Bates’ Pocket Guide to Physical Examination and History Taking, 8e (Nov 1, 2016)_(1496338480)_(LWW).pdf

and History Tak g

- - ~ Wolters Kluwer

B A T E S' Pocket Guide to

Physical Examination AND History Taking

B A T E S ' Pocket Guide to

Physical Examination AND History Taking EIGHTH EDITIO N

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 and Executive Vice-Chair Department of Pediatrics University of California at Los Angeles (UCLA) Los Angeles, California Gu est Edit or

Richard M. Hoffman, MD, MPH, FACP Professor of Internal Medicine and Epidemiology Director, Division of General Internal Medicine University of Iowa Carver College of Medicine Iowa City, Iowa

Acquisitions Editor: Crystal Taylor Product Development Editor: Greg Nicholl Marketing Manager: Michael McMahon Production Project Manager: Cynthia Rudy Design Coordinator: Holly McLaughlin Art Director: Jennifer Clements Illustrator: Body Scientific International Manufacturing Coordinator: Margie Orzech Prepress Vendor: Aptara, Inc. Eighth Edition Copyright © 2017 Wolters Kluwer. Copyright © 2013, 2009 by Wolters Kluwer Health | Lippincott Williams & Wilkins. Copyright © 2007, 2004, 2000 by Lippincott Williams & Wilkins. Copyright © 1995, 1991 by J. B. Lippincott Company. All rights reserved. This book is protected by copyright. No part of this book may be reproduced or transmitted in any form or by any means, including as photocopies or scanned-in or other electronic copies, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews. Materials appearing in this book prepared by individuals as part of their official duties as U.S. government employees are not covered by the above-mentioned copyright. To request permission, please contact Wolters Kluwer at Two Commerce Square, 2001 Market Street, Philadelphia, PA 19103, via email at [email protected], or via our website at lww.com (products and services). 9 8 7 6 5 4 3 2 1 Printed in China Library of Congress Cataloging-in-Publication Data Names: Bickley, Lynn S., author. | Szilagyi, Peter G., author. | Hoffman, Richard M., editor. | Abridgement of (expression): Bickley, Lynn S. Bates’ guide to physical examination and history-taking. 12th ed. Title: Bates’ pocket guide to physical examination and history taking / Lynn S. Bickley, Peter G. Szilagyi ; guest editor, Richard M. Hoffman. Other titles: Pocket guide to physical examination and history taking Description: Eighth edition. | Philadelphia : Wolters Kluwer, [2017] | Abridgement of: Bates’ guide to physical examination and history-taking. / Lynn S. Bickley, Peter G. Szilagyi. Twelfth edition. [2017]. | Includes bibliographical references and index. Identifiers: LCCN 2016030575 | ISBN 9781496338488 (alk. paper) Subjects: | MESH: Physical Examination–methods | Medical History Taking–methods | Handbooks Classification: LCC RC76 | NLM WB 39 | DDC 616.07/54–dc23 LC record available at https://lccn.loc.gov/2016030575 This work is provided “as is,” and the publisher disclaims any and all warranties, express or implied, including any warranties as to accuracy, comprehensiveness, or currency of the content of this work. This work is no substitute for individual patient assessment based upon healthcare professionals’ examination of each patient and consideration of, among other things, age, weight, gender, current or prior medical conditions, medication history, laboratory data and other factors unique to the patient. The publisher does not provide medical advice or guidance and this work is merely a reference tool. Healthcare professionals, and not the publisher, are solely responsible for the use of this work including all medical judgments and for any resulting diagnosis and treatments. Given continuous, rapid advances in medical science and health information, independent professional verification of medical diagnoses, indications, appropriate pharmaceutical selections and dosages, and treatment options should be made and healthcare professionals should consult a variety of sources. When prescribing medication, healthcare professionals are advised to consult the product information sheet (the manufacturer’s package insert) accompanying each drug to verify, among other things, conditions of use, warnings and side effects and identify any changes in dosage schedule or contraindications, particularly if the medication to be administered is new, infrequently used or has a narrow therapeutic range. To the maximum extent permitted under applicable law, no responsibility is assumed by the publisher for any injury and/or damage to persons or property, as a matter of products liability, negligence law or otherwise, or from any reference to or use by any person of this work. LWW.com

We would like to dedicate this book to all our students, tr ainees, and mentees who have taught us the tr ue value of both the science and the ar t of medicine.

Faculty Reviewers

J. D. Bartleson Jr., MD

Amit Garg, MD

Associate Professor of Neurology Mayo Clinic Rochester, Minnesota

Dermatologist Northwell Health Physician Partners Manhasset, New York

John D. Bartlett, MD

Catherine F. Gracey, MD

Assistant Clinical Professor of Ophthalmology Jules Stein Eye Institute David Geffen School of Medicine Los Angeles, California

Associate Professor Department of Medicine School of Medicine and Dentistry University of Rochester Medical Center Rochester, New York

Amy E. Blatt, MD Assistant Professor Department of Medicine School of Medicine and Dentistry University of Rochester Medical Center Rochester, New York

Adam Brodsky, MD Associate Professor Medical Director Geriatric Psychiatry Services Department of Psychiatry and Behavioral Sciences School of Medicine University of New Mexico Psychiatric Center & Sandoval Regional Medical Center Albuquerque, New Mexico

Thomas M. Carroll, MD, PhD Assistant Professor Department of Medicine School of Medicine and Dentistry University of Rochester Medical Center Rochester, New York

Adam J. Doyle, MD Assistant Professor Department of Surgery School of Medicine and Dentistry University of Rochester Medical Center Rochester, New York

vi

Carla Herman, MD, MPH Chief Division of Geriatrics and Palliative Medicine Professor Department of Internal Medicine School of Medicine University of New Mexico Albuquerque, New Mexico

William C. Hulbert, MD Professor Department of Urology School of Medicine and Dentistry University of Rochester Medical Center Rochester, New York

Mark Landig, OD Department of Ophthalmology Jules Stein Eye Institute David Geffen School of Medicine Los Angeles, California

Helen R. Levey, DO, MPH PGY5 Resident School of Medicine and Dentistry University of Rochester Medical Center Rochester, New York

Fa c ulty Re vie we rs

Patrick McCleskey, MD

Scott A. Vogelgesang, MD

Dermatologist Oakland Medical Center Oakland, California

Director Division of Immunology Clinical Professor Department of Internal Medicine– Immunology University of Iowa Carver College of Medicine Iowa City, Iowa

Jeanne H. S. O’Brien, MD Associate Professor Department of Urology School of Medicine and Dentistry University of Rochester Medical Center Rochester, New York

Alec B. O’Connor, MD, MPH Director, Internal Medicine Associate Professor Department of Medicine School of Medicine and Dentistry University of Rochester Medical Center Rochester, New York

A. Andrew Rudmann, MD Associate Professor Department of Medicine University of Rochester Medical Center School of Medicine and Dentistry Rochester, New York

Moira A. Szilagyi, MD, PhD

Brian P. Watkins, MD Surgeon Genesee Surgical Associates Rochester, New York

Paula Zozzaro-Smith, DO Fellow of Maternal-Fetal Medicine Department of Obstetrics and Gynecology The University of Rochester Rochester, New York S TU D EN T REVIEWERS

Ayala Danzig University of Rochester School of Medicine and Dentistry

Professor of Pediatrics University of California at Los Angeles (UCLA) Los Angeles, California

Benjamin Edmonds

Loralei Lacina Thornburg, MD

University of Rochester School of Medicine and Dentistry

Associate Professor Department of Obstetrics and Gynecology School of Medicine and Dentistry University of Rochester Medical Center Rochester, New York

University of Central Florida College of Medicine

Nicholas P. N. Goldstein

vii

Preface

Bates’ Pocket Guide to Physical Examination and History Taking, eighth edition, is a concise, portable text, with new chapters on assessing clinical evidence and examination of the skin, hair, and nails, that: ■ Recommends how to sequence the physical examination and document ■ ■ ■ ■ ■

an accurate written record. Clari es assessment of clinical evidence. Describes how to interview the patient and take the health history. Details and illustrates the steps of each of the regional physical examinations. Reminds students of common, normal, and abnormal physical ndings. Provides visual aids and comparative tables to guide recognition of common and selected ndings.

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 Chapter 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 section in each chapter. ■ To look up additional information about possible ndings, including abnormalities and standards of normal. The Pocket Guide is not intended to serve as a primary text for learning the skills of history taking or physical examination. Its detail is too brief. It is intended instead as an aid for student recall of the regional examinations and examinations for special populations and as a convenient, brief, and portable reference.

viii

Contents

Faculty Reviewers Preface viii CHAP TER CHAP TER CHAP TER CHAP TER

CHAP TER CHAP TER CHAP TER CHAP TER CHAP TER CHAP TER CHAP TER CHAP TER CHAP TER CHAP TER CHAP TER CHAP TER CHAP TER CHAP TER CHAP TER CHAP TER

Index

vi

1 2 3 4

Foundations for Clinical Proficiency

5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Behavior and Mental Status

Evaluating Clinical Evidence

1

27

Interviewing and the Health History

41

Beginning the Physical Examination: General Survey, Vital Signs, and Pain 59

The Skin, Hair, and Nails

77

89

The Head and Neck 115 The Thorax and Lungs

145

The Cardiovascular System The Breasts and Axillae The Abdomen

167

187

199

The Peripheral Vascular System Male Genitalia and Hernias Female Genitalia

219

233

247

The Anus, Rectum, and Prostate The Musculoskeletal System The Nervous System

265

275

311

Assessing Children: Infancy through Adolescence The Pregnant Woman The Older Adult

349

383

399

423 ix

1

C H A P T E R

Foundations for Clinical Proficiency

This chapter provides a road map to clinical pro ciency 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 of ce or hospital merit a comprehensive health history; however, in many situations, a more exible 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 uid and should follow the patient’s leads and cues, as described in Chapter 3. O v e r v ie w : C o m p o n e n t s o f t h e A d u lt H e a lt h H is t o r y Id e n t if y in g D a t a

●

●

●

Re lia b ilit y

●

C h ie f C o m p la in t (s )

●

P r e s e n t Illn e s s

●

●

●

●

Identifying d t —such s ge, gender, occu tion, rit l st tus Source of the history—usu lly the tient, but c n be f ily e ber or friend, letter of referr l, or the clinic l record If ro ri te, est blish source of referr l bec use written re ort y be needed V ries ccording to the tient’s e ory, trust, nd ood The one or ore sy to s or concerns c using the tient to seek c re A lifies the Chief Co l int; describes how e ch sy to develo ed Includes tient’s thoughts nd feelings bout the illness Pulls in relev nt ortions of the Review of Syste s, c lled “ ertinent ositives nd neg tives” (see . 3) M y include edic tions, llergies, h bits of s oking nd lcohol, which frequently re ertinent to the resent illness (continued )

1

2

Ba te s ’ Poc ke t Guide to Phys ic a l Exa mina tion a nd His tory Ta king

O v e r v ie w : C o m p o n e n t s o f t h e A d u lt H e a lt h H is t o r y (Continued ) P a s t His t o ry

● ●

●

Fa m ily His t o ry

●

●

P e r s o n a l a n d S o c ia l His t o ry

●

Re v ie w o f S y s t e m s

●

Lists childhood illnesses Lists dult illnesses with d tes for t le st four c tegories: edic l, surgic l, obstetric/gynecologic, nd sychi tric Includes he lth inten nce r ctices such s i uniz tions, screening tests, lifestyle issues, nd ho e s fety Outlines or di gr s ge nd he lth, or ge nd c use of de th, of siblings, rents, nd gr nd rents Docu ents resence or bsence of s ecific illnesses in f ily, such s hy ertension, coron ry rtery dise se, etc. Describes educ tion l level, f ily of origin, current household, erson l interests, nd lifestyle Docu ents resence or bsence of co on sy to s rel ted to e ch jor body syste

Decide if your assessment will be comprehensive or focused. Be sure to distinguish subjective from objective data. S u b je c t ive D a t a

O b je c t ive D a t a

Wh t the

Wh t you detect during the ex in tion, l bor tory infor tion, nd test d t All hysic l ex in tion findings, or signs

tient tells you

The sy to s nd history, fro Chief Co l int through Review of Syste s

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 re ects the quality of information the patient provides.

C h ie f C o m p la in t (s ) Quote the patient’s own words. “My stomach hurts and I feel awful”; or “I have come for my regular check-up.”

Chapter 1 | Foundations for Clinical Proficiency

3

P r e s e n t Illn e s s This section is a complete, clear, and chronologic account of the problems prompting the patient to seek care. It should include the problem’s onset, the setting in which it has developed, its manifestations, and any treatments. Every principal symptom should be well characterized, with descriptions 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. T h e S e v e n A t t r ib u t e s o f E v e r y S y m p t o m ● ● ● ● ● ● ●

Loc tion Qu lity Qu ntity or severity Ti ing, including onset, dur tion, nd frequency Setting in which it occurs Aggr v ting nd relieving f ctors Associ ted nifest tions

In addition, list medications, including name, dose, route, and frequency of use; allergies, including speci c reactions to each medication; tobacco use; and alcohol and drug use.

P a s t H is t o r y 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) ■ 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, in uenza, varicella, hepatitis B virus (HBV), human papillomavirus (HPV), Haemophilus in uenzae type B, pneumococcal vaccine, and herpes zoster vaccine; and screening tests, such as tuberculin tests, Pap smears, mammograms, stool tests for occult blood, colonoscopy, and cholesterol tests, together with the results and the dates they were last performed.

4


F a m ily H is t o r y 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, elevated 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.

P e r s o n a l a n d S o c ia l H is t o r y Include occupation and the last year of schooling; home situation and signi cant others; sources of stress, both recent and long term; important life experiences, such as military service; leisure activities; religious af liation 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.

R e v ie w o f S y s t e m s (R O S ) These “yes/no” questions go from “head to toe” and conclude the interview. 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 speci c questions about systems that may be of concern. For example, “How are your ears and hearing?” “How about your lungs and breathing?” “Any trouble with your heart?” “How is your digestion?” The Review of Systems questions 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. Ge n e ra l. Usual weight, recent weight change, clothing that ts more tightly or loosely than before; weakness, fatigue, fever. S k in . Rashes, lumps, sores, itching, dryness, color change; changes in hair or nails; changes in size or color of moles. He a d , Eye s , Ea r s , No s e , Th ro a t (HEENT). Head: Headache, head injury, dizziness, lightheadedness. Eyes: Vision, glasses or contact lenses, last examination, pain, redness, excessive tearing, double or blurred vision,


5

spots, specks, ashing lights, glaucoma, cataracts. Ears: Hearing, tinnitus, vertigo, earache, infection, discharge. If hearing is decreased, use or nonuse of hearing aid. Nose and sinuses: Frequent colds, nasal stuf ness, 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 t; last dental examination; sore tongue; dry mouth; frequent sore throats; hoarseness. Ne c k . Lumps, “swollen glands,” goiter, pain, stiffness. Bre a s t s . Lumps, pain or discomfort, nipple discharge, self-examination practices. Re s p ira t o ry. Cough, sputum (color, quantity), hemoptysis, dyspnea, wheezing, pleurisy, last chest x-ray. You may wish to include asthma, bronchitis, emphysema, pneumonia, and tuberculosis. Ca rd io va s c u la r. “Heart trouble,” hypertension, rheumatic fever, heart murmurs, chest pain or discomfort, palpitations, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, edema, past electrocardiographic or other cardiovascular tests. Ga s t ro in t e s t in a l. 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. P e r ip h e r a l Va s c u la r. Intermittent claudication; leg cramps; varicose veins; past clots in veins; swelling in calves, legs, or feet; color change in ngertips or toes during cold weather; swelling with redness or tenderness. Urin a ry. Frequency of urination, polyuria, nocturia, urgency, burning or pain on urination, hematuria, urinary infections, kidney stones, incontinence; in males, reduced caliber or force of urinary stream, hesitancy, dribbling. G e n it a l. Male: Hernias, discharge from or sores on penis, testicular pain or masses, history of sexually transmitted infections (STIs) 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, menopausal symptoms, postmenopausal bleeding. In patients born before 1971, exposure to

6


diethylstilbestrol (DES) from maternal use during pregnancy. Vaginal discharge, itching, sores, lumps, STIs and treatments. 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. M u s c u lo s k e le t a l. 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 limitation of motion or activity; include timing of symptoms (e.g., morning 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. P s yc h ia t ric . Nervousness; tension; mood, including depression, memory change, suicide attempts, if relevant. Ne u ro lo g ic . Changes in mood, attention, or speech; changes in orientation, 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. He m a t o lo g ic . Anemia, easy bruising or bleeding, past transfusions, transfusion reactions. En d o c rin e . “Thyroid trouble,” heat or cold intolerance, excessive sweating, excessive thirst or hunger, polyuria, change in glove or shoe size.

The Comprehensive Physical Examination 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 systematic

sequence of examination. With effort and practice, you will acquire your own routine sequence. This book recommends examining from the patient’s right side. ■ Apply the techniques of inspection, palpation, auscultation, and percus-

sion to each body region, but be sensitive to the whole patient.


7

■ 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.

B e g in n in g t h e E x a m in a t io n : S e t t in g t h e S t a g e Take the following steps to prepare for the physical examination. S t e p s in P r e p a r in g f o r t h e P h y s ic a l E x a m in a t io n 1. 2. 3. 4. 5. 6.

Reflect on your ro ch to the tient. Adjust the lighting nd the environ ent. Check your equi ent. M ke the tient co fort ble. Observe st nd rd nd univers l rec utions. Choose the sequence, sco e, nd ositioning of ex

in tion.

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. Re e c t o n Yo u r A p p r o a c h t o t h e P a t ie n t . 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 rst! Simply examine that area out of sequence, but smoothly. A d ju s t Lig h t in g a n d t h e En v ir o n m e n t . Adjust the bed to a convenient height (be sure to lower it when nished!). 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. Ch e c k Yo u r Eq u ip m e n t . Be sure your stethoscope, re ex hammer, and other equipment are readily at hand. M a k e t h e P a t ie n t C o m fo r t a b le . Show concern for privacy and modesty.

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■ 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 nished, 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. S t a n d a r d a n d M RS A P r e c a u t io n s . Observe standard and universal precautions. Use rigorous handwashing before and after all patient contact and, whenever indicated, personal protective equipment (gloves; gowns; and mouth, nose, and eye protection); safe injection practices; safe handling of contaminated equipment or surfaces; respiratory hygiene and cough etiquette; patient isolation criteria; and precautions relating to equipment, toys, solid surfaces, and laundry handling. Un ive r s a l P re c a u t io n s . Universal precautions are a set of precautions designed to prevent transmission of HIV, HBV, and other bloodborne pathogens when providing rst aid or health care. The following uids are considered potentially infectious: all blood and other body uids containing visible blood, semen, and vaginal secretions; and cerebrospinal, synovial, pleural, peritoneal, pericardial, and amniotic uids. 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. C h o o s e t h e S e q u e n c e , S c o p e , a n d P o s it io n in g o f t h e Ex a m in a t io n . The sequence of the examination should ■ maximize the patient’s comfort ■ avoid unnecessary changes in position, and ■ enhance the clinician’s ef ciency.


T h e P h y s ic a l E x a m in a t io n : S u g g e s t e d S e q u e n c e a n d P o s it io n in g ● ● ●

●

●

● ● ●

●

●

●

Gener l survey Vit l signs Skin: u er torso, nterior nd osterior He d nd neck, including thyroid nd ly h nodes Optional: Nervous syste ( ent l st tus, cr ni l nerves, u er extre ity otor strength, bulk, tone, cerebell r function) Thor x nd lungs Bre sts Musculoskelet l s indic ted: u er extre ities C rdiov scul r, including jugul r venous ressure (JVP), c rotid u strokes nd bruits, oint of xi l i ulse (PMI), S1, S2, ur urs, extr sounds C rdiov scul r, for S3 nd ur ur of itr l stenosis C rdiov scul r, for ur ur of ortic insufficiency

●

● ● ● ●

●

● ●

●

●

●

●

Optional: thor x nd lungs— nterior Bre sts nd xill e Abdo en Peri her l v scul r Optional: skin—lower torso nd extre ities Nervous syste : lower extre ity otor strength, bulk, tone, sens tion; reflexes; B binski reflex Musculoskelet l, s indic ted Optional: skin, nterior nd ost erior Optional: nervous syste , including g it Optional: usculoskelet l, co rehensive Women: elvic nd rect l ex in tion Men: rost te nd rect l ex in tion

Key to the Symbols for the Patient’s Position Sitting

Lying su ine

Lying su ine, with he d of bed r ised 3 degrees

St nding

S

e, t urned

rt ly t o left side

Sitting, le ning forw rd

Lying su ine, with hi s flexed, bducted, nd extern lly rot ted, nd knees flexed (lithoto y osition) Lying on the left side (left l ter l decubitus)

Each symbol pertains until a new one appears. Two symbols separated by a slash indicate either or both positions.

Choose whether to do a comprehensive or focused examination. In general, move from “head to toe.” An important goal as a student is to develop your own sequence with these principles in mind.

9

10


Examine the patient from the patient’s right side. Note that the right side 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 nish the rest of the examination with the patient again supine.

T h e P h y s ic a l E x a m in a t io n : H e a d t o T o e Ge n e ra l S u r ve y. Continue this survey throughout the patient visit. Observe general state of health, height, build, and sexual development. 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. Vit a l S ig n s . Ask the patient to sit on the edge of the bed or examining 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. S k in . 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. HEENT. Head: Examine the hair, scalp, skull, and face. Eyes: Check visual acuity and screen the visual elds. 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. Assess extraocular movements. Darken the room to promote pupillary dilation and visibility of the fundi. Compare the pupils, and test their reactions to light. 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.


11

Ne c k . 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. Ba c k . Inspect and palpate the spine and muscles. P o s t e rio r Th o ra x a n d Lu n g s . 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. 151). Bre a s t s , Axilla e , a n d Ep it ro ch le a r No d e s . The patient is still sitting. 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 N o t e o n t h e M u s c u lo s k e le t a l S y s t e m . By now, you have made

preliminary 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. (You may choose to examine upper extremity muscle bulk, tone, strength, and re exes at this time, or you may decide to wait until later.) Palpate the breasts, while continuing your inspection. An t e rio r Th o ra x a n d Lu n g s . 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. Ca rd io va s c u la r S ys t e m . Elevate head of bed to about 30 degrees, adjusting as necessary to see the jugular venous pulsations. 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.

12


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 auscultatory area with the diaphragm. Listen for S1 and S2 and for physiologic splitting of S2. Listen for any abnormal heart sounds or murmurs. Ab d o m e n . Lower the head of the bed to the at 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. / P e rip h e ra l Va s c u la r S ys t e m . 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. / Lo w e r Ext re m it ie s . Examine the legs, assessing the peripheral vascular, musculoskeletal, and nervous systems while the patient is still supine. Each of these systems can be further assessed when the patient stands. / Ne r vo u s S ys t e m . The patient is sitting or supine. The examination of the nervous system can also be divided into the upper extremity examination (when the patient is still sitting) and the lower extremity examination (when the patient is supine) after examination of the peripheral nervous system. M e n t a l S t a t u s . If indicated and not done during the interview, assess ori-

entation, mood, thought process, thought content, abnormal perceptions, insight and judgment, memory and attention, information and vocabulary, calculating abilities, abstract thinking, and constructional ability. C r a n ia l N e r ve s . 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 sternocleidomastoid muscles, and protrusion of tongue. M o t o r S y s t e m . 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. S e n s o ry S ys t e m . Pain, temperature, light touch, vibrations, and discrimina-

tion. Compare right and left sides and distal with proximal areas on the limbs.


13

Re f le xe s . Include biceps, triceps, brachioradialis, patellar, Achilles

deep tendon reflexes; also plantar reflexes or Babinski reflex (see pp. 327–328). Ad d it io n a l Exa m in a t io n s . The rectal and genital examinations are often performed at the end of the physical examination. / M a le G e n it a lia a n d He r n ia s . Examine the penis and scrotal

contents. Check for hernias. Re c t a l Ex a m in a t io n in M e n . 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 cannot stand, examine the genitalia before doing the rectal examination.) G e n it a l a n d Re c t a l Ex a m in a t io n in Wo m e n . The patient is

supine in the lithotomy position. Sit during the examination with the speculum, then stand during bimanual examination of uterus, 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.

Clinical Reasoning, Assessment, and Plan Using sound clinical reasoning, you must now analyze your ndings and identify the patient’s problems. You must share your impressions with the patient and document your ndings in the patient’s record in a succinct legible format that communicates the patient’s story and physical ndings, and the rationale for your assessment and plan, to other members of the health care team. As you make clinical decisions, you will turn to clinical evidence, calling on your knowledge of sensitivity, speci city, predictive value, and the analytical tools detailed in Chapter 2, Evaluating Clinical Evidence. The comprehensive health history and physical examination form the foundation of your clinical Assessment. The Plan is often wide-ranging and incorporates patient education, changes in medications, needed tests, referrals to other clinicians, and return visits for counseling and support. A successful Plan includes the patient’s responses to the problems identi ed and to the interventions that you recommend. It requires good interpersonal skills and sensitivity to the patient’s goals, economic means, competing responsibilities, and family structure and dynamics.

14


C lin ic a l R e a s o n in g a n d A s s e s s m e n t Because assessment takes place in the clinician’s mind, the process of clinical reasoning may seem opaque and even mysterious to beginning students. Study the steps described below. Focus on determining “What explains this patient’s concerns?” and “What are the ndings, problems, and diagnoses?” S t e p s f o r Id e n t if y in g P r o b le m s a n d M a k in g D ia g n o s e s 1. 2. 3. 4. 5. 6. 7.

Identify bnor l findings. Loc lize findings n to ic lly. Cluster the clinic l findings. Se rch for the rob ble c use of the findings. Cluster the clinic l d t . Gener te hy otheses bout the c uses of the tient’s roble s. Test the hy otheses nd est blish working di gnosis.

Id e n t ify Ab n o rm a l Fin d in g s . Make a list of the patient’s symptoms, the signs you observed during the physical examination, and any laboratory reports available to you. Lo c a lize Th e s e Fin d in g s An a t o m ic a lly. Often this step is straightforward. The symptom of scratchy throat and the sign of an erythematous in amed posterior pharynx, for example, clearly localize the problem to the pharynx. A complaint of headache leads you quickly to the structures of the skull and brain. Other symptoms, however, may present greater dif culty. Chest pain, for example, can originate in the coronary arteries, the stomach and esophagus, or the muscles and bones of the thorax. If the pain is exertional and relieved by rest, either the heart or the musculoskeletal components of the chest wall may be involved. If the patient notes pain only when carrying groceries with the left arm, the musculoskeletal system becomes the likely culprit.

When localizing ndings, be as speci c as your data allow; however, you may have to settle for a body region, such as the chest, or a body system, such as the musculoskeletal system. On the other hand, you may be able to de ne the exact structure involved, such as the left pectoral muscle. Some symptoms and signs are constitutional and cannot be localized, such as fatigue or fever, but are useful in the next set of steps. Clu s t e r t h e Clin ic a l Fin d in g s . Several clinical characteristics may help. ■ Patient age: The patient’s age may help; younger adults are more likely

to have a single disease, whereas older adults tend to have multiple diseases.


15

■ Timing of symptoms: The timing of symptoms is often useful. For example, an

episode of pharyngitis 6 weeks ago is probably unrelated to the fever, chills, pleuritic chest pain, and cough that prompted an of ce visit today. To use timing effectively, you need to know the natural history of various diseases and conditions. A yellow penile discharge followed 3 weeks later by a painless penile ulcer suggests two problems: gonorrhea and primary syphilis. ■ Involvement of different body systems: If symptoms and signs occur in a

single system, one disease may explain them. Problems in different, apparently unrelated, systems often require more than one explanation. For example, you might decide to group a patient’s high blood pressure and sustained apical impulse together with ame-shaped retinal hemorrhages, place them in the cardiovascular system, and label the constellation “hypertensive cardiovascular disease with hypertensive retinopathy.” ■ Multisystem conditions: With experience, you will become increasingly

adept at recognizing multisystem conditions and building plausible explanations that link manifestations that are seemingly unrelated. To explain cough, hemoptysis, and weight loss in a 60-year-old plumber who has smoked cigarettes for 40 years, you would rank lung cancer high in your differential diagnosis. You might support your diagnosis with your observation of the patient’s cyanotic nailbeds. ■ Key questions: You can also ask a series of key questions that may steer

your thinking in one direction and allow you to temporarily ignore the others. 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 (GI) system aside. If the pain is epigastric, you can logically focus on the GI tract. A series of discriminating questions helps you analyze the clinical data and reach logical explanations. S e a rc h fo r t h e P ro b a b le Ca u s e o f t h e Fin d in g s . Patient complaints often stem from a pathologic process involving diseases of a body system or structure. These processes are commonly classi ed as congenital, in ammatory or infectious, immunologic, neoplastic, metabolic, nutritional, degenerative, vascular, traumatic, and toxic.

Other problems are pathophysiologic, re ecting derangements of biologic functions, such as heart failure or migraine headache. Still other problems are psychopathologic, such as disorders of mood like depression or headache as an expression of a somatic symptom disorder. Ge n e ra t e Hyp o t h e s e s Ab o u t t h e Ca u s e s o f t h e P a t ie n t ’s P ro b le m . Draw on the full range of your knowledge and experience, and read widely. By consulting the clinical literature, you embark on the

16


lifelong goal of evidence-based decision making and clinical practice. The following steps may help. S t e p s f o r G e n e r a t in g C lin ic a l H y p o t h e s e s 1. 2. 3. 4. 5.

Select the ost s ecific nd critic l findings to su ort your hy othesis. M tch your findings g inst ll the conditions th t c n roduce the . Eli in te the di gnostic ossibilities th t f il to ex l in the findings. Weigh the co eting ossibilities nd select the ost likely di gnosis. Give s eci l ttention to otenti lly life-thre tening conditions.

Te s t Yo u r Hyp o t h e s e s . You are likely to need further history, additional maneuvers on physical examination, or laboratory studies or x-rays to con rm or rule out your tentative diagnosis or to clarify which diagnosis is most likely. Es t a b lis h a Wo r k in g D ia g n o s is . Establish a working de nition of the problem 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 de ne a problem more speci cally based on its anatomy, disease process, or cause. Routinely listing Health Maintenance helps you track several important health concerns more effectively: immunizations, screening tests such as mammograms or colonoscopies, instructions regarding nutrition and breast or testicular self-examinations, recommendations about exercise or use of seat belts, and responses to important life events.

U s e S h a r e d D e c is io n -M a k in g t o D e v e lo p a P la n Identify and record a Plan for each patient problem. Specify the next steps for each problem, ranging from tests and procedures to subspecialty consultations to new or changed medications to arranging a family meeting. It is critical to not only obtain patient agreement but to have the patient participate in the decision making whenever possible.

The Quality Clinical Record: The Case of Mrs. N. The clinical record serves a dual purpose—it re ects your analysis of the patient’s health status, and it documents the unique features of the patient’s history, examination, laboratory and test results, assessment, and plan in a formal written format. In a well-constructed record, each problem in the Assessment is listed in order of priority with an explanation of supporting


17

ndings and a differential diagnosis, followed by a Plan for addressing that problem. Compose the clinical record as soon after seeing the patient as possible, before your ndings fade from memory, and follow the tips below for a quality patient record. T ip s f o r E n s u r in g Q u a lit y P a t ie n t D a t a ● ●

● ●

● ●

●

Ask o en-ended questions nd listen c refully to the tient’s story. Cr ft thorough nd syste tic sequence to history t king nd hysic l ex in tion. Kee n o en ind tow rd both the tient nd the clinic l d t . Alw ys include “the worst-c se scen rio” in your list of ossible ex l n tions of the tient’s roble , nd ke sure it c n be s fely eli in ted. An lyze ny ist kes in d t collection or inter ret tion. Confer with colle gues nd review the ertinent clinic l liter ture to cl rify uncert inties. A ly the rinci les of ev lu ting clinic l evidence to tient infor tion nd testing.

Study the case of Mrs. N. and scrutinize the history, physical examination, assessment, and plan. Note the standard format of the clinical record. Th e C a s e o f M r s . N . HEALTH HISTORY 8/25/ 16 11: am Mrs. N. is le s nt, 54-ye r-old widowed s leswo New Mexico. Referral. None Source and Reliability. Self-referred; see s reli ble.

n residing in Es

nol ,

Chief Complaint “My he d ches.” Present Illness Mrs. N. re orts incre sing roble s with front l he d ches over the st 3 onths. These re usu lly bifront l, throbbing, nd ild to oder tely severe. She h s issed work on sever l occ sions bec use of ssoci ted n use nd vo iting. He d ches now ver ge once week, usu lly rel ted to stress, nd l st 4 to 6 hours. They re relieved by slee nd utting d towel over her forehe d. There is little relief fro s irin. There re no ssoci ted visu l ch nges, otorsensory deficits, or resthesi s. She h d he d ches with n use nd vo iting beginning t ge 15 ye rs. These recurred throughout her id-2 s, then decre sed to one every 2 or 3 onths nd l ost dis e red. (continued )

18


Th e C a s e o f M r s . N .

(Continued)

The tient re orts incre sed ressure t work fro de nding su ervisor; she is lso worried bout her d ughter (see Personal and Social History). She thinks her he d ches y be like those in the st, but w nts to be sure bec use her other h d he d che just before she died of stroke. She is concerned bec use her he d ches interfere with her work nd ke her irrit ble with her f ily. She e ts three e ls d y nd drinks three cu s of coffee d y nd te t night. Medications. Acet ino hen, 1 to 2 t blets every 4 to 6 hours s needed. “W ter ill” in the st for nkle swelling, none recently. Allergies. A icillin c uses r sh. Tobacco. About 1 ck of cig rettes er d y since ge 18 (36 ck-ye rs). Alcohol/drugs. Wine on r re occ sions. No illicit drugs. Past History Childhood Illnesses: Me sles, chicken ox. No sc rlet fever or rheu t ic fever. Adult Illnesses: Medical: Pyelone hritis, 1998, with fever nd right fl nk in; tre ted with icillin; develo ed gener lized r sh with itching sever l d ys l ter. Re orts x-r ys were nor l; no recurrence of infection. Surgical: Tonsillecto y, ge 6; endecto y, ge 13. Sutures for l cer tion, 2 1, fter ste ing on gl ss. Ob/ Gyn: 3–3– –3, with nor l v gin l deliveries. Three living children. Men rche ge 12. L st enses 6 onths go. Little interest in sex, nd not sexully ctive. No concerns bout HIV infection. Psychiatric: None. Health Maintenance: Immunizations: Or l olio v ccine, ye r uncert in; tet nus shots × 2, 1982, followed with booster 1 ye r l ter; flu v ccine, 2 , no re ction. Screening tests: L st P s e r, 2 14, nor l. No ogr s to d te. Family History The f ily history is de icted below. Tra in a ccide nt

S troke , va ricos e 67 ve ins , he a da che s

43 High blood pre s s ure 67

Infa ncy 58

Migra ine he a da che s Indica te s pa tie nt

54 He a rt a tta ck He a da che s

33

De ce a s e d ma le

31 De ce a s e d fe ma le

27 Living ma le

Living fe ma le (continued )



19

(Continued)

OR, ltern tively: F ther died t ge 43 ye rs in tr in ccident. Mother died t ge 67 ye rs fro stroke; h d v ricose veins, he d ches. One brother, ge 61 ye rs, with hy ertension, otherwise well; one brother, ge 58 ye rs, well exce t for ild rthritis; one sister, died in inf ncy of unknown c use. Husb nd died t ge 54 of he rt tt ck D ughter, ge 33 ye rs, with igr ine he d ches, otherwise well; son, ge 31 ye rs, with he d ches; son, ge 27 ye rs, well. No f ily history of di betes, tuberculosis, he rt or kidney dise se, c ncer, ne i , e ile sy, or ent l illness. Personal and Social History Born nd r ised in L s Cruces, finished high school, rried t ge 19 ye rs. Worked s s les clerk for 2 ye rs, then oved with husb nd to Es nol , h d three children. Returned to work 15 ye rs go to i rove f ily fin nces. Children ll rried. Four ye rs go Mr. N. died suddenly of he rt tt ck, le ving little s vings. Mrs. N. h s oved to s ll rt ent to be ne r d ughter, Is bel. Is bel’s husb nd, John, is de loyed overse s. Mrs. N.’s rt ent is now h ven for Is bel nd her two children, Kevin, ge 6 ye rs, nd Luci , ge 3 ye rs. Mrs. N. feels res onsible for hel ing the ; she feels tense nd nervous but denies de ression. She h s friends but r rely discusses f ily roble s: “I’d r ther kee the to yself. I don’t like gossi .” No church or other org niz tion l su ort. She is ty ic lly u t 7: am, works 9: am to 5:3 pm, nd e ts dinner lone. Exercise and diet. Gets little exercise. Diet high in c rbohydr tes. Safety measures. Uses se t belt regul rly. Uses sunblock. Medic t ions ke t in n unlocked edicine c binet . Cle ning solut ions in unlocked c binet below sink. Mr. N’s shotgun nd box of shells in unlocked closet u st irs. Review of Systems General: H s g ined 1 lb in the st 4 ye rs. Skin: No r shes or other ch nges. Head, Eyes, Ears, Nose, Throat (HEENT): See Present Illness. Head: No history of he d injury. Eyes: Re ding gl sses for 5 ye rs, l st checked 1 ye r go. No sy to s. Ears: He ring good. No tinnitus, vertigo, infections. Nose, sinuses: Occ sion l ild cold. No h y fever, sinus trouble. Throat (or mouth and pharynx): So e bleeding of gu s recently. L st dent l visit 2 ye rs go. Occ sion l c nker sore. Neck: No lu s, goiter, in. No swollen gl nds. Breasts: No lu s, in, disch rge. Does bre st self-ex in tion s or dic lly. Respiratory: No cough, wheezing, shortness of bre th. L st chest x-r y, 1986, St. M ry’s Hos it l; unre rk ble. Cardiovascular: No known he rt dise se or high blood ressure; l st blood ressure t ken in 2 7. No dys ne , ortho ne , chest in, l it tions. H s never h d n electroc rdiogr (ECG). (continued )

20



(Continued)

Gastrointestinal: A etite good; no n use , vo iting, indigestion. Bowel oveent bout once d ily, though so eti es h s h rd stools for 2 to 3 d ys when es eci lly tense; no di rrhe or bleeding. No in, j undice, g llbl dder or liver roble s. Urinary: No frequency, dysuri , he turi , or recent fl nk in; nocturi × 1, l rge volu e. Occ sion lly loses urine when coughing. Genital: No v gin l or elvic infections. No dys reuni . Peripheral vascular: V ricose veins e red in both legs during first regn ncy. For 1 ye rs, h s h d swollen nkles fter rolonged st nding; we rs light el stic su ort hose; tried “w ter ill” 5 onths go, but it didn’t hel uch; no history of hlebitis or leg in. Musculoskelet al: Mild low b ck ches, oft en t t he end of the workd y; no r di tion int o the legs; used to do b ck exercises but not now. No ot her joint in. Psychiatric: No history of de ression or tre t ent for sychi tric disorders. (See lso Present Illness nd Personal and Social History.) Neurologic: No f inting, seizures, otor or sensory loss. Me ory good. Hematologic: Exce t for bleeding gu s, no e sy bleeding. No ne i . Endocrine: No known thyroid disorders or he t or cold intoler nce. No sy to s or history of di betes. PHYSICAL EXAMINATION Mrs. N. is short , overweight , iddle- ged wo n, who is ni t ed nd res onds quickly t o quest ions. She is so ewh t t ense, wit h oist , cold h nds. Her h ir is well groo ed. Her color is good, nd she lies fl t without disco fort . Vital signs: Ht (without shoes) 157 c (5′2″). Wt (dressed) 65 kg (143 lb). BMI 26. BP 164/98 right r , su ine; 16 /96 left r , su ine; 152/ 88 right r , su ine with wide cuff. He rt r te (HR) 88 nd regul r. Res ir tory r te (RR) 18. Te er ture (or l) 98.6°F. Skin: P l s cold nd oist, but color good. Sc ttered cherry ngio s over u er trunk. N ils without clubbing, cy nosis. Head, Eyes, Ears, Nose, Throat (HEENT): Head: H ir of ver ge texture. Sc l without lesions, nor oce h lic/ tr u tic (NC/AT). Eyes: Vision 2 /3 in e ch eye. Visu l fields full by confront tion. Conjunctiv ink; scler white. Pu ils 4 constricting to 2 , round, regul r, equ lly re ctive to light. Extr ocul r ove ents int ct. Disc rgins sh r , without he orrh ges, exud tes. No rteriol r n rrowing or A-V nicking. Ears: W x rti lly obscures right ty nic e br ne (TM); left c n l cle r, TM with good cone of light. Acuity good to whis ered voice. Weber idline. AC > BC. Nose: Mucos ink, se tu idline. No sinus tenderness. Mouth: Or l ucos ink. Sever l interdent l ill e red, slightly swollen. Dentition good. Tongue idline, with 3 × 4 sh llow white ulcer on red b se on undersurf ce ne r ti ; tender but not indur ted. Tonsils bsent. Ph rynx without exud tes. (continued )



21

(Continued)

Neck: Neck su le. Tr che idline. Thyroid isth us b rely l ble, lobes not felt. Lymph nodes: S ll (<1 c ), soft, nontender, nd obile tonsill r nd osterior cervic l nodes bil ter lly. No xill ry or e itrochle r nodes. Sever l s ll inguin l nodes bil ter lly, soft nd nontender. Thorax and lungs: Thor x sy etric with good excursion. Lungs reson nt. Bre th sounds vesicul r with no dded sounds. Di hr g s descend 4 c bil ter lly. Cardiovascular: Jugul r venous ressure 1 c bove the stern l ngle, with he d of ex ining t ble r ised to 3 º. C rotid u strokes brisk, without bruits. A ic l i ulse discrete nd t ing, b rely l ble in the 5th left inters ce, 8 c l ter l to the idstern l line. Good S1, S2; no S3 or S4 . A II/ VI ediu itched idsystolic ur ur t the lower left stern l border. No di stolic ur urs. Breasts: Pendulous, sy etric. No sses; ni les without disch rge. Abdomen: Protuber nt. Well-he led sc r, right lower qu dr nt. Bowel sounds ctive. No tenderness or sses. Liver s n 7 c in right idcl vicul r line; edge s ooth, l ble 1 c below right cost l rgin (RCM). S leen nd kidneys not felt. No costovertebr l ngle tenderness (CVAT). Genitalia: Extern l genit li without lesions. Mild cystocele t introitus on str ining. V gin l ucos ink. Cervix ink, rous, nd without disch rge. Uterus nterior, idline, s ooth, not enl rged. Adnex not l ted due to obesity nd oor rel x tion. No cervic l or dnex l tenderness. P s e r t ken. Rectov gin l w ll int ct. Rectal: Rect l v ult without sses. Stool brown, neg tive for fec l blood. Extremities: W r nd without ede . C lves su le, nontender. Peripheral vascular: Tr ce ede t both nkles. Moder te v ricosities of s henous veins both in lower extre ities. No st sis ig ent tion or ulcers. Pulses (2+ = brisk, or nor l): Ra d ia l

Fe m o r a l

P o p lit e a l

D o r s a lis P e d is

P o s t e r io r Tib ia l

RT

2+

2+

2+

2+

2+

LT

2+

2+

2+

Absent

2+

Musculoskeletal: No joint defor ities. Good r nge of otion in h nds, wrists, elbows, shoulders, s ine, hi s, knees, nkles. Neurologic: Mental Status: Tense, but lert nd coo er tive. Thought coherent. Oriented to erson, l ce, nd ti e. Cranial nerves: II to XII int ct. Motor: Good uscle bulk nd tone. Strength 5/5 throughout. Cerebellar: R id ltern ting ove ents (RAMs), oint-to- oint ove ents int ct. G it st ble, fluid. Sensory: Pin rick, light touch, osition sense, vibr tion, nd stereognosis int ct. Ro berg neg tive. (continued )

22



(Continued)

Reflexes:

Bic e p s Tr ic e p s

Bra c h io ra d ia lis P a t e lla r Ac h ille s P la n t a r

RT

2+

2+

2+

2+

1+

↓

LT

2+

2+

2+

2+/2+

1+

↓

++ ++ ++ ++ + + +_+ +_+ + + ++ ++

OR

++

++ +

+

ASSESSMENT AND PLAN 1. Migraine headaches. A 54-ye r-old wo n with igr ine he d ches since childhood, with throbbing v scul r ttern nd frequent n use nd vo iting. He d ches re ssoci ted with stress nd relieved by slee nd cold co resses. There is no illede , nd there re no otor or sensory deficits on the neurologic ex in tion. The differenti l di gnosis includes tension he d che, lso ssoci ted with stress, but there is no relief with ss ge, nd the in is ore throbbing th n ching. There re no fever, stiff neck, or foc l findings to suggest eningitis, nd the lifelong recurrent ttern kes sub r chnoid he orrh ge unlikely (usu lly described s “the worst he d che of y life”). Pl n: ● Discuss fe tures of igr ine versus tension he d ches. ● Discuss biofeedb ck nd stress n ge ent. ● Advise tient to void c ffeine, including coffee, col s, nd other c rbon ted bever ges. ● St rt nonsteroid l nti-infl tory drugs (NSAIDs) for he d che, s needed. ● If needed next visit, begin ro hyl ctic edic tion if he d ches re occurring ore th n 2 d ys week or 8 d ys onth. 2. Elevat ed blood pressure. Systolic hy ertension is resent . M y be rel ted to nxiety fro first visit. No evidence of end-org n d ge to retin or he rt . Pl n: ● Discuss st nd rds for ssessing blood ressure; check BP in 1 onth. ● Recheck systolic ur ur. ● Check b sic et bolic nel; review urin lysis. ● Discuss weight reduction nd exercise rogr s (see #4). ● Reduce s lt int ke. 3. Cystocele with occasional stress incontinence. Cystocele on elvic ex in tion, rob bly rel ted to bl dder rel x tion. P tient is eri eno us l. Incontinence re orted with coughing, suggesting lter tion in bl dder neck n to y. No dysuri , fever, fl nk in. Not t king ny contributing edic tions. Usu lly involves s ll ounts of urine, no dribbling, so doubt urge or overflow incontinence. (continued )



4.

5.

6.

7.

8. 9. 10. 11.

23

(Continued )

Pl n: ● Ex l in c use of stress incontinence. ● Review urin lysis. ● Reco end Kegel exercises. ● Consider to ic l estrogen cre to v gin during next visit if no i rove ent. Overweight . P tient 5′2″, weighs 143 lbs. BMI is 26. Pl n: ● Ex lore diet history, sk tient to kee food int ke di ry. ● Ex lore otiv tion to lose weight, set t rget for weight loss by next visit. ● Schedule visit with dietiti n. ● Discuss exercise rogr , s ecific lly, w lking 3 inutes ost d ys week. Family stress. Son-in-l w de loyed, r rely t ho e; d ughter nd gr ndchildren often t tient’s ho e, le ding to tensions in these rel tionshi s. P tient lso h s fin nci l constr ints. Stress currently situ tion l. No current evidence of jor de ression. Pl n: ● Ex lore tient’s views on str tegies to co e with stress. ● Ex lore sources of su ort, including Al-Anon for d ughter nd fin nci l counseling for tient. ● Continue to onitor for de ression. Occasional musculoskelet al low back pain. Usu lly with rolonged st nding. No history of tr u or otor vehicle ccident. P in does not r di te; no tenderness or otor-sensory deficits on ex in tion. Doubt disc or nerve root co ression, troch nteric bursitis, s croiliitis. Pl n: ● Review benefits of weight loss nd exercises to strengthen low b ck uscles. Tobacco abuse. 1 ck er d y for 36 ye rs. Pl n: ● Check e k flow or FEV1/ FVC on office s iro etry. ● Give strong w rning to sto s oking. ● Offer referr l to tob cco cess tion rogr . ● Offer tch, current tre t ent to enh nce bstinence. Varicose veins, lower extremities. No co l ints currently. History of right pyelonephritis, 1998. Ampicillin allergy. Develo ed r sh but no other llergic re ction. Health maintenance. L st P s e r 2 14; h s never h d ogr . Pl n: ● Schedule ogr . ● P s e r sent tod y. ● Provide three c rds to test for fec l blood; next visit, discuss screening colonosco y. ● Suggest dent l c re for ild gingivitis. ● Advise tient to ove edic tions nd c ustic cle ning gents to locked c binet bove shoulder height . Urge tient to ove gun nd c rtridges to locked gun c binet.

24


T h e Im p o r t a n c e o f t h e P r o b le m Lis t After you complete the clinical record, it is good clinical practice to generate a Problem List that summarizes the patient’s problems that can be placed in the front of the of ce or hospital chart. List the most active and serious problems rst, and record their date of onset. Some clinicians make separate lists for active or inactive problems; others make one list in order of priority. A sample Problem List for Mrs. N. is provided below.

P r o b le m Lis t : T h e C a s e o f M r s . N . Da t e En t e r e d

8/25/ 16

P ro b le m No .

1 2 3 4 5 6 7 8 9 1 11

P ro b le m

Migr ine he d ches Elev ted blood ressure Cystocele wit h occ sion l st ress incontinence Overweight F ily stress Low b ck in Tob cco buse since ge 18 ye rs V ricose veins History of right yelone hritis 1998 Allergy to icillin He lth inten nce

Recording Your Findings A clear, well-organized clinical record is one of the most important adjuncts to patient care. Think especially about the order and readability of the record and the amount of detail needed. Use the following checklist to make sure your record is informative and easy to follow. C h e c k lis t t o E n s u r e a Q u a lit y C lin ic a l R e c o r d Is the Order Clear? Order is i er tive. M ke sure th t re ders c n e sily find s ecific oints of infor tion. Kee the subjective ite s of the history, for ex le, in the history; do not let the str y into the hysic l ex in tion. Did you: ● ● ●

M ke the he dings cle r? Accent your org niz tion with indent tions nd s cing? Arr nge the Present Illness in chronologic order, st rting with the current e isode, then filling in relev nt b ckground infor tion? (continued )


C h e c k lis t t o E n s u r e a Q u a lit y C lin ic a l R e c o r d

25

(Continued)

Do the Data Included Contribute Directly to the Assessment? S ell out the su orting evidence, both ositive nd neg tive, for e ch roble or di gnosis. M ke sure there is sufficient det il to su ort your differenti l di gnosis nd l n. Are Pertinent Negatives Speci cally Described? Often ortions of the history or ex in tion suggest th t n bnor lity ight exist or develo in th t re . For ex le, for the tient with not ble bruises, record the “ ertinent neg tives,” such s the bsence of injury or violence, f ili l bleeding disorders, or edic tions or nutrition l deficits th t ight le d to bruising. For the tient who is de ressed but not suicid l, recording both f cts is i ort nt. In the tient with tr nsient ood swing, on the other h nd, co ent on suicide is unnecess ry. Are There Overgeneralizations or Omissions of Important Data? Remember that data not recorded are data lost. No tter how vividly you c n rec ll clinic l det ils tod y, you will rob bly not re e ber the in few onths. The hr se “neurologic ex neg tive,” even in your own h ndwriting, y le ve you wondering in few onths’ ti e, “Did I re lly check the reflexes?” Is There Too Much Detail? Is there excess infor tion or redund ncy? Is i ort nt infor t ion buried in ss of det il, to be discovered by only t he ost ersistent re der? M ke your descri tions concise. “Cervix ink nd s oot h” indic tes you s w no redness, ulcers, nodules, sses, cyst s, or ot her sus icious lesions, but t his descri t ion is short er nd ore e sily re d. You c n o it uni ort nt struct ures even though you ex ined t he , such s nor l eyebrows nd eyel shes. Omit most of your negative findings unless they rel te directly to the tient’s co l ints or s ecific exclusions in your differenti l di gnosis. Instead, concentrate on major negative findings such s “no he rt ur urs.” Is the Written Style Succinct? Are Phrases, Short Words, and Abbreviations Used Appropriately? Is Data Unnecessarily Repeated? O it re etitive introductory hr ses such s “The tient re orts no . . .” bec use re ders ssu e the tient is the source of the history unless otherwise s ecified. ●

●

Using words or brief hr ses inste d of whole sentences is co on, but bbrevi tions nd sy bols should be used only if they re re dily understood. Use shorter words when ossible such s “felt” for “ l ted” or “he rd” for “ uscult ted.” O it unnecess ry words, such s those in rentheses in the ex les below. For ex le, “Cervix is ink (in color).” “Lungs re reson nt (to ercussion).” Describe wh t you observed, not wh t you did. “O tic discs seen” is less infor tive th n “disc rgins sh r .” (continued )

26


C h e c k lis t t o E n s u r e a Q u a lit y C lin ic a l R e c o r d

(Continued)

Are Diagrams and Precise Measurements Included Where Appropriate? Di gr s dd gre tly to the cl rity of the record.

To ensure ccur te ev lu tions nd future co in centi eters, not in fruits, nuts, or veget bles. ● ●

risons,

ke

e sure ents

“1 × 1 c ly h node” versus “ e -sized ly h node . . .” Or “2 × 2 c ss on the left lobe of the rost te” versus “w lnut-sized rost te ss.”

Is the Tone of the Write-up Neutral and Professional? It is i ort nt to be objective. Hostile or dis roving co ents h ve no l ce in the tient’s record. Never use infl tory or de e ning words or unctu tion. Co ents such s “P tient DRUNK nd LATE TO CLINIC AGAIN!!” re un rofession l nd set b d ex le for other clinici ns re ding the ch rt. They lso ight rove difficult to defend in leg l setting.

2

C H A P T E R

Evaluating Clinical Evidence

Excellence in clinical care requires integrating clinical expertise, patient preferences, and the best available clinical evidence. Carefully study the clear descriptions of how the history and physical examination can be viewed as diagnostic tests; how to assess the accuracy of laboratory tests, radiographic imaging, and diagnostic procedures; and how to evaluate clinical research studies and disease prevention guidelines. Throughout the regional examination chapters, you will nd evidencebased recommendations for health promotion interventions, especially screening and prevention. These recommendations are also based on evidence from the clinical literature that can be evaluated according to criteria presented in this chapter.

The History and Physical Examination as Diagnostic Tests The process of diagnostic reasoning begins with the history. As you learn about your patient, you will start to develop a differential diagnosis. You will assign probabilities to the various diagnoses that correspond to how likely you consider them to be explanations for your patient’s problem. As you approach clinical problems, your goal is to determine whether you need to perform additional testing (Fig. 2-1). Pro bability o f Diag no s is 0%

Te s t Thre s hold

P roba bility be low te s t thre s hold; no te s ting wa rra nte d

Tre a tme nt Thre s hold 100%

P roba bility be twe e n te s t a nd tre a tme nt thre s hold; furthe r te s ting re quire d

P roba bility a bove tre a tme nt thre s hold; te s ting comple te d; tre a tme nt comme nce s

Fig ure 2-1 Probability revis ions . (Adapte d w ith pe rm is s ion from Guyatt G, Re nnie D, Me ade M, e t al. Us e rs’ Guide s to the Me dical Lite rature . 2nd e d. New York, NY: McGraw-Hill Com pany; 2008; Chapte r 14, Figure 14–2.) 27

28


If your probability for a disease based on your history and examination is very high (i.e., exceeds the treatment threshold), then you can move ahead and initiate treatment. Conversely, if your probability for a disease is very low (i.e., below the test threshold), then you do not need further testing. The area between the test and treatment thresholds represents clinical uncertainty, and you need further testing to revise probabilities and guide your clinical management.

Evaluating Diagnostic Tests Two concepts in evaluating diagnostic tests are the validity of the ndings and the reproducibility of the test results.

V a lid it y Does the test provide valid results and accurately identify whether the patient has a disease? This involves comparing the test against a gold standard—the best measure of whether a patient has disease. This could be a biopsy, a structured psychiatric examination, or a colonoscopy. The 2 × 2 table is the basic format for evaluating the performance characteristics of a diagnostic test, which means how much the test results revise probabilities for disease. There are two columns—patients with disease present and patients with disease absent. These categorizations are based on the gold standard test. The two rows correspond to positive and negative test results. The four cells (a, b, c, d) correspond to true positives, false positives, false negatives, and true negatives, respectively.

S e t t in g u p t h e 2 ë 2 T a b le G o ld S t a n d a r d : Dis e a s e P r e s e n t

G o ld S t a n d a r d : D is e a s e A b s e n t

True ositive

b F lse ositive

c F lse neg tive

d True neg tive

Te s t p o s it ive Te s t n e g a t ive

S e n s it ivit y a n d S p e c i c it y. The rst test statistics to estimate are sensitivity and speci city.

Chapter 2 | Evaluating Clinical Evidence

29

S e n s it iv it y a n d S p e c if ic it y ●

●

●

Sensitivity is the rob bility th t erson with dise se h s ositive test. This is re resented s / ( + c) in the dise se resent colu n of the 2 × 2 t ble. Sensitivity is lso known s the true ositive r te. Specificity is the rob bility th t nondise sed erson h s neg tive test, re resented s d/ (b + d) in the dise se bsent colu n of the 2 × 2 t ble. S ecificity is lso known s the true neg tive r te. Examples. An ex le of these st tistics would be the rob bility th t s lenoeg ly (see Ch ter 11, . 21 ) is ssoci ted with ercussion dullness below the left cost l rgin (sensitivity). Conversely, the rob bility th t tient without s leno eg ly will h ve ercussion dullness is the f lse- ositive r te (1 − s ecificity) for this hysic l neuver.

A negative result from a test with a high sensitivity (i.e., a very low falsenegative rate) usually excludes disease. This is represented by the acronym SnNOUT—a Sensitive test with a Negative result rules OUT disease. Conversely, a positive result in a test with high speci city (e.g., a very low falsepositive rate) usually indicates disease. This is represented by the acronym SpPIN—a Speci c test with a Positive result rules IN disease. P o s it ive a n d Ne g a t ive P re d ic t ive Va lu e s . To determine the probability that a patient actually has disease based on a test result that is either positive or negative, calculate positive and negative predictive values. P o s it iv e a n d N e g a t iv e P r e d ic t iv e V a lu e s ●

●

The positive predictive value (PPV) is the rob bility th t erson with ositive test h s dise se, re resented s / ( + b) fro the test ositive row in the 2 × 2 t ble. An ex le of this st tistic is found in rost te c ncer screening (see Ch ter 15, . 266), where n with PSA v lue gre ter th n 4. ng/ L h s only 3 % rob bility of h ving rost te c ncer found on bio sy. The negative predictive value (NPV) is the rob bility th t erson with neg tive test does not h ve dise se, re resented s d/ (c + d) in the test neg tive row in 2 × 2 t ble. An ex le is: A ong en with PSA level of 4. ng/ L or below, 85% re found to be c ncer-free on bio sy.

P re va le n c e o f Dis e a s e . Predictive value statistics vary substantially according to the prevalence of disease (i.e., the proportion of patients in the disease present column), which is based on the characteristics of the patient population and the clinical setting. The box below shows a 2 × 2 table where both the sensitivity and speci city of the diagnostic test are 90% and the prevalence is 10%. The positive predictive value calculated

30


from the test positive row of the table would be 90/180 = 50%. This means that half of the people with a positive test have disease. P r e d ic t iv e V a lu e s : P r e v a le n c e o f 1 0 % w it h S e n s it iv it y a n d S p e c if ic it y = 9 0 % D is e a s e P r e s e n t

D is e a s e A b s e n t

b

Te s t p o s it ive

Te s t n e g a t ive

To t a l

To t a l

9

9

18

c 1

d 81

82

1

9

1,

Sensitivity = a/(a + c) = 90/100 or 90%; speci city = d/(b + d) = 810/900 = 90% Positive predictive value = a/(a + b) = 90/180 = 50% However, if the sensitivity and speci city remained the same, but prevalence was only 1%, then the cells would look very different. P r e d ic t iv e V a lu e s : P r e v a le n c e o f 1 % w it h S e n s it iv it y a n d S p e c if ic it y = 9 0 % Dis e a s e P r e s e n t

D is e a s e A b s e n t

To t a l

9

b 99

1 8

c 1

d 891

892

1

99

Te s t p o s it ive

Te s t n e g a t ive

To t a l

1,

Sensitivity = a/(a + c) = 9/10 or 90%; speci city = d/(b + d) = 891/990 = 90% Positive predictive value = a/(a + b) = 9/108 = 8.3% Lik e lih o o d Ra t io s . To evaluate the performance of a diagnostic test that can account for the varying disease prevalence observed in different patient populations, you can use likelihood ratio statistics, de ned as the probability of obtaining a given test result in a diseased patient divided by the probability of obtaining a given test result in a nondiseased patient. The likelihood ratio tells us how much a test result changes the pre-test disease probability (prevalence) to the post-test disease probability.

The likelihood ratio for a positive test is the ratio of getting a positive test result in a diseased person divided by the probability of getting a positive test result in


31

a nondiseased person. The 2 × 2 table shows that this is the same as saying the ratio of the true positive rate (sensitivity) over the false-positive rate (1 − specicity). A higher value (much >1) indicates that a positive test is much more likely to be coming from a diseased person than from a nondiseased person, increasing our con dence that a person with a positive result has disease. The likelihood ratio for a negative test is the ratio of the probability of getting a negative test result in a diseased person divided by the probability of getting a negative test result in a nondiseased person. The 2 × 2 table shows that this is the same as saying the ratio of the false-negative rate (1 − sensitivity) divided by the true negative rate (speci city). A lower value (much <1) indicates that the negative test is much more likely to be coming from a nondiseased person than from a diseased person, increasing our con dence that a person with a negative result does not have disease. In t e r p r e t in g Lik e lih o o d R a t io s Lik e lih o o d Ra t io s a

Eff e c t o n P r e - t o P o s t -t e s t P ro b a b ilit y

LRs > 1 LRs 5–1 LRs 2–5 LRs 1–2

Gener te l rge ch nges Gener te oder te ch nges Gener te s ll (so eti es i ort nt) ch nges Alter the rob bility to s ll degree (r rely i ort nt)

or < .1 or .1– .2 nd .5– .2 nd .5–1

Likelihood ratios >1 re ssoci ted with ositive results nd n incre sed rob bility for dise se. Likelihood ratios <1 re ssoci ted with neg tive results nd decre sed rob bility of dise se. A test with likelihood ratio of 1 rovides no ddition l infor tion bout the rob bility of dise se.

a

Ba ye s Th e o re m . One way to use likelihood ratios to revise probabilities for disease is with the Bayes theorem. This theorem requires converting the estimated prevalence (pre-test probability) to odds using the equation:

Pre-test odds = pre-test probability/(1 − pre-test probability) The pre-test odds are multiplied by the likelihood ratio to estimate the post-test odds using the following equation: Post-test odds = Pre-test odds × likelihood ratio The post-test odds are then converted to a probability using the equation: Post-test probability = post-test odds/(1 + post-test odds) Fa g a n No m o g ra m . If you are more comfortable thinking in terms of probability of having disease, then the Fagan nomogram may be an easier way for you to use likelihood ratios (Fig. 2-2). With this nomogram, you read the pre-test probabilities from the line on the left, then take a straight edge and draw a line from the pre-test probability through the likelihood

32


0.1

99

0.2

98

0.5

95

1

2000 1000

90

500 2

5 10 20

200 100

80

50 5 20 10

70

5

40

60 50

2

30

1

30

0.5

40 60

0.2 0.1 0.05

70

0.02 0

80

0.01 .0 0.005 00

50

90 95

20 10 5

2

0.002 02 0.001 0.0005 5

1 0.5

98

0.2

99

0.1

Pre -te s t Pro bability (%)

Like liho o d Ratio

Po s t-te s t Pro bability (%)

Fig ure 2-2 Fagan nom ogram . (Adapte d w ith pe rm is s ion from Fagan TJ. Le tte r: nom ogram for Baye s the ore m . N Engl J Me d. 1975;293:257.)

ratio in the middle line, and then read the post-test probability on the line on the right. Figure 2.2 shows how the Fagan nomogram displays probability revisions. In this example, the diagnostic test has a sensitivity of 90% and speci city of 91%. With a pre-test probability (prevalence) of 1%, a positive test result (blue line) leads to a post-test probability of 9%. A negative test result (red line) leads to a post-test probability of 0.1%.


33

R e p r o d u c ib ilit y Ka p p a S c o re . Two clinicians examining a patient may not always agree upon the presence of a given nding. Understanding whether there is agreement well beyond chance is important in knowing whether the nding is useful enough to support clinical decision making. The kappa score measures the amount of agreement that occurs beyond chance. The box shows how to interpret Kappa values. In t e r p r e t in g K a p p a V a lu e s Va lu e o f Ka p p a

S t r e n g t h o f Ag r e e m e n t

< .2 .21– .4 .41– .6 .61– .8 .81–1.

Poor F ir Moder te Good Excellent

For example, although clinicians agree 75% of the time that a patient has an abnormal physical nding, the expected agreement based on chance is 50%. This means that the potential agreement beyond chance is 50% and the actual observer agreement beyond chance is 25%. The kappa level is then 25%/50% = 0.5, which indicates moderate agreement. P re c is io n . In the context of reproducibility, precision refers to being able to apply the same test to the same unchanged person and obtain the same results. Precision is often used when referring to laboratory tests. A statistical test used to characterize precision is the coef cient of variation, de ned as the standard deviation divided by the mean value. Lower values indicate greater precision.

Health Promotion Throughout the book you will nd health promotion sections that make recommendations for primary prevention (interventions designed to prevent disease) as well as secondary prevention (screening tests designed to nd disease or disease processes at an early, asymptomatic stage). The rationale for secondary prevention is that treatment for early-stage disease is often more effective than treatment for later-stage disease. We highlight guidelines from professional organizations that are evidence-based, such as those of the U.S. Preventive Services Task Force (USPSTF) that consider the quality of the evidence and the strength of the recommendation to either provide or withhold the intervention. The strongest health promotion recommendations are based on results from randomized controlled trials (or

34


S ys te ma tic Re vie ws Ra ndomize d Control Tria ls Cohort S tudie s Ca s e -Control S tudie s Ca s e S e rie s , Ca s e Re ports Editoria ls , Expe rt Opinion Figure 2-3 Evidence pyramid. (Adapted with permission from Sackett DL, Straus SE, Richardson WS, et al. Evidence-Based Medicine: How to Practice and Teach EBM. 2nd ed. Edinburgh: Churchill Livingstone; 2000.)

syntheses of multiple such trials) of therapy or prevention. When searching for evidence-based information, you should select the highest level of available evidence (Fig. 2-3).

Critical Appraisal Learn the process of critically appraising the clinical literature in order to interpret new studies and guidelines as they appear throughout your professional career. The Evidence-Based Working Group, which consists of experts in epidemiology, has created a rigorous and standardized approach for evaluating studies that has been applied to a wide range of clinical topics, including therapeutic and prevention trials, diagnostic tests, metaanalysis, cost-effectiveness analyses, and practice guidelines. This approach asks three basic questions: 1. Are the results valid (can you believe them)? 2. What are the results (magnitude and precision)? 3. How can you apply the results to patient care?

U n d e r s t a n d in g B ia s When evaluating study results, it is important to have a thorough understanding of bias. The key sources of bias in clinical research are selection bias, performance bias, detection bias, and attrition bias.


35

T y p e s o f B ia s e s A f f e c t in g E v id e n c e S e le c t io n Bia s ●

●

●

Occurs when co rison grou s h ve syste tic differences in their b seline ch r cteristics th t c n ffect the outco e of the study Cre tes roble s in inter reting observed differences in outco es bec use they could result fro the interventions or the b seline differences between grou s R ndo ly lloc ting subjects to the intervention is the best ro ch to ini izing this bi s

P e r fo r m a n c e Bia s ●

● ●

Occurs when there re syste tic differences in the c re received between co rison grou s (other th n the intervention) Cre tes roble s in inter reting outco e differences Blinding subjects nd roviders to the intervention is the best ro ch to ini izing this bi s

D e t e c t io n Bia s ●

●

Occurs when there re syste tic differences in efforts to di gnose or scert in n outco e Blinding outco es ssessors (ensuring th t they re un w re of the intervention received by the subject) is the best ro ch to ini izing this bi s

A t t r it io n Bia s ●

●

●

Occurs when there re syste tic differences in the co rison grou s in the nu ber of subjects who do not co lete the study F iling to ccount for these differences c n le d to incorrectly esti ting the effectiveness of n intervention Using n intention-to-tre t n lysis, where ll n lyses consider ll subjects who were ssigned to co rison grou , reg rdless of whether they received or co leted the intervention, c n ini ize this bi s

R e s u lt s As s e s s in g P e rfo rm a n c e o f a Tre a t m e n t o r P re ve n t io n In t e rve n t io n . The statistics used to characterize the performance of a treatment or prevention intervention include relative risks, relative risk differences (can be a reduction or increase, re ecting bene t or harm), absolute risk differences (can be a reduction or increase, re ecting bene t or harm), numbers needed to treat, and numbers needed to harm.

2 ë 2 T a b le s f o r E v a lu a t in g S t u d ie s o f T r e a t m e n t o r P r e v e n t io n Eve n t O c c u r r e d

Ex eri ent l grou Control grou

c

N o Eve n t

To t a l

b

+b

d

c+d

36


Calculating these performance statistics from the 2 × 2 table begins with determining probabilities for outcomes. ■ The probability that an intervention subject had the outcome is

described by a/(a + b) from row 1 (experimental group); this also called the experimental event rate (EER). ■ The probability that a control subject had the outcome is c/(c + d) from

row 2 (control group), or the control event rate (CER). ■ The relative risk, the probability of an outcome in the intervention

group compared to the probability of an outcome in the control group, is expressed as the EER/CER. ■ The relative risk difference is de ned as |CER − EER|/CER × 100% or

100% − the relative risk, which describes the proportion of baseline risk is reduced/increased by the therapy. ■ The absolute risk difference, the difference in outcome rates between

the comparisons groups, is expressed by the |CER − EER|. ■ The reciprocal of the absolute risk difference (reported as a fraction) is

the number of subjects who need to be treated over a speci c period of time to prevent one outcome. If the intervention actually increases the risk for a bad outcome, then this statistic becomes the number needed to harm. In many studies these calculations are used to measure treatment effectiveness between control and treatment interventions comparing medications, procedures, or diagnostic tests.

G e n e r a liz a b ilit y To make this determination, you need to rst look at the demographics of the study subjects (e.g., age, gender, race/ethnicity, socioeconomic status, clinical conditions). Then, you need to determine: Are the study demographics applicable to your patient? Is the intervention feasible in your clinical setting? And, most importantly, is the range of potential bene ts and harm of the intervention acceptable for your patient?

G u id e lin e R e c o m m e n d a t io n s There are many approaches for rating the strength of recommendations and we will discuss several grading systems. Review the rating systems in Tables 2-1 to 2-3 (pp. 37–40).


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Aids to Interpretation Table 2-1 U.S . P r e ve n t ive S e r v ic e s Ta s k Fo r c e Ra t in g s : Gra d e De f in it io n s a n d Im p lic a t io n s fo r P r a c t ic e Gra d e

D e f in it io n

S u g g e s t io n s fo r P ra c t ic e

A

The USPSTF recommends the service. There is high certainty that the net benefit is substantial.

Offer or provide this service.

B

The USPSTF recommends the service. Offer or provide this There is high certainty that the net service. benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial.

C

The USPSTF recommends selectively offering or providing this service to individual patients based on professional judgment and patient preferences. There is at least moderate certainty that the net benefit is small.

Offer or provide this service for selected patients depending on individual circumstances.

D

The USPSTF recommends against the service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits.

Discourage the use of this service.

I

The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of the service. Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined.

If the service is offered, patients should understand the uncertainty about the balance of benefits and harms.

The USPSTF de nes certainty as the “likelihood that the USPSTF assessment of the net bene t of a preventive service is correct.” The net bene t is de ned as bene t minus harm of the preventive service as implemented in a general, primary care population. Source: Grade De nitions. U.S. Preventive Services Task Force. October 2014. http://www. uspreventiveservicestaskforce.org/Page/Name/grade-de nitions.

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Table 2-2 U.S . P re ve n t ive S e r vic e s Ta s k Fo rc e Le ve ls o f Ce r t a in t y Re g a rd in g Be n e f it Le ve l o f C e r t a in t y

D e s c r ip t io n

High

The available evidence usually includes consistent results from well-designed, well-conducted studies in representative primary care populations. These studies assess the effects of the preventive service on health outcomes. This conclusion is therefore unlikely to be strongly affected by the results of future studies.

Moderate

The available evidence is sufficient to determine the effects of the preventive service on health outcomes, but confidence in the estimate is constrained by such factors as: ■ ■ ■

■

The number, size, or quality of individual studies. Inconsistency of findings across individual studies. Limited generalizability of findings to routine primary care practice. Lack of coherence in the chain of evidence.

As more information becomes available, the magnitude or direction of the observed effect could change, and this change may be large enough to alter the conclusion. Low

The available evidence is insufficient to assess effects on health outcomes. Evidence is insufficient because of: ■ ■ ■ ■ ■

■

The limited number or size of studies. Important flaws in study design or methods. Inconsistency of findings across individual studies. Gaps in the chain of evidence. Findings not generalizable to routine primary care practice. Lack of information on important health outcomes.

More information may allow estimation of effects on health outcomes. Source: Update on Methods: Estimating Certainty and Magnitude of Net Bene t. U.S. Preventive Services Task Force. February 2014: http://www.uspreventiveservicestaskforce.org/Page/ Name/update-on-methods-estimating-certainty-and-magnitude-of-net-bene t.


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Table 2-3 Am e ric a n Co lle g e o f Ch e s t P h ys ic ia n s : Gra d in g Re c o m m e n d a t io n s Gra d e o f Be n e f it v s . Re c o m m e n d a t io n / Ris k a n d D e s c r ip t io n Bu r d e n s

M e t h o d o lo g ic Q u a lit y o f S u p p o r t in g Ev id e n c e Im p lic a t io n s

1A/Strong recommendation; high-quality evidence

Benefits clearly outweigh risk and burdens, or vice versa

RCTs without important limitations or overwhelming evidence from observational studies

Strong recommendation; can apply to most patients in most circumstances without reservation

1B/Strong recommendation; moderate-quality evidence


RCTs with important limitations (inconsistent results, methodologic flaws, indirect, or imprecise) or exceptionally strong evidence from observational studies

Strong recommendation; can apply to most patients in most circumstances without reservation

1C/Strong recommendation; low-quality or very low-quality evidence


Observational studies or case series

Strong recommendation but may change when higher-quality evidence becomes available

2A/Weak recommendation; high-quality evidence

Benefits closely balanced with risk and burdens

RCTs without important limitations or overwhelming evidence from observational studies

Weak recommendation; best action may differ depending on circumstances or patients’ societal values

(table continues on page 40)

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Table 2-3 Am e ric a n Co lle g e o f Ch e s t P h ys ic ia n s : Gra d in g Re c o m m e n d a t io n s (continued )

Gra d e o f Be n e f it v s . Re c o m m e n d a t io n / Ris k a n d D e s c r ip t io n Bu r d e n s

M e t h o d o lo g ic Q u a lit y o f S u p p o r t in g Ev id e n c e Im p lic a t io n s

2B/Weak recommendation; moderate-quality evidence

Benefits closely balanced with risk and burdens

RCTs with important limitations (inconsistent results, methodologic flaws, indirect, or imprecise) or exceptionally strong evidence from observational studies

2C/Weak recommendation; low-quality or very low-quality evidence

Uncertainty Observational in the estistudies or case mates of series benefits, risks, and burden; benefits, risks, and burdens may be closely balanced

Weak recommendation; best action may differ depending on circumstances or patients’ societal values

Very weak recommendation; other alternatives may be equally reasonable

Source: Guyatt G, Gutterman D, Baumann MH, et al. Grading strength of recommendations and quality of evidence in clinical guidelines: report from an American college of chest physicians task force. Chest. 2006;129(1):174.

3

C H A P T E R

Interviewing and the Health History

The health history is a conversation with a purpose. In social conversation, 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 signi cantly 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 affirmation, empathic responses, validation, reassurance, summarization, 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 speci c kinds of information you need to obtain, facilitates clinical reasoning, and clari es 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 Past History, the Family History, the Personal and Social History, and, most closed-ended of all, the Review of Systems. For new patients in the of ce, 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 speci c complaint, such as painful urination, a more limited interview, tailored to that speci c problem—sometimes called a focused or problem-oriented history—may be indicated.

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The Fundamentals of Skilled Interviewing Skilled interviewing requires the use of speci c learnable techniques perfected over a lifetime. Practice these techniques and nd ways to be observed or recorded so that you can receive feedback on your progress. Ac t ive Lis t e n in g . 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. Em p a t h ic Re s p o n s e s . Patients may express—with or without words—feelings they have not consciously acknowledged. Empathic responses are vital to patient rapport and convey that you experience some of the patient’s suffering. To express empathy, you must rst 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. Gu id e d Qu e s t io n in g . It is important to adapt your questioning to the patient’s verbal and nonverbal cues.

T e c h n iq u e s o f G u id e d Q u e s t io n in g ● ● ● ● ● ● ●

Moving fro o en-ended to focused questions Using questioning th t elicits gr ded res onse Asking series of questions, one t ti e Offering ulti le choices for nswers Cl rifying wh t the tient e ns Encour ging with continuers Using echoing

Proceed from the general to the speci c. 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.”

Chapter 3 | Interviewing and the Health History

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Ask questions that require a graded response rather than a single answer. “What physical activity do you do that makes you short of 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 following problems?” Be sure to pause and establish eye contact as you list each problem. Sometimes patients seem unable to describe symptoms. Offer multiplechoice answers. For patients using words that are ambiguous, request clari cation, as in “Tell me exactly what you meant by ‘the u.’” 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. No n ve rb a l Co m m u n ic a t io n . Being sensitive to nonverbal messages allows you to both “read the patient” more effectively and send messages of your own. Pay close attention to eye contact, facial expression, posture, head position and movement such as shaking or nodding, 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 qualities of speech such as pacing, tone, and volume, to increase rapport. Be sensitive to cultural variations in uses and meanings of nonverbal behaviors. Va lid a t io n . An important way to make a patient feel accepted is to provide verbal support that legitimizes or validates the patient’s emotional experience. Re a s s u ra n c e . Avoid premature or false reassurance. Such reassurance 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 reassurance at that moment. P a r t n e rin g . Express your desire to work with patients in an ongoing way. Reassure patients that regardless of what happens with their disease, as their provider, you are committed to a continuing partnership. Even in your role as a student, such support makes a big difference.

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S u m m a riza t io n . Giving a capsule summary lets the patient know that you have been listening carefully. It also clari es 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. Tra n s it io n s . Tell patients when you are changing directions during the interview. This gives patients a greater sense of control. Em p o w e rin g t h e P a t ie n t . 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 familiarity with the clinical evaluation process. Differences of gender, ethnicity, race, or class may also create power differentials. Ultimately, patients must be empowered to take care of themselves and follow through on your advice. Review the principles below.

E m p o w e r in g t h e P a t ie n t : T e c h n iq u e s f o r S h a r in g P o w e r ● ● ● ● ●

● ●

Evoke the tient’s ers ective. Convey interest in the erson, not just the roble . Follow the tient’s le d. Elicit nd v lid te e otion l content. Sh re infor tion with the tient, es eci lly t tr nsition oints during the visit. M ke your clinic l re soning tr ns rent to the tient. Reve l the li its of your knowledge.

The Sequence and Context of the Interview P r e p a r a t io n , S e q u e n c e , a n d C u lt u r a l C o n t e x t Interviewing patients to elicit their health history requires planning. ■ Review the clinical record. Before seeing the patient, review the clini-

cal record or chart. It often provides valuable information about past diagnoses and treatments; however, data may be incomplete or even disagree with what you learn from the patient, so be open to developing new approaches or ideas.


45

■ 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 disapproval, embarrassment, impatience, or boredom block communication. Patients nd 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.

T h e S e q u e n c e o f t h e In t e r v ie w 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 validate their signi cance. ■ 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 rst 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 rst names unless you have speci c permission from the patient. Whenever visitors are present, maintain con dentiality. 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. 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.

46


Give the patient your undivided attention. Spend enough time on small talk to put the patient at ease. If necessary, jot down short phrases, speci c dates, or words rather than trying to put them into a nal format. Maintain good eye contact, especially when using the electronic clinical record. 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 speci c complaint or problem. It is still important to start with the patient’s story. ■ Invite the patient’s story. Encourage patients to tell their own stories,

using their own words. 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 uses to organize symptoms that lead to a clinical diagnosis. Illness is a construct that explains how the patient experiences the disease, including its effects on relationships, function, and sense of well-being. 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 mnemonic “FIFE”—Feelings, Ideas, effect on Function, and Expectations. This is crucial to patient satisfaction, effective health care, and patient followthrough. E x p lo r in g t h e P a t ie n t ’s P e r s p e c t iv e (F -I-F -E ) ● ● ● ●

The tient’s Feelings, including fe rs or concerns, bout the roble The tient’s Ide s bout the n ture nd the c use of the roble The effect of the roble on the tient’s life nd Function The tient’s Ex ect tions of the dise se, of the clinici n, or of he lth c re, often b sed on rior erson l or f ily ex eriences


47

■ 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. C lu e s t o t h e P a t ie n t ’s P e r s p e c t iv e o n Illn e s s ●

● ● ● ● ●

Direct st te ent(s) by the tient of ex l n tions, e otions, ex ect tions, nd effects of the illness Ex ression of feelings bout the illness without n ing the illness Atte ts to ex l in or underst nd sy to s S eech clues (e.g., re etition, rolonged reflective uses) Sh ring erson l story Beh vior l clues indic tive of unidentified concerns, diss tisf ction, or un et needs such s reluct nce to cce t reco end tions, seeking second o inion, or e rly oint ent

Source: L ng F, Floyd MR, Beine KL. Clues to tients’ ex l n tions nd concerns bout their illnesses: c ll for ctive listening. Arch Fam Med. 2 ;9(3):222–227.

■ Expand and clarify the patient’s story. Each symptom has attributes

that must be clari ed, 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. 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, Radiation, Site, and Timing

T h e S e v e n A t t r ib u t e s o f a S y m p t o m 1. Location. Where is it? Does it r di te? 2. Quality. Wh t is it like? 3. Quantity or severity. How b d is it? (For in, sk for r ting on sc le of 1 to 1 .) 4. Timing. When did (does) it st rt? How long did (does) it l st? How often did (does) it occur? 5. Onset (setting in which symptom occurs). Include environ ent l f ctors, erson l ctivities, e otion l re ctions, or other circu st nces th t y h ve contributed to the illness. 6. Remitting or exacerbating factors. Does nything ke it better or worse? 7. Associated manifestations. H ve you noticed nything else th t cco nies it?

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Use language that is understandable and appropriate to the patient. Technical language confuses patients and blocks communication. Whenever possible, repeat back the patient’s words and expressions as the history unfolds, to af rm the patient’s experience as you clarify what he or she means. Facilitate the patient’s story by using different types of questions and the techniques of skilled interviewing on pp. 42–44. Often you will need to use directed questions (see pp. 42–43) that ask for speci c information the patient has not already offered. In general, an interview moves back and forth from open-ended questions to increasingly focused questions and then on to another open-ended question, returning the lead in the interview to the patient. Establishing the sequence and time course of the patient’s symptoms is important. Encourage a chronologic account by asking such questions as “What then?” or “What happened next?” ■ Generate and test diagnostic hypotheses. As you listen to the patient’s

concerns, you will generate and test diagnostic hypotheses about which disease process might be present. Identifying all the features of each symptom is fundamental to recognizing patterns of disease and to generating the differential diagnosis. It is important to fully esh out the patient’s story. This avoids the common trap of premature closure, or shutting down the patient’s story too quickly, which can lead to errors in diagnosis. It is helpful to visualize the process of evoking a full description of each symptom(s) as “the cone” (Fig. 3-1). Each symptom has its own “cone,” which becomes a paragraph in the History of Present Illness in the written record.

Firs t, ope n-e nde d que s tions to he a r “the s tory of the s ymptom” in the pa tie nt’s own words The n more s pe cific que s tions to e licit “the s e ve n fe a ture s of e ve ry s ymptom” Fina lly, the ye s -no que s tions or “pe rtine nt pos itive s a nd ne ga tive s ” from the re le va nt s e ction of the re vie w of s ys te ms Fig ure 3-1 Gathe r patie nt inform ation.


49

■ Share the treatment plan. Learning about the disease and conceptual-

izing the illness give you and the patient the basis for planning further evaluation (physical examination, laboratory tests, consultations, etc.). Shared decision-making involves a three-step process: introducing choices and describing options, using patient decision support tools when available; exploring patient preferences; and moving to a decision, checking that the patient is ready to make a decision and offering more time if needed. Motivational interviewing may help the patient achieve desired behavior changes. T h e G u id in g S t y le o f M o t iv a t io n a l In t e r v ie w in g ●

●

●

“Ask” o en-ended questions—invite the tient to consider how nd why they ight ch nge “Listen” to underst nd your tient’s ex erience—“c ture” their ccount with brief su ries or reflective listening st te ents such s “quitting s oking feels beyond you t the o ent”; these ex ress e thy, encourge the tient to el bor te, nd re often the best w y to res ond to resist nce “Infor ”—by sking er ission to rovide infor tion, nd then sking wh t the i lic tions ight be for the tient.

Source: Quoted directly fro ing. BMJ. 2 1 ;34 :1242.

Rollnick S, Butler CC, Kinnersly P, et l. Motiv tion l Interview-

■ Close the interview and visit. 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 nal questions. Ask the patient to “teach back” the plan of care to you in his or her own words. ■ Take time for self-re ection. 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-re ection brings a deepening personal awareness to our work with patients and is one of the most rewarding aspects of providing patient care.

T h e C u lt u r a l C o n t e x t o f t h e In t e r v ie w Cu lt u ra l Hu m ilit y—a Ch a n g in g P a ra d ig m . 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 in uences how we view the world, experience it emotionally, and behave in relation

50


to other people. This de nition of culture is broader than the term ethnicity. The in uence 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 organizations and staff to work effectively in crosscultural situations. It re ects the ability to acquire and use knowledge of the health-related bene ts, 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-re ection and self-critique as lifelong learners and re ective practitioners.” This process includes “the dif cult work of examining cultural beliefs and cultural systems of both patients and providers to locate the points of cultural 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 communities. The following three-point framework will help you. T h e T h r e e D im e n s io n s o f C u lt u r a l H u m ilit y 1. Self-awareness. Le rn bout your own bi ses; we ll h ve the . 2. Respectful communication. Work to eli in te ssu tions bout wh t is “nor l.” Le rn directly fro your tients; they re the ex erts on their culture nd illness. 3. Collaborative partnerships. Build your tient rel tionshi s on res ect nd utu lly cce t ble l ns.

Advanced Interviewing In t e r v ie w in g t h e C h a lle n g in g P a t ie n t Always remember the importance of listening to the patient and clarifying the patient’s agenda. S ile n t P a t ie n t . Silence has many meanings. Watch closely for nonverbal cues such as dif culty 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?


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Co n fu s in g P a t ie n t . 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 frustrated or confused. The history is vague and dif cult 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, orientation, and memory. Pa t ie n t w it h Alt e re d Co g n it io n . 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, determine whether the patient has decision-making capacity, or the ability to understand information related to health, to make clinical choices based on reason and a consistent set of values, and to declare preferences about treatments. Capacity is a clinical designation and can be assessed by clinicians, whereas competence is a legal designation and can only be decided by a court. If a patient lacks capacity to make a health care decision, then identify the health care proxy or the agent with power of attorney for health care. If the patient had not identi ed a surrogate decision maker, then that role may shift to a spouse or family member. It is critical to remember that decision-making capacity is both “temporal and situational.” It can uctuate depending on the condition of the patient and the complexity of the decision involved. Many patients with psychiatric or cognitive de cits still retain the ability to make decisions. E le m e n t s o f D e c is io n -M a k in g C a p a c it y P tients

ust h ve the bility to:

1. Underst nd the relev nt infor tion bout ro osed di gnostic tests or tre t ent, 2. A reci te their situ tion (including their underlying v lues nd current clinic l situ tion), 3. Use re son to ke decision, nd 4. Co unic te their choice. Source: Sessu s LL, Ze brzusk H, J ckson JL. Does this c city? JAMA. 2 11;3 6:42 .

tient h ve

edic l decision-

king

For patients with capacity, obtain their consent before talking about their health with others. 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.

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For patients with impaired capacity, nd 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. Ta lk a t ive P a t ie n t . Several techniques are helpful. For the rst 5 or 10 minutes, listen closely. Does the patient seem obsessively detailed or unduly anxious? Is there a ight of ideas or disorganized thought process? Try to focus on what seems most important to the patient. “You’ve described many concerns. Let’s focus on the hip pain rst. Can you tell me what it feels like?” Or you can ask, “What is your #1 concern today?” Cryin g P a t ie n t . 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.” An g ry o r Dis ru p t ive P a t ie n t . 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 the same questions over and over.” Some angry patients become hostile and disruptive. Before approaching them, alert security. 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. P a t ie n t w it h a La n g u a g e Ba rrie r. If the patient speaks a different language, make every effort to nd a trained interpreter. The ideal interpreter is a neutral, objective person trained in both languages and cultures. Avoid using family members or friends: con dentiality may be violated. As you work with the interpreter, make questions clear, short, and simple. Speak directly to the patient. Bilingual written questionnaires are valuable.

G u id e lin e s f o r W o r k in g w it h a n In t e r p r e t e r : “ IN T E R P R E T ” I N T

Introductions: M ke sure to introduce ll the individu ls in the roo . During the introduction, include infor tion s to the roles individu ls will l y. Note Goals: Note the go ls of the interview. Wh t is the di gnosis? Wh t will the tre t ent ent il? Will there be ny follow-u ? Transparency: Let the tient know th t everything s id will be inter reted throughout the session. (continued )


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G u id e lin e s f o r W o r k in g w it h a n In t e r p r e t e r : “ IN T E R P R E T ” (Continued) E

R

P

R

E

T

Ethics: Use qu lified inter reters (not f ily e bers or children) when conducting n interview. Qu lified inter reters llow the tient to int in utono y nd ke infor ed decisions bout his or her c re. Respect Beliefs: Li ited English Proficient (LEP) tients y h ve cultur l beliefs th t need to be t ken into ccount s well. The inter reter y be ble to serve s cultur l broker nd hel ex l in ny cultur l beliefs th t y exist. Patient Focus: The tient should re in the focus of the encounter. Providers should inter ct with the tient nd not the inter reter. M ke sure to sk nd ddress ny questions the tient y h ve rior to ending the encounter. If you don’t h ve tr ined inter reters on st ff, the tient y not be ble to c ll in with questions. Ret ain Cont rol: It is i ort nt s the rovider th t you re in in control of the inter ction nd not let the tient or the inter reter t ke over the convers tion. Explain: Use si le l ngu ge nd short sentences when working with n inter reter. This will ensure th t co r ble words c n be found in the second l ngu ge nd th t ll the infor tion c n be conveyed cle rly. Thanks: Th nk the inter reter nd the tient for their ti e. On the ch rt, note th t the tient needs n inter reter nd who served s n inter reter this ti e.

Source: U.S. De rt ent of He lt h nd Hu n Services. Int er ret Tool: working wit h int er ret ers in cult ur l set t ings. Av il ble t ht t s:www.t hinkcult ur lhe lt h.hhs.gov/ dfs/ Int er ret Tool. df. Accessed M y 3, 2 16.

P a t ie n t w it h Lo w Lit e r a c y o r Lo w He a lt h Lit e r a c y. 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. P a t ie n t w it h He a r in g Lo s s . Find out the patient’s preferred method of communicating. Patients may use American Sign Language, a unique language with its own syntax, or various other communication forms combining signs and speech. Determine whether the patient identi es 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 hearing side. If the patient

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has a hearing aid, make sure it is working. Eliminate background noise such as television. P a t ie n t w it h Im p a ire d Vis io n . Shake hands to establish contact and explain who you are and why you are there. If the room is unfamiliar, orient the patient to the surroundings. P a t ie n t w it h Lim it e d In t e llig e n c e . 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 nish, 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 condescending behavior. The sexual history is equally important and often overlooked. P a t ie n t w it h P e r s o n a l P ro b le m s . 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 therapeutic than any answer you could give. S e d u c t ive P a t ie n t . 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 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.

S e n s it iv e T o p ic s G u id e lin e s f o r B r o a c h in g S e n s it iv e T o p ic s ●

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The single ost i ort nt rule is to be nonjudg ent l. Your role is to le rn fro the tient nd hel the tient chieve better he lth. Acce t nce is the best w y to re ch this go l. Ex l in why you need to know cert in infor tion. This kes tients less rehensive. For ex le, s y to tients, “Bec use sexu l r ctices ut eo le t risk for cert in dise ses, I sk ll of y tients the following questions.” Find o ening questions for sensitive to ics nd le rn the s ecific kinds of infor tion needed for your sh red ssess ent nd l n. Consciously cknowledge wh tever disco fort you re feeling. Denying your disco fort y le d you to void the to ic ltogether.


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Th e S e xu a l His t o ry. You can introduce questions about sexual function and practices at multiple points in a patient’s history. An orienting 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.” T h e S e x u a l H is t o r y : S a m p le Q u e s t io n s ●

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“When w s the l st ti e you h d inti te hysic l cont ct with so eone?” “Did th t cont ct include sexu l intercourse?” The ter “sexu lly ctive” c n be biguous. P tients h ve been known to re ly, “No, I just lie there.” “Do you h ve sex with en, wo en, or both?” P tients y h ve s e-sex rtners yet not consider the selves g y, lesbi n, or bisexu l. So e g y nd lesbi n tients h ve h d o osite-sex rtners. “How ny sexu l rtners h ve you h d in t he l st 6 onths? In the l st 5 ye rs? In your lifeti e?” These quest ions ke it e sy for t he t ient to cknowledge ult i le rtners. Ask, “H ve you h d ny new rt ners in t he st 6 ont hs?” If tients question why this infor t ion is i ort nt , ex l in t h t new rt ners or ult i le rtners over lifeti e c n r ise t he risk for STIs. Ask bout routine use of condo s. “How often do you use condo s?” is n o en-ended question th t does not resu e n nswer. It is i ort nt to sk ll tients, “Do you h ve ny concerns bout HIV infection or AIDS?” since infection c n occur in the bsence of risk f ctors.

Me n t a l He a lt h His t o ry. Cultural constructs of mental illness vary widely, causing marked differences in acceptance and attitudes. Ask openended questions initially: “Have you ever had any problem with emotional or mental illnesses?” Then move to more speci c questions: “Have you ever visited a counselor or psychotherapist?” “Have you taken medication for emotional issues?” “Have you or a family member 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 validated 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 function in the community and tell you about their diagnoses, symptoms, hospitalizations, and medications. Investigate their symptoms and assess any effects on mood or daily activities.

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Alc o h o l a n d P re s c rip t io n a n d Illic it Dru g s . Clinicians should routinely ask about current and past use of alcohol or drugs, patterns of use, and family history. Be familiar with the de nitions below: A d d ic t io n , P h y s ic a l D e p e n d e n c e , a n d T o le r a n c e Tolerance: A st t e of d t tion in which ex osure t o drug induces ch nges th t result in di inut ion of one or ore of t he drug’s effects over t i e. Physical Dependence: A st te of d t tion th t is nifested by drug cl sss ecific withdr w l syndro e th t c n be roduced by bru t cess tion, r id dose reduction, decre sing blood level of the drug, nd/or d inistr tion of n nt gonist. Addiction: A ri ry, chronic, neurobiologic dise se, with genetic, sychosoci l, nd environ ent l f ctors influencing its develo ent nd nifest tions. It is ch r cterized by beh viors th t include one or ore of the following: i ired control over drug use, co ulsive use, continued use des ite h r , nd cr ving. Source: A eric n P in Society. Definitions Rel ted to the Use of O ioids for the Tre t ent of P in. A consensus st te ent fro the A eric n Ac de y of P in Medicine, the A eric n P in Society, nd the A eric n Society of Addiction Medicine, 2 1. Av il ble t htt :/ / www. s .org/docs/ ublicy- olicy-st te ents/ 1o ioid-definitions-consensus2– 11. df?sfvrsn= . Accessed M y 3, 2 16.

A lc o h o l. 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 affirmative 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 con ict, or legal problems. Ask speci cally about drinking while driving or operating machinery. P r e s c r ip t io n a n d Illic it D r u g s . 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 rst. “A lot of young people are using drugs these days. How about at your school? Your friends?”


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In t im a t e P a r t n e r Vio le n c e a n d Do m e s t ic Vio le n c e . Many authorities recommend routine screening of all female and older adult patients for domestic violence. Start with general “normalizing” questions: “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?” C lu e s t o P h y s ic a l a n d S e x u a l A b u s e ●

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● ● ● ● ● ●

Injuries th t re unex l ined, see inconsistent with the tient’s story, re conce led by the tient, or c use e b rr ss ent Del y in getting tre t ent for tr u History of re e ted injuries or “ ccidents” Presence of lcohol or drug buse in tient or rtner P rtner tries to do in te the visit, will not le ve the roo , or see s unusully nxious or solicitous Pregn ncy t young ge; ulti le rtners Re e ted v gin l infections nd STIs Difficulty w lking or sitting due to genit l/ n l in V gin l l cer tions or bruises Fe r of the elvic ex in tion or hysic l cont ct Fe r of le ving the ex in tion roo

De a t h a n d t h e Dyin g P a t ie n t . Work through your own feelings with the help of reading and discussion. Kübler-Ross has described ve 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 con de 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 dif cult, you must learn to ask speci c 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 cardiopulmonary 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.

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Ethics and Professionalism Clinical ethics come into play in almost every patient interaction. Fundamental maxims are as follows: B u ild in g B lo c k s o f P r o f e s s io n a l E t h ic s in P a t ie n t C a r e ●

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Nonmaleficence or primum non nocere, co only st ted s, “First, do no h r .” Beneficence, or the dictu th t the clinici n needs to “do good” for the tient. As clinici ns, our res onsibility is to lw ys ct in the best interest of the tient. Autonomy, whereby infor ed tients h ve the right to deter ine wh t is in their own best interest. Confidentiality, e ning th t we re oblig ted not to tell others wh t we le rn fro our tients. Note th t so e fr eworks osit Justice s the fourth critic l rinci le, n ely th t ll tients be tre ted f irly with equit ble distribution of he lth c re resources.

The Tavistock Principles guide behavior in health care for both individuals and institutions. T h e T a v is t o c k P r in c ip le s Rights: Peo le h ve right to he lth nd he lth c re. Balance: C re of individu l tients is centr l, but the he lth of o ul tions is lso our concern. Comprehensiveness: In ddition to tre ting illness, we h ve n oblig tion to e se suffering, ini ize dis bility, revent dise se, nd ro ote he lth. Cooperation: He lth c re succeeds only if we coo er te with those we serve, e ch other, nd those in other sectors. Improvement: I roving he lth c re is serious nd continuing res onsibility. Safety: Do no h r . Openness: Being o en, honest, nd trustworthy is vit l in he lth c re.

4

C H A P T E R

Beginning the Physical Examination: General Survey, Vital Signs, and Pain The Health History C o m m o n o r C o n c e r n in g S y m p t o m s ● ● ● ●

F tigue nd we kness Fever, chills, nd night swe ts Weight ch nge P in

Fa t ig u e a n d We a k n e s s . Fatigue is a nonspeci c 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. Fe ve r, Ch ills , a n d Nig h t S w e a t s . 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 feeling cold 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, or other unusual exposures. Be sure to inquire about medications, as they may cause fever. In contrast, recent ingestion of aspirin, acetaminophen, corticosteroids, and nonsteroidal anti-in ammatory drugs may mask fever.

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We ig h t Ch a n g e . 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 expenditure over

time. It also may re ect abnormal accumulation of body uids. ■ Weight loss has many causes: decreased food intake, dysphagia, vomit-

ing, and insuf cient supplies of food; defective absorption of nutrients; increased metabolic requirements; and loss of nutrients through the urine, feces, or injured skin. Also consider chronic illnesses, malignancy, and abuse of alcohol, cocaine, amphetamines, or opiates, or withdrawal from marijuana. Be alert for signs of malnutrition. P a in . Each year, approximately 100 million Americans report chronic pain, often underassessed. Adopt the comprehensive approach found on pp. 69–71.

Health Promotion and Counseling: Evidence and Recommendations Im p o r t a n t T o p ic s f o r H e a lt h P r o m o t io n a n d C o u n s e lin g ● ● ●

O ti l weight, nutrition, nd diet Blood ressure nd diet ry sodiu Exercise

Op t im a l We ig h t , Nu t rit io n , a n d Die t . Nearly 69% of U.S. adults are overweight (BMI ≥25 to 29 kg/m2) or obese (BMI ≥30 kg/m2). Obesity has increased in every segment of the population. More than 80% of people with type 2 diabetes and roughly 20% of those with hypertension or elevated cholesterol levels are overweight or obese. Increasing obesity in children contributes to rising rates of childhood diabetes. Reducing weight by even 5% to 10% can improve blood pressure, lipid levels, and glucose tolerance, and reduce the risk of diabetes and hypertension. Diet recommendations hinge on assessment of the patient’s motivation and readiness to lose weight and individual risk factors.

Chapter 4 | Beginning the Physical Examination: General Survey, Vital Signs, and Pain

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F o u r S t e p s t o P r o m o t e O p t im a l W e ig h t a n d N u t r it io n 1. Me sure BMI nd w ist circu ference; dults with BMI ≥25 kg/ 2, en with w ist circu ferences >4 inches, nd wo en with w ist circu ferences >35 inches re t incre sed risk for he rt dise se nd obesity-rel ted dise ses. R tios > .95 in en nd > .85 in wo en re considered elev ted. Deter ine ddition l risk f ctors for c rdiov scul r dise ses, including s oking, high blood ressure, high cholesterol, hysic l in ctivity, nd f ily history. 2. Assess diet ry int ke. 3. Assess the tient’s otiv tion to ch nge. 4. Provide counseling bout nutrition nd exercise.

Review the 2010 dietary guidelines of the U.S. Department of Agriculture and counsel patients to turn to its helpful MyPlate icon and website. Blo o d P re s s u re a n d Die t a ry S o d iu m . The Institute of Medicine (IOM) recommends a maximum daily dietary intake of 2,300 mg of sodium for adults to reduce risk of hypertension. Advise patients to read the Nutrition Facts panel on food labels to help them adhere to the 2,300-mg/day guideline and to consider adopting the well-investigated Dietary Approaches to Stop Hypertension, or DASH Eating Plan (see Table 4-1, Patients with Hypertension: Recommended Changes in Diet, p. 72). Exe rc is e . Adults should do at least 150 minutes (2 hours and 30 minutes) of moderate-intensity cardiorespiratory activity, for example, walking briskly at a pace of 3 to 4.5 miles per hour, each week. Alternatively, adults can engage in vigorous-intensity aerobic activity, such as jogging or running, for 75 minutes (1 hour and 15 minutes) each week. 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 Examination EXAMINATIO N TECHNIQ UES

P O SSIBLE FIN DIN G S

G e ne ra l S urve y Ap p a re n t S t a t e o f He a lt h

Acutely or chronically ill, frail, robust, vigorous

Le ve l o f Co n s c io u s n e s s . Is the patient awake, alert, and interactive?

If not, promptly assess level of consciousness (see p. 332)

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EXAMINATIO N TECHNIQ UES


S ig n s o f Dis t re s s ■ Cardiac or respiratory distress

Clutching the chest, pallor, diaphoresis; labored breathing, wheezing, cough

■ Pain

Wincing, sweating, protecting painful area

■ Anxiety or depression

Anxious face, fidgety movements, cold and moist palms; inexpressive or flat affect, poor eye contact, psychomotor slowing

S k in C o lo r a n d O b v io u s Le s io n s . See Chapter 6, The Skin, Hair, and Nails, for details.

Pallor, cyanosis, jaundice, rashes, bruises

Dre s s , Gro o m in g , a n d Pe rs o n a l Hyg ie n e ■ How is the patient dressed? Is

the clothing suitable for the temperature and weather? Is it clean and appropriate to the setting? ■ Note patient’s hair, ngernails,

and use of make-up.

Body p iercing or tattoos can b e associated with alcohol and drug use.

These may be clues to the patient’s personality, mood, lifestyle, and self-regard.

Fa c ia l Exp re s s io n . 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.

Od o r s o f Bo d y a n d Bre a t h . Odors can be important diagnostic clues.

Breat h od or of alcohol, acetone (d iab etes), uremia, or liver failure. Fruit y od or of d iab etes. (Never assume that alcohol on a p at ient ’s b reat h exp lains changes in mental status or neurologic find ings.)

Po s t u re , Ga it , a n d Mo t o r Ac t ivit y

Preference to sit up in left-sided heart failure and to lean forward with arms braced in chronic obstructive pulmonary disease (COPD).



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H e ig h t a n d W e ig h t He ig h t . Measure the patient’s height in stocking feet. Note the build— muscular or deconditioned, tall or short. Observe the body proportions.

Short stature in Turner syndrome; elongated arms in Marfan syndrome; loss of height in osteoporosis.

We ig h t . Is the patient emaciated? Plump? If obese, is there central or dispersed distribution of fat? Weigh the patient with shoes off.

Obesity (BMI ≥30 kg/m 2) increases risk of diabetes, heart disease, stroke, hypertension, osteoarthritis, sleep apnea syndrome, and some forms of cancer.

Calculate the body mass index (BMI), which incorporates estimated but more accurate measurements of body fat than weight alone.

M e t h o d s t o C a lc u la t e B o d y M a s s In d e x (B M I) U n it o f M e a s u r e

M e t h o d o f C a lc u la t io n

Weight in pounds, height in inches

(1) St nd rd BMI Ch rt (2) Weight (lb ) × 7 a Height (inches)

Weight in kilograms, height in meters squared

(3) Weight (kg) Height ( 2)

Either unit of measure

(4) “BMI C lcul tor” t htt :/ / www.nhlbi. nih.gov/ he lth/educ tion l/ lose_wt/ BMI/ b ic lc.ht

Sever l org niz tions use 7 4.5, but the v ri tion in BMI is negligible. Conversion for ul s: 2.2 lb = 1 kg; 1 inch = 2.54 c ; 1 c = 1 . Source: N tion l Institutes of He lth–N tion l He rt, Lung, nd Blood Institute: C lcul te Your Body M ss Index. Av il ble t: htt :/ / www.nhlbi.nih.gov/ he lth/educ tion l/ lose_ wt/ BMI/ b ic lc.ht . Accessed J nu ry 21, 2 15.

a

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 (see Table 4-2, Nutrition Screening, p. 73, and Table 4-3, Nutrition Counseling, p. 74).

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If the BMI falls below 17, be concerned about possible anorexia nervosa, bulimia, or other medical conditions (see Table 4-4, Eating Disorders and Excessively Low BMI, p. 75).

T h e V it a l S ig n s : B lo o d P r e s s u r e , H e a r t R a t e , R e s p ir a t o r y R a t e , a n d T e m p e r a t u r e Blo o d P re s s u re M e t h o d s f o r M e a s u r in g Blo o d P r e s s u r e . Office screening with

manual and automated cuffs remains common, but elevated readings increasingly require confirmation with home and ambulatory monitoring, which are more predictive of cardiovascular disease and end-organ damage than manual and automated measurements in the office. Automated ambulatory blood pressure monitoring measures blood pressure at preset intervals over 24 to 48 hours, usually every 15 to 20 minutes during the day and 30 to 60 minutes during the night. Be familiar with these different methods of blood pressure measurement and their varying criteria for hypertension. Ty p e s o f Hy p e r t e n s io n . Three types of hypertension are especially

important to recognize, described below. Suspicion of these entities and assessing the effects of treatment are indications for ambulatory blood pressure monitoring.

T y p e s o f H y p e r t e n s io n White coat hypertension (isolated clinic hypertension)

Masked hypertension

Blood ressure ≥14 /9 in edic l settings nd e n w ke bul tory re dings <135/ 85. Re orted in u to 2 % of tients with elev ted office blood ressure C rries nor l to slightly incre sed c rdiov scul r risk nd does not require tre t ent; ttributed to conditioned nxiety res onse Blood ressure <14 /9 , but n elev ted d yti e blood ressure of >135/ 85 on ho e or bul tory testing Re orted in n esti ted 1 % to 3 % of the gener l o ul tion If unt re t ed, it incre ses risk of c rdiov scul r dise se nd end-org n d ge (continued )


T y p e s o f H y p e r t e n s io n Nocturnal hypertension

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(Continued)

Physiologic blood ressure “di ing” occurs in ost tients s they shift fro w kefulness to slee A nocturn l f ll of <1 % of d yti e v lues is ssoci ted with oor c rdiov scul r outco es nd c n only be identified on 24-hour bul tory blood ressure onitoring Two other tterns h ve oor c rdiov scul r outco es, nocturn l rising ttern nd rked nocturn l f ll of >2 % of d yti e v lues

S e le c t in g t h e C o r r e c t S iz e B lo o d P r e s s u r e C u f f It is i ort nt for clinici ns nd tients to use cuff th t fits the Follow the guidelines outlined here for selecting the correct size: ●

●

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tient’s r .

Width of the infl t ble bl dder of the cuff should be bout 4 % of u er r circu ference ( bout 12 to 14 c in the ver ge dult). Length of the infl t ble bl dder should be bout 8 % of u er r circu ference ( l ost long enough to encircle the r ). The st nd rd cuff is 12 × 23 c , ro ri t e for r circu ferences u t o 28 c .

S t e p s t o E n s u r e A c c u r a t e B lo o d P re s s u re M e a s u re m e n t 1. The t ient should void s oking or drinking c ffein t ed bever ges for 3 inut es before t he blood ressure is t ken nd rest for t le st 5 inut es. 2. M ke sure the ex ining roo is quiet nd co fort bly w r . 3. M ke sure the r selected is free of clothing. There should be no rteriovenous fistul s for di lysis, sc rring fro rior br chi l rtery cutdowns, or signs of ly hede (seen fter xill ry node dissection or r di tion ther y). 4. P l te the br chi l rtery to confir th t it h s vi ble ulse. 5. Position the r so th t the br chi l rtery, t the ntecubit l cre se, is at heart level—roughly level with the 4th inters ce t its junction with the sternu . 6. If the tient is se ted, rest the r on t ble little bove the tient’s w ist; if st nding, try to su ort the tient’s r t the idchest level.

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M e a s u r in g B lo o d P r e s s u r e ●

●

● ●

●

●

●

● ●

Center the infl t ble bl dder over the br chi l rtery. The lower border of the cuff should be bout 2.5 c bove the ntecubit l cre se. Secure the cuff snugly. Position the tient’s r so th t it is slightly flexed t the elbow. To deter ine how high to r ise the cuff ressure, first esti te the systolic ressure by l tion. As you feel the r di l rtery with the fingers of one h nd, r idly infl te the cuff until the r di l ulse dis e rs. Re d this ressure on the no eter nd dd 3 Hg to it. Use of this su s the t rget for subsequent infl tions revents disco fort fro unnecess rily high cuff ressures. It lso voids the occ sion l error c used by n uscult tory g — silent interv l between the systolic nd di stolic ressures. Defl te the cuff ro tly. Now l ce the bell of stethosco e lightly over the br chi l rtery, t king c re to ke n ir se l with its full ri . Bec use the sounds to be he rd (Korotkoff sounds) re rel tively low in itch, they re he rd better with the bell. Infl te the cuff r idly g in to the level just deter ined, nd then defl te it slowly, t r te of bout 2 to 3 Hg er second. Note the level t which you he r the sounds of t le st two consecutive be ts. This is the systolic pressure. Continue to lower the ressure slowly. The dis e r nce oint, usu lly only few Hg below the uffling oint, is the best esti te of diastolic pressure. Re d both the systolic nd di stolic levels to the ne rest 2 Hg. W it 2 or ore inutes nd re e t. Aver ge your re dings. If the first two re dings differ by ore th n 5 Hg, t ke ddition l re dings. T ke blood ressure in both r s t le st once. In tients t king ntihy ertensive edic tions or with history of f inting, ostur l dizziness, or ossible de letion of blood volu e, t ke the blood ressure in two ositions—su ine nd st nding (unless contr indic ted). A f ll in systolic ressure of 2 Hg or ore within 3 inutes fter st nding u , es eci lly when cco nied by sy to s, indic tes orthostatic (postural) hypotension.

In 2013, the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure ( JNC) updated the classi cation of systolic blood pressure (SBP) and diastolic blood pressure (DBP). J N C 8 B lo o d P r e s s u r e C la s s if ic a t io n f o r A d u lt s C a t e g o ry

Nor l Prehy ertension St ge 1 hy ertension Ages ≥18 to <6 ye rs; di betes or ren l dise se Age ≥6 ye rsa St ge 2 hy ertension

S y s t o lic (m m Hg )

D ia s t o lic (m m Hg )

<12 12 –139

<8 8 –89

14 —159

9 —99

15 –159 ≥16

9 –99 ≥1

The A eric n Society of Hy ertension r ises this cutoff to ge ≥8 ye rs.

a


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When the systolic and diastolic levels fall in different categories, use the higher category. For example, 170/92 mm Hg is Stage 2 hypertension; 135/100 mm Hg is Stage 1 hypertension. In isolated systolic hypertension, SBP is ≥140 mm Hg, and DBP is <90 mm Hg. He a r t Ra t e . The radial pulse is used commonly to count the heart rate. With the pads of your index and middle ngers, compress the radial artery until you detect a maximal pulsation (Fig. 4-1). 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 cardiac apex (the apical pulse). EXAMINATIO N TECHNIQ UES

Fig ure 4-1 Palpate the radial puls e . P O SSIBLE FIN DIN G S

Rh yt h m . Palpate the radial pulse. Check the rhythm again by listening 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 fibrillation. For all irregular patterns, an ECG is needed to identify the arrhythmia.

Re s p ira t o ry Ra t e a n d Rhyt h m . 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 trachea with your stethoscope during examination of the head and neck or chest. Normally, adults take 14 to 20 breaths per minute in a quiet, regular pattern.

See Table 8-4, p. 162, Abnormalities in Rate and Rhythm of Breathing.

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Te m p e ra t u re . Average oral temperature, usually 37°C (98.6°F), uctuates considerably from the early morning to the late afternoon or evening. Rectal temperatures are higher than oral temperatures by about 0.4 to 0.5°C (0.7 to 0.9°F) but also vary. Axillary temperatures are lower than oral temperatures by approximately 1°C but take 5 to 10 minutes to register and are considered less accurate than other measurements.

Tympanic membrane temperatures can be more variable than oral or rectal temperatures. Studies suggest that in adults, oral and temporal artery temperatures correlate more closely with the pulmonary artery temperature, but are about 0.5°C lower.

P O SSIBLE FIN DIN G S 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 includ e infection, trauma (such as surgery or crush injuries), malignancy, b lood d isord ers (such as acute hemolyt ic anemia), d rug react ions, and immune d isord ers such as collagen vascular d isease. The chief cause of hypothermia is exp osure to cold. Other causes include reduced movement as in paralysis, interference with vasoconstriction as from sepsis or excess alcohol, starvation, hypothyroidism, and hypoglycemia. Older adults are especially susceptib le to hypothermia and also less likely to develop fever.

Oral temperatures: Choose either glass or electronic thermometer. ■ Glass thermometer: Shake the ther-

mometer 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: Carefully

place the disposable cover over the probe and insert the thermometer under the tongue for about 10 seconds. Rectal temperatures: Position the patient on one side with the hip exed. Select a rectal thermometer with a stubby tip, lubricate it, and

Taking rectal temperatures is common practice in unresponsive patients or those at risk for biting down on the thermometer.



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insert it about 3 to 4 cm (1½ inches) into the anal canal, in a direction pointing to the umbilicus. Remove it after 3 minutes, then read. Alternatively, use an electronic thermometer after lubricating the probe cover. Wait about 10 seconds for the digital temperature recording to appear. Tympanic membrane temperature: Make sure the external auditory canal is free of cerumen. Position the probe in the canal. Wait 2 to 3 seconds until the digital reading appears. This method measures core body temperature, which is higher than the normal oral temperature by approximately 0.8°C (11.4°F). Temporal artery temperature: Place the probe against the center of the forehead, depress the infrared scanning button, and brush the device across the forehead, down the cheek, and behind an earlobe. Read the display, which records the highest measure temperature. Industry information suggests that combined forehead and behindthe-ear contact is more accurate than scanning only the forehead.

A c u t e a n d C h r o n ic P a in The experience of pain is complex and multifactorial. It involves sensory, emotional, and cognitive processing but may lack a speci c physical etiology. Chronic pain is de ned in several ways: pain not associated with cancer or other clinical 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.

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Adopt a multidisciplinary measurement-based approach to assessing pain, carefully listening to the patient’s story, and any contributing factors. Pursue the seven features of pain, as you would with any symptom. Accept the patient’s 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 speci c 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. Co n t rib u t in g Fa c t o r s . 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 ef cacy.

Identify any comorbid conditions such as arthritis, diabetes, HIV/AIDS, substance abuse, sickle cell disease, or psychiatric disorders. These can signi cantly affect the patient’s experience of pain. He a lt h Dis p a rit ie s . Be aware of the well-documented health disparities 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, postoperative, and low back pain. Clinician stereotypes, language barriers, 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. P a in Ma n a g e m e n t . Managing pain is a complex clinical challenge.

Experts recommend a stepped-care approach, with an emphasis on measurement and tracking tools to follow responses to treatment and referrals to specialists, summarized below.

M a n a g in g C h r o n ic P a in : S t e p s f o r M e a s u r e m e n t -B a s e d C a r e Step 1: Measure pain intensity and pain interference. A v lid ted 2-ite questionn ire is v il ble for ri ry c re sking tients to r te in in the st onth nd interference with d ily ctivities on sc le of 1 to 1 . Step 2: Measure mood. Tre t ble de ression, nxiety, nd osttr u tic stress disorder (PTSD) frequently cco ny chronic in. The PHQ-4 is 4-ite questionn ire for detecting nxiety nd de ression. The Pri ry C re-PTSD is 4-question screen for PTSD. (continued )


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M a n a g in g C h r o n ic P a in : S t e p s f o r M e a s u r e m e n t -B a s e d C a r e (Continued) Step 3: Measure the effect of pain on sleep. O ioid doses correl te with slee disordered bre thing nd slee ne . Step 4: Me sure risk of co-occurring subst nce buse, esti ted t 18% to 3 %. Step 5: Measure the opioid dose nd c lcul te the o ioid dose equiv lency using v il ble web-b sed c lcul tors. Source: T uben D. Chronic in n ge ent: e sure ent-b sed ste ed c re solutions. P in: Clinic l U d tes. Intern tion l Associ tion for the Study of P in. Dece ber 2 12. Av il ble t htt :/ / www.i s - in.org/ Public tionsNews/ NewsletterIssue. s x?Ite Nu ber=2 64. Accessed J nu ry 28, 2 15.

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. (Common abbreviations for blood pressure, heart rate, and respiratory rate are selfexplanatory.) R e c o r d in g t h e P h y s ic a l E x a m in a t io n —G e n e r a l S u r v e y a n d V it a l S ig n s “Mrs. Scott is young, he lthye ring wo n, well-groo ed, fit, nd in good s irits. Height is 5′4″, weight 135 lb, BP 12 / 8 , HR 72 nd regul r, RR 16, te er ture 37.5°C.” OR ● “Mr. Jones is n elderly n who looks le nd chronic lly ill. He is lert, with good eye cont ct, but c nnot s e k ore th n two or three words t ti e bec use of shortness of bre th. He h s intercost l uscle retr ction when bre thing nd sits u right in bed. He is thin, with diffuse uscle w sting. Height is 6′2″, weight 175 lb, BP 16 /95, HR 1 8 nd irregul r, RR 32 nd l bored, te er ture 1 1.2°F.” (These findings suggest COPD exacerbation.) ●

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Aids to Interpretation Table 4-1 Pa t ie n t s w it h Hyp e rt e n s io n : Re c o m m e n d e d Ch a n g e s in Die t D ie t a ry C h a n g e

Fo o d S o u r c e

Increase foods high in potassium

Baked white or sweet potatoes, white beans, beet greens, soybeans, spinach, lentils, kidney beans Yogurt Tomato paste, juice, puree, and sauce Bananas, plantains, many dried fruits, orange juice

Decrease foods high in sodium

Canned foods (soups, tuna fish) Pretzels, potato chips, pizza, pickles, olives Many processed foods (frozen dinners, ketchup, mustard) Batter-fried foods Table salt, including for cooking

Source: Adapted from: U.S. Department of Agriculture and U.S. Department of Health and Human Services. Dietary Guidelines for Americans, 2010. Washington, D.C.: U.S. Government Printing Of ce; 2010; Choose MyPlate.gov. Available at http://www.choosemyplate.gov/ index.html. Accessed December 15, 2014; Of ce of Dietary Supplements, National Institutes of Health. Dietary Supplement Fact Sheets: Calcium; Vitamin D. Available at http://ods. od.nih.gov/factsheets/list-all/. Accessed December 15, 2014.


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Table 4-2 Nu t rit io n S c re e n in g Mini Nutritiona l As s e s s me nt

MNA®

La s t name : S ex:

Firs t name: Age :

Weight, kg:

He ight, cm:

Da te :

Complete the s cre e n by filling in the boxe s with the a ppropria te numbe rs . Tota l the numbe rs for the final scre ening s core.

S cre e ning A Has fo o d intake de cline d o ve r the pas t 3 mo nths due to lo s s o f appetite , dig e s tive pro ble ms , c hewing o r s wallo wing diffic ultie s ? 0 = s e ve re de cre as e in food inta ke 1 = mode rate decrea s e in food intake 2 = no decre as e in food inta ke B Weig ht lo s s during the las t 3 months 0 = weight los s grea te r tha n 3 kg (6.6 lbs ) 1 = doe s not know 2 = weight los s be twe en 1 a nd 3 kg (2.2 and 6.6 lbs ) 3 = no weight los s C Mo bility 0 = bed or chair bound 1 = a ble to ge t out of be d / cha ir but does not go out 2 = goe s out D Has s uffe re d ps yc ho lo g ic al s tres s o r acute dis e as e in the pas t 3 mo nths ? 0 = ye s 2 = no E Neuro ps ycho lo g ic al pro ble ms 0 = s e vere dementia or de pre ss ion 1 = mild dementia 2 = no ps ychologica l problems F1 Bo dy Mas s Inde x (BMI) (weig ht in kg ) / (heig ht in m)2 0 = BMI le ss than 19 1 = BMI 19 to le ss tha n 21 2 = BMI 21 to les s tha n 23 3 = BMI 23 or grea te r IF BMI IS NOT AVAILABLE, REP LACE QUES TION F1 WITH QUES TION F2. DO NOT ANSWER QUES TION F2 IF QUES TION F1 IS ALREADY COMP LETED. F2 Calf circ umfere nc e (CC) in cm 0 = CC le ss tha n 31 3 = CC 31 or grea te r

S cre e ning s core (ma x. 14 points ) 12 - 14 po ints : Norma l nutritional s tatus 8 - 11 po ints : At risk of ma lnutrition 0 - 7 po ints : Malnouris he d

Source: Vellas B, Villars H, Abellan G, et al. Overview of the MNA—Its history and challenges. J Nutr Health Aging. 2006;10:456. Rubenstein LZ, Harker JO, Salva A, et al. Screening for undernutrition in geriatric practice: developing the short-form mini nutritional assessment (MNA-SF). J Gerontol A Biol Sci Med Sci. 2001;56(6):M366. Guigoz Y. The Mini-Nutritional Assessment (MNA) Review of the Literature—What does it tell us? J Nutr Health Aging. 2006;10:466. Kaiser MJ, Bauer JM, Ramsch C, et al. Validation of the Mini Nutritional Assessment Short-Form (MNA-SF): a practical tool for identi cation of nutritional status. J Nutr Health Aging. 2009; 13:782. ®Société des Produits Nestlé, S.A., Vevey, Switzerland, Trademark Owners ©Nestlé, 1994, Revision 2009. N67200 12/99 10M For more information: www.mna-elderly.com

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Table 4-3 Nu t rit io n Co u n s e lin g : S o u rc e s o f N u t r i e n t s N u t r ie n t

Fo o d S o u r c e

C a lc iu m

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

Iro n

Lean meat, dark turkey meat, liver Clams, mussels, oysters, sardines, anchovies Iron-fortified cereals Enriched and whole grain bread Spinach, peas, lentils, turnip greens, and artichokes Dried prunes and raisins

Fo la t e

Cooked dried beans and peas Oranges, orange juice Liver Spinach, mustard greens Black-eyed peas, lentils, okra, chickpeas, peanuts Folate-fortified cereals

Vit a m in D

Vitamin D–fortified milk, orange juice, and cereals Cod liver oil; swordfish, salmon, herring, mackerel, tuna, trout Egg yolk Mushrooms

Source: Adapted from U.S. Department of Agriculture and U.S. Department of Health and Human Services. Dietary Guidelines for Americans, 2010. Washington, D.C.: U.S. Government Printing Of ce; 2010; Choose MyPlate.gov. Available at http://www.choosemyplate.gov/ index.html. Accessed December 15, 2014; Of ce of Dietary Supplements, National Institutes of Health. Dietary Supplement Fact Sheets: Calcium; Vitamin D. Available at http://ods. od.nih.gov/factsheets/list-all/. Accessed December 15, 2014.


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Table 4-4 Ea t in g Dis o rd e r s a n d Exc e s s ive ly Lo w BMI A n o r e x ia N e r vo s a

Bu lim ia N e r vo s a

Refusal to maintain minimally normal body weight (or BMI above 17.5 kg/m2)

Repeated binge eating followed by self-induced vomiting, misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise

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

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; Associated with depressive symptoms such as depressed mood, irritability, social craving and compulsion to eat; lack of control over eating; withdrawal, insomnia, decreased libido alternating with periods of Additional features supporting starvation diagnosis: self-induced vomiting or purging, excessive exercise, use of appetite Dread of fatness but may be obese suppressants and/or diuretics Subtypes of 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

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 Classi cation 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, PA: Lippincott Williams & Wilkins, 1663–1676, 2000. Mehler PS. Bulimia nervosa. N Engl J Med. 2003;349(9):875–880.

5

C H A P T E R

Behavior and Mental Status

Clinicians are uniquely poised to detect clues to mental illness and harmful behavior through empathic listening and close observation. Nonetheless, these clues are often missed. Recognizing mental illness is especially important given its signi cant prevalence and morbidity, the high likelihood that it is treatable, the shortage of psychiatrists, and the increasing importance of primary care clinicians as the rst to encounter the patient’s distress. The prevalence of mental health disorders in U.S. adults in 2012 was 18%, affecting 43.7 million people; yet, only 41% received treatment. Even for those receiving care, adherence to treatment guidelines in primary care of ces is <50% and disproportionately lower for ethnic minorities. Mental health disorders are commonly masked by other clinical conditions. Look for the interaction of anxiety and depression in patients with substance abuse, termed “dual diagnosis,” because both must be treated for the patient to achieve optimal function. Watch for underlying psychiatric conditions in “dif cult encounters” and patients with unexplained symptoms. Explore the outlook of patients with chronic illness, a group that is especially vulnerable to depression and anxiety. Nearly half of those with any single mental disorder meet the criteria for one or more additional disorders, with severity strongly related to comorbidity. Approximately 5% of somatic symptoms are acute, triggering immediate evaluation. Another 70% to 75% are minor or self-limited and resolve in 6 weeks. Nevertheless, approximately 25% of patients have persisting and recurrent symptoms that elude assessment and fail to improve. Overall, 30% of symptoms are medically unexplained, masking anxiety, depression, or even somatoform disorders (see Table 5-1, Somatoform Disorders: Types and Approach to Symptoms, p. 87). Depression and anxiety are highly correlated with substance abuse, for example, and clinicians are advised to look for overlap in these conditions. “Dif cult 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. 77

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M e n t a l H e a lt h D is o r d e r s a n d U n e x p la in e d S y m p t o m s in P r im a r y C a r e S e t t in g s M e n t a l D is o r d e r s in P r im a ry C a r e ●

●

A roxi tely 2 % of ri ry c re out tients h ve ent l disorders, but 5 % to 75% of these disorders re undetected nd untre ted. Prev lence of ent l disorders in ri ry c re settings is roughly: ● Anxiety—2 % ● Mood disorders including dysthy i , de ressive, nd bi ol r disorders—25% ● De ression—1 % ● So tofor disorders—1 % to 15% ● Alcohol nd subst nce buse—15% to 2 %

Ex p la in e d a n d U n e x p la in e d S y m p t o m s ● ●

●

Physic l sy to s ccount for roxi tely 5 % of office visits. Roughly one third of hysic l sy to s re unex l ined; in 2 % to 25% of tients, hysic l sy to s beco e chronic or recurring. In tients with unexplained symptoms, t he rev lence of de ression nd nxiet y exceeds 5 % nd incre ses wit h the t ot l nu ber of re ort ed hysic l sy t o s king det ection nd “du l di gnosis” i ort nt clinic l go ls.

C o m m o n Fu n c t io n a l S y n d ro m e s ●

●

●

Co-occurrence r tes for common functional syndromes such s irrit ble bowel syndro e, fibro y lgi , chronic f tigue, te oro ndibul r joint disorder, nd ulti le che ic l sensitivity re ch 3 % to 9 %, de ending on the disorders co red. The rev lence of symptom overlap is high in the co on function l syndro es: n ely, co l ints of f tigue, slee disturb nce, usculoskelet l in, he d che, nd g strointestin l roble s. The co on function l syndro es lso overl in r tes of function l i irent, sychi tric co orbidity, nd res onse to cognitive nd ntide ress nt ther y.

Pe rs o n a lit y Dis o rd e rs . Dif cult patients may have personality disorders resulting in problematic of ce behaviors that escape diagnosis. The DSM-5 characterizes these disorders as “an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and in exible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment.” These patients have dysfunctional interpersonal coping styles that disrupt and destabilize their relationships, including those with health care providers.

Chapter 5 | Behavior and Mental Status

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For unexplained conditions lasting beyond 6 weeks, experts recommend brief screening questions with high sensitivity and speci city, followed by more detailed investigation when indicated due to high rates of coexisting depression and anxiety. Me n t a l He a lt h S c re e n in g . Unexplained conditions lasting more than 6 weeks are increasingly recognized as chronic disorders that should prompt screening for depression, anxiety, or both. Because screening all patients is time consuming and expensive, experts recommend a two-tiered approach: brief screening questions with high sensitivity and speci city for patients at risk, followed by more detailed investigation when indicated.

P a t ie n t Id e n t if ie r s f o r M e n t a l H e a lt h S c r e e n in g ●

● ● ● ● ● ● ● ● ●

Medic lly unex l ined hysic l sy to s— ore th n h lf h ve de ressive or nxiety disorder Multi le hysic l or so tic sy to s or “high sy to count” High severity of the resenting so tic sy to Chronic in Sy to s for ore th n 6 weeks Physici n r ting s “difficult encounter” Recent stress Low self-r ting of over ll he lth High use of he lth c re services Subst nce buse

The Health History C o m m o n o r C o n c e r n in g S y m p t o m s ● ● ● ●

Ch nges in ttention, ood, or s eech Ch nges in insight, orient tion, or e ory Anxiety, nic, ritu listic beh vior, nd hobi s Deliriu or de enti

Your assessment of mental status begins with the patient’s rst 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

80


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). T e r m in o lo g y : T h e M e n t a l S t a t u s E x a m in a t io n Le ve l o f C o n s c io u s n e s s

A le r t n e s s o r S t a t e o f Aw a r e n e s s o f t h e En v iro n m e n t

Attention

The bility to focus or concentr te over ti e on one t sk or ctivity The rocess of registering or recording infor tion. Recent or short-ter e ory covers inutes, hours, or d ys; re ote or long-ter e ory refers to interv ls of ye rs. Aw reness of erson l identity, l ce, nd ti e; requires both e ory nd ttention Sensory w reness of objects in the environ ent nd their interrel tionshi s; lso refers to intern l sti uli (e.g., dre s) The logic, coherence, nd relev nce of the tient's thoughts, or how eo le think Wh t the tient thinks bout, including level of insight nd judg ent Aw reness th t sy to s or disturbed beh viors re nor l or bnor l Process of co ring nd ev lu ting ltern tives; reflects v lues th t y or y not be b sed on re lity nd soci l conventions or nor s An observ ble, usu lly e isodic, feeling tone ex ressed through voice, f ci l ex ression, nd de e nor A ore sust ined e otion th t y color erson's view of the world ( ffect is to ood s we ther is to cli te) A co lex sy bolic syste for ex ressing, receiving, nd co rehending words; essenti l for ssessing other ent l functions Assessed by voc bul ry, fund of infor tion, bstr ct thinking, c lcul tions, construction of objects with two or three di ensions

Memory

Orientation Perceptions

Thought processes Thought content Insight Judgment

Affect

Mood

Language

Higher cognitive functions

Assess level of consciousness, general appearance and mood, and ability to pay attention, remember, understand, and speak.


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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, preoccupations, beliefs, or perceptions as they arise during the interview (see Table 20-2, Delirium and Dementia, pp. 418–419).

Health Promotion and Counseling: Evidence and Recommendations Im p o r t a n t T o p ic s f o r H e a lt h P r o m o t io n a n d C o u n s e lin g ● ●

Screening for de ression nd suicid lity Screening for subst nce use disorders, including lcohol nd rescri tion drugs

M o o d D is o r d e r s a n d D e p r e s s io n . Depressive and bipolar disorders affect over 9% of the U.S. population. About 16 million adult Americans, or almost 7%, have major depression, often with coexisting anxiety disorders and substance abuse. Depression is nearly twice as common in women as men, and frequently accompanies chronic clinical illness, yet is frequently underdiagnosed. Look closely for early clues of depression in primary care settings such as low self-esteem, loss of pleasure in daily activities (anhedonia), sleep disorders, and dif culty 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?” S u ic id e . Suicide ranks as the 10th leading cause of death in the United States, accounting for nearly 40,000 deaths annually, and is the second leading cause of death among 15- to 24-year olds. Suicide rates are highest among those ages 45 to 54 years, followed by elderly adults ≥age 85 years. Men have suicide rates nearly four times higher than women, though women are three times more likely to attempt suicide. Risk factors include

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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 admission); substance abuse; personality disorder; and prior history or family history of suicide. Patients at high risk should be referred immediately for psychiatric evaluation and possible hospitalization. S u b s t a n c e U s e D is o r d e r s , In c lu d in g A lc o h o l a n d P r e s c r ip t io n D r u g s . The overlap of substance abuse and mental health disorders is extensive. The 2013 National Survey on Drug Use and Health showed that 23% of the U.S. population ages 12 years or older (60.1 million people) reported binge drinking, and over 6% reported heavy drinking. Over 24 million Americans, or 9.4% of the population, reported use of an illicit drug during the month before the survey, including nearly 20 million marijuana users, 1.6 million cocaine users, and 6.5 million users of prescription drugs for nonmedical indications. 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 T h e M e n t a l S t a t u s E x a m in a t io n ● ● ● ● ●

A e r nce nd beh vior S eech nd l ngu ge Mood Thoughts nd erce tions Cognition, including e ory, ttention, infor tion nd voc bul ry, c lcul tions, bstr ct thinking, nd construction l bility

Observe the patient’s mental status throughout your interaction. Test speci c functions if indicated during the interview or physical examination. The Mental Status Examination consists of ve components: appearance and behavior; speech and language; mood; thoughts and perceptions; and cognitive function.



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A p p e a r a n c e a n d B e h a v io r Assess the following: ■ Level of Consciousness. Observe

alertness and response to verbal and tactile stimuli. ■ Posture and Motor Behavior. Observe

pace, range, character, and appropriateness of movements. ■ Dress, Grooming, and Personal

Normal consciousness, lethargy, obtundation, stupor, coma (see pp. 331–332) Restlessness, agitation, bizarre postures, immobility, involuntary movements

Fastidiousness, neglect

Hygiene ■ Facial Expressions. Assess during

rest and interaction. ■ Manner, Affect, and Relation to

People and Things

Anxiety, depression, elation, anger, and facial immobility of parkinsonism An g e r, h ost ilit y, su sp iciou sn e ss, or e vasiven e ss in p at ie n t s wit h pa ra noia ; t h e elat ion an d eu p h o ria o f ma nia ; t h e flat affe ct an d re m ot e n e ss o f schizophrenia ; t h e ap at hy an d d u lle d affect of d e p re ssion an d dementia

S p e e c h a n d La n g u a g e Note quantity, rate, loudness, clarity, and fluency of speech. If indicated, test for aphasia. A person who can write a correct sentence does not have aphasia.

Ap h asia, d ysp h on ia, d ysart h ria, ch an g e s wit h m ood d isord e rs

T e s t in g f o r A p h a s ia Wo r d C o m p r e h e n s io n

Re p e t it io n

N a m in g Re a d in g C o m p r e h e n s io n Wr it in g

Ask tient to follow one-st ge co nd, such s “Point to your nose.” Try two-st ge co nd: “Point to your outh, then your knee.” Ask tient to re e t hr se of one-syll ble words (the ost difficult re etition t sk): “No ifs, nds, or buts.” Ask tient to n e the rts of w tch. Ask tient to re d r gr h loud. Ask tient to write sentence.

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M ood 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

T h o u g h t a n d P e r c e p t io n s Thought Processes. Assess logic, relevance, organization, and coherence.

Derailments, flight of ideas, incoherence, 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, imp ulsive, or unrealistic judgment

C o g n it iv e F u n c t io n s If indicated, assess: Orientation to time, place, and person

Disorientation

Attention ■ Digit span—ability to repeat a

series of numbers forward and then backward

Poor performance of digit span, serial 7s, and spelling backward are common in dementia and delirium but have other causes, too.

■ Serial 7s—ability to subtract 7

repeatedly, starting with 100 ■ Spelling backward of a ve-letter

word, such as W-O-R-L-D Remote Memory (e.g., birthdays, anniversaries, social security number, schools, jobs, wars)

Impaired in late stages of dementia



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

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P O SSIBLE FIN DIN G S Recent memory and new learning ability impaired in dementia, delirium, and amnestic disorders

H ig h e r C o g n it iv e F u n c t io n s If indicated, assess: Information and Vocabulary. Note range and depth of patient’s information, complexity of ideas expressed, and vocabulary used. For the fund of information, ask names of presidents, other political gures, or large cities.

These attributes reflect intelligence, education, and cultural background. They are limited by mental retardation but are fairly well preserved in early dementia.

Calculating Abilities, such as addition, subtraction, and multiplication

Poor calculation in mental retardation and dementia

Abstract Thinking—ability to respond abstractly to questions about

Concrete resp onses (observab le details rather than concepts) are common in mental retardation, dementia, and delirium. Responses are sometimes b izarre in schizophrenia.

■ 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 Constructional Ability. Ask patient: ■ To copy gures such as circle,

Imp aired ability common in dementia and with parietal lobe damage

cross, diamond, and box, and two intersecting pentagons, or ■ To draw a clock face with num-

bers and hands

S p e c ia l T e c h n iq u e Min i-Me n t a l S t a t e Exa m in a t io n (MMS E). 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.

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M M S E S a m p le It e m s Orient ation to Time Registration

Naming Reading

“Wh t is the d te?” “Listen c refully. I going to s y three words. You s y the b ck fter I sto . Re dy? Here they re . . . APPLE ( use), PENNY( use), TABLE ( use). Now re e t those words b ck to e.” (Re e t u to five ti es, but score only the first tri l.) “Wh t is this?” (Point to encil or en.) “Ple se re d this nd do wh t it s ys.” (Show ex inee the words on the sti ulus for .) CLOSE YOUR EYES

Re roduced by s eci l er ission of the Publisher, Psychologic l Assess ent Resources, Inc., 162 4 North Florid Avenue, Lutz, Florid 33549, fro the Mini Ment l St te Ex in tion, by M rsh l Folstein nd Sus n Folstein, Co yright 1975, 1998, 2 1 by Mini Ment l LLC, Inc. Published 2 1 by Psychologic l Assess ent Resources, Inc. Further re roduction is rohibited without er ission of PAR, Inc. The MMSE c n be urch sed fro PAR, Inc. by c lling (813) 968–3 3.

Recording Your Findings R e c o r d in g t h e B e h a v io r a n d M e n t a l S t a t u s E x a m in a t io n “Mental Status: The tient is lert, well-groo ed, nd cheerful. S eech is fluent nd words re cle r. Thought rocesses re coherent, insight is good. The tient is oriented to erson, l ce, nd ti e. Seri l 7s ccur te; recent nd re ote e ory int ct. C lcul tions int ct.” OR “Mental Status: The tient e rs s d nd f tigued; clothes re wrinkled. S eech is slow nd words re u bled. Thought rocesses re coherent, but insight into current life reverses is li ited. The tient is oriented to erson, l ce, nd ti e. Digit s n, seri l 7s, nd c lcul tions ccur te, but res onses del yed. Clock dr wing is good.” (These findings suggest depression.)


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Aids to Interpretation Table 5-1

S o m a t o fo rm Dis o rd e r s : Typ e s a n d Ap p ro a ch t o S ym p t o m s

Ty p e o f D is o r d e r

D ia g n o s t ic Fe a t u r e s

Somatic symptom disorder

Somatic symptoms are either very distressing or result in significant disruption of functioning, as well as excessive and disproportionate thoughts, feelings, and behaviors related to those symptoms. Symptoms should be specific if with predominant pain.

Illness anxiety disorder

Preoccupation with having or acquiring a serious illness where somatic symptoms, if present, are only mild in intensity.

Conversion disorder

Syndrome of symptoms of deficits mimicking neurologic or clinical illness in which psychological factors are judged to be of etiologic importance.

Psychological factors affecting other clinical conditions

Presence of one or more clinically significant psychological or behavioral factors that adversely affect a clinical condition by increasing the risk for suffering, death, or disability

Factitious disorder

Falsification of physical or psychological signs or symptoms, or induction of injury or disease, associated with identified deception. The individual presents himself or herself as ill, impaired, or injured even in the absence of external rewards.

O t h e r Re la t e d D is o r d e r s o r Be h a v io r s

Body dysmorphic disorder

Preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear only slight to others

Dissociative disorder

Disruption of and/or discontinuity in the normal integration of consciousness, memory, identity, emotion, perception, body representation, motor control, and behavior

Note to readers: Regarding tables in past editions on mood, anxiety, and psychotic disorders, per current DSM-5 copyright, readers are referred to the DSM-5 for further diagnostic information.

6

C H A P T E R

The Skin, Hair, and Nails

This edition provides a helpful new approach that features careful history taking; thorough inspection and palpation of benign and suspicious lesions to better detect the three major skin cancers–basal cell carcinoma, squamous cell carcinoma, and melanoma; focused techniques for assessing changes in the hair and nails; accurate use of terminology to describe your ndings; and visual familiarity with important common benign and malignant skin conditions.

The Health History C o m m o n o r C o n c e r n in g S y m p t o m s ● ● ●

Growths R sh H ir loss

Gro w t h s . Ask about any new growths or rashes: “Have you noticed any changes in your skin? . . . your hair? . . . your nails?” “Have you had any rashes? . . . sores? . . . lumps? . . . itching?” Pursue the personal and family history of skin cancer and note the type, location, and date of occurrence. Ask about regular self-skin examination and use of sunscreen. Ra s h e s . Ask about itching, the most important symptom when assessing rashes. Does itching precede the rash or follow the rash? For itchy rashes, ask about seasonal allergies with itching and watery eyes, asthma, and atopic dermatitis. Can the patient sleep all night or does itching wake up the patient?

Causes of generalized itching, without apparent rash, include dry skin; pregnancy; uremia; jaundice; lymphomas and leukemia; drug reactions; and, less commonly, polycythemia vera and thyroid disease.

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Ha ir Lo s s o r Na il Ch a n g e s . Ask if there is hair thinning or hair shedding and, if so, where. If shedding, does the hair come out at the roots or break along the hair shafts? Be familiar with common nail changes such as onychomycosis, habit tic deformity, and melanonychia, shown in Table 6-8, pp. 113–114.

Hair shedding at the roots is common in telogen effluvium and alopecia areata. Hair breaks along the shaft suggest damage from hair care or tinea ca pitis.


Skin c ncer revention Skin c ncer screening

S k in Ca n c e r P re ve n t io n . Skin cancers affect an estimated one in ve Americans during their lifetime. The most common skin cancer is BCC, followed by SCC, and melanoma. M e la n o m a . Although it is the least common skin cancer, melanoma is

the most lethal due to its high rate of metastasis and high mortality at advanced stages, causing over 70% of skin cancer deaths. The incidence of melanoma has the most rapid increase of any cancer and is now the fifth most frequently diagnosed cancer in men and the seventh most frequently diagnosed in women. Use of the Melanoma Risk Assessment Tool developed by the National Cancer Institute, available at http://www.cancer.gov/melanomarisktool/ to assess an individual’s 5-year risk of melanoma based on geographic location, gender, race, age, history of blistering sunburns, complexion, number and size of moles, freckling, and sun damage. Avo id in g U lt r a v io le t Ra d ia t io n a n d Ta n n in g Be d s . Increasing

lifetime sun exposure correlates directly with increasing risk of skin cancer. Intermittent sun exposure appears to be more harmful than chronic exposure. The best defense against skin cancers is to avoid ultraviolet radiation exposure by limiting time in the sun, avoiding midday sun, using sunscreen, and wearing sun-protective clothing with long sleeves and hats with wide brims. Advise patients to avoid indoor tanning, especially

Chapter 6 | The Skin, Hair, and Nails

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children, teens, and young adults. Use of indoor tanning beds, especially before age 35 years, increases risk of melanoma by as much as 75%. In 2009, the International Agency for Research on Cancer classified ultraviolet-emitting tanning devices as “carcinogenic to humans.” Re g u la r U s e o f S u n s c r e e n P r e ve n t s S k in C a n c e r. A landmark

study in 2011 demonstrated that the regular use of sunscreen decreases the incidence of melanoma. Advise patients to use at least sun-protective factor (SPF) 30 and broad-spectrum protection. For water exposure, patients should use water-resistant sunscreens. S k in Ca n c e r S c re e n in g . Although the USPSTF found insuf cient evidence (grade I) to recommend routine skin cancer screening, it does advise clinicians to “remain alert for skin lesions with malignant features” during routine physical examinations and reference the ABCDE criteria. The American Cancer Society (ACS) and the AAD recommend full-body examinations for patients over age 50 years or at high risk, because melanoma can appear in any location. High-risk patients are those with a personal or family history of multiple or dysplastic nevi or previous melanoma. Both new and changing nevi should be closely examined, as at least half of melanomas arise de novo from isolated melanocytes rather than pre-existing nevi. S c r e e n in g fo r M e la n o m a : Th e A BC D Es . Clinicians should apply the

ABCDE-EFG method when screening moles for melanoma (this does not apply for nonmelanocytic lesions like seborrheic keratoses). The sensitivity of this tool for detecting melanoma ranges from 43% to 97%, and specificity from 36% to 100%; diagnostic accuracy depends on how many criteria are used to define abnormality.

T h e A B C D E R u le If two or ore of the ABCDE criteri re resent, risk of el no incre ses nd bio sy should be considered. So e h ve suggested dding EFG to hel detect ggressive nodul r el no s. M e la n o m a

Be n ig n N e v u s

Asymmetry Of one side of ole co red to the other

(continued )

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T h e A B C D E R u le

(Continued)

M e la n o m a

Be n ig n N e v u s

Border irregularity Es eci lly if r gged, notched, or blurred

Color variations a More th n two colors, es eci lly blue-bl ck, white (loss of ig ent due to regression), or red (infl tory re ction to bnor l cells) Diameter >6 mmb A roxi tely the size of encil er ser

Evolving c Or ch nging r idly in size, sy to s, or or hology

● ● ●

Elev ted Fir to l tion Growing rogressively over sever l weeks

With the exce tion of ho ogeneous blue color in blue nevus, blue or bl ck color within l rger ig ented lesion is es eci lly concerning for el no . b E rly el no s y be <6 , nd ny benign lesions re >6 . c Evolution, or ch nge, is the ost sensitive of these criteri . A reli ble history of ch nge y ro t bio sy of benigne ring lesion. a

P a t ie n t S c r e e n in g : Th e S e lf -S k in Ex a m in a t io n . The AAD and the

ACS recommend regular self-skin examination. Instruct patients with risk factors for skin cancer and melanoma, especially those with a history of high sun exposure, prior or family history of melanoma, and ≥50 moles or >5 to 10 atypical moles, to perform regular self-skin examinations.


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F u ll-B o d y a n d In t e g r a t e d S k in E x a m in a t io n s Perform a full-body skin examination in the context of the overall physical examination. Inspect and palpate all skin lesions, focusing on key features that help distinguish if lesions are benign or suspicious for malignancy. Are they raised, at, or uid- lled? Are they rough or smooth? What about color? Is the lesion pink or brown? Measure the size. Is the size changing? Learn to describe each lesion accurately, using the terminology speci ed below. Changing moles, a history of skin cancer, and other risk factors all warrant a full-body skin examination.

See Tab le s 6-1 t o 6-5, p p. 100–108, for exam p le s of p rim ary le sion s (flat , raised , an d flu id -fille d ; p u st u les, fu ru n cle s, n od u le s, cyst s, wh e als, an d b u rrows); an d rou g h , p in k, an d b rown le sion s.

Even during routine examinations, you can pursue an integrated skin examination as you examine areas on the head and neck, arms and hands, and over the back as you listen to the lungs that are already easily accessible. Integrating the skin examination into the physical examination and routinely recording your ndings as part of the general write-up saves time and contributes to earlier detection of skin cancers, when they are easier to treat. Systemic illnesses also have many associated skin ndings.

P r e p a r in g f o r t h e E x a m in a t io n Make sure there is good overhead ambient lighting or natural light from windows. Add a strong light source if the room is dark. You will also need a small ruler or tape measure and a small magnifying glass to help you document important features of skin lesions, such as size, shape, color, and texture. Dermoscopy provides cross-polarized or unpolarized light to visualize patterns of pigmentation or vascular structures and improves the sensitivity and speci city of differentiating melanomas from benign lesions. Ask the patient to change into a gown with the opening in the back and clothes removed except for underwear. Before beginning the examination,

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cleanse your hands thoroughly. It is important for you to palpate lesions for texture, rmness, and scaliness. Im p o r t a n t Te r m s fo r D e s c r ib in g S k in Le s io n s . It is important to use speci c terminology. Good descriptions include each of the following elements: type of primary lesion, number, size, shape, color, texture, location, and con guration.

D e s c r ib in g S k in F in d in g s Primary lesions are flat or raised. ●

●

●

Flat: You c nnot l te the lesion with your eyes closed. ● Macule: Lesion is fl t nd <1 c . ● Patch: Lesion is fl t nd >1 c . Raised: You c n l te the lesion with eyes closed. ● Papule: Lesion is r ised, <1 c , nd not fluid-filled. ● Plaque: Lesion is r ised, >1 c , but not fluid-filled. ● Vesicle: Lesion is r ised, <1 c , nd filled with fluid. ● Bulla: Lesion is r ised, >1 c , nd fluid-filled. Other primary lesions include erosions, ulcers, nodules, ecchy oses, etechi e, nd l ble ur ur .

Number: Lesions c n be solit ry or ulti le. If ulti le, record how ny. Also consider esti ting the tot l nu ber of the ty e of lesion you re describing. Size: Me sure with ruler in illi eters or centi eters. For ov l lesions, e sure in the long xis then er endicul r to the xis. Shape: So e good words to le rn re “circul r,” “ov l,” “ nnul r” (ring-like, with centr l cle ring), “nu ul r” (coin-like, no centr l cle ring), nd “ olygon l.” Color: Be cre tive. Refer to color wheel if needed. There re ny sh des of brown, but you c n st rt with t n, light brown, nd d rk brown. ● ●

Use “skin-colored” when ro ri te. For red lesions or r shes, bl nch the lesion by ressing it fir ly with your finger or gl ss slide to see if the redness te or rily lightens then refills.

Texture: P l te the lesion to see if it is s ooth, fleshy, verrucous, w rty, or sc ly (fine, ker totic, or gre sy sc le).

Blanching lesions are erythematous and suggest inflammation. Nonblanching lesions, petechiae, purpura, and vascular structures are red, purple, and violaceous but not erythematous. See Table 6-6, Vascular and Purpuric Lesions of the Skin, pp. 109–110. Scaling can be greasy, like seborrheic dermatitis or seborrheic keratoses, dry and fine like tinea pedis, or hard and keratotic like actinic keratoses or SCC. (continued )



D e s c r ib in g S k in F in d in g s

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P O SSIBLE FIN DIN G S (Continued )

Location: Be s s ecific s ossible. For single lesions, e sure their dist nce fro other l nd rks (e.g., 1 c l ter l to left or l co issure). Configuration: Describing often very hel ful.

tterns is

For ore infor tion nd ddition l illustr tions of e ch of these ele ents, Le rnDer is free nd very hel ful website.

Te c h n iq u e s o f Exa m in a t io n — P a t ie n t S e a t e d . Choose one of two patient positions for performing the full-body skin examination. The patient can be seated or lie supine then prone. Plan to examine the skin in the same order every time, so you are less likely to skip part of the examination.

Examples are herpes zoster with unilateral and dermatomal vesicles; herpes simplex, with grouped vesicles or pustules on an erythematous base; tinea pedis with annular lesions; and poison ivy allergic contact dermatitis with linear lesions.

Fig ure 6-1 Part the hair on the s calp.

Stand in front of the patient and adjust the table to a comfortable height. Start by examining the hair and scalp (Fig. 6-1).

Alopecia, or hair loss, can be diffuse, patchy, or total. Male and female pattern hair loss are normal with aging. Focal patches may be lost suddenly in alopecia areata. Refer scarring alopecia to a dermatologist.

Sparse hair is seen in hypothyroidism; ne, silky hair in hyperthyroidism.

See Table 6-7, Hair Loss, pp. 111–112.

Inspect the head and neck, including the forehead; eyes including eyelids, conjunctivae, sclerae, eyelashes, and eyebrows; nose, cheeks, lips, oral cavity, and chin; and anterior neck (Figs. 6-2 to 6-4).

Look for signs of basal cell carcinoma on the face. See Table 6-4, Pink Lesions: Basal Cell Carcinoma and Its Mimics, p. 106.

Move the gown to see each area. Ask permission rst.

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Fig ure 6-2 Ins pe ct the fore he ad.


Fig ure 6-3 Ins pe ct the face , eye s , and e ars .

Fig ure 6-4 Ins pe ct the ante rior ne ck.

Inspect the shoulders, arms, and hands (Fig. 6-5). Inspect and palpate the ngernails. Note their color, shape, and any lesions.

See Table 6-8, Findings in or near the Nails, pp. 113–114.

Inspect the chest and abdomen (Fig. 6-6). Lower or raise the gown to expose these areas and cover up when you are nished.

Fig ure 6-5 Ins pe ct the arm s , hands ,

Fig ure 6-6 Ins pe ct the che s t and

and nails .

abdom e n.



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Inspect the thighs and lower legs (Fig. 6-7). Inspect and palpate the toenails, and inspect the soles and between the toes (Fig. 6-8).

Fig ure 6-7 Ins pe ct the thighs and

Fig ure 6-8 Ins pe ct the s ole s of the

lowe r le gs .

fe e t and be twe e n the toe s .

Ask the patient to stand so that you inspect the lower back and posterior legs (Fig. 6-9). If needed, uncover the buttocks. Examination of the breasts and genitalia may be saved for last. Te ch n iq u e s o f Exa m in a t io n —P a t ie n t S u p in e a n d P ro n e . Some clinicians prefer this positioning for more thorough examinations (Fig. 6-10). With the patient supine, inspect the scalp, face, and anterior neck; the shoulders, arms, and hands; the chest and abdomen; anterior thighs; and lower legs, feet, and, if appropriate, the genitalia. Ask permission when moving the gown to expose different areas, and let the patient know which areas you will be examining next.

Ask the patient to turn over to the prone position, lying face down. Look at the posterior scalp, posterior neck, back, posterior thighs, legs, soles of the feet, and buttocks (if appropriate).

Fig ure 6-9 Ins pe ct the back, buttocks , and pos te rior le gs .

Fig ure 6-10 Ins pe ct the s calp, arm s , hands , che s t, abdom e n, ante rior and pos te rior thighs , and fe e t.

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S p e c ia l T e c h n iq u e s Th e P a t ie n t S e lf -S k in Ex a m in a t io n . The patient will need a fulllength mirror, a hand-held mirror, and a well-lit room that provides privacy. Teach the patient the ABCDE-EFG method for assessing moles. Help them and to identify melanomas by looking at photographs of benign and malignant nevi on easy-to-access websites, handouts, or tables in this chapter. Ex a m in in g t h e P a t ie n t w it h Ha ir Lo s s . Examine the hair to determine the overall pattern of hair loss or hair thinning. Inspect the scalp for erythema, scaling, pustules, tenderness, bogginess, and scarring. Look at the width of the hair part in various sections of the scalp. For shedding from the roots, perform a hair pull test by gently grasping 50 to 60 hairs with your thumb and index and middle ngers, pulling rmly away from the scalp (Fig. 6-11). If all the hairs have telogen bulbs, the most likely diagnosis is telogen ef uvium. For fragility, perform the tug test by holding a group of hairs in one hand, pulling along the hair shafts with the other (Fig. 6-12); if any hairs break, it is abnormal.

Possible internal causes of diffuse nonscarring hair shedding in young women are iron-deficiency anemia and hyper- or hypothyroidism.

Fig ure 6-11 Hair pull te s t.

Fig ure 6-12 Tug te s t.

Eva lu a t in g t h e Be d b o u n d P a t ie n t . People con ned to bed, especially when they are emaciated, elderly, or neurologically impaired, are particularly susceptible to pressure sores. Carefully inspect the skin that overlies the sacrum, buttocks, greater trochanters, knees, and heels. Roll the patient onto one side to see the low back and gluteal area best.

Local redness of the skin warns of impending necrosis, although some deep pressure sores develop without antecedent redness. Inspect closely for skin breaks and ulcers.


99

Recording Your Findings As stated on p. 94, use speci c terms to describe skin lesions and rashes, including number of lesions, size, color, shape, texture, location, con guration, and whether a primary lesion. R e c o r d in g t h e S k in , H a ir , a n d N a ils E x a m in a t io n “Skin w r nd dry. N ils without clubbing or cy nosis. A roxi tely 2 brown, round cules on u er b ck, chest, nd r s, re ll sy etric in igent tion, none sus icious. No r sh, etechi e, or ecchy oses.” (These findings suggest normal nevi and perfusion without any rashes or suspicious lesions.) OR “Sc ttered stuck-on verrucous l ques on b ck nd bdo en. Over 3 s ll round brown cules with sy etric ig ent tion on b ck, chest, nd r s. Single 1.2 × 1.6 c sy etric d rk brown nd bl ck l que with erythe tous, uneven border, on left u er r .” (These findings suggest normal seborrheic keratoses and benign nevi, but also a possible malignant melanoma.)

100


Aids to Interpretation Table 6-1 De s c rib in g P rim a ry S k in Le s io n s : Fla t , Ra is e d , a n d Flu id -Fille d Describe skin lesions accurately, including number, size, color, texture, shape, primary lesion, location, and configuration. This table identifies common primary skin lesions and includes classic descriptions of each lesion with the diagnosis in italics. Fla t s p o t s : If you run your finger over the lesion but do not feel the

lesion, the lesion is flat. If a flat spot is small (<1 cm), it is a macule. If a flat spot is larger (>1 cm), it is a patch. Macules (flat, small) Multiple 3–8-mm erythematous confluent round macules on chest, back, and arms; morbilliform drug eruption

Patches (flat, large) Bilaterally symmetric erythematous patches on central cheeks and eyebrows, some with overlying greasy scale; seborrheic dermatitis

Large confluent completely depigmented patches on dorsal hands and distal forearms; vitiligo


Table 6-1

101

De s c rib in g P rim a ry S k in Le s io n s : Fla t , Ra is e d , a n d Flu id -Fille d (continued )

Ra is e d s p o t s : If you run your finger over the lesion and it is palpable

above the skin, it is raised. If a raised spot is small (<1 cm), it is a papule. If a raised spot is larger (>1 cm), it is a plaque. Papules (raised, small) Multiple 2–4-mm soft, fleshy skincolored to light brown papules on lateral neck and axillae in skin folds; skin tags

Scattered erythematous round drop-like, flat-topped well-circumscribed scaling papules and plaques on trunk; guttate psoriasis

Plaques (raised, large) Scattered erythematous to bright pink well-circumscribed flat-topped plaques on extensor knees and elbows, with overlying silvery scale; plaque psoriasis

Multiple round coin-like eczematous plaques on arms, legs, and abdomen, with overlying dried transudate crust; nummular dermatitis


102


Table 6-1

De s c rib in g P rim a ry S k in Le s io n s : Fla t , Ra is e d , a n d Flu id -Fille d (continued )

Flu id -f ille d le s io n s : If the lesion is raised, filled with fluid, and small

(<1 cm), it is a vesicle. If a fluid-filled spot is larger (>1 cm), it is a bulla. Vesicles (fluid-filled, small) Multiple 2–4-mm vesicles and pustules on erythematous base, grouped together on left neck; herpes simplex virus

Bullae (fluid-filled, large) Several tense bullae on lower legs; insect bites


103

Table 6-2 Ad d it io n a l P rim a ry Le s io n s : P u s t u le s , Fu ru n c le s , No d u le s , Cys t s , Wh e a ls , Bu rro w s Pustule: Small palpable collection of neutrophils or keratin that appears white 15–20 pustules and acneiform papules on buccal and parotid cheeks bilaterally; acne vulgaris

Furuncle: Inflamed hair follicle; multiple furuncles together form a carbuncle Two large (2-cm) furuncles on forehead, without fluctuance; furunculosis (Note: fluctuant deep infections are abscesses)

Nodule: Larger and deeper than a papule Solitary blue-brown 1.2-cm firm nodule with positive dimple sign and hyperpigmented rim on left lateral thigh; dermatofibroma

Solitary 4-cm pink and brown scar-like nodule on central chest at site of previous trauma; keloid


104


Table 6-2

Ad d it io n a l P rim a ry Le s io n s : P u s t u le s , Fu ru n c le s , No d u le s , Cys t s , Wh e a ls , Bu rro w s (continued )

Subcutaneous mass/cyst: Whether mobile or fixed, cysts are encapsulated collections of fluid or semisolid Three 6–8-mm mobile subcutaneous cysts on vertex scalp, that on excision reveal pearly white balls; pilar cysts

Solitary 9-cm mobile rubbery subcutaneous mass on left temple; lipoma

Wheal: Area of localized dermal edema that evanesces (comes and goes) within a period of 1–2 days; this is the essential primary lesion of urticaria Many variably sized (1–10-cm) wheals on lateral neck, shoulders, abdomen, arms, and legs; urticaria

Burrow: Small linear or serpiginous pathways in the epidermis created by the scabies mite Multiple small (3–6-mm) erythematous papules on abdomen, buttocks, scrotum, and shaft and head of penis, with four burrows noted on interdigital web spaces; scabies


105

Table 6-3 Ro u g h Le s io n s : Ac t in ic Ke ra t o s e s a n d S q u a m o u s Ce ll Ca rc in o m a Patients commonly report feeling rough lesions. Many are benign, like seborrheic keratoses or warts, but squamous cell carcinoma (SCC) and its precursor actinic keratosis can also feel rough or keratotic. Ac t in ic k e r a t o s is ■ ■

Often easier to feel than to see Superficial keratotic papules that “come and go,” on sun-damaged skin

Wa r t s ■

■ ■

Usually skin-colored to pink, texture more verrucous than keratotic May be filiform Often have hemorrhagic punctate that can be seen with a magnifying glass or dermatoscope

S q u a m o u s c e ll c a r c in o m a ■

■ ■

Keratoacanthomas are SCCs that arise rapidly and have a crateriform center Often have a smooth but firm border SCCs can become quite large if left untreated (Note: highest sites of metastasis are the scalp, lips, and ears)

106


Table 6-4 P in k Le s io n s : Ba s a l Ce ll Ca rc in o m a a n d it s Mim ic s Basal cell carcinoma (BCC) is the most common cancer in the world. Fortunately, it rarely spreads to other parts of the body. Nonetheless, it can invade and destroy local tissues, causing significant morbidity to the eye, nose, or brain. Ba s a l C e ll C a r c in o m a S u p e r f ic ia l b a s a l c e ll c a r c in o m a ■ ■

Pink patch that does not heal May have focal scaling

N o d u la r b a s a l c e ll c a r c in o m a ■

■ ■

Pink papule, often with translucent or pearly appearance and overlying telangiectasias May have focal pigmentation Dermoscopy shows arborizing vessels, focal pigment globules, and other specific patterns


107

Table 6-5 Bro w n Le s io n s : Me la n o m a a n d It s Mim ic s Most patients have brown spots on their body surface. Although these are usually freckles, benign nevi, solar lentigines, or seborrheic keratoses, you and the patient must look closely for any that stand out as a possible melanoma. With enough practice, when you see a melanoma, it will stick out as the “ugly duckling.” Review the ABCDE rule and photographs on pp. 91–92. M e la n o m a

M im ic s

A m e la n o t ic m e la n o m a

S k in t a g s o r in t ra d e rm a l n e vi

■

■

Usually in very fair-skinned people Evolution or rapid change is the most important feature, because variegation or dark pigment is missing in this type

■ ■

■

M e la n o m a in s it u

■

■

On sun-exposed or sunprotected skin Look for ABCDE features

Soft and fleshy Often around neck, axillae, or back Sessile nevi may have a hint of brown pigmentation

S o la r le n t ig o

■ ■

On sun-exposed skin Light brown and uniform in color but may be asymmetric (table continues on page 108)

108


Table 6-5

Bro w n Le s io n s : Me la n o m a a n d It s Mim ic s (continued )

M e la n o m a

M im ic s

M e la n o m a

D y s p la s t ic n e v u s

■

■

May arise de novo or in existing nevi and exhibits ABCDEs Patients with many dysplastic nevi have increased risk of melanoma

M e la n o m a

■

■

May have variegated color (browns, red) Has melanocytic features on dermoscopy

M e la n o m a

■

May be uniform in color but asymmetric; key feature is rapid change or evolution

■

■

May have macular base and papular central “fried egg” component Compare to the patient’s other nevi and monitor changes

In f la m e d s e b o rrh e ic k e ra t o s is

■

■

Can sometimes mimic a melanoma if it has an erythematous base Dermoscopy helps the trained eye distinguish these

S e b o r r h e ic k e r a t o s is

■

Stuck-on and verrucous, may be darkly pigmented


109

Table 6-6 Va s c u la r a n d P u rp u ric Le s io n s o f t h e S k in Le s io n s

Fe a t u r e s : A p p e a r a n c e , D is t r ib u t io n , S ig n if ic a n c e

C h e r ry A n g io m a ■

■ ■

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

S p id e r A n g io m a a ■

■

■

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

S p id e r Ve in a ■

■

■

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 (table continues on page 110)

110


Table 6-6

Va s c u la r a n d P u rp u ric Le s io n s o f t h e S k in (continued )

Le s io n s

Fe a t u r e s : A p p e a r a n c e , D is t r ib u t io n , S ig n if ic a n c e

P e t e c h ia /P u r p u r a ■

■ ■

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

Ec c h y m o s is ■

■ ■

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

These are telangiectasias, or dilated small vessels that look red or bluish. Sources of photos: Spider Angioma—Marks R. Skin Disease in Old Age. Philadelphia, PA: JB Lippincott; 1987; Petechia/Purpura—Kelley WN. Textbook of Internal Medicine. Philadelphia, PA: JB Lippincott; 1989.

a


111

Table 6-7 Ha ir Lo s s G e n e r a lize d o r D iff u s e Ha ir Lo s s In men, look for frontal hairline regression and thinning on the posterior vertex; in women look for thinning that spreads from the crown down without hairline regression.

Male pattern hair loss (MPHL)

Female pattern hair loss (FPHL)

Te lo g e n Eff lu v iu m a n d A n a g e n Eff lu v iu m

In telogen effluvium overall the patient’s scalp and hair distribution appear normal, but a positive hair pull test reveals most hairs have telogen bulbs. In anagen effluvium there is diffuse hair loss from the roots. The hair pull test shows few if any hairs with telogen bulbs.

Normal hair part width in telogen effluvium

Positive hair pull test in telogen effluvium showing all hairs have telogen bulbs

Anagen effluvium (table continues on page 112)

112


Table 6-7 Ha ir Lo s s (continued ) Fo c a l Ha ir Lo s s A lo p e c ia A r e a t a

There is sudden onset of clearly demarcated, usually localized, round or oval patches of hair loss leaving smooth skin without hairs, in children and young adults. There is no visible scaling or erythema.

Tin e a C a p it is (“ Rin g w o r m ” )

There are round scaling patches of alopecia, usually caused by Trichophyton tonsurans from humans, and less commonly, Microsporum canis from dogs or cats.

References: For a complete guide to evaluation of hair loss, review Mubki T, Rucnicka L, Olszewska M, et al. Evaluation and diagnosis of the hair loss patient. J Am Acad Dermatol. 2014;71:415. a See also Hair Loss Help. Hair loss classi cations. Available at http://www.hairlosshelp.com/ hair_loss_research/hair_loss_charts.cfm. Accessed February 13, 2015.


113

Table 6-8 Fin d in g s in o r n e a r t h e Na ils P a ro n yc h ia

A superficial infection of the proximal and lateral nail folds adjacent to the nail plate. The nail folds are often red, swollen, and tender. Represents the most common infection of the hand, usually from Staphylococcus aureus or Streptococcus. Creates a felon if it extends into the pulp space of the finger. C lu b b in g o f t h e Fin g e r s

Clinically a bulbous swelling of the soft tissue at the nail base, with loss of the normal angle between the nail and the proximal nail fold. The angle increases to 180 degrees or more, and the nail bed feels spongy or floating. The mechanism is still unknown. Seen in congenital heart disease, interstitial lung disease and lung cancer, inflammatory bowel diseases, and malignancies. Ha b it Tic D e fo r m it y

There is depression of the central nail with a “Christmas tree” appearance from small horizontal depressions, resulting from repetitive trauma from rubbing the index finger over the thumb or vice versa.

M e la n o n yc h ia

Caused by increased pigmentation in the nail matrix, leading to a streak as the nail grows out. This may be a normal ethnic variation if found in multiple nails. A wide streak, especially if growing or irregular, could represent a subungual melanoma. (table continues on page 114)

114


Table 6-8 Fin d in g s in o r n e a r t h e Na ils (continued ) O n yc h o ly s is

A painless separation of the whitened opaque nail plate from the pinker translucent nail bed.

O n yc h o m yc o s is

The most common cause of nail thickening and subungual debris is onychomycosis, most often from the dermatophyte Trichophyton rubrum.

Te r ry N a ils

Nail plate turns white with a groundglass appearance, a distal band of reddish brown, and obliteration of the lunula. Seen in liver disease, usually cirrhosis, heart failure, and diabetes.

Sources of photos: Clubbing of the Fingers, Paronychia, Onycholysis, Terry Nails—Habif TP. Clinical Dermatology: A Color Guide to Diagnosis and Therapy. 2nd ed. St. Louis, MO: CV Mosby; 1990.

7

C H A P T E R

The Head and Neck The Health History C o m m o n o r C o n c e r n in g S y m p t o m s ● ● ● ● ● ● ● ● ● ●

He d che Ch nge in vision: blurred vision, loss of vision, flo ters, fl shing lights Eye in, redness, or te ring Double vision (di lo i ) He ring loss, e r che, ringing in the e rs (tinnitus) Dizziness nd vertigo Nosebleed (e ist xis) Sore thro t, ho rseness Swollen gl nds Goiter

Th e He a d Headache is a common symptom that always requires careful evaluation because a small fraction 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. 128, and Table 7-2, Secondary Headaches, pp. 129–131. Tension and migraine headaches are the most common recurring headaches.

Is the headache one sided or bilateral? Severe with sudden onset, like a thunderclap? 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 headaches increase the likelihood of tumor, a bscess, or other mass lesion. Extremely severe headaches suggest subara chnoid hemorrhage or meningitis.

115

116


H e a d a c h e W a r n in g S ig n s f o r Im m e d ia t e In v e s t ig a t io n ● ● ● ● ● ● ● ● ● ● ●

Progressively frequent or severe over 3- onth eriod Sudden onset like “thundercl ” or “the worst he d che of y life” New onset fter ge 5 ye rs Aggr v ted or relieved by ch nge in osition Preci it ted by V ls lv neuver Associ ted sy to s of fever, night swe ts, or weight loss Presence of c ncer, HIV infection, or regn ncy Ch nge in ttern fro st he d ches L ck of si il r he d che in the st Recent he d tr u Associ ted illede , neck stiffness, or foc l neurologic deficits

■ Ask about associated symptoms,

such as nausea and vomiting, and neurologic symptoms, such as change in vision or motorsensory de cits. ■ Ask if coughing, sneezing, or

changing the position of the head affects (better, worse, or none) the headache. ■ Ask about family history.

Visual aura or scintillating scotomas may accompany migraine. Nausea and vomiting are common with migraine but also occur with brain tumor and subarachnoid hemorrhage. Such maneuvers may increase pain from brain tumor and acute sinusitis.

Family history is often positive in patients with migraine.

Th e Ey e s Ask “How is your vision?” If the patient reports a change in vision, pursue the related details:

Gradual blurring, often from refractive errors; also occurs in hyperglycemia.

■ Is the problem worse during

Difficulty with close work suggests hyperopia (farsightedness) or presbyopia (aging vision); difficulty with distances suggests myopia (nearsightedness).

close work or at distances?

■ Is the onset sudden or gradual?

Sudden visual loss suggests retinal detachment, vitreous hemorrhage, or occlusion of the central retinal artery.

■ Is there blurring of the entire

Slow central loss occurs in nuclea r ca ta ra ct and ma cula r degenera tion; p erip heral loss in advanced open-a ngle gla ucoma ; one -sid ed loss in hemia nopsia and q uadrantic defects (p. 132).

eld of vision or only parts? Is blurring central, peripheral, or only on one side?

Chapter 7 | The Head and Neck

■ Has the patient seen lights ash-

ing across the eld of vision? Vitreous oaters?

117

These symptoms suggest detachment of vitreous from the retina. Prompt eye consultation is indicated.

Ask about pain in or around the eyes, redness, and excessive tearing 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.

Th e Ea r s Ask “How is your hearing?” Does the patient have special dif culty understanding people as they talk? Does a noisy environment make a difference?

Sensorineura l loss (inner ear) leads to difficulty understanding speech, often complaining that others mumble; noisy environments worsen hearing. In conductive loss (external or middle ear), noisy environments may help.

For complaints of earache, or pain in the ear, ask about associated fever, sore throat, cough, and concurrent 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 disease.

Ask about vertigo, the perception that the patient or the environment is rotating or spinning.

Vertigo in labrynthitis (inner ear), CN VII lesions, brainstem lesions

T h e N o s e a n d S in u s e s Rhinorrhea, or drainage from the nose, frequently accompanies 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.

118


For epistaxis, or bleeding from the nose, identify the source carefully—is bleeding actually 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. Anticoagulants, NSAIDs, and coagulopathies may contribute.

Th e M o u t h , Th r o a t , a n d N e c k 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 pha ryngitis, or “strep throat”(p. 142).

Hoarseness may arise from overuse of the voice, allergies, smoking, or inhaled irritants.

If present more than 2 weeks, refer for laryngoscopy; consider hypothyroidism, reflux, vocal cord nodules, head and neck cancers, thyroid masses, and neurologic disorders (Parkinson disease, amyotrophic lateral sclerosis, or myasthenia gravis).

Assess thyroid function. Ask about goiter, temperature intolerance, and sweating.

With goiter, thyroid function may be increased, decreased, or normal. Cold intolerance in hypothyroidism; heat intolerance, palpitations, and involuntary weight loss in hyperthyroidism


Loss of vision: c t r cts, He ring loss Or l he lth

cul r degener tion, gl uco

Disorders of vision shift with age. Healthy young adults generally have refractive errors. Older adults have refractive errors, cataracts, macular degeneration, and glaucoma. Glaucoma is the leading cause of blindness in African Americans and the U.S. population overall. Glaucoma causes gradual vision loss, with damage to the optic nerve, loss of visual elds, beginning usually at the periphery, and pallor and increasing size of the optic cup (enlarging to more than half the diameter of the optic disc).


119

More than a third of adults older than 65 years have detectable hearing de cits. Questionnaires and handheld audioscopes work well for periodic screening. Be sure to promote oral health: 19% of children aged 2 to 19 years have untreated cavities, and about 5% of adults aged 40 to 59 years and 25% of those older than age 60 years have no teeth at all. Inspect the oral cavity for decayed or loose teeth, in ammation of the gingiva, signs of periodontal disease (bleeding, pus, receding gums, and bad breath), and oral cancers. Counsel patients to use uoride-containing toothpastes, brush, oss, and seek dental care at least annually.



Th e He a d Examine the: ■ Hair, including quantity,

distribution, and texture ■ Scalp, including lumps or

lesions ■ Skull, including size and

contour ■ Face, including symmetry and

facial expression ■ Skin, including color, texture,

Coarse and sparse in hypothyroidism, fine in hyperthyroidism Pilar cysts, psoriasis, seborrheic dermatitis, pigmented nevi Hydrocephalus, skull depression from trauma Facial paralysis; flat affect of depression, moods such as anger, sadness Pale, fine, hirsute, acne, skin cancer

hair distribution, and lesions

Th e Ey e s Test visual acuity in each eye with a Snellen wall chart or handheld card.

Vision of 20/200 means that at 20 feet, the patient can read print that a person with normal vision could read at 200 feet.

Assess visual elds by confrontation with the static nger wiggle test and the kinetic red target test, if indicated (Fig. 7-1).

Hemianopsia, quadrantic defects in cerebrovascular accidents (CVAs). See Table 7-3, Visual Field Defects, p. 132.

120




Fig ure 7-1 Static finge r w iggle te s t.

Inspect the:

See Table 7-4, Physical Findings in and Around the Eye, pp. 133–134.

■ Position and alignment of eyes

Exophthalmos, strabismus

■ Eyebrows

Seborrheic dermatitis

■ Eyelids

Sty, chalazion, ectropion, ptosis, xanthe lasma, blepharitis

■ Lacrimal apparatus

Swollen lacrimal sac, excessive tearing

■ Conjunctiva and sclera

Red eye, conjunctivitis, jaundice, episcleritis

■ Cornea, iris, and lens

Cataract, crescentic shadow of acute angle glaucoma

Inspect pupils for: ■ Size, shape, and symmetry

Miosis, mydriasis, anisocoria

■ Reactions to light, direct and

Absent in paralysis of CN III

consensual ■ The near reaction, namely pupil-

lary constriction with gaze shift to near object; note the accompanying convergence of the eyes and accommodation of the lens (becomes more convex) (Fig. 7-2)

Constriction slows in tonic (Adie) pupil and is absent in Argyll Robertson pupils of syphilis; poor convergence in hyperthyroidism



121


Fig ure 7-2 The pupils cons trict w he n the focus s hifts to a clos e obje ct.

Assess the extraocular muscles by observing: ■ The symmetry of corneal re ec-

tions from a midline light ■ The six cardinal directions of

Cranial nerve palsy, strabismus, nystagmus, lid lag of hyperthyroidism

gaze (Fig. 7-3)

S upe rior re ctus (III) La te ra l re ctus (VI) Infe rior re ctus (III)

Asymmetric reflection if deviation in ocular alignment

Infe rior oblique (III)

S upe rior re ctus (III)

Me dia l re ctus (III)

La te ra l re ctus (VI)

S upe rior oblique (IV)

Infe rior re ctus (III)

Fig ure 7-3 The s ix cardinal dire ctions of gaze .

Inspect the fundi with an ophthalmoscope. S t e p s f o r U s in g t h e O p h t h a lm o s c o p e ●

D rken the roo . Switch on the o hth l osco e light nd turn the lens disc until you see the l rge round be of white light.* Shine the light on the b ck of your h nd to check the ty e of light, its desired brightness, nd the electric l ch rge of the o hth l osco e. *So e clinici ns like to use the l rge round be for l rge u ils, nd the s ll round be for s ll u ils. The other be s re r rely hel ful. The slit-like be is so eti es used to ssess elev tions or conc vities in the retin , the green (or red-free) be to detect s ll red lesions, nd the grid to ke e sure ents. Ignore the l st three lights nd r ctice with the l rge or s ll round white be . (continued )

122




S t e p s f o r U s in g t h e O p h t h a lm o s c o p e ●

●

●

●

●

(Continued )

Turn the lens disc to the 0 dio ter. (A dio ter is unit th t e sures the ower of lens to converge or diverge light.) At this dio ter, the lens neither converges nor diverges light. Kee your finger on the edge of the lens disc so you c n turn the disc to focus the lens when you ex ine the fundus. Hold the o hth l osco e in your right hand and use your right eye to ex ine the patient’s right eye; hold it in your left hand and use your left eye to examine the patient’s left eye. This kee s you fro bu ing the tient’s nose nd gives you ore obility nd closer r nge for visu lizing the fundus. With r ctice, you will beco e ccusto ed to using your nondo in nt eye. Hold the o hth l osco e fir ly br ced g inst the edi l s ect of your bony orbit, with the h ndle tilted l ter lly t bout 2 -degree sl nt fro the vertic l. Check to ke sure you c n see cle rly through the erture. Instruct the patient to look slightly u nd over your shoulder at a point directly ahead on the wall. Pl ce yourself bout 15 inches w y fro the tient nd t n ngle 15-degree lateral to the patient’s line of vision. Shine the light be on the u il nd look for the or nge glow in the u il— the red reflex. Note ny o cities interru ting the red reflex. Now place the thumb of your other hand across the patient’s eyebrow, which ste dies your ex ining h nd. Kee ing the light be focused on the red reflex, ove in with the o hth l osco e on the 15-degree ngle tow rd the u il until you re very close to it, l ost touching the tient’s eyel shes nd the thu b of your other h nd.

Inspect the fundi for the following: ■ Red re ex

Cataracts, artificial eye

■ Optic disc (Fig. 7-4)

Papilledema, glaucomatous cupping, optic atrophy. See Table 7-5, Abnormalities of the Optic Disc, p. 135, and Table 7-6, Ocular Fundi: Diabetic Retinopathy, p. 136.



123

P O SSIBLE FIN DIN G S Arte ry Ve in Optic dis c

Ma cula

P hys iologic cup

Fig ure 7-4 The optic dis c. ■ Arteries, veins, and AV

AV nicking, copper wiring in hypertensive changes

crossings ■ Adjacent retina (note any

Hemorrhages, exudates, cotton-wool patches, microaneurysms, pigmentation

lesions) ■ Macular area

Macular degeneration

■ Anterior structures

Vitreous floaters, cataracts

T ip s f o r E x a m in in g t h e O p t ic D is c a n d R e t in a ● ●

●

●

Locate the optic disc. Look for the round yellowish-or nge structure. Now, bring the optic disc into sharp focus by djusting the lens of your o hth losco e. Inspect the optic disc. Note the following fe tures: ● The sharpness or clarity of the disc outline ● The color of the disc ● The size of the central physiologic cup ( n enl rged cu suggests chronic o en- ngle gl uco ) ● Venous pulsations in the retin l veins s they e erge fro the centr l ortion of the disc (loss of venous uls tions fro elev ted intr cr ni l ressure y occur in he d tr u , eningitis) Inspect the retina. Distinguish rteries fro veins b sed on the fe tures listed below.

Color Size Light Reflex (reflection)

● ●

●

A r t e r ie s

Ve in s

Light red S ller (2/3 to 3/4 the di eter of veins) Bright

D rk red L rger

Follow the vessels peripherally in each of four directions. Ins ect the fovea nd surrounding macula. M cul r degener tion ty es include dry atrophic ( ore co on but less severe) nd wet exudative (neov scul r). Undigested cellul r debris, c lled drusen, y be h rd or soft. Assess for ny papilledema fro incre sed intr cr ni l ressure le ding to swelling of the o tic nerve he d.

Incons icuous or bsent

124




Th e Ea r s Examine on each side: Th e Au ric le . Inspect the auricle.

Keloid, epidermoid cyst

If you suspect otitis: ■ Move the auricle up and down,

Pain in otitis externa (“the tug test”)

and press on the tragus. ■ Press rmly behind the ear.

Possible tenderness in otitis media and mastoiditis

Ea r Ca n a l a n d Dru m . Pull the auricle up, back, and slightly out. Inspect, through an otoscope with speculum: ■ The canal

Cerumen; swelling and erythema in otitis externa

■ The eardrum (Fig. 7-5)

Red bulging drum in acute otitis media; serous otitis media, tympanosclerosis, perforations. See Table 7-7, Abnormalities of the Eardrum, p. 137.

Pa rs fla ccida Incus Pa rs te ns a

S hort proce s s of ma lle us Ha ndle of ma lle us Umbo Cone of light

Fig ure 7-5 Anatomy of m iddle and inne r e ar.

He a rin g . “Do you feel you have a hearing loss or dif culty hearing?” is a sensitive screening question. Assess auditory acuity to spoken or whispered voice or with a handheld audiometer.



125


If hearing is diminished, use a 512-Hz tuning fork to: ■ Test lateralization (Weber test),

but only in patients with unilateral hearing loss. Place vibrating and tuning fork on vertex of skull and check hearing. ■ Compare air and bone conduction

(Rinne test). Place vibrating and tuning fork on mastoid bone, then remove and check hearing.

In unilateral conductive hearing loss, sound is heard in (lateralized to) the impaired ear. See Table 7-8, Patterns of Hearing Loss, p. 138.

In conductive hearing loss, sound is heard through bone longer than through air (BC = AC or BC > AC). In sensorineural hearing loss, sound is heard longer through air (AC > BC).

T h e N o s e a n d S in u s e s Inspect the external nose. Inspect, through a speculum, the: ■ Nasal mucosa that covers the

septum and turbinates, noting its color and any swelling

Swollen and red in viral rhinitis, swollen and pale in allergic rhinitis; polyps (Fig. 7-6); ulcer from cocaine use

Fig ure 7-6 Nas al polyps . ■ Nasal septum for position and

Deviation, perforation

integrity Palpate the frontal and maxillary sinuses.

Tender in acute sinusitis

126




Th e M o u t h a n d P h a r y n x Inspect the: ■ Lips

Cyanosis, pallor, cheilosis. See also Table 7-9, Abnormalities of the Lips, p. 139.

■ Oral mucosa

Aphthous ulcers (canker sores)

■ Gums

Gingivitis, periodontal disease

■ Teeth

Dental caries, tooth loss

■ Roof of the mouth

Torus palatinus (benign)

■ Tongue, including:

See Table 7-10, Abnormalities of the Tongue, pp. 140–141.

■

Papillae

Glossitis

■

Symmetry

Deviation to one side from paralysis of CN XII from CVA

■

Any lesions

Erythroplakia, leukoplakia (precancerous); squamous cell or other carcinomas

■ Floor of the mouth

Lesions suspicious for cancer

■ Pharynx, including:

See Table 7-11, Abnormalities of the Pharynx, p. 142.

■

Color or any exudate

Pharyngitis

■

Presence and size of tonsils

Exudates, tonsillitis, peritonsillar abscess

■

Symmetry of the soft palate as patient says “ah”

Soft palate fails to rise, uvula deviates to opposite side in CN X paralysis from CVA.

Th e N e c k Inspect the neck.

Scars, masses, torticollis

Palpate super cial and deep anterior, posterior cervical, and supraclavicular lymph nodes.

Cervical lymphadenopathy from HIV or AIDS, infectious mononucleosis, lymphoma, leukemia, and sarcoidosis. Enlarged supraclavicular node from possible abdominal malignancy

Inspect and palpate the position of the trachea.

Deviated trachea from neck mass or pneumothorax



127


Inspect the thyroid gland: ■ At rest

Goiter, nodules. See Table 7-12, Abnormalities of the Thyroid Gland, p. 143.

■ As patient swallows water

From behind patient, palpate the thyroid gland, including the isthmus, and rst one then the opposite lobe:

Goiter, nodules, tenderness of thyroiditis

■ At rest ■ As patient swallows water

(Fig. 7-7)

Fig ure 7-7 Thyroid gland w ith goite r w hile s w allow ing.

Alternative Examination Sequence—After examining the thyroid gland, you may proceed to musculoskeletal examination of the neck and upper back and check for costovertebral angle tenderness.

Recording Your Findings R e c o r d in g t h e H e a d , E y e s , E a r s , N o s e , a n d T h r o a t (H E E N T ) E x a m in a t io n Head—The skull is nor oce h lic/ tr u tic. Front l b lding. Eyes—Visu l cuity 2 / 1 bil ter lly. Scler white; conjunctiv injected. Pu ils constrict fro 3 to 2 , equ lly round nd re ctive to light nd cco od tion. Disc rgins sh r ; no he orrh ges or exud tes. Arteriol r-to-venous r tio (AV r tio) 2:4; no AV nicking. Ears—Acuity di inished to whis ered voice; int ct to s oken voice. TMs cle r. Nose—Mucos swollen with erythe nd cle r dr in ge. Se tu idline. Tender over xill ry sinuses. Throat—Or l ucos ink, dent l c ries in lower ol rs, h rynx erythe tous, no exud tes. Neck—Tr che idline. Neck su le; thyroid isth us idline, lobes l ble but not enl rged. Lymph Nodes—Sub ndibul r nd nterior cervic l ly h nodes tender, 1 × 1 c , rubbery nd obile; no osterior cervic l, e itrochle r, xill ry, or inguin l ly h deno thy. (These findings suggest myopia and mild arteriolar narrowing as well as upper respiratory infection.)

128


Aids to Interpretation Table 7-1 P rim a ry He a d a ch e s

P ro b le m

Co m m o n C h a r a c t e r is t ic s

Te n s io n

Location: variable Quality: pressing or tightening pain; mild-tomoderate intensity Onset: gradual Duration: minutes to days

Mig ra in e ■ ■

■

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 hours Duration: 4–72 hours

A s s o c ia t e d S y m p t o m s , P ro vo k in g a n d Re lie v in g Fa c t o r s Sometimes photophobia, phonophobia; nausea absent ↑ by sustained muscle tension, as in driving or typing ↓ possibly by massage, relaxation Nausea, vomiting, photophobia, phonophobia, visual auras (flickering zigzagging 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

Clu s te r

Location: unilateral, usually behind or around the eye

Lacrimation, rhinorrhea, miosis, ptosis, eyelid edema, conjunctival infection

Quality: deep, continuous, severe

↑ sensitivity to alcohol during some episodes

Onset: abrupt, peaks within minutes Duration: up to 3 hours


129

Table 7-2 S e c o n d a ry He a d a ch e s

P ro b le m


As s o c ia t e d S ym p t o m s , P ro vo k in g a n d Re lie vin g Fa c t o r s

An a lge s ic Re b o u n d

Location: previous headache pattern

Depends on prior headache pattern

Quality: variable

↑ by fever, carbon monoxide, hypoxia, withdrawal of caffeine, other headache triggers

Onset: variable Duration: depends on prior headache pattern He a d a ch e s fro m Eye Dis o rd e rs

Errors of Refraction (farsightedness and astigmatism, but not nearsightedness) Acute Glaucoma

↓ —depends on cause

Eye fatigue, “sandy” sensation Location: around and over the eyes; may radiate in eyes, redness of the conjunctiva to the occipital area Quality: steady, aching, dull Onset: gradual Duration: variable Location: in and around one eye Quality: steady, aching, often severe Onset: often rapid

↑ by prolonged use of the eyes, particularly for close work ↓ by resting the eyes Diminished vision, sometimes nausea and vomiting ↑ —sometimes by drops that dilate the pupils

Duration: variable, may depend on treatment He a d a ch e fro m S in u s it is

Location: usually above Local tenderness, nasal congestion, tooth pain, eye (frontal sinus) or discharge, and fever over maxillary sinus Quality: aching or throbbing, variable in severity; consider possible migraine

↑ by coughing, sneezing, or jarring the head ↓ by nasal decongestants, antibiotics

Onset: variable Duration: often several hours at a time, recurring over days or longer (table continues on page 130)

130


Table 7-2 S e c o n d a ry He a d a ch e s (continued )

P ro b le m


Me n in g it is

Location: generalized Quality: steady or throbbing, very severe Onset: fairly rapid Duration: variable, usually days

S u b a ra ch n o id He m o rrh a ge — “ Th u n d e rcla p He a d a ch e”

Location: generalized Quality: severe, “the worst of my life” Onset: usually abrupt; prodromal symptoms may occur

As s o c ia t e d S ym p t o m s , P ro vo k in g a n d Re lie vin g Fa c t o r s Fever, stiff neck, photophobia, change in mental status Can ↓ from immediate antibiotics until viral versus bacterial cause identified Nausea, vomiting, possibly loss of consciousness, neck pain ↑ rebleeding, ↑ intracranial pressure, cerebral edema ↓ by subspecialty treatments

Duration: variable, usually days Bra in Tu m o r

Location: varies with the location of the tumor

↑ by coughing, rebleeding, ↑ intracranial pressure, cerebral edema

Quality: aching, steady, ↓ by subspecialty treatments variable in intensity Onset: variable Duration: often brief Gia n t Ce ll (Te m p o ra l) Arte rit is

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 Often ↓ by steroids


131

Table 7-2 S e c o n d a ry He a d a ch e s (continued )

P ro b le m


As s o c ia t e d S ym p t o m s , P ro vo k in g a n d Re lie vin g Fa c t o r s

Postconcussion Headache

Location: often but not Drowsiness, poor always localized to the concentration, confusion, memory loss, blurred vision, injured area dizziness, irritability, Quality: generalized, restlessness, fatigue dull, aching, constant ↑ by mental and physical Onset: within hours to exertion, straining, stooping, 1–2 days of the injury emotional excitement, Duration: weeks, alcohol months, or even years ↓ by rest

Cra n ia l Ne u ra lg ia s : Trige m in a l Ne u ra lg ia (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 ↓ by medication; neurovascular decompression

132


Table 7-3 Vis u a l Fie ld De fe c t s 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)


133

Table 7-4 P h ys ic a l Fin d in g s in a n d Aro u n d t h e Eye Eye lid s

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 (table continues on page 134)

134


Table 7-4 P h ys ic a l Fin d in g s in a n d Aro u n d t h e Eye (continued ) In a n d A ro u n d t h e 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. Seen in rheumatoid arthritis, Sjögren syndrome, and herpes zoster

Sty. A pimple-like infection around a hair follicle near the lid margin, usually from Staphylococcus aureus

Chalazion. A beady nodule in either eyelid caused by a chronically inflamed meibomian gland

Xanthelasma. Yellowish plaque seen in lipid disorders. Half of affected patients have hyperlipidemia; also common in primary biliary cirrhosis

Blepharitis. Chronic inflammation of the eyelids at the base of the hair follicles, often from S. aureus. Also a scaling seborrheic variant


135

Table 7-5 Ab n o rm a lit ie s o f t h e Op t ic Dis c

No rm a l

P ro c e s s

Ap p e a ra n c e

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)

P a p ille d e m a

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

G la u c o m a t o u s C u p p in g

Increased pressure within the eye leads to increased cupping (backward depression of the disc) and atrophy

The base of the enlarged cup is pale

O p t ic A t ro p h y

Death of optic nerve fibers leads to loss of the tiny disc vessels

Disc is white Disc vessels are absent

136


Table 7-6 Oc u la r Fu n d i: Dia b e t ic Re t in o p a t h y N o n p ro lif e r a t ive Re t in o p a t h y, M o d e r a t e ly S e ve r e

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

N o n p ro lif e r a t ive Re t in o p a t h y, S e ve r e

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

P ro lif e r a t ive Re t in o p a t h y, w it h N e o va s c u la r iz a t io n

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%

P ro lif e r a t ive Re t in o p a t h y, Ad va n c e d

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.


137

Table 7-7 Ab n o rm a lit ie s o f t h e Ea rd ru m P e r fo r a t io n

Hole in the eardrum that may be central or marginal Usually from otitis media or trauma

Ty m p a n o s c le ro s is

A chalky white patch Scarring process of the middle ear from otitis media with deposition of hyaline and calcium and phosphate crystals in the eardrum and middle ear. When severe, it may entrap the ossicles and cause conductive hearing loss

S e ro u s Eff u s io n

Amber fluid behind the eardrum, with or without air bubbles Associated with viral upper respiratory infections or sudden changes in atmospheric pressure (diving, flying)

Ac u t e O t it is M e d ia w it h P u r u le n t Eff u s io n

Red, bulging drum, loss of landmarks Painful hemorrhagic vesicles appear on the tympanic membrane and/or ear canal causing earache, blood-tinged discharge from the ear, and conductive hearing loss. Seen in mycoplasma and viral infections and bacterial otitis media

138


Table 7-8 P a t t e rn s o f He a rin g Lo s s C o n d u c t ive Lo s s

S e n s o r in e u r a l Lo s s

Im p a ir e d U n d e r s t a n d in g o f Wo r d s

Minor

Often troublesome

Eff e c t s

Noisy environment may improve hearing

Noisy environment worsens hearing

Voice remains soft since cochlear nerve intact

Voice may be loud due to nerve damage

U s u a l Ag e o f On s e t

Childhood, young adulthood

Middle and later years

Ea r C a n a l a n d Dru m

Often a visible abnormality

Problem not visible

We b e r Te s t (in U n ila t e r a l He a r in g Lo s s )

Lateralizes to the impaired ear

Lateralizes to the good ear

Rin n e Te s t

BC ≥ AC

AC > BC

C a u s e s In c lu d e

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


139

Table 7-9 Ab n o rm a lit ie s o f t h e Lip s 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. Small red spots. Autosomal dominant disorder causing vascular fragility and arteriovascular malformations (AVMs), including in the brain and lungs. Associated bleeding in nose and GI tract Peutz–Jeghers syndrome. Brown spots of the lips and buccal mucosa, significant because of associated intestinal polyposis and high risk of GI cancer

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

140


Table 7-10 Ab n o rm a lit ie s o f t h e To n g u e Geographic tongue. Scattered areas in which the papillae are lost, giving a maplike appearance; benign

Hairy tongue. Results from elongated papillae that may look yellowish, brown, or black; benign

Fissured tongue. May appear with aging; benign

Smooth tongue. Results from loss of papillae; seen in deficiency of riboflavin, niacin, folic acid, vitamin B12, pyridoxine, or iron, and treatment with 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


141

Table 7-10 Ab n o rm a lit ie s o f t h e To n g u e (continued ) Hairy leukoplakia. White raised, feathery areas, usually on sides of tongue. Seen in HIV/AIDS

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. Malignancy should be considered in any nodule or nonhealing ulcer at the base or edges of the mouth

142


Table 7-11 Ab n o rm a lit ie s o f t h e P h a ryn x 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 spots. These small white specks that resemble grains of salt on a red background are an early sign of measles


143

Table 7-12 Ab n o rm a lit ie s o f t h e Th yro id Gla n d Diffuse enlargement. May result from Graves disease, Hashimoto 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

8

C H A P T E R

The Thorax and Lungs The Health History C o m m o n o r C o n c e r n in g S y m p t o m s ● ● ● ● ● ●

Chest in Shortness of bre th (dys ne ) Wheezing Cough Blood-stre ked s utu (he o tysis) D yti e slee iness or snoring nd disordered slee

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. 155–156. S o u r c e s o f C h e s t P a in a n d R e la t e d C a u s e s The

yoc rdiu

Angina pectoris, myocardial infarction, myocarditis The eric rdiu Pericarditis The ort Aortic dissection The tr che nd l rge bronchi Bronchitis The riet l leur Pericarditis, pneumonia, pneumothorax, pleural effusion, pulmonary embolus The chest w ll, including the usculo- Costochondritis, herpes zoster skelet l nd neurologic syste s The eso h gus Gastroesophageal reflux disease, esophageal spasm, esophageal tear Extr thor cic structures such s the Cervical arthritis, biliary colic, gastritis neck, g llbl dder, nd sto ch

For patients who are short of breath, focus on pulmonary complaints: ■ Dyspnea and wheezing

See Table 8-2, Dyspnea, pp. 157–158.

■ Cough and hemoptysis

See Table 8-3, Cough and Hemoptysis, pp. 159–161. 145

146


■ Daytime sleepiness or snoring

and disordered sleep

Snoring, witnessed apneas ≥10 seconds, awakening with a choking sensation, or morning headache point to obstructive sleep apnea.


Tob cco cess tion Lung c ncer I uniz tions—influenz

nd stre tococc l neu oni v ccines

Despite declines in smoking over the past several decades, 19% of Americans still smoke. Regularly counsel all adults, pregnant women, parents, and adolescents who smoke to stop. Use “the ve As” and the Stages of Change Model to assess readiness to quit. A s s e s s in g R e a d in e s s t o Q u it S m o k in g : B r ie f In t e r v e n t io n s M o d e ls 5 As Mo d e l

S t a g e s o f Ch a n g e Mo d e l

Ask bout tob cco use Advise to quit

Precontemplation—“I don’t w nt to quit.” Contemplation—“I concerned but not re dy to quit now.” Preparation—“I re dy to quit.”

Assess willingness to quit tte t Assist in quit tte t Arrange follow-u

ke

Action—“I just quit.” Maintenance—“I quit 6

onths go.”

Counsel patients to never smoke or quit smoking. The U.S. Preventive Services Task Force recommends annual low-dose computed tomography (LDCT) screening for current smokers (or those who have quit within the last 15 years) ages 55 to 79 years (grade B recommendation). Provide u 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.

Chapter 8 | The Thorax and Lungs

147



In it ia l In s p e c t io n o f T h o r a x Supra s ternal notch 2nd rib

Manubrium of s ternum

2nd rib inters pace 2nd cos tal ca rtilage

Sternal angle Body of s ternum Xyphoid proces s

Cos toc hondral junctions

Cos tal angle Fig ure 8-1 Che s t wall anatomy.

Inspect the thorax (Fig. 8-1) and its respiratory movements for signs of distress and note: ■ Facial color

Cyanosis and pallor in lips and oral mucosa signal hypoxia.

■ Rate, rhythm, depth, and effort

Tachypnea, hyperpnea, Cheyne –Stokes breathing. Normally 14 to 20 breaths/ minute in adults. See Table 8-4 Abnormalities in Rate and Rhythm of Breathing, p. 162.

of breathing

■ Inspiratory retraction of the

supraclavicular areas ■ Inspiratory contraction of the

sternocleidomastoids

Occurs in chronic obstructive pulmonary disease (COPD), asthma, upper airway obstruction Indicates severe breathing difficulty

148




If distress, auscultate the neck and lungs for: ■ Stridor

Stridor in upper airway obstruction from foreign body or epiglottitis

■ Wheezes

Expiratory wheezing in asthma and COPD

Observe shape of patient’s chest.

Normal or barrel chest (see Table 8-5, Deformities of the Thorax, pp. 163–164)

T h e P o s t e r io r C h e s t Inspect the chest for: ■ Deformities or asymmetry

Kyphoscoliosis

■ Abnormal inspiratory retraction

Retraction in asthma, COPD, upper airway obstruction

of the interspaces ■ Impairment or unilateral lag in

respiratory movement

Disease of the underlying lung or pleura, phrenic nerve palsy

Palpate the chest for: ■ Tender areas

Fractured ribs

■ Assessment of visible abnor-

Masses, sinus tracts

malities ■ Chest expansion (Fig. 8-2)

Impairment, both sides in COPD and restrictive lung disease; unilateral decrease or delay in chronic fibrosis of the underlying lung or pleura, pleural effusion, lobar pneumonia, pleural pain with associated splinting, unilateral bronchial obstruction, and paralysis of the hemidiaphragm

Fig ure 8-2 As s e s s lung expans ion. ■ Tactile fremitus as the patient

says “aa” or “blue moon”

Decreased or absent fremitus when transmission of vibrations to the chest is impeded by a thick chest wall, obstructed bronchus, COPD, or pleural effusion, fibrosis, air (pneumothorax), or an infiltrating tumor.



149

P O SSIBLE FIN DIN G S Asymmetric decreased fremitus in unilateral pleural effusion, pneumothorax, or neoplasm; asymmetric increased fremitus occurs in unilateral pneumonia, which increases transmission through consolidated tissue.

Percuss the chest, comparing one side with the other at each level, using the side-to-side “ladder pattern,” as shown in Figures 8-3 and 8-4.

6 7

1

1

2

2

3

3

4

4

5

5

Dullness when fluid or solid tissue replaces normally air-filled lung; hyperresonance in emphysema or pneumothorax

6 7

Fig ure 8-3 Pe rcus s and aus cultate in

Fig ure 8-4 Strike the plexim e te r

a “ ladde r” patte rn.

finge r w ith the right m iddle finge r.

P e r c u s s io n N o t e s a n d T h e ir C h a r a c t e r is t ic s Re la t ive In t e n s it y, P it c h , a n d D u r a t io n

Ex a m p le s

Flat Dull Resonant

Soft/ high/short Mediu / ediu / ediu Loud/ low/ long

Hyperresonant Tympanitic

Louder/ lower/ longer Loud/ high (ti bre is usic l)

Percuss level of diaphragmatic dullness on each side and estimate diaphragmatic descent after patient takes full inspiration (Fig. 8-5).

L rge leur l effusion Lob r neu oni He lthy lung, si le chronic bronchitis E hyse , neu othor x L rge neu othor x

Pleural effusion or a paralyzed diaphragm raises level of dullness.

150




Loca tion a nd s e que nce of pe rcus s ion

Re s ona nt Leve l of dia phra gm Dull

Figure 8-5 Identify the extent of diaphragmatic excursion.

Auscultate the chest with stethoscope in the “ladder” pattern, again comparing sides.

See Table 8-6, Physical Findings in Selected Chest Disorders, p. 165.

■ Evaluate the breath sounds.

Vesicular, bronchovesicular, or bronchial breath sounds; decreased breath sounds from decreased airflow.

■ Note any adventitious (added)

Crackles (fine and coarse) and continuous sounds (wheezes and rhonchi)

sounds. 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 atelectasis.

C h a r a c t e r is t ic s o f B r e a t h S o u n d s D u r a t io n

In t e n s it y a n d P it c h o f Ex p ir a t o ry S o u n d

Ex a m p le Lo c a t io n s

Ins > Ex

Soft/ low

Most of the lungs

Bronchovesicular Ins = Ex

Mediu / ediu

Bronchial

Ex > Ins

Loud/ high

1st nd 2nd inters ces, intersc ul r re Over the nubriu

Tracheal

Ins = Ex

Very loud/ high

Vesicular

Over the tr che

Dur tion is indic ted by the length of the line, intensity by the width of the line, nd itch by the slo e of the line.



151


A d v e n t it io u s o r A d d e d B r e a t h S o u n d s C r a c k le s (o r Ra le s )

Wh e e ze s a n d Rh o n c h i

Disco ntinuo us

Co ntinuo us

●

Inter ittent, nonmusical, nd brief

●

●

Like dots in ti e Fine crackles: soft, high- itched ( 65 Hz), very brief (5–1 s)

●

Coarse crackles: so ewh t louder, lower in itch ( 35 Hz), brief (15–3 s)

●

●

●

●

Sinusoid l, musical, rolonged (but not necess rily ersisting throughout the res ir tory cycle) Like d shes in ti e Wheezes: rel tively high- itched (≥4 Hz) with hissing or shrill qu lity (>8 s)

Rhonchi: rel tively low- itched (15 –2 Hz) with snoring qu lity (>8 s)

Source: Loudon R, Mur hy LH. Lung sounds. Am Rev Respir Dis. 1994;13 :663; Boh d n A, Izbicki G, Kr n SS. Fund ent ls of lung uscult tion. N Engl J Med. 2 14;37 :744.

Assess transmitted voice sounds and bronchial breath sounds heard in abnormal places. Ask patient to: ■ Say “ninety-nine” and “ee.”

Bronchophony if sounds become louder; egophony if “ee”to “A”change from lobar consolidation

■ Whisper “ninety-nine” or

Whispered pectoriloquy if whispered sounds transmit louder and more clearly

“one-two-three.” T r a n s m it t e d V o ic e S o u n d s Th ro u g h N o r m a lly A ir-Fille d Lu n g

Th ro u g h A ir le s s Lu n g a

Usu lly cco nied by vesicul r bre th sounds nd nor l t ctile fre itus S oken words uffled nd indistinct

Usu lly cco nied by bronchi l or bronchovesicul r bre th sounds nd incre sed t ctile fre itus S oken words louder, cle rer (bronchophony) S oken “ee” he rd s “ y” (egophony) Whis ered words louder, cle rer (whispered pectoriloquy)

S oken “ee” he rd s “ee” Whis ered words f int nd indistinct, if he rd t ll As in lob r neu oni

a

nd tow rd the to of l rge leur l effusion.

152




Alternative Examination 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.

T h e A n t e r io r C h e s t Mids te rna l line

Midclavicula r line Ante rior a xilla ry line

Fig ure 8-6 Mids te rnal and m idclavicu-

Ante rior a xilla ry line

Mida xilla ry line Pos te rior a xilla ry line

lar line s .

Fig ure 8-7 Ante rior, pos te rior, and m idaxillary line s .

Inspect the chest (Figs. 8-6 and 8-7) for: ■ Deformities or asymmetry

Pectus excavatum

■ Intercostal retraction

From obstructed airways

■ Impaired or lagging respiratory

Disease of the underlying lung or pleura, phrenic nerve palsy

movement Palpate the chest for: ■ Tender areas

Tender pectoral muscles, costochondritis

■ Assessment of visible abnor-

Flail chest

malities ■ Respiratory expansion ■ Tactile fremitus



Percuss the chest in the areas illustrated in Figure 8-8. 1

5 6

P O SSIBLE FIN DIN G S Normal cardiac dullness may disappear in emphysema.

1

2

2

3

3

4

153

4

5 6

Fig ure 8-8 Palate and pe rcus s in a “ ladde r” patte rn.

Auscultate the chest. Assess breath sounds, adventitious sounds, and if indicated transmitted voice sounds.

S p e c ia l T e c h n iq u e s Clin ic a l As s e s s m e n t o f P u lm o n a ry Fu n c t io n . Walk with patient down the hall or up a ight of stairs. Observe the rate, effort, and sound of breathing, and inquire about symptoms. Or learn to do a standardized “6-minute walk test.” Fo rc e d Exp ira t o ry Tim e . 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 stethoscope, and time audible expiration. Try to get three consistent readings, allowing rests as needed.

Older adults walking 8 feet in <3 seconds are less likely to be disabled than those taking >5 to 6 seconds.

Patients age ≥60 years with a forced expiratory time of ≥9 seconds are four times more likely to have COPD.

154


Recording Your Findings R e c o r d in g t h e T h o r a x a n d Lu n g s E x a m in a t io n “Thor x is sy etric with good ex nsion. Lungs reson nt. Bre th sounds vesicul r; no r les, wheezes, or rhonchi. Di hr g s descend 4 c bil ter lly.” OR “Thor x sy etric with oder te ky hosis nd incre sed ntero osterior (AP) di eter, decre sed ex nsion. Lungs re hy erreson nt. Bre th sounds dist nt with del yed ex ir tory h se nd sc ttered ex ir tory wheezes. Fre itus decre sed; no broncho hony, ego hony, or whis ered ectoriloquy. Di hr g s descend 2 c bil ter lly.” (These findings suggest COPD.)


155

Aids to Interpretation Table 8-1 Ch e s t P a in P ro b le m a n d Lo c a t io n

Q u a lit y, S e ve r it y, Tim in g , a n d A s s o c ia t e d S y m p t o m s

C a r d io va s c u la r An g in a Pe cto ris

Retrosternal or across the anterior chest, sometimes radiating to the shoulders, arms, neck, lower jaw, or upper abdomen

■

■

■

■

Myo ca rd ia l In fa rctio n

■

Same as in angina

■

■ ■

Pe rica rd itis

■

Retrosternal or Precordial: May radiate to the tip of the shoulder and to the neck

■ ■ ■ ■

Dis s e ctin g Ao rtic An e u rys m

■

Anterior chest, radiating to the neck, back, or 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 Same as in angina Often but not always a severe pain 20 min to several hours Associated with nausea, vomiting, sweating, weakness Sharp, knifelike quality Often severe Persistent timing Relieved by leaning forward Seen in autoimmune disorders, postmyocardial infarction, viral infection, chest irradiation Ripping, tearing quality Very severe Abrupt onset, early peak, persistent for hours or more Associated syncope, hemiplegia, paraplegia (table continues on page 156)

156


Table 8-1 Ch e s t P a in (continued ) P ro b le m a n d Lo c a t io n

Q u a lit y, S e ve r it y, Tim in g , a n d A s s o c ia t e d S y m p t o m s

P u lm o n a ry Ple u ritic Pa in

■

Chest wall overlying the process

■ ■ ■

Sharp, knifelike quality Often severe Persistent timing Associated symptoms of the underlying illness (often pneumonia, pulmonary embolism)

G a s t ro in t e s t in a l a n d O t h e r Ga s tro in te s tin a l Re flu x Dis e a s e

■

Retrosternal, may radiate to the back

■ ■ ■

Diffu s e Es o p h a g e a l S p a s m

■

Retrosternal, may radiate to the back, arms, and jaw

■ ■ ■

Ch e s t Wa ll Pa in , Co s to ch o n d ritis

■

Often below the left breast or along the costal cartilages; also elsewhere

■

An xie ty, Pa n ic Dis o rd e r

■

■ ■

■ ■

Burning quality, may be squeezing Mild to severe Variable timing Associated with regurgitation, dysphagia; also cough, laryngitis, asthma Usually squeezing quality Mild to severe Variable timing Associated dysphagia Stabbing, sticking, or dull aching quality Variable severity Fleeting timing, hours or days Often with local tenderness Pain may be stabbing, sticking, or dull, aching Can mimic angina Associated with breathlessness, palpitations, weakness, anxiety


157

Table 8-2 Dys p n e a P ro vo k in g /Re lie v in g Fa c t o r s ; A s s o c ia t e d Sym p t o m s

P ro b le m

Tim in g

Le ft -S id e d He a r t Fa ilu r e (Left Ventricular Failure or Mitral Stenosis)

Dyspnea may progress slowly or suddenly, as in acute pulmonary edema

↑ by exertion, lying down

Chronic productive cough followed by slowly progressive dyspnea

↑ by exertion, inhaled irritants, respiratory infections

C h ro n ic Bro n c h it is (may be seen with COPD)

↓ by rest, sitting up, though dyspnea may become persistent Associated Symptoms: Often cough, orthopnea, paroxysmal nocturnal dyspnea; sometimes wheezing

↓ by expectoration, rest though dyspnea may become persistent Associated Symptoms: Chronic productive cough, recurrent respiratory infections; wheezing possible

C h ro n ic O b s t r u c t ive P u lm o n a ry D is e a s e (CO P D )

Slowly progressive; relatively mild cough later

↑ by exertion ↓ by rest, though dyspnea may become persistent Associated Symptoms: Cough with scant mucoid sputum (table continues on page 158)

158


Table 8-2 Dys p n e a (continued ) P ro vo k in g /Re lie v in g Fa c t o r s ; A s s o c ia t e d S ym p t o m s

P ro b le m

Tim in g

As t h m a

Acute episodes, then symptomfree periods; nocturnal episodes common

↑ by allergens, irritants, respiratory infections, exercise, emotion

Diffu s e In t e r s t it ia l Lu n g Dis e a s e s (Sarcoidosis, Neoplasms, Asbestosis, Idiopathic Pulmonary Fibrosis)

Progressive; varies in rate of development depending on cause

↑ by exertion

P n e u m o n ia

Acute illness; timing varies with causative agent

Associated Symptoms: Pleuritic pain, cough, sputum, fever, though not necessarily present

Spontaneous P n e u m o t h o ra x

Sudden onset of dyspnea

Associated Symptoms: Pleuritic pain, cough

Ac u t e P u lm o n a ry Em b o lis m

Sudden onset of dyspnea

Associated Symptoms: Often none; retrosternal oppressive pain if massive occlusion; pleuritic pain, cough, syncope, hemoptysis, and/or unilateral leg swelling and pain from instigating deep vein thrombosis; anxiety

↓ by separation from aggravating factors Associated Symptoms: Wheezing, cough, tightness in chest ↓ by rest, though dyspnea may become persistent Associated Symptoms: Often weakness, fatigue; cough less common than in other lung diseases


159

Table 8-3 Co u g h a n d He m o p t ys is P ro b le m

C o u g h , S p u t u m , A s s o c ia t e d S y m p t o m s , a n d S e t t in g

Ac u t e In f la m m a t io n La ryn g itis

Cough and Sputum: Dry, or with variable amounts of sputum Associated Symptoms and Setting: Acute, fairly minor illness with hoarseness. Associated with viral nasopharyngitis

Acu te Bro n ch itis

Cough and Sputum: Dry or productive of sputum Associated Symptoms and Setting: An acute, often viral illness, with burning retrosternal discomfort

Myco p la s m a a n d Vira l Pn e u m o n ia s

Cough and Sputum: Dry and hacking often with mucoid sputum Associated Symptoms and Setting: Acute febrile illness, often with malaise, headache, and possibly dyspnea

Ba cte ria l Pn e u m o n ia s

Cough and Sputum: Sputum is mucoid or purulent; may be blood-streaked, diffusely pinkish, or rusty Associated Symptoms and Setting: Acute illness with chills, often high fever, dyspnea, and chest pain. Commonly from Streptococcus pneumonia, Haemophilus influenza, Moraxella catarrhalis; Klebsiella in alcoholism

C h ro n ic In f la m m a t io n Po s tn a s a l Drip

Cough and Sputum: Chronic cough with mucoid or mucopurulent sputum Associated Symptoms and Setting: Repeated attempts to clear the throat. Postnasal drip, discharge in posterior pharynx. Associated with chronic rhinitis, with or without sinusitis (table continues on page 160)

160


Table 8-3 Co u g h a n d He m o p t ys is (continued ) P ro b le m


Ch ro n ic Bro n ch itis

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

Bro n ch ie cta s is

Cough and Sputum: Chronic cough; sputum mucoid to purulent, may be bloodstreaked or even bloody Associated Symptoms and Setting: Recurrent bronchopulmonary infections common; sinusitis may coexist

Pu lm o n a ry Tu b e rcu lo s is

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

Lu n g Ab s ce s s

Cough and Sputum: Sputum purulent and foul-smelling; may be bloody Associated Symptoms and Setting: Often from aspiration pneumonia from oral anaerobes and poor dental hygiene; often with dysphagia, impaired consciousness

As th m a

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


161

Table 8-3 Co u g h a n d He m o p t ys is (continued ) P ro b le m


Ga s tro e s o p h a g e a l Re flu x

Cough and Sputum: Chronic cough, 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

N e o p la s m

Cough: Dry to productive

Lu n g Ca n ce r

Sputum and Cough: Cough, dry to productive; sputum may be blood-streaked or bloody Associated symptoms and setting: Commonly with dyspnea, weight loss, and history of tobacco abuse

C a r d io va s c u la r D is o r d e r s Le ft Ve n tricu la r Fa ilu re o r Mitra l S te n o s is

Cough and Sputum: 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.

Pu lm o n a ry Em b o lis m

Cough and Sputum: Dry cough, at times with hemoptysis Associated Symptoms and Setting: Tachypnea, chest or pleuritic pain, dyspnea, fever, syncope, anxiety; factors that predispose to deep venous thrombosis

Irrita tin g Pa rticle s , Ch e m ica ls , o r Ga s e s

Cough and Sputum: Variable. May be a latent period between exposure and symptoms Associated Symptoms and Setting: Exposure to irritants; eye, nose, and throat symptoms

162


Table 8-4 Ab n o rm a lit ie s in Ra t e a n d Rh yt h m o f Bre a t h in g Inspira tion Expira tion

No rm al. In adults, 14–20 per min; in infants, up to 44 per min. Rapid Shallow Breathing (Tachypnea). Many causes, including salicylate intoxication, restrictive lung disease, pleuritic 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.

Hype rpne a

Apne a

Cheyne –S to ke s Bre athing . 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) Bre athing. Unpredictable irregularity of depth and rate. Causes include meningitis, respiratory depression, and brain injury.

S ighs

P rolonge d e xpira tion

S ig hing Bre athing . Breathing punctuated by frequent sighs. When associated with other symptoms, it suggests the hyperventilation syndrome. Occasional sighs are normal. Obs tructive Bre athing . In obstructive lung disease, expiration is prolonged due to narrowed airways increase the resistance to air flow. Causes include asthma, chronic bronchitis, and COPD.


163

Table 8-5 De fo rm it ie s o f t h e Th o ra x C ro s s -S e c t io n o f Th o r a x N o r m a l Ad u lt

The thorax is wider than it is deep; lateral diameter is greater than anteroposterior (AP) diameter.

Ba r r e l C h e s t

Has increased AP diameter, seen in normal infants and normal aging; also in COPD.

Tr a u m a t ic Fla il C h e s t

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 Ins piration

Fu n n e l C h e s t (Pe ctu s Exca va tu m )

Depression in the lower portion of the sternum. Related compression of the heart and great vessels may cause murmurs.


164


Table 8-5 De fo rm it ie s o f t h e Th o ra x (continued ) C ro s s -S e c t io n o f Th o r a x P ig e o n C h e s t (Pe ctu s Ca rin a tu m )

Sternum is displaced anteriorly, increasing the AP diameter; costal cartilages adjacent to the protruding sternum are depressed.

Anteriorly dis placed s ternum

Depres s ed cos ta l cartilages

Th o r a c ic Ky p h o s c o lio s is

Abnormal spinal curvatures and vertebral rotation deform the chest, making interpretation of lung findings difficult.

Sp inal convexity to the right (patient be nding forward)

Rib s clos e together

Ribs widely s eparated

165

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9

C H A P T E R

The Cardiovascular System The Health History C o m m o n o r C o n c e r n in g S y m p t o m s ● ● ● ● ●

Chest in P l it tions Shortness of bre th: dys ne , ortho ne , or Swelling or ede F inting (synco e)

roxys

l nocturn l dys ne

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 about any palpitations, shortness of breath from orthopnea or paroxysmal nocturnal dyspnea (PND), swelling from edema, and fainting. Be systematic as you think through the range of possible cardiac, pulmonary, and extrathoracic etiologies. Know the presentations of chest pain, dyspnea, wheezing, cough, and even hemoptysis, because these symptoms can be cardiac as well as pulmonary in origin. Also, when assessing cardiac symptoms, it is important to quantify the patient’s baseline level of activity compared to the symptomatic episode. C o m m o n C a r d ia c S y m p t o m s ●

● ●

Chest pain refers to cl ssic exertion l in, ressure, or disco fort in the chest, shoulder, b ck, neck, or r in ngin ectoris, occurs in 18% of tients with cute MI; ty ic l descri tors lso re co on, such s cr ing, grinding, ricking or, r rely, tooth or j w in. Palpitations re n un le s nt w reness of the he rtbe t. Shortness of breath y re resent dys ne , ortho ne , or PND. ● Dyspnea is n unco fort ble w reness of bre thing th t is in ro ri te for given level of exertion. (continued )

167

168


C o m m o n C a r d ia c S y m p t o m s

(Continued )

Orthopnea is dys ne th t occurs when the tient is lying down nd i roves when the tient sits u . It suggests left ventricular heart failure or mitral stenosis; it lso y cco ny obstructive pulmonary disease. ● PND describes e isodes of sudden dys ne nd ortho ne th t w ken the tient fro slee , usu lly 1 to 2 hours fter going to bed, ro ting the tient to sit u , st nd u , or go to window for ir. Edema refers to the ccu ul tion of excessive fluid in the interstiti l tissue s ces; it e rs s swelling. Dependent edema e rs in the feet nd lower legs when sitting or in the s cru when bedridden. Fainting (“bl cking out”) or syncope, is tr nsient loss of consciousness followed by recovery. ●

●

●


●

S eci l o ul tions t risk Screening for c rdiov scul r risk f ctors ● Step 1: Screen for glob l risk f ctors ● Step 2: C lcul te 1 -ye r nd lifeti e c rdiov scul r dise se (CVD) risk using n online c lcul tor ● Step 3: Tr ck individu l risk f ctors—hy ertension, di betes, dysli ide i s, et bolic syndro e, s oking, f ily history, nd obesity Pro oting lifestyle ch nges nd risk f ctor odific tion

CVD, which consists primarily of hypertension (the vast majority of diagnoses), coronary heart disease (CHD), heart failure, and stroke, affects nearly 84 million U.S. adults. CVD is the leading cause of death for both men and women in the United States. Primary prevention, in those without evidence of CVD, and secondary prevention, in those with known cardiovascular events, remain important clinical priorities. Provide education and counseling to promote optimal levels of blood pressure, cholesterol, weight, exercise, and smoking cessation and to reduce risk factors for CVD and stroke. The American Heart Association recommends important goals for ideal cardiovascular health.

Chapter 9 | The Cardiovascular System

169

A H A 2 0 2 0 G o a ls f o r Id e a l C a r d io v a s c u la r H e a lt h 1. Tot l cholesterol <2 g/dL (untre ted) 2. Le n body ss 3. BP <12 / <8 (untre ted) 4. F sting glucose <1 g/dL (untre ted)

5. Abstinence fro s oking 6. Physic l ctivity go l: ≥15 in/ wk oder te intensity, ≥75 in/ wk vigorous intensity, or co bin tion 7. He lthy diet

S p e c ia l P o p u la t io n s a t R is k Virtually no U.S. adults have optimal health behaviors for all seven goals. Women and African Americans are groups at especially high risk.

S c r e e n in g f o r C a r d io v a s c u la r R is k F a c t o r s S t e p 1 : S c re e n fo r Glo b a l Ris k Fa c t o r s . Begin routine screening at age 20 for combined individual risk factors or “global” risk of CVD and any family history or premature heart disease, de ned as onset at age <55 years in rst-degree male relatives and <60 years in rst-degree female relatives. See the recommended screening intervals listed below.

M a jo r C a r d io v a s c u la r R is k F a c t o r s a n d S c r e e n in g F r e q u e n c y Ris k Fa c t o r

S c r e e n in g Fr e q u e n c y

F

U d te regul rly

ily history of re ture CVD Cig rette s oking Poor diet Physic l in ctivity Obesity, es eci lly centr l di osity

Hy ertension

Dysli ide i s

Go a l

At e ch visit At e ch visit

Cess tion I roved over ll e ting ttern At e ch visit 3 inutes oder te intensity d ily At e ch visit BMI 2 –25 kg/ 2; w ist circu ference: ≤4 inches for en, ≤35 inches for wo en At e ch visit <14 /9 for dults <6 ye rs, dults >6 ye rs with di betes or chronic kidney dise se; <15 /9 for ll other dults ≥6 ye rs Every 5 ye rs if low risk Initi te st tin ther y if eetEvery 2 ye rs if strong risk ing ACC/AHA guidelines (continued )

170


M a jo r C a r d io v a s c u la r R is k F a c t o r s a n d S c r e e n in g F r e q u e n c y (Continued ) Ris k Fa c t o r

S c r e e n in g Fr e q u e n c y

Go a l

Di betes

Every 3 ye rs (if nor l) beginning t ge 45 ye rs; ore frequently t ny ge if risk f ctors At e ch visit

Prevent/del y di betes for those with HbA1c of 5.7–6.4%

Pulse

Identify nd tre t tri l fibrill tion

Sources: see . 186.

S t e p 2 : Ca lc u la t e 10 -ye a r a n d Lo n g -Te rm CVD Ris k Us in g On lin e Ca lc u la t o r s . Use the CVD risk calculators to establish 10-year and lifetime risk for ages 40 to 79 years. The most recent ACC/AHA Cholesterol Guideline provides a new risk-assessment calculator. C V D R is k C a lc u la t o r s ● ●

htt :/ / y. eric nhe rt.org/cvriskc lcul tor htt :/ / www. cc.org/ tools- nd- r ctice-su ort/ obile-resources/ fe tures/2 13- revention-guidelines- scvd-risk-esti tor?w_n v=S.

S t e p 3 : Tra ck In d ivid u a l Ris k Fa c t o rs —Hyp e rt e n s io n , Dia b e t e s , Dys lip id e m ia s , Me t a b o lic S yn d ro m e , S m o k in g , Fa m ily His t o ry, a n d Ob e s it y Hy p e r t e n s io n . The U.S. Preventive Services Task Force recommends screening all people age ≥18 years 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). B lo o d P r e s s u r e C la s s if ic a t io n f o r A d u lt s —J N C 7 , A m e r ic a n S o c ie t y o f H y p e r t e n s io n C a t e g o ry

Nor l Prehy ertension St ge 1 hy ertension Age ≥18 to <6 ye rs Age ≥6 ye rsa



<12 12 –139

<8 8 –89

14 –159 15 –159

9 –99 9 –99 (continued )


171

B lo o d P r e s s u r e C la s s if ic a t io n f o r A d u lt s —J N C 7 , A m e r ic a n S o c ie t y o f H y p e r t e n s io n (Continued ) C a t e g o ry


St ge 2 hy ertension If di betes or ren l dise se (including ge ≥6 ye rs)

≥16 <14


≥1 <9

The A eric n Society of Hy ertension r ises this cutoff to ge ≥8 ye rs. Sources: Weber MA, Schiffrin EL, White WB, et l. Clinic l r ctice guidelines for the n geent of hy ertension in the co unity: st te ent by the A eric n Society of Hy ertension nd the Intern tion l Society of Hy ertension. J Clin Hypertens. 2 14;16:14; Chob ni n AV, B kris GL, Bl ck HR, et l. The Seventh Re ort of the Joint N tion l Co ittee on Prevention, Detection, Ev lu tion, nd Tre t ent of High Blood Pressure—The JNC 7 Re ort. JAMA. 2 3;289:256 . Av il ble t htt :/ / www.nhlbi.nih.gov/ he lth- ro/guidelines/ current/ .

a

D ia b e t e s . Use the screening and diagnostic criteria below.

A m e r ic a n D ia b e t e s A s s o c ia t io n 2 0 1 5 : C la s s if ic a t io n a n d D ia g n o s is o f D ia b e t e s S c r e e n in g C r it e r ia

Healthy adults with no risk factors: begin t ge 45 ye rs, re e t t 3-ye r interv ls Adults with BMI ≥25 kg/ m 2 and additional risk factors: ● Physic l in ctivity ● First-degree rel tive with di betes ● Me bers of high-risk ethnic o ul tion—Afric n A eric n, His nic/ L tino A eric n, Asi n A eric n, P cific Isl nder ● Mothers of inf nts ≥4. 8 kg (9 lb) t birth or di gnosed with GDM ● Hy ertension ≥14 /9 Hg or on ther y for hy ertension ● HDL cholesterol <35 g/dL nd/or triglycerides >25 g/dL ● Wo en with olycystic ov ry syndro e ● HbA1c ≥5.7%, i ired glucose toler nce, or i ired f sting glucose on revious testing ● Other conditions ssoci ted with insulin resist nce such s severe obesity, c nthosis nigric ns ● History of CVD D ia g n o s t ic C r it e r ia

D ia b e t e s a

P r e d ia b e t e s

HbA1c F sting l s occ sions)

≥6.5% ≥126 g/dL

5.7%–6.4% 1 –125 g/dL

glucose (on t le st 2

(continued )

172


A m e r ic a n D ia b e t e s A s s o c ia t io n 2 0 1 5 : C la s s if ic a t io n a n d D ia g n o s is o f D ia b e t e s

(Continued )

Dia g n o s t ic C r it e r ia

D ia b e t e s a

P r e d ia b e t e s

2-Hour l s glucose (or l glucose toler nce test) R ndo glucose if cl ssic sy to s

≥2

g/dL

14 –199

≥2

g/dL

g/dL

In the bsence of cl ssic sy to s, n bnor l test ust be re e ted to confir the di gnosis. However, if two different tests re both bnor l then no ddition l testing is necess ry. Source: A eric n Di betes Associ tion. Cl ssific tion nd di gnosis of di betes. Diabetes Care. 2 15;38(Su l):S8.

a

D y s lip id e m ia s . LDL is the primary target of cholesterol-lowering therapy.

The USPSTF has issued a grade A recommendation for routine lipid screening for all men of age >35 years and women >45 years who are at increased risk for CHD; and a grade B recommendation to screen for lipid disorders beginning at age 20 years for men and women who have diabetes, hypertension, obesity, tobacco use, noncoronary atherosclerosis, or family history of early CVD. In 2014 the ACC/AHA published “a guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults.” Use the CVD risk calculator to establish 10-year risk and lifetime gender and race-speci c risks for CHD and stroke events to guide statin use for primary prevention (ACC/AHA Risk Calculator: http://tools. cardiosource.org/ASCVD-Risk-Estimator). The most recent ACC/AHA Cholesterol Guideline provides evidence-based recommendations for initiating statin therapy based on high, moderately high, and low risk level.

A T P III G u id e lin e s : 1 0 -Y e a r R is k a n d LD L G o a ls 1 0 -Ye a r Ris k C a t e g o ry

LD L G o a l (m g /d L)

C o n s id e r D r u g Th e r a p y if LD L (m g /d L)

High risk (>2 %)

<1 Optional goal: <7 <13 Optional goal: <1 <13 <16

>1 (<1 : consider drug o tions, including further 3 %–4 % reduction in LDL) ≥13 1 –129: consider drug o tions to chieve go l of <1 ≥16 >19 (16 –189: drug ther y optional)

Moder tely high risk (1 %–2 %) Moder te risk (<1 %) Lower risk ( –1 risk f ctor)

Source: Ad ted fro N tion l Cholesterol Educ tion P nel Re ort. I lic tions of recent clinic l tri ls for the N tion l Cholesterol Educ tion Progr Adult Tre t ent P nel III Guidelines. Grundy SM, Clee n JI, Merz NB, et l., for the Coordin ting Co ittee of the N tion l Cholesterol Educ tion Progr . Circulation. 2 4;119:227–239.


173

M e t a b o lic S y n d ro m e . 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 ve risk factors listed below. M e t a b o lic S y n d r o m e : 2 0 0 9 D ia g n o s t ic C r it e r ia Waist circumference Fasting plasma glucose HDL cholesterol Triglycerides Blood pressure

Men ≥1 2 c , wo en ≥88 c ≥1 g/dL or being tre ted for elev ted glucose Men <4 g/dL, wo en <5 g/dL, or being tre ted ≥15 g/dL, or being tre ted ≥13 / ≥85, or being tre ted

Source: Alberti K, Eckel RH, Grundy SM, et l. H r onizing the et bolic syndro e: joint interi st te ent of the Intern l Di betes Feder tion T sk Force on E ide iology nd Prevention; N tion l He rt, Lung nd Blood Institute; A eric n He rt Associ tion; World He rt Feder tion; Intern l Atherosclerosis Society; nd Intern l Associ tion for the Study of Obesity. Circulation. 2 9;12 :162 –1645.

O t h e r Ris k Fa c t o r s : S m o k in g , Fa m ily His t o ry, a n d O b e s it y. Smoking

increases the risk of CHD and stroke by two- to fourfold compared to nonsmokers or past smokers who quit >10 years previously; about 14% of U.S. cardiovascular deaths are attributed to smoking annually. Among adults, 13% report a family history of heart attack or angina before age 50 years. Along with a family history of premature revascularization, this risk factor is associated with about a 50% increased lifetime risk for CHD and for CVD mortality. Obesity, or BMI over 30 kg/m2, contributed to 112,000 excess adult deaths compared to those of normal weight, and was associated with 13% of CVD deaths in 2004.

P r o m o t in g Lif e s t y le C h a n g e a n d R is k F a c t o r M o d if ic a t io n Motivating behavior change is challenging, but it is an essential clinical skill for promoting risk factor reduction. Encourage the ACC/AHA recommendations below.

Lif e s t y le M o d if ic a t io n s f o r C a r d io v a s c u la r H e a lt h ● ● ●

O ti l weight, or BMI of 18.5–24.9 kg/ 2 Int ke of <6 g of sodiu chloride or 2.3 g of sodiu er d y Regul r erobic exercise such s brisk w lking three to four ti es week, ver ging 4 inutes er session (continued )

174


Lif e s t y le M o d if ic a t io n s f o r C a r d io v a s c u la r H e a lt h ●

(Continued )

Moder te lcohol consu tion er d y of ≤2 drinks for en nd ≤1 drink for wo en (2 drinks = 1 oz eth nol, 24 oz beer, 1 oz wine, or 2–3 oz whiskey) Diet rich in fruits, veget bles, whole gr ins, nd low-f t d iry roducts with reduced int ke of s tur ted nd tot l f t, sweets, nd red e ts.

Source: Eckel RH, J kicic JM, Ard JD, et l. 2 13 AHA/ACC guideline on lifestyle n ge ent to reduce c rdiov scul r risk: re ort of the A eric n College of C rdiology/A eric n He rt Associ tion T sk Force on Pr ctice Guidelines. Circulation. 2 14;129:S76.



H e a r t R a t e a n d B lo o d P r e s s u r e If not already done, count 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 in ations.

This step helps you to detect an auscultatory gap and avoid recording an inappropriately low systolic blood pressure.

Measure blood pressure with a sphygmomanometer. If indicated, recheck it.

Orthostatic (postural) hypotension within 3 minutes of position change from supine to standing is SBP↓ ≥20 mm Hg; HR↑ ≥20 beats/min.

J u g u la r V e in s Jugular venous pulsations: In the right internal jugular vein identify their highest point in the neck. Start with head of the bed at 30 degrees; adjust the head of the bed as necessary, giving consideration to volume status. Jugular venous pressure ( JVP)— Measure the vertical distance between this highest point and the sternal angle, normally <3 to 4 cm (Fig. 9-1).

Elevated JVP in right-sided heart failure; decreased JVP in hypovolemia from dehydration or gastrointestinal bleeding.



175


Fig ure 9-1 Me as ure the he ight of the J VP.

Study the waves of venous pulsation. Note the a wave of atrial contraction and the v wave of venous lling.

Abnormally prominent a waves in tricuspid stenosis, pulmonary hypertension, and pulmonic stenosis; absent a waves in atrial fibrillation. Increased v waves in tricuspid regurgitation, atrial septal defects, and constrictive pericarditis.

C a r o t id P u ls e Palpate the amplitude and contour of the carotid upstroke.

A delayed upstroke in aortic stenosis; a bounding upstroke in aortic insufficiency.

P u ls u s Alt e rn a n s . Palpate for alteration in carotid pulse amplitude. Lower pressure of blood pressure cuff slowly to systolic level while you listen with your stethoscope over the brachial artery.

Alternating amplitude of pulse or sudden doubling of Korotkoff sounds indicates pulsus alternans—a sign of left ventricular heart failure.

P a r a d o x ic a l P u ls e . Lower pressure of BP cuff slowly and note two pressure levels: (1) where Korotkoff sounds are rst heard and (2) where they rst 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 inspiration signifies a paradoxical pulse. Consider obstructive pulmonary disease, asthma, COPD, pericardial tamponade, or constrictive pericarditis.

Listen for bruits.

Carotid bruits suggest atherosclerotic narrowing and increase stroke risk.

176



Th e H e a r t S e q u e n c e o f t h e C a r d ia c E x a m in a t io n P a t ie n t P o s it io n

Ex a m in a t io n

Supine, with the head elevated 30 degrees

After ex ining the JVP nd c rotid ulse, ins ect nd l te the recordiu : the 2nd right nd left inters ces; the right ventricle; nd the left ventricle, including the ic l i ulse (di eter, loc tion, litude, dur tion). P l te the ic l i ulse to ssess its di eter. Listen t the ex with the bell of the stethosco e. Listen t the six re s with the diaphragm then the bell: the 2nd right nd left inters ces, down the left stern l border to the 4th nd 5th inters ces, nd cross to the ex (see . 177). As indic ted, listen t the lower right stern l border for right-sided ur urs nd sounds, often ccentu ted with ins ir tion, with the diaphragm nd bell. Listen down the left stern l border nd t the ex with the diaphragm for the soft decrescendo ur ur of ortic insufficiency.

Left lateral decubitus Supine, with the head elevated 30 degrees

Sitting, leaning forward, after full exhalation

In s p e c t io n a n d P a lp a t io n . Inspect and palpate the anterior chest for heaves, lifts, or thrills.

Inspect and palpate the apical impulse (Fig. 9-2). Turn patient to left as necessary. Note:

Fig ure 9-2 Palpate the apical im puls e . ■ Location of impulse

Displaced to left in pregnancy.

■ Diameter

Increased diameter, amplitude, and duration in left ventricular dilatation from heart failure or ischemic cardiomyopathy.


177



■ Amplitude—usually tapping

Sustained in left ventricular hypertrophy; diffuse in CHF.

■ Duration

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.

Au s c u lt a t io n . Listen to the heart by “inching” your stethoscope from the base to the apex (or apex to base) in the areas illustrated in Figure 9-3.

Le ft 2nd inte rs pac e — P ulmonic a re a

Rig ht 2nd inte rs pac e — Aortic a re a

Rig ht ve ntric ular are a— Le ft s te rna l borde r

Epiga s tric (s ubxiphoid)

Le ft ve ntric ular are a—Apex

Fig ure 9-3 Aus cultate the he art from the bas e to the apex.

Use the diaphragm to detect the 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. 181; Table 9-2, Variations in the First Heart Sound—S1, p. 182; Table 9-3, Variations in the Second Heart Sound—S2 During Inspiration and Expiration, pp. 183–184.

■ S1

■ S2. Is splitting normal in left

2nd and 3rd interspaces?

Physiologic (inspiratory) or pathologic (expiratory) splitting

■ Extra sounds in systole

Systolic clicks

■ Extra sounds in diastole

S3, S4

178




■ Systolic murmurs

Midsystolic, pansystolic, late systolic murmurs

■ Diastolic murmurs

Early, mid-, or late diastolic murmurs

Use two maneuvers as needed to help identify the murmurs of mitral stenosis and aortic regurgitation. Listen at the apex with patient turned toward left side for lowpitched sounds (Fig. 9-4).

Left-sided S3, and diastolic murmur of mitral stenosis.

Fig ure 9-4 Lis te n at the apex for lowpitche d s ounds .

Listen down the left sternal border to the apex as patient sits, leaning forward, with breath held after exhalation (Fig. 9-5).

Diastolic decrescendo murmur of aortic regurgitation.

Fig ure 9-5 Lis te n at the lowe r le ft s te rnal borde r for aortic ins ufficie ncy.

As s e s s in g a n d De s c rib in g Mu rm u r s . Identify, if murmurs are present, their: ■ Timing in the cardiac cycle

(systole, diastole). It is helpful to

See Table 9-4, Heart Murmurs, p. 185.



179


palpate the carotid upstroke while listening to any murmur—murmurs occurring simultaneously with the upstroke are systolic. ■ Shape

Plateau, crescendo, decrescendo A crescendo–decrescendo murmur first rises in intensity, then falls (e.g., aortic stenosis).

S1

S2

A plateau murmur has the same intensity throughout (e.g., mitral regurgitation). S1

S2

A crescendo murmur grows louder (e.g., mitral stenosis). S2

S1

A decrescendo murmur grows softer (e.g., aortic regurgitation). S2

S1

■ Location of maximal intensity

Murmurs loudest at the base are often aortic; at the a pex, they are often mitral.

■ Radiation ■ Pitch

High, medium, low

■ Quality

Blowing, harsh, musical, rumbling

■ Intensity on a six-point scale (see

“Gradations of Murmurs” below) G r a d a t io n s o f M u r m u r s Gra d e

D e s c r ip t io n

Grade 1 Very f int, he rd only fter listener h s “tuned in”; y not be he rd in ll ositions Grade 2 Quiet, but he rd i edi tely fter l cing the stethosco e on the chest Grade 3 Moder tely loud Grade 4 Loud, with palpable thrill Grade 5 Very loud, with thrill. M y be he rd when the stethosco e is rtly off the chest Grade 6 Very loud, with thrill. M y be he rd with stethosco e entirely off the chest

180




S p e c ia l T e c h n iq u e s Aid s t o Id e n t ify S ys t o lic Mu rm u r s Va ls a lva M a n e u ve r. 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 (HCM), listen to the intensity of the murmur.

In AS, the murmur decreases; in HCM, it often increases.

/

S q u a t t in g a n d S t a n d in g . In

suspected MVP, listen for the click and murmur in both positions. Try to distinguish AS from HCM by listening to the murmur in both positions.

Squatting increases ventricular filling and delays the click and murmur. Standing reverses the changes. Squatting increases murmur of AS and decreases murmur of HCM. Standing reverses the changes.

Recording Your Findings R e c o r d in g t h e C a r d io v a s c u la r E x a m in a t io n “The jugul r venous ulse is 3 c bove the stern l ngle with the he d of the bed elev ted to 3 degrees. C rotid u strokes re brisk, without bruits. The oint of xi l i ulse (PMI) is t ing, 7 c l ter l to the idstern l line in the 5th intercost l s ce. Cris S1 nd S2. At the b se, S2 is gre ter th n S1 nd hysiologic lly s lit, with A2 > P2. At the ex, S1 is gre ter th n S2 nd const nt. No ur urs or extr sounds.” OR “The JVP is 5 c bove the stern l ngle with the he d of the bed elev ted to 5 degrees. C rotid u strokes re brisk; bruit is he rd over the left c rotid rtery. The PMI is diffuse, 3 c in di eter, l ted t the nterior xill ry line in the 5th nd 6th intercost l s ces. S1 nd S2 re soft. S3 resent t the ex. High- itched, h rsh 2/ 6 holosystolic ur ur best he rd t the ex, r di ting to the xill . No S4 or di stolic ur urs.” (These findings suggest CHF with possible left carotid stenosis and mitral regurgitation.)


181

Aids to Interpretation Table 9-1 He a r t S o u n d s

S 1 E1

S 2 OS S 3

S ys tole

S4 S1

Dia s tole

Fin d in g

P o s s ib le C a u s e s

S1 accentuated

Tachycardia, states of high cardiac output; mitral stenosis

S 1 d im in is h e d

First-degree heart block; reduced left ventricular contractility; immobile mitral valve, as in mitral regurgitation

S y s t o lic c lic k (s )

Mitral valve prolapse (as in E1 above)

S 2 a c c e n t u a t e d in r ig h t 2 n d in t e r s p a c e

Systemic hypertension, dilated aortic root

S 2 d im in is h e d o r a b s e n t in r ig h t 2 n d in t e r s p a c e

Immobile aortic valve, as in calcific aortic stenosis

P2 accentuated

Pulmonary hypertension, dilated pulmonary artery, atrial septal defect

P 2 d im in is h e d o r a b s e n t

Aging, pulmonic stenosis

O p e n in g s n a p

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

182


Table 9-2 Va ria t io n s in t h e Fir s t He a r t S o u n d —S 1 N o r m a l Va r ia t io n s

S1

S1 is softer than S2 at the base (right and left 2nd interspaces).

S2 S1 is often but not always louder than S2 at the apex.

S1

S2

Ac c e n t u a t e d S 1

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.

D im in is h e d S 1

S1

S2 S1 varies in complete heart block and any totally irregular rhythm (e.g., atrial fibrillation).

Va ry in g S 1

S1 S2

S1 S2

S p lit S 1

S1

Occurs in (1) tachycardia, rhythms with a short PR interval, and high cardiac output states (e.g., exercise, anemia, hyperthyroidism), and (2) mitral stenosis.

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.


183

Table 9-3 Va ria t io n s in t h e S e c o n d He a r t S o u n d — S 2 Du rin g In s p ira t io n a n d Exp ira t io n P h y s io lo g ic S p lit t in g

A2

S1

P2

S2

S1

S2

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. P a t h o lo g ic S p lit t in g

S1

S2

S1

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. Fixe d S p lit t in g

S1

S2

S1

S2

Does not vary with respiration, as in atrial septal defect, right ventricular failure. (table continues on page 184)

184


Table 9-3 Va ria t io n s in t h e S e c o n d He a rt S o u n d — S 2 Durin g Ins pira tion a n d Exp ira t io n (continued ) P a r a d o x ic a l o r Re ve r s e d S p lit t in g

P2

S1

S2

S1

A2

S2

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. Mo re o n A2 a n d P 2

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.


185

Table 9-4 He a r t Mu rm u r s Lik e ly C a u s e s Innocent murmurs (no valve abnormality)

M id s y s t o lic

S1

Physiologic murmurs (from ↑ flow across a semilunar valve, as in pregnancy, fever, anemia)

S2

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 Mitral regurgitation

P a n s y s t o lic

Tricuspid regurgitation S1

Ventricular septal defect

S2

Mitral valve prolapse, often with click (C)

La t e S y s t o lic

S1

C

S2

Aortic regurgitation

Ea r ly D ia s t o lic

S1

S2

S1

M id d ia s t o lic a n d P r e s y s t o lic

S1

S 2 OS

Mitral stenosis—note opening snap (OS)

S1

C o n t in u o u s M u r m u r s and Sounds S1

S1

S1

S2

S2

S2

S1

Patent ductus arteriosus—harsh, machinery-like

S1

Pericardial friction rub—a scratchy sound with 1–3 components

S1

Venous hum—continuous, above midclavicles, loudest in diastole

186


S o u r c e s fo r M a jo r C a r d io va s c u la r Ris k Fa c t o r s a n d S c r e e n in g Fr e q u e n c y Bo x o n p . 1 7 0 Sources: Ad ted fro : Goff DC, Jr., Lloyd-Jones DM, Bennett G, et l. 2 13 ACC/AHA guideline on the ssess ent of c rdiov scul r risk: re ort of the A eric n College of C rdiology/A eric n He rt Associ tion T sk Force on Pr ctice Guidelines. J Am Coll Cardiol. 2 14;63(25 Pt B):2935; Stone NJ, Robinson JG, Lichtenstein AH, et l. 2 13 ACC/AHA guideline on the tre t ent of blood cholesterol to reduce therosclerotic c rdiov scul r risk in dults: re ort of the A eric n College of C rdiology/A eric n He rt Associ tion T sk Force on Pr ctice Guidelines. Circulation. 2 14;129:S1; J es PA, O ril S, C rter BL, et l. 2 14 evidence-b sed guideline for the n ge ent of high blood ressure in dults: re ort fro the nel e bers ointed to the Eighth Joint N tion l Co ittee (JNC 8). JAMA. 2 14;311:5 7; Meschi JF, Bushnell C, Boden-Alb l B, et l. Guidelines for the riry revention of stroke: st te ent for he lthc re rofession ls fro the A eric n He rt Associ tion/A eric n Stroke Associ tion. Stroke. 2 14;45:3754; Fl ck JM, Sic DA, B kris G, et l. M n ge ent of high blood ressure in Bl cks: n u d te of the Intern tion l Society on Hy ertension in Bl cks consensus st te ent. Hypertension. 2 1 ;56:78 ; A eric n Di betes A. Executive su ry: St nd rds of edic l c re in di betes—2 14. Diabetes Care. 2 14;37 Su l 1:S5.

10 C H A P T E R

The Breasts and Axillae The Health History C o m m o n o r C o n c e r n in g S y m p t o m s ● ● ●

Bre st lu or ss Bre st in or disco fort Ni le disch rge

Ask, “Do you examine your breasts?” . . . “How often?” Ask about any discomfort, pain, or lumps in the breasts. Also ask about any discharge from the nipples, change in breast contour, dimpling, swelling, or puckering of the skin over the breasts.


P l ble sses of the bre st Assessing risk of bre st c ncer Bre st c ncer screening

Pa lp a b le Ma s s e s o f t h e Bre a s t . Breast masses show marked variation in etiology, from broadenomas and cysts seen in younger women, to abscess or mastitis, to primary breast cancer. All breast masses warrant careful evaluation, and de nitive diagnostic measures should be pursued.

187

188


P a lp a b le M a s s e s o f t h e B r e a s t Ag e

C o m m o n Le s io n

C h a r a c t e r is t ic s

15–25

Fibro deno

25–5

Cysts

Usu lly s ooth, rubbery, round, obile, nontender Usu lly soft to fir , round, obile; often tender Nodul r, ro e-like Irregul r, fir , y be obile or fixed to surrounding tissue As bove

Fibrocystic ch nges C ncer Over 5 Pregn ncy/ l ct tion

C ncer until roven otherwise L ct ting deno s, cysts, stitis, nd c ncer

As bove

Ad ted fro Schultz MZ, W rd BA, Reiss M. Bre st dise ses. In: Noble J, Greene HL, Levinson W, et l. (eds). Primary Care Medicine. 2nd ed. St. Louis: MO; 1996; Venet L, Str x P, Venet W, et l. Adequ cies nd in dequ cies of bre st ex in tions by hysici ns in ss screenings. Cancer. 1971;28(6):1546–1551.

As s e s s in g Ris k o f Bre a s t Ca n c e r. About 50% of affected women have no known predisposing risk factors; however, selected risk factors are well established. B r e a s t C a n c e r R is k F a c t o r s Nonmodifiable risk factors: ● Age ( ost i ort nt) ● F ily history of bre st nd ov ri n c ncers ● Inherited genetic ut tions ● Person l history of bre st c ncer or lobul r c rcino in situ ● High levels of endogenous hor ones ● Bre st tissue density ● Prolifer tive lesions with ty i on bre st bio sy ● Dur tion of uno osed estrogen ex osure rel ted to e rly en rche ● Age of first full-ter regn ncy ● L te eno use

Bre st density on ogr s (co nds incre sing i ort nce s strong inde endent risk f ctor) ● History of r di tion to the chest ● History of diethylstilbestrol (DES) ex osure Modifiable risk factors: ● Bre stfeeding for <1 ye r ● Post eno us l obesity ● Use of hor one re l ce ent ther y (HRT) ● Cig rette s oking ● Alcohol ingestion ● Physic l in ctivity ● Ty e of contr ce tion ●

See also Table 10-1, Breast Cancer in Women: Factors That Increase Relative Risk, p. 196. 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

Chapter 10 | The Breasts and Axillae

189

assess risk of BRCA1 or BRCA2 gene mutation. (See http://bcb.dfci.harvard. edu/bayesmendel/software.php.) Bre a s t Ca n c e r S c re e n in g . Mammography combined with the CBE are the most common screening modalities; however, recommendations from professional groups vary about how to screen, when to start screening, and screening intervals, as shown in the table below. Clinicians should be well informed as they counsel individual patients, particularly as more evidence emerges to guide risk-based screening. B r e a s t C a n c e r S c r e e n in g R e c o m m e n d a t io n s Ma m m o g ra p hy U.S. Preventive Services T sk Force— ver ge-risk wo en (2 16)

C lin ic a l Br e a s t Ex a m in a t io n

Br e a s t S e lf Ex a m in a t io n

Reco ends ≥4 ye rs— 5 –74 ye rs— g inst insufficient bienni lly ● <5 ye rs— te ching BSE evidence to ssess ddiindividu lize tion l benefits screening b sed nd h r s of on tient-s ecific CBE beyond f ctors screening ● ≥75 ye rs—insuffiogr hy cient evidence to reco end ● 4 –45 ye rs— A eric n C ncer Not reco ended Not reco ended Society— ver gedue to l ck of due to l ck of o tion l nnu l risk wo en (2 15) evidence evidence screening showing cle r showing cle r ● 45–54 ye rs— benefit benefit nnu l screening ● ≥55 ye rs—bienni l screening with o tion to continue nnu l screens ● Continue screening if good he lth nd life ex ect ncy ≥1 ye rs A eric n College of ≥4 ye rs— nnu lly ● 2 –39 ye rs— Encour ges Obstetrici ns nd bre st selfevery 1–3 ye rs Gynecologists ● ≥4 ye rs— w reness nnu lly ●

Sources: U.S. Preventive Services T sk Force. Bre st C ncer: Screening. J nu ry 2 16. At htt :/ / www.us reventiveservicest skforce.org/ P ge/ Docu ent/ U d teSu ryFin l/ bre st-c ncer-screening1?ds=1&s=BREAST CANCER. Accessed 2.11.16; Oeffinger KC, Fonth ETH, Etzioni R, et l. Bre st c ncer screening for wo en t ver ge risk 2 15 guideline u d te fro the A eric n C ncer Society. JAMA. 2 15;314:15 . See lso htt :/ / www.c ncer.org/c ncer/ bre stc ncer/ oreinfor tion/ bre stc ncere rlydetection/ bre st-c ncer-e rly-detection- cs-recs. Accessed Nove ber 14, 2 15. A eric n College of Obstetrici ns nd Gynecologists. Pr ctice bulletin No. 122: bre st c ncer screening. Obstet Gynecol. 2 11;118(2 t 1):372.

190




T h e F e m a le B r e a s t Inspect the breasts in four positions, identifying the quadrant where changes appear (Figs. 10-1 through 10-5).

12 Ta il of S pe nce Uppe r oute r qua dra nt

9

3

Lowe r oute r qua dra nt

Uppe r inne r qua dra nt Lowe r inne r qua dra nt

6 Fig ure 10-1 Bre as t quadrants .

Fig ure 10-2 Ins pe ct w ith arm s at

Fig ure 10-3 Ins pe ct w ith arm s ove r

s ide s .

he ad.



191


Fig ure 10-4 Ins pe ct w ith hands pre s s e d agains t hips .

Fig ure 10-5 Ins pe ct w hile le aning forward.

Note: ■ Size and symmetry

See Table 10-2, Visible Signs of Breast Cancer, pp. 197–198.

■ Contour

Flattening, dimpling suspicious for malignancy

■ Appearance of the skin

Edema (peau d’orange) in breast cancer

Inspect the nipples. ■ Compare their size, shape, and

Inversion, retraction, deviation

direction of pointing. ■ Note any rashes, ulcerations, or

Paget disease of the nipple, galactorrhea

discharge. Palpate the breasts, including augmented breasts. Breast tissue should be attened and the patient supine. Use a 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 (Fig. 10-6). Fig ure 10-6 Ve rtical s trip patte rn— late ral bre as t.

192




For the medial portion of the breast, ask the patient to lie with her shoulders at against the bed or examining table, place her hand at her neck, and lift up her elbow until it is even with her shoulder (Fig. 10-7). Fig ure 10-7 Ve rtical s trip patte rn— m e dial bre as t.

Palpate a rectangular area extending from the clavicle to the inframammary fold, and from the midsternal line to the posterior axillary line and well into the axilla for the tail of Spence. Note: ■ Consistency

Physiologic nodularity

■ Tenderness

Infection, premenstrual tenderness

■ Nodules. If present, note

Cyst, fibroadenoma, cancer

location, size, shape, consistency, delimitation, tenderness, and mobility. Palpate each nipple.

Thickening in cancer

Compress the areola in a spokelike pattern around the nipple. Watch for discharge.

Type and source of discharge may be identified.

Palpate and inspect along the incision lines of mastectomy.

Local recurrences of breast cancer

/

T h e M a le B r e a s t

Inspect and palpate the nipple and areola.

Gynecomastia, mass suspicious for cancer, fat




A x illa e Inspect for rashes, infection, and pigmentation.

Hidradenitis suppurativa, acanthosis nigricans

Palpate the axillary nodes, including the central, pectoral, lateral, and subscapular groups (Figs. 10-8).

Lymphadenopathy

Fig ure 10-8 Palpate the le ft axilla.

S p e c ia l T e c h n iq u e /

In s t ru c t io n s fo r t h e Bre a s t S e lf-Exa m in a t io n . For interested or high-risk patients, instruct the patient about how to perform the BSE.

193

194


P a t ie n t In s t r u c t io n s f o r t h e B r e a s t S e lf -E x a m in a t io n (B S E )—A m e r ic a n C a n c e r S o c ie t y Ly in g S u p in e

1. Lie down with illow under your right shoulder. Pl ce your right r behind your he d. 2. Use the finger ds of the three iddle fingers on your left h nd to feel for lu s in the right bre st. The finger ds re the to third of e ch finger. M ke overl ing, di e-sized circul r otions to feel the bre st tissue. 3. A ly three levels of ressure in e ch s ot: light, ediu , nd fir , using fir er ressure for tissue closest to the chest nd ribs. A fir ridge in the lower curve of e ch bre st is nor l. If you’re not sure how h rd to ress, t lk with your he lth c re rovider, or try to co y the w y the doctor or nurse does it.

4. Ex ine the bre st in n u - nddown or “stri ” ttern. St rt t n i gin ry str ight line under the r , oving u nd down cross the entire bre st, fro the ribs to the coll rbone, until you re ch the iddle of the chest bone (the sternu ). Re e ber how your bre st feels fro onth to onth. 5. Re e t the ex in tion on your left bre st, using the finger ds of the right h nd. 6. If you find ny sses, lu s, or skin ch nges, see your clinici n right w y.

(continued )


195

P a t ie n t In s t r u c t io n s f o r t h e B r e a s t S e lf -E x a m in a t io n (B S E )—A m e r ic a n C a n c e r S o c ie t y (Continued ) S t a n d in g

1. While st nding in front of irror with your h nds ressing fir ly down on your hi s, look t your bre sts for ny ch nges of size, sh e, contour, or di ling, or redness or sc liness of the ni le or bre st skin. (The ressing down on the hi s osition contr cts the chest w ll uscles nd enh nces ny bre st ch nges.)

2. Ex ine e ch under r while sitting u or st nding nd with your r only slightly r ised so you c n e sily feel in this re . R ising your r str ight u tightens the tissue in this re nd kes it h rder to ex ine.

Ad ted fro the A eric n C ncer Society. A eric n C ncer Society. Bre st w reness nd self-ex . U d ted A ril 9, 2 15. Av il ble t htt :/ / www.c ncer.org/c ncer/ bre stc ncer/ oreinfor tion/ bre stc ncere rlydetection/ bre st-c ncer-e rly-detection- cs-recs-bse. Accessed M y 7, 2 15.

Recording Your Findings R e c o r d in g t h e B r e a s t s a n d A x illa e E x a m in a t io n “Bre sts sy etric nd s ooth, without sses. Ni les without disch rge.” (Axill ry deno thy usu lly included fter Neck in section on Ly h Nodes.) OR “Bre sts endulous with diffuse fibrocystic ch nges. Single fir 1 × 1 c ss, obile nd nontender, with overlying e u d’or nge e r nce in right bre st, u er outer qu dr nt t 11 o’clock, 2 c fro the ni le.” (These findings suggest possible breast cancer.)

196


Aids to Interpretation Table 10-1 Fa c t o r s Th a t In c re a s e t h e Re la t ive Ris k fo r Bre a s t Ca n c e r in Wo m e n Re la t ive Ris k

Fa c t o r

>4.0

■

■ ■

■ ■ ■ ■

2.1–4.0

■ ■ ■

■

1.1–2.0

■ ■ ■ ■ ■ ■ ■ ■ ■

■ ■ ■ ■ ■ ■ ■

■

Age (65+ vs. <65 years, although risk increases across all ages until age 80) Biopsy-confirmed atypical hyperplasia Certain inherited genetic mutations for breast cancer (BRCA1 and/or BRCA2) Ductal carcinoma in situ Lobular carcinoma in situ Personal history of early-onset (<40 years) breast cancer Two or more first-degree relatives with breast cancer diagnosed at an early age High endogenous estrogen or testosterone levels (postmenopausal) High-dose radiation to chest Mammographically extremely dense (>50%) breasts compared to less dense (11%–25%) One first-degree relative with breast cancer Alcohol consumption Ashkenazi Jewish heritage Diethylstilbestrol exposure Early menarche (<12 years) Height ( >5 feet 3 inches) High socioeconomic status Late age at first full-term pregnancy (>30 years) Late menopause (>55 years) Mammographically dense (26%–50%) breasts compared to less dense (11%–25%) Non-atypical ductal hyperplasia or fibroadenoma Never breastfed a child No full-term pregnancies Obesity (postmenopausal)/adult weight gain Personal history of breast cancer (40+ years) Personal history of endometrium, ovary, or colon cancer Recent and long-term use of menopausal hormone therapy containing estrogen and progestin Recent oral contraceptive use

Source: American Cancer Society. Facts & Figures 2015–2016. Atlanta: American Cancer Society Inc, 2015. Available at http://www.cancer.org/acs/groups/content/@research/documents/ document/acspc-046381.pdf. Accessed May 1, 2015.


197

Table 10-2 Vis ib le S ig n s o f Bre a s t Ca n c e r Re t r a c t io n S ig n s

Fibrosis from breast cancer, fat necrosis, and mammary duct ectasia can produce the three retraction signs illustrated here.

Ca nce r Dimpling Re tra cte d nipple

S kin Dim p lin g

Ab n o rm a l Co n to u rs

Look for any variation in the normal convexity of each breast, and compare one side with the other.

Nip p le Re tra ctio n a n d De via tio n

A retracted nipple is flattened or pulled inward and may be broadened and thickened. Typically the nipple deviates toward the underlying cancer.


198


Table 10-2 Vis ib le S ig n s o f Bre a s t Ca n c e r (continued ) Ed e m a o f t h e S k in

From lymphatic blockade, appearing as thickened skin with enlarged pores—the so-called peau d’orange (orange peel) sign.

P a g e t D is e a s e o f t h e N ip p le

An uncommon form of breast cancer that usually starts as a scaly, eczema-like lesion that may weep, crust, or erode. A breast mass may be present. Suspect Paget disease in any persisting dermatitis of the nipple and areola.

De rma titis of a re ola

Eros ion of nipple

11 C H A P T E R

The Abdomen The Health History C o m m o n o r C o n c e r n in g S y m p t o m s G a s t ro in t e s t in a l D is o r d e r s ● ●

●

● ● ●

Abdo in l in, cute nd chronic Indigestion, n use , vo iting including blood (hematemesis), loss of etite (anorexia), e rly s tiety Difficulty sw llowing (dysphagia) nd/or inful sw llowing (odynophagia) Ch nge in bowel function Di rrhe , consti tion J undice

U r in a ry a n d Re n a l D is o r d e r s ● ●

●

●

● ● ●

Su r ubic in Difficulty urin ting (dysuria), urgency, or frequency Hesit ncy, decre sed stre in les Excessive urin tion (polyuria) or excess urin tion t night (nocturia) Urin ry incontinence Blood in the urine (hematuria) Fl nk in nd ureter l colic

M e c h a n is m s o f A b d o m in a l P a in 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 distention against its capsule from the various causes of hepatitis, including alcoholic hepatitis

■ May be dif cult to localize ■ Varies in quality; may be gnaw-

ing, burning, cramping, or aching ■ When severe, may be associated

with sweating, pallor, nausea, vomiting, restlessness. 199

200


Parietal pain—from in ammation of the parietal peritoneum. ■ Steady, aching ■ Usually more severe

Visceral periumbilical pain in early acute appendicitis from distention of inflamed appendix gradually changes to parietal pain in the right lower quadrant (RLQ) from inflammation of the adjacent parietal peritoneum.

■ Usually more precisely localized

over the involved structure than visceral pain 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 myocardial infarction may be referred to the epigastric area.

T h e G a s t r o in t e s t in a l T r a c t Ask patients to describe the pain in their own words, especially timing of the pain (acute or chronic); then ask them to point to the pain.

In emergency rooms, up to 45% of patients have nonspecific pain, but 15% to 30% need surgery, usually for appendicitis, intestinal obstruction, or cholecystitis.

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?”

Elicit any symptoms associated with the pain, such as fever or chills; ask about their sequence. Up p e r Ab d o m in a l P a in , Dis c o m fo r t , o r He a r t b u rn . Ask about chronic or recurrent upper abdominal discomfort, or dyspepsia. Related symptoms include bloating, nausea, upper abdominal fullness, and heartburn. Is there:

Doubling over with cramping colicky pain signals a renal stone. Sudden knife -like epigastric pain often radiating to the back is typical of pancreatitis. Epigastric pain occurs with gastroesophageal reflux disease (GERD), pancreatitis, and perforated ulcers. RUQ and upper abdominal pain are common in cholecystitis and cholangitis.

Chapter 11 | The Abdomen

■ Bloating from excessive gas,

especially with frequent belching, abdominal distention, or atus, the passage of gas by rectum ■ Unpleasant abdominal fullness

after normal meals or early satiety, the inability to eat a full meal ■ Heartburn, dysphagia, or regur-

gitation?

Lo w e r Ab d o m in a l P a in o r Dis c o m fo r t —Ac u t e a n d Ch ro n ic . If acute, is the pain sharp and continuous or intermittent and cramping?

201

Bloating may occur with lactose intolerance, inflammatory bowel disease, or ovarian cancer; belching results from aerophagia, or swallowing air.

Consider diabetic gastroparesis, anticholinergic drugs, gastric outlet obstruction, gastric cancer. Early satiety may signify hepatitis. Suggests GERD. Up to 90% of patients with asthma have GERD-like symptoms. If patient fails empiric therapy, is age >55 years, or has “alarm symptoms” (dysphagia, pain with swallowing or odynophagia, recurrent vomiting, gastro intestinal bleeding, risk factors for gastric cancer, or palpable mass), endoscopy is warranted. RLQ pain, or pain migrating from periumbilical region in appendicitis; in women with RLQ pain, possible pelvic inflammatory disease, ectopic pregnancy, ruptured ovarian follicle Left lower quadrant (LLQ) pain in diverticulitis, diffuse abdominal pain with abdominal distention, hyperactive bowel sounds, and tenderness on palpation in small or large bowel obstruction; pain with absent bowel sounds, rigidity, percussion tenderness, and guarding in peritonitis

If chronic, is there a change in bowel habits? Alternating diarrhea and constipation?

Colon ca ncer; irritable bowel syndrome

Ab d o m in a l Pa in w it h As s o c ia t e d GI S ym p t o m s ■ Nausea, vomiting, loss of

appetite (anorexia)

Pregnancy, diabetic ketoacidosis, adre nal insufficiency, hypercalcemia, uremia, liver disease. Induced vomiting without nausea in anorexia/bulimia.

202


■ Regurgitation

GERD, esophageal stricture, and esophageal cancer

■ Coffee ground emesis

Esophageal or gastric varices, Mallory– Weiss tears, peptic ulcer disease

(hematemesis) Ot h e r GI S ym p t o m s ■ Dif culty swallowing

(dysphagia)

■ Painful swallowing

(odynophagia)

■ Diarrhea, acute (<2 weeks)

and chronic

If solids and liquids, neuromuscular disorders affecting motility. If only solids, consider structural conditions like Zenker diverticulum, Scha tzki ring, stricture, neoplasm. Radiation; caustic ingestion, infection from cytomegalovirus, herpes simplex, HIV, esophageal ulceration from aspirin or NSAIDs Acute infection (viral, salmonella, shigella, etc.); chronic in Crohn disease, ulcerative colitis; oily diarrhea (steatorrhea)—in pancreatic insufficiency. See Table 11-1, Diarrhea, pp. 214–215.

■ Constipation

Medications, especially anticholinergic agents and opioids; colon cancer, diabetes, hypothyroidism, hypercalcemia, multiple sclerosis, Parkinson disease

■ Black tarry stools (melena)

GI bleed

■ Jaundice from increased levels of

bilirubin: Intrahepatic jaundice can be hepatocellular, from damage to the hepatocytes, or cholestatic, from impaired excretion caused by damaged hepatocytes or intrahepatic bile ducts

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

Common bile duct obstruction from gallstones or pancreatic, cholangio-, or duodenal carcinoma

Ask about the color of the urine and stool.

Dark urine from increased conjugated bilirubin excreted in urine (hepa titis); acholic clay-colored stool when bilirubin excretion into intestine is obstructed


203

R is k F a c t o r s f o r Liv e r D is e a s e ●

●

●

●

●

Hepatitis: Tr vel or e ls in re s of oor s nit tion, ingestion of cont in ted w ter or foodstuffs (hepatitis A); renter l or ucous e br ne ex osure to infectious body fluids such s blood, seru , se en, nd s liv , es eci lly through sexu l cont ct with n infected rtner or use of sh red needles for injection drug use (hepatitis B); illicit injection drug use or blood tr nsfusion (hepatitis C) Alcoholic hepatitis or alcoholic cirrhosis (screen tients c refully bout lcohol use) Toxic liver damage fro edic tions, industri l solvents, environ ent l toxins, or so e nesthetic gents Gallbladder disease or surgery th t y result in extr he tic bili ry obstruction Hereditary disorders in the F ily History

T h e U r in a r y T r a c t Ask about pain on urination, usually a burning sensation, sometimes termed dysuria (also refers to dif culty voiding).

Bladder infection (cystitis) Also seen in urethritis, urinary tract infections, bladder stones, tumors, and, in men, acute prostatitis. In women, internal burning in urethritis, external burning in vulvova ginitis

Is there: ■ Urgency, an unusually intense

May lead to urge incontinence

and immediate desire to void ■ Urinary frequency, or abnormally

Urinary tract infection

frequent voiding ■ Fever or chills; blood in the

Urinary tract infection

urine ■ Any pain in the abdomen, ank,

or back ■ 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.

Dull, steady pain in pyelonephritis; severe colicky pain in ureteral obstruction from renal stone Prostatitis, urethritis

204


Assess any: ■ Polyuria, a signi cant increase in

Diabetes mellitus, diabetes insipidus

24-hour urine volume ■ Nocturia, urinary frequency at

Bladder obstruction

night ■ Urinary incontinence, involuntary

loss of urine:

See Table 11-2, Urinary Incontinence, pp. 216–217.

■

From coughing, sneezing, lifting

Stress incontinence (poor urethral sphincter tone)

■

From urge to void

Urge incontinence (detrusor overactivity)

■

From bladder fullness with leaking but incomplete emptying

Overflow incontinence (anatomic obstruction, impaired neural innervation to bladder)


Screening for lcohol buse Vir l he titis: risk f ctors, v ccines, nd screening Screening for colorect l c ncer

S c re e n in g fo r Alc o h o l Ab u s e . Use the four CAGE questions (see Chapter 3, p. 56) to screen all adults in primary care settings, adolescents, and pregnant women for risky or hazardous alcohol use. Focus on detection, counseling, and, for signi cant impairment, speci c treatment recommendations. Brief counseling interventions have been shown to reduce alcohol consumption by 13% to 34% over 6 to 12 months.

S c r e e n in g f o r P r o b le m D r in k in g Standard Drink Equivalents: 1 st nd rd drink is equiv lent to 12 oz of regul r beer or wine cooler, 8 oz of lt liquor, 5 oz of wine, or 1.5 oz of 8 - roof s irits Initial Screening Question: “How ny ti es in the st ye r h ve you h d 4 or ore drinks d y (wo en), or 5 or ore drinks d y ( en)?” (continued )


S c r e e n in g f o r P r o b le m D r in k in g

205

(Continued)

D e f in it io n s o f D r in k in g Le ve ls fo r Ad u lt s —N a t io n a l In s t it u t e o f A lc o h o l Ab u s e a n d A lc o h o lis m Wo m e n

Moder te drinking Uns fe drinking levels (incre sed risk for develo ing n lcohol use disorder)a Binge drinkingb

Me n

≤1 drink/d ≤2 drinks/d >3 drinks/d nd >4 drinks/d nd >7 drinks/ wk >14 drinks/ wk ≥4 drinks on one ≥5 drinks on one occ sion occ sion

Pregn nt wo en nd those with he lth roble s th t could be worsened by drinking should not drink ny lcohol. b Brings blood lcohol level to . 8 g%, usu lly within 2 hours. a

Vira l He p a t it is : Ris k Fa c t o r s , S c re e n in g , a n d Va c c in a t io n . Protective measures against infectious hepatitis include counseling about transmission. ■ Hepatitis A: Transmission is fecal–oral. Illness occurs approximately

30 days after exposure. Advise hand washing with soap and water after bathroom use or changing diapers and before preparing or eating food. Diluted bleach can be used to clean environmental surfaces.

C D C R e c o m m e n d a t io n s f o r H e p a t it is A V a c c in a t io n ● ● ●

All children t ge 1 ye r Individu ls with chronic liver dise se Grou s t incre sed risk of cquiring HAV: tr velers to re s with high ende ic r tes of infection, en who h ve sex with en, injection nd illicit drug users, individu ls working with nonhu n ri tes, nd ersons who h ve clotting-f ctor disorders The v ccine lone ende ic re s.

y be d inistered t ny ti e before tr veling to

■ Hepatitis B: Transmission occurs during contact with infected body

uids, such as blood, semen, saliva, and vaginal secretions. Infection increases risk of fulminant hepatitis, chronic infection, and subsequent cirrhosis and hepatocellular carcinoma. Provide counseling and serologic screening for patients at risk.

206


C D C R e c o m m e n d a t io n s f o r H e p a t it is B V a c c in a t io n : H ig h -R is k G r o u p s a n d S e t t in g s ●

●

●

●

Sexual contacts, including sex rtners of he titis B surf ce ntigen- ositive ersons, eo le with ore th n one sex rtner in the rior 6 onths, eo le seeking ev lu tion nd tre t ent for sexu lly tr ns itted infections, nd en who h ve sex with en People with percutaneous or mucosal exposure to blood, including injection drug users, household cont cts of ntigen- ositive ersons, residents nd st ff of f cilities for the develo ent lly dis bled, he lth c re workers, nd eo le on di lysis Others, including tr velers to ende ic re s, eo le with chronic liver dise se nd HIV infection, nd eo le seeking rotection fro he titis B infection All adults in high-risk settings, such s sexu lly tr ns itted infection (STI) clinics, HIV testing nd tre t ent rogr s, drug- buse tre t ent rogr s nd rogr s for injection drug users, correction l f cilities, rogr s for en h ving sex with en, chronic he odi lysis f cilities nd end-st ge ren l dise se rogr s, nd f cilities for eo le with develo ent l dis bilities

■ Hepatitis C: Hepatitis C, now the most common form of hepatitis, is

spread by blood exposure and injection drug use. There is no vaccination for hepatitis C, so prevention targets counseling to avoid risk factors. Serologic screening should be recommended for high-risk groups. S c re e n in g fo r Co lo re c t a l Ca n c e r. Adopt the 2008 recommendations of the U.S. Preventive Services Task Force, listed below. S c r e e n in g f o r C o lo r e c t a l C a n c e r Assess Risk: Begin screening t ge 2 ye rs. If high risk, refer for ore co lex n ge ent. If ver ge risk t ge 5 (high-risk conditions bsent), offer the screening o tions listed. ●

●

Common high-risk conditions (25% of colorect l c ncers) ● Person l history of colorect l c ncer or deno ● First-degree rel tive with colorect l c ncer or deno tous oly s ● Person l history of bre st, ov ri n, or endo etri l c ncer ● Person l history of ulcer tive or Crohn colitis Heredit ary high-risk conditions (6% of colorect l c ncers) ● F ili l deno tous oly osis ● Heredit ry non oly osis colorect l c ncer (continued )


S c r e e n in g f o r C o lo r e c t a l C a n c e r

207

(Continued)

Screening recommendations ● Adults age 50 to 75 years—o tions ● High-sensitivity fec l occult blood testing (FOBT) nnu lly ● Sig oidosco y every 5 ye rs with FOBT every 3 ye rs ● Screening colonosco y every 1 ye rs ● Adults age 76 to 85 years—do not screen routinely, s g in in life-ye rs is s ll co red to colonosco y risks, nd screening benefits not seen for 7 ye rs; use individu l decision king if screening for the first ti e ● Adults older than age 85—do not screen, s “co eting c uses of ort lity reclude ort lity benefit th t outweighs h r s”



Th e A b d o m e n Inspect the abdomen, including: ■ Skin

Scars, striae, veins, ecchymoses (in intraor retroperitoneal hemorrhages)

■ Umbilicus

Hernia, inflammation

■ Contours for shape, symmetry,

Bulging flanks of ascites, suprapubic bulge, large liver or spleen, tumors

enlarged organs or masses ■ Any peristaltic waves

Increased in GI obstruction

■ Any pulsations

Increased in aortic aneurysm

Auscultate the abdomen for: ■ Bowel sounds

Increased or decreased motility

■ Bruits

Bruit of renal artery stenosis

■ Friction rubs

Liver tumor, splenic infarct

208




B o w e l S o u n d s a n d B r u it s Ch a n g e

S e e n w it h

Incre sed bowel sounds

Di rrhe E rly intestin l obstruction Adyn ic ileus Peritonitis Intestin l fluid Air under tension in dil ted bowel Intestin l obstruction

Decre sed, then bsent bowel sounds High- itched tinkling bowel sounds High- itched rushing bowel sounds with cr ing He tic bruit Arteri l bruits

C rcino of the liver Alcoholic he titis P rti l obstruction of the ort or ren l, ili c or fe or l rteries

Aorta Re na l a rte ry

Ilia c a rte ry Fe mora l a rte ry

Percuss the abdomen for patterns of tympany and dullness.

Ascites, GI obstruction, pregnant uterus, ovarian tumor

Palpate all quadrants of the abdomen: ■ Lightly for guarding, rebound,

and tenderness (Fig. 11-1)

See Table 11-3, Abdominal Tenderness, p. 217. “Acute abdomen”or peritonitis if: Firm, board-like abdominal wall— suggests peritoneal inflammation. Guarding if the patient flinches, grimaces, or reports pain during palpation.

Fig ure 11-1 Be gin w ith light palpation of the abdom e n.

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

(Fig. 11-2)

209

P O SSIBLE FIN DIN G S Tumors, a distended viscus Abdominal masses may be: physiologic (pregnant uterus), inflammatory (diverticulitis), vascular (an AAA), neoplastic (colon cancer), or obstructive (a distended bladder or dilated loop of bowel).

Fig ure 11-2 Us e two hands for de e p palpation.

T h e Liv e r Percuss span of liver dullness in the midclavicular line (MCL), Figure 11-3. 4–8 cm in mids te rna l line 6–12 cm in right midcla vicula r line

Increased dullness in hepatomegaly from acute hepatitis, heart failure; decreased dullness in cirrhosis

Norma l live r s pa ns

Fig ure 11-3 Me as ure the live r s pan.

Feel the liver edge, if possible, as patient breathes in.

Firm edge of cirrhosis

Starting well below the costal margin, measure distance of the liver edge from the costal margin in the MCL (Fig. 11-4).

Increased distance in hepatomegaly— may be missed (as in Fig. 11-5) by starting palpation too high in the RUQ

Fig ure 11-4 Palpate the live r e dge . Fig ure 11-5 Palpating firs t at the cos tal m argin m ay m is s the live r e dge .

Note any tenderness or masses.

Tender liver of hepatitis or heart failure; tumor mass

210




T h e S p le e n Percuss across left lower anterior chest (Traube space), noting change from tympany to dullness. Palpate the spleen with the patient supine then lying on the right side with legs exed at hips and knees (Fig. 11-6).

Splenomegaly

Figure 11-6 Spleen tip (purple) palpable below costal margin.

T h e Kid n e y s Try to palpate each kidney (Fig. 11-7).

Enlargement from cysts, cancer, hydronephrosis

Fig ure 11-7 Palpate e ach kidney.

Check for costovertebral angle (CVA) tenderness (Fig. 11-8).

Fig ure 11-8 Pe rcus s for cos tove rte bral angle te nde rne s s .

Tender in pyelonephritis



211


Th e A o r t a Palpate the aorta’s pulsations (Fig. 11-9). In older people, estimate its width.

Periumbilical mass with expansile pulsations ≥3 cm in diameter in abdominal aortic aneurysm. Assess further due to risk of rupture.

Fig ure 11-9 Palpate on both s ide s of the aorta.

A s s e s s in g A s c it e s / Palpate for shifting dullness. Map areas of tympany and dullness with patient supine, then lying on side (Fig. 11-10).

Ascitic fluid usually shifts to dependent side, changing the margin of dullness (Fig. 11-11).

Tympa ny Tympa ny Dullne s s S hifting dullne s s Fig ure 11-10 Pe rcus s outw ard to m ap

Fig ure 11-11 Pe rcus s for s hifting dull-

dullne s s from as cite s .

ne s s (he re patie nt turne d to right s ide ).

Check for a uid wave (Fig. 11-12). 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.

212




Fig ure 11-13 Ballotte the live r. Fig ure 11-12 Te s t for a fluid wave .

Ballotte an organ or mass in an ascitic abdomen. Place your stiffened and straightened ngers on the abdomen, brie y 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 (Fig. 11-13).

A s s e s s in g P o s s ib le A p p e n d ic it is Ask:

In classic appendicitis:

“Where did the pain begin?”

Near the umbilicus

“Where is it now?”

RLQ

Ask patient to cough. “Where does it hurt?”

RLQ at “the McBurney point”

Palpate for local tenderness.

RLQ tenderness

Palpate for muscular rigidity.

RLQ rigidity

Perform a rectal examination and, in women, a pelvic examination (see Chapters 14 and 15).

Local tenderness, especially if appendix is retrocecal

■ Rovsing sign: Press deeply and

Pain in the right lower quadrant during left-sided pressure suggests appendicitis (a positive Rovsing sign).

evenly in the left lower quadrant. Then quickly withdraw your ngers.



■ 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. ■ 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.

213

P O SSIBLE FIN DIN G S Pain from irritation of the psoas muscle suggests an inflamed appendix (a positive psoas sign).

Right hypogastric pain in a positive obturator sign, suggesting irritation of the obturator muscle by an inflamed appendix.

A s s e s s in g P o s s ib le A c u t e C h o le c y s t it is 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 the Murphy 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 sign.

Recording Your Findings R e c o r d in g t h e A b d o m in a l E x a m in a t io n “Abdo en is rotuber nt with ctive bowel sounds. It is soft nd nontender; no l ble sses or he tos leno eg ly. Liver s n is 7 c nd in the right MCL; edge is s ooth nd l ble 1 c below the right cost l rgin. S leen nd kidneys not felt. No CVA tenderness.” OR “Abdo en is fl t. No bowel sounds he rd. It is fir nd bo rd-like, with incre sed tenderness, gu rding, nd rebound in the right idqu dr nt. Liver ercusses to 7 c in the MCL; edge not felt. S leen nd kidneys not felt. No lble ss. No CVA tenderness.” (These findings suggest peritonitis from possible appendicitis; see pp. 212–213.)

214


Aids to Interpretation Table 11-1 Dia rrh e a P ro b le m /P ro c e s s

C h a r a c t e r is t ic s o f S t o o l

Ac u t e D ia r r h e a Se cre to ry In fe ctio n (noninflam m atory)

Infection by viruses; preformed bacterial toxins such as Staphylococcus aureus, Clostridium perfringens, toxigenic Escherichia coli; Vibrio cholerae, Cryptosporidium, Giardia lamblia, rotavirus

Watery, without blood, pus, or mucus

In fla m m a to ry In fe ctio n

Colonization or invasion of intestinal mucosa as in nontyphoid Salmonella, Shigella, Yersinia, Campylobacter, enteropathic E. coli, Entamoeba histolytica, Clostridium difficile

Loose to watery, often with blood, pus, or mucus

D r u g -In d u c e d D ia r r h e a

Action of many drugs, such as magnesium-containing antacids, antibiotics, antineoplastic agents, and laxatives

Loose to watery

C h ro n ic D ia r r h e a (ê 3 0 d a y s ) Dia rrh e a l Syn d ro m e s ■

■

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


215

Table 11-1 Dia rrh e a (continued ) P ro b le m /P ro c e s s

C h a r a c t e r is t ic s o f S t o o l

In fla m m a to ry Bo w e l Dis e a s e ■

■

Ulcerative colitis: inflammation and ulceration of the mucosa and submucosa of the rectum and colon Crohn 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)

Vo lu m in o u s Dia rrh e a s ■

■

■

Malabsorption syndrome: Defective absorption of fat, including fatsoluble 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

216


Table 11-2 Urin a ry In c o n t in e n c e P ro b le m

M e c h a n is m s

S t r e s s In c o n t in e n c e : 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.

■

U r g e In c o n t in e n c e : Detrusor

contractions are stronger than normal and overcome normal urethral resistance. Bladder is typically small. Results in voiding moderate amounts, urgency, frequency, and nocturia.

■

■

■

O ve r f lo w In c o n t in e n c e :

■

Detrusor contractions are insufficient to overcome urethral resistance. Bladder is typically large, even after an effort to void, leading to continuous dribbling.

■

■

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 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 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


217

Table 11-2 Urin a ry In c o n t in e n c e (continued ) P ro b le m

M e c h a n is m s

Fu n c t io n a l In c o n t in e n c e :

■

Problems in mobility from weakness, arthritis, poor vision, other conditions; environmental factors such as unfamiliar setting, distant bathroom facilities, bed rails, physical restraints

■

Sedatives, tranquilizers, anticholinergics, sympathetic blockers, potent diuretics

Inability to get to the toilet in time because of impaired health or environmental conditions

In c o n t in e n c e S e c o n d a ry t o M e d ic a t io n s : Drugs may

contribute to any type of incontinence listed.

Table 11-3 Ab d o m in a l Te n d e rn e s s Vis c e r a l Te n d e r n e s s

P e r it o n e a l Te n d e r n e s s

Enla rge d live r

Norma l a orta

Norma l ce cum

Norma l or s pa s tic s igmoid colon

Dive rticulitis Appe ndicitis Chole cys titis

Te n d e r n e s s f ro m D is e a s e in t h e C h e s t a n d P e lv is Acu te Ple u ris y

Acu te Sa lp in g itis

Unila te ra l or bila te ra l, uppe r or lowe r a bdome n

12 C H A P T E R

The Peripheral Vascular System The Health History C o m m o n o r C o n c e r n in g S y m p t o m s ● ● ● ● ● ● ●

Abdo in l, fl nk, or b ck in P in in the r s or legs Exercise-induced in (inter ittent cl udic tion) Cold, nu bness, llor in the legs; h ir loss Swelling in c lves, legs, or feet Color ch nge in fingerti s or toes in cold we ther Swelling with redness or tenderness

Ask about abdominal, ank, or back pain, especially in older male smokers.

An expanding abdominal aortic aneurysm (AAA) may compress arteries or ureters.

Ask about any pain in the arms and legs.

Cold-induced digital ischemic change with blanching then cyanosis then rubor in Raynaud phenomenon or disease

Is there intermittent claudication, 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 cramping in your legs when you walk or exercise?” “How far can you walk without stopping to rest?” and “Does pain improve with rest?”

Peripheral arteria l disea se (PAD) can cause symptomatic limb ischemia with exertion; distinguish this from the neurogenic pain of spinal stenosis, which produces leg pain with exertion, often reduced by leaning forward (stretching the spinal cord in the narrowed 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 gangrene may ensue.

219

220


Because patients have few symptoms, identify risk factors— tobacco abuse, hypertension, diabetes, hyperlipidemia, and coronary artery disease—and PAD warning signs.

Only 10% to 30% of affected patients have the classic symptoms of exertional calf pain relieved by rest.

P e r ip h e r a l A r t e r ia l D is e a s e “ W a r n in g S ig n s ” ●

●

●

F tigue, ching, nu bness, or in Symptom location suggests the site of th t li its w lking or exertion in the arterial ischemia: legs; if resent, identify the loc tion. aortoiliac Ask lso bout erectile dysfunction. iliac–pudendal Any oorly he ling or nonhe ling common femoral or aortoiliac wounds of the legs or feet superficia l femoral Any in resent when t rest in the popliteal tibial or peroneal lower leg or foot nd ch nges when st nding or su ine

●

Abdo in l in fter e ls nd ssoci ted “food fe r” nd weight loss

These symptoms suggest intestinal ischemia of the celiac or superior or inferior mesenteric arteries.

●

Any first-degree rel tives with n AAA

Prevalence of AAAs in first-degree relatives is 15% to 28%.

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 thrombosis (DVT); hyperpigmentation, edema, and possible cyanosis, especially when legs are dependent, in venous stasis ulcers; swelling with redness and tenderness in cellulitis.

Health Promotion and Counseling: Evidence and Recommendations Im p o r t a n t T o p ic s f o r H e a lt h P r o m o t io n a n d C o u n s e lin g ● ● ● ●

Screening for eri her l rteri l dise se The nkle–br chi l index Screening for ren l rtery dise se Screening for bdo in l ortic neurys

Chapter 12 | The Peripheral Vascular System

221

S c re e n in g fo r P e rip h e ra l Ar t e ria l Dis e a s e . PAD prevalence increases with age, ranging from around 5% before age 50 years to 15% to 20% in persons aged 80 years and older. Cardiovascular risk factors, particularly smoking and diabetes, increase risk: An estimated 40% to 60% of PAD patients have coexisting coronary artery disease and/or cerebral artery disease, and the presence of PAD signi cantly increases risk of cardiovascular events. Most patients with PAD have either no symptoms or a range of nonspeci c leg symptoms, such as aching, cramping, numbness, or fatigue. R is k F a c t o r s f o r Lo w e r -E x t r e m it y P e r ip h e r a l A r t e r ia l D is e a s e ● ● ● ●

Age ≥65 ye rs Age ≥5 ye rs with history of di betes or s oking Leg sy to s with exertion Nonhe ling wounds

Th e An k le –Bra c h ia l In d e x. To diagnose PAD, use the ankle–brachial index (ABI), which is reliable, reproducible, noninvasive, easy to perform in the of ce, and highly speci c. The ABI is the ratio of blood pressure measurements in the foot and arm; values <0.9 are considered abnormal.

A wide range of interventions reduces both onset and progression of PAD, including: supervised exercise programs; tobacco cessation; treatment of hyperlipidemia; optimal control of diabetes and hypertension; use of antiplatelet agents; meticulous foot care and well- tting shoes, particularly for diabetic patients; and revascularization. S c re e n in g fo r Re n a l Art e ry Dis e a s e . The American College of Cardiology and the American Heart Association recommend renal artery disease (RAS) screening with duplex ultrasonography, magnetic resonance angiography, or computed tomographic angiography in patients with the conditions listed in the box below. C o n d it io n s S u s p ic io u s f o r R e n a l A r t e r y D is e a s e ● ● ●

Onset of hy ertension t ge ≤3 ye rs Onset of severe hy ertension t ge ≥55 ye rs Acceler ted (sudden nd ersistent worsening of reviously controlled hy ertension), resist nt (not controlled with three drugs), or lign nt hy ertension (evidence of cute end-org n d ge) (continued )

222


C o n d it io n s S u s p ic io u s f o r R e n a l A r t e r y D is e a s e ●

●

●

(Continued )

New worsening of ren l function or worsening function fter use of n ngiotensin-converting enzy e inhibitor or n ngiotensin-rece tor blocking gent An unex l ined s ll kidney or size discre ncy of >1.5 c between the two kidneys Sudden unex l ined ul on ry ede , es eci lly in the setting of worsening ren l function

S c re e n in g fo r Ab d o m in a l Ao rt ic An e u rys m . An AAA is present when the infrarenal aortic diameter exceeds 3 cm. Rupture and mortality rates dramatically increase for AAAs exceeding 5.5 cm in 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 50% over 13 to 15 years, 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,” de ned as more than 100 cigarettes in a lifetime.



A rm s Inspect for: ■ Size and symmetry, any swelling

Lymphedema, venous obstruction

■ Venous pattern

Visible venous collaterals, swelling, edema, and discoloration signal upperextremity DVT.

■ Color and texture of skin and

Sharply demarcated pallor of the fingers in Raynaud disease

nails Palpate and grade the pulses: G r a d in g A r t e r ia l P u ls e s 3+ 2+ 1+

Bounding Brisk, expect ed (normal) Di inished, we ker th n ex ected Absent, un ble to l te



■ Radial (Fig. 12-1)

223

P O SSIBLE FIN DIN G S Bounding radial, carotid, and femoral pulses in aortic regurgita tion Lost in thromboangiitis obliterans or acute arterial occlusion

Fig ure 12-1 Palpate the radial puls e . ■ Brachial (Fig. 12-2)

Fig ure 12-2 Palpate the brachial puls e .

Feel for the epitrochlear nodes.

Lymphadenopathy from local or distal infection, lymphoma, or human immunodeficiency virus (HIV)

Abdom en Auscultate for aortic, renal, and femoral bruits. Palpate and estimate the width of the abdominal aorta between your two ngers (see p. 211).

Pulsatile mass, AAA if width ≥4 cm.

Palpate the super cial inguinal nodes (Fig. 12-3). Note size, consistency, discreteness, and any tenderness.

Lymphadenopathy in genital infections, lymphoma, AIDS

■ Horizontal group ■ Vertical group

224




Horizontal group Femoral vein Femoral artery Great s aphenous vein Vertical group

Fig ure 12-3 Supe rficial inguinal lym ph node s .

Le g s Inspect for:

See Table 12-1, Chronic Insufficiency of Arteries and Veins, p. 228, and Table 12-2, Common Ulcers of the Feet and Ankles, p. 229.

■ Size and symmetry, any swelling

Venous insufficiency, lymphedema; DVT. Calf asymmetry >3 cm (measure 10 cm below tibial tuberosity) doubles the risk of DVT.

in thigh or calf

■ Venous pattern

Varicose veins

■ Color and texture of skin

Pallor, rubor, cyanosis; erythema, warmth in cellulitis, thrombophlebitis; pigmentation, ulcers of the feet in PAD

■ Hair distribution, temperature

Atrophic hairless cool skin in PAD

Palpate and grade the pulses:

Loss of pulses in acute arterial occlusion and arteriosclerosis obliterans

■ Femoral ■ Popliteal (Fig. 12-4)

Figure 12-4 Palpate the popliteal pulse.



■ Dorsalis pedis and posterior

tibial (Figs. 12-5 and 12-6)

225

P O SSIBLE FIN DIN G S Absent pedal pulses with normal femoral and popliteal pulses make PAD highly likely. Confirm with the ABI (see Table 12-3, Using the Ankle –Brachial Index, pp. 230–231).

Fig ure 12-5 Palpate the dors alis pe dis puls e .

Fig ure 12-6 Palpate the poste rior tibial puls e .

Palpate for pitting edema.

Dependent edema, heart failure, hypoalbuminemia, nephrotic syndrome

Palpate the calves.

Possible cord and tenderness in DVT (not always present)

Ask patient to stand, and reinspect the venous pattern.

Varicose veins

S p e c ia l T e c h n iq u e s Eva lu a t in g Ar t e ria l S u p p ly t o t h e Ha n d . Feel ulnar pulse, if possible. Perform an Allen test.

226




1. Ask the patient to make a tight st, palm up. Occlude both radial and ulnar arteries with your thumb (Fig. 12-7).

2. Ask the patient to open hand into a relaxed, slightly exed position (Fig. 12-8).

Fig ure 12-7 Com pre s s the radial and

Fig ure 12-8 Pallor w he n hand re laxe d.

ulnar arte rie s .

3. Release your pressure over one artery. Palm should ush within 3 to 5 seconds (Fig. 12-9).

4. Repeat, releasing other artery. Persisting pallor of palm indicates occlusion of the released artery or its distal branches (Fig. 12-10).

Fig ure 12-9 Palm ar flus hing—Alle n

Fig ure 12-10 Palm ar pallor—Alle n

te s t ne gative .

te s t pos itive .

/ Po s t u ra l Co lo r Ch a n g e s o f Ch ro n ic Ar t e ria l In s u f c ie n c y. 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) lling of veins on feet and ankles (normally about 15 seconds).

Marked pallor of feet on elevation, delayed color return and venous filling, and rubor of dependent feet suggest arterial insufficiency.


227

Recording Your Findings R e c o r d in g t h e P e r ip h e r a l V a s c u la r S y s t e m E x a m in a t io n “Extre ities re w r nd without ede . No v ricosities or st sis ch nges. C lves re su le nd nontender. No fe or l or bdo in l bruits. Br chi l, r di l, fe or l, o lite l, dors lis edis (DP), nd osterior tibi l (PT) ulses re 2+ nd sy etric.” OR “Extre ities re le below the idc lf, with not ble h ir loss. Rubor noted when legs de endent but no ede or ulcer tion. Bil ter l fe or l bruits; no bdo in l bruits he rd. Br chi l nd r di l ulses 2+; fe or l, o lite l, DP, nd PT ulses 1+.” Altern tively, ulses c n be recorded s below. (These findings suggest atherosclerotic PAD.)

RT LT

Ra d ia l

Br a c h ia l

Fe m o r a l

P o p lit e a l

D o r s a lis P e d is

2+ 2+

2+ 2+

1+ 1+

1+ 1+

1+ 1+

P o s t e r io r Tib ia l

1+ 1+

228


Aids to Interpretation Table 12-1 Ch ro n ic In s u ffic ie n c y o f Art e rie s a n d Ve in s C o n d it io n


C h ro n ic A r t e r ia l In s u ff ic ie n c y

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 for gangrene.

Rubor Is che mic ulce r

C h ro n ic Ve n o u s In s u ff ic ie n c y

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.


229

Table 12-2 Co m m o n Ulc e r s o f t h e Fe e t a n d An k le s U lc e r


A r t e r ia l In s u ff ic ie n c y

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.

C h ro n ic Ve n o u s In s u ff ic ie n c y

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.

N e u ro p a t h ic U lc e r

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.

230


Table 12-3

Us in g t h e An k le –Bra ch ia l In d e x

In s t r u c t io n s fo r M e a s u r in g t h e A n k le –Br a c h ia l In d e x (A BI)

1. Patient should rest supine in a warm room for at least 10 min before testing. Dopple r

Bra chia l a rte ry

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 Dors a lis pe dis (DP ) a rte ry

Dopple r

Dopple r

P os te rior tibia l (P T) a rte ry

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


231

Table 12-3 Us in g t h e An k le –Bra ch ia l In d e x (continued ) 5. Calculate ABI Right ABI =

Left ABI =

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)

In t e r p r e t a t io n o f A n k le –Br a c h ia l In d e x An kle –Bra ch ia l In d e x Re s u lt

Clin ica l In te rp re ta tio n

>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.

13 C H A P T E R

Male Genitalia and Hernias The Health History C o m m o n o r C o n c e r n in g S y m p t o m s ● ● ● ●

Sexu l he lth Penile disch rge or lesions Scrot l in, swelling, or lesions Sexu lly tr ns itted infections (STIs)

S e xu a l He a lt h . Explain your concern for the patient’s sexual health. Pose questions in a neutral and nonjudgmental way. ■ “Are you currently dating, sexually active, or in a relationship?” “How

would you identify your sexual orientation?” Continue with “How would you describe your gender identity?” ■ “How is your current relationship?” “Are you satis ed with your rela-

tionship and your sexual activity?” “What about your ability to perform sexually?” To assess libido, or desire: “How is your desire for sex?”

Decreased libido from depression, endocrine dysfunction, or side effects of medications.

For the arousal phase: “Can you achieve and maintain an erection?”

Erectile d ysfunct ion from p sychogenic causes, esp ecially if early morning erection is p reserved ; also from d ecreased testosterone, d ecreased b lood flow in hyp ogast ric arterial system, imp aired neural innervation, d iab etes.

233

234


If ejaculation is premature or early: “About how long does intercourse last?” “Do you climax too soon?” For reduced or absent ejaculation: “Do you nd 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 uid, or both?”

Premature ejaculation is common, especially in young men. Less common is reduced or absent ejaculation affecting middle -aged or older men. Consider medications, surgery, neurologic deficits, or lack of androgen. Lack of orgasm with intact ejaculation is usually psychogenic.

P e n ile Dis c h a rg e o r Le s io n s , S c ro t a l S w e llin g o r P a in , S TIs a n d HIV. To assess possible infection from 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. 241, and Table 13-2, Sexually Transmitted Infections of Male Genitalia, pp. 242–243.

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.

Ask “Do you have any concerns about HIV infection?” and discuss the need for universal testing for HIV.


Screening for STIs nd HPV Screening for HIV infection nd AIDS; counseling bout sexu l r ctices Screening for testicul r c ncer; testicul r self-ex in tion

Chapter 13 | Male Genitalia and Hernias

235

S c re e n in g fo r S TIs a n d HP V. Focus on patient education about STIs and HPV, early detection of infection during history taking and physical examination, and identi cation and treatment of infected partners. Identify the patient’s sexual orientation, the number 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. Correct use of male condoms is highly effective in preventing the transmission of STIs, HPV, and HIV.

Routine HPV vaccination is recommended in males age 11 or 12 years and through age 21 years if not vaccinated previously (age 26 years if immunocompromised or having sex with other men). The vaccine can prevent HPV-related diseases in males (genital warts, anal cancer, and penile cancer) and possibly reduce HPV transmission to female sex partners and lower the risk of oropharyngeal cancers. S c re e n in g fo r HIV In fe c t io n a n d AIDS . The USPSTF recommends HIV screening for all adolescents and adults from age 15 to 65 years and all pregnant women. At least annual testing is recommended for high-risk groups (including adolescents younger than 15 years and older adults), de ned as men with male sex partners, individuals with multiple sexual partners, past or present injection-drug users, persons who exchange sex for money or drugs, and sex partners of persons who are HIV-infected, bisexual, or injection-drug users. The presence of any STI, or requests for STI testing, warrants testing for coinfection with HIV.

Patient counseling should be interactive and combine information about general risk reduction with personalized messages based on the patient’s personal risk behaviors. S c r e e n in g fo r Te s t ic u la r Ca n c e r ; Te s t ic u la r S e lf -Exa m in a t io n . Testicular cancer is rare but highly treatable when detected early. It is the most commonly diagnosed cancer in white men ages 20 to 34 years. Risk factors are white ethnicity, family history, HIV infection, and a history of cryptorchidism. The American Cancer Society encourages men, especially those between 15 and 35 years of age, to perform monthly testicular self-examinations.

236




M a le G e n it a lia Wear gloves to examine the male genitalia (Fig. 13-1). The patient may be standing or supine.

Vas deferens Blood ves s els Corpus cavernos um Corpus s pongios um Urethra

S eminal ves icle Ejaculatory duct Bulb of the penis

Corona Glans Prepuce Urethral meatus

Epididymis

S crotum

Tunica vaginalis

Spermatic cord

Tes tis

Fig ure 13-1 Anatomy of m ale ge nitalia.

/

Th e Pe n is

Inspect the: ■ Development of the penis and

Sexual maturation, lice

the skin and hair at its base ■ Prepuce (if present, retract the

Phimosis, cancer

foreskin) ■ Glans

Ba lanitis, chancre, herpes, wa rts, ca ncer



■ Urethral meatus (compress the

237

P O SSIBLE FIN DIN G S Hypospadias, discharge of urethritis

glans to inspect the meatus for discharge) Palpate: ■ Any visible lesions

Chancre, cancer

■ The shaft

Urethral stricture or cancer

Th e S c ro t u m a n d It s Co n t e n t s

Inspect: ■ Skin of scrotum

Rashes

■ Contours of scrotum

Hernia, hydrocele, cryptorchidism

■ Inguinal areas

Fungal infection

Palpate each: ■ Testis (Fig. 13-2), noting any:

See Table 13-3, Abnormalities of the Testis, p. 244.

■

Lumps

Testicular carcinoma

■

Tenderness

Acute epididymitis, acute orchitis, torsion of the spermatic cord, strangulated inguinal hernia.

Fig ure 13-2 Palpate the te s tis and e pididym is .

238




■ Epididymis

Epididymitis, cyst

■ Spermatic cord and adjacent

Varicocele if multiple tortuous veins; cystic structure may be a hydrocele

areas (Fig. 13-3)

See Table 13-4, Abnormalities of the Epididymis and Spermatic Cord, p. 245.

Fig ure 13-3 Palpate the s pe rm atic cord.

H e r n ia s Patient is usually standing.

See Table 13-5, Hernias in the Groin, p. 246.

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 (Fig. 13-4).

Indirect and direct inguinal hernias

Inguina l liga me nt Exte rna l inguina l ring

Fig ure 13-4 Invaginate the s crotum .


239

S p e c ia l T e c h n iq u e P a t ie n t In s t r u c t io n s f o r t h e T e s t ic u la r S e lf -E x a m in a t io n This ex in tion is best erfor ed fter w r b th or shower. This w y the scrot l skin is w r nd rel xed. It is best to do the test while st nding. ●

●

St nding in front of irror, check for ny swelling on the skin of the scrotu . With the enis out of the w y, gently feel your scrot l s c to loc te testicle. Ex ine e ch testicle se r tely. As noted by the A eric n C ncer Society, “It’s nor l for one testicle to be slightly l rger th n the other, nd for one to h ng lower th n the other. You should lso know th t e ch nor l testicle h s s ll, coiled tube (e ididyis) th t c n feel like s ll bu on the u er or iddle outer side of the testicle. Nor l testicles lso h ve blood vessels, su orting tissues, nd tubes th t c rry s er . So e en y confuse these with bnor l lu s t first. If you h ve ny concerns, sk your doctor or clinici n.”

●

●

Use one h nd to st bilize the testicle. Using the fingers nd thu b of your other h nd, fir ly but gently feel or roll the testicle between your fingers. Feel the entire surf ce. Find the e ididy is. This is soft, tube-like structure t the b ck of the testicle th t collects nd c rries s er , nd is not n bnorl lu . Check the other testicle nd e ididy is the s e w y. If you find h rd lu , n bsent or enl rged testicle, inful swollen scrotu , or ny other differences th t do not see nor l, do not w it. See your he lth c re rovider right w y.

Sources: A eric n C ncer Society. Testicul r self-ex . U d ted J nu ry 21, 2 15. Av il ble t htt :/ / www.c ncer.org/c ncer/ testicul rc ncer/ oreinfor tion/doih vetesticul rc ncer/ do-i-h ve-testicul r-c ncer-self-ex . Accessed M y 13, 2 15; U.S. N tion l Libr ry of Medicine, N tion l Institutes of He lth. MedlinePlus—Testicul r self-ex . U d ted Dece ber 27, 2 13. Av il ble t htt :/ / www.nl .nih.gov/ edline lus/ency/ rticle/ 39 9.ht . Accessed M y 13, 2 15.

240


Recording Your Findings R e c o r d in g t h e M a le G e n it a lia a n d H e r n ia E x a m in a t io n “Circu cised le. No enile disch rge or lesions. No scrot l swelling or discolor tion. Testes descended bil ter lly, s ooth, without sses. E ididy is nontender. No inguin l or fe or l herni s.” OR “Uncircu cised le; re uce e sily retr ctible. No enile disch rge or lesions. No scrot l swelling or discolor tion. Testes descended bil ter lly; right testicle s ooth; 1 × 1 c fir nodule on left l ter l testicle. It is fixed nd nontender. E ididy is nontender. No inguin l or fe or l herni s.” (These findings are suspicious for testicular carcinoma, the most common form of cancer in men between ages 15 and 35 years).


241

Aids to Interpretation Table 13-1 Ab n o rm a lit ie s o f t h e P e n is a n d S c ro t u m

Hy p o s p a d ia s

S c ro t a l Ed e m a

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.

Finge rs ca n ge t a bove ma s s

P e y ro n ie D is e a s e

Hyd ro c e le

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.

Finge rs ca nnot ge t a bove ma s s

C a r c in o m a o f t h e P e n is

S c ro t a l He r n ia

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.

242


Table 13-2 S e xu a lly Tra n s m it t e d In fe c t io n s o f Ma le Ge n it a lia

G e n it a l Wa r t s (C o n d y lo m a t a Ac u m in a t a ) ■

■

■

■

■

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 cauliflower-like (verrucous). Causative organism: Human papillomavirus (HPV), usually from subtypes 6, 11; carcinogenic subtypes rare, approximately 5%–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.

G e n it a l He r p e s S im p le x ■

■

■

■

■

Appearance: Small scattered or grouped vesicles, 1–3 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: 2–7 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.


243

Table 13-2 S e xu a lly Tra n s m it t e d In fe c t io n s o f Ma le Ge n it a lia (continued )

P r im a ry S y p h ilis ■

■

■

■

■

■

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 3–8 weeks. Causative organism: Treponema pallidum, a spirochete. Incubation: 9–90 days after exposure. May develop inguinal lymphadenopathy within 7 days; lymph nodes are rubbery, nontender, mobile. 20%–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; four variants, so difficult to identify).

C h a n c ro id ■

■

■

■

■

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: 3–7 days after exposure. Painful inguinal adenopathy; suppurative bobos in 25% of patients. Need to distinguish from: primary syphilis; genital herpes simplex; lymphogranuloma venereum, granuloma inguinale from Klebsiella granulomatis (both rare in the United States).

244


Table 13-3 Ab n o rm a lit ie s o f t h e Te s t is

C ry p t o r c h id is m

S m a ll Te s t is

Ac u t e O r c h it is

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.

In adults, testicular length is usually ≤3.5 cm. Small, firm testes seen in Klinefelter syndrome, usually ≤2 cm. Small, soft testes suggesting atrophy seen in cirrhosis, myotonic dystrophy, use of estrogens, and hypopituitarism; may also follow 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.

Ea rly

Tu m o r o f t h e Te s t is

Usually appears as a painless nodule. Any nodule within the testis warrants investigation for malignancy.

La te

As a testicular neoplasm grows and spreads, it may seem to replace the entire organ. The testicle characteristically feels heavier than normal.


245

Table 13-4 Ab n o rm a lit ie s o f t h e Ep id id ym is a n d S p e rm a t ic Co rd

Ac u t e Ep id id y m it is

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.

S p e r m a t o c e le a n d Cy s t o f t h e Ep id id y m is

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.

Va r ic o c e le o f t h e S p e r m a t ic C o r d

To r s io n o f t h e S p e r m a t ic C o r d

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.

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.

246


Table 13-5 He rn ia s in t h e Gro in In d ir e c t In g u in a l

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.

D ir e c t In g u in a l

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.

Fe m o r a l

Least common hernia, more common in women than in men. Originates below inguinal ligament, more lateral than inguinal hernia. Never enters scrotum.

14 C H A P T E R

Female Genitalia The Health History Com m on Conce rns ● ● ● ● ● ●

Men rche, enstru tion, eno use, ost eno Pregn ncy Vulvov gin l sy to s Sexu l he lth Pelvic in— cute nd chronic Sexu lly tr ns itted infections (STIs)

us l bleeding

Me n a rc h e , Me n s t ru a t io n , Me n o p a u s e , P o s t m e n o p a u s a l Ble e d in g ; P re g n a n c y. For the menstrual history, ask when menstrual periods began (age at menarche).

When did her last menstrual period (LMP) start, and the one prior menstrual period (PMP)? What is the interval between periods, from the rst day of one to the rst day of the next? Are menses regular or irregular? How long do they last? How heavy is the ow?

Changes in the interval between periods can signal possible pregnancy or menstrual irregularities.

Amenorrhea is the absence of periods. Failure to begin periods is primary amenorrhea, whereas cessation of established periods is secondary amenorrhea.

Secondary amenorrhea from pregnancy, lactation, menopause; low body weight from conditions of malnutrition, a norexia nervosa, stress, chronic illness, and hypothalamic–pituitary–ovarian dysfunction

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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 bleeding in threatened abortion or dysfunctional uterine bleeding

Dysmenorrhea, or painful menses, is common.

Primary dysmenorrhea from increased prostaglandin production; secondary dysmenorrhea from endometriosis, a denomyosis, pelvic infla mmatory disease, and endometrial polyps

Menopause, the absence of menses for 12 consecutive months, usually occurs between 48 and 55 years. Associated symptoms include hot ashes, ushing, sweating, and sleep disturbances.

Postmenopausa l bleeding, or bleeding occurring 6 months after cessation of menses, from endometrial cancer, hormone replacement therapy (HRT), or uterine or cervical polyps

Vu lvo va g in a l S ym p t o m s . For vaginal discharge and local itching, inquire about amount, color, consistency, and odor of discharge.

See Table 14-1, Lesions of the Vulva, pp. 258–259; and Table 14-2, Vaginal Discharge, p. 260.

S e xu a l He a lt h . Ask neutral questions about sexual orientation and gender identity: “Are you currently dating, sexually active, or in a relationship?” “How would you identify your sexual orientation?” Then, “How would you describe your gender identity?” and “Do you use protection such as birth control or condoms? . . . Has anyone ever tried to touch or have sex with you without your consent?”

To assess sexual health, be nonjudgmental. Ask “How is sex for you?” “Are you having any problems with sex? This includes sexual intercourse and anal and oral sex.” Or, “Are you satis ed with your sex life as it is now?”

Chapter 14 | Female Genitalia

249

Direct questions help you assess desire, arousal, and orgasm. “Do you have an interest in (appetite for) sex?” “Do you get sexually aroused?” “Are you able to reach climax?” Ask also about dyspareunia, or discomfort or pain during intercourse.

Superficial pain suggests local inflammation, atrophic vaginitis, or inadequate lubrication; deeper pain may result from pelvic disorders or pressure on a normal ovary.

P e lvic P a in . Assess acute and chronic (>6 months) pelvic pain.

Acute pelvic pain in PID, ruptured ovarian cyst, appendicitis; ectopic pregnancy; also mittelschmerz, ruptured ovarian cyst, tubo-ovarian abscess. Chronic pelvic pain in endometriosis, PID, adenosis and fibroids, history of sexual abuse; pelvic floor spasm.

S e xu a lly Tra n s m it t e d In fe c t io n . 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.

Health Promotion and Counseling: Evidence and Recommendations Im p o r t a n t T o p ic s f o r H e a lt h P r o m o t io n a n d C o u n s e lin g ● ● ● ● ●

Cervic l c ncer screening Ov ri n c ncer STIs nd HIV infection O tions for f ily l nning Meno use nd hor one re l ce ent ther

y

Ce r vic a l Ca n c e r S c re e n in g . In 2012, ve major societies released common guidelines for cervical cancer screening.

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C u r r e n t C e r v ic a l C a n c e r S c r e e n in g G u id e lin e s f o r A v e r a g e -R is k W o m e n a : U S P S T F , A C S / A S C C P / A S C P , a nd ACOG Va r ia b le

Re c o m m e n d a t io n

Age t which to begin screening Screening ethod nd interv l

21 ye rs Ages 21–65 ye rs: cytology every 3 ye rs OR Ages 21–29 ye rs: cytology every 3 ye rs Ages 3 –65 ye rs: cytology lus HPV testing (for high-risk or oncogenic HPV ty es) every 5 ye rs Age >65 ye rs, ssu ing three consecutive neg tive results on cytology or two consecutive neg tive results on cytology lus HPV testing within 1 ye rs before cess tion of screening, with the ost recent test erfor ed within 5 ye rs Not reco ended

Age t which to end screening

Screening fter hysterecto y with re ov l of the cervix

USPSTF, U.S. Preventive Services T sk Force; ACS/ASCCP/ASCP, A eric n C ncer Society/ A eric n Society for Col osco y nd Cervic l P thology/A eric n Society for Clinic l P thology; ACOG, A eric n College of Obstetrici ns nd Gynecologists; HPV, hu n illo virus. a Definition of Average Risk: No history of high-gr de, rec ncerous cervic l lesion (cervic l intr e itheli l neo l si gr de 2 or ore severe lesion) or cervic l c ncer; not i unoco ro ised (including being HIV-infected); nd no in utero ex osure to diethylstilbestrol. Source: S w y GF, Kul sing S, Denberg T, et l. Cervic l c ncer screening in ver ge-risk wo en: best r ctice dvice fro the Clinic l Guidelines Co ittee of the A eric n College of Physici ns. Ann Intern Med. 2 15;162:851.

The most important risk factor for cervical cancer is HPV infection from HPV strains 16, 18, 6, or 11. The three-dose HPV vaccination series prevents HPV infection from the strains when given before sexual exposure at age 11 years. The vaccine is also recommended for unvaccinated and immunocompromised girls and women up to age 26 years. Ova ria n Ca n c e r. There are no effective screening tests to date. Risk factors include family history of breast or ovarian cancer and BRCA1 or BRCA2 mutation. Watch for the nonspeci c symptoms of new abdominal distention, abdominal bloating, and urinary frequency. S TIs a n d HIV In fe c t io n . Assess risk factors by taking a careful sexual history and counseling patients about spread of disease and ways to reduce high-risk practices. Chlamydia trachomatis is the most commonly reported STI in the United States and the most common STI in women. The CDC


251

and the USPSTF strongly recommend screening for STIs as summarized in the box below. C D C S T D a n d H IV S c r e e n in g R e c o m m e n d a t io n s 2 0 1 4 ●

●

●

● ●

Chl ydi nd gonorrhe screening nnu lly for ll sexu lly ctive wo en ges <25 ye rs nd older wo en with risk f ctors such s new or ulti le sex rtners, or sex rtner infected with n STD. Chl ydi , sy hilis, he titis B, nd HIV screening for ll regn nt wo en nd gonorrhe screening for t-risk regn nt wo en st rting e rly in regn ncy, with re e t testing s needed to rotect the he lth of others nd their inf nts. Chl ydi , gonorrhe , nd sy hilis screening t le st once ye r for ll sexully ctive g y, bisexu l, nd other MSM. MSM who h ve ulti le or nonyous rtners should be screened ore frequently for STDs (i.e., t 3- to 6- onth interv ls). HIV testing t le st once for ll dults nd dolescents fro ges 13–64 ye rs. HIV testing t le st once ye r for nyone h ving uns fe sex or using injection drug equi ent. Sexu lly ctive g y nd bisexu l en y benefit fro testing every 3–6 onths.

Source: Centers for Dise se Control nd Prevention. Sexu lly tr ns itted dise ses. STD nd HIV screening reco end tions. U d ted Dece ber 16, 2 14. Av il ble t htt :/ / www. cdc.gov/std/ revention/screeningreccs.ht . Accessed M y 2 , 2 15.

Op t io n s fo r Fa m ily P la n n in g . More than half of U.S. pregnancies are unintended. Counsel women, particularly adolescents, about the timing of ovulation, midway in the regular menstrual cycle. Discuss methods for contraception and their effectiveness. O p t io n s f o r F a m ily P la n n in g Me t h o d s

Ty p e s o f C o n t r a c e p t io n

Natural

Fertility w reness/ eriodic bstinence, withdr w l, l ct tion M le condo , fe le condo , di hr g , cervic l c , s onge Intr uterine device, subder l i l nt of levonorgestrel S er icide, or l contr ce tives (estrogen nd rogesterone; rogestin only), estrogen/ rogesterone inject bles nd tch, horon l v gin l contr ce tive ring, e ergency contr ce tion Tub l lig tion; tr nscervic l steriliz tion; v secto y

Barrier Implantable Pharmacologic/ hormonal

Surgery (permanent)

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Me n o p a u s e a n d Ho rm o n e Re p la c e m e n t Th e ra p y. Be familiar with the psychological and physiologic changes of menopause. Help the patient to weigh the risks of HRT, including increased risk of stroke, pulmonary embolism, and breast cancer.

Techniques of Examination T ip s f o r t h e S u c c e s s f u l P e lv ic E x a m in a t io n Th e P a t ie n t ●

●

●

Avoids intercourse, douching, or use of v gin l su ositories for 24–48 hours before ex in tion E ties bl dder before ex in tion Lies su ine, with he d nd shoulders elev ted, r s t sides or folded cross chest to enh nce eye cont ct nd reduce tightening of bdo in l uscles

Th e Ex a m in e r ● ●

●

● ● ● ●

●

Obt ins er ission; selects ch erone Ex l ins e ch ste of the ex in tion in dv nce Dr es tient fro id bdo en to knees; de resses dr e between knees to rovide eye cont ct with tient Avoids unex ected or sudden ove ents Chooses s eculu th t is the correct size W r s s eculu with t w ter Monitors co fort of the ex in tion by w tching the tient’s f ce Uses excellent but gentle technique, es eci lly when inserting the s eculu

Male examiners should be accompanied by female chaperones. Female examiners should be assisted whenever possible. EXAMINATIO N TECHNIQ UES


E x t e r n a l G e n it a lia Observe pubic hair to assess sexual maturity.

Normal or delayed puberty

Examine the external genitalia (Fig. 14-1).

See Table 14-1, Lesions of the Vulva, pp. 258–259.

■ Labia minora

Ulceration in herpes simplex, syphilitic chancre; inflammation in Bartholin cyst

■ Clitoris

Enlarged in masculinization

■ Urethral ori ce

Urethral ca runcle or prolapse; tenderness in interstitial cystitis



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Mons pubis La bia ma jora

P re puce

La bia minora

Clitoris Ure thra l me a tus

Hyme n Va gina

Ope ning of pa ra ure thra l (S ke ne ) gla nd Ve s tibule

Ope ning of Ba rtholin gla nd

Introitus Pe rine um

Anus

Fig ure 14-1 Exte rnal fe m ale ge nitalia. ■ Introitus

Imperforate hymen

Milk the urethra for discharge if indicated.

Discharge of urethritis

In t e r n a l G e n it a lia a n d P a p S m e a r Locate the cervix with a gloved and water-lubricated index nger. Assess support of vaginal outlet by asking patient to strain down. Enlarge the introitus by pressing its posterior margin downward. Insert a water-lubricated speculum of suitable size. Start with speculum held obliquely (Fig. 14-2), then rotate to horizontal position for full insertion (Fig. 14-3).

Cystocele, cystourethrocele, rectocele

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Fig ure 14-2 Entry angle .


Fig ure 14-3 Care fully ins e rt the s pe culum to full le ngth.

Open the speculum gently and inspect cervix: ■ Position

Cervix faces forward if uterus is retroverted.

■ Color

Purplish in pregnancy

■ Shape of the cervical os

Oval (normal) or slit-like or transverse os from delivery; raised, friable, or lobed wart-like lesions in condylomata or cervical cancer (see Table 14-3, Abnormalities of the Cervix, p. 261)

(Fig. 14-4); epithelial surface (squamous–columnar epithelial junction)

Columna r e pithe lium

Exte rna l os of the ce rvix

S qua mocolumna r junction Tra ns forma tion zone

S qua mous e pithe lium

Fig ure 14-4 Ce rvical e pithe lial s urface . ■ Any discharge or bleeding

Discharge from os in mucopurulent cervicitis from Chlamydia or gonorrhea (see Table 14-2, Vaginal Discharge, p. 260)

■ Any ulcers, nodules, or masses

Herpes, polyp, cancer


255



Obtain specimens for cytology (Pap smears) with:

Early cancer before it is clinically evident

■ An endocervical broom

(Fig. 14-5) 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.

Fig ure 14-5 Endoce rvical broom . Bluish color and deep rugae in pregnancy; vaginal cancer (rare); vaginal discharge from infection from Candida, Trichomonas vaginalis, bacterial vaginosis (see Table 14-2, Vaginal Discharge, p. 260)

Palpate, by means of a bimanual examination (Fig. 14-6): ■ The cervix and fornices

Pain on moving cervix in PID

■ The uterus

Pregnancy, myomas; soft isthmus in early pregnancy (see Table 14-4, Positions of the Uterus and Uterine Myomas, p. 262)

■ Right and left adnexa (ovaries)

Ovarian cysts or masses, salpingitis, PID, tubal pregnancy

Fig ure 14-6 Palpate the ce rvix, ute rus , and adnexa.

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Assess strength of pelvic muscles. With your vaginal ngers clear of the cervix, ask patient to tighten her muscles around your ngers as hard and long as she can. / When indicated, perform a rectovaginal examination as shown in Figure 14-7 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. 269).

H e r n ia s Ask the woman to strain down, as you palpate for a bulge in:

P O SSIBLE FIN DIN G S A firm squeeze that compresses your fingers, moves them up and inward, and lasts more than 3 seconds is full strength (see Table 14-5, Relaxations of the Pelvic Floor, p. 263).

Retroverted uterus

Fig ure 14-7 Exam ine the re ctovaginal are a.

■ The femoral canal

Femoral hernia

■ The labia majora up to just

Indirect inguinal hernia

lateral to the pubic tubercle

S p e c ia l T e c h n iq u e As s e s s in g Ure t h rit is . Insert your index nger into the vagina and milk the urethra gently outward from the inside (Fig. 14-8). Note any discharge.

Discharge in C. trachomatis and Neisseria gonorrhoeae infection

Fig ure 14-8 Milk the ure thra if indicate d.


257

Recording Your Findings R e c o r d in g t h e F e m a le G e n it a lia E x a m in a t io n “No inguin l deno thy. Extern l genit li without erythe , lesions, or sses. V gin l ucos ink. Cervix rous, ink, nd without disch rge. Uterus nterior, idline, s ooth, nd not enl rged. No dnex l tenderness. P s e r obt ined. Rectov gin l w ll int ct. Rect l v ult without sses. Stool brown nd He occult neg tive.” OR “Bil ter l shotty inguin l deno thy. Extern l genit li without erythe or lesions. V gin l ucos nd cervix co ted with thin, white ho ogeneous disch rge with ild fishy odor. After sw bbing cervix, no disch rge visible in cervic l os. Uterus idline; no dnex l sses. Rect l v ult without sses. Stool brown nd He occult neg tive.” (These findings suggest bacterial vaginosis.)

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Aids to Interpretation Table 14-1 Le s io n s o f t h e Vu lva Ep id e r m o id Cy s t

Cys tic nodule in s kin

Ve n e r e a l Wa r t (C o n d y lo m a Ac u m in a t u m )

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.

Warty lesions on the labia and within the vestibule suggest condyloma acuminata from infection with human papillomavirus.

Wa rts

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.

G e n it a l He r p e s

S ha llow ulce rs on re d ba s e s


259

Table 14-1 Le s io n s o f t h e Vu lva (continued ) S y p h ilit ic C h a n c r e

A firm, painless ulcer suggests the chancre of primary syphilis. Because most chancres in women develop internally, they often go undetected.

S e c o n d a ry S y p h ilis (C o n d y lo m a La t u m )

Slightly raised, round or oval flat-topped papules covered by a gray exudate suggest condylomata lata, a manifestation of secondary syphilis. They are contagious. Fla t, gra y pa pule s

C a r c in o m a o f t h e Vu lva

An ulcerated or raised red vulvar lesion in an elderly woman may indicate vulvar carcinoma.

260


Table 14-2 Va g in a l Dis ch a rg e Note: Accurate diagnosis depends on laboratory assessment and cultures. Tr ic h o m o n a s va g in it is

Dis charg e : Yellowish green, often profuse, may be malodorous Othe r Sym pto m s : Itching, vaginal soreness, dyspareunia Vulva: May be red Vag ina: May be normal or red, with red spots, petechiae Laboratory Assessment: Saline wet mount for trichomonads

C a n d id a va g in it is

Dis charge : White, curdy, often thick, not malodorous Othe r Sym pto m s : Itching, vaginal soreness, external dysuria, dyspareunia Vulva: Often red and swollen Vag ina: Often red with white patches of discharge Labo rato ry As s e s s m e nt: KOH preparation for branching hyphae

Ba c t e r ia l va g in o s is

Lactoba cilli

Dis charg e : Gray or white, thin, homogeneous, scant, malodorous Othe r Sym pto m s : Fishy genital odor Vulva: Usually normal Vag ina: Usually normal Laboratory Assessment: Saline wet mount for “clue cells,” “whiff test” with KOH for fishy odor


261

Table 14-3 Ab n o rm a lit ie s o f t h e Ce r vix En d o c e r v ic a l p o ly p . A bright

red, smooth mass that protrudes from the os suggests a polyp. It bleeds easily.

M u c o p u r u le n t c e r v ic it is . A

yellowish exudate emerging from the cervical os suggests infection from Chlamydia, gonorrhea (often asymptomatic), or herpes.

C a r c in o m a o f t h e c e r v ix .

An irregular hard mass suggests carcinoma from HPV infection. Early lesions are best detected by pap smear and HPV screening, followed by colposcopy. Columna r e pithe lium Colla r

Va gina l a de nos is

Fe t a l e x p o s u r e t o d ie t h y ls t ilb e s t ro l (D ES ). 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.

262


Table 14-4 P o s it io n s o f t h e Ut e ru s a n d Ut e rin e Myo m a s A n a n t e ve r t e d u t e r u s 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 r e t ro ve r t e d u t e r u s is tilted posteriorly

with its cervix facing anteriorly.

A r e t ro f le xe d u t e r u s 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 m yo m a o f t h e u t e r u s 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 retrodisplaced uterus; one on the anterior surface may be mistaken for an anteverted uterus.


263

Table 14-5 Re la xa t io n s o f t h e P e lvic Flo o r When the pelvic floor is weakened, various structures may become displaced. These displacements are seen best when the patient strains down. A c y s t o c e le is a bulge of the anterior

wall of the upper part of the vagina, together with the urinary bladder above it.

A c y s t o u r e t h ro c e le involves both the

bladder and the urethra as they bulge into the anterior vaginal wall throughout most of its extent.

A r e c t o c e le is a bulge of the posterior

vaginal wall, together with a portion of the rectum.

A p ro la p s e d u t e r u s 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.

15 C H A P T E R

The Anus, Rectum, and Prostate The Health History C o m m o n o r C o n c e r n in g S y m p t o m s ● ● ● ● ● ● ●

Ch nge in bowel h bits Blood in the stool P in with defec tion; rect l bleeding or tenderness An l w rts or fissures We k stre of urine Burning with urin tion Blood in urine

Ask about any change in bowel habits or stool size or caliber, and any diarrhea or constipation. Is there any blood in the stool, or dark tarry stools? Any mucus in the stool?

Pencil-like stool or blood in stool in colon cancer; dark tarry stools if polyps, carcinoma, gastrointestinal bleeding; mucus in villous adenoma, inflammatory bowel disease (IBD), or irritable bowel syndrome (IBS)

Any pain with defecation, or rectal bleeding or tenderness?

Hemorrhoids; proctitis from sexually transmitted infections (STIs)

Any anal warts, ssures, or ulcerations?

Human papillomavirus (HPV), condylomata lata in secondary syphilis; fissures in Crohn disease, proctitis from receptive anal intercourse, ulcerations of herpes simplex, or chancres of primary syphilis

In men, is there dif culty starting the urine stream or holding back urine? Is the ow weak? What about frequent urination, especially 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 ca ncer, especially in men age ≥70 years. The American Urological Association (AUA) Symptom Index helps quantify BPH severity (see Table 15-1, BPH Symptom Score Index: American Urological Association (AUA), p. 271).

265

266



Prost te c ncer screening Colorect l c ncer screening Counseling for sexu lly tr ns itted infections

P ro s t a t e Ca n c e r S c re e n in g . Prostate cancer is the leading nonskin cancer diagnosed in the United States and the second leading cause of death in men. Risk factors are age, family history of prostate cancer, and African American ethnicity.

Screening methods such as prostate-speci c antigen (PSA) test and the digital rectal examination (DRE) are not highly accurate, which complicates decisions about screening men without symptoms. Th e P S A . PSA screening remains controversial, so warrants shared

decision making about risks and benefits and patient preferences. About 12% of men have a PSA screening test above 4 ng/mL, but only 30% of these men have prostate cancer on biopsy. At 4 ng/mL, PSA sensitivity is 21% and specificity is 91%. See recommendations of major societies below.

P r o s t a t e C a n c e r S c r e e n in g G u id e lin e s A m e r ic a n U ro lo g ic a l A s s o c ia t io n

Sh red decision king Age to begin offering screening Aver ge-risk High-risk Age to sto offering screening Screening tests

Yes

4 ye rs 4 ye rs Life ex ect ncy <1 ye rs PSA DRE (o tion l)

A m e r ic a n C a n c e r S o c ie t y

Yes (consider using decision id)

5 ye rs 4 –45 ye rs Life ex ect ncy <1 ye rs PSA DRE (o tion l)

U n it e d S t a t e s P r e ve n t ive S e r v ic e s Ta s k Fo r c e

Yes (when tient requests screening) No reco

end tion

No reco

end tion

No reco

end tion (continued )

Chapter 15 | The Anus, Rectum, and Prostate

P r o s t a t e C a n c e r S c r e e n in g G u id e lin e s A m e r ic a n U ro lo g ic a l A s s o c ia t io n

Frequency of screening Bio sy referr l criteri

Annu l

Am e r ic a n C a n c e r S o c ie t y

Annu l (bienni l when PSA <2.5 ng/ L) PSA ≥4 ng/ L Abnor l DRE Individu lized risk ssess ent for PSA levels 2.5–4 ng/ L

267

(Continued )

U n it e d S t a t e s P r e ve n t ive S e r v ic e s Ta s k Fo r c e

No reco

end tion

No reco

end tion

Abbrevi tions: PSA, rost te-s ecific ntigen; DRE, digit l rect l ex

in tion.

Th e D RE. reaches only the posterior and lateral surfaces of the prostate,

missing findings in the anterior and central areas. DRE sensitivity for prostate cancers is only 59%. Encourage men with symptomatic disorders such as incomplete emptying of the bladder, urinary frequency or urgency, weak or intermittent stream or straining to initiate ow, hematuria, nocturia, or even bony pains in the pelvis to seek evaluation and treatment early. C o lo r e c t a l C a n c e r S c r e e n in g . In 2008, screening recommendations were revised to promote more aggressive surveillance: ■ Clinicians should rst identify whether patients are at average or

increased risk, ideally by age 20 years. High-risk factors include a personal history of colorectal neoplasia or long-standing IBD—or a family history of colorectal neoplasia, including hereditary syndromes. People at increased risk should undergo colonoscopy at intervals ranging from 3 to 5 years. ■ Average-risk patients 50 years or older should be offered a range of

screening options to increase compliance: annual screening with highsensitivity fecal occult blood tests (including guaiac-based Hemoccult tests and fecal immunochemical tests), colonoscopy every 10 years, or sigmoidoscopy every 5 years (which can be combined with highsensitivity fecal occult blood testing performed every 3 years). Co u n s e lin g fo r S TIs . Anal intercourse increases risk for HIV and STIs. Promote abstinence from high-risk behaviors, use of condoms, vaccination for hepatitis B and HPV, and good hygiene.

268




Wear gloves to examine the anus, rectum, and prostate (Fig. 15-1).

Bla dde r P e ritone a l re fle ction Va lve of Hous ton

S e mina l ve s icle Re ctum Anore cta l junction Ana l ca na l Ure thra

P ros ta te

Fig ure 15-1 Anus and re ctum —s agittal view.

M a le Position the patient on his side, or standing leaning forward over the examining table and hips exed (Fig. 15-2).

Figure 15-2 Position the patie nt on the le ft side .

Inspect the: ■ Sacrococcygeal area

Pilonidal cyst or sinus

■ Perianal area

Hemorrhoids, warts, herpes, chancre, cancer, fissures from proctitis, STIs, or Crohn disease, fistula from anorectal abscess



269


Palpate the anal canal and rectum with a lubricated and gloved nger. Palpate the:

Lax sphincter tone in some neurologic disorders; tightness in proctitis

■ Walls of the rectum

Cancer of the rectum, polyps

■ Prostate gland, as shown in

Prostate nodule or cancer (Fig. 15-4); BPH; tenderness in prostatitis

Figure 15-3, including median sulcus

Fig ure 15-3 Palpate the pros tate

Fig ure 15-4 Re ctal cance r.

gland.

Try to palpate above the prostate for irregularities or tenderness, if indicated.

/

See Table 15-2, Abnormalities on Rectal Examination, pp. 272–273.

F e m a le

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)

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Recording Your Findings R e c o r d in g t h e A n u s , R e c t u m , a n d P r o s t a t e E x a m in a t io n “No erirect l lesions or fissures. Extern l s hincter tone int ct. Rect l v ult without sses. Prost te s ooth nd nontender with l ble edi n sulcus. (Or in fe le, uterine cervix nontender.) Stool brown nd He occult neg tive.” OR “Perirect l re infl ed; no ulcer tions, w rts, or disch rge. C nnot ex ine extern l s hincter, rect l v ult, or rost te bec use of s s of extern l s hincter nd rked infl tion nd tenderness of n l c n l.” (These findings suggest proctitis from infectious cause.) OR “No erirect l lesions or fissures. Extern l s hincter tone int ct. Rect l v ult without sses. Left l ter l rost te lobe with 1 × 1 c fir h rd nodule; right l ter l lobe s ooth; edi l sulcus is obscured. Stool brown nd He occult neg tive.” (These findings are suspicious for prostate cancer.)


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Aids to Interpretation Table 15-1 BP H S ym p t o m S c o re In d e x: Am e ric a n Uro lo g ic a l As s o c ia t io n (AUA) Score or ask the patient to score each of the questions below on a scale of 1 to 5, with 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, and 5 = almost always. Higher scores (maximum 35) indicate more severe symptoms; scores ≤7 are considered mild and generally do not warrant treatment. PA RT A

S c o re

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. Intermittency: 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 For Part B, 0 = none, 1 = 1 time, 2 = 2 times, 3 = 3 times, 4 = 4 times, 5 = 5 times. PA RT B

S c o re

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.

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Table 15-2 Ab n o rm a lit ie s o n Re c t a l Exa m in a t io n Ex t e r n a l He m o r r h o id s (Th ro m b o s e d ). Dilated

hemorrhoidal veins that originate below the pectinate line, covered with skin; a tender, swollen, bluish ovoid mass is visible at the anal margin.

A n a l Fis s u r e . Painful longitudinal

oval ulceration usually in posterior midline with swollen sentinel tag just below it.

S e ntine l ta g

Fis s ure

A n o r e c t a l Fis t u la . An

inflammatory tract or tube opening inside the anus or rectum and also onto the perianal area or into another viscus. Ope ning

Fis tula

P o ly p s o f t h e Re c t u m . A soft

mass that may or may not be on a stalk; may not be palpable.


Table 15-2 Ab n o rm a lit ie s o n Re c t a l Exa m in a t io n (continued ) Be n ig n P ro s t a t ic Hy p e r p la s ia .

An enlarged, nontender, smooth, firm but slightly elastic prostate gland; can cause symptoms without palpable enlargement.

Ac u t e P ro s t a t it is . A prostate that

is very tender, swollen, and firm because of acute infection.

C a n c e r o f t h e P ro s t a t e . A hard

area in the prostate that may or may not feel nodular.

C a n c e r o f t h e Re c t u m . Firm,

nodular, rolled edge of an ulcerated cancer.

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16

C H A P T E R

The Musculoskeletal System

Fundamentals for Assessing Joints Musculoskeletal disorders are the leading primary diagnosis during of ce visits in the United States. Your rst goal is to assess four key features of the patient’s complaint. Is the joint problem: ■ Articular or extra-articular; ■ Acute (usually <6 weeks) or chronic (usually >12 weeks); ■ In ammatory or nonin ammatory; and ■ Localized (monoarticular) or diffuse (polyarticular)?

Assessing joints requires knowledge of each joint’s structure and function. Learn the surface landmarks and underlying anatomy of each of the major joints. Use the descriptive terms below.

J o in t A n a t o m y —Im p o r t a n t T e r m s ●

●

Articular structures include the joint capsule nd articular cartilage, the synovium nd synovial fluid, intra-articular ligaments, nd juxta-articular bone. Articul r c rtil ge is co osed of coll gen trix cont ining ch rged ions nd w ter, llowing the c rtil ge to ch nge sh e in res onse to ressure or lo d, cting s cushion for underlying bone. Synovi l fluid rovides nutrition to the dj cent rel tively v scul r rticul r c rtil ge. Extra-articular structures include eri rticul r lig ents, tendons, burs e, uscle, f sci , bone, nerve, nd overlying skin. ● Ligaments re ro e-like bundles of coll gen fibrils th t connect bone to bone. ● Tendons re coll gen fibers connecting uscle to bone. ● Bursae re ouches of synovi l fluid th t cushion the ove ent of tendons nd uscles over bone or other joint structures.

275

276


Age also provides clues to causes of joint pain. C o m m o n C a u s e s o f J o in t P a in b y A g e Ag e <6 0 Ye a r s ●

●

●

●

Re etitive str in or overuse syndro es (tendinitis, bursitis) Cryst lline rthritis (gout; cryst lline yro hos h te de osition dise se [CPPD]) Rheu toid rthritis (RA), sori tic rthritis nd re ctive (Reiter) rthritis (in infl tory bowel dise se [IBD]) Infectious rthritis fro gonorrhe , Ly e dise se, or vir l or b cteri l infections

Ag e >6 0 Ye a r s

●

Osteo rthritis (OA) Osteo orotic fr cture Gout nd seudogout

●

Poly y lgi rheu

●

Se tic b cteri l rthritis

● ●

tic (PMR)

Review the three primary types of joint articulation—synovial, cartilaginous, and brous—and the varying degrees of movement each type allows. Note that joint anatomy determines its function and range of motion. T y p e s o f J o in t s S y n o v ia l J o in t s ●

●

● ● ●

●

●

●

Liga me nt S ynovia l me mbra ne J oint s pa ce J oint ca ps ule S ynovia l cavity Articula r ca rtila ge

Freely ov ble within li its of surrounding lig ents Se r ted by articular cartilage nd synovial cavity Lubric ted by synovi l fluid Surrounded by joint c sule Example: knee, shoulder

C a r t ila g in o u s J o in t s ●

Bone

Slightly ov ble Cont in fibroc rtil ginous discs th t se r te the bony surf ces H ve centr l nucleus pulposus of discs th t cushions bony cont ct Example: vertebr l bodies

Ve rte bra l body Nucle us pulpos us of the dis c Disc Liga me nt

Fib ro u s J o in t s ● ● ● ●

No reci ble ove ent Consist of fibrous tissue or c rtil ge L ck joint c vity Example: skull sutures

Chapter 16 | The Musculoskeletal System

277

Review the types of synovial joints and their associated features as well. T y p e s o f S y n o v ia l J o in t s S p h e ro id a l (b a ll a n d s o c k e t )

Articul r sh e: Convex surf ce in conc ve c vity Move ent: Wide-r nging flexion, extension, bduction, dduction, rot tion, circu duction Ex le: Shoulder, hi Hin g e

Articul r sh e: Fl t, l n r Move ent: Motion in one l ne; flexion, extension Ex le: Inter h l nge l joints of h nd nd foot; elbow C o n d y la r

Articul r sh e: Convex or conc ve Move ent: Move ent of two rticul ting surf ces, not dissoci ble Ex le: Knee; te oro ndibul r joint

The Health History C o m m o n o r C o n c e r n in g S y m p t o m s ●

●

● ●

Joint in: rticul r or extr - rticul r, cute or chronic, infl noninfl tory, loc lized or diffuse Joint in: ssoci ted constitution l sy to s nd syste ic fro other org n syste s Neck in Low b ck in

tory or nifest tions

278


Assess the seven features of any joint pain (see p. 47). T ip s f o r A s s e s s in g J o in t P a in ●

●

●

Ask the tient to “ oint to the in.” This y s ve consider ble ti e bec use ny tients h ve trouble in ointing in loc tion in words. Cl rify nd record when the in st rted nd the ech nis of injury, rticul rly if there is history of tr u . Deter ine whether the in is rticul r or extr - rticul r, cute or chronic, infl tory or noninfl tory, nd loc lized ( ono rticul r) or diffuse ( oly rticul r).

J o in t Pa in A r t ic u la r o r Ex t r a -a r t ic u la r.

Ask “Do you have any pains in your joints?” Ask the patient to point to the pain. If localized and involving only one joint, it is monoarticular.

See Table 16-1, Patterns of Pain in and Around the Joints, p. 304. Consider trauma, monoarticular arthritis, tendinitis, 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

If pain is extra-articular, are there generalized “aches and pains” (myalgia if in muscles, arthralgia if in joints with no evidence of arthritis)?

Bursitis if inflammation of bursae; tendinitis if in tendons, and tenosynovitis if in tendon sheaths; also sprains from stretching or tearing of ligaments

Ask if there is decreased joint movement or stiffness.

In articular pain, decreased active and passive range of motion and morning stiffness (“gelling”); in nonarticular joint pain, periarticular tenderness and only passive range of motion intact

Ac u t e o r C h ro n ic . Acute joint

Severe pain of rapid onset in red swollen joint in acute septic arthritis or crystalline arthritis (gout; CPPD). In children, osteomyelitis in bone contiguous to a joint.

pain typically lasts up to 6 weeks; chronic pain lasts >12 weeks. Assess the timing, quality, and severity of joint symptoms.


279

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?

See Table 16-1, Patterns of Pain in and Around the Joints, p. 304.

In f la m m a t o ry o r N o n in f la m m a t o ry. Is the problem inflamma-

If inflammatory, consider infectious causes (Neisseria gonorrhoeae or Mycobacterium tuberculosis), crystal-induced (gout, pseudogout), immune -related (RA, SLE), reactive (rheumatic fever, reactive arthritis), or idiopathic arthritis. If noninflammatory, consider trauma (rotator cuff tear), repetitive use (bursitis, tendinitis), OA, fibromyalgia.

tory or noninflammatory? Is there fever, chills, tenderness, warmth, or redness?

Assess any stiffness or limitations of motion.

Morning stiffness that gradually improves with activity in inflammatory disorders like RA and PMR; intermittent stiffness and gelling in OA

Lo c a liz e d o r D iff u s e . Ask the

Monoarticular arthritis in traumatic, crystalline, or septic arthritis; oligoarticular arthritis gonorrhea or rheumatic fever, connective tissue disease, and OA; polyarthritis if may be viral or inflammatory from RA, SLE, or psoriasis

patient to point to the joints that are painful to determine if joint pain is be monoarticular, oligoarticular involving two to four joints, or polyarticular. J o in t P a in : A s s o c ia t e d C o n s t it u t io n a l S y m p t o m s a n d S y s t e m ic M a n if e s t a t io n s f ro m O t h e r O r g a n S y s t e m s . Assess constitutional symptoms such as fever, chills, rash, fatigue, anorexia, weight loss, and weakness.

Common in RA, SLE, PMR, and other inflammatory arthritides. High fever and chills suggest an infectious cause.

Ne c k P a in . 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, p. 305.

If the patient reports neck trauma, common in motor vehicle accidents, ask about neck tenderness and consider clinical decision rules

280


that identify risk of cervical cord injury (NEXUS criteria and Canadian C-Spine Rule). Lo w Ba c k P a in . There are numerous clinical guidelines, but most categorize low back pain into three groups: nonspeci c (>90%), nerve root entrapment with radiculopathy or spinal stenosis ( 5%), and pain from a speci c underlying disease (1% to 2%). Ask, “Do you have any pains in your back?” and “Is the pain in the midline over the vertebrae, or off midline?”

See Table 16-3, Low Back Pain, pp. 306– 307. Midline back pa in in vertebral collapse, disc herniation, epidural abscess, spinal cord compression, or spinal cord metastases. Pain off the midline in muscle strain, sacroiliitis, trochanteric bursitis, sciatica, hip arthritis, renal conditions such as pyelonephritis or renal stones

If the pain radiates into the legs, ask about any associated numbness, tingling, or weakness. Ask about history of trauma.

Scia tica if radicular gluteal and posterior leg pain in the S1 distribution that increases with cough or Valsalva

Check for bladder or bowel dysfunction.

Present in cauda equina syndrome from S2–S4 tumor or disc herniation, especially if “saddle anesthesia”from perianal numbness

Elicit any “red ags” for serious underlying systemic disease. R e d F la g s f o r Lo w B a c k P a in f r o m U n d e r ly in g S y s t e m ic D is e a s e ● ● ● ● ● ● ● ● ● ●

Age <2 ye rs or >5 ye rs History of c ncer Unex l ined weight loss, fever, or decline in gener l he lth P in l sting ore th n 1 onth or not res onding to tre t ent P in t night or resent t rest History of intr venous drug use, ddiction, or i unosu ression Presence of ctive infection or hu n i unodeficiency virus (HIV) infection Long-ter steroid ther y S ddle nesthesi , bl dder or bowel incontinence Neurologic sy to s or rogressive neurologic deficit


281


Nutrition, weight, nd hysic l ctivity Low b ck in Osteo orosis: risk f ctors, screening, nd ssessing fr cture risk Tre ting osteo orosis nd reventing f lls

Nu t rit io n , We ig h t , a n d P h ys ic a l Ac t ivit y. Good nutrition supplies the calcium and vitamin D needed for bone mineralization and bone density, with supplements advised in selected age groups. 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. P h y s ic a l A c t iv it y G u id e lin e s f o r A m e r ic a n s ●

●

At le st 2 hours nd 3 inutes week of oder te-intensity, or 1 hour nd 15 inutes week of vigorous-intensity, aerobic physical activity, or n equiv lent co bin tion Moder te- or high-intensity muscle-strengthening activity th t involves ll jor uscle grou s on 2 or ore d ys week

Lo w Ba ck P a in . The estimated lifetime prevalence of low back pain in the U.S. population is over 80%. Most patients with acute low back pain get better within 6 weeks; for patients with nonspeci c symptoms, clinical guidelines emphasize reassurance, staying active, analgesics, muscle relaxants, and spinal manipulation therapy. About 10% to 15% of these patients develop chronic symptoms, often associated with long-term disability. Poor outcomes are linked to inappropriate beliefs about low back pain as a serious clinical condition, maladaptive pain-coping behaviors (avoiding work, movement, or other activities for fear of causing back damage), multiple nonorganic physical examination ndings, psychiatric disorders, poor general health, high levels of baseline functional impairment, and low work satisfaction. O s t e o p o ro s is : Ris k Fa c t o r s , S c re e n in g , a n d As s e s s in g Fra c t u r e Ris k . Osteoporosis is a major public health threat and a common U.S. health problem—9% of adults over age 50 years have

282


osteoporosis at the femoral neck or lumbar spine, including 16% of women and 4% of men. Half of all postmenopausal women sustain an osteoporosis-related fracture during their lifetime; 25% develop vertebral deformities, and 15% suffer hip fractures that increase risk of chronic pain, disability, loss of independence, and increased mortality. The U.S. Preventive Services Task Force (USPSTF) gives a grade B recommendation supporting osteoporosis screening for women age ≥65 years and for younger women whose 10-year fracture risk equals or exceeds that of an average-risk 65-year-old white woman. R is k F a c t o r s f o r O s t e o p o r o s is ● ● ● ● ● ● ● ●

Post eno us l st tus in wo en Age ≥5 ye rs Prior fr gility fr cture Low body ss index Low diet ry c lciu Vit in D deficiency Tob cco nd excessive lcohol use F ily history of fr cture in firstdegree rel tive, rticul rly with history of fr gility fr cture

●

●

Clinic l conditions such s thyrotoxicosis, celi c s rue, IBD, cirrhosis, chronic ren l dise se, org n tr ns l nt tion, di betes, HIV, hy ogon dis , ulti le yelo , norexi nervos , nd rheu tologic nd utoi une disorders Medic tions such s or l nd high-dose inh led corticosteroids, ntico gul nts (long-ter use), ro t se inhibitors for bre st c ncer, ethotrex te, selected ntiseizure edic tions, i unosu ressive gents, roton- u inhibitors (long-ter use), nd ntigon d l ther y for rost te c ncer

■ Use the country-speci c FRAX calculator to assess fracture risk. If risk

is >9.3% for any fracture and >3% for hip fracture, bone density screening is warranted. The website 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. W o r ld H e a lt h O r g a n iz a t io n B o n e D e n s it y C r it e r ia Osteoporosis: T score <−2.5 (>2.5 st nd rd devi tions below the young dult white wo en) Osteopenia: T score between −1. dult e n)

e n for

nd −2.5 (1. to 2.5 SDs below the young


283

Tre a t in g Os t e o p o ro s is a n d P re ve n t in g Fa lls . Learn the therapeutic uses of agents that inhibit bone resorption: calcium and vitamin D; antiresorptive agents such as bisphosphonates, selective estrogen-receptor modulators (SERMs), calcitonin, and postmenopausal estrogen; and anabolic agents such as PTH.

More than one in three adults over age 65 years falls each year. Risk factors for falls include increasing age, impaired gait and balance, postural hypotension, loss of strength, medication use, comorbid illness, depression, cognitive impairment, and visual de cits. The USPSTF gives a grade B recommendation for providing exercise or physical therapy and/or vitamin D supplementation to prevent falls among at-risk community-dwelling adults age ≥65 years. Effective exercise interventions target balance, gait, and strength training. Urge patients to correct poor lighting, dark or steep stairs, chairs at awkward heights, slippery or irregular surfaces, and ill- tting shoes. Scrutinize any medications affecting balance, especially benzodiazepines, vasodilators, and diuretics.

Techniques of Examination S t e p s f o r E x a m in in g t h e J o in t s 1. Ins ect for joint sy etry, lign ent, bony defor ities, nd swelling 2. Ins ect nd l te surrounding tissues for skin ch nges, nodules, uscle tro hy, tenderness 3. Assess r nge of otion nd neuvers to test joint function nd st bility nd the integrity of lig ents, tendons, burs e, es eci lly if in or tr u 4. Assess ny re s of infl tion, es eci lly tenderness, swelling, w r th, redness

Inspect and palpate any joints with signs of in ammation. T h e F o u r S ig n s o f In f la m m a t io n ●

●

Swelling. P l ble swelling y involve: (1) the synovi l e br ne, which c n feel boggy or doughy; (2) effusion fro excess synovi l fluid within the joint s ce; or (3) soft tissue structures, such s burs e, tendons, nd tendon she ths. Warmth. Use the b cks of your fingers to co re the involved joint with its un ffected contr l ter l joint, or with ne rby tissues if both joints re involved. (continued )

284


T h e F o u r S ig n s o f In f la m m a t io n ●

●

(Continued)

Redness. Redness of the overlying skin is the le st co on sign of infl tion ne r the joints nd is usu lly seen in ore su erfici l joints like fingers, toes, nd knees. Pain or tenderness. Try to identify the s ecific n to ic structure th t is tender.



T e m p o r o m a n d ib u la r J o in t Inspect the temporomandibular joint (TMJ) for swelling or redness. Palpate the TMJ as the patient opens and closes the mouth (Fig. 16-1). Palpate the muscles of mastication: the masseters, temporal muscles, and pterygoid muscles. Fig ure 16-1 Palpate the TMJ.

S h o u ld e r s 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. 308.

Palpate: ■ The clavicle from the sternocla-

“Step -offs”if fracture from trauma

vicular joint to the acromioclavicular joint (Fig. 16-2) ■ The bicipital tendon

Fig ure 16-2 Palpate the bicipital groove and te ndon.



■ The subacromial and subdeltoid

bursae after lifting arm posteriorly (Fig. 16-3) S uba cromia l burs a

285

P O SSIBLE FIN DIN G S Subacromial or subdeltoid bursitis; tenderness over the SITS (Supraspinatus, Infraspinatus, Teres minor, and Subscap ularis) muscle insertions and difficulty abducting the arm above shoulder level occurs in sprains, tears, tendon rupture of rotator cuff.

Rota tor cuff

Fig ure 16-3 Palpate the s ubacrom ial burs a.

Assess range of motion. ■ Flexion—“Raise your arm in

front of you and overhead.” ■ Extension—“Move your arms

behind you.”

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

■ Abduction—“Raise your arms

out to the side and overhead.” ■ Adduction—“Cross your arm in

front of your body, keeping the arm straight.”

Acromioclavicular joint arthritis

286



■ External and internal rotation

P O SSIBLE FIN DIN G S Shoulder arthritis

(Figs. 16-4 and 16-5)

Fig ure 16-4 Te s t abduction and

Fig ure 16-5 Te s t adduction and

exte rnal rotation.

inte rnal rotation.

Perform ve maneuvers to assess the “SITS” muscles of the rotator cuff and the bicipital tendon.

Pain or inability to perform these maneuvers in rotator cuff sprains, tendinitis, rupture

F iv e M a n e u v e r s f o r S IT S M u s c le A s s e s s m e n t P a in P ro vo c a t io n Te s t

180º

Painful arc test (Fig. 16-6). Fully dduct the tient’s r fro to 18 degrees.

120º No pa in

S uba cromia l pa in

90ºº S uba cromia l pa in

60º

No pa in

0º

Fig ure 16-6 Painful arc te s t. (continued )



287


F iv e M a n e u v e r s f o r S IT S M u s c le A s s e s s m e n t

(Continued)

S t r e n g t h Te s t s ●

External rotation lag test (Fig. 16-7). With the tient’s r flexed to 9 degrees with l u , rot te the r into full extern l rot tion.

9900 º 90º fle llee xio io on

200 º a bduction n

Fig ure 16-7 Inte rnal rotation lag te s t. ●

Internal rotation lag test (Fig. 16-8). Ask the tient to l ce the dorsu of the h nd on the low b ck with the elbow flexed to 9 degrees. Then you lift the h nd off the b ck, which further intern lly rot tes the shoulder. Ask the tient to kee the h nd in this osition.

90 90º fle xion xion

Fig ure 16-8 Exte rnal rotation lag te st. ●

Drop-arm test (Fig. 16-9). Ask the tient to fully bduct the r to shoulder level, u to 9 degrees, nd lower it slowly. Note th t bduction bove shoulder level, fro 9 to 12 degrees, reflects ction of the deltoid uscle.

Fig ure 16-9 Drop arm te s t. C o m p o s it e Te s t

External rotation resistance test (Fig. 16-10). Ask the tient to dduct nd flex the r to 9 degrees, with the thu bs turned u . St bilize the elbow with one h nd nd ly ressure roxi l to the tient’s wrist s the tient resses the wrist outw rd in extern l rot tion. Fig ure 16-10 Exte rnal rotation re s is tance te s t.

288




E lb o w s Inspect and palpate: ■ Olecranon process

Olecranon bursitis; posterior dislocation from direct trauma or supracondylar fracture

■ Medial and lateral epicondyles

Tenderness distal to epicondyle in epicondylitis (medial → “tennis elbow”; lateral → “pitcher’s elbow”)

■ Extensor surface of the ulna

Rheumatoid nodules

■ Grooves between the epicon-

Tender in arthritis

dyles and the olecranon Ask patient to:

o˚

■ Flex and extend elbows ■ Turn forearms and palms up and

down (supination and pronation), as shown in Figure 16-11

S upina tion

P rona tion

Fig ure 16-11 Elbow s upination and pronation.

W r is t s a n d H a n d s Inspect: ■ Movement of the wrist ( exion,

Guarded movement in injury

extension, ulnar and medial deviation), hands, and ngers ■ Contours of wrists, hands, and

ngers

■ Contours of palms

Asymmetric DIP, PIP deformities in OA; symmetric deformities in PIP, MCP, wrist joints in RA; swelling in arthritis, ganglia; impaired alignment of fingers in flexor tendon damage; flexion contractures in Dupuytren contractures Thenar atrophy in median nerve compression (carpal tunnel syndrome); hypothenar atrophy in ulnar nerve compression



289


Palpate: ■ Wrist joints (Fig. 16-12)

Swelling and tenderness in rheuma toid a rthritis, gonococcal infection of joint or extensor tendon sheaths

Fig ure 16-12 Palpate the w ris t joint.

■ Distal radius and ulna

Tenderness over ulnar styloid in Colles fracture

■ “Anatomic snuffbox,” the hollow

Tenderness suggests scaphoid fracture. Tenderness over extensor and abductor tendons in de Quervain tenosynovitis.

space distal to the radial styloid bone; thumb extensor and abductor tendons (Fig. 16-13).

Fig ure 16-13 Palpate the anatom ic s nuffbox.

■ Metacarpophalangeal joints

(Fig. 16-14)

Fig ure 16-14 Palpate the MCP joints .

Swelling in rheumatoid arthritis

290



■ Proximal and distal interphalan-

geal joint

P O SSIBLE FIN DIN G S Proximal nodules in RA; Bouchard (PIP) and Heberden (DIP) nodes in OA

Assess range of motion: ■ Wrists: Flexion, extension,

Arthritis, tenosynovitis

adduction (radial deviation), abduction (lateral deviation) ■ Fingers: Flexions, extension,

Trigger finger, Dupuytren contracture

abduction/adduction (spread ngers apart and back) ■ Thumbs (Figs. 16-15 to 16-18)

Fig ure 16-15 Flexion.

Fig ure 16-16 Exte ns ion.

Fig ure 16-17 Abduction and adduction.

Figure 16-18 Opposition.



291


Perform selected maneuvers. ■ Hand grip strength (Fig. 16-19)

■ Thumb movement (Fig. 16-20)

Te ndon

Fig ure 16-19 Te s t grip s tre ngth. Decreased grip strength if weakness of finger flexors or intrinsic hand muscles

Fig ure 16-20 Te s t thum b function. Pain if de Quervain tenosynovitis

■ Carpal tunnel testing ■

Thumb adduction (Fig. 16-21)

Fig ure 16-21 Te s t thum b abduction. Weakness of abductor pollicis longus is specific to the median nerve.

■

Tinel sign: Tap lightly over median nerve at volar wrist (Fig. 16-22)

Fig ure 16-22 Te s t Tine l s ign. Aching, tingling, and numbness in second, third, and fourth fingers is a positive Tinel sign.

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EXAMINATIO N TECHNIQ UES ■

Phalen sign: Patient exes wrists for 60 seconds (Fig. 16-23)

P O SSIBLE FIN DIN G S Aching, tingling, and numbness in second, third, and fourth volar fingers is a positive Phalen sign.

Fig ure 16-23 Te s t Phale n s ign.

S p in e 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 buttocks.

Scoliosis, pelvic tilt, unequal leg length

Identify and palpate (Fig. 16-24):

S pinous proce s s of L5 ve rte bra Inte rve rte bra l joint be twe e n L5 a nd s a crum Pos te riors upe rior ilia c s pine S a croilia c joint

Pa rave rte bra l mus cle s

S a croilia c notch S cia tic ne rve

Is chia l tube ros ity a nd s ite of is chia l burs a

Fig ure 16-24 Palpate the bony landm arks and m us cle s of the back. ■ Spinous processes of each

vertebra

Tender if trauma, infection; “step -offs”in spondylolisthesis, fracture



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■ Sacroiliac joints

Sacroiliitis, ankylosing spondylitis

■ Paravertebral muscles, if painful

Paravertebral muscle spasm in abnormal posture, degenerative and inflammatory muscle disorders, overuse

■ Sciatic nerve (midway between

Herniated disc or nerve root compression

greater trochanter and ischial tuberosity), Figure 16-25 S cia tic ne rve Gre a te r trocha nte r

Is chia l tube ros ity

Fig ure 16-25 Palpate the s ciatic ne rve .

Test the range of motion in the neck and spine in: exion, extension, rotation, and lateral bending.

Decreased mobility in arthritis

H ip s Inspect gait (Fig. 16-26) for:

He els trike

Foot flat

Mids ta nce

Fig ure 16-26 The s tance phas e of gait.

Pus h-off

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■ Stance (see Fig. 16-26) and swing

(foot moves forward, does not bear weight) ■ Width of base (usually 2 to

4 inches from heel to heel), shift of pelvis, exion of knee

P O SSIBLE FIN DIN G S Most problems arise during the weightbearing stance phase.

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: ■ Bony landmarks: anterior—iliac

crest and tubercle, anteriorsuperior iliac spine, greater trochanter, pubic tubercle; posterior—posterior-superior iliac spine, greater trochanter, ischial tuberosity, sacroiliac joint ■ Along the inguinal ligament.

Bulges in inguinal hernia, aneurysm

Identify the Nerve–Artery– Vein–Empty space–Lymph node (NAVEL). ■ The trochanteric bursa, on the

greater trochanter of the femur (Fig. 16-27)

Focal tenderness in trocha nteric bursitis, often described by patients as “low back pain”

Trocha nte ric burs a

Is chioglute a l burs a

Fig ure 16-27 Trochante ric and is chioglute al burs ae .

■ The ischiogluteal bursa, super -

cial to the ischial tuberosity

Tender in bursitis (“weaver’s bottom”) from prolonged sitting




Check range of motion, including: ■ Flexion—“Bend your knee and

pull it against your abdomen.” (Fig. 16-28)

Flexion of opposite leg suggests deformity of that hip.

Fig ure 16-28 Hip flexion and flatte ning of lum bar lordosis .

■ Extension (Fig. 16-29)

Painful in iliopsoas abscess

Fig ure 16-29 Abduct the le g. ■ Abduction and adduction

Restricted in hip arthritis

■ Internal and external rotation

Restricted in hip arthritis

(Fig. 16-30)

Fig ure 16-30 Te st inte rnal and exte rnal rotation of the hip.

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296




Kn e e s Identify the medial (Fig. 16-31) and lateral structures of the knee.

Me dia l fe mora l condyle Adductor tube rcle Pa te lla r te ndon Me dia l tibia l pla te a u

Me dia l fe mora l e picondyle Me dia l colla te ra l liga me nt Ans e rine burs a

Tibia l tube ros ity

Fig ure 16-31 Me dial com partm e nt of the kne e .

Inspect: ■ Gait for knee extension at heel

strike, exion during all other phases of swing and stance

Stumbling or “giving way”during heel strike in qua driceps weakness or abnormal patellar tracking

■ Alignment of knees

Bowlegs, knock-knees; flexion contractures in limb paralysis or hamstring tightness.

■ Contours of knees, including

Quadriceps atrophy with patellofemoral disorder; swelling over the patella in prepatellar bursitis (housemaid’s knee), over the tibial tubercle in infrapatellar or if more medial anserine bursitis

any atrophy of the quadriceps muscles

Inspect and palpate:

See Table 16-5, Painful Knees, pp. 309–310.

■ The tibiofemoral joint—with

knees exed, including: ■

Joint line—place thumbs on either side of the patellar tendon.

Irregular, bony ridges in osteoarthritis.



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■

Medial and lateral meniscus

Tenderness if meniscus tear

■

Medial and lateral collateral ligaments

Tenderness if MCL tear (LCL injuries less common)

■ The patellofemoral compart-

ment: ■

Patella

Swelling over the patella in prepatellar bursitis (“housemaid’s knee”)

■

Palpate the patellar tendon and ask patient to extend the leg.

Tenderness or inability to extend the leg in partial or complete tear of the patellar tendon

■

Press the patella against the underlying femur.

Pain, crepitus, and a history of knee pain in patellofemoral disorder

■

Push patella distally and ask patient to tighten knee against table.

Pain during contraction of quadriceps in chondroma lacia

■ Also: ■

Suprapatellar pouch

Swelling in synovitis and arthritis

■

Infrapatellar spaces (hollow areas adjacent to patella)

Swelling in arthritis

■

Medial tibial condyle

Swelling in pes anserine bursitis

■

Popliteal surface

Popliteal or Baker cyst

Assess any effusions. ■ Bulge sign (minor effusions):

Compress the suprapatellar pouch, stroke downward on medial surface (Fig. 16-32), apply pressure to force uid to lateral surface (Fig. 16-33), and then tap knee behind lateral margin of patella (Fig. 16-34).

A fluid wave returning to the medial surface after a lateral tap confirms an effusion—a positive “bulge sign.”

298



Fig ure 16-32 Milk dow nward.


Fig ure 16-33 Apply m e dial pre s s ure .

Fig ure 16-34 Tap and w atch for fluid w ave . ■ Balloon sign (major effusions):

A palpable fluid wave is a positive sign.

Compress suprapatellar pouch with one hand; with thumb and nger of other hand, feel for uid entering the spaces next to the patella (Fig. 16-35).

Fig ure 16-35 Te s t for the balloon s ign.

■ Ballotte the patella (major effu-

sion): Push the patella sharply against the femur; watch for uid returning to the suprapatellar space.

Visible wave is a positive sign.



299


Assess range of motion: exion, extension, internal and external rotation. Use maneuvers to assess menisci and ligaments. ■ Medial meniscus and lateral

meniscus—McMurray test (Fig. 16-36): With the patient supine, grasp the heel and ex the knee. Cup your other hand over the knee joint with ngers 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. ■ Medial collateral ligament

(Fig. 16-37): With knee slightly exed, push medially against lateral surface of knee with one hand and pull laterally at the ankle with the other hand (abduction or valgus stress).

Click or pop along the medial joint with valgus stress, external rotation, and leg extension in tear of posterior medial meniscus.

Fig ure 16-36 McMurray te s t.

Pain or a gap in the medial joint line points to a partial or complete MCL tear.

Fig ure 16-37 Me dial collate ral ligam e nt te s t.

300



■ Lateral collateral ligament (LCL)

(Fig. 16-38): With knee slightly exed, 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).

P O SSIBLE FIN DIN G S Pain or a gap in the lateral joint line points to a partial or complete LCL tear.

Fig ure 16-38 Late ral collate ral ligam e nt te s t.

■ Anterior cruciate ligament (ACL)

(Fig. 16-39): (1) With knee exed, place thumbs on medial and lateral joint line and place ngers on hamstring insertions. Pull tibia forward, observe if tibia slides forward “like a drawer.” Compare to opposite knee.

Forward slide of proximal tibia is a positive a nterior drawer sign in ACL laxity or tear.

Fig ure 16-39 Ante rior cruciate ligam e nt te s t.

(2) Lachman test (Fig. 16-40): 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

Fig ure 16-40 Lachm an te s t.



■ Posterior cruciate ligament

301

P O SSIBLE FIN DIN G S Isolated PCL tears are rare.

(PCL): Posterior drawer sign (Fig. 16-41): Position patient and hands as in the ACL test. Push the tibia posteriorly and observe for posterior movement, like a drawer sliding posteriorly.

Fig ure 16-41 Pos te rior cruciate ligam e nt te s t (pos te rior drawe r s ign).

A n k le s a n d F e e t Inspect ankles and feet.

Hallux valgus, corns, calluses

Palpate: ■ Ankle joint

Tender joint in arthritis

■ Ankle ligaments: medial-deltoid;

Tenderness in sprain: lateral ligaments weaker, making inversion injuries (ankle bows outward, heel bows inward) more common

lateral-anterior and posterior talo bular, calcaneo bular ■ Achilles tendon

Rheumatoid nodules, tenderness in tendinitis

■ Compress the metatarsophalan-

Tenderness in arthritis, Morton neuroma third and fourth MTP joints; inflammation of first MTP joint in gout

geal joints; then palpate each joint between the thumb and fore nger (Figs. 16-42 and 16-43).

Fig ure 16-42 Palpate the MTP joints .

Fig ure 16-43 Palpate the m e tatars al he ads .

302




Assess range of motion. ■ Dorsi ex and plantar ex the

ankle (tibiotalar joint). ■ Stabilize the ankle and

Arthritic joint often painful when moved in any direction; sprain, when injured ligament is stretched. Ankle sprain

invert (Fig. 16-44) and evert (Fig. 16-45) the heel (subtalar or talocalcaneal joint).

Fig ure 16-44 Inve rt the he e l. ■ Stabilize the heel and invert

Fig ure 16-45 Eve rt the he e l. Trauma, arthritis

(Fig. 16-46) and evert (Fig. 16-47) the forefoot (transverse tarsal joints).

Fig ure 16-46 Inve rt the fore foot. ■ Move proximal phalanx of each

toe up and down (metatarsophalangeal joints).

Fig ure 16-47 Eve rt the fore foot.



303


S p e c ia l T e c h n iq u e s Me a s u rin g Le g Le n g t h . 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.

/ Me a s u rin g Ra n g e o f Mo t io n . 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 indicated by red lines (Fig. 16-48).

A flexion deformity of 45 degrees and further flexion to 90 degrees (45 degrees → 90 degrees) 160 ˚

90 ˚

45 ˚ 0˚

Figure 16-48 Degrees of elbow flexion.

Recording Your Findings R e c o r d in g t h e M u s c u lo s k e le t a l S y s t e m E x a m in a t io n “Full r nge of otion in ll joints. No evidence of swelling or defor ity.” OR “Full r nge of otion in ll joints. H nd with degener tive ch nges of Heberden nodes t the dist l inter h l nge l joints, Bouch rd nodes t roxi l inter h l nge l joints. Mild in with flexion, extension, nd rot tion of both hi s. Full r nge of otion in the knees, with oder te cre itus; no effusion but boggy synoviu nd osteo hytes long the tibiofe or l joint line bil ter lly. Both feet with h llux v lgus t the first et t rso h l nge l joints.” (These findings suggest osteoarthritis.)

304


Aids to Interpretation Table 16-1 P a t t e rn s o f P a in in a n d Aro u n d t h e J o in t s

Rh e u m a t o id A r t h r it is

O s t e o a r t h r it is (D e g e n e r a t ive J o in t D is e a s e , o r D J D )

P ro c e s s

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

Co m m o n Lo c a t io n s

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

Pa tt e rn o f S p re a d

Symmetrically additive: progresses to other joints; persists in initial ones

Additive; however, sometimes only one joint affected

On s e t

Usually insidious

Usually insidious

P ro g r e s s io n and D u r a t io n

Often chronic, with remissions and exacerbations

Slowly progressive, with exacerbations after overuse

A s s o c ia t e d S ym p t o m s

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


305

Table 16-2 P a in s in t h e Ne ck Pa tt e rn s

P h y s ic a l S ig n s

M e c h a n ic a l N e c k P a in

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.

M e c h a n ic a l N e c k P a in — Wh ip la s h

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 20–40% 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.

C e r v ic a l Ra d ic u lo p a t h y — f ro m n e r ve ro o t c o m p r e s s io n

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.

C e r v ic a l M ye lo p a t h y —f ro m c e r v ic a l c o r d c o m p r e s s io n

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 sign: neck flexion with resulting sensation of electrical shock radiating down the spine. Confirmation of cervical myelopathy warrants neck immobilization and neurosurgical evaluation.

306


Table 16-3 Lo w Ba ck P a in Pa tt e rn s


M e c h a n ic a l Lo w Ba c k P a in

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.

S c ia t ic a (Ra d ic u la r Lo w Ba c k P a in )

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.

Lu m b a r S p in a l S t e n o s is

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


307

Table 16-3 Lo w Ba ck P a in (continued ) Pa tt e rn s


C h ro n ic Ba c k S t iff n e s s

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

N o c t u r n a l Ba c k P a in , U n r e lie ve d b y Re s t

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.

P a in Re f e r r e d f ro m t h e A b d o m e n o r P e lv is

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.

308


Table 16-4 P a in fu l S h o u ld e r s Ac ro m io c la v ic u la r A r t h r it is

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.

S u b a c ro m ia l a n d S u b d e lt o id Bu r s it is

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.

Ro t a t o r C u ff Te n d in it is

Tenderness over the rotator cuff, when elbow passively lifted posteriorly or with five maneuvers (pp. 286–287).

Bic ip it a l Te n d in it is

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.


309

Table 16-5 P a in fu l Kn e e s 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. Burs itis . Inflammation and thickening of bursa seen in repetitive motion Iliotibia l and overuse syndromes. ba nd Can involve prepatellar bursa (“housemaid’s knee”), pes anserine bursa medially (runners, osteoarthritis), iliotibial band laterally (over lateral femoral condyle), especially in runners.

P re pa te lla r burs a

Pes a ns e rine

Pate llo fe m o ral ins tability. 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.

P a te lla move s up a nd la te ra l

Le g e xte nds a nd foot ra is e s

La te ra l me nis cus

Me dia l me nis cus torn

Me nis cal te ar. 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. (table continues on page 310)

310


Table 16-5 P a in fu l Kn e e s (continued )

Ante rior crucia te liga me nt torn

Me dia l colla te ra l liga me nt torn

Ba ke r cys t

P os te rior kne e

Ante rio r cruciate te ar o r s prain. 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. Co llate ral ligam e nt s prain o r te ar. 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. Bake r cys t. 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.

17 C H A P T E R

The Nervous System Fundamentals for Assessing the Nervous System A pproa ch to A s s e s s m e nt

The history and neurologic examination respond to four guiding questions. These questions are not answered separately, but iteratively as you learn about the patient during the interview and establish your neurologic ndings. To acquire the skills of nervous system examination, it is important to test your physical ndings against those of your teachers and neurologists to re ne your clinical expertise.

G u id in g Q u e s t io n s f o r E x a m in a t io n o f t h e N e rvous S y s te m ● ●

● ●

Does the tient h ve neurologic dise se? If so, wh t is the loc liz tion of the lesion or lesions? Are your findings sy etric? Wh t is the tho hysiology of bnor l findings? Wh t is the reli in ry differenti l di gnosis?

C e n t r a l a n d P e r ip h e r a l N e r v o u s S y s t e m s Ce n t ra l Ne r vo u s S ys t e m . The central nervous system (CNS) consists of the brain and spinal cord. Th e Br a in . The brain has four regions: the cerebrum, the diencephalon,

the brainstem, and the cerebellum (Fig. 17-1). Each cerebral hemisphere is subdivided into frontal, parietal, temporal, and occipital lobes. The brain consists of gray matter and myelinated neuronal axons, or white matter. Important structures include the basal ganglia, the thalamus, the hypothalamus, the brainstem (midbrain, pons, and medulla), which connects the cortex with the spinal cord, the reticular activating (arousal) system linked to consciousness, and the cerebellum.

311

312


Frontal lobe

Pa rieta l lobe

Oc cipital lobe Diencephalon

Pituitary gland Midbrain Brains tem

Pons

Ce rebellum

Me dulla Fig ure 17-1 Right half of the brain, m e dial view. S p in a l C o r d . The spinal cord extends from the medulla to the first or

second lumbar vertebrae. The spinal cord: ■ is divided into ve segments: cervical (C1–C8), thoracic (T1–T12),

lumbar (L1–L5), sacral (S1–S5), and coccygeal. Its roots fan out like a horse’s tail at L1–L2, the cauda equina. ■ 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 the monosynaptic muscle stretch re exes.

P e rip h e ra l Ne r vo u s S ys t e m . 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 bers. C r a n ia l N e r ve s . The twelve pairs of cranial nerves (CNs) emerge from

the cranial vault through skull foramina and canals to structures in the head and neck. Some are limited to general motor and/or sensory functions, whereas others are specialized, serving smell, vision, or hearing (I, II, VIII). P e r ip h e r a l N e r ve s . 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. 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.

Chapter 17 | The Nervous System

313

The Health History C o m m o n o r C o n c e r n in g S y m p t o m s ● ● ● ● ● ● ●

He d che Dizziness or vertigo We kness (gener lized, roxi l, or dist l) Nu bness, bnor l or lost sens tions F inting or bl cking out (ne r-synco e nd synco e) Seizures Tre ors or involunt ry ove ents

He a d a c h e . Ask about location, severity, duration, and any associated symptoms, such as visual changes, weakness, or loss of sensation. Always elicit unusual headache warning signs, such as sudden onset “like a thunderclap,” onset after age 50 years, and associated symptoms such as fever and stiff neck, which warrant examination for papilledema and focal neurologic signs.

See Table 7-1, Primary Headaches, p. 128, and Table 7-2, Secondary Headaches, pp. 129–131. Subarachnoid hemorrhage may evoke “the worst headache of my life.”Dull headache especially on awakening and in the same location, especially when affected by examination maneuvers, may arise from mass lesions like a brain tumor or abscess.

Dizzin e s s o r Ve rt ig o . Dizziness or vertigo can have many meanings. Is the patient lightheaded or feeling faint (presyncope)? Is there unsteady gait from disequilibrium or ataxia, or true vertigo, a perception that the room is spinning or rotating?

Lightheadedness in palpitations; nearsyncope from vasovagal stimulation, low blood pressure, febrile illness, and others; vertigo in benign positional vertigo, Ménière disease, brainstem tumor

Are any medications contributing to dizziness? Are associated symptoms present, such as double vision (diplopia), dif culty forming words (dysarthria), or dif culty with gait or balance (ataxia)? Is there any weakness?

Diplopia, dysarthria, ataxia in vertebrobasilar transient ischemic a ttack (TIA) or stroke See Table 17-1, Types of Stroke, pp. 335– 336, and Table 17-2, Disorders of Speech, pp. 347–348. Weakness or paralysis in TIA or stroke

314


We a k n e s s . Distinguish proximal from distal weakness. For proximal weakness, ask about combing hair, reaching for things on a high shelf, dif culty getting out of a chair or taking a high step up.

Bilateral proximal limb weakness with intact sensation in myopathies from alcohol, drugs like glucocorticoids, and inflammatory muscle disorders like polymyositis and dermatomyositis

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 predominantly distal weakness, often with sensory loss, in polyneuropathy, as in diabetes

S e n s o ry Lo s s . Is there any loss of sensation or altered sensation such as tingling or pins and needles without an obvious stimulus (paresthesias)? Dysesthesias, or disordered sensations in response to a stimulus, may last longer than the stimulus itself.

Consider: paresthesias in hands and around the mouth in hyperventilation; local nerve compression or “entrap ment,”seen in hand numbness from median, ulnar, or radial nerve disorders; nerve root compression with dermatomal sensory loss from vertebral bone spurs or herniated discs; or central lesions from stroke or multiple sclerosis.

S yn c o p e . “Have you ever fainted or passed out?” leads to discussion of any loss of consciousness (syncope).

Syncope is complete but temporary loss of consciousness from decreased cerebral blood flow, commonly called fainting.

Get a complete description of the event including setting and triggers, any warning signs, position (standing, sitting, lying down), and duration. What brought on the episode? 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.

In myasthenia gravis, weakness is asymmetric and gets worse with effort (fatigability), and often has bulbar symptoms such as diplopia, ptosis, dysarthria, and dysphagia.

Consider:

vasovagal syncope, postural tachycardia syndrome, carotid sinus syncope, and orthostatic hypotension tachycardia and bradyarrhythmias, often with syncope of sudden onset and offset


Also ask if anyone observed the episode. What did the patient look like before, during, and after the episode? Was there any seizure-like movement of the arms or legs? Any incontinence of the bladder or bowel?

S e izu re . A seizure is a sudden excessive electrical discharge from cortical neurons, and may be symptomatic, with an identi able cause, or idiopathic. Elicit a careful history. Tre m o r s o r In vo lu n t a ry Mo ve m e n t s . Ask about any tremor, shaking, or body movements that the patient is unable to control. Does the tremor occur at rest? Get worse with voluntary intentional movement or with sustained postures?

315

Tonic–clonic motor activity, incontinence, and postictal state seizures. Unlike in syncope, tongue biting or bruising of limbs may occur.

may be loss of consciousness or abnormal feelings, thought processes, and sensations, including smells, as well as abnormal movements.

head trauma; alcohol, cocaine, and other insults from low or high glucose or low calcium or sodium; acute stroke; and meningitis or encephalitis. Low-frequency unilateral resting tremor, rigidity, and bradykinesia in Parkinson disease. Essential tremors if high-frequency, bilateral, upper extremity tremors that occur with both limb movement and sustained posture and subside when the limb is relaxed.

Health Promotion and Counseling: Evidence and Recommendations Im p o r t a n t T o p ic s f o r H e a lt h P r o m o t io n a n d C o u n s e lin g ● ● ● ● ●

Preventing stroke nd tr nsient ische ic tt ck (TIA) C rotid rtery screening Reducing risk of eri her l neuro thy Her es zoster v ccin tion Detecting the “three Ds”: deliriu , de enti , nd de ression

P re ve n t in g S t ro k e o r TIA. Cerebrovascular disease is the fourth leading cause of death in the United States. Stroke is a sudden neurologic de cit caused by cerebrovascular ischemia (87%) or hemorrhage (13%).

316


Hemorrhagic strokes may be intracerebral (10% of all strokes) or subarachnoid (3% of all strokes). Decreased vascular perfusion results in sudden focal but transient brain dysfunction in TIA, or in permanent neurologic de cits in stroke, as determined by neurodiagnostic imaging. Detecting TIAs is important—in the rst 3 months after a TIA, subsequent stroke occurs in approximately 15% of patients. A H A / A S A S t r o k e W a r n in g S ig n s a n d S y m p t o m s F A S

T

Face Drooping—Does one side of the f ce droo or is it nu b? Ask the erson to s ile. Is the erson’s s ile uneven? Arm Weakness—Is one r we k or nu b? Ask the erson to r ise both r s. Does one r drift downw rd? Speech Difficulty—Is s eech slurred? Is the erson un ble to s e k or h rd to underst nd? Ask the erson to re e t si le sentence, like “The sky is blue.” Is the sentence re e ted correctly? Time to call 9-1-1—If so eone shows ny of these sy to s, even if the sy to s go w y, c ll 9-1-1 nd get the erson to the hos it l i editely. Check the ti e so you’ll know when the first sy to s e red.

Beyond FAST: Other i ● ● ● ● ●

ort nt sy

to s

Sudden nu bness or we kness of the leg, r , or f ce Sudden confusion or trouble underst nding Sudden trouble seeing in one or both eyes Sudden trouble w lking, dizziness, loss of b l nce or coordin tion Sudden severe he d che with no known c use

AHA, A eric n He rt Associ tion; ASA, A eric n Stroke Associ tion.

Primary prevention of stroke requires aggressive management of risk factors and patient education. ■ Target modi able risk factors: hypertension, smoking, dyslipidemia,

excess weight, diabetes, poor diet and nutrition, physical inactivity, and alcohol use. ■ Address disease-speci c risk factors: atrial brillation, carotid artery

disease, and sleep apnea. Ca ro t id Ar t e ry S c re e n in g . Screen symptomatic patients with duplex ultrasound. The U.S. Preventive Services Task Force recommends against screening asymptomatic patients in the general population. Re d u c in g Ris k o f P e rip h e ra l Ne u ro p a t h y. In diabetics, promote optimal glucose control to reduce risk of sensorimotor polyneuropathy, autonomic dysfunction, mononeuritis multiplex, or diabetic neuropathy.


317

Examine diabetics regularly for neuropathy, including testing pinprick sensation, ankle re exes, vibration perception (with a 128-Hz tuning fork) and plantar light touch sensation (with a Semmes-Weinstein mono lament), as well as checking for skin breakdown, poor circulation, and musculoskeletal abnormalities. He rp e s Zo s t e r Va c c in a t io n . The herpes zoster vaccine reduces the short-term risks for zoster and postherpetic neuralgia in adults ≥50 years. The Advisory Committee on Immunization Practices (ACIP) currently recommends routinely offering onetime vaccination for adults ≥60 years; the vaccine is FDA-approved for adults ≥50 years. De t e c t in g t h e “ Th re e Ds ” : De liriu m , De m e n t ia , a n d De p re s s io n . Delirium is an acute confusional state marked by sudden onset, uctuating course, inattention and changes in the level of consciousness; it is often undetected. Learn to use the Confusional Assessment Method (CAM) algorithm. T h e C o n f u s io n A s s e s s m e n t M e t h o d (C A M ) D ia g n o s t ic A lg o r it h m 1. Acute ch nge in ent l st tus nd fluctu ting course ● Is there evidence of n cute ch nge in cognition fro b seline? ● Does the bnor l beh vior fluctu te during the d y? 2. In ttention ● Does the tient h ve difficulty focusing ttention? 3. Disorg nized thinking ● Does the tient h ve r bling or irrelev nt convers tions, uncle r or illogic l flow of ide s, or un redict ble switching fro subject to subject? 4. Abnor l level of consciousness ● Is the tient nything besides lert—hy er lert, leth rgic, stu orous, or co tose? Di gnosing deliriu

requires fe tures 1 nd 2 nd either 3 or 4.

Dementia is best assessed by the Mini-Mental State examination and the Mini-Cog (see Chapter 20, Table 20-3, p. 420), but may be dif cult to distinguish from benign forgetfulness and mild cognitive impairment. Depression is common in individuals with signi cant medical conditions. Ask the well-validated screening questions: “Have you been feeling down, depressed, or hopeless (depressed mood)?” and, “Have you felt little interest or pleasure in doing things (anhedonia)?” See also Chapter 20, The Older Adult, pp. 405–406, and Table 20-2, Delirium and Dementia, pp. 418–419.

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Techniques of Examination C r a n ia l N e r v e s a n d F u n c t io n No .

C r a n ia l N e r ve

Fu n c t io n

I II III

Olf ctory O tic Oculo otor

IV V

Trochle r Trige in l

VI VII

Abducens F ci l

VIII

Acoustic

IX

Glosso h rynge l

X

V gus

XI

S in l ccessory

XII

Hy ogloss l

Sense of s ell Vision Pu ill ry constriction, o ening the eye (lid elev tion), ost extr ocul r ove ents Downw rd, intern l rot tion of the eye Motor—te or l nd sseter uscles (j w clenching), l ter l terygoids (l ter l j w ove ent) Sensory—f ci l; the nerve h s three divisions: (1) o hth l ic, (2) xill ry, nd (3) ndibul r L ter l devi tion of the eye Motor—f ci l ove ents, including those of f ci l ex ression, closing the eye, closing the outh Sensory—t ste for s lty, sweet, sour, nd bitter subst nces on nterior two thirds of tongue; sens tion fro the e r He ring (cochle r division) nd b l nce (vestibul r division) Motor— h rynx Sensory— osterior ortions of the e rdru nd e r c n l, the h rynx, nd the osterior tongue, including t ste (s lty, sweet, sour, bitter) Motor— l te, h rynx, nd l rynx Sensory— h rynx nd l rynx Motor—sternocleido stoid; u er ortion of the tr ezius Motor—tongue



C r a n ia l N e r v e s CN I (Olfa c t o ry). Test sense of smell on each side.

Loss of smell in sinus conditions, head trauma, smoking, aging, cocaine use, Parkinson disease

CN II (Op t ic ). Assess visual acuity.

Blindness

Check visual elds.

Hemianopsia

Inspect optic discs.

Papilledema, optic atrophy, glaucoma



319


CN II, III (Op t ic a n d Oc u lo m o t o r). Test pupillary reactions to light. If abnormal, test reactions to near effort.

Blindness, CN III paralysis, tonic pupils; Horner syndrome may affect light reactions

CN III, IV, VI (Oc u lo m o t o r, Tro c h le a r, a n d Ab d u c e n s ). Assess extraocular movements.

Strabismus and binocular diplopia in CN III, IV, and VI neuropathy; diplopia in eye muscle disorders from myasthenia gravis, trauma, thyroid ophthalmopathy, and internuclear ophthalmoplegia; nystagmus

CN V (Trig e m in a l). Palpate the contractions of temporal and masseter muscles. Test pain and light touch sensations on face in (1) ophthalmic, (2) maxillary, and (3) mandibular zones (Fig. 17-2).

Motor or sensory loss from lesions of CN V or its higher motor pathways.

(1)

C2

(2) (3)

Figure 17-2 Te st for facial sensory loss.

Test corneal re exes (Fig. 17-3).

Fig ure 17-3 Te s t the corne al re flex.

CN VII (Fa c ia l). 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 palsy, or of CNS, as in a stroke. See Table 17-3, Types of Facial Paralysis, p. 339.

320




CN VIII (Ac o u s t ic ). Test hearing of whispered voice. If decreased: ■ Test for lateralization if unilateral

hearing loss (Weber test).

In unilateral sensorineural loss, sound is heard in the good ear where AC > BC. affected ear where BC > AC. See p. 125.

■ Compare air and bone conduction

(Rinne test).

CN IX, X (Glo s s o p h a ryn g e a l a n d Va g u s ). Observe any dif culty swallowing.

In sensorineural hearing loss, sound is heard longer through air than bone (AC > BC). In conductive loss sound is heard through bone longer than air (BC = AC or BC > AC). See p. 125.

A weakened palate or pharynx impairs swallowing.

Listen to the voice.

Hoarseness in vocal cord paralysis; nasal voice in paralysis of palate

Watch soft palate rise with “ah.”

Deviated uvula, palatal paralysis in CVA

Test gag re ex on each side.

Absent reflex is often normal.

CN XI (S p in a l Ac c e s s o ry). Trapezius muscles. Assess muscles for bulk, involuntary movements, and strength of shoulder shrug (Fig. 17-4).

Atrophy, fasciculations, weakness

Fig ure 17-4 Te s t trape zius s tre ngth.

Sternocleidomastoid muscles. Assess strength as head turns against your hand.

Weakness of sternocleidomastoid muscle when head turns to opposite side



321


CN XII (Hyp o g lo s s a l). 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.

In a unilateral cortical lesion, the protruded tongue deviates away from the side of cortical lesion; in CN XII lesion, tongue deviates to the weak side.

/ Th e M o t o r System

See Table 17-4, Motor Disorders, p. 340.

Bo d y P o s it io n . Observe the patient’s body position during movement and at rest.

Hemiplegia in stroke

In vo lu n t a ry Mo ve m e n t s . If present, observe location, quality, rate, rhythm, amplitude, and setting.

Tremors, fasciculations, tics, chorea, athetosis, oral–facial dyskinesias. See Table 17-5, Involuntary Movements, p. 341.

Mu s c le Bu lk a n d To n e . Inspect muscle contours.

Atrophy of bulk. See Table 17-6, Disorders of Muscle Tone, p. 342.

Assess resistance to passive stretch of arms and legs.

Spasticity, rigidity, flaccidity of tone

Mu s c le S t re n g t h . Test and grade the major muscle groups, with the examiner trying to overcome the strength of the patient’s resistance.

Is the pattern focal, from a lower motor neuron lesion in peripheral nerve or nerve root? Is there unilateral paralysis from an upper motor neuron cortical or subcortical lesion? Is there a symmetric distal weakness from polyneuropathy, or proximal weakness from myopathy? G r a d in g M u s c le S t r e n g t h Gra d e

1 2 3 4 5

D e s c r ip t io n

No uscul r contr ction detected A b rely detect ble tr ce of contr ction Active ove ent with gr vity eli in ted Active ove ent g inst gr vity Active ove ent g inst gr vity nd so e resist nce Active movement against full resistance (normal)

322




■ Flexion (C5, C6)—biceps and

brachioradialis and extension (C6, C7, C8)—triceps at the elbow ■ Wrist extension (C6, C7, C8,

radial nerve)—extensor carpi radialis longus and brevis

Peripheral radial nerve damage; central stroke or multiple sclerosis if hemiplegia

■ Grip (C7, C8, T1)

Weak grip in cervical radiculopathy, de Quervain tenosynovitis, carpal tunnel syndrome

■ Finger abduction (C8, T1, ulnar

Weak in ulnar nerve disorders

nerve) (Fig. 17-5)

Fig ure 17-5 Te s t finge r abduction.

■ Thumb opposition (C8, T1)—

median nerve (Fig. 17-6)

Fig ure 17-6 Te st oppos ition of the thum b.

■

Trunk— exion extension, lateral bending

Weak in carpal tunnel syndrome



■

323


/ Hip exion (L2, L3, L4)—iliopsoas (Fig. 17-7)

■ Hip extension (S1)—gluteus

maximus ■ Hip adduction (L2, L3, L4)—

adductors ■ Hip abduction (L4, L5, S1)—

Fig ure 17-7 Te s t hip flexion.

gluteus medius and minimus ■ Knee extension (L2, L3, L4)—

quadriceps ■ Knee exion (L4, L5, S1, S2)—

hamstrings ■ Ankle dorsi exion (L4, L5)—

tibialis anterior ■ Ankle plantar exion (S1)—

gastrocnemius, soleus Co o rd in a t io n . Test rapid alternating movements in hands (tap ngers), arms, and legs (tap foot) (Fig. 17-8)

Fig ure 17-8 Te s t rapid alte rnating arm m ove m e nt.

Clumsy, slow movements in cerebellar disease

324



Point-to-point movements in arms and legs— nger-to-nose, heel-toshin

P O SSIBLE FIN DIN G S Clumsy, unsteady movements in cerebellar disease

G a it . Ask patient to: ■ Walk away, turn, and come back

CVA, cerebellar ataxia, parkinsonism, or loss of position sense may affect performance.

■ Walk heel-to-toe

Ataxia

■ Walk on toes, then on heels

Corticospinal tract injury

■ Hop in place on each foot; do

Proximal hip girdle weakness increases risk of falls.

one-leg shallow knee bends. Substitute rising from a chair and climbing on a stool for hops and bends as indicated. 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. ■ Inspect for a pronator drift as

patient holds arms forward, with eyes closed, for 20 to 30 seconds (Fig. 17-9).

Fig ure 17-9 Te s t for pronator drift.

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 (Fig. 17-10)

Fig ure 17-10 Pos itive te s t for pronator drift.

Ask patient to keep arms up and tap them downward. A smooth return to position is normal.

Weakness, incoordination, poor position sense



325


/ Th e S e n s o r y S y s t e m Use an object like a sharp pin or stick portion of a broken cotton swab to test sharp and dull sensation; compare symmetric areas on the A hemisensory loss pattern suggests a contralateral cortical lesion. two sides of the body. Do not reuse the object on another patient. 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

Map any area of abnormal response, including dermatomes, if present.

Dermatomal sensory loss in herpes

See Table 17-7, Dermatomes, pp. 343– 344.

Assess response to the following stimuli, with the patient’s eyes closed. ■ Pain. Use the sharp end of a pin

Analgesia, hypalgesia, hyperalgesia

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 suitable temperature. ■ Light touch. Use a ne wisp of

Temperature and pain sensation usually correlate.

Anesthesia, hyperesthesia

cotton. Test for vibration and proprioception (joint position sense). If responses are abnormal, test more proximally. Vibration and position senses, both carried in the posterior columns, often correlate.

Loss of vibration and position senses in peripheral neuropathy from diabetes or alcoholism and in posterior column disease from tertiary syphilis or vitamin B12 deficiency

326




■ Vibration. Use a 128-Hz tuning

fork, held on a bony prominence at the ankle and wrist (Fig. 7-11).

Fig ure 17-11 Te s t vibration s e ns e . ■ Proprioception (joint position

sense). Holding patient’s nger or big toe by its sides, move it up or down (Fig. 17-12).

Fig ure 17-12 Te s t proprioce ption.

Assess discriminative sensations: ■ Stereognosis. Ask for identi ca-

tion of a common object placed in patient’s hand.

Lesions in the posterior columns or sensory cortex impair stereognosis, number identification, and two-point discrimination.

■ Number identi cation (graphes-

thesia). Draw a number on patient’s palm with blunt end of a pen and ask the patient to identify the number. ■ Two-point discrimination (Fig. 17-13).

Use two pins of the sides of a paper clip to nd minimal distance on pad of patient’s nger at which two points can be distinguished (normally <5 mm). Fig ure 17-13 Te s t two-point dis crim ination.



■ Point localization. Touch skin

brie y, and ask patient to open both eyes and identify the place touched.

327

P O SSIBLE FIN DIN G S A lesion in the sensory cortex may lateral side and cause contralateral extinction of the touch sensation.

■ Extinction. Simultaneously touch

opposite, corresponding areas of the body; ask whether the patient feels one touch or two.

/

R e f le x e s

Hold the re ex hammer loosely between your thumb and index nger so that it swings freely in an arc within the limits set by your palm and other ngers. Use the common grading system below.

Hyperactive deep tendon reflexes, absent abdominal reflexes, and a positive Babinski response in upper motor neuron lesions.

G r a d in g R e f le x e s Gra d e

4+ 3+ 2+ 1+

D e s c r ip t io n

Hy er ctive (clonus ust be resent) Brisker th n ver ge, not necess rily bnor Average, normal Di inished, low nor l No res onse

Biceps (C5, C6) (Fig. 17-14)

l

Triceps (C6, C7) (Fig. 17-15)

Fig ure 17-14 Bice ps re flex—patie nt s itting.

Fig ure 17-15 Trice ps re flex—patie nt s itting.

328



Brachioradialis (C5, C6) (Fig. 17-16)


/ Quadriceps (patellar) (L2, L3, L4) (Fig. 17-17)

Fig ure 17-17 Quadrice ps (pate llar) re flex.

Fig ure 17-16 Brachioradialis re flex.

Achilles (ankle) (S1) (Fig. 17-18)

Check for clonus if re exes seem hyperactive (Fig. 17-19).

Fig ure 17-18 Achille s re flex—patie nt

Fig ure 17-19 Te s t for ankle clonus .

s itting. Ankle jerks symmetrically, decreased or absent in peripheral polyneuropathy; slowed ankle jerk in hypothyroidism.



329


C u t a n e o u s o r S u p e r f ic ia l S t im u la t io n R e f le x e s Abdominal re exes (upper T8, T9, T10; lower T10, T11, T12) (Fig. 17-20)

May be absent in both central and peripheral nerve disorders

Fig ure 17-20 Te s t the abdom inal re flexe s .

Plantar response (L5, S1), normally exor (Fig. 17-21)

Babinski extensor response (big toe fans up) from corticospinal tract lesion (Fig. 17-22)

Fig ure 17-21 Te s t the plantar

Fig ure 17-22 Babins ki re s pons e

re s pons e .

(abnorm al).

Anal re ex. 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, S3, S4 level.

330




S p e c ia l T e c h n iq u e s M e n in g e a l S ig n s . Make sure there is no injury or fracture to the cervical vertebrae or cervical cord. This often requires radiologic evaluation. With patient supine, ex head and neck toward chest. Note resistance or pain, and watch for exion of hips and knees (Brudzinski sign).

Inflammation in the subarachnoid space causes resistance to movement that stretches the spinal nerves (neck flex-

Flex one of patient’s legs at hip and knee, then straighten knee (Fig. 17-23). Note resistance or pain (Kernig sign).

A compressed lumbosacral nerve root also causes pain on straightening the knee of the raised leg.

and the sciatic nerve (Kernig sign).

signs in meningitis ranges from 5% to 60%.

Fig ure 17-23 Te s t for Ke rnig s ign.

Lu m b o s a c ra l Ra d ic u lo p a t h y: S t ra ig h t -Le g Ra is e . With patient supine, raise relaxed and straightened leg, exing the leg at the hip. Then dorsi ex the foot (Fig. 17-24).

Fig ure 17-24 Te s t the s traight-le g rais e .

Pain radiating into the ipsilateral leg is a positive straight-leg test for lumbosacral radiculopathy. Foot dorsiflexion can further increase leg pain in lumbosacral radiculopathy, sciatic neuropathy, or both. Increased pain when the contralateral healthy leg is raised is a positive crossed straight-leg raise sign.



331


As t e rixis . Ask patient to hold both arms forward, with hands cocked up and ngers spread, like “stopping traf c.” Watch for 1 to 2 minutes.

Sudden brief flexions in liver disease, uremia and hypercapnia.

Win g in g o f t h e S c a p u la . Ask patient to push against the wall of your hand with a partially straightened arm (Fig. 17-25). Inspect scapula. It should stay close to the chest wall.

Winging of scapula away from chest wall suggests weakness of the serratus anterior muscle, seen in muscular dystrophy or injury to long thoracic nerve (Fig. 17-26).

Figure 17-25 Test for scapular winging.

Figure 17-26 Positive scapular w inging.

Th e S t u p o ro u s o r Co m a t o s e Pa t ie n t

Assess ABCs (airway, breathing, and circulation).

See Table 17-8, Metabolic and Structural Coma, p. 345, Table 17-9, Glasgow Coma Scale, p. 346, and Table 17-10, Pupils in Comatose Patients, p. 347.

■ Take pulse, blood pressure, and

rectal temperature. ■ Establish level of consciousness

with escalating stimuli. However, do not dilate pupils, and do not ex patient’s neck if any suspicion of cervical cord injury.

Lethargy, obtundation, stupor, coma

332




Le v e ls o f C o n s c io u s n e s s Ale rtne s s

Le thargy

Obtundatio n

S tupo r

Co m a

P tient is w ke nd w re of self nd environ ent. When s oken to in nor l voice, tient looks t you nd res onds fully nd ro ri tely to sti uli. When s oken to in loud voice, tient e rs drowsy but o ens eyes nd looks t you, res onds to questions, nd then f lls slee . When sh ken gently, tient o ens eyes nd looks t you but res onds slowly nd is so ewh t confused. Alertness nd interest in environ ent re decre sed. P tient rouses fro slee only fter inful sti uli. Verb l res onses re slow or bsent. P tient l ses into unres onsiveness when sti ulus sto s. P tient h s ini l w reness of self or environ ent. Des ite re e ted inful sti uli, tient re ins un rousble with eyes closed. No evident res onse to inner need or extern l sti uli is shown.

N e u r o lo g ic E x a m in a t io n Conduct neurologic examination, looking for asymmetric ndings. Observe: ■ Breathing pattern

Cheyne –Stokes, ataxic breathing

■ Pupils

Asymmetrical pupils and loss of the light reaction in structural lesions from stroke, abscess, or tumor

■ Ocular movements

Deviation to affected side in hemispheric stroke

Check for the oculocephalic re ex (doll’s eye movements), as shown in Figure 17-27. Holding upper eyelids open, turn head quickly to each side, and then ex and extend patient’s neck. This patient’s head will be turned to her right.

In a comatose patient with an int a ct b ra in st em, the eyes move in the opposite direction, in this case to her left (doll’s eye movements) as in Figure 17-28. Very deep coma or a lesion in the midbrain or pons abolishes this reflex, so eyes do not move.



333


Fig ure 17-27 Te s t the oculoce phalic

Fig ure 17-28 Oculoce phalic re flex

re flex.

intact.

Note posture of body.

Decorticate rigidity, decerebrate rigidity, flaccid hemiplegia

Test for accid paralysis. ■ Hold forearms vertically; note

wrist positions. ■ From 12 to 18 inches above bed,

A flaccid arm drops more rapidly.

drop each arm. ■ Support both knees in a some-

The flaccid leg drops more rapidly.

what exed position, and then extend each knee and let leg drop to the bed. ■ From a similar starting position,

release both legs.

A flaccid leg falls into extension and external rotation.

Complete the neurologic and general physical examination.

Recording Your Findings R e c o r d in g t h e N e r v o u s S y s t e m E x a m in a t io n “Mental Status: Alert, rel xed, nd coo er tive. Thought rocess coherent. Oriented to erson, l ce, nd ti e. Det iled cognitive testing deferred. Cranial Nerves: I—not tested; II through XII int ct. Motor: Good uscle bulk nd tone. (continued )

334


R e c o r d in g t h e N e r v o u s S y s t e m E x a m in a t io n

(Continued)

Strength 5/5 throughout. Cerebellar: R id ltern ting ove ents (RAMs), finger-to-nose (F→N), heel-to-shin (H→S) int ct. G it with nor l b se. Ro berg— int ins b l nce with eyes closed. No ron tor drift. Sensory: Pin rick, light touch, osition, nd vibr tion int ct. Reflexes: 2+ nd sy etric with l nt r reflexes downgoing.” OR “Mental Status: The tient is lert nd tries to nswer questions but h s difficulty finding words. Cranial Nerves: I—not tested; II—visu l cuity int ct; visu l fields full; III, IV, VI—extr ocul r ove ents int ct; V otor—te or l nd sseter strength int ct, sensory corne l reflexes resent; VII otor— ro inent right f ci l droo nd fl ttening of right n sol bi l fold, left f ci l ove ents int ct, sensory—t ste not tested; VIII—he ring int ct bil ter lly to whis ered voice; IX, X—g g int ct; XI—strength of sternocleido stoid nd tr ezius uscles 5/5; XII—tongue idline. Motor: strength in right bice s, trice s, ilio so s, glute ls, qu drice s, h string, nd nkle flexor nd extensor uscles 3/5 with good bulk but incre sed tone nd s sticity; strength in co r ble uscle grou s on the left 5/5 with good bulk nd tone. G it—un ble to test. Cerebell r—un ble to test on right due to right r nd leg we kness; RAMs, F→N, H→S int ct on left. Ro berg—un ble to test due to right leg we kness. Right ron tor drift resent. Sensory: decre sed sens tion to in rick over right f ce, r , nd leg; int ct on the left. Stereognosis nd two- oint discri in tion not tested. Reflexes (c n record in two w ys): (These findings suggest left hemispheric CVA in distribution of the left middle cerebral artery, with right-sided hemiparesis.)

RT LT

Bic e p s

Tr ic e p s

Br a c h

Kn e e

An k le

Pl

4+ 2+

4+ 2+

4+ 2+

4+ 2+

4+ 1+

↑ ↓

OR

R 4+ 4+ 4+ 4+

L 2+ 2+ 2+ 2+

4+


335

Aids to Interpretation Table 17-1 Typ e s o f S t ro k e C lin ic a l Fe a t u r e s a n d Va s c u la r Te r r it o r ie s o f S t ro k e

Assessment of stroke requires careful history taking and a detailed physical examination. Focus on 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 thrombosis or embolus? This brief overview is intended to prompt further study and practice. La te ra l ve ntrica l

Body of ca uda te

Ante rior ce re bra l a rte ry

Inte rna l ca ps ule

Ante rior choroida l a rte ry Middle ce re bra l a rte ry

P uta me n

Tha la mus

Globus pa llidus

Pos te rior ce re bra l a rte ry Uncus P re fronta l a re a

P rima ry a uditory cortex

P re motor a re a

Auditory a s s ocia tion a re a

P rima ry motor cortex

S e ns ory s pe e ch (We rnike ) a re a

Motor s pe e ch (Broca ) a re a

Re a ding compre he ns ion a re a

P rima ry s oma tic s e ns ory cortex

Vis ua l a s s ocia tion a re a

S oma tic s e ns ory a s s ocia tion a re a

Vis ua l cortex

Ta s te a re a

M a jo r C lin ic a l Fe a t u r e s

Va s c u la r Te r r it o ry

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 (table continues on page 336)

336


Table 17-1 Typ e s o f S t ro k e (continued ) Clin ic a l Fe a t u re s a n d Va s c u la r Te rrit o rie s o f S t ro k e (c o n t in u e d )

M a jo r C lin ic a l Fe a t u r e s

Va s c u la r Te r r it o ry

Contralateral face, arm > leg weakness, sensory loss, field cut, aphasia (left MCA) or neglect, apraxia (right MCA)

Anterior circulation—middle cerebral artery (MCA)

Contralateral motor or sensory deficit without cortical signs

Subcortical circulation—lenticulostriate deep penetrating branches of MCA

Contralateral field cut

Posterior circulation—posterior cerebral artery (PCA)

Largest vascular bed for stroke

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

Includes paired vertebral arteries, the basilar artery, paired posterior cerebral arteries. Bilateral PCA infarction causes cortical blindness but preserved pupillary light reaction. 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, PA: American College of Physicians; 2006:52.


337

Table 17-2 Dis o rd e r s o f S p e e ch Disorders of speech fall into three groups affecting: (1) phonation of the voice, (2) the articulation of words, and (3) the production and comprehension of language. ■

Aphonia refers to a loss of voice that accompanies disease affecting the larynx or its nerve supply. Dysphonia refers to less severe impairment in the volume, quality, or pitch of the voice. For example, a person may be hoarse or only able to speak in a whisper. Causes include laryngitis, laryngeal tumors, and unilateral vocal cord paralysis (CN X).

■

Dysarthria refers to a defect in the muscular control of the speech apparatus (lips, tongue, palate, or pharynx). Words may be nasal, slurred, or indistinct, but the central symbolic aspect of language remains intact. Causes include motor lesions of the central or peripheral nervous system, parkinsonism, and cerebellar disease.

■

Aphasia refers to a disorder in producing or understanding language. It is often caused by lesions in the dominant cerebral hemisphere, usually the left. (table continues on page 338)

338


Table 17-2 Dis o rd e r s o f S p e e ch (continued ) Compared below are two common types of aphasia: (1) Wernicke, a fluent (receptive) aphasia, and (2) Broca, a nonfluent (or expressive) aphasia. There are other less common kinds of aphasia, which are distinguished by differing responses on the specific tests listed. Neurologic consultation is usually indicated. We r n ic k e A p h a s ia

Bro c a A p h a s ia

Q u a lit ie s o f Spontaneous S p e e ch

Fluent; often rapid, voluble, and effortless. Inflection and articulation are good, but sentences lack meaning and words are malformed (paraphasias) or invented (neologisms). Speech may be totally incomprehensible.

Nonfluent; slow, with few words and laborious effort. Inflection and articulation are impaired but words are meaningful, with nouns, transitive verbs, and important adjectives. Small grammatical words are often dropped.

Wo r d C o m p r e h e n s io n

Impaired

Fair to good

Re p e t it io n

Impaired

Impaired

N a m in g

Impaired

Impaired, though the patient recognizes objects

Re a d in g C o m p r e h e n s io n

Impaired

Fair to good

Wr it in g

Impaired

Impaired

Lo c a t io n o f Le s io n

Posterior superior temporal lobe

Posterior inferior frontal lobe

Although it is important to recognize aphasia early in your encounter with a patient, integrate this information with your neurologic examination as you generate your differential diagnosis.


339

Table 17-3 Typ e s o f Fa c ia l P a ra lys is Distinguish peripheral from central lesions of CN VII by closely observing movements of the upper face. Because of innervation from both hemispheres, the upper facial movements are preserved in central lesions. C N VII—P e r ip h e r a l Le s io n

C N VII—C e n t r a l Le s io n

Peripheral nerve damage to CN VII paralyzes the entire right side of the face, including the forehead. Motor cortex

Motor c orte x CN VII c e ntral le s io n

CN VII pe riphe ral le s io n

Syna ps es in the pons

Syna ps es in the pons

Facia l ne rve

Facial ne rve

Clo s ing Eye s

Clo s ing Eye s

Eye does not clos e; e yeba ll rolls up

Eye clos es ; pe rha ps with s light we aknes s

Flat nas olabial fold

Flat na s ola bia l fold

Rais ing Eye bro w s Fore he ad not wrinkled; e yebrow not rais ed

Rais ing Eye bro w s

Smiling Paralys is of lower fac e

Forehea d wrinkle d; eye brow rais ed Smiling Para lys is of lower fa ce

340


Table 17-4 Mo t o r Dis o rd e r s P e r ip h e r a l N e r vo u s Sys t e m D is o r d e r

Ce n t ra l N e r vo u s S ys t e m D is o r d e r a

P a r k in s o n is m (Ba s a l G a n g lia D is o r d e r )

In vo lu n t a ry m o ve m e n t s

Often fascicu lations

No fasciculations

Resting tremors

Intention tremors

M u s c le b u lk

Atrophy

Normal or mild atrophy (disuse)

Normal

Normal

M u s c le tone

Decreased or absent

Increased, spastic

Increased, rigid

Decreased

M u s c le s t re n g t h

Decreased or lost

Decreased or lost

Normal or slightly decreased

Normal or slightly decreased

C o o r d in a t io n

Unimpaired, though limited by weakness

Slowed and limited by weakness

Good, though slowed and often tremulous

Impaired, ataxic

De e p te n d o n

Decreased or absent

Increased

Normal or decreased

Normal or decreased

Pla n ta r

Flexor or absent

Extensor

Flexor

Flexor

Ab d o m in a ls

Absent

Absent

Normal

Normal

C e r e b e lla r D is o r d e r

Re f le xe s

a

Upper motor neuron.


341

Table 17-5 In vo lu n t a ry Mo ve m e n t s Re s ting s tatic tre m o rs . Fine, “pill-rolling” tremor seen at rest, usually disappear with movement; seen in basal ganglia disorders like Parkinson disease.

Po s tural tre m o r. Seen when maintaining active posture; in anxiety, hyperthyroidism; also familial. From basal ganglia disorder. Inte ntio n tre m o r. Seen with intentional movement, absent at rest; in cerebellar disorders, including multiple sclerosis

Fas ciculations . Fine, rapid flickering of muscle bundles in lower motor neuron disorders.

Cho re a. Brief, rapid, irregular, jerky; face, head, arms, or hands (e.g., Huntington disease)

Athe to s is . Slow, twisting, writhing; face, distal limbs, often with associated spasticity (e.g., cerebral palsy)

342


Table 17-6 Dis o rd e r s o f Mu s c le To n e S p a s t ic it y

Rig id it y

Lo catio n. Upper motor neuron or corticospinal tract systems.

Lo catio n. Basal ganglia system

De s criptio n. Increased muscle tone (hypertonia) that is ratedependent. 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.

De s criptio n. Increased resistance that persists throughout the movement arc, independent of rate of movement, is called leadpipe rigidity. With flexion and extension of the wrist or forearm, a superimposed ratchet-like jerkiness is called cogwheel rigidity.

Co m m o n Caus e . Stroke, especially late or chronic stage

Co m m o n Caus e . Parkinsonism

Fla c c id it y

P a r a t o n ia

Lo catio n. Lower motor neuron at any point from the anterior horn cell to the peripheral nerves

Lo catio n. Both hemispheres, usually in the frontal lobes

De s criptio n. Loss of muscle tone (hypotonia), causing the limb to be loose or floppy. The affected limbs may be hyperextensible or even flail-like.

De s criptio n. 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).

Co m m o n Caus e . Guillain– Barré syndrome; also initial phase of spinal cord injury (spinal shock) or stroke

Co m m o n Caus e . Dementia


343

Table 17-7 De rm a t o m e s

C2 C3 Front of ne ck C3 C4 T2 T3

C5

C5

T4

T4 Nipple s

T5 T6 T7 T8 T9

C6 T1

T1

C6

T10

T10 Umbilicus

T11 L1 Inguina l

T12 L1 L2

C8

L2

C8

C7

C7 S 2,3

L3

L3 C8 Ring a nd little finge rs

L4

L4 L4 Kne e

L5

S1

L5

S1

L5 Ante rior a nkle a nd foot

Dermatomes Innervated by Posterior Roots (table continues on page 344)

344


Table 17-7 De rm a t o m e s (continued )

C2 C5 C6 C7 C8

C3

C3 Ba ck of ne ck T1 C4

T2 T3 T4 T5 T6 T7 T8 T9 T10 T11 T12 L1 L2 L3 L4 L5 S1 S2

C5

C6 T1

C5

C6 T1

S3 S4

C6 Thumb

S5

C8

C8

C7

C7

C8 Ring a nd little finge rs

S 5 Pe ria na l

S1

S2

S2

S1

L4, L5, S 1 Pos te rior a nkle a nd foot L4

L4

L5

L5

Dermatomes Innervated by Posterior Roots


345

Table 17-8 Me t a b o lic a n d S t ru c t u ra l Co m a To x ic –M e t a b o lic

S t ru c t u ra l

P a t h o p h y s io lo g y

Arousal centers poisoned or critical substrates depleted

Lesion destroys or compresses brainstem arousal areas, either directly or secondary to more distant expanding mass lesions.

C lin ic a l Fe a t u r e s ■

Re s p ira to ry p a tte rn . If regular, may be normal or hyperventilation. If irregular, usually Cheyne–Stokes

Re s p ira to ry p a tte rn . Irregular, especially Cheyne–Stokes or ataxic breathing. Also with selected stereotypical patterns like “apneustic” respiration (peak inspiratory arrest) or central hyperventilation.

■

Pu p illa ry s ize a n d re a ct io n . Equal, reactive to light. If pinpoint from opiates or cholinergics, you may need a magnifying glass to see the reaction.

Pu p illa ry s ize a n d re a ct io n . Unequal or unreactive to light (fixed)

May be unreactive if fixed and dilated from anticholinergics or hypothermia ■

Le ve l o f co n s cio u s n e s s . Changes after pupils change

Midposition, fixed—suggests midbrain compression Dilated, fixed—suggests compression of CN III from herniation Le ve l o f co n s cio u s n e s s . Changes before pupils change

Ex a m p le s o f C a u s e

Uremia, hyperglycemia Alcohol, drugs, liver failure Hypothyroidism, hypoglycemia Anoxia, ischemia Meningitis, encephalitis Hyperthermia, hypothermia

Epidural, subdural, or intracerebral hemorrhage Cerebral infarct or embolus Tumor, abscess Brainstem infarct, tumor, or hemorrhage Cerebellar infarct, hemorrhage, tumor, or abscess

346


Table 17-9 Gla s g o w Co m a S c a le Ac t iv it y

S c o re

Eye O p e n in g

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

M o t o r Re s p o n s e

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

Ve r b a l Re s p o n s e

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)a

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.

a


347

Table 17-10 P u p ils in Co m a t o s e P a t ie n t s S m a ll o r P in p o in t P u p ils

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.

M id p o s it io n Fixe d P u p ils

Midposition or slightly dilated pupils (4–6 mm) and fixed to light suggest damage in the midbrain.

La r g e P u p ils

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.

O n e La r g e P u p il

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.

18 C H A P T E R

Assessing Children: Infancy through Adolescence Child Development

Children display tremendous variations in physical, cognitive, and social development compared with adults. K e y P r in c ip le s o f C h ild D e v e lo p m e n t ● ● ●

●

Child develo ent roceeds long redict ble thw y. The r nge of nor l develo ent is wide. V rious hysic l, sychologic l, soci l, nd environ ent l f ctors, s well s dise ses, c n ffect child develo ent nd he lth. The child’s develo ent l level ffects how you conduct the history nd hysic l ex in tion.

The Health History The child’s history follows the same outline as the adult’s history, with certain additions presented here.

Id e n t if y in g D a t a Record date and place of birth, nickname, and rst and last names of parents.

C h ie f C o m p la in t s Determine if they are the concerns of the child, the parent(s), a schoolteacher, or some other person.

P r e s e n t Illn e s s Determine how each family member responds to the child’s symptoms, why he or she is concerned, and impact on the child’s functioning.

349

350


H is t o r y Bir t h His t o ry. This is especially important when neurologic or developmental 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

Fe e d in g His t o ry. This is particularly important with either undernutrition or obesity. ■ Breast-feeding—frequency and duration of feeds, dif culties, timing

and method of weaning ■ Bottle-feeding—type; amount; frequency; vomiting; colic; diarrhea ■ Vitamins, iron, and uoride supplements; introduction of solid foods ■ Eating habits—types and amounts of food eaten, parental attitudes and

responses to feeding problems Gro w t h a n d De ve lo p m e n t a l His t o ry. 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; BMI after age 2 years ■ Developmental milestones, 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; social risks such as poverty, food insecurity and adverse experiences

C u r r e n t H e a lt h S t a t u s Alle rg ie s . Pay particular attention to history of eczema, urticaria, perennial allergic rhinitis, asthma, food intolerance, insect hypersensitivity, and recurrent wheezing. Im m u n iza t io n s . Include dates given and any untoward reactions. S c r e e n in g Te s t s . These 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).

Chapter 18 | Assessing Children: Infancy through Adolescence

351

Health Promotion and Counseling: Evidence and Recommendations For the most up-to-date Bright Futures recommendations for preventive health care, see https://www.aap.org/en-us/Documents/periodicity_ schedule.pdf. Each child and family is unique; therefore, such recommendations are designed for the care of children who are receiving competent parenting, have no manifestation of any important health problems, and are growing and developing in satisfactory fashion. 1. Age-appropriate developmental achievement of the child ■

Physical (maturation, growth, puberty)

■

Motor (gross and ne motor skills)

■

Cognitive (milestones, language, school performance)

■

Emotional (self-regulation, self-ef cacy, self-esteem, independence)

■

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 ndings 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 ef cacy and self-esteem

■

Family relationships (interactions, strengths, supports)

■

Prevention or recognition of illness

352


■

Prevention of risky behaviors and addictions

■

School and vocation

■

Peer relationships

■

Community interactions

7. Partnership between health provider, child, and family

Techniques of Examination S e q u e n c e o f E x a m in a t io n The sequence of ex level. ●

●

in tion v ries ccording to the child’s ge nd co fort

For inf nts nd young children, perform nondisturbing maneuvers early and potentially distressing maneuvers toward the end. For ex le, l te the he d nd neck nd uscult te the he rt nd lungs e rly; ex ine the e rs nd outh nd l te the bdo en ne r the end. If the child re orts in in n re , ex ine th t rt l st. For older children nd dolescents, use the s e sequence s with dults, exce t ex ine the ost inful re s l st.

Assessing Newborns EXAMINATIO N TECHNIQ UES


Im m e d ia t e A s s e s s m e n t a t B ir t h Listen to the anterior thorax with your stethoscope. Palpate the abdomen. Inspect the head, face, oral cavity, extremities, genitalia, and perineum. Ap g a r S c o re . 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, proceed to a more complete examination.


353

T h e A p g a r S c o r in g S y s t e m A s s ig n e d S c o r e C lin ic a l S ig n

0

1

2

Heart rate Respiratory effort Muscle tone

Absent Absent

>1 Good; strong

Reflex irritabilitya Color

No res onses

<1 Slow nd irregul r So e flexion of the r s nd legs Gri ce

Fl ccid

Blue,

le

1-M in u t e A p g a r S c o r e

8–1 5–7 –4

Pink body, blue extre ities

Active

ove ent

Crying vigorously, sneeze, or cough Pink ll over

5 -M in u t e A p g a r S c o r e

Nor l 8–1 So e nervous sys–7 te de ression Severe de ression, requiring i edite resuscit tion

Nor l High risk for subsequent centr l nervous syste nd other org n syste dysfunction

Re ction to suction of n res with bulb syringe.

a

Ge s t a t io n a l Ag e a n d Bir t h We ig h t . Classify newborns according to their gestational age and birth weight (see Table 18-1, Classi cation of Newborn’s Level of Maturity, p. 373). C la s s if ic a t io n b y G e s t a t io n a l A g e a n d B ir t h W e ig h t G e s t a t io n a l Ag e C la s s if ic a t io n

Ge s t a t io n a l Ag e

Preterm Late preterm Term Postterm

<34 wks 34–36 wks 37–42 wks >42 wks

Bir t h We ig h t C la s s if ic a t io n

We ig h t

Extremely low birth weight Very low birth weight Low birth weight Normal birth weight

<1, <1,5 <2,5 ≥2,5

g g g g

354




N e w b o r n C la s s if ic a t io n s C a t e g o ry

Small for gestational age Appropriate for gestational age Large for gestational age

Ab b r e v ia t io n

SGA AGA LGA

P e r c e n t ile

<1 th 1 –9 th >9 th

A s s e s s m e n t S e v e r a l H o u r s A f t e r B ir t h During the rst 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 responsive. 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 associated with congenital anomalies. Umbilical hernia s 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 ne motor function, tone, cry, deep tendon re exes, and primitive re exes.

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.



355


Assessing Infants M e n t a l a n d P h y s ic a l S t a t u s 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, environmental and social problems, other pregnancy or perinatal problems, childhood diseases such as infection (e.g., meningitis), trauma, and severe chronic disease.

G e ne ra l S urve y Growth, re ected 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:

Fa ilure 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 gastrointestinal, neurologic, cardiac, endocrine, renal, and other diseases.

■ Normal values according to age

Measures above the 97th or below the 3rd percentile, or recent rises or falls from prior levels, require investigation.

and sex ■ Prior readings to assess trends

He ig h t a n d We ig h t . Plot each child’s height and weight on standard growth charts to determine progress.

Reduced growth in height may indicate endocrine disease, other causes of short stature, or, if weight is also low, other chronic diseases.

He a d Circ u m fe re n c e . Determine head circumference at every physical examination during the rst 2 years (Fig. 18-1).

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.

356




Fig ure 18-1 He ad circum fe re nce is a vital m e tric during e arly childhood.

V it a l S ig n s Blo o d P re s s u re . Measure blood pressure at least once during infancy. Although the hand-held method is shown in Figure 18-2, the most easily used measure of systolic blood pressure in infants and young children is obtained with the Doppler method.

Fig ure 18-2 Practice is re quire d to accurate ly m e as ure blood pre s s ure in e arly childhood.

C a u s e s o f S u s t a in e d H y p e r t e n s io n in C h ild r e n Ne w b o r n

M id d le C h ild h o o d

Ren l rtery dise se (stenosis, thro bosis) Congenit l ren l lfor tions Co rct tion of the ort

Pri

In f a n c y a n d Ea r ly C h ild h o o d

Ad o le s c e n c e

Ren l renchy l or rtery dise se Co rct tion of the ort

Pri ry hy ertension Ren l renchy l dise se Drug induced

P u ls e . 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.

ry hy ertension

Ren l renchy l or rteri l dise se Co rct tion of the ort

Tachycardia (>180–200 beats per minute) usually indicates paroxysma l supraventricular tachycardia . Bradycardia may result from serious underlying disease.



Re s p ira t o ry Ra t e . The respiratory rate has a very wide range and is more responsive to illness, exercise, and emotion than in adults.

357

P O SSIBLE FIN DIN G S Respiratory diseases such as bronchiolitis or pneumonia may cause rapid respirations (up to 80 to 90 breaths per minute), and increased work of breathing. Peaceful tachypnea (without increased work of breathing) may be a sign of cardiac failure.

T h e S k in Assess: ■ Texture and appearance

Cutis marmorata

■ Vasomotor changes

Acrocyanosis; cyanotic congenital heart disease

■ Pigmentation (e.g., Mongolian

Café-au-lait spots

spots) ■ Hair (e.g., lanugo)

Midline hair tuft on back

■ Common skin conditions (e.g.,

Herpes simplex

milia, erythema toxicum) ■ Color

Jaundice can be from hemolytic disease.

■ Turgor

Dehydration

Th e He a d Examine sutures and fontanelles carefully (Fig. 18-3). Ante rior fonta ne lle Pos te rior fonta ne lle La mbdoida l s uture S a gitta l s uture Corona l s uture Me topic s uture

Fig ure 18-3 Suture s and fontane lle s .

Head small with microcephaly, enlarged with hydrocephaly; fontanelles full and tense with meningitis, closed with microcephaly, separated with increa sed intracranial pressure (hydrocephaly, subdural hematoma, and brain tumor) Swelling from subperiosteal hemorrhage (cephalohematoma) does not cross suture lines; swelling from bleeding associated with a fracture does.

358




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 box below for evaluation). Examples include Down syndrome and fetal alcohol syndrome.

P e a r ls t o E v a lu a t e P o t e n t ia lly A b n o r m a l F a c ie s C refully review the history, es eci lly the family history, pregnancy, nd perinatal history. Note bnor lities of growth/develo ent or dys or hic so tic fe tures. Me sure nd lot ercentiles, es eci lly of head circumference, height, nd weight. Consider the three ech nis s of f ci l dys or hogenesis: ● Defor tions fro intr uterine constr int ● Disru tions fro niotic b nds or fet l tissue ● M lfor tions fro intrinsic bnor lity (either f ce/ he d or br in) Ex ine rents nd siblings (si il rity y be re ssuring but ight lso oint to f ili l disorder). Deter ine whether f ci l fe tures fit recogniz ble syndro e. Co re g inst references, ictures, t bles, nd d t b ses.

Th e Ey e s Newborns and young infants may look at your face and follow a bright light if you catch them while alert. Examine the red re ex.

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.

Normal visual milestones are as follows: V is u a l M ile s t o n e s o f In f a n c y Birth 1 month 1½–2 months 3 months 12 months

Blinks, y reg rd f ce Fixes on objects Coordin ted eye ove ents Eyes converge, b by re ches Acuity round 2 / 6 –2 / 8



359


Th e Ea r s Check position, shape, and features.

Small, deformed or low-set auricles may indicate associated congenital defects, especially renal disease.

S ig n s T h a t a n In f a n t C a n H e a r Ag e

S ig n s

0–2 months

St rtle res onse nd blink to sudden noise C l ing down with soothing voice or usic Ch nge in body ove ents in res onse to sound Ch nge in f ci l ex ression to f ili r sounds Turning eyes nd he d to sound Turning to listen to voices nd convers tion A ro ri te l ngu ge develo ent

2–3 months

3–4 months 6–7 months

Th e N o s e Test patency of the nasal passages by occluding alternately each nostril while holding the infant’s mouth closed.

With choanal atresia , the baby cannot breathe if one nostril is occluded.

Th e M o u t h a n d P h a r y n x Inspect (with a tongue blade and ashlight) and palpate.

Supernumerary teeth, Epstein 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.

Ora l candidiasis (thrush) Vesicles in the mouth can be caused by enteroviral infections and herpes simplex virus infections.

Th e N e c k Palpate the lymph nodes, and assess for any additional masses (e.g., congenital cysts), as shown in Figure 18-4.

Lymphadenopathy is usually from viral or bacterial infections. Other neck masses include malignancy, branchia l cleft or thyroglossa l duct cysts, and peria uricular cysts and sinuses.

360




Prea uric ula r c ys t Parotid nodes Epide rmoid c ys t Oc cipital node J uguloga s tric nod e

Re troa uric ular (ma s toid ) nodes

Sub mandibular nod e

Sup erior de ep c ervica l nodes Midd le de ep c ervica l nodes

Sub mental nod e

Pos te rior c ervica l nodes

Thyroglos s al duct c ys t

Cys tic hygroma 2nd branc hial cle ft c ys t

Supra clavicular node

Inferior d eep c ervic al node s

Ante rior ce rvic al node s

Fig ure 18-4 Node s and cys ts of the he ad and ne ck.

T h e T h o r a x a n d Lu n g s Carefully assess respirations and breathing pattern.

Apnea

Do not rush to the stethoscope, but observe the patient carefully rst.

Upper respiratory infections may cause nasal flaring.

E x a m in a t io n o f t h e Lu n g s in In f a n t s —B e f o r e Y o u T o u c h t h e C h ild ! As s e s s m e n t

P o s s ib le Fin d in g s

Ex p la n a t io n

General appearance

In bility to feed or s ile L ck of consol bility

Respiratory rate

T chy ne

Color Nasal component of breathing

P llor or cy nosis N s l fl ring (enl rge ent of both n s l o enings during ins ir tion)

Lower respiratory infections (e.g., bronchiolitis, pneumonia) re co on in inf nts. C rdi c or res ir tory dise se (e.g., neu oni ) C rdi c or ul on ry dise se U er or lower res ir tory infection (continued )



361


E x a m in a t io n o f t h e Lu n g s in In f a n t s —B e f o r e Y o u T o u c h t h e C h ild ! (Continued) As s e s s m e n t

P o s s ib le Fin d in g s

Ex p la n a t io n

Audible breath sounds

Grunting (re etitive, short ex ir tory sound) Wheezing ( usic l ex ir tory sound) Stridor (high- itched, ins ir tory noise) Obstruction (l ck of bre th sounds) N s l fl ring Grunting Retr ctions (chest indr wing): Su r cl vicul r ( otion of soft tissue bove cl vicles) Intercost l (indr wing of the skin between ribs) Substern l ( t xi hoid rocess) Subcost l (just below the cost l rgin)

Lower res ir tory dise se

Work of breathing

Asth

or bronchiolitis

Crou , e iglottitis, b cteri l tr cheitis Foreign body In inf nts, bnor l work of bre thing co bined with bnor l findings on uscult tion is the best finding for ruling in pneumonia.

Auscultate the chest, and try to distinguish upper airway from lower airway sounds. D is t in g u is h in g U p p e r A ir w a y f r o m Lo w e r A ir w a y S o u n d s Te c h n iq u e

U p p e r A ir w a y

Lo w e r A ir w a y

Compare sounds from nose/ stethoscope Listen to harshness of sounds Note symmetry (left/right) Compare sounds at different locations (higher or lower) Inspiratory vs. expiratory

S

Often different sounds V ri ble

e sounds

H rsh nd loud Sy etric Sounds louder s stethosco e is oved u chest Al ost lw ys ins ir tory

Often sy etric Sounds louder lower in chest Often h s ex ir tory h se

362




Th e H e a r t In s p e c t io n . Observe carefully for any cyanosis. The best body part to assess cyanosis is the tongue or inside of the mouth.

At birth: Tra nsposition of the great arteries; pulmonary valve atresia or stenosis

P a lp a t io n . Palpate the peripheral pulses. The point of maximal impulse (PMI) is not always palpable in infants. Thrills are palpable when enough turbulence is within the heart or great vessels.

No or diminished femoral pulses suggest coarcta tion of the aorta. Weak or thready, difficult-to-feel pulses may reflect myocardia l dysfunction and heart fa ilure.

Au s c u lt a t io n . 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 supra ventricular tachyca rdia.

Evaluate S1 and S2 carefully. They are normally crisp with intermittent splitting of S1 and S2 (fused in expiration).

A louder-than-normal pulmonic component suggests pulmonary hypertension. Persistent splitting of S2 may indicate atrial septal defect.

Listen for heart murmurs. Two common benign systolic murmurs are from a closing ductus or peripheral pulmonary ow murmur.

Most infants with cardiac pathology have signs beyond heart murmurs.

Within a few days of birth: The above; also total anomalous pulmonary venous return, hypopla stic left heart

Th e B r e a s t s The breasts of males and females may be enlarged for months after birth as a result of maternal estrogen.

Th e A b d o m e n You will nd it easy to palpate an infant’s abdomen, because infants like being touched. Palpate the liver and spleen and assess for hepatosplenomegaly.

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.



363


M a le G e n it a lia Inspect with the infant supine. The foreskin of a newborn is nonretractable at birth or just enough to visualize the urethral meatus.

Common scrotal masses are hydroceles and inguinal hernias.

In 3% of infants, one or both testes 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.

F e m a le G e n it a lia In females, genitalia may be prominent for several months after birth from the effects of maternal estrogen.

Ambiguous genita lia involves masculinization of the female external genitalia.

T h e M u s c u lo s k e le t a l S y s t e m 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 cla vicle can occur during a difficult delivery.

Examine the hips carefully at each visit for signs of dislocation. There are two major techniques: one to test for a posteriorly dislocated hip (Ortolani test), as shown in Figure 18-5, and the other to test for the ability to sublux or dislocate an intact but unstable hip (Barlow test), as shown in Figure 18-6.

Congenital hip dysplasia may have a positive Ortolani or Barlow test, particularly during the first 3 months of age. With a hip dysplasia , you feel a “clunk.”

Fig ure 18-5 Ortolani te s t, ove rhe ad

Fig ure 18-6 Barlow te s t, ove rhe ad

view.

view.

364



Some normal infants exhibit twisting or torsion of the tibia inwardly or outwardly on its longitudinal axis.

P O SSIBLE FIN DIN G S Pathologic tibial torsion occurs only in association with deformities of the feet or hips.

Th e N e r v o u s S y s t e m Evaluate the developing central nervous system by assessing infantile automatisms, called primitive re exes.

Suspect a neurologic or developmenta l abnormality if primitive reflexes are absent at appropriate age, present longer than normal, asymmetric, or associated with posturing or twitching.

Neurologic abnormalities in infants often present as developmental abnormalities such as failure to do age-appropriate tasks.

Hypotonia can be a sign of a variety of neurologic abnormalities.

Assessing Children (1 to 10 Years) T ip s f o r In t e r v ie w in g C h ild r e n ●

●

●

●

●

Establish rapport. Refer to children by n e nd eet the on their own level. M int in eye cont ct t their level (e.g., sit on the floor if needed). P rtici te in l y nd t lk bout their interests. Work with families. Ask si le, o en-ended questions such s “Are you sick? Tell e bout it,” followed by ore s ecific questions. Once the rent h s st rted the convers tion, direct questions b ck to the child. Also observe how rents inter ct with the child. Identify multiple agendas. Your job is to discover s ny ers ectives nd gend s s ossible. Use the family as the key resource. View rents s ex erts in the c re of their child nd you s their consult nt. Note hidden agendas. As with dults, the chief co l int y not rel te to the re l re son the rent h s brought the child to see you.

The following discussion focuses on those re s of the co rehensive hysic l ex in tion th t re different for children th n for inf nts nd for dults.



365


M e n t a l a n d P h y s ic a l S t a t u s In children age 1 to 5 years, observe the degree of sickness or wellness, mood, nutritional state, speech, cry, facial expression, and developmental skills. Note parent–child interaction, including separation tolerance, affection, and response to discipline.

This overall examination can uncover evidence of chronic disease, developmental delay, social or environmental disorders, 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.

Bo d y Ma s s In d e x fo r Ag e . Age- and sex-speci c 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.

Blo o d P re s s u re . Hypertension during childhood is more common than previously thought. Recognizing, con rming, and appropriately managing it is important. Blood pressure readings should be part of the physical examination of every child older than 2 years (see Table 18-2, Hypertension in Childhood, p. 374). 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 childhood include renal disease, coarctation of the aorta, and primary hypertension. Hypertension is often related to childhood obesity.

Th e Ey e s Test visual acuity in each eye and determine whether the gaze is conjugate or symmetric.

Any difference in visual acuity between eyes is abnormal. Myopia or hyperopia often present in school-aged children.

366




S p e c ia l T e c h n iq u e The corneal light re ex test (Fig. 18-7) and the cover–uncover test (Fig. 18-8) are particularly useful in young children.

Fig ure 18-7 Corne al light re flex te s t.

Strabismus can lead to a mblyopia.

Fig ure 18-8 Cove r–uncove r te s t.

V is u a l A c u it y Ag e

Vis u a l Ac u it y

3 months 12 months Younger than 4 years 4 years and older

Eyes converge, b by re ches 2 / 6 –2 / 8 2 /4 2 /3

Th e Ea r s 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 shown in Figures 18-9 and 18-10.

Pain on movement of the pinna occurs with otitis externa.

Fig ure 18-9 Ge ntly holding the child’s

Fig ure 18-10 Ge ntly pulling up on the

arm s re duce s re actions to the otoscope .

auricle give s a be tte r otos cope view w ith m any childre n.



■ Insert the speculum, obtaining a

proper seal. P n e u m a t ic Ot o s c o p e . Learn to use a pneumatic otoscope to improve accuracy of diagnosis of otitis media. When air is introduced into the normal ear canal, the tympanic membrane and its light re ex move inward. When air is removed, the tympanic membrane moves outward toward you.

367

P O SSIBLE FIN DIN G S Acute otitis media involves a red and bulging tympanic membrane. Diminished movement of tymp anic membrane with a cute otitis media ; no movement with otitis media with effusion.

Th e M o u t h a n d P h a r y n x 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 re ex.

A common cause of a strawberry tongue, red uvula, and pharyngeal exudate is streptococcal pharyngitis.

Examine the teeth for the timing 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 in Figure 18-11.

Nursing bottle ca ries; denta l caries; staining of the teeth, which may be intrinsic or extrinsic Dental ca ries are the most common health problem of children and are particularly prevalent in impoverished children.

Fig ure 18-11 Lift the lip to che ck for de ntal carie s .

368




Look for abnormalities of tooth position.

Malocclusion

Note the size, position, symmetry, and appearance of the tonsils.

Peritonsillar a bscess

Th e H e a r t A challenging aspect to cardiac examination of children is evaluation of heart murmurs, particularly distinguishing common benign murmurs from unusual or pathologic ones. Most children have one or more functional, or benign, heart murmurs at some point in time (Fig. 18-12).

See Table 18-3, Characteristics of Pathologic Heart Murmurs, pp. 375–376.

Venous hum

Carotid bruit Pulmonary flow Still’s murmur

Fig ure 18-12 Location of be nign he art m urm urs in childre n.

Th e A b d o m e n Most children are ticklish when you rst place your hand on their abdomens for palpation. This reaction tends to disappear, particularly if you distract the child.

A pathologically enlarged liver in children usually is palpable more than 2 cm below the costal margin, has a round, firm edge, and often is tender. A common condition of childhood that can occasionally cause a protuberant abdomen is constipation.



369


M a le G e n it a lia There is an art to palpation of the young boy’s scrotum and testes, because many have an active cremasteric re ex causing 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 testes are enlarged, with signs of pubertal changes. A painful testicle requires rapid treatment and may indicate torsion. Inguinal hernias in older boys present as they do in adult men.

F e m a le G e n it a lia Use a calm, gentle approach, including a developmentally appropriate explanation. Examine the genitalia in an ef cient and systematic manner. The normal hymen can have various con gurations (Fig. 18-13).

Fig ure 18-13 Se parate labia to as s e s s ge nital s tructure s .

Vaginal discha rge in early childhood can result from perinea l irritation (e.g., from bubble baths, soaps), foreign body, va ginitis, or sexually tra nsmitted infections from sexual abuse. Va ginal bleeding, a brasions, or signs of trauma to the external genitalia can result from sexua l a buse (see Table 18-7, Physical Signs of Sexual Abuse, p. 381).

370




T h e M u s c u lo s k e le t a l S y s t e m 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 sitting, run a short distance, and pick up objects. You will detect most abnormalities by watching carefully.

A screening musculoskeletal examination for children participating in sports can detect injuries or abnormalities that may result in problems during athletics. Extreme bowing or unilateral bowing may be from pathologic causes such as rickets or tibia vara (Blount disease).

Th e N e r v o u s S y s t e m Beyond infancy, the neurologic examination includes the components 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 neurologic signs can suggest minor developmental abnormalities.

Assessing Adolescents The key to successfully examining teens is a comfortable, con dential 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 con dentiality. Explain to both teens and parents that the purpose of con dentiality is to improve health care, not keep secrets. Your goal is to help adolescents bring their concerns or questions to their parents. Never make con dentiality unlimited, however. Always state to teens explicitly that you may need to act on information that makes you concerned about safety. 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 speci c techniques 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.



371


Th e B r e a s t s Assess normal maturational development.

See Table 18-4, Sex Maturity Ratings in Girls: Breasts, p. 377.

S p e c ia l T e c h n iq u e Te s t in g fo r S c o lio s is . Inspect any child who can stand for scoliosis. 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 scoliometer to test for the degree of scoliosis (Fig. 18-14). Fig ure 18-14 Me as ure and re cord s colios is w ith a s coliom e te r.

M a le a n d F e m a le G e n it a lia An important goal when examining adolescent males and females is to assign a sexual maturity rating, regardless of chronologic age.

See Table 18-5, Sex Maturity Ratings in Boys, pp. 378–379, and Table 18-6, Sex Maturity Ratings in Girls: Pubic Hair, p. 380.

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 ndings back to the traditional format. R e c o r d in g t h e P h y s ic a l E x a m in a t io n — T h e P e d ia t r ic P a t ie n t Bri n is chubby, ctive, nd energetic toddler. He l ys with the reflex h er, retending it is truck. He e rs closely bonded with his other, looking t her occ sion lly for co fort. She see s concerned th t Bri n will bre k so ething. His clothes re cle n. (continued )

372


R e c o r d in g t h e P h y s ic a l E x a m in a t io n — T h e P e d ia t r ic P a t ie n t (Continued ) Vit a l S ig n s . Ht 9 c

(9 th ercentile). Wt 16 kg (>95th ercentile). BMI 19.8 (>95th ercentile). He d circu ference 5 c (75th ercentile). BP 1 8/58. He rt r te 9 nd regul r. Res ir tory r te 3 ; v ries with ctivity. Te er ture (e r) 37.5°C. Obviously no in.

S k in . Nor

l exce t for bruises on legs, nd surf ce of elbows.

tchy, dry skin over extern l

HEEN T. Head: Nor oce h lic; no lesions. Eyes: Difficult to ex

ine bec use he won’t sit still. Sy etric with nor l extr ocul r ove ents. Pu ils 4 to 5 constricting. Discs difficult to visu lize; no he orrh ges noted. Ears: Nor l inn ; no extern l bnor lities. Nor l extern l c n ls nd ty nic e br nes (TMs). Nose: Nor l n res; se tu idline. Mouth: Sever l d rkened teeth on inside surf ce of u er incisors. One cle r c vity on u er right incisor. Tongue nor l. Cobblestoning of osterior h rynx; no exud tes. Tonsils l rge but dequ te g (1.5 c ) between the .

N e c k . Su

le,

idline tr che , no thyroid

l ble.

Ly m p h N o d e s . E sily

l ble (1.5 to 2 c ) tonsill r ly h nodes bil ter lly. S ll ( .5 c ) nodes in inguin l c n l bil ter lly. All ly h nodes obile nd nontender.

Lu n g s . Good ex

nsion. No t chy ne or dys ne . Congestion udible, but see s to be u er irw y (louder ne r outh, sy etric). No rhonchi, r les, or wheezes. Cle r to uscult tion.

C a r d io va s c u la r. PMI in 4th or 5th inters

ce nd idstern l line. Nor l S1 nd S2. No ur urs or bnor l he rt sounds. Nor l fe or l ulses; dors lis edis ulses l ble bil ter lly.

Br e a s t s . Nor

l, with so e f t under both.

A b d o m e n . Protuber nt but soft; no

below right cost l l ble.

sses or tenderness. Liver s n 2 c rgin (RCM) nd not tender. S leen nd kidneys not

G e n it a lia . T nner I circu cised enis; no ubic h ir, lesions, or disch rge.

Testes descended, difficult to Nor l scrotu both sides. M u s c u lo s k e le t a l. Nor

l te bec use of ctive cre

l r nge of otion of u nd ll joints. S ine str ight. G it nor l.

N e u ro lo g ic . Mental Status: H

steric reflex.

er nd lower extre ities

y, coo er tive child. Developmental: Gross otor—Ju s nd throws objects. Fine otor—I it tes vertic l line. L ngu ge—Does not co bine words; single words only, three to four noted during ex in tion. Person l–soci l—W shes f ce, brushes teeth, nd uts on shirt. Over ll—Nor l, exce t for l ngu ge, which e rs del yed. Cranial Nerves: Int ct, lthough sever l difficult to elicit. Cerebellar: Nor l g it; good b l nce. Deep tendon reflexes (DTRs): Nor l nd sy etric throughout with downgoing toes. Sensory: Deferred.


373

Aids to Interpretation Table 18-1 Cla s s if ic a t io n o f Ne w b o rn ’s Le ve l o f Ma t u rit y Intraute rine Gro wth Curve s 5 4.5 90%

4

La rge for ge s ta tiona l a ge Appropria te for ge s ta tiona l a ge

3

10%

2.5

S ma ll for ge s ta tiona l a ge

B

i

r

t

h

W

e

i

g

h

t

(

k

g

)

3.5

2

A

B

1.5 1 0.5 25

27

29

31

33 35 37 39 We e ks of Ge s ta tion

P re ma ture

Te rm

41

43

45

Pos tma ture

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. Classi cation of the low-birth-weight infant. In: Klaus MH, Fanaroff AA. Care of the High-Risk Neonate, 3rd ed. Philadelphia, PA: WB Saunders; 1986. Reproduced with permission.

374


Table 18-2 Hyp e r t e n s io n in Ch ild h o o d 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.

S

y

s

t

o

l

i

c

B

l

o

o

d

P

r

e

s

s

u

r

e

Boys S ys tolic Blood P re s s ure 95% Pe rce ntile 150 145 140 135 130 125 120 115 110 105 100 95 90 0

1

2

S ys tolic 5%

3

4

5

6

7

8 9 10 11 12 13 14 15 16 17 Age (Ye a rs )

S ys tolic 50%

S ys tolic 95%

Pa tie nt


375

Table 18-3 Ch a ra c t e ris t ic s o f P a t h o lo g ic He a r t Mu rm u r s C o n g e n it a l D e f e c t

C h a r a c t e r is t ic s o f M u r m u r

P u lm o n a ry Va lve S t e n o s is

Location. Upper left sternal border

Mild

Radiation. In mild degrees of stenosis, the murmur may be heard over the course of the pulmonary arteries in the lung fields.

S1

A2

P2

Intensity. Increases in intensity and duration as the degree of obstruction increases Quality. Ejection, peaking later in systole as the obstruction increases

Se ve re S1

A2

P2

Location. Midsternum, upper right sternal border

Ao r t ic Va lve S t e n o s is S1

A2

P2

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

Te t r a lo g y o f Fa llo t

General. Variable cyanosis, increasing with activity

With Pu lm o n ic S te n o s is

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.

With Pu lm o n ic Atre s ia

Radiation. Little, to upper left sternal border, occasionally to lung fields

S1

A2

S1

Intensity. Usually grade III–IV Quality. Midpeaking, systolic ejection murmur (table continues on page 376)

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Table 18-3 Ch a ra c t e ris t ic s o f P a t h o lo g ic He a r t Mu rm u r s (continued ) C o n g e n it a l D e f e c t

C h a r a c t e r is t ic s o f M u r m u r

Tr a n s p o s it io n o f t h e G r e a t A r t e r ie s

General. Intense generalized cyanosis Location. No characteristic murmur. If present, it may reflect an associated defect such as VSD. Radiation and quality. Depends on associated abnormalities

Ve n t r ic u la r S e p t a l D e f e c t

Location. Lower left sternal border

S m a ll to Mo d e ra te

Radiation. Little

S1

A2

P2

Intensity. Variable, only partially determined by the size of the shunt. Small shunts with a highpressure 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.


377

Table 18-4 S e x Ma t u rit y Ra t in g s in Girls : Bre a s t s 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 may continue to form a secondary mound).

Photos reprinted, with permission from the American Academy of Pediatrics, Assessment of Sexual Maturity Stages in Girls, 1995.

378


Table 18-5 S e x Ma t u rit y Ra t in g s in Bo ys 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

Pubic Hair: Preadolescent—no pubic hair except for the fine body hair (vellus hair) similar to that on the abdomen Genitalia ■

Stage 2

Penis, 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 ■ ■

Stage 3

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


379

Table 18-5 S e x Ma t u rit y Ra t in g s in Bo ys (continued ) Stage 4

Pubic Hair: Coarse and curly hair, as in the adult; area covered greater than in stage 3 but less than adult and not yet on thighs Genitalia ■

■

Stage 5

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.

380


Table 18-6 S e x Ma t u rit y Ra t in g s in Girls : P u b ic Ha ir 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.


381

Table 18-7 P h ys ic a l S ig n s o f S e xu a l Ab u s e P h y s ic a l S ig n s Th a t M a y In d ic a t e S e x u a l A b u s e in C h ild r e n a 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) P h y s ic a l S ig n s Th a t S t ro n g ly S u g g e s t S e x u a l A b u s e in C h ild r e n a 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. a

Any physical sign must be evaluated in light of the entire history, other parts of the physical examination, and laboratory data.

19 C H A P T E R

The Pregnant Woman The Health History Com m on Conce rns ●

● ●

Initi l ren t l history ● Confir tion of regn ncy ● Sy to s of regn ncy ● Concerns bout nd ttitudes tow rd the regn ncy ● Current he lth nd st edic l history ● P st obstetric history ● Risk f ctors for tern l nd fet l he lth ● F ily history of tient nd f ther of the newborn ● Pl ns for bre stfeeding ● Pl ns for ost rtu contr ce tion Gest tion l ge nd ex ected d te of delivery Subsequent ren t l visits

In it ia l P re n a t a l Vis it . Focus the initial prenatal visit on the health status of the mother and fetus. Con rm the pregnancy and estimate gestational age, develop a plan for continuing care, and counsel the mother about her expectations and concerns. At the end of the visit, reaf rm your commitment to the patient’s health and any ongoing concerns, review your ndings, and discuss any questions or tests or screenings that are needed. Ask about the following topics: ■ Con rmation of pregnancy. Has the patient had a con rmatory 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 con rm pregnancy. ■ Symptoms of pregnancy. Has the patient had absence of menses, breast

fullness or tenderness, nausea or vomiting, fatigue, and urinary frequency? Explain that serum or urine testing for beta human chorionic gonadotropin (HCG) offers the best con rmation of pregnancy.

383

384


■ 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. Respect diverse family structures, such as extended family support, single motherhood, or pregnancy conceived by sperm donation with or without a partner of either gender. ■ 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 surgeries, 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 transmitted infections, abnormal Pap smears, and exposure to diethylstilbestrol (DES) in utero. ■ Past obstetric history. Ask about prior pregnancies and outcomes. Has she

had any complications during past pregnancies? Were there any complications during labor and delivery such as large babies (fetal macrosomia), fetal distress, or emergency interventions? Were deliveries by vaginal delivery, assisted delivery (vacuum or forceps), or cesarean section? ■ Risk factors for maternal and fetal health. Does the patient use tobacco,

alcohol, or illicit drugs? Does she take any medications, over-thecounter 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 from obesity? Does she have an adequate social support network and income? Is there unusual 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 brosis, muscular dystrophy, and others. ■ Plans for breastfeeding. Education and encouragement during pregnancy

increase adoption and duration of breastfeeding. ■ Plans for postpartum contraception. Initiate this discussion early, as

postpartum contraception reduces the risk of unintended pregnancy and shortened interpregnancy intervals, which are linked to adverse pregnancy outcomes. Ge s t a t io n a l Ag e a n d Exp e c t e d Da t e o f De live ry. Accurate dating is best done early and contributes to appropriate management of the pregnancy. Dating establishes the timeframe for reassuring the patient about normal progress, establishing paternity, timing screening tests, tracking fetal growth, and effectively triaging preterm and postdated labor.

Chapter 19 | The Pregnant Woman

385

D e t e r m in in g G e s t a t io n a l A g e a n d t h e E x p e c t e d D a t e o f D e liv e r y ●

●

●

●

Gestational age. Count the nu ber of weeks nd d ys fro the first d y of the LMP. Counting this menstrual age fro the LMP– lthough biologic lly distinct fro the d te of conce tion, is the st nd rd e ns of c lcul ting fet l ge, yielding n ver ge regn ncy length of 4 weeks. If the ctu l d te of conce tion is known ( s with in vitro fertiliz tion), conce tion ge which is 2 weeks less th n the enstru l ge c n be used to c lcul te enstru l ge (i.e., corrected or djusted LMP d ting) to est blish d ting. Expected date of delivery (EDD). The ex ected d te of delivery is 4 weeks fro the first d te of the LMP. Using the Naegele rule, the EDD c n be esti ted by t king the LMP, dding 7 d ys, subtr cting 3 onths, nd dding 1ye r. Tools for calculations. Pregn ncy wheels nd online c lcul tors re co only used to c lcul te the EDD, but they should be checked for ccur cy. Limitations on pregnancy dating. P tient rec ll of the LMP is highly v ri ble. The LMP c n lso be bi sed by hor on l contr ce tives, enstru l irregul rities, or v ri tions in ovul tion th t result in ty ic l cycle lengths. Check LMP d ting g inst hysic l ex in tion rkers such s fund l height, cl rifying discre ncies g inst ultr sound ev lu tion.

S u b s e q u e n t P re n a t a l Vis it s . During subsequent visits, assess interim changes in the health status of the mother and fetus, review speci c physical examination ndings related to the pregnancy, and provide counseling and timely preventive screenings. Obstetric visits traditionally follow a set schedule: monthly until 28 gestational weeks, then biweekly until 36 weeks, then weekly until delivery. Update and document the history at every visit, especially fetal movement, contractions, leakage of uids and vaginal bleeding. At every visit, assess: vital signs (especially blood pressure and weight), fundal height, veri cation of FHR, and fetal position and activity. At each visit, test the urine for infection and protein.

Health Promotion and Counseling: Evidence and Recommendations Im p o r t a n t T o p ic s f o r H e a lt h P r o m o t io n a n d C o u n s e lin g ● ● ● ● ● ● ●

Nutrition Weight g in I uniz tions Exercise Subst nce buse Inti te rtner violence Pren t l l bor tory screenings

386


Nu t rit io n a n d We ig h t Ga in . Evaluate nutritional status, especially inadequate nutrition and obesity. ■ Assess diet history; measurement of height, weight, and body mass

index (BMI); and a hematocrit. Prescribe needed vitamin and mineral supplements. ■ To help prevent listeriosis, encourage pregnant patients to avoid:

unpasteurized milk and foods made with unpasteurized milk; raw and undercooked seafood, eggs, and meat; refrigerated paté, meat spreads, and smoked salmon; and hot dogs, luncheon meats, and cold cuts unless served steaming hot. ■ Recommend two servings a week of selected sh low in mercury and

shell sh. ■ Make a nutritional plan tailored to the patient’s BMI. Use the Pregnancy

Weight Gain Calculator and Super Tracker at the user-friendly ChooseMyPlate.gov website (http://www.choosemyplate.gov/pregnancy-weightgain-calculator). This calculator displays the daily recommended intake of each of the ve food groups for each trimester, based on height, prepregnancy weight, due date, and levels of weekly exercise. Monitor weight gain at each visit, with the results plotted on a graph, using the updated recommendations below. R e c o m m e n d a t io n s f o r T o t a l a n d R a t e o f W e ig h t G a in D u r in g P r e g n a n c y , b y P r e p r e g n a n c y B M I, 2 0 0 9

P re p re g n a n c y BM Ia

Underweight, or <18.5 Nor l weight, or 18.5–24.9 Overweight, or 25. –29.9 Obese, or ≥3 .

To t a l We ig h t G a in (Ra n g e in lb s )

28–4 25–35 15–25 11–2

Ra t e s o f We ig h t G a in b 2 n d a n d 3 r d Tr im e s t e r s (lb s /w k )

1 1 .6 .5

M e a n Ra n g e

1. –1.3 .8–1. .5– .7 .4– .6

To c lcul te BMI, go to C lcul te Your Body M ss Index, N tion l He rt, Lung, nd Blood Institute t htt :/ / www.nhlbi.nih.gov/ he lth/educ tion l/ lose_wt/ BMI/ b ic lc.ht . b C lcul tions ssu e 1.1–4.4 lbs-weight g in in the first tri ester. Source: R s ussen KM, Y ktine AL (eds.) nd Institute of Medicine. Committee to Re-examine IOM Pregnancy Weight Guidelines. Weight gain during pregnancy: re-examining the guidelines. W shington, DC: N tion l Ac de ies Press, 2 9. Av il ble t htt :/ / www.ncbi.nl .nih. gov/ books/ NBK32799/ t ble/su ry.t1/ ?re ort = objectonly. Accessed Se te ber 4, 2 15. a

Im m u n iza t io n s . Administer Tdap during each pregnancy, ideally at 27 to 36 weeks of gestation, regardless of the prior immunization history, and to caretakers in direct contact with the infant. Give inactivated in uenza vaccination in any trimester during the in uenza season.


387

S a f e a n d U n s a f e V a c c in e s d u r in g P r e g n a n c y S a f e d u r in g P r e g n a n c y ● ●

● ●

Pneu ococc l olys cch ride Meningococc l olys cch ride nd conjug te He titis A He titis B

N o t S a f e d u r in g P r e g n a n c y ● ● ●

Me sles/ u Polio V ricell

s/rubell

All women should have rubella titers drawn during pregnancy and be immunized after birth if found to be nonimmune. Check Rh(D) and antibody typing at the rst prenatal visit, at 28 weeks, and at delivery. Anti-D immunoglobulin should be given to all Rh-negative women at 28 weeks’ gestation and again within 3 days of delivery to prevent sensitization if the infant is Rh-D positive. Exe rc is e . Recommend ≥30 minutes of moderate exercise on most days of the week unless there are contraindications. Women initiating exercise during pregnancy should be cautious and consider programs developed speci cally for pregnant women. Water-based exercises can temporarily help alleviate musculoskeletal aches, but immersion in hot water should be avoided. After the rst trimester, women should avoid exercise in the supine position, which compresses the inferior vena cava and can cause dizziness and decreased placental blood ow. Because the center of gravity shifts in the third trimester, advise against exercises that cause loss of balance. Contact sports or activities that risk abdominal trauma are contraindicated throughout pregnancy. Pregnant women also should avoid overheating, dehydration, and any exertion that causes notable fatigue or discomfort. S u b s t a n c e Ab u s e . Promote abstinence as the immediate goal during pregnancy. Pursue universal screening in a neutral manner for: ■ Tobacco. Tobacco use accounts for up to 20% of all low-birth-weight

babies. It doubles the risk of placenta previa, placental abruption, and preterm labor and increases risk of spontaneous abortion, fetal death, and fetal digit anomalies. Cessation is the goal, but any decrease in use is favorable. ■ Alcohol. Fetal alcohol syndrome is the leading cause of preventable men-

tal retardation in the United States. The American Congress of Obstetricians and Gynecologists (ACOG) strongly recommends that women abstain throughout pregnancy. ■ Illicit drugs including narcotics. Women with addictions should be

referred for treatment immediately and counseled and screened for hepatitis C and HIV.

388


■ Abuse of prescription drugs. Ask about commonly abused prescription

drugs, including narcotics, stimulants, benzodiazepines. In t im a t e P a r t n e r Vio le n c e . Pregnancy is a time of increased risk from intimate partner violence ranging from verbal to physical abuse or from mild to severe physical abuse. Up to one in ve women experiences some form of abuse during pregnancy, contributing to delayed prenatal care, low infant birth weight, or even murder of the mother and fetus. ACOG recommends universal screening of all women for domestic violence at the rst prenatal visit and at least once each trimester. For a direct nonjudgmental approach, ACOG recommends the statement and simple questions listed below. A C O G S c r e e n in g A p p r o a c h f o r In t im a t e P a r t n e r V io le n c e Initial Statement: “Bec use violence is so co on in ny wo en’s lives nd bec use there is hel v il ble for wo en being bused, I now sk every tient bout do estic violence.” Screening Questions: 1. “Within the st ye r—or since you h ve been regn nt—h ve you been hit, sl ed, kicked or otherwise hysic lly hurt by so eone?” 2. “Are you in rel tionshi with erson who thre tens or hysic lly hurts you?” 3. “H s nyone forced you to h ve sexu l ctivities th t de you feel unco fort ble?” Source: A eric n Congress of Obstetrici ns nd Gynecologists. Screening tools–do estic violence. Av il ble t htt :/ / www. cog.org/About-ACOG/ACOG-De rt ents/ ViolenceAg inst-Wo en/ Screening-Tools–Do estic-Violence. Accessed Se te ber 2, 2 15.

Watch for nonverbal clues of abuse such as frequent last-minute appointment changes, unusual behavior during visits, partners who refuse to leave the patient alone during the visit, and bruises or other injuries. Once the patient acknowledges abuse, ask about the best way for you to help her. Respect limits she places on sharing information, with the caveat that if children are involved, you may be required to report harmful behaviors to the authorities. Maintain an updated list of shelters, counseling centers, hotline numbers, and other trusted local referrals. Plan future appointments at more frequent intervals. Perform as thorough a physical examination as the patient permits, and document all injuries on a body diagram. N a t io n a l D o m e s t ic V io le n c e H o t lin e ● ● ●

Website: www.thehotline.org 1–8 –799-SAFE (7233) TTY for he ring i ired: 1–8

–787–3224


389

P re n a t a l La b o ra t o ry S c re e n in g s . Initially include blood type and Rh, antibody screen, complete blood count—especially hematocrit and platelet count, rubella titer, syphilis test, hepatitis B surface antigen, HIV, STI screen for gonorrhea and chlamydia, and urinalysis with culture. Scheduled screenings include an oral glucose tolerance test for gestational diabetes around 24 weeks; a vaginal swab for group B streptococcus between 35 to 37 weeks’ gestation; and for obese pregnant patients, a glucose tolerance in the rst trimester. Pursue additional tests related to the mother’s risk factors, such as screening for aneuploidy, Tay–Sachs, or other genetic diseases, or amniocentesis.

Techniques of Examination P r e p a r in g f o r t h e E x a m in a t io n Be res onsive to the tient’s co fort nd riv cy, s well s her individu l nd cultur l sensitivities. During the initi l visit, t ke the history while she is clothed. Ask her to we r her gown with the o ening in front to e se the ex in tion of both bre sts nd the regn nt bdo en. Positioning ● The se isitting osition with the knees bent (see . 391) ffords the ost co fort nd rotects bdo in l org ns nd vessels fro the weight of the gr vid uterus. ● Avoid rolonged eriods of lying on the b ck. M ke your bdo in l l tion efficient nd ccur te. ● The elvic ex in tion lso should be rel tively quick. Equipment ● Gynecologic speculum and lubrication: Bec use of v gin l w ll rel x tion during regn ncy, l rger-th n-usu l s eculu y be needed. ● Sampling materials: The cervic l brush y c use bleeding, so the “broo ” s ling device is referred during regn ncy. Use ddition l sw bs if needed to screen for sexu lly tr ns itted infections, grou B stre , nd wet ount re r tions. ● Tape measure: Use l stic or er t e e sure to ssess the size of the uterus fter 2 gest tion l weeks. ● Doppler fetal heart rate monitor and gel: A ly “Do ler” or “Do tone” to the gr vid bdo en to ssess fet l he rt r te fter 1 weeks of gest tion.

H e ig h t , W e ig h t , a n d V it a l S ig n s Observe the general health, emotional state, nutritional status, and coordination as the pregnant woman comes into the room.

390


Measure height and weight. Calculate the BMI with standard tables, using 19 to 25 as normal for the prepregnant state.

Weight loss of more than 5% in excessive vomiting, or hyperemesis

Measure blood pressure at every visit. In midpregnancy, it may be lower than in the nonpregnant state. H y p e r t e n s io n in P r e g n a n c y ●

● ●

Gestational hypertension: Systolic blood ressure (SBP) >14 or di stolic blood ressure (DBP) >9 first docu ented fter 2 weeks, without roteinuri or reecl si , th t resolves by 12 weeks’ ost rtu . Chronic hypertension: SBP >14 or DBP >9 th t red tes regn ncy. Preeclampsia: SBP ≥14 or DBP ≥9 fter 2 weeks on two occ sions t le st 4 hours rt in wo n with reviously nor l BP or BP ≥16 / 11 confir ed within inutes and roteinuri ≥3 g/24 hours, rotein:cre tinine ≥ .3, or di stick 1+; or new onset hy ertension without roteinuri nd ny of the following: thro bocyto eni ( l telets <1 , / µL), i ired liver function (liver tr ns in se levels ore th n twice nor l), new ren l insufficiency (cre tinine >1.1 g/dL or doubles in the bsence of ren l dise se), ul on ry ede , or new onset cerebr l or visu l sy to s.

He a d a n d N e c k ■ Face. Inspect for the mask of

pregnancy, chloasma, or irregular brownish patches around the forehead and cheeks, across the bridge of the nose, or along the jaw.

Facial edema after 20 weeks in possible preeclampsia

■ Hair

Hair loss should not be attributed to pregnancy.

■ Eyes. Note the conjunctival

Anemia of pregnancy may cause conjunctival pallor.

color. ■ Nose, including nasal congestion

Nosebleeds are more common during pregnancy. Erosion of nasal septum if use of intranasal cocaine.

■ Mouth

Gingival enlargement common

■ Thyroid gland. Inspect and

Thyroid enlargement, goiters, and nodules are abnormal and should be investigated.

palpate. Modest symmetric enlargement is common.



391


T h o r a x a n d Lu n g s Inspect the thorax for contours. Observe the pattern of breathing. Auscultate the lungs.

Respiratory alkalosis in later trimesters. Increased respiratory rate, cough, rales, or respiratory distress in infection, asthma, pulmonary embolus, peripartum cardiomyopathy.

He a rt Palpate the apical impulse.

Impulse may be rotated upward and to the left toward the 4th intercostal space by the enlarging uterus.

Auscultate the heart. A venous hum and systolic or continuous mammary souf e (see p. 185) are common.

Murmurs may signal anemia; new diastolic murmurs should be investigated. If signs of heart failure, consider peripartum cardiomyopathy.

Bre a s ts Inspect the breasts and nipples for symmetry and color. Venous pattern, darkened nipples and areolae, and prominent Montgomery glands are normal.

Inverted nipples at the time of birth may hamper breastfeeding.

Palpate for masses. Tender nodular breasts are normal.

Focal tenderness in mastitis. Investigate any new discrete masses.

Compress each nipple between your index nger and thumb.

This may express colostrum from the nipples; investigate if abnormal bloody or purulent discharge.

Abdom en Place the pregnant woman in a semisitting position with her knees exed (Fig. 19-1).

Fig ure 19-1 The s e m is itting pos ition. ■ Inspect any scars or striae, the

shape and contour of the abdomen, and the fundal height.

Purplish striae and linea nigra are normal.

392




■ Assess the shape and contour

to estimate pregnancy size (Fig. 19-2).

36 32 28 24

wks wks wks wks

20 wks 16 wks 12–14 wks

■ Palpate for:

Fig ure 19-2 Grow th patte rns of the

■

Organs and masses

ute rine fundus by we e ks of pre gnancy.

■

Fetal movements, usually detected after 24 weeks

Ultrasound confirmation of fetal health and movement may be needed.

■

Uterine contractility

■

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 pregnant, 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.

If fundal height is more than 4 cm higher than expected, consider multiple gestation, a large fetus, extra amniotic fluid, or uterine leiomyoma. If more than 4 cm lower, consider low level of amniotic fluid, missed abortion, transverse lie, growth retardation, or fetal anomaly.

■ 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. ■

Location. From 10 to 18 weeks, the FHR is in the midline of the lower abdomen; later depends on fetal position. Use modi ed Leopold’s maneuvers to palpate the fetal head and back and identify where to listen.

Lack of an audible FHR may indicate pregnancy of fewer weeks than expected, fetal demise, or false pregnancy. If unable to locate the FHR, investigate with formal ultrasound.



393


■

Rate. The rate usually is 120 to 160 beats per minute. After 32 to 34 weeks, the FHR should increase with fetal movement.

Sustained dips in FHR, or “decelerations,” always warrant investigation, at least by formal FHR monitoring.

■

Rhythm. In the third trimester, 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.

G e n it a lia , A n u s , a n d R e c t u m Inspect the external genitalia.

Parous relaxation of the introitus, labial varicosities, enlargement of the labia and clitoris, scars from an episiotomy or perineal lacerations

Palpate Bartholin and Skene glands. Check for a cystocele or rectocele.

Bartholin cyst

Examine the internal genitalia. S p e c u lu m Exa m in a t io n ■ Inspect the cervix for color,

shape, and healed lacerations.

■ Perform a Pap smear, if

indicated. ■ Inspect the vaginal walls.

Bim a n u a l Exa m in a t io n . Insert two lubricated ngers into introitus, palmar side down, with slight pressure downward on the perineum. Slide the ngers into the posterior vaginal vault. Maintaining downward pressure, gently turn the ngers palmar side up.

Purplish color of pregnancy; lacerations from prior deliveries, cervical erosion, erythema, discharge, or irritation in cervicitis and STIs Specimens may be needed for diagnosis of vaginal or cervical infection Bluish or violet color, deep rugae, leukorrhea in normal pregnancy; vaginal discharge in candidiasis and bacterial vaginosis (can affect pregnancy outcome)

394



■ Assess the cervical os and degree

of effacement. Place your nger 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 ngers 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.

P O SSIBLE FIN DIN G S 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. Effacement prior to 37 weeks in preterm labor.

Hegar 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 bicornua te uterus, two distinct uterine cavities separated by a septum.

Early in pregnancy, it is important to rule out tubal (ectopic) pregnancy.

■ Evaluate pelvic oor strength

as you withdraw the examining ngers. ■ Inspect the anus. Rectal and

rectovaginal examinations are usually not indicated.

Hemorrhoids may engorge later in pregnancy.

E x t r e m it ie s Inspect the legs for varicose veins.

Varicose veins may worsen during pregnancy.

Palpate the hands and legs for edema.

Watch for swelling of preeclampsia or deep venous thrombosis.

Check knee and ankle deep tendon re exes.

Hyperreflexia may signal preeclampsia.



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S p e c ia l T e c h n iq u e s Le o p o ld Ma n e u ve rs

Identify: ■ The upper and lower fetal poles,

namely, the proximal and distal fetal parts

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.

■ The maternal side where the

fetal back is located ■ The descent of the presenting

part into the maternal pelvis ■ The extent of exion of the fetal

head ■ Estimated fetal weight and size

Fir s t Ma n e u ve r (Up p e r Fe t a l P o le ). Stand at the woman’s side, facing her head. Keep the ngers of both examining hands together. Palpate gently with the ngertips to determine what part of the fetus is in the upper pole of the uterine fundus (Fig. 19-3).

Fig ure 19-3 Palpate uppe r fe tal pole .

S e c o n d Ma n e u ve r (S id e s o f t h e Ma t e rn a l Ab d o m e n ). Place one hand on each side of the woman’s abdomen, capturing the fetal body between them (Fig. 19-4). Steady the uterus with one hand and palpate the fetus with the other, looking for the back on one side and extremities on the other.

Fig ure 19-4 Palpate fe tal back and extre m itie s .

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Th ird Ma n e u ve r (Lo w e r Fe t a l P o le a n d De s c e n t in t o P e lvis ). Face the woman’s feet. Palpate the area just above the symphysis pubis (Fig. 19-5). 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. Fig ure 19-5 Palpate lowe r fe tal pole .

Fo u r t h Ma n e u ve r (Fle xio n o f t h e Fe t a l He a d ). This maneuver assesses the exion 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 (Fig. 19-6). Using one hand at a time, slide your ngers down each side of the fetal body until you reach the “cephalic prominence,” that is, where the fetal brow or occiput juts out.

Fig ure 19-6 Palpate for the ce phalic prom ine nce .

Recording Your Findings Pregnant women are described in terms of number of pregnancies (Gravida, or “G”) and labors (Para, or “P”) they have experienced. Parity is further broken down into term deliveries, preterm deliveries, abortions (spontaneous abortions and terminated pregnancies), and living children, (which yields the mnemonic “TPAL”). ■ For example, a woman who has had two prior children and is pregnant

with her third pregnancy would be referred to simply as “G3P2.”


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■ A woman with two spontaneous losses prior to 20 weeks’ gestation,

three living children who delivered at term, and a current pregnancy, would be referred to as “G6P3023.” ■ One common error is to assign a multiple pregnancy, for example,

twins, as a count of two for either gravity or parity. In practice, each pregnancy receives only one count in any of the categories regardless of the number of fetuses, except for living children, when all are counted. So, designate a rst pregnancy with twins delivered at term as G1P1002. Typically, the write-up follows a standard order: age, Gs and Ps, weeks of gestation, means of determining gestational age (ultrasound vs. LMP), followed by chief complaint, chief pregnancy complications, then important history and examination ndings, as below. R e c o r d in g t h e P h y s ic a l E x a m in a t io n —T h e P re gna nt W om a n “32-ye r-old G3,P11 2 t 18 weeks’ gest tion s deter ined by LMP resents to est blish ren t l c re. P tient endorses fet l ove ent; denies contr ctions, v gin l bleeding, nd le k ge of fluids. On extern l ex in tion, low tr nsverse ces re n sc r is evident; fundus is l ble just below u bilicus. On intern l ex in tion, cervix is o en to fingerti t the extern l os but closed t the intern l os; cervix is 3 c long; uterus enl rged to size consistent with 18-week gest tion. S eculu ex in tion shows leukorrhe with ositive Ch dwick sign. FHT by Do ler re between 14 nd 145 BPM.” (This describes a healthy woman at 18 weeks’ gestation.)

20 C H A P T E R

The Older Adult

Older Americans now number more than 43 million people and are expected to reach 80 million by 2040, over 20% of the population. Life span at birth is currently 81 years for women and 76 years for men. The “demographic imperative” is to maximize not only life span but also “health span” so that older adults maintain full function for as long as possible, enjoying rich and active lives in their homes and communities. This 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 long-term health and safety. The aging population displays marked heterogeneity. Investigators distinguish “usual” aging, with its complex of diseases and impairments, 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%. T h e G e r ia t r ic A p p r o a c h f o r P r im a r y C a r e 1. Le rn to quickly identify fr il elderly tients; they re ost vulner ble to dverse outco es nd ost benefit fro holistic geri tric ro ch. 2. Look for co on geri tric syndro es, including f lls, deliriu /cognitive i ir ent, function l de endence, nd urin ry incontinence in every tient. 3. Le rn bout efficient ssess ent tools for geri trics nd geri tric syndro es nd te ch clinic l st ff to d inister the when ossible. 4. Be f ili r with co unity resources, such s f ll revention rogr s, PACE rogr s, nd senior centers. 5. T ke into ccount tient’s go ls, life ex ect ncy, nd function l st tus before considering ny test or rocedure. 6. Review dv nced directives nd go ls of c re eriodic lly. 7. Be knowledge ble bout the Beers Criteri ( J Am Geriatr Soc. 2 12;6 :616); use the to identify otenti lly in ro ri te edic tions in the elderly nd infor eriodic co rehensive edic tion review. 8. Ado t n evidence-b sed ro ch to he lth screening, es eci lly in the fr il elderly. (continued )

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T h e G e r ia t r ic A p p r o a c h f o r P r im a r y C a r e

(Continued)

9. W tch c refully for ood disorders in the fr il elderly nd consider using geri tric-s ecific screening tools, such s the five-ite Geri tric De ression Sc le. 10. Provide c regiver su ort when ossible. Source: C rlson C, Merel SE, Yuk w M. Geri tric syndro es nd geri tric ssess ent for the gener list. Med Clin N Am. 2 15:99:263; Ad ted fro A eric n Geri trics Society 2 12 Beers Criteri U d te Ex ert P nel. A eric n Geri trics Society u d ted Beers criteri for otenti lly in ro ri te edic tion use in older dults. J Am Geriatr Soc. 2 12;6 :616; nd Hoyl MT, Alessi CA, H rker JO, et l. Develo ent nd testing of five-ite version of the geri tric de ression sc le. J Am Geriatr Soc. 1999;47:873.

The Health History A p p r o a c h t o t h e O ld e r A d u lt As you talk with older adults, convey respect, patience, and cultural awareness. Be sure to address patients by their last name. Ad ju s t in g t h e O f c e En v iro n m e n t . Make sure the of ce 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 de cits. Free the room of distractions or noise. Consider using a “pocket talker,” a microphone that ampli es your voice and connects to an earpiece inserted by the patient. Chairs with higher seating and a wide stool with a handrail leading up to the examining table help patients with quadriceps weakness. S h a p in g t h e Co n t e n t a n d P a c e o f t h e Vis it . 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 endurance and possible fatigue. Consider dividing the initial assessment into two visits. Elic it in g S ym p t o m s in t h e Old e r Ad u lt . Older patients may overestimate their health even when increasing disease and disability are apparent. To reduce the risk of late recognition and delayed intervention, adopt more directed questions or health screening tools. Consult with family members and caretakers.

Acute illnesses present differently in older adults. Be sensitive to unusual presentations of myocardial infarction and thyroid disease. Older patients with infections are less likely to have fever.

Chapter 20 | The Older Adult

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Recognize the symptom clusters of different geriatric syndromes, characterized by interacting clusters of symptoms that lead to functional decline, for example, falls, dizziness, depression, urinary incontinence, and functional impairment. Searching for the usual “unifying diagnosis” may pertain to fewer than 50% of older adults. Although cognitive impairment may alter the patient’s history, most older adults even with mild cognitive impairment can provide suf cient history to reveal current disorders. Use simple sentences with prompts to trigger necessary information. If impairments are more severe, con rm symptoms with family members or caregivers. Ad d re s s in g Cu lt u ra l Dim e n s io n s o f Ag in g G e r ia t r ic D iv e r s it y —N o w a n d in 2 0 5 0 ●

●

●

●

Hispanic Americans over ge 65 will incre se fro 2.7 illion in 2 1 , or 6.9% of older dults, to 17.5 illion in 2 5 , or 19.8% of the older o ul tion. African American older dults will incre se fro 3.4 illion (8.5%), to 1 .5 illion in 2 5 (11.9%). Asian Americans nd other ethnic grou s, lthough s ller in nu ber currently, will incre se fro 1.4 illion to 7.5 illion, or fro 3.4% to 8.5%. Non-Hispanic whites will incre se fro 32.2 illion to 58.5 illion in 2 5 , but will dro s ercent ge of the older o ul tion fro 8 % to 58.5%.

Source: Feder l Inter gency Foru on Aging Rel ted St tistics. Older A eric ns 2 12, Key Indic tors of Well Being. Indic tor 2, R ci l nd Ethnic Co osition, . 86. Feder l Intergency Foru on Aging-Rel ted St tistics. W shington, DC: U.S. Govern ent Printing Office. June 2 12. Av il ble t htt :/ / gingst ts.gov/ gingst tsdotnet/ M in_Site/ D t /2 12_Docu ents/ Docs/ EntireCh rtbook. df. Accessed August 11, 2 15.

Cultural differences affect the epidemiology of illness and mental health, acculturation, the speci c concerns of the elderly, the potential for misdiagnosis, and disparities in health outcomes. Review the components of self-awareness needed for cultural responsiveness, discussed in Chapter 3 (pp. 49–50). Ask about spiritual advisors and native healers. Cultural values particularly affect decisions about the end of life. Elders, family, and even an extended community group may make these decisions with or for the older patient. Com m on Conce rns ● ●

● ●

Activities of d ily living Instru ent l ctivities of d ily living Medic tions Acute nd ersistent in

● ● ● ●

S oking nd lcohol Nutrition Fr ilty Adv nce directives nd c re

lli tive

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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. Ac t ivit ie s o f Da ily Livin g . Daily activities provide an important baseline for future evaluations. Ask, “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?” A c t iv it ie s o f D a ily Liv in g a n d In s t r u m e n t a l A c t iv it ie s o f D a ily Liv in g P h y s ic a l Ac t iv it ie s o f Da ily Liv in g (A D Ls )

In s t r u m e n t a l Ac t iv it ie s o f Da ily Liv in g (IA D Ls )

B thing Dressing Toileting Tr nsferring Continence Feeding

Using the tele hone Sho ing Pre ring food Housekee ing L undry Tr ns ort tion T king edicine M n ging oney

Me d ic a t io n s . Adults older than 65 take approximately 30% of all prescriptions. Almost 40% take ve or more prescription drugs daily. Older adults have more than 50% of all reported adverse drug reactions. Take a thorough medication history, including name, dose, frequency, and indication for each drug. Explore all components of 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 modi able risk factor associated with falls. “Start low, go slow” when prescribing doses. Ac u t e a n d P e r s is t e n t P a in . 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, leading to undue suffering, depression, social isolation, physical disability, and loss of function.

Inquire about pain each time you meet with the older patient. Ask speci cally, “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.


403

C h a r a c t e r is t ic s o f A c u t e a n d P e r s is t e n t P a in Ac u t e P a in

P e r s is t e n t P a in

Distinct onset Obvious thology

L sts ore th n 3 onths Often ssoci ted with sychologic l or function l i ir ent Short dur tion C n fluctu te in ch r cter nd intensity over ti e Co on c uses: ostsurgic l, Co on c uses: rthritis, c ncer, cl udic tion, tr u , he d che leg cr s, neuro thy, r diculo thy Source: Reuben DB, Herr KA, P c l JT, et l. Geriatrics at Your Fingertips: 2004. 6th ed. M lden, MA: Bl ckwell Publishing, for the A eric n Geri trics Society; 2 4:149.

S m o k in g a n d Alc o h o l. At each visit, advise elderly smokers to quit. From 10% to 15% of older patients in primary care practices have problem drinking. Rates of detection and treatment are low. Screen all older adults for excess alcohol use, which contributes to drug interactions and worsens comorbid illnesses. Use the CAGE questions to uncover problem drinking (see p. 56), and watch for clues of excess consumption such as memory loss, depression, and self-neglect. Nu t rit io n . Taking a diet history and using rapid screening tools (p. 73) are especially important in older adults. Fra ilt y. The prevalence of this multifactorial syndrome is 4% to 59%. Screen for three key features and pursue related interventions: weight loss of more than 5% over 3 years, inability to do ve chair stands, and selfreported exhaustion. Ad va n c e Dire c t ive s a n d P a llia t ive Ca re . Initiate these discussions before serious illness develops. Advance care planning involves providing information, invoking the patient’s preferences, identifying surrogate decision makers, and conveying empathy and support. Use clear, simple language. Clarify preferences related to “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 re ecting your wishes in case of confusion or emergency.” Discuss these decisions in the of ce rather than in the pressured environments of the emergency room or hospital.

When needed, provide palliative care “to relieve suffering and improve the quality of life for patients with advanced illnesses and their families through speci c 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 clinical and social services.”

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When to screen C ncer screening De ression, de enti , nd cognitive i Elder istre t ent nd buse

ir ent

Wh e n t o S c re e n . As the life span for older adults extends into the 80s, base screening decisions on the older adult’s individual health and functional status, including presence of comorbidity, rather than age alone. The American Geriatrics Society recommends a ve-step approach: assess patient preferences, interpret the available evidence, estimate prognosis, consider treatment feasibility, and optimize therapies and care plans. If life expectancy is short, adopt treatments that bene t the patient in the time that remains. Defer screening if it overburdens the older adults who have multiple clinical problems, shortened life expectancy, or dementia. ■ Screen for age-related changes in vision and hearing. These are included

in the 10-Minute Geriatric Screener (p. 407). ■ Recommend aerobic exercise, such as brisk walking for 150 minutes

every week and graded resistance training in major muscle groups to increase strength. ■ Promote household safety. Correct poor lighting, chairs at awkward

heights, slippery or irregular surfaces, and environmental hazards. ■ Immunizations. Recommend vaccination for in uenza; pneumonia, both

PPSV23 and PCV13; herpes zoster (shingles); and tetanus/diphtheria and pertussis (Tdap and Td). Consult the updated annual guidelines and contraindications provided by the CDC at http://www.cdc.gov/vaccines. Ca n c e r S c re e n in g . 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. S c r e e n in g R e c o m m e n d a t io n s f o r O ld e r A d u lt s : U . S . P r e v e n t iv e S e r v ic e s T a s k F o r c e ●

Breast cancer (2016): Reco ends ogr hy every 2 ye rs for wo en ges 5 to 74 nd cites insufficient evidence for screening wo en ges ≥75 ye rs. (continued )


405

S c r e e n in g R e c o m m e n d a t io n s f o r O ld e r A d u lt s : U . S . P r e v e n t iv e S e r v ic e s T a s k F o r c e (Continued) ●

●

●

●

●

Cervical cancer (2012): Reco ends g inst routine screening for wo en over ge 65 if they h ve h d dequ te recent screening with nor l P s e rs nd re not otherwise t high risk for cervic l c ncer, b sed on f ir evidence. Colorectal cancer (2008): Reco ends screening with colonosco y every 1 ye rs, sig oidosco y every 5 ye rs with high-sensitivity fec l occult blood tests (FOBTs) every 3 ye rs, or FOBTs every ye r beginning ge 5 ye rs through ge 75 ye rs. Reco ends g inst routine screening for dults ges 76 to 85 ye rs, due to oder te cert inty th t the net benefit is s ll. Prostate cancer (2012): Reco ends g inst rost te-s ecific ntigenb sed screening for rost te c ncer in en of ll ges due to evidence th t ex ected h r s re gre ter th n ex ected benefits. Lung cancer (2013): For dults ges 55 to 8 ye rs with 3 - ck/ ye r s oking history, nd those who currently s oke or h ve quit within the st 15 ye rs, reco ends nnu l screening with low-dose co uted to ogr hy. Screening should be discontinued once erson h s not s oked for 15 ye rs or develo s he lth roble th t subst nti lly li its life ex ect ncy or the bility or willingness to h ve cur tive lung surgery. Skin cancer (2009; updated in 2015): St tes th t evidence is insufficient to b l nce the benefits nd h r s of whole-body skin ex in tion.

De p re s s io n , De m e n t ia , a n d Co g n it ive Im p a irm e n t . Depression affects 5% to 7% of community-dwelling older adults and approximately 10% of older men and 18% of older women, but is often undiagnosed. Use the two validated screening questions in Chapter 5 on pp. 85–86.

Dementia is “an acquired condition that is characterized by a decline in at least two cognitive domains (e.g., loss of memory, attention, language, or visuospatial or executive functioning) that is severe enough to affect social or occupational functioning.” Alzheimer disease (AD), the predominant form, affects 11% of Americans over age 65 years; over two thirds are women. Probable AD, based on DSM-5 criteria, consists of evidence of a causative genetic mutation from family history or genetic testing, or the presence of cognitive decline in two or more cognitive domains, with all three of the following features: ■ Clear evidence of a decline in memory and learning and at least one

other cognitive domain (as described for dementia above); ■ Steady progressive decline in cognition without extended plateaus; and ■ No evidence of mixed etiology from other neurodegenerative, cerebro-

vascular, mental, or systemic disease. Most dementias represent AD (50% to 85%) or vascular multi-infarct dementia (10% to 20%). Other dementias include frontotemporal

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dementia, dementia with Lewy bodies, Parkinson disease with dementia, and dementia of mixed etiology. The spectrum of cognitive decline includes: ■ Age-related cognitive decline: with occasional mild forgetfulness, dif-

culty remembering names, and mildly reduced concentration but preservation of daily function. ■ Mild cognitive impairment (MCI): Daily function is preserved, but there is

evidence of modest cognitive decline in one or more cognitive domains (complex attention, executive function, learning and memory, language, perceptual-motor, or social cognition) based on objective tasks, as reported by the patient, an informant, or the clinician or on clinical testing. Alertness and attention is preserved (unlike delirium). Use recommended screening tests for dementia such as the Mini-Cog and the Montreal Cognitive Assessment (MoCA). See Table 20-3, p. 420, and Table 20-4, p. 421. Eld e r Mis t re a t m e n t a n d Ab u s e . Screen older patients for possible elder mistreatment, which includes abuse, neglect, exploitation, and abandonment. Prevalence ranges from 5% to 10% of older adults; however, many cases remain undetected.

Techniques of Examination Assessment of the older adult departs from the traditional history and physical examination. Enhanced interviewing, emphasis on daily function and the key topics described above, and functional assessment are especially important.

A s s e s s in g F u n c t io n a l S t a t u s : T h e “ S ix t h V it a l S ig n ” As s e s s in g Fu n c t io n a l Ab ilit y. Functional status is the ability to perform tasks and ful ll social roles associated with daily living across a wide range of complexity. The 10-Minute Geriatric Screener is brief, has high interrater agreement, and can be used easily by of ce staff. It covers the three important domains: physical, cognitive, and psychosocial function and addresses key sensory modalities and urinary incontinence, an often unreported problem. Mnemonics that help students assess incontinence are: DIAPERS (Delirium, Infection, Atrophic urethritis/vaginitis, Pharmaceuticals, Excess urine output from conditions like hyperglycemia or heart


407

failure, Restricted mobility, and Stool impaction) and DDRRIIPP (Delirium, Drug side effects, Retention of feces, Restricted mobility, Infection of urine, In ammation, Polyuria, and Psychogenic). 1 0 -M in u t e G e r ia t r ic S c r e e n e r P ro b le m a n d S c r e e n in g M e a s u r e

P o s it ive S c r e e n

Vision: Two P rts: Ask: “Do you h ve difficulty driving, or w tching television, or re ding, or doing ny of your d ily ctivities bec use of your eyesight?” If yes, then: Test e ch eye with Snellen ch rt while tient we rs corrective lenses (if lic ble). Hearing: Use udiosco e set t 4 dB. Test he ring using 1, nd 2, Hz.

Yes to question nd in bility to re d >2 /4 on Snellen ch rt

Leg mobility: Ti e the tient fter instructing: “Rise fro the ch ir. W lk 2 feet briskly, turn, w lk b ck to the ch ir, nd sit down.” Urinary incontinence: Two P rts: Ask: “In the l st ye r, h ve you ever lost your urine nd gotten wet?” If yes, then sk: “H ve you lost urine on t le st 6 se r te d tes?” Nutrition/ weight loss: Two rts: Ask: “H ve you lost 1 lb over the st 6 onths without trying to do so?” Weigh the tient. Memory: Three-ite rec ll

In bility to he r 1, or 2, Hz in both e rs or either of these frequencies in one e r Un ble to co lete t sk in 15 seconds Yes to both questions

Yes to the question or weight <1 lb

Un ble to re e ber ll three ite s fter 1 inute Yes to the question

Depression: Ask: “Do you often feel s d or de ressed?” Physical disability: Six questions: No to ny of the “Are you ble to . . . : questions ● “Do strenuous ctivities like f st w lking or bicycling?” ● “Do he vy work round the house like w shing windows, w lls, or floors?” ● “Go sho ing for groceries or clothes?” ● “Get to l ces out of w lking dist nce?” ● “B the, either s onge b th, tub b th, or shower?” ● “Dress, like utting on shirt, buttoning nd zi ing, or utting on shoes?”

Source: More AA, Siu AL. Screening for co on roble s in bul tory elderly: clinic l confir tion of screening instru ent. Am J Med. 1996;1 :438.

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Fu r t h e r A s s e s s m e n t fo r P r e ve n t in g Fa lls . Compelling evidence links falls, a multifactorial geriatric syndrome, to fatal and nonfatal injuries, mortality, and burgeoning clinical costs that exceed $34 billion annually. One in three older adults falls each year. Falls are the most common cause of traumatic brain injury in older adults and cause 95% of hip fractures.

The American Geriatrics Society, the British Geriatrics Society, and the CDC’s Injury Center has launched the STEADI (Stopping Elderly Accidents, Deaths, and Injuries) falls prevention toolkit to help primary care providers better assess, treat, and refer patients at risk. Also see Figure 20-1.

S T E A D I F a lls P r e v e n t io n A lg o r it h m : K e y F e a t u r e s f o r C lin ic a l P r a c t ic e ● ● ●

● ●

●

●

Screen all co unity-dwelling older dults bout risk for f lls. Encour ge all older tients to ursue g it nd b l nce exercise. Do g it, strength, nd b l nce ssess ent with the Ti ed Get U nd Go test in tients who screen ositive. Str tify tients ccording to low, oder te, nd high risk. Identify high-risk older adults, n ely, those with g it, strength, or b l nce roble nd t le st one f ll with n injury. In high-risk older adults, conduct ultif ctori l risk ssess ent, including: ● review of the St y Inde endent brochure; ● f lls history nd edic tion review; ● hysic l ex in tion including ssess ent of visu l cuity, ostur l hy otension, cognitive screen, ins ection of the feet nd use of footwe r, nd use of obility ids; ● function l ssess ent; nd ● environ ent l or ho e s fety ssess ent. I le ent individu lized interventions, including hysic l ther y nd follow-u in 3 d ys.



P h y s ic a l E x a m in a t io n o f t h e O ld e r A d u lt Vit a l S ig n s . Measure blood pressure, checking for increased systolic blood pressure (SBP) and widened pulse pressure (PP), de ned as SBP minus diastolic blood pressure (DBP).

Isolated systolic hypertension (SBP ≥140) after age 50 years and PP ≥60 increase risk of stroke, renal failure, and heart disease.


409

Pa tie nt c ompletes S tay Indep endent brochure

Sc re e n fo r falls and/o r fall ris k Pa tie nt a ns we rs YES to a ny key ques tion:

) s t (optional)

medications Vitamin D +/– calcium

hypotens ion s Addres s foot p roblems Optimize vis ion Optimize home s afety

L o w R i i s k H i

e nhanc e func tional mobility & improve s tre ngth & ba la nc e

fall ris k reduction beha viors es s barriers to adhe re nc e

g

Vita min D +/– ca lc ium

Fo llo w up with HIGH RISK patie nt within 30 days re p la n

h

inc luding: - Pos tura l dizzine s s /pos tural hyp ote ns ion - Medica tion review - Cognitive s cree n - Fee t & footwea r - Us e of mobility a id s - Vis ual ac uity c he ck

HIGH RISK Individualize d fall inte rve ntio ns

R

Co nduc t multifac to rial ris k as s e s s me nt S tay Inde pende nt brochure

No injury

i

Injury

0 falls

s

1 fa ll

k

≥2 falls

improve gait, strength & balance or refer to a community fall prevention program

R

e

t

Gait, s trength or balanc e problem

s

MODERATE RISK Individualize d fall inte rve ntio ns M

(re commended)

o

No gait, s tre ngth, or ba lance problems *

d

Evaluate g ait, s tre ng th & balanc e

e

YES to any ke y ques tion

k

Vitamin D +/– calcium ength & cise cise or fall prevention program

r

- Were you injur

LOW RISK Individualize d fall inte rve ntio ns

a

NO to all key ques tions

ans ition to cis e progra m whe n patient is read y

*For thes e patients , c ons ider additional ris k as s es s ment (e.g. medica tion review, cognitive s cree n, s yncope)

Fig ure 20-1 STEADI algo rithm . Source : Ce nte rs for Dis e as e Control and Preve ntion. National Ce nte r for Injury Preve ntion and Control. STEADI—Stopping Elde rly Accide nts , De aths and Injurie s . Available at http://w w w.cdc.gov/s te adi/pdf/ algorithm _2015–04-a.pdf. Acce s s e d Augus t 23, 2015.

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For adults ages ≥60 years, the JNC8 recommends blood pressure targets of ≤150/90 but notes that if treatment results in SBP <140 and is “well tolerated and without adverse effects to health or quality of life, treatment does not need to be adjusted.” Assess the patient for orthostatic hypotension, de ned 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 positions: 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.

Measure heart rate, respiratory rate, and temperature. Check the apical heart rate to help detect arrhythmias in older adults. Use thermometers accurate for lower temperatures.

Respiratory rate ≥25 breaths per minute indicates lower respiratory infection or possible CHF or COPD.

Weight and height are especially important and needed for calculation of the BMI (p. 63). Weight should be measured at every visit. Obtain oxygen saturation using a pulse oximeter.

Low weight is a key indicator of poor nutrition.

S k in . Note physiologic changes of aging, such as thinning, loss of elastic tissue and turgor, and wrinkling.

Dry, flaky, rough, and often itchy

Inspect the extensor surface of the hands and forearms.

White depigmented patches (pseudoscars); well-demarcated, vividly purple macules or patches that may fade after several weeks (actinic purpura)

Assess medications and causes such as autonomic disorders, diabetes, prolonged bed rest, volume depletion, amyloidosis, postprandial state, and cardiovascular disorders.

Hypothermia is more common in elderly patients.

Undernutrition in depression, alcoholism, cognitive impairment, malignancy, chronic organ failure (cardiac, renal, pulmonary), medication use, poor dentition, social isolation, and poverty

Benign comedones, or blackheads, on the cheeks or around the eyes; cherry angiomas (p. 113); and seborrheic keratoses (p. 112)



411


Look for changes from sun exposure: actinic lentigines, or “liver spots,” and actinic keratoses, supercial attened papules covered by a dry scale (p. 108).

Distinguish such lesions from a basal cell carcinoma and squamous cell carcinoma (p. 108). Dark, raised, asymmetric lesions with irregular borders are suspicious for melanoma

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. 133) 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 degeneration all increase with aging.

Inspect each lens for opacities.

Ca taracts 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 de ned, or soft and con uent 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).

412




Test hearing by the whispered voice test (see p. 124) or audioscope. Inspect ear canals for cerumen.

Removing cerumen often quickly improves hearing.

Examine the oral cavity for odor, appearance of the gingival mucosa, any caries, mobility of the teeth, and quantity of saliva.

Malodor in poor oral hygiene, periodontitis, or caries

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

Gingivitis if periodontal disease

Decreased salivation from medications, radiation, Sjögren syndrome, or dehydration Oral tumors, usually on lateral borders of tongue and floor of mouth

Th o ra x a n d Lu n g s . Percuss and auscultate the 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 pulmona ry disease

Ca rd io va s c u la r S ys t e m . Review blood pressure and heart rate.

Isolated systolic hypertension and a widened pulse pressure are cardiac risk factors. Search for left ventricular hypertrophy (LVH).

Inspect the jugular venous pulsation ( JVP), palpate 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.

Assess the point of maximal impulse (PMI), and then heart sounds.

Sustained PMI is found in LVH, hypertension, and aortic stenosis; diffuse PMI in heart failure (see p. 180).

Carotid bruits in possible ca rotid stenosis.

In older adults, S3 in dilatation of the left ventricle from heart failure or cardiomyopathy; S4 in hypertension



Listen for cardiac murmurs in all six listening areas (see p. 185). Describe timing, shape, location of maximal intensity, radiation, intensity, pitch, and quality of each murmur.

413

P O SSIBLE FIN DIN G S 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, common in older adults.

Bre a s t s a n d Axilla e . Palpate the breasts carefully for lumps or masses.

Possible breast cancer

Ab d o m e n . 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 of ≥3 cm and pulsatile mass in abdominal aortic a neurysm.

P e rip h e ra l Va s c u la r S ys t e m . Auscultate the abdomen for aortic, renal, femoral artery bruits.

Bruits over these vessels in atherosclerotic disease.

Palpate pulses.

Diminished or absent pulses in a rterial occlusion. Confirm with an office ankle –brachial index (see pp. 230–231).

Fe m a le Ge n it a lia a n d P e lvic Exa m in a t io n . Take special care to explain the steps of examination and allow time for careful positioning. For the woman with arthritis or spinal deformities who cannot ex 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 swellings may be varicosities.

Benign masses include condylomata, fibromas, leiomyomas, and sebaceous cysts. Bulging of the anterior vaginal wall below the urethra in urethrocele Erythema with satellite lesions in Candida infection; erythema with ulceration or a necrotic center in vulvar carcinoma.

414




Inspect the urethra for caruncles, or prolapse of eshy erythematous mucosal tissue at the urethral meatus.

Clitoral enlargement in androgenproducing tumors or use of androgen creams

S p e c u lu m Ex a m in a t io n . Inspect

Estrogen-stimulated cervical mucus with ferning in use of hormone replacement therapy, endometrial hyperplasia , and estrogen-producing tumors; lichen sclerosus

vaginal walls, which may be atrophic, and cervix.

If indicated, 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 examination.

Note any uterine retroversion, retroflexion, porolapse, or myomas (fibroids) Mobility of cervix restricted if inflammation, 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 ca ncer.

Ma le Ge n it a lia a n d P ro s t a t e . 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. Prosta te hyperplasia if enlargement; prostate cancer if nodules or masses.

Mu s c u lo s k e le t a l S ys t e m . Screen general range of motion and gait. Conduct timed “get up and go” test.

Review examination techniques for individual joints in Chapter 16, Musculoskeletal System.

If joint deformity, de cits in mobility, or pain with movement, conduct a more thorough examination.

Degenerative joint changes in osteoarthritis; joint inflammation in rheumatoid or gouty arthritis. See Tables 16-1 to 16-4, pp. 304–308.

See Table 20-1, Timed Get Up and Go Test, p. 417.



415


Ne r vo u s S ys t e m . Review results of 10-Minute Geriatric Screener, p. 407. Pursue further examination if any de cits. Focus especially on memory and affect.

Distinguish delirium from depression and dementia. See Table 20-2, Delirium and Dementia, pp. 418–419 and Table 20-3, Screening for Dementia: The Mini-Cog, p. 420. Table 20-4, Montreal Cognitive Assessment, p. 421.

Assess gait and balance, particularly 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 turning, are correlated with risk of falls.

Although neurologic abnormalities are common in older adults, their prevalence without identi 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, bradykinesia, micrographia, shuf ing gait, and dif culty turning in bed, opening jars, and rising from a chair.

In Parkinson 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, symmetric, with positive family history, and diminished by alcohol.

Recording Your Findings As you read through this physical examination, you will notice some atypical ndings. Test yourself to see if you can interpret these ndings in the context of all you have learned about the examination of the older adult. R e c o r d in g t h e P h y s ic a l E x a m in a t io n —T h e O ld e r A d u lt Mr. J is n older dult who e rs he lthy but underweight, with good uscle bulk. He is lert nd inter ctive, with good rec ll of his life history. He is cco nied by his son. Vital Signs: Ht (without shoes) 16 c (5′). Wt (dressed) 65 kg (143 lb). BMI 28. BP 145/ 88 right r , su ine; 154/94 left r , su ine. He rt r te (HR) 98 nd regul r. Res ir tory r te (RR) 18. Te er ture (or l) 98.6°F. (continued )

416


R e c o r d in g t h e P h y s ic a l E x a m in a t io n — T h e O ld e r A d u lt (Continued) 10-Minute Geriatric Screener: (see . 4 7) Vision: P tient re orts difficulty re ding. Visu l cuity 2 / 6 on Snellen ch rt. Needs further ev lu tion for gl sses nd ossibly he ring id. Hearing: C nnot he r whis ered voice in either e r. C nnot he r 1, 2, Hz with udiosco e in either e r.

or

Leg Mobility: C n w lk 2 feet briskly, turn, w lk b ck to ch ir, nd sit down in 14 seconds. Urinary Incontinence: H s lost urine nd gotten wet on 2 se

r te d ys.

Needs further ev lu tion for incontinence, including “DIAPER” ssess ent (see . 4 6), rost te ex in tion, nd ostvoid residu l, which is nor lly ≤5 L (requires bl dder c theteriz tion). Nutrition: H s lost 15 lb over the

st 6

onths without trying.

Needs nutrition l screen (see . 73). Memory: C n re e ber three ite s fter 1 inute. Depression: Does not often feel s d or de ressed. Physical Disability: C n w lk f st but c nnot ride bicycle. C n do oder te but not he vy work round the house. C n go sho ing for groceries or clothes. C n get to l ces out of w lking dist nce. C n b the e ch d y without difficulty. C n dress, including buttoning nd zi ing, nd c n ut on shoes. Consider exercise regi en with strength tr ining. Physical Examination: C refully describe your findings for e ch relev nt seg ent of the eri her l ex in tion, using ter inology found in the “Recording Your Findings” sections of the rior ch ters.


417

Aids to Interpretation Table 20-1 Tim e d Ge t Up a n d Go Te s t Performed with patient wearing regular footwear, using usual walking aid if needed, and sitting back in a chair with armrest. On the word, “Go,” the patient is asked to do the following: 1. 2. 3. 4. 5.

Stand up from the arm chair Walk 3 m (in a line) Turn Walk back to chair Sit down

Time the second effort. Observe patient for postural stability, steppage, stride length, and sway. S c o r in g :

1. Normal: completes task in <10 seconds 2. 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; 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.

418


Table 20-2 De liriu m a n d De m e n t ia D e lir iu m

D e m e n t ia

On s e t

Acute

Insidious

Co u rs e

Fluctuating, with lucid intervals; worse at night

Slowly progressive

Du ra tio n

Hours to weeks

Months to years

S le e p /Wa ke Cycle

Always disrupted

Sleep fragmented

Ge n e ra l Clin ica l Illn e s s o r Dru g Toxicity

Either or both present

Often absent, especially in Alzheimer disease

Le ve l o f Co n s cio u s n e s s

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

Be h a vio r

Activity often abnormally decreased (somnolence) or increased (agitation, hypervigilance)

Normal to slow; may become inappropriate

S p e e ch

May be hesitant, slow or rapid, incoherent

Difficulty in finding words, aphasia

Mo o d

Fluctuating, labile, from fearful or irritable to normal or depressed

Often flat, depressed

Th o u g h t Pro ce s s e s

Disorganized, may be incoherent

Impoverished. Speech gives little information

Th o u g h t Co n te n t

Delusions common, often transient

Delusions may occur

Pe rce p tio n s

Illusions, hallucinations, most often visual

Hallucinations may occur.

C lin ic a l Fe a t u r e s

Me n t a l S t a t u s


419

Table 20-2 De liriu m a n d De m e n t ia (continued ) D e lir iu m

D e m e n t ia

J udgm ent

Impaired, often to a varying degree

Increasingly impaired over the course of the illness

Orie n ta tio n

Usually disoriented, especially for time. A known place may seem unfamiliar.

Fairly well maintained, but becomes impaired in the later stages of illness

Atte n tio n

Fluctuates. Person easily distracted, unable to concentrate on selected tasks

Usually unaffected until late in the illness

Me m o ry

Immediate and recent memory impaired

Recent memory and new learning especially impaired

Ex a m p le s o f C a u s e

Delirium tremens (due to withdrawal from alcohol)

Reversible: Vitamin B12 deficiency, thyroid disorders

Uremia Acute hepatic failure Acute cerebral vasculitis Atropine poisoning

Irreversible: Alzheimer disease, vascular dementia (from multiple infarcts), dementia due to head trauma

420


Table 20-3 S c re e n in g fo r De m e n t ia : Th e Min i-Co g Ad m in is t r a t io n

The test is administered as follows: 1. Instruct the patient to listen carefully to and remember three 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 three previously stated words. S c o r in g

Word Recall: Give 1 point for each recalled word without cueing after doing the clock drawing test (CDT). 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 one to two words are classified based on the CDT (Abnormal = demented; Normal = nondemented). Clock Draw: The CDT is considered normal if all numbers are present in the correct sequence and position, and the hands readably display the requested time. Scoring is 2 (normal) or 0 (abnormal). Total Score (0–5 points): Score <3 has been validated for dementia. MINI-COG

3-Ite m Re ca ll = 0

3-Ite m Re ca ll = 1–2

DEMENTED

CDT Abnorma l

3-Ite m Re ca ll = 3

NONDEMENTED

CDT Norma l

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. Copyright John Wiley & Sons Limited. Reproduced with permission.


421

Table 20-4 S c re e n in g fo r De m e n t ia : Th e Mo n t re a l Co g n it ive As s e s s m e n t (Mo CA) NAME: Education: Sex: VISUOSPATIAL / EXECUTIVE

E D

Draw Clock (Ten past eight)

Copy cube

SCORE

(3 points)

A

3 End

Date of birth: DATE:

1

2

B

Begin

4

5

C

[ ]

[ ]

[ ]

[ ]

Contour

[ ]

Numbers

/5

Hands

NAMING

[ ]

[ ]

MEMORY

ROSE

Read list of words, subject must repeat them. Do 2 trials, even if 1st trial is successful. Do a recall after 5 minutes.

ATTENTION

[ ]

CHAIR

SPOON

HOUSE

RED No p o in t s

1st trial 2nd trial

Read list of digits (1 digit /sec.).

/3

[ ] 3 2 7 45 [ ] 2 7 4

Subject has to repeat them in the forward order Subject has to repeat them inthe backward order

/2

Read list of letters. The subject must point with his nger at each letter C. No points if ≥ 2 errors.

[ ] FBCAMNCCJKLBCFCKDECCJAMOFA [ ] 95

Serial 7 subtraction starting at 100

[ ] 86

[ ] 76

[ ] 65

[ ] 45

4 or 5 correct subtractions: 3 pts, 2 or 3 correct: 2pts, 1 correct: 1pt, 0 correct: 0pt

LANGUAGE

Repeat : I only know that Judy is the one to help today. [ ] The cat always hid under the couch when dogs were in the room. [ ]

Fluency / Name maximum number of words in one minute that begin with the letter F

ABSTRACTION DELAYED RECALL

Similarity between e.g. banana - orange = fruit Has to recall words WITH NO CUE

Optional ORIENTATION

ROSE [ ]

CHAIR [ ]

[ ] train - bicyle SPOON [ ]

[ ]

/1 /2

Points for UNCUED recall only

/5

Category cue Multiple choice cue

[ ] Date

[ ] Month

[ ] Year

[ ] Day

[ ] Place

Normal ≥ 26 / 30 Administered by:

(N ≥ 11 words)

RED [ ]

/3 /2

[ ] watch - ruler

HOUSE [ ]

/1

[ ] City

TOTAL Add 1 point if ≤ 12 yr edu

Source: © Z. Nasreddine MD. Reproduced with permission. Copies are available at www.mocatest.org.

/6 / 30

Index

Note: Page numbers followed by “b,” “f,” and “t” indicate boxed material, gure, and end-of-chapter tables, respectively.

A ABCDE criteria, for skin cancer screening, 91, 91b–92b Abdomen auscultation, 207, 208b in children, 368 concerning symptoms, 199b examination of, 12, 207–213, 223, 224f health history, 199–204 health promotion and counseling, 204–207 in infants, 362 inspection, 207 older adults and, 413 pain in (see Abdominal pain) palpation, 208–209, 208f, 209f percussion, 208 during pregnancy, 391–393 recording ndings, 213 Abdominal aortic aneurysm (AAA), 219 in older adults, 413 screening for, 222 Abdominal fullness, 201 Abdominal masses, 209 Abdominal pain, 199b with associated GI symptoms, 201–202 lower, 201 patterns and mechanisms of, 199–200 upper, 200–201 Abdominal re exes, 329, 329f Abdominal tenderness, 217t Abducens nerve, 318b, 319 Abscess, 103t headache and, 115 lung, 160t peritonsillar, 368 Abstract thinking, 85 Abuse elder, 406 illicit drugs, 56 physical, 57b prescription drugs, 56, 82, 388 sexual, 57b, 369, 381t

Acne vulgaris, 103t Acoustic nerve, 318b, 320 Acromioclavicular arthritis, 308t Actinic keratosis, 105t, 410 Actinic lentigines, 410 Actinic purpura, 410 Active listening, 42 Activities of daily living (ADLs), 402, 402b Acute otitis media, with purulent effusion, 137t Adams bend test, 371 Addiction, 56b Adolescents, 370 breasts, examination of, 371 genitalia, examination of, 371 Adult illnesses, in health history, 3 Advance directives, 403 Adventitious breath sounds, 151b Advisory Committee on Immunization Practices (ACIP), 314 Aerobic activity, 61 Affect, 83 de ned, 80b African-American, 70, 118, 169, 170. 266, 401,411 Alcohol use/abuse, 56 in health history, 3 health promotion and counseling for, 82, 204, 204b–205b older adults and, 403 during pregnancy, 387 Allen test, 225–226, 225f, 226f Allergic rhinitis, 117 Allergies, in health history, 3 Alopecia areata, 112t Altitudinal (horizontal) defect (visual eld defect), 132t Alzheimer disease (AD), 405–406 Ambiguous genitalia, 363 Amelanotic melanoma, 107t Amenorrhea, 248 primary, 248 secondary, 248 423

424

Inde x

American Cancer Society (ACS), 91 on Breast Self-Examination (BSE), 189b, 193, 194b–195b American College of Chest Physicians, grading recommendations, 39t–40t American Geriatrics Society, 404 American Heart Association, goals for ideal cardiovascular health, 169b American Sign Language, 53 American Urological Association (AUA) Symptom Index, 265, 271t Anagen ef uvium, 111t Anal ssure, 272t Analgesic rebound headache, 129t Anal re ex, 329 Anatomic snuffbox, 289, 289f Androgen-producing tumors, 413 Anemia of pregnancy, 390 Angina pectoris, 155t Angioedema, 139t Angry patient, 52 Angular cheilitis, 139t Ankle–brachial index (ABI), 221 interpretation of, 231t measurement of, 230t–231t Ankle clonus, 328, 328f Ankles, examination of, 301–302 Anorectal stula, 272t Anorexia nervosa, 72t Ante exion, 262t Anterior cruciate ligament test, 300, 300f Anterior cruciate tear/sprain, 310t Anus concerning symptoms, 265b examination of, 268–269, 268f health history, 265 during pregnancy, 394 recording ndings, 270 Anxiety, panic disorder, 156t Aorta, assessment of, 211, 211f Aortic aneurysm, dissecting, 155t Aortic stenosis (AS), 180 Aortic valve stenosis, 375t Apgar score, 352, 353b Aphasia, 83, 337t–338t testing for, 83b Aphonia, 337t Aphthous ulcer, 141t Appearance, assessment of, 83 Appendicitis, 212–213 Appropriate for gestational age (AGA), 354t, 373t Arcus senilis, 411 Arms, examination of, 222–223 Arterial insuf ciency, chronic, 226, 228t, 229t Arterial pulses, grading of, 222b

Arthritis, knee, 309t Articular structures, joint, 275b Asbestosis, 158t Ascites, assessment of, 211–212, 211f, 212f Ascitic uid, 211, 211f Asian-American, 171, 401 Assessment, 13. See also speci c topics clinical reasoning and, 14–16 of mental status, 79–80 (see also Mental status) Asterixis, 331 Asthma, 158t, 160t, 165t Ataxia, 313 Ataxic (Biot) breathing, 162t Atelectasis, 165t Atherosclerotic disease, 413 Atrial brillation, 67 Atrial septal defect, 362 Attention assessment of, 84 de ned, 80b in delirium and dementia, 419t Attention de cit disorder, 365 Attrition bias, 35b Auricle, examination of, 124 Automated ambulatory blood pressure monitoring, 64 Autonomy, 58b Axillae examination of, 11, 193, 193f recording ndings, 195 Axillary temperature, 68

B Babinski response, 329, 329f Back, in physical examination, 11 Back pain low, 280, 306t–307t (see also Low back pain) midline, 280 nocturnal, 307t Back stiffness, chronic, 307t Bacterial pneumonias, 159t Bacterial vaginosis, 260t Baker cyst, 310t Balance, in older adults, assessment of, 415 Balloon sign, 298, 298f Barlow test, 363, 363f Barrel chest, 163t Basal cell carcinoma (BCC), 106t nodular, 106t super cial, 106t Basal ganglia disorder, 340t Bayes theorem, 31

Inde x

Bedbound patient, evaluation of, 98 Behavior assessment of, 83 in delirium and dementia, 418t Bene cence, 58b Benign prostatic hyperplasia, 265, 273t Bias, in clinical research, 34, 35b Bicipital tendinitis, 308t Bilingual written questionnaires, 52 Bimanual examination, 255, 255f, 393–394, 414 Birth history, child, 350 Bitemporal hemianopsia, 132t Bleeding, postmenopausal, 248 Blepharitis, 134t Blindness, unilateral, 132t Bloating, 201 Blood pressure, 64–67. See also Hypertension in children, 365 cuff size, selection of, 65b diastolic, 66b in infants, 356 measurement of, 64, 66b, 174 during pregnancy, 390 recording of, steps in, 65b systolic, 66b Blount disease, 370 Body dysmorphic disorder, 87t Body mass index (BMI), 63–64, 365 calculation of, 63b and cardiovascular disease, 173 excessively low, 72t obesity and, 63 Bone density criteria, by WHO, 282b Bowel sounds, 207, 208b BPH symptom score index, 265, 271t Brachial pulse, 223f Bradypnea, 162t Brain, 311, 312f Brain tumor, and headache, 130t Breast cancer relative risk factor, 196t retraction signs, 197t risk factor assessment, 188 screening, 189, 189b visible signs of, 197t–198t Breast Cancer Risk Assessment Tool, 188 Breasts in adolescents, 371 concerning symptoms, 187b development of, 377t examination of, 11, 190–192 female, 190–192, 190f–192f health history, 187 health promotion and counseling, 187–189

425

in infants, 362 male, 192 in older adults, 413 palpable masses of, 187, 188b during pregnancy, 391 recording ndings, 195 in review of systems, 5 Breast Self-Examination (BSE), 189b, 193, 194b–195b Breathing abnormal, 162t normal, 162t rapid deep, 162t rapid shallow, 162t slow, 162t Breath odor, 62 Breath sounds adventitious (added), 151b characteristics of, 150b evaluation of, 150 Breech presentation, 395 Broca aphasia, 337t–338t Bronchiectasis, 160t Bronchiolitis, 357 Bronchitis acute, 159t chronic, 157t, 160t, 165t Brown lesions, 107t–108t Brudzinski sign, 330 Bruits, 207, 208b, 413 Bulge sign, 297, 298f Bulimia nervosa, 72t Bullae, 102t Burrow, 104t Bursae, 275b Bursitis, knee, 309t

C CAGE Questionnaire, 56, 204, 403 Calcium, food sources of, 74t Calculating abilities, assessment of, 85 Cancer breast (see Breast cancer) colorectal, 206, 206b–207b lung, 158t ovarian, 250 prostate, 265–267, 266b–247b, 273t rectum, 273t screening for, 404–405 sigmoid colon, 214t skin, 90–92 testicular, 235 Candida vaginitis, 260t Candidiasis, 140t Canker sore, 141t

426

Inde x

Carbuncle, 103t Carcinoma of cervix, 261t of lip, 139t of penis, 241t of tongue/ oor of mouth, 141t of vulva, 259t Cardiac failure, 357 Cardiopulmonary resuscitation (CPR), 57 Cardiovascular disease (CVD), 168 and chest pain, 155t lifestyle change and risk factor modi cation, 173b–174b primary prevention, 168 risk calculators, 170, 170b risk factors and screening frequency, 169b–170b screening for, 169–173 secondary prevention, 168 Cardiovascular system common cardiac symptoms, 167b–168b concerning symptoms, 167b examination of, 174–180 health history, 167 health promotion and counseling, 168–174 in older adults, 412–413 in physical examination, 11–12 recording ndings, 180 in review of systems, 5 Carotid artery screening, 316 Carotid bruits, 175, 412 Carotid pulse, 175 Carpal tunnel syndrome, 288 Carpal tunnel testing, 291 Caruncles, 413 Cataracts, 411 Cauda equina syndrome, 280 Caviar lesions, 141t Central nervous system (CNS), 311 brain, 311, 312f disorder, 340t spinal cord, 312 Cephalic prominence, 396 Cephalohematoma, 357 Cerebellar disorder, 340t Cerebellar function, examination of, 12 Cerebrovascular disease, 316 Cervical myelopathy, 305t Cervical radiculopathy, 305t Cervix abnormalities of, 261t inspection of, 253–254, 254f during pregnancy, 393–394

Chalazion, 134t Chancroid, 243t Cherry angioma, 109t Chest examination of, 147–153 palpation of, 152 Chest pain, 155t–156t, 167b sources of, 145b Chest wall, 147f Chest wall pain, costochondritis, 156t Cheyne–Stokes breathing, 162t Chief complaint(s), 1b, 2 Childhood hypertension in, 374t Childhood illnesses, in health history, 3 Children adolescents, 370–371 blood pressure in, 365 development, principles of, 349n ear in, 366–367, 366f examination of, sequence of, 352b eyes in, 365–366 health history, 349–350 health promotion and counseling, 351–352 heart, 368 hypertension in, 374t infants, 355–364 interviewing, 364b mental and physical status, 365 mouth and pharynx in, 367–368 newborns, 352–354 overweight, 365 recording ndings, 371–372 sexual abuse in, 381t sustained hypertension in, 356b 1 to 10 years children, 364–370 underweight, 365 Chill, 59 Chlamydia trachomatis, 250 Choanal atresia, 359 Cholecystitis, 213 Chorea, 341t Chronic bronchitis, 157t Chronic obstructive pulmonary disease (COPD), 157t, 165t, 412 Clasp-knife resistance, 342t Clinical reasoning, and assessment, 13–16, 14b abnormal ndings identi cation, 14 clustering clinical ndings, 14–15 generating clinical hypotheses, 15–16, 16b localizing ndings, 14 probable cause of ndings, 15 testing hypotheses, 16 working diagnosis, 16

Inde x

Clinical record checklist for, 24b–26b purpose of, 16 reviewing of, 44 standard format of, example of, 17b–23b tips for quality patient record, 17b Clinician–patient interview, 41. See also Interviewing Clubbing of ngers, 113t Cluster headache, 128t Cognitive functions assessment of, 84–85 de ned, 80b Cogwheel rigidity, 342t Coldness, in legs/feet, 219 Cold sore, 139t Collaborative partnerships, 50b Collateral ligament tear/sprain, 310t Colorectal cancer prevention of, 267 screening for, 206, 206b–207b Coma, 331 metabolic, 345t structural, 345t Comfort, patient, 45 Communication nonverbal, 43 respectful, 50b Condoms, male, 235 Conductive loss, 117 Condyloma latum, 259t Condylomata acuminata. See Genital warts Con dentiality, 45, 58b Confusing patient, 51 Confusional Assessment Method (CAM) algorithm, 314b Congenital hip dysplasia, 363 Consciousness, level of, 332b assessment of, 61, 83 de ned, 80b in delirium and dementia, 418t Consciousness, loss of, 314 Constipation, 202, 368 Constructional ability, assessment of, 85 Conversion disorder, 87t Coordination, 323–324 Corneal light re ex test, 366, 366f Corneal re exes, 319, 319f Corynebacterium diphtheriae, 142t Costovertebral angle (CVA) tenderness, 210, 210f Cough, 159t–161t Cover–uncover test, 366, 366f Crackles, 151b Cranial nerves (CNs), 312 examination of, 12, 318–321 functions of, 318b

427

Cranial neuralgias, 131t Critical appraisal, 34–36 bias in clinical research, 34, 35b generalizability, 36 guideline recommendations, 36, 37t–40t treatment/prevention intervention, performance of, 35–36 Crohn disease, 215t Crying patient, 52 Cryptorchidism, 244t Cues emotional, 47 verbal and nonverbal, 46 Cultural competence, 50 Cultural humility, 50, 50b Culture, 49–50 Cup-to-disc ratio, 411 CVD risk calculator, 170b, 172 Cyst Baker, 310t epidermoid, 258t of epididymis, 245t pilar, 104t Cystocele, 263t Cystourethrocele, 263t

D Death, interviewing about issues related to, 57 Decision-making capacity, 51, 51b Decision-making, shared, 49 Delirium, 314, 418t–419t clinical features, 418t mental status, 418t–419t screening for, 421t Dementia, 83, 314, 405, 418t–419t clinical features, 418t mental status, 418t–419t screening for, 420t Dental caries, 367 Denture sores, 412 Depression, 314 health promotion and counseling for, 81 older adults and, 405 Dermato broma, 103t Dermatomes, 343t–344t Dermoscopy, 93 Detection bias, 35b Developmental delay, causes of, 355 Diabetes, classi cation and diagnosis of, 171b–172b Diagnostic hypotheses, 48

428

Inde x

Diagnostic tests, evaluation of, 28 reproducibility of test results, 33 validity of ndings, 28–32 Diarrhea, 202, 214t–215t acute, 214t chronic, 214t–215t drug-induced, 214t Diastolic blood pressure, 66b Dietary Approaches to Stop Hypertension (DASH) eating plan, 61 Diet, hypertension and, 75t Differential diagnosis, 27, 48 Dif cult patients, 77 Diffuse esophageal spasm, 156t Diffuse interstitial lung diseases, 158t Digital rectal examination (DRE), 267 Digit span, 84 Diphtheria, 142t Diplopia, 117, 313 Direct inguinal hernia, 246t Disc herniation, and back pain, 306t Discriminative sensations, 326 Disease/illness model, 46 Disruptive patient, 52 Dissecting aortic aneurysm, chest pain in, 155t Dissociative disorder, 87t Distal weakness, 314 Distress, signs of, 62 Dizziness, 313 Doll’s eye movements. See Oculocephalic re ex Domestic violence, 57 Do Not Resuscitate (DNR) status, 57 Dorsalis pedis pulse, 225f Down syndrome, 358 Dress, patient, 62, 83 Dribbling, continuous, 216t Drop-arm test, 287b Drug use, in health history, 3 Drusen, 411 Dual diagnosis, 77 Durable power of attorney for health care, 52 Dysarthria, 313, 337t Dysesthesias, 314 Dyslipidemias, 172, 172b Dysmenorrhea, 248 Dyspareunia, 249 Dyspepsia, 200 Dysphagia, 199b, 201, 202 Dysphonia, 337t Dysplastic nevus, 108t Dyspnea, 157t–158t, 167b Dysuria, 203

E Earache, 117 Eardrum abnormalities of, 137t examination of, 124, 124f Ear(s) in children, 366–367, 366f concerning symptoms, 115b examination of, 124–125 health history, 117 health promotion and counseling, 119 in infants, 359 Eating disorders, and low body mass index, 72t Ecchymosis, 110t Ectopic pregnancy, 394 Ectropion, 133t Edema, 168b Ejaculation, premature, 234 Elbows, examination of, 288 Elder mistreatment, 406 Electronic thermometer, 68 Empathic responses, 42 Empowerment, patient, 44, 44b Endocervical polyp, 261t Endocrine system, in review of systems, 6 Entropion, 133t Environment, for examination, 7 Epidermoid cyst, 258t Epididymal cyst, 245t Epididymis abnormalities of, 245t examination of, 238 Epididymitis, acute, 245t Episcleritis, 134t Epistaxis, 118 Epitrochlear nodes, 223 inspection of, 11 Erectile dysfunction, 233 Essential tremor, 415 Ethics, professionalism and, 58, 58b Evidence-based information, 34, 34f Evidence-Based Working Group, 34 Exercise health promotion and counseling for, 61 during pregnancy, 387 Exercise-induced pain, 219 Exophthalmos, 133t Expected date of delivery (EDD), 385b Expressions, facial, 62, 83 External hemorrhoids, 272t External rotation lag test, 287b External rotation resistance test, 287b

Inde x

Extra-articular structures, joint, 275b Extraocular muscles, assessment of, 121 Extremities, 12 Extremities, during pregnancy, 394 Exudative pharyngitis, 142t Eye disorders, headache from, 129t Eye(s) in children, 365–366 concerning symptoms, 115b examination of, 119–123 health history, 116–117 health promotion and counseling, 118 in infants, 358, 358b physical ndings, 133t–134t during pregnancy, 390

F Face expressions of, 62, 83 in infants, 358, 358b during pregnancy, 390 Faces Pain Scale, 70 Facial nerve, 318b, 319 Facial paralysis, 339t Facies, abnormal, 358, 358b Factitious disorder, 87t Fagan nomogram, 31–32, 32f Failure to thrive, 355 Fainting, 168b, 314 Falls, in older adults, 283, 407–409, 408b, 409f STEADI falls prevention toolkit, 408b, 409f Family history, 2b, 4 of breast and ovarian cancers, 188 Family planning counseling on, 251 methods, 251b Fasciculations, 341t Fatigue, 59 Feeding history, child, 350 Feet, examination of, 301–302 Female genitalia in children, 369 common concerns, 247b examination of, 13, 252–256 external, 252–253, 253f health history, 247–249 health promotion and counseling, 249–252 in infants, 363 internal, 253–254, 254f older adults, examination in, 413

429

recording ndings, 257 in review of systems, 5–6 Femoral hernia, 246t Fetal alcohol syndrome, 358, 387 Fetal exposure to diethylstilbestrol (DES), 261t Fetal heart rate (FHR), 392–393 Fetal movements, 392 Fever, 59, 68 causes of, 68 Fever blister, 139t Fibromyalgia, 305t FIFE (mnemonic), 46 Fissured tongue, 140t Flaccidity, 342t Flat spots (skin lesions), 100t Fluid- lled lesions, 102t Folate, food sources of, 74t Fontanelles, 357, 357f Forced expiratory time, 153 Fracture of clavicle, 363 Frailty, older adults, 403 FRAX calculator for assessing fracture risk, 282 Functional incontinence, 217t Functional status, of older adults, 406, 406b–407b Fundal height, 392 Funnel chest, 163t Furuncle, 103t Furunculosis, 103t

G Gail model (breast cancer risk assessment), 188 Gait examination of, 62, 293f, 323 older adults, examination in, 415 Gastroesophageal re ux, 161t, 201 Gastrointestinal re ux disease, and chest pain, 156t Gastrointestinal system disorders related to, 199b pain related to, 200–201 in review of systems, 5 symptoms related to, 201–202 Gaze, cardinal directions of, 121, 121f Gegenhalten, 342t General survey in infants, 355 in physical examination, 10, 61–62 recording ndings, 71b in review of systems, 4 Genital herpes, 258t Genital herpes simplex, 242t

430

Inde x

Genitalia. See also Female genitalia; Male genitalia examination of, 13 during pregnancy, 393–394 in review of systems, 5–6 Genital warts, 242t Geographic tongue, 140t Gestational age, 385 Gestational hypertension, 390b Get Up and Go test, 417t, 418t–419t Giant cell arteritis, and headache, 130t Glasgow Coma Scale, 346t Glass thermometer, 68 Glaucoma, 118, 411 acute, 129t open-angle, 116, 411 Glaucomatous cupping, 135t Glossopharyngeal nerve, 318b, 320 Goiter, multinodular, 143t Gonorrhea, 251b, 254, 256, 261t Grooming, patient, 62, 83 Growth and developmental history, children, 350 Guided questioning, 42–43, 42b Gums, inspection of, 126 Guttate psoriasis, 101t Gynecomastia, 192

H Habit tic deformity, 113t Hair, examination of, 94f, 95, 98, 98f Hair loss, 90, 98 female pattern, 111t focal, 112t generalized/diffuse, 111t male pattern, 111t Hair pull test, 98, 98f Hairy leukoplakia, 141t Hairy tongue, 140t Hand, arterial supply to, 225–226, 225f, 226f Hand grip strength, 291, 291f Hands, examination of, 288–292 Head concerning symptoms, 115b examination of, 119 health history, 115–116 in infants, 357, 357f during pregnancy, 390 Headache, 115, 313 from eye disorders, 129t primary, 128t secondary, 129t–131t from sinusitis, 129t warning signs, 116b

Head circumference, in infants, 355, 356f Head, eyes, ears, nose, throat (HEENT) examination of, 10 older adults and, 411–412 recording ndings, 127 in review of systems, 4–5 Health care proxy, 52, 57 Health disparities, 70 Health history, 2–6, 41 chief complaint(s), 2 components of, 1b–2b concerning symptoms, 59–60 family history, 4 interviewing and, 41–58 past history, 3 personal and social history, 4 present illness, 3 review of systems, 4–6 Health Insurance Portability and Accountability Act (HIPAA), 51 Health literacy, 53 Health maintenance, 3, 16 Health promotion, 33–34, 34f Health promotion and counseling abdominal aortic aneurysm screening, 222 alcohol abuse, 82, 204, 204b–205b ankle–brachial index, 221 breast cancer risk assessment, 188 breast cancer screening, 189, 189b breast masses, 187, 188b cardiovascular risk factors, screening for, 169–173 carotid artery screening, 316 cervical cancer screening, 249–250, 250b colorectal cancer, 206, 206b–207b, 267 delirium, dementia, and depression detection, 317 depression, 81 diet, 60 exercise, 61, 387 family planning options, 251, 251b hearing de cits, 119 herpes zoster vaccination, 317 HIV/AIDS screening, 235 hormone replacement therapy, 252 immunizations, 386–387, 387b intimate partner violence, 388, 388b lifestyle modi cations for cardiovascular health, 173b–174b low back pain, 281 lung cancer, 146 menopause, 252 mood disorders, 81 nutrition, 61, 61b, 73t, 74t, 281, 386 older adults, 404–406 optimal weight, 60, 61b

Inde x

oral health, 119 osteoporosis, 281–283 ovarian cancer, 250 peripheral arterial disease, screening for, 221, 221b peripheral neuropathy risk prevention, 316–317 physical activity, 281, 281b pneumococcal vaccine, 146 prenatal laboratory screenings, 389 prescription drug abuse, 82 prostate cancer, 266–267 renal artery disease screening, 221, 221b–222b skin cancer, 90–92 STIs and HIV infection screening, 250–251, 251b, 267 stroke prevention, 316 substance abuse, 82, 387–388 suicide risk, 81–82 testicular cancer, 235 testicular self-examination, 235 tobacco cessation, 146, 146b viral hepatitis, 205–206 vision disorders, 118 weight gain during pregnancy, 386, 386b weight, optimal, 281 Health, state of, in general survey, 61 Hearing, assessment of, 124–125 Hearing loss conductive, 125, 138t sensorineural, 125, 138t Heart auscultation, 177–178, 177f, 178f in children, 368 in infants, 362 inspection and palpation, 176–177, 176f murmurs, 178–180, 185t during pregnancy, 391 sequence of examination, 176b Heart failure, left, 157t, 165t Heart murmurs, 185t. See also Murmurs Heart rate, 67, 174 Heart sounds, 181t rst, variations in, 182t second, variations in, 183t–184t Hegar sign, 394 Height in infants, 355 measurement of, 63, 390 older adults and, 410 Hematologic questions, in review of systems, 6 Hemianopsia, 116 Hemoptysis, 159t–161t Hepatitis A, 205, 205b Hepatitis B, 205, 206b

431

Hepatitis C, 206 Hereditary hemorrhagic telangiectasia, 139t Hernias direct inguinal, 246t examination for, 13 examination of, 238, 238f femoral, 246t indirect inguinal, 246t recording ndings, 240 Herpes simplex virus, 102t Herpes zoster, 411 Herpes zoster vaccine, 314 Hips, examination of, 293–295 Hispanic, 70,171b, 401 HIV/AIDS, screening for, 235 Hoarseness, 118 Homonymous hemianopsia, 132t Homonymous quadrantic defect, 132t Hormone replacement therapy (HRT), 252 Housemaid’s knee, 297 HPV infection, and cervical cancer, 250 Hydrocele, 241t, 363 Hyperlipidemia, 134t Hyperopia, 116 in school-aged children, 365 Hyperpnea, 162t Hyperpyrexia, 68 Hypertension, 64. See also Blood pressure in childhood, 374t chronic, 390b dietary guidelines, 75t in pregnancy, 390b screening for, 170 types of, 64b–65b Hyperthyroidism, 118 Hypertonia, 342t Hyperventilation, 162t Hypoglossal nerve, 318b, 321 Hypospadias, 241t Hypothermia, 68 Hypothyroidism, 118 Hypotonia, 342t, 364

I Idiopathic pulmonary brosis, 158t Iliotibial band, 309t Illicit drug use, 56, 82 during pregnancy, 387 Illness anxiety disorder, 87t Illness, patient’s perspective on, 46, 47b Immunizations in health history, 3 older adults and, 404 during pregnancy, 386–387, 387b

432

Inde x

Indirect inguinal hernia, 246t Infantile automatisms, 364 Infants, assessment of abdomen, 362 blood pressure, 356 breasts, 362 ear, 359 eyes, 358, 358b face, 358, 358b female genitalia, 363 general survey, 355 head, 357, 357f head circumference, 355, 356f heart, 362 height and weight, 355 male genitalia, 363 mental and physical status, 355 mouth and pharynx, 359 musculoskeletal system, 363–364, 363f neck, 359, 360f nervous system, 364 nose, 359 skin, 357 thorax and lungs, 360, 360b–361b upper airway vs. lower airway sounds, 361b vital signs, 356–357 In ammatory bowel disease, 215t Information, patient, 85 Inguinal hernias, 363 in older boys, 369 Inguinal nodes, super cial, 223, 224f Insect bites, 102t Insight, patient, 80b, 84 Institute of Medicine (IOM), 61 Instrumental activities of daily living (IADLs), 402b Intention tremor, 341t Intermittent claudication, 219 Internal rotation lag test, 287b Interpreter, working with, 52b–53b Interviewer, behavior and appearance, 45 Interviewing, 41 advanced, 50–57 challenging patient, 50–54 cultural context of, 49–50 ethics and professionalism, 58, 58b focused/ problem-oriented history, 41 goals for, 45 and health history, 41–58 open-ended, 41 patient’s perspective in, 46, 46b preparation for, 44–45 sensitive topics, 54–57 sequence for, 45–49 skilled, 42–44 techniques for, 42–44

Intimate partner violence, 57, 388, 388b Involuntary movements, 315, 341t Iron, food sources of, 74t Irritable bowel syndrome, 214t Irritating particles/chemicals, and cough, 161t Ischiogluteal bursa, 294, 294f Isolated clinic hypertension. See White coat hypertension Itching rashes and, 89 vaginal, 248

J Jaundice, 202 extrahepatic, 202 intrahepatic, 202 Joint pain acute or chronic, 278–279 articular or extra-articular, 278 assessment of, tips for, 278b constitutional symptoms with, 279 in ammatory or nonin ammatory, 279 localized or diffuse, 279 monoarticular, 278 polyarticular, 278 Joints aging, effect of, 276, 276b anatomy, terminology related to, 275b cartilaginous, 276b examination of, steps in, 283b brous, 276b in ammation, signs of, 283b–284b pain in, 304t (see also Joint pain) problem, 275 synovial, 276b, 277b Judgment in delirium and dementia, 419t patient, 80b, 84 Jugular venous pressure ( JVP), 174, 175f Jugular venous pulsations, 174

K Kappa score, 33 Keloid, 103t Kernig sign, 330, 330f Kidneys, examination of, 210, 210f Kinetic red target test, 119 Klinefelter syndrome, 244t Knee examination of, 296–301, 296f pain in, 309t–310t

Inde x

Koplik spots, 142t Korotkoff sounds, 66b

L Lachman test, 300, 300f Language barrier, 52 de ned, 80b Large for gestational age (LGA), 354t, 373t Laryngitis, 159t Lateral collateral ligament test, 300, 300f Leadpipe rigidity, 342t Left ventricular heart failure, 157t, 161t Left ventricular hypertrophy (LVH), 412 Leg length, measurement of, 303 Legs, examination of, 12, 224–225, 224f, 225f Leopold maneuvers, 395–396 Lesions skin, 62 vulva, 258t–259t Leukocoria, 358 Lhermitte sign, 305t Libido, assessment of, 233 Lid retraction, 133t Lifestyle habits, in health history, 4 Lifestyle modi cations, for cardiovascular health, 173b–174b Ligaments, 275b Lighting, for examination, 7 Likelihood ratio, 30 interpretation of, 31 for negative test, 31 for positive test, 30–31 Lipoma, 104t Lips abnormalities of, 139t inspection of, 126 Listening, active, 42 Liver, examination of, 209–210, 209f Lobar obstruction, 165t Low back pain, 280, 280b, 306t–307t health promotion and counseling, 281 red ags for, 280b Lower extremities, in physical examination, 12 Lumbar spinal stenosis, 306t Lumbosacral radiculopathy, 330 Lung abscess, 160t Lung cancer, 158t, 161t Lungs concerning symptoms, 145b examination of, 147–153 health history, 145–146 health promotion and counseling, 146

433

in infants, 360, 360b–361b in older adults, 412 in physical examination, 11 during pregnancy, 391 recording ndings, 154 Lymphadenopathy, 359

M Macular degeneration, 116, 123b, 411 Macules, 100t Malabsorption syndrome, 215t Male genitalia, 378t–379t anatomy of, 236f in children, 369 concerning symptoms, 233b examination of, 13, 236–239 health history, 233–234 health promotion and counseling, 234–235 in infants, 363 older adults, examination in, 414 recording ndings, 240 in review of systems, 5 sexually transmitted infections of, 242t–243t Mammography, 189, 189b Mania, 83 Masked hypertension, 64b McMurray test, 299, 299f Mechanical neck pain, 305t Medial collateral ligament test, 299, 299f Medications, in health history, 3 Melanoma, 90, 411 ABCDE-EFG method for, 91, 91b–92b incidence of, 90 and mimics, 107t–108t prevention of, 90–91 risk factors for, 90–91 screening for, 91 Melanoma in situ, 107t Melanoma Risk Assessment Tool, 90 Melanonychia, 113t Melena (black tarry stools), 202 Memory de ned, 80b in delirium and dementia, 419t Ménière disease, 117 Meningeal signs, 330 Meningitis, and headache, 130t Meniscal tear, 309t Menopause, 248, 252 Mental health disorders, 77, 78b, 87t personality disorders, 78 and unexplained symptoms, 77, 78b, 79

434

Inde x

Mental health history, 55 Mental illness, 77. See also Mental status Mental status assessment of, 12 behavior and, 77–88 examination of, 82–86 (see also Mental Status Examination) health history, 79–81 health promotion and counseling, 81–82 recording ndings, 86 screening, 79, 79b unexplained symptoms and, 77, 78b Mental Status Examination, 82, 82b appearance and behavior, 83 cognitive function, 84–85 mood, 84 speech and language, 83, 83b thoughts and perceptions, 84 Metabolic syndrome, 173, 173b Metacarpophalangeal joints, 289, 289f Metatarsophalangeal joints, 301, 301f Migraine, 116 with aura, 128t without aura, 128t Mini-Cog, 420t Mini-Mental State Examination (MMSE), 85, 86b, 314 Mitgehen, 342t Mitral regurgitation, 413 Mitral stenosis, 157t, 161t Mitral valve prolapse (MVP), 180 Montreal Cognitive Assessment (MoCA), 421t Mood assessment of, 84 de ned, 80b in delirium and dementia, 418t disorders, 81 Morbilliform drug eruption, 100t Morning stiffness, 279 Motivational interviewing, 49, 49b Motor behavior, assessment of, 83 Motor disorders, 340t Motor system, examination of, 12, 62, 321–324 Mouth in children, 367–368 concerning symptoms, 115b examination of, 126 health history, 118 health promotion and counseling, 119 in infants, 359 inspection of, 126 MRSA precautions, 7 Mucopurulent cervicitis, 261t Mucous patch of syphilis, 141t Multinodular goiter, 143t

Murmurs, 178–179 aortic, 179 in children, 368 crescendo, 179 crescendo–decrescendo, 178 decrescendo, 179 gradations of, 179b in older adults, 413 pathologic, 375t–376t plateau, 179 Murphy sign, 213 Muscle strength grading of, 321b testing of, 321–323 Muscle tone, disorders of, 342t Musculoskeletal disorders, 275 Musculoskeletal system, 275 in children, 370 concerning symptoms, 277b examination of, 283–303 health history, 277–280 health promotion and counseling, 281–283 in infants, 363–364, 363f joints, assessment of, 275–277 in older adults, 414 in physical examination, 11 recording ndings, 303 in review of systems, 6 Mycoplasma, 159t Myocardial infarction, chest pain in, 155t Myoma of uterus, 262t Myopia, 116, 365

N Nails changes in, 90 ndings, 113t–114t National Survey on Drug Use and Health, 82 Natural frequencies, 32 Neck concerning symptoms, 115b examination of, 126–127 health history, 118 in infants, 359, 360f pain in, 279–280, 305t in physical examination, 11 during pregnancy, 390 in review of systems, 5 Negative predictive value (NPV), 29b Nervous system, 311–312 central, 311–312 in children, 370 concerning symptoms, 313b

Inde x

examination of, 12, 318–333 guiding questions for examination of, 311b health history, 313–315 health promotion and counseling, 315–317 in infants, 364 older adults, examination in, 415 peripheral, 312 recording ndings, 333–334 Neurologic abnormalities, in older adults, 415 Neurologic examination, 332–333 Neurologic questions, in review of systems, 6 Neuropathic ulcer, 229t Newborn Apgar scoring system, 352, 353b assessment after some time, 354 bowlegged, 354 classi cations, 354b gestational age and birth weight, 353, 353b immediate assessment, 352–353 level of maturity, 373t neurologic screening of, 354 umbilical cord, 354 New learning ability, assessment of, 85 Night sweats, 59 Nocturia, 204 Nocturnal back pain, 307t Nocturnal hypertension, 65b Nodule, 103t Nonmale cence, 58b Nonproliferative retinopathy moderately severe, 136t severe, 136t Nonverbal communication, 43 Nose concerning symptoms, 115b examination of, 125 health history, 117–118 in infants, 359 during pregnancy, 390 Nosebleeds, 390 Number identi cation, 326 Numbness, in legs/feet, 219 Numeric Rating Scale, 70 Nummular dermatitis, 101, 101f Nutrients, sources of, 74t Nutrition health promotion and counseling for, 61, 61b older adults and, 403 during pregnancy, 386 screening checklist, 73t sources of nutrients, 74t

435

O Obesity, 60 body mass index and, 63 and cardiovascular disease, 173 childhood, 365 Obturator sign (appendicitis), 213 Oculocephalic re ex, 332, 333f Oculomotor nerve, 318b, 319 Odors, body and breath, 62 Odynophagia, 199b, 202 Older adults, 399–400 activities of daily living, 402, 402b approach to, 400–403 common concerns, 401b cultural dimensions, 401, 401b delirium and dementia, 418t–419t eliciting symptoms in, 400–401 examination of, 408–415 falls prevention in, 283, 407–409, 408b, 409f health history, 400–403 health promotion and counseling, 404–406 hearing de cits in, 119 hypothermia in, 68 medications and, 402 Mini-Cog, 420t 10-Minute Geriatric Screener, 406, 406b–407b mistreatment and abuse, 406 Montreal Cognitive Assessment (MoCA), 421t pain in, 402, 403b primary care, approach for, 399b–400b recording ndings, 415–416 vision disorders in, 118 Olfactory nerve, 318, 318b Onycholysis, 114t Onychomycosis, 114t Open-ended questions, 46 Ophthalmoscope, use of, 121b–122b Optic atrophy, 135t Optic disc abnormalities of, 135t examination of, 123, 123b Optic nerve, 318, 318b, 319 Oral candidiasis (thrush), 359 Oral mucosa, inspection of, 126 Orchitis, acute, 244t Orientation assessment of, 84 de ned, 80b in delirium and dementia, 419t Orthopnea, 168b Orthostatic hypotension, 410

436

Inde x

Orthostatic (postural) hypotension, 66b, 174 Ortolani test, 363, 363f Osmotic diarrheas, 215t Osteoarthritis, 304t Osteopenia, 282b Osteoporosis bone density criteria, 282b falls prevention, 283 health promotion and counseling, 281–283 risk factors for, 282b treatment of, 283 Otitis externa, 117, 366 Otitis media, 117, 367 Ovarian cancer, 250 Over ow incontinence, 204, 216t

P Paget disease of nipple, 198t Pain, 60, 69 assessment of, 69–70 chronic, 69, 70b–71b contributing factors, 70 health disparities in treatment of, 70 in knee, 309t–310t location of, 70 management of, 70, 70b–71b in neck, 305t in older adults, 402, 403b severity of, 70 in shoulder, 308t on urination, 203 Painful arc test, 286b Pain provocation test, 286b Palliative care, 403 Pallor, in legs/feet, 219, 226 Palpitations, 167b Papilledema, 135t Pap smear, 393 specimens for, 255, 255f Papules, 101t Paradoxical pulse, 175 Paranoia, 83 Paratonia, 342t Paresthesias, 314 Parietal pain (abdomen), 200 Parkinsonism, 340t Paronychia, 113t Paroxysmal nocturnal dyspnea (PND), 168b Paroxysmal supraventricular tachycardia, 356, 362 Partnerships, collaborative, 50b Past history, 2b, 3

Patches (skin), 100t Patellofemoral instability, 309t Patent ductus arteriosus, 177–178, 177f, 178f, 185t Patient with altered cognition, 51–52 angry, 52 bedbound, 98 confusing, 51 crying, 52 disruptive, 52 dying, 57 empowerment of, 44, 44b with hearing loss, 53–54 with impaired vision, 54 with language barrier, 52, 52b–53b with limited intelligence, 54 with low literacy, 53 partnering with, 43 with personal problems, 54 seductive, 54 silent, 50 talkative, 52 Patient care, ethics in, 58b Peau d’orange sign (breast cancer), 198t Pectus carinatum, 164t Pectus excavatum, 163t Pelvic examination, 252 in older adults, 413–414 Pelvic oor, relaxations of, 263t Pelvic pain, 249 Penile discharge, 234 Penis abnormalities of, 234, 241t examination of, 236–237 Perceptions assessment of, 84 de ned, 80b in delirium and dementia, 418t Percussion notes, 149b Perforation, eardrum, 137t Performance bias, 35b Pericarditis, chest pain in, 155t Perineal irritation, 369 Peripheral arterial disease (PAD), 219 risk factors for, 221b screening for, 221, 221b warning signs, 220b Peripheral nerves, 312 Peripheral nervous system, 312 disorder, 340t Peripheral neuropathy risk, prevention of, 316–317 Peripheral vascular system concerning symptoms, 219b examination of, 12, 222–226

Inde x

health history, 219–220 health promotion and counseling, 220–222 older adults and, 413 recording ndings, 227 in review of systems, 5 Personal history, 2b, 4 Personal hygiene, 62, 83 Personality disorders, 78 Pes anserine bursa, 309t Petechia/purpura, 110t Peutz–Jeghers syndrome, 139t Peyronie disease, 241t Phalen sign, 292, 292f Pharyngitis, 118, 142t Pharynx abnormalities of, 142t examination of, 126 in infants, 359 Physical abuse, 57b Physical activity, guidelines for, 281, 281b Physical contact, 43 Physical dependence, 56b Physical examination, 6–13 approach for, 7 beginning of, 7–10 comprehensive vs. focused, 9 general survey in, 61–62 health promotion and counseling in, 60–61 patient positioning for, 9b, 10 preparation for, 7b recording ndings, 71, 71b sequence of, 8, 9b standard and universal precautions in, 7 Pigeon chest, 164t Pilar cysts, 104t Pinguecula, 134t Pink lesions, 106t Plan, 13, 16 Plantar response, 329, 329f Plaque psoriasis, 101t Plaques, 101t Pleural effusion, 165t Pleuritic pain, 156t Pneumatic otoscope, 367 Pneumococcal vaccine, 146 Pneumonia, 158t, 357 Pneumothorax, 165t Point of maximal impulse (PMI), 412 Polydactyly, 363 Polyps of rectum, 272t Polyuria, 204 Popliteal pulse, 224f Positive predictive value (PPV), 29b Postconcussion headache, 131t Posterior cruciate ligament test, 301, 301f

437

Posterior drawer sign, 301, 301f Posterior tibial pulse, 225f Postmenopausal bleeding, 248 Postnasal drip, 159t Posture, assessment of, 62, 83 Precision, 33 Precocious puberty, 369 Predictive value negative, 29b positive, 29b Preeclampsia, 390b, 394 Pregnancy common concerns, 383b con rmation of, 383 examination in, 389–396 expected date of delivery, 385b gestational age, 385b health history, 383–385 health promotion and counseling, 385–389 hypertension in, 390b maternal concerns and attitudes, 384 obstetric visits, 385 postpartum contraception, plans for, 384 preparation for examination, 389b recording ndings, 396–397 risk factors for maternal and fetal health, 384 symptoms of, 383 Pregnancy Weight Gain Calculator, 386 Premature closure, 48 Premature ejaculation, 234 Prepatellar bursa, 309t Presbyopia, 116, 411 Prescription drugs abuse of, 56, 82 during pregnancy, 388 Present illness, 1b, 3 Pressure sores, 98, 411 Presyncope, 313 Preterm labor, 392 Prevalence of disease, 29–30 Primary biliary cirrhosis, 134t Primary prevention, 33 Primitive re exes, 364 Primum non nocere, 58b Probability revisions, 27–28, 27f Problem List, 24 Professionalism, and ethics, 58, 58b Prolapsed uterus, 263t Proliferative retinopathy advanced, 136t with neovascularization, 136t Pronator drift, test for, 324, 324f Proprioception, test for, 326, 326f

438

Inde x

Prostate cancer of, 273t concerning symptoms, 265b examination of, 268–269 health history, 265 recording ndings, 270 Prostate cancer, 265, 266 risk factors, 266 screening for, 266–267, 266b–247b Prostate-speci c antigen (PSA) test, 266 Prostatitis, acute, 273t Proximal weakness, 314 Pseudoclaudication pain, in back, 306t Psoas sign (appendicitis), 213 Psychiatric questions in review of systems, 6 Ptosis, 133t Pubic hair, 378t–380t Pulmonary disease, chest pain in, 156t Pulmonary embolism, 158t, 161t Pulmonary brosis, idiopathic, 158t Pulmonary function, clinical assessment of, 153 Pulmonary hypertension, 362 Pulmonary tuberculosis, 160t Pulmonary valve stenosis, 375t Pulse, in infants, 356 Pulsus alternans, 175 Pupils in comatose patients, 347t inspection of, 120, 121f large, 347t midposition xed, 347t one xed and dilated, 347t pinpoint, 347t small, 347t Pustules, 103t Pyloric stenosis, 362 Pyrexia. See Fever

R Race and ethnicity cultural ethnicity, 49–50 diabetic risk factors, 171 geriatric diversity, 401b, 401–402 prostate cancer risk factors, 266 testicular cancer risk factors, 235 Radial pulse, 67, 67f, 223, 223f irregular rhythm, 67 regular rhythm, 67 Radicular low back pain, 306t Raised spots (skin), 101t Range of motion ngers, 290 hip, 295, 295f

measurement of, 303 shoulder, 285–286 thumbs, 290f wrists, 290 Rashes, 89 Reassurance, 43 Rebound tenderness, 208 Recent memory, assessment of, 85 Rectal examination in men, 13 in women, 13 Rectal temperature, 68 measurement of, 68–69 Rectocele, 263t Rectovaginal examination, 256, 256f Rectum abnormalities of, 272t–273t cancer of, 273t concerning symptoms, 265b examination of, 268–269, 268f health promotion and counseling, 266–267 recording ndings, 270 Red re ex, 121f, 122b Referred pain (abdomen), 200 Re exes, 327 abdominal, 329, 329f Achilles, 328f biceps, 327f brachioradialis, 328f examination of, 13 grading, 327b quadriceps (patellar), 328f triceps, 327f Remnants of digits, 363 Remote memory, assessment of, 84 Renal artery disease (RAD), 221b–222b screening for, 221b Reproducibility, test, 33 Respiratory rate in infants, 357 and rhythm., 67 Respiratory system, 5 Responses, empathic, 42 Resting static tremors, 341t Retina, examination of, 123, 123b Retinoblastoma, 358 Retinopathy nonproliferative, 136t proliferative, 136t Review of systems (ROS), 2b, 4–6 Rheumatoid arthritis, 304t Rhinorrhea, 117 Rhonchi, 151b Rigidity, 342t Ringworm, 112t Rinne test, 125, 320

Inde x

Romberg test, 12, 324 Rotator cuff tendinitis, 308t Rough lesions (skin), 105t Rovsing sign (appendicitis), 212

S Sarcoidosis, 158t Scabies, 104t Scapular winging, 331, 331f Schizophrenia, 83 Sciatica, 306t Sciatic nerve, 293, 293f Scoliometer, 371 Scoliosis, testing for, 371, 371f Screening for abdominal aortic aneurysm, 222 for breast cancer, 189, 189b for cancer, 404–405 for cardiovascular disease, 169–173 for cervical cancer, 249–250, 250b for colorectal cancer, 206, 206b–207b for delirium, 421t for dementia, 406, 420t for high blood pressure, 170 for HIV/AIDS, 235 for intimate partner violence, 388, 388b lipid, 172 mental health, 79, 79b in older adults, 404 for peripheral arterial disease, 221, 221b for problem drinking, 204b–205b for renal artery disease, 221 for STIs and HPV, 235 Screening tests, in health history, 3 Scrotal edema, 241t Scrotal hernia, 241t Scrotum abnormalities of, 234, 241t examination of, 237 Seborrheic dermatitis, 100t Seborrheic keratosis, 108t in amed, 108t Secondary prevention, 33 Secondary syphilis, 259t Secretory diarrheas, 215t Seductive patient, 53 Seizure, 315 Selection bias, 35b Self-awareness, 50b Self-re ection, 49 Self-skin examination, 92, 98 Senile ptosis, 411 Sensitivity, 29b Sensorineural loss, 117 Sensory loss, 314

439

Sensory system assessment of, 324–327 examination of, 12–13 Serial 7s, 84 Serous effusion, 137t Sex maturity ratings, in boys, 378t–379t Sex maturity ratings, in girls breast, 377t pubic hair, 380t Sexual abuse, 57b, 369 physical signs of, 381t Sexual health female, 248–249 male, 233–234 Sexual history, 55, 55b Sexually transmitted infections of male genitalia, 234, 242t–243t screening for, 235 in women, 249 Shortness of breath, 167b Shoulder examination of, 284–287 pain in, 308t Sighing breathing, 162t Silent patient, 50 Sinuses concerning symptoms, 115b examination of, 125 health history, 117–118 Sinusitis, headache from, 129t SITS muscle (rotator cuff) assessment, 286, 286b–287b Skin, 89–114 color of, 62 description of ndings, terms for, 94, 94b–95b examination of, 10, 93–98 health history, 89 health promotion and counseling for, 90–92 in infants, 357 lesions of, 62, 100t–110t older adults and, 410–411 preparation for examination, 93–94 recording ndings, 99 in review of systems, 2b, 4–6 seated position, examination in, 95–97, 95f–97f supine and prone position, examination in, 97, 97f Skin cancer health promotion and counseling for, 90–92 prevention, 90–91 screening, 91, 91b–92b self-skin examination, 92, 98

440

Inde x

Skin lesions. See also speci c lesion assessment of, 62 brown, 107t–108t description of, 94, 94b–95b pink, 106t primary, 100t–102t, 103t–104t rough, 105t vascular and purpuric, 109t–110t Skin tags, 101t, 107t, 363 Small for gestational age (SGA), 354t, 373t Smoking and cardiovascular disease, 173 older adults and, 403 readiness for cessation, 146, 146b Smooth tongue, 140t SnNOUT mnemonic, 29 Social history, 2b, 4 Sodium, dietary, 61 Solar lentigo, 107t Somatic symptom disorder, 87t Sore throat, 118 Spasticity, 342t Speci city, 29b Speculum examination, 393, 414 Speech assessment of, 83 in delirium and dementia, 418t disorders of, 337t–338t Spelling backward, 84 Spermatic cord abnormalities of, 245t examination of, 238, 238f torsion of, 245t varicocele of, 245t Spermatocele, 245t Spider angioma, 109t Spider vein, 109t Spinal accessory nerve, 318b, 320 Spinal cord, 312 Spinal nerve, 312 Spinal stenosis, 219 Spine, examination of, 292–293 Spleen, examination of, 210, 210f Spontaneous pneumothorax, 158t SpPIN mnemonic, 29 Squamous cell carcinoma (SCC), 105t Stance, 324 Standard precautions, 7 Static nger wiggle test, 119, 120f Stereognosis, 326 Sternocleidomastoid muscles, assessment of, 320 Stool, color of, 202 Straight-leg raise, 306t, 330, 330f Streptococcal pharyngitis, 118, 367 Stress incontinence, 204, 216t Stridor, 148

Stroke prevention of, 316 risk factors management, 316 types of, 335t–336t warning signs and symptoms, 316b Sty, 134t Subacromial/subdeltoid bursitis, 285, 308t Subarachnoid hemorrhage, and headache, 130t Subcutaneous mass/cyst, 104t Substance abuse, 82 Subungual melanoma, 113t Suicide risk, 81–82 Summarization, 44 Sun exposure, and skin cancer cancer, 90–91 Sunscreen, use of, 91 Sutures, 357 Swelling of feet and legs, 220 Symptom, seven attributes of, 3, 3b, 47, 47b Syncope, 168b, 314–315 Syndactyly, 363 Syphilis primary, 243t secondary, 259t Syphilitic chancre, 139t, 259t Systems review, 2b, 4–6 Systolic blood pressure, 66b Systolic murmurs, identi cation, 180

T Tachypnea, 162t Tactile fremitus, 148 Talkative patient, 52 Tanning beds, and melanoma risk, 91 Tavistock Principles, 58, 58b Telogen ef uvium, 98, 111t Temperature axillary, 68 measurement of, 68–69 oral, 68 rectal, 68–69 temporal artery, 69 tympanic membrane, 68, 69 Temporal artery temperature, measurement of, 69 Temporomandibular joint (TMJ), 284, 284f Tendons, 275b Tension headache, 115, 128t Terry nails, 114t Testicular cancer, 235 Testicular self-examination, 235, 239b Testis abnormalities of, 244t

Inde x

examination of, 237, 237f small, 244t Tetralogy of Fallot, 375t Thoracic kyphoscoliosis, 164t Thorax concerning symptoms, 145b deformities of, 163t–164t examination of, 147–153 health history, 145–146 health promotion and counseling, 146 in infants, 360, 360b–361b normal, 163t in older adults, 412 in physical examination, 11 during pregnancy, 391 recording ndings, 154 Thought content assessment of, 84 in delirium and dementia, 418t patient, 80b Thought processes assessment of, 84 in delirium and dementia, 418t patient, 80b Thrills, 362 Throat concerning symptoms, 115b health history, 118 Thumb abduction, 291, 291f Thunderclap headache, 130t Thyroid gland abnormalities of, 143t diffuse enlargement, 143t examination of, 127 with goiter while swallowing, 127f during pregnancy, 390 Thyroid nodule (single), 143t Tibial torsion, 364 Tinea capitis, 112t Tinel sign, 291, 291f Tinnitus, 117 Tobacco use in health history, 3 during pregnancy, 387 Tolerance, 56b Tongue abnormalities of, 140t–141t inspection of, 126 Torsion of spermatic cord, 245t Torticollis, 305t Tortuous atherosclerotic aorta, 412 Transient ischemic attack (TIA), 313. See also Stroke Transitions, 44 Transposition of great arteries, 376t Trapezius muscles, assessment of, 320, 320f

441

Traumatic ail chest, 163t Treatment plan, sharing of, 48–49 Tremors, 315, 415 Trichomonas vaginitis, 260t Trichophyton rubrum, 114t Trigeminal nerve, 318b, 319, 319f Trochanteric bursa, 294, 294f Trochlear nerve, 318b, 319 Tug test, 98, 98f Tumor of testis, 244t Two-point discrimination, 326, 326f Tympanic membrane temperature, 68 measurement of, 69 Tympanosclerosis, 137t

U Ulcerative colitis, 215t Ulcers of feet and ankles, 229t Ultraviolet radiation exposure, avoidance of, 90 Umbilical hernias, in infants, 354 Undescended testicles, 363 Unilateral blindness, 132t Universal precautions, 7 Urethritis, assessment of, 256, 256f Urge incontinence, 204, 216t Urgency, urinary, 203 Urinary frequency, 203 Urinary incontinence, 204, 216t–217t functional, 217t over ow, 216t secondary to medications, 217t stress, 216t urge, 216t Urinary system in review of systems, 5 symptoms related to, 203–204 Urine, color of, 202 Urticaria, 104t U.S. Preventive Services Task Force (USPSTF), 33 abdominal aortic aneurysm screening, 222 breast cancer screening, 189b cancer screening in older adults, 399 carotid artery screening cervical cancer screening, 250b colorectal cancer screening, 206b grade de nitions and implications for practice, 37t hypertension screening, 170 levels of certainty, 38t low-dose computed tomography screening, 146 osteoporosis screening, 282

442

Inde x

Uterus anteverted, 262t bicornuate, 394 myoma of, 262t palpation of, 255, 255f during pregnancy, 394 prolapsed, 263t retro exed, 262t retroverted, 256, 256f, 262t

V Vaccination. See also Immunizations hepatitis A, 205b hepatitis B, 206b HPV, 235 Vaginal adenosis, 261t Vaginal discharge, 248, 260t, 369 Vagus nerve, 318b, 320 Validation, 43 Validity, test, 28–32 Valsalva maneuver, 180 Varicocele of spermatic cord, 245t Varicose veins (tongue), 141t Vasomotor rhinitis, 117 Venereal wart, 258t Venous insuf ciency, chronic, 228t, 229t Ventricular heart failure, left, 157t, 161t Ventricular septal defect, 376t Verbal support, 43 Vertigo, 117, 313 Vesicles, 102t Vibration sense, testing of, 325 Violence domestic, 57 intimate partner, 57 Viral hepatitis, health promotion and counseling for, 205–206 Viral pneumonias, 159t Visceral pain (abdomen), 199 Visual Analog Scale, 70, 402 Visual eld defects, 132t Visual loss central, 116 one-sided loss, 116 peripheral loss, 116 sudden, 116

Vital signs in infants, 356–357 in older adults, 408–410 in physical examination, 10, 64–69 recording ndings, 71b Vitamin D, food sources of, 74t Vitiligo, 100t Vocabulary, patient, 85 Voice sounds, transmitted, 151b Voluminous diarrheas, 215t Vulva, lesions of, 258t–259t Vulvar carcinoma, 259t

W 6-minute walk test, 153 Warts, 105t Weakness, 59, 314 distal, 314 proximal, 314 Weber test, 125, 320 Weight change in, 60 gain, 60 in infants, 355 loss, 60 measurement of, 63 older adults and, 410 optimal, 60, 61b during pregnancy, 390 Weight gain, during pregnancy, 386, 386b Wernicke aphasia, 337t–338t Wheal, 104t Wheezes, 148, 151b Whiplash syndrome, 305t White coat hypertension, 64b Winging of scapula, 331, 331f World Health Organization, bone density criteria, 282b Wrists, examination of, 288–290

X Xanthelasma, 134t

Bates’ Pocket Guide to Physical Examination and History Taking, 8e (Nov 1, 2016)_(1496338480)_(LWW).pdf

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