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Seidel's Guide to Physical Examination - E-Book

Seidel's Guide to Physical Examination - E-Book

Jane W. Ball | Joyce E. Dains | John A. Flynn | Barry S. Solomon | Rosalyn W. Stewart

(2014)

Additional Information

Book Details

Abstract

With a strong patient-centered approach to care and an author team comprised of nurses and physicians, Seidel’s Guide to Physical Examination, 8th Edition, addresses teaching and learning health assessment in nursing, medical, and a wide variety of other health-care programs, at both undergraduate and graduate levels. This new edition offers an increased focus on evidence-based practice and improved readability, along with integrated lifespan content and numerous special features such as Clinical Pearls and Physical Variations, Functional Assessment, and Staying Well boxes.

  • Evidence-Based Practice in Physical Examination boxes supply you with current data on the most effective techniques for delivering quality patient care.
  • Clinical Pearls lend insights and clinical expertise to help you develop clinical judgment skills.
  • Functional Assessment boxes present a more holistic approach to patient care that extends beyond the physical exam to patients’ functional ability.
  • Staying Well boxes focus you on patient wellness and health promotion.
  • Risk Factor boxes provide opportunities for patient teaching or genetic testing for a variety of conditions.
  • Differential diagnosis content offers you an understanding of how disease presentations vary and specific information for how to make diagnoses from similar abnormal findings.
  • Abnormal Findings tables equip you with a quick, illustrated reference that allows for comparisons of various abnormalities along with key symptoms and underlying pathophysiology.
  • Sample Documentation boxes clarify appropriate professional language for the process of recording patient assessment data.
  • NEW! Advance Practice Skills highlighted throughout text makes identification and reference easier for students.
  • NEW! Updated content throughout provides you with cutting-edge research and a strong evidence-based approach to care.
  • NEW! Vital Signs and Pain Assessment Chapter groups important, foundational tasks together for easy reference in one location.
  • NEW! Improve readability ensures content remains clear, straightforward, and easy to understand.
  • NEW! Updated illustrations and photographs enhances visual appeal and clarifies anatomic concepts and exam techniques.

Table of Contents

Section Title Page Action Price
Front Cover cover
Inside Front Cover ifc1
Half title page i
Brief TOC ii
Seidel's Guide to Physical Examination, 8/e iii
Copyright Page iv
Dedication v
About The Authors vii
Jane W. Ball, DrPH, RN, CPNP vii
Joyce E. Dains, DrPH, JD, RN, FNP-BC, FAANP vii
John A. Flynn, MD, MBA, MEd viii
Barry S. Solomon, MD, MPH viii
Rosalyn W. Stewart, MD, MS, MBA viii
Reviewers ix
Preface x
Organization x
Special Features xi
New to This Edition xi
Our Ancillary Package xi
Our Core Values xii
Acknowledgments xii
Table Of Contents xiii
1 The History and Interviewing Process 1
Developing a Relationship with the Patient 1
Effective Communication 2
Seeking Connection. 2
Enhancing Patient Responses. 4
Moments of Tension: Potential Barriers to Communication 4
Curiosity About You. 4
Anxiety. 4
Silence. 4
Depression. 5
Crying and Compassionate Moments. 5
Physical and Emotional Intimacy. 5
Seduction. 5
Anger. 5
Avoiding the Full Story. 5
Financial Considerations. 5
The Patient History 6
Setting for the Interview 6
Structure of the History 6
Building the History 6
Sensitive Issues 7
Alcohol. 8
Intimate Partner Violence. 8
Spirituality. 10
Sexuality. 10
Outline of the History 10
Chief Concern or the Reason for Seeking Care. 10
History of Present Illness or Problem. 11
Past Medical History. 11
Family History 12
Personal and Social History 12
Review of Systems (ROS). 13
Females 14
Males 14
Concluding Questions. 14
Adaptations for Age, Gender, and Possible Disabilities 14
Infants and Children 14
Chief Concern. 14
History of Present Illness. 14
Past Medical History 14
Family History 15
Personal and Social History 15
Review of Systems. 16
Adolescents 16
Pregnant Women 17
Basic Information 17
History of Present Illness or Problem. 17
Obstetric History. 18
Menstrual History. 18
Gynecologic History. 18
Past Medical History. 18
Family History. 18
Personal and Social History. 18
Review of Systems. 18
Risk Assessment. 18
Postpartum. 18
Older Adults 18
The Frail. 19
Patients with Disabilities 20
The Next Step 20
2 Cultural Competency 21
A Definition of Culture 21
Distinguishing Physical Characteristics 21
Cultural Competence 22
Cultural Humility 23
The Impact of Culture 23
The Blurring of Cultural Distinctions 23
The Primacy of the Individual in Health Care 24
Professional Cultures within the Health Professions 24
The Impact of Culture on Illness 24
The Components of a Cultural Response 25
Modes of Communication 26
Health Beliefs and Practices 27
Family Relationships 27
Diet and Nutritional Practices 28
Summing Up 28
3 Examination Techniques and Equipment 30
Precautions to Prevent Infection 30
Latex Allergy 30
Examination Technique 32
Patient Positions and Draping 32
Seated. 32
Supine. 32
Prone. 32
Dorsal Recumbent. 32
Lateral Recumbent. 32
Lithotomy. 32
Sims. 32
Inspection 32
Palpation 33
Percussion 34
Auscultation 35
Modifications for Patients with Disabilities 35
Patients with Mobility Impairments 35
Pivot Transfer. 35
Cradle Transfer. 35
Two-Person Transfer. 36
Equipment. 36
Patients with Sensory Impairment 36
Impaired Vision. 36
Impaired Hearing or Speech. 36
Special Concerns for Patients with Spinal Cord Injury or Lesion 37
Bowel and Bladder Concerns. 37
Autonomic Hyperreflexia. 37
Hypersensitivity. 37
Spasticity. 37
Equipment 37
Weight Scales and Height Measurement Devices 37
Thermometer 39
Stethoscope 39
Sphygmomanometer 40
Pulse Oximeter 40
Doppler 41
Portable Ultrasound 41
Fetal Monitoring Equipment 41
Ophthalmoscope 42
PanOptic Ophthalmoscope 43
StrabismoScope 43
Photoscreening 43
Visual Acuity Charts 43
Snellen Alphabet. 43
Tumbling E. 44
HOTV. 44
LH Symbols (LEA Symbols). 44
Broken Wheel Cards. 44
Near Vision Charts 44
Amsler Grid 44
Otoscope 45
Tympanometer 45
Nasal Speculum 45
Tuning Fork 45
Percussion (Reflex) Hammer 46
Neurologic Hammer 46
Tape Measure 46
Transilluminator 47
Vaginal Speculum 47
Goniometer 48
Wood’s Lamp 48
Dermatoscope 48
Calipers for Skinfold Thickness 49
Monofilament 49
Scoliometer 49
4 Vital Signs and Pain Assessment 50
Anatomy and Physiology 50
Temperature 50
Pulse Rate 50
Respiratory Rate 50
Blood Pressure 50
Pain 50
Infants 51
Pregnant Women 51
5 Mental Status 64
Anatomy and Physiology 64
Infants and Children 64
Adolescents 64
Older Adults 65
Review of Related History 65
History of Present Illness 65
Past Medical History 66
Family History 66
Personal and Social History 66
Children 66
Adolescents 66
Older Adults 66
Examination and Findings 66
Physical Appearance and Behavior 66
Grooming 66
Emotional Status 67
Nonverbal Communication (Body Language) 67
State of Consciousness 67
Cognitive Abilities 67
Analogies 67
Abstract Reasoning 69
Arithmetic Calculation 69
Writing Ability 69
Execution of Motor Skills 69
Memory 70
Attention Span 70
Judgment 70
Speech and Language Skills 70
Voice Quality 70
Articulation 70
Comprehension 70
Coherence 70
Emotional Stability 71
Mood and Feelings 71
Thought Process and Content 71
Perceptual Distortions and Hallucinations 71
Infants and Children 72
Pregnant Women 73
Older Adults 73
Abnormalities 75
Mental Status 75
Disorders of Altered Mental Status 75
Concussion 75
Delirium 75
Disorders of Mood 76
Depression 76
Mania 76
Anxiety Disorder 77
Schizophrenia 77
Infants and Children 77
Intellectual Disability 77
Attention-Deficit/Hyperactivity Disorder (ADHD) 77
Autism 78
Older Adults 78
Dementia 78
6 Growth and Measurement 79
Anatomy and Physiology 79
Differences in Growth by Organ System 80
Infants and Children 81
Pregnant Women 81
Older Adults 82
Review of Related History 82
History of Present Illness 82
Past Medical History 82
Family History 82
Personal and Social History 82
Infants 82
Children and Adolescents 82
Pregnant Women 82
Older Adults 83
Examination and Findings 83
Equipment 83
Weight and Standing Height 83
Body Mass Index 83
Infants 83
Recumbent Length 83
Weight 84
Head Circumference 84
Chest Circumference 85
Gestational Age 85
Size for Gestational Age. 85
Stature and Weight 86
Upper-to-Lower Segment Ratio 87
Arm Span 87
Sexual Maturation 87
Pregnant Women 88
Older Adults 89
Abnormalities 91
Growth and Measurement 91
Acromegaly 91
Cushing Syndrome 92
Turner Syndrome 92
Hydrocephalus 93
Failure To Thrive 93
Growth Hormone Deficiency 94
Precocious Puberty 94
7 Nutrition 95
Anatomy and Physiology 95
Macronutrients 95
Carbohydrate 95
Protein 96
Fat 96
Micronutrients 96
Water 96
Energy Requirements 97
Resting Energy Expenditure 97
Physical Activity 97
Thermogenesis 97
Review of Related History 97
History of Present Illness 97
Past Medical History 97
Family History 98
Personal and Social History 98
Infants and Children 98
Adolescents 99
Pregnant Women 99
Older Adults 99
Examination and Findings 99
Equipment 99
Anthropometrics 100
Waist Circumference and Waist-Height Ratio 100
Waist-to-Hip Circumference Ratio 100
Determination of Diet Adequacy 101
Twenty–Four-Hour Recall Diet 101
Food Diary 101
Measures of Nutrient Analysis 101
ChooseMyPlate.gov 101
Vegetarian Diets 102
Ethnic Food Guide Pyramids 102
Measures of Nutrient Adequacy 102
Special Procedures 107
Triceps Skinfold Thickness 107
Mid-Upper Arm Circumference 108
Midarm Muscle Circumference/ Midarm Muscle Area 108
Biochemical Measurement 108
Abnormalities 110
Nutrition 110
Obesity 110
Anorexia Nervosa 111
Bulimia Nervosa 112
Anemia 112
8 Skin, Hair, and Nails 114
Anatomy and Physiology 114
Epidermis 115
Dermis 115
Hypodermis 115
Appendages 115
Infants and Children 116
Adolescents 116
Pregnant Women 116
Older Adults 116
Review of Related History 117
History of Present Illness 117
Past Medical History 118
Family History 118
Personal and Social History 118
Infants 119
Children and Adolescents 119
Pregnant Women 119
Older Adults 119
Examination and Findings 119
Equipment 119
Skin 119
Inspection 119
Palpation 124
Skin Lesions 125
Characteristics 125
Hair 133
Nails 134
Inspection 134
Color. 134
Nail Plate. 135
Nail Base Angle. 135
Palpation 135
Infants and Children 137
Adolescents 140
Pregnant Women 140
Older Adults 141
Abnormalities 144
Skin, Hair, Nails 144
Skin: Inflammatory and Infectious Conditions 144
Eczematous Dermatitis 144
Folliculitis 144
Furuncle (Boil) 145
Cellulitis 145
Tinea (Dermatophytosis) 146
Pityriasis Rosea 147
Psoriasis 147
Rosacea 148
Herpes Zoster (Shingles) 148
Herpes Simplex 149
Lyme Disease 149
Skin: Cutaneous Reactions 150
Drug Eruptions 150
Acanthosis Nigricans (AN) 150
Skin: Disease Caused by Biologic Warfare 151
Skin: Malignant/Neoplastic Abnormalities 152
Basal Cell Carcinoma 152
Squamous Cell Carcinoma 152
Malignant Melanoma 153
Kaposi Sarcoma (KS) 154
Hair Disorders 154
Alopecia Areata 154
Scarring Alopecia 155
Traction Alopecia 155
Hirsutism 155
Nails: Infection 155
Paronychia 155
Onychomycosis 156
Nails: Injury 156
Ingrown Nails 156
Subungual Hematoma 157
Onycholysis 157
Nails: Changes Associated with Systemic Disease 158
Koilonychia (Spoon Nails) 158
Beau Lines 158
White Banding (Terry Nails) 158
Psoriasis 159
Nails: Periungual Growths 159
Warts 159
Digital Mucous Cysts 159
Pregnant Women 160
Pruritic Urticarial Papules and Plaques of Pregnancy (PUPPP) 160
Herpes Gestationis (Pemphigoid Gestationis) 160
Infants and Children 160
Seborrheic Dermatitis 160
Miliaria Rubra (“Prickly Heat”) 161
Impetigo 161
Acne Vulgaris 161
Chickenpox (Varicella) 162
Measles (Rubeola) 162
German Measles (Rubella) 163
Hair-Pulling (Trichotillomania) 163
Patterns of Injury in Physical Abuse 164
Older Adults 165
Stasis Dermatitis 165
Solar Keratosis (Actinic Keratosis) 165
Physical Abuse in Older Adults 165
9 Lymphatic System 166
Anatomy and Physiology 166
Lymph Nodes 167
Lymphocytes 169
Thymus 170
Spleen 170
Tonsils and Adenoids 170
Peyer Patches 170
Infants and Children 170
Pregnant Women 171
Older Adults 171
Review of Related History 171
History of Present Illness 171
Past Medical History 171
Family History 172
Personal and Social History 172
Infants and Children 172
Pregnant Women 172
Older Adults 172
Examination and Findings 172
Equipment 172
Inspection and Palpation 172
Head and Neck 174
Axillae 175
Epitrochlear Lymph Nodes 175
Inguinal and Popliteal Lymph Nodes 176
Spleen 176
Infants and Children 176
Abnormalities 178
Lymphatic System 178
Acute Lymphangitis 178
Acute Suppurative Lymphadenitis 178
Lymphedema 178
Lymphangioma/Cystic Hygroma 179
Lymphatic Filariasis (Elephantiasis) 179
Non-Hodgkin Lymphoma 180
Hodgkin Lymphoma 180
Epstein-Barr Virus Mononucleosis 181
Toxoplasmosis 181
Roseola Infantum (HHV-6) 181
Herpes Simplex (HSV) 181
Cat Scratch Disease 182
Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome (HIV/AIDS) 182
Serum Sickness (Type III Hypersensitivity Reaction) 182
Latex Allergy Type IV Dermatitis (Delayed Hypersensitivity) 183
Latex Allergy Type I Reaction 183
10 Head and Neck 184
Anatomy and Physiology 184
Infants 186
Children and Adolescents 186
Pregnant Women 186
Older Adults 186
Review of Related History 186
History of Present Illness 187
Past Medical History 188
Family History 188
Personal and Social History 188
Infants 188
Pregnant Women 188
Older Adults 188
Examination and Findings 188
Equipment 188
Head and Face 189
Inspection 189
Palpation 192
Percussion 192
Auscultation 192
Neck 192
Inspection 192
Palpation 193
Lymph Nodes 193
Thyroid Gland 193
Inspection 195
Palpation 196
Transillumination 196
Children 197
Pregnant Women 197
Older Adults 197
Abnormalities 198
Head 198
Headaches 198
Salivary Gland Tumor 198
Neck 199
Thyroglossal Duct Cyst 199
Branchial Cleft Cyst 199
Torticollis (Wry Neck) 200
Thyroid 200
Hypothyroidism 200
Hyperthyroidism 201
Myxedema 201
Graves Disease 201
Hashimoto Disease 201
Infants 202
Encephalocele 202
Hydrocephalus 202
Microcephaly 202
Craniosynostosis 203
11 Eyes 204
Anatomy and Physiology 204
External Eye 205
Eyelid 205
Conjunctiva 205
Lacrimal Gland 205
Eye Muscles 205
Internal Eye 205
Sclera 206
Cornea 206
Uvea 206
Lens 206
Retina 206
Infants and Children 206
Pregnant Women 206
Older Adults 206
Review of Related History 207
History of Present Illness 207
Past Medical History 208
Family History 208
Personal and Social History 208
Infants and Children 208
Pregnant Women 208
Older Adults 208
Examination and Findings 208
Equipment 208
Visual Acuity Testing 208
External Examination 209
Surrounding Structures 210
Eyelids 210
Palpation 211
Conjunctiva 211
Cornea 212
Iris and Pupil 212
Lens 214
Sclera 214
Lacrimal Apparatus 214
Extraocular Muscles 214
Ophthalmoscopic Examination 216
Unexpected Findings 218
Infants 218
Children 221
Pregnant Women 222
Older Adults 222
Abnormalities 223
External Eye 223
Exophthalmos 223
Episcleritis 223
Band Keratopathy 223
Corneal Ulcer 224
Extraocular Muscles 224
Strabismus 224
Internal Eye 225
Horner Syndrome 225
Cataracts 225
Diabetic Retinopathy (Background or Non-Proliferative) 225
Diabetic Retinopathy (Proliferative) 226
Lipemia Retinalis 226
Retinitis Pigmentosa 227
Glaucoma 227
Chorioretinitis (Chorioretinal Inflammation) 227
Visual Fields 228
Visual Field Defects 228
Children and Infants 229
Retinoblastoma 229
Retinopathy of Prematurity (ROP) 229
Retinal Hemorrhages in Infancy 230
Older Adult 230
Macular Degeneration 230
12 Ears, Nose, and Throat 231
Anatomy and Physiology 232
Ears and Hearing 232
Nose, Nasopharynx, and Sinuses 233
Mouth and Oropharynx 234
Infants and Children 235
Pregnant Women 235
Older Adults 236
Review of Related History 236
History of Present Illness 236
Past Medical History 237
Family History 237
Personal and Social History 238
Infants and Children 238
Pregnant Women 238
Older Adults 238
Examination and Findings 238
Equipment 238
Ears and Hearing 238
External Ear 238
Otoscopic Examination 239
Hearing Evaluation 241
Whispered Voice. 241
Weber and Rinne Tests. 241
Nose, Nasopharynx, and Sinuses 242
External Nose 242
Nasal Cavity 242
Sinuses 243
Mouth and Oropharynx 244
Lips 244
Buccal Mucosa, Teeth, and Gums 244
Oral Cavity 246
Oropharynx 248
Infants 249
Ears. 249
Nose and Sinuses. 249
Mouth. 250
Children 251
Ears. 251
Nose and Sinuses. 252
Mouth. 252
Pregnant Women 252
Older Adults 252
Ears and Hearing. 252
Nose. 252
Mouth. 253
Abnormalities 254
Ear 254
Otitis Media with Effusion and Acute Otitis Media 254
Otitis Externa 255
Cholesteatoma 255
Hearing Loss 256
Conductive Hearing Loss 256
Sensorineural Hearing Loss 256
Ménière Disease (Endolymphatic Hydrops) 256
Vertigo 257
Sinuses 257
Sinusitis 257
Mouth and Oropharynx 257
Acute Pharyngitis 257
Peritonsillar Abscess 258
Retropharyngeal Abscess 258
Oral Cancer 259
Periodontal Disease 259
Cleft Lip and Palate 259
13 Chest and Lungs 260
Anatomy and Physiology 260
Anatomic Landmarks 262
Infants and Children 262
Pregnant Women 263
Older Adults 263
Review of Related History 264
History of Present Illness 264
Coughs 264
Dry or Moist. 265
Onset. 265
Frequency of Occurrence. 265
Regularity. 265
Pitch and Loudness. 265
Postural Influences. 265
Quality. 265
Sputum 265
Past Medical History 265
Family History 266
Personal and Social History 266
Infants and Children 266
Pregnant Women 266
Older Adults 266
Equipment 267
Examination and Findings 267
Inspection 267
Observing Respiration 267
Looking for Clues at the Periphery 271
Palpation 271
Tactile Fremitus 272
Examining the Trachea 273
Percussion 273
Diaphragmatic Excursion 274
Auscultation 276
Breath Sounds 276
Crackles. 278
Rhonchi. 278
Wheezes. 278
Other Sounds. 278
Vocal Resonance 279
Infants 279
Children 280
Pregnant Women 281
Older Adults 281
Abnormalities 283
Asthma (Reactive Airway Disease) 284
Atelectasis 284
Bronchitis 284
Pleurisy 285
Pleural Effusion 285
Empyema 286
Lung Abscess 286
Pneumonia 287
Influenza 287
Tuberculosis 288
Pneumothorax 288
Hemothorax 289
Lung Cancer 289
Pulmonary Embolism 290
Infants, Children, and Adolescents 290
Diaphragmatic Hernia 290
Cystic Fibrosis 290
Epiglottitis 291
Croup (Laryngotracheal Bronchitis) 291
Tracheomalacia 292
Bronchiolitis 292
Chronic Obstructive Pulmonary Disease 292
Emphysema 292
Bronchiectasis 293
Chronic Bronchitis 293
14 Heart 294
Anatomy and Physiology 294
Structure 295
Cardiac Cycle 297
Electrical Activity 298
Infants and Children 299
Pregnant Women 299
Older Adults 301
Review of Related History 301
History of Present Illness 301
Past Medical History 302
Family History 303
Personal and Social History 303
Infants 303
Children 304
Pregnant Women 304
Older Adults 304
Examination and Findings 304
Equipment 304
Inspection 304
Palpation 305
Percussion 306
Auscultation 306
Basic Heart Sounds 307
S1 and S2. 307
Splitting. 308
S3 and S4. 310
Extra Heart Sounds 310
Heart Murmurs 311
Rhythm Disturbance 318
Infants 318
Children 319
Pregnant Women 319
Older Adults 319
Abnormalities 320
Heart 320
Angina 320
Bacterial Endocarditis 320
Congestive Heart Failure (CHF)—Left-Sided 321
Congestive Heart Failure (CHF)—Right-Sided 321
Pericarditis 322
Cardiac Tamponade 322
Cor Pulmonale 323
Myocardial Infarction 323
Myocarditis 324
Abnormalities in Heart Rate and Rhythm 324
Conduction Disturbances 324
Sick Sinus Syndrome 324
Infants and Children 328
Tetralogy of Fallot 328
Ventricular Septal Defect (VSD) 328
Patent Ductus Arteriosus 329
Atrial Septal Defect (ASD) 330
Acute Rheumatic Fever 330
Older Adults 331
Atherosclerotic Heart Disease (Atherosclerosis, Coronary Heart Disease) 331
Mitral Insufficiency, Regurgitation 331
Senile Cardiac Amyloidosis 331
15 Blood Vessels 332
Anatomy and Physiology 332
Blood Circulation 332
Arterial Pulse and Pressure 336
Jugular Venous Pulse and Pressure 336
Infants and Children 336
Pregnant Women 337
Older Adults 337
Review of Related History 337
History of Present Illness 337
Past Medical History 337
Family History 338
Personal and Social History 338
Infants and Children 338
Pregnant Women 338
Older Adults 338
Examination and Findings 338
Equipment 338
Peripheral Arteries 338
Palpation 338
Auscultation 340
Assessment for Peripheral Arterial Disease 340
Peripheral Veins 342
Jugular Venous Pressure 342
Hepatojugular Reflux 343
Evaluation of Hand Veins 343
Assessment for Venous Obstruction and Insufficiency 343
Thrombosis. 343
Homan Sign. 344
Edema. 344
Varicose Veins. 345
Infants 345
Children 345
Pregnant Women 345
Older Adults 345
Abnormalities 346
Blood Vessels 346
Vessel Disorders 346
Temporal Arteritis (Giant Cell Arteritis) 346
Arterial Aneurysm 346
Arteriovenous Fistula 346
Peripheral Arterial Disease 347
Raynaud Phenomenon 347
Arterial Embolic Disease 347
Venous Thrombosis 348
Jugular Venous Pressure Disorder 348
Tricuspid Regurgitation 348
Children 348
Coarctation of the Aorta 348
Kawasaki Disease 349
Pregnant Women 349
Preeclampsia-Eclampsia 349
Older Adults 349
Venous Ulcers 349
16 Breasts and Axillae 350
Anatomy and Physiology 350
Children and Adolescents 352
Pregnant Women 353
Lactating Women 353
Older Adults 353
Review of Related History 353
History of Present Illness 353
Past Medical History 353
Family History 355
Personal and Social History 355
Pregnant Women 355
Lactating Women 355
Older Adults 355
Examination and Findings 355
Equipment 355
Inspection 355
Breasts 355
Nipples and Areolae 356
Reinspection in Varied Positions 357
Palpation 358
Patient in Seated Position 360
Chest Wall Sweep. 360
Bimanual Digital Palpation. 360
Lymph Node Palpation. 360
Patient in Supine Position 360
Females. 363
Males. 363
Infants 363
Children and Adolescents 363
Pregnant Women 364
Lactating Women 365
Older Adults 365
Abnormalities 365
Breasts 365
Breast Lumps 365
Fibrocystic Changes 366
Fibroadenoma 366
Malignant Breast Tumors 366
Fat Necrosis 366
Nipples and Areolae 367
Intraductal Papillomas and Papillomatosis 367
Duct Ectasia 367
Galactorrhea 367
Paget Disease 368
Mastitis 368
Gynecomastia 369
Children 369
Premature Thelarche 369
17 Abdomen 370
Anatomy and Physiology 370
Alimentary Tract 370
Liver 372
Gallbladder 373
Pancreas 373
Spleen 373
Kidneys, Ureters, and Bladder 373
Musculature and Connective Tissues 373
Vasculature 373
Infants 374
Pregnant Women 374
Older Adults 375
Review of Related History 375
History of Present Illness 375
Past Medical History 377
Family History 377
Personal and Social History 377
Infants 377
Children 377
Pregnant Women 377
Older Adults 377
Examination and Findings 377
Equipment 377
Preparation 377
Inspection 378
Surface Characteristics 378
Contour 379
Movement 381
Auscultation 381
Bowel Sounds 381
Additional Sounds and Bruits 381
Percussion 381
Liver Span 381
Spleen 383
Gastric Bubble 383
Kidneys 383
Palpation 383
Light Palpation 383
Moderate Palpation 383
Deep Palpation 384
Masses 384
Umbilical Ring 385
Palpation of Specific Organs and Structures 385
Liver. 385
Liver: Alternative Techniques. 386
Gallbladder. 386
Spleen. 386
Left Kidney. 387
Right Kidney. 388
Aorta. 388
Urinary Bladder. 388
Advanced Skills 388
Ascites Assessment 388
Shifting Dullness. 388
Fluid Wave. 388
Pain Assessment 388
Abdominal Signs 391
Rebound Tenderness 391
Iliopsoas Muscle Test 393
Obturator Muscle Test 393
Ballottement 393
Infants and Children 394
Inspection 394
Auscultation and Percussion 395
Palpation 395
Liver Palpation 396
Deep Palpation 396
Adolescents 397
Pregnant Women 398
Older Adults 398
Abnormalities 399
Abdomen 399
Alimentary Tract 399
Acute Diarrhea 399
Gastroesophageal Reflux Disease 400
Irritable Bowel Syndrome 400
Hiatal Hernia with Esophagitis 401
Duodenal Ulcer (Duodenal Peptic Ulcer Disease) 401
Crohn Disease 401
Ulcerative Colitis 402
Stomach Cancer 403
Diverticular Disease 403
Colon Cancer (Colorectal Cancer) 403
Hepatobiliary System 404
Hepatitis 404
Cirrhosis 404
Primary Hepatocellular Carcinoma 405
Cholelithiasis 405
Cholecystitis 406
Nonalcoholic Fatty Liver Disease (NAFLD) 406
Pancreas 406
Acute Pancreatitis 406
Chronic Pancreatitis 407
Spleen 407
Spleen Laceration/Rupture 407
Kidney 407
Acute Glomerulonephritis 407
Hydronephrosis 408
Pyelonephritis 408
Renal Abscess 408
Renal Calculi 409
Acute Renal Failure 409
Infants 410
Intussusception 410
Pyloric Stenosis 410
Meconium Ileus 411
Biliary Atresia 412
Meckel Diverticulum 412
Necrotizing Enterocolitis 413
Children 413
Neuroblastoma 413
Wilms Tumor (Nephroblastoma) 414
Hirschsprung Disease (Congenital Aganglionic Megacolon) 414
Hemolytic Uremic Syndrome (HUS) 414
Older Adults 415
Fecal Incontinence 415
18 Female Genitalia 416
Anatomy and Physiology 416
External Genitalia 416
Internal Genitalia 418
Bony Pelvis 419
Infants and Children 422
Adolescents 422
Pregnant Women 422
Older Adults 423
Review of Related History 423
History of Present Illness 423
Past Medical History 424
Family History 425
Personal and Social History 425
Infants and Children 426
Adolescents 427
Pregnant Women 427
Older Adults 427
Examination and Findings 427
Equipment 427
Preparation 427
Positioning 428
Draping and Gloving 428
External Examination 428
Inspection and Palpation 428
Labia Majora 428
Labia Minora 429
Clitoris 429
Urethral Orifice 429
Vaginal Introitus 429
Skene and Bartholin Glands 429
Muscle Tone 430
Perineum 430
Anus 430
Internal Examination 430
Preparation 430
Insertion of Speculum 430
Cervix 431
Color. 431
Position. 431
Surface Characteristics. 431
Discharge. 431
Size and Shape. 431
Withdrawal of Speculum 435
Bimanual Examination 435
Cervix 436
Uterus 437
Position. 437
Size, Shape, and Contour. 437
Mobility. 437
Adnexa and Ovaries 437
Rectovaginal Examination 438
Preparation 438
Anal Sphincter 438
Rectal Walls and Rectovaginal Septum 439
Uterus 439
Adnexa 439
Stool 439
Completion 439
Infants 439
Indications for Examination 440
Inspection and Palpation 440
Discharge 441
Injuries 441
Bleeding 441
Rectal Examination 441
Adolescents 442
Pregnant Women 442
Gestational Age 442
Uterus Size and Contour 442
Pelvic Examination 443
Cervical Effacement and Dilation 443
Fetal Well-Being 443
Fetal Position 444
Station 445
Contractions 446
Fetal Head Position 447
Other Pregnancy-Associated Changes 447
Older Adults 447
Preparation 447
Alternative Positions for the Pelvic Examination 448
Knee-Chest Position. 448
Diamond-Shaped Position. 448
Obstetric Stirrups Position. 448
M-Shaped Position. 448
V-Shaped Position. 449
Women with Sensory Impairment 449
Abnormalities 450
Female Genitalia 450
Premenstrual Syndrome (PMS) 450
Infertility 450
Endometriosis 451
Lesions From Sexually Transmitted Infections 451
Condyloma Acuminatum (Genital Warts) 451
Molluscum Contagiosum 452
Syphilitic Chancre 453
Condyloma Latum 453
Genital Herpes 454
Vulva and Vagina 454
Inflammation of Bartholin Gland 454
Vaginal Carcinoma 455
Vulvar Carcinoma 456
Vaginal Infections 456
Cervix 457
Cervical Cancer 457
Uterus 458
Uterine Prolapse 458
Uterine Bleeding 459
Myomas (Leiomyomas, Fibroids) 459
Endometrial Cancer 460
Adnexa 460
Ovarian Cysts 460
Ovarian Cancer 461
Tubal (Ectopic) Pregnancy 461
Pelvic Inflammatory Disease (PID) 462
Salpingitis 462
Infants and Children 463
Ambiguous Genitalia 463
Hydrocolpos 464
Vulvovaginitis 464
Pregnant Women 465
Premature Rupture of Membranes 465
Vaginal Bleeding during Pregnancy 465
Older Adults 465
Atrophic Vaginitis 465
Urinary Incontinence 465
19 Male Genitalia 466
Anatomy and Physiology 466
Infants and Children 468
Adolescents 468
Older Adults 468
Review of Related History 468
History of Present Illness 468
Past Medical History 469
Family History 469
Personal and Social History 469
Infants and Children 469
Adolescents 469
Older Adults 469
Examination and Findings 471
Equipment 471
Inspection and Palpation 471
Genital Hair Distribution 471
Penis 471
Urethral Meatus 472
Penile Shaft 472
Scrotum 472
Hernia 472
Testes 473
Cremasteric Reflex 474
Prostate 474
Infants 474
Inspection and Palpation 474
Transillumination 475
Children 475
Inspection and Palpation 475
Adolescents 475
Older Adults 475
Abnormalities 476
Infertility 476
Hernia 476
Penis 477
Paraphimosis 477
Syphilitic Chancre 477
Genital Herpes 478
Condyloma Acuminata 478
Lymphogranuloma Venereum 478
Molluscum Contagiosum 479
Peyronie Disease 479
Penile Cancer 479
Scrotum 480
Hydrocele 480
Spermatocele 480
Varicocele 481
Orchitis 481
Epididymitis 482
Testicular Torsion 482
Testicular Cancer 483
Klinefelter Syndrome 483
Ambiguous Genitalia 484
Hypospadias 484
20 Anus, Rectum, and Prostate 485
Anatomy and Physiology 485
Infants and Children 486
Pregnant Women 487
Older Adults 487
Review of Related History 487
History of Present Illness 487
Past Medical History 488
Family History 488
Personal and Social History 488
Infants and Children 488
Pregnant Women 489
Older Adults 489
Examination and Findings 489
Equipment 489
Preparation 489
Positioning 489
Sacrococcygeal and Perianal Areas 489
Anus 489
Sphincter 489
Anal Ring 489
Lateral and Posterior Rectal Walls 490
Bidigital Palpation 490
Anterior Rectal Wall 490
Prostate 491
Uterus and Cervix 491
Stool 491
Infants and Children 491
Pregnant Women 493
Older Adults 493
Abnormalities 494
Anus, Rectum, and Surrounding Skin 494
Pilonidal Cyst 494
Anal Warts (Condyloma Acuminata) 494
Perianal and Perirectal Abscesses 495
Anorectal Fissure 495
Anal Fistula 496
Pruritus Ani 496
Hemorrhoids 496
Polyps 497
Anal Cancer 497
Colorectal Cancer 498
Prostate 498
Prostatitis 498
Benign Prostatic Hypertrophy (BPH) 498
Prostate Cancer 499
Infants and Children 499
Imperforate Anus 499
Enterobiasis (Roundworm, Pinworm) 500
21 Musculoskeletal System 501
Anatomy and Physiology 501
Upper Extremities 505
Head and Spine 505
Lower Extremities 507
Infants and Children 508
Adolescents 508
Pregnant Women 508
Older Adults 508
Review of Related History 508
History of Present Illness 508
Past Medical History 509
Family History 509
Personal and Social History 509
Infants and Children 509
Pregnant Women 510
Older Adults 510
Examination and Findings 510
Equipment 510
Inspection 510
Palpation 510
Range of Motion and Muscle Tone 511
Muscle Strength 511
Specific Joints and Muscles 512
Hands and Wrists 512
Elbows 513
Shoulders 514
Temporomandibular Joint 516
Cervical Spine 516
Thoracic and Lumbar Spine 518
Hips 519
Legs and Knees 520
Feet and Ankles 522
Advanced Skills 524
Hand and Wrist Assessment 524
Shoulder Assessment 524
Lower Spine Assessment 526
Hip Assessment 526
Knee Assessment 527
Limb Measurement 529
Infants 529
Children 530
Adolescents 532
Pregnant Women 533
Older Adults 534
Abnormalities 535
Musculoskeletal 535
Ankylosing Spondylitis 535
Lumbosacral Radiculopathy (Herniated Lumbar Disk) 535
Lumbar Stenosis 536
Carpal Tunnel Syndrome 536
Gout 536
Temporomandibular Joint Syndrome 537
Osteomyelitis 537
Bursitis 537
Paget Disease of the Bone (Osteitis Deformans) 537
Osteoarthritis 538
Rheumatoid Arthritis 538
Sports Injuries 538
Muscle Strain 539
Dislocation 539
Fracture 539
Tenosynovitis (Tendonitis) 539
Rotator Cuff Tear 540
Infants and Children 540
Clubfoot (Talipes Equinovarus) 540
Metatarsus Adductus (Metatarsus Varus) 540
Legg-Calvé-Perthes Disease 541
Osgood-Schlatter Disease 541
Slipped Capital Femoral Epiphysis 541
Muscular Dystrophy 541
Scoliosis 541
Radial Head Subluxation (Nursemaid’s Elbow) 542
Older Adults 542
Osteoporosis 542
Dupuytren Contracture 543
22 Neurologic System 544
Anatomy and Physiology 544
Brain 545
Cerebrum 545
Cerebellum 546
Brainstem 546
Cranial Nerves 547
Spinal Cord and Spinal Tracts 547
Spinal Nerves 547
Infants and Children 549
Pregnant Women 549
Older Adults 549
Review of Related History 550
History of Present Illness 550
Past Medical History 551
Family History 551
Personal and Social History 551
Infants 551
Children 551
Pregnant Women 552
Older Adults 552
Examination and Findings 552
Equipment 552
Cranial Nerves 553
Olfactory (I) 553
Optic (II) 554
Oculomotor, Trochlear, and Abducens (III, IV, and VI) 554
Trigeminal (V) 554
Facial (VII) 555
Acoustic (VIII) 556
Glossopharyngeal (IX) 556
Vagus (X) 556
Spinal Accessory (XI) 556
Hypoglossal (XII) 556
Proprioception and Cerebellar Function 556
Coordination and Fine Motor Skills 556
Rapid Rhythmic Alternating Movements. 556
Accuracy of Movements. 557
Balance 559
Equilibrium. 559
Gait. 559
Sensory Function 559
Primary Sensory Functions 561
Superficial Touch. 561
Superficial Pain. 561
Temperature and Deep Pressure. 561
Vibration. 561
Position of Joints. 561
Cortical Sensory Functions 561
Stereognosis. 562
Two-Point Discrimination. 562
Extinction Phenomenon. 562
Graphesthesia. 562
Point Location. 562
Reflexes 562
Superficial Reflexes 562
Plantar Reflex. 563
Abdominal Reflex. 563
Cremasteric Reflex. 564
Deep Tendon Reflexes 564
Biceps Reflex. 564
Brachioradial Reflex. 564
Triceps Reflex. 564
Patellar Reflex. 564
Achilles Reflex. 564
Clonus. 565
Advanced Skills 565
Protective Sensation 565
Meningeal Signs 565
Jolt Accentuation of Headache 566
Posturing 566
Infants 566
Children 569
Pregnant Women 570
Older Adults 570
Abnormalities 573
Neurologic System 573
Disorders of the Central Nervous System 573
Multiple Sclerosis (MS) 573
Seizure Disorder (Epilepsy) 573
Encephalitis 573
Meningitis 574
Intracranial Tumor 574
Pseudotumor Cerebri 574
Stroke (Brain Attack or Cerebrovascular Accident) 574
Disorders of the Peripheral Nervous System 576
Myasthenia Gravis 576
Guillain-Barré Syndrome 577
Trigeminal Neuralgia (Tic Douloureux) 577
Bell Palsy 577
Peripheral Neuropathy 578
Children 578
Cerebral Palsy (CP) 578
Myelomeningocele (Spina Bifida) 578
Shaken Baby Syndrome 579
Pregnant Women 579
Intrapartum Maternal Lumbosacral Plexopathy 579
Older Adults 579
Parkinson Disease 579
Normal Pressure Hydrocephalus 580
Postpolio Syndrome (Progressive Postpoliomyelitis Muscular Atrophy) 580
23 Sports Participation Evaluation 581
24 Putting It All Together 594
At the Start 594
Accuracy 595
The Potential for Error 596
Uncertainty 596
Examination Sequence 596
Adults and Adolescents 596
General Inspection 597
Preparation 597
Measurements 597
Patient Seated, Wearing Gown 597
Head and Face 598
Eyes 598
Ears 598
Nose 598
Mouth and Pharynx 598
Neck 598
Upper Extremities 598
Patient Seated, Back Exposed 599
Back and Posterior Chest 599
Lungs 599
Patient Seated, Chest Exposed 599
Anterior, Chest, Lungs, and Heart 599
Female Breasts 599
Male Breasts 599
Patient Reclining 45 Degrees 599
Patient Supine, Chest Exposed 600
Female Breasts 600
Heart 600
Patient Supine, Abdomen Exposed 600
Abdomen 600
Inguinal Area 600
External Genitalia, Males 600
Patient Supine, Legs Exposed 600
Feet and Legs 600
Hips 600
Patient Sitting, Lap Draped 600
Musculoskeletal. 600
Neurologic. 600
Patient Standing 601
Spine 601
Neurologic 601
Abdominal/Genital 601
Female Patient, Lithotomy Position 601
External Genitalia 601
Internal Genitalia 601
Male Patient, Bending Forward (Lateral Decubitus or Knee-Chest Positions Are Also Possible) 601
Newborns 602
Older Infants 602
Examination Sequence with Infants 603
General Inspection 603
Chest, Lungs, and Heart 603
Abdomen 603
Head and Neck. 604
Upper Extremities 604
Lower Extremities 604
Genitals and Rectum 605
Neurologic. 605
Back. 605
Behavior. 605
Children 605
General Inspection 606
Child Playing 606
Child on Parent’s Lap 606
Upper Extremities. 606
Lower Extremities. 606
Head and Neck. 607
Chest, Heart, and Lungs. 607
Child Relatively Supine, Still on Lap, Diaper Loosened 607
Child Standing 607
Child Returns to Parent’s Lap 607
Pregnant Women 607
Older Adults 608
The Closing Discussion 608
25 Taking the Next Steps: 610
The Clinical Examination 610
Critical Thinking 610
Assessment, Judgment, and Evidence 610
Problem Identification 610
Valid Hypotheses 611
Possible Barriers to Critical Thinking 611
Feelings, Attitudes, and Values. 612
The Ethical Context. 612
Mechanism and Probabilism. 612
Validity of the Clinical Examination 613
Bayes Theorem 613
Evidence-Based Practice 614
Evaluation and Management Plan and Setting Priorities 614
26 Recording Information 616
General Guidelines 616
EMR Replicating Functions 617
Organization of the Note 617
Organizing the Patient’s Health Record with SOAP Notes 618
Subjective Data 618
Objective Data 618
Location of Findings. 618
Incremental Grading. 618
Organs, Masses, and Lesions. 618
Discharge. 619
Illustrations 619
Problem-Oriented Medical Record 619
Comprehensive Health History and Physical Examination 619
Problem List 619
Assessment 620
Plan 620
SOAP Notes 620
APSO Notes 621
Notes from Subsequent Evaluations 621
Problem-Oriented Medical Record Format 621
The History 621
Identifying Information. 621
Problems, Allergies, Medications, and Immunizations (PAMI) List. 621
General Patient Information. 621
Source and Reliability of Information. 621
Chief Concern/Presenting Problem/Reason for Seeking Care. 621
History of Present Illness. 621
Recording the History of the Present Illness: OLDCARTS. 622
Past Medical History. 622
Family History. 622
Personal and Social History. 622
Review of Systems 622
Physical Examination Findings 624
General Statement 624
Mental Status 624
Skin 624
Head 624
Eyes 624
Ears 624
Nose 624
Throat and Mouth 624
Neck 624
Chest 624
Lungs 624
Breasts 625
Heart 625
Blood Vessels 625
Abdomen 625
Male Genitalia 625
Female Genitalia 625
Anus and Rectum 625
Lymphatic System 625
Musculoskeletal System 625
Neurologic System 625
Assessment (for Each Problem on Problem List) 625
Plan (for Each Problem on Problem List) 625
Infants 626
History 626
Present Problem. 626
Details of Pregnancy. 626
Infant’s Status at Birth. 626
First Month of Life. 626
Past Medical History. 626
Family History. 626
Personal and Social History. 626
Growth and Development. 626
Developmental Milestones. 626
Injury Prevention. 626
Diet. 626
Breast-Fed Infants. 626
Formula-Fed Infants. 626
Solid Foods. 626
Physical Examination Findings 626
General 626
Mental Status 626
Skin 626
Lymphatics 626
Head 626
Eyes 626
Ears 626
Nose 626
Mouth 626
Neck 626
Chest and Lungs 627
Heart and Blood Vessels 627
Abdomen 627
Male Genitalia 627
Female Genitalia 627
Anus, Rectum 627
Musculoskeletal System 627
Neurologic System 627
Children and Adolescents 627
27 Emergency or Life-Threatening Situations 632
Emergency Assessment of the Injured Patient 632
The Primary Survey 632
Airway and Cervical Spine. 632
Breathing. 632
Circulation. 633
Disability. 634
Exposure and Environmental Control. 635
Secondary Assessment of the Injured Patient 635
History. 635
Head and Neck. 635
Chest. 635
Abdomen. 635
Extremities and Back. 636
Rectum and Perineum. 636
Neurologic Examination. 636
Reevaluate the Patient. 636
Injury Mechanisms 636
Blunt Trauma 637
Penetrating Trauma 637
Burns 637
Assessment of an Acute Medical Emergency 637
Advanced Cardiac Life Support Survey 637
Assessment of Infants and Children 638
Assessment of Older Adults 638
Legal Considerations 641
Records 641
Consent for Treatment 641
Trauma Due to Violence 641
Medical Orders for Life-Sustaining Treatment 642
Summary 642
Abnormalities 642
Upper Airway Obstruction 642
Hypoxemia 642
Shock State 643
Ventilatory Failure 643
Increased Intracranial Pressure 643
Pulmonary Embolism 644
Severe Asthma Episode (Status Asthmaticus) 644
Status Epilepticus 644
Photo and Illustration Credits 645
References and Readings 647
Glossary 666
Appendix A Height/Weight Growth Charts 675
Appendix B Pediatric Blood Pressure Tables 679
Appendix C Conversion Tables and Anthropometric Measurements 684
Conversion Tables 684
Anthropometric Measurements 685
Index 686
A 686
B 689
C 690
D 693
E 694
F 696
G 697
H 697
I 699
J 700
K 700
L 701
M 702
N 703
O 704
P 705
Q 708
R 708
S 709
T 711
U 712
V 713
W 714
X 714
Y 714
Z 714
Inside Back Cover ibc1