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S E I D E L ’ S G U I D E T O

PHYSICAL EXAMINATION A N I N T E R P R O F E S S I O N A L A P P R O A C H

JANE W. BALL, DrPH, RN, CPNP Trauma Systems Consultant American College of Surgeons Gaithersburg, Maryland

JOYCE E. DAINS, DrPH, JD, RN, FNP-BC, FNAP, FAANP

Professor and Director Advanced Practice Nursing

Department of Nursing The University of Texas MD Anderson Cancer

Center Houston, Texas

JOHN A. FLYNN, MD, MBA, MEd Clinical Director and Professor of Medicine Division of General Internal Medicine The Johns Hopkins University School of Medicine Baltimore, Maryland

9T H E D I T I O N

BARRY S. SOLOMON, MD, MPH Associate Professor of Pediatrics Assistant Dean for Student Affairs Division of General Pediatrics and Adolescent

Medicine The Johns Hopkins University School of Medicine Baltimore, Maryland

ROSALYN W. STEWART, MD, MS, MBA Associate Professor of Pediatrics and Medicine Departments of Pediatrics and Internal

Medicine The Johns Hopkins University School of Medicine Baltimore, Maryland

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Jane W. Ball, DrPH, RN, CPNP Jane W. Ball graduated from The Johns Hopkins Hospital School of Nursing and subsequently received her master’s and doctoral degrees in public health from The Johns Hopkins University Bloomberg School of Public Health. She began her nursing career as a pediatric nurse and pediatric nurse practitioner in The Johns Hopkins Hospital. Since completing her public health degrees, she has held many positions that enable her to focus on improving the healthcare system for children and adults, such as serving as the chief of Child Health for the Commonwealth of Pennsylvania Department of Health, Assistant Professor at the University of Texas at Arlington School of Nursing, and executive director of the Emergency Medical Services for Children National Resource Center based at Children’s National Medical Center in Washington, DC. As the center

director, she provided support to two federal programs: Emergency Medical Services for Children and the Trauma- Emergency Medical Services Systems Program. Dr. Ball serves as a consultant to the American College of Surgeons’ Committee on Trauma to help states improve their trauma care systems. She also serves as a consultant to Children’s National Medical Center supporting the development of a project to expand resources for the care of injured children. She is also the author of several pediatric nursing textbooks. Dr. Ball was recognized as a distinguished alumnus of The Johns Hopkins University in 2010.

Joyce E. Dains, DrPH, JD, RN, FNP-BC, FNAP, FAANP As a board-certified family nurse practitioner with doctorates in both public health and law, Joyce E. Dains has had a rich and productive career in education and clinical practice. She graduated as valedictorian from the New England Baptist Hospital School of Nursing in Boston and subsequently earned a baccalaureate degree in nursing from Boston College, graduating magna cum laude; a master’s degree in nursing from Case Western Reserve University; and a doctorate in public health from the University of Texas–Houston. She also completed a post-graduate nurse practitioner program at the Texas Woman’s University. She earned her law degree at the University of Houston and practiced law for a brief period. In addition to her current position, Dr. Dains has been in clinical practice, teaching, and leadership positions at major universities and medical institutions including the Ohio State University, the Uni- versity of Texas-Houston, the Texas Woman’s University,

and Baylor College of Medicine. She has been instrumental in the education of nursing students, nurse practitioners, medical students, and other healthcare professionals. As a family nurse prac- titioner, she has maintained a clinical practice in a variety of primary care settings. She is currently at the Uni- versity of Texas MD Anderson Cancer Center where she is Director for Advanced Practice Nursing, a family nurse practitioner in the Cancer Prevention Center, and chair, ad interim, for the Department of Nursing. Dr. Dains is a Fellow of the American Association of Nurse Practitioners and is the recipient of other distinguished honors, including election to the National Academies of Practice. Dr. Dains is also the author of Elsevier’s Advanced Health Assessment and Clinical Diagnosis in Primary Care.

John A. Flynn, MD, MBA, MEd John A. Flynn completed his undergraduate work at Boston College, graduating magna cum laude with a bachelor’s degree in mathematics. He attended medical school at the University of Missouri–Columbia where he was recognized in 2004 with the “Outstanding Young Alumni” award. Dr. Flynn completed his internship and residency at The Johns Hopkins University School of Medicine, followed by a fellowship in rheumatology, and was selected to serve as an assistant chief of service for the Longcope Firm of the Osler Medical Service. Dr. Flynn also completed a master’s degree in business administration at The Johns Hopkins University. Dr. Flynn is currently the Vice President of the

Office of Johns Hopkins Physicians, as well as the Associate Dean and Executive Director of the Clinical Practice Association. He holds the John A. Flynn Professorship in Medi- cine. Dr. Flynn also serves as the medical director of the spondyloarthri- tis program at The Johns Hopkins University and is the co-director of the Primary Care Consortium. He is a founding member of the Vivien T. Thomas College within The Johns Hopkins University School of Medicine Colleges Advisory Program. Dr. Flynn is a Fellow with the American

About the Authors

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College of Rheumatology and a Diplomat of the American Board of Rheumatology, as well as a Fellow to the American College of Physicians. Dr. Flynn holds memberships in the American College of Physicians, the American College of Rheumatology, the Spondyloarthritis Research and Treat- ment Network, and the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis. He has served as an

editor of Cutaneous Medicine: Cutaneous Manifestations of Systemic Disease and the first and second editions of the Oxford American Handbook of Clinical Medicine. Dr. Flynn’s clinical interest is arthritis and his research interests include ambulatory education, the delivery of ambulatory care in an academic setting, and the care of patients with spondyloarthritis.

Barry S. Solomon, MD, MPH Barry S. Solomon graduated from the University of Penn- sylvania School of Medicine and completed his residency at the Children’s Hospital of Pittsburgh. He subsequently completed a fellowship in general academic pediatrics at The Johns Hopkins University School of Medicine, during which time he received a master of public health degree from The Johns Hopkins University Bloomberg School of Public Health. Barry is currently an associate professor of pediatrics in the Division of General Pediatrics and Ado- lescent Medicine in the School of Medicine. His clinical work, research, teaching, and advocacy efforts relate to addressing the social and emotional needs of urban youth and caregivers through educational curricula, clinic-based interventions, and innovations in primary care delivery. For many years he worked closely with colleagues in the Women and Children’s Health Policy Center in the Bloom- berg School of Public Health on the Dyson Community Pediatrics Training Initiative National Evaluation, a longi- tudinal study assessing the impact of integrating community- based experiences and child advocacy skills into residency training. Dr. Solomon has a joint appointment in the Department of Health, Behavior and Society in the Bloom- berg School of Public Health, where he conducts research with faculty in the Center for Injury Research and Policy to prevent childhood injury. For the past 10 years, as medical

director of The Johns Hopkins Chil- dren’s Center Harriet Lane Clinic, Dr. Solomon has developed a nationally recognized and award-winning model for delivering family-centered care in an urban pediatric primary care setting. Many of the clinic’s patients and fami- lies experience significant social and financial challenges associated with living in poverty. In collaboration with hospital and community partners, sup- ported by philanthropic organizations, Dr. Solomon has brought an array of wrap-around services to the clinic. Programming includes an on-site safety resource center, mental health services for children and adolescents, a maternal mental health clinic, parenting groups, and a help desk to connect families with community resources (Health Leads©). Dr. Solomon is also an active clinical teacher and research mentor to medical students, residents, fellows, and junior faculty interested in addressing social determinants of health through primary care redesign. His academic career and personal mission have been centered on providing high-quality, family-centered primary care, while training new generations of health professioals to become advocates for vulnerable populations.

Rosalyn W. Stewart, MD, MS, MBA Rosalyn W. Stewart began her career at the University of Texas Medical Branch where she earned her medical degree and subsequently completed her combined internal medi- cine–pediatrics residency and a master of science degree in preventive medicine. She is currently an associate profes- sor in internal medicine and pediatrics at The Johns Hopkins University and is also a member of the faculty in the Bloomberg School of Public Health and The Johns Hopkins School of Nursing. She completed a master of business administration degree with an emphasis on health care. She practices both general internal medicine and general pediatrics. Her academic focus is on medical education, primary care, and health disparities. She holds many posi- tions centered on these interests and has been recognized for her ability to carry forth the Osler philosophy, discipline,

and practice of medicine. She is associ- ate director of the Longitudinal Ambulatory Clerkship, a clinical clerk- ship devoted to primary care and systems of health practice. She focuses her efforts on assembling a cadre of excellent teachers, training the very best students of medicine in continuity of patient care, and developing new curricula for the education of the best clinicians. Her goal is to create physician leaders who will serve as primary care systems–level change agents and will provide effective, longitudinal, comprehensive, coordinated, person-focused care for the underinsured inner-city patient.

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Susan M. Beidler, PhD, MBE, APRN, FAANP Department of Nursing Briar Cliff University Sioux City, Iowa

Craig S. Boisvert, DO Professor and Chair of Clinical Sciences West Virginia School of Osteopathic Medicine Lewisberg, West Virginia

Diane Bridge, EdS, RN, MSN School of Nursing Liberty University Lynchburg, Virginia

Amber B. Carriveau, DNP, FNP-BC MSN Program Bellin College Green Bay, Wisconsin

Laura H. Clayton, RN, PhD, CNE Department of Nursing Education Shepherd University Shepherdstown, West Virginia

Shirlee Cohen, MPH, ANP-BC, NPP, CCRN DNP Candidate College of Nursing University of New Mexico Albuquerque, New Mexico

Tonya A Collado, RN, MSN St. Elizabeth School of Nursing University of Saint Francis Lafayette, Indiana

Amy Culbertson, DNP, MSN, BSN, FNP Assistant Professor School of Nursing & Health Sciences Georgetown University Washington, District of Columbia

Pamela Darby, RN, MSN, ACNS-BC, FNP-C Clinical Instructor Department of Nursing Angelo State University San Angelo, Texas

Reviewers Dian Colette Davitt, RN, PhD Professor Emeritus Department of Nursing Webster University St. Louis, Missouri

Lucinda Drohn, RN, MSN School of Nursing Liberty University Lynchburg, Virginia

Jason Ferguson, BPA, AAS NREMT-Paramedic EMS Program Head Central Virginia Community College Lynchburg, Virginia

Renee Fife, MSN, CPNP Professor Emeritus College of Nursing Purdue University Northwest Hammond, Indiana

Sarah J. Flynn, MD, MPhil Darwin College University of Cambridge Cambridge, England

Rebecca A. Fountain, RN, PhD Assistant Professor College of Nursing and Health Sciences University of Texas at Tyler Tyler, Texas

Brian Garibaldi, MD Pulmonary and Critical Care Medicine Department of Medicine Johns Hopkins University Baltimore, Maryland

Deanna Hanisch, MA Office of Information Technology Johns Hopkins University Baltimore, Maryland

Alicia C. Henning, RN, BSN, SANE Member of American College of Forensic Examiners Member of International Association of Forensic Nurses Breckenridge Memorial Hospital Hardinsburg, Kentucky

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Nancy J. Kern, EdD, MSN, FNP-C, AGPCNP-C, APRN School of Nursing Spalding University Louisville, Kentucky

Pamela L King, PhD, MSN, FNP, PNP School of Nursing Spalding University Louisville, Kentucky

Carla Lynch, BSN, MS Clinical Assistant Professor of Nursing School of Nursing The University of Tulsa Tulsa, Oklahoma

Duane F. Napier, RN, MSN Captio Department of Nursing The University of Charleston Charleston, West Virginia

Grace M. Nteff, DNP, MS, BSN School of Nursing Clayton State University Morrow, Georgia

Elizabeth Oakley, DHSc, MSPT Department of Physical Therapy Andrews University Berrien Springs, Michigan

Natacha Pierre, DNP, FNP-BC Health Systems Sciences Department University of Illinois at Chicago College of Nursing Chicago, Illinois

Kristin Ramirez, RN, MSN, ACNS-BC Assistant Clinical Professor of Nursing Department of Nursing Angelo State University San Angelo, Texas

Anita K. Reed, RN, MSN Department Chair Adult and Community Health

Practice Remington, Indiana

Susan K. Rice, RN, PhD, CPNP, CNS Professor College of Nursing University of Toledo Toledo, Ohio

Susan D. Rymer, RN, MSN Assistant Professor School of Nursing Bellin College Green Bay, Wisconsin

Marlene Sefton, PhD, APRN, FNP-BC Clinical Assistant Professor College of Nursing, Department of Health System

Sciences University of Illinois at Chicago Chicago, Illinois

Pamella Stockel, RN, PhD, CNE Associate Professor of Nursing Loretto Heights School of Nursing Regis University Denver, Colorado

Ruthann Taylor, MS, CRNP, NP-C, AGPCNP-BC, GCNS- BC, OCN, CME

Passan School of Nursing Wilkes University Wilkes-Barre, Pennsylvania

Karen Vanbeek, MSN, CCNS Assistant Professor of Nursing School of Nursing Bellin College Green Bay, Wisconsin

Joy Turner Washburn, RN, EdD, WHNP-BC Kirkhof College of Nursing Grand Valley State University Allendale, Michigan

Lynn Wimett, EdD, MS, BSN Professor of Nursing Loretto Heights School of Nursing Regis University Denver, Colorado

John Zampella, MD Department of Dermatology New York University New York, New York

vii

Seidel’s Guide to Physical Examination: An Interprofessional Approach was a landmark text when first published, in part because of the interprofessional team of nurse practi- tioner and physician authors. The use of interprofessional authors has continued through all editions, and the current team of nurse practitioner and physician authors brings the strengths of their respective disciplines to help students of all health disciplines learn to conduct a patient-centered inter- view and perform a physical examination. This text is written primarily for students beginning their careers as a healthcare professional.

The core message of the book is that patients are our central focus and must be served well. Learning how to take a history and perform a physical examination is neces- sary, but does not provide a full understanding of your patients. The relationship with your patients and the development of trust most often begins with conversation. Patients will more comfortably share personal and sensitive information when you develop a rapport and build trust. Such a relationship helps you obtain reliable information enabling you to serve your patients well. You are, after all, learning the stories of individuals with unique experiences and cultural heritage, and our interaction with them involves far more than the sum of body parts and systems. The art and skills involved in history taking and the physical examination are common to all of us, regardless of our particular health profession.

Organization The achievement of a constructive relationship with a patient begins with your mastery of sound history taking and physical examination. Chapter 1 offers vital “getting to know you” guidelines to help you learn about the patient as the patient learns about you. Chapter 2 stresses that “knowing” is incomplete without the mutual understanding of cultural backgrounds and differences. Chapter 3 gives an overview of examination processes and the equipment you will need.

Chapter 4 assists with the process of analyzing the information collected during the history and physical examination, and using clinical reasoning to support deci- sion making and problem solving. Chapter 5 provides guidance on recording the information collected into the patient’s written or electronic health record with particular emphasis on the Problem Oriented Medical Record (POMR) and the use of SOAP (Subjective findings, Objective findings, Assessment, and Plan).

Chapters 6 through 8 introduce important elements of assessment: vital signs and pain; mental status; and growth, development, and nutrition. Chapters 9 through 23 discuss

Preface specific body systems and body parts, with each chapter divided into four major sections: • Anatomy and Physiology • Review of Related History • Examination and Findings • Abnormalities

Each of these sections begins with consideration of the adult patient and ends, when appropriate, with variations for infants, children, and adolescents; pregnant persons; older adults; and individuals with disabilities.

To help you get organized, each chapter starts with a preview of physical examination components discussed. The Anatomy and Physiology sections begin with the physiologic basis for the interpretation of findings, as well as the key anatomic landmarks to guide physical examina- tion. The Review of Related History sections detail a specific method of inquiry when a system or organ-related health issue is discovered during the interview or examination. The Examination and Findings sections list needed equip- ment and then describe in detail the procedures for the examination and the expected findings. These sections encourage you to develop an approach and sequence that is comfortable for you and, also for the patient. In some chapters advanced examination procedures are described for use in specific circumstances or when specific conditions exist. Sample documentation of findings conclude these sections. You will note that the terms “normal” and “abnor- mal” are avoided whenever possible to describe findings because, in our view, these terms suggest a value judgment that may or may not prove valid with experience and additional information. The Abnormalities sections provide an overview of diseases and associated problems relevant to the particular system or body part. The Abnormalities sections include tables clearly listing pathophysiology in one column and patient subjective and objective data in another column for selected conditions. Full-color photos and illustrations are often included.

Chapter 24 details the issues relevant to the sports participation evaluation. Chapter 25 provides guid- ance for integrating examination of all body systems into an organized sequence and process. Chapter 26 provides guidelines for the change in standard exami- nation approaches in emergency and life-threatening situations. This information is only a beginning and is intended to be useful in your clinical decision making. You will need to add other resources to your base of knowledge.

The appendices and companion Evolve website content provide clinical tools and resources to document observa- tions or problems and complete the physical examination, preserving a continuous record.

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Special Features

The basic structure of the book—with its consistent chapter organization and the inclusion of special considerations sections for infants, children, adolescents, pregnant persons, and older adults—facilitates learning. • Differential Diagnosis Tables—a hallmark of this text—

appear throughout the text. • Evidence-Based Practice in Physical Examination boxes

are reminders that our clinical assessment—as much as possible—should be supported by research.

• Risk Factors boxes highlight modifiable and nonmodifi- able risk factors for a variety of conditions.

• Functional Assessment boxes help students to consider specific physical problems and to evaluate their effect on patient function.

• Patient Safety boxes offer guidance about ways to promote patient safety during the physical examination or about patient education that supports safe practices at home.

• Sample Documentation boxes at the end of each Examina- tion and Findings section model good documentation practice.

New to This Edition The entire book has been thoroughly updated for this edition. This includes the replacement of illustrations of abnormal findings with updated photos and the use of new full-color photos and drawings to replace one- and two-color illustrations in the eighth edition. There are approximately 1200 illustrations in addition to the numerous tables and boxes that have traditionally given readers easy access to information. Among the many changes: • Evidence-Based Practice in Physical Examination boxes

have been thoroughly updated. These boxes focus on the ongoing need to incorporate recent research into clinical practice and decision making.

• Clinical Pearls boxes have been updated and revised. • The Abnormalities section is now in two columns to

better show the relationship between the summary of the pathophysiology and patient data, both subjec- tive and objective, associated with the condition or disorder.

• The Techniques and Equipment chapter includes updated recommendations for Standard Precautions.

• The Recording Information: Documentation chapter has been revised to add a focus on electronic health records and recording information electronically.

• The Growth, Measurement, and Nutrition chapter, integrates two separate chapters to better demonstrate the interdependence of nutrition, growth, and health.

• Updated cancer screening controversies and summary evidence are included in the abdomen, breast, and prostate chapters.

• Information about sensitive and respectful approaches to history taking and physical examination of lesbian,

gay, bisexual, and transgender patients has been inte- grated into several chapters.

• The emergency or life-threatening situations chapter has been updated.

• The sports participation chapter includes recommenda- tions for assessing and managing patients with sports- related concussions.

Our Ancillary Package Seidel’s Physical Examination Handbook is a concise, pocket- sized companion for clinical experiences. It summarizes, reinforces, and serves as a quick reference to the core content of the textbook.

Student Laboratory Manual for Seidel’s Guide to Physical Examination is a practical printed workbook that helps readers integrate the content of the textbook and ensure content mastery through a variety of engaging exercises.

Instructor Resources on the companion Evolve website (http:/evolve.elsevier.com/Seidel) include an extensive electronic image collection and a PowerPoint lecture slide collection that includes integrated animations, case studies, and a series of audience response questions. In addition, TEACH provides learning objectives, key terms, nursing curriculum standards, content highlights, teaching strate- gies, and case studies. Also available on the Evolve website are two thoroughly revised Test Banks, in ExamView® format, which faculty can use to create customized exams for medical, allied health, or nursing programs. Together these resources provide the complete building blocks needed for course preparation.

Student Resources on the companion Evolve website include a wide variety of activities, including audio clips of heart, lung, and abdominal sounds; video clips of selected examination procedures; animations depicting content and processes; 270 NCLEX-style review questions; and download- able student checklists and key points.

Also available is the thoroughly revised and expanded online course library titled Health Assessment Online, which is an exhaustive multimedia library of online resources, including animations, video clips, interactive exercises, quizzes, and much more. Comprehensive self-paced learning modules offer flexibility to faculty or students, with tutorial learning modules and in-depth capstone case studies for each body system chapter in the text. Available for individual student purchase or as a required course supplement, Health Assessment Online unlocks a rich online learning experience.

This edition is also available on Elsevier eBooks on VitalSource. Easy-to-use, interactive features let you make highlights, share notes, run instant searches, and much more. You can access your eBook online through Evolve or with apps for PC, Mac, iOS, Android, and Kindle Fire.

The existing physical examination video series com- prises 14 examination videos, each of which features an examination of a specific body system with animations and

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illustration overlays to demonstrate examination techniques in greater depth, and a fifteenth “Putting It All Together” video that shows a head-to-toe examination of an adult along with appropriate life span variations. The series includes three special topics: Effective Communication and Interviewing Skills, Physical Examination of the Hospitalized Patient, and Putting It All Together: Physical Examination of the Child. All 18 videos in this video series are offered in two formats: streaming (online) and networkable (for institutional purchase).

Our Core Values In the ninth edition of Seidel’s Guide to Physical Examination: An Interprofessional Approach, we have made every attempt to consider patients in all of their variety and to preserve the fundamental messages explicit in earlier editions. These include the following: • Respect the patient. • Achieve the complementary forces of competence and

compassion. • The art and skill essential to history taking and physical

examination are the foundation of care; technologic resources complement these processes.

• The history and physical examination are inseparable; they are one.

• The computer and technology compliments you. Your care and skills are what builds a trusting, fruitful relation- ship with the patient.

• That relationship can be indescribably rewarding. We hope that you will find this a useful text and that it will continue to serve as a resource as your career evolves.

Dedication We dedicate the ninth edition of this text to two original authors, Henry M. Seidel, MD, and William Benedict, MD, who served on seven and six editions, respectively. Both physicians had academic appointments at The Johns Hopkins University School of Medicine for decades and made important contributions to patient care and medical student education in their specialties of pediatrics and endocrinology/internal medicine, respectively.

As original authors they contributed greatly to the initial text design as well as to its ongoing development. Both Dr. Seidel and Dr. Benedict understood the importance of communication, sensitivity, compassion, and connection with patients. This text was one of the earliest collabora- tions of a physician and nurse author team, in this case to develop a text targeted to students of medicine, nursing, and other allied health professions. The ability of these physicians to mesh their visions with that of the nurse authors and to collaborate as an effective team allowed the authors to shape this text and share important values with students.

This text was renamed in Henry Seidel’s honor for the eighth edition as Seidel’s Guide to Physical Examination.

Acknowledgments The ninth edition of our textbook is possible only because of the professionalism and skills of so many others who really know how to fashion a book and its ancillaries so that it is maximally useful to you. First, there are those instructors and students who have so thoughtfully and constructively offered comment over the years. Improvements in content and style are often the results of their suggestions.

While the authors have provided the content, it must be accessible to the reader. A textbook needs a style that ensures readability, and our partners at Elsevier have made that happen. Lee Henderson, our Executive Content Strate- gist, provided oversight and guidance with the eye of an experienced editor along with strategies to meet the changing environment of print and electronic publishing. The whole textbook revision is a demanding project requiring effective teamwork. Courtney Sprehe, Jennifer Hermes, and Saman- tha Dalton, our Content Development Specialists, maintained professional skill and calm while obtaining chapter reviews, editing chapters, and moving the project forward. Heather Bays did a spectacular job of keeping everything moving with her qualitative eye for detail and design throughout. Brian Salisbury’s design is visually appealing and showcases the content.

We also want to recognize the indispensable efforts of the entire marketing team led by Becky Ramsaroop, as well as the sales representatives, who make certain that our message is honestly portrayed and that comments and suggestions from the field are candidly reported. Indeed, there are so very many men and women who are essential to the creation and potential success of our ninth edition, and we are indebted to each of them.

The remarkable teaching tools we call the ancillaries need special attention. These are the laboratory manual, handbook, TEACH, test banks, Health Assessment Online, and video series, all demanding an expertise—if they are to be useful—that goes beyond that of the authors. Frances Donovan Monahan offers hers for the laboratory manual. Joanna Cain offers hers for the Power Point slides, nursing test bank NCLEX review questions, student checklists, and key points; Jennifer Hermes offers hers for TEACH; and Frank Bregar offers his for the advanced practice test bank. The careful attention to all asset development is overseen by Jason Gonulsen. The development of Health Assessment Online is led by Frances Donovan Monahan; Chris Lay; Nancy Priff, Glenn Harman, and Paul Trumbore’s efforts are essential to the success of the video series.

And finally—our families! They are patient with our necessary absences, support what we do, and are unstinting in their love. They have our love and our quite special thanks.

Jane W. Ball, DrPH, RN, CPNP Joyce E. Dains, DrPH, JD, RN, FNP-BC, FNAP, FAANP

John A. Flynn, MD, MBA, MEd Barry S. Solomon, MD, MPH

Rosalyn W. Stewart, MD, MS, MBA

1

The History and Interviewing Process

CHAPTER

1  This chapter discusses the development of relationships with patients and the building of the histories or health- care narratives. We write of it as “building” a history rather than “taking” one because you and your patient are involved in a joint effort, a partnership, which should have, among other outcomes, a history that truly reflects the patient’s perspectives and unique status (Haidet, 2010; Haidet and Paterniti, 2003). The chapter discusses the context of the relationship in emotional, physical, and ethical terms and offers suggestions in verbal and nonverbal behavior that you may adapt to your individual comfort and style. Finally, we offer widely accepted, time-tested approaches to the structure of a history with adaptations suggested for age, children, adolescents, pregnant patients, older adults, and patients with disabilities. The history is vital to the appropriate interpretation of the physical examination.

Developing a Relationship With the Patient Our purpose is to offer instruction in learning about the well and the sick as they seek care. History and physical examination are at the heart of this effort. It is not easy to get the sense of another person or to fully appreciate someone else’s orientation in the world. You and the patient may seem to have a similar experience but may in all likelihood interpret it differently (see Clinical Pearl, “Unique,” Originally Derived From Latin “Unus,” Meaning “One”). On the other hand, you and your patient may come from very different backgrounds without any shared experi- ences. If you are to prevent misinterpretations and misper- ceptions, you must make every effort to sense the world of the individual patient as that patient senses it. (See Chapter 2 for additional discussion.)

The first meeting with the patient sets the tone for a successful partnership as you inform the patient that you really want to know all that is needed and that you will be open, flexible, and eager to deal with questions and explana- tions. You can also explain the boundaries of your practice and the degree of your availability in any situation. Trust evolves from honesty and candor.

A primary objective is to discover the details about a patient’s concern, explore expectations for the encounter, and display genuine interest, curiosity, and partnership. Identifying underlying worries, believing them, and trying to address them optimizes your ability to be of help. You need to understand what is expected of you. If successful, the unique and intimate nature of the interview and physical examination will be reinforced. You will savor frequent tender moments with patients when you recognize that your efforts are going well and that trust is there. We want to help ensure those moments occur.

CLINICAL PEARL

“Unique,” Originally Derived From Latin “Unus,” Meaning “One” We use “unique” in that sense of being the only one. Each of us is unique, incomparably different from anyone in the past, present, or future. No relationship, then, has an exact counterpart. Each moment is unique, different from the time before with the same patient.

From Merriam-Webster’s Learner’s Dictionary, 2016.

CLINICAL PEARL

The Patient Relationship You will, in the course of your career, have numerous relationships with patients. Never forget that each time they are having an experience with you, it is important to them.

Much has been written about technology replacing the history and physical examination in some part, but personal- ized care of patients goes far beyond the merely technical. Appropriate care satisfies a need that can be fully met only by a human touch, intimate conversation, and the “laying on of hands.” Personal interactions and physical examination play an integral role in developing a meaningful and therapeutic relationships with patients (Kugler and Verghese, 2010).

This actual realization of relationships with patients, particularly when illness compounds vulnerability, cannot be replaced (see Clinical Pearl, “The Patient Relationship”).

Because cost containment is also essential, the well- performed history and physical examination can justify the appropriate and cost-effective use of technological resources. This underscores the need for judgment and the use of resources in a balance appropriate for the individual patient.

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ss them. You have to be aware of your cultural beliefs, faith, and conscience so that they do not inappropriately intrude as you discuss with patients a variety of issues. That means knowing yourself (Curlin et al, 2007; Gold, 2010; see also Chapter 2).

You react differently to different people. Why? How? Do you want to be liked too much? Does thinking about how you are doing get in the way of your effort? Why does a patient make you angry? Is there some frustration in your life? Which of your prejudices may influence your response to a patient? Discuss and reflect on such questions with others you trust rather than make this a lonely, introspective effort. You will better control possible barriers to a successful outcome.

Effective Communication Establishing a positive patient relationship depends on communication built on courtesy, comfort, connection, and confirmation (Box 1.2).

Be courteous; ensure comfort, both physical and emo- tional; be sure that you have connected with the patient with trust and candor; and confirm that all that has happened during the interaction is clearly understood and your patient is able to articulate the agreed-on plan. That is communication.

Seeking Connection. Examine your habits and modify them when necessary so that you are not a barrier to effective communication. Stiff formality may inhibit the patient; a too-casual attitude may fail to instill confidence. Do not be careless with words—what you think is innocuous may seem vitally important to a patient who may be anxious and searching for meaning in everything you say. Consider intellectual and emotional constraints related to how you ask questions and offer information, how fast you talk, and how often you punctuate speech with “uh-huh” and “you know.” The interaction requires the active encouragement of patient participation with questions and responses addressed to social and emotional issues as much as the physical nature of health problems.

At the start, greet the patient. Welcome others and ask how they are connected to the patient. Begin by asking open-ended questions (“How have you been feeling since we last met?” “What are your expectations in coming here today?” “What would you like to discuss?” “What do you want to make sure we cover in today’s visit?”). Resist the urge to interrupt in the beginning. You will be amazed how many times a complete history is provided without prompting. Later, as information accumulates, you will need to be more specific. However, early on, it is entirely appropriate to check the patient’s agenda and concerns and let the information flow. It is important not to interrupt the patient at the start of the interview and to ask whether there is “anything else” a few times to be sure the patient’s primary concerns are identified early in the visit. Thus, you and the patient can collaboratively set the current visit’s agenda.

At a first meeting, you are in a position of strength and your patients are vulnerable. You may not have similar per- spectives but you need to understand the patient’s if you are to establish a meaningful partnership. This partnership has been conceptualized as patient-centered care, identified by the Institute of Medicine (IOM) as an important element of high-quality care. The IOM report defined patient-centered care as “respecting and responding to patients’ wants, needs and preferences, so that they can make choices in their care that best fit their individual circumstances” (IOM, 2001). Box 1.1 identifies questions that represent a patient-centered approach in building a history. Your own beliefs, attitudes, and values cannot be discarded, but you do have to discipline

BoX 1.1 Patient-Centered Questions

The following questions represent a patient-centered approach in building a history. • How would you like to be addressed? • How are you feeling today? • What would you like for us to do today? • What do you think is causing your symptoms? • What is your understanding of your diagnosis? Its importance? Its

need for management? • How do you feel about your illness? Frightened? Threatened?

Angry? As a wage earner? As a family member? (Be sure, however, to allow a response without putting words in the patient’s mouth.)

• Do you believe treatment will help? • How are you coping with your illness? Crying? Drinking more?

Tranquilizers? Talking more? Less? Changing lifestyles? • Do you want to know all the details about your diagnosis and its

effect on your future? • How important to you is “doing everything possible”? • How important to you is “quality of life”? • Have you prepared advance directives? • Do you have people you can talk with about your illness? Where

do you get your strength? • Is there anyone else we should contact about your illness or

hospitalization? Family members? Friends? Employer? Religious advisor? Attorney?

• Do you want or expect emotional support from the healthcare team?

• Are you troubled by financial questions about your medical care? Insurance coverage? Tests or treatment you may not be able to afford? Timing of payments required from you?

• If you have had previous hospitalizations, does it bother you to be seen by teams of physicians, nurses, and students on rounds?

• How private a person are you? • Are you concerned about the confidentiality of your medical records? • Would you prefer to talk to an older/younger, male/female healthcare

provider? • Are there medical matters you do not wish to have disclosed to

others? We suggest that use of these questions should be determined by

the particular situation. For example, talking about a living will might alarm a patient seeking a routine checkup but may relieve a patient hospitalized with a life-threatening disease. Cognitive impairment, anxiety, depression, fear, or related feelings as well as racial, gender, ethnic, or other differences should modify your approach.

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CHAPTER 1 The History and Interviewing Process 3

Confidentiality, which is important in all aspects of care, is another essential element. The patient should provide the information. It is important to identify everyone in the room to be sure the patient is comfortable and wants others to participate in the visit. You may want to ask the parent, spouse, or other person to step out of the room so you can have a confidential discussion with the patient. If language

Having clear and agreed-upon goals for each interaction leads to successful communication. You must be a skilled listener and observer with a polished sense of timing and a kind of repose that is at once alert and reassuring. Your nonverbal behavior complements your listening. Your face need not be a mask. You can be expressive and nod in agreement, but it is better to avoid the extremes of reaction (e.g., startle, surprise, or grimacing). Eye contact should be assured and comfortable, and your body language should show that you are really in the room, open to and engaged with the patient. You should be comfortably seated close to the patient and, if using an electronic medical record, so you and the patient can both visualize the screen. Do not stand and do not reach for the doorknob (see Clinical Pearl, “Professional Dress and Grooming”).

Remember that patients also communicate nonverbally, and understanding this is advantageous to both you and the patient (Henry et al, 2012).

BoX 1.2 Communication

Courtesy, Comfort, Connection, Confirmation Courtesy • Knock before entering a room. • Address, first, the patient formally (e.g., Miss, Ms., Mrs., Mr.) It is

all right to shake hands. • Meet and acknowledge others in the room and establish their roles

and degree of participation. • Learn their names. • Ensure confidentiality. • Be in the room, sitting, with no effort to reach too soon for the

doorknob. • If taking notes, take notes sparingly; note key words as reminders

but do not let note-taking distract from your observing and listening.

• If typing in the electronic medical record, type briefly and maintain eye contact with patient, if possible.

• Respect the need for modesty. • Allow the patient time to be dressed and comfortably settled after

the examination. Follow-up discussion with the patient still “on the table” is often discomfiting.

Comfort • Ensure physical comfort for all, including yourself. • Try to have a minimum of furniture separating you and the

patient. • Maintain privacy, using available curtains and shades. • Ensure a comfortable room temperature or provide a blanket—a

cold room will make a patient want to cover up. • Ensure good lighting. • Ensure necessary quiet. Turn off the television set. • Try not to overtire the patient. It is not always necessary to do it all

at one visit.

Connection • Look at the patient; maintain good eye contact if cultural practices

allow.

• Watch your language. Avoid professional jargon. Do not patronize with what you say.

• Do not dominate the discussion. Listen alertly. Let the patient order priorities if several issues are raised.

• Do not accept a previous diagnosis as a chief concern. Do not too readily follow a predetermined path.

• Find out whether the patient has turned from other healthcare providers to come to you.

• Take the history and conduct the physical examination before you look at previous studies or tests. Consider first what the patient has to say.

• Avoid leading or direct questions at first. Open-ended questions are better for starters. Let specifics evolve from these.

• Avoid being judgmental. • Respect silence. Pauses can be productive. • Be flexible. Rigidity limits the potential of an interview. • Assess the patient’s potential as a partner. • Seek clues to problems from the patient’s verbal behaviors and body

language (e.g., talking too fast or too little). • Look for the hidden concerns underlying chief concerns. • Never trivialize any finding or clue. • Problems can have multiple causes. Do not leap to one cause too

quickly. • Define any concern completely: Where? How severe? How long? In

what context? What soothes or aggravates the problem?

Confirmation • Ask the patient to summarize the discussion. There should be clear

understanding and uncertainty should be eased. • Allow the possibility of more discussion with another open-ended

question: “Anything else you want to bring up?” • If there is a question that you cannot immediately answer, say so.

Be sure to follow up later if at all possible. • If you seem to have made a mistake, make every effort to repair it.

Candor is important for development of a trusting partnership. Most patients respect it.

CLINICAL PEARL

Professional Dress and Grooming Appropriate dress and grooming go a long way toward establishing a first good impression with the patient. Although clean fingernails, modest clothing, and neat hair are imperative, you need not be formal to be neat. You can easily avoid extremes so that appearance does not become an obstacle in the patient’s response to care.

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ss When asking how often something happened, allow the patient to define “often,” rather than asking, “It didn’t happen too often, did it?” Sometimes the patient does not quite understand what

you are asking and says so. Recognize the need when it is appropriate to: • Facilitate—encourage your patient to say more, either

with your words or with a silence that the patient may break when given the opportunity for reflection.

• Reflect—repeat what you have heard to encourage more detail.

• Clarify—ask, “What do you mean?” • Empathize—show your understanding and acceptance.

Do not hesitate to say “I understand,” or “I’m sorry” if the moment calls for it.

• Confront—do not hesitate to discuss a patient’s disturbing behavior.

• Interpret—repeat what you have heard to confirm the patient’s meaning. What you ask is complemented by how you ask it. Take

the following actions, if necessary, to clarify the patient’s point of view: • Ask what the patient thinks and feels about an issue. • Make sure you know what the chief concern is. • Ask about the patient’s life situation, so that nothing

seemingly extraneous to the chief concern and present illness has gone unnoticed.

• Suggest at appropriate times that you have the “feeling” that the patient could say more or that things may not be as well as they are reported.

• Suggest at appropriate times that it is all right to be angry, sad, or nervous, and it is all right to talk about it.

• Make sure that the patient’s expectations in the visit are met and that there are no further questions. Make sure your questions are clearly understood. Define

words when necessary and choose them carefully. Avoid technical terms if possible. Adapt your language when necessary to the patient’s education level. Ask the patient to stop you if he or she does not understand what you are talking about. Similarly, do the same if you do not grasp the patient’s meaning. For example, a patient may report that he had “low blood” (anemia), “high blood” (hyperten- sion), “bad blood” (syphilis), and “thin blood” (he was taking anticoagulants). It can take a bit of exploring to sort it all out. Do not assume every question needs a complex and technical answer. Avoid medical jargon with all patients, even those who are in the healthcare field.

Moments of Tension: Potential Barriers to Communication

Curiosity About You. Patients will sometimes ask about you. Although you are not the point, you may be comfortable revealing some relevant aspects of your experience (“I have trouble remembering to take medicines too” or “I remember when my children had tantrums”). A direct answer will usually do. Often, simply informing your patients that you have experienced similar life events (e.g., illness, pregnancy,

is a barrier, a professional interpreter, rather than a family member, should be used (Fig. 1.1).

Gentle guidance and polite redirection are sometimes necessary to keep the visit focused and moving forward (e.g., “Now let’s also talk about …” or “I’m sorry to interrupt, but let me make sure I understand …”). Be prepared with questions you think are important to address based on the patient’s history and main concerns. If the patient touches on something that does not seem immediately relevant to your purposes (e.g., introducing a possible problem not previously mentioned), be flexible enough to clarify at least the nature of the concern. Some apparent irrelevancies may contain clues to the care-seeking behaviors or concerns that may be hidden beneath the primary concern and may greatly help in understanding the patient’s illness perspec- tive. The patient’s body language will also suggest the intensity of an underlying feeling. Although too many digressions can lead to misspent time, paying attention may save a lot of time later, and information learned may be important to the future plan of care.

Enhancing Patient Responses. Carefully phrased questions can lead to more accurate responses. Ask one question at a time, avoiding a barrage that discourages the patient from being complete or that limits answers to a simple yes or no: • The open-ended question gives the patient discretion

about the extent of an answer: “Tell me about …” “And then what happened?” “What are your feelings about this?” “What else do you need to talk about?”

• The direct question seeks specific information: “How long ago did that happen?” “Where does it hurt?” “Please put a finger where it hurts.” “How many pills did you take each time?” and “How many times a day did you take them?”

• The leading question is the most risky because it may limit the information provided to what the patient thinks you want to know: “It seems to me that this bothered you a lot. Is that true?” “That wasn’t very difficult to do, was it?” “That’s a horrible-tasting medicine, isn’t it?”

FIg. 1.1 Interviewing a patient with the help of an interpreter. Someone other than a family member should act as interpreter to bridge the language difference between the healthcare provider and the patient.

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CHAPTER 1 The History and Interviewing Process 5

Crying and Compassionate Moments. People will cry. Let the emotion proceed at the patient’s pace. Resume your questioning only when the patient is ready. If you suspect a patient is holding back, give permission. Offer a tissue or simply say, “It seems like you’re feeling sad. It’s OK to cry.” Name the emotion. Be direct about such a tender circumstance, but gently, not too aggressively or insistently. Do not hesitate to say that you feel for the patient, that you are sorry for something that happened, and that you know it was painful. At times, the touch of a hand or even a hug is in order. Sometimes, a concern—a difficult family relation- ship, for example—must be confronted. You may have to check an assumption and hope that you have guessed correctly in bringing the patient’s feelings to the surface. If uncertain, ask without presupposing what the response might be.

Physical and Emotional Intimacy. It is not easy to be intimate with the emotions and the bodies of others. Cultural norms and behaviors are at once protective of and barriers to trusting relationships. The patient is in a dependent status as well. You can acknowledge this while explaining clearly and without apology what you must do for the patient’s benefit. Of course, respect modesty, using covers appropriately without hampering a complete examination. Be careful about the ways in which you use words or frame questions. You cannot be sure of the degree to which a given patient has been “desensitized” to the issues of intimacy. However, respect for modesty carried too far, such as skipping examination of the genitals, can be a trap delaying or barring access to much needed information. You can keep the necessary from becoming too big an issue by being calm and asking questions with professional poise.

Seduction. Some patients can be excessively flattering and manipulative and even seductive. Their illness and insecurity beg for extra-special attention. Do not be taken in by this. There are limits to warmth and cordiality. Certainly not all touch is sexually motivated; a heartfelt hug is sometimes just right. Nevertheless, beware of that trap. Avert it courteously and firmly, delivering the immedi- ate message that the relationship is and will remain profes- sional. It takes skill to do this while maintaining the patient’s dignity, but there is no room for sexual misconduct in the relationship, and there can be no tolerance for exploitation of the patient in this regard.

Anger. Sometimes the angriest patients (or persons with them) are the ones who may need you the most. Of course, it can be intimidating. Confront it. It is all right to say, “It seems like you’re angry. Please tell me why. I want to hear.” Speak softly and try not to argue the point. You may not know if or why you made someone angry. Most often, you have done nothing wrong, and the patient’s emotion is unrelated to you or the visit. Still, the stress of time, heavy workload, and the tension of caring for the acutely—even terminally—ill can generate your own impatience and potential for anger. Avoid being defensive, but acknowledge the problem. Only when appropriate, apologize and ask

and childbirth) can help alleviate fears and, with further exploration, can help in the identification of the patient’s concerns. The message that you are a “real” person can lead to a trust-enhancing or even therapeutic exchange. At the same time, it is wise to exercise caution and remain professional in what and how much you disclose (Lussier and Richard, 2007).

Anxiety. Anxiety has multiple sources, such as an impending procedure or anticipated diagnosis. Some disorders will be more likely to cause an intense response, such as those associated with crushing chest pain or dif- ficulty in breathing; with other disorders, just seeing a healthcare professional can cause anxiety. You can help by avoiding an overload of information, pacing the conversation, and presenting a calm demeanor.

Silence. Sometimes intimidated by silence, many health- care providers feel the urge to break it. Be patient. Do not force the conversation. You may have to move the moment along with an open-ended question (“What seems to worry you?”) or a mild nudge (“And after that?”). Remember, though, that silence allows the patient a moment of reflection or time to summon courage. Some issues can be so painful and sensitive that silence becomes necessary and should be allowed. Most people will talk when they are ready. The patient’s demeanor, use of hands, possible teary eyes, and facial expressions will help you interpret the moment. Silence may also be cultural: for example, some cultural groups take their time, ponder their responses to questions, and answer when they feel ready. Do not push too hard. Be comfortable with silence but give it reasonable bounds.

Depression. Being sick or thinking that you are sick can be enough to provoke situational depression. Indeed, serious or chronic, unrelenting illness or taking certain prescription medications (e.g., steroids) is often accompanied by depression. A sense of sluggishness in the daily experi- ence; disturbances in sleeping, eating, and social contact; and feelings of loss of self-worth can be clues. In addition to screening for depression at ambulatory visits, pay atten- tion. First ask, “When did you start feeling this way?” Then ask, “How do you feel about it?” “Have you stopped enjoying the things you like to do?” “Do you have trouble sleeping?” “Have you had thoughts about hurting yourself?” “Are you depressed?” A patient in this circumstance cannot be hurried and certainly cannot be relieved by superficial assurance. You need not worry about introducing the idea of suicide (see Clinical Pearl, “Adolescent Suicide”). It has most often been considered, if only briefly (see Chapter 7, Risk Factors box, “Suicide”).

CLINICAL PEARL

Adolescent Suicide Suicide is a major cause of mortality in the preteen and teen years, more often in boys. If the thought of it occurs to you, you can be pretty sure that it has to the patient too. You can mention it and thus give permission to talk about it. You will not be suggesting anything new. You may actually help prevent it.

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one of your prime concerns. You can do this only by concentrating on the matter at hand, giving it for that moment primacy in your life and putting aside both personal and professional distractions.

Structure of the History You build the history to establish a relationship with the patient, so that you jointly discover the issues and problems that need attention and priority. A widely accepted approach is provided that can and should be modified to fit the individual circumstance: • First, the identifiers: name, date, time, age, gender

identity, race, source of information, and referral source • Chief concern (CC) • History of present illness or problem (HPI) • Past medical history (PMH) • Family history (FH) • Personal and social history (SH) • Review of systems (ROS)

The chief concern is a brief statement about why the patient is seeking care. Direct quotes are helpful. It is important, however, to go beyond the given reason and to probe for underlying concerns that cause the patient to seek care rather than just getting up and going to work. If the patient has a sore throat, why is help sought? Is it the pain and fever, or is it the concern caused by past experience with a relative who developed rheumatic heart disease? Many interviewers include the duration of the problem as part of the chief concern.

Understanding the present illness or problem requires a step-by-step evaluation of the circumstances that surround the primary reason for the patient’s visit. The full history goes beyond this to an exploration of the patient’s overall health before the chief concern, including past medical and surgical experiences. The spiritual, psychosocial, and cultural contexts of the patient’s life are essential to an understanding of these events. The patient’s family also

how to make things better. Explore the feelings. Often, you can continue on a better footing after anger is vented. On occasion, nothing will seem to help. It is then all right to defer to another time or even to suggest a different profes- sional (Thomas, 2003).

Afterward, do not hesitate to talk about the episode with a trusted colleague. It helps. Discussing the incident later may lend insight into behaviors and help prevent the occurrence again. Better ways of responding can be explored.

Avoiding the Full Story. Patients may not always tell the whole story or even the truth, either purposely or uncon- sciously. Dementia, illness, alcoholism, sexual uncertainties, intimate partner violence, and child abuse are among the reasons. Do not push too hard when you think this is happening. Allow the interview to go on and then come back to a topic with gentle questioning. You might say, “I think that you may be more concerned than you are saying” or “I think you’re worried about what we might find out.” Unless there is concern about the safety of the patient or another individual, learning all that is necessary may not come in one sitting. You may have to pursue the topic at a later visit or perhaps with other members of the family or friends or your professional associates.

Financial Considerations. The cost of care and the resulting drain on resources (and the potential impact on employment or insurance coverage) are often sources of stress for the patient. Talk about them with candor and accurate knowledge. Provide resources (social worker or financial counselor). Otherwise, an appropriate care plan acceptable to the patient cannot be devised or implemented. Pressing circumstances and obligations may still present barriers to appropriate care.

The Patient History A first objective in building the history is to identify those matters the patient defines as problems, the subtle as well as the obvious. You need to establish a sense of the patient’s reliability as an interpreter of events. Consider the potential for intentional or unintentional suppression or underreport- ing of certain experiences that may give context to a problem that is at odds with your expectation. Constantly evaluate the patient’s words and behavior. The history is built on the patient’s perspective, not yours. Make modifications as required for the patient’s age and his or her physical and emotional disabilities.

Setting for the Interview Regardless of the setting, make everyone as comfortable as possible. Position yourself so that there are no bulky desks, tables, computer screens, or other electronic equip- ment between you and the patient (Fig. 1.2). If possible, have a clock placed where you can see it without obviously looking at your watch (preferably behind the patient’s chair). Sit comfortably and at ease, maintaining eye contact and a conversational tone of voice. Your manner can assure the patient that you care and that relieving worry or pain is

FIg. 1.2 Interviewing a young adult. Note the absence of an intervening desk or table.

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CHAPTER 1 The History and Interviewing Process 7

walk a fine line between permitting this leisure and meeting the many time constraints you are sure to have. Fix your attention on the patient, avoid interrupting as much as possible, and do not ask the next question before you have heard the complete answer to the prior one.

The patient’s responses may at times be unclear. Seek certainty: • “Of what you’ve told me, what concerns you the most?” • “What do you want to make sure we pay attention to

today?” • “Do you have any ideas about what we ought to do?” • Or a leading question sometimes, “I think _________

worries you the most. Am I right? Shall we talk about that first?” As the interview proceeds, thoroughly explore each

positive response with the following questions: • Where? Where are symptoms located, as precisely as

possible? If they seem to move, what is the range of their movement? Where is the patient when the complaint occurs—at work or play, active or resting?

• When? Everything happens in a chronologic sequence. When did it begin? Does it come and go? If so, how often and for how long? What time of day? What day of the week?

• What? What does it mean to the patient? What is its impact? What does it feel like? What is its quality and intensity? Has it been bad enough to interrupt the flow of the patient’s life, or has it been dealt with rather casually? What else happened during this time that might be related? What makes it feel better? Worse?

• How? The background of the symptom becomes impor- tant in answering the “how” question. How did it come about? Are other things going on at the same time, such as work, play, mealtime, or sleep? Is there illness in the family? Have there been similar episodes in the past? If so, how was it treated or did it resolve without treat- ment? Is there concern about similar symptoms in friends or relatives? Are there spouse complaints or concerns? How is the patient coping? Are there social supports? Nothing ever happens in isolation.

• Why? Of course, the answer to “why” is the solution to the problem. All other questions lead to this one. Once you have understood the patient’s chief concern

and present problem and you have a sense of underlying issues, you may go on to other segments of the history: the family and past medical histories; emotional, spiritual, and cultural concerns; and social and workplace accompani- ments to the present concerns. Remember that nothing in the patient’s experience is isolated. Aspects of the present illness or problem require careful integration with the medical and family history. The life of the patient is not constructed according to your outline, with many factors giving shape to the present illness and with any one chief concern possibly involving more than one illness.

A visit should conclude with a review: • Ask the patient to try to satisfy gaps in your

understanding.

requires attention—their health, past medical history, ill- nesses, deaths, and the genetic, social, and environmental influences. One question should underlie all of your inquiry: Why is this happening to this particular patient at this particular time? In other words, if many people are exposed to a potential problem and only some of them become ill after the exposure, what are the unique factors in this individual that led to that outcome? Careful inquiry about the personal and social experiences of the patient should include work habits and the variety of relationships in the family, school, and workplace. Finally, the ROS includes a detailed inquiry of possible concerns in each of the body’s systems, looking for complementary or seemingly unrelated symptoms that may not have surfaced during the rest of the history. Flexibility, the appreciation of subtlety, and the opportunity for the patient to ask questions and to explore feelings are explicit needs in the process.

Building the History Introduce yourself to the patient and accompanying persons if you have not already met, clearly stating your name and your role. If you are a student, say so. Be certain that you know the patient’s full name and that you pronounce it correctly. Ask if you are not certain.

Address the patient properly (e.g., as Mr., Miss, Mrs., Ms., or the manner of address preferred by the patient) and repeat the patient’s name at appropriate times. Avoid the familiarity of using a first name when you do not expect familiarity in return. Do not use a surrogate term for a person’s name; for example, when the patient is a child, do not address the parent as “Mother” or “Father.” It is respectful and courteous to take the time to learn each name.

It is respectful, too, to look at the patient and not at the electronic device that is usually close at hand. Use it if you must, but position it so that it does not distract from the patient. More and more the electronic device in the examination room is being introduced into the patient- provider dynamic for documentation as well as educational purposes (e.g., demonstrating the findings on an imaging study, showing the trend of a laboratory result over time, or reviewing a website together). Unless you already know the patient and know that there is urgency, proceed at a reasonable pace, asking for the reason for the visit with the intent of learning what their specific expectations of the visit are. Listen, and do not be too directive. You will often be surprised at how much of the story and details you will hear without pushing. Let the patient share his or her full story and reasons for seeking care. If 100 people wake up with a bad headache, and 97 go to work but 3 seek care, what underlying dimension prompted those decisions?

You have by then begun to give structure to the present illness or problem, giving it a chronologic and sequential framework. Unless there is urgency, go slowly, hear the full story, and refrain from striking out too quickly on what seems the obvious course of questioning. The patient will take cues from you on the leisure you will allow. You must

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Alcohol. The CAGE questionnaire is one model for discuss- ing the use of alcohol (Box 1.3). CAGE is an acronym for Cutting down, Annoyance by criticism, Guilty feeling, Eye-openers. Its use does not ensure absolute sensitivity in the detection of a problem. It can be complemented or supplemented by the TACE model (Box 1.4), particularly in the identification of alcoholism in a pregnant patient (because of the potential for damage to the fetus), or by CRAFFT, for identification of an alcohol problem in ado- lescents (Box 1.5). There is similarity in all of these question- naires. You can adapt them to your style and to the particular patient. You can also adapt them to concerns about drugs or substances other than alcohol (see Clinical Pearl, “Screening”).

• Ask for questions. • Interpret and summarize what you have heard. • Ask the patient to summarize for you to ensure complete

understanding. • Repeat instructions and ask to hear them back. • Explain the next steps: needed examinations and/or

studies, appointment times, keeping in touch.

Sensitive Issues Sensitive issues, which may be difficult to discuss (e.g., sex, drug or alcohol use, concerns about death) are important to address. The following guidelines, keys to any successful interview, are essential in an approach to sensitive issues. • Provide privacy. • Do not waffle. Be direct and firm. Avoid asking leading

questions. • Do not apologize for asking a question. • Do not preach. Avoid confrontation. You are not there

to pass judgment. • Use language that is understandable to the patient, yet

not patronizing (see Clinical Pearl, “Watch the Use of Jargon”).

• Do not push too hard. Afterward, document carefully, using the patient’s words (and those of others with the patient) whenever possible. It is all right to take notes, but try to do this sparingly, especially when discussing sensitive issues.

CLINICAL PEARL

Watch the Use of Jargon Unfortunately, many of us may too often lapse into the use of jargon, the language of our profession that is not accessible to the patient. Patient-demeaning words are worse. Stress, frustration, fatigue, and anger are common underlying causes for these lapses. Know yourself. Understand why you might fall into the habit, and do your best to avoid it.

BoX 1.3 CAGE Questionnaire

The CAGE questionnaire was developed in 1984 by Dr. John Ewing, and it includes four interview questions designed to help screen for alcoholism.

The CAGE acronym helps practitioners quickly recall the main concepts of the four questions (Cutting down, Annoyance by criticism, Guilty feeling, Eye-openers).

Probing questions may be asked as follow-up questions to the CAGE questionnaire.

Many online resources list the complete questionnaire (e.g., http:// addictionsandrecovery.org/addiction-self-test.htm). The exact wording of the CAGE Questionnaire can be found in O’Brien CP. The CAGE Questionnaire for Detection of Alcoholism. JAMA. 300:2054–2056, 2008.

From Sokol et al, 1989.

BoX 1.4 TACE Model

The following questions are included in the TACE model: T How many drinks does it Take to make you feel high? How many

when you first started drinking? When was that? What do you prefer: beer, wine, or liquor? (More than two drinks suggests a tolerance to alcohol that is a red flag.)

A Have people Annoyed you by criticizing your drinking? C Have you felt you ought to Cut down on your drinking? E Have you ever had an Eye-opener drink first thing in the morning

to steady your nerves or get rid of a hangover? An answer to T alone (more than two drinks) or a positive response

to two of A, C, or E may signal a problem with a high degree of probability. Positive answers to all four signal a problem with great certainty.

CLINICAL PEARL

Screening There is a difference between a screening and an assessment interview. The goal of screening is to find out if a problem exists. This is particularly true of CAGE, CRAFFT, and TACE screening tools. They are effective, but they are only the start, and assessment goes on from there. Discover- ing a problem early may lead to a better treatment outcome.

You must always be ready to explain again why you examine sensitive areas. A successful approach will have incorporated four steps: 1. An introduction, the moment when you bring up the

issue, alluding to the need to understand its context in the patient’s life.

2. Open-ended questions that first explore the patient’s feelings about the issue—whether, for example, it is alcohol, drugs, sex, cigarettes, education, or problems at home—and then the direct exploration of what is actually happening.

3. A period in which you thoughtfully attend to what the patient is saying and then repeat the patient’s words or offer other forms of feedback. This permits the patient to agree that your interpretation is appropriate, thus confirming what you have heard.

4. Finally, an opportunity for the patient to ask any questions that might be relevant.

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CHAPTER 1 The History and Interviewing Process 9

These cover two dimensions of partner violence, and a positive response to any one of them constitutes a positive screen. The first question addresses physical violence. The latter two questions evaluate the woman’s perception of safety and estimate her short-term risk of further violence and need for counseling.

Additionally, you may see something suggestive on physical examination and ask the following: “The bruises I see. How did you get them?”

Positive answers require accurate documentation, using words, drawings, and, if possible, photographs and the pres- ervation of any tangible evidence. Positive answers require that the patient’s safety be ensured. Ask the following: • Are you afraid to go home? • Are there guns or knives at home? • Is alcohol (or other drugs) part of the problem? • Has it gotten worse lately? • Are children involved?

A “yes” answer mandates an intervention that requires utilization of other healthcare professionals such as social workers and mental health providers who may be able to provide more in-depth assessment and linkage to resources. Get the patient’s viewpoint. Let her speak; assure her that she is not alone and that you will do your best to help her.

A “no” answer may still leave you uncomfortable. Get permission from the patient to document your concern and your suspicion of injury. Be unafraid to ask direct questions about your suspicion (“Where did that bruise come from?”). Ask her to come back to see you again.

Intimate Partner Violence. We too often underestimate the incidence of intimate partner violence (IPV) in the experience of our patients of any age or gender identity. IPV includes a range of abusive behaviors perpetrated by someone who is or was involved in an intimate relationship with the victim. It affects primarily women, children, and dependent older adults as victims and, in lesser frequency, men. Intimate partners are usually the perpetrators. Same- sex partners probably have the same prevalence, although underreporting may be more of a problem in this population. Alcohol is a common facilitator. Children exposed to IPV are at increased risk for social and emotional problems. There is significant overlap between IPV and child abuse, so when IPV is detected, child abuse should be considered.

Reluctance to screen for fear of offending patients and families is a misplaced concern. This is occasionally compounded by an inappropriate response to an abused woman, such as making too little of her experience or even laying the blame on her. She is, then, twice a victim. The “she” is used advisably. Although IPV affects both men and women as victims and perpetrators, more women experience IPV (Nelson et al, 2012), and transgendered women are at higher risk of physical and psychological IPV than are cisgender adults (Pitts et al, 2006). Likewise, lesbian, gay, bisexual, and transgender (LGBT) youth are at high risk for being victims of IPV (Whitton et al, 2016). Relatively few will discuss IPV willingly with a healthcare provider, and, in that event, the patient is almost always the initiator of the discussion. If a healthcare provider makes the initial inquiry, it is usually asked in an emergency department of a person who may have difficulty getting out of an abusive relationship, a minority woman, or one who is obviously vulnerable. All female patients should be routinely screened in all healthcare settings (Moyer and U.S. Preventive Services Task Force, 2013); however, we recommend all indiviuals be screened. A validated brief Partner Violence Screen (PVS) uses three questions to detect partner violence (MacMillan et al, 2006): 1. Have you been hit, kicked, punched, or otherwise hurt

by someone within the past year? 2. Do you feel safe in your current relationship? 3. Is there a partner from a previous relationship who is

making you feel unsafe now?

BoX 1.5 CRAFFT Questionnaire

The CRAFFT questionnaire was developed in 2002 as a screening tool for alcohol and substance abuse in adolescents.

The CRAFFT acronym helps practitioners remember the main concepts of the six questions: Car, Relax, Alone, Forget, Friends, Trouble.

The exact wording of the CRAFFT questions can be found here: Knight JR et al. Validity of the CRAFFT Substance Abuse Screening Test Among Adolescent Clinic Patients. Arch Pediatr Adolesc Med 156:607-614, 2002 (available online at http://archpedi.jamanetwork. com/article.aspx?articleid=203511).

Evidence-Based Practice in Physical Examination

Screening for Abuse and Intimate Partner Violence Data from a systematic review indicate that screening practices by healthcare professionals are inconsistent for several reasons, including the existence of a variety of screening instruments, a lack of consensus on which instrument to use, lack of specificity of risk factors, lack of training, lack of effectiveness studies about what to do if violence is identified, discomfort with screening, and time constraints. Several instruments have been developed for intimate partner violence screening, and their diagnostic accuracy has been evaluated in studies of different populations using various reference standards. Six instruments with one to eight items demonstrated sensitivity and specificity greater than 80% in clinical populations of asymptomatic women; results varied between studies and across instruments. The Feldhaus PVS three-item screening instrument had a higher sensitivity and specificity compared with two longer instruments. The HITS (Hurt-Insult-Threaten-Scream) four-item screening instrument for abuse (Box 1.6) demonstrated 86% sensitivity and 99% specificity (English version) and 100% percent sensitivity and 86% specificity (Spanish version).

Studies to develop and evaluate tools are generally lacking to assess screening older and vulnerable adults for abuse. Existing instruments to detect child abuse are not designed for direct administra- tion to the child, missing opportunities to screen older children in the context of usual health care.

Data from Nelson et al, 2004, and Kliegman et al, 2016.

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ss Spirituality. The basic condition that life imposes is death. It often stirs in us a spiritual or “sacred” feeling—always with us, frequently sublimated, sometimes not. Illness, however mild, may stir that feeling and may carry with it a sense of dread. Faith may be an intimate contributor to one’s perspective. An understanding of “spirituality” is, then, integral to the care we offer, but it is complicated by the fact that there is no universally agreed-on definition; each of us brings our own understanding to the care provided.

Many patients want attention paid to spirituality, and faith can be a key factor in the success of a management plan. Others may prefer that you not broach the subject. This requires the same degree of sensitivity and caution as talking about drugs, cigarettes, sex, and alcohol. The questions suggested by Puchalski and Romer (2000) with the acronym FICA and adapted by us suggest an approach: • Faith, Belief, Meaning

• What is your spiritual or religious heritage? Is the Bible, the Quran, or similar writings important to you?

• Do these beliefs help you cope with stress? • Importance and Influence

• How have these beliefs influenced how you handle stress? To what extent?

• Community • Do you belong to a formal spiritual or religious com-

munity? Does this community support you? In what way? Is there anyone there with whom you would like to talk?

• Address/Action in Care • How do your religious beliefs affect your healthcare

decisions (e.g., choice of birth control)? How would you like me to support you in this regard when your health is involved?

Answers to these questions may guide you to involve the clergy or other spiritual care providers or to become more deeply involved. There is some evidence that prayer can aid in healing. You may, if you are asked and are inclined, pray with a patient, although it is best that you not lead the prayer. You may even suggest it if the patient is sorely troubled and you understand the need. There are, however, boundaries. Except for very few of us, we are not theologians, and it is inappropriate to go beyond the limits of our professional expertise.

Auster (2004) suggests sensitivity on our part when patients ask about our personal beliefs and express their wish to talk of this only with someone of their own faith. You might say, “I want to help you as best I can, so please tell me why you ask about my faith” or, more directly, “I understand your feeling. Would it help if I found another person for you?” Let your sense of the situation guide you (Fosarelli, 2003; Puchalski and Romer, 2000).

Sexuality and Gender Identity Patients should be told that discussion is routine and confidential. Questions about the patient’s sexual history

The same approach works for men, but it is not neces- sarily used routinely. His statements or a suspicious injury may trigger your action. Infants and children have the protection of the legal mandate for you to report your suspicions. Questioning a child about abuse suffered or witnessed at home can be problematic because you want to avoid suggestion. In general, open-ended questions are comfortably asked of the young or of a parent in their presence: • Why did you come to see me today? (Do not mention

the concern directly.) • Tell me everything that happened to you, please. (No

leading questions.) • With infants, a bruise or burn with an odd shape or

unexpected location is very concerning for child abuse. It is difficult for an infant who is not yet crawling or toddling to break a femur or to have finger print–size bruises on the arms, for example.

• Adolescents may endure violence, particularly sexual, at home or away. The clue may be changes in behavior, such as dress and makeup, school effort, sleeping, and eating. Routinely screen adolescents for partner violence. Alcohol or drug use can become an issue. Former friends may be avoided. Most important, take your time and ask the following questions: • Have you ever had sexual intercourse? • When did you start? • Did you want to, or were you forced or talked

into it? • Do the people you are with ever scare you? • Did anyone ever touch you in a sexual way? Always be available for more conversation. The questions

are just a start. Note, too, that the young may also witness as well as endure violence at home, with a profound effect on their lives and behavior. These problems should be dealt with as if the patient were the direct victim.

The risk of abuse of older adults, often underreported, is greater if the older adult has had a history of mental illness, is physically or cognitively impaired, or is living in a dependent situation with inadequate financial resources. The abusers may have similar risks, perhaps alcohol or drug related. Both groups may well have a past history of domestic violence. In any event, confront the issue with an approach modeled on that for women in difficulty.

BoX 1.6 Brief Screening Tool for Domestic Violence: HITS

Verbal abuse is as intense a problem as physical violence. HITS stands for Hurt, Insult, Threaten, or Scream. The wording of the question is, “In the past year, how often did your partner: Hurt you physically?” Insult or talk down to you?” Threaten you with physical harm?” Scream or curse at you?”

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CHAPTER 1 The History and Interviewing Process 11

Chief Concern or the Reason for Seeking Care. This answers the question, “Why are you here?” (see Clinical Pearl, “Chief Complaint or Chief Concern?”). Follow-up questions ask about duration (e.g., “How long has this been going on?” or “When did these symptoms begin?”). The patient’s age, gender, marital status, previous hospital admissions, and occupation should be noted for the record. Other concerns may surface. A seemingly secondary issue may have greater significance than the original concern because the driving force for the chief concern may be found in it. What really made the patient seek care? Was it a possibly unexpressed fear or concern? Each hint of a care-seeking reason should be thoroughly explored (Box 1.7).

may first be indirect, addressing feelings rather than facts. “Are you satisfied with your sexual life, or do you have worries or concerns? Many people do.” Although this is a leading question, it does not suggest what the patient’s feelings should be. Rather, if there are concerns about sex, it may be comforting to know that one is not alone. The age of the patient should not deter discussion. Do not assume more or less for a given age, particularly older adults.

It is also important to ask questions about a patient’s sexual orientation and gender.

Identity. You should directly ask about patient’s prefer- ences. In general, patients support healthcare providers asking questions related to sexual orientation and gender identity and understand the importance of healthcare providers’ knowing their patients’ preferences (Cahill et al., 2014).

The sexual orientation of a patient must be known if appropriate continuity of care is to be offered. About 10% of the persons you serve are likely to be other than hetero- sexual (i.e., gay, lesbian, bisexual, or transgendered) (Makadon, 2011; Ward et al., 2014). Working with sexual minority individuals demands knowing yourself regarding any potential feelings about heterosexism and homophobia that you may have. The apprehension these patients may feel in revealing their preferences should be respected. Reassuring, nonjudgmental words help: “I’m glad you trust me. Thank you for telling me.” It is also supportive if the healthcare setting offers some recognition of the patients involved (e.g., by making relevant informational pamphlets available in waiting areas). • Trust can be better achieved if questions are “gender

neutral”: • Tell me about your living situation. • Are you sexually active? • In what way?

• Rather than: • Are you married? • Do you have a boyfriend/girlfriend?

If you use a nonjudgmental approach, a variety of questions applicable to any patient and any sexual circumstance becomes possible. The patient’s vernacular may be necessary. Once the barrier is broken, you can be more direct, asking, for example, about frequency of sexual intercourse, problems in achieving orgasm, variety and numbers of “partners” (a non–gender-linked term), masturbation, and particular likes and dislikes. Identifying risk factors for unintentional pregnancy and sexually transmitted infections (STIs) are an important part of the sexual history.

Outline of the History The outline offered is a guide derived over time from multiple sources, formal and informal. It is not rigid, and you can decide what meets the needs of your patient and your style. Take advantage of patient’s photographs and videos that complement what you learn in the history.

BoX 1.7 The Basis of Understanding

The following are vital questions that probe the unique experience of each patient: Why is this happening in the life of this particular person at this time? How is this patient different from all other patients? Can I assume that what is generally true for others is necessarily true

for this patient? How does this bear on my ultimate interpretation of possible problems

and solutions?

CLINICAL PEARL

Chief Complaint or Chief Concern? Many of us do not view patients as “complainers” and prefer to express the “chief complaint” differently, adopting “chief concern,” “presenting problem,” or “reason for seeking care” as a more appropriate term. Feel free to use the words that suit you best or are most appropriate in your healthcare setting.

History of Present Illness or Problem. You will often find that it is easiest to question the patient on the details of the current problem immediately after hearing the chief concern. Sometimes it may be of value to take the patient’s past and family history before returning to the present. The specific order in which you obtain the patient’s story is not critical. You want the patient’s version without the use of leading questions. Box 1.8 suggests many of the variables that can influence the patient’s version.

A complete HPI will include the following: • Chronologic ordering of events • State of health just before the onset of the present

problem • Complete description of the first symptoms. The question

“When did you last feel well?” may help define the time of onset and provide a date on which it might have been necessary to stop work or school, miss a planned event, or be confined to bed.

• Symptom analysis: Questions in the following categories assist the patient in specifying characteristics of the presenting symptom(s): location, duration, intensity,

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ss corrections (If there appears to be more than one problem, the process should be repeated for each one.)

Past Medical History. The past medical history is the baseline for assessing the present concern. • General health and strength • Gender identity: male, female, transmale, transfemale,

nonbinary; preferred pronoun; hormones and/or gender- affirming surgeries

• Childhood illnesses: measles, mumps, whooping cough, chickenpox, scarlet fever, acute rheumatic fever, diph- theria, poliomyelitis, asthma

• Major adult illnesses or chronic diseases: tuberculosis, hepatitis, diabetes, hypertension, myocardial infarction, heart disease, stroke, respiratory disease, tropical or parasitic diseases, other infections; any nonsurgical hospital admissions

• Immunizations: polio; diphtheria, pertussis, and tetanus toxoid; influenza; hepatitis A; hepatitis B; rotavirus, measles, mumps, rubella; varicella; herpes zoster vaccine; pneumococcus; meningococcus; human papillomavirus; bacille Calmette-Guérin; last tuberculosis or other skin tests; unusual reactions of any sort to immunizations or travel-related immunizations [e.g., typhoid, yellow fever]

• Surgery: dates, hospital, diagnosis/indication, complica- tions; gender-affirming surgeries

• Serious injuries and resulting disability; obtain complete details if present problem has potential medicolegal relation to an injury

• Limitation of ability to function as a result of past events • Medications: past, current, and recent medications,

including dosage of prescription and home remedies and nonprescription medications (when not mentioned in present problem); gender identity hormone use

• Allergies and the nature of reactions, especially to medications, but also to environmental allergens and foods

• Transfusions: reactions and the nature of reactions, date, and number of units transfused

• Recent screening tests (e.g., cholesterol, Pap smear, colonoscopy, mammogram)

• Emotional status: mood disorders, psychiatric problems

description/character, aggravating factors, alleviating factors.

• Description of a typical attack, including its persistence. If the present problem involves intermittent attacks separated by an illness-free interval, ask the patient to describe a typical attack (e.g., onset, duration, variation in intensity and associated symptoms, such as pain, chills, fever, jaundice, hematuria, or seizures) and any variations. Then ask the patient to define inciting, exacerbating, or relieving factors such as specific activi- ties, positions, diet, or medications.

• Possible exposure to infection, toxic agents, or other environmental hazards

• Impact of the illness on the patient’s usual lifestyle (e.g., sexual experience, leisure activity, ability to perform tasks or cope with stress), an assessment of the ability to function in the expected way with an indication of the limitations imposed by illness

• Immediate reason that prompted the patient to seek care, particularly if the problem has been long-standing

• Appropriate relevant system review • Medications: current and recent, including dosage of

prescription, home remedies, and nonprescription medications

• Use of complementary or alternative therapies and medications

• A review, at the end of the interview, of the chronology of events, seeking the patient’s confirmations and

BoX 1.8 Factors That Affect the Patient’s Expression of Illness

Disease is a real condition that prevents the body or mind from working normally (Merriam-Webster.com). Illness is the unique way in which a disease is expressed by the afflicted individual. An infinite number of variables come into play and may even cause illness without disease: • Recent termination of a significant relationship because of death,

divorce, or other stressors such as moving to a new city • Physical or emotional illness or disability in family members or

other significant individuals • Inharmonious spousal or family relationships • School problems and stresses • Poor self-image • Drug and alcohol misuse • Poor understanding of the facts of a physical problem and its

treatment • Influence from social media • Peer pressure (among adults as well as adolescents and

children) • Secondary gains from the complaints of symptoms (e.g., indulgent

family response to complaints, providing extra comforts or gifts, solicitous attention from others, distraction from other intimidating problems) At any age, such circumstances can contribute to the intensity

and persistence of symptoms or, quite the opposite, the denial of an insistent, objective complaint. The patient may then be led to seek help or, at other times, to avoid it.

Evidence-Based Practice in Physical Examination

History Taking There is evidence that the risk for type 2 diabetes or cardiovascular disease is detectable in childhood and that the diseases share risk factors, including obesity and dyslipidemia. Other studies suggest that these risks can be reduced in childhood. The pathway to detecting risk is the family history. Adults with one or more second-degree relatives with diabetes or cardiovascular disease are at high risk. So, too, are children with similar histories. The family history provides insight into the genetic effects on health and disease and offers clues that can lead to prevention strategies.

From Yang et al, 2010.

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CHAPTER 1 The History and Interviewing Process 13

cigarette use can be reported in “pack-years,” the number of packs a day multiplied by the number of years (e.g., 1.5 packs per day × 10 years = 15 pack-years; see Evidence- Based Practice in Physical Examination, “Smoking Cessation”).

• Self-care: use of home, herbal, natural, complementary or alternative therapies/exercise (quantity and type)

• Sexual history: concerns with sexual feelings and per- formance, frequency of intercourse, ability to achieve orgasm, number and variety of partners, specific sexual practices, modes of birth control, protection against STIs and past STIs. (“Partner” is a gender-free term, appropri- ate in the early stages of discussion; see Clinical Pearl, “The Five Ps of a Sexual History.”)

Family History. Blood relatives in the immediate or extended family with illnesses with features similar to the patient’s are an immediate concern. If a disease “runs in the family,” such as sickle cell disease, ask about everyone from grandparents to cousins and children. A pedigree diagram helps illustrate the family members with the disorder (see Chapter 5). A thorough and well-done family history is the essence of genetics (Pyeritz, 2012). Determine the health and, if applicable, the cause of death of first-degree relatives (parents, children, and siblings), including age at death; after that, second-degree relatives (grandparents, grandchildren, aunts, nieces, uncles, and nephews); and then third-degree relatives (first cousins). There should be at least three generations in the pedigree. • Include the following in your list of concerns: heart

disease, high blood pressure, cancer (including the type), tuberculosis, stroke, sickle cell disease, cystic fibrosis, epilepsy, diabetes, gout, kidney disease, thyroid disease, asthma or other allergic condition, forms of arthritis, blood diseases, STIs, familial hearing, and visual or other sensory problems.

• In particular, determine whether cancers have been multiple, bilateral, and occurring more than once in the family and at a young age (younger than age 50 years).

• Note the age and outcome of any illness. • Note the ethnic and racial background of the family. • Note the age and health of the patient’s spouse/partner

or the child’s parents.

Personal and Social History • Personal status: birthplace, where raised, home environ-

ment when young (e.g., parental divorce or separation, socioeconomic class, cultural and ethnic background), education, position in family, marital status, general life satisfaction, hobbies and interests, occupation, activities, sources of stress or strain (see Clinical Pearl, “Who Are You?”)

CLINICAL PEARL

Who Are You? We cannot assume how patients define themselves ethnically or cultur- ally without asking them. “Hispanic,” “non-Hispanic,” “black,” “white,” “Latino,” and “Asian,” among many other designations, are subject to a variety of interpretations. Just ask, “How do you see yourself?” “How do you define yourself?” “I respect your values and beliefs; what do I need to know to provide care for you?” Remember not to stereotype just because a patient is a member of a culture. Each person is his or her own unique culture.

• Habits: nutrition and diet; regularity and patterns of eating and sleeping; quantity of coffee, tea, tobacco, alcohol; use of street drugs (e.g., frequency, type, and amount); ability to perform activities of daily living (see Functional Assessment for All Patients). The extent of

CLINICAL PEARL

The Five Ps of a Sexual History The five Ps stand for: • Partners • Practices • Protection from STIs • Past history of STIs • Prevention of pregnancy (if necessary)

These are the areas that you should openly discuss with your patients. You will probably need to ask additional questions that are appropriate to each patient’s special situation or circumstances.

(From Centers for Disease Control and Prevention [2012]. Guide to Taking a Sexual History. Available at: http://www.cdc.gov/std/treatment/SexualHistory.pdf.)

• Home conditions: housing, economic condition, types of furnishings (e.g., carpeting and drapes), pets and their health

• Occupation: description of usual work (and present work if different); list of job changes; work conditions and hours; physical or mental strain; duration of employment; present and past exposure to heat and cold or industrial toxins (especially lead, arsenic, chromium, asbestos, beryllium, poisonous gases, benzene, and polyvinyl chloride or other carcinogens and teratogens); any protec- tive devices required (e.g., goggles or masks); excessive screen time

• Environment: travel and other exposure to contagious diseases, residence in tropics, water and milk supply, other sources of infection if applicable

• Military record: dates and geographic area of assignments • Religious and cultural preferences: any religious proscrip-

tions concerning food, medical care; spiritual needs • Access to care: transportation and other resources avail-

able to patient, type of health insurance coverage (if any), worries in this regard, primary care provider, customary pattern of seeking care

• Social needs: insurance/medication coverage, food insecurity, housing instability, employment assistance needs It is important to have candid discussion of issues.

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ss • Breasts: development, pain, tenderness, discharge, lumps, galactorrhea, mammogram results

• Heart and blood vessels: chest pain or distress, precipitat- ing causes, timing and duration, relieving factors, palpita- tions, dyspnea, orthopnea (number of pillows needed), edema, hypertension, previous myocardial infarction, estimate of exercise tolerance, past electrocardiogram or other cardiac tests and their results

• Peripheral vasculature: claudication—frequency, severity, tendency to bruise or bleed, thromboses, thrombophlebitis

• Hematologic: anemia, bruising, any known abnormality of blood cells

• Gastrointestinal: appetite, digestion, intolerance for any class of foods, dysphagia, heartburn, nausea, vomiting, hematemesis; regularity of bowels, constipation, diarrhea, change in stool color or contents (e.g., clay-colored, tarry, fresh blood, mucus, undigested food); flatulence, hemor- rhoids; jaundice, history of ulcer, gallstones, polyps, tumor; previous diagnostic imaging (indication, where, when, results)

• Diet: appetite, likes and dislikes, restrictions (e.g., prefer- ential, religious, allergy, or other disease), vitamins and other supplements, use of caffeine-containing beverages (e.g., coffee, tea, and cola); an hour-by-hour detailing of food and liquid intake (sometimes a written diary covering several days of intake may be necessary)

• Endocrine: thyroid enlargement or tenderness, heat or cold intolerance, unexplained weight change, diabe- tes, polydipsia, polyuria, distribution and changes in facial or body hair, increased hat and glove size, skin striae

• Genitourinary: dysuria, flank or suprapubic pain, urgency, frequency, nocturia, hematuria, polyuria, dark or dis- colored urine, hesitancy, dribbling, loss in force of stream, passage of stone; edema of face; stress incontinence; hernias; STIs (type, laboratory confirmations, and treatment)

• Musculoskeletal: joint stiffness, pain, restriction of motion, swelling, redness, heat, bony deformity

• Neurologic: syncope, seizures, weakness or paralysis, abnormalities of sensation or coordination, tremors, loss of memory

• Psychiatric: depression, mood changes, difficulty con- centrating, anxiety, agitation, tension, suicidal thoughts, irritability, sleep disturbances Females and Transmales

• Menses: age at menarche, regularity, duration and amount of flow, dysmenorrhea, last menstrual period (LMP), intermenstrual discharge or bleeding, itching, date of last Pap smear and/or HPV test and result, age at menopause, libido, frequency of intercourse, pain during intercourse, sexual difficulties, infertility

• Pregnancies: number, living children, multiple births, miscarriages, abortions, duration of pregnancy, each type of delivery, any complications during any pregnancy or postpartum period or with neonate; use of oral or other contraceptives

Review of Systems (ROS). Identify the presence or absence of health-related issues in each body system. You may not ask all of the questions relevant to each system each time you take a given patient’s history. Nevertheless, many should be asked, particularly at the first interview. A targeted ROS is appropriate in some circumstances. More comprehensive questions for particular circumstances in each system are detailed in subsequent chapters. Negative responses to ROS questions are as important as positive responses. • General constitutional symptoms: pain, fever, chills,

malaise, fatigue, night sweats, sleep patterns, weight (i.e., average, preferred, present, change)

• Skin, hair, and nails: rash or eruption, itching, pigmenta- tion or texture change; excessive sweating, abnormal nail or hair growth

• Head and neck • General: frequent or unusual headaches, their location;

dizziness, syncope, severe head injuries; concussions, periods of loss of consciousness (momentary or prolonged)

• Eyes: visual acuity, blurring, diplopia, photophobia, pain, recent change in appearance or vision; glaucoma; use of eye drops or other eye medications; history of trauma

• Ears: hearing loss, pain, discharge, tinnitus, vertigo, infections

• Nose: sense of smell, frequency of colds, obstruction, epistaxis, postnasal discharge, sinus pain

• Throat and mouth: hoarseness or change in voice, frequent sore throats, bleeding or swelling of gums, recent tooth abscesses or extractions, soreness of tongue or buccal mucosa, ulcers, disturbance of taste, dental care

• Lymph nodes: enlargement, tenderness, suppuration • Chest and lungs: pain related to respiration; dyspnea,

cyanosis, wheezing, cough, sputum (character and quantity), hemoptysis, night sweats, exposure to tuberculosis; indication, date and result of last chest x-ray

Evidence-Based Practice in Physical Examination

Smoking Cessation Abundant evidence indicates that patients in a trusting relationship with nurses, physicians, or other health professionals will respond positively to even brief, simple advice about smoking cessation.

Pooled data from 17 trials of brief advice versus no advice (or usual care) detected a significant increase in the rate of quitting (relative risk [RR] 1.66). Among 11 trials where the intervention was more intensive, the estimated effect was higher (RR 1.84), but there was no statistical difference between the intensive and minimal subgroups. Direct comparison of intensive versus minimal advice showed a small advantage of intensive advice (RR 1.37). The bottom line is that it pays to offer even minimal advice if given respectfully and earnestly. Simple advice has an effect on cessation rates. The challenge is to incorporate smoking cessation interventions as part of standard practice.

(From Stead et al, 2013.)

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CHAPTER 1 The History and Interviewing Process 15

Family dynamics become evident during history taking and may even lead to clues that a parent is in need of help. For example, an excessively tearful parent who does not seem to be having much pleasure in a child or seems self-absorbed, unresponsive, and uncommunicative—or even hostile—may be depressed. Your responsibility goes beyond the child. It is appropriate to screen the mother for depression (Weiss-Laxer et al, 2016) and suggest ways to help (see Chapter 7). Respect parental concerns about their children, and do what is needed to ease worry.

There are aspects of the history concerning the young that may complement the approach suggested for adults or vary from it. They are as follows.

Chief Concern. A parent or other responsible adult (Box 1.9) often makes a threesome. The relationship of that person should be recorded. However, the child should be included as much as possible and as is age appropriate. The latent fears underlying any chief concerns of the adults and children should be explored.

History of Present Illness. The degree and character of the reaction to the problem on the part of parent/guardian and child should be noted.

Past Medical History • Note general health and strength: age of the child and/

or the nature of the problem determine the approach to questioning

• Patient’s health during pregnancy: • General health as related by the patient if possible,

extent of prenatal care, gravidity, parity • Specific diseases or conditions: infectious disease

(approximate gestational month), weight gain, edema, hypertension, proteinuria, bleeding (approximate gestational month), preeclampsia

• Medications, hormones, vitamins, special or unusual diet, general nutritional status

• Quality of fetal movements and time of onset • Emotional and behavioral status (e.g., attitudes toward

pregnancy and children) • Radiation exposure • Use of recreational drugs

• Birth • Duration of pregnancy • Place of delivery

Males and Transfemales • Puberty onset, difficulty with erections, emissions,

testicular pain, libido, infertility

Concluding Questions. Give the patient further opportunity. “Is there anything else that you want me to know?” If there are several issues, ask, “What problem concerns you most?” When situations are vague, complicated, or contradictory, it may be helpful to ask “What do you think is the matter with you?” or “What worries you the most about how you are feeling?”

Adaptations for Age, Pregnancy, and Possible Disabilities There are pervasive concerns common to all patients, particular concerns common to some, and unique concerns that distinguish any one individual.

Infants and Children Many children love it when you get down on the floor to play with them. They often have anxieties and fears that must be eased (Fig. 1.3). Use language that they understand. When they are old enough, allow them to actively participate in the interview. Starting at age 7 years, children can be dependable reporters on aspects of their health (Olson et al, 2007). The older the child, the more productive it becomes to ask questions and to give information directly. The older child and the adolescent may seem passive and sometimes appear hostile to some degree. This may suggest a wish to be alone with you, which may help to get a more accurate history. Be proactive and arrange for this routinely (see Clinical Pearl, “Twins or More”).

FIg. 1.3 Interviewing a child with his parent. Note that the interviewer is sitting close to the patient and that the child is secure on his parent’s lap.

CLINICAL PEARL

Twins or More Your patients may be twins, triplets, or more! Each is an individual entitled to separate consideration. Ensure that each has confidential and separate time with you.

BoX 1.9 Consent by Proxy

Infants, children, and many adolescents are minors. They may come to you accompanied by someone other than their custodial parent or guardian, often a grandparent or other member of their extended family. Sometimes your informant might be a babysitter, an au pair or nanny, or, in the event of divorce and remarriage, a noncustodial parent, stepparent, or friend. Does that person have the right to consent to your care for the child? Learn about the policy and procedure for consent in your healthcare setting.

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ss Expand the list when indicated. Parents may have baby books, which can stimulate recall, or photographs may be helpful. Additional developmental information to inquire about includes the following:

• Age when toilet-trained: approaches to and attitudes regarding toilet training

• School: grade, performance, problems • Dentition: age of first teeth, loss of deciduous teeth,

eruption of first permanent teeth; last dental visit • Growth: height and weight in a sequence of ages;

changes in rates of growth or weight gain • Pubertal development: present status. In females,

development of breasts, nipples, sexual hair, menstrua- tion (onset, cycle, regularity, pain, description of menses), acne; in males, development of sexual hair, voice changes, acne, nocturnal emissions

• Puberty suspention/supression in gender- nonconforming minors

• Illnesses: immunizations, communicable diseases, injuries, hospitalizations

Family History • Pregnant patient’s gestational history listing all pregnan-

cies, together with the health status of living children. For deceased children, include date, age, cause of death, and dates and duration of pregnancies in the case of miscarriages.

• Patient’s health during pregnancies and the ages of parents at the birth of this child.

• Are the parents consanguineous? Again, a pedigree diagram helps (see Chapter 5).

Personal and Social History • Behavioral status: child care or school adjustment;

masturbation, nail biting, thumb sucking, breath holding, temper tantrums, pica, tics, rituals; bed wetting, constipa- tion or fecal soiling of pants; playing with fire; reactions to prior illnesses, injuries, or hospitalization

• An account of a day in the life of the patient (from parent, child, or both) is often helpful in providing insights. Box 1.10 emphasizes the particular needs of children who are adopted or are in foster care.

• Family circumstances: parents’ occupations, the principal caretakers of the child, whether parents are divorced or separated, educational attainment of parents; spiritual orientation; cultural heritage; food preparation and by whom; adequacy of clothing; dependence on relief or social agency

• Setting of the home: number of rooms in house and number of persons in household; sleep habits, sleeping arrangements available for the child, possible environ- mental hazards

Review of Systems. In addition to the usual concerns, inquire about any past medical or psychologic or education testing of the child (Box 1.11). Ask about the following: • Skin: eczema, seborrhea, “cradle cap”

• Labor: spontaneous or induced, duration, analgesia or anesthesia, complications

• Delivery: presentation, forceps, vacuum extraction, spontaneous, or cesarean section; complications

• Condition of infant, time of onset of cry, Apgar scores if available

• Birth weight of infant

Patient safety

Putting Prevention Into Practice Take time to consider prevention. Consider how you can include prevention-related advice when talking with your patient or surrogate. For example, infants should sleep alone on their backs in a crib or bassinet to decrease the risk of sudden infant death syndrome. In addition, too often, child safety seats are used incorrectly. Their correct use should be reviewed.

• Neonatal period • Congenital anomalies; baby’s condition in hospital,

oxygen requirements, color, feeding characteristics, vigor, cry; duration of baby’s stay in hospital and whether infant was discharged with the patient who gave birth; bilirubin phototherapy; prescriptions (e.g., antibiotics)

• First month of life: jaundice, color, vigor of crying, bleeding, convulsions, or other evidence of illness

• Degree of early bonding: opportunities at birth and during the first days of life for the parents to hold, talk to, and caress the infant (i.e., opportunities for both parents to relate to and develop a bond with the baby)

• The feelings of the patient after giving birth: loss of laughter; unreasonable anxiety or sense of panic; excessive crying and sadness; sleeplessness; feelings of guilt; suicidal ideation, clues singly but most often in combination may be related to postpartum depression

• Feeding • Formula or breast milk, reason for changes, if any; type

of formula and how it is prepared, amounts offered and consumed; frequency of feeding and weight gain

• Present diet and appetite; age of introduction of solids; age when child achieved three feedings per day; present feeding patterns, elaboration of any feeding problems; age weaned from bottle or breast; type of milk and daily intake; food preference; ability to feed self; cultural variations

• Development: Obtain the age when the child achieved common developmental milestones: • Holds head erect while in sitting position • Rolls over from front to back and back to front • Sits alone and unsupported • Stands with support and alone • Walks with support and alone • Uses words • Talks in sentences • Dresses self

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reluctant to talk and have a clear need for confidentiality. All adolescent patients should be given the opportunity to discuss their concerns with you privately. It is wise to let the parent or other caregiver know you will be asking them to step out of the room to provide this important opportunity for the adolescent. The visit can be an opportunity to provide a safe space for teens to talk with their caregivers about sensitive issues with your support. Every effort should be made to maintain confidentiality. The limits regarding confidentiality should be clearly discussed. Information that suggests the adolescent’s safety or the safety of another is at risk may be reasons to “break” confidentiality.

If a parent/guardian is present, acknowledge the patient first. In the beginning it is helpful to talk about what is happening in the patient’s day-to-day experiences. Do not force conversation because adolescents do not respond readily to confrontation. On the other hand, you will often sense a need to talk and an inability to get the words out. Silences can be long, sometimes sheepish, occasionally angry, and not always constructive.

The peer group and the desire to be like peers take on a dominant role during middle adolescence. Experimentation with risky behaviors begins, and frequent arguments with parents are common. Immature decision making can lead to destructive, life-changing experiences and lifelong bad habits. During late adolescence with approaching adulthood, a more thoughtful consideration of consequences ordinarily occurs, along with a more secure sense of self and an ability to establish intimate relationships and to start planning a career.

The adoption of risky behaviors depends on a number of factors: • Peer pressure • Loosening attachment to parents • Poor school performance • Nonparticipation in school extracurricular activities • Poor self-esteem • Need to act older • Susceptibility to advertising, the internet, or social media

These issues may make it difficult to transcend the barrier imposed by age in caring for the adolescent (see Clinical Pearl, “Identification of Concerns by Adolescents”). Make generous use of open-ended questions, and do not force an adolescent to talk.

• Ears: otitis media (frequency, laterality) • Nose: snoring, mouth breathing, allergic reaction • Teeth: dental care • Genitourinary: bedwetting

Adolescents Adolescence, the time from puberty to maturity, is different from childhood and adulthood both physically and psycho- socially. It is a time made vulnerable by a tendency to experiment with risky behaviors. Adolescents may be

BoX 1.10 Adoption and Foster Care

Patients who are adopted or in foster care may not have a sufficient history available. Learn as much as you can. Our outline for history taking is a starter and should be filled out by an exploration of the circumstances that led to adoption or foster care. Do this with care. Some adoptive parents may not yet have shared the knowledge with their children. The trials of the adoptive parents as they sought a child, the process of adoption, the country of origin of the adoptee, and the particular concerns of all involved must be explored.

The needs of foster children vary considerably from those who are adopted. The history may be offered by a social worker, and the issues you encounter will differ in variety and intensity. Foster parents have varying experience, and foster children have often lived in more than one home. Invariably, difficult social circumstances underlie the separation from their parents. The probable lack of stability and security and incomplete knowledge of past illnesses or other conditions make it more difficult to understand the full range of the child’s complex and urgent needs.

Modified from Augustyn et al, 1995. Reprinted with permission from Contemporary Pediatrics, vol 12, 1995. Contemporary Pediatrics is a copyrighted publication of Advanstar Communica- tions Inc. All rights reserved.

BoX 1.11 Violence or Traumatic Events in Childhood

Witnessing or experiencing violence or injury is a fact of life for many children and is a barrier to appropriate growth and development. Talk about the event in a straightforward, simple, and direct fashion: • Can you tell me what happened? • What did you see? What did you hear? • What scared you the most? • What were you doing when it happened? • Do you ever dream about it? • Do you think about it during the day? • Do you worry it will happen again? • Whom do you talk to when you feel worried or scared? • Why do you think it happened? • For the older child and adolescent: • How do you think it changed your life?

These questions are not value-laden and are not too constraining. The child is free to talk if you can be comfortable with the silences that may often ensue. Parents can also respond to the same questions to fill out the story, and you can then learn how they dealt with the circumstance and what they observed in their child’s behavior.

CLINICAL PEARL

Identification of Concerns by Adolescents Previsit screeners or questionnaires allow the adolescent to identify his or her concerns prior to the start of the visit. Sometimes allowing an opportunity to write a concern or allowing a choice of concerns presented in written, silent fashion may help (Box 1.12). Then you can phrase the appropriate questions and make the transition to a verbal discussion reasonably comfortable. Take an open-ended approach, always indicating a sense of alliance and partnership.

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Pregnant Patients Care during the prenatal period depends on the commitment of the patient to both patient and fetal health, in partnership with the healthcare provider. The patient’s approach to pregnancy is influenced by many factors, including previous experiences with childbearing and childrearing; the relation- ship with the patient’s parent and other individuals signifi- cant to the patient’s life; the patient’s desire for children; and the patient’s present life circumstances. The interaction of the patient with the fetus increases the complexity of care. The initial interview includes past history, assessment of health practices, identification of potential risk factors, and assessment of the patient’s knowledge, expectations, and perceptions as they affect pregnancy.

If you use an electronic device or preprinted history form to gather the history, bridge the distance by talking comfortably and at some length with the patient, particularly the patient’s expectations and concerns. There will, of course, be much “laying on of hands” as the pregnancy matures.

Basic Information • Patient’s age, ethnicity • Marital status, partner, or relationship

Flexibility, respect, and confidentiality are key; otherwise, little productive discussion will result. On occasion, the patient may ask to talk with someone of the same gender, and this should be facilitated if possible. Box 1.13 provides useful screening tools for adolescent issues. You can use them as a guide for an exploratory interview. Some questions that you can ask to structure the interview include the following: • “How are things at home?” “Tell me about your living

situation.” Do not assume the family structure. Do not ask directly about who else lives in the house. The open- ended question at the start can lead to greater specifics later on.

• “How is school?” “Are you working?” “What is it about school that appeals to you?” “What is it about school that doesn’t appeal to you?” You may expect to hear somewhat more about jobs outside of school and ideas about the future when the patient approaches 20 years of age.

• “Tell me about your friends.” “Where do you go with them?” “What do you do with them?” “To what groups do you belong?” “How would a friend describe you?”

• “What types of computer and electronic games do you play?”

• “What are you good at doing?” Open-ended conversations about home, school, jobs,

activities, and friends can suggest the areas that may trouble the adolescent (e.g., sex, drugs, bullying, suicidal ideation). Talk does not always flow easily as the adolescent transitions from dependency to independency, from parent/guardian to peer group, and ultimately to self, but you can help.

BoX 1.12 Adolescents’ Concerns

The following subjects list may be of concern to adolescents. These are highly charged issues mandating the effort for discussion but requiring sensitivity, knowledge of adolescent language, and an unforced approach. • Bed wetting • Menstrual pain • Concern with height or weight: too short, too tall, underweight,

overweight • Concern with breast size: too big, too small • Concern with penis size: too small • Worry about pregnancy • Worry about sexual preference • Concern about gender identity • Interpersonal violence • Sex? Ready or not? • HIV, AIDS • Gambling • Smoking • Substance use and abuse • Parents’ attitudes and demands • Friends and their pressures • Bullying • School: not doing well, excessive work • What am I going to do in life? • Thoughts about dying

From Goldenring and Rosen, 2004. Reprinted with permission from Contemporary Pediatrics, vol 12, 2004, pp. 64-90. Contemporary Pediatrics is a copyrighted publication of Advanstar Communications Inc. All rights reserved.

BoX 1.13 Screening Tools for Adolescent Issues

HEEADSSS • Home environment • Education, employment • Eating • Activities (peer-related), affect, ambitions, anger • Drugs • Sexuality • Suicide/depression • Safety from injury and violence

PACES • Parents, peers • Accidents, alcohol/drugs • Cigarettes • Emotional issues • School, sexuality

CRAFFT: (Car, Relax, Alone, Forget, Friends, Trouble) (Knight et al, 2002) • Have you ridden in a CAR driven by someone who was high or

had been using drugs and alcohol? • Do you ever use alcohol or drugs to RELAX, feel better about

yourself, or fit in? • Do you ever use drugs or alcohol when you are ALONE? • Do you FORGET things you did while using drugs or alcohol? • Do your family and FRIENDS ever tell you that you should cut

down your drinking or drug use? • Have you ever gotten into TROUBLE while using drugs or alcohol?

NOTE: HEEADSSS, PACES, and CRAFFT are screening tools and are not substitutes for earnest conversation in a trusting relationship.

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Personal and Social History. Other children, pets (cats can carry toxoplasmosis, which be teratogenetic to the fetus). In addition, obtain information about feelings toward the pregnancy, whether it was planned, consideration of adop- tion or abortion, gender preference, social and spiritual resources, experiences with parenting, experience with and plans for labor and breast-feeding, and history of past or present abuse in relationships (intimate partner violence).

Review of Systems. Perform a complete review of all systems because the effects of pregnancy are seen in all systems. Give special attention to the reproductive system (including breasts) and cardiovascular systems (documentation of prepregnancy blood pressure if possible). Assess the endocrine system for signs of diabetes and thyroid dysfunc- tion. Assess the urinary tract for infection, and review kidney function. Assess respiratory function because it may be compromised later in pregnancy or with tocolytic therapy for preterm labor. Evaluate dental care needs because treatment of periodontitis can prevent preterm birth and/ or low birth weight (George et al, 2011).

Risk Assessment. Identify conditions from the history and physical examination or circumstances that threaten the well- being of the patient and/or fetus. These include gestational diabetes, preterm labor, preeclampsia/eclampsia, pregnant patient malnutrition and vitamin deficiency, and use of potentially teratogenetic agents such as lithium valproic acid or angiotensin-converting enzyme inhibitors.

Postpartum. Postpartum depression is a significant mental health problem, and universal screening for this problem is recommended (see Chapter 7). The clues are similar to those of depression in other circumstances—feeling down, depressed, or hopeless, sleep disturbance, loss of energy, eating disturbance, trouble concentrating, restlessness, sad mood, anxiety, fatigue, feelings of worthlessness, inappropri- ate guilt, and suicidal ideation. A cluster of these symptoms should strongly postpartum depression (O’Connor et al, 2016; O’Hara and McCabe, 2013).

Older Adults A change in knowledge, experience, cognitive abilities, and personality may occur with aging (Box 1.14). It is important to anticipate the effect these changes may have on the interview. However, physiologic age and chronologic age may not match. It is equally important to recognize that not all adults experience the same changes, they do not occur at the same rate, and some abilities may not decline with age.

Some older adults have sensory losses, such as hearing, that make communication more difficult. Position yourself so that the patient can see your face. Speak clearly and slowly, taking care to always face the patient while you are talking. Shouting magnifies the problem by distorting consonants and vowels. In some instances, a written interview may be less frustrating. Impaired vision and light-dark adaptation are a problem with written interview

• LMP • Previous usual/normal menstrual period (PUMP or

PNMP) • Expected date of confinement/delivery (EDC) • Occupation • Parent(s) of the baby and his/her occupation (if

applicable)

History of Present Illness or Problem. Obtain a description of the current pregnancy, and identify previous medical care. Identify specific problems (e.g., bleeding or spotting, nausea, vomiting, fatigue, or edema). Include information about illness, injuries, surgeries, or accidents or other injuries since conception.

Obstetric History. Information on each previous preg- nancy (gravidity and parity) includes the date of delivery; length of pregnancy; weight and gender of infant(s); type of delivery (e.g., spontaneous vaginal; cesarean delivery and type of scar [an evaluation of the competency of the scar is needed for women attempting vaginal birth after cesarean delivery]); or spontaneous, therapeutic, or elec- tive abortion and the type of procedure; length of labor; and complications in pregnancy or labor, postpartum, or with the infant. It is also important to determine whether any previous children have been removed from the home (i.e., due to abuse or neglect or inability to care for the children).

Menstrual History. In addition to previous information, include age at menarche, characteristics of the cycle, unusual bleeding, and associated symptoms. If known, include dates of ovulation and conception, and the use of contraceptives before or during conception.

Gynecologic History. Record the date of the most recent Pap smear and human papilloma virus (HPV) test along with any history of abnormalities, treatments, or gynecologic surgery. A sexual history includes age of first intercourse and whether it was consensual, number of sex partners, safe-sex methods, partner orientation, and, if a minor, age of partner. Information regarding the types of contraceptives used and reason for discontinuing them, along with plans for use postpartum, is obtained. Any history of infertility should be explored. If any STIs are reported, discuss the type, dates, treatments, and complications. Give full attention to any history of sexual assault.

Past Medical History. The same information identified previously for adults is obtained, with the addition of risk factors for HIV, hepatitis, herpes, tuberculosis, and exposure to environmental and occupational hazards.

Family History. Obtain a family history of genetic condi- tions, multiple births, gestational diabetes, preeclampsia/ eclampsia or pregnancy-induced hypertension (PIH), and/ or congenital anomalies.

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ss Routinely include functional assessment as part of the older adult’s history (see “Functional Assessment for All Patients” and individual chapters with functional assessment specific to systems). Questions concerning the ability to take care of one’s daily needs are part of the ROS. The personal and social history should include other dimensions of functional capacity such as social, spiritual, and economic resources; recreational activity; sleep pat- terns; environmental control; and use of the healthcare system. Maintaining function is a compelling concern of older adults.

For all ages, a cognitive impairment that deprives the patient of the ability to join in the decision-making process emphasizes the need for a designated healthcare agent (medical power of attorney for health care) and/or advance directives (a document outlining the patient’s wishes regarding extraordinary means of life support). Be aware of the specific rules governing these issues in your state. Encourage the patient and family to pursue these documents if steps have not yet been taken.

The Frail. Frailty has its onset with the loss of physical reserve and the increased risk for loss of physical function and independence. Its prevalence increases with age, particularly past 80 years. Frailty is characterized by weak- ness, weight loss, low activity, and diminished ability to respond to stress and is associated with adverse health outcomes. It is considered an at-risk state caused by the age-associated accumulation of deficits. With multisystem dysregulation, decreased physiologic reserves, and increased vulnerability to stressors, frailty shares features of normal aging (Bandeen-Roche, et al, 2015). Nonetheless, age and frailty are not necessarily synonymous.

Patients With Disabilities You must adapt to the needs of all patients of any age with disabling physical or emotional states (e.g., deafness, blindness, depression, psychosis, developmental delays, or neurologic impairments). They may or may not be effective historians, but respect them regardless. Their perspectives and attitudes matter. Involve each fully to the limit of emotional and mental capacity or physical ability (Fig. 1.4). Still, when necessary, use the family, other health professionals involved in care, and the patient’s record for collateral information. Some of the most common communication barriers can be overcome by keeping the following in mind: • Family members are often available to make the patient

more comfortable and to provide information. • Persons with impaired hearing often read, write, sign,

and/or read lips, but you must speak slowly and clearly enunciate each word. A translator who signs may also be used.

• Persons with visual impairment usually can hear, and talking louder to make a point does not help. Remember that you must always vocalize what you are trying to communicate; gestures may not be seen.

forms. Ensure large print and ample lighting with a source that does not glare or reflect in the eyes.

Some older adults may be confused or experience memory loss, particularly for recent events. Take whatever extra time is needed. Ask short (but not leading) questions, and keep your language uncomplicated and free of double negatives. Consult other family members to clarify discrepancies or to fill in the gaps. On the other hand, older patients have a lifetime of experience that may be a rich source of wisdom and perspective. Listen for it.

The history is more complex and increasingly subtle with the chronic, progressive, and debilitating problems that occur with aging. Symptoms may be less dramatic, vague or nonspecific. Confusion may be the only indication of a major problem. Pain may be unreliably reported because, with age, its perception varies. The excruciating pain usually associated with pancreatitis, for example, may be perceived as a dull ache, and myocardial infarction can occur without any pain. Some patients may not report symptoms because they attribute them to old age or because they believe that nothing can be done. They may have lived with a chronic condition for so long that it has been part of their expectation of daily living.

From Appelbaum, 2007; Magauran, 2009; President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research, 1982.

BoX 1.14 Competency to Make Medical Decisions

Patients or their surrogates have the right to decide the extent of care they will accept under your guidance. Many may have lost the ability to make relevant competent decisions. To give informed consent, patients must be well informed about what is proposed, and they must be able to voluntarily give consent. Competency to make medical decisions is used interchangeably with the word capacity. In a report from the President’s Commission for the Study of Ethical Problems in Medicine, clinical decision-making capacity includes three specific elements: the patient has a set of values and goals, the patient is able to understand and communicate information, and the patient is able to reason and deliberate about the choice being made by the patient. Competency may fluctuate from hour to hour or day to day, depending on the age and the physical/emotional circumstance. It is often necessary to seek consultative help in deciding a patient’s status. The law in your state may require this, and it may ultimately be left to a judge to decide on legal competence. It is important to recognize that the patient who disagrees with you is not necessarily incompetent, and the patient who agrees with you is not necessarily competent.

Patient safety

Multiple problems needing multiple medications increase risk for iatrogenic disorders. A medication history with attention to interactions of drugs, diseases, and aging is needed for prescribed and over-the- counter medications and herbal preparations. It is particularly helpful to have patients (of all ages) bring in their medication bottles. Encourage patients with complex medication needs or several healthcare providers to use a single pharmacy so that the computer database available to the pharmacist can flag drug–drug interactions.

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FIg. 1.4 Interviewing a patient with a physical disability. Note the uncluttered surroundings; be sure the patient in a wheelchair has room to maneuver.

• Aging, debilitating illness, and frailty increase dependency on others, worry about tomorrow, and grieving for what has been lost. Recognize these concerns and the sense of loss in both the patient and the caregivers. You can acknowledge this and offer to talk about it.

The Next Step Once the history (Box 1.15) has been built, move on to the physical examination, the laying on of hands, which is discussed in subsequent chapters. These chapters are

BoX 1.15 Types of Histories

A “complete” history is not always necessary. You may already know the patient well and may be considering the same problem over time. Therefore, adjust your approach to the need at the moment. There are variations: • The complete history makes you as thoroughly familiar with the

patient as possible. Most often, this history is recorded the first time you see the patient.

• The inventory history is related to but does not replace the complete history. It touches on the major points without going into detail. This is useful when it is necessary to get a “feel” for the situation, and the entire history taking will be completed in more than one session.

• The problem (or focused) history is taken when the problem is acute, possibly life-threatening, requiring immediate attention so that only the need of the moment is given full attention.

• The interim history is designed to chronicle events that have occurred since your last meeting with the patient. Its substance is determined by the nature of the problem and the need of the moment. The interim history should always be complemented by the patient’s previous record.

• Key information to gather regardless of the type of history includes current medications and allergies.

segmented and are not meant to reflect the natural flow that you will develop with experience. Do not be intimidated because your patients expect you to be perfect. Just be disciplined, alert, and recognize that your value judgments are not necessarily imbued with wisdom.

FUNCTIoNAL AssEssMENT Functional Assessment for All Patients Quite simply, functional assessment is an attempt to understand a patient’s ability to achieve the basic activities of daily living. This assessment should be made for all older adults and for any person limited by disease or disability, acute or chronic. A well-taken history and a meticulous physical examination can bring out subtle influences, such as tobacco and alcohol use, sedentary habits, poor food selection, overuse of medications (prescribed and nonprescribed), and less than obvious emotional distress. Even some physical limitations may not be readily apparent (e.g., limitations of cognitive ability or of the senses). Keep in mind that patients tend to overstate their abilities and, quite often, to obscure reality.

When performing a functional assessment, consider a variety of disabilities: physical, cognitive, psychologic, social, and sexual. An individual’s social and spiritual support system must be as clearly understood as the physical disabilities. There are a variety of physical disabilities, including the following: • Mobility

• Difficulty walking standard distances: 12 mile, 2 to 3 blocks, 13 block, across a room

• Difficulty climbing stairs, up and down • Problems with balance

• Upper extremity function • Difficulty grasping small objects, opening jars • Difficulty reaching out or up overhead, such as taking something

off a shelf

• Household chores • Heavy (vacuuming, scrubbing floors) • Light (dusting) • Meal preparation

• Activities of daily living • Eating • Toileting • Selecting proper attire and putting on clothes • Grooming and bathing • Maintaining continence • Walking and transferring (moving from bed to [wheel] chair, chair

to standing) • Instrumental activities of daily living

• Shopping • Medication management • Money management • Transportation (driving or navigating public transit) • Preparing meals • Using telephone and other communication devices • Housework and basic home maintenance Any limitations, even mild, in any of these areas will affect a patient’s

independence and autonomy and, to the extent of the limitation, increase reliance on other people and on assistive devices. These limitations indicate the loss of physical reserve and the potential loss of physical function and independence that indicate the onset of frailty. The patient’s social support system and material resources are then integral to the development of reasonable management plans.

22

CHAPTER

2 Cultural Competency Achieving cultural competence is a learning process that requires self-awareness, reflective practice, and knowl- edge of core cultural issues. It involves recognizing one’s own culture, values, and biases and using effective patient- centered communication skills. A culturally competent healthcare provider adapts to the unique needs of patients of backgrounds and cultures that differ from his or her own. This adaptability, coupled with a genuine curiosity about a patient’s beliefs and values, lay the foundation for a trusting patient-provider relationship.

A Definition of Culture Culture, in its broadest sense, reflects the whole of human behavior, including ideas and attitudes, ways of relating to one another, manners of speaking, and the material products of physical effort, ingenuity, and imagination. Language is a part of culture. So, too, are the abstract systems of belief, etiquette, law, morals, entertainment, and education. Within the cultural whole, different populations may exist in groups and subgroups. Each group is identified by a particular body of shared traits (e.g., a particular art, ethos, or belief; or a particular behavioral pattern) and is rather dynamic in its evolving accommodations with internal and external influences. Any individual may belong to more than one group or subgroup, such as ethnic origin, religion, gender, sexual orientation, occupation, and profession.

Distinguishing Physical Characteristics The use of physical characteristics (e.g., gender or skin color) to distinguish a cultural group or subgroup is inap- propriate. There is a significant difference between distin- guishing cultural characteristics and distinguishing physical characteristics. Do not confuse the physical with the cultural or allow the physical to symbolize the cultural. To assume homogeneity in the beliefs, attitudes, and behaviors of all individuals in a particular group leads to misunderstandings about the individual. The stereotype, a fixed image of any group that denies the potential of originality or individuality within the group, must be rejected. People can and do respond differently to the same stimuli. Stereotyping occurs through two cognitive phases. In the first phase, a stereotype becomes activated when an individual is categorized into

a social group. When this occurs, the beliefs and feelings (prejudices) come to mind about what members of that particular group are like. Over time, this first phase occurs without effort or awareness. In the second phase, people use these activated beliefs and feelings when they interact with the individual, even when they explicitly deny these stereotypes. Multiple studies have shown that healthcare providers activate these implicit stereotypes, or unconscious biases, when communicating with and providing care to minority patients (Stone and Moskowitz, 2011). With this in mind, you can begin learning cultural competence by acknowledging your implicit, or unconscious, biases toward patients based on physical characteristics.

At the same time, this does not minimize the value of understanding the cultural characteristics of groups, nor does this deny the interdependence of the physical with the cultural. Genotype, for example, precedes the develop- ment of the intellect, sensitivity, and imagination that leads to unique cultural achievements, such as the creation of classical or jazz music. Similarly, a person’s phenotype, like skin color, precedes most of the experience of life and the subsequent interweaving of that phenotype with cultural experience. Although commonly used in clinical practice, the use of phenotypic traits to classify an individual’s race is problematic. The term race has been used to categorize individuals based on their continent or subcontinent of origin (e.g., Asian, Southeast Asian). However, there is ongoing debate about the usefulness of race, considering the degree of phenotypic and genetic variation of individuals from the same geographic region (Relethford, 2009). In addition, the origins of race date back to the 17th century, long before scientists identified genetic similarities. Over time, beliefs about particular racial groups were shaped by economic and political factors, and many believe race has become a social construct (Harawa and Ford, 2009).

Genomics and Personalized Medicine A growing body of research examines genetic markers associated with racial and ethnic groups and potential interactions with environmental determinants in predicting disease susceptibility and response to medical treatment. An explosion of genome-wide association studies (GWAS) are attempting to link genomic loci, or single-nucleotide polymorphisms (SNPs) with common diseases such as

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with core aspects of the patient-centered care model (Fig. 2.1). Seeleman et al (2009) have proposed a framework for teaching cultural competence that emphasizes an awareness of the social context in which specific ethnic groups live. For ethnic minority individuals, assessing the social context includes inquiring about stressors and support networks, sense of life control, and literacy. In doing so, healthcare providers will need to be flexible and creative in working with patients. Campinha-Bacote’s (2011) Process of Cultural Competence Model is another approach and includes five cultural constructs: encounters, desire, awareness, knowl- edge, and skill. Box 2.1 defines these five constructs.

Cultural Humility Cultural humility involves the ability to recognize one’s limitations in knowledge and cultural perspective and be open to new perspectives. Rather than assuming all patients of a particular culture fit a certain stereotype, healthcare providers should view patients as individuals. In doing so, cultural humility helps equalize the imbalance in the patient-provider relationship. (Borkan et al, 2008). A provider may know many specific details about a patient’s particular culture, yet not show cultural humility. Cultural humility involves self-reflection and self-critique with the goal of having a more balanced, mutually beneficial relationship. It involves meeting patients “where they are” without judgment to avoid the development of stereotypes. Attaining cultural humility is an ongoing process shaped by every

rheumatoid arthritis, type 1 and type 2 diabetes mellitus, and Crohn disease (Visscher et al, 2012). Personalized medicine, as defined by the National Cancer Institute, is “a form of healthcare that considers information about a person’s genes, proteins and environment to prevent, diagnose and treat disease” (Su, 2013). Direct-to-consumer genetic testing is rapidly evolving and will likely become more affordable and accessible to our patients. Healthcare providers in all disciplines will need to become fluent in the language of genomics and learn how to discuss risks and benefits of gene testing with their patients and families (Calzone et al, 2013; Demmer and Waggoner, 2014). With this new emphasis, it will be perhaps even more important to acknowledge unconscious biases and seek to understand the patient’s unique cultural and personal health beliefs and expectations.

Cultural Competence Culturally competent care requires that healthcare providers be sensitive to patient’s heritage, sexual orientation, socio- economic situation, ethnicity, and cultural background (Cuellar et al, 2008). Many models have been proposed to teach cultural competence. Most include the domains of acquiring knowledge (e.g., understanding the meaning of culture), shaping attitudes (e.g., respecting differences of individuals from other cultures), and developing skills (e.g., eliciting patient’s cultural beliefs about health and illness) (Saha et al, 2008). Some of these domains overlap

Patient-Centered Care • Curbs hindering

behavior such as technical language, frequent interruptions, or false reassurance

• Understands transference/ countertransference

• Understands the stages and functions of a medical interview

• Attends to health promotion/disease prevention

• Attends to physical comfort

Cultural Competence • Understands the meaning of culture • Is knowledgeable about different cultures • Appreciates diversity • Is aware of health

disparities and discrimination affecting minority groups

• Effectively uses interpreter services when needed

• Understands and is interested in the patient as unique person

• Uses a biopsychosocial model • Explores and respects patient

beliefs, values, meaning of illness, preferences, and needs

• Builds rapport and trust • Finds common ground • Is aware of own biases/

assumptions • Maintains and is able to convey

unconditional positive regard • Allows involvement of friends/

family when desired • Provides information and

education tailored to patient’s level of understanding

FIG. 2.1 Overlapping concepts of patient-centered care and cultural competence. (From Saha S et al, 2008.)

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healthcare professionals as well. Allopathic providers often demonstrate skepticism regarding the use of complementary and alternative medicine (CAM) without considering the possibility of potential benefit to patients.

The Blurring of Cultural Distinctions Some cultural differences may be malleable in a way that physical characteristics are not. For example, one group of people can be distinguished from another by language (see Clinical Pearl, “Language Is Not All”). However, globaliza- tion, the growing diversity of the U.S. population, and evidence of healthcare disparities mandate more and more that we learn one another’s languages. Although modern technology and economics may eventually lead to universal- ity in language, we can begin by acknowledging and

patient encounter that involves openness, partnership, and genuine interest in understanding our patients’ belief systems and lives (Fahlberg et al, 2016).

The Impact of Culture The information in Box 2.2 suggests that racial and ethnic differences, as well as social and economic conditions, may affect the provision of specific healthcare services to certain groups and subgroups in the United States. Poverty and inadequate education disproportionately affect various cultural groups (e.g., ethnic minorities and women); socioeconomic disparities negatively affect the health and medical care of individuals belonging to these groups. Although death rates have declined overall in the United States over the past 50 years, the poorly educated and those in poverty still die at higher rates from the same conditions than those who are better educated and economically advantaged. Morbidity, too, is greater among the poor. Data from the 2013 Centers for Disease Control and Prevention (CDC) Health Disparities and Inequalities Report reveal a variety of healthcare disparities. A significantly higher rate of Hispanic and non-Hispanic blacks were uninsured compared with Asian/Pacific Islanders and non-Hispanic whites. The infant mortality rate among infants born to non-Hispanic black women is more than double the rate for infants born to non-Hispanic white women. Compared with white women, a much higher percentage of black women die from coronary heart disease before age 75 (37.9% versus 19.4%). This same difference was observed between black and white men (61.5% versus 41.5%) (CDC, 2013). These rather stark facts are sufficient to underscore the need for cultural awareness in health and medical care professionals. Cultural and practice differences exist among

Data from Bukutu et al, 2008; Flores, 2010; Shao et al, 2016.

BoX 2.2 The Influence of Age, Race, Ethnicity, Socioeconomic Status, and Culture

Age, gender, race, ethnic group, and, with these variables, cultural attitudes, regional differences, and socioeconomic status influence the way patients seek medical care and the way clinicians provide care. Consider, for example, the ethnic and racial differences in the treatment of depression in the United States. The prevalence of major depressive disorders is similar across groups; however, compared with white Americans, black and Latino patients are less likely to receive treatment. Although some of the disparity is related to differing patient attitudes and perceptions of counseling and medication, there is growing evidence suggesting clinician communication style and treatment recommendations differ on the basis of patient race and ethnicity (Shao et al, 2016). Similarly, in the pediatric population, black and Latino children in the United States also experience health disparities, including lower overall health status and lower receipt of routine medical care and dental care compared with white children. Flores and colleagues (2010), in a systematic literature review, demonstrated that, compared with white children, black children have lower rates of preventive and population health care (e.g., breast-feeding and immunization coverage), higher adolescent health risk behaviors (e.g., sexually transmitted infections), higher rates of asthma emergency visits, and lower mental health service use. There is a clear need to better understand why these differences exist more globally, but removing cultural blindness at the individual patient level is an important first step.

Furthermore, the possible beneficial and harmful effects of many culturally important herbal medicines, which are used but not always acknowledged, must be understood and, in trusting relationships, reported to us if we are to guide their appropriate use. Crossing the cultural divide helps, but skepticism is a barrier. For example, many allopathic medical providers question the notion that complementary and alternative medicine might be a helpful adjuvant therapy for the prevention and treatment of acute otitis media. However, in several randomized controlled studies, xylitol, probiotics, herbal ear drops, and homeopathic treatments have been shown, compared with placebo, to have a greater effect in reducing pain duration and decreasing the use of antibiotics. Although skepticism can be put aside, evidence-driven guidance is still essential. Cultural competence is entirely consistent with that.

From Campinha-Bacote, 2011.

BoX 2.1 Dimensions of Cultural Competence

CULTURAL ENCOUNTERS—The continuous process of interacting with patients from culturally diverse backgrounds to validate, refine, or modify existing values, beliefs, and practices about a cultural group and to develop cultural desire, cultural awareness, cultural skill, and cultural knowledge.

CULTURAL DESIRE—The motivation of the healthcare professional to “want to” engage in the process of becoming culturally competent, not “have to.”

CULTURAL AWARENESS—The deliberate self-examination and in-depth exploration of one’s biases, stereotypes, prejudices, assumptions, and “isms” that one holds about individuals and groups who are different from them.

CULTURAL KNOWLEDGE—The process of seeking and obtaining a sound educational base about culturally and ethnically diverse groups.

CULTURAL SKILL—The ability to collect culturally relevant data regarding the patient’s presenting problem, as well as accurately performing a culturally based physical assessment in a culturally sensitive manner.

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Box 2.4 offers a guide to help understand the patient’s beliefs and practices that can lead to individualized, culturally competent care. Particular attention should be paid to caring for patients who self-identify as being lesbian, gay, bisexual, and transgender (LGBT). Unfortunately, these individuals face discrimination and disrespect in the healthcare setting. Thus, it is imperative that healthcare providers invest time in becoming culturally competent and develop cultural humility to work effectively with LGBT patients. Specific responsibilities include providing a welcoming and safe environment, gathering a history with sensitivity and compassion, and performing a physical examination using a “gender-affirming” approach (i.e., using the correct name and pronouns). Box 2.5 provides useful terminology (Center for Excellence for Transgender Health, 2016).

Interprofessional Care—A Culture Shift in the Health Professions There is a harmony—a unity—in the care of patients that is not constricted by the cultural and administrative boundar- ies of the individual health professions. To the extent that we stake out territories of care by allowing individual profes- sional cultures and needs to take precedence over patient needs, we may impede the achievement of harmony. In 2010, the World Health Organization (WHO) published

overcoming our individual biases and cultural stereotypes. Because it is impossible to learn the native languages of all of our patients, when language barriers arise, we must become aware of our resources and know how to effectively use interpreters (Seeleman et al, 2009). Use of medical interpreters has a positive impact on healthcare quality, but we continue to use suboptimal methods of communica- tion (e.g., family members). Although greater adoption of medical interpreter use involves policy and system-level changes, healthcare provider training and encouragement remain critically important (DeCamp et al, 2013).

ClInICal pearl

Language Is Not All A patient who knows the English language, however well, cannot be assumed to know the culture. Consider the diversity of the populations in Britain, India, American Samoa, and South Africa who are English speaking. The absence of a language barrier does not preclude a cultural barrier. You will likely still need to achieve a “cultural translation.”

The Primacy of the Individual in Health Care The individual patient may be visualized at the center of an indefinite number of concentric circles. The outermost circles represent constraining universal experiences (e.g., death). The circles closest to the center represent the various cultural groups or subgroups to which anyone must, of necessity, belong. The constancy of change forces adaptation and acculturation. The circles are constantly interweaving and overlapping. For example, a common experience in the United States has been the economic gain at the root of the assimilation of many ethnic groups. Although this results in greater homogeneity among the population, an individual’s gender, ethnic behaviors, or sexual orientation and identity will likely be unique. Predicting the individual’s character merely on the basis of the common cultural behavior, or stereotype, is not appropriate. Based on the Joint Commission 2010 report, “Checklist to Improve Effective Communication, Cultural Competence, and Patient- and Family-Centered Care Across the Care Con- tinuum,” White and Stubblefield-Tave (2016) remind us that unconscious bias, stereotyping, racism, gender bias, and limited English proficiency underlie healthcare inequali- ties. They offer their own checklist of recommendations for healthcare providers to address these issues with the goal of reducing disparities in care (Box 2.3).

Ethical issues often arise when the care of an individual comes into conflict with the utilitarian needs of the larger community, particularly with the recognition of limited resources and, in the United States, rising healthcare costs. Cultural attitudes of our patients, at times vague and poorly understood, may constrain our professional behavior and confuse the context in which we serve the individual.

Modified from White & Stubblefield-Tave, 2016.

BoX 2.3 Provider Role in Reducing Disparities in Health Care

This modified “culturally competent checklist” is provided as a guide to help providers partner with patients and families to provide high- quality care. Although some items are simple, others are quite complicated and difficult to achieve. On our path to achieving cultural humility, we should strive to incorporate as many of these recom- mendations as possible into our routine clinical practice.

1. Humanize your patient. 2. Identify and monitor conscious and unconscious biases. 3. Do a teach-back. 4. Help the patient to learn about his or her disease or condition. 5. Welcome a patient’s friend, partner, and/or family members. 6. Learn a few key words and phrases in the most common languages

in your area. 7. Use a qualified medical interpreter as appropriate. 8. Be aware of the potential for “false fluency” (clinician language

skill should be tested and certified). 9. Seek training in working with an interpreter.

10. Consider the health literacy of one’s patients. 11. Respond thoughtfully to patient complaints. 12. Hold one’s institutions accountable for providing culturally and

linguistically competent care. 13. Advocate that the affiliated institution’s analyses of patient satisfac-

tion and outcome include cultural group data and that the results lead to concrete action.

14. Encourage patients to complete patient satisfaction and demo- graphics forms.

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“The Framework for Action on Interprofessional Education and Collaborative Practice.” In this publication, interprofes- sional education is described as training in which “students from two or more professions learn about, from and with each other to enable effective collaboration and improve health outcomes.” The WHO believes this type of training can lead to “interprofessional collaborative practice,” in which health team members from different professional backgrounds work together to deliver high-quality care. In recent years, there has been a surge in published curricula on interprofessional education and team-based training for students and faculty. Although most curricula for nursing and medical students focus on improving communication skills, training programs need to evolve to address cultural humility and valuing diversity in patient populations (Foronda et al, 2016).

The Impact of Culture on Illness Disease is shaped by illness, and illness—the full expression of the impact of disease on the patient—is shaped by the

Modified from Stulc, 1991.

BoX 2.4 Cultural Assessment Guide: The Many Aspects of Understanding

Health Beliefs and Practices • How does the patient define health and illness? How are feelings

concerning pain, illness in general, or death expressed? • Are there particular methods used to help maintain health, such as

hygiene and self-care practices? • Are there particular methods being used for treatment of illness? • What is the attitude toward preventive health measures such as

immunizations? • Are there health topics that the patient may be particularly sensitive

to or consider taboo? • Are there restrictions imposed by modesty that must be respected;

for example, are there constraints related to exposure of parts of the body, discussion of sexual health, and attitudes toward various procedures such as termination of pregnancy or vasectomy?

• What are the attitudes toward mental illness, pain, chronic disease, death, and dying? Are there constraints in the way these issues are discussed with the patient or with reference to relatives and friends?

• Is there a person in the family responsible for various health-related decisions such as where to go, whom to see, and what advice to follow?

• Does the patient prefer a health professional of the same gender, age, and ethnic and racial background?

Faith-Based Influences and Special Rituals • Is there a religion or faith to which the patient adheres? • Is there a significant person to whom the patient looks for guidance

and support? • Are there any faith-based special practices or beliefs that may affect

health care when the patient is ill or dying?

Language and Communication • What language is spoken in the home? • How well does the patient understand English, both spoken and

written?

• Are there special signs of demonstrating respect or disrespect? • Is touch involved in communication? • Is an interpreter needed? (If so, this person ideally should be a

trained professional and not a family member.)

Parenting Styles and Role of Family • Who makes the decisions in the family? • What is the composition of the family? How many generations are

considered to be a single family, and which relatives compose the family unit?

• What is the role of and attitude toward children in the family? • Do family members demonstrate physical affection toward their

children and each other? • Are there special beliefs and practices surrounding conception,

pregnancy, childbirth, lactation, and childrearing? Is co-sleeping practiced? (If so, further inquiry is necessary regarding safe sleep practices for infants 12 months and younger.)

Sources of Support Beyond the Family • Are there ethnic or cultural organizations that may have an influence

on the patient’s approach to health care? • Are there individuals in the patient’s social network that can influence

perception of health and illness? • Is there a particular cultural group with which the patient identifies?

Can this be clarified by where the patient was born and has lived?

Dietary Practices • Who is responsible for food preparation? • Are any foods forbidden by the culture, or are some foods a cultural

requirement in observance of a rite or ceremony? • How is food prepared and consumed? • Are there specific beliefs or preferences concerning food, such as

those believed to cause or to cure an illness? • Are there periods of required fasting? What are they?

From Center for Excellence for Transgender Health, 2016.

BoX 2.5 Gender, Transgender, and Sexuality Terminology

Gender/gender identity: People’s internal sense of self and how they fit into the world from the perspective of gender.

Sex: Historically referred to the sex assigned at birth, based on external genitalia; often used interchangeably with gender, although there are differences, especially when considering the transgender population.

Transgender: Person whose gender identity differs from sex assigned at birth; a transgender man is someone with a male gender identity and a female birth assigned sex; a transgender woman is someone with a female gender identity and a male birth assigned sex.

Gender nonconforming: Person whose gender identity differs from that sex assigned at birth but may be more complex, fluid, less clearly defined than a transgender person.

They/Them/Their: Neutral pronouns used by some who have noncon- forming gender identity.

Sexual orientation: Term describing a person’s sexual attraction; sexual orientation of transgender people should be defined by the individual.

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In Japan, for example, the family is generally considered the legitimate decision-making authority for competent and incompetent patients. Persons of some cultures (e.g., Middle Eastern and Navajo Native American) believe that a patient should not be told of a diagnosis of a metastatic cancer or a terminal prognosis for any reason, but this attitude is not likely to be shared by Americans with European or African traditions. Traditionally, the members of the Navajo culture believe that thought and language have the power to shape reality. Talking about a possible outcome is thought to ensure the outcome. It is important, then, to avoid thinking or speaking in a negative way. The situation can be dealt with by talking in terms of a third person or an abstract possibility. You might even refer to an experience you have had in your own family. Obviously, the conflicts that may arise from differing views of autonomy, religion, and information sharing require an effort that is dominated by a clear understanding of the patient’s goals. However, it is important to remember that a patient may not typify the attitudes of the group of origin.

Modes of Communication Communication and culture are interrelated, particularly in the way feelings are expressed verbally and nonverbally. The same word may have different meanings for different people. For example, in the United States, a “practicing physician” is an experienced, trained person. “Practicing,” however, suggests inexperience and the status of a student to an Alaskan Native or to some Western Europeans. Similarly, touch, facial expressions, eye movement, and body posture all have varying significance.

In the United States, for example, people may tend to talk more loudly and to worry less about being overheard than others do. The English, on the other hand, tend to worry more about being overheard and speak in modulated voices. In the United States, people may be direct in conversation and eager to be thought logical, preferring to avoid the subjective and to come to the point quickly. The Japanese tend to do the opposite, using indirection, talking around points, and emphasizing attitudes and feelings. Silence, although sometimes uncomfortable for many of us, affords patients who are Native American time to think; the response should not be forced and the quiet time should be allowed.

Many groups use firm eye contact. The Spanish meet one another’s eyes and look for the impact of what is being said. The French, too, have a firm gaze and often stare openly at others. This, however, might be thought rude or immodest in some Asian or Middle Eastern cultures. Americans are more apt to let the eyes wander and to grunt, nod the head, or say, “I see,” or “uh huh,” to indicate understanding. Americans also tend to avoid touch and are less apt to pat you on the arm in a reassuring way than are, for example, Italians.

These are but a few examples of cultural variation in communication. They do, however, suggest a variety of behaviors within groups. As with any example we might

totality of the patient’s experience. Cancer is a disease. The patient dealing with, reacting to, and trying to live with cancer is having an illness—is “ill” or “sick.” The definition of “ill” or “sick” is based on the individual’s belief system and is determined in large part by his or her enculturation. This is so for a brief, essentially mild episode or for a chronic, debilitating, life-altering condition. If we do not consider the substance of illness—the biologic, emotional, and cultural aspects—we will too often fail to offer complete care. To make the point, imagine that while taking a shower you have conducted a self-examination and, still young, still looking ahead to your career, you have discovered an unexpected mass in a breast or a testicle. How will you respond? How might other individuals respond?

evidence-Based practice in physical examination

Cultural Adaptations for Screening We often use a variety of screening tools to identify health concerns and help our patients stay well. These screening tools are based on norms that may not be consistent across cultures. Screening tools may contain cultural biases and result in misleading information. Whenever possible, we should use instruments that have been adapted for and tested with individuals from our patients’ specific cultural groups. Screening, brief intervention, and referral to treatment (SBIRT) is an approach to identify and care for patients affected by alcohol and drug use. Using SBIRT involves the use of validated screening tools. Fortunately, a recent literature review indicates a variety of instruments have been validated in racial and ethnic subgroups (Manuel et al, 2015). Before implementing a screening tool, it is our responsibility to ensure the instrument is valid and at an appropriate literacy level for our specific patient populations.

The Components of a Cultural Response When cultural differences exist, be certain that you fully understand what the patient means and know exactly what he or she thinks you mean in words and actions. Asking the patient if you are unsure demonstrates curiosity and is far better than making an assumption, which could result in a damaging mistake. Avoid assumptions about cultural beliefs and behaviors made without validation from the patient.

Beliefs and behaviors that will have an impact on patient assessment include the following: • Modes of communication: the use of speech, body

language, and space • Health beliefs and practices that may vary from your

own or those of other patients you care for • Diet and nutritional practices • The nature of relationships within a family and

community A variety of ethnic attitudes toward autonomy may exist.

The patient-centered care model, still firmly respected in the United States, could be at odds with a more family- centered model that is more likely dominant elsewhere.

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be comfortable with Western approaches to health and medical care. However, the scientific view is reductionist and looks to a very narrow, specific cause and effect. A more naturalistic or “holistic” approach broadens the context. It views our lives as part of a much greater whole (the entire cosmos) that must be in harmony. If the balance is disturbed, illness can result. The goal, then, is to achieve balance and harmony. Aspects of this concept are evident among the beliefs of many Hispanics, Native Americans, Asians, and Middle Eastern groups, and they are increasingly evident in people of all ethnic groups in the United States today (Box 2.6). Other groups believe in the supernatural or forces of good and evil that determine individual fate. In such a context, illness may be thought of as a punishment for wrongdoing.

Clearly, there can be a confusing ambivalence in many of us, patient and healthcare provider alike, because our genuine faith-based or naturalistic beliefs may conflict with the options available for the treatment of illness. Consider, for example, a child with a broken bone, the result of an unintentional injury that occurred while the child was under the supervision of a babysitter. The first need is to tend to the fracture. That done, there is a need to talk with the parents about the guilt they may feel because they were away working. They might think this injury must be God’s punishment. It is important to be aware of, to respect, and to discuss without belittlement a belief that may vary from yours in a manner that may still allow you to offer your point of view. This can apply to the guilt of a parent and to the use of herbs, rituals, and religious artifacts. After all, the pharmacopoeia of Western medicine is replete with plants and herbs that we now call drugs (see Clinical Pearl, “Complementary and Alternative Treatments for the Common Cold”). Our difficulty in understanding the belief of another does not invalidate its substance, nor does a patient’s adherence to a particular belief preclude concurrent reliance on allopathic or osteopathic health practitioners.

use, they are not to be thought of as rigidly characteristic of the indicated groups. Still, the questions suggested in Box 2.4 can at times provide insight to particular situations and can help avoid misunderstanding and miscommunication.

The cultural and physical characteristics of both patient and healthcare provider may significantly influence com- munication (Fig. 2.2). Social class, race, age, and gender are variables that characterize everyone; they can intrude on successful communication if there is no effort for mutual knowledge and understanding (see Clinical Pearl, “The Impact of Gender”). The young student or healthcare provider and the older adult patient may have to work harder to develop a meaningful relationship. Recognizing these differences and talking about them, evoking feelings sooner rather than later, can result in a more positive encounter for both patient and provider. It is permissible to ask whether the patient is uncomfortable with you or your background and whether they are willing to talk about it.

FIG. 2.2 Being sensitive to cultural differences that may exist between you and the patient can help avoid miscommunication.

ClInICal pearl

The Impact of Gender In a qualitative study examining videotapes of primary care visits, compared with male physicians, female physicians were more “patient- centered” in their communication skills. The greatest amount of patient-centeredness was observed when female physicians interacted with female patients. Elderly hospitalized patients treated by female internists had lower mortality and readmissions compared with those cared for by male internists. On the flip side, compared with a female physician, obese men seen by a male physician were more likely to receive diet and exercise counseling.

From Bertakis and Azari, 2012; Pickett-Blakely et al, 2011; Tsugawa et al, 2017.

Health Beliefs and Practices The patient may have a view of health and illness and an approach to cure that are shaped by a particular cultural and/or faith belief or paradigm. If that view is “scientific,” in the sense that a cause can be determined for every problem in a very precise way, the patient is more apt to

ClInICal pearl

Complementary and Alternative Treatments for the Common Cold Home-based remedies for common colds are widely used. In children, the following therapies may be effective: buckwheat honey, vapor rub, geranium, and zinc sulfate. In adults, Echinacea purpurea, geranium extract, and zinc gluconate may be effective. When asking about medications, always remember to ask about use of complementary and alternative therapies. Using a nonjudgmental approach, you may wish to start with the question, “What else have you tried?”

From Fashner et al, 2012.

Family Relationships Family structure and the social organizations to which a patient belongs (e.g., faith-based organizations, clubs, and

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One type of already-known behavior may predict another type of behavior. For example, low-income urban mothers who take advantage of appropriate prenatal care generally take advantage of appropriate infant care, regardless of educational level (Van Berckelaer et al, 2011). Adolescents who are not monitored by their parents are more likely to smoke, use alcohol and marijuana, be depressed, and initiate sexual activity than are those who are monitored (Dittus et al, 2015; Pesola et al, 2015). Being aware of this sequence of related behaviors is especially important because it may be unrelated to the integrity of the family structure, gender, or background. Parenting style and childrearing practices such as setting boundaries and expectations may be cultur- ally driven. Many adolescents and young adults find comfort in their families’ cultural traditions and practices and benefit from their connectedness. In a large study of U.S. college students from immigrant families, compared with their peers, students who retained their heritage practices reported fewer health risk behaviors such as substance use, unsafe sex, and impaired driving (Schwartz et al, 2011). These examples remind us that one individual may belong to many subgroups and that the behaviors and attitudes of a subgroup—for example, a young man who remains con- nected to his cultural heritage—can override the impact of the cultural values of the larger group (e.g., youth whose peers are engaged in risk-taking behaviors).

Diet and Nutritional Practices Beliefs and practices related to food, as well as the social significance of food, play an obvious vital role in everyday life. Some of these beliefs of cultural and/or faith-based significance may have an impact on the care you provide to patients. An Orthodox Jewish patient will not take some medicines, particularly during a holiday period like Passover, because the preparation of a drug does not meet the religious rules for food during that time. A patient who is Muslim must respect Halal (prescribed diet), even throughout pregnancy. A Chinese person with hypertension and a salt-restricted diet may need to consider a limited use of monosodium glutamate (MSG) and soy sauce. Attitudes toward vitamins vary greatly, with or without scientific proof, in many of the subgroups in the United States. It is still possible to work out a mutually agreed-on management plan if the issues are recognized and freely discussed. This is also possible with attitudes toward home, herbal, and natural—complementary or alternative—therapies. Many will have benefit; others may be dangerous. For example, some herbal medications containing cassia senna may cause liver damage, and other herbal preparations interact with prescribed medications (Posadzki et al, 2013).

Summing Up As healthcare providers, we face a compelling need to meet each patient on his or her own terms and to resist forming a sense of the patient based on prior knowledge of the race, religion, gender, ethnicity, sexual identity and orientation, or

schools) are among the many imprinting and constraining cultural forces. The expectations of children and how they grow and develop are key in this regard and often culturally distinct. Determining these family and social structures needs emphasis in the United States today, with its shift toward dual-income families, single-parent families, and a significant number of teenage parents. The prevalence of divorce (nearly one for every two marriages) and the increasing involvement of both parents in child care in two-parent families suggest cultural shifts that need to be recognized.

Modified from Purnell, 2013.

BoX 2.6 The Balance of Life: The “Hot” and the “Cold”

A naturalistic or holistic approach often assumes that there are external factors—some good, some bad—that must be kept in balance if we are to remain well. The balance of “hot” and “cold” is a part of the belief system in many cultural groups (e.g., Middle Eastern, Asian, Southeast Asian, and Hispanic). To restore a disturbed balance, that is, to treat, requires the use of opposites (e.g., a “hot” remedy for a “cold” problem and vice versa). Different cultures may define “hot” and “cold” differently. It is not a matter of temperature, and the words used might vary: for example, the Chinese have named the forces yin (cold) and yang (hot). The bottom line: We cannot ignore the natu- ralistic view if many of our patients are to have appropriate care.

Hot and Cold Conditions and Their Corresponding Treatments

COLD CONDITIONS

HOT TREATMENTS

HOT CONDITIONS

COLD TREATMENTS

CONDITIONS FOODS CONDITIONS FOODS

Cancer Cold Earaches Headaches Joint pain Malaria Menses Pneumonia Stomach

cramps Teething Tuberculosis

Beef Cereals Chili peppers Chocolate Eggs Goat’s milk Liquor Onions Peas

Constipation Diarrhea Fever Infection Kidney

problems Rash Sore throat

Barley water Chicken Dairy products Fresh vegetables Fruits Honey Goat meat Raisins

MEDICINES AND HERBS

MEDICINES AND HERBS

Anise Aspirin Castor oil Cinnamon Cod liver oil Garlic Ginger root Iron Tobacco Penicillin Vitamins

Bicarbonate of soda

Milk of Magnesia Orange flower

water Sage

30 CHAPTER 2 Cultural Competency

30 CHAPTER 2 Cultural Competency C

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patients and display genuine curiosity about their beliefs and values, you will be making strides toward cultural competence. The U.S. Department of Health and Human Services Office of Minority Health provides continuing education, resources, and tools through the “Think Cultural Health” initiative (https://www.thinkculturalhealth.hhs.gov). The RESPECT model is one useful tool to bridge the cultural divide between patients and healthcare providers (Fig. 2.3).

It is not unusual to find tables of information about healthcare–related cultural attitudes for a variety of religious and ethnic groups in reference materials. Although this provides quick access to information about various

culture(s) from which that patient comes. That knowledge should not be formative in arriving at conclusions; rather, we must draw on it to help make the questions we ask more constructively probing to avoid viewing the patient as a stereotype (Box 2.7). You need to understand yourself well. Your involvement with any patient gives that interaction a unique quality, and your contribution to that interaction, to some extent, makes it different from what it might have been with anyone else. Remember that your attitudes and prejudices, which are largely culturally derived, may interfere with your understanding of the patient and increase the probability of unconscious bias and stereotypic judgment. When you’re able to adapt to the unique needs of your

BoX 2.7 Communication

This list of questions, derived over the years from our experience and multiple resources, illustrates the variation in human responses. Try not to be intimidated by the mass of “need to know” cultural issues, but begin reflecting on them as you work with patients to raise your cultural awareness and develop a greater sense of cultural humility. • How important are nonverbal clues? • Are moments of silence valued? • Is touching to be avoided? • Are handshakes, or even embracing, avoided or desired at meeting

and parting? • What is the attitude toward eye contact? • Is there a greater than expected need for “personal space”? • What is the verbal or nonverbal response if your suggestions are

not understood? • Is there candor in admitting lack of understanding? • What are the attitudes concerning respect for self and for authority

figures? • What are the attitudes toward persons in other groups, such as

minorities, majorities? • What are the language preferences? • What is the need for “chit-chat” before getting down to the primary

concern? • Is there a relaxed or rigid sense of time? • What is the degree of trust of healthcare professionals? • How easily are personal matters discussed? • Is there, even with you, a wish to avoid discussing income and other

family affairs?

Health Customs/Health Practices • What is the degree of dependence on the healthcare system, for

illness alone or also for preventive and health maintenance needs? • What is generally expected of a health professional and what defines

a “good one?” • What defines health? • Are there particularly common folk practices? • Is there a greater (or lesser) inclination to invoke self-care and use

home remedies? • Is there a particular suspicion or fear of hospitals? • What is the tendency to use alternative care approaches and/or

herbal remedies exclusively or as a complement? • What are the tendencies to invoke the magical or metaphysical? • Who is ultimately responsible for outcomes, you or the patient?

• Who is ultimately responsible for maintaining health, you or the patient?

• Is there a particular fear of painful or intrusive testing? • Is there a tendency toward stoicism? • What is the dependence on prayer? • Is illness thought of as punishment and a means of penance? • Is there “shame” attached to illness? • What is the belief about the origins of illness? • Is illness thought to be preventable and, if so, how? • What is the attitude toward autopsy? • Does a belief in reincarnation mandate that the body be left intact? • Are there particular cultural cooking habits that can influence diagnosis

or management? • Is the degree of modesty in both men and women more than you

would generally expect? • Do women, considering modesty, need a much more cautious and

protected approach than usual—for example, during the examination?

Family, Friends, and the Workplace • How tightly organized (and multigenerational) is the family

hierarchy? • How tight is the family? • Is social life extended beyond the family and, if so, to what degree? • Does the family tend to be matriarchal or patriarchal? • What are the relative roles of women and men? • Are there particular tasks assigned to individual genders—for example,

who does the laundry, family finances, grocery shopping? • To what extent are older adults and other authority figures given

deference, and how? • Who makes decisions for the family? • To what extent is power shared? • Who makes decisions for the children and adolescents? • How strongly are children valued? • Is there a greater value placed on one of the genders? • How much are self-reliance and personal discipline valued? • What is the work ethic? • What is the sense of obligation to the community? • How is education sought, that is, from school, reading, and/or

experience? • What is the emphasis on tradition and ritual practice?

CHAPTER 2 Cultural Competency 31

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CHAPTER 2 Cultural Competency 31

to meet your patients. Patient by patient, your insights will develop as you avoid stereotypes, consider the individual, and become increasingly culturally competent. View cultural competence as a lifelong journey and not a destination or endpoint in and of itself.

population groups, our experience suggests that the rigid superficiality in this information often does not adequately describe the beliefs and attitudes of a particular individual. Our purpose in this chapter is to review many of the ques- tions and frameworks that might be relevant as you prepare

Guide to Providing Effective Communication and Language Assistance Services www.ThinkCulturalHealth.hhs.gov

The RESPECT Model

What is most important in considering the effectiveness of your cross-cultural communication, whether it is verbal, nonverbal, or written, is that you remain open and maintain a sense of respect for your patients. The RESPECT Model1 can help you remain effective and patient- centered in all of your communication with patients.

apport • Connect on a social level • See the patient’s point of view • Consciously suspend judgment

Recognize and avoid making assumptions

mpathy • Remember the patient has come to you for help • Seek out and understand the patient’s rationale for his/her behaviors and

illness • Verbally acknowledge and legitimize the patient’s feelings

upport • Ask about and understand the barriers to care and compliance • Help the patient overcome barriers; Involve family members if appropriate • Reassure the patient you are and will be available to help

artnership • Be flexible • Negotiate roles when necessary • Stress that you are working together to address health problems

xplanations • Check often for understanding • Use verbal clarification techniques

ultural

competence

• Respect the patient’s cultural beliefs • Understand that the patient’s views of you may be defined by ethnic and

cultural stereotypes • Be aware of your own cultural biases and preconceptions • Know your limitations in addressing health issues across cultures • Understand your personal style and recognize when it may not be working

with a given patient

rust • Recognize that self-disclosure may be difficult for some patients; Consciously

work to establish trust

FIG. 2.3 The RESPECT Model.

32

CHAPTER

3 Examination Techniques and Equipment This chapter provides an overview of the techniques of inspection, palpation, percussion, and auscultation that are used throughout the physical examination. In addition, general use of the equipment for performing physical examination is discussed (Box 3.1). Specific details regarding techniques and equipment as they relate to specific parts of the examination can be found in the relevant chapters. This chapter also addresses special issues related to the physical examination process.

Precautions to Prevent Infection Because persons of all ages and backgrounds may be sources of infection, it is important to take proper precautions when examining patients. Standard Precautions are to be used for the care of all patients in any setting in which health care is delivered. These precautions are designed to prevent the transmission of HIV, hepatitis B, and other blood-borne pathogens based on the principle that all blood, body fluids, secretions, excretions except sweat, nonintact skin, and mucous membranes may contain transmissible infectious agents. Standard Precautions include the following: • Hand hygiene • Personal protective equipment (PPE): use of gloves,

gown, mask, eye protection, or face shield, depending on the anticipated exposure

• Respiratory hygiene/cough etiquette • Safe injection practices • Safe handling of potentially contaminated equipment

or surfaces in the patient environment. Guidelines for Standard Precautions are summarized in Table 3.1. Use precautions to protect yourself and patients. A second tier of precautions, Transmission-Based Precau-

tions, are designed to supplement Standard Precautions in the care of patients who are known or suspected to be infected by epidemiologically important pathogens that are spread by airborne or droplet transmission or by contact with dry skin or contaminated surfaces.

Guidelines and recommendations for the prevention of healthcare-associated infections are available from the Centers for Disease Control and Prevention (https://www .cdc.gov/infectioncontrol/guidelines/index.html).

Latex Allergy Allergic reactions to latex can be potentially serious, although rarely fatal from anaphylaxis. Latex allergy occurs when the body’s immune system reacts to proteins found in natural rubber latex. Latex products also contain added chemicals, such as antioxidants, that can cause irritant or delayed hypersensitivity reactions. Box 3.2 describes the various types of latex reactions.

Healthcare providers are at risk for developing latex allergy because of exposure to latex in the form of gloves and other equipment and supplies. Sensitization to the latex proteins occurs by direct skin or mucous membrane contact or through airborne exposure. Box 3.3 contains a summary of recommendations to protect you from latex exposure in the workplace. Be aware that some patients who have had multiple procedures or surgeries performed are at higher risk for the development of latex allergy. Those patients with latex allergies are at risk when exposed to the latex gloves worn by the clinician. Direct contact is not necessary; inhalation of latex airborne molecules from powder-filled latex gloves can trigger an allergic reaction.

Patient Safety

The Vulnerability of the Health Professional Healthcare providers do not have better immune systems than other people, although we sometimes behave as though we do. Nor are we invincible against the everyday work-related injuries. We stand a much better chance of staying well if we are scrupulous in protecting ourselves: • Follow Standard Precautions. • Use personal protective equipment (PPE) when appropriate. • Minimize latex exposure. • Use good body mechanics or lift devices in transferring or assisting

patients into various positions. NO EXCEPTIONS!

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*During aerosol-generating procedures on patients with suspected or proven infections transmitted by respiratory aerosols, wear a fit-tested N95 or higher respirator in addition to gloves, gown, and face/eye protection. From Siegel et al, 2007.

COMPONENT RECOMMENDATIONS

Hand hygiene After touching blood, body fluids, secretions, excretions, contaminated items; immediately after removing gloves; between patient contacts

Personal protective equipment

Gloves For touching blood, body fluids, secretions, excretions, contaminated items; for touching mucous membranes and nonintact skin

Gown During procedures and patient-care activities when contact of clothing/exposed skin with blood/body fluids, secretions, and excretions is anticipated

Mask, eye protection (goggles), face shield* During procedures and patient-care activities likely to generate splashes or sprays of blood, body fluids, secretions, especially suctioning, endotracheal intubation

Soiled patient-care equipment Handle in a manner that prevents transfer of microorganisms to others and to the environment; wear gloves if visibly contaminated; perform hand hygiene

Environmental control Develop procedures for routine care, cleaning, and disinfection of environmental surfaces, especially frequently touched surfaces in patient-care areas

Textiles and laundry Handle in a manner that prevents transfer of microorganisms to others and to the environment

Needles and other sharps Do not recap, bend, break, or hand-manipulate used needles; if recapping is required, use a one-handed scoop technique only; use safety features when available; place used sharps in puncture-resistant container

Patient resuscitation Use mouthpiece, resuscitation bag, other ventilation devices to prevent contact with mouth and oral secretions

Patient placement Prioritize for single-patient room if patient is at increased risk of transmission, is likely to contaminate the environment, does not maintain appropriate hygiene, or is at increased risk of acquiring infection or developing adverse outcome after infection

Respiratory hygiene/cough etiquette (source containment of infectious respiratory secretions in symptomatic patients, beginning at initial point of encounter, e.g., triage and reception areas in emergency departments and physician offices)

Instruct symptomatic persons to cover mouth/nose when sneezing/coughing; use tissues and dispose in no-touch receptacle; observe hand hygiene after soiling of hands with respiratory secretions; wear surgical mask if tolerated or maintain spatial separation, >3 feet if possible.

TaBLE 3.1 Recommendations for Application of Standard Precautions for the Care of All Patients in All Healthcare Settings

Examination Technique Patient Positions and Draping Most of the physical examination is conducted with the patient in seated and supine positions. Other positions are used for specific aspects of the examination. Special position- ing requirements are discussed in the relevant chapters.

Seated. When seated, position the drape to cover the patient’s lap and legs. You can move it to uncover parts of the body as they are examined.

Supine. In the supine position, the patient lies on his or her back, with arms at the sides and legs extended. The drape should cover the patient from chest to knees or toes.

Box 3.1 What Equipment Do You Need to Purchase?

Students are confronted by a large number and variety of pieces of equipment for physical examination. A commonly asked question is “What do I really need to buy?” The answer depends somewhat on the expectations from your educational program and where you will be practicing. If you are in a clinic setting, for example, wall-mounted ophthalmoscopes and otoscopes are provided. This is not necessarily true in a hospital setting.

The following list is intended only as a guideline to the equipment that you will use most often and should personally own. The price of stethoscopes, otoscopes, ophthalmoscopes, and blood pressure equipment can vary markedly. Different models, many with optional features, can affect the price. Because these pieces of equipment represent a significant monetary investment, evaluate the quality of the instrument, consider

the manufacturer’s warranty and support, and decide on the features that you will need. • Stethoscope • Ophthalmoscope or PanOptic ophthalmoscope • Otoscope • Blood pressure cuff and manometer • Centimeter ruler • Tape measure • Reflex hammer • Tuning forks: 500 to 1000 Hz for auditory screening; 100 to 400 Hz

for vibratory sensation • Penlight • Near vision screening chart

34 CHAPTER 3 Examination Techniques and Equipment Ex

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Again, you can move or reposition the drape to give appropri- ate exposure.

Prone. The patient lies on the stomach. This position may be used for special maneuvers as part of the musculoskeletal examination. Drape the patient to cover the torso.

Dorsal Recumbent. This position may be used for examina- tion of the genital or rectal areas. The patient lies supine with knees bent and feet flat on the table. Place the drape in a diamond position from chest to toes. Wrap each leg with the corresponding lateral corner of the “diamond.” Turn back the distal corner of the drape to perform the examination.

Lateral Recumbent. This is a side-lying position, with legs extended or flexed. The left lateral recumbent position (patient’s left side is down) may be used in listening to heart sounds or palpating the spleen.

Lithotomy. The lithotomy position is generally used for the pelvic examination. Variations of positioning are discussed in Chapter 19. Begin with the patient in the dorsal recumbent position, with feet at the corners of the table. Help the patient to stabilize the feet in the stirrups and slide the buttocks down to the edge of the table. Drape in the diamond position as with the dorsal recumbent position.

Sims. The Sims position can be used for examination of the rectum or obtaining rectal temperature. The patient starts in a lateral recumbent position. The torso is rolled toward a prone position; the top leg is flexed sharply at the hips and knee, and the bottom leg is flexed slightly. Drape the patient from shoulders to toes.

Inspection Inspection is the process of observation. Your eyes and nose are sensitive tools for gathering data throughout the examination (Box 3.4). Take time to practice and develop this skill. Challenge yourself to see how much information you can collect through inspection alone. As the patient enters the room, observe the gait and stance and the ease or difficulty with which getting onto the examining table are accomplished. These observations alone will reveal a great deal about the patient’s neurologic and musculoskeletal integrity. Is eye contact made? Is the demeanor appropriate for the situation? Is the clothing appropriate for the weather? The answers to these questions provide clues to the patient’s emotional and mental status. Color and moisture of the skin or an unusual odor can alert you to the possibility of underlying disease. These preliminary observations require only a few seconds, yet provide basic information that can influence the rest of the examination.

Inspection—unlike palpation, percussion, and auscultation— can continue throughout the history-taking process and during the physical examination. With this kind of continu- ity, observations about the patient can constantly be modified until a complete picture is created. Be aware of both the patient’s verbal statements and body language right up to the end of the encounter. The stance, stride, firmness of handshake, and eye contact can tell you a great deal about the patient’s perception of the encounter (see Clinical Pearl, “The Handshake”).

cLinicaL PEaRL

The Handshake Although a nice gesture (coupled with appropriate hand washing), be careful not to harm your patients by squeezing too tightly, especially those patients with conditions that may involve their hands—rheumatoid arthritis or osteoarthritis, for example.

Box 3.2 Types of Latex Reactions

Irritant contact dermatitis—Chemical irritation that does not involve the immune system. Symptoms are usually dry, itching, irritated areas on the skin, typically the hands.

Type IV dermatitis (delayed hypersensitivity)—Allergic contact dermatitis that involves the immune system and is caused by the chemicals used in latex products. The skin reaction usually begins 24 to 48 hours after contact and resembles that caused by poison ivy. The reaction may progress to oozing skin blisters.

Type I systemic reactions—True allergic reaction caused by protein antibodies (immunoglobulin E antibodies) that form as a result of interaction between a foreign protein and the body’s immune system. The antigen-antibody reaction causes release of histamine, leukotrienes, prostaglandins, and kinins. These chemicals cause the symptoms of allergic reactions. Type I reactions include the following symptoms: local urticaria (skin wheals), generalized urticaria with angioedema (tissue swelling), asthma, eye/nose itching, gastrointestinal symptoms, anaphylaxis (cardiovascular collapse), chronic asthma, and permanent lung damage.

From National Institute for Occupational Safety and Health, 1998.

Box 3.3 Summary of Recommendations for Workers to Prevent Latex Allergy

• Use NONLATEX gloves for activities not likely to involve infectious materials. Hypoallergenic gloves are not necessarily latex free, but they may reduce reactions to chemical additives in the latex.

• For barrier protection when handling infectious materials, use powder-free latex gloves with reduced protein content.

• Use vinyl, nitrile, or polymer gloves appropriate for infectious materials.

When wearing latex gloves, do not use oil-based hand creams or lotions because they may cause glove deterioration • After removing gloves, wash hands with mild soap and dry

thoroughly. • Use good housekeeping practices to remove latex-containing dust

from the workplace. • Take advantage of latex allergy education and training provided. • If you develop symptoms of latex allergy, avoid direct contact with

latex gloves and products

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of the fingers and finger pads is more sensitive than the fingertips. Use this surface whenever discriminatory touch is needed for determining position, texture, size, consistency, masses, fluid, and crepitus. The ulnar surface of the hand and fingers is the most sensitive area for distinguishing vibration. The dorsal surface of the hands is best for estimat- ing temperature. Of course, this estimate provides only a crude measure—use it to compare temperature differences among parts of the body.

Specific techniques of palpation are discussed in more detail as they occur in each part of the examination (see Clinical Pearl, “Right-Sided Examination?”). Palpation may be either light or deep and is controlled by the amount of pressure applied with the fingers or hand. Short fingernails are essential to avoid discomfort or injury to the patient.

TO DETERMINE USE

Position, texture, size, consistency, fluid, crepitus, form of a mass, or structure

Palmar surface of the fingers and finger pads

Vibration Ulnar surfaces of hand and fingers

Temperature Dorsal surface of hand

TaBLE 3.2 Areas of the Hand to Use in Palpation

cLinicaL PEaRL

Right-Sided Examination? It is the convention, at least in the United States, to examine patients from the right side and to palpate and percuss with the right hand. We continue with this convention, if only to simplify description of a procedure or technique. We feel no obligation to adhere strictly to the right-sided approach. Our suggestion is that students learn to use both hands for examination and that they be allowed to stand on either side of the patient, depending on both the patient’s and examiner’s convenience and comfort. The important issue is to develop an approach that is useful and practical and yields the desired results.

Some general guidelines will be helpful as you proceed through the examination and inspect each area of the body. Adequate lighting is essential. The primary lighting can be either daylight or artificial light, as long as the light is direct enough to reveal color, texture, and mobility without distor- tion from shadowing. Secondary, tangential lighting from a lamp that casts shadows is also important for observing contour and variations in the body surface. Inspection should be unhurried. Give yourself time to carefully observe what you are inspecting. Pay attention to detail and note your findings. An important rule to remember is that you have to expose what you want to inspect. All too often, necessary exposure is compromised for modesty, convenience, or haste at the cost of important information. Part of your job is to look and observe critically.

Knowing what to look for is, of course, essential to the process of focused attention. Be willing to validate inspection findings with your patient. The ability to narrow or widen your perceptual field selectively will come with time, experi- ence, and practice.

Palpation Palpation involves the use of the hands and fingers to gather information through the sense of touch. Certain parts of your hands and fingers are better than others for specific types of palpation (Table 3.2). The palmar surface

Touch is in many ways therapeutic, and palpation is the actuality of the “laying on of hands.” Our advice that your approach be gentle and your hands warm is not only practical but also symbolic of your respect for the patient and for the privilege the patient gives you.

Percussion Percussion involves striking one object against another to produce vibration and subsequent sound waves. In the physical examination, your finger functions as a hammer, and the impact of the finger against underlying tissue produces the vibration. Sound waves are heard as percussion tones (called resonance) that arise from vibrations 4 to 6 cm deep in the body tissue. The density of the medium through which the sound waves travel determines the degree of percussion tone. The more dense the medium, the quieter

From Kippenberger et al, 2012.

Box 3.4 The Sense of Smell: The Nose as an Aid to Physical Examination

The first observation when entering an examining room may be an odor, obvious and pervasive. A foreign body that has been present in a child’s nose may cause this. Distinctive odors provide clues leading to the diagnosis of certain conditions, some of which need early detection if life-threatening sequelae are to be avoided. However, do not rush to premature diagnosis. Appreciate these odors for what they are—clues that must be followed up with additional investigation. Examples of odor clues follow:

CONDITION SOURCE OF ODOR TYPE OF ODOR

Inborn errors of metabolism

Phenylketonuria Mousy

Tyrosinemia Fishy

Infectious diseases Tuberculosis Stale beer

Diphtheria Sweetish

Ingestions of poison or intoxication

Cyanide Bitter almond

Chloroform and salicylates

Fruity

Physiologic nondisease states

Sweaty feet Cheesy

Foreign bodies (e.g., in the nose or vagina)

Organic material (e.g., bead in a child’s nose)

Foul-smelling discharge

The odors may range from objectionable to bland to rather pleasant. The examiner often is the one to determine the characterization of the odor.

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on the body surface. Failing to press firmly enough is a common error. On the other hand, pressing too hard on an infant or very young chest can obscure the sound.

Several points are essential in developing the technique of percussion. The downward snap of the striking finger originates from the wrist and not the forearm or shoulder. Tap sharply and rapidly; once the finger has struck, snap the wrist back, quickly lifting the finger to prevent dampen- ing the sound. Use the tip and not the pad of the plexor finger (short fingernails are a necessity). Percuss one location several times to facilitate interpretation of the tone. Like other techniques, percussion requires practice to obtain the skill needed to produce the desired result. Box 3.5 describes common percussion errors. In learning to dis- tinguish between the tones, it may be helpful to close your eyes to block out other sensory stimuli, concentrating exclusively on the tone you are hearing.

You can also use your fist for percussion. Fist percussion is most commonly used to elicit tenderness arising from the liver, gallbladder, or kidneys. In this technique, use the ulnar aspect of the fist to deliver a firm blow to the flank and back areas. Too gentle a blow will not produce enough force to stimulate the tenderness, but too much force can cause unnecessary discomfort, even in a well patient. The force of a direct blow can be mediated by use of a second hand placed over the area. Practice on yourself or a colleague until you achieve the desired middle ground.

the percussion tone. The percussion tone over air is loud, over fluid less loud, and over solid areas soft. The degree of percussion tone is classified and ordered as listed in Table 3.3 and as follows: • Tympany • Hyperresonance • Resonance • Dullness • Flatness

Tympany is the loudest, and flatness is the quietest. Quantification of the percussion tone is difficult, especially for the beginner. For points of reference, as noted in Table 3.3, the gastric bubble is considered to be tympanic; air-filled lungs (as in emphysema) to be hyperresonant; healthy lungs to be resonant; the liver to be dull; and muscle to be flat. Degree of resonance is more easily distinguished by listening to the sound change as you move from one area to another. Because it is easier to hear the change from resonance to dullness (rather than from dullness to resonance), proceed with percussion from areas of resonance to areas of dullness. A partially full milk carton is a good tool for practicing percussion skills. Begin with percussion over the air-filled space of the carton, appreciating its resonant quality. Work your way downward and listen for the change in sound as you encounter the milk. This principle applies in percussion of body tissues and cavities.

The techniques of percussion are the same regardless of the structure you are percussing. Immediate (direct) percussion involves striking the finger or hand directly against the body. Indirect or mediate percussion is a technique in which the finger of one hand acts as the hammer (plexor) and a finger of the other hand acts as the striking surface. To perform indirect percussion, place your nondominant hand on the surface of the body with the fingers slightly spread. Place the distal phalanx of the middle finger firmly on the body surface with the other fingers slightly elevated off the surface. Snap the wrist of your other hand downward, and with the tip of the middle finger, sharply tap the interphalangeal joint of the finger that is on the body surface (Fig. 3.1). You may tap just distal to the interphalangeal joint if you choose, but decide on one and be consistent because the sound varies from one to the other. Percussion must be performed against bare skin. If you are not able to hear the percussion tone, try pressing harder against the patient’s skin with your finger that lies

TONE INTENSITY PITCH DURATION QUALITY EXAMPLE WHERE HEARD

Tympanic Loud High Moderate Drumlike Gastric bubble

Hyperresonant Very loud Low Long Boomlike Emphysematous lungs

Resonant Loud Low Long Hollow Healthy lung tissue

Dull Soft to moderate Moderate to high Moderate Thudlike Over liver

Flat Soft High Short Very dull Over muscle

TaBLE 3.3 Percussion Tones

FiG. 3.1 Percussion technique: tapping the interphalangeal joint. Only the middle finger of the examiner’s nondominant hand should be in contact with the patient’s skin surface.

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together. Do not anticipate the next sound; concentrate on the one at hand. Auscultation of the lungs is discussed in Chapter 14, of the heart in Chapter 15, and of the abdomen in Chapter 18.

Modifications for Patients With Disabilities Each disability affects each person differently; therefore, it is important for healthcare providers to educate themselves about relevant aspects of a patient’s disability. Sensitivity in asking only pertinent questions about the disability will increase the patient’s comfort and cooperation.

Keep some considerations in mind about the environment and the encounter. Speak directly to the patient. Often people will address a disabled person’s spouse, friend, an attendant, or an interpreter instead of speaking directly to the person. Remove or rearrange the furnishings in the examination room to provide space, such as that needed for a wheelchair. Take the paper covering off the examination table if it is a bother during transfers and positioning. Equipment such as a high-low examination table or a particularly wide examination table or a slide board can be obtained to facilitate safer, easier transfers and positioning. Obstetric or foot stirrups can be padded or equipped with a strap to increase the patient’s comfort and safety during a pelvic examination. For the pelvic examination, a patient can wear an easily removable skirt or pair of pants. A button-up or zippered shirt will facilitate the breast examina- tion. It is appropriate to suggest to your patient or the caregiver that such clothing be worn for future visits.

Patients With Mobility Impairments The patient is the expert in transferring from the wheelchair or in using assistants to climb onto the examination table. Transfers are relatively simple if the patient, assistant, and healthcare provider all understand the method that will best suit the patient’s disability, the room space, and the examination table (Box 3.6). You need to know your own physical limits for lifting or moving a patient—always seek assistance if uncertain. This will avoid falls and injuries to both you and the patient.

Pivot Transfer. Stand in front of the patient, take the patient’s knees between your own knees, grasp the patient around the back and under the arms, raise the patient to a vertical position, and then pivot from wheelchair to the table. The examination table must be low enough for the patient to sit on; therefore, a hydraulic high-low table may be needed when using this transfer method.

Cradle Transfer. While bending or squatting beside the patient, put one arm under both of the patient’s knees and the other arm around the back and under the armpits. Stand and carry the patient to the table.

Two-Person Transfer. In all two-person transfers, the assistants must be careful to work together to lift the patient

Auscultation Auscultation involves listening for sounds produced by the body. Some sounds, such as speech, are audible to the unassisted ear. Most others require a stethoscope to augment the sound. Specific types of stethoscopes, their use, and desired characteristics are discussed later in the section on stethoscopes.

There are some general principles that apply to all auscultatory procedures. The environment should be quiet and free from distracting noises. Place the stethoscope on the naked skin because clothing obscures the sound. Listen not only for the presence of sound but also its characteristics: intensity, pitch, duration, and quality. The sounds are often subtle or transitory, and you must listen intently to hear the nuances. Closing your eyes may prevent distraction by visual stimuli and narrow your perceptual field to help you focus on the sound. Try to target and isolate each sound, concentrating on one sound at a time. Take enough time to identify all the characteristics of each sound. Auscultation should be carried out last, except with the abdominal examination, after other techniques have provided informa- tion that will assist in interpreting what you hear (see Clinical Pearl, “Unexpected Findings”).

cLinicaL PEaRL

Unexpected Findings Respect your judgment and your instinct when you identify a physical examination finding you had not expected to find. Pay attention when this occurs, even if it does not seem to make sense or you cannot explain it easily. The flip side—not finding a previously documented “abnormal” finding—may simply be a learning opportunity, or it may reflect a change in the patient’s condition. It is OK to say “I couldn’t hear that” or “I’m not sure I felt that.” If in doubt, have someone else check it with you.

One of the most difficult achievements in auscultation is learning to isolate sounds. You cannot hear everything all at once. Whether it is a breath sound, a heartbeat, or the sequence of respirations and heartbeats, each segment of the cycle must be isolated and listened to specifically. After the individual sounds are identified, they are put

Box 3.5 Common Percussion Errors

Percussion requires practice. In learning percussion, beginning healthcare providers often make the following errors: • Failing to exert firm pressure with the finger placed on the skin

surface • Failing to separate the hammer finger from other fingers • Snapping downward from the elbow or shoulder rather than from

the wrist • Tapping by moving just the hammer finger rather than the whole

hand • Striking with the finger pad rather than the fingertip of the hammer

finger • Failing to trim the fingernail of the hammer finger

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T the patient’s back and under the knees and then stand and carry the patient to the table.

Equipment. Some persons with mobility impairments use a slide board, which forms a bridge to slide across from the wheelchair to the examination table. For this method to work, the table and chair must be approximately the same height. Most examination tables, however, are quite a bit higher than wheelchairs. Some examining rooms have high-low examination tables that can be adjusted to a height that will facilitate the safest and easiest transfer. A wider table, even if it is not adjustable in height, can also make transfers and positioning easier.

Patients With Sensory Impairment At the beginning of the visit by a patient with a hearing or speech impairment, discuss the communication system that will be used (e.g., a sign language interpreter, word board, or talk box). Specialized educational materials (e.g., Braille or audiotaped information, or three-dimensional anatomic models) can be acquired to make information accessible to sensory-impaired patients.

Impaired Vision. Remember to identify yourself upon enter- ing the examination room and inform the patient when you are leaving the room. A red-tipped white cane and guide animal are mobility aids used by many persons with visual impairments. If a patient is accompanied by a guide animal, do not pet or distract the animal, which is trained to respond only to its owner. A patient may prefer to keep the guide animal or white cane nearby in the examination room. Do not move either of these without the patient’s permission. Before the examination, ask whether the patient would like to examine any equipment or instruments that will be used during the examination. If three-dimensional models are available, they can be used to acquaint the patient with the examination process (e.g., with the genital examination). During the examination, the patient may feel more at ease if you maintain continuous tactile or verbal contact (e.g., by keeping a hand on the arm or by narrating what is taking place during the examination).

Some patients with visual impairments will want to be oriented to their surroundings, whereas others may not. Each should be encouraged to specify the kind of orienta- tion and assistance needed. Verbally describe and assist the patient in locating where to put the clothes, where the various furnishings are positioned, how to approach the examination table, and how to get positioned on the table.

Impaired Hearing or Speech. The patient should choose which form of communication to use during the examination (e.g., a sign language interpreter, lipreading, or writing). Although a patient may use an interpreter throughout most of the visit, she or he may decide not to use the interpreter during parts of the actual examination. If an interpreter is used, you and the patient should decide where the interpreter should stand or sit. When working with an interpreter, speak

over the arms of the wheelchair from a sitting position onto the examination table. A stronger, taller person should always lift the upper half of the patient’s body. • Method 1 requires the patient to fold the arms across

the chest. The assistant standing behind the patient kneels down, putting his or her elbows under the patient’s armpits, and grasps the patient’s opposite wrists. The second assistant lifts and supports the patient under the knees.

• Method 2 can be used if the patient cannot fold the arms. The assistant standing behind the patient puts his or her own hands together around the patient, if possible, so that there is less likelihood of losing hold of the patient. The second assistant lifts and supports the patient under the knees.

• Cradle transfer is a variation of the one-person cradle transfer. Two assistants grasp each other’s arms behind

Box 3.6 Transfer Guidelines

Guidelines for the Assistant The patient/parent/caregiver should direct the transfer and positioning

process. Assistants should not overestimate their ability to lift. Keep in mind that not all nonambulatory patients need assistance. Assistants should keep their backs straight, bend their knees, and lift

with their legs. It may be helpful to perform a test lift or to practice the transfer by

lifting the patient just over the wheelchair before attempting a complete transfer.

Assistants who feel that they may drop a patient during a transfer should not panic. It is important, whenever possible, to explain what is happening to reassure the patient throughout the situation. Assistants will usually have time to lower the patient safely to the floor until they can get additional help.

Guidelines for the Patient Explain clearly the preferred transfer method and direct the healthcare

provider and assistants during the process. Assistants can help by preparing equipment. Because many people

are not familiar with wheelchairs or supportive devices, the patient may need to explain to the healthcare providers and assistants how they can handle belongings. Patients who use wheelchairs should explain how to apply the brakes, detach the footrests and armrests, or turn off the motor of an electric wheelchair. Have the patient who wears adaptive devices (e.g., leg braces or supportive undergarments) explain how to remove them, if necessary, and where to put them if the patient cannot do so.

Patients who use urinary equipment should direct assistants in the moving or straightening of catheter tubing. The patient may wish to unstrap the leg bag and place it on the table beside or across the abdomen for proper drainage while supine. Assistants should be reminded not to pull on the tubing or allow kinks to develop.

Have the patient inform the healthcare provider and assistants when he or she is comfortable and balanced after the transfer is completed.

All parties should be aware of jewelry, clothing, tubing, or equipment that might catch or otherwise interfere with the transfer.

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body before the examination. Some patients may experience variable responses (e.g., spasms or pain) to ordinary tactile stimulation. Often, you can avoid sensitive areas or use an extra amount of lubricant jelly to decrease friction or pressure.

Spasticity. Spasms may range from slight tremors to quick, violent contractions. Spasms may occur during a transfer, while assuming an awkward or uncomfortable position, or from stimulation of the skin with an instrument. If spasm occurs during the examination, gently support the area (usually a leg, an arm, or the abdominal region) to avoid any injury to the patient. Allow the spasms to resolve before continuing the examination. A feeling of physical security can decrease spasm intensity or frequency. A patient who experiences spasms should never be left alone on the examination table. Have an assistant stand near the examina- tion table and maintain physical contact with the patient to provide a feeling of safety.

Equipment Weight Scales and Height Measurement Devices Height and weight of adults are measured on a standing platform scale with a height attachment. The scale uses a system of adding and subtracting weight in increments as small as 0.1 kg to counterbalance the weight placed on the scale platform. Manually calibrate the scale each time it is used to ensure its accuracy.

For manual scales, calibrate the scale to zero before the patient mounts the platform by moving both the large and small weights to zero. Level and steady the balance beam by adjusting the calibrating knob. Pull up the height attach- ment, before the patient steps on the scale, and then position the headpiece at the patient’s crown (Fig. 3.2). Place a paper towel on the platform before the patient steps on it to avoid the potential transmission of organisms from bare feet.

With electronic scales, weight is calculated electronically and provided as a digital readout. These scales are automati- cally calibrated each time they are used. Always note what the patient is wearing: adults and older children should wear lightweight clothing for more accurate measurement

The infant platform scale is used for measuring weights of infants and small children (Fig. 3.3). It works the same as the adult scale but measures in grams. The scale has a platform with curved sides in which the child may sit or lie. Place paper under the child, and never leave the child unattended on the scale. Weigh the infant either nude or with only a diaper for accuracy of weight.

Infant lengths can be measured by using an infant measuring device that comes with a rigid headboard and movable footboard (Fig. 3.4, A). An alternative to the rigid measuring device is a commercially available measure mat, consisting of a soft rubber graduated mat attached to a plastic headboard and footboard (Fig. 3.4, B). Place the measuring board on the table so that the headboard and footboard are perpendicular to the table. Position the infant

at a regular speed and directly to the patient instead of to the interpreter. If a patient wishes to lipread, be careful not to move your face out of sight of the patient without first explaining what you are doing. Look directly at the patient and enunciate words clearly. Some patients may wish to view a pelvic examination with a mirror while it is happening.

Special Concerns for Patients With Spinal Cord Injury or Lesion Bowel and bladder concerns and other conditions such as hyperreflexia, hypersensitivity, and spasticity should be given special attention during the examination process.

Bowel and Bladder Concerns. Some patients do not have voluntary bladder or bowel movements. A bladder or bowel routine could affect the pelvic or rectal examination. The physical stimulation of a speculum, bimanual, or rectal examination can mimic the stimulation for the bowel routine and cause a bowel movement during the examination. An indwelling catheter need not be removed during the examination unless it is not working; if it is removed, another catheter should be available for insertion. Likewise, it is not necessary to remove the catheter during a pelvic examination as it will not interfere.

If a patient uses intermittent catheterization to manually open the bladder sphincter at regular intervals during the day, tactile stimulation in the pelvic area during the examina- tion could cause the bladder sphincter to open and produce incontinence.

Autonomic Hyperreflexia. Autonomic hyperreflexia, also called dysreflexia, is a potentially life-threatening condi- tion associated with high-level spinal cord injury (T6 or higher), which can occur even after the acute injury phase. Symptoms include severe high blood pressure, sweating, blotchy skin, nausea, or goose bumps due to stimulation of the bowel, bladder, or skin below the spinal lesion. Some causes of hyperreflexia that may occur during the physical examination include reactions to a cold, hard examina- tion table or cold stirrups; insertion and manipulation of a vaginal speculum; pressure during the bimanual or rectal examination; or tactile contact with hypersensitive areas. If the patient experiences hyperreflexic high blood pressure, identify and remove the source of the stimulation. Once the hyperreflexia ceases, you and the patient should mutually decide whether to continue the examination. If the examination is continued and hyperreflexia recurs, stop the examination and reschedule for another time. If the blood pressure does not decrease with removal of stimulus, or if the hyperreflexic symptoms persist and lead to a throb- bing headache or nasal obstruction, treat the situation as a medical emergency. Do not leave a patient experiencing any degree of hyperreflexia unaccompanied.

Hypersensitivity. To help prevent possible discomfort or spasms, ask the patient about hypersensitive areas of the

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another at the heel of the extended leg. Then measure the length from pin to pin. The same technique can be used with a marking pen if the infant is lying on a disposable paper sheet.

Once a child is able to stand erect without support, use a stadiometer, a stature-measuring device, to measure height. The device consists of a movable headpiece attached to a rigid measurement bar and platform. Standing height is measured barefoot. With the child standing with the shoulders, buttocks, and heels against the wall, lower the head piece to the crown of the child’s head (Fig. 3.5).

Thermometer Electronic temperature measurement has decreased the time required for accurate temperature readings. One piece of equipment that contains an electronic sensing probe can be used for measurement of rectal, oral, and axillary temperatures (Fig. 3.6, A). The probe, covered by a dispos- able sheath, is placed under the tongue with the mouth tightly closed, in the rectum, or in the axillary space with the arm held close to the torso. A temperature reading (in either Fahrenheit or Celsius) is revealed on a digital display within 15 to 60 seconds, depending on the model used.

Professional grade infrared thermometers are also avail- able, which infer temperature from the thermal radiation from the patient source such as the temporal artery or the tympanic membrane, which shares its blood supply with the hypothalamus in the brain. The measurements obtained vary somewhat from those obtained by oral or rectal routes (Fig. 3.6, A) (El-Radhi, 2014; Gasim et al, 2013; Hamilton et al, 2013; Niven et al, 2015). In some situa- tions, as with very young infants or with the critically ill, traditional routes of measurement may be more accurate; in other situations, such as with children in an outpatient setting, an infrared thermometer is preferred. For tympanic

supine on the measuring board with the head against the headboard and knees held straight. Move the footboard until it touches the bottom of the infant’s feet. The infant’s length can be read in either inches or centimeters. Be sure to clean the mat between uses.

Infants can also be measured by placing them on a pad, putting one pin into the pad at the top of the head and

FiG. 3.2 Platform scale with height attachment.

FiG. 3.3 Infant platform scale.

A

B

FiG. 3.4 Devices used to measure length of an infant. A, Infant length board. B, Measure mat. (A, Courtesy Perspective Enterprises, Inc., Portage, MI. B, Courtesy Seca North America, Medical Scales and Measuring Systems, Seca Corp.)

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Stethoscope Auscultation of most sounds requires a stethoscope. Three basic types are available: acoustic, magnetic, and electronic (also called digital).

The acoustic stethoscope is a closed cylinder that trans- mits sound waves from their source and along its column to the ear (Fig. 3.7). Its rigid diaphragm has a natural frequency of around 300 Hz. It screens out low-pitched sounds and best transmits high-pitched sounds such as the second heart sound. The bell end piece has a natural frequency that varies with the amount of pressure exerted. It transmits low-pitched sounds when very light pressure is used. With firm pressure, the skin converts it to a dia- phragm end piece. The chest piece contains a closure valve so that only one end piece, either the diaphragm or bell, is operational at any one time (thus preventing inadvertent dissipation of sound waves).

The stereophonic stethoscope, a type of acoustic stetho- scope, is used to differentiate between the right and left auscultatory sounds using a two-channel design (Fig. 3.8). With a single tube, diaphragm, and bell, it looks and func- tions like an acoustic stethoscope. However, the right and left ear tubes are independently connected to right and left semicircular microphones in the chest piece.

The magnetic stethoscope has a single end piece that is a diaphragm. It contains an iron disk on the interior surface; behind this is a permanent magnet. A strong spring keeps the diaphragm bowed outward when it is not com- pressed against a body surface. Compression of the dia- phragm activates the air column as magnetic attraction is established between the iron disk and the magnet. Rotation of a dial adjusts for high-, low-, and full-frequency sounds.

The electronic stethoscope picks up vibrations transmit- ted to the surface of the body and converts them into electrical impulses. The impulses are amplified and transmitted to a speaker, where they are reconverted to sound. Newer versions of the electronic stethoscope can also provide additional features such as extended listening

membrane temperature measurement, a specially designed probe similar in shape to an otoscope is required. Gently place the covered probe tip at the external opening of the ear canal. Do not try to force the probe into the canal or to occlude it. The temperature is displayed in a few seconds.

A B

FiG. 3.6 Devices for electronic temperature measurement. A, Rectal, oral, or axillary thermometer. B, Tympanic membrane thermometer. (Courtesy Welch Allyn, Inc., Skaneateles Falls, NY.)

FiG. 3.7 Acoustic stethoscope.

FiG. 3.5 Device used to measure height of a child. (Courtesy Perspective Enterprises, Portage, MI.)

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bell functions by picking up vibrations, it must be positioned so that the vibrations are not dampened. Place the bell evenly and lightly on the skin, making sure there is skin contact around the entire edge. To prevent extraneous noise, do not touch the tubing with your hands or allow the tubing to rub against any surfaces.

Sphygmomanometer Blood pressure is measured indirectly with a stethoscope and either an aneroid or mercury sphygmomanometer. Electronic sphygmomanometers, which do not require the use of a stethoscope, are also available. Each sphygmoma- nometer is composed of a cuff with an inflatable bladder, a pressure manometer, and a rubber hand bulb with a pressure control valve to inflate and deflate the bladder. The electronic sphygmomanometer senses vibrations and converts them into electric impulses. The impulses are transmitted to a device that translates them into a digital readout. The instrument is relatively sensitive and is also capable of simultaneously measuring the pulse rate. It does not, however, indicate the quality, rhythm, and other characteristics of a pulse and should not be used in place of your touch in assessing pulse.

Pulse Oximeter Pulse oximetry measures the percentage of hemoglobin saturated with oxygen (oxyhemoglobin). Oxygen saturation is a measure of how much oxygen the blood is carrying as a percentage of the maximum it could carry. A sensor attached to a digit or earlobe has two light-emitting diodes, one that sends out invisible infrared light and one that sends out red light. Oxygenated hemoglobin absorbs more infrared light and allows more red light to pass through. Deoxygenated hemoglobin absorbs more red light and allows more infrared light to pass through. The ratio of the absorp- tion is used to calculate the oxy/deoxyhemoglobin ratio. The difference between the two gives a measure of the fraction of the oxyhemoglobin in the blood. The readout displays the result as a percentage.

Pulse oximetry requires a reasonably translucent site with good blood flow. Typical adult/pediatric sites are the finger, toe, pinna (top) or lobe of the ear. Infant sites are

ranges, digital readout, sound recording and storage, playback, murmur interpretation, visual display, tubeless connection, and electronic device linkage.

The traditional and most commonly used is the acoustic stethoscope, which comes in several models. The ability to auscultate accurately depends in part on the quality of the instrument, so it is important that the stethoscope have the following characteristics: • The diaphragm and bell are heavy enough to lie firmly

on the body surface. • The diaphragm cover is rigid. • The bell is large enough in diameter to span an intercostal

space in an adult and deep enough so that it will not fill with tissue.

• The bell and diaphragm are pediatric-sized for use in children

• A rubber or plastic ring is around the bell edges to ensure secure contact with the body surface.

• The tubing is thick, stiff, and heavy; this conducts better than thin, elastic, or very flexible tubing.

• The length of the tubing is between 30.5 and 40 cm (12 and 18 inches) to minimize distortion.

• The earpieces fit snugly and comfortably. Some instru- ments have several sizes of earpieces and some have hard and soft earpieces. The determining factors are how they fit and feel to the examiner. The earpieces should be large enough to occlude the auditory canal, thus blocking outside sound. If they are too small, they will slip into the ear canal and be painful.

• Angled binaurals point the earpieces toward the nose so that sound is projected toward the tympanic membrane. To stabilize the stethoscope when it is in place, hold the

end piece between the fingers, pressing the diaphragm firmly against the skin (Fig. 3.9). The diaphragm piece should never be used without the diaphragm. Because the

A B

FiG. 3.8 Stereophonic stethoscope. Note divided bell and diaphragm.

FiG. 3.9 Position the stethoscope between the index and middle fingers against the patient’s bare skin.

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the best signal. Arterial flow is heard as a pulsatile pumping sound, and venous flow resembles the sound of rushing wind. When using a Doppler, do not press so hard as to impede blood flow.

The Doppler can be used to detect systolic blood pres- sures in patients with weak or difficult-to-hear sounds (e.g., patients in shock, infants, or obese persons). It is used to auscultate fetal heart activity, locate vessels, take weak pulses, and assess vessel patency. Other uses include localization of acute and chronic arterial occlusions in the extremities, assessment of deep vein thrombosis and valvular incompetency, and assessment of testicular torsion and varicocele.

Portable Ultrasound Compact portable units (CPUs) are used for bedside and point-of-care ultrasonography (POCUS) (Wilson & Mayo, 2016). The ultrasound unit uses a transducer to emit sounds and detect returning echoes that are produced when the sound wave strikes an object. The returning echoes identify the distance, size, and shape of the object. A CPU analyzes the echoes and transforms them into a two- or three- dimensional image of the organs or tissues being examined. Ultrasound waves pass easily through fluids and soft tissues, making the procedure especially useful for assessing fluid- filled organs such as the urinary bladder for fullness, disten- tion, and incomplete emptying, and soft organs such as the gallbladder and liver. Because ultrasound produces dynamic moving images, it can show the structure and movement of the body’s internal organs, as well as blood flowing through blood vessels. Abnormalities that can be detected by ultrasound include cysts, tumors, fluid collection, infections, structural abnormalities of organs, and blockages in major blood vessels. Ultrasound provides a visual aid to improving targeted clinical procedures such as aspiration and drainage of pleural effusions, abscesses, and biopsies. Use of the ultrasound device requires training and skilled operation.

Fetal Monitoring Equipment The fetal heart rate is determined by the use of specially designed instruments called the fetoscope and Leff scope; by use of the clinical stethoscope, addressed previously; or with an electronic instrument that uses the Doppler effect. The fetoscope has a band that fits against the head of the listener and makes handling of the instrument unnecessary (Fig. 3.12). The metal band also aids in bone conduction of sound, so that the heart tones are heard more easily. The Leff scope has a weighted end that, when placed on the abdomen, does not need stabilization by the healthcare provider. These instruments can detect the fetal heart rate at 17 to 19 weeks of gestation.

The Doppler method employs a continuous ultrasound that picks up differing frequencies from the beating fetal heart. It is a more sensitive method and can detect the fetal heart at 10 to 12 weeks of gestation, and even earlier in some individuals. These instruments are often supplied

the foot or palm of the hand and the big toe or thumb (Fig. 3.10). The oximeter detects the slight change in color of the arterial blood caused by the beat of the heart when blood is pushed into the finger (or earlobe or toe). Because the change in color is so minute, it is imperative to ensure a strong pulse during testing. When the pulse is weak, the results may be inaccurate.

Doppler Some sounds are so difficult to auscultate that a regular stethoscope will not suffice. Dopplers are useful at these times (Fig. 3.11). Dopplers are ultrasonic stethoscopes that detect blood flow rather than amplify sounds, and they vary in frequency from 2 to 10 MHz. The use of a Doppler requires that you first place transmission gel over the skin area where you will be listening. Then place the tip of the instrument directly over the area being examined. Tilt the tip at an angle along the axis of blood flow to obtain

FiG. 3.10 Pulse oximeter monitor and sensor. (©2017 Medtronic. All rights reserved. Used with the permission of Medtronic.)

FiG. 3.11 Doppler.

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(described in Table 3.4) are selected by rotating the aperture selection dial.

The lenses in varying powers of magnification are used to bring the structure under examination into focus by converging or diverging light. An illuminating lens indicator displays the lens number positioned in the viewing aperture. The number, ranging from about ±20 to ±140, corresponds to the magnification power (diopter) of the lens. The positive numbers (plus lenses) are shown in black, and the nega- tive numbers (minus lenses) are shown in red. A way to remember this is that when you are using a minus lens, you are in the red. Clockwise rotation of the lens selector brings the plus sphere lenses into place. Counterclockwise rotation brings the minus sphere lenses into place. Fig. 3.14 shows the expected lens diopters to focus on eye structures. The system of plus and minus lenses can compensate for myopia or hyperopia in both the examiner and the patient. There is no compensation for astigmatism.

with amplifiers so that both the healthcare provider and parents can hear the fetal heartbeat at the same time.

Ophthalmoscope The ophthalmoscope has a system of lenses and mirrors that enables visualization of the interior structures of the eye (Fig. 3.13). The instrument has a light source that projects through various apertures while you focus on the inner eye. The large aperture, the one used most often, produces a large round beam. The various apertures

FiG. 3.12 Fetoscope.

Rubber brow rest

Lens selector

disk

Illuminated lens

indicator

Receptacle

Adapter

On/off switch

FiG. 3.13 Ophthalmoscope.

APERTURE EXAMINATION USE

Small aperture Small pupils

Red-free filter Produces a green beam for examination of the optic disc for pallor and minute vessel changes; also permits recognition of retinal hemorrhages, with blood appearing black

Slit Examination of the anterior eye and determination of the elevation of lesions on the retina

Grid Estimation of the size of fundal lesions

TaBLE 3.4 Apertures of the Ophthalmoscope

Posterior chamber Ciliary body

Hyaloid canal

Macula

Optic nerve

�20

�12

�7

�6

�5

�0

Canal for central retinal

vessels

Fovea

Sclera

Choroid

Retina

Vitreous

Canal of Schlemm

Anterior chamber

Iris muscle

Lens

Cornea

FiG. 3.14 Longitudinal cross section of eye showing lens diopters to focus on eye structures.

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CHAPTER 3 Examination Techniques and Equipment 45

a result, subtle eye movements associated with strabismus are more easily detected. With the StrabismoScope in place, watch for movement in both the covered and the uncovered eye. Repeat with the other eye. The instrument comes with test instructions and a guide to interpretation of test results.

Photoscreening Photoscreening is used to detect amblyopia (lazy eye) and strabismus in children through the use of an appropriately equipped camera or video system to obtain images of pupillary reflexes and red reflexes. Various optical systems can be used for photoscreening. The child need only visually fixate on the appropriate target long enough for the pho- toscreening to occur. Data are then analyzed by the evaluator, reviewing center, or electronically.

Visual Acuity Charts Snellen Alphabet and Sloan Letters Charts. The Snellen alphabet and Sloan letters charts are used for a screening examination of far vision (Fig. 3.17, A,B) for literate, verbal, and English-speaking adults and school-age children. The Snellen chart contain letters of graduated sizes; the Sloan letters chart presents letters that are almost equal in leg- ibility (C, D, H, K, N, O, R, S, V, Z) in a standardized fashion. Both types of charts come with standardized numbers at the end of each line of letters. These numbers indicate the degree of visual acuity when read from a dis- tance of 20 feet. Some charts are standardized for use at 10 feet.

Test visual acuity for each eye using the standardized numbers on the chart. Visual acuity is recorded as a fraction, with the numerator of 20 (the distance in feet between the patient and the chart) and the denominator as the distance from which a person with normal vision could read the lettering. The larger the denominator, the poorer is the vision. The standard used for normal vision is 20/20. Measurement other than 20/20 indicates either a refractive error or an optic disorder. Record the smallest complete

Seat the ophthalmoscope head in the handle by fitting the adapter of the handle into the head receptacle and pushing downward while turning the head in a clockwise direction. The two pieces lock into place.

Turn on the ophthalmoscope by depressing the on/off switch and turning the rheostat control clockwise to the desired intensity of light. Turn the instrument off when you have finished using it to preserve the life of the bulb.

The ophthalmoscopic examination is discussed in more detail in Chapter 12.

PanOptic Ophthalmoscope The “panoramic” ophthalmoscope head uses an optical design that allows a larger field of view (25 degrees versus the standard 5 degrees), and increases magnification. As a result, the view of the fundus is five times larger than the view achieved with the standard ophthalmoscope in an undilated eye. The PanOptic head connects to a standard handle (Fig. 3.15). Both the PanOptic and other models come with a smartphone adapter that can be used to photograph and video the fundus.

StrabismoScope The StrabismoScope is used for detecting strabismus (eye misalignment) and can be used as part of eye testing in children (Fig. 3.16). Instruct the child to focus on an accom- modative target, such as the wall poster that comes with the instrument. Turn on the StrabismoScope and place it over the patient’s eye. Because of a one-way mirror, you are able to see in but the patient is not able to see out. As

FiG. 3.15 PanOptic ophthalmoscope. (Courtesy Welch Allyn, Skaneateles Falls, NY.)

ABS housing

3.5v halogen lamp

Semi-silvered (one-way) mirror— allows direct observation of occluded eye

FiG. 3.16 StrabismoScope. (Courtesy Welch Allyn, Skaneateles Falls, NY.)

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LH Symbols (LEA Symbols). The LEA Symbols chart consists of four optotypes (circle, square, apple, house) that blur equally. The child has to find a matching block or point to the shape that matches the target presented. The visual acuity is determined by the smallest symbols that the child is able to identify accurately at 10 feet. For example, if the child is able to identify the 10/15 symbols at 10 feet, then the child’s visual acuity is 10/15 or 20/30. If it is not possible to perform testing at 10 feet, move closer to the child until he or she correctly identifies the largest symbol. Proceed down in size to the smallest symbols that the child is consistently able to correctly identify. Record the acuity as the smallest symbol identified (bottom number) at the testing distance (top number). For example, correctly identifying the 10/15 symbols at 5 feet is recorded as 5/15 or 20/60.

Near Vision Charts To assess near vision, a specially designed chart such as the Rosenbaum or Jaeger chart can be used, or simply use newsprint. The Rosenbaum chart contains a series of numbers, E’s, X’s, and O’s in graduated sizes. Test and record vision for each eye separately. Acuity is recorded as either distance equivalents such as 20/20 or Jaeger equivalents such as J-2. Both these measures are indicated on the chart. If newsprint is used, the patient should be able to read it without difficulty.

line that the patient can read accurately without missing any letters. If the patient is able to read some but not all letters of the next smaller line, indicate this by adding the number of letters read correctly on that next line (e.g., 20/25 + 2). This would indicate that the patient read all of the letters in the 20/25 line correctly and also two of the letters of the 20/20 line correctly.

For young children or adults not able to use the Snellen or Sloan chart, other options are available. The highest difficulty of test that the child is capable of performing should be used. In general, the HOTV characters or LEA symbols should be used for children 3 to 5 years of age, and Sloan letters or Snellen letters or numbers for children 6 years and older (American Academy of Pediatrics, 2015). For children, cover the nontested eye by an occluder held by the examiner or by an adhesive occluder patch applied to the eye. Ensure that it is not possible to peek with the nontested eye. Children usually stand 10 feet (3 m) away from the visual chart to minimize distraction (one standard- ized for that distance). Young children require training before testing.

HOTV. This test consists of a wall chart composed only of H’s, O’s, T’s, and V’s. The child is given a testing board containing a large H, O, T, and V. Point to a letter on the wall chart, and ask the child to point to (match) the correct letter on the testing board.

A

B

FiG. 3.17 Charts for testing distant vision. A, Snellen chart. B, Sloan chart. (B from Galetta and Balcer, 2012.)

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lie down. You will need to tilt the patient’s head at various angles for a complete nasal examination. Stabilize the speculum with your index finger to avoid contact of the blades with the nasal septum, which can cause discomfort. Squeezing the handles of the instrument opens the blades.

Tympanometer Various instruments are used to perform screening tym- panometry. Tympanometry is a simple, reliable, and objective means of assessing the functions of the ossicular chain, eustachian tube, and tympanic membrane, as well as the interrelation of these parts.

Position the probe at the opening of the ear canal (Fig. 3.20). When a tight seal is obtained, a known quantity of sound energy is introduced into the ear. The amount of the sound energy transmitted is the amount of sound energy introduced minus the amount of sound energy that returns to the probe microphone. The amount of energy transmitted is directly related to the compliance of the system. Compli- ance (measured in milliliters or cubic centimeters of

Amsler Grid A screening test for use with individuals at risk of macular degeneration is provided with the Amsler grid. The grid monitors about 10 degrees of central vision and is used when retinal drusen bodies are seen during an ophthal- mologic examination or when there is a strong family history of macular degeneration. The grid consists of straight lines that resemble graph paper. At the center of the grid is a black dot that acts as a fixation point. The patient views the grid with one eye at a time and notes the occurrence of line distortion or actual scotoma (see Chapter 12).

Otoscope The otoscope provides illumination for examining the external auditory canal and the tympanic membrane (Fig. 3.18). The traditional otoscope head is seated in the handle in the same manner as the ophthalmoscope and is turned on the same way. Newer models can provide a macro view and operate slightly differently. An attached speculum narrows and directs the beam of light. Select the largest size speculum that will fit comfortably into the patient’s ear canal. Chapter 13 discusses the specific techniques of examination.

You can also use the otoscope for the nasal examination if a nasal speculum is not available. Use the shortest, widest otoscope speculum and insert it gently into the patient’s naris.

The pneumatic attachment for the otoscope is used to evaluate the fluctuating capacity of the tympanic membrane. A short piece of rubber tubing is attached to the head of the otoscope. A hand bulb attached to the other end of the tubing, when squeezed, produces puffs of air that cause the tympanic membrane to move.

Nasal Speculum Use the nasal speculum with a penlight to visualize the lower and middle turbinates of the nose (Fig. 3.19). Be sure that the patient is in a comfortable position. You may need to support the patient’s head, or you can have the patient

FiG. 3.18 Otoscope with various sizes of specula and a pneumatic attachment.

FiG. 3.19 Nasal specula.

FiG. 3.20 Tympanometer. (Courtesy Welch Allyn, Skaneateles Falls, NY.)

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tone that is above the threshold level and requires time to quiet to a tone appropriate for auditory testing. The specific tuning fork tests for hearing are described in Chapter 13.

For vibratory sensation, use a fork of lower frequency. The greatest sensitivity to vibration occurs when the fork is vibrating between 100 and 400 Hz. Activate the tuning fork by tapping it against the heel of your hand, then apply the base of the fork to a bony prominence. The patient feels the vibration as a buzzing or tingling sensation. The specific areas of testing are described in Chapter 23.

Percussion (Reflex) Hammer The percussion hammer is used to test deep tendon reflexes. Hold the hammer loosely between the thumb and index finger so that the hammer moves in a swift arc and in a controlled direction. As you tap the tendon, use a rapid downward snap of the wrist, tap quickly and firmly, and then snap your wrist back so that the hammer does not linger on the tendon (Fig. 3.23). The tap should be brisk and direct. Practice this action to achieve smooth, rapid, and controlled motion. You can use either the pointed or flat end of the hammer. The flat end is more comfortable when striking the patient directly; the pointed end is useful in small areas, such as on your finger placed over the patient’s biceps tendon. Chapter 23 contains a detailed discussion of evaluation of deep tendon reflexes.

Your finger can also act as a reflex hammer; this can be particularly useful when you are examining very young patients. Certainly it is less threatening to a child than a hammer. Many pediatric specialists let the child hold the hammer while they use their fingers.

Neurologic Hammer A variant of the percussion hammer is the neurologic hammer, which is also used for testing deep tendon reflexes. Available in a variety of models, the hammer has two additional features that make it a multipurpose neurologic instrument: a soft brush (usually concealed in the handle) and a tapered tip. These additional implements were designed to determine sensory perception as part of the neurologic examination. Some models come with a rotating

FiG. 3.21 Tuning forks for testing vibratory sensation (top) and auditory screening (bottom). FiG. 3.22 Squeezing and stroking the tuning fork to activate it. Hold

the fork only by the handle so as not to dampen the sound.

equivalent volume) indicates the amount of mobility in the middle ear. A low compliance measurement indicates that more energy has returned to the probe, with less energy admitted to the middle ear. A high compliance reading indicates a flaccid or highly mobile system.

At this point, the probe introduces a pressure of 200 daPa (decaPascals; a measurement of air pressure) to the middle ear canal. This positive pressure forces the tympanic membrane inward, and the approximate ear canal volume is recorded. This volume gives a baseline from which the compliance curve is drawn. The pressure is then varied in the negative direction, constantly monitoring the compliance of the system. The pressure continues toward the negative direction until a pressure peak has been detected or until a pressure of 2400 daPa is present in the ear canal, whichever comes first. The point of peak compliance occurs once the pressure is equalized on both sides of the tympanic membrane.

A tympanogram is a graphic representation of the change in compliance of the middle ear system as air pressure is varied. The tympanogram results are displayed on the probe monitor or can be printed out for a hard copy.

Tuning Fork Tuning forks are used in screening tests for auditory func- tion and for vibratory sensation as part of the neurologic examination (Fig. 3.21). As tuning forks are activated, vibrations are created that produce a particular frequency of sound wave, expressed as cycles per second (cps) or Hertz (Hz). Thus a fork of 512 Hz vibrates at 512 cycles per second.

For auditory evaluation, use a fork with a frequency of 500 to 1000 Hz because it estimates hearing loss in the range of normal speech, approximately 300 to 3000 Hz. Forks of lower frequency can cause you to overestimate bone conduction and can be felt as vibration as well as heard. Activate the fork by gently squeezing and stroking the prongs or by tapping them against the knuckles of your hand so that they ring softly (Fig. 3.22). Because touching the tines will dampen the sound, hold the fork by the handle. Hearing is tested at near-threshold level; this is the lowest intensity of sound at which an auditory stimulus can be heard. Striking the prongs too vigorously results in a loud

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if necessary. Watch for the red glow of light through the body cavity. Note the presence or absence of illumination and any irregularities.

wheel to test sharp sensation. The procedure for testing sensory perception is described in detail in Chapter 23.

Tape Measure Use a tape measure 7 to 12 mm wide for determining circumference, length, and diameter. It may be helpful to have one that measures in both inches and metric units. Tape measures are available in a variety of materials, includ- ing paper (disposable), plastic or vinyl, and cloth. The tape measure should be nonstretchable for accuracy and pliable for circumference measurement. Because it is placed against the skin, beware of edges that are sharp and can cut.

When measuring, make sure that the tape is not caught or wrinkled beneath the patient. Pull the tape closely but not tightly enough to cause depression of the skin when measuring circumference.

When monitoring serial measures, such as head cir- cumferences or abdominal girth, it is important to place the tape measure in the same position each time. If serial measures are made over a period of days, an easy way to ensure accurate placement is to use a pen to mark the borders of the tape at several intervals on the skin. Subse- quently, the tape can be placed within the markings. Accurate placement of the tape for specific measurements is described in Chapter 8 and related chapters.

Transilluminator A transilluminator consists of a strong light source with a narrow beam. The beam is directed to a particular body cavity and is used to differentiate between various media present in that cavity. Air, fluid, and tissue differentially transmit light; this allows you to detect the presence of fluid in sinuses or the presence of blood or masses in the scrotum (see Clinical Pearl, “Transillumination”).

Specific transilluminating instruments are available, or a flashlight with a rubber adapter can be used. It is fine, when situations demand, to use a plain flashlight or penlight. Do not use a light source with a halogen bulb because this can burn the patient’s skin. Perform transillumination in a darkened room. Place the beam of light directly against the area to be observed, shielding the beam with your hand

BA

FiG. 3.23 A, Reflex hammer. B, Use a rapid downward snap of the wrist.

cLinicaL PEaRL

Transillumination Compared with imaging technology, transillumination may seem archaic and imprecise. Imaging is used when necessary, but transillumination maintains its value as a clinical tool and is far less expensive. Transil- lumination is effective, for example, in assessing for a hydrocele in the scrotum of an infant.

Vaginal Speculum A vaginal speculum is composed of two blades and a handle. There are three basic types of vaginal specula, which are used to view the vaginal canal and cervix. The Graves speculum is available in a variety of sizes with blades ranging from 76 mm to 170 mm in length and 22 mm to 36 mm in width. The blades are curved, with a space between the closed blades. The bottom blade is slightly longer than the top blade to conform to the longer posterior vaginal wall and to aid in visualization. The Pederson speculum has blades that are the same lengths as those of the Graves speculum but are both narrower (16–25 mm) and flatter. It is used for women with small vaginal openings. Pediatric or virginal specula are smaller in all dimensions, with short, narrow, flat blades (Fig. 3.24).

Specula are available in either disposable plastic or reusable metal. The metal speculum has two positioning devices. The top blade is hinged and has a positioning thumb piece lever attached. When you press down on the thumb piece, the distal end of the blade rises, thus opening the speculum. To lock the blade in an open position, tighten the thumbscrew on the thumb piece. Moving the top blade up or down controls the degree of opening of the proximal end of the blades; it is locked in place by another thumb- screw, which is on the handle.

The plastic speculum operates in a different way. The bottom blade is fixed to a posterior handle, and an anterior

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certain substances to fluoresce. It is used primarily to determine the presence of fungi on skin lesions. Darken the room, turn on the Wood’s lamp, and shine it on the area or lesion you are evaluating. A yellow-green fluorescence indicates the presence of fungi.

Darkening the room can sometimes be intimidating, particularly to children. Children and their parents react positively when they know what to expect. You can accom- plish this by shining the lamp on something fluorescent (e.g., a nondigital watch) to give them the sense of what you are looking for.

Monofilament The monofilament is a device designed to test for loss of protective sensation, particularly on the plantar surface of the foot (Fig. 3.27, A) such as with diabetic or other peripheral neuropathy and nerve damage. It bends at 10 g of linear pressure. Patients who cannot feel the application of the monofilament at the point that it bends have lost their protective sense and are at increased risk for injury.

Test intact skin on the plantar surface of the foot at various areas, including the great toe, heel, and ball of the foot (Fig. 3.27, B). Lock the monofilament in its handle at a 90-degree angle. With the patient’s eyes closed, apply the monofilament perpendicular to the surface of the skin.

lever handle controls the top blade. As you press on the lever, the distal end of the top blade elevates. At the same time, the base of the speculum also widens. Lock the speculum into position with a catch on the lever handle that snaps into place in a positioning groove.

Become familiar and practice with both types of specula to feel comfortable with them. Do not wait until you are in the process of doing your first examination, or you are likely to be embarrassed and cause discomfort to the patient because of your initial clumsiness in handling the instru- ment. The procedure for performing the speculum examina- tion is described in detail in Chapter 19.

Goniometer The goniometer is used to determine the degree of joint flexion and extension. The instrument consists of two straight arms that intersect and that can be angled and rotated around a protractor marked with degrees (Fig. 3.25). Place the center of the protractor over the joint and align the straight arms with the long axes of the extremities. The degree of angle flexion or extension is indicated on the protractor. The specific joint examinations are discussed in Chapter 22.

Wood’s Lamp The Wood’s lamp contains a light source with a wavelength of 360 nm (Fig. 3.26). This is the black light that causes

FiG. 3.24 Vaginal specula. (From Wilson and Giddens, 2009.)

FiG. 3.25 Goniometer. FiG. 3.26 Wood’s lamp. The purple color on the skin indicates no fungal infection is present. (From Wilson and Giddens, 2013.)

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View from the back. Note any rib elevation and/or symmetry in the low back area. Before measuring with the scoliometer, adjust the height of the patient’s bending position to the level at which the deformity of the spine is most pronounced. This position will vary depending on the location of the curvature. Lay the scoliometer across the deformity at right angles to the body, with the “0” mark over the top of the spinous process (Fig. 3.28). Let the scoliometer rest gently on the skin. Do not push down. Read the number of degrees of rotation. The screening examination is considered positive if the reading on the scoliometer is 7 degrees or more at any level of the spine. Lesser degrees of rotation may or may not indicate a mild degree of scoliosis.

Press hard enough to allow the monofilament to bend, holding pressure for approximately 1.5 seconds. Test at various locations in random order. Ask the patient to indicate whether the monofilament is felt. Vary the interval between applications. Note the response at each location in the patient record. Dispose of or clean the monofilament with alcohol. For a further discussion of skin testing with the monofila- ment, see Chapter 23.

Scoliometer A scoliometer measures the degree of rotation of the spine to screen for scoliosis. Ask the patient to bend forward slowly, stopping when the shoulders are level with the hips.

A B

FiG. 3.27 A, Monofilament. B, Press the monofilament against the skin hard enough to allow it to bend.

FiG. 3.28 The scoliometer. (Courtesy Ortholutions GmbH & Co. KG, Rosenheim, Germany.)

52

CHAPTER

4 Taking the Next Steps: Clinical Reasoning Clinical reasoning is the process by which the information gathered from the history and physical examination is merged with clinical knowledge, experience, and the current best evidence to formulate the next steps in patient care—development of the diagnostic and management plans. Critical reflection involves thinking through the reasoning for these decisions. This reflection can help you progress from rote decision making to clinical reasoning.

The Clinical Examination Thus far, we have been concerned with the initial patient interaction, establishment of respectful rapport, and information-gathering processes (i.e., history and physical examination). Organizing, integrating, and analyzing information represent the next step in caring for patients. This process, called clinical reasoning, leads to the develop- ment of potential diagnoses, workup priorities, and manage- ment plans (Box 4.1). Formulating management plans should occur in partnership with patients and their families. Working with the patient to determine the best course of action is often called “shared decision making” or “patient- centered care.”

Clinical Reasoning Assessment, Judgment, and Evidence Clinical reasoning involves bringing knowledge of the patient, clinical experience, and decision-making skills together with the current best evidence regarding the issues involved. The best available evidence must be carefully obtained from the volumes of information available in books, journals, and online. Use of evidence in decision making is called “evidence-based practice” (Box 4.2).

The first step in clinical reasoning is to assess what has been learned from the patient and to determine its value and significance. Priorities are then assigned to information that might influence clinical judgment as management plans and clinical impressions are created.

Further assessment depends on healthcare provider, patient, and family preferences, which may be influenced by feelings, attitudes, and values. By using clinical reasoning, you can think through your own beliefs, values, cultural practices, and attitudes for potential bias affecting the

decision-making process. Clinical impressions help direct further assessment, which must be balanced by benefits and risk to the patient, cost considerations, and available resources. Determining the leading diagnoses, potential diagnostic and management plans can be formulated using shared decision making.

Problem Identification A problem may be defined as anything that will need further evaluation and/or attention. It may be related to one or more of the following: • An uncertain diagnosis • New symptoms or physical examination findings related

to a previous diagnosis • New symptoms or findings of unknown etiology • Unusual findings revealed in the clinical examination

or by diagnostic tests • Personal, social, or emotional difficulties

Formulate problems as specifically as possible. Identify and list the signs and symptoms associated with each of the patient’s concerns as well as abnormalities discovered during the physical examination. This listing of findings, the problem list, is key to developing a complete understand- ing of a patient’s concern. The problem list is the foundation for clinical reasoning and is used to form hypotheses based on the available information (Box 4.3). Review the problem list and note the absence of findings that you might expect in support of your hypotheses. Think through the patient’s verbal and nonverbal communication and determine whether there are questions you may have neglected to ask or information you did not fully understand. Gather additional information from the patient to fill in these gaps. Beware of “red herrings,” the bits of information that are distracting and draw your thinking away from central issues (Box 4.4). Critically evaluate unexpected or unusual findings but do not let them distract you from full consideration of all you have learned.

After a match between the data (both subjective and objective) and a presumed diagnosis is made, consider the appropriate laboratory, imaging studies, or specialty consulta- tion needed to confirm the diagnosis. When determining next steps, it is important to consider primacy of patient welfare, patient autonomy, and need for resource allocation. We are after all strong advocates for our patients and, at

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BoX 4.2 Evidence-Based Practice

Evidence-based practice (EBP) incorporates best evidence, along with individual experience and patient preference, into making medical deci- sions (Sackett et al, 1996). EBP involves questioning physical examination findings, the effects of therapy, the utility of diagnostic tests, disease prognosis, and/or the etiology of disorders (Sackett et al, 1996).

Medical Decision Making

Best evidence

Pa ent preference

Clinical experience

BoX 4.3 Decision Making

There are several ways to make a diagnosis: • Recognizing patterns (on the assumption that “If it walks like a

duck, swims like a duck, and quacks like a duck—it is most likely a duck”)

• Sampling the universe (on the assumption that including everything precludes missing anything)

• Using algorithms (on the assumption that a rigidly defined thought process precludes error) Although each of these may have limited use in specific situations,

consideration of all your findings should most often result in the development of one or more hypotheses needing an evidence-based approach to solutions.

Guidelines to a sound decision-making process include the following: • Always derive possibilities that are consistent with the chief concern,

your findings, and known psychosocial and pathophysiologic mechanisms.

• Remember that common problems occur commonly, and rare ones do not.

• Common problems can have unusual presentations, and rare ones may have a seemingly common concern.

• Rare problems that have an available treatment should be considered.

• Do not rush to a diagnosis with no available treatment, and do not pursue a line of reasoning that will not alter your course of action. For example, if a patient cannot tolerate cancer treatment, do not peruse the screening and diagnostic evaluation.

• Do not undertake procedures that are not related to your hypotheses.

• Always consider potential harm and cost as well as benefit when determining the need for a test or action.

• Consider whether the risk is worth the potential gain in information, invoking the ethical principle of nonmaleficence: Primum non nocere—“First, do no harm.”

• Remain open in your thinking and be ready to discard or modify your hypotheses when necessary. Recognize that your leading hypotheses may not be valid, and avoid the tendency to discount information that may invalidate your favorite ideas.

• Try to have a single process explain all or most of your data, but do not be rigid in this regard. After all, a patient with many concerns and problems may have more than one disease; two common diseases may occur simultaneously more often than one rare disease alone.

• Probability and utility should always be your guides to sequencing your actions unless a life-threatening situation exists. A conscien- tious estimate of probability is the best way to define the limits of uncertainty and the best way to establish priorities.

BoX 4.4 Red Herrings

A patient with swollen cervical nodes and fever owns a cat, which had claws, but the patient did not have cat scratch disease. The too obvious apparent source of the problem, a “red herring,” delayed the ultimate diagnosis of non-Hodgkin lymphoma.

times, their only voice. As such we are responsible for appropriate resources allocation and scrupulous avoidance of superfluous tests and procedures (Cassel and Guest, 2012).

Valid Hypotheses Clinical reasoning allows you to consider and discard the variety of possible diagnoses—from the common to the rare—before settling on the best match between the patient’s signs and symptoms and a specific disorder. It has been said (Kopp, 1997) that there are at least three diagnoses for

BoX 4.1 Steps for Clinical Reasoning

The clinical examination (information gathering) ↓

Organization and integration of information ↓

Assessment of organized information ↓

Assignment of priorities (the need for clinical judgment) ↓

Clinical opinions ↓

Integration of preferences; the patient’s and the professional’s • Consideration of feelings, attitudes, and values • Consideration of probabilities and risks

↓ Further assessment; balancing advantages with risks in the light of

feelings, attitudes, and values ↓

Identification of problems (be as specific as possible) ↓

Hypothesis formation and determination of the next steps

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Possible Barriers to Clinical Reasoning Illness evolves from disease and is almost always multi- faceted. Not all of the findings can be explained on a pathophysiologic level because sometimes physical symp- toms are inseparable from emotional symptoms. Therefore avoid being misled into believing that, given a pathophysi- ologic conclusion, management targeted to that finding will necessarily solve the problem. You must consider the full range of issues—from the physical to the emotional, psychologic, social, and economic—that might affect the expected outcomes. The pitfall is that in allowing yourself to be lost in physical detail you lose the context of the broader view.

Feelings, Attitudes, and Values. Clinical reasoning becomes complex because of emotions in both patient and healthcare provider. Feelings, attitudes, and values may be strong enough that our decision making may be impaired. If these feelings are to be given a proper context, you must know yourself and take time for personal reflection (see Chapter 2 for a discussion of self-awareness). Critical reflection involves thinking through the reasoning for these decisions. The questioning of yourself must be relentless: • “What is really happening?” • “Have my feelings overtaken logic?” • “Have ethical concepts been ignored?” • “What are the issues that matter?” • “What should take precedence?” • “Do I understand my contribution to the interaction?” • “Do I understand the patient?” • “How do I feel about all this?” • “How does the patient feel about it?”

The Ethical Context. Ethics does not provide answers. Consideration of ethical principles provides the framework for respectful, flexible discussion and disciplined approach to decision making. For example, for a given problem, several concepts must be considered. • Autonomy: The patient’s need for self-determination.

Autonomy suggests that choices exist, and a patient may choose between alternatives. Uncertainty exists when the patient is a child or is cognitively impaired. Parents, guardians, family, or other significant persons should then be included, and the boundaries of that participation must be clearly set. In some cases, the boundaries are established by an advance directive from the patient. Competency is not always easily determined, and there may be disagreement. Both the mental status examination (see Chapter 7) and consultation with individuals who know the person well can assist.

• Beneficence: Do good for the patient. This may be too eagerly pursued and may result in a paternalism that might preclude autonomy of the patient. However, paternalism may have some benefit when used with constraint and respect for autonomy.

• Nonmaleficence: Do no harm to the patient.

every disease: the one that unifies what you have learned, the one you cannot afford to miss, and the one that it actually is. Sometimes they are the same one, but usually not. Do not have tunnel vision and let initial thoughts narrow the focus of questions during the interview. In other words, do not jump to conclusions.

One of the clichés of clinical practice is that all findings should be unified into one diagnosis, Occam’s razor or lex parsimoniae (“law of parsimony” or “law of succinctness”) (Thorburn, 1918). Although you should strive to look for the fewest possible causes that will account for all the symptoms, this may not always be possible. More than one disease process can exist at one time in the same person, an acute illness can occur in the context of a chronic one, and a chronic disease can cycle through remission and relapse. Carefully chosen laboratory or imaging studies can often help validate your observations and confirm your clinical impressions (Box 4.5).

BoX 4.5 “A Patient Can Have as Many Diagnoses as He Darn Well Pleases”

Common problems happen commonly and can occur at the same time (Hilliard et al, 2004). As Hilliard and colleagues note, C.F.M. Saint stated several decades ago that more than one disease may be responsible for a patient’s signs and symptoms when he could find no pathophysiologic explanation for the coexistence of hiatal hernia, gallbladder disease, and diverticulosis in one of his patients. That, they added, was the same point made by Hickam’s dictum: “A patient can have as many diagnoses as he darn well pleases.” It was William Osler, however, who invoked the competing 14th-century philosophy of William of Occam: “Plurality must not be posited without necessity.” In other words, do not consider more than one diagnosis unless you really have to, and “among competing hypotheses, favor the simplest one.” Thus, we are given the term “Occam’s razor” to signify this.

But suppose Occam’s razor doesn’t always work. Hilliard and coworkers write, “As the population continues to age—and as diagnostic studies increase in number and sophistication—the dulling of Occam’s razor is certain to continue.” Thus, we suggest that you think critically about Saint or Occam and use their hypotheses for appropriate balance as you make your clinical judgments.

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Validity of the Clinical Examination We practice in a time when there is considerable effort to reduce healthcare cost. Recognize that the majority of diagnoses can be achieved with information from a com- petent history and physical examination, and then limit indiscriminate use of unnecessary technology.

Keep the following definitions in mind (see Fig. 4.1): • Sensitivity: the ability of an observation to identify cor-

rectly those who have a disease • Specificity: the ability of an observation to identify cor-

rectly those who do not have a disease • True positive: an expected observation that is found when

the disease characterized by that observation is present • True negative: an expected observation that is not found

when the disease characterized by that observation is not present

• False positive: an observation made that suggests a disease when that disease is not present

• False negative: an observation that suggests a disease is not present when in fact it is (e.g., absence of cough or respiratory findings when lung cancer is present)

• Positive predictive value: the proportion of persons with an observation characteristic of a disease who have it (e.g., when an observation is made 100 times, and on 95 of those occasions that observation proves to be consistent with the ultimate diagnosis, the positive predictive value of the observation is 95%)

• Negative predictive value: the proportion of persons with an expected observation who ultimately prove not to have the expected condition (e.g., if 100 observations are made expecting a disease, and 95 times that observa- tion is not found and the condition proves not to have been the diagnosis, the negative predictive value of the observation is 95%)

Bayes Theorem As a critical thinker, you will discover that the likelihood of your diagnosis being related to your findings depends on:

• Utilitarianism: Consider appropriate use of resources with concern for the greater good of the larger com- munity. Choose wisely.

• Fairness and justice: Recognize the balance between autonomy and competing interests of the family and community.

• Deontologic imperatives: Our dutiful responsibilities for offering care are established by tradition and in cultural contexts. Because cultures vary, these may not be uni- versally binding for all patients. Ethical principles can come into conflict in any given circumstance. If it is difficult to make a decision, consider the following: • Is the problem one of ethics and not of poor

communication, internal family conflict, money problems, legal confusion, or cultural or personality conflict?

• Are the facts clearly stated and the attitudes of patients and/or their representatives clearly communicated?

• Is there a reasonable chance for a satisfactory health or medical care outcome?

In the end, the competent and autonomous patient’s point of view might well prevail without a compelling argument to do otherwise.

Mechanism and Probabilism. Mechanistic (deterministic) thinking is governed by a sense that knowledge must be certain and not subject to attributes of the observer. Knowl- edge is to be free of belief, attitudes, and values. Our decision making must have a balance between mechanism and probabilism (certainty in knowledge is impossible). There are variables in the decision-making process such as the individual patient, our age and experience, and fatigue. Accepting the inevitability of probability simply recognizes that the certainty of truth, whatever that may be, is hard to achieve. Why is this so? • Causes may act or interact differently at different times. • The same effect may not always have the same cause. • The effect of a given cause cannot be isolated with

certainty. Causes, effects, and our interpretations of them change

probabilistically with time. They involve uncertainty, conjecture, and chance. Dependence on the purely scientific and technical offers an unrealistic comfort (Box 4.6). Acknowledging this may be viewed as gambling. A high probability diminishes uncertainty; a low probability does not.

Do not be dominated by the mechanistic assumption that there is a precise and discoverable cause for every event. Make judgments on the basis of well-informed probabilities and recognize the complexity of the decision- making process. Clinical reasoning does not require a compulsive listing of all of the possible options in diagnosis and management. Rather, it is dominated by hypothesis development; asking whether a particular diagnosis should be made depending on its probability; and whether a test may be indicated, depending on the likelihood suggested by its sensitivity and specificity.

BoX 4.6 The Electronic Environment

The electronic environment provides remarkable resources. Patients now come to healthcare providers with a wealth of information, myths that need to be discredited, and false information. The Internet can be a terrific source of patient education information, but knowing which websites have accurate and valid information is challenging. It can remind you about unrecognized diagnostic possibilities and place the patient’s medical record at your fingertips. Still, it can also be considered a threat. There is at times an unacceptable temptation to substitute electronic support for clinical reasoning and judgment. As sophisticated and accessible as the electronic environment has become, the most advanced software coupled with the sleekest hardware still has no sense of the subtleties of the human dimension. It is your responsibility to artfully merge subjective and objective data with best evidence and your knowledge and experience to make a clinical judgment.

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Evidence-Based Practice Evidence-based practice (EBP) is a system that incorporates the best available scientific evidence to clinical decision making, in the care of the individual patient. EBP balances the strength of the evidence, the risks and benefits of treatment (including lack of treatment), and diagnostic tests while integrating clinical expertise. Evidence-based decision making is the intersection of your clinical observa- tions from the history and physical examination clinical expertise, patient values and preferences, and the best evidence (see Fig. 4.2) and translating this decision-making process to clinical reasoning.

Evaluation and Management Plan and Setting Priorities You decide what you think is going on (the diagnosis) and what you are going to do about it (the management plan). You often need to investigate further, deciding on which

1. The probability of those findings being associated with that diagnosis

2. The prevalence of both that particular diagnosis and that combination of findings in the community in which you are serving

These considerations have been formalized as Bayes theorem. This juggling of probabilities is implicit during diagnostic decision making. We do not think consciously of Bayes theorem most of the time, but we are using it at some level all of the time.

We have stressed that diagnostic decision making is generally best served by the development of hypotheses that will provide a disciplined approach to solutions. If you are uncertain about an observation, never hesitate to confirm its validity. That is vital to clinical reasoning. Much as you strive to be scientific and base what you do on the disciplined principles of science, at times you will make undeniable intuitive judgments. Intuition, however, must be as fully subject to clinical reasoning as any other aspect of your effort.

Test positive True positive (TP) False positive (FP)

Test negative True negative (TN)False negative (FN)

Has disease Does not have disease

Sensitivity: people with disease who test positive (true positive rate) TP/ (TP = FN)

Specificity: people without disease who test negative (true negative rate) TN/ (FP + TN)

Positive Predictive Value (people with positive test who have disease) (TP/ (TP+ FP)

Negative Predictive Value (people with negative test who do NOT have disease) (TN/ (TN + FN)

Fig. 4.1 Sensitivity and specificity, true positive/negative, and positive/negative predictive values.

Fig. 4.2 Evidenced-based decision making.

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meets priority needs, some that need to be done now and some that might await the information gleaned from an earlier step or the result of a first therapeutic attempt.

Certainly, the patient’s subsequent behavior is a major variable in his or her health status (e.g., smoking cessation) or therapy (e.g., medication adherence). The patient must be actively and positively involved for an optimal outcome. Does the patient want to take the necessary steps? Behavior change is a process involving progress through a series of stages. The Transtheoretical Model of Behavior Change assesses an individual’s readiness to change (Table 4.1). What is the extent of the patient’s commitment and recogni- tion that the benefits of action outweigh any possible disadvantages? What is the patient’s ability to sustain the effort?

Developing a sequence for your clinical reasoning can be facilitated by careful attention to recorded information (see Chapter 5) and its consideration of the problem-oriented medical record. Careful attention to recording the findings in the history and physical examination will aid in organizing your thoughts and lead to clinical reasoning.

of the available laboratory and imaging techniques you might use and who might help you with them. Having thought critically (using shared decision making), you and the patient can jointly arrive at an approach that may include the following: • Laboratory and imaging studies • Subspecialty consultation • Medications, equipment (e.g., walker or wheelchair), or

assistive technology (e.g., intravenous pumps, ventilator) • Special care (e.g., home nursing, physical therapy,

respiratory therapy) • Diet modification • Activity modification • Follow-up visit • Patient education In addition, you need to decide the degree of urgency, the next step, and what underlies the issues in terms of the social, economic, and pathophysiologic considerations. Priorities must be set. The following is only a partial guide: • What is the patient’s physical condition? • Is something going on that overrides every other con-

sideration (e.g., a problem with the central nervous system, heart, kidneys, pain, a change in mental status) and needs immediate attention?

• Are there abnormal laboratory values or imaging findings (e.g., mass identified on mammogram) that need immedi- ate attention?

• What is the patient’s social circumstance? • Will a job be threatened if there is an absence from

work? • Are there small children at home for whom no other

caretaker is available? • Is there available and convenient transportation to and

from services and care? • What is the patient’s economic circumstance? • Does the patient have adequate health insurance

coverage? • Is the cost of care or medication going to compromise

other areas of the patient’s life? These considerations suggest the kind of critical judg-

ment that helps to set priorities and develop a management plan in collaboration with the patient. Perhaps in some cases, tests, treatments, or therapies can be delayed without risk. Alternatively, there might be a sequence of steps that

STAGE OF CHANGE DESCRIPTION

Precontemplation Not yet admitting there is a problem behavior that needs to be changed, or not intending to take action

Contemplation Admitting that there is a problem but not yet ready or sure of wanting to make a change, starting to think about pros and cons for continued action

Preparation Intending to take action in the immediate future, beginning to take small steps toward change

Action Changing behavior, overt modification in behavior

Maintenance Being able to sustain action and working to prevent relapse

Termination No temptation and confidence in not returning to old behavior

Relapse Not considered a stage in itself but rather the shift from Action or Maintenance to an earlier stage (Precontemplation or Contemplation)

TaBle 4.1 Stages of Change

From DiClemente and Prochaska, 1998.

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CHAPTER

5 Recording Information After performing the history and physical examination, the healthcare provider must organize, synthesize, and record the data along with the problems identified, diagnostic evaluation, and plan of care. The information in the patient’s record enables you and your colleagues to care for the patient by identifying health problems, making diagnoses and judgments of diagnostic testing needed, planning appropriate care, and monitoring the patient’s responses to treatment. The patient’s record is only as good as the accuracy, depth, and detail provided. With the transition to the electronic medical record (EMR), it is even more critical to maintain standards of documentation excellence (Abramson et al, 2011).

The patient’s medical record is a legal document, and any information contained in it may be used in court and in other legal proceedings, as well as to make healthcare payment determinations. Your documentation will be read by many individuals; increasingly this includes the patient and their family members. It is your responsibility to document the facts of the history and your physical examina- tion findings accurately, and if handwritten, this must be legible. All entries when signed will be dated and timed in the EMR. If using a paper chart, recorded information should not be erased. Instead, make necessary changes by lining out data and leaving this crossed-out information legible and initialing and dating the changes. When using an EMR, include an addendum to correct or update your documentation. Any portion of the examination that has been deferred or omitted should be so noted, rather than neglecting to mention particular findings. It is appropriate in some circumstances to defer a portion of an examination, stating the reason for deferral. A clear, exact record of your assessment, an analysis of the problem, and a management plan are vital for communicating with other healthcare providers and for your protection in case there is ever a question relevant to your care of the patient.

General Guidelines It is certainly permissible to take brief notes about the patient’s concerns and your findings during the course of the interview and physical examination. It is respectful to request permission and inform the patient you will be taking notes or recording information in the EMR.

You should record certain data as you obtain it, specifically the vital signs and any measurements. Do not try to record all the details during the visit because writing or typing must not distract your attention from the patient. Document- ing simple notes should be sufficient in preparation for the subsequent write-up or EMR entry. This allows you to gather, reflect, and organize all the data appropriately before making the record final. It is essential to complete data recording as soon as possible after the examination while your memory for detail is fresh. Resist going on to other patients before noting key history and physical examination findings on the previous patient’s record. Although this is sometimes unavoidable, you can easily become confused about which patient had a particular finding and even forget to record an important finding.

It is unacceptable to copy other healthcare providers’ documented work (e.g., history taken, examination per- formed, or thought processes outlined) and enter it into your own documentation as if you did the work. Text copied from another person’s note must always be attributed to the source. Information integrity refers to the dependability of information and is further defined as the accuracy, consistency, and reliability of information content, processes, and systems. This is not only an important concept in a legal proceeding; it is critical for safe patient care. Hospital care is often fragmented, and handoffs and cross coverage prevail. Healthcare providers need to be able to trust the documentation on which they will base clinical decisions at the point of care.

Be concise! Use an outline form to avoid the repetition of phrases such as “patient states.” Avoid the use of abbrevia- tions and symbols as much as possible because meanings may differ among health professionals (Box 5.1 and Table 5.1) (Garbutt et al, 2008). Similarly, avoid the use of words such as “normal,” “good,” “poor,” and “negative” because these words are open to various interpretations by other examiners.

Document what you observe and what the patient tells you, rather than the conclusions you interpret or infer. Use direct quotes from the patient when a description is par- ticularly vivid, especially when documenting the chief concern. Keep subjective and symptomatic data in the history, making sure none gets woven into the physical findings. Physical examination findings should be the result

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of your direct observation. For example, when a patient reports pain (a symptom) during palpation, you should note tenderness (a sign) in the record, and report the patient’s reaction to pain, such as crying, withdrawal, rigid posturing, or facial expression. Record both what the patient tells you and what you observe. Detectable changes can then be better compared and documented in the future. Clues about health changes over time are lost if such details are not recorded in the patient’s record.

EMR Replicating Functions Although potentially an effective tool, the ability to easily copy and paste or carry forward (CPCF) text from one note to another has become the latest hazard in electronic medical documentation (Box 5.2). Whereas legibility is no longer an issue with electronic records, copy and paste is now looming as a patient safety, legal, and regulatory challenge for EMRs. When CPCF is used inappropriately (Box 5.3), it can affect patient safety by rendering meaningless an essential communication tool relied on at the point of care. All copied information must be verified and subsequently edited or removed if necessary to ensure that it is not erroneous or out of date. Text copied from another healthcare professional’s note must always be attributed to the source.

Organization of the Note Most healthcare providers use a customary organization of information from the interview and physical examination. Healthcare facilities often incorporate the information in

BoX 5.1 Abbreviations and Acronyms: The Initial Challenge to Reliability

There was a time when recorded histories and physical examinations contained few, if any, acronyms. After World War II, the use of initials began to proliferate. Today it is a compulsive problem leading to misunderstanding that is at times inconvenient and at times dangerous.

When our interprofessional languages are obscured by acronyms, communication suffers and the safety of patients may be compromised. For example, ROM has many meanings. The obstetrician uses ROM for “rupture of membranes.” The pediatrician uses ROM for “right otitis media.” The physiatrist uses ROM for “range of motion.” To show you how bad this can get, try interpreting the following statement seen in a hospital chart (Abushaiqa, 2007): 67yo CM who CVA, CABG×2, GERD, CRI on HD, POD #5 - Ex Lap for

MVC with OA, s for WO & RFCOAW.

CPCF = copy and paste or carry forward.

BoX 5.2 Use and Misuse of CPCF

Although text replication is generally discouraged, it can improve efficiency, decrease information drop-off, and decrease typing errors, and thus there may be some uses that are potentially acceptable.

Potentially Acceptable Uses of CPCF 1. The author’s previously documented assessment and plan on a

given patient that has carried forward to subsequent notes, subject to editing for relevance and accuracy

2. Auto populated, presumably static information (e.g., past medical history and family history) entered by other healthcare providers and carried forward into new documents, subject to confirmation and editing if needed

3. Cumulative, dated information that carries forward to create a running log of daily hospital events

4. Copying and pasting important lists or information (e.g., medication lists), which can prevent potential clinically relevant retyping errors

Unacceptable Uses of CPCF 1. Copying previous healthcare providers’ documented work (e.g.,

history, examination, or thought processes) and entering it into a new note unedited (or minimally edited) as if the new author did the work

2. Unedited text carried forward from other notes (including the author’s) that results in conflicting or inaccurate information

3. Unedited or minimally edited notes carried forward from day to day that do not allow readers to determine changes in clinical course

©2017 The Joint Commission. Reprinted with permission. *Applies to all orders and all medication-related documentation that is handwritten (including free-text computer entry) or on preprinted forms. †Exception: A “trailing zero” may be used only where required to demonstrate the level of precision of the value being reported, such as for laboratory results, imaging studies that report size of lesions, or catheter/tube sizes. It may not be used in medication orders or other medication-related documentation.

The Joint Commission has identified “improving communications among caregivers” as a patient safety goal (Joint Commission, 2017). Certain abbreviations have been placed on a “do not use” list when an error in misreading the abbreviation could cause harm.

When considering the use of initials, abbreviations, and acronyms to get things said and written in a hurry, resist the temptation.

OFFICIAL “DO NOT USE” LIST*

DO NOT USE POTENTIAL PROBLEM USE INSTEAD

U (unit) Mistaken for “0” (zero), the number “4” (four) or “cc”

Write “unit”

IU (International Unit) Mistaken for IV (intravenous) or the number 10 (ten)

Write “International Unit”

Q.D., QD, q.d., qd (daily)

Mistaken for each other Write “daily”

Q.O.D., QOD, q.o.d., qod (every other day)

Period after the Q mistaken for “I” and the “O” mistaken for “I”

Write “every other day”

Trailing zero (X.0 mg)†

Decimal point is missed Write X mg

Lack of leading zero (.X mg)

Write 0.X mg

MS Can mean morphine sulfate or magnesium sulfate

Write “morphine sulfate”

MSO4 and MgSO4 Confused for one another

Write “magnesium sulfate”

taBLe 5.1 Prohibited Abbreviations

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Describe the patient’s concerns or unexpected findings by their quality or character. For example, indicating the presence of pain without providing characteristics (e.g., timing, location, severity, and quality) is not useful either for determining the extent of the present problem or for future comparison. Record the severity of pain using the patient’s response or score on a pain scale. Be sure to name the pain scale in the record. The severity of pain may also be described by its interference with activity or disruption of sleep. Note whether the patient is able to continue regular activity despite pain or whether it is necessary to decrease or stop all activity until pain subsides (see Chapter 6, “Vital Signs and Pain Assessment”). Similar detail should be provided for other signs.

Objective Data Objective data are the findings resulting from direct observation—what you see, hear, and touch.

Relate physical findings to the processes of inspection, palpation, auscultation, and percussion, making clear the process of detection so confusion does not occur. For example, “no masses on palpation” may be stated when recording abdominal findings. Include details about expected objective findings, such as “tympanic membranes pearly gray, translucent, light reflex and bony landmarks present, mobility to positive and negative pressure bilaterally.” Also provide an accurate description of unexpected objective findings. Suggestions for recording the character and quality of objective findings follow.

Location of Findings. Use topographic and anatomic landmarks to add precision to your description of findings. Indicating the liver span measurement at the midclavicular line enables future comparison because measurement at this location can be replicated. The location of the apical impulse is commonly described by both a topographic landmark (the midsternal line) and an anatomic landmark (a specific intercostal space), for example, “the apical impulse is 4 cm from the midsternal line at the fifth intercostal space.”

In some cases, location of a finding on or near a specific structure (e.g., tympanic membrane, rectum, vaginal vestibule) may be described by its position on a clock. It is important that others recognize the same landmarks for the 12-o’clock reference point. For rectal findings, use the anterior midline, and for vaginal vestibule findings (e.g., Bartholin glands, episiotomy scar), use the clitoris.

Incremental Grading. Findings that vary by degrees are customarily graded or recorded in an incremental scale format. Pulse amplitude, heart murmur intensity, muscle strength, and deep tendon reflexes are findings often recorded in this manner. In addition, retinal vessel changes and prostate size are sometimes graded similarly. See the chapters in which these examination techniques are discussed for the grading system used to describe the findings.

standardized forms or templates within an EMR. Following this customary outline of information enables all healthcare providers in an integrated system to find and use the patient information more efficiently. The problem-oriented medical record (POMR) with SOAP (Subjective, Objective, Assess- ment, and Plan) notes is one such system. The POMR can also be created in the APSO (Assessment, Plan, Subjective, and Objective) format.

Organizing the Patient’s Health Record With SOAP Notes S Subjective data—the information, including the absence

or presence of pertinent symptoms, that the patient tells you

O Objective data—your direct observations from what you see, hear, smell, and touch and from diagnostic test results

A Assessment—your interpretations and conclusions, your rationale, the diagnostic possibilities, and present and anticipated problems

P Plan—diagnostic testing, therapeutic modalities, need for consultants, and rationale for these decisions

Subjective Data Subjective data are the information that patients offer about their condition.

From The Johns Hopkins Health System: Guidelines and principles for proper use of the EMR, 2013.

BoX 5.3 Implications of Misuse of CPCF

1. Copying subjective information obtained by other healthcare provid- ers without appropriate editing degrades patient narratives, which form the basis for complex decision making.

2. Perpetuation of inaccurate data or diagnoses cloned from previous notes can result in poor patient care decisions.

3. Incorporating (or not removing) redundant or irrelevant information lengthens the document, dwarfs the information that is most important at the time, and makes it difficult to determine what is old and new. When urgent information is needed at the point of care, patient safety can suffer.

4. Unless edited and reorganized daily, copied assessments and plans may not reflect changes in a patient’s status or clinical course (e.g., “pulmonary” is always on top though may not be currently relevant); in handwritten notes, healthcare providers usually filter and organize pieces of information that are most relevant to the patient’s care at the time.

5. When healthcare providers authenticate their notes containing large amounts of text from previous healthcare providers, it can appear as though they did not do the work (e.g., take the history, formulate the plan) themselves. Attributing authorship to oneself of parts of a note that one did not create is not only unethical, it can result in mistrust of the entire document by the legal system and be considered fraud by payers and regulators such as The Joint Commission.

6. When copied text is not edited appropriately, conflicting information or improper time representation can call into question the reliability of the entire note.

CPCF = copy and paste or carry forward.

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policies that apply to this practice. Many EMRs offer illustra- tion and photograph capability.

Problem-Oriented Medical Record The POMR is a commonly used process to organize patient data gained during the history and physical examination. After the history and physical examination are completed, the POMR provides a format for collecting and recording your thoughts that assists with critical thinking and clinical decision making—determining the patient’s problems as well as the possible and probable diagnoses.

After the subjective and objective data are documented, along with the problems identified, the diagnostic and therapeutic plan is made with the patient as a full participant. The record describes plans made and actions taken to address these problems, lists the information and education provided to the patient, and describes the patient’s response to care provided.

The record must be well organized, precise, legible, and concise to facilitate your thinking and the thinking of your colleagues who may need to care for the patient. The consistent recording format enables more effective com- munication and coordination among professionals caring for the patient.

There are six components of the POMR: 1. Comprehensive health history 2. Complete physical examination 3. Problem list 4. Assessment and plan 5. Baseline and problem-directed laboratory and radiologic

imaging studies 6. Progress notes

Comprehensive Health History and Physical Examination All relevant data regarding the comprehensive health history should be recorded, including both absence and presence of pertinent findings that contribute directly to your assess- ment. Arrange the history in chronologic order, starting with the current episode and then filling in relevant background information. Arrange the physical examination findings in a consistent order and style. This allows future readers, and you, to find specific points of information. It also enables you to quickly remember key components for assessment on each encounter.

Make your headings clear, using indentations and spacing to accentuate the organization of your documentation. Be concise yet complete! Avoid abbreviations as much as possible.

Problem List The problem list is created after the subjective and objective information has been organized. All pertinent data and examination findings, illustrations or pictures, laboratory data, imaging studies, and prior diagnoses are reviewed to develop a problem list in the form of a running log with

Organs, Masses, and Lesions. For organs, any type of mass (e.g., an enlarged lymph node), or skin lesion, describe the following characteristics noted during inspection and palpation: • Texture or consistency: smooth, soft, firm, nodular,

granular, fibrous, matted • Size: recorded in centimeters on two dimensions, plus

height if the lesion is elevated. Future changes in the lesion size can then be accurately detected. (This is more precise than comparing the lesion’s size to fruit or nuts, which have different dimensions.)

• Shape or configuration: annular, linear, tubular, elliptical • Mobility: moves freely under skin or fixed to overlying

skin or underlying tissue • Tenderness • Induration • Heat • Color: hyperpigmentation or hypopigmentation, redness

or erythema, or the specific color of the lesion • Location • Other characteristics, for example, oozing, bleeding,

discharge, scab formation, scarring, excoriation

Discharge. Regardless of the site, describe discharge by color and consistency (e.g., clear, serous, mucoid, white, green, yellow, purulent, bloody, or sanguineous), odor, and amount (e.g., minimal, moderate, copious).

Illustrations Drawings with labeling can sometimes provide a better description than words and should be used when appropri- ate. You do not have to be an artist to communicate informa- tion. Illustrations are particularly useful in describing the origin of pain and where it radiates and the size, shape, and location of a lesion (Fig. 5.1). Stick figures are useful to compare findings in extremities, such as pulse amplitude and deep tendon reflex response (Fig. 5.2). Photographs included in the chart can provide useful information, although you need to be aware of any institutional consent

fIg. 5.1 Illustration of the location of a breast mass.

fIg. 5.2 Illustration of a stick person.

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Develop an assessment for each problem on the problem list. Begin the process of making a differential diagnosis by discussing and giving priority to possible causes and contributing factors for a problem or symptom. Present the rationale for the potential causes and validate the assessment from data contained in the comprehensive health history, physical examination, consultations, and any laboratory data available. When a serious potential cause is no longer under consideration, explain why.

Describe any pertinent absence of information when other portions of the history or physical examination suggest that an abnormality might exist or develop in an area (e.g., absence of wheezing in someone with dyspnea). Avoid the use of words such as “normal” or phrases such as “within normal limits,” or worse yet “WNL,” because they do not describe what is inspected, palpated, percussed, or auscul- tated. Be as objective as possible. Assessment may include anticipated potential problems such as complications or progression of the disease.

Plan The plan describes the need to invoke diagnostic resources, therapeutic modalities, other professional resources, and the rationale for these decisions—what you intend to do.

Develop a plan for each problem on the problem list. The plan can be divided into three sections: diagnostics, therapeutics (if known), and patient education: • Diagnostics. List the diagnostic tests and consultations

to be performed or ordered. • Therapeutics. Describe the therapeutic treatment plan.

Provide a rationale for any change or addition to an established treatment plan. List any referrals initiated, with their purpose and to whom the referral is made. State the target date for reevaluating the plan.

• Patient education. Describe health education provided or planned. Include materials dispensed and evidence of the patient’s understanding or lack thereof.

SOAP Notes The organization of the patient data within the POMR, especially for care beyond the initial evaluation, is often recorded in a series of SOAP notes. Each problem is recorded separately. Subjective and objective data relevant to each problem are clustered together, followed by the assessment and the plan (Box 5.4). Alternatively, all of the subjective and objective data can be recorded in totality. Then the list of problems with the assessment and plan for each are written.

APSO Notes With widespread use of the EMR, one consequence that has occurred is an increased amount of data that can be incorporated in the note. The busy healthcare provider will be challenged to quickly find the most clinically useful information: the assessment and plan. In the SOAP format one may be required to scroll or click through multiple screens before locating this. With the APSO format, the

the following information: problem number, date of onset, description of problem, and date problem was resolved or became an inactive concern.

A problem may be defined as anything that will require further evaluation or attention. Problems arise in many varieties, for example, the questions regarding diagnosis, the availability of diagnostic and therapeutic resources, ethical issues, and factors in the patient’s life—social, emotional, financial, work related, school related, family related, and even the availability of caretakers. A problem may be related to any of the following: • A firmly established diagnosis (e.g., diabetes mellitus,

hypertension) • A new symptom or physical finding of unknown etiology

or significance (e.g., right knee effusion) • New findings revealed by laboratory tests (e.g., microcytic

anemia) • Personal or social difficulties (e.g., unemployment,

homelessness) • Risk factors for serious conditions (e.g., smoking, family

history of coronary artery disease) • Factors crucial to remember long term (e.g., allergy to

penicillin) You may list problems in separate lists, for example,

diagnostic issues, care and therapeutic issues, and long-range issues, or you may make one list. The needs of a particular patient and the resources available to you will influence your judgment and your ultimate approach. The nature of the patient’s problems determines the sequence in which you list them. Problems may be listed in chronologic order or listed according to the severity of problem. Some control- ling variables with regard to the sequencing of listed problems include the following: • Possibility that the diagnosis is life-threatening and needs

immediate attention; the relative gravity of the problem • Probability/possibility ratio: priority given to the probable

diagnoses or therapeutic actions • Likelihood of the probabilities in a differential diagnosis—

the more probable taking precedence • Availability and cost of the diagnostic, therapeutic, and

caretaking resources; cost relative to need and availability • Time sequence in which the problems arose and the

time sequence dictated by their relative urgency This list enables all healthcare providers to quickly assess

the patient’s history by the summary presented on this list. When a problem is resolved, the date of resolution should be entered, and this item can then be removed from the active problem list. Surgical correction of a condition and recovery from an acute infectious process are examples of resolved problems.

Assessment The assessment section is composed of your interpretations and conclusions, their rationale, the diagnostic strategy, present and anticipated problems, and the needs of ongoing as well as future care—what you think (see Chapter 4, “Taking the Next Steps: Critical Reasoning”).

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of information recorded. Most health agencies have forms or EMR templates with headings for each category of information to be recorded. This information should be contained on every page of documentation.

Problems, Allergies, Medications, and Immunizations List. Although the problems, allergies, medications, and immu- nizations (PAMI) list itself is added to the record after the subjective and objective information has been organized, the POMR form can be reviewed at a glance by medical personnel. The PAMI list is an ongoing record of a patient’s medical problems, allergies with associated reactions, medications with dosages and instructions of how these are administered, and past immunizations. This list should be reviewed, reconciled, and updated with the patient at each visit and when admitted to the hospital.

For each entry, the date of onset or initiation is recorded along with the date that the problem was resolved, the medication discontinued, or the date and route that an immunization was given.

General Patient Information. Additional identifying infor- mation for each patient includes address, home and/or cell phone number, employer, position or title, work address and telephone number, e-mail address, marital status, and health insurance status, plan name, and member identifica- tion number.

Source and Reliability of Information. Document the historian’s identity—that is, the patient or the person’s relationship to the patient. State your judgment about the reliability of the historian’s information. Indicate when the history is taken from the patient’s medical record.

Chief Concern/Presenting Problem/Reason for Seeking Care. The chief concern or presenting problem is a brief descrip- tion of the patient’s main reason for seeking care. The information may be stated verbatim in quotation marks. Always include the duration of the chief concern or problem.

History of Present Illness. This section contains a detailed description of all symptoms that may be related to the chief concern, and it describes the concern or problem chronologi- cally, dating events and symptoms. When describing the present illness, it is important for the examiner to record the absence of certain symptoms commonly associated with the particular area, or system, involved. Also inquire about anyone in the household with the same symptoms or possible exposure to infectious or toxic agents. If pertinent to the present illness, include relevant information from the review of systems, family history, and personal/social history. When more than one problem is identified, address each problem in a separate paragraph. Include the following details of each symptom’s occurrence, described in narrative form by categories: • Onset: when the problem or symptom first started;

chronologic order of events; setting and circumstances

assessment and plan are moved to the beginning of the document, with all remaining data available in the remainder of the note.

Notes From Subsequent Evaluations Whether it is during each of the hospital days after an inpatient admission (progress notes) or subsequent outpatient visits for episodic illness or preventative care (ambulatory care notes), the encounter is recorded within the medical record. Because there exists in the record an established amount of baseline information, record- ing of the POMR can be focused primarily on updating information.

An interval history—including subjective status of the problem, current medications, and review of systems related to the problem—is presented in the subjective portion of the note. The objective portion includes vital signs, a record of any physical examination performed at the time of the visit, and results of laboratory data or radiographic studies performed since the last visit.

The assessment section includes your evaluation of the problem status. If the problem was formerly a symptom, such as shortness of breath, you may have enough data to make a diagnosis. The rationale for the diagnosis is pre- sented in this section, and the problems, allergies, and medications list is updated accordingly.

Similar to the comprehensive health history and examina- tion documentation, plans are presented in three compo- nents: diagnostic, therapeutic, and patient education.

Problem-Oriented Medical Record Format The History The patient’s history, especially for an initial visit, provides a comprehensive database. The following organized sequence will guide you in creating a POMR.

Identifying Information. The patient’s name, date of birth, and an assigned medical record number are the first items

BoX 5.4 Governing Principles for Using POMR, APSO, and SOAP

• Record legibly the information you judge is needed; you will write more early in your career, but as time goes by, you will learn to edit with experience and wisdom, especially under the time pressures you will face.

• Organize! Tell the unique story of your patient chronologically and precisely, including positive as well as relevant negative information.

• Use clear headings. • Precision requires exact description; for example, use a tape

measure to measure the size of swelling. • Be terse. An “erythematous” throat may also be described as

“red,” and a bulge in an “eardrum” is as well understood as “tympanic membrane.”

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• Medications: past, current, and recent medications (dosage, nonprescription medications, vitamins); comple- mentary and herbal therapies

• Allergies: drugs, foods, environmental allergens, along with the allergic reaction (e.g., rash, anaphylaxis)

• Transfusions: reason, date, and number of units trans- fused; reaction, if any

• Mental health: mood disorders, psychiatric therapy, or medications

• Recent laboratory tests: glucose, cholesterol, Pap smear/ HPV, HIV, mammogram, colonoscopy

Family History. Include a pedigree (with at least three generations). An example is shown in Fig. 5.3. Many EMRs allow healthcare providers to create a pedigree. If it is not part of the pedigree, include a family history (FH) of major health or genetic disorders (e.g., hypertension, cancer, cardiac, respiratory, kidney disease, strokes, or thyroid disorders; asthma or other allergic manifestations; blood dyscrasias; psychiatric illness; tuberculosis; rheumatologic diseases; diabetes mellitus; hepatitis; or other familial disorders). Spontaneous abortions and stillbirths suggest genetic problems. Include the age and health of the spouse and children.

Personal and Social History. The information included in this section varies according to the concerns of the patient and the influence of the health problem on the patient’s life. • Cultural background and practices, birthplace, where

raised, home environment as youth, education, position in family, marital status or same-sex partner, general life satisfaction, hobbies, interests, sources of stress, religious preference (religious or cultural proscriptions concerning medical care)

• Home environment: number of individuals in household, pets, economic condition

• Occupation: usual work and present work if different, list of job changes, work conditions and hours, physical or mental strain, duration of employment; present and past exposure to heat and cold, industrial toxins; protec- tive devices required or used; military service

• Environment: home, school, work, structural barriers if physically disabled, community services utilized; travel and other exposure to contagious diseases, residence in tropics; water and milk supply, other sources of infection when applicable

• Current health habits and/or risk factors: exercise; smoking (packs per day times duration); salt intake; obesity/weight control; diet; alcohol intake: beer, wine, hard liquor (amount/day), duration; CAGE (see Box 1.3) or TACE (see Box 1.4) question responses; blackouts, seizures, or delirium tremens; drug or alcohol treatment program or support group; recreational drugs used (e.g., marijuana, cocaine, heroin, LSD, PCP, methamphet- amine) and methods (e.g., injection, ingestion, sniffing, smoking, or use of shared needles)

(e.g., while exercising, sleeping, working); manner of the onset (sudden versus gradual)

• Location: exact location of pain (localized, generalized, radiation patterns)

• Duration: length of problem or episode; if intermittent, duration of each episode

• Character: nature of pain (e.g., stabbing, burning, sharp, dull, gnawing)

• Aggravating and associated factors: food, activity, rest, certain movements; nausea, vomiting, diarrhea, fever, chills

• Relieving factors and effect on the problem: food, rest, activity, position, prescribed and/or home remedies, alternative or complementary therapies

• Temporal factors: frequency of occurrence (single attack, intermittent, chronic); describe typical attack; change in symptom intensity, improvement or worsening over time

• Severity of the symptoms: 0 to 10 scale, effect on lifestyle, work performance

Recording the History of the Present Illness: OLDCARTS. The OLDCARTS mnemonic helps make sure all characteristics of a problem are described in the history of present illness (HPI) to ensure a comprehensive presentation. The order of recording these characteristics does not need to be consistent. O Onset L Location D Duration C Character A Aggravating/associated factors R Relieving factors T Temporal factors S Severity of symptoms

Past Medical History. The past medical history (PMH) includes general health over the patient’s lifetime, as well as disabilities and functional limitations, as the patient perceives them. List and describe each of the following with dates of occurrence and any specific information available: • Hospitalizations and/or surgery (including outpatient

surgery): dates, hospital, diagnosis, complications, injuries, disabilities

• Major childhood illnesses: congenital heart defects, previous cancer, inflammatory bowel disease, asthma

• Major adult illnesses: tuberculosis, hepatitis, diabetes mellitus, hypertension, myocardial infarction, tropical or parasitic diseases, other infections

• Serious injuries: traumatic brain injury, liver laceration, spinal injury, fractures

• Immunizations: polio, diphtheria, pertussis, tetanus toxoid, hepatitis B, measles, mumps, rubella, Hae- mophilus influenzae, varicella, influenza, hepatitis A, meningococcal, human papillomavirus, pneumococ- cal, zoster, cholera, typhus, typhoid, anthrax, smallpox, bacille Calmette-Guérin (BCG), unusual reaction to immunizations

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• Ears: hearing loss, pain, discharge, tinnitus, vertigo • Nose: sense of smell, frequency of colds, obstruction,

nosebleeds, postnasal discharge, sinus pain • Throat and mouth: hoarseness or change in voice;

frequent sore throats, bleeding or swelling of gums; recent tooth abscesses or extraction; soreness of tongue or buccal mucosa, ulcers; disturbance of taste

• Lymphatic: enlargement, tenderness, suppuration • Chest and lungs: pain related to respiration, dyspnea,

cyanosis, wheezing, cough, sputum (character and quantity), hemoptysis, night sweats, exposure to tuber- culosis; last chest radiograph

• Breasts: development, pain, tenderness, discharge, lumps, galactorrhea, mammograms (screening or diagnostic)

• Heart and blood vessels: chest pain or distress, precipitat- ing causes, timing and duration, relieving factors, palpita- tions, dyspnea, orthopnea (number of pillows), edema, hypertension, previous myocardial infarction, exercise tolerance (flights of steps, distance walking), past elec- trocardiogram and cardiac tests

• Peripheral vasculature: claudication (frequency, severity), tendency to bruise or bleed, thromboses, thrombophlebitis

• Hematologic: anemia, any known blood cell disorder

• Exposure to chemicals, toxins, poisons, asbestos, or radioactive material at home or work and duration; caffeine use (cups/glasses/day)

• Sexual activity: contraceptive or barrier protection method used; past sexually transmitted infections (e.g., syphilis, gonorrhea, chlamydia, pelvic inflammatory disease, herpes, warts); treatment

• Concerns about cost of care, healthcare coverage

Review of Systems • General constitutional symptoms: fever, chills, malaise,

easily fatigued, night sweats, weight (average, preferred, present, change over a specified period and whether this change was intentional)

• Skin, hair, and nails: rash or eruption, itching, pigmenta- tion or texture change; excessive sweating, unusual nail or hair growth

• Head and neck: frequent or unusual headaches, their location, dizziness, syncope; brain injuries, concussions, loss of consciousness (momentary or prolonged)

• Eyes: visual acuity, blurring, double vision, light sensitiv- ity, pain, change in appearance or vision; use of glasses/ contacts, eye drops, other medication; history of trauma, glaucoma, cataracts, familial eye disease

30 12

14

Deceased

Male

Female

Proband (patient)

Gender Unknown

Spontaneous Abortion (SAB)

PregnancyA P

Unaffected Affected X-Linked Carrier Carrier

50 (deceased male, age 50)

Twins: Monozygous Dizygous

Union (parents) Consanguineous

Relationship

B

fIg. 5.3 A, Common pedigree symbols. B, Sample pedigree for autosomal recessive condition.

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• Vital signs: pain score and location of pain if present, temperature, pulse rate, respiratory rate, blood pressure, orthostatic (lying, sitting, and standing) pulse and blood pressure when appropriate

Mental Status • Physical appearance and behavior • Cognitive: consciousness level, response to questions,

reasoning or judgment, arithmetic ability, memory, attention span; specific mental test scores

• Emotional stability: depression, anxiety, disturbance in thought content, hallucinations

• Speech and language: voice quality, articulation, coher- ence, comprehension

Skin • Color, uniformity, integrity, texture, temperature, turgor,

hygiene, tattoos, scars • Presence of edema, moisture, excessive perspiration,

unusual odor • Presence and description of lesions (size, shape, location,

color, configuration, blanching, inflammation, tenderness, induration, discharge), trauma

• Hair texture, distribution, color, quality • Nail configuration, color, texture, condition, nail base

angle for clubbing, ridging, beading, pitting, peeling, nail plate firmness, adherence to nail bed

Head • Size and contour of head, scalp appearance, head

position • Symmetry and spacing of facial features, tics, charac-

teristic facies • Presence of edema or puffiness • Temporal arteries: pulsations, thickening, hardness,

tenderness, bruits

Eyes • Visual acuity (near, distant), visual fields • Appearance of orbits (edema, sagging tissue, puffiness),

color of conjunctivae and sclerae, eyelids (redness, flakiness, fasciculations, ptosis), eyebrows

• Extraocular movements, corneal light reflex, cover-uncover test, nystagmus

• Pupillary shape, size, consensual response to light and accommodation, depth of anterior chamber

• Ophthalmoscopic findings of cornea, lens, retina, red reflex, optic disc and macular characteristics, retinal vessel size, caliber, and arteriovenous (AV) crossings, arteriole-venule ratio, exudates, hemorrhages

Ears • Configuration, position, and alignment of auricles;

nodules; tenderness of auricles, or in mastoid area

• Otoscopic findings of canals (cerumen, lesions, discharge, foreign body) and tympanic membranes (integrity, color,

• Gastrointestinal: appetite, digestion, intolerance of any foods, dysphagia, heartburn, nausea, vomiting, hematemesis, bowel regularity, constipation, diarrhea, change in stool color or contents (clay, tarry, fresh blood, mucus, undigested food), flatulence, hemor- rhoids, hepatitis, jaundice, dark urine; history of ulcer, gallstones, polyps, tumor; previous radiographic studies, sigmoidoscopy, colonoscopy (where, when, findings)

• Diet: appetite, likes and dislikes, restrictions (because of religion, allergy, or other disease), vitamins and other supplement, caffeine-containing beverages (coffee, tea, cola); food diary or daily listing of food and liquid intake as needed

• Endocrine: thyroid enlargement or tenderness, heat or cold intolerance, unexplained weight change, polydipsia, polyuria, changes in facial or body hair, increased hat and glove size, skin striae

• Males: puberty onset, erections, emissions, testicular pain, libido, infertility

• Females: menses onset, regularity, duration, amount of flow; dysmenorrhea; last period; intermenstrual discharge or bleeding; itching; date of last Pap smear/HPV test; age at menopause; libido; frequency of intercourse; sexual difficulties

• Pregnancy: infertility; gravidity and parity (G = number of pregnancies, P = number of childbirths, A = number of abortions/miscarriages, L = number of living children); number and duration of each pregnancy, delivery method; complications during any pregnancy or postpartum period; use of oral or other contraceptives

• Genitourinary: dysuria, flank or suprapubic pain, urgency, frequency, nocturia, hematuria, polyuria, hesitancy, dribbling, loss in force of stream, passage of stone; edema of face, stress incontinence, hernias, sexually transmitted infection

• Musculoskeletal: joint stiffness, pain, restriction of motion, swelling, redness, heat, bony deformity, number and pattern of joint involvement

• Neurologic: syncope, seizures, weakness or paralysis, problems with sensation or coordination, tremors

• Mental health: depression, mania, mood changes, dif- ficulty concentrating, nervousness, tension, suicidal thoughts, irritability, sleep disturbances

Physical Examination Findings Record the objective data by body systems and anatomic location. Begin with a general statement about the overall health status of the patient. All observations of physical signs should be described in the appropriate body system or region, usually organized in sequence from head to toe. Take care to describe findings in detail rather than make diagnostic statements. The findings generally included in each category follow.

General Statement • Age, race, gender identity, general appearance • Weight, height, body mass index

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• Tissue consistency, presence of masses, scars, tenderness, thickening, retractions or dimpling

• Characteristics of nipples and areolae (inversion, eversion, retraction), discharge

Heart • Anatomic location of apical impulse, pulsations • Heart rate, rhythm • Palpation findings: thrills, heaves, or lifts • Auscultation findings: characteristics of S1 and S2 (loca-

tion, intensity, pitch, timing, splitting, systole, diastole) • Presence of murmurs, clicks, snaps, S3 or S4; description

by timing, location, radiation, intensity, pitch, quality, variation with respiration

Blood Vessels • Amplitude, symmetry of pulses in extremities • Jugular vein pulsations and distention, pressure measure-

ment; jugular vein and carotid artery pulse waves • Presence of bruits over abdominal aorta and carotid,

temporal, renal, iliac, and femoral arteries • Temperature, color, hair distribution, skin texture, muscle

atrophy, nail beds of lower extremities • Presence of edema, swelling, vein distention, varicosities,

circumference of extremities • Tenderness of lower extremities or along superficial vein

Abdomen • Shape, contour, visible aorta pulsations, surface motion,

venous patterns, scars, hernia or separation of muscles, peristalsis

• Auscultation findings: presence and character of bowel sounds, friction rub over liver or spleen

• Palpation findings: aorta, organs, feces, masses; location, size, contour, consistency, tenderness, muscle resistance

• Percussion findings: tone in each quadrant, areas of different percussion notes, costovertebral angle (CVA) tenderness, liver span

Male Genitalia • Appearance of external genitalia, penis (symmetry,

circumcision status, unusual thickening, color, texture, location and size of urethral opening, discharge), urethral discharge with stripping, lesions, distribution of pubic hair

• Palpation findings: penis, testes, epididymides, vasa deferentia, contour, consistency, tenderness

• Presence of hernia or scrotal swelling, transillumination findings

Female Genitalia • Appearance of external genitalia and perineum, distri-

bution of pubic hair, tenderness, scarring, discharge, inflammation, irritation, lesions, caruncle, polyps

• Internal examination findings: appearance of vaginal mucosa, cervix (color, position, surface characteristics, shape of os), discharge, odor

bony landmarks, light reflex, mobility, bulging, retrac- tion), fluid, air bubbles

• Hearing: Weber and Rinne tests, whispered voice, conversation

Nose • Appearance of external nose, nasal patency • Presence of discharge, crusting, flaring, polyp • Appearance of turbinates, alignment of septum • Presence of sinus tenderness, swelling • Discrimination of odors

Throat and Mouth • Number, occlusion, and condition of teeth; missing teeth;

presence of dental appliances • Characteristics of lips, tongue, buccal and oral mucosa,

and floor of mouth (color, moisture, surface character- istics, symmetry, induration)

• Appearance of oropharynx, palate, and tonsils; tonsil size

• Symmetry and movement of tongue, soft palate, and uvula; gag reflex

• Voice quality • Discrimination of taste

Neck • Fullness, mobility, suppleness, and strength • Position of trachea, tracheal tug, movement of hyoid

bone and cartilages with swallowing • Thyroid size, shape, nodules, tenderness, bruits • Presence of masses, webbing, skinfolds

Chest • Size and shape of chest, anteroposterior versus transverse

diameter, symmetry of movement with respiration, superficial venous patterns

• Tenderness over ribs, bony prominences • Presence of retractions, use of accessory muscles • Diaphragmatic excursion

Lungs • Respiratory rate, depth, regularity, quietness or ease of

respiration • Palpation findings: symmetry and quality of tactile

fremitus • Percussion findings: quality and symmetry of percussion

notes • Auscultation findings: characteristics of breath sounds

(intensity, pitch, duration, quality), phase and location where audible

• Characteristics of cough, stridor • Presence of friction rub, egophony, bronchophony,

whispered pectoriloquy, vocal resonance

Breasts • Size, contour, symmetry, supernumerary nipples, venous

patterns, lesions

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• Patient education: health education provided or planned; materials such as websites provided, handouts/pamphlets dispensed; evidence of patient’s understanding (or lack of understanding); counseling

• Referrals initiated (including to whom the patient is referred and the purpose)

• Target dates for reevaluating the results of the plan

Infants The organizational structure for recording the history and physical examination of newborns and infants is the same as for adults. The recorded information varies from the adult’s primarily because of the developmental status of the infant. With newborns the focus is on their transition to extrauterine life and the detection of any congenital anomalies. Specific additions to the history and physical examination follow.

History Present Problem. For older infants, record information

as for adults; however, for newborns include the details of the pregnancy and any untoward events occurring since birth.

Details of Pregnancy • Patient’s health during pregnancy, age, specific condi-

tions (e.g., hypertension, diabetes, lupus, seizures, bleeding, proteinuria, preeclampsia); infectious illnesses (gestational month of infection); radiation exposure; medications taken; use of tobacco, alcohol, or recreational drugs

• Prenatal care: weight gained, planned pregnancy, attitude toward pregnancy, duration of pregnancy, support from partner and family members

• Labor and delivery: spontaneous, induced, duration, analgesia or anesthesia, complications, presenta- tion, forceps, vacuum extraction, vaginal or cesarean delivery. Infant’s Status at Birth

• Birth weight, gestational age, respiratory status, color, Apgar scores at 1 and 5 minutes if known; newborn’s condition and duration of hospital stay, nutrition; congenital anomalies, meconium staining, bilirubin phototherapy, bleeding, seizures, prescriptions (e.g., antibiotics) First Month of Life

• Jaundice, bleeding, seizures, other evidence of illness Past Medical History. Birth history represents the

newborn’s past medical history. Older infants should have general health as well as prenatal and neonatal events added to this category unless this information is directly related to the present problem.

Family History. Focus on the number of miscarriages, number of deceased children, congenital anomalies, and hereditary disorders in the family.

Personal and Social History. Focus on the newborn’s and infant’s family and household structure, number

• Bimanual examination findings: size, contour, and position of uterus, tenderness and mobility of cervix, uterus, adnexa, and ovaries (size, shape, consistency, tenderness)

• Rectovaginal examination findings • Urinary incontinence when patient bears down

Anus and Rectum • Perianal area: appearance, presence of hemorrhoids,

fissures, skin tags, pilonidal dimpling, hair tufts, inflam- mation, excoriation

• Rectal wall contour, tenderness, sphincter tone and control

• Prostate size, contour, consistency, mobility • Color and consistency of stool

Lymphatic System • Presence of lymph nodes in head, neck, submandibular,

supraclavicular, infraclavicular, epitrochlear, axillary, or inguinal areas

• Size, shape, warmth, tenderness, mobility, consistency (matted or discreteness of nodes)

• Redness or streaks in localized area

Musculoskeletal System • Posture: alignment of extremities and spine, symmetry

of body parts • Symmetry of muscle mass, tone, fasciculation, spasms • Range of motion (active and passive) • Appearance of joints: presence of deformities, tenderness,

crepitus, swelling • Muscle strength

Neurologic System • Cranial nerves: specific findings for each or specify those

tested if findings are recorded in head and neck sections.

• Gait (posture, rhythm, sequence of stride and arm movements)

• Balance, coordination with rapid alternating motions • Sensory function: presence and symmetry of response

to pain, touch, vibration, temperature stimuli; monofila- ment test

• Superficial and deep tendon reflexes: symmetry, grade, plantar reflex, ankle clonus

Assessment (for Each Problem on Problem List) The diagnosis with rationale, derived from the subjective and objective data, is stated. If a diagnosis cannot yet be made, differential diagnoses are prioritized. Assessment includes anticipated potential problems, if appropriate (e.g., complications, progression of disease, sequelae).

Plan (for Each Problem on Problem List) • Diagnostic tests performed or ordered • Therapeutic treatment plan, including changes or addi-

tions to the established treatment plan, with rationale

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Head • Shape, molding, forceps or electrode marks • Fontanel size, dysmorphic facial features, swelling

Eyes • Red reflex, corneal light reflex, follows object with

eyes • Swelling of lids, discharge

Ears • Shape and alignment of auricles, presence of skin tags

or pits • Startle to noise or response to voice

Nose • Patency of nares, nasal flaring, discharge

Mouth • Palate and lip integrity • Presence and number of teeth • Strength of sucking, coordinated sucking, and

swallowing Neck

• Head position, neck control • Presence of masses, webbing, excess skinfolds

Chest and Lungs • Symmetry of shape, circumference • Breast swelling or discharge • Abdominal or thoracic breathing • Presence of retractions (intercostal, supraclavicular,

substernal), presence of grunting or stridor • Quality of cry

Heart and Blood Vessels • Recording as for adults, but with peripheral vascular

findings integrated in this section Abdomen

• Number of umbilical arteries and veins, stump dryness, color, odor

• Any bulging or separation of abdominal wall • Apparent peristaltic waves

Male Genitalia • Appearance of penis, scrotum; position of urethra • Location of testes: descended, descendible, not descended,

not palpable • Urinary stream • Presence of hernia or hydrocele

Female Genitalia • Appearance of labia, presence of discharge

Anus, Rectum • Perforate, sphincter control • Character of meconium or stool, if observed • Presence of sacral dimple, skin pigmentation or hair

tuft Musculoskeletal System

• Alignment of limbs and spine • Presence of joint deformity, fixed or flexible; integrity

of clavicles • Symmetry of movement in all extremities, hip

abduction • Number of fingers and toes, webbing or extra digits,

palmar creases

of siblings, other children in the home, presence of both parents in the home, other adult caregivers in and outside of the home, financial stressors, housing situation, arrangements for child care, and parents’ plans to return to work.

Growth and Development. Placement of this information is according to the purpose of the examination. For the infant with no growth or development problems, it may be recorded as either history or review of systems, or it may be a separate category. When a problem with growth or development is apparent, the information will be recorded in the section for the present problem. Passing or failing of a developmental screening tool would be recorded with objective data.

Developmental Milestones. List developmental mile- stones with the age at which they are attained (e.g., holds head erect while in sitting position, rolls over front to back and back to front, sits unsupported, stands and walks without support, first words and sentences, dresses self ).

Injury Prevention. List parents’ efforts to consis- tently prevent injuries based on infant’s chronologic and developmental age (e.g., use of car safety seat, stair gates).

Diet. Placement of this information varies by healthcare facility; it may appear in the present illness or review of systems, or it may be a separate category.

Breast-Fed Infants. Note the frequency; use of supple- mental formula and vitamin D supplementation; patient’s diet, fluid intake, concern with milk supply, any problems with nipple soreness, cracking, or infections; and age weaned.

Formula-Fed Infants. Note the specific formula and preparation method; concentration or powder and amount of water added; frequency of feeding; amount per feeding; total ounces per day; and whether juice, water, or vitamins are given.

Solid Foods. Note the age at which cereal and other foods were introduced; specifics about feeding methods, amount, food preparation; and the response of infant to foods.

Physical Examination Findings General

• Age in hours, days, weeks, or months; gender; race • Gestational age • Length, weight, and head circumference with percentiles;

for newborns, percentiles for gestational age Mental Status

• Infant state during examination (irritable, crying, sleep- ing, alert, quiet) Skin

• Color, texture, presence of lanugo or vernix, hyperpig- mented macule, nails

• Presence of hemangiomas, nevi, telangiectasia, milia Lymphatics

• Visible or palpable lymph nodes

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Pregnant Patients The organizational structure of the record does not vary from that of other adults; however, information about the pregnancy is added, and some aspects of the examination are modified.

History History of Present Illness. List the gravidity and parity,

last menstrual period, and expected delivery date. Is it a planned pregnancy? Describe details about specific problems such as bleeding or spotting, nausea, vomiting, fatigue, edema, illness, injury, surgery, or exposure to drugs, chemicals, radiation, or infections since conception.

Obstetric History. This additional history category should provide information on previous pregnancies, type of delivery, length of labor, complications in pregnancy, labor, postpartum; weight and gender of newborn; and previous abortions.

Menstrual and Gynecologic History. Age at menarche, characteristics of cycle, unusual bleeding, use of contracep- tives, sexual history, most recent Pap smear/HPV test, infertility.

Personal and Social History. In addition to the infor- mation usually obtained, include the adjustment to the pregnancy by the patient and the patient’s significant other, information about whether pregnancy was planned, acceptance by the other parent and family, any history of partner violence, and the other parent’s role or other support available to the parent who gave birth and child after delivery.

Physical Examination Findings Abdomen

• Status of the pregnancy, fundal height in relation to dates

• Fetal heart rate, position, well-being, movement • Contractions

Pelvic Region • Pelvic measurements • Uterine size • During late pregnancy and labor: centimeters of dilation

and effacement, station of the fetus, position of the fetal head or presenting part

• Leaking of fluid or rupture of membranes

Older Adults The organizational structure, again, does not vary from that recorded for other adults. A few modifications in aspects of the history and physical examination are made, as described in the following.

History Personal and Social History. Describe the community

and family support systems. Add the functional assessment of ability to prepare meals, manage personal affairs, and engage in social and other meaningful activities. Identify

Neurologic System • Presence and symmetry of primitive reflexes • Consolability, presence of tremors or jitteriness • Gross and fine motor development

Children and Adolescents As during infancy, some adaptations in the recorded history reflect the developmental progress of the child. Such modi- fications in recording the child’s history are discussed next.

History Past Medical History. Prenatal and neonatal history is

less important as the child gets older. Birth weight and major neonatal problems are generally included in the history of an initial examination until the child reaches school age. If a health problem can be related to birth events, more detail is recorded, often summarized from previous records, because the parent’s recall may not be as accurate as time elapses.

Personal and Social History. Record how the child gets along with parents and other adult caregivers, siblings, and other children; his or her temperament and behavior in group situations; and any evidence of family problems. Include the principal caretaker, parents’ relationship (e.g., married, divorced, separated, single parent, foster parent), education attainment of parents, involvement with social service agencies. Describe injury prevention strategies used by family.

For older children, record school performance: grade level, progress, adjustment to school, and parents’ attitude toward education. Note any habits of the child, such as nail biting or thumb sucking; note hobbies, sports participation, and clubs.

For adolescents, add peer group activities, conflicts, relationships, sexual activity, alcohol or recreational drug use, concerns with gender identity and independence, self-esteem, favorite activities, type of job, and potential hazards. This may be summarized with the HEEADSSS tool (see Box 1.13).

Growth and Development. For toddlers and young children, list motor skills and language milestones attained, age toilet trained, and age weaned from bottle.

Physical Examination Findings. The physical findings are recorded in the same format used for adults and infants. Some additional notations related to development include the following:

Mental Status. Record mental status and cognitive development status.

Breasts. For females, record the Tanner stage of breast development.

Genitalia. Record the Tanner stage of pubic hair and genital development as appropriate. Record the sexual maturity rating.

Neurologic System. Findings should indicate develop- mental expectations of cerebellar function, cranial nerves, and deep tendon reflexes.

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Musculoskeletal System • Posture and muscle mass changes • Functional assessment of mobility and muscle strength

Neurologic System • Functional assessment of fine motor movements • Gait and balance, sensation

Sample Records Information must be recorded as precisely as possible. Select words for the patient’s history carefully because some words may have different implications. Healthcare providers have commonly used the term denies when a patient reports that no symptom has occurred. The term denies may imply a confrontational or unproductive relationship. It is better to write either “reports no” or “indicates no” symptoms, statements that more positively record the patient’s coopera- tion in providing needed information. It is safe to assume that your note will be carefully read by many people.

Inpatient Admission Note Box 5.5 shows an example of a written admission note.

plans for advance directives and power of attorney for healthcare decisions.

Physical Examination Findings General Assessment

• Extra time to assume positions for physical examination

• Position modifications needed for specific systems • Mental status • Functional assessment of cognitive function, memory,

and reasoning and calculation • Skin • Presence of common lesions of older age • Turgor, resilience of skin • Condition and thickness of nails, especially toenails • Character and color of hair, baldness patterns

Chest and Lungs • Change in chest shape and percussion tones • Effect of chest shape on respiratory status

Heart and Blood Vessels • Location of the apical pulse • Characteristics of superficial vessels and distal pulses

BoX 5.5 Written Admission Note

Identifying Information: R.S. is a 68-year-old man admitted to the hospital on September 3, 2017. The history is obtained from the patient, and he is considered to be a reliable historian.

Chief Concern: “Having a hard time catching my breath.”

History of Present Illness The patient is a 68-year-old man with type 2 diabetes mellitus and hypertension who presented to the emergency department on 9/3/17 with 5 days of increasing difficulty in breathing. At that time he began to note increasing difficulty breathing when he would go up the steps in his home. This became progressively worse over the next several days to the point where he was feeling uncomfortable breathing even at rest. In that time he also has been having increasing difficulty sleeping at night, having to prop himself up on 4 pillows and waking up short of breath over the past 3 nights. He had to spend the entire night before his admission sitting up in a chair because he couldn’t lie down without becoming short of breath. Finally, when he “couldn’t talk without losing [his] breath,” he called 911 and was transported to the hospital.

R.S. has no prior history of these episodes and reports no prior history of cardiac or pulmonary disease. He reports no chest pain. Before the onset of these symptoms 5 days ago, he would go for daily walks with his dog and have no dyspnea or chest pain. He does report swelling developing in his ankles and feet over the past several days. He has also noticed a weight gain over the past several days of about 8 pounds, despite having a poor appetite. As far as he knows, his diabetes and hypertension have been well controlled, and he last saw his physician 2 months ago. He has had no cough, sputum production, hemoptysis, wheezing, fever, or chills. He does not report a history of hyperlipidemia or smoking but does report a family history (FH) of coronary artery disease in his parent and brother.

Past Medical History Childhood Illnesses: Reports having all “usual childhood illnesses”;

unable to recall specific ones.

Adult Illnesses 1. Hypertension—diagnosed in 2003, on medication since 2005 and

reportedly well controlled 2. Diabetes mellitus (type 2)—diagnosed in 2003, on oral medicine

since time of diagnosis. Last hemoglobin A1c 7.2% 2 months ago. No history of retinopathy, nephropathy, or peripheral neuropathy.

3. Hypothyroidism—diagnosed 2007, last TSH (thyroid-stimulating hormone) was 1.05 in 2016

Prior Surgery 1. Appendectomy—1959 2. Inguinal hernia repair, left side—1967 3. Sigmoid colectomy for sessile villous adenoma, 1999; last colonoscopy

was 2014 and was without pathology

Medications on Admission Hydrochlorothiazide 25 mg by mouth each day (hypertension) Lisinopril 20 mg by mouth each day (hypertension) Metformin 1000 mg by mouth twice daily (diabetes) L-Thyroxine 100 mcg by mouth each day (hypothyroidism) Acetaminophen as needed (used rarely for knee pain) Multivitamin (Centrum Silver) one by mouth each day No herbal medicines or other over the counter medicines

Allergies Penicillin: causes hives, no history of anaphylaxis No known environmental or food allergies

Family History The patient’s parents are deceased. His father died at age 61 of compli- cations of colon cancer. He also had type 2 diabetes mellitus. His mother died at age 72 of a myocardial infarction. She also had an ischemic stroke at age 68. She was a smoker and had hypertension as well as hypothyroidism. The patient has one living brother at age 70 who has coronary artery disease and had a coronary artery bypass graft last year.

Continued

72 CHAPTER 5 Recording Information

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He also has type 2 diabetes, is a smoker, and has mild chronic obstruc- tive lung disease (COPD). He has one brother who died in a motor vehicle accident at age 20. He had no prior medical problems. He has one sister who died at age 54 of breast cancer, without other medical problems. The patient has three children (two sons aged 46 and 44 and a daughter age 41), two of whom are in good health. One of his sons was diagnosed with hypertension at age 37. There is no other family history of heart disease, diabetes, or cancer. He has no history of anyone in his family having a similar presentation to his current illness.

Social History The patient was born in Louisville, KY. He completed school through the tenth grade and then joined the military for 5 years. After his military service, he moved to Baltimore and worked at City Marine Terminal for his entire career. He retired at age 60. He was exposed to asbestos and a variety of chemical agents through much of his career but couldn’t specify. He is now retired and spends time with his grandchildren and working on his house.

He was married at age 20. He and his wife were together for 44 years until her death 4 years ago due to lung cancer. He has three children, all of whom live in the area, and five grandchildren; he reports a good relationship with them. He is still grieving his wife’s death but feels that things are getting easier. He lives independently in the same house in which he and his wife raised their children.

He is not currently sexually active and has not been since his wife’s death. He has no prior history of sexually transmitted infections. He has never smoked, and he drinks one to two beers a month. He reports that he used to drink heavily during his military service but has not since that time. He reports no recreational drug use.

The patient does not get regular exercise other than walking his dog for about 30 to 40 minutes each morning. He does not watch his diet as closely as he thinks he should but does try to avoid sweets because of his diabetes.

Review of Systems Constitutional: weight as per history of present illness (HPI); no weakness,

fatigue, fever, or night sweats Eyes: He does wear glasses for reading only. He has no blurred vision,

eye pain, redness, tearing, diplopia, or flashing lights. Ears: no hearing loss, tinnitus, discharge Nose: no nasal congestion, epistaxis Mouth and throat: wears upper dentures, last saw dentist 4 months

ago, no mouth dryness, throat pain, hoarseness Neck: no lumps or swollen glands, pain, or neck stiffness Respiratory: as per HPI Cardiac: as per HPI Gastrointestinal: No dysphagia, heartburn, dyspepsia, nausea, vomiting.

He does report constipation over the last 5 to 6 years, no change recently. No blood in stool or black tarry stool. No abdominal pain, or diarrhea.

Genitourinary: Urinary frequency and nocturia over the past year, 6 times per night. No hesitancy, urgency, dysuria, or hematuria. No penile discharge or pain, no testicular pain. He has not been able to have an erection for 3 years.

Peripheral vascular: no intermittent claudication, no leg cramps Musculoskeletal: mild bilateral knee pain with extended ambulation,

stable over the last 1 to 2 years; no other joint pain, stiffness, swelling, or muscle pain

Hematologic: no easy bruising, bleeding, or history of blood clots; no prior blood transfusions

Endocrine: as per HPI and PMH Skin: no rashes, dryness, color change, or abnormalities of hair or nails Neurologic: no headaches, head injuries, lightheadedness, vertigo,

syncope, seizures, focal weakness, numbness, paresthesias, tremor, gait instability or falls, or declining memory

Mental health: Despite experiencing grief over his wife’s death at times, he expressed no pervasive sadness or worry, and feels optimistic about the future. Before this current illness, he had good energy, and reports good memory, concentration, and interest in activities.

Physical Examination General appearance: This is a well-developed white man appearing his

stated age, in no respiratory distress sitting up in bed. He is alert and cooperative with the examination.

Vital signs: heart rate 68 beats per minute, blood pressure (left arm, regular adult cuff) 135/70, temperature (oral) 37° C, respiratory rate 18 per minute, pain 0/10, weight 65 kg

HEENT: Head is normocephalic without scalp or facial tenderness. Eyes: Conjunctivae are pink and sclerae are without injection or jaundice. Bilateral arcus senilis is present. Pupils are equal in size and react equally (4–2 mm) to light. Fundi showed sharp disc margins, and arteriole/venous nicking was present. No hemorrhages or exudates seen. Ears: External auditory canals had moderate cerumen (left greater than right). Tympanic membranes were intact and without erythema. Hearing was grossly intact. Nasopharynx mucosa was pink with slight septal deviation from left to right. The oropharynx had no lesions or exudates, and the mucus membranes were moist. Upper dentures were present, lower teeth were in good repair.

Neck: Trachea was midline, the thyroid was not palpable. Jugular venous distention was present (approximately 9 cm). Hepatojugular reflux was present. Carotid upstrokes were strong without bruits. No meningismus.

Lymph nodes: No cervical or axillary lymph nodes were palpable. Small, shoddy, rubbery, mobile, nontender inguinal nodes were present bilaterally, all approximately 5 mm in size.

Chest: Thoracic expansion was symmetric. There was dullness to percus- sion at both bases. Diaphragmatic excursion was difficult to assess due to dullness to percussion at the bases. Breath sounds were remarkable for crackles up to the angle of scapula bilaterally. No rhonchi, wheezes, or stridor. No egophony, bronchophony, or tactile fremitus.

Cardiac: Point of maximal impulse is noted in the fifth intercostal space 4 cm laterally from the midclavicular line. Regular rate and rhythm. S1 normal, S2 physiologically split. S3 is present, no S4. A II/VI blowing, holosystolic murmur was present at the apex radiating into the axilla.

Abdomen: Nondistended, no tenderness to palpation. Bowel sounds were present but hypoactive. No masses were palpable. The liver span percussed to 8 cm and the edge was smooth and palpable 2 cm below the right costal margin. The spleen was not palpable.

GU: Penis and testicles are without lesions. No inguinal hernias are present. Rectal examination had intact tone. Moderately enlarged, firm, symmetric, nontender prostate without nodules.

Extremities: No cyanosis or clubbing. 1+ pitting edema was present in the lower extremities up to the knees and was symmetric. Peripheral pulses at the dorsalis pedis and posterior tibial positions were palpable and strong bilaterally.

Musculoskeletal: Hands were without joint deformities with good finger curl and wrist movement. Bilateral knees showed mild hypertrophic joint deformity with reduced range of motion in extension bilaterally

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(to about 160 degrees). No erythema, warmth, tenderness, or effusion. Bulge sign negative. Other joints unremarkable.

Skin: Warm and dry, no rashes. Tattoo present on right shoulder. Well- healed incisions over abdomen in the left inguinal region and right lower quadrant. Hair with male-pattern baldness. No skin or nail lesions.

Neurologic 1. Mental status—Awake, alert, and attentive. Oriented in all spheres.

Speech fluent and repetition intact, able to point way out of room. Mood is euthymic and affect is appropriate to situation with full range. Thoughts are appropriate; no evidence of disordered thinking.

2. Cranial nerves—II–XII are intact: visual acuity 20/20 with correction, visual fields intact, extraocular movements intact, facial sensation and movement—intact, hearing intact, soft palate—elevates well, tongue protrudes in midline, intact shoulder shrug.

3. Motor—Intact and symmetric; no pronator drift; strength 5/5 in deltoids, finger extensors, hip flexors, and foot dorsiflexion bilaterally

4. Sensory—Intact to monofilament and fine touch, fingers, midthighs, toes—bilaterally. Vibratory sense intact of great toes bilaterally. Proprioception in toes intact.

5. Reflexes—2+ and symmetric in biceps and patella. Babinski reflex negative.

6. Coordination/gait—Intact finger to nose bilaterally. Intact rapid alternating movement. Stands and walks 10 feet without difficulty. Romberg negative; tandem walk, heel walk, toe walk intact.

Assessment R.S. is a 68-year-old man who presents with new-onset dyspnea on exertion, orthopnea, and paroxysmal nocturnal dyspnea of 5 days’ duration. His physical examination is significant for the presence of jugular venous distention, hepatojugular reflux, a displaced point of maximal impulse with an S3 and a holosystolic murmur, and peripheral edema. The most likely etiology for his illness is congestive heart failure. Other etiologies for the progressive dyspnea include pneumonia, pul- monary embolus, pneumothorax, pleural effusion, and pericardial effusion. However, the history and findings are most consistent with congestive heart failure, and the absence of fever and constitutional symptoms argues against pneumonia. His physical examination is not consistent with a pneumothorax or pulmonary embolus. He likely does have pleural effusions present based on his examination, but this is most likely secondary to congestive heart failure.

In this patient the most likely explanation for congestive heart failure is coronary artery disease given his multiple risk factors, with the possibility of a silent myocardial infarction in the setting of diabetes. Other etiologies

to consider would be primary valvular disease given a murmur consistent with mitral regurgitation, but the rapidity with which his symptoms developed argues against this being the sole answer. He could have a primary cardiomyopathy either from long-standing hypertension, hypothyroidism, or alcohol (although his use is limited, unless he is underreporting his current use). Much less likely would be an occupational exposure such as to heavy metals given his work in the shipyard.

Plan 1. Cardiac: Obtain chest radiograph, complete metabolic panel and

complete blood count, and an electrocardiogram. • Perform serial cardiac enzyme screening to evaluate for myocardial

infarction. • Obtain echocardiogram to assess chamber size, valvular and left

ventricular function. • Give oxygen 2 L/min and begin diuresis with furosemide, 20 mg

IV every 12 hours. • Monitor intake/urine output, daily weight, and electrolytes. • Consider further assessment for coronary artery disease pending

results of data above. 2. Endocrine: Hold metformin while in the hospital if contrast studies

needed. Monitor finger sticks with sliding scale insulin for glucose control. Obtain hemoglobin A1c and thyroid stimulating hormone.

3. Ophthalmology: Continue current eye drops for glaucoma. 4. Musculoskeletal: As needed acetaminophen for likely bilateral

osteoarthritis of his knees. 5. Health maintenance: Consider Pneumovax given diabetes. Consider

influenza and zoster vaccine. Up to date with cancer screening.

61 Colon cancer

Diabetes Myocardial infarction

Ischemic strokes Hypertension

Tobacco abuse Hypothyroidism

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A+W A+W Hypertension

Motor vehicle accident

Breast cancer Coronary artery disease Heart bypass

Diabetes Tobacco abuse

COPD

41 44 46

68 20 54 70

72

BoX 5.5 Written Admission Note—cont’d

Summary As you begin to examine patients, it is often difficult to determine how to cluster information that will lead to a diagnosis. As a result, all collected information is initially part of the puzzle. With experience, you will be able to

identify appropriate groupings of information, enabling you to better organize and synthesize the raw data. Your first attempts to write a complete history and physical examination will be lengthy and perhaps disorganized, but clinical experience will eventually lead to a more concise and organized record.

74

CHAPTER

6 Vital Signs and Pain Assessment The vital signs include assessment of temperature, pulse, respiration, and blood pressure. They are considered the baseline indicators of a patient’s health status.

Pain assessment is considered the fifth vital sign. Pain is a subjective unpleasant symptom of many conditions and injuries. The pain experience, its characteristics, and intensity are unique for each person. The Joint Commission (2013) requires that all patients in all healthcare facilities have a documented pain assessment. Repeat assessment of pain is performed to evaluate the treatment response and to identify the presence of new or recurring pain.

Pulse Rate The arterial pulse results when the ventricular heart contrac- tion pushes a pressure wave of blood throughout the arterial system.

Respiratory Rate The primary muscles of respiration are the diaphragm and the intercostal muscles. The diaphragm is the dominant muscle. It contracts and moves downward during inspiration to increase the intrathoracic space. The external intercostal muscles increase the anteroposterior chest diameter during inspiration, and the internal intercostal muscles decrease the lateral diameter during expiration. Air is drawn into the lungs during inspiration and expelled during expiration when the intercostal muscles and diaphragm relax, allowing the chest wall to recoil.

Blood Pressure The arterial blood pressure is the force of the blood against the wall of an artery as the ventricles of the heart contract and relax. Systolic pressure, the force exerted when the ventricles contract, is largely the result of cardiac output, blood volume, and compliance of the arteries. Diastolic pressure is the force exerted by peripheral vascular resistance when the heart is in the filling or relaxed state. Blood pressure is highest during systole and falls to the lowest point during diastole. The pulse pressure is the difference between the systolic and diastolic pressures.

Pain Pain is an uncomfortable sensation and emotional experi- ence associated with actual or potential tissue damage. Acute pain is of short duration and has a sudden onset in association with injury, surgery, or an acute illness episode. Inflammation helps sustain the pain response. Persistent (chronic) pain lasts several months or longer and is often sustained by a pathophysiologic process (e.g., joint disease, chronic inflammation, headache, or cancer). Neuropathic pain is long-term pain associated with damage or dysfunc- tion of the central or peripheral nervous system (e.g., amputation, complex regional pain syndrome).

Nociceptors are free nerve endings in the peripheral nervous system that are activated to transmit pain impulses

Physical Examination Components

Temperature Pulse rate Respiratory rate Blood pressure

Self-report pain rating scales Assessing pain behaviors Pain scales for children

ANATOMY AND PHYSIOLOGY

Vital Signs Temperature Body temperature is regulated and maintained by the hypothalamus. When pathogens invade the body, exogenous pyrogens, endotoxins produced by the pathogen, are released and travel to the hypothalamus. Endogenous pyrogens such as prostaglandins are produced when phagocytic cells destroy microorganisms. The hypothalamus responds to the pyrogens by temporarily raising the body’s temperature set point, leading to a fever (pyrexia). Epinephrine is released, which increases the metabolic rate and muscle tone. The body generates heat by shivering, a rapid contraction and relaxation of the skeletal muscles. The body conserves heat by vasoconstriction, which reduces heat loss through the skin. Body cooling occurs by vasodilation, which increases heat loss through the skin, increased sweating, and evapora- tion of perspiration.

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Infants Infants are more susceptible to hypothermia—low body temperature—because of their large body surface area for weight ratio, thinner skin, and limited ability to cope with cold stress. Infants have a higher pulse rate and respiratory rate than adults, and the rates decrease as the child ages. Infants have a lower blood pressure than adults, and blood pressure increases as the child ages.

The peripheral and central nervous systems are adequately developed for neonates to feel pain. The ability to process pain develops early in fetal life. The immaturity of the neurologic system results in some differences in pain transmission and processing. Most pain impulses are transmitted along the nonmyelinated slower C fibers because myelination of the A-delta fibers continues to develop after birth. The transmission distance to the brain is short. Infants are less able to modify pain impulses due to immaturity of their dorsal horn synaptic connection and inhibition circuits in the descending spinal cord pathways. This results in greater sensitivity of the central nervous system to repeated painful stimuli. (American Academy of Pediatrics, Committee on Fetus and Newborn and Section on Anes- thesiology and Pain Medicine, 2016).

Pregnant Patients Blood pressure commonly decreases beginning at about 8 weeks’ gestation, gradually falling until a low point is

from the site of injury. Biochemical mediators such as bradykinin, prostaglandins, serotonin, glutamate, and substance P help transmit the pain impulses from the nerve endings along nerve pathways. Pain impulses travel from the site of injury to the dorsal horn of the spinal cord through the ascending spinal tracts to the thalamus and cerebral cortex. Two specialized nerve fibers transmit pain impulses (nociception). Sharp, well-localized pain is quickly transmitted by the large, myelinated A-delta fibers. Dull, burning, diffuse, and chronic pain is slowly transmitted by the small, unmyelinated C-polymodal fibers (Fig. 6.1).

A two-way control of pain transmission occurs in the spinal nerve pathways. After the pain impulses reach the spinal cord’s dorsal horn, the pain signal may be modified when other stimuli are present from either the brain or the periphery. Substances such as endorphins (endogenous opioids), and gamma-aminobutyric acid (GABA) can change or inhibit the pain perceived. Pain impulse transmission may be reduced when nonpain impulses (e.g., ice, massage) compete to transmit sensations along the same spinal pathways to the brain.

Response to pain is individualized because it is a physi- ologic, behavioral, and emotional phenomenon. Individuals have different thresholds at which pain is perceived and different pain tolerance levels. Emotions, cultural back- ground, sleep deprivation, previous pain experience, and age are some factors that have an impact on a person’s perception and interpretation of pain.

Cerebral cortex

Thalamus

Medulla

Spinal cord segment

Substantia gelatinosa Lamina II

Tract of Lissauer Posterior root ganglion

C fiber

Aδ fiber

Dorsal hornAnterolateral spinothalamic tract

Pain receptors

VIII XI

X VII VI

V IV

III

I

FIG. 6.1 Transmission of pain impulses from pain receptors to the central nervous system. Nociceptors transmit pain impulses from the periphery along A-delta (Aδ) and C fibers to the dorsal horn of the spinal cord.

76 CHAPTER 6 Vital Signs and Pain Assessment V

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• Intensity: ranges from slight to severe using a pain scale from 1 to 10 or from little to worst pain ever felt

• Location: Identify all sites: Can the patient point a finger to it? Does it travel or radiate?

• Associated symptoms: nausea, fatigue, behavior change, irritability, disturbed sleep, distress caused by pain

• What the patient thinks is causing the pain or what was the inciting event

• Effect of pain on daily activities: activity limitation, sleep disruption, need for increased rest, appetite change

• Effect of pain on psyche: change in mood or social interac- tions, poor concentration, can think only about pain; irritability

• Pain control measures: distraction, relaxation, ice, heat, massage, electrical stimulation, acupuncture

• Medications: opioids, anxiolytics, NSAIDs, nonprescription medications

Personal and Social History • Previous experiences with pain and its effect; typical

coping strategies for pain control • Family’s concerns and cultural beliefs about pain: Is

pain expected or tolerated in certain situations? • Attitude toward the use of opioids, anxiolytics, and other

pain medications for pain control; fear of addiction • Current or past use of recreational drugs

Children • Word(s) the child uses for pain, such as “owie,” “ouch,”

“ache,” or “hurt” • What do you tell your parent when you hurt? What do

you want him or her to do for the hurt? • What kinds of things caused hurt in the past? What

made the hurt feel better? • Pain behaviors (facial expressions, grimacing, protective

posture) the parent identifies in the infant or child

Pregnant Patients • Discomforts associated with increasing fetal size, descrip-

tion of discomfort, location, and when it occurs • Investigate all known medical conditions and physical

limitations to identify sources for persistent or acute pain.

Older Adults • Investigate all known medical conditions and physical

limitations to identify potential sources for persistent or acute pain.

• Word(s) used by the older adult for pain, such as “achy,” “sore,” or “discomfort.” Use this word consistently during the pain assessment.

• When the older adult is cognitively impaired, have a family member describe cues to the patient’s expression of pain.

reached at midpregnancy. The diastolic blood pressure gradually rises to prepregnant levels by term (Gabbe et al, 2012).

During pregnancy, some patients may experience pain due to several physiologic processes: • Back pain may be related to lax ligaments, weight gain,

hyperlordosis, and anterior tilt of the pelvis. • Cramping or pressure may be signs of premature labor

or Braxton Hicks contractions (sporadic uterine contrac- tions that start at around 6 weeks of pregnancy).

• Pressure from the gravid uterus may cause epigastric pain.

• Round ligament pain may be due to the stretching of the ligaments by the enlarging uterus.

• Pressure on the bladder may occur from the weight of the enlarging uterus. During labor, pain may be related to dilation of the cervix,

stretching of the lower uterine segment, and pressure on adjacent structures. During delivery additional pain is caused by pressure of the fetal head against the pelvic floor, vagina, and perineum.

Older Adults No evidence exists that older adults have a diminished perception of pain. However, some older adults may have a decreased pain threshold associated with peripheral neuropathies, thickened skin, or cognitive impairment (Huether et al, 2014). Many have chronic health conditions associated with pain, such as arthritis, osteoporosis, or peripheral neuropathy.

REVIEw OF RELATED HISTORY

For each of the conditions discussed in this section, topics to include in the history of the present illness are listed. Responses to questions about these topics help to assess the patient’s condition and provide clues for focusing the physical examination.

Present Problem Fever • Onset: date of onset, duration, cyclic nature, variability;

related to injury or illness exposure • Associated symptoms: sweating, chills, irritability, nausea,

vomiting, fatigue • Medications: acetaminophen or nonsteroidal antiinflam-

matory drugs (NSAIDs)

Pain • Onset: date of onset, sudden or gradual, time of day,

duration, precipitating factors, variation, rhythm (constant or intermittent)

• Quality: throbbing, shooting, stabbing, sharp, cramping, gnawing, hot or burning, aching, heavy, tender, splitting, tiring or exhausting, sickening, fear producing, punishing or cruel

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heart rhythm assessment. While counting the heart rate, also note the contour (waveform) and amplitude (force) of each pulsation. See Chapter 16 for a more detailed discussion of arterial pulse evaluation.

Respiratory Rate Assess the respiratory rate (number of breaths per minute) by inspecting the rise and fall of the chest. Count the number of breaths (inspiration and expiration) that occur in 1 minute, or count the number of breaths for 30 seconds and multiply by 2. Avoid telling the patient that you are counting the respiratory rate so the patient will not vary the rate or pattern of breathing. A good way to do this is to count the respira- tions just after counting the pulse, while you are still palpat- ing the radial artery.

The expected adult resting respiratory rate is 12 to 20 breaths per minute. The ratio of the respiratory rate to the heart rate is approximately 1 : 4. Respiratory rates can vary between waking and sleep states. The normal rate of respira- tions (breaths per minute) depends on a number of factors, including the age of the individual and the amount of activity. Tachypnea is a faster-than-normal respiratory rate. Bradypnea is a slower-than-normal respiratory rate. See Chapter 14 to further evaluate respiratory patterns.

Blood Pressure The blood pressure is most often measured in the arm when the patient is seated. Blood pressure readings taken in supine position tend to be lower than those taken in sitting position. Standards for blood pressure readings are based upon the seated position using the right arm.

Free the arm of clothing and apply a cuff of appropriate size around the upper arm (Box 6.1). Center the deflated bladder over the brachial artery, just medial to the biceps tendon, with the lower edge 2 to 3 cm above the antecubital

ExAMINATION AND FINDINGS

Temperature The assessment of body temperature may often provide an important clue to the severity of a patient’s illness. Temperature measurement is most commonly performed by oral, rectal, axillary, tympanic, and forehead routes. The temperature is read in either Fahrenheit or Celsius. The expected temperature range is 97.2° to 99.9° F (36.2° to 37.7° C) with an average of 98.6° F or 37.0° C (Huether et al, 2014). The body temperature normally varies over a 24-hour period and in response to activity.

Pulse Rate The pulse rate is best palpated over an artery close to the surface of the body that lies over bones, such as the carotid, brachial, radial, femoral, popliteal, dorsalis pedis, and posterior tibial arteries (Fig. 6.2). The radial pulse is most often used to assess the heart rate. With the pads of your second and third fingers, palpate the radial pulse on the flexor surface of the wrist laterally. If you have dif- ficulty finding a pulse, vary your pressure, feeling carefully throughout the area (see Fig. 16.8, C). Count the pulsations for 60 seconds (or count for 30 seconds and multiply by 2).

The average resting pulse rate in adults is 70 beats per minute, and ranges between 60 and 100 beats per minute. Well-conditioned athletes or individuals taking beta-blockers may have a resting pulse rate of 50 to 60 beats per minute. In adults, tachycardia is a pulse rate that exceeds 100 beats per minute, and bradycardia is a pulse rate less than 60 beats per minute.

Determine the steadiness of the heart rhythm; it should be regular. If an irregular rhythm is detected, count for a full 60 seconds. See Chapter 15 for more information about

CarotidCarotid

Popliteal

Brachial

Radial

Femoral

Dorsalis pedis Dorsalis pedis

Posterior tibial

A B C

FIG. 6.2 Location of the sites to palpate the pulse.

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cuff with the hand bulb 20 to 30 mm Hg above the point at which you no longer feel the peripheral pulse. Deflate the cuff slowly at a rate of 2 to 3 mm Hg per second until you again feel at least two beats of the pulse. This point is the palpable systolic blood pressure. Immediately deflate the cuff completely (Fig. 6.4, A).

Pause for 30 seconds, and then place the bell of the stethoscope over the brachial artery. The bell of the

crease. Make sure the cuff is snug and secure because a loose cuff will give an inaccurate diastolic reading. Flex the patient’s arm to be at the level of the heart and support it comfortably on a table, pillow, or your arm.

Check the palpable systolic blood pressure first to avoid being misled by an auscultatory gap when using the stethoscope. Place the fingers of one hand over the brachial or radial artery and palpate the pulse. Rapidly inflate the

BOx 6.1 Selecting the Correct Cuff Size

Cuffs are available in several sizes to match the size of the patient’s limb (see Fig. 6.3). The correct cuff size ensures that equal pressure will be exerted around the artery, resulting in an accurate measurement. If the cuff is too wide, the blood pressure will be underestimated. If the cuff is too narrow, an artificially high blood pressure reading will result. The size of the cuff is measured by the width and length of bladder, not the material covering the bladder. • For adults, choose a width that is one-third to one-half the circumfer-

ence of the limb.

• The length of the bladder should be twice the width or about 80% of the limb circumference. The bladder should not completely encircle the limb.

• If the patient has an obese arm, attempt to find a cuff size appropriate for the arm size. If a sufficiently large cuff is not available, wrap a standard-size cuff around the forearm and auscultate over the radial artery.

• If the adult patient is very thin, a pediatric cuff may be necessary. Record the size of the cuff used and the site of auscultation.

A B

FIG. 6.3 Select the correct size blood pressure cuff. A, Large adult, adult, and child cuffs. B, Infant cuff (top) and neonatal cuff for use with electronic vital signs monitor (bottom). (A, From Wilson and Giddens, 2013.)

A B

FIG. 6.4 Blood pressure measurement. A, Checking the systolic blood pressure by palpation. B, Using bell of stethoscope to auscultate the blood pressure.

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Blood pressure levels for adults are classified into healthy, prehypertensive, and hypertensive ranges (Table 6.1). The eighth Joint National Committee on the Prevention, Detec- tion, Evaluation, and Treatment of High Blood Pressure (JNC8) has identified guidelines for blood pressure levels for the treatment of adults with hypertension (James et al, 2014). Because the systolic pressure is labile and responsive to a wide range of physical, emotional, and pharmacologic (e.g., caffeine) stimuli, high blood pressure or hypertension is usually diagnosed on the basis of several measurements taken over time.

Repeat the process in the other arm. Readings between the arms may vary by as much as 5 to 10 mm Hg. Record both sets of measurements. The higher reading should be used as the patient’s blood pressure. Measure the blood pressure in both arms at least once annually and during a hospitalization (Box 6.2).

Most cases of hypertension in adults have no discoverable cause, and the condition is referred to as essential or primary hypertension. An elevated blood pressure may be the only significant clinical finding, and persons with hypertension are often asymptomatic. Individuals who complain of frequent nosebleeds (epistaxis) or recurrent morning headaches that disappear as the day progresses should have their blood pressure carefully monitored.

If the diastolic pressure reading in the arm is greater than 90 mm Hg, or if you suspect coarctation of the aorta, measure the blood pressure in the legs. Place the patient in prone position (if the patient is in supine position, flex

stethoscope is more effective than the diaphragm in transmitting the low-pitched sound produced by the tur- bulence of blood flow in the artery (Korotkoff sounds). Inflate the cuff until it is 20 to 30 mm Hg above the palpable systolic blood pressure (Fig. 6.4, B). Deflate the cuff slowly 2 to 3 mm Hg per second, listening for the following sounds (Fig. 6.5): • Two consecutive beats indicate the systolic pressure

reading, and the beginning of the Korotkoff sounds, phase 1.

• Sometimes the Korotkoff sounds will be heard, then disappear, and then reappear 10 to 15 mm Hg below the systolic pressure reading (Korotkoff sounds, phase 2). The period of silence is the auscultatory gap. Be aware of the possibility of this gap to avoid underestima- tion of the systolic pressure or overestimation of the diastolic pressure. The auscultatory gap widens with systolic hypertension in older persons due to the loss of arterial pliability. It also widens with a drop in diastolic pressure when chronic severe aortic regurgitation is present. The auscultatory gap narrows in the case of pulsus paradoxus due to cardiac tamponade or other constrictive cardiac events.

• Note the point at which the initial crisp sounds (Korotkoff sounds, phase 3) become muffled (Korotkoff sounds, phase 4). The muffled sound is the first diastolic sound, and it is considered to be the closest approximation of direct diastolic arterial pressure. It signals disappearance of the Korotkoff sounds.

• Note the point at which the sounds disappear (Korotkoff sounds, phase 5). This is the second diastolic sound. Now deflate the cuff completely. The two blood pressure readings recorded are the first

systolic and the second diastolic sounds (e.g., 110/68). The systolic pressure is expected to be below 120 mm Hg and less than 80 mm Hg for the (second) diastolic sound. The difference between the systolic and diastolic pressures is the pulse pressure. The pulse pressure should range from 30 to 40 mm Hg, even to as much as 50 mm Hg. Some studies suggest that the pulse pressure may be a more important predictor of heart disease than either the systolic or diastolic pressure alone.

Systolic Auscultatory gap

mm Hg 120 110 100 90 80 mm Hg

First diastolic Second diastolic

Sharp “thud” Blowing or swishing sound

PHASE 1 PHASE 2 PHASE 3 PHASE 4 PHASE 5

Softer thud than phase 1,

still crisp

Softer blowing sound that disappears

Silence Muffling

FIG. 6.5 Phases of Korotkoff sounds, including an example of auscultatory gap.

CATEGORY SYSTOLIC (MM HG) DIASTOLIC (MM HG)

Normal Less than 120 and Less than 80

Prehypertension 120–139 or 80–89

Hypertension

Stage 1 140–159 or 90–99

Stage 2 160 or higher or 100 or higher

TABLE 6.1 Categories for Blood Pressure Levels for Adults

From National Institutes of Health, 2004.

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donation), drugs, autonomic nervous system disease, or prolonged time in a recumbent position can contribute to orthostatic hypotension. Patients with active gastrointestinal bleeding will often have dramatic changes in blood pressure with postural change.

Pain Assessment When the chief concern is pain, the location and related symptoms may assist in the diagnosis of a patient’s condi- tion. If the pain is related to a diagnosed condition (e.g., trauma, surgery, sickle cell disease, cancer, or arthritis), assessment of its character and intensity is necessary for pain management (see Clinical Pearl, “The Fifth Vital Sign”). Remember that more than one cause of pain may exist.

the leg as little as possible). Center the thigh cuff bladder over the popliteal artery and wrap the cuff securely on the distal third of the femur. Auscultate the blood pressure over the popliteal artery. A Doppler measurement may be helpful in this regard. Leg blood pressures are expected to be higher than arm pressures. The leg blood pressure will be lower than the arm blood pressure in cases of coarctation of the aorta or aortic stenosis.

If the patient is taking antihypertensive medications, has a depleted blood volume, or complains of fainting or postural lightheadedness, measure the blood pressure in the arm within 3 minutes after the patient stands. Compare this reading to the sitting blood pressure. As a patient changes position from sitting to standing, a slight drop or no drop in systolic pressure and a slight rise in diastolic pressure occurs. If orthostatic (postural) hypotension is present, expect to see a significant drop in systolic pressure (greater than 20 mm Hg) and a 10 mm Hg drop in diastolic pressure (Arnold and Shibao, 2013). An increase in heart rate often occurs as well. Mild blood loss (e.g., blood

CLINICAL PEARL

The Fifth Vital Sign Pain is often referred to as the fifth vital sign because of its association with tissue damage, the pathophysiologic effect of pain on body systems, and the patient’s emotional response, which may worsen the pain perceived.

Self-Report Pain Rating Scales Because of the subjective nature of pain, assessment is often based on history and patient responses to various tools that evaluate pain intensity and quality. The patient’s report of pain is the most reliable indicator of pain and should be believed, even when observed behaviors do not seem to correspond. Encourage patients to report the presence, intensity, and character of discomfort.

Several pain rating scales have been developed for patients to report their pain intensity and quality; only a sample is presented here (Figs. 6.6 to 6.9). The patient’s rating of pain may not compare with another person’s pain rating for an equivalent injury or condition. The patient’s own rating should be used as the standard for future comparison after pain treatment. It is often helpful for a facility or group of healthcare providers to select a few self-report pain scales to use routinely. If all healthcare providers use the same set of pain scales, more consistent interpretation of patient pain ratings is likely to occur.

Introduce the patient to a pain scale by explaining its purpose and clearly describing the meaning of the numbers or figures on the scale (see Clinical Pearl, “Selection of Pain Scale”). Ask about the patient’s usual terms for different kinds of pain (e.g., “aching,” “burning,” “stabbing,” “sharp,” or “dull”). Allow the patient to practice using the pain scale to rate a prior painful episode (e.g., headache or specific injury) before evaluating the current pain level. Remember that the patient may have multiple sites of pain, and the pain rating may vary by site. The pain rating may also vary with procedures performed and activities such as moving, coughing, and deep breathing. Body drawings may help patients to identify painful sites. Document the pain rating for each site of pain.

BOx 6.2 Pointers for Taking the Blood Pressure

• Keep the mercury sphygmomanometer vertical and make all readings at eye level, no more than 3 feet away.

• Position the dial of the aneroid sphygmomanometer so it faces you directly, no more than 3 feet away. An aneroid manometer needs periodic calibration.

• Slow or repeated inflations of the cuff can cause venous congestion and result in inaccurate readings. Wait at least 15 seconds between readings, with the cuff fully deflated.

• Electronic sphygmomanometers with a Doppler or oscillometric device work by sensing vibrations, converting them to electrical impulses, and transmitting the information to a digital readout. These devices are more sensitive than a stethoscope to the first Korotkoff sound. The electronic device systolic reading is thus somewhat higher than the auscultatory systolic reading. The two techniques are not interchangeable. If the electronic reading and clinical impression are not consistent, take a manual blood pressure to validate the electronic reading.

• When documenting a patient’s blood pressure measurements over time, use the same position and the same arm.

• The accuracy of the blood pressure reading may be undermined by some conditions, even when using impeccable technique: • Cardiac dysrhythmias. If heart rate irregularity is sustained,

take the average of several blood pressure readings and document the problem.

• Aortic regurgitation. If the sounds of aortic regurgitation do not disappear, the diastolic pressure reading will be obscured.

• Venous congestion. If sluggish venous flow occurs due to a pathologic event or repeated slow inflations of the cuff, the systolic pressure will be heard lower than it actually is and the diastolic pressure will be higher.

• Valve replacement. If the sounds are heard all the way down to a zero gauge reading, listen carefully for the first muffling of the sound (Korotkoff phase 4) to determine the diastolic pressure. More modern valves do not cause this discrepancy.

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• Facial mask of pain: lackluster eyes, “beaten look,” wrinkled forehead, tightly closed or opened eyes, fixed or scattered movement, grimace or other distorted expression, a sad or frightened look

• Vocalizations: grunting, groaning, crying, talkative patient becomes quiet

• Body movements such as head rocking, pacing, or rubbing; an inability to keep the hands still

• Changes in vital signs: blood pressure, pulse, respiratory rate and depth, with acute onset of pain. Fewer changes in vital signs are found in patients with persistent pain or after they adapt to acute pain.

• Pallor and diaphoresis • Pupil dilation • Dry mouth

Assessing Pain Behaviors Throughout your examination of the patient, be alert to behaviors indicating acute pain, such as the following: • Guarding, protective behavior, hands over the painful

area, distorted posture, reluctance to be moved

None Slight Mild Moderate Severe Worst Pain

FIG. 6.6 Descriptive pain intensity scale.

Moderate Pain

No Pain

0 1 2 3 4 5 6 7 8 9 10

Worst Pain

FIG. 6.7 Numeric pain intensity scale.

No Pain Worst Pain

FIG. 6.8 Visual analog scale. Use a 10-cm line with word anchors (“No pain” and “Worst pain”) on each end. Ask the patient to mark the level of pain felt on the line. A centimeter ruler is then used to identify a numeric pain rating for future comparison.

FIG. 6.9 The Painometer. A multidimensional measure of pain, allowing a measure of intensity and quality and an opportunity to indicate pain location. (Courtesy Dr. Fannie Gaston-Johansson, School of Nursing, Johns Hopkins University, Baltimore, MD.)

CLINICAL PEARL

Selection of Pain Scale When more than one pain scale is available and used in a facility, ask the patient to select a pain scale. Use the same pain scale to evaluate and document the patient’s pain for the entire painful episode so comparisons of future pain ratings are interpreted accurately.

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62 mm Hg diastolic. A sustained increase in blood pressure is almost always significant (see Clinical Pearl, “Blood Pressure in Infants”). Hypertension in the newborn may be the result of many conditions, such as thrombosis after the use of an umbilical catheter, coarctation of the aorta, renal disorders (e.g., renal artery stenosis, cystic disease, or hydronephrosis), congenital adrenal hyperplasia, or central nervous system disease.

• Decreased attention span, greater confusion, irritability Cognitively impaired adults who are unable to use a

self-rating pain scale should have pain evaluated as described for older adults with cognitive impairment (see Fig. 6.13).

A number of classic pain patterns may provide valuable clues to underlying conditions, such as the following: • Bone and soft tissue pain may be tender, deep, and

aching. • Heavy, throbbing, and aching pain may be associated

with a tumor pressing on a cavity. • Burning, shocklike pain may indicate nerve tissue

damage. • A clenched fist over the chest with diaphoresis and

grimacing is the classic picture of myocardial infarction. Even a mild pain can require immediate attention in this regard.

• Cramping spasms may define visceral or colic pain.

Patient Safety

Pain Assessment Patient assessment for pain should occur during every healthcare visit and frequently during hospitalization. When pain is reported, repeated assessment is needed after administering pain medication and using comfort measures or complementary therapies. The assessment should use the same pain assessment tool each time so that comparisons can be made. When analgesia is administered, reassessment is essential at the expected time of peak action by analgesia to determine its effectiveness and to be assured that acute complications associated with analgesia (e.g., respiratory depression) have not occurred. This is especially important for patients with chronic conditions that place them at higher risk.

CLINICAL PEARL

Blood Pressure in Infants A very ill baby can maintain a “normal blood pressure” and quickly develop hemodynamic instability. Check the capillary refill, which is usually less than 2 seconds (see Chapter 16). It can be as long as 6 to 7 seconds (indicating very poor perfusion), even when the blood pressure seems normal. The lesson: both measurements are needed to fully evaluate the infant.

Newborns and Infants The pulses of the newborn are easily palpable. Rates close to 200 beats per minute may occur in neonates. The decrease in pulse rate is relatively rapid, and the rate may be closer to 120 beats per minute at a few hours of age. The newborn’s pulse rate is more variable than that of older infants with activities such as feeding, sleeping, and waking. The varia- tion is greatest around the time of birth and is even more marked in premature infants. A sustained tachycardia in a neonate may be the first indication of infection, or it may be a clue to an underlying cardiac rhythm disturbance, such as paroxysmal atrial contractions. See Chapter 15 for more information.

Count the respiratory rate for 1 minute. The expected rate for neonates varies from 40 to 60 breaths per minute, but a rate of up to 80 may be noted. Infants delivered by cesarean section may have a more rapid respiratory rate than babies delivered vaginally.

The blood pressure of infants is often determined using an electronic sphygmomanometer with a Doppler or other oscillometric technique. The expected newborn blood pressure ranges from 60 to 96 mm Hg systolic and 30 to

Pain Assessment Valid and reliable pain behavior scales have been developed for the assessment of pain in neonates and infants. Physi- ologic measures and behaviors are combined for develop- ment of these scales. A pain behavior score helps identify the presence of pain and can be used to evaluate pain management efforts (Pasero and McCaffery, 2011). These scales are not designed to measure pain intensity. • The Premature Infant Pain Profile (PIPP) is used to

assess procedural pain in preterm and full-term neonates between 28 and 40 weeks’ gestation. It measures physi- ologic signs (heart rate and oxygen saturation), pain behaviors (brow bulge, eye squeeze, and nasolabial furrow), gestational age, and behavioral state (Witt et al, 2016).

• The Neonatal Infant Pain Scale is used to assess proce- dure pain in preterm and full-term infants up to 6 weeks of age. The infant’s facial expression, cry, breathing pattern, arm and leg movements, and state of arousal are observed and scored (Witt et al, 2016).

• The Neonatal Pain, Agitation and Sedation Scale (N-PASS) is used to assess acute pain, ongoing pain, agitation, and sedation of critically ill newborns. The pain portion of the scale involves observation of crying/irritability, behavioral state, facial expression, extremity tone, and vital signs for scoring (Witt et al, 2016).

• The CRIES scale (Crying, Requires oxygen to keep satura- tion greater than 95, Increased vital signs, Expression, and Sleeplessness) is designed to evaluate postoperative pain in newborns and infants. The infant’s behaviors (crying, expression, and sleeplessness) as well as physi- ologic signs (oxygen saturation, heart rate, and blood pressure) are scored (Witt et al, 2016).

Children The heart rates of children are more variable than those of adults and react with wider swings related to exercise,

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gain better cooperation. Use Korotkoff phase 5 (disappear- ance of sound) as the diastolic reading unless the sounds are heard down to zero or very low. In that case use the Korotkoff phase 4 sound (muffling) as the diastolic reading (Kapur and Baracco, 2013).

Blood pressure standards for children are provided by gender, age, and height percentiles. Compare the reading to standards for normal blood pressure (less than 90th percentile), prehypertension (90th to 95th percentile), and hypertension (more than 95th percentile). After measuring the child’s height, determine the child’s height percentile using the standard length or height growth curve (see Appendix A). Select the correct table for the child’s gender, and compare the child’s systolic and diastolic blood pressure reading to that expected for age and height percentile (see Appendix B). The child’s systolic and diastolic blood pressure values should be below the 90th percentile for age and height percentile.

Do not make the diagnosis of hypertension based on one reading. Take at least three readings over several visits. If the systolic pressure is elevated and the diastolic is not, anxiety may be the cause. Take time to reassure the child and reduce anxiety. If the blood pressure is in the 90th to 95th percentile range, repeat the blood pressure later during the same visit and average the two systolic and diastolic readings. If the pressure is more than the 95th percentile, have the child return soon for additional blood pressure measurements. Many young children with a diagnosis of hypertension have an identifiable cause (secondary hyperten- sion), such as renal disease, but the incidence of primary hypertension is increasing with the rise in obesity in children in the United States (see Clinical Pearl, “Obesity in Children and Adolescents”).

fever, or stress. A child may have an increased heart rate of 10 to 14 beats per minute for each Celsius degree of temperature elevation (Thompson, 2009). The mean resting heart rate ranges gradually decrease as the child ages (Otschego et al, 2011):

AGE MEAN RESTING HEART RATE (BEATS PER MINUTE)

Less than 1 year 128–130

1 year 116–119

2–3 years 106–108

4–5 years 94–97

6–11 years 77–88

12–19 years 72–80

The usual range of respiratory rates for children of different ages is listed in the following table. Rates decrease with age with a greater variation in the first 2 years of life and without significant gender difference. If the respiratory rate is sustained at a level higher or lower than the expected range, further evaluation is needed (see Chapter 14).

AGE RESPIRATIONS PER MINUTE

Newborn 24–50

1 year 20–40

3 years 20–30

6 years 16–22

10 years 16–20

17 years 12–20

Select the correct cuff size to obtain an accurate blood pressure reading (Box 6.3). Children become more coopera- tive for the blood pressure measurement at 2 to 3 years of age. Allow the child to explore the sphygmomanometer. Explain that the cuff is a balloon that will squeeze the arm and then slowly stop squeezing. Take time to allow the child to play with the equipment and squeeze the bulb to

CLINICAL PEARL

Obesity in Children and Adolescents Because of the increase in numbers of children and adolescents who are obese, primary or essential hypertension is becoming more common. Although the overall prevalence of hypertension in children (>95th percentile by gender, age, and height percentile) is estimated to be 2.5% to 3%, the risk of hypertension is about 4 times higher in children at more than 85th percentile body mass index (Flynn, 2013).

Pain Assessment Some children as young as 3 years of age have adequate communication skills to self-report their pain perception. Assess the child’s ability to use a self-report pain scale by determining whether the child understands concepts of higher–lower and more–less. Give the child a chance to practice using the chosen pain scale by describing a previous painful episode (e.g., finger stick, earache, or skinned knee).

Valid and reliable self-rating pain scales for young children include the Wong-Baker Faces Rating Scale (Fig. 6.10) and the Oucher Scale (Fig. 6.11). Give the child clear From Brady et al, 2008.

BOx 6.3 Selecting a Blood Pressure Cuff for the Child

Choosing the correct blood pressure cuff for a child is more than selecting a cuff for the age of the child. Children, even those of the same age, are very different in build. Blood pressure cuffs for children also differ in dimensions by manufacturer. Use the following guidelines to select an appropriately sized cuff to obtain the most accurate blood pressure reading: • The cuff width should cover approximately 70% of the distance

between the acromion and the olecranon (tip of the elbow). • The bladder length should be 80% to 100% of the upper arm

circumference, and the bladder width should be at least 40% of the arm circumference at the midpoint of the acromion–olecranon distance.

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For nonverbal children the FLACC Behavioral Pain Assessment Scale can be used (Fig. 6.12). FLACC is an acronym for the five assessment categories: face, legs, activity, cry, and consolability. This scale is used most commonly to assess acute pain associated with surgery in children between 2 months and 7 years of age.

The FLACC in combination with a numeric pain scale can also be used to develop a customized pain behavioral scale for children with intellectual disability. Parents can be asked to recall one of the child’s prior painful episodes and think about unique pain behavior clues in association with the FLACC categories. The parent can then rate the behavior for each of the categories on a scale of 1 to 10 (Voepel-Lewis et al, 2005).

Pregnant Patients Vital Signs The heart rate gradually increases throughout pregnancy until it is 10% to 30% higher at term.

To identify the onset of hypertension during pregnancy, measure the blood pressure consistently in the right arm in the sitting position or left lateral recumbent position after 10 minutes rest. Document both Korotkoff phase 1 (muffling) and Korotkoff phase 5 (disappearance of sounds) at each visit (Foo et al, 2015). A gradual increase in blood pressure is common from the second to the third trimester. Gestational hypertension (blood pressure reading greater than or equal to 140 mm Hg systolic or 90 mm Hg diastolic) develops in 5% to 10% of pregnant patients (Foo et al, 2015). The rate is higher in patients with multiple gestations (Gabbe et al, 2012). Severe hypertension (blood pressure reading greater than or equal to 160 mm Hg systolic or 110 mm Hg diastolic) is one sign of preeclampsia; see Chapter 15 for more information.

Pain Assessment The majority of patients have significant pain during labor, often described as sharp, cramping, aching, throbbing, stabbing, shooting, heavy, and exhaustive. Childbirth training is not associated with very different perceptions of pain. Socioeconomic status and prior menstrual difficulties may be a better predictor of pain severity (Gabbe et al, 2012).

FIG. 6.10 The Wong/Baker Faces Rating Scale. Explain to the patient that each face is for a person who feels happy because he has no pain (hurt) or sad because he has some or a lot of pain. Face 0 is very happy because the person does not hurt at all. Face 1 hurts just a little bit. Face 2 hurts a little more. Face 3 hurts a little more. Face 4 hurts a whole lot. Face 5 hurts as much as you can imagine, although you do not have to be crying to feel this bad. Ask the patient to choose the face that best describes how he or she is feeling. Recommended for persons 3 years of age and older. (From Hockenberry et al, 2017.)

CA B

FIG. 6.11 A, Version of the Oucher for white children. B, Version of the Oucher for black children. C, Version of the Oucher for Hispanic children. (A, Developed and copyrighted in 1983 by Judith E. Beyer, PhD, RN [University of Missouri-Kansas City School of Nursing. B, Developed and copyrighted in 1990 by Mary J. Denyes, PhD, RN [Wayne State University], and Antonia M. Villarruel, PhD, RN [University of Michigan]. Cornelia P. Porter, PhD, RN, and Charlotta Marshall, RN, MSN, contributed to the development of this scale. C, Developed and copyrighted in 1990 by Antonia M. Villarruel, PhD, RN [University of Michigan], and Mary J. Denyes, PhD, RN [Wayne State University].)

instructions about the amount of pain each face means, beginning with the face with no pain/hurt and ending with the last face that is the most pain/hurt ever felt. Ask the child to select the face that is the best match for the amount of pain felt. Do not compare the child’s facial expression to that on the pain scale to evaluate the child’s pain. Older children and adolescents may use these pain scales or those listed for adults.

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55 years of age will have a 90% lifetime risk of developing hypertension (Aronow, 2009).

Pain Assessment Use self-report pain scales with older adults, but make sure the patient can see, hear, and understand the instructions for use of the scale. Repeat the instructions if necessary. If the patient has vision problems, use a scale with large print and give verbal descriptors for the self-report pain scale. As with children, consider alternate words for pain, such as “ache” or “hurt.” Provide adequate time

Older Adults Vital Signs The heart rate may be slower because of increased vagal tone or more rapid, with a wide range that may vary from the low 40s to more than 100 beats per minute.

Because of stiffness of the blood vessels and increased vascular resistance during the process of aging, the systolic blood pressure often increases. Hypertension in older adults is defined as a blood pressure greater than 140/90. Recent studies suggest that individuals who are normotensive at

Guidelines for Scoring the FLACC Face Score 0 if the patient has a relaxed face, makes eye contact, shows interest in surroundings. Score 1 if the patient has a worried facial expression, with eyebrows lowered, eyes partially closed, cheeks raised, mouth pursed. Score 2 if the patient has deep furrows in the forehead, closed eyes, an open mouth, deep lines around nose and lips.

Legs Score 0 if the muscle tone and motion in the limbs are normal. Score 1 if patient has increased tone, rigidity, or tension; if there is intermittent flexion or extension of the limbs. Score 2 if patient has hypertonicity, the legs are pulled tight, there is exaggerated flexion or extension of the limbs, tremors.

Activity Score 0 if the patient moves easily and freely, normal activity or restrictions. Score 1 if the patient shifts positions, appears hesitant to move, demonstrates guarding, a tense torso, pressure on a body part. Score 2 if the patient is in a fixed position, rocking; demonstrates side-to-side head movement or rubbing of a body part.

Cry Score 0 if the patient has no cry or moan, awake or asleep. Score 1 if the patient has occasional moans, cries, whimpers, sighs. Score 2 if the patient has frequent or continuous moans, cries, grunts.

Consolability Score 0 if the patient is calm and does not require consoling. Score 1 if the patient responds to comfort by touching or talking in 30 seconds to 1 minute. Score 2 if the patient requires constant comforting or is inconsolable.

Interpreting the Behavioral Score Each category is scored on the 0–2 scale, which results in a total score of 0–10.

0 = Relaxed and comfortable 4–6 = Moderate pain 1–3 = Mild discomfort 7–10 = Severe discomfort or pain or both

CATEGORIES

SCORING

0 1 2

Face No particular expression or smile

Occasional grimace or frown; withdrawn, disinterested

Frequent to constant frown, clenched jaw, quivering chin

Legs Normal position or relaxed

Uneasy, restless, tense Kicking or legs drawn up

Activity Lying quietly, normal position, moves easily

Squirming, shifting back and forth, tense

Arched, rigid, or jerking

Cry No cry (awake or asleep) Moans or whimpers, occasional complaint

Crying steadily, screams or sobs; frequent complaints

Consolability Content, relaxed Reassured by occasional touching, hugging, or being talked to; distractable

Difficult to console or comfort

FIG. 6.12 FLACC Behavioral Pain Assessment Scale for nonverbal children. (From Merkel S et al, 1997.)

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for pain behaviors such as vocalizing, facial grimacing, guarding a body area, resisting care, or a change in mental status (increased confusion, agitation, or withdrawal) (Gregory, 2015). The PAINAD tool has good validity and reliability for scoring pain behaviors in older adults with dementia and the inability to communicate (see Fig. 6.13) (Paulson et al, 2014). Perform the assessment when some activity is occurring, such as turning, walking, or transferring to the bed or chair. If pain behaviors are observed, an analgesia trial may confirm that the observed behaviors are caused by pain.

for the older adult to respond. For cases where pain may be localized, help the older adult focus by touching or pointing to the body area when asking about the patient’s current pain.

Many patients with mild or moderate cognitive impair- ment can use a simple pain rating scale (e.g., the numeric rating scale, faces scale, verbal descriptor scale, and pain thermometer) to report pain reliably. Many can describe their pain when asked (Ware et al, 2006). When a self-report pain rating scale cannot be used, observe for pain behaviors when a condition that can cause pain is present. Observe

PAIN ASSESSMENT IN ADVANCED DEMENTIA (PAINAD) SCALE

Note. Total scores range from 0 to 100 (based on a scale of 0 to 2 for each of five items), with a higher score indicating more behaviors indicating pain (0 =10 = no observable pain to highest observable pain). Adapted from Warden, V., Hurley, A.C., & Volicer, L. (2003). Development and psychometric evaluation of the Pain Assessment in Advanced Dementia (PAINAD) scale. Journal of the American Medical Directors Association, 4, 9 -15.

Items Score = 0 Score = 1 Score = 2 Score

Breathing (independent of vocalization)

Negative vocalization

Facial expression

Body language

Consolability

Total

Normal

None

Smiling or inexpressive

Relaxed

• Occasional labored breathing • Short period of hyperventilation

• Occasional moan or groan • Low level of speech with a negative or disapproving quality

• Sad • Frightened • Frown

• Tense • Distressed pacing • Fidgeting

No need to console • Unable to console, dis- tract, or reassure

• Distracted by or reassured voice or touch

• Noisy labored breathing • Long period of hyperventilation • Cheyne-Stokes respirations

• Repeated troubled calling out • Loud moaning or groaning • Crying

• Facial grimacing

• Rigid • Fists clenched • Knees pulled up • Pulling or pushing away • Striking out

FIG. 6.13 Pain Assessment in Advanced Dementia (PAINAD) Scale. (From Warden et al, 2003.)

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ABNORMALITIES Hypertension Hypertension is one of the most common diseases in the world; it is often responsible for stroke, renal failure, and congestive heart failure.

PATHOPHYSIOLOGY PATIENT DATA • Defined as a blood pressure consistently at 140/90 mm Hg or higher. • For essential hypertension, its pathologic origin is poorly understood. • For secondary hypertension, potential causes include renal disease,

renal artery stenosis, aldosteronism, thyroid disorders, coarctation of the aorta, or pheochromocytoma.

Subjective Data • Essential hypertension is asymptomatic. • In malignant (severe) hypertension, headache, blurred vision, dyspnea,

or encephalopathy may be present.

Objective Data • Multiple confirmed blood pressure readings at or above 140/90 or in

children greater than 95th percentile for age, gender, and height percentile.

• End organ damage (e.g., papilledema and evidence of heart failure) may be present with long-standing hypertension.

Neuropathic Pain A form of chronic pain caused by a primary lesion or dysfunction of the central nervous system that persists beyond expected after healing

PATHOPHYSIOLOGY PATIENT DATA • Potential causes include postherpetic neuralgia, diabetic peripheral

neuropathy, trigeminal neuralgia, or radiculopathy. • Damaged peripheral nerves fire repeatedly. Dorsal horn neurons are

hyperexcited and transmit enhanced pain to the brain. This causes sustained pain.

Subjective Data • Burning, intense tightness, shooting, stabbing, electric shocklike

sensations • Pain sensations may worsen at night. • Exaggerated pain response to pain stimuli (hyperalgesia) • Pain response to stimuli that are not typically painful (allodynia) • Sleep disturbance • Interference with activities of daily living, work, or social activities

Objective Data • Confirmed self-report of pain for all painful body regions • Distribution of pain sensations (e.g., glove or stocking, leg) • Pain response to nonpainful stimulus (e.g., stroking skin) • Sensory loss (light touch, pin prick, vibration sense, proprioception,

numbness) may be present in painful areas (Jensen and Finnerup, 2014).

Complex Regional Pain Syndrome A syndrome in which regional pain extends beyond a specific peripheral nerve injury in an extremity with motor, sensory, and autonomic changes

PATHOPHYSIOLOGY PATIENT DATA • No relationship between the original trauma severity and the severity

and cause of the symptoms. • Cause is unknown, but the sympathetic nervous system helps maintain

symptoms.

Subjective Data • Burning, shooting, or pain with aching character • Exaggerated sensitivity to cold or sweating changes • Pain increases or persists after light pressure • Allodynia • Numbness may be present.

Objective Data • Edema • Changes in skin blood flow: abnormal skin color; red and hot,

cyanotic, temperature difference of up to 1° C between the affected and unaffected extremity

• Increased sweating may be seen

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CHAPTER

7 Mental Status The mental status portion of the neurologic examination is a complex process. Mental status is the total expres- sion of a person’s emotional responses, mood, cognitive functioning (ability to think, reason, and make judgments), and personality. A major focus of the examination is identification of the individual’s strengths and capabilities for interaction with the environment. This chapter focuses on mental status evaluation of the individual’s overall cognitive state. See Chapter 23 for the assessment of neurologic lesions that cause alterations in mental status.

The temporal lobe is responsible for perception and interpretation of sounds as well as localizing their source. It contains the Wernicke speech area, which allows a person to understand spoken and written language. The temporal lobe is also involved in the integration of behavior, emotion, and personality, as well as long-term memory.

The limbic system mediates certain patterns of behavior that determine survival (e.g., mating, aggression, fear, and affection). Reactions to emotions such as anger, love, hostil- ity, and envy originate here, but the expression of emotion and behavior is mediated by connections between the limbic system and the frontal lobe. A major function is memory consolidation needed for long-term memory.

The reticular system, a collection of nuclei in the brainstem, regulates vital reflexes such as heart and respira- tory functioning. It also maintains wakefulness, which is important for consciousness and for awareness and arousal functions. Disruption of the ascending reticular activating system can lead to altered mental status (e.g., confusion and delirium).

Infants and Children All brain neurons are present at birth in a full-term infant, but brain development continues with myelinization of nerve cells over several years. Brain insults, such as infection (e.g., Zika virus or rubella), trauma, or metabolic imbalance, can damage brain cells, which may result in serious per- manent dysfunction in mental status. Genetic disorders may also affect cognitive development and mental status.

Adolescents Intellectual maturation continues, with greater capacity for information and vocabulary development. Abstract thinking (i.e., the ability to develop theories, use logical reasoning, make future plans, use generalizations, and consider risks and possibilities) develops during this period. Judgment begins to develop with education, intelligence, and experience.

Older Adults Cognitive function should be intact in the healthy older adult, but declines in cognitive abilities occur in some older adults after 60 or 70 years of age. Speed of information processing and psychomotor speed begin declining at a

Physical Examination Components

1. Observe physical appearance and behavior 2. Investigate cognitive abilities:

• State of consciousness • Response to analogies • Abstract reasoning • Arithmetic calculation • Memory • Attention span

3. Observe speech and language for voice quality, articulation, coher- ence, and comprehension.

4. Evaluate emotional stability for signs of depression, anxiety, thought content disturbance, and hallucinations.

ANATOMY AND PHYSIOLOGY

The cerebrum of the brain is primarily responsible for a person’s mental status. Many areas in the cerebrum con- tribute to the total functioning of a person’s mental processes. Two cerebral hemispheres, each divided into lobes, comprise the cerebrum. The gray outer layer—the cerebral cortex— houses the higher mental functions and is responsible for perception and behavior (Fig. 7.1).

The frontal lobe, containing the motor cortex, is associ- ated with speech formation (in the Broca area). This lobe is responsible for decision making, problem solving, the ability to concentrate, and short-term memory. Associated areas—related to emotions, affect, drive, and awareness of self and the autonomic responses related to emotional states—also originate in the frontal lobe.

The parietal lobe is primarily responsible for receiving and processing sensory data.

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amantadine, diuretics, digoxin, antiarrhythmics, sedatives, hypnotics, or alternative and complementary therapies such as gingko biloba and St. John’s wort

Depression • Troubling thoughts or feelings, constant worry; change

in outlook on life or change in feelings; feelings of hopelessness; inability to control feelings

• Low energy level, awakens feeling fatigued, agitation, feels best in the morning or at night

• Recent changes in living situation, death or relocation of friends or family members, changes in physical health

• Thoughts or plans for hurting self and/or others, thoughts about dying, hopelessness, no plans for the future

• Medications: antidepressants; medications that may cause or worsen depression (e.g., antihypertensive agents, corticosteroids, beta-blockers, calcium channel blockers, barbiturates, phenytoin, anabolic steroids)

Anxiety • Sudden, unexplained episodes of intense fear, anxiety,

or panic for no apparent reason; afraid will be unable to get help or will be unable to escape in certain situa- tions; unable to control worrying; spends more time than necessary repeatedly doing or checking things

• Feels uncomfortable in or avoids situations or events that involve being with people

• Prior experience with a frightening or traumatic event • Associated symptoms: panic attacks, obsessive thoughts,

or compulsive behaviors • Medications: antidepressants, steroids, benzodiazepines

Past Medical History • Neurologic disorder, brain surgery, brain injury, residual

effects, chronic disease, or debilitating condition • Psychiatric disorder or hospitalization

modest rate after 30 years of age. However, verbal skills and general knowledge continue to increase into the 60s and often remain stable into the 80s. Cognitive declines in executive functioning (the ability to plan and develop strategies, organize, concentrate and remember details, and manage activities) may precede memory loss and other cognitive impairments (Carlson et al, 2009). The cognitive decline leading to dementia may occur over 20 to 30 years, and it may begin as early as 45 years of age in some persons (Singh-Manoux et al, 2012).

REvIEw Of RELATED HISTORY

For each of the symptoms or conditions discussed in this section, targeted topics to include in the history of the present illness are listed. Responses to questions about these topics provide clues for focusing the physical examina- tion and the development of an appropriate diagnostic evaluation. Questions regarding medication use (prescription and over-the-counter preparations) as well as complementary and alternative therapies are relevant for each area.

History of Present Illness Disorientation and Confusion • Abrupt or insidious onset: intermittent, fluctuating, or

persistent; association with time of day or emotional crisis

• Associated health problems: new hearing or vision impairment; neurologic disorder, vascular occlusion, or brain injury; systemic infection; withdrawal from alcohol; metabolic or electrolyte disorder

• Associated symptoms: delusions, hallucinations (imagi- nary perceptions), mood swings, anxiety, sadness, lethargy or agitation, insomnia, change in appetite, drug toxicity

• Medications: anticholinergics, benzodiazepines, opioid analgesics, tricyclic antidepressants, levodopa or

Wernicke area (sensory speech area)

Visual cortex

Visual association area

Primary taste area

Central sulcus Precentral gyrus

(motor area) Premotor area

(intellectual functions)

Postcentral gyrus (sensory area)

Somatic sensory association area

Prefrontal area (behavioral, ethical,

moral, social)

Broca area (motor speech area)

Auditory association area

Primary auditory area

Transverse gyrus

fIG. 7.1 Functional subdivisions of the cerebral cortex. (From Patton, 2016.)

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Family History • Psychiatric disorders, mental illness, alcoholism • Alzheimer disease • Learning disorders, intellectual disability, autism

Personal and Social History • Emotional status: feelings about self; anxious, restless,

or irritable; discouraged or frustrated; problems with money, job, legal system, spouse, partner, or children; ability to cope with current stressors in life

• Life goals, attitudes, relationship with family members • Intellectual level: educational history, access to informa-

tion, mental stimulation • Communication pattern, able to understand questions,

coherent and appropriate speech, change in memory or cognitive thought processes

• Changes in sleeping or eating patterns; change in appetite or diet, weight loss or gain; decreased sexual activity

• Use of alcohol or recreational drugs, especially mood- altering drugs

Children • Speech and language: timing of first words, words

understood, progression to phrases and sentences • Behavior: temper tantrums, ease in separating from

family or adjusting to new situations • Performance of self-care activities: dressing, toileting,

feeding • Personality and behavior patterns: changes related to

any specific event, illness, or trauma • Learning or school difficulties: associated with interest,

hyperactivity, or ability to concentrate

Adolescents • Risk-taking behaviors • School performance and peer interactions • Family interactions • Reluctance to talk about attitudes, behaviors, and

experience

Older Adults • Changes in cognitive functioning, thought processes,

memory; association with medications prescribed (e.g., opiates, benzodiazepines, antidepressants, corticosteroids, muscle relaxants)

• Changes in activities of daily living, e.g., money manage- ment, food preparation

• Depression: somatic complaints, hopelessness, helpless- ness, lack of interest in personal care

ExAMINATION AND fINDINGS

Mental status is assessed continuously throughout the entire interaction with a patient by evaluating the patient’s

BOx 7.1 Procedures of the Mental Status Screening Examination

The shorter screening examination is commonly used for health visits when no known mental status problem is apparent. Information is generally obtained during the history by observation of behavior and responses to questions in the following areas.

Appearance and Behavior • Grooming • Emotional status • Body language

Emotional Stability • Mood and feelings • Thought processes

Cognitive Abilities • State of consciousness • Memory • Attention span • Judgment

Speech and Language • Voice quality • Articulation • Comprehension • Coherence • Aphasia

fIG. 7.2 During the initial greeting, observe the patient for behavior, emotional status, grooming, and body language. Note the patient’s body posture and ability to make eye contact.

alertness, orientation, cognitive abilities, and mood (Box 7.1). Observe the patient’s physical appearance, behavior, and responses to questions asked during the history (Fig. 7.2). Note any reliance on an accompanying adult to answer questions. Make a point of asking the patient to provide responses. Note any variations in response to questions of differing complexity. Speech should be clearly articulated. Questions should be answered appropriately, with ideas expressed logically, relating current and past events.

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The Glasgow Coma Scale is used to quantify the level of consciousness after an acute brain injury or medical condi- tion (see Chapter 26).

Cognitive Abilities Evaluate cognitive functions as the patient responds to questions during the history-taking process. Specific questions and tasks can provide a detailed assessment of cognition, the execution of complex mental processes (e.g., learning, perceiving, decision making, and memory). See tools (e.g., Montreal Cognitive Assessment and miniCog) later in the chapter to assess cognitive function in older adults if quantification of cognitive function is needed.

Signs of possible cognitive impairment include the following: significant memory loss, confusion (impaired cognitive function with disorientation, attention and memory deficits, and difficulty answering questions or following multiple-step directions), impaired communication, inap- propriate affect, personal care difficulties, hazardous behavior, agitation, and suspiciousness (see Clinical Pearl, “The Importance of Validation”).

Physical Appearance and Behavior Grooming Assess the patient’s hygiene, grooming, and appropriateness of dress for age and season. Poor hygiene, lack of concern with appearance, or inappropriate dress for season or occasion in a previously well-groomed individual may indicate depression, a psychiatric disorder, or dementia.

Emotional Status Note the patient’s behavior, which is usually cooperative and friendly. The patient’s manner should demonstrate concern appropriate for the topics discussed. Consider cultural variations when assessing emotional responses. Note patient behavior that conveys carelessness, apathy, loss of sympathetic reactions, unusual docility, hostility, rage reactions, or excessive irritability.

Nonverbal Communication (Body Language) Note the patient’s posture, eye contact, and facial expression. Some cultural groups will not maintain eye contact with you. Slumped posture and a lack of facial expression may indicate depression or a neurologic condition such as Parkinson disease. Excessively energetic movements or constantly watchful eyes suggest tension, mania, anxiety, a metabolic disorder, or the effects of recreational or prescrip- tion drug use (e.g., methamphetamine, amphetamine salts, cocaine, and steroids).

State of Consciousness The patient should be oriented to person, place, and time and make appropriate responses to questions, as well as physical and environmental stimuli. Person disorientation results from cerebral trauma, seizures, or amnesia. Place disorientation occurs with psychiatric disorders, delirium, and cognitive impairment. Time disorientation is associated with anxiety, delirium, depression, and cognitive impair- ment. See Table 7.1 for potential causes of unresponsiveness.

TYPE OF DISORDER CAUSE

Focal lesions of the brain Hemorrhage, hematoma, infarction, tumor, abscess, trauma

Diffuse brain disease Drug intoxications Disturbances of glucose, sodium, or calcium metabolism, renal failure, myxedema, pulmonary insufficiency

Hypothermia, hyperthermia Hypoxic or anoxic event such as strangulation, drowning, cardiac arrest, pulmonary embolism

Encephalitis, meningitis Seizures

Psychogenic unresponsiveness

Dementia

TABLE 7.1 Common Causes of Unresponsiveness

CLINICAL PEARL

The Importance of Validation Interview a family member or friend of the patient if you have any concerns about a patient’s responses or behavior. Determine whether the patient has any problems remembering appointments or important events, paying bills, shopping independently for food or clothing, preparing meals, taking medication, getting lost while walking or driving, making decisions about daily life, or asking the same thing again and again.

Analogies Ask the patient to describe simple analogies first and then more complex analogies: • What is similar about these objects: Peaches and lemons?

Ocean and lake? Trumpet and flute? • Complete this comparison: An engine is to an airplane

as an oar is to a ____. • What is different about these two objects: A magazine

and a cookbook? A bush and a tree? Correct responses should be given when the patient has

average intelligence. An inability to describe similarities or differences may indicate a lesion of the left or dominant cerebral hemisphere.

Abstract Reasoning Ask the patient to tell you the meaning of a fable, proverb, or metaphor, such as the following: • A stitch in time saves nine. • A bird in the hand is worth two in the bush. • A rolling stone gathers no moss.

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Attention Span Ask the patient to follow a short set of commands. Alter- natively, ask the patient to say either the days of the week or to spell the word “world” forward or backward. The ability to perform arithmetic calculations is another test of attention span. Appropriate response to directions is expected. Easy distraction, confusion, negativism, and impairment of recent and remote memory may all indicate a decreased attention span. This may be related to fatigue, depression, delirium, or toxic or metabolic causes that result in confusion.

Judgment Determine the patient’s judgment and reasoning skills by exploring the following topics: • How is the patient meeting social and family

obligations? • What are the patient’s plans for the future? Do they

seem appropriate? • Ask the patient to provide solutions to hypothetical situ-

ations, such as: “What would you do if you found a stamped envelope?” “What would you do if a police officer gave you a ticket after you drove through a red light?” If the patient is meeting social and family obligations

and adequately dealing with financial obligations, judgment is considered intact. The patient should be able to evaluate the situations presented and recognize the consequences of action. Impaired judgment may indicate intellectual disability, emotional disturbance, frontal lobe injury, dementia, or psychosis.

Speech and Language Skills Detailed evaluation of the patient’s communication skills, both receptive and expressive, should be performed if the patient has difficulty communicating during the history. The patient’s voice should have inflections, be clear and strong, and be able to increase in volume. Determine whether the patient’s rate of speech is excessively fast or slow, normal, or has hesitations. Speech should be fluent with clear expression of thoughts.

Voice Quality Determine whether there is any difficulty or discomfort in phonation, or if laryngeal speech sounds are present.

When the patient has average intelligence, an adequate interpretation should be given. Inability to explain a phrase may indicate poor cognition, dementia, brain damage, or schizophrenia.

Arithmetic Calculation Ask the patient to do simple arithmetic, without paper and pencil, such as the following: • Subtract 7 from 50, subtract 7 from that answer, and so

on, until the answer is 8. • Add 8 to 50, add 8 to that total, and so on, until the

answer is 98. The calculations should be completed with few errors

and within 1 minute when the patient has average intel- ligence. Impairment of arithmetic skills may be associated with depression, cognitive impairment, and diffuse brain disease.

Writing Ability For a comprehensive mental status examination, ask the patient to write his or her name and address or a dictated phrase. Omission or addition of letters, syllables, words, or mirror writing may indicate aphasia (impair- ment in language function). Alternatively, if poor literacy is a concern, ask the patient to draw simple geometric figures (e.g., a triangle, circle, or square) and then more complex figures such as a clock face, a house, or a flower. Uncoordinated writing or drawing may indicate dementia, parietal lobe damage, a cerebellar lesion, or peripheral neuropathy.

Execution of Motor Skills Ask the patient to unbutton a shirt button or to comb his or her hair. Apraxia (the inability to translate an intention into action that is unrelated to paralysis or lack of compre- hension) may indicate a cerebral disorder.

Memory Immediate recall or new learning: Ask the patient to listen

and then repeat a sentence or a series of numbers. Five to eight numbers forward or four to six numbers back- ward can usually be repeated.

Recent memory: Give the patient a short time to view four or five test objects, telling him or her that you will ask about them in a few minutes. Ten minutes later, ask the patient to list the objects. All objects should be remembered. See Clinical Pearl, “Testing Memory in the Visually Impaired.”

Remote memory: Ask the patient about verifiable past events or information such as sibling’s name, high school attended, or a subject of common knowledge. Memory loss may result from disease, infection, or

temporal lobe trauma. Impaired memory occurs with various neurologic or psychiatric disorders, such as anxiety and depression. Loss of immediate and recent memory with retention of remote memory suggests dementia.

CLINICAL PEARL

Testing Memory in the Visually Impaired When a patient is visually impaired, test recent memory with unrelated words rather than observed objects. Pick four unrelated words that sound distinctly different, such as “green,” “daffodil,” “hero,” and “sofa” or “bird,” “carpet,” “treasure,” and “orange.” Tell the patient to remember these words. After 5 minutes, ask the patient to list the four words.

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Aphasia, a speech disorder that can be receptive (understanding language) or expressive (speaking lan- guage), may be indicated by hesitations and other speech rhythm disturbances, omission of syllables or words, word transposition, circumlocutions, and neologisms. Aphasia can result from facial muscle or tongue weakness or from neurologic damage to brain regions controlling speech and language. Characteristics of different types of aphasia are listed in the Differential Diagnosis box following this section.

Emotional Stability Emotional stability is evaluated when the patient does not seem to be coping well or does not have resources to meet his or her personal needs.

Mood and Feelings During the history and physical examination, observe the mood and emotional expression evident from the patient’s verbal and nonverbal behaviors. Note any mood swings or behaviors indicating anxiety, depression, anger, hostility, or hypervigilance.

Ask the patient how he or she feels right now, whether feelings are a problem in daily life, and whether any time or experience is particularly difficult for the patient. The U.S. Preventive Health Task Force recommends depression screening of adults with the self-administered Patient Health Questionnaire (PHQ) (Siu and U.S. Preventive Health Task Force, 2016). Two- and a nine-item versions of the PHQ exist. The PHQ-2 has two questions with a reported sensitiv- ity of 96% and specificity of 57% (Snyderman and Rovner, 2009): • Over the past 2 weeks, have you felt down, depressed,

or hopeless? • Over the past 2 weeks, have you felt little interest or

pleasure in doing things? If the response is positive to both questions perform the

PHQ-9 or ask more questions about depression symptoms,

Dysphonia, a disorder of voice volume, quality (e.g., harsh, nasal, or breathy), or pitch (e.g., monotony of pitch or loudness), suggests a problem with laryngeal innervation or disease of the larynx.

Articulation Evaluate spontaneous speech for pronunciation and ease of expression. Abnormal articulation includes imprecise pronunciation of consonants, slurring, difficulty articulat- ing a single speech sound, hesitations, repetitions, and stuttering. Dysarthria, a motor speech disorder, is associ- ated with many conditions of the nervous system such as stroke, inebriation, cerebral palsy, and Parkinson disease.

Comprehension Ask the patient to follow simple one- and two-step directions during the examination, such as during the attention span assessment. The patient should be able to follow simple instructions.

Coherence The patient’s intentions or perceptions should be clearly conveyed to you. Communication characteristics that may be associated with a psychiatric disorder include the following: • Circumlocution—pantomime or word substitution to

avoid revealing that a word was forgotten • Perseveration—repetition of a word, phrase, or gesture • Flight of ideas or use of loose associations—disordered

words or sentences • Word salad—meaningless, disconnected word choices • Neologisms—made-up words that have meaning only

to the patient • Clang association—word choice based on sound so that

words rhyme in a nonsensical way (e.g., The far car mar to the star)

• Echolalia—Repetition of another person’s words • Utterances of unusual sounds

DIffERENTIAL DIAGNOSIS Distinguishing Characteristics of Aphasias

CHARACTERISTICS BROCA APHASIA (EXPRESSIVE) WERNICKE APHASIA (RECEPTIVE) GLOBAL APHASIA (EXPRESSIVE AND RECEPTIVE)

Word comprehension Fair to good Can hear words but cannot relate them to previous experiences

Absent or reduced to person’s own name, few select words

Spontaneous speech Impaired speech flow; laborious effort to speak; know what they want to say but cannot articulate properly; telegraphic speech (mostly nouns and verbs)

Fluent speech but uses words inappropriately, such as neologisms or word substitutions; may be totally incomprehensible

Absent or reduced to only a few words or sounds

Reading comprehension Intact Impaired Severely impaired

Writing Impaired Impaired Severely impaired

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be easy to follow with logical and goal-directed ideas expressed. Illogical, disorganized, or unrealistic thought processes, flight of ideas (rapid disconnected thoughts), blocking (i.e., an inappropriate pause in the middle of a thought, phrase, or sentence), or an impaired stream of thinking (e.g., repetition of a word, phrase, or behavior) indicates an emotional disturbance or a psychiatric disorder.

Evaluate disturbance in thought content by asking about obsessive thoughts related to fears, guilt, or making deci- sions. Does the patient ever feel like he or she is being watched or followed, is controlled or manipulated, or loses touch with reality? Does the patient compulsively repeat actions or check and recheck to make sure something is done? Obsessive thoughts, compulsive behaviors, phobias, or anxieties that interfere with daily life may indicate mental dysfunction or a psychiatric disorder.

Does the patient have delusions (false personal beliefs not shared by others in the same culture), such as delusions of grandeur or of being controlled by an outside force? Does the patient feel unrealistic persecution, jealousy, or paranoia? Delusions are often associated with psychiatric disorders, delirium, and alcohol or drug intoxication. See Clinical Pearl, “Distorted Thinking.”

such as trouble sleeping or sleeping too much, moving too slow or restlessness, poor appetite or overeating, poor concentration, feeling like a failure, or thoughts of hurting yourself. The PHQ-9 has good sensitivity and specificity for identifying a major depressive disorder (Manea et al, 2012). This tool has been translated into several lan- guages. See www.phqscreeners.com for full access to the PHQ-9.

Be concerned if the patient does not express appropri- ate feelings that correspond to the situation. For example, does the patient laugh when talking about a seriously ill family member? Unresponsiveness, hopelessness, agitation, aggression, anger, euphoria, irritability, or wide mood swings indicate disturbances in mood, affect, and feelings.

Identify the potential for suicide, particularly if the patient has signs of depression or risk factors for suicide could be present. See Risk Factors: Suicide. Two questions on the Columbia-Suicide Severity Risk Screener (C-SSRS) help identify the patient at higher risk for suicide ideation and behavior: • Have you wished you were dead or wished you could

go to sleep and not wake up? • Have you actually had any thoughts of killing

yourself? A positive response to the second item places the patient at higher risk, especially if the patient made any recent preparations for how to end his or her life. Implement patient safety monitoring and obtain an immediate psy- chiatry referral if preparations have occurred within the past week. Other patients with a positive response should have a more thorough suicide risk assessment (Posner et al, 2016). Full access to the C-SSRS is available at www.cssrs .columbia.edu/index.html

Risk factors

Suicide • Social isolation, older men or women, divorced or widowed, living

alone • Mental health disorder, depression, hopelessness • Serious chronic or terminal health condition (e.g., HIV infection,

cancer, renal failure) • Family history of suicide or suicide attempt • Knowing someone who recently attempted or committed suicide • Significant personal losses or challenges (e.g., bereavement, financial

or legal problems, unemployment, in abusive relationship, recent breakup with partner)

• Has thought about a plan for suicide; previous suicide attempt • Alcohol and substance use disorders • Access to firearms or other means of self-harm

CLINICAL PEARL

Distorted Thinking A patient who demonstrates an unrealistic sense of persecution, jealousy, grandiose ideas, or ideas of reference (e.g., neutral things in the environment have a special meaning to the person) may be experiencing distorted thinking.

Thought Process and Content Observe the patient’s thought patterns, especially the appropriateness of sequence, logic, coherence, and relevance to the topics discussed. The patient’s thought process should

Perceptual Distortions and Hallucinations Determine whether the patient perceives any sensations that are not caused by external stimuli (e.g., hears voices, sees vivid images or shadowy figures, smells offensive odors, tastes offensive flavors, feels worms crawling on the skin). Find out when these experiences occur. Auditory and visual hallucinations are associated with psychiatric disorders, severe depression, acute intoxication, delirium, and demen- tia. Tactile hallucinations are most commonly associated with alcohol withdrawal.

Infants and Children Evaluate an infant’s general behavior and level of conscious- ness by observing the level of activity and responsiveness to caregivers and environmental stimuli. Note whether the baby is lethargic, drowsy, stuporous, alert, active, or irritable (Fig. 7.3, A). By 2 months of age, the infant should appear alert, quiet, and content and should recognize the face of a primary caregiver (Fig. 7.3, B). The examiner who devotes time to developing a relationship with a 2- to 3-month old infant should be able to coax a smile. When it is difficult

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or impossible to elicit a social smile in an infant who appears ill, be concerned about a neurologic condition or infection, such as meningitis. Be concerned if the parent or primary caregiver seems detached or depressed. An infant’s social and emotional development is heavily influenced by interac- tion with the primary caregiver.

Crying and other vocal sounds are evaluated when language has not yet developed. The infant’s cry should be loud and angry. A shrill or whiny, high-pitched cry or catlike screeching cry suggests a central nervous system disorder. Cooing and babbling are expected after 3 and 4 months of age, respectively.

Evaluate the types of words and speech patterns used by the child. For example, does the child pronounce most words correctly as expected for age, do persons outside the immediate family understand the child’s speech, and does the child stammer or stutter? What is the child’s voice quality? Does the child’s voice have intonation (e.g., excite- ment)? Table 7.2 describes expressive language milestones for toddlers. Language development should be appropriate for age and speech should be more clearly understandable as the child ages.

Questionnaires completed by parents (e.g., Ages and Stages Questionnaire, see www.agesandstages.com; and Parent’s Evaluation of Developmental Status, see www .pedstest.com) are effective screening tools recommended for developmental assessment during routine well child visits. These questionnaires have good sensitivity and specificity for detecting developmental concerns. Ask children 5 years and older to draw a picture of a person, doing the best job possible. Scores for the detail in 14 body

A

B

fIG. 7.3 A, Note this newborn’s irritability and posturing associated with cocaine withdrawal. B, Note this infant’s level of alertness and interest in various objects and people.

Data from American Speech and Language Association, 2016.

AGE (MONTHS) EXPRESSIVE LANGUAGE MILESTONES

4–6 Babbles speech-like sounds, including p, b, and m

10–12 Imitates different speech sounds, has 1 or 2 words, such as “mama,” “dada,” “bye-bye,” but sounds may not be clear

12–24 Increases words each month, 2-word questions or phrases (e.g., “Where baby?” and “Want cookie”)

24–36 Uses two- to three-word sentences to ask for things or talk about things, large vocabulary, speech understood by family members most of time, asks why

36–48 Answers simple questions, uses pronouns like I, me, you

Sentences have four or more words, speech understood by most people

48–60 Says most sounds correctly except a few like l, s, r, v, z, ch, sh, th

Uses sentences with more than 2 action words Tells stories, and keeps conversation going.

TABLE 7.2 Expressive Language Milestones for Toddlers and Preschoolers

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Concerns about behaviors and mood disorders may be assessed in children 4 to 18 years of age with tools like the Pediatric Symptom Checklist (www2.massgeneral.org/ allpsych/psc/psc_home.htm). An adolescent version of the Patient Health Questionnaire—9 (PHQ-9) is also avail- able to screen for depression. Positive responses should prompt questions about school, family, friends, moods, and activities.

Pregnant Patients An estimated 39% of patients who have depression during pregnancy have postpartum depression. An estimated 13% of patients have postpartum depression (Underwood et al, 2016). Postpartum psychosis occurs in 0.1% to 0.2% of patients (Berrisford et al, 2015). Risk factors for postpartum depression include a history of depression, prior postpartum depression, and poor social support. Because the depression may interfere with the patient’s health, ability to work, attachment to the newborn, and the infant’s subsequent development, all pregnant patients should be screened for depressive symptoms during pregnancy and then in postpartum period, including during routine well-child visits (O’Connor et al, 2016).

The two PHQ-2 depression screening questions listed in the section on Mood and Feeling can be used for screen- ing. Ask additional questions to determine whether depres- sion is present when the response to screening questions is positive. The Edinburgh Postnatal Depression Scale is a 10-item self-administered screening test that may be used during pregnancy and the postpartum period. Patients are asked to identify the frequency of feelings (e.g., happiness, anxiety or worry, scared or panicky, and sad or miserable) over the past 7 days. See https://psychology-tools.com/epds/ for access to this tool.

Older Adults Assess cognitive function to identify mild cognitive impairment that may indicate the onset of dementia or cognitive changes associated with normal aging. As with all adults, assess the patient’s response to questions and directions during the history and physical assessment. Recent memory for important events and conversations is usually not impaired. The older adult may complain about memory loss, but this is not predictive of cogni- tive decline. Individuals who report that memory loss interfered with daily activities were at higher risk for cognitive decline (Sargent-Cox et al, 2011). Close family member concerns about the patient’s memory loss are an indication to use a standardized tool to assess cognition.

The Montreal Cognitive Assessment (MoCA) is a tool initially designed to detect mild cognitive impairment that may identify a transition between normal aging and dementia. This tool also helps identify patients needing a more comprehensive cognitive assessment. See Evidence- Based Practice in Physical Examination: Montreal Cognitive Assessment Battery.

part attributes are available to assess cognitive development (Kwan, 2018) (Fig. 7.4).

Observe the child’s behaviors during the patient history to identify mood, activity level, communication pattern, preferences, responsiveness to the parent, and ability to separate. Does the child have self-comforting measures? Does the child play and have fun?

Attempt memory testing at about 4 years of age if the child pays attention and is not too anxious. Expected memory skills vary with the age of the child. When testing immediate recall, a 4-year-old can repeat three digits or words, a 5-year- old can repeat four digits or words, and a 6-year-old can repeat five digits or words. Test recent memory in a child starting at 5 to 6 years by showing the child familiar objects and waiting no longer than 5 minutes to ask the child to recall the objects (Fig. 7.5). Remote memory is tested by asking the child what he or she ate for dinner last night or what his or her address is, or by asking the child to recite a nursery rhyme.

fIG. 7.4 Ask the child to draw a picture of a man or woman. The presence and form of body parts provide a clue about the child’s development when following the scoring criteria of the Goodenough-Harris Drawing Test.

fIG. 7.5 Test a child’s memory recall by using familiar objects.

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Evidence-Based Practice in Physical Examination

Montreal Cognitive Assessment Battery The Montreal Cognitive Assessment (MoCA) includes items in the following domains providing a broader assessment of cognitive status than the Mini-Mental State Examination (MMSE): • Immediate and delayed memory recall • Visuospatial abilities with clock drawing and copying a three-

dimensional cube • Executive functioning with trail-making, phonemic fluency, and

verbal abstraction tasks • Attention, concentration and working memory sustained attention

serial subtraction, and digits forward and backward tasks • Language with identification of low-familiarity animals, repetition

of two complex sentences • Orientation to time and place

It has more cognitively demanding tasks related to memory recall and executive functioning than the MMSE. The 30-point test takes 10 to 20 minutes to administer. In the identification of mild cognitive impairment with clinically objective signs of cognitive decline, the MoCA sensitivity is 89% and specificity is 95% (Nordlund et al, 2011). The MoCA was found to better discriminate patients with mild cognitive impairment at risk for dementia than the MMSE, as well as those patients with multiple domain versus single domain mild cognitive impairment (Dong et al, 2012). For access to the screening tool visit www.mocatest.org.

The Mini-Cog is a brief screening tool for measuring cognitive function that takes up to 5 minutes to administer. It involves immediate and delayed recall of three unrelated words and a clock-drawing test. (See Fig. 7.6 for test administration and scoring guidelines.) A score of 0 to 5 points is possible, and a score of 2 or less may be associated with dementia. The Mini-Cog has a sensitivity of 76% to 99% and a specificity of 89% to 96% for detecting probable dementia (McGee, 2012). It has been used successfully in non–English-speaking and culturally diverse populations, as well as those with varying educational levels (Milian et al, 2012).

The MMSE is a standardized tool to assess cognitive function changes over time. The 11 items—measuring orientation, registration, attention and calculation, recall, ability to follow commands, and language—take approxi- mately 5 to 10 minutes to administer. Fig. 7.7 shows testing of the copying skill under the language portion of the MMSE. The maximum score is 30. A score of 20 or less may be associated with dementia (sensitivity of 71% to 92%, specific- ity of 52% to 96%), and a score of 26 or higher is not associated with dementia. Higher education is associated with higher MMSE scores, even when dementia is present (McGee, 2012; Snyderman and Rovner, 2009). The MMSE has been translated into multiple languages and adapted for many cultures, and in some cases external validity, sensitivity, and specificity have been evaluated (Sties and Schrauf, 2009). MMSE Version 2 has been developed

(Folstein and Folstein, 2016). For access to the full tool, see www4.parinc.com.

Determine whether any changes in cerebral function could be the result of cardiovascular, hepatic, renal, or metabolic disease. Medications can also impair central nervous system function, causing slowed reaction time, disorientation, confusion, loss of memory, tremors, and anxiety. Problems may develop because of the dosage, number, or interaction of prescribed and over the counter medications. Review the patient’s ability to perform activities of daily living associated with mental status functioning.

fuNCTIONAL ASSESSMENT Activities of Daily Living Related to Mental Status The ability to perform instrumental activities of daily living (ADLs), or the ability to live independently, is an important assessment. When assessing the patient’s mental status, attempt to determine the patient’s ability to perform the following ADLs: • Shop, cook, and prepare nutritious meals • Use problem-solving skills • Manage medications (purchase, understand, and follow

directions) • Manage personal finances and business affairs • Speak, write, and understand spoken and written language • Remember appointments, family occasions, holidays, household

tasks

Older adults are expected to maintain the same level of interpersonal skills and have no personality changes. Depression, one of the most common conditions in older adults, may contribute to cognitive impairment. Depression can be identified with the Geriatric Depression Scale (Fig. 7.8). Paranoid thought may be a striking alteration in personality. Attempt to determine whether the thought process is accurate or a paranoid ideation, keeping in mind the incidence of elder abuse. Facial expressions that are masklike or overly dramatic, or a stance that is stooped and fearful, may indicate a progressive disease in the older adult.

Patient Safety

Older Adult’s Living Arrangements When impairment in ability to perform activities of daily living is identified, determine safety in the older adult’s living arrangements. Is a caregiver present in the home or does someone check in each day? Is food delivered to the home or are meals provided? Are medication dosages provided or monitored? Has the older adult stopped driving a car? How well can the older adult safely move around the home? If safety is a concern, have a discussion with the older adult’s family member or friend to encourage changes that will improve safety.

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The Mini-Cog Assessment Instrument for Dementia

The Mini-Cog assessment instrument combines an uncued three-item recall test with a clock- drawing test (CDT). The Mini-Cog can be administered in about three minutes, requires no special equipment, and is relatively uninfluenced by level of education or language variations.

Administration

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, such as 11:20. These instructions can be repeated, but no additional instructions should be given. Give the patient as much time as needed to complete the task. The CDT serves as the recall distractor.

3. Ask the patient to repeat the three previously presented words.

Scoring

Give 1 point for each recalled word after the CDT distractor. Score 1–3.

A score of O indicates positive screen for dementia.

A score of 1 or 2 with an abnormal CDT indicates positive screen for dementia.

A score of 1 or 2 with a normal CDT indicates negative screen for dementia.

A score of 3 indicates negative screen for dementia.

The CDT is considered normal if all numbers are present in the correct sequence and position, and the hands readably display the requested time.

fIG. 7.6 The Mini-Cog is a brief screening tool for measuring cognitive function. (Reprinted with permission from Borson et al, 2000.)

A B fIG. 7.7 A, Acceptable drawing of a clock with numbers appropriately spaced around the face and the requested time of 10 minutes after the 4 o’clock noted correctly by the long and short hands. B, Unacceptable drawing that shows poor planning regarding number placement around the clock face, and hands pointing to the 10 and 4, for 10 minutes after the 4 o’clock. (From Stern and Fricchione, 2010.)

SAMPLE DOCuMENTATION

History and Physical Examination

Subjective A 66-year-old woman accompanied by spouse who expresses concern about his wife’s memory loss. One week ago, she got lost in a shopping mall she often visited. Previously was a good cook, but over the past few months either does not have necessary ingredients or has difficulty following recipes. Needs help to ensure that she takes correct daily medications. Able to dress and undress self independently, but now needs help to select clothes appropriate for the occasion. Spouse has assumed more household work and some meal preparation. Patient recognizes all family members and social contacts and is able to talk with them.

Objective Pleasant patient with clear speech who responds correctly to simple questions. Turns to spouse frequently for answers to some history questions. Follows one-step directions but needs reminder with two- step directions. Immediate and recent memory impaired, but remote memory is intact. Arithmetic calculation impaired. Mini-Cog score = 2, and MMSE score = 20. For additional sample documentation, see Chapter 5.

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Ask the patient to choose the best answer for how he or she felt over the preceding week.

1. Are you basically satisfied with your life?

2. Have you dropped many of your activities and interests?

3. Do you feel that your life is empty?

4. Do you often get bored?

5. Are you in good spirits most of the time?

6. Are you afraid that something bad is going to happen to you?

7. Do you feel happy most of the time?

8. Do you feel helpless?

9. Do you prefer to stay at home rather than going out and doing new things?

10. Do you feel you have more problems with memory than most people?

11. Do you think it is wonderful to be alive now?

12. Do you feel pretty worthless the way you are now?

13. Do you feel full of energy?

14. Do you feel that your situation is hopeless?

15. Do you think most people are better off than you are?

Correct responses are the following: Yes for questions 2, 3, 4, 6, 8, 9, 10, 12, 14, and 15. No for questions 1, 5, 7, 11, and 13. Give 1 point for each correct answer. A score greater than 5 suggests depression.

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

fIG. 7.8 Geriatric Depression Scale (short form). (From Sheikh and Yesavage, 1986.)

ABNORMALITIES

MENTAL STATuS Disorders of Altered Mental Status Traumatic Brain Injury. An alteration in mental status resulting from a blow to the head, face, or neck, or a penetrating brain injury

PATHOPHYSIOLOGY PATIENT DATA Concussion A direct blow to the head or face that bruises the brain as it moves within

and against the skull and causes inflammation; often caused by a sports injury.

Subjective Data • Headache • Dazed or dizzy, may have brief loss of consciousness • Nausea and vomiting • Blurred vision • Ringing in ears • Restless or irritable

Objective Data • Dazed expression • Slow motor and verbal responses, slurred speech • Emotional lability • Hypersensitivity to stimuli • Deficits in coordination, cognition, memory, and attention • Symptoms may disappear within 15 minutes or persist for several

weeks • See the Sports Concussion Assessment Tool in Chapter 24.

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PATHOPHYSIOLOGY PATIENT DATA Moderate to Severe Brain Injury Higher forces cause acceleration-deceleration and rotational movement

of the brain in the skull. Nerve fibers are stretched, compressed, or torn. Brain chemicals responsible for brain functioning are disrupted and inflammation leads to brain swelling (see Chapter 23).

Subjective Data • May or may not have loss of consciousness for 5-10 minutes • Amnesia up to 24 hours after moderate injury; longer than 24 hours

for severe injury

Objective Data • Coma • Glasgow Coma Score <13 (see Chapter 26). • Increased intracranial pressure • Seizures

Disorders of Mood Depression. A mood disorder in which feelings of sadness, loss, anger, or frustration interfere with everyday life for an extended period (weeks or longer)

PATHOPHYSIOLOGY PATIENT DATA Associated with a neurochemical imbalance, a decreased level of mono-

amines, or increased plasma cortisol Genetic predisposition and family environmental influences Associated with stressful life event, grief, or change in lifestyle

Subjective Data • Feels sad, hopeless, worthless; guilt • No interest or pleasure in what was previously of interest or

pleasurable • Fatigue or loss of energy • Insomnia or excessive sleeping • Increased or decreased appetite; weight gain or loss (>5%) in a month

Objective Data • Poor concentration • Slowed thought processes and speech • Agitation, irritability, or restlessness • See Differential Diagnosis table later in the chapter

Mania. A persistently elevated, expansive, euphoric, or irritable and agitated mood lasting longer than a week; one phase of the bipolar psychiatric disorder

PATHOPHYSIOLOGY PATIENT DATA Associated with abnormally elevated levels of neurotransmitters, norepi-

nephrine, serotonin, dopamine, and glutamate, along with lower levels of gamma-aminobutyric acid (GABA); may also be associated with dysregulation of cellular mechanisms that mediate neurotransmission (Malhi et al, 2013).

Subjective Data • Hyperactivity • Overconfidence, exaggerated view of own abilities • Impaired occupational, social, and interpersonal functioning • Excessive involvement in pleasurable activities with high potential for

serious or painful consequences • Decreased need for sleep • Racing thoughts • Lack of impulse control

Objective Data • Grandiose or persecutory delusions, euphoria • Increased talkativeness or pressure to keep talking, may involve

excessive rhyming or puns; flight of ideas • Impaired attention, easily distracted • Impaired judgment • Hypersexual behavior

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Anxiety Disorder. A group of disorders with such marked anxiety or fear that it causes significant interference with personal, social, and occupational functioning

PATHOPHYSIOLOGY PATIENT DATA Abnormalities in the norepinephrine and serotonin systems; may have

genetic predisposition; increased sensitivity of brain pH chemosensors in sites that modulate fear and arousal, such as the prefrontal cortex and amygdala

Specific disorders include the following: • Panic attacks • Generalized anxiety disorder • Specific phobias • Obsessive-compulsive disorder (OCD) • Posttraumatic stress disorder (PTSD)

Subjective Data • Panic attacks: palpitations, sweating, shaking, dizziness, faintness,

chest pain, nausea, abdominal distress, chills or hot flashes, chronic social avoidance fear of losing control and dying

Objective Data • Panic attacks: tachycardia, diaphoresis, tremors

Subjective Data • Generalized anxiety disorder: chronic worry, restless, irritable, tense,

fatigue, poor concentration, sleep disturbance

Objective Data • Generalized anxiety disorder: impaired attention, motor tension, tremors,

restlessness

Subjective Data • OCD: preoccupation with contamination, religious, or sexual themes;

belief that failure to perform a specific act will lead to a bad outcome

Objective Data • OCD: Ritualized acts performed compulsively (washing, cleaning,

hoarding, organizing, counting)

Subjective Data • PTSD: recurrent intrusive flashbacks (e.g., images, odors, sounds, and

negative emotions), dreams, thoughts; avoidance behavior; sleeping difficulty; hypervigilance; poor concentration

Objective Data • PTSD: anger or rage reactions, impulsive behavior, hyperarousal,

emotional numbing, detachment from others

Schizophrenia. A severe, persistent, psychotic syndrome with impaired reality that relapses throughout life

PATHOPHYSIOLOGY PATIENT DATA A genetic disorder that involves many genes on different chromosomes

in patients who are vulnerable due to factors such as intrauterine infection, maternal nutritional deficiencies, perinatal complications, and neonatal hypoxia. Structural brain abnormalities exist such as enlarged lateral and third ventricles, reduced size of the temporal lobe and thalamus, and progressive loss of cortical gray matter (Takahashi, 2014).

Subjective Data • Hears voices • Unpleasant tastes or odors • Sees images • Paranoid thoughts • Unable to experience emotions, blunted affect, apathy, detached from

environment • Poor personal hygiene

Objective Data • Incoherent speech, loose associations, illogical answers to questions • Hallucinations (tactile, auditory, visual, somatic, gustatory, or olfactory) • Delusions • Repetitive or aimless behavior • Inappropriate affect in response to a situation

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Infants and Children

Intellectual Disability A developmental, cognitive, or intellectual deficit that begins before 18 years of age, with accompanying deficits in adaptive behavior, academic performance, and adaptive functioning; previously called mental retardation

PATHOPHYSIOLOGY PATIENT DATA May be associated with structural brain defects, genetic disorders, fetal

alcohol syndrome, or serious brain insult (infection or injury) during childhood

Genetic link (e.g., parents have intellectual disability) Cause may not be identified

Subjective Data • Delayed motor development • Delayed speech and language skills

Objective Data • Delayed developmental milestones • Impaired cognitive function and short-term memory • Poor academic performance • Lack of motivation

Attention-Deficit/Hyperactivity Disorder (ADHD) A neurobehavioral problem of impaired attention and hyperactive behavior affecting 5% to 10% of school-age children

PATHOPHYSIOLOGY PATIENT DATA Disorder with genetic component potentially affecting dopamine transport

and reception; may have impaired function of the neural network in the brain cortex as the child transitions from resting state (e.g., daydreaming) to engage the cognitive control neural network with attention-demanding activity (Posner et al, 2014). It may be associated with birth injuries, severe traumatic brain injury or abnormal brain structures (Urion, 2016)

Subjective Data • Short attention span, easily distracted, fails to complete school assign-

ments or follow instructions • Fidgets and squirms, often moving, running, climbing • Disruptive behavior, talks excessively, temper outbursts, labile moods,

poor impulse control

Objective Data • Onset before 7 years of age • Increased motor activity • Difficulty organizing tasks • Difficulty sustaining attention • Poor school performance • Low self-esteem • Has problems in more than one setting

Autism A pervasive neurodevelopmental disorder of unknown etiology; refers to a wide spectrum of disorders (including autistic disorder, Asperger syndrome, pervasive developmental disorder not otherwise specified [PDD-NOS]), typically identified before 3 years of age and in more boys than girls

PATHOPHYSIOLOGY PATIENT DATA A strong genetic influence that inactivates areas of the genome that affect

early brain development; potential intrauterine toxic insults leading to abnormal brain growth in the frontal, temporal, cerebellar, and limbic areas (Raviola et al, 2016).

The brain grows rapidly during the first 2–4 years, followed by slow or arrested growth, particularly in areas associated with higher cognition, language, emotional, and social functions.

Subjective Data • Does not make eye contact or point to objects for the purpose of

sharing experiences with others • Resists being held or touched • Odd and repetitive behaviors • Ritualized play, preoccupation with parts of objects • Motor development appropriate for age

Objective Data • Impaired social interactions • Impaired language, either delayed or undeveloped • Odd intonation to speech, pronoun reversal, nonsensical rhyming • Impaired symbolic and imaginative play • Lacks awareness of others • Cognitive impairment in many cases

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Older Adults

Delirium Impaired cognition, arousal, consciousness, mood and behavioral dysfunction of acute onset

PATHOPHYSIOLOGY PATIENT DATA Risk factors in older adults include serious illness or injury, impaired vision

or hearing, impaired cognitive function, poor pain management, anticholinergic medications, history of depression or alcohol abuse, and restraint use (Staus, 2011).

Subjective Data • Suspicious, fearful • Mood swings • See Differential Diagnosis later in the chapter

Objective Data • Altered consciousness, staring, unawareness, apathy or combative • Incoherence, illogical flow of ideas • Illusions, hallucinations, delusions • Poor memory

Dementia A chronic, slowly progressive disorder of failing memory, cognitive impairment, behavioral abnormalities, and personality changes that often begins after age 60 years.

PATHOPHYSIOLOGY PATIENT DATA Usually related to structural diseases of the brain. Incidence increases

with advancing age.

Dementia of Alzheimer Type Most common; accumulation of plaques containing amyloid beta protein

and neurofibrillary tangles to a toxic level leads to disruption of nerve impulse transmission and neuron death (Boss and Huether, 2014).

Vascular Dementia About 15% of cases; acute or recurrent embolic strokes, cerebral hemor-

rhage due to hypertension, and other forms of cerebrovascular disease (O’Brien and Thomas, 2015)

Other Dementias Associated with diffuse Lewy bodies in the brain, Parkinson disease, and

frontal lobe degeneration (Boss and Huether, 2014)

Subjective Data • Impaired memory, forgets appointments • Gets lost in familiar areas, wanders • Unable to manage shopping, food preparation, medication, finances,

and driving • Behavioral changes, such as socially inappropriate dress or conduct,

impaired grooming, impulsiveness, disinhibition • Aphasia, agnosia, apraxia • Apathy, withdrawal • Anxiety, irritability • Changes in mood (depression, uncharacteristic anger, anxiety,

agitation) • See Differential Diagnosis later in this chapter

Objective Data • Memory impairment • Disturbance in executive functioning • Impairment in social and occupational functioning • Impaired use of language • Impaired functioning in activities of daily living • Eventual profound disintegration of personality and complete

disorientation • Decreased taste and odor identification in Alzheimer and vascular

dementia (Suto et al, 2014) • Stepwise deterioration of cognitive function with plateaus and occasional

episodes of improvement characteristic of vascular dementia

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DIffERENTIAL DIAGNOSIS Distinguishing Characteristics of Delirium, Dementia, and Depression

CHARACTERISTIC DELIRIUM DEMENTIA DEPRESSION

Onset Acute Insidious, relentless Acute or insidious

Duration Hours, days Persistent For longer than 2 wk

Time of day Fluctuates during the day Stable, no change Throughout most of the day

Consciousness Altered Not impaired except in severe cases Not impaired

Cognition Impairment of memory, attentiveness, numerous errors in assessment tasks

Minimal cognitive impairment initially, progresses to impaired abstract thinking, judgment, memory, thought patterns, calculations, agnosia

Impaired concentration, reduced attention span, indecisiveness, slower thought processes, impaired short-term and long-term memory

Activity Increased or decreased activity, may fluctuate

Unchanged from usual behavior Insomnia or excessive sleeping, fatigue, restlessness, anxiety, increased or decreased appetite

Speech/language Rambling and irrelevant conversation, illogical flow of ideas, incoherent

Disordered, rambling, incoherent; struggles to find words

Slower speech, or possibly rapid speech

Mood and affect Rapid mood swings; fearful, suspicious Depressed, apathetic, uninterested Sad, hopeless, feels worthless, loss of interest or pleasure

Delusions/hallucinations Misperceptions, illusions, hallucinations, and delusions

Misperceptions usually absent, delusions, no hallucinations

Usually no delusions or hallucinations

Reversibility Potential No, progressive Can be treated, may recur

Pathophysiology Acute onset may be associated with inflammation, physiologic stressors, metabolic derangements, electrolyte disorders, and genetic factors in the older adult with reduced brain resilience (Inouye et al, 2014)

Usually related to structural diseases of the brain

Associated with grief, a stressful life event, reaction to medical or neurologic diseases, or a change in lifestyle

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CHAPTER

8 Growth and Nutrition Weight and body composition offer information about an individual’s health status and may provide a clue to the presence of disease when they are out of balance. Nutrition is considered the science of food as it relates to promoting optimal health and preventing chronic disease. Nutritional intake and status offer insight into an individual’s health status. A nutritional assessment is an analysis of an individual’s approximate nutrient intake and relates it to the history, physical examination findings, body size measurements, and biochemical measures. This chapter focuses on the assessment of an individual’s body size and nutritional status, and the examination for growth, gesta- tional age, and pubertal development.

expenditure associated with body size, composition, and the level of physical activity. An appropriate balance con- tributes to long-term health and allows for the maintenance of optimal physical activity. Adequate nutrition, from a well-balanced diet, supports growth, the increase in size of an individual, or of a single organ. Growth is also dependent on a sequence of endocrine, genetic, environ- mental, and nutritional influences.

Many hormones must interact and be in balance for normal growth and development to proceed (Fig. 8.1). Two hypothalamic hormones control growth hormone synthesis and secretion in the anterior pituitary gland. Growth hormone–releasing hormone (GHRH) stimulates the pituitary to release growth hormone. Somatostatin, or growth hormone–inhibiting hormone (GHIBH), inhibits the secre- tion of both GHRH and thyroid-stimulating hormone (TSH). Growth hormone is secreted in pulses, with 70% of secretion occurring during deep sleep (Sam and Frohman, 2008). Growth hormone promotes growth and increase in organ size, and it regulates carbohydrate, protein, and lipid metabolism.

Thyroid hormone stimulates growth hormone secretion and the production of insulin-like growth factor 1 (IGF-1) and interleukins 6 and 8 (IL-6 and IL-8), which have an important role in bone formation and resorption. Thyroid hormones also affect the growth and maturation of other body tissues.

IGF-1 is a growth hormone–produced by the liver and in peripheral tissues, like bone. Through activation of IGF-1 receptors throughout the body, IGF-1 exerts a negative feedback effect on growth hormone secretion and mediates the effect of growth hormone on bone, muscle, nervous system and immune system cells (Werner et al, 2008). Ghrelin, a peptide, known as the “hunger hormone,” helps control growth hormone release and influences food intake and obesity development (Sakata and Sakai, 2010).

Leptin has a key role in regulating body fat mass, and its concentration is thought to be a trigger for puberty by informing the central nervous system that adequate nutritional status and body fat mass are present to support pubertal changes and growth (Low, 2011). Before puberty, body composition does not differ much between males and females. During puberty, with an increase in leptin, a relative decrease in fat percentage develops in males and

Physical Examination Components

Nutritional Assessment From the history and physical examination, assess the patient’s nutritional status, including: • Recent growth, weight loss, or weight gain • Chronic illnesses affecting nutritional status or intake • Medication and supplement use • Assessment of nutrient intake

Growth Assessment Obtain the following body size measurements and compare them to standardized tables: • Standing height • Weight • Calculate the BMI • Waist circumference • Calculate waist-height ratio and waist-to-hip circumference ratio

ANATOMY AND PHYSIOLOGY

Food nourishes the body by supplying necessary nutrients and calories to function in one or all of three ways: • To provide energy for necessary activities • To build and maintain body tissues • To regulate body processes The nutrients necessary to the body are classified as macronutrients (carbohydrates, protein and fat), micronu- trients (vitamins, minerals and electrolytes), and water. Energy requirements are based on the balance of energy

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outcome, but the sequential growth patterns are consistent. An external environmental or abnormal pathophysiologic process may intervene and influence the expected growth pattern (Fig. 8.2).

The growth of the musculoskeletal system and most organs such as the liver and kidneys follows the growth curves described for stature. Skeletal growth is considered complete when the epiphyses of long bones have completely fused during late puberty. More than 90% of skeletal mass is present by 18 years of age (Reiter and Rosenfield, 2008).

Weight is closely related to growth in stature and organ development. Growth and development are influenced by nutritional adequacy, which contributes to the number and size of adipose cells. The number of adipose cells increases throughout childhood. Gender-related differences in fat deposition appear in infancy and continue through adolescence.

Lymphatic tissues (i.e., lymph nodes, spleen, tonsils, adenoids, and blood lymphocytes) are small in relation to total body size, but are well developed at birth. These tissues grow rapidly to reach adult size by 6 years of age. By age 10 to 12 years, the lymphatic tissues are at their peak, about double adult size. During adolescence, they decrease to adult size.

The internal and external reproductive organs grow slowly before puberty. The reproductive organs double

increases in females (Rogol, 2010). During puberty, the gonads begin to secrete testosterone and estrogen. Rising levels of these hormones trigger the release of gonadotropins (luteinizing hormone [LH] and follicle-stimulating hormone [FSH]) from the hypothalamus that stimulate the gonads to release more sex hormones. The genitalia begin growing to adult proportions. Testosterone enhances muscular development and sexual maturation, and it promotes bone maturation and epiphyseal closure. Estrogen stimulates the development of female secondary sexual characteris- tics, regulating the timing of the growth spurt and the acceleration of skeletal maturation and epiphyseal fusion. Androgens, secreted by the adrenal glands, promote mas- culinization of the secondary sex characteristics and skeletal maturation.

Growth at puberty is dependent on the interaction of growth hormone, IGF-1, leptin, and the sex steroids (andro- gens). The sex steroids stimulate an increased secretion of growth hormone, which in turn mediates the dramatic increase in IGF-1. This leads to the adolescent growth spurt.

Differences in Growth by Organ System Each organ or organ system has its particular period of rapid growth, marked by rapid cell differentiation. Each individual has a unique growth timetable and final growth

FIG. 8.1 Growth hormone (GH) directly accelerates the rate of protein synthesis in skeletal muscle and bones. Insulin-like growth factor 1 (IGF-1) is activated by growth hormone and indirectly supports the formation of new proteins in muscle cells and bone. (From Telleen, 2015)

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GENITAL

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LYMPHOID

B 2 4 6 8 10 12 14 16 18 20

FIG. 8.2 Growth rates for the body as a whole and three types of tissues. Lymphoid type: thymus, lymph nodes, and intestinal lymph masses. Neural type: brain, dura, spinal cord, optic apparatus, and head dimensions. General type: body as a whole; external dimensions; and respiratory, digestive, renal, circulatory, and musculoskeletal systems. Genital type: includes the reproductive organ system. (Modified from Harris JA et al, 1930.)

2 mo. fetus

3 mo. fetus

Newborn 2 yr. 5 yr. 13 yr. Adult

FIG. 8.3 Changes in body proportions from 8 weeks of gestation through adulthood.

in size during adolescence, achieving maturation and function.

The brain, along with the skull, eyes, and ears, completes physical development more quickly than any other body part. The most rapid and critical period of brain growth occurs between conception and 3 years of age. By 34 weeks’ gestation, 65% of the weight of a newborn’s brain is present. Gray matter and myelinated white matter increase dramati- cally between the 34th and 40th weeks of gestation. At the time of full-term birth, the brain’s structure is complete

and an estimated 1 billion neurons are present. Glial cells, dendrites, and myelin continue to develop after birth, and by 3 years of age, most brain growth is completed (Fiegel- man, 2011). The head circumference increases in infants and toddlers as brain growth occurs. During adolescence, the size of the head further increases because of the development of air sinuses and thickening of the scalp and skull.

Infants and Children As infants and children grow, the change in body proportion is related to the pattern of skeletal growth (Fig. 8.3).

Growth of the head predominates during the fetal period. Fetal weight gain follows growth in length, but weight reaches its peak during the third trimester with the increase in organ size. An infant’s birth weight is influenced by genetic predisposition, gestational age, the mother’s pre- pregnancy weight, weight gain during pregnancy, environ- mental exposures like secondhand smoke, overall maternal health, and intercurrent disease or complications in pregnancy such as gestational diabetes.

During infancy, the growth of the trunk predominates. Weight gain is initially rapid, but the speed with which weight is gained decreases over the first year of life. The fat content of the body increases slowly during early fetal development and then increases during infancy.

The legs are the fastest-growing body part during childhood, and weight is gained at a steady rate. Fat tissue increases slowly until 7 years of age, at which time a prepubertal fat spurt occurs before the true growth spurt.

The trunk and the legs lengthen during adolescence and lean body mass averages 80% in males and females (Cromer, 2011). During adolescence about 50% of the individual’s ideal weight is gained, and the skeletal mass and organ systems double in size.

During adolescence, males develop broader shoulders and greater musculature; females develop a wider pelvic outlet. Males have a slight increase in body fat during early adolescence and then have an average gain in lean body

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Older Adults Physical stature declines in older adults beginning at approximately 50 years of age. The intervertebral disks thin and kyphosis develops with the potential of osteoporotic vertebral compression.

Individuals older than 60 years often have a decrease in weight for height and BMI and a loss of 5% body weight over several years. An increase in body fat also occurs as skeletal muscle declines and anabolic steroid secretion is reduced. Older adults also frequently have decreased physical activity, which contributes to skeletal muscle loss with an associated increased risk for poor function and disability (Kalyani et al, 2014). Physical activity recommendations vary by age. See Table 8.1 for guidelines for physical activity by age group from the U.S. Department of Health and Human Services (HHS).

Along with a decline in physical activity, an increase in overweight and obese older adults has been documented over the past 15 to 20 years. An age-associated reduction in size and weight of various organs has been identified, especially of the liver, lungs, and kidneys (McCance et al, 2015).

rEvIEw OF rELATED HISTOrY

For each of the symptoms or conditions discussed in this section, topics to include in the history of the present illness are listed. Responses to questions about these topics provide clues for focusing the physical examination and developing an appropriate diagnostic evaluation. Questions regarding medication use (prescription and over-the-counter prepara- tions) as well as complementary and alternative therapies are relevant for each area.

History of Present Illness Weight Loss • Compared with usual weight; time period (sudden,

gradual); intentional or unintentional • Desired weight loss: eating pattern, diet plan used,

food preparation, food group avoidance, average daily calorie intake, appetite, exercise pattern, support group participation, weight goal

• Undesired weight loss: anorexia; vomiting or diarrhea, difficulty swallowing, other illness symptoms, time period; frequent urination, excessive thirst; change in lifestyle, activity, mood, and stress level

• Preoccupation with body weight or body shape: never feeling thin enough, fasting, unusually strict caloric intake; unusual food restrictions or cravings; laxative abuse, induced vomiting; amenorrhea; excessive exercise; alcohol intake

• Medications: chemotherapy, diuretics, insulin, fluoxetine, prescription and nonprescription appetite suppres- sants, laxatives, oral hypoglycemics, steroids, herbal supplements

mass to 90%. Females accumulate subcutaneous fat and have a slight decrease in lean body mass to an average of 75% (Cromer, 2011).

Pregnant Patients Progressive weight gain is expected during pregnancy, but the amount varies among patients. The growing fetus accounts for 6 to 8 pounds of the total weight gained. The remainder results from an increase in maternal tissues: • Fluid volume—2 to 3 pounds • Blood volume—3 to 4 pounds • Breast enlargement—1 to 2 pounds • Uterine enlargement—2 pounds • Amniotic fluid—2 pounds • Maternal fat and protein stores—4 to 6 pounds

The rate of desirable weight gain follows a curve through the trimesters of pregnancy, slowly during the first trimester and more rapidly during the second and third trimesters. Maternal tissue growth accounts for most of the weight gained in the first and second trimesters. Fetal growth accounts for most weight gained during the third trimester.

Maternal nutrition before and during pregnancy and during lactation may have subtle effects on the developing brain of the infant and on the outcome of the pregnancy. Patients who have inadequate weight gain are at greater risk for delivering a low-birth-weight infant. Epigenetic research is revealing the potential consequences of inad- equate maternal nutrition on the adult health of the fetus (Box 8.1).

Postpartum weight loss often occurs over the first 6 months after birth, with most weight loss occurring by 3 months after delivery. Patients who gained more than the recommended weight during pregnancy are less likely to return to their prepregnancy weight. They may be suscep- tible to future obesity and its health consequences.

BOX 8.1 Epigenetic Research and Nutrition

Epigenetic research is revealing an association between an individual’s genome and environmental exposures during fetal life and adult health. Undernutrition during the second and third trimesters of pregnancy is believed to influence the fetus during the critical growth stages. Undernutrition (poor maternal nutrition or poor intrauterine environment) stresses the fetus, leading to adaptive and permanent changes in the infant’s endocrine and metabolic processes. Restricted fetal growth and a low birth weight for gestational age are associated with increased adult cardiovascular risk factors such as hypertension, insulin resistance, and abnormal lipid metabolism. These risk factors are further influenced by nutrition and growth after birth. Increased nutrition can lead to compensatory growth in these higher risk infants during the first 2 years of life, resulting in a child who has an increased body mass index and body fat by 5 years of age.

(From Cota and Allen, 2010.)

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• External losses (e.g., fistulas, wounds, abscesses, chronic blood loss, chronic dialysis)

Past Medical History • Chronic illness: liver disease, celiac disease, inflammatory

bowel disease, surgical resection of the gastrointestinal tract, diabetes, congestive heart failure, hypothyroidism, hyperthyroidism, pancreatic insufficiency, chronic infec- tion (e.g., human immunodeficiency virus [HIV] and tuberculosis), or allergies

• Previous weight loss or gain efforts: weight at 21 years, maximum body weight, minimum weight as an adult

• Previously diagnosed eating disorder, hypoglycemia

Family History • Obesity, dyslipidemia (Box 8.2) • Constitutionally short or tall stature, precocious or delayed

puberty • Genetic or metabolic disorder: diabetes (see list of chronic

illnesses under Past Medical History)

Weight Gain • Total weight gained: time period, sudden or gradual,

desired or undesired, possibility of pregnancy • Change in lifestyle: change in social aspects of eating;

more meals eaten out of the home; meals eaten quickly and “on the go”; change in meal preparation patterns; change in exercise patterns, mood, stress level, or alcohol intake

• Medications: steroids, oral contraceptives, antidepressants, insulin

Changes in Body Proportions • Coarsening of facial features, enlargement of hands and

feet, moon facies • Change in fat distribution: trunk-girdle versus

generalized

Increased Metabolic Requirements • Infancy, prematurity, congenital heart disease • Fever, infection, burns, trauma, pregnancy, hyperthyroid-

ism, cancer, athlete

aModerate-intensity physical activity: Aerobic activity that increases a person’s heart rate and breathing to some extent. On a scale relative to a person’s capacity, moderate-intensity activity is usually a 5 or 6 on a 0 to 10 scale. Brisk walking, dancing, swimming, or bicycling on a level terrain are examples. bVigorous-intensity physical activity: Aerobic activity that greatly increases a person’s heart rate and breathing. On a scale relative to a person’s capacity, vigorous-intensity activity is usually a 7 or 8 on a 0 to 10 scale. Jogging, singles tennis, swimming continuous laps, or bicycling uphill are examples. cMuscle-strengthening activity: Physical activity, including exercise that increases skeletal muscle strength, power, endurance, and mass. It includes strength training, resistance training, and muscular strength and endurance exercises. dBone-strengthening activity: Physical activity that produces an impact or tension force on bones, which promotes bone growth and strength. Running, jumping rope, and lifting weights are examples.

AGE RECOMMENDATIONS

6–17 years Children and adolescents should do 60 minutes (1 hour) or more of physical activity daily. • Aerobic: Most of the 60 or more minutes a day should be either moderate-a or vigorous-intensityb aerobic physical activity and should

include vigorous-intensity physical activity at least 3 days a week. • Muscle strengthening:c As part of their 60 or more minutes of daily physical activity, children and adolescents should include

muscle-strengthening physical activity on at least 3 days of the week. • Bone strengthening:d As part of their 60 or more minutes of daily physical activity, children and adolescents should include bone-

strengthening physical activity on at least 3 days of the week. • It is important to encourage young people to participate in physical activities that are appropriate for their age, are enjoyable, and offer

variety.

18–64 years • All adults should avoid inactivity. Some physical activity is better than none, and adults who participate in any amount of physical activity gain some health benefits.

• For substantial health benefits, adults should do at least 150 minutes (2 hours and 30 minutes) a week of moderate-intensity or 75 minutes (1 hour and 15 minutes) a week of vigorous-intensity aerobic physical activity, or an equivalent combination of moderate- and vigorous-intensity aerobic activity. Aerobic activity should be performed in episodes of at least 10 minutes, preferably spread throughout the week.

• For additional and more extensive health benefits, adults should increase their aerobic physical activity to 300 minutes (5 hours) a week of moderate-intensity, or 150 minutes a week of vigorous-intensity aerobic physical activity, or an equivalent combination of moderate- and vigorous-intensity activity. Additional health benefits are gained by engaging in physical activity beyond this amount.

• Adults should also include muscle-strengthening activities that involve all major muscle groups on 2 or more days a week.

65 years and older • Older adults should follow the adult guidelines. When older adults cannot meet the adult guidelines, they should be as physically active as their abilities and conditions will allow.

• Older adults should do exercises that maintain or improve balance if they are at risk of falling. • Older adults should determine their level of effort for physical activity relative to their level of fitness. • Older adults with chronic conditions should understand whether and how their conditions affect their ability to do regular physical

activity safely.

TABLE 8.1 Physical Activity Guidelines for Americans Recommendations

Adapted from U.S. Department of Health and Human Services, 2008.

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Infants • Estimated gestational age, birth weight, length, head

circumference • Following an established percentile growth curve • Unexplained changes in length, weight, or head

circumference • Poor growth/failure to thrive: falling one or more standard

deviations off growth curve pattern; below fifth percentile for weight and height; infant small for gestational age; quality of parent-infant bond and interaction; psychosocial stressors and food insecurity

• Rapid weight gain: overfeeding • Nutrition: breastfeeding frequency and duration; type

and amount of infant formula; method of formula preparation; time it takes to drink one feeding; intake of protein, calories, vitamins, and minerals adequate for growth; vegetarianism; cow’s milk protein and other food allergies; vitamin and mineral supplements; number of fast food meals eaten per week; eligibility for Women, Infants, and Children (WIC) program or school breakfast and lunch programs

• Hours of screen time per day (i.e., television, computer use, video and electronic games); access to safe areas for physical activity

• Chronic illness: cystic fibrosis, phenylketonuria (PKU), celiac disease, inborn errors of carbohydrate metabolism, amino acid and fatty acid oxidation disorders, tyrosinemia, homocystinuria, Prader-Willi syndrome

• Development: achieving milestones at appropriate ages

• Congenital anomalies, prematurity, prolonged neonatal hospitalization, cleft palate, malformed palate, tongue thrust, feeding and swallowing disorders, prolonged enteral tube feeding (gastrostomy and gastrojejunostomy), gastroesophageal reflux, malabsorption syndrome or chronic diarrhea, formula intolerance, neurologic dis- orders, congenital heart disease, others

Adolescents • Initiation of sexual maturation of girls: early (before 7

years) or delayed (beyond 13 years); signs of breast development and pubic hair, age at menarche

• Initiation of sexual maturation of boys: early (before 9 years) or delayed (beyond 14 years); signs of genital development and pubic hair

• Short stature: not growing as fast as peers, change in shoe and clothing size in past year, extremities short or long for size of trunk, height of parents, size of head disproportionate to body

• Tall stature: height of parents, growing faster than peers, signs of early sexual maturation

• Nutrition: intake of protein, calories, vitamins, and minerals adequate for growth; vegetarianism; number of fast food meals eaten per week; food allergies; vitamin and mineral supplements; herbal supplements; appetite suppressants; laxative use; alcohol use

• Eating disorder: anorexia, bulimia • Alcoholism

Personal and Social History • Nutrition: appetite; usual calorie intake; vegetarianism;

medical nutrition therapy guidelines followed; religious/ cultural food practices; proportion of fat, protein, car- bohydrate in the diet; intake of major vitamins and minerals (e.g., vitamins A, C, and D; iron; calcium; folate)

• Use of vitamin, mineral, and herbal supplements • Usual weight and height; current weight and height;

ability to maintain weight, goal weight • Use of alcohol • Use of recreational drugs • Food insecurity (i.e., limited or uncertain availability of

nutritionally adequate and safe foods); limited/fixed income; eligibility for the Supplemental Nutrition Assistance Program (SNAP; formerly the Food Stamp Program); financial and psychosocial stressors

• Functional assessment (i.e., ability to shop and prepare foods); access to healthy foods in neighborhood; access to food storage/preparation equipment (refrigerator, stove, oven)

• Typical mealtime situations, companions, living environment

• Use of oral supplements, tube feedings, parenteral nutrition

• Dentition: dentures, missing teeth, gum disease

From the Centers for Disease Control and Prevention (www.cdc.gov/obesity/index.html) and the 2015-2020 Dietary Guidelines for Americans.

BOX 8.2 Statistics on Obesity and Diet-Related Chronic Diseases in the United States

In the United States just over one-third of adults older than 20 years are obese and an additional one-third are overweight. Poor diet and physical inactivity (regardless of weight status) are associated with serious chronic diseases including type 2 diabetes, hypertension, cardiovascular disease, osteoporosis, and some types of cancer. • About half of American adults (117 million individuals) have one

or more preventable chronic diseases related to poor diet and physical inactivity.

• More than 29 million U.S. adults (9.3% of the U.S. population) have diabetes. Over 90% of these individuals have type 2 diabetes. An additional 86 million adults have prediabetes.

• Cardiovascular disease (coronary heart disease, stroke, hypertension and high total blood cholesterol) affected 35% of the U.S. population in 2010. About 610,000 Americans die from heart disease each year; 73.5 million adults have high low-density lipoprotein (LDL). About 75 million adults have hypertension and an additional third have prehypertension.

• Cancers linked to poor diet include breast (postmenopausal), endometrial, colon, kidney, gallbladder, and liver.

• The Division of Nutrition, Physical Activity, and Obesity at the Centers for Disease Control and Prevention has a wealth of informa- tion and useful resources patients and health care professionals (www.cdc.gov/nccdphp/dnpao/index.html).

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Determination of Diet Adequacy The history of an individual’s food and beverage intake allows estimation of the adequacy of the diet. Histories may be obtained through 24-hour diet recalls or with a 3- or 4-day food diary that includes 1 weekend day. Various methods for measuring nutrient intake are available.

Twenty–Four-Hour Recall Diet The 24-hour recall is an often-used method for obtaining a food intake history. Ask the patient to list all foods, bever- ages, and snacks eaten during the past 24 hours. Ask specific questions about the method of food preparation, portion sizes, amount of sugar-sweetened beverages, and use of salt or other additives. Some believe the 24-hour recall method provides a limited view of an individual’s actual intake over time and may be misleading. Individuals may be unable to accurately remember everything they ate the day before, causing further inaccuracies in interpreting the information. There are now a variety of web-based 24-hour recall tools, including the Automated Self-Administered 24-Hour (ASA24) Dietary Assessment Tool (https:// epi.grants.cancer.gov/asa24/). Patients report minimal burden and high rates of satisfaction with these types of tools compared with a typical diet history assessment (Arab et al, 2010).

• Preoccupation with weight; overly concerned with developing muscle mass, losing body fat; excessive exercise; weighs self daily, boasts about weight loss, weight goals; omits perceived fattening foods and food groups from diet

• Risk factors for eating disorders • Weight preoccupation • Poor self-esteem, perfectionist personality • Self-image perceptual disturbances • Chronic medical illness (insulin-dependent diabetes) • Family history of eating disorders, obesity, alcoholism,

or affective disorders • Cultural pressure for thinness or outstanding

performance • Athlete driven to excel in sports (gymnasts, ice-skaters,

boxers, and wrestlers) • Food cravings, restrictions • Compulsive/binge eating • Difficulties with communication and conflict resolu-

tion; separation from families • Use of appetite suppressants and/or laxatives

• Chronic disease, such as inflammatory bowel disease, cystic fibrosis, malignancy

• Medications: steroids, growth hormones, anabolic steroids

Pregnant Patients • Prepregnancy weight and BMI, age, dietary intake • Age at menarche • Date of last menstrual period, weight gain pattern,

following established weight gain curve for gestational course

• Eating disorders • Weight gain during pregnancy; nutrient intake during

pregnancy (particularly protein, calories, iron, folate, calcium); supplementation with vitamins, iron, folic acid; eligibility for WIC program

• Pica (cravings for and eating nonnutritive substances such as laundry starch, ice, clay, raw icing)

• Nausea and vomiting • Lactation: nutrient intake during lactation (particularly

protein, calories, calcium, vitamins A and C); fluid intake (water, juice, milk, caffeine)

• Chronic illness: diabetes, renal disease, others

Older Adults • Nutrition: weight gain or loss, adequate income for food

purchases, interest and capability in preparing meals, participant in older adult feeding programs, social interaction at mealtime, number of daily meals and snacks, transportation to grocery stores and access to healthy foods, poorly fitting dentures

• Energy level, regular exercise/activities • Chronic illness: diabetes, renal disease, cancer, depres-

sion, heart disease, difficulty feeding self, chewing, or swallowing, swallowing dysfunction after stroke, difficulty feeding self, chewing, or swallowing;

• Food/nutrient/medication interactions (Box 8.3)

BOX 8.3 Food–Nutrient–Medication Interactions

Medications can affect nutritional intake and status just as some foods, and the nutrients contained in them, can affect absorption, metabolism, and excretion of medications. For example, a consistently high intake of grapefruit juice while taking simvastatin increases the bioavailability of the medication, often resulting in an increased risk of myopathy. It is important to assess the medications that a patient is taking to determine appropriateness and whether there are any possible interactions. The term “medications” includes those prescribed as well as those purchased over the counter. Often patients do not remember to list vitamin, mineral, herbal, and protein supplements during the history unless specifically asked about them.

risk Factors

Possible Medication Effects on Nutritional Intake and Status • Altered food intake resulting from altered taste/smell, gastric irrita-

tion, bezoars (food-ball found in the stomach and/or intestines), appetite increase/decrease, nausea/vomiting

• Modified nutrient absorption resulting from altered gastrointestinal pH, increased/decreased bile acid activity, altered gastrointestinal motility, inhibited enzymes, damaged mucosal cell walls, insoluble nutrient-drug complexes

• Modified nutrient metabolism resulting from vitamin antagonism (e.g., warfarin is a vitamin K antagonist)

• Modified nutrient excretion resulting from urinary loss, fecal loss

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BOX 8.4 Calculating the Body Mass Index

The formula to calculate the BMI using pounds (be sure to convert ounces to a decimal) and inches:

[ [ ] [ ] ]Weight in pounds Height in inches÷ ×2 703

The formula to calculate the BMI using kilograms and centimeters:

Weight in kg Height in meters[ ] [ ]÷ 2

Patient Safety

ChooseMyPlate.gov ChooseMyPlate.gov provides practical information, tips, and web-based tools to help individuals build healthier diets (Fig. 8.4). ChooseMyPlate. gov is based on the most up to date recommendations from the 2015 to 2020 Dietary Guidelines for Americans. The Guidelines, published every 5 years by HHS and the USDA, provide evidence-based information and advice for choosing a healthy eating pattern that focuses on nutrient-dense foods and beverages and helps individuals achieve and maintain a healthy weight. The full guidelines are available at www. cnpp.usda.gov/2015-2020-dietary-guidelines-americans. Individuals can use the ChooseMyPlate.gov website to create a Daily Food Plan based on age, gender, weight, height, and physical activity level. Individuals can track and analyze their diet and physical activity habits and check the nutritional value of specific foods.

ChooseMyPlate.gov emphasizes the following key messages: • Focus on variety, amount, and nutrition. • Choose foods and beverages with less saturated fat, sodium, and

added sugars. • Start with small changes to build healthier eating styles. • Support healthy eating for everyone. • See more at www.choosemyplate.gov/MyPlate

FIG. 8.4 Choose My Plate. (From U.S. Department of Agriculture, ChooseMyPlate.gov.)

Food Diary The food diary can be an accurate but time-consuming method for the patient and health professional. It provides a retrospective view of an individual’s eating habits and dietary intake, recorded as it happened. It can also collect relevant data that may aid in identifying problem areas. The USDA ChooseMyPlate.gov website has a useful web- based tool for tracking daily food and beverage intake by food groups (grains, vegetables, fruits, dairy, and protein foods) and physical activity at www.supertracker.usda.gov. See Box 8.4.

Measures of Nutrient Analysis You may wish to complete a nutrient analysis by using a method of diet history or recall. Nutrition screening forms and web-based tools can be found on the USDA Food and Nutrition Information Center website (https://fnic .nal.usda.gov). The questions can be modified for infants, children, older adults, or particular circumstances. Other web-based nutrient analysis programs and mobile device applications offer the quickest and most efficient method of analyzing an individual’s nutrient intake. Analysis may be performed for 1 or more days to obtain averages for all or selected nutrients.

Vegetarian Diets Vegetarian diets can meet all the recommendations for nutrients. The key is to consume a variety and the right amount of foods to meet an individual’s caloric needs. Five nutrients may be deficient in a vegetarian diet if it is not carefully planned: protein, calcium (lacto-ovo and vegan), iron, vitamin B12 (vegan), and vitamin D. The Office of Dietary Supplements at the National Institutes of Health has a variety of useful educational materials for patients and health care providers about the effectiveness, safety, and quality of dietary supplements (https://ods.od.nih.gov).

Ethnic Food Guide Pyramids Food Guide Pyramids for ethnic populations are available (e.g., Mediterranean, Indian, Mexican, and Asian). To see examples of ethnic and cultural food guide pyramids, go to the USDA Food and Nutrition Information Center (www.nal.usda.gov/fnic/ethniccultural-food-pyramids). In addition, Oldways Preservation Trust (www.oldwayspt.org) is a useful resource.

EXAMINATION AND FINDINGS

Equipment • Standing platform scale with height attachment • Measuring tape with millimeter markings • Infant scale • Recumbent measuring device (for infants) • Stature measuring device (for children) • Calculator

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Waist Circumference and Waist-Height Ratio Waist circumference and waist-height ratio are indicators of visceral fat or abdominal obesity. Waist circumference should be measured at the high point of the iliac crest when the individual is standing and at minimal respiration. Persons of normal weight who have increased waist cir- cumferences often fall into a higher disease risk classifica- tion. A large waist circumference (>35 inches in women, >40 inches in men) is associated with increased risk for type 2 diabetes, dyslipidemia, hypertension, and cardiovas- cular disease. Monitoring changes in a person’s waist circumference over time, with or without changes in BMI, may aid in predicting relative disease risk in terms of cardiovascular risk factors and obesity-related diseases.

Waist-height ratio is calculated as a ratio of the waist circumference (cm) and height (cm). Like waist circumfer- ence, waist-height ratio has been shown to be a strong predictor for diabetes and cardiovascular disease in adults (Ashwell and Gibson, 2016). A waist-height ratio greater than 0.5 is associated with increased risk.

See Centers for Disease Control and Prevention (CDC) Waist Circumference tables at www.cdc.gov/nchs/data/ series/sr_11/sr11_252.pdf.

Waist-to-Hip Circumference Ratio The waist-to-hip circumference ratio is another measure of fat distribution by body type, but it is not as helpful as the BMI in assessing total body fat. An excess proportion of trunk and abdominal fat (i.e., an ovoid or apple-shaped body) has a higher risk association with diabetes, dyslip- idemia, metabolic syndrome, stroke, and ischemic heart disease than does a greater proportion of gluteal fat (i.e., a pear-shaped body). Measure the waist at a midpoint between the costal margin and the iliac crest in millimeters. Then measure the hip at the widest part of the gluteal region (Fig. 8.5). Divide the waist circumference by the hip circumference to obtain the waist-to-hip ratio. Ratios greater than 1.0 in men and greater than 0.85 in women indicate central fat distribution and risk for obesity-related disorders.

Infants The care of children is exciting because of the continuous change that accompanies growth and development. Give careful attention to measuring weight and height and the sequence of developmental achievements as you get to know a child over time.

The newborn with the best chance to be a healthy infant is born at term, is an appropriate size for gestational age, and has no history of prenatal or perinatal difficulty. Most babies born at term to the same parents weigh within 6 ounces of their siblings at birth. Pay close attention to an unexpected birth weight difference. If the baby has a lower birth weight than older siblings, carefully assess for con- genital abnormality or factors that may have contributed

Weight and Standing Height To measure the weight, ask the patient to remove excess clothing and shoes. Have the patient stand in the middle of the scale platform and note the digital reading. If using a balance scale move the largest weight to the last 50-pound or 10-kg increment under the patient’s weight. Adjust the smaller weight to balance the scale. Read the weight to the nearest 0.1 kg or 0.25 pound. Weight variations occur during the day and from day to day with changes in body fluid and intestinal contents. When monitoring a patient’s weight daily or weekly, weigh the patient at the same time each day using the same scale.

To measure height, have the patient stand erect with his or her back to the stature-measuring device. Pull up the height attachment and position the headpiece on the top of the head. Make the reading at the nearest centimeter or 0.5 inch.

Body Mass Index The BMI is the most common method used to assess nutritional status and total body fat. It correlates to body fat measures using underwater body measuring and dual energy x-ray absorptiometry. Although most electronic medical records automatically calculate BMI, Box 8.4 pre- sents the formula. For adult men and women, the following are classifications of weight for height by BMI values (in kg/m2): • Undernutrition—under 18.5 • Appropriate weight for height—18.5 to 24.9 • Overweight—25 to 29.9 • Obesity—30 or greater

Track the change of a patient’s BMI over time to identify nutritional problems and obesity. The prevalence of obesity among adults 20 years of age and older in 2011 to 2014 was 36.3%. The prevalence of obesity varies by age group: 32.3% in adults 20 to 39 years old, 40.2% in adults 40 to 59 years old, and 37.0% in adults 60 years and older. Obesity also varies by race and ethnicity. The rate of obesity is highest among non-Hispanic blacks (48.1%), followed by Hispanics (42.5%) and non-Hispanic whites (34.5%) (Ogden et al, 2015). Severe weight loss and wasting are usually associated with a debilitating disease or self-starvation.

CLINICAL PEArL

Controlling Weight Exercise is a key factor in maintaining body weight or in reducing body weight. Aerobic exercise such as 30 minutes of walking at least 3 times a week is recommended. Look for ways to increase activity, such as using the stairs rather than an elevator or parking farther from the doors to businesses and workplaces. Limit the time children sit and view videos, television, computer screens or play with electronic devices. Encourage children to walk, ride a bicycle, and participate in sports or recreational activities.

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Hold the infant’s legs straight at the knees and place the footboard against the bottom of the infant’s feet. Read the length measurement to the nearest 0.5 cm or 0.25 inch. Plot the infant’s length on the World Health Organization growth curve for age and gender, and identify the infant’s percentile placement (Fig. 8.7). Use the same growth curve to plot future length measurements and to monitor the infant’s growth over time (Fig. 8.8 and Clinical Pearl, “Using the Correct Growth Chart”).

At birth, healthy term newborns have length variations between 45 and 55 cm (18 and 22 inches). Length increases by 50% in the first year of life (see Clinical Pearl, “Reliability of Length Measurements”).

to intrauterine growth restriction. Newborns with a greater birth weight than older siblings, at 10 pounds or greater, are at risk for hypoglycemia. A more rapid weight gain than expected during early infancy (e.g., the infant’s weight percentile keeps increasing rather than following a specific growth curve) is associated with increased cardiovascular disease risk and hypertension as an adult (Howe et al, 2014).

Recumbent Length Measure the length of infants between birth and 24 months of age in supine position on a measuring device (Fig. 8.6). Have the parent hold the infant’s head against the headboard.

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FIG. 8.5 Measurement of waist circumference (A) and hip circumference (B) to calculate the waist-to-hip circumference ratio: waist circumference (cm)/hip circumference (cm) = waist-to-hip ratio.

FIG. 8.6 Measurement of infant length. (From Hockenberry and Wilson, 2017.)

CLINICAL PEArL

Using the Correct Growth Chart Despite the toddler’s ability to stand, continue measuring length until 24 months of age and continue plotting the length on the World Health Organization growth curve. Measurements of length are 0.7 to 0.8 cm greater than height or stature (Grummer-Strawn et al, 2010). Using the child’s height rather than length on the World Health Organization growth curve will give an incorrect impression of poor growth. At 24 months of age, begin measuring the child’s height and plotting the child’s measurements on the Centers for Disease Control growth curves for children ages 2 to 18 years. Most electronic medical record systems have embedded the World Health Organization and Centers for Disease Control growth charts.

CLINICAL PEArL

Reliability of Length Measurements Obtaining a reliable length measurement in newborns is difficult because of the natural flexion of the infant and the molding of the head. In infants, reliability of the length measurement is difficult if the infant resists and moves. Use a consistent technique to increase reliability between examiners, and verify the length with a second measurement.

Weight Use an infant scale, measuring weight in grams for infants and small children. Infants and children are weighed on a scale that measures only in grams and kilograms to reduce medication errors because pediatric dosages are calculated per kilogram of body weight. Use distraction to help keep the infant quiet and still until the digital reading appears or until the scale is balanced. Read the weight to the nearest 10 g when the infant is most still. Plot the infant’s weight on the World Health Organization growth curve for age and gender, comparing the infant’s weight to the population standard (www.cdc.gov/growthcharts). Identify the infant’s percentile placement. As with length, monitor the child’s weight by plotting future measurements on the same growth curve. Beginning at 2 years of age, convert to the CDC growth curve for the child’s gender. Use conversion tables

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FIG. 8.7 Physical growth curves for children ages birth to 24 months: Boys. (From Centers for Disease Control and Prevention, National Center for Health Statistics, 2009.)

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2 to 20 years: Boys Stature Weight-for-age percentiles-for-age and

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y the National Center for Health Statistics in collaboration with the National Center for Chronic Disease Prevention and Health Promotion http://www.cdc.gov/growthcharts

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the head size or chest size. Wrap the measuring tape around the infant’s chest at the nipple line, firmly but not tight enough to cause an indentation of the skin (Fig. 8.11). Read the chest circumference measurement midway between inspiration and expiration to the nearest 0.5 cm or 0.25 inch.

The newborn’s head circumference may equal or exceed the chest circumference by 2 cm (0.75 inch) until 5 months of age. Between the ages of 5 months and 2 years, the infant’s chest circumference and head circumference are close to the same size. If an infant’s head circumference is smaller than the chest circumference, consider evaluating the infant for microcephaly. After 2 years of age, the chest circumference exceeds the head circumference because the chest grows faster than the head.

Gestational Age Gestational age is an indicator of a newborn’s maturity. One method of determining gestational age is to calculate the number of completed weeks between the first day of the mother’s last menstrual period and the date of birth. An estimate of gestational age is used to evaluate an infant’s developmental progress. It is also used to identify preterm newborns of appropriate size and term newborns who are small for gestational age.

The Ballard Gestational Age Assessment Tool evaluates six physical and six neuromuscular newborn characteristics within 36 hours of birth to establish or confirm the new- born’s gestational age (www.medcalc.com/ballard.html). The assessment is accurate within 2 weeks of the assigned gestational age. Scores are more accurate for extremely preterm newborns when the assessment occurs within 12 hours of birth.

The gestational ages of 37 through 41 weeks are consid- ered term and are associated with the best health outcomes. Infants born before 37 weeks of gestation are preterm, and infants born after 41 completed weeks of gestation are postterm. The incidence of premature birth in the United States reached a peak in 2006 when 12.8% of all infants were born at gestational age less than 37 weeks. Since that time, the rate of premature birth has continued to decrease slowly to just below 10% (Hamilton et al, 2015)

CLINICAL PEArL

Uses of Growth Charts Growth charts are designed to plot and track anthropometric data to screen for unusual size and growth patterns and to make an overall clinical assessment. For example, growth charts for children between birth and 24 months of age make it possible to identify excessive weight gain for length. A separate growth curve for very-low-birth weight infants compares the growth of these infants with growth of other low-birth-weight infants, although the World Health Organization growth charts may also be used to evaluate the growth of these infants.

FIG. 8.9 Place the measuring tape around the largest circumference of the infant’s head, across the occiput and the forehead.

available online to give parents the infant’s weight in pounds and ounces (www.medcalc.com/wtmeas.html).

Most term newborns vary in weight between 2500 and 4000 g (5 lb 8 oz to 8 lb 13 oz). After losing up to 10% of their birth weight, newborns regain that weight within 2 weeks, and then gain weight at a rate of approximately 30 g (1 oz) per day. This rate of weight gain decreases starting at about 3 months of age (Fiegelman, 2011). In general, infants double their birth weight by 4 to 5 months of age and triple their birth weight by 12 months of age.

After obtaining the length and weight, plot the infant’s weight for length on the World Health Organization growth curve. This provides information about whether the infant’s weight is proportional to length (see Clinical Pearl, “Uses of Growth Charts”).

Head Circumference Measure the infant’s head circumference at every health visit until 2 to 3 years of age. Wrap a paper measuring tape snugly around the child’s head at the occipital protuberance and the supraorbital prominence to find the point of largest circumference (Fig. 8.9). Make the reading to the nearest 0.5 cm or 0.25 inch. Confirm the accuracy of the head circumference measurement at least once. Plot the measure- ment on the appropriate growth curve, and identify the child’s percentile in comparison with the population standard. Compare measurements over time to monitor the head circumference growth pattern using the World Health Organization growth curve (Fig. 8.10).

Expected head circumferences for term newborns range between 32.5 and 37.5 cm (12.5 to 14.5 inches) with a mean of 33 to 35 cm (13 to 14 inches). At 2 years of age, the child’s head circumference is two-thirds its adult size. If the head circumference increases rapidly and plots in higher per- centile curves, increased intracranial pressure may be present. If the head circumference does not grow as expected and plots in lower percentile curves, microcephaly may be present.

Chest Circumference Although the chest circumference is not used routinely, it is a useful measurement for comparison with the head circumference when a problem is suspected with either

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FIG. 8.10 Head circumference-for-age curves for children ages birth to 24 months: Boys. (From Centers for Disease Control and Prevention, National Center for Health Statistics, 2009.)

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gestational age infants who are full term have an increased risk for respiratory distress, hypoglycemia, and other health problems. In 2014, 8.0% of infants were born at low birth weight (<2500 g, or 5 lb 8 oz). The low-birth-weight rate varies by race and ethnicity. In 2014 the highest percentage of low birth weight occurred in non-Hispanic black infants (12.8%), followed by Asian/Pacific Islander infants (8.1%), American Indian/Alaskan Native infants (7.6%), non- Hispanic white infants (7.0%), and Hispanic infants (7.1%) (Hamilton et al, 2015).

Large for gestational age infants are at higher risk for birth injuries such as shoulder dystocia, as well as health conditions such as respiratory distress syndrome, intraventricular hemorrhage, and bronchopulmonary dysplasia.

Children Stature and Weight Standing height (stature) is obtained beginning at 24 months when the child is walking well. Remove the child’s shoes and heavy clothing. To get the most accurate measurement, use a stature-measuring device (stadiometer) mounted on the wall rather than the height-measurement device on a scale. Have the child stand erect with heels, buttocks, and shoulders against the wall or freestanding stadiometer, looking straight ahead (Fig. 8.13). The outer canthus of the eye should be on the same horizontal plane as the external auditory canal while you position the headpiece at the top of the head. The stature reading is made to the nearest 0.5 cm or 0.25 inch (see Clinical Pearl, “Special Growth Charts”).

Size for Gestational Age. A newborn’s fetal growth pattern and size for gestational age can be determined once ges- tational age is assigned. An intrauterine growth curve is used to plot the newborn’s birth weight, length, and head circumference. The Fenton Growth Chart is recommended for tracking premature growth until 50 weeks postmenstrual age (http://ucalgary.ca/fenton/2013chart). The infant is classified as small, appropriate, or large for gestational age by percentile curve placement for weeks of gestation (Fig. 8.12). The classification system is as follows: • Appropriate for gestational age: 10th to 90th weight

percentile • Small for gestational age: less than 10th weight

percentile • Large for gestational age: greater than 90th weight

percentile Infants who are small or large for gestational age have

an increased risk for morbidity and mortality. Small for

FIG. 8.11 Measurement of infant chest circumference with the measuring tape at the level of the nipple line.

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FIG. 8.12 A, Small for gestational age infant and appropriate for gestational age infant. B, Large for gestational age infant. (From Zitelli et al, 2012.)

FIG. 8.13 Measuring the stature of a child.

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curve on the growth curve. Children adopted from other countries may not fit the U.S. population standard, but they should have a consistent growth pattern (percentile), even if it is near or below the fifth percentile. Infants and children who suddenly fall below or rise above their estab- lished percentile growth curve should be examined more closely to determine the cause.

Upper-to-Lower Segment Ratio The upper-to-lower segment ratio is calculated when a child’s body may have inappropriate proportions between the head and trunk to the lower extremities. Measure the lower body segment (distance from the symphysis pubis to the floor when a child stands). Calculate the upper body segment by subtracting the lower body segment from the total height. Then divide the upper body segment by the lower body segment to calculate the ratio. Expected ratios by age are as follows (Keane, 2011): • At birth—1.7 • At 3 years—1.3 • After 7 years—1.0

A higher upper-to-lower body segment ratio than expected may be associated with dwarfism or bone disorders.

Arm Span The arm-span measurement is not routinely obtained but may be useful when evaluating a child with tall stature. Have the child hold his or her arms fully extended from the sides of the body. Measure the distance from the middle fingertip of one hand to that of the other hand. The arm span should equal the child’s height or stature. Arm span that exceeds height is associated with Marfan syndrome.

Sexual Maturation Assessment of children and adolescents involves evaluation of secondary sexual characteristic development. In girls, breast and pubic hair development is evaluated; in boys, genital and pubic hair development is evaluated. The dura- tion and tempo of each stage vary between individuals. Sexual maturation begins earlier in girls with a higher body mass index. On average, black girls enter puberty first, followed by Mexican American girls and then white girls. Sexual maturation, as measured by the onset of pubic hair development, begins earlier in black boys than white boys (Euling et al, 2008).

When assessing children and adolescents for pubertal development, ask a clinical team member to serve as a chaperone. Have the girl sit while assessing the stage of breast development. Breast tissue may be seen and possibly palpated below a slightly enlarging areola (1 cm in diameter of palpable glandular tissue) (Hermann-Giddens et al, 2011). Most girls start puberty between 9 and 12 years of age with breast enlargement. A girl’s breasts often develop at different rates and appear asymmetric. Pubic hair begins lightly pigmented, sparse, and straight along the labia majora.

Height velocity represents the increase in height during a fixed period of time. It is often assessed when concerns arise about poor linear growth in childhood or adolescence. To calculate height velocity, determine the change in height over a time interval (e.g., 1 year). Shorter time intervals may reflect seasonal variations in growth. Make height measurements as close to 12 months apart as possible, no fewer than 10 months and no more than 14 months. Weigh young children older than 2 years of age on a standing scale in light garments. Read the weight to the nearest 0.1 kg.

Plot the child’s height and weight on the CDC growth curves for gender and age, comparing the child’s growth with the other children the same age.

The BMI is now standardized for use in children and adolescents, and it is calculated the same way as for adults. In children and adolescents the amount of body fat changes with age, and the body fat values differ between males and females. As a result, the BMI is interpreted using age- and gender-specific percentiles. Once the BMI is calculated, plot the value on the appropriate growth chart for gender. Established cutoff points used to identify underweight and overweight children and adolescents are based on the following percentiles: • Underweight—BMI for age under the 5th percentile • At risk of overweight—BMI for age greater than the

85th percentile • Overweight—BMI for age greater than the 95th percentile

A BMI greater than the 95th percentile indicating obesity in children was found in 18.6% of males and 15.0% of females between ages 2 and 19 years in 2009 to 2010 (Ogden et al, 2012). A BMI greater than the 85th percentile, indicat- ing children at risk for overweight, was found in 31.7% of youths. Unfortunately, in the United States, 17% of children and adolescents ages 2 to 19 years are obese, three times the rate as in 1980. Obese children often become obese adults. In 2010, 35.7% of adults in the United States were obese (CDC Division of Nutrition, Physical Activity, and Obesity, 2012). Adolescents between 12 and 19 years of age have an increased rate of obesity. Of non-Hispanic black adolescents, 24.4% are obese, followed by Mexican Ameri- cans (22.2%), all Hispanic adolescents (21.7%), and non- Hispanic whites (15.6%) (Ogden et al, 2012).

Evaluate the child’s growth pattern over time by placing all weight and height measurements on the growth curve. The child is expected to consistently follow a percentile

CLINICAL PEArL

Special Growth Charts Special growth charts exist for children with specific conditions such as Down syndrome and Turner syndrome, but use them in association with the World Health Organization and Centers for Disease Control and Prevention standardized charts. These special growth charts may be obtained online at www.magicfoundation.org/Growth-Charts.

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development or the boy’s stages of pubic hair and genital development.

The onset of puberty in females is the age at which breast stage 2 or public hair stage 2 is reached, whichever occurs first. Most girls have breast development before pubic hair appears. Completion of puberty is when breast stage 4 or public hair stage 5 has been reached. Menarche generally occurs in SMR 4 or breast stage 3 to 4. Even though the mean age at which stage 2 breast development occurs has become younger over time, the average age at menarche has remained fairly constant, between 12 and 13 years (Walvoort, 2010). The peak height velocity usually occurs before menarche. These events may be plotted on the standardized height velocity growth chart for adolescents. Breast development may begin as early as 6 years in black girls and 7 years in white girls. Breast development before

See Figs. 8.14 and 8.15 for expected stages of female sexual maturation.

Ask the boy to stand to assess pubertal development. Most boys start puberty between 10 and 13 years of age with testicular enlargement. Pubic hair development, enlargement of the penis, and the growth spurt follow. See Figs. 8.16 and 8.17 for expected stages of male sexual maturation.

After the secondary sexual characteristics are assessed and staged, a sexual maturity rating (SMR) may be assigned to determine the child’s overall pubertal development. The height growth spurt and timing of other physiologic events occurring during puberty (e.g., menarche or nocturnal emissions) are associated with the stage of secondary sexual characteristic development. An SMR is calculated by averaging the girl’s stages of pubic hair and breast

M1—Tanner 1 (preadolescent). Only the nipple is raised above the level of the breast, as in the child.

M2—Tanner 2. Budding stage; bud-shaped elevation of the areola; areola increased in diameter and surrounding area slightly elevated.

M3—Tanner 3. Breast and areola enlarged. No contour separation.

M4—Tanner 4. Increasing fat deposits. The areola forms a secondary elevation above that of the breast. This secondary mound occurs in approximately half of all girls and in some cases persists in adulthood.

M5—Tanner 5 (adult stage). The areola is (usually) part of general breast contour and is strongly pigmented. Nipple projects.

FIG. 8.14 Five stages of breast development in females. (From Van Wieringen et al, 1971.)

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a different time span. Ultimate height may still be the same. Further evaluation is needed if no evidence of pubertal development is seen in a boy by 14 years of age or a girl by 13 years of age (Kaplowitz et al, 2016).

Early development of sexual hair without signs of sexual maturation may be an indication of premature pubarche. In these children, pubescence usually occurs at the expected time, as with healthy children.

Pregnant Patients Calculate the weight gain during pregnancy from the patient’s prepregnancy weight. To provide guidance in weight gain during pregnancy, first determine the prepregnancy BMI. Then monitor the patient’s weight throughout preg- nancy using the BMI weight gain curve guidelines on the prenatal weight gain chart (Fig. 8.18).

Guidelines for recommended weight gain during preg- nancy are based on the patient’s prepregnancy BMI to improve reproductive outcomes. Patients with a prepreg- nancy BMI of 19.8 to 26.0 should gain 11.5 to 16 kg (25 to

these ages is abnormal and needs further evaluation (Biro et al, 2010).

The stage of genital and pubic hair development in males is related to age and the height spurt. External genital changes usually precede pubic hair development. Ejaculation generally occurs at SMR 3, with semen appearing between SMR 3 and 4. The peak height velocity occurs at a mean age of 13.5 years, usually in SMR 4 or genital development stage 4 to 5. These events may be plotted on the standardized height velocity growth chart for adoles- cents. Development of genitals or pubic hair in prepubertal boys younger than 9 years should be further investigated for cause.

Delayed onset of puberty and secondary sexual charac- teristic development (at an age later than the average) may be a normal variant in both boys and girls. It is usually accompanied by a lag of stature growth. A parent or sibling often may have had a similar adolescent growth pattern. Once pubertal changes begin, the sequence of development is the same as for other adolescents, but it may occur over

P2—Tanner 2. Initial, scarcely pigmented straight hair, especially along medial border of the labia.

P1—Tanner 1 (preadolescent). No growth of pubic hair.

P4—Tanner 4. Hair coarse and curly, abundant but less than adult.

P3—Tanner 3. Sparse, dark, visibly pigmented, curly pubic hair on labia.

P6—Tanner 6. Further extension laterally, upward, or dispersed (occurs in only 10% of women).

P5—Tanner 5. Lateral spreading; type and triangle spread of adult hair to medial surface of thighs.

FIG. 8.15 Six stages of pubic hair development in females. (From Van Wieringen et al, 1971.)

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Note any variation from the expected weight gain. First trimester gain is variable, from 1.4 to 2.7 kg (3 to 6 lb). In the second and third trimesters, weekly weight gain should be approximately 0.23 to 0.45 kg (0.5 to 1 lb) per week. Patients who gain too little weight during pregnancy are at risk for having a low-birth-weight infant. Those who gain too much weight are at risk for having a high-birth- weight infant, which may lead to a difficult delivery (Reinold et al, 2011).

Older Adults Measurement procedures for the older adult are the same as those used for other adults. Calculate the BMI. Identify any problems with underweight that could be associated with a health condition or food insecurity. Of older adults in the United States in 2009 and 2010, 36.6% of men and 42.3% of women were obese (Ogden et al, 2012).

35 lb) over the entire pregnancy. Underweight patients (BMI <19.8) should gain up to 12.2 to 18.2 kg (28 to 40 lb). Overweight patients (BMI 26.1 to 29) should gain 7 to 11.5 kg (15 to 25 lb). Those who are obese (BMI >29) should gain no more than 5 to 9.1 kg (11 to 20 lb) (Institute of Medicine and National Research Council, 2009). Adjust the recom- mended weight gain for patients with a twin or triplet pregnancy.

Obese patients are at increased risk of complications during pregnancy such as gestational hypertension, preeclampsia, gestational diabetes, cesarean delivery, and failure to initiate breastfeeding (Reinold et al, 2011). Pregnant adolescents younger than 16 years, or less than 2 years after menarche, may still be in their growth spurt. They may require higher weight gains during pregnancy to achieve an optimal infant birth weight (Fernandez et al, 2008).

G2—Tanner 2. Enlargement of scrotum and testes. The skin of the scrotum becomes redder, thinner, and wrinkled. Penis no larger or scarcely so.

G1—Tanner 1. Testes, scrotum, and penis are the same size and shape as in the young child.

G4—Tanner 4. Continued enlargement of the penis and sculpturing of the glans; increased pigmentation of scrotum. This stage is sometimes best described as “not quite adult.”

G3—Tanner 3. Enlargement of the penis, especially in length; further enlargement of testes; descent of scrotum.

G5—Tanner 5 (adult stage). Scrotum ample, penis reaching nearly to bottom of scrotum.

FIG. 8.16 Five stages of penis and testes/scrotum development in males. (From Van Wieringen et al, 1971.)

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P2—Tanner 2. Slightly pigmented, longer, straight hair, often still downy; usually at base of penis, sometimes on scrotum. Stage is difficult to photograph.

P1—Tanner 1 (preadolescent). No growth of pubic hair; that is, hair in pubic area no different from that on the rest of the abdomen.

P4—Tanner 4. Pubic hair definitely adult in type but not in extent (no further than inguinal fold).

P3—Tanner 3. Dark, definitely pigmented, curly pubic hair around base of penis. Stage 3 can be photographed.

P6—Hair spread along linea alba (occurs in 80% of men).

P5—Tanner 5 (adult distribution). Hair spread to medial surface of thighs, but not upward.

FIG. 8.17 Six stages of pubic hair development in males. (From Van Wieringen et al, 1971.)

0 �10

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2 4 6 8 10121416182022 Weeks of pregnancy

2426283032343638404244

Name

Date of birth

Due date

Height

Prepregnant weight

Prepregnancy BMI 19.8-26.0

Prepregnancy BMI �26.0

Prepregnancy BMI �19.8

FIG. 8.18 Prenatal weight gain curve by weeks of gestation. (From Food and Nutrition Board, Washington, DC, 2003.)

SAMPLE DOCuMENTATION

History and Physical Examination

Subjective A 4-month-old, former full-term female infant in for well-baby visit. Exclusively breast-fed, no other foods introduced. Feeds eagerly every 2 to 3 hours. Good urine and stool output. No illnesses.

Objective Weight 6.2 kg (13.5 lb) is 25th to 50th percentile; length 62 cm (24.5 inches) is at 50th percentile; head circumference 40.5 cm (16 inches) is at 50th percentile; weight for length ratio is at 50th percentile; following the same growth curves since the visit 2 months ago.

For additional sample documentation, see Chapter 5.

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ABNOrMALITIES

GrOwTH Acromegaly A rare disease of excessive growth and distorted proportions caused by hypersecretion of growth hormone and insulin-like growth factor after closure of the epiphyses

PATHOPHYSIOLOGY PATIENT DATA • A benign pituitary adenoma or other rare tumor is the most common

cause; familial syndromes (e.g., multiple endocrine neoplasia type 1 and McCune-Albright syndrome).

• Growth hormone excess leads to slow skeletal growth and soft tissue enlargement.

• Most common in middle-aged adults

Subjective Data • Slow progressive changes in facial feature exaggeration • Increased shoe size, ring size • No change in height • Oily and sweaty skin • Excessive snoring, sleep apnea • Decreased exercise tolerance • Pain in joints and hands • See Fig. 8.19

Objective Data • Face and skull—frontal skull bossing, cranial ridges, mandibular

overgrowth, maxillary widening, teeth separation, malocclusion, overbite • Skin thickening on the face (tongue, lips and nose), hands and feet

leading to enlargement • Joint enlargement, swelling, pain; vertebral enlargement,

kyphoscoliosis • Cardiac ventricular enlargement bilaterally with decreased exercise

tolerance

FIG. 8.19 Acromegaly. Note the large head, forward projection of jaw, protrusion of frontal bone, and the large hands. (From Liu et al, 2010.)

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Cushing Syndrome A disorder associated with a prolonged and excessively high exposure to glucocorticoids

PATHOPHYSIOLOGY PATIENT DATA • Most commonly caused by the use of medically prescribed

corticosteroids. • Other causes include adrenal gland oversecretion leading to excessive

production of cortisol or a pituitary tumor leading to excessive secretion of adrenocorticotropic hormone (ACTH).

• Leads to conditions caused by the excess cortisol such as diabetes, hypertension, depression, and menstrual irregularities.

Subjective Data • Weight gain, changes in appetite • Depression, irritability, decreased libido • Decreased concentration, impaired short-term memory • Easy bruising • Menstrual abnormalities • Weight gain but slow height velocity in children • See Fig. 11.8

Objective Data • Obesity, “buffalo hump” fat pad, supraclavicular and pendulous abdominal

fat distribution • Facial plethora or moon facies • Thin skin, reddish purple striae, poor skin healing • Proximal muscle weakness • Hirsutism or female balding • Peripheral edema • In children—short stature, abnormal genital virilization, delayed puberty,

or pseudoprecocious puberty

Turner Syndrome A genetic disorder in which there is partial or complete absence of a second X chromosome

PATHOPHYSIOLOGY PATIENT DATA • Phenotype results from a reduced complement of genes that are typically

expressed from both X chromosomes in females. • Turner syndrome incidence is 1 per 2500–3000 live births.

Subjective Data • Poor height growth • Lack of breast development and amenorrhea • Normal intelligence

Objective Data • Short stature • Webbed neck • Broad chest with widely spaced nipples • Wide carrying angle of elbow (cubitus valgus) • Low posterior hairline, misshapen or rotated ears, narrow palate with

crowded teeth • Coarctation of aorta, bicuspid aortic valve • Sensorineural hearing loss • Infertility • May be diagnosed prenatally by amniocentesis or chorionic villous

sampling • Karyotype or chromosome analysis to confirm diagnosis • See Fig. 8.20

FIG. 8.20 Turner syndrome. (From Patton, 2016.)

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Hydrocephalus An excess volume of cerebrospinal fluid (CSF) in the brain leading to an enlarged head circumference or increased intracranial pressure

PATHOPHYSIOLOGY PATIENT DATA • May be caused by an infection or obstruction in the subarachnoid

space that interferes with the reabsorption of CSF, or from an infection or injury that obstructs the flow of CSF to the subarachnoid space where it can be reabsorbed.

• Often occurs in association with meningomyelocele.

Subjective Data • Enlarged head • Difficulty holding head up or inability to lift head off bed • Irritable, lack of energy, poor feeding • After sutures close: severe headache, diplopia or other vision problems,

vomiting not associated with an illness

Objective Data • Rapidly increasing head circumference • Tense, full, or bulging fontanel; split sutures • Bossing (protrusion) of frontal area, face disproportionate to the skull

size • Prominent, distended scalp veins, translucent scalp skin • Increased tone or hyperreflexia, brisk deep tendon reflexes, positive

Babinski sign • Once skull sutures are closed, increased intracranial pressure,

papilledema • Paralysis of upward gaze (6th cranial nerve palsy) • See Fig. 8.21

FIG. 8.22 Psychosocial failure to thrive as the result of neglect. This 4-month-old infant was brought to the emergency department because of congestion. She was found to be below weight expectations and suffering from severe developmental delay. Note the marked loss of subcutaneous tissue manifested by the wrinkled skinfolds over the buttocks, shoulders, and upper arms. (From Zitelli et al, 2018.)

FIG. 8.21 Infantile hydrocephalus. Paralysis of the upward gaze is seen in an infant with hydrocephalus resulting from aqueductal stenosis. It appears more apparent on the right. This phenomenon is often termed the sunsetting sign. (Courtesy Dr. Albert Biglan, Children’s Hospital of Pittsburgh.)

Failure to Thrive Growth in an infant or child below the third to fifth percentiles on a growth chart, or a slower than expected rate of growth or crossing down two percentile lines in a short period of time (e.g., from the 50th percentile to below the 10th percentile on the growth chart)

PATHOPHYSIOLOGY PATIENT DATA • Psychosocial causes include poverty and inadequate food, errors in

food preparation, or a poor parent–child interaction (e.g., maternal depression, child abuse or neglect, or family dysfunction).

• Organic causes include an underlying medical condition such as major infection or organ system disease.

• May result from a combination of organic disease and psychosocial stressors.

Subjective Data • Insufficient food for infant or child, poor dietary intake • Breast-feeding failure, tires or sweats when feeding, refuses food • Smaller than infants or children of same age

Objective Data • Does not meet expected weight and length (height) norms for age • Reduced muscle mass, loss of subcutaneous fat, wasted buttocks,

thin extremities, prominent ribs, alopecia • May show signs of neglect (diaper rash, unwashed skin, skin infections,

unwashed clothing) • Developmental delay • See Fig. 8.22

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Growth Hormone Deficiency Failure of the anterior pituitary to secrete adequate growth hormone to support growth in stature

PATHOPHYSIOLOGY PATIENT DATA • May be congenital or develop from a pituitary tumor, radiation therapy

for a tumor, or brain trauma. Subjective Data • Normal birth weight and growth during the first year • Smaller than child of same age

Objective Data • Short stature; growth begins leveling off at 9–12 months • Body proportions of younger age child, cherubic or elfin appearance,

child appears younger than chronologic age • Excess subcutaneous fat • High-pitched voice • See Fig. 8.23

FIG. 8.23 The normal 3-year-old boy is in the 50th percentile for height. The short 3-year-old girl exhibits the characteristic “Kewpie doll” appearance, suggesting a diagnosis of growth hormone deficiency. (From Zitelli et al, 2012.)

Precocious Puberty The onset of secondary sexual characteristics before 7 years of age in white girls, 6 years in black girls, and 9 years of age in males with progressive sexual maturation (Kaplowitz et al, 2016; Lobo, 2012)

PATHOPHYSIOLOGY PATIENT DATA • A brain tumor or lesion (e.g., hypothalamic hamartoma) may activate

the hypothalamic-pituitary-gonadal axis with gonadotropins triggering the growth of the gonads, secretion of the sex hormones, and progressive sexual maturation.

• May also be related to McCune-Albright syndrome.

Subjective Data • Development of breast tissue or pubic hair at earlier age than expected

in girls • Enlargement of testes, then the penis, and appearance of pubic hair

at an earlier age than expected in boys

Objective Data • In young girls—breast development, pubic hair, maturation of external

genitalia, axillary hair development, and onset of menses • In boys—progressive signs of sexual maturation with testicular and

penis enlargement, pubic hair, acne, erections, and nocturnal emissions

• Accelerated height growth at an early age • Sex hormone concentrations are appropriate for stage of puberty • See Fig. 8.24

FIG. 8.24 Precocious puberty with pubic hair development in a young girl. (From Zitelli et al, 2012.)

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NuTrITION Obesity Excessive proportion of total body fat

PATHOPHYSIOLOGY PATIENT DATA • Genetic, behavioral, and environmental factors contribute to the

development of obesity. • Excess body fat develops as a result of energy imbalance of caloric

intake and energy expenditure (physical activity). • Disproportionately affects some racial groups (e.g., blacks) and those

of low socioeconomic status. • Body fat, especially visceral fat, increases the risk for numerous health

problems including type 2 diabetes, cardiovascular disease, dyslipidemia, and cancer.

• Medications (e.g., steroids) and certain disease processes (e.g., Cushing disease and polycystic ovarian syndrome) may cause weight gain and contribute to obesity.

Subjective Data • Weight gain; increase in daily caloric intake and high-fat foods • Decrease in physical activity • Medications • Recent life change or stressors • Obesity-related symptoms or conditions include snoring and sleep

apnea, shortness of breath, headaches, musculoskeletal symptoms, depression, irregular menses, polyuria, and polydipsia

Objective Data • Excess fat tissue generally located in breasts, buttocks, and thighs • May have acanthosis nigricans (see Fig. 9.57) and pale striae • Physical examination findings of obesity-related conditions can be

found in Table 8.2. • Characteristic features of genetic disorders should be assessed (e.g.,

Prader-Willi syndrome) • Adult classification of BMI: overweight 25–29.9; obesity ≥30 • Children and adolescents 2–18 years old: obesity is a BMI ≥95th

percentile for age and gender or BMI >30; overweight is a BMI ≥85th percentile but <95th percentile for age and gender or BMI 25–29.9 (Fig. 8.25)

FIG. 8.25 Childhood obesity has become a major public health problem in the United States. (From Hockenberry and Wilson, 2017.)

Anorexia Nervosa Eating disorder classified by the Diagnostic and Statistical Manual of Mental Disorders (fifth edition; DSM-V) as a psychiatric disease, characterized by low body weight and body image distortion

PATHOPHYSIOLOGY PATIENT DATA • Cause is unknown, but genetic, environmental, and sociocultural factors

likely to contribute to development of anorexia. • Adolescent and young adult women, usually from middle- and upper-

class families, are most commonly affected; also occurs in adolescent boys and men.

• Two types: restricting (food intake is voluntarily limited) and purging (patients engage in purging after eating).

Subjective Data • May report preoccupation with weight, excessive exercise and unusual

eating habits including voluntary starvation, purging, vomiting, and weight control measures such as diet pills, use of laxatives, and diuretics

• May report being overweight as a child and unhappiness with current weight as well as poor body image

• Symptoms may include fatigue, dizziness, low energy, amenorrhea, weight loss or gain, constipation, bloating, abdominal discomfort, heartburn, intolerance to cold, palpitations, depression or irritability, decreased libido, and interrupted sleep

Objective Data • Physical examination findings may include dry skin, lanugo hair, brittle

nails, bradycardia, hypothermia, orthostatic hypotension, and loss of muscle mass and subcutaneous fat

• May have hypoglycemia, elevated liver enzymes, and thyroid hormone abnormalities

• DSM-V criteria for diagnosis includes refusal to maintain body weight at or above a minimally normal weight for age and height (failure to maintain weight at 85% of ideal body weight); intense fear of gaining weight; disturbance in self-perception of body weight; and amenorrhea in females

• BMI ≤17.5 also characteristic

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SYSTEM FINDINGS POSSIBLE EXPLANATIONS

Anthropometric features

High BMI percentile Overweight or obesity

Short stature Underlying endocrine or genetic condition

Vital signs Elevated blood pressure Hypertension if systolic blood pressure ≥140 or diastolic blood pressure ≥90 on ≥3 occasions; for children and adolescents systolic or diastolic blood pressure ≥95th percentile for age, gender, and height percentile on ≥3 occasions

Skin Acanthosis nigricans Common in obese children, especially when skin is dark; increased risk of insulin resistance

Excessive acne, hirsutism Polycystic ovary syndrome Irritation, inflammation Consequence of severe obesity Violaceous striae Cushing syndrome

Eyes Papilledema, cranial nerve VI paralysis Pseudotumor cerebri

Throat Tonsillar hypertrophy Obstructive sleep apnea

Neck Goiter Hypothyroidism

Chest Wheezing Asthma (may explain or contribute to exercise intolerance)

Abdomen Tenderness Gastroesophageal reflux disorder, gallbladder disease, nonalcoholic fatty liver disease (NAFLD)

Hepatomegaly NAFLD

Reproductive system Tanner stage Premature puberty in <7-yr-old white girls, <6-yr-old black girls, and <9-yr-old boys Apparent micropenis May be normal penis that is buried in fat Undescended testes Prader-Willi syndrome

Extremities Abnormal gait, limited hip range of motion Slipped capital femoral epiphysis Bowing of tibia Blount disease Small hands and feet, polydactyly Some genetic syndromes

TABLE 8.2 Physical Examination Findings in Obesity Assessment and Possible Causes

From Barlow SE, 2007.

Bulimia Nervosa Eating disorder classified by the DSM-V as psychiatric disease

PATHOPHYSIOLOGY PATIENT DATA • Cause unknown, but genetic, environmental, and sociocultural factors

likely contribute to the development of bulimia • Adolescent and young adult women most commonly affected • Two types are purging and nonpurging type episodes followed by

fasting or excessive exercising

Subjective Data • Binge-eating episodes on average 2 times a week, usually high-calorie

or high-carbohydrate foods in purging type; followed by purging behaviors (e.g., vomiting, laxatives, diuretics)

• Bloating, fullness, lethargy, abdominal pain, heartburn, and sore throat

Objective Data • Body weight can be normal, underweight, or overweight • Knuckle calluses, dental enamel erosion, salivary gland enlargement • Metabolic alkalosis from vomiting, hypokalemia from laxative or diuretic

use, and elevated salivary amylase • DSM-V criteria for diagnosis includes recurrent binge-eating episodes

over a discrete period of time and lack of control over eating; recurrent compensatory behaviors to prevent weight gain (e.g., self-induced vomiting); behaviors occur on average twice per week for 3 months

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Skin, Hair, and Nails

CHAPTER

9  The anatomy of the skin does vary from one part of the body to another.

Skin structure and physiologic processes perform the following integral functions: • Protect against microbial and foreign substance invasion

and minor physical trauma • Restrict body fluid loss by providing a restrictive barrier • Regulate body temperature • Provide sensory perception via free nerve endings and

specialized receptors • Produce vitamin D from precursors in the skin • Contribute to blood pressure regulation through constric-

tion of skin blood vessels • Repair surface wounds by exaggerating the normal

process of cell replacement

Physical Examination Components

Skin, Hair, and Nails Skin 1. Systematically inspect the entire skin surface. During evaluation of

each organ system, evaluate the overlying skin for: • Color • Uniformity • Thickness • Symmetry • Hygiene • Lesions • Odors

2. Palpate skin surfaces for: • Moisture • Temperature • Texture • Turgor (fullness or tension produced by the fluid content of the

cells and tissue) • Elasticity

Hair 1. Inspect hair for:

• Color • Distribution • Density

2. Palpate hair for texture and fragility

Nails 1. Inspect for:

• Pigmentation of nail plates and nail beds • Length • Symmetry • Surface changes (ridging, beading, pitting, peeling)

2. Inspect and palpate proximal and lateral nail folds for: • Redness • Swelling • Pain • Exudate • Growths (warts, cysts, tumors) • Shape of lunulae

3. Palpate nail plate for: • Texture • Firmness • Thickness • Uniformity • Adherence to nail bed

4. Measure nail base angle 5. Observe the cuticles for:

• Color • Vasculature • Integrity

Skin provides an elastic, self-regenerating, protective covering for the body. The skin and its appendages are the primary means by which we are viewed in the world and physical appearances are often important to the well- being of patients. Examination of the skin, hair, and nails is performed as part of both the comprehensive and focused physical examination. The skin, hair, and nails can provide external visible clues to systemic disease that may not otherwise be apparent.

ANATOMY AND PHYSIOLOGY

The skin is a stratified organ composed of several function- ally related layers. Fig. 9.1 shows the main structural components and their approximate spatial relationships.

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dermis form a complex network to provide sensations of pain, touch, and temperature. The dermis also contains autonomic motor nerves that innervate blood vessels, glands, and the arrector pili muscles.

Hypodermis The dermis is connected to underlying tissue by the hypodermis, a subcutaneous layer that consists of loose connective tissue filled with adipose. This adipose layer generates heat and provides insulation, shock absorption, and a reserve of calories.

Appendages Cutaneous appendages are outgrowths of the skin and include eccrine sweat glands, apocrine sweat glands, sebaceous glands, hair, and nails.

The eccrine sweat glands open directly onto the surface of the skin and help regulate body temperature through sweat secretion. These glands are distributed throughout the body except at the lip margins, eardrums, nail beds, inner surface of the prepuce, and glans penis.

The apocrine glands are specialized structures found only in the axillae, nipples, areolae, anogenital area, eyelids, and external ears. Apocrine glands secrete an oily fluid containing protein, carbohydrate, and other substances. Secretions from these glands are odorless; body odor is produced by bacterial decomposition of apocrine sweat.

The sebaceous glands secrete sebum, a lipid-rich sub- stance that acts as a lubricant and moisturizer for skin and hair. Secretory activity, which is stimulated by sex hormones (primarily testosterone), varies according to hormonal levels throughout life.

• Excrete sweat, urea, and lactic acid • Express emotions

Epidermis The epidermis is the outermost portion of the skin and is composed of several cellular layers. The topmost layer is the stratum corneum (cornified layer), which is composed of closely packed, dead, keratin-filled squamous cells, which is the chief mechanical barrier protecting the body against environmental exposures, pathogens, and restricting water loss. The keratins that are contained in the stratum corneum are synthesized in the lower layers of the skin, beginning at the basal layer, which also contains the stem cells, which allow for the regenerative properties of the skin. As keratinocytes mature, they pass from the basal layer through the granular and spinous layers to the cornified layer, a process that takes 28 days.

The thick skin of the palms and soles contains an additional layer compared with other parts of the body called the stratum lucidum, which lies just below the stratum corneum. Mucosal skin on the other hand, lacks a stratum corneum, allowing for diffusion through the skin surface. The stratum basale also contains melanocytes, the cells that synthesize melanin, which gives the skin its color.

Dermis The dermis is the richly vascular connective tissue layer of the skin that supports and separates the epidermis from adipose tissue. Interdigitating papillae secure the epidermis to the dermis and provide nourishment for the epidermal cells. Elastin, collagen, and reticular fibers provide resilience, strength, and stability. Sensory nerve fibers located in the

Arrector pili muscle

Hair shaft

Sebaceous gland

Pore of sweat gland

Stratum corneum

Stratum lucidum E

piderm isStratum granulosum

Stratum germinativum

Papillary layer

Reticular layer

Elastic fibers

Artery

Vein Sweat gland

Cuticle

Huxley layer

Henley layer

External sheath

H ai

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Glassy membrane

Hair matrix

Papilla of hair follicle

Connective tissue layer

D erm

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FIG. 9.1 Anatomic structures of the skin.

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Lunula

Nail root

CuticlePosterior nail fold

Nail plate

Nail bed Eponychium

Eponychium

Body of nail Nail matrix

Eponychium

Paronychium

Nail plate FIG. 9.2 Anatomic structures of the nail. (Modified from Thompson et al, 2002.)

days. Some newborns are bald, whereas others have a large amount of head hair. Most of the hair is shed by about 2 to 3 months of age, to be replaced by more permanent hair with a new texture and often a different color.

The eccrine sweat glands begin to function after the first month of life, whereas apocrine function does not begin until puberty, thus children lack offensive perspiration.

Adolescents During adolescence, the apocrine glands enlarge and become active, causing increased axillary sweating and sometimes body odor. Sebaceous glands increase sebum production in response to increased hormone levels, primarily androgen, giving the skin an oily appearance and predisposing the individual to acne.

Coarse terminal hair appears in the axillae and pubic areas of both female and male adolescents and on the face of males. Hair production is one response to changing androgen levels. Refer to Chapter 8 for a more thorough discussion of maturational changes during adolescence.

Pregnant Patients Increased blood flow to the skin, especially to the hands and feet, results from peripheral vasodilation and increased numbers of capillaries. Acceleration of sweat and sebaceous gland activity occurs. Both processes assist in dissipating the excess heat caused by increased metabolism during pregnancy. Spider angiomas and cherry hemangiomas that are present may increase in size.

The skin thickens, and fat is deposited in the subdermal layers. Because of increased fragility of connective tissues, separation may occur with stretching. Most pregnant patients have some degree of increased pigmentation that is seen on the face, nipples, areolae, axillae, vulva, perianal skin, and umbilicus. During pregnancy, nevi may grow, change color, and new nevi may appear.

Older Adults Sebaceous and sweat gland activity decreases in older adults, and as a result, the skin becomes drier with less perspiration

A hair consists of a root and a shaft, which sit in a follicle. At the base of the follicle the papilla contains a loop of capillaries supplying nourishment for growth. Melanocytes in the follicle synthesize pigment giving hair its color. Adults have both vellus and terminal hair. Vellus hair is short, fine, soft, and nonpigmented. Terminal hair is coarser, longer, thicker, and usually pigmented. Each hair goes through cyclic changes: anagen (growth), catagen (atrophy), and telogen (rest), after which the hair is shed (exogen). Males and females have about the same number of hair follicles with differential stimulation by hormones. The shape of the hair follicle directly relates to the shape of the hair itself (straight versus curly). This shape does vary by race and ethnicity.

The nails are appendages of the skin, which are composed of epidermal cells converted to hard plates of keratin. They protect the fingertips and are important in dexterity. The nail plate sits on the highly vascular nail bed which lies on periosteum. The white crescent-shaped area extending beyond the proximal nail fold marks the end of the nail matrix, the site of nail growth. The layer of skin covering the nail root is the cuticle, or eponychium, which pushes up and over the lower part of the nail body. The paro- nychium is the soft tissue surrounding the nail border (Fig. 9.2).

Infants and Children The skin of infants and children is smoother than that of adults, due to the absence of coarse terminal hair and less exposure to the elements, particularly the sun. Desquama- tion of the stratum corneum may be present at birth or very shortly after. It may vary from mild flakiness to course shedding of large sheets of skin. Postterm infants often have cracked, peeling skin. Vernix caseosa, a mixture of sebum and cornified epidermis, covers the infant’s body at birth. The subcutaneous fat layer is poorly developed in newborns, predisposing them to hypothermia. The new- born’s body, particularly the shoulders and back, can be covered with fine, silky hair called lanugo. More commonly seen in preterm infants, this hair is shed within 10 to 14

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From Centers for Disease Control and Prevention, 2013.

BOX 9.1 Skin Type

People burn or tan depending on their skin type, the time of year, and how long they are exposed to UV rays. The six types of skin, based on how likely it is to tan or burn, are as follows: I: Always burns, never tans, sensitive to UV exposure II: Burns easily, tans minimally III: Burns moderately, tans gradually to light brown IV: Burns minimally, always tans well to moderately brown V: Rarely burns, tans profusely to dark VI: Never burns, deeply pigmented, least sensitive

Although everyone’s skin can be damaged by UV exposure, people with skin types I and II are at the highest risk.

Risk Factors

Melanoma • Exposure to sunlight or ultraviolet radiation (UVA and UVB)

including • Severe blistering sunburns, even as a child • Indoor tanning device usage • Geographic exposure (people who live in areas that get large

amounts of UV radiation from the sun, e.g., higher altitude) • Previous personal history of melanoma • Family history of melanoma (first-degree relative) • Moles • Dysplastic or atypical nevi • Large congenital nevus (>15 cm) • Immune suppression • Skin type, relative inability to tan (Skin types, Box 9.1)

You can use the National Cancer Institute’s Melanoma Risk Assess- ment Tool to estimate a person’s absolute risk of developing invasive melanoma at: https://www.cancer.gov/melanomarisktool

produced. With aging and increased sun exposure, the epidermis thins and becomes more fragile, with decreased resistance to trauma. Epidermal permeability is increased, reducing the efficiency of the barrier function of the stratum corneum causing skin to become dry.

Aging and sun exposure also contribute to decreasing elasticity and collagen loss in the dermis. The dermis shrinks, causing the epidermis to fold and become wrinkled. This effect is increased in whites, who have an earlier onset and greater skin wrinkling and sagging signs than darker races (Rawlings, 2006).

Subcutaneous tissues also decrease, particularly in the extremities, giving joints and bony prominences a sharp, angular appearance. The hollows in the thoracic, axillary, and supraclavicular regions deepen.

Gray hair results from a decrease in the number of functioning melanocytes. Similarly, nevi also regress and disappear. Axillary and pubic hair production declines because of a reduction in hormones. The density and rate of scalp hair growth (anagen phase) decline with age. The size of hair follicles also changes, and terminal scalp hair progressively transitions into vellus hair, causing age- associated baldness in both men and women. The opposite transition, from vellus to terminal, occurs in the hair of the nares and on the tragus of men’s ears. Women produce increased coarse facial hair because of higher androgen- estrogen ratios. Both genders experience overall loss of hair from the trunk and extremities. Peripheral extremity hair loss may also occur when peripheral vascular disease is present.

Nail growth slows and nails become more brittle because of decreased peripheral circulation. The nails, particularly the toenails, become thick, brittle, hard, and yellowish. They develop longitudinal ridges and are prone to splitting into layers.

REvIEw OF RELATED HISTORY

For each of the symptoms or conditions discussed in this section, targeted topics to include in the history of the present illness are listed. Responses to questions about these topics provide clues for focusing the physical examina- tion and developing an appropriate diagnostic evaluation. Questions regarding medication use (prescription and over the counter preparations) as well as complementary and alternative therapies are relevant for each.

History of Present Illness Skin • Changes in skin: dryness, pruritus, sores, rashes, lumps,

color, texture, odor, amount of perspiration; changes in wart or mole; lesion that does not heal or is chronically irritated (see Risk Factors boxes)

• Temporal sequence: date of initial onset; time sequence of occurrence and development; sudden or gradual onset; date of recurrence, if any

• Symptoms: itching, pain, exudate, bleeding, color changes, seasonal or climate variations

• Location: skinfolds, extensor or flexor surfaces, localized or generalized, sun exposed or protected, mucosal involvement

• Associated symptoms: presence of systemic disease or fever, relationship to stress or leisure activities

• Recent exposure to environmental or occupational toxins or chemicals, new skin or personal care products, new household cleaning products (aerosols)

• Recent exposure to persons with similar skin condition

• Apparent cause of problem, patient’s perception of cause • Travel history: where, when, length of stay, exposure to

diseases, contact with travelers • What the patient has been doing for the problem,

response to treatment, what makes the condition worse or better

• How the patient is adjusting to the problem • Medications: antibiotics, any new medications, topical

preparations to treat—steroids, antifungals

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Past Medical History Skin • Previous skin problems: sensitivities, allergic skin reac-

tions, skin disorders (e.g., atopic dermatitis), congenital or acquired lesions, treatment

• Tolerance to sunlight (Box 9.1) • Diminished or heightened sensitivity to touch • Cardiac, respiratory, liver, endocrine, or other systemic

diseases • Hair • Previous hair problems: loss, thinning, unusual growth

or distribution, brittleness, breakage, treatment • Systemic problems: thyroid disorder, rheumatologic

disease, any severe illness, malnutrition, associated skin disorder

Nails • Previous nail problems: injury; bacterial, fungal, or viral

infection • Systemic problems: associated skin disorder; congenital

anomalies; respiratory, cardiac, endocrine, hematologic, or other systemic disease

Family History • Current or past dermatologic diseases or disorders in

family members; melanoma; dermatoses (e.g., psoriasis); infestations; bacterial, fungal, or viral infections

• Allergic hereditary diseases such as asthma or allergic rhinitis

• Familial hair loss or pigmentation patterns

Personal and Social History • Skin care habits: cleansing routine; soaps, oils, emollients,

or local applications used; cosmetics; home remedies or preparations used; sun exposure patterns and history; sunburn history; use of sunscreen agents; recent changes in skin care habits (see Patient Safety, “Sunscreen”)

• Skin self-examination (Box 9.2) • Hair care habits: cleansing routine, shampoos and oils

and moisturizers, coloring preparations used, perma- nents, applied heat, hair straightening, extensions, recent changes in hair care habits. Note that hair care practices can vary by race and hair type.

• Nail care habits: any difficulty in clipping or trimming nails, instruments used; biting nails; use of artificial nail overlays

• Exposure to environmental or occupational hazards: dyes, chemicals, plants, toxic substances, frequent immersion of hands in water, frequent sun exposure

• Recent psychological or physiologic stress • Use of alcohol, tobacco • Sexual history: sexually transmitted infections (syphilis,

gonorrhea, human immunodeficiency virus [HIV]) • Use of recreational drugs

Hair • Changes in hair: loss or growth, distribution, texture,

color • Occurrence: sudden or gradual onset, symmetric or

asymmetric pattern, recurrence • Associated symptoms: pain, itching, lesions, presence

of systemic disease or high fever, recent stress, hair- pulling, infection

• Exposure to drugs, environmental or occupational toxins or chemicals, commercial hair care chemicals

• Nutrition: dietary changes, dieting • What the patient has been doing for the problem,

response to treatment, what makes the problem worse or better

• How the patient is adjusting to the problem • Medications: drugs or preparations for hair loss

(minoxidil, finasteride, dihydrotestosterone [DHT] inhibitors)

Nails • Changes in nails: splitting, breaking, discoloration,

ridging, thickening, markings, separation from nail bed

• Recent history: systemic illness, high fever, trauma, stress, biting

• Associated symptoms: pain, swelling, exudate • Temporal sequence: sudden or gradual onset, relationship

to injury of nail or finger • Recent exposure to drugs, environmental or occu-

pational toxins or chemicals; frequent immersion in water

• What the patient has been doing for the problem, response to treatment, what makes the problem worse or better

• Medications: chemotherapy (taxanes, anthracyclines), psoralens, retinoids, tetracyclines, antimalarials

Risk Factors

Basal and Squamous Cell Cancer • Age (older than 50 years) • Exposure to sunlight or ultraviolet radiation (UVA and UVB)

• Indoor tanning device usage • Blistering sunburns • Chronic and cumulative exposure—squamous cell carcinoma • Intermittent exposure—basal cell carcinoma • Geographic location: near equator or at high altitudes

• Skin type, relative inability to tan (see Skin Type, Box 9.1) • Exposure to arsenic, creosote, coal tar, and/or petroleum

products • Overexposure to radium, radioisotopes, or x-rays • Repeated trauma or irritation to skin • Precancerous dermatoses • Large scars

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• Teach children good sun protection habits at an early age: the damage that leads to adult skin cancers starts in childhood.

Infants • Feeding history: breast or formula, type of formula, what

foods introduced and when (see Clinical Pearl, “Carotenemia”)

• Diaper history: type of diapers used, skin cleansing routines, and methods of cleaning

• Types of clothing and washing practices: soaps and detergents used, new blanket or clothing

• Bathing practices: frequency, types of soap, oils, shampoos or emollients used

• Dress habits: amount and type of clothing in relation to environmental temperature

• Temperature and humidity of the home environ- ment: air conditioning, heating system (drying or humidified)

Other recommendations include: • Do not sunbathe. • Avoid unnecessary sun exposure, especially between

10:00 am and 4:00 pm, the peak hours for harmful ultraviolet (UV) radiation.

• When exposed to sunlight, wear protective clothing such as long pants, long-sleeved shirts, broad-brimmed hats, and UV-protective sunglasses. Look for SPF-containing clothing, which offers the benefit of not needing reapplication.

• Never use tanning booths.

BOX 9.2 Patient Instructions for Skin Self-Examination

• Always use a good light, positioned to minimize distracting glare. Look for a new growth or any skin change.

• Be aware of the locations and appearance of moles and birthmarks.

• Examine your back and other hard-to-see areas of the body using full-length and handheld mirrors. Ask a friend or relative to help inspect those areas that are difficult to see, such as the scalp and back.

• Begin with your face and scalp using one or more mirrors. Proceed downward, focusing on neck, chest, and torso. Patients, check under breasts. With back to the mirror, use hand mirror to inspect back of neck, shoulders, upper arms, back, buttocks, legs. Concentrate especially on areas where dysplastic nevi (those with unexpected changes) are most common—the shoulders and back; and areas where ordinary moles are rarely found—the scalp, breast, and buttocks. Check hands, including nails. In a full-length mirror, examine elbows, arms, underarms. Sitting down, check legs and feet, including soles, heels, nails, and between the toes. Use a hand mirror to examine genitals. See rather than feel any early signs of a mole change. Use a cell phone to take photos of moles and compare the photographs of the same moles over a period of several months. Monitor change in size by measuring. It can be done simply with a small ruler or even by comparing the moles to the size of your thumb or fingernail.

• Consult your healthcare provider promptly if any pigmented skin spots look like melanoma, if new moles have appeared, or if any existing moles have changed. See also the ABCDE changes in moles (Melanoma, in Abnormalities).

Patient Safety

Sunscreen Do you ask if your patients use sunscreen? Keep this in mind when they respond: Skin should be the same color all year long. Those who use sunscreen with a protection factor of 30 or higher are still at risk for significant sunburn. Why? People often don’t use enough sunscreen. They think they are protected, but they are in fact getting significant UV exposure. It is necessary to apply sunscreen generously (about 1 shot glass full over entire body) and frequently. Apply minutes before exposure and then reapply after swimming, or bathing and every 2 to 3 hours of exposure.

CLINICAL PEARL

Carotenemia Carotenemia, or xanthoderma, common in infants who have started eating baby foods, is yellow pigmentation of the skin and increased beta-carotene levels in the blood. Carotenemia does not cause orange discoloration of the sclerae, and thus is usually easy to distinguish from jaundice. In most cases, this benign condition follows increased consumption of carotene-rich foods, such as carrots, squash, and sweet potatoes. If parental anxiety is high, provide reassurance and counsel that after discontinuation of carotene-rich foods, the skin color will normalize in weeks to months.

Children and Adolescents • Eating habits and types of food • Food allergies. Note that food allergies do not classically

cause eczema. • Exposure to infectious diseases at day care, school:

impetigo; viruses that produce skin rashes (Coxsackie); measles, mumps, rubella, varicella in unvaccinated children

• Allergic disorders: eczema, urticaria, pruritus, hay fever, asthma, other chronic respiratory disorders

• Pets or animal exposure • Outdoor exposures such as play areas, hiking, camping,

picnics, gardening • Skin injury history: frequency of falls, cuts, abrasions;

repeated history of unexplained injuries • Chronic hair-pulling or manipulation • Nail-biting

Pregnant Patients • Weeks of gestation or postpartum • Hygiene practices

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Skin Use inspection and palpation to examine the skin. The most important tools are your own eyes and powers of observation. When gross inspection leaves you uncertain, sometimes a handheld magnifying glass or dermatoscope may help.

Inspection Adequate lighting is essential. Direct, overhead lighting should be used when examining patients. Inadequate lighting can result in inadequate assessment. Tangential lighting is helpful in assessing contour.

Although the skin is commonly observed as each part of the body is examined, it is important to make a brief but careful overall visual sweep of the entire body. This “bird’s-eye view” gives a good idea of the distribution, extent, and symmetry of any lesions. It also allows for identification of “ugly duckling” lesions that stand out. The gross view will allow the practitioner to know where to pay particular attention during the remainder of the examination (Box 9.3).

Adequate exposure of the skin is necessary. It is essential to remove clothing and to fully remove drapes or coverings as each section of the body is examined. Make sure that the room temperature is comfortable. Look carefully at all areas, remembering to inspect areas that are usually not exposed, such as the axillae, buttocks, perineum, backs of thighs, and inner upper thighs. Remove shoes and socks to look at the feet. Pay careful attention to intertriginous surfaces (areas where two skin surfaces may touch, e.g., axillae and groin), especially in infants, older adults and

• Presence of skin problems before pregnancy (e.g., acne may worsen)

• Effects of pregnancy on preexisting conditions (e.g., autoimmune disorders may remit; condylomata acuminata commonly become larger and more numerous)

Older Adults • Increased or decreased sensation to touch or to the

environment • Generalized chronic itching; exposure to skin irritants,

detergents, lotions (any moisturizer that comes in a pump has a high alcohol content), woolen clothing, humidity of environment

• Susceptibility to skin infections • Healing response: delayed or interrupted • Frequent falls resulting in multiple cuts or bruises • Risk for pressure ulcers secondary to immobilization

or nonambulatory status • History of chronic medical conditions (e.g., diabetes

mellitus, vascular disease) • Medications and polypharmacy

EXAMINATION AND FINDINGS

Equipment • Centimeter ruler (flexible, clear) • Flashlight or penlight • Handheld magnifying lens or dermatoscope • Wood’s lamp (to view fluorescing or depigmented

lesions)

BOX 9.3 Cutaneous Manifestations of Traditional Health Practices

The use of certain traditional health practices by various cultural groups can produce cutaneous manifestations that could be wrongly confused with disease or physical abuse. Two such practices are “coining” and “cupping” as used by some Asian subcultures. In coining, a coin dipped in mentholated oil is vigorously rubbed across the skin in a prescribed manner, causing a mild dermabrasion. This practice is believed to release

excess force from the body and hence restore balance. In cupping, a series of small, heated glasses are placed on the skin, forming a suction that leaves a red or purpuric circular mark, drawing out the bad force. The skin markings may alarm the healthcare provider who is unaware of such practices. The lesson: in the history, ask about home remedies or practices.

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Individuals with dark skin may show pigmentary demarcation lines. These lines, a normal variation, mark the border between deeply pigmented skin and lighter pigmented skin. They are most commonly seen on the arms, legs, chest, and back and have been reported most often in black and Japanese populations. Accentuation of preexisting lines or appearance of new lines may occur during pregnancy.

Nevi (moles) occur in forms that vary in size and degree of pigmentation. Nevi are present on most persons regard- less of skin color, and may occur anywhere on the body. They may be flat, raised, dome-shaped, smooth, rough, or hairy. Their color ranges from pink, tan, gray, and shades of brown to black. Table 9.1 describes the features and occurrence of various types of pigmented nevi.

FIG. 9.3 Corn. (From White, 1994.)

FIG. 9.4 Calluses are common on both the sole (heels and metatarsal heads) and the dorsum of the foot (especially in women). (From Lawrence and Cox, 1993.)

TYPE FEATURES OCCURRENCE COMMENTS

Halo nevus Sharp, oval, or circular; depigmented halo around mole; may undergo many morphologic changes; usually disappears and halo repigments (may take years)

Usually on back in young adult Usually benign; biopsy indicated because same process can occur around melanoma

Intradermal nevus Dome-shaped; raised; flesh to black color; may be pedunculated or hair bearing

Cells limited to dermis No indication for removal other than cosmetic

Junction nevus Flat or slightly elevated; dark brown Nevus cells lining dermoepidermal junction

Should be removed if exposed to repeated trauma

Compound nevus Slightly elevated brownish papule: indistinct border Nevus cells in dermis and lining dermoepidermal junction

Should be removed if exposed to repeated trauma

Hairy nevus May be present at birth; may cover large area; hair growth may occur after several years

Should be removed if changes occur

TABLE 9.1 Features and Occurrence of Various Types of Pigmented Nevi

bedridden patients. As you complete the examination for each area, redrape or cover the patient. When inspecting the skin, it is important to have a systematic routine in place to ensure that no areas are forgotten. Skin thickness varies over the body, with the thinnest skin on the eyelids and the thickest at areas of pressure or rubbing, most notably the soles, palms, and elbows. Note calluses on the hands or feet. Look for corns on pressure points. Corns are flat or slightly elevated, circumscribed, painful lesions with a smooth, hard surface (Fig. 9.3). A superficial area of hyperkeratosis is called a callus. Calluses usually occur on the weight-bearing areas of the feet and on the palmar surface of the hands. Calluses are less well demarcated than corns and are usually not tender (Fig. 9.4).

The range of expected skin color varies from dark brown to white with pink or yellow overtones. Although color should assume an overall uniformity, there is often pigment variation that may be sun related, trauma induced, or simply normal (e.g., knuckles may be darker in dark-skinned patients). Callused areas may appear yellow. Vascular flush areas (e.g., cheeks, neck, upper chest, and genital area) may appear pink or red, especially with anxiety or excitement. Be aware that skin color may be masked by cosmetics and tanning agents. Look for localized areas of discoloration.

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Nevi occur more often in lighter-skinned than in darker- skinned individuals. There is a strong association between sun exposure and the number of nevi. They increase in number throughout infancy and childhood, with peak incidence in the fourth to fifth decades. Nevi involute and diminish in number with advancing age.

Although most nevi are harmless, some may be dysplastic or develop into melanoma. Of note, the term “atypical” denotes the clinical appearance whereas dysplastic is a histologic term. Table 9.2 describes differences in the features of normal and atypical moles. Atypical nevi tend to occur on heavily sun damaged skin, classically upper back in men and on the legs in women (Box 9.4 “Atypical Mole or Melanoma?”).

Several variations in skin color occur in almost all healthy adults and children, including nonpigmented striae (i.e., silver or pink “stretch marks” that occur during pregnancy or weight gain), freckles in sun-exposed areas, birthmarks, and nevi (Fig. 9.5). Adult women (and sometimes men) will commonly have melasma (see Fig. 9.34), areas of hyperpigmentation on the face and neck that are associated with pregnancy or hormonal variation. This condition is more noticeable in darker-skinned patients. The absence of melanin produces patches of unpigmented skin or hair, such as with vitiligo (Fig. 9.6).

Alterations in color in dark-skinned persons are best seen in the sclera, conjunctiva, buccal mucosa, tongue, lips, nail beds, and palms. Particular variations in skin color

FEATURE NORMAL MOLE DYSPLASTIC MOLE

Color Uniformly tan or brown; all moles on one person tend to look alike

Mixture of tan, brown, black, and red/pink; moles on one person often do not look alike

Shape Round or oval with a clearly defined border that separates the mole from surrounding skin

Irregular borders may include notches; may fade into surrounding skin and include a flat portion level with skin

Surface Begins as flat, smooth spot on skin; becomes raised; forms a smooth bump

May be smooth, slightly scaly, or have a rough, irregular, “pebbly” appearance

Size Usually less than 6 mm (size of a pencil eraser)

Often larger than 6 mm and sometimes larger than 10 mm

Number Typical adult has 10-40 moles scattered over the body

Many persons do not have increased number; however, persons severely affected may have more than 100 moles

Location Usually above the waist on sun-exposed surfaces of the body; scalp, breast, and buttocks rarely have normal moles

May occur anywhere on the body, but most commonly on back; may also appear below the waist and on scalp, breast, and buttocks

TABLE 9.2 Features of Normal and Dysplastic Moles BOX 9.4 Dysplastic Mole or Melanoma?

Dysplastic nevi (atypical moles) occur predominantly on the trunk. They tend to be large, usually greater than 5 mm, with a flat component. The border is typically ill defined. The shape can be round, oval, or irregular. The color is usually brown but can be mottled with dark brown, pink, and tan. Some individuals have only 1 to 5 moles; others have more than 100.

In melanoma, the border is more irregular. Lesions tend to be larger, often greater than 6 mm. Color variation within the lesion is characteristic, ranging from tan-brown, dark brown, or black to pink, red, gray, blue, or white.

Any lesion suggestive of a melanoma must be biopsied. Individuals with dysplastic moles are at increased risk for melanoma.

A

B

C

FIG. 9.5 Commonly occurring nevi. A, Junction nevus. Color and shape of this black lesion are uniform. B, Compound nevus. Center is elevated and surrounding area is flat, retaining features of a junction nevus. C, Dermal nevus. Papillomatous with soft, flabby, wrinkled surface. (From Habif, 2004.)

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FIG. 9.6 Vitiligo. (From Kumar and Clark, 2017.)

COLOR CAUSE DISTRIBUTION SELECT CONDITIONS

Brown Darkening of melanin pigment Generalized Pituitary, adrenal, liver disease Localized Nevi, neurofibromatosis

White Absence of melanin Generalized Albinism Localized Vitiligo

Red (erythema) Increased cutaneous blood flow Localized Inflammation Generalized Fever, viral exanthem, urticaria

Increased intravascular red blood cells Generalized Polycythemia

Yellow Increased bile pigmentation (jaundice) Generalized Liver disease Increased carotene pigmentation Generalized (except sclera) Hypothyroidism, increased intake of vegetables containing carotene

Blue Increased unsaturated hemoglobin secondary to hypoxia

Lips, mouth, nail beds Cardiovascular and pulmonary diseases

TABLE 9.3 Cutaneous Color Changes

FIG. 9.7 Petechiae. (From Weston et al, 2007.)

FIG. 9.8 Senile purpura. (From Hoffbrand et al, 2010.)

may be the result of physiologic pigment distribution. The palms and soles are lighter in color than the rest of the body and should be assessed when concerned for diffuse skin changes such as erythroderma, which is an intense, widespread reddening of the skin. Hyperpigmented nevi on the palms and soles of the feet are common in darker skinned patients. Freckling of the buccal cavity, gums, and tongue commonly occurs and is benign. The sclera may appear yellowish brown (often described as “muddy”) or may contain brownish pigment that resemble moles. A bluish hue of the lips and gums can be a normal finding in persons with dark skin. Some dark-skinned persons have very blue lips, giving a false impression of cyanosis.

Systemic disorders can produce generalized or localized color changes; these are described in Table 9.3. Localized redness often results from an inflammatory process. Pale, shiny skin of the lower extremities may reflect peripheral changes that occur with systemic diseases such as diabetes mellitus and peripheral vascular disease. Injury, steroids, vasculitis, stasis, and several systemic disorders can cause localized hemorrhage into the skin, producing red-purple discolorations. Bleeding into the skin results in ecchymoses (i.e., bruising); pinpoint bleeding from capillaries occurs is called petechiae (smaller than 0.5 cm in diameter) (Fig. 9.7) or purpura (larger than 0.5 cm in diameter) (Fig. 9.8).

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Vascular skin lesions are characterized in Fig. 9.9 (see Clinical Pearl, “Telangiectasias: Capillary Spider/Spider Angioma”). Box 9.5 describes some characteristic odors that you may note as you examine the skin.

Palpation As you inspect, palpate the skin for moisture, temperature, texture, turgor, and elasticity. Palpation may yield additional data for describing lesions, particularly in relation to eleva- tion or depression.

Spider angioma— red central body with radiating spi- der-like legs that blanch with pres- sure to the central body Cause: Liver dis- ease, vitamin B deficiency, idio- pathic

Venous star— bluish spider, lin- ear or irregularly shaped; does not blanch with pres- sure Cause: Increased pressure in super- ficial veins

Purpura—red- purple nonblanch- able discoloration greater than 0.5 cm in diameter Cause: Intravascular defects, infection

Petechiae—red- purple nonblanch- able discoloration less than 0.5 cm diameter Cause: Intravas- cular defects, in- fection

Ecchymoses— red-purple non- blanchable discoloration of variable size Cause: Vascular wall destruction, trauma, vasculitis

Telangiectasia— fine, irregular red line Cause: Dilation of capillaries

Capillary heman- gioma (nevus flammeus)—red irregular macular patches Cause: Dilation of dermal capillaries

FIG. 9.9 Characteristics and causes of vascular skin lesions.

CLINICAL PEARL

Telangiectasias: Capillary Spider/Spider Angioma Telangiectasias are permanently dilated, small blood vessels consisting of venules, capillaries, or arterioles. How do you tell the difference between a capillary spider and a spider angioma? Capillary spiders are little masses of venules. When you blanch them, they will refill in an erratic, not-at-all-organized way. Spider angiomas are arterial. Blanch the center, and they will refill in a very organized way, from the center out and evenly in all directions (see Fig. 9.9).

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sign of a systemic disorder such as exposure to arsenic, other toxins, or a sign of internal malignancy.

Assessment of skin elasticity can be helpful to detect certain conditions. Gently pinch a small section of skin on the forearm or sternal area between the thumb and fore- finger and then release the skin (Fig. 9.11). The skin should move easily when pinched and return to place immediately when released. Poor skin turgor can indicate severe dehydra- tion. The skin is very slow to return to normal and “tents” up. This may occur with excessive vomiting, diarrhea, or dehydration for another cause. Skin that is firm or cannot be pinched may suggest an underlying connective tissue disease such as scleroderma.

Skin Lesions As you assess the skin, pay particular attention to any lesions that may be present. “Skin lesion” is a general term that collectively describes any pathologic skin change or occur- rence. Lesions may be primary (i.e., those that occur as initial spontaneous manifestations of a pathologic process) or secondary (i.e., those that result from later evolution of or external trauma to a primary lesion).

Tables 9.4 and 9.5 show the characteristics of primary and secondary lesions. The nomenclature is often used inaccurately; if you are uncertain about a lesion, use the descriptors rather than the name. Be aware that several types of lesions may occur concurrently and that secondary changes may obscure primary characteristics.

Describe lesions according to characteristics (Table 9.6), exudates, configuration, and location and distribution:

Characteristics • Size (measure all dimensions) • Shape • Color • Texture • Elevation or depression • Attachment at base: pedunculated (having a stalk) or

sessile (without a stalk) • Exudates

Minimal perspiration or oiliness should be present. Increased perspiration may be associated with activity, warm environment, obesity, anxiety, or excitement; it may be especially noticeable on the palms, scalp, forehead, and in the axillae. The intertriginous areas or skin in body folds may also be damp leading to development of intertrigo (Fig. 9.10).

The skin should range from cool to warm to the touch. Use the dorsal surface of your hands or fingers because these areas are most sensitive to temperature perception. At best, this assessment is a rough estimate of skin tem- perature; what you are really looking for is bilateral sym- metry. Environmental conditions, including the temperature of the examining room, as well as body location may affect surface temperature.

The texture should feel smooth, soft, and even. Rough- ness on exposed areas or areas of pressure (particularly the elbows, soles, and palms) may be caused by dry skin or irritation. Extensive or widespread roughness may be the result of a keratinization disorder or damaged skin. Hyper- keratoses, especially of the palms and soles, may be the

BOX 9.5 Smell the Skin

Even the skin may have odors suggesting a variety of problems: infectious, metabolic, or neurologic. Sweatiness intensifies the smell.

CAUSE OF ODOR TYPE OF ODOR

Clostridium gas gangrene Rotten apples

Proteus infection Mousy

Pseudomonas infection (especially burns) Grapelike

Tuberculous lymphadenitis (scrofula) Stale beer

Anaerobic infection; scurvy Putrid

Intestinal obstruction, peritonitis Feculent

Phenylketonuria Mousy, musty

FIG. 9.10 Examining an intertriginous area. (From Kliegman and Stanton, 2016.)

FIG. 9.11 Testing skin turgor.

Text continued on p. 149

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DESCRIPTION EXAMPLES

Macule A flat, circumscribed

area that is a change in the color of the skin; less than 1 cm in diameter

Freckles, flat moles (nevi), petechiae, measles

Papule An elevated, firm, circumscribed area; less than 1 cm in diameter

Wart (verruca), elevated moles, lichen planus

Patch A flat, nonpalpable, irregularly shaped macule greater than 1 cm in diameter

Vitiligo, port-wine stains, hyperpigmented macule, café au lait patch

Plaque Elevated, firm, and rough lesion with flat top surface greater than 1 cm in diameter

Psoriasis, seborrheic, and actinic keratosis

TABLE 9.4 Primary Skin Lesions

Measles.

Lichen planus.

Vitiligo. At, ut vit, pecrit, Cat fit aureviu vis contis. Sulem

Psoriasis.

Continued

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DESCRIPTION EXAMPLES

Wheal Elevated, irregular- shaped area of cutaneous edema; solid, transient, variable diameter

Insect bites, urticaria, allergic reaction

Nodule Elevated, firm, circumscribed lesion; deeper in dermis than a papule; 1-2 cm in diameter

Erythema nodosum, lipoma

Mass Elevated and solid lesion; may or may not be clearly demarcated; deeper in dermis; greater than 2 cm in diameter

Neoplasms, benign tumor, lipoma

Vesicle Elevated, circumscribed, superficial, not into dermis; filled with serous fluid; less than 1 cm in diameter

Varicella (chickenpox), herpes zoster (shingles)

TABLE 9.4 Primary Skin Lesions—cont'd

Wheal from allergic reaction.

Fine scaling.

Lipoma.

Vesicles caused by varicella.

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DESCRIPTION EXAMPLES

Bulla Vesicle greater than 1 cm in diameter

Blister, pemphigus vulgaris

Pustule Elevated, superficial lesion; similar to a vesicle but filled with purulent fluid

Impetigo, acne

Cyst Elevated, circumscribed, encapsulated lesion; in dermis or subcutaneous layer; filled with liquid or semisolid material

Sebaceous cyst, cystic acne

Telangiectasia Fine, irregular, red lines produced by capillary dilation

Telangiectasia in rosacea

TABLE 9.4 Primary Skin Lesions—cont'd

Blister.

Acne.

Sebaceous cyst.

Telangiectasia.

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DESCRIPTION EXAMPLES

Scale Heaped-up, keratinized cells; flaky skin; irregular; thick or thin; dry or oily; variation in size

Flaking of skin with seborrheic dermatitis or after a drug reaction; dry skin

Lichenification Rough, thickened epidermis secondary to persistent rubbing, itching, or skin irritation; often involves flexor surface of extremity

Chronic dermatitis

Keloid Irregularly shaped, elevated, progressively enlarging scar; grows beyond the boundaries of the wound; caused by excessive collagen formation during healing

Keloid formation after surgery

Scar Thin to thick fibrous tissue that replaces

normal skin after injury or laceration to the dermis

Healed wound or surgical incision

TABLE 9.5 Secondary Skin Lesions

Fine scaling.

Lichenification (chronic dermatitis).

Keloid.

Hypertrophic scar.

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DESCRIPTION EXAMPLES

Excoriation Loss of the epidermis; linear hollowed-out, crusted area

Abrasion or scratch, scabies

Fissure Linear crack or break from the epidermis to the dermis; may be moist or dry

Athlete’s foot, cracks at the corner of the mouth

Erosion Loss of part of the epidermis; depressed, moist, glistening; follows rupture of a vesicle or bulla

Varicella, variola after rupture

Ulcer Loss of epidermis and dermis; concave; varies in size

Decubiti, stasis ulcers

TABLE 9.5 Secondary Skin Lesions—cont'd

Scaling and fissures from tinea pedis.

Excoriation from tree branch.

Erosion—in varicella (chickenpox after rupture of blister).

Stasis ulcer.

Continued

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DESCRIPTION EXAMPLES

Crust Dried serum, blood, or purulent exudates; slightly elevated; size varies; brown, red, black, tan, or straw-colored

Scab on abrasion, eczema

Atrophy Thinning of skin surface and loss of skin markings; skin translucent and paper-like

Striae; aged skin

TABLE 9.5 Secondary Skin Lesions—cont'd

Scab.

Striae.

Photos from Public Health Image Library (PHIL), Centers for Disease Control and Prevention: macule/measles, Heinz F. Eichenwald, MD, Bob Craig; Patch/Vitiligo, Brian Hill, New Zealand; Plaque/psoriasis, Richard S. Hibbets; Wheal/allergic reaction, Dr. Frank Perlman, M.A. Parsons; Vesicle/varicella, Dr. John Noble, Jr.; sebaceous cyst, Dr. Gavin Hart; fissure/tinea pedis, Dr. Lucille K. Georg Hypertrophic nodule; hypertrophic scar, from Goldman and Fitzpatrick, 1994. Bulla/blister; papule/lichen planus; keloid, from Weston et al, 2007. Pustule/acne, from Ferri, 2009. Tumor/lipoma; telangiectasia; excoriation; lichenification, from Lemmi and Lemmi, 2000. Scaling, from Baran et al, 1991. Stasis ulcer, from Pozez et al, 2007. Striae, courtesy of Antoinette Hood, MD, Department of Dermatology, Indiana University School of Medicine, Indianapolis.

CHARACTERISTIC DESCRIPTION EXAMPLES

Distribution Localized Lesion appears in one small area Impetigo, herpes simplex (e.g., labialis), tinea

corporis (ringworm)

Regional Lesions involve a specific region of the body Acne vulgaris (pilosebaceous gland distribution), herpes zoster (nerve dermatomal distribution), psoriasis (flexural surfaces and skin folds)

Generalized Lesions appear widely distributed or in numerous areas simultaneously Urticaria, disseminated drug eruptions

Shape/Arrangement Round/discoid Coin-shaped (no central clearing) Nummular eczema

Oval Ovoid shape Pityriasis rosea

Annular Round, active margins with central clearing Tinea corporis, sarcoidosis

Zosteriform (dermatomal) Following a nerve or segment of the body Herpes zoster

Polycyclic Interlocking or coalesced circles (formed by enlargement of annular lesions) Psoriasis, urticaria

Linear In a line Contact dermatitis, poison ivy

Iris/target lesion Pink macules with purple central papules Erythema multiforme

TABLE 9.6 Morphologic Characteristics of Skin Lesions

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CHARACTERISTIC DESCRIPTION EXAMPLES

Stellate Star-shaped Meningococcal septicemia

Serpiginous Snakelike or wavy line track Cutanea larva migrans

Reticulate Netlike or lacy Polyarteritis nodosa, lichen planus, lesions of erythema infectiosum

Morbilliform Measles-like: maculopapular lesions that become confluent on the face and body

Measles, roseola, drug eruptions

Border/Margin Discrete Well demarcated or defined, able to draw a line around it with confidence Psoriasis

Indistinct Poorly defined, have borders that merge into normal skin or outlying ill-defined papules

Nummular eczema

Active Margin of lesion shows greater activity than center Tinea capitus

Irregular Nonsmooth or notched margin Malignant melanoma

Border raised above Center of lesion depressed compared with the edge Basal cell carcinoma center

Advancing Expanding at margins Cellulitis

Associated Changes Within Lesions Central clearing An erythematous border surrounds lighter skin Tinea eruptions

Desquamation Peeling or sloughing of skin Rash of toxic shock syndrome

Keratotic Hypertrophic stratum corneum Calluses, warts

Punctation Central umbilication or dimpling Basal cell carcinoma, molluscum contagiosum

Telangiectasias Dilated blood vessels within lesion blanch completely, may be markers of systemic disease

Basal cell carcinoma, actinic keratosis

Pigmentation Flesh Same tone as the surrounding skin Neurofibroma, some nevi

Pink Light red undertones Eczema, pityriasis rosea

Erythematous Dark pink to red Tinea eruptions, psoriasis

Salmon Orange-pink Psoriasis

Tan-brown Light to dark brown Most nevi, pityriasis versicolor

Black Black or blue-black Malignant melanoma

Pearly Shiny white, almost iridescent Basal cell carcinoma

Purple Dark red-blue-violet Purpura, Kaposi sarcoma

Violaceous Light violet Erysipelas

Yellow Waxy Lipoma

White Absent of color Lichen planus

TABLE 9.6 Morphologic Characteristics of Skin Lesions—cont'd

• Color • Odor • Amount • Consistency • Configuration • Annular (rings) • Grouped • Linear • Arciform (bow-shaped) • Diffuse • Location and distribution • Generalized or localized • Region of the body (Box 9.6) • Patterns (Figs. 9.12 to 9.14) • Discrete or confluent

A small, clear, flexible ruler is necessary for measuring the size of lesions. Examiners often use comparisons to common objects such as coins to estimate the size or shape of lesions. Subjective estimates should not be used as measures of size; instead, use the ruler and report sizes in centimeters. Try to measure size in all dimensions (i.e., height, width, and depth) when possible.

Use a light for closer inspection of a particular lesion to detect its nuances of color, elevation, and borders. A ×5 to ×10 power handheld magnifying lens is useful in evaluating the subtle details of a lesion. Transillumination may be used to determine the presence of fluid in cysts or bullae. Darken the room and place the tip of the transilluminator against the side of the cyst or mass. Fluid-filled lesions will transilluminate with a red glow, whereas solid lesions will not.

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Hair Palpate the hair for texture while inspecting it for color, distribution, and quantity. The scalp hair may be coarse or fine, curly or straight, and should be shiny, smooth, and resilient. Palpate the scalp hair for dryness and brittleness that could indicate a systemic or genetic disorder. Color will vary from very light blond to black to gray and may show alterations with rinses, dyes, or permanents.

The quantity and distribution of hair vary according to individual genetic makeup. Hair is commonly present on the scalp, lower face, neck, nares, ears, chest, axillae, back and shoulders, arms, legs, toes, pubic area, and around the nipples. Note hair loss, which can be either generalized or localized. Inspect the lower legs and feet for hair loss that may indicate poor circulation or nutritional deficit. Look for any inflammation or scarring that accompanies hair loss, particularly when it is localized. Diffuse hair loss usually occurs without inflammation and scarring. Note

The Wood’s lamp can be used to evaluate epidermal hypopigmented areas and to distinguish fluorescing lesions. Depigmented lesions will enhance, whereas hypopigmented lesions will not. Darken the room and shine the light on the area to be examined. Look for the enhancement of depigmented lesions like vitiligo, hyperpigmentation of café au lait spots, and the yellow-green fluorescence that indicates the presence of some types of fungal infection.

FIG. 9.12 Clustering of lesions. (Reproduced by permission of the Wellcome Foundation, Ltd.)

FIG. 9.13 Linear formation of lesions (herpes zoster). (From Morse and Ballard, 2010.)

FIG. 9.14 Annular formation of lesions (granuloma annulare). An annular plaque or plaques may occur on the dorsa of the feet or hands as a manifestation of granuloma annulare. (From Keimig, 2015.)

BOX 9.6 Regional Distribution of Skin Lesions

Sun-Exposed Areas • Sunburn • Lupus erythematosus • Viral exanthem • Porphyria

Cloth-Covered Areas • Irritant contact dermatitis • Miliaria

Flexural Aspects of Extremities • Atopic dermatitis • Intertrigo • Candidiasis • Tinea cruris

Extensor Aspects of Extremities • Psoriasis

Stocking and Glove (Acrodermatitis) • Viral exanthem/atopic dermatitis • Tinea pedis with “id” reaction* • Poststreptococcal infection • Child abuse burns

Truncal • Pityriasis rosea (Christmas tree pattern) • Atopic dermatitis • Drug reaction

Face, Shoulder, Back • Acne vulgaris • Drug-induced acne • Cushing syndrome

*An “id” reaction is a generalized acute cutaneous reaction, probably immunologic in origin, to a variety of stimuli, including fungal infection.

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FIG. 9.15 Pigmented bands in nails are expected in persons with dark skin. (From Johr et al, 2004.)

whether the hair shafts are completely absent or simply broken off.

Genetically predisposed men often display a gradual symmetric hair loss on the frontal or vertex of the scalp during adulthood. Asymmetric hair loss may indicate a pathologic condition. Women in their 20s and 30s may also develop adrenal androgenic female-pattern alopecia (hair loss), with a gradual loss of hair from the central scalp.

Fine vellus hair covers the body, whereas coarse terminal hair occurs on the scalp, pubic, and axillary areas, on the arms and legs (to some extent), and in the beard of men. The male pubic hair configuration is an upright triangle with the hair extending midline to the umbilicus (see Chapter 8, Fig. 8.17). The female pubic configuration is an inverted triangle; the hair may extend midline to the umbilicus (see Chapter 8, Fig. 8.15). Look for hirsutism in women—growth of terminal hair in a male distribution pattern on the face, body, and pubic area. Hirsutism, by itself or associated with other signs of virilization, may be a sign of an endocrine disorder.

Hair patterns vary across races and ethnicities. African hair is typically coarser, drier, and curlier than Asian or White hair. People of African descent may have multiple hairs protruding from the same shaft (pili-multigemini). This can be a normal finding but may also indicate an underlying scarring process. Asians have very straight, shiny hair and often have sparser body hair. Note that cosmetic procedures may alter the color, texture, and distribution of hair on patients.

Nails Inspection Inspect the nails for color, length, configuration, symmetry, and cleanliness. The condition of the fingernails can provide important insight to the patient’s sense of self as the condi- tion of the hair and nails gives a clue about the patient’s level of self-care and some sense of emotional order and social integration. The nails also can demonstrate physical examination signs that may indicate an underlying systemic disease.

Nail edges should be smooth and rounded. Jagged, broken, or bitten edges or cuticles are indicators of poor care habits and may predispose the patient to localized infection. Ragged cuticles are also a classic sign of dermatomyositis. Peeling nails (from the plate splitting into layers) are usually found in individuals whose hands are subject to repeated water immersion or who have underlying psoriasis.

Examine the proximal and lateral nail folds for redness, swelling, pus, warts, cysts, and tumors. Pain usually accompanies ingrown nails and infections.

Color. The shape and opacity of nails vary considerably among individuals. Nail bed color should be variations of pink. Pigment deposits or bands may be present in the nail beds of persons with dark skin (Fig. 9.15). Yellow discolor- ation occurs with several nail diseases, including psoriasis and fungal infections, and may also occur with chronic

respiratory disease. Proximal subungual fungal infection is associated with HIV infection. Diffuse darkening of the nails may arise from antimalarial drug therapy, candidal infection, hyperbilirubinemia, and chronic trauma, such as occurs from tight-fitting shoes. Green-black discoloration, which is associated with Pseudomonas infection, may be confused with similar discoloration caused by injury to the nail bed (subungual hematoma). Pain accompanies a subungual hematoma, whereas Pseudomonas infection is painless. Nail beds that are blue may be a transient response to a cold examining room. A single blue or black nail may indicate melanoma or bruising/bleeding from trauma. Generalized blue nails may be caused by conditions that produce cyanosis such as asthma, cardiac disorders, or severe anemia. Other causes of blue nails include silver poisoning, medication side effects, and Wilson disease, an inherited disorder of copper metabolism. Splinter hemorrhages, longitudinal red or brown streaks, may occur in endocarditis, vasculitis, with severe psoriasis of the nail matrix or as the result of minor injury to the proximal nail fold (habit-tic deformity). White spots in the nail plate (leukonychia punctate), a common finding, result from cuticle manipulation or other forms of mild trauma that injure the nail matrix (Fig. 9.16). These spots need to be differentiated from longitudinal white streaks or transverse white bands that are indicative of a systemic disorder. Separation of the nail plate from the bed produces a white, yellow, or green tinge on the nonadherent portion of the nail.

Nail Plate. The nail plate should appear smooth and flat or slightly convex. Complete absence of the nail (anonychia) may occur as a congenital condition. Look for nail ridging, grooves, depressions, and pitting. Longitudinal ridging and beading are common expected variants (Fig. 9.17). Longi- tudinal ridges and grooves may also occur with lichen planus of the nail. Transverse grooves result from repeated injury to the nail, usually the thumb, as with chronic manipulation to the proximal nail fold (Fig. 9.18). The most common cause is picking at the thumb with the index finger (habit-tic deformity). Chronic inflammation, such as occurs with

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chronic paronychia or chronic eczema, produces transverse rippling of the nail plate. Transverse depressions that appear at the base of the lunula occur after stress that temporarily interrupts nail formation.

Involvement of a single nail usually points to an injury to the nail matrix. Assure the patient that the nail will grow out and assume normal appearance in about 6 months for fingernails and 9 months for toenails. Depressions that occur in all the nails are usually a response to systemic disease, including syphilis, disorders producing high fevers, peripheral vascular disease, and uncontrolled diabetes mellitus. Pitting is seen most commonly with psoriasis. Broadening and flattening of the nail plate may be seen in secondary syphilis. Fig. 9.19 illustrates unexpected nail findings. Pigmented deposits or bands may be present in the nail beds of persons with dark skin. The sudden appearance of such a band in any race may indicate melanoma. Extension of the pigment backward onto the proximal nail fold is a worrisome sign for possible melanoma.

Inward folding of the lateral edges of the nail causes the nail bed to draw up; this often becomes painful. Cur- vature is most common in the toenails and is thought to be caused by shoe compression.

Nail Base Angle. The nail base angle should measure 160 degrees. One way to observe this is to place a ruler or a sheet of paper across the nail and dorsal surface of the finger and examine the angle formed by the proximal nail fold and nail plate. In clubbing, the angle increases and approaches or exceeds 180 degrees. Another method of assessment is the Schamroth technique (Fig. 9.20). Have the patient place together the nail (dorsal) surfaces of the thumbs from the right and left hands. When the nails are clubbed, the diamond-shaped window at the base of the nails disappears, and the angle between the distal tips increases. Clubbing is associated with a variety of respiratory and cardiovascular diseases, cirrhosis, colitis, and thyroid disease (Fig. 9.21).

Palpation The nail plates should feel hard and smooth with a uniform thickness. Thickening of the nail may occur from tight- fitting shoes, chronic trauma, and some fungal infections. Thinning of the nail plate may also accompany some nail diseases. Pain in the area of a nail groove may be secondary to ischemia.

Gently squeeze the nail between your thumb and the pad of your finger to test for adherence of the nail to the nail bed. Separation of the nail plate from the bed is common with psoriasis, trauma, candidal or Pseudomonas infections, and some medications. The nail base should feel firm (Fig. 9.22). A boggy nail base accompanies clubbing.

Infants and Children In the first few hours of life, the infant’s skin may look very red. The gentle pink coloring that predominates in

FIG. 9.16 White spots on nail from injury (leukonychia punctate). (From Scher RK and Daniel CR, 2005.)

FIG. 9.17 Aging nails. Longitudinal ridging of the nail is a common expected variation. (From White and Cox, 2006.)

FIG. 9.18 Median nail dystrophy. (From James et al, 2016.)

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day of life and disappears by the eighth to tenth day but may persist for as long as 3 to 4 weeks. Intense and per- sistent jaundice suggests liver disease, a hemolytic process, or severe, overwhelming infection. Risk factors for hyper- bilirubinemia and causes of jaundice in the newborn are listed in the Risk Factors box.

In examining the newborn for hyperbilirubinemia, look at the whole body. Be sure to examine the oral mucosa and sclera of the eyes, where jaundice can be detected more easily. Examine the baby in natural daylight if possible.

infancy usually surfaces in the first day after birth. Skin color is partly determined by the amount of subcutaneous fat: the less subcutaneous fat, the redder and more transpar- ent the skin. Dark-skinned newborns do not always manifest the intensity of melanosis that will be readily evident in 2 to 3 months. The exceptions in this regard are the nail beds and skin of the scrotum. The expected color changes in newborns are described in Box 9.7.

Physiologic jaundice may be present to a mild degree in many newborn infants. It usually starts after the first

Spoon nail (koilonychia) Anonychia (absence of nail)

Broadening of nail Paronychia

Clubbing—early almost 180° Darkening of nail

Clubbing—middle 180° Terry nails

Transverse grooving (Beau lines) Nail pitting

Curvature of nail Onycholysis

Spoon nail (koilonychia) Anonychia (absence of nail)

Broadening of nail Paronychia

Clubbing—severe �180° Splinter hemorrhages

FIG. 9.19 Nails: unexpected findings and appearance.

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Both artificial light and environmental colors (e.g., orange drapes) can produce a false color.

Check the skin of the newborn carefully for small defects, especially over the entire length of the spine; the midline of the head, from the nape of the neck to the bridge of the nose; and the neck extending to the ear. This may offer a clue to brachial sinus tracts or brachial cleft cysts. The skin should feel soft and smooth. Also look for skin findings that may signal underlying systemic conditions (Box 9.8).

Inspect the skin for distortions in contour suggestive of congenital vascular malformations, any nodules, congenital birth marks, and/or tumors. Transillumination may help if there is a question about the density of the mass or the amount of fluid. With more density and less fluid, there is less tendency to glow on transillumination.

Examine the hands and feet of newborns for skin creases. Flexion results in creases that are readily discernible on the fingers, palms, and soles (Fig. 9.23). One indicator of maturity is the number of creases; the older the baby, the more creases there are. Examine the crease patterns of the

A

B

FIG. 9.20 Schamroth technique. A, Patient with healthy nails, illustrating window. B, Patient with nail clubbing, illustrating loss of the window and prominent distal angle. (From Spicknall et al, 2005.)

FIG. 9.21 Finger clubbing. Nail is enlarged and curved. (From Hochberg et al, 2015.)

FIG. 9.22 Testing nail bed adherence.

BOX 9.7 Expected Color Changes in the Newborn

• Acrocyanosis: Cyanosis of hands and feet • Cutis marmorata: Transient mottling when infant is exposed to

decreased temperature • Erythema toxicum: Pink papular rash with vesicles superimposed

on thorax, back, buttocks, and abdomen; may appear in 24 to 48 hours and resolves after several days

• Congenital dermal melanocytosis: Irregular areas of deep blue pigmentation, usually in the sacral and gluteal regions; seen predominantly in newborns of African, Native American/American Indian, Asian, or Latin descent

• Salmon patches (“stork bites”): Flat, deep pink localized areas usually seen on the midforehead, eyelids, upper lip, and back of neck

Risk Factors

Major Risk Factors for Severe Hyperbilirubinemia in Infants of 35 or More Weeks’ Gestation • Total serum bilirubin (TSB) or transcutaneous bilirubin (TcB) greater

than 75th percentile • Jaundice observed in the first 24 hours • Blood group incompatibility with positive direct antiglobulin test,

other known hemolytic disease (e.g., G6PD [glucose-6-phosphate dehydrogenase] deficiency), elevated ETCOc (End-Tidal Carbon Monoxide concentration)

• Gestational age 35 to 36 weeks • Previous sibling received phototherapy • Cephalohematoma or significant bruising (e.g., from vacuum-assisted

delivery) • Exclusive breast-feeding, particularly if nursing is not going well

and weight loss is excessive • East Asian race

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BOX 9.8 Skin Lesions: External Clues to Internal Problems

Many systemic conditions or disorders may present congenital external clues that are apparent on physical examination. The following are a few examples of cutaneous markers that may signal underlying disease. A thorough evaluation is necessary, although some clues may be isolated findings and may require no intervention, follow-up, or treatment. • Faun tail nevus: Tuft of hair overlying the spinal column at birth,

usually in the lumbosacral area; may be associated with spina bifida occulta

• Epidermal verrucous nevi: Warty lesions in a linear or whorled pattern that may be pigmented or skin colored; present at birth or in early childhood; associated most commonly with skeletal, central nervous system, and ocular abnormalities

• Café au lait macules: Flat, evenly pigmented spots varying in color from light brown to dark brown or black in dark skin; larger than 5 mm in diameter; present at birth or shortly thereafter; may be associated with neurofibromatosis or miscellaneous other conditions including pulmonary stenosis, temporal lobe dysrhythmia, and tuberous sclerosis

• Freckling in the axillary or inguinal area: Multiple flat pigmented macules associated with neurofibromatosis; may occur in conjunc- tion with café au lait macules

• Ash leaf macule: White macules present at birth associated with tuberous sclerosis. Occur most commonly on the trunk, but may also appear on the face and limbs

• Facial port-wine stain: When it involves the ophthalmic division of trigeminal nerve, may be associated with ocular defects, most notably glaucoma; or may be accompanied by angiomatous malformation of the meninges (Sturge-Kalischer-Weber syndrome), resulting in atrophy and calcification of the adjacent cerebral cortex

• Port-wine stain of limb and/or trunk: When accompanied by varicosities and hypertrophy of underlying soft tissues and bones, may be associated with orthopedic problems (Klippel-Trenaunay- Weber syndrome)

• Congenital lymphedema with or without transient hemangio- mas: May be associated with gonadal dysgenesis caused by absence of an X chromosome, producing an XO karyotype (Turner syndrome)

• Supernumerary nipples: Congenital accessory nipples with or without glandular tissue, located along the mammary ridge (see Chapter 17); may be associated with renal abnormalities, especially in the presence of other minor anomalies, particularly in whites

• “Hair collar” sign: A ring of long, dark, coarse hair surrounding a midline scalp nodule in infants is usually an isolated cutaneous anomaly that may indicate neural tube closure defects of the scalp.

fingers and palms because abnormalities are associated with specific patterns. The most commonly recognized pattern is a single transverse crease in the palm that is commonly seen in children with Down syndrome (trisomy 21), but may also be a normal finding (Fig. 9.24).

All newborn infants are covered to some degree by vernix caseosa, a whitish, moist, cheeselike substance. Transient puffiness of the hands, feet, eyelids, legs, pubis, or sacrum occurs in some newborns. It has no discernible cause, and

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FIG. 9.23 Expected creases of newborn’s hands (A) and feet (B).

FIG. 9.24 Unexpected palmar crease. Single transverse crease in child with Down syndrome. Compare to Fig. 9.23, A. (From Zitelli et al, 2012.)

it should not create concern if it disappears within 2 to 3 days.

Newborn infants are particularly susceptible to hypother- mia, partly because of their poorly developed subcutaneous fat. In addition, infants have a relatively large body surface area, providing greater area for heat loss. Combined with an inability to shiver, these factors cause term newborns to lose heat. Care should be taken to use a warm surface or heat lamp when uncovering the newborn for examination.

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Cutis marmorata, a mottled appearance of the body and extremities, is part of the newborn’s response to changes in ambient temperature, whether cooling or heating. It is more common in premature infants and children with Down syndrome or hypothyroidism (Fig. 9.25). Cyanosis of the hands and feet (acrocyanosis) may be present at birth and may persist for several days or longer if the newborn is kept in cool ambient temperatures. It often recurs when the baby is chilled. If cyanosis persists, suspect an underlying cardiac or pulmonary defect (Fig. 9.26).

Bluish black to slate gray spots are sometimes seen on the back, buttocks, shoulders, and legs of well babies. These hyperpigmented patches occur most often in babies with dark skin and usually disappear in the preschool years. Hyperpigmented patches are easily mistaken for bruises by the inexperienced examiner (Fig. 9.27).

Several vascular lesions are common in infancy. Infantile hemangiomas are true neoplasms, which develop in the first 1 to 2 months of life, grow for 2 to 6 months, and regress over the next 5 to 10 years (Fig. 9.28). A salmon

FIG. 9.25 Mottling (cutis marmorata). (From Baren et al, 2008.)

FIG. 9.26 Acrocyanosis of hands in newborn.

FIG. 9.27 Hyperpigmented patches are common in babies with dark skin. (From Taïeb and Boralevi, 2007.)

FIG. 9.28 Hemangioma. (From Kliegman and Stanton, 2016.)

patch (“stork bite”) represents a common capillary vascular formation, found most frequently on the midforehead, eyelids, upper lip, and back of neck. A port wine stain is also a capillary malformation that may be associated with underlying arteriovenous malformations in Sturge-Weber syndrome.

Coffee-colored patches (café au lait macules) may be either harmless or indicative of underlying disease. Be suspicious of neurofibromatosis (NF-1) if six or more café au lait macules more than 5 mm in greatest diameter are found in prepubertal individuals or more than 15 mm in greatest diameter after puberty (Fig. 9.29).

Milia are small whitish, discrete papules on the face commonly found during the first 2 to 3 months of life. The sebaceous glands function in an immature fashion at this age and are easily clogged by sebum (Fig. 9.30).

Sebaceous hyperplasia produces numerous tiny yellow macules and papules in the newborn, probably the result of androgen stimulation from the parent. It commonly

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eyes, sufficiently sometimes to cause an extra crease or pleat of skin below the eye. This is known as the Dennie-Morgan fold and often referred to as the allergic salute; it is secondary to chronic rubbing and inflamma- tion. Also see Clinical Pearl, “Bald Spots in Infants and Children.”

occurs on the forehead, cheeks, nose, and chin of the full- term infant. Sebaceous hyperplasia disappears quickly within 1 to 2 months of life but may recur in later life in patients with rosacea or chronic sun damage.

The skin and subcutaneous tissues of an infant and young child, more readily than in the older child and adolescent, can give an important indication of the state of hydration and nutrition (Table 9.7). The tissue turgor is best evaluated by gently pinching a fold of the abdominal skin between the index finger and thumb. As with the adult, resiliency allows it to return to its undisturbed state when released. A child who is seriously dehydrated (i.e., more than 10% of body weight) or very poorly nourished will have skin that retains “tenting” after it is pinched. How quickly the tent disappears provides a clue to the degree of dehydration or malnutrition (Fig. 9.31).

Because the normal range of skin moisture is broad, look at other factors that may suggest a problem. Excessive sweating or dryness alone rarely has pathologic significance in infants or children.

Children with atopic dermatitis or chronic skin changes involving the face will commonly rub their

FIG. 9.29 Café au lait patches. (From Epstein et al, 2008.)

FIG. 9.30 Milia in infant. (From Cohen, 2013.)

RETURN TO NORMAL AFTER THE PINCH DEGREE OF DEHYDRATION

<2 seconds <5% loss of body weight

2-3 seconds 5%-8% loss of body weight

3-4 seconds 9%-10% loss of body weight

>4 seconds >10% loss of body weight

TABLE 9.7 Estimating Dehydration

FIG. 9.31 Testing skin turgor in an infant.

CLINICAL PEARL

Bald Spots in Children and Infants Bald spots in children? History is important. The differential diagnosis includes tinea capitis, alopecia areata, or trichotillomania (compulsive hair-pulling). Infants who sleep on their backs may develop areas of alopecia from pressure on the occiput. Supine sleeping is proven to reduce the risk for sudden infant death (SIDS). Providing tummy time while the infant is awake can promote motor development and decrease the likelihood of developing a bald spot.

Adolescents The examination of the adolescent’s skin is the same as that for the adult. The adolescent’s skin may have increased oiliness and perspiration, and hair oiliness may also be increased. Increased sebum production predisposes the adolescent to develop acne.

As a reflection of maturing apocrine gland function, increased axillary perspiration occurs, and the characteristic adult body odor develops during adolescence. Hair on the extremities darkens and becomes coarser. Pubic and axillary

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but is likely related to estrogens, and it usually disappears after delivery.

Itching over the abdomen and breasts resulting from skin stretching is common and not a cause for concern; however, itching accompanied by a rash may signal a pregnancy-specific dermatosis, which requires further investigation. Itching during pregnancy can also be caused by impaired flow of bile from the liver, which may also produce jaundice. The itching is generalized but may be more severe on the palms and soles. Be alert to these serious manifestations of underlying pathology. Hair growth is altered in pregnancy by the circulating hormones. The growing phase of the hair is lengthened and hair loss is decreased. Two to 6 months after delivery, increased hair shedding occurs (telogen effluvium). Regrowth will occur in 6 to 12 months. Acne vulgaris may be aggravated during the first trimester of pregnancy but often improves in the third trimester.

Older Adults The skin of the older adult may appear more transparent and paler in light-skinned individuals. Pigment deposits, increased freckling, and hypopigmented patches may develop, causing the skin to take on a less uniform appearance.

Flaking or scaling, associated with the drier skin that comes with aging, occurs most commonly over the

hair in both males and females develops and assumes adult characteristics. Males develop facial and chest hair that varies in quantity and coarseness. Chapter 8 provides a more thorough discussion of the maturational changes that occur during adolescence.

Pregnant Patients Striae gravidarum (stretch marks) may appear over the abdomen, thighs, and breasts during the second trimester of pregnancy. They fade after delivery but never disappear (Fig. 9.32). There is an increase in telangiectasias, which may be found on the face, neck, chest, and arms; these appear during the second to fifth months of pregnancy and usually resolve after delivery. Hemangiomas that were present before pregnancy may increase in size, or new ones may develop. Cutaneous tags (molluscum fibrosum gravidarum) are either pedunculated or sessile skin tags that are most often found on the neck and upper chest. They result from epithelial hyperplasia and are not inflammatory. Most resolve spontaneously or can be removed easily.

An increase in pigmentation is common and is found to some extent in all pregnant patients. The areas usually affected include the areolae and nipples, vulvar and perianal regions, axillae, and the linea alba. Pigmentation of the linea alba is called the linea nigra. It extends from the symphysis pubis to the top of the fundus in the midline (Fig. 9.33). Preexisting pigmented moles (nevi) and freckles may darken, with some nevi increasing in size. New nevi may form. Melasma or “mask of pregnancy,” occurs fre- quently in pregnant patients. The darkened, blotchy skin is usually symmetric and found on the forehead, cheeks, bridge of the nose, and chin (Fig. 9.34).

Palmar erythema is a common finding in pregnancy. A diffuse redness covers the entire palmar surface or the thenar and hypothenar eminences. The cause is unknown

FIG. 9.32 Striae. (From Buchanan K et al, 2010.)

FIG. 9.33 Linea nigra on abdomen during pregnancy.

FIG. 9.34 Facial hyperpigmentation: chloasma (melasma). (From White and Cox, 2006.)

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shearing forces. Heels and the sacrum are common sites in patients who are confined to bed. Do not neglect to examine less obvious areas such as the elbows, scapulae, and back of the head. Assess the diameter and depth of the ulcer and stage it accordingly. The staging criteria are described in Table 9.8.

Increased wrinkling is evident, especially in areas exposed to sun and in expressive areas of the face. Sagging or droop- ing is most obvious under the chin, beneath the eyes, and in the earlobes, breasts, and scrotum. Senile purpura (bruises), particularly dorsal surfaces of hands and lower arm that get tapped or bumped, is commonly seen in older adults, especially when on anticoagulant or antiplatelet therapy.

Several types of lesions may occur on the skin of healthy older adults. The following lesions are considered expected findings: • Cherry angiomas are tiny, bright ruby-red to dark blue/

black, round papules that may become brown with time. They occur in virtually everyone older than 30 years and increase numerically with age (Fig. 9.38).

• Seborrheic keratoses are pigmented, raised, warty lesions, usually appearing on the trunk. These must be distinguished from other growths such as nevi or actinic keratoses, which may have malignant potential. Because the lesions may look similar, seek the assistance of an experienced practitioner for differential diagnosis (Fig. 9.39).

extremities. The skin also thins (especially over bony prominences, the dorsal surface of hands and feet, forearms, and lower legs) and takes on a parchment-like appearance and texture (Fig. 9.35).

The skin often appears to hang loosely on the bony frame as a result of a general loss of elasticity, loss of underlying adipose tissue, and years of gravitational pull (Fig. 9.36). You may observe tenting of the skin when testing for turgor (Fig. 9.37) (see Clinical Pearl, “Hydration Status in Older Adults”).

FIG. 9.35 Hands of older adult. Note prominent veins and thin appearance of skin.

FIG. 9.36 Skin hanging loosely, especially around bony prominences.

FIG. 9.37 Skin turgor in older adult. Note tenting.

CLINICAL PEARL

Hydration Status in Older Adults Because loss of skin turgor is a common finding in older adults, it is not a good indicator of hydration status. To determine hydration status, use other assessments, such as amount of saliva, urine output, and urine specific gravity.

FIG. 9.38 Cherry angioma in older adult. (From Ignatavicius and Workman, 2016.)

The immobility of some older adults, especially when combined with decreased peripheral vascular circulation, increases their risk for pressure ulcers (decubitus ulcers). During examination, pay particular attention to bony prominences and areas subject to persistent pressure or

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• Sebaceous hyperplasia occurs as yellowish, flattened papules with central depressions that are often difficult to discern from a basal cell carcinoma (Fig. 9.40).

• Cutaneous tags (acrochordon) are small, soft, skin-colored, pedunculated (narrow stalk) papules of skin, usually appearing on the neck and upper chest (Fig. 9.41).

• Cutaneous horns are small, hard projections of the epidermis, usually occurring on the forehead and face and can be the manifestation an underlying squamous cell carcinoma or a wart (Fig. 9.42).

From National Pressure Ulcer Advisory Panel, 2014.

STAGE CHARACTERISTICS

Suspected deep tissue injury Localized area of discolored intact skin (purple or maroon) or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler compared with adjacent tissue.

I Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area.

The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage I may be difficult to detect in individuals with dark skin tones. May indicate “at risk” individuals (a heralding sign of risk).

II Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serumfilled blister.

Presents as a shiny or dry shallow ulcer without slough or bruising.* This Category/Stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation.

*Bruising indicates suspected deep tissue injury.

III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.

The depth of a Category/Stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Category/Stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage III pressure ulcers. Bone/tendon is not visible or directly palpable.

IV Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling.

The depth of a Category/Stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput, and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Category/Stage

IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable.

Unstageable Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed.

Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/Stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as ‘the body’s natural (biological) cover’ and should not be removed.

TABLE 9.8 Staging of Pressure Ulcers (Decubitus Ulcers)

FIG. 9.39 Seborrheic keratoses in older adult. (From Glynn and Drake, 2012.)

FIG. 9.40 Sebaceous hyperplasia. (From Carey, 2010.)

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FIG. 9.41 Multiple cutaneous tags in axilla. (From Salvo, 2014.)

FIG. 9.42 Cutaneous horn. (From White, 1994.)

FIG. 9.43 Lentigo, a brown macule that appears in sun-exposed areas. (From Ignatavicius and Workman, 2016.)

• Solar lentigines (singular lentigo) are irregular, gray- brown macules that occur in sun-exposed areas that can range in size from a few millimeters to over a centimeter. These are often referred to as “age spots” or incorrectly as “liver spots” (Fig. 9.43). Note that “liver spots” have no relationship to the liver. They are epidermal prolifera- tions and are signs of photoaging of the skin. The hair turns gray or white as melanocytes cease

functioning. Head, body, pubic, and axillary hair thins and becomes sparse and drier. Men may show an increase in coarse aural, nasal, and eyebrow hair; women tend to develop coarse facial hair. Symmetric balding, usually frontal or occipital, often occurs in men.

The nails thicken, become more brittle, and may be deformed, misshapen, striated, distorted, or peeling. They can take on a yellowish color and may lose their transpar- ency. These changes occur most often in the toenails.

SAMPLE DOCUMENTATION

History and Physical Examination

Subjective A 23-year-old Caucasian patient, skin type 2 without past medical history, reports a full body rash that she first noticed 4 days ago. She thinks it may be from drinking new citrus juice. Describes rash as red, itchy, transient bumps on face, neck, arms, legs, and torso. No known food allergies. Denies exposure to new contact irritants. No new medications; is currently taking antihistamine for allergic rhinitis. Denies respiratory difficulty, difficulty swallowing, and edema. Denies fever, cough, and malaise.

Objective Skin: Blanchable, pink, irregularly, 5- to 8-mm papules on face, torso,

and extremities; large 3-cm urticarial wheal on right cheek. No excoriation, scaling, or secondary infection. Skin uniformly warm and dry. No edema.

Hair: Curly, black, thick, with female distribution pattern. Texture coarse. Nails: Opaque, short, well-groomed, uniform and without deformities.

Nail bed pink. Nail base angle 160 degrees. No redness, exudates, or swelling in the surrounding folds, and no tenderness to palpation. For additional sample documentation, see Chapter 5.

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ABNORMALITIES

SKIN, HAIR, NAILS

Skin: Inflammatory and Infectious Conditions Eczematous Dermatitis Most common inflammatory skin disorder; several forms, including irritant contact dermatitis, allergic contact dermatitis, and atopic dermatitis

PATHOPHYSIOLOGY PATIENT DATA • Common factor of the various forms are intercellular edema and

epidermal breakdown. • Eczematous dermatitis has three stages: acute, subacute, and chronic. • Itch-scratch cycle perpetuates the rash. • Excoriation from scratching predisposes to infection and causes crust

formation (Fig. 9.44).

Subjective Data • Itching is typically present. • Those with atopic dermatitis often report allergy history (allergic rhinitis,

asthma). • For irritant or allergic contact, exposure history is important.

Objective Data • Acute phase characterized by erythematous, pruritic, weeping

vesicles • Subacute eczema characterized by erythema and scaling • Chronic stage characterized by thick, lichenified, pruritic plaques • Atopic dermatitis: during childhood, lesions involve flexures, the nape,

and the dorsal aspects of the limbs; in adolescence and adulthood, lichenified plaques affect the flexures, head, and neck

FIG. 9.44 Contact dermatitis. (From Morison and Moffatt, 1994.)

FIG. 9.45 Beard folliculitis. (From Bolognia and Jorizzo, 2012.)

Folliculitis Inflammation and infection of the hair follicle and surrounding dermis

PATHOPHYSIOLOGY PATIENT DATA • Presence of inflammatory cells within the wall and ostia of the hair

follicle creates a follicular-based pustule. • Inflammation can be either superficial or deep; deep folliculitis can

result from chronic lesions of superficial folliculitis or from lesions that are manipulated.

• Persistent or recurrent lesions may result in scarring and permanent hair loss.

Subjective Data • Acute onset of papules and pustules associated with pruritus or mild

discomfort; may have pain with deep folliculitis • Risk factors: frequent shaving, immunosuppression, hot tubs without

adequate chlorine, preexisting dermatoses, long-term antibiotic use, occlusive clothing and/or occlusive dressings, exposure to hot humid temperatures, diabetes mellitus, obesity, and use of EGFR (epithelial growth factor receptor) inhibitor medications

Objective Data • Primary lesion is a small pustule 1-2 cm in diameter that is located

over a pilosebaceous orifice and may be perforated by a hair. • Pustule may be surrounded by inflammation or nodular lesions; after

the pustule ruptures, a crust forms (Fig. 9.45). • May have suppurative drainage with deep folliculitis. • Any hair-bearing site can be affected; the sites most often involved

are the face, scalp, thighs, axilla, and inguinal area.

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Furuncle (Boil) A deep-seated infection of the pilosebaceous unit

PATHOPHYSIOLOGY PATIENT DATA • Staphylococcus aureus is the most common organism. • Initially, a small perifollicular abscess that spreads to the surrounding

dermis and subcutaneous tissue. • May occur singly or in multiples; when infection involves several adjacent

follicles, a coalescent purulent mass or carbuncle forms.

Subjective Data • Acute onset of tender red nodule with center filled with pus.

Objective Data • Skin is red, hot, and tender. • Center of the lesion is purulent and forms a core that may rupture

spontaneously or require surgical incision (Fig. 9.46). • Sites commonly involved are the face and neck, arms, axillae, breasts,

thighs, and buttocks.

FIG. 9.46 Furuncle. (From Cordoro and Ganz JE, 2005.)

Cellulitis Diffuse, acute, infection of the skin and subcutaneous tissue

PATHOPHYSIOLOGY PATIENT DATA • Majority of cases caused by Streptococcus pyogenes or Staphylococcus

aureus. Subjective Data • Break in the skin, such as a fissure, cut, laceration, insect bite, or

puncture wound • Pain and swelling at the site • May have fever

Objective Data • Skin is red, hot, tender, and indurated; borders are not well demarcated

(Fig. 9.47). • Lymphangitic streaks and regional lymphadenopathy may be present. • Rare to have bilateral cellulitis.

FIG. 9.47 Cellulitis of the leg. (From Gawkrodger and Ardern-Jones, 2017.)

Tinea (Dermatophytosis) Group of noncandidal fungal infections that involve the stratum corneum, nails, or hair

PATHOPHYSIOLOGY PATIENT DATA • Infection by dermatophytes, typically acquired by direct contact with

infected humans or animals; invade the skin and survive on dead keratin.

• Lesions are usually classified according to anatomic location and can occur on nonhairy parts of the body (tinea corporis), on the groin and inner thigh (tinea cruris), on the scalp (tinea capitis), on the feet (tinea pedis), and on the nails (tinea unguium).

Subjective Data • May report pruritus. • May report hair breaking. • Nail changes accompany onychomycosis.

Objective Data • Lesions vary in appearance and may be papular, pustular, vesicular,

erythematous, or scaling (Fig. 9.48). • Secondary bacterial infection may be present. • Microscopic examination of skin scraping with potassium hydroxide

(KOH) solution shows presence of hyphae. • Infected nails are yellow and thick and may separate from the nail

bed.

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D FIG. 9.48 A, Tinea corporis. B, Tinea cruris. C, Tinea capitis. D, Tinea pedis. (From Callen et al, 2000.)

FIG. 9.49 Pityriasis rosea. (From Salvo, 2014.)

Pityriasis Rosea Self-limiting inflammation of unknown cause

PATHOPHYSIOLOGY PATIENT DATA • Possible infectious etiology (Drago et al, 2015), likely herpesvirus

(HHV)-6 or HHV-7 • Not contagious

Subjective Data • Sudden onset with occurrence of a primary (herald) oval or round

plaque. • Herald lesion is often missed. • Eruption occurs 1-3 weeks later and lasts for several weeks. • Pruritus may be present with the generalized eruption. • Often occurs in young adults during the spring time.

Objective Data • Lesions are usually pale, erythematous, flat-topped papules and plaques

with fine scaling (Fig. 9.49). • Lesions develop on the extremities and trunk; palms and soles are

not involved, and facial involvement is rare. • Trunk lesions are characteristically distributed in parallel alignment

following the skin tension lines in a Christmas tree–like pattern.

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Psoriasis Chronic and recurrent disease of keratinocyte proliferation

PATHOPHYSIOLOGY PATIENT DATA • Multifactorial origin with genetic component and immune regulation • Characterized by increased epidermal cell turnover, increased numbers

of epidermal stem cells, and abnormal differentiation of keratin expres- sion leading to thickened skin with copious scale

• Related to tumor necrosis factor (TNF)-alpha

Subjective Data • May have pruritus • Concerns about appearance • Does not typically get superinfected

Objective Data • Characterized by well-circumscribed, dry, silvery, scaling papules and

plaques (Fig. 9.50). • Lesions commonly occur on the back, buttocks, extensor surfaces of

the extremities, and the scalp. • Can be associated with psoriatic arthritis in up to 30% of patients. • May have pitting nail involvement.

FIG. 9.50 Psoriasis. Note characteristic silver scaling. (From Glynn and Drake, 2012.)

Rosacea Chronic inflammatory skin disorder

PATHOPHYSIOLOGY PATIENT DATA • Cause unknown; occurs most often in persons with a fair

complexion • Lasts for years, with episodes of activity followed by quiescent periods

of variable length

Subjective Data • Itching is absent. • Many patients report a stinging pain associated with flushing

episodes. • Common triggers are exposure to the sun, cold weather, sudden emotion,

(e.g., laughter or embarrassment), hot beverages, spicy foods, and alcohol consumption.

Objective Data • Eruptions appear on the forehead, cheeks, nose, and occasionally

about the eyes. • Characterized by telangiectasia, erythema, papules, and pustules that

occur particularly in the central area of the face (Fig. 9.51). • Although rosacea resembles acne, comedones are not present. • Tissue hypertrophy of the nose (rhinophyma) may occur, characterized

by sebaceous hyperplasia, redness, prominent vascularity, and swelling of the skin of the nose (Fig. 9.52).

FIG. 9.51 Rosacea. (From Wollina, 2011.)

FIG. 9.52 Rhinophyma. (From Tüzün et al, 2014.)

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Herpes Zoster (Shingles) Varicella-zoster viral (VZV) infection

PATHOPHYSIOLOGY PATIENT DATA • VZV morphologically and antigenically identical to the virus causing

varicella (chickenpox) • Dormant viral particles (since the original episode of varicella) in the

posterior spinal ganglia or cranial sensory ganglia become activated and spread along the nerve

Subjective Data • Pain, itching, or burning of the dermatome area usually precedes

eruption by 4-5 days. • After eruption resolves, there may be persistent pain called postherpetic

neuralgia.

Objective Data • Single dermatome that consists of red, swollen plaques or vesicles

that become filled with purulent fluid (Fig. 9.53) • Does not cross midline • Disseminated lesions in immunosuppressed or older adults

Herpes Simplex Infection by herpes simplex virus (HSV)

PATHOPHYSIOLOGY PATIENT DATA • Two virus types cause the infection: type 1, usually associated with

oral infection, and type 2, with genital infection. • Crossover infections are becoming common.

Subjective Data • Tenderness, pain, paresthesia, or mild burning at the infected site

before onset of the lesions

Objective Data • Grouped vesicles appear on an erythematous base and then erode,

forming a crust (Fig. 9.54). • Lesions last 2-6 weeks. • Can occur anywhere on the body.

FIG. 9.53 Herpes zoster (shingles) confined to one dermatome. (From Busam, 2016.)

A B C

FIG. 9.54 Herpes simplex. A, Oral. B, Female genital. C, Male genital. (A, from Salvo, 2009; B, from Swartz, 2010; C, from Morse et al, 1996.)

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Lyme Disease A tick-borne disease that can lead to multisystemic infection

PATHOPHYSIOLOGY PATIENT DATA • Spirochetal infection caused by Borrelia burgdorferi • Most common tick-borne disease in the United States • The spirochete deposited by the tick into the skin rather than directly

into the bloodstream. • Three phases of the disease are recognized: early localized, early

disseminated, and late disease. • The objective clinical manifestations are thought to be due to an

inflammatory response to live spirochetes or to their antigens.

Subjective Data • Exposure to ticks • Constitutional symptoms of fatigue, anorexia, and headache may develop. • Expanding rash

Objective Data • Early localized infection typically manifested by a single erythema

migrans skin lesion, a flat to slightly raised, erythematous skin lesion (usually ≥5 cm in diameter) that is round or oval in shape, with central clearing (Fig. 9.55) (classic target or bull’s-eye appearance).

• Early disseminated infection is usually manifested by multiple erythema migrans skin lesions, by neurologic symptoms such as facial palsy, meningitis, or encephalitis, or by symptoms of carditis such as lightheadedness, palpitations, dyspnea, chest pain, or syncope.

• Late disease usually manifested by arthritis atrophicans or atrophic dermatitis.

FIG. 9.55 Erythema migrans (lyme disease).

FIG. 9.56 Drug eruption. (From Zaoutis and Chiang, 2007.)

Skin: Cutaneous Reactions

Drug Eruptions Cutaneous reactions to medications

PATHOPHYSIOLOGY PATIENT DATA • Immunologically mediated cutaneous reactions to medications include

immunoglobulin E (IgE)–dependent, cytotoxic, immune complex, and cell-mediated hypersensitivity reactions.

• Nonimmunologically mediated reactions include direct release of mast cell mediators and idiosyncratic reactions.

Subjective Data • Rash appears from 1 to several weeks after taking a drug. • Pruritus may be present. • Offending drug often difficult to find. Do not forget about supplements

or over-the-counter treatments.

Objective Data • Most common: discrete to confluent erythematous macules and papules

on the trunk, face, extremities, palms, or soles of the feet (Fig. 9.56). • Rash fades in 1-3 weeks and may desquamate.

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Skin: Malignant/Neoplastic Abnormalities

Basal Cell Carcinoma The most common form of skin cancer

PATHOPHYSIOLOGY PATIENT DATA • Arises from the basal layer of the epidermis • Occurs in various clinical forms including nodular, pigmented, cystic,

sclerosing, and superficial • Occurs most frequently on exposed parts of the body—the face, ears,

neck, scalp, shoulders

Subjective Data • Persistent sore or lesion that has not healed • May have crusting • May itch

Objective Data • Shiny nodule that is pearly or translucent; may be pink, red, or white,

tan, black, or brown (Fig. 9.58) • Open sore; may have crusting; may bleed • Reddish patch or irritated area, frequently occurring on the face, chest,

shoulders, arms, or legs • Pink growth with a slightly elevated rolled border and a crusted

indentation in the center; as the growth slowly enlarges, tiny blood vessels may develop on the surface.

• Scarlike area that is white, yellow, or waxy and often has poorly defined borders; the skin appears shiny and taut.

FIG. 9.57 Acanthosis nigricans. (From Scheinfeld, 2004.)

Acanthosis Nigricans (AN) A nonspecific reaction pattern associated with obesity, certain endocrine syndromes, or malignancies or as an inherited disorder

PATHOPHYSIOLOGY PATIENT DATA • Insulin resistance and hyperinsulinism may lead to an activation of

insulin-like growth factor receptors, promoting epidermal growth. • Inherited form: rare, autosomal dominant trait with no obesity or

associated endocrinopathies • Malignant form: results from secretion of tumor products with insulin-like

activity or transforming growth factor alpha, which stimulates keratinocytes to proliferate

Subjective Data • May have history of obesity, endocrine disorders • With a rise in childhood obesity, this is seen more often in children

and adolescents. • Appearance in older adult associated with malignancy

Objective Data • Symmetric, brown thickening of the skin with plaques or patches of

thickened skin with a velvety or slightly verrucous texture (Fig. 9.57) • Lesions range in severity from slight discoloration of a small area to

extensive involvement of wide areas. • Most common site of involvement is the axillae, but the changes may

be observed in other flexural areas of the neck, groin, and arms. • Involvement of the dorsal and palmar hands or mucosal surfaces may

indicate malignant association.

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FIG. 9.58 Common presentations of basal cell carcinoma. (From Fitzsimons Army Medical Center. Scholes and Ramakrishnan, 2016.)

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Squamous Cell Carcinoma Second most common form of skin cancer

PATHOPHYSIOLOGY PATIENT DATA • This malignant tumor arises in the epithelium and has squamous

differentiation. • Lesions occur most commonly in sun-exposed areas, particularly the

scalp, back of hands, lower lip, and ear; the rim of the ear and the lower lip are especially vulnerable.

Subjective Data • Persistent sore or lesion that has not healed or that has grown in size • May have crusting and/or bleeding

Objective Data • Elevated growth with volcano-type pattern (Fig. 9.59) • Wartlike growth; may have crusting, may bleed • Scaly red patch with irregular borders may have crusting, may bleed • Open sore; may have crusting

FIG. 9.59 Squamous cell carcinoma. (From Neville et al, 2016.)

Malignant Melanoma Lethal form of skin cancer that develops from melanocytes

PATHOPHYSIOLOGY PATIENT DATA • Melanocytes migrate into the skin, eye, central nervous system, and

mucous membrane during fetal development. • Less than half of the melanomas develop from nevi; the majority arise

de novo from melanocytes. • The exact cause of malignancy is not known; heredity, hormonal factors,

ultraviolet light exposure, or an autoimmunologic effect may contribute to causation.

Subjective Data • New mole or preexisting mole that has changed or is changing • New pigmented lesion that has irregularities (Fig. 9.60) • History of melanoma • History of dysplastic or atypical nevi • Family history of melanoma (first-degree relative) • Significant tanning bed use

Objective Data • ABCDE changes in moles (Fig. 9.61) • A Asymmetry of lesion: one-half of a mole or birthmark does not match

the other • B Borders: edges are irregular, ragged, notched, or blurred. Pigment

may be streaming from the border. • C Color: the color is not the same all over and may have differing

shades of brown or black, sometimes with patches of red, white, or blue.

• D Diameter: the diameter is >6 mm (about the size of a pencil eraser) or is growing larger.

• E Evolution: changes seen in existing pigmented lesions, particularly in a nonuniform, asymmetric manner.

FIG. 9.60 Malignant melanoma. (From the Centers for Disease Control and Prevention/Carl Washington, MD, Emory University School of Medicine; Mona Saraiya, MD, MPH.)

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Kaposi Sarcoma (KS) A neoplasm of the endothelium and epithelial layer of the skin

PATHOPHYSIOLOGY PATIENT DATA • Caused by the Kaposi sarcoma herpes virus 8 (KSHV or HHV-8) • Individuals infected with KSHV are more likely to develop KS if their

immune system is compromised. • Commonly associated with human immunodeficiency virus (HIV)

infection.

Subjective Data • Soft bluish purple and painless skin plaques • May report peripheral lymphedema • May be presenting symptom of HIV/acquired immune deficiency

syndrome (AIDS)

Objective Data • Cutaneous lesions are characteristically soft, vascular, bluish purple,

and painless. • Lesions may be either macular or papular and may appear as plaques,

keloids, or ecchymotic areas (Fig. 9.62). • KS lesions may be limited to the skin or involve the mucosa, viscera,

and lymph nodes or any organ.

retemaiDroloCredroByrtemmysA

FIG. 9.61 ABCD changes in moles. (Reproduced with permission from the American Academy of Dermatology, 2010. All rights reserved.)

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FIG. 9.62 A, Violaceous plaques on the heel and lateral foot. B, Brown nodule of Kaposi sarcoma.

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Hair Disorders

Alopecia Areata Sudden, rapid, coin-shaped loss of hair, usually from the scalp or face

PATHOPHYSIOLOGY PATIENT DATA • Cause unknown; autoimmune phenomenon from a genetic–environmental

interaction may trigger the disease. • Any hair-bearing surface may be affected. • Regrowth begins in 1-3 months; the prognosis for total regrowth is

excellent in cases with limited involvement.

Subjective Data • Sudden, rapid, round patches of hair loss • May also report nail pitting • May have family history

Objective Data • Hair loss is in sharply defined, round areas (Fig. 9.63). • Nonscarring • The hair shaft is poorly formed and breaks off at the skin surface. • Small villous hairs indicate hair regrowth.

FIG. 9.63 Alopecia areata. (From Champagne and Farrant, 2015.)

Scarring Alopecia Replacement of hair follicles with scar tissue

PATHOPHYSIOLOGY PATIENT DATA • Skin disorders of the scalp or follicles result in scarring and destruction

of hair follicles and permanent hair loss. Subjective Data • May have other concurrent skin or systemic disorders such as systemic

lupus erythematosus

Objective Data • Patchy, irregular hair loss • Scalp may be inflamed • Hair follicles are lost and may be pustular or plugged.

Traction Alopecia Hair loss that is the result of prolonged, tightly pulled hairstyles

PATHOPHYSIOLOGY PATIENT DATA • Prolonged tension of the hair from traction breaks the hair shaft • Follicle is not damaged and the loss is reversible

Subjective Data • History of wearing certain hairstyles such as braids or from using hair

rollers and hot combs

Objective Data • Patchy hair loss that corresponds directly to the area of stress • Scalp may or may not be inflamed • Often with small, short hairs at site of pulling

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Hirsutism Growth of terminal hair in women in the male distribution pattern on the face, body, and pubic areas

PATHOPHYSIOLOGY PATIENT DATA • Caused by high androgen levels (from ovaries or adrenal glands) or

by hair follicles that are more sensitive to normal androgen levels; free testosterone is the androgen that causes hair growth.

• Many causes, including genetic, physiologic, endocrine, drug-related, and systemic disorders

Subjective Data • Excessive hair growth on the face or body • Onset, severity, and rate depend on underlying cause

Objective Data • Presence of thick, dark terminal hairs in androgen-sensitive sites:

face, chest, areola, external genitalia, upper and lower back, buttocks, inner thigh, and linea alba (Fig. 9.64)

• Hirsutism may or may not be accompanied by other signs of virilization.

Nails: Infection

Paronychia Inflammation of the paronychium

PATHOPHYSIOLOGY PATIENT DATA • Invasion of bacteria or yeast between the nail fold and the nail plate • Can occur as an acute or chronic process

Subjective Data • Acute: history of nail trauma or manipulation; acute onset • Chronic: history of repeated exposure to moisture, e.g., through

handwashing; evolves slowly initially, with tenderness and mild swelling

Objective Data • Redness, swelling, and tenderness at the lateral and proximal nail

folds • Purulent drainage often accumulates under the cuticle (Fig. 9.65). • Chronic paronychia can produce rippling of the nails.

FIG. 9.64 Facial hirsutism. Terminal hair growth is visible on the chin of this 40-year-old patient with idiopathic hirsutism. (From Lawrence and Cox NH, 1993.)

FIG. 9.65 Paronychia. (From Cuppett and Walsh, 2012.)

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Onychomycosis Fungal infection of the nail

PATHOPHYSIOLOGY PATIENT DATA • The fungus grows in the nail plate, causing it to crumble. Subjective Data

• Characteristic nail changes • May report associated discomfort, paresthesia, loss of manual dexterity;

may interfere with ability to exercise or walk

Objective Data • In the most common form, the distal nail plate turns yellow or white

as hyperkeratotic debris accumulates, causing the nail to separate from the nail bed (onycholysis).

• Pitting does not occur, distinguishing it from psoriasis (Fig. 9.66). • Often associated with tinea pedis

FIG. 9.66 Onychomycosis. (From Hay et al, 2011.)

FIG. 9.67 Ingrown toenail. Swelling and inflammation occur at lateral nail fold. (From Di Chiacchio and Di Chiacchio, 2015.)

Nails: Injury

Ingrown Nails Nail pierces the lateral nail fold and grows into the dermis

PATHOPHYSIOLOGY PATIENT DATA • Caused by lateral pressure of poorly fitting shoes, improper or excessive

trimming of the lateral nail plate, or trauma Subjective Data • Pain and swelling • History related to cause: tight shoes, excessive trimming, trauma

Objective Data • Redness and swelling at the area of nail penetration (Fig. 9.67) • Commonly involves the large toe

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Onycholysis Loosening of the nail plate with separation from the nail bed that begins at the distal groove

PATHOPHYSIOLOGY PATIENT DATA • Associated most commonly with minor trauma to long fingernails • Other causes include psoriasis, Candida or Pseudomonas infection,

medications, allergic contact dermatitis, and hyperthyroidism.

Subjective Data • Painless separation of the plate from the bed • May report history of nail trauma

Objective Data • Nonadherent portion of the nail opaque with a white, yellow, or green

tinge (Fig. 9.69)

FIG. 9.68 Subungual hematoma. (From Baren et al, 2008.)

FIG. 9.69 Onycholysis. Separation of nail plate starts at distal groove. (From Scher and Daniel, 2005.)

Subungual Hematoma Trauma to the nail plate severe enough to cause immediate bleeding and pain

PATHOPHYSIOLOGY PATIENT DATA • Amount of bleeding may be sufficient to cause separation and loss of

the nail plate • Trauma to the proximal nail fold may also cause bleeding that is not

apparent for several days. • Hematoma remains until the nail grows out or is decompressed to

release the blood and relieve the pressure.

Subjective Data • Trauma to the nail • May be very painful

Objective Data • Discolored dark nail (Fig. 9.68) • Color is typically red to purple as opposed to truly brown or black that

might indicate a subungual melanoma

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Nails: Changes Associated With Systemic Disease

Koilonychia (Spoon Nails) Central depression of the nail with lateral elevation of the nail plate

PATHOPHYSIOLOGY PATIENT DATA • Associated with iron deficiency anemia, syphilis, fungal dermatoses,

and hypothyroidism Subjective Data • History consistent with associated disorders

Objective Data • Concave curvature and spoon appearance (Fig. 9.70; see also Fig.

9.19)

FIG. 9.70 Koilonychia. (From White, 1994.)

Beau Lines • Transverse depression in the nail bed

PATHOPHYSIOLOGY PATIENT DATA • Temporary interruption of nail formation due to systemic disorders • Associated with coronary occlusion, hypercalcemia, and skin disease

Subjective Data • History consistent with associated disorders

Objective Data • Transverse depressions at the bases of the lunulae (crescent-shaped

“moon”) in all of the nails • Grooves disappear when the nails grow out (Fig. 9.71).

FIG. 9.71 Beau lines following systemic disease. (From Schachner and Hansen, 2011.)

FIG. 9.72 Terry nails; transverse white bands. (From Swartz, 2014.)

white Banding (Terry Nails) Whitening of the proximal half to three-quarters of the nail bed

PATHOPHYSIOLOGY PATIENT DATA • Associated with cirrhosis, chronic congestive heart failure, adult-onset

diabetes mellitus, and age • Speculated that it occurs as part of aging and that associated diseases

age the nail

Subjective Data • History consistent with associated disorders

Objective Data • Transverse white bands cover the nail except for a narrow zone at the

distal tip (Fig. 9.72).

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FIG. 9.73 Nail pitting. (From Goldman and Schafer, 2016.)

FIG. 9.74 Periungual warts. (From Lawrence and Cox, 1993.)

Psoriasis Chronic and recurrent disease of keratinocyte proliferation.

PATHOPHYSIOLOGY PATIENT DATA • Nail involvement usually occurs simultaneously with skin disease but

may occur as an isolated finding (see Psoriasis in Skin: Inflammatory and Infectious Conditions)

Subjective Data • Psoriatic lesions on skin • Joint pains associated with psoriatic arthritis

Objective Data • Pitting, onycholysis, discoloration, and subungual thickening • Yellow scaly debris often accumulates, elevating the nail plate • Severe psoriasis of the matrix and nail bed results in grossly malformed

nails and splinter hemorrhages (Fig. 9.73). • Can be associated with psoriatic arthritis in up to 30% of patients

Nails: Periungual Growths

warts Epidermal neoplasms caused by viral infection

PATHOPHYSIOLOGY PATIENT DATA • Caused by human papilloma virus (HPV) Subjective Data

• A growth at the nail fold

Objective Data • Occur at the nail folds and extend under the nail • Longitudinal nail groove in the nail may occur from warts located over

the nail matrix (Fig. 9.74)

Digital Mucous Cysts Cyst-like structures contain a clear, jelly-like substance

PATHOPHYSIOLOGY PATIENT DATA • Cysts on the proximal nail fold are not connected to the joint space

or tendon sheath; they result from localized fibroblast proliferation; compression of the nail-matrix cells induces a longitudinal nail groove.

• Cysts located on the dorsal-lateral finger at the distal interphalangeal (DIP) joint are probably caused by herniation of tendon sheaths or joint linings and are related to ganglion and synovial cysts.

Subjective Data • Cyst on the proximal nail fold or dorsal-lateral aspect of distal finger

Objective Data • Cyst containing clear substance • Longitudinal nail groove may occur from cysts located at the proximal

nail fold (Fig. 9.75).

FIG. 9.75 Digital mucous cysts causing a groove in the nail plate. (From White, 1994.)

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Pregnant Patients

Polymorphic Eruption of Pregnancy A benign dermatosis that usually arises late in the third trimester of a first pregnancy

PATHOPHYSIOLOGY PATIENT DATA • Etiology unclear • Immunologic mechanisms, hormonal abnormalities, and abdominal

skin distention have been suggested as etiologic mechanisms (Brzoza, 2007)

• Relationship between the maternal immune system and fetal cells has been proposed (Tunzi and Gray, 2007)

• Eruption usually resolves promptly after delivery and does not usually recur in subsequent pregnancies

Subjective Data • Intensely pruritic rash that began on the abdomen • After a few days, the eruption spreads to the thighs, buttocks, and

arms.

Objective Data • Erythematous, urticaria-like papules and plaques on abdomen, thighs,

buttock, arms • Periumbilical area is spared (distinguishes it from pemphigoid

gestationis). • Usually no lesions on face, palms, or soles • Often halos of blanching surround the papules. • Small vesicles may be present, but larger bullae do not occur and

would suggest the more rare herpes gestationis.

Infants and Children

Seborrheic Dermatitis Chronic, recurrent, erythematous scaling eruption localized in areas where sebaceous glands are concentrated (e.g., scalp, back, and intertriginous and diaper areas)

PATHOPHYSIOLOGY PATIENT DATA • Cause is unknown. • Condition most commonly occurs in infants within the first 3 months

of life.

Subjective Data • Parent reports thick greasy scalp scales or body rash. • No associated symptoms

Objective Data • Scalp lesions are scaling, adherent, thick, yellow, and crusted (“cradle

cap”) and can spread over the ear and down the nape of the neck (Fig. 9.76).

• Lesions elsewhere are erythematous, scaling, and fissured, typically on central body or in diaper area.

FIG. 9.76 Pustular seborrheic dermatitis. (From James and Elston, 2018.)

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Impetigo Common, contagious superficial skin infection

PATHOPHYSIOLOGY PATIENT DATA • Caused by staphylococcal or streptococcal infection and/or infection

of the epidermis Subjective Data • Lesion, typically on the face, that itches and burns • Also on other parts of body associated with minor injuries or insect

bites

Objective Data • Initial lesion is a small erythematous macule that changes into a vesicle

or bulla with a thin roof. • Lesion crusts with a characteristic honey color from the exudate as

the vesicles or bullae rupture (Fig. 9.78). • May have regional lymphadenopathy.

Miliaria Rubra (“Prickly Heat”)

PATHOPHYSIOLOGY PATIENT DATA • Caused by sweat retention from occlusion of sweat ducts during periods

of heat and high humidity • Results from immaturity of skin structures • Overdressed babies are susceptible to this condition in the summer.

Subjective Data • Parent reports rash noted when undressing the infant.

Objective Data • Irregular, red, macular rash, usually on covered areas of the skin (Fig.

9.77)

FIG. 9.77 Miliaria in infant. (From Baren et al, 2008.)

FIG. 9.78 Impetigo. Note characteristic crusting. (From Neville et al, 2016.)

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Acne vulgaris

PATHOPHYSIOLOGY PATIENT DATA • Androgens stimulate the pilosebaceous units at the time of puberty to

enlarge and produce large amounts of sebum. • Simultaneously, the keratinization process in the pilosebaceous canal

is disrupted with impaction and obstruction of the outflow of sebum resulting in comedo formation—open blackheads and closed whiteheads.

• Wall of the closed comedo may rupture, spilling the follicular contents into the dermis, leading to the development of inflammatory papules.

• The presence of Propionibacterium acnes brings in neutrophils, which cause the inflammatory response.

Subjective Data • Most commonly reported by adolescent • May occur initially as an adult or continue into the adult years • Patient reports comedones (plugged follicles—blackheads and

whiteheads), papules, and pustules over the forehead, nose, cheeks, lower face, chest, and back that evolve on the face, chest, and back.

Objective Data • Noninflammatory acne: open (whiteheads) and closed (blackheads)

comedones • Inflammatory acne: papules, nodules, or cystic lesions (Fig. 9.79) • Characteristic “ice pick” scarring may be present from previous lesions

FIG. 9.79 Acne in adolescent. (From Swartz, 2014.)

Chickenpox (varicella) Acute, highly communicable disease common in children and young adults

PATHOPHYSIOLOGY PATIENT DATA • Caused by the varicella zoster virus (VZV) • VZV is communicable by direct contact, droplet transmission, and

airborne transmission • Incubation period 2-3 weeks; the period of communicability lasts from

1 or 2 days before onset of the rash until lesions have crusted over. • Routine childhood immunization has resulted in a significant decline

in incidence • After primary infection, VZV remains dormant in sensory nerve roots

for life. • Can reactivate to cause shingles

Subjective Data • Fever, headache, sore throat, mild malaise • Pruritic rash that started on scalp and then moved to extremities • Started as papular and in a few hours became vesicular • Child has not had varicella vaccine.

Objective Data • Papular and vesicular lesions on trunk, extremities, face, buccal mucosa,

palate, or conjunctivae (Fig. 9.80) • Lesions usually occur in successive clusters eventually spreading to

entire body, with several stages of maturity present at one time. • Complications include conjunctival involvement, secondary bacterial

infection, viral pneumonia, encephalitis, aseptic meningitis, myelitis, Guillain-Barré syndrome, and Reye syndrome.

FIG. 9.80 Varicella (chickenpox). Note vesicular lesions. (From Swartz, 2014.)

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Measles (Rubeola) Also called hard measles or red measles

PATHOPHYSIOLOGY PATIENT DATA • Measles virus infects by invasion of the respiratory epithelium. • Local multiplication at the respiratory mucosa leads to a primary viremia,

during which the virus spreads in leukocytes to the reticuloendothelial system.

• Both endothelial and epithelial cells are infected; infected tissues include thymus, spleen, lymph nodes, liver, skin, conjunctiva, and lung.

• Incubation period is commonly 18 days; the period of communicability lasts from a few days before the fever to 4 days after appearance of the rash.

• Disease is preventable by immunization.

Subjective Data • Fever, conjunctivitis, stuffy nose, and cough, followed by a red, blotchy

rash first on the face and then spreading to trunk and extremities • Child has not had measles vaccine. • International travel or exposure to individuals from endemic areas

Objective Data • Koplik spots (discrete white macular lesions) on the buccal mucosa • Macular rash on the face and neck • Maculopapular lesions on trunk and extremities in irregular confluent

patches • Rash lasts 4-7 days (Fig. 9.81) • Symptoms may be mild or severe • Complications involve infection of the respiratory tract and central

nervous system.

FIG. 9.81 Rubeola. (From Kremer and Muller, 2009.)

German Measles (Rubella) Mild, febrile, highly communicable viral disease

PATHOPHYSIOLOGY PATIENT DATA • Spread in droplets that are shed from respiratory secretions of infected

persons • Patients are most contagious while the rash is erupting, but they may

shed virus from the throat from 10 days before until 15 days after the onset of the rash.

• Incubation period is 14-23 days. • Disease is preventable by immunization.

Subjective Data • Low-grade fever, stuffy nose, sore throat, and cough • This is followed by a macular rash on the face and trunk that rapidly

becomes papular.

Objective Data • Generalized light pink to red morbilliform rash • By the second day, rash spreads to the upper and lower extremities;

it fades within 3 days. • Reddish spots occur on the soft palate during the prodrome or on the

first day of the rash (Forchheimer spots) (Fig. 9.82). • Infection during the first trimester of pregnancy may lead to infection

of the fetus and may produce a variety of congenital anomalies (congenital rubella syndrome).

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FIG. 9.82 Rubella (German measles). A, Note the pinkish red, maculopapular eruption. B, Red palatal lesions (Forchheimer spots) are seen in some patients on day 1 of the rash. (From James and Elston, 2018.)

FIG. 9.83 Trichotillomania. (From Paller and Mancini, 2016.)

FIG. 9.84 This contusion in the configuration of a closed horseshoe with a central linear abrasion was inflicted with a belt buckle. (From Zitelli et al, 2012.)

Hair-Pulling (Trichotillomania) Loss of scalp hair can be caused by physical manipulation

PATHOPHYSIOLOGY PATIENT DATA • Hair is twisted around the finger and pulled or rubbed until it breaks

off; the act of manipulation is usually an unconscious habit. Subjective Data • May report tension, anxiety, emotional stressors

Objective Data • Affected area has an irregular border, and hair density is greatly reduced,

but the site is not bald (Fig. 9.83)

Patterns of Injury in Physical Abuse Physical findings in children who are physically abused include bruises, burns, lacerations, scars, bony deformities, alopecia, retinal hemorrhages, dental trauma, and head and abdominal injuries. Skin and hair abnormalities may be the most visible clues in detecting this problem. It is important to examine the skin that is usually covered by clothing. Some skin and hair findings commonly associated with physical abuse are described in the following paragraphs. • Bruises: These may be patterned consistent with the implement used, such as belt marks (Fig. 9.84), marks from a looped electric cord, and oval

or fingertip grab marks. Bruising associated with abuse occurs over soft tissue; toddlers and older children who bruise themselves accidentally do so over bony prominences. Any bruise in an infant who is not yet developmentally able to be mobile should be cause for concern.

• Lacerations: Lacerations of the frenulum and lips are associated with forced feeding. Human bites can cause breaks in the skin and leave a characteristic bite mark.

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FIG. 9.85 Burns on the perineum, thighs, legs, and feet. (Courtesy Dr. Thomas Layton, Mercy Hospital, Pittsburgh; from Zitelli et al, 2012.)

FIG. 9.86 Cigarette burns. These burns demonstrate various stages of healing. (From Paller and Mancini, 2016.)

FIG. 9.87 Stasis dermatitis in older adult. (From Swartz, 2014.)

• Burns: Patterns that are common include scald burns in stocking and glove distribution (when hands or feet are placed on hot surface or immersed); buttock burns consistent with immersion (Fig. 9.85); and cigarette burns (Fig. 9.86), a characteristic small, round burn, often on areas hidden by clothing. The absence of splash marks or a pattern consistent with spills of hot liquids may be helpful in differentiating accidental from deliberate burns.

• Hair loss: Patchy hair loss or bald spots, in the absence of a scalp disorder such as ringworm, may indicate repeated hair-pulling. • Presence of anogenital warts in a child under 2 years should also raise suspicion of physical and/or sexual abuse, although these can be

auto-inoculated.

Older Adults

Stasis Dermatitis

PATHOPHYSIOLOGY PATIENT DATA • Occurs on the lower legs in some patients with venous insufficiency • Incompetent venous valves, inadequate tissue support, and postural

hydrostatic pressure contribute to the development of venous stasis. • Dermatologic changes secondary to the effects of extravasated blood,

which induces a mild inflammatory response in the dermis and sub- cutaneous fat

• Most patients with venous insufficiency do not develop dermatitis, which suggests that genetic or environmental factors may play a role.

• May occur as an allergic response to an epidermal protein antigen created through increased hydrostatic pressure, or because the skin has been compromised and is more susceptible to irritation and trauma

Subjective Data • Sense of fullness or dull aching in the lower legs and ankles • Gradual increase in pigmentation and redness • Area may be itchy and/or painful

Objective Data • Erythematous, scaling, weeping patches on lower extremity; ulceration

may be present (Fig. 9.87). • Dermatitis may be acute, subacute, or chronic and recurrent.

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FIG. 9.88 Actinic keratosis in older adult in area of sun exposure. (From Busam, 2016.)

Actinic Keratosis Atypical squamous cells confined to the upper layers of epidermis

PATHOPHYSIOLOGY PATIENT DATA • Occurs secondary to chronic sun damage • Most lesions remain superficial; lesions can progress into squamous

cell carcinoma over time.

Subjective Data • History of chronic sun exposure • Increasing number of lesions with age

Objective Data • Raised, gritty, erythematous lesion that is usually with an irregular,

rough surface • Lesion is most common on the dorsal surface of the hands, arms,

neck, and face (Fig. 9.88).

Physical Abuse in Older Adults Abuse in older adults can assume the form of physical abuse, neglect, sexual abuse, psychological abuse, financial abuse, or violation of rights. Physical neglect is probably the most common type of abuse encountered by health care professionals. However, be aware that when one form of abuse is present, it is typically accompanied by other forms.

Physical abuse and neglect may present with clues that aid in detection. Assessment of general appearance may indicate poor hygiene, emaciation, healed fractures with deformity, and unexplained trauma. Carefully inspect the skin, particularly on hidden areas such as the axillae, inner thighs, soles of the feet, palms, and abdomen; look for bruising, burns, abrasions, or areas of tenderness. Bruising on extensor surfaces is common and usually occurs accidentally; bruising at various stages of resolution located on inner soft surfaces is more likely to indicate abuse.

Careful history taking is essential. When abuse is suspected, it is important to ask direct questions, such as “Is anyone hurting or harming you?” or “Have you been confined against your will?” This questioning should occur in a private setting away from accompanying family members or caregivers. Determination of mental status is also essential (see Chapter 5), because unintended self-neglect or abuse is also possible. If the patient is cognitively impaired, abuse by another may still be present but needs to be corroborated.

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CHAPTER

10 Lymphatic System The lymphatic system is examined region by region during the examination of the other body systems (i.e., head and neck, breast and axillary, genitalia, and extremities) and by palpating the spleen. Sometimes you may perform a comprehensive lymphatic examination, exploring all the areas in which the lymph nodes are accessible. Individual chapters in this book discuss the lymphatic system in specific body areas.

system with a normal immune response to antigen exposure. Tissue rejection of transplanted organs is an unwelcome manifestation of immunocompetence. When the immune system fails, the individual may experience a variety of illnesses, such as an allergic reaction or an immunodeficiency—either congenital or acquired (e.g., infection with human immunodeficiency virus [HIV]), or autoimmune, that is allergy to oneself (e.g., systemic lupus erythematosus). An integral part of the immune system, the lymphatic system supports a network of defenses against microorganisms.

Except for the placenta and the brain, every tissue sup- plied by blood vessels has lymphatic vessels. This wide- ranging presence is essential to the system’s role in immunologic and metabolic processes. That role involves the following: • Movement of lymph fluid within the cardiovascular

system, a major factor in the maintenance of fluid balance. Without lymphatic drainage, fluid would build up in interstitial spaces because more fluid leaves capil- laries than veins can absorb.

• Filtration of fluid before it is returned to the bloodstream, filtering out substances that could be harmful to the body, and filtering microorganisms from the blood

• Phagocytosis—the ingestion and digestion by cells of solid substances such as other cells, bacteria, and bits of dead tissue or foreign particles—is a specific function of cells in lymph nodes

• Production of lymphocytes within the lymph nodes, tonsils, adenoids, spleen, and bone marrow

• Production of antibodies • Absorption of fat and fat-soluble substances from the

intestinal tract In addition, the lymphatic system plays an undesirable

role in providing at least one pathway for the spread of malignancy.

Lymph is a clear, sometimes milky-colored or yellow- tinged fluid. It contains a variety of white blood cells (mostly lymphocytes) and, on occasion, red blood cells. The lym- phatic and cardiovascular systems are intimately related. The fluids and proteins that constitute lymphatic fluid move from the bloodstream into the interstitial spaces. They are then collected throughout the body by a profusion of microscopic tubules (Fig. 10.2). These tubules unite, forming

Physical Examination Components

Lymphatic System 1. Inspect the visible nodes and surrounding area for:

• Edema • Erythema • Red streaks

2. Palpate the superficial lymph nodes and compare side to side for: • Size • Consistency • Mobility • Discrete borders or matting • Tenderness • Warmth If you discover an enlarged node, consider the associated region

drained by the node to suggest possible sources for a presenting problem.

ANATOMY AND PHYSIOLOGY

The lymphatic system consists of lymph fluid, the collecting lymphatic ducts, and various tissues including the lymph nodes, spleen, thymus, tonsils, adenoids, and Peyer patches in the small intestine. Bits of lymph tissue are found in other parts of the body including the mucosa of the stomach and appendix, bone marrow, and lungs (Fig. 10.1). Functions of the lymphatic system include conserving fluid and plasma that leak from capillaries, defending the body against disease as part of the immune system, and absorbing lipids from the intestinal tract.

The immune system protects the body from the antigenic substances of invading organisms, removes damaged cells from the circulation, and provides a partial barrier to the maturation of malignant cells within the body. When it functions well, the individual has a competent immune

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Tonsils, bilaterally, between palatine arches in the pharynx

Lymph nodes Bronchial-associated

lymphoid tissues

Lymph nodes

Small intestine

Intestinal-associated lymphoid tissues

Pancreas

Spleen

Thymus

Liver

Gallbladder

Large intestine

Appendix

FIG. 10.1 Lymphatic system (lymphoreticular system).

Tracheal nodes

Bronchial nodes

Mediastinal nodes

Mesentery nodes

Preaortic nodes

Iliac nodes

Inguinal nodes

Right jugular trunk Right internal

jugular vein

Right lymphatic duct

Right subclavian vein

Right subclavian trunk Internal mammary

Thoracic duct

Cisterna chyli Intestinal lymph vessels

Right and left lumbar trunks

Testicular lymph vessels

Lower extremity lymph vessels

Left jugular trunk Left internal jugular vein

Left subclavian trunk

Bronchomediastinal trunk

Left subclavian vein

Twelfth thoracic vertebra First lumbar vertebra

FIG. 10.2 Lymphatic drainage pathways. Shaded area of the body is drained via the right lymphatic duct, which is formed by the union of three vessels: right jugular trunk, right subclavian trunk, and right broncho- mediastinal trunk. Lymph from the remainder of the body enters the venous system by way of the thoracic duct.

larger ducts that collect lymph and carry it to the lymph nodes around the body.

The lymph nodes receive lymph from the collecting ducts in the various regions (Figs. 10.3 to 10.11), passing it on through efferent vessels. Ultimately, the large ducts merge into the venous system at the subclavian veins.

The drainage point for the right upper body is a lymphatic trunk that empties into the right subclavian vein. The

thoracic duct, the major vessel of the lymphatic system, drains lymph from the rest of the body into the left sub- clavian vein. It returns the various fluids and proteins to the cardiovascular system, forming a closed but porous circle.

The lymphatic system has no built-in pumping mecha- nisms of its own. Because it depends on the cardiovascular system for this, the movement of lymph is sluggish compared with that of blood. As lymph fluid volume increases, it flows faster in response to mounting capillary pressure, greater permeability of the capillary walls of the cardiovascular system, increased bodily or metabolic activity, and mechanical compression. Conversely, mechanical obstruction will slow or stop the movement of lymph, dilating the system. The permeability of the lymphatic system is protective; if it is obstructed, lymph may diffuse into the vascular system, or collateral connecting channels may develop.

Lymph Nodes Lymph nodes are discrete structures surrounded by a capsule composed of connective tissue and a few elastic fibrils. Lymph nodes usually occur in groups. Superficial nodes are located in subcutaneous connective tissues, and deeper nodes lie beneath the fascia of muscles and within the various body cavities. The nodes are numerous and tiny, but some of them may have diameters as large as 0.5 to

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Y Inferior superficial inguinal nodes

Superior superficial inguinal nodes

Great saphenous lymphatic vessels Popliteal

nodes

Small saphenous lymphatic vessels

Deep sublinguinal node

ANTERIOR VIEW POSTERIOR VIEWFIG. 10.3 Lymphatic drainage of lower extremity.

Preaortic nodes

Preaortic nodes

Internal iliac nodes

Obturator nodes

Superficial inguinal nodes

Deep inguinal

nodes

External iliac nodes

Common iliac nodes

FIG. 10.4 Lymphatic drainage of female genital tract.

ANTERIOR VIEW POSTERIOR VIEW

Radial lymphatic vessels

Epitrochlear nodes

Epitrochlear nodes

Radial lymphatic

vessels

Brachial (axillary) nodes

Ulnar lymphatic vessels

Median lymphatic vessels

FIG. 10.5 Systems of deep and superficial collecting ducts, carrying lymph from upper extremity to subclavian lymphatic trunk. The only peripheral lymph center is the epitrochlear, which receives some of the collecting ducts from the pathway of the ulnar and radial nerves.

Brachial

Central axillary

Subclavian

Subscapular

External mammary (anterior pectoral)

Mammary (Rotter nodes)

FIG. 10.6 Six groups of lymph nodes may be distinguished in the axillary fossa.

External mammary (anterior pectoral)

Mammary (Rotter nodes) Internal mammary

Subscapular

Brachial (axillary)

Central axillary

SupraclavicularSubclavian

FIG. 10.7 Lymphatic drainage of breast.

Internal jugular

chain

Posterior auricular (mastoid)

Sternomastoid Retropharyngeal (tonsilar)

Parotid

Preauricular

FIG. 10.8 Lymph nodes involved with the ear.

1 cm. They defend against the invasion of microorganisms and other particles with filtration and phagocytosis, and they aid in the maturation of lymphocytes and monocytes.

The superficial lymph nodes are the gateway to assessing the health of the entire lymphatic system. Readily accessible to inspection and palpation, they provide some of the earliest clues to the presence of infection or malignancy (Box 10.1).

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Submandibular Submental

Sublingual

Suprahyoid Thyrolinguofacial

Internal jugular chain

FIG. 10.9 Lymph nodes involved with the tongue.

Preauricular nodes

Parotid

Facial Submandibular

Submental Sublingual

Suprahyoid node Thyrolinguofacial

Anterior deep and superficial cervical

Internal jugular chain

Posterior auricular (mastoid nodes) Occipital nodes Sternomastoid nodes External jugular Retropharyngeal (tonsillar) Posterior cervical spinal nerve chain Posterior superficial cervical chain

Supraclavicular nodes

FIG. 10.10 Lymphatic drainage system of head and neck. If the group of nodes is commonly referred to by another name, the second name appears in parentheses.

Posterior cervical spinal nerve chain

Posterior superficial cervical

Anterior deep and superficial cervical

Sternocleidomastoid muscle Internal jugular chain

Trapezius muscle

Internal jugular vein

Sternocleidomastoid muscle

Supraclavicular

Thyrolinguofacial

Submental Occipital Retropharyngeal

Submandibular

Suprahyoid

Anterior jugular

FIG. 10.11 Lymph nodes of neck. Note relationship to the sternocleidomastoid muscle.

BOX 10.1 The Lymph Nodes Most Accessible to Inspection and Palpation

The more superficial the node, the more accessible it is.

The “Necklace” of Nodes Parotid and retropharyngeal (tonsillar) Submandibular Submental Sublingual (facial) Superficial anterior cervical Superficial posterior cervical Preauricular and postauricular Sternocleidomastoid Occipital Supraclavicular

The Arms Axillary Epitrochlear (cubital)

The Legs Superficial superior inguinal Superficial inferior inguinal Occasionally, popliteal

For example, a palpable supraclavicular node should be suspected as a probable sign of malignancy.

Lymphocytes Lymphocytes are central to the body’s response to antigenic substances. They are not uniform in size or function. Some are small, approximately 7 to 8 μm in diameter; others range in size to as much as five times that. They arise from a number of sites in the body, including the lymph nodes, tonsils, adenoids, and spleen, but primarily they are pro- duced in the bone marrow, where early cells (i.e., stem cells) capable of developing in a variety of pathways arise. Lymphocytes that are derived primarily from bone marrow (i.e., B lymphocytes) produce antibodies and are character- ized by the various arrangements of immunoglobulins on their surface. They are involved in the humoral immune response.

Marrow-derived cells that mature in the thymus (T lymphocytes) are further differentiated into types of T cells, each with a distinct function. A unique feature of T cells is their ability to discriminate between healthy and abnormal

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Spleen The spleen is situated in the left upper quadrant of the abdominal cavity between the stomach and the diaphragm. A highly vascular organ, it is composed of two systems: (1) the white pulp, made up of lymphatic nodules and diffuse lymphatic tissue; and (2) the red pulp, made up of venous sinusoids. The spleen has several functions including destroying old red blood cells, producing antibodies, storing red blood cells, and filtering micro- organisms from the blood. Its examination therefore is essential to the evaluation of the immune system (see Chapter 18).

Tonsils and Adenoids The palatine tonsils are commonly referred to as “the tonsils.” Small and diamond-shaped, they are set between the palatine arches on either side of the pharynx just beyond the base of the tongue. Composed principally of lymphoid tissue, the tonsils are organized as follicles and crypts; both are covered by mucous membrane. The pharyngeal tonsils, or adenoids, are located at the nasopharyngeal border; the lingual tonsils are located near the base of the tongue. Defensive responses to inhaled and intranasal antigens are activated in these tissues. When enlarged, the adenoids and tonsils can obstruct the nasopharyngeal passageway.

Peyer Patches Peyer patches are small, raised areas of lymph tissue on the mucosa of the small intestine and consist of many clustered lymphoid nodules. Peyer patches are important in immune surveillance in the intestinal tract. They facilitate an immune response when pathogenic microorganisms are detected.

Infants and Children The immune system and the lymphoid system begin developing at about 20 weeks of gestation. The ability to produce antibodies is still immature at birth, increasing the infant’s vulnerability to infection during the first few months of life (see Clinical Pearl, “Umbilical Cord”). The mass of lymphoid tissue is relatively plentiful in infants; increases during childhood, especially between 6 and 9 years of age; then regresses to adult levels by puberty (see Chapter 8, Fig. 8.2).

Anterior viewB Lateral view

Thymus gland

Pericardium

Anterior viewA Lateral view

Thymus gland

Pericardium

FIG. 10.12 Location of thymus gland and its size relative to the rest of the body. A, During infancy. B, During adult life.

CLINICAL PEARL

Umbilical Cord The umbilical cord should drop off by 1 to 2 weeks after birth. Delayed umbilical cord separation is associated with leukocyte adhesion deficiency, an autosomal recessive disorder that causes recurrent infections.

cells. Activation by their specific antigen (e.g., a living virus, bacterium, parasite, chemical, malignant change) elicits an immune response. T lymphocytes also have an important role in controlling the immune responses brought about by B lymphocytes.

Among lymphocytes, B cells have a relatively short life span of 3 to 4 days. T cells, which are four or five times as numerous as B cells, have a life span of 100 to 200 days. An increased number of lymphocytes in the blood represents a systemic response to most viral infections and to some bacterial infections.

Thymus The thymus is located in the superior mediastinum, extend- ing upward into the lower neck. In early life, the thymus is essential to the development of the protective immune function (Fig. 10.12). It is the site for production of T lymphocytes, the cells responsible for cell-mediated immu- nity reactions and the controlling agent for the humoral immune responses generated by B lymphocytes. It is largest and most active during the neonatal and preadolescent periods and atrophies after puberty.

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The thymus is at its largest relative to the rest of the body shortly after birth but reaches its greatest absolute weight at puberty. Then it involutes, replacing much of its tissue with fat and becoming a rudimentary organ in the adult.

The palatine tonsils, like much lymphoid tissue, are much larger during early childhood than after puberty. An enlargement of the tonsils in children is not necessarily an indication of problems. They also appear larger as the mouth and throat are not as large.

The lymph nodes have the same distribution in children that they do in adults. The finding of small 2- to 3-mm, dis- crete, palpable, mobile nodes in the neonate is not unusual. Before 2 years of age, inguinal, occipital, and postauricular nodes are common; after 2 years of age, they are more indicative of a problem. On the other hand, cervical and submandibular nodes are uncommon during the first year and much more common in older children. Supraclavicular nodes are not usually palpable; their presence, associated with a high incidence of malignancy, is always a cause for concern. Circumcision does not increase the likelihood of inguinal nodes. It is possible that the infant’s relatively large mass of lymphoid tissue is needed to compensate for an immature ability to produce antibodies, thus adding to the demand for filtration and phagocytosis.

The lymphatic system gradually reaches adult competency during childhood (Fig. 10.13).

Pregnant Patients Pregnancy is a state of altered immune function. The complex changes are not yet fully understood and reflect

multiple mechanisms to achieve and maintain fetal tolerance during pregnancy while still allowing for normal immune defense in the pregnant patient (Gabbe et al, 2017). The immune changes in pregnancy can lead to temporary remission of the pregnant individual’s autoimmune/ inflammatory diseases (e.g., rheumatoid arthritis).

Older Adults The number of lymph nodes may diminish and size may decrease with advanced age; some of the lymphoid structures are lost. The nodes of older patients are more likely to be fibrotic and fatty than those of the young, a contributing factor to impaired ability to resist infection.

REvIEw OF RELATED HISTORY

For each of the symptoms or conditions discussed in this section, targeted topics to include in the history of the present illness are listed. Responses to questions about these topics provide clues for focusing the physical examina- tion and the development of an appropriate diagnostic evaluation. Questions regarding medication use (prescription and over-the-counter preparations) as well as complementary and alternative therapies are relevant for each.

History of Present Illness • Enlarged node(s) (lumps, knots, bumps, kernels, swollen

glands) • Character: onset, location, duration, number,

tenderness • Associated local symptoms: pain, redness, warmth,

red streaks • Associated systemic symptoms: malaise, fever, weight

loss, night sweats, abdominal pain or fullness, itching (some tumors cause pruritus)

• Predisposing factors: infection, surgery, trauma • Medications: chemotherapy, antibiotics

• Swelling of extremity • Unilateral or bilateral, intermittent or constant,

duration • Predisposing factors: cardiac or renal disorder, surgery,

infection, trauma, venous insufficiency • Associated symptoms: warmth, redness or discolor-

ation, ulceration • Efforts at treatment and their effect: support stockings,

elevation

Past Medical History • Chest imaging; reason and results • Tuberculosis and other skin testing • Blood transfusions, use of blood products • Chronic illness: cardiac, renal, malignancy, HIV infection

(see Risk Factors box for HIV infection) • Surgery: trauma to regional lymph nodes, organ trans-

plant, lymph node biopsy

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• Present or recent infections, trauma distal to nodes • Poor growth, failure to thrive • Loss of interest in play or eating • Immunization history • Maternal HIV infection

Pregnant Patients • Weeks of gestation • Exposure to infections • Presence of pets in household (exposure to cat feces or

litter) • Immunization status: influenza, pneumonia, meningo-

coccal, tetanus/diphtheria/pertussis

Older Adults • Presence of an autoimmune disease • Present or recent infection or trauma distal to nodes • Delayed healing • Immunization status: influenza, pneumococcal, tetanus/

diphtheria/pertussis, shingles (herpes zoster)

EXAMINATION AND FINDINGS

Equipment • Centimeter ruler • Skin-marking pencil

Inspection and Palpation Disorders of the lymph system present with three physical signs: enlarged lymph nodes (lymphadenopathy), red streaks on the overlying skin (lymphangitis), and lymphedema (Box 10.2). Inspect each area of the body for apparent lymph nodes, edema, erythema, red streaks, and skin lesions. Using the pads of the second, third, and fourth fingers, gently palpate for superficial lymph nodes (see Box 10.1 and Fig. 10.14). Try to detect any hidden enlargement, and

• Recurrent infections • Autoimmune disorder • Allergies

Risk Factors

HIV Infection Adolescents and Adults Multiple Sexual Contacts • Prostitution • Unprotected sexual activity with persons of known history of risk

or unknown history • Sexual activity with persons infected with HIV • Sexual activity with homosexual or bisexual men Injection Drug Use • Parenteral exposure to HIV blood–contaminated needles and/or

syringes • Sexual activity with injection drug users Hepatitis, Tuberculosis (TB), or Sexually Transmitted Infection (STI) • Diagnosis of, or been treated for, hepatitis, TB, or an STI such as

syphilis Blood or Clotting Factor Transfusion • Transfusion with infected blood or blood concentrates (e.g., factor

VIII, factor IX) between 1978 and 1985 Work Related (Rare) • Puncture of the skin with needles or other sharp objects contaminated

with the blood of an HIV-infected patient

Infants and Children Mother With HIV Infection • Antiretroviral treatment during pregnancy • During gestation • At birth • During breast-feeding Sexual Abuse

Family History • Malignancy • Anemia • Recent infectious diseases • Tuberculosis • Immune disorders • Hemophilia

Personal and Social History • Travel, especially to Asia, Africa, the Western Pacific,

India, Philippines • Use of recreational drugs, especially injected • Sexual history (risk factors for HIV exposure)

Infants and Children • Recurrent infections: tonsillitis, adenoiditis, bacterial

infections (e.g., acute otitis media, cutaneous abscesses, sinus and pulmonary infections), oral candidiasis, chronic diarrhea, chronic severe eczema

BOX 10.2 Terms

Conditions Lymphadenopathy (adenopathy)—enlarged lymph node(s) Lymphadenitis—inflamed and enlarged lymph node(s) Lymphangitis—inflammation of the lymphatics that drain an area of

infection; tender erythematous streaks extend proximally from the infected area; regional nodes may also be tender

Lymphedema—edematous swelling due to excess accumulation of lymph fluid in tissues caused by inadequate lymph drainage

Lymphangioma—congenital malformation of dilated lymphatics

Nodes Shotty—small nontender nodes that feel like BBs or buckshot under

the skin Fluctuant—wavelike motion that is felt when the node is palpated Matted—group of nodes that feel connected and seem to move as

a unit

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note the consistency, mobility, tenderness, size, and warmth of the nodes. In areas where the skin is more mobile, move the skin over the area of the nodes. Press lightly at first, then gradually increase pressure. Heavier pressure alone can push nodes out of the way before you have had a chance to recognize their presence. Superficial nodes are accessible to palpation but are not large or firm enough to be felt. Easily palpable lymph nodes generally are not found in healthy adults. You may detect small, movable, discrete, “shotty” nodes (small, multiple nodes that feel like BBs or buckshot under the skin) less than 1 cm in diameter that move under your fingers. Shotty nodes are generally of no clinical consequence and usually represent enlargement of the lymph nodes after viral infection. However, even shotty nodes in the epitrochlear or supraclavicular regions require additional evaluation. A node fixed to surrounding tissues is cause for concern.

When enlarged lymph nodes are encountered, explore the accessible adjacent areas and regions drained by those nodes for signs of possible infection or malignancy. Examine other regions for enlargement. Enlarged lymph nodes in any region should be characterized according to location, size, shape, consistency (fluctuant, soft, firm, hard), tender- ness, mobility or fixation to surrounding tissues, and discreteness. Lymph nodes that are enlarged and juxtaposed so that they feel like a large mass rather than discrete nodes are described as “matted.” Marking with a skin pencil at the periphery of the node at the 12, 3, 6, and 9 o’clock

Preauricular Postauricular

Occipital

Epitrochlear

Axillary

Superficial superior inguinal

Superficial inferior inguinal

Superficial posterior cervical

Supraclavicular

Submandibular

Submental

Facial

Tonsillar

Superficial anterior deep cervical

FIG. 10.14 Some of the accessible lymph nodes.

CLINICAL PEARL

Reminders About Nodes • A hard, fixed, painless node suggests a malignant process. • The more tender a node, the more likely it is an inflammatory

process. • Nodes do not pulsate; arteries do. • A palpable supraclavicular node on the left (Virchow node) is a

significant clue to thoracic or abdominal malignancy. • Slow nodal enlargement over weeks and months suggests a benign

process; rapid enlargement without signs of inflammation suggests malignancy.

positions defines the extent of the node and helps guide the assessment of change (see Clinical Pearl, “Reminders About Nodes”).

If there is tenderness on touch, note the degree of discoloration or redness and any unusual increase in vascularity, heat, or pulsations. If bruits are audible with the stethoscope, it is a blood vessel, not a lymph node. When you are uncertain of the nature of the findings, check whether any large mass transilluminates; as a rule, nodes do not and fluid-filled cysts do.

Lymph nodes that are large, fixed or matted, inflamed, or tender indicate a problem. With bacterial infection, nodes may become warm or tender to the touch, matted, and much less discrete, particularly if the infection persists. It

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possible with the basic structure of nodes (see the Dif- ferential Diagnosis table).

is possible to infer the site of an infection from the pattern of lymph node enlargement. For example, infections of the ear usually drain to the preauricular, retropharyngeal, and deep cervical nodes (see Fig. 10.8).

Lymph nodes to which a malignancy has spread vary greatly in size, from tiny to many centimeters in diameter. They are sometimes discrete, sometimes matted and firmly fixed to underlying tissues; they tend to be harder than expected. Involvement is often asymmetric; contralateral nodes in similar locations may not be palpable.

Fluctuant nodes—nodes that feel like they contain fluid—suggest suppuration from infection. Fixation of the nodes to underlying tissue is most common in metastatic cancer but can also occur with chronic inflammation (see Clinical Pearl, “Not Always Pathology”).

CLINICAL PEARL

Not Always Pathology Palpable lymph nodes do not always have a pathologic cause; a submandibular or cervical node less than 1 cm in diameter or an inguinal node less than 2 cm in diameter in an adult may be considered normal. Solitary nodes in other areas are more likely to have a pathologic cause (Armitage, 2016).

Importantly, however, the supraclavicular node that warns of malignancy lies anterior to the sternocleidomastoid muscle.

CLINICAL PEARL

Drugs and Nodes Diphenylhydantoin in particular can cause nodal enlargement. So too, on occasion, can aspirin, barbiturates, penicillin, tetracycline, potassium iodide, cephalosporin, sulfonamide, allopurinol, atenolol, captopril, carbamazepine, hydralazine, phenytoin, primidone, pyrimethamine, and quinidine, among others.

DIFFERENTIAL DIAGNOSIS Conditions Simulating Lymph Node Enlargement

• Lymphangioma (transilluminates; hemangiomas do not) • Cystic hygroma (thin-walled, contains clear lymph fluid) • Hemangioma (tends to feel spongy; appears reddish blue, with

color depending on size and extent of blood vessel involvement; Valsalva maneuver may enlarge the mass)

• Branchial cleft cyst (sometimes accompanied by a tiny orifice in the neck along the lower third of the anteromedial border of the sternocleidomastoid muscle between the muscle and the overlying skin; may fluctuate in size when inflamed)

• Thyroglossal duct cyst (midline in the neck; may retract when tongue is protruded)

• Granular cell tumor • Laryngocele • Esophageal diverticulum • Thyroid goiter • Graves disease • Hashimoto thyroiditis • Parotid swelling (e.g., from parotitis or tumor) • Femoral hernia (below inguinal ligament; protrudes with cough;

reducible)

In tuberculosis, the lymph nodes, often felt in the cervical chains, are usually body temperature, soft, matted, and not tender or painful.

Lymphadenopathy that is widespread, involving several lymph node regions, indicates systemic disease or disorder. Also see Clinical Pearl, “Drugs and Nodes.”

Internal jugular vein

Common carotid artery

Posterior triangle

Sternocleidomastoid muscle

Posterior triangle

Anterior triangle

Sternocleidomastoid muscle (cut)

Hyoid bone

Anterior triangle

Trapezius muscle

FIG. 10.15 The triangles of the neck.

Head and Neck

Lightly palpate the entire neck for nodes. The anterior border of the sternocleidomastoid muscle is the dividing line for the anterior and posterior triangles of the neck and is a useful landmark for describing location. The muscles and bones of the neck together create these “triangles” (Fig. 10.15).

Bending the patient’s head slightly forward or to the side will ease taut tissues and allow better accessibility to palpation. Feel for nodes on the head in the following six-step sequence (Fig. 10.16): 1. The occipital nodes at the base of the skull 2. The postauricular nodes located superficially over the

mastoid process 3. The preauricular nodes just in front of the ear (Fig.

10.17) 4. The parotid and retropharyngeal (tonsillar) nodes at the

angle of the mandible 5. The submandibular nodes halfway between the angle

and the tip of the mandible

The differentiation of an enlarged lymph node from other masses depends on many variables; for example, some sites are incompatible with the distribution of nodes, and some palpable sensations (e.g., thrill, consistency) are not

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chest wall, and muscles as you palpate. A firm, deliberate, yet gentle touch may feel less ticklish to the patient.

On palpation of the axillary lymph nodes, support the patient’s forearm with your contralateral arm and bring the palm of your examining hand flat into the axilla; alternatively, let the patient’s forearm rest on that of your examining hand (Fig. 10.20). Rotate your fingertips and palm, feeling the nodes; if they are palpable, attempt to glide your fingers beneath the nodes (see Clinical Pearl, “Vaccinations and Nodes”). A more complete examination of the breast, the axilla, and adjacent areas is described in Chapter 17.

Epitrochlear Lymph Nodes To palpate the epitrochlear nodes, support the arm in one hand as you explore the elbow with the other. Grasp the patient’s right wrist, palm facing up, with your left hand. The elbow should be in a relaxed position at approximately

6. The submental nodes in the midline behind the tip of the mandible

Then move down to the neck, palpating in the following four-step sequence: 1. The superficial cervical nodes at the sternocleidomastoid

muscle 2. The posterior cervical nodes along the anterior border

of the trapezius muscle (Fig. 10.18) 3. The cervical nodes deep to the sternocleidomastoid (the

deep cervical nodes may be difficult to feel if you press too vigorously; probe gently with your thumb and fingers around the muscle)

4. The supraclavicular areas, probing deeply in the angle formed by the clavicle and the sternocleidomastoid muscle, the area of Virchow nodes (Fig. 10.19) On occasion, postauricular nodes associated with ear

infection (particularly external otitis) may be surrounded by some cellulitis; this may cause the ears to protrude.

Axillae Think of the axillary examination by imagining a pentagonal structure: the pectoral muscles anteriorly, the back muscles (i.e., latissimus dorsi and subscapularis) posteriorly, the rib cage medially, the upper arm laterally, and the axilla at the apex. Let the soft tissues roll between your fingers, the

Occipital

Postauricular

Posterior cervical

Supraclavicular nodes (palpable when there

is disease)

Anterior cervical Submental

Submandibular (submaxillary)

Retropharyngeal (tonsillar)

Parotid

Preauricular

FIG. 10.16 Palpable lymph nodes of the head and neck.

FIG. 10.17 Palpation of preauricular lymph nodes. Compare the nodes bilaterally.

FIG. 10.18 Palpation of posterior cervical nodes. Use the dorsal surfaces (pads) of the fingertips to palpate along the anterior surface of the trapezius muscle and then move slowly in a circular motion toward the posterior surface of the sternocleidomastoid muscle.

FIG. 10.19 Palpation for supraclavicular lymph nodes. Encourage the patient to relax the musculature of the upper extremities so that the clavicles drop. The examiner’s free hand is used to flex the patient’s head forward to relax the soft tissues of the anterior neck. The fingers are hooked over the clavicle lateral to the sternocleidomastoid muscle.

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FIG. 10.20 Soft tissues of axilla are gently rolled against the chest wall and the muscles surrounding the axilla.

CLINICAL PEARL

Vaccinations and Nodes Immunizations, particularly BCG (bacillus Calmette-Guérin), MMR (measles/mumps/rubella), and smallpox vaccination, administered in the upper arm may cause temporary axillary node enlargement. Rarely, human papilloma virus (HPV) vaccination may cause node enlargement in the head and neck region (Studdiford et al, 2008).

FIG. 10.21 Palpation for epitrochlear lymph nodes is performed in the depression above and posterior to the medial condyle of the humerus.

90 degrees. Place your right hand under the patient’s right elbow and cup your fingers around the elbow to find the area that is proximal and slightly anterior to the medial epicondyle of the humerus. There is a groove between the triceps and biceps muscles. Palpate that groove with your fingers using a circular motion (Fig. 10.21). Repeat using your left hand for the patient’s left elbow. An enlarged node can indicate local infection or systemic illness.

Inguinal and Popliteal Lymph Nodes Use a systematic approach when palpating sites of lymph node clusters. Move the hand in a circular fashion, probing gently without pressing hard. Relieve tension by flexion of the extremity.

To palpate the inguinal and popliteal area, have the patient lie supine with the knee slightly flexed. The superior superficial inguinal (femoral) nodes are close to the surface over the inguinal canals. The inferior superficial inguinal nodes lie deeper in the groin (Fig. 10.22).

The lymphatic drainage of the testes is into the abdomen. Enlarged nodes there are not accessible to inspection and palpation. Nodes in the inguinal area enlarge if there are lesions of the penile and scrotal surfaces. Similarly, the internal female genitalia drain into the pelvic and para-aortic nodes and are not accessible to inspection and palpation; however, the vulva and lower third of the vagina drain into the inguinal nodes. Enlargement of the inguinal nodes suggests infection or metastatic carcinoma in the associated anatomic area. To examine the popliteal nodes, relax the posterior popliteal fossa by flexing the knee. Wrap your hand around the knee and palpate the fossa with your fingers.

A

B

FIG. 10.22 A, Palpation of inferior superficial inguinal (femoral) lymph nodes. B, Palpation of superior inguinal lymph nodes.

Patient Safety

Hold Back on Invasive Procedures One way to promote patient safety is to judiciously limit the number of invasive tests and procedures ordered. Psychological discomfort and physical discomfort are frequent companions to invasive procedures. The best way to avoid the unnecessary discomfort is to perform a knowledgeable and skilled history and physical examination. There are many indications in this chapter for the biopsy of suspicious lymph nodes, but just as important—perhaps more so—indications to resist biopsy.

Spleen Examination of the spleen is detailed in Chapter 18. The spleen is involved in all systemic inflammations, generalized hematopoietic disorders, and many metabolic disturbances. In each of these situations, the spleen enlarges. When sufficiently enlarged, the patient may report a pain or a heavy sensation in the left upper quadrant. Massive

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BOX 10.3 When Lymphadenopathy Requires Further Investigation

Although the detection of lymphadenopathy is common and the number of associated diseases is great, it is not often necessary to perform a biopsy or other laboratory tests. Yet there are situations that indicate a risk for malignancy and require consideration for further investigation: • Older patients with localized and persistent lymphadenopathy,

without evidence of infection or inflammation, might have cancer unless a biopsy proves otherwise

• Young adults and children with localized supraclavicular lymphadenopathy

• Posterior cervical lymphadenopathy adds a risk for malignancy, more than lymphadenopathy that occurs in the anterior cervical chain

• Any lump that grows rapidly and insistently, at any age

DIFFERENTIAL DIAGNOSIS Mumps Versus Cervical Adenitis

Mumps, epidemic parotitis, is characterized by a somewhat painful swelling of the parotid glands unilaterally or bilaterally and, occasionally, by swelling and tenderness of the other salivary glands along the mandible. The swelling can obscure the angle of the jaw and may appear on inspection as a cervical adenitis. On palpation, however, the two are easily distinguished. A cervical adenitis does not ordinarily obscure the angle of the jaw. Your fingers can separate the node from the angle so that you can feel the hard sharpness of the bone, a finding generally not associated with parotid swelling.

DIFFERENTIAL DIAGNOSIS How to Discover an Immune Deficiency Disease in a Child

Begin with a thorough history: • The family history • Risk factors for HIV infection • Illness in siblings • Previous infections and the age of onset of frequent infection • Previous hospitalizations • Serious recurring infections and infections that are uncommon

(e.g., infection with Pneumocystis jirovecii; other infections, particularly fungal, that do not yield to therapy)

Note unusual findings on the physical examination (e.g., generalized lymphadenopathy and enlargement of the liver and/or spleen).

The child who is not growing well, who has recurrent infection, and in whom unusual findings persist could have an immune deficiency. HIV infection in the young can have a long clinical latency. The least suspicion in a child at risk should lead to testing.

CLINICAL PEARL

Cervical Nodes The childhood diseases of rubella, rubeola, and varicella often present with obvious cervical nodes, usually posterior rather than anterior. Hepatitis A or B and infectious mononucleosis have the same pattern of cervical node involvement.

SAMPLE DOCUMENTATION

History and Physical Examination

Subjective A 24-year-old student reports fatigue, fever, sore throat, and discomfort with swallowing for the past 4 days.

Objective Tonsils enlarged. On palpation, bilateral tender and enlarged anterior cervical, posterior cervical, submandibular, and epitrochlear nodes. No supraclavicular, inguinal, or axillary lymphadenopathy. No splenomegaly.

For additional sample documentation, see Chapter 5.

splenomegaly may cause early satiety or discomfort after eating.

Infants and Children The technique of examination is similar for all ages. You may find small, firm, discrete, and movable nodes that are neither warm nor tender located in the occipital, postau- ricular, cervical, and inguinal chains (Bamji et al, 1986). Inguinal nodes may even be readily visible in a very thin child. In children, such nodes are not as worrisome as in the adult. Their shape is usually globular or ovoid, some- times flatter or more cylindrical.

Lymph node enlargement in children is a more common finding compared with adults. In the well child, they are typically not warm, tender, or fluctuant; do not mat together; are not associated with erythema; and have not been demonstrated to be associated with serious illness. It is not unusual to find enlarged postauricular and occipital nodes in children younger than 2 years of age. Past that age, such enlargement is relatively uncommon and may be significant (see the Differential Diagnosis boxes for mumps and for immune deficiency disease in a child). Conversely, cervical and submandibular nodal enlargement is relatively less common in children younger than 1 year

of age and much more common in older children (see Clinical Pearl, “Cervical Nodes”). These age distributions should be considered in your decision to further evaluate lymph node enlargement. The discovery of small lymph nodes in the inguinal, cervical, or axillary chains of neonates may not in itself require further investigation (Box 10.3). In general, laboratory tests are not indicated in otherwise well children who have cervical lymphadenopathy.

Nodes smaller than 0.5 cm generally are not cause for concern, and nodes with a diameter of 1 cm or less in the cervical and inguinal chains do not always indicate a problem. If nodes have grown rapidly and are suspiciously large (i.e., more than 2 cm), mildly painful, or fixed to contiguous tissues and relatively immovable, investigate further.

The palatine tonsils may be enlarged in children; this in itself is not a problem. Excessive enlargement may obstruct the nasopharynx, increasing the risk of sleep apnea and, on rare occasions, pulmonary hypertension (see Chapter 13, Fig. 13.34).

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ABNORMALITIES

Lymphatic System

Acute Lymphangitis Inflammation of one or more lymphatic vessels

PATHOPHYSIOLOGY PATIENT DATA • Pathogenic organisms enter the lymphatic vessels directly through a

wound or as a complication of infection and produce a local inflammatory response.

• Inflammation or infection then extends proximally toward regional lymph nodes.

Subjective Data • Enlarged lymph node • Pain, malaise, possibly fever • Minor trauma to the skin distal to the area of infection

Objective Data • Red streaks in the skin after the course of the lymphatic collecting

duct • Appears as a tracing of rather fine lines streaking up the extremity • Sometimes indurated and palpable to gentle touch • Look distal to the inflammation for sites of infection, particularly between

digits.

Acute Suppurative Lymphadenitis Infection and inflammation of a lymph node; may affect a single or localized group of nodes

PATHOPHYSIOLOGY PATIENT DATA • Most commonly caused by group A beta-hemolytic streptococci and

coagulase-positive staphylococcal infection • Other pathogens may include actinomycotic adenitis as a result of

dental disease; mycobacterial lymphadenitis in the presence of the tuberculosis organism; Pasteurella multocida infection at the site of a scratch or bite from a dog or cat

• Lymph nodes enlarged because of the cellular infiltration and edema • Nodes tender because of distention of the capsule • Acute lymphadenitis most often seen in the cervical region due to

microbial drainage from infections of the teeth or tonsils and in the axillary or inguinal regions secondary to infections in the extremities

• Systemic viral infections (particularly in children) and bacteremia often produce generalized lymphadenopathy.

Subjective Data • Enlarged lymph nodes • Pain from enlarged lymph nodes

Objective Data • Involved node usually firm and tender • Overlying tissue edematous; skin appears erythematous, usually within

72 hours • When abscess formation is extensive, nodes fluctuant • Mycobacterial adenitis characterized by an inflammation without warmth

that may or may not be slightly tender

Lymphedema Edematous swelling due to excess accumulation of lymph fluid in tissues caused by inadequate lymph drainage

PATHOPHYSIOLOGY PATIENT DATA • Result of protein-rich interstitial volume overload, secondary to lymph

drainage failure • Four major physiologic mechanisms: increased blood capillary hydrostatic

pressure, decreased plasma protein concentration, increased blood permeability, and blockage of lymph return

• Primary lymphedema: hypoplasia and maldevelopment of the lymphatic system, more common in females than in males; can manifest in infants or later; termed praecox in adolescence and tarda in patients approaching 40 years of age

• Secondary: acquired damage to regional lymph nodes—pressure from tumors, scar tissue after radiation, or surgical removal of lymph nodes

Subjective Data • Painless swelling of a limb; unilateral or bilateral • Onset usually gradual • History of trauma, surgery, or radiation to a regional area • Travel to areas where filariasis is common • Family history of leg swelling

Objective Data • Swelling and often grotesque distortion of the extremities (Fig. 10.23) • Lymphedema may or may not pit. • Overlying skin eventually thickens and feels tougher than usual • Primary lymphedema often apparent at birth and most often involves

the legs, particularly the dorsum of the foot; the degree varies with the severity and distribution of the abnormality and may not appear until young adulthood

• See Table 10.1 for grading of lymphedema.

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STAGING DESCRIPTION

Stage 0 Latent or subclinical Swelling is not evident despite impaired lymph transport.

Stage I Pitting may occur. There is early accumulation of fluid relatively high in protein content (e.g., in comparison with “venous” edema), and it subsides with limb elevation.

Stage II Tissue fibrosis is present. Limb elevation alone rarely reduces tissue swelling. Pitting may be present. Late in stage II, the limb may or may not pit as tissue fibrosis supervenes.

Stage III Pitting is absent. Trophic skin changes are present (acanthosis nigricans, fat deposits, and warty overgrowths).

TABLE 10.1 Grading of Lymphedema by the International Society of Lymphology Criteria

Stages refer only to the physical condition of the extremities. From the International Society of Lymphology Consensus Document, 2013.

DIFFERENTIAL DIAGNOSIS Lymphedema or Edema?

• Both can be either pitting or nonpitting. • Except in early stages, lymphedema does not resolve with

elevation of the affected area. Edema secondary to increased capillary filtration (e.g., chronic venous insufficiency) usually improves.

• Diuretics do not help lymphedema. They may help edema. • Be aware that some patients may have both edema and

lymphedema.

FIG. 10.23 Lymphedema.

Lymphangioma/Cystic Hygroma Congenital malformation of dilated lymphatics

PATHOPHYSIOLOGY PATIENT DATA • Results from a failure of complete development and subsequent

obstruction of the lymphatic system; commonly found in the neck Subjective Data • Painless cystic masses • Usually manifest during the first year of life and often enlarged after

an upper respiratory infection • Asymptomatic when in the posterior triangle of the neck, but if found

anteriorly, may cause airway or swallowing problems

Objective Data • Soft, nontender, and easily compressible spongy fluid-containing mass

without discrete margins • Most present at birth and apparent early in life, usually in the neck or

axilla, less commonly in the chest or extremities • May be large enough to distort face and neck • Diagnosis through physical examination and imaging studies (ultrasound,

computed tomography, or magnetic resonance imaging), which show a thin-walled, multiloculated cystic mass

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Lymphatic Filariasis (Elephantiasis) Massive accumulation of lymphedema throughout the body; the most common cause of secondary lymphedema worldwide

PATHOPHYSIOLOGY PATIENT DATA • Results from widespread inflammation and obstruction of the lymphatics

by the filarial worms Wuchereria bancrofti or Brugia malayi; transmitted by mosquitoes

• Adequate drainage is prevented, and the patient becomes more susceptible to infection, cellulitis, and fibrosis

• The term elephantiasis often incorrectly used to describe the result of any obstruction, congenital or acquired.

• See Differential Diagnosis table.

Subjective Data • Swelling of limb or body area • Travel to infected areas: Asia, Africa, the Western Pacific, India,

Philippines • Many patients asymptomatic, but some may develop fever with

lymphangitis and lymphadenitis, chronic pulmonary infection, and progressive lymphedema.

Objective Data • Lymphedema of the entire arm or leg; the genital regions (vulva, scrotum,

breasts) • Diagnosis can be made by identification of microfilariae microscopically

in blood.

DIFFERENTIAL DIAGNOSIS When the Body Swells

A number of pathologic processes can cause swelling of the extremities and other areas in the body. These can stem from, but are not limited to, the cardiovascular system (e.g., congestive heart failure or constrictive pericarditis), diseases of the liver (e.g., obstruction of the hepatic vein [Chiari syndrome] and portal vein thrombosis), and kidney malfunction. The most common cause, particularly of the feet and the ankles, is stasis. This may occur in otherwise well individuals who must stand or sit for long periods. The failure to move with some regularity increases orthostatic pressure in the legs. Pregnancy is also a common contributor, even in the absence of venous abnormality in the legs. There can also be a significant disruption of lymphatic circulation in the arms after breast surgery with its disruption of lymph flow. Myxedema, a finding associated with hypothyroidism, is typified by a dry, waxy swelling (see Chapter 11, Fig. 11.10). The edema in this condition can cause a rather typical facies, with swollen lips and a thick nose; it also does not pit.

Non-Hodgkin Lymphoma Malignant neoplasm of the lymphatic system and the reticuloendothelial tissues

PATHOPHYSIOLOGY PATIENT DATA • Non-Hodgkin lymphomas occur most often in lymph nodes in the

chest, neck, abdomen, tonsils, and skin; they may also develop in sites other than lymph nodes such as the digestive tract, central nervous system, and around the tonsils.

• Most arise in B cells; the rest occur in T cells • Histologically, their cells are often undifferentiated but resemble

lymphocytes, histiocytes, or plasma cells.

Subjective Data • Painless enlarged lymph node(s) • Fever, weight loss, night sweats, abdominal pain, or fullness • Family history of non-Hodgkin lymphomas

Objective Data • Nodes may be localized in the posterior cervical triangle or may become

matted, crossing into the anterior triangle. • Nodes usually well defined and solid • Cannot distinguish the findings of these conditions from those in Hodgkin

lymphoma through physical examination alone

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Hodgkin Lymphoma Malignant lymphoma

PATHOPHYSIOLOGY PATIENT DATA • Unknown etiology, several subtypes • Starts in a single node or chain and spreads to contiguous lymph

nodes, spleen, liver, and bone marrow • Neoplastic giant cells release factors that induce the accumulation of

reactive lymphocytes, macrophages, and granulocytes. • Occurs in all races, generally in late adolescence and young adulthood,

although it also occurs in people older than 50 years; males are twice as likely to develop Hodgkin lymphoma as are females.

• Most often, Hodgkin lymphoma starts in B-cell lymphocytes located in lymph nodes in the neck area, although any lymph node may be the site of initial disease.

Subjective Data • Painless enlarged lymph nodes • May have abdominal pain, sometimes fever • May have history of infectious mononucleosis

Objective Data • Clinical presentation variable • Most commonly, painless enlargement of the cervical lymph nodes,

often in the posterior triangle, that is generally asymmetric and progres- sive (Fig. 10.24)

• Nodes sometimes matted and firm, almost rubbery • Usually asymmetric; may occasionally be enlarged in similar patterns

on both sides of the body • Nodal size may fluctuate

FIG. 10.24 Hodgkin disease. Note the impressive extent of the enlargement.

Epstein-Barr virus Mononucleosis Infectious mononucleosis

PATHOPHYSIOLOGY PATIENT DATA • Initially infects oral epithelial cells; after intracellular viral replication

and cell lysis with release of new virions, virus spreads to contiguous structures such as the salivary glands, with eventual viremia and infection of the entire lymphoreticular system, including the liver and spleen

• Incubation period of infectious mononucleosis in adolescents is 30–50 days

Subjective Data • Malaise, fatigue, acute or prolonged (longer than 1 week) fever,

headache, sore throat, nausea, abdominal pain, and myalgia • Prodromal period may last 1–2 weeks

Objective Data • Generalized lymphadenopathy most commonly in the anterior and

posterior cervical nodes and the submandibular lymph nodes and less commonly in the axillary and inguinal lymph nodes

• Epitrochlear lymphadenopathy is particularly suggestive of infectious mononucleosis.

• Hepatomegaly; symptomatic hepatitis or jaundice is uncommon, but elevated liver enzymes are common.

• Splenomegaly to 2–3 cm below the costal margin is typical; massive enlargement is uncommon.

• Moderate to severe pharyngitis with tonsillar enlargement, occasionally with exudates

• Petechiae at the junction of the hard and soft palate frequently seen • Diagnosis with mononucleosis spot test

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Toxoplasmosis Zoonosis, caused by the parasite Toxoplasma gondii

PATHOPHYSIOLOGY PATIENT DATA • Ingestion or inhalation of oocysts in soil/fomites, undercooked meat,

or raw eggs; cat feces or litter • Infection persists for life without signs of disease. • In immunosuppressed persons, quiescent parasites multiply, resulting

in neurologic disease or other organ manifestations. • May cause serious congenital infection if exposed during pregnancy,

particularly in the first trimester; transmitted directly from pregnant mother to fetus

Subjective Data • No significant symptoms • History of eating raw or rare meat or uncooked eggs • History of direct contact with cat feces, cleaning the litter box, gardening

in feces-contaminated soil

Objective Data • Single node, chronically enlarged and nontender • Node is usually in the posterior cervical chain

Roseola Infantum (HHv-6) Infection by human herpes virus 6

PATHOPHYSIOLOGY PATIENT DATA • Common in infancy with peak age of acquisition 2 years • Virus present in the saliva of most adults and is readily transmitted

by oral secretions • Latency permits persistence of the virus in the presence of a fully

developed immune response and allows lifelong infection of the host. • Through periodic reactivation of latent virus and the production of

recurrent infection; virus shedding occurs at intervals throughout life, allowing the virus to be spread to new susceptible hosts

Subjective Data • Fever—usually high grade and persistent over 3–4 days • Sometimes associated with a mild respiratory illness and

lymphadenopathy

Objective Data • Adenopathy, discrete and not tender, involves the occipital and

postauricular chains and may last for some time • When the fever diminishes, a morbilliform fine maculopapular rash

occurs, spreading from the trunk to the extremities; the child begins feeling much better.

Herpes Simplex (HSv) Infection by human herpes virus 1 (HSV-1) or human herpes virus 2 (HSV-2)

PATHOPHYSIOLOGY PATIENT DATA • Transmitted by oral secretions, genital secretions, and close contact • HSV causes lytic infection of fibroblasts and epithelial cells, and

establishes latent infection in neurons; HSV-1 has predilection for oropharyngeal infection and HSV-2 for genital infection; although both viruses can infect and produce latent infection at either site, reactivation of each is most common at the preferred site.

Subjective Data • Burning, itching lesions • May report enlarged lymph nodes

Objective Data • Discrete labial and gingival vesicles or ulcers (Fig. 10.25) • May have enlargement of the anterior cervical and submandibular

nodes • These nodes tend to be somewhat firm, quite discrete, movable, and

tender; the frequency of this condition and the symptoms are generally sufficient to establish the diagnosis; a viral culture can be obtained if necessary.

FIG. 10.25 Herpes simplex.

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Cat Scratch Disease A common cause of subacute or chronic lymphadenitis in children

PATHOPHYSIOLOGY PATIENT DATA • Caused mainly by Bartonella henselae and Bartonella clarridgeiae;

usually follows a bite, scratch, or other penetrating injury from a kitten or cat; the organisms, however, rarely cause illness in the cat

Subjective Data • Bite, scratch, or wound from cat or kitten • Inoculation lesion: a papule or pustule lasts 3–5 days and then becomes

vesicular and crusts in 2–3 days • Painful enlarged lymph nodes

Objective Data • Inoculation lesion; may be healing • Lymphadenopathy develops in 1–2 weeks in the region that drains

the primary lesion. • Single lymph node most often, but multiple nodes are involved

occasionally • Tender nodes commonly in head, neck, and axillae; the accessible

nodal areas in the arms and legs are less often involved. • Nodes can be very large—up to several centimeters; often red and

tender and occasionally suppurate • Diagnosis can be made in the presence of a nodal enlargement lasting

longer than 3 weeks, accompanied by an inoculation lesion of the skin and after an interaction with a cat, a cat scratch, or cat lick on a break in the skin.

• Lymphadenopathy can last for 2–4 months or even longer.

Human Immunodeficiency virus/Acquired Immune Deficiency Syndrome (HIv/AIDS)

PATHOPHYSIOLOGY PATIENT DATA • Characterized by the dysfunction of cell-mediated immunity • HIV seropositivity (HIV+): antibodies to HIV present, but sequelae of

recurrent infections and neoplastic disease has not yet occurred • AIDS manifested clinically as the development of recurrent, often severe,

opportunistic infections • Common life-threatening diseases associated with full-blown AIDS

include Kaposi sarcoma, Pneumocystis jiroveci pneumonia, pulmonary tuberculosis, recurrent pneumonia, invasive cervical cancer, a parotid enlargement simulating mumps, anemia and thrombocytopenia, chronic diarrhea, and recurrent infections

Subjective Data • Enlarged lymph nodes • Initial symptoms include severe fatigue, malaise, weakness, persistent

unexplained weight loss, fevers, arthralgias, and persistent diarrhea.

Objective Data • Generalized lymphadenopathy • In children there may be a prolonged clinical latent period, but initial

signs may include neurodevelopmental problems with loss of devel- opmental milestones.

• Progressive infection characterized by decreasing CD4+ T-lymphocyte count and increasing viral load level

Serum Sickness (Type III Hypersensitivity Reaction) An immune complex disease

PATHOPHYSIOLOGY PATIENT DATA • Systemic type III hypersensitivity reaction in response to antigens • Mediated by the tissue deposition of circulating immune complexes,

the activation of complement, and the ensuing inflammatory response • Patient can react similarly to repeated exposure to the stimuli; sub-

sequent reactions may be more severe and even fatal

Subjective Data • Enlarged lymph nodes • Pain, pruritus, and erythematous swelling at the injection site • Urticaria, other rashes, lymphadenopathy, joint pain, fever, and at

times facial edema • Medications: beta-lactam antibiotics (especially cefaclor), sulfonamide

antibiotics, minocycline • Organ transplant

Objective Data • Findings become apparent about 7–10 days after administration of

the provoking substance. • Urticaria, maculopapular or purpuric lesions • Lymphadenopathy most prominent in the area draining the injection

site; can be generalized • Facial and neck edema • Symptoms subside slowly, recurring at times over several weeks.

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Latex Allergy Type Iv Dermatitis Delayed hypersensitivity reaction

PATHOPHYSIOLOGY PATIENT DATA • T cell–mediated, delayed response • Allergic contact dermatitis that involves the immune system and is

caused by the chemicals used in latex products

Subjective Data • Exposure to latex products • Rash at area of contact

Objective Data • Skin reaction usually begins 48–72 hours after contact • Vesicular lesions, erythema localized to area of contact • Reaction may progress to oozing skin blisters

Latex Allergy Type I Reaction True allergic reaction caused by protein antibodies

PATHOPHYSIOLOGY PATIENT DATA • Immunoglobulin E antibodies form as a result of interaction between

a foreign protein and the body’s immune system. • Antigen-antibody reaction causes release of histamine, leukotrienes,

prostaglandins, and kinins.

Subjective Data • Exposure to latex • Allergy to cross-sensitizing foods (e.g., banana, avocado, potato, tomato,

kiwi)

Objective Data • Local: urticaria (skin wheals), • Systemic: generalized urticaria with angioedema (tissue swelling),

asthma, eye/nose itching and gastrointestinal symptoms, anaphylaxis (cardiovascular collapse)

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Head and Neck

CHAPTER

11  The head provides the bony housing and protective cover for the brain, including the organs that provide senses of vision, hearing, smell, and taste. The neck provides stability and support for the head and holds vital vessels, the trachea, esophagus, and spinal cord. A flexible cervical spine is necessary for head movement, balance adaptation, and increasing extent of vision.

ANATOMY AND PHYSIOLOGY

The skull is composed of seven bones (two frontal, two parietal, two temporal, and one occipital) that are fused together and covered by the scalp. Bones of the skull are helpful in identifying landmarks on the head (Fig. 11.1).

The bony structure of the face is formed from the fused frontal, nasal, zygomatic, ethmoid, lacrimal, sphenoid, and maxillary bones and the movable mandible. The face has cavities for the eyes, nose, and mouth.

Major facial landmarks are the palpebral fissures and the nasolabial folds (Fig. 11.2). Facial muscles are innervated by cranial nerve (CN) V and CN VII. The temporal artery is the major accessible artery of the face, passing just anterior to the ear, over the temporal muscle, and onto the forehead.

The paired parotid, submandibular, and sublingual salivary glands produce saliva, which moistens the mouth, inhibits formation of dental caries, and starts the digestion of carbohydrates. The parotid glands are located anterior to the ear and above the mandible, the submandibular

Physical Examination Components

Head 1. Observe head position

• Tilted • Tremor

2. Inspect skull and scalp for • Size • Shape (molding) • Symmetry • Lesions • Trauma

3. Inspect facial features, including • Symmetry • Shape • Unusual features • Tics • Characteristic facies • Pallor or pigmentation variations

4. Palpate head and scalp, noting • Symmetry • Tenderness (particularly over areas of frontal and maxillary sinuses) • Scalp movement • Sutures/fontanels • Hair texture, color, and distribution

5. When appropriate, auscultate the temporal arteries and palpate, noting • Thickening • Hardness • Tenderness

6. Inspect and palpate the salivary glands 7. Transilluminate skull of infants with rapidly increasing head

circumference.

Neck 1. Inspect the neck for:

• Symmetry • Alignment of trachea • Fullness • Masses, webbing, and skinfolds

2. Palpate the neck, noting the following: • Tracheal position • Tracheal tug • Movement of hyoid bone and cartilages with swallowing • Lymph nodes • Paravertebral musculature and spinous processes

3. Palpate the thyroid gland for the following: • Size • Shape • Configuration • Consistency • Tenderness • Nodules • If gland is enlarged, auscultate for bruits

4. Evaluate range of motion of the neck (also see Chapter 22)

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the upper sternum and medial third of the clavicle to the mastoid process (see Fig. 22.2, C). The trapezius muscle extends from the scapula, the lateral third of the clavicle, and the vertebrae to the occipital prominence (see Fig. 22.2, C and D).

The relationship of these muscles to each other and to adjacent bones creates triangles used as anatomic landmarks. The anterior triangle is formed by the medial border of the sternocleidomastoid muscles, the mandible, and the midline (Fig. 11.4). The posterior triangle is formed by the trapezius and sternocleidomastoid muscles and the clavicle (see Fig. 11.4) and contains the posterior cervical lymph nodes (Fig. 11.5). For a complete description of the lymph nodes of the head and neck, see Figs. 10.8 through 10.22.

The hyoid bone, cricoid cartilage, trachea, thyroid, and anterior cervical lymph nodes lie inside these triangles (see Fig. 11.3). The common carotid artery and internal jugular vein are deep and run parallel to the sternocleidomastoid muscle along its medial margin. The external jugular vein crosses the surface of the sternocleidomastoid muscle diagonally. The hyoid bone lies just below the mandible. The thyroid cartilage is shaped like a shield, its notch on the upper edge marks the level of bifurcation of the common carotid artery. The cricoid cartilage is the uppermost ring of the tracheal cartilages.

The thyroid is the largest endocrine gland in the body, producing two hormones, thyroxine (T4) and triiodothyronine (T3). The two lateral lobes are butterfly shaped and are joined by an isthmus at their lower aspect (see Fig. 11.3). This isthmus lies across the trachea below the cricoid cartilage. A pyramidal lobe, extending upward from the isthmus and slightly to the left of midline, is present in about one-third of the population. The lobes curve posteriorly around the cartilages and are in large part covered by the sternocleidomastoid muscles.

glands are located medial to the mandible at the angle of the jaw, and the sublingual glands are located anteriorly in the floor of the mouth.

The neck is formed by the cervical vertebrae, ligaments, and the sternocleidomastoid and trapezius muscles, which give it support and movement. The neck begins at the clavicles and sternum inferiorly and at the base of the skull superiorly. It contains the trachea, esophagus, internal and external jugular veins, common carotid, internal and external carotid arteries, and thyroid (Fig. 11.3). Horizontal mobility is greatest between cervical vertebrae 4 and 5 or 5 and 6 in adults. The sternocleidomastoid muscle extends from

Coronal suture Squamous suture

Parietal bone

Temporal bone

Lambdoidal suture

Occipital bone

External acoustic meatus

Mastoid process Condyloid process

Styloid process Zygomatic arch

Coronoid process Mandible

Maxilla

Zygomatic bone

Nasal bone

Lacrimal bone

Sphenoid bone

Frontal bone

FIG. 11.1 Bones of the skull.

Palpebral fissures

Nasolabial fold

FIG. 11.2 Landmarks of the face.

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by 2 months of age and the anterior fontanel closing by 12 to 15 months of age.

The process of birth through the vaginal canal often causes molding of the newborn skull, during which the cranial bones may shift and overlap. Within days, the newborn skull usually resumes its appropriate shape and size.

Children and Adolescents Subtle changes in facial appearance occur throughout childhood. In the male adolescent, the nose and thyroid cartilage enlarge, and facial hair develops, emerging first on the upper lip, then the cheeks, lower lip, and chin.

Pregnant Patients The fetal thyroid gland becomes functional in the second trimester. Before this time, the pregnant patient is the source of thyroid hormone for the fetus and requires increased iodine intake.

As long as adequate iodine intake is maintained, the size of the thyroid will not detectably change on physical examination; however, a slight enlargement may be detect- able on ultrasound (Fig. 11.7).

Older Adults The rate of T4 production and degradation gradually decreases with aging, and the thyroid gland becomes more fibrotic.

Infants

In infants, the seven cranial bones are soft and separated by the sagittal, coronal, and lambdoid sutures (Fig. 11.6). The anterior and posterior fontanels are the membranous spaces formed where four cranial bones meet and intersect. Spaces between the cranial bones permit the expansion of the skull to accommodate brain growth. Ossification of the sutures begins after completion of brain growth, at about 6 years of age, and is finished by adulthood. The fontanels ossify earlier, with the posterior fontanel usually closing

External carotid artery

Hyoid bone

Common carotid artery

Thyroid cartilage

Internal jugular vein

Right subclavian artery

Right subclavian vein

Trachea Lymph node

Left subclavian artery

Left subclavian vein

External jugular vein Thyroid gland

Pyramidal lobe (thyroid gland)

Carotid sinus

Internal carotid artery

Arch of aorta Brachiocephalic vein and artery

A

Internal carotid artery External carotid artery Carotid sinus

Common carotid artery External jugular vein

Internal jugular vein Left subclavian artery

Left subclavian veinTrachea

B

Thyroid gland Cricoid cartilage Thyroid cartilage Hyoid bone

FIG. 11.3 Underlying structures of the neck. A, Anterior view. B, Lateral view.

Posterior

triangle

Anterior

triangle

Clavicle

FIG. 11.4 Anterior and posterior triangles of the neck.

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REvIEw OF RELATED HISTORY

For each of the symptoms or conditions discussed in this section, targeted topics to include in the history of the present illness are listed. Responses to questions about these topics provide clues for focusing the physical examination and the development of an appropriate diag- nostic evaluation. Questions regarding medication use (prescription and over-the-counter preparations) as well as complementary and alternative therapies are relevant for each.

History of Present Illness Traumatic Brain Injury • Independent observer’s description of event • State of consciousness after injury: immediately and 5

minutes later; duration of unconsciousness; combative, confused, alert, or dazed (see Chapter 23)

• Predisposing factors: seizure disorder, hypoglycemia, poor vision, lightheadedness, syncope, sports participation

• Associated symptoms: head or neck pain, laceration, local tenderness, change in breathing pattern, blurred or double vision, discharge from nose or ears, nausea or vomiting, urinary or fecal incontinence, ability to move all extremities

Posterior auricular (mastoid nodes)

Occipital nodes

Sternomastoid nodes

External jugular Retropharyngeal (tonsilar) Posterior cervical spinal nerve chain

Posterior superficial cervical chain

Supraclavicular nodes

Preauricular nodes

Parotid

Facial

Submandibular Submental Sublingual

Suprahyoid node Thyrolinguofacial

Anterior deep and superficial cervical

Internal jugular chain

FIG. 11.5 Lymphatic drainage system of head and neck. (If the group of nodes is often referred to by a second name, that name appears in parentheses.)

Posterior fontanel

Mastoid fontanel

Anterior fontanel

Sphenoid fontanel

Sagittal suture

Coronal suture

Anterior fontanel Posterior fontanel

Lambdoid suture

FIG. 11.6 Fontanels and sutures on the infant’s skull.

FIG. 11.7 Thyroid enlargement in pregnancy. Note the large nodule in the patient’s left lobe. Thyroid size increases in pregnancy in areas of iodine deficiency but not in those with sufficient iodine. (From Gaw and Murphy, 2013.)

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• Neck swelling; difficulty swallowing; redness; pain with touch, swallowing, or hyperextension of the neck

• Change in texture of hair, skin, or nails; increased pigmentation of skin at pressure points

• Change in mood and energy, irritability, nervousness, or lethargy, disinterest

• Increased prominence of eyes (exophthalmos), periorbital swelling, blurred or double vision

• Tachycardia, palpitations • Change in menses • Change in bowel habits • Medications: thyroid preparations

Past Medical History • Traumatic brain injury • Subdural hematoma • Recent lumbar puncture • Radiation treatment around head and neck • Headaches (see Differential Diagnosis) • Surgery for tumor, goiter • Seizure disorder • Thyroid dysfunction

Family History • Headaches: type, character, similarity to that of the patient • Thyroid dysfunction

Personal and Social History • Employment: type of work, risk of traumatic brain injury,

use of hard hat or other protective head gear, exposure to toxins or chemicals

• Stress; tension; demands at home, work, or school • Potential risk of injury: handrails available; use of seat

belts, car seats, and booster seats; unsafe environment • Nutrition: recent weight gain or loss, food intolerances,

eating habits (e.g., skipping meals) • Use of recreational drugs • Sports participation, weight training, use of protective

padding and helmet, if necessary

Infants • Prenatal history: maternal use of drugs or alcohol, uterine

abnormalities, treatment of hyperthyroidism • Birth history: birth order (firstborn more likely to experi-

ence torticollis); vaginal or cesarean section delivery; presentation, difficulty of delivery, use of forceps or other assist device (associated with caput succedaneum, cephalhematoma, Bell palsy, molding)

• Unusual head shape: bulging or flattening (congenital anomaly or positioning in utero), preterm infant, head held at angle, preferred position at rest, frequency of supine position (see Patient Safety, “Back to Sleep”)

• Strength of head control

Headache • Onset: early morning, during day, during night; gradual

versus abrupt • Duration: minutes, hours, days, weeks; relieved by

medication or sleep; resolves spontaneously; occurs in clusters; headache-free periods

• Location: entire head, unilateral, specific site (neck, sinus region, behind eyes, hatband distribution)

• Character: throbbing, pounding, boring, dull, nagging, constant pressure, aggravated with movement

• Severity: grade each event severity on a scale from 1 (mild) to 10 (severe)

• Visual prodrome: scotoma; hemianopia (decreased vision or blindness takes place in half the visual field of one or both eyes); distortion of size, shape, or location

• Pattern: worse in morning or evening, worse or better as day progresses, awakens patient from or occurs only during sleep

• Episodes closer together or worsening, lasting longer • Change in level of consciousness as pain increases • Associated symptoms: nausea, vomiting, diarrhea,

photophobia, visual disturbance, difficulty falling asleep, increased lacrimation, nasal discharge, tinnitus, pares- thesias, mobility impairment

• Precipitating factors: fever, fatigue, stress, food additives, prolonged fasting, alcohol, seasonal allergies, menstrual cycle, sexual intercourse, oral contraceptives, amount of caffeine intake

• Efforts to treat: sleep, pain medication, need for daily medications, rebound if pain medications are not taken or if caffeine not consumed

• Medications: antiepileptic drugs, antiarrhythmics, beta- blockers, calcium channel blockers, oral contraceptives, serotonin antagonists or agonists, selective serotonin reuptake inhibitors, antidepressants, nonsteroidal antiinflammatory drugs, narcotics, caffeine-containing medication

Stiff Neck • Neck injury or strain, traumatic brain injury, neck

swelling • Fever, associated headache, other symptoms of meningitis

(confusion, drowsiness/lethargy, photophobia, cranial nerve deficits, and seizure)

• Character: limitation of movement; pain with movement, pain relieved by movement; continuous or cramping pain; radiation patterns to arms, shoulders, hands, or down the back

• Predisposing factors: unilateral vision or hearing loss, work position (e.g., long hours in front of a computer)

• Efforts to treat: heat, physical therapy, complementary medicine (e.g., chiropractor)

• Medications: analgesics, muscle relaxants • Symptoms of thyroid disease • Change in temperature preference: more or less clothing

than worn by other members of the household

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features, exophthalmos, hirsutism, lack of expression, excessive perspiration, pallor, or pigmentation variations. Facies may develop slowly, and the health care provider should be alert to early changes suggestive of a developing facies. For example, a patient with early changes of acro- megaly is shown in Fig. 11.14. One way to better appreciate these changes is to ask the patient to provide an older photograph of herself. Figs. 11.8 through 11.22 demonstrate some facies and their associated disorders.

When facial asymmetry is present, note whether all features on one side of the face are affected, or only a portion of the face, such as the forehead, lower face, or mouth. Suspect facial nerve paralysis when the entire side of the face is affected, and suspect facial nerve weakness

• Acute illness: diarrhea, vomiting, fever, limited neck movement, irritability (associated with meningitis)

• Congenital anomalies: craniofacial abnormalities (e.g., Pierre-Robin sequence, encephalocele, microcephaly, hydrocephaly)

• Neonatal screening for congenital hypothyroidism

Pregnant Patients • Weeks of gestation or postpartum • Presence of preexisting disease (e.g., hypothyroidism,

hyperthyroidism), access to iodine-rich foods or use of antithyroid medication

• History of pregnancy-induced hypertension (PIH) • Alcohol use

Older Adults • Dizziness or vertigo with head or neck movement • Weakness or impaired balance (increases risk of falling

and head injury)

ExAMINATION AND FINDINGS

Equipment • Tape measure (primarily for infants) • Stethoscope • Cup of water (for evaluation of thyroid gland) • Transilluminator (or flashlight) for infants

Head and Face Inspection Begin examining the head and neck with inspection of head position and facial features. The patient’s head should be upright and still. A horizontal jerking or bobbing motion may be associated with a tremor; a nodding movement may be associated with aortic insufficiency, especially if the nodding is synchronized with the pulse. Holding the head tilted to one side to favor a good eye or ear often occurs with unilateral hearing or vision loss, but it is also associated with torticollis (shortening or excessive contraction of the sternocleidomastoid muscle; see Fig. 11.36).

Inspect facial features (i.e., eyelids, eyebrows, palpebral fissures, nasolabial folds, and mouth) for shape and sym- metry with rest (some slight asymmetry is common) movement, and expression. By doing this, the integrity of CN V and VII (trigeminal and facial) has been partially tested. Complete evaluation of the cranial nerves is detailed in Chapter 23.

Facies is defined as an expression or appearance of the face and features of the head and neck that, when considered together, is characteristic of a clinical condition or syndrome. Once a facies is recognized, the examiner may be able to diagnose the condition or syndrome even before completing the examination. Note any change in the shape of the face or any unusual features, such as edema, bruising, coarsened

A B

FIG. 11.8 Cushing syndrome. A, Facies include a rounded or “moon- shaped” face with thin, erythematous skin. B, Side view. Shows upper thoracic fat pad (buffalo hump). (From Melmed et al, 2016.)

FIG. 11.9 Hippocratic facies. Note sunken appearance of the eyes, cheeks, and temporal areas; sharp nose; and dry, rough skin seen in this patient in the terminal stages of throat cancer. (From Lemmi and Lemmi, 2009.)

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FIG. 11.10 Myxedema facies. Note dull, puffy, yellowed skin; coarse, sparse hair; temporal loss of eyebrows; periorbital edema; and prominent tongue. (From Lemmi and Lemmi, 2009.)

FIG. 11.11 Hyperthyroid facies. Note fine, moist skin with fine hair, prominent eyes and lid retraction, and staring or startled expression. (From Gaw and Murphy, 2013.)

FIG. 11.12 Butterfly rash of systemic lupus erythematosus. Note butterfly shaped rash over malar surfaces and bridge of nose. Either a blush with swelling or scaly, red, maculopapular lesions may be present. (Courtesy Walter Tunnessen, MD, Chapel Hill, NC.)

FIG. 11.13 Bell palsy. Left facial palsy (cranial nerve VII). Facies include asymmetry of one side of the face, eyelid not closing completely, drooping lower eyelid and corner of mouth, and loss of nasolabial fold. (From Mancall, 2011.)

FIG. 11.14 Early acromegaly. Note the coarsening of features with broadening of the nasal alae and prominence of the zygomatic arches. (Courtesy Gary Wand, MD, The Johns Hopkins University and Hospital, Baltimore, MD.)

FIG. 11.15 Pierre-Robin sequence; a triad of micrognathia, glossoptosis, and palatal clefting. Shows a lateral view with severe micrognathia and cleft palate. Note the small retruded mandible. (From Neligan, 2013.)

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FIG. 11.16 Down syndrome. Note depressed nasal bridge, epicanthal folds, mongoloid slant of eyes, and low-set ears. (From Hockenberry and Wilson, 2012.)

FIG. 11.17 Hurler syndrome. Facies includes enlarged skull with low forehead, corneal clouding, and short neck. (From Ansell et al, 1992.)

BA

FIG. 11.18 Hydrocephalus. A, Coronal view with characteristic enlarged head, thinning of the scalp with dilated scalp veins, and bossing of the skull. B, Anteroposterior view demonstrating sclera visible above the iris. In this case the infant has paresis of upward gaze. This phenomenon is often termed the “sunsetting sign.” (From Amelot et al, 2013.)

FIG. 11.20 Treacher-Collins syndrome. Note the maxillary hypoplasia, micrognathia, and auricular deformity. (From Neligan, 2013.)

FIG. 11.21 Apert syndrome. Note the severe maxillary and midfacial hypoplasia. (From Jones, 2013.)

FIG. 11.19 Fetal alcohol syndrome. This is one of the most common causes of acquired intellectual disability. Note the poorly formed philtrum; widespread eyes, with inner epicanthal folds and mild ptosis; hirsute forehead; short nose; and relatively thin upper lip. (From Zitelli and Davis, 1997.)

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FIG. 11.22 Crouzon syndrome. Observe the severe maxillary and midfacial hypoplasia with low-set ears. (From Dicus Brookes et al, 2014.)

FIG. 11.23 Inspection of the scalp.

when the lower face is affected (see Fig. 11.13). If only the mouth is involved, suspect a problem with the peripheral trigeminal nerve.

Tics, spasmodic muscular contractions of the face, head, or neck, should be noted. They may be associated with pressure on or degenerative changes of the facial nerves, a feature of Tourette syndrome, or possibly psychogenic in origin.

Inspect the skull for size, shape, and symmetry. Examine the scalp by systematically parting the hair from the frontal to occipital region, noting any lesions, scabs, tenderness, nits, or scaliness (Fig. 11.23). Pay special attention to the areas behind the ears, at the hairline, and at the crown of the head. Note any hair loss (alopecia) pattern, such as bitemporal recession of hair or balding over the crown of

the head (more common in men than in women), or hair loss associated with tight braiding. In children, a common cause of hair loss is tinea capitis (fungal infection of the scalp).

Palpation Palpate the skull in a gentle rotary movement progressing systematically from front to back. The skull should be sym- metric and smooth. The bones should be indistinguishable as the sites of fusion are not generally palpable after 6 months of age; however, the ridge of the sagittal suture may be felt on some individuals. The scalp should move freely over the skull, and no tenderness, swelling, or depressions on palpation are expected. Tenderness with an indentation or a depression of the skull may indicate a skull fracture.

Palpate the patient’s hair, noting its texture, color, and distribution. Hair should be smooth and symmetrically distributed and have no splitting or cracked ends. Coarse, dry, and brittle hair may be associated with hypothyroidism. Fine, silky hair may be associated with hyperthyroidism or may be familial.

Palpate the temporomandibular joint space bilaterally, as described in Chapter 22, Figs. 22.26 and 22.27.

Inspect for any asymmetry or enlargement of the salivary glands. If noted, palpate for possible discrete enlargement (see Fig. 11.33), noting whether the gland is fixed or movable, soft or hard, tender or nontender. With the patient’s mouth open, try to express material through the salivary ducts as you press on the glands. The parotid duct, also known as the Stensen duct, opens into the mouth next to the maxillary second molar tooth. The submandibular duct (Wharton duct) opens in a small papilla at the sides of the frenulum.

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FIG. 11.24 Auscultation for a temporal bruit.

FIG. 11.25 Position of the thumbs to evaluate the midline position of the trachea. An enlarged, tender gland may suggest either viral or

bacterial infection or a ductal stone preventing saliva from exiting the gland. A discrete nodule may represent a cyst or tumor, either benign or malignant.

Percussion Percussion of the head and neck is not routinely performed. One exception is when evaluating for hypocalcemia, percus- sion on the masseter muscle may produce a hyperactive masseteric reflex, the Chvostek sign.

Auscultation Auscultation of the skull is not routinely performed. However, intracranial bruits are considered uncommon in neonates but common in childhood. For example, in individuals who develop diplopia, a bruit or blowing sound over the orbit may be rarely heard and suggests an expanding cerebral aneurysm. If you suspect a vascular anomaly of the brain, use the bell of the stethoscope and listen over the temporal region, over the eyes, and below the occiput (Fig. 11.24). A bruit is highly suggestive of a vascular anomaly. It can also be associated with temporal arteritis.

Neck Inspection Inspect the neck in the usual anatomic position, in slight hyperextension, and as the patient swallows. Look for bilateral symmetry of the sternocleidomastoid and trapezius muscles, alignment of the trachea, landmarks of the anterior and posterior triangles, and any subtle fullness at the base of the neck. Note any apparent masses, webbing, excess skinfolds, unusual shortness, or asymmetry. Observe for any distention of the jugular vein or prominence of the carotid arteries. Carotid artery and jugular vein examination is described in Chapter 16.

Webbing, excessive posterior cervical skin, or an unusu- ally short neck may be associated with chromosomal abnormalities (e.g., Turner syndrome). The transverse

portion of the omohyoid muscle in the posterior triangle can sometimes be mistaken for a mass. Marked edema of the neck may be associated with local infections (e.g., cervical lymphadenitis). A mass filling the base of the neck or visible thyroid tissue that glides upward when the patient swallows may indicate an enlarged thyroid or goiter (see Fig. 11.7).

Evaluate range of motion by asking the patient to flex, extend, rotate, and laterally turn the head and neck (see Chapter 22). Movement should be smooth and painless and should not cause dizziness. Nuchal rigidity, resistance to flexion of the neck, may be associated with meningeal irritation. CN XI (spinal accessory) may also be examined (see Chapter 23 and Table 23.3).

Palpation The ability to palpate and identify structures in the neck varies with the patient’s habitus.

Palpate the trachea for midline position. Place a thumb along each side of the trachea in the lower portion of the neck (Fig. 11.25). Compare the space between the trachea and the sternocleidomastoid muscle on each side. An unequal space indicates displacement of the trachea from the midline and may be associated with a mass or pathologic condition in the chest.

Identify the hyoid bone and the thyroid and cricoid cartilages. They should be smooth and nontender and should move under your finger when the patient swallows. On palpation, the cartilaginous rings of the trachea in the lower portion of the neck should be distinct and nontender.

With the patient’s neck extended, position the index finger and thumb of one hand on each side of the trachea below the thyroid isthmus (Fig. 11.26). A tugging sensation, synchronous with the pulse, is evidence of tracheal tug sign (Cardarelli sign or Oliver sign), suggesting the presence of an aortic aneurysm (see Clinical Pearl, “Cardarelli Sign and Oliver Sign”).

The paravertebral muscles and posterior spinous processes should be palpated for tenderness. This

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FIG. 11.26 Position of the thumb and finger to detect tracheal tugging.

facilitates the correlation of inspection with palpation findings. It is also more convenient in examining rooms where the table is against a wall. Choose one approach to use consistently.

CLINICAL PEARL

Cardarelli Sign and Oliver Sign Cardarelli sign can be felt by pressing on the thyroid cartilage and displacing it to the patient’s left. This increases contact between the left bronchus and the aorta, allowing systolic pulsations from the aorta to be felt at the surface if an aneurysm is present. Oliver sign is elicited by gently grasping the cricoid cartilage and applying upward pressure while the patient stands with his or her chin extended upward. Due to the anatomic position of the aortic arch, which overrides the left main bronchus, a downward tug of the trachea may be felt if an aneurysm is present.

examination coupled with neck range of motion is helpful in evaluation of a stiff neck. See Chapter 22.

Lymph Nodes Inspect and palpate the head and neck for lymph nodes. A description of the sequence is given in Chapter 10.

Thyroid Gland Examination of the thyroid gland involves inspection, palpa- tion, and occasionally auscultation. Begin by asking patients to gently extend their neck. (Hyperextension can actually make the examination more difficult.) Ask them to swallow, which often permits visualization of the gland’s size, sym- metry, and contour as it moves with swallowing. An enlarged thyroid gland may be visible only when observing from the lateral aspect. A glass of water is an indispensable aid for proper examination of the thyroid, as it helps the patient swallow multiple times.

Palpation of the thyroid gland requires a gentle touch. Nodules and asymmetry will be more difficult to detect while pressing too hard. Palpate the thyroid for size, shape, configuration, consistency, tenderness, and the presence of any nodules. Although the thyroid gland may be palpated from in front or behind the patient, facing the patient

Evidence-Based Practice in Physical Examination

Thyroid Examination Estimates of thyroid size tend to be exaggerated when the gland is small and underestimated when the gland is markedly enlarged (more than twice normal size). Evaluations were made by comparing the estimated size on physical examination with the size measured by ultrasound or after surgical excision. The estimation of thyroid size by lateral inspection is the most sensitive test for determining the presence of a goiter; a thyroid that is not visible on lateral inspection rules out a goiter (Siminoski, 1995).

For both approaches, position the patient to relax the sternocleidomastoid, with the neck flexed slightly forward and laterally toward the side being examined. Ask the patient to hold a sip of water in the mouth until you have your hands positioned, and then instruct the patient to swallow.

To palpate the thyroid using the frontal approach, have the patient sit on the examining table. First place your thumb over the trachea approximately 3 cm beneath the prominence of the thyroid cartilage, and during a swallow, attempt to identify the isthmus. To examine the right lobe of the thyroid, use your left thumb to press the trachea toward the patient’s right. Such pressure helps move the right lobe out of the tracheoesophageal groove for easier palpation. Then place the first three fingers of your right hand in the right thyroid bed with your fingertips medial to the margin of the sternocleidomastoid muscle. Leave your fingers still while the patient again swallows, thus allowing the gland to move beneath your fingers (Fig. 11.27). To examine the left lobe, move your hands to the reverse corresponding positions. By palpating above the cricoid

FIG. 11.27 Palpation of the right thyroid lobe and lateral border from in front of the patient.

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cartilage, you may be able to feel the pyramidal lobe of the thyroid, if present.

For examining the thyroid from behind, have the patient sit with the neck at a comfortable level. Position two fingers of each hand on the sides of the trachea just beneath the cricoid cartilage. Ask the patient to swallow, feeling for movement of the isthmus. Then displace the trachea to the left (using your fingers of your right hand), and with the first three fingers of your left hand medial to the left sternocleidomastoid palpate the left lobe as the patient again swallows. To palpate the right lobe, repeat using your hands in the reverse corresponding positions (Fig. 11.28).

FIG. 11.28 Palpation of the right thyroid lobe from behind the patient. Displace the trachea to the patient’s right and palpate the right lobe as the patient again swallows.

CLINICAL PEARL

Is It the Thyroid Gland? The thyroid gland moves with swallowing; subcutaneous fat that mimics a goiter does not.

Infants

Inspection Measure the infant’s head circumference and compare it with expected size for age and previous points on the growth chart, as detailed in Chapter 8. Inspect the infant’s head from all angles for symmetry of shape, noting any prominent bulges or depressions (see Clinical Pearl, “Examining the Head”). Inspect the scalp for scaling and crusting, birth- marks or skin lesions, dilated scalp veins, the presence of excessive hair, or unusual hairline. Dilated scalp veins and a head circumference increasing faster than expected may indicate increased intracranial pressure (hydrocephalus; see Fig. 11.18).

CLINICAL PEARL

Examining the Head Examining the head from above is helpful for evaluating head shape.

FIG. 11.29 Caput succedaneum. Significant scalp edema as a result of compression during transit through birth canal. Edema does cross suture lines. (From Price, 2012.)

The thyroid lobes, if felt, should be small, smooth, and free of nodules. The gland should rise freely with swallow- ing. The thyroid at its broadest dimension is approximately 4 cm, and the right lobe is often 25% larger than the left. The consistency of the thyroid tissue should be firm yet pliable. Coarse tissue or a gritty sensation suggests an inflammatory process. If nodules are present, they should be characterized by number, whether they are smooth or irregular, and whether they are soft or hard. An enlarged, tender thyroid may indicate thyroiditis (see Clinical Pearl, “Is It the Thyroid Gland?”).

If the thyroid gland is enlarged, auscultate for vascular sounds with the bell of the stethoscope. In a hypermetabolic state, the blood supply is dramatically increased and a vascular bruit (a soft rushing sound) may be heard.

Birth trauma may cause swelling of the scalp. Caput succedaneum is subcutaneous edema over the presenting part of the head at delivery (Fig. 11.29). It is the most common form of birth trauma of the scalp and usually occurs over the occiput, and the edema crosses suture lines. The affected part of the scalp feels soft, and the margins are poorly defined. Generally, the edema goes away in a few days.

Cephalhematoma is a subperiosteal collection of blood and is therefore bound by the suture lines. It is commonly found in the parietal region and, unlike caput, may not be immediately obvious at birth. A cephalhematoma is firm, and its edges are well defined; it does not cross suture lines. As it ages, the cephalhematoma may liquefy and become fluctuant on palpation (Fig. 11.30).

Inspect the face for spacing of the features, symmetry, paralysis, skin color, and texture. Uterine positioning can cause some facial asymmetry in the newborn.

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Cephalhematoma

Periosteum

SkullCranial suture Cerebrum

Subgaleal hemorrhage

Galea (aponeurosis)

Loose connective tissue

Scalp

Dura mater

FIG. 11.30 Cephalhematoma. Swelling does not cross suture lines. (From Martin et al, 2015.)

Head shape with an unusual contour may be related to premature or irregular closing of suture lines. Preterm infants often have long, narrow heads (brachycephaly) because their soft cranial bones become flattened with positioning and the weight of the head. Note any skull asymmetry or a particularly flattened spot on the back or one side of the head (plagiocephaly). Plagiocephaly can result from premature fusion of one of the sutures (cra- niosynostosis; see Fig. 11.39) or from external deformation (positional plagiocephaly). Positional plagiocephaly is common among infants with torticollis or those who prefer one head position for sleep. Bossing (bulging of the skull) of the frontal areas is associated with prematurity, thalas- semia, Paget disease, and rickets. Bulging in other areas of the skull may indicate cranial defects or intracranial masses.

Patient Safety

Back to Sleep The American Academy of Pediatrics recommendations focus on a safe sleep environment to reduce the risk of all sleep-related infant deaths, including SIDS. The recommendations include supine positioning (“Back to Sleep”), use of a firm sleep surface, breast-feeding, room- sharing without bed-sharing, routine immunizations, consideration of pacifier use, as well as avoidance of soft bedding, overheating, and exposure to tobacco smoke, alcohol, and illicit drugs. Although “Back to Sleep” greatly reduced the incidence of SIDS, there has been a dramatic increase in positional plagiocephaly. The risk of positional plagiocephaly can be reduced by supervised, awake tummy time to facilitate development and to minimize development of positional plagiocephaly. In addition, beginning at birth, alternate the supine head position (i.e., left and right occiputs) during sleep nightly. For infants who prefer to face an open door, alternate the infant’s position between the head and foot of the crib. Additionally, periodically changing the orientation of the infant to outside activity can also be beneficial for prevention (American Academy of Pediatrics Task Force on Sudden Infant Death Syndrome, 2016).

Observe the infant’s head control, position, and move- ment. Note any jerking, tremors, or inability to move the head in one direction. Chapters 22 and 23 provide further details.

Inspect the infant’s neck for symmetry, size, and shape. Note the presence of edema, distended neck veins, pulsa- tions, masses, webbing, or excessive nuchal skin. To observe the newborn’s neck, which is usually not easily visible in the supine position, elevate the upper back of the infant and permit the head to fall back into extension. The neck appears short during infancy and lengthens by 3 to 4 years of age. Marked edema may indicate a localized infection. A cystic mass high in the neck may be a thyroglossal duct cyst or a branchial cleft cyst. A mass over the clavicle, changing size with crying or respiration, suggests a cystic hygroma.

Palpation Palpate the infant’s head, identifying suture lines and fontanels. Note any tenderness over the scalp. Suture lines feel ridge-like until about 6 months of age, after which they are usually no longer palpable. Vaginally delivered newborns may have molding with prominent ridges from overriding sutures. Fontanels may be small or not palpable at birth. A third fontanel (the mastoid fontanel), located between the anterior and posterior fontanels, may be an expected variant and is common in infants with Down syndrome. Any palpable ridges in addition to the expected suture lines may indicate skull fractures.

Measure the size of the anterior and posterior fontanels using two dimensions (anteroposterior and lateral). In infants younger than 6 months, the anterior fontanel diameter should not exceed 4 to 5 cm. It should get progres- sively smaller beyond that age, closing completely by 12 to 15 months of age.

CLINICAL PEARL

Resolution of Molding Molding of the head at delivery can be very distressing for parents. Reassure the parents that the abnormal shape generally resolves rela- tively quickly (Fig. 11.31). Drawings can help you explain that the infant’s cranial bones overlap and that their relative lack of development is a protective device for the brain. Symmetry of the head is usually regained within 1 week of birth, with fontanels and suture line resuming their appropriate shape and size.

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With the infant in a supported sitting position, palpate the anterior fontanel for bulging or depression. It should feel slightly depressed, and some pulsation is expected. A bulging fontanel protrudes above the level of the bones of the skull when the infant is sitting and feels tense, similar to the fontanel of an infant during the expiratory phase of crying. A bulging fontanel with marked pulsations may indicate increased intracranial pressure from a space- occupying mass or meningitis.

FIG. 11.31 Molding of the newborn head. (From Graham and Sanchez-Lara, 2016.)