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This is completed downloadable of Test Bank for Seidels Guide to Physical Examination 8th Edition by Ball

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ISBN-10 ‏ : ‎ 0323112404
ISBN-13 ‏ : ‎ 978-0323112406
Author: Ball

Seidel’s Guide to Physical Examination is a comprehensive textbook of physical examination, history-taking, and health assessment with a unique emphasis on differential diagnosis and variations across the lifespan. The book conveys a uniquely compassionate, patient-centered approach to physical examination with a strong evidence-based foundation.

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

Table of Content:

Chapter 1 The History and Interviewing Process
http://evolve.elsevier.com/Seidel
Developing a Relationship with the Patient
Clinical Pearl
“Unique,” Originally Derived from Latin “Unus,” Meaning “One”
Clinical Pearl
The Patient Relationship
Effective Communication
Seeking Connection.
Box 1-1 Patient-Centered Questions
Box 1-2 Communication
Courtesy, Comfort, Connection, Confirmation
Courtesy
Comfort
Connection
Confirmation
Clinical Pearl
Professional Dress and Grooming
FIGURE 1-1 Interviewing a patient with the help of an interpreter. Someone other than a family member should act as interpreter to bridge the language difference between the health care provider and the patient.
Enhancing Patient Responses.
Moments of Tension: Potential Barriers to Communication
Curiosity About You.
Anxiety.
Silence.
Depression.
Clinical Pearl
Adolescent Suicide
Crying and Compassionate Moments.
Physical and Emotional Intimacy.
Seduction.
Anger.
Avoiding the Full Story.
Financial Considerations.
FIGURE 1-2 Interviewing a young adult. Note the absence of an intervening desk or table.
The Patient History
Setting for the Interview
Structure of the History
Building the History
Sensitive Issues
Clinical Pearl
Watch the Use of Jargon
Alcohol.
Box 1-3 CAGE Questionnaire
Clinical Pearl
Screening
Box 1-4 TACE Questionnaire
Box 1-5 CRAFFT Questionnaire
Intimate Partner Violence.
Evidence-Based Practice in Physical Examination
Box 1-6 Brief Screening Tool for Domestic Violence: HITS
Spirituality.
Sexuality.
Outline of the History
Chief Concern or the Reason for Seeking Care.
Clinical Pearl
Chief Complaint or Chief Concern?
Box 1-7 The Basis of Understanding
History of Present Illness or Problem.
Box 1-8 Factors That Affect the Patient’s Expression of Illness
Past Medical History.
Evidence-Based Practice in Physical Examination
Family History
Personal and Social History
Clinical Pearl
Who Are You?
Clinical Pearl
The Five Ps of a Sexual History.
Evidence-Based Practice in Physical Examination
Review of Systems (ROS).
Females
Males
Concluding Questions.
Adaptations for Age, Gender, and Possible Disabilities
Infants and Children
FIGURE 1-3 Interviewing a child with his parent. Note that the interviewer is sitting close to the patient and that the child is secure on his father’s lap.
Clinical Pearl
Twins or More
Chief Concern.
Box 1-9 Consent by Proxy
History of Present Illness.
Past Medical History
Staying Well
Family History
Personal and Social History
Box 1-10 Adoption and Foster Care
Box 1-11 Violence or Traumatic Events in Childhood
Review of Systems.
Adolescents
Clinical Pearl
Identification of Concerns by Adolescents:
Box 1-12 Adolescents’ Concerns
Box 1-13 Screening Tools for Adolescent Issues
HEEADSSS
PACES
Pregnant Women
Basic Information
History of Present Illness or Problem.
Obstetric History.
Menstrual History.
Gynecologic History.
Past Medical History.
Family History.
Personal and Social History.
Review of Systems.
Risk Assessment.
Postpartum.
Older Adults
Box 1-14 Competency to Make Medical Decisions
The Frail.
Functional Assessment
FIGURE 1-4 Interviewing a patient with a physical disability. Note the uncluttered surroundings; be sure the patient in a wheelchair has room to maneuver.
Patients with Disabilities
Box 1-15 Types of Histories
The Next Step
Chapter 2 Cultural Competency
http://evolve.elsevier.com/Seidel
A Definition of Culture
Distinguishing Physical Characteristics
Cultural Competence
Box 2-1 Dimensions of Cultural Competence
FIGURE 2-1 Overlapping concepts of patient-centered care and cultural competence.
Cultural Humility
The Impact of Culture
The Blurring of Cultural Distinctions
Box 2-2 The Influence of Age, Race, Ethnicity, Socioeconomic Status, and Culture
Clinical Pearl
Language Is Not All
The Primacy of the Individual in Health Care
Box 2-3 Questions That Explore the Patient’s Culture
Professional Cultures within the Health Professions
The Impact of Culture on Illness
Staying Well
Consider the “Norm” with Care
Box 2-4 Cultural Assessment Guide: The Many Aspects of Understanding
Health Beliefs and Practices
Faith-Based Influences and Special Rituals
Language and Communication
Parenting Styles and Role of Family
Sources of Support beyond the Family
Dietary Practices
The Components of a Cultural Response
Box 2-5 Comparison of Value Orientations among Cultural Groups
Value Orientation
Time Orientation
Activity Orientation
Human Nature Orientation
People-to-Nature Orientation
Relational Orientation
Modes of Communication
FIGURE 2-2 Being sensitive to cultural differences that may exist between you and the patient can help avoid miscommunication.
Clinical Pearl
The Impact of Gender
Health Beliefs and Practices
Box 2-6 The Balance of Life: The “Hot” and the “Cold”
Hot and Cold Conditions and Their Corresponding Treatments
Family Relationships
Clinical Pearl
Complementary and Alternative Treatments for the Common Cold
Diet and Nutritional Practices
Summing Up
Box 2-7 Communication
Health Customs/Health Practices
Family, Friends, and the Workplace
Chapter 3 Examination Techniques and Equipment
http://evolve.elsevier.com/Seidel
Precautions to Prevent Infection
Latex Allergy
Staying Well
Box 3-1 What Equipment Do You Need to Purchase?
Table 3-1 Recommendations for Application of Standard Precautions for the Care of All Patients in All Health Care Settings
Box 3-2 Types of Latex Reactions
Box 3-3 Summary of Recommendations for Workers to Prevent Latex Allergy
Examination Technique
Patient Positions and Draping
Seated.
Supine.
Prone.
Dorsal Recumbent.
Lateral Recumbent.
Lithotomy.
Sims.
Inspection
Box 3-4 The Sense of Smell: The Nose as an Aid to Physical Examination
Clinical Pearl
The Handshake
Table 3-2 Areas of the Hand to Use in Palpation
Palpation
Clinical Pearl
Right-Sided Examination?
Table 3-3 Percussion Tones
Percussion
FIGURE 3-1 Percussion technique: tapping the interphalangeal joint. Only the middle finger of the examiner’s nondominant hand should be in contact with the patient’s skin surface.
Box 3-5 Common Percussion Errors
Auscultation
Clinical Pearl
Unexpected Findings
Modifications for Patients with Disabilities
Patients with Mobility Impairments
Pivot Transfer.
Cradle Transfer.
Box 3-6 Transfer Guidelines
Guidelines for the Assistant
Guidelines for the Patient
Two-Person Transfer.
Equipment.
Patients with Sensory Impairment
Impaired Vision.
Impaired Hearing or Speech.
Special Concerns for Patients with Spinal Cord Injury or Lesion
Bowel and Bladder Concerns.
Autonomic Hyperreflexia.
Hypersensitivity.
Spasticity.
Equipment
Weight Scales and Height Measurement Devices
FIGURE 3-2 Platform scale with height attachment.
FIGURE 3-3 Infant platform scale.
FIGURE 3-4 Devices used to measure length of an infant. A, Infant length board. B, Measure mat.
FIGURE 3-5 Device used to measure height of a child.
FIGURE 3-6 Devices for electronic temperature measurement. A, Rectal, oral, or axillary thermometer. B and C, Tympanic membrane thermometers.
Thermometer
Stethoscope
FIGURE 3-7 Acoustic stethoscope.
FIGURE 3-8 Stereophonic stethoscope. Note divided bell and diaphragm.
FIGURE 3-9 Position the stethoscope between the index and middle fingers against the patient’s bare skin.
Sphygmomanometer
Pulse Oximeter
FIGURE 3-10 Pulse oximeter monitor and sensor.
Doppler
FIGURE 3-11 Doppler.
Portable Ultrasound
Fetal Monitoring Equipment
FIGURE 3-12 Fetoscope.
FIGURE 3-13 Ophthalmoscope.
Ophthalmoscope
Table 3-4 Apertures of the Ophthalmoscope
FIGURE 3-14 Longitudinal cross section of eye showing lens diopters to focus eye structures.
FIGURE 3-15 PanOptic ophthalmoscope.
PanOptic Ophthalmoscope
StrabismoScope
Photoscreening
FIGURE 3-16 StrabismoScope.
Visual Acuity Charts
Snellen Alphabet.
FIGURE 3-17 Charts for testing distant vision. A, Snellen chart. B, Tumbling E chart.
Tumbling E.
HOTV.
LH Symbols (LEA Symbols).
Broken Wheel Cards.
Near Vision Charts
Amsler Grid
FIGURE 3-18 Otoscope with various sizes of specula and a pneumatic attachment.
Otoscope
Tympanometer
FIGURE 3-19 Tympanometer.
Nasal Speculum
Tuning Fork
FIGURE 3-20 Nasal specula.
FIGURE 3-21 Tuning forks for testing vibratory sensation (top) and auditory screening (bottom).
FIGURE 3-22 Squeezing and stroking the tuning fork to activate it. Hold the fork only by the handle so as not to dampen the sound.
Percussion (Reflex) Hammer
Neurologic Hammer
Tape Measure
FIGURE 3-23 A, Reflex hammer. B, Use a rapid downward snap of the wrist.
Clinical Pearl
The Transience of Memory
Transilluminator
Vaginal Speculum
Clinical Pearl
Transillumination
FIGURE 3-24 Vaginal specula.
FIGURE 3-25 Goniometer.
Goniometer
Wood’s Lamp
Dermatoscope
FIGURE 3-26 Wood’s lamp. The purple color on the skin indicates no fungal infection is present.
FIGURE 3-27 Dermatoscopes. A, Epiluminescence microscope. B, Digital epiluminescence microscope.
FIGURE 3-28 Triceps skinfold caliper. Grasp the handle and depress the lever with thumb.
Calipers for Skinfold Thickness
Monofilament
FIGURE 3-29 A, Monofilament. B, Press the monofilament against the skin hard enough to allow it to bend.
FIGURE 3-30 The scoliometer.
Scoliometer
Chapter 4 Vital Signs and Pain Assessment
http://evolve.elsevier.com/Seidel
Physical Examination Preview
Anatomy and Physiology
Temperature
Pulse Rate
Respiratory Rate
Blood Pressure
Pain
FIGURE 4-1 Transmission of pain impulses from pain receptors to the central nervous system. Nociceptors transmit pain impulses from the periphery along A-delta (Aδ) and C fibers to the dorsal horn of the spinal cord.
Infants
Pregnant Women
Older Adults
Review of Related History
Present Problem
Personal and Social History
Children
Pregnant Women
Older Adults
Examination and Findings
Temperature
FIGURE 4-2 Location of the sites to palpate the pulse.
Pulse Rate
Respiratory Rate
Blood Pressure
Box 4-1 Selecting the Correct Cuff Size
FIGURE 4-3 Select the correct size blood pressure cuff. A, Large adult, adult, and child cuffs. B, Infant cuff (top) and neonatal cuff for use with electronic vital signs monitor (bottom).
FIGURE 4-4 Blood pressure measurement. A, Checking the systolic blood pressure by palpation. B, Using bell of stethoscope to auscultate the blood pressure.
FIGURE 4-5 Phases of Korotkoff sounds, including an example of auscultatory gap.
Table 4-1 Categories for Blood Pressure Levels for Adults
Box 4-2 Pointers for Taking the Blood Pressure
Pain Assessment
Clinical Pearl
The Fifth Vital Sign
Self-Report Pain Rating Scales
Clinical Pearl
Selection of Pain Scale
Assessing Pain Behaviors
FIGURE 4-6 Descriptive pain intensity scale.
FIGURE 4-7 Numeric pain intensity scale.
FIGURE 4-8 Visual analogue scale. Use a 10-cm line with word anchors (“No pain” and “Worst pain”) on each end. Ask the patient to mark the level of pain felt on the line. A centimeter ruler is then used to identify a numeric pain rating for future comparison.
FIGURE 4-9 The Painometer. A multidimensional measure of pain, allowing a measure of intensity and quality and an opportunity for localization. It is the first handheld instrument that meets the standards of The Joint Commission.
Newborns and Infants
Clinical Pearl
Blood Pressure in Infants
Pain Assessment
Staying Well
Children
Box 4-3 Selecting a Blood Pressure Cuff for the Child
Clinical Pearl
Obesity in Children and Adolescents
Pain Assessment
FIGURE 4-10 The Wong/Baker FACES Rating Scale. Explain to the patient that each face is for a person who feels happy because he has no pain (hurt) or sad because he has some or a lot of pain. Face 0 is very happy because the person does not hurt at all. Face 1 hurts just a little bit. Face 2 hurts a little more. Face 3 hurts a little more. Face 4 hurts a whole lot. Face 5 hurts as much as you can imagine, although you do not have to be crying to feel this bad. Ask the patient to choose the face that best describes how he or she is feeling. Recommended for persons 3 years of age and older.
FIGURE 4-11 A, Version of the Oucher for white children. (A, Developed and copyrighted in 1983 by Judith E. Beyer, PhD, RN [University of Missouri-Kansas City School of Nursing].) B, Version of the Oucher for black children. (B, Developed and copyrighted in 1990 by Mary J. Denyes, PhD, RN [Wayne State University], and Antonia M. Villarruel, PhD, RN [University of Michigan]. Cornelia P. Porter, PhD, RN, and Charlotta Marshall, RN, MSN, contributed to the development of this scale.) C, Version of the Oucher for Hispanic children.
Vital Signs
Pain Assessment
Vital Signs
Pain Assessment
FIGURE 4-12 FLACC Behavioral Pain Assessment Scale for nonverbal children.
FIGURE 4-13 The Checklist of Non-Verbal Pain Indicators with movement and at rest.
Abnormalities
Hypertension
Neuropathic Pain
Complex Regional Pain Syndrome
Chapter 5 Mental Status
http://evolve.elsevier.com/Seidel
Physical Examination Preview
Anatomy and Physiology
Infants and Children
Adolescents
FIGURE 5-1 Functional subdivisions of the cerebral cortex.
Older Adults
Review of Related History
History of Present Illness
Past Medical History
Family History
Personal and Social History
Children
Adolescents
Older Adults
Examination and Findings
Box 5-1 Procedures of the Mental Status Screening Examination
Appearance and Behavior
Emotional Stability
Cognitive Abilities
Speech and Language
FIGURE 5-2 During the initial greeting, observe the patient for behavior, emotional status, grooming, and body language. Note the patient’s body posture and ability to make eye contact.
Physical Appearance and Behavior
Grooming
Emotional Status
Nonverbal Communication (Body Language)
State of Consciousness
Cognitive Abilities
Table 5-1 Common Causes of Unresponsiveness
Clinical Pearl
The Importance of Validation
Analogies
Evidence-Based Practice in Physical Examination
FIGURE 5-3 Sample items from the Mini-Mental State Examination (MMSE).
FIGURE 5-4 Copying intersecting pentagons and drawing a clock face are tasks on the Mini-Mental State Examination.
FIGURE 5-5 The Mini-Cog is a brief screening tool for measuring cognitive function.
Abstract Reasoning
Arithmetic Calculation
Writing Ability
Execution of Motor Skills
Memory
Clinical Pearl
Testing Memory in the Visually Impaired
Attention Span
Judgment
Speech and Language Skills
Voice Quality
Articulation
Comprehension
Coherence
DIFFERENTIAL DIAGNOSIS: Distinguishing Characteristics of Aphasias
Emotional Stability
Mood and Feelings
Thought Process and Content
Risk Factors
Perceptual Distortions and Hallucinations
Clinical Pearl
Distorted Thinking
Infants and Children
FIGURE 5-6 A, Note this newborn’s irritability and posturing associated with cocaine withdrawal. B, Note this infant’s level of alertness and interest in various objects and people.
Table 5-2 Expressive Language Milestones for Toddlers and Preschoolers
FIGURE 5-7 Ask the child to draw a picture of a man or woman. The presence and form of body parts provide a clue about the child’s development when following the scoring criteria of the Goodenough-Harris Drawing Test.
FIGURE 5-8 Test a child’s memory recall by using familiar objects.
Pregnant Women
Older Adults
Staying Well
Functional Assessment
Sample Documentation
Subjective
Objective
FIGURE 5-9 Geriatric Depression Scale (short form).
Abnormalities
Mental Status
Disorders of Altered Mental Status
Concussion
Delirium
DIFFERENTIAL DIAGNOSIS: Distinguishing Characteristics of Delirium, Dementia, and Depression
Disorders of Mood
Depression
Mania
Anxiety Disorder
Schizophrenia
Infants and Children
Intellectual Disability
Attention-Deficit/Hyperactivity Disorder (ADHD)
Autism
Older Adults
Dementia
Chapter 6 Growth and Measurement
http://evolve.elsevier.com/Seidel
Physical Examination Preview
Anatomy and Physiology
FIGURE 6-1 Hormones affecting growth during childhood and the ages at which they are most influential.
Differences in Growth by Organ System
FIGURE 6-2 Growth rates for the body as a whole and three types of tissues. Lymphoid type: thymus, lymph nodes, and intestinal lymph masses. Neural type: brain, dura, spinal cord, optic apparatus, and head dimensions. General type: body as a whole; external dimensions; and respiratory, digestive, renal, circulatory, and musculoskeletal systems. Genital type: includes the reproductive organ system.
FIGURE 6-3 Changes in body proportions from 8 weeks of gestation through adulthood.
Infants and Children
Pregnant Women
Box 6-1 Epigenetic Research and Nutrition
Older Adults
Review of Related History
History of Present Illness
Past Medical History
Family History
Personal and Social History
Infants
Children and Adolescents
Pregnant Women
Older Adults
Examination and Findings
Equipment
Weight and Standing Height
Body Mass Index
Box 6-2 Calculating the Body Mass Index
Physical Variations
Obesity
Staying Well
Infants
Recumbent Length
FIGURE 6-4 Measurement of infant length.
Clinical Pearl
Using the Correct Growth Chart
Clinical Pearl
Reliability of Length Measurements
Weight
Clinical Pearl
Uses of Growth Charts
Head Circumference
FIGURE 6-5 Place the measuring tape around the largest circumference of the infant’s head, across the occiput and the forehead.
FIGURE 6-6 Measurement of infant chest circumference with the measuring tape at the level of the nipple line.
Chest Circumference
Gestational Age
Size for Gestational Age.
FIGURE 6-7 A, Small for gestational age infant and appropriate for gestational age infant. B, Large for gestational age infant.
Physical Variations
Low Birth Weight
Stature and Weight
Clinical Pearl
Special Growth Charts
FIGURE 6-8 Measuring the stature of a child.
Physical Variations
Body Mass Index in Children and Youth
Upper-to-Lower Segment Ratio
Arm Span
Sexual Maturation
Physical Variations
Sexual Maturation
FIGURE 6-9 Five stages of breast development in females.
Pregnant Women
FIGURE 6-10 Six stages of pubic hair development in females.
Older Adults
FIGURE 6-11 Five stages of penis and testes/scrotum development in males.
Sample Documentation
Subjective
Objective
FIGURE 6-12 Six stages of pubic hair development in males.
FIGURE 6-13 Prenatal weight gain curve by weeks of gestation.
Abnormalities
Growth and Measurement
Acromegaly
FIGURE 6-14 Acromegaly. Note the large head, forward projection of jaw, protrusion of frontal bone, and the large hands.
Cushing Syndrome
Turner Syndrome
FIGURE 6-15 Turner syndrome.
Hydrocephalus
FIGURE 6-16 Infantile hydrocephalus. Paralysis of the upward gaze is seen in an infant with hydrocephalus resulting from aqueductal stenosis. It appears more apparent on the right. This phenomenon is often termed the sunsetting sign.
Failure To Thrive
FIGURE 6-17 Psychosocial failure to thrive as the result of neglect. This 4-month-old infant was brought to the emergency department because of congestion. She was found to be below weight expectations and suffering from severe developmental delay. Note the marked loss of subcutaneous tissue manifested by the wrinkled skinfolds over the buttocks, shoulders, and upper arms.
Growth Hormone Deficiency
FIGURE 6-18 The normal 3-year-old boy is in the 50th percentile for height. The short 3-year-old girl exhibits the characteristic “Kewpie doll” appearance, suggesting a diagnosis of growth hormone deficiency.
Precocious Puberty
FIGURE 6-19 Precocious puberty with pubic hair development in a young girl.
Chapter 7 Nutrition
http://evolve.elsevier.com/Seidel
Physical Examination Preview
Nutrition Assessment
Anatomy and Physiology
Macronutrients
Carbohydrate
Box 7-1 Nine Essential Amino Acids
Protein
Fat
Micronutrients
Water
Table 7-1 Equations for Predicting Resting Energy Expenditure (REE) from Body Weight*
Energy Requirements
Resting Energy Expenditure
Physical Activity
Thermogenesis
Review of Related History
History of Present Illness
Past Medical History
Table 7-2 Guidelines For Physical Activity by Age
Family History
Personal and Social History
Infants and Children
Box 7-2 Statistics on Obesity and Diet-Related Chronic Diseases in the United States
Adolescents
Risk Factors
Clinical Pearl
Eating Disorders
Pregnant Women
Older Adults
Examination and Findings
Equipment
Box 7-3 Food–Nutrient–Medication Interactions
Risk Factors
Anthropometrics
Waist Circumference and Waist-Height Ratio
Box 7-4 Assessing Height and Weight
Waist-to-Hip Circumference Ratio
FIGURE 7-1 Measurement of waist circumference (A) and hip circumference (B) to calculate the waist-to-hip circumference ratio: waist circumference (cm)/hip circumference (cm) = waist-to-hip ratio.
Determination of Diet Adequacy
Twenty–Four-Hour Recall Diet
FIGURE 7-2 Choose My Plate.
Food Diary
Measures of Nutrient Analysis
ChooseMyPlate.gov
Vegetarian Diets
Ethnic Food Guide Pyramids
Measures of Nutrient Adequacy
Clinical Pearl
Table 7-3 Fat-Soluble Vitamin Summary
Table 7-4 Water-Soluble Vitamin Summary
Table 7-5 Mineral Summary
Table 7-6 Clinical Signs and Symptoms of Various Nutrient Deficiencies
Special Procedures
Triceps Skinfold Thickness
FIGURE 7-3 Placement of calipers for triceps skinfold thickness measurement.
FIGURE 7-4 Measurement of mid–upper arm circumference.
Mid-Upper Arm Circumference
Midarm Muscle Circumference/Midarm Muscle Area
Biochemical Measurement
Sample Documentation
Subjective
Objective
Table 7-7 Biochemical Indicators of Good Nutrition Status
Abnormalities
Nutrition
Obesity
FIGURE 7-5 Childhood obesity has become a major public health problem in the United States.
Table 7-8 Physical Examination Findings in Obesity Assessment and Possible Causes
Table 7-9 Comparison of Laboratory Test Results for Anemias
Table 7-10 Cutoffs for Total and LDL Cholesterol Levels in Children and Adolescents
Anorexia Nervosa
Bulimia Nervosa
Anemia
Staying Well
Nutrient Composition of the TLC Diet
Staying Well
Chapter 8 Skin, Hair, and Nails
http://evolve.elsevier.com/Seidel
Physical Examination Preview
Skin, Hair, and Nails
Skin
Hair
Nails
Anatomy and Physiology
FIGURE 8-1 Anatomic structures of the skin.
Epidermis
Dermis
Hypodermis
Appendages
FIGURE 8-2 Anatomic structures of the nail.
Infants and Children
Adolescents
Pregnant Women
Older Adults
Review of Related History
History of Present Illness
Risk Factors: Melanoma
Risk Factors: Basal and Squamous Cell Cancer
Past Medical History
Box 8-1 Skin Type
Family History
Personal and Social History
Box 8-2 Patient Instructions for Skin Self-Examination
Clinical Pearl: Sunscreen
Infants
Clinical Pearl: Carotenemia
Children and Adolescents
Pregnant Women
Older Adults
Examination and Findings
Equipment
Skin
Inspection
FIGURE 8-3 Corn.
Box 8-3 Cutaneous Manifestations of Traditional Health Practices
FIGURE 8-4 Calluses are common on both the sole (heels and metatarsal heads) and the dorsum of the foot (especially in women).
Physical Variations: Pigmentary Demarcation Lines
Physical Variations: Nevi
Table 8-1 Features and Occurrence of Various Types of Pigmented Nevi
Table 8-2 Features of Normal and Dysplastic Moles
Box 8-4 Dysplastic Mole or Melanoma?
FIGURE 8-5 Commonly occurring nevi. A, Junction nevus. Color and shape of this black lesion are uniform. B, Compound nevus. Center is elevated and surrounding area is flat, retaining features of a junction nevus. C, Dermal nevus. Papillomatous with soft, flabby, wrinkled surface.
FIGURE 8-6 Vitiligo.
Table 8-3 Cutaneous Color Changes
Clinical Pearl: Telangiectasias: Capillary Spider/Spider Angioma
FIGURE 8-7 Petechiae.
FIGURE 8-8 Senile purpura.
FIGURE 8-9 Characteristics and causes of vascular skin lesions.
Palpation
Box 8-5 Smell the Skin
FIGURE 8-10 Examining an intertriginous area.
Skin Lesions
FIGURE 8-11 Testing skin turgor.
Characteristics
Table 8-4 Primary Skin Lesions
Measles.(From Hockenberry and Wilson, 2007.)
Lichen planus.(From Weston et al, 1996.)
Vitiligo.(From Weston and Lane, 1991.)
Plaque.(From James et al, 2000.)
Wheal.(From Farrar et al, 1992.)
Hypertrophic nodule.(From Goldman and Fitzpatrick, 1994.)
Lipoma.(From Lemmi and Lemmi, 2000.)
Vesicles caused by varicella.(From Farrar et al, 1992.)
Blister.(From White, 1994.)
Acne.(From Weston et al, 1996.)
Sebaceous cyst.(From Weston et al, 1996.)
Telangiectasia.(From Lemmi and Lemmi, 2000.)
TABLE 8-5 Secondary Skin Lesions
Fine scaling.(From Baran et al, 1991.)
Lichenification.(From Lemmi and Lemmi, 2000.)
Keloid.(From Weston et al, 1996.)
Hypertrophic scar.(From Goldman and Fitzpatrick, 1994.)
Excoriation from a tree branch.(From Lemmi and Lemmi, 2000.)
Scaling and fissures of tinea pedis.(From Lemmi and Lemmi, 2000.)
Erosion.(From Cohen, 1993.)
Stasis ulcer.(From Swartz 2009.)
Scab.
Striae.(Courtesy Antoinette Hood, MD, Department of Dermatology, University of Indiana, Department of Medicine, Indianapolis.)
Table 8-6 Morphologic Characteristics of Skin Lesions
Box 8-6 Regional Distribution of Skin Lesions
Sun-Exposed Areas
Cloth-Covered Areas
Flexural Aspects of Extremities
Extensor Aspects of Extremities
Stocking and Glove (Acrodermatitis)
Truncal
Face, Shoulder, Back
FIGURE 8-12 Clustering of lesions.
FIGURE 8-13 Linear formation of lesions (herpes zoster).
FIGURE 8-14 Annular formation of lesions (granuloma annulare). An annular plaque or plaques may occur on the dorsa of the feet or hands as a manifestation of granuloma annulare.
Staying Well: Practice Sun Safety
Hair
Nails
Inspection
Color.
FIGURE 8-15 Pigmented bands in nails are expected in persons with dark skin.
FIGURE 8-16 White spots on nail from injury (leukonychia punctata).
Physical Variations: Pigment in the Nail Beds
FIGURE 8-17 Aging nails. Longitudinal ridging of the nail is a common expected variation.
FIGURE 8-18 Median nail dystrophy.
Nail Plate.
Nail Base Angle.
Palpation
FIGURE 8-19 Nails: unexpected findings and appearance.
FIGURE 8-20 Schamroth technique. A, Patient with healthy nails, illustrating window. B, Patient with nail clubbing, illustrating loss of the window and prominent distal angle.
FIGURE 8-21 Finger clubbing. Nail is enlarged and curved.
FIGURE 8-22 Testing nail bed adherence.
Infants and Children
Box 8-7 Expected Color Changes in the Newborn
Risk Factors: Major Risk Factors for Severe Hyperbilirubinemia in Infants of 35 or More Weeks’ Gestation
Box 8-8 Skin Lesions: External Clues to Internal Problems
FIGURE 8-23 Expected creases of newborn’s hands (A) and feet (B).
FIGURE 8-24 Unexpected palmar crease. Single transverse crease in child with Down syndrome. Compare to Figure 8-23, A.
FIGURE 8-25 Mottling (cutis marmorata).
FIGURE 8-26 Acrocyanosis of hands in newborn.
FIGURE 8-27 Hyperpigmented patches (Mongolian spots) are common in babies with dark skin.
FIGURE 8-28 Hemangiomas in infant.
FIGURE 8-29 Café au lait patches.
FIGURE 8-30 Milia in infant.
Table 8-7 Estimating Dehydration
FIGURE 8-31 Testing skin turgor in an infant.
Clinical Pearl: Bald Spots in Children and Infants
Adolescents
Pregnant Women
FIGURE 8-32 Striae.
FIGURE 8-33 Linea nigra on abdomen of pregnant woman.
FIGURE 8-34 Facial hyperpigmentation: chloasma (melasma).
FIGURE 8-35 Hands of older adult. Note prominent veins and thin appearance of skin.
Older Adults
Clinical Pearl: Hydration Status in Older Adults
Table 8-8 Staging of Pressure Ulcers (Decubitus Ulcers)
FIGURE 8-36 Skin hanging loosely, especially around bony prominences.
FIGURE 8-37 Skin turgor in older adult. Note tenting.
FIGURE 8-38 Cherry angioma in older adult.
FIGURE 8-39 Seborrheic keratoses in older adult.
FIGURE 8-40 Sebaceous hyperplasia.
FIGURE 8-41 Multiple cutaneous tags in axilla.
Sample Documentation: History and Physical Examination
Subjective
Objective
FIGURE 8-42 Cutaneous horn.
FIGURE 8-43 Lentigo, a brown macule that appears in sun-exposed areas.
Abnormalities
Skin, Hair, Nails
Skin: Inflammatory and Infectious Conditions
Eczematous Dermatitis
FIGURE 8-44 Contact dermatitis.
Folliculitis
FIGURE 8-45 Beard folliculitis.
Furuncle (Boil)
FIGURE 8-46 Furuncle.
Cellulitis
FIGURE 8-47 Cellulitis of the leg.
Tinea (Dermatophytosis)
FIGURE 8-48 A, Tinea corporis. B, Tinea cruris. C, Tinea capitis. D, Tinea pedis.
Pityriasis Rosea
FIGURE 8-49 Pityriasis rosea.
Psoriasis
FIGURE 8-50 Psoriasis. Note characteristic silver scaling.
Rosacea
FIGURE 8-51 Rosacea.
FIGURE 8-52 Rhinophyma.
Herpes Zoster (Shingles)
FIGURE 8-53 Herpes zoster (shingles) confined to one dermatome.
Herpes Simplex
FIGURE 8-54 Herpes simplex. A, Oral. B, Female genital. C, Male genital.
Lyme Disease
FIGURE 8-55 Erythema migrans (lyme disease).
Skin: Cutaneous Reactions
Drug Eruptions
FIGURE 8-56 Drug eruption.
Acanthosis Nigricans (AN)
FIGURE 8-57 Acanthosis nigricans.
Skin: Disease Caused by Biologic Warfare
Differential Diagnosis Cutaneous Manifestations of Two Pathogens That May Be Used in Biologic Warfare
Anthrax (Skin Form). A Gram-stained smear of material taken from the lesion will reveal the gram-positive rods of Bacillus anthracis.
Smallpox. This archival photograph shows eczema vaccinatum acquired from a relative who had recently been vaccinated against smallpox.
Skin: Malignant/Neoplastic Abnormalities
Basal Cell Carcinoma
FIGURE 8-58 Two common presentations of basal cell carcinoma.
Squamous Cell Carcinoma
FIGURE 8-59 Squamous cell carcinoma.
Malignant Melanoma
FIGURE 8-60 Malignant melanoma.
FIGURE 8-61 ABCD changes in moles.
Kaposi Sarcoma (KS)
FIGURE 8-62 A, Violaceous plaques on the heel and lateral foot. B, Brown nodule of Kaposi sarcoma.
Hair Disorders
Alopecia Areata
FIGURE 8-63 Alopecia areata.
Scarring Alopecia
Traction Alopecia
Hirsutism
FIGURE 8-64 Facial hirsutism. Terminal hair growth is visible on the chin of this 40-year-old woman with idiopathic hirsutism.
Nails: Infection
Paronychia
FIGURE 8-65 Paronychia.
Onychomycosis
FIGURE 8-66 Onychomycosis.
Nails: Injury
Ingrown Nails
FIGURE 8-67 Ingrown toenail. Swelling and inflammation occur at lateral nail fold.
Subungual Hematoma
FIGURE 8-68 Subungual hematoma.
Onycholysis
FIGURE 8-69 Onycholysis. Separation of nail plate starts at distal groove.
Nails: Changes Associated with Systemic Disease
Koilonychia (Spoon Nails)
FIGURE 8-70 Koilonychia.
Beau Lines
FIGURE 8-71 Beau lines following systemic disease.
White Banding (Terry Nails)
FIGURE 8-72 Terry nails; transverse white bands.
Psoriasis
FIGURE 8-73 Nail pitting.
Nails: Periungual Growths
Warts
FIGURE 8-74 Periungual warts.
Digital Mucous Cysts
FIGURE 8-75 Digital mucous cysts causing a groove in the nail plate.
Pregnant Women
Pruritic Urticarial Papules and Plaques of Pregnancy (PUPPP)
Herpes Gestationis (Pemphigoid Gestationis)
Infants and Children
Seborrheic Dermatitis
FIGURE 8-76 Pustular seborrheic dermatitis.
Miliaria Rubra (“Prickly Heat”)
FIGURE 8-77 Miliaria in infant.
Impetigo
FIGURE 8-78 Impetigo. Note characteristic crusting.
Acne Vulgaris
FIGURE 8-79 Acne in dolescent.
Chickenpox (Varicella)
FIGURE 8-80 Varicella (Chickenpox). Note vesicular lesions.
Measles (Rubeola)
FIGURE 8-81 Rubeola.
German Measles (Rubella)
FIGURE 8-82 Rubella (German measles). A, Note the pinkish red, maculopapular eruption. B, Red palatal lesions (Forschheimer spots) are seen in some patients on day 1 of the rash.
Hair-Pulling (Trichotillomania)
FIGURE 8-83 Trichotillomania.
Patterns of Injury in Physical Abuse
FIGURE 8-84 This contusion in the configuration of a closed horseshoe with a central linear abrasion was inflicted with a belt buckle.
FIGURE 8-85 Burns on the perineum, thighs, legs, and feet.
FIGURE 8-86 Cigarette burn. This older burn has begun to granulate.
Older Adults
Stasis Dermatitis
FIGURE 8-87 Stasis dermatitis in older adult.
Solar Keratosis (Actinic Keratosis)
FIGURE 8-88 Actinic keratosis in older adult in area of sun exposure.
Physical Abuse in Older Adults
Chapter 9 Lymphatic System
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Physical Examination Preview
Lymphatic System
Anatomy and Physiology
FIGURE 9-1 Lymphatic system (lymphoreticular system).
Lymph Nodes
FIGURE 9-2 Lymphatic drainage pathways. Shaded area of the body is drained via the right lymphatic duct, which is formed by the union of three vessels: right jugular trunk, right subclavian trunk, and right bronchomediastinal trunk. Lymph from the remainder of the body enters the venous system by way of the thoracic duct.
FIGURE 9-3 Lymphatic drainage of lower extremity.
FIGURE 9-4 Lymphatic drainage of female genital tract.
FIGURE 9-5 Systems of Deep and Superficial Collecting Ducts, Carrying Lymph from Upper Extremity to Subclavian Lymphatic Trunk. The only peripheral lymph center is the epitrochlear, which receives some of the collecting ducts from the pathway of the ulnar and radial nerves.
FIGURE 9-6 Six groups of lymph nodes may be distinguished in the axillary fossa.
FIGURE 9-7 Lymphatic drainage of breast.
FIGURE 9-8 Lymph nodes involved with the ear.
FIGURE 9-9 Lymph nodes involved with the tongue.
FIGURE 9-10 Lymphatic drainage system of head and neck. If the group of nodes is commonly referred to by another name, the second name appears in parentheses.
FIGURE 9-11 Lymph nodes of neck. Note relationship to the sternocleidomastoid muscle.
Lymphocytes
Box 9-1 The Lymph Nodes Most Accessible to Inspection and Palpation
The “Necklace” of Nodes
The Arms
The Legs
Thymus
Spleen
FIGURE 9-12 Location of thymus gland and its size relative to the rest of the body. A, During infancy. B, During adult life.
Tonsils and Adenoids
Peyer Patches
Infants and Children
Clinical Pearl
Pregnant Women
FIGURE 9-13 Relative levels of presence and function of the immune factors.
Older Adults
Review of Related History
History of Present Illness
Past Medical History
Risk Factors
Adolescents and Adults
Infants and Children
Family History
Personal and Social History
Infants and Children
Pregnant Women
Older Adults
Examination and Findings
Equipment
Inspection and Palpation
Box 9-2 Terms!
Conditions
Nodes
FIGURE 9-14 Some of the accessible lymph nodes.
Clinical Pearl
Clinical Pearl
Clinical Pearl
DIFFERENTIAL DIAGNOSIS Conditions Simulating Lymph Node Enlargement
Head and Neck
FIGURE 9-15 The triangles of the neck.
FIGURE 9-16 Palpable lymph nodes of the head and neck.
FIGURE 9-17 Palpation of preauricular lymph nodes. Compare the nodes bilaterally.
FIGURE 9-18 Palpation of posterior cervical nodes. Use the dorsal surfaces (pads) of the fingertips to palpate along the anterior surface of the trapezius muscle and then move slowly in a circular motion toward the posterior surface of the sternocleidomastoid muscle.
Axillae
Epitrochlear Lymph Nodes
FIGURE 9-19 Palpation for supraclavicular lymph nodes. Encourage the patient to relax the musculature of the upper extremities so that the clavicles drop. The examiner’s free hand is used to flex the patient’s head forward to relax the soft tissues of the anterior neck. The fingers are hooked over the clavicle lateral to the sternocleidomastoid muscle.
FIGURE 9-20 Soft tissues of axilla are gently rolled against the chest wall and the muscles surrounding the axilla.
FIGURE 9-21 Palpation for epitrochlear lymph nodes is performed in the depression above and posterior to the medial condyle of the humerus.
Clinical Pearl
Inguinal and Popliteal Lymph Nodes
FIGURE 9-22 A, Palpation of inferior superficial inguinal (femoral) lymph nodes. B, Palpation of superior inguinal lymph nodes.
Staying Well
Spleen
Infants and Children
DIFFERENTIAL DIAGNOSIS Mumps Versus Cervical Adenitis
DIFFERENTIAL DIAGNOSIS How to Discover an Immune Deficiency Disease in a Child
Box 9-3 When Lymphadenopathy Requires Further Investigation
Clinical Pearl
Sample Documentation
Subjective
Objective
Abnormalities
Lymphatic System
Acute Lymphangitis
Acute Suppurative Lymphadenitis
Lymphedema
FIGURE 9-23 Lymphedema.
DIFFERENTIAL DIAGNOSIS: Lymphedema or Edema?
Table 9-1 Grading of Lymphedema by the International Society of Lymphology Criteria
Lymphangioma/Cystic Hygroma
Lymphatic Filariasis (Elephantiasis)
DIFFERENTIAL DIAGNOSIS When the Body Swells
Non-Hodgkin Lymphoma
Hodgkin Lymphoma
FIGURE 9-24 Hodgkin disease. Note the impressive extent of the enlargement.
Epstein-Barr Virus Mononucleosis
Toxoplasmosis
Roseola Infantum (HHV-6)
Herpes Simplex (HSV)
FIGURE 9-25 Herpes simplex.
Cat Scratch Disease
Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome (HIV/AIDS)
Serum Sickness (Type III Hypersensitivity Reaction)
Latex Allergy Type IV Dermatitis (Delayed Hypersensitivity)
Latex Allergy Type I Reaction
Chapter 10 Head and Neck
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Physical Examination Preview
Head and Neck
Head
Neck
Anatomy and Physiology
FIGURE 10-1 Bones of the skull.
FIGURE 10-2 Landmarks of the face.
FIGURE 10-3 Underlying structures of the neck. A, Anterior view. B, Lateral view.
FIGURE 10-4 Anterior and posterior triangles of the neck.
Infants
Children and Adolescents
Pregnant Women
Older Adults
Review of Related History
FIGURE 10-5 Lymphatic drainage system of head and neck. (If the group of nodes is often referred to by a second name, that name appears in parentheses.)
FIGURE 10-6 Fontanels and sutures on the infant’s skull.
FIGURE 10-7 Thyroid enlargement in pregnancy. Note the large nodule in the patient’s left lobe. Thyroid size increases in pregnancy in areas of iodine deficiency but not in those with sufficient iodine.
History of Present Illness
Past Medical History
Family History
Personal and Social History
Infants
Pregnant Women
Older Adults
Examination and Findings
Equipment
Head and Face
Inspection
FIGURE 10-8 Cushing syndrome. A, Facies include a rounded or “moon-shaped” face with thin, erythematous skin. B, Side view. Shows upper thoracic fat pad (buffalo hump).
FIGURE 10-9 Hippocratic facies. Note sunken appearance of the eyes, cheeks, and temporal areas; sharp nose; and dry, rough skin seen in this patient in the terminal stages of throat cancer.
FIGURE 10-10 Myxedema facies. Note dull, puffy, yellowed skin; coarse, sparse hair; temporal loss of eyebrows; periorbital edema; and prominent tongue.
FIGURE 10-11 Hyperthyroid facies. Note fine, moist skin with fine hair, prominent eyes and lid retraction, and staring or startled expression.
FIGURE 10-12 Butterfly rash of systemic lupus erythematosus. Note butterfly-shaped rash over malar surfaces and bridge of nose. Either a blush with swelling or scaly, red, maculopapular lesions may be present.
FIGURE 10-13 Bell palsy. Left facial palsy (cranial nerve VII). Facies include asymmetry of one side of the face, eyelid not closing completely, drooping lower eyelid and corner of mouth, and loss of nasolabial fold.
FIGURE 10-14 Early acromegaly. Note the coarsening of features with broadening of the nasal alae and prominence of the zygomatic arches.
FIGURE 10-15 Pierre-Robin sequence; a triad of micrognathia, glossoptosis, and palatal clefting. Shows a lateral view with severe micrognathia and cleft palate. Note the small retruded mandible.
FIGURE 10-16 Down syndrome. Note depressed nasal bridge, epicanthal folds, mongoloid slant of eyes, and low-set ears.
FIGURE 10-17 Hurler syndrome. Facies includes enlarged skull with low forehead, corneal clouding, and short neck.
FIGURE 10-18 Hydrocephalus. A, Coronal view with characteristic enlarged head, thinning of the scalp with dilated scalp veins, and bossing of the skull. B, Anteroposterior view demonstrating sclera visible above the iris. In this case, the infant has paresis of upward gaze. This phenomenon is often termed the “sunsetting sign.”
FIGURE 10-19 Fetal alcohol syndrome. This is one of the most common causes of acquired intellectual disability. Note the poorly formed philtrum; widespread eyes, with inner epicanthal folds and mild ptosis; hirsute forehead; short nose; and relatively thin upper lip.
FIGURE 10-20 Treacher-Collins syndrome. Note the maxillary hypoplasia, micrognathia, and auricular deformity.
FIGURE 10-21 Apert syndrome. Note the severe maxillary and midfacial hypoplasia.
FIGURE 10-22 Crouzon syndrome. Observe the severe maxillary and midfacial hypoplasia with low-set ears.
FIGURE 10-23 Inspection of the scalp.
Palpation
Percussion
Auscultation
Neck
Inspection
FIGURE 10-24 Auscultation for a temporal bruit.
Palpation
FIGURE 10-25 Position of the thumbs to evaluate the midline position of the trachea.
FIGURE 10-26 Position of the thumb and finger to detect tracheal tugging.
Lymph Nodes
Thyroid Gland
Clinical Pearl
Evidence-Based Practice in Physical Examination
FIGURE 10-27 Palpation of the right thyroid lobe and lateral border from in front of the patient.
Clinical Pearl
FIGURE 10-28 Palpation of the right thyroid lobe from behind the patient. Displace the trachea to the patient’s right and palpate the right lobe as the patient again swallows.
Inspection
Clinical Pearl
FIGURE 10-29 Caput succedaneum. Significant scalp edema as a result of compression during transit through birth canal. Edema does cross suture lines.
FIGURE 10-30 Cephalhematoma. Swelling does not cross suture lines.
Staying Well
Palpation
FIGURE 10-31 Molding of the newborn head.
Transillumination
FIGURE 10-32 Transillumination of the infant’s scalp.
Children
Pregnant Women
Older Adults
Sample Documentation
Subjective
Objective
DIFFERENTIAL DIAGNOSIS Comparison of Various Types of Headaches
Abnormalities
Head
Headaches
Salivary Gland Tumor
FIGURE 10-33 Malignant right parotid gland tumor.
Neck
Thyroglossal Duct Cyst
FIGURE 10-34 Thyroglossal duct cyst location.
Branchial Cleft Cyst
FIGURE 10-35 Branchial cleft cyst location in relation to other neck masses.
Torticollis (Wry Neck)
FIGURE 10-36 Torticollis, or wry neck.
Thyroid
Hypothyroidism
Table 10-1 Hyperthyroidism Versus Hypothyroidism
Hyperthyroidism
Myxedema
Graves Disease
Hashimoto Disease
Infants
Encephalocele
FIGURE 10-37 Encephalocele.
Hydrocephalus
Microcephaly
FIGURE 10-38 Primary familial microcephaly. The facial features of an infant with fetal alcohol syndrome (FAS) include short palpebral (eye) fissures; a flat nasal bridge; a thin, flat upper lip; a poorly formed groove at the center of the upper lip; and a small head (microcephaly).
Craniosynostosis
FIGURE 10-39 A, Vertex view of right-sided deformational plagiocephaly exhibiting a parallelogram head shape. B, Vertex view of right-sided lambdoid craniosynostosis exhibiting a trapezoid-like head shape.
Chapter 11 Eyes
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Physical Examination Preview
Eyes
Anatomy and Physiology
FIGURE 11-1 Anatomy of the human eye.
FIGURE 11-2 Extraocular muscles of the eye as viewed from above. A, The oblique muscles. B, The recti muscles (om, oculomotor). The cranial nerves, which innervate the muscles, are listed in Figure 11-22.
External Eye
Eyelid
FIGURE 11-3 Important landmarks of the left external eye.
Conjunctiva
Lacrimal Gland
Eye Muscles
Internal Eye
Sclera
Cornea
Uvea
Lens
Retina
Infants and Children
FIGURE 11-4 The optic chiasm.
Pregnant Women
Older Adults
Table 11-1 Chronology of Visual Development
Risk Factors
Review of Related History
History of Present Illness
Past Medical History
Family History
Personal and Social History
Infants and Children
Pregnant Women
Older Adults
Examination and Findings
Equipment
Visual Acuity Testing
Clinical Pearl
Clinical Pearl
FIGURE 11-5 Evaluation of peripheral fields of vision. A, Temporal field. B, Nasal field.
External Examination
FIGURE 11-6 Xanthelasma.
Surrounding Structures
Eyelids
FIGURE 11-7 Ptosis, a drooping of the upper eyelid.
FIGURE 11-8 Ectropion.
FIGURE 11-9 Entropion. Note that this patient has undergone corneal transplantation.
FIGURE 11-10 Acute hordeolum of upper eyelid.
FIGURE 11-11 Blepharitis.
Palpation
Conjunctiva
FIGURE 11-12 Pulling lower eyelid down to inspect the conjunctiva.
FIGURE 11-13 Everting upper eyelid. A, Placing applicator above the globe. B, Withdrawing the lid from the globe.
FIGURE 11-14 Erythematous eye from a chemical allergy.
FIGURE 11-15 Acute purulent conjunctivitis.
FIGURE 11-16 Subconjunctival hemorrhage.
Cornea
FIGURE 11-17 Pterygium.
FIGURE 11-18 Testing corneal sensitivity.
FIGURE 11-19 Corneal arcus senilis.
Iris and Pupil
FIGURE 11-20 Arcus senilis and pterygium.
Table 11-2 Descriptions of Various Pupil Abnormalities
Lens
Sclera
Lacrimal Apparatus
FIGURE 11-21 Senile hyaline plaque.
Extraocular Muscles
FIGURE 11-22 Cranial nerves and extraocular muscles associated with the six cardinal fields of gaze.
Physical Variations
FIGURE 11-23 Evaluating eye fixation by the cover-uncover test. A, Patient focuses on near object. B, Examiner evaluates movement of covered eye as cover is removed.
FIGURE 11-24 Strabismus.
Ophthalmoscopic Examination
FIGURE 11-25 A, Visualization of the red reflex. B, Examination of the optic fundus.
Box 11-1 Test for Applying Mydriatics
Evaluation of depth of anterior chambers. A, Usual anterior chamber. B, Shallow anterior chamber.
FIGURE 11-26 Retinal structures of the left eye.
FIGURE 11-27 A, Normal right fundus in a white patient. B, Normal left fundus.
FIGURE 11-28 Fundus of a black patient.
Clinical Pearl
FIGURE 11-29 Method of describing the position and dimension of a lesion in terms of disc diameter. The lesion in this illustration is described as being 2 disc diameters (DD) from the optic disc at the 2 o’clock position. The lesion is DD long and DD wide.
FIGURE 11-30 Myelinated retinal nerve fibers.
FIGURE 11-31 Severe papilledema.
FIGURE 11-32 Marked glaucomatous optic nerve head cupping. Compare the disappearance of blood vessels here with the blood vessels of the optic disc in Figures 11-26 and 11-27.
Unexpected Findings
Infants
Table 11-3 Unexpected Retinal Findings
FIGURE 11-33 A, Drusen bodies. B, Amsler grid showing visual changes seen caused by fluid leakage under the retina.
Clinical Pearl
FIGURE 11-34 A, Hemorrhage at the disc margin. B, Flame hemorrhages.
FIGURE 11-35 Epicanthal folds.
Box 11-2 Hypertensive Retinopathy
FIGURE 11-36 Drawing a line between the two medial canthi and extending it temporally to determine whether a Mongolian or anti-Mongolian slant is present.
FIGURE 11-37 Swollen eyelids in a newborn.
Children
Table 11-4 Pediatric Eye Evaluation Screening Recommendations for Health Care Providers
Pregnant Women
Older Adults
Sample Documentation
Subjective
Objective
Abnormalities
External Eye
Exophthalmos
FIGURE 11-38 Thyroid exophthalmos. See also Figure 10-11.
Episcleritis
FIGURE 11-39 Episcleritis.
Band Keratopathy
FIGURE 11-40 Band keratopathy.
Corneal Ulcer
FIGURE 11-41 Corneal ulcer in the lower temporal quadrant of the left cornea stained with rose bengal.
Extraocular Muscles
Strabismus
Internal Eye
Horner Syndrome
FIGURE 11-42 Horner syndrome (right eye).
Cataracts
FIGURE 11-43 A, Snowflake cataract of diabetes. B, Senile cataract.
Diabetic Retinopathy (Background or Non-Proliferative)
FIGURE 11-44 Background diabetic retinopathy. Note flame-shaped and dot-blot hemorrhages, cotton-wool spots, and microaneurysms.
Diabetic Retinopathy (Proliferative)
FIGURE 11-45 Proliferative diabetic retinopathy.
Lipemia Retinalis
FIGURE 11-46 Lipemia retinalis.
Retinitis Pigmentosa
FIGURE 11-47 Retinitis pigmentosa. A, Optic atrophy and narrowing of the arterioles. B, Classic “bone spicule” pigmentation in the retinal periphery.
Glaucoma
Chorioretinitis (Chorioretinal Inflammation)
FIGURE 11-48 Patches of chorioretinitis adjacent to the optic disc.
Visual Fields
Visual Field Defects
FIGURE 11-49 Site of lesions causing visual loss. 1, Total blindness left eye. 2, Bitemporal hemianopia. 3, Left homonymous hemianopia.
FIGURE 11-50 Visual fields corresponding to lesions shown in Figure 11-49. A, Total blindness left eye. B, Bitemporal hemianopia. C, Left homonymous hemianopia.
Children and Infants
Retinoblastoma
FIGURE 11-51 Retinoblastoma.
Retinopathy of Prematurity (ROP)
FIGURE 11-52 Retinopathy of prematurity. Changes found in posterior pole of the left eye in the cicatricial (scar forming) stage of the disease with traction on the retina in the posterior pole.
Retinal Hemorrhages in Infancy
FIGURE 11-53 Multiple retinal hemorrhages are seen on funduscopic examination of this infant who was a victim of the shaken baby syndrome.
Older Adult
Macular Degeneration
Chapter 12 Ears, Nose, and Throat
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Physical Examination Preview
Ears
Nose and Sinuses
Mouth
Anatomy and Physiology
Ears and Hearing
FIGURE 12-1 Cross section of the external, middle, and inner ear in relation to other structures of the head and face.
FIGURE 12-2 Anatomy of the ear.
FIGURE 12-3 Anatomic structures of the auricle. The helix is the prominent outer rim, whereas the antihelix is the area parallel and anterior to the helix. The concha is the deep cavity containing the auditory canal meatus. The tragus is the protuberance lying anterior to the auditory canal meatus, and the antitragus is the protuberance on the antihelix opposite the tragus. The lobule is the soft lobe on the bottom of the auricle.
FIGURE 12-4 Structural landmarks of the right tympanic membrane in relation to a clock face.
Nose, Nasopharynx, and Sinuses
FIGURE 12-5 Anatomic structures of the external nose.
FIGURE 12-6 Cross-sectional view of the anatomic structures of the nose and nasopharynx.
FIGURE 12-7 Anterior view of the cranial sinuses. A, Six-year-old child. B, Adult.
Mouth and Oropharynx
FIGURE 12-8 Anatomic structures of the oral cavity.
FIGURE 12-9 Landmarks of the ventral surface of the tongue.
FIGURE 12-10 A, Dentition of deciduous teeth and their sequence of eruption. B, Dentition of permanent teeth and their sequence of eruption.
Infants and Children
Pregnant Women
Older Adults
Review of Related History
History of Present Illness
Risk Factors: Hearing Loss
Adults
Infants and Children
Risk Factors: Oral Cavity and Oropharyngeal Cancer
Past Medical History
Family History
Personal and Social History
Infants and Children
Pregnant Women
Older Adults
Evidence-Based Practice in Physical Examination: Detection of Hearing Loss
Examination and Findings
Equipment
Ears and Hearing
External Ear
FIGURE 12-11 A, Preauricular skin tag. B, Auricular sinus. C, Darwin tubercle. D, Cauliflower ear. E, Tophi. F, Sebaceous cysts.
FIGURE 12-12 Assessment of auricle alignment showing expected position. Imaginary line extends from inner eye canthus to occiput.
Otoscopic Examination
FIGURE 12-13 To examine the adult’s ear with the otoscope, straighten the external auditory canal by pulling the auricle up and back.
Physical Variations: Types of Cerumen
Clinical Pearl: Cleaning an Obstructed Auditory Canal
FIGURE 12-14 A, Healthy tympanic membrane. B, Tympanic membrane partially obscured by cerumen. C, Bulging tympanic membrane with loss of bony landmarks. D, Perforated tympanic membrane. E, Perforated tympanic membrane that has healed. F, Tympanostomy tube protruding from the right tympanic membrane.
Table 12-1 Tympanic Membrane Signs and Associated Conditions
Hearing Evaluation
Whispered Voice.
FIGURE 12-15 Weber Test. Touching only the handle, place the base of the tuning fork on the midline of the skull. Avoid touching the vibrating tines.
Weber and Rinne Tests.
FIGURE 12-16 Rinne test. A, Place the tuning fork on the mastoid bone for bone conduction. B, To test for air conduction hold the tuning fork 1 to 2 cm ( to 1 inch) from the ear with the tines facing forward.
Clinical Pearl: Ménière Disease
Nose, Nasopharynx, and Sinuses
External Nose
Table 12-2 Interpretation of Tuning Fork Tests
Nasal Cavity
Clinical Pearl: Cocaine Abuse
FIGURE 12-17 A, Use of the nasal speculum. Avoid touching the nasal septum. B, View of the nasal mucosa through the nasal speculum.
Sinuses
FIGURE 12-18 Unexpected findings on nasal examination. A, Nasal polyp (allergic). B, Deviation of the nasal septum.
FIGURE 12-19 Transillumination of the sinuses: placement of the light source and expected area of transillumination. A, For the maxillary sinus. B, For the frontal sinus.
Evidence-Based Practice in Physical Examination: Predictors of Sinusitis
Mouth and Oropharynx
Lips
Buccal Mucosa, Teeth, and Gums
FIGURE 12-20 Unexpected findings on the lips. A, Angular cheilitis. B, Actinic cheilitis. C, Angioedema. D, Herpes simplex lesions (cold sores). E, Squamous cell carcinoma of the lip. F, Peutz-Jeghers syndrome.
FIGURE 12-21 A, Class I malocclusion. B, Class III malocclusion.
Table 12-3 Classification of Malocclusion
Physical Variations: Buccal Mucosa, Teeth, and Gums
FIGURE 12-22 Findings on the buccal mucosa. A, Fordyce spots. B, Patchy coloration of mucous membranes in individual of dark skin color. C, Aphthous ulcer. D, Leukoplakia.
FIGURE 12-23 Unexpected findings of the gingiva. A, Plasma cell gingivitis. B, Phenytoin-related hyperplasia of the gingival.
Oral Cavity
FIGURE 12-24 Findings on the tongue and mouth floor. A, Left hypoglossal paralysis. The tongue deviates to the weak side. Note atrophy on the tongue’s right side. B, Geographic tongue. C, Glossitis, smooth tongue resulting from vitamin deficiency. D, Black hairy tongue. E, Ranula (obstructed sublingual salivary gland). F, Primary gingivostomatitis showing lesions on the tongue.
FIGURE 12-25 Inspection of lateral borders of the tongue.
Staying Well: Screening for Oral Cancer
Physical Variations: Mandible and Uvula
Table 12-4 Oral Manifestations of HIV Infection
FIGURE 12-26 Oral Kaposi sarcoma. A, Moderately advanced. B, Advanced lesion.
FIGURE 12-27 A, Torus palatinus. B, Bifid uvula.
Oropharynx
Clinical Pearl: Use of a Tongue Blade
Evidence-Based Practice in Physical Examination: Predictors of Streptococcal Pharyngitis
FIGURE 12-28 Findings of the oropharynx. A, Tonsillitis and pharyngitis. B, Acute viral pharyngitis. C, Postnasal drip.
Infants
Ears.
Nose and Sinuses.
Table 12-5 The Sequence of Expected Hearing and Speech Response
Mouth.
Physical Variations: Cleft Lip and Palate
FIGURE 12-29 Findings in the infant’s mouth. A, Candidiasis infection (thrush). B, Natal teeth. C, Short frenulum. D, Macroglossia. E, Epstein pearls.
Children
Ears.
FIGURE 12-30 Positioning of toddler for oral examination. A, Sitting position. B, Supine position.
FIGURE 12-31 Tympanometer wave pattern associated with middle ear conditions.
Physical Variations: Acute Otitis Media
Nose and Sinuses.
Mouth.
FIGURE 12-32 Early childhood caries.
Pregnant Women
Older Adults
Ears and Hearing.
Nose.
Functional Assessment: Ears, Nose, and Throat
Mouth.
FIGURE 12-33 Enlarged tonsils are graded to describe their size: A, 1+, visible; B, 2+, halfway between tonsillar pillars and the uvula; C, 3+, nearly touching the uvula; D, 4+, touching each other.
FIGURE 12-34 Common findings in the older adult’s mouth. A, Fissured tongue. B, Varicose veins on tongue. C, Attrition of teeth and resorption of gums.
Sample Documentation: History and Physical Examination
Subjective
Objective
Abnormalities
Ear
Otitis Media with Effusion and Acute Otitis Media
FIGURE 12-35 Otitis media with effusion. A, The middle ear filled with serous fluid; note the bulging appearance and distorted light reflex. B, Air-fluid levels in upper middle ear. C, Acute otitis media. Note the red bulging tympanic membrane with obscured bony landmarks and distorted light reflex.
Otitis Externa
FIGURE 12-36 Otitis externa. The inflammation in the auditory canal often extends with inflammation of the pinna.
Differential DIAGNOSIS Otitis Externa, Otitis Media with Effusion, and Acute Otitis Media
Cholesteatoma
FIGURE 12-37 Cholesteatoma.
Hearing Loss
Conductive Hearing Loss
Sensorineural Hearing Loss
Ménière Disease (Endolymphatic Hydrops)
Vertigo
Sinuses
Sinusitis
Mouth and Oropharynx
Acute Pharyngitis
FIGURE 12-38 Tonsillitis and pharyngitis. Notice the erythema and exudate in crypts of the tonsils.
Peritonsillar Abscess
FIGURE 12-39 Swelling of peritonsillar abscess.
Retropharyngeal Abscess
FIGURE 12-40 Retropharyngeal abscess. Note the reduced airway size next to the epiglottis.
Oral Cancer
FIGURE 12-41 Squamous cell cancer on the tongue.
Periodontal Disease
Cleft Lip and Palate
FIGURE 12-42 Unilateral cleft lip and palate.
Chapter 13 Chest and Lungs
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Anatomy and Physiology
Physical Examination Preview
FIGURE 13-1 The bony structures of the chest form a protective expandable cage around the lungs and heart. A, Anterior view. B, Posterior view.
FIGURE 13-2 Chest cavity and related anatomic structures.
FIGURE 13-3 Muscles of ventilation. A, Anterior view. B, Posterior view.
FIGURE 13-4 The Lobes of the lungs.
Box 13-1 Visualizing the Lungs from the Surface
Anteriorly
Posteriorly
Right Lateral
Left Lateral
Anatomic Landmarks
Infants and Children
FIGURE 13-5 Pulmonary circulation.
FIGURE 13-6 Topographic landmarks of the chest.
Clinical Pearl: Patent Ductus Arteriosus (PDA)
Pregnant Women
Older Adults
FIGURE 13-7 Chest of healthy infant. Note that the anteroposterior diameter is approximately the same as the lateral diameter.
Review of Related History
History of Present Illness
Coughs
Staying Well: Discuss Cigarette Use
Dry or Moist.
Onset.
Frequency of Occurrence.
Regularity.
Pitch and Loudness.
Postural Influences.
Quality.
Sputum
DIFFERENTIAL DIAGNOSIS Some Causes of Sputum
Box 13-2 Descriptors of Respiration
Past Medical History
Clinical Pearl: Chest Pain
Family History
Personal and Social History
Clinical Pearl: Pain from Cocaine
Infants and Children
Pregnant Women
Older Adults
Equipment
Clinical Pearl: The Sequence of Steps
Examination and Findings
Inspection
Observing Respiration
FIGURE 13-8 Thorax of healthy adult male. Note that the anteroposterior diameter is less than the lateral diameter.
FIGURE 13-9 Barrel chest. Note increase in the anteroposterior diameter.
Risk Factors: Respiratory Disability: Barriers to Competent Function
Box 13-3 Thoracic Landmarks
FIGURE 13-10 Thoracic landmarks. A, Anterior thorax. B, Right lateral thorax. C, Posterior thorax.
FIGURE 13-11 Rib cage. A, Anterior view. B, Posterior view.
FIGURE 13-12 A, Pectus excavatum. B, Pectus carinatum.
Box 13-4 Influences on the Rate and Depth of Breathing
FIGURE 13-13 Patterns of respiration. The horizontal axis indicates the relative rates of these patterns. The vertical swings of the lines indicate the relative depth of respiration.
Looking for Clues at the Periphery
Palpation
Box 13-5 Apnea
FIGURE 13-14 Palpating thoracic expansion. The thumbs are at the level of the tenth rib.
Box 13-6 Is the Airway Patent or Obstructed?
Tactile Fremitus
Evidence-Based Practice in Physical Examination: Is There a Pleural Effusion?
FIGURE 13-15 Two methods for evaluating tactile fremitus. A, With palmar surface of both hands. B, With ulnar aspect.
Examining the Trachea
Clinical Pearl: Clue to a Mediastinal Mass
FIGURE 13-16 Palpating to evaluate midline position of the trachea.
Percussion
Table 13-1 Percussion Tones Heard over the Chest
FIGURE 13-17 Percussion tones throughout chest. A, Anterior view. B, Posterior view.
Box 13-7 Bad Breath: a Possible Sign of Infection
Smell the Breath
Diaphragmatic Excursion
FIGURE 13-18 A, Direct percussion using ulnar aspect of fist. B, Indirect percussion.
FIGURE 13-19 Suggested sequence for systematic percussion and auscultation of the thorax. A, Posterior thorax. B, Right lateral thorax. C, Left lateral thorax. D, Anterior thorax. The pleximeter finger or the stethoscope is moved in the numeric sequence suggested; however, other sequences are possible. It is beneficial to be systematic.
FIGURE 13-20 Measuring diaphragmatic excursion. Excursion distance is usually 3 to 5 cm.
Auscultation
Clinical Pearl: Congestive Heart Failure
FIGURE 13-21 Auscultation with a stethoscope.
Breath Sounds
Clinical Pearl: Sickle Cell Disease
FIGURE 13-22 Expected auscultatory sounds. A, Anterior view. B, Posterior view.
Table 13-2 Characteristics of Normal Breath Sounds
FIGURE 13-23 Schema of breath sounds in the ill and well patient.
Box 13-8 Adventitious Breath Sounds
Crackles.
Rhonchi.
Wheezes.
Other Sounds.
Vocal Resonance
Clinical Pearl: Vocal Resonance
Infants
Box 13-9 Summary of Expected Findings of the Chest and Lungs
Table 13-3 Infant Evaluation at Birth: Apgar Scoring System
FIGURE 13-24 Diaphragmatic hernia.
Clinical Pearl: The Sobbing Baby
Children
Box 13-10 Assessment of Respiratory Distress
Clinical Pearl: Foreign Body
Pregnant Women
Older Adults
Sample Documentation: History and Physical Examination
Subjective
Objective
FIGURE 13-25 Pronounced dorsal curvature in older adult.
Abnormalities
Table 13-4 Physical Findings Associated with Common Respiratory Conditions*
Asthma (Reactive Airway Disease)
Atelectasis
FIGURE 13-26 Atelectasis.
Bronchitis
FIGURE 13-27 Acute bronchitis.
Pleurisy
FIGURE 13-28 Pleurisy.
Pleural Effusion
FIGURE 13-29 Pleural effusion.
Empyema
FIGURE 13-30 Empyema.
Lung Abscess
FIGURE 13-31 Lung abscess.
Pneumonia
FIGURE 13-32 Lobar pneumonia and lobular or bronchopneumonia.
Influenza
FIGURE 13-33 Influenza.
Tuberculosis
FIGURE 13-34 Tuberculosis.
Pneumothorax
FIGURE 13-35 Pneumothorax.
Hemothorax
FIGURE 13-36 Hemothorax.
Lung Cancer
FIGURE 13-37 Cancer of the lung. A, Squamous (epidermoid) cell carcinoma. B, Small cell (oat cell) carcinoma. C, Adenocarcinoma. D, Large cell carcinoma.
Pulmonary Embolism
Infants, Children, and Adolescents
Diaphragmatic Hernia
Cystic Fibrosis
FIGURE 13-38 Cystic fibrosis.
Epiglottitis
FIGURE 13-39 Croup syndrome. A, Acute epiglottitis. B, Laryngotracheobronchitis.
Croup (Laryngotracheal Bronchitis)
Tracheomalacia
Bronchiolitis
Chronic Obstructive Pulmonary Disease
Emphysema
FIGURE 13-40 Chronic obstructive pulmonary disease with lobar emphysema.
Bronchiectasis
FIGURE 13-41 Bronchiectasis.
Chronic Bronchitis
Chapter 14 Heart
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Physical Examination Preview
Heart
Anatomy and Physiology
FIGURE 14-1 Frontal section of the heart.
Structure
FIGURE 14-2 Heart within the pericardium.
FIGURE 14-3 Cross section of the cardiac muscle.
FIGURE 14-4 Views of the heart. A, Anterior. B, Posterior.
FIGURE 14-5 Anterior cross section showing the valves and chambers of the heart.
FIGURE 14-6 Blood flow through the heart. A, Systole. B, Diastole.
Clinical Pearl
Order of Valves
Cardiac Cycle
FIGURE 14-7 Events of the cardiac cycle, showing venous pressure waves, ECG (the graphic representing the electrical activity during the cardiac cycle), and heart sounds in systole and diastole. PCG, Phonocardiogram.
Electrical Activity
FIGURE 14-8 Cardiac conduction.
FIGURE 14-9 Usual electrocardiogram waveform.
Infants and Children
FIGURE 14-10 Anatomy of the fetal heart.
Pregnant Women
FIGURE 14-11 Fetal circulation. A, In utero. B, After delivery.
Table 14-1 Hemodynamic Changes during Pregnancy
Older Adults
Review of Related History
History of Present Illness
Box 14-1 Chest Pain
Some Possible Causes of Chest Pain
Cardiac
Aortic
Pleuropericardial Pain
Gastrointestinal Disease
Pulmonary Disease
Musculoskeletal
Psychoneurotic
Box 14-2 Characteristics of Chest Pain
DIFFERENTIAL DIAGNOSIS: Comparison of Some Types of Chest Pain
Past Medical History
Risk Factors
Family History
Personal and Social History
Box 14-3 Exercise Intensity
Infants
Children
Pregnant Women
Older Adults
Examination and Findings
Equipment
Staying Well
Inspection
FIGURE 14-12 Sequence for palpation of the precordium. A, Apex. B, Left sternal border. C, Base.
Palpation
FIGURE 14-13 Palpation of the apical pulse.
Box 14-4 The Thrill of Heart Examination
Percussion
FIGURE 14-14 Palpation of the carotid artery to time events felt over the precordium.
Auscultation
FIGURE 14-15 Areas for auscultation of the heart.
Clinical Pearl
Heart Sounds
Basic Heart Sounds
S1 and S2.
Box 14-5 Procedure for Auscultating the Heart
FIGURE 14-16 Auscultation positions.
Splitting.
Table 14-2 Intensity of Heart Sounds According to Auscultatory Area
Box 14-6 S1 Intensity: Diagnostic Clues
FIGURE 14-17 Heart sounds.
Box 14-7 S2 Intensity: Diagnostic Clues
Box 14-8 Unexpected Splitting of Heart Sounds
Wide Splitting
Fixed Splitting
Paradoxical (Reversed) Splitting
FIGURE 14-18 Variations in splitting of S2.
S3 and S4.
Extra Heart Sounds
FIGURE 14-19 Assessment of heart sounds. LICS, Left intercostal space; RICS, right intercostal space.
Clinical Pearl
Heart Sounds After Surgical Procedures
Heart Murmurs
Table 14-3 Extra Heart Sounds
Table 14-4 Characterization of Heart Murmurs
FIGURE 14-20 Valvular heart disease.
Table 14-5 Heart Murmurs
Box 14-9 Are Some Murmurs Innocent?
Evidence-Based Practice in Physical Examination
DIFFERENTIAL DIAGNOSIS Comparison of Systolic Murmurs
Rhythm Disturbance
Infants
Clinical Pearl
The Infant Heart and Liver
Children
Pregnant Women
Older Adults
Sample Documentation
Subjective
Objective
Abnormalities
Heart
Angina
Bacterial Endocarditis
FIGURE 14-21 Bacterial endocarditis.
Congestive Heart Failure (CHF)—Left-Sided
Evidence-Based Practice in Physical Examination
Congestive Heart Failure (CHF)—Right-Sided
Pericarditis
FIGURE 14-22 Pericarditis.
Cardiac Tamponade
FIGURE 14-23 Hemopericardium and cardiac tamponade.
Cor Pulmonale
FIGURE 14-24 Cor pulmonale. Notice extensive pulmonary emphysema and right ventricular hypertrophy.
Myocardial Infarction
Myocarditis
Abnormalities in Heart Rate and Rhythm
Conduction Disturbances
Sick Sinus Syndrome
Table 14-6 Abnormalities in Rates and Rhythms
Infants and Children
Tetralogy of Fallot
FIGURE 14-25 Tetralogy of Fallot.
Ventricular Septal Defect (VSD)
FIGURE 14-26 Ventricular septal defect.
Patent Ductus Arteriosus
FIGURE 14-27 Patent ductus arteriosus.
Atrial Septal Defect (ASD)
FIGURE 14-28 Atrial septal defect.
Acute Rheumatic Fever
Box 14-10 Jones Criteria for Diagnosis of Rheumatic Fever
Supporting Evidence of Streptococcal Infection
Older Adults
Atherosclerotic Heart Disease (Atherosclerosis, Coronary Heart Disease)
Mitral Insufficiency, Regurgitation
Senile Cardiac Amyloidosis
Chapter 15 Blood Vessels
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Physical Examination Preview
Blood Vessels
Anatomy and Physiology
Blood Circulation
FIGURE 15-1 Anatomic location of the great vessels and their relationship to the heart valves.
FIGURE 15-2 Circulatory system.
FIGURE 15-3 Systemic circulation. A, Arteries. B, Veins.
Arterial Pulse and Pressure
FIGURE 15-4 Structure of arteries and veins. Note the relative thickness of the arterial wall.
Jugular Venous Pulse and Pressure
Infants and Children
FIGURE 15-5 Diagram of usual pulse.
Pregnant Women
Older Adults
FIGURE 15-6 Inspection of jugular venous pressure.
Review of Related History
History of Present Illness
Past Medical History
FIGURE 15-7 Expected venous pulsations.
Family History
Personal and Social History
Staying Well
Infants and Children
Pregnant Women
Risk Factors
Older Adults
Risk Factors
Examination and Findings
Equipment
Peripheral Arteries
Palpation
FIGURE 15-8 Palpation of arterial pulses. A, Carotid. B, Brachial. C, Radial. D, Femoral. E, Popliteal. F, Dorsalis pedis. G, Posterior tibial.
Clinical Pearl
Carotid Palpation
Box 15-1 The Allen Test
Auscultation
Assessment for Peripheral Arterial Disease
FIGURE 15-9 Pulse abnormalities.
FIGURE 15-10 Auscultation for bruits in the carotid artery.
Box 15-2 Listening to the Neck
Venous Hum
Carotid Artery Bruits
Box 15-3 Capillary Refill Time
Peripheral Veins
Jugular Venous Pressure
FIGURE 15-11 Measuring jugular venous pressure.
Table 15-1 Comparison of the Jugular and Carotid Pulse Waves
Hepatojugular Reflux
Evaluation of Hand Veins
Assessment for Venous Obstruction and Insufficiency
Thrombosis.
FIGURE 15-12 Evaluation of hand veins. A, Engorged veins in dependent hand. B, Collapsed veins in elevated hand.
FIGURE 15-13 Assessing for pitting edema.
Clinical Pearl
Calf Pain
Homan Sign.
Edema.
Clinical Pearl
Edema
Varicose Veins.
Infants
Children
FIGURE 15-14 Auscultation for venous hum.
Pregnant Women
Older Adults
Sample Documentation
Subjective
Objective
Abnormalities
Blood Vessels
Vessel Disorders
Temporal Arteritis (Giant Cell Arteritis)
Arterial Aneurysm
FIGURE 15-15 Aortic aneurysm.
Arteriovenous Fistula
Peripheral Arterial Disease
Raynaud Phenomenon
FIGURE 15-16 Raynaud phenomenon.
Arterial Embolic Disease
FIGURE 15-17 Embolic phenomenon.
Venous Thrombosis
Jugular Venous Pressure Disorder
Tricuspid Regurgitation
FIGURE 15-18 Diagram of pulsation in tricuspid regurgitation.
Children
Coarctation of the Aorta
FIGURE 15-19 Coarctation of the aorta.
Kawasaki Disease
FIGURE 15-20 Strawberry tongue.
Pregnant Women
Preeclampsia-Eclampsia
Older Adults
Venous Ulcers
FIGURE 15-21 Venous stasis ulcer.
Chapter 16 Breasts and Axillae
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Physical Examination Preview
Breasts and Axillae
Females
Males
Anatomy and Physiology
FIGURE 16-1 Anatomy of the breast showing position and major structures.
FIGURE 16-2 Quadrants of the left breast and axillary tail of Spence.
Table 16-1 Patterns of Lymph Drainage
Children and Adolescents
Physical Variations
Breast Development
FIGURE 16-3 Lymphatic drainage of the breast. Nodes in bold notation are accessible to palpation.
Pregnant Women
Lactating Women
Older Adults
Review of Related History
History of Present Illness
Past Medical History
Box 16-1 Screening Recommendations for Breast Cancer
Summary of Recommendations
CBE
Mammogram
MRI
Breast Self-Awareness
Risk Factors
Nonmodifiable Factors
Modifiable/Lifestyle Factors
Family History
Personal and Social History
Staying Well
Pregnant Women
Lactating Women
Older Adults
Examination and Findings
Equipment
Inspection
Breasts
FIGURE 16-4 Variations in breast size and contour. A, Conical. B, Convex. C, Pendulous. D, Large pendulous. E, Right larger than left.
Nipples and Areolae
FIGURE 16-5 Peau d’orange appearance from edema.
FIGURE 16-6 Montgomery tubercles. A, Light-skinned woman. B, Dark-skinned woman.
FIGURE 16-7 A, Left nipple inverted; right nipple everted. B, Close-up of nipple inversion.
FIGURE 16-8 Nipple retraction laterally and swelling behind right nipple in Asian woman with breast cancer.
Reinspection in Varied Positions
Evidence-Based Practice in Physical Examination
CBE
Mammography
MRI
FIGURE 16-9 Variations in color of areola. A, Pink. B, Brown. C, Black.
Palpation
FIGURE 16-10 Supernumerary nipples and tissue may arise along the “milk line,” an embryonic ridge.
FIGURE 16-11 A, Supernumerary nipple without glandular tissue. B, Supernumerary breast and nipple on left side and supernumerary nipple alone on right side.
FIGURE 16-12 Inspect the breasts in the following positions. A, Arms extended overhead. B, Hands pressed against hips. C, Pressing hands together (an alternative way to flex the pectoral muscles). D, Leaning forward from the waist.
FIGURE 16-13 Chest wall sweep. With the palm of your hand, sweep from the clavicle to the nipple, covering the area from the sternum to the midaxillary line.
FIGURE 16-14 Bimanual digital palpation. Walk your fingers across the breast tissue, compressing it between your fingers and the palmar surface of your other hand.
Patient in Seated Position
Chest Wall Sweep.
Bimanual Digital Palpation.
Lymph Node Palpation.
FIGURE 16-15 Palpation of the axilla for lymph nodes.
Patient in Supine Position
Box 16-2 Documenting Breast Masses
FIGURE 16-16 Supine position for palpation.
FIGURE 16-17 Various methods for palpation of the breast. A, Palpate from top to bottom in vertical strips. B, Palpate in concentric circles. C, Palpate out from the center in wedge sections.
FIGURE 16-18 A, Palpating for consistency of a breast lesion. B, Palpating for delineation of borders of breast mass. C, Palpating for mobility of breast mass.
FIGURE 16-19 A, Clinical signs of cancer. B, Nipple retraction and dimpling of skin.
FIGURE 16-20 Depressing nipple inward into well behind the areola.
Staying Well
FIGURE 16-21 Types of nipple discharge. A, Milky discharge. B, Multicolored sticky discharge. C, Purulent discharge. D, Watery discharge. E, Serous discharge. F, Serosanguineous discharge.
Clinical Pearl
Females.
Males.
Infants
Children and Adolescents
Box 16-3 Examining the Patient Who Has Had a Mastectomy
FIGURE 16-22 Breast changes in pregnancy. A, Note venous network, darkened areolae and nipples, and vascular spider. B, Increased pigmentation and the development of raised sebaceous glands known as Montgomery tubercles. C, Marked pigmentation in woman with dark skin.
Pregnant Women
Lactating Women
Older Adults
Sample Documentation
Subjective
Objective
Abnormalities
Breasts
Breast Lumps
DIFFERENTIAL DIAGNOSIS Signs and Symptoms of Breast Masses
Fibrocystic Changes
Fibroadenoma
Malignant Breast Tumors
FIGURE 16-23 A, Patient with lump and nipple retraction in left breast. B, Patient with altered nipple height resulting from breast cancer in left breast.
Fat Necrosis
FIGURE 16-24 Fat necrosis presenting as a hard mass in the breast following an episode of trauma sufficient to cause bruising.
Nipples and Areolae
Intraductal Papillomas and Papillomatosis
Duct Ectasia
Galactorrhea
FIGURE 16-25 Galactorrhea produced by a prolactin-secreting pituitary tumor.
Paget Disease
FIGURE 16-26 Paget disease.
Mastitis
FIGURE 16-27 Mastitis.
Gynecomastia
FIGURE 16-28 Adult gynecomastia.
FIGURE 16-29 Prepubertal gynecomastia, small and subareolar.
Children
Premature Thelarche
Chapter 17 Abdomen
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Physical Examination Preview
Abdomen
Anatomy and Physiology
Alimentary Tract
FIGURE 17-1 Anatomic structures of the abdominal cavity.
Liver
Gallbladder
Pancreas
Spleen
Kidneys, Ureters, and Bladder
Musculature and Connective Tissues
Vasculature
Infants
Pregnant Women
FIGURE 17-2 Linea nigra in the third trimester of pregnancy.
Older Adults
Review of Related History
History of Present Illness
Risk Factors
Past Medical History
Family History
Personal and Social History
Infants
Children
Pregnant Women
Older Adults
Risk Factors
Examination and Findings
Equipment
Preparation
FIGURE 17-3 Four quadrants of the abdomen.
FIGURE 17-4 Nine regions of the abdomen. 1, Epigastric; 2, umbilical; 3, hypogastric; 4 and 5, right and left hypochondriac; 6 and 7, right and left lumbar; 8 and 9, right and left inguinal.
FIGURE 17-5 Landmarks of the abdomen.
Inspection
Surface Characteristics
Box 17-1 Landmarks for Abdominal Examination
Anatomic Correlates of the Four Quadrants of the Abdomen
Anatomic Correlates of the Nine Regions of the Abdomen
Clinical Pearl
Contour
Clinical Pearl
FIGURE 17-6 Abdominal venous patterns. A, Expected. B, Portal hypertension. C, Inferior vena cava obstruction.
Movement
Auscultation
Bowel Sounds
Additional Sounds and Bruits
Percussion
Liver Span
FIGURE 17-7 Sites to auscultate for bruits: renal arteries, iliac arteries, aorta, and femoral arteries.
Table 17-1 Percussion Notes of the Abdomen
FIGURE 17-8 Liver percussion routes along midclavicular and midsternal lines.
Clinical Pearl
FIGURE 17-9 Percussion of the spleen.
Spleen
Evidence-Based Practice in Physical Examination
Gastric Bubble
Kidneys
Palpation
Light Palpation
Moderate Palpation
FIGURE 17-10 Fist percussion of the costovertebral angle for kidney tenderness. A, Indirect percussion. B, Direct percussion.
Box 17-2 Examining the Abdomen in a Ticklish Patient
FIGURE 17-11 Light palpation of the abdomen. With fingers extended and approximated, press in no more than 1 cm.
FIGURE 17-12 Moderate palpation using the side of the hand.
Deep Palpation
Masses
FIGURE 17-13 Deep palpation of the abdomen. Press deeply and evenly with the palmar surface of extended fingers.
FIGURE 17-14 Deep bimanual palpation.
Umbilical Ring
Palpation of Specific Organs and Structures
Liver.
FIGURE 17-15 Abdominal structures commonly felt as masses.
FIGURE 17-16 Palpating the liver. A, Fingers are extended, with tips on right midclavicular line below the level of liver dullness and pointing toward the head. B, Alternative method for liver palpation with the fingers parallel to the costal margin.
FIGURE 17-17 Palpating the liver with fingers hooked over the costal margin.
Liver: Alternative Techniques.
Gallbladder.
FIGURE 17-18 Scratch technique for auscultating the liver. With the stethoscope over the liver, lightly scratch the abdominal surface, moving toward the liver. The sound will be intensified over the liver.
Spleen.
FIGURE 17-19 Palpating the spleen. A, Press upward with the left hand at the patient’s left costovertebral angle. Feel for the spleen with the right hand below the left costal margin. B, Palpating the spleen with the patient lying on the side. Press inward with the left hand and tips of the right fingers.
Box 17-3 An Enlarged Spleen or an Enlarged Left Kidney?
Left Kidney.
FIGURE 17-20 Palpating the left kidney. Elevate the left flank with the left hand. Palpate deeply with the right hand.
FIGURE 17-21 Capture technique for palpating the kidney (left kidney palpation shown). As the patient takes a deep breath, press the fingers of both hands together. As the patient exhales, slowly release the pressure and feel for the kidney to slip between the fingers.
FIGURE 17-22 Palpating the aorta. Place the thumb on one side of the aorta and the fingers on the other side.
Right Kidney.
Aorta.
Evidence-Based Practice in Physical Examination
Urinary Bladder.
Advanced Skills
Ascites Assessment
Shifting Dullness.
Fluid Wave.
Evidence-Based Practice in Physical Examination
Pain Assessment
FIGURE 17-23 Testing for shifting dullness. Dullness shifts to the dependent side.
FIGURE 17-24 Testing for fluid wave. Strike one side of the abdomen sharply with the fingertips. Feel for the impulse of a fluid wave with the other hand.
Box 17-4 Clues in Diagnosing Abdominal Pain
Evidence-Based Practice in Physical Examination
Table 17-2 Conditions Producing Acute Abdominal Pain
Table 17-3 Conditions Producing Chronic Abdominal Pain
Table 17-4 Quality and Onset of Abdominal Pain
Abdominal Signs
Rebound Tenderness
Box 17-5 Some Causes of Pain Perceived in Anatomic Regions
Box 17-6 Findings in Peritoneal Irritation
Table 17-5 Abdominal Signs Associated with Common Abdominal Conditions
FIGURE 17-25 Testing for rebound tenderness. A, Press deeply and gently into the abdomen. B, Then rapidly withdraw the hands and fingers.
Clinical Pearl
Iliopsoas Muscle Test
FIGURE 17-26 Iliopsoas muscle test. A, The patient raises the leg from the hip while the examiner pushes downward against it. B, Alternate technique. The examiner hyperextends the right leg by drawing it backward while the patient lies on the left side.
Obturator Muscle Test
Ballottement
FIGURE 17-27 Obturator muscle test. With the right leg flexed at the hip and knee, rotate the leg laterally and medially.
Infants and Children
Inspection
FIGURE 17-28 Ballottement technique. A, Single-handed ballottement. Push inward at a 90-degree angle. If the object is freely movable, it will float upward to touch the fingertips. B, Bimanual ballottement: P, pushing; R, receiving hand.
FIGURE 17-29 Positioning for examination of the infant’s abdomen.
FIGURE 17-30 Positioning for examination of a toddler in a parent’s lap.
FIGURE 17-31 Umbilical hernia in an infant.
Clinical Pearl
Auscultation and Percussion
Palpation
Clinical Pearl
Clinical Pearl
Liver Palpation
Deep Palpation
DIFFERENTIAL DIAGNOSIS Abdominal Masses in Infants and Children
DIFFERENTIAL DIAGNOSIS Causes of Acute Abdominal Pain in Infants, Children, and Adolescents
Adolescents
FIGURE 17-32 Potbellied stance of a toddler.
Evidence-Based Practice in Physical Examination
Pregnant Women
Older Adults
Clinical Pearl
Sample Documentation
Subjective
Objective
Abnormalities
Abdomen
Alimentary Tract
Acute Diarrhea
Gastroesophageal Reflux Disease
Irritable Bowel Syndrome
Staying Well
Hiatal Hernia with Esophagitis
Duodenal Ulcer (Duodenal Peptic Ulcer Disease)
Crohn Disease
FIGURE 17-33 Crohn disease showing a perianal abscess, raised and erythematous lesion, above a small scar from a prior incision and drainage procedure.
FIGURE 17-34 Crohn disease. Note a scar from a previous incision and drainage. Perianal skin tags are common in Crohn disease and a good clue to diagnosis.
Ulcerative Colitis
FIGURE 17-35 Ulcerative colitis showing severe mucosal edema and inflammation with ulcerations and bleeding.
Stomach Cancer
Diverticular Disease
FIGURE 17-36 Diverticulosis (diverticulitis).
Colon Cancer (Colorectal Cancer)
Evidence-Based Practice in Physical Examination
Which to Recommend?
Hepatobiliary System
Hepatitis
Cirrhosis
FIGURE 17-37 Marked ascites and an umbilical hernia, which had ruptured a few days before the photograph, in a patient with cirrhosis and portal hypertension secondary to hepatitis C.
Primary Hepatocellular Carcinoma
Cholelithiasis
Cholecystitis
Nonalcoholic Fatty Liver Disease (NAFLD)
Pancreas
Acute Pancreatitis
Chronic Pancreatitis
Spleen
Spleen Laceration/Rupture
Kidney
Acute Glomerulonephritis
Hydronephrosis
Pyelonephritis
Renal Abscess
Renal Calculi
Acute Renal Failure
Infants
Intussusception
FIGURE 17-38 Jejunojejunal intussusception in an adult patient.
Pyloric Stenosis
FIGURE 17-39 Epigastric distention and a visible wave of peristalsis in an infant with pyloric stenosis.
Meconium Ileus
Biliary Atresia
FIGURE 17-40 Child with biliary atresia and cirrhosis with prominent abdominal veins.
Meckel Diverticulum
FIGURE 17-41 Meckel diverticulum.
Necrotizing Enterocolitis
Children
Neuroblastoma
Wilms Tumor (Nephroblastoma)
FIGURE 17-42 Wilms tumor. Large left-sided flank mass seen on visual inspection.
Hirschsprung Disease (Congenital Aganglionic Megacolon)
Hemolytic Uremic Syndrome (HUS)
Older Adults
Fecal Incontinence
DIFFERENTIAL DIAGNOSIS Urinary Incontinence
Chapter 18 Female Genitalia
http://evolve.elsevier.com/Seidel
Physical Examination Preview
External Genitalia
Internal Genitalia Speculum Examination
Bimanual Examination
Rectovaginal Examination
Anatomy and Physiology
External Genitalia
FIGURE 18-1 External female genitalia.
FIGURE 18-2 Musculature of the perineum.
FIGURE 18-3 Midsagittal view of the female pelvic organs.
Internal Genitalia
FIGURE 18-4 Cross-sectional view of internal female genitalia and pelvic contents.
FIGURE 18-5 Comparative sizes of uteri at various stages of development. A, Prepubertal. B, Adult nulliparous. C, Adult multiparous. D, Lateral view, adult multiparous. The fractions give the relative proportion of the size of the corpus and the cervix.
Bony Pelvis
FIGURE 18-6 Female menstrual cycle. Diagram shows the interrelationship of the cerebral, hypothalamic, pituitary, and uterine functions throughout a standard 28-day menstrual cycle.
Table 18-1 The Menstrual Cycle
FIGURE 18-7 Adult female pelvis. A, Anterior view. The three embryonic parts of the left innominate bone are lightly shaded. B, External view of right innominate bone (fused).
FIGURE 18-8 Female pelvis. A, Cavity of the false pelvis is a shallow basin above the inlet; the true pelvis is a deeper cavity below the inlet. B, Cavity of the true pelvis is an irregularly curved canal (arrows).
Infants and Children
Adolescents
Pregnant Women
Older Adults
FIGURE 18-9 Comparison of vulva and cervix in a nullipara (A) and a multipara (B) woman at the same stage of pregnancy.
Review of Related History
History of Present Illness
Box 18-1 Abnormal Uterine Bleeding: Terminology
Past Medical History
Family History
Personal and Social History
Risk Factors
Risk Factors
Risk Factors
Staying Well
Infants and Children
Box 18-2 Evaluation of Masturbation in Children
Adolescents
Pregnant Women
Older Adults
Examination and Findings
Equipment
Preparation
Clinical Pearl
Positioning
Draping and Gloving
FIGURE 18-10 Draped patient in dorsal lithotomy position.
Clinical Pearl
External Examination
Inspection and Palpation
Labia Majora
FIGURE 18-11 Separation of the labia.
FIGURE 18-12 Normal vulva with finely textured papular sebaceous glands on the inner labia majora and labia minora.
Labia Minora
Clitoris
FIGURE 18-13 Urethral caruncle, a red fleshy lesion at the urethral meatus.
Urethral Orifice
Vaginal Introitus
Skene and Bartholin Glands
FIGURE 18-14 Palpation of Skene glands.
FIGURE 18-15 Palpation of Bartholin glands.
Muscle Tone
Perineum
FIGURE 18-16 Palpating the perineum.
Anus
Internal Examination
Preparation
Insertion of Speculum
Evidence-Based Practice in Physical Examination
Cervix
Color.
Position.
Surface Characteristics.
Discharge.
Size and Shape.
FIGURE 18-17 Examination of the internal genitalia with a speculum. Begin by inserting a finger and applying downward pressure to relax the vaginal muscles. A, Gently insert the closed speculum blades into the vagina. B, Direct the speculum along the path of least resistance. C, Insert the speculum the length of the vaginal canal. D, Speculum is in place, locked, and stabilized. Note cervix in full view.
FIGURE 18-18 Normal cervix. The squamocolumnar junction and lower part of the endocervical canal are seen.
FIGURE 18-19 Polyp protruding through the cervical os.
FIGURE 18-20 Common appearances of the cervix. A, Normal nulliparous cervix. The surface is covered with pink squamous epithelium that is uniform in consistency. The os is small and round. A small area of ectropion is visible inferior to the os. B, Parous cervix. Note slit appearance of os. C, Multiparous, lacerated. D, Everted. Columnar mucosal cells usually found in the endocervical canal have extended out into the surface of the cervix, creating a circular raised erythematous appearance. Note the normal nonpurulent cervical mucus. This normal variant is not to be confused with cervicitis. E, Eroded. F, Nabothian cysts.
Box 18-3 Obtaining Vaginal Smears and Specimens
Conventional Papanicolaou Smear
FIGURE 18-21 Scrape the cervix with the bifid end of the spatula for obtaining pap smear.
FIGURE 18-22 Implements used to obtain a Pap smear. A, Close-up of spatula. B, Brush device. C, Close-up of brush. D, Broom device.
Liquid-Based Pap Testing
Gonococcal Culture Specimen
FIGURE 18-23 Obtaining a cervical specimen by inserting a swab into the cervical os.
DNA Testing for Organisms
Wet Mount and Potassium Hydroxide (KOH) Procedures
Withdrawal of Speculum
Bimanual Examination
FIGURE 18-24 Cystocele.
FIGURE 18-25 Rectocele.
FIGURE 18-26 Bimanual palpation of the uterus.
Evidence-Based Practice in Physical Examination
Cervix
Box 18-4 Examining the Woman Who Has Had a Hysterectomy
Staying Well
Uterus
Position.
Size, Shape, and Contour.
Mobility.
Adnexa and Ovaries
Clinical Pearl
FIGURE 18-27 Varying positions of uteri. A, Anteverted. B, Anteflexed. C, Retroverted. D, Retroflexed. E, Midposition.
Rectovaginal Examination
Preparation
Anal Sphincter
FIGURE 18-28 Bimanual palpation of adnexa. Sweep abdominal fingers downward to capture ovary.
Rectal Walls and Rectovaginal Septum
Uterus
Adnexa
Stool
FIGURE 18-29 Rectovaginal palpation.
Completion
Infants
FIGURE 18-30 Normal appearance of the female genitalia. A, Genitalia of a newborn girl. The labia majora are full, and the thickened labia minora protrude between them. B, Genitalia of a 2-year-old girl. The labia majora are flattened, and the labia minora and hymen are thin and flat.
Indications for Examination
Inspection and Palpation
Discharge
Injuries
Bleeding
Rectal Examination
Box 18-5 Red Flags for Sexual Abuse
Medical Concerns and Findings
Examples of Nonspecific Behavioral Manifestations
Examples of Sexual Behaviors That Are Concerning
Box 18-6 Causes of Genital Bleeding in Children
Adolescents
Pregnant Women
Gestational Age
Uterus Size and Contour
Table 18-2 Estimates of Uterine Size in Early Pregnancy
FIGURE 18-31 Measurement of fundal height from the symphysis pubis to the superior fundus uterus.
FIGURE 18-32 Changes in fundal height with pregnancy. Weeks 10 to 12: Uterus within pelvis; fetal heartbeat can be detected with Doppler. Week 12: Uterus palpable just above symphysis pubis. Week 16: Uterus palpable halfway between symphysis and umbilicus; ballottement of fetus is possible by abdominal and vaginal examination. Week 20: Uterine fundus at lower border of umbilicus; fetal heartbeat can be auscultated with a fetoscope. Weeks 24 to 26: Uterus changes from globular to ovoid shape; fetus palpable. Week 28: Uterus approximately halfway between umbilicus and xiphoid; fetus easily palpable. Week 34: Uterine fundus just below xiphoid. Week 40: Fundal height drops as fetus begins to engage in pelvis.
Pelvic Examination
Box 18-7 Early Signs of Pregnancy
Cervical Effacement and Dilation
Fetal Well-Being
Fetal Position
FIGURE 18-33 Leopold maneuvers. A, First maneuver. Place hand(s) over fundus and identify the fetal part. B, Second maneuver. Use the palmar surface of one hand to locate the back of the fetus. Use the other hand to feel the irregularities, such as hands and feet. C, Third maneuver. Use thumb and third finger to grasp presenting part over the symphysis pubis. D, Fourth maneuver. Use both hands to outline the fetal head. With a head presenting deep in the pelvis, only a small portion may be felt.
FIGURE 18-34 Abdominal palpation of twin pregnancy.
Station
FIGURE 18-35 Areas of maximal intensity of fetal heart rate (FHR) for differing positions: RSA, right sacrum anterior; ROP, right occipitoposterior; RMA, right mentum anterior; ROA, right occipitoanterior; LSA, left sacrum anterior; LOP, left occipitoposterior; LMA, left mentum anterior; and LOA, left occipitoanterior. A, Presentation is breech if FHR is heard above umbilicus. B, Presentation is vertex if FHR is heard below umbilicus.
FIGURE 18-36 Stations of presenting part (degree of descent). Silhouette shows head of infant at station 0.
Contractions
FIGURE 18-37 A, Locating the sagittal suture on vaginal examination. B, Differentiating the fontanels on vaginal examination.
Fetal Head Position
Other Pregnancy-Associated Changes
Older Adults
Preparation
FIGURE 18-38 The knee-chest position.
Alternative Positions for the Pelvic Examination
Knee-Chest Position.
FIGURE 18-39 The diamond-shaped position.
FIGURE 18-40 The obstetric stirrups position.
Diamond-Shaped Position.
Obstetric Stirrups Position.
M-Shaped Position.
FIGURE 18-41 The M-shaped position.
FIGURE 18-42 The V-shaped position.
V-Shaped Position.
FIGURE 18-43 Positioning the visually impaired woman.
FIGURE 18-44 Positioning the hearing-impaired woman.
Women with Sensory Impairment
Sample Documentation
Subjective
Objective
Abnormalities
Female Genitalia
Premenstrual Syndrome (PMS)
Infertility
Endometriosis
FIGURE 18-45 Endometriosis.
FIGURE 18-46 Common sites of endometriosis.
Lesions From Sexually Transmitted Infections
Condyloma Acuminatum (Genital Warts)
FIGURE 18-47 Condyloma acuminatum.
Molluscum Contagiosum
FIGURE 18-48 Molluscum contagiosum. Note that these have occurred around the eyes.
Syphilitic Chancre
Condyloma Latum
FIGURE 18-49 Primary syphilitic chancre in vagina.
FIGURE 18-50 Condyloma latum.
Genital Herpes
FIGURE 18-51 Herpes lesions. Scattered erosions covered with exudate.
FIGURE 18-52 Herpetic cervicitis. Erythema, purulent exudate, and erosions are present on the cervix.
Vulva and Vagina
Inflammation of Bartholin Gland
FIGURE 18-53 Inflammation of Bartholin gland.
Vaginal Carcinoma
Vulvar Carcinoma
FIGURE 18-54 A, Ulcerative squamous cell carcinoma of the vulva. B, Basal cell carcinoma of the vulva.
Vaginal Infections
FIGURE 18-55 Trichomoniasis. The vaginal mucosa is inflamed and often speckled with petechial lesions. In adolescents, petechial hemorrhages may also be found on the cervix, resulting in the so-called strawberry cervix.
FIGURE 18-56 Microscopic differentiation of vaginal infections. A, Bacterial vaginosis: “clue cells.” B, Candida vulvovaginitis: “budding, branching hyphae.” C, Trichomoniasis: motile trichomonads.
DIFFERENTIAL DIAGNOSIS Vaginal Discharges and Infections
Cervix
Cervical Cancer
FIGURE 18-57 The cervical cancer lesion is predominantly around the external os.
Uterus
Uterine Prolapse
FIGURE 18-58 Uterine prolapse. A, Expected uterine position. B, First-degree prolapse of the uterus. C, Second-degree prolapse of the uterus. D, Complete prolapse of the uterus.
FIGURE 18-59 A third-degree prolapse of the uterus and vaginal walls.
Uterine Bleeding
Table 18-3 Types of Uterine Bleeding and Associated Causes
Myomas (Leiomyomas, Fibroids)
FIGURE 18-60 Myomas of the uterus (fibroids). A, Common location of myomas. B, Multiple uterine fibroids. C, Multiple uterine fibroids with enlarged ovaries resulting from multiple small cysts.
Endometrial Cancer
Adnexa
Ovarian Cysts
FIGURE 18-61 Ovarian cyst.
Ovarian Cancer
Tubal (Ectopic) Pregnancy
FIGURE 18-62 Ruptured tubal pregnancy.
Pelvic Inflammatory Disease (PID)
Salpingitis
FIGURE 18-63 Pelvic inflammatory disease. Photograph shows sheet of fine adhesions covering the fallopian tubes and ovary, which is buried beneath the fallopian tubes.
FIGURE 18-64 Salpingitis. Photograph shows acute salpingitis with adhesions. Dye has been instilled into the grossly swollen fallopian tube on the right. Dense adhesions obscure the ovary.
Infants and Children
Ambiguous Genitalia
FIGURE 18-65 Ambiguous genitalia.
Clinical Pearl
Normal infant female external genitalia.
Normal infant male external genitalia.
Hydrocolpos
Vulvovaginitis
FIGURE 18-66 Nonspecific inflammation characteristic of chemical irritant vulvovaginitis.
Pregnant Women
Premature Rupture of Membranes
Vaginal Bleeding during Pregnancy
Older Adults
Atrophic Vaginitis
Urinary Incontinence
Chapter 19 Male Genitalia
http://evolve.elsevier.com/Seidel
Anatomy and Physiology
Physical Examination Preview
Male Genitalia
FIGURE 19-1 Male pelvic organs.
FIGURE 19-2 Anatomy of the penis.
FIGURE 19-3 Anatomy of urethra and penis.
FIGURE 19-4 Scrotum and its contents.
Infants and Children
Adolescents
Older Adults
Review of Related History
History of Present Illness
Past Medical History
Staying Well
Family History
Personal and Social History
Infants and Children
Adolescents
Older Adults
Staying Well
Left, Self-examination of penis. Right, Self-examination of scrotum and testicle.
Risk Factors
Penile
Testicular
FIGURE 19-5 Appearance of male genitalia. A, Circumcised. B, Uncircumcised.
Examination and Findings
Equipment
Inspection and Palpation
Genital Hair Distribution
Penis
Box 19-1 Minimizing the Patient’s Anxiety
FIGURE 19-6 Phimosis.
FIGURE 19-7 Balanitis.
Urethral Meatus
Penile Shaft
Scrotum
FIGURE 19-8 Examination of urethral orifice.
FIGURE 19-9 Priapism.
Hernia
FIGURE 19-10 Inspection of scrotum and ventral surface of penis as the patient positions his penis.
FIGURE 19-11 Sebaceous glands on the scrotum.
Testes
FIGURE 19-12 Checking for inguinal hernia; gloved finger inserted through inguinal canal.
FIGURE 19-13 Palpating contents of the scrotal sac.
Cremasteric Reflex
Prostate
Infants
Inspection and Palpation
Clinical Pearl
Box 19-2 Male Circumcision
FIGURE 19-14 Palpating the scrotum of an infant.
Transillumination
Children
Inspection and Palpation
FIGURE 19-15 Position of child to push testicles into the scrotum. An alternative maneuver is to seat the child in tailor position.
Adolescents
Clinical Pearl
Older Adults
Sample Documentation
Subjective
Objective
Abnormalities
Infertility
Hernia
FIGURE 19-16 Anatomy of region of common pelvic hernias. A, Indirect inguinal hernia. B, Direct inguinal hernia. C, Femoral hernia.
FIGURE 19-17 Large indirect inguinal hernia.
DIFFERENTIAL DIAGNOSIS Distinguishing Characteristics of Hernias
Penis
Paraphimosis
FIGURE 19-18 Paraphimosis.
Syphilitic Chancre
FIGURE 19-19 Syphilitic chancre.
Genital Herpes
FIGURE 19-20 Genital herpes.
Condyloma Acuminata
FIGURE 19-21 Condyloma acuminatum (genital warts).
FIGURE 19-22 Condyloma acuminatum (genital warts).
Lymphogranuloma Venereum
FIGURE 19-23 Lymphogranuloma venereum.
Molluscum Contagiosum
FIGURE 19-24 Molluscum contagiosum. Close-up showing central umbilication.
Peyronie Disease
FIGURE 19-25 Peyronie disease.
Penile Cancer
FIGURE 19-26 Cancer of the penis.
Scrotum
Hydrocele
FIGURE 19-27 Hydrocele.
Spermatocele
FIGURE 19-28 Spermatocele.
Varicocele
FIGURE 19-29 Varicocele.
Orchitis
FIGURE 19-30 Orchitis.
Epididymitis
FIGURE 19-31 Epididymitis.
Testicular Torsion
DIFFERENTIAL DIAGNOSIS Acute Testicular Swelling
Testicular Cancer
FIGURE 19-32 Testicular tumor.
Klinefelter Syndrome
FIGURE 19-33 Klinefelter syndrome.
Ambiguous Genitalia
Hypospadias
FIGURE 19-34 Hypospadias.
Chapter 20 Anus, Rectum, and Prostate
http://evolve.elsevier.com/Seidel
Physical Examination Preview
Anus, Rectum, and Prostate
Anatomy and Physiology
FIGURE 20-1 Anatomy of the anus and rectum.
Infants and Children
FIGURE 20-2 Anatomy of the prostate gland and seminal vesicles. A, Cross section. B, Lateral view. C, Posterior view.
Pregnant Women
Older Adults
Review of Related History
History of Present Illness
Past Medical History
Family History
Personal and Social History
Risk Factors
Box 20-1 Screening for Sexually Transmitted Infections in Men Who Have Sex with Men (MSM)
Risk Factors
Infants and Children
Pregnant Women
Older Adults
Examination and Findings
Equipment
Preparation
Clinical Pearl
Positioning
Sacrococcygeal and Perianal Areas
Anus
Sphincter
Anal Ring
FIGURE 20-3 A, Correct procedure for introducing finger into rectum. Press pad of finger against the anal opening. B, As external sphincter relaxes, slip the fingertip into the anal canal. Note that patient is in the hips-flexed position.
FIGURE 20-4 A, Palpation of subcutaneous external sphincter. Feel it tighten around the examining finger. B, Palpation of deep external sphincter. C, Palpation of the posterior rectal wall.
Lateral and Posterior Rectal Walls
Bidigital Palpation
Anterior Rectal Wall
FIGURE 20-5 Palpation of the posterior surface of the prostate gland. Feel for the lateral lobes and median sulcus.
Box 20-2 Prostate Enlargement
Prostate
Uterus and Cervix
Evidence-Based Practice in Physical Examination
Stool
Infants and Children
Box 20-3 Stool Characteristics in Disease
Box 20-4 Common Causes of Rectal Bleeding
Table 20-1 Sequence and Description of Stools in Infants
FIGURE 20-6 Positioning the infant or child for rectal examination.
Pregnant Women
Clinical Pearl
Older Adults
Sample Documentation
Subjective
Objective
Staying Well
Abnormalities
Anus, Rectum, and Surrounding Skin
Pilonidal Cyst
FIGURE 20-7 Pilonidal cyst.
Anal Warts (Condyloma Acuminata)
FIGURE 20-8 Anal warts (condyloma acuminata).
Perianal and Perirectal Abscesses
FIGURE 20-9 Perianal and perirectal abscesses. Common sites of abscess formation.
Anorectal Fissure
FIGURE 20-10 Lateral anal fissure in adult.
Anal Fistula
Pruritus Ani
Hemorrhoids
FIGURE 20-11 A, Prolapsed hemorrhoids. B, Primary internal hemorrhoids.
Polyps
FIGURE 20-12 A, Fibroepithelial polyp of the rectum. B, Infant with prolapsed rectal polyp.
Anal Cancer
Colorectal Cancer
Prostate
Prostatitis
FIGURE 20-13 Prostatitis.
Clinical Pearl
Benign Prostatic Hypertrophy (BPH)
FIGURE 20-14 Benign prostatic hypertrophy.
Prostate Cancer
FIGURE 20-15 Cancer of prostate.
Infants and Children
Imperforate Anus
FIGURE 20-16 Imperforate anus: various anorectal malformations. A, Congenital anal stenosis. B, Anal membrane atresia. C, Anal agenesis. D, Rectal atresia. E, Rectoperineal fistula. F, Rectovaginal fistula.
FIGURE 20-17 Imperforate anus.
FIGURE 20-18 Rectal atresia.
Enterobiasis (Roundworm, Pinworm)
Chapter 21 Musculoskeletal System
http://evolve.elsevier.com/Seidel
Anatomy and Physiology
Physical Examination Preview
Hands and Wrists
Elbows
Shoulders
Temporomandibular Joint
Cervical Spine
Thoracic and Lumbar Spine
Hips
Legs and Knees
Feet and Ankles
Hand and Wrist Assessment (p. 524)
Shoulder Assessment (p. 524)
Lower Spine Assessment (p. 526)
Hip Assessment (p. 526)
Knee Assessment (p. 527)
Limb Measurement
FIGURE 21-1 A, Bones of the upper and lower extremities. B, Muscles of the upper extremities. C, Muscles of the lower extremities.
FIGURE 21-2 A, Bones of the trunk, anterior view. B, Bones of the trunk, posterior view. C, Superficial muscles of the trunk, anterior view. D, Superficial muscles of the trunk, posterior view.
Upper Extremities
FIGURE 21-3 Structures of the wrist and hand joints.
Head and Spine
FIGURE 21-4 Structures of the left elbow joint, posterior view.
FIGURE 21-5 Structures of the shoulder. A, Structures of glenohumeral and acromioclavicular joints, anterior view. B, Rotator cuff muscles of shoulder, posterior view.
FIGURE 21-6 Muscles of the face and head, left lateral view.
FIGURE 21-7 Structures of the temporomandibular joint.
FIGURE 21-8 Structures of vertebral joints.
Lower Extremities
FIGURE 21-9 Structures of the hip.
FIGURE 21-10 Structures of the knee, anterior view. A, Bones and ligaments of the joint. B, Muscles attaching at the knee.
FIGURE 21-11 Bones and joints of the ankle and foot.
Infants and Children
Adolescents
Pregnant Women
Older Adults
Staying Well
Review of Related History
History of Present Illness
Past Medical History
Family History
Risk Factors
Personal and Social History
Infants and Children
Pregnant Women
Older Adults
Risk Factors
Examination and Findings
Equipment
Inspection
Clinical Pearl
Palpation
FIGURE 21-12 Inspection of overall body posture. Note the even contour of the shoulders, level scapulae and iliac crests, alignment of the head over the gluteal folds, and symmetry and alignment of extremities. A, Anterior view. B, Posterior view. C, Lateral view. The occiput, shoulders, buttocks, and heels should be able to touch the wall the patient stands against.
Range of Motion and Muscle Tone
Muscle Strength
FIGURE 21-13 Use of goniometer to measure joint range of motion.
FIGURE 21-14 Evaluation of muscle strength: flexion of the elbow against opposing force.
Table 21-1 Assessing Muscle Strength
Specific Joints and Muscles
Hands and Wrists
FIGURE 21-15 A, Bony structure of the right hand and wrist; note the alignment of the fingers with the radius. B, Features of the palmar aspect of the hand; note creases, thenar eminence and hypothenar eminence, and gradual tapering of the fingers.
FIGURE 21-16 Unexpected findings of the hand. A, Ulnar deviation and subluxation of metacarpophalangeal joints. B, Swan neck deformities. C, Boutonnière deformity.
Elbows
FIGURE 21-17 Palpation of joints of the hand and wrist. A, Proximal interphalangeal joints. B, Metacarpophalangeal joints. C, Radiocarpal groove and wrist.
FIGURE 21-18 Unexpected findings of the fingers. A, Fusiform swelling or spindle-shaped enlargement of the proximal interphalangeal joints. B, Degenerative joint disease; Heberden nodes at the distal interphalangeal joints and Bouchard nodes at the proximal interphalangeal joints. C, Telescoping digits with hypermobile joints.
Shoulders
FIGURE 21-19 Range of motion of the hand and wrist. A, Metacarpophalangeal flexion and hyperextension. B, Finger flexion: thumb to each fingertip and to the base of the little finger. C, Finger flexion: fist formation. D, Finger abduction. E, Wrist flexion and hyperextension. F, Wrist radial and ulnar movement.
FIGURE 21-20 Subcutaneous nodules on the extensor surface of the forearm near the elbow.
FIGURE 21-21 Expected carrying angle of the arm, at 5 to 15 degrees.
Temporomandibular Joint
FIGURE 21-22 Palpation of the olecranon process grooves.
FIGURE 21-23 Range of motion of the elbow. A, Flexion and extension. B, Pronation and supination.
Cervical Spine
FIGURE 21-24 Contour changes of the shoulder. A, With dislocation. B, Winging of the scapula with abduction of the arm.
FIGURE 21-25 Range of motion of the shoulder. A, Forward flexion and hyperextension. B, Abduction and adduction. C, Internal rotation. D, External rotation. E, Shrugged shoulders.
FIGURE 21-26 Palpation of the temporomandibular joint.
FIGURE 21-27 Lateral range of motion in the temporomandibular joint.
FIGURE 21-28 Range of motion of the cervical spine. A, Flexion and hyperextension. B, Lateral bending. C, Rotation.
FIGURE 21-29 Examining the strength of the sternocleidomastoid and trapezius muscles. A, Flexion with palpation of the sternocleidomastoid muscle. B, Extension against resistance. C, Rotation against resistance.
Thoracic and Lumbar Spine
FIGURE 21-30 Landmarks of the back.
FIGURE 21-31 Deviations in spinal column curvatures. A, Expected spine curvatures. B, Kyphosis. C, Lordosis. D, Gibbus.
FIGURE 21-32 Palpation of the spinal processes of the vertebrae.
FIGURE 21-33 Inspection of the spine for lateral curvature and lumbar convexity.
Hips
Staying Well
FIGURE 21-34 Range of motion of the thoracic and lumbar spine. A, Flexion. B, Hyperextension. C, Lateral bending. D, Rotation of the upper trunk.
Legs and Knees
FIGURE 21-35 Range of motion of the hip. A, Hip flexion, knee extended. B, Hip extension, knee extended. C, Hip flexion, knee flexed. D, Abduction. E, Internal rotation. F, External rotation.
FIGURE 21-36 Range of motion of the knee: flexion and extension.
Feet and Ankles
FIGURE 21-37 Pronation of heel. Note that weight bearing is not through the midline of the foot.
FIGURE 21-38 Variations in the longitudinal arch of the foot. A, Commonly expected arch. B1 and B2, Pes planus (flatfoot). C1 and C2, Pes cavus (high instep).
FIGURE 21-39 Unexpected findings of the feet. A, Hallux valgus with bunion. B, Protruding metatarsal heads with callosities. C, Hammertoes. D, Mallet toe. E, Claw toes.
FIGURE 21-40 Range of motion of the foot and ankle. A, Dorsiflexion and plantar flexion. B, Inversion and eversion. C, Abduction and adduction.
Evidence-Based Practice in Physical Examination
Advanced Skills
Hand and Wrist Assessment
Table 21-2 Special Procedures for Assessment of the Musculoskeletal System
Evidence-Based Practice in Physical Examination
Shoulder Assessment
FIGURE 21-41 Assessment for carpal tunnel syndrome. A, Katz hand diagram. B, Classic and probable patterns of pain, tingling, and numbness using the Katz hand diagram.
FIGURE 21-42 Additional procedures for assessment of carpal tunnel syndrome. A, Thumb abduction test. B, Phalen maneuver. C, Elicitation of Tinel sign.
FIGURE 21-43 Assessment for rotator cuff inflammation or tear. A, Neer test. B, Hawkins test.
Lower Spine Assessment
Hip Assessment
FIGURE 21-44 Femoral stretch test for high lumbar nerve root irritation.
FIGURE 21-45 Procedures for examination of the hip with the thomas test. Note the elevation of the extended leg off the examining table.
Knee Assessment
FIGURE 21-46 Test for the Trendelenburg sign. Note any asymmetry in the level of the iliac crests with weight bearing.
FIGURE 21-47 Procedure for ballottement examination of the knee.
FIGURE 21-48 Testing for the Bulge sign in examination of the knee. A, Milk the medial aspect of the knee two or three times. B, Tap the lateral side of the patella.
FIGURE 21-49 Procedure for examination of the knee with the McMurray test. Knee is flexed after lower leg was rotated to medial position.
FIGURE 21-50 Examination of the knee with the drawer test for anterior and posterior stability.
FIGURE 21-51 Valgus stress test of the knee with knee extended.
Evidence-Based Practice in Physical Examination
FIGURE 21-52 Measuring limb length (A) and leg circumference (B).
Limb Measurement
Infants
FIGURE 21-53 Kyphosis, expected convex curvature of the newborn’s thoracic and lumbar spine.
FIGURE 21-54 Anomalies of the newborn’s hand. A, Simian crease. B, Syndactyly. C, Polydactyly.
FIGURE 21-55 Bifid defect of the vertebra identified by palpation.
Children
FIGURE 21-56 Barlow-Ortolani maneuver to detect hip dislocation. A, Phase I, adduction. B, Phase II, abduction.
FIGURE 21-57 Signs of hip dislocation: limitation of abduction and asymmetric gluteal folds.
FIGURE 21-58 Examination for the Allis sign. Unequal upper leg length would indicate a positive sign.
FIGURE 21-59 Evaluation of shoulder muscle strength in the newborn.
FIGURE 21-60 Lumbar curvature of the toddler’s spine.
FIGURE 21-61 Reverse tailor sitting position.
FIGURE 21-62 Examination for tibial torsion.
FIGURE 21-63 Genu valgum (knock-knee) in the young child.
Adolescents
FIGURE 21-64 Gower sign of generalized muscle weakness. A, B, The child maneuvers to a position supported by both the arms and legs. C, D, The child pushes off the floor, rests the hand on the knee, and pushes self up with the hands and arms on the legs. E, The child stands upright.
Pregnant Women
FIGURE 21-65 Postural changes with pregnancy.
Older Adults
Sample Documentation
Subjective
Objective
Functional Assessment
Abnormalities
Musculoskeletal
Ankylosing Spondylitis
FIGURE 21-66 Gross postural changes in woman affected by ankylosing spondylitis.
Lumbosacral Radiculopathy (Herniated Lumbar Disk)
FIGURE 21-67 Distribution of paresthesia and radiating pain associated with herniated disks at the L4, L5, and S1 nerve roots.
Lumbar Stenosis
Carpal Tunnel Syndrome
Gout
FIGURE 21-68 Gouty tophus on right foot.
Temporomandibular Joint Syndrome
Osteomyelitis
Bursitis
FIGURE 21-69 Olecranon bursitis.
Paget Disease of the Bone (Osteitis Deformans)
Osteoarthritis
Rheumatoid Arthritis
DIFFERENTIAL DIAGNOSIS Comparison of Osteoarthritis with Rheumatoid Arthritis
Sports Injuries
Box 21-1 Neurovascular Assessment
Risk Factors
Muscle Strain
Dislocation
Fracture
Tenosynovitis (Tendonitis)
Rotator Cuff Tear
Infants and Children
Clubfoot (Talipes Equinovarus)
FIGURE 21-70 Clubfoot deformity, talipes equinovarus (bilateral deviation).
Metatarsus Adductus (Metatarsus Varus)
FIGURE 21-71 Metatarsus adductus.
Legg-Calvé-Perthes Disease
Osgood-Schlatter Disease
Slipped Capital Femoral Epiphysis
Muscular Dystrophy
Scoliosis
FIGURE 21-72 Scoliosis, lateral curvature of the spine. Scapular asymmetry is easily discernible in the upright position.
Radial Head Subluxation (Nursemaid’s Elbow)
Older Adults
Osteoporosis
FIGURE 21-73 Hallmark of osteoporosis: Dowager hump.
Dupuytren Contracture
FIGURE 21-74 Dupuytren contracture.
Chapter 22 Neurologic System
http://evolve.elsevier.com/Seidel
Anatomy and Physiology
Physical Examination Preview
Cerebellar Function and Proprioception
Sensory Function
Superficial and Deep Tendon Reflexes
Brain
Cerebrum
FIGURE 22-1 Frontal section of the superior portion of the head, as viewed from the front. Both bony and membranous coverings of the brain can be seen.
FIGURE 22-2 Arterial blood supply to the brain. The internal carotid arteries supply 80%, and the vertebral basilar arteries supply 20%.
FIGURE 22-3 Lobes and principal fissures of the cerebral cortex, cerebellum, and brainstem (left hemisphere, lateral view).
Cerebellum
Brainstem
Table 22-1 Structures of the Brainstem and Their Functions
Cranial Nerves
Spinal Cord and Spinal Tracts
Table 22-2 The Cranial Nerves and Their Functions
Spinal Nerves
FIGURE 22-4 Tracts of the spinal cord. A, Pathway of spinal tracts from spinal cord to motor cortex. Note decussation of the pyramids at the level of the medulla. B, Major ascending (sensory) tracts, shown here only on the left, are highlighted in blue. Major descending (motor) tracts, shown here only on the right, are highlighted in red.
FIGURE 22-5 Location of exiting spinal nerves in relation to the vertebrae. A, Posterior view. B, Anterior view of brainstem and spinal cord. C, Lateral view showing relationship of spinal cord to vertebrae. D, Enlargement of caudal area with group of nerve fibers composing the cauda equina.
FIGURE 22-6 Dermatomes of the body, the area of body surface innervated by particular spinal nerves; C1 usually has no cutaneous distribution. A, Anterior view. B, Posterior view. It appears that there is a distinct separation of surface area controlled by each dermatome, but there is almost always overlap between spinal nerves. C = cervical, T = thoracic, S = sacral, L = lumbar.
Infants and Children
Pregnant Women
Older Adults
FIGURE 22-7 Cross section of spinal cord showing simple reflex arc.
Review of Related History
History of Present Illness
Risk Factors
Past Medical History
Family History
Personal and Social History
Infants
Children
Pregnant Women
Older Adults
Risk Factors
Examination and Findings
Equipment
Box 22-1 Procedure for the Neurologic Screening Examination
Cranial Nerves
Proprioception and Cerebellar Function
Sensory Function
Deep Tendon Reflexes
Cranial Nerves
Olfactory (I)
Clinical Pearl
Table 22-3 Procedure for Cranial Nerve Examination
Optic (II)
Oculomotor, Trochlear, and Abducens (III, IV, and VI)
FIGURE 22-8 Examination of the olfactory cranial nerve. Occlude one naris, hold the vial with aromatic substance under the nose, and ask the patient to deeply inspire. If the patient’s eyes are open, make sure there are no visual cues to odors. The patient should discriminate between odors.
Trigeminal (V)
FIGURE 22-9 Examination of the trigeminal cranial nerve for motor function. Have the patient tightly clench the teeth, and then palpate the muscles over the jaw for tone.
FIGURE 22-10 Examination of the trigeminal cranial nerve for sensory function. Touch each side of the face at the scalp, cheek, and chin areas alternately using no predictable pattern (A) with the point and rounded edge of a paper clip or broken tongue blade and (B) with a brush or cotton wisp. Ask the patient to discriminate between sensations.
Facial (VII)
Clinical Pearl
FIGURE 22-11 Examination of the facial cranial nerve for motor function. Ask the patient to (A) wrinkle the forehead by raising the eyebrows; (B) smile; (C) puff out the cheeks; (D) purse the lips and blow out; (E) show the teeth; and (F) squeeze the eyes shut.
FIGURE 22-12 Location of the taste bud regions tested for the sensory function of the facial and glossopharyngeal cranial nerves.
Clinical Pearl
Acoustic (VIII)
Glossopharyngeal (IX)
Vagus (X)
Spinal Accessory (XI)
Hypoglossal (XII)
Proprioception and Cerebellar Function
Coordination and Fine Motor Skills
Rapid Rhythmic Alternating Movements.
FIGURE 22-13 Examination of the hypoglossal cranial nerve. A, Inspect the protruded tongue for size, shape, symmetry, and fasciculation. B, Observe movement of the tongue from side to side.
DIFFERENTIAL DIAGNOSIS Tremors
Accuracy of Movements.
FIGURE 22-14 Examination of coordination with rapid alternating movements. A, B, Pat the knees with both hands, alternately using the palm and back of the hand. C, Touch the thumb to each finger of the hand in sequence from index finger to small finger and back.
FIGURE 22-15 Examination of fine motor function. A and B, The patient alternately touches own nose and the examiner’s index finger with the index finger of one hand; C, Alternately touches own nose with the index finger of each hand; and D, runs the heel of one foot down the shin or tibia of the other leg.
FIGURE 22-16 Evaluation of balance with the Romberg test.
Balance
Equilibrium.
Gait.
FIGURE 22-17 Evaluation of gait and balance with heel-toe walking on a straight line.
Sensory Function
FIGURE 22-18 Unexpected gait patterns. A, Spastic hemiparesis. B, Spastic diplegia (scissoring). C, Steppage gait. D, Cerebellar ataxia. E, Sensory ataxia.
Table 22-4 Characteristics of Unexpected Gait Patterns
Primary Sensory Functions
Superficial Touch.
Superficial Pain.
Temperature and Deep Pressure.
Vibration.
Position of Joints.
Cortical Sensory Functions
FIGURE 22-19 Evaluation of primary sensory function. A, Superficial tactile sensation; use a light stroke to touch the skin with a cotton wisp or brush. B, Superficial pain sensation; use the sharp and rounded edge of a broken tongue blade in an unpredictable alternate pattern. C, Vibratory sensation; place the stem of a vibrating tuning fork against several bony prominences. D, Position sense of joints; hold the toe or finger by the lateral aspects while raising and lowering the toe.
FIGURE 22-20 Evaluation of cortical sensory function. A, Stereognosis; patient identifies a familiar object by touch. B, Two-point discrimination; using two sterile needles or two points of a paper clip, alternately place one or two points simultaneously on the skin, and ask the patient to determine whether one or two sensations are felt. C, Graphesthesia; draw a letter or number on the body (without actually marking skin) and ask the patient to identify it.
Box 22-2 Patterns of Sensory Loss Injury or Defect and Description of Findings
Single Peripheral Nerve
Multiple Peripheral Nerves (Polyneuropathy)
Multiple Spinal Nerve Roots
Complete Transverse Lesion of the Spinal Cord
Partial Spinal Sensory Syndrome (Brown-Séquard Syndrome)
Stereognosis.
Two-Point Discrimination.
Extinction Phenomenon.
Graphesthesia.
Point Location.
Reflexes
Superficial Reflexes
Plantar Reflex.
Table 22-5 Procedures for Testing the Integrity of Individual Spinal Tracts for Upper and Lower Motor Neuron Disorders
Abdominal Reflex.
Table 22-6 Spinal Nerve Level Evaluated by Superficial and Deep Tendon Reflexes
FIGURE 22-21 Superficial reflexes. A, Plantar reflex indicating the direction of the stroke and the Babinski sign—dorsiflexion of the great toe with or without fanning of the toes. B, One of several approaches for the abdominal reflexes. Stroke the lower abdominal area downward, away from the umbilicus. Stroke the upper abdominal area upward, away from the umbilicus.
Cremasteric Reflex.
Deep Tendon Reflexes
Table 22-7 Scoring Deep Tendon Reflexes
Biceps Reflex.
Brachioradial Reflex.
Triceps Reflex.
Patellar Reflex.
Achilles Reflex.
DIFFERENTIAL DIAGNOSIS Characteristics of Upper and Lower Motor Neuron Disorders
FIGURE 22-22 Location of tendons for evaluation of deep tendon reflexes. A, Biceps. B, Brachioradial. C, Triceps. D, Patellar. E, Achilles. F, Evaluation of ankle clonus.
Clonus.
Advanced Skills
Protective Sensation
Meningeal Signs
FIGURE 22-23 A, Sites for application of the 5.07 monofilament to test for protective sensation. Indicate presence (+) or absence (−) of sensory perception on a drawing of the foot. B, Apply the monofilament to the patient’s foot with just enough pressure to bend the monofilament.
FIGURE 22-24 A, Brudzinski sign, flex the neck and observe for involuntary flexion of the hips and knees. B, Kernig sign, flex the leg at the knee and hip when the patient is supine, and then attempt to straighten the leg. Observe for pain in the lower back and resistance to straightening the leg.
Staying Well
Jolt Accentuation of Headache
Posturing
Evidence-Based Practice
Infants
FIGURE 22-25 A, Decorticate or flexor posture. The upper arms are held tightly to the sides of the body. The elbows, wrists, and fingers are flexed, and the feet are plantar flexed. The legs are extended and internally rotated. Fine tremors or intense stiffness may be present. B, Decerebrate or extensor posture. The arms are fully extended with forearms pronated. The wrists and fingers are flexed, the jaw is clenched. The neck is extended and the back may be arched. The feet are plantar flexed.
Table 22-8 Indirect Cranial Nerve Evaluation in Newborns and Infants*
Clinical Pearl
FIGURE 22-26 Observe purposeful movement such as reaching for the block.
Table 22-9 Primitive Reflexes Routinely Evaluated in Infants
Children
Table 22-10 Cranial Nerve Examination Procedures for Young Children
Pregnant Women
Older Adults
Staying Well
FIGURE 22-27 Short, uncertain steps are characteristic of gait with advancing age.
Sample Documentation
Subjective
Objective
Functional Assessment
Balance Tests
Gait Tests
Abnormalities
Neurologic System
Disorders of the Central Nervous System
Multiple Sclerosis (MS)
Seizure Disorder (Epilepsy)
Encephalitis
Meningitis
Intracranial Tumor
Pseudotumor Cerebri
Stroke (Brain Attack or Cerebrovascular Accident)
FIGURE 22-28 Areas of the brain affected by occlusion of the anterior, middle, and posterior cerebral artery branches. A, Inferior view. B, Lateral view.
DIFFERENTIAL DIAGNOSIS Neurologic Signs Associated with Stroke by Artery Affected
Disorders of the Peripheral Nervous System
Myasthenia Gravis
Guillain-Barré Syndrome
Trigeminal Neuralgia (Tic Douloureux)
Bell Palsy
FIGURE 22-29 Characteristic features of Bell palsy.
Peripheral Neuropathy
Children
Cerebral Palsy (CP)
Myelomeningocele (Spina Bifida)
FIGURE 22-30 Myelomeningocele.
Shaken Baby Syndrome
Pregnant Women
Intrapartum Maternal Lumbosacral Plexopathy
Older Adults
Parkinson Disease
FIGURE 22-31 Characteristic features of Parkinson disease. A, Excessive sweating. B, Drooling with excess saliva. C, Gait with rapid, short, shuffling steps and reduced arm swinging.
Normal Pressure Hydrocephalus
Postpolio Syndrome (Progressive Postpoliomyelitis Muscular Atrophy)
Chapter 23 Sports Participation Evaluation
http://evolve.elsevier.com/Seidel
Box 23-1 Special Olympics
Clinical Pearl
Clinical Pearl
Evidence-Based Practice in Physical Examination
Box 23-2 Recommended Components of the Preparticipation Physical Evaluation (PPE)*
General Medical History
Cardiac
Respiratory
Neurologic
Vision
Orthopedic
Psychosocial
Genitourinary and Abdominal
Dermatologic
FIGURE 23-1 The 14-step screening orthopedic examination. The athlete should be dressed so that the joints and muscle groups included in the examination are easily visible—usually gym shorts for males and gym shorts and a T-shirt for females. Keep in mind that one of the most important points to look for in the orthopedic screening examination is symmetry.
Table 23-1 Classification of Sports According to Contact
Box 23-3 Sports-Related Concussions
FIGURE 23-2 SCAT3 Sport Concussion Assessment Tool 3.
Staying Well
Chapter 24 Putting It All Together
http://evolve.elsevier.com/Seidel
At the Start
Box 24-1 A Few Reminders for Emphasis
If You Want Effective Relationships with Patients
Clinical Pearl
Box 24-2 The Patient We Define as Difficult
Accuracy
The Potential for Error
Uncertainty
Box 24-3 Humans and Machines
Examination Sequence
Adults and Adolescents
Box 24-4 Equipment Supplies for Physical Examination
Basic Materials
Materials for Gathering Specimens
FIGURE 24-1 Observe the patient while entering the examining room for manner, dress, interest or apprehension, and mobility.
General Inspection
Preparation
Measurements
Patient Seated, Wearing Gown
Box 24-5 Examining People with Disabilities
FIGURE 24-2 Face the patient who is seated on the examining table.
Head and Face
Eyes
Ears
Nose
Mouth and Pharynx
Neck
Upper Extremities
FIGURE 24-3 Examine the patient’s back without the gown.
Patient Seated, Back Exposed
Back and Posterior Chest
Lungs
Patient Seated, Chest Exposed
Anterior, Chest, Lungs, and Heart
FIGURE 24-4 Examine the patient’s anterior chest while exposed.
Female Breasts
Male Breasts
Patient Reclining 45 Degrees
FIGURE 24-5 Examine the patient while reclining with chest exposed.
Patient Supine, Chest Exposed
Female Breasts
Heart
Patient Supine, Abdomen Exposed
Abdomen
FIGURE 24-6 Examine the patient while reclining with abdomen exposed.
Inguinal Area
External Genitalia, Males
Patient Supine, Legs Exposed
Feet and Legs
Hips
Patient Sitting, Lap Draped
Musculoskeletal.
Neurologic.
FIGURE 24-7 Examine the patient in supine position with legs exposed.
FIGURE 24-8 Examine the patient seated with a drape across the lap.
Patient Standing
Spine
FIGURE 24-9 Examine the patient while standing.
Neurologic
Abdominal/Genital
Female Patient, Lithotomy Position
External Genitalia
Internal Genitalia
FIGURE 24-10 Examining the female patient in lithotomy position, appropriately draped.
Male Patient, Bending Forward (Lateral Decubitus or Knee-Chest Positions Are Also Possible)
FIGURE 24-11 Examining the male patient while bending over the examining table.
Newborns
Older Infants
Examination Sequence with Infants
General Inspection
FIGURE 24-12 Infants are often more comfortable when examined on a parent’s lap.
FIGURE 24-13 Examining the chest of an infant on the parent’s lap.
Chest, Lungs, and Heart
Abdomen
FIGURE 24-14 Examining the infant’s abdomen while reclining on parent’s lap.
Head and Neck.
FIGURE 24-15 Inspect and palpate the infant’s face.
Upper Extremities
Lower Extremities
FIGURE 24-16 Examine the infant’s lower extremities.
Genitals and Rectum
Neurologic.
Back.
FIGURE 24-17 Examining the infant’s back while held by the parent.
Behavior.
Children
Box 24-6 Some Tips for Examining a Young Child
General Inspection
Child Playing
FIGURE 24-18 Provide toys or other items to observe the child’s development.
FIGURE 24-19 Young children can also be examined on the parent’s lap.
Child on Parent’s Lap
Upper Extremities.
Lower Extremities.
FIGURE 24-20 Inspect and palpate the child’s head and neck.
Head and Neck.
Chest, Heart, and Lungs.
Child Relatively Supine, Still on Lap, Diaper Loosened
Child Standing
FIGURE 24-21 Examine the child while standing and bending to touch the toes.
FIGURE 24-22 In some children, it is better to postpone the use of instruments until the end of the examination.
Child Returns to Parent’s Lap
Pregnant Women
Older Adults
The Closing Discussion
Box 24-7 How Are You Doing?
Did You at the Start?
Did You, as You Talked with the Patient?
Did You, Throughout?
Did You, at the Finish?
Box 24-8 The Stressful Moment
Chapter 25 Taking the Next Steps: Critical Thinking
http://evolve.elsevier.com/Seidel
The Clinical Examination
Critical Thinking
Assessment, Judgment, and Evidence
Problem Identification
Box 25-1 Steps for Critical Thinking
Valid Hypotheses
Possible Barriers to Critical Thinking
Box 25-2 Decision Making
Box 25-3 Red Herrings
Box 25-4 “A Patient Can Have as Many Diagnoses as He Darn Well Pleases”
Feelings, Attitudes, and Values.
The Ethical Context.
Mechanism and Probabilism.
Validity of the Clinical Examination
Box 25-5 The Electronic Environment
Bayes Theorem
FIGURE 25-1 Sensitivity and specificity, true positive/negative, and positive/negative predictive values.
FIGURE 25-2 Evidenced-based decision making.
Evidence-Based Practice
Evaluation and Management Plan and Setting Priorities
Table 25-1 Stages of Change
Chapter 26 Recording Information
http://evolve.elsevier.com/Seidel
General Guidelines
Box 26-1 Abbreviations and Acronyms
Table 26-1 Prohibited Abbreviations
EMR Replicating Functions
Organization of the Note
Box 26-2 Use and Misuse of CPCF
Potentially Acceptable Uses of CPCF
Unacceptable Uses of CPCF
Box 26-3 Implications of Misuse of CPCF
Organizing the Patient’s Health Record with SOAP Notes
Subjective Data
Objective Data
Location of Findings.
Incremental Grading.
Organs, Masses, and Lesions.
Discharge.
Illustrations
FIGURE 26-1 Illustration of the location of a breast mass.
FIGURE 26-2 Illustration of a stick person.
Problem-Oriented Medical Record
Comprehensive Health History and Physical Examination
Problem List
Assessment
Plan
SOAP Notes
Box 26-4 Governing Principles for Using POMR, APSO, and SOAP
APSO Notes
Notes from Subsequent Evaluations
Problem-Oriented Medical Record Format
The History
Identifying Information.
Problems, Allergies, Medications, and Immunizations (PAMI) List.
General Patient Information.
Source and Reliability of Information.
Chief Concern/Presenting Problem/Reason for Seeking Care.
History of Present Illness.
Recording the History of the Present Illness: OLDCARTS.
Past Medical History.
Family History.
Personal and Social History.
Review of Systems
FIGURE 26-3 A, Common pedigree symbols. B, Sample pedigree for autosomal recessive condition.
Physical Examination Findings
General Statement
Mental Status
Skin
Head
Eyes
Ears
Nose
Throat and Mouth
Neck
Chest
Lungs
Breasts
Heart
Blood Vessels
Abdomen
Male Genitalia
Female Genitalia
Anus and Rectum
Lymphatic System
Musculoskeletal System
Neurologic System
Assessment (for Each Problem on Problem List)
Plan (for Each Problem on Problem List)
Infants
History
Present Problem.
Details of Pregnancy.
Infant’s Status at Birth.
First Month of Life.
Past Medical History.
Family History.
Personal and Social History.
Growth and Development.
Developmental Milestones.
Injury Prevention.
Diet.
Breast-Fed Infants.
Formula-Fed Infants.
Solid Foods.
Physical Examination Findings
General
Mental Status
Skin
Lymphatics
Head
Eyes
Ears
Nose
Mouth
Neck
Chest and Lungs
Heart and Blood Vessels
Abdomen
Male Genitalia
Female Genitalia
Anus, Rectum
Musculoskeletal System
Neurologic System
Children and Adolescents
History
Past Medical History.
Personal and Social History.
Growth and Development.
Physical Examination Findings.
Mental Status.
Breasts.
Genitalia.
Neurologic System.
Pregnant Women
History
History of Present Illness.
Obstetric History.
Menstrual and Gynecologic History.
Personal and Social History.
Physical Examination Findings
Abdomen
Pelvic Region
Older Adults
History
Personal and Social History.
Physical Examination Findings
General Assessment
Mental Status
Skin
Chest and Lungs
Heart and Blood Vessels
Musculoskeletal System
Neurologic System
Sample Records
Inpatient Admission Note
History of Present Illness
Past Medical History
Adult Illnesses
Prior Surgery
Medications on Admission
Allergies
Family History
Social History
Review of Systems
Physical Exam
Neurologic
Assessment
Plan
Summary
Chapter 27 Emergency or Life-Threatening Situations
http://evolve.elsevier.com/Seidel
Emergency Assessment of the Injured Patient
The Primary Survey
Airway and Cervical Spine.
Breathing.
Box 27-1 Basic Life Support Survey for an Unconscious Patient
Box 27-2 Assessment of Airway Patency
Signs of Obstruction
Symptoms of Obstruction
FIGURE 27-1 Look, listen, and feel for adequate breathing to assess patency of the upper airway.
FIGURE 27-2 Use a chin lift to lift the tongue out of the oropharynx and ensure an open airway.
FIGURE 27-3 Properly position both hands to stabilize and maintain the head and neck in a neutral position, in alignment with the body.
Circulation.
FIGURE 27-4 Check the carotid pulse to confirm circulation, one side at a time.
Disability.
Clinical Pearl
Table 27-1 Glasgow Coma Scale
Exposure and Environmental Control.
Clinical Pearl
Secondary Assessment of the Injured Patient
History.
Clinical Pearl
Head and Neck.
Chest.
Abdomen.
FIGURE 27-5 Signs that indicate serious injury associated with trauma.
Extremities and Back.
Rectum and Perineum.
Neurologic Examination.
Reevaluate the Patient.
Injury Mechanisms
Blunt Trauma
Penetrating Trauma
Burns
FIGURE 27-6 To estimate to total body surface area burned, mark the areas of the patient’s burns on the chart. Then estimate the area of each body part burned, using the percentage of body surface area for each body part according to the age of the patient. Insert the percentages into the chart and sum to obtain the total body surface area burned. ANT, Anterior; POST, posterior.
Assessment of an Acute Medical Emergency
Advanced Cardiac Life Support Survey
Box 27-3 Differential Diagnosis Assessment
Assessment of Infants and Children
Physical Variations
Assessment of Older Adults
Table 27-2 Symptoms and Risks of Serious and Life-Threatening Conditions
Box 27-4 Ways in Which Children Differ Physically from Adults
Characteristics of Young Children
Skin
Head
Airway
Chest and Lungs
Heart and Circulation
Abdomen
Extremities
Nervous System
Table 27-3 Assessment Findings that Indicate a Sense of Urgency in Infants and Children
Legal Considerations
Records
Consent for Treatment
Trauma Due to Violence
Medical Orders for Life-Sustaining Treatment
Summary
Abnormalities
Upper Airway Obstruction
Hypoxemia
Shock State
Ventilatory Failure
Increased Intracranial Pressure
Pulmonary Embolism
Severe Asthma Episode (Status Asthmaticus)
Status Epilepticus
Photo and Illustration Credits
References and Readings
Glossary
Appendix A Height/Weight Growth Charts
FIGURE A-1 Physical growth curves for children ages birth to 24 months: Boys.
FIGURE A-2 Physical growth curves for children ages birth to 24 months: Girls.
FIGURE A-3 Physical growth curves for ages 2 to 20 years: Boys.
FIGURE A-4 Physical growth curves for ages 2 to 20 years: Girls.
Appendix B Pediatric Blood Pressure Tables
Appendix C Conversion Tables and Anthropometric Measurements
Conversion Tables
Table C-1 Length
Table C-2 Weight
Anthropometric Measurements
Table C-3 Body Weight in Pounds According to Height and Body Mass Index
Index
A
B
C
D
E
F
G
H
I
J
K
L
M
N
O
P
Q
R
S
T
U
V
W
X
Y
Z
Special Features
Clinical Pearls
DIFFERENTIAL DIAGNOSES
Evidence-Based Practice in Physical Examination
Sample Documentation
Staying Well
Physical Variations
Risk Factors
Functional Assessment

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