BOOK
Advanced Health Assessment & Clinical Diagnosis in Primary Care - E-Book
Joyce E. Dains | Linda Ciofu Baumann | Pamela Scheibel
(2015)
Additional Information
Book Details
Abstract
Take the ‘next step’ in health assessment! Advanced Health Assessment and Clinical Diagnosis in Primary Care, 5th Edition goes beyond basic history and physical examination to help you master the diagnostic reasoning process. You’ll develop this key skill by following assessment guidelines that focus on a specific complaint rather than beginning with a previously established diagnosis or disease entity. Written by advanced practice nursing experts Joyce Dains, Linda Baumann, and Pamela Scheibel, this edition includes new chapters on evidence-based preventive health screening and on heartburn and indigestion, along with a new full-color design. Master the differential diagnosis process outlined in this book, and you’ll be able to accurately diagnose the majority of patients seen in today’s primary care settings.
- A clear, consistent diagnostic reasoning process takes you to the next step of health assessment — beyond basic history and physical examination to diagnostic reasoning.
- Diagnostic Reasoning: Focused History sections use ‘self-questions’ to walk you through the thinking process involved in obtaining a pertinent, relevant, problem-specific history that will assist in differential diagnosis.
- Diagnostic Reasoning: Focused Physical Examination sections explain how to perform more advanced diagnostic techniques and interpret the findings.
- Key Questions guide you through assessment and toward an accurate diagnosis by listing questions to ask the patient, followed by explanations of what the patient's responses might signify.
- Laboratory and Diagnostic Studies sections outline the types of studies that might be appropriate based on the focused history and focused physical examination.
- Differential Diagnosis sections offer the most common diagnoses for each patient problem and summarize the history and physical examination findings, along with recommended laboratory and diagnostic studies.
- Differential Diagnosis tables provide a quick-reference summary of possible diagnoses for each patient problem.
- Evidence-Based Practice boxes — more than 30 are NEW — summarize the scientific evidence related to the diagnosis of patient problems.
- Alphabetical Table of Contents provides a convenient listing of common health problems.
Table of Contents
| Section Title | Page | Action | Price |
|---|---|---|---|
| Front Cover | Cover | ||
| Table of contents | IFC | ||
| List of chapters by body system | i | ||
| Common problems of the head, eyes, ears, nose, and throat | i | ||
| Common problems of the skin | i | ||
| Common problems of the cardiovascular system | i | ||
| Common problems of the respiratory system | i | ||
| Common problems of the abdomen and gastrointestinal system | i | ||
| Common problems of the genitourinary system | i | ||
| Common gynecological problems | i | ||
| Common problems of the breasts | i | ||
| Common problems of the musculoskeletal system | i | ||
| Common problems of the neurological system | i | ||
| Common problems in mental status | i | ||
| Common systemic problems | i | ||
| Front matter | iii | ||
| Advanced health assessment and clinical diagnosis in primary care 5th Edition | iii | ||
| Copyright Page | iv | ||
| Reviewers | v | ||
| Acknowledgments | viii | ||
| Introduction | ix | ||
| How to use this book | ix | ||
| I An Introduction to Clinical Reasoning | 1 | ||
| 1 Clinical reasoning, differential diagnosis, evidence-based practice, and symptom analysis | 1 | ||
| Diagnostic reasoning | 1 | ||
| The diagnostic process | 1 | ||
| The primary care context | 1 | ||
| Symptom analysis | 1 | ||
| Performing a physical examination | 2 | ||
| Formulating and testing a hypothesis | 2 | ||
| Expert versus novice practitioners | 2 | ||
| Developing clinical reasoning | 3 | ||
| Negotiating goals and expectations of a patient encounter | 3 | ||
| Evidence-based practice | 4 | ||
| Evidence-based practice boxes | 4 | ||
| Summary | 4 | ||
| References and readings | 5 | ||
| 2 Evidence-based health screening | 6 | ||
| Steps in evidence-based screening | 6 | ||
| Sources of evidence | 7 | ||
| Levels of screening | 7 | ||
| Population versus targeted screening | 8 | ||
| Ethical guidelines for screening | 8 | ||
| United states preventive services task force | 8 | ||
| Current screening environment | 9 | ||
| Summary | 10 | ||
| References and readings | 10 | ||
| II Common Symptoms in Primary Care | 11 | ||
| 3 Abdominal pain | 11 | ||
| Diagnostic reasoning: Focused history | 12 | ||
| Onset/duration | 12 | ||
| Severity and progression | 13 | ||
| Last bowel movement | 14 | ||
| Previous pain | 14 | ||
| Will the location of pain give me any clues? | 14 | ||
| Location of the pain | 14 | ||
| Radiation of pain | 14 | ||
| What do the pain characteristics tell me? | 15 | ||
| Character of pain | 15 | ||
| Precipitating or aggravating factors | 15 | ||
| Relieving factors | 16 | ||
| Are there any precipitating events that will help narrow my diagnosis? | 16 | ||
| Relation to other events | 16 | ||
| What does the presence of vomiting or diarrhea tell me? | 16 | ||
| Vomiting | 16 | ||
| Diarrhea | 16 | ||
| Are there any clues to implicate a particular organ system? | 17 | ||
| Is the pain psychogenic, organic, or functional? | 18 | ||
| What else do I need to consider? | 18 | ||
| Medications | 18 | ||
| Surgery | 18 | ||
| Involuntary weight loss | 18 | ||
| Camping or day care | 18 | ||
| Diagnostic reasoning: Focused physical examination | 18 | ||
| Note general appearance | 18 | ||
| Assess vital signs | 19 | ||
| Examine the throat | 19 | ||
| Observe abdominal musculature | 19 | ||
| Note coloring of abdominal skin | 19 | ||
| Note abdominal distention | 19 | ||
| Auscultate bowel sounds | 19 | ||
| Percuss for tones and guarding | 19 | ||
| Palpate the abdomen | 19 | ||
| Palpate for masses | 20 | ||
| Palpate the groin | 20 | ||
| Palpate for hernias | 20 | ||
| Percuss for flank tenderness | 20 | ||
| Test for peritoneal irritation | 20 | ||
| Perform a pelvic examination in women | 20 | ||
| Perform genital and prostate examinations in men | 20 | ||
| Perform digital rectal examination | 21 | ||
| Check peripheral pulses | 21 | ||
| Perform a generalized examination as indicated | 21 | ||
| Laboratory and diagnostic studies | 21 | ||
| Complete blood count with differential | 21 | ||
| Pregnancy test | 21 | ||
| Erythrocyte sedimentation rate | 21 | ||
| Cardiac enzymes | 21 | ||
| Urinalysis | 21 | ||
| Urine for culture and sensitivity | 21 | ||
| DNA probe for sexually transmitted infection | 21 | ||
| Potassium hydroxide test | 21 | ||
| Saline wet prep | 21 | ||
| Fecal occult blood test | 21 | ||
| Fecal immunochemical test | 22 | ||
| Rapid strep screen | 22 | ||
| Electrocardiogram | 22 | ||
| Helicobacter pylori testing | 22 | ||
| Radiography | 22 | ||
| Abdominal/pelvic ultrasound | 22 | ||
| Computed tomography/magnetic resonance imaging | 22 | ||
| Colonoscopy or sigmoidoscopy | 22 | ||
| Anorectal manometry | 22 | ||
| Differential diagnosis | 23 | ||
| Acute conditions that cause abdominal pain | 23 | ||
| Chronic conditions that cause lower abdominal pain | 26 | ||
| Chronic conditions that cause upper abdominal pain | 27 | ||
| References and readings | 32 | ||
| 4 Affective changes | 33 | ||
| Diagnostic reasoning: Focused history | 33 | ||
| Presenting concern | 33 | ||
| Behavioral cues | 33 | ||
| Could this be a result of a physiological problem? | 33 | ||
| Symptoms | 33 | ||
| Major illness/chronic conditions | 34 | ||
| Could this be caused by medication? | 35 | ||
| Medication history | 35 | ||
| Is this a situation of domestic or partner violence? | 35 | ||
| Could this be situational stress or normal grief? | 35 | ||
| Bathe model | 36 | ||
| Could this be a result of substance abuse? | 36 | ||
| How can I narrow my diagnosis? | 36 | ||
| Prior mental illness, family history | 37 | ||
| Down, depressed, hopeless, loss of interest or pleasure | 37 | ||
| Anxious or nervous | 37 | ||
| Happy, energetic, hyper | 37 | ||
| What about special considerations for adolescents? | 37 | ||
| Is this patient at risk for suicide? | 38 | ||
| Initial questions | 39 | ||
| Follow-up questions | 39 | ||
| How do I evaluate for a diagnosable psychological disorder? | 39 | ||
| Diagnostic reasoning: Focused physical examination | 39 | ||
| Assess vital signs | 39 | ||
| Observe general appearance | 39 | ||
| Observe mental status | 39 | ||
| Note speech and thought process | 40 | ||
| Examine the eyes | 40 | ||
| Examine the ears, nose, and mouth | 40 | ||
| Examine the skin | 40 | ||
| Assess balance and gait | 40 | ||
| Laboratory and diagnostic studies | 40 | ||
| Complete blood count with indices and differential | 40 | ||
| Serum electrolytes | 40 | ||
| Thyroid function tests | 40 | ||
| Toxicology screen and blood alcohol level | 40 | ||
| Serum B₁₂ and folate | 40 | ||
| Differential diagnosis | 40 | ||
| Normal stress | 40 | ||
| Normal grief | 41 | ||
| Domestic/partner violence | 41 | ||
| Substance use disorders | 41 | ||
| Autism spectrum disorder | 41 | ||
| Adjustment disorders | 42 | ||
| Anxiety disorders | 42 | ||
| Mood disorders | 42 | ||
| References and readings | 46 | ||
| 5 Amenorrhea | 47 | ||
| Diagnostic reasoning: Focused history | 47 | ||
| Pregnancy | 47 | ||
| Contraceptive use | 48 | ||
| Seeking pregnancy | 48 | ||
| Is this primary or secondary amenorrhea? | 49 | ||
| Onset of menstruation | 49 | ||
| Pubertal development | 49 | ||
| Age of menarche | 50 | ||
| Menstrual history | 51 | ||
| Are there any constitutional delays causing the amenorrhea? | 51 | ||
| Change in weight, percentage body fat, and athletic training intensity | 52 | ||
| Emotional state | 52 | ||
| Congenital or chronic diseases | 52 | ||
| Could this be thyroid dysfunction? | 52 | ||
| Hair and skin changes and temperature intolerance | 52 | ||
| Energy and bowel changes | 52 | ||
| Could this be caused by hyperprolactinemia? | 52 | ||
| Galactorrhea | 52 | ||
| Nipple stimulation and chest wall stimulation | 53 | ||
| Could the amenorrhea be caused by medications? | 53 | ||
| Medication history | 53 | ||
| Is a pituitary tumor causing the amenorrhea? | 53 | ||
| Visual changes and headaches | 53 | ||
| Is this a problem of the hpo axis? | 53 | ||
| Infertility | 53 | ||
| Androgen excess | 53 | ||
| Estrogen deficiency | 53 | ||
| Hemorrhage at childbirth | 54 | ||
| Is this a problem of the uterus? | 54 | ||
| Gynecological problem | 54 | ||
| What symptoms support a structural outflow problem? | 54 | ||
| Presence of premenstrual symptoms or dysmenorrhea | 54 | ||
| Amenorrhea following cervical procedure | 54 | ||
| Diagnostic reasoning: Focused physical examination | 54 | ||
| Note general appearance | 54 | ||
| Assess nutritional status and plot measurements on growth chart in adolescents | 54 | ||
| Assess sexual maturity | 54 | ||
| Screen for eating disorders | 54 | ||
| Calculate the body mass index | 55 | ||
| Examine the skin and hair | 55 | ||
| Perform a head and neck examination | 55 | ||
| Palpate the thyroid gland and lymph nodes | 55 | ||
| Perform clinical breast examination | 55 | ||
| Perform a pelvic examination | 55 | ||
| Laboratory and diagnostic studies | 56 | ||
| Pregnancy test | 56 | ||
| Thyroid-stimulating hormone | 56 | ||
| Prolactin levels | 56 | ||
| Serum follicle-stimulating hormone levels | 56 | ||
| Serum luteinizing hormone levels | 56 | ||
| Dehydroepiandrosterone sulfate | 56 | ||
| Central nervous system imaging | 56 | ||
| Pelvic ultrasound and vaginal ultrasound | 56 | ||
| Progesterone challenge test | 56 | ||
| Estrogen/progesterone challenge test | 57 | ||
| Chromosome analysis (karyotyping) | 57 | ||
| Endometrial biopsy | 57 | ||
| Basal body temperature charting | 57 | ||
| Maturation index | 57 | ||
| Progesterone levels | 57 | ||
| Differential diagnosis | 57 | ||
| Pregnancy | 57 | ||
| Constitutional problems | 57 | ||
| Congenital or chronic disorders | 57 | ||
| Uterine and outflow tract problems | 58 | ||
| Hypothalamic-pituitary-ovarian axis problem | 58 | ||
| References and readings | 60 | ||
| 6 Breast lumps and nipple discharge | 61 | ||
| Diagnostic reasoning: Focused history for breast lumps | 61 | ||
| Duration and growth | 61 | ||
| Unilateral versus bilateral | 61 | ||
| Postmenopausal | 61 | ||
| Nipple discharge with a lump | 62 | ||
| Infection | 62 | ||
| Does the person have additional risk factors for breast cancer? | 62 | ||
| Risk factors | 62 | ||
| Is this condition more likely to be benign? | 62 | ||
| Age | 62 | ||
| Timing, consistency, and duration | 63 | ||
| Previous mammograms or biopsies | 63 | ||
| Breast implants | 63 | ||
| Could this lump be mastitis related to lactation? | 63 | ||
| Childbirth | 63 | ||
| Sore, cracked, or pierced nipples | 63 | ||
| Painful or hot breast | 63 | ||
| Fever | 63 | ||
| Diagnostic reasoning: Focused history for nipple discharge | 63 | ||
| Menstrual cycle | 64 | ||
| Pregnancy and lactation | 64 | ||
| Color of discharge | 64 | ||
| Duration of discharge | 64 | ||
| Is the discharge related to high prolactin levels? | 64 | ||
| Medicines | 64 | ||
| Behavioral activities | 64 | ||
| Other causes of galactorrhea | 64 | ||
| Newborn | 65 | ||
| Can the nipple discharge be a sign of malignancy? | 65 | ||
| Spontaneous versus expressed discharge | 65 | ||
| Unilateral versus bilateral discharge | 65 | ||
| Single-duct versus multiple-duct discharge | 65 | ||
| Associated mass | 65 | ||
| Postmenopausal | 65 | ||
| Diagnostic reasoning: Focused physical examination | 65 | ||
| Inspect breasts and nipples | 65 | ||
| Observe skin of breasts and nipples | 66 | ||
| Palpate breasts with patient sitting | 66 | ||
| Palpate lymph nodes | 66 | ||
| Palpate breasts and nipples with patient supine | 67 | ||
| Assess nipple well | 67 | ||
| Examine nipple for discharge | 67 | ||
| Transilluminate breast masses | 67 | ||
| Characterize lumps | 67 | ||
| Laboratory and diagnostic studies | 67 | ||
| Ultrasound | 67 | ||
| Mammography: Diagnostic | 68 | ||
| Magnetic resonance imaging | 68 | ||
| Fine needle aspiration and cytological examination | 68 | ||
| Stereotactic or needle localization biopsy | 68 | ||
| Core needle biopsy | 68 | ||
| Excisional biopsy | 68 | ||
| Microscopy | 68 | ||
| Cytological smear | 68 | ||
| Ductography (ductogram) | 68 | ||
| Serum prolactin level | 68 | ||
| Thyroid function testing | 68 | ||
| Differential diagnosis | 69 | ||
| Single breast mass | 69 | ||
| Inflammatory breast mass | 70 | ||
| Multiple or bilateral breast lumps | 70 | ||
| Nipple discharge | 70 | ||
| Male breast disease | 70 | ||
| References and readings | 72 | ||
| 7 Breast pain | 73 | ||
| Diagnostic reasoning: Focused history | 73 | ||
| Hot, red, or swollen breast, lactation | 73 | ||
| Premenopausal or postmenopausal | 73 | ||
| Relationship to menstrual cycle | 73 | ||
| What other characteristics of the pain will help me with a diagnosis? | 74 | ||
| Pain description | 74 | ||
| Localization, radiation | 74 | ||
| Is the pain associated with a lump or discharge? | 74 | ||
| Lumps | 74 | ||
| Previous mammograms or biopsies | 74 | ||
| Nipple discharge | 74 | ||
| What else could be causing the pain? | 74 | ||
| Missed periods/pregnancy | 74 | ||
| Pain with deep inspiration | 74 | ||
| Medications | 74 | ||
| Trauma to chest | 74 | ||
| Runner or jogger | 74 | ||
| Chicken pox | 75 | ||
| Could the pain be related to another system? | 75 | ||
| Chest pain or shortness of breath | 75 | ||
| Abdominal pain | 75 | ||
| Diagnostic reasoning: Focused physical examination | 75 | ||
| Perform a breast examination | 75 | ||
| Characterize lumps | 75 | ||
| Examine the chest wall | 75 | ||
| Skin | 75 | ||
| Examine the genital area in the male | 75 | ||
| Laboratory and diagnostic studies | 75 | ||
| Pregnancy testing | 75 | ||
| Mammography | 75 | ||
| Ultrasound | 75 | ||
| Karyotyping | 77 | ||
| Differential diagnosis | 77 | ||
| Cyclic mastalgia | 77 | ||
| Noncyclic mastalgia | 78 | ||
| Mastitis/abscess | 78 | ||
| Inflammatory breast cancer | 78 | ||
| Mammary duct ectasia | 78 | ||
| Pregnancy | 78 | ||
| Costochondritis | 78 | ||
| Herpes zoster (shingles) | 78 | ||
| Klinefelter syndrome | 78 | ||
| Breast lumps/nipple discharge associated with breast pain | 79 | ||
| References and readings | 80 | ||
| 8 Chest pain | 81 | ||
| Diagnostic reasoning: Focused history | 81 | ||
| Characteristics of pain | 81 | ||
| Onset of pain | 82 | ||
| Duration | 82 | ||
| Associated symptoms | 82 | ||
| Does the patient have risk factors for coronary artery disease? | 82 | ||
| Risk factors | 82 | ||
| If this is not a life-threatening condition, what does a description of the pain tell me? | 82 | ||
| Acute or chronic | 83 | ||
| Location and character of pain | 83 | ||
| Sleep | 83 | ||
| What do associated symptoms tell me? | 83 | ||
| Cough and sputum production | 83 | ||
| Fever | 84 | ||
| Lightheadedness, dizziness, or fainting | 84 | ||
| Palpitations | 84 | ||
| Is the pattern of pain related to activity and position change? | 84 | ||
| Recent activities | 84 | ||
| History of chest trauma | 84 | ||
| Pain with movement | 84 | ||
| Is there a gastrointestinal origin for the patient’s chest pain? | 84 | ||
| Food association | 84 | ||
| Could this pain be from a systemic cause? | 85 | ||
| Skin symptoms | 85 | ||
| Systemic conditions | 85 | ||
| What does the family history tell me? | 85 | ||
| Family history | 85 | ||
| What is the emotional state of the patient? | 85 | ||
| Panic disorder | 86 | ||
| Diagnostic reasoning: Focused physical examination | 86 | ||
| Observe general appearance | 86 | ||
| Measure vital signs and note respiratory patterns | 86 | ||
| Inspect the skin | 86 | ||
| Palpate trachea and chest | 86 | ||
| Percuss the chest | 87 | ||
| Auscultate breath sounds | 87 | ||
| Auscultate for adventitious sounds | 87 | ||
| Auscultate heart sounds | 88 | ||
| Observe the spine for evidence of scoliosis | 88 | ||
| Examine the abdomen | 88 | ||
| Examine the extremities | 88 | ||
| Laboratory and diagnostic studies | 88 | ||
| Electrocardiogram | 88 | ||
| Stress testing | 88 | ||
| Exercise myocardial perfusion imaging | 89 | ||
| Echocardiography | 89 | ||
| Computed tomography scanning | 89 | ||
| Ventilation-perfusion lung scan | 89 | ||
| Pulmonary angiography | 89 | ||
| Radiography | 89 | ||
| Magnetic resonance imaging | 89 | ||
| Abdominal ultrasound | 89 | ||
| Bronchoscopy | 89 | ||
| Endoscopy | 90 | ||
| Esophageal pH | 90 | ||
| Cardiac enzymes | 90 | ||
| D-dimer assay | 90 | ||
| Arterial blood gases | 90 | ||
| Activated partial thromboplastin time and prothrombin time | 90 | ||
| Serum amylase and lipase | 90 | ||
| Complete blood count | 90 | ||
| Erythrocyte sedimentation rate | 90 | ||
| Differential diagnosis of common causes of emergent chest pain | 90 | ||
| Acute myocardial infarction | 90 | ||
| Aortic dissection | 91 | ||
| Acute coronary insufficiency | 91 | ||
| Pulmonary embolus | 91 | ||
| Pneumothorax | 92 | ||
| Arrhythmias | 92 | ||
| Congenital coronary anomalies | 92 | ||
| Common causes of nonemergent chest pain | 92 | ||
| References and readings | 96 | ||
| 9 Confusion in older adults | 97 | ||
| Diagnostic reasoning: Focused history | 97 | ||
| Onset and duration | 98 | ||
| Fluctuation in symptoms | 98 | ||
| Disturbance in sleep/wake cycle | 98 | ||
| Level of consciousness | 98 | ||
| Hallucinations | 98 | ||
| Head trauma | 98 | ||
| Are there any associated symptoms that will point me in the right direction? | 98 | ||
| Tremor and gait disturbance | 98 | ||
| Headache, nausea, and fever | 98 | ||
| Change in weight and usual activities | 98 | ||
| What does the pattern of cognitive losses tell me? | 99 | ||
| Changes in mental abilities and behaviors | 99 | ||
| Is the confusion caused by a concurrent health problem? | 99 | ||
| Current and past health status | 99 | ||
| Could the confusion be caused by medication? | 100 | ||
| Medications | 100 | ||
| Taking medication correctly | 100 | ||
| What risk factors do I need to consider? | 100 | ||
| Age | 100 | ||
| Polypharmacy | 100 | ||
| Human immunodeficiency virus | 100 | ||
| Recent bereavement | 100 | ||
| Diagnostic reasoning: Focused physical examination | 100 | ||
| Take vital signs | 100 | ||
| Note level of consciousness | 100 | ||
| Perform a mental status examination | 100 | ||
| Perform a complete neurological examination | 101 | ||
| Perform a respiratory examination | 103 | ||
| Evaluate the cardiovascular system | 103 | ||
| Examine the abdomen | 103 | ||
| Laboratory and diagnostic studies | 103 | ||
| Complete blood count | 103 | ||
| Blood chemistry | 103 | ||
| Thyroid function tests | 103 | ||
| Serum B₁₂ and folate | 103 | ||
| Serology for syphilis | 103 | ||
| Arterial blood gases | 103 | ||
| Toxicology screen and blood alcohol level | 104 | ||
| Urinalysis | 104 | ||
| Chest radiograph | 104 | ||
| Lumbar puncture | 104 | ||
| Electrocardiography | 104 | ||
| Electroencephalography | 104 | ||
| Computed tomography or magnetic resonance imaging | 104 | ||
| Positron emission tomography scan | 104 | ||
| Differential diagnosis | 104 | ||
| Delirium | 104 | ||
| Confusion | 104 | ||
| Dementia | 104 | ||
| Depression | 107 | ||
| References and readings | 109 | ||
| 10 Constipation | 110 | ||
| Diagnostic reasoning: Focused history | 110 | ||
| Frequency of stool | 110 | ||
| Stool consistency | 110 | ||
| What red flags do I need to consider? | 110 | ||
| Bleeding | 111 | ||
| Unintentional weight loss | 111 | ||
| History of inflammatory bowel disease (ibd)/colorectal cancer | 111 | ||
| Is the constipation acute or chronic? | 111 | ||
| Onset and duration | 111 | ||
| Age of onset | 111 | ||
| If the constipation is acute, what conditions should I consider? | 111 | ||
| Recent illness | 111 | ||
| Chronic illness | 111 | ||
| If the constipation is chronic or recurrent, what should I consider? | 111 | ||
| Dietary pattern | 111 | ||
| Breakfast | 112 | ||
| Bowel habits | 112 | ||
| Activity level | 112 | ||
| Medications | 112 | ||
| Use of enemas, laxatives, and suppositories | 112 | ||
| How can I further narrow the causes? | 112 | ||
| Size or caliber of stool | 112 | ||
| Consistency of stool/fecal incontinence | 112 | ||
| Alternating constipation and diarrhea | 112 | ||
| What else do I need to consider? | 112 | ||
| Urge to defecate | 112 | ||
| Associated urinary tract problems | 112 | ||
| Vomiting | 112 | ||
| Pain | 113 | ||
| Bleeding | 113 | ||
| Color | 113 | ||
| If this is a child, is there anything else I need to consider? | 113 | ||
| Crying with defecation | 113 | ||
| Fecal soiling of underpants | 113 | ||
| History of delayed passage of meconium stool | 113 | ||
| Change in diet | 113 | ||
| Toilet training | 113 | ||
| History of urinary frequency | 113 | ||
| Is there a family history or genetic predisposition? | 113 | ||
| Diagnostic reasoning: Focused physical examination | 113 | ||
| Plot growth curve in children | 113 | ||
| Perform abdominal examination | 113 | ||
| Perform digital rectal examination | 114 | ||
| Perform a focused neurological examination | 114 | ||
| Laboratory and diagnostic studies | 114 | ||
| Fecal occult blood test | 114 | ||
| Fecal immunochemical test | 115 | ||
| Fecal/stool DNA | 115 | ||
| Complete blood count | 115 | ||
| Serum electrolytes | 115 | ||
| Serum thyroid-stimulating hormone | 115 | ||
| Urinalysis | 115 | ||
| Anoscopy | 115 | ||
| Flexible sigmoidoscopy and colonoscopy | 115 | ||
| Barium enema | 115 | ||
| Colon transit studies | 115 | ||
| Anorectal manometry | 115 | ||
| Differential diagnosis | 115 | ||
| Simple constipation | 116 | ||
| Functional constipation | 116 | ||
| Irritable bowel syndrome (IBS) | 116 | ||
| Fecal impaction | 116 | ||
| Idiopathic slow transit | 116 | ||
| Hirschsprung disease (congenital aganglionic megacolon) | 116 | ||
| Secondary constipation from anorectal lesion | 116 | ||
| Drug-induced constipation | 116 | ||
| Tumors | 116 | ||
| References and readings | 117 | ||
| 11 Cough | 118 | ||
| Diagnostic reasoning: Focused history | 118 | ||
| Duration | 118 | ||
| Shortness of breath | 119 | ||
| History of asthma | 119 | ||
| Foreign body | 119 | ||
| What do I need to know if the cough is acute (less than 3 weeks duration)? | 119 | ||
| Nasal congestion | 119 | ||
| Fever | 119 | ||
| Headache | 120 | ||
| What does the nature of the sputum tell me? | 120 | ||
| What does the nature of the cough tell me? | 120 | ||
| Severity and progression of cough | 120 | ||
| Timing of cough | 120 | ||
| History of choking episode | 120 | ||
| Occupation | 120 | ||
| Nature of the cough | 121 | ||
| Is the cough related to any event that would help me narrow down the cause? | 121 | ||
| Eating | 121 | ||
| Season | 121 | ||
| Exercise | 121 | ||
| Is this something that is going around? | 121 | ||
| Is there anything that would lead me to suspect allergies or reactive airway disease? | 121 | ||
| Family history | 121 | ||
| Environmental exposure | 122 | ||
| Smoke exposure | 122 | ||
| Getting better or worse | 122 | ||
| Does the patient have any risk factors for systemic disease that could present with cough? | 122 | ||
| Chronic health problems | 122 | ||
| Immunocompromise | 122 | ||
| Tuberculosis | 122 | ||
| Immunization | 122 | ||
| Diagnostic reasoning: Focused physical examination | 122 | ||
| Note general appearance | 122 | ||
| Assess mental status | 122 | ||
| Take vital signs | 123 | ||
| Weigh the patient | 123 | ||
| Examine the head and neck | 123 | ||
| Inspect the chest for shape, symmetry, and use of accessory muscles | 123 | ||
| Observe respirations | 123 | ||
| Listen to the cough | 123 | ||
| Palpate the chest | 124 | ||
| Percuss the chest | 124 | ||
| Auscultate breath sounds | 124 | ||
| Auscultate heart sounds | 124 | ||
| Examine the skin and extremities | 124 | ||
| Examine the abdomen | 124 | ||
| Laboratory and diagnostic studies | 124 | ||
| Complete blood count | 125 | ||
| Esophageal probe | 125 | ||
| Sputum culture | 125 | ||
| Sweat test | 125 | ||
| Tuberculin skin testing | 125 | ||
| Nasal swab for pertussis and polymerase chain reaction | 125 | ||
| Rapid influenza testing | 125 | ||
| Chest radiograph | 126 | ||
| Differential diagnosis | 126 | ||
| Common cold (nasopharyngitis) | 126 | ||
| Chronic obstructive pulmonary disease exacerbation | 126 | ||
| Bordetella pertussis infection | 126 | ||
| Bacterial pneumonia | 126 | ||
| Viral upper respiratory infection | 127 | ||
| Mycoplasma pneumoniae | 127 | ||
| Chlamydial pneumonia | 127 | ||
| Bronchiolitis | 127 | ||
| Acute bronchitis | 127 | ||
| Croup (acute laryngotracheobronchitis) | 127 | ||
| Subacute and chronic cough | 127 | ||
| Gastroesophageal reflux disease | 128 | ||
| Chronic bronchitis | 128 | ||
| Angiotensin-converting enzyme inhibitor–induced cough | 128 | ||
| Bronchogenic carcinoma | 128 | ||
| Cystic fibrosis | 128 | ||
| Foreign body aspiration | 128 | ||
| Allergic rhinitis | 129 | ||
| Chronic sinusitis | 129 | ||
| Tuberculosis | 129 | ||
| Smoking | 129 | ||
| Psychogenic origin | 129 | ||
| References and readings | 131 | ||
| 12 Diarrhea | 133 | ||
| Diagnostic reasoning: Focused history | 133 | ||
| Frequency of stools | 133 | ||
| Stool volume and consistency | 133 | ||
| Intervals | 133 | ||
| Proximal colon symptoms | 133 | ||
| Distal colon symptoms | 133 | ||
| If this is an infant, is there a risk of dehydration? | 134 | ||
| Wet diapers | 134 | ||
| Thirst | 134 | ||
| Tears | 134 | ||
| If this is an adult, is there risk for dehydration? | 134 | ||
| Dehydration | 134 | ||
| Is this an acute or chronic problem? | 134 | ||
| Acute diarrhea in adults | 134 | ||
| Acute diarrhea in children | 134 | ||
| Chronic diarrhea in adults | 134 | ||
| Chronic diarrhea in children | 134 | ||
| Does the presence or absence of blood help me narrow the cause? | 135 | ||
| Blood in the stools | 135 | ||
| Color of stools | 135 | ||
| What does the presence or absence of pain tell me? | 135 | ||
| Occurrence of pain | 135 | ||
| Location of pain | 135 | ||
| Severity of pain | 135 | ||
| Sleep-related pain | 136 | ||
| What do associated symptoms tell me? | 136 | ||
| Fever | 136 | ||
| Vomiting | 136 | ||
| Occurrence of vomiting and diarrhea | 136 | ||
| Could this be caused by exposure to others or to contaminated food? | 136 | ||
| Day care attendance | 136 | ||
| Others with similar symptoms | 136 | ||
| Could this be the result of exposure to animals? | 136 | ||
| Exposure to infectious agents through animal contact | 136 | ||
| Could this be caused by exposure to contaminated water? | 136 | ||
| Recent travel | 136 | ||
| Could sexual activities explain the diarrhea? | 136 | ||
| Could this be the result of an immune problem? | 137 | ||
| Immunocompromised host | 137 | ||
| Could this be caused by medications? | 137 | ||
| Recent treatment with antibiotics | 137 | ||
| Medications | 137 | ||
| Could this be related to a surgical procedure? | 137 | ||
| Recent gastrointestinal surgery | 137 | ||
| Is this diet-related? | 137 | ||
| Excessive intake of high-carbohydrate fluids | 137 | ||
| Lactose intolerance | 137 | ||
| Cow’s milk protein/soy protein hypersensitivity | 137 | ||
| Celiac sprue (gluten enteropathy) | 137 | ||
| Starvation stools | 137 | ||
| Could this be caused by food preparation problems? | 138 | ||
| Dietary exposure to infectious agents | 138 | ||
| Other ill people | 138 | ||
| Is there any family predisposition that can point to a cause? | 138 | ||
| Family history of cystic fibrosis | 138 | ||
| Family history of diarrheal illnesses | 138 | ||
| Diagnostic reasoning: Focused physical examination | 138 | ||
| Inspect general appearance | 138 | ||
| Assess hydration status | 138 | ||
| Indicators of hydration status | 139 | ||
| Measure temperature | 139 | ||
| Weigh patient and note persistent or involuntary weight loss | 139 | ||
| Observe abdominal contour | 139 | ||
| Auscultate the abdomen | 139 | ||
| Palpate the abdomen for tenderness | 139 | ||
| Perform a digital rectal examination | 139 | ||
| Palpate lymph nodes | 140 | ||
| Laboratory and diagnostic studies | 140 | ||
| Fecal leukocytes | 140 | ||
| Fecal occult blood testing | 140 | ||
| Fecal immunochemical test | 140 | ||
| Fecal fat | 140 | ||
| D-xylose absorption test | 140 | ||
| Stool pH | 140 | ||
| Wet mount | 140 | ||
| C. difficile toxin assay | 140 | ||
| Stool culture | 141 | ||
| Stool for ova and parasites | 141 | ||
| Giardia antigen test | 141 | ||
| Indirect hemagglutinin assay | 141 | ||
| Tissue transglutaminase antibody | 141 | ||
| PCR testing | 141 | ||
| Complete blood count with differential | 141 | ||
| Peripheral blood smear | 141 | ||
| Blood urea nitrogen and creatinine | 141 | ||
| Endoscopic studies | 141 | ||
| Differential diagnosis | 141 | ||
| Acute diarrhea | 141 | ||
| Chronic diarrhea | 143 | ||
| References and readings | 147 | ||
| 13 Dizziness | 148 | ||
| Diagnostic reasoning: Focused history | 148 | ||
| Sensation | 148 | ||
| Other health problems | 149 | ||
| Anxiety | 149 | ||
| Relationship to activity or movement | 149 | ||
| Is the vertigo central (brainstem or cerebellar) or peripheral (vestibular) in origin? | 149 | ||
| Headaches | 149 | ||
| Other symptoms | 149 | ||
| Timing | 149 | ||
| What do characteristics of the episodes tell me? | 150 | ||
| Duration of episodes | 150 | ||
| Onset | 150 | ||
| Hearing loss and tinnitus | 150 | ||
| What else should I consider? | 150 | ||
| Medications | 150 | ||
| Current or recent illness | 150 | ||
| History of head trauma | 150 | ||
| Previous otology history and procedures | 151 | ||
| Diagnostic reasoning: Focused physical examination | 151 | ||
| Take vital signs and note blood pressure | 151 | ||
| Note general appearance | 151 | ||
| Have patient hyperventilate and perform valsalva maneuver | 151 | ||
| Perform vision examination | 151 | ||
| Perform ear examination | 151 | ||
| Perform screening hearing tests | 151 | ||
| Assess nystagmus | 151 | ||
| Perform positional nystagmus testing/provoking maneuvers | 152 | ||
| Assess the vestibular ocular reflex | 152 | ||
| Perform neurological examination | 153 | ||
| Perform cardiovascular evaluation | 154 | ||
| Laboratory and diagnostic studies | 154 | ||
| Audiometry | 154 | ||
| Electronystagmography | 154 | ||
| Magnetic resonance imaging | 154 | ||
| Computed tomography | 154 | ||
| Electroencephalography | 154 | ||
| Cardiac monitoring | 154 | ||
| Hematology and urinalysis | 154 | ||
| Serological testing for syphilis | 154 | ||
| Differential diagnosis | 154 | ||
| Central causes | 154 | ||
| Peripheral causes | 155 | ||
| Systemic causes | 156 | ||
| Other causes | 156 | ||
| References and readings | 158 | ||
| 14 Dyspnea | 159 | ||
| Diagnostic reasoning: Focused history | 159 | ||
| Onset | 159 | ||
| Foreign body aspiration | 159 | ||
| Anaphylaxis | 160 | ||
| Is the dyspnea caused by a secondary obstruction in the lower respiratory tract? | 160 | ||
| Cough | 160 | ||
| History of asthma | 160 | ||
| Is the dyspnea caused by trauma to the chest? | 160 | ||
| Trauma | 160 | ||
| Is the dyspnea caused by a pulmonary embolus? | 160 | ||
| Confinement, surgery, and fracture | 160 | ||
| Family history of clotting disorders | 161 | ||
| Trauma to leg | 161 | ||
| Anxiety | 161 | ||
| Oral contraceptives/estrogen | 161 | ||
| Medications | 161 | ||
| Is the dyspnea related to a preexisting disease? | 161 | ||
| Past history of disease | 161 | ||
| Hyperventilation | 162 | ||
| What factors precipitate or aggravate the dyspnea? | 162 | ||
| Precipitating factors | 162 | ||
| Medication use | 162 | ||
| Allergies | 162 | ||
| Alleviating factors | 162 | ||
| Is the dyspnea caused by a neuromuscular problem? | 162 | ||
| Immunizations | 162 | ||
| Honey | 162 | ||
| Farm residence | 162 | ||
| Neuromuscular effects | 163 | ||
| Secondary causes | 163 | ||
| Does the patient have any pertinent risk factors that will point me in the right direction? | 163 | ||
| Risk factors | 163 | ||
| Work | 163 | ||
| Obesity | 163 | ||
| Eczema history | 163 | ||
| Diagnostic reasoning: Focused physical examination | 163 | ||
| Note general appearance and observe posture | 163 | ||
| Assess level of consciousness | 163 | ||
| Observe chest movement | 164 | ||
| Inspect the shape and symmetry of the chest | 164 | ||
| Look for retractions | 164 | ||
| Observe the rate, rhythm, and depth of respiration for 1 full minute | 164 | ||
| Listen for stridor | 165 | ||
| Listen for audible wheeze | 165 | ||
| Listen for voice changes | 165 | ||
| Take pulse, temperature, and blood pressure | 165 | ||
| Inspect the oral cavity | 165 | ||
| Inspect the nose | 166 | ||
| Palpate the neck | 166 | ||
| Examine the skin and extremities | 166 | ||
| Palpate the chest | 166 | ||
| Assess for tactile fremitus | 166 | ||
| Percuss the chest | 166 | ||
| Auscultate breath sounds | 167 | ||
| Auscultate heart sounds | 167 | ||
| Laboratory and diagnostic studies | 168 | ||
| Transcutaneous pulse oximetry | 168 | ||
| Chest radiography | 168 | ||
| Electrocardiography | 168 | ||
| Echocardiography | 168 | ||
| Hemoglobin and hematocrit | 168 | ||
| Spirometry | 168 | ||
| Additional testing | 168 | ||
| Differential diagnosis | 169 | ||
| Emergent conditions manifested by dyspnea | 169 | ||
| Nonemergent conditions manifested by dyspnea | 170 | ||
| References and readings | 173 | ||
| 15 Earache | 174 | ||
| Diagnostic reasoning: Focused history | 174 | ||
| Age | 174 | ||
| Fever | 174 | ||
| Upper respiratory infection | 174 | ||
| Previous infections | 174 | ||
| Family history | 174 | ||
| What environmental conditions might suggest increased risk? | 174 | ||
| Smoke exposure | 175 | ||
| Attending day care | 175 | ||
| Bottle propping | 175 | ||
| Swimming | 176 | ||
| Airplane travelers, divers | 176 | ||
| Could this be related to another organ system? | 176 | ||
| Diabetes mellitus | 176 | ||
| Immunosuppression | 176 | ||
| History of seborrheic dermatitis or psoriasis | 176 | ||
| Cleft palate | 176 | ||
| What does the presence of pain tell me? | 176 | ||
| Location of the pain | 176 | ||
| Quality of the pain | 176 | ||
| Quantity and severity of the pain | 176 | ||
| Onset, timing, and duration of the pain | 176 | ||
| What does the presence of discharge or itching tell me? | 177 | ||
| Itching or drainage | 177 | ||
| What does a history of trauma or injury tell me? | 177 | ||
| Ear trauma | 177 | ||
| Head trauma | 177 | ||
| Cerumen impaction | 177 | ||
| Foreign bodies | 177 | ||
| Insect bites | 177 | ||
| Loud noise | 177 | ||
| Is hearing loss a clue? | 177 | ||
| Difficulty in hearing | 178 | ||
| Hearing loss in children | 178 | ||
| Dizziness, ringing in ear | 178 | ||
| Diagnostic reasoning: Focused physical examination | 178 | ||
| Note behaviors in children | 178 | ||
| Inspect external ears | 178 | ||
| Palpate external ears | 178 | ||
| Inspect ear canals | 178 | ||
| Inspect tympanic membranes | 179 | ||
| Perform pneumatic otoscopy (insufflation) | 179 | ||
| Test hearing acuity | 179 | ||
| Examine related body systems | 180 | ||
| Perform an intraotic manipulation | 180 | ||
| Evaluate cranial nerves V, VII, and IX | 180 | ||
| Laboratory and diagnostic studies | 180 | ||
| Tympanometry | 180 | ||
| Audiometry | 180 | ||
| Mastoid process radiography | 180 | ||
| Computed tomography scanning | 180 | ||
| Differential diagnosis | 180 | ||
| External otitis | 180 | ||
| Acute otitis media | 181 | ||
| Otitis media with effusion | 181 | ||
| Cholesteatoma | 181 | ||
| Mastoiditis | 182 | ||
| Foreign bodies | 182 | ||
| Cerumen impaction | 182 | ||
| Barotrauma | 182 | ||
| Trauma | 182 | ||
| Cervical lymphadenitis | 182 | ||
| Referred pain from cervical and cranial nerves | 182 | ||
| Temporomandibular joint disorder | 182 | ||
| References and readings | 183 | ||
| 16 Fatigue | 184 | ||
| Diagnostic reasoning: Focused history | 184 | ||
| Fatigue versus weakness | 184 | ||
| Lifestyle habits | 184 | ||
| Sleep pattern | 185 | ||
| Last normal menstrual period | 185 | ||
| Do I need to consider an organic cause? | 185 | ||
| Exposure to body fluids | 185 | ||
| Medications | 185 | ||
| Alcohol and drug use | 185 | ||
| What other clues can help me rule out an organic cause? | 185 | ||
| Appetite | 185 | ||
| Weight loss | 185 | ||
| Increased urination | 185 | ||
| Joint tenderness | 185 | ||
| Associated symptoms | 186 | ||
| Could this have an environmental cause? | 186 | ||
| Occupational exposure | 186 | ||
| Camping | 186 | ||
| What else do I need to know about the fatigue? | 186 | ||
| Onset and pattern | 186 | ||
| Severity | 186 | ||
| Aggravating/alleviating factors | 186 | ||
| Fever | 186 | ||
| Bleeding | 186 | ||
| If I suspect a psychological cause, what else do I need to know? | 186 | ||
| Stress | 186 | ||
| Anxiety and depression | 186 | ||
| School performance | 187 | ||
| Diagnostic reasoning: Focused physical examination | 187 | ||
| Note general appearance | 187 | ||
| Take vital signs | 187 | ||
| Inspect skin, hair, and nails | 187 | ||
| Examine the nose, eyes, mouth, and throat | 187 | ||
| Conduct a cardiovascular examination | 187 | ||
| Examine the lungs | 187 | ||
| Examine the abdomen | 187 | ||
| Perform a musculoskeletal examination | 188 | ||
| Conduct a neurological examination | 188 | ||
| Laboratory and diagnostic studies | 188 | ||
| Complete blood count with indices and differential | 188 | ||
| Ferritin | 188 | ||
| Total iron-binding capacity | 188 | ||
| Urinalysis | 188 | ||
| Erythrocyte sedimentation rate | 188 | ||
| Fasting blood glucose | 188 | ||
| Hepatic function | 189 | ||
| Thyroid-stimulating hormone | 189 | ||
| HIV infection | 189 | ||
| Tuberculin skin testing | 189 | ||
| Monospot | 189 | ||
| Chest radiograph | 189 | ||
| Differential diagnosis | 189 | ||
| Physiological causes | 189 | ||
| Psychological causes | 190 | ||
| Organic causes of acute fatigue | 190 | ||
| Organic causes of chronic fatigue | 190 | ||
| References and readings | 193 | ||
| 17 Fever | 194 | ||
| Diagnostic reasoning: Focused history | 194 | ||
| Occurrence of fever | 194 | ||
| Measurement of temperature | 194 | ||
| Should sepsis or meningitis be of concern? | 195 | ||
| Head trauma, otitis media, and contact | 195 | ||
| Headache, vomiting, lethargy, or stiff neck | 195 | ||
| Infant | 195 | ||
| What does the pattern of fever tell me? | 195 | ||
| Duration of fever | 195 | ||
| Height of fever | 195 | ||
| Is the fever caused by a localized infection? | 195 | ||
| Location of symptoms | 195 | ||
| Genitourinary tract | 196 | ||
| Ear, nose, and throat symptoms | 196 | ||
| Respiratory or gastrointestinal symptoms | 196 | ||
| Joint pain | 196 | ||
| Can I narrow the diagnostic possibilities or eliminate a cause? | 196 | ||
| Skin rash | 196 | ||
| Ache | 196 | ||
| Does the patient have an increased risk for complications? | 196 | ||
| Chronic disease | 196 | ||
| Health problems, surgery, and recent infection | 196 | ||
| Sexual activity | 197 | ||
| Immunizations | 197 | ||
| Tuberculosis or hepatitis exposure | 197 | ||
| Does the parent report a behavior change in the child? | 197 | ||
| Could the fever be caused by something acquired while traveling? | 197 | ||
| Travel | 197 | ||
| Camping | 197 | ||
| Could the fever be medication-related or caused by poisoning? | 197 | ||
| Medications | 197 | ||
| Food poisoning | 197 | ||
| Plants | 197 | ||
| Could exposure to animals explain the fever? | 198 | ||
| Cat-scratch disease | 198 | ||
| Animal exposure | 198 | ||
| Could this be the result of a recent immunization? | 198 | ||
| Immunization reactions | 198 | ||
| Could the fever be caused by heat exposure? | 199 | ||
| Overdressing | 199 | ||
| Air conditioning and room temperature | 199 | ||
| Diagnostic reasoning: Focused physical examination | 199 | ||
| Fever in a child younger than 2 months old | 199 | ||
| Observe the patient | 200 | ||
| Take vital signs and note temperature | 200 | ||
| Observe skin and mucous membranes | 201 | ||
| Examine the head and neck | 201 | ||
| Palpate the lymph nodes | 201 | ||
| Examine the heart, lungs and chest | 201 | ||
| Palpate breasts if indicated | 201 | ||
| Examine abdomen if indicated | 201 | ||
| Examine genitourinary system if indicated | 201 | ||
| Examine musculoskeletal system if indicated | 202 | ||
| Perform neurological/mental status examination | 202 | ||
| Laboratory and diagnostic studies | 202 | ||
| Complete blood count | 202 | ||
| Erythrocyte sedimentation rate | 202 | ||
| Antistreptolysin titer | 203 | ||
| HIV testing | 203 | ||
| Urinalysis | 203 | ||
| Urine culture and sensitivity | 203 | ||
| Stool for leukocytes | 203 | ||
| Stool culture and sensitivity | 203 | ||
| Stool sample for ova and parasites | 203 | ||
| Sputum for acid-fast bacilli | 203 | ||
| Sputum for gram staining | 203 | ||
| Sputum for culture and sensitivity | 203 | ||
| Cultures of discharge | 203 | ||
| Molecular testing for infectious organisms | 203 | ||
| Blood cultures | 204 | ||
| Lumbar puncture | 204 | ||
| Radiographic imaging | 204 | ||
| Differential diagnosis | 204 | ||
| Upper respiratory infection | 204 | ||
| Gastroenteritis | 204 | ||
| Urinary tract infection | 204 | ||
| Pelvic inflammatory disease | 204 | ||
| Prostatitis | 204 | ||
| Pharyngitis | 204 | ||
| Acute sinusitis | 204 | ||
| Ear infections | 205 | ||
| Meningitis | 205 | ||
| Osteomyelitis | 205 | ||
| Kawasaki disease | 205 | ||
| Factitious fever | 205 | ||
| Roseola infantum | 205 | ||
| Fevers without localizing signs | 205 | ||
| Enterovirus | 206 | ||
| Occult bacteremia | 206 | ||
| Periodic fever in children | 206 | ||
| References and readings | 207 | ||
| 18 Genitourinary problems in males | 208 | ||
| Diagnostic reasoning: Focused history | 208 | ||
| Fever and chills | 208 | ||
| Immunocompromised patients | 208 | ||
| Anuria | 209 | ||
| Is there hematuria? | 209 | ||
| Hematuria | 209 | ||
| Timing | 209 | ||
| Pain | 209 | ||
| Can the symptoms be localized within the urinary tract? | 209 | ||
| Slow urinary stream, hesitancy, intermittency, dribbling of urine | 209 | ||
| Low back, flank, or abdominal pain | 209 | ||
| Testicular/scrotal pain | 211 | ||
| Aching in the perineal area | 211 | ||
| Suprapubic discomfort and urinary incontinence | 211 | ||
| Penile discharge with frequency, urgency, and dysuria | 211 | ||
| Nocturia | 211 | ||
| Polyuria | 211 | ||
| Are there any risk factors to point me in the right direction? | 211 | ||
| History of similar problems | 211 | ||
| Family history of urinary problems | 211 | ||
| Age | 211 | ||
| Confinement to bed | 211 | ||
| Sexual activity | 211 | ||
| Bicycle riding | 212 | ||
| What else could this be? | 212 | ||
| Recent procedure or catheter | 212 | ||
| Recent sexually transmitted infection | 212 | ||
| Drugs | 212 | ||
| Toxic exposures | 212 | ||
| Scrotal swelling | 212 | ||
| Diagnostic reasoning: Focused physical examination | 212 | ||
| Note general appearance | 212 | ||
| Obtain vital signs | 212 | ||
| Inspect skin and mucous membranes | 212 | ||
| Palpate and percuss for flank pain at the costovertebral angle | 212 | ||
| Auscultate the abdomen | 212 | ||
| Palpate and percuss the abdomen | 212 | ||
| Inspect and palpate the external genitalia | 213 | ||
| Observe voiding | 213 | ||
| Perform digital rectal prostate examination | 213 | ||
| Laboratory and diagnostic studies | 213 | ||
| Urine dipstick | 213 | ||
| Urinalysis with microscopic examination | 214 | ||
| Segmented urine collection (meares-stamey 4-glass test) for gram stain, culture and sensitivity, and leukocyte count | 214 | ||
| Urodynamic testing | 215 | ||
| Gram stain | 215 | ||
| Culture and sensitivity | 215 | ||
| DNA testing for infectious organisms | 215 | ||
| Creatinine and blood urea nitrogen | 215 | ||
| Prostate-specific antigen | 215 | ||
| Radiography | 215 | ||
| Ultrasound | 215 | ||
| Computed tomography | 216 | ||
| Doppler flow studies | 216 | ||
| Biopsy | 216 | ||
| Differential diagnosis | 216 | ||
| Cystitis/urethritis | 216 | ||
| Pyelonephritis | 216 | ||
| Urolithiasis | 217 | ||
| Acute bacterial prostatitis | 217 | ||
| Chronic bacterial prostatitis | 217 | ||
| Chronic prostatitis/chronic pelvic pain syndrome | 217 | ||
| Asymptomatic inflammatory prostatitis | 217 | ||
| Epididymitis/orchitis | 217 | ||
| Testicular torsion | 218 | ||
| Hydrocele, spermatocele, and varicocele | 218 | ||
| Benign prostatic hyperplasia | 218 | ||
| Prostate cancer | 218 | ||
| Bladder or kidney tumor | 218 | ||
| Perineal compression syndrome | 218 | ||
| References and readings | 220 | ||
| 19 Headache | 221 | ||
| Diagnostic reasoning: Focused history | 221 | ||
| Onset and severity | 223 | ||
| History of trauma | 223 | ||
| Associated symptoms | 223 | ||
| Presence of chronic disease | 223 | ||
| After determining that a headache is not serious, how can I narrow down the causes? | 224 | ||
| Characteristics of the pain | 224 | ||
| Location | 224 | ||
| Aggravating factors | 224 | ||
| Duration | 224 | ||
| Aura and prodrome | 224 | ||
| What does the chronicity of pain suggest? | 224 | ||
| Frequency | 224 | ||
| Pattern and duration of headache | 225 | ||
| Prior history of headache | 225 | ||
| Age of patient at first onset | 225 | ||
| Lifestyle habits and medications | 226 | ||
| What other symptoms does the patient have? | 226 | ||
| Nausea and vomiting | 226 | ||
| Vision changes | 226 | ||
| Photophobia | 226 | ||
| Dizziness | 226 | ||
| What do the alleviating and aggravating factors suggest? | 226 | ||
| Alleviating factors | 226 | ||
| Aggravating factors | 226 | ||
| What does family history indicate? | 226 | ||
| Family history | 226 | ||
| Is there anything else that would help narrow the cause or causes? | 226 | ||
| Recent health history | 226 | ||
| History of medications | 227 | ||
| Exposures | 227 | ||
| Diagnostic reasoning: Focused physical examination | 227 | ||
| Observe the patient | 227 | ||
| Take vital signs and obtain growth parameters | 227 | ||
| Palpate and percuss the skull | 227 | ||
| Auscultate the cranium | 227 | ||
| Inspect the ears, eyes, nose, mouth, and tmj | 227 | ||
| Perform ophthalmoscopy | 228 | ||
| Assess cranial nerve function | 228 | ||
| Examine the neck | 228 | ||
| Test for meningismus | 228 | ||
| Assess motor strength and coordination of extremities | 229 | ||
| Test balance and gait | 229 | ||
| Assess deep tendon reflexes | 229 | ||
| Have children draw pictures of their headaches | 229 | ||
| Laboratory and diagnostic studies | 229 | ||
| Complete blood count | 229 | ||
| Blood cultures | 229 | ||
| Computed tomography scan | 229 | ||
| Magnetic resonance imaging | 229 | ||
| Lumbar puncture | 229 | ||
| Erythrocyte sedimentation rate | 229 | ||
| Skull radiograph | 229 | ||
| Differential diagnosis | 229 | ||
| Primary headaches | 229 | ||
| Secondary headaches | 230 | ||
| References and readings | 234 | ||
| 20 Heartburn and indigestion | 235 | ||
| Diagnostic reasoning: Focused history | 235 | ||
| Alarm symptoms | 235 | ||
| Symptom characteristics | 236 | ||
| Cardiac risk factors | 236 | ||
| What symptom characteristics will help me narrow the differential? | 236 | ||
| Description of the sensation | 236 | ||
| Regurgitation | 236 | ||
| Postprandial fullness, early satiation | 236 | ||
| Aggravating or precipitating factors | 236 | ||
| Relieving factors | 236 | ||
| Nocturnal symptoms | 237 | ||
| Extraesophageal symptoms | 237 | ||
| Is this patient at risk for a serious underlying condition? | 237 | ||
| At-risk patients | 237 | ||
| What else do I need to consider? | 237 | ||
| Child | 237 | ||
| Recent GI surgery | 237 | ||
| Medications | 237 | ||
| Alcohol | 237 | ||
| Diagnostic reasoning: Focused physical examination | 238 | ||
| Note general appearance | 238 | ||
| Assess vital signs | 238 | ||
| Assess weight | 238 | ||
| Inspect the eyes, nose, and mouth | 238 | ||
| Palpate supraclavicular lymph nodes | 238 | ||
| Examine the skin | 238 | ||
| Auscultate the lungs and percuss the chest | 238 | ||
| Auscultate heart sounds | 238 | ||
| Percuss and palpate the abdomen | 238 | ||
| Laboratory and diagnostic studies | 238 | ||
| Complete blood count | 238 | ||
| Blood chemistries | 238 | ||
| Response to antacids | 239 | ||
| Trial of proton pump inhibitors | 239 | ||
| Sublingual nitroglycerin | 239 | ||
| Helicobacter pylori testing | 239 | ||
| Endoscopy | 239 | ||
| Esophageal pH monitoring | 239 | ||
| Esophageal manometry | 239 | ||
| Upper GI series | 239 | ||
| Electrocardiography and cardiac enzymes | 239 | ||
| Differential diagnosis | 239 | ||
| Gastroesophageal reflux | 239 | ||
| Gastroesophageal reflux disease or reflux esophagitis | 240 | ||
| Other causes of esophagitis | 240 | ||
| Functional heartburn | 241 | ||
| Hiatal hernia | 241 | ||
| Peptic ulcer disease | 241 | ||
| Esophageal cancer | 241 | ||
| Gastric cancer | 242 | ||
| Gastritis | 242 | ||
| Dyspepsia | 242 | ||
| Functional dyspepsia (nonulcer dyspepsia) | 242 | ||
| Gas and gas entrapment | 242 | ||
| Cardiac causes of heartburn and indigestion (see chapter 8) | 243 | ||
| References and readings | 247 | ||
| 21 Hoarseness | 248 | ||
| Diagnostic reasoning: Focused history | 248 | ||
| Duration | 248 | ||
| Recurrence | 248 | ||
| Progression | 249 | ||
| What does the onset of hoarseness tell me? | 249 | ||
| Onset | 249 | ||
| Trauma | 249 | ||
| Surgical history | 249 | ||
| Does the presence of risk factors help narrow the diagnosis? | 249 | ||
| Upper respiratory infection | 249 | ||
| Allergies and asthma | 250 | ||
| Smoking | 250 | ||
| Alcohol consumption | 250 | ||
| Voice habits | 250 | ||
| Exposures | 250 | ||
| Immunizations | 250 | ||
| What other clues will help narrow the diagnostic possibilities? | 250 | ||
| Timing | 250 | ||
| Pain | 250 | ||
| Associated symptoms | 250 | ||
| Neurological disease | 251 | ||
| Gastroesophageal reflux disease | 251 | ||
| Diagnostic reasoning: Focused physical examination | 251 | ||
| Listen to the quality of voice | 251 | ||
| Examine the respiratory system | 251 | ||
| Perform a general inspection | 251 | ||
| Examine the head and neck | 251 | ||
| Assess cranial nerve function | 252 | ||
| Assess hearing (cranial nerve VIII) | 252 | ||
| Palpate lymph nodes | 252 | ||
| Palpate thyroid | 252 | ||
| Laboratory and diagnostic studies | 252 | ||
| Flexible fiberoptic laryngoscopy | 252 | ||
| Radiography | 252 | ||
| Barium esophagram | 252 | ||
| Differential diagnosis | 253 | ||
| Acute laryngitis | 253 | ||
| Acute epiglottitis | 253 | ||
| Trauma | 253 | ||
| Acute laryngeal edema | 253 | ||
| Laryngotracheobronchitis (croup) | 253 | ||
| Chronic laryngitis | 253 | ||
| Polyps | 253 | ||
| Neoplasm | 253 | ||
| Gastroesophageal reflux disease | 253 | ||
| Hypothyroidism | 253 | ||
| Vocal cord paralysis | 254 | ||
| Psychogenic hoarseness | 254 | ||
| Laryngeal papillomas | 254 | ||
| References and readings | 255 | ||
| 22 Lower extremity limb pain | 256 | ||
| Diagnostic reasoning: Focused history | 256 | ||
| Injury | 256 | ||
| Constitutional symptoms | 256 | ||
| Severity of pain | 257 | ||
| What does the location of the pain tell me? | 257 | ||
| Location | 257 | ||
| Could this be caused by a sprain or strain? | 257 | ||
| Strain | 257 | ||
| Sprain | 257 | ||
| Fracture | 257 | ||
| If there is no history of trauma or a precipitating event, what else is causing the pain? | 257 | ||
| Activities | 258 | ||
| Other illnesses | 258 | ||
| History of injury | 258 | ||
| In joint pain with injury, what do I need to know about the specific joints involved? | 258 | ||
| Could this be musculoskeletal or joint disease? | 258 | ||
| What does the history of swelling tell me? | 258 | ||
| Swelling | 258 | ||
| Is this an acute or a chronic problem? | 259 | ||
| How is activity affected? | 259 | ||
| What does joint stiffness or locking tell me? | 259 | ||
| Joint locking | 259 | ||
| What does the history of a limp tell me? | 259 | ||
| Limp | 259 | ||
| Could this be caused by systemic disease? | 260 | ||
| Medications | 260 | ||
| Night pain | 260 | ||
| Could the pain be caused by lyme disease? | 260 | ||
| Lyme disease | 260 | ||
| What does the health history tell me? | 260 | ||
| Chronic conditions | 260 | ||
| Is this a mixed condition? | 260 | ||
| Diagnostic reasoning: Focused physical examination | 260 | ||
| Observe the patient | 260 | ||
| Look for limp | 261 | ||
| Have patient locate the pain | 262 | ||
| Note any deformities | 262 | ||
| Assess vital signs | 262 | ||
| Inspect the skin and nails | 262 | ||
| Measure limb circumference and length | 263 | ||
| Palpate extremities and joints | 263 | ||
| Perform passive/active range of motion of hips, knees, and ankles | 263 | ||
| Test for muscle strength | 264 | ||
| Perform a neurological examination | 264 | ||
| Laboratory and diagnostic studies | 264 | ||
| Complete blood count | 264 | ||
| Erythrocyte sedimentation rate | 264 | ||
| Joint aspiration | 264 | ||
| Radiography | 264 | ||
| Antinuclear antibodies | 264 | ||
| Rheumatoid factor | 264 | ||
| C4 complement | 264 | ||
| C-reactive protein | 264 | ||
| Lyme titer enzyme-linked immunosorbent assay serology | 265 | ||
| Differential diagnosis | 265 | ||
| Musculoskeletal inflammation | 265 | ||
| Joint inflammation | 265 | ||
| Musculoskeletal pain related to trauma or overuse | 266 | ||
| Muscle pain (myalgia) | 269 | ||
| Systemic disorders | 270 | ||
| Nerve entrapment syndromes | 271 | ||
| References and readings | 274 | ||
| 23 Upper extremity limb pain | 275 | ||
| Diagnostic reasoning: Focused history | 275 | ||
| Injury | 275 | ||
| Constitutional symptoms | 275 | ||
| Severity of pain | 275 | ||
| What does the location of the pain tell me? | 275 | ||
| Location | 275 | ||
| Could this be caused by a sprain or strain? | 275 | ||
| Strain | 275 | ||
| Sprain | 275 | ||
| Fracture | 276 | ||
| If there is no history of trauma or a precipitating event, what else is causing the pain? | 276 | ||
| Overuse | 276 | ||
| Activities | 276 | ||
| In upper extremity (shoulder, WRIST, elbow) joint pain with injury, what do I need to know about the specific joints involved? | 276 | ||
| Could this be musculoskeletal or joint disease? | 276 | ||
| What does the history of swelling tell me? | 276 | ||
| Swelling | 276 | ||
| Is this an acute or a chronic problem? | 276 | ||
| How is activity affected? | 277 | ||
| What does joint stiffness tell me? | 277 | ||
| Joint stiffness | 277 | ||
| Could this be caused by systemic disease? | 277 | ||
| Medications | 277 | ||
| Night pain | 277 | ||
| What does the health history tell me? | 277 | ||
| Diagnostic reasoning: Focused physical examination | 277 | ||
| Observe patient walking, removing coat/jacket | 277 | ||
| Have patient locate the pain | 277 | ||
| Note any deformities | 278 | ||
| Assess vital signs | 278 | ||
| Inspect the skin and nails | 278 | ||
| Measure limb circumference and length | 278 | ||
| Palpate extremities and joints | 279 | ||
| Perform passive/active range of motion of all limbs | 279 | ||
| Test for muscle strength | 279 | ||
| Perform a neurological examination | 279 | ||
| Laboratory and diagnostic studies | 279 | ||
| Complete blood count | 279 | ||
| Erythrocyte sedimentation rate | 279 | ||
| Joint aspiration | 279 | ||
| Radiography | 279 | ||
| Antinuclear antibodies | 281 | ||
| Rheumatoid factor | 281 | ||
| C4 complement | 281 | ||
| C-reactive protein | 281 | ||
| Differential diagnosis | 281 | ||
| Musculoskeletal inflammation | 281 | ||
| Joint inflammation | 282 | ||
| Musculoskeletal pain related to trauma or overuse | 282 | ||
| Muscle pain (myalgia) | 283 | ||
| Systemic disorders | 284 | ||
| Nerve entrapment syndromes | 284 | ||
| References and readings | 287 | ||
| 24 Low back pain (acute) | 288 | ||
| Diagnostic reasoning: Focused history | 288 | ||
| Fever | 288 | ||
| Trauma | 288 | ||
| Systemic disease, cancer | 289 | ||
| Age | 289 | ||
| Bowel and bladder symptoms | 290 | ||
| Medications | 290 | ||
| What does the location of pain tell me? | 290 | ||
| Location of pain | 290 | ||
| What does the pattern of pain tell me? | 290 | ||
| Onset | 290 | ||
| Duration | 290 | ||
| Pain characteristics | 290 | ||
| Night pain | 291 | ||
| Recurring pain | 291 | ||
| What does the pain in relation to activity tell me? | 291 | ||
| Aggravating factors | 291 | ||
| Alleviating factors | 291 | ||
| Backpack | 291 | ||
| What does radiation of pain tell me? | 291 | ||
| Radiation of pain | 291 | ||
| Are there signs of neurological damage? | 291 | ||
| Stumbling | 292 | ||
| Numbness and tingling | 292 | ||
| Is there a family history of back pain? | 292 | ||
| Family history | 292 | ||
| Could this pain be caused by systemic disease? | 292 | ||
| Illness | 292 | ||
| Diagnostic reasoning: Focused physical examination | 292 | ||
| Observe the patient’s general appearance and behavior | 292 | ||
| Observe gait | 292 | ||
| Assess vital signs | 292 | ||
| Examine skin | 292 | ||
| Examine eyes, ears, nose, and mouth | 292 | ||
| Inspect the back and extremities | 292 | ||
| Percuss and palpate back and spine | 293 | ||
| Perform range of motion of the spine | 293 | ||
| Perform straight leg raising | 293 | ||
| Check hip mobility | 294 | ||
| Examine feet | 294 | ||
| Evaluate muscle strength | 294 | ||
| Measure muscle circumference | 294 | ||
| Test sensory function | 294 | ||
| Assess deep tendon reflexes | 295 | ||
| Palpate the abdomen | 295 | ||
| Check rectal sphincter tone | 295 | ||
| Laboratory and diagnostic studies | 295 | ||
| Plain radiographs | 295 | ||
| Standing anteroposterior and lateral views of the spine | 295 | ||
| Oblique and flexion views of the spine | 295 | ||
| Spine radiograph | 295 | ||
| Bone scan | 295 | ||
| Electromyography | 295 | ||
| Diagnostic imaging | 295 | ||
| Urinalysis | 296 | ||
| Erythrocyte sedimentation rate | 296 | ||
| Complete blood count | 296 | ||
| Differential diagnosis | 296 | ||
| Potentially serious causes of acute low back pain | 296 | ||
| Sciatic problems | 296 | ||
| Nonspecific back problems | 297 | ||
| Nonspinal causes | 297 | ||
| Psychogenic causes | 298 | ||
| References and readings | 300 | ||
| 25 Nasal symptoms and sinus congestion | 301 | ||
| Diagnostic reasoning: Focused history | 301 | ||
| Acute symptoms | 301 | ||
| Chronic symptoms | 302 | ||
| Location of pain | 302 | ||
| Seasonal occurrence of symptoms | 302 | ||
| Family history | 303 | ||
| If I suspect sinus problems, what do I need to know? | 303 | ||
| Position change | 303 | ||
| Does the presence of other symptoms provide any clues? | 303 | ||
| Other acute symptoms | 303 | ||
| Other chronic symptoms | 303 | ||
| Is the cause viral, bacterial, or allergic? | 303 | ||
| Are symptoms unilateral or bilateral? | 303 | ||
| Are there risk factors that will narrow the diagnosis? | 303 | ||
| Smoking history | 304 | ||
| Trauma history | 304 | ||
| Diving and swimming | 304 | ||
| Exposure | 304 | ||
| Pregnancy | 304 | ||
| Is the patient using any drugs that would cause nasal congestion? | 304 | ||
| Nasal spray | 304 | ||
| Recreational drug use | 304 | ||
| Medications | 304 | ||
| Is there systemic disease present? | 304 | ||
| Systemic disorders and chronic health problems | 304 | ||
| Diagnostic reasoning: Focused physical examination | 305 | ||
| Perform a general inspection | 305 | ||
| Take vital signs | 305 | ||
| Inspect the face | 305 | ||
| Perform a regional examination of the head and neck | 305 | ||
| Examine the mouth and teeth | 305 | ||
| Test for smell | 305 | ||
| Inspect condition of nasal mucosa and turbinates | 305 | ||
| Inspect for masses | 305 | ||
| Note the presence and color of any discharge | 306 | ||
| Transilluminate the sinuses | 306 | ||
| Palpate and percuss frontal and maxillary sinuses for tenderness | 306 | ||
| Test for facial fullness and pressure | 306 | ||
| Examine the lungs | 306 | ||
| Perform neurological testing if indicated | 306 | ||
| Laboratory and diagnostic studies | 306 | ||
| Nasal smear | 306 | ||
| Sinus radiographs | 306 | ||
| Computed tomography scan | 306 | ||
| Magnetic resonance imaging | 307 | ||
| Sinus aspiration | 307 | ||
| Nasal endoscopy | 307 | ||
| Allergy skin testing | 307 | ||
| Differential diagnosis | 307 | ||
| Infectious rhinitis | 307 | ||
| Allergic rhinitis | 307 | ||
| Nonallergic rhinitis | 307 | ||
| Rhinitis medicamentosa | 307 | ||
| Acute sinusitis | 307 | ||
| Chronic sinusitis | 308 | ||
| Nasal or sinus obstruction | 308 | ||
| Nasal polyposis | 308 | ||
| Osteomyelitis of the frontal bone | 308 | ||
| References and readings | 309 | ||
| 26 Palpitations | 310 | ||
| Diagnostic reasoning: Focused history | 310 | ||
| Coronary artery disease | 310 | ||
| Lightheadedness/syncope | 310 | ||
| Chest pain, dyspnea | 310 | ||
| Sudden cardiac death | 310 | ||
| Cardiac surgery | 310 | ||
| What else do I need to know about the palpitation? | 310 | ||
| Description of palpitations | 311 | ||
| Occurrence of palpitations | 311 | ||
| Could this be related to stress or a psychological condition? | 311 | ||
| Panic disorder/stress/anxiety | 311 | ||
| Other symptoms | 312 | ||
| Could this be secondary to a systemic condition? | 312 | ||
| Symptoms/illness | 312 | ||
| Pregnancy | 312 | ||
| Are drugs, medications, or other stimulants implicated? | 312 | ||
| Medications | 312 | ||
| Stimulants | 312 | ||
| Diagnostic reasoning: Focused physical examination | 312 | ||
| Note general appearance | 312 | ||
| Take vital signs | 313 | ||
| Assess jugular venous pressure | 313 | ||
| Auscultate the heart | 313 | ||
| Assess mental status | 313 | ||
| Inspect the head and neck | 313 | ||
| Examine the thyroid | 313 | ||
| Examine the extremities | 313 | ||
| Check reflexes | 313 | ||
| Laboratory and diagnostic studies | 313 | ||
| Twelve-lead electrocardiogram | 313 | ||
| Cardiac monitoring: Event or continuous-loop | 313 | ||
| Echocardiogram | 314 | ||
| Complete blood count | 314 | ||
| Electrolytes | 314 | ||
| Thyroid-stimulating hormone and free t4 | 314 | ||
| Catecholamines/metanephrines | 314 | ||
| Differential diagnosis | 314 | ||
| Cardiac causes | 314 | ||
| Noncardiac causes | 315 | ||
| Drugs and stimulants | 316 | ||
| References and readings | 317 | ||
| 27 Penile discharge | 318 | ||
| Diagnostic reasoning: Focused history | 318 | ||
| Sexual history | 318 | ||
| Unprotected sex | 318 | ||
| Number of days between exposure and symptom onset | 318 | ||
| Are there any risk factors that point me in the right direction? | 318 | ||
| History of drug or substance abuse | 318 | ||
| What do the characteristics of the discharge tell me? | 318 | ||
| Color, consistency, and amount of discharge | 318 | ||
| Is this a local infection or process? | 319 | ||
| Red, inflamed glans penis | 319 | ||
| Hygienic practices | 319 | ||
| Is this complicated urethritis? | 319 | ||
| Symptoms of complicated urethritis | 319 | ||
| Symptoms that may indicate reiter syndrome | 319 | ||
| Symptoms that may indicate disseminated systemic urethral infection | 319 | ||
| Is this an upper urinary tract problem? | 319 | ||
| Fever | 319 | ||
| Hematuria | 319 | ||
| Acute pain | 319 | ||
| What else could this be? | 319 | ||
| Scrotal pain or fever | 320 | ||
| Recent surgery or instrumentation | 320 | ||
| Recent treatment for an sti | 320 | ||
| Immigrant patient/partner or recent foreign travel | 320 | ||
| Diagnostic reasoning: Focused physical examination | 320 | ||
| Note general appearance | 320 | ||
| Palpate lymph nodes | 320 | ||
| Examine body hair | 320 | ||
| Examine the penis and urethral meatus | 320 | ||
| Examine the scrotum and testicles | 321 | ||
| Inspect and examine other sites for lesions and discharge | 321 | ||
| Laboratory and diagnostic studies | 321 | ||
| Urine dipstick | 321 | ||
| Urinalysis with microscopic examination | 321 | ||
| Segmented urine collection for culture and sensitivity | 321 | ||
| Gram stain of specimens | 321 | ||
| Culture and sensitivity | 321 | ||
| DNA testing for infectious organisms | 321 | ||
| Doppler blood flow | 322 | ||
| Complete blood count | 322 | ||
| Syphilis testing | 322 | ||
| Differential diagnosis | 322 | ||
| Urethritis | 322 | ||
| Gonococcal urethritis | 322 | ||
| Nongonococcal urethritis | 322 | ||
| Complicated urethritis | 323 | ||
| Prostatitis | 323 | ||
| Epididymitis and orchitis | 323 | ||
| Balanitis | 323 | ||
| References and readings | 324 | ||
| 28 Rashes and skin lesions | 325 | ||
| Diagnostic reasoning: Initial focused physical examination | 325 | ||
| Initial inspection | 325 | ||
| Morphological criteria | 325 | ||
| Diagnostic reasoning: Focused history | 325 | ||
| Fever | 331 | ||
| Allergic reaction | 331 | ||
| Rash with mucosal involvement | 331 | ||
| Is the rash acute or chronic (recurrent)? | 331 | ||
| Onset | 331 | ||
| Where is the rash in its evolution? | 331 | ||
| Initial presentation | 331 | ||
| Change in lesion | 331 | ||
| Spread | 332 | ||
| What does the presence of pruritus tell me? | 332 | ||
| Itching | 332 | ||
| What does associated pain tell me? | 332 | ||
| Pain | 332 | ||
| Burning | 332 | ||
| What do associated symptoms tell me? | 332 | ||
| Fever, sore throat, and headache | 332 | ||
| General health | 332 | ||
| Are there possible contacts or sources of contagion? | 332 | ||
| Living situation | 333 | ||
| Travel | 333 | ||
| Other exposures | 333 | ||
| Pets | 333 | ||
| Is there anything that exacerbates or triggers the reaction? | 333 | ||
| Triggers | 333 | ||
| Could this rash be caused by a medication? | 334 | ||
| Medication | 334 | ||
| Recent vaccination | 334 | ||
| Is there a significant dermatological family history? | 334 | ||
| Family history | 334 | ||
| Diagnostic reasoning: Focused physical examination | 334 | ||
| Look at all the skin and mucous membranes | 334 | ||
| Inspect for distribution | 334 | ||
| Inspect the mouth | 334 | ||
| Inspect the hair | 334 | ||
| Palpate the skin | 335 | ||
| Palpate the regional lymph glands | 335 | ||
| Perform an abdominal examination | 335 | ||
| Laboratory and diagnostic studies | 335 | ||
| Diascopy | 335 | ||
| Dermoscopy | 335 | ||
| Wood’s light | 335 | ||
| Skin scraping and potassium hydroxide preparation | 335 | ||
| Tzanck smear | 335 | ||
| Bacterial or viral culture | 335 | ||
| Punch biopsy | 336 | ||
| Excisional biopsy | 336 | ||
| Differential diagnosis | 336 | ||
| Follicular eruptions | 336 | ||
| Infectious eruptions | 336 | ||
| Macular and papular eruptions | 336 | ||
| Vesicular and bullous eruptions | 337 | ||
| Fungal infections | 338 | ||
| Immunological and inflammatory eruptions | 338 | ||
| Allergic reactions | 338 | ||
| Neoplastic eruptions | 339 | ||
| References and readings | 343 | ||
| 29 Rectal pain, itching, and bleeding | 344 | ||
| Diagnostic reasoning: Focused history | 344 | ||
| Bleeding | 344 | ||
| Infant | 344 | ||
| Anticoagulation therapy or bleeding disorder | 345 | ||
| Immunocompromised with an infection | 345 | ||
| What do the presenting symptoms tell me? | 345 | ||
| Bleeding | 345 | ||
| Age of the child with bleeding | 346 | ||
| Pain | 346 | ||
| Tenesmus | 346 | ||
| Itching | 346 | ||
| Mass | 347 | ||
| Fecal soiling | 347 | ||
| Diarrhea | 347 | ||
| Constipation | 347 | ||
| Could this be caused by sexual practices? | 347 | ||
| Multiple sexual partners | 347 | ||
| Anal intercourse | 347 | ||
| Foreign bodies | 347 | ||
| Could this be the result of sexual abuse? | 347 | ||
| Sexual contact | 347 | ||
| A child’s reporting | 347 | ||
| A parent’s reporting | 347 | ||
| Do risk factors point to a likely condition? | 348 | ||
| Straining | 348 | ||
| Chronic constipation | 348 | ||
| Prolonged sitting | 348 | ||
| Hygiene | 348 | ||
| Pregnancy and childbirth | 348 | ||
| HIV, chemotherapy, diabetes mellitus | 348 | ||
| History of colon polyps | 348 | ||
| History of hereditary colon cancer syndrome | 348 | ||
| Inflammatory bowel disease | 348 | ||
| Diverticulosis | 348 | ||
| Diagnostic reasoning: Focused physical examination | 348 | ||
| Obtain vital signs | 348 | ||
| Note gender | 349 | ||
| Palpate the abdomen | 349 | ||
| Inspect the perirectal area and anus | 349 | ||
| Perform a digital rectal examination | 349 | ||
| Perform anoscopy if indicated | 349 | ||
| Laboratory and diagnostic studies | 349 | ||
| Fecal occult blood testing | 349 | ||
| Fecal immunochemical test | 350 | ||
| Fecal/stool DNA | 350 | ||
| Abdominal x-ray | 350 | ||
| Colonoscopy | 350 | ||
| Computed tomography | 350 | ||
| Gram stain rectal discharge | 350 | ||
| Cultures for infectious organisms | 350 | ||
| DNA testing for infectious organisms | 350 | ||
| Herpes virus antigen detection test | 350 | ||
| Testing for syphilis | 351 | ||
| Alum-precipitated toxoid test | 351 | ||
| Meckel (technetium-99m) scan | 351 | ||
| Microscopic examination of stool | 351 | ||
| Stool for ova and parasites | 351 | ||
| Scotch tape test | 351 | ||
| Differential diagnosis | 351 | ||
| Pain | 351 | ||
| Itching | 353 | ||
| Bleeding | 353 | ||
| Ingestion of maternal blood | 354 | ||
| Allergic colitis | 354 | ||
| References and readings | 356 | ||
| 30 Red eye | 357 | ||
| Diagnostic reasoning: Focused history | 357 | ||
| Chemical injury | 357 | ||
| Swelling, redness, and fever | 357 | ||
| Pain with attempted motion of the eye | 357 | ||
| Recent sinus infection | 357 | ||
| Can I rule in or rule out trauma? | 358 | ||
| Is this an acute or chronic condition? | 358 | ||
| Onset | 358 | ||
| Recurrence | 358 | ||
| Can I narrow the problem by location? | 358 | ||
| What does the presence or absence of pain tell me? | 359 | ||
| Location of pain | 359 | ||
| Severity of pain | 359 | ||
| Foreign body sensation | 359 | ||
| Do I need to worry about vision changes? | 359 | ||
| Vision loss | 359 | ||
| Blurring | 359 | ||
| Double vision | 359 | ||
| Halos | 360 | ||
| Floaters | 360 | ||
| What does the presence or characteristic of the discharge tell me? | 360 | ||
| Presence and characteristics of discharge | 360 | ||
| What does the presence of photophobia tell me? | 360 | ||
| What other things do I need to consider? | 360 | ||
| Tears | 360 | ||
| Itching and tearing | 360 | ||
| Cough and fever | 360 | ||
| Diagnostic reasoning: Focused physical examination | 360 | ||
| Test visual acuity | 361 | ||
| Test visual fields | 361 | ||
| Inspect the lids, lid margins, periorbital tissues, and orbital tissues | 361 | ||
| Observe for entropion and ectropion | 361 | ||
| Evert the eyelid | 361 | ||
| Inspect the conjunctiva | 361 | ||
| Inspect the sclera | 362 | ||
| Examine the cornea | 362 | ||
| Examine the iris, pupil, and lens | 362 | ||
| Perform ophthalmoscopy | 362 | ||
| Test extraocular movements | 363 | ||
| Palpate the lid/lacrimal puncta | 363 | ||
| Examine the tympanic membranes | 363 | ||
| Palpate preauricular nodes | 363 | ||
| Laboratory and diagnostic studies | 363 | ||
| Fluorescein staining | 363 | ||
| Culture | 363 | ||
| Gram stain | 363 | ||
| Complete blood count | 363 | ||
| Blood cultures | 363 | ||
| Computed tomography | 363 | ||
| Intraocular pressure | 363 | ||
| Differential diagnosis | 364 | ||
| Lacrimal sac | 364 | ||
| Eyelids | 364 | ||
| Conjunctiva | 364 | ||
| Anterior chamber | 365 | ||
| Sclera | 365 | ||
| Cornea | 365 | ||
| Orbit | 366 | ||
| Uveal tract | 366 | ||
| References and readings | 368 | ||
| 31 Sleep problems | 369 | ||
| Diagnostic reasoning: Focused history | 369 | ||
| Nature of the problem | 369 | ||
| Difficulty falling asleep | 370 | ||
| Difficulty staying asleep | 370 | ||
| Daytime sleepiness | 370 | ||
| Medications | 370 | ||
| Duration of the problem | 371 | ||
| Is this a specific sleep disorder? | 371 | ||
| Limb sensation | 371 | ||
| Limb jerking | 371 | ||
| Snoring | 371 | ||
| Daytime dozing, excessive daytime sleepiness, and muscle weakness | 371 | ||
| Could the sleep problem be secondary to a health condition? | 371 | ||
| Illness: Acute or chronic | 371 | ||
| Medications | 372 | ||
| Pain | 372 | ||
| Psychological causes | 372 | ||
| Could this be related to sleep hygiene? | 372 | ||
| Bedtime routine | 372 | ||
| Environment | 372 | ||
| Consumption of stimulants | 373 | ||
| Exercise | 373 | ||
| Child’s routine | 373 | ||
| Infant sleeping environment | 373 | ||
| Could this be related to lifestyle? | 373 | ||
| Shift work | 373 | ||
| Sleep environment | 373 | ||
| Travel | 373 | ||
| Could this be related to age? | 373 | ||
| Age: Child | 374 | ||
| Age: Adolescent | 374 | ||
| Age: Menopausal women | 374 | ||
| Age: Older adult | 374 | ||
| Could this be conditioned insomnia? | 374 | ||
| Sleep location | 374 | ||
| Child’s need for comfort or food | 374 | ||
| Could this be somnambulism? | 375 | ||
| Diagnostic reasoning: Focused physical examination | 375 | ||
| Obtain growth parameters and/or body mass index | 375 | ||
| Inspect the ears | 375 | ||
| Inspect the nose | 375 | ||
| Inspect the mouth, throat, and nose | 375 | ||
| Auscultate the lungs and heart | 375 | ||
| Palpate the abdomen | 375 | ||
| Laboratory and diagnostic studies | 375 | ||
| Sleep diary | 375 | ||
| Sleep studies | 375 | ||
| Home sleep studies | 375 | ||
| Actigraphy | 375 | ||
| Ferritin level | 375 | ||
| Differential diagnosis | 376 | ||
| Restless legs syndrome | 376 | ||
| Periodic leg movement | 376 | ||
| Obstructive sleep apnea | 376 | ||
| Narcolepsy | 376 | ||
| Delayed sleep phase syndrome | 377 | ||
| Secondary to a health condition or medications (comorbid insomnia) | 377 | ||
| Poor sleep hygiene | 377 | ||
| Lifestyle | 377 | ||
| Age-related sleep disorders | 377 | ||
| Conditioned insomnia | 378 | ||
| Somnambulism | 379 | ||
| References and readings | 380 | ||
| 32 Sore throat | 381 | ||
| Diagnostic reasoning: Focused history | 381 | ||
| History | 381 | ||
| Associated symptoms | 381 | ||
| What does the presence of fever tell me? | 381 | ||
| Patterns of fever | 382 | ||
| Is the sore throat related to an infectious cause? | 382 | ||
| Exposure | 382 | ||
| Onset | 382 | ||
| Severity | 382 | ||
| What does the presence of upper respiratory tract symptoms tell me? | 382 | ||
| Cough and rhinorrhea | 382 | ||
| Conjunctivitis | 382 | ||
| Sneezing | 383 | ||
| Hoarseness | 383 | ||
| What do the associated symptoms tell me? | 383 | ||
| Systemic symptoms | 383 | ||
| Does the presence of risk factors help me narrow the cause? | 383 | ||
| Age | 383 | ||
| Irritant exposures | 383 | ||
| Sexual behavior | 383 | ||
| Medications and chronic health problems | 383 | ||
| Immunizations | 383 | ||
| Diagnostic reasoning: Focused physical examination | 383 | ||
| Assess severity of illness | 383 | ||
| Inspect the mouth | 384 | ||
| Inspect the posterior pharynx and observe swallowing | 384 | ||
| Palpate the cervicofacial lymph nodes | 385 | ||
| Inspect the nasal mucosa | 385 | ||
| Inspect the conjunctivae | 385 | ||
| Inspect the tympanic membrane | 385 | ||
| Palpate the thyroid | 385 | ||
| Inspect the skin | 385 | ||
| Auscultate the lungs | 385 | ||
| Palpate the abdomen | 386 | ||
| Laboratory and diagnostic studies | 386 | ||
| Rapid screening tests | 386 | ||
| Culture | 386 | ||
| Antistreptolysin o titer | 386 | ||
| Potassium hydroxide smear for wet mount | 386 | ||
| Complete blood count with differential | 386 | ||
| Computed tomography scan | 386 | ||
| Nasal smear | 386 | ||
| Differential diagnosis | 386 | ||
| Pharyngitis without ulcers | 386 | ||
| Pharyngitis with ulcers | 388 | ||
| References and readings | 389 | ||
| 33 Syncope | 390 | ||
| Diagnostic reasoning: Focused history | 390 | ||
| Loss of consciousness | 390 | ||
| Prodromal symptoms | 390 | ||
| Pre-event characteristics | 391 | ||
| Event and postevent characteristics | 391 | ||
| Witness | 391 | ||
| Does this require immediate referral? | 391 | ||
| History of heart disease/congenital heart problem | 391 | ||
| Palpitations | 391 | ||
| Chest pain or shortness of breath | 391 | ||
| After exercise | 392 | ||
| What do associated symptoms tell me? | 392 | ||
| Headaches | 392 | ||
| Vertigo, dizziness, and visual symptoms | 392 | ||
| Is this neurocardiogenic in origin? | 392 | ||
| Situational fainting | 392 | ||
| Is this orthostasis? | 392 | ||
| Medications | 392 | ||
| Other health problems or conditions | 392 | ||
| Is this explained by other factors? | 392 | ||
| Frequent syncope with no heart disease | 393 | ||
| After sudden head rotation | 393 | ||
| History of kawasaki disease | 393 | ||
| Lyme disease | 393 | ||
| What else do I need to consider? | 393 | ||
| Family history of sudden death | 393 | ||
| Family history of fainting | 393 | ||
| Prenatal systemic lupus erythematosus | 393 | ||
| Diagnostic reasoning: Focused physical examination | 393 | ||
| Measure blood pressure and pulse rate | 393 | ||
| Observe hydration status | 393 | ||
| Perform heart and lung examination | 393 | ||
| Perform a neurological examination | 393 | ||
| Perform an abdominal examination | 393 | ||
| Examine extremities | 393 | ||
| Laboratory and diagnostic studies | 394 | ||
| Suspected or known cardiac cause | 394 | ||
| Suspected neurological cause | 394 | ||
| Unexplained syncope | 394 | ||
| Differential diagnosis | 395 | ||
| Cardiac causes | 395 | ||
| Neurocardiogenic causes | 395 | ||
| Orthostasis | 395 | ||
| Medication-related causes | 395 | ||
| Neurological causes | 395 | ||
| Psychiatric causes | 395 | ||
| Unknown causes | 396 | ||
| References and readings | 397 | ||
| 34 Urinary incontinence | 398 | ||
| Diagnostic reasoning: Focused history | 398 | ||
| Adults | 398 | ||
| Could this be the result of reversible factors? ( box 34-1) | 398 | ||
| Medications | 399 | ||
| Urinary tract infection, vaginal dryness, and dyspareunia | 399 | ||
| Bowel function | 399 | ||
| Mental status, mobility, and chronic health problems | 399 | ||
| What do the presenting symptoms tell me? | 399 | ||
| Primary symptom | 400 | ||
| Frequency of voiding | 400 | ||
| Amount of urine lost with each episode | 400 | ||
| Character of stream | 400 | ||
| Are there any other symptoms that will point me in the right direction? | 400 | ||
| Fluid intake | 400 | ||
| Thirst | 400 | ||
| Weight loss or gain | 400 | ||
| Children | 400 | ||
| Is this primary or secondary enuresis? | 400 | ||
| Is this organic enuresis? | 400 | ||
| Genitourinary system | 401 | ||
| Nervous system | 401 | ||
| Other | 401 | ||
| What risk factors does this child have for nonorganic enuresis? | 401 | ||
| Gender | 401 | ||
| Family history | 401 | ||
| Twin/birth order | 401 | ||
| Institutionalization | 401 | ||
| Sickle cell disease | 401 | ||
| Fluid intake | 402 | ||
| Diagnostic reasoning: Focused physical examination | 402 | ||
| Perform mental status examination | 402 | ||
| Observe gait | 402 | ||
| Take vital signs | 402 | ||
| Examine the abdomen | 402 | ||
| Examine genitalia in males | 402 | ||
| Perform pelvic examination in females | 402 | ||
| Examine vaginal area in children | 402 | ||
| Perform provocative stress testing | 402 | ||
| Perform digital rectal examination | 402 | ||
| Conduct a neurological examination | 402 | ||
| Examine and palpate the spine in children | 402 | ||
| Perform musculoskeletal examination | 402 | ||
| Additional procedures | 403 | ||
| Laboratory and diagnostic studies | 403 | ||
| Urinalysis | 403 | ||
| Specific gravity | 403 | ||
| Urine culture | 403 | ||
| Urine cytology | 403 | ||
| Bladder diary | 403 | ||
| Blood urea nitrogen and creatinine | 403 | ||
| Vaginal specimen microscopy, DNA testing, or culture | 403 | ||
| Office cystometrography | 403 | ||
| Urodynamic testing | 403 | ||
| Cystoscopy and contrast radiography | 403 | ||
| Ultrasound | 403 | ||
| Differential diagnosis | 403 | ||
| Incontinence from anatomical causes | 403 | ||
| Incontinence from reversible factors (functional incontinence) | 405 | ||
| Enuresis from organic causes | 405 | ||
| Enuresis from nonorganic causes | 406 | ||
| References and readings | 408 | ||
| 35 Urinary problems in females and children | 409 | ||
| Diagnostic reasoning: Focused history | 409 | ||
| Fever and chills | 409 | ||
| Nausea and vomiting | 409 | ||
| Acute pain | 409 | ||
| Immunocompromised patients | 409 | ||
| Irritable infant | 409 | ||
| Is there hematuria? | 410 | ||
| Hematuria | 410 | ||
| Pain | 410 | ||
| Bleeding without urination | 410 | ||
| Strenuous exercise | 410 | ||
| Can the symptoms be localized to the lower urinary tract? | 410 | ||
| Primary symptoms | 410 | ||
| Suprapubic discomfort and urinary incontinence | 410 | ||
| Could this be the result of trauma? | 411 | ||
| Recent injury | 411 | ||
| Trauma | 411 | ||
| Foreign objects | 411 | ||
| Could this be genitourinary in origin? | 411 | ||
| Sexual activity | 411 | ||
| Diaphragm use | 411 | ||
| Vaginal discharge and hormone therapy | 411 | ||
| Are there any specific risk factors to point me in the right direction? | 411 | ||
| History of similar problems | 411 | ||
| Recent instrumentation | 412 | ||
| Family history of urinary problems | 412 | ||
| History of diabetes mellitus | 412 | ||
| Types of food consumed | 412 | ||
| Decreased fluid intake | 412 | ||
| Urge to urinate | 412 | ||
| Bubble bath and hygiene products | 412 | ||
| Constipation | 412 | ||
| What else could this be? | 412 | ||
| Sexually transmitted infections | 412 | ||
| Excessive urination | 412 | ||
| Recent streptococcal infection | 412 | ||
| Diagnostic reasoning: Focused physical examination | 412 | ||
| Note general appearance | 412 | ||
| Obtain vital signs, height, and weight | 412 | ||
| Examine the skin | 412 | ||
| Palpate and percuss for flank pain and at the costovertebral angle bilaterally | 412 | ||
| Palpate and percuss the abdomen | 413 | ||
| Inspect the perirectal area | 413 | ||
| Perform a pelvic examination if indicated | 413 | ||
| Laboratory and diagnostic studies | 413 | ||
| Urine dipstick | 413 | ||
| Urinalysis with microscopic examination | 414 | ||
| Urine culture and sensitivity | 414 | ||
| Potassium hydroxide and wet mount/preparation | 415 | ||
| Vaginal culture/dna testing for infectious organisms | 415 | ||
| Ultrasonography | 415 | ||
| Radiography | 415 | ||
| Computed tomography | 415 | ||
| Differential diagnosis | 415 | ||
| Uncomplicated urinary tract infection | 415 | ||
| Urethritis | 415 | ||
| Vulvovaginitis | 415 | ||
| Atrophic vaginitis | 415 | ||
| Interstitial cystitis | 416 | ||
| Pyelonephritis | 416 | ||
| Urolithiasis | 416 | ||
| Poststreptococcal glomerulonephritis | 417 | ||
| Chemical irritation | 417 | ||
| References and readings | 418 | ||
| 36 Vaginal bleeding | 419 | ||
| Diagnostic reasoning: Focused history | 419 | ||
| Amount of bleeding | 419 | ||
| Bleeding disorder/anticoagulants | 419 | ||
| Could this be related to pregnancy? | 419 | ||
| Pregnancy | 419 | ||
| Recent childbirth | 419 | ||
| If the patient is pregnant, is this a complication? | 420 | ||
| III Diagnostic Imaging | 470 | ||
| 40 Abdominal x-ray | 471 | ||
| Diagnostic reasoning: Viewing the abdominal image | 471 | ||
| Image and patient identification | 471 | ||
| Views | 471 | ||
| Image box placement | 471 | ||
| Image quality | 471 | ||
| Reviewing anatomy | 472 | ||
| What approach should be used when viewing the image? | 472 | ||
| Initial impression | 472 | ||
| Systematic examination | 472 | ||
| Diagnostic reasoning: Systematic examination | 472 | ||
| Bones | 472 | ||
| Bladder | 472 | ||
| Uterus | 473 | ||
| Liver | 473 | ||
| Spleen | 473 | ||
| Psoas muscle | 473 | ||
| Kidneys | 473 | ||
| Stomach | 473 | ||
| Colon | 473 | ||
| Small bowel | 475 | ||
| Calcifications | 475 | ||
| Gas patterns/extraluminal air | 475 | ||
| Artifacts | 475 | ||
| If the patient has abdominal pain, what other x-ray should I consider? | 475 | ||
| Upright abdominal x-ray and standing chest x-ray | 475 | ||
| Left lateral x-ray | 476 | ||
| Additional causes of abdominal pain | 476 | ||
| What other imaging studies should I consider? | 476 | ||
| Upper gastrointestinal series | 476 | ||
| Small bowel series | 476 | ||
| Lower gastrointestinal series | 476 | ||
| Colonoscopy | 477 | ||
| Sigmoidoscopy | 477 | ||
| Computed tomography | 477 | ||
| Endoscopy | 477 | ||
| Ultrasound | 477 | ||
| References and readings | 478 | ||
| 41 Chest x-ray | 479 | ||
| Diagnostic reasoning: Viewing the chest image | 479 | ||
| Identification of image and patient | 479 | ||
| Views | 479 | ||
| Image box placement | 480 | ||
| Image quality | 481 | ||
| Previous x-rays | 481 | ||
| Reviewing anatomy | 481 | ||
| What approach should be used when viewing an image? | 481 | ||
| Initial impression | 481 | ||
| Diagnostic reasoning: Systematic examination | 482 | ||
| Soft tissue | 482 | ||
| Trachea | 482 | ||
| Clavicles | 482 | ||
| Bony thorax | 482 | ||
| Scapulae | 482 | ||
| Thoracic spine | 482 | ||
| Ribs and intercostal spaces | 482 | ||
| Diaphragm | 483 | ||
| Costophrenic angle | 483 | ||
| Gastric air bubble | 483 | ||
| Mediastinum | 483 | ||
| Hilar area | 483 | ||
| Pulmonary vasculature | 484 | ||
| Heart | 484 | ||
| Pleura | 484 | ||
| Lungs | 484 | ||
| Final look | 484 | ||
| How do I assess the lateral view? | 484 | ||
| Anatomy | 485 | ||
| Vertebral bodies | 485 | ||
| Diaphragm | 485 | ||
| Costophrenic angle | 485 | ||
| Fissures | 485 | ||
| Pleura | 485 | ||
| Retrosternal area | 486 | ||
| Heart/retrocardiac area | 486 | ||
| Lungs | 486 | ||
| Final look | 486 | ||
| What other imaging studies should I consider? | 486 | ||
| Computed tomography | 486 | ||
| Magnetic resonance imaging | 486 | ||
| Positron emission tomography | 486 | ||
| Echocardiogram | 486 | ||
| References and readings | 488 | ||
| Index | 489 | ||
| A | 489 | ||
| B | 491 | ||
| C | 492 | ||
| D | 495 | ||
| E | 497 | ||
| F | 498 | ||
| G | 499 | ||
| H | 500 | ||
| I | 501 | ||
| J | 502 | ||
| K | 502 | ||
| L | 502 | ||
| M | 503 | ||
| N | 504 | ||
| O | 505 | ||
| P | 506 | ||
| Q | 507 | ||
| R | 507 | ||
| S | 508 | ||
| T | 510 | ||
| U | 511 | ||
| V | 512 | ||
| W | 513 | ||
| X | 514 | ||
| Y | 514 | ||
| Inside back cover | IBC | ||
| Differential diagnosis tables | IBC | ||
| Evidence-based practice boxes | IBC |