ch ie f Co m p la in t (s ) ● The one or ore sy to s or concerns c using the tient to seek c re

P re s e n t Illn e s s ● A lifies the Chief Co l int; describes how e ch sy to develo ed

● Includes tient’s thoughts nd feelings bout the illness

● Pulls in relev nt ortions of the Review of Syste s, c lled “ ertinent ositives nd neg tives” (see . 3)

● M y include edic tions, llergies, h bits of s ok- ing nd lcohol, which frequently re ertinent to the resent illness

(continued )

2 Ba tes ’ Pocke t Guide to Physica l Examina tion and His tory Taking

Decide if your assessment will be comprehensive or focused. Be sure to distinguish subjective from objective data.

S u b je c t ive Da t a Ob je c t ive Da t a

Wh t the tient tells you Wh t you detect during the ex in - tion, l bor tory infor tion, nd test d t

The sy to s nd history, fro Chief Co l int through Review of Syste s

All hysic l ex in tion findings, or signs

The Comprehensive Adult Health History

As you elicit the adult health history, be sure to include the following: date and time of history; identifying data, which include age, gender, marital status, and occupation; and reliability, which re ects the quality of infor- mation the patient provides.

C h ie f C o m p la in t (s ) Quote the patient’s own words. “My stomach hurts and I feel awful”; or “I have come for my regular check-up.”

O v e r v ie w : C o m p o n e n t s o f t h e A d u lt H e a lt h H is t o r y (Continued)

Pa s t His t o ry ● Lists childhood illnesses ● Lists dult illnesses with d tes for t le st four

c tegories: edic l, surgic l, obstetric/gynecologic, nd sychi tric

● Includes he lth inten nce r ctices such s i uniz tions, screening tests, lifestyle issues, nd ho e s fety

Fa m ily His t o ry ● Outlines or di gr s ge nd he lth, or ge nd c use of de th, of siblings, rents, nd gr nd rents

● Docu ents resence or bsence of s ecific illnesses in f ily, such s hy ertension, coron ry rtery dise se, etc.

Pe r s o n a l a n d S o c ia l His t o ry

● Describes educ tion l level, f ily of origin, current household, erson l interests, nd lifestyle

Re vie w o f S ys t e m s ● Docu ents resence or bsence of co on sy to s rel ted to e ch jor body syste

Chapter 1 | Foundations for Clinical Proficiency 3

P r e s e n t Illn e s s This section is a complete, clear, and chronologic account of the problems prompting the patient to seek care. It should include the problem’s onset, the setting in which it has developed, its manifestations, and any treatments.

Every principal symptom should be well characterized, with descriptions of the seven features listed below and pertinent positives and negatives from relevant areas of the Review of Systems that help clarify the differential diagnosis.

T h e S e v e n A t t r ib u t e s o f E v e r y S y m p t o m

● Loc tion ● Qu lity ● Qu ntity or severity ● Ti ing, including onset, dur tion, nd frequency ● Setting in which it occurs ● Aggr v ting nd relieving f ctors ● Associ ted nifest tions

In addition, list medications, including name, dose, route, and frequency of use; allergies, including speci c reactions to each medication; tobacco use; and alcohol and drug use.

P a s t H is t o r y List childhood illnesses, then list adult illnesses in each of four areas:

■ Medical (e.g., diabetes, hypertension, hepatitis, asthma, HIV), with dates of onset; also information about hospitalizations with dates; number and gender of sexual partners; risky sexual practices

■ Surgical (dates, indications, and types of operations)

■ Obstetric/gynecologic (obstetric history, menstrual history, birth control, and sexual function)

■ Psychiatric (illness and time frame, diagnoses, hospitalizations, and treatments)

Also discuss Health Maintenance, including immunizations, such as tetanus, pertussis, diphtheria, polio, measles, rubella, mumps, in uenza, varicella, hepatitis B virus (HBV), human papillomavirus (HPV), Haemophilus in uenzae type B, pneumococcal vaccine, and herpes zoster vaccine; and screening tests, such as tuberculin tests, Pap smears, mammograms, stool tests for occult blood, colonoscopy, and cholesterol tests, together with the results and the dates they were last performed.

4 Ba tes ’ Pocke t Guide to Physica l Examina tion and His tory Taking

Fa m ily H is t o r y Outline or diagram the age and health, or age and cause of death, of each immediate relative, including grandparents, parents, siblings, children, and grandchildren. Record the following conditions as either present or absent in the family: hypertension, coronary artery disease, elevated cholesterol levels, stroke, diabetes, thyroid or renal disease, cancer (specify type), arthritis, tuberculosis, asthma or lung disease, headache, seizure disorder, mental illness, suicide, alcohol or drug addiction, and allergies, as well as conditions that the patient reports.

P e r s o n a l a n d S o c ia l H is t o r y Include occupation and the last year of schooling; home situation and signi cant others; sources of stress, both recent and long term; important life experiences, such as military service; leisure activities; religious af liation and spiritual beliefs; and activities of daily living (ADLs). Also include lifestyle habits such as exercise and diet, safety measures, and alternative health care practices.

R e v ie w o f S y s t e m s (R O S ) These “yes/no” questions go from “head to toe” and conclude the interview. Selected sections can also clarify the Chief Complaint; for example, the respiratory ROS helps characterize the symptom of cough. Start with a fairly general question. This allows you to shift to more speci c questions about systems that may be of concern. For example, “How are your ears and hearing?” “How about your lungs and breathing?” “Any trouble with your heart?” “How is your digestion?” The Review of Systems questions may uncover problems that the patient overlooked. Remember to move major health events to the Present Illness or Past History in your write-up.

Some clinicians do the Review of Systems during the physical exami- nation. If the patient has only a few symptoms, this combination can be efficient but may disrupt the flow of both the history and the examination.

Ge n e ra l. Usual weight, recent weight change, clothing that ts more tightly or loosely than before; weakness, fatigue, fever.

S k in . Rashes, lumps, sores, itching, dryness, color change; changes in hair or nails; changes in size or color of moles.

He a d , Eye s , Ea rs , No s e , Th ro a t (HEENT). Head: Headache, head injury, dizziness, lightheadedness. Eyes: Vision, glasses or contact lenses, last examination, pain, redness, excessive tearing, double or blurred vision,

Chapter 1 | Foundations for Clinical Proficiency 5

spots, specks, ashing lights, glaucoma, cataracts. Ears: Hearing, tinni- tus, vertigo, earache, infection, discharge. If hearing is decreased, use or nonuse of hearing aid. Nose and sinuses: Frequent colds, nasal stuf ness, discharge or itching, hay fever, nosebleeds, sinus trouble. Throat (or mouth and pharynx): Condition of teeth and gums; bleeding gums; dentures, if any, and how they t; last dental examination; sore tongue; dry mouth; frequent sore throats; hoarseness.

Ne ck . Lumps, “swollen glands,” goiter, pain, stiffness.

Bre a s t s . Lumps, pain or discomfort, nipple discharge, self-examination practices.

Re s p ira t o ry. Cough, sputum (color, quantity), hemoptysis, dyspnea, wheezing, pleurisy, last chest x-ray. You may wish to include asthma, bron- chitis, emphysema, pneumonia, and tuberculosis.

Ca rd io va s c u la r. “Heart trouble,” hypertension, rheumatic fever, heart murmurs, chest pain or discomfort, palpitations, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, edema, past electrocardiographic or other cardiovascular tests.

Ga s t ro in t e s t in a l. Trouble swallowing, heartburn, appetite, nausea. Bowel movements, color and size of stools, change in bowel habits, rectal bleeding or black or tarry stools, hemorrhoids, constipation, diarrhea. Abdominal pain, food intolerance, excessive belching or passing of gas. Jaundice, liver or gallbladder trouble, hepatitis.

P e r ip h e ra l Va s c u la r. Intermittent claudication; leg cramps; varicose veins; past clots in veins; swelling in calves, legs, or feet; color change in ngertips or toes during cold weather; swelling with redness or tenderness.

Urin a ry. Frequency of urination, polyuria, nocturia, urgency, burning or pain on urination, hematuria, urinary infections, kidney stones, incon- tinence; in males, reduced caliber or force of urinary stream, hesitancy, dribbling.

Ge n it a l. Male: Hernias, discharge from or sores on penis, testicular pain or masses, history of sexually transmitted infections (STIs) and treatments, testicular self-examination practices. Sexual habits, interest, function, satisfaction, birth control methods, condom use, problems. Concerns about HIV infection. Female: Age at menarche; regular- ity, frequency, and duration of periods; amount of bleeding, bleeding between periods or after intercourse, last menstrual period; dysmenor- rhea, premenstrual tension. Age at menopause, menopausal symptoms, postmenopausal bleeding. In patients born before 1971, exposure to

6 Ba tes ’ Pocke t Guide to Physica l Examina tion and His tory Taking

diethylstilbestrol (DES) from maternal use during pregnancy. Vaginal discharge, itching, sores, lumps, STIs and treatments. Number of preg- nancies, number and type of deliveries, number of abortions (spontane- ous and induced), complications of pregnancy, birth control methods. Sexual preference, interest, function, satisfaction, problems (including dyspareunia). Concerns about HIV infection.

Mu s c u lo s k e le t a l. Muscle or joint pain, stiffness, arthritis, gout, backache. If present, describe location of affected joints or muscles, any swelling, redness, pain, tenderness, stiffness, weakness, or limitation of motion or activity; include timing of symptoms (e.g., morning or evening), duration, and any history of trauma. Neck or low back pain. Joint pain with systemic features such as fever, chills, rash, anorexia, weight loss, or weakness.

P s ych ia t ric . Nervousness; tension; mood, including depression, mem- ory change, suicide attempts, if relevant.

Ne u ro lo g ic . Changes in mood, attention, or speech; changes in orienta- tion, memory, insight, or judgment; headache, dizziness, vertigo; fainting, blackouts, seizures, weakness, paralysis, numbness or loss of sensation, tingling or “pins and needles,” tremors or other involuntary movements, seizures.

He m a t o lo g ic . Anemia, easy bruising or bleeding, past transfusions, transfusion reactions.

En d o c rin e . “Thyroid trouble,” heat or cold intolerance, excessive sweating, excessive thirst or hunger, polyuria, change in glove or shoe size.

The Comprehensive Physical Examination

Conduct a comprehensive physical examination on most new patients or patients being admitted to the hospital. For more problem-oriented, or focused, assessments, the presenting complaints will dictate which segments you elect to perform.

■ The key to a thorough and accurate physical examination is a systematic sequence of examination. With effort and practice, you will acquire your own routine sequence. This book recommends examining from the patient’s right side.

■ Apply the techniques of inspection, palpation, auscultation, and percus- sion to each body region, but be sensitive to the whole patient.

Chapter 1 | Foundations for Clinical Proficiency 7

■ Minimize the number of times you ask the patient to change position from supine to sitting, or standing to lying supine.

■ For an overview of the physical examination, study the sequence that follows. Note that clinicians vary in where they place different segments, especially for the musculoskeletal and nervous systems.

B e g in n in g t h e E x a m in a t io n : S e t t in g t h e S t a g e Take the following steps to prepare for the physical examination.

S t e p s in P r e p a r in g f o r t h e P h y s ic a l E x a m in a t io n

1. Reflect on your ro ch to the tient. 2. Adjust the lighting nd the environ ent. 3. Check your equi ent. 4. M ke the tient co fort ble. 5. Observe st nd rd nd univers l rec utions. 6. Choose the sequence, sco e, nd ositioning of ex in tion.

Think through your approach, your professional demeanor, and how to make the patient comfortable and relaxed. Always wash your hands in the patient’s presence before beginning the examination.

Re e c t o n Yo u r A p p ro a c h t o t h e P a t ie n t . Identify yourself as a student. Try to appear calm, organized, and competent, even if you feel differently. If you forget to do part of the examination, this is not uncom- mon, especially at rst! Simply examine that area out of sequence, but smoothly.

Ad ju s t Lig h t in g a n d t h e En v iro n m e n t . Adjust the bed to a convenient height (be sure to lower it when nished!). Ask the patient to move toward you if this makes it easier to do your physical examination. Good lighting and a quiet environment are important. Tangential lighting is optimal for structures such as the jugular venous pulse, the thyroid gland, and the apical impulse of the heart. It throws contours, elevations, and depressions, whether moving or stationary, into sharper relief.

Ch e ck Yo u r Eq u ip m e n t . Be sure your stethoscope, re ex hammer, and other equipment are readily at hand.

Ma k e t h e P a t ie n t Co m fo r t a b le . Show concern for privacy and modesty.

8 Ba tes ’ Pocke t Guide to Physica l Examina tion and His tory Taking

■ Close nearby doors and draw curtains before beginning.

■ Acquire the art of draping the patient with the gown or draw sheet as you learn each examination segment in future chapters. Your goal is to visualize one body area at a time.

■ As you proceed, keep the patient informed, especially when you antic- ipate embarrassment or discomfort, as when checking for the femoral pulse. Also try to gauge how much the patient wants to know.

■ Make sure your instructions to the patient at each step are courteous and clear.

■ Watch the patient’s facial expression and even ask “Is it okay?” as you move through the examination.

When you have nished, tell the patient your general impressions and what to expect next. Lower the bed to avoid risk of falls and raise the bedrails if needed. As you leave, clean your equipment, dispose of waste materials, and wash your hands.

S t a n d a rd a n d MRS A P re c a u t io n s . Observe standard and universal precautions. Use rigorous handwashing before and after all patient contact and, whenever indicated, personal protective equipment (gloves; gowns; and mouth, nose, and eye protection); safe injection practices; safe handling of contaminated equipment or surfaces; respiratory hygiene and cough etiquette; patient isolation criteria; and precautions relating to equipment, toys, solid surfaces, and laundry handling.

Un ive rs a l P re c a u t io n s . Universal precautions are a set of precautions designed to prevent transmission of HIV, HBV, and other bloodborne patho- gens when providing rst aid or health care. The following uids are consid- ered potentially infectious: all blood and other body uids containing visible blood, semen, and vaginal secretions; and cerebrospinal, synovial, pleural, peritoneal, pericardial, and amniotic uids. Protective barriers include gloves, gowns, aprons, masks, and protective eyewear. All health care work- ers should observe the important precautions for safe injections and preven- tion of injury from needlesticks, scalpels, and other sharp instruments and devices. Report to your health service immediately if such injury occurs.

Ch o o s e t h e S e q u e n c e , S c o p e , a n d P o s it io n in g o f t h e Exa m in a t io n . The sequence of the examination should

■ maximize the patient’s comfort

■ avoid unnecessary changes in position, and

■ enhance the clinician’s ef ciency.

Chapter 1 | Foundations for Clinical Proficiency 9

● Gener l survey ● Vit l signs ● Skin: u er torso, nterior nd

osterior ● He d nd neck, including

thyroid nd ly h nodes ● Optional: Nervous syste

( ent l st tus, cr ni l nerves, u er extre ity otor strength, bulk, tone, cerebell r function)

● Thor x nd lungs ● Bre sts ● Musculoskelet l s indic ted:

u er extre ities ● C rdiov scul r, including

jugul r venous ressure (JVP), c rotid u strokes nd bruits, oint of xi l i ulse (PMI), S1, S2, ur urs, extr sounds

● C rdiov scul r, for S3 nd ur ur of itr l stenosis

● C rdiov scul r, for ur ur of ortic insufficiency

● Optional: thor x nd lungs— nterior

● Bre sts nd xill e ● Abdo en ● Peri her l v scul r ● Optional: skin—lower torso

nd extre ities ● Nervous syste : lower

extre ity otor strength, bulk, tone, sens t ion; reflexes; B binski reflex

● Musculoskelet l, s indic ted ● Optional: skin, nterior

nd osterior ● Optional: nervous syste ,

including g it ● Optional: usculoskelet l,

co rehensive ● Women: elvic nd rect l

ex in tion ● Men: rost te nd rect l

ex in tion

Key to the Symbols for the Patient’s Position

Sitting

Lying su ine, with he d of bed r ised 3 degrees

S e, turned rt ly to left side

Sitting, le ning forw rd

Lying su ine

St nding

Lying su ine, with hi s flexed, bducted, nd extern lly rot ted, nd knees flexed (lithoto y osit ion)

Lying on the left side (left l ter l decubitus)

Each symbol pertains until a new one appears. Two symbols separated by a slash indicate either or both positions.

T h e P h y s ic a l E x a m in a t io n : S u g g e s t e d S e q u e n c e a n d P o s it io n in g

Choose whether to do a comprehensive or focused examination. In general, move from “head to toe.” An important goal as a student is to develop your own sequence with these principles in mind.

10 Ba tes’ Pocke t Guide to Physica l Examina tion and His tory Taking

Examine the patient from the patient’s right side. Note that the right side is more reliable to estimate jugular venous pressure from the right, the palpating hand rests more comfortably on the apical impulse, the right kidney is more frequently palpable than the left, and examining tables are frequently positioned to accommodate a right-handed approach.

To examine the supine patient, you can examine the head, neck, and ante- rior chest. Then roll the patient onto each side to listen to the lungs, exam- ine the back, and inspect the skin. Roll the patient back and nish the rest of the examination with the patient again supine.

T h e P h y s ic a l E x a m in a t io n : H e a d t o T o e Ge n e ra l S u rve y. Continue this survey throughout the patient visit. Observe general state of health, height, build, and sexual development. Note posture, motor activity, and gait; dress, grooming, and personal hygiene; and any odors of the body or breath. Watch facial expressions and note manner, affect, and reactions to persons and things in the envi- ronment. Listen to the patient’s manner of speaking and note the state of awareness or level of consciousness.

Vit a l S ig n s . Ask the patient to sit on the edge of the bed or examining table, unless this position is contraindicated. Stand in front of the patient, moving to either side as needed. Measure the blood pressure. Count pulse and respiratory rate. If indicated, measure body temperature.

S k in . Observe the face. Identify any lesions, noting their location, dis- tribution, arrangement, type, and color. Inspect and palpate the hair and nails. Study the patient’s hands. Continue to assess the skin as you examine the other body regions.

HEENT. Head: Examine the hair, scalp, skull, and face. Eyes: Check visual acuity and screen the visual elds. Note position and alignment of the eyes. Observe the eyelids. Inspect the sclera and conjunctiva of each eye. With oblique lighting, inspect each cornea, iris, and lens. Assess extraocular movements. Darken the room to promote pupillary dilation and visibility of the fundi. Compare the pupils, and test their reactions to light. With an ophthalmoscope, inspect the ocular fundi. Ears: Inspect the auricles, canals, and drums. Check auditory acuity. If acuity is diminished, check lateralization (Weber test) and compare air and bone conduction (Rinne test). Nose and sinuses: Examine the external nose; using a light and nasal speculum, inspect nasal mucosa, septum, and turbinates. Palpate for tenderness of the frontal and maxillary sinuses. Throat (or mouth and pharynx): Inspect the lips, oral mucosa, gums, teeth, tongue, palate, ton- sils, and pharynx. You may wish to assess the cranial nerves at this point in the examination.

Chapter 1 | Foundations for Clinical Proficiency 11

Ne ck . Move behind the sitting patient to feel the thyroid gland and to examine the back, posterior thorax, and lungs. Inspect and palpate the cervical lymph nodes. Note any masses or unusual pulsations in the neck. Feel for any deviation of the trachea. Observe sound and effort of the patient’s breathing. Inspect and palpate the thyroid gland.

Ba ck . Inspect and palpate the spine and muscles.

Po s t e rio r Th o ra x a n d Lu n g s . Inspect and palpate the spine and muscles of the upper back. Inspect, palpate, and percuss the chest. Iden- tify the level of diaphragmatic dullness on each side. Listen to the breath sounds; identify any adventitious (or added) sounds, and, if indicated, listen to transmitted voice sounds (see p. 151).

Bre a s t s , Axilla e , a n d Ep it ro ch le a r No d e s . The patient is still sitting. Move to the front again. In a woman, inspect the breasts with patient’s arms relaxed, then elevated, and then with her hands pressed on her hips. In either sex, inspect the axillae and feel for the axillary nodes; feel for the epitrochlear nodes.

A No t e o n t h e Mu s c u lo s k e le t a l S ys t e m . By now, you have made preliminary observations of the musculoskeletal system, including the hands, the upper back, and, in women, the shoulders’ range of motion (ROM). Use these observations to decide whether a full musculoskeletal examination is warranted: With the patient still sitting, examine the hands, arms, shoulders, neck, and temporomandibular joints. Inspect and pal- pate the joints and check their ROM. (You may choose to examine upper extremity muscle bulk, tone, strength, and re exes at this time, or you may decide to wait until later.)

Palpate the breasts, while continuing your inspection.

An t e rio r Th o ra x a n d Lu n g s . The patient position is supine. Ask the patient to lie down. Stand at the right side of the patient’s bed. Inspect, palpate, and percuss the chest. Listen to the breath sounds, any adventi- tious sounds, and, if indicated, transmitted voice sounds.

Ca rd iova s c u la r S ys t e m . Elevate head of bed to about 30 degrees, adjusting as necessary to see the jugular venous pulsations. Observe the jugular venous pulsations, and measure the jugular venous pressure in rela- tion to the sternal angle. Inspect and palpate the carotid pulsations. Listen for carotid bruits.

/ Ask the patient to roll partly onto the left side while you listen at the apex. Then have the patient roll back to supine while you listen to the rest of the heart. Ask the patient to sit, lean forward, and exhale while you listen for the murmur of aortic regurgitation. Inspect and palpate the precordium.

12 Ba tes’ Pocke t Guide to Physica l Examina tion and His tory Taking

Note the location, diameter, amplitude, and duration of the apical impulse. Listen at the apex and the lower sternal border with the bell of a stethoscope. Listen at each auscultatory area with the diaphragm. Listen for S1 and S2 and for physiologic splitting of S2. Listen for any abnormal heart sounds or murmurs.

Ab d o m e n . Lower the head of the bed to the at position. The patient should be supine. Inspect, auscultate, and percuss. Palpate lightly, then deeply. Assess the liver and spleen by percussion and then palpation. Try to feel the kidneys; palpate the aorta and its pulsations. If you suspect kidney infection, percuss posteriorly over the costovertebral angles.

/ Pe rip h e ra l Va s c u la r S ys t e m . With the patient supine, palpate the femoral pulses and, if indicated, popliteal pulses. Palpate the inguinal lymph nodes. Inspect for edema, discoloration, or ulcers in the lower extremities. Palpate for pitting edema. With the patient standing, inspect for varicose veins.

/ Lo w e r Ext re m it ie s . Examine the legs, assessing the peripheral vascular, musculoskeletal, and nervous systems while the patient is still supine. Each of these systems can be further assessed when the patient stands.

/ Ne rvo u s S ys t e m . The patient is sitting or supine. The examina- tion of the nervous system can also be divided into the upper extremity examination (when the patient is still sitting) and the lower extremity examination (when the patient is supine) after examination of the periph- eral nervous system.

Me n t a l S t a t u s . If indicated and not done during the interview, assess ori- entation, mood, thought process, thought content, abnormal perceptions, insight and judgment, memory and attention, information and vocabulary, calculating abilities, abstract thinking, and constructional ability.

Cra n ia l Ne r ve s . If not already examined, check sense of smell, fun- duscopic examination, strength of the temporal and masseter muscles, corneal reflexes, facial movements, gag reflex, strength of the trapezia and sternocleidomastoid muscles, and protrusion of tongue.

Mo t o r S ys t e m . Muscle bulk, tone, and strength of major muscle groups. Cerebellar function: rapid alternating movements (RAMs), point-to-point movements such as finger to nose (F → N) and heel to shin (H → S); gait. Observe patient’s gait and ability to walk heel to toe, on toes, and on heels; to hop in place; and to do shallow knee bends. Do a Romberg test; check for pronator drift.

S e n s o ry S ys t e m . Pain, temperature, light touch, vibrations, and discrimina- tion. Compare right and left sides and distal with proximal areas on the limbs.

Chapter 1 | Foundations for Clinical Proficiency 13

Re f le xe s . Include biceps, triceps, brachioradialis, patellar, Achilles deep tendon reflexes; also plantar reflexes or Babinski reflex (see pp. 327–328).

Ad d it io n a l Exa m in a t io n s . The rectal and genital examinations are often performed at the end of the physical examination.

/ Ma le Ge n it a lia a n d He rn ia s . Examine the penis and scrotal contents. Check for hernias.

Re c t a l Exa m in a t io n in Me n . The patient is lying on his left side for the rectal examination. Inspect the sacrococcygeal and perianal areas. Palpate the anal canal, rectum, and prostate. (If the patient cannot stand, examine the genitalia before doing the rectal examination.)

G e n it a l a n d Re c t a l Ex a m in a t io n in Wo m e n . The patient is supine in the lithotomy position. Sit during the examination with the speculum, then stand during bimanual examination of uterus, adnexa, and rectum. Examine the external genitalia, vagina, and cervix. Obtain a Pap smear. Palpate the uterus and adnexa. Do a bimanual and rectal examination.

Clinical Reasoning, Assessment, and Plan

Using sound clinical reasoning, you must now analyze your ndings and identify the patient’s problems. You must share your impressions with the patient and document your ndings in the patient’s record in a succinct legible format that communicates the patient’s story and physical ndings, and the rationale for your assessment and plan, to other members of the health care team. As you make clinical decisions, you will turn to clinical evidence, calling on your knowledge of sensitivity, speci city, predictive value, and the analytical tools detailed in Chapter 2, Evaluating Clinical Evidence.

The comprehensive health history and physical examination form the foundation of your clinical Assessment. The Plan is often wide-ranging and incorporates patient education, changes in medications, needed tests, referrals to other clinicians, and return visits for counseling and support. A successful Plan includes the patient’s responses to the problems identi ed and to the interventions that you recommend. It requires good interpersonal skills and sensitivity to the patient’s goals, economic means, competing responsibilities, and family structure and dynamics.

14 Ba tes’ Pocke t Guide to Physica l Examina tion and His tory Taking

C lin ic a l R e a s o n in g a n d A s s e s s m e n t Because assessment takes place in the clinician’s mind, the process of clinical reasoning may seem opaque and even mysterious to beginning students. Study the steps described below. Focus on determining “What explains this patient’s concerns?” and “What are the ndings, problems, and diagnoses?”

S t e p s f o r Id e n t if y in g P r o b le m s a n d M a k in g D ia g n o s e s

1. Identify bnor l findings. 2. Loc lize findings n to ic lly. 3. Cluster the clinic l findings. 4. Se rch for the rob ble c use of the findings. 5. Cluster the clinic l d t . 6. Gener te hy otheses bout the c uses of the tient’s roble s. 7. Test the hy otheses nd est blish working di gnosis.

Id e n t ify Ab n o rm a l Fin d in g s . Make a list of the patient’s symptoms, the signs you observed during the physical examination, and any labora- tory reports available to you.

Lo c a lize Th e s e Fin d in g s An a t o m ic a lly. Often this step is straight- forward. The symptom of scratchy throat and the sign of an erythematous in amed posterior pharynx, for example, clearly localize the problem to the pharynx. A complaint of headache leads you quickly to the structures of the skull and brain. Other symptoms, however, may present greater dif culty. Chest pain, for example, can originate in the coronary arteries, the stomach and esophagus, or the muscles and bones of the thorax. If the pain is exertional and relieved by rest, either the heart or the musculoskel- etal components of the chest wall may be involved. If the patient notes pain only when carrying groceries with the left arm, the musculoskeletal system becomes the likely culprit.

When localizing ndings, be as speci c as your data allow; however, you may have to settle for a body region, such as the chest, or a body system, such as the musculoskeletal system. On the other hand, you may be able to de ne the exact structure involved, such as the left pectoral muscle. Some symptoms and signs are constitutional and cannot be localized, such as fatigue or fever, but are useful in the next set of steps.

Clu s t e r t h e Clin ic a l Fin d in g s . Several clinical characteristics may help.

■ Patient age: The patient’s age may help; younger adults are more likely to have a single disease, whereas older adults tend to have multiple diseases.

Chapter 1 | Foundations for Clinical Proficiency 15

■ Timing of symptoms: The timing of symptoms is often useful. For example, an episode of pharyngitis 6 weeks ago is probably unrelated to the fever, chills, pleuritic chest pain, and cough that prompted an of ce visit today. To use timing effectively, you need to know the natural history of various diseases and conditions. A yellow penile discharge followed 3 weeks later by a painless penile ulcer suggests two problems: gonorrhea and primary syphilis.

■ Involvement of different body systems: If symptoms and signs occur in a single system, one disease may explain them. Problems in different, apparently unrelated, systems often require more than one explanation. For example, you might decide to group a patient’s high blood pressure and sustained apical impulse together with ame-shaped retinal hemor- rhages, place them in the cardiovascular system, and label the constella- tion “hypertensive cardiovascular disease with hypertensive retinopathy.”

■ Multisystem conditions: With experience, you will become increasingly adept at recognizing multisystem conditions and building plausible expla- nations that link manifestations that are seemingly unrelated. To explain cough, hemoptysis, and weight loss in a 60-year-old plumber who has smoked cigarettes for 40 years, you would rank lung cancer high in your differential diagnosis. You might support your diagnosis with your observation of the patient’s cyanotic nailbeds.

■ Key questions: You can also ask a series of key questions that may steer your thinking in one direction and allow you to temporarily ignore the others. For example, you may ask what produces and relieves the patient’s chest pain. If the answer is exercise and rest, you can focus on the cardiovascular and musculoskeletal systems and set the gastrointes- tinal (GI) system aside. If the pain is epigastric, you can logically focus on the GI tract. A series of discriminating questions helps you analyze the clinical data and reach logical explanations.

S e a rch fo r t h e P ro b a b le Ca u s e o f t h e Fin d in g s . Patient com- plaints often stem from a pathologic process involving diseases of a body system or structure. These processes are commonly classi ed as congenital, in ammatory or infectious, immunologic, neoplastic, metabolic, nutritional, degenerative, vascular, traumatic, and toxic.

Other problems are pathophysiologic, re ecting derangements of biologic functions, such as heart failure or migraine headache. Still other problems are psychopathologic, such as disorders of mood like depression or headache as an expression of a somatic symptom disorder.

Ge n e ra t e Hyp o t h e s e s Ab o u t t h e Ca u s e s o f t h e Pa t ie n t ’s P ro b le m . Draw on the full range of your knowledge and experience, and read widely. By consulting the clinical literature, you embark on the

16 Ba tes’ Pocke t Guide to Physica l Examina tion and His tory Taking

lifelong goal of evidence-based decision making and clinical practice. The following steps may help.

S t e p s f o r G e n e r a t in g C lin ic a l H y p o t h e s e s

1. Select the ost s ecific nd critic l findings to su ort your hy othesis. 2. M tch your findings g inst ll the conditions th t c n roduce the . 3. Eli in te the di gnostic ossibilities th t f il to ex l in the findings. 4. Weigh the co eting ossibilities nd select the ost likely di gnosis. 5. Give s eci l t tention to otenti lly life-thre tening conditions.

Te s t Yo u r Hyp o t h e s e s . You are likely to need further history, addi- tional maneuvers on physical examination, or laboratory studies or x-rays to con rm or rule out your tentative diagnosis or to clarify which diagnosis is most likely.

Es t a b lis h a Wo rk in g Dia g n o s is . Establish a working de nition of the problem at the highest level of explicitness and certainty that the data allow. You may be limited to a symptom, such as “tension headache, cause unknown.” At other times, you can de ne a problem more speci - cally based on its anatomy, disease process, or cause. Routinely listing Health Maintenance helps you track several important health concerns more effectively: immunizations, screening tests such as mammograms or colonoscopies, instructions regarding nutrition and breast or testicular self-examinations, recommendations about exercise or use of seat belts, and responses to important life events.

U s e S h a r e d D e c is io n -M a k in g t o D e v e lo p a P la n Identify and record a Plan for each patient problem. Specify the next steps for each problem, ranging from tests and procedures to subspecialty con- sultations to new or changed medications to arranging a family meeting. It is critical to not only obtain patient agreement but to have the patient participate in the decision making whenever possible.

The Quality Clinical Record: The Case of Mrs. N.

The clinical record serves a dual purpose—it re ects your analysis of the patient’s health status, and it documents the unique features of the patient’s history, examination, laboratory and test results, assessment, and plan in a formal written format. In a well-constructed record, each problem in the Assessment is listed in order of priority with an explanation of supporting

Chapter 1 | Foundations for Clinical Proficiency 17

ndings and a differential diagnosis, followed by a Plan for addressing that problem.

Compose the clinical record as soon after seeing the patient as possible, before your ndings fade from memory, and follow the tips below for a quality patient record.

T ip s f o r E n s u r in g Q u a lit y P a t ie n t D a t a

● Ask o en-ended questions nd listen c refully to the tient’s story. ● Cr ft thorough nd syste tic sequence to history t king nd hysic l

ex in tion. ● Kee n o en ind tow rd both the tient nd the clinic l d t . ● Alw ys include “the worst-c se scen rio” in your list of ossible ex l n tions

of the tient’s roble , nd ke sure it c n be s fely eli in ted. ● An lyze ny ist kes in d t collection or inter ret tion. ● Confer with colle gues nd review the ertinent clinic l liter ture to cl rify

uncert inties. ● A ly the rinci les of ev lu ting clinic l evidence to tient infor tion

nd testing.

Study the case of Mrs. N. and scrutinize the history, physical examination, assessment, and plan. Note the standard format of the clinical record.

T h e C a s e o f M r s . N .

HEALTH HISTORY 8/25/16 11: am Mrs. N. is le s nt , 54-ye r-old widowed s leswo n residing in Es nol ,

New Mexico. Referral. None Source and Reliability. Self-referred; see s reli ble.

Chief Complaint “My he d ches.”

Present Illness Mrs. N. re orts incre sing roble s with front l he d ches over the st 3 onths. These re usu lly bifront l, throbbing, nd ild to oder tely severe. She h s issed work on sever l occ sions bec use of ssoci ted n use nd vo iting. He d ches now ver ge once week, usu lly rel ted to stress, nd l st 4 to 6 hours. They re relieved by slee nd utting d towel over her forehe d. There is little relief fro s irin. There re no ssoci ted visu l ch nges, otor- sensory deficits, or resthesi s. She h d he d ches with n use nd vo iting beginning t ge 15 ye rs. These recurred throughout her id-2 s, then decre sed to one every 2 or 3 onths nd l ost dis e red.

(continued )

18 Ba tes’ Pocket Guide to Phys ica l Examination and His tory Taking

T h e C a s e o f M r s . N . (Continued)

The tient re orts incre sed ressure t work fro de nding su ervisor; she is lso worried bout her d ughter (see Personal and Social History). She thinks her he d ches y be like those in the st , but w nts to be sure bec use her other h d he d che just before she died of stroke. She is concerned bec use her he d ches interfere with her work nd ke her irrit ble with her f ily. She e ts three e ls d y nd drinks three cu s of coffee d y nd te t night.

Medications. Acet ino hen, 1 to 2 t blets every 4 to 6 hours s needed. “W ter ill” in the st for nkle swelling, none recently.

Allergies. A icillin c uses r sh. Tobacco. About 1 ck of cig rettes er d y since ge 18 (36 ck-ye rs). Alcohol/drugs. Wine on r re occ sions. No illicit drugs.

Past History Childhood Illnesses: Me sles, chicken ox. No sc rlet fever or rheu t ic fever. Adult Illnesses: Medical: Pyelone hritis, 1998, with fever nd right fl nk in; tre ted with icillin; develo ed gener lized r sh with itching sever l d ys l ter. Re orts x-r ys were nor l; no recurrence of infection. Surgical: Tonsillec- to y, ge 6; endecto y, ge 13. Sutures for l cer tion, 2 1, fter ste ing on gl ss. Ob/ Gyn: 3–3– –3, with nor l v gin l deliveries. Three living children. Men rche ge 12. L st enses 6 onths go. Little interest in sex, nd not sexu- lly ctive. No concerns bout HIV infection. Psychiatric: None. Health Maintenance: Immunizations: Or l olio v ccine, ye r uncert in; tet nus shots × 2, 1982, followed with booster 1 ye r l ter; flu v ccine, 2 , no re ction. Screening tests: L st P s e r, 2 14, nor l. No ogr s to d te.

Family History The f ily history is de icted below.

Tra in accident S troke , va ricose ve ins , headaches

High blood

pressure Heart a ttack

Infancy

HeadachesMigra ine headaches

Indica te s pa tient Deceased ma le Deceased fema le Living ma le

Living female

43 67

67 58 54

33 31 27

(continued )

Chapter 1 | Foundations for Clinical Proficiency 19

T h e C a s e o f M r s . N . (Continued)

OR, ltern tively: F ther died t ge 43 ye rs in tr in ccident. Mother died t ge 67 ye rs fro stroke; h d v ricose veins, he d ches.

One brother, ge 61 ye rs, with hy ertension, otherwise well; one brother, ge 58 ye rs, well exce t for ild rthrit is; one sister, died in inf ncy of unknown c use.

Husb nd died t ge 54 of he rt tt ck D ughter, ge 33 ye rs, with igr ine he d ches, otherwise well; son, ge

31 ye rs, with he d ches; son, ge 27 ye rs, well. No f ily history of di betes, tuberculosis, he rt or kidney dise se, c ncer,

ne i , e ile sy, or ent l illness.

Personal and Social History Born nd r ised in L s Cruces, finished high school, rried t ge 19 ye rs. Worked s s les clerk for 2 ye rs, then oved with husb nd to Es nol , h d three children. Returned to work 15 ye rs go to i rove f ily fin nces. Chil- dren ll rried. Four ye rs go Mr. N. died suddenly of he rt tt ck, le ving little s vings. Mrs. N. h s oved to s ll rt ent to be ne r d ughter, Is bel. Is bel’s husb nd, John, is de loyed overse s. Mrs. N.’s rt ent is now h ven for Is bel nd her two children, Kevin, ge 6 ye rs, nd Luci , ge 3 ye rs. Mrs. N. feels res onsible for hel ing the ; she feels tense nd nervous but denies de ression. She h s friends but r rely discusses f ily roble s: “I’d r ther kee the to yself. I don’t like gossi .” No church or other org niz - tion l su ort . She is ty ic lly u t 7: am, works 9: am to 5:3 pm, nd e ts dinner lone.

Exercise and diet. Gets little exercise. Diet high in c rbohydr tes. Safety measures. Uses se t belt regul rly. Uses sunblock. Medic t ions ke t

in n unlocked edicine c binet . Cle ning solut ions in unlocked c binet below sink. Mr. N’s shotgun nd box of shells in unlocked closet u st irs.

Review of Systems General: H s g ined 1 lb in the st 4 ye rs. Skin: No r shes or other ch nges. Head, Eyes, Ears, Nose, Throat (HEENT): See Present Illness. Head: No history of he d injury. Eyes: Re ding gl sses for 5 ye rs, l st checked 1 ye r go. No sy to s. Ears: He ring good. No tinnitus, vertigo, infect ions. Nose, sinuses: Occ sion l ild cold. No h y fever, sinus trouble. Throat (or mouth and phar- ynx): So e bleeding of gu s recently. L st dent l visit 2 ye rs go. Occ sion l c nker sore. Neck: No lu s, goiter, in. No swollen gl nds. Breasts: No lu s, in, disch rge. Does bre st self-ex in tion s or dic lly. Respiratory: No cough, wheezing, shortness of bre th. L st chest x-r y, 1986, St. M ry’s Hos it l; unre rk ble. Cardiovascular: No known he rt dise se or high blood ressure; l st blood ressure t ken in 2 7. No dys ne , ortho ne , chest in, l it tions. H s never h d n electroc rdiogr (ECG).

(continued )

20 Ba tes’ Pocke t Guide to Physica l Examina tion and His tory Taking

T h e C a s e o f M r s . N . (Continued)

Gastrointestinal: A etite good; no n use , vo iting, indigestion. Bowel ove- ent bout once d ily, though so eti es h s h rd stools for 2 to 3 d ys when es eci lly tense; no di rrhe or bleeding. No in, j undice, g llbl dder or liver roble s. Urinary: No frequency, dysuri , he turi , or recent fl nk in; nocturi × 1, l rge volu e. Occ sion lly loses urine when coughing. Genital: No v gin l or elvic infections. No dys reuni . Peripheral vascular: V ricose veins e red in both legs during first regn ncy. For 1 ye rs, h s h d swollen nkles fter rolonged st nding; we rs light el s- tic su ort hose; tried “w ter ill” 5 onths go, but it didn’t hel uch; no history of hlebitis or leg in. Musculoskeletal: Mild low b ck ches, often t the end of the workd y; no r di t ion into the legs; used to do b ck exercises but not now. No other joint in. Psychiatric: No history of de ression or tre t ent for sychi tric disorders. (See lso Present Illness nd Personal and Social History.) Neurologic: No f inting, seizures, otor or sensory loss. Me ory good. Hematologic: Exce t for bleeding gu s, no e sy bleeding. No ne i . Endocrine: No known thyroid disorders or he t or cold intoler nce. No sy to s or history of di betes.

PHYSICAL EXAMINATION Mrs. N. is short , overweight , iddle- ged wo n, who is ni ted nd res onds quickly to quest ions. She is so ewh t tense, with oist , cold h nds. Her h ir is well groo ed. Her color is good, nd she lies fl t without disco fort . Vital signs: Ht (without shoes) 157 c (5′2″). Wt (dressed) 65 kg (143 lb). BMI 26. BP 164/98 right r , su ine; 16 /96 left r , su ine; 152/88 right r , su ine with wide cuff. He rt r te (HR) 88 nd regul r. Res ir tory r te (RR) 18. Te - er ture (or l) 98.6°F. Skin: P l s cold nd oist , but color good. Sc ttered cherry ngio s over u er trunk. N ils without clubbing, cy nosis. Head, Eyes, Ears, Nose, Throat (HEENT): Head: H ir of ver ge texture. Sc l without lesions, nor oce h lic/ tr u tic (NC/AT). Eyes: Vision 2 /3 in e ch eye. Visu l fields full by confront tion. Conjunctiv ink; scler white. Pu ils 4 constricting to 2 , round, regul r, equ lly re ctive to light. Extr ocul r ove ents int ct . Disc rgins sh r , without he orrh ges, exud tes. No rteriol r n rrowing or A-V nicking. Ears: W x rti lly obscures right ty nic e br ne (TM); left c n l cle r, TM with good cone of light. Acuity good to whis ered voice. Weber idline. AC > BC. Nose: Mucos ink, se tu idline. No sinus tenderness. Mouth: Or l ucos ink. Sever l interdent l ill e red, slightly swollen. Dentition good. Tongue idline, with 3 × 4 sh llow white ulcer on red b se on undersurf ce ne r ti ; tender but not indur ted. Tonsils bsent. Ph rynx without exud tes.

(continued )

Chapter 1 | Foundations for Clinical Proficiency 21

T h e C a s e o f M r s . N . (Continued)

Neck: Neck su le. Tr che idline. Thyroid isth us b rely l ble, lobes not felt . Lymph nodes: S ll (<1 c ), soft , nontender, nd obile tonsill r nd osterior cervic l nodes bil ter lly. No xill ry or e itrochle r nodes. Sever l s ll inguin l nodes bil ter lly, soft nd nontender. Thorax and lungs: Thor x sy etric with good excursion. Lungs reson nt . Bre th sounds vesicul r with no dded sounds. Di hr g s descend 4 c bil ter lly. Cardiovascular: Jugul r venous ressure 1 c bove the stern l ngle, with he d of ex ining t ble r ised to 3 º . C rotid u strokes brisk, without bruits. A ic l i ulse discrete nd t ing, b rely l ble in the 5th left inters ce, 8 c l ter l to the idstern l line. Good S1, S2; no S3 or S4. A II/ VI ediu - itched idsystolic ur ur t the lower left stern l border. No di stolic ur urs. Breasts: Pendulous, sy etric. No sses; ni les without disch rge. Abdomen: Protuber nt. Well-he led sc r, right lower qu dr nt. Bowel sounds ctive. No tenderness or sses. Liver s n 7 c in right idcl vicul r line; edge s ooth, l ble 1 c below right cost l rgin (RCM). S leen nd kidneys not felt . No costovertebr l ngle tenderness (CVAT). Genitalia: Extern l genit li without lesions. Mild cystocele t introitus on str ining. V gin l ucos ink. Cervix ink, rous, nd without disch rge. Uterus nterior, idline, s ooth, not enl rged. Adnex not l ted due to obesity nd oor rel x tion. No cervic l or dnex l tenderness. P s e r t ken. Rectov gin l w ll int ct . Rectal: Rect l v ult without sses. Stool brown, neg tive for fec l blood. Extremities: W r nd without ede . C lves su le, nontender. Peripheral vascular: Tr ce ede t both nkles. Moder te v ricosities of s he- nous veins both in lower extre ities. No st sis ig ent tion or ulcers. Pulses (2+ = brisk, or nor l):

Ra d ia l Fe m o ra l Po p lit e a l Do rs a lis P e d is P o s t e r io r Tib ia l

RT 2+ 2+ 2+ 2+ 2+

LT 2+ 2+ 2+ Absent 2+

Musculoskeletal: No joint defor ities. Good r nge of otion in h nds, wrists, elbows, shoulders, s ine, hi s, knees, nkles. Neurologic: Mental Status: Tense, but lert nd coo er tive. Thought coherent. Oriented to erson, l ce, nd ti e. Cranial nerves: II to XII int ct . Motor: Good uscle bulk nd tone. Strength 5/5 throughout. Cerebellar: R id ltern ting ove ents (RAMs), oint-to- oint ove ents int ct . G it st ble, fluid. Sensory: Pin rick, light touch, osition sense, vibr tion, nd stereognosis int ct . Ro berg neg tive.

(continued )

22 Ba tes’ Pocke t Guide to Physica l Examina tion and His tory Taking

T h e C a s e o f M r s . N . (Continued)

Reflexes:

Bic e p s Tric e p s Bra ch io - ra d ia lis P a t e lla r Ach ille s P la n t a r

RT 2+ 2+ 2+ 2+ 1+ ↓

LT 2+ 2+ 2+ 2+/2+ 1+ ↓

ASSESSMENT AND PLAN 1. Migraine headaches. A 54-ye r-old wo n with igr ine he d ches since

childhood, with throbbing v scul r ttern nd frequent n use nd vo - iting. He d ches re ssoci ted with stress nd relieved by slee nd cold co resses. There is no illede , nd there re no otor or sensory deficits on the neurologic ex in tion. The differenti l di gnosis includes tension he d che, lso ssoci ted with stress, but there is no relief with ss ge, nd the in is ore throbbing th n ching. There re no fever, stiff neck, or foc l findings to suggest eningitis, nd the lifelong recurrent ttern kes sub r chnoid he orrh ge unlikely (usu lly described s “the worst he d che of y life”).

Pl n: ● Discuss fe tures of igr ine versus tension he d ches. ● Discuss biofeedb ck nd stress n ge ent. ● Advise tient to void c ffeine, including coffee, col s, nd other

c rbon ted bever ges. ● St rt nonsteroid l nti-infl tory drugs (NSAIDs) for he d che, s

needed. ● If needed next visit , begin ro hyl ctic edic tion if he d ches re

occurring ore th n 2 d ys week or 8 d ys onth. 2. Elevated blood pressure. Systolic hy ertension is resent . M y be rel ted

to nxiety fro first visit . No evidence of end-org n d ge to retin or he rt .

Pl n: ● Discuss st nd rds for ssessing blood ressure; check BP in 1 onth. ● Recheck systolic ur ur. ● Check b sic et bolic nel; review urin lysis. ● Discuss weight reduction nd exercise rogr s (see #4). ● Reduce s lt int ke.

3. Cystocele with occasional stress incontinence. Cystocele on elvic ex i- n tion, rob bly rel ted to bl dder rel x tion. P tient is eri eno us l. Incontinence re orted with coughing, suggesting lter tion in bl dder neck n to y. No dysuri , fever, fl nk in. Not t king ny contributing edic - tions. Usu lly involves s ll ounts of urine, no dribbling, so doubt urge or overflow incontinence.

(continued )

++ ++

++ ++ ++ ++

++++

+ +

_ _

Chapter 1 | Foundations for Clinical Proficiency 23

T h e C a s e o f M r s . N . (Continued )

Pl n: ● Ex l in c use of stress incontinence. ● Review urin lysis. ● Reco end Kegel exercises. ● Consider to ic l estrogen cre to v gin during next visit if no i rove ent.

4. Overweight . P tient 5′2″, weighs 143 lbs. BMI is �26. Pl n:

● Ex lore diet history, sk tient to kee food int ke di ry. ● Ex lore otiv tion to lose weight, set t rget for weight loss by next visit . ● Schedule visit with dietiti n. ● Discuss exercise rogr , s ecific lly, w lking 3 inutes ost d ys week.

5. Family stress. Son-in-l w de loyed, r rely t ho e; d ughter nd gr ndchil- dren often t tient’s ho e, le ding to tensions in these rel tionshi s. P tient lso h s fin nci l constr ints. Stress currently situ tion l. No current evidence of jor de ression.

Pl n: ● Ex lore tient’s views on str tegies to co e with stress. ● Ex lore sources of su ort , including Al-Anon for d ughter nd fin nci l

counseling for tient . ● Continue to onitor for de ression.

6. Occasional musculoskeletal low back pain. Usu lly with rolonged st nd- ing. No history of tr u or otor vehicle ccident. P in does not r di te; no tenderness or otor-sensory deficits on ex in tion. Doubt disc or nerve root co ression, troch nteric bursitis, s croiliitis.

Pl n: ● Review benefits of weight loss nd exercises to strengthen low b ck

uscles. 7. Tobacco abuse. 1 ck er d y for 36 ye rs. Pl n:

● Check e k flow or FEV1/ FVC on office s iro etry. ● Give strong w rning to sto s oking. ● Offer referr l to tob cco cess tion rogr . ● Offer tch, current tre t ent to enh nce bstinence.

8. Varicose veins, lower extremit ies. No co l ints currently. 9. History of right pyelonephrit is, 1998. 10. Ampicillin allergy. Develo ed r sh but no other llergic re ction. 11. Health maintenance. L st P s e r 2 14; h s never h d ogr .

Pl n: ● Schedule ogr . ● P s e r sent tod y. ● Provide three c rds to test for fec l blood; next visit , discuss screening

colonosco y. ● Suggest dent l c re for ild gingivitis. ● Advise t ient to ove edic t ions nd c ustic cle ning gents to

locked c binet bove shoulder height . Urge t ient to ove gun nd c rtridges to locked gun c binet .

24 Ba tes’ Pocke t Guide to Physica l Examina tion and His tory Taking

T h e Im p o r t a n c e o f t h e P r o b le m Lis t After you complete the clinical record, it is good clinical practice to gener- ate a Problem List that summarizes the patient’s problems that can be placed in the front of the of ce or hospital chart. List the most active and serious problems rst, and record their date of onset. Some clinicians make separate lists for active or inactive problems; others make one list in order of prior- ity. A sample Problem List for Mrs. N. is provided below.

P r o b le m Lis t : T h e C a s e o f M r s . N .

Da t e En t e re d P ro b le m No . P ro b le m

8/25/16 1 2 3

4 5 6 7 8 9 1 11

Migr ine he d ches Elev ted blood ressure Cystocele with occ sion l st ress

incontinence Overweight F ily stress Low b ck in Tob cco buse since ge 18 ye rs V ricose veins History of right yelone hritis 1998 Allergy to icillin He lth inten nce

A clear, well-organized clinical record is one of the most important adjuncts to patient care. Think especially about the order and readability of the record and the amount of detail needed. Use the following checklist to make sure your record is informative and easy to follow.

Recording Your Findings

C h e c k lis t t o E n s u r e a Q u a lit y C lin ic a l R e c o r d

Is the Order Clear? Order is i er tive. M ke sure th t re ders c n e sily find s ecific oints of infor tion. Kee the subjective ite s of the history, for ex le, in the history; do not let the str y into the hysic l ex in tion. Did you:

● M ke the he dings cle r? ● Accent your org niz tion with indent tions nd s cing? ● Arr nge the Present Illness in chronologic order, st rting with the current

e isode, then filling in relev nt b ckground infor tion? (continued )

Chapter 1 | Foundations for Clinical Proficiency 25

C h e c k lis t t o E n s u r e a Q u a lit y C lin ic a l R e c o r d (Continued)

Do the Data Included Contribute Directly to the Assessment? S ell out the su orting evidence, both ositive nd neg tive, for e ch roble or di gnosis. M ke sure there is sufficient det il to su ort your differenti l di gnosis nd l n.

Are Pertinent Negatives Speci cally Described? Often ortions of the history or ex in tion suggest th t n bnor lity ight exist or develo in th t re . For ex le, for the tient with not ble bruises, record the “ ertinent neg tives,” such s the bsence of injury or violence, f ili l bleeding disorders, or edic tions or nutrition l deficits th t ight le d to bruising. For the tient who is de ressed but not suicid l, recording both f cts is i ort nt . In the tient with tr nsient ood swing, on the other h nd, co ent on suicide is unnecess ry.

Are There Overgeneralizations or Omissions of Important Data? Remember that data not recorded are data lost. No tter how vividly you c n rec ll clinic l det ils tod y, you will rob bly not re e ber the in few onths. The hr se “neurologic ex neg tive,” even in your own h ndwriting, y le ve you wondering in few onths’ ti e, “Did I re lly check the reflexes?”

Is There Too Much Detail? Is there excess infor t ion or redund ncy? Is i ort nt infor t ion buried in ss of det il, to be discovered by only the ost ersistent re der? M ke your descri t ions concise. “Cervix ink nd s ooth” indic tes you s w no redness, ulcers, nodules, sses, cysts, or other sus icious lesions, but this descri t ion is shorter nd ore e sily re d. You c n o it uni ort nt structures even though you ex ined the , such s nor l eyebrows nd eyel shes.

Omit most of your negative findings unless they rel te directly to the tient’s co l ints or s ecific exclusions in your differenti l di gnosis. Instead, concentrate on major negative findings such s “no he rt ur urs.”

Is the Written Style Succinct? Are Phrases, Short Words, and Abbreviations Used Appropriately? Is Data Unnecessarily Repeated? O it re etitive introductory hr ses such s “The tient re orts no . . .” bec use re ders ssu e the tient is the source of the history unless other- wise s ecified.

● Using words or brief hr ses inste d of whole sentences is co on, but bbrevi tions nd sy bols should be used only if they re re dily understood. Use shorter words when ossible such s “felt” for “ l ted” or “he rd” for “ uscult ted.” O it unnecess ry words, such s those in rentheses in the ex les below. For ex le, “Cervix is ink (in color).” “Lungs re reson nt (to ercussion).”

● Describe wh t you observed, not wh t you did. “O tic discs seen” is less infor tive th n “disc rgins sh r .”

(continued )

26 Ba tes’ Pocke t Guide to Physica l Examina tion and His tory Taking

C h e c k lis t t o E n s u r e a Q u a lit y C lin ic a l R e c o r d (Continued)

Are Diagrams and Precise Measurements Included Where Appropriate? Di gr s dd gre tly to the cl rity of the record.

To ensure ccur te ev lu tions nd future co risons, ke e sure ents in centi eters, not in fruits, nuts, or veget bles.

● “1 × 1 c ly h node” versus “ e -sized ly h node . . .” ● Or “2 × 2 c ss on the left lobe of the rost te” versus “w lnut-sized

rost te ss.”

Is the Tone of the Write-up Neutral and Professional? It is i ort nt to be objective. Hostile or dis roving co ents h ve no l ce in the tient’s record. Never use infl tory or de e ning words or unc- tu tion. Co ents such s “P tient DRUNK nd LATE TO CLINIC AGAIN!!” re un rofession l nd set b d ex le for other clinici ns re ding the ch rt . They lso ight rove difficult to defend in leg l setting.

C H A P T E R

2Evaluating Clinical Evidence

Excellence in clinical care requires integrating clinical expertise, patient preferences, and the best available clinical evidence. Carefully study the clear descriptions of how the history and physical examination can be viewed as diagnostic tests; how to assess the accuracy of laboratory tests, radiographic imaging, and diagnostic procedures; and how to evaluate clinical research studies and disease prevention guidelines.

Throughout the regional examination chapters, you will nd evidence- based recommendations for health promotion interventions, especially screening and prevention. These recommendations are also based on evidence from the clinical literature that can be evaluated according to criteria presented in this chapter.

The History and Physical Examination as Diagnostic Tests

The process of diagnostic reasoning begins with the history. As you learn about your patient, you will start to develop a differential diagnosis. You will assign probabilities to the various diagnoses that correspond to how likely you consider them to be explanations for your patient’s problem. As you approach clinical problems, your goal is to determine whether you need to perform additional testing (Fig. 2-1).

Tes t Threshold0%

Probability o f Diagnos is

Probability be low tes t threshold; no tes ting warranted

Trea tment Threshold 100%

Probability be tween tes t and trea tment threshold;

furthe r te s ting required

Probability above trea tment thre shold; tes ting comple ted;

trea tment commences

Figure 2-1 Probability revis ions . (Adapted with permiss ion from Guyatt G, Rennie D, Meade M, e t al. Users’ Guides to the Medical Lite rature . 2nd ed. New York, NY: McGraw-Hill Company; 2008; Chapte r 14, Figure 14–2.)

28 Ba tes’ Pocke t Guide to Physica l Examina tion and His tory Taking

If your probability for a disease based on your history and examination is very high (i.e., exceeds the treatment threshold), then you can move ahead and initiate treatment. Conversely, if your probability for a disease is very low (i.e., below the test threshold), then you do not need further testing. The area between the test and treatment thresholds represents clinical uncertainty, and you need further testing to revise probabilities and guide your clinical management.

S e n s it ivit y a n d S p e c i c it y. The rst test statistics to estimate are sensitivity and speci city.

S e t t in g u p t h e 2 ë 2 T a b le

Go ld S t a n d a rd : Dis e a s e P re s e n t

Go ld S t a n d a rd : Dis e a s e Ab s e n t

Te s t p o s it ive True ositive

b F lse ositive

Te s t n e g a t ive c F lse neg tive

d True neg tive

Evaluating Diagnostic Tests Two concepts in evaluating diagnostic tests are the validity of the ndings and the reproducibility of the test results.

V a lid it y Does the test provide valid results and accurately identify whether the patient has a disease? This involves comparing the test against a gold standard—the best measure of whether a patient has disease. This could be a biopsy, a structured psychiatric examination, or a colonoscopy.

The 2 × 2 table is the basic format for evaluating the performance char- acteristics of a diagnostic test, which means how much the test results revise probabilities for disease.

There are two columns—patients with disease present and patients with disease absent. These categorizations are based on the gold standard test. The two rows correspond to positive and negative test results. The four cells (a, b, c, d) correspond to true positives, false positives, false negatives, and true negatives, respectively.

Chapter 2 | Evaluating Clinical Evidence 29

A negative result from a test with a high sensitivity (i.e., a very low false- negative rate) usually excludes disease. This is represented by the acronym SnNOUT—a Sensitive test with a Negative result rules OUT disease. Con- versely, a positive result in a test with high speci city (e.g., a very low false- positive rate) usually indicates disease. This is represented by the acronym SpPIN—a Speci c test with a Positive result rules IN disease.

Po s it ive a n d Ne g a t ive P re d ic t ive Va lu e s . To determine the prob- ability that a patient actually has disease based on a test result that is either positive or negative, calculate positive and negative predictive values.

S e n s it iv it y a n d S p e c if ic it y

● Sensitivity is the rob bility th t erson with dise se h s ositive test . This is re resented s / ( + c) in the dise se resent colu n of the 2 × 2 t ble. Sensitivity is lso known s the true ositive r te.

● Specificity is the rob bility th t nondise sed erson h s neg tive test , re resented s d/ (b + d) in the dise se bsent colu n of the 2 × 2 t ble. S ec- ificity is lso known s the true neg tive r te.

● Examples. An ex le of these st tistics would be the rob bility th t s leno- eg ly (see Ch ter 11, . 21 ) is ssoci ted with ercussion dullness below the left cost l rgin (sensitivity). Conversely, the rob bility th t tient without s leno eg ly will h ve ercussion dullness is the f lse- ositive r te (1 − s ecificity) for this hysic l neuver.

P o s it iv e a n d N e g a t iv e P r e d ic t iv e V a lu e s

● The positive predictive value (PPV) is the rob bility th t erson with ositive test h s dise se, re resented s / ( + b) fro the test ositive row in the 2 × 2 t ble. An ex le of this st tistic is found in rost te c ncer screening (see

Ch ter 15, . 266), where n with PSA v lue gre ter th n 4. ng/ L h s only 3 % rob bility of h ving rost te c ncer found on bio sy.

● The negative predictive value (NPV) is the rob bility th t erson with neg tive test does not h ve dise se, re resented s d/ (c + d) in the test neg tive row in 2 × 2 t ble. An ex le is: A ong en with PSA level of 4. ng/ L or below, 85% re

found to be c ncer-free on bio sy.

P re va le n c e o f Dis e a s e . Predictive value statistics vary substantially according to the prevalence of disease (i.e., the proportion of patients in the disease present column), which is based on the characteristics of the patient population and the clinical setting. The box below shows a 2 × 2 table where both the sensitivity and speci city of the diagnostic test are 90% and the prevalence is 10%. The positive predictive value calculated

30 Ba tes’ Pocke t Guide to Physica l Examina tion and His tory Taking

from the test positive row of the table would be 90/180 = 50%. This means that half of the people with a positive test have disease.

Sensitivity = a/(a + c) = 90/100 or 90%; speci city = d/(b + d) = 810/900 = 90%

Positive predictive value = a/(a + b) = 90/180 = 50%

However, if the sensitivity and speci city remained the same, but prevalence was only 1%, then the cells would look very different.

Sensitivity = a/(a + c) = 9/10 or 90%; speci city = d/(b + d) = 891/990 = 90%

Positive predictive value = a/(a + b) = 9/108 = 8.3%

Lik e lih o o d Ra t io s . To evaluate the performance of a diagnostic test that can account for the varying disease prevalence observed in different patient populations, you can use likelihood ratio statistics, de ned as the probability of obtaining a given test result in a diseased patient divided by the probability of obtaining a given test result in a nondiseased patient. The likelihood ratio tells us how much a test result changes the pre-test disease probability (prevalence) to the post-test disease probability.

The likelihood ratio for a positive test is the ratio of getting a positive test result in a diseased person divided by the probability of getting a positive test result in

P r e d ic t iv e V a lu e s : P r e v a le n c e o f 1 0 % w it h S e n s it iv it y a n d S p e c if ic it y = 9 0 %

Dis e a s e P re s e n t Dis e a s e Ab s e n t To t a l

Te s t p o s it ive 9

b 9

Te s t n e g a t ive c 1

d 81

To t a l 1 9 1,

P r e d ic t iv e V a lu e s : P r e v a le n c e o f 1 % w it h S e n s it iv it y a n d S p e c if ic it y = 9 0 %

Dis e a s e P re s e n t Dis e a s e Ab s e n t To t a l

Te s t p o s it ive 9

b 99

1 8

Te s t n e g a t ive c 1

d 891

892

To t a l 1 99 1,

Chapter 2 | Evaluating Clinical Evidence 31

a nondiseased person. The 2 × 2 table shows that this is the same as saying the ratio of the true positive rate (sensitivity) over the false-positive rate (1 − speci- city). A higher value (much >1) indicates that a positive test is much more likely to be coming from a diseased person than from a nondiseased person, increasing our con dence that a person with a positive result has disease.

The likelihood ratio for a negative test is the ratio of the probability of getting a negative test result in a diseased person divided by the probability of getting a negative test result in a nondiseased person. The 2 × 2 table shows that this is the same as saying the ratio of the false-negative rate (1 − sensitivity) divided by the true negative rate (speci city). A lower value (much <1) indicates that the negative test is much more likely to be coming from a nondiseased person than from a diseased person, increasing our con dence that a person with a negative result does not have disease.

Ba ye s Th e o re m . One way to use likelihood ratios to revise probabilities for disease is with the Bayes theorem. This theorem requires converting the estimated prevalence (pre-test probability) to odds using the equation:

Pre-test odds = pre-test probability/(1 − pre-test probability)

The pre-test odds are multiplied by the likelihood ratio to estimate the post-test odds using the following equation:

Post-test odds = Pre-test odds × likelihood ratio

The post-test odds are then converted to a probability using the equation:

Post-test probability = post-test odds/(1 + post-test odds)

Fa g a n No m o g ra m . If you are more comfortable thinking in terms of probability of having disease, then the Fagan nomogram may be an easier way for you to use likelihood ratios (Fig. 2-2). With this nomogram, you read the pre-test probabilities from the line on the left, then take a straight edge and draw a line from the pre-test probability through the likelihood

In t e r p r e t in g Lik e lih o o d R a t io s

Lik e lih o o d Ra t io s a Effe c t o n P re - t o Po s t -t e s t P ro b a b ilit y

LRs > 1 or < .1 Gener te l rge ch nges LRs 5–1 or .1– .2 Gener te oder te ch nges LRs 2–5 nd .5– .2 Gener te s ll (so eti es i ort nt) ch nges LRs 1–2 nd .5–1 Alter the rob bility to s ll degree (r rely

i ort nt)

aLikelihood ratios >1 re ssoci ted with ositive results nd n incre sed rob bility for dise se. Likelihood ratios <1 re ssoci ted with neg tive results nd decre sed rob bil- ity of dise se. A test with likelihood ratio of 1 rovides no ddition l infor t ion bout the rob bility of dise se.

32 Ba tes’ Pocke t Guide to Physica l Examina tion and His tory Taking

0.1

Pre-tes t Probability (%)

Like lihood Ratio

0.2

0.5

40 50

99 0.1

0.2

0.5

2000 1000

500 200 100

50 20 10

5 2

0.002

0.005 0.01 0.02

0.05 0.1 0.2

0.5

0.001 0.0005

Pos t-tes t Probability (%)

5 20

00 .0

5 20

00 .0

Figure 2-2 Fagan nomogram. (Adapted with permiss ion from Fagan TJ. Le tte r: nomogram for Bayes theorem. N Engl J Med. 1975;293:257.)

ratio in the middle line, and then read the post-test probability on the line on the right.

Figure 2.2 shows how the Fagan nomogram displays probability revisions. In this example, the diagnostic test has a sensitivity of 90% and speci c- ity of 91%. With a pre-test probability (prevalence) of 1%, a positive test result (blue line) leads to a post-test probability of 9%. A negative test result (red line) leads to a post-test probability of 0.1%.

Chapter 2 | Evaluating Clinical Evidence 33

R e p r o d u c ib ilit y Ka p p a S c o re . Two clinicians examining a patient may not always agree upon the presence of a given nding. Understanding whether there is agreement well beyond chance is important in knowing whether the nd- ing is useful enough to support clinical decision making. The kappa score measures the amount of agreement that occurs beyond chance. The box shows how to interpret Kappa values.

In t e r p r e t in g Ka p p a V a lu e s

Va lu e o f Ka p p a S t re n g t h o f Ag re e m e n t

< .2 Poor .21– .4 F ir .41– .6 Moder te .61– .8 Good .81–1. Excellent

For example, although clinicians agree 75% of the time that a patient has an abnormal physical nding, the expected agreement based on chance is 50%. This means that the potential agreement beyond chance is 50% and the actual observer agreement beyond chance is 25%. The kappa level is then 25%/50% = 0.5, which indicates moderate agreement.

P re c is io n . In the context of reproducibility, precision refers to being able to apply the same test to the same unchanged person and obtain the same results. Precision is often used when referring to laboratory tests. A statisti- cal test used to characterize precision is the coef cient of variation, de ned as the standard deviation divided by the mean value. Lower values indicate greater precision.

Throughout the book you will nd health promotion sections that make recommendations for primary prevention (interventions designed to prevent disease) as well as secondary prevention (screening tests designed to nd disease or disease processes at an early, asymptomatic stage). The rationale for secondary prevention is that treatment for early-stage disease is often more effective than treatment for later-stage disease. We highlight guide- lines from professional organizations that are evidence-based, such as those of the U.S. Preventive Services Task Force (USPSTF) that consider the quality of the evidence and the strength of the recommendation to either provide or withhold the intervention. The strongest health promotion rec- ommendations are based on results from randomized controlled trials (or

Health Promotion

34 Ba tes’ Pocke t Guide to Physica l Examina tion and His tory Taking

Sys tematic Reviews

Randomized Control Tria ls

Cohort S tudies

Case-Control S tudies

Case Serie s , Case Reports

Editoria ls , Expert Opinion

Figure 2-3 Evidence pyramid. (Adapted with permission from Sackett DL, Straus SE, Richardson WS, et al. Evidence-Based Medicine: How to Practice and Teach EBM. 2nd ed. Edinburgh: Churchill Livingstone; 2000.)

syntheses of multiple such trials) of therapy or prevention. When search- ing for evidence-based information, you should select the highest level of available evidence (Fig. 2-3).

Critical Appraisal Learn the process of critically appraising the clinical literature in order to interpret new studies and guidelines as they appear throughout your professional career. The Evidence-Based Working Group, which consists of experts in epidemiology, has created a rigorous and standardized approach for evaluating studies that has been applied to a wide range of clinical topics, including therapeutic and prevention trials, diagnostic tests, meta- analysis, cost-effectiveness analyses, and practice guidelines. This approach asks three basic questions:

1. Are the results valid (can you believe them)? 2. What are the results (magnitude and precision)? 3. How can you apply the results to patient care?

U n d e r s t a n d in g B ia s When evaluating study results, it is important to have a thorough under- standing of bias. The key sources of bias in clinical research are selection bias, performance bias, detection bias, and attrition bias.

Chapter 2 | Evaluating Clinical Evidence 35

T y p e s o f B ia s e s A f f e c t in g E v id e n c e

S e le c t io n Bia s ● Occurs when co rison grou s h ve syste tic differences in their b seline

ch r cteristics th t c n ffect the outco e of the study ● Cre tes roble s in inter reting observed differences in outco es bec use they

could result fro the interventions or the b seline differences between grou s ● R ndo ly lloc t ing subjects to the intervention is the best ro ch to

ini izing this bi s P e rfo rm a n c e Bia s ● Occurs when there re syste tic differences in the c re received between

co rison grou s (other th n the intervention) ● Cre tes roble s in inter reting outco e differences ● Blinding subjects nd roviders to the intervention is the best ro ch to

ini izing this bi s De t e c t io n Bia s ● Occurs when there re syste t ic differences in efforts to di gnose or

scert in n outco e ● Blinding outco es ssessors (ensuring th t they re un w re of the interven-

tion received by the subject) is the best ro ch to ini izing this bi s At t r it io n Bia s ● Occurs when there re syste tic differences in the co rison grou s in

the nu ber of subjects who do not co lete the study ● F iling to ccount for these differences c n le d to incorrectly esti ting the

effectiveness of n intervention ● Using n intention-to-tre t n lysis, where ll n lyses consider ll subjects

who were ssigned to co rison grou , reg rdless of whether they received or co leted the intervention, c n ini ize this bi s

R e s u lt s As s e s s in g Pe rfo rm a n c e o f a Tre a t m e n t o r P reve n t io n In t e r- ve n t io n . The statistics used to characterize the performance of a treatment or prevention intervention include relative risks, relative risk differences (can be a reduction or increase, re ecting bene t or harm), absolute risk differ- ences (can be a reduction or increase, re ecting bene t or harm), numbers needed to treat, and numbers needed to harm.

2 ë 2 T a b le s f o r E v a lu a t in g S t u d ie s o f T r e a t m e n t o r P r e v e n t io n

Eve n t Oc c u rre d No Eve n t To t a l

Ex eri ent l grou b + b

Control grou c d c + d

36 Ba tes’ Pocke t Guide to Physica l Examina tion and His tory Taking

Calculating these performance statistics from the 2 × 2 table begins with determining probabilities for outcomes.

■ The probability that an intervention subject had the outcome is described by a/(a + b) from row 1 (experimental group); this also called the experimental event rate (EER).

■ The probability that a control subject had the outcome is c/(c + d) from row 2 (control group), or the control event rate (CER).

■ The relative risk, the probability of an outcome in the intervention group compared to the probability of an outcome in the control group, is expressed as the EER/CER.

■ The relative risk difference is de ned as |CER − EER|/CER × 100% or 100% − the relative risk, which describes the proportion of baseline risk is reduced/increased by the therapy.

■ The absolute risk difference, the difference in outcome rates between the comparisons groups, is expressed by the |CER − EER|.

■ The reciprocal of the absolute risk difference (reported as a fraction) is the number of subjects who need to be treated over a speci c period of time to prevent one outcome. If the intervention actually increases the risk for a bad outcome, then this statistic becomes the number needed to harm.

In many studies these calculations are used to measure treatment effective- ness between control and treatment interventions comparing medications, procedures, or diagnostic tests.

G e n e r a liz a b ilit y To make this determination, you need to rst look at the demographics of the study subjects (e.g., age, gender, race/ethnicity, socioeconomic status, clinical conditions). Then, you need to determine: Are the study demographics applicable to your patient? Is the intervention feasible in your clinical setting? And, most importantly, is the range of potential ben- e ts and harm of the intervention acceptable for your patient?

G u id e lin e R e c o m m e n d a t io n s There are many approaches for rating the strength of recommendations and we will discuss several grading systems. Review the rating systems in Tables 2-1 to 2-3 (pp. 37–40).

Chapter 2 | Evaluating Clinical Evidence 37

Aids to Interpretation

Gra d e De f in it io n S u g g e s t io n s fo r P ra c t ic e

A The USPSTF recommends the service. There is high certainty that the net benefit is substantial.

Offer or provide this service.

B The USPSTF recommends the service. There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial.

Offer or provide this service.

C The USPSTF recommends selectively offering or providing this service to individual patients based on professional judgment and patient preferences. There is at least moderate certainty that the net benefit is small.

Offer or provide this service for selected patients depending on individual circumstances.

D The USPSTF recommends against the service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits.

Discourage the use of this service.

I The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service. Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined.

If the service is offered, patients should understand the uncertainty about the balance of benefits and harms.

U.S . P re ve n t ive S e r v ic e s Ta s k Fo rc e Ra t in g s : Gra d e De f in it io n s a n d Im p lic a t io n s fo r P ra c t ic e

Table 2-1

The USPSTF de nes certainty as the “likelihood that the USPSTF assessment of the net bene t of a preventive service is correct.” The net bene t is de ned as bene t minus harm of the preventive service as implemented in a general, primary care population.

Source: Grade De nitions. U.S. Preventive Services Task Force. October 2014. http://www. uspreventiveservicestaskforce.org/Page/Name/grade-de nitions.

38 Ba tes’ Pocke t Guide to Physica l Examina tion and His tory Taking

Le ve l o f Ce r t a in t y De s c r ip t io n

High The available evidence usually includes consistent results from well-designed, well-conducted studies in representative primary care populations. These studies assess the effects of the preventive service on health outcomes. This conclusion is therefore unlikely to be strongly affected by the results of future studies.

Moderate The available evidence is sufficient to determine the effects of the preventive service on health outcomes, but confidence in the estimate is constrained by such factors as: ■ The number, size, or quality of individual studies. ■ Inconsistency of findings across individual studies. ■ Limited generalizability of findings to routine primary

care practice. ■ Lack of coherence in the chain of evidence.

As more information becomes available, the magnitude or direction of the observed effect could change, and this change may be large enough to alter the conclusion.

Low The available evidence is insufficient to assess effects on health outcomes. Evidence is insufficient because of: ■ The limited number or size of studies. ■ Important flaws in study design or methods. ■ Inconsistency of findings across individual studies. ■ Gaps in the chain of evidence. ■ Findings not generalizable to routine primary care

practice. ■ Lack of information on important health outcomes.

More information may allow estimation of effects on health outcomes.

U.S . P reve n t ive Se rvic e s Ta s k Fo rc e Le ve ls o f Ce r t a in t y Re g a rd in g Be n e f it

Table 2-2

Source: Update on Methods: Estimating Certainty and Magnitude of Net Bene t. U.S. Preven- tive Services Task Force. February 2014: http://www.uspreventiveservicestaskforce.org/Page/ Name/update-on-methods-estimating-certainty-and-magnitude-of-net-bene t.

Chapter 2 | Evaluating Clinical Evidence 39

Am e ric a n Co lle g e o f Ch e s t P hys ic ia n s : Gra d in g Re c o m m e n d a t io n s

Table 2-3

Gra d e o f Re c o m m e n d a t io n / De s c r ip t io n

Be n e f it v s . Ris k a n d Bu rd e n s

Me t h o d o lo g ic Qu a lit y o f S u p p o r t in g Evid e n c e Im p lic a t io n s

1A/Strong recommendation; high-quality evidence

Benefits clearly outweigh risk and burdens, or vice versa

RCTs without important limitations or overwhelming evidence from observational studies

Strong recommendation; can apply to most patients in most circumstances without reservation

1B/Strong recommendation; moderate-quality evidence

Benefits clearly outweigh risk and burdens, or vice versa

RCTs with important limitations (inconsistent results, method- ologic flaws, indirect, or imprecise) or exceptionally strong evidence from observa- tional studies

Strong recommen- dation; can apply to most patients in most circum- stances without reservation

1C/Strong recommendation; low-quality or very low-quality evidence

Benefits clearly outweigh risk and burdens, or vice versa

Observational studies or case series

Strong recommendation but may change when higher-quality evidence becomes available

2A/Weak recommendation; high-quality evidence

Benefits closely balanced with risk and burdens

RCTs without important limitations or overwhelming evidence from observational studies

Weak recommendation; best action may differ depending on circumstances or patients’ societal values

(table continues on page 40)

40 Ba tes’ Pocke t Guide to Physica l Examina tion and His tory Taking

Gra d e o f Re c o m m e n d a t io n / De s c r ip t io n

Be n e f it v s . Ris k a n d Bu rd e n s

Me t h o d o lo g ic Qu a lit y o f S u p p o r t in g Evid e n c e Im p lic a t io n s

2B/Weak recommendation; moderate-quality evidence

Benefits closely balanced with risk and burdens

RCTs with important limitations (inconsistent results, methodologic flaws, indirect, or imprecise) or exceptionally strong evidence from observational studies

Weak recommenda- tion; best action may differ depend- ing on circum- stances or patients’ societal values

2C/Weak recommendation; low-quality or very low-quality evidence

Uncertainty in the esti- mates of benefits, risks, and burden; benefits, risks, and burdens may be closely balanced

Observational studies or case series

Very weak recommendation; other alternatives may be equally reasonable

Am e ric a n Co lle g e o f Ch e s t P hys ic ia n s : Gra d in g Re c o m m e n d a t io n s (continued )

Table 2-3

Source: Guyatt G, Gutterman D, Baumann MH, et al. Grading strength of recommendations and quality of evidence in clinical guidelines: report from an American college of chest physicians task force. Chest. 2006;129(1):174.

C H A P T E R

3Interviewing and the Health History

The health history is a conversation with a purpose. In social conver- sation, you express your own needs and interests with responsibility only for yourself. The primary goal of the clinician–patient interview is to listen and improve the well-being of the patient through a trust- ing and supportive relationship. The interviewing process differs sig- ni cantly from the format for the health history presented in Chapter 1. Both are fundamental to your work with patients but serve different purposes.

■ The interviewing process that generates the patient’s story is fluid and requires empathy, effective communication, and the relational skills to respond to patient cues, feelings, and concerns. It is “open-ended,” drawing on a range of techniques that affirm and empower the patient—active listening, guided questioning, non- verbal affirmation, empathic responses, validation, reassurance, summarization, and partnering. These techniques are especially pertinent to eliciting the patient’s chief concerns and the History of the Present Illness.

■ The health history format is a structured framework for organizing patient information into written or verbal form. This format focuses your attention on the speci c kinds of information you need to obtain, facilitates clinical reasoning, and clari es communication of patient concerns, diagnoses, and plans to other health care providers involved in the patient’s care. More “clinician-centered” closed-ended yes/no questions are more pertinent to the Past History, the Family History, the Personal and Social History, and, most closed-ended of all, the Review of Systems.

For new patients in the of ce, hospital, or long-term care setting, you will do a comprehensive health history, described for adults in Chapter 1. For patients who seek care for a speci c complaint, such as painful urination, a more limited interview, tailored to that speci c problem—sometimes called a focused or problem-oriented history—may be indicated.

42 Ba tes’ Pocke t Guide to Physica l Examina tion and His tory Taking

Skilled interviewing requires the use of speci c learnable techniques perfected over a lifetime. Practice these techniques and nd ways to be observed or recorded so that you can receive feedback on your progress.

Ac t ive Lis t e n in g . This requires listening closely to what the patient is communicating, being aware of the patient’s emotional state, and using verbal and nonverbal skills to encourage the patient to continue and expand both concerns and fears.

Em p a t h ic Re s p o n s e s . Patients may express—with or without words—feelings they have not consciously acknowledged. Empathic responses are vital to patient rapport and convey that you experience some of the patient’s suffering. To express empathy, you must rst recognize the patient’s feelings. Elicit these feelings rather than assume how the patient feels.

Respond with understanding and acceptance. Responses may be as simple as “I understand,” “That sounds upsetting,” or “You seem sad.” Empathy also may be nonverbal—for example, placing your hand on the patient’s arm if the patient is crying.

Gu id e d Qu e s t io n in g . It is important to adapt your questioning to the patient’s verbal and nonverbal cues.

The Fundamentals of Skilled Interviewing

T e c h n iq u e s o f G u id e d Q u e s t io n in g

● Moving fro o en-ended to focused questions ● Using questioning th t elicits gr ded res onse ● Asking series of questions, one t ti e ● Offering ulti le choices for nswers ● Cl rifying wh t the tient e ns ● Encour ging with continuers ● Using echoing

Proceed from the general to the speci c. Directed questions should not be leading questions that call for a “yes” or “no” answer: not “Did your stools look like tar?” but “Please describe your stools.”

Chapter 3 | Interviewing and the Health History 43

Ask questions that require a graded response rather than a single answer. “What physical activity do you do that makes you short of breath?” is better than “Do you get short of breath climbing stairs?” Be sure to ask one question at a time. Try “Do you have any of the following problems?” Be sure to pause and establish eye contact as you list each problem.

Sometimes patients seem unable to describe symptoms. Offer multiple- choice answers.

For patients using words that are ambiguous, request clari cation, as in “Tell me exactly what you meant by ‘the u.’”

Posture, actions, or words encourage the patient to say more but do not specify the topic. Nod your head or remain silent. Lean forward, make eye contact, and use continuers like “Mm-hmm,” “Go on,” or “I’m listening.”

Repetition and echoing of the patient’s words encourage the patient to express both factual details and feelings.

No nve rb a l Co m m u n ic a t io n . Being sensitive to nonverbal messages allows you to both “read the patient” more effectively and send messages of your own. Pay close attention to eye contact, facial expression, posture, head position and movement such as shaking or nodding, interpersonal distance, and placement of the arms or legs, such as crossed, neutral, or open. Physi- cal contact (like placing your hand on the patient’s arm) can convey empathy or help the patient gain control of feelings. You also can mirror the patient’s paralanguage, or qualities of speech such as pacing, tone, and volume, to increase rapport. Be sensitive to cultural variations in uses and meanings of nonverbal behaviors.

Va lid a t io n . An important way to make a patient feel accepted is to provide verbal support that legitimizes or validates the patient’s emotional experience.

Re a s s u ra n c e . Avoid premature or false reassurance. Such reassur- ance may block further disclosures, especially if the patient feels that exposing anxiety is a weakness. The first step to effective reassurance is identifying and accepting the patient’s feelings without offering reassurance at that moment.

Pa r t n e rin g . Express your desire to work with patients in an ongoing way. Reassure patients that regardless of what happens with their disease, as their provider, you are committed to a continuing partnership. Even in your role as a student, such support makes a big difference.

44 Ba tes’ Pocke t Guide to Physica l Examina tion and His tory Taking

S u m m a riza t io n . Giving a capsule summary lets the patient know that you have been listening carefully. It also clari es what you know and what you don’t know. Summarization allows you to organize your clinical reasoning and to convey your thinking to the patient, which makes the relationship more collaborative.

Tra n s it io n s . Tell patients when you are changing directions during the interview. This gives patients a greater sense of control.

Em p o w e rin g t h e Pa t ie n t . The clinician–patient relationship is inherently unequal. Patients have many reasons to feel vulnerable: pain, worry, feeling overwhelmed with the health care system, lack of familiarity with the clinical evaluation process. Differences of gender, ethnicity, race, or class may also create power differentials. Ultimately, patients must be empowered to take care of themselves and follow through on your advice. Review the principles below.

Em p o w e r in g t h e P a t ie n t : Te c h n iq u e s f o r S h a r in g P o w e r

● Evoke the tient’s ers ective. ● Convey interest in the erson, not just the roble . ● Follow the tient’s le d. ● Elicit nd v lid te e otion l content. ● Sh re infor tion with the tient, es eci lly t tr nsition oints during the

visit . ● M ke your clinic l re soning tr ns rent to the tient . ● Reve l the li its of your knowledge.

The Sequence and Context of the Interview

P r e p a r a t io n , S e q u e n c e , a n d C u lt u r a l C o n t e x t Interviewing patients to elicit their health history requires planning.

■ Review the clinical record. Before seeing the patient, review the clini- cal record or chart. It often provides valuable information about past diagnoses and treatments; however, data may be incomplete or even disagree with what you learn from the patient, so be open to developing new approaches or ideas.

Chapter 3 | Interviewing and the Health History 45

■ Set goals for the interview. Clarify your goals for the interview. A clinician must balance provider-centered goals with patient-centered goals. The clinician’s task is to balance these multiple agendas.

■ Review your clinical behavior and appearance. Consciously or not, you send messages through your behavior. Posture, gestures, eye contact, and tone of voice all can express interest, attention, acceptance, and understanding. The skilled interviewer is calm and unhurried, even when time is limited. Reactions that betray disap- proval, embarrassment, impatience, or boredom block communica- tion. Patients nd cleanliness, neatness, conservative dress, and a name tag reassuring.

■ Adjust the environment. Always consider the patient’s privacy. Pull shut any bedside curtains. Suggest moving to an empty room rather than having a conversation that can be overheard.

T h e S e q u e n c e o f t h e In t e r v ie w In general, an interview moves through several stages. Throughout this sequence, as the clinician, you must always stay attuned to the patient’s feelings, help the patient express them, respond to their content, and vali- date their signi cance.

■ Greet the patient and establish rapport. Greet the patient by name and introduce yourself, giving your name. If possible, shake hands. If this is the rst contact, explain your role, including your status as a student and how you will be involved in the patient’s care. Using a title to address the patient (e.g., Mr. O’Neil, Ms. Wu) is always best. Avoid rst names unless you have speci c permission from the patient.

Whenever visitors are present, maintain con dentiality. Let the patient decide if visitors or family members should remain in the room, and ask for the patient’s permission before conducting the interview in front of them.

Attend to the patient’s comfort. Ask how he or she is feeling and if you are coming at a convenient time. Look for signs of discomfort, such as frequent changes of position or facial expressions that show pain or anxiety. Arranging the bed may make the patient more comfortable.

Consider the best way to arrange the room. Choose a distance that facili- tates conversation and good eye contact. Try to sit at eye level with the patient. Move any physical barriers between you and the patient, such as desks or bedside tables, out of the way.

46 Ba tes’ Pocke t Guide to Physica l Examina tion and His tory Taking

Give the patient your undivided attention. Spend enough time on small talk to put the patient at ease. If necessary, jot down short phrases, spe- ci c dates, or words rather than trying to put them into a nal format. Maintain good eye contact, especially when using the electronic clinical record. Whenever the patient is talking about sensitive or disturbing material, put down your pen.

■ Establish an agenda. It is important to identify both your own and the patient’s issues at the beginning of the encounter. Often, you may need to focus the interview by asking the patient which problem is most pressing. For example, “Do you have some special concerns today? Which one are you most concerned about?” Some patients may not have a speci c com- plaint or problem. It is still important to start with the patient’s story.

■ Invite the patient’s story. Encourage patients to tell their own stories, using their own words. Begin with open-ended questions that allow full freedom of response: “Tell me more about…” Avoid questions that restrict the patient to a minimally informative “yes” or “no” answer. Listen to the patient’s answers without interrupting.

Train yourself to follow the patient’s leads. Use verbal and nonverbal cues that prompt patients to recount their stories spontaneously. Use con- tinuers, especially at the outset, such as nodding your head and using phrases such as “Uh huh,” “Go on,” and “I see.”

■ Explore the patient’s perspective. The disease/illness model helps you understand the difference between your perspective and the patient’s perspective. In this model, disease is the explanation that the clinician uses to organize symptoms that lead to a clinical diagnosis. Illness is a construct that explains how the patient experiences the disease, includ- ing its effects on relationships, function, and sense of well-being. The health history interview needs to include both of these views of reality.

Learning how patients perceive illness means asking patient-centered questions in the four domains listed below, which follow the mnemonic “FIFE”—Feelings, Ideas, effect on Function, and Expectations. This is crucial to patient satisfaction, effective health care, and patient follow- through.

E x p lo r in g t h e P a t ie n t ’s P e r s p e c t iv e (F -I-F -E )

● The tient’s Feelings, including fe rs or concerns, bout the roble ● The tient’s Ide s bout the n ture nd the c use of the roble ● The effect of the roble on the tient’s life nd Function ● The tient’s Ex ect tions of the dise se, of the clinici n, or of he lth c re,

often b sed on rior erson l or f ily ex eriences

Chapter 3 | Interviewing and the Health History 47

■ Identify and respond to the patient’s emotional cues. Patients offer various clues to their concerns that may be direct or indirect, verbal or nonverbal; they may express them as ideas or emotions. Acknowledging and responding to these clues help build rapport, expand the clinician’s understanding of the illness, and improve patient satisfaction. Clues to the patient’s perspective on illness are provided in the box below.

C lu e s t o t h e P a t ie n t ’s P e r s p e c t iv e o n Illn e s s

● Direct st te ent(s) by the tient of ex l n tions, e otions, ex ect tions, nd effects of the illness

● Ex ression of feelings bout the illness without n ing the illness ● Atte ts to ex l in or underst nd sy to s ● S eech clues (e.g., re etition, rolonged reflective uses) ● Sh ring erson l story ● Beh vior l clues indic tive of unidentified concerns, diss tisf ction, or un et

needs such s reluct nce to cce t reco end tions, seeking second o in- ion, or e rly oint ent

Source: L ng F, Floyd MR, Beine KL. Clues to tients’ ex l n tions nd concerns bout their illnesses: c ll for ctive listening. Arch Fam Med. 2 ;9(3):222–227.

■ Expand and clarify the patient’s story. Each symptom has attributes that must be clari ed, including context, associations, and chronology, especially for pain. It is critical to understand fully every symptom’s essential characteristics. Always elicit the seven features of every symptom.

To pursue the seven attributes, two mnemonics may help:

■ OLD CARTS, or Onset, Location, Duration, Character, Aggravating/Alleviating Factors, Radiation, and Timing; and

■ OPQRST, or Onset, Palliating/Provoking Factors, Quality, Radiation, Site, and Timing

T h e S e v e n A t t r ib u t e s o f a S y m p t o m

1. Location. Where is it? Does it r di te? 2. Quality. Wh t is it like? 3. Quantity or severity. How b d is it? (For in, sk for r ting on sc le of 1

to 1 .) 4. Timing. When did (does) it st rt? How long did (does) it l st? How often did

(does) it occur? 5. Onset (set t ing in which symptom occurs). Include environ ent l f ctors,

erson l ctivities, e otion l re ctions, or other circu st nces th t y h ve contributed to the illness.

6. Remitt ing or exacerbating factors. Does nything ke it better or worse? 7. Associated manifestations. H ve you noticed nything else th t cco nies it?

48 Ba tes’ Pocke t Guide to Physica l Examina tion and His tory Taking

Use language that is understandable and appropriate to the patient. Technical language confuses patients and blocks communication. Whenever pos- sible, repeat back the patient’s words and expressions as the history unfolds, to af rm the patient’s experience as you clarify what he or she means.

Facilitate the patient’s story by using different types of questions and the techniques of skilled interviewing on pp. 42–44. Often you will need to use directed questions (see pp. 42–43) that ask for speci c information the patient has not already offered. In general, an interview moves back and forth from open-ended questions to increasingly focused questions and then on to another open-ended question, returning the lead in the interview to the patient.

Establishing the sequence and time course of the patient’s symptoms is important. Encourage a chronologic account by asking such questions as “What then?” or “What happened next?”

■ Generate and test diagnostic hypotheses. As you listen to the patient’s concerns, you will generate and test diagnostic hypotheses about which dis- ease process might be present. Identifying all the features of each symp- tom is fundamental to recognizing patterns of disease and to generating the differential diagnosis. It is important to fully esh out the patient’s story. This avoids the common trap of premature closure, or shutting down the patient’s story too quickly, which can lead to errors in diagnosis.

It is helpful to visualize the process of evoking a full description of each symptom(s) as “the cone” (Fig. 3-1). Each symptom has its own “cone,” which becomes a paragraph in the History of Present Illness in the writ- ten record.

Firs t, open-ended ques tions to hear “the s tory of the symptom” in the pa tient’s own words

Then more specific ques tions to e licit “the seven fea tures of every symptom”

Fina lly, the yes-no ques tions or “pertinent pos itives and nega tives” from the re levant section of the review of sys tems

Figure 3-1 Gathe r patient information.

Chapter 3 | Interviewing and the Health History 49

■ Share the treatment plan. Learning about the disease and conceptual- izing the illness give you and the patient the basis for planning further evaluation (physical examination, laboratory tests, consultations, etc.). Shared decision-making involves a three-step process: introducing choices and describing options, using patient decision support tools when available; exploring patient preferences; and moving to a decision, checking that the patient is ready to make a decision and offering more time if needed. Motivational interviewing may help the patient achieve desired behavior changes.

T h e G u id in g S t y le o f M o t iv a t io n a l In t e r v ie w in g

● “Ask” o en-ended questions—invite the tient to consider how nd why they ight ch nge

● “Listen” to underst nd your tient’s ex erience—“c ture” their ccount with brief su ries or reflective listening st te ents such s “quitting s oking feels beyond you t the o ent”; these ex ress e thy, encour- ge the tient to el bor te, nd re often the best w y to res ond to resis- t nce

● “Infor ”—by sking er ission to rovide infor tion, nd then sking wh t the i lic tions ight be for the tient .

Source: Quoted directly fro Rollnick S, Butler CC, Kinnersly P, et l. Motiv tion l Interview- ing. BMJ. 2 1 ;34 :1242.

■ Close the interview and visit. Make sure the patient fully understands the plans you have developed together. You can say, “We need to stop now. Do you have any questions about what we’ve covered?” Review future evaluation, treatments, and follow-up. Give the patient a chance to ask any nal questions. Ask the patient to “teach back” the plan of care to you in his or her own words.

■ Take time for self-re ection. As clinicians, we encounter a wide variety of people, each one unique. Because we bring our own values, assump- tions, and biases to every encounter, we must look inward to clarify how our expectations and reactions may affect what we hear and how we behave. Self-re ection brings a deepening personal awareness to our work with patients and is one of the most rewarding aspects of providing patient care.

T h e C u lt u r a l C o n t e x t o f t h e In t e r v ie w Cu lt u ra l Hu m ilit y—a Ch a n g in g Pa ra d ig m . As you provide care for an ever-expanding and diverse group of patients, it is important to understand how culture shapes not just the patient’s beliefs, but your own. Culture is a system of shared ideas, rules, and meanings that in uences how we view the world, experience it emotionally, and behave in relation

50 Ba tes’ Pocke t Guide to Physica l Examina tion and His tory Taking

to other people. This de nition of culture is broader than the term ethnicity. The in uence of culture is not limited to minority groups—it is relevant to everyone, including the culture of clinicians and their training. Cultural competence commonly is viewed as: “a set of attitudes, skills, behaviors, and policies that enable organizations and staff to work effectively in cross- cultural situations. It re ects the ability to acquire and use knowledge of the health-related bene ts, attitudes, practices, and communication pat- terns of clients and their families to improve services, strengthen programs, increase community participation, and close the gaps in health status among diverse population groups.”

Clinicians are increasingly challenged to adopt cultural humility, a “process that requires humility as individuals continually engage in self-re ection and self-critique as lifelong learners and re ective practitioners.” This pro- cess includes “the dif cult work of examining cultural beliefs and cultural systems of both patients and providers to locate the points of cultural dis- sonance or synergy that contribute to patients’ health outcomes.” It calls for clinicians to “bring into check the power imbalances that exist in the dynamics of (clinician)–patient communication” and maintain mutually respectful and dynamic partnerships with patients and communities. The following three-point framework will help you.

T h e T h r e e D im e n s io n s o f C u lt u r a l H u m ilit y

1. Self-awareness. Le rn bout your own bi ses; we ll h ve the . 2. Respectful communication. Work to eli in te ssu tions bout wh t is

“nor l.” Le rn directly fro your tients; they re the ex erts on their culture nd illness.

3. Collaborative partnerships. Build your tient rel tionshi s on res ect nd utu lly cce t ble l ns.

Advanced Interviewing In t e r v ie w in g t h e C h a lle n g in g P a t ie n t Always remember the importance of listening to the patient and clarifying the patient’s agenda.

S ile n t Pa t ie n t . Silence has many meanings. Watch closely for nonver- bal cues such as dif culty controlling emotions. You may need to shift your inquiry to symptoms of depression or begin an exploratory mental status examination. Silence may be the patient’s response to how you are asking questions. Are you asking too many direct questions? Have you offended the patient?

Chapter 3 | Interviewing and the Health History 51

Co n fu s in g Pa t ie n t . Some patients have multiple symptoms or a soma- tization disorder. Focus on the context of the symptoms and guide the interview into a psychosocial assessment. At other times, you may be frus- trated or confused. The history is vague and dif cult to understand, and patients may describe symptoms in bizarre terms. Try to learn more about the unusual symptoms. Watch for delirium in acutely ill or intoxicated patients and for dementia in the elderly. When you suspect a psychiatric or neurologic disorder, shift to a mental status examination, focusing on level of consciousness, orientation, and memory.

Pa t ie n t w it h Alt e re d Co g n it io n . Some patients cannot provide their own histories because of delirium, dementia, or other conditions. Others cannot relate certain parts of the history. In such cases, determine whether the patient has decision-making capacity, or the ability to understand informa- tion related to health, to make clinical choices based on reason and a con- sistent set of values, and to declare preferences about treatments. Capacity is a clinical designation and can be assessed by clinicians, whereas competence is a legal designation and can only be decided by a court. If a patient lacks capacity to make a health care decision, then identify the health care proxy or the agent with power of attorney for health care. If the patient had not identi ed a surrogate decision maker, then that role may shift to a spouse or family member. It is critical to remember that decision-making capacity is both “temporal and situational.” It can uctuate depending on the condition of the patient and the complexity of the decision involved. Many patients with psychiatric or cognitive de cits still retain the ability to make decisions.

For patients with capacity, obtain their consent before talking about their health with others. Consider dividing the interview into two segments—one with the patient and the other with both the patient and a second informant. Also learn the tenets of the Health Insurance Portability and Accountability Act (HIPAA) passed by Congress in 1996, which sets strict standards for disclo- sure for both institutions and providers when sharing patient information.

E le m e n t s o f D e c is io n -M a k in g C a p a c it y

P tients ust h ve the bility to:

1. Underst nd the relev nt infor tion bout ro osed di gnostic tests or tre t ent,

2. A reci te their situ t ion (including their underlying v lues nd current clinic l situ t ion),

3. Use re son to ke decision, nd 4. Co unic te their choice.

Source: Sessu s LL, Ze brzusk H, J ckson JL. Does this tient h ve edic l decision- king c city? JAMA. 2 11;3 6:42 .

52 Ba tes’ Pocke t Guide to Physica l Examina tion and His tory Taking

For patients with impaired capacity, nd a surrogate informant or decision maker to assist with the history. Check whether the patient has a durable power of attorney for health care or a health care proxy. If not, in many cases, a spouse or family member can represent the patient’s wishes.

Ta lk a t ive Pa t ie n t . Several techniques are helpful. For the rst 5 or 10 minutes, listen closely. Does the patient seem obsessively detailed or unduly anxious? Is there a ight of ideas or disorganized thought pro- cess? Try to focus on what seems most important to the patient. “You’ve described many concerns. Let’s focus on the hip pain rst. Can you tell me what it feels like?” Or you can ask, “What is your #1 concern today?”

Cryin g Pa t ie n t . Usually crying is therapeutic, as is quiet acceptance of the patient’s distress. Make a facilitating or supportive remark like “I’m glad that you were able to express your feelings.”

An g ry o r Dis ru p t ive Pa t ie n t . Many patients have reasons to be angry: they are ill, they have suffered a loss, they lack accustomed control over their own lives, and they feel relatively powerless. They may direct this anger toward you. Accept angry feelings from patients and allow them to express such emotions without getting angry in return. Validate their feelings without agreeing with their reasons. “I understand that you felt very frus- trated by the long wait and answering the same questions over and over.” Some angry patients become hostile and disruptive. Before approaching them, alert security. Stay calm, appear accepting, and avoid being challeng- ing. Keep your posture relaxed and nonthreatening. Once you have estab- lished rapport, gently suggest moving to a different location.

Pa t ie n t w it h a La n g u a g e Ba rrie r. If the patient speaks a different language, make every effort to nd a trained interpreter. The ideal inter- preter is a neutral, objective person trained in both languages and cultures. Avoid using family members or friends: con dentiality may be violated. As you work with the interpreter, make questions clear, short, and simple. Speak directly to the patient. Bilingual written questionnaires are valuable.

G u id e lin e s f o r W o r k in g w it h a n In t e r p r e t e r : “ IN T E R P R E T ”

I Introductions: M ke sure to introduce ll the individu ls in the roo . During the introduction, include infor tion s to the roles individu ls will l y.

N Note Goals: Note the go ls of the interview. Wh t is the di gnosis? Wh t will the tre t ent ent il? Will there be ny follow-u ?

T Transparency: Let the tient know th t everything s id will be inter reted throughout the session.

(continued )

Chapter 3 | Interviewing and the Health History 53

P a t ie n t w it h Lo w Lit e ra c y o r Lo w He a lt h Lit e ra c y. Assess the ability to read. Some patients may try to hide their reading problems. Ask the patient to read whatever instructions you have written. Simply handing the patient written material upside down to see if the patient turns it around may settle the question. Assess health literacy, or the skills to function effectively in the health care system: interpreting documents, reading labels and medication instructions, and speaking and listening effectively.

P a t ie n t w it h He a r in g Lo s s . Find out the patient’s preferred method of communicating. Patients may use American Sign Language, a unique language with its own syntax, or various other communica- tion forms combining signs and speech. Determine whether the patient identi es with the Deaf or Hearing culture. Handwritten questions and answers may be the best solution. When patients have partial hear- ing impairment or can read lips, face them directly, in good light. If the patient has a unilateral hearing loss, sit on the hearing side. If the patient

E Ethics: Use qu lified inter reters (not f ily e bers or children) when conducting n interview. Qu lified inter reters llow the tient to in- t in utono y nd ke infor ed decisions bout his or her c re.

R Respect Beliefs: Li ited English Proficient (LEP) tients y h ve cultur l beliefs th t need to be t ken into ccount s well. The inter reter y be ble to serve s cultur l broker nd hel ex l in ny cultur l beliefs th t y exist .

P Patient Focus: The tient should re in the focus of the encounter. Pro- viders should inter ct with the tient nd not the inter reter. M ke sure to sk nd ddress ny questions the tient y h ve rior to ending the encounter. If you don’t h ve tr ined inter reters on st ff, the tient y not be ble to c ll in with questions.

R Retain Control: It is i ort nt s the rovider th t you re in in control of the inter ction nd not let the t ient or the inter reter t ke over the convers t ion.

E Explain: Use si le l ngu ge nd short sentences when working with n inter reter. This will ensure th t co r ble words c n be found in the second l ngu ge nd th t ll the infor tion c n be conveyed cle rly.

T Thanks: Th nk the inter reter nd the tient for their ti e. On the ch rt , note th t the tient needs n inter reter nd who served s n inter reter this ti e.

Source: U.S. De rt ent of He lth nd Hu n Services. Inter ret Tool: working with inter reters in cultur l set t ings. Av il ble t ht t s:www.thinkcultur lhe lth.hhs.gov/ dfs/ Inter retTool. df. Accessed M y 3, 2 16.

G u id e lin e s f o r W o r k in g w it h a n In t e r p r e t e r : “ IN T E R P R E T ” (Continued)

54 Ba tes’ Pocke t Guide to Physica l Examina tion and His tory Taking

has a hearing aid, make sure it is working. Eliminate background noise such as television.

Pa t ie n t w it h Im p a ire d Vis io n . Shake hands to establish contact and explain who you are and why you are there. If the room is unfamiliar, ori- ent the patient to the surroundings.

Pa t ie n t w it h Lim it e d In t e llig e n c e . Patients of moderately limited intelligence usually can give adequate histories. Pay special attention to the patient’s schooling and ability to function independently. How far has the patient gone in school? If he or she didn’t nish, why not? Assess simple calculations, vocabulary, memory, and abstract thinking. For patients with severe mental retardation, obtain the history from the family or caregivers. Avoid “talking down” or using condescending behavior. The sexual history is equally important and often overlooked.

Pa t ie n t w it h Pe rs o n a l P ro b le m s . Patients may ask you for advice about personal problems outside the range of health. Letting the patient talk through the problem is usually more valuable and therapeutic than any answer you could give.

S e d u c t ive Pa t ie n t . The emotional and physical intimacy of the clini- cian–patient relationship may lead to sexual feelings. If you become aware of such feelings, accept them as a normal human response, and bring them to the conscious level so they will not affect your behavior. Denying these feelings makes it more likely that you will act inappropriately. Any sexual contact or romantic relationship with patients is unethical; keep your relationship with the patient within professional bounds and seek help if you need it.

S e n s it iv e T o p ic s

G u id e lin e s f o r B r o a c h in g S e n s it iv e T o p ic s

● The single ost i ort nt rule is to be nonjudg ent l. Your role is to le rn fro the tient nd hel the tient chieve better he lth. Acce t nce is the best w y to re ch this go l.

● Ex l in why you need to know cert in infor t ion. This kes t ients less rehensive. For ex le, s y to t ients, “Bec use sexu l r ct ices ut eo le t risk for cert in dise ses, I sk ll of y t ients the following questions.”

● Find o ening questions for sensitive to ics nd le rn the s ecific kinds of infor tion needed for your sh red ssess ent nd l n.

● Consciously cknowledge wh tever disco fort you re feeling. Denying your disco fort y le d you to void the to ic ltogether.

Chapter 3 | Interviewing and the Health History 55

Th e S e xu a l His t o ry. You can introduce questions about sexual func- tion and practices at multiple points in a patient’s history. An orienting sentence or two is often helpful. “Now I’d like to ask you some questions about your sexual health and practices” or “I routinely ask all patients about their sexual function.”

T h e S e x u a l H is t o r y : S a m p le Q u e s t io n s

● “When w s the l st ti e you h d inti te hysic l cont ct with so eone?” “Did th t cont ct include sexu l intercourse?” The ter “sexu lly ctive” c n be biguous. P tients h ve been known to re ly, “No, I just lie there.”

● “Do you h ve sex with en, wo en, or both?” P tients y h ve s e-sex rtners yet not consider the selves g y, lesbi n, or bisexu l. So e g y nd lesbi n tients h ve h d o osite-sex rtners.

● “How ny sexu l rtners h ve you h d in the l st 6 onths? In the l st 5 ye rs? In your lifet i e?” These quest ions ke it e sy for the t ient to cknowledge ult i le rtners. Ask, “H ve you h d ny new rtners in the st 6 onths?” If t ients quest ion why this infor t ion is i or- t nt , ex l in th t new rtners or ult i le rtners over lifet i e c n r ise the risk for STIs. Ask bout routine use of condo s. “How often do you use condo s?” is n o en-ended quest ion th t does not resu e n nswer.

● It is i ort nt to sk ll tients, “Do you h ve ny concerns bout HIV infec- tion or AIDS?” since infection c n occur in the bsence of risk f ctors.

Me n t a l He a lt h His t o ry. Cultural constructs of mental illness vary widely, causing marked differences in acceptance and attitudes. Ask open- ended questions initially: “Have you ever had any problem with emotional or mental illnesses?” Then move to more speci c questions: “Have you ever visited a counselor or psychotherapist?” “Have you taken medication for emotional issues?” “Have you or a family member ever been hospitalized for a mental health problem?”

Be sensitive to reports of mood changes or symptoms such as fatigue, tearfulness, appetite or weight changes, insomnia, and vague somatic com- plaints. Two validated screening questions are: “Over the past 2 weeks, have you felt down, depressed, or hopeless?” and “Over the past 2 weeks, have you felt little interest or pleasure in doing things?” Ask about thoughts of suicide: “Have you ever thought about hurting yourself or ending your life?” Evaluate severity.

Many patients with schizophrenia or other psychotic disorders can func- tion in the community and tell you about their diagnoses, symptoms, hos- pitalizations, and medications. Investigate their symptoms and assess any effects on mood or daily activities.

56 Ba tes’ Pocke t Guide to Physica l Examina tion and His tory Taking

Alc o h o l a n d P re s c rip t io n a n d Illic it Dru g s . Clinicians should routinely ask about current and past use of alcohol or drugs, patterns of use, and family history. Be familiar with the de nitions below:

Alc o h o l. For assessing alcohol intake, “What do you like to drink?” or “Tell me about your use of alcohol” are good opening questions that avoid the easy yes or no response. The most widely used screening questions are the CAGE questions about Cutting down, Annoyance when criticized, Guilty feelings, and Eye-openers. Two or more affirmative answers to the CAGE questions suggest alcoholism. The CAGE Questionnaire is readily available online.

Also ask about blackouts (loss of memory for events during drinking), seizures, accidents or injuries while drinking, job loss, marital con ict, or legal problems. Ask speci cally about drinking while driving or operating machinery.

P r e s c r ip t io n a n d Illic it D r u g s . Questions about drugs are similar. “How much marijuana do you use? Cocaine? Heroin? Amphetamines?” (Ask about each one by name.) “How about prescription drugs such as sleeping pills?” “Diet pills?” “Painkillers?” Use the CAGE questions but relate them to drug use. With adolescents, it may be helpful to ask about substance use by friends or family members rst. “A lot of young people are using drugs these days. How about at your school? Your friends?”

A d d ic t io n , P h y s ic a l D e p e n d e n c e , a n d T o le r a n c e

Tolerance: A st te of d t t ion in which ex osure to drug induces ch nges th t result in di inut ion of one or ore of the drug’s effects over t i e.

Physical Dependence: A st te of d t tion th t is nifested by drug cl ss- s ecific withdr w l syndro e th t c n be roduced by bru t cess tion, r id dose reduction, decre sing blood level of the drug, nd/or d inistr - tion of n nt gonist .

Addict ion: A ri ry, chronic, neurobiologic dise se, with genetic, sychoso- ci l, nd environ ent l f ctors influencing its develo ent nd nifest - tions. It is ch r cterized by beh viors th t include one or ore of the following: i ired control over drug use, co ulsive use, continued use des ite h r , nd cr ving.

Source: A eric n P in Society. Definitions Rel ted to the Use of O ioids for the Tre t ent of P in. A consensus st te ent fro the A eric n Ac de y of P in Medicine, the A eri- c n P in Society, nd the A eric n Society of Addiction Medicine, 2 1. Av il ble t htt :/ /www. s .org/docs/ ublicy- olicy-st te ents/1o ioid-definitions-consensus- 2– 11. df?sfvrsn= . Accessed M y 3, 2 16.

Chapter 3 | Interviewing and the Health History 57

In t im a t e Pa r t n e r Vio le n c e a n d Do m e s t ic Vio le n c e . Many authorities recommend routine screening of all female and older adult patients for domestic violence. Start with general “normalizing” questions: “Because abuse is common in many women’s lives, I’ve begun to ask about it routinely.” “Are there times in your relationships that you feel unsafe or afraid?” “Have you ever been hit, kicked, punched, or hurt by someone you know?”

C lu e s t o P h y s ic a l a n d S e x u a l A b u s e

● Injuries th t re unex l ined, see inconsistent with the tient’s story, re conce led by the tient, or c use e b rr ss ent

● Del y in getting tre t ent for tr u ● History of re e ted injuries or “ ccidents” ● Presence of lcohol or drug buse in tient or rtner ● P rtner tries to do in te the visit , will not le ve the roo , or see s unusu-

lly nxious or solicitous ● Pregn ncy t young ge; ulti le rtners ● Re e ted v gin l infections nd STIs ● Difficulty w lking or sitting due to genit l/ n l in ● V gin l l cer tions or bruises ● Fe r of the elvic ex in tion or hysic l cont ct ● Fe r of le ving the ex in tion roo

De a t h a n d t h e Dyin g Pa t ie n t . Work through your own feelings with the help of reading and discussion. Kübler-Ross has described ve stages in our response to loss or the anticipatory grief of impending death: denial and isolation, anger, bargaining, depression or sadness, and acceptance. These stages may occur sequentially or overlap in different combinations. Dying patients rarely want to talk about their illnesses all the time, nor do they wish to con de in everyone they meet. Give them opportunities to talk and then listen receptively, but be supportive if they prefer to stay at a social level.

Understanding the patient’s wishes about treatment at the end of life is an important clinician responsibility. Even if discussions of death and dying are dif cult, you must learn to ask speci c questions. Ask about Do Not Resuscitate (DNR) status. Find out about the patient’s frame of reference. “What experiences have you had with the death of a close friend or rela- tive?” “What do you know about cardiopulmonary resuscitation (CPR)?” Assure patients that relieving pain and taking care of their other spiritual and physical needs will be a priority. Encourage any adult, but especially the elderly or chronically ill, to establish a health care proxy, an individual who can act for the patient in life-threatening situations.

58 Ba tes’ Pocke t Guide to Physica l Examina tion and His tory Taking

Ethics and Professionalism Clinical ethics come into play in almost every patient interaction. Funda- mental maxims are as follows:

B u ild in g B lo c k s o f P r o f e s s io n a l E t h ic s in P a t ie n t C a r e

● Nonmaleficence or primum non nocere, co only st ted s, “First , do no h r .”

● Beneficence, or the dictu th t the clinici n needs to “do good” for the tient. As clinici ns, our res onsibility is to lw ys ct in the best interest of the tient.

● Autonomy, whereby infor ed tients h ve the right to deter ine wh t is in their own best interest .

● Confidentiality, e ning th t we re oblig ted not to tell others wh t we le rn fro our tients. Note th t so e fr eworks osit Justice s the fourth critic l rinci le, n ely th t ll t ients be tre ted f irly with equit - ble distribution of he lth c re resources.

T h e T a v is t o c k P r in c ip le s

Rights: Peo le h ve right to he lth nd he lth c re. Balance: C re of individu l tients is centr l, but the he lth of o ul tions is

lso our concern. Comprehensiveness: In ddition to tre ting illness, we h ve n oblig tion to e se

suffering, ini ize dis bility, revent dise se, nd ro ote he lth. Cooperation: He lth c re succeeds only if we coo er te with those we serve,

e ch other, nd those in other sectors. Improvement: I roving he lth c re is serious nd continuing res onsibility. Safety: Do no h r . Openness: Being o en, honest, nd trustworthy is vit l in he lth c re.

The Tavistock Principles guide behavior in health care for both individuals and institutions.

C H A P T E R

4Beginning the Physical Examination: General Survey, Vital Signs, and Pain

Fa t ig u e a n d We a k n e s s . Fatigue is a nonspeci c symptom with many causes. Use open-ended questions to explore the attributes of the patient’s fatigue, and encourage the patient to fully describe what he or she is experiencing.

Weakness differs from fatigue. It denotes a demonstrable loss of muscle power and will be discussed later with other neurologic symptoms.

Fe ve r, Ch ills , a n d Nig h t S w e a t s . Ask about fever if the patient has an acute or chronic illness. Find out whether the patient has used a ther- mometer to measure the temperature. Distinguish between feeling cold and a shaking chill, with shivering throughout the body and chattering of teeth. Night sweats raise concerns about tuberculosis or malignancy.

Focus your questions on the timing of the illness and its associated symptoms. Become familiar with patterns of infectious diseases that may affect your patient. Inquire about travel, contact with sick people, or other unusual exposures. Be sure to inquire about medications, as they may cause fever. In contrast, recent ingestion of aspirin, acet- aminophen, corticosteroids, and nonsteroidal anti-in ammatory drugs may mask fever.

The Health History

C o m m o n o r C o n c e r n in g S y m p t o m s

● F tigue nd we kness ● Fever, chills, nd night swe ts ● Weight ch nge ● P in

60 Ba tes’ Pocke t Guide to Physica l Examina tion and His tory Taking

We ig h t Ch a n g e . Good opening questions include “How often do you check your weight?” and “How is it compared to a year ago?”

■ Weight gain occurs when caloric intake exceeds caloric expenditure over time. It also may re ect abnormal accumulation of body uids.

■ Weight loss has many causes: decreased food intake, dysphagia, vomit- ing, and insuf cient supplies of food; defective absorption of nutrients; increased metabolic requirements; and loss of nutrients through the urine, feces, or injured skin. Also consider chronic illnesses, malignancy, and abuse of alcohol, cocaine, amphetamines, or opiates, or withdrawal from marijuana. Be alert for signs of malnutrition.

Pa in . Each year, approximately 100 million Americans report chronic pain, often underassessed. Adopt the comprehensive approach found on pp. 69–71.

Health Promotion and Counseling: Evidence and Recommendations

Im p o r t a n t T o p ic s f o r H e a lt h P r o m o t io n a n d C o u n s e lin g

● O ti l weight, nutrition, nd diet ● Blood ressure nd diet ry sodiu ● Exercise

Op t im a l We ig h t , Nu t rit io n , a n d Die t . Nearly 69% of U.S. adults are overweight (BMI ≥25 to 29 kg/m2) or obese (BMI ≥30 kg/m2). Obesity has increased in every segment of the population. More than 80% of people with type 2 diabetes and roughly 20% of those with hypertension or elevated cholesterol levels are overweight or obese. Increasing obesity in children contributes to rising rates of childhood diabetes. Reducing weight by even 5% to 10% can improve blood pressure, lipid levels, and glucose tolerance, and reduce the risk of diabetes and hypertension. Diet recommendations hinge on assessment of the patient’s motivation and readiness to lose weight and individual risk factors.

Chapter 4 | Beginning the Physical Examination: General Survey, Vital Signs, and Pain 61

Review the 2010 dietary guidelines of the U.S. Department of Agriculture and counsel patients to turn to its helpful MyPlate icon and website.

Blo o d P re s s u re a n d Die t a ry S o d iu m . The Institute of Medicine (IOM) recommends a maximum daily dietary intake of 2,300 mg of sodium for adults to reduce risk of hypertension. Advise patients to read the Nutrition Facts panel on food labels to help them adhere to the 2,300-mg/day guideline and to consider adopting the well-investigated Dietary Approaches to Stop Hypertension, or DASH Eating Plan (see Table 4-1, Patients with Hypertension: Recommended Changes in Diet, p. 72).

Exe rc is e . Adults should do at least 150 minutes (2 hours and 30 min- utes) of moderate-intensity cardiorespiratory activity, for example, walk- ing briskly at a pace of 3 to 4.5 miles per hour, each week. Alternatively, adults can engage in vigorous-intensity aerobic activity, such as jogging or running, for 75 minutes (1 hour and 15 minutes) each week. Patients can increase exercise by such simple measures as parking further away from their place of work or using stairs instead of elevators.

F o u r S t e p s t o P r o m o t e O p t im a l W e ig h t a n d N u t r it io n

1. Me sure BMI nd w ist circu ference; dults with BMI ≥25 kg/ 2, en with w ist circu ferences >4 inches, nd wo en with w ist circu ferences >35 inches re t incre sed risk for he rt dise se nd obesity-rel ted dise ses. R tios > .95 in en nd > .85 in wo en re considered elev ted. Deter ine ddition l risk f ctors for c rdiov scul r dise ses, including s oking, high blood ressure, high cholesterol, hysic l in ctivity, nd f ily history.

2. Assess diet ry int ke. 3. Assess the tient’s otiv tion to ch nge. 4. Provide counseling bout nutrition nd exercise.

Techniques of Examination EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

G e n e r a l S u r v e y

Ap p a re n t S t a t e o f He a lt h

Leve l o f Co n s c io u s n e s s . Is the patient awake, alert, and interactive?

Acutely or chronically ill, frail, robust, vigorous

If not, promptly assess level of consciousness (see p. 332)

62 Ba tes’ Pocke t Guide to Physica l Examina tion and His tory Taking

S ig n s o f Dis t re s s

■ Cardiac or respiratory distress

■ Pain

■ Anxiety or depression

S k in Co lo r a n d Ob vio u s Le s io n s . See Chapter 6, The Skin, Hair, and Nails, for details.

Dre s s , Gro o m in g , a n d Pe rs o n a l Hyg ie n e

■ How is the patient dressed? Is the clothing suitable for the temperature and weather? Is it clean and appropriate to the setting?

■ Note patient’s hair, ngernails, and use of make-up.

Fa c ia l Exp re s s io n . Watch for eye contact. Is it natural? Sustained and unblinking? Averted quickly? Absent?

Od o rs o f Bo d y a n d Bre a t h . Odors can be important diagnostic clues.

Po s t u re , Ga it , a n d Mo t o r Ac t ivit y

Clutching the chest, pallor, diaphoresis; labored breathing, wheezing, cough

Wincing, sweating, protecting painful area

Anxious face, fidgety movements, cold and moist palms; inexpressive or flat affect, poor eye contact, psychomotor slowing

Pallor, cyanosis, jaundice, rashes, bruises

These may be clues to the patient’s personality, mood, lifestyle, and self-regard.

Breath odor of alcohol, acetone (d iabetes), uremia, or liver failure. Fruity odor of d iabetes. (Never assume that alcohol on a pat ient ’s breath explains changes in mental status or neurologic findings.)

Stare of hyperthyroidism; flat or sad affect of depression. Decreased eye contact may be cultural or may suggest anxiety, fear, or sadness.

Preference to sit up in left-sided heart failure and to lean forward with arms braced in chronic obstructive pulmonary disease (COPD).

Body piercing or tattoos can be associated with alcohol and drug use.

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Chapter 4 | Beginning the Physical Examination: General Survey, Vital Signs, and Pain 63

H e ig h t a n d W e ig h t He igh t . Measure the patient’s height in stocking feet. Note the build— muscular or deconditioned, tall or short. Observe the body proportions.

We ig h t . Is the patient emaciated? Plump? If obese, is there central or dispersed distribution of fat? Weigh the patient with shoes off.

Calculate the body mass index (BMI), which incorporates estimated but more accurate measurements of body fat than weight alone.

Obesity (BMI ≥30 kg/m2) increases risk of diabetes, heart disease, stroke, hyper- tension, osteoarthritis, sleep apnea syn- drome, and some forms of cancer.

Short stature in Turner syndrome; elongated arms in Marfan syndrome; loss of height in osteoporosis.

M e t h o d s t o C a lc u la t e B o d y M a s s In d e x (B M I)

Un it o f Me a s u re Me t h o d o f Ca lc u la t io n

Weight in pounds, height in inches (1) St nd rd BMI Ch rt (2) Weight (lb) × 7 a

Height (inches) Weight in kilograms, height in

meters squared (3) Weight (kg)

Height ( )2

Either unit of measure (4) “BMI C lcul tor” t htt :/ /www.nhlbi. nih.gov/ he lth/educ tion l/ lose_wt/ BMI/ b ic lc.ht

aSever l org niz tions use 7 4.5, but the v ri tion in BMI is negligible. Conversion for ul s: 2.2 lb = 1 kg; 1 inch = 2.54 c ; 1 c = 1 .

Source: N tion l Institutes of He lth–N tion l He rt , Lung, nd Blood Institute: C lcul te Your Body M ss Index. Av il ble t : htt :/ /www.nhlbi.nih.gov/ he lth/educ tion l/ lose_ wt/ BMI/ b ic lc.ht . Accessed J nu ry 21, 2 15.

If the BMI is above 25, engage the patient in a 24-hour dietary recall and compare the intake of food groups and number of servings per day with current recommendations. Or, choose a screening tool and provide appro- priate counseling or referral (see Table 4-2, Nutrition Screening, p. 73, and Table 4-3, Nutrition Counseling, p. 74).

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

64 Ba tes’ Pocke t Guide to Physica l Examina tion and His tory Taking

If the BMI falls below 17, be concerned about possible anorexia nervosa, bulimia, or other medical conditions (see Table 4-4, Eating Disorders and Excessively Low BMI, p. 75).

T h e V it a l S ig n s : B lo o d P r e s s u r e , H e a r t R a t e , R e s p ir a t o r y R a t e , a n d T e m p e r a t u r e Blo o d P re s s u re M e t h o d s fo r M e a s u r in g Blo o d P re s s u r e . Office screening with manual and automated cuffs remains common, but elevated readings increasingly require confirmation with home and ambulatory monitoring, which are more predictive of cardiovascular disease and end-organ damage than manual and automated measurements in the office. Auto- mated ambulatory blood pressure monitoring measures blood pressure at preset intervals over 24 to 48 hours, usually every 15 to 20 minutes during the day and 30 to 60 minutes during the night. Be familiar with these different methods of blood pressure measurement and their varying criteria for hypertension.

Typ e s o f Hyp e r t e n s io n . Three types of hypertension are especially important to recognize, described below. Suspicion of these entities and assessing the effects of treatment are indications for ambulatory blood pressure monitoring.

T y p e s o f H y p e r t e n s io n

White coat hypertension (isolated clinic hypertension)

Blood ressure ≥14 /9 in edic l set- tings nd e n w ke bul tory re dings <135/85.

Re orted in u to 2 % of tients with elev ted office blood ressure

C rries nor l to slightly incre sed c rdio- v scul r risk nd does not require tre t ent; ttributed to conditioned nxiety res onse

Masked hypertension Blood ressure <14 /9 , but n elev ted d yti e blood ressure of >135/85 on ho e or bul tory testing

Re orted in n esti ted 1 % to 3 % of the gener l o ul tion

If untre ted, it incre ses risk of c rdio- v scul r dise se nd end-org n d ge

(continued )

Chapter 4 | Beginning the Physical Examination: General Survey, Vital Signs, and Pain 65

T y p e s o f H y p e r t e n s io n (Continued)

Nocturnal hypertension Physiologic blood ressure “di ing” occurs in ost tients s they shift fro w kefulness to slee

A nocturn l f ll of <1 % of d yti e v lues is ssoci ted with oor c rdiov scul r outco es nd c n only be identified on 24-hour bul tory blood ressure onitoring

Two other tterns h ve oor c rdiov scu- l r outco es, nocturn l rising ttern nd rked nocturn l f ll of >2 % of d yti e v lues

S e le c t in g t h e C o r r e c t S iz e B lo o d P r e s s u r e C u f f

It is i ort nt for clinici ns nd tients to use cuff th t fits the tient’s r . Follow the guidelines outlined here for selecting the correct size:

● Width of the infl t ble bl dder of the cuff should be bout 4 % of u er r circu ference ( bout 12 to 14 c in the ver ge dult).

● Length of the infl t ble bl dder should be bout 8 % of u er r circu fer- ence ( l ost long enough to encircle the r ).

● The st nd rd cuff is 12 × 23 c , ro ri te for r circu ferences u to 28 c .

S t e p s t o E n s u r e A c c u r a t e B lo o d P r e s s u r e M e a s u r e m e n t

1. The t ient should void s oking or drinking c ffein ted bever ges for 3 inutes before the blood ressure is t ken nd rest for t le st 5 inutes.

2. M ke sure the ex ining roo is quiet nd co fort bly w r . 3. M ke sure the r selected is free of clothing. There should be no rteriovenous

fistul s for di lysis, sc rring fro rior br chi l rtery cutdowns, or signs of ly hede (seen fter xill ry node dissection or r di tion ther y).

4. P l te the br chi l rtery to confir th t it h s vi ble ulse. 5. Position the r so th t the br chi l rtery, t the ntecubit l cre se, is

at heart level—roughly level with the 4th inters ce t its junction with the sternu .

6. If the t ient is se ted, rest the r on t ble lit t le bove the t ient’s w ist; if st nding, try to su ort the t ient’s r t the idchest level.

66 Ba tes’ Pocke t Guide to Physica l Examina tion and His tory Taking

M e a s u r in g B lo o d P r e s s u r e

● Center the infl t ble bl dder over the br chi l rtery. The lower border of the cuff should be bout 2.5 c bove the ntecubit l cre se. Secure the cuff snugly. Position the tient’s r so th t it is slightly flexed t the elbow.

● To deter ine how high to r ise the cuff ressure, first esti te the systolic ressure by l tion. As you feel the r di l rtery with the fingers of one h nd, r idly infl te the cuff until the r di l ulse dis e rs. Re d this res- sure on the no eter nd dd 3 Hg to it . Use of this su s the t rget for subsequent infl tions revents disco fort fro unnecess rily high cuff ressures. It lso voids the occ sion l error c used by n uscult tory g — silent interv l between the systolic nd di stolic ressures.

● Defl te the cuff ro tly. ● Now l ce the bell of stethosco e lightly over the br chi l rtery, t king c re

to ke n ir se l with its full ri . Bec use the sounds to be he rd (Korotkoff sounds) re rel tively low in itch, they re he rd better with the bell.

● Infl te the cuff r idly g in to the level just deter ined, nd then defl te it slowly, t r te of bout 2 to 3 Hg er second. Note the level t which you he r the sounds of t le st two consecutive be ts. This is the systolic pressure.

● Continue to lower the ressure slowly. The dis e r nce oint, usu lly only few Hg below the uffling oint, is the best esti te of diastolic pressure.

● Re d both the systolic nd di stolic levels to the ne rest 2 Hg. W it 2 or ore inutes nd re e t . Aver ge your re dings. If the first two re dings differ by ore th n 5 Hg, t ke ddition l re dings.

● T ke blood ressure in both r s t le st once. ● In tients t king ntihy ertensive edic tions or with history of f inting,

ostur l dizziness, or ossible de letion of blood volu e, t ke the blood ressure in two ositions—su ine nd st nding (unless contr indic ted). A f ll in systolic ressure of 2 Hg or ore within 3 inutes fter st nd- ing u , es eci lly when cco nied by sy to s, indic tes orthostatic (postural) hypotension.

In 2013, the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure ( JNC) updated the classi cation of systolic blood pressure (SBP) and diastolic blood pressure (DBP).

J N C 8 B lo o d P r e s s u r e C la s s if ic a t io n f o r A d u lt s

Ca t e g o ry S ys t o lic (m m Hg ) Dia s t o lic (m m Hg )

Nor l <12 <8 Prehy ertension 12 –139 8 –89 St ge 1 hy ertension

Ages ≥18 to <6 ye rs; di betes or ren l dise se

Age ≥6 ye rsa

14 —159

15 –159

9 —99

9 –99 St ge 2 hy ertension ≥16 ≥1

aThe A eric n Society of Hy ertension r ises this cutoff to ge ≥8 ye rs.

Chapter 4 | Beginning the Physical Examination: General Survey, Vital Signs, and Pain 67

When the systolic and diastolic levels fall in different categories, use the higher category. For example, 170/92 mm Hg is Stage 2 hypertension; 135/100 mm Hg is Stage 1 hypertension. In isolated systolic hypertension, SBP is ≥140 mm Hg, and DBP is <90 mm Hg.

Figure 4-1 Palpate the radial pulse .

Palpation of an irregularly irregular rhythm reliably indicates atrial fibrillation. For all irregular patterns, an ECG is needed to identify the arrhythmia.

See Table 8-4, p. 162, Abnormalities in Rate and Rhythm of Breathing.

He a r t Ra t e . The radial pulse is used commonly to count the heart rate. With the pads of your index and middle ngers, compress the radial artery until you detect a maximal pulsation (Fig. 4-1). If the rhythm is regular, count the rate for 15 seconds and multiply by 4. If the rate is unusually fast or slow, count it for 60 seconds. When the rhythm is irregular, evaluate the rate by auscultation at the cardiac apex (the apical pulse).

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Rhyt h m . Palpate the radial pulse. Check the rhythm again by listening with your stethoscope at the cardiac apex. Is the rhythm regular or irregular? If irregular, try to identify a pattern: (1) Do early beats appear in a basically regular rhythm? (2) Does the irregularity vary consistently with respiration? (3) Is the rhythm totally irregular?

Resp ira to ry Ra te and Rhythm . Observe the rate, rhythm, depth, and effort of breathing. Count the number of respirations in 1 minute either by visual inspection or by subtly listening over the patient’s trachea with your stethoscope during examination of the head and neck or chest. Normally, adults take 14 to 20 breaths per minute in a quiet, regular pattern.

68 Ba tes’ Pocke t Guide to Physica l Examina tion and His tory Taking

Te m p e ra t u re . Average oral tem- perature, usually 37°C (98.6°F), uctuates considerably from the early morning to the late afternoon or evening. Rectal temperatures are higher than oral temperatures by about 0.4 to 0.5°C (0.7 to 0.9°F) but also vary. Axillary temperatures are lower than oral temperatures by approximately 1°C but take 5 to 10 minutes to register and are considered less accurate than other measurements.

Tympanic membrane temperatures can be more variable than oral or rectal temperatures. Studies sug- gest that in adults, oral and tem- poral artery temperatures correlate more closely with the pulmonary artery temperature, but are about 0.5°C lower.

Oral temperatures: Choose either glass or electronic thermometer.

■ Glass thermometer: Shake the ther- mometer down to 35°C (96°F) or below, insert it under the tongue, instruct the patient to close both lips, and wait 3 to 5 minutes. Then read the thermometer, reinsert for 1 minute, and read it again. Avoid breakage.

■ Electronic thermometer: Carefully place the disposable cover over the probe and insert the ther- mometer under the tongue for about 10 seconds.

Rectal temperatures: Position the patient on one side with the hip exed. Select a rectal thermometer with a stubby tip, lubricate it, and

Fever or pyrexia refers to an elevated body temperature. Hyperpyrexia refers to extreme elevation in temperature, above 41.1°C (106°F), while hypothermia refers to an abnormally low temperature, below 35°C (95°F) rectally.

Causes of fever include infection, t rauma (such as surgery or crush injuries), malignancy, b lood disorders (such as acute hemolyt ic anemia), drug react ions, and immune disorders such as collagen vascular d isease.

The chief cause of hypothermia is exposure to cold. Other causes include reduced movement as in paralysis, interference with vasoconstriction as from sepsis or excess alcohol, starvation, hypothyroidism, and hypoglycemia. Older adults are especially susceptib le to hypothermia and also less likely to develop fever.

Taking rectal temperatures is common practice in unresponsive patients or those at risk for biting down on the thermometer.

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Chapter 4 | Beginning the Physical Examination: General Survey, Vital Signs, and Pain 69

insert it about 3 to 4 cm (1½ inches) into the anal canal, in a direction pointing to the umbi- licus. Remove it after 3 minutes, then read. Alternatively, use an electronic thermometer after lubri- cating the probe cover. Wait about 10 seconds for the digital tempera- ture recording to appear.

Tympanic membrane temperature: Make sure the external auditory canal is free of cerumen. Position the probe in the canal. Wait 2 to 3 seconds until the digital reading appears. This method measures core body temperature, which is higher than the normal oral tem- perature by approximately 0.8°C (11.4°F).

Temporal artery temperature: Place the probe against the center of the forehead, depress the infra- red scanning button, and brush the device across the forehead, down the cheek, and behind an earlobe. Read the display, which records the highest measure temperature. Industry information suggests that combined forehead and behind- the-ear contact is more accurate than scanning only the forehead.

A c u t e a n d C h r o n ic P a in The experience of pain is complex and multifactorial. It involves sensory, emotional, and cognitive processing but may lack a speci c physical etiology.

Chronic pain is de ned in several ways: pain not associated with cancer or other clinical conditions that persists for more than 3 to 6 months; pain lasting more than 1 month beyond the course of an acute illness or injury; or pain recurring at intervals of months or years. Chronic noncancer pain affects 5% to 33% of patients in primary care settings.

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

70 Ba tes’ Pocke t Guide to Physica l Examina tion and His tory Taking

Adopt a multidisciplinary measurement-based approach to assessing pain, carefully listening to the patient’s story, and any contributing factors. Pursue the seven features of pain, as you would with any symptom. Accept the patient’s self-report, which experts state is the most reliable indicator of pain.

Location: Ask the patient to point to the pain. Lay terms may not be spe- ci c enough to localize the site of origin.

Severity: Use a consistent method to determine severity. Three scales are common: the Visual Analog Scale, and two scales using ratings from 1 to 10—the Numeric Rating Scale and the Faces Pain Scale.

Co n t rib u t in g Fa c t o rs . Be sure to ask about any treatments that the patient has tried, including medications, physical therapy, and alterna- tive medicines. A comprehensive medication history helps you to identify drugs that interact with analgesics and reduce their ef cacy.

Identify any comorbid conditions such as arthritis, diabetes, HIV/AIDS, substance abuse, sickle cell disease, or psychiatric disorders. These can signi cantly affect the patient’s experience of pain.

He a lt h Dis p a rit ie s . Be aware of the well-documented health dispari- ties in pain treatment and delivery of care, which range from lower use of analgesics in emergency rooms for African-American and Hispanic patients to disparities in use of analgesics for cancer, postoperative, and low back pain. Clinician stereotypes, language barriers, and unconscious clinician biases in decision making all contribute to these disparities. Critique your own communication style, seek information and best practice standards, and improve your techniques of patient education and empowerment.

Pa in Ma n a g e m e n t . Managing pain is a complex clinical challenge.

Experts recommend a stepped-care approach, with an emphasis on mea- surement and tracking tools to follow responses to treatment and referrals to specialists, summarized below.

M a n a g in g C h r o n ic P a in : S t e p s f o r M e a s u r e m e n t -B a s e d C a r e

Step 1: Measure pain intensity and pain interference. A v lid ted 2-ite question- n ire is v il ble for ri ry c re sking tients to r te in in the st onth nd interference with d ily ctivities on sc le of 1 to 1 .

Step 2: Measure mood. Tre t ble de ression, nxiety, nd osttr u tic stress disorder (PTSD) frequently cco ny chronic in. The PHQ-4 is 4-ite questionn ire for detecting nxiety nd de ression. The Pri ry C re-PTSD is 4-question screen for PTSD.

(continued )

Chapter 4 | Beginning the Physical Examination: General Survey, Vital Signs, and Pain 71

Record the vital signs taken at the time of your examination. They are preferable to those taken earlier in the day by other providers. (Common abbreviations for blood pressure, heart rate, and respiratory rate are self- explanatory.)

M a n a g in g C h r o n ic P a in : S t e p s f o r M e a s u r e m e n t -B a s e d C a r e (Continued)

Step 3: Measure the effect of pain on sleep. O ioid doses correl te with slee - disordered bre thing nd slee ne .

Step 4: Me sure risk of co-occurring subst nce buse, esti ted t 18% to 3 %. Step 5: Measure the opioid dose nd c lcul te the o ioid dose equiv lency using

v il ble web-b sed c lcul tors.

Source: T uben D. Chronic in n ge ent: e sure ent-b sed ste ed c re solutions. P in: Clinic l U d tes. Intern tion l Associ tion for the Study of P in. Dece ber 2 12. Av il ble t htt :/ /www.i s - in.org/ Public tionsNews/ NewsletterIssue. s x?Ite Nu ber=2 64. Accessed J nu ry 28, 2 15.

Recording Your Findings

R e c o r d in g t h e P h y s ic a l E x a m in a t io n —G e n e r a l S u r v e y a n d V it a l S ig n s

● “Mrs. Scott is young, he lthy- e ring wo n, well-groo ed, fit , nd in good s irits. Height is 5′4″, weight 135 lb, BP 12 /8 , HR 72 nd regul r, RR 16, te er ture 37.5°C.”

OR ● “Mr. Jones is n elderly n who looks le nd chronic lly ill. He is lert ,

with good eye cont ct , but c nnot s e k ore th n two or three words t t i e bec use of shortness of bre th. He h s intercost l uscle retr ction when bre thing nd sits u right in bed. He is thin, with diffuse uscle w st- ing. Height is 6′2″, weight 175 lb, BP 16 /95, HR 1 8 nd irregul r, RR 32 nd l bored, te er ture 1 1.2°F.” (These findings suggest COPD exacerbation.)

72 Ba tes’ Pocke t Guide to Physica l Examina tion and His tory Taking

Aids to Interpretation

Die t a ry Ch a n g e Fo o d S o u rc e

Increase foods high in potassium

Baked white or sweet potatoes, white beans, beet greens, soybeans, spinach, lentils, kidney beans Yogurt Tomato paste, juice, puree, and sauce Bananas, plantains, many dried fruits, orange juice

Decrease foods high in sodium

Canned foods (soups, tuna fish) Pretzels, potato chips, pizza, pickles, olives Many processed foods (frozen dinners, ketchup, mustard) Batter-fried foods Table salt, including for cooking

Pa t ie n t s w it h Hyp e rt e n s io n : Re c o m m e n d e d Ch a n g e s in Die t

Table 4-1

Source: Adapted from: U.S. Department of Agriculture and U.S. Department of Health and Human Services. Dietary Guidelines for Americans, 2010. Washington, D.C.: U.S. Govern- ment Printing Of ce; 2010; Choose MyPlate.gov. Available at http://www.choosemyplate.gov/ index.html. Accessed December 15, 2014; Of ce of Dietary Supplements, National Institutes of Health. Dietary Supplement Fact Sheets: Calcium; Vitamin D. Available at http://ods. od.nih.gov/factsheets/list-all/. Accessed December 15, 2014.

Chapter 4 | Beginning the Physical Examination: General Survey, Vital Signs, and Pain 73

Source: Vellas B, Villars H, Abellan G, et al. Overview of the MNA—Its history and challenges. J Nutr Health Aging. 2006;10:456.

Rubenstein LZ, Harker JO, Salva A, et al. Screening for undernutrition in geriatric practice: developing the short-form mini nutritional assessment (MNA-SF). J Gerontol A Biol Sci Med Sci. 2001;56(6):M366.

Guigoz Y. The Mini-Nutritional Assessment (MNA) Review of the Literature—What does it tell us? J Nutr Health Aging. 2006;10:466.

Kaiser MJ, Bauer JM, Ramsch C, et al. Validation of the Mini Nutritional Assessment Short-Form (MNA-SF): a practical tool for identi cation of nutritional status. J Nutr Health Aging. 2009; 13:782.

®Société des Produits Nestlé, S.A., Vevey, Switzerland, Trademark Owners ©Nestlé, 1994, Revision 2009. N67200 12/99 10M For more information: www.mna-elderly.com

Nu t rit io n Sc re e n in g

Mini Nutritiona l Assessment MNA®

Las t name: Firs t name:

Sex: Age: Weight, kg: Height, cm: Date :

Screening

A Has food intake declined over the pas t 3 months due to los s of appetite , diges tive problems , chewing or s wallowing difficulties ? 0 = severe decrease in food intake 1 = moderate decrease in food intake 2 = no decrease in food intake

B Weight los s during the las t 3 months 0 = weight loss grea te r than 3 kg (6.6 lbs ) 1 = does not know 2 = weight loss be tween 1 and 3 kg (2.2 and 6.6 lbs ) 3 = no weight loss

C Mobility 0 = bed or chair bound 1 = able to ge t out of bed / cha ir but does not go out 2 = goes out

D Has s uffered ps ycholog ical s tres s or acute dis eas e in the pas t 3 months ? 0 = yes 2 = no

E Neurops ycholog ical problems 0 = severe dementia or depress ion 1 = mild dementia 2 = no psychologica l problems

F1 Body Mas s Index (BMI) (weight in kg) / (height in m)2

0 = BMI less than 19 1 = BMI 19 to less than 21 2 = BMI 21 to less than 23 3 = BMI 23 or grea te r

IF BMI IS NOT AVAILABLE, REPLACE QUESTION F1 WITH QUESTION F2. DO NOT ANSWER QUESTION F2 IF QUESTION F1 IS ALREADY COMPLETED.

Complete the screen by filling in the boxes with the appropria te numbers . Tota l the numbers for the final screening score.

F2 Calf c ircumference (CC) in cm 0 = CC less than 31

Screening score (max. 14 points)

12 - 14 points : Normal nutritional s tatus 8 - 11 points : At risk of malnutrition 0 - 7 po ints : Malnourished

3 = CC 31 or grea te r

Table 4-2

74 Ba tes ’ Pocke t Guide to Physica l Examina tion and His tory Taking

Nu t r ie n t Fo o d S o u rc e

Ca lc iu m Dairy foods such as milk, natural cheeses, and yogurt Calcium-fortified cereals, fruit juice, soy milk, and tofu Dark green leafy vegetables like collard, turnip, and mustard greens; bok choy Sardines

Iro n Lean meat, dark turkey meat, liver Clams, mussels, oysters, sardines, anchovies Iron-fortified cereals Enriched and whole grain bread Spinach, peas, lentils, turnip greens, and artichokes Dried prunes and raisins

Fo la t e Cooked dried beans and peas Oranges, orange juice Liver Spinach, mustard greens Black-eyed peas, lentils, okra, chickpeas, peanuts Folate-fortified cereals

Vit a m in D Vitamin D–fortified milk, orange juice, and cereals Cod liver oil; swordfish, salmon, herring, mackerel, tuna, trout Egg yolk Mushrooms

Nu t rit io n Co u n se lin g : So u rce s o f N u t r ie n t sTable 4-3

Source: Adapted from U.S. Department of Agriculture and U.S. Department of Health and Human Services. Dietary Guidelines for Americans, 2010. Washington, D.C.: U.S. Govern- ment Printing Of ce; 2010; Choose MyPlate.gov. Available at http://www.choosemyplate.gov/ index.html. Accessed December 15, 2014; Of ce of Dietary Supplements, National Institutes of Health. Dietary Supplement Fact Sheets: Calcium; Vitamin D. Available at http://ods. od.nih.gov/factsheets/list-all/. Accessed December 15, 2014.

Chapter 4 | Beginning the Physical Examination: General Survey, Vital Signs, and Pain 75

An o re xia Ne r vo s a Bu lim ia Ne r vo s a

Refusal to maintain minimally normal body weight (or BMI above 17.5 kg/m2) Fear of appearing fat Frequently starving but in denial; lacking insight Often brought in by family members May present as failure to make expected weight gains in childhood or adolescence, amenorrhea in women, loss of libido or potency in men Associated with depressive symptoms such as depressed mood, irritability, social withdrawal, insomnia, decreased libido Additional features supporting diagnosis: self-induced vomiting or purging, excessive exercise, use of appetite suppressants and/or diuretics Biologic complications ■ Neuroendocrine changes: amenorrhea,

hormonal alterations ■ Cardiovascular disorders: bradycardia,

hypotension, dysrhythmias, cardiomyopathy

■ Metabolic disorders: hypokalemia, hypochloremic metabolic alkalosis, increased BUN, edema

■ Other: dry skin, dental caries, delayed gastric emptying, constipation, anemia, osteoporosis

Repeated binge eating followed by self-induced vomiting, misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise Often with normal weight Overeating at least twice a week during 3-month period; large amounts of food consumed in short period (�2 hrs) Preoccupation with eating; craving and compulsion to eat; lack of control over eating; alternating with periods of starvation Dread of fatness but may be obese Subtypes of ■ Purging: bulimic episodes

accompanied by self-induced vomiting or use of laxatives, diuretics, or enemas

■ Nonpurging: bulimic episodes accompanied by compensatory behavior such as fasting, exercise without purging

Biologic complications; see changes listed for anorexia nervosa.

Ea t in g Dis o rd e rs a n d Exc e s s ive ly Lo w BMITable 4-4

Sources: World Health Organization. The ICD-10 Classi cation of Mental and Behavioral Disorders: Diagnostic Criteria for Research. Geneva: World Health Organization, 1993; American Psy- chiatric Association. DSM-IV-TR: Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Text Revision. Washington, DC: American Psychiatric Association, 2000. Halmi KA: Eating disorders: In: Kaplan HI, Sadock BJ, eds. Comprehensive Textbook of Psychiatry, 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins, 1663–1676, 2000. Mehler PS. Bulimia nervosa. N Engl J Med. 2003;349(9):875–880.

C H A P T E R

5Behavior and Mental Status

Clinicians are uniquely poised to detect clues to mental illness and harmful behavior through empathic listening and close observation. Nonetheless, these clues are often missed. Recognizing mental illness is especially important given its signi cant prevalence and morbidity, the high likelihood that it is treatable, the shortage of psychiatrists, and the increasing importance of primary care clinicians as the rst to encounter the patient’s distress. The prevalence of mental health disorders in U.S. adults in 2012 was 18%, affecting 43.7 million people; yet, only 41% received treatment. Even for those receiving care, adherence to treatment guidelines in primary care of ces is <50% and disproportionately lower for ethnic minorities.

Mental health disorders are commonly masked by other clinical condi- tions. Look for the interaction of anxiety and depression in patients with substance abuse, termed “dual diagnosis,” because both must be treated for the patient to achieve optimal function. Watch for underly- ing psychiatric conditions in “dif cult encounters” and patients with unexplained symptoms. Explore the outlook of patients with chronic illness, a group that is especially vulnerable to depression and anxiety. Nearly half of those with any single mental disorder meet the criteria for one or more additional disorders, with severity strongly related to comorbidity.

Approximately 5% of somatic symptoms are acute, triggering immediate evaluation. Another 70% to 75% are minor or self-limited and resolve in 6 weeks. Nevertheless, approximately 25% of patients have persist- ing and recurrent symptoms that elude assessment and fail to improve. Overall, 30% of symptoms are medically unexplained, masking anxiety, depression, or even somatoform disorders (see Table 5-1, Somatoform Disorders: Types and Approach to Symptoms, p. 87). Depression and anxiety are highly correlated with substance abuse, for example, and clinicians are advised to look for overlap in these conditions. “Dif cult patients” are frequently those with multiple unexplained symptoms and underlying psychiatric conditions that are amenable to therapy. Without better “dual diagnosis,” patient health, function, and quality of life are at risk.

78 Ba tes’ Pocke t Guide to Physica l Examina tion and His tory Taking

Pe rs o n a lit y Dis o rd e rs . Dif cult patients may have personality disor- ders resulting in problematic of ce behaviors that escape diagnosis. The DSM-5 characterizes these disorders as “an enduring pattern of inner experience and behavior that deviates markedly from the expec- tations of the individual’s culture, is pervasive and in exible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment.” These patients have dysfunctional interper- sonal coping styles that disrupt and destabilize their relationships, in- cluding those with health care providers.

M e n t a l H e a lt h D is o r d e r s a n d U n e x p la in e d S y m p t o m s in P r im a r y C a r e S e t t in g s

Me n t a l Dis o rd e r s in P r im a ry Ca re ● A roxi tely 2 % of ri ry c re out tients h ve ent l disorders, but

5 % to 75% of these disorders re undetected nd untre ted. ● Prev lence of ent l disorders in ri ry c re settings is roughly:

● Anxiety—2 % ● Mood disorders including dysthy i , de ressive, nd bi ol r

disorders—25% ● De ression—1 % ● So tofor disorders—1 % to 15% ● Alcohol nd subst nce buse—15% to 2 %

Exp la in e d a n d Un e xp la in e d S ym p t o m s ● Physic l sy to s ccount for roxi tely 5 % of office visits. ● Roughly one third of hysic l sy to s re unex l ined; in 2 % to 25% of

tients, hysic l sy to s beco e chronic or recurring. ● In t ients with unexplained symptoms, the rev lence of de ression nd

nxiety exceeds 5 % nd incre ses with the tot l nu ber of re orted hysic l sy to s king detect ion nd “du l di gnosis” i ort nt clinic l go ls.

Co m m o n Fu n c t io n a l S yn d ro m e s ● Co-occurrence r tes for common functional syndromes such s irrit ble bowel

syndro e, fibro y lgi , chronic f tigue, te oro ndibul r joint disorder, nd ulti le che ic l sensitivity re ch 3 % to 9 %, de ending on the disor- ders co red.

● The rev lence of symptom overlap is high in the co on function l syn- dro es: n ely, co l ints of f tigue, slee disturb nce, usculoskelet l in, he d che, nd g strointestin l roble s.

● The co on function l syndro es lso overl in r tes of function l i ir- ent, sychi tric co orbidity, nd res onse to cognitive nd ntide ress nt ther y.

Chapter 5 | Behavior and Mental Status 79

For unexplained conditions lasting beyond 6 weeks, experts recommend brief screening questions with high sensitivity and speci city, followed by more detailed investigation when indicated due to high rates of coexisting depression and anxiety.

Me n t a l He a lt h S c re e n in g . Unexplained conditions lasting more than 6 weeks are increasingly recognized as chronic disorders that should prompt screening for depression, anxiety, or both. Because screening all patients is time consuming and expensive, experts recommend a two-tiered approach: brief screening questions with high sensitivity and speci city for patients at risk, followed by more detailed investigation when indicated.

P a t ie n t Id e n t if ie r s f o r M e n t a l H e a lt h S c r e e n in g

● Medic lly unex l ined hysic l sy to s— ore th n h lf h ve de ressive or nxiety disorder

● Multi le hysic l or so tic sy to s or “high sy to count” ● High severity of the resenting so tic sy to ● Chronic in ● Sy to s for ore th n 6 weeks ● Physici n r ting s “difficult encounter” ● Recent stress ● Low self-r ting of over ll he lth ● High use of he lth c re services ● Subst nce buse

The Health History

C o m m o n o r C o n c e r n in g S y m p t o m s

● Ch nges in ttention, ood, or s eech ● Ch nges in insight, orient tion, or e ory ● Anxiety, nic, ritu listic beh vior, nd hobi s ● Deliriu or de enti

Your assessment of mental status begins with the patient’s rst words. As you gather the health history, you will quickly observe the patient’s level of alertness and orientation, mood, attention, and memory. You will learn about the patient’s insight and judgment, as well as any recurring or unusual

80 Ba tes’ Pocke t Guide to Physica l Examina tion and His tory Taking

thoughts or perceptions. For some, you will need to conduct a more formal evaluation of mental status.

Many of the terms used to describe the mental status examination are familiar to you from social conversation. Take the time to learn their precise meanings in the context of the formal evaluation of mental status (see below).

Assess level of consciousness, general appearance and mood, and ability to pay attention, remember, understand, and speak.

T e r m in o lo g y : T h e M e n t a l S t a t u s E x a m in a t io n

Le ve l o f Co n s c io u s n e s s

Ale r t n e s s o r S t a t e o f Aw a re n e s s o f t h e En viro n m e n t

Attention The bility to focus or concentr te over ti e on one t sk or ctivity

Memory The rocess of registering or recording infor tion. Recent or short-ter e ory covers inutes, hours, or d ys; re ote or long-ter e ory refers to interv ls of ye rs.

Orientation Aw reness of erson l identity, l ce, nd ti e; requires both e ory nd ttention

Perceptions Sensory w reness of objects in the environ ent nd their interrel tionshi s; lso refers to intern l sti - uli (e.g., dre s)

Thought processes The logic, coherence, nd relev nce of the tient 's thoughts, or how eo le think

Thought content Wh t the tient thinks bout, including level of insight nd judg ent

Insight Aw reness th t sy to s or disturbed beh viors re nor l or bnor l

Judgment Process of co ring nd ev lu ting ltern tives; reflects v lues th t y or y not be b sed on re lity nd soci l conventions or nor s

Affect An observ ble, usu lly e isodic, feeling tone ex ressed through voice, f ci l ex ression, nd de e nor

Mood A ore sust ined e otion th t y color erson's view of the world ( ffect is to ood s we ther is to cli te)

Language A co lex sy bolic syste for ex ressing, receiving, nd co rehending words; essenti l for ssessing other ent l functions

Higher cognitive functions

Assessed by voc bul ry, fund of infor tion, bstr ct thinking, c lcul tions, construction of objects with two or three di ensions

Chapter 5 | Behavior and Mental Status 81

Assess the patient’s responses to illness and life circumstances, which often tell you about his or her insight and judgment. Test orientation and memory.

Health Promotion and Counseling: Evidence and Recommendations

Mo o d Dis o rd e r s a n d De p re s s io n . Depressive and bipolar disor- ders affect over 9% of the U.S. population. About 16 million adult Amer- icans, or almost 7%, have major depression, often with coexisting anxiety disorders and substance abuse. Depression is nearly twice as common in women as men, and frequently accompanies chronic clinical illness, yet is frequently underdiagnosed. Look closely for early clues of depression in primary care settings such as low self-esteem, loss of pleasure in daily activities (anhedonia), sleep disorders, and dif culty concentrating or making decisions.

Failure to diagnose depression can have fatal consequences—suicide rates in patients with major depression are eight times higher than in the general population. Ask, “Over the past 2 weeks, have you felt down, depressed, or hopeless?” and “Over the past 2 weeks, have you felt little interest or pleasure in doing things?”

S u ic id e . Suicide ranks as the 10th leading cause of death in the United States, accounting for nearly 40,000 deaths annually, and is the second leading cause of death among 15- to 24-year olds. Suicide rates are highest among those ages 45 to 54 years, followed by elderly adults ≥age 85 years. Men have suicide rates nearly four times higher than women, though women are three times more likely to attempt suicide. Risk factors include

Explore any unusual thoughts, preoccupations, beliefs, or perceptions as they arise during the interview (see Table 20-2, Delirium and Dementia, pp. 418–419).

Im p o r t a n t T o p ic s f o r H e a lt h P r o m o t io n a n d C o u n s e lin g

● Screening for de ression nd suicid lity ● Screening for subst nce use disorders, including lcohol nd rescri tion

drugs

82 Ba tes’ Pocke t Guide to Physica l Examina tion and His tory Taking

suicidal or homicidal ideation, intent, or plan; access to the means for sui- cide; current symptoms of psychosis or severe anxiety; any history of psy- chiatric illness (especially linked to a hospital admission); substance abuse; personality disorder; and prior history or family history of suicide. Patients at high risk should be referred immediately for psychiatric evaluation and possible hospitalization.

S u b s t a n c e Us e Dis o rd e r s , In c lu d in g Alc o h o l a n d P re s c r ip t io n Dru g s . The overlap of substance abuse and mental health disorders is extensive. The 2013 National Survey on Drug Use and Health showed that 23% of the U.S. population ages 12 years or older (60.1 million people) reported binge drinking, and over 6% reported heavy drinking. Over 24 million Americans, or 9.4% of the popula- tion, reported use of an illicit drug during the month before the survey, including nearly 20 million marijuana users, 1.6 million cocaine users, and 6.5 million users of prescription drugs for nonmedical indications. Prescription drug abuse now kills more people than illicit substances. Because screening for alcohol and drug use is part of every patient his- tory, review the screening questions recommended in Chapter 3, Inter- viewing and the Health History.

Techniques of Examination

T h e M e n t a l S t a t u s E x a m in a t io n

● A e r nce nd beh vior ● S eech nd l ngu ge ● Mood ● Thoughts nd erce tions ● Cognition, including e ory, ttention, infor tion nd voc bul ry, c lcul -

tions, bstr ct thinking, nd construction l bility

Observe the patient’s mental status throughout your interaction. Test speci c functions if indicated during the interview or physical examination. The Mental Status Examination consists of ve compo- nents: appearance and behavior; speech and language; mood; thoughts and perceptions; and cognitive function.

Chapter 5 | Behavior and Mental Status 83

A p p e a r a n c e a n d B e h a v io r

Normal consciousness, lethargy, obtundation, stupor, coma (see pp. 331–332)

Restlessness, agitation, bizarre postures, immobility, involuntary movements

Fastidiousness, neglect

Anxiety, depression, elation, anger, and facial immobility of parkinsonism

Anger, host ilit y, susp iciousness, or evasiveness in pat ien ts with pa ra noia ; the elat ion and euphoria of ma nia ; the flat affect and remoteness of schizophrenia ; the apathy and dulled affect of dep ression and dementia

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Assess the following:

■ Level of Consciousness. Observe alertness and response to verbal and tactile stimuli.

■ Posture and Motor Behavior. Observe pace, range, character, and appro- priateness of movements.

■ Dress, Grooming, and Personal Hygiene

■ Facial Expressions. Assess during rest and interaction.

■ Manner, Affect, and Relation to People and Things

Aphasia , dysphonia, dysarthria , changes with mood d isorders

S p e e c h a n d La n g u a g e Note quantity, rate, loudness, clarity, and fluency of speech. If indicated, test for aphasia. A person who can write a correct sentence does not have aphasia.

T e s t in g f o r A p h a s ia

Wo rd Co m p re h e n s io n Ask tient to follow one-st ge co nd, such s “Point to your nose.” Try two-st ge co - nd: “Point to your outh, then your knee.”

Re p e t it io n Ask tient to re e t hr se of one-syll ble words (the ost difficult re etition t sk): “No ifs, nds, or buts.”

Na m in g Ask tient to n e the rts of w tch. Re a d in g Co m p re h e n s io n Ask tient to re d r gr h loud. Writ in g Ask tient to write sentence.

84 Ba tes’ Pocke t Guide to Physica l Examina tion and His tory Taking

M o o d Ask about the patient’s spirits. Note nature, intensity, duration, and stability of any abnormal mood. If indicated, assess risk of suicide.

Happiness, elation, depression, anxiety, anger, indifference

Derailments, flight of ideas, incoherence, confabulation, blocking

Obsessions, compulsions, delusions, feelings of unreality

Illusions, hallucinations

Recognition or denial of mental cause of symptoms; bizarre, impulsive, or unrealistic judgment

Disorientation

Impaired in late stages of dementia

T h o u g h t a n d P e r c e p t io n s Thought Processes. Assess logic, rele- vance, organization, and coherence.

Thought Content. Ask about and explore any unusual or unpleasant thoughts.

Perceptions. Ask about any unusual perceptions (e.g., seeing or hearing things).

Insight and Judgment. Assess patient’s insight into the illness and level of judgment used in making decisions or plans.

C o g n it iv e Fu n c t io n s If indicated, assess:

Orientation to time, place, and person

Attention

■ Digit span—ability to repeat a series of numbers forward and then backward

■ Serial 7s—ability to subtract 7 repeatedly, starting with 100

■ Spelling backward of a ve-letter word, such as W-O-R-L-D

Remote Memory (e.g., birthdays, anniversaries, social security num- ber, schools, jobs, wars)

Poor performance of digit span, serial 7s, and spelling backward are common in dementia and delirium but have other causes, too.

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Chapter 5 | Behavior and Mental Status 85

Recent Memory (e.g., events of the day)

New Learning Ability—ability to repeat three or four words after a few minutes of unrelated activity

Recent memory and new learning ability impaired in dementia, delirium, and amnestic disorders

These attributes reflect intelligence, education, and cultural background. They are limited by mental retardation but are fairly well preserved in early dementia.

Poor calculation in mental retardation and dementia

Concrete responses (observable details rather than concepts) are common in mental retardation, dementia, and delirium. Responses are sometimes bizarre in schizophrenia.

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

H ig h e r C o g n it iv e Fu n c t io n s If indicated, assess:

Information and Vocabulary. Note range and depth of patient’s information, complexity of ideas expressed, and vocabulary used. For the fund of information, ask names of presidents, other political gures, or large cities.

Calculating Abilities, such as addi- tion, subtraction, and multiplication

Abstract Thinking—ability to respond abstractly to questions about

■ The meaning of proverbs, such as “A stitch in time saves nine.”

■ The similarities of beings or things, such as a cat and a mouse or a piano and a violin

Constructional Ability. Ask patient:

■ To copy gures such as circle, cross, diamond, and box, and two intersecting pentagons, or

■ To draw a clock face with num- bers and hands

Impaired ability common in dementia and with parietal lobe damage

S p e c ia l T e c h n iq u e Min i-Me n t a l S t a t e Exa m in a t io n (MMS E). This brief test is useful in screening for cognitive dysfunction and dementia and following their course over time. For more detailed information regarding the MMSE, con- tact the Publisher, Psychological Assessment Resources, Inc., 16204 North Florida Avenue, Lutz, Florida 33549. Some sample questions are given on the next page.

86 Ba tes’ Pocke t Guide to Physica l Examina tion and His tory Taking

Orientat ion to Time “Wh t is the d te?” Registrat ion “Listen c refully. I going to s y three words.

You s y the b ck fter I sto . Re dy? Here they re . . . APPLE ( use), PENNY ( use), TABLE ( use). Now re e t those words b ck to e.” (Re e t u to five ti es, but score only the first tri l.)

Naming “Wh t is this?” (Point to encil or en.) Reading “Ple se re d this nd do wh t it s ys.” (Show

ex inee the words on the sti ulus for .) CLOSE YOUR EYES

Re roduced by s eci l er ission of the Publisher, Psychologic l Assess ent Resources, Inc., 162 4 North Florid Avenue, Lutz, Florid 33549, fro the Mini Ment l St te Ex in - tion, by M rsh l Folstein nd Sus n Folstein, Co yright 1975, 1998, 2 1 by Mini Ment l LLC, Inc. Published 2 1 by Psychologic l Assess ent Resources, Inc. Further re roduc- tion is rohibited without er ission of PAR, Inc. The MMSE c n be urch sed fro PAR, Inc. by c lling (813) 968–3 3.

Recording Your Findings

R e c o r d in g t h e B e h a v io r a n d M e n t a l S t a t u s E x a m in a t io n

“Mental Status: The tient is lert , well-groo ed, nd cheerful. S eech is fluent nd words re cle r. Thought rocesses re coherent , insight is good. The tient is oriented to erson, l ce, nd ti e. Seri l 7s ccur te; recent nd re ote e ory int ct . C lcul tions int ct .” OR “Mental Status: The tient e rs s d nd f tigued; clothes re wrinkled. S eech is slow nd words re u bled. Thought rocesses re coherent , but insight into current life reverses is li ited. The tient is oriented to erson, l ce, nd ti e. Digit s n, seri l 7s, nd c lcul tions ccur te, but res onses del yed. Clock dr wing is good.” (These findings suggest depression.)

M M S E S a m p le It e m s

Chapter 5 | Behavior and Mental Status 87

Aids to Interpretation

Typ e o f Dis o rd e r Dia g n o s t ic Fe a t u re s

Somatic symptom disorder

Somatic symptoms are either very distressing or result in significant disruption of functioning, as well as excessive and disproportionate thoughts, feelings, and behaviors related to those symptoms. Symptoms should be specific if with predominant pain.

Illness anxiety disorder

Preoccupation with having or acquiring a serious illness where somatic symptoms, if present, are only mild in intensity.

Conversion disorder Syndrome of symptoms of deficits mimicking neurologic or clinical illness in which psychological factors are judged to be of etiologic importance.

Psychological factors affecting other clinical conditions

Presence of one or more clinically significant psychological or behavioral factors that adversely affect a clinical condition by increasing the risk for suffering, death, or disability

Factitious disorder Falsification of physical or psychological signs or symptoms, or induction of injury or disease, associated with identified deception. The individual presents himself or herself as ill, impaired, or injured even in the absence of external rewards.

Ot h e r Re la t e d Dis o rd e r s o r Be h a vio r s

Body dysmorphic disorder

Preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear only slight to others

Dissociative disorder Disruption of and/or discontinuity in the normal integration of consciousness, memory, identity, emotion, perception, body representation, motor control, and behavior

So m a t o fo rm Dis o rd e rs : Typ e s a n d Ap p ro a ch t o Sym p t o m s

Table 5-1

Note to readers: Regarding tables in past editions on mood, anxiety, and psychotic disorders, per current DSM-5 copyright, readers are referred to the DSM-5 for further diagnostic information.

C H A P T E R

6The Skin, Hair, and Nails

This edition provides a helpful new approach that features careful history taking; thorough inspection and palpation of benign and suspicious lesions to better detect the three major skin cancers–basal cell carcinoma, squamous cell carcinoma, and melanoma; focused techniques for assessing changes in the hair and nails; accurate use of terminology to describe your ndings; and visual familiarity with important common benign and malignant skin conditions.

The Health History

Gro w t h s . Ask about any new growths or rashes: “Have you noticed any changes in your skin? . . . your hair? . . . your nails?” “Have you had any rashes? . . . sores? . . . lumps? . . . itching?” Pursue the personal and family history of skin cancer and note the type, location, and date of occurrence. Ask about regular self-skin examination and use of sunscreen.

C o m m o n o r C o n c e r n in g S y m p t o m s

● Growths ● R sh ● H ir loss

Causes of generalized itching, without apparent rash, include dry skin; preg- nancy; uremia; jaundice; lymphomas and leukemia; drug reactions; and, less commonly, polycythemia vera and thyroid disease.

Ra s h e s . Ask about itching, the most important symptom when assessing rashes. Does itching precede the rash or follow the rash? For itchy rashes, ask about seasonal allergies with itching and watery eyes, asthma, and atopic dermatitis. Can the patient sleep all night or does itching wake up the patient?

90 Ba tes’ Pocke t Guide to Physica l Examina tion and His tory Taking

Hair shedding at the roots is common in telogen effluvium and alopecia areata. Hair breaks along the shaft suggest damage from hair care or tinea capitis.

S k in Ca n c e r P re ve n t io n . Skin cancers affect an estimated one in ve Americans during their lifetime. The most common skin cancer is BCC, followed by SCC, and melanoma.

Me la n o m a . Although it is the least common skin cancer, melanoma is the most lethal due to its high rate of metastasis and high mortality at advanced stages, causing over 70% of skin cancer deaths. The incidence of melanoma has the most rapid increase of any cancer and is now the fifth most frequently diagnosed cancer in men and the seventh most frequently diagnosed in women.

Use of the Melanoma Risk Assessment Tool developed by the National Cancer Institute, available at http://www.cancer.gov/melanomarisktool/ to assess an individual’s 5-year risk of melanoma based on geographic location, gender, race, age, history of blistering sunburns, complexion, number and size of moles, freckling, and sun damage.

Avo id in g Ult ra v io le t Ra d ia t io n a n d Ta n n in g Be d s . Increasing lifetime sun exposure correlates directly with increasing risk of skin can- cer. Intermittent sun exposure appears to be more harmful than chronic exposure. The best defense against skin cancers is to avoid ultraviolet radiation exposure by limiting time in the sun, avoiding midday sun, using sunscreen, and wearing sun-protective clothing with long sleeves and hats with wide brims. Advise patients to avoid indoor tanning, especially

Health Promotion and Counseling: Evidence and Recommendations

Ha ir Lo s s o r Na il Ch a n g e s . Ask if there is hair thinning or hair shedding and, if so, where. If shedding, does the hair come out at the roots or break along the hair shafts? Be familiar with common nail changes such as onychomy- cosis, habit tic deformity, and melanonychia, shown in Table 6-8, pp. 113–114.

Im p o r t a n t T o p ic s f o r H e a lt h P r o m o t io n a n d C o u n s e lin g

● Skin c ncer revention ● Skin c ncer screening

Chapter 6 | The Skin, Hair, and Nails 91

children, teens, and young adults. Use of indoor tanning beds, especially before age 35 years, increases risk of melanoma by as much as 75%. In 2009, the International Agency for Research on Cancer classified ultraviolet-emitting tanning devices as “carcinogenic to humans.”

Re g u la r Us e o f S u n s c re e n P re ve n t s S k in Ca n c e r. A landmark study in 2011 demonstrated that the regular use of sunscreen decreases the incidence of melanoma. Advise patients to use at least sun-protective fac- tor (SPF) 30 and broad-spectrum protection. For water exposure, patients should use water-resistant sunscreens.

S k in Ca n c e r S c re e n in g . Although the USPSTF found insuf cient evidence (grade I) to recommend routine skin cancer screening, it does advise clinicians to “remain alert for skin lesions with malignant features” during routine physical examinations and reference the ABCDE criteria. The American Cancer Society (ACS) and the AAD recommend full-body examinations for patients over age 50 years or at high risk, because mela- noma can appear in any location. High-risk patients are those with a personal or family history of multiple or dysplastic nevi or previous mela- noma. Both new and changing nevi should be closely examined, as at least half of melanomas arise de novo from isolated melanocytes rather than pre-existing nevi.

S c re e n in g fo r Me la n o m a : Th e ABCDEs . Clinicians should apply the ABCDE-EFG method when screening moles for melanoma (this does not apply for nonmelanocytic lesions like seborrheic keratoses). The sensitivity of this tool for detecting melanoma ranges from 43% to 97%, and specific- ity from 36% to 100%; diagnostic accuracy depends on how many criteria are used to define abnormality.

T h e A B C D E R u le

If two or ore of the ABCDE criteri re resent, risk of el no incre ses nd bio sy should be considered. So e h ve suggested dding EFG to hel detect ggressive nodul r el no s.

Me la n o m a Be n ig n Ne vu s

Asymmetry Of one side of ole co - red to the other

(continued )

92 Ba tes’ Pocke t Guide to Physica l Examina tion and His tory Taking

P a t ie n t S c re e n in g : Th e S e lf -S k in Exa m in a t io n . The AAD and the ACS recommend regular self-skin examination. Instruct patients with risk factors for skin cancer and melanoma, especially those with a history of high sun exposure, prior or family history of melanoma, and ≥50 moles or >5 to 10 atypical moles, to perform regular self-skin examinations.

T h e A B C D E R u le (Continued)

Me la n o m a Be n ig n Ne vu s

Border irregularity Es eci lly if r gged, notched, or blurred

Color variationsa

More th n two colors, es eci lly blue-bl ck, white (loss of ig ent due to regression), or red (infl - tory re ction to bnor l cells)

Diameter >6 mmb

A roxi tely the size of encil er ser

Evolvingc

Or ch nging r idly in size, sy to s, or or hology

● Elev ted ● Fir to l t ion ● Growing rogressively over sever l weeks

aWith the exce tion of ho ogeneous blue color in blue nevus, blue or bl ck color within l rger ig ented lesion is es eci lly concerning for el no .

bE rly el no s y be <6 , nd ny benign lesions re >6 . cEvolution, or ch nge, is the ost sensitive of these criteri . A reli ble history of ch nge y

ro t bio sy of benign- e ring lesion.

Chapter 6 | The Skin, Hair, and Nails 93

EXAMINATION TECHNIQUES

Techniques of Examination

P O SSIBLE FIN DIN GS

Fu ll-B o d y a n d In t e g r a t e d S k in E x a m in a t io n s See Tab les 6-1 to 6-5, pp. 100–108, for examples of p rimary lesions (flat , ra ised , and flu id -filled ; pustules, furuncles, nodules, cysts, wheals, and burrows); and rough, p ink, and brown lesions.

Perform a full-body skin examina- tion in the context of the overall physical examination. Inspect and palpate all skin lesions, focusing on key features that help distinguish if lesions are benign or suspicious for malignancy. Are they raised, at, or uid- lled? Are they rough or smooth? What about color? Is the lesion pink or brown? Measure the size. Is the size changing? Learn to describe each lesion accurately, using the terminology speci ed below. Changing moles, a history of skin cancer, and other risk fac- tors all warrant a full-body skin examination.

Even during routine examinations, you can pursue an integrated skin exami- nation as you examine areas on the head and neck, arms and hands, and over the back as you listen to the lungs that are already easily accessible.

Integrating the skin examination into the physical examination and rou- tinely recording your ndings as part of the general write-up saves time and contributes to earlier detection of skin cancers, when they are easier to treat. Systemic illnesses also have many associated skin ndings.

P r e p a r in g f o r t h e E x a m in a t io n Make sure there is good overhead ambient lighting or natural light from windows. Add a strong light source if the room is dark. You will also need a small ruler or tape measure and a small magnifying glass to help you document important features of skin lesions, such as size, shape, color, and texture. Dermoscopy provides cross-polarized or unpolarized light to visualize patterns of pigmentation or vascular structures and improves the sensitivity and speci city of differentiating melanomas from benign lesions.

Ask the patient to change into a gown with the opening in the back and clothes removed except for underwear. Before beginning the examination,

94 Ba tes’ Pocke t Guide to Physica l Examina tion and His tory Taking

cleanse your hands thoroughly. It is important for you to palpate lesions for texture, rmness, and scaliness.

Im p o r t a n t Te rm s fo r De s c r ib in g S k in Le s io n s . It is important to use speci c terminology. Good descriptions include each of the following elements: type of primary lesion, number, size, shape, color, texture, location, and con guration.

D e s c r ib in g S k in F in d in g s

Primary lesions are flat or raised.

● Flat: You c nnot l te the lesion with your eyes closed. ● Macule: Lesion is fl t nd <1 c . ● Patch: Lesion is fl t nd >1 c .

● Raised: You c n l te the lesion with eyes closed. ● Papule: Lesion is r ised, <1 c , nd not fluid-filled. ● Plaque: Lesion is r ised, >1 c , but not fluid-filled. ● Vesicle: Lesion is r ised, <1 c , nd filled with fluid. ● Bulla: Lesion is r ised, >1 c , nd fluid-filled.

● Other primary lesions include erosions, ulcers, nodules, ecchy oses, etechi e, nd l ble ur ur .

Number: Lesions c n be solit ry or ulti le. If ulti le, record how ny. Also consider esti ting the tot l nu ber of the ty e of lesion you re describing.

Size: Me sure with ruler in illi eters or centi eters. For ov l lesions, e - sure in the long xis then er endicul r to the xis.

Shape: So e good words to le rn re “circul r,” “ov l,” “ nnul r” (ring-like, with centr l cle ring), “nu ul r” (coin-like, no centr l cle ring), nd “ olygon l.”

Color: Be cre tive. Refer to color wheel if needed. There re ny sh des of brown, but you c n st rt with t n, light brown, nd d rk brown.

(continued )

● Use “skin-colored” when ro ri te. ● For red lesions or r shes, bl nch the

lesion by ressing it fir ly with your finger or gl ss slide to see if the redness te or rily lightens then refills.

Texture: P l te the lesion to see if it is s ooth, fleshy, verrucous, w rty, or sc ly (fine, ker totic, or gre sy sc le).

Blanching lesions are erythematous and suggest inflammation. Nonblanching lesions, petechiae, purpura, and vascular structures are red, purple, and violaceous but not erythematous. See Table 6-6, Vascular and Purpuric Lesions of the Skin, pp. 109–110.

Scaling can be greasy, like seborrheic dermatitis or seborrheic keratoses, dry and fine like tinea pedis, or hard and keratotic like actinic keratoses or SCC.

Chapter 6 | The Skin, Hair, and Nails 95

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Te ch n iq u e s o f Exa m in a t io n — Pa t ie n t S e a t e d . Choose one of two patient positions for perform- ing the full-body skin examination. The patient can be seated or lie supine then prone. Plan to examine the skin in the same order every time, so you are less likely to skip part of the examination.

Stand in front of the patient and adjust the table to a comfortable height. Start by examining the hair and scalp (Fig. 6-1).

Sparse hair is seen in hypothyroid- ism; ne, silky hair in hyperthy- roidism.

Inspect the head and neck, includ- ing the forehead; eyes including eyelids, conjunctivae, sclerae, eye- lashes, and eyebrows; nose, cheeks, lips, oral cavity, and chin; and anterior neck (Figs. 6-2 to 6-4).

Move the gown to see each area. Ask permission rst.

Alopecia, or hair loss, can be diffuse, patchy, or total. Male and female pattern hair loss are normal with aging. Focal patches may be lost suddenly in alopecia areata. Refer scarring alopecia to a dermatologist.

Figure 6-1 Part the hair on the scalp.

See Table 6-7, Hair Loss, pp. 111–112.

Look for signs of basal cell carcinoma on the face. See Table 6-4, Pink Lesions: Basal Cell Carcinoma and Its Mimics, p. 106.

D e s c r ib in g S k in F in d in g s (Continued)

Examples are herpes zoster with unilat- eral and dermatomal vesicles; herpes simplex, with grouped vesicles or pus- tules on an erythematous base; tinea pedis with annular lesions; and poison ivy allergic contact dermatitis with linear lesions.

Location: Be s s ecific s ossible. For single lesions, e sure their dist nce fro other l nd rks (e.g., 1 c l ter l to left or l co issure).

Configuration: Describing tterns is often very hel ful.

For ore infor tion nd ddition l illustr tions of e ch of these ele ents, Le rnDer is free nd very hel ful website.

96 Ba tes’ Pocke t Guide to Physica l Examina tion and His tory Taking

Figure 6-5 Inspect the arms , hands , and nails .

Figure 6-6 Inspect the ches t and abdomen.

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

See Table 6-8, Findings in or near the Nails, pp. 113–114.

Inspect the shoulders, arms, and hands (Fig. 6-5). Inspect and palpate the ngernails. Note their color, shape, and any lesions.

Inspect the chest and abdomen (Fig. 6-6). Lower or raise the gown to expose these areas and cover up when you are nished.

Figure 6-2 Inspect the forehead. Figure 6-3 Inspect the face , eyes , and ears .

Figure 6-4 Inspect the anterior neck.

Chapter 6 | The Skin, Hair, and Nails 97

Figure 6-7 Inspect the thighs and lower legs .

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Figure 6-8 Inspect the sole s of the fee t and be tween the toes .

Inspect the thighs and lower legs (Fig. 6-7). Inspect and palpate the toenails, and inspect the soles and between the toes (Fig. 6-8).

Figure 6-9 Inspect the back, buttocks , and pos te rior legs .

Ask the patient to stand so that you inspect the lower back and posterior legs (Fig. 6-9). If needed, uncover the buttocks. Examination of the breasts and genitalia may be saved for last.

Te ch n iqu e s o f Exa m in a - t io n —Pa t ie n t S u p in e a n d P ro n e . Some clinicians prefer this positioning for more thorough examinations (Fig. 6-10). With the patient supine, inspect the scalp, face, and anterior neck; the shoulders, arms, and hands; the chest and abdo- men; anterior thighs; and lower legs, feet, and, if appropriate, the genitalia. Ask permission when moving the gown to expose different areas, and let the patient know which areas you will be examining next.

Ask the patient to turn over to the prone position, lying face down. Look at the posterior scalp, poste- rior neck, back, posterior thighs, legs, soles of the feet, and buttocks (if appropriate).

Figure 6-10 Inspect the scalp, arms , hands , ches t, abdomen, ante rior and pos te rior thighs , and fee t.

98 Ba tes’ Pocke t Guide to Physica l Examina tion and His tory Taking

Figure 6-11 Hair pull te s t.

Figure 6-12 Tug te s t.

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Possible internal causes of diffuse nonscarring hair shedding in young women are iron-deficiency anemia and hyper- or hypothyroidism.

Local redness of the skin warns of impending necrosis, although some deep pressure sores develop without antecedent redness. Inspect closely for skin breaks and ulcers.

S p e c ia l T e c h n iq u e s Th e P a t ie n t S e lf -S k in Exa m in a t io n . The patient will need a full- length mirror, a hand-held mirror, and a well-lit room that provides privacy. Teach the patient the ABCDE-EFG method for assessing moles. Help them and to identify melanomas by looking at photographs of benign and malig- nant nevi on easy-to-access websites, handouts, or tables in this chapter.

Exa m in in g t h e P a t ie n t w it h Ha ir Lo s s . Examine the hair to determine the overall pattern of hair loss or hair thinning. Inspect the scalp for erythema, scaling, pustules, tenderness, bogginess, and scarring. Look at the width of the hair part in various sections of the scalp. For shedding from the roots, perform a hair pull test by gently grasping 50 to 60 hairs with your thumb and index and middle ngers, pulling rmly away from the scalp (Fig. 6-11). If all the hairs have telogen bulbs, the most likely diagnosis is telogen ef uvium. For fragility, perform the tug test by holding a group of hairs in one hand, pulling along the hair shafts with the other (Fig. 6-12); if any hairs break, it is abnormal.

Eva lu a t in g t h e Be d b o u n d Pa t ie n t . People con ned to bed, especially when they are emaciated, elderly, or neurologically impaired, are particularly susceptible to pres- sure sores. Carefully inspect the skin that overlies the sacrum, buttocks, greater trochanters, knees, and heels. Roll the patient onto one side to see the low back and gluteal area best.

Chapter 6 | The Skin, Hair, and Nails 99

Recording Your Findings As stated on p. 94, use speci c terms to describe skin lesions and rashes, including number of lesions, size, color, shape, texture, location, con gu- ration, and whether a primary lesion.

R e c o r d in g t h e S k in , H a ir , a n d N a ils E x a m in a t io n

“Skin w r nd dry. N ils without clubbing or cy nosis. A roxi tely 2 brown, round cules on u er b ck, chest, nd r s, re ll sy etric in ig- ent tion, none sus icious. No r sh, etechi e, or ecchy oses.” (These findings suggest normal nevi and perfusion without any rashes or suspicious lesions.) OR “Sc ttered stuck-on verrucous l ques on b ck nd bdo en. Over 3 s ll round brown cules with sy etric ig ent tion on b ck, chest, nd r s. Single 1.2 × 1.6 c sy etric d rk brown nd bl ck l que with erythe tous, uneven border, on left u er r .” (These findings suggest normal seborrheic ker- atoses and benign nevi, but also a possible malignant melanoma.)

100 Ba tes’ Pocke t Guide to Physica l Examina tion and His tory Taking

Aids to Interpretation

Describe skin lesions accurately, including number, size, color, texture, shape, primary lesion, location, and configuration. This table identifies common primary skin lesions and includes classic descriptions of each lesion with the diagnosis in italics.

Fla t s p o t s : If you run your finger over the lesion but do not feel the lesion, the lesion is flat. If a flat spot is small (<1 cm), it is a macule. If a flat spot is larger (>1 cm), it is a patch.

Macules (flat, small)

Multiple 3–8-mm erythematous confluent round macules on chest, back, and arms; morbilliform drug eruption

Patches (flat, large) Bilaterally symmetric erythematous patches on central cheeks and eyebrows, some with overlying greasy scale; seborrheic dermatitis

Large confluent completely depigmented patches on dorsal hands and distal forearms; vitiligo

De s c rib in g P rim a ry S k in Le s io n s : Fla t , Ra is e d , a n d Flu id -Fille d

Table 6-1

Chapter 6 | The Skin, Hair, and Nails 101

(table continues on page 102)

Ra is e d s p o t s : If you run your finger over the lesion and it is palpable above the skin, it is raised. If a raised spot is small (<1 cm), it is a papule. If a raised spot is larger (>1 cm), it is a plaque.

Papules (raised, small)

Multiple 2–4-mm soft, fleshy skin- colored to light brown papules on lateral neck and axillae in skin folds; skin tags

Scattered erythematous round drop-like, flat-topped well-circumscribed scaling papules and plaques on trunk; guttate psoriasis

Plaques (raised, large)

Scattered erythematous to bright pink well-circumscribed flat-topped plaques on extensor knees and elbows, with overlying silvery scale; plaque psoriasis

Multiple round coin-like eczematous plaques on arms, legs, and abdomen, with overlying dried transudate crust; nummular dermatitis

De s c rib in g P rim a ry S k in Le s io n s : Fla t , Ra is e d , a n d Flu id -Fille d (continued )

Table 6-1

102 Ba tes’ Pocket Guide to Phys ica l Examination and His tory Taking

Flu id -f ille d le s io n s : If the lesion is raised, filled with fluid, and small (<1 cm), it is a vesicle. If a fluid-filled spot is larger (>1 cm), it is a bulla.

Vesicles (fluid-filled, small)

Multiple 2–4-mm vesicles and pustules on erythematous base, grouped together on left neck; herpes simplex virus

Bullae (fluid-filled, large)

Several tense bullae on lower legs; insect bites

De s c rib in g P rim a ry S k in Le s io n s : Fla t , Ra is e d , a n d Flu id -Fille d (continued )

Table 6-1

Chapter 6 | The Skin, Hair, and Nails 103

Pustule: Small palpable collection of neutrophils or keratin that appears white

�15–20 pustules and acneiform papules on buccal and parotid cheeks bilaterally; acne vulgaris

Furuncle: Inflamed hair follicle; multiple furuncles together form a carbuncle

Two large (2-cm) furuncles on forehead, without fluctuance; furunculosis (Note: fluctuant deep infections are abscesses)

Nodule: Larger and deeper than a papule

Solitary blue-brown 1.2-cm firm nodule with positive dimple sign and hyperpigmented rim on left lateral thigh; dermatofibroma

Solitary 4-cm pink and brown scar-like nodule on central chest at site of previous trauma; keloid

Ad d it io n a l P rim a ry Le s io n s : Pu s t u le s , Fu ru n c le s , No d u le s , Cys t s , Wh e a ls , Bu rrow s

Table 6-2

(table continues on page 104)

104 Ba tes’ Pocket Guide to Phys ica l Examination and His tory Taking

Subcutaneous mass/cyst: Whether mobile or fixed, cysts are encapsulated collections of fluid or semisolid

Three 6–8-mm mobile subcutaneous cysts on vertex scalp, that on excision reveal pearly white balls; pilar cysts

Solitary 9-cm mobile rubbery subcutaneous mass on left temple; lipoma

Wheal: Area of localized dermal edema that evanesces (comes and goes) within a period of 1–2 days; this is the essential primary lesion of urticaria

Many variably sized (1–10-cm) wheals on lateral neck, shoulders, abdomen, arms, and legs; urticaria

Burrow: Small linear or serpiginous pathways in the epidermis created by the scabies mite

Multiple small (3–6-mm) erythematous papules on abdomen, buttocks, scrotum, and shaft and head of penis, with four burrows noted on interdigital web spaces; scabies

Ad d it io n a l Prim a ry Le s io n s : Pu s t u le s , Fu ru n c le s , No d u le s , Cys t s , Wh e a ls , Bu rrow s (continued )

Table 6-2

Chapter 6 | The Skin, Hair, and Nails 105

Patients commonly report feeling rough lesions. Many are benign, like seborrheic keratoses or warts, but squamous cell carcinoma (SCC) and its precursor actinic keratosis can also feel rough or keratotic.

Ac t in ic k e ra t o s is

■ Often easier to feel than to see ■ Superficial keratotic papules that

“come and go,” on sun-damaged skin

Wa r t s

■ Usually skin-colored to pink, texture more verrucous than keratotic

■ May be filiform ■ Often have hemorrhagic punctate

that can be seen with a magnifying glass or dermatoscope

S q u a m o u s c e ll c a rc in o m a

■ Keratoacanthomas are SCCs that arise rapidly and have a crateriform center

■ Often have a smooth but firm border ■ SCCs can become quite large if left

untreated (Note: highest sites of metastasis are the scalp, lips, and ears)

Ro u g h Le s io n s : Ac t in ic Ke ra t o s e s a n d S q u a m o u s Ce ll Ca rc in o m a

Table 6-3

106 Ba tes’ Pocket Guide to Phys ica l Examination and His tory Taking

Basal cell carcinoma (BCC) is the most common cancer in the world. Fortunately, it rarely spreads to other parts of the body. Nonetheless, it can invade and destroy local tissues, causing significant morbidity to the eye, nose, or brain.

Ba s a l Ce ll Ca rc in o m a S u p e r f ic ia l b a s a l c e ll c a rc in o m a

■ Pink patch that does not heal ■ May have focal scaling

No d u la r b a s a l c e ll c a rc in o m a

■ Pink papule, often with translucent or pearly appearance and overlying telangiectasias

■ May have focal pigmentation ■ Dermoscopy shows arborizing

vessels, focal pigment globules, and other specific patterns

P in k Le s io n s : Ba s a l Ce ll Ca rc in o m a a n d it s Mim ic s

Table 6-4

Chapter 6 | The Skin, Hair, and Nails 107

(table continues on page 108)

Most patients have brown spots on their body surface. Although these are usually freckles, benign nevi, solar lentigines, or seborrheic keratoses, you and the patient must look closely for any that stand out as a possible melanoma. With enough practice, when you see a melanoma, it will stick out as the “ugly duckling.” Review the ABCDE rule and photographs on pp. 91–92.

Me la n o m a Mim ic s

Am e la n o t ic m e la n o m a

■ Usually in very fair-skinned people

■ Evolution or rapid change is the most important feature, because variegation or dark pigment is missing in this type

S k in t a g s o r in t ra d e rm a l n e vi

■ Soft and fleshy ■ Often around neck, axillae, or

back ■ Sessile nevi may have a hint of

brown pigmentation

Me la n o m a in s it u S o la r le n t ig o

■ On sun-exposed or sun- protected skin

■ Look for ABCDE features

■ On sun-exposed skin ■ Light brown and uniform in

color but may be asymmetric

Brow n Le s io n s : Me la n o m a a n d It s Mim ic sTable 6-5

108 Ba tes’ Pocket Guide to Phys ica l Examination and His tory Taking

Me la n o m a Mim ic s

Me la n o m a Dys p la s t ic n e vu s

■ May arise de novo or in existing nevi and exhibits ABCDEs

■ Patients with many dysplastic nevi have increased risk of melanoma

■ May have macular base and papular central “fried egg” component

■ Compare to the patient’s other nevi and monitor changes

Me la n o m a In f la m e d s e b o rrh e ic k e ra t o s is

■ May have variegated color (browns, red)

■ Has melanocytic features on dermoscopy

■ Can sometimes mimic a melanoma if it has an erythematous base

■ Dermoscopy helps the trained eye distinguish these

Me la n o m a S e b o r rh e ic k e ra t o s is

■ May be uniform in color but asymmetric; key feature is rapid change or evolution

■ Stuck-on and verrucous, may be darkly pigmented

Bro w n Le s io n s : Me la n o m a a n d It s Mim ic s (continued )

Table 6-5

Chapter 6 | The Skin, Hair, and Nails 109

(table continues on page 110)

Le s io n s Fe a t u re s : Ap p e a ra n c e , D is t r ib u t io n , S ig n if ic a n c e

Ch e rry An g io m a ■ Bright or ruby red, may become

purplish with age; 1–3 mm; round, flat, sometimes raised; may be surrounded by a pale halo

■ Found on trunk or extremities ■ Not significant; increase in size and

number with aging

S p id e r An g io m a a

■ Fiery red; very small to 2 cm; central body, sometimes raised, radiating with erythema

■ Face, neck, arms, and upper trunk, but almost never below the waist

■ Seen in liver disease, pregnancy, vitamin B deficiency; normal in some people

S p id e r Ve in a

■ Bluish; varies from very small to several inches; may resemble a spider or be linear, irregular, or cascading

■ Most often on the legs, near veins; also on anterior chest

■ Often accompanies increased pressure in the superficial veins, as in varicose veins

Va s c u la r a n d Pu rp u ric Le s io n s o f t h e S k inTable 6-6

110 Ba tes’ Pocke t Guide to Physica l Examina tion and His tory Taking

Va s c u la r a n d Pu rp u ric Le s io n s o f t h e S k in (continued )

Table 6-6

Le s io n s Fe a t u re s : Ap p e a ra n c e , Dis t r ib u t io n , S ig n if ic a n c e

P e t e ch ia /P u rp u ra ■ Deep red or reddish purple; fades

over time; 1–3 mm or larger; rounded, sometimes irregular, flat

■ Varied distribution ■ Seen if blood outside the vessels;

may suggest a bleeding disorder or, if petechiae, emboli to skin

Ec ch ym o s is ■ Purple or purplish blue, fading to

green, yellow, and brown over time; larger than petechiae; rounded, oval, or irregular

■ Varied distribution ■ Seen if blood outside the vessels;

often secondary to bruising or trauma; also seen in bleeding disorders

aThese are telangiectasias, or dilated small vessels that look red or bluish. Sources of photos: Spider Angioma—Marks R. Skin Disease in Old Age. Philadelphia, PA: JB Lip-

pincott; 1987; Petechia/Purpura—Kelley WN. Textbook of Internal Medicine. Philadelphia, PA: JB Lippincott; 1989.

Chapter 6 | The Skin, Hair, and Nails 111

Ge n e ra lize d o r Diffu s e Ha ir Lo s s In men, look for frontal hairline regression and thinning on the posterior vertex; in women look for thinning that spreads from the crown down without hairline regression.

Male pattern hair loss (MPHL) Female pattern hair loss (FPHL)

Te lo g e n Eff lu v iu m a n d An a g e n Eff lu v iu m In telogen effluvium overall the patient’s scalp and hair distribution appear normal, but a positive hair pull test reveals most hairs have telogen bulbs. In anagen effluvium there is diffuse hair loss from the roots. The hair pull test shows few if any hairs with telogen bulbs.

Normal hair part width in telogen effluvium

Positive hair pull test in telogen effluvium showing all hairs have telogen bulbs

Anagen effluvium

Ha ir Lo s sTable 6-7

(table continues on page 112)

112 Ba tes ’ Pocke t Guide to Physica l Examina tion and His tory Taking

Fo c a l Ha ir Lo s s Alo p e c ia Are a t a There is sudden onset of clearly demarcated, usually localized, round or oval patches of hair loss leaving smooth skin without hairs, in children and young adults. There is no visible scaling or erythema.

Tin e a Ca p it is (“ Rin g w o rm ” ) There are round scaling patches of alopecia, usually caused by Trichophyton tonsurans from humans, and less commonly, Microsporum canis from dogs or cats.

Ha ir Lo s s (continued )Table 6-7

References: For a complete guide to evaluation of hair loss, review Mubki T, Rucnicka L, Olszewska M, et al. Evaluation and diagnosis of the hair loss patient. J Am Acad Dermatol. 2014;71:415.

aSee also Hair Loss Help. Hair loss classi cations. Available at http://www.hairlosshelp.com/ hair_loss_research/hair_loss_charts.cfm. Accessed February 13, 2015.

Chapter 6 | The Skin, Hair, and Nails 113

P a ro n ych ia A superficial infection of the proximal and lateral nail folds adjacent to the nail plate. The nail folds are often red, swollen, and tender. Represents the most common infection of the hand, usually from Staphylococcus aureus or Streptococcus. Creates a felon if it extends into the pulp space of the finger.

Clu b b in g o f t h e Fin g e r s Clinically a bulbous swelling of the soft tissue at the nail base, with loss of the normal angle between the nail and the proximal nail fold. The angle increases to 180 degrees or more, and the nail bed feels spongy or floating. The mechanism is still unknown. Seen in congenital heart disease, interstitial lung disease and lung cancer, inflammatory bowel diseases, and malignancies.

Ha b it Tic De fo rm it y There is depression of the central nail with a “Christmas tree” appearance from small horizontal depressions, resulting from repetitive trauma from rubbing the index finger over the thumb or vice versa.

Me la n o n ych ia Caused by increased pigmentation in the nail matrix, leading to a streak as the nail grows out. This may be a normal ethnic variation if found in multiple nails. A wide streak, especially if growing or irregular, could represent a subungual melanoma.

Fin d in g s in o r n e a r t h e Na ilsTable 6-8

(table continues on page 114)

114 Ba tes ’ Pocke t Guide to Physica l Examina tion and His tory Taking

On ych o lys is A painless separation of the whitened opaque nail plate from the pinker translucent nail bed.

On ych o m yc o s is The most common cause of nail thickening and subungual debris is onychomycosis, most often from the dermatophyte Trichophyton rubrum.

Te r ry Na ils Nail plate turns white with a ground- glass appearance, a distal band of reddish brown, and obliteration of the lunula. Seen in liver disease, usually cirrhosis, heart failure, and diabetes.

Fin d in g s in o r n e a r t h e Na ils (continued )Table 6-8

Sources of photos: Clubbing of the Fingers, Paronychia, Onycholysis, Terry Nails—Habif TP. Clinical Dermatology: A Color Guide to Diagnosis and Therapy. 2nd ed. St. Louis, MO: CV Mosby; 1990.

115

C H A P T E R

7The Head and Neck

The Health History

T h e H e a d

C o m m o n o r C o n c e r n in g S y m p t o m s

● He d che ● Ch nge in vision: blurred vision, loss of vision, flo ters, fl shing lights ● Eye in, redness, or te ring ● Double vision (di lo i ) ● He ring loss, e r che, ringing in the e rs (tinnitus) ● Dizziness nd vertigo ● Nosebleed (e ist xis) ● Sore thro t , ho rseness ● Swollen gl nds ● Goiter

See Table 7-1, Primary Headaches, p. 128, and Table 7-2, Secondary Headaches, pp. 129–131. Tension and migraine head- aches are the most common recurring headaches.

Headache is a common symptom that always requires careful evalu- ation because a small fraction of headaches arise from life-threatening conditions. Elicit a full description of the headache and all seven attributes of the patient’s pain (see p. 3).

Is the headache one sided or bilat- eral? Severe with sudden onset, like a thunderclap? Steady or throb- bing? Continuous or comes and goes? Ask the patient to point to the area of pain or discomfort. Assess chronologic pattern and severity.

Changing or progressively severe head- aches increase the likelihood of tumor, abscess, or other mass lesion. Extremely severe headaches suggest subarachnoid hemorrhage or meningitis.

Tension headaches often arise in the temporal areas; cluster headaches may be retro-orbital.

116 Ba tes ’ Pocke t Guide to Physica l Examina tion and His tory Taking

■ Ask about associated symptoms, such as nausea and vomiting, and neurologic symptoms, such as change in vision or motor- sensory de cits.

■ Ask if coughing, sneezing, or changing the position of the head affects (better, worse, or none) the headache.

■ Ask about family history.

T h e E y e s Ask “How is your vision?” If the patient reports a change in vision, pursue the related details:

■ Is the problem worse during close work or at distances?

■ Is the onset sudden or gradual?

■ Is there blurring of the entire eld of vision or only parts? Is blurring central, peripheral, or only on one side?

H e a d a c h e W a r n in g S ig n s f o r Im m e d ia t e In v e s t ig a t io n

● Progressively frequent or severe over 3- onth eriod ● Sudden onset like “thundercl ” or “the worst he d che of y life” ● New onset fter ge 5 ye rs ● Aggr v ted or relieved by ch nge in osition ● Preci it ted by V ls lv neuver ● Associ ted sy to s of fever, night swe ts, or weight loss ● Presence of c ncer, HIV infection, or regn ncy ● Ch nge in ttern fro st he d ches ● L ck of si il r he d che in the st ● Recent he d tr u ● Associ ted illede , neck stiffness, or foc l neurologic deficits

Such maneuvers may increase pain from brain tumor and acute sinusitis.

Family history is often positive in patients with migraine.

Visual aura or scintillating scotomas may accompany migraine. Nausea and vomit- ing are common with migraine but also occur with brain tumor and subarachnoid hemorrhage.

Gradual blurring, often from refractive errors; also occurs in hyperglycemia.

Difficulty with close work suggests hyperopia (farsightedness) or presbyopia (aging vision); difficulty with distances suggests myopia (nearsightedness).

Sudden visual loss suggests retinal detachment, vitreous hemorrhage, or occlusion of the central retinal artery.

Slow central loss occurs in nuclea r ca ta - ract and macula r degenera tion; periph- eral loss in advanced open-angle glaucoma; one -sided loss in hemianop- sia and quadrantic defects (p. 132).

Chapter 7 | The Head and Neck 117

■ Has the patient seen lights ash- ing across the eld of vision? Vitreous oaters?

Ask about pain in or around the eyes, redness, and excessive tearing or watering.

Check for diplopia, or double vision.

T h e E a r s Ask “How is your hearing?”

Does the patient have special dif - culty understanding people as they talk? Does a noisy environment make a difference?

For complaints of earache, or pain in the ear, ask about associ- ated fever, sore throat, cough, and concurrent upper respiratory infection.

Tinnitus is an internal musical ring- ing or rushing or roaring noise, often unexplained.

Ask about vertigo, the perception that the patient or the environment is rotating or spinning.

These symptoms suggest detachment of vitreous from the retina. Prompt eye consultation is indicated.

Eye pain in acute glaucoma and optic neuritis.

Diplopia in brainstem or cerebellum lesions, also from weakness or paralysis of one or more extraocular muscles.

Sensorineura l loss (inner ear) leads to difficulty understanding speech, often complaining that others mumble; noisy environments worsen hearing. In con- ductive loss (external or middle ear), noisy environments may help.

Consider otitis externa if pain in the ear canal; otitis media if pain associated with respiratory infection.

When associated with hearing loss and vertigo, t innitus suggests Ménière disease.

Vertigo in labrynthitis (inner ear), CN VII lesions, brainstem lesions

T h e N o s e a n d S in u s e s Rhinorrhea, or drainage from the nose, frequently accompanies nasal congestion. Ask further about sneez- ing, watery eyes, throat discomfort, and itching in the eyes, nose, and throat.

Causes include viral infections, a llergic rhinitis (“hay fever”), and vasomotor rhinitis. Itching favors an allergic cause.

118 Ba tes’ Pocket Guide to Phys ica l Examination and His tory Taking

For epistaxis, or bleeding from the nose, identify the source carefully—is bleeding actually from the nose, or has the patient coughed up or vomited blood? Assess the site of bleeding, its severity, and associated symptoms.

Local causes of epistaxis include trauma (especially nose-picking), inflammation, drying and crusting of the nasal mucosa, tumors, and foreign bodies. Anticoagu- lants, NSAIDs, and coagulopathies may contribute.

Fever, pharyngeal exudates, and anterior cervical lymphadenopathy, especially without cough, suggest streptococcal pharyngitis, or “strep throat”(p. 142).

If present more than 2 weeks, refer for laryngoscopy; consider hypothyroidism, reflux, vocal cord nodules, head and neck cancers, thyroid masses, and neurologic disorders (Parkinson disease, amyotrophic la teral sclerosis, or myasthenia gravis).

With goiter, thyroid function may be increased, decreased, or normal. Cold intolerance in hypothyroidism; heat intolerance, palpitations, and involun- tary weight loss in hyperthyroidism

T h e M o u t h , T h r o a t , a n d N e c k Sore throat or pharyngitis is a fre- quent complaint. Ask about fever, swollen glands, and any associated cough.

Hoarseness may arise from overuse of the voice, allergies, smoking, or inhaled irritants.

Assess thyroid function. Ask about goiter, temperature intolerance, and sweating.

Health Promotion and Counseling: Evidence and Recommendations

Im p o r t a n t T o p ic s f o r H e a lt h P r o m o t io n a n d C o u n s e lin g

● Loss of vision: c t r cts, cul r degener tion, gl uco ● He ring loss ● Or l he lth

Disorders of vision shift with age. Healthy young adults generally have refractive errors. Older adults have refractive errors, cataracts, macular degeneration, and glaucoma. Glaucoma is the leading cause of blindness in African Americans and the U.S. population overall. Glaucoma causes gradual vision loss, with damage to the optic nerve, loss of visual elds, beginning usually at the periphery, and pallor and increasing size of the optic cup (enlarging to more than half the diameter of the optic disc).

Chapter 7 | The Head and Neck 119

More than a third of adults older than 65 years have detectable hearing de cits. Questionnaires and handheld audioscopes work well for periodic screening.

Be sure to promote oral health: 19% of children aged 2 to 19 years have untreated cavities, and about 5% of adults aged 40 to 59 years and 25% of those older than age 60 years have no teeth at all. Inspect the oral cavity for decayed or loose teeth, in ammation of the gingiva, signs of periodon- tal disease (bleeding, pus, receding gums, and bad breath), and oral can- cers. Counsel patients to use uoride-containing toothpastes, brush, oss, and seek dental care at least annually.

Techniques of Examination EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

T h e H e a d Examine the:

■ Hair, including quantity, distribution, and texture

■ Scalp, including lumps or lesions

■ Skull, including size and contour

■ Face, including symmetry and facial expression

■ Skin, including color, texture, hair distribution, and lesions

Coarse and sparse in hypothyroidism, fine in hyperthyroidism

Pilar cysts, psoriasis, seborrheic dermati- tis, pigmented nevi

Hydrocephalus, skull depression from trauma

Facial paralysis; flat affect of depression, moods such as anger, sadness

Pale, fine, hirsute, acne, skin cancer

T h e E y e s Test visual acuity in each eye with a Snellen wall chart or handheld card.

Assess visual elds by confronta- tion with the static nger wiggle test and the kinetic red target test, if indicated (Fig. 7-1).

Vision of 20/200 means that at 20 feet, the patient can read print that a person with normal vision could read at 200 feet.

Hemianopsia, quadrantic defects in cerebrovascular accidents (CVAs). See Table 7-3, Visual Field Defects, p. 132.

120 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

Inspect the:

■ Position and alignment of eyes

■ Eyebrows

■ Eyelids

■ Lacrimal apparatus

■ Conjunctiva and sclera

■ Cornea, iris, and lens

Inspect pupils for:

■ Size, shape, and symmetry

■ Reactions to light, direct and consensual

■ The near reaction, namely pupil- lary constriction with gaze shift to near object; note the accom- panying convergence of the eyes and accommodation of the lens (becomes more convex) (Fig. 7-2)

Figure 7-1 Static finger wiggle tes t.

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

See Table 7-4, Physical Findings in and Around the Eye, pp. 133–134.

Exophthalmos, strabismus

Seborrheic dermatitis

Sty, chalazion, ectropion, ptosis, xanthe- lasma, blepharitis

Swollen lacrimal sac, excessive tearing

Red eye, conjunctivitis, jaundice, episcle- ritis

Cataract, crescentic shadow of acute angle glaucoma

Miosis, mydriasis, anisocoria

Absent in paralysis of CN III

Constriction slows in tonic (Adie) pupil and is absent in Argyll Robertson pupils of syphilis; poor convergence in hyper- thyroidism

Chapter 7 | The Head and Neck 121

Figure 7-2 The pupils cons trict when the focus shifts to a close object.

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Superior rectus (III)

Latera l rectus (VI)

Infe rior rectus (III)

Superior rectus (III)

Late ra l rectus (VI)

Infe rior rectus (III)

Superior oblique (IV)

Media l rectus (III)

Inferior oblique (III)

Figure 7-3 The s ix cardinal directions of gaze .

Inspect the fundi with an ophthal- moscope.

Assess the extraocular muscles by observing:

■ The symmetry of corneal re ec- tions from a midline light

■ The six cardinal directions of gaze (Fig. 7-3)

Asymmetric reflection if deviation in ocular alignment

Cranial nerve palsy, strabismus, nystag- mus, lid lag of hyperthyroidism

S t e p s f o r U s in g t h e O p h t h a lm o s c o p e

● D rken the roo . Switch on the o hth l osco e light nd turn the lens disc until you see the l rge round be of white light .* Shine the light on the b ck of your h nd to check the ty e of light, its desired brightness, nd the electri- c l ch rge of the o hth l osco e.

*So e clinici ns like to use the l rge round be for l rge u ils, nd the s ll round be for s ll u ils. The other be s re r rely hel ful. The slit-like be is so eti es used to ssess elev tions or conc vities in the retin , the green (or red-free) be to detect s ll red lesions, nd the grid to ke e sure ents. Ignore the l st three lights nd r ctice with the l rge or s ll round white be .

(continued )

122 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

S t e p s f o r U s in g t h e O p h t h a lm o s c o p e (Continued)

● Turn the lens disc to the 0 dio ter. (A dio ter is unit th t e sures the ower of lens to converge or diverge light.) At this dio ter, the lens neither converges nor diverges light. Kee your finger on the edge of the lens disc so you c n turn the disc to focus the lens when you ex ine the fundus.

● Hold the o hth l osco e in your right hand and use your right eye to ex ine the patient’s right eye; hold it in your left hand and use your left eye to examine the patient’s left eye. This kee s you fro bu ing the tient’s nose nd gives you ore obility nd closer r nge for visu lizing the fundus. With r ctice, you will beco e ccusto ed to using your nondo in nt eye.

● Hold the o hth l osco e fir ly br ced g inst the edi l s ect of your bony orbit , with the h ndle tilted l ter lly t bout 2 -degree sl nt fro the vertic l. Check to ke sure you c n see cle rly through the erture. Instruct the patient to look slightly u nd over your shoulder at a point directly ahead on the wall.

● Pl ce yourself bout 15 inches w y fro the tient nd t n ngle 15-degree lateral to the patient’s line of vision. Shine the light be on the u il nd look for the or nge glow in the u il— the red reflex. Note ny o cities interru ting the red reflex.

● Now place the thumb of your other hand across the patient’s eyebrow, which ste dies your ex ining h nd. Kee ing the light be focused on the red reflex, ove in with the o hth l osco e on the 15-degree ngle tow rd the u il until you re very close to it , l ost touching the tient’s eyel shes nd the thu b of your other h nd.

Inspect the fundi for the following:

■ Red re ex

■ Optic disc (Fig. 7-4)

Cataracts, artificial eye

Papilledema, glaucomatous cupping, optic atrophy. See Table 7-5, Abnormalities of the Optic Disc, p. 135, and Table 7-6, Ocular Fundi: Diabetic Retinopathy, p. 136.

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Chapter 7 | The Head and Neck 123

Arte ry

Vein

Optic disc

Phys iologic cupMacula

Figure 7-4 The optic disc.

AV nicking, copper wiring in hyperten- sive changes

Hemorrhages, exudates, cotton-wool patches, microaneurysms, pigmentation

Macular degeneration

Vitreous floaters, cataracts

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

■ Arteries, veins, and AV crossings

■ Adjacent retina (note any lesions)

■ Macular area

■ Anterior structures

T ip s f o r E x a m in in g t h e O p t ic D is c a n d R e t in a

● Locate the optic disc. Look for the round yellowish-or nge structure. ● Now, bring the optic disc into sharp focus by djusting the lens of your o hth l-

osco e. ● Inspect the optic disc. Note the following fe tures:

● The sharpness or clarity of the disc outline ● The color of the disc ● The size of the central physiologic cup ( n enl rged cu suggests chronic

o en- ngle gl uco ) ● Venous pulsations in the retin l veins s they e erge fro the centr l or-

tion of the disc (loss of venous uls tions fro elev ted intr cr ni l res- sure y occur in he d tr u , eningitis)

● Inspect the retina. Distinguish rteries fro veins b sed on the fe tures listed below.

Ar t e r ie s Ve in s

Color Light red D rk red Size S ller (2/3 to 3/4 the

di eter of veins) L rger

Light Reflex (reflect ion) Bright Incons icuous or bsent

● Follow the vessels peripherally in each of four directions. ● Ins ect the fovea nd surrounding macula. M cul r

degener tion ty es include dry atrophic ( ore co - on but less severe) nd wet exudative (neov scu- l r). Undigested cellul r debris, c lled drusen, y be h rd or soft .

● Assess for ny papilledema fro incre sed intr cr ni l ressure le ding to swelling of the o tic nerve he d.

124 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

T h e E a r s Examine on each side:

Th e Au ric le . Inspect the auricle.

If you suspect otitis:

■ Move the auricle up and down, and press on the tragus.

■ Press rmly behind the ear.

Ea r Ca n a l a n d Dru m . Pull the auricle up, back, and slightly out. Inspect, through an otoscope with speculum:

■ The canal

■ The eardrum (Fig. 7-5)

Keloid, epidermoid cyst

Pain in otitis externa (“the tug test”)

Possible tenderness in otitis media and mastoiditis

Cerumen; swelling and erythema in oti- tis externa

Pars flaccida

Incus

Pars tensa Umbo Cone of light

Handle of ma lleus

Short process of ma lleus

Figure 7-5 Anatomy of middle and inner ear.

Red bulging drum in acute otitis media; serous otitis media, tympanosclerosis, perforations. See Table 7-7, Abnormali- ties of the Eardrum, p. 137.

He a rin g . “Do you feel you have a hearing loss or dif culty hearing?” is a sensitive screening question. Assess auditory acuity to spoken or whispered voice or with a hand- held audiometer.

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Chapter 7 | The Head and Neck 125

If hearing is diminished, use a 512-Hz tuning fork to:

■ Test lateralization (Weber test), but only in patients with unilat- eral hearing loss. Place vibrating and tuning fork on vertex of skull and check hearing.

■ Compare air and bone conduction (Rinne test). Place vibrating and tuning fork on mastoid bone, then remove and check hearing.

In unilateral conductive hearing loss, sound is heard in (lateralized to) the impaired ear. See Table 7-8, Patterns of Hearing Loss, p. 138.

In conductive hearing loss, sound is heard through bone longer than through air (BC = AC or BC > AC). In sensorineural hearing loss, sound is heard longer through air (AC > BC).

T h e N o s e a n d S in u s e s Inspect the external nose.

Inspect, through a speculum, the:

■ Nasal mucosa that covers the septum and turbinates, noting its color and any swelling

Figure 7-6 Nasal polyps .

Swollen and red in viral rhinitis, swollen and pale in allergic rhinitis; polyps (Fig. 7-6); ulcer from cocaine use

■ Nasal septum for position and integrity

Palpate the frontal and maxillary sinuses.

Deviation, perforation

Tender in acute sinusitis

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

126 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

T h e M o u t h a n d P h a r y n x

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Inspect the:

■ Lips

■ Oral mucosa

■ Gums

■ Teeth

■ Roof of the mouth

■ Tongue, including:

■ Papillae

■ Symmetry

■ Any lesions

■ Floor of the mouth

■ Pharynx, including:

■ Color or any exudate

■ Presence and size of tonsils

■ Symmetry of the soft palate as patient says “ah”

T h e N e c k

Cyanosis, pallor, cheilosis. See also Table 7-9, Abnormalities of the Lips, p. 139.

Aphthous ulcers (canker sores)

Gingivitis, periodontal disease

Dental caries, tooth loss

Torus palatinus (benign)

See Table 7-10, Abnormalities of the Tongue, pp. 140–141.

Glossitis

Deviation to one side from paralysis of CN XII from CVA

Erythroplakia, leukoplakia (precancerous); squamous cell or other carcinomas

Lesions suspicious for cancer

See Table 7-11, Abnormalities of the Pharynx, p. 142.

Pharyngitis

Exudates, tonsillitis, peritonsillar abscess

Soft palate fails to rise, uvula deviates to opposite side in CN X paralysis from CVA.

Scars, masses, torticollis

Cervical lymphadenopathy from HIV or AIDS, infectious mononucleosis, lym- phoma, leukemia, and sarcoidosis. Enlarged supraclavicular node from possible abdominal malignancy

Deviated trachea from neck mass or pneumothorax

Inspect the neck.

Palpate super cial and deep ante- rior, posterior cervical, and supra- clavicular lymph nodes.

Inspect and palpate the position of the trachea.

Chapter 7 | The Head and Neck 127

Inspect the thyroid gland:

■ At rest

■ As patient swallows water

From behind patient, palpate the thyroid gland, including the isthmus, and rst one then the opposite lobe:

■ At rest

■ As patient swallows water (Fig. 7-7)

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Goiter, nodules. See Table 7-12, Abnor- malities of the Thyroid Gland, p. 143.

Goiter, nodules, tenderness of thyroiditis

Figure 7-7 Thyroid gland with goite r while swallowing.

Alternative Examination Sequence—After examining the thyroid gland, you may proceed to musculoskeletal examination of the neck and upper back and check for costovertebral angle tenderness.

Recording Your Findings

R e c o r d in g t h e H e a d , E y e s , E a r s , N o s e , a n d T h r o a t (H E E N T ) E x a m in a t io n

Head—The skull is nor oce h lic/ tr u tic. Front l b lding. Eyes—Visu l cu- ity 2 /1 bil ter lly. Scler white; conjunctiv injected. Pu ils constrict fro 3 to 2 , equ lly round nd re ctive to light nd cco od tion. Disc rgins sh r ; no he orrh ges or exud tes. Arteriol r-to-venous r tio (AV r tio) 2:4; no AV nicking. Ears—Acuity di inished to whis ered voice; int ct to s oken voice. TMs cle r. Nose—Mucos swollen with erythe nd cle r dr in ge. Se tu idline. Tender over xill ry sinuses. Throat—Or l ucos ink, dent l c ries in lower ol rs, h rynx erythe tous, no exud tes.

Neck—Tr che idline. Neck su le; thyroid isth us idline, lobes l - ble but not enl rged.

Lymph Nodes—Sub ndibul r nd nterior cervic l ly h nodes tender, 1 × 1 c , rubbery nd obile; no osterior cervic l, e itrochle r, xill ry, or inguin l ly h deno thy.

(These findings suggest myopia and mild arteriolar narrowing as well as upper respiratory infection.)

128 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

Aids to Interpretation

P ro b le m Co m m o n Ch a ra c t e r is t ic s

As s o c ia t e d S ym p t o m s , P ro vo k in g a n d Re lie v in g Fa c t o r s

Tens ion Location: variable

Quality: pressing or tightening pain; mild-to- moderate intensity

Onset: gradual

Duration: minutes to days

Sometimes photophobia, phonophobia; nausea absent

↑ by sustained muscle tension, as in driving or typing

↓ possibly by massage, relaxation

Migra ine ■ With aura ■ Without

aura ■ Variants

Location: unilateral in �70%; bifrontal or global in �30%

Quality: throbbing or aching, variable in severity

Onset: fairly rapid, peaks in 1–2 hours

Duration: 4–72 hours

Nausea, vomiting, photophobia, phonophobia, visual auras (flickering zig- zagging lines), motor auras affecting hand or arm, sensory auras (numbness, tingling usually precede headache)

↑ by alcohol, certain foods, tension, noise, bright light. More common premenstrually

↓ by quiet dark room, sleep

Clus te r Location: unilateral, usually behind or around the eye

Quality: deep, continuous, severe

Onset: abrupt, peaks within minutes

Duration: up to 3 hours

Lacrimation, rhinorrhea, miosis, ptosis, eyelid edema, conjunctival infection

↑ sensitivity to alcohol during some episodes

P rim a ry He a d a ch e sTable 7-1

Chapter 7 | The Head and Neck 129

P ro b le m Co m m o n Ch a ra c t e r is t ic s

As s o c ia t e d S ym p t o m s , P ro vo k in g a n d Re lievin g Fa c t o rs

Analges ic Rebound

Location: previous headache pattern

Quality: variable

Onset: variable

Duration: depends on prior headache pattern

Depends on prior headache pattern

↑ by fever, carbon monoxide, hypoxia, withdrawal of caffeine, other headache triggers

↓—depends on cause Headaches from Eye Diso rders Errors of Refraction (farsightedness and astigmatism, but not nearsightedness)

Location: around and over the eyes; may radiate to the occipital area

Quality: steady, aching, dull

Onset: gradual

Duration: variable

Eye fatigue, “sandy” sensation in eyes, redness of the conjunctiva

↑ by prolonged use of the eyes, particularly for close work

↓ by resting the eyes

Acute Glaucoma Location: in and around one eye

Quality: steady, aching, often severe

Onset: often rapid

Duration: variable, may depend on treatment

Diminished vision, sometimes nausea and vomiting

↑—sometimes by drops that dilate the pupils

Headache from Sinus it is

Location: usually above eye (frontal sinus) or over maxillary sinus

Quality: aching or throbbing, variable in severity; consider possible migraine

Onset: variable

Duration: often several hours at a time, recurring over days or longer

Local tenderness, nasal congestion, tooth pain, discharge, and fever

↑ by coughing, sneezing, or jarring the head

↓ by nasal decongestants, antibiotics

Se c o n d a ry He a d a ch e sTable 7-2

(table continues on page 130)

130 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

P ro b le m Co m m o n Ch a ra c t e r is t ic s

As s o c ia t e d Sym p t o m s , P ro vo k in g a n d Re lie vin g Fa c t o rs

Mening it is Location: generalized

Quality: steady or throbbing, very severe

Onset: fairly rapid

Duration: variable, usually days

Fever, stiff neck, photophobia, change in mental status

Can ↓ from immediate antibiotics until viral versus bacterial cause identified

Subarachno id Hem orrhage— “Thunderclap Headache”

Location: generalized

Quality: severe, “the worst of my life”

Onset: usually abrupt; prodromal symptoms may occur

Duration: variable, usually days

Nausea, vomiting, possibly loss of consciousness, neck pain

↑ rebleeding, ↑ intracranial pressure, cerebral edema

↓ by subspecialty treatments

Bra in Tum or Location: varies with the location of the tumor

Quality: aching, steady, variable in intensity

Onset: variable

Duration: often brief

↑ by coughing, rebleeding, ↑ intracranial pressure, cerebral edema

↓ by subspecialty treatments

Gian t Ce ll (Tem pora l) Arte rit is

Location: near the involved artery, often the temporal, also the occipital; age related

Quality: throbbing, generalized, persistent, often severe

Onset: gradual or rapid

Duration: variable

Tenderness of the adjacent scalp; fever (in �50%), fatigue, weight loss; new headache (�60%), jaw claudication (�50%), visual loss or blindness (�15– 20%), polymyalgia rheumatica (�50%)

↑ by movement of neck and shoulders

Often ↓ by steroids

Se c o n d a ry He a d a ch e s (continued )Table 7-2

Chapter 7 | The Head and Neck 131

S e c o n d a ry He a d a ch e s (continued )Table 7-2

P ro b le m Co m m o n Ch a ra c t e r is t ic s

As s o c ia t e d Sym p t o m s , P ro vo k in g a n d Re lievin g Fa c t o rs

Postconcussion Headache

Location: often but not always localized to the injured area

Quality: generalized, dull, aching, constant

Onset: within hours to 1–2 days of the injury

Duration: weeks, months, or even years

Drowsiness, poor concentration, confusion, memory loss, blurred vision, dizziness, irritability, restlessness, fatigue

↑ by mental and physical exertion, straining, stooping, emotional excitement, alcohol

↓ by rest Cran ia l Neura lg ias : Trigem ina l Neura lg ia (CN V)

Location: cheek, jaws, lips, or gums; trigeminal nerve divisions 2 and 3 >1

Quality: shocklike, stabbing, burning, severe

Onset: abrupt, paroxysmal

Duration: each jab lasts seconds but recurs at intervals of seconds or minutes

Exhaustion from recurrent pain

↑ by touching certain areas of the lower face or mouth; chewing, talking, brushing teeth

↓ by medication; neurovascular decompression

132 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

Altitudinal (horizontal) defect, usually resulting from a vascular lesion of the retina

Unilateral blindness, from a lesion of the retina or optic nerve

Bitemporal hemianopsia, from a lesion at the optic chiasm

Homonymous hemianopsia, from a lesion of the optic tract or optic radiation on the side contralateral to the blind area

Homonymous quadrantic defect, from a partial lesion of the optic radiation on the side contralateral to the blind area

Vis u a l Fie ld De fe c t sTable 7-3

Left Right (from patient’s viewpoint)

Chapter 7 | The Head and Neck 133

Eye lid s

Ptosis. A drooping upper eyelid that narrows the palpebral fissure from a muscle or nerve disorder

Ectropion. Outward turning of the margin of the lower lid, exposing the palpebral conjunctiva

Entropion. Inward turning of the lid margin, causing irritation of the cornea or conjunctiva

Lid retraction and exophthalmos. A wide-eyed stare suggests hyperthyroidism. Note the rim of sclera between the upper lid and the iris. Retracted lids and “lid lag” when eyes move from up to down markedly increase the likelihood of hyperthyroidism, especially when accompanied by fine tremor, moist skin, and heart rate >90 beats per minute. Exophthalmos describes protrusion of the eyeball, a common feature of Graves ophthalmopathy, triggered by autoreactive T lymphocytes

P hys ic a l Fin d in g s in a n d Aro u n d t h e EyeTable 7-4

(table continues on page 134)

134 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

In a n d Aro u n d t h e Eye

Pinguecula. Harmless yellowish nodule in the bulbar conjunctiva on either side of the iris; associated with aging

Episcleritis. A localized ocular redness from inflammation of the episcleral vessels. Seen in rheumatoid arthritis, Sjögren syndrome, and herpes zoster

Sty. A pimple-like infection around a hair follicle near the lid margin, usually from Staphylococcus aureus

Chalazion. A beady nodule in either eyelid caused by a chronically inflamed meibomian gland

Xanthelasma. Yellowish plaque seen in lipid disorders. Half of affected patients have hyperlipidemia; also common in primary biliary cirrhosis

Blepharitis. Chronic inflammation of the eyelids at the base of the hair follicles, often from S. aureus. Also a scaling seborrheic variant

P hys ic a l Fin d in g s in a n d Aro u n d t h e Eye (continued )

Table 7-4

Chapter 7 | The Head and Neck 135

P ro c e s s Ap p e a ra n c e

No rm a l Tiny disc vessels give normal color to the disc

Disc is yellowish orange to creamy pink

Disc vessels are tiny

Disc margins are sharp (except perhaps nasally)

P a p ille d e m a Venous stasis leads to engorgement and swelling

Disc is pink, hyperemic

Disc vessels are more visible, more numerous, and curve over the borders of the disc

Disc is swollen, with margins blurred

Gla u c o m a t o u s Cu p p in g

Increased pressure within the eye leads to increased cupping (backward depression of the disc) and atrophy

The base of the enlarged cup is pale

Op t ic At ro p h y Death of optic nerve fibers leads to loss of the tiny disc vessels

Disc is white

Disc vessels are absent

Ab n o rm a lit ie s o f t h e Op t ic Dis cTable 7-5

136 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

No n p ro lif e ra t ive Re t in o p a t h y, Mo d e ra t e ly S e ve re

Note tiny red dots or microaneurysms, also the ring of hard exudates (white spots) located superotemporally. Retinal thickening or edema in the area of hard exudates can impair visual acuity if it extends to center of macula. Detection requires specialized stereoscopic examination

No n p ro lif e ra t ive Re t in o p a t h y, S e ve re

In superior temporal quadrant, note large retinal hemorrhage between two cotton-wool patches, beading of the retinal vein just above, and tiny tortuous retinal vessels above the superior temporal artery, termed intraretinal microvascular abnormalities

P ro lif e ra t ive Re t in o p a t h y, w it h Ne o va s c u la r iza t io n

Note new preretinal vessels arising on disc and extending across disc margins. Visual acuity is still normal, but the risk of severe visual loss is high. Photocoagulation can reduce this risk by >50%

P ro lif e ra t ive Re t in o p a t h y, Ad va n c e d

Same eye as above, but 2 years later and without treatment. Neovascularization has increased, now with fibrous proliferations, distortion of the macula, and reduced visual acuity

Oc u la r Fu n d i: Dia b e t ic Re t in o p a t hyTable 7-6

Source of photos: Nonproliferative Retinopathy, Moderately Severe; Proliferative Retinopathy, With Neovascularization; Nonproliferative Retinopathy, Severe; Proliferative Retinopathy, Advanced—Early Treatment Diabetic Retinopathy Study Research Group. Courtesy of MF Davis, MD, University of Wisconsin, Madison. Source: Frank RB. Diabetic retinopathy. N Engl J Med 2004;350:48.

Chapter 7 | The Head and Neck 137

P e r fo ra t io n Hole in the eardrum that may be central or marginal

Usually from otitis media or trauma

Tym p a n o s c le ro s is A chalky white patch

Scarring process of the middle ear from otitis media with deposition of hyaline and calcium and phosphate crystals in the eardrum and middle ear. When severe, it may entrap the ossicles and cause conductive hearing loss

S e ro u s Effu s io n Amber fluid behind the eardrum, with or without air bubbles

Associated with viral upper respiratory infections or sudden changes in atmospheric pressure (diving, flying)

Ac u t e Ot it is Me d ia w it h P u ru le n t Effu s io n

Red, bulging drum, loss of landmarks

Painful hemorrhagic vesicles appear on the tympanic membrane and/or ear canal causing earache, blood-tinged discharge from the ear, and conductive hearing loss. Seen in mycoplasma and viral infections and bacterial otitis media

Ab n o rm a lit ie s o f t h e Ea rd ru mTable 7-7

138 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

Co n d u c t ive Lo s s S e n s o rin e u ra l Lo s s

Im p a ire d Un d e r s t a n d in g o f Wo rd s

Minor Often troublesome

Effe c t s Noisy environment may improve hearing

Voice remains soft since cochlear nerve intact

Noisy environment worsens hearing

Voice may be loud due to nerve damage

Us u a l Ag e o f On s e t

Childhood, young adulthood

Middle and later years

Ea r Ca n a l a n d Dru m

Often a visible abnormality

Problem not visible

We b e r Te s t (in Un ila t e ra l He a r in g Lo s s )

Lateralizes to the impaired ear

Lateralizes to the good ear

Rin n e Te s t BC ≥ AC AC > BC

Ca u s e s In c lu d e Plugged ear canal, otitis media, immobile or perforated drum, otosclerosis, foreign body

Sustained loud noise, drugs, inner ear infections, trauma, hereditary disorder, aging, acoustic neuroma

Pa t t e rn s o f He a rin g Lo s sTable 7-8

Chapter 7 | The Head and Neck 139

Angular cheilitis. Softening and cracking of the angles of the mouth

Herpes simplex. Painful vesicles, followed by crusting; also called cold sore or fever blister

Angioedema. Diffuse, tense, subcutaneous swelling, usually allergic in cause

Hereditary hemorrhagic telangiectasia. Small red spots. Autosomal dominant disorder causing vascular fragility and arteriovascular malformations (AVMs), including in the brain and lungs. Associated bleeding in nose and GI tract

Peutz–Jeghers syndrome. Brown spots of the lips and buccal mucosa, significant because of associated intestinal polyposis and high risk of GI cancer

Syphilitic chancre. A firm lesion that ulcerates and may crust

Carcinoma of the lip. A thickened plaque or irregular nodule that may ulcerate or crust; malignant

Ab n o rm a lit ie s o f t h e Lip sTable 7-9

140 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

Geographic tongue. Scattered areas in which the papillae are lost, giving a map- like appearance; benign

Hairy tongue. Results from elongated papillae that may look yellowish, brown, or black; benign

Fissured tongue. May appear with aging; benign

Smooth tongue. Results from loss of papillae; seen in deficiency of riboflavin, niacin, folic acid, vitamin B12, pyridoxine, or iron, and treatment with chemotherapy

Candidiasis. May show a thick, white coat, which, when scraped off, leaves a raw red surface; tongue may also be red; antibiotics, corticosteroids, AIDS may predispose

Ab n o rm a lit ie s o f t h e To n g u eTable 7-10

Chapter 7 | The Head and Neck 141

Hairy leukoplakia. White raised, feathery areas, usually on sides of tongue. Seen in HIV/AIDS

Varicose veins. Dark round spots in the undersurface of the tongue, associated with aging; also called caviar lesions

Aphthous ulcer (canker sore). Painful, small, whitish ulcer with a red halo; heals in 7–10 days

Mucous patch of syphilis. Slightly raised, oval lesion, covered by a grayish membrane

Carcinoma of the tongue or floor of the mouth. Malignancy should be considered in any nodule or nonhealing ulcer at the base or edges of the mouth

Ab n o rm a lit ie s o f t h e To n g u e (continued )Table 7-10

142 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

Pharyngitis, mild to moderate. Note redness and vascularity of the pillars and uvula

Pharyngitis, diffuse. Note redness is diffuse and intense. Cause may be viral or, if patient has fever, bacterial. If patient has no fever, exudate, or cervical lymphadenopathy, viral infection is more likely

Exudative pharyngitis. A sore red throat with patches of white exudate on the tonsils is associated with streptococcal pharyngitis and some viral illnesses

Diphtheria. An acute infection caused by Corynebacterium diphtheriae. The throat is dull red, and a gray exudate appears on the uvula, pharynx, and tongue

Koplik spots. These small white specks that resemble grains of salt on a red background are an early sign of measles

Ab n o rm a lit ie s o f t h e P h a ryn xTable 7-11

Chapter 7 | The Head and Neck 143

Diffuse enlargement. May result from Graves disease, Hashimoto thyroiditis, endemic goiter (iodine deficiency), or sporadic goiter

Multinodular goiter. An enlargement with two or more identifiable nodules, usually metabolic in cause

Single nodule. May result from a cyst, a benign tumor, or cancer of the thyroid, or may be one palpable nodule in a clinically unrecognized multinodular goiter

Ab n o rm a lit ie s o f t h e Thyro id Gla n dTable 7-12

145

C H A P T E R

8The Thorax and Lungs

The Health History

Complaints of chest pain or chest discomfort raise the specter of heart disease but often arise from conditions in the thorax and lungs. For this important symptom, keep the possible causes below in mind. Also see Table 8-1, Chest Pain, pp. 155–156.

C o m m o n o r C o n c e r n in g S y m p t o m s

● Chest in ● Shortness of bre th (dys ne ) ● Wheezing ● Cough ● Blood-stre ked s utu (he o tysis) ● D yti e slee iness or snoring nd disordered slee

S o u r c e s o f C h e s t P a in a n d R e la t e d C a u s e s

The yoc rdiu Angina pectoris, myocardial infarction, myocarditis

The eric rdiu Pericarditis The ort Aortic dissection The tr che nd l rge bronchi Bronchitis The riet l leur Pericarditis, pneumonia, pneumothorax,

pleural effusion, pulmonary embolus The chest w ll, including the usculo-

skelet l nd neurologic syste s Costochondritis, herpes zoster

The eso h gus Gastroesophageal reflux disease, esoph- ageal spasm, esophageal tear

Extr thor cic structures such s the neck, g llbl dder, nd sto ch

Cervical arthritis, biliary colic, gastritis

For patients who are short of breath, focus on pulmonary complaints:

■ Dyspnea and wheezing

■ Cough and hemoptysis

See Table 8-2, Dyspnea, pp. 157–158.

See Table 8-3, Cough and Hemoptysis, pp. 159–161.

146 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

Health Promotion and Counseling: Evidence and Recommendations

Im p o r t a n t T o p ic s f o r H e a lt h P r o m o t io n a n d C o u n s e lin g

● Tob cco cess tion ● Lung c ncer ● I uniz tions—influenz nd stre tococc l neu oni v ccines

Despite declines in smoking over the past several decades, 19% of Ameri- cans still smoke. Regularly counsel all adults, pregnant women, parents, and adolescents who smoke to stop. Use “the ve As” and the Stages of Change Model to assess readiness to quit.

A s s e s s in g R e a d in e s s t o Q u it S m o k in g : B r ie f In t e r v e n t io n s M o d e ls

5 As Mo d e l S t a g e s o f Ch a n g e Mo d e l

Ask bout tob cco use Precontemplation—“I don’t w nt to quit .” Advise to quit Contemplat ion—“I concerned but not

re dy to quit now.” Assess willingness to ke

quit tte t Preparation—“I re dy to quit .”

Assist in quit tte t Action—“I just quit .” Arrange follow-u Maintenance—“I quit 6 onths go.”

Counsel patients to never smoke or quit smoking. The U.S. Preventive Services Task Force recommends annual low-dose computed tomography (LDCT) screening for current smokers (or those who have quit within the last 15 years) ages 55 to 79 years (grade B recommendation).

Provide u shots to everyone age 6 months or older and especially to those with chronic pulmonary conditions, nursing home residents, household contacts, and health care personnel.

Recommend pneumococcal vaccine to adults 65 years and older, smokers between the ages of 16 and 64 years, and those with increased risk of pneumococcal infection.

Snoring, witnessed apneas ≥10 seconds, awakening with a choking sensation, or morning headache point to obstructive sleep apnea.

■ Daytime sleepiness or snoring and disordered sleep

Chapter 8 | The Thorax and Lungs 147

Techniques of Examination

In it ia l In s p e c t io n o f T h o r a x

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Manubrium of s ternum

Body of s ternum

Xyphoid process

2nd cos tal cartilage

2nd rib interspace

Cos tochondral junctions

Supras ternal notch

Sternal angle

2nd rib

Cos tal angle Figure 8-1 Ches t wall anatomy.

Inspect the thorax (Fig. 8-1) and its respiratory movements for signs of distress and note:

■ Facial color

■ Rate, rhythm, depth, and effort of breathing

■ Inspiratory retraction of the supraclavicular areas

■ Inspiratory contraction of the sternocleidomastoids

Cyanosis and pallor in lips and oral mucosa signal hypoxia.

Tachypnea, hyperpnea, Cheyne–Stokes breathing. Normally 14 to 20 breaths/ minute in adults. See Table 8-4 Abnor- malities in Rate and Rhythm of Breath- ing, p. 162.

Occurs in chronic obstructive pulmonary disease (COPD), asthma, upper airway obstruction

Indicates severe breathing difficulty

148 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

If distress, auscultate the neck and lungs for:

■ Stridor

■ Wheezes

Observe shape of patient’s chest.

T h e P o s t e r io r C h e s t Inspect the chest for:

■ Deformities or asymmetry

■ Abnormal inspiratory retraction of the interspaces

■ Impairment or unilateral lag in respiratory movement

Palpate the chest for:

■ Tender areas

■ Assessment of visible abnor- malities

■ Chest expansion (Fig. 8-2)

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Stridor in upper airway obstruction from foreign body or epiglottitis

Expiratory wheezing in asthma and COPD

Normal or barrel chest (see Table 8-5, Deformities of the Thorax, pp. 163–164)

Kyphoscoliosis

Retraction in asthma, COPD, upper air- way obstruction

Disease of the underlying lung or pleura, phrenic nerve palsy

Fractured ribs

Masses, sinus tracts

Figure 8-2 Assess lung expans ion.

Impairment, both sides in COPD and restrictive lung disease; unilateral decrease or delay in chronic fibrosis of the underlying lung or pleura, pleural effusion, lobar pneumonia, pleural pain with associated splinting, unilateral bronchial obstruction, and paralysis of the hemidiaphragm

■ Tactile fremitus as the patient says “aa” or “blue moon”

Decreased or absent fremitus when transmission of vibrations to the chest is impeded by a thick chest wall, obstructed bronchus, COPD, or pleural effusion, fibrosis, air (pneumothorax), or an infil- trating tumor.

Chapter 8 | The Thorax and Lungs 149

Percuss the chest, comparing one side with the other at each level, using the side-to-side “ladder pattern,” as shown in Figures 8-3 and 8-4.

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Asymmetric decreased fremitus in uni- lateral pleural effusion, pneumothorax, or neoplasm; asymmetric increased fremitus occurs in unilateral pneumonia, which increases transmission through consolidated tissue.

6 6

7 7

Figure 8-3 Percuss and auscultate in a “ ladder” patte rn.

Figure 8-4 Strike the pleximete r finger with the right middle finger.

Dullness when fluid or solid tissue replaces normally air-filled lung; hyper- resonance in emphysema or pneumo- thorax

P e r c u s s io n N o t e s a n d T h e ir C h a r a c t e r is t ic s

Re la t ive In t e n s it y, P it ch , a n d Du ra t io n Exa m p le s

Flat Soft/ high/short L rge leur l effusion Dull Mediu / ediu / ediu Lob r neu oni Resonant Loud/ low/ long He lthy lung, si le chronic

bronchitis Hyperresonant Louder/ lower/ longer E hyse , neu othor x Tympanitic Loud/ high (ti bre is usic l) L rge neu othor x

Percuss level of diaphragmatic dullness on each side and estimate diaphragmatic descent after patient takes full inspiration (Fig. 8-5).

Pleural effusion or a paralyzed diaphragm raises level of dullness.

150 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

Resonant

Leve l of diaphragm

Dull

Loca tion and sequence of percuss ion

Figure 8-5 Identify the extent of diaphragmatic excursion.

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

See Table 8-6, Physical Findings in Selected Chest Disorders, p. 165.

Vesicular, bronchovesicular, or bronchial breath sounds; decreased breath sounds from decreased airflow.

Crackles (fine and coarse) and continu- ous sounds (wheezes and rhonchi)

Clearing after cough suggests atelectasis.

Auscultate the chest with stetho- scope in the “ladder” pattern, again comparing sides.

■ Evaluate the breath sounds.

■ Note any adventitious (added) sounds.

Observe qualities of breath sound, timing in the respiratory cycle, and location on the chest wall. Do they clear with deep breathing or coughing?

C h a r a c t e r is t ic s o f B r e a t h S o u n d s

Du ra t io n In t e n s it y a n d P it ch o f Exp ira t o ry S o u n d

Exa m p le Lo c a t io n s

Vesicular Ins > Ex Soft/ low Most of the lungs

Bronchovesicular Ins = Ex Mediu / ediu 1st nd 2nd inter- s ces, intersc - ul r re

Bronchial Ex > Ins Loud/ high Over the nu- briu

Tracheal Ins = Ex Very loud/ high Over the tr che

Dur tion is indic ted by the length of the line, intensity by the width of the line, nd itch by the slo e of the line.

Chapter 8 | The Thorax and Lungs 151

Assess transmitted voice sounds and bronchial breath sounds heard in abnormal places. Ask patient to:

■ Say “ninety-nine” and “ee.”

■ Whisper “ninety-nine” or “one-two-three.”

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Bronchophony if sounds become louder; egophony if “ee”to “A”change from lobar consolidation

Whispered pectoriloquy if whispered sounds transmit louder and more clearly

T r a n s m it t e d V o ic e S o u n d s

Th ro u g h No rm a lly Air-Fille d Lu n g Th ro u g h Air le s s Lu n g a

Usu lly cco nied by vesicul r bre th sounds nd nor l t ctile fre itus

Usu lly cco nied by bronchi l or bronchovesicul r bre th sounds nd incre sed t ctile fre itus

S oken words uffled nd indistinct S oken words louder, cle rer (bronchophony)

S oken “ee” he rd s “ee” S oken “ee” he rd s “ y” (egophony) Whis ered words f int nd indistinct,

if he rd t ll Whis ered words louder, cle rer

(whispered pectoriloquy)

A d v e n t it io u s o r A d d e d B r e a t h S o u n d s

Cra ck le s (o r Ra le s ) Wh e e ze s a n d Rh o n ch i

Discontinuous Continuous ● Inter ittent , nonmusical, nd

brief

● Like dots in ti e ● Fine crackles: soft , high- itched

(�65 Hz), very brief (5–1 s)

● Coarse crackles: so ewh t louder, lower in itch (�35 Hz), brief (15–3 s)

● Sinusoid l, musical, rolonged (but not necess rily ersisting throughout the res ir tory cycle)

● Like d shes in ti e ● Wheezes: rel tively high- itched

(≥4 Hz) with hissing or shrill qu lity (>8 s)

● Rhonchi: rel tively low- itched (15 –2 Hz) with snoring qu lity (>8 s)

Source: Loudon R, Mur hy LH. Lung sounds. Am Rev Respir Dis. 1994;13 :663; Boh d n A, Izbicki G, Kr n SS. Fund ent ls of lung uscult tion. N Engl J Med. 2 14;37 :744.

aAs in lob r neu oni nd tow rd the to of l rge leur l effusion.

152 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

Alternative Examination Sequence—While the patient is still sitting, you may inspect the breasts and examine the axillary and epitrochlear lymph nodes, and examine the temporomandibular joint and the musculoskeletal system of the upper extremities.

T h e A n t e r io r C h e s t

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Inspect the chest (Figs. 8-6 and 8-7) for:

■ Deformities or asymmetry

■ Intercostal retraction

■ Impaired or lagging respiratory movement

Palpate the chest for:

■ Tender areas

■ Assessment of visible abnor- malities

■ Respiratory expansion

■ Tactile fremitus

Midste rna l line

Midclavicula r line

Ante rior axilla ry line

Figure 8-6 Mids te rnal and midclavicu- lar lines .

Anterior axilla ry line

Pos te rior axilla ry line

Midaxilla ry line

Figure 8-7 Anterior, pos te rior, and midaxillary lines .

Pectus excavatum

From obstructed airways

Disease of the underlying lung or pleura, phrenic nerve palsy

Tender pectoral muscles, costochondritis

Flail chest

Chapter 8 | The Thorax and Lungs 153

44 55 66

Figure 8-8 Palate and percuss in a “ ladder” patte rn.

Normal cardiac dullness may disappear in emphysema.

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Auscultate the chest. Assess breath sounds, adventitious sounds, and if indicated transmitted voice sounds.

Older adults walking 8 feet in <3 seconds are less likely to be disabled than those taking >5 to 6 seconds.

Patients age ≥60 years with a forced expiratory time of ≥9 seconds are four times more likely to have COPD.

Percuss the chest in the areas illus- trated in Figure 8-8.

S p e c ia l T e c h n iq u e s Clin ic a l As s e s s m e n t o f

P u lm o n a ry Fu n c t io n . Walk with patient down the hall or up a ight of stairs. Observe the rate, effort, and sound of breathing, and inquire about symptoms. Or learn to do a standardized “6-minute walk test.”

Fo rc e d Exp ira t o ry Tim e . Ask the patient to take a deep breath in and then breathe out as quickly and completely as possible, with mouth open. Listen over trachea with diaphragm of stethoscope, and time audible expi- ration. Try to get three consistent readings, allowing rests as needed.

154 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

R e c o r d in g t h e T h o r a x a n d Lu n g s E x a m in a t io n

“Thor x is sy etric with good ex nsion. Lungs reson nt. Bre th sounds vesicul r; no r les, wheezes, or rhonchi. Di hr g s descend 4 c bil ter lly.” OR “Thor x sy etric with oder te ky hosis nd incre sed ntero osterior (AP) di eter, decre sed ex nsion. Lungs re hy erreson nt. Bre th sounds dist nt with del yed ex ir tory h se nd sc ttered ex ir tory wheezes. Fre itus decre sed; no broncho hony, ego hony, or whis ered ectoriloquy. Di hr g s descend 2 c bil ter lly.” (These findings suggest COPD.)

Recording Your Findings

Chapter 8 | The Thorax and Lungs 155

Aids to Interpretation

P ro b le m a n d Lo c a t io n Qu a lit y, S e ve r it y, Tim in g , a n d As s o c ia t e d S ym p t o m s

Ca rd io va s c u la r

Angina Pectoris Retrosternal or across the anterior chest, sometimes radiating to the shoulders, arms, neck, lower jaw, or upper abdomen

■ Pressing, squeezing, tight, heavy, occasionally burning

■ Mild to moderate severity, sometimes perceived as discomfort rather than pain

■ Usually 1–3 min but up to 10 min; prolonged episodes up to 20 min

■ Sometimes with dyspnea, nausea, swelling

Myocard ia l In fa rction Same as in angina

■ Same as in angina ■ Often but not always a severe

pain ■ 20 min to several hours ■ Associated with nausea,

vomiting, sweating, weakness

Pericard itis Retrosternal or Precordial: May radiate to the tip of the shoulder and to the neck

■ Sharp, knifelike quality ■ Often severe ■ Persistent timing ■ Relieved by leaning forward ■ Seen in autoimmune disorders,

postmyocardial infarction, viral infection, chest irradiation

Dissecting Aortic Aneurysm Anterior chest, radiating to the neck, back, or abdomen

■ Ripping, tearing quality ■ Very severe ■ Abrupt onset, early peak,

persistent for hours or more ■ Associated syncope, hemiplegia,

paraplegia

Ch e s t Pa inTable 8-1

(table continues on page 156)

156 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

P ro b le m a n d Lo c a t io n Qu a lit y, S e ve r it y, Tim in g , a n d As s o c ia t e d S ym p t o m s

P u lm o n a ry

Pleuritic Pa in Chest wall overlying the process

■ Sharp, knifelike quality ■ Often severe ■ Persistent timing ■ Associated symptoms of the

underlying illness (often pneumonia, pulmonary embolism)

Ga s t ro in t e s t in a l a n d Ot h e r

Gas tro in tes tina l Reflux Disease Retrosternal, may radiate to the back

■ Burning quality, may be squeezing

■ Mild to severe ■ Variable timing ■ Associated with regurgitation,

dysphagia; also cough, laryngitis, asthma

Diffuse Esophagea l Spasm Retrosternal, may radiate to the back, arms, and jaw

■ Usually squeezing quality ■ Mild to severe ■ Variable timing ■ Associated dysphagia

Ches t Wall Pa in , Cos tochondritis Often below the left breast or along the costal cartilages; also elsewhere

■ Stabbing, sticking, or dull aching quality

■ Variable severity ■ Fleeting timing, hours or days ■ Often with local tenderness

Anxie ty, Panic Diso rder ■ Pain may be stabbing, sticking, or dull, aching

■ Can mimic angina ■ Associated with breathlessness,

palpitations, weakness, anxiety

Ch e s t Pa in (continued )Table 8-1

Chapter 8 | The Thorax and Lungs 157

P ro b le m Tim in g

P ro vo k in g /Re lie v in g Fa c t o r s ; As s o c ia t e d S ym p t o m s

Le ft -S id e d He a r t Fa ilu re (Left Ventricular Failure or Mitral Stenosis)

Dyspnea may progress slowly or suddenly, as in acute pulmonary edema

↑ by exertion, lying down ↓ by rest, sitting up, though dyspnea may become persistent Associated Symptoms: Often cough, orthopnea, paroxysmal nocturnal dyspnea; sometimes wheezing

Ch ro n ic Bro n ch it is (may be seen with COPD)

Chronic productive cough followed by slowly progressive dyspnea

↑ by exertion, inhaled irritants, respiratory infections ↓ by expectoration, rest though dyspnea may become persistent Associated Symptoms: Chronic productive cough, recurrent respiratory infections; wheezing possible

Ch ro n ic Ob s t ru c t ive P u lm o n a ry Dis e a s e (COP D)

Slowly progressive; relatively mild cough later

↑ by exertion ↓ by rest, though dyspnea may become persistent Associated Symptoms: Cough with scant mucoid sputum

Dys p n e aTable 8-2

(table continues on page 158)

158 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

Dys p n e a (continued )Table 8-2

P ro b le m Tim in g

P ro vo k in g /Re lie v in g Fa c t o r s ; As s o c ia t e d S ym p t o m s

As t h m a Acute episodes, then symptom- free periods; nocturnal episodes common

↑ by allergens, irritants, respiratory infections, exercise, emotion ↓ by separation from aggravating factors Associated Symptoms: Wheezing, cough, tightness in chest

Diffu s e In t e rs t it ia l Lu n g Dis e a s e s (Sarcoidosis, Neoplasms, Asbestosis, Idiopathic Pulmonary Fibrosis)

Progressive; varies in rate of development depending on cause

↑ by exertion ↓ by rest, though dyspnea may become persistent Associated Symptoms: Often weakness, fatigue; cough less common than in other lung diseases

P n e u m o n ia Acute illness; timing varies with causative agent

Associated Symptoms: Pleuritic pain, cough, sputum, fever, though not necessarily present

S p o n t a n e o u s P n e u m o t h o ra x

Sudden onset of dyspnea

Associated Symptoms: Pleuritic pain, cough

Ac u t e P u lm o n a ry Em b o lis m

Sudden onset of dyspnea

Associated Symptoms: Often none; retrosternal oppressive pain if massive occlusion; pleuritic pain, cough, syncope, hemoptysis, and/or unilateral leg swelling and pain from instigating deep vein thrombosis; anxiety

Chapter 8 | The Thorax and Lungs 159

P ro b le m Co u g h , S p u t u m , As s o c ia t e d S ym p t o m s , a n d S e t t in g

Ac u t e In f la m m a t io n

Laryng itis Cough and Sputum: Dry, or with variable amounts of sputum Associated Symptoms and Setting: Acute, fairly minor illness with hoarseness. Associated with viral nasopharyngitis

Acute Bronch itis Cough and Sputum: Dry or productive of sputum Associated Symptoms and Setting: An acute, often viral illness, with burning retrosternal discomfort

Mycop lasm a and Vira l Pneum onias

Cough and Sputum: Dry and hacking often with mucoid sputum Associated Symptoms and Setting: Acute febrile illness, often with malaise, headache, and possibly dyspnea

Bacte ria l Pneum onias Cough and Sputum: Sputum is mucoid or purulent; may be blood-streaked, diffusely pinkish, or rusty Associated Symptoms and Setting: Acute illness with chills, often high fever, dyspnea, and chest pain. Commonly from Streptococcus pneumonia, Haemophilus influenza, Moraxella catarrhalis; Klebsiella in alcoholism

Ch ro n ic In f la m m a t io n

Pos tnasa l Drip Cough and Sputum: Chronic cough with mucoid or mucopurulent sputum Associated Symptoms and Setting: Repeated attempts to clear the throat. Postnasal drip, discharge in posterior pharynx. Associated with chronic rhinitis, with or without sinusitis

Co u g h a n d He m o p t ys isTable 8-3

(table continues on page 160)

160 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

P ro b le m Co u g h , S p u t u m , As s o c ia t e d S ym p t o m s , a n d S e t t in g

Chron ic Bronch itis Cough: Chronic Sputum: Mucoid to purulent; may be blood-streaked or even bloody Associated Symptoms and Setting: Often long history of cigarette smoking. Recurrent superimposed infections; often wheezing and dyspnea

Bronchiecta s is Cough and Sputum: Chronic cough; sputum mucoid to purulent, may be blood- streaked or even bloody Associated Symptoms and Setting: Recurrent bronchopulmonary infections common; sinusitis may coexist

Pu lm onary Tuberculos is

Cough and Sputum: Dry, mucoid or purulent; may be blood-streaked or bloody Associated Symptoms and Setting: Early, no symptoms. Later, anorexia, weight loss, fatigue, fever, and night sweats

Lung Abscess Cough and Sputum: Sputum purulent and foul-smelling; may be bloody Associated Symptoms and Setting: Often from aspiration pneumonia from oral anaerobes and poor dental hygiene; often with dysphagia, impaired consciousness

As thm a Cough and Sputum: Thick and mucoid, especially near end of an attack Associated Symptoms and Setting: Episodic wheezing and dyspnea, but cough may occur alone. Often a history of allergy

Co u g h a n d He m o p t ys is (continued )Table 8-3

Chapter 8 | The Thorax and Lungs 161

P ro b le m Co u g h , S p u t u m , As s o c ia t e d S ym p t o m s , a n d S e t t in g

Gas troesophagea l Re flux

Cough and Sputum: Chronic cough, especially at night or early morning Associated Symptoms and Setting: Wheezing, especially at night (often mistaken for asthma), early morning hoarseness, repeated attempts to clear throat. Often with history of heartburn and regurgitation

Ne o p la s m Cough: Dry to productive

Lung Cance r Sputum and Cough: Cough, dry to productive; sputum may be blood-streaked or bloody Associated symptoms and setting: Commonly with dyspnea, weight loss, and history of tobacco abuse

Ca rd io va s c u la r Dis o rd e r s

Left Ventricu la r Fa ilure o r Mitra l S tenos is

Cough and Sputum: Cough often dry, especially on exertion or at night. Sputum may progress to pink and frothy, as in pulmonary edema, or to frank hemoptysis Associated Symptoms and Setting: Dyspnea, orthopnea, paroxysmal nocturnal dyspnea.

Pu lm onary Em bolism Cough and Sputum: Dry cough, at times with hemoptysis Associated Symptoms and Setting: Tachypnea, chest or pleuritic pain, dyspnea, fever, syncope, anxiety; factors that predispose to deep venous thrombosis

Irrita ting Particles , Chem ica ls , o r Gases

Cough and Sputum: Variable. May be a latent period between exposure and symptoms Associated Symptoms and Setting: Exposure to irritants; eye, nose, and throat symptoms

Co u g h a n d He m o p t ys is (continued )Table 8-3

162 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

Inspira tion Expira tion Normal. In adults, 14–20 per min; in infants, up to 44 per min.

Rapid Shallow Breathing (Tachypnea). Many causes, including salicylate intoxication, restrictive lung disease, pleuritic chest pain, and an elevated diaphragm.

Rapid Deep Breathing (Hyperpnea, Hyperventilat ion). Many causes, including exercise, anxiety, metabolic acidosis, brainstem injury. Kussmaul breathing, due to metabolic acidosis, is deep, but rate may be fast, slow, or normal.

Slow Breathing (Bradypnea). May be secondary to diabetic coma, drug-induced respiratory depression.

Hyperpnea Apnea

Cheyne–Stokes Breathing . Rhythmically alternating periods of hyperpnea and apnea. In infants and the aged, may be normal during sleep; also accompanies brain damage, heart failure, uremia, drug-induced respiratory depression.

Ataxic (Biot) Breathing. Unpredictable irregularity of depth and rate. Causes include meningitis, respiratory depression, and brain injury.

Sighs Sighing Breathing . Breathing punctuated by frequent sighs. When associated with other symptoms, it suggests the hyperventilation syndrome. Occasional sighs are normal.

Prolonged expira tion Obstructive Breathing . In obstructive lung disease, expiration is prolonged due to narrowed airways increase the resistance to air flow. Causes include asthma, chronic bronchitis, and COPD.

Ab n o rm a lit ie s in Ra t e a n d Rhyt h m o f Bre a t h in g

Table 8-4

Chapter 8 | The Thorax and Lungs 163

Cro s s -S e c t io n o f Th o ra x

No rm a l Ad u lt

The thorax is wider than it is deep; lateral diameter is greater than anteroposterior (AP) diameter.

Ba r re l Ch e s t

Has increased AP diameter, seen in normal infants and normal aging; also in COPD.

Tra u m a t ic Fla il Ch e s t

If multiple ribs are fractured, can see paradoxical movements of the thorax. Descent of the diaphragm decreases intrathoracic pressure on inspiration. The injured area may cave inward; on expiration, it moves outward.

Expiration

Inspiration

Fu n n e l Ch e s t (Pectus Excava tum )

Depression in the lower portion of the sternum. Related compression of the heart and great vessels may cause murmurs.

De fo rm it ie s o f t h e Th o ra xTable 8-5

(table continues on page 164)

164 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

Cro s s -S e c t io n o f Th o ra x P ig e o n Ch e s t (Pectus Carina tum )

Sternum is displaced anteriorly, increasing the AP diameter; costal cartilages adjacent to the protruding sternum are depressed.

Depressed cos ta l cartilages

Anteriorly displaced s ternum

Th o ra c ic Kyp h o s c o lio s is

Abnormal spinal curvatures and vertebral rotation deform the chest, making interpretation of lung findings difficult.

Spinal convexity to the right (patient bending forward)

Ribs widely

separated

Ribs close together

De fo rm it ie s o f t h e Th o ra x (continued )Table 8-5

165

(

)

;

(

)

167

C H A P T E R

9The Cardiovascular System

The Health History

As you assess reports of chest pain or discomfort, keep serious adverse events in mind, such as angina pectoris, myocardial infarction, or even a dissecting aortic aneurysm. Ask about any palpitations, shortness of breath from orthopnea or paroxysmal nocturnal dyspnea (PND), swelling from edema, and fainting. Be systematic as you think through the range of possible cardiac, pulmonary, and extrathoracic etiologies. Know the presentations of chest pain, dyspnea, wheezing, cough, and even hemoptysis, because these symptoms can be cardiac as well as pulmonary in origin. Also, when assessing cardiac symptoms, it is important to quantify the patient’s baseline level of activity compared to the symptomatic episode.

C o m m o n o r C o n c e r n in g S y m p t o m s

● Chest in ● P l it tions ● Shortness of bre th: dys ne , ortho ne , or roxys l nocturn l dys ne ● Swelling or ede ● F inting (synco e)

C o m m o n C a r d ia c S y m p t o m s

● Chest pain refers to cl ssic exertion l in, ressure, or disco fort in the chest, shoulder, b ck, neck, or r in ngin ectoris, occurs in 18% of tients with cute MI; ty ic l descri tors lso re co on, such s cr ing, grinding, ricking or, r rely, tooth or j w in.

● Palpitations re n un le s nt w reness of the he rtbe t . ● Shortness of breath y re resent dys ne , ortho ne , or PND.

● Dyspnea is n unco fort ble w reness of bre thing th t is in ro ri te for given level of exertion.

(continued )

168 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

CVD, which consists primarily of hypertension (the vast majority of diagnoses), coronary heart disease (CHD), heart failure, and stroke, affects nearly 84 million U.S. adults. CVD is the leading cause of death for both men and women in the United States. Primary prevention, in those without evidence of CVD, and secondary prevention, in those with known cardio- vascular events, remain important clinical priorities. Provide education and counseling to promote optimal levels of blood pressure, cholesterol, weight, exercise, and smoking cessation and to reduce risk factors for CVD and stroke.

The American Heart Association recommends important goals for ideal cardiovascular health.

Health Promotion and Counseling: Evidence and Recommendations

Im p o r t a n t T o p ic s f o r H e a lt h P r o m o t io n a n d C o u n s e lin g

● S eci l o ul tions t risk ● Screening for c rdiov scul r risk f ctors

● Step 1: Screen for glob l risk f ctors ● Step 2: C lcul te 1 -ye r nd lifeti e c rdiov scul r dise se (CVD) risk

using n online c lcul tor ● Step 3: Tr ck individu l risk f ctors—hy ertension, di betes, dysli ide i s,

et bolic syndro e, s oking, f ily history, nd obesity ● Pro oting lifestyle ch nges nd risk f ctor odific tion

C o m m o n C a r d ia c S y m p t o m s (Continued )

● Orthopnea is dys ne th t occurs when the t ient is lying down nd i roves when the t ient sits u . It suggests left ventricular heart failure or mitral stenosis; it lso y cco ny obstructive pulmonary disease.

● PND describes e isodes of sudden dys ne nd ortho ne th t w ken the tient fro slee , usu lly 1 to 2 hours fter going to bed, ro ting the tient to sit u , st nd u , or go to window for ir.

● Edema refers to the ccu ul tion of excessive fluid in the interstiti l tissue s ces; it e rs s swelling. Dependent edema e rs in the feet nd lower legs when sitting or in the s cru when bedridden.

● Fainting (“bl cking out”) or syncope, is tr nsient loss of consciousness followed by recovery.

Chapter 9 | The Cardiovascular System 169

S p e c ia l P o p u la t io n s a t R is k Virtually no U.S. adults have optimal health behaviors for all seven goals. Women and African Americans are groups at especially high risk.

S c r e e n in g f o r C a r d io v a s c u la r R is k Fa c t o r s S t e p 1 : S c re e n fo r Glo b a l Ris k Fa c t o rs . Begin routine screening at age 20 for combined individual risk factors or “global” risk of CVD and any family history or premature heart disease, de ned as onset at age <55 years in rst-degree male relatives and <60 years in rst-degree female relatives. See the recommended screening intervals listed below.

A H A 2 0 2 0 G o a ls f o r Id e a l C a r d io v a s c u la r H e a lt h

1. Tot l cholesterol <2 g/dL (untre ted)

2. Le n body ss 3. BP <12 / <8 (untre ted) 4. F sting glucose <1 g/dL

(untre ted)

5. Abstinence fro s oking 6. Physic l ctivity go l: ≥15 in/wk

oder te intensity, ≥75 in/wk vigorous intensity, or co bin tion

7. He lthy diet

M a jo r C a r d io v a s c u la r R is k Fa c t o r s a n d S c r e e n in g F r e q u e n c y

Ris k Fa c t o r S c re e n in g Fre q u e n c y Go a l

F ily history of re ture CVD

U d te regul rly

Cig rette s oking At e ch visit Cess tion Poor diet At e ch visit I roved over ll e ting

ttern Physic l in ctivity At e ch visit 3 inutes oder te

intensity d ily Obesity, es eci lly

centr l di osity At e ch visit BMI 2 –25 kg/ 2; w ist

circu ference: ≤4 inches for en, ≤35 inches for wo en

Hy ertension At e ch visit <14 /9 for dults <6 ye rs, dults >6 ye rs with di betes or chronic kidney dise se; <15 /9 for ll other dults ≥6 ye rs

Dysli ide i s Every 5 ye rs if low risk Every 2 ye rs if strong risk

Initi te st tin ther y if eet- ing ACC/AHA guidelines

(continued )

170 Ba tes’ Pocket Guide to Phys ica l Examination and His tory Taking

M a jo r C a r d io v a s c u la r R is k Fa c t o r s a n d S c r e e n in g F r e q u e n c y (Continued )

S t e p 2 : Ca lc u la t e 10 -ye a r a n d Lo n g -Te rm CVD Ris k Us in g On lin e Ca lc u la t o r s . Use the CVD risk calculators to establish 10-year and lifetime risk for ages 40 to 79 years. The most recent ACC/AHA Cholesterol Guideline provides a new risk-assessment calculator.

B lo o d P r e s s u r e C la s s if ic a t io n f o r A d u lt s —J N C 7 , A m e r ic a n S o c ie t y o f H y p e r t e n s io n

Ca t e g o ry S ys t o lic (m m Hg ) Dia s t o lic (m m Hg )

Nor l <12 <8 Prehy ertension 12 –139 8 –89 St ge 1 hy ertension

Age ≥18 to <6 ye rs 14 –159 9 –99 Age ≥6 ye rsa 15 –159 9 –99

C V D R is k C a lc u la t o r s

● htt :/ / y. eric nhe rt .org/cvriskc lcul tor ● htt :/ /www. cc.org/ tools- nd- r ctice-su ort/ obile-resources/

fe tures/2 13- revention-guidelines- scvd-risk-esti tor?w_n v=S.

S t e p 3 : Tra ck In d ivid u a l Ris k Fa c t o rs —Hyp e r t e n s io n , Dia b e t e s , Dys lip id e m ia s , Me t a b o lic S yn d ro m e , S m o k in g , Fa m ily His t o ry, a n d Ob e s it y Hyp e r t e n s io n . The U.S. Preventive Services Task Force recommends screening all people age ≥18 years for high blood pressure. Use the blood pressure classification of the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure ( JNC 7).

Ris k Fa c t o r S c re e n in g Fre q u e n c y Go a l

Di betes Every 3 ye rs (if nor l) beginning t ge 45 ye rs; ore fre- quently t ny ge if risk f ctors

Prevent/del y di betes for those with HbA1c of 5.7–6.4%

Pulse At e ch visit Identify nd tre t tri l fibrill tion

Sources: see . 186.

(continued )

Chapter 9 | The Cardiovascular System 171

Dia b e t e s . Use the screening and diagnostic criteria below.

A m e r ic a n D ia b e t e s A s s o c ia t io n 2 0 1 5 : C la s s if ic a t io n a n d D ia g n o s is o f D ia b e t e s

S c re e n in g Crit e r ia Healthy adults with no risk factors: begin t ge 45 ye rs, re e t t 3-ye r interv ls

Adults with BMI ≥25 kg/m2 and addit ional risk factors: ● Physic l in ctivity ● First-degree rel tive with di betes ● Me bers of high-risk ethnic o ul tion—Afric n A eric n, His nic/

L tino A eric n, Asi n A eric n, P cific Isl nder ● Mothers of inf nts ≥4. 8 kg (9 lb) t birth or di gnosed with GDM ● Hy ertension ≥14 /9 Hg or on ther y for hy ertension ● HDL cholesterol <35 g/dL nd/or triglycerides >25 g/dL ● Wo en with olycystic ov ry syndro e ● HbA1c ≥5.7%, i ired glucose toler nce, or i ired f sting glucose on

revious testing ● Other conditions ssoci ted with insulin resist nce such s severe obesity,

c nthosis nigric ns ● History of CVD

Dia g n o s t ic Crit e r ia Dia b e t e s a P re d ia b e t e s

HbA1c ≥6.5% 5.7%–6.4% F sting l s glucose (on t le st 2

occ sions) ≥126 g/dL 1 –125 g/dL

(continued )

B lo o d P r e s s u r e C la s s if ic a t io n f o r A d u lt s —J N C 7 , A m e r ic a n S o c ie t y o f H y p e r t e n s io n (Continued )

aThe A eric n Society of Hy ertension r ises this cutoff to ge ≥8 ye rs. Sources: Weber MA, Schiffrin EL, White WB, et l. Clinic l r ctice guidelines for the n ge-

ent of hy ertension in the co unity: st te ent by the A eric n Society of Hy erten- sion nd the Intern tion l Society of Hy ertension. J Clin Hypertens. 2 14;16:14; Chob ni n AV, B kris GL, Bl ck HR, et l. The Seventh Re ort of the Joint N tion l Co ittee on Pre- vention, Detection, Ev lu tion, nd Tre t ent of High Blood Pressure—The JNC 7 Re ort. JAMA. 2 3;289:256 . Av il ble t htt :/ /www.nhlbi.nih.gov/ he lth- ro/guidelines/ current/ .

Ca t e g o ry S ys t o lic (m m Hg ) Dia s t o lic (m m Hg )

St ge 2 hy ertension ≥16 ≥1 If di betes or ren l dise se

(including ge ≥6 ye rs) <14 <9

172 Ba tes’ Pocket Guide to Phys ica l Examination and His tory Taking

Dys lip id e m ia s . LDL is the primary target of cholesterol-lowering therapy. The USPSTF has issued a grade A recommendation for routine lipid screening for all men of age >35 years and women >45 years who are at increased risk for CHD; and a grade B recommendation to screen for lipid disorders beginning at age 20 years for men and women who have diabe- tes, hypertension, obesity, tobacco use, noncoronary atherosclerosis, or family history of early CVD. In 2014 the ACC/AHA published “a guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovas- cular risk in adults.” Use the CVD risk calculator to establish 10-year risk and lifetime gender and race-speci c risks for CHD and stroke events to guide statin use for primary prevention (ACC/AHA Risk Calculator: http://tools. cardiosource.org/ASCVD-Risk-Estimator). The most recent ACC/AHA Cho- lesterol Guideline provides evidence-based recommendations for initiating statin therapy based on high, moderately high, and low risk level.

A m e r ic a n D ia b e t e s A s s o c ia t io n 2 0 1 5 : C la s s if ic a t io n a n d D ia g n o s is o f D ia b e t e s (Continued )

Dia g n o s t ic Crit e r ia Dia b e t e s a P re d ia b e t e s

2-Hour l s glucose (or l glucose toler nce test)

≥2 g/dL 14 –199 g/dL

R ndo glucose if cl ssic sy to s ≥2 g/dL

aIn the bsence of cl ssic sy to s, n bnor l test ust be re e ted to confir the di gnosis. However, if two different tests re both bnor l then no ddition l testing is necess ry.

Source: A eric n Di betes Associ tion. Cl ssific tion nd di gnosis of di betes. Diabetes Care. 2 15;38(Su l):S8.

A T P III G u id e lin e s : 1 0 -Y e a r R is k a n d LD L G o a ls

10 -Ye a r Ris k Ca t e g o ry

LDL Go a l (m g /d L)

Co n s id e r Dru g Th e ra p y if LDL (m g /d L)

High risk (>2 %) <1 Optional goal:

>1 (<1 : consider drug o tions, including

further 3 %–4 % reduction in LDL) Moder tely high risk

(1 %–2 %) <13 Optional goal:

≥13 1 –129: consider drug o tions to

chieve go l of <1 Moder te risk (<1 %) <13 ≥16 Lower risk ( –1 risk

f ctor) <16 >19

(16 –189: drug ther y optional)

Source: Ad ted fro N tion l Cholesterol Educ tion P nel Re ort. I lic tions of recent clinic l tri ls for the N tion l Cholesterol Educ tion Progr Adult Tre t ent P nel III Guidelines. Grundy SM, Clee n JI, Merz NB, et l., for the Coordin ting Co ittee of the N tion l Cholesterol Educ tion Progr . Circulation. 2 4;119:227–239.

Chapter 9 | The Cardiovascular System 173

Me t a b o lic S yn d ro m e . The metabolic syndrome consists of a cluster of risk factors which confer and increased risk of both CVD and diabetes. In 2009, the International Diabetes Association and other societies harmo- nized diagnostic criteria as the presence of three or more of the ve risk factors listed below.

Ot h e r Ris k Fa c t o r s : S m o k in g , Fa m ily His t o ry, a n d Ob e s it y. Smoking increases the risk of CHD and stroke by two- to fourfold compared to non- smokers or past smokers who quit >10 years previously; about 14% of U.S. cardiovascular deaths are attributed to smoking annually. Among adults, 13% report a family history of heart attack or angina before age 50 years. Along with a family history of premature revascularization, this risk factor is associ- ated with about a 50% increased lifetime risk for CHD and for CVD mortality. Obesity, or BMI over 30 kg/m2, contributed to 112,000 excess adult deaths compared to those of normal weight, and was associated with 13% of CVD deaths in 2004.

P r o m o t in g Lif e s t y le C h a n g e a n d R is k Fa c t o r M o d if ic a t io n Motivating behavior change is challenging, but it is an essential clinical skill for promoting risk factor reduction. Encourage the ACC/AHA recom- mendations below.

M e t a b o lic S y n d r o m e : 2 0 0 9 D ia g n o s t ic C r it e r ia

Waist circumference Men ≥1 2 c , wo en ≥88 c Fasting plasma glucose ≥1 g/dL or being tre ted for elev ted glucose HDL cholesterol Men <4 g/dL, wo en <5 g/dL, or being tre ted Triglycerides ≥15 g/dL, or being tre ted Blood pressure ≥13 /≥85, or being tre ted

Source: Alberti K, Eckel RH, Grundy SM, et l. H r onizing the et bolic syndro e: joint interi st te ent of the Intern l Di betes Feder tion T sk Force on E ide iology nd Prevention; N tion l He rt , Lung nd Blood Institute; A eric n He rt Associ tion; World He rt Feder tion; Intern l Atherosclerosis Society; nd Intern l Associ tion for the Study of Obesity. Circulation. 2 9;12 :162 –1645.

Lif e s t y le M o d if ic a t io n s f o r C a r d io v a s c u la r H e a lt h

● O ti l weight, or BMI of 18.5–24.9 kg/ 2

● Int ke of <6 g of sodiu chloride or 2.3 g of sodiu er d y ● Regul r erobic exercise such s brisk w lking three to four ti es week,

ver ging 4 inutes er session (continued )

174 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

Techniques of Examination

H e a r t R a t e a n d B lo o d P r e s s u r e

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

If not already done, count the radial or apical pulse.

Estimate systolic blood pressure by palpation and add 30 mm Hg. Use this sum as the target for further cuff in ations.

Measure blood pressure with a sphygmomanometer. If indicated, recheck it.

This step helps you to detect an auscultatory gap and avoid recording an inappropriately low systolic blood pressure.

Orthostatic (postural) hypotension within 3 minutes of position change from supine to standing is SBP↓ ≥20 mm Hg; HR↑ ≥20 beats/min.

Elevated JVP in right-sided heart failure; decreased JVP in hypovolemia from dehydration or gastrointestinal bleeding.

Lif e s t y le M o d if ic a t io n s f o r C a r d io v a s c u la r H e a lt h (Continued )

● Moder te lcohol consu tion er d y of ≤2 drinks for en nd ≤1 drink for wo en (2 drinks = 1 oz eth nol, 24 oz beer, 1 oz wine, or 2–3 oz whiskey)

Diet rich in fruits, veget bles, whole gr ins, nd low-f t d iry roducts with reduced int ke of s tur ted nd tot l f t , sweets, nd red e ts.

Source: Eckel RH, J kicic JM, Ard JD, et l. 2 13 AHA/ACC guideline on lifestyle n ge ent to reduce c rdiov scul r risk: re ort of the A eric n College of C rdiology/A eric n He rt Associ tion T sk Force on Pr ctice Guidelines. Circulation. 2 14;129:S76.

J u g u la r V e in s Jugular venous pulsations: In the right internal jugular vein identify their highest point in the neck. Start with head of the bed at 30 degrees; adjust the head of the bed as necessary, giving consideration to volume status.

Jugular venous pressure ( JVP)— Measure the vertical distance between this highest point and the sternal angle, normally <3 to 4 cm (Fig. 9-1).

Chapter 9 | The Cardiovascular System 175

Study the waves of venous pulsa- tion. Note the a wave of atrial con- traction and the v wave of venous lling.

C a r o t id P u ls e Palpate the amplitude and contour of the carotid upstroke.

P u ls u s Alt e rn a n s . Palpate for alteration in carotid pulse ampli- tude. Lower pressure of blood pressure cuff slowly to systolic level while you listen with your stetho- scope over the brachial artery.

P a ra d o x ic a l P u ls e . Lower pressure of BP cuff slowly and note two pressure levels: (1) where Korotkoff sounds are rst heard and (2) where they rst persist through the respiratory cycle. These levels are normally not more than 3 to 4 mm Hg apart.

Listen for bruits.

Figure 9-1 Measure the he ight of the JVP.

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Abnormally prominent a waves in tricus- pid stenosis, pulmonary hypertension, and pulmonic stenosis; absent a waves in atrial fibrillation. Increased v waves in tricuspid regurgitation, atrial septal defects, and constrictive pericarditis.

A delayed upstroke in aortic stenosis; a bounding upstroke in aortic insufficiency.

Alternating amplitude of pulse or sudden doubling of Korotkoff sounds indicates pulsus alternans—a sign of left ventricular heart failure.

A drop of >10 mm Hg during inspiration signifies a paradoxical pulse. Consider obstructive pulmonary disease, asthma, COPD, pericardial tamponade, or con- strictive pericarditis.

Carotid bruits suggest atherosclerotic narrowing and increase stroke risk.

176 Ba tes ’ Pocke t Guide to Physica l Examina tion and His tory Taking

T h e H e a r t

EXAMINATION TECHNIQUES

In s p e c t io n a n d Pa lp a t io n . Inspect and palpate the anterior chest for heaves, lifts, or thrills.

Inspect and palpate the apical impulse (Fig. 9-2). Turn patient to left as necessary. Note:

Figure 9-2 Palpate the apical impulse .

Displaced to left in pregnancy.

Increased diameter, amplitude, and duration in left ventricular dilatation from heart failure or ischemic cardiomyopathy.

S e q u e n c e o f t h e C a r d ia c E x a m in a t io n

Pa t ie n t Po s it io n Exa m in a t io n

Supine, with the head elevated 30 degrees

After ex ining the JVP nd c rotid ulse, ins ect nd l te the recordiu : the 2nd right nd left inters ces; the right ventricle; nd the left ventricle, including the ic l i ulse (di eter, loc tion, litude, dur tion).

Left lateral decubitus

P l te the ic l i ulse to ssess its di eter. Listen t the ex with the bell of the stethosco e.

Supine, with the head elevated 30 degrees

Listen t the six re s with the diaphragm then the bell: the 2nd right nd left inters ces, down the left stern l border to the 4th nd 5th inters ces, nd cross to the ex (see . 177). As indic ted, listen t the lower right stern l border for right-sided ur urs nd sounds, often ccentu ted with ins ir tion, with the diaphragm nd bell.

Sitting, leaning forward, after full exhalation

Listen down the left stern l border nd t the ex with the diaphragm for the soft decrescendo ur ur of ortic insufficiency.

■ Location of impulse

■ Diameter

Chapter 9 | The Cardiovascular System 177

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

■ Amplitude—usually tapping

■ Duration

Feel for a right ventricular impulse in left parasternal and epigastric areas.

Palpate left and right second inter- spaces close to sternum. Note any thrills in these areas.

Au s c u lt a t io n . Listen to the heart by “inching” your stethoscope from the base to the apex (or apex to base) in the areas illustrated in Figure 9-3.

Sustained in left ventricular hypertrophy; diffuse in CHF.

Prominent impulses suggest right ven- tricular enlargement.

Pulsations of great vessels; accentuated S2; thrills of aortic or pulmonic stenosis.

Left ventricular area—Apex

Right 2nd inters pace— Aortic a rea

Left 2nd inters pace— Pulmonic a rea

Epigas tric (subxiphoid)

Right ventricular area— Left s te rna l borde r

Figure 9-3 Auscultate the heart from the base to the apex.

Use the diaphragm to detect the relatively high-pitched sounds like S1, S2.

Use the bell for low-pitched sounds at the lower left sternal border and apex.

Listen at each area for:

■ S1

■ S2. Is splitting normal in left 2nd and 3rd interspaces?

■ Extra sounds in systole

■ Extra sounds in diastole

Also murmurs of aortic and mitral regur- gitation, pericardial friction rubs.

S3, S4, murmur of mitral stenosis.

See Table 9-1, Heart Sounds, p. 181; Table 9-2, Variations in the First Heart Sound—S1, p. 182; Table 9-3, Variations in the Second Heart Sound—S2 During Inspiration and Expiration, pp. 183–184.

Physiologic (inspiratory) or pathologic (expiratory) splitting

Systolic clicks

S3, S4

178 Ba tes’ Pocket Guide to Phys ica l Examination and His tory Taking

■ Systolic murmurs

■ Diastolic murmurs

Use two maneuvers as needed to help identify the murmurs of mitral stenosis and aortic regurgitation.

Listen at the apex with patient turned toward left side for low- pitched sounds (Fig. 9-4).

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Midsystolic, pansystolic, late systolic murmurs

Early, mid-, or late diastolic murmurs

See Table 9-4, Heart Murmurs, p. 185.

Figure 9-5 Lis ten at the lower le ft s te rnal border for aortic insufficiency.

Diastolic decrescendo murmur of aortic regurgitation.

As s e s s in g a n d De s c rib in g Mu rm u rs . Identify, if murmurs are present, their:

■ Timing in the cardiac cycle (systole, diastole). It is helpful to

Figure 9-4 Lis ten at the apex for low- pitched sounds .

Left-sided S3, and diastolic murmur of mitral stenosis.

Listen down the left sternal border to the apex as patient sits, leaning forward, with breath held after exhalation (Fig. 9-5).

Chapter 9 | The Cardiovascular System 179

Plateau, crescendo, decrescendo

A crescendo–decrescendo murmur first rises in intensity, then falls (e.g., aortic stenosis).

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

A plateau murmur has the same intensity throughout (e.g., mitral regurgitation).

A crescendo murmur grows louder (e.g., mitral stenosis).

A decrescendo murmur grows softer (e.g., aortic regurgitation).

Murmurs loudest at the base are often aortic; at the apex, they are often mitral.

High, medium, low

Blowing, harsh, musical, rumbling

G r a d a t io n s o f M u r m u r s

Gra d e De s c r ip t io n

Grade 1 Very f int , he rd only fter listener h s “tuned in”; y not be he rd in ll ositions

Grade 2 Quiet, but he rd i edi tely fter l cing the stethosco e on the chest Grade 3 Moder tely loud Grade 4 Loud, with palpable thrill Grade 5 Very loud, with thrill. M y be he rd when the stethosco e is rtly off

the chest Grade 6 Very loud, with thrill. M y be he rd with stethosco e entirely off the chest

palpate the carotid upstroke while listening to any murmur—mur- murs occurring simultaneously with the upstroke are systolic.

■ Shape

S 2S 1

S 2 S 1

■ Location of maximal intensity

■ Radiation

■ Pitch

■ Quality

■ Intensity on a six-point scale (see “Gradations of Murmurs” below)

180 Ba tes’ Pocke t Guide to Physica l Examina tion and His tory Taking

S p e c ia l T e c h n iq u e s Aid s t o Id e n t ify S ys t o lic Mu rm u rs

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Va ls a lva Ma n e u ve r. Ask patient to strain down.

In suspected mitral valve prolapse (MVP), listen to the timing of click and murmur.

To distinguish aortic stenosis (AS) from hypertrophic cardiomyopathy (HCM), listen to the intensity of the murmur.

/ S q u a t t in g a n d S t a n d in g . In suspected MVP, listen for the click and murmur in both positions.

Try to distinguish AS from HCM by listening to the murmur in both positions.

Ventricular filling decreases, the systolic click of MVP is earlier, and the murmur lengthens.

In AS, the murmur decreases; in HCM, it often increases.

Squatting increases ventricular filling and delays the click and murmur. Standing reverses the changes.

Squatting increases murmur of AS and decreases murmur of HCM. Standing reverses the changes.

Recording Your Findings

R e c o r d in g t h e C a r d io v a s c u la r E x a m in a t io n

“The jugul r venous ulse is 3 c bove the stern l ngle with the he d of the bed elev ted to 3 degrees. C rotid u strokes re brisk, without bruits. The oint of xi l i ulse (PMI) is t ing, 7 c l ter l to the idstern l line in the 5th intercost l s ce. Cris S1 nd S2. At the b se, S2 is gre ter th n S1 nd hysiologic lly s lit , with A2 > P2. At the ex, S1 is gre ter th n S2 nd const nt . No ur urs or extr sounds.” OR “The JVP is 5 c bove the stern l ngle with the he d of the bed elev ted to 5 degrees. C rotid u strokes re brisk; bruit is he rd over the left c rotid rtery. The PMI is diffuse, 3 c in di eter, l ted t the nterior xill ry line in the 5th nd 6th intercost l s ces. S1 nd S2 re soft . S3 resent t the ex. High- itched, h rsh 2/6 holosystolic ur ur best he rd t the ex, r di ting to the xill . No S4 or di stolic ur urs.” (These findings suggest CHF with possible left carotid stenosis and mitral regurgitation.)

Chapter 9 | The Cardiovascular System 181

Aids to Interpretation

Systole Dias tole

S 1 S 3S 2OS S 1E1 S 4

Fin d in g P o s s ib le Ca u s e s

S 1 a c c e n t u a t e d Tachycardia, states of high cardiac output; mitral stenosis

S 1 d im in is h e d First-degree heart block; reduced left ventricular contractility; immobile mitral valve, as in mitral regurgitation

S ys t o lic c lick (s ) Mitral valve prolapse (as in E1 above)

S 2 a c c e n t u a t e d in r ig h t 2 n d in t e r s p a c e

Systemic hypertension, dilated aortic root

S 2 d im in is h e d o r a b s e n t in r ig h t 2 n d in t e r s p a c e

Immobile aortic valve, as in calcific aortic stenosis

P 2 a c c e n t u a t e d Pulmonary hypertension, dilated pulmonary artery, atrial septal defect

P 2 d im in is h e d o r a b s e n t Aging, pulmonic stenosis

Op e n in g s n a p Mitral stenosis

S 3 Physiologic (usually in children and young adults); volume overload of ventricle, as in mitral regurgitation or heart failure

S 4 Excellent physical conditioning (trained athletes); resistance to ventricular filling because of decreased compliance, left ventricular hypertrophy from pressure overload, as in hypertensive heart disease or aortic stenosis

He a r t So u n d sTable 9-1

182 Ba tes’ Pocke t Guide to Physica l Examina tion and His tory Taking

No rm a l Va r ia t io n s

S 1 S 2

S1 is softer than S2 at the base (right and left 2nd interspaces).

S 1 S 2

S1 is often but not always louder than S2 at the apex.

Ac c e n t u a t e d S 1

S 1 S 2

Occurs in (1) tachycardia, rhythms with a short PR interval, and high cardiac output states (e.g., exercise, anemia, hyperthyroidism), and (2) mitral stenosis.

Dim in is h e d S 1

S 1 S 2

Occurs in first-degree heart block, calcified mitral valve of mitral regurgitation, and ↓ left ventricular contractility in heart failure or coronary heart disease.

Va ry in g S 1

S 1 S 2 S 1 S 2

S1 varies in complete heart block and any totally irregular rhythm (e.g., atrial fibrillation).

S p lit S 1

S 1 S 2

Normally heard along the lower left sternal border if audible tricuspid component. If S1 sounds split at apex, consider an S4, an aortic ejection sound, an early systolic click, right bundle branch block, and premature ventricular contractions.

Va ria t io n s in t h e Fir s t He a r t So u n d —S 1Table 9-2

Chapter 9 | The Cardiovascular System 183

P h ys io lo g ic S p lit t in g

S 1 S 2S 1 S 2

A2 P 2

Heard in the 2nd or 3rd left interspace: the pulmonic component of S2 is usually too faint to be heard at the apex or aortic area, where S2 is single and derived from aortic valve closure alone. Accentuated by inspiration; usually disappears on exertion.

P a t h o lo g ic S p lit t in g

S 1 S 2S 1 S 2

Wide splitting of S2 persists throughout respiration; arises from delayed closure of the pulmonic valve (e.g., by pulmonic stenosis or right bundle branch block); also from early closure of the aortic valve, as in mitral regurgitation.

Fixe d S p lit t in g

S 1 S 2S 1 S 2

Does not vary with respiration, as in atrial septal defect, right ventricular failure.

Va ria t io n s in t h e Se c o n d He a r t So u n d — S 2 Du rin g In s p ira t io n a n d Exp ira t io n

Table 9-3

(table continues on page 184)

184 Ba tes’ Pocke t Guide to Physica l Examina tion and His tory Taking

Va ria t io n s in t h e Se c o n d He a rt So u n d — S2 During Inspirat ion and Expirat ion (continued )

Table 9-3

P a ra d o x ic a l o r Re ve r s e d S p lit t in g

S 1 S 2 S 1 S 2

P 2 A2

Appears on expiration and disappears on inspiration. Closure of the aortic valve is abnormally delayed, so A2 follows P2 on expiration, as in left bundle branch block.

Mo re o n A 2 a n d P 2

Increased Intensity of A2, 2nd Right Interspace (where only A2 can usually be heard) occurs in systemic hypertension because of the increased ejection pressure. It also occurs when the aortic root is dilated, probably because the aortic valve is then closer to the chest wall.

Decreased or Absent A2, 2nd Right Interspace is noted in calcific aortic stenosis because of immobility of the valve. If A2 is inaudible, no splitting is heard.

Increased Intensity of P2. When P2 is equal to or louder than A2, pulmonary hypertension may be suspected. Other causes include a dilated pulmonary artery and an atrial septal defect. When a split S2 is heard widely, even at the apex and the right base, P2 is accentuated.

Decreased or Absent P2 is most commonly due to the increased anteroposterior diameter of the chest associated with aging. It can also result from pulmonic stenosis. If P2 is inaudible, no splitting is heard.

Chapter 9 | The Cardiovascular System 185

Lik e ly Ca u s e s

Mid s ys t o lic

S 1 S 2

Innocent murmurs (no valve abnormality) Physiologic murmurs (from ↑ flow across a semilunar valve, as in pregnancy, fever, anemia) Aortic stenosis Murmurs that mimic aortic stenosis— aortic sclerosis, bicuspid aortic valve, dilated aorta, and pathologically ↑ systolic flow across aortic valve Hypertrophic cardiomyopathy Pulmonic stenosis

P a n s ys t o lic

S 1 S 2

Mitral regurgitation Tricuspid regurgitation Ventricular septal defect

La t e S ys t o lic

S 1 S 2C

Mitral valve prolapse, often with click (C)

Ea r ly Dia s t o lic

S 1 S 1S 2

Aortic regurgitation

Mid d ia s t o lic a n d P re s ys t o lic

S 1 S 1S 2 OS

Mitral stenosis—note opening snap (OS)

Co n t in u o u s Mu rm u r s a n d S o u n d s

S 1 S 2 S 1

Patent ductus arteriosus—harsh, machinery-like Pericardial friction rub—a scratchy sound with 1–3 components Venous hum—continuous, above midclavicles, loudest in diastole

He a r t Mu rm u rsTable 9-4

186 Ba tes’ Pocke t Guide to Physica l Examina tion and His tory Taking

Sources: Ad ted fro : Goff DC, Jr., Lloyd-Jones DM, Bennett G, et l. 2 13 ACC/AHA guide- line on the ssess ent of c rdiov scul r risk: re ort of the A eric n College of C rdiol- ogy/A eric n He rt Associ tion T sk Force on Pr ctice Guidelines. J Am Coll Cardiol. 2 14;63(25 Pt B):2935; Stone NJ, Robinson JG, Lichtenstein AH, et l. 2 13 ACC/AHA guide- line on the tre t ent of blood cholesterol to reduce therosclerotic c rdiov scul r risk in dults: re ort of the A eric n College of C rdiology/A eric n He rt Associ tion T sk Force on Pr ctice Guidelines. Circulation. 2 14;129:S1; J es PA, O ril S, C rter BL, et l. 2 14 evidence-b sed guideline for the n ge ent of high blood ressure in dults: re ort fro the nel e bers ointed to the Eighth Joint N tion l Co it tee (JNC 8). JAMA. 2 14;311:5 7; Meschi JF, Bushnell C, Boden-Alb l B, et l. Guidelines for the ri- ry revention of stroke: st te ent for he lthc re rofession ls fro the A eric n He rt Associ tion/A eric n Stroke Associ tion. Stroke. 2 14;45:3754; Fl ck JM, Sic DA, B kris G, et l. M n ge ent of high blood ressure in Bl cks: n u d te of the Intern - tion l Society on Hy ertension in Bl cks consensus st te ent . Hypertension. 2 1 ;56:78 ; A eric n Di betes A. Executive su ry: St nd rds of edic l c re in di betes—2 14. Diabetes Care. 2 14;37 Su l 1:S5.

S o u rc e s fo r Ma jo r Ca rd io va s c u la r Ris k Fa c t o r s a n d S c re e n in g Fre q u e n c y Bo x o n p . 17 0

187

C H A P T E R

10The Breasts and Axillae

The Health History

Ask, “Do you examine your breasts?” . . . “How often?” Ask about any discomfort, pain, or lumps in the breasts. Also ask about any discharge from the nipples, change in breast contour, dimpling, swelling, or puckering of the skin over the breasts.

Pa lp a b le Ma s s e s o f t h e Bre a s t . Breast masses show marked variation in etiology, from broadenomas and cysts seen in younger women, to abscess or mastitis, to primary breast cancer. All breast masses warrant careful evalu- ation, and de nitive diagnostic measures should be pursued.

C o m m o n o r C o n c e r n in g S y m p t o m s

● Bre st lu or ss ● Bre st in or disco fort ● Ni le disch rge

Health Promotion and Counseling: Evidence and Recommendations

Im p o r t a n t T o p ic s f o r H e a lt h P r o m o t io n a n d C o u n s e lin g

● P l ble sses of the bre st ● Assessing risk of bre st c ncer ● Bre st c ncer screening

188 Ba tes’ Pocke t Guide to Physica l Examina tion and His tory Taking

As s e s s in g Ris k o f Bre a s t Ca n c e r. About 50% of affected women have no known predisposing risk factors; however, selected risk factors are well established.

P a lp a b le M a s s e s o f t h e B r e a s t

Ag e Co m m o n Le s io n Ch a ra c t e r is t ic s

15–25 Fibro deno Usu lly s ooth, rubbery, round, obile, nontender

25–5 Cysts Usu lly soft to fir , round, obile; often tender

Fibrocystic ch nges Nodul r, ro e-like C ncer Irregul r, fir , y be obile or

fixed to surrounding tissue Over 5 C ncer until roven oth-

erwise As bove

Pregn ncy/ l ct tion

L ct ting deno s, cysts, stitis, nd c ncer

As bove

Ad ted fro Schultz MZ, W rd BA, Reiss M. Bre st dise ses. In: Noble J, Greene HL, Levinson W, et l. (eds). Primary Care Medicine. 2nd ed. St. Louis: MO; 1996; Venet L, Str x P, Venet W, et l. Adequ cies nd in dequ cies of bre st ex in tions by hysici ns in ss screenings. Cancer. 1971;28(6):1546–1551.

B r e a s t C a n c e r R is k F a c t o r s

Nonmodifiable risk factors: ● Age ( ost i ort nt) ● F ily history of bre st nd ov ri n

c ncers ● Inherited genetic ut tions ● Person l history of bre st c ncer or

lobul r c rcino in situ ● High levels of endogenous hor ones ● Bre st tissue density ● Prolifer tive lesions with ty i on

bre st bio sy ● Dur tion of uno osed estrogen

ex osure rel ted to e rly en rche ● Age of first full-ter regn ncy ● L te eno use

● Bre st density on ogr s (co nds incre sing i ort nce s strong inde endent risk f ctor)

● History of r di tion to the chest ● History of diethylstilbestrol (DES)

ex osure Modifiable risk factors: ● Bre stfeeding for <1 ye r ● Post eno us l obesity ● Use of hor one re l ce ent

ther y (HRT) ● Cig rette s oking ● Alcohol ingestion ● Physic l in ctivity ● Ty e of contr ce tion

See also Table 10-1, Breast Cancer in Women: Factors That Increase Relative Risk, p. 196.

Use the Breast Cancer Risk Assessment Tool of the National Cancer Insti- tute (http://www.cancer.gov/bcrisktool) or other available clinical models, such as the Gail model, to individualize risk factor assessment for your patients. Ask women beginning in their 20s about any family history of breast or ovarian cancer, or both, on the maternal or paternal side, to help

Chapter 10 | The Breasts and Axillae 189

assess risk of BRCA1 or BRCA2 gene mutation. (See http://bcb.dfci.harvard. edu/bayesmendel/software.php.)

Bre a s t Ca n c e r S c re e n in g . Mammography combined with the CBE are the most common screening modalities; however, recommendations from professional groups vary about how to screen, when to start screening, and screening intervals, as shown in the table below. Clinicians should be well informed as they counsel individual patients, particularly as more evidence emerges to guide risk-based screening.

B r e a s t C a n c e r S c r e e n in g R e c o m m e n d a t io n s

Ma m m o g ra p hy Clin ic a l Bre a s t Exa m in a t io n

Bre a s t S e lf- Exa m in a t io n

U.S. Preventive Services T sk Force— ver ge-risk wo en (2 16)

● 5 –74 ye rs— bienni lly

● <5 ye rs— individu lize screening b sed on tient-s ecific f ctors

● ≥75 ye rs—insuffi- cient evidence to reco end

≥4 ye rs— insufficient evidence to ssess ddi- tion l benefits nd h r s of CBE beyond screening ogr hy

Reco ends g inst te ching BSE

A eric n C ncer Society— ver ge- risk wo en (2 15)

● 4 –45 ye rs— o tion l nnu l screening

● 45–54 ye rs— nnu l screening

● ≥55 ye rs—bienni l screening with o tion to continue nnu l screens

● Continue screening if good he lth nd life ex ect ncy ≥1 ye rs

Not reco ended due to l ck of evidence showing cle r benefit

A eric n College of Obstetrici ns nd Gynecologists

≥4 ye rs— nnu lly ● 2 –39 ye rs— every 1–3 ye rs

● ≥4 ye rs— nnu lly

Encour ges bre st self- w reness

Sources: U.S. Preventive Services T sk Force. Bre st C ncer: Screening. J nu ry 2 16. At htt :/ /www.us reventiveservicest skforce.org/ P ge/ Docu ent/ U d teSu ryFin l/ bre st-c ncer-screening1?ds=1&s=BREAST CANCER. Accessed 2.11.16; Oeffinger KC, Fonth ETH, Etzioni R, et l. Bre st c ncer screening for wo en t ver ge risk 2 15 guideline u d te fro the A eric n C ncer Society. JAMA. 2 15;314:15 . See lso htt :/ / www.c ncer.org/c ncer/ bre stc ncer/ oreinfor tion/ bre stc ncere rlydetection/ bre st-c ncer-e rly-detection- cs-recs. Accessed Nove ber 14, 2 15.

A eric n College of Obstetrici ns nd Gynecologists. Pr ctice bulletin No. 122: bre st c ncer screening. Obstet Gynecol. 2 11;118(2 t 1):372.

190 Ba tes’ Pocke t Guide to Physica l Examina tion and His tory Taking

T h e Fe m a le B r e a s t Inspect the breasts in four posi- tions, identifying the quadrant where changes appear (Figs. 10-1 through 10-5).

Techniques of Examination EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Ta il of Spence

Upper oute r

quadrant

Lower oute r

quadrant

Upper inner quadrant

Lower inner quadrant

Figure 10-1 Breas t quadrants .

Figure 10-2 Inspect with arms at s ides .

Figure 10-3 Inspect with arms over head.

Chapter 10 | The Breasts and Axillae 191

Note:

■ Size and symmetry

■ Contour

■ Appearance of the skin

Inspect the nipples.

■ Compare their size, shape, and direction of pointing.

■ Note any rashes, ulcerations, or discharge.

Palpate the breasts, including augmented breasts. Breast tissue should be attened and the patient supine.

Use a vertical strip pattern (cur- rently the best validated technique) or a circular or wedge pattern. Pal- pate in small, concentric circles.

For the lateral portion of the breast, ask the patient to roll onto the opposite hip, place her hand on her forehead, but keep shoulders pressed against the bed or examin- ing table (Fig. 10-6).

Figure 10-4 Inspect with hands pressed agains t hips . Figure 10-5 Inspect while leaning

forward.

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

See Table 10-2, Visible Signs of Breast Cancer, pp. 197–198.

Flattening, dimpling suspicious for malignancy

Edema (peau d’orange) in breast cancer

Inversion, retraction, deviation

Paget disease of the nipple, galactorrhea

Figure 10-6 Vertical s trip patte rn— late ral breas t.

192 Ba tes’ Pocke t Guide to Physica l Examina tion and His tory Taking

For the medial portion of the breast, ask the patient to lie with her shoulders at against the bed or examining table, place her hand at her neck, and lift up her elbow until it is even with her shoulder (Fig. 10-7).

Palpate a rectangular area extend- ing from the clavicle to the infra- mammary fold, and from the mid- sternal line to the posterior axillary line and well into the axilla for the tail of Spence.

Note:

■ Consistency

■ Tenderness

■ Nodules. If present, note location, size, shape, consistency, delimitation, tenderness, and mobility.

Palpate each nipple.

Compress the areola in a spoke- like pattern around the nipple. Watch for discharge.

Palpate and inspect along the incision lines of mastectomy.

/ T h e M a le B r e a s t Inspect and palpate the nipple and areola.

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Figure 10-7 Vertical s trip patte rn— medial breas t.

Physiologic nodularity

Infection, premenstrual tenderness

Cyst, fibroadenoma, cancer

Thickening in cancer

Type and source of discharge may be identified.

Local recurrences of breast cancer

Gynecomastia, mass suspicious for cancer, fat

Chapter 10 | The Breasts and Axillae 193

A x illa e Inspect for rashes, infection, and pigmentation.

Palpate the axillary nodes, including the central, pectoral, lateral, and subscapular groups (Figs. 10-8).

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Hidradenitis suppurativa, acanthosis nigricans

Figure 10-8 Palpate the le ft axilla.

Lymphadenopathy

S p e c ia l T e c h n iq u e / In s t ru c t io n s fo r t h e

Bre a s t S e lf-Exa m in a t io n . For interested or high-risk patients, instruct the patient about how to perform the BSE.

194 Ba tes’ Pocke t Guide to Physica l Examina tion and His tory Taking

P a t ie n t In s t r u c t io n s f o r t h e B r e a s t S e lf -E x a m in a t io n (B S E )—A m e r ic a n C a n c e r S o c ie t y

Lyin g S u p in e

1. Lie down with illow under your right shoulder. Pl ce your right r behind your he d.

2. Use the finger ds of the three iddle fingers on your left h nd to feel for lu s in the right bre st . The finger ds re the to third of e ch finger. M ke overl ing, di e-sized circul r otions to feel the bre st tissue.

3. A ly three levels of ressure in e ch s ot: light, ediu , nd fir , using fir er ressure for tissue closest to the chest nd ribs. A fir ridge in the lower curve of e ch bre st is nor l. If you’re not sure how h rd to ress, t lk with your he lth c re rovider, or try to co y the w y the doctor or nurse does it .

4. Ex ine the bre st in n u - nd- down or “stri ” ttern. St rt t n i gin ry str ight line under the r , oving u nd down cross the entire bre st , fro the ribs to the coll rbone, until you re ch the iddle of the chest bone (the ster- nu ). Re e ber how your bre st feels fro onth to onth.

5. Re e t the ex in tion on your left bre st , using the finger ds of the right h nd.

6. If you find ny sses, lu s, or skin ch nges, see your clinici n right w y.

(continued )

Chapter 10 | The Breasts and Axillae 195

S t a n d in g

1. While st nding in front of irror with your h nds ressing fir ly down on your hi s, look t your bre sts for ny ch nges of size, sh e, contour, or di ling, or red- ness or sc liness of the ni le or bre st skin. (The ressing down on the hi s osition contr cts the chest w ll uscles nd enh nces ny bre st ch nges.)

2. Ex ine e ch under r while sit- ting u or st nding nd with your r only slightly r ised so you c n e sily feel in this re . R ising your r str ight u tightens the tissue in this re nd kes it h rder to ex ine.

P a t ie n t In s t r u c t io n s f o r t h e B r e a s t S e lf -E x a m in a t io n (B S E )—A m e r ic a n C a n c e r S o c ie t y (Continued)

Ad ted fro the A eric n C ncer Society. A eric n C ncer Society. Bre st w reness nd self-ex . U d ted A ril 9, 2 15. Av il ble t htt :/ /www.c ncer.org/c ncer/ bre stc ncer/ oreinfor t ion/ bre stc ncere rlydetection/ bre st-c ncer-e rly-detection- cs-recs-bse. Accessed M y 7, 2 15.

Recording Your Findings

R e c o r d in g t h e B r e a s t s a n d A x illa e E x a m in a t io n

“Bre sts sy etric nd s ooth, without sses. Ni les without disch rge.” (Axill ry deno thy usu lly included fter Neck in section on Ly h Nodes.) OR “Bre sts endulous with diffuse fibrocystic ch nges. Single fir 1 × 1 c ss, obile nd nontender, with overlying e u d’or nge e r nce in right bre st , u er outer qu dr nt t 11 o’clock, 2 c fro the ni le.” (These findings suggest possible breast cancer.)

196 Ba tes’ Pocke t Guide to Physica l Examina tion and His tory Taking

Aids to Interpretation

Re la t ive Ris k Fa c t o r

>4.0 ■ Age (65+ vs. <65 years, although risk increases across all ages until age 80)

■ Biopsy-confirmed atypical hyperplasia ■ Certain inherited genetic mutations for breast cancer

(BRCA1 and/or BRCA2) ■ Ductal carcinoma in situ ■ Lobular carcinoma in situ ■ Personal history of early-onset (<40 years) breast cancer ■ Two or more first-degree relatives with breast cancer diagnosed at

an early age

2.1–4.0 ■ High endogenous estrogen or testosterone levels (postmenopausal) ■ High-dose radiation to chest ■ Mammographically extremely dense (>50%) breasts compared to

less dense (11%–25%) ■ One first-degree relative with breast cancer

1.1–2.0 ■ Alcohol consumption ■ Ashkenazi Jewish heritage ■ Diethylstilbestrol exposure ■ Early menarche (<12 years) ■ Height ( >5 feet 3 inches) ■ High socioeconomic status ■ Late age at first full-term pregnancy (>30 years) ■ Late menopause (>55 years) ■ Mammographically dense (26%–50%) breasts compared to less

dense (11%–25%) ■ Non-atypical ductal hyperplasia or fibroadenoma ■ Never breastfed a child ■ No full-term pregnancies ■ Obesity (postmenopausal)/adult weight gain ■ Personal history of breast cancer (40+ years) ■ Personal history of endometrium, ovary, or colon cancer ■ Recent and long-term use of menopausal hormone therapy

containing estrogen and progestin ■ Recent oral contraceptive use

Fa c t o rs Th a t In c re a s e t h e Re la t ive Ris k fo r Bre a s t Ca n c e r in Wo m e n

Table 10-1

Source: American Cancer Society. Facts & Figures 2015–2016. Atlanta: American Cancer Society Inc, 2015. Available at http://www.cancer.org/acs/groups/content/@research/documents/ document/acspc-046381.pdf. Accessed May 1, 2015.

Chapter 10 | The Breasts and Axillae 197

Re t ra c t io n S ig n s

Fibrosis from breast cancer, fat necrosis, and mammary duct ectasia can produce the three retraction signs illustrated here. Cancer

Dimpling

Retracted nipple

Skin Dim pling

Abnorm al Contours Look for any variation in the normal convexity of each breast, and compare one side with the other.

Nipp le Re traction and Devia tion A retracted nipple is flattened or pulled inward and may be broadened and thickened. Typically the nipple deviates toward the underlying cancer.

Vis ib le S ig n s o f Bre a s t Ca n c e rTable 10-2

(table continues on page 198)

198 Ba tes’ Pocke t Guide to Physica l Examina tion and His tory Taking

Ed e m a o f t h e S k in

From lymphatic blockade, appearing as thickened skin with enlarged pores—the so-called peau d’orange (orange peel) sign.

P a g e t Dis e a s e o f t h e Nip p le

An uncommon form of breast cancer that usually starts as a scaly, eczema-like lesion that may weep, crust, or erode. A breast mass may be present. Suspect Paget disease in any persisting dermatitis of the nipple and areola.

Dermatitis of a reola

Eros ion of nipple

Vis ib le S ig n s o f Bre a s t Ca n c e r (continued )Table 10-2

199

C H A P T E R

11 The Abdomen

The Health History

M e c h a n is m s o f A b d o m in a l P a in

C o m m o n o r C o n c e r n in g S y m p t o m s

Ga s t ro in t e s t in a l Dis o rd e r s Ur in a ry a n d Re n a l Dis o rd e r s ● Abdo in l in, cute nd chronic ● Indigestion, n use , vo iting

including blood (hematemesis), loss of etite (anorexia), e rly s tiety

● Difficulty sw llowing (dysphagia) nd/or inful sw llowing (odynophagia)

● Ch nge in bowel function ● Di rrhe , consti tion ● J undice

● Su r ubic in ● Difficulty urin ting (dysuria),

urgency, or frequency ● Hesit ncy, decre sed stre in

les ● Excessive urin tion (polyuria) or

excess urin tion t night (nocturia) ● Urin ry incontinence ● Blood in the urine (hematuria) ● Fl nk in nd ureter l colic

Be familiar with three broad categories:

Visceral pain—occurs when hol- low abdominal organs such as the intestine or biliary tree contract unusually forcefully or are dis- tended or stretched.

■ May be dif cult to localize

■ Varies in quality; may be gnaw- ing, burning, cramping, or aching

■ When severe, may be associated with sweating, pallor, nausea, vomiting, restlessness.

Visceral pain in the right upper quadrant (RUQ) from liver distention against its capsule from the various causes of hepatitis, including alcoholic hepatitis

200 Ba tes ’ Pocke t Guide to Physica l Examina tion and His tory Taking

Parietal pain—from in ammation of the parietal peritoneum.

■ Steady, aching

■ Usually more severe

■ Usually more precisely localized over the involved structure than visceral pain

Referred pain—occurs in more distant sites innervated at approxi- mately the same spinal levels as the disordered structure.

Pain from the chest, spine, or pelvis may be referred to the abdomen.

Visceral periumbilical pain in early acute appendicitis from distention of inflamed appendix gradually changes to parietal pain in the right lower quadrant (RLQ) from inflammation of the adjacent parietal peritoneum.

Pain of duodenal or pancreatic origin may be referred to the back; pain from the biliary tree—to the right shoulder or right posterior chest.

Pain from pleurisy or acute myocardial infarction may be referred to the epigas- tric area.

T h e G a s t r o in t e s t in a l T r a c t Ask patients to describe the pain in their own words, especially timing of the pain (acute or chronic); then ask them to point to the pain.

Pursue important details:

“Where does the pain start?” “Does it radiate or travel?” “What is the pain like?” “How severe is it?” “How about on a scale of 1 to 10?” “What makes it better or worse?”

Elicit any symptoms associated with the pain, such as fever or chills; ask about their sequence.

Up p e r Ab d o m in a l Pa in , Dis - c o m fo r t , o r He a r t b u rn . Ask about chronic or recurrent upper abdominal discomfort, or dyspepsia. Related symptoms include bloating, nausea, upper abdominal fullness, and heartburn. Is there:

In emergency rooms, up to 45% of patients have nonspecific pain, but 15% to 30% need surgery, usually for appendicitis, intestinal obstruction, or cholecystitis.

Doubling over with cramping colicky pain signals a renal stone. Sudden knife-like epigastric pain often radiating to the back is typical of pancreatitis.

Epigastric pain occurs with gastroesoph- ageal reflux disease (GERD), pancreatitis, and perforated ulcers. RUQ and upper abdominal pain are common in chole- cystitis and cholangitis.

Chapter 11 | The Abdomen 201

■ Bloating from excessive gas, especially with frequent belch- ing, abdominal distention, or atus, the passage of gas by rectum

■ Unpleasant abdominal fullness after normal meals or early satiety, the inability to eat a full meal

■ Heartburn, dysphagia, or regur- gitation?

Lo w e r Ab d o m in a l Pa in o r Dis c o m fo r t —Ac u t e a n d Ch ro n ic . If acute, is the pain sharp and continuous or intermit- tent and cramping?

If chronic, is there a change in bowel habits? Alternating diarrhea and constipation?

Ab d o m in a l Pa in w it h As s o c ia t e d GI S ym p t o m s

■ Nausea, vomiting, loss of appetite (anorexia)

Bloating may occur with lactose intoler- ance, inflammatory bowel disease, or ovarian cancer; belching results from aerophagia, or swallowing air.

Consider diabetic gastroparesis, anticho- linergic drugs, gastric outlet obstruction, gastric cancer. Early satiety may signify hepatitis.

Suggests GERD. Up to 90% of patients with asthma have GERD-like symptoms. If patient fails empiric therapy, is age >55 years, or has “alarm symptoms” (dysphagia, pain with swallowing or odynophagia, recurrent vomiting, gastro intestinal bleeding, risk factors for gastric cancer, or palpable mass), endoscopy is warranted.

RLQ pain, or pain migrating from periumbilical region in appendicitis; in women with RLQ pain, possible pelvic inflammatory disease, ectopic pregnancy, ruptured ovarian follicle

Left lower quadrant (LLQ) pain in diver- ticulitis, diffuse abdominal pain with abdominal distention, hyperactive bowel sounds, and tenderness on palpa- tion in small or large bowel obstruction; pain with absent bowel sounds, rigidity, percussion tenderness, and guarding in peritonitis

Colon cancer; irritable bowel syndrome

Pregnancy, diabetic ketoacidosis, adre- nal insufficiency, hypercalcemia, uremia, liver disease. Induced vomiting without nausea in anorexia/bulimia.

202 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

■ Regurgitation

■ Coffee ground emesis (hematemesis)

Ot h e r GI S ym p t o m s

■ Dif culty swallowing (dysphagia)

■ Painful swallowing (odynophagia)

■ Diarrhea, acute (<2 weeks) and chronic

■ Constipation

■ Black tarry stools (melena)

■ Jaundice from increased levels of bilirubin: Intrahepatic jaundice can be hepatocellular, from damage to the hepatocytes, or cholestatic, from impaired excretion caused by damaged hepatocytes or intrahepatic bile ducts

Extrahepatic jaundice arises from obstructed extrahepatic bile ducts, commonly the cystic and common bile ducts

Ask about the color of the urine and stool.

GERD, esophageal stricture, and esophageal cancer

Esophageal or gastric varices, Mallory– Weiss tears, peptic ulcer disease

If solids and liquids, neuromuscular disorders affecting motility. If only solids, consider structural conditions like Zenker diverticulum, Schatzki ring, stricture, neoplasm.

Radiation; caustic ingestion, infection from cytomegalovirus, herpes simplex, HIV, esophageal ulceration from aspirin or NSAIDs

Acute infection (viral, salmonella, shigella, etc.); chronic in Crohn disease, ulcerative colitis; oily diarrhea (steatorrhea)—in pancreatic insufficiency. See Table 11-1, Diarrhea, pp. 214–215.

Medications, especially anticholinergic agents and opioids; colon cancer, diabetes, hypothyroidism, hypercalcemia, multiple sclerosis, Parkinson disease

GI bleed

Impaired excretion of conjugated bilirubin in viral hepatitis, cirrhosis, primary biliary cirrhosis, drug-induced cholestasis

Common bile duct obstruction from gallstones or pancreatic, cholangio-, or duodenal carcinoma

Dark urine from increased conjugated bilirubin excreted in urine (hepatitis); acholic clay-colored stool when bilirubin excretion into intestine is obstructed

Chapter 11 | The Abdomen 203

T h e U r in a r y T r a c t

R is k F a c t o r s f o r Liv e r D is e a s e

● Hepatitis: Tr vel or e ls in re s of oor s nit tion, ingestion of cont i- n ted w ter or foodstuffs (hepatitis A); renter l or ucous e br ne ex osure to infectious body fluids such s blood, seru , se en, nd s liv , es eci lly through sexu l cont ct with n infected rtner or use of sh red needles for injection drug use (hepatitis B); illicit injection drug use or blood tr nsfusion (hepatitis C)

● Alcoholic hepatitis or alcoholic cirrhosis (screen tients c refully bout lcohol use)

● Toxic liver damage fro edic tions, industri l solvents, environ ent l toxins, or so e nesthetic gents

● Gallbladder disease or surgery th t y result in extr he tic bili ry obstruction

● Hereditary disorders in the F ily History

Ask about pain on urination, usually a burning sensation, sometimes termed dysuria (also refers to dif culty voiding).

Is there:

■ Urgency, an unusually intense and immediate desire to void

■ Urinary frequency, or abnormally frequent voiding

■ Fever or chills; blood in the urine

■ Any pain in the abdomen, ank, or back

■ In men, hesitancy in starting the urine stream, straining to void, reduced caliber and force of the urine stream, or dribbling as they complete voiding.

Bladder infection (cystitis)

May lead to urge incontinence

Urinary tract infection

Dull, steady pain in pyelonephritis; severe colicky pain in ureteral obstruction from renal stone

Prostatitis, urethritis

Also seen in urethritis, urinary tract infections, bladder stones, tumors, and, in men, acute prostatitis. In women, internal burning in urethritis, external burning in vulvovaginitis

204 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

Assess any:

■ Polyuria, a signi cant increase in 24-hour urine volume

■ Nocturia, urinary frequency at night

■ Urinary incontinence, involuntary loss of urine:

■ From coughing, sneezing, lifting

■ From urge to void

■ From bladder fullness with leaking but incomplete emptying

Diabetes mellitus, diabetes insipidus

Bladder obstruction

See Table 11-2, Urinary Incontinence, pp. 216–217.

Stress incontinence (poor urethral sphincter tone)

Urge incontinence (detrusor overactivity)

Overflow incontinence (anatomic obstruction, impaired neural innerva- tion to bladder)

Health Promotion and Counseling: Evidence and Recommendations

S c re e n in g fo r Alc o h o l Ab u s e . Use the four CAGE questions (see Chap- ter 3, p. 56) to screen all adults in primary care settings, adolescents, and pregnant women for risky or hazardous alcohol use. Focus on detection, counseling, and, for signi cant impairment, speci c treatment recom- mendations. Brief counseling interventions have been shown to reduce alcohol consumption by 13% to 34% over 6 to 12 months.

Im p o r t a n t T o p ic s f o r H e a lt h P r o m o t io n a n d C o u n s e lin g

● Screening for lcohol buse ● Vir l he titis: risk f ctors, v ccines, nd screening ● Screening for colorect l c ncer

S c r e e n in g f o r P r o b le m D r in k in g

Standard Drink Equivalents: 1 st nd rd drink is equiv lent to 12 oz of regul r beer or wine cooler, 8 oz of lt liquor, 5 oz of wine, or 1.5 oz of 8 - roof s irits

Initial Screening Question: “How ny ti es in the st ye r h ve you h d 4 or ore drinks d y (wo en), or 5 or ore drinks d y ( en)?”

(continued )

Chapter 11 | The Abdomen 205

Vira l He p a t it is : Ris k Fa c t o rs , S c re e n in g , a n d Va c c in a t io n . Protective measures against infectious hepatitis include counseling about transmission.

■ Hepatitis A: Transmission is fecal–oral. Illness occurs approximately 30 days after exposure. Advise hand washing with soap and water after bathroom use or changing diapers and before preparing or eating food. Diluted bleach can be used to clean environmental surfaces.

S c r e e n in g f o r P r o b le m D r in k in g (Continued)

De f in it io n s o f Drin k in g Le ve ls fo r Ad u lt s —Na t io n a l In s t it u t e o f Alc o h o l Ab u s e a n d Alc o h o lis m

Wo m e n Me n

Moder te drinking ≤1 drink/d ≤2 drinks/d Uns fe drinking levels (incre sed risk for

develo ing n lcohol use disorder)a >3 drinks/d nd

>7 drinks/wk >4 drinks/d nd

>14 drinks/wk Binge drinkingb ≥4 drinks on one

occ sion ≥5 drinks on one

occ sion

aPregn nt wo en nd those with he lth roble s th t could be worsened by drinking should not drink ny lcohol.

bBrings blood lcohol level to . 8 g%, usu lly within 2 hours.

■ Hepatitis B: Transmission occurs during contact with infected body uids, such as blood, semen, saliva, and vaginal secretions. Infection increases risk of fulminant hepatitis, chronic infection, and subsequent cirrhosis and hepatocellular carcinoma. Provide counseling and serologic screening for patients at risk.

C D C R e c o m m e n d a t io n s f o r H e p a t it is A V a c c in a t io n

● All children t ge 1 ye r ● Individu ls with chronic liver dise se ● Grou s t incre sed risk of cquiring HAV: tr velers to re s with high

ende ic r tes of infection, en who h ve sex with en, injection nd illicit drug users, individu ls working with nonhu n ri tes, nd ersons who h ve clotting-f ctor disorders

The v ccine lone y be d inistered t ny ti e before tr veling to ende ic re s.

206 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

■ Hepatitis C: Hepatitis C, now the most common form of hepatitis, is spread by blood exposure and injection drug use. There is no vaccina- tion for hepatitis C, so prevention targets counseling to avoid risk factors. Serologic screening should be recommended for high-risk groups.

S c re e n in g fo r Co lo re c t a l Ca n c e r. Adopt the 2008 recommendations of the U.S. Preventive Services Task Force, listed below.

C D C R e c o m m e n d a t io n s f o r H e p a t it is B V a c c in a t io n : H ig h -R is k G r o u p s a n d S e t t in g s

● Sexual contacts, including sex rtners of he titis B surf ce ntigen- ositive ersons, eo le with ore th n one sex rtner in the rior 6 onths, eo le seeking ev lu tion nd tre t ent for sexu lly tr ns itted infections, nd en who h ve sex with en

● People with percutaneous or mucosal exposure to blood, including injection drug users, household cont cts of ntigen- ositive ersons, residents nd st ff of f cilities for the develo ent lly dis bled, he lth c re workers, nd eo le on di lysis

● Others, including tr velers to ende ic re s, eo le with chronic liver dise se nd HIV infect ion, nd eo le seeking rotection fro he t it is B infect ion

● All adults in high-risk settings, such s sexu lly tr ns itted infection (STI) clinics, HIV testing nd tre t ent rogr s, drug- buse tre t ent rogr s nd rogr s for injection drug users, correction l f cilities, rogr s for en h ving sex with en, chronic he odi lysis f cilit ies nd end-st ge ren l dise se rogr s, nd f cilit ies for eo le with develo ent l dis bilit ies

S c r e e n in g f o r C o lo r e c t a l C a n c e r

Assess Risk: Begin screening t ge 2 ye rs. If high risk, refer for ore co lex n ge ent. If ver ge risk t ge 5 (high-risk conditions bsent), offer the screening o tions listed.

● Common high-risk conditions (25% of colorect l c ncers) ● Person l history of colorect l c ncer or deno ● First-degree rel tive with colorect l c ncer or deno tous oly s ● Person l history of bre st , ov ri n, or endo etri l c ncer ● Person l history of ulcer tive or Crohn colitis

● Hereditary high-risk condit ions (6% of colorect l c ncers) ● F ili l deno tous oly osis ● Heredit ry non oly osis colorect l c ncer

(continued )

Chapter 11 | The Abdomen 207

T h e A b d o m e n Inspect the abdomen,

including:

■ Skin

■ Umbilicus

■ Contours for shape, symmetry, enlarged organs or masses

■ Any peristaltic waves

■ Any pulsations

Auscultate the abdomen for:

■ Bowel sounds

■ Bruits

■ Friction rubs

Techniques of Examination EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Scars, striae, veins, ecchymoses (in intra- or retroperitoneal hemorrhages)

Hernia, inflammation

Bulging flanks of ascites, suprapubic bulge, large liver or spleen, tumors

Increased in GI obstruction

Increased in aortic aneurysm

Increased or decreased motility

Bruit of renal artery stenosis

Liver tumor, splenic infarct

S c r e e n in g f o r C o lo r e c t a l C a n c e r (Continued)

Screening recommendations ● Adults age 50 to 75 years—o tions

● High-sensitivity fec l occult blood testing (FOBT) nnu lly ● Sig oidosco y every 5 ye rs with FOBT every 3 ye rs ● Screening colonosco y every 1 ye rs

● Adults age 76 to 85 years—do not screen routinely, s g in in life-ye rs is s ll co red to colonosco y risks, nd screening benefits not seen for 7 ye rs; use individu l decision king if screening for the first ti e

● Adults older than age 85—do not screen, s “co eting c uses of ort lity reclude ort lity benefit th t outweighs h r s”

208 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

Percuss the abdomen for patterns of tympany and dullness.

Palpate all quadrants of the abdomen:

■ Lightly for guarding, rebound, and tenderness (Fig. 11-1)

B o w e l S o u n d s a n d B r u it s

Ch a n g e S e e n w it h

Incre sed bowel sounds Di rrhe E rly intestin l obstruction

Decre sed, then bsent bowel sounds Adyn ic ileus Peritonitis

High- itched tinkling bowel sounds Intestin l fluid Air under tension in dil ted bowel

High- itched rushing bowel sounds with cr ing

Intestin l obstruction

He tic bruit C rcino of the liver Alcoholic he titis

Arteri l bruits P rti l obstruction of the ort or ren l, ili c or fe or l rteries

Aorta

Rena l a rte ry

Iliac a rte ry

Femora l a rte ry

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Ascites, GI obstruction, pregnant uterus, ovarian tumor

See Table 11-3, Abdominal Tenderness, p. 217. “Acute abdomen”or peritonitis if:

Figure 11-1 Begin with light palpation of the abdomen.

Firm, board-like abdominal wall— suggests peritoneal inflammation.

Guarding if the patient flinches, grimaces, or reports pain during palpation.

Rebound tenderness from peritoneal inflammation; pain is greater when you withdraw your hand than when you press down. Press slowly on a ten- der area, then quickly “let go.”

Chapter 11 | The Abdomen 209

T h e Liv e r Percuss span of liver dullness

in the midclavicular line (MCL), Figure 11-3.

Figure 11-2 Use two hands for deep palpation.

■ Deeply for masses or tenderness (Fig. 11-2)

Tumors, a distended viscus

Abdominal masses may be: physiologic (pregnant uterus), inflammatory (diver- ticulitis), vascular (an AAA), neoplastic (colon cancer), or obstructive (a dis- tended bladder or dilated loop of bowel).

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

4–8 cm in mids te rna l line

6–12 cm in right midclav- icula r line

Norma l live r spans

Figure 11-3 Measure the live r span.

Increased dullness in hepatomegaly from acute hepatitis, heart failure; decreased dullness in cirrhosis

Feel the liver edge, if possible, as patient breathes in.

Starting well below the costal mar- gin, measure distance of the liver edge from the costal margin in the MCL (Fig. 11-4).

Firm edge of cirrhosis

Figure 11-4 Palpate the live r edge .

Increased distance in hepatomegaly— may be missed (as in Fig. 11-5) by starting palpation too high in the RUQ

Figure 11-5 Palpating firs t at the cos tal margin may miss the liver edge .

Note any tenderness or masses. Tender liver of hepatitis or heart failure; tumor mass

210 Ba tes’ Pocket Guide to Phys ica l Examination and His tory Taking

T h e S p le e n Percuss across left lower ante- rior chest (Traube space), noting change from tympany to dullness.

Palpate the spleen with the patient supine then lying on the right side with legs exed at hips and knees (Fig. 11-6).

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Figure 11-6 Spleen tip (purple) palpable below costal margin.

Splenomegaly

T h e Kid n e y s Try to palpate each kidney

(Fig. 11-7).

Figure 11-7 Palpate each kidney.

Enlargement from cysts, cancer, hydronephrosis

Figure 11-8 Percuss for cos tovertebral angle tenderness .

Tender in pyelonephritisCheck for costovertebral angle (CVA) tenderness (Fig. 11-8).

Chapter 11 | The Abdomen 211

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

T h e A o r t a Palpate the aorta’s pulsations

(Fig. 11-9). In older people, esti- mate its width.

Figure 11-9 Palpate on both s ides of the aorta.

Periumbilical mass with expansile pulsa- tions ≥3 cm in diameter in abdominal aortic aneurysm. Assess further due to risk of rupture.

A s s e s s in g A s c it e s / Palpate for shifting dull-

ness. Map areas of tympany and dullness with patient supine, then lying on side (Fig. 11-10).

Tympany

Dullness

Figure 11-10 Percuss outward to map dullness from ascites .

Ascitic fluid usually shifts to dependent side, changing the margin of dullness (Fig. 11-11).

Tympany

Shifting dullness

Figure 11-11 Percuss for shifting dull- ness (here patient turned to right s ide ).

Check for a uid wave (Fig. 11-12). Ask patient or an assistant to press edges of both hands into midline of abdomen. Tap one side and feel for a wave transmitted to the other side.

A palpable wave suggests but does not prove ascites.

212 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

Ballotte an organ or mass in an ascitic abdomen. Place your stiffened and straightened ngers on the abdomen, brie y jab them toward the structure, and try to touch its surface.

Figure 11-12 Test for a fluid wave .

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Figure 11-13 Ballotte the live r.

Your hand, quickly displacing the fluid, stops abruptly as it touches the solid surface (Fig. 11-13).

A s s e s s in g P o s s ib le A p p e n d ic it is Ask:

“Where did the pain begin?”

“Where is it now?”

Ask patient to cough. “Where does it hurt?”

Palpate for local tenderness.

Palpate for muscular rigidity.

Perform a rectal examination and, in women, a pelvic examination (see Chapters 14 and 15).

■ Rovsing sign: Press deeply and evenly in the left lower quad- rant. Then quickly withdraw your ngers.

In classic appendicitis:

Near the umbilicus

RLQ

RLQ at “the McBurney point”

RLQ tenderness

RLQ rigidity

Local tenderness, especially if appendix is retrocecal

Pain in the right lower quadrant during left-sided pressure suggests appendicitis (a positive Rovsing sign).

Chapter 11 | The Abdomen 213

■ Psoas sign: Place your hand just above the patient’s right knee. Ask the patient to raise that thigh against your hand. Or, ask the patient to turn onto the left side. Then extend the patient’s right leg at the hip to stretch the psoas muscle.

■ Obturator sign: Flex the patient’s right thigh at the hip, with the knee bent, and rotate the leg internally at the hip, which stretches the internal obturator muscle.

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Pain from irritation of the psoas muscle suggests an inflamed appendix (a positive psoas sign).

Right hypogastric pain in a positive obturator sign, suggesting irritation of the obturator muscle by an inflamed appendix.

A s s e s s in g P o s s ib le A c u t e C h o le c y s t it is Auscultate, percuss, and palpate the abdomen for tenderness.

Assess for the Murphy sign. Hook your thumb under the right costal margin at edge of rectus muscle, and ask patient to take a deep breath.

Bowel sounds may be active or decreased; tympany may increase with an ileus: Assess any RUQ tenderness.

Sharp tenderness and a sudden stop in inspiratory effort constitute a positive Murphy sign.

Recording Your Findings

R e c o r d in g t h e A b d o m in a l E x a m in a t io n

“Abdo en is rotuber nt with ctive bowel sounds. It is soft nd nontender; no l ble sses or he tos leno eg ly. Liver s n is 7 c nd in the right MCL; edge is s ooth nd l ble 1 c below the right cost l rgin. S leen nd kidneys not felt . No CVA tenderness.” OR “Abdo en is fl t . No bowel sounds he rd. It is fir nd bo rd-like, with incre sed tenderness, gu rding, nd rebound in the right idqu dr nt . Liver ercusses to 7 c in the MCL; edge not felt . S leen nd kidneys not felt . No l- ble ss. No CVA tenderness.” (These findings suggest peritonitis from possible appendicitis; see pp. 212–213.)

214 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

Aids to Interpretation

P ro b le m /P ro c e s s Ch a ra c t e r is t ic s o f S t o o l

Ac u t e Dia r rh e a

Secre tory In fection (noninflammatory) Infection by viruses; preformed bacterial toxins such as Staphylococcus aureus, Clostridium perfringens, toxigenic Escherichia coli; Vibrio cholerae, Cryptosporidium, Giardia lamblia, rotavirus

Watery, without blood, pus, or mucus

Inflam m atory Infection Colonization or invasion of intestinal mucosa as in nontyphoid Salmonella, Shigella, Yersinia, Campylobacter, enteropathic E. coli, Entamoeba histolytica, Clostridium difficile

Loose to watery, often with blood, pus, or mucus

Dru g -In d u c e d Dia r rh e a

Action of many drugs, such as magnesium-containing antacids, antibiotics, antineoplastic agents, and laxatives

Loose to watery

Ch ro n ic Dia r rh e a (ê3 0 d a ys )

Diarrhea l Syndrom es ■ Irritable bowel syndrome: A disorder

of bowel motility with alternating diarrhea and constipation

■ Cancer of the sigmoid colon: Partial obstruction by a malignant neoplasm

Loose; may show mucus but no blood. Small, hard stools with constipation May be blood-streaked

Dia rrh e aTable 11-1

Chapter 11 | The Abdomen 215

P ro b le m /P ro c e s s Ch a ra c t e r is t ic s o f S t o o l

In flam m atory Bowel Disease ■ Ulcerative colitis: inflammation and

ulceration of the mucosa and submucosa of the rectum and colon

■ Crohn disease of the small bowel (regional enteritis) or colon (granulomatous colitis): chronic inflammation of the bowel wall, typically involving the terminal ileum, proximal colon, or both

Soft to watery, often containing blood

Small, soft to loose or watery, usually free of gross blood (enteritis) or with less bleeding than ulcerative colitis (colitis)

Volum inous Diarrheas ■ Malabsorption syndrome: Defective

absorption of fat, including fat- soluble vitamins, with steatorrhea (excessive excretion of fat) as in pancreatic insufficiency, bile salt deficiency, bacterial overgrowth

■ Osmotic Diarrheas ■ Lactose intolerance: Deficiency in

intestinal lactase ■ Abuse of osmotic purgatives:

Laxative habit, often surreptitious ■ Secretory diarrheas from bacterial

infection, secreting villous adenoma, fat or bile salt malabsorption, hormone-mediated conditions (gastrin in Zollinger–Ellison syndrome, vasoactive intestinal peptide): Process is variable.

Typically bulky, soft, light yellow to gray, mushy, greasy or oily, and sometimes frothy; particularly foul-smelling; usually floats in the toilet

Watery diarrhea of large volume

Dia rrh e a (continued )Table 11-1

216 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

P ro b le m Me ch a n is m s

S t re s s In c o n t in e n c e : Urethral sphincter weakened. Transient increases in intra-abdominal pressure raise bladder pressure to levels exceeding urethral resistance. Leads to voiding small amounts during laughing, coughing, and sneezing.

■ In women, weakness of the pelvic floor with inadequate muscular support of the bladder and proximal urethra and a change in the angle between the bladder and the urethra from childbirth, surgery, and local conditions affecting the internal urethral sphincter, such as postmenopausal atrophy of the mucosa and urethral infection

■ In men, prostatic surgery

Urg e In c o n t in e n c e : Detrusor contractions are stronger than normal and overcome normal urethral resistance. Bladder is typically small. Results in voiding moderate amounts, urgency, frequency, and nocturia.

■ Decreased cortical inhibition of detrusor contractions, as in stroke, brain tumor, dementia, and lesions of the spinal cord above the sacral level

■ Hyperexcitability of sensory pathways, as in bladder infection, tumor, and fecal impaction

■ Deconditioning of voiding reflexes, caused by frequent voluntary voiding at low bladder volumes

Ove rf lo w In c o n t in e n c e : Detrusor contractions are insufficient to overcome urethral resistance. Bladder is typically large, even after an effort to void, leading to continuous dribbling.

■ Obstruction of the bladder outlet, as by benign prostatic hyperplasia or tumor

■ Weakness of detrusor muscle associated with peripheral nerve disease at the sacral level

■ Impaired bladder sensation that interrupts the reflex arc, as in diabetic neuropathy

Urin a ry In c o n t in e n c eTable 11-2

Chapter 11 | The Abdomen 217

P ro b le m Me ch a n is m s

Fu n c t io n a l In c o n t in e n c e : Inability to get to the toilet in time because of impaired health or environmental conditions

■ Problems in mobility from weakness, arthritis, poor vision, other conditions; environmental factors such as unfamiliar setting, distant bathroom facilities, bed rails, physical restraints

In c o n t in e n c e S e c o n d a ry t o Me d ic a t io n s : Drugs may contribute to any type of incontinence listed.

■ Sedatives, tranquilizers, anticholinergics, sympathetic blockers, potent diuretics

Urin a ry In c o n t in e n c e (continued )Table 11-2

Vis c e ra l Te n d e rn e s s P e r it o n e a l Te n d e rn e s s

Enlarged liver Normal cecum

Normal aorta

Normal or spas tic s igmoid colon

Appendicitis Dive rticulitis

Cholecys titis

Te n d e rn e s s f ro m Dis e a s e in t h e Ch e s t a n d P e lv is

Acute Pleurisy Acu te Sa lp ing itis

Unila te ra l or bila te ra l, upper or lower abdomen

Ab d o m in a l Te n d e rn e s sTable 11-3

219

C H A P T E R

12The Peripheral Vascular System

The Health History

Ask about abdominal, ank, or back pain, especially in older male smokers.

Ask about any pain in the arms and legs.

Is there intermittent claudication, exercise-induced pain that is absent at rest, makes the patient stop exertion, and abates within about 10 minutes? Ask “Have you ever had any pain or cramping in your legs when you walk or exer- cise?” “How far can you walk with- out stopping to rest?” and “Does pain improve with rest?”

Ask also about coldness, numbness, or pallor in legs or feet or hair loss over the anterior tibial surfaces.

C o m m o n o r C o n c e r n in g S y m p t o m s

● Abdo in l, fl nk, or b ck in ● P in in the r s or legs ● Exercise-induced in (inter ittent cl udic tion) ● Cold, nu bness, llor in the legs; h ir loss ● Swelling in c lves, legs, or feet ● Color ch nge in fingerti s or toes in cold we ther ● Swelling with redness or tenderness

An expanding abdominal aortic aneurysm (AAA) may compress arteries or ureters.

Cold-induced digital ischemic change with blanching then cyanosis then rubor in Raynaud phenomenon or disease

Peripheral arteria l disease (PAD) can cause symptomatic limb ischemia with exertion; distinguish this from the neurogenic pain of spinal stenosis, which produces leg pain with exertion, often reduced by leaning forward (stretching the spinal cord in the narrowed vertebral canal) and less readily relieved by rest.

Hair loss over the anterior tibiae in PAD. “Dry”or brown–black ulcers from gan- grene may ensue.

220 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

Because patients have few symp- toms, identify risk factors— tobacco abuse, hypertension, diabetes, hyperlipidemia, and coronary artery disease—and PAD warning signs.

Only 10% to 30% of affected patients have the classic symptoms of exertional calf pain relieved by rest.

Ask about swelling of feet and legs, or any ulcers on lower legs, often near the ankles from peripheral vascular disease.

Calf swelling in deep venous thrombosis (DVT); hyperpigmentation, edema, and possible cyanosis, especially when legs are dependent, in venous stasis ulcers; swelling with redness and tenderness in cellulitis.

Health Promotion and Counseling: Evidence and Recommendations

Im p o r t a n t T o p ic s f o r H e a lt h P r o m o t io n a n d C o u n s e lin g

● Screening for eri her l rteri l dise se ● The nkle–br chi l index ● Screening for ren l rtery dise se ● Screening for bdo in l ortic neurys

P e r ip h e r a l A r t e r ia l D is e a s e “ W a r n in g S ig n s ”

● F tigue, ching, nu bness, or in th t li its w lking or exertion in the legs; if resent, identify the loc tion. Ask lso bout erectile dysfunction.

● Any oorly he ling or nonhe ling wounds of the legs or feet

● Any in resent when t rest in the lower leg or foot nd ch nges when st nding or su ine

● Abdo in l in fter e ls nd ssoci ted “food fe r” nd weight loss

These symptoms suggest intestinal ischemia of the celiac or superior or inferior mesenteric arteries.

● Any first-degree rel tives with n AAA

Prevalence of AAAs in first-degree relatives is 15% to 28%.

Symptom location suggests the site of arterial ischemia:

aortoiliac iliac–pudendal common femora l or aortoiliac superficia l femoral popliteal tibial or peroneal

Chapter 12 | The Peripheral Vascular System 221

S c re e n in g fo r P e r ip h e ra l Ar t e r ia l Dis e a s e . PAD prevalence in- creases with age, ranging from around 5% before age 50 years to 15% to 20% in persons aged 80 years and older. Cardiovascular risk factors, particularly smoking and diabetes, increase risk: An estimated 40% to 60% of PAD patients have coexisting coronary artery disease and/or ce- rebral artery disease, and the presence of PAD signi cantly increases risk of cardiovascular events. Most patients with PAD have either no symptoms or a range of nonspeci c leg symptoms, such as aching, cramping, numbness, or fatigue.

R is k F a c t o r s f o r Lo w e r -E x t r e m it y P e r ip h e r a l A r t e r ia l D is e a s e

● Age ≥65 ye rs ● Age ≥5 ye rs with history of di betes or s oking ● Leg sy to s with exertion ● Nonhe ling wounds

Th e An k le –Bra ch ia l In d e x. To diagnose PAD, use the ankle–brachial index (ABI), which is reliable, reproducible, noninvasive, easy to per- form in the of ce, and highly speci c. The ABI is the ratio of blood pressure measurements in the foot and arm; values <0.9 are considered abnormal.

A wide range of interventions reduces both onset and progression of PAD, including: supervised exercise programs; tobacco cessation; treatment of hyperlipidemia; optimal control of diabetes and hypertension; use of anti- platelet agents; meticulous foot care and well- tting shoes, particularly for diabetic patients; and revascularization.

S c re e n in g fo r Re n a l Ar t e ry Dis e a s e . The American College of Cardiol- ogy and the American Heart Association recommend renal artery disease (RAS) screening with duplex ultrasonography, magnetic resonance angiogra- phy, or computed tomographic angiography in patients with the conditions listed in the box below.

C o n d it io n s S u s p ic io u s f o r R e n a l A r t e r y D is e a s e

● Onset of hy ertension t ge ≤3 ye rs ● Onset of severe hy ertension t ge ≥55 ye rs ● Acceler ted (sudden nd ersistent worsening of reviously controlled

hy ertension), resist nt (not controlled with three drugs), or lign nt hy ertension (evidence of cute end-org n d ge)

(continued )

222 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

S c re e n in g fo r Ab d o m in a l Ao r t ic An e u rys m . An AAA is present when the infrarenal aortic diameter exceeds 3 cm. Rupture and mortality rates dramatically increase for AAAs exceeding 5.5 cm in diameter. Additional risk factors are smoking, age older than 65 years, family history, coronary artery disease, PAD, hypertension, and elevated cholesterol level. Because symptoms are rare, and screening is now shown to reduce mortality by 50% over 13 to 15 years, the U.S. Preventive Services Task Force recom- mends one-time screening by ultrasound in men between 65 and 75 years of age with a history of “ever smoking,” de ned as more than 100 cigarettes in a lifetime.

C o n d it io n s S u s p ic io u s f o r R e n a l A r t e r y D is e a s e (Continued)

● New worsening of ren l function or worsening function fter use of n ngiotensin-converting enzy e inhibitor or n ngiotensin-rece tor blocking gent

● An unex l ined s ll kidney or size discre ncy of >1.5 c between the two kidneys

● Sudden unex l ined ul on ry ede , es eci lly in the setting of worsening ren l function

Techniques of Examination

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

A r m s Inspect for:

■ Size and symmetry, any swelling

■ Venous pattern

■ Color and texture of skin and nails

Palpate and grade the pulses:

Lymphedema, venous obstruction

Visible venous collaterals, swelling, edema, and discoloration signal upper- extremity DVT.

Sharply demarcated pallor of the fingers in Raynaud disease

G r a d in g A r t e r ia l P u ls e s

3+ Bounding 2+ Brisk, expect ed (normal) 1+ Di inished, we ker th n ex ected Absent, un ble to l te

Chapter 12 | The Peripheral Vascular System 223

■ Radial (Fig. 12-1)

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Figure 12-1 Palpate the radial pulse .

Bounding radial, carotid, and femoral pulses in aortic regurgita tion

Lost in thromboangiitis obliterans or acute arterial occlusion

■ Brachial (Fig. 12-2)

Figure 12-2 Palpate the brachial pulse .

Feel for the epitrochlear nodes. Lymphadenopathy from local or distal infection, lymphoma, or human immu- nodeficiency virus (HIV)

A b d o m e n Auscultate for aortic, renal, and femoral bruits.

Palpate and estimate the width of the abdominal aorta between your two ngers (see p. 211).

Palpate the super cial inguinal nodes (Fig. 12-3). Note size, consistency, discreteness, and any tenderness.

■ Horizontal group

■ Vertical group

Pulsatile mass, AAA if width ≥4 cm.

Lymphadenopathy in genital infections, lymphoma, AIDS

224 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

Le g s Inspect for:

■ Size and symmetry, any swelling in thigh or calf

■ Venous pattern

■ Color and texture of skin

■ Hair distribution, temperature

Palpate and grade the pulses:

■ Femoral

■ Popliteal (Fig. 12-4)

Femoral vein Femoral artery

Great saphenous vein

Vertical group

Horizontal group

Figure 12-3 Superficial inguinal lymph nodes .

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

See Table 12-1, Chronic Insufficiency of Arteries and Veins, p. 228, and Table 12-2, Common Ulcers of the Feet and Ankles, p. 229.

Venous insufficiency, lymphedema; DVT. Calf asymmetry >3 cm (measure 10 cm below tibial tuberosity) doubles the risk of DVT.

Varicose veins

Pallor, rubor, cyanosis; erythema, warmth in cellulitis, thrombophlebitis; pigmentation, ulcers of the feet in PAD

Atrophic hairless cool skin in PAD

Loss of pulses in acute arterial occlusion and arteriosclerosis obliterans

Figure 12-4 Palpate the popliteal pulse.

Chapter 12 | The Peripheral Vascular System 225

■ Dorsalis pedis and posterior tibial (Figs. 12-5 and 12-6)

Absent pedal pulses with normal femoral and popliteal pulses make PAD highly likely. Confirm with the ABI (see Table 12-3, Using the Ankle–Brachial Index, pp. 230–231).

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Figure 12-5 Palpate the dorsalis pedis pulse .

Figure 12-6 Palpate the posterior tibial pulse .

Palpate for pitting edema.

Palpate the calves.

Ask patient to stand, and reinspect the venous pattern.

S p e c ia l T e c h n iq u e s

Eva lu a t in g Ar t e ria l S u p p ly t o t h e Ha n d . Feel ulnar pulse, if possible. Perform an Allen test.

Dependent edema, heart failure, hypoal- buminemia, nephrotic syndrome

Possible cord and tenderness in DVT (not always present)

Varicose veins

226 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Figure 12-9 Palmar flushing—Allen tes t negative .

Figure 12-10 Palmar pallor—Allen tes t pos itive .

1. Ask the patient to make a tight st, palm up. Occlude both radial and ulnar arteries with your thumb (Fig. 12-7).

Marked pallor of feet on elevation, delayed color return and venous filling, and rubor of dependent feet suggest arterial insufficiency.

Figure 12-8 Pallor when hand re laxed.

2. Ask the patient to open hand into a relaxed, slightly exed position (Fig. 12-8).

/ Po s t u ra l Co lo r Ch a n g e s o f Ch ro n ic Ar t e ria l In s u f c ie n c y. Raise both legs to 60 degrees for about 1 minute. Then ask patient to sit up with legs dangling down. Note time required for (1) return of pinkness (nor- mally 10 seconds) and (2) lling of veins on feet and ankles (normally about 15 seconds).

Figure 12-7 Compress the radial and ulnar arte rie s .

3. Release your pressure over one artery. Palm should ush within 3 to 5 seconds (Fig. 12-9).

4. Repeat, releasing other artery. Persisting pallor of palm indicates occlusion of the released artery or its distal branches (Fig. 12-10).

Chapter 12 | The Peripheral Vascular System 227

Recording Your Findings

R e c o r d in g t h e P e r ip h e r a l V a s c u la r S y s t e m E x a m in a t io n

“Extre ities re w r nd without ede . No v ricosities or st sis ch nges. C lves re su le nd nontender. No fe or l or bdo in l bruits. Br chi l, r di l, fe or l, o lite l, dors lis edis (DP), nd osterior tibi l (PT) ulses re 2+ nd sy etric.” OR “Extre ities re le below the idc lf, with not ble h ir loss. Rubor noted when legs de endent but no ede or ulcer tion. Bil ter l fe or l bruits; no bdo in l bruits he rd. Br chi l nd r di l ulses 2+; fe or l, o lite l, DP, nd PT ulses 1+.” Altern tively, ulses c n be recorded s below. (These findings suggest atherosclerotic PAD.)

Ra d ia l Bra ch ia l Fe m o ra l P o p lit e a l Do r s a lis

P e d is Po s t e r io r

Tib ia l

RT 2+ 2+ 1+ 1+ 1+ 1+ LT 2+ 2+ 1+ 1+ 1+ 1+

228 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

Aids to Interpretation

Co n d it io n Ch a ra c t e r is t ic s

Ch ro n ic Ar t e r ia l In s u ff ic ie n c y

Rubor

Ischemic ulce r

Intermittent claudication progressing to pain at rest. Decreased or absent pulses. Pale, especially on elevation; dusky red on dependency. Cool. Absent or mild edema, which may develop on lowering the leg to relieve pain. Thin, shiny, atrophic skin; hair loss over foot and toes; thickened, ridged nails. Possible ulceration on toes or points of trauma on feet. Potential for gangrene.

Ch ro n ic Ve n o u s In s u ff ic ie n c y No pain to aching pain on dependency. Normal pulses, though may be hard to feel because of edema. Color normal or cyanotic on dependency; petechiae or brown pigment may develop. Often marked edema. Stasis dermatitis, possible thickening of skin, and narrowing of leg as scarring develops. Potential ulceration at sides of ankles. No gangrene.

Ch ro n ic In s u ffic ie n cy o f Art e rie s a n d Ve in sTable 12-1

Chapter 12 | The Peripheral Vascular System 229

Ulc e r Ch a ra c t e r is t ic s

Ar t e r ia l In s u ff ic ie n c y Located on toes, feet, or possible areas of trauma. No callus or excess pigment. May be atrophic. Pain often severe, unless masked by neuropathy. Possible gangrene. Decreased pulses, trophic changes, pallor of foot on elevation, dusky rubor on dependency.

Ch ro n ic Ve n o u s In s u ff ic ie n c y Located on inner or outer ankle. Pigmented, sometimes fibrotic. Pain not severe. No gangrene. Edema, pigmentation, stasis dermatitis, and possibly cyanosis of feet on dependency.

Ne u ro p a t h ic Ulc e r Located on pressure points in areas with diminished sensation, as in diabetic neuropathy. Skin calloused. No pain (which may cause ulcer to go unnoticed). Usually no gangrene. Decreased sensation, absent ankle jerks.

Co m m o n Ulc e rs o f t h e Fe e t a n d An k le sTable 12-2

230 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

In s t ru c t io n s fo r Me a s u r in g t h e An k le –Bra ch ia l In d e x (ABI)

1. Patient should rest supine in a warm room for at least 10 min before testing.

Dopple r

Brachia l a rte ry

2. Place blood pressure cuffs on both arms and ankles as illustrated, then apply ultrasound gel over brachial, dorsalis pedis, and posterior tibial arteries.

3. Measure systolic pressures in the arms ■ Use vascular Doppler to locate brachial pulse ■ Inflate cuff 20 mm Hg above last audible pulse ■ Deflate cuff slowly and record pressure at which pulse becomes

audible ■ Obtain 2 measures in each arm and record the average as the

brachial pressure in that arm

Dopple r

Dorsa lis pedis (DP) a rte ry

Pos te rior tibia l (PT)

a rte ry

4. Measure systolic pressures in ankles ■ Use vascular Doppler to locate dorsalis pedis pulse ■ Inflate cuff 20 mm Hg above last audible pulse ■ Deflate cuff slowly and record pressure at which pulse becomes

audible ■ Obtain 2 measures in each ankle and record the average as the

dorsalis pedis pressure in that leg ■ Repeat above steps for posterior tibial arteries

Us in g t h e An k le –Bra ch ia l In d exTable 12-3

Chapter 12 | The Peripheral Vascular System 231

5. Calculate ABI

Right ABI = highest right average ankle pressure (DP or PT)

highest average arm pressure (right or left)

Left ABI = highest left average ankle pressure (DP or PT)

highest average arm pressure (right or left)

In t e rp re t a t io n o f An k le –Bra ch ia l In d e x

Ankle–Brach ia l Index Resu lt Clin ica l In te rp re ta tion >0.90 (with a range of 0.90 to 1.30) Normal lower-extremity

blood flow

<0.89 to >0.60 Mild PAD

<0.59 to >0.40 Moderate PAD

<0.39 Severe PAD

Us in g t h e An k le –Bra ch ia l In d ex (continued )Table 12-3

Source: Wilson JF, Laine C, Goldman D. In the clinic: peripheral arterial disease. Ann Int Med. 2007;146(5):ITC3.

233

C H A P T E R

13Male Genitalia and Hernias

The Health History

C o m m o n o r C o n c e r n in g S y m p t o m s

● Sexu l he lth ● Penile disch rge or lesions ● Scrot l in, swelling, or lesions ● Sexu lly tr ns itted infections (STIs)

S e xu a l He a lt h . Explain your concern for the patient’s sexual health. Pose questions in a neutral and nonjudgmental way.

■ “Are you currently dating, sexually active, or in a relationship?” “How would you identify your sexual orientation?” Continue with “How would you describe your gender identity?”

■ “How is your current relationship?” “Are you satis ed with your rela- tionship and your sexual activity?” “What about your ability to perform sexually?”

Decreased libido from depression, endocrine dysfunction, or side effects of medications.

Erectile dysfunct ion from psychogenic causes, especially if early morning erection is p reserved; also from decreased testosterone, decreased b lood flow in hypogastric arterial system, impaired neural innervation, d iabetes.

To assess libido, or desire: “How is your desire for sex?”

For the arousal phase: “Can you achieve and maintain an erection?”

234 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

If ejaculation is premature or early: “About how long does intercourse last?” “Do you climax too soon?” For reduced or absent ejaculation: “Do you nd that you cannot have orgasm even though you can have an erection?” “Does the problem involve the pleasurable sensation of orgasm, the ejaculation of seminal uid, or both?”

Pe n ile Dis ch a rg e o r Le s io n s , S c ro t a l S w e llin g o r Pa in , S TIs a n d HIV. To assess possible infection from STIs, ask about any discharge from the penis.

Inquire about sores or growths on the penis and any pain or swelling in the scrotum.

STIs may involve other parts of the body. Ask about practices of oral and anal sex and any related sore throat, oral itching or pain, diarrhea, or rectal bleeding.

Ask “Do you have any concerns about HIV infection?” and discuss the need for universal testing for HIV.

Premature ejaculation is common, especially in young men. Less common is reduced or absent ejaculation affecting middle-aged or older men. Consider medications, surgery, neurologic deficits, or lack of androgen. Lack of orgasm with intact ejaculation is usually psychogenic.

Penile discharge in gonococcal (usually yellow) and nongonococcal (clear or white) urethritis.

See Table 13-1, Abnormalities of the Penis and Scrotum, p. 241, and Table 13-2, Sexually Transmitted Infections of Male Genitalia, pp. 242–243.

Rash in disseminated gonococcal infection.

Health Promotion and Counseling: Evidence and Recommendations

Im p o r t a n t T o p ic s f o r H e a lt h P r o m o t io n a n d C o u n s e lin g

● Screening for STIs nd HPV ● Screening for HIV infection nd AIDS; counseling bout sexu l r ctices ● Screening for testicul r c ncer; testicul r self-ex in tion

Chapter 13 | Male Genitalia and Hernias 235

S c re e n in g fo r S TIs a n d HP V. Focus on patient education about STIs and HPV, early detection of infection during history taking and physical examination, and identi cation and treatment of infected partners. Iden- tify the patient’s sexual orientation, the number of sexual partners in the past month, and any history of STIs. Also query use of alcohol and drugs, particularly injection drugs. Counsel patients at risk about limiting the number of partners, using condoms, and establishing regular medical care for treatment. Correct use of male condoms is highly effective in preventing the transmission of STIs, HPV, and HIV.

Routine HPV vaccination is recommended in males age 11 or 12 years and through age 21 years if not vaccinated previously (age 26 years if immu- nocompromised or having sex with other men). The vaccine can prevent HPV-related diseases in males (genital warts, anal cancer, and penile cancer) and possibly reduce HPV transmission to female sex partners and lower the risk of oropharyngeal cancers.

S c re e n in g fo r HIV In fe c t io n a n d AIDS . The USPSTF recommends HIV screening for all adolescents and adults from age 15 to 65 years and all pregnant women. At least annual testing is recommended for high-risk groups (including adolescents younger than 15 years and older adults), de ned as men with male sex partners, individuals with multiple sexual partners, past or present injection-drug users, persons who exchange sex for money or drugs, and sex partners of persons who are HIV-infected, bisexual, or injection-drug users. The presence of any STI, or requests for STI testing, warrants testing for coinfection with HIV.

Patient counseling should be interactive and combine information about general risk reduction with personalized messages based on the patient’s personal risk behaviors.

S c re e n in g fo r Te s t ic u la r Ca n c e r ; Te s t ic u la r S e lf -Exa m in a t io n . Testicular cancer is rare but highly treatable when detected early. It is the most commonly diagnosed cancer in white men ages 20 to 34 years. Risk factors are white ethnicity, family history, HIV infection, and a history of cryptorchidism. The American Cancer Society encourages men, especially those between 15 and 35 years of age, to perform monthly testicular self-examinations.

236 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

M a le G e n it a lia Wear gloves to examine the male genitalia (Fig. 13-1). The patient may be standing or supine.

Techniques of Examination

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Tunica vaginalis Scrotum

Tes tis Epididymis Spermatic cord

Ejaculatory duct

Seminal ves icle

Prepuce

Urethral meatus

Glans Corona

Corpus spongiosum

Corpus cavernosum

Blood vessels

Vas deferens

Urethra

Bulb of the penis

Figure 13-1 Anatomy of male genitalia.

/ Th e Pe n is

Inspect the:

■ Development of the penis and the skin and hair at its base

■ Prepuce (if present, retract the foreskin)

■ Glans

Sexual maturation, lice

Phimosis, cancer

Balanitis, chancre, herpes, warts, cancer

Chapter 13 | Male Genitalia and Hernias 237

■ Urethral meatus (compress the glans to inspect the meatus for discharge)

Palpate:

■ Any visible lesions

■ The shaft

Th e S c ro t u m a n d It s Co n t e n t s

Inspect:

■ Skin of scrotum

■ Contours of scrotum

■ Inguinal areas

Palpate each:

■ Testis (Fig. 13-2), noting any:

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Hypospadias, discharge of urethritis

Chancre, cancer

Urethral stricture or cancer

Rashes

Hernia, hydrocele, cryptorchidism

Fungal infection

See Table 13-3, Abnormalities of the Testis, p. 244.

Figure 13-2 Palpate the tes tis and epididymis .

■ Lumps

■ Tenderness

Testicular carcinoma

Acute epididymitis, acute orchitis, tor- sion of the spermatic cord, strangulated inguinal hernia.

238 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

■ Epididymis

■ Spermatic cord and adjacent areas (Fig. 13-3)

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Figure 13-3 Palpate the spermatic cord.

Varicocele if multiple tortuous veins; cystic structure may be a hydrocele

See Table 13-4, Abnormalities of the Epididymis and Spermatic Cord, p. 245.

H e r n ia s Patient is usually standing.

Inspect inguinal and femoral areas as patient strains down.

Palpate external inguinal ring through scrotal skin and ask patient to strain down (Fig. 13-4).

See Table 13-5, Hernias in the Groin, p. 246.

Inguinal and femoral hernias

Inguina l ligament

Exte rna l inguina l

ring

Figure 13-4 Invaginate the scrotum.

Indirect and direct inguinal hernias

Epididymitis, cyst

Chapter 13 | Male Genitalia and Hernias 239

S p e c ia l T e c h n iq u e

P a t ie n t In s t r u c t io n s f o r t h e Te s t ic u la r S e lf -E x a m in a t io n

This ex in tion is best erfor ed fter w r b th or shower. This w y the scrot l skin is w r nd rel xed. It is best to do the test while st nding.

● St nding in front of irror, check for ny swelling on the skin of the scro- tu .

● With the enis out of the w y, gently feel your scrot l s c to loc te testicle. Ex ine e ch testicle se r tely.

As noted by the A eric n C ncer Society, “It’s nor l for one testicle to be slightly l rger th n the other, nd for one to h ng lower th n the other. You should lso know th t e ch nor l testicle h s s ll, coiled tube (e ididy- is) th t c n feel like s ll bu on the u er or iddle outer side of the testicle. Nor l testicles lso h ve blood vessels, su orting tissues, nd tubes th t c rry s er . So e en y confuse these with bnor l lu s t first . If you h ve ny concerns, sk your doctor or clinici n.”

● Use one h nd to st bilize the testicle. Using the fingers nd thu b of your other h nd, fir ly but gently feel or roll the testicle between your fingers. Feel the entire surf ce. Find the e ididy is. This is soft , tube-like structure t the b ck of the testicle th t collects nd c rries s er , nd is not n bnor- l lu . Check the other testicle nd e ididy is the s e w y.

● If you find h rd lu , n bsent or enl rged testicle, inful swollen scro- tu , or ny other differences th t do not see nor l, do not w it . See your he lth c re rovider right w y.

Sources: A eric n C ncer Society. Testicul r self-ex . U d ted J nu ry 21, 2 15. Av il ble t htt :/ /www.c ncer.org/c ncer/ testicul rc ncer/ oreinfor tion/doih vetesticul rc ncer/ do-i-h ve-testicul r-c ncer-self-ex . Accessed M y 13, 2 15; U.S. N tion l Libr ry of Medicine, N tion l Institutes of He lth. MedlinePlus—Testicul r self-ex . U d ted Dece ber 27, 2 13. Av il ble t htt :/ /www.nl .nih.gov/ edline lus/ency/ rticle/ 39 9.ht . Accessed M y 13, 2 15.

240 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

Recording Your Findings

R e c o r d in g t h e M a le G e n it a lia a n d H e r n ia E x a m in a t io n

“Circu cised le. No enile disch rge or lesions. No scrot l swelling or discolor tion. Testes descended bil ter lly, s ooth, without sses. E ididy is nontender. No inguin l or fe or l herni s.” OR “Uncircu cised le; re uce e sily retr ctible. No enile disch rge or lesions. No scrot l swelling or discolor tion. Testes descended bil ter lly; right testicle s ooth; 1 × 1 c fir nodule on left l ter l testicle. It is fixed nd nontender. E ididy is nontender. No inguin l or fe or l herni s.” (These findings are suspicious for testicular carcinoma, the most common form of cancer in men between ages 15 and 35 years).

Chapter 13 | Male Genitalia and Hernias 241

Aids to Interpretation

Hyp o s p a d ia s S c ro t a l Ed e m a

A congenital displacement of the urethral meatus to the inferior surface of the penis. A groove extends from the actual urethral meatus to its normal location on the tip of the glans.

Pitting edema may make the scrotal skin taut; seen in heart failure or nephrotic syndrome.

P e yro n ie Dis e a s e

Fingers can ge t above mass

Hyd ro c e le

Palpable, nontender, hard plaques are found just beneath the skin, usually along the dorsum of the penis. The patient complains of crooked, painful erections.

A nontender, fluid-filled mass within the tunica vaginalis. It transilluminates, and the examining fingers can get above the mass within the scrotum.

Ca rc in o m a o f t h e P e n is

Fingers cannot ge t above mass

S c ro t a l He rn ia

An indurated nodule or ulcer that is usually nontender. Limited almost completely to men who are not circumcised, it may be masked by the prepuce. Any persistent penile sore is suspicious.

Usually an indirect inguinal hernia that comes through the external inguinal ring, so the examining fingers cannot get above it within the scrotum.

Ab n o rm a lit ie s o f t h e Pe n is a n d Sc ro t u mTable 13-1

242 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

Ge n it a l Wa r t s (Co n d y lo m a t a Ac u m in a t a ) ■ Appearance: Single or multiple

papules or plaques of variable shapes; may be round, acuminate (or pointed), or thin and slender. May be raised, flat, or cauliflower-like (verrucous).

■ Causative organism: Human papillomavirus (HPV), usually from subtypes 6, 11; carcinogenic subtypes rare, approximately 5%–10% of all anogenital warts.

■ Incubation: Weeks to months; infected contact may have no visible warts.

■ Can arise on penis, scrotum, groin, thighs, anus; usually asymptomatic, occasionally cause itching and pain.

■ May disappear without treatment.

Ge n it a l He rp e s S im p le x ■ Appearance: Small scattered or

grouped vesicles, 1–3 mm in size, on glans or shaft of penis. Appear as erosions if vesicular membrane breaks.

■ Causative organism: Usually Herpes simplex virus 2 (90%), a double-stranded DNA virus. Incubation: 2–7 days after exposure.

■ Primary episode may be asymptomatic; recurrence usually less painful, of shorter duration.

■ Associated with fever, malaise, headache, arthralgias; local pain and edema, lymphadenopathy.

■ Need to distinguish from genital herpes zoster (usually in older patients with dermatomal distribution); candidiasis.

Sexu a lly Tra n s m it t e d In fe c t io n s o f Ma le Ge n it a lia

Table 13-2

Chapter 13 | Male Genitalia and Hernias 243

P r im a ry S yp h ilis ■ Appearance: Small red papule

that becomes a chancre, or painless erosion up to 2 cm in diameter. Base of chancre is clean, red, smooth, and glistening; borders are raised and indurated. Chancre heals within 3–8 weeks.

■ Causative organism: Treponema pallidum, a spirochete.

■ Incubation: 9–90 days after exposure.

■ May develop inguinal lymphadenopathy within 7 days; lymph nodes are rubbery, nontender, mobile.

■ 20%–30% of patients develop secondary syphilis while chancre still present (suggests coinfection with HIV).

■ Distinguish from: genital herpes simplex, chancroid, granuloma inguinale from Klebsiella granulomatis (rare in the United States; four variants, so difficult to identify).

Ch a n c ro id ■ Appearance: Red papule or

pustule initially, then forms a painful deep ulcer with ragged nonindurated margins; contains necrotic exudate, has a friable base.

■ Causative organism: Haemophilus ducreyi, an anaerobic bacillus.

■ Incubation: 3–7 days after exposure.

■ Painful inguinal adenopathy; suppurative bobos in 25% of patients.

■ Need to distinguish from: primary syphilis; genital herpes simplex; lymphogranuloma venereum, granuloma inguinale from Klebsiella granulomatis (both rare in the United States).

Sexu a lly Tra n s m it t e d In fe c t io n s o f Ma le Ge n it a lia (continued )

Table 13-2

244 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

Cryp t o rch id is m Testis is atrophied and may lie in the inguinal canal or the abdomen, resulting in an unfilled scrotum. As above, there is no palpable left testis or epididymis. Cryptorchidism markedly raises the risk for testicular cancer.

S m a ll Te s t is In adults, testicular length is usually ≤3.5 cm. Small, firm testes seen in Klinefelter syndrome, usually ≤2 cm. Small, soft testes suggesting atrophy seen in cirrhosis, myotonic dystrophy, use of estrogens, and hypopituitarism; may also follow orchitis.

Ac u t e Orch it is The testis is acutely inflamed, painful, tender, and swollen. It may be difficult to distinguish from the epididymis. The scrotum may be reddened. Seen in mumps and other viral infections; usually unilateral.

Early

Tu m o r o f t h e Te s t is Usually appears as a painless nodule. Any nodule within the testis warrants investigation for malignancy.

Late

As a testicular neoplasm grows and spreads, it may seem to replace the entire organ. The testicle characteristically feels heavier than normal.

Ab n o rm a lit ie s o f t h e Te s t isTable 13-3

Chapter 13 | Male Genitalia and Hernias 245

Ac u t e Ep id id ym it is An acutely inflamed epididymis is tender and swollen and may be difficult to distinguish from the testis. The scrotum may be reddened and the vas deferens inflamed. It occurs chiefly in adults. Coexisting urinary tract infection or prostatitis supports the diagnosis.

S p e rm a t o c e le a n d Cys t o f t h e Ep id id ym is A painless, movable cystic mass just above the testis suggests a spermatocele or an epididymal cyst. Both transilluminate. The former contains sperm, and the latter does not, but they are clinically indistinguishable.

Va r ic o c e le o f t h e S p e rm a t ic Co rd Varicocele refers to varicose veins of the spermatic cord, usually found on the left. It feels like a soft “bag of worms” separate from the testis, and slowly collapses when the scrotum is elevated in the supine patient.

To r s io n o f t h e S p e rm a t ic Co rd Twisting of the testicle on its spermatic cord produces an acutely painful and swollen organ that is retracted upward in the scrotum, which becomes red and edematous. There is no associated urinary infection. It is a surgical emergency because of obstructed circulation.

Ab n o rm a lit ie s o f t h e Ep id id ym is a n d S p e rm a t ic Co rd

Table 13-4

246 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

In d ire c t In g u in a l Most common hernia at all ages, both sexes. Originates above inguinal ligament and often passes into scrotum. May touch examiner’s fingertip in inguinal canal.

Dire c t In g u in a l Less common than indirect hernia, usually occurs in men older than 40 years. Originates above inguinal ligament near external inguinal ring and rarely enters scrotum. May bulge anteriorly, touching side of examiner’s finger.

Fe m o ra l Least common hernia, more common in women than in men. Originates below inguinal ligament, more lateral than inguinal hernia. Never enters scrotum.

He rn ia s in t h e Gro inTable 13-5

247

C H A P T E R

14Female Genitalia

The Health History

Me n a rch e , Me n s t ru a t io n , Me n o p a u s e , Po s t m e n o - p a u s a l Ble e d in g ; P re g n a n c y. For the menstrual history, ask when menstrual periods began (age at menarche).

When did her last menstrual period (LMP) start, and the one prior menstrual period (PMP)? What is the interval between peri- ods, from the rst day of one to the rst day of the next? Are menses regular or irregular? How long do they last? How heavy is the ow?

Amenorrhea is the absence of periods. Failure to begin periods is primary amenorrhea, whereas cessation of established periods is secondary amenorrhea.

C o m m o n C o n c e r n s

● Men rche, enstru tion, eno use, ost eno us l bleeding ● Pregn ncy ● Vulvov gin l sy to s ● Sexu l he lth ● Pelvic in— cute nd chronic ● Sexu lly tr ns itted infections (STIs)

Changes in the interval between periods can signal possible pregnancy or men- strual irregularities.

Secondary amenorrhea from pregnancy, lactation, menopause; low body weight from conditions of malnutrition, anorexia nervosa, stress, chronic illness, and hypothalamic–pituitary–ovarian dysfunction

248 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

In amenorrhea from pregnancy, com- mon early symptoms are tender- ness, tingling, or increased size of breasts; urinary frequency; nausea and vomiting; easy fatigability; and feelings that the baby is moving (usually noted at about 20 weeks).

Dysmenorrhea, or painful menses, is common.

Menopause, the absence of menses for 12 consecutive months, usually occurs between 48 and 55 years. Associated symptoms include hot ashes, ushing, sweating, and sleep disturbances.

Vu lvo va g in a l S ym p t o m s . For vaginal discharge and local itching, inquire about amount, color, con- sistency, and odor of discharge.

S e xu a l He a lt h . Ask neutral questions about sexual orientation and gender identity: “Are you cur- rently dating, sexually active, or in a relationship?” “How would you identify your sexual orientation?” Then, “How would you describe your gender identity?” and “Do you use protection such as birth control or condoms? . . . Has anyone ever tried to touch or have sex with you without your consent?”

To assess sexual health, be non- judgmental. Ask “How is sex for you?” “Are you having any prob- lems with sex? This includes sexual intercourse and anal and oral sex.” Or, “Are you satis ed with your sex life as it is now?”

Primary dysmenorrhea from increased prostaglandin production; secondary dysmenorrhea from endometriosis, ade- nomyosis, pelvic inflammatory disease, and endometrial polyps

Postmenopausal bleeding, or bleeding occurring 6 months after cessation of menses, from endometrial cancer, hor- mone replacement therapy (HRT), or uterine or cervical polyps

See Table 14-1, Lesions of the Vulva, pp. 258–259; and Table 14-2, Vaginal Discharge, p. 260.

Amenorrhea followed by heavy bleeding in threatened abortion or dysfunctional uterine bleeding

Chapter 14 | Female Genitalia 249

Direct questions help you assess desire, arousal, and orgasm.

“Do you have an interest in (appe- tite for) sex?” “Do you get sexually aroused?” “Are you able to reach climax?”

Ask also about dyspareunia, or dis- comfort or pain during intercourse.

Pe lvic Pa in . Assess acute and chronic (>6 months) pelvic pain.

S e xu a lly Tra n s m it t e d In fe c - t io n . Identify sexual preference (male, female, or both) and the number of sexual partners in the previous month. Ask if the patient has concerns about HIV infection, desires HIV testing, or has current or past partners at risk.

Superficial pain suggests local inflam- mation, atrophic vaginitis, or inadequate lubrication; deeper pain may result from pelvic disorders or pressure on a normal ovary.

Acute pelvic pain in PID, ruptured ovar- ian cyst, appendicitis; ectopic preg- nancy; also mittelschmerz, ruptured ovarian cyst, tubo-ovarian abscess. Chronic pelvic pain in endometriosis, PID, adenosis and fibroids, history of sexual abuse; pelvic floor spasm.

In women, some STIs do not produce symptoms, but do increase the risk of infertility.

Health Promotion and Counseling: Evidence and Recommendations

Im p o r t a n t T o p ic s f o r H e a lt h P r o m o t io n a n d C o u n s e lin g

● Cervic l c ncer screening ● Ov ri n c ncer ● STIs nd HIV infection ● O tions for f ily l nning ● Meno use nd hor one re l ce ent ther y

Ce rvic a l Ca n c e r S c re e n in g . In 2012, ve major societies released common guidelines for cervical cancer screening.

250 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

The most important risk factor for cervical cancer is HPV infection from HPV strains 16, 18, 6, or 11. The three-dose HPV vaccination series pre- vents HPV infection from the strains when given before sexual exposure at age 11 years. The vaccine is also recommended for unvaccinated and immunocompromised girls and women up to age 26 years.

Ova ria n Ca n c e r. There are no effective screening tests to date. Risk factors include family history of breast or ovarian cancer and BRCA1 or BRCA2 mutation. Watch for the nonspeci c symptoms of new abdominal distention, abdominal bloating, and urinary frequency.

S TIs a n d HIV In fe c t io n . Assess risk factors by taking a careful sexual history and counseling patients about spread of disease and ways to reduce high-risk practices. Chlamydia trachomatis is the most commonly reported STI in the United States and the most common STI in women. The CDC

C u r r e n t C e r v ic a l C a n c e r S c r e e n in g G u id e lin e s f o r A v e r a g e -R is k W o m e n a: U S P S T F , A C S / A S C C P / A S C P , a n d A C O G

Va ria b le Re c o m m e n d a t io n

Age t which to begin screening 21 ye rs Screening ethod nd interv l Ages 21–65 ye rs: cytology every 3 ye rs

OR Ages 21–29 ye rs: cytology every 3 ye rs Ages 3 –65 ye rs: cytology lus HPV test-

ing (for high-risk or oncogenic HPV ty es) every 5 ye rs

Age t which to end screening Age >65 ye rs, ssu ing three consecutive neg tive results on cytology or two con- secutive neg tive results on cytology lus HPV testing within 1 ye rs before cess tion of screening, with the ost recent test erfor ed within 5 ye rs

Screening fter hysterecto y with re ov l of the cervix

Not reco ended

USPSTF, U.S. Preventive Services T sk Force; ACS/ASCCP/ASCP, A eric n C ncer Society/ A eric n Society for Col osco y nd Cervic l P thology/A eric n Society for Clinic l P thology; ACOG, A eric n College of Obstetrici ns nd Gynecologists; HPV, hu n illo virus.

aDefinition of Average Risk: No history of high-gr de, rec ncerous cervic l lesion (cervic l intr e itheli l neo l si gr de 2 or ore severe lesion) or cervic l c ncer; not i uno- co ro ised (including being HIV-infected); nd no in utero ex osure to diethylstilbestrol.

Source: S w y GF, Kul sing S, Denberg T, et l. Cervic l c ncer screening in ver ge-risk wo en: best r ctice dvice fro the Clinic l Guidelines Co ittee of the A eric n College of Physici ns. Ann Intern Med. 2 15;162:851.

Chapter 14 | Female Genitalia 251

and the USPSTF strongly recommend screening for STIs as summarized in the box below.

Op t io n s fo r Fa m ily P la n n in g . More than half of U.S. pregnancies are unintended. Counsel women, particularly adolescents, about the timing of ovulation, midway in the regular menstrual cycle. Discuss methods for con- traception and their effectiveness.

C D C S T D a n d H IV S c r e e n in g R e c o m m e n d a t io n s 2 0 1 4

● Chl ydi nd gonorrhe screening nnu lly for ll sexu lly ctive wo en ges <25 ye rs nd older wo en with risk f ctors such s new or ulti le sex rtners, or sex rtner infected with n STD.

● Chl ydi , sy hilis, he titis B, nd HIV screening for ll regn nt wo en nd gonorrhe screening for t-risk regn nt wo en st rting e rly in reg- n ncy, with re e t testing s needed to rotect the he lth of others nd their inf nts.

● Chl ydi , gonorrhe , nd sy hilis screening t le st once ye r for ll sexu- lly ctive g y, bisexu l, nd other MSM. MSM who h ve ulti le or nony- ous rtners should be screened ore frequently for STDs (i.e., t 3- to 6- onth interv ls).

● HIV testing t le st once for ll dults nd dolescents fro ges 13–64 ye rs. ● HIV testing t le st once ye r for nyone h ving uns fe sex or using injec-

tion drug equi ent. Sexu lly ctive g y nd bisexu l en y benefit fro testing every 3–6 onths.

Source: Centers for Dise se Control nd Prevention. Sexu lly tr ns it ted dise ses. STD nd HIV screening reco end tions. U d ted Dece ber 16, 2 14. Av il ble t htt :/ /www. cdc.gov/std/ revention/screeningreccs.ht . Accessed M y 2 , 2 15.

O p t io n s f o r Fa m ily P la n n in g

Me t h o d s Typ e s o f Co n t ra c e p t io n

Natural Fertility w reness/ eriodic bstinence, withdr w l, l ct tion

Barrier M le condo , fe le condo , di hr g , cervic l c , s onge

Implantable Intr uterine device, subder l i l nt of levonorgestrel

Pharmacologic/ hormonal S er icide, or l contr ce tives (estrogen nd rogesterone; rogestin only), estrogen/ rogesterone inject bles nd tch, hor- on l v gin l contr ce tive ring, e ergency contr ce tion

Surgery (permanent) Tub l lig tion; tr nscervic l steriliz tion; v secto y

252 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

Me n o p a u s e a n d Ho rm o n e Re p la c e m e n t Th e ra p y. Be familiar with the psychological and physiologic changes of menopause. Help the patient to weigh the risks of HRT, including increased risk of stroke, pul- monary embolism, and breast cancer.

Techniques of Examination

Male examiners should be accompanied by female chaperones. Female examiners should be assisted whenever possible.

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

E x t e r n a l G e n it a lia Observe pubic hair to assess

sexual maturity.

Examine the external genitalia (Fig. 14-1).

■ Labia minora

■ Clitoris

■ Urethral ori ce

Normal or delayed puberty

See Table 14-1, Lesions of the Vulva, pp. 258–259.

Ulceration in herpes simplex, syphilitic chancre; inflammation in Bartholin cyst

Enlarged in masculinization

Urethral caruncle or prolapse; tenderness in interstitial cystitis

T ip s f o r t h e S u c c e s s f u l P e lv ic E x a m in a t io n

Th e P a t ie n t Th e Exa m in e r

● Avoids intercourse, douch- ing, or use of v gin l su os- itories for 24–48 hours before ex in tion

● E ties bl dder before ex in tion

● Lies su ine, with he d nd shoulders elev ted, r s t sides or folded cross chest to enh nce eye cont ct nd reduce tightening of bdo i- n l uscles

● Obt ins er ission; selects ch erone ● Ex l ins e ch ste of the ex in tion in

dv nce ● Dr es tient fro id bdo en to

knees; de resses dr e between knees to rovide eye cont ct with tient

● Avoids unex ected or sudden ove ents ● Chooses s eculu th t is the correct size ● W r s s eculu with t w ter ● Monitors co fort of the ex in tion by

w tching the tient’s f ce ● Uses excellent but gentle technique, es e-

ci lly when inserting the s eculu

Chapter 14 | Female Genitalia 253

■ Introitus

Milk the urethra for discharge if indicated.

Mons pubis

Prepuce

Clitoris

Ure thra l meatus

Opening of pa raure thra l

(Skene) gland

Ves tibule

Introitus

Perineum

Labia ma jora

Labia minora

Hymen

Vagina

Opening of Bartholin gland

Anus

Figure 14-1 External female genitalia.

Imperforate hymen

Discharge of urethritis

Cystocele, cystourethrocele, rectocele

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

In t e r n a l G e n it a lia a n d P a p S m e a r Locate the cervix with a gloved and water-lubricated index nger.

Assess support of vaginal outlet by asking patient to strain down.

Enlarge the introitus by pressing its posterior margin downward.

Insert a water-lubricated speculum of suitable size. Start with specu- lum held obliquely (Fig. 14-2), then rotate to horizontal position for full insertion (Fig. 14-3).

254 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

Open the speculum gently and inspect cervix:

■ Position

■ Color

■ Shape of the cervical os (Fig. 14-4); epithelial surface (squamous–columnar epithelial junction)

Figure 14-2 Entry angle . Figure 14-3 Carefully inse rt the speculum to full length.

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Cervix faces forward if uterus is retro- verted.

Purplish in pregnancy

Columnar epithe lium

Squamocolumnar junction

Squamous epithe lium

Exte rna l os of the ce rvix

Trans formation zone

Figure 14-4 Cervical epithe lial surface .

Oval (normal) or slit-like or transverse os from delivery; raised, friable, or lobed wart-like lesions in condylomata or cer- vical cancer (see Table 14-3, Abnormali- ties of the Cervix, p. 261)

■ Any discharge or bleeding

■ Any ulcers, nodules, or masses

Discharge from os in mucopurulent cer- vicitis from Chlamydia or gonorrhea (see Table 14-2, Vaginal Discharge, p. 260)

Herpes, polyp, cancer

Chapter 14 | Female Genitalia 255

Obtain specimens for cytology (Pap smears) with:

■ An endocervical broom (Fig. 14-5) or brush with scraper (except in pregnant women), to collect both squamous and columnar cells

■ Or, if the woman is pregnant, use a cotton-tipped applicator moistened with water

Inspect the vaginal mucosa as you withdraw the speculum.

Palpate, by means of a bimanual examination (Fig. 14-6):

■ The cervix and fornices

■ The uterus

■ Right and left adnexa (ovaries)

Early cancer before it is clinically evident

Figure 14-5 Endoce rvical broom.

Bluish color and deep rugae in preg- nancy; vaginal cancer (rare); vaginal dis- charge from infection from Candida, Trichomonas vaginalis, bacterial vaginosis (see Table 14-2, Vaginal Discharge, p. 260)

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Figure 14-6 Palpate the ce rvix, ute rus , and adnexa.

Pain on moving cervix in PID

Pregnancy, myomas; soft isthmus in early pregnancy (see Table 14-4, Positions of the Uterus and Uterine Myomas, p. 262)

Ovarian cysts or masses, salpingitis, PID, tubal pregnancy

256 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

Assess strength of pelvic muscles. With your vaginal ngers clear of the cervix, ask patient to tighten her muscles around your ngers as hard and long as she can.

/ When indicated, per- form a rectovaginal examination as shown in Figure 14-7 to palpate a retroverted uterus, uterosacral ligaments, cul-de-sac, and adnexa or screen for colorectal cancer in women 50 years or older (see p. 269).

A firm squeeze that compresses your fingers, moves them up and inward, and lasts more than 3 seconds is full strength (see Table 14-5, Relaxations of the Pelvic Floor, p. 263).

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Retroverted uterus

Figure 14-7 Examine the rectovaginal area.

H e r n ia s Ask the woman to strain down, as you palpate for a bulge in:

■ The femoral canal

■ The labia majora up to just lateral to the pubic tubercle

S p e c ia l T e c h n iq u e As s e s s in g Ure t h rit is . Insert your index nger into the vagina and milk the urethra gently outward from the inside (Fig. 14-8). Note any discharge.

Femoral hernia

Indirect inguinal hernia

Figure 14-8 Milk the ure thra if indicated.

Discharge in C. trachomatis and Neisseria gonorrhoeae infection

Chapter 14 | Female Genitalia 257

Recording Your Findings

R e c o r d in g t h e F e m a le G e n it a lia E x a m in a t io n

“No inguin l deno thy. Extern l genit li without erythe , lesions, or sses. V gin l ucos ink. Cervix rous, ink, nd without disch rge. Uterus nterior, idline, s ooth, nd not enl rged. No dnex l tenderness. P s e r obt ined. Rectov gin l w ll int ct . Rect l v ult without sses. Stool brown nd He occult neg tive.” OR “Bil ter l shotty inguin l deno thy. Extern l genit li without erythe or lesions. V gin l ucos nd cervix co ted with thin, white ho ogeneous disch rge with ild fishy odor. After sw bbing cervix, no disch rge visible in cervic l os. Uterus idline; no dnex l sses. Rect l v ult without sses. Stool brown nd He occult neg tive.” (These findings suggest bacterial vaginosis.)

258 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

Aids to Interpretation

Ep id e rm o id Cys t

Cys tic nodule in skin

A small, firm, round cystic nodule in the labia suggests an epidermoid cyst. They are yellowish in color. Look for the dark punctum marking the blocked opening of the gland.

Ve n e re a l Wa r t (Co n d ylo m a Ac u m in a t u m )

Warts

Warty lesions on the labia and within the vestibule suggest condyloma acuminata from infection with human papillomavirus.

Ge n it a l He rp e s

Sha llow ulcers on red bases

Shallow, small, painful ulcers on red bases suggest a herpes infection. Initial infection may be extensive, as illustrated here. Recurrent infections are usually confined to a small local patch.

Le s io n s o f t h e Vu lvaTable 14-1

Chapter 14 | Female Genitalia 259

S yp h ilit ic Ch a n c re A firm, painless ulcer suggests the chancre of primary syphilis. Because most chancres in women develop internally, they often go undetected.

S e c o n d a ry S yp h ilis (Co n d y lo m a La t u m )

Fla t, gray papule s

Slightly raised, round or oval flat-topped papules covered by a gray exudate suggest condylomata lata, a manifestation of secondary syphilis. They are contagious.

Ca rc in o m a o f t h e Vu lva An ulcerated or raised red vulvar lesion in an elderly woman may indicate vulvar carcinoma.

Le s io n s o f t h e Vu lva (continued )Table 14-1

260 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

Note: Accurate diagnosis depends on laboratory assessment and cultures.

Tr ich o m o n a s va g in it is Discharge : Yellowish green, often profuse, may be malodorous Other Symptoms: Itching, vaginal soreness, dyspareunia Vulva: May be red Vagina: May be normal or red, with red spots, petechiae Laboratory Assessment: Saline wet mount for trichomonads

Ca n d id a va g in it is Discharge: White, curdy, often thick, not malodorous Other Symptoms: Itching, vaginal soreness, external dysuria, dyspareunia Vulva: Often red and swollen Vagina: Often red with white patches of discharge Laboratory As se ss me nt: KOH preparation for branching hyphae

Ba c t e r ia l va g in o s is

Lactobacilli

Discharge : Gray or white, thin, homogeneous, scant, malodorous Other Symptoms: Fishy genital odor Vulva: Usually normal Vagina: Usually normal Laboratory Assessment: Saline wet mount for “clue cells,” “whiff test” with KOH for fishy odor

Va g in a l Dis ch a rg eTable 14-2

Chapter 14 | Female Genitalia 261

En d o c e r v ic a l p o lyp . A bright red, smooth mass that protrudes from the os suggests a polyp. It bleeds easily.

Mu c o p u ru le n t c e r v ic it is . A yellowish exudate emerging from the cervical os suggests infection from Chlamydia, gonorrhea (often asymptomatic), or herpes.

Ca rc in o m a o f t h e c e r v ix . An irregular hard mass suggests carcinoma from HPV infection. Early lesions are best detected by pap smear and HPV screening, followed by colposcopy.

Vagina l adenos is

Columnar epithe lium

Colla r

Fe t a l e xp o s u re t o d ie t h y l- s t ilb e s t ro l (DES ). Several changes may occur: a collar of tissue around the cervix, columnar epithelium that covers the cervix or extends to the vaginal wall (then termed vaginal adenosis), and, rarely, carcinoma of the vagina.

Ab n o rm a lit ie s o f t h e Ce rvixTable 14-3

262 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

An a n t e ve r t e d u t e ru s lies in a forward position at roughly a right angle to the vagina. This is the most common position. Anteflexion—a forward flexion of the uterine body in relation to the cervix—often coexists.

A re t ro ve r t e d u t e ru s is tilted posteriorly with its cervix facing anteriorly.

A re t ro f le xe d u t e ru s has a posterior tilt that involves the uterine body but not the cervix. A uterus that is retroflexed or retroverted may be felt only through the rectal wall; some cannot be felt at all.

A m yo m a o f t h e u t e ru s is a very common benign tumor that feels firm and often irregular. There may be more than one. A myoma on the posterior surface of the uterus may be mistaken for a retrodisplaced uterus; one on the anterior surface may be mistaken for an anteverted uterus.

Po s it io n s o f t h e Ut e ru s a n d Ut e rin e Myo m a s

Table 14-4

Chapter 14 | Female Genitalia 263

When the pelvic floor is weakened, various structures may become displaced. These displacements are seen best when the patient strains down.

A c ys t o c e le is a bulge of the anterior wall of the upper part of the vagina, together with the urinary bladder above it.

A c ys t o u re t h ro c e le involves both the bladder and the urethra as they bulge into the anterior vaginal wall throughout most of its extent.

A re c t o c e le is a bulge of the posterior vaginal wall, together with a portion of the rectum.

A p ro la p s e d u t e ru s has descended down the vaginal canal. There are three degrees of severity: first, still within the vagina (as illustrated); second, with the cervix at the introitus; and third, with the cervix outside the introitus.

Re la xa t io n s o f t h e Pe lvic Flo o rTable 14-5

265

C H A P T E R

15The Anus, Rectum, and Prostate

The Health History

C o m m o n o r C o n c e r n in g S y m p t o m s

● Ch nge in bowel h bits ● Blood in the stool ● P in with defec tion; rect l bleeding or tenderness ● An l w rts or fissures ● We k stre of urine ● Burning with urin tion ● Blood in urine

Ask about any change in bowel habits or stool size or caliber, and any diarrhea or constipation. Is there any blood in the stool, or dark tarry stools? Any mucus in the stool?

Any pain with defecation, or rectal bleeding or tenderness?

Any anal warts, ssures, or ulcer- ations?

In men, is there dif culty starting the urine stream or holding back urine? Is the ow weak? What about fre- quent urination, especially at night? Or pain or burning when passing urine? Any blood in the urine or semen or pain with ejaculation? Is there frequent pain or stiffness in the lower back, hips, or upper thighs?

Pencil-like stool or blood in stool in colon cancer; dark tarry stools if polyps, carci- noma, gastrointestinal bleeding; mucus in villous adenoma, inflammatory bowel disease (IBD), or irritable bowel syndrome (IBS)

Hemorrhoids; proctitis from sexually transmitted infections (STIs)

Human papillomavirus (HPV), condylomata lata in secondary syphilis; fissures in Crohn disease, proctitis from receptive anal intercourse, ulcerations of herpes simplex, or chancres of primary syphilis

These symptoms suggest urethral obstruction from benign prostatic hyper- plasia (BPH) or prostate cancer, especially in men age ≥70 years. The American Urological Association (AUA) Symptom Index helps quantify BPH severity (see Table 15-1, BPH Symptom Score Index: American Urological Association (AUA), p. 271).

266 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

P ro s t a t e Ca n c e r S c re e n in g . Prostate cancer is the leading nonskin cancer diagnosed in the United States and the second leading cause of death in men. Risk factors are age, family history of prostate cancer, and African American ethnicity.

Screening methods such as prostate-speci c antigen (PSA) test and the digital rectal examination (DRE) are not highly accurate, which complicates decisions about screening men without symptoms.

Th e P S A. PSA screening remains controversial, so warrants shared decision making about risks and benefits and patient preferences. About 12% of men have a PSA screening test above 4 ng/mL, but only 30% of these men have prostate cancer on biopsy. At 4 ng/mL, PSA sensitivity is 21% and specificity is 91%. See recommendations of major societies below.

Health Promotion and Counseling: Evidence and Recommendations

Im p o r t a n t T o p ic s f o r H e a lt h P r o m o t io n a n d C o u n s e lin g

● Prost te c ncer screening ● Colorect l c ncer screening ● Counseling for sexu lly tr ns itted infections

P r o s t a t e C a n c e r S c r e e n in g G u id e lin e s

Am e ric a n Uro lo g ic a l As s o c ia t io n

Am e ric a n Ca n c e r S o c ie t y

Un it e d S t a t e s P re ve n t ive S e rvic e s Ta s k Fo rc e

Sh red decision king

Yes Yes (consider using decision id)

Yes (when tient requests screening)

Age to begin offering screening

Aver ge-risk High-risk

4 ye rs 4 ye rs

5 ye rs 4 –45 ye rs

No reco end tion

Age to sto offering screening

Life ex ect ncy <1 ye rs

No reco end tion

Screening tests PSA DRE (o tion l)

PSA DRE (o tion l)

No reco end tion

(continued )

Chapter 15 | The Anus, Rectum, and Prostate 267

P r o s t a t e C a n c e r S c r e e n in g G u id e lin e s (Continued)

Am e ric a n Uro lo g ic a l As s o c ia t io n

Am e ric a n Ca n c e r S o c ie t y

Un it e d S t a t e s P re ve n t ive S e rvic e s Ta s k Fo rc e

Frequency of screening

Annu l Annu l (bienni l when PSA <2.5 ng/ L)

No reco end tion

Bio sy referr l criteri

PSA ≥4 ng/ L Abnor l DRE Individu lized risk

ssess ent for PSA levels 2.5–4 ng/ L

No reco end tion

Abbrevi tions: PSA, rost te-s ecific ntigen; DRE, digit l rect l ex in tion.

Th e DRE. reaches only the posterior and lateral surfaces of the prostate, missing findings in the anterior and central areas. DRE sensitivity for prostate cancers is only 59%.

Encourage men with symptomatic disorders such as incomplete emptying of the bladder, urinary frequency or urgency, weak or intermittent stream or straining to initiate ow, hematuria, nocturia, or even bony pains in the pelvis to seek evaluation and treatment early.

Co lo re c t a l Ca n c e r S c re e n in g . In 2008, screening recommendations were revised to promote more aggressive surveillance:

■ Clinicians should rst identify whether patients are at average or increased risk, ideally by age 20 years. High-risk factors include a personal history of colorectal neoplasia or long-standing IBD—or a family history of colorectal neoplasia, including hereditary syndromes. People at increased risk should undergo colonoscopy at intervals ranging from 3 to 5 years.

■ Average-risk patients 50 years or older should be offered a range of screening options to increase compliance: annual screening with high- sensitivity fecal occult blood tests (including guaiac-based Hemoccult tests and fecal immunochemical tests), colonoscopy every 10 years, or sigmoidoscopy every 5 years (which can be combined with high- sensitivity fecal occult blood testing performed every 3 years).

Co u n s e lin g fo r S TIs . Anal intercourse increases risk for HIV and STIs. Promote abstinence from high-risk behaviors, use of condoms, vaccination for hepatitis B and HPV, and good hygiene.

268 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

Wear gloves to examine the anus, rectum, and prostate (Fig. 15-1).

Techniques of Examination

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Valve of Houston

Peritonea l re flection

Rectum

Pros ta te

Anorecta l junction

Anal cana l

Ure thra

Bladder

Semina l ves icle

Figure 15-1 Anus and rectum—sagittal view.

M a le Position the patient on his side, or standing leaning forward over the examining table and hips exed (Fig. 15-2).

Figure 15-2 Position the patient on the left s ide .

Inspect the:

■ Sacrococcygeal area

■ Perianal area

Pilonidal cyst or sinus

Hemorrhoids, warts, herpes, chancre, cancer, fissures from proctitis, STIs, or Crohn disease, fistula from anorectal abscess

Chapter 15 | The Anus, Rectum, and Prostate 269

Palpate the anal canal and rectum with a lubricated and gloved nger. Palpate the:

■ Walls of the rectum

■ Prostate gland, as shown in Figure 15-3, including median sulcus

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Figure 15-3 Palpate the pros tate gland.

Figure 15-4 Rectal cancer.

Lax sphincter tone in some neurologic disorders; tightness in proctitis

Cancer of the rectum, polyps

Prostate nodule or cancer (Fig. 15-4); BPH; tenderness in prostatitis

Try to palpate above the prostate for irregularities or tenderness, if indicated.

/ Fe m a le The patient is usually in the lithotomy position or lying on her side.

Inspect the anus.

Palpate the anal canal and rectum.

See Table 15-2, Abnormalities on Rectal Examination, pp. 272–273.

Rectal shelf of peritoneal metastases; tenderness of inflammation

Hemorrhoids

Rectal cancer, normal uterine cervix or tampon (felt through the rectal wall)

270 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

Recording Your Findings

R e c o r d in g t h e A n u s , R e c t u m , a n d P r o s t a t e E x a m in a t io n

“No erirect l lesions or fissures. Extern l s hincter tone int ct. Rect l v ult without sses. Prost te s ooth nd nontender with l ble edi n sulcus. (Or in fe le, uterine cervix nontender.) Stool brown nd He occult neg tive.” OR “Perirect l re infl ed; no ulcer tions, w rts, or disch rge. C nnot ex ine extern l s hincter, rect l v ult, or rost te bec use of s s of extern l s hincter nd rked infl tion nd tenderness of n l c n l.” (These findings suggest proctitis from infectious cause.) OR “No erirect l lesions or fissures. Extern l s hincter tone int ct . Rect l v ult without sses. Left l ter l rost te lobe with 1 × 1 c fir h rd nodule; right l ter l lobe s ooth; edi l sulcus is obscured. Stool brown nd He occult neg tive.” (These findings are suspicious for prostate cancer.)

Chapter 15 | The Anus, Rectum, and Prostate 271

Aids to Interpretation

Score or ask the patient to score each of the questions below on a scale of 1 to 5, with 0 = not at all, 1 = less than 1 time in 5, 2 = less than half the time, 3 = about half the time, 4 = more than half the time, and 5 = almost always. Higher scores (maximum 35) indicate more severe symptoms; scores ≤7 are considered mild and generally do not warrant treatment.

PART A S c o re

1. Incomplete emptying: Over the past month, how often have you had a sensation of not emptying your bladder completely after you finished urinating?

2. Frequency: Over the past month, how often have you had to urinate again <2 hours after you finished urinating?

3. Intermittency: Over the past month, how often have you stopped and started again several times when you urinated?

4. Urgency: Over the past month, how often have you found it difficult to postpone urination?

5. Weak stream: Over the past month, how often have you had a weak urinary stream?

6. Straining: Over the past month, how often have you had to push or strain to begin urination?

PART A TOTAL SCORE

For Part B, 0 = none, 1 = 1 time, 2 = 2 times, 3 = 3 times, 4 = 4 times, 5 = 5 times.

PART B S c o re

7. Nocturia: Over the past month, how many times did you most typically get up to urinate from the time you went to bed at night until the time you got up in the morning? (Score 0 to 5 times on night)

TOTAL PARTS A and B (maximum 35)

BP H Sym p t o m Sc o re In d ex: Am e ric a n Uro lo g ic a l As s o c ia t io n (AUA)

Table 15-1

Adapted from: Madsen FA, Burskewitz RC. Clinical manifestations of benign prostatic hyperplasia. Urol Clin North Am. 1995;22:291.

272 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

Ext e rn a l He m o rrh o id s (Th ro m b o s e d ). Dilated hemorrhoidal veins that originate below the pectinate line, covered with skin; a tender, swollen, bluish ovoid mass is visible at the anal margin.

An a l Fis s u re . Painful longitudinal oval ulceration usually in posterior midline with swollen sentinel tag just below it.

FissureSentine l tag

An o re c t a l Fis t u la . An inflammatory tract or tube opening inside the anus or rectum and also onto the perianal area or into another viscus.

Opening

Fis tula

P o lyp s o f t h e Re c t u m . A soft mass that may or may not be on a stalk; may not be palpable.

Ab n o rm a lit ie s o n Re c t a l Exa m in a t io nTable 15-2

Chapter 15 | The Anus, Rectum, and Prostate 273

Be n ig n P ro s t a t ic Hyp e rp la s ia . An enlarged, nontender, smooth, firm but slightly elastic prostate gland; can cause symptoms without palpable enlargement.

Ac u t e P ro s t a t it is . A prostate that is very tender, swollen, and firm because of acute infection.

Ca n c e r o f t h e P ro s t a t e . A hard area in the prostate that may or may not feel nodular.

Ca n c e r o f t h e Re c t u m . Firm, nodular, rolled edge of an ulcerated cancer.

Ab n o rm a lit ie s o n Re c t a l Exa m in a t io n (continued )

Table 15-2

275

C H A P T E R

16The Musculoskeletal System

Fundamentals for Assessing Joints Musculoskeletal disorders are the leading primary diagnosis during of ce visits in the United States. Your rst goal is to assess four key features of the patient’s complaint. Is the joint problem:

■ Articular or extra-articular;

■ Acute (usually <6 weeks) or chronic (usually >12 weeks);

■ In ammatory or nonin ammatory; and

■ Localized (monoarticular) or diffuse (polyarticular)?

Assessing joints requires knowledge of each joint’s structure and function. Learn the surface landmarks and underlying anatomy of each of the major joints. Use the descriptive terms below.

J o in t A n a t o m y —Im p o r t a n t T e r m s

● Articular structures include the joint capsule nd articular cartilage, the synovium nd synovial fluid, intra-articular ligaments, nd juxta-articular bone. Articul r c rtil ge is co osed of coll gen trix cont ining ch rged ions nd w ter, llowing the c rtil ge to ch nge sh e in res onse to ressure or lo d, cting s cushion for underlying bone. Synovi l fluid rovides nutrition to the dj cent rel tively v scul r rticul r c rtil ge.

● Extra-articular structures include eri rticul r lig ents, tendons, burs e, uscle, f sci , bone, nerve, nd overlying skin. ● Ligaments re ro e-like bundles of coll gen fibrils th t connect bone to bone. ● Tendons re coll gen fibers connecting uscle to bone. ● Bursae re ouches of synovi l fluid th t cushion the ove ent of tendons

nd uscles over bone or other joint structures.

276 Ba tes’ Pocke t Guide to Physica l Examina tion and His tory Taking

Age also provides clues to causes of joint pain.

Review the three primary types of joint articulation—synovial, cartilagi- nous, and brous—and the varying degrees of movement each type allows. Note that joint anatomy determines its function and range of motion.

T y p e s o f J o in t s

S yn o via l J o in t s ● Freely ov ble within li its of

surrounding lig ents ● Se r ted by art icular cart ilage

nd synovial cavity ● Lubric ted by synovi l fluid ● Surrounded by joint c sule ● Example: knee, shoulder

Ca r t ila g in o u s J o in t s ● Slightly ov ble ● Cont in fibroc rtil ginous discs

th t se r te the bony surf ces ● H ve centr l nucleus pulposus of

discs th t cushions bony cont ct ● Example: vertebr l bodies

Fib ro u s J o in t s ● No reci ble ove ent ● Consist of fibrous tissue or c rtil ge ● L ck joint c vity ● Example: skull sutures

Bone

Synovia l membrane

Articula r cartilage

Synovia l cavity

Ligament

Joint space Joint capsule

Vertebra l body

Nucleus pulposus

of the disc

Disc

Ligament

C o m m o n C a u s e s o f J o in t P a in b y A g e

Ag e <6 0 Ye a r s Ag e >6 0 Ye a r s

● Re etitive str in or overuse syn- dro es (tendinitis, bursitis)

● Cryst lline rthritis (gout; cryst lline yro hos h te de osition dise se [CPPD])

● Rheu toid rthritis (RA), sori tic rthritis nd re ctive (Reiter) rthritis (in infl tory bowel dise se [IBD])

● Infectious rthritis fro gonorrhe , Ly e dise se, or vir l or b cteri l infections

● Osteo rthritis (OA) ● Osteo orotic fr cture ● Gout nd seudogout

● Poly y lgi rheu tic (PMR)

● Se tic b cteri l rthritis

Chapter 16 | The Musculoskeletal System 277

Review the types of synovial joints and their associated features as well.

T y p e s o f S y n o v ia l J o in t s

S p h e ro id a l (b a ll a n d s o ck e t ) Articul r sh e: Convex surf ce in conc ve

c vity Move ent: Wide-r nging flexion, extension,

bduction, dduction, rot tion, circu duction

Ex le: Shoulder, hi

Hin g e Articul r sh e: Fl t , l n r Move ent: Motion in one l ne; flexion,

extension Ex le: Inter h l nge l joints of h nd nd

foot; elbow

Co n d yla r Articul r sh e: Convex or conc ve Move ent: Move ent of two rticul ting

surf ces, not dissoci ble Ex le: Knee; te oro ndibul r joint

The Health History

C o m m o n o r C o n c e r n in g S y m p t o m s

● Joint in: rticul r or extr - rticul r, cute or chronic, infl tory or noninfl tory, loc lized or diffuse

● Joint in: ssoci ted constitution l sy to s nd syste ic nifest tions fro other org n syste s

● Neck in ● Low b ck in

278 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

Assess the seven features of any joint pain (see p. 47).

J o in t Pa in

Ar t ic u la r o r Ex t ra -a r t ic u la r. Ask “Do you have any pains in your joints?” Ask the patient to point to the pain. If localized and involving only one joint, it is monoarticular.

If polyarticular, does it migrate from joint to joint, or steadily spread from one joint to multiple joint involvement? Is the involvement symmetric?

If pain is extra-articular, are there generalized “aches and pains” (myalgia if in muscles, arthralgia if in joints with no evidence of arthritis)?

Ask if there is decreased joint movement or stiffness.

Ac u t e o r Ch ro n ic . Acute joint pain typically lasts up to 6 weeks; chronic pain lasts >12 weeks. Assess the timing, quality, and severity of joint symptoms.

See Table 16-1, Patterns of Pain in and Around the Joints, p. 304.

Consider trauma, monoarticular arthri- tis, tendinitis, or bursitis. Hip pain near the greater trochanter suggests trochanteric bursitis.

Migratory pattern in rheumatic fever or gonococcal arthritis; progressive and symmetric pattern in rheumatoid arthritis

Bursitis if inflammation of bursae; tendi- nitis if in tendons, and tenosynovitis if in tendon sheaths; also sprains from stretching or tearing of ligaments

In articular pain, decreased active and passive range of motion and morning stiffness (“gelling”); in nonarticular joint pain, periarticular tenderness and only passive range of motion intact

Severe pain of rapid onset in red swollen joint in acute septic arthritis or crystal- line arthritis (gout; CPPD). In children, osteomyelitis in bone contiguous to a joint.

T ip s f o r A s s e s s in g J o in t P a in

● Ask the tient to “ oint to the in.” This y s ve consider ble ti e bec use ny tients h ve trouble in ointing in loc tion in words.

● Cl rify nd record when the in st rted nd the ech nis of injury, rtic- ul rly if there is history of tr u .

● Deter ine whether the in is rticul r or extr - rticul r, cute or chronic, infl tory or noninfl tory, nd loc lized ( ono rticul r) or diffuse ( oly rticul r).

Chapter 16 | The Musculoskeletal System 279

If from trauma, what was the mech- anism of injury or series of events that caused the joint pain? Further- more, what aggravates or relieves the pain? What are the effects of exercise, rest, and treatment?

In f la m m a t o ry o r No n in f la m - m a t o ry. Is the problem inflamma- tory or noninflammatory? Is there fever, chills, tenderness, warmth, or redness?

Assess any stiffness or limitations of motion.

Lo c a lize d o r D iffu s e . Ask the patient to point to the joints that are painful to determine if joint pain is be monoarticular, oligoar- ticular involving two to four joints, or polyarticular.

J o in t P a in : As s o c ia t e d Co n s t it u t io n a l S ym p t o m s a n d S ys t e m ic Ma n ife s t a - t io n s f ro m Ot h e r Org a n S ys t e m s . Assess constitutional symptoms such as fever, chills, rash, fatigue, anorexia, weight loss, and weakness.

Ne ck Pa in . Ask about location, radiation into the shoulders or arms, arm or leg weakness, bladder or bowel dysfunction.

If the patient reports neck trauma, common in motor vehicle acci- dents, ask about neck tenderness and consider clinical decision rules

See Table 16-1, Patterns of Pain in and Around the Joints, p. 304.

If inflammatory, consider infectious causes (Neisseria gonorrhoeae or Myco- bacterium tuberculosis), crystal-induced (gout, pseudogout), immune-related (RA, SLE), reactive (rheumatic fever, reac- tive arthritis), or idiopathic arthritis. If noninflammatory, consider trauma (rotator cuff tear), repetitive use (bursitis, tendinitis), OA, fibromyalgia.

Morning stiffness that gradually improves with activity in inflammatory disorders like RA and PMR; intermittent stiffness and gelling in OA

Monoarticular arthritis in traumatic, crystalline, or septic arthritis; oligoar- ticular arthritis gonorrhea or rheumatic fever, connective tissue disease, and OA; polyarthritis if may be viral or inflamma- tory from RA, SLE, or psoriasis

Common in RA, SLE, PMR, and other inflammatory arthritides. High fever and chills suggest an infectious cause.

C7 or C6 spinal nerve compression from foraminal impingement more common than disc herniation. See Table 16-2, Pains in the Neck, p. 305.

280 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

that identify risk of cervical cord injury (NEXUS criteria and Canadian C-Spine Rule).

Lo w Ba ck Pa in . There are numerous clinical guidelines, but most categorize low back pain into three groups: nonspeci c (>90%), nerve root entrapment with radicu- lopathy or spinal stenosis (�5%), and pain from a speci c underlying disease (1% to 2%). Ask, “Do you have any pains in your back?” and “Is the pain in the midline over the vertebrae, or off midline?”

If the pain radiates into the legs, ask about any associated numb- ness, tingling, or weakness. Ask about history of trauma.

Check for bladder or bowel dys- function.

Elicit any “red ags” for serious underlying systemic disease.

See Table 16-3, Low Back Pain, pp. 306– 307. Midline back pain in vertebral col- lapse, disc herniation, epidural abscess, spinal cord compression, or spinal cord metastases. Pain off the midline in mus- cle strain, sacroiliitis, trochanteric bursi- tis, sciatica, hip arthritis, renal conditions such as pyelonephritis or renal stones

Scia tica if radicular gluteal and posterior leg pain in the S1 distribution that increases with cough or Valsalva

Present in cauda equina syndrome from S2–S4 tumor or disc herniation, espe- cially if “saddle anesthesia”from perianal numbness

R e d F la g s f o r Lo w B a c k P a in f r o m U n d e r ly in g S y s t e m ic D is e a s e

● Age <2 ye rs or >5 ye rs ● History of c ncer ● Unex l ined weight loss, fever, or decline in gener l he lth ● P in l sting ore th n 1 onth or not res onding to tre t ent ● P in t night or resent t rest ● History of intr venous drug use, ddiction, or i unosu ression ● Presence of ctive infection or hu n i unodeficiency virus (HIV) infection ● Long-ter steroid ther y ● S ddle nesthesi , bl dder or bowel incontinence ● Neurologic sy to s or rogressive neurologic deficit

Chapter 16 | The Musculoskeletal System 281

Nu t rit io n , We ig h t , a n d P hys ic a l Ac t ivit y. Good nutrition sup- plies the calcium and vitamin D needed for bone mineralization and bone density, with supplements advised in selected age groups. Optimal weight reduces excess mechanical stress on weight-bearing joints like the hips and knees. Exercise helps maintain bone mass and improves outlook and stress management.

Health Promotion and Counseling: Evidence and Recommendations

Im p o r t a n t T o p ic s f o r H e a lt h P r o m o t io n a n d C o u n s e lin g

● Nutrition, weight, nd hysic l ctivity ● Low b ck in ● Osteo orosis: risk f ctors, screening, nd ssessing fr cture risk ● Tre ting osteo orosis nd reventing f lls

Lo w Ba ck Pa in . The estimated lifetime prevalence of low back pain in the U.S. population is over 80%. Most patients with acute low back pain get better within 6 weeks; for patients with nonspeci c symptoms, clinical guidelines emphasize reassurance, staying active, analgesics, muscle relax- ants, and spinal manipulation therapy. About 10% to 15% of these patients develop chronic symptoms, often associated with long-term disability. Poor outcomes are linked to inappropriate beliefs about low back pain as a seri- ous clinical condition, maladaptive pain-coping behaviors (avoiding work, movement, or other activities for fear of causing back damage), multiple nonorganic physical examination ndings, psychiatric disorders, poor general health, high levels of baseline functional impairment, and low work satisfaction.

Os t e o p o ro s is : Ris k Fa c t o rs , S c re e n in g , a n d As s e s s in g Fra c t u re Ris k . Osteoporosis is a major public health threat and a common U.S. health problem—9% of adults over age 50 years have

P h y s ic a l A c t iv it y G u id e lin e s f o r A m e r ic a n s

● At le st 2 hours nd 3 inutes week of oder te-intensity, or 1 hour nd 15 inutes week of vigorous-intensity, aerobic physical activity, or n equiv lent co bin tion

● Moder te- or high-intensity muscle-strengthening activity th t involves ll jor uscle grou s on 2 or ore d ys week

282 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

osteoporosis at the femoral neck or lumbar spine, including 16% of women and 4% of men. Half of all postmenopausal women sustain an osteoporosis-related fracture during their lifetime; 25% develop vertebral deformities, and 15% suffer hip fractures that increase risk of chronic pain, disability, loss of independence, and increased mortality.

The U.S. Preventive Services Task Force (USPSTF) gives a grade B recom- mendation supporting osteoporosis screening for women age ≥65 years and for younger women whose 10-year fracture risk equals or exceeds that of an average-risk 65-year-old white woman.

■ Use the country-speci c FRAX calculator to assess fracture risk. If risk is >9.3% for any fracture and >3% for hip fracture, bone density screen- ing is warranted. The website for the FRAX Calculator for Assessing Fracture Risk for the United States is http://www.shef.ac.uk/FRAX/tool. jsp?country=9.

■ Use the World Health Organization scoring criteria to determine bone density.

R is k Fa c t o r s f o r O s t e o p o r o s is

● Post eno us l st tus in wo en ● Age ≥5 ye rs ● Prior fr gility fr cture ● Low body ss index ● Low diet ry c lciu ● Vit in D deficiency ● Tob cco nd excessive lcohol use ● F ily history of fr cture in first-

degree rel tive, rticul rly with history of fr gility fr cture

● Clinic l conditions such s thyro- toxicosis, celi c s rue, IBD, cirrho- sis, chronic ren l dise se, org n tr ns l nt tion, di betes, HIV, hy ogon dis , ulti le yelo , norexi nervos , nd rheu to- logic nd utoi une disorders

● Medic tions such s or l nd high-dose inh led corticosteroids, ntico gul nts (long-ter use), ro t se inhibitors for bre st c ncer, ethotrex te, selected ntiseizure edic tions, i uno- su ressive gents, roton- u inhibitors (long-ter use), nd ntigon d l ther y for rost te c ncer

W o r ld H e a lt h O r g a n iz a t io n B o n e D e n s it y C r it e r ia

Osteoporosis: T score <−2.5 (>2.5 st nd rd devi tions below the e n for young dult white wo en)

Osteopenia: T score between −1. nd −2.5 (1. to 2.5 SDs below the young dult e n)

Chapter 16 | The Musculoskeletal System 283

Tre a t in g Os t e o p o ro s is a n d P re ve n t in g Fa lls . Learn the thera- peutic uses of agents that inhibit bone resorption: calcium and vitamin D; antiresorptive agents such as bisphosphonates, selective estrogen-receptor modulators (SERMs), calcitonin, and postmenopausal estrogen; and anabolic agents such as PTH.

More than one in three adults over age 65 years falls each year. Risk factors for falls include increasing age, impaired gait and balance, postural hypo- tension, loss of strength, medication use, comorbid illness, depression, cognitive impairment, and visual de cits.

The USPSTF gives a grade B recommendation for providing exercise or physical therapy and/or vitamin D supplementation to prevent falls among at-risk community-dwelling adults age ≥65 years. Effective exercise inter- ventions target balance, gait, and strength training. Urge patients to correct poor lighting, dark or steep stairs, chairs at awkward heights, slippery or irregular surfaces, and ill- tting shoes. Scrutinize any medications affecting balance, especially benzodiazepines, vasodilators, and diuretics.

Inspect and palpate any joints with signs of in ammation.

Techniques of Examination

S t e p s f o r E x a m in in g t h e J o in t s

1. Ins ect for joint sy etry, lign ent, bony defor ities, nd swelling 2. Ins ect nd l te surrounding tissues for skin ch nges, nodules, uscle

tro hy, tenderness 3. Assess r nge of otion nd neuvers to test joint function nd st bility nd

the integrity of lig ents, tendons, burs e, es eci lly if in or tr u 4. Assess ny re s of infl tion, es eci lly tenderness, swelling, w r th,

redness

T h e F o u r S ig n s o f In f la m m a t io n

(continued )

● Swelling. P l ble swelling y involve: (1) the synovi l e br ne, which c n feel boggy or doughy; (2) effusion fro excess synovi l fluid within the joint s ce; or (3) soft tissue structures, such s burs e, tendons, nd tendon she ths.

● Warmth. Use the b cks of your fingers to co re the involved joint with its un ffected contr l ter l joint, or with ne rby tissues if both joints re involved.

284 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

Figure 16-2 Palpate the bicipital groove and tendon.

T h e F o u r S ig n s o f In f la m m a t io n (Continued)

● Redness. Redness of the overlying skin is the le st co on sign of infl - tion ne r the joints nd is usu lly seen in ore su erfici l joints like fingers, toes, nd knees.

● Pain or tenderness. Try to identify the s ecific n to ic structure th t is tender.

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Inspect the temporomandibular joint (TMJ) for swelling or redness.

Palpate the TMJ as the patient opens and closes the mouth (Fig. 16-1).

Palpate the muscles of mastication: the masseters, temporal muscles, and pterygoid muscles.

S h o u ld e r s Inspect the contour of the shoul- ders and shoulder girdles from front and back.

Palpate:

■ The clavicle from the sternocla- vicular joint to the acromiocla- vicular joint (Fig. 16-2)

■ The bicipital tendon

Figure 16-1 Palpate the TMJ.

Muscle atrophy; anterior or posterior dislocation of humeral head; scoliosis if shoulder heights asymmetric

See Table 16-4, Painful Shoulders, p. 308.

“Step-offs”if fracture from trauma

T e m p o r o m a n d ib u la r J o in t

Chapter 16 | The Musculoskeletal System 285

■ The subacromial and subdeltoid bursae after lifting arm posteri- orly (Fig. 16-3)

Subacromia l bursa

Rota tor cuff

Figure 16-3 Palpate the subacromial bursa.

Subacromial or subdeltoid bursitis; ten- derness over the SITS (Supraspinatus, Infraspinatus, Teres minor, and Subscap- ularis) muscle insertions and difficulty abducting the arm above shoulder level occurs in sprains, tears, tendon rupture of rotator cuff.

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Assess range of motion.

■ Flexion—“Raise your arm in front of you and overhead.”

■ Extension—“Move your arms behind you.”

■ Abduction—“Raise your arms out to the side and overhead.”

■ Adduction—“Cross your arm in front of your body, keeping the arm straight.”

Intact glenohumeral motion if patient raises arms to shoulder level, palms facing down

Intact scapulothoracic motion if patient raises arms an additional 60 degrees, palms facing up

Acromioclavicular joint arthritis

286 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

■ External and internal rotation (Figs. 16-4 and 16-5)

Perform ve maneuvers to assess the “SITS” muscles of the rotator cuff and the bicipital tendon.

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Figure 16-4 Tes t abduction and exte rnal rotation.

Figure 16-5 Tes t adduction and inte rnal rotation.

Shoulder arthritis

Pain or inability to perform these maneuvers in rotator cuff sprains, tendinitis, rupture

F iv e M a n e u v e r s f o r S IT S M u s c le A s s e s s m e n t

P a in P ro vo c a t io n Te s t Painful arc test (Fig. 16-6). Fully dduct the tient’s r fro to 18 degrees.

180º

90ºº

0º

60º

120º120º

No pa in

Subacromia l pa in

Figure 16-6 Painful arc te s t. (continued )

Chapter 16 | The Musculoskeletal System 287

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

F iv e M a n e u v e r s f o r S IT S M u s c le A s s e s s m e n t (Continued)

S t re n g t h Te s t s ● External rotation lag test (Fig. 16-7).

With the tient’s r flexed to 9 degrees with l u , rot te the r into full extern l rot tion.

● Internal rotation lag test (Fig. 16-8). Ask the tient to l ce the dorsu of the h nd on the low b ck with the elbow flexed to 9 degrees. Then you lift the h nd off the b ck, which further intern lly rot tes the shoulder. Ask the tient to kee the h nd in this osition.

● Drop-arm test (Fig. 16-9). Ask the tient to fully bduct the r to shoulder level, u to 9 degrees, nd lower it slowly. Note th t bduction bove shoulder level, fro 9 to 12 degrees, reflects ction of the deltoid uscle.

Co m p o s it e Te s t External rotation resistance test (Fig. 16-10). Ask the tient to dduct nd flex the r to 9 degrees, with the thu bs turned u . St bilize the elbow with one h nd nd ly res- sure roxi l to the tient’s wrist s the tient resses the wrist out- w rd in extern l rot tion.

9909090ººº fleflexioexioexiooflexiolexioiol ofle n 2020200ººº

aabductabducta ionnion

Figure 16-7 Inte rnal rotation lag tes t.

9090º flexiflexionon

Figure 16-8 External rotation lag tes t.

Figure 16-9 Drop arm tes t.

Figure 16-10 External rotation res is tance te s t.

288 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

E lb o w s Inspect and palpate:

■ Olecranon process

■ Medial and lateral epicondyles

■ Extensor surface of the ulna

■ Grooves between the epicon- dyles and the olecranon

Ask patient to:

■ Flex and extend elbows

■ Turn forearms and palms up and down (supination and prona- tion), as shown in Figure 16-11

W r is t s a n d H a n d s Inspect:

■ Movement of the wrist ( exion, extension, ulnar and medial deviation), hands, and ngers

■ Contours of wrists, hands, and ngers

■ Contours of palms

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Olecranon bursitis; posterior dislocation from direct trauma or supracondylar fracture

Tenderness distal to epicondyle in epi- condylitis (medial → “tennis elbow”; lateral → “pitcher’s elbow”)

Rheumatoid nodules

Tender in arthritis

o˚

Supina tion Pronation

Figure 16-11 Elbow supination and pronation.

Guarded movement in injury

Asymmetric DIP, PIP deformities in OA; symmetric deformities in PIP, MCP, wrist joints in RA; swelling in arthritis, ganglia; impaired alignment of fingers in flexor tendon damage; flexion contractures in Dupuytren contractures

Thenar atrophy in median nerve com- pression (carpal tunnel syndrome); hypothenar atrophy in ulnar nerve compression

Chapter 16 | The Musculoskeletal System 289

Palpate:

■ Wrist joints (Fig. 16-12)

Figure 16-12 Palpate the wris t joint.

■ Distal radius and ulna

■ “Anatomic snuffbox,” the hollow space distal to the radial styloid bone; thumb extensor and abductor tendons (Fig. 16-13).

Figure 16-13 Palpate the anatomic snuffbox.

■ Metacarpophalangeal joints (Fig. 16-14)

Figure 16-14 Palpate the MCP joints .

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Swelling and tenderness in rheumatoid arthritis, gonococcal infection of joint or extensor tendon sheaths

Tenderness over ulnar styloid in Colles fracture

Tenderness suggests scaphoid fracture. Tenderness over extensor and abductor tendons in de Quervain tenosynovitis.

Swelling in rheumatoid arthritis

290 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

■ Proximal and distal interphalan- geal joint

Assess range of motion:

■ Wrists: Flexion, extension, adduction (radial deviation), abduction (lateral deviation)

■ Fingers: Flexions, extension, abduction/adduction (spread ngers apart and back)

■ Thumbs (Figs. 16-15 to 16-18)

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Arthritis, tenosynovitis

Trigger finger, Dupuytren contracture

Figure 16-15 Flexion. Figure 16-16 Extens ion.

Figure 16-17 Abduction and adduction. Figure 16-18 Opposition.

Proximal nodules in RA; Bouchard (PIP) and Heberden (DIP) nodes in OA

Chapter 16 | The Musculoskeletal System 291

Perform selected maneuvers.

■ Hand grip strength (Fig. 16-19)

Figure 16-19 Tes t grip s trength.

Decreased grip strength if weakness of finger flexors or intrinsic hand muscles

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

■ Thumb movement (Fig. 16-20)

Tendon

Figure 16-20 Tes t thumb function.

Pain if de Quervain tenosynovitis

■ Carpal tunnel testing

■ Thumb adduction (Fig. 16-21)

Figure 16-21 Tes t thumb abduction.

■ Tinel sign: Tap lightly over median nerve at volar wrist (Fig. 16-22)

Figure 16-22 Tes t Tine l s ign.

Aching, tingling, and numbness in second, third, and fourth fingers is a positive Tinel sign.

Weakness of abductor pollicis longus is specific to the median nerve.

292 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

■ Phalen sign: Patient exes wrists for 60 seconds (Fig. 16-23)

Figure 16-23 Tes t Phalen s ign.

S p in e Inspect spine from the side and back, noting any abnormal curvatures.

Look for asymmetric heights of shoulders, iliac crests, or buttocks.

Identify and palpate (Fig. 16-24):

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Aching, tingling, and numbness in sec- ond, third, and fourth volar fingers is a positive Phalen sign.

Kyphosis, scoliosis, lordosis, gibbus, list curvatures

Scoliosis, pelvic tilt, unequal leg length

Parave rtebra l muscle s

Spinous process of L5 ve rtebra

Ischia l tube ros ity and s ite of ischia l bursa

Pos te rior- supe rior iliac spine Sacroiliac joint

Sacroiliac notch Scia tic ne rve

Inte rve rtebra l joint be tween L5 and sacrum

Figure 16-24 Palpate the bony landmarks and muscles of the back.

■ Spinous processes of each vertebra

Tender if trauma, infection; “step-offs”in spondylolisthesis, fracture

Chapter 16 | The Musculoskeletal System 293

■ Sacroiliac joints

■ Paravertebral muscles, if painful

■ Sciatic nerve (midway between greater trochanter and ischial tuberosity), Figure 16-25

Scia tic nerve Grea te r trochante r

Ischia l tube ros ity

Figure 16-25 Palpate the sciatic ne rve .

Test the range of motion in the neck and spine in: exion, exten- sion, rotation, and lateral bending.

H ip s Inspect gait (Fig. 16-26) for:

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Sacroiliitis, ankylosing spondylitis

Paravertebral muscle spasm in abnormal posture, degenerative and inflammatory muscle disorders, overuse

Herniated disc or nerve root compres- sion

Decreased mobility in arthritis

Heels trike Foot flat Mids tance Push-off Figure 16-26 The s tance phase of gait.

294 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

■ Stance (see Fig. 16-26) and swing (foot moves forward, does not bear weight)

■ Width of base (usually 2 to 4 inches from heel to heel), shift of pelvis, exion of knee

Palpate:

■ Bony landmarks: anterior—iliac crest and tubercle, anterior- superior iliac spine, greater trochanter, pubic tubercle; posterior—posterior-superior iliac spine, greater trochanter, ischial tuberosity, sacroiliac joint

■ Along the inguinal ligament. Identify the Nerve–Artery– Vein–Empty space–Lymph node (NAVEL).

■ The trochanteric bursa, on the greater trochanter of the femur (Fig. 16-27)

Trochante ric bursa

Ischioglutea l bursa

Figure 16-27 Trochante ric and ischio- gluteal bursae .

■ The ischiogluteal bursa, super - cial to the ischial tuberosity

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Most problems arise during the weight- bearing stance phase.

Cerebellar disease or foot problems if wide base; impaired shift of pelvis in arthritis, hip dislocation, abductor weak- ness; disrupted gait if poor knee flexion

Bulges in inguinal hernia, aneurysm

Focal tenderness in trochanteric bursitis, often described by patients as “low back pain”

Tender in bursitis (“weaver’s bottom”) from prolonged sitting

Chapter 16 | The Musculoskeletal System 295

Check range of motion, including:

■ Flexion—“Bend your knee and pull it against your abdomen.” (Fig. 16-28)

Figure 16-28 Hip flexion and flattening of lumbar lordosis .

■ Extension (Fig. 16-29)

Figure 16-29 Abduct the leg.

■ Abduction and adduction

■ Internal and external rotation (Fig. 16-30)

Figure 16-30 Test internal and external rotation of the hip.

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Flexion of opposite leg suggests deformity of that hip.

Painful in iliopsoas abscess

Restricted in hip arthritis

296 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

Kn e e s Identify the medial (Fig. 16-31) and lateral structures of the knee.

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Media l femora l condyle

Media l femora l epicondylePa te lla r tendon

Media l tibia l pla teau

Tibia l tube ros ity

Adductor tubercle

Media l colla te ra l ligament

Anse rine bursa

Figure 16-31 Medial compartment of the knee .

Inspect:

■ Gait for knee extension at heel strike, exion during all other phases of swing and stance

■ Alignment of knees

■ Contours of knees, including any atrophy of the quadriceps muscles

Inspect and palpate:

■ The tibiofemoral joint—with knees exed, including:

■ Joint line—place thumbs on either side of the patellar tendon.

Stumbling or “giving way”during heel strike in quadriceps weakness or abnor- mal patellar tracking

Bowlegs, knock-knees; flexion contrac- tures in limb paralysis or hamstring tightness.

Quadriceps atrophy with patellofemoral disorder; swelling over the patella in prepatellar bursitis (housemaid’s knee), over the tibial tubercle in infrapatellar or if more medial anserine bursitis

See Table 16-5, Painful Knees, pp. 309–310.

Irregular, bony ridges in osteoarthritis.

Chapter 16 | The Musculoskeletal System 297

■ Medial and lateral meniscus

■ Medial and lateral collateral ligaments

■ The patellofemoral compart- ment:

■ Patella

■ Palpate the patellar tendon and ask patient to extend the leg.

■ Press the patella against the underlying femur.

■ Push patella distally and ask patient to tighten knee against table.

■ Also:

■ Suprapatellar pouch

■ Infrapatellar spaces (hollow areas adjacent to patella)

■ Medial tibial condyle

■ Popliteal surface

Assess any effusions.

■ Bulge sign (minor effusions): Compress the suprapatellar pouch, stroke downward on medial surface (Fig. 16-32), apply pressure to force uid to lateral surface (Fig. 16-33), and then tap knee behind lateral margin of patella (Fig. 16-34).

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Tenderness if meniscus tear

Tenderness if MCL tear (LCL injuries less common)

Swelling over the patella in prepatellar bursitis (“housemaid’s knee”)

Tenderness or inability to extend the leg in partial or complete tear of the patellar tendon

Pain, crepitus, and a history of knee pain in patellofemoral disorder

Pain during contraction of quadriceps in chondromalacia

Swelling in synovitis and arthritis

Swelling in arthritis

Swelling in pes anserine bursitis

Popliteal or Baker cyst

A fluid wave returning to the medial surface after a lateral tap confirms an effusion—a positive “bulge sign.”

298 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

■ Balloon sign (major effusions): Compress suprapatellar pouch with one hand; with thumb and nger of other hand, feel for uid entering the spaces next to the patella (Fig. 16-35).

■ Ballotte the patella (major effu- sion): Push the patella sharply against the femur; watch for uid returning to the suprapatellar space.

Figure 16-32 Milk downward. Figure 16-33 Apply medial pressure .

Figure 16-34 Tap and watch for fluid wave .

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

A palpable fluid wave is a positive sign.

Visible wave is a positive sign.

Figure 16-35 Tes t for the balloon s ign.

Chapter 16 | The Musculoskeletal System 299

Assess range of motion: exion, extension, internal and external rotation.

Use maneuvers to assess menisci and ligaments.

■ Medial meniscus and lateral meniscus—McMurray test (Fig. 16-36): With the patient supine, grasp the heel and ex the knee. Cup your other hand over the knee joint with ngers and thumb along the medial joint line. From the heel, externally rotate the lower leg, then push on the lateral side to apply a valgus stress on the medial side of the joint. Slowly extend the lower leg in external rotation.

The same maneuver with inter- nal rotation stresses the lateral meniscus.

■ Medial collateral ligament (Fig. 16-37): With knee slightly exed, push medially against lateral surface of knee with one hand and pull laterally at the ankle with the other hand (abduction or valgus stress).

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Click or pop along the medial joint with valgus stress, external rotation, and leg extension in tear of posterior medial meniscus.

Figure 16-36 McMurray tes t.

Pain or a gap in the medial joint line points to a partial or complete MCL tear.

Figure 16-37 Medial collate ral liga- ment te s t.

300 Ba tes ’ Pocke t Guide to Physica l Examina tion and His tory Taking

■ Lateral collateral ligament (LCL) (Fig. 16-38): With knee slightly exed, push laterally along medial surface of knee with one hand and pull medially at the ankle with the other hand (an adduction or varus stress).

■ Anterior cruciate ligament (ACL) (Fig. 16-39): (1) With knee exed, place thumbs on medial and lateral joint line and place ngers on hamstring insertions. Pull tibia forward, observe if tibia slides forward “like a drawer.” Compare to opposite knee.

(2) Lachman test (Fig. 16-40): Grasp the distal femur with one hand and the proximal tibia with the other (place the thumb on the joint line). Move the femur forward and the tibia back.

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Pain or a gap in the lateral joint line points to a partial or complete LCL tear.

Figure 16-38 Late ral collate ral liga- ment te s t.

Forward slide of proximal tibia is a posi- tive anterior drawer sign in ACL laxity or tear.

Figure 16-39 Anterior cruciate liga- ment te s t.

Figure 16-40 Lachman tes t.

Significant forward excursion of tibia in ACL tear

Chapter 16 | The Musculoskeletal System 301

■ Posterior cruciate ligament (PCL): Posterior drawer sign (Fig. 16-41): Position patient and hands as in the ACL test. Push the tibia posteriorly and observe for posterior movement, like a drawer sliding posteriorly.

A n k le s a n d Fe e t Inspect ankles and feet.

Palpate:

■ Ankle joint

■ Ankle ligaments: medial-deltoid; lateral-anterior and posterior talo bular, calcaneo bular

■ Achilles tendon

■ Compress the metatarsophalan- geal joints; then palpate each joint between the thumb and fore n- ger (Figs. 16-42 and 16-43).

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Isolated PCL tears are rare.

Figure 16-41 Pos te rior cruciate liga- ment te s t (pos te rior drawer s ign).

Hallux valgus, corns, calluses

Tender joint in arthritis

Tenderness in sprain: lateral ligaments weaker, making inversion injuries (ankle bows outward, heel bows inward) more common

Rheumatoid nodules, tenderness in tendinitis

Tenderness in arthritis, Morton neuroma third and fourth MTP joints; inflamma- tion of first MTP joint in gout

Figure 16-42 Palpate the MTP joints . Figure 16-43 Palpate the metatarsal heads .

302 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

Assess range of motion.

■ Dorsi ex and plantar ex the ankle (tibiotalar joint).

■ Stabilize the ankle and invert (Fig. 16-44) and evert (Fig. 16-45) the heel (subtalar or talocalcaneal joint).

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Arthritic joint often painful when moved in any direction; sprain, when injured ligament is stretched.

Ankle sprain

Figure 16-44 Invert the hee l. Figure 16-45 Evert the hee l.

■ Stabilize the heel and invert (Fig. 16-46) and evert (Fig. 16-47) the forefoot (transverse tarsal joints).

Trauma, arthritis

Figure 16-46 Invert the fore foot. Figure 16-47 Evert the fore foot.

■ Move proximal phalanx of each toe up and down (metatarsopha- langeal joints).

Chapter 16 | The Musculoskeletal System 303

S p e c ia l T e c h n iq u e s Me a s u rin g Le g Le n g t h .

Patient’s legs should be aligned symmetrically. With a tape, mea- sure distance from anterior-supe- rior iliac spine to medial malleolus. Tape should cross knee medially.

/ Me a s u rin g Ra n g e o f Mo t io n . To measure range of motion precisely, a simple pocket goniometer is needed. Estimates may be made visually. Movement in the elbow at the right is limited to range indicated by red lines (Fig. 16-48).

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Unequal leg length may be the cause of scoliosis.

A flexion deformity of 45 degrees and further flexion to 90 degrees (45 degrees → 90 degrees)

45˚

0˚

90˚

160˚

Figure 16-48 Degrees of elbow flexion.

Recording Your Findings

R e c o r d in g t h e M u s c u lo s k e le t a l S y s t e m E x a m in a t io n

“Full r nge of otion in ll joints. No evidence of swelling or defor ity.” OR “Full r nge of otion in ll joints. H nd with degener tive ch nges of Heberden nodes t the dist l inter h l nge l joints, Bouch rd nodes t roxi l inter h - l nge l joints. Mild in with flexion, extension, nd rot tion of both hi s. Full r nge of otion in the knees, with oder te cre itus; no effusion but boggy synoviu nd osteo hytes long the tibiofe or l joint line bil ter lly. Both feet with h llux v lgus t the first et t rso h l nge l joints.” (These findings sug- gest osteoarthritis.)

304 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

Aids to Interpretation

Rh e u m a t o id Ar t h r it is

Os t e o a r t h r it is (De g e n e ra t ive J o in t D is e a s e , o r DJ D)

P ro c e s s Chronic inflammation of synovial membranes with secondary erosion of adjacent cartilage and bone, damage to ligaments and tendons

Degeneration and progressive loss of cartilage within joints, damage to underlying bone, formation of new bone at margins of cartilage

Co m m o n Lo c a t io n s

Hands (proximal interphalangeal and metacarpophalangeal joints), feet (metatarsophalangeal joints), wrists, knees, elbows, ankles

Knees, hips, hands (distal, sometimes proximal interphalangeal joints), cervical and lumbar spine, and wrists (first carpometacarpal joint); also joints previously injured or diseased

P a t t e rn o f S p re a d

Symmetrically additive: progresses to other joints; persists in initial ones

Additive; however, sometimes only one joint affected

On s e t Usually insidious Usually insidious

P ro g re s s io n a n d Du ra t io n

Often chronic, with remissions and exacerbations

Slowly progressive, with exacerbations after overuse

As s o c ia t e d S ym p t o m s

Frequent swelling of synovial tissue in joints or tendon sheaths; also subcutaneous nodules

Small joint effusions may be present, especially in knees; also bony enlargement

Tender, often warm but seldom red

Tender, seldom warm or red

Prominent stiffness, often for >1 hour in mornings

Frequent but brief stiffness in the morning

Pa t t e rn s o f Pa in in a n d Aro u n d t h e J o in t s

Table 16-1

Chapter 16 | The Musculoskeletal System 305

P a t t e rn s P h ys ic a l S ig n s

Me ch a n ic a l Ne ck P a in Aching pain in the cervical paraspinal muscles and ligaments with associated muscle spasm, stiffness, and tightness in the upper back and shoulder, lasting up to 6 weeks. No associated radiation, paresthesias, or weakness. Headache may be present.

Local muscle tenderness, pain on movement. No neurologic deficits. Possible trigger points in fibromyalgia. Torticollis if prolonged abnormal neck posture and muscle spasm.

Me ch a n ic a l Ne ck P a in — Wh ip la s h Also mechanical neck pain with aching paracervical pain and stiffness, often beginning the day after injury. Occipital headache, dizziness, malaise, and fatigue may be present. Chronic whiplash syndrome if symptoms last more than 6 months, present in 20–40% of injuries.

Localized paracervical tenderness, decreased neck range of motion, perceived weakness of the upper extremities. Causes of cervical cord compression such as fracture, herniation, head injury, or altered consciousness are excluded.

Ce r v ic a l Ra d ic u lo p a t h y— fro m n e r ve ro o t c o m p re s s io n Sharp burning or tingling pain in the neck and one arm, with associated paresthesias and weakness. Sensory symptoms often in myotomal pattern, deep in muscle, rather than dermatomal pattern.

C7 nerve root affected most often (45–60%), with weakness in triceps and finger flexors and extensors. C6 nerve root involvement also common, with weakness in biceps, brachioradialis, wrist extensors.

Ce r v ic a l Mye lo p a t h y—fro m c e r v ic a l c o rd c o m p re s s io n Neck pain with bilateral weakness and paresthesias in both upper and lower extremities, often with urinary frequency. Hand clumsiness, palmar paresthesias, and gait changes may be subtle. Neck flexion often exacerbates symptoms.

Hyperreflexia; clonus at the wrist, knee, or ankle; extensor plantar reflexes (positive Babinski signs); and gait disturbances. May also see Lhermitte sign: neck flexion with resulting sensation of electrical shock radiating down the spine. Confirmation of cervical myelopathy warrants neck immobilization and neurosurgical evaluation.

Pa in s in t h e Ne ckTable 16-2

306 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

P a t t e rn s P h ys ic a l S ig n s

Me ch a n ic a l Lo w Ba ck P a in Aching pain in lumbosacral area; may radiate into lower leg, along L5 or S1 dermatomes. Usually acute, work related, in age group 30 to 50 years; no underlying pathology

Paraspinal muscle or facet tenderness, muscle spasm or pain with back movement, loss of normal lumbar lordosis but no motor or sensory loss or reflex abnormalities. In osteoporosis, check for thoracic kyphosis, percussion tenderness over a spinous process, or fractures in the thoracic spine or hip.

S c ia t ic a (Ra d ic u la r Lo w Ba c k P a in ) Usually from disc herniation; more rarely from nerve root compression, primary or metastatic tumor

Disc herniation most likely if calf wasting, weak ankle dorsiflexion, absent ankle jerk, positive crossed straight-leg raise (pain in affected leg when healthy leg tested); negative straight-leg raise makes diagnosis highly unlikely.

Lu m b a r S p in a l S t e n o s is Pseudoclaudication pain in the back or legs that improves with rest, forward lumbar flexion. Pain vague but usually bilateral, with paresthesias in one or both legs; usually from arthritic narrowing of spinal canal

Posture may be flexed forward with lower extremity weakness and hyporeflexia; straight-leg raise usually negative

Lo w Ba ck Pa inTable 16-3

Chapter 16 | The Musculoskeletal System 307

P a t t e rn s P h ys ic a l S ig n s

Ch ro n ic Ba ck S t iffn e s s Consider ankylosing spondylitis in inflammatory polyarthritis, most common in men younger than 40 years. Diffuse idiopathic skeletal hyperostosis (DISH) affects men more than women, usually age older than 50 years.

Loss of the normal lumbar lordosis, muscle spasm, limited anterior and lateral flexion; improves with exercise. Lateral immobility of the spine, especially thoracic segment

No c t u rn a l Ba ck P a in , Un re lie ve d b y Re s t Consider metastasis to spine from cancer of the prostate, breast, lung, thyroid, and kidney, and multiple myeloma.

Findings vary with the source. Local vertebral tenderness may be present.

P a in Re fe r re d f ro m t h e Ab d o m e n o r P e lv is Usually a deep, aching pain, the level of which varies with the source (�2% of low back pain)

Spinal movements are not painful and range of motion is not affected. Look for signs of the primary disorder, such as peptic ulcer, pancreatitis, dissecting aortic aneurysm.

Lo w Ba ck Pa in (continued )Table 16-3

308 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

Ac ro m io c la v ic u la r Ar t h r it is Tenderness over the acromioclavicular joint, especially with adduction of the arm across the chest. Pain often increases with shrugging the shoulders, due to movement of scapula.

S u b a c ro m ia l a n d S u b d e lt o id Bu r s it is

Pain over anterior-superior aspect of shoulder, particularly when raising the arm overhead. Tenderness common anterolateral to the acromion, in hollow recess formed by the acromiohumeral sulcus. Often seen in overuse syndromes.

Ro t a t o r Cu ff Te n d in it is Tenderness over the rotator cuff, when elbow passively lifted posteriorly or with five maneuvers (pp. 286–287).

Bic ip it a l Te n d in it is Tenderness over the long head of the biceps when rolled in the bicipital groove or when flexed arm is supinated against resistance suggests bicipital tendinitis.

Pa in fu l S h o u ld e rsTable 16-4

Chapter 16 | The Musculoskeletal System 309

Iliotibia l band

Arthritis . Degenerative arthritis usually occurs after age 50; associated with obesity. Often with medial joint line tenderness, palpable osteophytes, bowleg appearance, suprapatellar bursae and joint effusion. Systemic involvement, swelling, and subcutaneous nodules in rheumatoid arthritis.

Prepa te lla r bursa

Pes anserine

Burs itis . Inflammation and thickening of bursa seen in repetitive motion and overuse syndromes. Can involve prepatellar bursa (“housemaid’s knee”), pes anserine bursa

medially (runners, osteoarthritis), iliotibial band laterally (over lateral femoral condyle), especially in runners.

Pa te lla moves up

and la te ra l

Leg extends and foot

ra ise s

Pate llofemoral ins tability. During flexion and extension of knee, due to subluxation and/or malalignment, patella tracks laterally instead of centrally in trochlear groove of femoral condyle. Inspect or palpate for lateral motion with leg extension. May lead to chondromalacia, osteoarthritis.

La te ra l meniscus

Media l meniscus torn

Meniscal tear. Commonly arises from twisting injury of knee; in older patients may be degenerative, often with clicking, popping, or locking sensation. Check for tenderness along joint line over medial or lateral meniscus and for effusion. May have associated tears of medial collateral of anterior cruciate ligaments.

Pa in fu l Kn e e sTable 16-5

(table continues on page 310)

310 Ba tes’ Pocket Guide to Phys ica l Examination and His tory Taking

Anterior crucia te ligament torn

Anterior cruciate tear or sprain. In twisting injuries of the knee, often with popping sensation, immediate swelling, pain with flexion/extension, difficulty walking, and sensation of knee “giving way.” Check for anterior drawer sign, swelling of hemarthrosis, injuries to medial meniscus or medial collateral ligament. Consider evaluation by an orthopedic surgeon.

Media l colla te ra l ligament torn

Collateral ligament sprain or tear. From force applied to medial or lateral surface of knee (valgus or varus stress), producing localized swelling, pain, stiffness. Patients able to walk but may develop an effusion. Check for tenderness over affected ligament and ligamentous laxity during valgus or varus stress.

Baker cys t

Pos te rior knee

Baker cys t. Cystic swelling palpable on the medial surface of the popliteal fossa, prompting complaints of aching or fullness behind the knee. Inspect, palpate for swelling adjacent to medial hamstring tendons. If present, suggests involvement of posterior horn of medial meniscus. In rheumatoid arthritis, cyst may expand into calf or ankle.

Pa in fu l Kn e e s (continued )Table 16-5

311

C H A P T E R

17The Nervous System

Fundamentals for Assessing the Nervous System

A p p r o a c h t o A s s e s s m e n t The history and neurologic examination respond to four guiding questions. These questions are not answered separately, but iteratively as you learn about the patient during the interview and establish your neurologic nd- ings. To acquire the skills of nervous system examination, it is important to test your physical ndings against those of your teachers and neurologists to re ne your clinical expertise.

G u id in g Q u e s t io n s f o r E x a m in a t io n o f t h e N e r v o u s S y s t e m

● Does the tient h ve neurologic dise se? ● If so, wh t is the loc liz tion of the lesion or lesions? Are your findings

sy etric? ● Wh t is the tho hysiology of bnor l findings? ● Wh t is the reli in ry differenti l di gnosis?

C e n t r a l a n d P e r ip h e r a l N e r v o u s S y s t e m s Ce n t ra l Ne rvo u s S ys t e m . The central nervous system (CNS) consists of the brain and spinal cord.

Th e Bra in . The brain has four regions: the cerebrum, the diencephalon, the brainstem, and the cerebellum (Fig. 17-1). Each cerebral hemisphere is subdivided into frontal, parietal, temporal, and occipital lobes. The brain consists of gray matter and myelinated neuronal axons, or white matter. Important structures include the basal ganglia, the thalamus, the hypo- thalamus, the brainstem (midbrain, pons, and medulla), which connects the cortex with the spinal cord, the reticular activating (arousal) system linked to consciousness, and the cerebellum.

312 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

S p in a l Co rd . The spinal cord extends from the medulla to the first or second lumbar vertebrae. The spinal cord:

■ is divided into ve segments: cervical (C1–C8), thoracic (T1–T12), lumbar (L1–L5), sacral (S1–S5), and coccygeal. Its roots fan out like a horse’s tail at L1–L2, the cauda equina.

■ contains important motor and sensory nerve pathways that exit and enter the cord via anterior and posterior nerve roots and spinal and peripheral nerves.

■ mediates the monosynaptic muscle stretch re exes.

Pe rip h e ra l Ne rvo u s S ys t e m . The peripheral nervous system consists of the 12 pairs of cranial nerves and the spinal and peripheral nerves. Most peripheral nerves contain both motor and sensory bers.

Cra n ia l Ne r ve s . The twelve pairs of cranial nerves (CNs) emerge from the cranial vault through skull foramina and canals to structures in the head and neck. Some are limited to general motor and/or sensory functions, whereas others are specialized, serving smell, vision, or hearing (I, II, VIII).

P e r ip h e ra l Ne r ve s . Thirty-one pairs of nerves carry impulses to and from the cord: 8 cervical, 12 thoracic, 5 lumbar, 5 sacral, and 1 coccygeal. Each nerve has an anterior (ventral) root containing motor fibers, and a posterior (dorsal) root containing sensory fibers. These merge to form a short (<5 mm) spinal nerve. Spinal nerve fibers commingle with similar fibers in plexuses outside the cord—from these emerge peripheral nerves.

Frontal lobe Parieta l lobe

Pituitary gland

Brains tem Medulla

Pons Midbrain

Occipital lobe

Diencephalon

Cerebellum

Figure 17-1 Right half of the brain, medial view.

Chapter 17 | The Nervous System 313

He a d a ch e . Ask about location, severity, duration, and any associated symptoms, such as visual changes, weakness, or loss of sensation. Always elicit unusual headache warning signs, such as sudden onset “like a thunderclap,” onset after age 50 years, and associated symptoms such as fever and stiff neck, which warrant examination for papilledema and focal neurologic signs.

Dizzin e s s o r Ve r t ig o . Dizziness or vertigo can have many mean- ings. Is the patient lightheaded or feeling faint (presyncope)? Is there unsteady gait from disequilibrium or ataxia, or true vertigo, a percep- tion that the room is spinning or rotating?

Are any medications contributing to dizziness?

Are associated symptoms present, such as double vision (diplopia), dif culty forming words (dys- arthria), or dif culty with gait or balance (ataxia)? Is there any weakness?

The Health History

C o m m o n o r C o n c e r n in g S y m p t o m s

● He d che ● Dizziness or vertigo ● We kness (gener lized, roxi l, or dist l) ● Nu bness, bnor l or lost sens tions ● F inting or bl cking out (ne r-synco e nd synco e) ● Seizures ● Tre ors or involunt ry ove ents

See Table 7-1, Primary Headaches, p. 128, and Table 7-2, Secondary Head- aches, pp. 129–131. Subarachnoid hem- orrhage may evoke “the worst headache of my life.”Dull headache especially on awakening and in the same location, especially when affected by examination maneuvers, may arise from mass lesions like a brain tumor or abscess.

Lightheadedness in palpitations; near- syncope from vasovagal stimulation, low blood pressure, febrile illness, and oth- ers; vertigo in benign positional vertigo, Ménière disease, brainstem tumor

Diplopia, dysarthria, ataxia in vertebro- basilar transient ischemic a ttack (TIA) or stroke

See Table 17-1, Types of Stroke, pp. 335– 336, and Table 17-2, Disorders of Speech, pp. 347–348.

Weakness or paralysis in TIA or stroke

314 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

We a k n e s s . Distinguish proximal from distal weakness. For proximal weakness, ask about combing hair, reaching for things on a high shelf, dif culty getting out of a chair or taking a high step up.

For distal weakness, ask about hand movements such as opening a jar or can or using hand tools (e.g., scissors, pliers, screwdriver). Ask about frequent tripping.

S e n s o ry Lo s s . Is there any loss of sensation or altered sensation such as tingling or pins and needles without an obvious stimulus (par- esthesias)? Dysesthesias, or disor- dered sensations in response to a stimulus, may last longer than the stimulus itself.

S yn c o p e . “Have you ever fainted or passed out?” leads to discussion of any loss of consciousness (syncope).

Get a complete description of the event including setting and trig- gers, any warning signs, position (standing, sitting, lying down), and duration. What brought on the epi- sode? Could voices be heard while passing out and coming to? How rapid was recovery? Were onset and offset slow or fast?

Bilateral proximal limb weakness with intact sensation in myopathies from alcohol, drugs like glucocorticoids, and inflammatory muscle disorders like polymyositis and dermatomyositis

In myasthenia gravis, weakness is asym- metric and gets worse with effort (fatigability), and often has bulbar symptoms such as diplopia, ptosis, dysarthria, and dysphagia.

Bilateral predominantly distal weakness, often with sensory loss, in polyneuropa- thy, as in diabetes

Consider: paresthesias in hands and around the mouth in hyperventilation; local nerve compression or “entrap- ment,”seen in hand numbness from median, ulnar, or radial nerve disorders; nerve root compression with dermato- mal sensory loss from vertebral bone spurs or herniated discs; or central lesions from stroke or multiple sclerosis.

Syncope is complete but temporary loss of consciousness from decreased cerebral blood flow, commonly called fainting.

Young people with emotional stress and warning symptoms of flushing, warmth, or nausea may have vasodepressor (or vasovagal) syncope of slow onset, slow offset.

Consider:

vasovagal syncope, postural tachycar- dia syndrome, carotid sinus syncope, and orthostatic hypotension

tachycardia and bradyarrhythmias, often with syncope of sudden onset and offset

Chapter 17 | The Nervous System 315

Also ask if anyone observed the episode. What did the patient look like before, during, and after the episode? Was there any seizure-like movement of the arms or legs? Any incontinence of the bladder or bowel?

S e izu re . A seizure is a sudden excessive electrical discharge from cortical neurons, and may be symptomatic, with an identi able cause, or idiopathic. Elicit a careful history.

Tre m o rs o r Invo lu n t a ry Mo ve m e n t s . Ask about any tremor, shaking, or body move- ments that the patient is unable to control. Does the tremor occur at rest? Get worse with voluntary intentional movement or with sustained postures?

Tonic–clonic motor activity, inconti- nence, and postictal sta te seizures. Unlike in syncope, tongue biting or bruising of limbs may occur.

may be loss of consciousness or abnor- mal feelings, thought processes, and sensations, including smells, as well as abnormal movements.

head trauma; alcohol, cocaine, and other - insults from low or high glucose or low calcium or sodium; acute stroke; and meningitis or encephalitis.

Low-frequency unilateral resting tremor, rigidity, and bradykinesia in Parkinson disease.

Health Promotion and Counseling: Evidence and Recommendations

Im p o r t a n t T o p ic s f o r H e a lt h P r o m o t io n a n d C o u n s e lin g

● Preventing stroke nd tr nsient ische ic tt ck (TIA) ● C rotid rtery screening ● Reducing risk of eri her l neuro thy ● Her es zoster v ccin tion ● Detecting the “three Ds”: deliriu , de enti , nd de ression

Essential tremors if high-frequency, bilateral, upper extremity tremors that occur with both limb movement and sustained posture and subside when the limb is relaxed.

P re ve n t in g S t ro k e o r TIA. Cerebrovascular disease is the fourth leading cause of death in the United States. Stroke is a sudden neurologic de cit caused by cerebrovascular ischemia (87%) or hemorrhage (13%).

316 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

Hemorrhagic strokes may be intracerebral (10% of all strokes) or subarach- noid (3% of all strokes). Decreased vascular perfusion results in sudden focal but transient brain dysfunction in TIA, or in permanent neurologic de cits in stroke, as determined by neurodiagnostic imaging. Detecting TIAs is important—in the rst 3 months after a TIA, subsequent stroke occurs in approximately 15% of patients.

Primary prevention of stroke requires aggressive management of risk factors and patient education.

■ Target modi able risk factors: hypertension, smoking, dyslipidemia, excess weight, diabetes, poor diet and nutrition, physical inactivity, and alcohol use.

■ Address disease-speci c risk factors: atrial brillation, carotid artery disease, and sleep apnea.

Ca ro t id Ar t e ry S c re e n in g . Screen symptomatic patients with duplex ultrasound. The U.S. Preventive Services Task Force recommends against screening asymptomatic patients in the general population.

Re d u c in g Ris k o f Pe rip h e ra l Ne u ro p a t hy. In diabetics, promote optimal glucose control to reduce risk of sensorimotor polyneuropathy, autonomic dysfunction, mononeuritis multiplex, or diabetic neuropathy.

A H A / A S A S t r o k e W a r n in g S ig n s a n d S y m p t o m s

F Face Drooping—Does one side of the f ce droo or is it nu b? Ask the erson to s ile. Is the erson’s s ile uneven?

A Arm Weakness—Is one r we k or nu b? Ask the erson to r ise both r s. Does one r drift downw rd?

S Speech Difficulty—Is s eech slurred? Is the erson un ble to s e k or h rd to underst nd? Ask the erson to re e t si le sentence, like “The sky is blue.” Is the sentence re e ted correctly?

T Time to call 9-1-1—If so eone shows ny of these sy to s, even if the sy to s go w y, c ll 9-1-1 nd get the erson to the hos it l i edi- tely. Check the ti e so you’ll know when the first sy to s e red.

Beyond FAST: Other i ort nt sy to s

● Sudden nu bness or we kness of the leg, r , or f ce ● Sudden confusion or trouble underst nding ● Sudden trouble seeing in one or both eyes ● Sudden trouble w lking, dizziness, loss of b l nce or coordin tion ● Sudden severe he d che with no known c use

AHA, A eric n He rt Associ tion; ASA, A eric n Stroke Associ tion.

Chapter 17 | The Nervous System 317

Examine diabetics regularly for neuropathy, including testing pinprick sensation, ankle re exes, vibration perception (with a 128-Hz tuning fork) and plantar light touch sensation (with a Semmes-Weinstein mono la- ment), as well as checking for skin breakdown, poor circulation, and musculoskeletal abnormalities.

He rp e s Zo s t e r Va c c in a t io n . The herpes zoster vaccine reduces the short-term risks for zoster and postherpetic neuralgia in adults ≥50 years. The Advisory Committee on Immunization Practices (ACIP) currently recommends routinely offering onetime vaccination for adults ≥60 years; the vaccine is FDA-approved for adults ≥50 years.

De t e c t in g t h e “ Th re e Ds ” : De liriu m , De m e n t ia , a n d De p re s s io n . Delirium is an acute confusional state marked by sudden onset, uctuating course, inattention and changes in the level of conscious- ness; it is often undetected. Learn to use the Confusional Assessment Method (CAM) algorithm.

T h e C o n f u s io n A s s e s s m e n t M e t h o d (C A M ) D ia g n o s t ic A lg o r it h m

1. Acute ch nge in ent l st tus nd fluctu ting course ● Is there evidence of n cute ch nge in cognition fro b seline? ● Does the bnor l beh vior fluctu te during the d y?

2. In ttention ● Does the tient h ve difficulty focusing ttention?

3. Disorg nized thinking ● Does the tient h ve r bling or irrelev nt convers tions, uncle r or

illogic l flow of ide s, or un redict ble switching fro subject to subject? 4. Abnor l level of consciousness

● Is the tient nything besides lert—hy er lert , leth rgic, stu orous, or co tose?

Di gnosing deliriu requires fe tures 1 nd 2 nd either 3 or 4.

Dementia is best assessed by the Mini-Mental State examination and the Mini-Cog (see Chapter 20, Table 20-3, p. 420), but may be dif cult to distinguish from benign forgetfulness and mild cognitive impairment.

Depression is common in individuals with signi cant medical conditions. Ask the well-validated screening questions: “Have you been feeling down, depressed, or hopeless (depressed mood)?” and, “Have you felt little interest or pleasure in doing things (anhedonia)?”

See also Chapter 20, The Older Adult, pp. 405–406, and Table 20-2, Delirium and Dementia, pp. 418–419.

318 Ba tes’ Pocke t Guide to Physica l Examina tion and His tory Taking

Techniques of Examination

C r a n ia l N e r v e s a n d F u n c t io n

No . Cra n ia l Ne rve Fu n c t io n

I Olf ctory Sense of s ell II O tic Vision III Oculo otor Pu ill ry constriction, o ening the eye (lid elev tion),

ost extr ocul r ove ents IV Trochle r Downw rd, intern l rot tion of the eye V Trige in l Motor—te or l nd sseter uscles (j w clench-

ing), l ter l terygoids (l ter l j w ove ent) Sensory—f ci l; the nerve h s three divisions:

(1) o hth l ic, (2) xill ry, nd (3) ndibul r VI Abducens L ter l devi tion of the eye VII F ci l Motor—f ci l ove ents, including those of f ci l

ex ression, closing the eye, closing the outh Sensory—t ste for s lty, sweet, sour, nd bitter

subst nces on nterior two thirds of tongue; sens tion fro the e r

VIII Acoustic He ring (cochle r division) nd b l nce (vestibul r division)

IX Glosso h rynge l Motor— h rynx Sensory— osterior ortions of the e rdru nd e r

c n l, the h rynx, nd the osterior tongue, including t ste (s lty, sweet, sour, bitter)

X V gus Motor— l te, h rynx, nd l rynx Sensory— h rynx nd l rynx

XI S in l ccessory Motor—sternocleido stoid; u er ortion of the tr ezius

XII Hy ogloss l Motor—tongue

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

C r a n ia l N e r v e s CN I (Olfa c t o ry). Test sense of smell on each side.

CN II (Op t ic ). Assess visual acuity.

Check visual elds.

Inspect optic discs.

Loss of smell in sinus conditions, head trauma, smoking, aging, cocaine use, Parkinson disease

Blindness

Hemianopsia

Papilledema, optic atrophy, glaucoma

Chapter 17 | The Nervous System 319

CN II, III (Op t ic a n d Oc u lo m o - t o r). Test pupillary reactions to light. If abnormal, test reactions to near effort.

CN III, IV, VI (Oc u lo m o t o r, Tro ch le a r, a n d Ab d u c e n s ). Assess extraocular movements.

CN V (Trig e m in a l). Palpate the contractions of temporal and mas- seter muscles. Test pain and light touch sensations on face in (1) ophthalmic, (2) maxillary, and (3) mandibular zones (Fig. 17-2).

Test corneal re exes (Fig. 17-3).

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Blindness, CN III paralysis, tonic pupils; Horner syndrome may affect light reactions

Strabismus and binocular diplopia in CN III, IV, and VI neuropathy; diplopia in eye muscle disorders from myasthenia gra- vis, trauma, thyroid ophthalmopathy, and internuclear ophthalmoplegia; nystagmus

(1)

(2)

(3)

Figure 17-2 Test for facial sensory loss .

Figure 17-3 Tes t the corneal re flex.

CN VII (Fa c ia l). Ask patient to raise both eyebrows, frown, close eyes tightly, show teeth, smile, and puff out cheeks.

Motor or sensory loss from lesions of CN V or its higher motor pathways.

Weakness from lesion of peripheral nerve, as in Bell palsy, or of CNS, as in a stroke. See Table 17-3, Types of Facial Paralysis, p. 339.

320 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

CN VIII (Ac o u s t ic ). Test hearing of whispered voice. If decreased:

■ Test for lateralization if unilateral hearing loss (Weber test).

■ Compare air and bone conduction (Rinne test).

CN IX, X (Glo s s o p h a ryn g e a l a n d Va g u s ). Observe any dif culty swallowing.

Listen to the voice.

Watch soft palate rise with “ah.”

Test gag re ex on each side.

CN XI (S p in a l Ac c e s s o ry). Trapezius muscles. Assess muscles for bulk, involuntary movements, and strength of shoulder shrug (Fig. 17-4).

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

In unilateral sensorineural loss, sound is heard in the good ear where AC > BC. affected ear where BC > AC. See p. 125.

In sensorineural hearing loss, sound is heard longer through air than bone (AC > BC). In conductive loss sound is heard through bone longer than air (BC = AC or BC > AC). See p. 125.

A weakened palate or pharynx impairs swallowing.

Hoarseness in vocal cord paralysis; nasal voice in paralysis of palate

Deviated uvula, palatal paralysis in CVA

Absent reflex is often normal.

Figure 17-4 Tes t trapezius s trength.

Atrophy, fasciculations, weakness

Weakness of sternocleidomastoid mus- cle when head turns to opposite side

Sternocleidomastoid muscles. Assess strength as head turns against your hand.

Chapter 17 | The Nervous System 321

CN XII (Hyp o g lo s s a l). Listen to patient’s articulation.

Inspect the resting tongue.

Inspect the protruded tongue.

/ T h e M o t o r S y s t e m Bo d y Po s it io n . Observe the patient’s body position during movement and at rest.

Invo lu n t a ry Mo ve m e n t s . If present, observe location, qual- ity, rate, rhythm, amplitude, and setting.

Mu s c le Bu lk a n d To n e . Inspect muscle contours.

Assess resistance to passive stretch of arms and legs.

Dysarthria from damage to CN X or CN XII

Atrophy, fasciculations in ALS, polio

In a unilateral cortical lesion, the pro- truded tongue deviates away from the side of cortical lesion; in CN XII lesion, tongue deviates to the weak side.

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

See Table 17-4, Motor Disorders, p. 340.

Hemiplegia in stroke

Tremors, fasciculations, tics, chorea, athetosis, oral–facial dyskinesias. See Table 17-5, Involuntary Movements, p. 341.

Atrophy of bulk. See Table 17-6, Disor- ders of Muscle Tone, p. 342.

Spasticity, rigidity, flaccidity of tone

Mu s c le S t re n g t h . Test and grade the major muscle groups, with the examiner trying to overcome the strength of the patient’s resistance.

Is the pattern focal, from a lower motor neuron lesion in peripheral nerve or nerve root? Is there unilateral paralysis from an upper motor neuron cortical or subcortical lesion? Is there a symmetric distal weakness from polyneuropathy, or proximal weakness from myopathy?

G r a d in g M u s c le S t r e n g t h

Gra d e De s c r ip t io n

No uscul r contr ction detected 1 A b rely detect ble tr ce of contr ction 2 Active ove ent with gr vity eli in ted 3 Active ove ent g inst gr vity 4 Active ove ent g inst gr vity nd so e resist nce 5 Active movement against full resistance (normal)

322 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

■ Flexion (C5, C6)—biceps and brachioradialis and extension (C6, C7, C8)—triceps at the elbow

■ Wrist extension (C6, C7, C8, radial nerve)—extensor carpi radialis longus and brevis

■ Grip (C7, C8, T1)

■ Finger abduction (C8, T1, ulnar nerve) (Fig. 17-5)

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Peripheral radial nerve damage; central stroke or multiple sclerosis if hemiplegia

Weak grip in cervical radiculopathy, de Quervain tenosynovitis, carpal tunnel syndrome

Figure 17-5 Tes t finge r abduction.

Weak in ulnar nerve disorders

Figure 17-6 Test opposition of the thumb.

Weak in carpal tunnel syndrome■ Thumb opposition (C8, T1)— median nerve (Fig. 17-6)

■ Trunk— exion extension, lateral bending

Chapter 17 | The Nervous System 323

Figure 17-8 Tes t rapid alte rnating arm movement.

■ / Hip exion (L2, L3, L4)—iliopsoas (Fig. 17-7)

■ Hip extension (S1)—gluteus maximus

■ Hip adduction (L2, L3, L4)— adductors

■ Hip abduction (L4, L5, S1)— gluteus medius and minimus

■ Knee extension (L2, L3, L4)— quadriceps

■ Knee exion (L4, L5, S1, S2)— hamstrings

■ Ankle dorsi exion (L4, L5)— tibialis anterior

■ Ankle plantar exion (S1)— gastrocnemius, soleus

Co o rd in a t io n . Test rapid alter- nating movements in hands (tap ngers), arms, and legs (tap foot) (Fig. 17-8)

Figure 17-7 Tes t hip flexion.

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Clumsy, slow movements in cerebellar disease

324 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

Point-to-point movements in arms and legs— nger-to-nose, heel-to- shin

Ga it . Ask patient to:

■ Walk away, turn, and come back

■ Walk heel-to-toe

■ Walk on toes, then on heels

■ Hop in place on each foot; do one-leg shallow knee bends. Substitute rising from a chair and climbing on a stool for hops and bends as indicated.

S t a n c e ■ Do a Romberg test (a sensory test of stance). Ask patient to stand with feet together and eyes open, then closed for 20 to 30 seconds. Mild swaying may occur. Stand close by to prevent falls.

■ Inspect for a pronator drift as patient holds arms forward, with eyes closed, for 20 to 30 seconds (Fig. 17-9).

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Figure 17-9 Tes t for pronator drift. Figure 17-10 Pos itive tes t for pronator drift.

Ask patient to keep arms up and tap them downward. A smooth return to position is normal.

Weakness, incoordination, poor position sense

Loss of balance when eyes are closed is a positive Romberg test, suggesting poor position sense.

Flexion and pronation at elbow and downward drift of arm from contra lat- eral corticospinal tract lesion (Fig. 17-10)

Proximal hip girdle weakness increases risk of falls.

Clumsy, unsteady movements in cerebellar disease

CVA, cerebellar ataxia, parkinsonism, or loss of position sense may affect performance.

Ataxia

Corticospinal tract injury

Chapter 17 | The Nervous System 325

/ T h e S e n s o r y S y s t e m

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

“Glove-and-stocking”loss of peripheral neuropathy, often seen in alcoholism and diabetes

See Table 17-7, Dermatomes, pp. 343– 344.

Dermatomal sensory loss in herpes

Analgesia, hypalgesia, hyperalgesia

Temperature and pain sensation usually correlate.

Anesthesia, hyperesthesia

Loss of vibration and position senses in peripheral neuropathy from diabetes or alcoholism and in posterior column dis- ease from tertiary syphilis or vitamin B12 deficiency

A hemisensory loss pattern suggests a contralateral cortical lesion.

Use an object like a sharp pin or stick portion of a broken cotton swab to test sharp and dull sensa- tion; compare symmetric areas on the two sides of the body. Do not reuse the object on another patient.

Compare proximal and distal areas of arms and legs for pain, tempera- ture, and touch sensation. Scatter stimuli to sample most dermatomes and major peripheral nerves.

Map any area of abnormal response, including dermatomes, if present.

Assess response to the following stimuli, with the patient’s eyes closed.

■ Pain. Use the sharp end of a pin or other suitable tool. The dull end serves as a control.

■ Temperature (if indicated). Use test tubes with hot and cold water, or other objects of suit- able temperature.

■ Light touch. Use a ne wisp of cotton.

Test for vibration and proprioception (joint position sense). If responses are abnormal, test more proximally. Vibration and position senses, both carried in the posterior columns, often correlate.

326 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

■ Proprioception (joint position sense). Holding patient’s nger or big toe by its sides, move it up or down (Fig. 17-12).

Figure 17-12 Tes t proprioception.

Assess discriminative sensations:

■ Stereognosis. Ask for identi ca- tion of a common object placed in patient’s hand.

■ Number identi cation (graphes- thesia). Draw a number on patient’s palm with blunt end of a pen and ask the patient to identify the number.

■ Two-point discrimination (Fig. 17-13). Use two pins of the sides of a paper clip to nd minimal dis- tance on pad of patient’s nger at which two points can be distin- guished (normally <5 mm).

Lesions in the posterior columns or sensory cortex impair stereognosis, number identification, and two-point discrimination.

Figure 17-13 Tes t two-point discrimi- nation.

Figure 17-11 Tes t vibration sense .

■ Vibration. Use a 128-Hz tuning fork, held on a bony prominence at the ankle and wrist (Fig. 7-11).

Chapter 17 | The Nervous System 327

A lesion in the sensory cortex may - lateral side and cause contralateral extinction of the touch sensation.

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

■ Point localization. Touch skin brie y, and ask patient to open both eyes and identify the place touched.

■ Extinction. Simultaneously touch opposite, corresponding areas of the body; ask whether the patient feels one touch or two.

/ R e f le x e s Hold the re ex hammer loosely between your thumb and index n- ger so that it swings freely in an arc within the limits set by your palm and other ngers. Use the common grading system below.

Hyperactive deep tendon reflexes, absent abdominal reflexes, and a positive Babinski response in upper motor neuron lesions.

G r a d in g R e f le x e s

Gra d e De s c r ip t io n

4+ Hy er ctive (clonus ust be resent) 3+ Brisker th n ver ge, not necess rily bnor l 2+ Average, normal 1+ Di inished, low nor l No res onse

Biceps (C5, C6) (Fig. 17-14) Triceps (C6, C7) (Fig. 17-15)

Figure 17-14 Biceps re flex—patient s itting.

Figure 17-15 Triceps re flex—patient s itting.

328 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

Brachioradialis (C5, C6) (Fig. 17-16)

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Figure 17-16 Brachioradialis re flex.

Figure 17-17 Quadriceps (pate llar) re flex.

/ Quadriceps (patellar) (L2, L3, L4) (Fig. 17-17)

Achilles (ankle) (S1) (Fig. 17-18)

Figure 17-18 Achilles re flex—patient s itting.

Figure 17-19 Tes t for ankle clonus .

Check for clonus if re exes seem hyperactive (Fig. 17-19).

Ankle jerks symmetrically, decreased or absent in peripheral polyneuropathy; slowed ankle jerk in hypothyroidism.

Chapter 17 | The Nervous System 329

Plantar response (L5, S1), normally exor (Fig. 17-21)

C u t a n e o u s o r S u p e r f ic ia l S t im u la t io n R e f le x e s

Abdominal re exes (upper T8, T9, T10; lower T10, T11, T12) (Fig. 17-20)

Figure 17-20 Tes t the abdominal re flexes .

May be absent in both central and peripheral nerve disorders

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Figure 17-21 Tes t the plantar response .

Babinski extensor response (big toe fans up) from corticospinal tract lesion (Fig. 17-22)

Figure 17-22 Babinski response (abnormal).

Anal re ex. With a dull object, stroke outward from anus in four quadrants. Watch for anal contraction.

Loss of reflex suggests cauda equina lesion at the S2, S3, S4 level.

330 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

S p e c ia l T e c h n iq u e s Me n in g e a l S ig n s . Make

sure there is no injury or fracture to the cervical vertebrae or cervical cord. This often requires radiologic evaluation. With patient supine, ex head and neck toward chest. Note resistance or pain, and watch for exion of hips and knees (Brudzinski sign).

Flex one of patient’s legs at hip and knee, then straighten knee (Fig. 17-23). Note resistance or pain (Kernig sign).

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Inflammation in the subarachnoid space causes resistance to movement that stretches the spinal nerves (neck flex- and the sciatic nerve (Kernig sign).

Figure 17-23 Tes t for Kernig s ign.

signs in meningitis ranges from 5% to 60%.

A compressed lumbosacral nerve root also causes pain on straightening the knee of the raised leg.

Lu m b o s a c ra l Ra d ic u lo p a - t hy: S t ra ig h t -Le g Ra is e . With patient supine, raise relaxed and straightened leg, exing the leg at the hip. Then dorsi ex the foot (Fig. 17-24).

Figure 17-24 Tes t the s traight-leg raise .

Pain radiating into the ipsilateral leg is a positive straight-leg test for lumbosacral radiculopathy. Foot dorsiflexion can further increase leg pain in lumbosacral radiculopathy, sciatic neuropathy, or both. Increased pain when the contralat- eral healthy leg is raised is a positive crossed straight-leg raise sign.

Chapter 17 | The Nervous System 331

As t e rixis . Ask patient to hold both arms forward, with hands cocked up and ngers spread, like “stopping traf c.” Watch for 1 to 2 minutes.

Win g in g o f t h e Sc a p u la . Ask patient to push against the wall of your hand with a partially straightened arm (Fig. 17-25). Inspect scapula. It should stay close to the chest wall.

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Sudden brief flexions in liver disease, uremia and hypercapnia.

Figure 17-25 Test for scapular winging.

Winging of scapula away from chest wall suggests weakness of the serratus ante- rior muscle, seen in muscular dystrophy or injury to long thoracic nerve (Fig. 17-26).

Figure 17-26 Positive scapular winging.

Th e S t u p o ro u s o r Co m a t o s e Pa t ie n t

Assess ABCs (airway, breathing, and circulation).

■ Take pulse, blood pressure, and rectal temperature.

■ Establish level of consciousness with escalating stimuli.

However, do not dilate pupils, and do not ex patient’s neck if any suspicion of cervical cord injury.

See Table 17-8, Metabolic and Structural Coma, p. 345, Table 17-9, Glasgow Coma Scale, p. 346, and Table 17-10, Pupils in Comatose Patients, p. 347.

Lethargy, obtundation, stupor, coma

332 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

N e u r o lo g ic E x a m in a t io n

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Le v e ls o f C o n s c io u s n e s s

Alertness P tient is w ke nd w re of self nd environ ent. When s oken to in nor l voice, tient looks t you nd res onds fully nd ro ri tely to sti uli.

Lethargy When s oken to in loud voice, tient e rs drowsy but o ens eyes nd looks t you, res onds to questions, nd then f lls slee .

Obtundation When sh ken gently, t ient o ens eyes nd looks t you but res onds slowly nd is so ewh t confused. Alertness nd interest in environ ent re decre sed.

Stupor P tient rouses fro slee only fter inful sti uli. Verb l res onses re slow or bsent. P tient l ses into unre- s onsiveness when sti ulus sto s. P tient h s ini l w reness of self or environ ent.

Coma Des ite re e ted inful sti uli, t ient re ins un rous- ble with eyes closed. No evident res onse to inner need or extern l sti uli is shown.

Conduct neurologic examination, looking for asymmetric ndings. Observe:

■ Breathing pattern

■ Pupils

■ Ocular movements

Check for the oculocephalic re ex (doll’s eye movements), as shown in Figure 17-27. Holding upper eyelids open, turn head quickly to each side, and then ex and extend patient’s neck. This patient’s head will be turned to her right.

Cheyne–Stokes, ataxic breathing

Asymmetrical pupils and loss of the light reaction in structural lesions from stroke, abscess, or tumor

Deviation to affected side in hemi- spheric stroke

In a comatose patient with an intact b ra instem, the eyes move in the opposite direction, in this case to her left (doll’s eye movements) as in Figure 17-28.

Very deep coma or a lesion in the mid- brain or pons abolishes this reflex, so eyes do not move.

Chapter 17 | The Nervous System 333

Note posture of body.

Test for accid paralysis.

■ Hold forearms vertically; note wrist positions.

■ From 12 to 18 inches above bed, drop each arm.

■ Support both knees in a some- what exed position, and then extend each knee and let leg drop to the bed.

■ From a similar starting position, release both legs.

Complete the neurologic and general physical examination.

Figure 17-27 Tes t the oculocephalic re flex.

Figure 17-28 Oculocephalic re flex intact.

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Decorticate rigidity, decerebrate rigidity, flaccid hemiplegia

A flaccid arm drops more rapidly.

The flaccid leg drops more rapidly.

A flaccid leg falls into extension and external rotation.

Recording Your Findings

R e c o r d in g t h e N e r v o u s S y s t e m E x a m in a t io n

“Mental Status: Alert , rel xed, nd coo er tive. Thought rocess coherent. Oriented to erson, l ce, nd ti e. Det iled cognitive testing deferred. Cranial Nerves: I—not tested; II through XII int ct . Motor: Good uscle bulk nd tone.

(continued )

334 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

R e c o r d in g t h e N e r v o u s S y s t e m E x a m in a t io n (Continued)

Strength 5/5 throughout. Cerebellar: R id ltern ting ove ents (RAMs), finger-to-nose (F→N), heel-to-shin (H→S) int ct . G it with nor l b se. Ro berg— int ins b l nce with eyes closed. No ron tor drift . Sensory: Pin rick, light touch, osition, nd vibr tion int ct . Reflexes: 2+ nd sy etric with l nt r reflexes downgoing.” OR “Mental Status: The tient is lert nd tries to nswer questions but h s difficulty finding words. Cranial Nerves: I—not tested; II—visu l cuity int ct; visu l fields full; III, IV, VI—extr ocul r ove ents int ct; V otor—te or l nd sseter strength int ct , sensory corne l reflexes resent; VII otor— ro inent right f ci l droo nd fl ttening of right n sol bi l fold, left f ci l ove ents int ct , sensory—t ste not tested; VIII—he ring int ct bil ter lly to whis ered voice; IX, X—g g int ct; XI—strength of sternocleido stoid nd tr ezius uscles 5/5; XII—tongue idline. Motor: strength in right bice s, trice s, ilio so s, glute ls, qu drice s, h string, nd nkle flexor nd extensor uscles 3/5 with good bulk but incre sed tone nd s sticity; strength in co - r ble uscle grou s on the left 5/5 with good bulk nd tone. G it—un ble to test . Cerebell r—un ble to test on right due to right r nd leg we kness; RAMs, F→N, H→S int ct on left . Ro berg—un ble to test due to right leg we kness. Right ron tor drift resent. Sensory: decre sed sens tion to in rick over right f ce, r , nd leg; int ct on the left . Stereognosis nd two- oint discri in tion not tested. Reflexes (c n record in two w ys):

(These findings suggest left hemispheric CVA in distribution of the left middle cere- bral artery, with right-sided hemiparesis.)

Bic e p s Tric e p s Bra ch Kn e e An k le P l

RT 4+ 4+ 4+ 4+ 4+ ↑ LT 2+ 2+ 2+ 2+ 1+ ↓

4+ 4+

4+ 2+

2+ 2+ 2+

R L

Chapter 17 | The Nervous System 335

Aids to Interpretation

Clin ic a l Fe a t u re s a n d Va s c u la r Te r r it o r ie s o f S t ro k e

Assessment of stroke requires careful history taking and a detailed physical examination. Focus on three fundamental questions: What brain area and related vascular territory explain the patient’s findings? Is the stroke ischemic or hemorrhagic? If ischemic, is the mechanism thrombosis or embolus? This brief overview is intended to prompt further study and practice.

Body of cauda te

Inte rna l capsule

Putamen

Globus pa llidus

Uncus

Tha lamus

Ante rior ce rebra l a rte ry

Middle cerebra l a rte ry

Pos te rior ce rebra l a rte ry

Ante rior choroida l a rte ry

La te ra l ventrica l

Pre fronta l a rea

Premotor a rea

Primary motor cortex

Primary somatic sensory cortex Somatic sensory associa tion a rea

Tas te a rea

Primary auditory cortex

Auditory associa tion a rea Sensory speech (Wernike ) a rea

Reading compre - hens ion a rea

Visua l a s socia tion area

Visua l cortex

Motor speech (Broca ) a rea

Ma jo r Clin ic a l Fe a t u re s Va s c u la r Te r r it o ry

Contralateral leg weakness Anterior circulation—anterior cerebral artery (ACA) Includes stem of circle of Willis connecting internal carotid artery to ACA, and the segment distal to ACA and its anterior choroidal branch

Typ e s o f S t ro keTable 17-1

(table continues on page 336)

336 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

Typ e s o f S t ro k e (continued )Table 17-1

Contralateral face, arm > leg weakness, sensory loss, field cut, aphasia (left MCA) or neglect, apraxia (right MCA)

Anterior circulation—middle cerebral artery (MCA) Largest vascular bed for stroke

Contralateral motor or sensory deficit without cortical signs

Subcortical circulation—lenticulostriate deep penetrating branches of MCA Small vessel subcortical lacunar infarcts in internal capsule, thalamus, or brainstem. Four common syndromes: pure motor hemiparesis; pure sensory hemianesthesia; ataxic hemiparesis; clumsy hand—dysarthria syndrome

Contralateral field cut Posterior circulation—posterior cerebral artery (PCA) Includes paired vertebral arteries, the basilar artery, paired posterior cerebral arteries. Bilateral PCA infarction causes cortical blindness but preserved pupillary light reaction.

Dysphagia, dysarthria, tongue/ palate deviation and/or ataxia with crossed sensory/motor deficits ( = ipsilateral face with contralateral body)

Posterior circulation—brainstem, vertebral, or basilar artery branches

Oculomotor deficits and/or ataxia with crossed sensory/ motor deficits

Posterior circulation—basilar artery Complete basilar artery occlusion— “locked-in syndrome” with intact consciousness but inability to speak and quadriplegia

Ma jo r Clin ic a l Fe a t u re s Va s c u la r Te r r it o ry

Source: Adapted from American College of Physicians. Stroke, in Neurology. Medical Knowledge Self-Assessment Program (MKSAP) 14. Philadelphia, PA: American College of Physicians; 2006:52.

Clin ic a l Fe a t u re s a n d Va s c u la r Te rrit o rie s o f S t ro ke (c o n t in u e d )

Chapter 17 | The Nervous System 337

Disorders of speech fall into three groups affecting: (1) phonation of the voice, (2) the articulation of words, and (3) the production and comprehension of language.

■ Aphonia refers to a loss of voice that accompanies disease affecting the larynx or its nerve supply. Dysphonia refers to less severe impairment in the volume, quality, or pitch of the voice. For example, a person may be hoarse or only able to speak in a whisper. Causes include laryngitis, laryngeal tumors, and unilateral vocal cord paralysis (CN X).

■ Dysarthria refers to a defect in the muscular control of the speech apparatus (lips, tongue, palate, or pharynx). Words may be nasal, slurred, or indistinct, but the central symbolic aspect of language remains intact. Causes include motor lesions of the central or peripheral nervous system, parkinsonism, and cerebellar disease.

■ Aphasia refers to a disorder in producing or understanding language. It is often caused by lesions in the dominant cerebral hemisphere, usually the left.

Dis o rd e rs o f S p e e chTable 17-2

(table continues on page 338)

338 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

Compared below are two common types of aphasia: (1) Wernicke, a fluent (receptive) aphasia, and (2) Broca, a nonfluent (or expressive) aphasia. There are other less common kinds of aphasia, which are distinguished by differing responses on the specific tests listed. Neurologic consultation is usually indicated.

We rn ick e Ap h a s ia Bro c a Ap h a s ia

Qu a lit ie s o f S p o n t a n e o u s S p e e ch

Fluent; often rapid, voluble, and effortless. Inflection and articulation are good, but sentences lack meaning and words are malformed (paraphasias) or invented (neologisms). Speech may be totally incomprehensible.

Nonfluent; slow, with few words and laborious effort. Inflection and articulation are impaired but words are meaningful, with nouns, transitive verbs, and important adjectives. Small grammatical words are often dropped.

Wo rd Co m p re h e n s io n

Impaired Fair to good

Re p e t it io n Impaired Impaired

Na m in g Impaired Impaired, though the patient recognizes objects

Re a d in g Co m p re h e n s io n

Impaired Fair to good

Writ in g Impaired Impaired

Lo c a t io n o f Le s io n

Posterior superior temporal lobe

Posterior inferior frontal lobe

Although it is important to recognize aphasia early in your encounter with a patient, integrate this information with your neurologic examination as you generate your differential diagnosis.

Dis o rd e rs o f S p e e ch (continued )Table 17-2

Chapter 17 | The Nervous System 339

Distinguish peripheral from central lesions of CN VII by closely observing movements of the upper face. Because of innervation from both hemispheres, the upper facial movements are preserved in central lesions.

CN VII—P e r ip h e ra l Le s io n CN VII—Ce n t ra l Le s io n

Peripheral nerve damage to CN VII paralyzes the entire right side of the face, including the forehead.

Motor cortex

Synapses in the pons

Facial nerve

CN VII pe riphe ral

le s ion

Motor cortex

Synapses in the pons

Facial nerve

CN VII c e ntral le s ion

Eye does not close;

eyeball rolls up

Flat nasolabial fold

Clos ing Eye s

Eye closes ; perhaps with

s light weakness

Flat nasolabia l fold

Clos ing Eye s

Forehead not wrinkled;

eyebrow not raised

Paralys is of lower face

Rais ing Eye brows

Smiling

Forehead wrinkled; eyebrow raised

Paralys is of lower face

Rais ing Eye brows

Smiling

Typ e s o f Fa c ia l Pa ra lys isTable 17-3

340 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

P e r ip h e ra l Ne r vo u s S ys t e m Dis o rd e r

Ce n t ra l Ne r vo u s S ys t e m Dis o rd e r a

P a rk in s o n is m (Ba s a l Ga n g lia Dis o rd e r )

Ce re b e lla r D is o rd e r

In vo lu n t a ry m o ve m e n t s

Often fascicu lations

No fascicu- lations

Resting tremors Intention tremors

Mu s c le b u lk

Atrophy Normal or mild atrophy (disuse)

Normal Normal

Mu s c le t o n e

Decreased or absent

Increased, spastic

Increased, rigid Decreased

Mu s c le s t re n g t h

Decreased or lost

Normal or slightly decreased

Co o rd in a - t io n

Unimpaired, though limited by weakness

Slowed and limited by weakness

Good, though slowed and often tremulous

Impaired, ataxic

Re f le xe s

Deep tendon Decreased or absent

Increased Normal or decreased

Normal or decreased

Plan ta r Flexor or absent

Extensor Flexor Flexor

Abdom inals Absent Absent Normal Normal

Mo t o r Dis o rd e rsTable 17-4

aUpper motor neuron.

Chapter 17 | The Nervous System 341

Resting s tatic tremors . Fine, “pill-rolling” tremor seen at rest, usually disappear with movement; seen in basal ganglia disorders like Parkinson disease.

Postural tremor. Seen when maintaining active posture; in anxiety, hyperthyroidism; also familial. From basal ganglia disorder.

Intention tremor. Seen with intentional movement, absent at rest; in cerebellar disorders, including multiple sclerosis

Fasciculations. Fine, rapid flickering of muscle bundles in lower motor neuron disorders.

Chorea. Brief, rapid, irregular, jerky; face, head, arms, or hands (e.g., Huntington disease)

Athetos is . Slow, twisting, writhing; face, distal limbs, often with associated spasticity (e.g., cerebral palsy)

Invo lu n t a ry Mo ve m e n t sTable 17-5

342 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

S p a s t ic it y Rig id it y

Location. Upper motor neuron or corticospinal tract systems.

Location. Basal ganglia system

Description. Increased muscle tone (hypertonia) that is rate- dependent. Tone is greater when passive movement is rapid, and less when passive movement is slow. Tone is also greater at the extremes of the movement arc. During rapid passive movement, initial hypertonia may give way suddenly as the limb relaxes. This spastic “catch” and relaxation is known as “clasp-knife” resistance.

Description. Increased resistance that persists throughout the movement arc, independent of rate of movement, is called lead- pipe rigidity. With flexion and extension of the wrist or forearm, a superimposed ratchet-like jerkiness is called cogwheel rigidity.

Common Cause . Stroke, especially late or chronic stage

Common Cause . Parkinsonism

Fla c c id it y P a ra t o n ia

Location. Lower motor neuron at any point from the anterior horn cell to the peripheral nerves

Location. Both hemispheres, usually in the frontal lobes

Description. Loss of muscle tone (hypotonia), causing the limb to be loose or floppy. The affected limbs may be hyperextensible or even flail-like.

Description. Sudden changes in tone with passive range of motion. Sudden loss of tone that increases the ease of motion is called mitgehen (moving with). Sudden increase in tone making motion more difficult is called gegenhalten (holding against).

Common Cause . Guillain– Barré syndrome; also initial phase of spinal cord injury (spinal shock) or stroke

Common Cause . Dementia

Dis o rd e rs o f Mu s c le To n eTable 17-6

Chapter 17 | The Nervous System 343

C3 Front of neck

C5 C5

C6 C6

C7 C7

C8 C8

T1 T1

T5 T6 T7 T8 T9

T10

T11

T12

S1 S1

S2,3

L1 L2 L2

L3 L3

L4 L4

L5 L5

C8 Ring and little fingers

L4 Knee

L1 Inguina l

L5 Ante rior ankle and foot

T4 Nipples

T10 Umbilicus

De rm a t o m e sTable 17-7

Dermatomes Innervated by Posterior Roots

(table continues on page 344)

344 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

De rm a t o m e s (continued )Table 17-7

C3C3 Back of neck

C5C5

C6C6

C6 Thumb

C7C7

C8C8

T1T1

T2 T3 T4 T5 T6 T7 T8 T9

T10 T11 T12

S1S1

S2S2

S3 S4

L1 L2 L3 L4

L4L4

L4, L5, S1 Pos te rior ankle

and foot

L5L5

C8 Ring and little fingersS5 Periana l

Dermatomes Innervated by Posterior Roots

Chapter 17 | The Nervous System 345

To xic –Me t a b o lic S t ru c t u ra l

P a t h o p h ys io lo g y

Arousal centers poisoned or critical substrates depleted

Lesion destroys or compresses brainstem arousal areas, either directly or secondary to more distant expanding mass lesions.

Clin ic a l Fe a t u re s ■ Resp ira to ry pa tte rn . If

regular, may be normal or hyperventilation. If irregular, usually Cheyne–Stokes

■ Pup illa ry s ize and react ion . Equal, reactive to light. If pinpoint from opiates or cholinergics, you may need a magnifying glass to see the reaction. May be unreactive if fixed and dilated from anticholinergics or hypothermia

■ Leve l o f consciousness . Changes after pupils change

Resp ira to ry pa tte rn . Irregular, especially Cheyne–Stokes or ataxic breathing. Also with selected stereotypical patterns like “apneustic” respiration (peak inspiratory arrest) or central hyperventilation. Pup illa ry s ize and react ion . Unequal or unreactive to light (fixed)

Midposition, fixed—suggests midbrain compression Dilated, fixed—suggests compression of CN III from herniation

Leve l o f consciousness . Changes before pupils change

Exa m p le s o f Ca u s e

Uremia, hyperglycemia

Alcohol, drugs, liver failure

Hypothyroidism, hypoglycemia

Anoxia, ischemia

Meningitis, encephalitis

Hyperthermia, hypothermia

Epidural, subdural, or intracerebral hemorrhage

Cerebral infarct or embolus

Tumor, abscess

Brainstem infarct, tumor, or hemorrhage

Cerebellar infarct, hemorrhage, tumor, or abscess

Me t a b o lic a n d S t ru c t u ra l Co m aTable 17-8

346 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

Ac t iv it y S c o re

Eye Op e n in g

None 1 = Even to supraorbital pressure

To pain 2 = Pain from sternum/limb/ supraorbital pressure

To speech 3 = Nonspecific response, not necessarily to command

Spontaneous 4 = Eyes open, not necessarily aware

Mo t o r Re s p o n s e

None 1 = To any pain; limbs remain flaccid

Extension 2 = Shoulder adducted and shoulder and forearm internally rotated

Flexor response 3 = Withdrawal response or assumption of hemiplegic posture

Withdrawal 4 = Arm withdraws to pain, shoulder abducts

Localizes pain 5 = Arm attempts to remove supraorbital/chest pressure

Obeys commands 6 = Follows simple commands

Ve rb a l Re s p o n s e

None 1 = No verbalization of any type

Incomprehensible 2 = Moans/groans, no speech

Inappropriate 3 = Intelligible, no sustained sentences

Confused 4 = Converses but confused, disoriented

Oriented 5 = Converses and is oriented

TOTAL (3–15)a

Gla s g o w Co m a Sc a leTable 17-9

aInterpretation: Patients with scores of 3–8 usually are considered to be in a coma. Source: Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical

scale. Lancet. 1974;304(7872):81.

Chapter 17 | The Nervous System 347

S m a ll o r P in p o in t P u p ils Bilaterally small pupils (1–2.5 mm) suggest (1) damage to the sympathetic pathways in the hypothalamus or (2) metabolic encephalopathy (a diffuse failure of cerebral function from drugs and other causes). Light reactions are usually normal. Pinpoint pupils (<1 mm) suggest (1) a hemorrhage in the pons or (2) the effects of morphine, heroin, or other narcotics. Use a magnifying glass to see the light reactions.

Mid p o s it io n Fixe d P u p ils Midposition or slightly dilated pupils (4–6 mm) and fixed to light suggest damage in the midbrain.

La rg e P u p ils Bilaterally fixed and dilated pupils in severe anoxia with sympathomimetic effects, may be seen with cardiac arrest. They also result from atropine- like agents, phenothiazines, or tricyclic antidepressants.

On e La rg e P u p il One fixed and dilated pupil warns of herniation of the temporal lobe, causing compression of the oculomotor nerve and midbrain. Also seen in diabetes with CN III infarction.

Pu p ils in Co m a t o s e Pa t ie n t sTable 17-10

349

C H A P T E R

18Assessing Children: Infancy through Adolescence

Child Development Children display tremendous variations in physical, cognitive, and social development compared with adults.

The child’s history follows the same outline as the adult’s history, with certain additions presented here.

Id e n t if y in g D a t a Record date and place of birth, nickname, and rst and last names of parents.

C h ie f C o m p la in t s Determine if they are the concerns of the child, the parent(s), a school- teacher, or some other person.

P r e s e n t Illn e s s Determine how each family member responds to the child’s symptoms, why he or she is concerned, and impact on the child’s functioning.

The Health History

Ke y P r in c ip le s o f C h ild D e v e lo p m e n t

● Child develo ent roceeds long redict ble thw y. ● The r nge of nor l develo ent is wide. ● V rious hysic l, sychologic l, soci l, nd environ ent l f ctors, s well s

dise ses, c n ffect child develo ent nd he lth. ● The child’s develo ent l level ffects how you conduct the history nd

hysic l ex in tion.

350 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

H is t o r y Bir t h His t o ry. This is especially important when neurologic or develop- mental problems are present. Get hospital records if necessary.

■ Prenatal—maternal health: medications; tobacco, drug, and alcohol use; weight gain; duration of pregnancy

■ Natal—nature of labor and delivery, birth weight, Apgar scores at 1 and 5 minutes

■ Neonatal—resuscitation efforts, cyanosis, jaundice, infections, bonding

Fe e d in g His t o ry. This is particularly important with either undernutri- tion or obesity.

■ Breast-feeding—frequency and duration of feeds, dif culties, timing and method of weaning

■ Bottle-feeding—type; amount; frequency; vomiting; colic; diarrhea

■ Vitamins, iron, and uoride supplements; introduction of solid foods

■ Eating habits—types and amounts of food eaten, parental attitudes and responses to feeding problems

Gro w t h a n d De ve lo p m e n t a l His t o ry. This is particularly important with delayed growth or development and behavioral disturbances.

■ Physical growth—weight and height at all ages; head circumference at birth and younger than 2 years; periods of slow or rapid growth; BMI after age 2 years

■ Developmental milestones, speech development, performance in preschool and school

■ Social development—day and night sleeping patterns; toilet training; habitual behaviors; discipline problems; school behavior; relationships with family and peers; social risks such as poverty, food insecurity and adverse experiences

C u r r e n t H e a lt h S t a t u s Alle rg ie s . Pay particular attention to history of eczema, urticaria, perennial allergic rhinitis, asthma, food intolerance, insect hypersensitivity, and recurrent wheezing.

Im m u n iza t io n s . Include dates given and any untoward reactions.

S c re e n in g Te s t s . These vary according to the child’s medical and social conditions. Include newborn screening results, anemia screening, blood lead, sickle cell disease, vision, hearing, developmental screening, and others (e.g., tuberculosis).

Chapter 18 | Assessing Children: Infancy through Adolescence 351

Health Promotion and Counseling: Evidence and Recommendations

For the most up-to-date Bright Futures recommendations for preventive health care, see https://www.aap.org/en-us/Documents/periodicity_ schedule.pdf. Each child and family is unique; therefore, such recommen- dations are designed for the care of children who are receiving competent parenting, have no manifestation of any important health problems, and are growing and developing in satisfactory fashion.

1. Age-appropriate developmental achievement of the child

■ Physical (maturation, growth, puberty)

■ Motor (gross and ne motor skills)

■ Cognitive (milestones, language, school performance)

■ Emotional (self-regulation, self-ef cacy, self-esteem, independence)

■ Social (social competence, self-responsibility, integration with family and community)

2. Health supervision visits (per health supervision schedule)

■ Periodic assessment of medical and oral health

■ Adjustment of frequency for children or families with special needs

3. Integration of physical examination ndings

4. Immunizations

5. Screening procedures

6. Anticipatory guidance

■ Healthy habits

■ Nutrition and healthy eating

■ Emotional and mental health

■ Oral health

■ Safety and prevention of injury

■ Sexual development and sexuality

■ Self-responsibility and ef cacy and self-esteem

■ Family relationships (interactions, strengths, supports)

■ Prevention or recognition of illness

352 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

■ Prevention of risky behaviors and addictions

■ School and vocation

■ Peer relationships

■ Community interactions

7. Partnership between health provider, child, and family

Im m e d ia t e A s s e s s m e n t a t B ir t h

Assessing Newborns EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

If the 5-minute score is 8 or more, pro- ceed to a more complete examination.

Techniques of Examination

S e q u e n c e o f E x a m in a t io n

The sequence of ex in tion v ries ccording to the child’s ge nd co fort level.

● For inf nts nd young children, perform nondisturbing maneuvers early and potentially distressing maneuvers toward the end. For ex le, l te the he d nd neck nd uscult te the he rt nd lungs e rly; ex ine the e rs nd outh nd l te the bdo en ne r the end. If the child re orts in in n re , ex ine th t rt l st .

● For older children nd dolescents, use the s e sequence s with dults, exce t ex ine the ost inful re s l st .

Listen to the anterior thorax with your stethoscope. Palpate the abdo- men. Inspect the head, face, oral cavity, extremities, genitalia, and perineum.

Ap g a r Sc o re . Score each new- born according to the following table, at 1 and 5 minutes after birth, according to the 3-point scale (0, 1, or 2) for each component.

Chapter 18 | Assessing Children: Infancy through Adolescence 353

Ge s t a t io n a l Ag e a n d Bir t h We ig h t . Classify newborns according to their gestational age and birth weight (see Table 18-1, Classi cation of Newborn’s Level of Maturity, p. 373).

T h e A p g a r S c o r in g S y s t e m

As s ig n e d S c o re

Clin ic a l S ig n 0 1 2

Heart rate Absent <1 >1 Respiratory effort

Absent Slow nd irregul r

Good; strong

Muscle tone Fl ccid So e flexion of the r s nd legs

Active ove ent

Reflex irritabilitya

No res onses Gri ce Crying vigorously, sneeze, or cough

Color Blue, le Pink body, blue extre ities

Pink ll over

1-Min u t e Ap g a r S c o re 5 -Min u t e Ap g a r S c o re

8–1 Nor l 8–1 Nor l 5–7 –4

So e nervous sys- te de ression

Severe de ression, requiring i edi- te resuscit tion

–7 High risk for subse- quent centr l ner- vous syste nd other org n sys- te dysfunction

aRe ction to suction of n res with bulb syringe.

C la s s if ic a t io n b y G e s t a t io n a l A g e a n d B ir t h W e ig h t

Ge s t a t io n a l Ag e

Cla s s if ic a t io n Ge s t a t io n a l Ag e

Preterm Late preterm Term Postterm

<34 wks 34–36 wks 37–42 wks >42 wks

Bir t h We ig h t

Cla s s if ic a t io n We ig h t

Extremely low birth weight Very low birth weight Low birth weight Normal birth weight

<1, g <1,5 g <2,5 g ≥2,5 g

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EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

N e w b o r n C la s s if ic a t io n s

Ca t e g o ry Ab b re via t io n Pe rc e n t ile

Small for gestational age SGA <1 th Appropriate for gestational age AGA 1 –9 th Large for gestational age LGA >9 th

Most newborns are bowlegged, reflect- ing their curled up intrauterine position.

A single umbilical artery may be associ- ated with congenital anomalies. Umbili- cal hernias in infants are from a defect in the abdominal wall.

Signs of severe neurologic disease include extreme irritability; persistent asymmetry of posture or extension of extremities; constant turning of head to one side; marked extension of head, neck, and extremities (opisthotonus); severe flaccidity; and limited pain response.

During the rst day of life, newborns should have a compre- hensive examination following the technique outlined under “Infants.” Wait until 1 or 2 hours after a feeding, when the newborn is more responsive. Ask parents to remain.

Observe the baby’s color, size, body proportions, nutritional status, posture, respirations, and movements of the head and extremities.

Inspect the newborn’s umbilical cord to detect abnormalities. Normally, there are two thick-walled umbili- cal arteries and one larger but thin-walled umbilical vein, which is usually located at the 12-o’clock position.

The neurologic screening examina- tion of all newborns should include assessment of mental status, gross and ne motor function, tone, cry, deep tendon re exes, and primitive re exes.

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EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Assessing Infants

M e n t a l a n d P h y s ic a l S t a t u s Common causes of developmental delay include abnormalities in embryonic development, hereditary and genetic disorders, environmental and social problems, other pregnancy or perinatal problems, childhood diseases such as infection (e.g., meningitis), trauma, and severe chronic disease.

Failure to thrive is a condition reflecting significantly low weight gain (e.g., below 2nd percentile) for gestational-age cor- rected age and sex. Causes can be envi- ronmental or psychosocial, or various gastrointestinal, neurologic, cardiac, endocrine, renal, and other diseases.

Measures above the 97th or below the 3rd percentile, or recent rises or falls from prior levels, require investigation.

Reduced growth in height may indicate endocrine disease, other causes of short sta ture, or, if weight is also low, other chronic diseases.

Premature closure of the sutures or microcephaly may cause small head size. Hydrocephalus, subdural hematoma, or, rarely, brain tumor or inherited syn- dromes may cause an abnormally large head size.

Observe the parents’ affect when talking about the baby and their manner of holding, moving, and dressing the baby. Observe a breast or bottle-feeding. Determine attain- ment of developmental milestones, optimally using a standardized developmental screening test.

G e n e r a l S u r v e y Growth, re ected in increases in height and weight within expected limits, is an excellent indicator of health during infancy and child- hood. Deviations from normal may be early indications of an underly- ing problem. To assess growth, compare a child’s parameters with respect to:

■ Normal values according to age and sex

■ Prior readings to assess trends

He ig h t a n d We ig h t . Plot each child’s height and weight on stan- dard growth charts to determine progress.

He a d Circ u m fe re n c e . Deter- mine head circumference at every physical examination during the rst 2 years (Fig. 18-1).

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Figure 18-1 Head circumference is a vital metric during early childhood.

V it a l S ig n s Blo o d P re s s u re . Measure blood pressure at least once during infancy. Although the hand-held method is shown in Figure 18-2, the most easily used measure of systolic blood pressure in infants and young children is obtained with the Doppler method. Figure 18-2 Practice is required to

accurate ly measure blood pressure in early childhood.

C a u s e s o f S u s t a in e d H y p e r t e n s io n in C h ild r e n

Ne w b o rn Mid d le Ch ild h o o d

Ren l rtery dise se (stenosis, thro bosis)

Congenit l ren l lfor tions Co rct tion of the ort

Pri ry hy ertension

Ren l renchy l or rteri l dise se Co rct tion of the ort

In fa n c y a n d Ea r ly Ch ild h o o d Ad o le s c e n c e

Ren l renchy l or rtery dise se Co rct tion of the ort

Pri ry hy ertension Ren l renchy l dise se Drug induced

P u ls e . The heart rate is quite variable and will increase markedly with excitement, crying, or anxiety. Therefore, measure the pulse when the infant or child is quiet.

Tachycardia (>180–200 beats per min- ute) usually indicates paroxysmal supra- ventricular tachycardia . Bradycardia may result from serious underlying disease.

Chapter 18 | Assessing Children: Infancy through Adolescence 357

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Re s p ira t o ry Ra t e . The respira- tory rate has a very wide range and is more responsive to illness, exer- cise, and emotion than in adults.

T h e S k in Assess:

■ Texture and appearance

■ Vasomotor changes

■ Pigmentation (e.g., Mongolian spots)

■ Hair (e.g., lanugo)

■ Common skin conditions (e.g., milia, erythema toxicum)

■ Color

■ Turgor

T h e H e a d Examine sutures and fontanelles carefully (Fig. 18-3).

Respiratory diseases such as bronchiolitis or pneumonia may cause rapid respira- tions (up to 80 to 90 breaths per minute), and increased work of breathing. Peaceful tachypnea (without increased work of breathing) may be a sign of cardiac failure.

Cutis marmorata

Acrocyanosis; cyanotic congenital heart disease

Café-au-lait spots

Midline hair tuft on back

Herpes simplex

Jaundice can be from hemolytic disease.

Dehydration

Head small with microcephaly, enlarged with hydrocephaly; fontanelles full and tense with meningitis, closed with micro- cephaly, separated with increased intra- cranial pressure (hydrocephaly, subdural hematoma, and brain tumor)

Swelling from subperiosteal hemor- rhage (cephalohematoma) does not cross suture lines; swelling from bleed- ing associated with a fracture does.

Ante rior fontane lle

Pos te rior fontane lle

Lambdoida l suture

Sagitta l suture

Corona l suture

Metopic suture

Figure 18-3 Suture s and fontane lle s .

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EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Check the face for symmetry. Examine for an overall impression of the facies; comparing with the faces of the parents is helpful.

Abnormal facies occurs in a child with a constellation of facial features that appear abnormal. A variety of syn- dromes can cause abnormal facies (see box below for evaluation). Examples include Down syndrome and fetal a lcohol syndrome.

T h e E y e s Newborns and young infants may look at your face and follow a bright light if you catch them while alert. Examine the red re ex.

Normal visual milestones are as follows:

Nystagmus, strabismus

Leukocoria is a white papillary reflex (instead of the normal red papillary reflex). It can be a sign of a rare tumor called retinoblastoma.

P e a r ls t o E v a lu a t e P o t e n t ia lly A b n o r m a l F a c ie s

C refully review the history, es eci lly the family history, pregnancy, nd perinatal history.

Note bnor lities of growth/develo ent or dys or hic so tic fe tures. Me sure nd lot ercentiles, es eci lly of head circumference, height, nd

weight. Consider the three ech nis s of f ci l dys or hogenesis:

● Defor tions fro intr uterine constr int ● Disru tions fro niotic b nds or fet l tissue ● M lfor tions fro intrinsic bnor lity (either f ce/ he d or br in)

Ex ine rents nd siblings (si il rity y be re ssuring but ight lso oint to f ili l disorder).

Deter ine whether f ci l fe tures fit recogniz ble syndro e. Co re g inst references, ictures, t bles, nd d t b ses.

V is u a l M ile s t o n e s o f In f a n c y

Birth Blinks, y reg rd f ce 1 month Fixes on objects 1½–2 months Coordin ted eye ove ents 3 months Eyes converge, b by re ches 12 months Acuity round 2 /6 –2 /8

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T h e E a r s Check position, shape, and features. Small, deformed or low-set auricles may

indicate associated congenital defects, especially renal disease.

S ig n s T h a t a n In f a n t C a n H e a r

Ag e S ig n s

0–2 months St rtle res onse nd blink to sudden noise C l ing down with soothing voice or usic

2–3 months Ch nge in body ove ents in res onse to sound Ch nge in f ci l ex ression to f ili r sounds Turning eyes nd he d to sound

3–4 months Turning to listen to voices nd convers tion 6–7 months A ro ri te l ngu ge develo ent

T h e N o s e Test patency of the nasal passages by occluding alternately each nostril while holding the infant’s mouth closed.

With choanal a tresia , the baby cannot breathe if one nostril is occluded.

Supernumerary teeth, Epstein pearls

Oral candidiasis (thrush)

Vesicles in the mouth can be caused by enteroviral infections and herpes simplex virus infections.

Lymphadenopathy is usually from viral or bacterial infections.

Other neck masses include malignancy, branchia l cleft or thyroglossa l duct cysts, and periauricular cysts and sinuses.

T h e M o u t h a n d P h a r y n x Inspect (with a tongue blade and ashlight) and palpate.

You may see a whitish covering on the tongue. If this coating is from milk, you can easily remove it by scraping or wiping it away.

T h e N e c k Palpate the lymph nodes, and assess for any additional masses (e.g., congenital cysts), as shown in Figure 18-4.

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Preauricular cys t

Parotid nodes

Occipital node

Retroauricular (mas toid) nodes

Superior deep cervical nodes

Middle deep cervical nodes

Pos terior cervical nodes

Epidermoid cys t

J ugulogas tric node

Submandibular node

Submental node

Thyroglossal duct cys t

Cys tic hygroma

Anterior cervical nodes

Inferior deep cervical nodes

Supraclavicular node

2nd branchial cleft cys t

Figure 18-4 Nodes and cys ts of the head and neck.

E x a m in a t io n o f t h e Lu n g s in In f a n t s —B e f o r e Y o u T o u c h t h e C h ild !

As s e s s m e n t Po s s ib le Fin d in g s Exp la n a t io n

General appear- ance

In bility to feed or s ile L ck of consol bility

Lower respiratory infections (e.g., bronchiolitis, pneumo- nia) re co on in inf nts.

Respiratory rate T chy ne C rdi c or res ir tory dise se (e.g., neu oni )

Color P llor or cy nosis C rdi c or ul on ry dise se Nasal compo-

nent of breathing

N s l fl ring (enl rge ent of both n s l o enings during ins ir tion)

U er or lower res ir tory infection

(continued )

T h e T h o r a x a n d Lu n g s Apnea

Upper respiratory infections may cause nasal flaring.

Carefully assess respirations and breathing pattern.

Do not rush to the stethoscope, but observe the patient carefully rst.

Chapter 18 | Assessing Children: Infancy through Adolescence 361

Auscultate the chest, and try to dis- tinguish upper airway from lower airway sounds.

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

E x a m in a t io n o f t h e Lu n g s in In f a n t s —B e f o r e Y o u T o u c h t h e C h ild ! (Continued)

As s e s s m e n t Po s s ib le Fin d in g s Exp la n a t io n

Audible breath sounds

Grunting (re etitive, short ex ir tory sound)

Wheezing ( usic l ex ir - tory sound)

Stridor (high- itched, ins ir tory noise)

Obstruction (l ck of bre th sounds)

Lower res ir tory dise se

Asth or bronchiolitis

Crou , e iglottitis, b cteri l tr cheitis

Foreign body

Work of breath- ing

N s l fl ring Grunting Retr ctions (chest

indr wing): Su r cl vicul r ( otion

of soft tissue bove cl vicles)

Intercost l (indr wing of the skin between ribs)

Substern l ( t xi hoid rocess)

Subcost l (just below the cost l rgin)

In inf nts, bnor l work of bre thing co bined with bnor l findings on us- cult tion is the best finding for ruling in pneumonia.

D is t in g u is h in g U p p e r A ir w a y f r o m Lo w e r A ir w a y S o u n d s

Te ch n iq u e Up p e r Airw a y Lo w e r Airw a y

Compare sounds from nose/ stethoscope

S e sounds Often different sounds

Listen to harshness of sounds

H rsh nd loud V ri ble

Note symmetry (left/right) Sy etric Often sy etric Compare sounds at differ-

ent locations (higher or lower)

Sounds louder s stetho- sco e is oved u chest

Sounds louder lower in chest

Inspiratory vs. expiratory Al ost lw ys ins ir - tory

Often h s ex ir tory h se

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T h e H e a r t In s p e c t io n . Observe carefully for any cyanosis. The best body part to assess cyanosis is the tongue or inside of the mouth.

Pa lp a t io n . Palpate the peripheral pulses. The point of maximal impulse (PMI) is not always palpable in infants. Thrills are palpable when enough turbulence is within the heart or great vessels.

Au s c u lt a t io n . Heart rhythm is evaluated more easily in infants by listening to the heart than by feel- ing the peripheral pulses.

Evaluate S1 and S2 carefully. They are normally crisp with intermit- tent splitting of S1 and S2 (fused in expiration).

Listen for heart murmurs. Two common benign systolic mur- murs are from a closing ductus or peripheral pulmonary ow murmur.

T h e B r e a s t s The breasts of males and females may be enlarged for months after birth as a result of maternal estrogen.

T h e A b d o m e n You will nd it easy to palpate an infant’s abdomen, because infants like being touched. Palpate the liver and spleen and assess for hepatosplenomegaly.

At birth: Transposition of the great arter- ies; pulmonary valve atresia or stenosis

Within a few days of birth: The above; also total anomalous pulmonary venous return, hypoplastic left heart

No or diminished femoral pulses suggest coarcta tion of the aorta . Weak or thready, difficult-to-feel pulses may reflect myo- cardia l dysfunction and heart fa ilure.

The most common dysrhythmia in chil- dren is paroxysmal supraventricular tachycardia .

A louder-than-normal pulmonic compo- nent suggests pulmonary hypertension. Persistent splitting of S2 may indicate atria l septal defect.

Most infants with cardiac pathology have signs beyond heart murmurs.

Abnormal abdominal masses can be associated with kidney, bladder, or bowel tumors. In pyloric stenosis, deep palpation in the right upper quadrant or midline can reveal an “olive,”or a 2-cm firm pyloric mass.

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EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

M a le G e n it a lia Inspect with the infant supine. The foreskin of a newborn is nonre- tractable at birth or just enough to visualize the urethral meatus.

In 3% of infants, one or both testes cannot be felt in the scrotum or inguinal canal. Try to milk the tes- tes into the scrotum.

Fe m a le G e n it a lia In females, genitalia may be promi- nent for several months after birth from the effects of maternal estrogen.

Common scrotal masses are hydroceles and inguinal hernias.

Inability to palpate testes, even with maneuvers, indicates undescended testicles.

Ambiguous genita lia involves masculin- ization of the female external genitalia.

Skin tags, remnants of digits, polydactyly (extra fingers), or syndactyly (webbed fingers) are congenital defects. Fracture of the clavicle can occur during a difficult delivery.

Figure 18-5 Ortolani te s t, ove rhead view.

Figure 18-6 Barlow tes t, overhead view.

Congenital hip dysplasia may have a positive Ortolani or Barlow test, particu- larly during the first 3 months of age. With a hip dysplasia , you feel a “clunk.”

T h e M u s c u lo s k e le t a l S y s t e m Examine the extremities by inspec- tion and palpation to detect congen- ital abnormalities, particularly in the hands, spine, hips, legs, and feet.

Examine the hips carefully at each visit for signs of dislocation. There are two major techniques: one to test for a posteriorly dislocated hip (Ortolani test), as shown in Fig- ure 18-5, and the other to test for the ability to sublux or dislocate an intact but unstable hip (Barlow test), as shown in Figure 18-6.

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Some normal infants exhibit twist- ing or torsion of the tibia inwardly or outwardly on its longitudinal axis.

T h e N e r v o u s S y s t e m Evaluate the developing central nervous system by assessing infan- tile automatisms, called primitive re exes.

Neurologic abnormalities in infants often present as develop- mental abnormalities such as failure to do age-appropriate tasks.

Pathologic tibial torsion occurs only in association with deformities of the feet or hips.

Suspect a neurologic or developmenta l abnormality if primitive reflexes are absent at appropriate age, present lon- ger than normal, asymmetric, or associ- ated with posturing or twitching.

Hypotonia can be a sign of a variety of neurologic abnormalities.

Assessing Children (1 to 10 Years)

T ip s f o r In t e r v ie w in g C h ild r e n

● Establish rapport. Refer to children by n e nd eet the on their own level. M int in eye cont ct t their level (e.g., sit on the floor if needed). P r- tici te in l y nd t lk bout their interests.

● Work with families. Ask si le, o en-ended questions such s “Are you sick? Tell e bout it ,” followed by ore s ecific questions. Once the rent h s st rted the convers tion, direct questions b ck to the child. Also observe how rents inter ct with the child.

● Identify multiple agendas. Your job is to discover s ny ers ectives nd gend s s ossible.

● Use the family as the key resource. View rents s ex erts in the c re of their child nd you s their consult nt .

● Note hidden agendas. As with dults, the chief co l int y not rel te to the re l re son the rent h s brought the child to see you.

The following discussion focuses on those re s of the co rehensive hysic l ex in tion th t re different for children th n for inf nts nd for dults.

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EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

In children age 1 to 5 years, observe the degree of sickness or wellness, mood, nutritional state, speech, cry, facial expression, and devel- opmental skills. Note parent–child interaction, including separation tolerance, affection, and response to discipline.

In children 6 to 10 years, determine orientation to time and place, factual knowledge, and language and number skills. Observe motor skills used in writing, tying laces, buttoning, cutting, and drawing.

Bo d y Ma s s In d e x fo r Ag e . Age- and sex-speci c charts are now available to assess body mass index (BMI) in children.

Blo o d P re s s u re . Hypertension during childhood is more common than previously thought. Recogniz- ing, con rming, and appropriately managing it is important. Blood pressure readings should be part of the physical examination of every child older than 2 years (see Table 18-2, Hypertension in Childhood, p. 374). Proper cuff size is essential for accurate determination of blood pressure in children.

T h e E y e s Test visual acuity in each eye and determine whether the gaze is conjugate or symmetric.

This overall examination can uncover evi- dence of chronic disease, developmental delay, social or environmental disorders, and family problems.

Observing children performing tasks can reveal signs of inattentiveness or impul- sivity, which may indicate attention defi- cit disorder.

Underweight is <5th percentile, at risk of overweight is ≥85th percentile, and overweight is ≥95th percentile.

The most frequent “cause”of elevated blood pressure in children is probably an improperly performed examination, often from an incorrect cuff size.

Causes of sustained hypertension in childhood include renal disease, coarcta- tion of the aorta, and primary hyperten- sion. Hypertension is often related to childhood obesity.

Any difference in visual acuity between eyes is abnormal.

Myopia or hyperopia often present in school-aged children.

M e n t a l a n d P h y s ic a l S t a t u s

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S p e c ia l T e c h n iq u e The corneal light re ex test (Fig. 18-7) and the cover–uncover test (Fig. 18-8) are particularly useful in young children.

Strabismus can lead to amblyopia.

Figure 18-8 Cover–uncover te s t.Figure 18-7 Corneal light re flex tes t.

V is u a l A c u it y

Ag e Vis u a l Ac u it y

3 months Eyes converge, b by re ches 12 months 2 /6 –2 /8 Younger than 4 years 2 /4 4 years and older 2 /3

T h e E a r s Examine the ear canal and drum. There are two positions for the child (lying down or sitting), and also two ways to hold the otoscope, as shown in Figures 18-9 and 18-10.

Pain on movement of the pinna occurs with otitis externa.

Figure 18-9 Gently holding the child’s arms reduces reactions to the otoscope.

Figure 18-10 Gently pulling up on the auricle gives a be tte r otoscope view with many children.

Chapter 18 | Assessing Children: Infancy through Adolescence 367

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

■ Insert the speculum, obtaining a proper seal.

P n e u m a t ic Ot o s c o p e . Learn to use a pneumatic otoscope to improve accuracy of diagnosis of otitis media. When air is intro- duced into the normal ear canal, the tympanic membrane and its light re ex move inward. When air is removed, the tympanic mem- brane moves outward toward you.

Acute otitis media involves a red and bulging tympanic membrane.

Diminished movement of tympanic membrane with acute otitis media ; no movement with otitis media with effusion.

T h e M o u t h a n d P h a r y n x For anxious or young children, leave this examination toward the end. The best technique for a tongue blade is to push down and pull slightly forward toward you while the child says “ah.” Do not place the blade too far posteriorly, eliciting a gag re ex.

Examine the teeth for the timing and sequence of eruption, number, character, condition, and position.

Carefully inspect the inside of the upper teeth, as shown in Figure 18-11.

A common cause of a strawberry tongue, red uvula, and pharyngeal exudate is streptococcal pharyngitis.

Abnormalities of the enamel may reflect local or general disease.

Nursing bottle caries; denta l caries; sta in- ing of the teeth, which may be intrinsic or extrinsic

Dental caries are the most common health problem of children and are particularly prevalent in impoverished children.

Figure 18-11 Lift the lip to check for dental caries .

368 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

Look for abnormalities of tooth position.

Note the size, position, symmetry, and appearance of the tonsils.

T h e H e a r t A challenging aspect to cardiac examination of children is evalua- tion of heart murmurs, particularly distinguishing common benign murmurs from unusual or patho- logic ones. Most children have one or more functional, or benign, heart murmurs at some point in time (Fig. 18-12).

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Malocclusion

Peritonsillar abscess

Venous hum Carotid bruit

Still’s murmur

Pulmonary flow

Figure 18-12 Location of benign heart murmurs in children.

See Table 18-3, Characteristics of Patho- logic Heart Murmurs, pp. 375–376.

T h e A b d o m e n Most children are ticklish when you rst place your hand on their abdomens for palpation. This reac- tion tends to disappear, particularly if you distract the child.

A pathologically enlarged liver in chil- dren usually is palpable more than 2 cm below the costal margin, has a round, firm edge, and often is tender.

A common condition of childhood that can occasionally cause a protuberant abdomen is constipation.

Chapter 18 | Assessing Children: Infancy through Adolescence 369

M a le G e n it a lia There is an art to palpation of the young boy’s scrotum and testes, because many have an active crem- asteric re ex causing the testes to retract upward into the inguinal canal and appear undescended. A useful technique is to have the boy sit cross-legged on the examining table.

Fe m a le G e n it a lia Use a calm, gentle approach, including a developmentally appro- priate explanation.

Examine the genitalia in an ef - cient and systematic manner. The normal hymen can have various con gurations (Fig. 18-13).

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

In precocious puberty, the penis and tes- tes are enlarged, with signs of pubertal changes.

A painful testicle requires rapid treat- ment and may indicate torsion.

Inguinal hernias in older boys present as they do in adult men.

Figure 18-13 Separate labia to assess genital s tructures .

Vaginal discharge in early childhood can result from perineal irrita tion (e.g., from bubble baths, soaps), foreign body, vagi- nitis, or sexually transmitted infections from sexual abuse. Vaginal bleeding, abrasions, or signs of trauma to the external genitalia can result from sexual abuse (see Table 18-7, Physical Signs of Sexual Abuse, p. 381).

370 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

T h e M u s c u lo s k e le t a l S y s t e m

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Abnormalities of the upper extremi- ties are rare in the absence of injury. To assess the lower extremities, observe the child standing and walking barefoot, and ask the child to touch the toes, rise from sitting, run a short distance, and pick up objects. You will detect most abnor- malities by watching carefully.

T h e N e r v o u s S y s t e m Beyond infancy, the neurologic examination includes the compo- nents evaluated in adults. Again, combine the neurologic and devel- opmental assessments. You can turn this into a game with the child to assess optimal development and neurologic performance.

A screening musculoskeletal examina- tion for children participating in sports can detect injuries or abnormalities that may result in problems during athletics.

Extreme bowing or unilateral bowing may be from pathologic causes such as rickets or tibia vara (Blount disease).

Delayed language or cognitive skills can be due to neurologic disease as well as developmental disorders.

Soft neurologic signs can suggest minor developmental abnormalities.

Assessing Adolescents The key to successfully examining teens is a comfortable, con dential envi- ronment that makes the examination relaxed and informative. Adolescents are more likely to open up when the interview focuses on them rather than on their problems.

Consider the patient’s cognitive and social development when deciding issues of privacy, parental involvement, and con dentiality. Explain to both teens and parents that the purpose of con dentiality is to improve health care, not keep secrets. Your goal is to help adolescents bring their concerns or questions to their parents. Never make con dentiality unlim- ited, however. Always state to teens explicitly that you may need to act on information that makes you concerned about safety.

The physical examination of the adolescent is similar to that of the adult. Keep in mind issues particularly relevant to teens, such as puberty, growth, development, family and peer relationships, sexuality, decision making, and risk behaviors. For more details on speci c techniques of examina- tion, the reader should refer to the corresponding chapter for the regional examination of interest or concern. Following are special areas to highlight when examining adolescents.

Chapter 18 | Assessing Children: Infancy through Adolescence 371

T h e B r e a s t s

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Assess normal maturational development.

S p e c ia l T e c h n iq u e Te s t in g fo r S c o lio s is . Inspect any child who can stand for sco- liosis. Make sure the child bends forward with the knees straight (Adams bend test). Evaluate any asymmetry in positioning or gait. If you detect scoliosis, use a scoliome- ter to test for the degree of scoliosis (Fig. 18-14).

See Table 18-4, Sex Maturity Ratings in Girls: Breasts, p. 377.

Figure 18-14 Measure and record scolios is w ith a scoliomete r.

M a le a n d Fe m a le G e n it a lia An important goal when examin- ing adolescent males and females is to assign a sexual maturity rating, regardless of chronologic age.

See Table 18-5, Sex Maturity Ratings in Boys, pp. 378–379, and Table 18-6, Sex Maturity Ratings in Girls: Pubic Hair, p. 380.

Recording Your Findings The format of the pediatric medical record is the same as that of the adult. Thus, although the sequence of the physical examination may vary, convert your written ndings back to the traditional format.

R e c o r d in g t h e P h y s ic a l E x a m in a t io n — T h e P e d ia t r ic P a t ie n t

Bri n is chubby, ctive, nd energetic toddler. He l ys with the reflex h - er, retending it is truck. He e rs closely bonded with his other, look- ing t her occ sion lly for co fort . She see s concerned th t Bri n will bre k so ething. His clothes re cle n.

(continued )

372 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

R e c o r d in g t h e P h y s ic a l E x a m in a t io n — T h e P e d ia t r ic P a t ie n t (Continued)

Vit a l S ig n s . Ht 9 c (9 th ercentile). Wt 16 kg (>95th ercentile). BMI 19.8 (>95th ercentile). He d circu ference 5 c (75th ercentile). BP 1 8/58. He rt r te 9 nd regul r. Res ir tory r te 3 ; v ries with ctivity. Te er ture (e r) 37.5°C. Obviously no in.

S k in . Nor l exce t for bruises on legs, nd tchy, dry skin over extern l surf ce of elbows.

HEENT. Head: Nor oce h lic; no lesions. Eyes: Difficult to ex ine bec use he won’t sit still. Sy etric with nor l extr ocul r ove ents. Pu ils 4 to 5 constricting. Discs difficult to visu lize; no he orrh ges noted. Ears: Nor l inn ; no extern l bnor lities. Nor l extern l c n ls nd ty nic e - br nes (TMs). Nose: Nor l n res; se tu idline. Mouth: Sever l d rkened teeth on inside surf ce of u er incisors. One cle r c vity on u er right incisor. Tongue nor l. Cobblestoning of osterior h rynx; no exud tes. Tonsils l rge but dequ te g (1.5 c ) between the .

Ne ck . Su le, idline tr che , no thyroid l ble.

Lym p h No d e s . E sily l ble (1.5 to 2 c ) tonsill r ly h nodes bil ter lly. S ll ( .5 c ) nodes in inguin l c n l bil ter lly. All ly h nodes obile nd nontender.

Lu n g s . Good ex nsion. No t chy ne or dys ne . Congestion udible, but see s to be u er irw y (louder ne r outh, sy etric). No rhonchi, r les, or wheezes. Cle r to uscult tion.

Ca rd io va s c u la r. PMI in 4th or 5th inters ce nd idstern l line. Nor l S1 nd S2. No ur urs or bnor l he rt sounds. Nor l fe or l ulses; dors lis edis ulses l ble bil ter lly.

Bre a s t s . Nor l, with so e f t under both.

Ab d o m e n . Protuber nt but soft; no sses or tenderness. Liver s n 2 c below right cost l rgin (RCM) nd not tender. S leen nd kidneys not l ble.

Ge n it a lia . T nner I circu cised enis; no ubic h ir, lesions, or disch rge. Testes descended, difficult to l te bec use of ctive cre steric reflex. Nor l scrotu both sides.

Mu s c u lo s k e le t a l. Nor l r nge of otion of u er nd lower extre ities nd ll joints. S ine str ight . G it nor l.

Ne u ro lo g ic . Mental Status: H y, coo er tive child. Developmental: Gross otor—Ju s nd throws objects. Fine otor—I it tes vertic l line. L ngu ge—Does not co bine words; single words only, three to four noted during ex in tion. Person l–soci l—W shes f ce, brushes teeth, nd uts on shirt . Over ll—Nor l, exce t for l ngu ge, which e rs del yed. Cranial Nerves: Int ct , lthough sever l difficult to elicit . Cerebellar: Nor l g it; good b l nce. Deep tendon reflexes (DTRs): Nor l nd sy etric throughout with downgoing toes. Sensory: Deferred.

Chapter 18 | Assessing Children: Infancy through Adolescence 373

Aids to Interpretation

25 27 29 31 33 35 37 39 41 43 45

4.5

3.5

2.5

1.5

0.5

90%

10%

(

)

Weeks of Ges ta tion

Large for ges ta tiona l age

Appropria te for ges ta tiona l age

Small for ges ta tiona l age

Premature Term Pos tmature

A B

Intrauterine Growth Curve s

Weight Small for Gestational Age (SGA) = Birth weight <10th percentile on the intrauterine growth curve Weight Appropriate for Gestational Age (AGA) = Birth weight within the 10th and 90th percentiles on the intrauterine growth curve Weight Large for Gestational Age (LGA) = Birth weight >90th percentile on the intrauterine growth curve

Cla s s if ic a t io n o f Ne w b o rn ’s Leve l o f Ma t u rit y

Table 18-1

Level of intrauterine growth based on birth weight and gestational age of liveborn, single, white infants. Point A represents a premature infant, while point B indicates an infant of similar birth weight who is mature but small for gestational age; the growth curves are representative of the 10th and 90th percentiles for all of the newborns in the sampling.

Adapted from Sweet YA. Classi cation of the low-birth-weight infant. In: Klaus MH, Fanaroff AA. Care of the High-Risk Neonate, 3rd ed. Philadelphia, PA: WB Saunders; 1986. Reproduced with permission.

374 Ba tes’ Pocke t Guide to Physica l Examina tion and His tory Taking

Hypertension can start in childhood. Although young children with elevated blood pressure are more likely to have a renal, cardiac, or endocrine cause older children and adolescents with hypertension are most likely to have primary or essential hypertension. Hypertension is often related to obesity. This child developed hypertension before adolescence, and it “tracked” into adulthood. Children tend to remain in the same percentile for blood pressure as they grow. This tracking of blood pressure continues into adulthood, supporting the concept that adult essential hypertension begins during childhood. The consequences of untreated hypertension can be severe.

90 0 1 2 3 4 5 6 7 8 9

Age (Years )

Boys Sys tolic Blood Pressure 95% Percentile

Sys tolic 5%

10 11 12 13 14 15 16 17

120

150

95 100 105 110 115

125 130 135 140 145

Sys tolic 50% Sys tolic 95% Patient

Hyp e r t e n s io n in Ch ild h o o dTable 18-2

Chapter 18 | Assessing Children: Infancy through Adolescence 375

Co n g e n it a l De fe c t Ch a ra c t e r is t ic s o f Mu rm u r

P u lm o n a ry Va lve S t e n o s is

Mild S 1 A2

P 2

Location. Upper left sternal border Radiation. In mild degrees of stenosis, the murmur may be heard over the course of the pulmonary arteries in the lung fields. Intensity. Increases in intensity and duration as the degree of obstruction increases

Severe S 1 A2

P 2

Quality. Ejection, peaking later in systole as the obstruction increases

Ao r t ic Va lve S t e n o s is S 1 A2

P 2

Location. Midsternum, upper right sternal border Radiation. To the carotid arteries and suprasternal notch; may also be a thrill Intensity. Varies, louder with increasingly severe obstruction Quality. An ejection, often harsh, systolic murmur

Te t ra lo g y o f Fa llo t General. Variable cyanosis, increasing with activity

With Pu lm onic S tenos is Location. Mid to upper left sternal border. If pulmonary atresia, there is no systolic murmur but the continuous murmur of ductus arteriosus flow at upper left sternal border or in the back.

With Pu lm onic Atres ia S 1 A2 S 1

Radiation. Little, to upper left sternal border, occasionally to lung fields Intensity. Usually grade III–IV Quality. Midpeaking, systolic ejection murmur

Ch a ra c t e ris t ic s o f Pa t h o lo g ic He a r t Mu rm u rs

Table 18-3

(table continues on page 376)

376 Ba tes’ Pocke t Guide to Physica l Examina tion and His tory Taking

Co n g e n it a l De fe c t Ch a ra c t e r is t ic s o f Mu rm u r

Tra n s p o s it io n o f t h e Gre a t Ar t e r ie s

General. Intense generalized cyanosis Location. No characteristic murmur. If present, it may reflect an associated defect such as VSD. Radiation and quality. Depends on associated abnormalities

Ve n t r ic u la r S e p t a l De fe c t Location. Lower left sternal border

Sm all to Modera te S 1 A2 P 2

Radiation. Little Intensity. Variable, only partially determined by the size of the shunt. Small shunts with a high- pressure gradient may have very loud murmurs. Large defects with elevated pulmonary vascular resistance may have no murmur. Grade II–IV/VI, with a thrill if grade IV/VI or higher.

Ch a ra c t e ris t ic s o f Pa t h o lo g ic He a r t Mu rm u rs (continued )

Table 18-3

Chapter 18 | Assessing Children: Infancy through Adolescence 377

S t a g e 1

Preadolescent—elevation of nipple only

S t a g e 2 S t a g e 3

Breast bud stage. Elevation of breast and nipple as a small mound; enlargement of areolar diameter

Further enlargement and elevation of breast and areola, with no separation of the contours

S t a g e 4 S t a g e 5

Projection of areola and nipple to form a secondary mound above the level of the breast

Mature stage; projection of nipple only. Areola has receded to general contour of the breast (although may continue to form a secondary mound).

S ex Ma t u rit y Ra t in g s in Girls : Bre a s t sTable 18-4

Photos reprinted, with permission from the American Academy of Pediatrics, Assessment of Sexual Maturity Stages in Girls, 1995.

378 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

In assigning SMRs in boys, observe each of the three characteristics separately. Record two separate ratings: pubic hair and genital. If the penis and testes differ in their stages, average the two into a single figure for the genital rating.

S t a g e 1 Pubic Hair: Preadolescent—no pubic hair except for the fine body hair (vellus hair) similar to that on the abdomen Genitalia ■ Penis, Testes, and Scrotum:

Preadolescent—same size and proportions as in childhood

S t a g e 2 Pubic Hair: Sparse growth of long, slightly pigmented, downy hair, straight or only slightly curled, chiefly at the base of the penis Genitalia ■ Penis: Slight to no enlargement ■ Testes and Scrotum: Testes larger;

scrotum larger, somewhat reddened, and altered in texture

S t a g e 3 Pubic Hair: Darker, coarser, curlier hair spreading sparsely over the pubic symphysis Genitalia ■ Penis: Larger, especially in length ■ Testes and Scrotum: Further enlarged

Sex Ma t u rit y Ra t in g s in Bo ysTable 18-5

Chapter 18 | Assessing Children: Infancy through Adolescence 379

S t a g e 4 Pubic Hair: Coarse and curly hair, as in the adult; area covered greater than in stage 3 but less than adult and not yet on thighs Genitalia ■ Penis: Further enlarged in length and

breadth, with development of the glans ■ Testes and Scrotum: Further enlarged;

scrotal skin darkened

S t a g e 5 Pubic Hair: Hair adult quantity and quality, spread to the medial surfaces of the thighs but not up over the abdomen Genitalia ■ Penis: Adult in size and shape ■ Testes and Scrotum: Adult in size and

shape

S ex Ma t u rit y Ra t in g s in Bo ys (continued )Table 18-5

Photos reprinted from Pediatric Endocrinology and Growth, 2nd ed., Wales & Wit, 2003, with permission from Elsevier.

380 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

S t a g e 1 Preadolescent—no pubic hair except for the fine body hair (vellus hair) similar to that on the abdomen

S t a g e 2 Sparse growth of long, slightly pigmented, downy hair, straight or only slightly curled, chiefly along the labia

S t a g e 3 Darker, coarser, curlier hair, spreading sparsely over the pubic symphysis

S t a g e 4 Coarse and curly hair as in adults; area covered greater than in stage 3 but not as great as in the adult and not yet including the thighs

S t a g e 5 Hair adult in quantity and quality, spread on the medial surfaces of the thighs but not up over the abdomen

Sex Ma t u rit y Ra t in g s in Girls : Pu b ic Ha irTable 18-6

Photos reprinted, with permission from the American Academy of Pediatrics, Assessment of Sexual Maturity Stages in Girls, 1995.

Chapter 18 | Assessing Children: Infancy through Adolescence 381

P h ys ic a l S ig n s Th a t Ma y In d ic a t e S e xu a l Ab u s e in Ch ild re n a

1. Marked and immediate dilatation of the anus in knee–chest position, with no constipation, stool in the vault, or neurologic disorders

2. Hymenal notch or cleft that extends >50% of the inferior hymenal rim (confirmed in knee–chest position)

3. Condyloma acuminata in a child older than 3 years 4. Bruising, abrasions, lacerations, or bite marks of labia or perihymenal

tissue 5. Herpes of the anogenital area beyond the neonatal period 6. Purulent or malodorous vaginal discharge in a young girl (all discharges

should be cultured and viewed under a microscope for evidence of a sexually transmitted infection)

P h ys ic a l S ig n s Th a t S t ro n g ly S u g g e s t S e xu a l Ab u s e in Ch ild re n a

1. Lacerations, ecchymoses, and newly healed scars of the hymen or the posterior fourchette

2. No hymenal tissue from 3 to 9 o’clock (confirmed in various positions) 3. Healed hymenal transections, especially between 3 and 9 o’clock

(complete cleft) 4. Perianal lacerations extending to external sphincter

A sexual abuse expert must evaluate a child with concerning physical signs for a complete history and sexual abuse examination.

P hys ic a l S ig n s o f Sexu a l Ab u s eTable 18-7

aAny physical sign must be evaluated in light of the entire history, other parts of the physical examination, and laboratory data.

383

C H A P T E R

19The Pregnant Woman

The Health History

In it ia l P re n a t a l Vis it . Focus the initial prenatal visit on the health status of the mother and fetus. Con rm the pregnancy and estimate gestational age, develop a plan for continuing care, and counsel the mother about her expectations and concerns. At the end of the visit, reaf rm your commit- ment to the patient’s health and any ongoing concerns, review your nd- ings, and discuss any questions or tests or screenings that are needed. Ask about the following topics:

■ Con rmation of pregnancy. Has the patient had a con rmatory urine pregnancy test, and when? When was her last menstrual period (LMP)? Has an ultrasound been done to establish dates? Explain that serum pregnancy tests are rarely required to con rm pregnancy.

■ Symptoms of pregnancy. Has the patient had absence of menses, breast fullness or tenderness, nausea or vomiting, fatigue, and urinary fre- quency? Explain that serum or urine testing for beta human chorionic gonadotropin (HCG) offers the best con rmation of pregnancy.

C o m m o n C o n c e r n s

● Initi l ren t l history ● Confir tion of regn ncy ● Sy to s of regn ncy ● Concerns bout nd ttitudes tow rd the regn ncy ● Current he lth nd st edic l history ● P st obstetric history ● Risk f ctors for tern l nd fet l he lth ● F ily history of tient nd f ther of the newborn ● Pl ns for bre stfeeding ● Pl ns for ost rtu contr ce tion

● Gest tion l ge nd ex ected d te of delivery ● Subsequent ren t l visits

384 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

■ Maternal concerns and attitudes. Review the mother’s feelings about the pregnancy and whether she plans to continue to term. Ask about any fears and about support from the father. Respect diverse family structures, such as extended family support, single motherhood, or pregnancy conceived by sperm donation with or without a partner of either gender.

■ Current health and past medical history. Does the patient have any acute or chronic medical concerns, past or present? Pay particular attention to issues that affect pregnancy, such as abdominal surgeries, hypertension, diabetes, cardiac conditions including any that were surgically corrected in childhood, asthma, hypercoagulability states involving lupus or anticardiolipin antibodies, mental health disorders including postpartum depression, HIV, sexually transmitted infections, abnormal Pap smears, and exposure to diethylstilbestrol (DES) in utero.

■ Past obstetric history. Ask about prior pregnancies and outcomes. Has she had any complications during past pregnancies? Were there any compli- cations during labor and delivery such as large babies (fetal macrosomia), fetal distress, or emergency interventions? Were deliveries by vaginal delivery, assisted delivery (vacuum or forceps), or cesarean section?

■ Risk factors for maternal and fetal health. Does the patient use tobacco, alcohol, or illicit drugs? Does she take any medications, over-the- counter drugs, or herbal prescriptions? Does she have any toxic expo- sures at work, home, or otherwise? Is her nutritional intake adequate, or is she at risk from obesity? Does she have an adequate social support network and income? Is there unusual stress at home or work? Is there any history of physical abuse or domestic violence?

■ Family history of chronic illnesses or genetically transmitted diseases: sickle cell anemia, cystic brosis, muscular dystrophy, and others.

■ Plans for breastfeeding. Education and encouragement during pregnancy increase adoption and duration of breastfeeding.

■ Plans for postpartum contraception. Initiate this discussion early, as postpartum contraception reduces the risk of unintended pregnancy and shortened interpregnancy intervals, which are linked to adverse pregnancy outcomes.

Ge s t a t io n a l Ag e a n d Exp e c t e d Da t e o f De live ry. Accurate dat- ing is best done early and contributes to appropriate management of the pregnancy. Dating establishes the timeframe for reassuring the patient about normal progress, establishing paternity, timing screening tests, tracking fetal growth, and effectively triaging preterm and postdated labor.

Chapter 19 | The Pregnant Woman 385

S u b s e q u e n t P re n a t a l Vis it s . During subsequent visits, assess interim changes in the health status of the mother and fetus, review speci c physi- cal examination ndings related to the pregnancy, and provide counseling and timely preventive screenings. Obstetric visits traditionally follow a set schedule: monthly until 28 gestational weeks, then biweekly until 36 weeks, then weekly until delivery. Update and document the history at every visit, especially fetal movement, contractions, leakage of uids and vaginal bleeding. At every visit, assess: vital signs (especially blood pres- sure and weight), fundal height, veri cation of FHR, and fetal position and activity. At each visit, test the urine for infection and protein.

D e t e r m in in g G e s t a t io n a l A g e a n d t h e E x p e c t e d D a t e o f D e liv e r y

● Gestational age. Count the nu ber of weeks nd d ys fro the first d y of the LMP. Counting this menstrual age fro the LMP– lthough biologic lly dis- tinct fro the d te of conce tion, is the st nd rd e ns of c lcul ting fet l ge, yielding n ver ge regn ncy length of 4 weeks. If the ctu l d te of conce tion is known ( s with in vitro fertiliz tion), conce tion ge which is 2 weeks less th n the enstru l ge c n be used to c lcul te enstru l ge (i.e., corrected or djusted LMP d ting) to est blish d ting.

● Expected date of delivery (EDD). The ex ected d te of delivery is 4 weeks fro the first d te of the LMP. Using the Naegele rule, the EDD c n be esti ted by t king the LMP, dding 7 d ys, subtr cting 3 onths, nd dding 1 ye r.

● Tools for calculations. Pregn ncy wheels nd online c lcul tors re co only used to c lcul te the EDD, but they should be checked for ccur cy.

● Limitations on pregnancy dating. P tient rec ll of the LMP is highly v ri ble. The LMP c n lso be bi sed by hor on l contr ce tives, enstru l irregul ri- ties, or v ri tions in ovul tion th t result in ty ic l cycle lengths. Check LMP d ting g inst hysic l ex in tion rkers such s fund l height, cl rifying discre ncies g inst ultr sound ev lu tion.

Health Promotion and Counseling: Evidence and Recommendations

Im p o r t a n t T o p ic s f o r H e a lt h P r o m o t io n a n d C o u n s e lin g

● Nutrition ● Weight g in ● I uniz tions ● Exercise ● Subst nce buse ● Inti te rtner violence ● Pren t l l bor tory screenings

386 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

Nu t rit io n a n d We ig h t Ga in . Evaluate nutritional status, especially inadequate nutrition and obesity.

■ Assess diet history; measurement of height, weight, and body mass index (BMI); and a hematocrit. Prescribe needed vitamin and mineral supplements.

■ To help prevent listeriosis, encourage pregnant patients to avoid: unpasteurized milk and foods made with unpasteurized milk; raw and undercooked seafood, eggs, and meat; refrigerated paté, meat spreads, and smoked salmon; and hot dogs, luncheon meats, and cold cuts unless served steaming hot.

■ Recommend two servings a week of selected sh low in mercury and shell sh.

■ Make a nutritional plan tailored to the patient’s BMI. Use the Pregnancy Weight Gain Calculator and Super Tracker at the user-friendly Choose- MyPlate.gov website (http://www.choosemyplate.gov/pregnancy-weight- gain-calculator). This calculator displays the daily recommended intake of each of the ve food groups for each trimester, based on height, prepregnancy weight, due date, and levels of weekly exercise.

Monitor weight gain at each visit, with the results plotted on a graph, using the updated recommendations below.

R e c o m m e n d a t io n s f o r T o t a l a n d R a t e o f W e ig h t G a in D u r in g P r e g n a n c y , b y P r e p r e g n a n c y B M I, 2 0 0 9

P re p re g n a n c y BMIa

To t a l We ig h t Ga in (Ra n g e

in lb s )

Ra t e s o f We ig h t Ga in b 2 n d a n d 3 rd Trim e s t e r s

(lb s /w k ) Me a n Ra n g e

Underweight, or <18.5 28–4 1 1. –1.3 Nor l weight, or 18.5–24.9 25–35 1 .8–1. Overweight, or 25. –29.9 15–25 .6 .5– .7 Obese, or ≥3 . 11–2 .5 .4– .6

aTo c lcul te BMI, go to C lcul te Your Body M ss Index, N tion l He rt , Lung, nd Blood Institute t htt :/ /www.nhlbi.nih.gov/ he lth/educ tion l/ lose_wt/ BMI/ b ic lc.ht .

bC lcul tions ssu e 1.1–4.4 lbs-weight g in in the first tri ester. Source: R s ussen KM, Y ktine AL (eds.) nd Institute of Medicine. Committee to Re-examine

IOM Pregnancy Weight Guidelines. Weight gain during pregnancy: re-examining the guidelines. W shington, DC: N tion l Ac de ies Press, 2 9. Av il ble t htt :/ /www.ncbi.nl .nih. gov/ books/ NBK32799/ t ble/su ry.t1/ ?re ort = objectonly. Accessed Se te ber 4, 2 15.

Im m u n iza t io n s . Administer Tdap during each pregnancy, ideally at 27 to 36 weeks of gestation, regardless of the prior immunization history, and to caretakers in direct contact with the infant. Give inactivated in uenza vaccination in any trimester during the in uenza season.

Chapter 19 | The Pregnant Woman 387

All women should have rubella titers drawn during pregnancy and be immunized after birth if found to be nonimmune. Check Rh(D) and anti- body typing at the rst prenatal visit, at 28 weeks, and at delivery. Anti-D immunoglobulin should be given to all Rh-negative women at 28 weeks’ gestation and again within 3 days of delivery to prevent sensitization if the infant is Rh-D positive.

Exe rc is e . Recommend ≥30 minutes of moderate exercise on most days of the week unless there are contraindications. Women initiating exercise during pregnancy should be cautious and consider programs developed speci cally for pregnant women. Water-based exercises can temporarily help alleviate musculoskeletal aches, but immersion in hot water should be avoided. After the rst trimester, women should avoid exercise in the supine position, which compresses the inferior vena cava and can cause dizziness and decreased placental blood ow. Because the center of gravity shifts in the third trimester, advise against exercises that cause loss of balance. Contact sports or activities that risk abdominal trauma are contraindicated through- out pregnancy. Pregnant women also should avoid overheating, dehydration, and any exertion that causes notable fatigue or discomfort.

S u b s t a n c e Ab u s e . Promote abstinence as the immediate goal during pregnancy. Pursue universal screening in a neutral manner for:

■ Tobacco. Tobacco use accounts for up to 20% of all low-birth-weight babies. It doubles the risk of placenta previa, placental abruption, and preterm labor and increases risk of spontaneous abortion, fetal death, and fetal digit anomalies. Cessation is the goal, but any decrease in use is favorable.

■ Alcohol. Fetal alcohol syndrome is the leading cause of preventable men- tal retardation in the United States. The American Congress of Obstetri- cians and Gynecologists (ACOG) strongly recommends that women abstain throughout pregnancy.

■ Illicit drugs including narcotics. Women with addictions should be referred for treatment immediately and counseled and screened for hepatitis C and HIV.

S a f e a n d U n s a f e V a c c in e s d u r in g P r e g n a n c y

S a fe d u r in g P re g n a n c y No t S a fe d u rin g P re g n a n c y

● Pneu ococc l olys cch ride ● Meningococc l olys cch ride nd

conjug te ● He titis A ● He titis B

● Me sles/ u s/rubell ● Polio ● V ricell

388 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

■ Abuse of prescription drugs. Ask about commonly abused prescription drugs, including narcotics, stimulants, benzodiazepines.

In t im a t e Pa r t n e r Vio le n c e . Pregnancy is a time of increased risk from intimate partner violence ranging from verbal to physical abuse or from mild to severe physical abuse. Up to one in ve women experiences some form of abuse during pregnancy, contributing to delayed prenatal care, low infant birth weight, or even murder of the mother and fetus. ACOG recommends universal screening of all women for domestic violence at the rst prenatal visit and at least once each trimester. For a direct nonjudgmental approach, ACOG recommends the statement and simple questions listed below.

A C O G S c r e e n in g A p p r o a c h f o r In t im a t e P a r t n e r V io le n c e

Initial Statement: “Bec use violence is so co on in ny wo en’s lives nd bec use there is hel v il ble for wo en being bused, I now sk every tient bout do estic violence.”

Screening Questions: 1. “Within the st ye r—or since you h ve been regn nt—h ve you been hit ,

sl ed, kicked or otherwise hysic lly hurt by so eone?” 2. “Are you in rel tionshi with erson who thre tens or hysic lly hurts you?” 3. “H s nyone forced you to h ve sexu l ctivities th t de you feel

unco fort ble?”

Source: A eric n Congress of Obstetrici ns nd Gynecologists. Screening tools–do estic violence. Av il ble t htt :/ /www. cog.org/About-ACOG/ACOG-De rt ents/ Violence- Ag inst-Wo en/ Screening-Tools–Do estic-Violence. Accessed Se te ber 2, 2 15.

Watch for nonverbal clues of abuse such as frequent last-minute appoint- ment changes, unusual behavior during visits, partners who refuse to leave the patient alone during the visit, and bruises or other injuries. Once the patient acknowledges abuse, ask about the best way for you to help her. Respect limits she places on sharing information, with the caveat that if children are involved, you may be required to report harmful behaviors to the authorities. Maintain an updated list of shelters, counseling centers, hotline numbers, and other trusted local referrals. Plan future appointments at more frequent intervals. Perform as thorough a physical examination as the patient permits, and document all injuries on a body diagram.

N a t io n a l D o m e s t ic V io le n c e H o t lin e

● Website: www.thehotline.org ● 1–8 –799-SAFE (7233) ● TTY for he ring i ired: 1–8 –787–3224

Chapter 19 | The Pregnant Woman 389

P re n a t a l La b o ra t o ry S c re e n in g s . Initially include blood type and Rh, antibody screen, complete blood count—especially hematocrit and platelet count, rubella titer, syphilis test, hepatitis B surface antigen, HIV, STI screen for gonorrhea and chlamydia, and urinalysis with culture. Scheduled screenings include an oral glucose tolerance test for gestational diabetes around 24 weeks; a vaginal swab for group B streptococcus between 35 to 37 weeks’ gestation; and for obese pregnant patients, a glucose tolerance in the rst trimester. Pursue additional tests related to the mother’s risk factors, such as screening for aneuploidy, Tay–Sachs, or other genetic diseases, or amniocentesis.

Techniques of Examination

P r e p a r in g f o r t h e E x a m in a t io n

Be res onsive to the tient’s co fort nd riv cy, s well s her individu l nd cultur l sensitivities. During the initi l visit , t ke the history while she is clothed. Ask her to we r her gown with the o ening in front to e se the ex i- n tion of both bre sts nd the regn nt bdo en.

Positioning ● The se isitting osition with the knees bent (see . 391) ffords the ost

co fort nd rotects bdo in l org ns nd vessels fro the weight of the gr vid uterus.

● Avoid rolonged eriods of lying on the b ck. M ke your bdo in l l tion efficient nd ccur te.

● The elvic ex in tion lso should be rel tively quick.

Equipment ● Gynecologic speculum and lubrication: Bec use of v gin l w ll rel x tion during

regn ncy, l rger-th n-usu l s eculu y be needed. ● Sampling materials: The cervic l brush y c use bleeding, so the “broo ”

s ling device is referred during regn ncy. Use ddition l sw bs if needed to screen for sexu lly tr ns itted infections, grou B stre , nd wet ount re r tions.

● Tape measure: Use l stic or er t e e sure to ssess the size of the uterus fter 2 gest tion l weeks.

● Doppler fetal heart rate monitor and gel: A ly “Do ler” or “Do tone” to the gr vid bdo en to ssess fet l he rt r te fter 1 weeks of gest tion.

H e ig h t , W e ig h t , a n d V it a l S ig n s Observe the general health, emotional state, nutritional status, and coordi- nation as the pregnant woman comes into the room.

390 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

Measure height and weight. Calculate the BMI with standard tables, using 19 to 25 as normal for the prepreg- nant state.

Measure blood pressure at every visit. In midpregnancy, it may be lower than in the nonpregnant state.

Weight loss of more than 5% in excessive vomiting, or hyperemesis

H y p e r t e n s io n in P r e g n a n c y

● Gestational hypertension: Systolic blood ressure (SBP) >14 or di stolic blood ressure (DBP) >9 first docu ented fter 2 weeks, without rotein- uri or reecl si , th t resolves by 12 weeks’ ost rtu .

● Chronic hypertension: SBP >14 or DBP >9 th t red tes regn ncy. ● Preeclampsia: SBP ≥14 or DBP ≥9 fter 2 weeks on two occ sions t le st

4 hours rt in wo n with reviously nor l BP or BP ≥16 /11 confir ed within inutes and roteinuri ≥3 g/24 hours, rotein:cre tinine ≥ .3, or di stick 1+; or new onset hy ertension without roteinuri nd ny of the fol- lowing: thro bocyto eni ( l telets <1 , / µL), i ired liver function (liver tr ns in se levels ore th n twice nor l), new ren l insufficiency (cre tinine >1.1 g/dL or doubles in the bsence of ren l dise se), ul on ry ede , or new onset cerebr l or visu l sy to s.

H e a d a n d N e c k ■ Face. Inspect for the mask of pregnancy, chloasma, or irregular brownish patches around the forehead and cheeks, across the bridge of the nose, or along the jaw.

■ Hair

■ Eyes. Note the conjunctival color.

■ Nose, including nasal congestion

■ Mouth

■ Thyroid gland. Inspect and palpate. Modest symmetric enlargement is common.

Facial edema after 20 weeks in possible preeclampsia

Hair loss should not be attributed to pregnancy.

Anemia of pregnancy may cause con- junctival pallor.

Nosebleeds are more common during pregnancy. Erosion of nasal septum if use of intranasal cocaine.

Gingival enlargement common

Thyroid enlargement, goiters, and nod- ules are abnormal and should be investi- gated.

Chapter 19 | The Pregnant Woman 391

T h o r a x a n d Lu n g s Inspect the thorax for contours. Observe the pattern of breathing. Auscultate the lungs.

H e a r t Palpate the apical impulse.

Auscultate the heart. A venous hum and systolic or continuous mammary souf e (see p. 185) are common.

B r e a s t s Inspect the breasts and nipples for symmetry and color. Venous pat- tern, darkened nipples and areolae, and prominent Montgomery glands are normal.

Palpate for masses. Tender nodular breasts are normal.

Compress each nipple between your index nger and thumb.

A b d o m e n Place the pregnant woman in a semisitting position with her knees exed (Fig. 19-1).

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Respiratory alkalosis in later trimesters. Increased respiratory rate, cough, rales, or respiratory distress in infection, asthma, pulmonary embolus, peripar- tum cardiomyopathy.

Impulse may be rotated upward and to the left toward the 4th intercostal space by the enlarging uterus.

Murmurs may signal anemia; new dia- stolic murmurs should be investigated. If signs of heart failure, consider peripar- tum cardiomyopathy.

Inverted nipples at the time of birth may hamper breastfeeding.

Focal tenderness in mastitis. Investigate any new discrete masses.

This may express colostrum from the nipples; investigate if abnormal bloody or purulent discharge.

Figure 19-1 The semis itting pos ition.

■ Inspect any scars or striae, the shape and contour of the abdo- men, and the fundal height.

Purplish striae and linea nigra are normal.

392 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

■ Assess the shape and contour to estimate pregnancy size (Fig. 19-2).

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

36 wks 32 wks 28 wks 24 wks

20 wks

16 wks

12–14 wks

Figure 19-2 Growth patte rns of the ute rine fundus by weeks of pregnancy.

■ Palpate for:

■ Organs and masses

■ Fetal movements, usually detected after 24 weeks

■ Uterine contractility

■ Irregular contractions after 12 weeks or after palpation during the third trimester

■ If woman is >20 weeks preg- nant, measure fundal height with a tape measure from the top of the symphysis pubis to the top of the uterine fundus. After 20 weeks, measurement in centimeters should roughly equal the weeks of gestation.

■ Auscultate the fetal heart tones, noting rate (FHR), location, and rhythm. A Doptone detects the FHR after 10 weeks. The FHR is audible with a fetoscope after 18 weeks.

■ Location. From 10 to 18 weeks, the FHR is in the midline of the lower abdomen; later depends on fetal position. Use modi ed Leopold’s maneuvers to palpate the fetal head and back and identify where to listen.

Ultrasound confirmation of fetal health and movement may be needed.

Prior to 37 weeks, regular uterine contractions or bleeding are abnormal, suggesting preterm labor.

If fundal height is more than 4 cm higher than expected, consider multiple gesta- tion, a large fetus, extra amniotic fluid, or uterine leiomyoma. If more than 4 cm lower, consider low level of amniotic fluid, missed abortion, transverse lie, growth retardation, or fetal anomaly.

Lack of an audible FHR may indicate pregnancy of fewer weeks than expected, fetal demise, or false pregnancy. If unable to locate the FHR, investigate with formal ultrasound.

Chapter 19 | The Pregnant Woman 393

■ Rate. The rate usually is 120 to 160 beats per minute. After 32 to 34 weeks, the FHR should increase with fetal movement.

■ Rhythm. In the third trimester, expect a variance of 10 to 15 beats per minute (BPM) over 1 to 2 minutes.

Sustained dips in FHR, or “decelerations,” always warrant investigation, at least by formal FHR monitoring.

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Lack of beat-to-beat variability late in pregnancy warrants investigation with an FHR monitor.

G e n it a lia , A n u s , a n d R e c t u m Inspect the external genitalia.

Palpate Bartholin and Skene glands. Check for a cystocele or rectocele.

Examine the internal genitalia.

S p e c u lu m Exa m in a t io n

■ Inspect the cervix for color, shape, and healed lacerations.

■ Perform a Pap smear, if indicated.

■ Inspect the vaginal walls.

Bim a n u a l Exa m in a t io n . Insert two lubricated ngers into introi- tus, palmar side down, with slight pressure downward on the perineum. Slide the ngers into the posterior vaginal vault. Maintaining downward pressure, gently turn the ngers palmar side up.

Parous relaxation of the introitus, labial varicosities, enlargement of the labia and clitoris, scars from an episiotomy or perineal lacerations

Bartholin cyst

Purplish color of pregnancy; lacerations from prior deliveries, cervical erosion, erythema, discharge, or irritation in cervicitis and STIs

Specimens may be needed for diagnosis of vaginal or cervical infection

Bluish or violet color, deep rugae, leukorrhea in normal pregnancy; vaginal discharge in candidiasis and bacterial vaginosis (can affect pregnancy outcome)

394 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

■ Assess the cervical os and degree of effacement. Place your nger gently in the os, and then sweep it around the surface of the cervix.

■ Estimate the length of the cervix. Palpate the lateral surface from the cervical tip to the lateral fornix.

■ Palpate the uterus for size, shape, consistency, and position.

■ Estimate uterine size. With your internal ngers placed at either side of cervix, palmar surfaces upward, gently lift the uterus toward the abdominal hand. Capture the fundal portion of the uterus between your two hands and gently estimate size.

■ Palpate the left and right adnexa.

■ Evaluate pelvic oor strength as you withdraw the examining ngers.

■ Inspect the anus. Rectal and rectovaginal examinations are usually not indicated.

E x t r e m it ie s Inspect the legs for varicose veins.

Palpate the hands and legs for edema.

Check knee and ankle deep tendon re exes.

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Closed external os if nulliparous; os open to size of fingertip if multiparous

Prior to 34 to 36 weeks, cervix should retain normal length of ≥3 cm. Effacement prior to 37 weeks in preterm labor.

Hegar sign, or early softening of the isthmus; pear-shaped uterus up to 8 weeks, then globular

An irregularly shaped uterus suggests uterine myomata or a bicornuate uterus, two distinct uterine cavities separated by a septum.

Early in pregnancy, it is important to rule out tubal (ectopic) pregnancy.

Hemorrhoids may engorge later in pregnancy.

Varicose veins may worsen during pregnancy.

Watch for swelling of preeclampsia or deep venous thrombosis.

Hyperreflexia may signal preeclampsia.

Chapter 19 | The Pregnant Woman 395

S p e c ia l T e c h n iq u e s Le o p o ld Ma n e u ve rs

Identify:

■ The upper and lower fetal poles, namely, the proximal and distal fetal parts

■ The maternal side where the fetal back is located

■ The descent of the presenting part into the maternal pelvis

■ The extent of exion of the fetal head

■ Estimated fetal weight and size

Fir s t Ma n e u ve r (Up p e r Fe t a l Po le ). Stand at the woman’s side, facing her head. Keep the ngers of both examining hands together. Palpate gently with the ngertips to determine what part of the fetus is in the upper pole of the uterine fundus (Fig. 19-3).

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Common deviations include breech presentation (fetal buttocks present at the outlet of the maternal pelvis) and absence of the presenting part well down into the maternal pelvis at term.

Figure 19-3 Palpate uppe r fe tal pole .

Figure 19-4 Palpate fe tal back and extremitie s .

S e c o n d Ma n e u ve r (S id e s o f t h e Ma t e rn a l Ab d o m e n ). Place one hand on each side of the woman’s abdomen, capturing the fetal body between them (Fig. 19-4). Steady the uterus with one hand and palpate the fetus with the other, looking for the back on one side and extremities on the other.

396 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

Th ird Ma n e u ve r (Lo w e r Fe t a l Po le a n d De s c e n t in t o Pe lvis ). Face the woman’s feet. Palpate the area just above the symphysis pubis (Fig. 19-5). Note whether the hands diverge with downward pressure or stay together to learn if the presenting part of the fetus, head or buttocks, is descending into the pelvic inlet.

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Figure 19-5 Palpate lower fe tal pole .

Figure 19-6 Palpate for the cephalic prominence .

Fo u r t h Ma n e u ve r (Fle xio n o f t h e Fe t a l He a d ). This maneuver assesses the exion or extension of the fetal head, presuming that the fetal head is the presenting part in the pelvis. Still facing the woman’s feet, with your hands positioned on either side of the gravid uterus as in the third maneuver, iden- tify the fetal front and back sides (Fig. 19-6). Using one hand at a time, slide your ngers down each side of the fetal body until you reach the “cephalic prominence,” that is, where the fetal brow or occiput juts out.

Recording Your Findings

Pregnant women are described in terms of number of pregnancies (Gravida, or “G”) and labors (Para, or “P”) they have experienced. Parity is further broken down into term deliveries, preterm deliveries, abortions (spontaneous abortions and terminated pregnancies), and living children, (which yields the mnemonic “TPAL”).

■ For example, a woman who has had two prior children and is pregnant with her third pregnancy would be referred to simply as “G3P2.”

Chapter 19 | The Pregnant Woman 397

■ A woman with two spontaneous losses prior to 20 weeks’ gestation, three living children who delivered at term, and a current pregnancy, would be referred to as “G6P3023.”

■ One common error is to assign a multiple pregnancy, for example, twins, as a count of two for either gravity or parity. In practice, each pregnancy receives only one count in any of the categories regardless of the number of fetuses, except for living children, when all are counted. So, designate a rst pregnancy with twins delivered at term as G1P1002.

Typically, the write-up follows a standard order: age, Gs and Ps, weeks of gestation, means of determining gestational age (ultrasound vs. LMP), fol- lowed by chief complaint, chief pregnancy complications, then important history and examination ndings, as below.

R e c o r d in g t h e P h y s ic a l E x a m in a t io n —T h e P r e g n a n t W o m a n

“32-ye r-old G3,P11 2 t 18 weeks’ gest tion s deter ined by LMP resents to est blish ren t l c re. P tient endorses fet l ove ent; denies contr ctions, v gin l bleeding, nd le k ge of fluids. On extern l ex in tion, low tr nsverse ces re n sc r is evident; fundus is l ble just below u bilicus. On intern l ex in tion, cervix is o en to fingerti t the extern l os but closed t the intern l os; cervix is 3 c long; uterus enl rged to size consistent with 18-week gest tion. S eculu ex in tion shows leukorrhe with ositive Ch dwick sign. FHT by Do ler re between 14 nd 145 BPM.” (This describes a healthy woman at 18 weeks’ gestation.)

399

C H A P T E R

20The Older Adult

Older Americans now number more than 43 million people and are expected to reach 80 million by 2040, over 20% of the population. Life span at birth is currently 81 years for women and 76 years for men. The “demographic imperative” is to maximize not only life span but also “health span” so that older adults maintain full function for as long as possible, enjoying rich and active lives in their homes and communities. This entails a focus on healthy or “successful” aging; understanding and mobilizing family, social, and community supports; skills directed to functional assessment, “the sixth vital sign”; and promoting long-term health and safety.

The aging population displays marked heterogeneity. Investigators distin- guish “usual” aging, with its complex of diseases and impairments, from optimal aging. Optimal aging occurs in those people who escape debilitat- ing disease entirely and maintain healthy lives late into their 80s and 90s. Studies of centenarians show that genes account for approximately 20% of the probability of living to 100, with healthy lifestyles accounting for approximately 20% to 30%.

T h e G e r ia t r ic A p p r o a c h f o r P r im a r y C a r e

1. Le rn to quickly identify fr il elderly tients; they re ost vulner ble to dverse outco es nd ost benefit fro holistic geri tric ro ch.

2. Look for co on geri tric syndro es, including f lls, deliriu /cognitive i ir ent, function l de endence, nd urin ry incontinence in every tient .

3. Le rn bout efficient ssess ent tools for geri trics nd geri tric syndro es nd te ch clinic l st ff to d inister the when ossible.

4. Be f ili r with co unity resources, such s f ll revention rogr s, PACE rogr s, nd senior centers.

5. T ke into ccount t ient’s go ls, life ex ect ncy, nd function l st tus before considering ny test or rocedure.

6. Review dv nced directives nd go ls of c re eriodic lly. 7. Be knowledge ble bout the Beers Criteri ( J Am Geriatr Soc. 2 12;6 :616);

use the to identify otenti lly in ro ri te edic tions in the elderly nd infor eriodic co rehensive edic tion review.

8. Ado t n evidence-b sed ro ch to he lth screening, es eci lly in the fr il elderly.

(continued )

400 Ba tes ’ Pocke t Guide to Physica l Examina tion and His tory Taking

T h e G e r ia t r ic A p p r o a c h f o r P r im a r y C a r e (Continued)

9. W tch c refully for ood disorders in the fr il elderly nd consider using geri tric-s ecific screening tools, such s the five-ite Geri tric De res- sion Sc le.

10. Provide c regiver su ort when ossible.

Source: C rlson C, Merel SE, Yuk w M. Geri tric syndro es nd geri tric ssess ent for the gener list . Med Clin N Am . 2 15:99:263; Ad ted fro A eric n Geri trics Society 2 12 Beers Criteri U d te Ex ert P nel. A eric n Geri trics Society u d ted Beers criteri for otenti lly in ro ri te edic tion use in older dults. J Am Geriatr Soc. 2 12;6 :616; nd Hoyl MT, Alessi CA, H rker JO, et l. Develo ent nd testing of five-ite version of the geri tric de ression sc le. J Am Geriatr Soc. 1999;47:873.

A p p r o a c h t o t h e O ld e r A d u lt As you talk with older adults, convey respect, patience, and cultural awareness. Be sure to address patients by their last name.

Ad ju s t in g t h e Of c e Enviro n m e n t . Make sure the of ce is neither too cool nor too warm. Face the patient directly, sitting at eye level. A well-lit room allows the older adult to see your facial expressions and gestures.

More than 50% of older adults have hearing de cits. Free the room of distractions or noise. Consider using a “pocket talker,” a microphone that ampli es your voice and connects to an earpiece inserted by the patient. Chairs with higher seating and a wide stool with a handrail leading up to the examining table help patients with quadriceps weakness.

S h a p in g t h e Co n t e n t a n d Pa c e o f t h e Vis it . Older people often reminisce. Listen to this process of life review to gain important insights and help patients as they work through painful feelings or recapture joys and accomplishments. Balance the need to assess complex problems with the patient’s endurance and possible fatigue. Consider dividing the initial assessment into two visits.

Elic it in g S ym p t o m s in t h e Old e r Ad u lt . Older patients may overestimate their health even when increasing disease and disability are apparent. To reduce the risk of late recognition and delayed intervention, adopt more directed questions or health screening tools. Consult with family members and caretakers.

Acute illnesses present differently in older adults. Be sensitive to unusual presentations of myocardial infarction and thyroid disease. Older patients with infections are less likely to have fever.

The Health History

Chapter 20 | The Older Adult 401

Recognize the symptom clusters of different geriatric syndromes, character- ized by interacting clusters of symptoms that lead to functional decline, for example, falls, dizziness, depression, urinary incontinence, and functional impairment. Searching for the usual “unifying diagnosis” may pertain to fewer than 50% of older adults.

Although cognitive impairment may alter the patient’s history, most older adults even with mild cognitive impairment can provide suf cient history to reveal current disorders. Use simple sentences with prompts to trigger necessary information. If impairments are more severe, con rm symptoms with family members or caregivers.

Ad d re s s in g Cu lt u ra l Dim e n s io n s o f Ag in g

G e r ia t r ic D iv e r s it y —N o w a n d in 2 0 5 0

● Hispanic Americans over ge 65 will incre se fro 2.7 illion in 2 1 , or 6.9% of older dults, to 17.5 illion in 2 5 , or 19.8% of the older o ul tion.

● African American older dults will incre se fro 3.4 illion (8.5%), to 1 .5 illion in 2 5 (11.9%).

● Asian Americans nd other ethnic grou s, lthough s ller in nu ber currently, will incre se fro 1.4 illion to 7.5 illion, or fro 3.4% to 8.5%.

● Non-Hispanic whites will incre se fro 32.2 illion to 58.5 illion in 2 5 , but will dro s ercent ge of the older o ul tion fro 8 % to 58.5%.

Source: Feder l Inter gency Foru on Aging Rel ted St tistics. Older A eric ns 2 12, Key Indic tors of Well Being. Indic tor 2, R ci l nd Ethnic Co osition, . 86. Feder l Inter- gency Foru on Aging-Rel ted St tistics. W shington, DC: U.S. Govern ent Printing Office. June 2 12. Av il ble t htt :/ / gingst ts.gov/ gingst tsdotnet/ M in_Site/ D t /2 12_Docu ents/ Docs/ EntireCh rtbook. df. Accessed August 11, 2 15.

Cultural differences affect the epidemiology of illness and mental health, acculturation, the speci c concerns of the elderly, the potential for mis- diagnosis, and disparities in health outcomes. Review the components of self-awareness needed for cultural responsiveness, discussed in Chapter 3 (pp. 49–50). Ask about spiritual advisors and native healers. Cultural values particularly affect decisions about the end of life. Elders, family, and even an extended community group may make these decisions with or for the older patient.

C o m m o n C o n c e r n s

● Activities of d ily living ● Instru ent l ctivities of d ily

living ● Medic tions ● Acute nd ersistent in

● S oking nd lcohol ● Nutrition ● Fr ilty ● Adv nce directives nd lli tive

c re

402 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

Place symptoms in the context of your overall functional assessment, always focusing on helping the older adult to maintain optimal well-being and level of function.

Ac t ivit ie s o f Da ily Livin g . Daily activities provide an important baseline for future evaluations. Ask, “Tell me about your typical day” or “Tell me about your day yesterday.” Then move to a greater level of detail: “You got up at 8 AM? How is it getting out of bed?”

A c t iv it ie s o f D a ily Liv in g a n d In s t r u m e n t a l A c t iv it ie s o f D a ily Liv in g

P hys ic a l Ac t iv it ie s o f Da ily Livin g (ADLs )

In s t ru m e n t a l Ac t iv it ie s o f Da ily Livin g (IADLs )

B thing Using the tele hone Dressing Sho ing Toileting Pre ring food Tr nsferring Housekee ing Continence L undry Feeding Tr ns ort tion

T king edicine M n ging oney

Me d ic a t io n s . Adults older than 65 take approximately 30% of all pre- scriptions. Almost 40% take ve or more prescription drugs daily. Older adults have more than 50% of all reported adverse drug reactions. Take a thorough medication history, including name, dose, frequency, and indica- tion for each drug. Explore all components of polypharmacy, including concurrent use of multiple drugs, underuse, inappropriate use, and non- adherence. Ask about use of over-the-counter medications, vitamin and nutrition supplements, and mood-altering drugs. Medications are the most common modi able risk factor associated with falls. “Start low, go slow” when prescribing doses.

Ac u t e a n d Pe rs is t e n t Pa in . Pain and associated complaints account for 80% of clinician visits, usually for musculoskeletal complaints like back and joint pain. Older patients are less likely to report pain, leading to undue suffering, depression, social isolation, physical disability, and loss of function.

Inquire about pain each time you meet with the older patient. Ask spe- ci cally, “Are you having any pain right now? How about over the past week?” Unidimensional scales such as the Visual Analog Scale, graphic pictures, and the Verbal 0–10 Scale have all been validated and are easiest to use.

Chapter 20 | The Older Adult 403

S m o k in g a n d Alc o h o l. At each visit, advise elderly smokers to quit. From 10% to 15% of older patients in primary care practices have problem drinking. Rates of detection and treatment are low. Screen all older adults for excess alcohol use, which contributes to drug interactions and worsens comorbid illnesses. Use the CAGE questions to uncover problem drinking (see p. 56), and watch for clues of excess consumption such as memory loss, depression, and self-neglect.

Nu t rit io n . Taking a diet history and using rapid screening tools (p. 73) are especially important in older adults.

Fra ilt y. The prevalence of this multifactorial syndrome is 4% to 59%. Screen for three key features and pursue related interventions: weight loss of more than 5% over 3 years, inability to do ve chair stands, and self- reported exhaustion.

Ad va n c e Dire c t ive s a n d Pa llia t ive Ca re . Initiate these discussions before serious illness develops. Advance care planning involves providing information, invoking the patient’s preferences, identifying surrogate decision makers, and conveying empathy and support. Use clear, simple language. Clarify preferences related to “Do Not Resuscitate” orders speci- fying life support measures “if the heart or lungs were to stop or give out.” Seek a written health care proxy or durable power of attorney for health care, “someone who can make decisions re ecting your wishes in case of confusion or emergency.” Discuss these decisions in the of ce rather than in the pressured environments of the emergency room or hospital.

When needed, provide palliative care “to relieve suffering and improve the quality of life for patients with advanced illnesses and their families through speci c knowledge and skills, including communication with patients and family members; management of pain and other symptoms; psychosocial, spiritual, and bereavement support; and coordination of an array of clinical and social services.”

C h a r a c t e r is t ic s o f A c u t e a n d P e r s is t e n t P a in

Ac u t e Pa in Pe r s is t e n t Pa in

Distinct onset L sts ore th n 3 onths Obvious thology Often ssoci ted with sychologic l or function l

i ir ent Short dur tion C n fluctu te in ch r cter nd intensity over ti e Co on c uses: ostsurgic l,

tr u , he d che Co on c uses: rthritis, c ncer, cl udic tion,

leg cr s, neuro thy, r diculo thy

Source: Reuben DB, Herr KA, P c l JT, et l. Geriatrics at Your Fingertips: 2004. 6th ed. M lden, MA: Bl ckwell Publishing, for the A eric n Geri trics Society; 2 4:149.

404 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

Wh e n t o S c re e n . As the life span for older adults extends into the 80s, base screening decisions on the older adult’s individual health and functional status, including presence of comorbidity, rather than age alone. The American Geriatrics Society recommends a ve-step approach: assess patient preferences, interpret the available evidence, estimate prognosis, consider treatment feasibility, and optimize therapies and care plans. If life expectancy is short, adopt treatments that bene t the patient in the time that remains. Defer screening if it overburdens the older adults who have multiple clinical problems, shortened life expectancy, or dementia.

■ Screen for age-related changes in vision and hearing. These are included in the 10-Minute Geriatric Screener (p. 407).

■ Recommend aerobic exercise, such as brisk walking for 150 minutes every week and graded resistance training in major muscle groups to increase strength.

■ Promote household safety. Correct poor lighting, chairs at awkward heights, slippery or irregular surfaces, and environmental hazards.

■ Immunizations. Recommend vaccination for in uenza; pneumonia, both PPSV23 and PCV13; herpes zoster (shingles); and tetanus/diphtheria and pertussis (Tdap and Td). Consult the updated annual guidelines and contraindications provided by the CDC at http://www.cdc.gov/vaccines.

Ca n c e r S c re e n in g . Cancer screening can be controversial because of limited evidence about adults older than age 70 to 80. The U.S. Preventive Services Task Force (USPSTF) guidelines are summarized below.

Health Promotion and Counseling: Evidence and Recommendations

Im p o r t a n t T o p ic s f o r H e a lt h P r o m o t io n a n d C o u n s e lin g

● When to screen ● C ncer screening ● De ression, de enti , nd cognitive i ir ent ● Elder istre t ent nd buse

S c r e e n in g R e c o m m e n d a t io n s f o r O ld e r A d u lt s : U . S . P r e v e n t iv e S e r v ic e s T a s k F o r c e

● Breast cancer (2016): Reco ends ogr hy every 2 ye rs for wo en ges 5 to 74 nd cites insufficient evidence for screening wo en ges ≥75 ye rs.

(continued )

Chapter 20 | The Older Adult 405

De p re s s io n , De m e n t ia , a n d Co g n it ive Im p a irm e n t . Depression affects 5% to 7% of community-dwelling older adults and approximately 10% of older men and 18% of older women, but is often undiagnosed. Use the two validated screening questions in Chapter 5 on pp. 85–86.

Dementia is “an acquired condition that is characterized by a decline in at least two cognitive domains (e.g., loss of memory, attention, language, or visuospatial or executive functioning) that is severe enough to affect social or occupational functioning.” Alzheimer disease (AD), the predominant form, affects 11% of Americans over age 65 years; over two thirds are women.

Probable AD, based on DSM-5 criteria, consists of evidence of a causative genetic mutation from family history or genetic testing, or the presence of cognitive decline in two or more cognitive domains, with all three of the following features:

■ Clear evidence of a decline in memory and learning and at least one other cognitive domain (as described for dementia above);

■ Steady progressive decline in cognition without extended plateaus; and

■ No evidence of mixed etiology from other neurodegenerative, cerebro- vascular, mental, or systemic disease.

Most dementias represent AD (50% to 85%) or vascular multi-infarct dementia (10% to 20%). Other dementias include frontotemporal

S c r e e n in g R e c o m m e n d a t io n s f o r O ld e r A d u lt s : U . S . P r e v e n t iv e S e r v ic e s T a s k F o r c e (Continued)

● Cervical cancer (2012): Reco ends g inst routine screening for wo en over ge 65 if they h ve h d dequ te recent screening with nor l P s e rs nd re not otherwise t high risk for cervic l c ncer, b sed on f ir evidence.

● Colorectal cancer (2008): Reco ends screening with colonosco y every 1 ye rs, sig oidosco y every 5 ye rs with high-sensitivity fec l occult blood tests (FOBTs) every 3 ye rs, or FOBTs every ye r beginning ge 5 ye rs through ge 75 ye rs. Reco ends g inst routine screening for dults ges 76 to 85 ye rs, due to oder te cert inty th t the net benefit is s ll.

● Prostate cancer (2012): Reco ends g inst rost te-s ecific ntigen- b sed screening for rost te c ncer in en of ll ges due to evidence th t ex ected h r s re gre ter th n ex ected benefits.

● Lung cancer (2013): For dults ges 55 to 8 ye rs with 3 - ck/ye r s ok- ing history, nd those who currently s oke or h ve quit within the st 15 ye rs, reco ends nnu l screening with low-dose co uted to ogr hy. Screening should be discontinued once erson h s not s oked for 15 ye rs or develo s he lth roble th t subst nti lly li its life ex ect ncy or the bility or willingness to h ve cur tive lung surgery.

● Skin cancer (2009; updated in 2015): St tes th t evidence is insufficient to b l nce the benefits nd h r s of whole-body skin ex in tion.

406 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

dementia, dementia with Lewy bodies, Parkinson disease with dementia, and dementia of mixed etiology.

The spectrum of cognitive decline includes:

■ Age-related cognitive decline: with occasional mild forgetfulness, dif- culty remembering names, and mildly reduced concentration but preservation of daily function.

■ Mild cognitive impairment (MCI): Daily function is preserved, but there is evidence of modest cognitive decline in one or more cognitive domains (complex attention, executive function, learning and memory, language, perceptual-motor, or social cognition) based on objective tasks, as reported by the patient, an informant, or the clinician or on clinical testing. Alertness and attention is preserved (unlike delirium).

Use recommended screening tests for dementia such as the Mini-Cog and the Montreal Cognitive Assessment (MoCA). See Table 20-3, p. 420, and Table 20-4, p. 421.

Eld e r Mis t re a t m e n t a n d Ab u s e . Screen older patients for possible elder mistreatment, which includes abuse, neglect, exploitation, and aban- donment. Prevalence ranges from 5% to 10% of older adults; however, many cases remain undetected.

Techniques of Examination

Assessment of the older adult departs from the traditional history and physical examination. Enhanced interviewing, emphasis on daily function and the key topics described above, and functional assessment are especially important.

A s s e s s in g Fu n c t io n a l S t a t u s : T h e “ S ix t h V it a l S ig n ” As s e s s in g Fu n c t io n a l Ab ilit y. Functional status is the ability to per- form tasks and ful ll social roles associated with daily living across a wide range of complexity. The 10-Minute Geriatric Screener is brief, has high interrater agreement, and can be used easily by of ce staff. It covers the three important domains: physical, cognitive, and psychosocial function and addresses key sensory modalities and urinary incontinence, an often unreported problem. Mnemonics that help students assess incontinence are: DIAPERS (Delirium, Infection, Atrophic urethritis/vaginitis, Pharma- ceuticals, Excess urine output from conditions like hyperglycemia or heart

Chapter 20 | The Older Adult 407

1 0 -M in u t e G e r ia t r ic S c r e e n e r

P ro b le m a n d S c re e n in g Me a s u re Po s it ive S c re e n

Vision: Two P rts: Ask: “Do you h ve difficulty driving, or w tching

television, or re ding, or doing ny of your d ily ctivities bec use of your eyesight?”

Yes to question nd in bility to re d >2 /4 on Snellen ch rt

If yes, then: Test e ch eye with Snellen ch rt while tient we rs corrective lenses (if lic ble).

Hearing: Use udiosco e set t 4 dB. Test he ring using 1, nd 2, Hz.

In bility to he r 1, or 2, Hz in both e rs or either of these frequencies in one e r

Leg mobility: Ti e the tient fter instructing: “Rise fro the ch ir. W lk 2 feet briskly, turn, w lk b ck to the ch ir, nd sit down.”

Un ble to co lete t sk in 15 seconds

Urinary incontinence: Two P rts: Ask: “In the l st ye r, h ve you ever lost your

urine nd gotten wet?”

Yes to both questions

If yes, then sk: “H ve you lost urine on t le st 6 se r te d tes?”

Nutrition/ weight loss: Two rts: Ask: “H ve you lost 1 lb over the st 6 onths

without trying to do so?” Weigh the tient .

Yes to the question or weight <1 lb

Memory: Three-ite rec ll Un ble to re e ber ll three ite s fter 1 inute

Depression: Ask: “Do you often feel s d or de ressed?”

Yes to the question

Physical disability: Six questions: “Are you ble to . . . : ● “Do strenuous ctivities like f st w lking or

bicycling?” ● “Do he vy work round the house like w shing

windows, w lls, or floors?” ● “Go sho ing for groceries or clothes?” ● “Get to l ces out of w lking dist nce?” ● “B the, either s onge b th, tub b th, or shower?” ● “Dress, like utting on shirt , buttoning nd

zi ing, or utting on shoes?”

No to ny of the questions

Source: More AA, Siu AL. Screening for co on roble s in bul tory elderly: clinic l confir tion of screening instru ent. Am J Med. 1996;1 :438.

failure, Restricted mobility, and Stool impaction) and DDRRIIPP (Delirium, Drug side effects, Retention of feces, Restricted mobility, Infection of urine, In ammation, Polyuria, and Psychogenic).

408 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

S T E A D I F a lls P r e v e n t io n A lg o r it h m : Ke y Fe a t u r e s f o r C lin ic a l P r a c t ic e

● Screen all co unity-dwelling older dults bout risk for f lls. ● Encour ge all older tients to ursue g it nd b l nce exercise. ● Do g it , strength, nd b l nce ssess ent with the Ti ed Get U nd Go

test in tients who screen ositive. ● Str tify tients ccording to low, oder te, nd high risk. ● Identify high-risk older adults, n ely, those with g it , strength, or b l nce

roble nd t le st one f ll with n injury. ● In high-risk older adults, conduct ultif ctori l risk ssess ent, including:

● review of the St y Inde endent brochure; ● f lls history nd edic tion review; ● hysic l ex in tion including ssess ent of visu l cuity, ostur l hy o-

tension, cognitive screen, ins ection of the feet nd use of footwe r, nd use of obility ids;

● function l ssess ent; nd ● environ ent l or ho e s fety ssess ent.

● I le ent individu lized interventions, including hysic l ther y nd follow-u in 3 d ys.

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

P h y s ic a l E x a m in a t io n o f t h e O ld e r A d u lt

Isolated systolic hypertension (SBP ≥140) after age 50 years and PP ≥60 increase risk of stroke, renal failure, and heart disease.

Vit a l S ig n s . Measure blood pressure, checking for increased systolic blood pressure (SBP) and widened pulse pressure (PP), de ned as SBP minus diastolic blood pressure (DBP).

Fu r t h e r As s e s s m e n t fo r P re ve n t in g Fa lls . Compelling evidence links falls, a multifactorial geriatric syndrome, to fatal and nonfatal inju- ries, mortality, and burgeoning clinical costs that exceed $34 billion annually. One in three older adults falls each year. Falls are the most common cause of traumatic brain injury in older adults and cause 95% of hip fractures.

The American Geriatrics Society, the British Geriatrics Society, and the CDC’s Injury Center has launched the STEADI (Stopping Elderly Accidents, Deaths, and Injuries) falls prevention toolkit to help primary care providers bet- ter assess, treat, and refer patients at risk. Also see Figure 20-1.

Chapter 20 | The Older Adult 409

Patient completes S tay Independent brochure

YES to any key ques tion

No gait, s trength, or

balance problems*

NO to all key

ques - tions

Gait, s trength or balance problem

≥2 falls 1 fa ll

Injury No injury

0 falls

Conduc t multifac torial

ris k as s e s s me nt

HIGH RISK Individualize d fall

inte rve ntions

Fo llow up with HIGH RISK patie nt within

30 days

MODERATE RISK Individualize d fall

inte rve ntions

LOW RISK Individualize d fall

inte rve ntions L

*For these patients , cons ider additional risk assessment (e.g. medication review, cognitive screen, syncope)

Sc re e n for falls and/or fall ris k Patient answers YES to any key ques tion: - Were you injur

S tay Independent

brochure including: - Pos tural dizziness /pos tural hypotens ion - Medication review - Cognitive screen - Feet & footwear - Use of mobility a ids - Visual acuity check

Vitamin D +/– calc ium enhance functional mobility & improve s trength & balance hypotens ion s Address foot problems Optimize vis ion Optimize home safety

re p lan fall risk reduction behaviors es s barriers to adherence

ans ition to c ise program when patient is ready

medications Vitamin D +/– calcium improve gait, s trength & balance

or refer to a community fall prevention program

Vitamin D +/– calcium ength & cise cise or fall prevention program

Evaluate gait, s tre ngth & balanc e (recommended) ) s t (optional)

Figure 20-1 STEADI algorithm. Source : Cente rs for Disease Control and Prevention. National Cente r for Injury Prevention and Control. STEADI—Stopping Elderly Accidents , Deaths and Injuries . Available at http://www.cdc.gov/s teadi/pdf/ algorithm_2015–04-a.pdf. Accessed Augus t 23, 2015.

410 Ba tes’ Pocket Guide to Phys ica l Examination and His tory Taking

For adults ages ≥60 years, the JNC8 recommends blood pressure targets of ≤150/90 but notes that if treatment results in SBP <140 and is “well tolerated and without adverse effects to health or quality of life, treatment does not need to be adjusted.”

Assess the patient for orthostatic hypotension, de ned as a drop in SBP of ≥20 mm Hg or DBP of ≥10 mm Hg or HR increase of ≥20 BPM, within 3 minutes of standing. Measure in two positions: supine after the patient rests for up to 10 minutes, then within 2 to 3 minutes after standing up.

Measure heart rate, respiratory rate, and temperature. Check the apical heart rate to help detect arrhythmias in older adults. Use thermometers accurate for lower temperatures.

Weight and height are especially important and needed for calcula- tion of the BMI (p. 63). Weight should be measured at every visit. Obtain oxygen saturation using a pulse oximeter.

S k in . Note physiologic changes of aging, such as thinning, loss of elastic tissue and turgor, and wrinkling.

Inspect the extensor surface of the hands and forearms.

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Orthostatic hypotension occurs in 10% to 20% of older adults and in up to 30% of frail nursing home residents, especially when they first arise in the morning. Watch for lightheadedness, weakness, unsteadiness, visual blurring, and, in 20% to 30% of patients, syncope.

Assess medications and causes such as autonomic disorders, diabetes, prolonged bed rest, volume depletion, amyloidosis, postprandial state, and cardiovascular disorders.

Respiratory rate ≥25 breaths per minute indicates lower respiratory infection or possible CHF or COPD.

Hypothermia is more common in elderly patients.

Low weight is a key indicator of poor nutrition.

Undernutrition in depression, alcohol- ism, cognitive impairment, malignancy, chronic organ failure (cardiac, renal, pulmonary), medication use, poor dentition, social isolation, and poverty

Dry, flaky, rough, and often itchy

Benign comedones, or blackheads, on the cheeks or around the eyes; cherry angiomas (p. 113); and seborrheic keratoses (p. 112)

White depigmented patches (pseudos- cars); well-demarcated, vividly purple macules or patches that may fade after several weeks (actinic purpura)

Chapter 20 | The Older Adult 411

Look for changes from sun expo- sure: actinic lentigines, or “liver spots,” and actinic keratoses, super- cial attened papules covered by a dry scale (p. 108).

Inspect for painful vesicular lesions in a dermatomal distribution.

In older bedbound patients, espe- cially when emaciated or neurolog- ically impaired, inspect for damage or ulceration.

HEENT. Inspect the eyelids, the bony orbit, and the eye.

Test visual acuity, using a pocket Snellen chart or wall-mounted chart.

Examine the lenses and fundi.

Inspect each lens for opacities.

Assess the cup-to-disc ratio, usually ≤1:2.

Inspect the fundi for colloid bodies causing alterations in pigmentation called drusen. These may be hard and sharply de ned, or soft and con uent with altered pigmentation.

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Herpes zoster from reactivation of latent varicella-zoster virus in the dorsal root ganglia

Pressure sores if obliteration of arteriolar and capillary blood flow to the skin or shear forces with movement across sheets or lifting upright incorrectly

Senile ptosis arising from weakening of the levator palpebrae, relaxation of the skin, and increased weight of the upper eyelid

Ectropion or entropion of lower lids (p. 133)

Yellowing of the sclera and arcus senilis, a benign whitish ring around the limbus

More than 40 million Americans have refractive errors—presbyopia.

Cataracts, glaucoma, and macular degeneration all increase with aging.

Cataracts are the world’s leading cause of blindness.

Increased cup-to-disc ratio suggests open-angle glaucoma and possible loss of peripheral and central vision, and blindness. Prevalence is three to four times higher in African Americans.

Macular degeneration causes poor central vision and blindness: types include dry atrophic (more common but less severe) and wet exudative (or neovascular).

Distinguish such lesions from a basal cell carcinoma and squamous cell carcinoma (p. 108). Dark, raised, asymmetric lesions with irregular borders are suspicious for melanoma

412 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

Test hearing by the whispered voice test (see p. 124) or audio- scope. Inspect ear canals for cerumen.

Examine the oral cavity for odor, appearance of the gingival mucosa, any caries, mobility of the teeth, and quantity of saliva.

Inspect for lesions on mucosal surfaces. Ask patient to remove dentures so you can check gums for denture sores.

Th o ra x a n d Lu n g s . Percuss and auscultate the lungs. Note subtle signs of changes in pulmo- nary function.

Ca rd iovasc u la r Sys t em . Review blood pressure and heart rate.

Inspect the jugular venous pulsa- tion ( JVP), palpate the carotid upstrokes, and listen for any overlying carotid bruits.

Assess the point of maximal impulse (PMI), and then heart sounds.

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Removing cerumen often quickly improves hearing.

Malodor in poor oral hygiene, periodon- titis, or caries

Gingivitis if periodontal disease

Dental plaque and cavitation if caries. Increased tooth mobility; risk of tooth aspiration

Decreased salivation from medications, radiation, Sjögren syndrome, or dehy- dration

Oral tumors, usually on lateral borders of tongue and floor of mouth

Increased anteroposterior diameter, purse-lipped breathing, and dyspnea with talking or minimal exertion in chronic obstructive pulmonary disease

Isolated systolic hypertension and a widened pulse pressure are cardiac risk factors. Search for left ventricular hypertrophy (LVH).

A tortuous atherosclerotic aorta can raise pressure in the left jugular veins by impairing drainage into right atrium.

Carotid bruits in possible carotid stenosis.

Sustained PMI is found in LVH, hypertension, and aortic stenosis; diffuse PMI in heart failure (see p. 180).

In older adults, S3 in dilatation of the left ventricle from heart failure or cardiomy- opathy; S4 in hypertension

Chapter 20 | The Older Adult 413

Listen for cardiac murmurs in all six listening areas (see p. 185). Describe timing, shape, location of maximal intensity, radiation, intensity, pitch, and quality of each murmur.

Bre a s t s a n d Axilla e . Palpate the breasts carefully for lumps or masses.

Ab d o m e n . Listen for bruits over the aorta, renal arteries, and femoral arteries.

Inspect the upper abdomen; palpate to the left of the midline for aortic pulsations.

Pe rip h e ra l Va s c u la r S ys t e m . Auscultate the abdomen for aortic, renal, femoral artery bruits.

Palpate pulses.

Fe m a le Ge n it a lia a n d Pe lvic Exa m in a t io n . Take special care to explain the steps of examination and allow time for careful position- ing. For the woman with arthritis or spinal deformities who cannot ex her hips or knees, an assistant can gently raise and support the legs, or help the woman into the left lateral position.

Inspect the vulva for changes related to menopause; identify any labial masses. Bluish swellings may be varicosities.

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

A systolic crescendo–decrescendo murmur in the second right interspace in aortic sclerosis or aortic stenosis. Both carry increased risk of cardiovascular disease and death.

A harsh holosystolic murmur at the apex suggests mitral regurgitation, common in older adults.

Possible breast cancer

Bruits in atherosclerotic vascular disease

Widened aorta of ≥3 cm and pulsatile mass in abdominal aortic aneurysm.

Bruits over these vessels in atheroscle- rotic disease.

Diminished or absent pulses in arterial occlusion. Confirm with an office ankle–brachial index (see pp. 230–231).

Benign masses include condylomata, fibromas, leiomyomas, and sebaceous cysts. Bulging of the anterior vaginal wall below the urethra in urethrocele

Erythema with satellite lesions in Candida infection; erythema with ulceration or a necrotic center in vulvar carcinoma.

414 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

Inspect the urethra for caruncles, or prolapse of eshy erythematous mucosal tissue at the urethral meatus.

S p e c u lu m Exa m in a t io n . Inspect vaginal walls, which may be atrophic, and cervix.

If indicated, obtain endocervical cells for the Pap smear. Use a blind swab if the atrophic vagina is too small.

Removing speculum, ask patient to bear down.

Perform the bimanual examination.

Perform the rectovaginal examina- tion if indicated.

Ma le Ge n it a lia a n d P ro s t a t e . Examine the penis; retract foreskin if present. Examine the scrotum, testes, and epididymis.

Do a rectal examination.

Mu s c u lo s k e le t a l S ys t e m . Screen general range of motion and gait. Conduct timed “get up and go” test.

If joint deformity, de cits in mobil- ity, or pain with movement, conduct a more thorough examination.

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Estrogen-stimulated cervical mucus with ferning in use of hormone replacement therapy, endometrial hyperplasia , and estrogen-producing tumors; lichen sclerosus

Uterine prolapse, cystocele, urethrocele, or rectocele.

Note any uterine retroversion, retroflex- ion, porolapse, or myomas (fibroids)

Mobility of cervix restricted if inflamma- tion, malignancy, or surgical adhesion

Palpable ovaries in ovarian cancer.

Enlarged, fixed, or irregular uterus if adhesions or malignancy. Rectal masses in colon cancer.

Smegma, penile cancer, and scrotal hydroceles

Rectal masses in colon cancer. Prosta te hyperplasia if enlargement; prostate cancer if nodules or masses.

Review examination techniques for individual joints in Chapter 16, Musculoskeletal System.

See Table 20-1, Timed Get Up and Go Test, p. 417.

Degenerative joint changes in osteoar- thritis; joint inflammation in rheumatoid or gouty arthritis. See Tables 16-1 to 16-4, pp. 304–308.

Clitoral enlargement in androgen- producing tumors or use of androgen creams

Chapter 20 | The Older Adult 415

Ne rvo u s S ys t e m . Review results of 10-Minute Geriatric Screener, p. 407. Pursue further examination if any de cits. Focus especially on memory and affect.

Assess gait and balance, particu- larly standing balance; timed 8-foot walk; stride characteristics like width, pace, and length of stride; and careful turning.

Although neurologic abnormalities are common in older adults, their prevalence without identi able disease increases with age, ranging from 30% to 50%.

Assess any tremor, rigidity, brady- kinesia, micrographia, shuf ing gait, and dif culty turning in bed, opening jars, and rising from a chair.

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Distinguish delirium from depression and dementia. See Table 20-2, Delirium and Dementia, pp. 418–419 and Table 20-3, Screening for Dementia: The Mini-Cog, p. 420. Table 20-4, Montreal Cognitive Assessment, p. 421.

Abnormalities of gait and balance, especially widening of base, slowing and lengthening of stride, and difficulty turning, are correlated with risk of falls.

Physiologic changes of aging: unequal pupil size, decreased arm swing and spontaneous movements, increased leg rigidity and abnormal gait, presence of the snout and grasp reflexes, and decreased toe vibratory sense.

In Parkinson disease, tremor is slow frequency and at rest, with a “pill-rolling” quality, aggravated by stress and inhibited during sleep or movement.

Essential tremor is often bilateral, symmetric, with positive family history, and diminished by alcohol.

As you read through this physical examination, you will notice some atypical ndings. Test yourself to see if you can interpret these ndings in the context of all you have learned about the examination of the older adult.

Recording Your Findings

R e c o r d in g t h e P h y s ic a l E x a m in a t io n —T h e O ld e r A d u lt

Mr. J is n older dult who e rs he lthy but underweight , with good uscle bulk. He is lert nd inter ctive, with good rec ll of his life history. He is cco nied by his son.

Vital Signs: Ht (without shoes) 16 c (5′). Wt (dressed) 65 kg (143 lb). BMI 28. BP 145/88 right r , su ine; 154/94 left r , su ine. He rt r te (HR) 98 nd regul r. Res ir tory r te (RR) 18. Te er ture (or l) 98.6°F.

(continued )

416 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

R e c o r d in g t h e P h y s ic a l E x a m in a t io n — T h e O ld e r A d u lt (Continued)

10-Minute Geriatric Screener: (see . 4 7) Vision: P tient re orts difficulty re ding. Visu l cuity 2 /6 on Snellen ch rt . Needs further ev lu tion for gl sses nd ossibly he ring id. Hearing: C nnot he r whis ered voice in either e r. C nnot he r 1, or

2, Hz with udiosco e in either e r. Leg Mobility: C n w lk 2 feet briskly, turn, w lk b ck to ch ir, nd sit down in

14 seconds. Urinary Incontinence: H s lost urine nd gotten wet on 2 se r te d ys. Needs further ev lu tion for incontinence, including “DIAPER” ssess ent

(see . 4 6), rost te ex in tion, nd ostvoid residu l, which is nor lly ≤5 L (requires bl dder c theteriz tion).

Nutrition: H s lost 15 lb over the st 6 onths without trying. Needs nutrition l screen (see . 73). Memory: C n re e ber three ite s fter 1 inute. Depression: Does not often feel s d or de ressed. Physical Disability: C n w lk f st but c nnot ride bicycle. C n do oder te

but not he vy work round the house. C n go sho ing for groceries or clothes. C n get to l ces out of w lking dist nce. C n b the e ch d y without difficulty. C n dress, including buttoning nd zi ing, nd c n ut on shoes.

Consider exercise regi en with strength tr ining. Physical Examination: C refully describe your findings for e ch relev nt

seg ent of the eri her l ex in tion, using ter inology found in the “Recording Your Findings” sections of the rior ch ters.

Chapter 20 | The Older Adult 417

Aids to Interpretation

Performed with patient wearing regular footwear, using usual walking aid if needed, and sitting back in a chair with armrest. On the word, “Go,” the patient is asked to do the following: 1. Stand up from the arm chair 2. Walk 3 m (in a line) 3. Turn 4. Walk back to chair 5. Sit down Time the second effort. Observe patient for postural stability, steppage, stride length, and sway. S c o r in g : 1. Normal: completes task in <10 seconds 2. Abnormal: completes task in >20 seconds Low scores correlate with good functional independence; high scores correlate with poor functional independence and higher risk of falls.

Tim e d Ge t Up a n d Go Te s tTable 20-1

Reproduced from: Get-up and Go Test. In: Mathias S, Nayak USL, Isaacs B. “Balance in elderly patient” The “Get Up and Go” Test. Arch Phys Med Rehabil. 1986;67:387; Podsiadlo D, Richardson S. The Timed “Up and Go”: A test of basic functional mobility for frail elderly persons. J Am Geriatr Soc. 1991;39:142.

418 Ba tes’ Pocke t Guide to Physica l Examina tion and His tory Taking

De lir iu m De m e n t ia

Clin ic a l Fe a t u re s

Onse t Acute Insidious

Course Fluctuating, with lucid intervals; worse at night

Slowly progressive

Dura tion Hours to weeks Months to years

S leep /Wake Cycle Always disrupted Sleep fragmented

Genera l Clin ica l Illness o r Drug Toxicity

Either or both present Often absent, especially in Alzheimer disease

Me n t a l S t a t u s

Leve l of Consciousness

Disturbed. Person less clearly aware of the environment and less able to focus, sustain, or shift attention

Usually normal until late in the course of the illness

Behavio r Activity often abnormally decreased (somnolence) or increased (agitation, hypervigilance)

Normal to slow; may become inappropriate

Speech May be hesitant, slow or rapid, incoherent

Difficulty in finding words, aphasia

Mood Fluctuating, labile, from fearful or irritable to normal or depressed

Often flat, depressed

Thought Processes Disorganized, may be incoherent

Impoverished. Speech gives little information

Thought Con ten t Delusions common, often transient

Delusions may occur

Perceptions Illusions, hallucinations, most often visual

Hallucinations may occur.

De liriu m a n d De m e n t iaTable 20-2

Chapter 20 | The Older Adult 419

De lir iu m De m e n t ia

J udgm ent Impaired, often to a varying degree

Increasingly impaired over the course of the illness

Orien ta tion Usually disoriented, especially for time. A known place may seem unfamiliar.

Fairly well maintained, but becomes impaired in the later stages of illness

Atten tion Fluctuates. Person easily distracted, unable to concentrate on selected tasks

Usually unaffected until late in the illness

Mem ory Immediate and recent memory impaired

Recent memory and new learning especially impaired

Exa m p le s o f Ca u s e Delirium tremens (due to withdrawal from alcohol) Uremia

Reversible: Vitamin B12 deficiency, thyroid disorders

Acute hepatic failure Acute cerebral vasculitis Atropine poisoning

Irreversible: Alzheimer disease, vascular dementia (from multiple infarcts), dementia due to head trauma

De liriu m a n d De m e n t ia (continued )Table 20-2

420 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

Ad m in is t r a t io n The test is administered as follows: 1. Instruct the patient to listen carefully to and remember three

unrelated words and then to repeat the words. 2. Instruct the patient to draw the face of a clock, either on a blank

sheet of paper or on a sheet with the clock circle already drawn on the page. After the patient puts the numbers on the clock face, ask him or her to draw the hands of the clock to read a specific time.

3. Ask the patient to repeat the three previously stated words.

S c o r in g Word Recall: Give 1 point for each recalled word without cueing after doing the clock drawing test (CDT). Patients recalling none of the three words are classified as demented (Score = 0). Patients recalling all three words are classified as nondemented (Score = 3). Patients with intermediate word recall of one to two words are classified based on the CDT (Abnormal = demented; Normal = nondemented). Clock Draw: The CDT is considered normal if all numbers are present in the correct sequence and position, and the hands readably display the requested time. Scoring is 2 (normal) or 0 (abnormal). Total Score (0–5 points): Score <3 has been validated for dementia.

3-Item Reca ll = 1–2

NONDEMENTEDDEMENTED

CDT Abnormal CDT Normal

MINI-COG

3-Item Reca ll = 33-Item Reca ll = 0

Sc re e n in g fo r De m e n t ia : Th e Min i-Co gTable 20-3

From Borson S, Scanlan J, Brush M, et al. The Mini-Cog: a cognitive “vital signs” measure for dementia screening in multi-lingual elderly. Int J Geriatr Psychiatry. 2000;15(11):1021. Copyright John Wiley & Sons Limited. Reproduced with permission.

Chapter 20 | The Older Adult 421

5 D

Begin

End

Copy cube

Draw Clock (Ten past eight) (3 points)

SCORE

Read list of words, subject must repeat them. Do 2 trials, even if 1st trial is successful. Do a recall after 5 minutes.

Serial 7 subtraction starting at 100

1st trial

2nd trial

ROSE CHAIR REDSPOON HOUSE

Contour HandsNumbers

Read list of digits (1 digit /sec.). Subject has to repeat them in the forward order Subject has to repeat them inthe backward order

[ ] [ ] [ ]

[ ] [ ] [ ] [ ] [ ]

[ ] 3 2 7 4 5 [ ] 2 7 4

Read list of letters. The subject must point with his nger at each letter C. No points if ≥ 2 errors.

[ ] FBCAMNCCJKLBCFCKDECCJAMOFA [ ] 95 [ ] 86 [ ] 76 [ ] 65 [ ] 45

[ ] Date [ ] Month [ ] Year [ ] Day [ ] Place [ ] City

4 or 5 correct subtractions: 3 pts, 2 or 3 correct: 2pts, 1 correct: 1pt, 0 correct: 0pt

Repeat : Ionly know that Judy is the one to help today. [ ] The cat always hid under the couch when dogs were in the room. [ ]

Fluency / Name maximum number of words in one minute that begin with the letter F [ ] (N≥ 11 words)

ROSE [ ]

CHAIR [ ]

RED [ ]

SPOON [ ]

HOUSE [ ]

Similarity between e.g. banana - orange = fruit [ ] train - bicyle [ ] watch - ruler

Has to recall words

WITHNO CUE

Category cue

Multiple choice cue

Points for UNCUED recall only

Normal ≥ 26 / 30 TOTAL Add 1 point if ≤ 12 yr eduAdministered by:

/ 30

/ 6

/ 5

/ 2

/ 1

/ 2

/ 3

/ 1

/ 2

/ 3

No p o in t s

/ 5

NAME: Education:

Sex: Date of birth:

DATE:

VISUOSPATIAL / EXECUTIVE

NAMING

MEMORY

ATTENTION

LANGUAGE

ABSTRACTION

DELAYED RECALL

ORIENTATION

Optional

S c re e n in g fo r De m e n t ia : Th e Mo n t re a l Co g n it ive As s e s s m e n t (Mo CA)

Table 20-4

423

Index

Note: Page numbers followed by “b,” “f,” and “t” indicate boxed material, gure, and end-of-chapter tables, respectively.

A ABCDE criteria, for skin cancer

screening, 91, 91b–92b Abdomen

auscultation, 207, 208b in children, 368 concerning symptoms, 199b examination of, 12, 207–213, 223, 224f health history, 199–204 health promotion and counseling,

204–207 in infants, 362 inspection, 207 older adults and, 413 pain in (see Abdominal pain) palpation, 208–209, 208f, 209f percussion, 208 during pregnancy, 391–393 recording ndings, 213

Abdominal aortic aneurysm (AAA), 219 in older adults, 413 screening for, 222

Abdominal fullness, 201 Abdominal masses, 209 Abdominal pain, 199b

with associated GI symptoms, 201–202 lower, 201 patterns and mechanisms of, 199–200 upper, 200–201

Abdominal re exes, 329, 329f Abdominal tenderness, 217t Abducens nerve, 318b, 319 Abscess, 103t

headache and, 115 lung, 160t peritonsillar, 368

Abstract thinking, 85 Abuse

elder, 406 illicit drugs, 56 physical, 57b prescription drugs, 56, 82, 388 sexual, 57b, 369, 381t

Acne vulgaris, 103t Acoustic nerve, 318b, 320 Acromioclavicular arthritis, 308t Actinic keratosis, 105t, 410 Actinic lentigines, 410 Actinic purpura, 410 Active listening, 42 Activities of daily living (ADLs), 402,

402b Acute otitis media, with purulent

effusion, 137t Adams bend test, 371 Addiction, 56b Adolescents, 370

breasts, examination of, 371 genitalia, examination of, 371

Adult illnesses, in health history, 3 Advance directives, 403 Adventitious breath sounds, 151b Advisory Committee on Immunization

Practices (ACIP), 314 Aerobic activity, 61 Affect, 83

de ned, 80b African-American, 70, 118, 169, 170.

266, 401,411 Alcohol use/abuse, 56

in health history, 3 health promotion and counseling for,

82, 204, 204b–205b older adults and, 403 during pregnancy, 387

Allen test, 225–226, 225f, 226f Allergic rhinitis, 117 Allergies, in health history, 3 Alopecia areata, 112t Altitudinal (horizontal) defect (visual

eld defect), 132t Alzheimer disease (AD), 405–406 Ambiguous genitalia, 363 Amelanotic melanoma, 107t Amenorrhea, 248

primary, 248 secondary, 248

424 Index

American Cancer Society (ACS), 91 on Breast Self-Examination (BSE),

189b, 193, 194b–195b American College of Chest Physicians,

grading recommendations, 39t–40t American Geriatrics Society, 404 American Heart Association, goals for

ideal cardiovascular health, 169b American Sign Language, 53 American Urological Association (AUA)

Symptom Index, 265, 271t Anagen ef uvium, 111t Anal ssure, 272t Analgesic rebound headache, 129t Anal re ex, 329 Anatomic snuffbox, 289, 289f Androgen-producing tumors, 413 Anemia of pregnancy, 390 Angina pectoris, 155t Angioedema, 139t Angry patient, 52 Angular cheilitis, 139t Ankle–brachial index (ABI), 221

interpretation of, 231t measurement of, 230t–231t

Ankle clonus, 328, 328f Ankles, examination of, 301–302 Anorectal stula, 272t Anorexia nervosa, 72t Ante exion, 262t Anterior cruciate ligament test, 300, 300f Anterior cruciate tear/sprain, 310t Anus

concerning symptoms, 265b examination of, 268–269, 268f health history, 265 during pregnancy, 394 recording ndings, 270

Anxiety, panic disorder, 156t Aorta, assessment of, 211, 211f Aortic aneurysm, dissecting, 155t Aortic stenosis (AS), 180 Aortic valve stenosis, 375t Apgar score, 352, 353b Aphasia, 83, 337t–338t

testing for, 83b Aphonia, 337t Aphthous ulcer, 141t Appearance, assessment of, 83 Appendicitis, 212–213 Appropriate for gestational age (AGA),

354t, 373t Arcus senilis, 411 Arms, examination of, 222–223 Arterial insuf ciency, chronic, 226,

228t, 229t Arterial pulses, grading of, 222b

Arthritis, knee, 309t Articular structures, joint, 275b Asbestosis, 158t Ascites, assessment of, 211–212, 211f, 212f Ascitic uid, 211, 211f Asian-American, 171, 401 Assessment, 13. See also speci c topics

clinical reasoning and, 14–16 of mental status, 79–80 (see also

Mental status) Asterixis, 331 Asthma, 158t, 160t, 165t Ataxia, 313 Ataxic (Biot) breathing, 162t Atelectasis, 165t Atherosclerotic disease, 413 Atrial brillation, 67 Atrial septal defect, 362 Attention

assessment of, 84 de ned, 80b in delirium and dementia, 419t

Attention de cit disorder, 365 Attrition bias, 35b Auricle, examination of, 124 Automated ambulatory blood pressure

monitoring, 64 Autonomy, 58b Axillae

examination of, 11, 193, 193f recording ndings, 195

Axillary temperature, 68

B Babinski response, 329, 329f Back, in physical examination, 11 Back pain

low, 280, 306t–307t (see also Low back pain)

midline, 280 nocturnal, 307t

Back stiffness, chronic, 307t Bacterial pneumonias, 159t Bacterial vaginosis, 260t Baker cyst, 310t Balance, in older adults, assessment

of, 415 Balloon sign, 298, 298f Barlow test, 363, 363f Barrel chest, 163t Basal cell carcinoma (BCC), 106t

nodular, 106t super cial, 106t

Basal ganglia disorder, 340t Bayes theorem, 31

Index 425

Bedbound patient, evaluation of, 98 Behavior

assessment of, 83 in delirium and dementia, 418t

Bene cence, 58b Benign prostatic hyperplasia, 265, 273t Bias, in clinical research, 34, 35b Bicipital tendinitis, 308t Bilingual written questionnaires, 52 Bimanual examination, 255, 255f,

393–394, 414 Birth history, child, 350 Bitemporal hemianopsia, 132t Bleeding, postmenopausal, 248 Blepharitis, 134t Blindness, unilateral, 132t Bloating, 201 Blood pressure, 64–67.

See also Hypertension in children, 365 cuff size, selection of, 65b diastolic, 66b in infants, 356 measurement of, 64, 66b, 174 during pregnancy, 390 recording of, steps in, 65b systolic, 66b

Blount disease, 370 Body dysmorphic disorder, 87t Body mass index (BMI), 63–64, 365

calculation of, 63b and cardiovascular disease, 173 excessively low, 72t obesity and, 63

Bone density criteria, by WHO, 282b Bowel sounds, 207, 208b BPH symptom score index, 265, 271t Brachial pulse, 223f Bradypnea, 162t Brain, 311, 312f Brain tumor, and headache, 130t Breast cancer

relative risk factor, 196t retraction signs, 197t risk factor assessment, 188 screening, 189, 189b visible signs of, 197t–198t

Breast Cancer Risk Assessment Tool, 188 Breasts

in adolescents, 371 concerning symptoms, 187b development of, 377t examination of, 11, 190–192 female, 190–192, 190f–192f health history, 187 health promotion and counseling,

187–189

in infants, 362 male, 192 in older adults, 413 palpable masses of, 187, 188b during pregnancy, 391 recording ndings, 195 in review of systems, 5

Breast Self-Examination (BSE), 189b, 193, 194b–195b

Breathing abnormal, 162t normal, 162t rapid deep, 162t rapid shallow, 162t slow, 162t

Breath odor, 62 Breath sounds

adventitious (added), 151b characteristics of, 150b evaluation of, 150

Breech presentation, 395 Broca aphasia, 337t–338t Bronchiectasis, 160t Bronchiolitis, 357 Bronchitis

acute, 159t chronic, 157t, 160t, 165t

Brown lesions, 107t–108t Brudzinski sign, 330 Bruits, 207, 208b, 413 Bulge sign, 297, 298f Bulimia nervosa, 72t Bullae, 102t Burrow, 104t Bursae, 275b Bursitis, knee, 309t

C CAGE Questionnaire, 56, 204, 403 Calcium, food sources of, 74t Calculating abilities, assessment of, 85 Cancer

breast (see Breast cancer) colorectal, 206, 206b–207b lung, 158t ovarian, 250 prostate, 265–267, 266b–247b, 273t rectum, 273t screening for, 404–405 sigmoid colon, 214t skin, 90–92 testicular, 235

Candida vaginitis, 260t Candidiasis, 140t Canker sore, 141t

426 Index

Carbuncle, 103t Carcinoma

of cervix, 261t of lip, 139t of penis, 241t of tongue/ oor of mouth, 141t of vulva, 259t

Cardiac failure, 357 Cardiopulmonary resuscitation

(CPR), 57 Cardiovascular disease (CVD), 168

and chest pain, 155t lifestyle change and risk factor

modi cation, 173b–174b primary prevention, 168 risk calculators, 170, 170b risk factors and screening frequency,

169b–170b screening for, 169–173 secondary prevention, 168

Cardiovascular system common cardiac symptoms,

167b–168b concerning symptoms, 167b examination of, 174–180 health history, 167 health promotion and counseling,

168–174 in older adults, 412–413 in physical examination, 11–12 recording ndings, 180 in review of systems, 5

Carotid artery screening, 316 Carotid bruits, 175, 412 Carotid pulse, 175 Carpal tunnel syndrome, 288 Carpal tunnel testing, 291 Caruncles, 413 Cataracts, 411 Cauda equina syndrome, 280 Caviar lesions, 141t Central nervous system (CNS), 311

brain, 311, 312f disorder, 340t spinal cord, 312

Cephalic prominence, 396 Cephalohematoma, 357 Cerebellar disorder, 340t Cerebellar function, examination

of, 12 Cerebrovascular disease, 316 Cervical myelopathy, 305t Cervical radiculopathy, 305t Cervix

abnormalities of, 261t inspection of, 253–254, 254f during pregnancy, 393–394

Chalazion, 134t Chancroid, 243t Cherry angioma, 109t Chest

examination of, 147–153 palpation of, 152

Chest pain, 155t–156t, 167b sources of, 145b

Chest wall, 147f Chest wall pain, costochondritis, 156t Cheyne–Stokes breathing, 162t Chief complaint(s), 1b, 2 Childhood

hypertension in, 374t Childhood illnesses, in health history, 3 Children

adolescents, 370–371 blood pressure in, 365 development, principles of, 349n ear in, 366–367, 366f examination of, sequence of, 352b eyes in, 365–366 health history, 349–350 health promotion and counseling,

351–352 heart, 368 hypertension in, 374t infants, 355–364 interviewing, 364b mental and physical status, 365 mouth and pharynx in, 367–368 newborns, 352–354 overweight, 365 recording ndings, 371–372 sexual abuse in, 381t sustained hypertension in, 356b 1 to 10 years children, 364–370 underweight, 365

Chill, 59 Chlamydia trachomatis, 250 Choanal atresia, 359 Cholecystitis, 213 Chorea, 341t Chronic bronchitis, 157t Chronic obstructive pulmonary disease

(COPD), 157t, 165t, 412 Clasp-knife resistance, 342t Clinical reasoning, and assessment,

13–16, 14b abnormal ndings identi cation, 14 clustering clinical ndings, 14–15 generating clinical hypotheses,

15–16, 16b localizing ndings, 14 probable cause of ndings, 15 testing hypotheses, 16 working diagnosis, 16

Index 427

Clinical record checklist for, 24b–26b purpose of, 16 reviewing of, 44 standard format of, example of, 17b–23b tips for quality patient record, 17b

Clinician–patient interview, 41. See also Interviewing

Clubbing of ngers, 113t Cluster headache, 128t Cognitive functions

assessment of, 84–85 de ned, 80b

Cogwheel rigidity, 342t Coldness, in legs/feet, 219 Cold sore, 139t Collaborative partnerships, 50b Collateral ligament tear/sprain, 310t Colorectal cancer

prevention of, 267 screening for, 206, 206b–207b

Coma, 331 metabolic, 345t structural, 345t

Comfort, patient, 45 Communication

nonverbal, 43 respectful, 50b

Condoms, male, 235 Conductive loss, 117 Condyloma latum, 259t Condylomata acuminata. See Genital warts Con dentiality, 45, 58b Confusing patient, 51 Confusional Assessment Method (CAM)

algorithm, 314b Congenital hip dysplasia, 363 Consciousness, level of, 332b

assessment of, 61, 83 de ned, 80b in delirium and dementia, 418t

Consciousness, loss of, 314 Constipation, 202, 368 Constructional ability, assessment of, 85 Conversion disorder, 87t Coordination, 323–324 Corneal light re ex test, 366, 366f Corneal re exes, 319, 319f Corynebacterium diphtheriae, 142t Costovertebral angle (CVA) tenderness,

210, 210f Cough, 159t–161t Cover–uncover test, 366, 366f Crackles, 151b Cranial nerves (CNs), 312

examination of, 12, 318–321 functions of, 318b

Cranial neuralgias, 131t Critical appraisal, 34–36

bias in clinical research, 34, 35b generalizability, 36 guideline recommendations, 36,

37t–40t treatment/prevention intervention,

performance of, 35–36 Crohn disease, 215t Crying patient, 52 Cryptorchidism, 244t Cues

emotional, 47 verbal and nonverbal, 46

Cultural competence, 50 Cultural humility, 50, 50b Culture, 49–50 Cup-to-disc ratio, 411 CVD risk calculator, 170b, 172 Cyst

Baker, 310t epidermoid, 258t of epididymis, 245t pilar, 104t

Cystocele, 263t Cystourethrocele, 263t

D Death, interviewing about issues

related to, 57 Decision-making capacity, 51, 51b Decision-making, shared, 49 Delirium, 314, 418t–419t

clinical features, 418t mental status, 418t–419t screening for, 421t

Dementia, 83, 314, 405, 418t–419t

clinical features, 418t mental status, 418t–419t screening for, 420t

Dental caries, 367 Denture sores, 412 Depression, 314

health promotion and counseling for, 81

older adults and, 405 Dermato broma, 103t Dermatomes, 343t–344t Dermoscopy, 93 Detection bias, 35b Developmental delay, causes of, 355 Diabetes, classi cation and diagnosis

of, 171b–172b Diagnostic hypotheses, 48

428 Index

Diagnostic tests, evaluation of, 28 reproducibility of test results, 33 validity of ndings, 28–32

Diarrhea, 202, 214t–215t acute, 214t chronic, 214t–215t drug-induced, 214t

Diastolic blood pressure, 66b Dietary Approaches to Stop

Hypertension (DASH) eating plan, 61

Diet, hypertension and, 75t Differential diagnosis, 27, 48 Dif cult patients, 77 Diffuse esophageal spasm, 156t Diffuse interstitial lung diseases, 158t Digital rectal examination (DRE),

267 Digit span, 84 Diphtheria, 142t Diplopia, 117, 313 Direct inguinal hernia, 246t Disc herniation, and back pain, 306t Discriminative sensations, 326 Disease/illness model, 46 Disruptive patient, 52 Dissecting aortic aneurysm, chest pain

in, 155t Dissociative disorder, 87t Distal weakness, 314 Distress, signs of, 62 Dizziness, 313 Doll’s eye movements. See

Oculocephalic re ex Domestic violence, 57 Do Not Resuscitate (DNR) status, 57 Dorsalis pedis pulse, 225f Down syndrome, 358 Dress, patient, 62, 83 Dribbling, continuous, 216t Drop-arm test, 287b Drug use, in health history, 3 Drusen, 411 Dual diagnosis, 77 Durable power of attorney for health

care, 52 Dysarthria, 313, 337t Dysesthesias, 314 Dyslipidemias, 172, 172b Dysmenorrhea, 248 Dyspareunia, 249 Dyspepsia, 200 Dysphagia, 199b, 201, 202 Dysphonia, 337t Dysplastic nevus, 108t Dyspnea, 157t–158t, 167b Dysuria, 203

E Earache, 117 Eardrum

abnormalities of, 137t examination of, 124, 124f

Ear(s) in children, 366–367, 366f concerning symptoms, 115b examination of, 124–125 health history, 117 health promotion and counseling,

119 in infants, 359

Eating disorders, and low body mass index, 72t

Ecchymosis, 110t Ectopic pregnancy, 394 Ectropion, 133t Edema, 168b Ejaculation, premature, 234 Elbows, examination of, 288 Elder mistreatment, 406 Electronic thermometer, 68 Empathic responses, 42 Empowerment, patient, 44, 44b Endocervical polyp, 261t Endocrine system, in review of

systems, 6 Entropion, 133t Environment, for examination, 7 Epidermoid cyst, 258t Epididymal cyst, 245t Epididymis

abnormalities of, 245t examination of, 238

Epididymitis, acute, 245t Episcleritis, 134t Epistaxis, 118 Epitrochlear nodes, 223

inspection of, 11 Erectile dysfunction, 233 Essential tremor, 415 Ethics, professionalism and, 58, 58b Evidence-based information, 34, 34f Evidence-Based Working Group, 34 Exercise

health promotion and counseling for, 61

during pregnancy, 387 Exercise-induced pain, 219 Exophthalmos, 133t Expected date of delivery (EDD), 385b Expressions, facial, 62, 83 External hemorrhoids, 272t External rotation lag test, 287b External rotation resistance test, 287b

Index 429

Extra-articular structures, joint, 275b Extraocular muscles, assessment

of, 121 Extremities, 12 Extremities, during pregnancy, 394 Exudative pharyngitis, 142t Eye disorders, headache from, 129t Eye(s)

in children, 365–366 concerning symptoms, 115b examination of, 119–123 health history, 116–117 health promotion and counseling,

118 in infants, 358, 358b physical ndings, 133t–134t during pregnancy, 390

F Face

expressions of, 62, 83 in infants, 358, 358b during pregnancy, 390

Faces Pain Scale, 70 Facial nerve, 318b, 319 Facial paralysis, 339t Facies, abnormal, 358, 358b Factitious disorder, 87t Fagan nomogram, 31–32, 32f Failure to thrive, 355 Fainting, 168b, 314 Falls, in older adults, 283, 407–409,

408b, 409f STEADI falls prevention toolkit,

408b, 409f Family history, 2b, 4

of breast and ovarian cancers, 188 Family planning

counseling on, 251 methods, 251b

Fasciculations, 341t Fatigue, 59 Feeding history, child, 350 Feet, examination of, 301–302 Female genitalia

in children, 369 common concerns, 247b examination of, 13, 252–256 external, 252–253, 253f health history, 247–249 health promotion and counseling,

249–252 in infants, 363 internal, 253–254, 254f older adults, examination in, 413

recording ndings, 257 in review of systems, 5–6

Femoral hernia, 246t Fetal alcohol syndrome, 358, 387 Fetal exposure to diethylstilbestrol

(DES), 261t Fetal heart rate (FHR), 392–393 Fetal movements, 392 Fever, 59, 68

causes of, 68 Fever blister, 139t Fibromyalgia, 305t FIFE (mnemonic), 46 Fissured tongue, 140t Flaccidity, 342t Flat spots (skin lesions), 100t Fluid- lled lesions, 102t Folate, food sources of, 74t Fontanelles, 357, 357f Forced expiratory time, 153 Fracture of clavicle, 363 Frailty, older adults, 403 FRAX calculator for assessing fracture

risk, 282 Functional incontinence, 217t Functional status, of older adults, 406,

406b–407b Fundal height, 392 Funnel chest, 163t Furuncle, 103t Furunculosis, 103t

G Gail model (breast cancer risk

assessment), 188 Gait

examination of, 62, 293f, 323 older adults, examination in, 415

Gastroesophageal re ux, 161t, 201 Gastrointestinal re ux disease, and

chest pain, 156t Gastrointestinal system

disorders related to, 199b pain related to, 200–201 in review of systems, 5 symptoms related to, 201–202

Gaze, cardinal directions of, 121, 121f Gegenhalten, 342t General survey

in infants, 355 in physical examination, 10, 61–62 recording ndings, 71b in review of systems, 4

Genital herpes, 258t Genital herpes simplex, 242t

430 Index

Genitalia. See also Female genitalia; Male genitalia

examination of, 13 during pregnancy, 393–394 in review of systems, 5–6

Genital warts, 242t Geographic tongue, 140t Gestational age, 385 Gestational hypertension, 390b Get Up and Go test, 417t, 418t–419t Giant cell arteritis, and headache, 130t Glasgow Coma Scale, 346t Glass thermometer, 68 Glaucoma, 118, 411

acute, 129t open-angle, 116, 411

Glaucomatous cupping, 135t Glossopharyngeal nerve, 318b, 320 Goiter, multinodular, 143t Gonorrhea, 251b, 254, 256, 261t Grooming, patient, 62, 83 Growth and developmental history,

children, 350 Guided questioning, 42–43, 42b Gums, inspection of, 126 Guttate psoriasis, 101t Gynecomastia, 192

H Habit tic deformity, 113t Hair, examination of, 94f, 95, 98, 98f Hair loss, 90, 98

female pattern, 111t focal, 112t generalized/diffuse, 111t male pattern, 111t

Hair pull test, 98, 98f Hairy leukoplakia, 141t Hairy tongue, 140t Hand, arterial supply to, 225–226,

225f, 226f Hand grip strength, 291, 291f Hands, examination of, 288–292 Head

concerning symptoms, 115b examination of, 119 health history, 115–116 in infants, 357, 357f during pregnancy, 390

Headache, 115, 313 from eye disorders, 129t primary, 128t secondary, 129t–131t from sinusitis, 129t warning signs, 116b

Head circumference, in infants, 355, 356f Head, eyes, ears, nose, throat (HEENT)

examination of, 10 older adults and, 411–412 recording ndings, 127 in review of systems, 4–5

Health care proxy, 52, 57 Health disparities, 70 Health history, 2–6, 41

chief complaint(s), 2 components of, 1b–2b concerning symptoms, 59–60 family history, 4 interviewing and, 41–58 past history, 3 personal and social history, 4 present illness, 3 review of systems, 4–6

Health Insurance Portability and Accountability Act (HIPAA), 51

Health literacy, 53 Health maintenance, 3, 16 Health promotion, 33–34, 34f Health promotion and counseling

abdominal aortic aneurysm screening, 222

alcohol abuse, 82, 204, 204b–205b ankle–brachial index, 221 breast cancer risk assessment, 188 breast cancer screening, 189, 189b breast masses, 187, 188b cardiovascular risk factors, screening

for, 169–173 carotid artery screening, 316 cervical cancer screening, 249–250, 250b colorectal cancer, 206, 206b–207b, 267 delirium, dementia, and depression

detection, 317 depression, 81 diet, 60 exercise, 61, 387 family planning options, 251, 251b hearing de cits, 119 herpes zoster vaccination, 317 HIV/AIDS screening, 235 hormone replacement therapy, 252 immunizations, 386–387, 387b intimate partner violence, 388, 388b lifestyle modi cations for

cardiovascular health, 173b–174b low back pain, 281 lung cancer, 146 menopause, 252 mood disorders, 81 nutrition, 61, 61b, 73t, 74t, 281, 386 older adults, 404–406 optimal weight, 60, 61b

Index 431

oral health, 119 osteoporosis, 281–283 ovarian cancer, 250 peripheral arterial disease, screening

for, 221, 221b peripheral neuropathy risk

prevention, 316–317 physical activity, 281, 281b pneumococcal vaccine, 146 prenatal laboratory screenings, 389 prescription drug abuse, 82 prostate cancer, 266–267 renal artery disease screening, 221,

221b–222b skin cancer, 90–92 STIs and HIV infection screening,

250–251, 251b, 267 stroke prevention, 316 substance abuse, 82, 387–388 suicide risk, 81–82 testicular cancer, 235 testicular self-examination, 235 tobacco cessation, 146, 146b viral hepatitis, 205–206 vision disorders, 118 weight gain during pregnancy, 386, 386b weight, optimal, 281

Health, state of, in general survey, 61 Hearing, assessment of, 124–125 Hearing loss

conductive, 125, 138t sensorineural, 125, 138t

Heart auscultation, 177–178, 177f, 178f in children, 368 in infants, 362 inspection and palpation, 176–177, 176f murmurs, 178–180, 185t during pregnancy, 391 sequence of examination, 176b

Heart failure, left, 157t, 165t Heart murmurs, 185t. See also Murmurs Heart rate, 67, 174 Heart sounds, 181t

rst, variations in, 182t second, variations in, 183t–184t

Hegar sign, 394 Height

in infants, 355 measurement of, 63, 390 older adults and, 410

Hematologic questions, in review of systems, 6

Hemianopsia, 116 Hemoptysis, 159t–161t Hepatitis A, 205, 205b Hepatitis B, 205, 206b

Hepatitis C, 206 Hereditary hemorrhagic telangiectasia,

139t Hernias

direct inguinal, 246t examination for, 13 examination of, 238, 238f femoral, 246t indirect inguinal, 246t recording ndings, 240

Herpes simplex virus, 102t Herpes zoster, 411 Herpes zoster vaccine, 314 Hips, examination of, 293–295 Hispanic, 70,171b, 401 HIV/AIDS, screening for, 235 Hoarseness, 118 Homonymous hemianopsia, 132t Homonymous quadrantic defect, 132t Hormone replacement therapy (HRT), 252 Housemaid’s knee, 297 HPV infection, and cervical cancer, 250 Hydrocele, 241t, 363 Hyperlipidemia, 134t Hyperopia, 116

in school-aged children, 365 Hyperpnea, 162t Hyperpyrexia, 68 Hypertension, 64. See also Blood pressure

in childhood, 374t chronic, 390b dietary guidelines, 75t in pregnancy, 390b screening for, 170 types of, 64b–65b

Hyperthyroidism, 118 Hypertonia, 342t Hyperventilation, 162t Hypoglossal nerve, 318b, 321 Hypospadias, 241t Hypothermia, 68 Hypothyroidism, 118 Hypotonia, 342t, 364

I Idiopathic pulmonary brosis, 158t Iliotibial band, 309t Illicit drug use, 56, 82

during pregnancy, 387 Illness anxiety disorder, 87t Illness, patient’s perspective on, 46, 47b Immunizations

in health history, 3 older adults and, 404 during pregnancy, 386–387, 387b

432 Index

Indirect inguinal hernia, 246t Infantile automatisms, 364 Infants, assessment of

abdomen, 362 blood pressure, 356 breasts, 362 ear, 359 eyes, 358, 358b face, 358, 358b female genitalia, 363 general survey, 355 head, 357, 357f head circumference, 355, 356f heart, 362 height and weight, 355 male genitalia, 363 mental and physical status, 355 mouth and pharynx, 359 musculoskeletal system, 363–364, 363f neck, 359, 360f nervous system, 364 nose, 359 skin, 357 thorax and lungs, 360, 360b–361b upper airway vs. lower airway

sounds, 361b vital signs, 356–357

In ammatory bowel disease, 215t Information, patient, 85 Inguinal hernias, 363

in older boys, 369 Inguinal nodes, super cial, 223, 224f Insect bites, 102t Insight, patient, 80b, 84 Institute of Medicine (IOM), 61 Instrumental activities of daily living

(IADLs), 402b Intention tremor, 341t Intermittent claudication, 219 Internal rotation lag test, 287b Interpreter, working with, 52b–53b Interviewer, behavior and appearance, 45 Interviewing, 41

advanced, 50–57 challenging patient, 50–54 cultural context of, 49–50 ethics and professionalism, 58, 58b focused/ problem-oriented history, 41 goals for, 45 and health history, 41–58 open-ended, 41 patient’s perspective in, 46, 46b preparation for, 44–45 sensitive topics, 54–57 sequence for, 45–49 skilled, 42–44 techniques for, 42–44

Intimate partner violence, 57, 388, 388b

Involuntary movements, 315, 341t Iron, food sources of, 74t Irritable bowel syndrome, 214t Irritating particles/chemicals, and

cough, 161t Ischiogluteal bursa, 294, 294f Isolated clinic hypertension. See White

coat hypertension Itching

rashes and, 89 vaginal, 248

J Jaundice, 202

extrahepatic, 202 intrahepatic, 202

Joint pain acute or chronic, 278–279 articular or extra-articular, 278 assessment of, tips for, 278b constitutional symptoms with, 279 in ammatory or nonin ammatory, 279 localized or diffuse, 279 monoarticular, 278 polyarticular, 278

Joints aging, effect of, 276, 276b anatomy, terminology related to, 275b cartilaginous, 276b examination of, steps in, 283b brous, 276b in ammation, signs of, 283b–284b pain in, 304t (see also Joint pain) problem, 275 synovial, 276b, 277b

Judgment in delirium and dementia, 419t patient, 80b, 84

Jugular venous pressure ( JVP), 174, 175f Jugular venous pulsations, 174

K Kappa score, 33 Keloid, 103t Kernig sign, 330, 330f Kidneys, examination of, 210, 210f Kinetic red target test, 119 Klinefelter syndrome, 244t Knee

examination of, 296–301, 296f pain in, 309t–310t

Index 433

Koplik spots, 142t Korotkoff sounds, 66b

L Lachman test, 300, 300f Language

barrier, 52 de ned, 80b

Large for gestational age (LGA), 354t, 373t Laryngitis, 159t Lateral collateral ligament test, 300, 300f Leadpipe rigidity, 342t Left ventricular heart failure, 157t, 161t Left ventricular hypertrophy (LVH), 412 Leg length, measurement of, 303 Legs, examination of, 12, 224–225,

224f, 225f Leopold maneuvers, 395–396 Lesions

skin, 62 vulva, 258t–259t

Leukocoria, 358 Lhermitte sign, 305t Libido, assessment of, 233 Lid retraction, 133t Lifestyle habits, in health history, 4 Lifestyle modi cations, for

cardiovascular health, 173b–174b Ligaments, 275b Lighting, for examination, 7 Likelihood ratio, 30

interpretation of, 31 for negative test, 31 for positive test, 30–31

Lipoma, 104t Lips

abnormalities of, 139t inspection of, 126

Listening, active, 42 Liver, examination of, 209–210, 209f Lobar obstruction, 165t Low back pain, 280, 280b, 306t–307t

health promotion and counseling, 281 red ags for, 280b

Lower extremities, in physical examination, 12

Lumbar spinal stenosis, 306t Lumbosacral radiculopathy, 330 Lung abscess, 160t Lung cancer, 158t, 161t Lungs

concerning symptoms, 145b examination of, 147–153 health history, 145–146 health promotion and counseling, 146

in infants, 360, 360b–361b in older adults, 412 in physical examination, 11 during pregnancy, 391 recording ndings, 154

Lymphadenopathy, 359

M Macular degeneration, 116, 123b, 411 Macules, 100t Malabsorption syndrome, 215t Male genitalia, 378t–379t

anatomy of, 236f in children, 369 concerning symptoms, 233b examination of, 13, 236–239 health history, 233–234 health promotion and counseling,

234–235 in infants, 363 older adults, examination in, 414 recording ndings, 240 in review of systems, 5 sexually transmitted infections of,

242t–243t Mammography, 189, 189b Mania, 83 Masked hypertension, 64b McMurray test, 299, 299f Mechanical neck pain, 305t Medial collateral ligament test, 299, 299f Medications, in health history, 3 Melanoma, 90, 411

ABCDE-EFG method for, 91, 91b–92b

incidence of, 90 and mimics, 107t–108t prevention of, 90–91 risk factors for, 90–91 screening for, 91

Melanoma in situ, 107t Melanoma Risk Assessment Tool, 90 Melanonychia, 113t Melena (black tarry stools), 202 Memory

de ned, 80b in delirium and dementia, 419t

Ménière disease, 117 Meningeal signs, 330 Meningitis, and headache, 130t Meniscal tear, 309t Menopause, 248, 252 Mental health disorders, 77, 78b, 87t

personality disorders, 78 and unexplained symptoms, 77, 78b, 79

434 Index

Mental health history, 55 Mental illness, 77. See also Mental status Mental status

assessment of, 12 behavior and, 77–88 examination of, 82–86 (see also

Mental Status Examination) health history, 79–81 health promotion and counseling, 81–82 recording ndings, 86 screening, 79, 79b unexplained symptoms and, 77, 78b

Mental Status Examination, 82, 82b appearance and behavior, 83 cognitive function, 84–85 mood, 84 speech and language, 83, 83b thoughts and perceptions, 84

Metabolic syndrome, 173, 173b Metacarpophalangeal joints, 289, 289f Metatarsophalangeal joints, 301, 301f Migraine, 116

with aura, 128t without aura, 128t

Mini-Cog, 420t Mini-Mental State Examination

(MMSE), 85, 86b, 314 Mitgehen, 342t Mitral regurgitation, 413 Mitral stenosis, 157t, 161t Mitral valve prolapse (MVP), 180 Montreal Cognitive Assessment (MoCA),

421t Mood

assessment of, 84 de ned, 80b in delirium and dementia, 418t disorders, 81

Morbilliform drug eruption, 100t Morning stiffness, 279 Motivational interviewing, 49, 49b Motor behavior, assessment of, 83 Motor disorders, 340t Motor system, examination of, 12, 62,

321–324 Mouth

in children, 367–368 concerning symptoms, 115b examination of, 126 health history, 118 health promotion and counseling, 119 in infants, 359 inspection of, 126

MRSA precautions, 7 Mucopurulent cervicitis, 261t Mucous patch of syphilis, 141t Multinodular goiter, 143t

Murmurs, 178–179 aortic, 179 in children, 368 crescendo, 179 crescendo–decrescendo, 178 decrescendo, 179 gradations of, 179b in older adults, 413 pathologic, 375t–376t plateau, 179

Murphy sign, 213 Muscle strength

grading of, 321b testing of, 321–323

Muscle tone, disorders of, 342t Musculoskeletal disorders, 275 Musculoskeletal system, 275

in children, 370 concerning symptoms, 277b examination of, 283–303 health history, 277–280 health promotion and counseling,

281–283 in infants, 363–364, 363f joints, assessment of, 275–277 in older adults, 414 in physical examination, 11 recording ndings, 303 in review of systems, 6

Mycoplasma, 159t Myocardial infarction, chest pain in, 155t Myoma of uterus, 262t Myopia, 116, 365

N Nails

changes in, 90 ndings, 113t–114t

National Survey on Drug Use and Health, 82

Natural frequencies, 32 Neck

concerning symptoms, 115b examination of, 126–127 health history, 118 in infants, 359, 360f pain in, 279–280, 305t in physical examination, 11 during pregnancy, 390 in review of systems, 5

Negative predictive value (NPV), 29b Nervous system, 311–312

central, 311–312 in children, 370 concerning symptoms, 313b

Index 435

examination of, 12, 318–333 guiding questions for examination

of, 311b health history, 313–315 health promotion and counseling,

315–317 in infants, 364 older adults, examination in, 415 peripheral, 312 recording ndings, 333–334

Neurologic abnormalities, in older adults, 415

Neurologic examination, 332–333 Neurologic questions, in review of

systems, 6 Neuropathic ulcer, 229t Newborn

Apgar scoring system, 352, 353b assessment after some time, 354 bowlegged, 354 classi cations, 354b gestational age and birth weight,

353, 353b immediate assessment, 352–353 level of maturity, 373t neurologic screening of, 354 umbilical cord, 354

New learning ability, assessment of, 85 Night sweats, 59 Nocturia, 204 Nocturnal back pain, 307t Nocturnal hypertension, 65b Nodule, 103t Nonmale cence, 58b Nonproliferative retinopathy

moderately severe, 136t severe, 136t

Nonverbal communication, 43 Nose

concerning symptoms, 115b examination of, 125 health history, 117–118 in infants, 359 during pregnancy, 390

Nosebleeds, 390 Number identi cation, 326 Numbness, in legs/feet, 219 Numeric Rating Scale, 70 Nummular dermatitis, 101, 101f Nutrients, sources of, 74t Nutrition

health promotion and counseling for, 61, 61b

older adults and, 403 during pregnancy, 386 screening checklist, 73t sources of nutrients, 74t

O Obesity, 60

body mass index and, 63 and cardiovascular disease, 173 childhood, 365

Obturator sign (appendicitis), 213 Oculocephalic re ex, 332, 333f Oculomotor nerve, 318b, 319 Odors, body and breath, 62 Odynophagia, 199b, 202 Older adults, 399–400

activities of daily living, 402, 402b approach to, 400–403 common concerns, 401b cultural dimensions, 401, 401b delirium and dementia, 418t–419t eliciting symptoms in, 400–401 examination of, 408–415 falls prevention in, 283, 407–409,

408b, 409f health history, 400–403 health promotion and counseling,

404–406 hearing de cits in, 119 hypothermia in, 68 medications and, 402 Mini-Cog, 420t 10-Minute Geriatric Screener, 406,

406b–407b mistreatment and abuse, 406 Montreal Cognitive Assessment

(MoCA), 421t pain in, 402, 403b primary care, approach for,

399b–400b recording ndings, 415–416 vision disorders in, 118

Olfactory nerve, 318, 318b Onycholysis, 114t Onychomycosis, 114t Open-ended questions, 46 Ophthalmoscope, use of, 121b–122b Optic atrophy, 135t Optic disc

abnormalities of, 135t examination of, 123, 123b

Optic nerve, 318, 318b, 319 Oral candidiasis (thrush), 359 Oral mucosa, inspection of, 126 Orchitis, acute, 244t Orientation

assessment of, 84 de ned, 80b in delirium and dementia, 419t

Orthopnea, 168b Orthostatic hypotension, 410

436 Index

Orthostatic (postural) hypotension, 66b, 174

Ortolani test, 363, 363f Osmotic diarrheas, 215t Osteoarthritis, 304t Osteopenia, 282b Osteoporosis

bone density criteria, 282b falls prevention, 283 health promotion and counseling,

281–283 risk factors for, 282b treatment of, 283

Otitis externa, 117, 366 Otitis media, 117, 367 Ovarian cancer, 250 Over ow incontinence, 204, 216t

P Paget disease of nipple, 198t Pain, 60, 69

assessment of, 69–70 chronic, 69, 70b–71b contributing factors, 70 health disparities in treatment of, 70 in knee, 309t–310t location of, 70 management of, 70, 70b–71b in neck, 305t in older adults, 402, 403b severity of, 70 in shoulder, 308t on urination, 203

Painful arc test, 286b Pain provocation test, 286b Palliative care, 403 Pallor, in legs/feet, 219, 226 Palpitations, 167b Papilledema, 135t Pap smear, 393

specimens for, 255, 255f Papules, 101t Paradoxical pulse, 175 Paranoia, 83 Paratonia, 342t Paresthesias, 314 Parietal pain (abdomen), 200 Parkinsonism, 340t Paronychia, 113t Paroxysmal nocturnal dyspnea (PND),

168b Paroxysmal supraventricular

tachycardia, 356, 362 Partnerships, collaborative, 50b Past history, 2b, 3

Patches (skin), 100t Patellofemoral instability, 309t Patent ductus arteriosus, 177–178,

177f, 178f, 185t Patient

with altered cognition, 51–52 angry, 52 bedbound, 98 confusing, 51 crying, 52 disruptive, 52 dying, 57 empowerment of, 44, 44b with hearing loss, 53–54 with impaired vision, 54 with language barrier, 52, 52b–53b with limited intelligence, 54 with low literacy, 53 partnering with, 43 with personal problems, 54 seductive, 54 silent, 50 talkative, 52

Patient care, ethics in, 58b Peau d’orange sign (breast cancer),

198t Pectus carinatum, 164t Pectus excavatum, 163t Pelvic examination, 252

in older adults, 413–414 Pelvic oor, relaxations of, 263t Pelvic pain, 249 Penile discharge, 234 Penis

abnormalities of, 234, 241t examination of, 236–237

Perceptions assessment of, 84 de ned, 80b in delirium and dementia, 418t

Percussion notes, 149b Perforation, eardrum, 137t Performance bias, 35b Pericarditis, chest pain in, 155t Perineal irritation, 369 Peripheral arterial disease (PAD), 219

risk factors for, 221b screening for, 221, 221b warning signs, 220b

Peripheral nerves, 312 Peripheral nervous system, 312

disorder, 340t Peripheral neuropathy risk, prevention

of, 316–317 Peripheral vascular system

concerning symptoms, 219b examination of, 12, 222–226

Index 437

health history, 219–220 health promotion and counseling,

220–222 older adults and, 413 recording ndings, 227 in review of systems, 5

Personal history, 2b, 4 Personal hygiene, 62, 83 Personality disorders, 78 Pes anserine bursa, 309t Petechia/purpura, 110t Peutz–Jeghers syndrome, 139t Peyronie disease, 241t Phalen sign, 292, 292f Pharyngitis, 118, 142t Pharynx

abnormalities of, 142t examination of, 126 in infants, 359

Physical abuse, 57b Physical activity, guidelines for, 281, 281b Physical contact, 43 Physical dependence, 56b Physical examination, 6–13

approach for, 7 beginning of, 7–10 comprehensive vs. focused, 9 general survey in, 61–62 health promotion and counseling in,

60–61 patient positioning for, 9b, 10 preparation for, 7b recording ndings, 71, 71b sequence of, 8, 9b standard and universal precautions in, 7

Pigeon chest, 164t Pilar cysts, 104t Pinguecula, 134t Pink lesions, 106t Plan, 13, 16 Plantar response, 329, 329f Plaque psoriasis, 101t Plaques, 101t Pleural effusion, 165t Pleuritic pain, 156t Pneumatic otoscope, 367 Pneumococcal vaccine, 146 Pneumonia, 158t, 357 Pneumothorax, 165t Point of maximal impulse (PMI), 412 Polydactyly, 363 Polyps of rectum, 272t Polyuria, 204 Popliteal pulse, 224f Positive predictive value (PPV), 29b Postconcussion headache, 131t Posterior cruciate ligament test, 301, 301f

Posterior drawer sign, 301, 301f Posterior tibial pulse, 225f Postmenopausal bleeding, 248 Postnasal drip, 159t Posture, assessment of, 62, 83 Precision, 33 Precocious puberty, 369 Predictive value

negative, 29b positive, 29b

Preeclampsia, 390b, 394 Pregnancy

common concerns, 383b con rmation of, 383 examination in, 389–396 expected date of delivery, 385b gestational age, 385b health history, 383–385 health promotion and counseling,

385–389 hypertension in, 390b maternal concerns and attitudes,

384 obstetric visits, 385 postpartum contraception, plans

for, 384 preparation for examination, 389b recording ndings, 396–397 risk factors for maternal and fetal

health, 384 symptoms of, 383

Pregnancy Weight Gain Calculator, 386 Premature closure, 48 Premature ejaculation, 234 Prepatellar bursa, 309t Presbyopia, 116, 411 Prescription drugs

abuse of, 56, 82 during pregnancy, 388

Present illness, 1b, 3 Pressure sores, 98, 411 Presyncope, 313 Preterm labor, 392 Prevalence of disease, 29–30 Primary biliary cirrhosis, 134t Primary prevention, 33 Primitive re exes, 364 Primum non nocere, 58b Probability revisions, 27–28, 27f Problem List, 24 Professionalism, and ethics, 58, 58b Prolapsed uterus, 263t Proliferative retinopathy

advanced, 136t with neovascularization, 136t

Pronator drift, test for, 324, 324f Proprioception, test for, 326, 326f

438 Index

Prostate cancer of, 273t concerning symptoms, 265b examination of, 268–269 health history, 265 recording ndings, 270

Prostate cancer, 265, 266 risk factors, 266 screening for, 266–267, 266b–247b

Prostate-speci c antigen (PSA) test, 266 Prostatitis, acute, 273t Proximal weakness, 314 Pseudoclaudication pain, in back, 306t Psoas sign (appendicitis), 213 Psychiatric questions

in review of systems, 6 Ptosis, 133t Pubic hair, 378t–380t Pulmonary disease, chest pain in, 156t Pulmonary embolism, 158t, 161t Pulmonary brosis, idiopathic, 158t Pulmonary function, clinical assessment

of, 153 Pulmonary hypertension, 362 Pulmonary tuberculosis, 160t Pulmonary valve stenosis, 375t Pulse, in infants, 356 Pulsus alternans, 175 Pupils

in comatose patients, 347t inspection of, 120, 121f large, 347t midposition xed, 347t one xed and dilated, 347t pinpoint, 347t small, 347t

Pustules, 103t Pyloric stenosis, 362 Pyrexia. See Fever

R Race and ethnicity

cultural ethnicity, 49–50 diabetic risk factors, 171 geriatric diversity, 401b, 401–402 prostate cancer risk factors, 266 testicular cancer risk factors, 235

Radial pulse, 67, 67f, 223, 223f irregular rhythm, 67 regular rhythm, 67

Radicular low back pain, 306t Raised spots (skin), 101t Range of motion

ngers, 290 hip, 295, 295f

measurement of, 303 shoulder, 285–286 thumbs, 290f wrists, 290

Rashes, 89 Reassurance, 43 Rebound tenderness, 208 Recent memory, assessment of, 85 Rectal examination

in men, 13 in women, 13

Rectal temperature, 68 measurement of, 68–69

Rectocele, 263t Rectovaginal examination, 256, 256f Rectum

abnormalities of, 272t–273t cancer of, 273t concerning symptoms, 265b examination of, 268–269, 268f health promotion and counseling,

266–267 recording ndings, 270

Red re ex, 121f, 122b Referred pain (abdomen), 200 Re exes, 327

abdominal, 329, 329f Achilles, 328f biceps, 327f brachioradialis, 328f examination of, 13 grading, 327b quadriceps (patellar), 328f triceps, 327f

Remnants of digits, 363 Remote memory, assessment of, 84 Renal artery disease (RAD), 221b–222b

screening for, 221b Reproducibility, test, 33 Respiratory rate

in infants, 357 and rhythm., 67

Respiratory system, 5 Responses, empathic, 42 Resting static tremors, 341t Retina, examination of, 123, 123b Retinoblastoma, 358 Retinopathy

nonproliferative, 136t proliferative, 136t

Review of systems (ROS), 2b, 4–6 Rheumatoid arthritis, 304t Rhinorrhea, 117 Rhonchi, 151b Rigidity, 342t Ringworm, 112t Rinne test, 125, 320

Index 439

Romberg test, 12, 324 Rotator cuff tendinitis, 308t Rough lesions (skin), 105t Rovsing sign (appendicitis), 212

S Sarcoidosis, 158t Scabies, 104t Scapular winging, 331, 331f Schizophrenia, 83 Sciatica, 306t Sciatic nerve, 293, 293f Scoliometer, 371 Scoliosis, testing for, 371, 371f Screening

for abdominal aortic aneurysm, 222 for breast cancer, 189, 189b for cancer, 404–405 for cardiovascular disease, 169–173 for cervical cancer, 249–250, 250b for colorectal cancer, 206, 206b–207b for delirium, 421t for dementia, 406, 420t for high blood pressure, 170 for HIV/AIDS, 235 for intimate partner violence, 388, 388b lipid, 172 mental health, 79, 79b in older adults, 404 for peripheral arterial disease, 221, 221b for problem drinking, 204b–205b for renal artery disease, 221 for STIs and HPV, 235

Screening tests, in health history, 3 Scrotal edema, 241t Scrotal hernia, 241t Scrotum

abnormalities of, 234, 241t examination of, 237

Seborrheic dermatitis, 100t Seborrheic keratosis, 108t

in amed, 108t Secondary prevention, 33 Secondary syphilis, 259t Secretory diarrheas, 215t Seductive patient, 53 Seizure, 315 Selection bias, 35b Self-awareness, 50b Self-re ection, 49 Self-skin examination, 92, 98 Senile ptosis, 411 Sensitivity, 29b Sensorineural loss, 117 Sensory loss, 314

Sensory system assessment of, 324–327 examination of, 12–13

Serial 7s, 84 Serous effusion, 137t Sex maturity ratings, in boys,

378t–379t Sex maturity ratings, in girls

breast, 377t pubic hair, 380t

Sexual abuse, 57b, 369 physical signs of, 381t

Sexual health female, 248–249 male, 233–234

Sexual history, 55, 55b Sexually transmitted infections

of male genitalia, 234, 242t–243t screening for, 235 in women, 249

Shortness of breath, 167b Shoulder

examination of, 284–287 pain in, 308t

Sighing breathing, 162t Silent patient, 50 Sinuses

concerning symptoms, 115b examination of, 125 health history, 117–118

Sinusitis, headache from, 129t SITS muscle (rotator cuff) assessment,

286, 286b–287b Skin, 89–114

color of, 62 description of ndings, terms for, 94,

94b–95b examination of, 10, 93–98 health history, 89 health promotion and counseling

for, 90–92 in infants, 357 lesions of, 62, 100t–110t older adults and, 410–411 preparation for examination, 93–94 recording ndings, 99 in review of systems, 2b, 4–6 seated position, examination in,

95–97, 95f–97f supine and prone position,

examination in, 97, 97f Skin cancer

health promotion and counseling for, 90–92

prevention, 90–91 screening, 91, 91b–92b self-skin examination, 92, 98

440 Index

Skin lesions. See also speci c lesion assessment of, 62 brown, 107t–108t description of, 94, 94b–95b pink, 106t primary, 100t–102t, 103t–104t rough, 105t vascular and purpuric, 109t–110t

Skin tags, 101t, 107t, 363 Small for gestational age (SGA), 354t, 373t Smoking

and cardiovascular disease, 173 older adults and, 403 readiness for cessation, 146, 146b

Smooth tongue, 140t SnNOUT mnemonic, 29 Social history, 2b, 4 Sodium, dietary, 61 Solar lentigo, 107t Somatic symptom disorder, 87t Sore throat, 118 Spasticity, 342t Speci city, 29b Speculum examination, 393, 414 Speech

assessment of, 83 in delirium and dementia, 418t disorders of, 337t–338t

Spelling backward, 84 Spermatic cord

abnormalities of, 245t examination of, 238, 238f torsion of, 245t varicocele of, 245t

Spermatocele, 245t Spider angioma, 109t Spider vein, 109t Spinal accessory nerve, 318b, 320 Spinal cord, 312 Spinal nerve, 312 Spinal stenosis, 219 Spine, examination of, 292–293 Spleen, examination of, 210, 210f Spontaneous pneumothorax, 158t SpPIN mnemonic, 29 Squamous cell carcinoma (SCC), 105t Stance, 324 Standard precautions, 7 Static nger wiggle test, 119, 120f Stereognosis, 326 Sternocleidomastoid muscles,

assessment of, 320 Stool, color of, 202 Straight-leg raise, 306t, 330, 330f Streptococcal pharyngitis, 118, 367 Stress incontinence, 204, 216t Stridor, 148

Stroke prevention of, 316 risk factors management, 316 types of, 335t–336t warning signs and symptoms, 316b

Sty, 134t Subacromial/subdeltoid bursitis, 285,

308t Subarachnoid hemorrhage, and

headache, 130t Subcutaneous mass/cyst, 104t Substance abuse, 82 Subungual melanoma, 113t Suicide risk, 81–82 Summarization, 44 Sun exposure, and skin cancer cancer,

90–91 Sunscreen, use of, 91 Sutures, 357 Swelling of feet and legs, 220 Symptom, seven attributes of, 3, 3b, 47, 47b Syncope, 168b, 314–315 Syndactyly, 363 Syphilis

primary, 243t secondary, 259t

Syphilitic chancre, 139t, 259t Systems review, 2b, 4–6 Systolic blood pressure, 66b Systolic murmurs, identi cation, 180

T Tachypnea, 162t Tactile fremitus, 148 Talkative patient, 52 Tanning beds, and melanoma risk, 91 Tavistock Principles, 58, 58b Telogen ef uvium, 98, 111t Temperature

axillary, 68 measurement of, 68–69 oral, 68 rectal, 68–69 temporal artery, 69 tympanic membrane, 68, 69

Temporal artery temperature, measurement of, 69

Temporomandibular joint (TMJ), 284, 284f Tendons, 275b Tension headache, 115, 128t Terry nails, 114t Testicular cancer, 235 Testicular self-examination, 235, 239b Testis

abnormalities of, 244t

Index 441

examination of, 237, 237f small, 244t

Tetralogy of Fallot, 375t Thoracic kyphoscoliosis, 164t Thorax

concerning symptoms, 145b deformities of, 163t–164t examination of, 147–153 health history, 145–146 health promotion and counseling, 146 in infants, 360, 360b–361b normal, 163t in older adults, 412 in physical examination, 11 during pregnancy, 391 recording ndings, 154

Thought content assessment of, 84 in delirium and dementia, 418t patient, 80b

Thought processes assessment of, 84 in delirium and dementia, 418t patient, 80b

Thrills, 362 Throat

concerning symptoms, 115b health history, 118

Thumb abduction, 291, 291f Thunderclap headache, 130t Thyroid gland

abnormalities of, 143t diffuse enlargement, 143t examination of, 127 with goiter while swallowing, 127f during pregnancy, 390

Thyroid nodule (single), 143t Tibial torsion, 364 Tinea capitis, 112t Tinel sign, 291, 291f Tinnitus, 117 Tobacco use

in health history, 3 during pregnancy, 387

Tolerance, 56b Tongue

abnormalities of, 140t–141t inspection of, 126

Torsion of spermatic cord, 245t Torticollis, 305t Tortuous atherosclerotic aorta, 412 Transient ischemic attack (TIA), 313.

See also Stroke Transitions, 44 Transposition of great arteries, 376t Trapezius muscles, assessment of, 320,

320f

Traumatic ail chest, 163t Treatment plan, sharing of, 48–49 Tremors, 315, 415 Trichomonas vaginitis, 260t Trichophyton rubrum, 114t Trigeminal nerve, 318b, 319, 319f Trochanteric bursa, 294, 294f Trochlear nerve, 318b, 319 Tug test, 98, 98f Tumor of testis, 244t Two-point discrimination, 326, 326f Tympanic membrane temperature, 68

measurement of, 69 Tympanosclerosis, 137t

U Ulcerative colitis, 215t Ulcers of feet and ankles, 229t Ultraviolet radiation exposure,

avoidance of, 90 Umbilical hernias, in infants, 354 Undescended testicles, 363 Unilateral blindness, 132t Universal precautions, 7 Urethritis, assessment of, 256, 256f Urge incontinence, 204, 216t Urgency, urinary, 203 Urinary frequency, 203 Urinary incontinence, 204, 216t–217t

functional, 217t over ow, 216t secondary to medications, 217t stress, 216t urge, 216t

Urinary system in review of systems, 5 symptoms related to, 203–204

Urine, color of, 202 Urticaria, 104t U.S. Preventive Services Task Force

(USPSTF), 33 abdominal aortic aneurysm screening,

222 breast cancer screening, 189b cancer screening in older adults, 399 carotid artery screening cervical cancer screening, 250b colorectal cancer screening, 206b grade de nitions and implications for

practice, 37t hypertension screening, 170 levels of certainty, 38t low-dose computed tomography

screening, 146 osteoporosis screening, 282

442 Index

Uterus anteverted, 262t bicornuate, 394 myoma of, 262t palpation of, 255, 255f during pregnancy, 394 prolapsed, 263t retro exed, 262t retroverted, 256, 256f, 262t

V Vaccination. See also Immunizations

hepatitis A, 205b hepatitis B, 206b HPV, 235

Vaginal adenosis, 261t Vaginal discharge, 248, 260t, 369 Vagus nerve, 318b, 320 Validation, 43 Validity, test, 28–32 Valsalva maneuver, 180 Varicocele of spermatic cord, 245t Varicose veins (tongue), 141t Vasomotor rhinitis, 117 Venereal wart, 258t Venous insuf ciency, chronic, 228t, 229t Ventricular heart failure, left, 157t, 161t Ventricular septal defect, 376t Verbal support, 43 Vertigo, 117, 313 Vesicles, 102t Vibration sense, testing of, 325 Violence

domestic, 57 intimate partner, 57

Viral hepatitis, health promotion and counseling for, 205–206

Viral pneumonias, 159t Visceral pain (abdomen), 199 Visual Analog Scale, 70, 402 Visual eld defects, 132t Visual loss

central, 116 one-sided loss, 116 peripheral loss, 116 sudden, 116

Vital signs in infants, 356–357 in older adults, 408–410 in physical examination, 10,

64–69 recording ndings, 71b

Vitamin D, food sources of, 74t Vitiligo, 100t Vocabulary, patient, 85 Voice sounds, transmitted, 151b Voluminous diarrheas, 215t Vulva, lesions of, 258t–259t Vulvar carcinoma, 259t

W 6-minute walk test, 153 Warts, 105t Weakness, 59, 314

distal, 314 proximal, 314

Weber test, 125, 320 Weight

change in, 60 gain, 60 in infants, 355 loss, 60 measurement of, 63 older adults and, 410 optimal, 60, 61b during pregnancy, 390

Weight gain, during pregnancy, 386, 386b

Wernicke aphasia, 337t–338t Wheal, 104t Wheezes, 148, 151b Whiplash syndrome, 305t White coat hypertension, 64b Winging of scapula, 331, 331f World Health Organization, bone

density criteria, 282b Wrists, examination of, 288–290

X Xanthelasma, 134t