Read chapters 1, 3, and 18 of Bickley Bates’ textbook, Guide to Physical Examination and Medical History, and bring a summary of the chapters read.

Read chapters 1, 3, and 18 of Bickley Bates’ textbook, Guide to Physical Examination and Medical History, and bring a summary of the chapters read. 3-page essay APA. the book is attached 

Lynn S. Bickley, MD, FACP
Clinical Professor of Internal Medicine
School of Medicine
University of New Mexico
Albuquerque, New Mexico
Peter G. Szilagyi, MD, MPH
Professor of Pediatrics
Chief, Division of General Pediatrics
University of Rochester School of Medicine and Dentistry
Rochester, New York

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7th Edition
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Library of Congress Cataloging-in-Publication Data
Bickley, Lynn S.
Bates’ pocket guide to physical examination and history taking / Lynn S. Bickley,
Peter G. Szilagyi. — 7th ed.
p. ; cm.
Pocket guide to physical examination and history taking
Abridgement of: Bates’ guide to physical examination and history-taking. 11th ed. / Lynn S.
Bickley, Peter G. Szilagyi. c2013.
Includes bibliographical references and index.
Summary: “This concise pocket-sized guide presents the classic Bates approach to physical exami-
nation and history taking in a quick-reference outline format. It contains all the critical information
needed to obtain a clinically meaningful health history and to conduct a thorough physical assessment.
Fully revised and updated, the Seventh Edition will help health professionals elicit relevant facts from
the patient’s history, review examination procedures, highlight common findings, learn special assess-
ment techniques, and sharpen interpretive skills.The book features a vibrant full-color art program
and an easy-to-follow two-column format with step-by-step examination techniques on the left and
abnormalities with differential diagnoses on the right.”—Provided by publisher.
ISBN 978-1-4511-7322-2 (pbk. : alk. paper)
I. Bates, Barbara, 1928-2002. II. Szilagyi, Peter G. III. Bickley, Lynn S. Bates’ guide to physical
examination and history-taking. IV. Title. V. Title: Pocket guide to physical examination and history taking.
[DNLM: 1. Physical Examination—methods—Handbooks. 2. Medical History Taking—
methods—Handbooks. WB 39]

616.07′51—dc23 2012030529
Care has been taken to confirm the accuracy of the information presented and to describe gener-
ally accepted practices. However, the authors, editors, and publisher are not responsible for errors
or omissions or for any consequences from application of the information in this book and make no
warranty, expressed or implied, with respect to the currency, completeness, or accuracy of the contents
of the publication. Application of this information in a particular situation remains the professional
responsibility of the practitioner; the clinical treatments described and recommended may not be con-
sidered absolute and universal recommendations.
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dosage set forth in this text are in accordance with the current recommendations and practice at the
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To Randolph B. Schiffer, for lifelong care and support,
and to students world-wide committed to clinical excellence.

I n t r o d u c t i o n
The Pocket Guide to Physical Examination and History Taking,
7th edition is a concise, portable text that:
● Describes how to interview the patient and take the health history.
● Provides an illustrated review of the physical examination.
● Reminds students of common, normal, and abnormal physical
findings.
● Describes special techniques of assessment that students may need in
specific instances.
● Provides succinct aids to interpretation of selected findings.
There are several ways to use the Pocket Guide:
● To review and remember the content of a health history.
● To review and rehearse the techniques of examination. This can be
done while learning a single section and again while combining the
approaches to several body systems or regions into an integrated
examination (see Chap. 1).
● To review common variations of normal and selected abnormalities.
Observations are keener and more precise when the examiner knows
what to look, listen, and feel for.
● To look up special techniques as the need arises. Maneuvers such
as The Timed Get Up and Go test are included in the Special
Techniques sections in each chapter.
● To look up additional information about possible findings, including
abnormalities and standards of normal.
The Pocket Guide is not intended to serve as a primary text for learn-
ing the skills of history taking or physical examination. Its detail is too
brief for these purposes. It is intended instead as an aid for student
review and recall and as a convenient, brief, and portable reference.
vii

C o n t e n t s
1 Overview: Physical Examination
and History Taking 1
2 Clinical Reasoning, Assessment, and
Recording Your Findings 15
3 Interviewing and the Health History 31
4 Beginning the Physical Examination: General
Survey, Vital Signs, and Pain 49
5 Behavior and Mental Status 67
6 The Skin, Hair, and Nails 83
7 The Head and Neck 99
8 The Thorax and Lungs 127
9 The Cardiovascular System 147
10 The Breasts and Axillae 167
11 The Abdomen 179
12 The Peripheral Vascular System 199
13 Male Genitalia and Hernias 211
14 Female Genitalia 225
15 The Anus, Rectum, and Prostate 241
16 The Musculoskeletal System 251
17 The Nervous System 285
18 Assessing Children: Infancy Through
Adolescence 323
19 The Pregnant Woman 359
20 The Older Adult 373
Index 395
ix

1
C H A P T E R
1Overview: Physical
Examination and
History Taking
This chapter provides a road map to clinical proficiency in two critical
areas: the health history and the physical examination.
For adults, the comprehensive history includes Identifying Data
and Source of the History, Chief Complaint(s), Present Illness, Past
History, Family History, Personal and Social History, and Review of
Systems. New patients in the office or hospital merit a comprehensive
health history; however, in many situations, a more flexible focused,
or problem-oriented, interview is appropriate. The components of the
comprehensive health history structure the patient’s story and the
format of your written record, but the order shown below should
not dictate the sequence of the interview. The interview is more
fluid and should follow the patient’s leads and cues, as described in
Chapter 3.
Over view: Components of the Adult Health History
Identifying Data ◗ Identifying data—such as age, gender, occupation,
marital status
◗ Source of the history—usually the patient, but can be
a family member or friend, letter of referral, or the
medical record
◗ If appropriate, establish source of referral because a
written report may be needed
Reliability ◗ Varies according to the patient’s memory, trust, and
mood
Chief Complaint(s) ◗ The one or more symptoms or concerns causing the
patient to seek care
(continued)

2 Bates’ Pocket Guide to Physical Examination and History Taking
Be sure to distinguish subjective from objective data. Decide if your
assessment will be comprehensive or focused.
Over view: Components of the Adult Health History (continued)
Present Illness ◗ Amplifies the Chief Complaint; describes how each
symptom developed
◗ Includes patient’s thoughts and feelings about the
illness
◗ Pulls in relevant portions of the Review of Systems,
called “pertinent positives and negatives” (see p. 3)
◗ May include medications, allergies, habits of smoking
and alcohol, which frequently are pertinent to the
present illness
Past History ◗ Lists childhood illnesses
◗ Lists adult illnesses with dates for at least four
categories: medical, surgical, obstetric/gynecologic,
and psychiatric
◗ Includes health maintenance practices such as
immunizations, screening tests, lifestyle issues, and
home safety
Family History ◗ Outlines or diagrams age and health, or age and cause
of death, of siblings, parents, and grandparents
◗ Documents presence or absence of specific illnesses
in family, such as hypertension, coronary artery
disease, etc.
Personal and Social
History
◗ Describes educational level, family of origin, current
household, personal interests, and lifestyle
Review of Systems ◗ Documents presence or absence of common symp-
toms related to each major body system
Subjective Data Objective Data
What the patient tells you What you detect during the examination
The history, from Chief Complaint
through Review of Systems
All physical examination findings
The Comprehensive Adult Health History
As you elicit the adult health history, be sure to include the following:
date and time of history; identifying data, which include age, gender,
marital status, and occupation; and reliability, which reflects the quality
of information the patient provides.
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Chapter 1 | Overview: Physical Examination and History Taking 3
CHIEF COMPLAINT(S)
Quote the patient’s own words. “My stomach hurts and I feel awful”;
or “I have come for my regular check-up.”
PRESENT ILLNESS
This section is a complete, clear, and chronologic account of the prob-
lems prompting the patient to seek care. It should include the prob-
lem’s onset, the setting in which it has developed, its manifestations,
and any treatments.
Every principal symptom should be well characterized, with descrip-
tions of the seven features listed below and pertinent positives and
negatives from relevant areas of the Review of Systems that help clarify
the differential diagnosis.
The Seven Attributes of Every Symptom
◗ Location
◗ Quality
◗ Quantity or severity
◗ Timing, including onset, duration, and frequency
◗ Setting in which it occurs
◗ Aggravating and relieving factors
◗ Associated manifestations
In addition, list medications, including name, dose, route, and frequency
of use; allergies, including specific reactions to each medication; tobacco
use; and alcohol and drug use.
HISTORY
List childhood illnesses, then list adult illnesses in each of four areas:
● Medical (e.g., diabetes, hypertension, hepatitis, asthma, HIV),
with dates of onset; also information about hospitalizations
with dates; number and gender of sexual partners; risky sexual
practices
● Surgical (dates, indications, and types of operations)

4 Bates’ Pocket Guide to Physical Examination and History Taking
● Obstetric/gynecologic (obstetric history, menstrual history, birth
control, and sexual function)
● Psychiatric (illness and time frame, diagnoses, hospitalizations, and
treatments)
Also discuss Health Maintenance, including immunizations, such as
tetanus, pertussis, diphtheria, polio, measles, rubella, mumps, influenza,
varicella, hepatitis B, Haemophilus influenzae type b, pneumococcal
vaccine, and herpes zoster vaccine; and screening tests, such as tuber-
culin tests, Pap smears, mammograms, stool tests, for occult blood
colonoscopy, and cholesterol tests, together with the results and the
dates they were last performed.
FAMILY HISTORY
Outline or diagram the age and health, or age and cause of death, of
each immediate relative, including grandparents, parents, siblings,
children, and grandchildren. Record the following conditions as either
present or absent in the family: hypertension, coronary artery disease, ele-
vated cholesterol levels, stroke, diabetes, thyroid or renal disease, cancer
(specify type), arthritis, tuberculosis, asthma or lung disease, headache,
seizure disorder, mental illness, suicide, alcohol or drug addiction, and
allergies, as well as conditions that the patient reports.
PERSONAL AND SOCIAL HISTORY
Include occupation and the last year of schooling; home situation and
significant others; sources of stress, both recent and long term; impor-
tant life experiences, such as military service; leisure activities; religious
affiliation and spiritual beliefs; and activities of daily living (ADLs).
Also include lifestyle habits such as exercise and diet, safety measures,
and alternative health care practices.
REVIEW OF SYSTEMS (ROS)
These “yes/no” questions go from “head to toe” and conclude the inter-
view. Selected sections can also clarify the Chief Complaint; for example,
the respiratory ROS helps characterize the symptom of cough. Start with
a fairly general question. This allows you to shift to more specific ques-
tions about systems that may be of concern. For example, “How are your
ears and hearing?” “How about your lungs and breathing?” “Any trouble

Chapter 1 | Overview: Physical Examination and History Taking 5
with your heart?” “How is your digestion?” The Review of Systems ques-
tions may uncover problems that the patient overlooked. Remember to move
major health events to the Present Illness or Past History in your write-up.
Some clinicians do the Review of Systems during the physical examination.
If the patient has only a few symptoms, this combination can be efficient
but may disrupt the flow of both the history and the examination.
General. Usual weight, recent weight change, clothing that fits
more tightly or loosely than before; weakness, fatigue, fever.
Skin. Rashes, lumps, sores, itching, dryness, color change; changes
in hair or nails; changes in size or color of moles.
Head, Eyes, Ears, Nose, Throat (HEENT). Head: Headache, head
injury, dizziness, lightheadedness. Eyes: Vision, glasses or contact
lenses, last examination, pain, redness, excessive tearing, double or
blurred vision, spots, specks, flashing lights, glaucoma, cataracts.
Ears: Hearing, tinnitus, vertigo, earache, infection, discharge. If hear-
ing is decreased, use or nonuse of hearing aid. Nose and sinuses: Fre-
quent colds, nasal stuffiness, discharge or itching, hay fever, nosebleeds,
sinus trouble. Throat (or mouth and pharynx): Condition of teeth
and gums; bleeding gums; dentures, if any, and how they fit; last dental
examination; sore tongue; dry mouth; frequent sore throats; hoarseness.
Neck. Lumps, “swollen glands,” goiter, pain, stiffness.
Breasts. Lumps, pain or discomfort, nipple discharge, self-examination
practices.
Respiratory. Cough, sputum (color, quantity), hemoptysis, dyspnea,
wheezing, pleurisy, last chest x-ray. You may wish to include asthma,
bronchitis, emphysema, pneumonia, and tuberculosis.
Cardiovascular. “Heart trouble,” hypertension, rheumatic fever,
heart murmurs, chest pain or discomfort, palpitations, dyspnea,
orthopnea, paroxysmal nocturnal dyspnea, edema, past electrocardio-
graphic or other cardiovascular tests.
Gastrointestinal. Trouble swallowing, heartburn, appetite, nausea.
Bowel movements, color and size of stools, change in bowel habits,
rectal bleeding or black or tarry stools, hemorrhoids, constipation,
diarrhea. Abdominal pain, food intolerance, excessive belching or
passing of gas. Jaundice, liver or gallbladder trouble, hepatitis.

6 Bates’ Pocket Guide to Physical Examination and History Taking
Peripheral Vascular. Intermittent claudication; leg cramps; varicose
veins; past clots in veins; swelling in calves, legs, or feet; color change in
fingertips or toes during cold weather; swelling with redness or tenderness.
Urinary. Frequency of urination, polyuria, nocturia, urgency, burn-
ing or pain on urination, hematuria, urinary infections, kidney stones,
incontinence; in males, reduced caliber or force of urinary stream,
hesitancy, dribbling.
Genital. Male: Hernias, discharge from or sores on penis, testicu-
lar pain or masses, history of sexually transmitted infections (STIs) or
diseases (STDs) and treatments, testicular self-examination practices.
Sexual habits, interest, function, satisfaction, birth control methods,
condom use, problems. Concerns about HIV infection. Female: Age
at menarche; regularity, frequency, and duration of periods; amount of
bleeding, bleeding between periods or after intercourse, last menstrual
period; dysmenorrhea, premenstrual tension. Age at menopause, meno-
pausal symptoms, postmenopausal bleeding. In patients born before
1971, exposure to diethylstilbestrol (DES) from maternal use during
pregnancy. Vaginal discharge, itching, sores, lumps, STIs and treat-
ments. Number of pregnancies, number and type of deliveries, number
of abortions (spontaneous and induced), complications of pregnancy,
birth control methods. Sexual preference, interest, function, satisfaction,
problems (including dyspareunia). Concerns about HIV infection.
Musculoskeletal. Muscle or joint pain, stiffness, arthritis, gout,
backache. If present, describe location of affected joints or muscles,
any swelling, redness, pain, tenderness, stiffness, weakness, or limita-
tion of motion or activity; include timing of symptoms (e.g., morn-
ing or evening), duration, and any history of trauma. Neck or low
back pain. Joint pain with systemic features such as fever, chills, rash,
anorexia, weight loss, or weakness.
Psychiatric. Nervousness; tension; mood, including depression,
memory change, suicide attempts, if relevant.
Neurologic. Changes in mood, attention, or speech; changes in ori-
entation, memory, insight, or judgment; headache, dizziness, vertigo;
fainting, blackouts, seizures, weakness, paralysis, numbness or loss of
sensation, tingling or “pins and needles,” tremors or other involuntary
movements, seizures.
Hematologic. Anemia, easy bruising or bleeding, past transfusions,
transfusion reactions.

Chapter 1 | Overview: Physical Examination and History Taking 7
Endocrine. “Thyroid trouble,” heat or cold intolerance, excessive
sweating, excessive thirst or hunger, polyuria, change in glove or shoe size.
The Physical Examination:
Approach and Overview
Conduct a comprehensive physical examination on most new patients or
patients being admitted to the hospital. For more problem-oriented, or
focused, assessments, the presenting complaints will dictate which segments
you elect to perform.
● The key to a thorough and accurate physical examination is a sys-
tematic sequence of examination. With effort and practice, you will
acquire your own routine sequence. This book recommends exam-
ining from the patient’s right side.
● Apply the techniques of inspection, palpation, auscultation, and per-
cussion to each body region, but be sensitive to the whole patient.
● Minimize the number of times you ask the patient to change position
from supine to sitting, or standing to lying supine.
● For an overview of the physical examination, study the sequence
that follows. Note that clinicians vary in where they place different
segments, especially for the musculoskeletal and nervous systems.
BEGINNING THE EXAMINATION:
SET TING THE STAGE
Take the following steps to prepare for the physical examination.
Preparing for the Physical Examination
◗ Reflect on your approach to the patient.
◗ Adjust the lighting and the environment.
◗ Make the patient comfortable.
◗ Determine the scope of the examination.
◗ Choose the sequence of the examination.
◗ Observe the correct examining position (the patient’s right side) and handedness.
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AAAppprrrooacchhh annddd OOveervieewww
Think through your approach, your professional demeanor, and how
to make the patient comfortable and relaxed. Always wash your hands
in the patient’s presence before beginning the examination.

8 Bates’ Pocket Guide to Physical Examination and History Taking
The Physical Examination: Suggested Sequence and Positioning
◗ General survey
◗ Vital signs
◗ Skin: upper torso, anterior and
posterior
◗ Head and neck, including
thyroid and lymph nodes
◗ Optional: Nervous system
(mental status, cranial
nerves, upper extremity motor
strength, bulk, tone, cerebellar
function)
◗ Thorax and lungs
◗ Breasts
◗ Musculoskeletal as indicated:
upper extremities
◗ Cardiovascular, including JVP,
carotid upstrokes and bruits,
PMI, etc.
◗ Cardiovascular, for S3 and
murmur of mitral stenosis
◗ Nervous system: lower
extremity motor strength,
bulk, tone, sensation;
reflexes; Babinskis
◗ Musculoskeletal, as indicated
◗ Optional: Skin, anterior and
posterior
◗ Optional: Nervous system,
including gait
◗ Optional: Musculoskeletal,
comprehensive
◗ Women: Pelvic and rectal
examination
◗ Men: Prostate and rectal
examination
◗ Cardiovascular, for murmur of
aortic insufficiency
◗ Optional: Thorax and lungs—
anterior
◗ Breasts and axillae
◗ Abdomen
◗ Peripheral vascular; Optional:
Skin—lower torso and
extremities
Key to the Symbols for the Patient’s Position
Sitting
Lying supine, with head
of bed raised 30 degrees
Same, turned partly to
left side
Standing
Lying supine, with hips flexed,
abducted, and externally rotated,
and knees flexed (lithotomy
position)
Lying on the left side (left lateral
decubitus)
Sitting, leaning forward
Lying supine
Each symbol pertains until a new one appears. Two symbols separated by a slash
indicate either or both positions.

Chapter 1 | Overview: Physical Examination and History Taking 9
Reflect on Your Approach to the Patient. Identify yourself as a
student. Try to appear calm, organized, and competent, even if you
feel differently. If you forget to do part of the examination, this is
not uncommon, especially at first! Simply examine that area out of
sequence, but smoothly.
Adjust Lighting and the Environment. Adjust the bed to a
convenient height (be sure to lower it when finished!). Ask the
patient to move toward you if this makes it easier to do your
physical examination. Good lighting and a quiet environment are
important. Tangential lighting is optimal for structures such as the
jugular venous pulse, the thyroid gland, and the apical impulse of
the heart. It throws contours, elevations, and depressions, whether
moving or stationary, into sharper relief.
Make the Patient Comfortable. Show concern for privacy and
modesty.
● Close nearby doors and draw curtains before beginning.
● Acquire the art of draping the patient with the gown or draw sheet
as you learn each examination segment in future chapters. Your goal
is to visualize one body area at a time.
● As you proceed, keep the patient informed, especially when you antic-
ipate embarrassment or discomfort, as when checking for the femoral
pulse. Also try to gauge how much the patient wants to know.
● Make sure your instructions to the patient at each step are courteous
and clear.
● Watch the patient’s facial expression and even ask “Is it okay?” as
you move through the examination.
When you have finished, tell the patient your general impressions and
what to expect next. Lower the bed to avoid risk of falls and raise the
bedrails if needed. As you leave, clean your equipment, dispose of
waste materials, and wash your hands.
Determine the Scope of the Examination. Comprehensive or
Focused? Choose whether to do a comprehensive or focused examination.

10 Bates’ Pocket Guide to Physical Examination and History Taking
Choose the Sequence of the Examination. The sequence of the
examination should
● maximize the patient’s comfort
● avoid unnecessary changes in position, and
● enhance the clinician’s efficiency.
In general, move from “head to toe.” An important goal as a student
is to develop your own sequence with these principles in mind. See
Chapter 1 of the textbook for a suggested examination sequence.
Observe the Correct Examining Position and Handedness. Examine
the patient from the patient’s right side. Note that it is more reliable
to estimate jugular venous pressure from the right, the palpating hand
rests more comfortably on the apical impulse, the right kidney is more
frequently palpable than the left, and examining tables are frequently
positioned to accommodate a right-handed approach. To examine the
supine patient, you can examine the head, neck, and anterior chest.
Then roll the patient onto each side to listen to the lungs, examine the
back, and inspect the skin. Roll the patient back and finish the rest of
the examination with the patient again supine.
The Comprehensive Adult Physical
Examination
General Survey. Continue this survey throughout the patient visit.
Observe general state of health, height, build, and sexual develop-
ment. Note posture, motor activity, and gait; dress, grooming, and
personal hygiene; and any odors of the body or breath. Watch facial
expressions and note manner, affect, and reactions to persons and
things in the environment. Listen to the patient’s manner of speaking
and note the state of awareness or level of consciousness.
Vital Signs. Ask the patient to sit on the edge of the bed or exam-
ining table, unless this position is contraindicated. Stand in front of the
patient, moving to either side as needed. Measure the blood pressure.
Count pulse and respiratory rate. If indicated, measure body temperature.
Skin. Observe the face. Identify any lesions, noting their location,
distribution, arrangement, type, and color. Inspect and palpate the hair
and nails. Study the patient’s hands. Continue to assess the skin as you
examine the other body regions.
TTThee CCCoommpppreeheennsivvee AAduuult Phhyssicaal
EEExaammminaattiionn

Chapter 1 | Overview: Physical Examination and History Taking 11
HEENT. Darken the room to promote pupillary dilation and vis-
ibility of the fundi. Head: Examine the hair, scalp, skull, and face.
Eyes: Check visual acuity and screen the visual fields. Note position
and alignment of the eyes. Observe the eyelids. Inspect the sclera and
conjunctiva of each eye. With oblique lighting, inspect each cornea,
iris, and lens. Compare the pupils, and test their reactions to light.
Assess extraocular movements. With an ophthalmoscope, inspect the
ocular fundi. Ears: Inspect the auricles, canals, and drums. Check
auditory acuity. If acuity is diminished, check lateralization (Weber
test) and compare air and bone conduction (Rinne test). Nose and
sinuses: Examine the external nose; using a light and nasal speculum,
inspect nasal mucosa, septum, and turbinates. Palpate for tenderness
of the frontal and maxillary sinuses. Throat (or mouth and pharynx):
Inspect the lips, oral mucosa, gums, teeth, tongue, palate, tonsils, and
pharynx. (You may wish to assess the Cranial Nerves at this point in the
examination.)
Neck. Move behind the sitting patient to feel the thyroid gland and
to examine the back, posterior thorax, and lungs. Inspect and palpate
the cervical lymph nodes. Note any masses or unusual pulsations in the
neck. Feel for any deviation of the trachea. Observe sound and effort
of the patient’s breathing. Inspect and palpate the thyroid gland.
Back. Inspect and palpate the spine and muscles.
Posterior Thorax and Lungs. Inspect and palpate the spine and
muscles of the upper back. Inspect, palpate, and percuss the chest.
Identify the level of diaphragmatic dullness on each side. Listen to the
breath sounds; identify any adventitious (or added) sounds, and, if
indicated, listen to transmitted voice sounds (see p. 133).
Breasts, Axillae, and Epitrochlear Nodes. The patient is still sit-
ting. Move to the front again. In a woman, inspect the breasts with
patient’s arms relaxed, then elevated, and then with her hands pressed
on her hips. In either sex, inspect the axillae and feel for the axillary
nodes; feel for the epitrochlear nodes.
A Note on the Musculoskeletal System. By now, you have made pre-
liminary observations of the musculoskeletal system, including
the hands, the upper back, and, in women, the shoulders’ range
of motion (ROM). Use these observations to decide whether a full
musculoskeletal examination is warranted: With the patient still sitting,
examine the hands, arms, shoulders, neck, and temporomandibular
joints. Inspect and palpate the joints and check their ROM.

12 Bates’ Pocket Guide to Physical Examination and History Taking
(You may choose to examine upper extremity muscle bulk, tone, strength,
and reflexes at this time, or you may decide to wait until later.)
Palpate the breasts, while continuing your inspection.
Anterior Thorax and Lungs. The patient position is supine.
Ask the patient to lie down. Stand at the right side of the patient’s bed.
Inspect, palpate, and percuss the chest. Listen to the breath sounds,
any adventitious sounds, and, if indicated, transmitted voice sounds.
Cardiovascular System. Elevate head of bed to about
30 degrees, adjusting as necessary to see the jugular venous pulsa-
tions. Observe the jugular venous pulsations, and measure the jugular
venous pressure in relation to the sternal angle. Inspect and palpate
the carotid pulsations. Listen for carotid bruits.
/ Ask the patient to roll partly onto the left side while you
listen at the apex. Then have the patient roll back to supine while you
listen to the rest of the heart. Ask the patient to sit, lean forward, and
exhale while you listen for the murmur of aortic regurgitation. Inspect
and palpate the precordium. Note the location, diameter, amplitude,
and duration of the apical impulse. Listen at the apex and the lower
sternal border with the bell of a stethoscope. Listen at each ausculta-
tory area with the diaphragm. Listen for S1 and S2 and for physiologic
splitting of S2. Listen for any abnormal heart sounds or murmurs.
Abdomen. Lower the head of the bed to the flat position. The
patient should be supine. Inspect, auscultate, and percuss. Palpate lightly,
then deeply. Assess the liver and spleen by percussion and then palpation.
Try to feel the kidneys; palpate the aorta and its pulsations. If you suspect
kidney infection, percuss posteriorly over the costovertebral angles.
/ Peripheral Vascular System. With the patient supine,
palpate the femoral pulses and, if indicated, popliteal pulses. Palpate
the inguinal lymph nodes. Inspect for edema, discoloration, or ulcers
in the lower extremities. Palpate for pitting edema. With the patient
standing, inspect for varicose veins.
/ Lower Extremities. Examine the legs, assessing the three
systems (see next page) while the patient is still supine. Each of these
systems can be further assessed when the patient stands.
/ Nervous System. The patient is sitting or supine. The exami-
nation of the nervous system can also be divided into the upper extremity

Chapter 1 | Overview: Physical Examination and History Taking 13
examination (when the patient is still sitting) and the lower extremity
examination (when the patient is supine) after examination of the
peripheral nervous system.
Mental Status. If indicated and not done during the interview, assess
orientation, mood, thought process, thought content, abnormal per-
ceptions, insight and judgment, memory and attention, information
and vocabulary, calculating abilities, abstract thinking, and construc-
tional ability.
Cranial Nerves. If not already examined, check sense of smell, fun-
duscopic examination, strength of the temporal and masseter muscles,
corneal reflexes, facial movements, gag reflex, strength of the trapezia
and sternomastoid muscles, and protrusion of tongue.
Motor System. Muscle bulk, tone, and strength of major muscle
groups. Cerebellar function: rapid alternating movements (RAMs),
point-to-point movements such as finger to nose (F → N) and heel
to shin (H → S); gait. Observe patient’s gait and ability to walk heel
to toe, on toes, and on heels; to hop in place; and to do shallow knee
bends. Do a Romberg test; check for pronator drift.
Sensory System. Pain, temperature, light touch, vibrations, and
discrimination. Compare right and left sides and distal with proximal
areas on the limbs.
Reflexes. Include biceps, triceps, brachioradialis, patellar, Achilles
deep tendon reflexes; also plantar reflexes or Babinski reflex (see
pp. 301–303).
Additional Examinations. The rectal and genital examinations are
often performed at the end of the physical examination.
/ Male Genitalia and Hernias. Examine the penis and scrotal
contents. Check for hernias.
Rectal Examination in Men. The patient is lying on his left side
for the rectal examination. Inspect the sacrococcygeal and perianal
areas. Palpate the anal canal, rectum, and prostate. (If the patient can-
not stand, examine the genitalia before doing the rectal examination.)
Genital and Rectal Examination in Women. The patient is
supine in the lithotomy position. Sit during the examination with
the speculum, then stand during bimanual examination of uterus,

14 Bates’ Pocket Guide to Physical Examination and History Taking
adnexa, and rectum. Examine the external genitalia, vagina, and cervix.
Obtain a Pap smear. Palpate the uterus and adnexa. Do a bimanual and
rectal examination.
Standard and Universal Precautions
The Centers for Disease Control and Prevention (CDC) have issued
several guidelines to protect patients and examiners from the spread
of infectious disease. All clinicians examining patients are well advised
to study and observe these precautions at the CDC Web sites. Advi-
sories for standard and methicillin-resistant Staphylococcus aureus
(MRSA) precautions and for universal precautions are briefly sum-
marized below.
● Standard and MRSA precautions: Standard precautions are based on
the principle that all blood, body fluids, secretions, excretions except
sweat, nonintact skin, and mucous membranes may contain trans-
missible infectious agents. These practices apply to all patients in any
setting. They include hand hygiene; when to use gloves, gowns, and
mouth, nose, and eye protection; respiratory hygiene and cough eti-
quette; patient isolation criteria; precautions relating to equipment,
toys and solid surfaces, and handling of laundry; and safe needle-
injection practices.
Be sure to wash your hands before and after examining the patient.
This will show your concern for the patient’s welfare and display
your awareness of a critical component of patient safety. Antimicro-
bial fast-drying soaps are often within easy reach. Change your white
coat frequently, because cuffs can become damp and smudged and
transmit bacteria.
● Universal precautions: Universal precautions are a set of precautions
designed to prevent transmission of HIV, hepatitis B virus (HBV), and
other blood-borne pathogens when providing first aid or health care.
The following fluids are considered potentially infectious: all blood
and other body fluids containing visible blood, semen, and vaginal
secretions; and cerebrospinal, synovial, pleural, peritoneal, pericardial,
and amniotic fluids. Protective barriers include gloves, gowns, aprons,
masks, and protective eyewear. All health care workers should observe
the important precautions for safe injections and prevention of injury
from needlesticks, scalpels, and other sharp instruments and devices.
Report to your health service immediately if such injury occurs.
SSStaannddarrd anndd UUnivveerssal Prrecaautioonss

15
C H A P T E R
2Clinical Reasoning,
Assessment, and
Recording Your Findings
Assessment and Plan: the Process of
Clinical Reasoning
Because assessment takes place in the clinician’s mind, the process
of clinical reasoning often seems inaccessible to beginning students.
As an active learner, ask your teachers and clinicians to elaborate on
the fine points of their clinical reasoning and decision making.
As you gain experience, your clinical reasoning will begin at the outset
of the patient encounter, not at the end. Listed below are principles
underlying the process of clinical reasoning and certain explicit steps
to help guide your thinking.
Identifying Problems and Making Diagnoses:
Steps in Clinical Reasoning
◗ Identify abnormal findings. Make a list of the patient’s symptoms,
the signs you observed during the physical examination, and available
laboratory reports.
◗ Localize these findings anatomically. The symptom of a scratchy throat and
the sign of an erythematous inflamed pharynx, for example, clearly localize
the problem to the pharynx. Some symptoms and signs, such as fatigue or
fever, cannot be localized but are useful in the next steps.
◗ Interpret the findings in terms of the probable process. There are a
number of pathologic processes, including congenital, inflammatory or
infectious, immunologic, neoplastic, metabolic, nutritional, degenerative,
vascular, traumatic, and toxic. Other problems are pathophysiologic, reflect-
ing derangements of biologic functions, such as heart failure. Still other
problems are psychopathologic, such as headache as an expression of a
somatization disorder.
(continued)
AAAssseessssmmeeentt aanndd PPllaan:: thhhe Proooceess off
CCCliniiccaal Reeeassooniinggg

16 Bates’ Pocket Guide to Physical Examination and History Taking
The Case of Mrs. N
Now study the case of Mrs. N. Scrutinize the findings recorded, apply
your clinical reasoning, and analyze the assessment and plan.
◗ Make hypotheses about the nature of the patient’s problems. Draw on
your knowledge, experience, and reading about patterns of abnormali-
ties and diseases. By consulting the clinical literature, you embark on
the lifelong goal of evidence-based decision making. The following steps
should help:
1. Select the most specific and critical findings to support your
hypothesis.
2. Match your findings against all the conditions you know that can produce
them.
3. Eliminate the diagnostic possibilities that fail to explain the findings.
4. Weigh the competing possibilities and select the most likely diagnosis.
5. Give special attention to potentially life-threatening and treatable
conditions. One rule of thumb is always to include “ the worst-case
scenario” in your list of differential diagnoses and make sure you
have ruled out that possibility based on your findings and patient
assessment.
◗ Test your hypotheses. You may need further history, additional maneuvers
on physical examination, or laboratory studies or x-rays to confirm or to rule
out your tentative diagnosis or to clarify which possible diagnosis is most
likely.
◗ Establish a working diagnosis. Make this at the highest level of explicitness
and certainty that the data allow. You may be limited to a symptom, such as
“tension headache, cause unknown.” At other times, you can define a prob-
lem explicitly in terms of its structure, process, and cause, such as “bacterial
meningitis, pneumococcal.” Routinely listing Health Maintenance helps you
track several important health concerns more effectively: immunizations,
screening measures (e.g., mammograms, prostate examinations), instruc-
tions regarding nutrition and breast or testicular self-examinations, recom-
mendations about exercise or use of seat belts, and responses to important
life events.
◗ Develop a plan agreeable to the patient. Identify and record a Plan for each
patient problem, ranging from tests to confirm or further evaluate a diagno-
sis; to consultations for subspecialty evaluation; to additions, deletions, or
changes in medication; or to arranging a family meeting.
Identifying Problems and Making Diagnoses:
Steps in Clinical Reasoning (continued)
TTThee CCCaasee oof MMrss. NN

Chapter 2 | Clinical Reasoning, Assessment, and Recording Your Findings 17
Health History
8/25/12 11:00 am
Mrs. N is a pleasant, 54-year-old widowed saleswoman residing in Espanola,
New Mexico.
Referral. None
Source and Reliability. Self-referred; seems reliable.
Chief Complaint: “My head aches.”
Present Illness: For about 3 months, Mrs. N has had increasing problems with
frontal headaches. These are usually bifrontal, throbbing, and mild to moder-
ately severe. She has missed work on several occasions because of associated
nausea and vomiting. Headaches now average once a week, usually are related
to stress, and last 4 to 6 hours. They are relieved by sleep and putting a damp
towel over the forehead. There is little relief from aspirin. No associated visual
changes, motor-sensory deficits, or paresthesias.
“Sick headaches” with nausea and vomiting began at age 15, recurred
throughout her mid-20s, then decreased to one every 2 or 3 months and
almost disappeared.
The patient reports increased pressure at work from a new and demanding
boss; she is also worried about her daughter (see Personal and Social History).
She thinks her headaches may be like those in the past but wants to be sure,
because her mother died following a stroke. She is concerned that they inter-
fere with her work and make her irritable with her family. She eats three meals
a day and drinks three cups of coffee a day and tea at night.
Medications. Aspirin, 1 to 2 tablets every 4 to 6 hours as needed. “Water
pill” in the past for ankle swelling, none recently.
*Allergies. Ampicillin causes rash.
Tobacco. About 1 pack of cigarettes per day since age 18 (36 pack-years).
Alcohol/drugs. Wine on rare occasions. No illicit drugs.
Past History
Childhood Illnesses. Measles, chickenpox. No scarlet fever or rheumatic fever.
Adult Illnesses. Medical: Pyelonephritis, 1998, with fever and right flank
pain; treated with ampicillin; developed generalized rash with itching
several days later. Reports x-rays were normal; no recurrence of infection.
Surgical: Tonsillectomy, age 6; appendectomy, age 13. Sutures for laceration,
2001, after stepping on glass. Ob/Gyn: 3-3-0-3, with normal vaginal deliver-
ies. Three living children. Menarche age 12. Last menses 6 months ago. Little
interest in sex, and not sexually active. No concerns about HIV infection.
Psychiatric: None.
Health Maintenance. Immunizations: Oral polio vaccine, year uncertain;
tetanus shots × 2, 1991, followed with booster 1 year later; flu vaccine, 2000,
no reaction. Screening tests: Last Pap smear, 2008, normal. No mammograms
to date.
*You may wish to add an asterisk or underline important points.
(continued)

18 Bates’ Pocket Guide to Physical Examination and History Taking
Family History
Train accident Stroke, varicose veins, headaches
43 67
High
blood
pressure
Heart
attack
Infancy
67 58 54
33 31 27
Headaches
Migraine
headaches
Indicates patient
Deceased male
Deceased female
Living male
Living female

OR
Father died at age 43 in train accident. Mother died at age 67 from stroke; had
varicose veins, headaches.
One brother, 61, with hypertension, otherwise well; second brother, 58, well
except for mild arthritis; one sister, died in infancy of unknown cause.
Husband died at age 54 of heart attack.
Daughter, 33, with migraine headaches, otherwise well; son, 31, with head-
aches; son, 27, well.
No family history of diabetes, tuberculosis, heart or kidney disease, cancer,
anemia, epilepsy, or mental illness.
Personal and Social History: Born and raised in Las Cruces, finished high
school, married at age 19. Worked as sales clerk for 2 years, then moved with
husband to Amarillo, had 3 children. Returned to work 15 years ago because of
financial pressures. Children all married. Four years ago, Mr. N died suddenly
of a heart attack, leaving little savings. Mrs. N has moved to small apartment
to be near her daughter, Isabel. Isabel’s husband, John, has an alcohol problem.
Mrs. N’s apartment now a haven for Isabel and her 2 children, Kevin, 6 years,
and Lucia, 3 years. Mrs. N feels responsible for helping them; feels tense and
nervous but denies depression. She has friends but rarely discusses family
problems: “I’d rather keep them to myself. I don’t like gossip.” No church or
other organizational support. She is typically up at 7:00 a.m., works 9:00 to
5:30, eats dinner alone.
Exercise and diet. Gets little exercise. Diet high in carbohydrates.
Safety measures. Uses seat belt regularly. Uses sunblock. Medications kept
in an unlocked medicine cabinet. Cleaning solutions in unlocked cabinet
below sink. Mr. N’s shotgun and box of shells in unlocked closet upstairs.
(continued)

Chapter 2 | Clinical Reasoning, Assessment, and Recording Your Findings 19
Review of Systems
General. *Has gained about 10 lbs in the past 4 years.
Skin. No rashes or other changes.
Head, Eyes, Ears, Nose, Throat (HEENT). See Present Illness. No history of head
injury. Eyes: Reading glasses for 5 years, last checked 1 year ago. No symptoms.
Ears: Hearing good. No tinnitus, vertigo, infections. Nose, sinuses: Occasional
mild cold. No hay fever, sinus trouble. *Throat (or mouth and pharynx): Some
bleeding of gums recently. Last dental visit 2 years ago. Occasional canker sore.
Neck. No lumps, goiter, pain. No swollen glands.
Breasts. No lumps, pain, discharge. Does breast self-exam sporadically.
Respiratory. No cough, wheezing, shortness of breath. Last chest x-ray, 1986,
St. Vincent’s Hospital; unremarkable.
Cardiovascular. No known heart disease or high blood pressure; last blood
pressure taken in 2006. No dyspnea, orthopnea, chest pain, palpitations. Has
never had an electrocardiogram (ECG).
Gastrointestinal. Appetite good; no nausea, vomiting, indigestion. Bowel
movement about once daily, *though sometimes has hard stools for 2 to 3 days
when especially tense; no diarrhea or bleeding. No pain, jaundice, gallbladder
or liver problems.
Urinary. No frequency, dysuria, hematuria, or recent flank pain; nocturia × 1,
large volume. *Occasionally loses some urine when coughs hard.
Genital. No vaginal or pelvic infections. No dyspareunia.
Peripheral Vascular. Varicose veins appeared in both legs during first preg-
nancy. For 10 years, has had swollen ankles after prolonged standing; wears
light elastic pantyhose; tried “water pill” 5 months ago, but it didn’t help much;
no history of phlebitis or leg pain.
Musculoskeletal. Mild, aching, low back pain, often after a long day’s work;
no radiation down the legs; used to do back exercises but not now. No other
joint pain.
Psychiatric. No history of depression or treatment for psychiatric disorders.
See also Present Illness and Personal and Social History.
Neurologic. No fainting, seizures, motor or sensory loss. Memory good.
Hematologic. Except for bleeding gums, no easy bleeding. No anemia.
Endocrine. No known thyroid trouble, temperature intolerance. Sweating
average. No symptoms or history of diabetes.
Physical Examination
Mrs. N is a short, overweight, middle-aged woman, who is animated and
responds quickly to questions. She is somewhat tense, with moist, cold
hands. Her hair is well-groomed. Her color is good, and she lies flat without
discomfort.
Vital Signs. Ht (without shoes) 157 cm (5′2″ ). Wt (dressed) 65 kg (143 lb).
BMI 26. BP 164/98 right arm, supine; 160/96 left arm, supine; 152/88 right arm,
supine with wide cuff. Heart rate (HR) 88 and regular. Respiratory rate (RR) 18.
Temperature (oral) 98.6°F.
(continued)

20 Bates’ Pocket Guide to Physical Examination and History Taking
Skin. Palms cold and moist, but color good. Scattered cherry angiomas over
upper trunk. Nails without clubbing, cyanosis.
Head, Eyes, Ears, Nose, Throat (HEENT). Head: Hair of average texture.
Scalp without lesions, normocephalic/atraumatic (NC/AT). Eyes: Vision 20/30
in each eye. Visual fields full by confrontation. Conjunctiva pink; sclera white.
Pupils 4 mm constricting to 2 mm, round, regular, equally reactive to light.
Extraocular movements intact. Disc margins sharp, without hemorrhages,
exudates. No arteriolar narrowing or A-V nicking. Ears: Wax partially obscures
right tympanic membrane (TM); left canal clear, TM with good cone of light. Acu-
ity good to whispered voice. Weber midline. AC > BC. Nose: Mucosa pink, septum
midline. No sinus tenderness. Mouth: Oral mucosa pink. Several interdental
papillae red, slightly swollen. Dentition good. Tongue midline, with 3 × 4 mm
shallow white ulcer on red base on undersurface near tip; tender but not indu-
rated. Tonsils absent. Pharynx without exudates.
Neck. Neck supple. Trachea midline. Thyroid isthmus barely palpable, lobes not felt.
Lymph Nodes. Small (<1 cm), soft, nontender, and mobile tonsillar and poste- rior cervical nodes bilaterally. No axillary or epitrochlear nodes. Several small inguinal nodes bilaterally, soft and nontender. Thorax and Lungs. Thorax symmetric with good excursion. Lungs resonant. Breath sounds vesicular with no added sounds. Diaphragms descend 4 cm bilaterally. Cardiovascular. Jugular venous pressure 1 cm above the sternal angle, with head of examining table raised to 30°. Carotid upstrokes brisk, without bruits. Apical impulse discrete and tapping, barely palpable in the 5th left interspace, 8 cm lateral to the midsternal line. Good S1, S2; no S3 or S4. A II/VI medium- pitched midsystolic murmur at the 2nd right interspace; does not radiate to the neck. No diastolic murmurs. Breasts. Pendulous, symmetric. No masses; nipples without discharge. Abdomen. Protuberant. Well-healed scar, right lower quadrant. Bowel sounds active. No tenderness or masses. Liver span 7 cm in right midclavicular line; edge smooth, palpable 1 cm below right costal margin (RCM). Spleen and kidneys not felt. No costovertebral angle tenderness (CVAT). Genitalia. External genitalia without lesions. Mild cystocele at introitus on straining. Vaginal mucosa pink. Cervix pink, parous, and without discharge. Uterus anterior, midline, smooth, not enlarged. Adnexa not palpated due to obesity and poor relaxation. No cervical or adnexal tenderness. Pap smear taken. Rectovaginal wall intact. Rectal. Rectal vault without masses. Stool brown, negative for occult blood. Extremities. Warm and without edema. Calves supple, nontender. Peripheral Vascular. Trace edema at both ankles. Moderate varicosities of saphenous veins in both lower extremities. No stasis pigmentation or ulcers. Pulses (2+ = brisk, or normal): Radial Femoral Popliteal Dorsalis Pedis Posterior Tibial RT 2+ 2+ 2+ 2+ 2+ LT 2+ 2+ 2+ 2+ 2+ (continued) Chapter 2 | Clinical Reasoning, Assessment, and Recording Your Findings 21 Musculoskeletal. No joint deformities. Good range of motion in hands, wrists, elbows, shoulders, spine, hips, knees, ankles. Neurologic. Mental Status: Tense but alert and cooperative. Thought coher- ent. Oriented to person, place, and time. Cranial Nerves: II–XII intact. Motor: Good muscle bulk and tone. Strength 5/5 throughout (see p. 295 for grading system). Cerebellar: Rapid alternating movements (RAMs), point- to-point movements intact. Gait stable, fluid. Sensory: Pinprick, light touch, position sense, vibration, and stereognosis intact. Romberg negative. Reflexes: Biceps Triceps Brachioradialis Patellar Achilles Plantar RT 2+ 2+ 2+ 2+ 1+ ↓ LT 2+ 2+ 2+ 2+/2+ 1+ ↓ OR Laboratory Data None Currently. See Plan. Assessment and Plan 1. Migraine headaches. A 54-year-old woman with migraine headaches since childhood, with a throbbing vascular pattern and frequent nausea and vomiting. Headaches are associated with stress and relieved by sleep and cold compresses. There is no papilledema, and there are no motor or sensory deficits on the neurologic examination. The differential diagnosis includes tension headache, also associated with stress, but there is no relief with massage, and the pain is more throbbing than aching. There are no fever, stiff neck, or focal findings to suggest meningitis, and the lifelong recurrent pattern makes subarachnoid hemorrhage unlikely (usually described as “the worst headache of my life”). (continued) ++ ++ ++ ++ ++ ++ ++ ++ ++ ++++ ++ + + _ _ 22 Bates’ Pocket Guide to Physical Examination and History Taking Assessment and Plan (continued) Plan: ◗ Discuss features of migraine vs. tension headaches. ◗ Discuss biofeedback and stress management. ◗ Advise patient to avoid caffeine, including coffee, colas, and other caf- feinated beverages. ◗ Start NSAIDs for headache, as needed. ◗ If needed next visit, begin prophylactic medication, because patient is having more than three migraines per month. 2. Elevated blood pressure. Systolic hypertension is present. May be related to anxiety from first visit. No evidence of end-organ damage to retina or heart. Plan: ◗ Discuss standards for assessing blood pressure. ◗ Recheck blood pressure in 1 month. ◗ Check basic metabolic panel; review urinalysis. ◗ Introduce weight reduction and/or exercise programs (see #4). ◗ Reduce salt intake. 3. Cystocele with occasional stress incontinence. Cystocele on pelvic exami- nation, probably related to bladder relaxation. Patient is perimenopausal. Incontinence reported with coughing, suggesting alteration in bladder neck anatomy. No dysuria, fever, flank pain. Not taking any contributing medica- tions. Usually involves small amounts of urine, no dribbling, so doubt urge or overflow incontinence. Plan: ◗ Explain cause of stress incontinence. ◗ Review urinalysis. ◗ Recommend Kegel exercises. ◗ Consider topical estrogen cream to vagina next visit if no improvement. 4. Overweight. Patient 5′2″, weighs 143 lb. BMI is ∼26. Plan: ◗ Explore diet history; ask patient to keep food intake diary. ◗ Explore motivation to lose weight; set target for weight loss by next visit. ◗ Schedule visit with dietitian. ◗ Discuss exercise program, specifically, walking 30 minutes most days each week. 5. Family stress. Son-in-law with alcohol problem; daughter and grand- children seeking refuge in patient’s apartment, leading to tensions in these relationships. Patient also has financial constraints. Stress currently situational. No evidence of major depression at present. Plan: ◗ Explore patient’s views on strategies to cope with stress. ◗ Explore sources of support, including Al-Anon for daughter and financial counseling for patient. ◗ Continue to monitor for depression. (continued) Chapter 2 | Clinical Reasoning, Assessment, and Recording Your Findings 23 Assessment and Plan (continued) 6. Occasional musculoskeletal low back pain. Usually with prolonged standing. No history of trauma or motor vehicle accident. Pain does not radiate; no tenderness or motor-sensory deficits on examination. Doubt disc or nerve root compression, trochanteric bursitis, sacroiliitis. Plan: ◗ Review benefits of weight loss and exercises to strengthen low back muscles. 7. Tobacco abuse. 1 pack per day for 36 years. Plan: ◗ Check peak flow or FEV1/FVC on office spirometry. ◗ Give strong warning to stop smoking. ◗ Offer referral to tobacco cessation program. ◗ Offer patch, current treatment to enhance abstinence. 8. Varicose veins, lower extremities. No complaints currently. 9. History of right pyelonephritis, 1998. 10. Ampicillin allergy. Developed rash but no other allergic reaction. 11. Health maintenance. Last Pap smear 2004; has never had a mammogram. Plan: ◗ Teach patient breast self-examination; schedule mammogram. ◗ Schedule Pap smear next visit. ◗ Provide three stool guaiac cards; next visit discuss screening colonoscopy. ◗ Suggest dental care for mild gingivitis. ◗ Advise patient to move medications, caustic cleaning agents, gun and ammunition to locked cabinet—if possible, above shoulder height. Approaching the Challenges of Clinical Data As you can see from the case of Mrs. N, organizing the patient’s clini- cal data poses several challenges. The following guidelines will help you address these challenges. ● Clustering data into single vs. multiple problems. The patient’s age may help. Young people are more likely to have a single disease, while older people tend to have multiple diseases. The timing of symptoms is often useful. For example, an episode of pharyngitis 6 weeks ago probably is unrelated to fever, chills, pleuritic chest pain, and cough that prompt an office visit today. If symptoms and signs are in a single system, one disease may explain them. Problems in different, apparently unrelated systems often require more than one explanation. Again, knowledge of dis- ease patterns is necessary. AAAppprrrooacchhhing tthhe CCChhallleenggess off Cliniiccal DData 24 Bates’ Pocket Guide to Physical Examination and History Taking Some diseases involve multisystem conditions. To explain cough, hemoptysis, and weight loss in a 60-year-old plumber who has smoked cigarettes for 40 years, you probably even now would rank lung cancer high in your list of differential diagnoses. ● Sifting through an extensive array of data. Try to tease out sepa- rate clusters of observations and analyze one cluster at a time. You also can ask a series of key questions that may steer your thinking in one direction. For example, you may ask what produces and relieves the patient’s chest pain. If the answer is exercise and rest, you can focus on the cardiovascular and musculoskeletal systems and set the gastrointestinal system aside. ● Assessing the quality of the data. To avoid errors in interpreting clinical information, acquire the habits of skilled clinicians, summa- rized below. Tips for Ensuring the Quality of Patient Data ◗ Ask open-ended questions and listen carefully and patiently to the patient’s story. ◗ Craft a thorough and systematic sequence to history taking and physical examination. ◗ Keep an open mind toward the patient and the data. ◗ Always include “the worst-case scenario” in your list of possible explanations of the patient’s problem, and make sure it can be safely eliminated. ◗ Analyze any mistakes in data collection or interpretation. ◗ Confer with colleagues and review the pertinent medical literature to clarify uncertainties. ◗ Apply principles of data analysis to patient information and testing. ● Improving your assessment of clinical data and laboratory tests. Apply several key principles for selecting and using clinical data and tests: reliability, validity, sensitivity, specificity, and predictive value. Learn to apply these principles to your clinical findings and the tests you order. ● Displaying clinical data. To use these principles, it is important to display the data in the 2 × 2 format diagrammed on page 32. Always using this format will ensure the accuracy of your calculations of sensitivity, specificity, and predictive value. Chapter 2 | Clinical Reasoning, Assessment, and Recording Your Findings 25 Principles of Test Selection and Use Reliability: The reproducibility of a measurement. It indicates how well repeated measurements of the same relatively stable phenomenon will give the same result, also known as precision. Reliability may be measured for one observer or more observers. Example. If on several occasions one clinician consistently percusses the same span of a patient’s liver dullness, intraobserver reliability is good. If, on the other hand, several observers find quite different spans of liver dullness on the same patient, interobserver reliability is poor. Validity: The closeness with which a measurement reflects the true value of an object. It indicates how closely a given observation agrees with “the true state of affairs,” or the best possible measure of reality. Example. Blood pressure measurements by mercury-based sphygmoma- nometers are less valid than intra-arterial pressure tracings. Sensitivity: Identifies the proportion of people who test positive in a group of people known to have the disease or condition, or the proportion of people who are true positives compared with the total number of people who actu- ally have the disease. When the observation or test is negative in people who have the disease, the result is termed false negative. Good observations or tests have a sensitivity of more than 90% and when negative help “rule out” disease because false negatives are few. Such observations or tests are especially useful for screening. Example. The sensitivity of Homan’s sign in the diagnosis of deep venous thrombosis (DVT) of the calf is 50%. In other words, compared with a group of patients with DVT confirmed by venous ultrasound, a much bet- ter test, only 50% will have a positive Homan’s sign, so this sign, if absent, is not helpful, because 50% of patients may have DVT. Specificity: Identifies the proportion of people who test negative in a group known to be without a given disease or condition, or the proportion of people who are true negatives compared with the total number of people without the disease. When the observation or test is positive in people without the disease, the result is termed false positive. Good observations or tests have a specificity of more than 90% and help “rule in” disease, because the test is rarely positive when disease is absent, and false positives are few. Example: The specificity of serum amylase in patients with possible acute pancreatitis is 70%. In other words, of 100 patients without pancreatitis, 70% will have a normal serum amylase; in 30%, the serum amylase will be falsely elevated. Predictive value: Indicates how well a given symptom, sign, or test result— either positive or negative—predicts the presence or absence of disease. Positive predictive value is the probability of disease in a patient with a posi- tive (abnormal) test, or the proportion of “true positives” out of the total population with the disease. Negative predictive value is the probability of not having the condition or disease when the test is negative (normal), or (continued) 26 Bates’ Pocket Guide to Physical Examination and History Taking Principles of Test Selection and Use (continued) the proportion of “true negatives” out of the total population without the disease. Examples. In a group of women with palpable breast nodules in a cancer screening program, the proportion with confirmed breast cancer would con- stitute the positive predictive value of palpable breast nodules for diagnosing breast cancer. In a group of women without palpable breast nodules in a cancer screening program, the proportion without confirmed breast cancer constitutes the negative predictive value of absence of breast nodules. Sensitivity, specificity, and predictive values are illustrated in a 2 × 2 table, as shown below in an example of 200 people, half of whom have the disease in question. In this example, the disease prevalence of 50% is much higher than in most clinical situations. Because the positive predictive value increases with prevalence, its calculated value here is unusually high. Negative predictive value = = × 100 = 94.7% d c + d 90 90 + 5 Specificity = = × 100 = 90% d b + d 90 90 + 10 Sensitivity = Observation Disease Present Absent 100 total persons with the disease 100 total persons without the disease 200 total persons 95 true-positive observations 95 false-positive observations 105 total positive observations 95 total negative observations 90 true-negative observations 5 false-negative observations + – = × 100 = 95% a a + c 95 95 + 5 Positive predictive value = = × 100 = 90.5% a a + b 95 95 + 10 a b c d Likelihood ratio (LR): Conveys the odds that a finding occurs in a patient with the condition compared with a patient without the condition. When the LR is >1.0, the probability of the condition goes up; when the LR is < 1.0, the prob- ability of the condition goes down. (continued) Chapter 2 | Clinical Reasoning, Assessment, and Recording Your Findings 27 Principles of Test Selection and Use (continued) ◗ A positive LR = ◗ A negative LR = Example. The LR of a subarachnoid hemorrhage (SAH) is 10 if neck stiffness is present and 0.4 if neck stiffness is absent. The odds of SAH are 10 times higher if neck stiffness is present compared with patients without SAH. When neck stiffness is absent, the odds the patient has SAH are reduced by a factor of 0.4. For example, suppose the pre-test probability of SAH in the patient is 25% or a pre-test odds of 1:3. If the patient has neck stiffness, the post-test probability is revised upward by the LR to 77% (post-test odds of 10.3). If there is no neck stiffness, the post-test probability is revised downward by the negative LR to 12% (post-test odds of 4:30). (1 – sensitivity) specificity sensitivity (1 – specificity) Organizing the Patient Record A clear, well-organized clinical record is one of the most important adjuncts to your patient care. Think about the order and readability of the record and the amount of detail needed. Use the following check- list to make sure your record is clear, informative, and easy to follow. OOOrggaannizzinnng thhe Paattieennt RRReccorrdd Checklist for a Clear Patient Record Is the order clear? Order is imperative. Make sure that future readers, including you, can find specific points of information easily. Keep the subjective items of the history, for example, in the history; do not let them stray into the physical examina- tion. Did you . . . ◗ Make the headings clear? ◗ Accent your organization with indentations and spacing? ◗ Arrange the Present Illness in chronologic order, starting with the current episode, then filling in relevant background information? Do the data included contribute directly to the assessment? Spell out the supporting data—both positive and negative—for every problem or diagnosis that you identify. (continued) 28 Bates’ Pocket Guide to Physical Examination and History Taking Checklist for a Clear Patient Record (continued) (continued) Are pertinent negatives specifically described? Often portions of the history or examination suggest a potential or actual abnormality. Examples. For the patient with notable bruises, record the “pertinent nega- tives,” such as the absence of injury or violence, familial bleeding disorders, or medications or nutritional deficits that might lead to bruising. For the patient who is depressed but not suicidal, record both facts. In the patient with a transient mood swing, on the other hand, a comment on suicide is unnecessary. Are there overgeneralizations or omissions of important data? Remember that data not recorded are data lost. No matter how vividly you can recall selected details today, you probably will not remember them in a few months. The phrase “neurologic exam negative,” even in your own handwriting, may leave you wondering in a few months’ time, “Did I really do the sensory exam?” Is there too much detail? Avoid burying important information in a mass of excessive detail, to be dis- covered by only the most persistent reader. Omit most negative findings unless they relate directly to the patient’s complaints or to specific exclusions in your diagnostic assessment. Do not list abnormalities that you did not observe. Instead, concentrate on a few major ones, such as “no heart murmurs,” and try to describe structures concisely and positively. Examples. “Cervix pink and smooth” indicates you saw no redness, ulcers, nodules, masses, cysts, or other suspicious lesions, but the description is shorter and much more readable. You can omit certain body structures even though you examined them, such as normal eyebrows and eyelashes. Are phrases and short words used appropriately? Is there unnecessary repetition of data? Omit unnecessary words, such as those in parentheses in the examples below. This saves valuable time and space. Examples. “Cervix is pink (in color).” “Lungs are resonant (to percussion).” “Liver is tender (to palpation).” “Both (right and left) ears with cerumen.” “II/VI systolic ejection murmur (audible).” “Thorax symmetric (bilaterally).” Omit repetitive introductory phrases such as “The patient reports no . . . ,” be- cause readers assume the patient is the source of the history unless otherwise specified. Use short words instead of longer, fancier ones when they mean the same thing, such as “felt” for “palpated” or “heard” for “auscultated.” Describe what you observed, not what you did. “Optic discs seen” is less informative than “disc margins sharp,” even if it marks your first glimpse as an examiner! Chapter 2 | Clinical Reasoning, Assessment, and Recording Your Findings 29 Checklist for a Clear Patient Record (continued) Is the written style succinct? Is there excessive use of abbreviations? Records are scientific and legal documents, so they should be clear and understandable. Using words and brief phrases instead of whole sentences is common, but abbreviations and symbols should be used only if they are readily understood. Likewise, an overly elegant style is less appealing than a concise summary. Be sure your record is legible; otherwise, all that you have recorded is worthless to your readers. Are diagrams and precise measurements included where appropriate? Diagrams add greatly to the clarity of the record. Examples. Study the examples below: To ensure accurate evaluations and future comparisons, make measure- ments in centimeters, not in fruits, nuts, or vegetables. Example. “1 × 1 cm lymph node” vs. “a pea-sized lymph node . . .” Or “2 × 2 cm mass on the left lobe of the prostate” vs. “a walnut-sized pros- tate mass.” Is the tone of the write-up neutral and professional? It is important to be objective. Hostile, moralizing, or disapproving comments have no place in the patient’s record. Never use words, penmanship, or punc- tuation that are inflammatory or demeaning. Example. Comments such as “Patient DRUNK and LATE TO CLINIC AGAIN!!” are unprofessional and set a bad example for other providers reading the chart. They also might prove difficult to defend in a legal setting. 30 Bates’ Pocket Guide to Physical Examination and History Taking After you have completed your assessment and written record, you will find it helpful to generate a Problem List that summarizes the patient’s problems for the front of the office or hospital chart. A sample Problem List for Mrs. N is provided below. Sample Problem List Date Entered Problem No. Problem 8/30/12 1 Migraine headaches 2 Elevated blood pressure 3 Cystocele with occasional stress incontinence 4 Overweight 5 Family stress 6 Low back pain 7 Tobacco abuse 8 Varicose veins 9 History of right pyelonephritis 10 Allergy to ampicillin 11 Health maintenance 31 C H A P T E R 3Interviewing and the Health History The health history is a conversation with a purpose. In social conversa- tion, you express your own needs and interests with responsibility only for yourself. The primary goal of the clinician–patient interview is to listen and improve the well-being of the patient through a trusting and supportive relationship. The interviewing process differs significantly from the format for the health history presented in Chapter 1. Both are fundamental to your work with patients but serve different purposes. ● The interviewing process that generates the patient’s story is fluid and requires empathy, effective communication, and the relational skills to respond to patient cues, feelings, and concerns. It is “open- ended,” drawing on a range of techniques that affirm and empower the patient—active listening, guided questioning, nonverbal affirma- tion, empathic responses, validation, reassurance, and partnering. These techniques are especially pertinent to eliciting the patient’s chief concerns and the History of the Present Illness. ● The health history format is a structured framework for organizing patient information into written or verbal form. This format focuses your attention on the specific kinds of information you need to obtain, facilitates clinical reasoning, and clarifies communication of patient concerns, diagnoses, and plans to other health care providers involved in the patient’s care. More “clinician-centered” closed- ended yes/no questions are more pertinent to the Medical History, the Family History, the Personal and Social History, and, most closed-ended of all, the Review of Systems. For new patients in the office, hospital, or long-term care setting, you will do a comprehensive health history, described for adults in Chapter 1. For patients who seek care for a specific complaint, such as painful urination, a more limited interview, tailored to that specific problem—sometimes called a focused or problem-oriented history—may be indicated. 32 Bates’ Pocket Guide to Physical Examination and History Taking The Fundamentals of Skilled Interviewing Skilled interviewing requires the use of specific learnable techniques perfected over a lifetime. Practice these techniques and find ways to be observed or recorded so that you can receive feedback on your progress. Active Listening. This requires listening closely to what the patient is communicating, being aware of the patient’s emotional state, and using verbal and nonverbal skills to encourage the patient to continue and expand both concerns and fears. Empathic Responses. Patients may express—with or without words—feelings they have not consciously acknowledged. Emphatic responses are vital to patient rapport and healing and convey that you experience some of the patient’s suffering. To express empathy, you must first recognize the patient’s feelings. Elicit these feelings rather than assume how the patient feels. Respond with understanding and acceptance. Responses may be as simple as “I understand,” “That sounds upsetting,” or “You seem sad.” Empathy also may be nonverbal—for example, placing your hand on the patient’s arm if the patient is crying. Guided Questioning. It is important to adapt your questioning to the patient’s verbal and nonverbal cues. Types of Guided Questioning ◗ Moving from open-ended to focused questions ◗ Using questioning that elicits a graded response ◗ Asking a series of questions, one at a time ◗ Offering multiple choices for answers ◗ Clarifying what the patient means ◗ Encouraging with continuers ◗ Using echoing TTThee FFFuundaammeennttalsss oof SSkkilleed IInttervvieewwing Proceed from the general to the specific. Directed questions should not be leading questions that call for a “yes” or “no” answer: not “Did your stools look like tar?” but “Please describe your stools.” Ask questions that require a graded response rather than a single answer. “What physical activity do you do that makes you short of Chapter 3 | Interviewing and the Health History 33 breath?” is better than “Do you get short of breath climbing stairs?” Be sure to ask one question at a time. Try “Do you have any of the fol- lowing problems?” Be sure to pause and establish eye contact as you list each problem. Sometimes patients seem unable to describe symptoms. Offer multiple-choice answers. For patients using words that are ambiguous, request clarification, as in “Tell me exactly what you meant by ‘the flu.’” Posture, actions, or words encourage the patient to say more but do not specify the topic. Nod your head or remain silent. Lean forward, make eye contact, and use continuers like “Mm-hmm,” “Go on,” or “I’m listening.” Repetition and echoing of the patient’s words encourage the patient to express both factual details and feelings. Nonverbal Communication. Being sensitive to nonverbal mes- sages allows you to both “read the patient” more effectively and send messages of your own. Pay close attention to eye contact, facial expres- sion, posture, head position and movement such as shaking or nod- ding, interpersonal distance, and placement of the arms or legs, such as crossed, neutral, or open. Physical contact (like placing your hand on the patient’s arm) can convey empathy or help the patient gain control of feelings. You also can mirror the patient’s paralanguage, or quali- ties of speech such as pacing, tone, and volume, to increase rapport. Be sensitive to cultural variations in uses and meanings of nonverbal behaviors. Validation. An important way to make a patient feel accepted is to provide verbal support that legitimizes or validates the patient’s emotional experience. Reassurance. Avoid premature or false reassurance. Such reassur- ance may block further disclosures, especially if the patient feels that exposing anxiety is a weakness. The first step to effective reassurance is identifying and accepting the patient’s feelings without offering reassur- ance at that moment. Partnering. Express your desire to work with patients in an on- going way. Reassure patients that regardless of what happens with their disease, as their provider, you are committed to a continuing 34 Bates’ Pocket Guide to Physical Examination and History Taking partnership. Even in your role as a student, such support can make a big difference. Summarization. Giving a capsule summary lets the patient know that you have been listening carefully. It also clarifies what you know and what you don’t know. Summarization allows you to organize your clinical reasoning and to convey your thinking to the patient, which makes the relationship more collaborative. Transitions. Tell patients when you are changing directions during the interview. This gives patients a greater sense of control. Empowering the Patient. The clinician–patient relationship is inherently unequal. Patients have many reasons to feel vulnerable: pain, worry, feeling overwhelmed with the health care system, lack of famil- iarity with the clinical evaluation process. Differences of gender, ethnic- ity, race, or class may also create power differentials. Ultimately, patients must be empowered to take care of themselves and feel confident about following through on your advice. Review the principles below. Empowering the Patient: Principles of Sharing Power ◗ Evoke the patient’s perspective. ◗ Convey interest in the person, not just the problem. ◗ Follow the patient’s lead. ◗ Elicit and validate emotional content. ◗ Share information with the patient, especially at transition points during the visit. ◗ Make your clinical reasoning transparent to the patient. ◗ Reveal the limits of your knowledge. The Sequence and Context of the Interview PREPARATION Interviewing patients to elicit their health history requires planning. ● Review the medical record. Before seeing the patient, review the medical record or chart. It often provides valuable information about past diagnoses and treatments; however, data may be incom- plete or even disagree with what you learn from the patient, so be open to developing new approaches or ideas. TTThee SSSeequeenceee andd CConntteextt offf thhe IIntteervieew Chapter 3 | Interviewing and the Health History 35 ● Set goals for the interview. Clarify your goals for the interview. A clinician must balance provider-centered goals with patient- centered goals. The clinician’s task is to balance these multiple agendas. ● Review your clinical behavior and appearance. Consciously or not, you send messages through your behavior. Posture, gestures, eye contact, and tone of voice all can express interest, attention, acceptance, and understanding. The skilled interviewer is calm and unhurried, even when time is limited. Reactions that betray disap- proval, embarrassment, impatience, or boredom block communica- tion. Patients find cleanliness, neatness, conservative dress, and a name tag reassuring. ● Adjust the environment. Always consider the patient’s privacy. Pull shut any bedside curtains. Suggest moving to an empty room rather than having a conversation that can be overheard. THE SEQUENCE OF THE INTERVIEW In general, an interview moves through several stages. Throughout this sequence, as the clinician, you must always stay attuned to the patient’s feelings, help the patient express them, respond to their content, and vali- date their significance. ● Greet the patient and establish rapport. Greet the patient by name and introduce yourself, giving your name. If possible, shake hands. If this is the first contact, explain your role, including your status as a student and how you will be involved in the patient’s care. Using a title to address the patient (e.g., Mr. O’Neil, Ms. Wu) is always best. Avoid first names unless you have specific permission from the patient. Whenever visitors are present, maintain confidentiality. Let the patient decide if visitors or family members should remain in the room, and ask for the patient’s permission before conducting the interview in front of them. Attend to the patient’s comfort. Ask how he or she is feeling and if you are coming at a convenient time. Look for signs of discomfort, such as frequent changes of position or facial expressions that show pain or anxiety. Arranging the bed may make the patient more comfortable. 36 Bates’ Pocket Guide to Physical Examination and History Taking Consider the best way to arrange the room. Choose a distance that facilitates conversation and good eye contact. Try to sit at eye level with the patient. Move any physical barriers between you and the patient, such as desks or bedside tables, out of the way. Give the patient your undivided attention. Spend enough time on small talk to put the patient at ease. If necessary, jot down short phrases, specific dates, or words rather than trying to put them into a final format. Maintain good eye contact, and whenever the patient is talking about sensitive or disturbing material, put down your pen. ● Establish an agenda. It is important to identify both your own and the patient’s issues at the beginning of the encounter. Often, you may need to focus the interview by asking the patient which problem is most pressing. For example, “Do you have some special concerns today? Which one are you most concerned about?” Some patients may not have a specific complaint or problem. It is still important to start with the patient’s story. ● Invite the patient’s story. As you probe the patient’s concern, begin with open-ended questions that allow full freedom of response: “Tell me more about….” Avoid questions that restrict the patient to a minimally informative “yes” or “no” answer. Listen to the patient’s answers without interrupting. Train yourself to follow the patient’s leads. Use verbal and nonverbal cues that prompt patients to recount their stories spontaneously. Use continuers, especially at the outset, such as nodding your head and using phrases such as “Uh huh,” “Go on,” and “I see.” ● Explore the patient’s perspective. The disease/illness model helps you understand the difference between your perspective and the patient’s perspective. In this model, disease is the explanation that the clinician brings to the symptoms. It is the way that the clinician organizes what he or she learns from the patient into a coherent picture that leads to a clinical diagnosis and treatment plan. Illness can be defined as how the patient experiences symp- toms. The health history interview needs to include both of these views of reality. Learning how patients perceive illness means asking patient-centered questions in the four domains listed below, which follow the Chapter 3 | Interviewing and the Health History 37 mnemonic “FIFE”—Feelings, Ideas, effect on Function, and Expec- tations. This is crucial to patient satisfaction, effective health care, and patient follow-through. Exploring the Patient’s Perspective (F-I-F-E) ◗ The patient’s Feelings, including fears or concerns, about the problem ◗ The patient’s Ideas about the nature and the cause of the problem ◗ The effect of the problem on the patient’s life and Function ◗ The patient’s Expectations of the disease, of the clinician, or of health care, often based on prior personal or family experiences Clues to the Patient’s Perspective on Illness ◗ Direct statement(s) by the patient of explanations, emotions, expectations, and effects of the illness ◗ Expression of feelings about the illness without naming the illness ◗ Attempts to explain or understand symptoms ◗ Speech clues (e.g., repetition, prolonged reflective pauses) ◗ Sharing a personal story ◗ Behavioral clues indicative of unidentified concerns, dissatisfaction, or unmet needs such as reluctance to accept recommendations, seeking a second opinion, or early appointment Source: Lang F, Floyd MR, Beine KL. Clues to patients’ explanations and concerns about their illnesses: a call for active listening. Arch Fam Med 2000;9(3):222–227. ● Identify and respond to the patient’s emotional cues. Patients offer various clues to their concerns that may be direct or indirect, verbal or nonverbal; they may express them as ideas or emotions. Acknowledging and responding to these clues help build rapport, expand the clinician’s understanding of the illness, and improve patient satisfaction. Clues to the patient’s perspective on illness are provided in the box below. ● Expand and clarify the patient’s story. Each symptom has attri- butes that must be clarified, including context, associations, and chronology, especially for pain. It is critical to understand fully every symptom’s essential characteristics. Always elicit the seven features of every symptom. 38 Bates’ Pocket Guide to Physical Examination and History Taking The Seven Attributes of a Symptom 1. Location. Where is it? Does it radiate? 2. Quality. What is it like? 3. Quantity or severity. How bad is it? (For pain, ask for a rating on a scale of 1 to 10.) 4. Timing. When did (does) it start? How long did (does) it last? How often did (does) it occur? 5. Setting in which it occurs. Include environmental factors, personal activities, emotional reactions, or other circumstances that may have contributed to the illness. 6. Remitting or exacerbating factors. Does anything make it better or worse? 7. Associated manifestations. Have you noticed anything else that accompanies it? To pursue the seven attributes, two mnemonics may help: ● OLD CARTS, or Onset, Location, Duration, Character, Aggravating/Alleviating Factors, Radiation, and Timing; and ● OPQRST, or Onset, Palliating/Provoking Factors, Quality, Radia- tion, Site, and Timing Use language that is understandable and appropriate to the patient. Technical language confuses patients and blocks communication. Whenever possible, use the patient’s words, making sure you clarify their meaning. Facilitate the patient’s story by using different types of questions and the techniques of skilled interviewing on pp. 32–34. Often you will need to use directed questions (see p. 32) that ask for spe- cific information the patient has not already offered. In general, the patient interview moves back and forth from an open-ended question to a directed question and then on to another open-ended question. Establishing the sequence and time course of the patient’s symptoms is important. You can encourage a chronologic account by asking such questions as “What then?” or “What happened next?” Some students visualize the process of evoking a full description of the symptom as “the cone”, as shown on the following page. Chapter 3 | Interviewing and the Health History 39 First, open-ended questions to hear “the story of the symptom” in the patient’s own words Then more specific questions to elicit “the seven features of every symptom” Finally, the yes-no questions or “pertinent positives and negatives” from the relevant section of the review of systems Each symptom has its own “cone,” which becomes a paragraph in the History of Present Illness in the written record. ● Generate and test diagnostic hypotheses. As you listen to the patient’s concerns, you will begin to generate hypotheses about what disease process might be the cause. Identifying the various attributes of the patient’s symptoms and pursuing specific details are funda- mental to recognizing patterns of disease and differentiating one disease from another. ● Share the treatment plan. Learning about the disease and concep- tualizing the illness give you and the patient the basis for planning further evaluation (physical examination, laboratory tests, consul- tations, etc.). Motivational interviewing techniques may help the patient achieve desired behavior changes. ● Close the interview. Make sure the patient fully understands the plans you have developed together. You can say, “We need to stop now. Do you have any questions about what we’ve covered?” Review future evaluation, treatments, and follow-up. Give the patient a chance to ask any final questions. Ask the patient to repeat the plan back to you. ● Take time for self-reflection. As clinicians, we encounter a wide variety of people, each one unique. Because we bring our own values, assumptions, and biases to every encounter, we must look inward to clarify how our expectations and reactions may affect what we hear and how we behave. Self-reflection brings a deepening personal awareness to our work with patients and is one of the most rewarding aspects of providing patient care. 40 Bates’ Pocket Guide to Physical Examination and History Taking THE CULTURAL CONTEXT OF THE INTERVIEW Cultural Humility—A Changing Paradigm. As you provide care for an ever-expanding and diverse group of patients, it is important to understand how culture shapes not just the patient’s beliefs, but your own. Culture is a system of shared ideas, rules, and meanings that influences how we view the world, experience it emotionally, and behave in relation to other people. This definition of culture is broader than the term ethnicity. The influence of culture is not limited to minority groups—it is relevant to everyone, including the culture of clinicians and their training. Cultural competence commonly is viewed as “a set of attitudes, skills, behaviors, and policies that enable orga- nizations and staff to work effectively in cross-cultural situations. It reflects the ability to acquire and use knowledge of the health-related benefits, attitudes, practices, and communication patterns of clients and their families to improve services, strengthen programs, increase community participation, and close the gaps in health status among diverse population groups.” Clinicians are increasingly challenged to adopt cultural humility, a “process that requires humility as individuals continually engage in self- reflection and self-critique as lifelong learners and reflective practitioners.” This process includes “the difficult work of examining cultural beliefs and cultural systems of both patients and providers to locate the points of cul- tural dissonance or synergy that contribute to patients’ health outcomes.” It calls for clinicians to “bring into check the power imbalances that exist in the dynamics of (clinician)–patient communication” and maintain mutually respectful and dynamic partnerships with patients and commu- nities. The following three-point framework will help you. ● Self-awareness. As clinicians, we face the task of bringing our own values and biases to a conscious level. Values are the standards we use to measure our own and others’ beliefs and behaviors. Biases are the attitudes or feelings that we attach to perceived differences, for example, the way an individual relates to time, which can be a cul- turally determined phenomenon. Are you always on time—a posi- tive value in the dominant Western culture? Or do you tend to run a little late? How do you feel about people whose habits are opposite to yours? Think about the role of physical appearance. Do you con- sider yourself thin, midsize, or heavy? How do you feel about people who have different weights? ● Respectful Communication. Maintain an open, respectful, and inquiring attitude. “What did you hope to get from this visit?” If Chapter 3 | Interviewing and the Health History 41 you have established rapport and trust, patients will be willing to teach you. Be ready to acknowledge your ignorance or bias. “I mis- takenly made assumptions about you that are not right. I apologize. Would you be willing to tell me more about yourself and your future goals?” Learn about different cultures: do pertinent reading; go to movies that are made in different countries; learn about different consumer health agendas. ● Collaborative Partnerships. Communication based on trust, respect, and a willingness to re-examine assumptions helps allow patients to express concerns that run counter to the dominant culture. You, the clinician, must be willing to listen to and validate these emotions, and not let your own feelings prevent you from exploring painful areas. You also must be willing to re-examine your beliefs. Advanced Interviewing CHALLENGING PATIENTS Always remember the importance of listening to the patient and clarify- ing the patient’s agenda. Silent Patient. Silence has many meanings and purposes. Watch closely for nonverbal cues such as difficulty controlling emotions. You may need to shift your inquiry to symptoms of depression or begin an exploratory mental status examination. Silence may be the patient’s response to how you are asking questions. Are you asking too many direct questions? Have you offended the patient? Confusing Patient. Some patients have multiple symptoms or a somatization disorder. Focus on the context of the symptoms and guide the interview into a psychosocial assessment. At other times, you may be baffled, frustrated, or confused. The history is vague and difficult to understand, and patients may describe symptoms in bizarre terms. Try to learn more about the unusual symptoms. Watch for delirium in acutely ill or intoxicated patients and for dementia in the elderly. When you suspect a psychiatric or neurologic disorder, shift to a mental status examination, focusing on level of consciousness, orien- tation, and memory. AAAdvaaannceeddd Innteeervvieeewwinng 42 Bates’ Pocket Guide to Physical Examination and History Taking Patient With Altered Capacity. Some patients cannot provide their own histories because of delirium, dementia, or other conditions. Others cannot relate certain parts of the history. In such cases, deter- mine whether the patient has decision-making capacity, or the ability to understand information related to health, to make medical choices based on reason and a consistent set of values, and to declare prefer- ences about treatments. Many patients with psychiatric or cognitive deficits still retain the ability to make decisions. For patients with capacity, obtain their consent before talking about their health with others. Maintain confidentiality and clarify what you can discuss with others. They may offer surprising and important information. Consider dividing the interview into two segments—one with the patient and the other with both the patient and a second informant. Also learn the tenets of the Health Insurance Portability and Accountability Act (HIPAA) passed by Congress in 1996, which sets strict standards for disclosure for both institutions and providers when sharing patient information. These can be found at www.hhs. gov/ocr/hipaa/. For patients with impaired capacity, find a surrogate informant or decision maker to assist with the history. Check whether the patient has a durable power of attorney for health care or a health care proxy. If not, in many cases, a spouse or family member can represent the patient’s wishes. Talkative Patient. Several techniques are helpful. For the first 5 or 10 minutes, listen closely. Does the patient seem obsessively detailed or unduly anxious? Is there a flight of ideas or disorganized thought pro- cess? Try to focus on what seems most important to the patient. “You’ve described many concerns. Let’s focus on the hip pain first. Can you tell me what it feels like?” Or you can ask, “What is your #1 concern today?” Crying Patient. Usually crying is therapeutic, as is quiet acceptance of the patient’s distress. Make a facilitating or supportive remark like “I’m glad that you were able to express your feelings.” Angry or Disruptive Patient. Many patients have reasons to be angry: they are ill, they have suffered a loss, they lack accustomed control over their own lives, and they feel relatively powerless. They may direct this anger toward you. Accept angry feelings from patients and allow them to express such emotions without getting angry in return. Validate their feelings without agreeing with their reasons. “I understand that you felt very frustrated by the long wait and answering http://www.hhs.gov/ocr/hipaa http://www.hhs.gov/ocr/hipaa Chapter 3 | Interviewing and the Health History 43 the same questions over and over.” Some angry patients become hostile and disruptive. Before approaching them, alert security. It is important to stay calm, appear accepting, and avoid being challenging. Keep your posture relaxed and nonthreatening. Once you have established rapport, gently suggest moving to a different location. Patient With a Language Barrier. The ideal interpreter is a neu- tral, objective person trained in both languages and cultures. Avoid using family members or friends as interpreters: confidentiality may be violated. As you begin working with the interpreter, make questions clear, short, and simple. Speak directly to the patient. Bilingual written questionnaires are valuable. Guidelines for Working With an Interpreter: “INTERPRET ” I Introductions: Make sure to introduce all the individuals in the room. During the introduction, include information as to the roles individuals will play. N Note Goals: Note the goals of the interview. What is the diagnosis? What will the treatment entail? Will there be any follow-up? T Transparency: Let the patient know that everything said will be inter- preted throughout the session. E Ethics: Use qualified interpreters (not family members or children) when conducting an interview. Qualified interpreters allow the patient to main- tain autonomy and make informed decisions about his or her care. R Respect Beliefs: Limited English Proficient (LEP) patients may have cul- tural beliefs that need to be taken into account as well. The interpreter may be able to serve as a cultural broker and help explain any cultural beliefs that may exist. P Patient Focus: The patient should remain the focus of the encounter. Providers should interact with the patient and not the interpreter. Make sure to ask and address any questions the patient may have prior to ending the encounter. If you don’t have trained interpreters on staff, the patient may not be able to call in with questions. R Retain Control: It is important as the provider that you remain in con- trol of the interaction and not let the patient or the interpreter take over the conversation. E Explain: Use simple language and short sentences when working with an interpreter. This will ensure that comparable words can be found in the second language and that all the information can be conveyed clearly. T Thanks: Thank the interpreter and the patient for their time. On the chart, note that the patient needs an interpreter and who served as an interpreter this time. Source: U.S. Department of Health and Human Services. Interpret Tool: working with interpreters in cultural settings. Available at https: www.thinkculturalhealth.hhs.gov/pdfs/ InterpretTool . Accessed June 6, 2012. http://www.thinkculturalhealth.hhs.gov/pdfs/InterpretTool http://www.thinkculturalhealth.hhs.gov/pdfs/InterpretTool 44 Bates’ Pocket Guide to Physical Examination and History Taking Patient With Low Literacy or Low Health Literacy. Assess the ability to read. Some patients may try to hide their reading problems. Ask the patient to read whatever instructions you have written. Simply handing the patient written material upside-down to see if the patient turns it around may settle the question. Assess health literacy, or the skills to function effectively in the health care system: interpreting documents, reading labels and medication instructions, and speaking and listening effectively. Patient With Hearing Loss. Find out the patient’s preferred method of communicating. Patients may use American Sign Lan- guage, a unique language with its own syntax, or various other com- munication forms combining signs and speech. Determine whether the patient identifies with the Deaf or Hearing culture. Handwritten questions and answers may be the best solution. When patients have partial hearing impairment or can read lips, face them directly, in good light. If the patient has a unilateral hearing loss, sit on the hear- ing side. If the patient has a hearing aid, make sure it is working. Eliminate background noise such as television. Patient With Impaired Vision. Shake hands to establish contact and explain who you are and why you are there. If the room is unfa- miliar, orient the patient to the surroundings. Patient With Limited Intelligence. Patients of moderately limited intelligence usually can give adequate histories. Pay special attention to the patient’s schooling and ability to function independently. How far has the patient gone in school? If he or she didn’t finish, why not? Assess simple calculations, vocabulary, memory, and abstract thinking. For patients with severe mental retardation, obtain the history from the family or caregivers. Avoid “talking down” or using condescend- ing behavior. The sexual history is equally important and often over- looked. Patient With Personal Problems. Patients may ask you for advice about personal problems outside the range of health. Letting the patient talk through the problem is usually more valuable and thera- peutic than any answer you could give. Seductive Patient. The emotional and physical intimacy of the clinician–patient relationship may lead to sexual feelings. If you become aware of such feelings, accept them as a normal human response, and bring them to the conscious level so they will not affect your behavior. Denying these feelings makes it more likely that you Chapter 3 | Interviewing and the Health History 45 will act inappropriately. Any sexual contact or romantic relationship with patients is unethical; keep your relationship with the patient within professional bounds and seek help if you need it. SENSITIVE TOPICS The Sexual History. You can introduce questions about sexual function and practices at multiple points in a patient’s history. An ori- enting sentence or two is often helpful. “Now I’d like to ask you some questions about your sexual health and practices” or “I routinely ask all patients about their sexual function.” ● “When was the last time you had intimate physical contact with someone?” “Did that contact include sexual intercourse?” ● “Do you have sex with men, women, or both?” The health implications of heterosexual, homosexual, or bisexual experiences are significant. ● “How many sexual partners have you had in the last 6 months?” “In the last 5 years?” “In your lifetime?” ● Because no explicit risk factors may be present, it is important to ask all patients “Do you have any concerns about HIV or AIDS?” Also ask about routine use of condoms. Mental Health History. Cultural constructs of mental illness vary widely, causing marked differences in acceptance and attitudes. Ask open-ended questions initially: “Have you ever had any problem with emotional or mental illnesses?” Then move to more specific questions: “Have you ever visited a counselor or psychotherapist?” “Have you taken medication for emotional issues?” “Have you or a family mem- ber ever been hospitalized for a mental health problem?” Be sensitive to reports of mood changes or symptoms such as fatigue, tearfulness, appetite or weight changes, insomnia, and vague somatic complaints. Two opening screening questions are: “Over the past 2 weeks, have you felt down, depressed, or hopeless?” and “Over the past 2 weeks, have you felt little interest or pleasure in doing things?” Ask about thoughts of suicide: “Have you ever thought about hurting yourself or ending your life?” Evaluate severity. Many patients with schizophrenia or other psychotic disorders can func- tion in the community and tell you about their diagnoses, symptoms, 46 Bates’ Pocket Guide to Physical Examination and History Taking hospitalizations, and medications. Investigate their symptoms and assess any effects on mood or daily activities. Alcohol and Prescription and Illicit Drugs. Clinicians should routinely ask about current and past use of alcohol or drugs, patterns of use, and family history. Be familiar with the definitions below: ● Tolerance: A state of adaptation in which exposure to a drug induces changes that result in a diminution of one or more of the drug’s effects over time. ● Physical Dependence: A state of adaptation that is manifested by a drug class–specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist. ● Addiction: A primary, chronic, neurobiologic disease with genetic, psychosocial, and environmental factors influencing its development and manifestations. It is characterized by behaviors that include one or more of the following: impaired control over drug use, compul- sive use, continued use despite harm, and craving. For assessing alcohol intake, “What do you like to drink?” or “Tell me about your use of alcohol” are good opening questions that avoid the easy yes or no response. The most widely used screening questions are the CAGE questions about Cutting down, Annoyance when criticized, Guilty feelings, and Eye-openers. Two or more affirma- tive answers to the CAGE questions suggest alcoholism. The CAGE Questionnaire is readily available online. Also ask about blackouts (loss of memory for events during drinking), seizures, accidents or injuries while drinking, job loss, marital conflict, or legal problems. Ask specifically about drinking while driving or operating machinery. Questions about drugs are similar. “How much marijuana do you use? Cocaine? Heroin? Amphetamines?” (Ask about each one by name.) “How about prescription drugs such as sleeping pills?” “Diet pills?” “Painkillers?” Use the CAGE questions but relate them to drug use. With adolescents, it may be helpful to ask about substance use by friends or family members first. “A lot of young people are using drugs these days. How about at your school? Your friends?” Chapter 3 | Interviewing and the Health History 47 Intimate Partner Violence and Domestic Violence. Many authorities recommend routine screening of all female and older adult patients for domestic violence. Start with general “normalizing” ques- tions: “Because abuse is common in many women’s lives, I’ve begun to ask about it routinely.” “Are there times in your relationships that you feel unsafe or afraid?” “Have you ever been hit, kicked, punched, or hurt by someone you know?” Clues to Physical and Sexual Abuse ◗ Injuries that are unexplained, seem inconsistent with the patient’s story, are concealed by the patient, or cause embarrassment ◗ Delay in getting treatment for trauma ◗ History of repeated injuries or “accidents” ◗ If the patient or a person close to the patient has a history of alcohol or drug abuse ◗ Partner tries to dominate the visit, will not leave the room, or seems unusu- ally anxious or solicitous ◗ Pregnancy at a young age; multiple partners ◗ Repeated STIs; vaginal lacerations or bruises ◗ Fear of the pelvic examination or leaving the examination room Death and the Dying Patient. Work through your own feelings with the help of reading and discussion. Kübler-Ross has described five stages in our response to loss or the anticipatory grief of impending death: denial and isolation, anger, bargaining, depression or sadness, and acceptance. These stages may occur sequentially or overlap in different combinations. Dying patients rarely want to talk about their illnesses all the time, nor do they wish to confide in everyone they meet. Give them opportunities to talk and then listen receptively, but be supportive if they prefer to stay at a social level. Understanding the patient’s wishes about treatment at the end of life is an important clinician responsibility. Even if discussions of death and dying are difficult, you must learn to ask specific questions. Ask about Do Not Resuscitate (DNR) status. Find out about the patient’s frame of reference. “What experiences have you had with the death of a close friend or relative?” “What do you know about cardiopul- monary resuscitation (CPR)?” Assure patients that relieving pain and taking care of their other spiritual and physical needs will be a priority. Encourage any adult, but especially the elderly or chronically ill, to establish a health care proxy, an individual who can act for the patient in life-threatening situations. 48 Bates’ Pocket Guide to Physical Examination and History Taking Ethics and Professionalism Medical ethics come into play in almost every patient interaction. Fundamental maxims are as follows: ● Nonmaleficence or primum non nocere, commonly stated as “First, do no harm” ● Beneficence, or the dictum that the clinician needs to “do good” for the patient. As clinicians, our actions need to be motivated by what is in the patient’s best interest. ● Autonomy, whereby patients have the right to determine what is in their own best interest ● Confidentiality, meaning that we are obligated not to tell others what we learn from our patients The Tavistock Principles guide behavior in health care for both individuals and institutions. The Tavistock Principles Rights: People have a right to health and health care. Balance: Care of individual patients is central, but the health of populations is also our concern. Comprehensiveness: In addition to treating illness, we have an obligation to ease suffering, minimize disability, prevent disease, and promote health. Cooperation: Health care succeeds only if we cooperate with those we serve, each other, and those in other sectors. Improvement: Improving health care is a serious and continuing responsibility. Safety: Do no harm. Openness: Being open, honest, and trustworthy is vital in health care. EEEthhicccs annddd PProoofeesssiioonaaliiismm 49 C H A P T E R 4Beginning the Physical Examination: General Survey, Vital Signs, and Pain The Health History Fatigue and Weakness. Fatigue is a nonspecific symptom with many causes. Use open-ended questions to explore the attributes of the patient’s fatigue, and encourage the patient to fully describe what he or she is experiencing. Weakness differs from fatigue. It denotes a demonstrable loss of muscle power and will be discussed later with other neurologic symptoms. Fever, Chills, and Night Sweats. Ask about fever if the patient has an acute or chronic illness. Find out whether the patient has used a thermometer to measure the temperature. Distinguish between subjective chilliness and a shaking chill, with shivering throughout the body and chattering of teeth. Night sweats raise concerns about tuberculosis or malignancy. Focus your questions on the timing of the illness and its associated symptoms. Become familiar with patterns of infectious diseases that may affect your patient. Inquire about travel, contact with sick people, Common or Concerning Symptoms ◗ Fatigue and weakness ◗ Fever, chills, night sweats ◗ Changes in weight ◗ Pain 50 Bates’ Pocket Guide to Physical Examination and History Taking or other unusual exposures. Be sure to inquire about medications, as they may cause fever. In contrast, recent ingestion of aspirin, acet- aminophen, corticosteroids, and nonsteroidal anti-inflammatory drugs may mask it. Weight Changes. Good opening questions include “How often do you check your weight?” and “How is it compared to a year ago?” ● Weight gain occurs when caloric intake exceeds caloric expen- diture over time. It also may reflect abnormal accumulation of body fluids. ● Weight loss has many causes: decreased food intake, dysphagia, vomiting, and insufficient supplies of food; defective absorption of nutrients; increased metabolic requirements; and loss of nutrients through the urine, feces, or injured skin. Be alert for signs of malnutrition. Pain. Approximately 70 million Americans report persisting or intermittent pain, often underassessed. Adopt the comprehensive approach found on p. 59. Health Promotion and Counseling: Evidence and Recommendations HHHeealltthh PPrroommoootioonn andd CCCouunsselingg: EEEviideenncce aannd Reecooommmmeeenddattionns Important Topics for Health Promotion and Counseling Optimal Weight, Nutrition, and Diet. Less than half of U.S. adults maintain a healthy weight (BMI ≥19 but <25). Obesity has increased in every segment of the population. More than 85% of people with type 2 diabetes and roughly 20% of those with hyper- tension or elevated cholesterol levels are overweight or obese. Increasing obesity in children contributes to rising rates of child- hood diabetes. Diet recommendations hinge on assessment of the patient’s motivation and readiness to lose weight and individual risk ◗ Optimal weight, nutrition, and diet ◗ Exercise Chapter 4 | Beginning the Physical Examination 51 factors. Experts urge that everyone restrict salt intake to a half tea- spoon a day. General national guidelines recommend: ● A 10% weight reduction over 6 months, or a decrease of 300 to 500 kcal/day, for people with BMIs between 27 and 35 ● A weight loss goal of ½ to 1 pound per week because more rapid weight loss does not lead to better results at 1 year Exercise. Thirty minutes of moderate activity (defined as walking 2 miles in 30 minutes, or its equivalent, on most days of the week) is recommended. Patients can increase exercise by such simple measures as parking further away from their place of work or using stairs instead of elevators. Techniques of ExaminationTTTecchhnniiquees offf EExaammminnatttionn E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S GENERAL SURVEY Apparent State of Health Acutely or chronically ill, frail, robust, vigorous Level of Consciousness. Is the patient awake, alert, and interactive? If not, promptly assess level of consciousness (see p. 305) Signs of Distress ● Cardiac or respiratory distress ● Pain ● Anxiety or depression Clutching the chest, pallor, diapho- resis; labored breathing, wheezing, cough Wincing, sweating, protecting painful area Anxious face, fidgety movements, cold and moist palms; inexpressive or flat affect, poor eye contact, psychomotor slowing Skin Color and Obvious Lesions. See Chapter 6, The Skin, Hair, and Nails, for details. Pallor, cyanosis, jaundice, rashes, bruises 52 Bates’ Pocket Guide to Physical Examination and History Taking E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S Dress, Grooming, and Personal Hygiene ● Is the patient wearing any unusual jewelry? Where? Is there any body piercing or tattoo? ● Note patient’s hair, fingernails, and use of cosmetics. Risk of hepatitis C Facial Expression. Watch for eye contact. Is it natural? Sustained and unblinking? Averted quickly? Absent? Stare of hyperthyroidism; flat or sad affect of depression. Decreased eye contact may be cultural or may suggest anxiety, fear, or sadness. Odors of Body and Breath. Odors can be important diagnostic clues. Breath odor of alcohol, acetone, uremia, or liver failure. Fruity odor of diabetes. (Never assume that alcohol on a patient’s breath explains changes in mental status or neuro- logic findings.) Posture, Gait, and Motor Activity Preference to sit up in left-sided heart failure and to lean forward with arms braced in chronic obstructive pulmonary disease (COPD) HEIGHT AND WEIGHT Height. Measure the patient’s height in stocking feet. Note the build—muscular or decondi- tioned, tall or short. Observe the body proportions. Short stature in Turner’s syndrome; elon- gated arms in Marfan’s syndrome; loss of height in osteoporosis Weight. Is the patient emaci- ated? Plump? If obese, is there central or dispersed distribution of fat? Weigh the patient with shoes off. More than 50% of U.S. adults are overweight (BMI >25); nearly 25% are
obese (BMI >30). These excesses are
proven risk factors for diabetes, heart
disease, stroke, hypertension, osteo-
arthritis, sleep apnea syndrome, and
some forms of cancer.

Methods to Calculate BMI
Unit of Measure Method of Calculation
◗ Weight in pounds, height in
inches
◗ Weight in kilograms, height in
meters squared
◗ Either
1. Body Mass Index Chart (see
p. 54)
2.
3.
4. BMI Calculator at Web site
www.nhlbisupport.com/bmi
*Several organizations use 704.5, but the variation in BMI is negligible. Conversion formu-
las: 2.2 lb = 1 kg; 1.0 inch = 2.54 cm; 100 cm = 1 meter
Source: National Institutes of Health–National Heart, Lung and Blood Institute. Body Mass
Index Calculator. Available at: www.nhlbisupport.com/bmi. Accessed June 25, 2011.
Weight (lbs) × 700*
Height (inches)
Height (inches)
⎛
⎝⎜
⎞
⎠⎟
Weight (kg)
Height (m2)
If the BMI is above 25, engage the patient in a 24-hour dietary recall
and compare the intake of food groups and number of servings per
day with current recommendations. Or, choose a screening tool and
provide appropriate counseling or referral.
If the BMI falls below 17, be concerned about possible anorexia
nervosa, bulimia, or other medical conditions (see Table 4-1, Eating
Disorders and Excessively Low BMI, p. 61).
If the BMI is ≤35, measure the waist circumference just above the hip
bones. The patient may have excess body fat if the waist measures
≥40 inches for men.
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
Calculate the body mass index
(BMI), which incorporates
estimated but more accurate
measurements of body fat than
weight alone.
Chapter 4 | Beginning the Physical Examination 53

http://www.nhlbisupport.com/bmi

http://www.nhlbisupport.com/bmi

54 Bates’ Pocket Guide to Physical Examination and History Taking
BMI Char t
Normal Overweight Obese
BMI 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35
Height
(inches) Body Weight (pounds)
58 91 96 100 105 110 115 119 124 129 134 138 143 148 153 158 162 167
59 94 99 104 109 114 119 124 128 133 138 143 148 153 158 163 168 173
60 97 102 107 112 118 123 128 133 138 143 148 153 158 163 168 174 179
61 100 105 111 116 122 127 132 137 143 148 153 158 164 169 174 180 185
62 104 109 115 120 126 131 136 142 147 153 158 164 169 175 180 185 191
63 107 113 118 124 130 135 141 145 152 158 163 169 174 180 185 191 197
64 110 116 122 128 134 140 145 151 157 163 169 174 180 185 192 197 204
65 114 120 126 132 138 144 150 156 162 168 174 180 186 192 198 204 210
66 118 124 130 136 142 148 155 161 167 173 179 186 192 198 204 210 216
67 121 127 134 140 146 153 159 166 172 178 185 191 198 204 211 217 223
68 125 131 138 144 151 158 164 171 177 184 190 197 203 210 216 223 230
69 128 135 142 149 155 162 169 176 182 189 196 203 209 216 223 230 236
70 132 139 146 153 160 167 174 181 188 189 196 203 209 216 223 230 236
71 136 143 150 157 165 172 179 186 193 200 208 215 222 229 236 243 250
72 140 147 154 162 169 177 184 191 199 206 213 221 228 235 242 250 258
73 144 151 159 166 174 182 189 197 204 212 219 227 235 242 250 257 265
74 148 155 163 171 179 186 194 202 210 218 225 233 241 249 256 264 272
75 152 160 168 176 184 192 200 208 216 224 232 240 248 256 264 272 279
76 156 164 172 180 189 197 205 213 221 230 238 246 254 263 271 279 287
Source: National Heart, Lung, and Blood Institute, National Institutes of Health. Body Mass Index
Table. Available at: www.nhlbi.nih.gov/guidelines/obesity/bmi_tbl . Accessed June 25, 2011.
THE VITAL SIGNS: BLOOD PRESSURE, HEART
RATE, RESPIRATORY RATE, AND TEMPERATURE
Blood Pressure. To measure blood pressure accurately, choose a
cuff of appropriate size and ensure careful technique.
Selecting the Correct Blood Pressure Cuff
◗ Width of the inflatable bladder of the cuff should be about 40% of upper arm
circumference (about 12–14 cm in the average adult).
◗ Length of inflatable bladder should be about 80% of upper arm circumference
(almost long enough to encircle the arm)
E XA M I N AT I O N T E C H N I Q U E S

http://www.nhlbi.nih.gov/guidelines/obesity/bmi_tbl

Measuring Blood Pressure
◗ Center the inflatable bladder over the brachial artery. The lower border of
the cuff should be about 2.5 cm above the antecubital crease. Secure the cuff
snugly. Position the patient’s arm so that it is slightly flexed at the elbow.
◗ To determine how high to raise the cuff pressure, first estimate the systolic
pressure by palpation. As you feel the radial artery with the fingers of one
hand, rapidly inflate the cuff until the radial pulse disappears. Read this pres-
sure on the manometer and add 30 mm Hg to it. Use of this sum as the tar-
get for subsequent inflations prevents discomfort from unnecessarily high
cuff pressures. It also avoids the occasional error caused by an auscultatory
gap—a silent interval between the systolic and diastolic pressures.
◗ Deflate the cuff promptly.
◗ Now place the bell of a stethoscope lightly over the brachial artery, taking care
to make an air seal with its full rim. Because the sounds to be heard (Korotkoff
sounds) are relatively low in pitch, they are heard better with the bell.
◗ Inflate the cuff rapidly again to the level just determined, and then deflate it
slowly, at a rate of about 2 to 3 mm Hg per second. Note the level at which you
hear the sounds of at least two consecutive beats. This is the systolic pressure.
◗ Continue to lower the pressure slowly. The disappearance point, usually only a
few mm Hg below the muffling point, is the best estimate of diastolic pressure.
◗ Read both the systolic and diastolic levels to the nearest 2 mm Hg. Wait 2 or
more minutes and repeat. Average your readings. If the first two readings
differ by more than 5 mm Hg, take additional readings.
◗ Take blood pressure in both arms at least once.
◗ In patients taking antihypertensive medications or with a history of fainting,
postural dizziness, or possible depletion of blood volume, take the blood
pressure in two positions—supine and standing (unless contraindicated). A
fall in systolic pressure of 20 mm Hg or more, especially when accompanied
by symptoms, indicates orthostatic (postural) hypotension.
Chapter 4 | Beginning the Physical Examination 55
Steps to Ensure Accurate Blood Pressure Recordings
◗ Ideally, ask the patient to avoid smoking or drinking caffeinated beverages for
30 minutes before the blood pressure is taken and to rest for at least 5 minutes.
◗ Make sure the examining room is quiet and comfortably warm.
◗ Make sure the arm selected is free of clothing. There should be no arterio-
venous fistulas for dialysis, scarring from prior brachial artery cutdowns,
or signs of lymphedema (seen after axillary node dissection or radiation
therapy).
◗ Palpate the brachial artery to confirm that it has a viable pulse.
◗ Position the arm so that the brachial artery, at the antecubital crease, is at heart
level—roughly level with the 4th interspace at its junction with the sternum.
◗ If the patient is seated, rest the arm on a table a little above the patient’s
waist; if standing, try to support the patient’s arm at the midchest level.
E XA M I N AT I O N T E C H N I Q U E S

56 Bates’ Pocket Guide to Physical Examination and History Taking
In 2003, the Joint National Committee on Detection, Evaluation,
and Treatment of High Blood Pressure (JNC) categorized four levels
of systolic blood pressure (SBP) and diastolic blood pressure (DBP).
JNC VII Blood Pressure Classification for Adults
Category Systolic (mm Hg) Diastolic (mm Hg)
Normal <120 <80 Prehypertension 120–139 80–89 Stage 1 Hypertension 140–159 90–99 Stage 2 Hypertension ≥160 ≥100 If Diabetes or Renal Disease <130 <80 When the systolic and diastolic levels fall in different categories, use the higher category. For example, 170/92 mm Hg is Stage 2 hyper- tension; 135/100 mm Hg is Stage 1 hypertension. In isolated systolic hypertension, systolic blood pressure is ≥140 mm Hg, and diastolic blood pressure is <90 mm Hg. Heart Rate. The radial pulse is used commonly to assess heart rate. With the pads of your index and middle fingers, compress the radial artery until you detect a maximal pulsa- tion. If the rhythm is regular, count the rate for 15 seconds and multiply by 4. If the rate is unusually fast or slow, count it for 60 seconds. When the rhythm is irregular, evaluate the rate by auscultation at the car- diac apex (the apical pulse). E XA M I N AT I O N T E C H N I Q U E S Chapter 4 | Beginning the Physical Examination 57 Rhythm. Feel the radial pulse. Check the rhythm again by lis- tening with your stethoscope at the cardiac apex. Is the rhythm regular or irregular? If irregular, try to identify a pattern: (1) Do early beats appear in a basically regular rhythm? (2) Does the irregularity vary consistently with respiration? (3) Is the rhythm totally irregular? Palpation of an irregularly irregular rhythm reliably indicates atrial fibrilla- tion. For all irregular patterns, an ECG is needed to identify the arrhythmia. Respiratory Rate and Rhythm. Observe the rate, rhythm, depth, and effort of breathing. Count the number of respirations in 1 minute either by visual inspection or by subtly listening over the patient’s tra- chea with your stethoscope dur- ing examination of the head and neck or chest. Normally, adults take 14 to 20 breaths per min- ute in a quiet, regular pattern. See Table 4-5, p. 65, Abnormalities in Rate and Rhythm of Breathing. Temperature. Average oral temperature, usually 37°C (98.6°F), fluctuates considerably from the early morning to the late afternoon or evening. Rectal tem- peratures are higher than oral tem- peratures by about 0.4 to 0.5°C (0.7 to 0.9°F) but also vary. Fever or pyrexia refers to an elevated body temperature. Hyperpyrexia refers to extreme elevation in temperature, above 41.1°C (106°F), while hypothermia refers to an abnormally low temperature, below 35°C (95°F) rectally. Causes of fever include infection, trauma (such as surgery or crush injuries), malignancy, blood disorders (such as acute hemolytic anemia), drug reactions, and immune disorders such as collagen vascular disease. The chief cause of hypothermia is expo- sure to cold. Other predisposing causes include reduced movement as in paraly- sis, interference with vasoconstriction as from sepsis or excess alcohol, starvation, hypothyroidism, and hypoglycemia. Older adults are especially susceptible to hypothermia and also less likely to develop fever. In contrast, axillary temperatures are lower than oral temperatures by approximately 1° but take 5 to 10 minutes to register and are considered less accurate than other measurements. E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S 58 Bates’ Pocket Guide to Physical Examination and History Taking Oral temperatures: Choose either glass or electronic thermometer. ● Glass thermometer: Shake the thermometer down to 35°C (96°F) or below, insert it under the tongue, instruct the patient to close both lips, and wait 3 to 5 minutes. Then read the thermometer, reinsert for 1 minute, and read it again. Avoid breakage. ● Electronic thermometer : Care- fully place the disposable cover over the probe and insert the thermometer under the tongue for about 10 seconds. Tympanic membrane tem- perature: Make sure the external auditory canal is free of cerumen. Position the probe in the canal. Wait 2 to 3 seconds until the dig- ital reading appears. This method measures core body temperature, which is higher than the normal oral temperature by approxi- mately 0.8°C (11.4°F). Rectal temperatures: Ask the patient to lie on one side with the hip flexed. Select a rectal ther- mometer with a stubby tip, lubri- cate it, and insert it about 3 cm to 4 cm (1½ inches) into the anal canal, in a direction pointing to the umbilicus. Remove it after 3 min- utes, then read. Alternatively, use an electronic thermometer after lubricating the probe cover. Wait about 10 seconds for the digital temperature recording to appear. Taking rectal temperatures is common practice in unresponsive patients at risk for biting down on the thermometer. E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S ACUTE AND CHRONIC PAIN The experience of pain is complex and multifactorial. It involves sensory, emotional, and cognitive processing but may lack a specific physical etiology. Chronic pain is defined in several ways: pain not associated with cancer or other medical conditions that persists for more than 3 to 6 months; pain lasting more than 1 month beyond the course of an acute illness or injury; or pain recurring at intervals of months or years. Chronic noncancer pain affects 5% to 33% of patients in primary care settings. Adopt a comprehensive approach, carefully listening to the patient’s description of the many features of pain and contributing factors. Accept the self-report, which experts state is the most reliable indicator of pain. Location. Ask the patient to point to the pain. Lay terms may not be specific enough to localize the site of origin. Severity. Use a consistent method to determine severity. Three scales are common: the Visual Analog Scale, and two scales using ratings from 1 to 10—the Numeric Rating Scale and the Faces Pain Scale. Associated Features. Ask the patient to describe the pain and how it started. Pursue the seven features of pain, as you would with any symptom. Attempted Treatments, Medications, Related Illnesses, and Impact on Daily Activities. Be sure to ask about any treatments that the patient has tried, including medications, physical therapy, and alternative medicines. A comprehensive medication history helps you to identify drugs that interact with analgesics and reduce their efficacy. Identify any comorbid conditions such as arthritis, diabetes, HIV/AIDS, substance abuse, sickle cell disease, or psychiatric disorders. These can significantly affect the patient’s experience of pain. Health Disparities. Be aware of the well-documented health dis- parities in pain treatment and delivery of care, which range from lower use of analgesics in emergency rooms for African American and Hispanic patients to disparities in use of analgesics for cancer, Chapter 4 | Beginning the Physical Examination 59 E XA M I N AT I O N T E C H N I Q U E S 60 Bates’ Pocket Guide to Physical Examination and History Taking postoperative, and low back pain. Clinician stereotypes, language bar- riers, and unconscious clinician biases in decision making all contribute to these disparities. Critique your own communication style, seek information and best practice standards, and improve your techniques of patient education and empowerment. Pain Management. Monitor the effectiveness of pain interven- tions, especially narcotics, by assessing the “four As”: Analgesia, Activities of daily living, Adverse effects, and Aberrant drug-related behaviors. Risk of death from overdose of opioids rise four- to eight- fold for doses above 100 mg/day. Recording Your Findings Record the vital signs taken at the time of your examination. They are preferable to those taken earlier in the day by other providers. (Com- mon abbreviations for blood pressure, heart rate, and respiratory rate are self-explanatory.) Recording the Physical Examination—General Sur vey and Vital Signs ◗ “Mrs. Scott is a young, healthy-appearing woman, well-groomed, fit, and in good spirits. Height is 5′4″, weight 135 lb, BP 120/80, HR 72 and regular, RR 16, temperature 37.5°C.” OR ◗ “Mr. Jones is an elderly man who looks pale and chronically ill. He is alert, with good eye contact, but cannot speak more than two or three words at a time because of shortness of breath. He has intercostal muscle retraction when breathing and sits upright in bed. He is thin, with diffuse muscle wast- ing. Height is 6′2″, weight 175 lbs, BP 160/95, HR 108 and irregular, RR 32 and labored, temperature 101.2°F.” (Suggests COPD exacerbation.) RRReccoorddinnggg YYouuur FinnddinngssYY E XA M I N AT I O N T E C H N I Q U E S Aids to InterpretationAAAiddss ttoo Inntterrpprreetaattioonn Eating Disorders and Excessively Low BMITable 4-1 Anorexia Nervosa Bulimia Nervosa Refusal to maintain minimally normal body weight (or BMI above 17.5 kg/m2) Fear of appearing fat Frequently starving but in denial; lacking insight Often brought in by family members May present as failure to make expected weight gains in childhood or adolescence, amenorrhea in women, loss of libido or potency in men Associated with depressive symptoms such as depressed mood, irritability, social withdrawal, insomnia, decreased libido Additional features supporting diagnosis: self-induced vomiting or purging, excessive exercise, use of appetite suppressants and/or diuretics Biologic complications ● Neuroendocrine changes: amenorrhea, hormonal alterations ● Cardiovascular disorders: bradycardia, hypotension, dysrhythmias, cardiomyopathy ● Metabolic disorders: hypokalemia, hypochloremic metabolic alkalosis, increased BUN, edema Other: dry skin, dental caries, delayed gastric emptying, constipation, anemia, osteoporosis Repeated binge eating followed by self-induced vomiting, misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise Often with normal weight Overeating at least twice a week during 3-month period; large amounts of food consumed in short period (∼2 hrs) Preoccupation with eating; craving and compulsion to eat; lack of control over eating; alternating with periods of starvation Dread of fatness but may be obese Subtypes of ● Purging: bulimic episodes accompanied by self-induced vomiting or use of laxatives, diuretics, or enemas ● Nonpurging: bulimic episodes accompanied by compensatory behavior such as fasting, exercise without purging Biologic complications; see changes listed for anorexia nervosa. Sources: World Health Organization. The ICD-10 Classification of Mental and Behavioral Disorders: Diagnostic Criteria for Research. Geneva: World Health Organization, 1993; American Psychiatric Association. DSM-IV-TR: Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Text Revision. Washington, DC: American Psychiatric Association, 2000. Halmi KA: Eating disorders: In: Kaplan HI, Sadock BJ, eds. Comprehensive Textbook of Psychiatry, 7th ed. Philadelphia: Lippincott Williams & Wilkins, 1663–1676, 2000. Mehler PS. Bulimia nervosa. N Engl J Med 2003;349(9):875–880. Chapter 4 | Beginning the Physical Examination 61 62 Bates’ Pocket Guide to Physical Examination and History Taking Table 4-2 Nutrition Screening Checklist I have an illness or condition that made me change the kind and/or amount of food I eat. Yes (2 pts) _________ I eat fewer than 2 meals per day. Yes (3 pts) _________ I eat few fruits or vegetables, or milk products. Yes (2 pts) _________ I have 3 or more drinks of beer, liquor, or wine almost every day. Yes (2 pts) _________ I have tooth or mouth problems that make it hard for me to eat. Yes (2 pts) _________ I don’t always have enough money to buy the food I need. Yes (4 pts) _________ I eat alone most of the time. Yes (1 pt) _________ I take 3 or more different prescribed or over-the-counter drugs each day. Yes (1 pt) _________ Without wanting to, I have lost or gained 10 pounds in the last 6 months. Yes (2 pts) _________ I am not always physically able to shop, cook, and/or feed myself. Yes (2 pts) _________ TOTAL _________ Instructions: Check “yes” for each condition that applies, then total the nutritional score. For total scores between 3 and 5 points (moderate risk) or ≥6 points (high risk), further evaluation is needed (especially for the elderly). Source: American Academy of Family Physicians. The Nutrition Screening Initiative. Available at: www.aafp.org/PreBuilt/NSI_DETERMINE . Accessed January 23, 2008. http://www.aafp.org/PreBuilt/NSI_DETERMINE Table 4-3 Nutrition Counseling: Sources of Nutrients Nutrient Food Source Calcium Dairy foods such as milk, natural cheeses, and yogurt Calcium-fortified cereals, fruit juice, soy milk, and tofu Dark green leafy vegetables like collard, turnip, and mustard greens; bok choy Sardines Iron Lean meat, dark turkey meat, liver Clams, mussels, oysters, sardines, anchovies Iron-fortified cereals Enriched and whole grain bread Spinach, peas, lentil, turnip greens, peas, and artichokes Dried prunes and raisins Folate Cooked dried beans and peas Oranges, orange juice Liver Black-eyed peas, lentils, okra, chick peas, peanuts Folate-fortified cereals Vitamin D Vitamin D–fortified milk Cod liver oil; salmon, mackerel, tuna Egg yolks, butter, margarine Vitamin D–fortified cereals Source: Adapted from: Dietary Guidelines Committee, 2000 Report. Nutrition and Your Health: Dietary Guidelines for Americans. Washington, DC: Agricultural Research Service, U.S. Department of Agriculture, 2000; Choose MyPlate.gov. Available at http://www.choosemyplate.gov/index.html. Accessed June 24, 2011; Office of Dietary Supplements, National Institutes of Health. Dietary Supplement Fact Sheets: Calcium; Vitamin D. At http://ods.od.nih.gov/factsheets/list-all/. Accessed June 24, 2011. Chapter 4 | Beginning the Physical Examination 63 http://www.choosemyplate.gov/index.html http://ods.od.nih.gov/factsheets/list-all 64 Bates’ Pocket Guide to Physical Examination and History Taking Table 4-4 Patients With Hypertension: Recommended Changes in Diet Dietary Change Food Source Increase foods high in potassium Baked white or sweet potatoes White beans, beet greens, soybeans, spinach, lentils, kidney beans Bananas, plantains, many dried fruits, orange juice Tomato sauce, juice, and paste Decrease foods high in sodium Canned foods (soups, tuna fish) Pretzels, potato chips, pickles, olives Many processed foods (frozen dinners, ketchup, mustard) Batter-fried foods Table salt, including for cooking Source: Adapted from Dietary Guidelines Committee. 2000 Report. Nutrition and Your Health: Dietary Guidelines for Americans. Washington, DC: Agricultural Research Service, U.S. Department of Agriculture, 2000. Choose MyPlate.gov. Available at http://www.choosemyplate.gov/index.html. Accessed June 24, 2011; Office of Dietary Supplements, National Institutes of Health. Dietary Supplement Fact Sheets: Calcium; Vitamin D. At http://ods.od.nih.gov/factsheets/list-all/. Accessed June 24, 2011. http://www.choosemyplate.gov/index.html http://ods.od.nih.gov/factsheets/list-all Table 4-5 Abnormalities in Rate and Rhythm of Breathing Normal. In adults, 14–20 per min; in infants, up to 44 per min. Rapid Shallow Breathing (Tachypnea). Many causes, including restrictive lung disease, pleural chest pain, and an elevated diaphragm. Rapid Deep Breathing (Hyperpnea, Hyperventilation). Many causes, including exercise, anxiety, metabolic acidosis, brainstem injury. Kussmaul breathing, due to metabolic acidosis, is deep, but rate may be fast, slow, or normal. Slow Breathing (Bradypnea). May be secondary to diabetic coma, drug- induced respiratory depression, increased intracranial pressure. Cheyne-Stokes Breathing. Rhythmically alternating periods of hyperpnea and apnea. In infants and the aged, may be normal during sleep; also accompanies brain damage, heart failure, uremia, drug-induced respiratory depression. Ataxic (Biot’s) Breathing. Unpredictable irregularity of depth and rate. Causes include brain damage and respiratory depression. Sighing Breathing. Breathing punctuated by frequent sighs. When associated with other symptoms, it suggests the hyperventilation syndrome. Occasional sighs are normal. Chapter 4 | Beginning the Physical Examination 65 67 C H A P T E R 5Behavior and Mental Status Empathic listening, careful observation, and skilled history tak- ing help patients to reveal their deepest concerns and experiences. Clinicians often miss clues to trauma, mental illness, and harmful dysfunctional behaviors. The prevalence of mental health disorders in the U.S. population is 30%, yet only approximately 20% of affected patients receive treatment. Even for patients who obtain care, evi- dence suggests that adherence to treatment guidelines in primary care offices is <50%. Often, patients have health symptoms that mirror medical illnesses. Thirty percent of symptoms last more than 6 weeks and are “medically unexplained,” masking anxiety, depression, or even somatoform disorders. See Table 5-1, Somatoform Disorders: Types and Approach, pp. 76–78. Depression and anxiety are highly correlated with substance abuse, for example, and clinicians are advised to look for overlap in these conditions. “Difficult patients” are frequently those with multiple unexplained symptoms and underlying psychiatric conditions that are amenable to therapy. Without better “dual diagnosis,” patient health, function, and quality of life are at risk. Mental Health Disorders and Unexplained Symptoms in Primary Care Settings Mental Health Disorders in Primary Care ◗ Approximately 20% of primary care outpatients have mental disorders, but up to 50% to 75% of these disorders are undetected and untreated. ◗ Prevalence of mental disorders in primary care settings is roughly: ◗ Anxiety—20% ◗ Mood disorders including dysthymia, depressive, and bipolar disorders—25% ◗ Depression—10% ◗ Somatoform disorder—10% to 15% ◗ Alcohol and substance abuse—15% to 20% (continued) 68 Bates’ Pocket Guide to Physical Examination and History Taking For unexplained conditions lasting beyond 6 weeks, experts recom- mend brief screening questions with high sensitivity and specificity, followed by more detailed investigation when indicated due to high rates of coexisting depression and anxiety. Mental Health Disorders and Unexplained Symptoms in Primary Care Settings (continued) Explained and Unexplained Symptoms ◗ Physical symptoms account for approximately 50% of office visits. ◗ Roughly one-third of physical symptoms are unexplained; in 20% to 25% of patients, physical symptoms become chronic or recurring. ◗ In patients with unexplained symptoms, the prevalence of depression and anxiety exceeds 50% and increases with the total number of reported physical symptoms, making detection and “dual diagnosis” important clinical goals. Common Functional Syndromes ◗ Co-occurrence rates for common functional syndromes such as irritable bowel syndrome, fibromyalgia, chronic fatigue, temporomandibular joint disorder, and multiple chemical sensitivity reach 30% to 90%, depending on the dis- orders compared. ◗ The prevalence of symptom overlap is high in the common functional syn- dromes: namely, complaints of fatigue, sleep disturbance, musculoskeletal pain, headache, and gastrointestinal problems. ◗ The common functional syndromes also overlap in rates of functional impairment, psychiatric comorbidity, and response to cognitive and antidepressant therapy. Patient Identifiers for Mental Health Screening ◗ Medically unexplained physical symptoms—more than half have a depressive or anxiety disorder ◗ Multiple physical or somatic symptoms or “high symptom count” ◗ High severity of the presenting somatic symptom ◗ Chronic pain ◗ Symptoms for more than 6 weeks ◗ Physician rating as a “difficult encounter” ◗ Recent stress ◗ Low self-rating of overall health ◗ High use of health care services ◗ Substance abuse Chapter 5 | Behavior and Mental Status 69 The Health History Common or Concerning Symptoms ◗ Changes in attention, mood, or speech ◗ Changes in insight, orientation, or memory ◗ Anxiety, panic, ritualistic behavior, and phobias ◗ Delirium or dementia Your assessment of mental status begins with the patient’s first words. As you gather the health history, you will quickly observe the patient’s level of alertness and orientation, mood, attention, and memory. You will learn about the patient’s insight and judgment, as well as any recurring or unusual thoughts or perceptions. For some, you will need to conduct a more formal evaluation of mental status. Many of the terms used to describe the mental status examination are familiar to you from social conversation. Take the time to learn their precise meanings in the context of the formal evaluation of mental status (see below). TTThee HHeeaaltth HHiisstoryy Terminology: The Mental Status Examination Level of Consciousness Alertness or State of Awareness of the Environment Attention The ability to focus or concentrate over time on one task or activity Memory The process of registering or recording information. Recent or short-term memory covers minutes, hours, or days; remote or long-term memory refers to intervals of years. Orientation Awareness of personal identity, place, and time; requires both memory and attention Perceptions Sensory awareness of objects in the environment and their in- terrelationships; also refers to internal stimuli (e.g., dreams) Thought processes The logic, coherence, and relevance of the patient’s thoughts, or how people think Thought content What the patient thinks about, including level of insight and judgment Insight Awareness that symptoms or disturbed behaviors are normal or abnormal Judgment Process of comparing and evaluating alternatives; reflects values that may or may not be based on reality and social conventions or norms (continued) 70 Bates’ Pocket Guide to Physical Examination and History Taking Assess level of consciousness, general appear- ance and mood, and ability to pay attention, remember, understand, and speak. See Table 5-2, Disorders of Mood, pp. 78–79. Assess the patient’s responses to illness and life circumstances, which often tell you about his or her insight and judgment. Test orientation and memory. Explore any unusual thoughts, preoccupa- tions, beliefs, or perceptions as they arise during the interview. See Table 5-3, Anxiety Disor- ders, pp. 80–81, and Table 5-4, Selected Psychotic Disorders, p. 82. All patients with documented or suspected brain lesions, psychiatric symptoms, or reports from family members of vague or changed behavioral symptoms need further systematic assessment. See Table 20-2, Delirium and Dementia, pp. 391–392. Terminology: The Mental Status Examination (continued) Level of Consciousness Alertness or State of Awareness of the Environment Affect An observable, usually episodic, feeling tone expressed through voice, facial expression, and demeanor Mood A more sustained emotion that may color a person’s view of the world (affect is to mood as weather is to climate) Language A complex symbolic system for expressing, receiving, and comprehending words; essential for assessing other mental functions Higher cognitive functions Assessed by vocabulary, fund of information, abstract thinking, calculations, construction of objects with two or three dimensions Mood Disorders and Depression. Lifetime prevalence of major depression meeting formal diagnostic criteria in the United States is approximately 7%. Primary care providers fail to diagnose major Important Topics for Health Promotion and Counseling ◗ Screening for depression and suicidality ◗ Screening for alcohol, prescription drug, and substance abuse Health Promotion and Counseling: Evidence and Recommendations Chapter 5 | Behavior and Mental Status 71 depression in up to 50% of affected patients, often missing early clues such as low self-esteem, anhedonia (lack of pleasure in daily activities), sleep disorders, and difficulty concentrating or making decisions. Failure to diagnose depression can have fatal consequences—suicide rates in patients with major depression are eight times higher than in the general population. Ask, “Over the past 2 weeks, have you felt down, depressed, or hopeless?” and “Over the past 2 weeks, have you felt little interest or pleasure in doing things?” Suicide. Suicide rates are highest among men 75 years and older and are increasing among teenagers and young adults. More than half of patients committing suicide have visited their physicians in the prior month. More than 90% of suicide deaths occur in patients with depression or other mental health disorders or substance abuse. Risk factors include suicidal or homicidal ideation, intent, or plan; access to the means for suicide; current symptoms of psychosis or severe anxiety; any history of psychiatric illness (especially linked to a hospital admis- sion); substance abuse; personality disorder; and prior history or family history of suicide. Patients with these risk factors should be immediately referred for psychiatric care and possibly hospitalization. Alcohol, Prescription Drug, and Substance Abuse. The comor- bidity of alcohol and substance abuse with mental health disorders and suicide are extensive. Alcohol, tobacco, and illicit drugs account for more illness, deaths, and disabilities than any other preventable condi- tion. Lifetime prevalence of alcohol and illicit drug use in the United States is 13% and 3%. In recent U.S. surveys, 8% of those 12 years or older, or 19 million people, reported use of illicit drugs in the prior 30 days. An estimated 3% are dependent on or abuse illicit drugs; of these, 60% use marijuana. Prescription drug abuse now kills more people than illicit substances. Because screening for alcohol and drug use is part of every patient history, review the screening questions recommended in Chapter 3, Interviewing and the Health History. Techniques of Examination The Mental Status Examination ◗ Appearance and behavior ◗ Speech and language ◗ Mood ◗ Thoughts and perceptions ◗ Cognition, including memory, attention, information and vocabulary, calculations, abstract thinking, and constructional ability 72 Bates’ Pocket Guide to Physical Examination and History Taking E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S Observe patient’s mental status throughout your interaction. Test specific functions if indicated during the interview or physical examination. APPEARANCE AND BEHAVIOR Assess the following: ● Level of Consciousness. Observe alertness and response to verbal and tactile stimuli. Normal consciousness, lethargy, obtundation, stupor, coma (see p. 304–305) ● Posture and Motor Behavior. Observe pace, range, character, and appropriateness of movements. Restlessness, agitation, bizarre postures, immobility, involuntary movements ● Dress, Grooming, and Personal Hygiene Fastidiousness, neglect ● Facial Expressions. Assess during rest and interaction. Anxiety, depression, elation, anger, responses to imaginary people or objects, withdrawal ● Manner, Affect, and Relation to People and Things SPEECH AND LANGUAGE Note quantity, rate, loudness, clarity, and fluency of speech. If indicated, test for aphasia. Aphasia, dysphonia, dysarthria, changes with mood disorders Testing for Aphasia Word Comprehension Ask patient to follow a one-stage command, such as “Point to your nose.” Try a two-stage command: “Point to your mouth, then your knee.” Repetition Ask patient to repeat a phrase of one-syllable words (the most difficult repetition task): “No ifs, ands, or buts.” Naming Ask patient to name the parts of a watch. Reading Comprehension Ask patient to read a paragraph aloud. Writing Ask patient to write a sentence. Chapter 5 | Behavior and Mental Status 73 E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S MOOD Ask about the patient’s spirits. Note nature, intensity, duration, and stability of any abnormal mood. If indicated, assess risk of suicide. Happiness, elation, depression, anxiety, anger, indifference THOUGHT AND PERCEPTIONS Thought Processes. Assess logic, rel- evance, organization, and coherence. Derailments, flight of ideas, incoher- ence, confabulation, blocking Thought Content. Ask about and explore any unusual or unpleasant thoughts. Obsessions, compulsions, delusions, feelings of unreality Perceptions. Ask about any unusual perceptions (e.g., seeing or hearing things). Illusions, hallucinations Insight and Judgment. Assess patient’s insight into the illness and level of judgment used in making decisions or plans. Recognition or denial of mental cause of symptoms; bizarre, impulsive, or unrealistic judgment COGNITIVE FUNCTIONS If indicated, assess: Orientation to time, place, and person Disorientation Attention ● Digit span—ability to repeat a series of numbers forward and then backward ● Serial 7s—ability to subtract 7 repeatedly, starting with 100 ● Spelling backward of a five-letter word, such as W-O-R-L-D Poor performance of digit span, serial 7s, and spelling backward are common in dementia and delirium but have other causes, too. Remote Memory (e.g., birthdays, anniversaries, social security number, schools, jobs, wars) Impaired in late stages of dementia 74 Bates’ Pocket Guide to Physical Examination and History Taking E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S Recent Memory (e.g., events of the day) New Learning Ability—ability to repeat three or four words after a few minutes of unrelated activity Recent memory and new learning ability impaired in dementia, delir- ium, and amnestic disorders HIGHER COGNITIVE FUNCTIONS If indicated, assess: Information and Vocabulary. Note range and depth of patient’s informa- tion, complexity of ideas expressed, and vocabulary used. For the fund of information, ask names of presidents, other political figures, or large cities. These attributes reflect intelligence, education, and cultural background. They are limited by mental retarda- tion but are fairly well preserved in early dementia. Calculating Abilities, such as addi- tion, subtraction, and multiplication Poor calculation in mental retardation and dementia Abstract Thinking—ability to respond abstractly to questions about ● The meaning of proverbs, such as “A stitch in time saves nine” ● The similarities of beings or things, such as a cat and a mouse or a piano and a violin Concrete responses (observable details rather than concepts) are common in mental retardation, dementia, and delirium. Responses are sometimes bizarre in schizo- phrenia. Constructional Ability. Ask patient: Impaired ability common in demen- tia and with parietal lobe damage ● To copy figures such as circle, cross, diamond, and box, and two intersecting pentagons, or ● To draw a clock face with numbers and hands SPECIAL TECHNIQUE Mini-Mental State Examination (MMSE). This brief test is useful in screening for cognitive dysfunction and dementia and following their course over time. For more detailed information regarding the MMSE, contact the Publisher, Psychological Assessment Resources, Inc., 16204 North Florida Avenue, Lutz, Florida 33549. Some sample questions are given on the next page. Chapter 5 | Behavior and Mental Status 75 MMSE Sample Items Orientation to Time “What is the date?” Registration “Listen carefully; I am going to say three words. You say them back after I stop. Ready? Here they are . . . HOUSE (pause), CAR (pause), LAKE (pause). Now repeat those words back o me.” [Repeat up to five times, but score only the first trial.] Naming “What is this?” [Point to a pencil or pen.] Reading “Please read this and do what it says.” [Show examinee the words on the stimulus form.] CLOSE YOUR EYES Reproduced by special permission of the Publisher, Psychological Assessment Resources, Inc., 16204 North Florida Avenue, Lutz, FL 33549, from the Mini Mental State Examination, by Marshal Folstein and Susan Folstein, Copyright 1975, 1998, 2001 by Mini Mental LLC, Inc. Published 2001 by Psychological Assessment Resources, Inc. Further reproduction is prohibited without permission of PAR, Inc. The MMSE can be purchased from PAR, Inc. Recording Your FindingsRRReccoorddinnggg YYouuur Finnddinngss Recording Behavior and Mental Status “Mental Status: The patient is alert, well-groomed, and cheerful. Speech is fluent and words are clear. Thought processes are coherent, insight is good. The patient is oriented to person, place, and time. Serial 7s accurate; recent and remote memory intact. Calculations intact.” OR “Mental Status: The patient appears sad and fatigued; clothes are wrinkled. Speech is slow and words are mumbled. Thought processes are coherent, but insight into current life reverses is limited. The patient is oriented to person, place, and time. Digit span, serial 7s, and calculations accurate, but responses delayed. Clock drawing is good.” (Suggests depression) E XA M I N AT I O N T E C H N I Q U E S 76 Bates’ Pocket Guide to Physical Examination and History Taking Aids to InterpretationAAAiddss ttoo IInntterrpprreetaattioonn Somatoform Disorders: Types and Approach to SymptomsTable 5-1 Types of Somatoform Disorders Somatoform Disorders* Disorder Features Somatization disorder Chronic multisystem disorder characterized by complaints of pain, gastrointestinal and sexual dysfunction, and pseudoneurologic symptoms. Onset is usually early in life, and psychosocial and vocational achievements are limited. Conversion disorder Syndrome of symptoms of deficits mimicking neurologic or medical illness in which psychological factors are judged to be of etiologic importance Pain disorder Clinical syndrome characterized predominantly by pain in which psychological factors are judged to be of etiologic importance Hypochondriasis Chronic preoccupation with the idea of having a serious disease. The preoccupation is usually poorly amenable to reassurance Body dysmorphic disorder Preoccupation with an imagined or exaggerated defect in physical appearance Other Somatoform-like Disorders Factitious disorder Intentional production or feigning of physical or psychological signs when external reinforcers (e.g., avoidance of responsibility, financial gain) are not clearly present Malingering Intentional production or feigning of physical or psychological signs when external reinforcers (e.g., avoidance of responsibility, financial gain) are present Dissociative disorders Disruptions of consciousness, memory, identity, or perception judged to be due to psychological factors Approach to Somatic and Unexplained Symptoms Stepped Care Approach to Somatic Symptoms in Primary Care† Is the somatic symptom likely to be . . . Clinician action might be . . . Acutely serious? (<5% of cases) Expedited diagnostic workup Minor/self-limited? (70%–75% of cases) Address patient expectations Symptom-specific therapy Follow-up in 2–6 weeks Chapter 5 | Behavior and Mental Status 77 Is the somatic symptom likely to be . . . Clinician action might be . . . Chronic or recurrent? (20%– 25% of cases) Screen for depression and anxiety Caused or aggravated by a depressive or anxiety disorder? Antidepressant therapy and/or cognitive–behavioral therapy (CBT) Due to a functional somatic syndrome? Syndrome-specific therapy Antidepressant therapy and/or CBT Persistent and medically unexplained? Regular, time-limited clinic visits Consider mental health referral Symptom management strategies, if evidence-based (e.g., behavioral treatments, pain self-management programs, pain or other specialty clinics, complementary and alternative medicine) Rehabilitative rather than disability approach Management Guidelines for Patients With Medically Unexplained Symptoms‡ General Aspects Show empathy and understanding for the complaints and frustrating experiences the patient has had so far (e.g., explain that medically unexplained symptoms are common). Develop a good patient–physician relationship; try to be the “coordinator” of diagnostic procedures and care. Diagnosis Explore not only the history of complaints and former treatments, but any impairment, anxiety, and psychosocial issues. Use screeners and self-report questionnaires to enhance detection; use symptom diaries to assess course and factors influencing symptoms. When the patient presents with a new symptom, examine the relevant organ system. Provide the results of investigations to give clear reassurance that there is no serious physical disease. Avoid unnecessary diagnostic tests or surgical procedures. Treatment Provide regularly scheduled visits (e.g., every 4–6 weeks), especially in the case of a history of very frequent healthcare utilization. Explain that treatment is coping, not curing (when pathology cannot be found or does not explain degree of complaints). Somatoform Disorders: Types and Approach to Symptoms (continued)Table 5-1 (continued) 78 Bates’ Pocket Guide to Physical Examination and History Taking Is the somatic symptom likely to be . . . Clinician action might be . . . Referral Suggest coping strategies like regular physical activity, relaxation, distraction. If referral is necessary to start psychotherapy or psychopharmacotherapy, prepare the patient for the treatment and provide reassurance that you will continue to be the patient’s doctor. Sources: *Schiffer RB. Psychiatric disorders in medical practice. In: Goldman L, Ausiello D, eds. Cecil Textbook of Medicine. 22nd ed. Philadelphia: Saunders 2004, pp. 2628–2639; †Kroenke K. Patients presenting with somatic complaints: epidemiology, psychiatric comorbidity, and management. Int J Methods Psychiatr Res 2003;12(1):34–43. ‡Reif W, Martin A, Rauh E, et al. Evaluation of general practitioners’ training: how to manage patients with unexplained physical symptoms. Psychosomatics 2006;47(4):304–311. Somatoform Disorders: Types and Approach to Symptoms (continued)Table 5-1 Disorders of MoodTable 5-2 Major Depressive Episode Manic Episode At least five of the symptoms listed below (including one of the first two) must be present during the same 2-week period; they must represent a change from the person’s previous state. ● Depressed mood (may be an irritable mood in children and adolescents) most of the day, nearly every day ● Markedly diminished interest or pleasure in almost all activities most of the day, nearly every day ● Significant weight gain or loss (not dieting) or increased or decreased appetite nearly every day A distinct period of abnormally and persistently elevated, expansive, or irritable mood must be present for at least a week (any duration if hospitalization is necessary). During this time, at least three of the symptoms listed below have been persistent and significant. (Four symptoms are required if the mood is only irritable.) ● Inflated self-esteem or grandiosity ● Decreased need for sleep (feels rested after sleeping 3 hours) ● More talkative than usual or pressure to keep talking Chapter 5 | Behavior and Mental Status 79 Disorders of Mood (continued)Table 5-2 Major Depressive Episode Manic Episode ● Insomnia or hypersomnia nearly every day ● Psychomotor agitation or retardation nearly every day ● Fatigue or loss of energy nearly every day ● Feelings of worthlessness or inappropriate guilt nearly every day ● Inability to think or concentrate or indecisiveness nearly every day ● Recurrent thoughts of death or suicide, or a specific plan for or attempt at suicide The symptoms cause significant distress or impair social, occupational, or other important functions. In severe cases, hallucinations and delusions may occur. ● Flight of ideas or racing thoughts ● Distractibility ● Increased goal-directed activity (either socially at work or school, or sexually) or psychomotor agitation ● Excessive involvement in pleasurable high-risk activities (buying sprees, foolish business ventures, sexual indiscretions) The disturbance is severe enough to impair social or occupational functions or relationships. It may necessitate hospitalization for the protection of self or others. In severe cases, hallucinations and delusions may occur. Mixed Episode Hypomanic Episode A mixed episode, which must last at least 1 week, meets the criteria for both major and manic depressive episodes. The mood and symptoms resemble those in a manic episode but are less impairing, do not require hospitalization, do not include hallucinations or delusions, and have a shorter minimum duration—4 days. Dysthymic Disorder Cyclothymic Episode A depressed mood and symptoms for most of the day, for more days than not, over at least 2 years (1 year in children and adolescents). Freedom from symptoms lasts no more than 2 months at a time. Numerous periods of hypomanic and depressive symptoms that last for at least 2 years (1 year in children and adolescents). Freedom from symptoms lasts no more than 2 months at a time. Tables 5-2 to 5-4 are based, with permission, on the Diagnostic and Statistical Manual of Mental Disorders, 4th ed., Text Revision [DSM IV-TR]. Washington, DC: American Psychiatric Association, 2000. For further details and criteria, the reader should consult this manual, its successor, or comprehensive textbooks of psychiatry. 80 Bates’ Pocket Guide to Physical Examination and History Taking Anxiety DisordersTable 5-3 Panic Disorder. Recurrent, unexpected panic attacks, at least one of which has been followed by a month or more of persistent concern about further attacks, worry over their implications or consequences, or a significant change in behavior in relation to the attacks. A panic attack is a discrete period of intense fear or discomfort that develops abruptly and peaks within 10 minutes. It involves at least four of the following symptoms: (1) palpitations, pounding heart, or accelerated heart rate; (2) sweating; (3) trembling or shaking; (4) shortness of breath or a sense of smothering; (5) a feeling of choking; (6) chest pain or discomfort; (7) nausea or abdominal distress; (8) feeling dizzy, unsteady, lightheaded, or faint; (9) feelings of unreality or depersonalization; (10) fear of losing control or going crazy; (11) fear of dying; (12) paresthesias (numbness or tingling); and (13) chills or hot flushes. Agoraphobia. Anxiety about being in places or situations where escape may be difficult or embarrassing or help for sudden symptoms unavailable. Such situations are avoided, require a companion, or cause marked anxiety. Specific Phobia. A marked, persistent, and excessive or unreasonable fear that is cued by the presence or anticipation of a specific object or situation, such as dogs, injections, or flying. The person recognizes the fear as excessive or unreasonable, but exposure to the cue provokes immediate anxiety. Avoidance or fear impairs the person’s normal routine, occupational or academic functioning, or social activities or relationships. Social Phobia. A marked, persistent fear of one or more social or performance situations that involve exposure to unfamiliar people or to scrutiny by others. Those afflicted fear that they will act in embarrassing or humiliating ways, as by showing their anxiety. Exposure creates anxiety and possibly a panic attack, and the person avoids precipitating situations. He or she recognizes the fear as excessive or unreasonable. Normal functioning, social activities, or relationships are impaired. Chapter 5 | Behavior and Mental Status 81 Anxiety Disorders (continued)Table 5-3 Obsessive–Compulsive Disorder. Obsessions or compulsions that cause marked anxiety or distress. Although recognized as excessive or unreasonable, they are time-consuming and interfere with the person’s normal routine and relationships. Acute Stress Disorder. Exposure to a traumatic event that involved actual or threatened death or serious injury to self or others, leading to intense fear, helplessness, or horror. During or immediately after this event, the person has at least three dissociative symptoms: (1) a subjective sense of numbing, detachment, or absence of emotional responsiveness; (2) a reduced awareness of surroundings, as in a daze; (3) feelings of unreality; (4) feelings of depersonalization; and (5) amnesia for an important part of the event. The event is persistently reexperienced, as in thoughts, images, dreams, illusions, and flashbacks. The person is anxious, shows increased arousal, and avoids stimuli that evoke memories of the event. Causes marked distress or impairs social, occupational, or other important functions. Symptoms occur within 4 weeks of the event and last from 2 days to 4 weeks. Posttraumatic Stress Disorder. The event, fearful response, and persistent reexperiencing of the traumatic event resemble acute stress disorder. Hallucinations may occur. The person has increased arousal, tries to avoid stimuli related to the trauma, and has numbing of general responsiveness. Causes marked distress and impaired social or occupational function, and lasts for more than a month. Generalized Anxiety Disorder. Lacks a specific traumatic event or focus for concern. Excessive anxiety and worry are hard to control and generalize to a number of events or activities. At least three of the following symptoms are associated: (1) feeling restless, keyed up, or on edge; (2) being easily fatigued; (3) difficulty in concentrating or mind going blank; (4) irritability; (5) muscle tension; and (6) difficulty in falling or staying asleep, or restless, unsatisfying sleep. Causes significant distress or impairs daily function. 82 Bates’ Pocket Guide to Physical Examination and History Taking Selected Psychotic DisordersTable 5-4 Schizophrenia. Impairs major functioning at work or school, in interpersonal relations, or in self-care. Performance of one or more of these functions must decrease for a significant time to a level markedly below prior achievement. Person displays at least two of the following for a significant part of 1 month: (1) delusions; (2) hallucinations; (3) disorganized speech; (4) grossly disorganized or catatonic behavior; and (5) negative symptoms such as a flat affect, alogia (lack of content in speech), or avolition (lack of interest, drive, and ability to set and pursue goals). Continuous signs of the disturbance must persist for at least 6 months. Subtypes of this disorder include paranoid, disorganized, and catatonic schizophrenia. Schizophreniform Disorder. Symptoms are similar to those of schizophrenia but last <6 months. Functional impairment need not be present. Schizoaffective Disorder. Features both a major mood disturbance and schizophrenia. Mood disturbance (depressive, manic, or mixed) present during most of the illness and must, for a time, be concurrent with symptoms of schizophrenia and demonstrate delusions or hallucinations for at least 2 weeks without prominent mood symptoms. Delusional Disorder. Nonbizarre delusions involve situations in real life, such as having a disease, and persists for at least a month. Functioning is not markedly impaired and behavior is not obviously odd or bizarre. Symptoms of schizophrenia, except for tactile and olfactory hallucinations, are not present. Brief Psychotic Disorder. At least one of the following psychotic symptoms must be present: delusions, hallucinations, disordered speech such as frequent derailment or incoherence, or grossly disorganized or catatonic behavior. Disturbance lasts ≥1 day but <1 month, and person returns to prior functional level. 83 C H A P T E R 6The Skin, Hair, and Nails The Health History Common or Concerning Symptoms ◗ Hair loss ◗ Rash ◗ Growths Health Promotion and Counseling: Evidence and Recommendations Important Topics for Health Promotion and Counseling ◗ Skin cancers: types and risk factors ◗ Avoidance of excessive sun exposure Counsel patients to avoid unnecessary sun exposure, tanning beds, and sunlamps and to use sunscreen with at least SPF-15. It is helpful to show patients pictures of basal cell carcinomas, squamous cell carci- nomas and melanomas (pp. 94–95). Teach the ABCDE screen for dysplastic nevi/melanomas: Asymmetry, irregular Borders, variation in Color, Diameter ≥6 mm, and Evolution or change in size, symptoms, or morphology. Survey skin at 3-year intervals for patients 20 to 40 years of age and annually for patients older than 40 years. For those older than age 50 or with dysplastic nevi or history of melanoma, encourage monthly self-examination and do regular clinical screening. 84 Bates’ Pocket Guide to Physical Examination and History Taking E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S SKIN Examine the entire skin surface under good lighting. Inspect and palpate any growths. Note: ● Color ● Moisture ● Temperature ● Texture ● Mobility—ease with which a fold of skin can be moved ● Turgor—speed with which the fold returns into place Cyanosis, jaundice, carotenemia, changes in melanin Dry, oily Cool, warm Smooth, rough Decreased if edema Decreased if dehydration Note any lesions and their: ● Anatomical location and distribution ● Patterns and shapes ● Type ● Color Generalized, localized Linear, clustered, dermatomal Macule, papule, pustule, bulla, tumor Red, white, brown, heliotrope Techniques of Examination Chapter 6 | The Skin, Hair, and Nails 85 E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S HAIR Inspect and palpate the hair. Note: ● Quantity ● Distribution ● Texture Thin, thick Patchy or total alopecia Fine, coarse NAILS Inspect and palpate the fingernails and toenails. Note: ● Color ● Shape ● Any lesions Cyanosis, pallor Clubbing Paronychia, onycholysis Recording the Physical Examination—The Skin Recording Your Findings “Color pink. Skin warm and moist. Nails without clubbing or cyanosis. No suspicious nevi, rash, petechiae, or ecchymoses.” 86 Bates’ Pocket Guide to Physical Examination and History Taking Aids to Interpretation Color/Mechanism Selected Causes Brown: Increased melanin (greater than a person’s genetic norm) Sun exposure Pregnancy (melasma) Addison’s disease Blue (cyanosis): Increased deoxyhemoglobin from hypoxia: ● Peripheral ● Central (arterial) Anxiety or cold environment Heart or lung disease Abnormal hemoglobin Methemoglobinemia, sulfhemoglobinemia Red: Increased visibility of oxyhemoglobin from: ● Dilated superficial blood vessels or increased blood flow in skin ● Decreased use of oxygen in skin Fever, blushing, alcohol intake, local inflammation Cold exposure (e.g., cold ears) Yellow: Increased bilirubin of jaundice (sclera looks yellow) Carotenemia (sclera does not look yellow) Liver disease, hemolysis of red blood cells Increased carotene intake from yellow fruits and vegetables Pale: Decreased melanin Decreased visibility of oxyhemoglobin from: ● Decreased blood flow to skin ● Decreased amount of oxyhemoglobin Edema (may mask skin pigments) Albinism, vitiligo, tinea versicolor Syncope or shock Anemia Nephrotic syndrome Color Changes in the SkinTable 6-1 Chapter 6 | The Skin, Hair, and Nails 87 Primary Skin LesionsTable 6-2 Flat, Nonpalpable Lesions With Changes in Skin Color Macule—Small flat spot, up to 1.0 cm Examples: ● Hemangioma ● Vitiligo Patch—Flat spot, 1.0 cm or larger Example: Café-au-lait spot Palpable Elevations: Solid Bumps Papule—Up to 1.0 cm Example: An elevated nevus (continued) 88 Bates’ Pocket Guide to Physical Examination and History Taking Table 6-2 Primary Skin Lesions (continued) Plaque—Elevated superficial lesion 1.0 cm or larger, often formed by coalescence of papules Example: Psoriasis Nodule—Knot-like lesion larger than 0.5 cm, deeper and more firm than a papule Example: Dermatofibroma Cyst—Nodule filled with expressible material, either liquid or semisolid Example: Epidermal inclusion cyst Wheal—A somewhat irregular, relatively transient, superficial area of localized skin edema Examples: Mosquito bite, hives (urticaria) Chapter 6 | The Skin, Hair, and Nails 89 Table 6-2 Primary Skin Lesions (continued) Palpable Elevations With Fluid-Filled Cavities Vesicle—Up to 1.0 cm; filled with serous fluid Example: Herpes simplex Example: Herpes zoster Bulla—1.0 cm or larger; filled with serous fluid Example: Insect bite Example: Insect bite Pustule—Filled with pus (yellow proteinaceous fluid filled with neutrophils) Example: Acne (continued) 90 Bates’ Pocket Guide to Physical Examination and History Taking Table 6-2 Primary Skin Lesions (continued) Example: Small pox Burrow—A minute, slightly raised tunnel in the epidermis, commonly found on the finger webs and on the sides of the fingers. It looks like a short (5–15 mm), linear or curved gray line and may end in a tiny vesicle. With a magnifying lens, look for the burrow of the mite that causes scabies. Example: Scabies Table 6-3 Secondary Skin Lesions May arise from primary lesions, overtreatment, excess scratching Scale—A thin flake of dead, exfoliated epidermis Example: Ichthyosis vulgaris Example: Dry skin Chapter 6 | The Skin, Hair, and Nails 91 Table 6-3 Secondary Skin Lesions (continued) Crust—The dried residue of skin exudates such as serum, pus, or blood Example: Impetigo Lichenification—Visible and palpable thickening of the epidermis and roughening of the skin with increased visibility of the normal skin furrows (often from chronic rubbing) Example: Neurodermatitis Scars—Increased connective tissue that arises from injury or disease Example: Hypertrophic scar from steroid injections Keloids—Hypertrophic scarring that extends beyond the borders of the initiating injury Example: Keloid—ear lobe Sources of photos: Hemangioma, Café-au-Lait Spot, Elevated Nevus, Psoriasis [bottom], Dermatofibroma, Herpes Simplex, Insect Bite [bottom], Impetigo, Lichenification—Hall JC. Sauer’s Manual of Skin Diseases, 9th ed. Philadelphia: Lippincott Williams & Wilkins, 2006; Vitiligo, Psoriasis [top], Epidermal Inclusion Cyst, Urticaria, Insect Bite [top], Acne, Ichthyosis, Psoriasis, Acne Scar, Keloids— Goodheart HP. Goodheart’s Photoguide of Common Skin Disorders: Diagnosis and Management, 2nd ed. Philadelphia: Lippincott Williams & Wilkins, 2003; Small Pox—Ostler HB, Mailbach HI, Hoke AW, Schwab IR. Diseases of the Eye and Skin: A Color Atlas. Philadelphia: Lippincott Williams & Wilkins, 2004. 92 Bates’ Pocket Guide to Physical Examination and History Taking Table 6-4 Secondary Skin Lesions—Depressed Erosion—Nonscarring loss of the superficial epidermis; surface is moist but does not bleed Example: Aphthous stomatitis, moist area after the rupture of a vesicle, as in chickenpox Excoriation—Linear or punctate erosions caused by scratching Example: Cat scratches Fissure—A linear crack in the skin, often resulting from excessive dryness Example: Athlete’s foot Ulcer—A deeper loss of epidermis and dermis; may bleed and scar Examples: Stasis ulcer of venous insufficiency, syphilitic chancre Sources of photos: Erosion, Excoriation, Fissure—Goodheart HP. Goodheart’s Photoguide of Common Skin Disorders: Diagnosis and Management, 2nd ed. Philadelphia: Lippincott Williams & Wilkins, 2003; Ulcer—Hall JC. Sauer’s Manual of Skin Diseases, 9th ed. Philadelphia: Lippincott Williams & Wilkins, 2006. Chapter 6 | The Skin, Hair, and Nails 93 Table 6-5 Vascular and Purpuric Lesions of the Skin Lesion Features: Appearance; Distribution; Significance Cherry Angioma ● Bright or ruby red, may become purplish with age; 1–3 mm; round, flat, sometimes raised; may be surrounded by a pale halo ● Found on trunk or extremities ● Not significant; increase in size and number with aging Spider Angioma ● Fiery red; very small to 2 cm; central body, sometimes raised, radiating with erythema ● Face, neck, arms, and upper trunk, but almost never below the waist ● Seen in liver disease, pregnancy, vitamin B deficiency; normal in some people Spider Vein ● Bluish; varies from very small to several inches; may resemble a spider or be linear, irregular, or cascading ● Most often on the legs, near veins; also on anterior chest ● Often accompanies increased pressure in the superficial veins, as in varicose veins Petechia/Purpura ● Deep red or reddish purple; fades over time; 1–3 mm or larger; rounded, sometimes irregular, flat ● Varied distribution ● Seen if blood outside the vessels; may suggest a bleeding disorder or, if petechiae, emboli to skin (continued) 94 Bates’ Pocket Guide to Physical Examination and History Taking Table 6-5 Vascular and Purpuric Lesions of the Skin (continued) Lesion Features: Appearance; Distribution; Significance Ecchymosis ● Purple or purplish blue, fading to green, yellow, and brown over time; larger than petechiae; rounded, oval, or irregular ● Varied distribution ● Seen if blood outside the vessels; often secondary to bruising or trauma; also seen in bleeding disorders Table 6-6 Skin Tumors Actinic Keratoses Superficial, flattened papules covered by a dry scale. Often multiple; may be round or irregular; pink, tan, or grayish. Appear on sun- exposed skin of older, fair-skinned persons. Considered dysplastic or precancerous: 1 out of 1,000 per year develop into squamous cell carcinoma (look for continued growth, induration, redness at the base, and ulceration). Typically on face and hands. Seborrheic Keratoses Common, benign, whitish-yellowish to brown, raised papules or plaques that feel slightly greasy, velvety or warty; have a “stuck-on” appearance. Typically multiple and symmetrical, distributed on the trunk of older people, also on the face and elsewhere. In blacks, may appear as small, deeply pigmented papules on cheeks and temples (dermatosis papulosa nigra). Chapter 6 | The Skin, Hair, and Nails 95 Table 6-6 Skin Tumors (continued) Basal Cell Carcinoma Though malignant, grows slowly and almost never metastasizes. Most common in fair-skinned adults 40 years or older; usually on the face. Initial translucent red macule or papule may develop a depressed center and firm elevated border. Telangiectatic vessels often visible. Squamous Cell Carcinoma Usually on sun-exposed skin of fair-skinned adults 60 years or older. May develop in an actinic keratosis. Usually grows more quickly than a basal cell carcinoma, is firmer, and looks redder. The face and the dorsum of the hand are often affected. Kaposi’s Sarcoma in AIDS May appear in many forms: macules, papules, plaques, or nodules almost anywhere on the body. Lesions are often multiple and may involve internal structures. Sources of photos: Basal Cell Carcinoma: Rapini R. Squamous Cell Carcinoma, Actinic Keratosis, and Seborrheic Keratosis—Hall JC. Sauer’s Manual of Skin Diseases, 9th ed. Philadelphia: Lippincott Williams & Wilkins, 2006; Kaposi’s Sarcoma in AIDS— DeVita VT Jr, Hellman S, Rosenberg SA [eds]. AIDS: Etiology, Diagnosis, Treatment, and Prevention. Philadelphia: JB Lippincott, 1985. 96 Bates’ Pocket Guide to Physical Examination and History Taking Table 6-7 Benign and Malignant Nevi Benign Diameter <6 mm Symmetric; regular borders; even in color Malignant Melanoma: “ABCDE” Asymmetric Borders irregular Color varied Diameter >6 mm
Evolution or change in size, symptoms or
morphology
Courtesy of American Cancer Society; American Academy of Dermatology.

Chapter 6 | The Skin, Hair, and Nails 97
Table 6-8 Hair Loss
Alopecia Areata Clearly demarcated round or oval patches of hair loss,
usually affecting young adults and children. There is no visible scaling or
inflammation.
Trichotillomania Hair loss from pulling, plucking, or twisting hair.
Hair shafts are broken and of varying lengths. More common in
children, often in settings of family or psychosocial stress.
Tinea Capitis (“Ringworm”) Round scaling patches of alopecia.
Hairs are broken off close to the surface of the scalp. Usually caused
by fungal infection from Trichophyton tonsurans from humans,
microsporum canis from dogs or cats. Mimics seborrheic dermatitis.
Sources of photos: Alopecia Areata [top], Trichotillomania [top]—Hall JC. Sauer’s
Manual of Skin Diseases, 9th ed. Philadelphia: Lippincott Williams & Wilkins, 2006;
Alopecia Areata [bottom], Tinea Capitis—Goodheart HP. Goodheart’s Photoguide
of Common Skin Disorders: Diagnosis and Management, 2nd ed. Philadelphia:
Lippincott Williams & Wilkins, 2003; Trichotillomania [bottom]—Ostler HB,
Mailbach HI, Hoke AW, Schwab IR. Diseases of the Eye and Skin: A Color Atlas.
Philadelphia: Lippincott Williams & Wilkins, 2004.

98 Bates’ Pocket Guide to Physical Examination and History Taking
Table 6-9 Findings in or Near the Nails
Clubbing Dorsal phalanx rounded and bulbous;
convexity of nail plate increased. Angle
between plate and proximal nail fold
increased to 180° or more. Proximal nail
folds feel spongy. Many causes, including
chronic hypoxia and lung cancer.
Paronychia Inflammation of proximal and lateral nail
folds, acute or chronic. Folds red, swollen,
may be tender.
Onycholysis Painless separation of nail plate from nail bed,
starting distally. Many causes.
Terry’s Nails Whitish with a distal band of reddish brown.
Seen in aging and some chronic diseases.
Leukonychia White spots caused by trauma. They grow out
with nail(s).
Transverse
White Lines
Curved white lines similar to curve of lunula.
They follow an illness and grow out with
nails.

99
C H A P T E R
7The Head and Neck
The Health History
Common or Concerning Symptoms
THE HEAD
Headache is a common symp-
tom that always requires careful
evaluation because a small frac-
tion of headaches arise from life-
threatening conditions. Elicit a
full description of the headache
and all seven attributes of the
patient’s pain (see p. 3).
See Table 7-1, Primary Headaches,
p. 111, and Table 7-2, Secondary Head-
aches, pp. 112–114. Tension and migraine
headaches are the most common
recurring headaches.
Is the headache one-sided or
bilateral? Steady or throbbing?
Continuous or comes and
goes? Ask the patient to point
to the area of pain or discomfort.
Assess chronologic pattern and
severity.
Tension headaches often arise
in the temporal areas; cluster headaches
may be retro-orbital.
Changing or progressively severe head-
aches increase the likelihood of tumor,
abscess, or other mass lesion. Extremely
severe headaches suggest subarachnoid
hemorrhage or meningitis.
TTThee HHeeaaltth HHiisstoryy
◗ Nosebleed, or epistaxis
◗ Sore throat, hoarseness
◗ Swollen glands
◗ Goiter
◗ Headache
◗ Change in vision
◗ Double vision, or diplopia
◗ Hearing loss, earache, tinnitus
◗ Vertigo

100 Bates’ Pocket Guide to Physical Examination and History Taking
● Ask about associated symptoms,
such as nausea and vomiting,
and neurologic symptoms such
as change in vision or motor-
sensory deficits.
Visual aura or scintillating scotomas may
accompany migraine. Nausea and vomit-
ing are common with migraine but also
occur with brain tumor and subarachnoid
hemorrhage.
● Ask if coughing, sneezing, or
changing the position of the
head affects (better, worse, or
none) the headache.
Such maneuvers may increase pain from
brain tumor and acute sinusitis.
● Ask about family history. Family history is often positive in
patients with migraine.
THE EYES
Ask “How is your vision?” If
the patient reports a change in
vision, pursue the related details:
Gradual blurring, often from refractive
errors; also in hyperglycemia.
● Is the onset sudden or
gradual?
Sudden visual loss suggests retinal
detachment, vitreous hemorrhage, or
occlusion of the central retinal artery.
● Is the problem worse during
close work or at distances?
Difficulty with close work suggests hyper-
opia (farsightedness) or presbyopia (aging
vision); difficulty with distances suggests
myopia (nearsightedness).
● Is there blurring of the entire
field of vision or only parts? Is
blurring central, peripheral, or
only on one side?
Slow central loss occurs in nuclear
cataract and macular degeneration;
peripheral loss in advanced open-angle
glaucoma; one-sided loss in hemianopsia
and quadrantic defects (p. 115).
Headache Warning Signs
◗ Progressively frequent or severe over a 3-month period
◗ Sudden onset like a “thunderclap” or “the worst headache of my life”
◗ New onset after age 50 years
◗ Aggravated or relieved by change in position
◗ Precipitated by Valsalva maneuver
◗ Associated symptoms of fever, night sweats, or weight loss
◗ Presence of cancer, HIV infection, or pregnancy
◗ Recent head trauma
◗ Associated papilledema, neck stiffness, or focal neurologic deficits

Chapter 7 | The Head and Neck 101
● Has the patient seen lights
flashing across the field of
vision? Vitreous floaters?
These symptoms suggest detachment
of vitreous from retina. Prompt eye
consultation is indicated.
Ask about pain in or around the
eyes, redness, and excessive tear-
ing or watering.
Eye pain in acute glaucoma and optic
neuritis.
Check for diplopia, or double
vision.
Diplopia in brainstem or cerebellum
lesions, also from weakness or paralysis
of one or more extraocular muscles.
THE EARS
Ask “How is your hearing?” See Table 7-8, Patterns of Hearing Loss,
p. 121.
Does the patient have special
difficulty understanding people
as they talk? Does a noisy envi-
ronment make a difference?
Sensorineural loss leads to difficulty
understanding speech, often complain-
ing that others mumble; noisy environ-
ments worsen hearing. In conductive
loss, noisy environments may help.
For complaints of earache, or pain
in the ear, ask about associated
fever, sore throat, cough, and con-
current upper respiratory infection.
Consider otitis externa if pain in the ear
canal; otitis media if pain associated with
respiratory infection.
Tinnitus is an internal musical
ringing or rushing or roaring
noise, often unexplained.
When associated with hearing loss and
vertigo, tinnitus suggests Ménière’s
disease.
Ask about vertigo, the percep-
tion that the patient or the envi-
ronment is rotating or spinning.
Vertigo in labrynthitis (inner ear), CN VII
lesions, brainstem lesions
THE NOSE AND SINUSES
Rhinorrhea, or drainage from
the nose, frequently accom-
panies nasal congestion. Ask
further about sneezing, watery
eyes, throat discomfort, and
itching in the eyes, nose, and
throat.
Causes include viral infections, allergic
rhinitis (“hay fever”), and vasomotor
rhinitis. Itching favors an allergic cause.

102 Bates’ Pocket Guide to Physical Examination and History Taking
For epistaxis, or bleeding from
the nose, identify the source
carefully—is bleeding from the
nose or has the patient coughed
up or vomited blood? Assess the
site of bleeding, its severity, and
associated symptoms.
Local causes of epistaxis include trauma
(especially nose-picking), inflammation,
drying and crusting of the nasal mucosa,
tumors, and foreign bodies. Anticoagu-
lants, NSAIDs, and coagulopathies may
contribute.
THE MOUTH, THROAT, AND NECK
Sore throat or pharyngitis is a
frequent complaint. Ask about
fever, swollen glands, and any
associated cough.
Fever, pharyngeal exudates, and anterior
cervical lymphadenopathy, especially
without cough, suggest streptococcal
pharyngitis, or “strep throat” (p. 125).
Hoarseness may arise from over-
use of the voice, allergies, smok-
ing, or inhaled irritants.
Also present in viral laryngitis, hypo-
thyroidism, laryngeal disease, or when
extrapharyngeal lesions press on the
laryngeal nerves
Assess thyroid function. Ask
about goiter, temperature intol-
erance, and sweating.
With goiter, thyroid function may be
increased, decreased, or normal. Cold
intolerance in hypothyroidism; heat
intolerance, palpitations, and involun-
tary weight loss in hyperthyroidism
Important Topics for Health Promotion
and Counseling
Disorders of vision shift with age. Healthy young adults generally
have refractive errors. Up to 25% of adults older than 65 years have
refractive errors; cataracts, macular degeneration, and glaucoma also
become more prevalent. Glaucoma is the leading cause of blindness in
African Americans and the second leading cause of blindness overall.
Glaucoma causes gradual vision loss, with damage to the optic nerve,
loss of visual fields, beginning usually at the periphery, and pallor
Health Promotion and Counseling:
Evidence and Recommendations
◗ Loss of vision: cataracts, macular degeneration, glaucoma
◗ Hearing loss
◗ Oral health

Chapter 7 | The Head and Neck 103
and increasing size of the optic cup (enlarging to more than half the
diameter of the optic disc).
More than a third of adults older than 65 years have detectable hear-
ing deficits. Questionnaires and handheld audioscopes work well for
periodic screening.
Be sure to promote oral health: Up to half of all children 5 to 17 years
of age have one to eight cavities, and the average U.S. adult has 10 to
17 decayed, missing, or filled teeth. More than half of all adults older
than 65 years have no teeth! Inspect the oral cavity for decayed or
loose teeth, inflammation of the gingiva, and signs of periodontal dis-
ease (bleeding, pus, receding gums, and bad breath). Counsel patients
to use fluoride-containing toothpastes, brush, floss, and seek dental
care at least annually.
Techniques of Examination
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
THE HEAD
Examine the:
● Hair, including quantity,
distribution, and texture
● Scalp, including lumps or
lesions
● Skull, including size and con-
tour
● Face, including symmetry and
facial expression
● Skin, including color, texture,
hair distribution, and lesions
Coarse and sparse in hypothyroidsm, fine
in hyperthyroidism
Pilar cysts, psoriasis, pigmented nevi
Hydrocephalus, skull depression from
trauma
Facial paralysis; flat affect of depression,
moods such as anger, sadness
Pale, fine, hirsute, acne, skin cancer
THE EYES
Test visual acuity in each eye. Diminished acuity
Assess visual fields, if indicated. Hemianopsia, quadrantic defects in
cerebrovascular accidents (CVAs). See
Table 7-3, Visual Field Defects, p. 115.
TTTecchhnniquees offf EExaammminnatttionn

104 Bates’ Pocket Guide to Physical Examination and History Taking
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
Inspect the: See Table 7-4, Physical Findings In and
Around the Eye, pp. 116–117.
● Position and alignment of eyes
● Eyebrows
● Eyelids
● Lacrimal apparatus
● Conjunctiva and sclera
● Cornea, iris, and lens
Exophthalmos, strabismus
Seborrheic dermatitis
Sty, chalazion, ectropion, ptosis,
xanthelasma
Swollen lacrimal sac
Red eye, conjunctivitis, jaundice,
episcleritis
Corneal opacity, cataract
Examine pupils for:
● Size, shape, and symmetry
● Reactions to light, direct and
consensual
● The near reaction: pupillary
constriction with gaze shift
to near objection; with con-
vergence and accommodation
(lens becomes more convex)
Miosis, mydriasis, anisocoria
Absent in paralysis of CN III
Useful in tonic (Adie’s) versus Argyll
Robertson pupils: constriction slows in
tonic pupil; absent in Argyll Robertson
pupils of syphilis; poor convergence in
hyperthyroidism
THE NEAR REACTION
Assess the extraocular muscles by
observing:
● The corneal reflections from a
midline light
● The six cardinal directions of
gaze
Asymmetric reflection if deviation in
ocular alignment
Cranial nerve palsy, strabismus, nystag-
mus, lid lag of hyperthyroidism

Chapter 7 | The Head and Neck 105
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
Superior
rectus (III)
Lateral
rectus
(VI)
Inferior
rectus (III)
Superior
rectus (III)
Lateral
rectus
(VI)
Inferior
rectus (III)
Superior
oblique (IV)
Medial
rectus (III)
Inferior
oblique (III)
Inspect the fundi with an
ophthalmoscope.
Inspect the fundi for the following:
● Red reflex
● Optic disc
Cataracts, artificial eye
Papilledema, glaucomatous cupping,
optic atrophy. See Table 7-5, Abnormali-
ties of the Optic Disc, p. 118, and Table 7-6,
Ocular Fundi: Diabetic Retinopathy, p. 119.
Tips for Using the Ophthalmoscope
◗ Darken the room. Turn the lens disc to the large round beam of white light.
Lower the brightness of the light beam to make the examination more com-
fortable for the patient.
◗ Turn the lens disc to the 0 diopter (a diopter measures the power of a lens to
converge or diverge light).
◗ Hold the ophthalmoscope in your right hand and use your right eye to exam-
ine the patient’s right eye; hold it in your left hand and use your left eye to
examine the patient’s left eye to avoid bumping the patient’s nose.
◗ Brace the ophthalmoscope firmly against the medial aspect of your bony
orbit, with the handle tilted laterally at about a 20-degree slant from the
vertical. Instruct the patient to look slightly up and over your shoulder at a
point directly ahead on the wall.
◗ Place yourself about 15 inches away from the patient and at an angle 15
degrees lateral to the patient’s line of vision. Look for the orange glow in the
pupil—the red reflex. Note any opacities interrupting the red reflex. No red
reflex suggests an opacity of the lens (cataract) or possibly the vitreous.
◗ Place the thumb of your other hand across the patient’s eyebrow. Keeping the
light beam focused on the red reflex, move in at a 15-degree angle toward the
pupil until you almost touch the patient’s eyelashes. Adjust the position of
your ophthalmoscope and angle of vision as a unit until you see the fundus.

106 Bates’ Pocket Guide to Physical Examination and History Taking
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
Artery
Vein
Optic disc
Physiologic cupMacula
● Arteries, veins, and AV
crossings
● Adjacent retina (note any
lesions)
AV nicking, copper wiring in
hypertensive changes
Hemorrhages, exudates, cotton-wool
patches, microaneurysms, pigmentation
● Macular area
● Anterior structures
Macular degeneration
Vitreous floaters, cataracts
Tips for Examining the Optic Disc and Retina
◗ Locate the optic disc. Look for the round yellowish-orange structure.
◗ Now, bring the optic disc into sharp focus by adjusting the lens of your
ophthalmoscope.
◗ Inspect the optic disc. Note the following features:
◗ The sharpness or clarity of the disc outline
◗ The color of the disc
◗ The size of the central physiologic cup (an enlarged cup suggests chronic
open-angle glaucoma)
◗ Venous pulsations in the retinal veins as they emerge from the central por-
tion of the disc (loss of venous pulsations from elevated intracranial pres-
sure may occur in head trauma, meningitis)
◗ Inspect the retina. Distinguish arteries from veins based on the features listed below.
Arteries Veins
Color Light red Dark red
Size Smaller (2⁄3 to 3⁄4 the diam-
eter of veins)
Larger
Light Reflex (reflection) Bright Inconspicuous or
absent
(continued)

Chapter 7 | The Head and Neck 107
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
Tips for Examining the Optic Disc and Retina (continued)
◗ Follow the vessels peripherally in each of four directions.
◗ Inspect the fovea and surrounding macula. Macular degeneration types
include dry atrophic (more common but less severe) and wet exudative (neo-
vascular). Undigested cellular debris, called drusen, may be hard or soft.
◗ Assess for any papilledema from
increased intracranial pressure
leading to swelling of the optic
nerve head.
PAPILLEDEMA
THE EARS
Examine on each side:
The Auricle
Inspect the auricle. Keloid, epidermoid cyst
If you suspect otitis:
● Move the auricle up and down,
and press on the tragus.
● Press firmly behind the ear.
Pain in otitis externa (“the tug test”)
Possible tenderness in otitis media and
mastoiditis
Ear Canal and Drum
Pull the auricle up, back, and
slightly out. Inspect, through an
otoscope speculum:
● The canal
● The eardrum
Cerumen; swelling and erythema in
otitis externa
Red bulging drum in acute otitis media;
serous otitis media, tympanosclerosis,
perforations. See Table 7-7, Abnormalities
of the Eardrum, p. 120.

108 Bates’ Pocket Guide to Physical Examination and History Taking
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
Short process of malleus
Handle of malleus
Cone of light
Umbo
Pars tensa
Incus
Pars flaccida
Hearing
Assess auditory acuity to
whispered or spoken voice.
If hearing is diminished, use a
512-Hz tuning fork to:
● Test lateralization (Weber
test). Place vibrating and
tuning fork on vertex of skull
and check hearing.
● Compare air and bone con-
duction (Rinne test). Place
vibrating and tuning fork on
mastoid bone, then remove
and check hearing.
These tests help distinguish between
sensorineural and conduction hearing
loss.
See Table 7-8, Patterns of Hearing Loss,
p. 121.
THE NOSE AND SINUSES
Inspect the external nose.
Inspect, through a speculum, the:
● Nasal mucosa that covers the
septum and turbinates, noting
its color and any swelling
● Nasal septum for position and
integrity
Swollen and red in viral rhinitis, swollen
and pale in allergic rhinitis; polyps; ulcer
from cocaine use
Deviation, perforation
Palpate the frontal and maxillary
sinuses.
Tender in acute sinusitis

Chapter 7 | The Head and Neck 109
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
THE MOUTH AND PHARYNX
Inspect the:
● Lips
● Oral mucosa
● Gums
● Teeth
● Roof of the mouth
● Tongue, including:
● Papillae
● Symmetry
● Any lesions
● Floor of the mouth
● Pharynx, including:
● Color or any exudate
● Presence and size of tonsils
● Symmetry of the soft palate
as patient says “ah”
Cyanosis, pallor, cheilosis. See also Table
7-9, Abnormalities of the Lips, p. 122.
Aphthous ulcers (canker sores)
Gingivitis, periodontal disease
Dental caries, tooth loss
Torus palatinus
See Table 7-10, Abnormalities of the
Tongue, pp. 123–124.
Glossitis
Deviation to one side from paralysis of
CN XII from CVA
Cancer
Cancer
See Table 7-11, Abnormalities of the
Pharynx, p. 125.
Pharyngitis
Exudates, tonsillitis, peritonsillar abscess
Soft palate fails to rise in paralysis of
CN X from CVA
THE NECK
Inspect the neck. Scars, masses, torticollis
Palpate the lymph nodes. Cervical lymphadenopathy from inflam-
mation, malignancy, HIV

110 Bates’ Pocket Guide to Physical Examination and History Taking
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
Inspect and palpate the position
of the trachea.
Deviated trachea from neck mass or
pneumothorax
Inspect the thyroid gland:
● At rest
● As patient swallows water
Goiter, nodules. See Table 7-12, Abnor-
malities of the Thyroid Gland, p. 126.
From behind patient, palpate
the thyroid gland, including the
isthmus and the lateral lobes:
Goiter, nodules, tenderness of thyroiditis
● At rest
● As patient swallows water
Alternate Sequence. After examining the thyroid gland from behind
the patient, you may proceed to musculoskeletal examination of the
neck and upper back and check for costovertebral angle tenderness.
Recording the Physical Examination—The Head,
Eyes, Ears, Nose, and Throat (HEENT)
HEENT: Head—The skull is normocephalic/atraumatic (NC/AT). Hair with aver-
age texture. Eyes—Visual acuity 20/20 bilaterally. Sclera white; conjunctiva
pink. Pupils constrict 4 mm to 2 mm, equally round and reactive to light and
accommodations. Disc margins sharp; no hemorrhages or exudates; no arte-
riolar narrowing. Ears—Acuity good to whispered voice. Tympanic membranes
(TMs) with good cone of light. Weber midline. AC > BC. Nose—Nasal mucosa
pink, septum midline; no sinus tenderness. Throat (or Mouth)—Oral mucosa
pink; dentition good; pharynx without exudates. Neck—Trachea midline. Neck
supple; thyroid isthmus palpable, lobes not felt. Lymph Nodes—No cervical,
axillary, epitrochlear, inguinal adenopathy.
Recording Your FindingsRRReccoorddinnggg YYouuur Finnddinngss

Chapter 7 | The Head and Neck 111
Aids to InterpretationAAAiddss ttoo IInntterrpprreetaattioonn
Table 7-1 Primary Headaches
Problem
Common
Characteristics
Associated Symptoms, With
Provoking and Relieving
Factors
Tension Location: Variable
Quality: Pressing or
tightening pain;
mild to moderate
intensity
Onset: Gradual
Duration: Minutes
to days
Sometimes photophobia,
phonophobia; nausea
absent
↑ by sustained muscle
tension, as in driving or
typing
↓ possibly by massage,
relaxation
Migraine
● With aura
● Without
aura
● Variants
Location: Unilateral in
∼70%; bifrontal or
global in ∼30%
Quality: Throbbing or
aching, variable in
severity
Onset: Fairly rapid,
peaks in 1–2 hr
Duration: 4–72 hr
Nausea, vomiting,
photophobia,
phonophobia, visual auras
(flickering zig-zagging
lines), motor auras
affecting hand or arm,
sensory auras (numbness,
tingling usually precede
headache)
↑ by alcohol, certain foods,
tension, noise, bright
light. More common
premenstrually.
↓ by quiet dark room, sleep
Cluster Location: Unilateral,
usually behind or
around the eye
Quality: Deep,
continuous, severe
Onset: Abrupt, peaks
within minutes
Duration: Up to 3 hr
Lacrimation, rhinorrhea,
miosis, ptosis, eyelid
edema, conjunctival
infection
↑ sensitivity to alcohol
during some episodes

112 Bates’ Pocket Guide to Physical Examination and History Taking
Table 7-2 Secondary Headaches
Problem

Common Characteristics
Associated Symptoms,
With Provoking and
Relieving Factors
Analgesic
Rebound
Location: Previous
headache pattern
Quality: Variable
Onset: Variable
Duration: Depends on
prior headache pattern
Depends on prior
headache pattern
↑ by fever, carbon
monoxide, hypoxia,
withdrawal of
caffeine, other
headache triggers
↓ —depends on cause
Headaches From
Eye Disorders
Errors of
Refraction
(farsighted ness
and astigmatism,
but not near –
sightedness)
Location: Around and over
the eyes; may radiate to
the occipital area
Quality: Steady, aching,
dull
Onset: Gradual
Duration: Variable
Eye fatigue, “sandy”
sensation in eyes,
redness of the
conjunctiva
↑ by prolonged use of
the eyes, particularly
for close work
↓ by rest of the eyes
Acute Glaucoma Location: In and around
one eye
Quality: Steady, aching,
often severe
Onset: Often rapid
Duration: Variable, may
depend on treatment
Diminished vision,
sometimes nausea
and vomiting
↑ —sometimes by
drops that dilate the
pupils
Headache From
Sinusitis
Location: Usually above
eye (frontal sinus) or
over maxillary sinus
Quality: Aching or
throbbing, variable
in severity; consider
possible migraine
Onset: Variable
Duration: Often several
hours at a time, recurring
over days or longer
Local tenderness, nasal
congestion, tooth
pain, discharge, and
fever
↑ by coughing,
sneezing, or jarring
the head
↓ by nasal
decongestants,
antibiotics

Chapter 7 | The Head and Neck 113
Problem

Common Characteristics
Associated Symptoms,
With Provoking and
Relieving Factors
Meningitis Location: Generalized
Quality: Steady or
throbbing, very severe
Onset: Fairly rapid
Duration: Variable,
usually days
Fever, stiff neck
Subarachnoid
Hemorrhage
Location: Generalized
Quality: Severe, “the
worst of my life”
Onset: Usually abrupt;
prodromal symptoms
may occur
Duration: Variable,
usually days
Nausea, vomiting,
possibly loss of
consciousness, neck
pain
Brain Tumor Location: Varies with the
location of the tumor
Quality: Aching, steady,
variable in intensity
Onset: Variable
Duration: Often brief
↑ by coughing,
sneezing, or sudden
movements of the
head
Cranial
Neuralgias:
Trigeminal
Neuralgia (CN V)
Location: Cheek, jaws,
lips, or gums; trigeminal
nerve divisions 2 and
3 > 1
Quality: Shocklike,
stabbing, burning,
severe
Onset: Abrupt,
paroxysmal
Duration: Each jab lasts
seconds but recurs at
intervals of seconds or
minutes
Exhaustion from
recurrent pain
↑ by touching certain
areas of the lower
face or mouth;
chewing, talking,
brushing teeth
Table 7-2 Secondary Headaches (continued)
(continued)

114 Bates’ Pocket Guide to Physical Examination and History Taking
Problem

Common Characteristics
Associated Symptoms,
With Provoking and
Relieving Factors
Giant Cell
(Temporal)
Arteritis
Location: Near the
involved artery, often
the temporal, also the
occipital; age-related
Quality: Throbbing,
generalized, persistent,
often severe
Onset: Gradual or rapid
Duration: Variable
Tenderness of the
adjacent scalp; fever
(in ∼50%), fatigue,
weight loss; new
headache (∼60%),
jaw claudication
(∼50%), visual
loss or blindness
(∼15%–20%),
polymyalgia
rheumatica (∼50%)
↑ by movement of
neck and shoulders
Postconcu ssion
Headache
Location: Injured area,
but not necessarily
Quality: Generalized,
dull, aching, constant
Onset: Within hours to
1–2 days of the injury
Duration: Weeks, months,
or even years
Poor concentration,
problems with
memory, vertigo,
irritability,
restlessness, fatigue
↑ by mental and
physical exertion,
straining, stooping,
emotional
excitement, alcohol
↓ by rest
Table 7-2 Secondary Headaches (continued)

Chapter 7 | The Head and Neck 115
Table 7-3 Visual Field Defects
Altitudinal (horizontal) defect, usually
resulting from a vascular lesion of the retina
Unilateral blindness, from a lesion of the
retina or optic nerve
Bitemporal hemianopsia, from a lesion at the
optic chiasm
Homonymous hemianopsia, from a lesion of
the optic tract or optic radiation on the side
contralateral to the blind area
Homonymous quadrantic defect, from a
partial lesion of the optic radiation on the side
contralateral to the blind area
LEFT RIGHT
(from patient’s viewpoint)

116 Bates’ Pocket Guide to Physical Examination and History Taking
Table 7-4 Physical Findings in and Around the Eye
Eyelids
Ptosis. A drooping upper eyelid that
narrows the palpebral fissure from a
muscle or nerve disorder
Ectropion. Outward turning of the margin
of the lower lid, exposing the palpebral
conjunctiva
Entropion. Inward turning of the lid
margin, causing irritation of the cornea
or conjunctiva
Lid Retraction and Exophthalmos. A wide-
eyed stare suggests hyperthyroidism. Note
the rim of sclera between the upper lid and
the iris. Retracted lids and “lid lag” when
eyes move from up to down markedly
increase the likelihood of hyperthyroidism,
especially when accompanied by fine
tremor, moist skin, and heart rate
>90 beats per minute. Exophthalmos
describes protrusion of the eyeball,
a common feature of Graves’
ophthalmopathy, triggered by
autoreactive T lymphocytes.

Chapter 7 | The Head and Neck 117
In and Around the Eye
Pinguecula. Harmless yellowish nodule in
the bulbar conjunctiva on either side of
the iris; associated with aging
Episcleritis. A localized ocular redness
from inflammation of the episcleral
vessels
Sty. A pimplelike infection around a hair
follicle near the lid margin
Chalazion. A beady nodule in either
eyelid caused by a chronically inflamed
meibomian gland
Xanthelasma. Yellowish plaque seen in
lipid disorders
Inflammation of the Lacrimal Sac
(Dacryocystitis). From inflammation
or obstruction of the lacrimal duct
Table 7-4
Physical Findings in and Around
the Eye (continued)

118 Bates’ Pocket Guide to Physical Examination and History Taking
Table 7-5 Abnormalities of the Optic Disc
Process Appearance
Normal Tiny disc vessels
give normal
color to the disc.
Disc is yellowish orange
to creamy pink.
Disc vessels are tiny.
Disc margins are sharp
(except perhaps
nasally).
Papilledema Venous stasis leads
to engorgement
and swelling.
Disc is pink, hyperemic.
Disc vessels are more
visible, more numerous,
and curve over the
borders of the disc.
Disc is swollen, with
margins blurred.
Glaucomatous
Cupping
Increased pressure
within the eye
leads to increased
cupping (backward
depression of the
disc) and atrophy.
The base of the enlarged
cup is pale.
Optic Atrophy Death of optic
nerve fibers leads
to loss of the
tiny disc vessels.
Disc is white.
Disc vessels are absent.

Chapter 7 | The Head and Neck 119
Table 7-6 Ocular Fundi: Diabetic Retinopathy
Nonproliferative
Retinopathy,
Moderately Severe
Note tiny red dots or microaneurysms,
also the ring of hard exudates (white
spots) located superotemporally. Retinal
thickening or edema in the area of hard
exudates can impair visual acuity if it
extends to center of macula. Detection
requires specialized stereoscopic
examination.
Nonproliferative
Retinopathy, Severe
In superior temporal quadrant, note large
retinal hemorrhage between two cotton-
wool patches, beading of the retinal vein
just above, and tiny tortuous retinal
vessels above the superior temporal
artery, termed intraretinal microvascular
abnormalities.
Proliferative
Retinopathy, With
Neovascularization
Note new preretinal vessels arising on disc and
extending across disc margins. Visual acuity
is still normal, but the risk of severe visual
loss is high. Photocoagulation can reduce
this risk by >50%.
Proliferative
Retinopathy,
Advanced
Same eye as above, but 2 years later and
without treatment. Neovascularization
has increased, now with fibrous
proliferations, distortion of the macula,
and reduced visual acuity.
Source of photos: Nonproliferative Retinopathy, Moderately Severe; Proliferative
Retinopathy, With Neovascularization; Nonproliferative Retinopathy, Severe;
Proliferative Retinopathy, Advanced—Early Treatment Diabetic Retinopathy Study
Research Group. Courtesy of MF Davis, MD, University of Wisconsin, Madison.
Source: Frank RB. Diabetic retinopathy. N Engl J Med 2004;350:48–58.

120 Bates’ Pocket Guide to Physical Examination and History Taking
Table 7-7 Abnormalities of the Eardrum
Perforation Hole in the eardrum that may be central
or marginal
Usually from otitis media or trauma
Tympanosclerosis A chalky white patch
Scar of an old otitis media; of little or no
clinical consequence
Serous Effusion Amber fluid behind the eardrum, with
or without air bubbles
Associated with viral upper respiratory
infections or sudden changes in
atmospheric pressure (diving, flying)
Acute Otitis Media With
Purulent Effusion
Red, bulging drum, loss of landmarks
Associated with bacterial infection

Chapter 7 | The Head and Neck 121
Table 7-8 Patterns of Hearing Loss
Conductive Loss Sensorineural Loss
Impaired
Understanding
of Words
Minor Often troublesome
Effect of Noisy
Environment
May help Increases the hearing
difficulty
Usual Age of
Onset
Childhood, young
adulthood
Middle and later years
Ear Canal and
Drum
Often a visible
abnormality
Problem not visible
Weber Test
(in Unilateral
Hearing Loss)
Lateralizes to the
impaired ear
Lateralizes to the
good ear
Rinne Test BC ≥ AC AC > BC
Causes Include Plugged ear canal, otitis
media, immobile or
perforated drum,
otosclerosis, foreign
body
Sustained loud noise,
drugs, inner ear
infections, trauma,
hereditary disorder,
aging, acoustic
neuroma

122 Bates’ Pocket Guide to Physical Examination and History Taking
Table 7-9 Abnormalities of the Lips
Angular cheilitis. Softening and cracking
of the angles of the mouth
Herpes simplex. Painful vesicles, followed
by crusting; also called cold sore or
fever blister
Angioedema. Diffuse, tense, subcutaneous
swelling, usually allergic in cause
Hereditary hemorrhagic
telangiectasia. Red spots, significant
because of associated bleeding from
nose and GI tract
Peutz-Jeghers syndrome. Brown spots of
the lips and buccal mucosa, significant
because of their association with
intestinal polyposis
Syphilitic chancre. A firm lesion that
ulcerates and may crust
Carcinoma of the lip. A thickened plaque
or irregular nodule that may ulcerate or
crust; malignant

Chapter 7 | The Head and Neck 123
Table 7-10 Abnormalities of the Tongue
Geographic tongue. Scattered areas in
which the papillae are lost, giving a
maplike appearance; harmless

Hairy tongue. Results from elongated
papillae that may look yellowish, brown,
or black; harmless
Fissured tongue. May appear with aging;
harmless
Smooth tongue. Results from loss of
papillae, caused by vitamin B or iron
deficiency or possibly chemotherapy

Candidiasis. May show a thick, white coat,
which, when scraped off, leaves a raw
red surface; tongue may also be red;
antibiotics, corticosteroids, AIDS may
predispose
Hairy leukoplakia. White raised, feathery
areas, usually on sides of tongue. Seen in
HIV/AIDS
(continued)

124 Bates’ Pocket Guide to Physical Examination and History Taking

Varicose veins. Dark round spots in the
undersurface of the tongue, associated
with aging; also called caviar lesions
Aphthous ulcer (canker sore). Painful,
small, whitish ulcer with a red halo;
heals in 7–10 days
Mucous patch of syphilis. Slightly raised,
oval lesion, covered by a grayish
membrane
Carcinoma of the tongue or floor of the
mouth. A malignancy that should be
considered in any nodule or nonhealing
ulcer at the base or edges of the mouth
Table 7-10 Abnormalities of the Tongue (continued)

Chapter 7 | The Head and Neck 125
Table 7-11 Abnormalities of the Pharynx
Pharyngitis, mild to moderate. Note
redness and vascularity of the pillars
and uvula.
Pharyngitis, diffuse. Note redness is
diffuse and intense. Cause may be
viral or, if patient has fever, bacterial.
If patient has no fever, exudate,
or cervical lymphadenopathy, viral
infection is more likely.
Exudative pharyngitis. A sore red
throat with patches of white exudate
on the tonsils is associated with
streptococcal pharyngitis and some
viral illnesses.
Diphtheria. An acute infection caused
by Corynebacterium diphtheriae. The
throat is dull red, and a gray exudate
appears on the uvula, pharynx, and
tongue.
Koplik’s spots. These small white
specks that resemble grains of salt on
a red background are an early sign of
measles.

126 Bates’ Pocket Guide to Physical Examination and History Taking
Table 7-12 Abnormalities of the Thyroid Gland
Diffuse enlargement. May result
from Graves’ disease, Hashimoto’s
thyroiditis, endemic goiter (iodine
deficiency), or sporadic goiter
Multinodular goiter. An enlargement
with two or more identifiable
nodules, usually metabolic in cause
Single nodule. May result from a cyst,
a benign tumor, or cancer of the
thyroid, or may be one palpable
nodule in a clinically unrecognized
multinodular goiter

127
C H A P T E R
8The Thorax and Lungs
The Health History
● The myocardium
● The pericardium
● The aorta
● The trachea and large bronchi
● The parietal pleura
● The chest wall, including the
musculoskeletal system and skin
● The esophagus
● Extrathoracic structures such as
the neck, gallbladder, stomach
Angina pectoris, myocardial infarction
Pericarditis
Dissecting aortic aneurysm
Bronchitis
Pericarditis, pneumonia
Costochondritis, herpes zoster
Reflux esophagitis, esophageal spasm
Cervical arthritis, biliary colic, gastritis
Common or Concerning Symptoms
◗ Chest pain
◗ Shortness of breath (dyspnea)
◗ Wheezing
◗ Cough
◗ Blood-streaked sputum (hemoptysis)
Complaints of chest pain or chest discomfort raise the specter of heart
disease but often arise from conditions in the thorax and lungs. For
this important symptom, keep the possible causes below in mind. Also
see Table 8-1, Chest Pain, pp. 137–138.

128 Bates’ Pocket Guide to Physical Examination and History Taking
For patients who are short of breath, focus on such pulmonary
complaints as:
● dyspnea and wheezing
● cough and hemoptysis
See Table 8-2, Dyspnea, pp. 139–140.
See Table 8-3, Cough and Hemoptysis,
pp. 141–143.
Health Promotion and Counseling:
Evidence and Recommendations
Despite declines in smoking over the past several decades, 21% of
Americans still smoke. Regularly counsel all adults, pregnant women,
parents, and adolescents who smoke to stop. Include “the five As” and
assess readiness to quit, using the Stages of Change Model.
Provide flu shots to everyone age 6 months or older and especially to
those with chronic pulmonary conditions, nursing home residents,
household contacts, and health care personnel.
Recommend pneumococcal vaccine to adults 65 years and older,
smokers between the ages of 16 and 64 years, and those with
increased risk of pneumococcal infection.
Assessing Readiness to Quit Smoking: Brief
Inter ventions Models
5 As Model Stages of Change Model
Ask about tobacco use Precontemplation—“I don’t want
to quit.”
Advise to quit Contemplation—“I am concerned but
not ready to quit now.”
Assess willingness to make a
quit attempt
Preparation—“I am ready to quit.”
Assist in quit attempt Action—“I just quit.”
Arrange follow-up Maintenance—“I quit 6 months ago.”

Chapter 8 | The Thorax and Lungs 129
Techniques of Examination
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
SURVEY OF THORAX
Manubrium of sternum
Body of sternum
Xyphoid
process
Costal angle
Costochondral junctions
Suprasternal notch
Sternal angle
2nd costal cartilage
Cardiac notch of left lung
2nd rib
2nd rib interspace
Inspect the thorax and its
respiratory movements.
Note:
● Rate, rhythm, depth, and
effort of breathing
● Inspiratory retraction of the
supraclavicular areas
● Inspiratory contraction of the
sternomastoids
Tachypnea, hyperpnea, Cheyne–
Stokes breathing
Occurs in chronic obstructive pulmo-
nary disease (COPD), asthma, upper
airway obstruction
Indicates severe breathing difficulty
Observe shape of patient’s chest. Normal or barrel chest (see Table 8-4,
Deformities of the Thorax, pp. 144–145)
Listen to patient’s breathing for:
● Rate and rhythm of breathing
● Stridor
● Wheezes
14–16 breaths/minute in adults (see
Chapter 4, pp. 57, 65)
Stridor in upper airway obstruction
from foreign body or epiglottitis
Expiratory wheezing in asthma and
COPD

130 Bates’ Pocket Guide to Physical Examination and History Taking
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
THE POSTERIOR CHEST
Inspect the chest for:
● Deformities or asymmetry
● Abnormal inspiratory retrac-
tion of the interspaces
● Impairment or unilateral lag in
respiratory movement
Kyphoscoliosis
Retraction in airway obstruction
Disease of the underlying lung or
pleura, phrenic nerve palsy
Palpate the chest for:
● Tender areas
● Assessment of visible abnor-
malities
● Chest expansion
● Tactile fremitus as the patient
says “aa” or “blue moon”
Fractured ribs
Masses, sinus tracts
Impairment, both sides in COPD and
restrictive lung disease
Local or generalized decrease or
increase

Chapter 8 | The Thorax and Lungs 131
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
Percuss the chest in the areas
illustrated, comparing one side
with the other at each level, using
the side-to-side “ladder pattern.”
Dullness when fluid or solid tissue
replaces normally air-filled lung;
hyperresonance in emphysema or
pneumothorax
1
2
3
4
5
1
2
3
4
5
6 6
7 7
Percuss level of diaphragmatic
dullness on each side and esti-
mate diaphragmatic descent after
patient takes full inspiration.
Pleural effusion or a paralyzed
diaphragm raises level of dullness.
Resonant
Level of
diaphragm
Dull
Location
and sequence
of percussion
Percussion Notes and Their Characteristics

Relative Intensity,
Pitch, and Duration

Examples
Flat Soft/high/short Large pleural effusion
Dull Medium/medium/medium Lobar pneumonia
Resonant Loud/low/long Normal lung, simple
chronic bronchitis
Hyperresonant Louder/lower/longer Emphysema, pneumothorax
Tympanitic Loud/high (timbre is musical) Large pneumothorax

132 Bates’ Pocket Guide to Physical Examination and History Taking
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
Listen to chest with stethoscope
in the “ladder” pattern, again
comparing sides.
See Table 8-5, Physical Findings in
Selected Chest Disorders, p. 146.
● Evaluate the breath sounds.
● Note any adventitious (added)
sounds.
Vesicular, bronchovesicular, or bron-
chial breath sounds; decreased breath
sounds from decreased airflow
Crackles (fine and coarse) and continuous
sounds (wheezes and rhonchi)
Observe qualities of breath
sound, timing in the respiratory
cycle, and location on the chest
wall. Do they clear with deep
breathing or coughing?
Clearing after cough suggests atelec-
tasis
Characteristics of Breath Sounds
Duration
Intensity and
Pitch of
Expiratory Sound
Example
Locations
Vesicular Insp > Exp Soft/low Most of the lungs
Bronchovesicular Insp = Exp Medium/medium 1st and 2nd
interspaces, in-
terscapular area
Bronchial Exp > Insp Loud/high Over the manu-
brium
Tracheal Insp = Exp Very loud/high Over the trachea
Duration is indicated by the length of the line, intensity by the width of the line, and pitch
by the slope of the line.

Chapter 8 | The Thorax and Lungs 133
Adventitious or Added Breath Sounds
Crackles (or Rales) Wheezes and Rhonchi
◗ Discontinuous
◗ Intermittent, nonmusical,
and brief
◗ Like dots in time
◗ Fine crackles: Soft, high-
pitched, very brief (5–10 msec)
◗ Coarse crackles: Somewhat
louder, lower in pitch, brief
(20–30 msec)
◗ Continuous
◗ ≥250 msec, musical, prolonged (but not
necessarily persisting throughout the
respiratory cycle)
◗ Like dashes in time
◗ Wheezes: Relatively high-pitched
(≥400 Hz) with hissing or shrill quality
◗ Rhonchi: Relatively low-pitched
(≤200 Hz) with snoring quality
Transmitted Voice Sounds
Through Normally Air-Filled Lung Through Airless Lung*
Usually accompanied by vesicular
breath sounds and normal tactile
fremitus
Usually accompanied by bronchial
or bronchovesicular breath sounds
and increased tactile fremitus
Spoken words muffled and indistinct Spoken words louder, clearer
(bronchophony)
Spoken “ee” heard as “ee” Spoken “ee” heard as “ay” (egophony)
Whispered words faint and indistinct,
if heard at all
Whispered words louder, clearer
(whispered pectoriloquy)
*As in lobar pneumonia and toward the top of a large pleural effusion
Assess transmitted voice sounds,
bronchial breath sounds heard in
abnormal places. Ask patient to:
● Say “ninety-nine” and “ee.”
● Whisper “ninety-nine” or “one-
two-three.”
Bronchophony if sounds become
louder; egophony if “ee” to “A”
change to lobar consolidation
Whispered pectoriloquy
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S

134 Bates’ Pocket Guide to Physical Examination and History Taking
Alternate Sequence. While the patient is still sitting, you may inspect
the breasts and examine the axillary and epitrochlear lymph nodes, and
examine the temporomandibular joint and the musculoskeletal system of
the upper extremities.
THE ANTERIOR CHEST
Midsternal
line
Midclavicular
line
Anterior
axillary
line
Anterior
axillary
line
Posterior
axillary
line
Midaxillary
line
Inspect the chest for:
● Deformities or asymmetry
● Intercostal retraction
● Impaired or lagging respiratory
movement
Pectus excavatum
From obstructed airways
Disease of the underlying lung or
pleura, phrenic nerve palsy
Palpate the chest for:
● Tender areas
● Assessment of visible
abnormalities
● Respiratory expansion
● Tactile fremitus
Tender pectoral muscles,
costochondritis
Flail chest
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
ANTERIOR VIEW RIGHT ANTERIOR
OBLIQUE VIEW

Chapter 8 | The Thorax and Lungs 135
Percuss the chest in the areas
illustrated.
11
22
33
44 55
66
Normal cardiac dullness may disap-
pear in emphysema.
Listen to the chest with stetho-
scope. Note:
● Breath sounds
● Adventitious sounds
● If indicated, transmitted voice
sounds
SPECIAL TECHNIQUES
CLINICAL ASSESSMENT OF PULMONARY FUNCTION
Walk with patient down the hall or
up a flight of stairs. Observe the
rate, effort, and sound of breath-
ing, and inquire about symptoms.
Or do a “6-minute walk test.”
Older adults walking 8 feet in <3 seconds are less likely to be disabled than those taking >5 to 6 seconds.
FORCED EXPIRATORY TIME
Ask the patient to take a deep
breath in and then breathe out as
quickly and completely as possible,
with mouth open. Listen over
trachea with diaphragm of stetho-
scope, and time audible expiration.
Try to get three consistent read-
ings, allowing rests as needed.
If the patient understands and cooper-
ates well, a forced expiratory time of
6 to 8 seconds strongly suggests COPD.
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S

136 Bates’ Pocket Guide to Physical Examination and History Taking
Recording Your Findings
Recording the Physical Examination—The
Thorax and Lungs
“Thorax is symmetric with good expansion. Lungs resonant. Breath sounds
vesicular; no rales, wheezes, or rhonchi. Diaphragms descend 4 cm bilaterally.”
OR
“Thorax symmetric with moderate kyphosis and increased anteroposterior
(AP) diameter, decreased expansion. Lungs are hyperresonant. Breath sounds
distant with delayed expiratory phase and scattered expiratory wheezes.
Fremitus decreased; no bronchophony, egophony, or whispered pectoriloquy.
Diaphragms descend 2 cm bilaterally.” (Suggests COPD)

Chapter 8 | The Thorax and Lungs 137
Table 8-1 Chest Pain
Problem and Location
Quality, Severity, Timing, and
Associated Symptoms
Cardiovascular
Angina Pectoris
Retrosternal or across the
anterior chest, sometimes
radiating to the shoulders,
arms, neck, lower jaw, or
upper abdomen
● Pressing, squeezing, tight, heavy,
occasionally burning
● Mild to moderate severity,
sometimes perceived as discomfort
rather than pain
● Usually 1–3 min but up to
10 min; prolonged episodes up to
20 min
● Sometimes with dyspnea, nausea,
swelling
Myocardial Infarction
Same as in angina
● Same as in angina
● Often but not always a severe pain
● 20 min to several hours
● Associated with nausea, vomiting,
sweating, weakness
Pericarditis
Precordial: May radiate to the
tip of the shoulder and to
the neck
● Sharp, knifelike quality
● Often severe
● Persistent timing
● Symptoms of the underlying
illness; relieved by leaning forward
Retrosternal ● Crushing quality
● Severe
● Persistent timing
● Symptoms of the underlying
illness
Dissecting Aortic Aneurysm
Anterior chest, radiating to the
neck, back, or abdomen
● Ripping, tearing quality
● Very severe
● Abrupt onset, early peak,
persistent for hours or more
● Associated syncope, hemiplegia,
paraplegia
Aids to Interpretation
(continued)

138 Bates’ Pocket Guide to Physical Examination and History Taking
Table 8-1 Chest Pain (continued)
Problem and Location
Quality, Severity, Timing, and
Associated Symptoms
Pulmonary
Tracheobronchitis
Upper sternal or on either
side of the sternum
● Burning qualtiy
● Mild to moderate severity
● Variable timing
● Associated cough
Pleural Pain
Chest wall overlying the
process
● Sharp, knifelike quality
● Often severe
● Persistent timing
● Associated symptoms of the
underlying illness
Gastrointestinal and Other
Reflex Esophagitis
Retrosternal, may radiate to
the back
● Burning quality, may be squeezing
● Mild to severe
● Variable timing
● Associated with regurgitation,
dysphagia
Diffuse Esophageal Spasm
Retrosternal, may radiate to
the back, arms, and jaw
● Usually squeezing quality
● Mild to severe
● Variable timing
● Associated dysphagia
Chest Wall Pain
Often below the left breast or
along the costal cartilages;
also elsewhere
● Stabbing, sticking, or dull aching
quality
● Variable severity
● Fleeting timing, hours or days
● Often with local tenderness
Anxiety ● Pain may be sharp, intense, or
severe
● Can mimic angina
● Associated with stress of anxiety

Chapter 8 | The Thorax and Lungs 139
Table 8-2 Dyspnea
Problem Timing
Provoking and
Relieving Factors
Left-Sided Heart
Failure (left
ventricular
failure or mitral
stenosis)
Dyspnea may
progress slowly
or suddenly,
as in acute
pulmonary
edema
↑ by exertion, lying down
↓ by rest, sitting up, though
dyspnea may become
persistent
Associated Symptoms: Often
cough, orthopnea,
paroxysmal nocturnal
dyspnea; sometimes
wheezing
Chronic Bronchitis
(may be seen
with COPD)
Chronic
productive
cough followed
by slowly
progressive
dyspnea
↑ by exertion, inhaled
irritants, respiratory
infections
↓ by expectoration, rest
though dyspnea may
become persistent
Associated Symptoms:
Chronic productive
cough, recurrent
respiratory infections;
wheezing possible
Chronic
Obstructive
Pulmonary Disease
(COPD)
Slowly
progressive;
relatively mild
cough later
↑ by exertion
↓ by rest, though dyspnea
may become persistent
Associated Symptoms: Cough
with scant mucoid
sputum
Asthma Acute episodes,
then symptom-
free periods;
nocturnal
episodes
common
↑ by allergens, irritants,
respiratory infections,
exercise, emotion
↓ by separation from
aggravating factors
Associated Symptoms:
Wheezing, cough,
tightness in chest
(continued)

140 Bates’ Pocket Guide to Physical Examination and History Taking
Table 8-2 Dyspnea (continued)
Problem Timing
Provoking and
Relieving Factors
Acute Pulmonary
Embolism
Sudden onset of
dyspnea
Associated Symptoms:
Often none; retrosternal
oppressive pain if
occlusion is massive;
pleuritic pain, cough, and
hemoptysis may follow an
embolism if pulmonary
infarction ensues;
symptoms of anxiety
Pneumonia Acute illness;
timing varies
with causative
agent
Associated Symptoms:
Pleuritic pain, cough,
sputum, fever, though
not necessarily present
Diffuse Interstitial
Lung Diseases
(sarcoidosis,
neoplasms,
asbestosis, idiopathic
pulmonary fibrosis)
Progressive;
varies in rate of
development
depending on
cause
↑ by exertion
↓ by rest, though dyspnea
may become persistent
Associated Symptoms: Often
weakness, fatigue; cough
less common than in
other lung diseases
Spontaneous
Pneumothorax
Sudden onset of
dyspnea
Associated Symptoms:
Pleuritic pain, cough

Chapter 8 | The Thorax and Lungs 141
(continued)
Table 8-3 Cough and Hemoptysis
Problem
Cough, Sputum, Associated
Symptoms, and Setting
Acute Inflammation
Laryngitis Cough and Sputum: Dry, or with variable
amounts of sputum
Associated Symptoms and Setting: Acute,
fairly minor illness with hoarseness. May
be associated with viral nasopharyngitis
Tracheobronchitis Cough and Sputum: Dry or productive of
sputum
Associated Symptoms and Setting: An
acute, often viral illness, with burning
retrosternal discomfort
Mycoplasma and Viral
Pneumonias
Cough: Dry and hacking
Sputum: Often mucoid
Associated Symptoms and Setting: An
acute febrile illness, often with malaise,
headache, and possibly dyspnea
Bacterial Pneumonias Cough and Sputum: With pneumococcal
infection, mucoid or purulent; may be
blood streaked, diffusely pinkish, or rusty.
With Klebsiella, similar to pneumococcal,
or sticky red and jellylike.
Associated Symptoms and Setting: An acute
illness with chills, high fever, dyspnea,
and chest pain; often preceded by acute
upper respiratory infection. Klebsiella
often in older alcoholic men.
Chronic Inflammation
Postnasal Drip Cough: Chronic
Sputum: Mucoid or mucopurulent
Associated Symptoms and Setting: Repeated
attempts to clear the throat. Postnasal
drip, discharge in posterior pharynx.
Associated with chronic rhinitis, with or
without sinusitis

142 Bates’ Pocket Guide to Physical Examination and History Taking
Table 8-3 Cough and Hemoptysis (continued)
Problem
Cough, Sputum, Associated
Symptoms, and Setting
Chronic Bronchitis Cough: Chronic
Sputum: Mucoid to purulent; may be
blood-streaked or even bloody
Associated Symptoms and Setting: Often
long history of cigarette smoking.
Recurrent superimposed infections; often
wheezing and dyspnea.
Bronchiectasis Cough: Chronic
Sputum: Purulent, often copious and foul
smelling; may be blood-streaked or
bloody
Associated Symptoms and Setting: Recurrent
bronchopulmonary infections common;
sinusitis may coexist
Pulmonary Tuberculosis Cough and Sputum: Dry, mucoid or
purulent; may be blood-streaked or
bloody
Associated Symptoms and Setting: Early, no
symptoms. Later, anorexia, weight loss,
fatigue, fever, and night sweats.
Lung Abscess Cough and Sputum: Purulent and foul
smelling; may be bloody
Associated Symptoms and Setting: A febrile
illness. Often poor dental hygiene and a
prior episode of impaired consciousness
Asthma Cough and Sputum: Thick and mucoid,
especially near end of an attack
Associated Symptoms and Setting: Episodic
wheezing and dyspnea, but cough may
occur alone. Often a history of allergy

Chapter 8 | The Thorax and Lungs 143
Table 8-3 Cough and Hemoptysis (continued)
Problem
Cough, Sputum, Associated
Symptoms, and Setting
Gastroesophageal
Reflux
Cough and Sputum: Chronic, especially at
night or early morning
Associated Symptoms and Setting: Wheezing,
especially at night (often mistaken for
asthma), early morning hoarseness,
repeated attempts to clear throat.
Often with history of heartburn and
regurgitation
Neoplasm Cough: Dry to productive
Cancer of the Lung Sputum: May be blood-streaked or bloody
Associated Symptoms and Setting: Usually a
long history of cigarette smoking
Cardiovascular Disorders
Left Ventricular Failure
or Mitral Stenosis
Cough: Often dry, especially on exertion or
at night
Sputum: May progress to pink and frothy,
as in pulmonary edema, or to frank
hemoptysis
Associated Symptoms and Setting: Dyspnea,
orthopnea, paroxysmal nocturnal dyspnea
Pulmonary Emboli Cough: Dry to productive
Sputum: May be dark, bright red, or mixed
with blood
Associated Symptoms and Setting: Dyspnea,
anxiety, chest pain, fever; factors that
predispose to deep venous thrombosis
Irritating Particles,
Chemicals, or Gases
Cough and Sputum: Variable. There may
be a latent period between exposure and
symptoms.
Associated Symptoms and Setting: Exposure
to irritants; eye, nose, and throat
symptoms

144 Bates’ Pocket Guide to Physical Examination and History Taking
Table 8-4 Deformities of the Thorax
Cross-Section of Thorax
Normal Adult
The thorax is wider than it
is deep; lateral diameter is
greater than anteroposterior
(AP) diameter.
Barrel Chest
Has increased AP diameter,
seen in normal infants
and normal aging; also in
COPD.
Traumatic Flail Chest
If multiple ribs are fractured,
can see paradoxical
movements of the thorax.
Descent of the diaphragm
decreases intrathoracic
pressure on inspiration.
The injured area may cave
inward; on expiration, it
moves outward.
Expiration
Inspiration
Funnel Chest
(Pectus Excavatum)
Depression in the lower
portion of the sternum.
Related compression of the
heart and great vessels may
cause murmurs.

Chapter 8 | The Thorax and Lungs 145
Table 8-4 Deformities of the Thorax (continued)
Cross-Section of Thorax
Pigeon Chest
(Pectus Carinatum)
Depressed
costal cartilages
Anteriorly
displaced sternum
Sternum is displaced
anteriorly, increasing the
AP diameter; costal
cartilages adjacent to the
protruding sternum are
depressed.
Thoracic Kyphoscoliosis
Spinal convexity to the right
(patient bending forward)
Ribs
widely
separated
Ribs close
together
Abnormal spinal curvatures
and vertebral rotation
deform the chest, making
interpretation of lung
findings difficult.

T
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146

147
C H A P T E R
9The Cardiovascular System
The Health History
Common or Concerning Symptoms
◗ Chest pain
◗ Palpitations
◗ Shortness of breath: dyspnea, orthopnea, or paroxysmal nocturnal dyspnea
◗ Swelling or edema
As you assess reports of chest pain or discomfort, keep serious adverse
events in mind, such as angina pectoris, myocardial infarction, or even
a dissecting aortic aneurysm. Ask also about any associated palpitations,
orthopnea, paroxysmal nocturnal dyspnea (PND), and edema.
● Palpitations are an unpleasant awareness of the heartbeat.
● Shortness of breath may represent dyspnea, orthopnea, or PND.
● Dyspnea is an uncomfortable awareness of breathing that is inap-
propriate for a given level of exertion.
● Orthopnea is dyspnea that occurs when the patient is lying down
and improves when the patient sits up. It suggests left ventricular
heart failure or mitral stenosis; it also may accompany obstructive
pulmonary disease.
● PND describes episodes of sudden dyspnea and orthopnea that awaken
the patient from sleep, usually 1 to 2 hours after going to bed, prompt-
ing the patient to sit up, stand up, or go to a window for air.
● Edema refers to the accumulation of excessive fluid in the interstitial
tissue spaces; it appears as swelling. Dependent edema appears in the
feet and lower legs when sitting or in the sacrum when bedridden.

148 Bates’ Pocket Guide to Physical Examination and History Taking
Health Promotion and Counseling:
Evidence and Recommendations
Important Topics for Health Promotion
and Counseling
HHHeealltthh PPrroommoootioonn andd CCCouunsselingg:
EEEviideenncce aannd Reecooommmmeeenddattionns
◗ Screening for cardiovascular risk factors
◗ Step 1: Screen for global risk factors
◗ Step 2: Calculate 10-year and long-term CVD risk using online calculators
◗ Step 3: Track individual risk factors—hypertension, diabetes, dyslipidemias,
metabolic syndrome, smoking, family history and obesity
◗ Promoting lifestyle modification and risk factor reduction
Cardiovascular disease is the leading cause of death for both men and
women in the United States. Primary prevention, in those without
evidence of cardiovascular disease, and secondary prevention, in those
with known cardiovascular events (e.g., myocardial infarction, heart
failure), remain important clinical priorities. Use education and coun-
seling to help your patients maintain optimal levels of blood pressure,
cholesterol, weight, and exercise and to reduce risk factors for cardio-
vascular disease and stroke.
The American Heart Association recommends a new goal for 2020,
“ideal cardiovascular health,” namely:
● Total cholesterol <200 mg/dL (untreated) ● Lean body mass ● BP <120/<80 (untreated) ● Fasting glucose <100 mg/dL (untreated) ● Abstinence from smoking ● Physical activity goal: ≥150 min/wk moderate intensity, ≥75 min/wk vigorous intensity, or combination ● Healthy diet Only 3% of U.S. adults have optimal health behaviors for all 7 goals. Women and African Americans have emerged as groups at especially high risk. CVD Screening Steps Step 1: Screen for Global Risk Factors. Begin routine screening at age 20 for combined individual risk factors or “global” risk of CVD Chapter 9 | The Cardiovascular System 149 and any family history or premature heart disease. See the recom- mended screening intervals listed below. Major Cardiovascular Risk Factors and Screening Frequency Risk Factor Screening Frequency Goal Family history of premature CVD (at age <55 years in first-degree male relatives and <65 years in first-degree female relatives) Update regularly Cigarette smoking At each visit Cessation Poor diet At each visit Improved overall eating pattern Physical inactivity At each visit 30 min moderate intensity daily Obesity, especially central adiposity At each visit BMI 20–25 kg/m2; waist circumference 40 inches in men, ≤35 inches in women Hypertension At each visit <140/90 <135/85 if African American with HTN and without end- organ or CVD <130/80 if diabetes or African American with HTN and end-organ or CVD <125/75 if renal disease Dyslipidemias Every 5 years if low risk Every 2 years if risk factors See ATP III guidelines Diabetes Every 3 years beginning at age 45 More frequently at any age if risk factors HgA1C ≥6.5%, at risk if 5.7%–6.4% Pulse At each visit Identify and treat atrial fibrillation Source: Adapted from: Pearson TA, Blair SN, Daniels SR et al. AHA Guidelines for Primary Prevention of Cardiovascular Disease and Stroke: 2002Update. Consensus Panel Guide to Com prehensive Risk Reduction for Adult Patients without Coronary or Other Ath- erosclerotic Vascular Diseases. Circulation 2002;106:388–391; Flack JM, Sica DA, Bakris G et al. Management of high blood pressure in blacks. An update of the International Society on Hypertension in Blacks Consensus Statement. Hypertension 2010;56:780–800; American Diabetes Association. Standards of medical care in diabetes–2011. Diabetes Care 2001;34:S1–S61. 150 Bates’ Pocket Guide to Physical Examination and History Taking Step 2: Calculate 10-year and Long-Term CVD Risk Using Online Calculators. For Step 2, assemble risk factor data and calculate mul- tivariable global risk assessment. This is easily accomplished by access- ing well-validated online calculators that provide 10-year CVD risk assessments that can also be used to guide treatment of dyslipidemias. ● Framingham 10-year and 30-year risk calculator: http://www.framing hamheartstudy.org/risk/gencardio.html ● Stroke risk calculator (Cleveland Clinic): http://my.clevelandclinic. org/p2/stroke-risk-calculator.aspx Step 3: Track Individual Risk Factors–Hypertension, Diabetes, Dyslipidemias, Metabolic Syndrome, Obesity, Smoking, and Family History. Hypertension. The U.S. Preventive Services Task Force recom- mends screening all people 18 years or older for high blood pressure. Use the blood pressure classification of the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7). JNC 7: Classification and Management of Blood Pressure for Adults Normal <120/80 mm Hg Prehypertension 120–139/80–89 mm Hg Stage 1 Hypertension 140–159/90–99 mm Hg Stage 2 Hypertension >160/>100 mm Hg
If diabetes or kidney disease <130/80 mm Hg Diabetes. Use the screening and diagnostic criteria below. American Diabetes Association 2011: Criteria for Diabetes Screening and Diagnosis Screening Criteria Healthy adults with no risk factors: Begin at age 45 years, repeat at 3 year intervals Adults with BMI ≥25 kg/m2 and additional risk factors: ◗ Physical inactivity ◗ First-degree relative with diabetes (continued) http://www.framinghamheartstudy.org/risk/gencardio.html http://my.clevelandclinic.org/p2/stroke-risk-calculator.aspx http://www.framinghamheartstudy.org/risk/gencardio.html http://my.clevelandclinic.org/p2/stroke-risk-calculator.aspx Chapter 9 | The Cardiovascular System 151 Dyslipidemias. LDL is the primary target of cholesterol-lowering therapy. Ten-year risk categories are as follows: ● High risk (10-year CVD risk >20%): established CVD and CHD risk
equivalents
● Moderately high risk (10-year CVD risk 10% to 20%): multiple or ≥2
risk factors
● Low risk (10-year CVD risk <10%): 0 to 1 risk factor For high-risk people, the recommended LDL goal is <70 mg/dL and intensive lipid therapy is a therapeutic option. ◗ Members of a high-risk ethnic population–African American, Latino American, Asian American, Pacific Islander ◗ Mothers of infants ≥9 lb or diagnosed with GDM ◗ Hypertension ≥140/90 mm Hg or on therapy for hypertension ◗ HDL cholesterol <35 mg/dL and/or triglycerides >250 mg/dL
◗ Women with polycystic ovary syndrome
◗ A1C ≥5.7%, impaired glucose tolerance, or impaired fasting glucose on
previous testing
◗ Other conditions associated with insulin resistance such as severe obesity,
acanthosis nigricans
◗ History of cardiovascular disease
Diagnostic Criteria Diabetes Prediabetes
A1C ≤6.5% 5.7%–6.4%
Fasting plasma glucose (on at least
2 occasions)
≥126 mg/dL 100–125 mg/dL
2-hour plasma glucose (oral
tolerance test)
≥200 mg/dL 140–199 mg/dL
Random glucose if classic
symptoms
≥200 mg/dL
American Diabetes Association 2011: Criteria for Diabetes
Screening and Diagnosis (continued)

152 Bates’ Pocket Guide to Physical Examination and History Taking
The Metabolic Syndrome. The metabolic syndrome consists of a
cluster of risk factors which confer and increased risk of both CVD and
diabetes. In 2009, the International Diabetes Association and other
societies harmonized diagnostic criteria as the presence of three or
more of the five risk factors listed below.
ATP III Guidelines: 10-Year Risk and LDL Goals
10-Year Risk
Category
LDL Goal
(mg/dL)
Consider Drug Therapy if LDL
(mg/dL)
High risk (>20%) <100 Optional goal: <70 >100
(<100: consider drug options, including further 30%–40% reduction in LDL) Moderately high risk (10%–20%) <130 Optional goal: <100 ≥130 100–129: consider drug options to achieve goal of <100 Moderate risk (<10%) <130 ≥160 Lower risk (0–1 risk factor) <160 >190
(160–189: drug therapy optional)
Source: Adapted from National Cholesterol Education Panel Report. Implications of recent
clinical trials for the National Cholesterol Education Program Adult Treatment Panel III
Guidelines. Grundy SM, Cleeman JI, Merz NB, et al., for the Coordinating Committee of the
National Cholesterol Education Program. Circulation 2004;119:227–239.
Metabolic Syndrome: 2009 Diagnostic Criteria
Waist circumference Men ≥102 cm, women ≥88 cm
Fasting plasma glucose ≥100 mg/dL or being treated for elevated
glucose
HDL cholesterol Men <40 mg/dL, women <50 mg/dL, or being treated Triglycerides ≥150 mg/dL, or being treated Blood pressure ≥130/≥85, or being treated Source: Alberti K, Eckel RH, Grundy SM et al. Harmonizing the metabolic syndrome: a joint interim statement of the Internal Diabetes Federation Task Force on Epidemiology and Prevention; National Heart, Lung and Blood Institute; American Heart Association; World Heart Federation; Internal Atherosclerosis Society; and Internal Association for the Study of Obesity. Circulation 2009;120:1620–1645. Chapter 9 | The Cardiovascular System 153 Other Risk Factors: Smoking, Family History, and Obesity. In adult smokers, 33% of deaths are related to CVD. Smoking increases the risk of coronary heart disease by two- to fourfold. Among adults, 13% report a family history of heart attack before age 50, which roughly doubles the risk the risk of heart attack. Obesity, or BMI more than 30, contributed to 112,000 excess adult deaths compared to normal weight in recent data and was associated with 13% of CVD deaths in 2004. Promoting Lifestyle Modification and Risk Factor Reduction. The JNC 7 and AHA encourage well-studied effective lifestyle modifica- tion and risk interventions to prevent hypertension, CHD, and stroke. Lifestyle Modifications for Cardiovascular Health ◗ Optimal weight (BMI of 18.5–24.9 kg/m2) ◗ Salt intake <½ teaspoon or 1500 mg/day of sodium ◗ Regular aerobic exercise (e.g., brisk walking) for at least 30 min/day, most days of the week ◗ Moderate alcohol consumption of 2 or fewer drinks per day for men and 1 drink or fewer per day for women ◗ Diet rich in fruits, vegetables, and low-fat dairy products with reduced saturated and total fat ◗ Dietary intake of >3,500 mg of potassium
◗ Optimal blood pressure control (see p. 150)
◗ Lipid management
◗ Diabetes management so that fasting glucose level is <100 mg/dL and HgA1C is <7% ◗ Complete smoking cessation ◗ Conversion of atrial fibrillation to normal sinus rhythm or, if chronic, anticoagulation Techniques of Examination E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S HEART RATE AND BLOOD PRESSURE If not already done, measure the radial or apical pulse. Estimate systolic blood pressure by palpation and add 30 mm Hg. Use this sum as the target for further cuff inflations. This step helps you to detect an ausculta- tory gap and avoid recording an inappro- priately low systolic blood pressure. TTTecchhnniiquees offf EExaammminnatttionn 154 Bates’ Pocket Guide to Physical Examination and History Taking E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S Measure blood pressure with a sphygmomanometer. If indi- cated, recheck it. Orthostatic (postural) hypotension with position change from supine to standing, SBP↓ ≥20 mm Hg; HR↑ ≥20 beats/min JUGULAR VEINS Identify jugular venous pulsa- tions and their highest point in the neck. Start with head of the bed at 30 degrees; adjust angle of the bed as necessary. Study the waves of venous pul- sation. Note the a wave of atrial contraction and the v wave of venous filling. Absent a waves in atrial fibrillation; prom- inent v waves in tricuspid regurgitation Measure jugular venous pressure (JVP)—the vertical distance between this highest point and the sternal angle, normally <3 to 4 cm. Elevated JVP in right-sided heart fail- ure; decreased JVP in hypovolemia from dehydration or gastrointestinal bleeding CAROTID PULSE Assess the amplitude and con- tour of the carotid upstroke. A delayed upstroke in aortic stenosis; a bounding upstroke in aortic insufficiency Check for variations in pulse amplitude. See pulsus alternans and paradoxical pulse, p. 159 Listen for bruits. Carotid bruits suggest atherosclerotic narrowing and increase stroke risk. Chapter 9 | The Cardiovascular System 155 INSPECTION AND PALPATION Inspect and palpate the anterior chest for heaves, lifts, or thrills. Identify the apical impulse. Turn patient to left as necessary. Note: ● Location of impulse ● Diameter ● Amplitude—usually tapping ● Duration Displaced to left in pregnancy Increased diameter, amplitude, and duration in left ventricular dilatation from congestive heart failure (CHF) or ischemic cardiomyopathy Sustained in left ventricular hypertro- phy; diffuse in CHF Sequence of the Cardiac Examination Patient Position Examination Supine, with the head elevated 30 degrees Inspect and palpate the precordium: the 2nd interspaces; the right ventricle; and the left ventricle, including the apical impulse (diameter, location, amplitude, duration). Left lateral decubitus Palpate the apical impulse if not previously de- tected. Listen at the apex with the bell of the stethoscope for low-pitched extra sounds (S3, open- ing snap, diastolic rumble of mitral stenosis). Supine, with the head elevated 30 degrees Listen at the 2nd right and left interspaces, along the left sternal border, and across to the apex with the diaphragm. Listen with the bell at the right sternal border for tricuspid murmurs and sounds. Sitting, leaning forward, after full exhalation Listen along the left sternal border and at the apex for the soft decrescendo diastolic murmur of aortic insufficiency. THE HEART E XA M I N AT I O N T E C H N I Q U E S P OS S I B L E F I N D I N G S 156 Bates’ Pocket Guide to Physical Examination and History Taking Feel for a right ventricular impulse in left parasternal and epigastric areas. Prominent impulses suggest right ventricular enlargement. Palpate left and right second interspaces close to sternum. Note any thrills in these areas. Pulsations of great vessels; accentuated S2; thrills of aortic or pulmonic stenosis AUSCULTATION Listen to heart by “inching” your stethoscope from the base to the apex (or apex to base) in the areas illustrated. Apex—left ventricular area Right 2nd interspace— aortic area Left 2nd interspace— pulmonic area Epigastric (subxiphoid) Left sternal border—right ventricular area Use the diaphragm in the areas illustrated above for relatively high-pitched sounds like S1, S2. Also murmurs of aortic and mitral regurgitation; pericardial friction rubs Use the bell for low-pitched sounds at the lower left sternal border and apex. S3, S4, murmur of mitral stenosis Listen at each area for: See Table 9-1, Heart Sounds, p. 161; Table 9-2, Variations in the First Heart Sound—S1, p. 162; Table 9-3, Variations in the Second Heart Sound—S2, pp. 163–164. ● S1 ● S2. Is splitting normal in left 2nd and 3rd interspaces? ● Extra sounds in systole ● Extra sounds in diastole ● Systolic murmurs ● Diastolic murmurs Physiologic (inspiratory) or pathologic (expiratory) splitting Systolic clicks S3, S4 Midsystolic, pansystolic, late systolic murmurs Early, mid-, or late diastolic murmurs E XA M I N AT I O N T E C H N I Q U E S P OS S I B L E F I N D I N G S Chapter 9 | The Cardiovascular System 157 ASSESSING AND DESCRIBING MURMURS Identify, if murmurs are present, their: ● Timing in the cardiac cycle (systole, diastole). It is help- ful to palpate the carotid upstroke while listening to any murmur—murmurs occur- ring simultaneously with the upstroke are systolic. ● Shape S2S1 S2S1 S2 S1 S2 S1 ● Location of maximal intensity ● Radiation ● Pitch ● Quality ● Intensity on a 6-point scale See Table 9-4, Heart Murmurs, p. 165. Plateau, crescendo, decrescendo A crescendo–decrescendo murmur first rises in intensity, then falls (e.g., aortic stenosis). A plateau murmur has the same intensity throughout (e.g., mitral regurgitation). A crescendo murmur grows louder (e.g., mitral stenosis). A decrescendo murmur grows softer (e.g., aortic regurgitation). Murmurs loudest at the base are often aortic; at the apex, they are often mitral. High, medium, low Blowing, harsh, musical, rumbling See “Gradations of Murmurs” on next page. Listen at the apex with patient turned toward left side for low-pitched sounds. Left-sided S3, and diastolic murmur of mitral stenosis E XA M I N AT I O N T E C H N I Q U E S P OS S I B L E F I N D I N G S 158 Bates’ Pocket Guide to Physical Examination and History Taking Listen down left sternal border to the apex as patient sits, leaning forward, with breath held after exhalation. Diastolic decrescendo murmur of aortic regurgitation Gradations of Murmurs Grade Description Grade 1 Very faint, heard only after listener has “tuned in”; may not be heard in all positions Grade 2 Quiet, but heard immediately after placing the stetho- scope on the chest Grade 3 Moderately loud Grade 4 Loud, with palpable thrill Grade 5 Very loud, with thrill. May be heard when the stetho- scope is partly off the chest Grade 6 Very loud, with thrill. May be heard with stethoscope entirely off the chest E XA M I N AT I O N T E C H N I Q U E S P OS S I B L E F I N D I N G S Chapter 9 | The Cardiovascular System 159 SPECIAL TECHNIQUES E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S PULSUS ALTERNANS Feel pulse for alternation in ampli- tude. Lower pressure of blood pressure cuff slowly to systolic level while you listen with stetho- scope over brachial artery. Alternating amplitude of pulse or sudden doubling of Korotkoff sounds indicates pulsus alternans—a sign of left ventricular heart failure. PARADOXICAL PULSE Lower pressure of blood pres- sure cuff slowly and note two pressure levels: (1) where Korotkoff sounds are first heard and (2) where they first persist through the respiratory cycle. These levels are normally not more than 3 to 4 mm Hg apart. A drop of >10 mm Hg during inspira-
tion signifies a paradoxical pulse. Con-
sider obstructive pulmonary disease,
pericardial tamponade, or constrictive
pericarditis.
AIDS TO IDENTIFY SYSTOLIC MURMURS
Valsalva Maneuver
Ask patient to strain down.
In suspected mitral valve prolapse
(MVP), listen to the timing of
click and murmur.
Ventricular filling decreases, the
systolic click of MVP is earlier, and the
murmur lengthens.
To distinguish aortic stenosis (AS)
from hypertrophic cardiomyopathy
(HC), listen to the intensity of the
murmur.
In AS, the murmur decreases; in HC, it
often increases.
/ Squatting and Standing
In suspected MVP, listen for the
click and murmur in both positions.
Squatting increases ventricular fill-
ing and delays the click and murmur.
Standing reverses the changes.
Try to distinguish AS from HC by
listening to the murmur in both
positions.
Squatting increases murmur of AS and
decreases murmur of HC. Standing
reverses the changes.

160 Bates’ Pocket Guide to Physical Examination and History Taking
Recording Your FindingsRRReccoorddinnggg YYouuur Finnddinngss
Recording the Physical Examination—The
Cardiovascular Examination
“The jugular venous pulse (JVP) is 3 cm above the sternal angle with the head
of the bed elevated to 30 degrees. Carotid upstrokes are brisk, without bruits.
The point of maximal impulse (PMI) is tapping, 7 cm lateral to the midsternal
line in the 5th intercostal space. Crisp S1 and S2. At the base, S2 is greater than
S1 and physiologically split, with A2 > P2. At the apex, S1 is greater than S2 and
constant. No murmurs or extra sounds.”
OR
“The JVP is 5 cm above the sternal angle with the head of the bed elevated to
50 degrees. Carotid upstrokes are brisk; a bruit is heard over the left carotid
artery. The PMI is diffuse, 3 cm in diameter, palpated at the anterior axillary
line in the 5th and 6th intercostal spaces. S1 and S2 are soft. S3 present at the
apex. High-pitched, harsh 2/6 holosystolic murmur best heard at the apex,
radiating to the axilla. No S4 or diastolic murmurs.” (Suggests CHF with possible
left carotid stenosis and mitral regurgitation.)

Chapter 9 | The Cardiovascular System 161
Table 9-1 Heart Sounds
Systole Diastole
S1 S3S2OS S1E1 S4
Finding Possible Causes
S1 accentuated Tachycardia, states of high cardiac
output; mitral stenosis
S1 diminished First-degree heart block; reduced
left ventricular contractility;
immobile mitral valve, as in mitral
regurgitation
Systolic clicks(s) Mitral valve prolapse (as in E1 above)
S2 accentuated in right
2nd interspace
Systemic hypertension, dilated aortic
root
S2 diminished or absent in
right 2nd interspace
Immobile aortic valve, as in calcific
aortic stenosis
P2 accentuated Pulmonary hypertension, dilated
pulmonary artery, atrial septal defect
P2 diminished or absent Aging, pulmonic stenosis
Opening snap Mitral stenosis
S3 Physiologic (usually in children and
young adults); volume overload of
ventricle, as in mitral regurgitation
or heart failure
S4 Excellent physical conditioning
(trained athletes); resistance
to ventricular filling because
of decreased compliance, left
ventricular hypertrophy from
pressure overload, as in hypertensive
heart disease or aortic stenosis
Aids to Interpretation

162 Bates’ Pocket Guide to Physical Examination and History Taking
Table 9-2 Variations in the First Heart Sound—S1
Normal Variations
S1 S2
S1 is softer than S2 at the base (right and
left 2nd interspaces).
S1 S2
S1 is often but not always louder than S2 at
the apex.
Accentuated S1
S1 S2
Occurs in (1) tachycardia, rhythms with
a short PR interval, and high cardiac
output states (e.g., exercise, anemia,
hyperthyroidism), and (2) mitral stenosis.
Diminished S1
S1 S2
Occurs in first-degree heart block, calcified
mitral valve of mitral regurgitation, and
↓ left ventricular contractility in heart
failure or coronary heart disease.
Varying S1
S1 S2 S1 S2
S1 varies in complete heart block and any
totally irregular rhythm (e.g., atrial
fibrillation).
Split S1
S1 S2
Normally heard along the lower left sternal
border if audible tricuspid component. If
S1 sounds split at apex, consider an S4,
an aortic ejection sound, an early systolic
click, right bundle branch block, and
premature ventricular contractions.

Chapter 9 | The Cardiovascular System 163
Table 9-3
Variations in the Second Heart Sound—S2
During Inspiration and Expiration
Physiologic Splitting
S1 S2S1 S2
A2 P2
Heard in the 2nd or 3rd left interspace: the pulmonic component of
S2 is usually too faint to be heard at the apex or aortic area,
where S2 is single and derived from aortic valve closure alone.
Accentuated by inspiration; usually disappears on exertion.
Pathologic Splitting
S1 S2S1 S2
Wide splitting of S2 persists throughout respiration; arises from delayed
closure of the pulmonic valve (e.g., by pulmonic stenosis or right
bundle branch block); also from early closure of the aortic valve, as
in mitral regurgitation.
Fixed Splitting
S1 S2S1 S2
Does not vary with respiration, as in atrial septal defect, right
ventricular failure.
(continued)

164 Bates’ Pocket Guide to Physical Examination and History Taking
Paradoxical or Reversed Splitting
S1 S2 S1 S2
P2 A2
Appears on expiration and disappears on inspiration. Closure of the
aortic valve is abnormally delayed, so A2 follows P2 on expiration,
as in left bundle branch block.
More on A2 and P2
Increased Intensity of A2, 2nd Right Interspace (where only A2
can usually be heard) occurs in systemic hypertension because of
the increased ejection pressure. It also occurs when the aortic root
is dilated, probably because the aortic valve is then closer to the
chest wall.
Decreased or Absent A2, 2nd Right Interspace is noted in
calcific aortic stenosis because of immobility of the valve. If A2 is
inaudible, no splitting is heard.
Increased Intensity of P2. When P2 is equal to or louder than A2,
pulmonary hypertension may be suspected. Other causes include
a dilated pulmonary artery and an atrial septal defect. When a
split S2 is heard widely, even at the apex and the right base, P2 is
accentuated.
Decreased or Absent P2 is most commonly due to the increased
anteroposterior diameter of the chest associated with aging. It can
also result from pulmonic stenosis. If P2 is inaudible, no splitting
is heard.
Table 9-3
Variations in the Second Heart Sound—S2
During Inspiration and Expiration (continued )

Chapter 9 | The Cardiovascular System 165
Table 9-4 Heart Murmurs
Likely Causes
Midsystolic
S1 S2
Innocent murmurs (no valve abnormality)
Physiologic murmurs (from ↑ flow across
a semilunar valve, as in pregnancy, fever,
anemia)
Aortic stenosis
Murmurs that mimic aortic stenosis—aortic
sclerosis, bicuspid aortic valve, dilated
aorta, and pathologically ↑ systolic flow
across aortic valve
Hypertrophic cardiomyopathy
Pulmonic stenosis
Pansystolic
S1 S2
Mitral regurgitation
Tricuspid regurgitation
Ventricular septal defect
Late Systolic
S1 S2C
Mitral valve prolapse, often with click (C)
Early Diastolic
S1 S1S2
Aortic regurgitation
Middiastolic and
Presystolic
S1 S1S2 OS
Mitral stenosis—note opening snap (OS)
Continuous Murmurs
and Sounds
S1 S2 S1
S1 S2 S1
S1 S2 S1
Patent ductus arteriosus—harsh, machinery-
like
Pericardial friction rub—a scratchy sound
with 1–3 components
Venous hum—continuous, above
midclavicles, loudest in diastole

167
C H A P T E R
10The Breasts and Axillae
Ask, “Do you examine your breasts?” . . . “How often?” Ask about
any discomfort, pain, or lumps in the breasts. Also ask about any dis-
charge from the nipples, change in breast contour, dimpling, swelling,
or puckering of the skin over the breasts.
The Health History
Common or Concerning Symptoms
◗ Breast lump or mass
◗ Breast pain or discomfort
◗ Nipple discharge
Health Promotion and Counseling:
Evidence and Recommendations
Important Topics for Health Promotion and Counseling
◗ Palpable masses of the breast
◗ Assessing risk of breast cancer
◗ Breast cancer screening
◗ Breast self-examination (BSE)
Palpable Masses of the Breast. Breast masses show marked
variation in etiology, from fibroadenomas and cysts seen in younger
women, to abscess or mastitis, to primary breast cancer. All breast
masses warrant careful evaluation, and definitive diagnostic measures
should be pursued.

168 Bates’ Pocket Guide to Physical Examination and History Taking
Palpable Masses of the Breast
Age Common Lesion Characteristics
15–25 Fibroadenoma Usually smooth, rubbery, round,
mobile, nontender
25–50 Cysts Usually soft to firm, round, mo-
bile; often tender
Fibrocystic changes Nodular, ropelike
Cancer Irregular, firm, may be mobile or
fixed to surrounding tissue
Over 50 Cancer until proven
otherwise
As above
Pregnancy/
lactation
Lactating adenomas, cysts,
mastitis, and cancer
As above
Adapted from Schultz MZ, Ward BA, Reiss M. Breast diseases. In: Noble J, Greene HL,
Levinson W, et al., eds: Primary Care Medicine, 2nd ed. St. Louis: Mosby, 1996. See also
Venet L, Strax P, Venet W, et al. Adequacies and inadequacies of breast examinations by
physicians in mass screenings. Cancer 1971;28(6):1546–1551.
Assessing Risk of Breast Cancer. Although 70% of affected
women have no known predisposing factors, selected risk factors are
well established. Use the Breast Cancer Risk Assessment Tool of the
National Cancer Institute (http://www.cancer.gov/bcrisktool) or
other available clinical models, such as the Gail model, to individualize
risk factor assessment for your patients. Ask women beginning in their
20s about any family history of breast or ovarian cancer, or both, on
the maternal or paternal side, to help assess risk of BRCA1 or BRCA2
gene mutation. (See http: astor.som.jhmi.edu/Bayesmendel/brcapro.
html). See also Table 10-1, Breast Cancer in Women: Factors That
Increase Relative Risk, p. 175.
Breast Cancer Screening. The American Cancer Society recom-
mendations, listed below, vary slightly from those of the U.S. Preven-
tive Services Task Force.
● Yearly mammography for women 40 years of age and older. For
women at increased risk, many clinicians advise initiating screening
mammography between ages 30 and 40, then every 2 to 3 years
until 50 years of age.

http://www.cancer.gov/bcrisktool

http//www.astor.som.jhmi.edu/Bayesmendel/brcapro.html

http//www.astor.som.jhmi.edu/Bayesmendel/brcapro.html

Chapter 10 | The Breasts and Axillae 169
● Clinical breast examination (CBE) by a health care professional every
3 years for women between 20 and 39 years of age, and annually
after 40 years of age
● Regular breast self-examination (BSE), in conjunction with mam-
mography and CBE, to help promote health awareness
Techniques of Examination
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
Subclavian vein
Subclavian
lymph nodes
Axillary vein
Axillary
lymph nodes
Axillary tail
of breast
Fat
Serratus anterior
Pectoralis major
Areola
Upper
inner
Upper
outer
Lower
outer
Lower
innerGland lobules
THE FEMALE BREAST
Inspect the breasts in four
positions.
Note:
● Size and symmetry See Table 10-2, Visible Signs of Breast
Cancer, pp. 176–177, development,
asymmetry.
● Contour Flattening, dimpling

170 Bates’ Pocket Guide to Physical Examination and History Taking
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
● Appearance of the skin Edema (peau d’orange) in breast
cancer
ARMS AT SIDES ARMS OVER HEAD
HANDS PRESSED AGAINST HIPS LEANING FORWARD
Inspect the nipples.
● Compare their size, shape,
and direction of pointing.
Inversion, retraction, deviation
● Note any rashes, ulcerations,
or discharge.
Paget’s disease of the nipple,
galactorrhea
Palpate the breasts, includ-
ing augmented breasts. Breast
tissue should be flattened and
the patient supine. Palpate a
rectangular area extending from
the clavicle to the inframam-
mary fold, and from the
midsternal line to the posterior
axillary line and well into the
axilla for the tail of Spence.

Chapter 10 | The Breasts and Axillae 171
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
Note:
● Consistency Physiologic nodularity
● Tenderness Infection, premenstrual tenderness
● Nodules. If present, note
location, size, shape, consis-
tency, delimitation, tenderness,
and mobility.
Cyst, fibroadenoma, cancer
Use vertical strip pattern
(currently the best validated
technique) or a circular or
wedge pattern. Palpate in small,
concentric circles.
● For the lateral portion of the
breast, ask the patient to roll
onto the opposite hip, place
her hand on her forehead,
but keep shoulders pressed
against the bed or examining
table.
● For the medial portion of the
breast, ask the patient to lie
with her shoulders flat against
the bed or examining table,
place her hand at her neck,
and lift up her elbow until it is
even with her shoulder.
Palpate each nipple. Thickening in cancer
Palpate and inspect along the
incision lines of mastectomy.
Local recurrences of breast cancer

172 Bates’ Pocket Guide to Physical Examination and History Taking
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
THE MALE BREAST
/ Inspect and palpate the
nipple and areola.
Gynecomastia, mass suspicious for
cancer, fat
AXILLAE
Inspect for rashes, infection,
and pigmentation.
Hidradenitis suppurativa, acanthosis
nigricans
Palpate the axillary nodes,
including the central, pectoral,
lateral, and subscapular groups.
Lymphadenopathy
Lateral
Central
(deep within axilla)
Subscapular
(posterior)
Pectoral
(anterior)
Supraclavicular
Infraclavicular
ARROWS INDICATE DIRECTION OF
LYMPH FLOW
SPECIAL TECHNIQUE
BREAST DISCHARGE
Compress the areola in a
spokelike pattern around the
nipple. Watch for discharge.
Type and source of discharge may be
identified.

Chapter 10 | The Breasts and Axillae 173
/ BREAST SELF-EXAMINATION
Patient Instructions for the Breast Self-Examination (BSE)
Supine
1. Lie down with a pillow under
your right shoulder. Place your
right arm behind your head.
2. Use the finger pads of the three
middle fingers on your left hand
to feel for lumps in the right
breast. The finger pads are the
top third of each finger.
3. Press firmly enough to know
how your breast feels. A firm
ridge in the lower curve of each
breast is normal. If you’re not
sure how hard to press, talk with
your health care provider, or try
to copy the way the doctor or
nurse does it.
4. Press firmly on the breast in an
up-and-down or “strip” pattern.
You can also use a circular or
wedge pattern, but be sure to
use the same pattern every
time. Check the entire breast
area, and remember how your
breast feels from month to
month.
5. Repeat the examination on your
left breast, using the finger pads
of the right hand.
6. If you find any changes, see
your doctor right away.
(continued)

174 Bates’ Pocket Guide to Physical Examination and History Taking
Patient Instructions for the Breast
Self-Examination (BSE) (continued)
Standing
1. While standing in front of a
mirror with your hands
pressing firmly down on your
hips, look at your breasts for
any changes of size, shape,
contour, or dimpling, or redness
or scaliness of the nipple or
breast skin. (The pressing down
on the hips position contracts
the chest wall muscles and
enhances any breast changes.)
2. Examine each underarm while
sitting up or standing and with
your arm only slightly raised so
you can easily feel in this area.
Raising your arm straight up
tightens the tissue in this area
and makes it harder to examine.
Adapted from the American Cancer Society, updated September 2010. Available at http://
www.cancer.org/Cancer/BreastCancer/MoreInformation/BreastCancerEarlyDetection/
breast-cancer-early-detection-a-c-s-recs-b-s-e. Accessed December 3, 2010.
Recording Your Findings
Recording the Physical Examination—
Breasts and Axillae
“Breasts symmetric and smooth, without masses. Nipples without discharge.”
(Axillary adenopathy usually included after Neck in section on Lymph Nodes;
see p. 123.)
OR
“Breasts pendulous with diffuse fibrocystic changes. Single firm 1 × 1 cm mass,
mobile and nontender, with overlying peau d’orange appearance in right
breast, upper outer quadrant at 11 o’clock, 2 cm from the nipple.” (Suggests
possible breast cancer.)

http://www.cancer.org/Cancer/BreastCancer/MoreInformation/BreastCancerEarlyDetection/breast-cancer-early-detection-a-c-s-recs-b-s-e

http://www.cancer.org/Cancer/BreastCancer/MoreInformation/BreastCancerEarlyDetection/breast-cancer-early-detection-a-c-s-recs-b-s-e

http://www.cancer.org/Cancer/BreastCancer/MoreInformation/BreastCancerEarlyDetection/breast-cancer-early-detection-a-c-s-recs-b-s-e

Chapter 10 | The Breasts and Axillae 175
Aids to Interpretation
Breast Cancer in Women: Factors That
Increase Relative RiskTable 10-1
Relative Risk Factor
>4.0 ● Female
● Age (65+ versus <65 years, although risk increases across all ages until age 80) ● Certain inherited genetic mutations for breast cancer (BRCA1 and/or BRCA2) ● Two or more first-degree relatives with breast cancer diagnosed at an early age ● Personal history of breast cancer ● High breast tissue density ● Biopsy-confirmed atypical hyperplasia 2.1–4.0 ● One first-degree relative with breast cancer ● High-dose radiation to chest ● High bone density (postmenopausal) 1.1–2.0 Factors that affect circulating hormones ● Late age at first full-term pregnancy (>30 years)
● Early menarche (<12 years) ● Late menopause (>55 years)
● No full-term pregnancies
● Never breast-fed a child
● Recent oral contraceptive use
● Recent and long-term use of hormone
replacement therapy
● Obesity (postmenopausal)
Other factors ● Personal history of endometrium, ovary,
or colon cancer
● Alcohol consumption
● Height (tall)
● High socioeconomic status
● Jewish heritage
Source: American Cancer Society. Breast Cancer Facts and Figures 2009–2010, p. 11.
Available at: www.cancer.org/acs/groups/content/cnho/documents/document/
f861009final90809pdf . Accessed July 31, 2012.

http://www.cancer.org/acs/groups/content/cnho/documents/document/f861009final90809pdf

http://www.cancer.org/acs/groups/content/cnho/documents/document/f861009final90809pdf

176 Bates’ Pocket Guide to Physical Examination and History Taking
Visible Signs of Breast CancerTable 10-2
Retraction Signs
Fibrosis from breast cancer
produces retraction signs:
dimpling, changes in contour,
and retraction or deviation of the
nipple. Other causes of retraction
include fat necrosis and mammary
duct ectasia.
Cancer
Dimpling
Retracted
nipple
Skin Dimpling
Abnormal Contours
Look for any variation in the normal
convexity of each breast, and
compare one side with the other.
Nipple Retraction and Deviation
A retracted nipple is flattened or
pulled inward. It may also be
broadened and feel thickened.
The nipple may deviate, or point
in a different direction, typically
toward the underlying cancer.

Chapter 10 | The Breasts and Axillae 177
Visible Signs of Breast Cancer (continued)Table 10-2
Edema of the Skin
From lymphatic blockade, appearing
as thickened skin with enlarged
pores—the so-called peau
d’orange (orange peel) sign.
Paget’s Disease of the Nipple
An uncommon form of breast
cancer that usually starts as a
scaly, eczemalike lesion. The skin
may also weep, crust, or erode.
A breast mass may be present.
Suspect Paget’s disease in any
persisting dermatitis of the nipple
and areola.
Dermatitis of
areola
Erosion of
nipple

179
C H A P T E R
11The Abdomen
The Health History
Common or Concerning Symptoms
Gastrointestinal Disorders Urinary and Renal Disorders
◗ Abdominal pain, acute and chronic
◗ Indigestion, nausea, vomiting includ-
ing blood, loss of appetite, early
satiety
◗ Dysphagia and/or odynophagia
◗ Change in bowel function
◗ Diarrhea, constipation
◗ Jaundice
◗ Suprapubic pain
◗ Dysuria, urgency, or frequency
◗ Hesitancy, decreased stream
in males
◗ Polyuria or nocturia
◗ Urinary incontinence
◗ Hematuria
◗ Kidney or flank pain
◗ Ureteral colic
PATTERNS AND MECHANISMS OF ABDOMINAL PAIN
Be familiar with three broad
categories:
Visceral pain—occurs when hollow
abdominal organs such as the
intestine or biliary tree contract
unusually forcefully or are distended
or stretched.
Visceral pain in the right upper
quadrant (RUQ) from liver disten-
tion against its capsule in alcoholic
hepatitis
● May be difficult to localize
● Varies in quality; may be gnawing,
burning, cramping, or aching

180 Bates’ Pocket Guide to Physical Examination and History Taking
● When severe, may be associated
with sweating, pallor, nausea,
vomiting, restlessness.
Parietal pain—from inflammation
of the parietal peritoneum.
● Steady, aching
● Usually more severe
● Usually more precisely localized
over the involved structure than
visceral pain
Visceral periumbilical pain in early
acute appendicitis from distention
of inflamed appendix gradually
changes to parietal pain in the right
lower quadrant (RLQ) from inflam-
mation of the adjacent parietal
peritoneum.
Referred pain—occurs in
more distant sites innervated at
approximately the same spinal levels
as the disordered structure.
Pain of duodenal or pancreatic
origin may be referred to the back;
pain from the biliary tree—to the
right shoulder or right posterior
chest.
Pain from the chest, spine, or pelvis
may be referred to the abdomen.
Pain from pleurisy or acute myocar-
dial infarction may be referred to
the upper abdomen.
THE GASTROINTESTINAL TRACT
Ask patients to describe the
abdominal pain in their own words,
especially timing of the pain (acute
or chronic); then ask them to point
to the pain.
Pursue important details:
“Where does the pain start?”
“Does it radiate or travel?”
“What is the pain like?”
“How severe is it?”
“How about on a scale of 1 to 10?”
“What makes it better or worse?”

Chapter 11 | The Abdomen 181
Elicit any symptoms associated with
the pain, such as fever or chills; ask
their sequence.
Upper Abdominal Pain,
Discomfort, or Heartburn. Ask
about chronic or recurrent upper
abdominal discomfort, or dyspepsia.
Related symptoms include bloating,
nausea, upper abdominal fullness,
and heartburn.
Find out just what your patient
means. Possibilities include:
● Bloating from excessive gas,
especially with frequent belching,
abdominal distention, or flatus,
the passage of gas by rectum
● Nausea and vomiting
● Unpleasant abdominal fullness
after normal meals or early satiety,
the inability to eat a full meal
● Heartburn
Consider diabetic gastroparesis,
anticholinergic drugs, gastric outlet
obstruction, gastric cancer. Early
satiety may signify hepatitis.
Suggests gastroesophageal reflux
disease (GERD)
Lower Abdominal Pain
or Discomfort—Acute and
Chronic. If acute, is the pain sharp
and continuous or intermittent and
cramping?
Right lower quadrant (RLQ) pain,
or pain migrating from perium-
bilical region in appendicitis; in
women with RLQ pain, possible
pelvic inflammatory disease, ectopic
pregnancy
Left lower quadrant (LLQ) pain in
diverticulitis

182 Bates’ Pocket Guide to Physical Examination and History Taking
If chronic, is there a change in
bowel habits? Alternating
diarrhea and constipation?
Colon cancer; irritable bowel
syndrome
Other GI Symptoms
● Anorexia
● Dysphagia or difficulty
swallowing
Liver disease, pregnancy, diabetic
ketoacidosis, adrenal insufficiency,
uremia, anorexia nervosa
If solids and liquids, neuro-
muscular disorders affecting
motility. If only solids, consider
structural conditions like Zenker’s
diverticulum, Schatzki’s ring, stric-
ture, neoplasm
● Odynophagia, or painful
swallowing
● Diarrhea, acute (<2 weeks) and chronic ● Constipation ● Melena, or black tarry stools ● Jaundice from increased levels of bilirubin: Intrahepatic jaundice can be hepatocellular, from damage to the hepatocytes, or cholestatic, from impaired excretion caused by dam- aged hepatocytes or intrahepatic bile ducts Radiation; caustic ingestion, infection from cytomegalovirus, herpes simplex, HIV Acute infection (viral, salmonella, shigella, etc.); chronic in Crohn’s disease, ulcerative colitis; oily diarrhea (steatorrhea)—in pancre- atic insufficiency. See Table 11-1, Diarrhea, pp. 194–195. Medications, especially anticho- linergic agents and opioids; colon cancer GI bleed Impaired excretion of conjugated bilirubin in viral hepatitis, cirrhosis, primary biliary cirrhosis, drug- induced cholestasis Extrahepatic jaundice arises from obstructed extrahepatic bile ducts, commonly the cystic and common bile ducts Chapter 11 | The Abdomen 183 Ask about the color of the urine and stool. Dark urine from increased conju- gated bilirubin excreted in urine; acholic clay-colored stool when excretion of bilirubin into intestine is obstructed Risk Factors for Liver Disease ◗ Hepatitis A: Travel or meals in areas with poor sanitation, ingestion of con- taminated water or foodstuffs ◗ Hepatitis B: Parenteral or mucous membrane exposure to infectious body fluids such as blood, serum, semen, and saliva, especially through sexual contact with an infected partner or use of shared needles for injection drug use ◗ Hepatitis C: Illicit intravenous drug use or blood transfusion ◗ Alcoholic hepatitis or alcoholic cirrhosis: Interview the patient carefully about alcohol use ◗ Toxic liver damage from medications, industrial solvents, environmental toxins or some anesthetic agents ◗ Extrahepatic biliary obstruction that may result from gallbladder disease or surgery ◗ Hereditary disorders reported in the Family History THE URINARY TRACT Ask about pain on urination, usually a burning sensation, some- times termed dysuria (also refers to difficulty voiding). Bladder infection Also, consider bladder stones, foreign bodies, tumors, and acute prostatitis. In women, internal burn- ing in urethritis, external burning in vulvovaginitis Other associated symptoms include: ● Urgency, an unusually intense and immediate desire to void ● Urinary frequency, or abnormally frequent voiding ● Fever or chills; blood in the urine ● Any pain in the abdomen, flank, or back May lead to urge incontinence Dull, steady pain in pyelonephritis; severe colicky pain in ureteral obstruction from renal stone 184 Bates’ Pocket Guide to Physical Examination and History Taking In men, hesitancy in starting the urine stream, straining to void, reduced caliber and force of the urine stream, or dribbling as they complete voiding. Prostatitis, urethritis Assess any: ● Polyuria, a significant increase in 24-hour urine volume ● Nocturia, urinary frequency at night ● Urinary incontinence, involuntary loss of urine: ● From coughing, sneezing, lifting ● From urge to void ● From bladder fullness with leaking but incomplete emptying Diabetes mellitus, diabetes insipidus Bladder obstruction See Table 11-2, Urinary Inconti- nence, pp. 196–197. Stress incontinence (poor urethral sphincter tone) Urge incontinence (detrusor over- activity) Overflow incontinence (anatomic obstruction, impaired neural innervation to bladder) Health Promotion and Counseling: Evidence and Recommendations Important Topics for Health Promotion and Counseling ◗ Screening for alcohol abuse ◗ Risk factors for hepatitis A, B, and C ◗ Screening for colon cancer Alcohol Abuse. Assessing use of alcohol is an important clinician responsibility. Focus on detection, counseling, and, for significant impairment, specific treatment recommendations. Use the four CAGE questions to screen for alcohol dependence or abuse in all adolescents and adults, including pregnant women (see Chapter 3, p. 46). Brief HHHeealltthh PPrroommoootioonn andd CCCouunsselingg: EEEviideenncce aannd Reecooommmmeeenddattionns Chapter 11 | The Abdomen 185 counseling interventions have been shown to reduce alcohol con- sumption by 13% to 34% over 6 to 12 months. Hepatitis. Protective measures against infectious hepatitis include counseling about transmission: ● Hepatitis A: Transmission is fecal–oral. Illness occurs approximately 30 days after exposure. Hepatitis A vaccine is recommended for chil- dren after age 1 and groups at risk: travelers to endemic areas; food handlers; military personnel; caretakers of children; Native Americans and Alaska Natives; selected health care, sanitation, and laboratory workers; homosexual men; and injection drug users. ● Hepatitis B: Transmission occurs during contact with infected body fluids, such as blood, semen, saliva, and vaginal secretions. Infec- tion increases risk of fulminant hepatitis, chronic infection, and sub- sequent cirrhosis and hepatocellular carcinoma. Provide counseling and serologic screening for patients at risk. Hepatitis B vaccine is recommended for infants at birth and groups at risk: all young adults not previously immunized, injection drug users and their sexual partners, people at risk for sexually transmitted infections, travelers to endemic areas, recipients of blood products as in hemo- dialysis, and health care workers with frequent exposure to blood products. Many of these groups also should be screened for HIV infection, especially pregnant women at their first prenatal visit. ● Hepatitis C: Hepatitis C, now the most common form, is spread by blood exposure and is associated with injection drug use. No vaccine is available. Colorectal Cancer. The U.S. Preventive Services Task Force made the recommendations below in 2008. Screening for Colorectal Cancer Assess Risk: Begin screening at age 20 years. If high risk, refer for more com- plex management. If average risk at age 50 (high-risk conditions absent), offer the screening options listed. ◗ Common high-risk conditions (25% of colorectal cancers) ◗ Personal history of colorectal cancer or adenoma ◗ First-degree relative with colorectal cancer or adenomatous polyps ◗ Personal history of breast, ovarian, or endometrial cancer ◗ Personal history of ulcerative or Crohn’s colitis (continued) 186 Bates’ Pocket Guide to Physical Examination and History Taking Detection rates for colorectal cancer and insertion depths of colon- oscopy are roughly as follows: 25% to 30% at 20 cm; 50% to 55% at 35 cm; 40% to 65% at 40 cm to 50 cm. Full colonoscopy or air con- trast barium enema detects 80% to 95% of colorectal cancers. Techniques of Examination E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S THE ABDOMEN Inspect the abdomen, including: ● Skin ● Umbilicus ● Contours for shape, symmetry, enlarged organs or masses ● Any peristaltic waves ● Any pulsations Scars, striae, veins, ecchymoses (in intra- or retroperitoneal hemorrhages) Hernia, inflammation Bulging flanks of ascites, suprapubic bulge, large liver or spleen, tumors Increase in GI obstruction Increased in aortic aneurysm Screening for Colorectal Cancer (continued) ◗ Hereditary high-risk conditions (6% of colorectal cancers) ◗ Familial adenomatous polyposis ◗ Hereditary nonpolyposis colorectal cancer Screening recommendations—U.S. Preventive Services Task Force 2008 ◗ Adults age 50 to 75 years—options ◗ High-sensitivity fecal occult blood testing (FOBT) annually ◗ Sigmoidoscopy every 5 years with FOBT every 3 years ◗ Screening colonoscopy every 10 years ◗ Adults age 76 to 85 years—do not screen routinely, as gain in life-years is small compared to colonoscopy risks, and screening benefits not seen for 7 years; use individual decision making if screening for the first time ◗ Adults older than age 85—do not screen, as “competing causes of mortality preclude a mortality benefit that outweighs harms” TTTecchnniiquees offf EExaammminnattionn Chapter 11 | The Abdomen 187 Bowel Sounds and Bruits Change Seen With Increased bowel sounds Diarrhea Early intestinal obstruction Decreased, then absent bowel sounds Adynamic ileus Peritonitis High-pitched tinkling bowel sounds Intestinal fluid Air under tension in a dilated bowel High-pitched rushing bowel sounds with cramping Intestinal obstruction Hepatic bruit Carcinoma of the liver Alcoholic hepatitis Arterial bruits Partial obstruction of the aorta or renal, iliac or femoral arteries Aorta Renal artery Iliac artery Femoral artery Percuss the abdomen for patterns of tympany and dullness. Ascites, GI obstruction, pregnant uterus, ovarian tumor Palpate all quadrants of the abdomen: See Table 11-3, Abdominal Tenderness, p. 197. E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S Auscultate the abdomen for: ● Bowel sounds ● Bruits ● Friction rubs Increased or decreased motility Bruit of renal artery stenosis Liver tumor, splenic infarct 188 Bates’ Pocket Guide to Physical Examination and History Taking ● Lightly for guarding, rebound, and tenderness “Acute abdomen” or peritonitis if: • Firm, boardlike abdominal wall— suggests peritoneal inflammation. • Guarding if the patient flinches, grimaces, or reports pain during palpation. • Rebound tenderness from peritoneal inflammation; pain is greater when you withdraw your hand than when you press down. Press slowly on a tender area, then quickly “let go.” ● Deeply for masses or tenderness Tumors, a distended viscus THE LIVER Percuss span of liver dullness in the midclavicular line (MCL). Hepatomegaly 4–8 cm in midsternal line 6–12 cm in right midclavicular line Normal liver spans Feel the liver edge, if possible, as patient breathes in. Firm edge of cirrhosis E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S Chapter 11 | The Abdomen 189 Measure its distance from the costal margin in the MCL. Increased in hepatomegaly—may be missed (as below) by starting palpation too high in the RUQ Note any tenderness or masses. Tender liver of hepatitis or heart failure; tumor mass THE SPLEEN Percuss across left lower anterior chest, noting change from tym- pany to dullness. Try to feel spleen with the patient: Splenomegaly ● Supine ● Lying on the right side with legs flexed at hips and knees E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S 190 Bates’ Pocket Guide to Physical Examination and History Taking THE KIDNEYS Try to palpate each kidney. Enlargement from cysts, cancer, hydronephrosis Check for costovertebral angle (CVA) tenderness. Tender in pyelonephritis THE AORTA Palpate the aorta’s pulsa- tions. In older people, estimate its width. Periumbilical mass with expansile pulsa- tions ≥3 cm in diameter in abdominal aortic aneurysm. Assess further due to risk of rupture. E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S Chapter 11 | The Abdomen 191 ASSESSING ASCITES / Palpate for shifting dullness. Map areas of tympany and dullness with patient supine, then lying on side (see below). Ascitic fluid usually shifts to dependent side, changing the margin of dullness (see below) Tympany Dullness Tympany Shifting dullness Check for a fluid wave. Ask patient or an assistant to press edges of both hands into midline of abdomen. Tap one side and feel for a wave transmitted to the other side. A palpable wave suggests but does not prove ascites. E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S 192 Bates’ Pocket Guide to Physical Examination and History Taking Ballotte an organ or mass in an ascitic abdomen. Place your stiffened and straightened fingers on the abdomen, briefly jab them toward the structure, and try to touch its surface. Your hand, quickly displacing the fluid, stops abruptly as it touches the solid surface. ASSESSING POSSIBLE APPENDICITIS Ask: In classic appendicitis: “Where did the pain begin?” Near the umbilicus “Where is it now?” Right lower quadrant (RLQ) Ask patient to cough. “Where does it hurt?” RLQ at “McBurney’s point” Palpate for local tenderness. RLQ tenderness Palpate for muscular rigidity. RLQ rigidity Perform a rectal examination and, in women, a pelvic examina- tion (see Chapters 14 and 15). Local tenderness, especially if appendix is retrocecal ● Rovsing’s sign: Press deeply and evenly in the left lower quadrant. Then quickly with- draw your fingers. Pain in the right lower quadrant during left-sided pressure suggests appendici- tis (a positive Rovsing’s sign). ● Psoas sign: Place your hand just above the patient’s right knee. Ask the patient to raise that thigh against your hand. Or, ask the patient to turn onto the left side. Then extend the patient’s right leg at the hip to stretch the psoas muscle. Pain from irritation of the psoas muscle suggests an inflamed appendix (a posi- tive psoas sign). E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S Chapter 11 | The Abdomen 193 ● Obturator sign: Flex the patient’s right thigh at the hip, with the knee bent, and rotate the leg internally at the hip, which stretches the internal obturator muscle. Right hypogastric pain in a positive obturator sign, suggesting irritation of the obturator muscle by an inflamed appendix. ASSESSING POSSIBLE ACUTE CHOLECYSTITIS Auscultate, percuss, and palpate the abdomen for tenderness. Bowel sounds may be active or decreased; tympany may increase with an ileus: Assess any RUQ tenderness. Assess for Murphy’s sign. Hook your thumb under the right costal margin at edge of rectus muscle, and ask patient to take a deep breath. Sharp tenderness and a sudden stop in inspiratory effort constitute a positive Murphy’s sign. Recording Your Findings Recording the Physical Examination—The Abdomen “Abdomen is protuberant with active bowel sounds. It is soft and nontender; no palpable masses or hepatosplenomegaly. Liver span is 7 cm and in the right MCL; edge is smooth and palpable 1 cm below the right costal margin. Spleen and kidneys not felt. No CVA tenderness.” OR “Abdomen is flat. No bowel sounds heard. It is firm and boardlike, with in- creased tenderness, guarding, and rebound in the right midquadrant. Liver percusses to 7 cm in the MCL; edge not felt. Spleen and kidneys not felt. No palpable mass. No CVA tenderness.” (Suggests peritonitis from possible appendi- citis; see pp. 192–193.) E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S RRReccoorddinnggg YYouuur Finnddinngss 194 Bates’ Pocket Guide to Physical Examination and History Taking Aids to InterpretationAAAiddss ttoo IInntterrpprreetaattioonn DiarrheaTable 11-1 Problem/Process Characteristics of Stool Acute Diarrhea Secretory Infections (noninflammatory) Infection by viruses; preformed bacterial toxins such as Staphylococcus aureus, Clostridium perfringens, toxigenic Escherichia coli; Vibrio cholerae, Cryptosporidium, Giardia lamblia Watery, without blood, pus, or mucus Inflammatory Infections Colonization or invasion of intestinal mucosa as in nontyphoid Salmonella, Shigella, Yersinia, Campylobacter, enteropathic E. coli, Entamoeba histolytica Loose to watery, often with blood, pus, or mucus Drug-Induced Diarrhea Action of many drugs, such as magnesium-containing antacids, antibiotics, antineoplastic agents, and laxatives Loose to watery Chronic Diarrhea ( 30 days) Diarrheal Syndromes ● Irritable bowel syndrome: A disorder of bowel motility with alternating diarrhea and constipation ● Cancer of the sigmoid colon: Partial obstruction by a malignant neoplasm Loose; may show mucus but no blood. Small, hard stools with constipation May be blood-streaked Chapter 11 | The Abdomen 195 Problem/Process Characteristics of Stool Inflammatory Bowel Disease ● Ulcerative colitis: inflammation and ulceration of the mucosa and submucosa of the rectum and colon ● Crohn’s disease of the small bowel (regional enteritis) or colon (granulomatous colitis): chronic inflammation of the bowel wall, typically involving the terminal ileum, proximal colon, or both Soft to watery, often containing blood Small, soft to loose or watery, usually free of gross blood (enteritis) or with less bleeding than ulcerative colitis (colitis) Voluminous Diarrheas ● Malabsorption syndrome: Defective absorption of fat, including fat-soluble vitamins, with steatorrhea (excessive excretion of fat) as in pancreatic insufficiency, bile salt deficiency, bacterial overgrowth ● Osmotic diarrheas ● Lactose intolerance: Deficiency in intestinal lactase ● Abuse of osmotic purgatives: Laxative habit, often surreptitious ● Secretory diarrheas from bacterial infection, secreting villous adenoma, fat or bile salt malabsorption, hormone- mediated conditions (gastrin in Zollinger–Ellison syndrome, vasoactive intestinal peptide): Process is variable. Typically bulky, soft, light yellow to gray, mushy, greasy or oily, and sometimes frothy; particularly foul-smelling; usually floats in the toilet Watery diarrhea of large volume Watery diarrhea of large volume Watery diarrhea of large volume Diarrhea (continued)Table 11-1 196 Bates’ Pocket Guide to Physical Examination and History Taking Urinary IncontinenceTable 11-2 Problem Mechanisms Stress Incontinence: Urethral sphincter weakened. Transient increases in intra-abdominal pressure raise bladder pressure to levels exceeding urethral resistance. Leads to voiding small amounts during laughing, coughing, and sneezing. ● In women, weakness of the pelvic floor with inadequate muscular support of the bladder and proximal urethra and a change in the angle between the bladder and the urethra from childbirth, surgery, and local conditions affecting the internal urethral sphincter, such as postmenopausal atrophy of the mucosa and urethral infection ● In men, prostatic surgery Urge Incontinence: Detrusor contractions are stronger than normal and overcome normal urethral resistance. Bladder is typically small. Results in voiding moderate amounts, urgency, frequency, and nocturia. ● Decreased cortical inhibition of detrusor contractions, as in stroke, brain tumor, dementia, and lesions of the spinal cord above the sacral level ● Hyperexcitability of sensory pathways, as in bladder infection, tumor, and fecal impaction ● Deconditioning of voiding reflexes, caused by frequent voluntary voiding at low bladder volumes Overflow Incontinence: Detrusor contractions are insufficient to overcome urethral resistance. Bladder is typically large, even after an effort to void, leading to continuous dribbling. ● Obstruction of the bladder outlet, as by benign prostatic hyperplasia or tumor ● Weakness of detrusor muscle associated with peripheral nerve disease at the sacral level ● Impaired bladder sensation that interrupts the reflex arc, as in diabetic neuropathy Chapter 11 | The Abdomen 197 Urinary Incontinence (continued)Table 11-2 Problem Mechanisms Functional Incontinence: Inability to get to the toilet in time because of impaired health or environmental conditions ● Problems in mobility from weakness, arthritis, poor vision, other conditions; environmental factors such as unfamiliar setting, distant bathroom facilities, bed rails, physical restraints Incontinence Secondary to Medications: Drugs may contribute to any type of incontinence listed. ● Sedatives, tranquilizers, anticholinergics, sympathetic blockers, potent diuretics Abdominal TendernessTable 11-3 Visceral Tenderness Peritoneal Tenderness Enlarged liver Normal cecum Normal aorta Normal or spastic sigmoid colon Diverticulitis Appendicitis Cholecystitis Tenderness From Disease in the Chest and Pelvis Acute Pleurisy Acute Salpingitis Unilateral or bilateral, upper or lower abdomen 199 C H A P T E R 12The Peripheral Vascular System Ask about abdominal, flank, or back pain, especially in older male smokers. An expanding abdominal aortic aneu- rysm (AAA) may compress arteries or ureters. Ask about any pain in the arms and legs. Is there intermittent claudica- tion, exercise-induced pain that is absent at rest, makes the patient stop exertion, and abates within about 10 minutes? Ask “Have you ever had any pain or cramp- ing in your legs when you walk or exercise?” “How far can you walk without stopping to rest?” and “Does pain improve with rest?” Peripheral arterial disease (PAD) can cause symptomatic limb ischemia with exer- tion; distinguish this from spinal stenosis, which produces leg pain with exertion often reduced by leaning forward (stretching the spinal cord in the nar- rowed vertebral canal) and less readily relieved by rest. Ask also about coldness, numbness, or pallor in legs or feet or hair loss over the anterior tibial surfaces. Hair loss over the anterior tibiae in PAD. “Dry” or brown–black ulcers from gan- grene may ensue. The Health History ◗ Abdominal, flank, or back pain ◗ Pain in the arms or legs ◗ Intermittent claudication ◗ Cold, numbness, pallor in the legs; hair loss ◗ Color change in fingertips or toes in cold weather ◗ Swelling in calves, legs, or feet ◗ Swelling with redness or tenderness Common or Concerning Symptoms 200 Bates’ Pocket Guide to Physical Examination and History Taking Because patients have few symptoms, identify risk factors— tobacco abuse, hypertension, diabetes, hyperlipidemia, and history of myocardial infarction or stroke. Only approximately 10% to 30% of affected patients have the classic symp- toms of exertional calf pain relieved by rest. “Do your fingertips or toes ever change color in cold weather or when you handle cold objects?” Digital ischemic changes from arte- rial spasm cause blanching, followed by cyanosis and then rubor with cold exposure and rewarming in Raynaud’s phenomenon or disease Ask about swelling of feet and legs, or any ulcers on lower legs, often near the ankles from peripheral vascular disease. Calf swelling in deep venous thrombo- sis; hyperpigmentation, edema, and possible cyanosis, especially when legs are dependent, in venous stasis ulcers; swelling with redness and tenderness in cellulitis ◗ Screening for peripheral arterial disease (PAD); the ankle–brachial index ◗ Screening for renal artery disease ◗ Screening for abdominal aortic aneurysm Screening for Peripheral Arterial Disease (PAD). PAD involves the femoral and popliteal arteries most commonly, followed by the tibial and peroneal arteries. PAD affects from 12% to 29% of community populations; despite significant association with cardio- vascular and cerebrovascular disease, PAD often is underdiagnosed in office practices. Most patients with PAD have either no symptoms or a range of nonspecific leg symptoms, such as aching, cramping, numb- ness, or fatigue. Health Promotion and Counseling: Evidence and Recommendations Important Topics for Health Promotion and Counseling Chapter 12 | The Peripheral Vascular System 201 Screen patients for PAD risk factors, such as tobacco abuse, elevated cholesterol, diabetes, age older than 70 years, hypertension, or athero- sclerotic coronary, carotid, or renal artery disease. Pursue aggressive risk factor intervention. Consider use of the ankle–brachial index (ABI), a highly accurate test for detecting stenoses of 50% or more in major vessels of the legs (see pp. 209–210). A wide range of interventions reduces both onset and progression of PAD, including meticulous foot care and well-fitting shoes, tobacco cessation, treatment of hyperlipidemia, optimal control and treatment of diabetes and hypertension, use of antiplatelet agents, graded exer- cise, and surgical revascularization. Patients with ABIs in the lowest category have a 20% to 25% annual risk of death. Screening for Renal Ar ter y Disease. The American College of Cardiology and the American Heart Association recommend diagnostic studies for renal artery disease, usually beginning with ultrasound, in patients with hypertension before age 30 years; severe hypertension (see p. 56) after age 55 years; accelerated, resistant, or malignant hypertension; new worsening of renal func- tion or worsening after use of an angiotensin-converting enzyme inhibitor or an angiotensin-receptor blocking agent; an unex- plained small kidney; or sudden unexplained pulmonary edema, especially in the setting of worsening renal function. Symptoms arise from these conditions rather than directly from atherosclerotic changes in the renal artery. Screening for Abdominal Aor tic Aneurysm (AAA). An AAA is present when the infrarenal aortic diameter exceeds 3.0 cm. Rup- ture and mortality rates dramatically increase for AAAs exceeding 5.5 cm in diameter. The strongest risk factor for rupture is excess aortic diameter. Additional risk factors are smoking, age older than 65 years, family history, coronary artery disease, PAD, hypertension, and elevated cholesterol level. Because symptoms are rare, and screening is now shown to reduce mortality by approximately 40%, the U.S. Preventive Services Task Force recommends one-time screening by ultrasound in men between 65 and 75 years of age with a history of “ever smoking,” defined as more than 100 cigarettes in a lifetime. 202 Bates’ Pocket Guide to Physical Examination and History Taking ● Radial Bounding radial, carotid, and femoral pulses in aortic regurgitation Lost in thromboangiitis obliterans or acute arterial occlusion ● Brachial Techniques of Examination E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S ARMS Inspect for: ● Size and symmetry, any swelling ● Venous pattern ● Color and texture of skin and nails Lymphedema, venous obstruction Venous obstruction Raynaud’s disease Palpate and grade the pulses: Grading Ar terial Pulses 3+ Bounding 2+ Brisk, expected (normal) 1+ Diminished, weaker than expected 0 Absent, unable to palpate Chapter 12 | The Peripheral Vascular System 203 E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S Feel for the epitrochlear nodes. Lymphadenopathy from local cut, infection ABDOMEN Palpate and estimate the width of the abdominal aorta between your two fingers. (See p. 190) Pulsatile mass, AAA if width ≥4 cm. LEGS Inspect for: See Table 12-1, Chronic Insufficiency of Arteries and Veins, p. 207, and Table 12-2, Common Ulcers of the Feet and Ankles, p. 208. ● Size and symmetry, any swell- ing in thigh or calf ● Venous pattern ● Color and texture of skin ● Hair distribution, temperature Venous insufficiency, lymphedema; deep venous thrombosis Varicose veins Pallor, rubor, cyanosis; erythema, warmth in cellulitis, thrombophlebitis Loss hair and coldness in arterial insufficiency Palpate the inguinal lymph nodes: Lymphadenopathy in genital infections, lymphoma, AIDs ● Horizontal group ● Vertical group Vertical group Great saphenous vein Femoral vein femoral arteryHorizontal group 204 Bates’ Pocket Guide to Physical Examination and History Taking E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S Palpate and grade the pulses: Loss of pulses in acute arterial occlu- sion and arteriosclerosis obliterans ● Femoral ● Popliteal ● Dorsalis pedis ● Posterior tibial Check for pitting edema. See Table 12-3, Using the Ankle-Brachial Index, p. 209–210. Dependent edema, heart failure, hypo- albuminemia, nephrotic syndrome Palpate the calves. Tenderness in deep venous thrombosis (though tenderness often not present) Ask patient to stand, and rein- spect the venous pattern. Varicose veins Chapter 12 | The Peripheral Vascular System 205 SPECIAL TECHNIQUES EVALUATING ARTERIAL SUPPLY TO THE HAND Persisting pallor of palm indicates occlusion of the released artery or its distal branches. Feel ulnar pulse, if possible. Perform an Allen test. 1. Ask the patient to make a tight fist, palm up. Occlude both radial and ulnar arteries with your thumb. 2. Ask the patient to open hand into a relaxed, slightly flexed position. 3. Release your pressure over one artery. Palm should flush within 3 to 5 seconds. 4. Repeat, releasing other artery. E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S 206 Bates’ Pocket Guide to Physical Examination and History Taking Recording Your Findings Recording the Physical Examination—The Peripheral Vascular System “Extremities are warm and without edema. No varicosities or stasis changes. Calves are supple and nontender. No femoral or abdominal bruits. Brachial, radial, femoral, popliteal, dorsalis pedis (DP), and posterior tibial (PT) pulses are 2+ and symmetric.” OR “Extremities are pale below the midcalf, with notable hair loss. Rubor noted when legs dependent but no edema or ulceration. Bilateral femoral bruits; no abdominal bruits heard. Brachial and radial pulses 2+; femoral, popliteal, DP, and PT pulses 1+.” (Alternatively, pulses can be recorded as below.) Suggests atherosclerotic PAD. Radial Brachial Femoral Popliteal Dorsalis Pedis Posterior Tibial RT 2+ 2+ 1+ 1+ 1+ 1+ LT 2+ 2+ 1+ 1+ 1+ 1+ E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S POSTURAL COLOR CHANGES OF CHRONIC ARTERIAL INSUFFICIENCY Marked pallor of feet on elevation, delayed color return and venous filling, and rubor of dependent feet suggest arterial insufficiency. Raise both legs to 60 degrees for about 1 minute. Then ask patient to sit up with legs dangling down. Note time required for (1) return of pinkness (normally 10 seconds) and (2) filling of veins on feet and ankles (normally about 15 seconds). Chapter 12 | The Peripheral Vascular System 207 Aids to InterpretationAAAiddss ttoo IInntterrpprreetaattioonn Chronic Insufficiency of Arteries and VeinsTable 12-1 Condition Characteristics Chronic Arterial Insufficiency Rubor Ischemic ulcer Intermittent claudication progressing to pain at rest. Decreased or absent pulses. Pale, especially on elevation; dusky red on dependency. Cool. Absent or mild edema, which may develop on lowering the leg to relieve pain. Thin, shiny, atrophic skin; hair loss over foot and toes; thickened, ridged nails. Possible ulceration on toes or points of trauma on feet. Potential gangrene. Chronic Venous Insufficiency No pain to aching pain on dependency. Normal pulses, though may be hard to feel because of edema. Color normal or cyanotic on dependency; petechiae or brown pigment may develop. Often marked edema. Stasis dermatitis, possible thickening of skin, and narrowing of leg as scarring develops. Potential ulceration at sides of ankles. No gangrene. 208 Bates’ Pocket Guide to Physical Examination and History Taking Common Ulcers of the Feet and AnklesTable 12-2 Ulcer Characteristics Arterial Insufficiency Located on toes, feet, or possible areas of trauma. No callus or excess pigment. May be atrophic. Pain often severe, unless masked by neuropathy. Possible gangrene. Decreased pulses, trophic changes, pallor of foot on elevation, dusky rubor on dependency. Chronic Venous Insufficiency Located on inner or outer ankle. Pigmented, sometimes fibrotic. Pain not severe. No gangrene. Edema, pigmentation, stasis dermatitis, and possibly cyanosis of feet on dependency. Neuropathic Ulcer Located on pressure points in areas with diminished sensation, as in diabetic neuropathy. Skin calloused. No pain (which may cause ulcer to go unnoticed). Usually no gangrene. Decreased sensation, absent ankle jerks. Chapter 12 | The Peripheral Vascular System 209 Using the Ankle–Brachial Index Table 12-3 Instructions for Measuring the Ankle–Brachial Index (ABI) 1. Patient should rest supine in a warm room for at least 10 minutes before testing. Doppler Brachial artery 2. Place blood pressure cuffs on both arms and ankles as illustrated, then apply ultrasound gel over brachial, dorsalis pedis, and posterior tibial arteries. 3. Measure systolic pressures in the arms ● Use vascular Doppler to locate brachial pulse ● Inflate cuff 20 mm Hg above last audible pulse ● Deflate cuff slowly and record pressure at which pulse becomes audible ● Obtain 2 measures in each arm and record the average as the brachial pressure in that arm Doppler Doppler Dorsalis pedis (DP) artery Posterior tibial (PT) artery (continued) 210 Bates’ Pocket Guide to Physical Examination and History Taking 4. Measure systolic pressures in ankles ● Use vascular Doppler to locate dorsalis pedis pulse ● Inflate cuff 20 mm Hg above last audible pulse ● Deflate cuff slowly and record pressure at which pulse becomes audible ● Obtain 2 measures in each ankle and record the average as the dorsalis pedis pressure in that leg ● Repeat above steps for posterior tibial arteries 5. Calculate ABI Right ABI = Left ABI = Interpretation of Ankle–Brachial Index Ankle–Brachial Index Result Clinical Interpretation >0.90 (with a range of 0.90 to 1.30) Normal lower extremity
blood flow
<0.89 to >0.60 Mild PAD
<0.59 to >0.40 Moderate PAD
<0.39 Severe PAD Source: Wilson JF, Laine C, Goldman D. In the clinic: peripheral arterial disease. Ann Int Med 2007;146(5):ITC3-1. highest right average ankle pressure (DP or PT) highest average arm pressure (right or left) highest left average ankle pressure (DP or PT) highest average arm pressure (right or left) Using the Ankle–Brachial Index (continued)Table 12-3 211 C H A P T E R 13Male Genitalia and Hernias The Health History Common or Concerning Symptoms ◗ Sexual orientation and sexual response ◗ Penile discharge or lesions ◗ Scrotal pain, swelling, or lesions ◗ Sexually transmitted infections (STIs) Cavity of tunica vaginalis Scrotum Testis Epididymis Spermatic cord Ejaculatory duct Seminal vesicle Prepuce Urethral meatus Glans Corona Corpus spongiosum Corpus cavernosum Blood vessels Vas deferens Urethra 212 Bates’ Pocket Guide to Physical Examination and History Taking Explain your concern for the patient’s sexual health. Pose questions in a neutral and nonjudgmental way. ● “What is your relationship status? Tell me about your sexual preference.” ● “How is sexual function for you?” “Are you satisfied with your sexual life?” “What about your ability to perform sexu- ally?” To assess libido, or desire: “Have you maintained an interest in sex?” Decreased libido from depression, endocrine dysfunction, or side effects of medications For the arousal phase: “Can you achieve and maintain an erection?” Erectile dysfunction from psychogenic causes, especially if early morning erection is preserved; also from decreased testosterone, decreased blood flow in hypogastric arterial system, impaired neural innervation, diabetes If ejaculation is premature or early: “About how long does intercourse last?” “Do you climax too soon?” For reduced or absent ejaculation: “Do you find that you cannot have orgasm even though you can have an erection?” “Does the problem involve the pleasurable sensation of orgasm, the ejaculation of seminal fluid, or both?” Premature ejaculation is common, especially in young men. Less common is reduced or absent ejaculation affect- ing middle-aged or older men. Consider medications, surgery, neurologic deficits, or lack of androgen. Lack of orgasm with intact ejaculation is usually psychogenic. Chapter 13 | Male Genitalia and Hernias 213 To assess possible infection from sexually transmitted infections (STIs), ask about any discharge from the penis. Penile discharge in gonococcal (usually yellow) and nongonococcal (clear or white) urethritis Inquire about sores or growths on the penis and any pain or swelling in the scrotum. See Table 13-1, Abnormalities of the Penis and Scrotum, p. 218, and Table 13-2, Sexually Transmitted Infections of Male Genitalia, pp. 219–220. STIs may involve other parts of the body. Ask about practices of oral and anal sex and any related sore throat, oral itching or pain, diarrhea, or rectal bleeding. Rash in disseminated gonococcal infection Prevention of STIs and HIV Infection. Focus on patient educa- tion about STIs and HIV, early detection of infection during history taking and physical examination, and identification and treatment of infected partners. Identify the patient’s sexual orientation, the num- ber of sexual partners in the past month, and any history of STIs. Also query use of alcohol and drugs, particularly injection drugs. Counsel patients at risk about limiting the number of partners, using condoms, and establishing regular medical care for treatment of STIs and HIV infection. Counseling and testing for HIV are recommended for: all people at increased risk for infection with HIV, STIs, or both; men with male Health Promotion and Counseling: Evidence and Recommendations Important Topics for Health Promotion and Counseling ◗ Prevention of STIs and HIV ◗ Screening for testicular cancer; testicular self-examination 214 Bates’ Pocket Guide to Physical Examination and History Taking partners; past or present injection drug users; men and women hav- ing unprotected sex with multiple partners; sex workers; any past or present partners of people with HIV infection, bisexual practices, or injection drug use; and patients with a history of transfusion between 1978 and 1985. Testicular Self-Examination. Encourage men, especially those between 15 and 35 years of age, to perform monthly testicular self-examinations. Testicular cancer strikes men ages 15 to 34, especially those with a positive family history or cyptorchidism (see p. 221). Techniques of Examination E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S MALE GENITALIA Wear gloves. The patient may be standing or supine. / THE PENIS Inspect the: ● Development of the penis and the skin and hair at its base ● Prepuce ● Glans ● Urethral meatus Sexual maturation, lice Phimosis Balanitis, chancre, herpes, warts, cancer Hypospadias, discharge of urethritis Palpate: ● Any visible lesions ● The shaft Chancre, cancer Urethral stricture or cancer Chapter 13 | Male Genitalia and Hernias 215 E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S THE SCROTUM AND ITS CONTENTS Inspect: ● Contours of scrotum ● Skin of scrotum Hernia, hydrocele, cryptorchidism Rashes Palpate each: ● Testis, noting any: ● Lumps ● Tenderness ● Epididymis ● Spermatic cord and adjacent areas See Table 13-3, Abnormalities of the Testis, p. 221. Testicular carcinoma Orchitis, torsion of the spermatic cord, strangulated inguinal hernia Epididymitis, cyst Varicocele if multiple tortuous veins; cystic structure may be a hydrocele See Table 13-4, Abnormalities of the Epididymis and Spermatic Cord, p. 222. 216 Bates’ Pocket Guide to Physical Examination and History Taking E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S HERNIAS Patient is usually standing. See Table 13-5, Hernias in the Groin, p. 223. Inspect inguinal and femoral areas as patient strains down. Inguinal and femoral hernias Palpate external inguinal ring through scrotal skin and ask patient to strain down. Indirect and direct inguinal hernias Inguinal ligament External inguinal ring SPECIAL TECHNIQUE Patient Instructions for the Testicular Self-Examination This examination is best performed after a warm bath or shower. The heat relaxes the scrotum and makes it easier to find anything unusual. ◗ Standing in front of a mirror, check for any swelling on the skin of the scrotum. ◗ With the penis out of the way, examine each testicle separately. ◗ Cup the testicle between your thumbs and forefingers with both hands and roll it gently between the thumbs and fingers. One testicle may be larger than the other; that’s normal, but be concerned about any lump or area of pain. (continued) Chapter 13 | Male Genitalia and Hernias 217 Recording the Physical Examination—Male Genitalia and Hernias “Circumcised male. No penile discharge or lesions. No scrotal swelling or dis- coloration. Testes descended bilaterally, smooth, without masses. Epididymis nontender. No inguinal or femoral hernias.” OR “Uncircumcised male; prepuce easily retractible. No penile discharge or lesions. No scrotal swelling or discoloration. Testes descended bilaterally; right testicle smooth; 1 × 1 cm firm nodule on left lateral testicle. It is fixed and nontender. Epididymis nontender. No inguinal or femoral hernias.” (Suspicious for testicular carcinoma, the most common form of cancer in men between 15 and 35 years of age.) Recording Your FindingsRRReccoorddinnggg YYouuur Finnddinngss Patient Instructions for the Testicular Self-Examination (continued) ◗ Find the epididymis. This is a soft, tubelike structure at the back of the testicle that collects and carries sperm, not an abnormal lump. ◗ If you find any lump, don’t wait. See your doctor. The lump may just be an infection, but if it is cancer, it will spread unless stopped by treatment. Source: Medline Plus. U.S. National Library of Medicine and National Institutes of Health. Medical Encyclopedia—Testicular self-examination. Available at www.nlm.nih.gov/medlineplus/ ency/article/003909.htm. Accessed December 19, 2010. E XA M I N AT I O N T E C H N I Q U E S http://www.nlm.nih.gov/medlineplus/ency/article/003909.htm http://www.nlm.nih.gov/medlineplus/ency/article/003909.htm 218 Bates’ Pocket Guide to Physical Examination and History Taking Aids to InterpretationAAAiddss ttoo IInntterrpprreetaattioonn Hypospadias Scrotal Edema A congenital displacement of the urethral meatus to the inferior surface of the penis. A groove extends from the actual urethral meatus to its normal location on the tip of the glans. Pitting edema may make the scrotal skin taut; seen in heart failure or nephrotic syndrome. Peyronie’s Disease Fingers can get above mass Hydrocele Palpable, nontender, hard plaques are found just beneath the skin, usually along the dorsum of the penis. The patient complains of crooked, painful erections. A nontender, fluid-filled mass within the tunica vaginalis. It transilluminates, and the examining fingers can get above the mass within the scrotum. Carcinoma of the Penis Fingers cannot get above mass Scrotal Hernia An indurated nodule or ulcer that is usually nontender. Limited almost completely to men who are not circumcised, it may be masked by the prepuce. Any persistent penile sore is suspicious. Usually an indirect inguinal hernia that comes through the external inguinal ring, so the examining fingers cannot get above it within the scrotum. Abnormalities of the Penis and ScrotumTable 13-1 Chapter 13 | Male Genitalia and Hernias 219 Sexually Transmitted Infections of Male GenitaliaTable 13-2 Genital Warts (condylomata acuminata) ● Appearance: Single or multiple papules or plaques of variable shapes; may be round, acuminate (or pointed), or thin and slender. May be raised, flat, or cauliflowerlike (verrucous). ● Causative organism: Human papillomavirus (HPV), usually from subtypes 6, 11; carcinogenic subtypes rare, approximately 5% to 10% of all anogenital warts. ● Incubation: weeks to months; infected contact may have no visible warts. ● Can arise on penis, scrotum, groin, thighs, anus; usually asymptomatic, occasionally cause itching and pain. ● May disappear without treatment. Genital Herpes Simplex ● Appearance: Small scattered or grouped vesicles, 1 to 3 mm in size, on glans or shaft of penis. Appear as erosions if vesicular membrane breaks. ● Causative organism: Usually Herpes simplex virus 2 (90%), a double-stranded DNA virus. Incubation: 2 to 7 days after exposure. ● Primary episode may be asymptomatic; recurrence usually less painful, of shorter duration. ● Associated with fever, malaise, headache, arthralgias; local pain and edema, lymphadenopathy. ● Need to distinguish from genital herpes zoster (usually in older patients with dermatomal distribution); candidiasis. (continued) 220 Bates’ Pocket Guide to Physical Examination and History Taking Primary Syphilis ● Appearance: Small red papule that becomes a chancre, or painless erosion up to 2 cm in diameter. Base of chancre is clean, red, smooth, and glistening; borders are raised and indurated. Chancre heals within 3 to 8 weeks. ● Causative organism: Treponema pallidum, a spirochete. ● Incubation: 9 to 90 days after exposure. ● May develop inguinal lymphadenopathy within 7 days; lymph nodes are rubbery, nontender, mobile. ● 20% to 30% of patients develop secondary syphilis while chancre still present (suggests coinfection with HIV). ● Distinguish from: genital herpes simplex, chancroid, granuloma inguinale from Klebsiella granulomatis (rare in the United States; 4 variants, so difficult to identify). Chancroid ● Appearance: Red papule or pustule initially, then forms a painful deep ulcer with ragged nonindurated margins; contains necrotic exudate, has a friable base. ● Causative organism: Haemophilus ducreyi, an anaerobic bacillus. ● Incubation: 3 to 7 days after exposure. ● Painful inguinal adenopathy; suppurative bobos in 25% of patients. ● Need to distinguish from: primary syphilis; genital herpes simplex; lymphomogranuloma venereum, granuloma inguinale from Klebsiella granulomatis (both rare in the United States). Sexually Transmitted Infections of Male Genitalia (continued)Table 13-2 Chapter 13 | Male Genitalia and Hernias 221 Abnormalities of the TestesTable 13-3 Cryptorchidism Testis is atrophied and may lie in the inguinal canal or the abdomen, resulting in an unfilled scrotum. As above, there is no palpable left testis or epididymis. Cryptorchidism markedly raises the risk for testicular cancer. Small Testis In adults, testicular length is usually ≤3.5 cm. Small, firm testes seen in Klinefelter’s syndrome, usually ≤2 cm. Small, soft testes suggesting atrophy seen in cirrhosis, myotonic dystrophy, use of estrogens, and hypopituitarism; may also follow orchitis. Acute Orchitis The testis is acutely inflamed, painful, tender, and swollen. It may be difficult to distinguish from the epididymis. The scrotum may be reddened. Seen in mumps and other viral infections; usually unilateral. Early Tumor of the Testis Usually appears as a painless nodule. Any nodule within the testis warrants investigation for malignancy. Late As a testicular neoplasm grows and spreads, it may seem to replace the entire organ. The testicle characteristically feels heavier than normal. 222 Bates’ Pocket Guide to Physical Examination and History Taking Abnormalities of the Epididymis and Spermatic CordTable 13-4 Acute Epididymitis An acutely inflamed epididymis is tender and swollen and may be difficult to distinguish from the testis. The scrotum may be reddened and the vas deferens inflamed. It occurs chiefly in adults. Coexisting urinary tract infection or prostatitis supports the diagnosis. Spermatocele and Cyst of the Epididymis A painless, movable cystic mass just above the testis suggests a spermatocele or an epididymal cyst. Both transilluminate. The former contains sperm, and the latter does not, but they are clinically indistinguishable. Varicocele of the Spermatic Cord Varicocele refers to varicose veins of the spermatic cord, usually found on the left. It feels like a soft “bag of worms” separate from the testis, and slowly collapses when the scrotum is elevated in the supine patient. Torsion of the Spermatic Cord Twisting of the testicle on its spermatic cord produces an acutely painful and swollen organ that is retracted upward in the scrotum, which becomes red and edematous. There is no associated urinary infection. It is a surgical emergency because of obstructed circulation. Chapter 13 | Male Genitalia and Hernias 223 Hernias in the Groin Table 13-5 Indirect Inguinal Most common hernia at all ages, both sexes. Originates above inguinal ligament and often passes into scrotum. May touch examiner’s fingertip in inguinal canal. Direct Inguinal Less common than indirect hernia, usually occurs in men older than 40 years. Originates above inguinal ligament near external inguinal ring and rarely enters scrotum. May bulge anteriorly, touching side of examiner’s finger. Femoral Least common hernia, more common in women than in men. Originates below inguinal ligament, more lateral than inguinal hernia. Never enters scrotum. 225 C H A P T E R 14Female Genitalia Common Concerns ◗ Menarche, menstruation, menopause, postmenopausal bleeding ◗ Pregnancy ◗ Vulvovaginal symptoms ◗ Sexual preference and sexual response ◗ Pelvic pain—acute and chronic ◗ Sexually transmitted infections (STIs) Mons pubis Prepuce Clitoris Urethral meatus Opening of paraurethral (Skene's) gland Vestibule Introitus Perineum Labia majora Labia minora Hymen Vagina Opening of Bartholin's gland Anus The Health History For the menstrual history, ask when menstrual periods began (age at menarche). Changes in the interval between peri- ods can signal possible pregnancy or menstrual irregularities. 226 Bates’ Pocket Guide to Physical Examination and History Taking When did her last menstrual period (LMP) start, and the one prior menstrual period (PMP)? What is the interval between periods, from the first day of one to the first day of the next? Are menses regular or irregular? How long do they last? How heavy is the flow? In amenorrhea from pregnancy, common early symptoms are tenderness, tingling, or increased size of breasts; urinary frequency; nausea and vomiting; easy fatigability; and feelings that the baby is moving (usually noted at about 20 weeks). Amenorrhea followed by heavy bleed- ing in threatened abortion or dysfunc- tional uterine bleeding Dysmenorrhea, or painful menses, is common. Primary dysmenorrhea from increased prostaglandin production; secondary dysmenorrhea from endometriosis, pelvic inflammatory disease, and endometrial polyps Amenorrhea is the absence of periods. Failure to begin periods is primary amenorrhea, whereas cessation of established periods is secondary amenorrhea. Secondary amenorrhea from low body weight is seen in malnutrition, anorexia nervosa, stress, chronic illness, and hypothalamic–pituitary–ovarian dysfunction. Menopause, the absence of menses for 12 consecutive months, usually occurs between 48 and 55 years. Associated symptoms include hot flashes, flushing, sweating, and sleep disturbances. Postmenopausal bleeding, or bleeding occurring 6 months after menses have stopped, suggests endometrial cancer, hormone replacement therapy, or uterine or cervical polyps. For vaginal discharge and local itching, inquire about amount, color, consistency, and odor of discharge. See Table 14-1, Lesions of the Vulva, pp. 233–234; and Table 14-2, Vaginal Discharge, p. 235. Chapter 14 | Female Genitalia 227 Ask, “Tell me about your sexual preferences. Are your partners men, women or do you have partners of both sexes?” To assess sexual function, start with general nonjudgmental questions like “How is sex for you?” or “Are you having any problems with sex?” Direct questions help you assess each phase of the sexual response: desire, arousal, and orgasm. Ask also about dyspareunia, or discomfort or pain during intercourse. Superficial pain suggests local inflam- mation, atrophic vaginitis, or inad- equate lubrication; deeper pain may result from pelvic disorders or pressure on a normal ovary. For sexually transmitted infections (STIs) and diseases, identify sexual preference (male, female, or both) and the number of sexual partners in the previous month. Ask if the patient has concerns about HIV infection, desires HIV testing, or has current or past partners at risk. In women, some STIs do not produce symptoms, but do increase the risk of infertility. Important Topics for Health Promotion and Counseling ◗ Cervical cancer screening; Pap smear and HPV infection ◗ Ovarian cancer: symptoms and risk factors ◗ STIs and HIV ◗ Options for family planning ◗ Menopause and hormone replacement therapy Health Promotion and Counseling: Evidence and Recommendations 228 Bates’ Pocket Guide to Physical Examination and History Taking New Pap Smear Screening Guidelines. Observe the new Pap smear guidelines from the American College of Obstetricians and Gynecologists (ACOG) in 2012 based on scientific advances related to the biology of human papillomavirus (HPV) infection. ● First screening: Begin screening at age 21 ● Women ages 21–29: ● Screen every 3 years if normal pap smears ● Screen more frequently in patients with positive Pap or at high risk of positive HPV test; HIV infection; immunosuppression; DES exposure in utero; prior history of cervical cancer ● Women ages 30–65: Screen every 3 years with cytology if 3 con- secutive normal Pap smears, no history of CIN 2 or CIN 3, and no high-risk factors; or with cytology and HPV testing every 5 years. ● Women with hysterectomy: Discontinue routine screening if hys- terectomy for benign indications and no history of high-grade CIN. If hysterectomy for CIN 2, CIN 3, or cancer and cervix removed, screen annually for 20 years ● Women ages >65: Discontinue screening if ≥3 negative pap smears
in a row and no abnormal Pap smears for 20 years
The most important risk factor for cervical cancer is HPV infection
from HPV strains 16, 18, 6, or 11. The HPV vaccine prevents
HPV infection from the strains when given before sexual exposure
at age 11.
Ovarian Cancer. There are no effective screening tests to date. Risk
factors include family history of breast or ovarian cancer and BRCA1
or BRCA2 mutation.
STIs and HIV Infection. For STIs and HIV, assess risk factors
by taking a careful sexual history and counseling patients about
spread of disease and ways to reduce high-risk practices. Test
women younger than 26 years and pregnant women for Chlamydia;
in women at increased risk and pregnant women, test for gonor-
rhea, syphilis, and HIV. In 2006, the CDC recommended universal
screening for HIV for those ages 13 to 64 because infection occurs
in many without known risk factors.

Chapter 14 | Female Genitalia 229
Options for Family Planning. More than half of U.S. pregnancies
are unintended. Counsel women, particularly adolescents, about the
timing of ovulation, which occurs midway in the regular menstrual cycle.
Discuss methods for contraception and their effectiveness: natural (peri-
odic abstinence, withdrawal, lactation); barrier (condom, diaphragm,
cervical cap); implantable (intrauterine device, subdermal implant);
pharmacologic (spermicide, oral contraceptives, subdermal implant of
levonorgestrel, estrogen/progesterone injectables and patch, vaginal
ring); and surgical (tubal ligation, transcervical sterilization).
Menopause and Hormone Replacement Therapy (HRT). Be famil-
iar with the psychological and physiologic changes of menopause. Help
the patient to weigh the risks of hormone replacement therapy (HRT),
including increased risk of stroke, pulmonary embolism, and breast can-
cer. One to 2 years of HRT may be indicated for menopausal symptoms.
Techniques of Examination
Tips for the Successful Pelvic Examination
The Patient The Examiner
◗ Avoids intercourse, douching, or
use of vaginal suppositories for 24
to 48 hours before examination
◗ Empties bladder before examination
◗ Lies supine, with head and shoul-
ders elevated, arms at sides or
folded across chest to enhance eye
contact and reduce tightening of
abdominal muscles
◗ Obtains permission; selects chap-
erone
◗ Explains each step of the examina-
tion in advance
◗ Drapes patient from midabdomen
to knees; depresses drape between
knees to provide eye contact with
patient
◗ Avoids unexpected or sudden
movements
◗ Chooses a speculum that is the
correct size
◗ Warms speculum with tap water
◗ Monitors comfort of the examina-
tion by watching the patient’s face
◗ Uses excellent but gentle tech-
nique, especially when inserting
the speculum
TTTecchhnniiquees offf EExaammminnatttionn
Male examiners should be accompanied by female chaperones. Female
examiners should be assisted whenever possible.

230 Bates’ Pocket Guide to Physical Examination and History Taking
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
EXTERNAL GENITALIA
Observe pubic hair to assess
sexual maturity.
Normal or delayed puberty
Examine the external genitalia.
● Labia minora
● Clitoris
● Urethral orifice
● Introitus
Ulceration in herpes simplex, syphiliti
chancre; inflammation in Bartholin’s cyst
Enlarged in masculinization
Urethral caruncle or prolapse;
tenderness in interstitial cystitis
Imperforate hymen
Milk the urethra for discharge,
if indicated.
Discharge of urethritis
INTERNAL GENITALIA AND PAP SMEAR
Locate the cervix with a gloved
and water-lubricated index finger.
Assess support of vaginal outlet
by asking patient to strain down.
Cystocele, cystourethrocele, rectocele
Enlarge the introitus by pressing
its posterior margin downward.
Insert a water-lubricated
speculum of suitable size. Start
with speculum held obliquely,
then rotate to horizontal
position for full insertion.
ENTRY ANGLE ANGLE AT FULL INSERTION

Chapter 14 | Female Genitalia 231
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
Open the speculum and inspect
cervix.
See Table 14-3, Shapes of the Cervical
Os, p. 236, and Table 14-4, Abnormalities
of the Cervix, p. 237.
Observe:
● Position
● Color
● Epithelial surface
Cervix faces forward if uterus is
retroverted.
Purplish in pregnancy
Squamous and columnar epithelium
External os of
the cervix
Transformation
zone
Columnar epithelium
Squamocolumnar junction
Squamous epithelium
● Any discharge or bleeding
● Any ulcers, nodules, or masses
Discharge from os in mucopurulent cer-
vicitis from Chlamydia or gonorrhea
Herpes, polyp, cancer
Obtain specimens for cytology
(Pap smears) with:
Early cancer before it is clinically
evident
● An endocervical broom or
brush with scraper (except in
pregnant women), to collect
both squamous and columnar
cells
● Or, if the woman is pregnant,
use a cotton-tipped applicator
moistened with water
Inspect the vaginal mucosa as
you withdraw the speculum.
Bluish color and deep rugae in preg-
nancy; vaginal cancer

232 Bates’ Pocket Guide to Physical Examination and History Taking
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
Palpate, by means of a bimanual
examination:
● The cervix and fornices
● The uterus
● Right and left adnexa (ovaries)
Pain on moving cervix in pelvic inflam-
matory disease
Pregnancy, myomas; soft isthmus in
early pregnancy
Ovarian cysts or masses, salpingitis, PID,
tubal pregnancy
Assess strength of pelvic muscles.
With your vaginal fingers clear of
the cervix, ask patient to tighten
her muscles around your fingers
as hard and long as she can.
A firm squeeze that compresses your
fingers, moves them up and inward,
and lasts more than 3 seconds is full
strength.
/ Perform a rectovaginal
examination to palpate a
retroverted uterus, uterosacral
ligaments, cul-de-sac, and adnexa
or screen for colorectal cancer in
women 50 years or older
(see p. 245).
Retroverted
uterus
SPECIAL TECHNIQUE
HERNIAS
Ask the woman to strain down,
as you palpate for a bulge in:
● The femoral canal
● The labia majora up to just
lateral to the pubic tubercle
Femoral hernia
Indirect inguinal hernia

Chapter 14 | Female Genitalia 233
Recording Your FindingsRRReccoorddinnggg YYouuur Finnddinngss
Recording the Physical Examination—Female
Genitalia
“No inguinal adenopathy. External genitalia without erythema, lesions, or
masses. Vaginal mucosa pink. Cervix parous, pink, and without discharge.
Uterus anterior, midline, smooth, and not enlarged. No adnexal tenderness.
Pap smear obtained. Rectovaginal wall intact. Rectal vault without masses.
Stool brown and Hemoccult negative.”
OR
“Bilateral shotty inguinal adenopathy. External genitalia without erythema
or lesions. Vaginal mucosa and cervix coated with thin, white homogenous
discharge with mild fishy odor. After swabbing cervix, no discharge visible in
cervical os. Uterus midline; no adnexal masses. Rectal vault without masses.
Stool brown and Hemoccult negative.” (Suggests bacterial vaginosis.)
Aids to InterpretationAAAiddss ttoo IInntterrpprreetaattioonn
Lesions of the VulvaTable 14-1
Epidermoid Cyst
Cystic
nodule
in skin
A small, firm, round cystic nodule in the
labia suggests an epidermoid cyst. They
are yellowish in color. Look for the
dark punctum marking the blocked
opening of the gland.
Venereal Wart
(Condyloma Acuminatum)
Warts
Warty lesions on the labia and within
the vestibule suggest condylomata
acuminata from infection with
human papillomavirus.
(continued)
E XA M I N AT I O N T E C H N I Q U E S

234 Bates’ Pocket Guide to Physical Examination and History Taking
Lesions of the Vulva (continued)Table 14-1
Genital Herpes
Shallow
ulcers on
red bases
Shallow, small, painful ulcers on red
bases suggest a herpes infection.
Initial infection may be extensive, as
illustrated here. Recurrent infections
are usually confined to a small local
patch.
Syphilitic Chancre A firm, painless ulcer suggests the
chancre of primary syphilis. Because
most chancres in women develop
internally, they often go undetected.
Secondary Syphilis
(Condyloma Latum)
Flat,
gray
papules
Slightly raised, round or oval flat-
topped papules covered by a gray
exudate suggest condylomata lata,
a manifestation of secondary syphilis.
They are contagious.
Carcinoma of the Vulva An ulcerated or raised red vulvar lesion
in an elderly woman may indicate
vulvar carcinoma.

Chapter 14 | Female Genitalia 235
Vaginal DischargeTable 14-2
Note: Accurate diagnosis depends on laboratory assessment and
cultures.
Trichomonas vaginitis Discharge: Yellowish green, often
profuse, may be malodorous
Other Symptoms: Itching, vaginal
soreness, dyspareunia
Vulva: May be red
Vagina: May be normal or red, with red
spots, petechiae
Laboratory Assessment: Saline wet
mount for trichomonads
Candida vaginitis Discharge: White, curdy, often thick,
not malodorous
Other Symptoms: Itching, vaginal
soreness, external dysuria,
dyspareunia
Vulva: Often red and swollen
Vagina: Often red with white patches of
discharge
Laboratory Assessment: KOH
preparation for branching hyphae
Bacterial vaginosis Discharge: Gray or white, thin,
homogeneous, scant, malodorous
Other Symptoms: Fishy genital odor
Vulva: Usually normal
Vagina: Usually normal
Laboratory Assessment: Saline wet
mount for “clue cells,” “whiff test”
with KOH for fishy odor

236 Bates’ Pocket Guide to Physical Examination and History Taking
Shapes of the Cervical OsTable 14-3
Normal Variations
Oval Slitlike
Lacerations
Unilateral Transverse Bilateral Transverse
Stellate

Chapter 14 | Female Genitalia 237
Abnormalities of the CervixTable 14-4
Endocervical polyp. A bright red,
smooth mass that protrudes from
the os suggests a polyp. It bleeds
easily.
Mucopurulent cervicitis. A
yellowish exudate emerging from
the cervical os suggests infection
from Chlamydia, gonorrhea (often
asymptomatic), or herpes.
Carcinoma of the cervix. An
irregular, hard mass suggests
cancer. Early lesions are best
detected by colposcopy following
abnormal Pap smear from of high
risk of HPV.
Vaginal
adenosis
Columnar
epithelium
Collar
Fetal exposure to diethylstilbestrol
(DES). Several changes may occur:
a collar of tissue around the
cervix, columnar epithelium that
covers the cervix or extends to the
vaginal wall (then termed vaginal
adenosis), and, rarely, carcinoma of
the vagina.

238 Bates’ Pocket Guide to Physical Examination and History Taking
Relaxations of the Pelvic FloorTable 14-5
When the pelvic floor is weakened, various structures may become
displaced. These displacements are seen best when the patient
strains down.
A cystocele is a bulge of the anterior wall
of the upper part of the vagina, together
with the urinary bladder above it.
A cystourethrocele involves both the blad-
der and the urethra as they bulge into
the anterior vaginal wall throughout
most of its extent.
A rectocele is a bulge of the posterior
vaginal wall, together with a portion of
the rectum.
A prolapsed uterus has descended down
the vaginal canal. There are three
degrees of severity: first, still within the
vagina (as illustrated); second, with the
cervix at the introitus; and third, with
the cervix outside the introitus.

Chapter 14 | Female Genitalia 239
Positions of the Uterus and Uterine MyomasTable 14-6
An anteverted uterus lies in a forward
position at roughly a right angle to the
vagina. This is the most common position.
Anteflexion—a forward flexion of the
uterine body in relation to the cervix—
often coexists.
A retroverted uterus is tilted posteriorly
with its cervix facing anteriorly.
A retroflexed uterus has a posterior tilt
that involves the uterine body but not
the cervix. A uterus that is retroflexed or
retroverted may be felt only through the
rectal wall; some cannot be felt at all.
A myoma of the uterus is a very common
benign tumor that feels firm and often
irregular. There may be more than one. A
myoma on the posterior surface of the
uterus may be mistaken for a retrodis-
placed uterus; one on the anterior surface
may be mistaken for an anteverted uterus.

241
C H A P T E R
15The Anus, Rectum,
and Prostate
The Health History
Common or Concerning Symptoms
◗ Change in bowel habits
◗ Blood in the stool
◗ Pain with defecation; rectal bleeding or tenderness
◗ Anal warts or fissures
◗ Weak stream of urine
◗ Burning with urination
Valve of
Houston
Peritoneal
reflection
Rectum
Prostate
Anorectal
junction
Anal canalUrethra
Bladder

242 Bates’ Pocket Guide to Physical Examination and History Taking
Ask about any change in bowel
habits, diarrhea, or constipation.
Is there any blood in the stool,
or dark tarry stools?
Pencil-like stool or blood in stool in
colon cancer; dark tarry stools in
gastrointestinal bleeding
Any pain with defecation, or
rectal bleeding or tenderness?
Hemorrhoids; proctitis from STIs
Any anal warts or fissures? Human papillomavirus (HPV), condy-
lomata lata in secondary syphilis;
fissures in proctitis, Crohn’s disease
In men, is there difficulty starting
the urine stream or holding back
urine? Is the flow weak? What
about frequent urination, espe-
cially at night? Or pain or burning
when passing urine? Any blood in
the urine or semen or pain with
ejaculation? Is there frequent pain
or stiffness in the lower back, hips,
or upper thighs?
These symptoms suggest urethral
obstruction from benign prostatic
hyperplasia (BPH) or prostate can-
cer, especially in men age ≥70. The
American Urological Association
(AUA) Symptom Index helps quantify
BPH severity (see Table 15-1, BPH
Score Index: American Urological
Association (AUA), pp. 246–247).
Screening for Prostate Cancer. Prostate cancer is the leading cancer
diagnosed in U.S. men and the second leading cause of death. Risk factors
are age, family history of prostate cancer, and African American ethnicity.
Screening methods such as the digital rectal examination (DRE) and
the prostate-specific antigen (PSA) test are not highly accurate, which
complicates decisions about screening men without symptoms.
● The DRE reaches only the posterior and lateral surfaces of the pros-
tate, missing 25% to 35% of tumors in other areas. Sensitivity of the
Important Topics for Health Promotion
and Counseling
◗ Screening for prostate cancer
◗ Screening for colorectal cancer
◗ Counseling for sexually transmitted infections (STIs)
Health Promotion and Counseling:
Evidence and Recommendations

Chapter 15 | The Anus, Rectum, and Prostate 243
DRE for prostate cancer is low, 59%, and the rate of false positives
is high.
● The PSA. PSA testing is controversial. The PSA can be elevated in
benign conditions like hyperplasia, prostatitis, ejaculation, and urinary
retention. Its detection rate for prostate cancer is about 28% to 35%
in asymptomatic men. It does not distinguish small-volume indo-
lent cancers from aggressive life-threatening disease. Discussion and
shared decision making are warranted. Several groups recommend
annual combined screening with PSA and DRE for men older than
50 years and for African Americans and men older than 40 years with
a positive family history. Studies of baseline PSA testing at age 40, and
reducing the threshold for biopsy from 4.0 ng/mL to 2.5 ng/mL are
inconclusive.
For symptomatic prostate disorders, the clinician’s role is more straight-
forward. Men with incomplete emptying of the bladder, urinary fre-
quency or urgency, weak or intermittent stream or straining to initiate
flow, hematuria, nocturia, or even bony pains in the pelvis should be
encouraged to seek evaluation and treatment early.
Screening for Colorectal Cancer. In 2008, screening recommen-
dations were revised to promote more aggressive surveillance:
● Clinicians should first identify whether patients are at average or
increased risk, ideally by age 20 years, but earlier if the patient has
inflammatory bowel disease or a family history of familial adenoma-
tous polyposis.
● Average-risk patients 50 years or older should be offered a range
of screening options to increase compliance: annual screening with
high-sensitivity fecal occult blood tests (FOBTs); flexible sigmoidos-
copy every 5 years, with annual high-sensitivity FOBT every 3 years;
or colonoscopy every 10 years.
● People at increased risk should undergo colonoscopy at intervals
ranging from 3 to 5 years.
Clinicians should also use the 6-sample fecal occult blood test. Avoid
single-sample FOBT and DRE, which have inadequate detection
rates.
Counseling for STIs. Anal intercourse increases risk for HIV and
STIs. Promote abstinence, use of condoms, and good hygiene.

244 Bates’ Pocket Guide to Physical Examination and History Taking
Techniques of Examination
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
Wear gloves.
MALE
Position the patient on his side,
or standing leaning forward over
the examining table and hips
flexed.
Inspect the:
● Sacrococcygeal area
● Perianal area
Pilonidal cyst or sinus
Hemorrhoids, warts, herpes, chancre,
cancer, fissures from proctitis or
Crohn’s disease
Palpate the anal canal and
rectum with a lubricated and
gloved finger. Feel the:
Lax sphincter tone in some neurologic
disorders; tightness in proctitis
● Walls of the rectum
● Prostate gland, as shown
below, including median
sulcus
Cancer of the rectum, polyps
Prostate nodule or cancer; BPH;
tenderness in prostatitis
TTTecchhnniiquees offf EExaammminnatttionn

Chapter 15 | The Anus, Rectum, and Prostate 245
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
Try to feel above the prostate
for irregularities or tenderness,
if indicated.
See Table 15-2, Abnormalities on Rectal
Examination, pp. 248–249.
/ FEMALE
The patient is usually in the
lithotomy position or lying
on her side.
Rectal shelf of peritoneal metastases;
tenderness of inflammation
Inspect the anus. Hemorrhoids
Palpate the anal canal and
rectum.
Rectal cancer, normal uterine cervix or
tampon (felt through the rectal wall)
Recording Your Findings
Recording the Physical Examination—The Anus,
Rectum, and Prostate
“No perirectal lesions or fissures. External sphincter tone intact. Rectal vault
without masses. Prostate smooth and nontender with palpable median sul-
cus. (Or in a female, uterine cervix nontender.) Stool brown and Hemoccult
negative.”
OR
“Perirectal area inflamed; no ulcerations, warts, or discharge. Cannot exam-
ine external sphincter, rectal vault, or prostate because of spasm of external
sphincter and marked inflammation and tenderness of anal canal.” (Raises
concern of proctitis from infectious cause.)
OR
“No perirectal lesions or fissures. External sphincter tone intact. Rectal vault
without masses. Left lateral prostate lobe with 1 × 1 cm firm hard nodule; right
lateral lobe smooth; medial sulcus is obscured. Stool brown and Hemoccult
negative.” (Raises concern of prostate cancer.)
RRReccoorddinnggg YYouuur Finnddinngss

246 Bates’ Pocket Guide to Physical Examination and History Taking
Aids to InterpretationAAAidds ttoo Inntterrpprreetaattioonn
BPH Symptom Score Index: American
Urological Association (AUA)Table 15-1
Score or ask the patient to score each of the questions below on a scale of 1 to 5.
0 = Not at all
1 = Less than 1 time in 5
2 = Less than half the time
3 = About half the time
4 = More than half the time
5 = Almost always
Higher scores (maximum 35) indicate more severe symptoms; scores ≤7 are
considered mild and generally do not warrant treatment.
PART A Score
1. Incomplete emptying: Over the past month, how often have
you had a sensation of not emptying your bladder completely
after you finished urinating? ————
2. Frequency: Over the past month, how often have you had to
urinate again <2 hours after you finished urinating? ———— 3. Inter-mittency: Over the past month, how often have you stopped and started again several times when you urinated? ———— 4. Urgency: Over the past month, how often have you found it difficult to postpone urination? ———— 5. Weak stream: Over the past month, how often have you had a weak urinary stream? ———— 6. Straining: Over the past month, how often have you had to push or strain to begin urination? ———— PART A TOTAL SCORE ———— Chapter 15 | The Anus, Rectum, and Prostate 247 Score or ask the patient to score each of the questions below on a scale of 1 to 5. 0 = Not at all 1 = Less than 1 time in 5 2 = Less than half the time 3 = About half the time 4 = More than half the time 5 = Almost always Higher scores (maximum 35) indicate more severe symptoms; scores ≤7 are considered mild and generally do not warrant treatment. PART B Score 7. Nocturia: Over the past month, how many times did you most typically get up to urinate from the time you went to bed at night until the time you got up in the morning? (Score 0 to 5 times on night) ———— TOTAL PARTS A and B (maximum 35) ———— Adapted from: Madsen FA, Burskewitz RC. Clinical Manifestations of benign prostatic hyperplasia. Urol Clin North Am 1995;22:291–298. BPH Symptom Score Index: American Urological Association (AUA) (continued)Table 15-1 248 Bates’ Pocket Guide to Physical Examination and History Taking Abnormalities on Rectal ExaminationTable 15-2 External Hemorrhoids (Thrombosed). Dilated hemorrhoidal veins that originate below the pectinate line, covered with skin; a tender, swollen, bluish ovoid mass is visible at the anal margin Polyps of the Rectum. A soft mass that may or may not be on a stalk; may not be palpable Benign Prostatic Hyperplasia. An enlarged, nontender, smooth, firm but slightly elastic prostate gland; can cause symptoms without palpable enlargement Acute Prostatitis. A prostate that is very tender, swollen, and firm because of acute infection Chapter 15 | The Anus, Rectum, and Prostate 249 Abnormalities on Rectal Examination (continued)Table 15-2 Cancer of the Prostate. A hard area in the prostate that may or may not feel nodular Cancer of the Rectum. Firm, nodular, rolled edge of an ulcerated cancer 251 C H A P T E R 16The Musculoskeletal System Fundamentals for Assessing Joints Assessing joints requires knowledge of their structure and function. Learn the surface landmarks and underlying anatomy of each major joint. Be familiar with the following terms: ● Articular structures include the joint capsule and articular cartilage, synovium and synovial fluid, intra-articular ligaments, and juxta- articular bone. ● Extra-articular structures include periarticular ligaments, tendons, bursae, muscle, fascia, bone, nerve, and overlying skin. ● Ligaments are the ropelike bundles of collagen fibrils that connect bone to bone. ● Tendons are collagen fibers that connect muscle to bone. ● Bursae are pouches of synovial fluid that cushion the movement of tendons and muscles over bone or other joint structures. Review the three primary types of joint articulation—synovial, car- tilaginous, and fibrous—and the varying degrees of movement each type allows. 252 Bates’ Pocket Guide to Physical Examination and History Taking Review the types of synovial joints and their associated features as well. Note that joint structure determines joint function and range of motion. Joints Synovial Joints ◗ Freely movable within limits of surrounding ligaments ◗ Separated by articular cartilage and a synovial cavity ◗ Lubricated by synovial fluid ◗ Surrounded by a joint capsule ◗ Example: knee, shoulder Cartilaginous Joints ◗ Slightly movable ◗ Contain fibrocartilaginous discs that separate the bony surfaces ◗ Have a central nucleus pulposus of discs that cushions bony contact ◗ Example: vertebral bodies Fibrous Joints ◗ No appreciable movement ◗ Consist of fibrous tissue or cartilage ◗ Lack a joint cavity ◗ Example: skull sutures FIBROUS Vertebral body Nucleus pulposus of the disc Disc Ligament CARTILAGINOUS Bone Synovial membrane Articular cartilage Synovial cavity Ligament Joint space Joint capsule SYNOVIAL Chapter 16 | The Musculoskeletal System 253 Synovial Joints Type of Joint Articular Shape Movement Example Spheroidal (ball and socket) Convex surface in concave cavity Wide-ranging flexion, extension, abduction, adduction, rotation, cir- cumduction Shoulder, hip Hinge Flat, planar Motion in one plane; flexion, extension Interphalan- geal joints of hand and foot; elbow Condylar Convex or concave Movement of two ar- ticulating surfaces, not dissociable Knee; temporo- mandibular joint The Health History Common or Concerning Symptoms ◗ Low back pain ◗ Neck pain ◗ Monoarticular or polyarticular joint pain ◗ Inflammatory or infectious joint pain ◗ Joint pain with systemic features such as fever, chills, rash, anorexia, weight loss, and weakness ◗ Joint pain with symptoms from other organ systems TTThee HHeeaaltth HHiisstoryy 254 Bates’ Pocket Guide to Physical Examination and History Taking Assess the seven features of any joint pain (see p. 38). Tips for Assessing Joint Pain ◗ Ask the patient to “point to the pain.” This may save considerable time, because the patient’s verbal description is often imprecise. ◗ Clarify and record the onset of pain and the mechanism of injury, particularly if there is a history of trauma. ◗ Determine whether the pain is localized or diffuse, acute or chronic, inflamma- tory or noninflammatory. Low Back Pain. Ask, “Any pains in your back?” Low back pain is the second most common reason for office visits. Ask if the pain is in the midline over the vertebrae, or off midline. If the pain radiates into the legs, ask about any associ- ated numbness, tingling, or weak- ness. Ask about history of trauma. See Table 16-1, Low Back Pain, pp. 277–278. Causes of midline back pain include vertebral collapse, disc hernia- tion, epidural abscess, spinal cord com- pression, or spinal cord metastases. Pain off the midline in muscle strain, sacroiliitis, trochanteric bursitis, sciat- ica, hip arthritis, renal conditions such as pyelonephritis or renal stones Check for bladder or bowel dysfunction. Present in cauda equine syndrome from S2–4 tumor or disc herniation, especially if “saddle anesthesia” from perianal numbness Neck Pain. Ask about location, radiation into the shoulders or arms, arm or leg weakness, bladder or bowel dysfunction. C7 or C6 spinal nerve compression from foraminal impingement more common than disc herniation. See Table 16-2, Pains in the Neck, pp. 279–280. Joint Pain. Proceed with “Do you have any pain in your joints?” See Table 16-3, Patterns of Pain in and Around the Joints, p. 281. Ask the patient to point to the pain. If localized and involving only one joint, it is monoarticular. Consider trauma, monoarticular arthri- tis, tendonitis, or bursitis. Hip pain near the greater trochanter suggests trochanteric bursitis. If polyarticular, does it migrate from joint to joint, or steadily spread from one joint to multiple joint involvement? Is the involvement symmetric? Migratory pattern in rheumatic fever or gonococcal arthritis; progressive and symmetric pattern in rheumatoid arthritis Chapter 16 | The Musculoskeletal System 255 Ask if pain is extra-articular (bones, muscles, and tissues around the joint, such as the tendons, bursae, or even overlying skin). Are there generalized “aches and pains” (myalgia if in muscles, arthralgia if in joints with no evidence of arthritis)? Bursitis if inflammation of bursae; ten- donitis if in tendons, and tenosynovitis if in tendon sheaths; also sprains from stretching or tearing of ligaments Assess the timing, quality, and severity of joint symptoms. If from trauma, what was the mechanism of injury or series of events that caused the joint pain? Furthermore, what aggravates or relieves the pain? What are the effects of exercise, rest, and treatment? Severe pain of rapid onset in a red, swollen joint in acute septic arthritis or gout Is the problem inflammatory or noninflammatory? Is there tenderness, warmth, or redness? Fever, chills, warmth, redness in septic arthritis; also consider gout or rheumatic fever Is the pain articular in origin, with swelling, stiffness, or decreased range of motion? Pain, swelling, loss of active and passive motion, “locking,” deformity in articular joint pain; loss of active but not passive motion, tenderness outside the joint, no deformity in nonarticular pain Assess any limitations of motion. Transient stiffness after limited activity in degenerative arthritis; prolonged stiffness in rheumatoid arthritis, fibromyalgia, polymyalgia rheumatica Ask about any systemic symptoms such as fever, chills, rash, anorexia, weight loss, and weakness. Common in rheumatoid arthritis, sys- temic lupus erythematosus, polymyalgia rheumatica, and other inflammatory arthritides. High fever and chills sug- gest an infectious cause. 256 Bates’ Pocket Guide to Physical Examination and History Taking Health Promotion and Counseling: Evidence and Recommendations Nutrition, Weight, and Physical Activity. Advise patients that a healthy lifestyle conveys direct benefits to the skeleton. Good nutrition supplies the calcium needed for bone mineralization and bone density. Optimal weight reduces excess mechanical stress on weight-bearing joints like the hips and knees. Exercise helps maintain bone mass and improves outlook and stress management. Profiling Low Back Pain. The low back is especially vulnerable, most notably at L5–S1, where the sacral vertebrae make a sharp pos- terior angle. Approximately 60% to 80% of the population experiences low back pain at least once. Current evidence supports active exercise with minimal bed rest and delay of back-specific exercise while pain is acute; cognitive-behavioral counseling; and occupational interventions targeting graded exercise and early return to modified work. Depres- sion is a major predictor of new low back pain, warranting prompt treatment of psychiatric comorbidities. Osteoporosis Screening and Prevention. Osteoporosis is a major public health threat for postmenopausal women and some men. The U.S. Preventive Services Task Force recommends routine bone density screening for women 65 years or older and earlier for those with the risk factors on next page. HHHeealltthh PPrroommoootioonn andd CCCouunsselingg: EEEviideenncce aannd Reecooommmmeeenddattionns Important Topics for Health Promotion and Counseling ◗ Nutrition, weight, and physical activity ◗ Profiling low back pain ◗ Osteoporosis: screening and prevention ◗ Preventing falls Chapter 16 | The Musculoskeletal System 257 Use the country-specific FRAX calculator to assess fracture risk. If risk is >9.3% for any fracture and >3% for hip fracture, bone density screen-
ing is warranted. The Web site for the FRAX Calculator for Assessing
Fracture Risk for the United States is http://www.shef.ac.uk/FRAX/
tool.jsp?country=9.
Use the World Health Organization scoring criteria to determine
bone density. A 10% drop in bone density, equivalent to 1.0 standard
deviation, is associated with a 20% increase in risk of fracture.
Risk Factors for Osteoporosis and Fracture
◗ Prior fragility fracture
◗ Postmenopausal status in white women
◗ Age ≥50 years
◗ Weight ≤70 kg (154 lb)
◗ Lower dietary calcium
◗ Vitamin D deficiency
◗ Tobacco and alcohol use
◗ Family history of fracture in a first-degree relative
◗ Use of corticosteroids
◗ Medical conditions such as thyrotoxicosis, celiac sprue, chronic renal
disease, organ transplantation, diabetes, HIV, primary or secondary
hypogonadism, multiple myeloma, and anorexia nervosa
◗ Medications such as aromatase inhibitors for breast cancer, methotrexate,
selected antiseizure medications, immunosuppressive agents, and anti-
gonadal therapy
◗ Inflammatory disorders of the musculoskeletal, pulmonary, or gastrointestinal
systems, including rheumatoid arthritis
Several agents inhibit bone resorption: calcium, vitamin D, and anti-
resorptive agents such as bisphosphonates, selective estrogen-receptor
modulators (SERMs), and calcitonin. Learn the therapeutic uses of
these agents and exercise.
World Health Organization Bone Density Criteria
Osteoporosis: T score <−2.5 (>2.5 standard deviations below the mean for
young adult white women)
Osteopenia: T score −2.5 to 1.5 (1.0 to 2.5 standard deviations below the mean
for young adult white women)

http://www.shef.ac.uk/FRAX/tool.jsp?country=9

http://www.shef.ac.uk/FRAX/tool.jsp?country=9

258 Bates’ Pocket Guide to Physical Examination and History Taking
Preventing Falls. Falls are the leading cause of nonfatal injuries and
account for a dramatic rise in death rates after 65 years of age. Risk
factors include unstable gait, imbalanced posture, reduced strength,
cognitive loss and dementia, deficits in vision and proprioception, and
osteoporosis. Urge patients to correct poor lighting, dark or steep
stairs, chairs at awkward heights, slippery or irregular surfaces, and ill-
fitting shoes. Scrutinize any medications affecting balance, especially
benzodiazepines, vasodilators, and diuretics.
Techniques of Examination
Approach to Individual Joint Examination
Inspect the joints and surrounding tissues as you do the various regional
examinations.
Identify joints with changes in structure and function, carefully assessing for:
◗ Symmetry of involvement—one or both sides of the body; one joint or
several
◗ Deformity or malalignment of bones
◗ Changes in surrounding soft tissue—skin changes, subcutaneous nodules,
muscle atrophy, crepitus
◗ Limitations in range of motion and maneuvers, ligamentous laxity
◗ Changes in muscle strength
Note signs of inflammation and arthritis: swelling, warmth, tenderness,
redness.
TTTecchhnniiquees offf EExaammminnatttionn
Recommended Dietary Intakes of Calcium and Vitamin D for
Adults (Institute of Medicine 2010)
Age Group
Calcium (elemental)
mg/day
Vitamin D
IU/day
19–50
50–71
Women
Men
≥71
1,000
1,200
1,000
1,200
600
600
600
800
Source: Ross AC, Manson JE, Abrams SA, et al. The 2011 report on dietary reference intakes
for calcium and vitamin D from the Institute of Medicine: what clinicians need to know. J
Endocrinol Metab 2011;96:53–58.

Chapter 16 | The Musculoskeletal System 259
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TEMPOROMANDIBULAR JOINT (TMJ)
Inspect the TMJ for swelling or
redness.
Palpate the TMJ as the patient
opens and closes the mouth.
Palpate the muscles of mastica-
tion: the masseters, temporal
muscles, and pterygoid muscles.
SHOULDERS
Inspect the contour of the
shoulders and shoulder girdles
from front and back.
Muscle atrophy; anterior or posterior
dislocation of humeral head; scoliosis
if shoulder heights asymmetric
See Table 16-4, Painful Shoulders, p. 282.
Palpate:
● The clavicle from the sterno-
clavicular joint to the acro-
mioclavicular joint
“Step-offs” if fracture from trauma
● The bicipital tendon
Subacromial bursa
Rotator cuff
● The subacromial and sub-
deltoid bursae after lifting
arm posteriorly
Subacromial or subdeltoid bursitis

260 Bates’ Pocket Guide to Physical Examination and History Taking
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
Assess range of motion.
● Flexion—“Raise your arm in
front of you and overhead.”
● Extension—“Move your arms
behind you.”
● Abduction—“Raise your arms
out to the side and overhead.”
● Adduction—“Cross your arm
in front of your body, keeping
the arm straight.”
● External and internal rotation
Intact glenohumeral motion if patient
raises arms to shoulder level, palms
facing down
Intact scapulothoracic motion if
patient raises arms an additional
60 degrees, palms facing up
Acromioclavicular joint arthritis
Shoulder arthritis
TESTS ABDUCTION AND
EXTERNAL ROTATION
TESTS ADDUCTION AND
INTERNAL ROTATION
Perform maneuvers to assess the
“SITS” muscles and tendons of the
rotator cuff—supraspinatus, infra-
spinatus, teres minor, subscapu-
laris, and the bicipital tendon.
● “Empty can test” for
supraspinatus strength
Weakness in rotator cuff tear

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● Infraspinatus strength
● Forearm supination
● “Drop arm” test
Weakness in rotator cuff tear or bicipital
tendonitis
Pain in rotator cuff tear
If patient cannot hold arm fully
abducted at shoulder level, possible
rotator cuff tear

262 Bates’ Pocket Guide to Physical Examination and History Taking
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
ELBOWS
Inspect and palpate:
● Olecranon process
● Medial and lateral epicondyles
● Extensor surface of the ulna
● Grooves between the
epicondyles and the olecranon
Olecranon bursitis; posterior disloca-
tion from direct trauma or supracon-
dylar fracture
Tenderness distal to epicondyle in
epicondylitis (medial → “tennis
elbow”; lateral → “pitcher’s elbow”)
Rheumatoid nodules
Tender in arthritis
Ask patient to: o˚
Supination Pronation
● Flex and extend elbows
● Turn palms up and down
(supination and pronation)
WRISTS AND HANDS
Inspect:
● Movement of the wrist (flexion,
extension, ulnar and medial
deviation), hands, and fingers
● Contours of wrists, hands,
and fingers
● Contours of palms
Guarded movement in injury
Deformities in rheumatoid and degen-
erative arthritis; swelling in arthritis,
ganglia; impaired alignment of fingers
in flexor tendon damage; flexion con-
tractures in Dupuytren’s contractures
Thenar atrophy in median nerve
compression (carpal tunnel syndrome);
hypothenar atrophy in ulnar nerve
compression

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Palpate:
● Wrist joints
● Distal radius and ulna
● “Anatomic snuffbox,” the hol-
low space distal to the radial
styloid bone; thumb extensor
and abductor tendons.
● Metacarpophalangeal joint
Swelling and tenderness in rheumatoid
arthritis, gonococcal infection of joint
or extensor tendon sheaths
Tenderness over ulnar styloid in
Colles’ fracture
Tenderness suggests scaphoid frac-
ture. Tenderness over extensor and
abductor tendons in de Quervain’s
tenosynovitis.
Swelling in rheumatoid arthritis

264 Bates’ Pocket Guide to Physical Examination and History Taking
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
● Proximal and distal interpha-
langeal joint
Proximal nodules in rheumatoid
arthritis (Bouchard’s nodes), distal
nodules in osteoarthritis (Heberden’s
nodes)
Assess range of motion:
● Wrists: Flexion, extension,
adduction (radial deviation),
abduction (lateral deviation)
● Fingers: Flexions, extension,
abduction/adduction (spread
fingers apart and back)
● Thumbs
Arthritis, tenosynovitis
Trigger finger, Dupuytren’s
contracture
FLEXION EXTENSION
ABDUCTION AND ADDUCTION OPPOSITION

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Perform selected maneuvers.
● Hand grip strength
Decreased grip strength if weakness
of finger flexors or intrinsic hand
muscles
● Carpal tunnel testing
● Thumb adduction
Weakness of abductor pollicis longus is
specific to median nerve.
● Thumb movement
Tendon
Pain if de Quervain’s tenosynovitis
● Tinel’s sign: Tap lightly
over median nerve at volar
wrist
Aching, tingling, and numbness in
second, third, and fourth fingers is a
positive Tinel’s sign.

266 Bates’ Pocket Guide to Physical Examination and History Taking
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
● Phalen’s sign: Patient flexes
wrists for 60 seconds
Aching, tingling, and numbness in sec-
ond, third, and fourth volar fingers is a
positive Phalen’s sign.
SPINE
Inspect spine from the side
and back, noting any abnormal
curvatures.
Kyphosis, scoliosis, lordosis, gibbus,
list curvatures
Look for asymmetric heights of
shoulders, iliac crests, or but-
tocks.
Scoliosis, pelvic tilt, unequal leg length
Paravertebral
muscles
Spinous process
of L5 vertebra
Ischial tuberosity
and site of
ischial bursa
Posterior
superior
iliac spine
Sacroiliac
joint
Sacroiliac
notch
Sciatic
nerve
Intervertebral
joint between
L5 and sacrum

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Identify and palpate:
● Spinous processes of each
vertebra
● Sacroiliac joints
● Paravertebral muscles, if painful
● Sciatic nerve (midway
between greater trochanter
and ischial tuberosity)
Tender if trauma, infection; “step-offs”
in spondylolisthesis, fracture
Sacroiliitis, ankylosing spondylitis
Paravertebral muscle spasm in abnor-
mal posture, degenerative and inflam-
matory muscle disorders, overuse
Herniated disc or nerve root
compression
Sciatic nerve
Greater trochanter
Ischial tuberosity
Test the range of motion in
the neck and spine in: flexion,
extension, rotation, and lateral
bending.
Decreased mobility in arthritis
HIPS
Inspect gait for:
● Stance (see below) and swing
(foot moves forward, does
not bear weight)
Most problems arise during the
weight-bearing stance phase.
Heelstrike Foot flat Midstance Push-off
PHASES OF GAIT: STANCE (RIGHT LEG) AND SWING (LEFT LEG)

268 Bates’ Pocket Guide to Physical Examination and History Taking
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● Width of base (usually 2 to
4 inches from heel to heel),
shift of pelvis, flexion of knee
Cerebellar disease or foot problems
if wide base; impaired shift of pelvis
in arthritis, hip dislocation, abductor
weakness; disrupted gait if poor knee
flexion
Palpate:
● Along the inguinal ligament
● The trochanteric bursa, on
the greater trochanter of the
femur
● The ischiogluteal bursa, super-
ficial to the ischial tuberosity
Trochanteric bursa
Ischiogluteal bursa
TROCHANTERIC AND
ISCHIOGLUTEAL BURSA
Bulges in inguinal hernia, aneurysm
Focal tenderness in trochanteric bursitis,
often described by patients as “low
back pain”
Tender in bursitis (“weaver’s bottom”)
from prolonged sitting
Check range of motion,
including:
● Flexion—“Bend your knee
and pull it against your
abdomen.”
Flexion of opposite leg suggests
deformity of that hip.

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● Extension
● Abduction and adduction
● Internal and external rotation
Painful in iliopsoas abscess
Restricted in hip arthritis
Restricted in hip arthritis
KNEES
Review the structures of the
knee.
Medial femoral
condyle
Medial femoral
epicondyle
Patellar tendon
Medial tibial
plateau
Tibial tuberosity
Adductor
tubercle
Medial
collateral
ligament
Pes anserine
bursa

270 Bates’ Pocket Guide to Physical Examination and History Taking
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Inspect:
● Gait for knee extension at heel
strike, flexion during all other
phases of swing and stance
● Alignment of knees
● Contours of knees, including
any atrophy of the quadriceps
muscles
Stumbling or “giving way” during heel
strike in quadriceps weakness or abnor-
mal patellar tracking
Bowlegs, knock-knees; flexion contrac-
tures in limb paralysis or hamstring
tightness
Quadriceps atrophy with patellofemoral
disorder
Inspect and palpate: See Table 16-5, Painful Knees,
pp. 283–284.
● The tibiofemoral joint—with
knees flexed, including:
● Joint line—place thumbs
on either side of the patellar
tendon.
Irregular, bony ridges in osteoarthritis.
● Medial and lateral meniscus
● Medial and lateral collateral
ligaments
Tenderness if meniscus tear
Tenderness if MCL tear (LCL injuries
less common)
● The patellofemoral compart-
ment:
● Patella
● Palpate the patellar tendon
and ask patient to extend
the leg.
● Press the patella against the
underlying femur.
● Push patella distally and
ask patient to tighten knee
against table.
Swelling over the patella in prepatellar
bursitis (“housemaid’s knee”)
Tenderness or inability to extend the
leg in partial or complete tear of the
patellar tendon
Pain, crepitus, and a history of knee
pain in patellofemoral disorder
Pain during contraction of quadriceps
in chondromalacia

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● Also:
● Suprapatellar pouch
● Infrapatellar spaces (hollow
areas adjacent to patella)
● Medial tibial condyle
● Popliteal surface
Swelling in synovitis and arthritis
Swelling in arthritis
Swelling in pes anserine bursitis
Popliteal or Baker’s cyst
Assess any effusions.
● Bulge sign (minor effusions):
Compress the suprapatellar
pouch, stroke downward on
medial surface, apply pres-
sure to force fluid to lateral
surface, and then tap knee
behind lateral margin of
patella.
A fluid wave returning to the medial
surface after a lateral tap confirms an
effusion—a positive “bulge sign.”
Tap and watch
for fluid wave
Apply medial
pressure
Milk downward

272 Bates’ Pocket Guide to Physical Examination and History Taking
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
● Balloon sign (major effusions):
Compress suprapatellar pouch
with one hand; with thumb
and finger of other hand, feel
for fluid entering the spaces
next to the patella.
● Ballotte the patella (major
effusion): Push the patella
sharply against the femur;
watch for fluid returning to
the suprapatellar space.
A palpable fluid wave is a positive sign.
Visible wave is a positive sign.
Assess range of motion: flexion,
extension, internal and external
rotation.
Use maneuvers to assess menisci
and ligaments.
● Medial meniscus and lateral
meniscus—McMurray test:
With the patient supine, grasp
the heel and flex the knee.
Cup your other hand over the
knee joint with fingers and
thumb along the medial joint
line. From the heel, externally
rotate the lower leg, then
push on the lateral side to
apply a valgus stress on the
medial side of the joint.
Slowly extend the lower leg
in external rotation.
The same maneuver with
internal rotation stresses the
lateral meniscus.
Click or pop along the medial joint
with valgus stress, external rotation,
and leg extension in tear of posterior
medial meniscus.

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● Medial collateral ligament:
With knee slightly flexed,
push medially against lateral
surface of knee with one hand
and pull laterally at the ankle
with the other hand (abduc-
tion or valgus stress).
● Lateral collateral ligament
(LCL): With knee slightly
flexed, push laterally along
medial surface of knee with
one hand and pull medially at
the ankle with the other hand
(an adduction or varus stress).
Pain or a gap in the medial joint line
points to a partial or complete MCL
tear.
Pain or a gap in the lateral joint line
points to a partial or complete LCL
tear.
● Anterior cruciate ligament
(ACL): (1) With knee flexed,
place thumbs on medial and
lateral joint line and place fin-
gers on hamstring insertions.
Pull tibia forward, observe
if tibia slides forward “like a
drawer.” Compare to oppo-
site knee.
Forward slide of proximal tibia is a
positive anterior drawer sign in ACL
laxity or tear.
(2) Lachman test: Grasp the
distal femur with one hand
and the proximal tibia with
the other (place the thumb
on the joint line). Move the
femur forward and the tibia
back.
Significant forward excursion of tibia
in ACL tear

274 Bates’ Pocket Guide to Physical Examination and History Taking
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● Posterior cruciate ligament
(PCL): Posterior drawer sign:
Position patient and hands
as in the ACL test. Push the
tibia posteriorly and observe
for posterior movement, like a
drawer sliding posteriorly.
Isolated PCL tears are rare.
ANKLES AND FEET
Inspect ankles and feet. Hallux valgus, corns, calluses
Palpate:
● Ankle joint
● Ankle ligaments: medial-
deltoid; lateral-anterior and
posterior talofibular, calca-
neofibular
Tender joint in arthritis
Tenderness in sprain: lateral ligaments
weaker, inversion injuries (ankle bows
outward) more common
● Achilles tendon
● Compress the metatarsopha-
langeal joints; then palpate
each joint between the thumb
and forefinger.
Rheumatoid nodules, tenderness in
tendonitis
Tenderness in arthritis, Morton’s
neuroma third and fourth MTP joints;
inflammation of first MTP joint in gout

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Assess range of motion.
● Dorsiflex and plantar flex the
ankle (tibiotalar joint).
● Stabilize the ankle and invert
and evert the heel (subtalar or
talocalcaneal joint).
Arthritic joint often painful when
moved in any direction; sprain, when
injured ligament is stretched
Ankle sprain
INVERSION EVERSION
● Stabilize the heel and invert
and evert the forefoot
(transverse tarsal joints).
Trauma, arthritis
INVERSION EVERSION
● Move proximal phalanx of
each toe up and down (meta-
tarsophalangeal joints).

276 Bates’ Pocket Guide to Physical Examination and History Taking
SPECIAL TECHNIQUES
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
Measuring Leg Length.
Patient’s legs should be aligned
symmetrically. With a tape,
measure distance from anterior
superior iliac spine to medial
malleolus. Tape should cross
knee medially.
Unequal leg length may be the cause
of scoliosis.
Measuring Range of
Motion. To measure range
of motion precisely, a simple
pocket goniometer is needed.
Estimates may be made visually.
Movement in the elbow at the
right is limited to range indi-
cated by red lines.
A flexion deformity of 45 degrees
and further flexion to 90 degrees
(45 degrees → 90 degrees)
0˚
45˚
90˚
160˚
Recording Your FindingsRRReccoorddinnggg YYouuur Finnddinngss
Recording the Physical Examination—The
Musculoskeletal System
“Full range of motion in all joints. No evidence of swelling or deformity.”
OR
“Full range of motion in all joints. Hand with degenerative changes of He-
berden’s nodes at the distal interphalangeal joints, Bouchard’s nodes at
proximal interphalangeal joints. Mild pain with flexion, extension, and rota-
tion of both hips. Full range of motion in the knees, with moderate crepitus;
no effusion but boggy synovium and osteophytes along the tibiofemoral joint
line bilaterally. Both feet with hallux valgus at the first metatarsophalangeal
joints.” (Suggests osteoarthritis.)

Chapter 16 | The Musculoskeletal System 277
Aids to Interpretation
Table 16-1
Patterns Physical Signs
Mechanical Low Back Pain
Aching pain in lumbosacral area;
may radiate into lower leg,
along L5 or S1 dermatomes.
Usually acute, work related, in
age group 30 to 50 years; no
underlying pathology
Paraspinal muscle or facet
tenderness, muscle spasm or pain
with back movement, loss of
normal lumbar lordosis but no
motor or sensory loss or reflex
abnormalities. In osteoporosis,
check for thoracic kyphosis,
percussion tenderness over a
spinous process, or fractures in
the thoracic spine or hip.
Sciatica (Radicular Low
Back Pain)
Usually from disc herniation;
more rarely from nerve root
compression, primary or
metastatic tumor
Disc herniation most likely
if calf wasting, weak ankle
dorsiflexion, absent ankle
jerk, positive crossed straight-
leg raise (pain in affected leg
when healthy leg tested);
negative straight-leg raise makes
diagnosis highly unlikely.
Lumbar Spinal Stenosis
Pseudoclaudication pain in the
back or legs that improves
with rest, forward lumbar
flexion. Pain vague but usually
bilateral, with paresthesias in
one or both legs; usually from
arthritic narrowing of spinal
canal
Posture may be flexed forward
with lower extremity weakness
and hyporeflexia; straight-leg
raise usually negative
Low Back Pain
(continued)

278 Bates’ Pocket Guide to Physical Examination and History Taking
Patterns Physical Signs
Chronic Back Stiffness
Consider ankylosing spondylitis
in inflammatory polyarthritis,
most common in men
younger than 40 years. Diffuse
idiopathic skeletal hyperostosis
(DISH) affects men more than
women, usually age older than
50 years.
Loss of the normal lumbar
lordosis, muscle spasm, limited
anterior and lateral flexion;
improves with exercise. Lateral
immobility of the spine,
especially thoracic segment
Nocturnal Back Pain,
Unrelieved by Rest
Consider metastasis to spine
from cancer of the prostate,
breast, lung, thyroid, and
kidney, and multiple myeloma.
Findings vary with the source.
Local vertebral tenderness may
be present.
Pain Referred from the
Abdomen or Pelvis
Usually a deep, aching pain, the
level of which varies with the
source (∼2% of low back pain)
Spinal movements are not painful
and range of motion is not
affected. Look for signs of the
primary disorder, such as peptic
ulcer, pancreatitis, dissecting
aortic aneurysm.
Table 16-1 Low Back Pain (continued)

Chapter 16 | The Musculoskeletal System 279
Table 16-2 Pains in the Neck
Patterns Physical Signs
Mechanical Neck Pain
Aching pain in the cervical
paraspinal muscles and ligaments
with associated muscle spasm,
stiffness, and tightness in the
upper back and shoulder, lasting
up to 6 weeks. No associated
radiation, paresthesias, or
weakness. Headache may be
present.
Local muscle tenderness,
pain on movement.
No neurologic deficits.
Possible trigger points in
fibromyalgia. Torticollis if
prolonged abnormal neck
posture and muscle spasm.
Mechanical Neck Pain—Whiplash
Also mechanical neck pain with
aching paracervical pain and
stiffness, often beginning the day
after injury. Occipital headache,
dizziness, malaise, and fatigue
may be present. Chronic whiplash
syndrome if symptoms last more
than 6 months, present in 20% to
40% of injuries.
Localized paracervical
tenderness, decreased neck
range of motion, perceived
weakness of the upper
extremities. Causes of
cervical cord compression
such as fracture, herniation,
head injury, or altered
consciousness are excluded.
Cervical Radiculopathy—from
nerve root compression
Sharp burning or tingling pain
in the neck and one arm, with
associated paresthesias and
weakness. Sensory symptoms
often in myotomal pattern,
deep in muscle, rather than
dermatomal pattern.
C7 nerve root affected
most often (45%–60%),
with weakness in triceps
and finger flexors and
extensors. C6 nerve root
involvement also common,
with weakness in biceps,
brachioradialis, wrist
extensors.
(continued)

280 Bates’ Pocket Guide to Physical Examination and History Taking
Patterns Physical Signs
Cervical Myelopathy—from
cervical cord compression
Neck pain with bilateral weakness
and paresthesias in both upper
and lower extremities, often
with urinary frequency. Hand
clumsiness, palmar paresthesias,
and gait changes may be subtle.
Neck flexion often exacerbates
symptoms.
Hyperreflexia; clonus at
the wrist, knee, or ankle;
extensor plantar reflexes
(positive Babinski signs);
and gait disturbances. May
also see Lhermitte’s sign:
neck flexion with resulting
sensation of electrical shock
radiating down the spine.
Confirmation of cervical
myelopathy warrants
neck immobilization and
neurosurgical evaluation.
Table 16-2 Pains in the Neck (continued)

Chapter 16 | The Musculoskeletal System 281
Table 16-3 Patterns of Pain in and Around the Joints
Rheumatoid Arthritis
Osteoarthritis
(Degenerative Joint
Disease, or DJD)
Process Chronic inflammation of
synovial membranes
with secondary
erosion of adjacent
cartilage and bone,
damage to ligaments
and tendons
Degeneration and
progressive loss of
cartilage within joints,
damage to underlying
bone, formation of
new bone at margins
of cartilage
Common
Locations
Hands (proximal
interphalangeal and
metacarpophalangeal
joints), feet
(metatarsophalangeal
joints), wrists, knees,
elbows, ankles
Knees, hips, hands (distal,
sometimes proximal
interphalangeal joints),
cervical and lumbar
spine, and wrists (first
carpometacarpal joint);
also joints previously
injured or diseased
Pattern of
Spread
Symmetrically additive:
progresses to other
joints; persists in initial
ones
Additive; however,
sometimes only one
joint affected
Onset Usually insidious Usually insidious
Progression
and Duration
Often chronic, with
remissions and
exacerbations
Slowly progressive, with
exacerbations after
overuse
Associated
Symptoms
Frequent swelling of
synovial tissue in joints
or tendon sheaths;
also subcutaneous
nodules
Small joint effusions may
be present, especially
in knees; also bony
enlargement
Tender, often warm but
seldom red
Tender, seldom warm
or red
Prominent stiffness,
often for >1 hour in
mornings
Frequent but brief
stiffness in the
morning

282 Bates’ Pocket Guide to Physical Examination and History Taking
Table 16-4 Painful Shoulders
Acromioclavicular Arthritis Tenderness over the acromioclavicular
joint, especially with adduction
of the arm across the chest. Pain
often increases with shrugging the
shoulders, due to movement of
scapula.
Subacromial and
Subdeltoid Bursitis
Pain over anterior superior aspect of
shoulder, particularly when raising
the arm overhead. Tenderness
common anterolateral to the
acromion, in hollow recess formed
by the acromiohumeral sulcus.
Often seen in overuse syndromes.
Rotator Cuff Tendinitis Tenderness over the rotator cuff,
when elbow passively lifted
posteriorly or with “drop-arm”
maneuver.
Bicipital Tendinitis Tenderness over the long head of
the biceps when rolled in the
bicipital groove or when flexed
arm is supinated against resistance
suggests bicipital tendinitis.

Chapter 16 | The Musculoskeletal System 283
Table 16-5 Painful Knees
Arthritis. Degenerative arthritis usually
occurs after age 50; associated with
obesity. Often with medial joint line
tenderness, palpable osteophytes,
bowleg appearance, suprapatellar
bursae and joint effusion. Systemic
involvement, swelling, and
subcutaneous nodules in rheumatoid
arthritis.
Prepatellar
bursa
Pes
anserine
Iliotibial
band
Bursitis. Inflam-
mation and
thickening of bursa
seen in repetitive
motion and overuse
syndromes. Can
involve prepatellar
bursa (“housemaid’s knee”), pes anserine
bursa medially (runners, osteoarthritis),
iliotibial band laterally (over lateral
femoral condyle), especially in runners.
Patella
moves up
and lateral
Leg extends
and foot
raises
Patellofemoral instability. During
flexion and extension of knee, due to
subluxation and/or malalignment,
patella tracks laterally instead of
centrally in trochlear groove of femoral
condyle. Inspect or palpate for lateral
motion with leg extension. May lead to
chondromalacia, osteoarthritis.
Lateral
meniscus
Medial
meniscus
torn
Meniscal tear. Commonly arises from
twisting injury of knee; in older patients
may be degenerative, often with
clicking, popping, or locking sensation.
Check for tenderness along joint line
over medial or lateral meniscus and for
effusion. May have associated tears of
medial collateral of anterior cruciate
ligaments.
(continued)

284 Bates’ Pocket Guide to Physical Examination and History Taking
Anterior
cruciate
ligament
torn
Anterior cruciate tear or sprain. In
twisting injuries of the knee, often with
popping sensation, immediate swelling,
pain with flexion/extension, difficulty
walking, and sensation of knee “giving
way.” Check for anterior drawer sign,
swelling of hemarthrosis, injuries to
medial meniscus or medial collateral
ligament. Consider evaluation by an
orthopedic surgeon.
Medial
collateral
ligament
torn
Collateral ligament sprain or tear.
From force applied to medial or lateral
surface of knee (valgus or varus stress),
producing localized swelling, pain,
stiffness. Patients able to walk but
may develop an effusion. Check for
tenderness over affected ligament and
ligamentous laxity during valgus or
varus stress.
Baker’s
cyst
Posterior knee
Baker’s cyst. Cystic swelling palpable
on the medial surface of the popliteal
fossa, prompting complaints of aching
or fullness behind the knee. Inspect,
palpate for swelling adjacent to medial
hamstring tendons. If present, suggests
involvement of posterior horn of medial
meniscus. In rheumatoid arthritis, cyst
may expand into calf or ankle.
Painful Knees (continued)Table 16-5

285
C H A P T E R
17The Nervous System
Fundamentals for Assessing
the Nervous System
The central nervous system (CNS) consists of the brain and spinal cord.
The peripheral nervous system consists of the 12 pairs of cranial nerves
and the spinal and peripheral nerves. Most peripheral nerves contain
both motor and sensory fibers.
CENTRAL NERVOUS SYSTEM
The Brain
● Gray matter, or aggregations of neuronal cell bodies; rims the sur-
faces of the cerebral hemispheres, forming the cerebral cortex
● White matter, or neuronal axons coated with myelin, allowing nerve
impulses to travel more rapidly
● Basal ganglia, which affect movement
● Thalamus, which processes and relays sensory impulses to the cerebral
cortex
● Hypothalamus, which maintains homeostasis and regulates tem-
perature, heart rate, and blood pressure; affects endocrine system,
and governs emotional behaviors such as anger and sex drive; and
contains hormones that act directly on the pituitary gland
● Brainstem, which connects the upper part of the brain with the spinal
cord and has three sections: midbrain, pons, and medulla
FFFunndddaammeenntaalss fforr AAAsssessssinng
tthee NNNeervvooouss SSSyssteemmm

286 Bates’ Pocket Guide to Physical Examination and History Taking
● Reticular activating (arousal) system, in the diencephalon and upper
brainstem; activation linked to consciousness
● Cerebellum, at the base of the brain, which coordinates all movement
and helps maintain the body upright in space
The Spinal Cord
● A cylindrical mass of nerve tissue encased within the bony vertebral
column, extending from medulla to first or second lumbar
vertebra
● Contains important motor and sensory nerve pathways that exit and
enter the cord via anterior and posterior nerve roots and spinal and
peripheral nerves
● Mediates reflex activity of the deep tendon (or spinal nerve)
reflexes
● Divided into five segments: cervical (C1–8), thoracic (T1–12),
lumbar (L1–5), sacral (S1–5), and coccygeal
● Roots fan out like a horse’s tail at L1–2, the cauda equina
PERIPHERAL NERVOUS SYSTEM
The Cranial Nerves
● Cranial nerves I and II are actually fiber tracts emerging from the
brain.
● Cranial nerves III through XII arise from the diencephalon and
brainstem.
The Peripheral Nerves
● Thirty-one pairs of nerves carry impulses to and from the cord: 8
cervical, 12 thoracic, 5 lumbar, 5 sacral, and 1 coccygeal.
● Each nerve has an anterior (ventral) root containing motor fibers,
and a posterior (dorsal) root containing sensory fibers.

Chapter 17 | The Nervous System 287
● These merge to form a short (<5 mm) spinal nerve. ● Spinal nerve fibers commingle with similar fibers in plexuses outside the cord—from these emerge peripheral nerves. The Health History Common or Concerning Symptoms ◗ Headache ◗ Dizziness or vertigo ◗ Generalized, proximal, or distal weakness ◗ Numbness, abnormal or lost sensations ◗ Loss of consciousness, syncope, or near-syncope ◗ Seizures ◗ Tremors or involuntary movements Headache: ask about location, severity, duration, and any associated symptoms, such as visual changes, weakness, or loss of sensation. Ask if coughing, sneezing, or sudden movements of the head affect the headache. See Table 7-1, Primary Headaches, p. 111, and Table 7-2, Secondary Headaches, pp. 112–113. Subarachnoid hemorrhage may evoke “the worst headache of my life.” Dull headache affected by maneu- vers, especially on awakening and in the same location are seen in mass lesions such as brain tumors Dizziness can have many mean- ings. Is the patient lightheaded or feeling faint (presyncope)? Is there unsteady gait from dis- equilibrium or ataxia, or true vertigo, a perception that the room is spinning or rotating? Are any medications contribut- ing to dizziness? Lightheadedness in palpitations; near- syncope from vasovagal stimulation, low blood pressure, febrile illness, and others; vertigo in benign positional ver- tigo, Ménière’s disease, brainstem tumor 288 Bates’ Pocket Guide to Physical Examination and History Taking Are associated symptoms pres- ent, such as double vision (dip- lopia), difficulty forming words (dysarthria), or difficulty with gait or balance (ataxia)? Is there any weakness? Diplopia, dysarthria, ataxia in vertebro- basilar transient ischemic attack (TIA) or stroke See Table 17-1, Types of Stroke, pp. 308–311 Weakness or paralysis in TIA or stroke Distinguish proximal from distal weakness. For proximal weakness, ask about combing hair, reach- ing for things on a high shelf, difficulty getting out of a chair or taking a high step up. For distal weakness, ask about hand movements such as opening a jar or can or using hand tools (e.g., scissors, pliers, screwdriver). Ask about frequent tripping. Bilateral proximal weakness in myo- pathy; bilateral, predominantly distal weakness in polyneuropathy; weak- ness worsened by repeated effort and improved by rest in myasthenia gravis Is there any loss of sensation, difficulty moving a limb, or altered sensation such as tingling or pins and needles? Peculiar sensations without an obvious stimulus (paresthesias)? Dysesthe- sias, or disordered sensations in response to a stimulus, may last longer than the stimulus itself. Loss of sensation, paresthesias, and dysesthesias in brain and spinal cord lesions; also in disorders of peripheral sensory roots and nerves; paresthesias in hands and around mouth in hyper- ventilation Synope: “Have you ever fainted or passed out?” leads to discussion of any loss of consciousness (syncope). Syncope if sudden but temporary loss of consciousness from decreased cerebral blood flow, commonly called fainting. Get a complete description of the event. What brought on the episode? Were there any warn- ing symptoms? Was the patient standing, sitting, or lying down when it began? How long did it last? Could voices be heard while passing out and coming to? How rapid was recovery? Were onset and offset slow or fast? Young people with emotional stress and warning symptoms of flushing, warmth, or nausea may have vasodepressor (or vasovagal) syncope of slow onset, slow offset. Cardiac syncope from dysrhyth- mias, more common in older patients, often with sudden onset, sudden offset. Chapter 17 | The Nervous System 289 Also ask if anyone observed the episode. What did the patient look like before, during, and after the episode? Was there any seizurelike movement of the arms or legs? Any incontinence of the bladder or bowel? Tonic–clonic motor activity, inconti- nence, and postictal state in generalized seizures. Unlike syncope, injury such as tongue biting or bruising of limbs may occur. A seizure is a paroxysmal dis- order caused by sudden exces- sive electrical discharge in the cerebral cortex or its underlying structures. Depending on the type of seizure, there may be loss of consciousness or abnor- mal feelings, thought processes, and sensations, including smells, as well as abnormal movements. Health Promotion and Counseling: Evidence and Recommendations Important Topics for Health Promotion and Counseling ◗ Preventing stroke or transient ischemic attack (TIA) ◗ Preventing risk of peripheral neuropathy ◗ Preventing the “three Ds”: delirium, dementia, and depression Preventing Stroke or TIA. Cerebrovascular disease is the third leading cause of death in the United States. Decreased vascular perfu- sion results in sudden focal but transient brain dysfunction in TIA, or in permanent neurological deficits in stroke, as determined by neurodiagnostic imaging. Counsel patients about the warning signs of stroke: sudden numbness or weakness of the face, arm, or leg; sudden confusion or trouble speaking or understanding; sudden difficulty walking, dizziness, or loss of balance or coordination; sudden trouble seeing in one or both eyes; or sudden severe headache. Detecting TIAs is important—in the first 3 months after a TIA, subsequent stroke occurs in approximately 15% of patients. HHHeealtthh PPrroommoootioonn andd CCCouunsselingg: EEEviideeenncee aannd Reecooommmmeenddatiionns 290 Bates’ Pocket Guide to Physical Examination and History Taking Primary prevention of stroke requires aggressive management of risk factors and patient education. Risk factors include smoking, excess weight, hypertension, dyslipidemia, heavy alcohol use, physical inactiv- ity, obesity, and diabetes. Blood pressure should be ≤140/90 mm Hg and ≤130/80 mm Hg for those with diabetes or renal disease with proteinuria. Lipid-lowering agents may reduce risk of stroke. Urge patients to replace saturated and transunsaturated fats, found in dairy products, meat, and stick margarine, with polyunsaturated and unhy- drogenated monosaturated fats, found in soybeans, liquid margarine, and fish oils. Or recommend increased intake of fruits, vegetables, and fiber. Encourage regular exercise, optimal body weight, and moderate intake of alcohol. Aim for optimal blood glucose levels, approximately 100 mg/dL for patients with diabetes. Preventing Risk of Peripheral Neuropathy. In diabetics, pro- mote optimal glucose control to reduce risk of sensorimotor polyneu- ropathy, autonomic dysfunction, mononeuritis multiplex, or diabetic neuropathy. Preventing the “Three Ds”: Delirium, Dementia, and Depression Delirium is an acute confusional state marked by sudden onset, fluctu- ating course, inattention and changes in the level of consciousness; it is often undetected. Learn to use the Confusional Assessment Method (CAM) algorithm. Dementia is best assessed by the Mini-Mental State examination and the Mini-Cog, but may be difficult to distinquish from benign forget- fulness and mild cognitive impairment. Depression is common in individuals with significant medical conditions. See screening questions on p. 45, Chapter 3. See also Chapter 20, The Older Adult, pp. 378–379, and Table 20-2, Delirium and Dementia, pp. 391–392, and Table 20-3, Screening for Dementia: The Mini-Cog, p. 393. Chapter 17 | The Nervous System 291 Techniques of ExaminationTTTecchhnniiquees offf TT Exaammminnatttionn Cranial Ner ves and Function No. Cranial Nerve Function I Olfactory Sense of smell II Optic Vision III Oculomotor Pupillary constriction, opening the eye (lid elevation), and most extraocular movements IV Trochlear Downward, internal rotation of the eye V Trigeminal Motor—temporal and masseter muscles (jaw clenching), also lateral pterygoid’s (lateral jaw movement) Sensory—facial. The nerve has three divisions: (1) ophthalmic, (2) maxillary, and (3) man- dibular. VI Abducens Lateral deviation of the eye VII Facial Motor—facial movements, including those of facial expression, closing the eye, and closing the mouth Sensory—taste for salty, sweet, sour, and bitter substances on the anterior two-thirds of the tongue VIII Acoustic Hearing (cochlear division) and balance (ves- tibular division) IX Glossopharyngeal Motor—pharynx Sensory—posterior portions of the eardrum and ear canal, the pharynx, and the posterior tongue, including taste (salty, sweet, sour, bitter) X Vagus Motor—palate, pharynx, and larynx Sensory—pharynx and larynx XI Spinal accessory Motor—the sternomastoid and upper portion of the trapezius XII Hypoglossal Motor—tongue 292 Bates’ Pocket Guide to Physical Examination and History Taking E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S CRANIAL NERVES CN I (OLFACTORY) Test sense of smell on each side. Loss in frontal lobe lesions CN II (OPTIC) Assess visual acuity. Blindness Check visual fields. Hemianopsia Inspect optic discs. Papilledema, optic atrophy CN II, III (OPTIC AND OCULOMOTOR) Test pupillary reactions to light. If abnormal, test reactions to near effort. Blindness, CN III paralysis, tonic pupils; Horner’s syndrome may affect light reactions CN III, IV, VI (OCULOMOTOR, TROCHLEAR, AND ABDUCENS) Assess extraocular movements. Strabismus from paralysis of CN III, IV, or VI; nystagmus, intranuclear opthal- moplegia CN V (TRIGEMINAL) Test pain and light touch sensations on face in (1) ophthalmic, (2) maxillary and (3) mandibular zones. (1) (2) (3) C2 CN V—SENSORY Chapter 17 | The Nervous System 293 E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S Feel the contractions of temporal and masseter muscles. Motor or sensory loss from lesions of CN V or its higher motor pathways TEMPORAL MUSCLES MASSETER MUSCLES Check corneal reflexes. CN VII (FACIAL) Ask patient to raise both eyebrows, frown, close eyes tightly, show teeth, smile, and puff out cheeks. Weakness from lesion of peripheral nerve, as in Bell’s palsy, or of CNS, as in a stroke. See Table 17-2, Facial Paraly- sis, p. 312. CN VIII (ACOUSTIC) Assess hearing of whispered voice. If decreased: ● Test for lateralization (Weber test). ● Compare air and bone conduction (Rinne test). Sensorineural loss causes lateralization to affected ear where AC > BC. Con-
duction loss causes lateralization to
affected ear and BC > AC. See p. 108.
See p. 108.

294 Bates’ Pocket Guide to Physical Examination and History Taking
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
CN IX, X (GLOSSOPHARYNGEAL AND VAGUS)
Observe any difficulty
swallowing.
A weakened palate or pharynx impairs
swallowing.
Listen to the voice. Hoarseness or nasality
Watch soft palate rise with “ah.” Palatal paralysis in CVA
Test gag reflex on each side. Absent reflex is often normal.
CN XI (SPINAL ACCESSORY)
Trapezius Muscles. Assess
muscles for bulk, involuntary
movements, and strength of
shoulder shrug.
Atrophy, fasciculations, weakness
Sternomastoid Muscles. Assess
strength as head turns against
your hand.
Weakness of sternomastoid muscle
when head turns to opposite side
CN XII (HYPOGLOSSAL)
Listen to patient’s articulation. Dysarthria from damage to CN X or
CN XII
Inspect the resting tongue. Atrophy, fasciculations in ALS, polio
Inspect the protruded tongue. Deviation to weak side in contralateral
CVA
THE MOTOR
SYSTEM
See Table 17-3, Motor Disorders, p. 313.
BODY POSITION
Observe the patient’s body
position during movement
and at rest.
Hemiplegia in stroke

Chapter 17 | The Nervous System 295
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
INVOLUNTARY
MOVEMENTS
If present, observe location,
quality, rate, rhythm, amplitude,
and setting.
Tremors, fasciculations, tics, chorea,
athetosis, oral–facial dyskinesias. See
Table 17-4, Involuntary Movements,
pp. 314–315.
MUSCLE BULK AND TONE
Inspect muscle contours. Atrophy of bulk. See Table 17-5,
Disorders of Muscle Tone, p. 316.
Assess resistance to passive
stretch of arms and legs.
Spasticity, rigidity, flaccidity of tone
MUSCLE STRENGTH
Test and grade the major
muscle groups, with the
examiner providing resistance.
Grading Muscle Strength
Grade Description
0 No muscular contraction detected
1 A barely detectable trace of contraction
2 Active movement with gravity eliminated
3 Active movement against gravity
4 Active movement against gravity and some resistance
5 Active movement against full resistance (normal)
Look for a pattern if any detectable weakness. It may suggest a
lower motor neuron lesion affecting a peripheral nerve or nerve
root. Weakness of one side of body suggests an upper motor neuron
lesion. A polyneuropathy causes symmetric distal weakness, and a
myopathy usually causes proximal weakness. Weakness that worsens
with repeated effort and improves with rest suggests myasthenia
gravis.

296 Bates’ Pocket Guide to Physical Examination and History Taking
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
● Elbow flexion
(C5, C6)—biceps
● Elbow extension
(C6, C7, C8)—triceps
● Wrist extension (C6, C7,
C8)—radial nerve
● Grip (C7, C8, T1)
● Finger abduction
(C8, T1)—ulnar nerve
● Thumb opposition
(C8, T1)—median nerve
● Trunk—flexion extension,
lateral bending
● Hip flexion (L2, L3,
L4)—iliopsoas
Peripheral radial nerve damage; central
stroke or multiple sclerosis if hemiplegia
Weak grip in cervical radiculopathy,
de Quervain’s tenosynovitis, carpal
tunnel syndrome
Weak in ulnar nerve disorders
Weak in Carpal tunnel syndrome

Chapter 17 | The Nervous System 297
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
● Hip extension (S1)—gluteus
maximus
● Hip adduction (L2, L3,
L4)—adductors
● Hip abduction (L4, L5, S1)—
gluteus medius and minimus
● Knee extension
(L2, L3, L4)—quadriceps
● Knee flexion
(L4, L5, S1, S2)—hamstrings
● Ankle dorsiflexion (L4, L5)
● Ankle plantar flexion (S1)
COORDINATION
Check rapid alternating
movements in arms and legs
(tap foot)
Clumsy, slow movements in cerebellar
disease
Point-to-point movements in arms
and legs–finger to nose, heel to shin
Clumsy, unsteady movements in
cerebellar disease
Gait. Ask patient to:
● Walk away, turn, and come
back
CVA, cerebellar ataxia, parkinsonism,
or loss of position sense may affect
performance.

298 Bates’ Pocket Guide to Physical Examination and History Taking
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
● Walk heel to toe
● Walk on toes, then on heels
● Hop in place on each foot;
do one-legged shallow knee
bends. Substitute rising from a
chair and climbing on a stool
for hops and bends as indicated.
Ataxia
Corticospinal tract injury
Proximal hip girdle weakness increases
risk of falls.
Stance
● Do a Romberg test (a sensory test
of stance). Ask patient to stand
with feet together and eyes open,
then closed for 20 to 30 seconds.
Mild swaying may occur. Stand
close by to prevent falls.
● Look for a pronator drift as
patient holds arms forward,
with eyes closed, for 20 to
30 seconds.
Loss of balance when eyes are closed is a
positive Romberg test, suggesting poor
position sense.
Flexion and pronation at elbow and
downward drift of arm from contra-
lateral corticospinal tract lesion
Ask patient to keep arms up and
tap them downward. A smooth
return to position is normal.
Weakness, incoordination, poor position
sense
THE SENSORY SYSTEM
Use an object like a
broken cotton swab to test sharp
and dull sensation; compare
symmetric areas on the two
sides of the body. Do not reuse
the object on another patient.
A hemisensory loss pattern suggests a
contralateral cortical lesion.

Chapter 17 | The Nervous System 299
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
Compare proximal and distal
areas of arms and legs for pain,
temperature, and touch sensation.
Scatter stimuli to sample
most dermatomes and major
peripheral nerves.
“Glove-and-stocking” loss of peripheral
neuropathy, often seen in alcoholism
and diabetes
See Table 17-6, Dermatones, pp.
317–318.
Map any area of abnormal response,
including dermatomes, if present.
Dermatomal sensory loss in herpes
zoster, nerve root compression.
Assess response to the following
stimuli, with the patient’s eyes
closed.
● Pain. Use the sharp end of a
pin or other suitable tool. The
dull end serves as a control.
● Temperature (if indicated). Use
test tubes with hot and cold
water, or other objects of suit-
able temperature.
● Light touch. Use a fine wisp of
cotton.
Analgesia, hypalgesia, hyperalgesia
Temperature and pain sensation usually
correlate.
Anesthesia, hyperesthesia
Check for vibration and position
senses. If responses are abnormal,
test more proximally
Loss of vibration and position senses in
peripheral neuropathy from diabetes
or alcoholism and in posterior column
disease from syphilis or vitamin B12
deficiency
● Vibration and position. Vibra-
tion: Use a 128-Hz tuning
fork, held on a bony promi-
nence. Vibration and position
senses, both carried in the pos-
terior columns, often correlate.

300 Bates’ Pocket Guide to Physical Examination and History Taking
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
● Position. Holding patient’s
finger or big toe by its sides,
move it up or down.
Assess discriminative sensations:
● Stereognosis. Ask for identifi-
cation of a common object
placed in patient’s hand.
● Number identification
(graphesthesia). Draw a num-
ber on patient’s palm with
blunt end of a pen and ask the
patient to identify the number.
Lesions in the posterior columns or
sensory cortex impair stereognosis,
number identification, and two-point
discrimination.
● Two-point discrimination. Use
two pins of the sides of a paper
clip to find minimal distance
on pad of patient’s finger at
which two points can be distin-
guished (normally <5 mm). Chapter 17 | The Nervous System 301 REFLEXES Grading Reflexes Grade Description 4+ Hyperactive (clonus must be present) 3+ Brisker than average, not necessarily abnormal 2+ Average, normal 1+ Diminished, low normal 0 No response E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S ● Point localization. Touch skin briefly, and ask patient to open both eyes and identify the place touched. A lesion in the sensory cortex may impair point localization on the contra- lateral side and cause extinction of the touch sensation. ● Extinction. Simultaneously touch opposite, corresponding areas of the body; ask whether the patient feels one touch or two. Biceps (C5, C6) Triceps (C6, C7) Hyperactive deep tendon reflexes, absent abdominal reflexes, and a positive Babinski response in upper motor neuron lesions 302 Bates’ Pocket Guide to Physical Examination and History Taking Supinator (brachioradialis) (C5, C6) Knee (L2, L3, L4) Ankle (S1) Check for clonus if reflexes seem hyperactive. Ankle jerks symmetrically, decreased or absent in peripheral polyneuropathy; slowed ankle jerk in hypothyroidism. CUTANEOUS STIMULATION REFLEXES Abdominal reflexes (upper T8, T9, T10; lower T10, T11, T12) May be absent with upper or lower neuron lesions E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S Chapter 17 | The Nervous System 303 Plantar response (L5, S1), normally flexor Babinski extensor response (big toe fans up) from corticospinal tract lesion Anal Reflex. With a dull object, stroke outward from anus in four quadrants. Watch for anal contraction. Loss of reflex suggests cauda equina lesion at the S2–3–4 level. SPECIAL TECHNIQUES Meningeal Signs. With patient supine, flex head and neck toward chest. Note resistance or pain, and watch for flexion of hips and knees (Brudzinski’s sign). Meningeal irritation in the subarachnoid space may cause resistance or pain on flexion during both maneuvers. Flex one of patient’s legs at hip and knee, then straighten knee. Note resistance or pain (Kernig’s sign). A compressed lumbosacral nerve root also causes pain on straightening the knee of the raised leg. E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S 304 Bates’ Pocket Guide to Physical Examination and History Taking Lumbosacral Radiculopathy: Straight-Leg Raise. With patient supine, raise relaxed and straightened leg, flexing the leg at the hip. Then dorsiflex the foot. Pain and muscle weakness if herniated disc; ipsilateral calf wasting and weak ankle dorsiflexion may also be present. Asterixis. Ask patient to hold both arms forward, with hands cocked up and fingers spread. Watch for 1 to 2 minutes. Sudden brief flexions in liver disease, uremia and hypercapnia. Winging of the Scapula. Ask patient to push against the wall of your hand with a par- tially straightened arm. Inspect scapula. It should stay close to the chest wall. Winging of scapula away from chest wall suggests weakness of the serratus ante- rior muscle, seen in muscular dystrophy or injury to long thoracic nerve. The Stuporous or Comatose Patient. Assess ABCs (airway, breathing, and circulation). See Table 17-7, Metabolic and Structural Coma, p. 319, Table 17-8, Glascow Coma Scale, p. 320, and Table 17-9, Pupils in Comatose Patients, p. 321. E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S Chapter 17 | The Nervous System 305 ● Take pulse, blood pressure, and rectal temperature. ● Establish level of conscious- ness with escalating stimuli. Lethargy, obtundation, stupor, coma However, don’t dilate pupils, and don’t flex patient’s neck if any suspicion of cervical cord injury. E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S Levels of Consciousness Alertness Patient is awake and aware of self and environ- ment. When spoken to in a normal voice, patient looks at you and responds fully and appropriately to stimuli. Lethargy When spoken to in a loud voice, patient appears drowsy but opens eyes and looks at you, re- sponds to questions, and then falls asleep. Obtundation When shaken gently, patient opens eyes and looks at you but responds slowly and is somewhat confused. Alertness and interest in environment are decreased. Stupor Patient arouses from sleep only after painful stim- uli. Verbal responses are slow or absent. Patient lapses into unresponsiveness when stimulus stops. Patient has minimal awareness of self or environment. Coma Despite repeated painful stimuli, patient remains unarousable with eyes closed. No evident re- sponse to inner need or external stimuli is shown. ● Conduct neurological examina- tion, looking for asymmetric findings. NEUROLOGIC EXAMINATION Observe: ● Breathing pattern ● Pupils ● Ocular movements Cheyne-Stokes, ataxic breathing Asymmetric if structural lesions or brain herniation Deviation to affected side in hemispheric stroke 306 Bates’ Pocket Guide to Physical Examination and History Taking E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S Check for the oculocephalic reflex (doll’s eye movements). Holding upper eyelids open, turn head quickly to each side, and then flex and extend patient’s neck. This patient’s head will be turned to her right. In a comatose patient with an intact brainstem, the eyes move in the oppo- site direction, in this case to her left (doll’s eye movements) as below. Very deep coma or a lesion in the mid- brain or pons abolishes this reflex, so eyes do not move. Note posture of body. Decorticate rigidity, decerebrate rigidity, flaccid hemiplegia Test for flaccid paralysis. ● Hold forearms vertically; note wrist positions. ● From 12 to 18 inches above bed, drop each arm. ● Support both knees in a some- what flexed position, and then extend each knee and let leg drop to the bed. ● From a similar starting position, release both legs. A flaccid hand droops to the horizontal. A flaccid arm drops more rapidly. The flaccid leg drops more rapidly. A flaccid leg falls into extension and external rotation. Complete the neurologic and general physical examination. Chapter 17 | The Nervous System 307 Recording Your Findings Recording the Examination—The Nervous System “Mental Status: Alert, relaxed, and cooperative. Thought process coherent. Oriented to person, place, and time. Detailed cognitive testing deferred. Cranial Nerves: I—not tested; II through XII intact. Motor: Good muscle bulk and tone. Strength 5/5 throughout. Cerebellar: Rapid alternating movements (RAMs), finger-to-nose (F→N), heel-to-shin (H→ S) intact. Gait with nor- mal base. Romberg—maintains balance with eyes closed. No pronator drift. Sensory: Pinprick, light touch, position, and vibration intact. Reflexes: 2+ and symmetric with plantar reflexes downgoing.” OR “Mental Status: The patient is alert and tries to answer questions but has dif- ficulty finding words. Cranial Nerves: I—not tested; II—visual acuity intact; visual fields full; III, IV, VI—extraocular movements intact; V motor—temporal and masseter strength intact, sensory corneal reflexes present; VII motor— prominent right facial droop and flattening of right nasolabial fold, left facial movements intact, sensory—taste not tested; VIII—hearing intact bilaterally to whispered voice; IX, X—gag intact; XI—strength of sternomastoid and trapezius muscles 5/5; XII—tongue midline. Motor: strength in right biceps, triceps, iliopsoas, gluteals, quadriceps, hamstring, and ankle flexor and exten- sor muscles 3/5 with good bulk but increased tone and spasticity; strength in comparable muscle groups on the left 5/5 with good bulk and tone. Gait— unable to test. Cerebellar—unable to test on right due to right arm and leg weakness; RAMs, F→N, H→S intact on left. Romberg—unable to test due to right leg weakness. Right pronator drift present. Sensory: decreased sensation to pinprick over right face, arm, and leg; intact on the left. Stereognosis and two-point discrimination not tested. Reflexes (can record in two ways): Suggests left hemispheric CVA in distribution of the left middle cerebral artery, with right sided hemiparesis. Biceps Triceps Brach Knee Ankle Pl RT 2+ 2+ 2+ 2+ 2+ ↓ OR LT 2+ 2+ 2+ 2+ 1+ ↓ R L E XA M I N AT I O N T E C H N I Q U E S 308 Bates’ Pocket Guide to Physical Examination and History Taking Aids to Interpretation Types of StrokeTable 17-1 Assessing patients with stroke involves three fundamental questions: ● What brain area and related vascular territory explain the patient’s findings? ● Is the stroke ischemic or hemorrhagic? ● If ischemic, is the mechanism thrombus or embolus? Stroke is a medical emergency, and timing is of the essence. Answers to these questions are critical to patient outcomes and use of antithrombotic therapies. In acute ischemic stroke, ischemic brain injury begins with a central core of very low perfusion and often irreversible cell death. This core is surrounded by an ischemic penumbra of metabolically disturbed cells that are still potentially viable, depending on restoration of blood flow and duration of ischemia. Because most irreversible damage occurs in the first 3 to 6 hours after onset of symptoms, therapies targeted to the initial 3-hour window achieve the best outcomes, with recovery in up to 50% of patients in some studies. Understanding the pathophysiology of stroke takes dedication, expert supervision to improve techniques of neurological examination, and perseverance. This brief overview is intended to prompt further study and practice. Chapter 17 | The Nervous System 309 Types of Stroke (continued)Table 17-1 Body of caudate Internal capsule Putamen Globus pallidus Uncus Thalamus Anterior cerebral artery Middle cerebral artery Posterior cerebral artery Anterior choroidal artery Lateral ventrical Prefrontal area Premotor area Primary motor cortex Primary somatic sensory cortex Somatic sensory association area Taste area Primary auditory cortex Auditory association area Sensory speech (Wernike's) area Reading compre- hension area Visual association area Visual cortex Motor speech (Broca's) area (continued) 310 Bates’ Pocket Guide to Physical Examination and History Taking Types of Stroke (continued)Table 17-1 Clinical Features and Vascular Territories of Stroke Major Clinical Features Vascular Territory Contralateral leg weakness Anterior circulation—anterior cerebral artery (ACA) Includes stem of circle of Willis connecting internal carotid artery to ACA, and the segment distal to ACA and its anterior choroidal branch Contralateral face, arm >
leg weakness, sensory
loss, field cut, aphasia
(left MCA) or neglect,
apraxia (right MCA)
Anterior circulation—middle cerebral
artery (MCA)
Largest vascular bed for stroke
Contralateral motor or
sensory deficit without
cortical signs
Subcortical circulation—lenticulostriate
deep penetrating branches of MCA
Small vessel subcortical lacunar infarcts
in internal capsule, thalamus, or
brainstem. Four common syndromes:
pure motor hemiparesis; pure sensory
hemianesthesia; ataxic hemiparesis;
clumsy hand—dysarthria syndrome
Contralateral field cut Posterior circulation—posterior cerebral
artery (PCA)
Includes paired vertebral arteries, the
basilar artery, paired posterior cerebral
arteries. Bilateral PCA infarction
causes cortical blindness but preserved
pupillary light reaction.

Chapter 17 | The Nervous System 311
Types of Stroke (continued)Table 17-1
Clinical Features and Vascular Territories
of Stroke (continued)
Major Clinical Features Vascular Territory
Dysphagia, dysarthria,
tongue/palate deviation
and/or ataxia with
crossed sensory/motor
deficits (= ipsilateral face
with contralateral body)
Posterior circulation—brainstem,
vertebral, or basilar artery branches
Oculomotor deficits and/
or ataxia with crossed
sensory/motor deficits
Posterior circulation—basilar artery
Complete basilar artery occlusion—
“locked-in syndrome” with intact
consciousness but inability to speak
and quadriplegia
Source: Adapted from American College of Physicians. Stroke, in Neurology. Medical
Knowledge Self-Assessment Program (MKSAP) 14. Philadelphia: American College of
Physicians, 2006. pp. 52–68.

312 Bates’ Pocket Guide to Physical Examination and History Taking
Facial ParalysisTable 17-2
Distinguish peripheral from central lesions of CN VII by closely
observing movements of the upper face. Because of innervation from
both hemispheres, the movements are preserved in central lesions.
Lesion of Peripheral
Nervous System
Lesion of Central
Nervous System
Side of face
affected
Same side as the
lesion
Side opposite the
lesion
Upper face Unable to wrinkle
forehead, raise
eyebrow, close eye
Movements normal or
slightly weak
Lower face Unable to smile,
show teeth
Same
Common cause Bell’s palsy (injury
to CN VII)
CVA
Motor
cortex
CN VII
peripheral
lesion
Synapses
in the
pons
Facial
nerve
Motor cortex
CN VII
central
lesion
Synapses in
the pons
Facial nerve

Chapter 17 | The Nervous System 313
Motor DisordersTable 17-3
Peripheral
Nervous
System
Disorder
Central
Nervous
System
Disorder*
Parkinsonism
(Basal
Ganglia
Disorder)
Cerebellar
Disorder
Involuntary
movements
Often
fascicu-
lations
No fascicu-
lations
Resting
tremors
Intention
tremors
Muscle
bulk
Atrophy Normal
or mild
atrophy
(disuse)
Normal Normal
Muscle tone Decreased
or absent
Increased,
spastic
Increased,
rigid
Decreased
Muscle
strength
Decreased
or lost
Decreased
or lost
Normal
or slightly
decreased
Normal
or slightly
decreased
Coordina-
tion
Unimpaired,
though
limited by
weakness
Slowed and
limited by
weakness
Good,
though
slowed
and often
tremulous
Impaired,
ataxic
Reflexes
Deep tendon Decreased
or absent
Increased Normal or
decreased
Normal or
decreased
Plantar Flexor or
absent
Extensor Flexor Flexor
Abdominals Absent Absent Normal Normal
* Upper motor neuron.

314 Bates’ Pocket Guide to Physical Examination and History Taking
Involuntary MovementsTable 17-4
Resting static tremors. Fine, “pin-
rolling” tremor seen at rest, usually
disappear with movement; seen
in basal ganglia disorders like
Parkinson’s disease.
Postural tremor. Seen when
maintaining active posture; in
anxiety, hyperthyroidism; also
familial. From basal ganglia
disorder.
Intention tremor. Seen with
intentional movement, absent
at rest; in cerebellar disorders,
including multiple sclerosis
Fasciculations. Fine, rapid flickering
of muscle bundles in lower motor
neuron disorders.
Chorea. Brief, rapid, irregular, jerky;
face, head, arms, or hands (e.g.,
Huntington’s disease)
Athetosis. Slow, twisting, writhing;
face, distal limbs, often with
associated spasticity (e.g., cerebral
palsy)

Chapter 17 | The Nervous System 315
Involuntary Movements (continued)Table 17-4
Oral-facial dyskinesias. Rhythmic,
repetitive, bizarre movements of
face, mouth. Tardive dyskinesias
with prolonged use of psychotropic
drugs such as phenothiazines
Tics. Brief, irregular, repetitive,
coordinated movements (e.g.,
winking, shrugging); in Tourette’s
syndrome, users of phenothiazines,
amphetamines
Dystonia. Grotesque, twisted
postures, often in trunk or,
as shown, in neck (spasmodic
torticollis)

316 Bates’ Pocket Guide to Physical Examination and History Taking
Table 17-5 Disorders of Muscle Tone
Spasticity Rigidity
Location. Upper motor neuron
or corticospinal tract systems.
Location. Basal ganglia system
Description. Increased muscle
tone (hypertonia) that is rate-
dependent. Tone is greater
when passive movement is
rapid, and less when passive
movement is slow. Tone is
also greater at the extremes
of the movement arc. During
rapid passive movement, initial
hypertonia may give way
suddenly as the limb relaxes.
This spastic “catch” and
relaxation is known as “clasp-
knife” resistance.
Description. Increased resistance
that persists throughout the
movement arc, independent
of rate of movement, is called
lead-pipe rigidity. With flexion
and extension of the wrist
or forearm, a superimposed
rachetlike jerkiness is called
cogwheel rigidity.
Common Cause. Stroke,
especially late or chronic stage
Common Cause. Parkinsonism
Flaccidity Paratonia
Location. Lower motor neuron
at any point from the anterior
horn cell to the peripheral
nerves
Location. Both hemispheres,
usually in the frontal lobes
Description. Loss of muscle
tone (hypotonia), causing the
limb to be loose or floppy.
The affected limbs may be
hyperextensible or even
flaillike.
Description. Sudden changes
in tone with passive range
of motion. Sudden loss of
tone that increases the ease
of motion is called mitgehen
(moving with). Sudden
increase in tone making
motion more difficult is called
gegenhalten (holding against).
Common Cause. Guillain–Barré
syndrome; also initial phase
of spinal cord injury (spinal
shock) or stroke
Common Cause. Dementia

Chapter 17 | The Nervous System 317
Table 17-6 Dermatomes
C3 Front of neck
C4
C5 C5
C6 C6
C7 C7
C8 C8
T1
T1
T2
T3
T4
T5
T6
T7
T8
T9
T10
T11
T12
S1 S1
S2,3
L1
L2 L2
L3 L3
L4 L4
L5 L5
C8 Ring and
little fingers
L4 Knee
L1 Inguinal
L5 Anterior
ankle and foot
T4 Nipples
T10 Umbilicus
C2
C3
CN V
DERMATOMES INNERVATED BY POSTERIOR ROOTS
(continued)

318 Bates’ Pocket Guide to Physical Examination and History Taking
Dermatomes (continued)Table 17-6
C2
C3C3 Back of neck
C4
C5
C5C5
C6
C6C6
C6
Thumb
C7
C7C7
C8
C8C8
T1
T1T1
T2
T3
T4
T5
T6
T7
T8
T9
T10
T11
T12
S1
S1S1
S2
S2S2
S3
S4
S5
L1
L2
L3
L4
L4L4
L4, L5, S1
Posterior ankle
and foot
L5
L5L5
C8 Ring and
little fingersS5 Perianal
DERMATOMES INNERVATED BY POSTERIOR ROOTS

Chapter 17 | The Nervous System 319
Table 17-7 Metabolic and Structural Coma
Toxic–Metabolic Structural
Pathophysiology
Arousal centers poisoned or
critical substrates depleted
Lesion destroys or compresses
brainstem arousal areas,
either directly or secondary
to more distant expanding
mass lesions.
Clinical Features
● Respiratory pattern. If
regular, may be normal or
hyperventilation. If irregular,
usually Cheyne-Stokes
Respiratory pattern. Irregular,
especially Cheyne-Stokes or
ataxic breathing. Also with
selected stereotypical patterns
like “apneustic” respiration
(peak inspiratory arrest) or
central hyperventilation.
● Pupillary size and reaction.
Equal, reactive to light. If
pinpoint from opiates or
cholinergics, you may need
a magnifying glass to see the
reaction.
May be unreactive if fixed and
dilated from anticholinergics
or hypothermia
Pupillary size and reaction.
Unequal or unreactive to light
(fixed)
Midposition, fixed—suggests
midbrain compression
Dilated, fixed—suggests com-
pression of CN III
from herniation
● Level of consciousness.
Changes after pupils change
Level of consciousness. Changes
before pupils change
Examples of Cause Examples of Cause
Uremia, hyperglycemia Epidural, subdural, or
intracerebral hemorrhage
Alcohol, drugs, liver failure Cerebral infarct or embolus
Hypothyroidism, hypoglycemia Tumor, abscess
Anoxia, ischemia
Meningitis, encephalitis Brainstem infarct, tumor, or
hemorrhage
Hyperthermia, hypothermia Cerebellar infarct, hemorrhage,
tumor, or abscess

320 Bates’ Pocket Guide to Physical Examination and History Taking
Activity Score
Eye Opening
None 1 = Even to supraorbital pressure
To pain 2 = Pain from sternum/limb/
supraorbital pressure
To speech 3 = Nonspecific response, not
necessarily to command
Spontaneous 4 = Eyes open, not necessarily
aware
___________
Motor Response
None 1 = To any pain; limbs remain
flaccid
Extension 2 = Shoulder adducted and
shoulder and forearm
internally rotated
Flexor response 3 = Withdrawal response or
assumption of hemiplegic
posture
Withdrawal 4 = Arm withdraws to pain,
shoulder abducts
Localizes pain 5 = Arm attempts to remove
supraorbital/chest pressure
Obeys commands 6 = Follows simple commands __________
Verbal Response
None 1 = No verbalization of any type
Incomprehensible 2 = Moans/groans, no speech
Inappropriate 3 = Intelligible, no sustained
sentences
Confused 4 = Converses but confused,
disoriented
Oriented 5 = Converses and is oriented __________
TOTAL (3–15)*
*Interpretation: Patients with scores of 3–8 usually are considered to be in a coma.
Source: Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A
practical scale. Lancet 1974;304(7872):81–84.
Table 17-8 Glasgow Coma Scale

Chapter 17 | The Nervous System 321
Table 17-9 Pupils in Comatose Patients
Small or Pinpoint Pupils Bilaterally small pupils (1–2.5 mm)
suggest (1) damage to the sympathetic
pathways in the hypothalamus or
(2) metabolic encephalopathy (a
diffuse failure of cerebral function
from drugs and other causes). Light
reactions are usually normal.
Pinpoint pupils (<1 mm) suggest (1) a hemorrhage in the pons or (2) the effects of morphine, heroin, or other narcotics. Use a magnifying glass to see the light reactions. Midposition Fixed Pupils Midposition or slightly dilated pupils (4–6 mm) and fixed to light suggest damage in the midbrain. Large Pupils Bilaterally fixed and dilated pupils in severe anoxia with sympathomimetic effects, may be seen with cardiac arrest. They also result from atropinelike agents, phenothiazines, or tricyclic antidepressants. One Large Pupil One fixed and dilated pupil warns of herniation of the temporal lobe, causing compression of the oculomotor nerve and midbrain. Also seen in diabetes with CN III infarction. 323 C H A P T E R 18Assessing Children: Infancy Through Adolescence Child Development Children display tremendous variations in physical, cognitive, and social development compared with adults. CCChilddd DDeevveeloopppmmennt Key Principles of Child Development ◗ Child development proceeds along a predictable pathway marked by devel- opmental milestones. ◗ The range of normal development is wide. Children mature at different rates. ◗ Various physical, psychological, social, and environmental factors, as well as diseases, can affect child development and health. For example, chronic dis- eases, child abuse, and poverty can contribute to detectable physical abnor- malities and influence the rate and course of developmental advancement. ◗ The child’s developmental level affects how you conduct the medical history and physical examination. The Health History The child’s history follows the same outline as the adult’s history, with certain additions presented here. Identifying Data. Record date and place of birth, nickname, and first names of parents (and last name of each, if different). Chief Complaints. Determine if they are the concerns of the child, the parent(s), a schoolteacher, or some other person. Present Illness. Determine how each family member responds to the child’s symptoms, why he or she is concerned, and whether the illness may provide for the child any secondary gain. 324 Bates’ Pocket Guide to Physical Examination and History Taking History Birth History. This is especially important when neurologic or devel- opmental problems are present. Get hospital records if necessary. ● Prenatal—maternal health: medications; tobacco, drug, and alcohol use; weight gain; duration of pregnancy ● Natal—nature of labor and delivery, birth weight, Apgar scores at 1 and 5 minutes ● Neonatal—resuscitation efforts, cyanosis, jaundice, infections, bonding Feeding History. This is particularly important with either under- nutrition or obesity. ● Breast-feeding—frequency and duration of feeds, difficulties, timing and method of weaning ● Bottle-feeding—type; amount; frequency; vomiting; colic; diarrhea ● Vitamins, iron, and fluoride supplements; introduction of solid foods ● Eating habits—types and amounts of food eaten, parental attitudes and responses to feeding problems Growth and Developmental History. This is particularly important with delayed growth or development and behavioral disturbances. ● Physical growth—weight and height at all ages; head circumference at birth and younger than 2 years; periods of slow or rapid growth ● Developmental milestones—ages child held head up, rolled over, sat, stood, walked, and talked ● Speech development, performance in preschool and school ● Social development—day and night sleeping patterns; toilet training; habitual behaviors; discipline problems; school behavior; relationships with family and peers Chapter 18 | Assessing Children: Infancy Through Adolescence 325 Current Health Status Allergies. Pay particular attention to history of eczema, urticaria, perennial allergic rhinitis, asthma, food intolerance, insect hyper- sensitivity, and recurrent wheezing. Immunizations. Include dates given and any untoward reactions. Screening Tests. These are likely to vary according to the child’s medical and social conditions. Include newborn screening results, anemia screening, blood lead, sickle cell disease, vision, hearing, developmental screening, and others (e.g., tuberculosis). Health Promotion and Counseling: Evidence and Recommendations 1. Age-appropriate developmental achievement of the child ● Physical (maturation, growth, puberty) ● Motor (gross and fine motor skills) ● Cognitive (milestones, language, school performance) ● Emotional (self-efficacy, self-esteem, independence, morality) ● Social (social competence, self-responsibility, integration with family and community) 2. Health supervision visits (per health supervision schedule) ● Periodic assessment of medical and oral health ● Adjustment of frequency for children or families with special needs 3. Integration of physical examination findings 4. Immunizations 5. Screening procedures 6. Anticipatory guidance ● Healthy habits ● Nutrition and healthy eating ● Emotional and mental health ● Oral health ● Safety and prevention of injury ● Sexual development and sexuality ● Self-responsibility and efficacy ● Family relationships (interactions, strengths, supports) ● Prevention or recognition of illness ● Prevention of risky behaviors and addictions ● School and vocation ● Peer relationships ● Community interactions 7. Partnership between health provider, child, and family 326 Bates’ Pocket Guide to Physical Examination and History Taking Assessing Newborns Sequence of Examination The sequence of examination varies according to the child’s age and comfort level. ◗ For infants and young children, perform nondisturbing maneuvers early and potentially distressing maneuvers toward the end. For example, palpate the head and neck and auscultate the heart and lungs early; examine the ears and mouth and palpate the abdomen near the end. If the child reports pain in an area, examine that part last. ◗ For older children and adolescents, use the same sequence as with adults, except examine the most painful areas last. E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S IMMEDIATE ASSESSMENT AT BIRTH Listen to the anterior thorax with your stethoscope. Palpate the abdomen. Inspect the head, face, oral cavity, extremities, genitalia, and perineum. Apgar Score. Score each newborn according to the following table, at 1 and 5 minutes after birth, according to the 3-point scale (0, 1, or 2) for each component. If the 5-minute score is 8 or more, pro- ceed to a more complete examination. Techniques of Examination Chapter 18 | Assessing Children: Infancy Through Adolescence 327 E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S The Apgar Scoring System Assigned Score Clinical Sign 0 1 2 Heart rate Absent <100 >100
Respiratory
effort
Absent Slow and irregular Good; strong
Muscle tone Flaccid Some flexion of the
arms and legs
Active
movement
Reflex
irritability*
No responses Grimace Crying vigor-
ously, sneeze,
or cough
Color Blue, pale Pink body, blue
extremities
Pink all over
1-Minute Apgar Score 5-Minute Apgar Score
8–10 Normal 8–10 Normal
5–7
0–4
Some nervous
system
depression
Severe depres-
sion, requir-
ing immediate
resuscitation
0–7 High risk for
subsequent
central ner-
vous system
and other
organ system
dysfunction
*Reaction to suction of nares with bulb syringe.
Gestational Age and Birth Weight.
Classify newborns according to their
gestational age and birth weight.
Classification by Gestational Age and Bir th Weight
Gestational Age
Classification Gestational Age
◗ Preterm
◗ Term
◗ Postterm
<37 wks (<259th day) 37–42 wks >42 wks (>294th day)
Birth Weight
Classification Weight
◗ Extremely low birth weight
◗ Very low birth weight
◗ Low birth weight
◗ Normal birth weight
<1,000 g <1,500 g <2,500 g ≥2,500 g 328 Bates’ Pocket Guide to Physical Examination and History Taking Assessment Several Hours After Birth During the first day of life, newborns should have a comprehensive examination following the technique outlined under “Infants.” Wait until 1 or 2 hours after a feeding, when the newborn is more respon- sive. Ask parents to remain. Observe the baby’s color, size, body proportions, nutritional status, posture, respirations, and movements of the head and extremities. Most newborns are bowlegged, reflecting their curled up intrauterine position. Inspect the newborn’s umbilical cord to detect abnormalities. Normally, there are two thick- walled umbilical arteries and one larger but thin-walled umbilical vein, which is usually located at the 12-o’clock position. A single umbilical artery may be asso- ciated with congenital anomalies. Umbilical hernias in infants are from a defect in the abdominal wall. The neurologic screening examination of all newborns should include assessment of mental status, gross and fine motor function, tone, cry, deep tendon reflexes, and primitive reflexes. Signs of severe neurologic disease include extreme irritability; persistent asymmetry of posture or extension of extremities; constant turning of head to one side; marked extension of head, neck, and extremities (opisthotonus); severe flaccidity; and limited pain response. AAAssseessssmmeeentt SSeevverraall HHouuurss Afftteer BBirtthh E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S Newborn Classifications Category Abbreviation Percentile Small for gestational age SGA <10th Appropriate for gestational age AGA 10–90th Large for gestational age LGA >90th

Chapter 18 | Assessing Children: Infancy Through Adolescence 329
Assessing InfantsAAAssseessssinnggg Innfaaannts
MENTAL AND PHYSICAL STATUS
Observe the parents’ affect when
talking about the baby and their
manner of holding, moving, and
dressing the baby. Observe a breast or
bottle feeding. Determine attainment
of developmental milestones,
optimally using a standardized
developmental screening test.
Common causes of developmental
delay include abnormalities in
embryonic development, hereditary
and genetic disorders, environ-
mental and social problems, other
pregnancy or perinatal problems,
childhood diseases such as infec-
tion (e.g., meningitis), trauma, and
severe chronic disease.
GENERAL SURVEY
Growth, reflected in increases
in height and weight within
expected limits, is an excellent
indicator of health during infancy
and childhood. Deviations from
normal may be early indications
of an underlying problem. To
assess growth, compare a child’s
parameters with respect to:
Failure to thrive is a condition
reflecting significantly low weight
gain (e.g., below 2nd percentile) for
gestational-age corrected age and
sex. Causes can be environmental or
psychosocial, or various gastrointes-
tinal, neurologic, cardiac, endocrine,
renal, and other diseases.
● Normal values according to
age and sex
● Prior readings to assess trends
Measures above the 97th or below
the 3rd percentile, or recent rises
or falls from prior levels, require
investigation.
Height and Weight. Plot each
child’s height and weight on standard
growth charts to determine progress.
Reduced growth in height may indi-
cate endocrine disease, other causes
of short stature, or, if weight is also
low, other chronic diseases.
Head Circumference. Determine
head circumference at every physical
examination during the first 2 years.
Premature closure of the sutures
or microcephaly may cause small
head size. Hydrocephalus, subdural
hematoma, or, rarely, brain tumor or
inherited syndromes may cause an
abnormally large head size.
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330 Bates’ Pocket Guide to Physical Examination and History Taking
VITAL SIGNS
Blood Pressure. Measure
blood pressure at least once during
infancy. Although the hand-held
method is shown here, the most
easily used measure of systolic
blood pressure in infants and young
children is obtained with the
Doppler method.
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
Causes of Sustained Hyper tension in Children
Newborn Middle Childhood
Renal artery disease (stenosis,
thrombosis)
Congenital renal malformations
Coarctation of the aorta
Primary hypertension
Renal parenchymal or arterial disease
Coarctation of the aorta
Infancy and Early Childhood Adolescence
Renal parenchymal or artery disease
Coarctation of the aorta
Primary hypertension
Renal parenchymal disease
Drug induced
Pulse. The heart rate is
quite variable and will increase
markedly with excitement, crying,
or anxiety. Therefore, measure
the pulse when the infant or child
is quiet.
Tachycardia (>180–200 beats per
minute) usually indicates paroxysmal
supraventricular tachycardia. Bradycar-
dia may result from serious underlying
disease.
Respiratory Rate. The
respiratory rate has a very wide
range and is more responsive to
illness, exercise, and emotion
than in adults.
Respiratory diseases such as bronchi-
olitis or pneumonia may cause rapid
respirations (up to 80–90 breaths
per minute), and increased work of
breathing.

Chapter 18 | Assessing Children: Infancy Through Adolescence 331
THE SKIN
Assess:
● Texture and appearance
● Vasomotor changes
● Pigmentation (e.g.,
Mongolian spots)
● Hair (e.g., lanugo)
● Common skin conditions
(e.g., milia, erythema toxicum)
● Color
● Turgor
Cutis marmorata
Acrocyanosis; cyanotic congenital heart
disease
Café-au-lait spots
Midline hair tuft on back
Herpes simplex
Jaundice can be from hemolytic disease.
Dehydration
THE HEAD
Examine sutures and fontanelles
carefully.
Anterior fontanelle
Posterior fontanelle
Lambdoidal suture
Sagittal
suture
Coronal
suture
Metopic
suture
Head small with microcephaly, enlarged
with hydrocephaly; fontanelles full and
tense with meningitis, closed with
microcephaly, separated with increased
intracranial pressure (hydrocephaly,
subdural hematoma, and brain tumor)
Swelling from subperiosteal hemor-
rhage (cephalohematoma) does not
cross suture lines; swelling from
bleeding associated with a fracture
does.
Check the face for symmetry.
Examine for an overall impression
of the facies; comparing with the
faces of the parents is helpful.
Abnormal facies occurs in a child with
a constellation of facial features that
appear abnormal. A variety of
syndromes can cause abnormal facies
(see table below for evaluation).
Examples include Down syndrome and
fetal alcohol syndrome.
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332 Bates’ Pocket Guide to Physical Examination and History Taking
THE EYES
Newborns and young infants
may look at your face and follow
a bright light if you catch them
while alert. Normal visual mile-
stones are as follows:
Nystagmus, strabismus
Leukocoria is a white papillary reflex
(instead of the normal red papillary
reflex). It can be a sign of a rare tumor
called retinoblastoma.
THE EARS
Check position, shape, and
features.
Small, deformed or low-set auricles
may indicate associated congenital
defects, especially renal disease.
Pearls to Evaluate Potentially Abnormal Facies
Carefully review the history, especially the family history, pregnancy, and
perinatal history.
Note abnormalities, especially of growth, development, or dysmorphic somatic
features.
Measure and plot percentiles, especially of head circumference, height, and
weight.
Consider the three mechanisms of facial dysmorphogenesis:
◗ Deformations from intrauterine constraint
◗ Disruptions from amniotic bands or fetal tissue
◗ Malformations from an intrinsic abnormality (either face/head or brain)
Examine parents and siblings (similarity may be reassuring but might point to
a familial disorder).
Determine whether facial features fit a recognizable syndrome. Compare
against references, pictures, tables, and databases.
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
Visual Milestones of Infancy
Birth Blinks, may regard face
1 month Fixes on objects
1½–2 months Coordinated eye movements
3 months Eyes converge, baby reaches
12 months Acuity around 20/50

Chapter 18 | Assessing Children: Infancy Through Adolescence 333
Signs That an Infant Can Hear
Age Signs
0–2 months Startle response and blink to a sudden noise
Calming down with soothing voice or music
2–3 months Change in body movements in response to sound
Change in facial expression to familiar sounds
3–4 months Turning eyes and head to sound
6–7 months Turning to listen to voices and conversation
THE NOSE
Test patency of the nasal pas-
sages by occluding alternately
each nostril while holding the
infant’s mouth closed.
With choanal atresia, the baby cannot
breathe if one nostril is occluded.
THE MOUTH AND PHARYNX
Inspect (with a tongue blade
and flashlight) and palpate.
Supernumerary teeth, Epstein’s pearls
You may see a whitish covering
on the tongue. If this coating is
from milk, you can easily remove
it by scraping or wiping it away.
Oral candidiasis (thrush)
Vesicles in the mouth can be caused by
enteroviral infections and herpes simplex
virus infections.
THE NECK
Palpate the lymph nodes, and
assess for any additional masses
(e.g., congenital cysts).
Lymphadenopathy is usually from viral or
bacterial infections.
Other neck masses include malignancy,
branchial cleft or thyroglossal duct cysts,
and periauricular cysts and sinuses.
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
Jugulogastric
node
Epidermoid cyst
Submandibular
node
Submental node
Cystic hygroma
Thyroglossal
duct cyst
Parotid nodes
Occipital node
Retroauricular
(mastoid) nodes
Superior deep
cervical nodes
Middle deep
cervical nodes
Posterior
cervical nodes
2nd branchial
cleft cyst
Supraclavicular
node
Inferior deep
cervical nodes
Anterior
cervical nodes

334 Bates’ Pocket Guide to Physical Examination and History Taking
THE THORAX AND LUNGS
Carefully assess respirations and
breathing pattern.
Apnea
Do not rush to the stethoscope,
but observe the patient care-
fully first.
Upper respiratory infections may cause
nasal flaring.
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
Examination of the Lungs in Infants—Before You
Touch the Child!
Assessment Possible Findings Explanation
General
appearance
Inability to feed or smile
Lack of consolability
Lower respiratory
infections below the
vocal cords (e.g., bron-
chiolitis, pneumonia) are
common in infants.
Respiratory
rate
Tachypnea Cardiac or respiratory
disease
Color Pallor or cyanosis Cardiac or pulmonary disease
Nasal
component of
breathing
Nasal flaring
(enlargement of both
nasal openings during
inspiration)
Upper or lower
respiratory infection
Audible
breath sounds
Grunting (repetitive, short
expiratory sound)
Wheezing (musical
expiratory sound)
Stridor (high-pitched,
inspiratory noise)
Obstruction (lack of
breath sounds)
Acute stridor is a potentially
serious condition with
causes such as laryngo-
tracheobronchitis (croup),
epiglottitis, bacterial
tracheitis, foreign body,
vascular ring
Work of
breathing
Nasal flaring
Grunting
Retractions (chest
indrawing):
Supraclavicular
(motion of soft tissue
above clavicles)
Intercostal (indraw
ing of the skin
between ribs)
Subcostal (just below
the costal margin)
In infants, abnormal
work of breathing com-
bined with abnormal
findings on ausculta-
tion is the best finding
for ruling in pneumonia.

Chapter 18 | Assessing Children: Infancy Through Adolescence 335
Distinguishing Upper Air way From Lower Air way Sounds
Technique Upper Airway Lower Airway
Compare sounds from
nose/stethoscope
Same sounds Often different
sounds
Listen to harshness of
sounds
Harsh and loud Variable
Note symmetry
(left/right)
Symmetric Often asymmetric
Compare sounds at
different locations
(higher or lower)
Sounds louder as
stethoscope is
moved up chest
Sounds louder
lower in chest
Inspiratory vs. expiratory Almost always
inspiratory
Often has expiratory
phase
THE HEART
Inspection. Observe care-
fully for any cyanosis. The best
body part to assess cyanosis is the
tongue or inside of the mouth.
At birth: Transposition of the great
arteries; pulmonary valve atresia or
stenosis
Within a few days of birth: The above;
also total anomalous pulmonary venous
return, hypoplastic left heart
Palpation. Palpate the periph-
eral pulses. The point of maximal
impulse (PMI) is not always
palpable in infants. Thrills are
palpable when enough turbu-
lence is within the heart or
great vessels.
No or diminished femoral pulses sug-
gest coarctation of the aorta. Weak or
thready, difficult-to-feel pulses may
reflect myocardial dysfunction and
heart failure.
Auscultation. Heart rhythm
is evaluated more easily in infants
by listening to the heart than by
feeling the peripheral pulses.
The most common dysrhythmia in
children is paroxysmal supraventricular
tachycardia.
Heart Sounds. Evaluate S1
and S2 carefully. They are
normally crisp.
A louder-than-normal pulmonic compo-
nent suggests pulmonary hypertension.
Persistent splitting of S2 may indicate
atrial septal defect.
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336 Bates’ Pocket Guide to Physical Examination and History Taking
THE BREASTS
The breasts of males and females
may be enlarged for months
after birth as a result of maternal
estrogen, and even engorged for
1 to 2 weeks with a white liquid.
THE ABDOMEN
You will find it easy to palpate an
infant’s abdomen, because infants
like being touched. Palpate the
liver and spleen and assess for
hepatosplenomagaly.
Abnormal abdominal masses can be
associated with kidney, bladder, or
bowel tumors. In pyloric stenosis, deep
palpation in the right upper quadrant or
midline can reveal an “olive,” or a 2-cm
firm pyloric mass.
MALE GENITALIA
Inspect with the infant supine. Common scrotal masses are hydroceles
and inguinal hernias.
In 3% of infants, one or both tes-
tes cannot be felt in the scrotum
or inguinal canal. Try to milk the
testes into the scrotum.
Inability to palpate testes, even with
maneuvers, indicates undescended
testicles.
FEMALE GENITALIA
In females, genitalia may be
prominent for several months
after birth from the effects of
maternal estrogen.
Ambiguous genitalia involves masculin-
ization of the female external genitalia.
THE MUSCULOSKELETAL SYSTEM
Examine the extremities by
inspection and palpation to
detect congenital abnormalities,
particularly in the hands, spine,
hips, legs, and feet.
Skin tags, remnants of digits, polydactyly
(extra fingers), or syndactyly (webbed
fingers) are congenital defects. Fracture
of the clavicle can occur during a difficult
delivery.
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S

Chapter 18 | Assessing Children: Infancy Through Adolescence 337
Examine the hips carefully at
each visit for signs of dislocation.
There are two major techniques:
one to test for a posteriorly dis-
located hip (Ortolani test) and
the other to test for the ability to
sublux or dislocate an intact but
unstable hip (Barlow test).
Congenital hip dysplasia may have a
positive Ortolani or Barlow test, particu-
larly during the first 3 months of age.
With a hip dysplasia, you feel a “clunk.”
ORTOLANI TEST BARLOW TEST
Some normal infants exhibit
twisting or torsion of the tibia
inwardly or outwardly on its
longitudinal axis.
Pathologic tibial torsion occurs only in
association with deformities of the feet
or hips.
THE NERVOUS SYSTEM
Evaluate the developing central
nervous system by assessing
infantile automatisms, called
primitive reflexes.
Suspect a neurologic or developmental
abnormality if primitive reflexes are
absent at appropriate age, present lon-
ger than normal, asymmetric, or associ-
ated with posturing or twitching.
Neurologic and developmental abnor-
malities often co-exist. Hypotonia can
be a sign of a variety of neurologic
abnormalities.
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338 Bates’ Pocket Guide to Physical Examination and History Taking
Assessing Children (1 to 10 Years)
Tips for Interviewing Children
MENTAL AND PHYSICAL STATUS
In children 1 to 5 years, observe
the degree of sickness or well-
ness, mood, nutritional state,
speech, cry, facial expression,
and developmental skills. Note
parent–child interaction, includ-
ing separation tolerance, affec-
tion, and response to discipline.
This overall examination can uncover
evidence of chronic disease, developmen-
tal delay, social or environmental disor-
ders, and family problems.
In children 6 to 10 years, determine
orientation to time and place,
factual knowledge, and language
and number skills. Observe motor
skills used in writing, tying laces,
buttoning, cutting, and drawing.
Observing children performing tasks
can reveal signs of inattentiveness or
impulsivity, which may indicate attention
deficit disorder.
Body Mass Index for Age.
Age- and sex-specific charts are
now available to assess body mass
index (BMI) in children.
Underweight is <5th percentile, at risk of overweight is ≥85th percentile, and overweight is ≥95th percentile. E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S ◗ Establish rapport. Refer to children by name and meet them on their own level. Maintain eye contact at their level (e.g., sit on the floor if needed). Participate in play and talk about their interests. ◗ Work with families. Ask simple, open-ended questions such as “Are you sick? Tell me about it,” followed by more specific questions. Once the par- ent has started the conversation, direct questions back to the child. Also observe how parents interact with the child. ◗ Identify multiple agendas. Your job is to discover as many perspectives and agendas as possible. ◗ Use the family as the key resource. View parents as experts in the care of their child and you as their consultant. ◗ Note hidden agendas. As with adults, the chief complaint may not relate to the real reason the parent has brought the child to see you. The following discussion focuses on those areas of the comprehensive physical examination that are different for children than for infants and for adults. Chapter 18 | Assessing Children: Infancy Through Adolescence 339 BLOOD PRESSURE Hypertension during childhood is more common than previously thought. Recognizing, confirm- ing, and appropriately managing it is important. Blood pressure readings should be part of the physical examination of every child older than 2 years. Proper cuff size is essential for accurate determination of blood pressure in children. The most frequent “cause” of elevated blood pressure in children is probably an improperly performed examination, often from an incorrect cuff size. Causes of sustained hypertension in child- hood include renal disease, coarctation of the aorta, and primary hypertension. Hypertension is often related to child- hood obesity. THE EYES Test visual acuity in each eye and determine whether the gaze is conjugate or symmetric. Strabismus can lead to amblyopia Myopia or hyperopia often present in school-aged children. SPECIAL TECHNIQUE The corneal light reflex test (left) and the cover–uncover test (right) are particularly use- ful in young children. Any difference in visual acuity between eyes is abnormal. E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S 340 Bates’ Pocket Guide to Physical Examination and History Taking THE EARS Examine the ear canal and drum. There are two positions for the child (lying down or sitting), and also two ways to hold the otoscope, as illustrated. Pain on movement of the pinna occurs with otitis externa. Pneumatic Otoscope. Learn to use a pneumatic oto- scope to improve accuracy of diagnosis of otitis media. ● Insert the speculum, obtain- ing a proper seal. Acute otitis media involves a red and bulging tympanic membrane. E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S Visual Acuity Age Visual Acuity 3 months Eyes converge, baby reaches 12 months ∼20/200 Younger than 4 years 20/40 4 years and older 20/30 Chapter 18 | Assessing Children: Infancy Through Adolescence 341 ● When air is introduced into the normal ear canal, the tym- panic membrane and its light reflex move inward. When air is removed, the tympanic membrane moves outward toward you. Diminished movement of tympanic membrane with acute otitis media; no movement with otitis media with effusion. THE MOUTH AND PHARYNX For anxious or young children, leave this examination toward the end. The best technique for a tongue blade is to push down and pull slightly forward toward you while the child says “ah.” Do not place the blade too far posteriorly, eliciting a gag reflex. A common cause of a strawberry tongue, red uvula, and pharyngeal exudate is streptococcal pharyngitis. Examine the teeth for the tim- ing and sequence of eruption, number, character, condition, and position. Abnormalities of the enamel may reflect local or general disease. Carefully inspect the inside of the upper teeth, as shown. Nursing bottle caries; dental caries; stain- ing of the teeth, which may be intrinsic or extrinsic Dental caries are the most common health problem of children and are particularly prevalent in impoverished children. E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S 342 Bates’ Pocket Guide to Physical Examination and History Taking Look for abnormalities of tooth position. Malocclusion Note the size, position, sym- metry, and appearance of the tonsils. Peritonsillar abscess THE HEART A challenging aspect to car- diac examination of children is evaluation of heart murmurs, particularly distinguishing com- mon benign murmurs from unusual or pathologic ones. Most children have one or more functional, or benign, heart murmurs at some point in time (see below). See Table 18-4, Characteristics of Pathologic Heart Murmurs, pp. 351–352. Still's Carotid bruit Venous hum Pulmonary flow Location of Benign Heart Murmurs in Children THE ABDOMEN Most children are ticklish when you first place your hand on their abdomens for palpation. This reaction tends to disap- pear, particularly if you distract the child. A pathologically enlarged liver in chil- dren usually is palpable more than 2 cm below the costal margin, has a round, firm edge, and often is tender. E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S Chapter 18 | Assessing Children: Infancy Through Adolescence 343 MALE GENITALIA There is an art to palpation of the young boy’s scrotum and testes, because many have an active cremasteric reflex caus- ing the testes to retract upward into the inguinal canal and appear undescended. A useful technique is to have the boy sit cross-legged on the examining table. In precocious puberty, the penis and tes- tes are enlarged, with signs of pubertal changes. A painful testicle requires rapid treat- ment and may indicate torsion. Inguinal hernias in older boys present as they do in adult men. FEMALE GENITALIA Use a calm, gentle approach, including a developmentally appropriate explanation. Examine the genitalia in an efficient and systematic manner. The normal hymen can have various configurations. Vaginal discharge in early childhood can result from perineal irritation (e.g., from bubble baths, soaps), foreign body, vaginitis, or sexually transmitted infections from sexual abuse. Vaginal bleeding, abrasions, or signs of trauma to the external genitalia can result from sexual abuse. E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S 344 Bates’ Pocket Guide to Physical Examination and History Taking THE MUSCULOSKELETAL SYSTEM Abnormalities of the upper extremities are rare in the absence of injury. To assess the lower extremities, observe the child standing and walking barefoot, and ask the child to touch the toes, rise from sit- ting, run a short distance, and pick up objects. You will detect most abnormalities by watching carefully. A screening musculoskeletal examina- tion for children participating in sports can detect injuries or abnormalities that may result in problems during athletics. THE NERVOUS SYSTEM Beyond infancy, the neurologic examination includes the com- ponents evaluated in adults. Again, combine the neurologic and developmental assessments. You can turn this into a game with the child to assess optimal development and neurologic performance. Delayed language or cognitive skills can be due to neurologic disease as well as developmental disorders. Soft neurological signs can suggest minor developmental abnormalities. Assessing Adolescents The key to successfully examining teens is a comfortable, confidential environment that makes the examination relaxed and informative. Adolescents are more likely to open up when the interview focuses on them rather than on their problems. Consider the patient’s cognitive and social development when deciding issues of privacy, parental involvement, and confidentiality. Explain to both teens and parents that the purpose of confidentiality is to improve health care, not keep secrets. Your goal is to help adoles- cents bring their concerns or questions to their parents. Never make confidentiality unlimited, however. Always state to teens explicitly that you may need to act on information that makes you concerned about safety. E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S AAAssseessssinnggg AAdoooleescceents Chapter 18 | Assessing Children: Infancy Through Adolescence 345 The physical examination of the adolescent is similar to that of the adult. Keep in mind issues particularly relevant to teens, such as puberty, growth, development, family and peer relationships, sexuality, decision making, and risk behaviors. For more details on specific tech- niques of examination, the reader should refer to the corresponding chapter for the regional examination of interest or concern. Following are special areas to highlight when examining adolescents. THE BREASTS Assess normal maturational development. See Table 18-5, Sex Maturity Ratings in Girls: Breasts, p. 353. SPECIAL TECHNIQUE Testing for Scoliosis. Inspect any child who can stand for sco- liosis. Make sure the child bends forward with the knees straight (Adams’ bend test). Evaluate any asymmetry in positioning or gait. If you detect scoliosis, use a scolio meter to test for the degree of scoliosis. MALE AND FEMALE GENITALIA An important goal when examin- ing adolescent males and females is to assign a sexual maturity rating, regardless of chronologic age. See Table 18-6, Sex Maturity Ratings in Boys, pp. 354–355, and Table 18-7, Sex Maturity Ratings in Girls: Pubic Hair, p. 356. E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S 346 Bates’ Pocket Guide to Physical Examination and History Taking Recording the Physical Examination— The Pediatric Patient Brian is a chubby, active, and energetic toddler. He plays with the reflex ham- mer, pretending it is a truck. He appears closely bonded with his mother, look- ing at her occasionally for comfort. She seems concerned that Brian will break something. His clothes are clean. Vital Signs. Ht 90 cm (90th percentile). Wt 16 kg (>95th percentile). BMI 19.8
(>95th percentile). Head circumference 50 cm (75th percentile). BP 108/58.
Heart rate 90 and regular. Respiratory rate 30; varies with activity. Tempera-
ture (ear) 37.5°C. Obviously no pain.
Skin. Normal except for bruises on legs, and patchy, dry skin over external
surface of elbows.
HEENT. Head: Normocephalic; no lesions. Eyes: Difficult to examine because
he won’t sit still. Symmetric with normal extraocular movements. Pupils 4 to
5 mm constricting. Discs difficult to visualize; no hemorrhages noted. Ears:
Normal pinna; no external abnormalities. Normal external canals and tym-
panic membranes (TMs). Nose: Normal nares; septum midline. Mouth: Several
darkened teeth on inside surface of upper incisors. One clear cavity on upper
right incisor. Tongue normal. Cobblestoning of posterior pharynx; no exudates.
Tonsils large but adequate gap (1.5 cm) between them.
Neck. Supple, midline trachea, no thyroid palpable.
Lymph Nodes. Easily palpable (1.5 to 2 cm) tonsillar lymph nodes bilaterally.
Small (0.5 cm) nodes in inguinal canal bilaterally. All lymph nodes mobile and
nontender.
Lungs. Good expansion. No tachypnea or dyspnea. Congestion audible, but
seems to be upper airway (louder near mouth, symmetric). No rhonchi, rales,
or wheezes. Clear to auscultation.
Cardiovascular. PMI in 4th or 5th interspace and midsternal line. Normal S1
and S2. No murmurs or abnormal heart sounds. Normal femoral pulses;
dorsalis pedis pulses palpable bilaterally.
(continued)
Recording Your Findings
The format of the pediatric medical record is the same as that of the
adult. Thus, although the sequence of the physical examination may
vary, convert your written findings back to the traditional format.
E XA M I N AT I O N T E C H N I Q U E S

Chapter 18 | Assessing Children: Infancy Through Adolescence 347
Breasts. Normal, with some fat under both.
Abdomen. Protuberant but soft; no masses or tenderness. Liver span 2 cm below
right costal margin (RCM) and not tender. Spleen and kidneys not palpable.
Genitalia. Tanner I circumcised penis; no pubic hair, lesions, or discharge.
Testes descended, difficult to palpate because of active cremasteric reflex.
Normal scrotum both sides.
Musculoskeletal. Normal range of motion of upper and lower extremities and
all joints. Spine straight. Gait normal.
Neurologic. Mental Status: Happy, cooperative child. Developmental: Gross
motor—Jumps and throws objects. Fine motor—Imitates vertical line. Lan-
guage—Does not combine words; single words only, three to four noted during
examination. Personal–social—Washes face, brushes teeth, and puts on shirt.
Overall—Normal, except for language, which appears delayed. Cranial Nerves:
Intact, althwough several difficult to elicit. Cerebellar: Normal gait; good bal-
ance. Deep tendon reflexes (DTRs): Normal and symmetric throughout with
downgoing toes. Sensory: Deferred.
E XA M I N AT I O N T E C H N I Q U E S

348 Bates’ Pocket Guide to Physical Examination and History Taking
Classification of Newborn’s Level of MaturityTable 18-1
25 27 29 31 33 35 37 39 41 43 45
5
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3
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Weight Small for Gestational Age (SGA) = Birth weight <10th percentile on the intrauterine growth curve Weight Appropriate for Gestational Age (AGA) = Birth weight within the 10th and 90th percentiles on the intrauterine growth curve Weight Large for Gestational Age (LGA) = Birth weight >90th
percentile on the intrauterine growth curve
Level of intrauterine growth based on birth weight and gestational age of liveborn,
single, white infants. Point A represents a premature infant, while point B indicates
an infant of similar birth weight who is mature but small for gestational age; the
growth curves are representative of the 10th and 90th percentiles for all of the
newborns in the sampling.
Adapted from Sweet YA. Classification of the low-birth-weight infant. In: Klaus
MH, Fanaroff AA. Care of the High-Risk Neonate, 3rd ed. Philadelphia: WB
Saunders, 1986. Reproduced with permission.
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< 4 8 h o u rs a ft er d el iv er y. 2 B y h is to ry a n d a pp ro pr ia te p h ys ic al e xa m in at io n : if s u sp ic io u s, b y sp ec ifi c o b je ct iv e d ev el o pm en t te st in g. 3 A t ea ch v is it , a co m pl et e ph ys ic al e xa m in at io n is e ss en ti al , w it h in fa n t to ta lly u n cl o th ed , o ld er c h ild u n d re ss ed a n d s u it ab ly d ra pe d . K ey : • = t o b e pe rf o rm ed S = s u b je ct iv e, b y h is to ry O = o b je ct iv e, b y a st an d ar d t es ti n g m et h o d A d ap te d f ro m R ec o m m en d at io n s F o r P re ve n ti ve P ed ia tr ic H ea lt h C ar e pr o m u lg at ed b y th e A m er ic an A ca d em y o f P ed ia tr ic s C o m m it te e o n P ra ct ic e an d A m b u la to ry M ed ic in e, 1 9 9 9 . 349 350 Bates’ Pocket Guide to Physical Examination and History Taking Hypertension in ChildhoodTable 18-3 Hypertension can start in childhood. Although young children with elevated blood pressure are more likely to have a renal, cardiac, or endocrine cause older children and adolescents with hypertension are most likely to have primary or essential hypertension. Hypertension is often related to obesity. This child developed hypertension before adolescence, and it “tracked” into adulthood. Children tend to remain in the same percentile for blood pressure as they grow. This tracking of blood pressure continues into adulthood, supporting the concept that adult essential hypertension begins during childhood. The consequences of untreated hypertension can be severe. 90 0 1 2 3 4 5 6 7 8 9 Age Girls Systolic Blood Pressure 95% Percentile 10 11 12 13 14 15 16 17 120 S ys to lic B lo o d P re ss u re 95 100 105 110 115 125 130 135 140 90 0 1 2 3 4 5 6 7 8 9 Age Boys Systolic Blood Pressure 95% Percentile Systolic 5% 10 11 12 13 14 15 16 17 120 150 S ys to lic B lo o d P re ss u re 95 100 105 110 115 125 130 135 140 145 Systolic 50% Systolic 95% Patient Chapter 18 | Assessing Children: Infancy Through Adolescence 351 Characteristics of Pathologic Heart MurmursTable 18-4 Congenital Defect Characteristics of Murmur Pulmonary Valve Stenosis Location. Upper left sternal border Radiation. In mild degrees of stenosis, the murmur may be heard over the course of the pulmonary arteries in the lung fields. Mild S1 A2 P2 Moderate S1 A2 P2 Intensity. Increases in intensity and duration as the degree of obstruction increases Severe S1 A2 P2 Quality. Ejection, peaking later in systole as the obstruction increases Aortic Valve Stenosis S1 A2 P2 Location. Midsternum, upper right sternal border Radiation. To the carotid arteries and suprasternal notch; may also be a thrill Intensity. Varies, louder with increasingly severe obstruction Quality. An ejection, often harsh, systolic murmur Tetralogy of Fallot General. Variable cyanosis, increasing with activity With Pulmonic Stenosis Location. Mid to upper left sternal border. If pulmonary atresia, there is no systolic murmur but the continuous murmur of ductus arteriosus flow at upper left sternal border or in the back. (continued) 352 Bates’ Pocket Guide to Physical Examination and History Taking Characteristics of Pathologic Heart Murmurs (continued) Congenital Defect Characteristics of Murmur With Pulmonic Atresia S1 A2 S1 Radiation. Little, to upper left sternal border, occasionally to lung fields Intensity. Usually grade III–IV Quality. Midpeaking, systolic ejection murmur Transposition of the Great Arteries General. Intense generalized cyanosis Location. No characteristic murmur. If a murmur is present, it may reflect an associated defect such as VSD or patent ductus arteriosus. Radiation. Depends on associated abnormalities Quality. Depends on associated abnormalities Ventricular Septal Defect Location. Lower left sternal border Small to Moderate S1 A2 P2 Radiation. Little Intensity. Variable, only partially determined by the size of the shunt. Small shunts with a high pressure gradient may have very loud murmurs. Large defects with elevated pulmonary vascular resistance may have no murmur. Grade II–IV/VI with a thrill if grade IV/VI or higher. Table 18-4 Chapter 18 | Assessing Children: Infancy Through Adolescence 353 Sex Maturity Ratings in Girls: BreastsTable 18-5 Stage 1 Preadolescent—elevation of nipple only Stage 2 Stage 3 Breast bud stage. Elevation of breast and nipple as a small mound; enlargement of areolar diameter Further enlargement and elevation of breast and areola, with no separation of the contours Stage 4 Stage 5 Projection of areola and nipple to form a secondary mound above the level of the breast Mature stage; projection of nipple only. Areola has receded to general contour of the breast (although in some normal individuals areola continues to form a secondary mound). Photos reprinted, with permission from the American Academy of Pediatrics, Assessment of Sexual Maturity Stages in Girls, 1995. Table 18-6 Sex Maturity Ratings in Boys In assigning SMRs in boys, observe each of the three characteristics separately. Record two separate ratings: pubic hair and genital. If the penis and testes differ in their stages, average the two into a single figure for the genital rating Stage 1 Stage 2 Stage 3 Pubic Hair: Preadolescent—no pubic hair except for the fine body hair (vellus hair) similar to that on the abdomen Genitalia • Penis: Preadolescent—same size and proportions as in childhood • Testes and Scrotum: Preadolescent—same size and proportions as in childhood Pubic Hair: Sparse growth of long, slightly pigmented, downy hair, straight or only slightly curled, chiefly at the base of the penis Genitalia • Penis: Slight to no enlargement • Testes and Scrotum: Testes larger; scrotum larger, somewhat reddened, and altered in texture Pubic Hair: Darker, coarser, curlier hair spreading sparsely over the pubic symphysis Genitalia • Penis: Larger, especially in length • Testes and Scrotum: Further enlarged 354 Bates’ Pocket Guide to Physical Examination and History Taking Table 18-6 Sex Maturity Ratings in Boys (continued) Stage 4 Stage 5 Pubic Hair: Coarse and curly hair, as in the adult; area covered greater than in stage 3 but not as great as in the adult and not yet including the thighs Genitalia • Penis: Further enlarged in length and breadth, with development of the glans • Testes and Scrotum: Further enlarged; scrotal skin darkened Pubic Hair: Hair adult quantity and quality, spread to the medial surfaces of the thighs but not up over the abdomen Genitalia • Penis: Adult in size and shape • Testes and Scrotum: Adult in size and shape Photos reprinted from Pediatric Endocrinology and Growth 2nd ed., Wales & Wit, 2003, with permission from Elsevier. Chapter 18 | Assessing Children: Infancy Through Adolescence 355 356 Bates’ Pocket Guide to Physical Examination and History Taking Sex Maturity Ratings in Girls: Pubic HairTable 18-7 Stage 1 Preadolescent—no pubic hair except for the fine body hair (vellus hair) similar to that on the abdomen Stage 2 Sparse growth of long, slightly pigmented, downy hair, straight or only slightly curled, chiefly along the labia Stage 3 Darker, coarser, curlier hair, spreading sparsely over the pubic symphysis Stage 4 Coarse and curly hair as in adults; area covered greater than in stage 3 but not as great as in the adult and not yet including the thighs Stage 5 Hair adult in quantity and quality, spread on the medial surfaces of the thighs but not up over the abdomen Photos reprinted, with permission from the American Academy of Pediatrics, Assessment of Sexual Maturity Stages in Girls, 1995. Chapter 18 | Assessing Children: Infancy Through Adolescence 357 Physical Signs of Sexual AbuseTable 18-8 Physical Signs That May Indicate Sexual Abuse in Children* 1. Marked and immediate dilatation of the anus in knee–chest position, with no constipation, stool in the vault, or neurologic disorders 2. Hymenal notch or cleft that extends >50% of the inferior hymenal
rim (confirmed in knee–chest position)
3. Condyloma acuminata in a child older than 3 years
4. Bruising, abrasions, lacerations, or bite marks of labia or
perihymenal tissue
5. Herpes of the anogenital area beyond the neonatal period
6. Purulent or malodorous vaginal discharge in a young girl (all
discharges should be cultured and viewed under a microscope for
evidence of a sexually transmitted infection)
Physical Signs That Strongly Suggest Sexual Abuse in Children*
1. Lacerations, ecchymoses, and newly healed scars of the hymen or
the posterior fourchette
2. No hymenal tissue from 3 to 9 o’clock (confirmed in various
positions)
3. Healed hymenal transections, especially between 3 and 9 o’clock
(complete cleft)
4. Perianal lacerations extending to external sphincter
A sexual abuse expert must evaluate a child with concerning
physical signs for a complete history and sexual abuse
examination.
*Any physical sign must be evaluated in light of the entire history, other parts of the
physical examination, and laboratory data.

359
C H A P T E R
19The Pregnant Woman
Focus the initial prenatal visit on confirming the pregnancy, assessing
the health status of the mother and any risks for complications, and
counseling to ensure a healthy pregnancy. Ask about the following
topics:
● Confirmation of pregnancy. Has the patient had a confirmatory urine
pregnancy test, and when? When was her last menstrual period
(LMP)? Has an ultrasound been done to establish dates? Explain
that serum pregnancy tests are rarely required to confirm pregnancy.
● Symptoms of pregnancy. absence of menses, breast fullness or tender-
ness, nausea or vomiting, fatigue, and urinary frequency. Explain
that serum or urine testing for beta human chorionic gonadotropin
(HCG) offers the best confirmation of pregnancy.
● Maternal concerns and attitudes. Review the mother’s feelings about
the pregnancy and whether she plans to continue to term. Ask about
any fears and about support from the father.
The Health History
Common Concerns
◗ Initial prenatal history
◗ Confirmation of pregnancy
◗ Symptoms of pregnancy
◗ Concerns about and attitudes toward the pregnancy
◗ Current health and past medical history
◗ Past obstetric history
◗ Risk factors for maternal and fetal health
◗ Family history
◗ Plans for breast-feeding
◗ Determining gestational age and expected date of delivery

360 Bates’ Pocket Guide to Physical Examination and History Taking
● Current health and past medical history. Does the patient have any
acute or chronic medical concerns, past or present? Pay particular
attention to issues that affect pregnancy, such as abdominal surger-
ies, hypertension, diabetes, cardiac conditions including any that
were surgically corrected in childhood, asthma, hypercoagulability
states involving lupus or anticardiolipin antibodies, mental health
disorders including postpartum depression, HIV, sexually transmit-
ted infections, abnormal Pap smears, and exposure to diethylstilbes-
trol (DES) in utero.
● Past obstetric history. Ask about prior pregnancies and outcomes. Has
she had any complications during past pregnancies, including labor
and delivery? Has she had a premature or growth-retarded infant, or
a baby large for gestational age? Has there been a prior fetal demise?
● Risk factors for maternal and fetal health. Does the patient use
tobacco, alcohol, or illicit drugs? Does she take any medications,
over-the-counter drugs, or herbal prescriptions? Does she have any
toxic exposures at work, home, or otherwise? Is her nutritional
intake adequate, or is she at risk for problems stemming from obe-
sity? Does she have an adequate social support network and income
sources? Are there unusual sources of stress at home or work? Is
there any history of physical abuse or domestic violence?
● Family history of chronic illnesses or genetically transmitted diseases:
sickle cell anemia, cystic fibrosis, muscular dystrophy, and others.
● Plans for breast-feeding. Education and encouragement during preg-
nancy are recommended.
Gestational age and expected date of delivery.
● Gestational age. Count the number of weeks and days from the
first day of the LMP. Counting this menstrual age from the LMP–
although biologically distinct from the date of conception, it is the
standard means of calculating fetal age, yielding an average preg-
nancy length of 40 weeks. Rarely, the actual date of conception is
known (as with in vitro fertilization.) In these cases, use a conception
age, which is 2 weeks less than the menstrual age. However, this
number should never be used to make clinical judgements that rely
on the menstrual age for standards of care.
● Expected date of delivery (EDD). The expected date of delivery is 40
weeks from the first date of the LMP. Using Naegele’s rule, the EDD

Chapter 19 | The Pregnant Woman 361
can be estimated by taking the LMP, adding 7 days, subtracting
3 months and adding 1 year.
● Tools for calculations. Pregnancy wheels and online calculators are
commonly used to expedite these calculations, but they should be
checked for accuracy.
● Limitations on pregnancy dating. Patient recall of the LMP is highly
variable. The LMP can also be biased by hormonal contraceptives
or lengthly menstrual cycles. Check LMP dating against physical
exam markers such as fundal height, clarifying discrepancies against
ultrasound evaluation.
Subsequent Prenatal Visits. Obstetric visits traditionally follow a
set schedule: monthly until 30 gestational weeks, then biweekly until
36 weeks, then weekly until delivery. Update and document the his-
tory at every visit, especially fetal movement, contractions, leakage of
fluids and vaginal bleeding. At every visit, assess: vital signs (especially
blood pressure and weight), fundal height, verification of FHR, and
fetal position and activity.
Nutrition and Weight Gain. Evaluate nutritional status during
the first prenatal visit, including: diet history; measurement of height,
weight, and body mass index (BMI); and a hematocrit. Prescribe
needed vitamin and mineral supplements. Develop a nutrition plan
appropriate to cultural preferences, typically three balanced meals each
day, including 300 additional kcal plus prenatal supplements. Caution
against excess amounts of vitamin A, which can become toxic; fish
with mercury exposure such as sharks, swordfish, or even canned tuna;
unpasteurized dairy products; and undercooked meats.
Health Promotion and Counseling:
Evidence and Recommendations
◗ Nutrition
◗ Weight gain
◗ Exercise
◗ Substance abuse
◗ Domestic violence
◗ Prenatal laboratory screenings
◗ Immunizations
Important Topics for Health Promotion
and Counseling

362 Bates’ Pocket Guide to Physical Examination and History Taking
Weigh the woman at each visit, with the results plotted on a graph,
using the updated recommendations below.
Exercise. Recommend 30 minutes of moderate exercise or more on
most days of the week unless contraindications exist. Women initiating
exercise during pregnancy should consider programs developed specifi-
cally for pregnant women. Immersion in hot water should be avoided.
After the first trimester, women should avoid exercise in the supine
position, which can compress the inferior vena cava, resulting in dizzi-
ness and decreased placental blood flow. In the third trimester, advise
against exercises that may cause loss of balance. Contact sports or activ-
ities that risk abdominal trauma are unwise in all trimesters. Pregnant
woman should avoid overheating, dehydration, and any exertion that
causes notable fatigue or discomfort.
Substances of Abuse. Promote abstinence as the immediate goal
during pregnancy. Pursue universal screening in a neutral manner for:
● Tobacco. Tobacco use accounts for a third of all low-birth-weight
babies and many poor pregnancy outcomes, including placental
Recommendations for Total and Rate of Weight Gain
During Pregnancy, by Prepregnancy BMI, 2009
Prepregnancy
BMI

BMI*
Total Weight
Gain (lbs)
Rates of Weight Gain†
2nd and 3rd Trimester
(lbs/wk)
Underweight <18.5 28–40 1 (1–1.3) Normal weight 18.5–24.9 25–35 1 (0.8–1) Overweight 25–29.9 15–25 0.6 (0.5–0.7) Obese (includes all classes) ≥30 11–20 0.5 (0.4–0.6) ∗To calculate BMI, go to www.nhlbisupport.com/bmi. †Calculations assume a 0.5–2 kg (1.1–4.4 lbs) weight gain in the first trimester (based on Siega-Riz et al., 1994; Abrams et al., 1995; Carmichael et al., 1997) Source: Rasmussen KM, Yaktine AL (eds) and Institute of Medicine. Committee to Reex- amine IOM Pregnancy Weight Guidelines. Weight gain during pregnancy: re-examing the guidelines. Washington, DC: National Academics Press, 2009. (Available at http://www. iom.edu/Reports/2009/Weight-Gain-During-Pregnancy-Reexamining-the-Guidelines.aspx.) Accessed February 26, 2011. http://www.nhlbisupport.com/bmi http://www.iom.edu/Reports/2009/Weight-Gain-During-Pregnancy-Reexamining-the-Guidelines.aspx http://www.iom.edu/Reports/2009/Weight-Gain-During-Pregnancy-Reexamining-the-Guidelines.aspx Chapter 19 | The Pregnant Woman 363 abruption and preterm labor. Cessation is the goal, but any decrease in usage is favorable. ● Alcohol. Fetal alcohol syndrome is the leading cause of preventable mental retardation in the United States. Abstinence is widely recom- mended throughout pregnancy. ● Illicit drugs including narcotics. Women with addictions should be referred for treatment immediately and counseled and screened for hepatitis C and HIV. ● Prescription drugs. Ask about commonly abused prescription drugs, including narcotics, stimulants, benzodiazepines. Domestic Violence. Pregnancy is a time when risk of intimate part- ner violence increases. Up to one in five women experience some form of abuse during pregnancy. Pursue universal screening of all pregnant women without regard to socioeconomic status. Ask, “Since you’ve been pregnant, have you been slapped or otherwise physically hurt by anyone?” Nonverbal clues include frequent changes in appoint- ments at the last minute, unusual behavior during visits, partners that refuse to leave the patient alone, and bruises or other injuries. When abuse becomes apparent, ask the patient how you might best help her. Respect limits she places on sharing information. Maintain an updated list of shelters, counseling centers, hotline numbers and other trusted local referrals. Plan future appointments at accelerated intervals. Com- plete a thorough physical exam as much as she permits and document all injuries on a body diagram. National Domestic Violence Hotline ◗ Web site: www.thehotline.org ◗ 1-800-799-SAFE (7233) ◗ TTY for hearing impaired: 1-800-787-3224 Prenatal Laboratory Screenings. Initially include blood type and Rh, antibody screen, complete blood count—especially hemato- crit and platelet count, rubella titer, syphilis test, hepatitis B surface antigen, HIV, STI screen for gonorrhea and chlamydia and urinalysis with culture. Timed screenings include an oral glucose tolerance test for gestational diabetes around 24 weeks, and a vaginal swab for group B streptococcus between 35 to 37 weeks’ gestation. Pursue additional tests related to the mother’s risk factors, such as screening for aneuploidy, http://www.thehotline.org 364 Bates’ Pocket Guide to Physical Examination and History Taking screening for Tay-Sachs or other genetic diseases, amniocentesis, or checking for infectious diseases such as hepatitis C. Immunizations. As indicated, give tetanus and influenza vaccinations in the second or third trimester. The following vaccines are safe dur- ing pregnancy: pneumococcal, meningococcal, and hepatitis B. The following vaccines are NOT safe during pregnancy: measles/mumps/ rubella, polio, varicella. However, all women should have rubella titers drawn during pregnancy and be immunized after birth if non- immune. Rho (D) immunoglobulin, or RhoGAM, should be given to all Rh-negative women at 28 weeks’ gestation and again within 3 days of delivery to prevent sensitization to an Rh-positive infant. Techniques of Examination Preparing for the Examination Show respect for the woman’s comfort and privacy, as well as for her individual needs and sensitivities. Ask her to wear her gown with the opening in front to ease the examination of both breasts and the pregnant abdomen. Positioning ◗ The semisitting position with the knees bent (see p. 366) affords the most comfort and protects abdominal organs and vessels from the weight of the gravid uterus. ◗ Avoid prolonged periods of lying on the back. Make your abdominal palpa- tion efficient and accurate. ◗ The pelvic examination also should be relatively quick. Equipment ◗ Gynecologic speculum and lubrication: Because of vaginal wall relaxation during pregnancy, a larger-than-usual speculum may be needed. ◗ Sampling materials: The cervical brush may cause bleeding, so the Ayre wooden spatula or “broom” sampling device is preferred during pregnancy. Additional swabs may be needed to screen for sexually transmitted infections, group B strep, and wet mount preparations. ◗ Tape measure: Use a plastic or paper tape measure to assess the size of the uterus after 20 gesta- tional weeks. ◗ Doppler fetal heart rate monitor and gel: Apply a “Doppler” or “Doptone” to the gravid belly to assess fetal heart rate after 10 weeks of gestation. Chapter 19 | The Pregnant Woman 365 HEIGHT, WEIGHT, AND VITAL SIGNS Observe the general health, emotional state, nutritional status, and coordination as the pregnant woman comes into the room. HEAD AND NECK ● Face. Check for the mask of pregnancy, chloasma, or irregular brownish patches around the fore- head and cheeks, across the bridge of the nose, or along the jaw. ● Hair ● Eyes. Note the conjunctival color. ● Nose, including nasal congestion ● Mouth ● Thyroid gland. Inspect and palpate. Modest symmetric enlargement is common. Facial edema after 20 weeks in gesta- tional hypertension Hair loss should not be attributed to pregnancy. Anemia of pregnancy may cause conjunctival pallor. Nosebleeds are more common during pregnancy. Erosion of nasal septum if use of intranasal cocaine. Gingival enlargement common Significant enlargement is abnormal and should be investigated. Measure the height and weight. Calculate BMI. First-trimester weight loss should not exceed 5% of prepartum weight. Weight loss of more than 5% in excessive vomiting, or hyperemesis Measure the blood pressure at every visit. In midpregnancy, it may be lower than in the nonpregnant state. Gestational hypertension: if systolic blood pressure (SBP) ≥140 mm Hg and diastolic blood pressure (DBP) ≥90 mm Hg, first occurring after week 20 and without proteinuria Chronic hypertension: if SBP ≥140 mm Hg and DBP ≥90 mm Hg prior to pregnancy, before week 20, and after 12 weeks postpartum Preeclampsia: if SBP ≥140 mm Hg and DBP ≥90 mm Hg after week 20 and with proteinuria E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S 366 Bates’ Pocket Guide to Physical Examination and History Taking E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S THORAX AND LUNGS Inspect the thorax for contours. Observe the pattern of breathing. Auscultate the lungs. Respiratory alkalosis in later tri- mesters. Elevated respiratory rate in infection, pulmonary embolism, peripartum cardiomyopathy. HEART Palpate the apical impulse. Impulse may be higher than normal in the fourth intercostal space because of transverse and leftward rotation of the heart from the higher diaphragm. Auscultate the heart. A venous hum and systolic or continuous mammary souffle (see p. 165) are common. Murmurs may signal anemia; new diastolic murmurs should be inves- tigated. If signs of heart failure, con- sider peripartum cardiomyopathy. BREASTS Inspect the breasts and nipples for symmetry and color. The venous pattern may be marked, the nipples and areolae are dark, and Montgomery’s glands are prominent. Palpate for masses. During pregnancy, breasts are tender and nodular; focal tenderness in mastitis. Investigate any new discrete masses. Compress each nipple between your index finger and thumb. This may express colostrum from the nipples; investigate if abnormal bloody or purulent discharge. ABDOMEN Place the pregnant woman in a semisitting position with her knees flexed. Chapter 19 | The Pregnant Woman 367 E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S ● Inspect any scars or striae, the shape and contour of the abdomen, and the fundal height. ● Assess the shape and contour to estimate pregnancy size. ● Palpate for: ● Organs and masses ● Fetal movements, usually detected after 24 weeks ● Uterine contractility Purplish striae and linea nigra are normal. 36 wks 32 wks 28 wks 24 wks 16 wks 20–22 wks 12–14 wks EXPECTED HEIGHT OF UTERINE FUNDUS OF PREGNANCY Ultrasound confirmation of fetal health and movement may be needed. Irregular contractions after 12 weeks or after palpation during the third trimester Prior to 37 weeks, regular uterine contractions or bleeding are abnormal, suggesting preterm labor. ● If woman is >20 weeks preg-
nant, measure fundal height
with a tape measure from the
top of the symphysis pubis to
the top of the uterine fundus.
After 20 weeks, measurement
in centimeters should roughly
equal the weeks of gestation.
● Auscultate the fetal heart tones,
noting rate (FHR), location,
and rhythm. A Doptone detects
the FHR after 10 weeks. The
FHR is audible with a fetoscope
after 18 weeks.
If fundal height is more than 4 cm
higher than expected, consider mul-
tiple gestation, a large fetus, extra
amniotic fluid, or uterine leiomyoma.
If more than 4 cm lower, consider low
level of amniotic fluid, missed abor-
tion, transverse lie, growth retarda-
tion, or fetal anomaly.
Lack of an audible FHR may indicate
pregnancy of fewer weeks than
expected, fetal demise, or false
pregnancy.

368 Bates’ Pocket Guide to Physical Examination and History Taking
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
● Location. From 10 to 18 weeks,
the FHR is in the midline of the
lower abdomen; later depends
on fetal position. Use modified
Leopold’s maneuvers to palpate
the fetal head and back and
identify where to listen.
● Rate. The rate usually is 120
to 160 beats per minute.
After 32 to 34 weeks, the
FHR should increase with
fetal movement.
An FHR that drops noticeably near
term with fetal movement could
indicate poor placental circulation.
● Rhythm. In the third trimes-
ter, expect a variance of 10 to
15 beats per minute (BPM)
over 1 to 2 minutes.
Lack of beat-to-beat variability late
in pregnancy warrants investigation
with an FHR monitor.
GENITALIA, ANUS, AND RECTUM
Inspect the external genitalia. Parous relaxation of the introitus,
labial varicosities, enlargement of the
labia and clitoris, scars from an episi-
otomy or perineal lacerations
Palpate Bartholin’s and Skene’s
glands. Check for a cystocele
or rectocele.
Bartholin’s cyst
Examine the internal genitalia.
Speculum Examination
● Inspect the cervix for color,
shape, and healed lacerations.
Purplish color of pregnancy; lacera-
tions from prior deliveries
● Perform a Pap smear, if
indicated.
Specimens may be needed for diag-
nosis of vaginal or cervical infection
● Inspect the vaginal walls. Bluish or violet color, deep rugae, leu-
korrhea in normal pregnancy; vaginal
irritation, itching, and discharge in
infection

Chapter 19 | The Pregnant Woman 369
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
Bimanual Examination
Insert two lubricated fingers into
introitus, palmar side down, with
slight pressure downward on the
perineum. Slide fingers into the
posterior vaginal vault. Maintain-
ing downward pressure, gently
turn fingers palmar side up.
● Assess cervical os and degree of
effacement. Place your finger
gently in the os, and then sweep
it around the surface of the cervix.
● Estimate the length of the cervix.
Palpate the lateral surface from
the cervical tip to the lateral fornix.
● Palpate the uterus for size,
shape, consistency, and position.
● Estimate uterine size. With your
internal fingers placed at either
side of cervix, palmar surfaces
upward, gently lift the uterus
toward the abdominal hand.
Capture the fundal portion of
the uterus between your two
hands and gently estimate size.
● Palpate the left and right
adnexa.
● Evaluate pelvic floor strength
as you withdraw the examining
fingers.
● Inspect the anus. Rectal and
rectovaginal examinations are
usually not indicated.
Closed external os if nulliparous;
os open to size of fingertip if
multiparous
Prior to 34 to 36 weeks, cervix should
retain normal length of ≥3 cm.
Hegar’s sign, or early softening of the
isthmus; pear-shaped uterus up to
8 weeks, then globular
An irregularly shaped uterus suggests
uterine myomata or a bicornuate
uterus, two distinct uterine cavities
separated by a septum.
Early in pregnancy, it is important to
rule out tubal (ectopic) pregnancy.

Hemorrhoids may engorge later in
pregnancy.

370 Bates’ Pocket Guide to Physical Examination and History Taking
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S
EXTREMITIES
Inspect the legs for varicose veins.
Palpate the hands and legs for
edema.
Watch for swelling of preeclampsia or
deep venous thrombosis.
Check knee and ankle deep
tendon reflexes.
Hyperreflexia may signal preeclampsia.
SPECIAL TECHNIQUES
LEOPOLD’S MANEUVERS
To identify:
● The upper and lower fetal poles,
namely, the proximal and distal
fetal parts
● The maternal side where the
fetal back is located
● The descent of the presenting
part into the maternal pelvis
● The extent of flexion of the
fetal head
● Estimated fetal weight and size
Common deviations include breech
presentation (fetal buttocks present at
the outlet of the maternal pelvis) and
absence of the presenting part well
down into the maternal pelvis at term.
FIRST MANEUVER
(Upper Fetal Pole)
Stand at the woman’s side, facing
her head. Keep the fingers of both
examining hands together. Pal-
pate gently with the fingertips to
determine what part of the fetus
is in the upper pole of the uterine
fundus.

Chapter 19 | The Pregnant Woman 371
SECOND MANEUVER
(Sides of the Maternal
Abdomen)
Place one hand on each side of
the woman’s abdomen, aiming
to capture the body of the fetus
between them. Use one hand to
steady the uterus and the other
to palpate the fetus. Look for the
back on one side and the extremi-
ties on the other.
THIRD MANEUVER
(Lower Fetal Pole and
Descent into Pelvis)
Face the woman’s feet. Palpate
the area just above the symphysis
pubis. Note whether the hands
diverge with downward pressure
or stay together to learn if the
presenting part of the fetus, head
or buttocks, is descending into
the pelvic inlet.
FOURTH MANEUVER
(Flexion of the fetal
head)
This maneuver assesses the flexion
or extension of the fetal head,
presuming that the fetal head is the
presenting part in the pelvis. Still
facing the woman’s feet, with
your hands positioned on either
side of the gravid uterus as in the
third maneuver, identify the fetal
front and back sides. Using one
hand at a time, slide your fingers
down each side of the fetal body
until you reach the “cephalic prom-
inence,” that is, where the fetal
brow or occiput juts out.
E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S

372 Bates’ Pocket Guide to Physical Examination and History Taking
Recording Your Findings
Recording the Physical Examination—The
Pregnant Woman
“32-year-old G3,P1102 at 18 weeks’ gestation as determined by LMP presents to
establish prenatal care. Patient endorses fetal movement; denies contractions,
vaginal bleeding, and leakage of fluids. On external exam, low transverse cesar-
ean scar is evident; fundus is palpable just below umbilicus. On internal exam,
cervix is open to fingertip at the external os but closed at the internal os; cervix
is 3 cm long; uterus enlarged to size consistent with 18-week gestation. Specu-
lum exam shows leucorrhea with positive Chadwick’s sign. FHT by Doppler are
between 140 and 145 BPM.” Describes healthy woman at 18 weeks’ gestation.
E XA M I N AT I O N T E C H N I Q U E S

373
C H A P T E R
20The Older Adult
Older adults now number more than 39 million in the United States,
growing to 88 million by 2050. Life span at birth is currently 84 years
for women and 82 years for men. The “demographic imperative” is to
maximize not only life span but also “health span” for older adults so
that seniors maintain full function for as long as possible, enjoying rich
and active lives in their homes and communities.
● Assessing the older adult entails a focus on healthy or “successful”
aging; understanding and mobilizing family, social, and community
supports; skills directed to functional assessment, “the sixth vital
sign”; and promoting the older adult’s long-term health and safety.
● The aging population displays marked heterogeneity. Investigators
distinguish “usual” aging, with its complex of diseases and impair-
ments, from optimal aging. Optimal aging occurs in those people
who escape debilitating disease entirely and maintain healthy lives
late into their 80s and 90s. Studies of centenarians show that genes
account for approximately 20% of the probability of living to 100,
with healthy lifestyles accounting for approximately 20% to 30%.
The Health History
APPROACH TO THE PATIENT
As you talk with older adults, convey respect, patience, and cultural
awareness. Be sure to address patients by their last name.
Adjusting the Office Environment. Make sure the office is neither
too cool nor too warm. Face the patient directly, sitting at eye level. A
well-lit room allows the older adult to see your facial expressions and
gestures.
More than 50% of older adults have hearing deficits. Free the room of
distractions or noise. Consider using a “pocket talker,” a microphone

374 Bates’ Pocket Guide to Physical Examination and History Taking
that amplifies your voice and connects to an earpiece inserted by the
patient. Chairs with higher seating and a wide stool with a handrail lead-
ing up to the examining table help patients with quadriceps weakness.
Shaping the Content and Pace of the Visit. Older people often
reminisce. Listen to this process of life review to gain important
insights and help patients as they work through painful feelings or
recapture joys and accomplishments.
Balance the need to assess complex problems with the patient’s endur-
ance and possible fatigue. Consider dividing the initial assessment into
two visits.
Eliciting Symptoms in the Older Adult. Older patients may over-
estimate healthiness even when increasing disease and disability are
apparent. To reduce the risk of late recognition and delayed interven-
tion, adopt more directed questions or health screening tools. Consult
with family members and caretakers.
Acute illnesses present differently in older adults than in younger age
groups. Be sensitive to changes in presentation of myocardial infarc-
tion and thyroid disease. Older patients with infections are less likely
to have fever.
Recognize the symptom clusters typical of different geriatric syn-
dromes, notable interacting clusters of symptoms, for example, falls,
dizziness, depression, urinary incontinence, and functional impair-
ment. Searching for the usual “unifying diagnosis” may pertain to
fewer than 50% of older adults.
Cognitive impairment may affect the patient’s history. Even elders
with mild cognitive impairment, however, can provide sufficient
history to reveal concurrent disorders. Use simple sentences with
prompts to trigger necessary information. If impairments are more
severe, confirm symptoms with family members or caregivers.
Addressing Cultural Dimensions of Aging. By 2050, the older
adult population will increase by 230%, and the minority older adult
population by 510%. Cultural differences affect the epidemiology of
illness and mental health, acculturation, the specific concerns of the
elderly, the potential for misdiagnosis, and disparities in health out-
comes. Review the components of self-awareness needed for cultural
responsiveness, discussed in Chapter 3 (pp. 40–41). Ask about spiritual
advisors and native healers. Cultural values particularly affect decisions

Chapter 20 | The Older Adult 375
about the end of life. Elders, family, and even an extended community
group may make these decisions with or for the older patient.
Place symptoms in the context of your overall functional assessment,
always focusing on helping the older adult to maintain optimal well-
being and level of function.
Activities of Daily Living. Daily activities provide an important
baseline for the future. You might say “Tell me about your typical day”
or “Tell me about your day yesterday.” Then move to a greater level of
detail: “You got up at 8 AM? How is it getting out of bed?”
COMMON CONCERNS
Activities of Daily Living and Instrumental
Activities of Daily Living
Physical Activities of Daily
Living (ADLs)
Instrumental Activities of
Daily Living (IADLs)
Bathing Using the telephone
Dressing Shopping
Toileting Preparing food
Transferring Housekeeping
Continence Laundry
Feeding Transportation
Taking medicine
Managing money
Medications. Adults older than 65 take approximately 30% of all
prescriptions. Roughly 30% take more than eight prescribed drugs
each day! Take a thorough medication history, including name, dose,
frequency, and indication for each drug. Explore all components of
◗ Activities of daily living
◗ Instrumental activities of daily living
◗ Medications
◗ Smoking and alcohol
◗ Acute and persistent pain
◗ Nutrition
◗ Frailty
◗ Advance directives and palliative care

376 Bates’ Pocket Guide to Physical Examination and History Taking
polypharmacy, including concurrent use of multiple drugs, underuse,
inappropriate use, and nonadherence. Ask about use of over-the-
counter medications, vitamin and nutrition supplements, and mood-
altering drugs. Medications are the most common modifiable risk
factor associated with falls.
Smoking and Alcohol. At each visit, advise elderly smokers to quit.
An estimated 2% to 20% of older adults have alcohol-related problems.
This percentage is expected to rise as the population ages in com-
ing decades. Despite the prevalence of alcohol problems among the
elderly, rates of detection and treatment are low. Use the CAGE ques-
tions to uncover problem drinking (see p. 46), which contributes to
drug interactions and worsens comorbid illnesses.
Acute and Persistent Pain. Pain and associated complaints account
for 80% of clinician visits, usually for musculoskeletal complaints like
back and joint pain. Older patients are less likely to report pain, lead-
ing to undue suffering, depression, social isolation, physical disability,
and loss of function.
Inquire about pain each time you meet with the older patient. Ask
specifically, “Are you having any pain right now? How about over the
past week?” Unidimensional scales such as the Visual Analog Scale,
graphic pictures, and the Verbal 0–10 Scale have all been validated and
are easiest to use.
Characteristics of Acute and Persistent Pain
Acute Pain Persistent Pain
Distinct onset Lasts more than 3 months
Obvious pathology Often associated with psychological or
functional impairment
Short duration Can fluctuate in character and intensity
over time
Common causes: postsurgical,
trauma, headache
Common causes: arthritis, cancer, clau-
dication, leg cramps, neuropathy,
radiculopathy
Source: Reuben DB, Herr KA, Pacala JT, et al. Geriatrics at Your Fingertips: 2004, 6th ed.
Malden, MA: Blackwell Publishing, for the American Geriatrics Society, 2004:149.
Nutrition. Taking a diet history and using the Rapid Screen for
Dietary Intake and the Nutrition Screening Checklist (p. 62) are
especially important in older adults.

Chapter 20 | The Older Adult 377
Frailty. The prevalence of this multifactorial syndrome related to
declines in physiologic reserves, muscle mass, energy and exercise
capacity is 4% to 22%. Pursue related interventions.
Advance Directives and Palliative Care. Initiate these discus-
sions before serious illness develops. Advance care planning involves
providing information, invoking the patient’s preferences, identify-
ing proxy decision makers, and conveying empathy and support.
Use clear, simple language. Ask about preferences relating to writ-
ten “Do Not Resuscitate” orders specifying life support measures
“if the heart or lungs were to stop or give out.” Seek a written
health care proxy or durable power of attorney for health care,
“someone who can make decisions reflecting your wishes in case of
confusion or emergency.” Include these discussions in office settings
rather than the uncertain and stressful environment of emergency or
acute care.
The goal of palliative care is “to relieve suffering and improve the
quality of life for patients with advanced illnesses and their families
through specific knowledge and skills, including communication with
patients and family members; management of pain and other symptoms;
psychosocial, spiritual, and bereavement support; and coordination of
an array of medical and social services.”
Health Promotion and Counseling:
Evidence and Recommendations
Important Topics for Health Promotion and
Counseling in the Older Adult
◗ When to screen
◗ Cancer screening
◗ Depression, dementia, and cognitive impairment
◗ Elder mistreatment and abuse
When to Screen. As the life span for older adults extends into the
80s, new issues for screening emerge. In general, base screening deci-
sions on each older person’s particular circumstances, rather than on
age alone. Consider life expectancy, time interval until benefit from
screening accrues, and patient preference. The American Geriatrics
Society recommends that if life expectancy is short, give priority

378 Bates’ Pocket Guide to Physical Examination and History Taking
to treating conditions that will benefit the patient in the time that
remains.
● Screen for age-related changes in vision and hearing. These are
included in the 10-Minute Geriatric Screener (pp. 380–381).
● Recommend regular aerobic exercise, resistance training to increase
strength, and balance exercise like tai chi.
● Immunizations. Include the pneumococcal vaccine once after age
65, annual influenza vaccinations, Td boosters every 10 years, and
the herpes zoster vaccine.
● Promote household safety. Correct poor lighting, chairs at awk-
ward heights, slippery or irregular surfaces, and environmental
hazards.
Cancer Screening. Cancer screening can be controversial because
of limited evidence about adults older than age 70 to 80. The U.S.
Preventive Services Task Force (USPSTF) guidelines are summarized
below:
● Breast cancer (2009): Mammography every 2 years between ages
50 and 74; insufficient evidence thereafter.
● Cervical cancer (2003): Routine screening up to age 65 if low risk.
● Colorectal cancer (2008): Colonoscopy every 10 years, beginning
at age 50; This examination is difficult for many older patients,
sigmoidoscopy every 5 years with high-sensitivity fecal occult
blood tests (FOBTs) every 3 years, or FOBTs every year ages
50 to 75.
● Prostate cancer (2008): Insufficient evidence to declare recommen-
dation.
● Skin cancer (2006), lung cancer (2004): Insufficient evidence.
American Geriatrics Society recommends checking for skin and oral
cancers in high-risk patients.
Depression, Dementia, and Cognitive Impairment. Depression
affects 10% of older men and 18% of older women. Use the two
screening questions in Chapter 5 p. 68.

Chapter 20 | The Older Adult 379
Dementia is “an acquired syndrome of decline in memory and at least
one other cognitive domain such as language, visuospatial, or executive
function sufficient to interfere with social or occupational functioning.”
It affects 13% of Americans over age 65. Prominent features include:
● Normal alertness but short-term memory deficits and subtle lan-
guage errors.
● Visuospatial perceptual difficulties and loss of orientation to place.
● Changes in executive function, or ability to perform sequential
tasks.
● In later stages, impaired judgment, aphasia, apraxia and loss of
ADLs.
Most dementias represent Alzheimer’s disease (50% to 85%) or vascu-
lar multi-infarct dementia (10% to 20%). Dementia often has a slow,
insidious onset. The early stages of mild cognitive impairment may be
detected only on neurocognitive testing. Watch for family complaints
of new or unusual behaviors. Investigate contributing factors such as
medications, depression, metabolic abnormalities, or other medical
and psychiatric conditions.
Elder Mistreatment and Abuse. Screen older patients for possible
elder mistreatment, which includes abuse, neglect, exploitation, and
abandonment. Prevalence is approximately 1% to 10% of the older
population; however, many more cases may remain undetected.
Techniques of Examination
Assessment of the older adult departs from the traditional format of
the history and physical examination. Enhanced interviewing, empha-
sis on daily function and key topics related to elder health, and func-
tional assessment are especially important.
ASSESSING FUNCTIONAL STATUS:
THE “SIXTH VITAL SIGN”
Assessing Functional Ability. Functional status is the ability to
perform tasks and fulfill social roles associated with daily living across
TTTecchhnniiquees offf Exaammminnatttionn

380 Bates’ Pocket Guide to Physical Examination and History Taking
a wide range of complexity. Several performance-based assessment
instruments are available. The screening tool below is brief, has
high inter-rater agreement, and can be used easily by office staff.
It covers the three important domains of geriatric assessment:
physical, cognitive, and psychosocial function. It addresses key
sensory modalities and urinary incontinence, an often unreported
problem that greatly affects social interactions and self-esteem in
the elderly. One mnemonic that helps students assess incontinence
is DIAPERS: Delirium, Infection, Atrophic urethritis/vaginitis,
Pharmaceuticals, Excess urine output (e.g., due to heart failure,
hyperglycemia), Restricted mobility, Stool impaction.
10-Minute Geriatric Screener
Problem and Screening Measure Positive Screen
Vision: Two Parts:
Ask: “Do you have difficulty driving, or
watching television, or reading, or doing
any of your daily activities because of
your eyesight?
Yes to question and inability
to read >20/40 on Snellen
chart
If yes, then: Test each eye with Snellen chart
while patient wears corrective lenses (if
applicable).
Hearing: Use audioscope set at 40 dB.
Test hearing using 1,000 and 2,000 Hz.
Inability to hear 1,000 or
2,000 Hz in both ears or
either of these frequencies
in one ear
Leg mobility: Time the patient after in-
structing: “Rise from the chair. Walk 20
feet briskly, turn, walk back to the chair,
and sit down.”
Unable to complete task in
15 seconds
Urinary incontinence: Two Parts:
Ask: “In the last year, have you ever lost
your urine and gotten wet?”
Yes to both questions
If yes, then ask: “Have you lost urine on at
least 6 separate dates?”
Nutrition/weight loss: Two parts:
Ask: “Have you lost 10 lbs over the past
6 months without trying to do so?”
Weigh the patient.
Yes to the question or weight
<100 lbs (continued) Chapter 20 | The Older Adult 381 10-Minute Geriatric Screener (continued) Problem and Screening Measure Positive Screen Memory: Three-item recall Unable to remember all three items after 1 minute Depression: Ask: “Do you often feel sad or depressed?” Yes to the question Physical disability: Six questions: “Are you able to. . . : No to any of the questions ◗ “Do strenuous activities like fast walking or bicycling?” ◗ “Do heavy work around the house like washing windows, walls, or floors?” ◗ “Go shopping for groceries or clothes?” ◗ “Get to places out of walking distance?” ◗ “Bathe, either a sponge bath, tub bath, or shower?” ◗ “Dress, like putting on a shirt, buttoning and zipping, or putting on shoes?” Source: More AA, Siu AL. Screening for common problems in ambulatory elderly: clinical confirmation of a screening instrument. Am J Med 1996;100:438–440. Further Assessment for Preventing Falls. Each year approximately 35% to 40% of healthy community-dwelling older adults experience falls. Incidence rates in nursing homes and hospitals are almost three times higher, with related injuries in approximately 25%. The American Geriatrics Society (AGS) recommends risk factor assess- ment for falls during routine primary care visits, with more intensive assessment in high-risk groups—those with first or recurrent falls, nurs- ing home residents, and those prone to fall-related injuries. Assess how the fall occurred, seeking details from any witnesses, and identify risk factors, medical comorbidities, functional status, and environmen- tal risks. Couple your assessment with interventions for prevention, including gait and balance training and exercise to strengthen muscles, vitamin D supplementation, reduction of home hazards, discontinu- ation of psychotropic medication, and multifactorial assessment with targeted interventions. The AGS recommendations are provided on the next page. 382 Bates’ Pocket Guide to Physical Examination and History Taking 1. Obtain relevant medical history, physical examination, cognitive and functional assessment. 2. Determine multifactorial fall risk: a. History of falls b. Medications c. Gait, balance, and mobility d. Visual acuity e. Other neurological impairments f. Muscle strength g. Heart rate and rhythm h. Postural hypotension i. Feet and footwear j. Environmental hazards Initiate multifactorial/multicomponent intervention to address identified risk(s) and prevent falls: 1. Minimize medications 2. Provide individually tailored exercise program 3. Treat vision impairment (including cataract) 4. Manage postural hypotension 5. Manage heart rate and rhythm abnormalities 6. Supplement vitamin D 7. Manage foot and footwear problems 8. Modify the home environment 9. Provide education and information Any indication for additional intervention? Reassess periodically Older person encounters health care provider Prevention of Falls in Older Persons Living in the Community Screen for fall(s) or risk for falling: 1. Two or more falls in prior 12 months? 2. Presents with acute fall? 3. Difficulty with walking or balance? Answers yes to any screening questions Does the person report a single fall in the past 12 months? Are abnormalities in gait or unsteadiness identified? No No No No Yes Yes Yes Evaluate gait and balance E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S PHYSICAL EXAMINATION OF THE OLDER ADULT Vital Signs. Measure blood pressure, checking for increased systolic blood pressure (SBP) and widened pulse pressure (PP), defined as SBP minus dia- stolic blood pressure (DBP). Isolated systolic hypertension (SBP ≥140) after age 50 triples the risk of coronary heart disease in men. PP ≥60 is a risk fac- tor for cardiovascular and renal disease and stroke. Source: Panel on Prevention of Falls in Older Persons, American Geriatrics Society and British Geriatrics Society. Summary of the Updated American Geriatrics Society/British Geriatrics Society. Clinical Practice guideline for prevention of falls in older persons, 2010. J Am Geriatr Soc 59:148–157, 2011. Also at http://www. americangeriatrics.org/files/documents/health_care_pros/JAGS.Falls.Guidelines . Accessed January 24, 2011. See also U.S. Preventive Services Task Force. Interventions to Prevent Falls in Older Adults, Topic Page. December 2010. At http://www. uspreventiveservicestaskforce.org/uspstf/uspsfalls.htm. Accessed January 24, 2011. http://www.americangeriatrics.org/files/documents/health_care_pros/JAGS.Falls.Guidelines http://www.uspreventiveservicestaskforce.org/uspstf/uspsfalls.htm http://www.americangeriatrics.org/files/documents/health_care_pros/JAGS.Falls.Guidelines http://www.uspreventiveservicestaskforce.org/uspstf/uspsfalls.htm E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S Review the JNC 7 categories of hypertension to guide early detection and treatment. Assess the patient for orthostatic hypotension, defined as a drop in SBP of ≥20 mm Hg or DBP of ≥10 mm Hg or HR increase of ≥20 BPM, within 3 minutes of standing. Measure in two posi- tions: supine after the patient rests for up to 10 minutes, then within 2 to 3 minutes after standing up. Orthostatic hypotension occurs in 10% to 20% of older adults and in up to 30% of frail nursing home residents, especially when they first arise in the morning. Watch for lightheadedness, weakness, unsteadiness, visual blurring, and, in 20% to 30% of patients, syncope. Assess for medications, autonomic disor- ders, diabetes, prolonged bedrest, blood loss, and cardiovascular disorders. Measure heart rate, respira- tory rate, and temperature. The apical heart rate may yield more information about arrhythmias in older patients. Use thermometers accurate for lower temperatures. Respiratory rate ≥25 breaths per minute indicates lower respiratory infection or possible CHF or COPD. Hypothermia is more common in elderly patients. Weight and height are especially important and needed for calcula- tion of the body mass index (p. 53). Weight should be mea- sured at every visit. Obtain oxygen saturation using a pulse oximeter. Low weight is a key indicator of poor nutrition. Undernutrition in depression, alcohol- ism, cognitive impairment, malignancy, chronic organ failure (cardiac, renal, pul- monary), medication use, social isolation, and poverty Skin. Note physiologic changes of aging, such as thin- ning, loss of elastic tissue and turgor, and wrinkling. Dry, flaky, rough, and often itchy Check the extensor surface of the hands and forearms. White depigmented patches (pseudos- cars); well-demarcated, vividly purple macules or patches that may fade after several weeks (actinic purpura) Look for changes from sun exposure. There may be actinic lentigines, or “liver spots,” and actinic keratoses, superficial flat- tened papules covered by a dry scale (p. 94). Distinguish such lesions from a basal cell carcinoma and squamous cell carcinoma (p. 95). Dark, raised, asymmetric lesion with irregular borders is suspicious for melanoma Chapter 20 | The Older Adult 383 384 Bates’ Pocket Guide to Physical Examination and History Taking E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S Inspect for the benign com- edones, or blackheads, on the cheeks or around the eyes; cherry angiomas (p. 93); and seborrheic keratoses, (p. 94). Inspect for painful vesicular lesions in a dermatomal distribution. Herpes zoster from reactivation of latent varicella-zoster virus in the dorsal root ganglia In older bedbound patients, especially when emaciated or neurologically impaired, inspect for damage or ulceration. Pressure sores if obliteration of arteriolar and capillary blood flow to the skin or shear forces with movement across sheets or lifting upright incorrectly HEENT. Inspect the eyelids, the bony orbit, and the eye. Senile ptosis arising from weakening of the levator palpebrae, relaxation of the skin, and increased weight of the upper eyelid Ectropion or entropion of lower lids (p. 116) Yellowing of the sclera and arcus senilis, a benign whitish ring around the limbus Test visual acuity, using a pocket Snellen chart or wall-mounted chart. More than 40 million Americans have refractive errors—presbyopia. Examine the lenses and fundi. Cataracts, glaucoma, and macular degen- eration all increase with aging. Inspect each lens for opacities. Cataracts are the world’s leading cause of blindness. Assess the cup-to-disc ratio, usually ≤1:2. Increased cup-to-disc ratio suggests open-angle glaucoma and possible loss of peripheral and central vision, and blindness. Prevalence is three to four times higher in African Americans. Inspect the fundi for colloid bodies causing alterations in pigmentation called drusen. These may be hard and sharply defined, or soft and confluent with altered pigmentation. Macular degeneration causes poor central vision and blindness: types include dry atrophic (more common but less severe) and wet exudative (or neovascular). Chapter 20 | The Older Adult 385 E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S Test hearing by the whispered voice (see p. 108) or audio- scope. Inspect ear canals for cerumen. Removing cerumen often quickly improves hearing. Examine the oral cavity for odor, appearance of the gingi- val mucosa, any caries, mobility of the teeth, and quantity of saliva. Malodor in poor oral hygiene, periodon- titis, or caries Gingivitis if periodontal disease Inspect for lesions on mucosal surfaces. Ask patient to remove dentures so you can check gums for denture sores. Dental plaque and cavitation if caries. Increased tooth mobility; risk of tooth aspiration Decreased salivation from medications, radiation, Sjögren’s syndrome, or dehy- dration Oral tumors, usually on lateral borders of tongue and floor of mouth Thorax and Lungs. Note subtle signs of changes in pulmonary function. Increased anteroposterior diameter, purse-lipped breathing, and dyspnea with talking or minimal exertion in chronic obstructive pulmonary disease Cardiovascular System. Review blood pressure and heart rate. Isolated systolic hypertension and a widened pulse pressure are cardiac risk factors. Search for left ventricular hyper- trophy (LVH). Inspect the jugular venous pulsa- tion (JVP), palpating the carotid upstrokes, and listen for any overlying carotid bruits. A tortuous atherosclerotic aorta can raise pressure in the left jugular veins by impairing drainage into right atrium. Carotid bruits in possible carotid stenosis. Assess the point of maximal impulse (PMI), and then heart sounds. Sustained PMI is found in LVH; diffuse PMI is found within heart failure (see p. 155). In older adults, S3 in dilatation of the left ventricle from heart failure or cardiomy- opathy; S4 in hypertension 386 Bates’ Pocket Guide to Physical Examination and History Taking E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S Listen for cardiac murmurs in all areas (see p. 157). Describe timing, shape, location of maximal intensity, radiation, intensity, pitch, and quality of each murmur. A systolic crescendo–decrescendo murmur in the second right interspace in aortic sclerosis or aortic stenosis. Both carry increased risk of cardiovascular disease and death. A harsh holosystolic murmur at the apex suggests mitral regurgitation, also com- mon in the elderly. For systolic murmurs over the clavicle, check for delay between the brachial and radial pulses. Delay during simultaneous palpation (but not compression) of brachial and radial pulses in aortic stenosis. Breasts and Axillae. Palpate the breasts carefully for lumps or masses. Possible breast cancer Abdomen Listen for bruits over the aorta, renal arteries, and femoral arteries. Bruits in atherosclerotic vascular disease Inspect the upper abdomen; palpate to the left of the midline for aortic pulsations. Widened aorta and pulsatile mass may be found in abdominal aortic aneurysm. Female Genitalia and Pelvic Examination. Take special care to explain the steps of the examination and allow time for careful positioning. For the woman with arthritis or spinal deformities who cannot flex her hips or knees, an assistant can gently raise and support the legs, or help the woman into the left lateral position. Inspect the vulva for changes related to menopause; identify any labial masses. Bluish swell- ings may be varicosities. Benign masses include condylomata, fibromas, leiomyomas, and sebaceous cysts. Bulging of the anterior vaginal wall below the urethra in urethrocele Inspect the urethra for caruncles, or prolapse of fleshy erythema- tous mucosal tissue at the urethral meatus. Clitoral enlargement in androgen- producing tumors or use of androgen creams Chapter 20 | The Older Adult 387 E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S Speculum Examination. Inspect vaginal walls, which may be atrophic, and cervix. Estrogen-stimulated cervical mucus with ferning in use of hormone replacement therapy, endometrial hyperplasia, and estrogen-producing tumors Obtain endocervical cells for the Pap smear. Use a blind swab if the atrophic vagina is too small. Removing speculum, ask patient to bear down. Uterine prolapse, cystocele, urethrocele, or rectocele. Perform the bimanual examina- tion. See Table 14-6, Positions of the Uterus, and Uterine Myomas, p. 239. Mobility of cervix restricted if inflam- mation, malignancy, or surgical adhesion Palpable ovaries in ovarian cancer. Perform the rectovaginal examination if indicated. Enlarged, fixed, or irregular uterus if adhesions or malignancy. Rectal masses in colon cancer. Male Genitalia and Prostate. Examine the penis; retract foreskin if present. Examine the scrotum, testes, and epididymis. Smegma, penile cancer, and scrotal hydroceles Do a rectal examination. Rectal masses in colon cancer. Prostate hyperplasia if enlargement; prostate cancer if nodules or masses. Peripheral Vascular System. Auscultate the abdomen for aortic, renal, femoral artery bruits. Bruits over these vessels in atheroscle- rotic disease. Palpate pulses. Diminished or absent pulses in arterial occlusion. Confirm with an office ankle– brachial index (see pp. 209–210). 388 Bates’ Pocket Guide to Physical Examination and History Taking E XA M I N AT I O N T E C H N I Q U E S P O S S I B L E F I N D I N G S Musculoskeletal System. Screen general range of motion and gait. Conduct timed “get up and go” test. If joint deformity, deficits in mobility, or pain with move- ment, conduct a more thorough examination. Review examination techniques for indi- vidual joints in Chapter 16, Musculosk- elatal System. See Table 20-1, Timed Get Up and Go Test, p. 390. Degenerative joint changes in osteoar- thritis; joint inflammation in rheumatoid or gouty arthritis. See Tables 16-1 to 16-4, pp. 277–282. Nervous System. Refer to results of 10-Minute Geriatric Screener, pp. 380–381. Pursue further examination if any defi- cits. Focus especially on memory and affect. Learn to distinguish delirium from depression and dementia. See Table 20-2, Delirium and Dementia, pp. 391–392 and Table 20-3, Screening for Dementia: The Mini-Cog, p. 393. Assess gait and balance, particu- larly standing balance; timed 8-foot walk; stride characteristics like width, pace, and length of stride; and careful turning. Abnormalities of gait and balance, especially widening of base, slowing and lengthening of stride, and difficulty turn- ing, are correlated with risk of falls. Although neurologic abnormali- ties are common in older adults, their prevalence without identifi- able disease increases with age, ranging from 30% to 50%. Physiologic changes of aging: unequal pupil size, decreased arm swing and spontaneous movements, increased leg rigidity and abnormal gait, presence of the snout and grasp reflexes, and decreased toe vibratory sense. Assess any tremor, rigidity, bra- dykinesia, micrographia, shuf- fling gait, and difficulty turning in bed, opening jars, and rising from a chair. Seen in Parkinson’s disease. Tremor is slow frequency and at rest, with a “pill- rolling” quality, aggravated by stress and inhibited during sleep or movement. Essential tremor is often bilateral, sym- metric, with positive family history, and diminished by alcohol Chapter 20 | The Older Adult 389 E XA M I N AT I O N T E C H N I Q U E S Mr. J is an older adult who appears healthy but underweight, with good muscle bulk. He is alert and interactive, with good recall of his life history. He is ac- companied by his son. Vital Signs: Ht (without shoes) 160 cm (5 ′). Wt (dressed) 65 kg (143 lb). BMI 28. BP 145/88 right arm, supine; 154/94 left arm, supine. Heart rate (HR) 98 and regular. Respiratory rate (RR) 18. Temperature (oral) 98.6°F. 10-Minute Geriatric Screener: (see pp. 380–381) Vision: Patient reports difficulty reading. Visual acuity 20/60 on Snellen chart. Needs further evaluation for glasses and possibly hearing aid. Hearing: Cannot hear whispered voice in either ear. Cannot hear 1,000 or 2,000 Hz with audioscope in either ear. Leg Mobility: Can walk 20 feet briskly, turn, walk back to chair, and sit down in 14 seconds. Urinary Incontinence: Has lost urine and gotten wet on 20 separate days. Needs further evaluation for incontinence, including “DIAPER” assessment (see p. 380), prostate examination, and postvoid residual, which is normally ≤50 mL (requires bladder catheterization). Nutrition: Has lost 15 lbs over the past 6 months without trying. Needs nutritional screen (see p. 62). Memory: Can remember three items after 1 minute. Depression: Does not often feel sad or depressed. Physical Disability: Can walk fast but cannot ride a bicycle. Can do moderate but not heavy work around the house. Can go shopping for groceries or clothes. Can get to places out of walking distance. Can bathe each day without diffi- culty. Can dress, including buttoning and zipping, and can put on shoes. Consider exercise regimen with strength training. Physical Examination: Record the vital signs and weight. Carefully describe your findings for each relevant segment of the peripheral examination, using terminology found in the “Recording Your Findings” sections of the prior chapters. Recording Your Findings As you read through this physical examination, you will notice some atypical findings. Test yourself to see if you can interpret these findings in the context of all you have learned about the examination of the older adult. Recording the Physical Examination— The Older Adult 390 Bates’ Pocket Guide to Physical Examination and History Taking Aids to InterpretationAAAiddss ttoo Inntterrpprreetaattioonn Timed Get Up and Go TestTable 20-1 Performed with patient wearing regular footwear, using usual walking aid if needed, and sitting back in a chair with arm rest. On the word, “Go,” the patient is asked to do the following: 1. Stand up from the arm chair 2. Walk 3 meters (in a line) 3. Turn 4. Walk back to chair 5. Sit down Time the second effort. Observe patient for postural stability, steppage, stride length, and sway. Scoring: ● Normal: completes task in <10 seconds ● Abnormal: completes task in >20 seconds
Low scores correlate with good functional independence; high scores
correlate with poor functional independence and higher risk of falls.
Reproduced from: Get-up and Go Test. In: Mathias S, Nayak USL, Isaacs B. “Balance
in elderly patient” The “Get Up and Go” Test. Arch Phys Med Rehabil 1986;67:387–
389; Podsiadlo D, Richardson S. The Timed “Up and Go”: A test of basic functional
mobility for frail elderly persons. J Am Geriatr Soc 1991;39:142–148.

Chapter 20 | The Older Adult 391
Table 20-2 Delirium and Dementia
Delirium Dementia
Clinical Features
Onset Acute Insidious
Course Fluctuating, with
lucid intervals;
worse at night
Slowly progressive
Duration Hours to weeks Months to years
Sleep/Wake Cycle Always disrupted Sleep fragmented
General Medical
Illness or Drug
Toxicity
Either or both
present
Often absent,
especially in
Alzheimer’s disease
Mental Status
Level of
Consciousness
Disturbed. Person
less clearly aware
of the environment
and less able to
focus, sustain, or
shift attention
Usually normal until
late in the course of
the illness
Behavior Activity often
abnormally
decreased
(somnolence)
or increased
(agitation,
hypervigilance)
Normal to slow;
may become
inappropriate
Speech May be hesitant,
slow or rapid,
incoherent
Difficulty in finding
words, aphasia
Mood Fluctuating, labile,
from fearful or
irritable to normal
or depressed
Often flat, depressed
Thought Processes Disorganized, may be
incoherent
Impoverished.
Speech gives little
information
(continued)

392 Bates’ Pocket Guide to Physical Examination and History Taking
Delirium Dementia
Thought Content Delusions common,
often transient
Delusions may occur
Perceptions Illusions,
hallucinations,
most often visual
Hallucinations may
occur.
Judgment Impaired, often to a
varying degree
Increasingly impaired
over the course of
the illness
Orientation Usually disoriented,
especially for time.
A known place may
seem unfamiliar.
Fairly well maintained,
but becomes
impaired in the later
stages of illness
Attention Fluctuates. Person
easily distracted,
unable to
concentrate on
selected tasks
Usually unaffected
until late in the
illness
Memory Immediate and recent
memory impaired
Recent memory
and new learning
especially impaired
Examples of Cause Delirium tremens
(due to withdrawal
from alcohol)
Uremia
Acute hepatic failure
Acute cerebral
vasculitis
Atropine poisoning
Reversible: Vitamin B12
deficiency, thyroid
disorders
Irreversible:
Alzheimer’s disease,
vascular dementia
(from multiple
infarcts), dementia
due to head trauma
Table 20-2 Delirium and Dementia (continued)

Chapter 20 | The Older Adult 393
Table 20-3 Screening for Dementia: The Mini-Cog
Administration
The test is administered as follows:
1. Instruct the patient to listen carefully to and remember
3 unrelated words and then to repeat the words.
2. Instruct the patient to draw the face of a clock, either on a blank
sheet of paper or on a sheet with the clock circle already drawn on
the page. After the patient puts the numbers on the clock face, ask
him or her to draw the hands of the clock to read a specific time.
3. Ask the patient to repeat the 3 previously stated words.
Scoring
Give 1 point for each recalled word after the clock drawing test
(CDC) distractor.
Patients recalling none of the three words are classified as demented
(Score = 0).
Patients recalling all three words are classified as nondemented
(Score = 3).
Patients with intermediate word recall of 1–2 words are classified based
on the CDT (Abnormal = demented; Normal = nondemented).
Note: The CDT is considered normal if all numbers are present in
the correct sequence and position, and the hands readably display
the requested time.
3-Item Recall = 1-2
NONDEMENTEDDEMENTED
CDT Abnormal CDT Normal
MINI-COG
3-Item Recall = 33-Item Recall = 0
From Borson S, Scanlan J, Brush M, et al. The Mini-Cog: a cognitive ‘vital signs’ measure
for dementia screening in multi-lingual elderly. Int J Geriatr Psychiatry 2000;15(11):
1021–1027. Copyright John Wiley & Sons Limited. Reproduced with permission.

395
Page numbers followed by “b” indicate boxed material; those followed by “t”
indicate end-of-chapter tables.
A
ABCDE screening, 83, 96t
Abdomen, 179–193
in children, 336, 342
concerning symptoms, 179–184
examination of, 12, 186–193
fullness of, 181
health history, 179–184
health promotion and counseling,
184–186
in older adults, 386
pain or tenderness, 179–182, 197t
during pregnancy, 366–368
recording findings, 193b
Abdominal aortic aneurysm, 190,
199, 201, 203, 386
Abdominal fullness, 181
Abdominal reflexes, 302, 313t
Abducens nerve, 291b, 292
Abscess
of brain, 99
lung, 142t
peritonsillar, 109, 342
Abstract thinking, 74
Abuse
of alcohol, 71, 184–185
of drugs, 46, 71, 363
intimate partner, 47, 47b, 363,
363b
of older adults, 379
during pregnancy, 363, 363b
sexual, in children, 343, 357t
Acoustic nerve, 291b, 293
Acquired immunodeficiency
syndrome (AIDS). See also HIV
infection
Kaposi’s sarcoma, 95t
Acromioclavicular arthritis, 282t
Actinic keratoses, 94t, 383
Actinic lentigines, 383
Actinic purpura, 383
Activities of daily living (ADLs), 375,
375b
Acute stress disorder, 81t
Adam’s bend test, 345
Adnexa (ovaries), 228, 232, 369, 387
Adolescents
examination of, 344–346
hypertension in, 330b, 350t
recommended preventative care
for, 349t
sexual maturity ratings in,
353t–356t
Advance directive, 377
Adventitious breath sounds, 132,
133b, 135
Agoraphobia, 80t
Airway, upper vs. lower, 335b
Alcohol abuse, 71, 184–185
Alcohol use
CAGE questionnaire for, 46, 184
interviewing about, 46
in older adults, 376
during pregnancy, 363
Allen test, 205
Allergic rhinitis, 101
Allergies, 3, 101, 325
Alopecia areata, 97t
Alzheimer’s disease, 379
Amblyopia, 339
Amenorrhea, 226
Anal reflex, 303
Analgesic rebound headache, 112t
Anatomic snuffbox, 263
Androgen-producing tumors, 386
Angina pectoris, 137t, 147
Angioedema, 122t
Angioma
cherry, 93t, 384
spider, 93t
Angular cheilitis, 122t
Ankle jerks, 302
Ankle reflex, 302
I n d e x

396 Index
Ankle–brachial index, 209t–210t
Ankles
examination of, 274–275, 297
ulcers of, 208t
Anorexia, 182
Anorexia nervosa, 61t, 226
Anterior cruciate ligament,
273, 284t
Anterior drawer sign, 273
Anteverted uterus, 239t
Anticipatory guidance, 325–326
Anus, during pregnancy, 369
Anxiety disorders, 80t–81t
Aorta
abdominal aortic aneurysm, 190,
199, 201, 203, 386
coarctation of the, 335
dissecting aneurysm, 137t, 147
examination of, 190
tortuous atherosclerotic, 385
Aortic insufficiency, 154, 155b, 202
Aortic regurgitation, 156–158
Aortic sclerosis, 386
Aortic stenosis, 154, 156–157, 159,
351t, 386
Apgar score, 326, 327b
Aphasia, assessment for, 72b
Aphthous ulcer, 124t
Apical impulse
assessment of, 56, 155–156
in children, 335
in older adults, 385
during pregnancy, 366
Apnea, 334
Appearance, assessment of, 72
Appendicitis, 180, 181, 197t
assessment for, 192–193
Arcus senilis, 384
Argyll Robertson pupil, 104
Arms
examination of, 202–203
flaccid, 306
Arousal, 212
Arousal system, 286
Arrhythmias, 57, 161t–164t, 330
Arterial insufficiency, 206, 207t–208t
Arterial occlusion, 202, 204, 387
Arteriosclerosis obliterans, 204
Arthralgia, 255
Arthritis
acromioclavicular, 282t
acute septic, 255
in ankles and feet, 274–275
degenerative (osteoarthritis), 255,
262, 281t, 388
gonococcal, 254, 263
gouty, 388
of hip, 269
knee, 270–271, 283t
patterns of pain in, 281t
rheumatoid, 254–55, 262–263,
281t, 388
Articular structures, 251
Asbestosis, 140t
Ascites, assessment of, 191–192
Assessment, 15–23
clinical reasoning in, 15–16
comprehensive vs. focused, 1, 9, 31
organizing data, 23–24
recording, 27b–29b
test selection for, 25b–27b
tips for, 24b
Asterixis, 304
Asthma, 139t, 142t, 146t
Ataxia, 288
Ataxic breathing, 65t
Atelectasis, 132
Atherosclerotic disease, 387
Athetosis, 314t
Atrial fibrillation, 57, 154
Atrial septal defect, 335
Attention
assessment of, 73, 392t
defined, 69b
Attention deficit disorder, 338
Auricle, examination of, 107
Auscultation
of abdomen, 187, 187b
of chest, 132, 132b, 135
of fetal heart, 367–368
of heart, 156–158, 158b
of infant heart, 335
Axillae
examination of, 11, 172
in older adults, 386
Axillary temperature, 57
B
Babinski response, 303
Back
examination of, 11
stiffness of, 278t
Back pain, low, 254, 256, 277t–278t
Bacterial vaginitis, 235t
Baker’s cyst, 271, 284t
Balance, 388, 390t
Balanitis, 214
Balloon sign, 272

Index 397
Ballotte, patella, 272
Barlow test, 337
Barrel chest, 144t
Bartholin’s gland, 225, 368
Basal cell carcinoma, 95t, 383
Basal ganglia, 285
Basal ganglia disorder, 313t
Behavior
assessment of, 72
in delirium and dementia, 391t
in older adults, 390t
Bell’s palsy, 293, 312t
Benign prostatic hyperplasia (BPH),
242, 246t–247t, 248t–249t, 387
Biceps reflex, 301
Bicipital tendinitis, 282t
Biliary obstruction, 183b
Bimanual examination, 232, 369, 387
Biot’s breathing, 65t
Birth history, 324
Bitemporal hemianopsia, 115t
Bladder, disorders of, 183–184,
196t–197t
Bleeding
gastrointestinal, 242
from nose, 102
postmenopausal, 226
sputum and, 141t–143t
subarachnoid, 99–100, 113t, 287
uterine, 226
vitreous, 100
Blood, in stool, 182
Blood pressure
assessment of, 54–56, 153–154
in children, 330, 339
classifications for, 56b, 150b
cuff size, 54b
high. See Hypertension
low, 154, 383
measuring, 55b
in older adults, 382–383, 385
during pregnancy, 365
tips for accurate, 55b
Blood pressure cuff, sizing, 54b
Body mass index (BMI), 52–54
calculation of, 53b
chart for, 54b
in children, 338
excessively low, 61t
for obesity, 52
during pregnancy, 362b
Bone density, criteria for, 257b
Bouchard’s nodes, 264
Bowel sounds, 187b
Bowlegged, 328
Brachial pulse, 202
Brachioradialis reflex, 302
Brain
abscess of, 99
tumors of, 99–100, 113t
Brainstem, 285
Breast self-examination (BSE), 169,
173b–174b
Breastfeeding, 360
Breasts, 167–175
in adolescents, 345, 353t
anatomy of, 169
cancer of, 167–169, 168b,
175t–177t, 378
concerning symptoms, 167–169
cysts of, 168b, 171
discharge from, 172
examination of, 11, 169–172
health history, 167–169
in infants, 336
male, 172
masses of, 167, 168b
in older adults, 386
during pregnancy, 366
recording findings, 174b
in review of systems, 5
sexual maturity ratings for, 353t
Breath odor, 52
Breath sounds, 132, 132b, 135
adventitious, 132, 133b, 135
Breathing
abnormal, 65t
assessment of, 57, 129
in children, 330
in comatose patient, 319t
effort of, 57
normal, 57, 65t
in older adults, 383
shortness of breath, 128, 147
Breech presentation, 370
Brief psychotic disorder, 82t
Bronchial breath sounds, 132b
Bronchiectasis, 142t
Bronchiolitis, 330
Bronchitis, chronic, 139t,
142t, 146t
Bronchophony, 133, 133b
Bronchovesicular breath sounds,
132b
Brudzinski’s sign, 303
Bruits
abdominal, 187b, 386
carotid, 154
Bulge sign, 271
Bulimia nervosa, 61t

398 Index
Bulla, 89t
Burrow, 90t
Bursa, 251
Bursitis, 255
in hip, 268
in knee, 270–271, 283t
olecranon, 262
in shoulder, 259, 282t
C
CAGE questionnaire, 46, 184
Calcium
food sources of, 63t
recommended dietary intake for,
258b
Calf swelling, 200
Cancer
breast, 167–169, 168b, 175t–177t,
378
cervical, 228, 237t, 378
colorectal, 182, 185b–186b, 194t,
242, 378, 387
lip, 122t
ovarian, 228, 387
penis, 218t
prostate, 242, 249t, 378, 387
rectal, 249t
screening in older adults, 378
skin, 95t, 378, 383
testicular, 221t
tongue, 124t
vulvar, 234t
Candidiasis
in infants, 333
oral, 124t, 333
tongue, 123t
vaginitis, 235t
Canker sore, 124t
Capacity, altered, 42
Carcinoma
basal cell, 95t, 383
cervical, 237t
of lip, 122t
of penis, 218t
squamous cell, 95t, 383
of tongue, 124t
of vulva, 234t
Cardiac examination, 155–159
auscultation, 156–159
heart sounds, 156
in infants, 335
inspection and palpation, 155–156
murmurs, 157–159, 158b
during pregnancy, 366
sequence for, 155b
Cardiac syncope, 288
Cardinal directions of gaze, 104–105
Cardiomyopathy, 155
hypertrophic, 159
peripartum, 366
Cardiovascular disease
major risk factors for, 149b
screening for, 148–153
Cardiovascular system, 147–160
cardiac examination, 155–159
concerning symptoms, 147
examination of, 12, 153–159
health history, 147
health promotion and counseling,
148–153
in older adults, 385–386
during pregnancy, 366
recording findings, 160b
in review of systems, 5
Carotid bruits, 154
Carotid pulse, 154
Carotid stenosis, 385
Carpal tunnel syndrome, 262,
265–266, 296
Cartilaginous joints, 252b
Caruncles, 386
Cataracts, 100, 102, 384
Cauda equina, 286
Cauda equine syndrome, 254
Cellulitis, 200, 203
Central nervous system, 285–286
disorders of, 313t
Cerebellar disorders, 297, 313t
Cerebellum, 286
Cerebrovascular accident (CVA), 103
Cervical myelopathy, 280t
Cervical radiculopathy, 279t, 296
Cervicitis, 237t
Cervix
abnormalities of, 237t
cancer of, 228, 237t, 378
examination of, 231
during pregnancy, 369
shapes of Os, 236t
Chalazion, 117t
Chancre
female genitalia, 234t
lip, 122t
male genitalia, 214, 220t
Cheilitis, angular, 122t
Cherry angioma, 93t, 384
Chest. See Thorax (chest)
Chest pain, 127, 137t–138t, 147

Index 399
Chest wall pain, 138t
Cheyne-Stokes breathing, 65t
Chief complaint, 1b, 3, 323
Childhood illnesses, 3–4
Children. See also Adolescents
development of, 323b, 324–325
examination of, 338–344
health history, 323–326
health promotion and counseling,
325–326
heart murmurs in, 335, 342,
351t–352t
hypertension in, 330b, 339, 350t
infants, 329–337
interviewing, 338b
newborns, 326–328
recommended preventative care
for, 349t
recording findings, 346b–347b
sexual abuse in, 343, 357t
sexual maturity ratings in, 353t–356t
Chills, 49
Chloasma, 365
Choanal atresia, 333
Cholecystitis, 193
Chondromalacia, 270
Chorea, 314t
Chronic obstructive pulmonary
disease (COPD), 135, 139t,
146t, 385
Chronic pain, defined, 59
Cirrhosis, 182, 183b
Clavicle fracture, 336
Clinical breast examination (CBE), 169
Clinical reasoning, 15–16. See also
Assessment
Clinician
behavior and appearance, 35
self-reflection of, 39
Clitoris, 230
Clubbing, 98t
Cluster headache, 99, 111t
Coarctation of the aorta, 335
Cognitive function
assessment of, 73
higher, 70b, 74
Cognitive impairment, 290b
mild, 379
in older adults, 378–379
Cogwheel rigidity, 316t
Collaborative partnerships, 41
Colles’ fracture, 263
Colonoscopy, 243
Colorectal cancer, 182, 185b–186b,
194t, 242, 243, 378, 387
Coma, 305
Glasgow Coma Scale, 320t
structural, 319t
toxic-metabolic, 319t
Comatose patient
assessment of, 304–306
pupils in, 305–306, 319t, 321t
Comedones, 384
Communication
nonverbal, 33
respectful, 40–41
Comprehensive health history. See
Health history
Concussion, headache due to, 114t
Conductive hearing loss, 101, 121t,
293
Condylar joints, 253b
Condyloma acuminatum, 233t
Condyloma latum, 234t
Condylomata acuminata, 219t
Congestive heart failure, 335. See also
Heart failure
Consciousness, level of, 305b
assessment of, 51, 72
in comatose patient, 319t
defined, 69b
in delirium and dementia, 391t
loss of, 288
Constipation, 182
Constructional ability, assessment of, 74
Coordination, 297–298, 313t
Corneal light reflex, 339
Corneal reflexes, 104, 293
Corticospinal lesion, 298
Costovertebral angle, 190
Cough, 141t–143t
Crackles, 133b
Cranial nerves, 286
assessment of, 292–294
examination of, 13
functions of, 291b
Cranial neuralgias, 113t
Crohn’s disease, 182, 195t, 242, 244
Crossed straight-leg raise, 277
Croup, 334b
Crust, skin, 91t
Cryptorchidism, 215, 221t
Cultural competence, defined, 40
Cultural considerations
health disparities in pain
management, 59–60
in older adults, 374–375
patient with language barrier, 43,
43b
working with interpreter, 43b

400 Index
Cultural humility, 40–41
Culture, defined, 40
Cutaneous stimulation reflexes,
302–3
Cyanosis, 86t
Cyclothymic episode, 79t
Cystocele, 230, 238t, 368
Cystourethrocele, 230, 238t
Cysts, 88t
Baker’s, 271
breast, 168b, 171
congenital, 333
epidermoid, 233t
periauricular, 333
pilar, 103
pilonidal, 244
thyroglossal duct, 333
Cytomegalovirus, 182
D
Dacryocystitis, 117t
Data
identifying, 323
organizing, 23–24
subjective vs. objective, 2b
Death, interviewing about issues
related to, 47
Decerebrate rigidity, 306
Decorticate rigidity, 306
Deep tendon reflexes, 301, 313t
Deep venous thrombosis, 204
Degenerative joint disease, 255, 262,
281t, 388
Delirium, 290b, 391t–392t
Delusional disorder, 82t
Dementia, 290b
in older adults, 378–379
screening for, 393t
vs. delirium, 391t–392t
Dental caries, 341
Dependent edema, 147
Depression, 290b
health promotion and counseling
for, 70–71
low back pain and, 256
in older adults, 378–379
de Quervain’s tenosynovitis, 263,
265, 296
Dermatomes, 317t–318t
Development, child, 323b,
324–325
Developmental delay/abnormality,
329, 338, 344
Diabetes
in cardiovascular disease, 149b
screening for, 150b–151b
Diabetes insipidus, 184
Diabetes mellitus, 184
Diabetic retinopathy, 119t
Diarrhea, 182, 194t–196t
Diet
health promotion and counseling
for, 50–51, 256
in older adults, 376
during pregnancy, 361
recommendations for hypertension,
64t
screening checklist, 62t
sources of nutrients, 63t
Diethylstilbestrol (DES), 237t
Diffuse esophageal spasm, 138t
Digital rectal examination, 242–243
Diphtheria, 125t
Diplopia, 101, 288
Discharge
breast, 172
penile, 213
vaginal, 226, 235t, 343
Discriminative sensations, 300
Disease, defined, 36
Disease/illness model, defined, 36
Dissecting aortic aneurysm, 137t, 147
Distal weakness, 288
Distress, signs of, 51
Diverticulitis, 181, 197t
Dizziness, 287
Do Not Resuscitate (DNR), 47, 377
Doll’s eye movements, 306
Domestic violence, 47, 47b, 363, 363b
Doppler method, blood pressure, 330
Dorsalis pedis pulse, 204
Down’s syndrome, 331
Drawer sign
anterior, 273
posterior, 274
Dress, patient, 52, 72
Drug abuse, 46, 71, 363
Drug use
allergies and, 3
diarrhea related to, 194t
health history, 3, 46
in older adults, 375–376
during pregnancy, 363
prescription abuse, 46
urinary incontinence related to, 197t
Drusen, 384
Dullness, percussion notes, 131b, 135
Dupuytren’s contracture, 262, 264

Index 401
Durable medical power of attorney,
42
Dying patient, 47
Dysarthria, 288
Dyskinesia, oral-facial, 315t
Dyslipidemia
in cardiovascular disease, 149b
classification of, 151
in metabolic syndrome, 152b
screening for, 151, 152b
treatment of, 152b
Dysmenorrhea, 226
Dyspareunia, 227
Dyspepsia, 181
Dysphagia, 182
Dyspnea, 139t–140t, 147
Dysrhythmias, 57, 161t–164t,
330
Dysthymic disorder, 79t
Dystonia, 315t
Dysuria, 183
E
Ear canal, 107
Earache, 101
Eardrum, 107–108, 120t
Ears
in children, 340
examination of, 11, 107
health history of, 101
in infants, 332, 333b
in older adults, 385
pain in, 101
recording findings, 110b
in review of systems, 5
Eating disorders, 61t, 226
Ecchymosis, 94t
Echoing, 33
Ectopic pregnancy, 181, 369
Ectropion, 116t
Edema, 147
dependent, 147
pitting, 204
during pregnancy, 370
Effusion
of knee, 271–272
pleural, 131, 146t
Egophony, 133, 133b
Ejaculation, 212
Elbow, 262, 296
Elder mistreatment, 379
Elderly patients. See Older adults
Empathetic response, 32
Empowerment, patient, 34, 34b
Endocervical broom, 231
Endocervical polyp, 237t
Endocrine system, 6
Endometrial hyperplasia, 387
Endometriosis, 226
Enteroviral infections, 333
Entropion, 116t
Environment for examination, 9, 35,
373–374
Epidermoid cyst, 233t
Epididymis, 215, 222t
Epididymitis, 222t
Episcleritis, 117t
Episiotomy, 368
Epistaxis, 102
Epitrochlear lymph nodes, 11, 203
Epstein’s pearls, 333
Erectile dysfunction, 212
Erosion, skin, 92t
Esophageal spasm, diffuse, 138t
Esophagitis, reflex, 138t
Estrogen-producing tumors, 387
Ethics, professionalism and, 48, 48b
Excoriation, 92t
Exercise
health promotion and counseling
for, 51, 256
during pregnancy, 362
Exophthalmos, 116t
Expected date of delivery (EDD),
360–361
Expressions, facial, 52, 72
Extinction, sensation, 301
Extra-articular structures, 251
Extraocular muscles, 101
Extremities, lower. See also specific
structures
examination of, 12, 370
Eyelid
abnormalities of, 116t–117t
in older adults, 384
retraction, 116t
Eyes
abnormalities of, 116t–117t
in children, 339–340
in comatose patient, 305–306
disorders of, 112t
examination of, 11, 103–104
health history of, 100–101
in infants, 332, 332b
in older adults, 384
during pregnancy, 365
recording findings, 110b
in review of systems, 5

402 Index
F
Face
expressions of, 52, 72
of infants, 331, 332b
paralysis of, 103, 312t
during pregnancy, 365
Facial nerve, 291b, 293
Failure to thrive, 329
Fainting, 288
Fall prevention, 258, 381–382
Fallot, tetralogy of, 351t–352t
Family history, 2b, 4, 149b, 153, 360
Family planning, 229
Fasciculations, 314t
Fatigue, 49
Fecal occult blood test (FOBT), 243
Feeding history, 324
Feet
swelling of, 200
ulcers of, 208t
Female genital examination, 225–232
anatomical considerations, 225
concerning symptoms, 225–227
examination techniques, 13–14,
229–232, 229b
health history, 225–227
health promotion and counseling,
227–229
recording findings, 233b
sexually transmitted infections
(STIs) in, 227–228, 231
Female genitalia
in adolescents, 345
in children, 343
examination of, 13–14
in infants, 336
in older adults, 386–387
during pregnancy, 368–369
in review of systems, 6
sexual maturity ratings for, 356t
Femoral hernia, 216, 223t, 232
Femoral pulse, 204
Fetal alcohol syndrome, 331, 363
Fetal heart rate (FHR), 367–368
Fever, 49, 57
Fibroadenoma, of breast, 168b, 171
Fibromyalgia, 255, 279t
Fibrous joints, 252b
Fingernails, 85, 98t
Fingers, 264, 296
Fissure, 92t
Fissured tongue, 123t
Flaccid paralysis, 306
Flaccidity, 316t
Flail chest, 144t
Flat percussion note, 131b
Flu shots, 128
Folate, food sources of, 63t
Fontanelles, 331
Forced expiratory time, 135
Forgetfulness, 290b
Fracture
clavicle, 259, 336
Colles’, 263
osteoporosis and, 257b
scaphoid, 263
Frailty, 377
Functional assessment, 375
Functional status, 379–380
Fundal height, 367
Funnel chest, 144t
G
Gait
assessment of, 52, 267–268, 297–298
in older adults, 388, 390t
Gastroesophageal reflux disease
(GERD), 181
Gastrointestinal reflux, 143t
Gastrointestinal system
bleeding, 242
chest pain and, 138t
pain related to, 180–183
in review of systems, 5
symptoms related to, 182–183
Gaze, cardinal directions of, 104–105
Gegenhalten, 316t
General survey
in infants, 329–330
in physical examination, 10,
51–52
recording findings, 60
in review of systems, 5
Generalized anxiety disorder, 81t
Genital herpes, 219t, 234t
Genital warts, 219t, 233t
Genitalia
ambiguous, 336
examination of, 13–14
female, 225. See also Female genital
examination
male, 211. See also Male genital
examination
in review of systems, 6
Geographic tongue, 123t
Geriatric competencies, minimum,
391t–393t

Index 403
Geriatric Screener, 10-Minute, 378,
380b–381b
Geriatric syndromes, 374
Gestational age, 327b, 328b, 348t,
360–361
Gestational hypertension, 365b
“Get Up and Go” test, 388, 390t
Giant cell arteritis, 114t
Gingivitis, 385
Glasgow Coma Scale, 320t
Glaucoma
acute, 101, 112t
health promotion and counseling
for, 102–103
open-angle, 100, 384
Glaucomatous cupping, 118t
Glossopharyngeal nerve, 291b, 294
Goiter, 102, 110, 126t
Gonococcal arthritis, 254, 263
Gout, 255, 388
Gray matter, 285
Great arteries, transposition of the,
335, 352t
Grip strength, hand, 265
Growth, of child, 324
Guarding, abdominal, 188
Gums, 109
H
Hair
examination of, 85
loss of, 97t, 199
pubic, 354t–356t
Hairy leukoplakia, 123t
Hairy tongue, 123t
Hand
arterial supply to, 205
flaccid, 306
grip strength of, 265
Head, 99–102
circumference of, 329
examination of, 11, 103–111
health history, 99–102
health promotion and counseling,
102–103
in infants, 331
in older adults, 384–385
during pregnancy, 365
recording findings, 110b
in review of systems, 5
Headache, 99, 287
cluster, 99, 111t
migraine, 100, 111t
primary, 111t
red flags for, 100b
secondary, 112t–114t
tension, 99, 111t
Health care proxy, 42, 47
Health disparities
in cardiovascular screening and risk
factors, 149
in diabetes screening and diagnosis,
151
in pain management, 59–60
in osteoporosis risk factors,
256–257
in risk of prostate cancer, 242–243
Health history, 2–7, 2b
in children, 323–326
components of, 1b–2b
comprehensive vs. focused, 1, 9, 31
concerning symptoms, 49–50
interview and, 31–48
in older adults, 373–377
prenatal, 359–361
Health Insurance Portability and
Accountability Act (HIPAA), 42
Health maintenance, 4
Health promotion and counseling,
227–229
abdominal aortic aneurysm, 201
alcohol abuse, 71, 184–185
cardiovascular disease screening,
148–153
cervical cancer screening, 228
in children, 325–326
colorectal cancer, 185b–186b
colorectal cancer screening, 243
depression, 70–71
diet, 50–51, 62t, 63t, 256
exercise, 51, 256
fall prevention, 258
family planning, 229
flu shots, 128
hearing loss, 103
hepatitis prevention, 185
low back pain, 256
for menopause, 229
nutrition, 50–51, 62t, 63t, 256
in older adults, 377–379, 391t
optimal weight, 50–51
oral health, 103
osteoporosis, 256–257, 257b–258b
ovarian cancer screening, 228
peripheral neuropathy, 290
peripheral vascular disease, 200–201
pneumococcal vaccine, 128
during pregnancy, 361–364

404 Index
Health promotion and
counseling (continued)
prostate cancer screening, 242–243
renal artery disease, 201
sexually transmitted infections
(STIs) prevention, 213–214, 228
skin cancer screening, 83
smoking cessation, 128b
stroke prevention, 289–290
substance abuse, 71
suicide risk, 71
testicular self-examination, 214
vision loss, 102–103
Health supervision visits, 325
Hearing
assessment of, 108, 121t
in infants, 333b
in older adults, 385
Hearing loss, 293
conductive, 101, 121t
health promotion and counseling,
103
sensorineural, 101, 121t
Heart. See also Cardiovascular system
examination of. See Cardiac
examination
in infants, 335
in older adults, 385–386
during pregnancy, 366
Heart failure
congestive, 335
left ventricular, 139t, 143t, 146t,
147, 155, 159
Heart murmurs
assessment of, 156–158
causes of, 165t
in children, 335, 342, 351t–352t
grading of, 158b
in older adults, 386
during pregnancy, 366
systolic murmur identification, 159
Heart rate
assessment of, 56–57, 153
fetal, 367–368
in older adults, 383
Heart rhythm, 57, 161t–164t, 330
Heart sounds
assessment of, 156, 161t–164t
in infants, 335
Heartburn, 181
Heberden’s nodes, 264
HEENT (head, ears, eyes, nose, and
throat), 99–102
examination of, 11, 103–110
health history, 99–102
health promotion and counseling,
102–103
in older adults, 384–385
recording findings, 110b
in review of systems, 5
Height
assessment of, 52
in infants, 329
in older adults, 383
Hematoma, subdural, 329
Hemianopsia, 103, 115t
Hemoptysis, 141t–143t
Hemorrhage
subarachnoid, 99–100, 113t,
287
vitreous, 100
Hemorrhagic telangiectasia,
hereditary, 122t
Hemorrhoids, 249t, 369
Hepatitis, 181, 182
alcoholic, 179, 183b
prevention of, 185
types of, 183b, 185
Hepatomegaly, 188–189, 342
Hereditary hemorrhagic
telangiectasia, 122t
Hernia
in children, 328, 336, 343
in female, 232
femoral, 216, 223t, 232
indirect vs. direct, 216, 223t
inguinal, 216, 232, 336, 343
scrotal, 218t
umbilical, 328
Herpes simplex
female genital, 234t
in infants, 333
lip, 122t
male genital, 219t
Herpes zoster, 384
Higher cognitive functions, defined,
70b
Hinge joints, 253b
Hip dysplasia, congenital, 337
Hips, examination of, 267–268,
296–297
History. See Health history
HIV infection
female genital examination, 228
male genital examination, 213–214
Hoarseness, 102
Homonymous hemianopsia, 115t
Hormone replacement therapy
(HRT), 229
Housemaid’s knee, 270, 283t

Index 405
Human immunodeficiency virus
(HIV). See HIV infection
Human papillomavirus (HPV), 219t,
242
Hydrocele, 215, 218t, 336
Hydrocephalus, 103, 329
Hymen, imperforate, 230
Hyperglycemia, 100
Hyperopia, 100
Hyperpnea, 65t
Hyperpyrexia, defined, 57
Hyperresonance, 131, 131b
Hypertension
in cardiovascular disease, 149b
in children, 330b, 339, 350t
classification of, 56b, 150b
dietary recommendations for, 64t
gestational, 365b
isolated systolic, 56, 382
during pregnancy, 365, 365b
pulmonary, 335
screening for, 150
Hyperthyroidism, 102, 103
Hypertonia, 316t
Hypoglossal nerve, 291b, 294
Hypomanic episode, 79t
Hypoplastic left heart, 335
Hypospadias, 214, 218t
Hypotension, orthostatic, 154, 383
Hypothalamus, 285
Hypothermia
causes of, 57
defined, 57
Hypothesis, generating, 38–39
Hypothyroidism, 102
Hypotonia, 316t, 337
Hypovolemia, 154
I
Illicit drug abuse, 71, 363
Illness, defined, 36
Immunizations, 4, 325
in older adults, 378
during pregnancy, 364
Imperforate hymen, 230
Impulse, point of maximal, 56,
155–156, 335, 366, 385
Incontinence, urinary, types of, 184,
196t–197t
Infantile automatisms, 337
Infants
assessment of, 329–337
head circumference, 329
hypertension in, 330b
maturity classification for, 348t
recommended preventative care
for, 349t
Infection
diarrhea related to, 194t
sexually transmitted. See Sexually
transmitted infections (STIs)
Inflammatory bowel disease (IBD),
194t, 195t
Inguinal hernia, 216, 232, 336, 343
Inguinal lymph nodes, 203
Insight, patient, 69b, 73
Intention tremor, 314t
Intercourse, pain with, 227
Intermittent claudication, 199, 207t
Interpreter, working with, 43b
Interviewing, 31–48
children, 338b
comprehensive vs. focused, 1, 9, 31
cultural humility in, 40–41
ethics and professionalism, 48, 48b
format of, 31
patient with hearing loss, 44
patient with vision loss, 44
patient’s perspective in, 37, 37b
preparation for, 34–35
sensitive topics, 45–47
sequence for, 35–39
specific situations, 41–45
techniques for, 32–34
Intimate partner abuse, 47, 47b
Intracranial pressure, increased, 331
Introitus, 230
Involuntary movements, 295, 313t,
314t–315t
Iron, food sources of, 63t
Irritable bowel syndrome, 182
Ischiogluteal bursa, 268
Isolated systolic hypertension, 56, 382
J
Jaundice, 86t, 182
Joint pain, 281t
assessment of, 254–255, 254b
monoarticular, 254
polyarticular, 254
Joints. See also specific joint
concerning symptoms, 253–255
examination of, 258–275, 258b
recording findings, 276b
stiffness, 255
types of, 252b–253b

406 Index
Judgment, patient, 70b, 73, 392t
Jugular veins, 154
Jugular venous pressure, 154
Jugular venous pulsations, 154,
385
K
Kaposi’s sarcoma, 95t
Keloid, 91t
Keratoses
actinic, 94t
seborrheic, 94t
Kernig’s sign, 303
Kidneys, examination of, 190
Klinefelter’s syndrome, 221t
Knee
anatomical considerations, 269
examination of, 269–274, 297
painful, 283t–284t
Knee reflex, 302
Koplik’s spots, 125t
Korotkoff sounds, 159
Kussmaul breathing, 65t
Kyphoscoliosis, thoracic, 145t
L
Labia, 230
Labor, preterm, 367
Labyrinthitis, 101
Lachman test, 273
Language, 70b, 72
Language barrier, 43, 43b
Laryngitis, 141t
Laryngotracheobronchitis, 334b
Last period start (LMP), 226
Lateral collateral ligament, 273,
284t
Lateral meniscus, 272, 283t
Lead-pipe rigidity, 316t
Left ventricular heart failure, 139t,
143t, 146t, 147, 155, 159
Left ventricular hypertrophy, 155, 385
Legs
coldness, numbness, pallor on,
199
examination of, 203–204
flaccid, 306
hair loss on, 199
length measurement, 276
peripheral vascular disease and,
199–200, 203–204, 207t–210t
swelling of, 200
Leopold’s maneuvers, 368,
370–371
Lesions
brainstem, 101
corticospinal, 298
skin, 51, 87t–94t
upper motor neuron, 301
Lethargy, 305
Leukocoria, 332
Leukonychia, 98t
Leukoplakia, hairy, 123t
Level of consciousness, 305b, 319t,
391t
Lhermitte’s sign, 280t
Libido, 212
Lichenification, 91t
Lifestyle, in cardiovascular disease,
153, 153b
Ligaments, 251
knee, 273–274, 284t
Light reflex, 106b
Lighting, 9
Likelihood ratio, 26b–27b
Lips, 109, 122t
Listening, active, 32
Literacy, low, 44
Liver
enlarged, 188–189, 342
examination of, 188–189
normal, 188
risk factors for disease, 183b
Lumbar spinal stenosis, 277t
Lumbosacral radiculopathy, 304
Lungs
abscess of, 143t
anterior, 12
cancer of, 140t, 143t
concerning symptoms, 127–128
disorders of, 137t–140t, 146t
examination of, 129–135
health history, 127–128
health promotion and counseling,
128
in infants, 334, 334b–335b
in older adults, 385
posterior, 11
during pregnancy, 366
recording findings, 136b
Lymph nodes
axillae, 172
cervical, 109
epitrochlear, 203
in infants, 333
inguinal, 203
Lymphadenopathy, 203, 333

Index 407
M
Macular degeneration, 100, 102, 384
Macule, 87t
Major depressive episode, 78t–79t
Malabsorption syndrome, 195t
Male genital examination, 211–217
anatomical considerations, 211
concerning symptoms, 211–213
examination techniques, 13, 214–217
health history, 211–213
recording findings, 217b
sexually transmitted infections
(STIs) in, 213–214, 219t–220t
testicular self-examination, 214
Male genitalia
in adolescents, 345
in children, 343
examination of, 13
in infants, 336
in older adults, 387
in review of systems, 6
sexual maturity ratings for,
354t–355t
Malignant melanoma, 96t
Malocclusion, 342
Malodor, 385
Mammography, 168
Manic episode, 78t– 79t
Masseter muscles, 259, 293
Maximal impulse, point of, 56,
155–156, 335, 366, 385
McBurney’s point, 192
McMurray test, 272
Medial collateral ligament, 273, 284t
Medial meniscus, 272, 283t
Melanoma, 96t, 383
Melena, 182
Memory
defined, 69b
in delirium and dementia, 394t
recent, 74
remote, 73
Ménière’s disease, 101
Meningeal signs, 303
Meningitis, 99, 113t, 303, 331
Meniscus of knee, 272, 283t
Menopause, 226, 229
Menstrual history, 225
Mental health history, 45–46
Mental health screening, red flags
for, 68b
Mental status, 67–82
in children, 338
concerning symptoms, 69
disorders of, 76t–82t
examination of, 13, 71–75, 71b
health history, 69–70
health promotion and counseling,
70–71
in infants, 329
recording findings, 75b
red flags for mental health
screening, 68b
unexplained symptoms and, 67,
67b–68b
Metabolic syndrome, 152, 152b
Methicillin-resistant Staphylococcus
aureus (MRSA) precautions, 14
Microcephaly, 331
Migraine headache, 100, 111t
Mini-Cog exam, 290b, 393t
Mini-Mental State Examination
(MMSE), 74, 75b
Mitgehen, 316t
Mitral regurgitation, 156–157, 386
Mitral stenosis, 139t, 143t, 147,
155b, 156–157
Mitral valve prolapse, 159
Mixed episode, 79t
Mood
assessment of, 73, 391t
defined, 70b
disorders of, 78t–79t
Motor system (motor activity)
assessment of, 13, 52, 72, 294–98
disorders of, 313t
Mouth
abnormalities of, 122t–124t
assessment of, 109
cancers of, 122t, 124t
candidiasis of, 124t, 333
in children, 341–342
health history of, 102
in infants, 333
in older adults, 385
during pregnancy, 365
Movements, involuntary, 295, 313t,
314t–315t
MRSA precautions, 14
Multiple sclerosis, 296
Murmurs. See Heart murmurs
Murphy’s sign, 193
Muscle bulk, 295, 313t
Muscle strength
assessment of, 295–297, 295b
in motor system disorders, 313t
Muscle tone, 313t
assessment of, 295
disorders of, 316t

408 Index
Musculoskeletal system, 251–276
abnormalities of, 277t–281t
in children, 344
concerning symptoms, 253–255
examination of, 11–12, 258–275,
258b
health history, 253–255
health promotion and counseling,
256–258
in infants, 336–337
joint assessment, 251, 252b–253b
in older adults, 388
recording findings, 276b
in review of systems, 6
Myalgia, 255
Myasthenia gravis, 288, 295
Mycoplasma, 141t
Myelopathy, cervical, 280t
Myocardial infarction, 137t, 147, 180
Myoma, of uterus, 239t
Myopathy, 288, 295
Myopia, 100
Myxedema, 103
N
Naegele’s rule, 360–361
Nails
abnormalities of, 98t
examination of, 85
Nasal congestion, 101
Nausea, 181
Near reaction, pupillary, 104
Neck
examination of, 11, 109–110
health history, 102
in infants, 333
pain in, 254, 279t–280t
during pregnancy, 365
in review of systems, 5
Negative predictive value, 26b
Nerves
cranial, 13, 286, 291b, 292–294
peripheral, 286–287
spinal, 287
Nervous system, 285–307
central, 285–286
in children, 344
concerning symptoms, 287–289
examination of, 12–13
health promotion and counseling,
289–290
in older adults, 388
peripheral, 286–387
recording findings, 307b
in review of systems, 6
Neuralgias, cranial, 113t
Neurologic screening, in newborns,
328
Neuropathic ulcers, 208t
Neuropathy, peripheral, 290
Nevi, ABCDE screening for, 83, 96t
Newborns
Apgar score, 326, 327b
assessment of, 326–328
birth weight, 327b
classification of, 327b–328b, 348t
head circumference, 329
hypertension in, 330b
Night sweats, 49
Nipple
discharge of, 172
inspection of, 170
Paget’s disease of, 170, 177t
retraction or deviation, 170, 176t
Nocturia, 184
Nose
assessment of, 108
bleeding from, 365
examination of, 11
health history of, 101–102
in infants, 333
in older adults, 384–385
during pregnancy, 365
recording findings, 110b
in review of systems, 5
Numbness, 199
Nursing bottle caries, 341
Nutrients, sources of, 63t
Nutrition
health promotion and counseling
for, 50–51, 256
in older adults, 376
during pregnancy, 361
screening checklist, 62t
sources of nutrients, 63t
Nystagmus, 332
O
Obesity
body mass index (BMI) for, 52
in cardiovascular disease, 149b
during pregnancy, 362b
Objective data, 2b
Obsessive-compulsive disorder, 81t
Obstetric history, 360
Obstructive pulmonary disease, 147

Index 409
Obtundation, 305
Obturator sign, 192
Occlusion, arterial, 202, 204, 387
Oculocephalic reflex, 306
Oculomotor nerve, 291b, 292
Odor, body and breath, 52
Odynophagia, 182
OLD CARTS mnemonics, 38
Older adults, 373–389
abuse of, 379
cancer screening in, 378
concerning symptoms, 375–377
cultural considerations, 374–375
delirium and dementia, 391t–392t
examination of, 379–388
fall prevention in, 381–382
health history, 373–389, 373–377
health promotion and counseling,
377–379
Mini-Cog exam, 393t
recording findings, 389b
Olfactory nerve, 291b, 292
Onycholysis, 98t
Open-angle glaucoma, 100, 384
Ophthalmoscope, 105b
OPQRST mnemonics, 38
Optic disc
abnormalities of, 118t
examination of, 105–106,
106b–107b
Optic nerve, 291b, 292
Optic neuritis, 101
Oral health, health promotion and
counseling, 103
Oral mucosa, 109
Oral temperature, 57–58
Oral-facial dyskinesias, 315t
Orchitis, 221t
Orgasm, 212
Orientation
assessment of, 73, 392t
defined, 69b
Orthopnea, 147
Orthostatic hypotension, 154, 383
Ortolani test, 337
Osteoarthritis, 255, 262, 281t,
388
Osteopenia, 257b
Osteoporosis, 256–257, 257b–258b
Otitis externa, 101, 340
Otitis media, 101, 120t, 340–341
Ovaries
cancer of, 228, 387
examination of, 232, 369
Ovulation, 229
P
Paget’s disease, of nipple, 170, 177t
Pain
abdominal, 179–182, 197t
acute, 376, 376b
in arms and legs, 199
assessment of, 59–60
chest, 127, 137t–138t, 147
chronic, 59
in health history, 50
joint, 254–255, 254b, 281t
knee, 283t–284t
low back, 254, 256, 277t–278t
neck, 254, 279t–280t
in older adults, 376
persistent, 376, 376b
sensation of, 299
shoulder, 282t
Pain management, 60
health disparities in, 59–60
Palliative care, 377
Pallor, 199
Palpitations, 147
Panic attack, 80t
Panic disorder, 80t
Pap smear, 230–231, 368, 387
Papilledema, 118t
Papule, 87t
Paradoxical pulse, 159
Paralysis
of face, 312t
flaccid, 306
Paratonia, 316t
Parietal pain, 180
Parkinsonism, 313t
Paronychia, 98t
Paroxysmal nocturnal dyspnea
(PND), 147
Paroxysmal supraventricular
tachycardia, 330, 335
Partnering with patient, 33–34
Partnerships, collaborative, 41
Patch, skin, 87t
Patellofemoral compartment, 270
Patellofemoral disorder, 270, 283t
Patient
with altered capacity, 42
angry or disruptive, 42–43
comfort of, 9
confusing, 41
crying, 42
dying, 47
empowerment of, 34, 34b
with impaired hearing, 44

410 Index
Patient (continued)
with impaired vision, 44
with language barrier, 43, 43b
with limited intelligence, 44
with low literacy, 44
with personal problems, 44
perspective, 37, 37b
positioning of, 8b, 10
seductive, 44–45
silent, 41
talkative, 42
Peau d’orange, 170, 177t
Pectus carinatum (pigeon chest), 145t
Pectus excavatum (funnel chest), 144t
Pediatrics. See Children
Pelvic examination, 229–232, 229b
in older adults, 386–387
during pregnancy, 368–369
Pelvic floor, 238t, 369
Pelvic inflammatory disease (PID),
181, 226, 232
Pelvic muscles, 232
Penis
abnormalities of, 218t
cancer of, 218t
in children and adolescents,
354t–355t
discharge from, 213
examination of, 214
Perceptions, patient, 69b, 73, 392t
Percussion, chest, 131, 131b, 135
Perforation, eardrum, 120t
Pericardial friction, 156
Pericarditis, 137t, 159
Peripheral nerves, 286–287
Peripheral nervous system, 286–287,
313t
Peripheral neuropathy, 290
Peripheral vascular disease, 200–201
Peripheral vascular system, 199–206
concerning symptoms, 199–200
disorders of, 199–201, 207t–208t
examination of, 12, 202–206
health history, 199–200
health promotion and counseling,
200–201
in older adults, 387
recording findings, 206b
in review of systems, 6
Peritonsillar abscess, 109, 342
Personal history, 2b, 4
Personal hygiene, 52, 72
Pes anserine bursitis, 271, 283t
Petechia, 93t
Peutz-Jeghers syndrome, 122t
Phalen’s sign, 266
Pharyngitis, 125t
streptococcal, 102, 341
Pharynx
abnormalities of, 125t
in children, 341
examination of, 11, 102, 109
in infants, 333
in older adults, 384–385
Phimosis, 214
Phobias, types of, 80t
Physical activity, 51, 256
Physical examination, 7–14
approach to, 7
in children, 338–344
general survey in, 51–52
health history in, 49–50
health promotion and counseling
in, 50–51
of older adults, 379–388
pain in, 59–60
patient positioning for, 8b, 10
during pregnancy, 364–371,
364b
preparation for, 7b
recording findings, 60
sequence for, 8b, 10
standard and universal precautions
in, 14
vital signs, 54–58
Physical status
in children, 338
in infants, 329
Pigeon chest, 145t
Pilar cyst, 103
Pilonidal cyst, 244
Pinguecula, 117t
Plantar reflex, 303, 313t
Plaque, skin, 88t
Pleural effusion, 131, 146t
Pleural pain, 138t
Pleurisy, 180, 197t
Pneumatic otoscope, 340
Pneumococcal vaccine, 128
Pneumonia, 140t–141t, 330, 334b
Pneumothorax, 140t, 146t
Point localization, 301
Point of maximal impulse, 385
assessment of, 56, 155–156
in children, 335
in older adults, 385
during pregnancy, 366
Polydactyly, 336
Polymyalgia rheumatica, 255
Polyneuropathy, 288, 295

Index 411
Polyps
endocervical, 237t
of rectum, 249t
Polyuria, 184
Popliteal cyst, 271, 284t
Popliteal pulse, 204
Position sensation, 299–300
Positive predictive value, 26b
Postconcussion headache, 114t
Posterior cruciate ligament, 274
Posterior drawer sign, 274
Posterior tibial pulse, 204
Postictal state, 289
Postmenopausal bleeding, 226
Postnasal drip, 141t
Posttraumatic stress disorder, 81t
Postural hypotension, 154, 383
Postural tremor, 314t
Posture, assessment of, 52, 72
Potassium, food sources of, 64t
Precocious puberty, 343
Predictive value, 25b–26b
negative, 26b
positive, 26b
Preeclampsia, 365b, 370
Pregnancy
amenorrhea due to, 226
concerning symptoms, 359–361
ectopic, 181, 369
examination during, 364–371, 364b
family planning and, 229
health promotion and counseling,
361–364
hypertension during, 365b
prenatal laboratory screenings,
363–364
recording findings, 372b
symptoms of, 226
Premature ejaculation, 212
Prenatal visit
initial, 359–360
subsequent, 361
Prepatellar bursitis, 270, 283t
Presbyopia, 100, 384
Prescription drug use. See Drug use
Present illness, 2b, 3, 3b, 323
Pressure sores, 384
Presyncope, 287
Prevention
primary, 148
secondary, 148
Primary prevention, 148
Primitive reflexes, 337
Problem list, 30b
Proctitis, 244
Professionalism, and ethics, 48, 48b
Pronator drift, 298
Prostate
benign prostatic hyperplasia, 242,
246t–247t, 248t–249t
cancer of, 242–243, 249t, 378, 387
concerning symptoms, 241–242
examination of, 244–245
in older adults, 387
recording findings, 245
Prostate-specific antigen (PSA),
242–243
Prostatitis, 183–184, 249t
Proximal weakness, 288
Pseudoscars, 383
Psoas sign, 192
Psoriasis, 88t, 103
Psychiatric disorders. See Mental status
Psychotic disorders, 82t
Pterygoid muscles, 259
Ptosis, 116t
senile, 384
Puberty
delayed, 230
precocious, 343
Pubic hair, 354t–356t
Pulmonary embolism, 140t, 143t
Pulmonary fibrosis, 140t
Pulmonary function, assessment of,
135
Pulmonary tuberculosis, 142t
Pulmonary valve atresia, 335
Pulmonary valve stenosis, 156, 335
Pulse
apical, 56, 155
brachial, 202
carotid, 154
in children, 330
dorsalis pedis, 204
femoral, 204
grading of, 202b
in older adults, 386
paradoxical, 159
popliteal, 204
posterior tibial, 204
pulsus alternans, 159
radial, 56, 202
Pulse pressure, 382
Pulsus alternans, 159
Pupils
Argyll Robertson, 104
in comatose patient, 305–306,
319t, 321t
examination of, 104
near reaction, 104

412 Index
Purpura, 93t
Pustule, 89t
Pyelonephritis, 183
Pyloric stenosis, 336
Pyrexia, defined, 57
Q
Questioning
guided, 32–33, 32b
open-ended, 36, 39
R
Radial pulse, 56, 202
Radiculopathy
cervical, 279t, 296
lumbosacral, 304
Rales, 133b
Range of motion (ROM)
ankle, 275
elbow, 262
hip, 268–269
measuring, 276
shoulder, 260
spine, 267
wrist and hands, 262, 264
Rapport, 35
Raynaud’s disease, 200, 202
Reasoning, clinical, 15–16
Reassurance, 33
Rebound tenderness, 188
Record, patient
checklist for, 27b–29b
organizing, 27b–30b
Rectal examination, 13–14
in female, 245
in male, 244–245
in older adults, 387
during pregnancy, 369
Rectal thermometer, 58
Rectocele, 230, 238t, 368
Rectovaginal examination, 232,
387
Rectum
abnormalities of, 249t
cancer of, 249t
concerning symptoms, 241–242
examination of, 244–245
health history, 241–242
recording findings, 245
Red reflex, 105
Referred pain, 180, 278t
Reflex esophagitis, 138t
Reflexes
assessment of, 13, 301–303
corneal light, 339
cutaneous stimulation, 302–303
grading of, 301b
in infants, 337
in motor system disorders, 313t
during pregnancy, 370
primitive, 337
Reliability, 25b
Renal artery disease, 201
Resonant percussion note, 131b
Respiratory infection, upper, 334
Respiratory rate
abnormal, 65t
assessment of, 57, 129
in children, 330
in comatose patient, 319t
normal, 57, 65t
in older adults, 383
Respiratory rhythm
abnormal, 65t
assessment of, 57, 129
Respiratory system, 127–136
anterior thorax, 12, 134–135
concerning symptoms, 127–128
disorders of, 137t–140t,
144t–146t
examination of, 129–135
health history, 127–128
health promotion and counseling,
128
posterior thorax, 11, 130–134
recording findings, 136b
in review of systems, 5
Reticular activating system, 286
Retina, examination of, 106b–107b
Retinal detachment, 100–101
Retinoblastoma, 332
Retinopathy, diabetic, 119t
Retroflexed uterus, 239t
Retroverted uterus, 239t
Review of systems, 2b, 4–7
Rheumatic fever, 254
Rheumatoid arthritis, 254–255,
262–263, 281t, 388
Rhinitis, 101
Rhinorrhea, 101
Rhonchi, 133b
Right ventricular enlargement,
156
Rigidity, 316t
Ringworm, 97t
Rinne test, 108, 121t, 293
Romberg test, 298

Index 413
Rotator cuff, 259–260
tear, 260–261
tendinitis, 282t
Rovsing’s sign, 192
S
Sacroiliitis, 254
Safety, 378
Salpingitis, 197t
Sarcoidosis, 140t
Sarcoma, Kaposi’s, 95t
Scabies, 90t
Scale, skin, 90t
Scaphoid fracture, 263
Scapula, winging of, 304
Scar, 91t
Schizoaffective disorder, 82t
Schizophrenia, 82t
Schizophreniform disorder, 82t
Sciatica, 277t
Scoliometer, 345
Scoliosis, assessment of, 345
Screening
for breast cancer, 168–169
for cardiovascular disease, 148–153
for cervical cancer, 228
in children, 325
for colorectal cancer, 243
for diabetes, 150b–151b
for dyslipidemia, 151, 152b
for hypertension, 150
in older adults, 377–378
for ovarian cancer, 228
prenatal laboratory, 363–364
for prostate cancer, 242–243
for skin cancer, 83, 96t
Scrotum
abnormalities of, 218t
edema of, 218t
examination of, 215
in hernia, 218t
Seborrheic keratoses, 94t, 384
Secondary prevention, 148
Seizure, 289
Self-awareness, 40
Self-care capacity, in older adults, 390t
Self-examination
breast, 169, 173b–174b
testicular, 214, 216b–217b
Senile ptosis, 384
Sensitivity, statistical, 25b–26b
Sensorineural hearing loss, 101, 121t,
293
Sensory system, assessment of, 13,
298–301
Serous effusion, 120t
Sexual abuse, in children, 343, 357t
Sexual history, 45
Sexual maturity ratings, in
adolescents, 353t–356t
Sexually transmitted infections (STIs)
counseling for, 213–214, 228, 243
in females, 227–228, 231
in males, 213–214, 219t–220t
Short stature, 329
Shortness of breath, 128, 147
Shoulder
examination of, 259–261
painful, 282t
Signing breathing, 65t
Sinuses
assessment of, 11, 108
health history of, 101–102
in review of systems, 5
Sinusitis, 112t
Skene’s gland, 225, 368
Skin, 83–98
cancer of, 83, 94t–96t, 378
color of, 51, 86t
concerning symptoms, 83
examination of, 10, 84–85
health promotion and counseling
for, 83
in infants, 331
lesions of, 51, 87t–94t
nevi, 83, 96t
in older adults, 383–384
recording findings, 85
in review of systems, 5
tags, 336
Skin cancer
ABCDE screening for, 83, 96t
in older adults, 378
types of, 95t–96t
Skin lesions
assessment of, 51
primary, 87t–90t
secondary, 90t–92t
vascular and purpuric, 93t–94t
Smoking
in cardiovascular disease, 153
in older adults, 376
during pregnancy, 362–363
readiness for cessation, 128b
Sneezing, 101
Social development, 324
Social history, 2b, 4
Social phobia, 80t

414 Index
Sodium, food sources of, 64t
Somatoform disorders, 76t–78t
Spasticity, 316t
Specificity, statistical, 25b–26b
Speculum examination, 230–231,
368
Speech
aphasia, 72b
assessment of, 72
in delirium and dementia, 391t
development of, 324
Spermatic cord, 215, 222t
Spermatocele, 222t
Spheroidal joints, 253b
Spider angioma, 93t
Spider vein, 93t
Spinal accessory nerve, 291b, 294
Spinal cord, 286
Spinal nerve, 287
Spinal stenosis, 199
lumbar, 277t
Spine, examination of, 266–267
Spleen, examination of, 189
Splenomegaly, 189
Spontaneous pneumothorax, 140t
Sprains, 255, 274–275, 284t
Squamous cell carcinoma, 95t, 383
Stance, assessment of, 298
Standard precautions, 14
Steatorrhea, 182
Stereognosis, 300
Sternomastoid muscles, 294
Stiffness
back, 278t
joint, 255
Stool, 182–183
Strabismus, 332, 339
Straight leg rise, 304
Strep throat, 102
Stress disorder, acute, 81t
Stridor, 129, 334b
Stroke
face paralysis in, 312t
prevention of, 289–290
types of, 308t–309t
vascular territories of, 310t–311t
Structural coma, 319t
Stupor, 305
Sty, 117t
Subacromial bursitis, 282t
Subarachnoid hemorrhage, 99–100,
113t, 287
Subdeltoid bursitis, 282t
Subdural hematoma, 329
Subjective data, 2b
Substance abuse, 46, 71, 363
Subtalar joint, 275
Suicide risk, 71
Summarization, 34
Supernumerary teeth, 333
Supinator reflex, 302
Sutures, cranial, 331
Swallowing, 182
Swelling
of feet, 200
of infant head, 331
joint, 255
of legs, 200
Symptoms
seven attributes of, 3b, 38b
unexplained and mental status, 67,
67b–68b
Syncope, 288
Syndactyly, 336
Synovial joints, 252b–253b
Syphilis
female genital, 234t
lip, 122t
male genital, 220t
primary, 220t, 234t
secondary, 234t
tongue, 124t
Systemic lupus erythematosus (SLE),
255
Systems review, 2b, 4–7
Systolic hypertension, isolated, 56,
382
Systolic murmur, 159
T
Tachycardia, paroxysmal
supraventricular, 330
Tachypnea, 65t
Tactile fremitus, 130
Talocalcaneal joint, 275
Tangential lighting, 9
Tavistock principles, 48b
Teeth, 109
in children, 341–342
supernumerary, 333
Telangiectasia, hereditary
hemorrhagic, 122t
Temperature, body, assessment of,
57–58
Temperature sensation, 299
Temporal muscles, 259, 293
Temporomandibular joint,
examination of, 259

Index 415
Tendonitis, 255
of shoulder, 282t
Tendons, 251
10-Minute Geriatric Screener, 378,
380b–381b
Tenosynovitis, 264
Tension headache, 99, 111t
Terry’s nails, 98t
Testes
abnormalities of, 221t
cancer of, 221t
examination of, 215
sexual maturity ratings, 354t–355t
small, 221t
undescended, 336
Testicular self-examination, 214,
216b–217b
Tetralogy of Fallot, 351t–352t
Thalamus, 285
Thermometers, 58
Thorax (chest), 127–136
anterior, 12, 134–135
concerning symptoms, 127–128
deformities of, 144t–145t
disorders of, 137t–140t,
144t–146t
examination of, 129–135
health history, 127–128
health promotion and counseling,
128
in infants, 334, 334b–335b
in older adults, 385
posterior, 11, 130–134
during pregnancy, 366
recording findings, 136b
Thought content
assessment of, 73, 392t
defined, 69b
Thought processes
assessment of, 73, 391t
defined, 69b
Throat
abnormalities of, 125t
in children, 333, 341–342
examination of, 11, 102, 109
health history, 102
in older adults, 384–385
recording findings, 110b
in review of systems, 5
sore, 102, 125t
Thromboangiitis obliterans, 202
Thrombophlebitis, 203
Thrush, 333
Thumbs, examination of,
264–265
Thyroid gland
abnormalities of, 126t
examination of, 110
in health history, 102
during pregnancy, 365
TIA (transient ischemic attack), 288,
289
Tibia, torsion of the, 337
Tibial pulse, posterior, 204
Tibiofemoral joint, 270
Tibiotalar joint, 275
Tics, 315t
Tinea capitis, 97t
Tinnitus, 101
Tinsel’s sign, 265
Tobacco use. See Smoking
Tongue
abnormalities of, 123t–124t
assessment of, 109
in children, 333, 341
Tonsillitis, 109
Tonsils, 109, 342
Torsion of spermatic cord, 222t
Torsion of the tibia, 337
Torticollis, 279t
Tortuous atherosclerotic aorta,
385
Total anomalous pulmonary venous
return, 335
Touch sensation, 299
Toxic-metabolic coma, 319t
Tracheal breath sounds, 132b
Tracheobronchitis, 138t, 141t
Transient ischemic attack (TIA),
288, 289
Transmitted voice sounds, 133,
133b
Transposition of the great arteries,
335, 352t
Transverse tarsal joint, 275
Trapezius muscles, 294
Traumatic flail chest, 144t
Tremors, 314t
essential, 388
in older adults, 388
Triceps reflex, 301
Trichomonas vaginitis, 235t
Trichotillomania, 97t
Tricuspid regurgitation, 154
Trigeminal nerve, 291b, 292–293
Trigeminal neuralgia, 113t
Trigger finger, 264
Trochanteric bursa, 268
Tuberculosis, pulmonary, 142t
Tug test, 107

416 Index
Tumors
androgen-producing, 386
of brain, 99–100, 113t
estrogen-producing, 387
skin, 94t–95t
of testis, 321t
Turgor, skin, 84, 331
Two-point discrimination, 300
Tympanic membrane temperature, 58
Tympanic percussion note, 131b
Tympanosclerosis, 120t
U
Ulcerative colitis, 195t
Ulcers
aphthous, 124t
arterial insufficiency, 208t
of feet and ankles, 208t
neuropathic, 208t
of skin, 92t, 384
venous insufficiency, 208t
Umbilical cord, 328
Umbilical hernia, 328
Universal precautions, 14
Upper motor neuron lesion, 301
Urethral caruncle, 230
Urethral orifice, 230
Urethritis, 183–184, 213, 230
Urinary frequency, 183
Urinary incontinence, types of, 184,
196t–197t
Urinary system
concerning symptoms, 179b
examination of, 183–184
in review of systems, 6
Urinary urgency, 183
Urination, 183–184
Urine, 183
Uterus
bicornuate, 369
examination of, 232
myoma of, 239t
positions of, 239t
during pregnancy, 367, 369
prolapsed, 238t
V
Vagina
adenosis of, 237t
discharge from, 226, 235t, 343
examination of, 231–232
Vaginitis, 235t, 343
Vaginosis, 235t
Vagus nerve, 291b, 294
Validation, 33
Validity, test, 25b
Valsalva maneuver, 159
Values, defined, 40
Varicocele, 215, 222t
Varicose veins, 204, 370
Vasovagal (vasodepressor) syncope,
288
Veins
jugular, 154
spider, 93t
varicose, 124t, 204, 370
Venereal warts, 219t, 233t
Venous insufficiency, 207t–208t
Venous stasis ulcers, 200
Ventricular heart failure, left, 139t,
143t, 146t, 147, 155, 159
Ventricular hypertrophy
left, 155, 385
right, 156
Ventricular septal defect, 352t
Vertigo, 101, 287
Vesicle, 89t
Vesicular breath sounds, 132b
Vibration sensation, 299–300
Visceral pain, 179
Vision
in children, 339, 340b
disorders of, 102–103, 112t, 115t
headaches and, 112t
health promotion and counseling
for, 102–103
in infants, 332, 332b
interviewing patient with
impairment, 44
in older adults, 384
Visual field defects, 115t
Vital signs
assessment of, 10, 54–58
blood pressure, 54–56
in children, 330, 339
functional status, 379–380
heart rate and rhythm, 56–57
in older adults, 382–383
during pregnancy, 365
recording findings, 60
respiratory rate and rhythm, 57
temperature, 57–58
Vitamin D
food sources of, 63t
recommended dietary intake for,
258b
Vitreous floaters, 101

Index 417
Vitreous hemorrhage, 100
Vocabulary, assessment of, 74
Voice sounds, transmitted, 133, 133b
Vomiting, 181
Vulva, 233t–234t
Vulvovaginitis, 183
W
Warts, genital, 219t, 233t
Weakness, 49, 288
Weaver’s bottom, 268
Weber test, 108, 121t, 293
Weight
assessment of, 52–53
body mass index (BMI) and, 52–54
changes in, 50
in children, 338
health history, 50
in infants, 329
in older adults, 383
optimal, 50–51
during pregnancy, 361, 362b
Wheal, 88t
Wheezes, 129, 133b
Whiplash, 279t
Whispered pectoriloquy, 133, 133b
White matter, 285
Winging of scapula, 304
Wrist, 262, 264, 296
X
Xanthelasma, 117t

Bates’ Pocket Guide to Physical Examination and History Taking
Half Title Page
Title Page
Copyright
Dedication
Introduction
Contents
Chapter 1: Overview: Physical Examination and History Taking
The Comprehensive Adult Health History
CHIEF COMPLAINT(S)
PRESENT ILLNESS
HISTORY
FAMILY HISTORY
PERSONAL AND SOCIAL HISTORY
REVIEW OF SYSTEMS (ROS)
The Physical Examination: Approach and Overview
BEGINNING THE EXAMINATION: SETTING THE STAGE
The Comprehensive Adult Physical Examination
Standard and Universal Precautions
Chapter 2: Clinical Reasoning, Assessment, and Recording Your Findings
Assessment and Plan: the Process of Clinical Reasoning
The Case of Mrs. N
Approaching the Challenges of Clinical Data
Organizing the Patient Record
Chapter 3: Interviewing and the Health History
The Fundamentals of Skilled Interviewing
The Sequence and Context of the Interview
PREPARATION
THE SEQUENCE OF THE INTERVIEW
THE CULTURAL CONTEXT OF THE INTERVIEW
Advanced Interviewing
CHALLENGING PATIENTS
SENSITIVE TOPICS
Ethics and Professionalism
Chapter 4: Beginning the Physical Examination: General Survey, Vital Signs, and Pain
The Health History
Health Promotion and Counseling: Evidence and Recommendations
Techniques of Examination
THE VITAL SIGNS: BLOOD PRESSURE, HEART RATE, RESPIRATORY RATE, AND TEMPERATURE
ACUTE AND CHRONIC PAIN
Recording Your Findings
Aids to Interpretation
Chapter 5: Behavior and Mental Status
The Health History
Health Promotion and Counseling: Evidence and Recommendations
Techniques of Examination
SPECIAL TECHNIQUE
Recording Your Findings
Aids to Interpretation
Chapter 6: The Skin, Hair, and Nails
The Health History
Health Promotion and Counseling: Evidence and Recommendations
Techniques of Examination
Recording Your Findings
Aids to Interpretation
Chapter 7: The Head and Neck
The Health History
Health Promotion and Counseling: Evidence and Recommendations
Techniques of Examination
Recording Your Findings
Aids to Interpretation
Chapter 8: The Thorax and Lungs
The Health History
Health Promotion and Counseling: Evidence and Recommendations
Techniques of Examination
SPECIAL TECHNIQUES
Recording Your Findings
Aids to Interpretation
Chapter 9: The Cardiovascular System
The Health History
Health Promotion and Counseling: Evidence and Recommendations
Techniques of Examination
SPECIAL TECHNIQUES
Recording Your Findings
Aids to Interpretation
Chapter 10: The Breasts and Axillae
The Health History
Health Promotion and Counseling: Evidence and Recommendations
Techniques of Examination
SPECIAL TECHNIQUE
Recording Your Findings
Aids to Interpretation
Chapter 11: The Abdomen
The Health History
Health Promotion and Counseling: Evidence and Recommendations
Techniques of Examination
Recording Your Findings
Aids to Interpretation
Chapter 12: The Peripheral Vascular System
The Health History
Health Promotion and Counseling: Evidence and Recommendations
Techniques of Examination
SPECIAL TECHNIQUES
Recording Your Findings
Aids to Interpretation
Chapter 13: Male Genitalia and Hernias
The Health History
Health Promotion and Counseling: Evidence and Recommendations
Techniques of Examination
SPECIAL TECHNIQUE
Recording Your Findings
Aids to Interpretation
Chapter 14: Female Genitalia
The Health History
Health Promotion and Counseling: Evidence and Recommendations
Techniques of Examination
SPECIAL TECHNIQUE
Recording Your Findings
Aids to Interpretation
Chapter 15: The Anus, Rectum, and Prostate
The Health History
Health Promotion and Counseling: Evidence and Recommendations
Techniques of Examination
Recording Your Findings
Aids to Interpretation
Chapter 16: The Musculoskeletal System
Fundamentals for Assessing Joints
The Health History
Health Promotion and Counseling: Evidence and Recommendations
Techniques of Examination
SPECIAL TECHNIQUES
Recording Your Findings
Aids to Interpretation
Chapter 17: The Nervous System
Fundamentals for Assessing the Nervous System
CENTRAL NERVOUS SYSTEM
PERIPHERAL NERVOUS SYSTEM
The Health History
Health Promotion and Counseling: Evidence and Recommendations
Techniques of Examination
SPECIAL TECHNIQUES
Recording Your Findings
Aids to Interpretation
Chapter 18: Assessing Children: Infancy Through Adolescence
Child Development
The Health History
Health Promotion and Counseling: Evidence and Recommendations
Techniques of Examination
Assessing Newborns
Assessment Several Hours After Birth
Assessing Infants
Assessing Children (1 to 10 Years)
SPECIAL TECHNIQUE
Assessing Adolescents
SPECIAL TECHNIQUE
Recording Your Findings
Aids to Interpretation
Chapter 19: The Pregnant Woman
The Health History
Health Promotion and Counseling: Evidence and Recommendations
Techniques of Examination
SPECIAL TECHNIQUES
Recording Your Findings
Chapter 20: The Older Adult
The Health History
APPROACH TO THE PATIENT
COMMON CONCERNS
Health Promotion and Counseling: Evidence and Recommendations
Techniques of Examination
ASSESSING FUNCTIONAL STATUS: THE “SIXTH VITAL SIGN”
Recording Your Findings
Aids to Interpretation
Index