Physical Diagnosis Secrets E-Book

Salvatore Mangione

BOOK

Physical Diagnosis Secrets E-Book

Salvatore Mangione

(2012)

Additional Information

Book Details

ISBN: 978-0-323-11211-6
Edition: 2
Language: English
Pages: 712
Subjects: Clinical & internal medicine
Medical study & revision guides & reference material

Abstract

This popular reference presents essential knowledge on physical diagnosis and health assessment in a practical and engaging question-and-answer format. A wealth of high-quality illustrations guide you through the first and most important of challenges involved in diagnosing any patient: performing the history and physical exam. Assessment techniques are highlighted and weighted based on their clinical importance. This detailed, highly focused and practical guide will equip you with the skills you need to confidently evaluate your patients!

The proven question-and-answer format of the highly acclaimed Secrets Series® makes it easy to master all of the most important "need-to-know" information on physical diagnosis.
Chapters are arranged by body system for practical, easy retrieval of key information.
Author pearls, tips, memory aids, and "secrets" provide concise answers to the common questions encountered in everyday practice.

The "Top 100" Secrets of History Taking and Physical Examination are conveniently listed in one place for quick review.
A new chapter on interpreting presenting symptoms and physical findings to facilitate diagnosis.
Key Points boxes in each chapter place essential information at your fingertips.
The Secrets Heart and Lung Sounds Workshop—both in CD-ROM and online format—is available for purchase with the book, and through Student Consult online access, and features audio clips from actual patients, along with Dr. Mangione's commentary and a 32-page downloadable manual, to help you obtain the maximum diagnostic benefit from listening to heart and lung sounds.
STUDENT CONSULT access allows you to view the complete contents of the book online, anywhere you go...perform quick searches...and add your own notes and bookmarks.

Section Title	Page	Action	Price
Front Cover	Cover
Physical Diagnosis Secrets	i
Copyright	ii
Dedication	iii
Contents	v
Contributors	vii
Preface	ix
Preface to the First Edition	ix
Preface to the Second Edition	x
Top 100 Secrets	1
Chapter 1: General Appearance, Facies, and Body Habitus	9
General Appearance	9
1. What is the value of carefully examining the patient's general appearance?	9
2. Which aspects of the patient should be assessed?	9
A. Posture	10
3. What information can be obtained from observing the patient's posture?	10
4. What is the posture of patients with dyspnea?	10
B. State of Hydration	10
5. What is hypovolemia?	10
6. Which is more common-volume depletion or dehydration?	11
7. Is there any reason why these two processes should be kept separated?	11
8. What are the goals of physical examination in assessing hypovolemia?	11
9. How do you determine the presence of hypovolemia?	11
10. Why is important to have the patient supine for at least 2 minutes before (s)he stands?	11
11. What physiologic changes occur on standing?	11
12. Should the patient lie supine for more than 2 minutes before standing up?	11
13. Is sitting equivalent to standing?	11
14. What is the normal response to the tilt test?	12
15. Does the tilt test changes with age?	12
16. What is orthostatic hypotension?	12
17. What is the heart rate response to a tilt test?	12
18. So what are the findings of a positive tilt test for hypovolemia?	12
19. What is the significance of an orthostatic drop in systolic blood pressure?	12
20. In addition to volume loss, are there any other causes of an abnormal tilt test?	12
21. How do you assess skin turgor?	13
22. What is poor skin turgor?	13
23. What is the capillary refill time?	13
24. What is the significance of a prolonged CRT?	13
25. How useful is CRT prolongation in estimating dehydration of infantile diarrhea?	13
26. How valuable is CRT in adults?	13
27. What other bedside findings can estimate the patient's volume status?	13
28. How valuable are dry mucous membranes in adults?	14
29. What is the significance of dry mucous membranes in children?	14
C. State of Nutrition	14
30. What information should be obtained about the patient's state of nutrition?	14
31. What is the BMI?	14
32. How common is obesity?	14
33. Why is the BMI important?	15
34. What are the cutoffs for BMI?	15
35. What is a comorbid condition?	15
36. How do you measure the BMI?	15
37. Is the BMI foolproof?	15
38. How important is the distribution of body fat?	16
39. How do you assess body fat distribution?	16
40. How do you measure the WC?	16
41. How do you measure the WHR?	16
42. What is the WHR threshold for cardiovascular risk?	16
43. What is the WC threshold for cardiovascular risk?	17
44. Why is abdominal obesity such a good marker of insulin resistance?	17
45. Does WC correlate with BMI?	17
46. How do you define malnutrition on the basis of BMI?	17
47. How else can you identify malnutrition?	17
48. What are the physical examination components of the SGA?	17
49. Why should one bother to evaluate for malnutrition?	18
D. Facies	18
50. What is facies?	18
51.Which disease processes are associated with a typical facies?	18
52.Who was Greig?	21
53.What is Lincoln's sign?	21
54.Who was De Musset?	22
E.Apparent Age	22
55.Which conditions make you look older than your stated age?	22
56.What is Werner's syndrome?	22
57.Which conditions make you look younger than your stated age?	22
58.What is a toxic-looking patient?	22
F.Gait	23
59.Why is gait important?	23
60.What is the difference between stance and gait?	23
61.What are the two principal forms of human gaits?	23
62.What are the phases of a normal gait cycle?	23
63.Which muscles contract during gait?	23
64.What is the position of head, body, legs, and feet during gait?	23
65.How are stance and gait coordinated?	23
66.What are the two physiologic requirements of walking?	24
67.What is the impact of aging on gait?	24
68.What are the four most common reasons for gait disturbance?	24
69.What historic information should be gathered to adequately ev	24
70.How much information can be obtained through the assessment of a patient's gait?	26
71.How should one observe a patient with a gait abnormality?	26
72.What should be the focus of physical examination?	27
(1)Gait Disturbances Due to Pain	27
73.What is an antalgic gait?	27
(2)Gait Disturbances Due to Immobile Joints	27
74.What are examples of abnormal gait due to a fixed joint?	27
(3)Gait Disturbances Due to Muscle Weakness	28
75.What is the most common gait abnormality due to muscle weakness?	28
76.What is the anatomy of gluteus medius and minimus?	28
77.What is a Trendelenburg gait?	28
78.What is an anserine gait?	28
79.What are the causes of a Trendelenburg gait?	28
80.Describe the gait of \"foot drop.	28
81.What are the causes of foot drop?	29
82.What is a Charcot-Marie-Tooth (CMT) gait?	29
83.What is CMT?	29
84.Who were Charcot, Marie, and Tooth?	29
(4)Gait Disturbances Due to Abnormal Neurologic Control	30
85.What are the most common causes of neurologic gait disturbance?	30
86.What is the most common cause of myelopathy?	30
87.Describe the gait of spinal stenosis.	30
88.Describe the gait of spastic paraplegia.	30
89.What are the causes of a spastic paraplegic gait?	30
90.What is an ataxic gait?	31
91.What is the gait of sensory ataxia?	31
92.What is Drachman-Hart syndrome?	31
93.What is a cerebellar gait?	31
94.Describe the gait of a toxic-metabolic encephalopathy.	31
95.What is a gait of spastic hemiplegia (circumduction gait)?	31
96.What is apraxic (frontal) gait?	31
97.What are the causes of apraxic gait?	32
98.What is a Parkinsonian gait?	32
99.What is a malingering gait?	32
Selected Bibliography	33
Chapter 2: Vital Signs	34
Generalities	34
A.Vital Statistics	34
1.What are the vital statistics?	34
B.\x0BVital Signs	34
2.What are the vital signs?	34
C.Temperature	34
3.What is a fever?	34
4.Which is higher, rectal or oral temperature?	35
5.Are there any other conditions that can alter oral temperature?	35
6.What about tympanic membrane temperatures?	35
7.What about axillary temperatures?	35
8.How long does it take for a thermometer to equilibrate when placed under the tongue?	35
9.What is the clinical significance of a fever?	35
10.What are the most commonly encountered fever patterns?	35
11.What are the most common fever types?	35
12.What are the main types of \"intermittent\" fever?	36
13.What are the other most common types of intermittent fever?	36
14.What is Charcot's intermittent fever?	36
15.What is a \"hectic\" fever?	36
16.What is Pel-Ebstein fever?	209
17.What is factitious fever?	209
18.Are there any other terms in this alphabet soup of \"fevers\"?	37
19.What is an \"essential\" fever?	37
20.What are the causes of an essential fever?	37
21.What is a temperature/pulse dissociation?	37
22.What are the causes of extreme pyrexia?	37
23.What are the causes of an inappropriately low fever?	37
24.What other physical findings may help identify the cause of a fever?	37
25.What is hypothermia?	38
26.What are the causes of hypothermia?	38
27.What are the signs and symptoms of hypothermia?	38
D.Heart Rate and Rhythm	39
28.What is the history behind the measurement of heart rate through the arterial pulse?	39
29.How should the pulse be examined?	39
30.What is a pulse deficit?	39
31.So what is a normal heart rate?	40
32.In addition to rate, which other characteristics should be assessed in a pulse?	40
33.What is the clinical significance of tachycardia?	40
34.What bedside information can help to evaluate an arrhythmia?	40
35.What are the features of the pulse one should consider when evaluating arrhythmias?	40
36.What other findings might help to recognize an arrhythmia?	40
E.Blood Pressure	41
37.How is blood pressure measured?	41
38.Why is it important to measure blood pressure accurately?	41
39.What does sphygmomanometer mean?	41
40.Who invented it?	41
41.Who made the first direct measurement of blood pressure?	41
42.Who was Potain? How did he contribute to the measurement of blood pressure?	41
43.Who first thought of the mercury sphygmomanometer?	42
44.How did Riva-Rocci's device reach the United States?	42
45.What were the problems of Riva-Rocci's tool? Who perfected the \"indirect\" method?	42
46.What is the systolic pressure?	43
47.What is the diastolic pressure?	43
48.What are the various Korotkoff phases?	43
49.Where (and how) are Korotkoff sounds produced?	43
50.What is the proper technique for indirect measurement of blood pressure?	43
51.When should blood pressure be measured?	43
52.How about comparison of upper extremities' pressure?	43
53.What is a significant difference between the two arms?	45
54.Which factors can affect the accuracy of blood pressure measurement?	45
55.How variable can pressure be?	45
56.And how about the physician's expertise?	45
57.What is the most common \"equipment\" error?	48
58.How do you calibrate an aneroid sphygmomanometer?	48
59.What is the silent or auscultatory gap?	48
60.How common is the auscultatory gap? What are its causes?	48
61.How accurate is blood pressure measurement by sphygmomanometer?	48
62.What is the palpatory systolic blood pressure?	48
63.Can the palpatory method be used to determine diastolic pressure?	49
64.Are there differences in systolic pressure determined by palpation versus auscultation?	49
65.How common is hypertension?	49
66.How is hypertension defined?	49
67.What are the key aspects of the latest guidelines?	49
68.What is pseudohypertension?	50
69.What is the cause of pseudohypertension?	50
70.What is Osler's maneuver?	50
71.What is the significance of a positive Osler's sign?	50
72.How useful is Osler's sign?	50
73.What is malignant hypertension?	50
74.What is pseudohypotension?	50
75.What is the clinical significance of hypotension?	50
76.What is a mean arterial pressure?	50
77.What is a pulse pressure?	51
78.What is a wide pulse pressure? What are its causes?	51
79.What is the significance of a wide pulse pressure in aortic regurgitation (AR)?	51
80.What is the significance of a wide pulse pressure in only one extremity?	51
81.What is Branham's sign?	51
82.How does one test for the Branham's sign?	51
83.Who were Branham and Bainbridge?	52
84.When is a pulse pressure considered \"narrow\"? What are its causes?	52
85.What is pulsus paradoxus?	52
86.How wide does this swing in systolic pressure have to get to become palpable?	52
87.Why is it called paradoxical?	52
88.Describe the pathophysiology of pulsus paradoxus	52
89.How does one measure pulsus paradoxus?	53
90.Can pulsus paradoxus be identified on arterial tracing?	53
91.Which arteries are best suited for detecting pulsus paradoxus: peripheral or central?	53
92.What are the values to remember for pulsus paradoxus?	53
93.What is cardiac tamponade?	53
94.What are the characteristics of pulsus paradoxus in tamponade?	53
95.In addition to pulsus paradoxus, what are the other clinical features of tamponade?	54
96.What is Beck's triad?	54
97.Can pulsus paradoxus be falsely negative in tamponade?	54
98.What other conditions can cause pulsus paradoxus 10 mmHg?	54
99.What about pulsus paradoxus in airflow obstruction?	54
100.How does pulsus paradoxus behave in intubated and mechanically ventilated patients?	55
101.What is \"reversed\" pulsus paradoxus?	55
102.What is pseudo-pulsus paradoxus?	55
103.What is the usefulness of Kussmaul's sign in pulsus paradoxus?	56
104.What is Trousseau's sign?	56
105.What are the causes of an \"obstetrician's hand\"?	56
106.How can one trigger carpal spasm in patients with \"latent\" tetany?	56
107.Who was Trousseau?	56
108.Who was Chvostek?	57
109.What is the Rumpel-Leede sign?	57
110.What is Hill's sign?	57
111.Is Hill's sign real?	57
112.What is the mechanism of Hill's sign?	57
113.So what about Hill's sign in AR?	57
115.How do you perform Hill's test?	57
116.What causes the systolic pressure to be less in the lower than in the upper extremities?	58
117.What is the standard bedside test for assessing chronic lower extremity ischemia?	58
118.How is the ABPI measured?	58
119.Can the ABPI be misleading?	58
120.Who was Hill?	58
121.What is the Valsalva's maneuver? How does it modify blood pressure?	58
122.How good is Valsalva for detecting congestive heart failure?	60
123.In addition to an abnormal Valsalva response, are there other findings that might diagnose congestive heart failure (CHF)?	60
124.And what about patients with \"systolic\" dysfunction?	60
125.Can physical exam predict outcome in patients with CHF?	61
126.Who was Valsalva?	61
127.What are the diagnostic and therapeutic uses of Valsalva?	61
F.Respiration	61
Respiratory Rate and Rhythm	61
128.How useful is it to assess the patient's rate, rhythm, and depth of respiration?	61
Selected Bibliography	62
Chapter 3: The Skin	63
Basic Terminology and Diagnostic Techniques	63
1.How many skin diseases exist? What are the two main categories of skin lesions?	63
2. What are the major primary lesions?	63
3.What are the major secondary lesions?	66
4.Are there other ways to classify skin lesions?	68
5.What is the pattern of distribution?	68
6.What is the configuration of a skin lesion?	68
7.How should an initial cutaneous exam be done?	68
8.How should a specific lesion be examined in order to better classify it?	69
9.And so, what are the required components of a dermatologic diagnosis?	69
10.What are the tools necessary for a dermatologic diagnosis?	69
11.How does one prepare a potassium hydroxide (KOH) stain for fungi?	69
12.What is a Tzanck test?	69
13.What skin appendages should be part of a thorough dermatologic exam?	69
14.How should fingernails and toenails be assessed?	69
15.What systemic conditions are associated with changes in nail shape or growth?	70
16.What systemic conditions are associated with changes in nail color?	70
17.How are nail findings classified?	72
Nails	72
Growth Disturbances	72
18.What are the main growth disturbances of the nail?	72
19.What is clubbing?	72
20.What is onycholysis?	72
21.What is nail pitting?	72
22.What are the nail findings of psoriasis?	72
23.What is koilonychia (spooning)?	73
24.What is yellow nail syndrome?	73
25.What are brittle nails (onychorrhexis)?	73
26.What is longitudinal ridging (Reedy nails)?	73
27.What is nail beading?	73
28.What is onychogryphosis?	74
Transverse Linear Lesions	74
29.What are the main transverse linear lesions of the nail?	74
30.What is leukonychia?	74
31.What are Beau's lines?	74
32.What are bitten nails lesions?	74
33.What are Muehrcke's lines (ML)?	74
34.What are Mees' lines?	75
35.What are the traumatic changes of the nail?	75
Longitudinal Linear Lesions	75
36.What are the main longitudinal linear lesions of the nail?	75
37.What is longitudinal melanonychia?	75
38.What is lichen planus of the nail?	75
Vascular and Nail Bed Changes	75
39.What are the main vascular and nail bed changes of the nail?	75
40.What are splinter hemorrhages?	75
41.What are azure half-moons in nail beds?	75
42.What are Lindsay's nails?	75
43.What are Terry's nails?	76
44.What are red half-moons in nail beds?	76
45.How does vasculitis of the nail present?	76
Infections	76
46.What are the main infections of the nail?	76
47.What is tinea unguium?	76
48.What is paronychia?	76
49.How does pseudomonal infection of the nail present?	76
50.What are blue lines?	76
Hair	76
51.How is the hair assessed?	76
52.What is folliculitis?	77
53.What is eosinophilic folliculitis?	77
Fluid-Filled Lesions: PUS (Pustules)	77
Acne	77
54.What does acne look like?	77
55.Who develops acne?	77
56.What are the other clinical presentations of acne?	77
57.What is acne rosacea?	77
58.What is steroid acne?	78
59.How is acne diagnosed?	78
Fluid-Filled Lesions: Clear Fluid (Vesiculobullous Diseases)	78
Herpes Simplex	78
60.How does herpes simplex present?	78
61.Who develops herpes simplex?	79
62.What is the typical clinical course of herpes simplex?	79
63.What are the other clinical presentations of herpes simplex?	79
64.How is herpes simplex diagnosed?	79
Varicella	79
65.What are the features of varicella?	79
66.Who develops varicella?	79
67.What is the typical clinical course of varicella?	79
68.How are the other clinical presentations of varicella?	80
69.How is varicella diagnosed?	80
Herpes Zoster	80
70.What are the clinical features of herpes zoster?	80
71.Who develops herpes zoster?	80
72.What is the typical clinical course?	80
73.What are the other presentations of herpes zoster?	80
Scabies (see questions 255-257)	80
Dermatitis herpetiformis	80
74.What is dermatitis herpetiformis (DH)?	80
75.What are the skin lesions of DH?	81
76.What is the course of DH?	81
Pemphigus and Pemphigoid	81
77.What is Pemphigus?	81
78.What are the clinical features of pemphigus vulgaris (PV)?	81
79.Are there any other causes of PV?	81
80.What is bullous pemphigoid (BP)?	81
81.What is Nikolsky's sign? What is its significance?	81
82.What is Asboe-Hansen sign?	82
Drug Reactions	82
83.What are the most important cutaneous manifestations of drug reactions?	82
84.What is erythema multiforme (EM)?	82
85.What is Stevens-Johnson syndrome (SJS)?	82
86.What is toxic epidermal necrolysis (TEN)?	82
87.Describe the presentation of SJS/TEN	83
88.What is the difference between \"targetoid\" lesions of SJS/TEN and \"targets\" of EM?	83
89.What are the skin manifestations of SJS/TEN?	83
90.Is there any mucosal involvement in SJS/TEN?	84
91.What are the sequelae of SJS/TEN?	84
92.What is the cause of SJS/TEN?	84
93.What is the mechanism of TEN?	84
94.How do you separate staphylococcal scalded skin syndrome (SSSS) from TEN?	84
95.What are the other major cutaneous manifestations of drug reactions?	85
96.What is a drug-induced photosensitivity reaction?	85
97.What are the most common photosensitizing medications?	85
Urticaria	85
98What is urticaria (hives)?	85
99.What are the skin manifestations of urticaria?	85
100.What is angioedema?	85
101.What is the clinical course of urticaria?	86
102.What are the other clinical presentations of urticaria?	86
103.How is urticaria diagnosed?	86
Miscellaneous	86
104.Are there any other diseases that may cause vesiculobullous lesions?	86
Solid Lesions: Tan Or Pink	86
Warts	86
105.What are warts?	86
106.How are warts transmitted?	87
107.What are the major types of warts?	87
Actinic Keratosis	88
108.What is actinic keratosis (AK)?	88
Squamous Cell Carcinoma (SCC)	89
109.How does SCC present?	89
110.Where in the skin does SCC originate?	89
111.Describe the evolution of SCC. Why is it important?	89
112.What is the course of SCC?	90
Bowen's Disease	90
113.What is Bowen's disease (BD)?	90
Basal Cell Carcinoma (BCC)	90
114.How does BCC present?	90
115.What is the usual clinical course of BCC?	90
Acrochordons (Skin Tags)	90
116.What are acrochordons (skin tags)?	90
117.What are the causes of skin tags?	90
118.What is the evidence behind the association between skin tags and type 2 diabetes?	91
Solid Lesions: White	91
Vitiligo	91
119.What is vitiligo?	91
120.How does vitiligo present?	91
121.What are the other associated cutaneous findings?	92
122.What is piebaldism?	92
123.What are the characteristics of piebaldism?	92
124.When does vitiligo appear?	92
125.What is the typical course of vitiligo?	92
126.What are the other clinical presentations of vitiligo?	92
127.How is vitiligo diagnosed?	92
128.What systemic diseases are associated with vitiligo?	92
Tinea Versicolor	93
129.What is tinea versicolor (TV)?	93
130.How does TV look?	93
131.How does TV present in immunocompromised hosts?	93
Solid Lesions: Brown	93
Tinea Versicolor (previously discussed)	93
Acanthosis Nigricans	93
132.What is acanthosis nigricans (AN)?	93
133.What are the causes of AN?	93
134.How common is acanthosis nigricans associated with malignancy? How does it present?	94
Melanocytic Nevi (Common, Atypical, Dysplastic)	94
135.What are melanocytic nevi?	94
136.What about congenital nevi?	94
137.List and describe the different types of common nevi (moles).	94
138.What are the features of a melanocytic nevus?	95
139.What are atypical or dysplastic nevi (Clark nevi)?	95
140.Describe the characteristics of dysplastic nevi.	95
141.What is FAMMM?	95
Seborrheic Keratoses	95
142.What are seborrheic keratoses?	95
143.Describe the morphology of seborrheic keratoses (SK).	95
144.What is dermatosis papulosa nigra?	95
Signs of Leser-Treacutelat	96
145.What is the sign of Leser-Treacutelat?	96
Melanoma	96
146.Summarize the risk of developing melanoma.	96
147.Who gets melanomas?	96
148.What are the morphologic warning signs of melanoma?	96
149.What is the ABCD(E) checklist?	96
150.How good is the ABCD(E) checklist?	96
151.How capable are physicians of recognizing melanomas?	98
152.What is the Revised Glasgow 7-Point Checklist?	98
153.How good is the 7-point checklist?	98
154.How should the physical exam be conducted?	98
155.What are the major clinical-histopathologic types of melanoma?	98
156.What is the major prognostic indicator of stage I melanoma?	99
Signs of Sun Damage	99
157. What are the characteristic signs of sun damage?	99
Solid Lesions: Yellow	100
158.What are the most common yellow lesions of the skin?	100
159.What are xanthomas?	100
160.What is the significance of cutaeous xanthomas?	100
161.How do xanthomas present?	100
162.What is xanthelasma palpebrarum?	100
163.What are tuberous xanthomas?	100
164.What are tendinous xanthomas?	100
165.What are eruptive xanthomas?	100
166.What are plane xanthomas?	101
167.What is xanthoma disseminatum and verruciform?	101
Solid Lesions: Red or Purple	101
Scaling Diseases Without Epithelial Disruption	101
Psoriasis	101
168.What is psoriasis?	101
169.What is the cause of psoriasis? Who gets it?	101
170.What are the clinical features of psoriasis?	101
171.What are other characteristics of psoriatic lesions?	102
172.Who was Koebner?	102
173.What is the typical clinical course of psoriasis?	102
174.What are the other clinical presentations of psoriasis?	102
175.How is psoriasis diagnosed?	103
176.What other disease is often associated with psoriasis?	103
Dermatophytes	103
177.What are dermatophytoses?	103
178.What is tinea?	103
179.How are dermatophytoses classified?	103
182.How are dermatophytoses diagnosed?	104
Lupus Erythematosus (see later)	105
Pityriasis Rosea (PR)	105
183.What is pityriasis rosea?	105
184.Who gets it?	105
185.What are the clinical features of pityriasis rosea?	105
186.What is the typical clinical course of pityriasis rosea?	105
187.What are the causes of pityriasis rosea?	105
188.How is pityriasis rosea diagnosed?	105
Secondary Syphilis (see later)	106
Scaling Diseases With Epithelial Disruption	106
Eczematous Diseases: Atopic Dermatitis	106
189.What is atopic dermatitis?	106
190.What are the clinical features of atopic dermatitis?	106
191.Describe the distribution of atopic dermatitis lesions.	106
192. Who develops atopic dermatitis?	106
193.Describe the course of atopic dermatitis.	106
194. What are the other clinical presentations of atopic dermatitis?	106
195. How is atopic dermatitis diagnosed?	106
196. What other skin diseases can be associated with atopic dermatitis?	107
Eczematous Diseases: Stasis Dermatitis	108
197.What is stasis dermatitis?	108
198.How does it present?	108
199.Who develops stasis dermatitis and ulceration?	108
200.What is the clinical course?	108
201.How are stasis dermatitis and ulceration diagnosed?	108
Eczematous Diseases: Seborrheic Dermatitis	108
202.What is seborrheic dermatitis (SD)?	108
203.What causes it?	108
204.What are the primary lesions of seborrheic dermatitis?	108
205.Who develops seborrheic dermatitis?	108
206.How does SD present in babies?	109
207.What is the typical course of seborrheic dermatitis in adults?	109
208.How is seborrheic dermatitis diagnosed?	109
Nonscaling Lesions	109
Cherry Angiomas	109
209.What are cherry angiomas?	109
Lichen Planus	110
210.What is lichen planus (LP)?	110
211.Who gets lichen planus?	110
212. What is the primary lesion of lichen planus?	110
213.What other sites beside the skin may be involved?	110
214.How common are mucosal lesions?	110
215.How about the genital lesions of LP?	110
216.What is the course of lichen planus?	110
Vascular Reactions	110
Purpura	110
217.What is purpura?	110
218.What are the two major types of purpura?	111
219.What is noninflammatory purpura?	111
220.How are noninflammatory purpuras classified?	111
221.What about the \"inflammatory\" purpura?	111
222.What is leukocytoclastic vasculitis (LCV)?	111
223. How do LCV lesions present?	111
224.What are the characteristics of LCV lesions?	111
225.What is livedo reticularis?	111
226.What are the causes of cutaneous vasculitis?	111
Miscellaneous Disorders	112
Kaposi's Sarcoma	112
227.What are the major types of Kaposi's sarcoma? Describe each.	112
228.What is the presentation of KS?	112
229.What is the cause of KS?	112
230.How is Kaposi's sarcoma (KS) diagnosed?	112
231.Who was Kaposi?	112
Lupus Erythematosus	113
232.What is lupus erythematosus (LE)?	113
233.What are the cutaneous manifestations of LE?	113
234.What is the presentation of acute cutaneous lupus erythematosus?	113
235. Is ACLE associated with SLE?	113
236.What is the course of ACLE?	113
237.What laboratory studies are positive in ACLE?	113
238.What are the lesions of SCLE?	114
239.Is SCLE associated with SLE?	114
240.Can any drugs elicit SCLE skin lesions?	114
241.What is the association with discoid lupus erythematosus (DLE)?	114
242.What is discoid lupus?	114
243. What is the difference between DLE and the discoid lesions of SLE?	114
244. How does DLE present?	114
245. What are localized and generalized DLE?	115
246. What are the serologic markers of DLE?	115
247. Is skin involvement common in systemic lupus erythematosus?	115
248. What are the disease-nonspecific manifestations of SLE?	115
249. What is lupus profundus?	115
250. Who develops lupus?	115
251. Can drugs trigger lupus erythematosus?	115
Syphilis	115
252. What are the primary lesions of syphilis?	115
253. Who develops syphilis?	116
254. What are the other clinical presentations of syphilis?	116
Insect Infestations	116
255. What are the most common insect infestations?	116
256. Who develops insect infestations?	117
257. What is Norwegian scabies?	117
Skin Manifestations of Systemic Disorders	117
Necrobiosis Lipoidica	117
258. What is necrobiosis lipoidica (diabeticorum)?	117
259. What is the presentation of NL?	117
Porphyria Cutanea Tarda (PCT)	118
260. What is PCT?	118
261. What is the presentation of PCT?	118
Sarcoidosis	118
262. How common is cutaneous involvement in sarcoidosis?	118
263. What are the skin manifestations of sarcoidosis?	118
264. What is ‘‘plaque’’ sarcoidosis?	118
265. What is lupus pernio?	118
266. What is erythema nodosum (EN)?	119
267. What are the characteristics of EN?	119
268. Which sarcoid patients get EN?	119
269. What is Lo¨ fgren’s syndrome?	119
270. Is erythema nodosum exclusive of sarcoid?	119
Behc¸ et’s disease	119
271. What is Behc¸ et’s disease (BD)?	119
272. What is the presentation of BD?	120
273. What is the apperance of oral ulcers?	120
274. What are the eye lesions of BD?	120
275. Describe the skin lesions of BD.	120
276. What are the genital manifestations of BD?	120
277. What are the other manifestations of BD?	120
278. What is pathergy?	120
Dermatomyositis	121
279. How common are dermatologic manifestations in dermatomyositis (DM)?	121
280. What are the most typical manifestations?	121
281. What is the heliotrope rash?	121
282. What are Gottron papules?	121
283. What is poikiloderma?	121
Diabetes Mellitus	121
284. What other skin manifestations can be observed in diabetes mellitus?	121
Scleroderma	121
285. What are the major cutaneous manifestations of scleroderma?	121
286. What is sclerodactyly?	121
287. What is proximal scleroderma?	121
288. What are the minor cutaneous manifestations of scleroderma?	122
289. What are the characteristics of the hand lesions of scleroderma?	122
290. What is limited cutaneous scleroderma?	122
291. What is diffuse cutaneous scleroderma?	122
292. What about Raynaud’s phenomenon?	122
Hyperthyroidism	122
293. What are the skin manifestations of hyperthyroidism?	122
Pyoderma gangrenosum	122
294. What is pyoderma gangrenosum (PG)?	122
295. How does PG look?	123
296. What are the causes of PG?	123
Sweet’s Syndrome	123
297. What is Sweet’s syndrome?	123
298. What are the skin lesions of Sweet’s syndrome?	123
299. What do these lesions appear like histopathologically?	123
300. How often is Sweet’s syndrome associated with an underlying malignancy?	124
301. Is there anything unique in the Sweet’s syndrome of cancer?	124
302. Which cancers metastasize to the skin?	124
303. How do skin metastases present?	124
304. What are the unusual patterns of skin metastases?	124
Acknowledgment	125
Selected Bibliography	125
Chapter 4: The Eye	126
Generalities	126
1.Who should have visual acuity testing?	126
2.What is needed to measure visual acuity?	126
3.What is a Snellen chart?	126
4.Who was Snellen?	126
5.How is the Snellen chart used?	126
6.What does 20/20 mean?	127
7.Can visual acuity be better than 20/20?	127
8.What is a pinhole vision?	127
9.How do you measure vision in patients who cannot read any letters on the chart?	127
10.How is vision measured in illiterate patients or children?	127
11.How is vision measured in bedridden patients?	127
12.What is the significance of reduced visual acuity?	127
13.How can one confirm the cause of reduced visual acuity?	128
14.What are the refracting problems that can be corrected by glasses?	128
15.When should you refer a patient with subnormal visual acuity?	128
Color Vision	128
16.What are color vision screening plates?	128
17.How is color vision tested?	128
18.What is dyschromatopsia?	128
19.What causes dyschromatopsia?	128
C. Visual Fields	128
20.Why is visual field testing important?	128
21.Describe the normal anatomy of the visual pathways.	129
22.How do you test visual fields?	130
23.What are visual field defects?	130
24.How are visual fields defects classified?	130
25.What is the difference between anterior and posterior visual field defects?	131
26.What are the causes of visual field defects?	131
27.What is the most important step after finding a monocular visual field defect?	131
28.What are the other characteristics of prechiasmal (ocular) defects?	131
29.What are the main types of prechiasmal defects?	131
30.What are severely constricted visual fields? What are their causes?	131
31.What are chiasmal defects?	131
32.What is a bitemporal hemianopia?	131
33.What are postchiasmal defects?	131
34.What is homonymous hemianopia?	131
35.What are the causes of inferior and superior quadrantanopias?	132
36.What is an asymmetric optokinetic nystagmus?	132
D. Pupils	132
37.Why is examination of the pupils important?	132
38.What is the size of a normal pupil?	132
39.How does one examine the pupils?	132
40.What major features should be identified in the pupil?	132
41.What is unique about the light reflex?	132
42.What is anisocoria?	132
43.What is accommodation?	134
44.What are the most common abnormalities in pupillary shape?	134
45.What is hippus?	134
46.How is the pupillary diameter controlled?	135
47.What are the most common causes of anisocoria?	135
48.What is the most common cause of a third-nerve palsy?	136
49.What is a posterior communicating artery aneurysm?	136
50.Who was Hutchinson?	136
51.What is the pupillary response to a close-up target?	137
52.What is the pupillary response to light being suddenly directed onto the eye?	137
53.What are Argyll Robertson (AR) pupils?	137
54.What is \"near-light\" dissociation?	137
55.Who was Argyll Robertson?	137
56.What is Adie's tonic pupil?	137
57.What is the significance of Adie's pupil?	137
58.What are the causes of Adie's pupil?	137
59.Who was Adie?	138
60.What is the swinging flashlight test?	138
61.What is a Marcus Gunn (MG) pupil?	138
62.What is the response of an MG pupil when the light is shone on it first?	138
63.What is a common cause of an afferent pupillary defect (MG pupil)?	138
64.Who was Marcus Gunn?	138
65.What are the pupillary manifestations of diabetes?	138
E. External Eye	139
66.Summarize the examination of the external eye.	139
(1)Tear Film	139
67.What is Schirmer's test?	139
68.How is Schirmer's performed?	139
(2)Eyebrows	139
(3)Eyelids and Orbit	139
70.What are xanthelasmas?	139
71.What is an ectropion?	139
72.What is an entropion?	139
73.What is a sty (hordeolum)?	139
74.What is a chalazion?	140
75.What is blepharitis?	140
76.What is ptosis?	140
77.What are the causes of ptosis? How can they be differentiated?	140
78.What is proptosis?	140
79.What is the most common cause of exophthalmos in adults?	140
80.What is the most common cause of unilateral exophthalmos in children?	140
81.What is the difference between preseptal and orbital cellulitis?	141
82.What is a blow-out fracture?	141
83.What is enophthalmos?	141
(4)Extraocular Movements	141
84.How valuable is testing of extraocular movements?	141
85.What is diplopia?	141
86.What are the main forms of diplopia?	141
87.What is heterotropia?	141
88.What are the causes of monocular diplopia?	141
89.What is the approach to the patient with binocular diplopia?	142
90.How can one identify the weak ocular muscle(s)?	142
(5)Nystagmus	142
91.What is nystagmus?	142
92.How do you classify nystagmus?	142
93.What is the clinical significance of nystagmus?	142
(6)Sclera	142
94.What are blue sclerae?	142
95.How much bilirubin is needed to produce scleral icterus?	143
96.Does conjunctival icterus look any different in dark-skinned patients?	143
(7)Conjunctiva	143
97.What is a pingueculum?	143
98.What is a pterygium?	143
99.What is a subconjunctival hemorrhage?	143
100.What causes subconjunctival hemorrhage?	143
101.How does conjunctivitis present?	143
102.What is the significance of a palpable preauricular lymph node?	144
103.Can conjunctival discharge differentiate the various forms of conjunctivitis?	144
104.How can one differentiate the injected vessels of uveitis from those of conjunctivitis?	144
105.What is chemosis?	144
(8)Iris	144
106.What is iris heterochromia?	144
107.Can heterochromia occur in Horner's syndrome?	144
108.Can iris color be used as a paternity test?	144
(9)Cornea	144
109.What is arcus senilis?	144
110.What is the significance of arcus?	144
(10)Anterior Portion of the Globe	145
111.What is uveitis?	145
112.How is uveitis classified?	145
113. What is a ciliaryflush?	145
114. What are the symptoms of uveitis?	145
115. What is a hypopyon?	145
116. What is a hyphema?	145
117. What is an eight-ball hyphema?	145
118. What is the value of gauging the depth of the anterior chamber with a penlight?	145
(11) Corneal Light Reflex	145
119. What is the corneal light reflex?	145
120. What is the Hirschberg test?	146
121. What is strabismus?	146
122. What is pseudostrabismus?	146
123. How do you tell strabismus from pseudostrabismus?	146
F.Ophthalmoscopy	146
124. Is ophthalmoscopy an important skill?	146
(1) Technique	146
125. What is the clinical value of ophthalmoscopy?	146
126. Who should undergo ophthalmoscopy? When?	146
127. How does one perform ophthalmoscopy?	146
128. How close should one get?	146
129. What is the best way to examine the macula?	147
130. How can one dilate the pupils?	147
131. Do mydriatics have systemic effects?	147
132. Are there any local contraindications to dilation of the pupils?	147
(2) Red Reflex	147
133. What is the red reflex?	147
134. How is the red reflex viewed?	147
135. What is leukocoria?	147
136. What common conditions may cause an abnormal red reflex?	147
(3) Anterior Eye Structures	148
137. What are the most common opacities of the anterior eye?	148
(4) Posterior Eye Structures	148
138. What is the vitreous?	148
139. What are the most common opacities of the vitreous?	148
140. After visualization of the red reflex, which eye structures should be examined?	148
G. Optic Disc	148
141. What is the optic disc?	148
142. How does one find the optic disc?	148
143. In following vessels toward the disc, how do you know the direction is right?	148
144. What does a normal optic disc look like?	148
145. Are there any optic disc anatomic variants?	148
146. What is the optic cup?	149
147. What pathologic changes can be detected in the disc?	149
(1) Changes in Color	149
148. What causes redness of the disc?	149
149. What causes pallor of the disc?	149
150. Does pallor of the disc always suggest a disorder of the optic nerve?	149
151. What are the common causes of optic atrophy?	149
(2) Changes in Cup Size	149
152. What is the aqueous humor?	149
153. What is the normal intraocular pressure?	149
154. What is glaucoma?	150
155. Why \"glaucoma\"?	150
156. What is chronic (or open-angle) glaucoma? What are its symptoms?	150
157. What are the symptoms of acute (or angle-closure) glaucoma?	150
158. What are the eye findings in acute glaucoma?	150
159. How does the optic disc look in glaucoma?	150
160. How accurate is funduscopy in diagnosing glaucoma?	151
161. Who should be screened for glaucoma?	151
162. What is the utility of Schiotz tonometry?	151
(3) Changes in Disc Size	151
163. What is papilledema?	151
164. What are the fundus findings of papilledema?	151
165. What are spontaneous retinal venous pulsations (SRVPs)?	151
166. What is the clinical significance of absent SRVPs?	151
167. Is there any loss of visual activity in papilledema?	151
168. How important is papilledema?	152
169. What are the most common causes of papilledema?	152
170. What else can make the optic disc swell?	152
171. What is optic neuritis?	152
172. What is papillitis?	152
173. What is retrobulbar optic neuritis?	152
174. What is anterior ischemic optic neuropathy (AION)?	152
175. What are the manifestations of AION?	152
176. What causes AION?	152
H. Retinal Circulation	153
177. What is the normal organization of the retinal circulation?	153
178. How can one differentiate retinal veins from retinal arteries?	153
179. Can the retinal arterial light reflex predict disease?	153
180. What is hypertensive retinopathy?	153
181. Does AV nicking revert with control of hypertension?	153
182. What are the manifestations of central retinal artery occlusion (CRAO)?	153
183. What are the causes of CRAO?	153
184. What are the manifestations of central retinal vein occlusion (CRVO)?	153
185. What causes CRVO?	154
186. What are the funduscopic findings in branch retinal vein occlusion (BRVO)?	154
187. What causes BRVO?	154
188. What is a Hollenhorst plaque?	154
189. What is the clinical significance of a Hollenhorst plaque?	154
190. What is retinal neovascularization?	154
191. What conditions cause neovascularization?	154
I. Retinal Background	154
192. What retinal lesions can be identified by ophthalmoscopy?	154
(1) Yellow-White Retinal Spots	154
193. What are yellow-white retinal spots?	154
194. What are cotton-wool spots?	155
195. What are the causes of cotton-wool spots?	155
196. What are hard exudates?	155
197. What are the causes of hard exudates?	155
198. What are drusen?	155
199. What are chorioretinal scars?	156
200. What are myelinated nerve fibers?	156
(2) Red Spots	156
201. What are the most common red lesions of the retina?	156
202. What causes retinal hemorrhages?	156
203. What other lesions may be associated with red spots?	156
204. Why do red lesions have different shapes and sizes?	156
205. What are microaneurysms?	156
206. What diseases present with dot-and-blot hemorrhages?	156
207. Which processes are associated with flame and splinter hemorrhages?	156
208. What are white-centered hemorrhages?	157
209. Who was Roth?	157
(3) Brown-Black Spots	157
210. What are brown-black retinal lesions?	157
211. What is retinitis pigmentosa?	157
212.How does retinitis pigmentosa present on funduscopy?	157
213. What is retinal pigment epithelium hypertrophy?	157
214. How does retinal pigment epithelium hypertrophy present ophthalmoscopically?	157
215. What are choroidal melanomas and benign nevi?	157
J. Diabetic Retinopathy	158
216. What is the relevance of diabetic retinopathy?	158
217. Is there any correlation between diabetic retinopathy and nephropathy?	158
218. What are the findings of diabetic retinopathy?	158
219. What is proliferative diabetic retinopathy (PDR)?	158
220. What are the late manifestations of PDR?	159
221. What are the best predictors of proliferative retinopathy?	159
222. What is macular edema?	159
K. Retinal Detachment	159
223. What is retinal detachment?	159
224. What are the causes of retinal detachment?	159
225. Who is at risk for retinal detachment?	160
226. How does retinal detachment present?	160
227. What are the ophthalmoscopic findings in retinal detachment?	160
L. Macula	160
228. How does a normal macula look?	160
229. What are the most common macular abnormalities?	161
230. What is macular degeneration?	161
231. How many types of macular degeneration are there?	161
232. How does macular degeneration appear ophthalmoscopically?	161
M. Red Eye	161
233. What is a red eye?	161
234. What causes a red eye?	161
235. What other ocular signs may accompany a red eye?	162
236. What other ocular symptoms may accompany a red eye?	162
Acknowledgment	163
Selected Bibliography	163
Chapter 5: The Ear	164
Generalities	164
1.What are the components of the ear?	164
A.External Ear	164
2. What is the external auditory canal?	164
3. What is \"wax\" made of?	164
4. What is the best way to remove cerumen?	164
5. What is the nervous supply of the external canal?	164
6.What is the auricle (or pinna)?	165
7.What are auricular bumps? What causes them?	165
8.Can I really diagnose gout by looking at the ear?	166
9.What are the causes of itching of the ear?	166
10.What is otorrhea?	166
11.How can the color of the discharge provide clues to its origin?	166
12.Why is otitis externa \"maligna\" so malignant?	166
13.What is instead garden variety \"otitis externa\"?	167
14.What is swimmer's ear?	167
15.How do you tell an earache due to otitis media from one due to otitis externa?	167
16.What is the value of pushing over the mastoid process?	167
17.Is otalgia always due to ear problems?	167
18.Distinguish among vesicles, bullae, and pustules	167
19.What may induce vesicles in the auricle?	167
20.What are the causes of auricular red spots?	167
21.Who were Sturge and Weber?	167
22.What is a tender and swollen auricle?	168
23.Why should one palpate the pulse anterior to the tragus?	168
24.Why should one inspect (and palpate) the postauricular space?	168
25.When does Battle's sign occur?	168
26.Where are preauricular and postauricular lymph nodes? What may cause their swelling?	168
27.Can I diagnose coronary artery disease by looking at the auricle?	168
28.Why should a clinician auscultate over an auricle?	169
29.How is auscultation of the auricle performed?	170
B.Middle Ear (Tympanic Cavity)	170
30.What are the boundaries of the middle ear?	170
31.What are the functions of the middle ear?	170
32.What is the function of the Eustachian tube?	170
33.Does the middle ear house anything else?	170
34.How can the tympanic membrane be examined?	170
C.Otoscopic Examination	170
35.What is the best way to otoscopically visualize the tympanic membrane?	170
36.Other than cerumen, what else may prevent visualization of the tympanic membrane?	170
37.How should the external canal appear otoscopically?	171
38.What does the normal tympanic membrane look like?	171
39.What are the distinguishing otoscopic features in purulent otitis media?	171
40.What are the distinguishing otoscopic features in Serous otitis media?	172
41.What does bulging indicate?	172
42.What does \"retraction\" indicate?	172
43.What is a hemotympanum? What are the other manifestations of basilar skull fracture?	172
44.What does a perforation of the tympanic membrane look like?	172
45.What is Angel's sign?	172
46.What does chronic otitis media look like?	172
47.What is bullous myringitis?	172
48.What is Ramsay Hunt syndrome?	172
49.Who was Ramsay Hunt?	173
50.What is a cholesteatoma? What does it look like?	173
51.What is the significance of dense, white, and horseshoe-shaped eardrum plaques?	173
D.Pneumatic Otoscopy	173
52.Is there any reason to perform pneumatic otoscopy?	173
53.How is pneumatic otoscopy performed?	173
54.What if I do not have a pneumatic bulb?	173
E.Inner Ear	173
55.What is the function of the inner ear?	173
F.Bedside Hearing Tests	174
56.How do you test hearing at the bedside?	174
57.What is the whispered voice test?	174
58.How accurate is the whispered voice test?	174
59.What are the tuning fork tests?	174
60.How do these tests work?	174
61.How do you carry out Weber's test?	175
62.How do you carry out Rinne's test?	175
63.How accurate are these tests?	175
64.Can tuning forks of different frequencies be used for these tests?	175
65.Who were Weber and Rinne?	175
Acknowledgment	176
Selected Bibliography	176
Chapter 6: Nose and Mouth	177
A.The Nose	177
(1)Generalities	177
(2)The External Nose	177
1.What are the normal structures of the external nose?	177
2.What is rhinophyma?	178
3.What are the causes of rhinophyma?	178
4.Is there any scientific basis for the \"Pinocchio effect\"?	178
5.What is a saddle nose? Does it really exist outside of board questions?	178
6.What are nasal fractures?	178
7.What is a septal hematoma? How does it differ from septal deviation?	178
8.What is lupus pernio?	179
9.What did Rudolph of the reindeer story really have?	179
(3)The Internal Nose	179
10.What are the normal structures of the internal nose?	179
11.What are paranasal sinuses?	180
12.And what about the adenoids?	180
13.What is the significance of flaring of the nostrils?	181
14.What are the best tools for inspecting nares and internal nose?	181
15.Is inspection of nasal secretions useful?	181
16.What is an abscess of the nasal vestibule?	181
17.What are the causes of swelling/bumps in the nasal septum?	181
18.What are the most common causes of airflow obstruction in one or both nares?	181
19.What are nasal polyps?	182
20.What is a papilloma of the nasal vestibule?	182
21.What is a nasopharyngeal carcinoma (lymphoepithelioma)?	182
22.What does a nasal septal perforation look like?	182
23.What are the common causes of a septal perforation?	182
24.What are the less-common causes of perforation?	182
25.What are the nasal manifestations of a basilar skull fracture?	182
26.How do you recognize CSF rhinorrhea?	182
27.What is a cold? What are its nasal manifestations?	183
28.What results in swelling of the nasal mucosa?	183
29.Can you diagnose the cause of GI bleeding by peeking into the patient's nose?	183
30.Who was Rendu?	183
31.Who was Weber?	183
32.Who was Osler?	183
33.What is anosmia?	184
34.Do smell and taste interact?	184
35.Is perception of alcohol odor an indication that the sense of smell is intact?	184
B.The Oral Cavity	184
(1)Generalities	184
(2)Posterior Pharynx and Tonsils	185
36.What are the two main structures of the posterior pharynx?	185
37.What is a cleft palate?	185
38.What is the uvula? What disease processes may affect it?	185
39.What is uvulomegaly? What are its causes?	186
40.What is a localized reddening of both anterior pharyngeal pillars? What are its causes?	186
41.What are the causes of a diffuse reddening of the oropharynx?	186
42.How common is sore throat?	186
43.What are the causes of an exudate (i.e., pus) on the posterior pharynx?	186
44.What are the clinical features of viral upper respiratory tract infections?	186
45.What are the clinical features of group A beta-hemolytic streptococcal infection?	187
46.What is scarlatina (scarlet fever)?	187
47.When should you think of gonococcal pharyngitis?	187
48.What is infectious mononucleosis? What are its features?	187
49.What are the glandular fever-like syndromes?	187
50.Can strep throat be diagnosed by history and physical examination?	188
51.What are the causes of a nodule in the posterior pharynx?	188
52.What is Vincent's angina of the tonsil?	189
(3)Oral Mucosa	189
53.What is the magic of \"Ahhhh\"?	189
54.What are the best sound and tongue positions for the task?	189
55.What is the descriptive nomenclature of lesions in the oral mucosa?	189
56.What are the colors of oral lesions?	189
57.What causes flesh-covered palpable lesions in the oral mucosa?	189
58.What is a ranula?	190
59.What is a torus?	190
60.Who were Wharton and Stensen?	190
61.What is a buccal exostosis?	191
62.What are the two most common causes of white spots in the oral mucosa?	191
63.What is hairy leukoplakia?	191
64.What is oral thrush?	191
65.What are Koplik's spots?	192
66.Are Koplik's spots specific for rubeola?	192
67.Who was Koplik anyway?	192
68.What are Fordyce's spots?	192
69.What is Wickham's sign?	192
70.Who was Wickham?	192
71.Why is leukoplakia a \"garbage can diagnosis\" that should be abolished?	192
72.What features of a white lesion increase its chance of being malignant?	192
73.List the causes of pigmented spots in the oral mucosa.	193
74.What is Peutz-Jeghers syndrome?	193
75.What is smokers' melanosis?	193
76.How are skin and mucosae in Addison's disease? Who was Addison?	193
77.How do you distinguish Peutz-Jeghers syndrome from plain freckling?	193
78.List the common causes of red spots in the oral mucosa.	193
79.What does pyogenic granuloma look like?	194
80.Describe the lesions of erythema migrans.	194
81.What are palatal petechiae?	194
82.What do the oral lesions of Kaposi's sarcoma look like?	194
83.What are the causes of ulcers and erosions in the oral mucosa?	194
84.What are aphthous ulcers?	194
85.How do you differentiate between a canker and a chancre?	194
86.Can the vermilion border of the lip identify the cause of oral mucosal ulcers and vesicles?	195
87.Where is Coxsackie? Who there has the disease?	195
88.What is Bornholm and why is it in geographic competition with Coxsackie?	195
89.Why should you examine the palms and soles of patients with oropharyngeal vesicles/erosions?	195
C.Tongue	195
90.Describe the anatomy of the tongue.	195
91.What is dysgeusia?	195
92.What is the best way to inspect the tongue?	196
93.Summarize the abnormalities of the tongue.	196
94.What is macroglossia? What are its causes?	196
95.What is a scrotal tongue?	196
96.What is a hairy tongue?	196
97.What is a geographic tongue?	197
98.What is a median rhomboid glossitis (MRG)?	198
99.Can the tongue be white?	198
100.What is a white hairy tongue (hairy leukoplakia)?	198
101.What is the cause of a smooth, red tongue?	198
102.What causes atrophic glossitis?	198
103.What causes palpable lingual nodules and papules?	199
104.Is an indurated tongue ulcer neoplastic?	199
105.What is a tongue-tie?	199
106.What are sublingual varicosities? What is their significance?	199
107.What is the significance of tongue-biting?	199
D.Lips	200
108.What is the difference between cheilosis and cheilitis?	200
109.What are the causes of lip ulcers or erosions?	200
110.What causes a diffusely enlarged lip?	200
111.What is angioedema (angioneurotic edema)?	200
112.What is hereditary angioedema?	200
113.What is the cause of pigmented areas on the lips?	200
114.What lip lesion may result in an ophthalmologic emergency?	201
E.Gums and Teeth	201
115.What is a parulis?	201
116.What is an epulis fissuratum (denture-induced hyperplasia)?	201
117.What is a pyogenic granuloma?	201
118.What is the most common cause of a diffuse thickening of the gums? What are the other possible causes?	201
119.What is scurvy?	201
120.What is the most ominous cause of gum hypertrophy and bleeding?	202
121.What are the local complications of gingivitis vulgaris?	202
122.What does \"long of tooth\" mean?	202
123.What causes tooth loss?	202
124.If you plumb a sulcus and it is normal, can the patient still have plumbism?	202
125.What are Hutchinson's teeth?	202
126.What is halitosis?	203
127.What is the diagnostic importance of halitosis?	203
128.What nonpathologic factors may cause halitosis?	203
129.What are the pathologic causes of halitosis?	203
130.What about psychiatric conditions that may be related to halitosis?	203
Acknowledgment	204
Selected Bibliography	204
Chapter 7: The Neck	205
A.Neck Features And Swellings	205
(1)Generalities	205
1.What neck features should be identified during inspection?	205
2.What is Turner's syndrome?	205
3.What is Noonan's syndrome?	205
4.What is Bonnevie-Ullrich syndrome?	205
5.What is Klippel-Feil syndrome?	205
6.With what syndrome is a buffalo hump at the base of the neck most commonly associated?	206
7.What are the anterior and posterior triangles of the neck?	206
8.What are the contents of the cervical triangles?	207
9.Which swellings may be encountered during inspection of the neck?	207
(2) Swellings of the Anterior Triangle (Midline)	207
10.What is the origin of midline swellings of the anterior cervical triangle?	207
11.What is a thyroglossal (duct) cyst?	207
12.Do thyroglossal cysts transilluminate?	208
13.How common is a thyroglossal cyst?	209
14.What accounts for the other 25% of congenital neck masses?	209
15.What is a thyroglossal fistula?	209
16.What is a dermoid (cyst)?	209
(3)Swellings of the Anterior Triangle (Lateral Aspect)	209
17.What are branchial cleft cysts?	209
18.Where do branchial cleft cysts originate?	209
19.Where are branchial cysts located?	209
What does a branchial cyst look like on exam?	209
Is adenopathy common in branchial cysts?	210
How does a branchial fistula present?	210
What is a branchial hygroma?	210
What is a cystic hygroma?	210
What is a laryngocele?	210
How does a laryngocele form?	210
What bedside maneuver can be used to identify a laryngocele?	210
How does congenital hypertrophy of the masseter present?	210
What is torticollis?	210
Swellings of the Posterior Triangle	210
What are the most common swellings of the posterior triangle?	210
What are the most common neoplastic swellings?	211
How can lymphadenitis be differentiated from other inflammatory neck swellings?	211
What are the causes of chronic enlargement of a cervical node?	211
How does a tuberculous cervical abscess typically present?	211
Where do neck abscesses typically originate?	211
Do neck abscesses always present as localized fluctuant masses?	211
What is Ludwig's angina?	211
What is the role of dental ailments in Ludwig's angina?	211
How does Ludwig's angina spread?	212
How does Ludwig's angina present on exam?	212
Who was Ludwig?	212
What is a submental sinus?	212
What other inflammatory condition may occur in the neck?	213
Salivary Glands	213
Which salivary glands are palpable?	213
Where are the parotids?	213
Where are the submaxillary glands?	213
Where are the sublingual glands?	213
What is the submandibular triangle of the neck?	213
What are the causes of salivary gland swelling?	213
How do the parotids feel in acute parotitis?	214
Is parotitis exclusively limited to the parotids?	214
What do parotid tumors look like?	214
How common is a pleomorphic adenoma?	214
What is Frey's (auriculotemporal) syndrome?	214
Who was Frey? When did she describe her syndrome?	214
Trachea	214
Describe the physical exam of the trachea.	214
Acknowledgment	215
Selected Bibliography	215
Chapter 8:The Thyroid	216
A.Generalities	216
B.Anatomic Review And Thyroid Gland Inspection	216
1.What are the thyroid's landmarks?	216
2.Where are the thyroid lobes in relation to other neck structures?	216
3.What is the pyramidal lobe?	216
4.What is the best way to Inspect the thyroid?	217
5.How helpful is swallowing during inspection or palpation?	218
6.Should the patient be given a glass of water?	218
7.How much information can be gained by inspection?	218
8.What is Marantildeoacuten's sign?	218
C.Thyroid Gland Palpation	219
9.What are the goals of palpation?	219
10.What does the normal gland feel like?	219
11.Should a normal thyroid be palpable?	219
12.What is the average size of the gland?	219
13.How do you palpate a thyroid?	219
14.What are the normal variants in size and location?	220
D.Additional Components Of The Focused Thyroid Examination	221
15.What other aspects of the general exam should be emphasized?	221
16.What additional aspects of the neck exam are important in thyroid evaluation?	221
17.What are the potential complications of a large goiter?	221
18.What is the Pemberton's maneuver?	221
19.What is the significance of a positive Pemberton's maneuver?	222
20.Is Pemberton's sign specific for a substernal goiter?	222
21.Who was Pemberton?	222
22.When should one auscultate the thyroid?	224
23.How do you distinguish a thyroid bruit from other neck sounds?	224
24.What is Berry's sign?	224
25.Who was Berry?	224
26.How can one categorize thyroid abnormalities?	224
E.Goiter	224
27.What is the normal thyroid size?	224
28.Which physical examination techniques can help establish thyroid size?	224
29.How precise are inspection and/or palpation in estimating thyroid size?	225
30.Why is estimating size clinically important?	225
31.What is a goiter?	226
32.What is the threshold for a goiter?	226
33.Are goiters neoplastic?	226
34.So what is the nature of goiters? Are they euthyroid?	226
35.What are the three most common forms of a goiter?	226
36.What about subacute thyroidits?	226
37.Is goiter common in pregnancy?	227
38.What is the prevalence of goiter in iodine-replete countries?	227
39.Can goiters be easily differentiated from normal glands?	227
40.So how can physical examination help identify a goiter?	227
41.What may lead to false-positive and false-negative results of goiter detection?	227
42.What is the overall accuracy of physical examination in detecting a goiter?	228
43.What is the clinical significance of a positive exam for goiter?	228
44.What is the significance of a negative exam?	228
45.What is the accuracy of physical examination in assessing thyroid size?	228
46.Is the accuracy of detecting a goiter modified by the presence of thyroid nodules?	228
F.Thyroid Nodules	228
47.How common are nodules?	228
48.Why are nodules so commonly missed?	229
49.What is the average size of a palpable nodule?	229
50.Are thyroid nodules necessarily neoplastic?	229
51. And so, what is the significance of a thyroid nodule?	229
G.Graves' Disease	229
52.What is hyperthyroidism?	229
53.How common is hyperthyroidism?	229
54.What are its most common causes?	229
55.How does hyperthyroidism present?	229
56.What are the findings most suggestive of hyperthyroidism?	229
57.And so, how does hyperthyroidism present in the elderly?	230
58.What are the three major manifestations of Graves' disease?	230
59.What is the frequency of Graves' disease?	230
60.Who was Graves?	230
61.What is the dermopathy of Graves?	230
62.What does pretibial myxedema look like?	231
63.How do you distinguish pretibial myxedema from the myxedema of hypo-thyroidism?	231
64.What is thyroid acropachy?	231
65.What other autoimmune findings can occur in Graves' disease?	231
66.What are the ocular manifestations of Graves'?	231
67.Can proptosis be unilateral?	231
68.How do you detect and assess the degree of proptosis?	231
69.Does the degree of proptosis predict optic nerve involvement and loss of vision?	231
70.What are the characteristics of Graves' congestive ophthalmopathy?	231
71.What is ophthalmoplegia?	233
72.What is onycholysis?	233
73.Who was Plummer?	233
H.Hypothyroidism	236
74.What is hypothyroidism?	236
75.What is its frequency?	236
76.What is the value of physical exam in hypothyroidism?	236
77.How does hypothyroidism present?	236
78.What are the manifestations of hypothyroidism?	236
79.What is the clinical significance of hypothyroid findings?	236
Acknowledgment	238
Selected Bibliography	238
Chapter 9:The Breast	239
A.Generalities	239
1.Why do a clinical breast examination (CBE)?	239
2.Who should undergo a screening CBE? How frequently?	239
3.What is the precision of CBE?	239
4.What is the accuracy of CBE?	239
5.What is the value of breast examination as compared to mammography?	239
6.What examiner's factors are associated with CBE's greater accuracy?	240
7.What patient's factors can adversely affect CBE's accuracy?	240
8.What is the bottom line for CBE modifiers?	240
(1)Inspection	240
9.Which areas should be examined?	240
10.What is the best way to inspect the breasts?	240
11.Which bedside maneuver can help to detect breast abnormalities on inspection?	241
12.What are the most significant abnormalities that can be detected by inspection?	242
13.What is skin dimpling?	242
14.What are the suspensory ligaments of the breast?	242
15.What is peau d'orange?	242
What is Paget's disease of the breast?	242
17.Who was Paget?	242
(2)Palpation	243
18.What is the best way to palpate the breast?	243
19.Describe the proper patient position.	243
20.What should the examiner remember about breast boundaries?	243
21.What is meant by an adequate examination pattern?	243
22.Describe the correct finger position, movement, and pressure.	243
23.What are the final steps in the CBE?	244
24.What is the bottom line of the breast exam?	244
25.How does normal breast tissue feel?	244
26.How should a breast lump (or nodule) be described?	244
27.What are the characteristics of malignant breast tissue?	245
28.Are lumps ever normal?	245
29.How common is breast cancer? What are its risk factors?	210
30.How accurate is physical exam for the detection of a breast lump?	245
31.How high is the interobserver variability in describing a breast lump?	245
32.What are the most common benign breast lesions?	246
33.What is a florid nipple adenoma?	246
34.What is the differential diagnosis of an inflammatory breast mass?	246
35.How can one separate acute mastitis from inflammatory breast carcinoma?	246
36.Describe the lymphatic drainage of the breasts.	246
B.Nipple Discharge	246
37.How do you assess for nipple discharge?	246
38.What are the causes of a serous nipple discharge?	246
39.How about a bloody discharge?	247
40.How common is a watery nipple discharge? What are the causes?	248
41.What is galactorrhea?	248
42.What is the milk line?	248
43.What is polythelia?	248
44.What is polymastia?	248
45.What is athelia?	248
46.Who was Poland?	248
47.What can one learn from examining the chest wall of postmastectomy patients?	249
C.Breast Self Examination (BSE)	249
48.What is the role of breast self-examination (BSE)?	249
49.What is the value of BSE?	249
D.Gynecomastia	249
50.What is gynecomastia?	249
Acknowledgment	250
Selected Bibliography	250
Chapter 10:The Cardiovascular Exam	251
A. Generalities	251
1. What are the main components of the cardiovascular physical examination?	251
B. General (Physical) Appearance	252
2. What aspects of general appearance should be observed in evaluating cardiacpatients?	252
C.The Arterial Pulse	252
3. Which arteries should be examined during the evaluation of the arterial pulse?	252
4. Isn’t the radial artery the most commonly used vessel for the evaluation of thepulse?	252
5. What alterations occur in peripheral arteries?	254
6. Are there any findings that are better evaluated in peripheral rather thancentral arteries?	254
7. What alterations result from decreased arterial compliance?	256
8. What about vasoconstricted arteries?	257
9. What is the best technique for evaluating the arterial pulse in carotid arteries?	257
10. What is the best technique for evaluating the arterial pulse in brachial arteries?	257
11. What should you evaluate when examining the arterial pulse?	257
12. What are the characteristics of a normal arterial pulse?	257
13. Are both the primary and secondary waves palpable?	257
14. How are primary and secondary waves generated?	257
15. What is the significance of a normal rate of rise of the arterial pulse?	258
16. What is the meaning of a slow rate of rise of the arterial pulse?	258
17. Is there any correlation between the slow rise of the arterial pulse and theseverity of AS?	209
18. How can you differentiate supravalvular from valvular aortic stenosis?	258
19. And what about subvalvular stenosis?	258
20. What is the significance of a brisk arterial upstroke?	258
21. In addition to AR, which other processes cause rapid upstroke and widenedpulse pressure?	259
22. What is pulsus paradoxus?	259
23. What is pulsus alternans?	259
24. What is electrical alternans?	260
25. What is the best way to feel a pulsus alternans?	260
26. What is the mechanism of pulsus alternans?	260
27. Can pulsus alternans ever be normal?	260
28. What is total alternans?	260
29. What is a bigeminal pulse?	260
30. What is a double-peaked pulse?	260
31. Define pulsus bisferiens.	260
32. What is the best way to detect a pulsus bisferiens?	261
33. What is the diagnostic significance of a pulsus bisferiens?	261
34. What is Duroziez’s double murmur?	210
35. Who was Duroziez?	262
36. What is the usefulness of all these auscultatory findings?	262
37. What is the mechanism of pulsus bisferiens?	262
38. What is the prognostic value of a pulsus bisferiens?	262
39. What is a bifid pulse?	262
40. What is the mechanism of the bifid pulse?	262
41. What is a dicrotic pulse?	262
42. What is the clinical significance of a dicrotic pulse?	262
43. What is a hypokinetic pulse?	263
44. Is there any difference in sensitivity/specificify for tardus versus parvus?	263
45. Can arterial characteristics modify a pulsus tardus?	263
46. Are there any other manifestations of arterial delay?	263
47. What is the carotid shudder?	263
48. What is an anacrotic pulse?	263
49. What is a hyperkinetic pulse?	263
50. What are the causes of a hyperkinetic pulse?	264
51. What is Corrigan’s pulse?	264
52. Who was Corrigan?	264
53. What is a water hammer?	264
54. What is the best way to feel a Corrigan’s pulse?	264
55. What is a pulsus durus?	264
56. Can the compressibility of the arterial pulse predict the systolic blood pressure?	264
57. How do you auscultate for carotid bruits?	264
58. What other findings can mimic a carotid bruit?	265
59. What is the interobserver agreement on carotid bruits?	265
60. Can carotid bruits occur in children?	265
61. And what about adults?	265
62. What is the significance of a carotid bruit in asymptomatic ambulatory patients?	265
63. What is the significance of a carotid bruit in an asymptomatic preoperativepatient?	265
64. What is the correlation between symptomatic carotid bruit and high-gradestenosis?	265
D. Central Venous Pressure and Jugular Venous Pulse (Waveform)	266
65. What is the history behind the examination of neck veins?	266
66. What is the role of physical exam in assessing neck veins?	266
67. What is the central venous pressure (CVP)?	267
68. Which veins should be evaluated for assessing venous pulse and CVP?	267
69. What is the clinical value of jugular venous distention and pulse?	267
70. How difficult is it to evaluate the jugular veins?	267
71. Should one inspect the right or the left internal jugular vein?	267
72. Can the external jugulars be used for evaluating central venous pressure?	267
73. But don’t external jugulars have valves?	267
74. Still, aren’t the internal jugulars too deep for an accurate inspection?	268
75. What is the anatomy of internal and external jugular veins?	268
76. How do you examine neck veins?	268
77. How important is the patient’s position during examination of the neck veins?	268
78. How do you tell apart the carotid pulse from the jugular venous pulse?	269
79. How do you evaluate the jugular venous pulse?	269
80. What are the components of the jugular waveform?	269
81. What is the physiology of the jugular venous pulse?	270
82. What is the physiology of the various ascents and descents of the jugularvenous pulse?	270
83. Who was Wenckebach?	271
84. What is the influence of respiration on the jugular venous pulse?	272
85. What is the influence of respiration on the jugular venous pressure?	272
86. Which diseases can be diagnosed by jugular venous pulse?	272
87. What are the most important abnormalities of jugular waves?	272
88. What are the most important abnormalities of jugular descents?	274
89. How do you estimate the CVP?	274
90. How is ‘‘Louis’’ pronounced?	275
91. What is the normal central venous pressure?	276
92. Is there any faster way to assess central venous pressure?	276
93. Are there alternative methods to assess the CVP?	276
94. How precise is the clinical assessment of CVP?	276
95. So what conclusions can be drawn about the clinical use of CVP assessment?	276
96. Why does bedside assessment tend to underestimate central venous pressure?	277
97. What is the significance of a low jugular venous pressure?	277
98. What is the significance of an elevated jugular venous pressure?	277
99. What is the significance of neck vein distention in assessing chronic heartfailure?	277
100. What is the prognostic significance of abnormal jugular venous pressure inheart failure?	278
101. How are the neck veins in tamponade?	278
102. What is the significance of leg swelling without increased central venouspressure?	278
103. What is the significance of leg edema plus ascites in the absence ofincreased CVP?	278
104. What is the prognostic value of an increased CVP in preoperative patients?	278
105. What are the jugular findings of right ventricular infarction?	278
106. What is the hepatojugular reflux?	278
107. What is it used for?	279
108. What is the physiology of the abdominojugular reflux?	279
109. Does abdominal pressure cause any change in cardiac output?	279
110. Is compression of the liver necessary to elicit a response?	279
111. How do you perform an abdominojugular test?	279
112. When is the abdominojugular test considered positive?	280
113. What is the significance of a positive abdominojugular reflux?	280
114. Shouldn’t the abdominal pressure be applied for at least 1 minute?	280
115. What is Kussmaul’s sign?	281
116. Which disease processes are associated with a positive Kussmaul’s?	281
117. What can be said about the association of pulsus paradoxus andKussmaul’s sign?	281
118. What is the association between Kussmaul’s sign and theabdominojugular reflux?	281
119. How can you improve the clinical examination of the jugular veins?	281
120. What is the ‘‘venous hum’’?	281
121. What is the best way to elicit a venous hum?	282
122. What is the mechanism of the venous hum?	282
123. How prevalent is this finding?	282
124. Can any other cardiac event be heard at the neck?	282
E. The Precordial Movement and Impulse	282
125. What is the history behind precordial palpation?	282
126. Which precordial impulse can be appreciated on physical exam?	283
127. What precordial areas should be examined?	283
128. Can the right ventricle be appreciated in a normal person?	283
129. How do you assess the precordial impulse(s)?	283
130. How do you time precordial events?	283
131. Which characteristics of the apical impulse should be analyzed?	283
132. What are the most common abnormal apical movements?	284
133. What is the significance of a precordial movement in the left lower sternal area?	284
134. What is a retracting impulse?	285
135. What are the causes of a retracting impulse?	285
136. What are the precordial findings of tricuspid regurgitation?	285
137. What precordial evidence suggests mitral stenosis?	285
138. What precordial evidence suggests angina? Previous infarction?	285
139. What are the precordial findings of a dilated aorta or pulmonary artery?	285
140. What is a thrill?	285
141. What is the value of precordial percussion?	285
Selected Bibliography	286
Chapter 11:Heart Sounds and Extra Sounds	287
A. Generalities	287
B. Cardiac Auscultation: Some Suggestions	287
1. Why is cardiac auscultation so difficult?	287
2. How can you make auscultation a little easier?	288
C. Normal Heart Sounds	288
3. What are the normal heart sounds?	288
4. What are the hemodynamic and acoustic characteristics of the cardiac cycle?	288
5. What are the cardiac areas?	288
(1)First Heart Sound (S1)	288
6. Where is S1 best heard?	288
7. How is S1 generated?	288
8. Which characteristics of S1 are clinically valuable and should therefore beidentified?	289
9. How do you tell S1 from S2?	289
10. What is the significance of S2 being louder than S1 at the apex?	289
11. Which factors are responsible for the loudness of S1?	289
12. What factors can affect the rate of rise of ventricular pressure?	289
13. Which diseases present with a variable intensity of S1?	289
14. What was the role of Morgagni in describing complete heart block?	290
15. Who was Mobitz?	290
16. What is the intensity of S1 in atrial fibrillation?	290
17. How can you separate the variable S1 of atrial fibrillation from that of completeA-V block?	290
18. How is S1 in mitral stenosis (MS)?	291
19. What other conditions can be associated with a loud S1?	291
20. Which conditions can be associated with a soft S1?	291
21. Which atrioventricular valve closes first?	291
22. Which semilunar valve opens first?	291
23. What is the sequence of closure and opening of the various valves at the timeof S1?	291
24. What is the significance of a narrowly split S1?	291
25. Is the tricuspid component of S1 (T1) audible at the apex?	292
26. What is the significance of a split S1 at the base?	292
27. What is the significance of a widely split S1 at the LLSB?	292
28. What is the significance of an apparently split S1 at the apex?	292
29. How can one separate a truly split S1 from a ‘‘pseudo-split’’ S1?	292
(2) Second Heart Sound (S2)	292
30. Where is S2 best heard?	292
31. How is S2 generated?	292
32. Which of the two semilunar valve closes earlier?	292
33. How clinically useful is S2?	292
34. Which S2 characteristics are more valuable clinically?	292
35. What is a physiologic splitting of S2?	292
36. What is the effect of exhalation on semilunar valve closure?	293
37. How common is a physiologic splitting of S2?	293
38. Why does S2 splitting disappear with aging?	293
39. How important is a patient’s position on S2 splitting?	293
40. What is the significance of a true expiratory splitting of S2?	293
41. What is a wide (physiologic) splitting of S2? What causes it?	293
42. What are the causes of delayed closure of the pulmonic valve?	293
43. What are the causes of premature closure of the aortic valve?	294
44. What is a fixed splitting of S2? What does it mean?	295
45. What is the differential diagnosis of a fixed splitting of S2?	295
46. What about tumor plop and pericardial knock?	296
47. What is a paradoxical splitting of S2? What does it mean?	296
48. What are the causes of paradoxical S2 splitting?	296
49. Is paradoxical S2 splitting a sign of myocardial ischemia?	297
50. What is the significance of a ‘‘single splitting’’ of S2?	297
51. Which is louder: A2 or P2?	297
52. How can you differentiate the two components of S2?	297
53. What is the significance of S2 physiologically split at the apex?	297
54. What is the significance of a loud P2 or A2?	297
55. What is the significance of S2 softer than S1 at the base?	297
56. What is a ‘‘Tambour’’ S2?	298
57. What makes P2 louder than A2?	298
58. What are the other precordial findings of pulmonary hypertension?	298
59. What can soften A2 or P2?	298
D. Extra Sounds	298
60. What are extra heart sounds?	298
61. Are S3 and S4 extra sounds?	298
62. Where are these extra soundsbest heard?	299
63. Where are S3 and S4 bestheard?	299
64. Which bedside maneuverscan intensify S3 and S4?	299
(1) Diastolic Extra Sounds	300
65. How many diastolic extra sounds can be encountered?	300
Third Heart Sound (S3)	300
66. What is an S3?	300
67. How easy is it to detect an S3?	300
68. How is S3 best detected?	300
69. Why the bell?	300
70. How is S3 after an extra systole?	300
71. Should S3 be pursued over the point of maximal apical impulse (PMI)?	300
72. Can S3 be palpable?	300
73. Can S3 be transmitted to the supraclavicular fossa?	300
74. Which is easier to detect: S3 or S4?	301
75. How is S3 produced?	301
76. Why does S3 occur in early diastole?	301
77. Is S3 always a gallop?	301
78. Can a gallop be physiologic?	301
79. Who first used the term gallop?	301
80. What are the most important gallops?	301
81. What is a summation gallop?	301
82. What are the causes of a summation gallop?	301
83. What are the acoustic characteristics of a summation gallop?	302
84. Is a quadruple rhythm the same as a summation gallop?	302
85. What is a physiologic S3?	302
86. Can a physiologic S3 occur in any other situation?	302
87. What is the clinical significance of a pathologic S3?	302
88. How does a pathologic S3 differ from a physiologic S3?	302
89. Why is the pathologic S3 softer and lower pitched?	302
90. What is the low-pitched diastolic murmur that often follows a pathologic S3?	302
91. What are the hemodynamic implications of an S3?	302
92. Does the presence of S3 predict higher levels of B-type natriuretic peptide (BNP)?	303
93. So what are the clinical implications of S3?	303
94. Which conditions are responsible for an S3 of diastolic overload?	303
95. What about the diastolic overload of aortic regurgitation (AR)?	303
96. What is the effect of pulmonary hypertension on the S3 due to diastolic overload?	303
97. What is Eisenmenger’s syndrome?	304
98. Is S3 common in aortic stenosis (AS)?	304
99. How common is S3 during a myocardial infarction?	304
100. Is S3 always generated by the left ventricle?	304
101. Which disease processes are associated with a right-sided S3?	304
102. How can you differentiateright from left ventricularS3?	304
103. What is the differential diagnosis of S3?	304
104. How can S3 be further differentiated from an opening snap (OS)?	305
105. How common is S3 in mitral stenosis (MS)?	305
Fourth Heart Sound (S4)	305
106. What is an S4?	305
107. How is S4 best detected?	305
108. Can S4 be palpable?	305
109. How common is S4? Can it be normal?	305
110. Can S4 occur in younger individuals?	305
111. What are the auscultatory differences between S3 and S4?	305
112. Why is S4 late diastolic?	306
113. How is S4 produced?	306
114. What is the hemodynamic significance of an S4?	306
115. What are the clinical implications of S4?	306
116. Which disease processes can cause an S4?	306
117. What happens when these hypertrophic ventricles fail?	306
118. How common is S4 in myocardial infarction (MI)?	306
119. Can S4 occur in mitral regurgitation?	306
120. Can a right-sided S4 be differentiated from a left-sided one?	306
121. Can patients with atrial fibrillation have an S4?	307
122. What is the differential diagnosis of an S4?	307
Opening Snap	307
123. What is an opening snap?	307
124. Why are these sounds called‘‘snaps’’?	307
125. Is the opening of a normal atrioventricular valve audible?	308
126. How can one distinguish an opening snap from the closing of S2?	308
127. Does the timing of OS (i.e., the length of A2–OS) reflect the severity of stenosis?	308
128. Does the intensity of OS reflect the severity of stenosis?	308
129. How common is an opening snap in patients with mitral stenosis?	308
130. How can one distinguish the pulmonary sound of a split S2 from an openingsnap?	308
131. What is a tricuspid opening snap?	308
132. How can one differentiate a mitral from a tricuspid opening snap?	308
Pericardial Knock	309
133. What is a pericardial knock?	309
134. How is the pericardial knock produced?	309
135. Is the pericardial knock common in acute pericarditis?	309
136. What other physical findings may accompany constrictive pericarditis?	309
137. What is the differential diagnosis of a pericardial knock?	309
Mitral (or Tricuspid) Valve Myxoma	309
138. What is a tumor plop?	309
(2) Systolic Extra Sounds	310
Early Systolic Click (i.e., Ejection Sound)	310
139. What is an ejection sound (ES)?	310
140. What is the mechanism ofproduction?	310
141. How do you distinguish an aortic from a pulmonic ejection sound?	310
142. Can an ejection sound be accompanied by a systolic murmur?	311
143. And so, what causes an aortic ES?	311
144. Where is the aortic ES best heard?	311
145. What is the significance of an aortic ejection sound in aortic stenosis?	311
146. What is the clinical significance of the intensity of an aortic ES?	311
147. Can the opening of a pulmonary bicuspid valve be responsible for an ejectionsound?	311
148. Does a pulmonic ejection sound indicate severity of pulmonary stenosis (PS)?	311
149. What is the significance baseline of the intensity of a pulmonic ES?	311
150. What causes a nonvalvular pulmonic ejection sound?	311
151. What is the differential diagnosis of an ejection click?	312
152. What is the Means-Lerman scratch of hyperthyroidism?	312
Mid- to Late-Systolic Click	312
153. What are mid- to late-systolic click(s)?	312
154. What is the clinical significance of a single (or multiple) mid- to late-systolicclick(s)?	312
155. What are the auscultatory characteristics of a systolic click due to MVP?	312
156. Why do clicks of mitral valve prolapse not occur in early systole?	312
157. How can one recognize MVP when the click coincides with S1?	313
158. What are the acoustic characteristics of the click(s)?	313
159. How are these clicks generated?	313
160. Which bedside maneuvers can change the timing of an MVP click/murmur?	313
161. Are mid- to late-systolic clicks always associated with a late systolic murmur?	313
162. Can patients with MVP present with a diastolic click?	313
163. What is the differential diagnosis of a mid-systolic click?	313
E. Pericardial Friction Rub	313
164. What are the auscultatory characteristics of a pericardial friction rub?	313
165. How many components are in a rub?	314
166. Do rubs always present with three components?	314
167. Where are rubs best heard?	315
168. Can rubs be palpable?	315
169. What bedside maneuverscan intensify a pericardialfriction rub?	315
170. How can one separate a pericardial from a pleural rub?	315
171. Which disease processes are associated with rubs?	315
172. Does the presence of a rub exclude a pericardial effusion?	316
173. What is the differential diagnosis of a pericardial friction rub?	316
174. How about constrictive pericarditis?	316
Selected Bibliography	316
Chapter 12:Heart Murmurs	318
Introduction and Basic Issues	318
1. What are the auscultatory areas of murmurs?	318
2. What is Erb’s point?	318
3. How accurate is physical examination in detecting asymptomatic valvulardisease?	318
4. What is the clinical significance of murmurs?	319
5. What, then, should be the approach to a newly detected murmur?	319
6. Do the acoustic characteristics of the murmur help separate benign frompathologic?	321
7. What is a thrill?	321
Mechanisms of Production	321
8. How are murmurs produced?	321
9. What are the structural abnormalities that produce local narrowing and turbulentflow?	206
Classification	321
10. How are murmurs classified?	321
11. What are continuous murmurs?	323
12. Why are systolic murmurs much more common than diastolic ones?	323
13. Can exercise increase the intensity of a diastolic murmur?	323
14. Once the phase of the cardiac cycle has been identified, which othercharacteristics of a murmur should be analyzed and described?	323
15. Are shape and frequency of a murmur clinically useful?	324
16. What about location and radiation of a murmur?	324
17. And what about the ‘‘quality’’ of a murmur?	324
18. Which interventions and maneuvers can be used at the bedside to modifythe intensity and characteristics of murmurs and make them more easilyrecognizable?	324
19. What is the effect of respiration on murmurs?	324
20. What is the reversed Rivero-Carvallo sign?	325
21. Who was Carvallo?	325
22. What is the effect of Valsalva on sounds and murmurs?	325
23. Does S2 change with Valsava?	325
24. What are the effects of posture on murmurs?	325
25. What is isometric hand grip? What does it do to the murmur?	326
26. What about variations in cardiac cycle?	326
A. Functional Murmurs	327
27. What are functional murmurs?	327
28. How can physical examination help differentiate functional from pathologicmurmurs?	327
29. Are these rules written in stone?	328
30. So what should functional murmurs be like?	328
31. What should be the characteristics of ‘‘bad’’ systolic murmurs?	328
32. What are the synonyms for functional murmurs?	328
33. Can functional murmurs occur outside systole?	328
34. What are the causes of benign diastolic murmurs?	328
35. What are the clinical implications of functional murmurs?	328
36. How common are these functional murmurs?	328
37. Why are these murmurs better heard in children than adults?	329
38. Can functional murmurs occur immediately after birth?	329
39. Is high flow velocity present in nonpediatric patients?	329
40. How significant is a murmur that appears only after exercise, anemia, or fever?	329
41. Are there other conditions where a higher stroke volume causes an ejectionmurmur?	329
42. Is a functional murmur always caused by an increase in flow velocity?	329
43. What are the functional murmurs caused by reduced flow velocity?	329
44. How many types of functional murmurs are known?	329
45. What is the mechanism responsible for the generation of these functionalmurmurs?	330
46. What is Still’s murmur ?	330
47. Who has it?	330
48. What causes it?	330
49. What does it mean prognostically?	330
50. Who was Still?	331
51. What is a pulmonary systolic ejection murmur?	331
52. What is the supraclavicular arterial bruit?	331
53. What is a venous hum?	331
54. What is a mammary souffle´?	331
55. What can one do to sort out functional murmurs from pathologic ones?	331
56. What is the most common systolic ejection murmur of the elderly?	332
57. Why does the murmur of aortic sclerosis peak early?	332
58. What are the risk factors for aortic sclerosis?	332
59. What causes the murmur of aortic sclerosis?	332
60. What are the degenerative changes of the aortic valve that can cause aorticsclerosis?	332
61. What are the prognostic implications of aortic valve sclerosis?	332
62. How frequent are MAC and ARS?	333
63. What is the reason for the worse clinical outcome of patients with aorticsclerosis?	333
64. Is there any evidence for this ‘‘inflammatory’’ theory?	333
65. What should one do in clinical practice?	333
B. Systolic Murmurs	333
66. How common are systolic murmurs?	333
67. What are the causes of a systolic murmur?	333
68. What characteristics of a systolic murmur help differentiate ejection fromregurgitation?	333
69. What is the precision of physical examination for the evaluation of systolicmurmurs?	334
(1) Systolic Ejection Murmurs	334
70. What is the definition of an ejection murmur?	334
71. What are the characteristics of an ejection murmur?	334
72. Are all ejection murmurs crescendo-decrescendo?	334
73. What is the pitch of a systolic ejection murmur?	334
74. In addition to pitch, are there other differences between ejection and regurgitantmurmurs?	334
75. Everything else being equal, is the intensity of an ejection murmur related to itsseverity?	335
76. Does loudness of an ejection murmur always predict severity of disease?	335
77. What are the effects of respiration on left-sided ejection murmurs?	335
78. What is the effect of inspiration on right-sided ejection murmurs like pulmonicstenosis?	335
79. What is the effect of standing on the intensity of a PS murmur?	335
80. What is the effect of Valsalva on systolic ejection murmurs?	335
I. Aortic Stenosis	335
81. What are the three main types of aortic stenosis?	335
Valvular Aortic Stenosis	335
82. What are the causes of valvular AS?	335
83. What is the most common congenital cause of valvular AS?	336
84. What is the progression of valvular changes in aortic stenosis?	336
85. Is aortic root dilation a common feature of valvular AS?	336
86. What is the link between AS and coronary artery disease (CAD)?	336
87. How much reduction in valvular area is necessary for the AS murmur to becomeaudible?	336
88. What is the normal aortic area?	336
89. What is the frequency of clinically significant outflow obstruction?	336
90. What is the pathophysiology of left ventricular outflow obstruction?	336
91. Where is the murmur of aortic stenosis louder?	337
92. What is the Gallavardin phenomenon?	337
93. Who was Gallavardin?	337
94. What are the characteristics of the AS murmur?	337
95. How can one separate the murmur of AS from that of aortic sclerosis?	337
96. Of all these characteristics, which are the most useful for ruling in (or ruling out)aortic stenosis?	338
97. What is the apical–carotid and brachioradial delay?	338
98. How valuable is a pulse that is parvus and tardus?	338
99. Is the timing of peak intensity always reflective of severity of disease?	338
100. And how can one differentiate AS from the other systolic murmurs?	338
101. Are there any other murmur characteristics that can predict the severity of AS?	338
102. And what about the intensity of S2?	339
103. What are the reasons for a soft S2 in AS?	339
104. What about the transmission of the murmur?	339
105. Is there any other acoustic event that may suggest severe AS?	339
106. Are there any other findings that do not predict severity of AS?	339
107. How is the point of maximal impulse (PMI) in AS?	339
108. How are the neck veins in patients with AS?	339
109. What is the ‘‘Bernheim phenomenon’’?	339
110. What is the ‘‘reverse Bernheim phenomenon’’?	340
111. What then are the valuable clinical predictors of severe AS?	340
112. And what about bedside predictors of clinical outcome?	340
113. Why is physical examination inadequate in predicting disease severity?	340
114. In summary, what is the role of physical examination in valvular AS?	340
115. What are the clinical implications for a primary care physician?	341
Aortic Subvalvular Stenosis	341
Subvalvular \"Hypertrophic	341
116. What is the pathophysiology of HOCM?	341
117. Where is this murmur best heard?	341
118. How can one differentiate the systolic ejection murmur of valvular AS from thatof HOCM?	341
119. Does timing of onset of the HOCM murmur reflect severity of disease?	341
120. What bedside maneuvers can modify the murmur of HOCM?	341
121. Which factors increase left ventricular volume?	342
122. Which factors reduce left ventricular volume?	342
123. How accurate are these maneuvers in recognizing HOCM?	342
124. How does valvular AS respond to these maneuvers?	342
125. How does a long diastolic pause after a premature beat affect the murmur ofHOCM?	342
126. Can the murmur of HOCM be partially related to a murmur of mitralregurgitation?	342
127. Are there any other associated physical findings in HOCM?	343
128. In summary, how accurate is physical exam for the diagnosis of HOCM?	343
Subvalvular \"Fixed	343
129. What is the cause of a ‘‘fixed’’ subvalvular aortic stenosis?	343
Aortic Supravalvular Stenosis	343
130. What are the characteristics of supravalvular aortic stenosis?	343
131. What are the other characteristics of supravalvular AS?	343
II. Aortic Versus Pulmonic Stenosis	343
132. How does the murmur of pulmonic stenosis (PS) differ from that of aorticstenosis (AS)?	343
133. What other auscultatory features can help differentiate pulmonic from aorticstenosis?	344
III. Miscellaneous Ejection Murmurs	344
Ventricular Septal Defect (VSD)	344
134. What are the characteristics of a VSD murmur?	344
135. Can the shape of a VSD murmur help identify the type of defect?	344
136. Is there any relationship between the intensity of the murmur and the size of thedefect?	344
137. Where is the VSD murmur best heard?	344
138. How can one differentiate MR from VSD?	344
(2) Systolic Regurgitant Murmurs	344
139. What is a systolic regurgitant murmur?	344
140. Is ‘‘regurgitation’’ the same as ‘‘insufficiency’’?	345
141. What are the auscultatory characteristics of systolic regurgitant murmurs?	345
I. Mitral Regurgitation	345
142. How prevalent is mitral valve regurgitation (MR)?	345
143. What is the pathophysiology of MR?	345
144. What are the causes of MR?	345
145. What are the most common ‘‘valvular’’ causes of MR in adults?	345
146. What are the most common ‘‘valvular’’ causes of MR in children?	346
147. Can left ventricular dilation and systolic dysfunction cause MR?	346
148. Once the typical murmur is detected and recognized, what is the prognosisof MR?	346
149. How is MR detected in adults?	346
150. What is the significance of detecting a typical MR murmur?	346
151. What are the characteristics of the MR murmur?	346
152. Can the ‘‘pitch’’ identify gradient?	347
153. Can the murmur of MR radiate medially?	347
154. Are all MR murmurs plateau?	347
155. Can the MR murmur extend beyond S2?	347
156. What are the best bedside predictors of MR severity?	347
157. What is the implication for the clinician?	347
158. What are the other bedside signs of severe MR?	347
159. So what is the role of echocardiography in MR?	348
160. Since both MR and AR cause similar peripheral findings, how can you separatethe two?	348
161. Can a murmur of severe regurgitation be nonetheless soft and almost silent?	348
162. Can the shape of the murmur differentiate the various causes of regurgitation?	348
163. Is there any bedside maneuver that can help identify papillary muscledysfunction?	348
164. Can you separate MR of ruptured chordae from MR of dysfunctional papillarymuscles?	348
165. What is the cause of ruptured chordae tendineae?	349
166. What are the characteristics of the acute MR murmur?	349
167. Is the murmur of MR increased or softened by respiration?	349
168. What are the effects of other bedside maneuvers/vasoactive drugs on theintensity of MR?	349
169. What is the effect on MR of standing?	349
170. In summary, how accurate is physical examination for diagnosing MR?	349
II. Mitral Valve Prolapse	350
171. What is mitral valve prolapse (MVP)?	350
172. What is the underlying abnormality of MVP?	350
173. Which leaflet is most commonly involved?	350
174. Is myxomatous degeneration limited to the mitral valve?	350
175. Who was Barlow?	350
176. What are the characteristics of the mitral valve prolapse murmur?	351
177. Can mitral valve prolapse be silent? Can anything make it louder?	351
178. Which bedside maneuvers can reduce left ventricular size?	351
179. Which bedside maneuvers can increase left ventricular size?	351
180. In summary, how accurate is physical examination for the diagnosis of MVP?	351
181. Do patients with an isolated click necessarily develop regurgitation?	351
182. And what about the need for valvular replacement in patients with a murmur?	351
183. What is the differential diagnosis of MVP?	352
184. Can bedside maneuvers identify a murmur of papillary muscle dysfunction?	352
III. Tricuspid Regurgitant (TR) Murmur	352
185. What are the most common causes of tricuspid regurgitation?	352
186. What is the most common cause of pulmonary hypertension in the UnitedStates?	352
187. Where is the TR murmur best heard?	352
188. What are the diagnostic features of a TR murmur?	352
189. How can one differentiate TR from MR?	353
190. Does the Lancisi sign predict severity?	353
191. How can one measure central venous pressure (CVP) in TR?	353
192. What are the other bedside findings of chronic TR?	353
193. In summary, how accurate is physical examination for the diagnosis of TR?	353
194. How does acute TR differ from its chronic counterpart?	353
C. Diastolic Murmurs	353
195. What are the causes of a diastolic murmur?	353
196. How are diastolic murmurs classified?	354
(1) Diastolic Atrioventricular Valve Murmurs	354
I. Mitral Stenosis	354
197. What are the most common causes of mitral stenosis (MS)?	354
198. Where is the murmur of MS best heard?	354
199. What is the timing of the diastolic murmur of MS? What is its relationship to S2?	354
200. What is the shape of the diastolic rumble of MS?	354
201. What is the pitch of the MS rumble?	354
202. Is a very intense murmur reflective of more severe stenosis?	355
203. What are the other physical findings of mitral stenosis?	355
204. Which maneuvers can be used to intensify the MS rumble?	355
205. And what about respiration?	355
206. What is then the best strategy to detect the MS murmur?	355
207. And what about the concomitant presence of mitral regurgitation?	355
208. Which conditions are instead associated with a softer murmur of MS?	356
209. What is the effect of atrial fibrillation on the intensity of MS?	356
II. Mitral Diastolic Flow Murmur	356
210. What are ‘‘mitral diastolic flow murmurs’’?	356
211. What is the mechanism of a tricuspid diastolic murmur?	356
212. Where are these murmurs mostly heard?	356
213. What are the most common causes of a tricuspid diastolic flow murmur?	356
214. How frequently does tricuspid stenosis occur in patients with MS?	357
215. How can one differentiate TS from MS?	357
(2) Diastolic Semilunar Valve Murmurs	357
Aortic Regurgitation (AR)	357
216. How frequent is AR?	357
217. What are its causes?	357
218. How does rheumatic fever cause aortic regurgitation?	357
219. What are the other ‘‘valvular’’ causes of AR?	357
220. What are the ‘‘root’’ causes of aortic regurgitation?	357
221. What about hypertension?	357
222. Is there any way to separate at the bedside \"valvular\" AR from \"root\" AR?	358
223. What is the pathophysiology of chronic AR?	358
224. What are the symptoms of AR?	358
225. What are the ‘‘central’’ signs of chronic AR?	358
226. What are the typical auscultatory findings of AR?	359
227. What is the click of AR?	359
228. What about the systolic murmur?	359
229. Is there any way to separate the comitans murmur of AR from the systolic	359
230. What about the two diastolic murmurs?	359
231. What are the characteristics of the decrescendo murmur of AR?	359
232. Where is it best heard?	359
233. What is the typical pitch of the AR murmur?	359
234. What maneuvers can increase the loudness of a soft AR murmur?	360
235. How do you differentiate the MS murmur from that of AR?	360
236. What auscultatory characteristics of AR correlate with severity of	360
237. How does intensity of AR predict severity?	360
238. What is Austin Flint (A-F)?	360
239. How common is this finding?	360
240. Is the presence of an Austin Flint murmur an indication of severe	360
241. How can one differentiate the A-F murmur from one of mitral stenosis?	360
242. Who was Austin Flint?	360
243. Which other bedside findings correlate with severity of regurgitation?	361
244. What are the other auscultatory findings of AR?	361
245. And how about the presence of S3 in AR?	361
246. What are the \"peripheral\" signs of AR?	361
247. What is Quincke's pulse (sign)?	362
248. Who was Quincke?	362
249. What are the signs of acute and severe AR?	362
250.What are the causes of \"acute\" AR?	362
251.What are the morbidity and mortality of AR ?	362
II.Pulmonary Regurgitation	363
252.What is the differential diagnosis of an AR murmur?	363
253.What is the Graham Steell murmur?	363
254.Who was Graham Steell?	363
255.What are the other findings of a PR murmur?	363
256.How sensitive is this murmur for pulmonic regurgitation?	363
257.Is a PR murmur common in pulmonary embolism (PE)?	363
258.What about the other findings of PE?	363
D.Continuous Murmurs	364
259.What are continuous murmurs?	364
260.If continous murmurs are extracardiac, what conditions are responsible for them?	364
261.Why are these murmurs continuous?	364
262.What is the Nicoladoni-Israel-Branham sign?	364
E.Systolic-Diastolic Murmurs/Sounds	364
263. What is the differential diagnosis of \"lots of noise\" throughout the cardiac cycle?	364
Selected Bibliography	365
Chapter 13:Chest Inspection, Palpation, and Percussion	367
Generalities	367
1.What are the main components of the chest exam?	367
2.What is the usual sequence in a typical pulmonary exam?	367
A.Chest Inspection	368
3.What kind of information can be gathered through inspection?	368
4.What are the most common abnormalities of respiration?	368
5.What are the abnormalities of posture?	369
6.What are the main abnormalities in the use of respiratory muscles?	369
7.What about asymmetry in thoracic expansion?	369
8.What abnormalities of the chest cage can be detected by inspection?	369
9.And what about abnormalities of the chest surface?	369
10.What about assessment of extremities and neck veins?	369
(1)Abnormalities of Respiration	369
Abnormalities in the Rate of Inspiration	369
11.What are the main abnormalities in respiratory rate?	369
12.Can tachypnea be considered normal?	369
13.What is the clinical significance of true tachypnea?	370
14.Can absence of tachypnea be helpful?	370
15.Does tachypnea predict hypoxemia?	370
16.What is the clinical significance of bradypnea?	370
17.What is apnea?	370
Abnormalities in the Depth of Respiration	370
18.What are the main abnormalities in the depth of respiration?	370
19.What is hyperpnea?	370
20.Is there a difference between hyperpnea and the hyperventilation of cardiorespiratory disease?	370
21.Who was Kussmaul?	371
22.What is hypopnea?	371
Abnormalities in Rhythm and Pattern of Respiration	371
23.What are the main abnormalities in respiratory rhythm?	371
24.What is Cheyne-Stokes respiration?	372
25.What is the physiologic repercussion of Cheyne-Stokes?	372
26.What is the clinical significance of Cheyne-Stokes?	372
27.What are the therapeutic implications of Cheyne-Stokes?	372
28.Who were Cheyne and Stokes?	372
29.What other abnormalities in rhythm are worthy of recognition? What is their significance?	373
30.What is a grunting respiration?	373
31.What is the clinical significance of a grunting respiration?	373
32.What is pursed-lip respiration?	374
33.What is the physiologic impact of pursed-lip respiration?	374
34.What is nasal flaring?	374
(2)Abnormalities of Posture	374
35.What are the most common compensatory postures for improving oxygenation and ventilation?	374
36.What is orthopnea?	374
37.What is the clinical and physiologic significance of orthopnea?	374
38.Can orthopnea also occur in patients with lung disease?	375
39.And what about patients with COPD?	375
40.What about asthma?	375
41.So, is orthopnea a cardiac or a pulmonary sign?	375
42.Can orthopnea be encountered in patients with neither cardiac nor pulmonary disease?	375
43.What is PND?	375
44.What is the mechanism of relief in PND?	375
45.Can PND be seen in pulmonary patients, too?	376
46.What is platypnea?	376
47.What is the clinical significance of platypnea?	376
48.What is trepopnea?	376
49.What is the physiology behind trepopnea?	376
50.What are some of the disease processes associated with trepopnea?	376
51.Are there any contraindications to lying with the \"good\" lung down?	376
(3)Abnormalities in the Use of Respiratory Muscles	377
52.What are these?	377
53.What is abdominal paradox?	377
54.What is the best way to detect abdominal paradox?	377
55.Are patients with abdominal paradox orthopneic?	377
56.How clinically valuable is this maneuver in predicting respiratory failure?	377
57.What is asynchronous breathing?	377
58.What is respiratory alternans?	377
59.How is respiration in patients with peritonitis?	377
(4)Asymmetry in Thoracic Expansion	378
60.Can inspection identify an asymmetry in thoracic expansion?	378
61.What is the best way to identify a thoracic asymmetry by inspection alone?	378
(5)Abnormalities of the Chest Cage	378
62.What type of information about the chest cage should be gathered through inspection?	378
63.What are the main chest cage abnormalities?	378
Abnormalities of the Spinal Column	378
64.Which spinal abnormalities can be detected by inspection?	378
65.What abnormalities may be seen on the sagittal plane?	378
66.What abnormalities may be seen on the frontal plane?	378
67.What is kyphoscoliosis?	378
68.Is physical exam the best way to assess kyphoscoliosis?	379
69.What are the most common causes of kyphoscoliosis?	379
70.What is a gibbus?	380
71.What are the consequences of these spinal column abnormalities?	380
Abnormalities of the Sternum	380
72.What are the two most common abnormalities of the sternum?	380
73.What is a funnel chest?	380
74.How common is pectus excavatum?	380
75.When does a funnel chest become recognized?	381
76.What are the symptoms of a funnel chest?	381
77.What is a pigeon chest?	381
78.What are the clinical consequences of a pigeon chest?	381
79.What can be done to correct these conditions?	381
Abnormalities of the Ribs	382
80.What rib abnormalities can be detected on inspection?	382
81.What is the normal slope?	382
82.How is the rib slope modified by disease?	382
83.What is a barrel chest?	382
84.How good is the interobserver reliability for the detection of this abnormality?	382
85.How are the physiologic consequences of a barrel chest?	382
86.What is the clinical significance of a barrel chest?	382
87. What are the most common abnormalities in rib shape?	382
88.What is the Harrison's groove?	382
89.What is Hoover's sign?	382
90.What is the normal behavior of the lower rib cage during inspiration?	383
91.Is this paradoxical inward movement also affecting the sternum?	383
92.What is the pathophysiology of Hoover's sign?	383
93.Are there any other disease states characterized by Hoover's sign?	383
94.What is Hoover's groove?	383
95.What is the clinical and prognostic significance of Hoover's sign in COPD?	383
96.What is the diagnostic accuracy and observer agreement for Hoover's sign?	383
97.Who was Hoover?	384
98.Are there any other bony abnormalities that should be observed?	384
(6)Abnormalities of the Chest Surface	384
99.Why is it important to observe the characteristics of the chest surface?	384
(7)Abnormalities of Extremities and Neck Veins	384
100.Which respiratory findings can be detected on the extremities?	384
Clubbing	385
101.What is digital clubbing?	385
102.What is the history of this finding?	385
103.Is clubbing painful?	385
104.Is clubbing limited to fingers?	385
105.Which are the causes of \"differential\" clubbing?	385
106.What is the cause of unilateral clubbing?	385
107.What are the diagnostic features of clubbing?	385
108.Is ballotability of the nail an exclusive indication of clubbing?	387
109.How quickly can these changes occur?	387
110.Is increased curvature of the nail a sign of clubbing?	387
111.What is a drumstick finger?	387
112.What is Schamroth's sign?	388
113.What is the clinical significance of clubbing?	388
114.What is the pathogenesis of clubbing?	388
115.What about congenital clubbing?	389
116.What is pseudoclubbing?	389
Hypertrophic Osteoarthropathy (HOA)	390
117.What is digital clubbing with periostosis?	390
118.Which bones are most prominently affected by the periostosis of HOA?	390
119.What is the boundary between HOA and clubbing?	390
120.Is HOA symptomatic?	390
121.How is the diagnosis of HOA established?	390
122.What is primary HOA?	391
123.What is pachydermoperiostosis?	391
124.What is cutis verticis gyrata (CVG)?	391
125.What is thyroid acropachy?	391
Inspection of the Neck	391
126.What respiratory information can be gathered through neck inspection?	391
127.Which areas should be paid attention to?	391
128.What should be noted about the accessory muscles of respiration?	391
129.What are the most important of these accessory muscles?	392
130.What is the physiology of these muscles?	392
131.What about inspiratory retractions of the suprasternal and supraclavicular fossa?	392
132.What about accessory expiratory muscles?	392
133.Which neck vein abnormalities may provide clues to the diagnosis of lung disease?	392
B.Chest Palpation	393
134.What is the clinical value of palpation?	393
135.What are the main components of palpation?	393
Assessment of the Trachea	393
136.How do you assess the trachea?	393
137.What is the value of a tracheal shift?	393
138.How do you detect a tracheal deviation?	393
139.What are the possible causes of a tracheal shift?	394
140.How can one distinguish tracheal deviation of lung collapse from that of effusion?	394
141.How do you assess for mobility of the trachea?	394
142.What is Oliver's sign?	394
143.What is Cardarelli's sign?	394
144.What is Campbell's sign?	394
145.What are laryngeal height and laryngeal descent?	395
146.What is the value of laryngeal height?	395
147.What is the value of tracheal auscultation?	395
Assessment of the Vocal Tactile Fremitus	396
148.What is the vocal tactile fremitus (VTF)?	396
149.What is the clinical value of the VTF?	396
150.Can any disease increase the VTF?	396
151.How good is agreement for VTF among physicians?	397
Assessment of Expansion of Hemithoraces	397
152.What is the role of palpatory assessment of hemithoracic expansion?	397
153.How do you assess hemithoracic expansion?	397
Other Goals of Palpation	397
154.What are the other goals of palpation?	397
C.Chest Percussion	397
155.How valuable is percussion?	397
156.What is the history of percussion?	397
157.Who was Auenbrugger?	398
158.What is the physics behind percussion?	398
Percussion Techniques	399
159.What is \"direct\" percussion?	399
160.What is the current role of direct percussion?	400
161.What is mediated or \"indirect\" percussion?	400
162.What is the current technique for indirect percussion?	400
163.What is the current value of indirect percussion?	400
164.Are there differences between the percussion note of lung collapse from effusion and consolidation from pneumonia?	401
165.What is the current role for topographic percussion?	401
166.What is auscultatory percussion?	401
167. Is there a role for auscultatory percussion in the detection of pleural effusion?	401
Selected Bibliography	402
Chapter 14: Lung Auscultation	404
Generalities	404
1.Who invented lung auscultation?	404
2. How do modern stethoscopes differ from Laeumlnnec's original cylinder?	405
3.In addition to issues of nomenclature, why is pulmonary auscultation difficult?	405
4.How high is the interobserver variability of chest auscultation?	405
5.What are lung sounds?	406
6.What are the major types of lung sounds (respiratory sounds)?	406
7.How are lung sounds produced?	406
A.Breath Sounds (Basic Lung Sounds)	406
8.What are breath sounds?	406
9.What are the major types of breath sounds?	406
10.What is the air movement responsible for the production of breath sounds?	406
11.How are breath sounds produced?	409
12.Can breath sounds be heard over both the chest and mouth?	409
13.Are breath sounds at the chest different from those at the mouth?	409
14.What are the acoustic characteristics of breath sounds at the mouth?	409
15.What is the value of comparing breath sounds at the mouth with those at the chest?	409
16.How do breath sounds at the mouth get produced?	410
17.Are there differences in intensity of breath sounds between the various types of airflow obstruction?	410
18.Are there any other unique breath sounds' characteristics in patients with chronic bronchitis?	410
19.How accurate is auscultation in identifying patients with chronic bronchitis?	411
20.Should patients with suspected chronic bronchitis be asked to cough during exam?	411
(1) Tubular Versus Vesicular Breath Sounds	411
21.What are tubular breath sounds?	411
22. What are the main characteristics of tubular breath sounds?	411
23.Which of these characteristics is the most important?	411
24.What is the clinical significance of tracheal breath sounds?	412
25.What happens to tracheal sounds once they enter the chest?	412
26.What are the three characteristics of vesicular breath sounds?	412
27.Why are these sounds called vesicular?	412
28.What is the clinical significance of vesicular breath sounds?	412
29.Is the ability of the lung to act as a high-frequency filter a constant phenomenon?	412
30.What are the acoustic differences between bronchial and vesicular breath sounds?	412
31.What is the most striking physical characteristic of bronchial breath sounds?	412
32. What is the clinical significance of tubular breath sounds?	413
33. Where are vesicular breath sounds produced?	413
34.Are there acoustic differences in vesicular breath sounds between inspiration/expiration?	413
35.Do vesicular breath sounds change with age?	413
36.Why does this happen?	413
37.Are vesicular breath sounds normally heard throughout the chest?	413
38.What are the breath sounds characteristics of patients with pneumothorax?	414
39.Is the intensity of vesicular breath sounds important?	414
40.Is the intensity of breath sounds in airflow obstruction equally diminished at the mouth?	414
41.What is the best bedside predictor for the presence of chronic obstructive lung disease?	414
42.How can one objectively measure breath sounds' intensity at the bedside?	414
43.How good is interobsever reliability for BSI determination?	415
44.In addition to airflow obstruction, is there any other process associated with distant breath sounds?	415
45.Can a change in lung sounds' intensity help monitor patients' response to airway challenge?	415
46.What is the mechanism of decreased BSI in COPD?	416
47.How does BSI compare to other bedside findings of airflow obstruction?	416
48.What is the best bedside predictor for severity of airflow obstruction?	416
49.Is there any finding that argues against the presence of COPD?	416
(2)Bronchial Breath Sounds	416
50.Are bronchial breath sounds (BBS) ever \"physiologic\"?	416
51.How are bronchial breath sounds produced?	416
52.What is the cause of this improved transmission?	416
53.How deep should the consolidation be in order to generate bronchial breath sounds?	417
54.Can one separate bronchial sounds of fluid-filled alveoli from those of collapsed alveoli?	417
55.What is a common reason for bronchial breath sounds unaccompanied by crackles?	417
56.Other than consolidation, do bronchial breath sounds indicate anything else?	417
57.Bronchial breath sounds can indicate tamponade and mitral stenosis?	417
58.Who was Ewart?	417
(3) Amphoric Breath Sounds	418
59.What are amphoric breath sounds?	418
(4)Bronchovesicular Breath Sounds	418
60.What are bronchovesicular breath sounds?	418
61.What are the three acoustic characteristics of bronchovesicular breath sounds?	418
62.What is the clinical significance of bronchovesicular breath sounds?	418
B.Adventitious Lung Sounds	419
63.What are adventitious lung sounds?	419
64.How were these sounds first described?	419
65.When was the classification of adventitious lung sounds revised?	419
66.What were the recommendations of the 1977 classification?	419
67.So how should crackles be described?	419
68.How much has this terminology been implemented?	421
69.How are adventitious lung sounds produced?	421
(1)Discontinuous Adventitious Lung Sounds	422
70.What are discontinuous adventitious lung sounds (DALs)?	422
71.How useful are crackles?	422
72.What do crackles sound like?	423
73.What is the underlying breath sound of crackles?	424
74.How do crackles get produced?	424
75.What are the characteristics of early and mid-inspiratory crackles?	425
76.What are the characteristics of late-inspiratory crackles?	425
77.Are there any regional preferences for late-inspiratory crackles?	425
78.Can crackles occur in normal people?	425
79.What should one do at the bedside when confronted with crackles?	425
80.Summarize the characteristics of early, mid-inspiratory, and late-inspiratory crackles.	425
81.How good is interobserver agreement for crackles?	426
82.Are the crackles of pulmonary fibrosis limited to late inspiration?	426
83.Are late-inspiratory crackles present in all interstitial lung disease?	426
84.Why are crackles so rare in sarcoidosis but so common in other fibrotic lung diseases?	426
85.How common are crackles in asbestosis?	426
86.Where are asbestosis crackles localized?	427
87.Is there a correlation between the number of crackles and disease severity?	427
88.Are crackles common in patients with idiopathic pulmonary fibrosis (IPF)?	427
89.Is there a correlation between late-inspiratory crackles and severity of IPF?	427
90.Can crackles occur in exhalation?	427
91.What is the mechanism of production of late-expiratory crackles?	428
92.What is the clinical significance of expiratory crackles?	428
(2)Special Problem-Pneumonia	428
93.What are the traditional findings of pneumonia?	428
94.What is the time course of these findings?	428
95.What about the presence of diminished breath sounds?	428
96.What are the most valuable bedside predictors in pneumonia patients?	428
97.Is there any diagnostic clue that may suggest pneumonia in ambulatory patients?	429
98.What are the characteristics of crackles in pneumonia?	429
99.What about crackles of congestive heart failure (CHF)?	429
(3)Special Problem-Posturally Induced Crackles (PICs)	429
100.What are posturally induced crackles (PICs)?	429
101.What's the best way to elicit PICs?	429
102.How should this maneuver be interpreted?	430
103.What is the clinical significance of PICs?	430
104.Do PICs represent an independent variable?	430
(4)Continuous Adventitious Lung Sounds (CALS)	430
105.What are continuous adventitious lung sounds?	430
106.How long should these sounds be in order to qualify as \"continuous\"?	431
107.What are the physical characteristics of CALs?	431
108.What are monophonic and polyphonic CALs?	431
109.If a polyphonic CAL may have more than one frequency, how does one determine its pitch?	431
110.How are wheezes produced?	431
111.What is the physical principle behind this mechanism?	432
112. Is the pitch of a wheeze related to its site of production?	432
113. How are CALs classified?	432
114.What are the causes of a late-inspiratory squeak?	433
115. How are CALs graphically represented?	433
116. What are the most common causes of airway narrowing responsible for wheezes?	433
117. Does the presence of wheezing rule in bronchial narrowing?	433
118. What are the underlying breath sounds of asthmatic patients?	434
119.Asthmatics have breath sounds of lower intensity?	434
120.Are there any wheeze characteristics that correlate with the degree of airflow obstruction?	434
121.So how can wheezing help assess the severity of airflow obstruction?	434
122.How does one express the length of a wheeze?	434
123.What are then the acoustic characteristics of a resolving asthma attack?	434
124.Summarize the time course of status asthmaticus based on auscultation.	434
125.How sensitive and specific are wheezes for the diagnosis of airflow obstruction?	435
126.What about pulsus paradoxus?	435
127.And how about diaphoresis and orthopnea in asthma?	435
128.What is the differential diagnosis of wheezes?	435
129.What is cardiac asthma?	435
130.What about wheezes over the neck?	435
(5)Stridor	436
131.What is stridor?	436
132.Are there any acoustic differences between wheezes and stridor?	436
133.What is the time course of stridor due to posttracheostomy tracheal stenosis?	436
(6)Pleural Rub	437
134.What is a pleural rub?	437
135.What does a rub sound like?	437
136.Are rubs inspiratory or expiratory?	437
137.How can one differentiate rubs from crackles?	437
138.How can one differentiate rubs from wheezes?	437
139.How can one separate pleural from pericardial rubs?	437
140.What is the natural history of a pleural rub?	437
141.What is the histology underlying a pleural rub?	437
142.What are the most common causes of a pleural rub?	438
143.What are the physical characteristics of a rub?	438
C.Transmitted Voice Sounds	438
144.What are transmitted voice sounds? Why are they important?	438
145.What are the most important transmitted voice sounds?	438
146.Is there any magic word that one should ask patients to say in order to elicit these sounds?	439
147.What is the significance of these maneuvers?	439
148.Are the bronchi of patients with abnormally transmitted voice sounds open or closed?	439
149.When should one check for the presence of these sounds?	439
150.How do voice sounds get produced and transmitted?	439
151.Who first described egophony?	439
152.Who came up with the idea of asking patients to say \"E\"?	440
153.What is the mechanism behind E-to-A changes?	440
154.What are the most common causes of extensive consolidation?	440
155.How does consolidation transform an \"E\" into an \"A\"?	440
156.What is the mechanism of production for whispered pectoriloquy?	441
157.What breath sounds accompany these transmitted voice sounds?	441
158.What is the radiologic equivalent of abnormally transmitted voice sounds?	441
159.What is the most useful of all these transmitted voice sounds?	441
160.Summarize disease processes associated with lung auscultation findings.	441
Selected Bibliography	443
Chapter 15:The Abdomen	445
Generalities	445
A.The Abdominal Wall	445
(1)Inspection	445
1.Outline the topographic divisions of the abdomen.	x
I.Evaluation of the Abdominal Contour	205
2.What are the most important contours of the abdomen?	205
3.What are the most important contours on lateral inspection?	205
II.Evaluation of the Umbilicus	446
4.What are the major abnormalities of the umbilicus?	446
5.What are the most common protuberances?	447
6.What is an eversion of the umbilical scar?	447
7.What is Sister Mary Joseph's nodule?	207
8.What is the significance of a purplish discoloration of the umbilicus?	447
9.What are the most common vertical shifts of the umbilicus?	447
10.What other important points should be included in the inspection of the abdominal wall?	448
III. Abdominal Respiratory Motion	208
11.How should the abdominal wall behave during normal respiration?	448
IV.Abnormal Skin Markings	448
12.What kind of skin markings can be seen on the abdominal wall?	448
13.What are ecchymoses?	448
14.What are striae?	449
15.What about surgical scars?	449
V.Abnormal Venous Patterns	449
16.What are the collateral venous circulations of the abdominal wall?	449
17.How can you distinguish them?	449
18.How can you assess the direction of blood?	450
19.What is caput medusae?	450
20.Who was Medusa?	451
(2)Auscultation	451
21.What is the value of abdominal auscultation?	451
Bowel Sounds	451
22.Should bowel sounds be pursued before or after palpating/percussing the abdomen?	451
23.Where are these bowel sounds produced?	451
24.Is the abdominal location indicative of the production site?	451
25.What causes these sounds?	451
26.What is the significance of increased bowel sounds?	451
I.Murmurs and Bruits	452
27.What is the difference between an abdominal murmur and a bruit?	452
28.How frequent are these findings?	452
29.What is the significance of an abdominal murmur/bruit?	452
30.What is the significance of an epigastric murmur?	452
31.What is the significance of a right or left upper quadrant murmur/bruit?	452
II.Venous Hums	452
32.What is the significance of a venous hum?	452
33.What is the mechanism of production of this sound?	453
34.What are Cruveilhier-Baumgarten disease and Cruveilhier-Baumgarten syndrome?	453
35.Who were these guys?	453
III.Friction Rubs	453
36.What is the significance of friction rubs?	453
IV.Succussion Splash	453
37.What is a succussion splash?	453
(3)Percussion	454
38.What is the value of abdominal percussion?	454
39.How should one percuss?	454
(4)Palpation	454
40.How should the abdomen be palpated?	454
41.What is the difference between a light and a deep palpation?	454
42.How can one distinguish between an intra-abdominal and an intramural mass?	454
Examples of Abnormalities Detectable On Palpation	455
43.How can one detect an abdominal aortic aneurysm?	455
44.When is this maneuver considered positive?	455
B.Liver	455
45.What are the two goals of bedside evaluation of the liver?	455
(1)Palpation of the Liver	455
46.Which edge can be palpated? How?	455
47.What can be learned from palpation of the liver?	456
48.How reliable is palpation of the liver edge as a measure of hepatic consistency?	456
49.What is the significance of liver tenderness?	456
50.What is the significance of a firm and hard liver edge?	457
51.What is the significance of a pulsatile liver edge?	457
52.How can one distinguish these two entities?	457
53.What is the hepatojugular reflux?	457
(2)Percussion of the Liver	457
54.Is assessment of liver size another goal of palpation?	457
55.Does a palpable liver edge reflect hepatomegaly?	457
56.Should the lower liver edge then be assessed by percussion alone?	458
57.So what is the best way to determine liver size on physical exam?	458
58.How can one best determine hepatic size by percussion?	458
59.What is a normal liver span?	458
60.What is the scratch test?	458
61.How reliable is the scratch test in localizing the lower liver edge?	459
62.How accurate are these bedside techniques in diagnosing hepatomegaly?	459
63.In summary, what are the pros and cons of bedside assessment of liver size?	459
(3)Auscultation of the Liver	460
64. What is the role of auscultation of the liver?	460
I. Hepatic Friction Rubs	460
65. What is the significance of hepatic friction rubs?	460
II. Hepatic Arterial Murmurs	460
66. What is the significance of an arterial murmur over the liver?	460
67. What is the significance of a hepatic murmur associated with a rub?	460
III. Hepatic Venous Hums	460
68. What is the significance of a hepatic venous hum?	460
69. How can one differentiate a venous hum from an arterial murmur?	460
(4)Special Problems	461
70What is jaundice?	461
71.Is there any diagnostic difference in the hue of pigmentation?	461
72.How can you separate obstructive from hepatocellular jaundice?	461
73.What are spider nevi (telangiectasias)?	461
74.Can spider nevi occur in normal individuals?	461
75.What is the hepatopulmary syndrome (HPS)?	462
76.What is palmar erythema?	462
77.What is Dupuytren's contracture?	462
78.Who was Dupuytren?	463
79.What is asterixis?	464
80.What is fetor hepaticus?	464
81.What other physical findings can be encountered in patients with portal hypertension?	464
C.Gallbladder	464
82.What is Murphy's sign?	464
83.What are Murphy's signs?	464
84.Who was Dr. Murphy?	465
85.How accurate is Murphy's sign in predicting cholecystitis?	465
86.What is the current role of Murphy's sign in the evaluation of acute cholecystitis?	465
87.What is the sonographic Murphy's sign?	466
88.Do patients with cholecystitis exhibit other findings?	466
(2)Courvoisier's Law	466
89.What does Courvoisier's law state?	466
90.Why should the gallbladder of patients with cholelithiasis remain small?	466
91.How accurate is Courvoisier's law?	466
92.In the final analysis, what is the significance of Courvoisier's sign?	466
93.Is right upper quadrant tenderness indicative of cholelithiasis?	467
94.Who was Courvoisier?	467
D.The Spleen	467
95.How effective is abdominal examination in assessing the spleen?	467
(1)Palpation of the Spleen	467
96Is there any contraindication to palpating the spleen?	467
97What can be learned from palpation?	467
98What is the best way to palpate the spleen?	467
99.If the splenic tip is palpable, can you conclude that the spleen is enlarged?	468
100.Does lack of a palpable spleen rule out splenomegaly?	469
101.How accurate are these bedside maneuvers in diagnosing splenomegaly?	469
102.Which other findings may help identifying the cause of splenomegaly?	469
103.What is Kehr's sign?	469
(2)Percussion of the Spleen	469
104.How do you percuss the spleen?	469
105.Who was Traube?	470
106.What are the limitations of percussion in detecting splenomegaly?	470
107.What are the recommendations for the bedside assessment of spleen size?	471
108.What are the technologic alternatives for assessing the spleen?	471
109.Summarize bedside and technology-based methods of assessing splenomegaly.	472
(3)Auscultation of the Spleen	472
110.What is the role of auscultation of the spleen?	472
E.The Stomach	472
111.What is the role of physical diagnosis in assessing the stomach?	472
112. What maneuvers can be used to test for gastric retention?	473
113. What is clapotage?	473
114. What is a succussion splash?	473
115.Is there any role for auscultating the stomach?	473
F.The Pancreas	473
116.What is the role of physical diagnosis in assessing the pancreas?	473
G.\x0BThe Kidneys	474
117.What is the best way to assess renal size?	474
118.What is the value of testing for costophrenic tenderness?	474
119.How do you percuss the costophrenic angle?	474
120.What is the thumb pressure test?	474
121.What are the physical findings of a renal colic?	474
(1)Auscultation of the Kidneys	474
122.What is the role of renal auscultation?	474
123.What is the significance of anterior bruits?	475
H.The Urinary Bladder	475
124.What is the main purpose of physical diagnosis in assessing the urinary bladder?	475
125.Is the urinary bladder palpable?	475
126.What is \"subjective\" palpation of the bladder?	475
127.How accurate is this technique?	475
128.What is the physical diagnosis gold standard for detecting a full bladder?	475
129.How accurate is auscultatory percussion?	476
130.How accurate is plain percussion in diagnosing a full bladder?	476
I.Ascites (DROPSY)	476
131.How useful is physical diagnosis of ascites?	476
132.What is ascites?	476
133.What are the best tools for diagnosing ascites?	476
134.What are the causes of ankle edema in ascites?	477
135.What is the role of physical diagnosis in assessing ascites?	477
136.What bedside maneuvers may be used to detect ascites?	477
137.What are bulging flanks?	477
138. How does one percuss for flank dullness?	477
139.How is the shifting-dullness maneuver performed?	477
140.How accurate is this test?	477
141.How is the fluid-wave maneuver performed?	477
142.How reliable is this test?	478
143.What is the ballottement (or dipping) maneuver?	478
144.What is the puddle sign? How is it elicited?	478
145.What is the Guarino's variation?	479
146.What is the overall accuracy of these signs for ascites?	479
147.How can one improve the diagnostic accuracy of these maneuvers?	479
148.What is the role of the Bayes' theorem in diagnosing ascites at the bedside?	479
J.The Acute Abdomen (Peritoneal Signs)	480
149.Summarize the role of physical examination in patients with peritonitis.	481
150.What are the most commonly used maneuvers for the bedside evaluation of peritonitis?	481
151.What is guarding?	481
152.What is the significance of \"localized\" rigidity?	481
153.What is \"induced guarding\"? How can it be triggered?	481
154.What is Carnett's sign?	481
155. What is abdominal wall tenderness (AWT)?	481
156. What is the significance of a positive abdominal wall tenderness?	482
157. What are the causes of abdominal wall tenderness?	482
158. Does the AWT maneuver have limitations?	482
159. When should one use the AWT maneuver?	482
160. How accurate is the modified induced guarding technique (AWT)?	482
161. What is rebound tenderness?	482
162.Who was Blumberg?	483
163.What is the referred rebound tenderness test?	483
164.What is a cough test?	483
165.What is jar tenderness?	483
166.What is the role of a Valsalva maneuver in patients with acute abdomen?	483
167.What is the stethoscope sign?	483
168.How reliable is this sign?	483
169.While performing these maneuvers, should you look at the patient's face or abdomen?	484
170.What is the closed-eyes sign?	484
171. Explain the use and cause of a closed-eyes sign.	484
172. How accurate is the closed-eyes sign in diagnosing nonspecific abdominal pain?	484
173.What is abdominal hyperesthesia?	484
174.How can one detect abdominal hypersensitivity?	484
175.Is abdominal hyperesthesia specific to localized peritonitis?	484
176.What is Boas' sign?	485
177.Who was Boas?	485
K.Special Problems-Appendicitis	485
178.Which maneuvers can be used for evaluating patients with suspected appendicitis?	485
179.What is McBurney's sign?	485
180.Who was McBurney?	485
181.What is Rovsing's sign?	485
182.Who was Rovsing?	486
183.What is the obturator test?	486
184.What is the reverse psoas maneuver?	486
185.What is rectal tenderness?	486
Selected Bibliography	486
Chapter 16:Male Genitalia, Hernias, and Rectal Exam	488
Generalities	488
A. Male Genitalia	488
1. What are the main components of the male reproductive system?	488
2. What is the best technique for examining male genitalia?	488
3.What should I focus on during inspection of this region?	488
(1)Penis	488
4.Describe the anatomy of the penis.	488
5.What steps should I take to properly examine the penis?	488
6.What is priapism?	489
7.What is the pathophysiology of priapism?	491
8.Does priapism involve all erectile tissue?	491
9.What is the cause of priapism?	491
10.And what about drugs?	491
11.What is phimosis?	491
12.Is a phimosis always pathologic?	491
13.What is paraphimosis?	492
14.What are the causes of paraphimosis?	492
15.What is balanoposthitis?	492
16. What are the causes of balanoposthitis?	492
17.What is balanitis?	492
18.What is Reiter's syndrome? What are its manifestations?	493
19.Who was Reiter?	493
20.What about gonococcal urethritis?	493
21.What kind of skin lesions can be seen on the penis?	493
22.How do ulcerating lesions present?	209
23.Describe the ulcerating lesion of primary syphilis.	210
24. Describe the ulcerating lesion of chancroid.	494
25. Describe the ulcerating lesion of granuloma inguinale.	494
26. Describe the ulcerating lesion of lymphogranuloma venereum.	494
27. Which other dermatoses can be transmitted through sexual contact?	494
28. What about multiple ulcerating lesions?	494
29. What are the most important acute multiple ulcerating lesions?	494
30. Describe the multiple ulcerating lesions of secondary syphilis.	495
31. What are aphthous ulcers?	495
32. Describe the multiple ulcerating lesions of herpes simplex.	495
33. Are genital herpetic lesions due to HSV-1 or HSV-2?	495
34. What are the most important chronic multiple ulcerating lesions?	495
35. And what about nonulcerating lesions?	495
36. Describe penile papules. What are the most important lesions of this sort?	495
37. How does lichen planus present on the penis?	496
38. What are the characteristics of penile psoriasis?	496
39. What is molluscum contagiosum?	496
40. And what about genital warts?	211
41. What are condylomata lata?	496
42. What about penile plaques?	212
43. What is Zoon’s balanitis?	497
44. What is the erythroplasia of Queyrat?	497
45. What about squamous cell carcinoma of the penis?	497
46. What is lichen sclerosus et atrophicus?	497
47. What is Peyronie’s disease (PD)?	497
48. Who was Peyronie?	498
49. Define hypospadias and epispadias.	498
(2)Scrotum	498
50. Describe the anatomy of the scrotum.	498
51. Which scrotal abnormalities can be identified through inspection?	498
52. What are Fordyce lesions ?	499
53. What are Fordyce spots?	499
54. What are the causes of scrotal swelling?	499
55. What is a varicocele?	499
56. What are the normal characteristics of testes and epididymides?	500
57. How should the testes and epididymides be examined?	500
58. What is transillumination of a scrotal mass?	500
59. What is a hydrocele?	500
60. What is a spermatocele?	501
61. What is cryptorchidism?	501
62. What about small testes?	501
63. What are the causes of an enlarged and solid testis?	501
64. What are the causes of a tender epididymis?	501
B.Hernia Examination	501
65. What are the two possible sites of groin hernias?	501
66. What is the best way to detect ahernia?	502
67. How do you separate indirect from direct inguinal hernias?	503
70. Are hernias painless?	503
71. How large are inguinal hernias?	503
72. What is Zieman’s tridigital examination for hernia?	503
C.Digital Rectal Examination (DRE)	503
73. What is the role of the digital rectal exam?	503
74. Is it routinely performed?	503
75. Is the rectal exam performed with the patient standing or in the lateral decubitusposition?	504
76. What are the steps to follow in a rectal exam?	504
77. What perianal findings can be detected by rectal examination?	504
78. How do you assess a reduced sphincter tone? What is its significance?	504
79. What characteristics of the prostate should you assess?	505
80. What causes prostatic nodules?	505
81. What causes a tender prostate?	505
82. What does the normal prostate look like?	505
83. What is the diagnostic value of DRE in primary care screening for cancer?	505
84. What are the limitations of DRE for the screening of prostatic cancer?	505
85. How about the effectiveness of DRE for the detection of colorectal cancer?	505
86. Should rectal exam be deferred in patients with a myocardial infarction?	506
Selected Bibliography	506
Chapter 17:Female Genitalia and the Pelvis	507
1. What is the role of the pelvic exam?	507
2. How can I make my patient as comfortable as possible during the pelvic exam?	507
3. When should a chaperone attend the pelvic exam?	507
4. What circumstances can make pelvic exams difficult for women?	507
5. What are some techniques that can assist you in a difficult exam?	508
6. Who is qualified to perform a pelvic exam for sexual assault victims?	508
7. What are the tools needed for a pelvic exam?	508
8. What are the components of the pelvic exam?	509
A.Inspection/Palpation of External Genitalia: Vulva and Perineum	509
9. What is the anatomy of the vulva?	509
10. What should you look for in the external genitalia?	509
11. Where are the openings of Skene’s (paraurethral) glands?	509
12. Who was Skene?	509
13. What important information can be gained by inspecting the vulva?	509
14. What is the female escutcheon?	509
15. What are Tanner’s stages of sexual maturation?	509
16. What is the differential diagnosis of enlarged inguinal nodes?	510
17. What is the significance of white vulvar lesions?	510
18. What are the benign white lesions of the vulva?	510
19. What are the most common premalignant white lesions?	510
20. What are malignant white lesions?	511
21. What are other vulvar malignancies?	511
22. What is the differential diagnosis of a painful vulvar ulceration?	511
23. What is the differential diagnosis of a painless vulvar ulceration?	511
24. What is a labial hernia?	511
25. Where are Bartholin’s glands located?	511
26. How do you examine them?	511
27. What is the differential diagnosis of a mass or swelling of theBartholin’s gland?	511
28. Who was Bartholin?	511
29. What is the hymen? What are the myths surrounding it?	512
30. What is an imperforate hymen?	512
31. What is the normal size of the glans clitoris?	512
32. What is the clitoral index (CI)? How do you calculate it?	512
33. What is the appearance of the clitoris and vulva in congenital adrenalhyperplasia?	512
34. What is congenital adrenal hyperplasia?	512
35. What should one look for when inspecting the labia?	513
36. What are condylomata lata?	513
37. What are condylomata acuminata?	513
38. How does genital herpes simplex present?	513
B.Examination With Speculum-The Vagina	513
39. What is a speculum?	513
40. What are Pedersen’s and Graves’? What are their differences?	513
41. How do you insert the speculum?	513
42. When do you withdraw the speculum? How?	514
43. What is a colpocele?	514
44. What is a cystocele? How can you detect it?	514
45. What is a rectocele? How can you detect it?	514
46. What are the clues to the presence of a rectovaginal fistula?	514
47. What is Chadwick’s sign?	514
48. Who was Chadwick?	514
49. What is diethylstilbestrol (DES)? What is the vaginal appearance of women withprenatal exposure to it?	515
50. What is a Gartner’s duct cyst?	515
51. Who was Gartner?	515
52. What is the normal vaginal pH?	515
53. What is the significance of tenderness in the vaginal fornices?	515
C.Examination With Speculum-The Cervix	515
54. What is the best way to visualize the cervix?	515
55. How does a normal nonparous cervix appear?	515
56. What are endocervical polyps? What is their significance?	515
57. What is the cause of cervical duplication?	515
58. What is the squamocolumnar junction?	516
59. What is a Pap smear? What is the best way to obtain it?	516
60. Which patients benefit from regular Pap smear screening?	516
61. Who was ‘‘Pap’’?	516
62. What is the significance of a purulent cervical discharge?	516
63. What is the significance of cervical motion tenderness?	516
64. What additional laboratory tests should be obtained from the cervix?	516
D.Bimanual Palpation-The Uterine Corpus	516
65. What is the normal shape and location of the uterus?	516
66. What is the best way to examine the uterus?	517
67. What is Goodell’s sign?	517
68. Who was Goodell?	517
69. What is Hegar’s sign?	517
70. What is the difference between uterine retroversion and retroflexion?	517
71. What is uterine prolapse?	517
72. What is fundal height? How does it change with weeks of gestation?	517
73. What are Leopold’s maneuvers?	518
74. Who were Hegar and Leopold?	518
75. What are leiomyomata?	518
76. Are ‘‘fibroids’’ ever malignant?	518
E. Bimanual Palpation-The Adnexa	518
77. What are the adnexa?	518
78. When do you examine them?	518
79. How large are the ovaries?	519
80. What is the differential diagnosis of adnexal masses?	519
81. What is the differential diagnosis of adnexal tenderness?	519
82. What are the physical characteristics of malignant ovarian tumors?	519
F.Bimanual Palpation-The Cul-DE-Sac	519
83. What is the cul-de-sac?	519
G.Rectovaginal Palpation	519
84. What is rectovaginal palpation?	519
85. What is the role of rectovaginal examination?	519
86. When is the rectovaginal exam carried out?	519
Acknowledgment	520
Selected Bibliography	520
Chapter 18:Lymph Nodes	521
A.General Considerations	521
1.Which nodes are normally palpable in the healthy individual?	521
2.What is lymphadenopathy?	521
3.How many adenopathies turn out to be \"bad\"?	521
4.What is the first approach to adenopathy?	521
5.What is a generalized adenopathy?	521
6.Where should you look for enlarged nodes?	522
7.Which parts of the exam should be emphasized in cases of generalized adenopathy?	522
8.What is the differential diagnosis of a generalized adenopathy?	522
9.Should a biopsy be done in patients with generalized lymphadenopathy?	522
10.Which is more common, localized or generalized adenopathy?	523
11.Can the region of involvement narrow the diagnosis?	523
12.Should one know the regions drained by the various lymphonodal stations?	523
13.What are the general characteristics that can help interpret an abnormal node?	523
14.Why does the patient's age help?	523
15.What about associated signs and symptoms?	523
16.What about splenomegaly?	523
17.What about fever?	525
18.Are there any epidemiologic clues that might narrow the differential diagnosis?	525
19.Which node characteristics can be clinically helpful?	525
20.What is the best way to deal with adenopathy?	528
21.What is unexplained lymphadenopathy?	528
22.What is the differential diagnosis of an unexplained lymphadenopathy?	528
23.Which clinical presentations may help identify the cause of lymphadenopathy?	529
B.Cervical and Supraclavicular Nodes	529
24.How do you palpate cervical nodes?	529
25.What are the important head and neck stations?	529
26.And so, what is the overall significance of cervical lymphadenopathy?	530
27.Can cervical nodes remain permanently enlarged after an infection?	531
28.What are \"shotty\" nodes?	531
29.What is scrofula?	531
30.What are Delphian nodes?	531
31.What is the clinical significance of a palpable supraclavicular node?	532
32.What is Troisier's node? What is its significance?	532
33.Who was Troisier?	532
34.What is Virchow's node?	532
35.Who was Virchow?	532
36.What is the best way to palpate a supraclavicular node?	533
C.Upper Extremity Nodes	533
37.What is the best way to search for axillary nodes?	533
38.What is the clinical significance of axillary adenopathy?	533
39.How do you palpate an epitrochlear node?	534
40.What is the significance of epitrochlear nodes?	534
D.Lower Extremity Nodes	534
41.What is the significance of inguinal adenopathy?	534
42.What is the node of Rosenmuumlller-Cloquet?	534
43.How significant is a femoral lymphadenopathy?	534
44.What is the significance of popliteal lymphadenopathy?	534
E.Abdominal Nodes	535
45.What is Sister Mary Joseph's nodule?	535
46.Who was Sister Mary Joseph?	535
Selected Bibliography	535
Chapter 19:The Neurologic System	536
Generalities	536
1.What is the purpose of the neurologic exam?	536
2.What are the most important components of the neurologic exam?	536
A.Mental Status Examination	537
3.What is dementia?	537
4.What are frontal release signs?	537
5.What are the snouting, rooting, and sucking reflexes?	537
6.What is the palmomental reflex?	537
7.What is the glabellar reflex?	537
8.How do you separate \"normal\" primitive reflexes from the pathologic ones?	538
9.How long does it take to do a complete mental status examination?	538
10.What are the most important levels of consciousness? How do they deteriorate?	538
11.What is orientation? How do you assess it?	538
12.What is memory? How do you assess it?	538
13.How do you assess attention and calculation?	538
14.How can one efficiently examine all aspects of mental status?	538
15.How reliable is the MMSE in assessing cognitive function?	538
16.What is the clock-drawing test?	538
17.How do you test for delirium?	539
18.What is intelligence? How do you test it?	539
(1)Language	539
19.What are the components of language? How do you assess them?	539
20.What is dysphonia?	539
21.What is dysarthria?	539
22.What is cerebellar speech?	539
23.Beside cerebellar speech, what are the two most important types of dysarthria?	539
24.What is aphasia?	540
25.What are the most important defects in aphasia?	540
26.What are the clinical differences between fluent and nonfluent aphasia?	540
27.Summarize the common aphasias.	540
28.Who was Broca?	540
29.Who was Wernicke?	541
30.What is perserveration?	541
31.What is cortical dementia? What is subcortical dementia?	541
32.What is dyspraxia?	541
33.What is agnosia?	541
B.Cranial Nerves Examination	542
34.What is the role of cranial nerve examination?	542
35.How do you test CN I (olfactory nerve)?	542
36.How do you test CN II (optic nerve)?	542
37.How do you test CN III, IV, and VI?	542
38.What abnormal eye movements result from damage to CN III, IV, or VI?	542
39.How do you test CN V (trigeminal nerve)?	543
40.Where are the sensory and motor nuclei of the trigeminal nerve?	543
41.How do you test the sensory function of CN V?	543
42.How do you test the motor function of CN V?	544
43.What are the manifestations of trigeminal motor deficit?	544
44.What is the significance of unilateral trigeminal motor deficit?	544
45.What is the significance of a sensory deficit of the trigeminal nerve?	544
46.What is Hutchinson's sign?	544
47.What is the jaw-jerk reflex?	544
48.How do you test CN VII (facial nerve)?	544
49.What determines the difference between central and peripheral lesions of the VII?	544
50.What are the signs of central lesions of the facial nerve?	544
51.What are the signs of peripheral lesions of the facial nerve?	545
52.Are there any other functions of CN VII that can be affected?	545
53.What about ptosis?	545
54.What is Bell's palsy?	545
55.What are the causes of Bell's palsy?	546
56.What is Bell's phenomenon?	546
57.Who was Bell?	546
58.What is the corneal reflex?	546
59.What is the significance of an abnormal corneal reflex?	546
60.How do you test CN VIII (acoustic/vestibular nerve)?	547
61.How do we maintain balance?	547
62.How do you perform the Romberg test?	547
63.Who was Romberg?	547
64.What is the anatomy of CN IX (glossopharyngeal) and CN X (vagus)? How do you test them?	547
65.What is pseudobulbar palsy?	548
66.How do you rule out the possibility of aspiration in patients with bilateral strokes?	548
67.And what about the gag reflex?	548
68.What is the anatomy of CN XI (spinal accessory nerve)?	548
69.How do you test CN XI?	548
70.How do you test CN XII (hypoglossal nerve)?	549
C.Motor System Examination	549
71.Which CNS areas participate in the creation/coordination of muscle movement?	549
72.What is the motor system made of?	549
73.What is the function of upper motor neurons?	550
74.What are the manifestations of upper motor neuron dysfunction?	550
75.What are the manifestations of damage to lower motor neurons or their axons?	550
76.What are the main components of examination of the motor system?	550
(1) Atrophy, Hypertrophy, and Fasciculations	550
77.What is muscle atrophy?	550
78.What is muscle hypertrophy?	550
79.What are fasciculations?	550
(2)Muscle Strength and Tone	551
80.Which conditions are characterized by reduction in strength?	551
81.How is muscle strength graded?	551
82.What are the limitations of muscle strength grading?	551
83.What muscles should be tested during the neurologic exam?	551
84.What is muscle tone?	551
85.What are the most common forms of altered tone?	552
86.In addition to lower motor neuron disease, are there any other causes of hypotonia?	552
87.What are the extreme forms of hypertonia?	552
88.Name the four commonly used examples of hypertonia.	552
89.What are the clinical features of Parkinson's disease (PD)?	552
90.What is bradykinesia?	552
91.What is flaccidity?	552
92.What is asterixis?	552
(3)Muscle Percussion	553
93.What is the response of a muscle to the stroke of a reflex hammer?	553
94.What is percussion myotonia?	553
95.What is myoedema?	553
(4)Reflexes	553
96.What are reflexes?	553
97.What are the main superficial reflexes?	553
98.How do you elicit the corneal/conjunctival reflex?	553
99.How do you elicit the abdominal reflex?	553
100.How do you elicit the cremasteric reflex?	553
101.How do you elicit the anal wink reflex?	553
102.How do you elicit muscle stretch reflexes?	553
103.Is there any evidence that one hammer is better than the others?	553
104.What are the most important muscle stretch reflexes?	553
105.How are reflexes graded?	554
106.What is the Jendrassik maneuver?	554
107. What is the significance of areflexia or hyporeflexia?	554
108.What is the significance of hyperreflexia?	554
109.What is a finger flexor reflex?	554
110.Can decreased (or increased) reflexes be normal?	555
111.What are the characteristics of muscle stretch reflexes in spinal cord disease?	555
112.What is a crossed adduction reflex?	555
113.What is the plantar reflex?	555
114.What is the Babinski sign?	555
115.Are there any false negatives?	556
116.Name the different techniques to elicit the extensor plantar response	556
117.Who was Babinski?	557
118.What are movement disorders?	557
119.How do you examine patients with \"abnormal movements\"?	557
120. What are the most important abnormal involuntary movements?	557
121.Name the three types of tremors and how to elicit them.	558
122.What is chorea?	558
123. What is athetosis? How does it differ from chorea?	558
124.What is hemiballismus?	558
125.What is myoclonus?	558
126.What is dystonia? How can be detected on physical exam?	558
127.What is a tic?	559
128.What is Tourette's syndrome?	559
129.Who was Tourette?	559
D.Sensory System Examination	559
130. What are the two components of the sensory system?	559
131.What are the simple sensations conveyed by the noncortical sensory system?	559
132.How are nociceptive sensations carried by the nervous system?	559
133. How are proprioceptive sensations carried by the nervous system?	559
134.How do you describe excess of, or lack of, sensation?	560
135.What is a dermatome?	560
136.Which dermatomeric rules should be kept in mind during the exam?	560
137.Which sensations should be tested during the neurologic exam?	560
138.How do you assess pain?	560
139.How do you assess light touch?	560
140.How do you assess temperature?	561
141.What is the clinical significance of nociceptive loss?	561
142.What are the causes of hyperpathia and allodynia?	561
143.How do you assess vibration?	561
144.Which vibration frequencies are well perceived by humans?	561
145.What is the difference between a nociceptive and a proprioceptive loss?	561
146.What is the role of an intact sense of position?	561
147.How do you test for position sensation?	561
148.Which conditions are associated with proprioceptive loss?	562
149.How does the sense of joint position differ from other sensory modalities?	562
150.How do you assess the discriminative sensory function?	562
151.What is two-point discrimination (2PD)? How do you assess it?	563
152.What is touch localization?	563
153.What is stereognosis? How do you assess it?	563
154.What is graphesthesia? How do you assess it?	563
155.What is bilateral simultaneous tactile stimulation?	563
156.What is extinction? How do you test for it?	563
157.What is the clinical significance of a sensory loss?	563
E.Cerebellum	564
158.What are the functions of the cerebellar system?	564
159.Which clinical findings suggest damage to the cerebellum and its tracts?	564
160.Are cerebellar manifestations ipsilateral or contralateral to the site of lesion?	564
161.What is ataxia?	564
162.How do you test for ataxia?	564
163.What is intention tremor?	565
164.How do patients with cerebellar deficits walk? How do they stand?	565
165.How common is ataxic gait in cerebellar disease?	565
166.How is the muscle tone of cebellar patients?	565
167.What is nystagmus?	565
168.Is the direction of nystagmus diagnostically helpful?	565
169.What is optokinetic nystagmus?	565
170.How is the speech of cerebellar disease?	565
171.How common is dysarthria in cerebellar disease?	566
F.Gait	566
172.What is the control of walking? How is gait assessed?	566
G.Application of the Neurologic Examination	566
173.How do you best evaluate patients with neurologic symptoms?	566
174.How can neuroanatomy be applied clinically, given the great complexity of the CNS?	566
175.What is the peripheral nervous system (PNS) made of?	566
176.What are the causes of neuromuscular weakness/paralysis?	566
177.What are the manifestations of upper motor neuron disease?	566
178.What is dexterity?	567
179.How do you separate upper from lower motor neuron disease?	567
180.What are the manifestations of lower motor neuron disease?	567
181.Describe ways to localize peripheral weakness/paralysis	567
182.What about combined upper and lower motor neuron disease?	567
183.What is myelopathy? What are its manifestations?	567
184.What is ALS?	567
185.What are the symptoms of muscle disease?	568
186.After eliciting myopathic symptoms, which findings can you expect on exam?	568
187.What are the symptoms of neuromuscular junction (NMJ) disease?	568
188.After eliciting NMJ symptoms, which findings can you expect on exam?	568
189.What are the symptoms of peripheral neuropathy?	568
190.After eliciting neuropathic symptoms, which findings can you expect on exam?	569
191.What are the symptoms of root diseases (radiculopathies)?	569
192.After eliciting radiculopathic symptoms, which findings can you expect on exam?	569
193.What is the presentation of spinal cord disease (SCD)?	569
194.After eliciting SCD symptoms, which findings can you expect on exam?	569
195.What are the symptoms of brain stem disease?	569
196.After eliciting brain stem symptoms, which findings can you expect on exam?	570
197.What are the symptoms of cerebellar disease?	570
198.After eliciting cerebellar symptoms, which findings can you expect on exam?	570
199.What are the symptoms of cerebral hemispheric disease (CHD)?	570
200.After eliciting CHD symptoms, which findings can you expect on exam?	570
201.What is apraxia? How can you test for it?	571
202.What is the cause of apraxia?	571
H.Special Problems-Meningeal Signs	571
203.What are meningeal signs?	571
204.What is their mechanism?	571
205.What is nuchal rigidity (or stiffness)?	571
206.What is Kernig's sign?	571
207.What is Brudzinski's sign?	571
208.How clinically useful are these signs in the detection of meningitis?	571
Acknowledgment	572
Selected Bibliography	572
Chapter 20: The Bedside Diagnosis of Coma	573
Generalities	573
1.How important is the bedside evaluation of coma?	573
2.What is coma?	573
3.What is consciousness?	573
4.What is the content of consciousness?	573
5.What is stupor? Obtundation?	573
6.What is arousal? What does it depend on?	573
7. Are the patient's eyes open or closed in coma?	574
8.So why are comatose patients unconscious?	574
9.Why can thalamic lesions cause coma?	574
10.What is the neurologic basis of coma?	574
11.What is the ascending reticular activating system (RAS)?	574
12.So what is the mechanism of coma?	574
13.Does a unilateral hemispheric lesion cause coma?	574
14.Do all brain stem lesions cause coma?	574
15.So what are the causes of coma?	575
16.What is the function of the neurologic exam in comatose patients?	575
17.What is the neurologic exam of a comatose patient?	575
18.What is a level-by-level exam of the brain stem?	577
19.What is the first step in evaluating coma?	577
20.Which reflex tests thalamic function?	577
21.What are the proper/improper responses of a comatose patient to painful stimuli?	577
22.What are these postures?	577
23.What about other involuntary movements?	577
24.What is the second layer in the brain stem?	577
25.Which reflex tests the function of the midbrain?	577
26.What is the significance of pupillary abnormalities?	578
27.What is anisocoria?	579
28.How can one distinguish physiologic from pathologic anisocoria?	580
29.What is the third level in the brain stem?	580
30.Which reflex tests the function of the pons?	580
31.What is the doll's eye reflex?	580
32.What is the pathway of the oculocephalic reflex?	580
33.What is a normal oculocephalic response?	580
34.Does any other reflex test the function of the pons?	580
35.What is the fourth and lowermost layer of the brain stem?	581
36.Which reflex tests medullary function?	581
37.What is an apnea test?	581
38.What is the implication of a global absence of brain stem function?	581
39.What is a toxic-metabolic coma?	581
40.Can a localized process cause coma?	581
41.What are the causes of a toxic-metabolic coma?	581
42.How common is coma due to cardiac arrest?	582
43.In addition to cardiac arrest, what are the other causes of PSV?	582
44.What is the Glasgow Coma Scale (GCS)?	582
45.What are the crucial maneuvers in the evaluation of hypoxic coma?	582
46.What signs best predict lack of recovery after cardiac arrest?	583
47.Do seizures or myoclonus have significance in coma after cardiac arrest?	583
48.How precise is the clinical exam of coma?	583
49.What is the bottom line for the neurologic exam of coma?	583
50.What is asterixis?	583
51How can you elicit asterixis?	584
52.What is the clinical significance of asterixis?	584
53.What is the definition of death?	584
54.What conditions may look like coma but are not coma?	585
55.What is uncal herniation?	585
56.What are the most common causes of uncal herniation?	585
57.Is the pattern of breathing helpful in identifying the site of a brain stem lesion?	586
Selected Bibliography	586
Chapter 21:The Musculoskeletal System	588
Generalities	205
1.What are the cardinal signs of joint inflammation?	588
2.What are tendons? What is tendinitis?	588
3.How are disorders of tendons differentiated from joint problems?	588
4.What are ligaments? What are the findings of a ligament injury?	588
5.What are bursae? How do you identify bursitis?	588
6.Describe joint swelling (tumor).	589
7.What is the significance of joint tenderness (dolor)?	590
8.What is the significance of articular warmth and erythema (calor and rubor)?	590
9.What is crepitus?	590
10.What is the significance of joint cracking or popping?	590
11.What are the main patterns of joint involvement?	590
12.How do you measure range of motion (ROM)?	590
13.What are the findings of joint hypermobility?	590
A.The Shoulder	590
14.What is the anatomy of the shoulder?	590
15.Describe the muscles and tendons of the shoulder.	590
16.What are the shoulder's movements? How do you test its ROM?	591
17.What areas of the shoulder girdle should be palpated?	591
18.Can history identify the cause of a shoulder ailment?	591
19.What is the general approach to the shoulder exam?	592
20.What is the shoulder pad sign?	592
21.What are the most common musculoskeletal causes of shoulder pain?	592
22.What are the origins of referred shoulder pain?	592
23.In addition to history, how else do you identify referred shoulder pain?	592
24.What is shoulder synovitis? How do you diagnose it?	593
25.What is acromioclavicular (AC) arthritis? How do you diagnose it?	593
26.What is AC separation?	593
27.What is bicipital (or biceps) tendinitis?	593
28.What are the symptoms/findings of bicipital tendinitis?	593
29.Which specific maneuvers can reproduce the pain of bicipital tendinitis?	593
30.What is the \"Popeye\" sign?	594
31.What is shoulder impingement?	594
32.What is the cause of shoulder impingement?	594
33.How do you diagnose rotator cuff tendinitis?	594
34.What is the \"drop arm\" test?	595
35.What are the symptoms of shoulder impingement?	595
36.How do you examine for shoulder impingement?	595
37.Are there any special maneuvers that can be used for testing impingement?	595
38.How do you perform the Neer (impingement) test?	595
39.How do you perform the Hawkins-Kennedy test?	595
40.How else can one elicit pain in supraspinatus tendinitis?	596
41.What is the \"painful arc\" sign?	596
42.What are rotator cuff injuries?	596
43.What are the causes of rotator cuff tear?	596
44.What are the symptoms of rotator cuff tear?	596
45.What are the findings of a complete rotator cuff tear?	596
46.What is glenohumeral (shoulder) dislocation?	596
47.What are the causes of dislocation?	597
48.What is the presentation of dislocation?	597
49.How do you test for glenohumeral instability?	597
50.How do you test for anterior shoulder instability?	597
51.How do you test for inferior shoulder instability?	598
52.How do you diagnose multidirectional instability?	598
53.How do you test for glenoid labral tears?	598
54.How do you perform the O'Brien test?	598
55.How do you perform the anterior slide test?	598
56.What is adhesive capsulitis?	598
57.What is the mechanism of adhesive capsulitis?	598
58.What are the symptoms of adhesive capsulitis?	598
59.How is the diagnosis made?	598
B.The Elbow	599
60.What are the elbow's movements? Range of motion?	599
61.Is the elbow varus or valgus?	599
62.What do valgus and varus mean?	599
63.How do you detect swelling of the elbow?	599
64.What is the most common finding of an abnormal elbow?	599
65.What is \"tennis elbow\" (lateral epicondylitis)?	599
66.Other than tennis, does anything else cause tennis elbow?	599
67.What is the presentation of tennis elbow?	599
68.What is \"golfer's elbow\" (medial epicondylitis)?	600
69.What is the cause of golfer's elbow?	600
70.What is the presentation of golfer's elbow?	600
71.How frequent is ulnar nerve entrapment at the elbow?	601
72.What are the causes of cubital tunnel syndrome?	601
73. What is the presentation of cubital tunnel syndrome?	601
74.How do you diagnose cubital tunnel syndrome?	601
75.What is olecranon bursitis?	601
76.How does it present?	601
77.What are the causes of olecranon bursitis?	601
78.Which finding differentiates infection from other causes of olecranon bursitis?	602
79.How do you tell rheumatoid nodules from gouty tophi?	602
C.The Wrist	602
80.What is the carpal tunnel?	602
81.What is carpal tunnel syndrome (CTS)?	602
82.What is the cause of CTS?	602
83.What are the symptoms of CTS?	602
84.What is the physical exam of CTS?	602
85.How do you elicit Tinel's sign?	603
86.How do you elicit Phalen's sign?	603
87.How do you elicit the flick sign?	603
88.How valuable is physical exam in confirming the diagnosis?	603
89.Who was Tinel?	604
90.What is the piano key sign?	604
91.What is a common cause of pain on the radial side of the wrist?	604
92.How do you diagnose de Quervain's tendinitis?	604
93.Who was de Quervain?	604
94.What is the \"intersection\" syndrome?	605
95.How do you differentiate de Quervain's tendinitis from an intersection syndrome?	605
96.What causes the intersection syndrome?	605
97.What is a wrist ganglion? How is identified?	605
98.What is the cause?	605
99.What are the typical wrist findings of rheumatoid arthritis?	605
100.What is Guyon's canal syndrome?	605
101.What is the anatomy of the Guyon's canal?	606
102.What are the symptoms of ulnar compression?	606
103.What are the symptoms of median nerve compression?	606
D.The Hand	606
104.What is the nerve supply of the hand?	606
105.How can you differentiate ostheoarthritis from rheumatoid arthritis (RA)?	607
106Describe the typical deformities of rheumatoid arthritis.	607
107What is a trigger finger?	607
108.What are the physical findings of a trigger finger?	608
109.What other typical deformities can be seen in the hand?	608
110.What are Heberden's nodes?	608
111.Who were Heberden and Bouchard?	609
112.What are Haygarth's nodes?	609
113.Who was Haygarth?	609
114.What are tophi?	609
115.What are Janeway's lesions?	610
116.Who was Janeway?	610
117.What is the Pachuco mark?	610
118.What is the shape of the hand in acromegaly?	610
119.What is arachnodactyly?	610
120.Who was Marfan?	610
121.What is a short fourth metacarpophalangeal bone?	611
122.What is the significance of calluses and abrasions on the dorsal aspect of the fingers?	611
123.What is the anatomy of the first carpometacarpal (CMC) joint?	611
124.What is CMC squaring?	611
125.What is the presentation of CMC squaring?	611
126.What is a sausage digit?	611
127.What is a telescoped digit?	612
128.Describe the Bunnell-Littler test.	612
129.What is a stiff hand syndrome?	612
130.What is a paronychia? A felon?	612
131.Can the fingers provide a clue to a patient's sexual orientation?	612
E.The Head and Neck	613
132.How do you assess the cervical spine?	613
133.How do you evaluate its ROM?	613
134.How do you diagnose temporomandibular joint (TMJ) arthritis?	613
135.What is torticollis?	613
136.What is occipital neuralgia? What are its findings?	613
137.What is spinal stenosis? How is it classified?	613
138.What are the findings of cervical stenosis?	614
139.List sensory distribution, reflexes, and motor innervation of cervical spinal roots.	614
F.The Thoracic Spine	614
140.What is the most common type of spinal deformity?	614
141.Describe the difference between scoliosis and kyphosis.	614
142How is scoliosis appreciated?	615
143.What is Sprengel's deformity?	615
144.What is the significance of tenderness over the spinous process(es)?	615
145.How do you measure chest expansion?	615
146.What is winging of the scapula? How is it demonstrated?	615
147.What are the causes of scapular winging?	615
148.What are the consequences of scapular winging?	615
G.The Lumbar Spine	615
149.What are the normal movements of the lumbar spine?	615
150.What is Schober's test?	616
151.How valid is Schober's test?	616
152.How can relative leg length be assessed?	616
153.What are the symptoms of spinal (lumbar) stenosis?	616
154.How are radicular symptoms reproduced in patients with spinal stenosis?	616
155.What are the physical findings of spinal stenosis?	616
156.What is the stoop test?	616
157.What is the cauda equina syndrome?	617
158.What is the Lasegravegue test? How is it performed?	617
159.What is the significance of a positive straight-leg raising test?	617
160.What is the \"crossed\" straight-leg raising test?	617
161.How do you perform the \"reverse\" straight-leg raising test?	618
162.What is the \"distracted\" straight-leg raising test?	618
163.How else can one separate organic from non organic back pain?	618
164.Who was Lasegravegue?	618
165.What is low back pain?	619
166.What are the causes of low back pain?	619
167.What is a nerve root syndrome?	619
168.What are the causes of nerve impingement?	619
169.What is the most common site of disk herniation?	619
170.What is sciatica?	619
171.In a nerve root syndrome, can you separate impingement from inflammation/irritation?	620
172.What are the physical findings of patients with low back pain?	620
173.What are the physical findings of patients with a true herniated disk?	620
174.What are musculoskeletal pain syndromes?	620
175.What are the other skeletal causes of low back pain?	621
176.What is the Trendelenburg's sign?	621
177.How do you elicit it?	621
178.What are the causes of a Trendelenburg's sign?	621
179.What is a Trendelenburg's gait?	621
180. What is Hoover's test?	622
181.How is Hoover's test carried out?	622
182.List sensory distribution, reflexes, and motor innervation of lumbar spinal roots syndromes.	622
H.The Sacroiliac Joint	623
183.Where is the sacroiliac joint (SIJ)? What is its clinical importance?	623
184.How do I locate the SIJ?	623
185.What are the presenting symptoms of patients with SIJ disease?	623
186.What is the presentation of sacroiliitis?	623
187.How do you assess sacroiliac joint tenderness?	623
I.The Hip	623
188.How many muscles control the hip?	623
189.What is the normal range of motion of the hip?	623
190.How many bursae does the hip have? Why are they important?	624
191.What hip structure can cause inguinal swelling?	624
192.Which structures traverse the inguinal fossa?	624
193.What are the causes of pain referred to the inguinal area? How do you identify it?	624
194. What is a trochanteric bursitis?	624
195. What are the symptoms of trochanteric bursitis?	624
196.What is \"log-rolling\" of the hip?	624
197.What is the FABER maneuver?	625
198.How do you detect a flexion contracture of the hip?	625
199.How should one approach a patient with hip pain?	625
200.How should one examine the hip of a patient complaining of pain?	625
J.The Knee	626
201.How common are knee disorders?	626
202.What are the main types of knee disorders?	626
203.Can history identify the site of injury?	626
204.What are the main mechanisms of injury?	626
205.What is the anatomy of the knee?	626
206.How many ligaments support the knee?	626
207.What are the menisci?	627
208.What are the primary muscles of the knee?	627
209.What is prepatellar bursitis?	627
210.How do you examine the knee?	627
211.What do you look for when inspecting the knee?	627
212.What is the Q-angle (or \"quadriceps angle\")?	627
213.What are the most common types of knee misalignment?	628
214.Can osteoarthritis cause misalignment of the knee?	628
215.How do you demonstrate patellar tracking?	628
216.What is patellofemoral syndrome (disease)?	629
217.What are the symptoms and findings of patellofemoral disease?	629
218.What is anserine bursitis?	629
219.How do you test for patellofemoral syndrome?	629
220. What is an extension lag of the knee?	629
221.What is the patellar inhibition test (patellofemoral grinding test)?	629
222.What is the role of palpation?	629
223.How do you palpate the knee?	630
224.How do you evaluate the knee's range of motion?	630
225.What is osteoarthritis of the knee?	630
226.What is the mechanism of osteoarthritis?	630
227.What are the symptoms of gonarthrosis?	630
228.How do you detect knee effusions?	630
229.What about intermediate-sized effusions?	631
230.What are the mechanisms of ligament injuries?	631
231.What are the symptoms of ligamentous injuries?	631
232.How does the function of cruciate ligaments relate to symptoms?	631
233.Which maneuvers test the anterior cruciate ligaments?	632
234.How do you perform the Lachman maneuver?	632
235.How do you perform the anterior drawer test?	632
236.How do you perform the lateral pivot shift test?	632
237. How do you assess the posterior cruciate ligaments?	632
238.How do you perform the posterior drawer test?	632
239.How do you perform the tibial sag test?	632
240.How do you assess the collateral ligaments?	633
241.How accurate are these maneuvers?	633
242.How common are meniscal injuries?	633
243.What is their mechanism?	633
244.What is the best way to evaluate a meniscal injury?	633
245.What are the symptoms of meniscal tear? What are their causes?	634
246.What are the physical findings of a meniscal tear?	634
247.In addition to tenderness over the joint line, what other maneuvers can detect meniscal tears?	634
248.How do you perform the medial-lateral grind test?	634
249.What is the McMurray test? How do you perform it?	634
250.What is the Apley's grind and distraction test? How do you perform it?	635
251.Who were these folks?	635
252.How accurate are these tests?	635
253.When should x-rays be ordered?	636
254.How is quadriceps atrophy detected?	636
255.What is a Baker's (popliteal) cyst? Where can it be palpated?	636
256.What is the pseudothrombophlebitis syndrome?	636
K.The Ankle and the Foot	636
257.What is the function of the ankle?	636
258.What is the anatomy of the ankle?	636
259.How do you approach a patient with ankle injury?	637
260.What should one look for in the ankle exam?	637
261.How do you test ROM?	637
262.What ankle structures should be palpated?	637
263.How do you identify an injury of the lateral ligaments?	637
264.How do you assess the anterior talofibular ligament?	637
265.What is the \"talar tilt\" test?	637
266.What is the cause of pain posterior to the fibula?	638
267.What is the \"squeeze test\"?	638
268.When should x-rays be ordered?	638
269.What are pes cavus and pes planus?	638
270.What ankle deformity is associated with pes planus?	638
271.What are the typical changes of the rheumatoid foot?	638
272.What are hammer toes?	638
273.What is hallux valgus? What are bunions?	639
274.Describe the findings with dropped metatarsal heads.	639
275.What are corns?	639
276.What is Morton's neuroma? How is it demonstrated?	639
277.What is the Achilles tendon? What is Achilles tendinitis?	640
278.What are the physical findings of Achilles tendinitis?	640
279.What is Achilles tendon bursitis?	640
280.What are the causes of this bursitis?	640
281.What about tendon tear?	640
282.What is the presentation of an Achilles tendon tear?	641
283.What is the plantar fascia?	641
284.What is plantar fasciitis? What is its presentation?	641
285.What are the causes of plantar fasciitis?	641
286.What is tarsal tunnel syndrome (TTS)?	641
287.What are the symptoms of tarsal tunnel syndrome?	642
288.What are the causes of tarsal tunnel syndrome?	642
Acknowledgment	642
Selected Bibliography	642
Chapter 22:The Extremities and Peripheral Vascular Exam	644
A.Generalities	644
1.What is the role of the extremities' exam?	644
2.Which arteries should be examined in the upper and lower extremities?	644
3.Which veins should be examined?	644
B.The Peripheral Arteries	644
(1)Asymmetric Pulses	644
4.What causes a weaker and delayed pulse in the left arm as compared to the right?	644
(2)Raynaud's Phenomenon	644
5.What is Raynaud's phenomenon?	644
6.What causes Raynaud's phenomenon?	645
7.How can Raynaud's phenomenon be artificially triggered?	647
8.What is the clinical significance of Raynaud's phenomenon?	647
9.Who was Raynaud?	648
(3)Allen's Test	649
10.What is Allen's test? What does it mean?	649
11.Isn't the test conducted by simultaneously compressing the ulnar and radial arteries?	649
12.How do you report the results of an Allen's test?	649
13.Who was Allen?	649
(4)Peripheral Vascular Disease	650
14.Can peripheral pulses be absent in normal individuals?	650
15.What is peripheral vascular disease (PVD)?	650
16.What are the symptoms of PVD?	650
17.What are the physical findings of PVD?	650
18.Can these findings predict severity of the disease?	651
19.What is an increased venous filling time?	651
20.What is a capillary refill time (CRT)?	651
21.What is the Buerger's test?	652
22.How accurate is physical examination for diagnosing PVD?	652
23.Is there any finding that argues against the presence of PVD?	652
24.How accurate is physical examination for diagnosing the distribution of PVD?	652
25.What are the limitations of physical exam in evaluating PVD?	653
(5)Diabetic Foot	653
26.To what lower extremity complications are diabetics uniquely predisposed?	653
27.What are the predisposing factors?	653
28.How common is peripheral neuropathy in diabetics?	653
29.What are the characteristics of this neuropathy?	653
30.What is the best way to recognize peripheral neuropathy in diabetics?	654
31.What is the Semmes-Weinstein (SW) monofilament test?	654
32.How is the test conducted?	654
33.When is the test considered positive for neuropathy?	654
34.How do you separate an ischemic from a neuropathic (diabetic) foot ulcer?	654
35.What about ulcers of chronic venous stasis?	654
36.What is the role of physical exam in a diabetic ulcer?	654
37.Where is a diabetic foot ulcer located?	655
38.What is Charcot's foot?	655
39.Which joints are most affected by Charcot's changes?	655
40.Are there any other causes of Charcot's foot?	655
C.The Peripheral Veins	655
(1)Edema	655
41.What is edema of an extremity?	655
42.What is \"pitting\"?	655
43.How do you elicit pitting edema?	655
44.How do you grade pitting edema?	656
45.How does lymphedema present? What are its causes?	656
46.What is the most common cause of neoplastic lymphedema in the lower extremities?	656
47.How can physical exam help in the diagnosis of edema?	656
48.How do you separate edema of deep venous thrombosis (DVT) from edema of congestive heart failure?	656
(2)Venous Insufficiency	656
49.What is the Trendelenburg's test?	656
50.How do you interpret the test?	656
51.Can the saphenous vein serve as a manometer of intra-abdominal pressure?	656
52.How do you check for presence of communicating veins?	659
53.What is the Trendelenburg's position?	659
54.Who was Trendelenburg?	659
55.What is Perthes' test?	659
56.What is the role of palpation in assessing varicose veins of the saphenous system?	659
(3)Deep Venous Thrombosis	660
57.What is the role of physical exam for diagnosing DVT?	660
58.What are the traditional physical findings of DVT? How valuable are they?	660
59.How accurate is physical exam for DVT?	661
60.What should then be the approach to a patient with suspected DVT?	661
61.In summary, what is the role of bedside examination for the evaluation of DVT?	661
62.Who was Homans?	661
Selected Bibliography	661
Top 10+10 ‘‘Secret’’ Reasons Why it is Good to be a Doctor	663
Index	665

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