Posted: March 11th, 2023

HEENT SOAP

Please see atachment for instructions

Pt is a female 22 years old came to the clinic for wellness examination of the HEENT: head, ears, eyes, nose and throat and face.

General inspection:

Head: normal hair distribution, texture, no lesions, no hematomas normocephalic and atraumatic

Eye: no exophthalmos, ptosis. Vision is 20/20

Cranial nerves: oculomotor 3, trochlear 4, abducens 6, no abnormalities.

-Weber test: patient reported hearing the equal sound in both ears which is normal test.

-Rinne test : used to evaluate hearing loss in one ear. Air conduction is greater than bone conduction.

Nose: no discharges, mucosa and turbinate’s looks normal no pain in the frontal or maxillary sinus.

Ear: no external ears discharge. No hearing problems. Tympanic membrane without abnormalities

Mouth: no lips deformities, no gingivitis. Dentures no cavities, No tongue deviation, CN 12 intact. Posterior pharynx normal, no exudates. Tonsils grade 2

Neck: Range of motion: normal flexion and hyperextension. No lymph nodes enlargements. No thyroid enlargement.

——Please feel free to add any normal information and plug in with references and APA format as usual.

Expectations

Initial Post:

Please format to support and expand the information I have written, with in citations.

Everything in APA format with intext citations

References: 2 high-level scholarly references within the last 5 years in APA format.

Plagiarism free.

Turnitin receipt.

Physical
Examination
AND History Taking

B A T E S’ Pocket Guide to

E I G H T H E D I T I O 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

Guest 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

Physical
Examination
AND History Taking

B A T E S’ Pocket Guide to

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Eighth Edition

Copyright © 2013, 2009 by Wolters Kluwer Health | Lippincott Williams & Wilkins. Copyright
© 2007, 2004, 2000 by Lippincott Williams & Wilkins. Copyright © 1995, 1991 by J. B.
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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
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matter of products liability, negligence law or otherwise, or from any reference to or use by any
person of this work.

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We would like to dedicate this book to all our

students, trainees, and mentees who have

taught us the true value of both

the science and the

ar t of medicine.

Faculty Reviewers

J. D. Bartleson Jr., MD
Associate Professor of Neurology
Mayo Clinic
Rochester, Minnesota

John D. Bartlett, MD
Assistant Clinical Professor of

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

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

Amit Garg, MD
Dermatologist
Northwell Health Physician Partners
Manhasset, New York

Catherine F. Gracey, MD
Associate Professor
Department of Medicine
School of Medicine and Dentistry
University of Rochester Medical

Center
Rochester, New York

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

Faculty Reviewers vii

Patrick McCleskey, MD
Dermatologist
Oakland Medical Center
Oakland, California

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
Professor of Pediatrics
University of California at Los Angeles

(UCLA)
Los Angeles, California

Loralei Lacina Thornburg, MD
Associate Professor
Department of Obstetrics and

Gynecology
School of Medicine and Dentistry
University of Rochester Medical Center
Rochester, New York

Scott A. Vogelgesang, MD
Director
Division of Immunology
Clinical Professor
Department of Internal Medicine–

Immunology
University of Iowa Carver College

of Medicine
Iowa City, Iowa

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 TUD EN T REVIEWERS

Ayala Danzig
University of Rochester School of

Medicine and Dentistry

Benjamin Edmonds
University of Central Florida College

of Medicine

Nicholas P. N. Goldstein
University of Rochester School of

Medicine and Dentistry

viii

Preface

Bates’ Pocket Guide to Physical Examination and History Taking, eighth edi-
tion, 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 examina-
tions.

■ 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.

Contents

Faculty Reviewers vi
Preface viii

C H A P T E R 1 Foundations for Clinical Proficiency 1

C H A P T E R 2 Evaluating Clinical Evidence 27

C H A P T E R 3 Interviewing and the Health History 41

C H A P T E R 4 Beginning the Physical Examination: General Survey,
Vital Signs, and Pain 59

C H A P T E R 5 Behavior and Mental Status 77

C H A P T E R 6 The Skin, Hair, and Nails 89

C H A P T E R 7 The Head and Neck 115

C H A P T E R 8 The Thorax and Lungs 145

C H A P T E R 9 The Cardiovascular System 167

C H A P T E R 10 The Breasts and Axillae 187

C H A P T E R 11 The Abdomen 199

C H A P T E R 12 The Peripheral Vascular System 219

C H A P T E R 13 Male Genitalia and Hernias 233

C H A P T E R 14 Female Genitalia 247

C H A P T E R 15 The Anus, Rectum, and Prostate 265

C H A P T E R 16 The Musculoskeletal System 275

C H A P T E R 17 The Nervous System 311

C H A P T E R 18 Assessing Children: Infancy through Adolescence 349

C H A P T E R 19 The Pregnant Woman 383

C H A P T E R 2 0 The Older Adult 399

Index 423

C H A P T E R

1Foundations 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 ify in g Da t a ● 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

Re lia b ilit y ● V ries ccording to the tient’s e ory, trust, nd
ood

Ch ie f Co m p la in t (s ) ● The one or ore sy to s or concerns c using the
tient to seek c re

P re s e n t Illn e s s ● 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 ok-
ing nd lcohol, which frequently re ertinent to
the resent illness

(continued )

2 Ba tes ’ Pocke t Guide to Physica l Examina tion and His tory Taking

Decide if your assessment will be comprehensive or focused. Be sure to
distinguish subjective from objective data.

S u b je c t ive Da t a Ob je c t ive Da t a

Wh t the tient tells you Wh t you detect during the ex in –
tion, l bor tory infor tion, nd
test d t

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

All hysic l ex in tion findings, or
signs

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 infor-
mation 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.”

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)

Pa s t His t o ry ● 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

Fa m ily His t o ry ● 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.

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

● Describes educ tion l level, f ily of origin, current
household, erson l interests, nd lifestyle

Re vie w o f S ys t e m s ● Docu ents resence or bsence of co on
sy to s rel ted to e ch jor body syste

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 Ba tes ’ Pocke t Guide to Physica l Examina tion and His tory Taking

Fa 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 exami-
nation. 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 rs , 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,

Chapter 1 | Foundations for Clinical Proficiency 5

spots, specks, ashing lights, glaucoma, cataracts. Ears: Hearing, tinni-
tus, 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 ck . 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, bron-
chitis, 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 ra 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, incon-
tinence; in males, reduced caliber or force of urinary stream, hesitancy,
dribbling.

Ge 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; regular-
ity, frequency, and duration of periods; amount of bleeding, bleeding
between periods or after intercourse, last menstrual period; dysmenor-
rhea, premenstrual tension. Age at menopause, menopausal symptoms,
postmenopausal bleeding. In patients born before 1971, exposure to

6 Ba tes ’ Pocke t Guide to Physica l Examina tion and His tory Taking

diethylstilbestrol (DES) from maternal use during pregnancy. Vaginal
discharge, itching, sores, lumps, STIs and treatments. Number of preg-
nancies, number and type of deliveries, number of abortions (spontane-
ous and induced), complications of pregnancy, birth control methods.
Sexual preference, interest, function, satisfaction, problems (including
dyspareunia). Concerns about HIV infection.

Mu 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 ych ia t ric . Nervousness; tension; mood, including depression, mem-
ory change, suicide attempts, if relevant.

Ne u ro lo g ic . Changes in mood, attention, or speech; changes in orienta-
tion, 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.

Chapter 1 | Foundations for Clinical Proficiency 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. Reflect on your ro ch to the tient.
2. Adjust the lighting nd the environ ent.
3. Check your equi ent.
4. M ke the tient co fort ble.
5. Observe st nd rd nd univers l rec utions.
6. 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 ro 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 uncom-
mon, especially at rst! Simply examine that area out of sequence, but
smoothly.

Ad ju s t Lig h t in g a n d t h e En v iro 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 ck Yo u r Eq u ip m e n t . Be sure your stethoscope, re ex hammer,
and other equipment are readily at hand.

Ma k e t h e P a t ie n t Co m fo r t a b le . Show concern for privacy and
modesty.

8 Ba tes ’ Pocke t Guide to Physica l Examina tion and His tory Taking

■ 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 rd a n d MRS A P re 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 rs 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 patho-
gens when providing rst aid or health care. The following uids are consid-
ered 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 work-
ers should observe the important precautions for safe injections and preven-
tion of injury from needlesticks, scalpels, and other sharp instruments and
devices. Report to your health service immediately if such injury occurs.

Ch 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
Exa 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.

Chapter 1 | Foundations for Clinical Proficiency 9

● 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 t ion;
reflexes; B binski reflex

● Musculoskelet l, s indic ted
● Optional: skin, nterior

nd osterior
● 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, with he d of bed r ised
3 degrees

S e, turned rt ly to left side

Sitting, le ning forw rd

Lying su ine

St nding

Lying su ine, with hi s flexed,
bducted, nd extern lly rot ted,
nd knees flexed (lithoto y
osit ion)

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.

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

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.

10 Ba tes’ Pocke t Guide to Physica l Examina tion and His tory Taking

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 ante-
rior chest. Then roll the patient onto each side to listen to the lungs, exam-
ine 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 rve 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 envi-
ronment. 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, dis-
tribution, 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, ton-
sils, and pharynx. You may wish to assess the cranial nerves at this point in
the examination.

Chapter 1 | Foundations for Clinical Proficiency 11

Ne ck . 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 ck . Inspect and palpate the spine and muscles.

Po 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. Iden-
tify 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 No t e o n t h e Mu s c u lo s k e le t a l S ys 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 pal-
pate 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 adventi-
tious sounds, and, if indicated, transmitted voice sounds.

Ca rd iova 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 rela-
tion 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 Ba tes’ Pocke t Guide to Physica l Examina tion and His tory Taking

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.

/ Pe 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 rvo u s S ys t e m . The patient is sitting or supine. The examina-
tion 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 periph-
eral nervous system.

Me 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.

Cra n ia l Ne 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.

Mo t o r S ys 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.

Chapter 1 | Foundations for Clinical Proficiency 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.

/ Ma le Ge n it a lia a n d He rn ia s . Examine the penis and scrotal
contents. Check for hernias.

Re c t a l Exa m in a t io n in Me 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 Ba tes’ Pocke t Guide to Physica l Examina tion and His tory Taking

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. Identify bnor l findings.
2. Loc lize findings n to ic lly.
3. Cluster the clinic l findings.
4. Se rch for the rob ble c use of the findings.
5. Cluster the clinic l d t .
6. Gener te hy otheses bout the c uses of the tient’s roble s.
7. 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 labora-
tory 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 straight-
forward. 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 musculoskel-
etal 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.

Chapter 1 | Foundations for Clinical Proficiency 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 hemor-
rhages, place them in the cardiovascular system, and label the constella-
tion “hypertensive cardiovascular disease with hypertensive retinopathy.”

■ Multisystem conditions: With experience, you will become increasingly
adept at recognizing multisystem conditions and building plausible expla-
nations 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 gastrointes-
tinal (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 rch 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 com-
plaints 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 Pa 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 Ba tes’ Pocke t Guide to Physica l Examina tion and His tory Taking

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. Select the ost s ecific nd critic l findings to su ort your hy othesis.
2. M tch your findings g inst ll the conditions th t c n roduce the .
3. Eli in te the di gnostic ossibilities th t f il to ex l in the findings.
4. Weigh the co eting ossibilities nd select the ost likely di gnosis.
5. Give s eci l t tention 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, addi-
tional 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 rk in g Dia 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 con-
sultations 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

Chapter 1 | Foundations for Clinical Proficiency 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.

T h 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 n residing in Es nol ,

New Mexico.
Referral. None
Source and Reliability. Self-referred; see s reli ble.

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, otor-
sensory 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 Ba tes’ Pocket Guide to Phys ica l Examination and His tory Taking

T h 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: Tonsillec-
to 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 sexu-
lly 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 accident S troke , va ricose
ve ins , headaches

High
blood

pressure Heart
a ttack

Infancy

HeadachesMigra ine
headaches

Indica te s pa tient Deceased ma le Deceased fema le Living ma le

Living female

43 67

67 58 54

33 31 27

(continued )

Chapter 1 | Foundations for Clinical Proficiency 19

T h e C a s e o f M r s . N . (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 rthrit is; 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. Chil-
dren 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, infect ions. Nose, sinuses:
Occ sion l ild cold. No h y fever, sinus trouble. Throat (or mouth and phar-
ynx): 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 Ba tes’ Pocke t Guide to Physica l Examina tion and His tory Taking

T h e C a s e o f M r s . N . (Continued)

Gastrointestinal: A etite good; no n use , vo iting, indigestion. Bowel ove-
ent 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 s-
tic su ort hose; tried “w ter ill” 5 onths go, but it didn’t hel uch; no
history of hlebitis or leg in.
Musculoskeletal: Mild low b ck ches, often t the end of the workd y; no
r di t ion into the legs; used to do b ck exercises but not now. No other 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 ted nd
res onds quickly to quest ions. She is so ewh t tense, with 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 )

Chapter 1 | Foundations for Clinical Proficiency 21

T h e C a s e o f M r s . N . (Continued)

Neck: Neck su le. Tr che idline. Thyroid isth us b rely l ble, lobes
not felt .
Lymph nodes: S ll (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 or 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 bil-
ity of dise se. A test with likelihood ratio of 1 rovides no ddition l infor t ion bout
the rob bility of dise se.

32 Ba tes’ Pocke t Guide to Physica l Examina tion and His tory Taking

0.1

Pre-tes t
Probability (%)

Like lihood
Ratio

0.2

0.5

40
50

99 0.1

0.2

0.5

2000
1000

500
200
100

50
20
10

5
2

0.002

0.005
0.01
0.02

0.05
0.1
0.2

0.5

0.001
0.0005

Pos t-tes t
Probability (%)

5
20

00
.0

5
20

00
.0

Figure 2-2 Fagan nomogram. (Adapted with permiss ion from Fagan TJ. Le tte r:
nomogram for Bayes theorem. N Engl J Med. 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 c-
ity 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%.

Chapter 2 | Evaluating Clinical Evidence 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 nd-
ing 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 Ka p p a V a lu e s

Va lu e o f Ka p p a S t re n g t h o f Ag re e m e n t

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.

Techniques of Examination
EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

G e n e r a l S u r v e y

Ap p a re n t S t a t e o f He a lt h

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

Acutely or chronically ill, frail, robust,
vigorous

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

62 Ba tes’ Pocke t Guide to Physica l Examina tion and His tory Taking

S ig n s o f Dis t re s s

■ Cardiac or respiratory distress

■ Pain

■ Anxiety or depression

S k in Co lo r a n d Ob vio u s
Le s io n s . See Chapter 6, The Skin,
Hair, and Nails, for details.

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.

Fa c ia l Exp re s s io n . Watch for
eye contact. Is it natural? Sustained
and unblinking? Averted quickly?
Absent?

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

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

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

Wincing, sweating, protecting painful
area

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

Pallor, cyanosis, jaundice, rashes, bruises

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

Breath odor of alcohol, acetone
(d iabetes), uremia, or liver failure.
Fruity odor of d iabetes. (Never assume
that alcohol on a pat ient ’s breath
explains changes in mental status or
neurologic findings.)

Stare of hyperthyroidism; flat or sad
affect of depression. Decreased eye
contact may be cultural or may suggest
anxiety, fear, or sadness.

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

Body piercing or tattoos can be
associated with alcohol and drug use.

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Chapter 4 | Beginning the Physical Examination: General Survey, Vital Signs, and Pain 63

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

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.

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

Obesity (BMI ≥30 kg/m2) increases risk of
diabetes, heart disease, stroke, hyper-
tension, osteoarthritis, sleep apnea syn-
drome, and some forms of cancer.

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

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)

Un it o f Me a s u re Me t h o d o f Ca 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

aSever 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.

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 appro-
priate counseling or referral (see Table 4-2, Nutrition Screening, p. 73, and
Table 4-3, Nutrition Counseling, p. 74).

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

64 Ba tes’ Pocke t Guide to Physica l Examina tion and His tory Taking

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 fo r M e a s u r in g Blo o d P re 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. Auto-
mated 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.

Typ e s o f Hyp 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)

Blood ressure ≥14 /9 in edic l set-
tings 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 rdio-
v scul r risk nd does not require
tre t ent; ttributed to conditioned
nxiety res onse

Masked hypertension Blood ressure 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 untre ted, it incre ses risk of c rdio-
v scul r dise se nd end-org n
d ge

(continued )

Chapter 4 | Beginning the Physical Examination: General Survey, Vital Signs, and Pain 65

T y p e s o f H y p e r t e n s io n (Continued)

Nocturnal hypertension Physiologic blood ressure “di ing”
occurs in ost tients s they shift
fro w kefulness to slee

A 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 tient’s r .
Follow the guidelines outlined here for selecting the correct size:

● 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 fer-
ence ( l ost long enough to encircle the r ).

● The st nd rd cuff is 12 × 23 c , ro ri te for r circu ferences u to
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 r e s s u r e M e a s u r e m e n t

1. The t ient should void s oking or drinking c ffein ted bever ges
for 3 inutes before the blood ressure is t ken nd rest for t le st
5 inutes.

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 t ient is se ted, rest the r on t ble lit t le bove the t ient’s
w ist; if st nding, try to su ort the t ient’s r t the idchest level.

66 Ba tes’ Pocke t Guide to Physica l Examina tion and His tory Taking

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 res-
sure 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 nd-
ing 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

Ca t e g o ry S ys t o lic (m m Hg ) Dia s t o lic (m m Hg )

Nor l <12 <8
Prehy ertension 12 –139 8 –89
St ge 1 hy ertension

Ages ≥18 to <6 ye rs;
di betes or ren l dise se

Age ≥6 ye rsa

14 —159

15 –159

9 —99

9 –99
St ge 2 hy ertension ≥16 ≥1

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

Chapter 4 | Beginning the Physical Examination: General Survey, Vital Signs, and Pain 67

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.

Figure 4-1 Palpate the radial pulse .

Palpation of an irregularly irregular
rhythm reliably indicates atrial fibrillation.
For all irregular patterns, an ECG is
needed to identify the arrhythmia.

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

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).

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Rhyt 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?

Resp ira to ry Ra te and Rhythm .
Observe the rate, rhythm, depth, and
effort of breathing. Count the number
of respirations in 1 minute either
by visual inspection or by subtly
listening over the patient’s 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.

68 Ba tes’ Pocke t Guide to Physica l Examina tion and His tory Taking

Te m p e ra t u re . Average oral tem-
perature, 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 sug-
gest that in adults, oral and tem-
poral artery temperatures correlate
more closely with the pulmonary
artery temperature, but are about
0.5°C lower.

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 ther-
mometer 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

Fever or pyrexia refers to an elevated
body temperature. Hyperpyrexia refers to
extreme elevation in temperature, above
41.1°C (106°F), while hypothermia refers
to an abnormally low temperature, below
35°C (95°F) rectally.

Causes of fever include infection,
t rauma (such as surgery or crush
injuries), malignancy, b lood disorders
(such as acute hemolyt ic anemia), drug
react ions, and immune disorders such
as collagen vascular d isease.

The chief cause of hypothermia is
exposure 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.

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

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Chapter 4 | Beginning the Physical Examination: General Survey, Vital Signs, and Pain 69

insert it about 3 to 4 cm
(1½ inches) into the anal canal,
in a direction pointing to the umbi-
licus. Remove it after 3 minutes,
then read. Alternatively, use an
electronic thermometer after lubri-
cating the probe cover. Wait about
10 seconds for the digital tempera-
ture 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 tem-
perature by approximately 0.8°C
(11.4°F).

Temporal artery temperature:
Place the probe against the center
of the forehead, depress the infra-
red 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 behind-
the-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.

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

70 Ba tes’ Pocke t Guide to Physica l Examina tion and His tory Taking

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 spe-
ci 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 rs . Be sure to ask about any treatments that the
patient has tried, including medications, physical therapy, and alterna-
tive 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 dispari-
ties 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.

Pa 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 mea-
surement 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 question-
n 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 )

Chapter 4 | Beginning the Physical Examination: General Survey, Vital Signs, and Pain 71

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 self-
explanatory.)

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

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 lthy- e 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
t i 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 st-
ing. 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.)

72 Ba tes’ Pocke t Guide to Physica l Examina tion and His tory Taking

Aids to Interpretation

Die t a ry Ch a n g e Fo o d S o u rc 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

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

Table 4-1

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. Govern-
ment 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.

Chapter 4 | Beginning the Physical Examination: General Survey, Vital Signs, and Pain 73

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

Nu t rit io n Sc re e n in g

Mini Nutritiona l Assessment
MNA®

Las t name: Firs t name:

Sex: Age: Weight, kg: Height, cm: Date :

Screening

A Has food intake declined over the pas t 3 months due to los s of appetite , diges tive problems , chewing or
s wallowing difficulties ?
0 = severe decrease in food intake
1 = moderate decrease in food intake
2 = no decrease in food intake

B Weight los s during the las t 3 months
0 = weight loss grea te r than 3 kg (6.6 lbs )
1 = does not know
2 = weight loss be tween 1 and 3 kg (2.2 and 6.6 lbs )
3 = no weight loss

C Mobility
0 = bed or chair bound
1 = able to ge t out of bed / cha ir but does not go out
2 = goes out

D Has s uffered ps ycholog ical s tres s or acute dis eas e in the pas t 3 months ?
0 = yes 2 = no

E Neurops ycholog ical problems
0 = severe dementia or depress ion
1 = mild dementia
2 = no psychologica l problems

F1 Body Mas s Index (BMI) (weight in kg) / (height in m)2

0 = BMI less than 19
1 = BMI 19 to less than 21
2 = BMI 21 to less than 23
3 = BMI 23 or grea te r

IF BMI IS NOT AVAILABLE, REPLACE QUESTION F1 WITH QUESTION F2.
DO NOT ANSWER QUESTION F2 IF QUESTION F1 IS ALREADY COMPLETED.

Complete the screen by filling in the boxes with the appropria te numbers . Tota l the numbers for the final screening score.

F2 Calf c ircumference (CC) in cm
0 = CC less than 31

Screening score (max. 14 points)

12 – 14 points : Normal nutritional s tatus
8 – 11 points : At risk of malnutrition
0 – 7 po ints : Malnourished

3 = CC 31 or grea te r

Table 4-2

74 Ba tes ’ Pocke t Guide to Physica l Examina tion and His tory Taking

Nu t r ie n t Fo o d S o u rc e

Ca 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

Nu t rit io n Co u n se lin g : So u rce s o f N u t r ie n t sTable 4-3

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. Govern-
ment 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.

Chapter 4 | Beginning the Physical Examination: General Survey, Vital Signs, and Pain 75

An o re xia Ne r vo s a Bu lim ia Ne r vo s a

Refusal to maintain minimally normal
body weight (or BMI above 17.5 kg/m2)
Fear of appearing fat
Frequently starving but in denial;
lacking insight
Often brought in by family members
May present as failure to make expected
weight gains in childhood or adolescence,
amenorrhea in women, loss of libido or
potency in men
Associated with depressive symptoms
such as depressed mood, irritability, social
withdrawal, insomnia, decreased libido
Additional features supporting
diagnosis: self-induced vomiting or
purging, excessive exercise, use of appetite
suppressants and/or diuretics
Biologic complications
■ Neuroendocrine changes: amenorrhea,

hormonal alterations
■ Cardiovascular disorders: bradycardia,

hypotension, dysrhythmias,
cardiomyopathy

■ Metabolic disorders: hypokalemia,
hypochloremic metabolic alkalosis,
increased BUN, edema

■ Other: dry skin, dental caries, delayed
gastric emptying, constipation,
anemia, osteoporosis

Repeated binge eating followed
by self-induced vomiting,
misuse of laxatives, diuretics, or
other medications; fasting; or
excessive exercise
Often with normal weight
Overeating at least twice a week
during 3-month period; large
amounts of food consumed in
short period (�2 hrs)
Preoccupation with eating;
craving and compulsion to eat;
lack of control over eating;
alternating with periods of
starvation
Dread of fatness but may be
obese
Subtypes of
■ Purging: bulimic episodes

accompanied by self-induced
vomiting or use of laxatives,
diuretics, or enemas

■ Nonpurging: bulimic episodes
accompanied by compensatory
behavior such as fasting,
exercise without purging

Biologic complications; see
changes listed for anorexia
nervosa.

Ea t in g Dis o rd e rs a n d Exc e s s ive ly Lo w BMITable 4-4

Sources: World Health Organization. The ICD-10 Classi cation of Mental and Behavioral Disorders:
Diagnostic Criteria for Research. Geneva: World Health Organization, 1993; American Psy-
chiatric 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.

C H A P T E R

5Behavior 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 5 to 10 atypical moles, to perform regular self-skin examinations.

T h e A B C D E R u le (Continued)

Me la n o m a Be n ig n Ne vu s

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

Color variationsa

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

Evolvingc

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

● Elev ted
● Fir to l t ion
● Growing rogressively over sever l weeks

aWith 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 .

bE rly el no s y be 6 .
cEvolution, or ch nge, is the ost sensitive of these criteri . A reli ble history of ch nge y

ro t bio sy of benign- e ring lesion.

Chapter 6 | The Skin, Hair, and Nails 93

EXAMINATION TECHNIQUES

Techniques of Examination

P O SSIBLE FIN DIN GS

Fu 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
See Tab les 6-1 to 6-5, pp. 100–108,
for examples of p rimary lesions (flat ,
ra ised , and flu id -filled ; pustules,
furuncles, nodules, cysts, wheals, and
burrows); and rough, p ink, and brown
lesions.

Perform a full-body skin examina-
tion 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 fac-
tors all warrant a full-body skin
examination.

Even during routine examinations, you can pursue an integrated skin exami-
nation 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 rou-
tinely 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,

94 Ba tes’ Pocke t Guide to Physica l Examina tion and His tory Taking

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 rm s fo r De 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 .

● Raised: You c n l te the lesion with eyes closed.
● Papule: Lesion is r ised, 1 c , but not fluid-filled.
● Vesicle: 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.

(continued )

● 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.

Chapter 6 | The Skin, Hair, and Nails 95

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Te ch n iq u e s o f Exa m in a t io n —
Pa t ie n t S e a t e d . Choose one of
two patient positions for perform-
ing 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.

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

Sparse hair is seen in hypothyroid-
ism; ne, silky hair in hyperthy-
roidism.

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

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

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.

Figure 6-1 Part the hair on the scalp.

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

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

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

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

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 tterns is
often very hel ful.

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.

96 Ba tes’ Pocke t Guide to Physica l Examina tion and His tory Taking

Figure 6-5 Inspect the arms , hands ,
and nails .

Figure 6-6 Inspect the ches t and
abdomen.

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

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

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

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

Figure 6-2 Inspect the forehead. Figure 6-3 Inspect the face , eyes ,
and ears .

Figure 6-4 Inspect the anterior neck.

Chapter 6 | The Skin, Hair, and Nails 97

Figure 6-7 Inspect the thighs and
lower legs .

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Figure 6-8 Inspect the sole s of the
fee t and be tween the toes .

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).

Figure 6-9 Inspect the back, buttocks ,
and pos te rior legs .

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 iqu e s o f Exa m in a –
t io n —Pa 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 abdo-
men; 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, poste-
rior neck, back, posterior thighs, legs,
soles of the feet, and buttocks (if
appropriate).

Figure 6-10 Inspect the scalp, arms ,
hands , ches t, abdomen, ante rior and
pos te rior thighs , and fee t.

98 Ba tes’ Pocke t Guide to Physica l Examina tion and His tory Taking

Figure 6-11 Hair pull te s t.

Figure 6-12 Tug te s t.

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

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

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.

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 Exa m in a t io n . The patient will need a full-
length 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 malig-
nant nevi on easy-to-access websites, handouts, or tables in this chapter.

Exa 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.

Eva lu a t in g t h e Be d b o u n d
Pa t ie n t . People con ned to bed,
especially when they are emaciated,
elderly, or neurologically impaired,
are particularly susceptible to pres-
sure 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.

Chapter 6 | The Skin, Hair, and Nails 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 gu-
ration, 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 ig-
ent 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 ker-
atoses and benign nevi, but also a possible malignant melanoma.)

100 Ba tes’ Pocke t Guide to Physica l Examina tion and His tory Taking

Aids to Interpretation

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 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

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

Table 6-1

Chapter 6 | The Skin, Hair, and Nails 101

(table continues on page 102)

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 plaque.

Papules (raised, small)

Multiple 2–4-mm soft, fleshy skin-
colored 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

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 )

Table 6-1

102 Ba tes’ Pocket Guide to Phys ica l Examination and His tory Taking

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 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

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 )

Table 6-1

Chapter 6 | The Skin, Hair, and Nails 103

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

Ad d it io n a l P rim a ry Le s io n s : Pu s t u le s ,
Fu ru n c le s , No d u le s , Cys t s , Wh e a ls , Bu rrow s

Table 6-2

(table continues on page 104)

104 Ba tes’ Pocket Guide to Phys ica l Examination and His tory Taking

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

Ad d it io n a l Prim a ry Le s io n s : Pu s t u le s ,
Fu ru n c le s , No d u le s , Cys t s , Wh e a ls ,
Bu rrow s (continued )

Table 6-2

Chapter 6 | The Skin, Hair, and Nails 105

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 ra 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 rc 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)

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

Table 6-3

106 Ba tes’ Pocket Guide to Phys ica l Examination and His tory Taking

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 Ce ll Ca rc in o m a
S u p e r f ic ia l b a s a l c e ll c a rc in o m a

■ Pink patch that does not heal
■ May have focal scaling

No d u la r b a s a l c e ll c a rc 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

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

Table 6-4

Chapter 6 | The Skin, Hair, and Nails 107

(table continues on page 108)

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.

Me la n o m a Mim ic s

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

■ 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

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

■ Soft and fleshy
■ Often around neck, axillae, or

back
■ Sessile nevi may have a hint of

brown pigmentation

Me la n o m a in s it u S o la r le n t ig o

■ On sun-exposed or sun-
protected skin

■ Look for ABCDE features

■ On sun-exposed skin
■ Light brown and uniform in

color but may be asymmetric

Brow n Le s io n s : Me la n o m a a n d It s Mim ic sTable 6-5

108 Ba tes’ Pocket Guide to Phys ica l Examination and His tory Taking

Me la n o m a Mim ic s

Me la n o m a Dys p la s t ic n e vu s

■ May arise de novo or in existing
nevi and exhibits ABCDEs

■ Patients with many dysplastic
nevi have increased risk of
melanoma

■ May have macular base and
papular central “fried egg”
component

■ Compare to the patient’s other
nevi and monitor changes

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

■ May have variegated color
(browns, red)

■ Has melanocytic features on
dermoscopy

■ Can sometimes mimic a
melanoma if it has an
erythematous base

■ Dermoscopy helps the trained
eye distinguish these

Me la n o m a S e b o r rh e ic k e ra t o s is

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

■ Stuck-on and verrucous, may be
darkly pigmented

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

Table 6-5

Chapter 6 | The Skin, Hair, and Nails 109

(table continues on page 110)

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

Ch e rry An 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 An 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

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

110 Ba tes’ Pocke t Guide to Physica l Examina tion and His tory Taking

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

Table 6-6

Le s io n s
Fe a t u re s : Ap p e a ra n c e ,
Dis t r ib u t io n , S ig n if ic a n c e

P e t e ch ia /P u rp u ra
■ 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 ch ym 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

aThese 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 Lip-

pincott; 1987; Petechia/Purpura—Kelley WN. Textbook of Internal Medicine. Philadelphia, PA:
JB Lippincott; 1989.

Chapter 6 | The Skin, Hair, and Nails 111

Ge n e ra lize d o r Diffu 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 An 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

Ha ir Lo s sTable 6-7

(table continues on page 112)

112 Ba tes ’ Pocke t Guide to Physica l Examina tion and His tory Taking

Fo c a l Ha ir Lo s s
Alo p e c ia Are 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 Ca p it is (“ Rin g w o rm ” )
There are round scaling patches of alopecia, usually caused by Trichophyton
tonsurans from humans, and less commonly, Microsporum canis from dogs
or cats.

Ha ir Lo s s (continued )Table 6-7

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.

aSee 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.

Chapter 6 | The Skin, Hair, and Nails 113

P a ro n ych 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.

Clu 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 De fo rm 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.

Me la n o n ych 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.

Fin d in g s in o r n e a r t h e Na ilsTable 6-8

(table continues on page 114)

114 Ba tes ’ Pocke t Guide to Physica l Examina tion and His tory Taking

On ych o lys is
A painless separation of the whitened
opaque nail plate from the pinker
translucent nail bed.

On ych 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 Na ils
Nail plate turns white with a ground-
glass appearance, a distal band of
reddish brown, and obliteration of the
lunula. Seen in liver disease, usually
cirrhosis, heart failure, and diabetes.

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

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.

115

C H A P T E R

7The Head and Neck

The Health History

T h e H e a d

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

See Table 7-1, Primary Headaches, p. 128,
and Table 7-2, Secondary Headaches,
pp. 129–131. Tension and migraine head-
aches are the most common recurring
headaches.

Headache is a common symptom
that always requires careful evalu-
ation 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).

Is the headache one sided or bilat-
eral? Severe with sudden onset, like
a thunderclap? Steady or throb-
bing? Continuous or comes and
goes? Ask the patient to point to the
area of pain or discomfort. Assess
chronologic pattern and severity.

Changing or progressively severe head-
aches increase the likelihood of tumor,
abscess, or other mass lesion. Extremely
severe headaches suggest subarachnoid
hemorrhage or meningitis.

Tension headaches often arise in the
temporal areas; cluster headaches may
be retro-orbital.

116 Ba tes ’ Pocke t Guide to Physica l Examina tion and His tory Taking

■ Ask about associated symptoms,
such as nausea and vomiting,
and neurologic symptoms, such
as change in vision or motor-
sensory de cits.

■ Ask if coughing, sneezing, or
changing the position of the
head affects (better, worse, or
none) the headache.

■ Ask about family history.

T h e E y e s
Ask “How is your vision?” If the
patient reports a change in vision,
pursue the related details:

■ Is the problem worse during
close work or at distances?

■ Is the onset sudden or gradual?

■ Is there blurring of the entire
eld of vision or only parts? Is
blurring central, peripheral, or
only on one side?

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

Such maneuvers may increase pain from
brain tumor and acute sinusitis.

Family history is often positive in
patients with migraine.

Visual aura or scintillating scotomas may
accompany migraine. Nausea and vomit-
ing are common with migraine but also
occur with brain tumor and subarachnoid
hemorrhage.

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

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

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

Slow central loss occurs in nuclea r ca ta –
ract and macula r degenera tion; periph-
eral loss in advanced open-angle
glaucoma; one -sided loss in hemianop-
sia and quadrantic defects (p. 132).

Chapter 7 | The Head and Neck 117

■ Has the patient seen lights ash-
ing across the eld of vision?
Vitreous oaters?

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

Check for diplopia, or double
vision.

T h e E a 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?

For complaints of earache, or
pain in the ear, ask about associ-
ated fever, sore throat, cough,
and concurrent upper respiratory
infection.

Tinnitus is an internal musical ring-
ing or rushing or roaring noise,
often unexplained.

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

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

Eye pain in acute glaucoma and optic
neuritis.

Diplopia in brainstem or cerebellum
lesions, also from weakness or paralysis
of one or more extraocular muscles.

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

Consider otitis externa if pain in the ear
canal; otitis media if pain associated with
respiratory infection.

When associated with hearing loss
and vertigo, t innitus suggests Ménière
disease.

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 sneez-
ing, watery eyes, throat discomfort,
and itching in the eyes, nose, and
throat.

Causes include viral infections, a llergic
rhinitis (“hay fever”), and vasomotor
rhinitis. Itching favors an allergic cause.

118 Ba tes’ Pocket Guide to Phys ica l Examination and His tory Taking

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. Anticoagu-
lants, NSAIDs, and coagulopathies may
contribute.

Fever, pharyngeal exudates, and
anterior cervical lymphadenopathy,
especially without cough, suggest
streptococcal pharyngitis, or “strep
throat”(p. 142).

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
la teral sclerosis, or myasthenia gravis).

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

T h e M o u t h , T h r o a t , a n d N e c k
Sore throat or pharyngitis is a fre-
quent complaint. Ask about fever,
swollen glands, and any associated
cough.

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

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

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

● Loss of vision: c t r cts, cul r degener tion, gl uco
● He ring loss
● Or l he lth

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).

Chapter 7 | The Head and Neck 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 periodon-
tal disease (bleeding, pus, receding gums, and bad breath), and oral can-
cers. Counsel patients to use uoride-containing toothpastes, brush, oss,
and seek dental care at least annually.

Techniques of Examination
EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

T h e H e 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,
hair distribution, and lesions

Coarse and sparse in hypothyroidism,
fine in hyperthyroidism

Pilar cysts, psoriasis, seborrheic dermati-
tis, pigmented nevi

Hydrocephalus, skull depression from
trauma

Facial paralysis; flat affect of depression,
moods such as anger, sadness

Pale, fine, hirsute, acne, skin cancer

T h e E y e s
Test visual acuity in each eye with
a Snellen wall chart or handheld
card.

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

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.

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

120 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

Inspect the:

■ Position and alignment of eyes

■ Eyebrows

■ Eyelids

■ Lacrimal apparatus

■ Conjunctiva and sclera

■ Cornea, iris, and lens

Inspect pupils for:

■ Size, shape, and symmetry

■ Reactions to light, direct and
consensual

■ The near reaction, namely pupil-
lary constriction with gaze shift
to near object; note the accom-
panying convergence of the eyes
and accommodation of the lens
(becomes more convex)
(Fig. 7-2)

Figure 7-1 Static finger wiggle tes t.

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

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

Exophthalmos, strabismus

Seborrheic dermatitis

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

Swollen lacrimal sac, excessive tearing

Red eye, conjunctivitis, jaundice, episcle-
ritis

Cataract, crescentic shadow of acute
angle glaucoma

Miosis, mydriasis, anisocoria

Absent in paralysis of CN III

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

Chapter 7 | The Head and Neck 121

Figure 7-2 The pupils cons trict when the focus shifts to a close object.

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Superior
rectus (III)

Latera l
rectus
(VI)

Infe rior
rectus (III)

Superior
rectus (III)

Late ra l
rectus
(VI)

Infe rior
rectus (III)

Superior
oblique (IV)

Media l
rectus (III)

Inferior
oblique (III)

Figure 7-3 The s ix cardinal directions of gaze .

Inspect the fundi with an ophthal-
moscope.

Assess the extraocular muscles by
observing:

■ The symmetry of corneal re ec-
tions from a midline light

■ The six cardinal directions of
gaze (Fig. 7-3)

Asymmetric reflection if deviation in
ocular alignment

Cranial nerve palsy, strabismus, nystag-
mus, lid lag of hyperthyroidism

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 electri-
c 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 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

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

■ Optic disc (Fig. 7-4)

Cataracts, artificial eye

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.

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Chapter 7 | The Head and Neck 123

Arte ry

Vein

Optic disc

Phys iologic cupMacula

Figure 7-4 The optic disc.

AV nicking, copper wiring in hyperten-
sive changes

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

Macular degeneration

Vitreous floaters, cataracts

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

■ Arteries, veins, and AV
crossings

■ Adjacent retina (note any
lesions)

■ Macular area

■ Anterior structures

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 l-

osco 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 or-

tion of the disc (loss of venous uls tions fro elev ted intr cr ni l res-
sure y occur in he d tr u , eningitis)

● Inspect the retina. Distinguish rteries fro veins b sed on the fe tures listed below.

Ar t e r ie s Ve in s

Color Light red D rk red
Size S ller (2/3 to 3/4 the

di eter of veins)
L rger

Light Reflex (reflect ion) Bright Incons icuous
or bsent

● 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 scu-
l 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.

124 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

T h e E a r s
Examine on each side:

Th e Au ric le . Inspect the auricle.

If you suspect otitis:

■ Move the auricle up and down,
and press on the tragus.

■ Press rmly behind the ear.

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

■ The eardrum (Fig. 7-5)

Keloid, epidermoid cyst

Pain in otitis externa (“the tug test”)

Possible tenderness in otitis media and
mastoiditis

Cerumen; swelling and erythema in oti-
tis externa

Pars flaccida

Incus

Pars tensa Umbo
Cone of light

Handle of ma lleus

Short process of ma lleus

Figure 7-5 Anatomy of middle and inner ear.

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

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 hand-
held audiometer.

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Chapter 7 | The Head and Neck 125

If hearing is diminished, use a
512-Hz tuning fork to:

■ Test lateralization (Weber test),
but only in patients with unilat-
eral 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

Figure 7-6 Nasal polyps .

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

■ Nasal septum for position and
integrity

Palpate the frontal and maxillary
sinuses.

Deviation, perforation

Tender in acute sinusitis

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

126 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

T h e M o u t h a n d P h a r y n x

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Inspect the:

■ Lips

■ Oral mucosa

■ Gums

■ Teeth

■ Roof of the mouth

■ Tongue, including:

■ Papillae

■ Symmetry

■ Any lesions

■ Floor of the mouth

■ Pharynx, including:

■ Color or any exudate

■ Presence and size of tonsils

■ Symmetry of the soft palate as
patient says “ah”

T h e N e c k

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

Aphthous ulcers (canker sores)

Gingivitis, periodontal disease

Dental caries, tooth loss

Torus palatinus (benign)

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

Glossitis

Deviation to one side from paralysis of
CN XII from CVA

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

Lesions suspicious for cancer

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

Pharyngitis

Exudates, tonsillitis, peritonsillar abscess

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

Scars, masses, torticollis

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

Deviated trachea from neck mass or
pneumothorax

Inspect the neck.

Palpate super cial and deep ante-
rior, posterior cervical, and supra-
clavicular lymph nodes.

Inspect and palpate the position of
the trachea.

Chapter 7 | The Head and Neck 127

Inspect the thyroid gland:

■ At rest

■ As patient swallows water

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

■ At rest

■ As patient swallows water
(Fig. 7-7)

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

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

Goiter, nodules, tenderness of thyroiditis

Figure 7-7 Thyroid gland with goite r
while swallowing.

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 cu-
ity 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 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

Aids to Interpretation

P ro b le m
Co m m o n
Ch a ra c t e r is t ic s

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 v in g Fa c t o r s

Tens ion Location: variable

Quality: pressing or
tightening pain; mild-to-
moderate intensity

Onset: gradual

Duration: minutes to days

Sometimes photophobia,
phonophobia; nausea absent

↑ by sustained muscle
tension, as in driving or
typing

↓ possibly by massage,
relaxation

Migra ine
■ 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

Nausea, vomiting,
photophobia, phonophobia,
visual auras (flickering zig-
zagging lines), motor auras
affecting hand or arm, sensory
auras (numbness, tingling
usually precede headache)

↑ by alcohol, certain foods,
tension, noise, bright light.
More common premenstrually

↓ by quiet dark room, sleep

Clus te r Location: unilateral,
usually behind or around
the eye

Quality: deep,
continuous, severe

Onset: abrupt, peaks
within minutes

Duration: up to 3 hours

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

↑ sensitivity to alcohol during
some episodes

P rim a ry He a d a ch e sTable 7-1

Chapter 7 | The Head and Neck 129

P ro b le m
Co m m o n
Ch a ra c t e r is t ic s

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 lievin g Fa c t o rs

Analges ic
Rebound

Location: previous
headache pattern

Quality: variable

Onset: variable

Duration: depends on
prior headache pattern

Depends on prior headache
pattern

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

↓—depends on cause
Headaches
from Eye
Diso rders
Errors of
Refraction
(farsightedness
and astigmatism,
but not
nearsightedness)

Location: around and
over the eyes; may radiate
to the occipital area

Quality: steady,
aching, dull

Onset: gradual

Duration: variable

Eye fatigue, “sandy” sensation
in eyes, redness of the
conjunctiva

↑ by prolonged use of the
eyes, particularly for close
work

↓ by resting the eyes

Acute Glaucoma Location: in and
around one eye

Quality: steady,
aching, often severe

Onset: often rapid

Duration: variable, may
depend on treatment

Diminished vision,
sometimes nausea and
vomiting

↑—sometimes by drops that
dilate the pupils

Headache from
Sinus it is

Location: usually above
eye (frontal sinus) or
over maxillary sinus

Quality: aching or
throbbing, variable in
severity; consider
possible migraine

Onset: variable

Duration: often several
hours at a time, recurring
over days or longer

Local tenderness, nasal
congestion, tooth pain,
discharge, and fever

↑ by coughing, sneezing, or
jarring the head

↓ by nasal decongestants,
antibiotics

Se c o n d a ry He a d a ch e sTable 7-2

(table continues on page 130)

130 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

P ro b le m
Co m m o n
Ch a ra c t e r is t ic s

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

Mening it is Location: generalized

Quality: steady or
throbbing, very severe

Onset: fairly rapid

Duration: variable,
usually days

Fever, stiff neck,
photophobia, change in
mental status

Can ↓ from immediate
antibiotics until viral versus
bacterial cause identified

Subarachno id
Hem orrhage—
“Thunderclap
Headache”

Location: generalized

Quality: severe, “the
worst of my life”

Onset: usually abrupt;
prodromal symptoms
may occur

Duration: variable,
usually days

Nausea, vomiting, possibly
loss of consciousness, neck
pain

↑ rebleeding, ↑ intracranial
pressure, cerebral edema

↓ by subspecialty treatments

Bra in Tum or Location: varies with
the location of the
tumor

Quality: aching, steady,
variable in intensity

Onset: variable

Duration: often brief

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

↓ by subspecialty treatments

Gian t Ce ll
(Tem pora 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

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

Chapter 7 | The Head and Neck 131

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

P ro b le m
Co m m o n
Ch a ra c t e r is t ic s

As s o c ia t e d Sym p t o m s ,
P ro vo k in g a n d
Re lievin g Fa c t o rs

Postconcussion
Headache

Location: often but not
always localized to the
injured area

Quality: generalized,
dull, aching, constant

Onset: within hours to
1–2 days of the injury

Duration: weeks,
months, or even years

Drowsiness, poor
concentration, confusion,
memory loss, blurred vision,
dizziness, irritability,
restlessness, fatigue

↑ by mental and physical
exertion, straining, stooping,
emotional excitement,
alcohol

↓ by rest
Cran ia l
Neura lg ias :
Trigem ina l
Neura 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 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

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

Vis u a l Fie ld De fe c t sTable 7-3

Left Right
(from patient’s viewpoint)

Chapter 7 | The Head and Neck 133

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

P hys ic a l Fin d in g s in a n d Aro u n d t h e EyeTable 7-4

(table continues on page 134)

134 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

In a n d Aro 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

P hys ic a l Fin d in g s in a n d Aro u n d
t h e Eye (continued )

Table 7-4

Chapter 7 | The Head and Neck 135

P ro c e s s Ap p e a ra n c e

No rm a l 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

Gla u c o m a t o u s
Cu 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

Op t ic At ro p h y Death of optic
nerve fibers leads
to loss of the tiny
disc vessels

Disc is white

Disc vessels are absent

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

136 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

No n p ro lif e ra t ive
Re t in o p a t h y,
Mo d e ra t e ly S e ve re

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

No n p ro lif e ra t ive
Re t in o p a t h y, S e ve re

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 ra t ive Re t in o p a t h y,
w it h Ne o va s c u la r iza 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 ra 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

Oc u la r Fu n d i: Dia b e t ic Re t in o p a t hyTable 7-6

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.

Chapter 7 | The Head and Neck 137

P e r fo ra t io n Hole in the eardrum that may be central
or marginal

Usually from otitis media or trauma

Tym 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 Effu 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 Ot it is Me d ia
w it h P u ru le n t Effu 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

Ab n o rm a lit ie s o f t h e Ea rd ru mTable 7-7

138 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

Co n d u c t ive Lo s s S e n s o rin e u ra l Lo s s

Im p a ire d
Un d e r s t a n d in g
o f Wo rd s

Minor Often troublesome

Effe c t s Noisy environment
may improve hearing

Voice remains soft
since cochlear nerve
intact

Noisy environment
worsens hearing

Voice may be loud due
to nerve damage

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

Childhood, young
adulthood

Middle and later years

Ea r Ca n a l a n d
Dru m

Often a visible
abnormality

Problem not visible

We b e r Te s t (in
Un ila t e ra 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

Ca 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

Pa t t e rn s o f He a rin g Lo s sTable 7-8

Chapter 7 | The Head and Neck 139

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

Ab n o rm a lit ie s o f t h e Lip sTable 7-9

140 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

Geographic tongue. Scattered areas in
which the papillae are lost, giving a map-
like 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

Ab n o rm a lit ie s o f t h e To n g u eTable 7-10

Chapter 7 | The Head and Neck 141

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

Ab n o rm a lit ie s o f t h e To n g u e (continued )Table 7-10

142 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

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

Ab n o rm a lit ie s o f t h e P h a ryn xTable 7-11

Chapter 7 | The Head and Neck 143

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

Ab n o rm a lit ie s o f t h e Thyro id Gla n dTable 7-12

145

C H A P T E R

8The Thorax and Lungs

The Health History

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.

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

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-

skelet l nd neurologic syste s
Costochondritis, herpes zoster

The eso h gus Gastroesophageal reflux disease, esoph-
ageal spasm, esophageal tear

Extr thor cic structures such s the
neck, g llbl dder, nd sto ch

Cervical arthritis, biliary colic, gastritis

For patients who are short of breath, focus on pulmonary complaints:

■ Dyspnea and wheezing

■ Cough and hemoptysis

See Table 8-2, Dyspnea, pp. 157–158.

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

146 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

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

● 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 Ameri-
cans 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 Precontemplation—“I don’t w nt to quit .”
Advise to quit Contemplat ion—“I concerned but not

re dy to quit now.”
Assess willingness to ke

quit tte t
Preparation—“I re dy to quit .”

Assist in quit tte t Action—“I just quit .”
Arrange follow-u 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.

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

■ Daytime sleepiness or snoring
and disordered sleep

Chapter 8 | The Thorax and Lungs 147

Techniques of Examination

In it ia l In s p e c t io n o f T h o r a x

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Manubrium
of s ternum

Body of
s ternum

Xyphoid
process

2nd cos tal
cartilage

2nd rib
interspace

Cos tochondral
junctions

Supras ternal notch

Sternal
angle

2nd rib

Cos tal angle
Figure 8-1 Ches t wall anatomy.

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

■ Facial color

■ Rate, rhythm, depth, and effort
of breathing

■ Inspiratory retraction of the
supraclavicular areas

■ Inspiratory contraction of the
sternocleidomastoids

Cyanosis and pallor in lips and oral
mucosa signal hypoxia.

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

Occurs in chronic obstructive pulmonary
disease (COPD), asthma, upper airway
obstruction

Indicates severe breathing difficulty

148 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

If distress, auscultate the neck and
lungs for:

■ Stridor

■ Wheezes

Observe shape of patient’s chest.

T h e P o s t e r io r C h e s t
Inspect the chest for:

■ Deformities or asymmetry

■ Abnormal inspiratory retraction
of the interspaces

■ Impairment or unilateral lag in
respiratory movement

Palpate the chest for:

■ Tender areas

■ Assessment of visible abnor-
malities

■ Chest expansion (Fig. 8-2)

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Stridor in upper airway obstruction from
foreign body or epiglottitis

Expiratory wheezing in asthma and
COPD

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

Kyphoscoliosis

Retraction in asthma, COPD, upper air-
way obstruction

Disease of the underlying lung or pleura,
phrenic nerve palsy

Fractured ribs

Masses, sinus tracts

Figure 8-2 Assess lung expans ion.

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

■ 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 infil-
trating tumor.

Chapter 8 | The Thorax and Lungs 149

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.

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Asymmetric decreased fremitus in uni-
lateral pleural effusion, pneumothorax,
or neoplasm; asymmetric increased
fremitus occurs in unilateral pneumonia,
which increases transmission through
consolidated tissue.

6 6

7 7

Figure 8-3 Percuss and auscultate in
a “ ladder” patte rn.

Figure 8-4 Strike the pleximete r
finger with the right middle finger.

Dullness when fluid or solid tissue
replaces normally air-filled lung; hyper-
resonance in emphysema or pneumo-
thorax

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 ch , a n d Du ra t io n Exa m p le s

Flat Soft/ high/short L rge leur l effusion
Dull Mediu / ediu / ediu Lob r neu oni
Resonant Loud/ low/ long He lthy lung, si le chronic

bronchitis
Hyperresonant Louder/ lower/ longer E hyse , neu othor x
Tympanitic Loud/ high (ti bre is usic l) L rge neu othor x

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

Pleural effusion or a paralyzed diaphragm
raises level of dullness.

150 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

Resonant

Leve l of
diaphragm

Dull

Loca tion
and sequence
of percuss ion

Figure 8-5 Identify the extent of diaphragmatic excursion.

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

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

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

Crackles (fine and coarse) and continu-
ous sounds (wheezes and rhonchi)

Clearing after cough suggests atelectasis.

Auscultate the chest with stetho-
scope in the “ladder” pattern, again
comparing sides.

■ Evaluate the breath sounds.

■ Note any adventitious (added)
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?

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

Du ra t io n
In t e n s it y a n d P it ch
o f Exp ira t o ry S o u n d

Exa m p le
Lo c a t io n s

Vesicular Ins > Ex Soft/ low Most of the lungs

Bronchovesicular Ins = Ex Mediu / ediu 1st nd 2nd inter-
s ces, intersc –
ul r re

Bronchial Ex > Ins Loud/ high Over the nu-
briu

Tracheal Ins = Ex Very loud/ high 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.

Chapter 8 | The Thorax and Lungs 151

Assess transmitted voice sounds
and bronchial breath sounds heard
in abnormal places. Ask patient to:

■ Say “ninety-nine” and “ee.”

■ Whisper “ninety-nine” or
“one-two-three.”

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

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

Whispered pectoriloquy if whispered
sounds transmit louder and more
clearly

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 No rm a lly Air-Fille d Lu n g Th ro u g h Air le s s Lu n g a

Usu lly cco nied by vesicul r
bre th sounds nd nor l t ctile
fre itus

Usu lly cco nied by bronchi l or
bronchovesicul r bre th sounds
nd incre sed t ctile fre itus

S oken words uffled nd indistinct S oken words louder, cle rer
(bronchophony)

S oken “ee” he rd s “ee” S oken “ee” he rd s “ y” (egophony)
Whis ered words f int nd indistinct,

if he rd t ll
Whis ered words louder, cle rer

(whispered pectoriloquy)

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

Cra ck le s (o r Ra le s ) Wh e e ze s a n d Rh o n ch i

Discontinuous Continuous
● 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.

aAs in lob r neu oni nd tow rd the to of l rge leur l effusion.

152 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

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

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Inspect the chest (Figs. 8-6 and
8-7) for:

■ Deformities or asymmetry

■ Intercostal retraction

■ Impaired or lagging respiratory
movement

Palpate the chest for:

■ Tender areas

■ Assessment of visible abnor-
malities

■ Respiratory expansion

■ Tactile fremitus

Midste rna l
line

Midclavicula r
line

Ante rior
axilla ry
line

Figure 8-6 Mids te rnal and midclavicu-
lar lines .

Anterior
axilla ry
line

Pos te rior
axilla ry
line

Midaxilla ry
line

Figure 8-7 Anterior, pos te rior, and
midaxillary lines .

Pectus excavatum

From obstructed airways

Disease of the underlying lung or pleura,
phrenic nerve palsy

Tender pectoral muscles, costochondritis

Flail chest

Chapter 8 | The Thorax and Lungs 153

44 55
66

Figure 8-8 Palate and percuss in a
“ ladder” patte rn.

Normal cardiac dullness may disappear
in emphysema.

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

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

Older adults walking 8 feet in 5 to 6 seconds.

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

Percuss the chest in the areas illus-
trated in Figure 8-8.

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 expi-
ration. Try to get three consistent
readings, allowing rests as needed.

154 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

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.)

Recording Your Findings

Chapter 8 | The Thorax and Lungs 155

Aids to Interpretation

P ro b le m a n d Lo c a t io n
Qu a lit y, S e ve r it y, Tim in g ,
a n d As s o c ia t e d S ym p t o m s

Ca rd io va s c u la r

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

■ Pressing, squeezing, tight,
heavy, occasionally burning

■ Mild to moderate severity,
sometimes perceived as
discomfort rather than pain

■ Usually 1–3 min but up to
10 min; prolonged episodes up
to 20 min

■ Sometimes with dyspnea,
nausea, swelling

Myocard ia l In fa rction
Same as in angina

■ Same as in angina
■ Often but not always a severe

pain
■ 20 min to several hours
■ Associated with nausea,

vomiting, sweating, weakness

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

■ Sharp, knifelike quality
■ Often severe
■ Persistent timing
■ Relieved by leaning forward
■ Seen in autoimmune disorders,

postmyocardial infarction, viral
infection, chest irradiation

Dissecting Aortic Aneurysm
Anterior chest, radiating to the
neck, back, or abdomen

■ Ripping, tearing quality
■ Very severe
■ Abrupt onset, early peak,

persistent for hours or more
■ Associated syncope, hemiplegia,

paraplegia

Ch e s t Pa inTable 8-1

(table continues on page 156)

156 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

P ro b le m a n d Lo c a t io n
Qu a lit y, S e ve r it y, Tim in g ,
a n d As s o c ia t e d S ym p t o m s

P u lm o n a ry

Pleuritic Pa in
Chest wall overlying the process

■ Sharp, knifelike quality
■ Often severe
■ Persistent timing
■ Associated symptoms of the

underlying illness (often
pneumonia, pulmonary
embolism)

Ga s t ro in t e s t in a l a n d Ot h e r

Gas tro in tes tina l Reflux Disease
Retrosternal, may radiate to the
back

■ Burning quality, may be
squeezing

■ Mild to severe
■ Variable timing
■ Associated with regurgitation,

dysphagia; also cough,
laryngitis, asthma

Diffuse Esophagea l Spasm
Retrosternal, may radiate to the
back, arms, and jaw

■ Usually squeezing quality
■ Mild to severe
■ Variable timing
■ Associated dysphagia

Ches t Wall Pa in ,
Cos tochondritis
Often below the left breast or
along the costal cartilages; also
elsewhere

■ Stabbing, sticking, or dull
aching quality

■ Variable severity
■ Fleeting timing, hours or days
■ Often with local tenderness

Anxie ty, Panic Diso rder ■ Pain may be stabbing, sticking,
or dull, aching

■ Can mimic angina
■ Associated with breathlessness,

palpitations, weakness, anxiety

Ch e s t Pa in (continued )Table 8-1

Chapter 8 | The Thorax and Lungs 157

P ro b le m Tim in g

P ro vo k in g /Re lie v in g
Fa c t o r s ; As s o c ia t e d
S ym p t o m s

Le ft -S id e d He a r t
Fa ilu re (Left Ventricular
Failure or Mitral Stenosis)

Dyspnea may
progress slowly
or suddenly, as
in acute
pulmonary
edema

↑ by exertion, lying
down
↓ by rest, sitting up,
though dyspnea may
become persistent
Associated Symptoms:
Often cough, orthopnea,
paroxysmal nocturnal
dyspnea; sometimes
wheezing

Ch ro n ic Bro n ch it is
(may be seen with COPD)

Chronic
productive
cough followed
by slowly
progressive
dyspnea

↑ by exertion, inhaled
irritants, respiratory
infections
↓ by expectoration, rest
though dyspnea may
become persistent
Associated Symptoms:
Chronic productive
cough, recurrent
respiratory infections;
wheezing possible

Ch ro n ic Ob s t ru c t ive
P u lm o n a ry Dis e a s e
(COP D)

Slowly
progressive;
relatively mild
cough later

↑ by exertion
↓ by rest, though
dyspnea may become
persistent
Associated Symptoms:
Cough with scant mucoid
sputum

Dys p n e aTable 8-2

(table continues on page 158)

158 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

Dys p n e a (continued )Table 8-2

P ro b le m Tim in g

P ro vo k in g /Re lie v in g
Fa c t o r s ; As s o c ia t e d
S ym p t o m s

As t h m a Acute episodes,
then symptom-
free periods;
nocturnal
episodes
common

↑ by allergens, irritants,
respiratory infections,
exercise, emotion
↓ by separation from
aggravating factors
Associated Symptoms:
Wheezing, cough,
tightness in chest

Diffu s e In t e rs 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
↓ by rest, though
dyspnea may become
persistent
Associated Symptoms:
Often weakness, fatigue;
cough less common than
in other lung diseases

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

S p o n t a n e o u s
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

Chapter 8 | The Thorax and Lungs 159

P ro b le m
Co u g h , S p u t u m , As s o c ia t e d
S ym 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

Laryng 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

Acute Bronch itis Cough and Sputum: Dry or productive of
sputum
Associated Symptoms and Setting: An acute,
often viral illness, with burning retrosternal
discomfort

Mycop lasm a and Vira l
Pneum onias

Cough and Sputum: Dry and hacking often
with mucoid sputum
Associated Symptoms and Setting: Acute
febrile illness, often with malaise,
headache, and possibly dyspnea

Bacte ria l Pneum onias 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

Ch ro n ic In f la m m a t io n

Pos tnasa 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

Co u g h a n d He m o p t ys isTable 8-3

(table continues on page 160)

160 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

P ro b le m
Co u g h , S p u t u m , As s o c ia t e d
S ym p t o m s , a n d S e t t in g

Chron ic Bronch 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

Bronchiecta s is Cough and Sputum: Chronic cough; sputum
mucoid to purulent, may be blood-
streaked or even bloody
Associated Symptoms and Setting: Recurrent
bronchopulmonary infections common;
sinusitis may coexist

Pu lm onary
Tuberculos 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

Lung Abscess 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 thm 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

Co u g h a n d He m o p t ys is (continued )Table 8-3

Chapter 8 | The Thorax and Lungs 161

P ro b le m
Co u g h , S p u t u m , As s o c ia t e d
S ym p t o m s , a n d S e t t in g

Gas troesophagea l
Re flux

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

Ne o p la s m Cough: Dry to productive

Lung Cance 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

Ca rd io va s c u la r Dis o rd e r s

Left Ventricu la r Fa ilure
o r Mitra l S tenos 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 onary Em bolism 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 ting Particles ,
Chem ica ls , o r Gases

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

Co u g h a n d He m o p t ys is (continued )Table 8-3

162 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

Inspira tion Expira tion Normal. 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,
Hyperventilat ion). 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.

Hyperpnea Apnea

Cheyne–Stokes Breathing .
Rhythmically alternating periods of
hyperpnea and apnea. In infants and the
aged, may be normal during sleep; also
accompanies brain damage, heart failure,
uremia, drug-induced respiratory depression.

Ataxic (Biot) Breathing. Unpredictable
irregularity of depth and rate. Causes
include meningitis, respiratory depression,
and brain injury.

Sighs Sighing Breathing . Breathing
punctuated by frequent sighs. When
associated with other symptoms, it
suggests the hyperventilation syndrome.
Occasional sighs are normal.

Prolonged expira tion Obstructive Breathing . In obstructive
lung disease, expiration is prolonged
due to narrowed airways increase the
resistance to air flow. Causes include
asthma, chronic bronchitis, and COPD.

Ab n o rm a lit ie s in Ra t e a n d
Rhyt h m o f Bre a t h in g

Table 8-4

Chapter 8 | The Thorax and Lungs 163

Cro s s -S e c t io n o f Th o ra x

No rm a l Ad u lt

The thorax is wider than it is
deep; lateral diameter is greater
than anteroposterior (AP)
diameter.

Ba r re l Ch e s t

Has increased AP diameter,
seen in normal infants and
normal aging; also in COPD.

Tra u m a t ic Fla il Ch 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

Inspiration

Fu n n e l Ch e s t
(Pectus Excava tum )

Depression in the lower portion
of the sternum. Related
compression of the heart and
great vessels may cause
murmurs.

De fo rm it ie s o f t h e Th o ra xTable 8-5

(table continues on page 164)

164 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

Cro s s -S e c t io n o f Th o ra x
P ig e o n Ch e s t
(Pectus Carina tum )

Sternum is displaced anteriorly,
increasing the AP diameter;
costal cartilages adjacent to the
protruding sternum are
depressed.

Depressed
cos ta l cartilages

Anteriorly
displaced s ternum

Th o ra c ic Kyp h o s c o lio s is

Abnormal spinal curvatures and
vertebral rotation deform the
chest, making interpretation of
lung findings difficult.

Spinal convexity to the right
(patient bending forward)

Ribs
widely

separated

Ribs close
together

De fo rm it ie s o f t h e Th o ra x (continued )Table 8-5

165

(

)

;

(

)

–

167

C H A P T E R

9The Cardiovascular
System

The Health History

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 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 roxys l nocturn l dys ne
● Swelling or ede
● F inting (synco e)

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 )

168 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

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 cardio-
vascular 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.

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

● 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

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 t ient is lying down nd
i roves when the t ient 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.

Chapter 9 | The Cardiovascular System 169

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 Fa 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 rs . 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.

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

M a jo r C a r d io v a s c u la r R is k Fa 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 re e n in g Fre q u e n c y Go a l

F ily history of
re ture CVD

U d te regul rly

Cig rette s oking At e ch visit Cess tion
Poor diet At e ch visit I roved over ll e ting

ttern
Physic l in ctivity At e ch visit 3 inutes oder te

intensity d ily
Obesity, es eci lly

centr l di osity
At e ch visit BMI 2 –25 kg/ 2; w ist

circu ference:
≤4 inches for en,
≤35 inches for wo en

Hy ertension At e ch visit <14 /9 for dults 6 ye rs with
di betes or chronic kidney
dise se; <15 /9 for ll
other dults ≥6 ye rs

Dysli ide i s Every 5 ye rs if low risk
Every 2 ye rs if strong risk

Initi te st tin ther y if eet-
ing ACC/AHA guidelines

(continued )

170 Ba tes’ Pocket Guide to Phys ica l Examination and His tory Taking

M a jo r C a r d io v a s c u la r R is k Fa 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 )

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.

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

Ca t e g o ry S ys t o lic (m m Hg ) Dia s t o lic (m m Hg )

Nor l <12 <8
Prehy ertension 12 –139 8 –89
St ge 1 hy ertension

Age ≥18 to <6 ye rs 14 –159 9 –99
Age ≥6 ye rsa 15 –159 9 –99

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 r t 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
Hyp 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).

Ris k Fa c t o r S c re e n in g Fre 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 fre-
quently t ny ge
if risk f ctors

Prevent/del y di betes for
those with HbA1c of
5.7–6.4%

Pulse At e ch visit Identify nd tre t tri l
fibrill tion

Sources: see . 186.

(continued )

Chapter 9 | The Cardiovascular System 171

Dia 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 re e n in g Crit 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/m2 and addit ional 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 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

Dia g n o s t ic Crit e r ia Dia b e t e s a P re d ia b e t e s

HbA1c ≥6.5% 5.7%–6.4%
F sting l s glucose (on t le st 2

occ sions)
≥126 g/dL 1 –125 g/dL

(continued )

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 )

aThe 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 ge-

ent of hy ertension in the co unity: st te ent by the A eric n Society of Hy erten-
sion 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 Pre-
vention, 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/ .

Ca t e g o ry S ys t o lic (m m Hg ) Dia s t o lic (m m Hg )

St ge 2 hy ertension ≥16 ≥1
If di betes or ren l dise se

(including ge ≥6 ye rs)
<14 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 diabe-
tes, 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 cardiovas-
cular 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 Cho-
lesterol Guideline provides evidence-based recommendations for initiating
statin therapy based on high, moderately high, and low risk level.

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 Crit e r ia Dia b e t e s a P re d ia b e t e s

2-Hour l s glucose (or l glucose
toler nce test)

≥2 g/dL 14 –199 g/dL

R ndo glucose if cl ssic sy to s ≥2 g/dL

aIn 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 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

10 -Ye a r Ris k
Ca t e g o ry

LDL Go a l
(m g /d L)

Co n s id e r Dru g Th e ra p y if LDL
(m g /d L)

High risk (>2 %) <1
Optional goal:

1
(<1 : consider drug o tions, including

further 3 %–4 % reduction in LDL)
Moder tely high risk

(1 %–2 %)
<13
Optional goal:

≥13
1 –129: consider drug o tions to

chieve go l of <1
Moder te risk (<1 %) <13 ≥16
Lower risk ( –1 risk

f ctor)
19

(16 –189: drug ther y optional)

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.

Chapter 9 | The Cardiovascular System 173

Me t a b o lic S yn 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 harmo-
nized diagnostic criteria as the presence of three or more of the ve risk
factors listed below.

Ot 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 Ob e s it y. Smoking
increases the risk of CHD and stroke by two- to fourfold compared to non-
smokers 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 associ-
ated 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 Fa 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 recom-
mendations 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 Men ≥1 2 c , wo en ≥88 c
Fasting plasma glucose ≥1 g/dL or being tre ted for elev ted glucose
HDL cholesterol Men <4 g/dL, wo en <5 g/dL, or being tre ted
Triglycerides ≥15 g/dL, or being tre ted
Blood pressure ≥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.

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 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

Techniques of Examination

H e a r t R a t e a n d B lo o d P r e s s u r e

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

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.

Measure blood pressure with a
sphygmomanometer. If indicated,
recheck it.

This step helps you to detect an
auscultatory gap and avoid recording
an inappropriately low systolic blood
pressure.

Orthostatic (postural) hypotension
within 3 minutes of position change from
supine to standing is SBP↓ ≥20 mm Hg;
HR↑ ≥20 beats/min.

Elevated JVP in right-sided heart failure;
decreased JVP in hypovolemia from
dehydration or gastrointestinal
bleeding.

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.

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 10 mm Hg during inspiration
signifies a paradoxical pulse. Consider
obstructive pulmonary disease, asthma,
COPD, pericardial tamponade, or con-
strictive pericarditis.

Carotid bruits suggest atherosclerotic
narrowing and increase stroke risk.

176 Ba tes ’ Pocke t Guide to Physica l Examina tion and His tory Taking

T h e H e a r t

EXAMINATION TECHNIQUES

In s p e c t io n a n d Pa 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:

Figure 9-2 Palpate the apical impulse .

Displaced to left in pregnancy.

Increased diameter, amplitude, and
duration in left ventricular dilatation from
heart failure or ischemic cardiomyopathy.

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

Pa t ie n t Po s it io n Exa 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).

Left lateral
decubitus

P l te the ic l i ulse to ssess its di eter.
Listen t the ex with the bell of the stethosco e.

Supine, with the
head elevated
30 degrees

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.

Sitting, leaning
forward, after
full exhalation

Listen down the left stern l border nd t the ex with the
diaphragm for the soft decrescendo ur ur of ortic
insufficiency.

■ Location of impulse

■ Diameter

Chapter 9 | The Cardiovascular System 177

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

■ Amplitude—usually tapping

■ Duration

Feel for a right ventricular impulse
in left parasternal and epigastric
areas.

Palpate left and right second inter-
spaces close to sternum. Note any
thrills in these areas.

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.

Sustained in left ventricular hypertrophy;
diffuse in CHF.

Prominent impulses suggest right ven-
tricular enlargement.

Pulsations of great vessels; accentuated
S2; thrills of aortic or pulmonic stenosis.

Left
ventricular
area—Apex

Right 2nd
inters pace—
Aortic a rea

Left 2nd
inters pace—
Pulmonic a rea

Epigas tric
(subxiphoid)

Right
ventricular
area—
Left s te rna l
borde r

Figure 9-3 Auscultate the heart from
the base to the apex.

Use the diaphragm to detect the
relatively high-pitched sounds like
S1, S2.

Use the bell for low-pitched sounds at
the lower left sternal border and apex.

Listen at each area for:

■ S1

■ S2. Is splitting normal in left
2nd and 3rd interspaces?

■ Extra sounds in systole

■ Extra sounds in diastole

Also murmurs of aortic and mitral regur-
gitation, pericardial friction rubs.

S3, S4, murmur of mitral stenosis.

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.

Physiologic (inspiratory) or pathologic
(expiratory) splitting

Systolic clicks

S3, S4

178 Ba tes’ Pocket Guide to Phys ica l Examination and His tory Taking

■ Systolic murmurs

■ 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 low-
pitched sounds (Fig. 9-4).

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Midsystolic, pansystolic, late systolic
murmurs

Early, mid-, or late diastolic murmurs

See Table 9-4, Heart Murmurs, p. 185.

Figure 9-5 Lis ten at the lower le ft
s te rnal border for aortic insufficiency.

Diastolic decrescendo murmur of aortic
regurgitation.

As s e s s in g a n d De s c rib in g
Mu rm u rs . Identify, if murmurs are
present, their:

■ Timing in the cardiac cycle
(systole, diastole). It is helpful to

Figure 9-4 Lis ten at the apex for low-
pitched sounds .

Left-sided S3, and diastolic murmur of
mitral stenosis.

Listen down the left sternal
border to the apex as patient sits,
leaning forward, with breath held
after exhalation (Fig. 9-5).

Chapter 9 | The Cardiovascular System 179

Plateau, crescendo, decrescendo

A crescendo–decrescendo murmur first
rises in intensity, then falls (e.g., aortic
stenosis).

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

A plateau murmur has the same intensity
throughout (e.g., mitral regurgitation).

A crescendo murmur grows louder (e.g.,
mitral stenosis).

A decrescendo murmur grows softer (e.g.,
aortic regurgitation).

Murmurs loudest at the base are often
aortic; at the apex, they are often mitral.

High, medium, low

Blowing, harsh, musical, rumbling

G r a d a t io n s o f M u r m u r s

Gra d e De 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

palpate the carotid upstroke while
listening to any murmur—mur-
murs occurring simultaneously
with the upstroke are systolic.

■ Shape

S 2S 1

S 2 S 1

■ Location of maximal intensity

■ Radiation

■ Pitch

■ Quality

■ Intensity on a six-point scale (see
“Gradations of Murmurs” below)

180 Ba tes’ Pocke t Guide to Physica l Examina tion and His tory Taking

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 rs

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Va ls a lva Ma n e u ve r. Ask patient
to strain down.

In suspected mitral valve prolapse
(MVP), listen to the timing of click
and murmur.

To distinguish aortic stenosis (AS)
from hypertrophic cardiomyopathy
(HCM), listen to the intensity of the
murmur.

/ 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.

Ventricular filling decreases, the systolic
click of MVP is earlier, and the murmur
lengthens.

In AS, the murmur decreases; in HCM, it
often increases.

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.)

Chapter 9 | The Cardiovascular System 181

Aids to Interpretation

Systole Dias tole

S 1 S 3S 2OS S 1E1 S 4

Fin d in g P o s s ib le Ca u s e s

S 1 a c c e n t u a t e d 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 ys t o lic c lick (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

P 2 a c c e n t u a t e d 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

Op e n in g s n a p Mitral stenosis

S 3 Physiologic (usually in children and
young adults); volume overload of
ventricle, as in mitral regurgitation or
heart failure

S 4 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

He a r t So u n d sTable 9-1

182 Ba tes’ Pocke t Guide to Physica l Examina tion and His tory Taking

No rm a l Va r ia t io n s

S 1 S 2

S1 is softer than S2 at the base (right and
left 2nd interspaces).

S 1 S 2

S1 is often but not always louder than S2 at
the apex.

Ac c e n t u a t e d S 1

S 1 S 2

Occurs in (1) tachycardia, rhythms with
a short PR interval, and high cardiac
output states (e.g., exercise, anemia,
hyperthyroidism), and (2) mitral stenosis.

Dim in is h e d S 1

S 1 S 2

Occurs in first-degree heart block, calcified
mitral valve of mitral regurgitation, and
↓ left ventricular contractility in heart
failure or coronary heart disease.

Va ry in g S 1

S 1 S 2 S 1 S 2

S1 varies in complete heart block and
any totally irregular rhythm (e.g., atrial
fibrillation).

S p lit S 1

S 1 S 2

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.

Va ria t io n s in t h e Fir s t He a r t So u n d —S 1Table 9-2

Chapter 9 | The Cardiovascular System 183

P h ys io lo g ic S p lit t in g

S 1 S 2S 1 S 2

A2 P 2

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

S 1 S 2S 1 S 2

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

S 1 S 2S 1 S 2

Does not vary with respiration, as in atrial septal defect, right ventricular
failure.

Va ria t io n s in t h e Se c o n d He a r t So u n d —
S 2 Du rin g In s p ira t io n a n d Exp ira t io n

Table 9-3

(table continues on page 184)

184 Ba tes’ Pocke t Guide to Physica l Examina tion and His tory Taking

Va ria t io n s in t h e Se c o n d He a rt So u n d —
S2 During Inspirat ion and Expirat ion (continued )

Table 9-3

P a ra d o x ic a l o r Re ve r s e d S p lit t in g

S 1 S 2 S 1 S 2

P 2 A2

Appears on expiration and disappears on inspiration. Closure of the
aortic valve is abnormally delayed, so A2 follows P2 on expiration, as in
left bundle branch block.

Mo re o n A 2 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.

Chapter 9 | The Cardiovascular System 185

Lik e ly Ca u s e s

Mid s ys t o lic

S 1 S 2

Innocent murmurs (no valve abnormality)
Physiologic murmurs (from ↑ flow across
a semilunar valve, as in pregnancy, fever,
anemia)
Aortic stenosis
Murmurs that mimic aortic stenosis—
aortic sclerosis, bicuspid aortic valve,
dilated aorta, and pathologically ↑ systolic
flow across aortic valve
Hypertrophic cardiomyopathy
Pulmonic stenosis

P a n s ys t o lic

S 1 S 2

Mitral regurgitation
Tricuspid regurgitation
Ventricular septal defect

La t e S ys t o lic

S 1 S 2C

Mitral valve prolapse, often with click (C)

Ea r ly Dia s t o lic

S 1 S 1S 2

Aortic regurgitation

Mid d ia s t o lic a n d
P re s ys t o lic

S 1 S 1S 2 OS

Mitral stenosis—note opening snap (OS)

Co n t in u o u s Mu rm u r s
a n d S o u n d s

S 1 S 2 S 1

Patent ductus arteriosus—harsh,
machinery-like
Pericardial friction rub—a scratchy sound
with 1–3 components
Venous hum—continuous, above
midclavicles, loudest in diastole

He a r t Mu rm u rsTable 9-4

186 Ba tes’ Pocke t Guide to Physica l Examina tion and His tory Taking

Sources: Ad ted fro : Goff DC, Jr., Lloyd-Jones DM, Bennett G, et l. 2 13 ACC/AHA guide-
line on the ssess ent of c rdiov scul r risk: re ort of the A eric n College of C rdiol-
ogy/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 guide-
line 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 it tee (JNC 8).
JAMA. 2 14;311:5 7; Meschi JF, Bushnell C, Boden-Alb l B, et l. Guidelines for the ri-
ry 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.

S o u rc e s fo r Ma jo r Ca rd io va s c u la r Ris k Fa c t o r s a n d S c re e n in g
Fre q u e n c y Bo x o n p . 17 0

187

C H A P T E R

10The Breasts and Axillae

The Health History

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.

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 evalu-
ation, and de nitive diagnostic measures should be pursued.

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

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

● P l ble sses of the bre st
● Assessing risk of bre st c ncer
● Bre st c ncer screening

188 Ba tes’ Pocke t Guide to Physica l Examina tion and His tory Taking

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.

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 Co m m o n Le s io n Ch a ra c t e r is t ic s

15–25 Fibro deno Usu lly s ooth, rubbery, round,
obile, nontender

25–5 Cysts Usu lly soft to fir , round,
obile; often tender

Fibrocystic ch nges Nodul r, ro e-like
C ncer Irregul r, fir , y be obile or

fixed to surrounding tissue
Over 5 C ncer until roven oth-

erwise
As bove

Pregn ncy/
l ct tion

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.

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 Insti-
tute (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
Clin ic a l Bre a s t
Exa m in a t io n

Bre a s t S e lf-
Exa m in a t io n

U.S. Preventive
Services T sk
Force—
ver ge-risk
wo en (2 16)

● 5 –74 ye rs—
bienni lly

● 4.0 ■ 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 (50%) breasts compared to

less dense (11%–25%)
■ One first-degree relative with breast cancer

1.1–2.0 ■ Alcohol consumption
■ Ashkenazi Jewish heritage
■ Diethylstilbestrol exposure
■ Early menarche (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

Fa c t o rs 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

Table 10-1

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 . Accessed May 1, 2015.

Chapter 10 | The Breasts and Axillae 197

Re t ra 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. Cancer

Dimpling

Retracted
nipple

Skin Dim pling

Abnorm al Contours
Look for any variation in the normal
convexity of each breast, and compare
one side with the other.

Nipp le Re traction and Devia tion
A retracted nipple is flattened or pulled
inward and may be broadened and
thickened. Typically the nipple deviates
toward the underlying cancer.

Vis ib le S ig n s o f Bre a s t Ca n c e rTable 10-2

(table continues on page 198)

198 Ba tes’ Pocke t Guide to Physica l Examina tion and His tory Taking

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 Dis e a s e o f t h e Nip 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.

Dermatitis of
a reola

Eros ion of
nipple

Vis ib le S ig n s o f Bre a s t Ca n c e r (continued )Table 10-2

199

C H A P T E R

11
The Abdomen

The Health History

M e c h a n is m s o f A b d o m in a l P a in

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

Ga s t ro in t e s t in a l Dis o rd e r s Ur in a ry a n d Re n a l Dis o rd 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

● 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

Be familiar with three broad
categories:

Visceral pain—occurs when hol-
low abdominal organs such as the
intestine or biliary tree contract
unusually forcefully or are dis-
tended or stretched.

■ 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.

Visceral pain in the right upper quadrant
(RUQ) from liver distention against its
capsule from the various causes of
hepatitis, including alcoholic hepatitis

200 Ba tes ’ Pocke t Guide to Physica l Examina tion and His tory Taking

Parietal pain—from in ammation
of the parietal peritoneum.

■ Steady, aching

■ Usually more severe

■ Usually more precisely localized
over the involved structure than
visceral pain

Referred pain—occurs in more
distant sites innervated at approxi-
mately the same spinal levels as the
disordered structure.

Pain from the chest, spine, or
pelvis may be referred to the
abdomen.

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.

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 pleurisy or acute myocardial
infarction may be referred to the epigas-
tric 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.

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 Pa 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:

In emergency rooms, up to 45% of
patients have nonspecific pain, but
15% to 30% need surgery, usually for
appendicitis, intestinal obstruction, or
cholecystitis.

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 gastroesoph-
ageal reflux disease (GERD), pancreatitis,
and perforated ulcers. RUQ and upper
abdominal pain are common in chole-
cystitis and cholangitis.

Chapter 11 | The Abdomen 201

■ Bloating from excessive gas,
especially with frequent belch-
ing, 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 Pa 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 intermit-
tent and cramping?

If chronic, is there a change in
bowel habits? Alternating diarrhea
and constipation?

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)

Bloating may occur with lactose intoler-
ance, inflammatory bowel disease, or
ovarian cancer; belching results from
aerophagia, or swallowing air.

Consider diabetic gastroparesis, anticho-
linergic 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 diver-
ticulitis, diffuse abdominal pain with
abdominal distention, hyperactive
bowel sounds, and tenderness on palpa-
tion in small or large bowel obstruction;
pain with absent bowel sounds, rigidity,
percussion tenderness, and guarding in
peritonitis

Colon cancer; irritable bowel syndrome

Pregnancy, diabetic ketoacidosis, adre-
nal insufficiency, hypercalcemia, uremia,
liver disease. Induced vomiting without
nausea in anorexia/bulimia.

202 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

■ Regurgitation

■ Coffee ground emesis
(hematemesis)

Ot h e r GI S ym p t o m s

■ Dif culty swallowing
(dysphagia)

■ Painful swallowing
(odynophagia)

■ Diarrhea, acute (3 drinks/d nd

>7 drinks/wk
>4 drinks/d nd

>14 drinks/wk
Binge drinkingb ≥4 drinks on one

occ sion
≥5 drinks on one

occ sion

aPregn nt wo en nd those with he lth roble s th t could be worsened by drinking should
not drink ny lcohol.

bBrings blood lcohol level to . 8 g%, usu lly within 2 hours.

■ 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.

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 y be d inistered t ny ti e before tr veling to
ende ic re s.

206 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

■ Hepatitis C: Hepatitis C, now the most common form of hepatitis, is
spread by blood exposure and injection drug use. There is no vaccina-
tion 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.

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 infect ion, nd eo le seeking rotection fro he t it is B
infect ion

● 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 cilit ies nd end-st ge
ren l dise se rogr s, nd f cilit ies for eo le with develo ent l
dis bilit ies

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

● Hereditary high-risk condit ions (6% of colorect l c ncers)
● F ili l deno tous oly osis
● Heredit ry non oly osis colorect l c ncer

(continued )

Chapter 11 | The Abdomen 207

T h e A b d o m e n
Inspect the abdomen,

including:

■ Skin

■ Umbilicus

■ Contours for shape, symmetry,
enlarged organs or masses

■ Any peristaltic waves

■ Any pulsations

Auscultate the abdomen for:

■ Bowel sounds

■ Bruits

■ Friction rubs

Techniques of Examination
EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Scars, striae, veins, ecchymoses (in intra-
or retroperitoneal hemorrhages)

Hernia, inflammation

Bulging flanks of ascites, suprapubic
bulge, large liver or spleen, tumors

Increased in GI obstruction

Increased in aortic aneurysm

Increased or decreased motility

Bruit of renal artery stenosis

Liver tumor, splenic infarct

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 (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”

208 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

Percuss the abdomen for patterns
of tympany and dullness.

Palpate all quadrants of the
abdomen:

■ Lightly for guarding, rebound,
and tenderness (Fig. 11-1)

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

Decre sed, then bsent bowel sounds Adyn ic ileus
Peritonitis

High- itched tinkling bowel sounds Intestin l fluid
Air under tension in dil ted bowel

High- itched rushing bowel sounds
with cr ing

Intestin l obstruction

He tic bruit C rcino of the liver
Alcoholic he titis

Arteri l bruits P rti l obstruction of the ort or
ren l, ili c or fe or l rteries

Aorta

Rena l a rte ry

Iliac a rte ry

Femora l a rte ry

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Ascites, GI obstruction, pregnant uterus,
ovarian tumor

See Table 11-3, Abdominal Tenderness,
p. 217. “Acute abdomen”or peritonitis if:

Figure 11-1 Begin with light palpation
of the abdomen.

Firm, board-like abdominal wall—
suggests peritoneal inflammation.

Guarding if the patient flinches,
grimaces, or reports pain during
palpation.

Rebound tenderness from peritoneal
inflammation; pain is greater when
you withdraw your hand than when
you press down. Press slowly on a ten-
der area, then quickly “let go.”

Chapter 11 | The Abdomen 209

T h e Liv e r
Percuss span of liver dullness

in the midclavicular line (MCL),
Figure 11-3.

Figure 11-2 Use two hands for
deep palpation.

■ Deeply for masses or tenderness
(Fig. 11-2)

Tumors, a distended viscus

Abdominal masses may be: physiologic
(pregnant uterus), inflammatory (diver-
ticulitis), vascular (an AAA), neoplastic
(colon cancer), or obstructive (a dis-
tended bladder or dilated loop of bowel).

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

4–8 cm in
mids te rna l
line

6–12 cm
in right
midclav-
icula r
line

Norma l
live r
spans

Figure 11-3 Measure the live r span.

Increased dullness in hepatomegaly
from acute hepatitis, heart failure;
decreased dullness in cirrhosis

Feel the liver edge, if possible, as
patient breathes in.

Starting well below the costal mar-
gin, measure distance of the liver
edge from the costal margin in the
MCL (Fig. 11-4).

Firm edge of cirrhosis

Figure 11-4 Palpate the live r edge .

Increased distance in hepatomegaly—
may be missed (as in Fig. 11-5) by
starting palpation too high in the RUQ

Figure 11-5 Palpating firs t at the cos tal
margin may miss the liver edge .

Note any tenderness or masses. Tender liver of hepatitis or heart failure;
tumor mass

210 Ba tes’ Pocket Guide to Phys ica l Examination and His tory Taking

T h e S p le e n
Percuss across left lower ante-
rior 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).

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Figure 11-6 Spleen tip (purple) palpable
below costal margin.

Splenomegaly

T h e Kid n e y s
Try to palpate each kidney

(Fig. 11-7).

Figure 11-7 Palpate each kidney.

Enlargement from cysts, cancer,
hydronephrosis

Figure 11-8 Percuss for cos tovertebral
angle tenderness .

Tender in pyelonephritisCheck for costovertebral angle
(CVA) tenderness (Fig. 11-8).

Chapter 11 | The Abdomen 211

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

T h e A o r t a
Palpate the aorta’s pulsations

(Fig. 11-9). In older people, esti-
mate its width.

Figure 11-9 Palpate on both s ides of
the aorta.

Periumbilical mass with expansile pulsa-
tions ≥3 cm in diameter in abdominal
aortic aneurysm. Assess further due to
risk of rupture.

A s s e s s in g A s c it e s
/ Palpate for shifting dull-

ness. Map areas of tympany and
dullness with patient supine, then
lying on side (Fig. 11-10).

Tympany

Dullness

Figure 11-10 Percuss outward to map
dullness from ascites .

Ascitic fluid usually shifts to dependent
side, changing the margin of dullness
(Fig. 11-11).

Tympany

Shifting
dullness

Figure 11-11 Percuss for shifting dull-
ness (here patient turned 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 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

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.

Figure 11-12 Test for a fluid wave .

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Figure 11-13 Ballotte the live r.

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:

“Where did the pain begin?”

“Where is it now?”

Ask patient to cough. “Where does
it hurt?”

Palpate for local tenderness.

Palpate for muscular rigidity.

Perform a rectal examination and,
in women, a pelvic examination
(see Chapters 14 and 15).

■ Rovsing sign: Press deeply and
evenly in the left lower quad-
rant. Then quickly withdraw
your ngers.

In classic appendicitis:

Near the umbilicus

RLQ

RLQ at “the McBurney point”

RLQ tenderness

RLQ rigidity

Local tenderness, especially if appendix
is retrocecal

Pain in the right lower quadrant during
left-sided pressure suggests appendicitis
(a positive Rovsing sign).

Chapter 11 | The Abdomen 213

■ 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.

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

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.

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.

Bowel sounds may be active or
decreased; tympany may increase with
an ileus: Assess any RUQ tenderness.

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 l-
ble ss. No CVA tenderness.” (These findings suggest peritonitis from possible
appendicitis; see pp. 212–213.)

214 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

Aids to Interpretation

P ro b le m /P ro c e s s Ch a ra c t e r is t ic s o f S t o o l

Ac u t e Dia r rh e a

Secre tory In fection (noninflammatory)
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

Inflam m atory Infection
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

Dru g -In d u c e d Dia r rh e a

Action of many drugs, such as
magnesium-containing antacids,
antibiotics, antineoplastic agents, and
laxatives

Loose to watery

Ch ro n ic Dia r rh e a (ê3 0 d a ys )

Diarrhea l Syndrom es
■ 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

Dia rrh e aTable 11-1

Chapter 11 | The Abdomen 215

P ro b le m /P ro c e s s Ch a ra c t e r is t ic s o f S t o o l

In flam m atory Bowel Disease
■ 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)

Volum inous Diarrheas
■ Malabsorption syndrome: Defective

absorption of fat, including fat-
soluble vitamins, with steatorrhea
(excessive excretion of fat) as in
pancreatic insufficiency, bile salt
deficiency, bacterial overgrowth

■ Osmotic Diarrheas
■ Lactose intolerance: Deficiency in

intestinal lactase
■ Abuse of osmotic purgatives:

Laxative habit, often surreptitious
■ Secretory diarrheas from bacterial

infection, secreting villous adenoma,
fat or bile salt malabsorption,
hormone-mediated conditions
(gastrin in Zollinger–Ellison
syndrome, vasoactive intestinal
peptide): Process is variable.

Typically bulky, soft, light
yellow to gray, mushy, greasy
or oily, and sometimes frothy;
particularly foul-smelling;
usually floats in the toilet

Watery diarrhea of large volume

Dia rrh e a (continued )Table 11-1

216 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

P ro b le m Me ch a n is m s

S t re 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.

■ 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

Urg 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.

■ 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

Ove rf 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.

■ 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

Urin a ry In c o n t in e n c eTable 11-2

Chapter 11 | The Abdomen 217

P ro b le m Me ch a n is m s

Fu n c t io n a l In c o n t in e n c e :
Inability to get to the toilet in time
because of impaired health or
environmental conditions

■ Problems in mobility from
weakness, arthritis, poor vision,
other conditions; environmental
factors such as unfamiliar setting,
distant bathroom facilities, bed
rails, physical restraints

In c o n t in e n c e S e c o n d a ry
t o Me d ic a t io n s : Drugs may
contribute to any type of
incontinence listed.

■ Sedatives, tranquilizers,
anticholinergics, sympathetic
blockers, potent diuretics

Urin a ry In c o n t in e n c e (continued )Table 11-2

Vis c e ra l Te n d e rn e s s P e r it o n e a l Te n d e rn e s s

Enlarged
liver
Normal
cecum

Normal
aorta

Normal
or
spas tic
s igmoid
colon

Appendicitis
Dive rticulitis

Cholecys titis

Te n d e rn e s s f ro m Dis e a s e in t h e Ch e s t a n d P e lv is

Acute Pleurisy Acu te Sa lp ing itis

Unila te ra l or
bila te ra l, upper
or lower abdomen

Ab d o m in a l Te n d e rn e s sTable 11-3

219

C H A P T E R

12The Peripheral
Vascular System

The Health History

Ask about abdominal, ank, or
back pain, especially in older male
smokers.

Ask about any pain in the arms
and legs.

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 exer-
cise?” “How far can you walk with-
out stopping to rest?” and “Does
pain improve with rest?”

Ask also about coldness, numbness,
or pallor in legs or feet or hair loss
over the anterior tibial surfaces.

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

An expanding abdominal aortic aneurysm
(AAA) may compress arteries or ureters.

Cold-induced digital ischemic change
with blanching then cyanosis then rubor
in Raynaud phenomenon or disease

Peripheral arteria l disease (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.

Hair loss over the anterior tibiae in PAD.
“Dry”or brown–black ulcers from gan-
grene may ensue.

220 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

Because patients have few symp-
toms, 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.

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

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
th t li its w lking or exertion in the
legs; if resent, identify the loc tion.
Ask lso bout erectile dysfunction.

● Any oorly he ling or nonhe ling
wounds of the legs or feet

● Any in resent when t rest in the
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%.

Symptom location suggests the site of
arterial ischemia:

aortoiliac
iliac–pudendal
common femora l or aortoiliac
superficia l femoral
popliteal
tibial or peroneal

Chapter 12 | The Peripheral Vascular System 221

S c re e n in g fo r P e r ip h e ra l Ar t e r ia l Dis e a s e . PAD prevalence in-
creases 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 ce-
rebral 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 ch ia l In d e x. To diagnose PAD, use the ankle–brachial
index (ABI), which is reliable, reproducible, noninvasive, easy to per-
form in the of ce, and highly speci c. The ABI is the ratio of blood
pressure measurements in the foot and arm; values 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

Techniques of Examination

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

A r m s
Inspect for:

■ Size and symmetry, any swelling

■ Venous pattern

■ Color and texture of skin and
nails

Palpate and grade the pulses:

Lymphedema, venous obstruction

Visible venous collaterals, swelling,
edema, and discoloration signal upper-
extremity DVT.

Sharply demarcated pallor of the fingers
in Raynaud disease

G r a d in g A r t e r ia l P u ls e s

3+ Bounding
2+ Brisk, expect ed (normal)
1+ Di inished, we ker th n ex ected
Absent, un ble to l te

Chapter 12 | The Peripheral Vascular System 223

■ Radial (Fig. 12-1)

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Figure 12-1 Palpate the radial pulse .

Bounding radial, carotid, and femoral
pulses in aortic regurgita tion

Lost in thromboangiitis obliterans or
acute arterial occlusion

■ Brachial (Fig. 12-2)

Figure 12-2 Palpate the brachial pulse .

Feel for the epitrochlear nodes. Lymphadenopathy from local or distal
infection, lymphoma, or human immu-
nodeficiency virus (HIV)

A b d o m e n
Auscultate for aortic, renal, and
femoral bruits.

Palpate and estimate the width of
the abdominal aorta between your
two ngers (see p. 211).

Palpate the super cial inguinal nodes
(Fig. 12-3). Note size, consistency,
discreteness, and any tenderness.

■ Horizontal group

■ Vertical group

Pulsatile mass, AAA if width ≥4 cm.

Lymphadenopathy in genital infections,
lymphoma, AIDS

224 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

Le g s
Inspect for:

■ Size and symmetry, any swelling
in thigh or calf

■ Venous pattern

■ Color and texture of skin

■ Hair distribution, temperature

Palpate and grade the pulses:

■ Femoral

■ Popliteal (Fig. 12-4)

Femoral vein
Femoral artery

Great
saphenous vein

Vertical group

Horizontal group

Figure 12-3 Superficial inguinal lymph nodes .

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

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.

Venous insufficiency, lymphedema; DVT.
Calf asymmetry >3 cm (measure 10 cm
below tibial tuberosity) doubles the risk
of DVT.

Varicose veins

Pallor, rubor, cyanosis; erythema,
warmth in cellulitis, thrombophlebitis;
pigmentation, ulcers of the feet in PAD

Atrophic hairless cool skin in PAD

Loss of pulses in acute arterial occlusion
and arteriosclerosis obliterans

Figure 12-4 Palpate the popliteal pulse.

Chapter 12 | The Peripheral Vascular System 225

■ Dorsalis pedis and posterior
tibial (Figs. 12-5 and 12-6)

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).

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Figure 12-5 Palpate the dorsalis pedis
pulse .

Figure 12-6 Palpate the posterior
tibial pulse .

Palpate for pitting edema.

Palpate the calves.

Ask patient to stand, and reinspect
the venous pattern.

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.

Dependent edema, heart failure, hypoal-
buminemia, nephrotic syndrome

Possible cord and tenderness in DVT
(not always present)

Varicose veins

226 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Figure 12-9 Palmar flushing—Allen
tes t negative .

Figure 12-10 Palmar pallor—Allen
tes t pos itive .

1. Ask the patient to make a tight
st, palm up. Occlude both
radial and ulnar arteries with
your thumb (Fig. 12-7).

Marked pallor of feet on elevation,
delayed color return and venous filling,
and rubor of dependent feet suggest
arterial insufficiency.

Figure 12-8 Pallor when hand re laxed.

2. Ask the patient to open hand
into a relaxed, slightly exed
position (Fig. 12-8).

/ 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 (nor-
mally 10 seconds) and (2) lling of
veins on feet and ankles (normally
about 15 seconds).

Figure 12-7 Compress the radial and
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).

Chapter 12 | The Peripheral Vascular System 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.)

Ra d ia l Bra ch ia l Fe m o ra l P o p lit e a l
Do r s a lis

P e d is
Po s t e r io r

Tib ia l

RT 2+ 2+ 1+ 1+ 1+ 1+
LT 2+ 2+ 1+ 1+ 1+ 1+

228 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

Aids to Interpretation

Co n d it io n Ch a ra c t e r is t ic s

Ch ro n ic Ar t e r ia l In s u ff ic ie n c y

Rubor

Ischemic ulce r

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.

Ch 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.

Ch ro n ic In s u ffic ie n cy o f Art e rie s a n d Ve in sTable 12-1

Chapter 12 | The Peripheral Vascular System 229

Ulc e r Ch a ra c t e r is t ic s

Ar 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.

Ch 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.

Ne u ro p a t h ic Ulc 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.

Co m m o n Ulc e rs o f t h e Fe e t a n d An k le sTable 12-2

230 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

In s t ru c t io n s fo r Me a s u r in g t h e An k le –Bra ch ia l In d e x (ABI)

1. Patient should rest supine in a warm room for at least 10 min before
testing.

Dopple r

Brachia 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

Dopple r

Dorsa lis pedis
(DP) a rte ry

Pos te rior
tibia l (PT)

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

Us in g t h e An k le –Bra ch ia l In d exTable 12-3

Chapter 12 | The Peripheral Vascular System 231

5. Calculate ABI

Right ABI =
highest right average ankle pressure (DP or PT)

highest average arm pressure (right or left)

Left ABI =
highest left average ankle pressure (DP or PT)

highest average arm pressure (right or left)

In t e rp re t a t io n o f An k le –Bra ch ia l In d e x

Ankle–Brach ia l Index Resu lt Clin ica l In te rp re ta tion
>0.90 (with a range of 0.90 to 1.30) Normal lower-extremity

blood flow

0.60 Mild PAD

0.40 Moderate PAD

6 months) pelvic pain.

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.

Superficial pain suggests local inflam-
mation, atrophic vaginitis, or inadequate
lubrication; deeper pain may result from
pelvic disorders or pressure on a normal
ovary.

Acute pelvic pain in PID, ruptured ovar-
ian cyst, appendicitis; ectopic preg-
nancy; also mittelschmerz, ruptured
ovarian cyst, tubo-ovarian abscess.
Chronic pelvic pain in endometriosis,
PID, adenosis and fibroids, history of
sexual abuse; pelvic floor spasm.

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 rvic 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.

250 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

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 pre-
vents 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

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 n d A C O G

Va ria b le Re c o m m e n d a t io n

Age t which to begin screening 21 ye rs
Screening ethod nd interv l 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 test-

ing (for high-risk or oncogenic HPV
ty es) every 5 ye rs

Age t which to end screening Age >65 ye rs, ssu ing three consecutive
neg tive results on cytology or two con-
secutive 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

Screening fter hysterecto y
with re ov l of the cervix

Not reco ended

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.

aDefinition 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 uno-
co 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.

Chapter 14 | Female Genitalia 251

and the USPSTF strongly recommend screening for STIs as summarized in
the box below.

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 con-
traception and their effectiveness.

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 reg-
n 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 sexu-
lly ctive g y, bisexu l, nd other MSM. MSM who h ve ulti le or nony-
ous 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 injec-

tion 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 it ted 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.

O p t io n s f o r Fa m ily P la n n in g

Me t h o d s Typ e s o f Co n t ra c e p t io n

Natural Fertility w reness/ eriodic bstinence,
withdr w l, l ct tion

Barrier M le condo , fe le condo , di hr g ,
cervic l c , s onge

Implantable Intr uterine device, subder l i l nt of
levonorgestrel

Pharmacologic/ hormonal S er icide, or l contr ce tives (estrogen nd
rogesterone; rogestin only), estrogen/
rogesterone inject bles nd tch, hor-
on l v gin l contr ce tive ring, e ergency
contr ce tion

Surgery (permanent) Tub l lig tion; tr nscervic l steriliz tion;
v secto y

252 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

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, pul-
monary embolism, and breast cancer.

Techniques of Examination

Male examiners should be accompanied by female chaperones. Female
examiners should be assisted whenever possible.

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

E x t e r n a l G e n it a lia
Observe pubic hair to assess

sexual maturity.

Examine the external genitalia
(Fig. 14-1).

■ Labia minora

■ Clitoris

■ Urethral ori ce

Normal or delayed puberty

See Table 14-1, Lesions of the Vulva,
pp. 258–259.

Ulceration in herpes simplex, syphilitic
chancre; inflammation in Bartholin cyst

Enlarged in masculinization

Urethral caruncle or prolapse; tenderness
in interstitial cystitis

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 Th e Exa m in e r

● Avoids intercourse, douch-
ing, or use of v gin l su os-
itories 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 i-
n l uscles

● 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 e-

ci lly when inserting the s eculu

Chapter 14 | Female Genitalia 253

■ Introitus

Milk the urethra for discharge if
indicated.

Mons pubis

Prepuce

Clitoris

Ure thra l
meatus

Opening of
pa raure thra l

(Skene) gland

Ves tibule

Introitus

Perineum

Labia ma jora

Labia minora

Hymen

Vagina

Opening of
Bartholin
gland

Anus

Figure 14-1 External female genitalia.

Imperforate hymen

Discharge of urethritis

Cystocele, cystourethrocele, rectocele

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

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 specu-
lum held obliquely (Fig. 14-2),
then rotate to horizontal position
for full insertion (Fig. 14-3).

254 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

Open the speculum gently and
inspect cervix:

■ Position

■ Color

■ Shape of the cervical os
(Fig. 14-4); epithelial surface
(squamous–columnar epithelial
junction)

Figure 14-2 Entry angle . Figure 14-3 Carefully inse rt the
speculum to full length.

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Cervix faces forward if uterus is retro-
verted.

Purplish in pregnancy

Columnar epithe lium

Squamocolumnar junction

Squamous epithe lium

Exte rna l os of
the ce rvix

Trans formation
zone

Figure 14-4 Cervical epithe lial surface .

Oval (normal) or slit-like or transverse os
from delivery; raised, friable, or lobed
wart-like lesions in condylomata or cer-
vical cancer (see Table 14-3, Abnormali-
ties of the Cervix, p. 261)

■ Any discharge or bleeding

■ Any ulcers, nodules, or masses

Discharge from os in mucopurulent cer-
vicitis from Chlamydia or gonorrhea (see
Table 14-2, Vaginal Discharge, p. 260)

Herpes, polyp, cancer

Chapter 14 | Female Genitalia 255

Obtain specimens for cytology
(Pap smears) with:

■ 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.

Palpate, by means of a bimanual
examination (Fig. 14-6):

■ The cervix and fornices

■ The uterus

■ Right and left adnexa (ovaries)

Early cancer before it is clinically evident

Figure 14-5 Endoce rvical broom.

Bluish color and deep rugae in preg-
nancy; vaginal cancer (rare); vaginal dis-
charge from infection from Candida,
Trichomonas vaginalis, bacterial vaginosis
(see Table 14-2, Vaginal Discharge, p. 260)

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Figure 14-6 Palpate the ce rvix,
ute rus , and adnexa.

Pain on moving cervix in PID

Pregnancy, myomas; soft isthmus in
early pregnancy (see Table 14-4,
Positions of the Uterus and Uterine
Myomas, p. 262)

Ovarian cysts or masses, salpingitis, PID,
tubal pregnancy

256 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

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, per-
form 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).

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).

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Retroverted
uterus

Figure 14-7 Examine the rectovaginal
area.

H e r n ia s
Ask the woman to strain down, as
you palpate for a bulge in:

■ The femoral canal

■ The labia majora up to just
lateral to the pubic tubercle

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.

Femoral hernia

Indirect inguinal hernia

Figure 14-8 Milk the ure thra if
indicated.

Discharge in C. trachomatis and Neisseria
gonorrhoeae infection

Chapter 14 | Female Genitalia 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.)

258 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

Aids to Interpretation

Ep id e rm o id Cys t

Cys tic
nodule
in skin

A small, firm, round cystic
nodule in the labia suggests an
epidermoid cyst. They are
yellowish in color. Look for the
dark punctum marking the
blocked opening of the gland.

Ve n e re a l Wa r t (Co n d ylo m a
Ac u m in a t u m )

Warts

Warty lesions on the labia and
within the vestibule suggest
condyloma acuminata from
infection with human
papillomavirus.

Ge n it a l He rp e s

Sha llow
ulcers
on red
bases

Shallow, small, painful ulcers on
red bases suggest a herpes
infection. Initial infection may be
extensive, as illustrated here.
Recurrent infections are usually
confined to a small local patch.

Le s io n s o f t h e Vu lvaTable 14-1

Chapter 14 | Female Genitalia 259

S yp h ilit ic Ch a n c re 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 yp h ilis
(Co n d y lo m a La t u m )

Fla t,
gray
papule s

Slightly raised, round or oval
flat-topped papules covered by a
gray exudate suggest condylomata
lata, a manifestation of secondary
syphilis. They are contagious.

Ca rc 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.

Le s io n s o f t h e Vu lva (continued )Table 14-1

260 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

Note: Accurate diagnosis depends on laboratory assessment and
cultures.

Tr ich o m o n a s va g in it is Discharge : Yellowish green,
often profuse, may be
malodorous
Other Symptoms: Itching,
vaginal soreness, dyspareunia
Vulva: May be red
Vagina: May be normal or red,
with red spots, petechiae
Laboratory Assessment: Saline
wet mount for trichomonads

Ca n d id a va g in it is Discharge: White, curdy, often
thick, not malodorous
Other Symptoms: Itching,
vaginal soreness, external
dysuria, dyspareunia
Vulva: Often red and swollen
Vagina: Often red with white
patches of discharge
Laboratory As se ss me nt:
KOH preparation for branching
hyphae

Ba c t e r ia l va g in o s is

Lactobacilli

Discharge : Gray or white,
thin, homogeneous, scant,
malodorous
Other Symptoms: Fishy
genital odor
Vulva: Usually normal
Vagina: Usually normal
Laboratory Assessment: Saline
wet mount for “clue cells,” “whiff
test” with KOH for fishy odor

Va g in a l Dis ch a rg eTable 14-2

Chapter 14 | Female Genitalia 261

En d o c e r v ic a l p o lyp . A bright
red, smooth mass that protrudes
from the os suggests a polyp. It
bleeds easily.

Mu c o p u ru 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.

Ca rc 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.

Vagina l
adenos is

Columnar
epithe lium

Colla r

Fe t a l e xp o s u re t o d ie t h y l-
s t ilb e s t ro l (DES ). Several
changes may occur: a collar of
tissue around the cervix,
columnar epithelium that covers
the cervix or extends to the
vaginal wall (then termed vaginal
adenosis), and, rarely, carcinoma
of the vagina.

Ab n o rm a lit ie s o f t h e Ce rvixTable 14-3

262 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

An a n t e ve r t e d u t e ru 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 re t ro ve r t e d u t e ru s is tilted posteriorly
with its cervix facing anteriorly.

A re t ro f le xe d u t e ru 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 ru 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.

Po 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

Table 14-4

Chapter 14 | Female Genitalia 263

When the pelvic floor is weakened, various structures may become
displaced. These displacements are seen best when the patient strains
down.

A c ys 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 ys t o u re 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 re 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 ru 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.

Re la xa t io n s o f t h e Pe lvic Flo o rTable 14-5

265

C H A P T E R

15The 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?

Any pain with defecation, or rectal
bleeding or tenderness?

Any anal warts, ssures, or ulcer-
ations?

In men, is there dif culty starting the
urine stream or holding back urine?
Is the ow weak? What about fre-
quent 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?

Pencil-like stool or blood in stool in colon
cancer; dark tarry stools if polyps, carci-
noma, gastrointestinal bleeding; mucus
in villous adenoma, inflammatory bowel
disease (IBD), or irritable bowel
syndrome (IBS)

Hemorrhoids; proctitis from sexually
transmitted infections (STIs)

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

These symptoms suggest urethral
obstruction from benign prostatic hyper-
plasia (BPH) or prostate cancer, 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).

266 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

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.

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

● Prost te c ncer screening
● Colorect l c ncer screening
● Counseling for sexu lly tr ns itted infections

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

Am e ric a n
Uro lo g ic a l
As s o c ia t io n

Am e ric a n
Ca n c e r S o c ie t y

Un it e d S t a t e s
P re ve n t ive S e rvic e s
Ta s k Fo rc e

Sh red decision
king

Yes Yes (consider
using decision
id)

Yes (when tient
requests screening)

Age to begin
offering
screening

Aver ge-risk
High-risk

4 ye rs
4 ye rs

5 ye rs
4 –45 ye rs

No reco end tion

Age to sto
offering
screening

Life
ex ect ncy
<1 ye rs

Life ex ect ncy
<1 ye rs

No reco end tion

Screening tests PSA
DRE (o tion l)

PSA
DRE (o tion l)

No reco end tion

(continued )

Chapter 15 | The Anus, Rectum, and Prostate 267

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 (Continued)

Am e ric a n
Uro lo g ic a l
As s o c ia t io n

Am e ric a n
Ca n c e r S o c ie t y

Un it e d S t a t e s
P re ve n t ive S e rvic e s
Ta s k Fo rc e

Frequency of
screening

Annu l Annu l (bienni l
when PSA
<2.5 ng/ L)

No reco end tion

Bio sy referr l
criteri

PSA ≥4 ng/ L
Abnor l DRE
Individu lized risk

ssess ent for
PSA levels
2.5–4 ng/ L

No reco end tion

Abbrevi tions: PSA, rost te-s ecific ntigen; DRE, digit l rect l ex in tion.

Th e DRE. 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.

Co lo re c t a l Ca n c e r S c re 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 high-
sensitivity 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 high-
sensitivity 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 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

Wear gloves to examine the
anus, rectum, and prostate
(Fig. 15-1).

Techniques of Examination

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Valve of
Houston

Peritonea l
re flection

Rectum

Pros ta te

Anorecta l
junction

Anal cana l

Ure thra

Bladder

Semina l
ves icle

Figure 15-1 Anus and rectum—sagittal 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 patient on the
left s ide .

Inspect the:

■ Sacrococcygeal area

■ Perianal area

Pilonidal cyst or sinus

Hemorrhoids, warts, herpes, chancre,
cancer, fissures from proctitis, STIs, or
Crohn disease, fistula from anorectal
abscess

Chapter 15 | The Anus, Rectum, and Prostate 269

Palpate the anal canal and rectum
with a lubricated and gloved nger.
Palpate the:

■ Walls of the rectum

■ Prostate gland, as shown in
Figure 15-3, including median
sulcus

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Figure 15-3 Palpate the pros tate
gland.

Figure 15-4 Rectal cancer.

Lax sphincter tone in some neurologic
disorders; tightness in proctitis

Cancer of the rectum, polyps

Prostate nodule or cancer (Fig. 15-4);
BPH; tenderness in prostatitis

Try to palpate above the prostate
for irregularities or tenderness, if
indicated.

/ Fe m a le
The patient is usually in the
lithotomy position or lying on
her side.

Inspect the anus.

Palpate the anal canal and rectum.

See Table 15-2, Abnormalities on Rectal
Examination, pp. 272–273.

Rectal shelf of peritoneal metastases;
tenderness of inflammation

Hemorrhoids

Rectal cancer, normal uterine cervix or
tampon (felt through the rectal wall)

270 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

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.)

Chapter 15 | The Anus, Rectum, and Prostate 271

Aids to Interpretation

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.

PART 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.

PART 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)

BP H Sym p t o m Sc o re In d ex: Am e ric a n
Uro lo g ic a l As s o c ia t io n (AUA)

Table 15-1

Adapted from: Madsen FA, Burskewitz RC. Clinical manifestations of benign prostatic hyperplasia.
Urol Clin North Am. 1995;22:291.

272 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

Ext e rn a l He m o rrh 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.

An a l Fis s u re . Painful longitudinal
oval ulceration usually in posterior
midline with swollen sentinel tag
just below it.

FissureSentine l tag

An o re 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.

Opening

Fis tula

P o lyp 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.

Ab n o rm a lit ie s o n Re c t a l Exa m in a t io nTable 15-2

Chapter 15 | The Anus, Rectum, and Prostate 273

Be n ig n P ro s t a t ic Hyp e rp 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.

Ca 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.

Ca n c e r o f t h e Re c t u m . Firm,
nodular, rolled edge of an ulcerated
cancer.

Ab n o rm a lit ie s o n Re c t a l
Exa m in a t io n (continued )

Table 15-2

275

C H A P T E R

16The 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 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.

276 Ba tes’ Pocke t Guide to Physica l Examina tion and His tory Taking

Age also provides clues to causes of joint pain.

Review the three primary types of joint articulation—synovial, cartilagi-
nous, 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 yn o via l J o in t s
● Freely ov ble within li its of

surrounding lig ents
● Se r ted by art icular cart ilage

nd synovial cavity
● Lubric ted by synovi l fluid
● Surrounded by joint c sule
● Example: knee, shoulder

Ca r t ila g in o u s J o in t s
● 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

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

Bone

Synovia l
membrane

Articula r
cartilage

Synovia l
cavity

Ligament

Joint
space
Joint
capsule

Vertebra l
body

Nucleus
pulposus

of the disc

Disc

Ligament

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 syn-
dro 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

● Osteo rthritis (OA)
● Osteo orotic fr cture
● Gout nd seudogout

● Poly y lgi rheu tic (PMR)

● Se tic b cteri l rthritis

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 ck 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

Co n d yla 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 tory or
noninfl tory, loc lized or diffuse

● Joint in: ssoci ted constitution l sy to s nd syste ic nifest tions
fro other org n syste s

● Neck in
● Low b ck in

278 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

Assess the seven features of any joint pain (see p. 47).

J o in t Pa in

Ar t ic u la r o r Ex t ra -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.

If polyarticular, does it migrate from
joint to joint, or steadily spread
from one joint to multiple joint
involvement? Is the involvement
symmetric?

If pain is extra-articular, are there
generalized “aches and pains”
(myalgia if in muscles, arthralgia
if in joints with no evidence of
arthritis)?

Ask if there is decreased joint
movement or stiffness.

Ac u t e o r Ch ro n ic . Acute joint
pain typically lasts up to 6 weeks;
chronic pain lasts >12 weeks. Assess
the timing, quality, and severity of
joint symptoms.

See Table 16-1, Patterns of Pain in and
Around the Joints, p. 304.

Consider trauma, monoarticular arthri-
tis, tendinitis, or bursitis. Hip pain near
the greater trochanter suggests
trochanteric bursitis.

Migratory pattern in rheumatic fever or
gonococcal arthritis; progressive and
symmetric pattern in rheumatoid arthritis

Bursitis if inflammation of bursae; tendi-
nitis if in tendons, and tenosynovitis
if in tendon sheaths; also sprains from
stretching or tearing of ligaments

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

Severe pain of rapid onset in red swollen
joint in acute septic arthritis or crystal-
line arthritis (gout; CPPD). In children,
osteomyelitis in bone contiguous to a
joint.

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, rtic-
ul 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).

Chapter 16 | The Musculoskeletal System 279

If from trauma, what was the mech-
anism of injury or series of events
that caused the joint pain? Further-
more, what aggravates or relieves
the pain? What are the effects of
exercise, rest, and treatment?

In f la m m a t o ry o r No n in f la m –
m a t o ry. Is the problem inflamma-
tory or noninflammatory? Is there
fever, chills, tenderness, warmth,
or redness?

Assess any stiffness or limitations
of motion.

Lo c a lize d o r D iffu s e . Ask the
patient to point to the joints that
are painful to determine if joint
pain is be monoarticular, oligoar-
ticular involving two to four joints,
or polyarticular.

J o in t P a in : As s o c ia t e d
Co n s t it u t io n a l S ym p t o m s
a n d S ys t e m ic Ma n ife s t a –
t io n s f ro m Ot h e r Org a n
S ys t e m s . Assess constitutional
symptoms such as fever, chills, rash,
fatigue, anorexia, weight loss, and
weakness.

Ne ck Pa in . Ask about location,
radiation into the shoulders or
arms, arm or leg weakness, bladder
or bowel dysfunction.

If the patient reports neck trauma,
common in motor vehicle acci-
dents, ask about neck tenderness
and consider clinical decision rules

See Table 16-1, Patterns of Pain in and
Around the Joints, p. 304.

If inflammatory, consider infectious
causes (Neisseria gonorrhoeae or Myco-
bacterium tuberculosis), crystal-induced
(gout, pseudogout), immune-related
(RA, SLE), reactive (rheumatic fever, reac-
tive arthritis), or idiopathic arthritis. If
noninflammatory, consider trauma
(rotator cuff tear), repetitive use
(bursitis, tendinitis), OA, fibromyalgia.

Morning stiffness that gradually
improves with activity in inflammatory
disorders like RA and PMR; intermittent
stiffness and gelling in OA

Monoarticular arthritis in traumatic,
crystalline, or septic arthritis; oligoar-
ticular arthritis gonorrhea or rheumatic
fever, connective tissue disease, and OA;
polyarthritis if may be viral or inflamma-
tory from RA, SLE, or psoriasis

Common in RA, SLE, PMR, and other
inflammatory arthritides. High fever and
chills suggest an infectious cause.

C7 or C6 spinal nerve compression from
foraminal impingement more common
than disc herniation. See Table 16-2,
Pains in the Neck, p. 305.

280 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

that identify risk of cervical cord
injury (NEXUS criteria and
Canadian C-Spine Rule).

Lo w Ba ck Pa in . There are
numerous clinical guidelines, but
most categorize low back pain into
three groups: nonspeci c (>90%),
nerve root entrapment with radicu-
lopathy 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?”

If the pain radiates into the legs,
ask about any associated numb-
ness, tingling, or weakness. Ask
about history of trauma.

Check for bladder or bowel dys-
function.

Elicit any “red ags” for serious
underlying systemic disease.

See Table 16-3, Low Back Pain, pp. 306–
307. Midline back pain in vertebral col-
lapse, disc herniation, epidural abscess,
spinal cord compression, or spinal cord
metastases. Pain off the midline in mus-
cle strain, sacroiliitis, trochanteric bursi-
tis, sciatica, hip arthritis, renal conditions
such as pyelonephritis or renal stones

Scia tica if radicular gluteal and posterior
leg pain in the S1 distribution that
increases with cough or Valsalva

Present in cauda equina syndrome from
S2–S4 tumor or disc herniation, espe-
cially if “saddle anesthesia”from perianal
numbness

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 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

Chapter 16 | The Musculoskeletal System 281

Nu t rit io n , We ig h t , a n d P hys ic a l Ac t ivit y. Good nutrition sup-
plies 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.

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, 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

Lo w Ba ck Pa 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 relax-
ants, 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 seri-
ous 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.

Os t e o p o ro s is : Ris k Fa c t o rs , S c re e n in g , a n d As s e s s in g
Fra c t u re Ris k . Osteoporosis is a major public health threat and a
common U.S. health problem—9% of adults over age 50 years have

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

282 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

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 recom-
mendation 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.

■ 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 screen-
ing 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.

R is k Fa 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 first-

degree rel tive, rticul rly with
history of fr gility fr cture

● Clinic l conditions such s thyro-
toxicosis, celi c s rue, IBD, cirrho-
sis, 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 to-
logic 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 uno-
su ressive gents, roton- u
inhibitors (long-ter use), nd
ntigon d l ther y for rost te
c ncer

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 st nd rd devi tions below the e n for
young dult white wo en)

Osteopenia: T score between −1. nd −2.5 (1. to 2.5 SDs below the young
dult e n)

Chapter 16 | The Musculoskeletal System 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 thera-
peutic 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 hypo-
tension, 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 inter-
ventions 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.

Inspect and palpate any joints with signs of in ammation.

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

T h e F o u r S ig n s o f In f la m m a t io n

(continued )

● 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.

284 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

Figure 16-2 Palpate the bicipital
groove and tendon.

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.

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

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.

S h o u ld e r s
Inspect the contour of the shoul-
ders and shoulder girdles from
front and back.

Palpate:

■ The clavicle from the sternocla-
vicular joint to the acromiocla-
vicular joint (Fig. 16-2)

■ The bicipital tendon

Figure 16-1 Palpate the TMJ.

Muscle atrophy; anterior or posterior
dislocation of humeral head; scoliosis if
shoulder heights asymmetric

See Table 16-4, Painful Shoulders, p. 308.

“Step-offs”if fracture from trauma

T e m p o r o m a n d ib u la r J o in t

Chapter 16 | The Musculoskeletal System 285

■ The subacromial and subdeltoid
bursae after lifting arm posteri-
orly (Fig. 16-3)

Subacromia l bursa

Rota tor cuff

Figure 16-3 Palpate the subacromial
bursa.

Subacromial or subdeltoid bursitis; ten-
derness 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.

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Assess range of motion.

■ Flexion—“Raise your arm in
front of you and overhead.”

■ Extension—“Move your arms
behind you.”

■ Abduction—“Raise your arms
out to the side and overhead.”

■ Adduction—“Cross your arm in
front of your body, keeping the
arm straight.”

Intact glenohumeral motion if patient
raises arms to shoulder level, palms
facing down

Intact scapulothoracic motion if patient
raises arms an additional 60 degrees,
palms facing up

Acromioclavicular joint arthritis

286 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

■ External and internal rotation
(Figs. 16-4 and 16-5)

Perform ve maneuvers to assess
the “SITS” muscles of the rotator
cuff and the bicipital tendon.

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Figure 16-4 Tes t abduction and
exte rnal rotation.

Figure 16-5 Tes t adduction and
inte rnal rotation.

Shoulder arthritis

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
Painful arc test (Fig. 16-6). Fully
dduct the tient’s r fro to
18 degrees.

180º

90ºº

0º

60º

120º120º

No pa in

Subacromia l
pa in

Figure 16-6 Painful arc te s t.
(continued )

Chapter 16 | The Musculoskeletal System 287

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

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 re 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.

● 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.

● 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.

Co 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 res-
sure roxi l to the tient’s wrist
s the tient resses the wrist out-
w rd in extern l rot tion.

9909090ººº
fleflexioexioexiooflexiolexioiol ofle n 2020200ººº

aabductabducta ionnion

Figure 16-7 Inte rnal rotation lag tes t.

9090º
flexiflexionon

Figure 16-8 External rotation lag tes t.

Figure 16-9 Drop arm tes t.

Figure 16-10 External rotation
res is tance te s t.

288 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

E lb o w s
Inspect and palpate:

■ Olecranon process

■ Medial and lateral epicondyles

■ Extensor surface of the ulna

■ Grooves between the epicon-
dyles and the olecranon

Ask patient to:

■ Flex and extend elbows

■ Turn forearms and palms up and
down (supination and prona-
tion), as shown in Figure 16-11

W r is t s a n d H a n d s
Inspect:

■ Movement of the wrist ( exion,
extension, ulnar and medial
deviation), hands, and ngers

■ Contours of wrists, hands, and
ngers

■ Contours of palms

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Olecranon bursitis; posterior dislocation
from direct trauma or supracondylar
fracture

Tenderness distal to epicondyle in epi-
condylitis (medial → “tennis elbow”;
lateral → “pitcher’s elbow”)

Rheumatoid nodules

Tender in arthritis

o˚

Supina tion Pronation

Figure 16-11 Elbow supination and
pronation.

Guarded movement in injury

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 com-
pression (carpal tunnel syndrome);
hypothenar atrophy in ulnar nerve
compression

Chapter 16 | The Musculoskeletal System 289

Palpate:

■ Wrist joints (Fig. 16-12)

Figure 16-12 Palpate the
wris t joint.

■ Distal radius and ulna

■ “Anatomic snuffbox,” the hollow
space distal to the radial styloid
bone; thumb extensor and
abductor tendons (Fig. 16-13).

Figure 16-13 Palpate the
anatomic snuffbox.

■ Metacarpophalangeal joints
(Fig. 16-14)

Figure 16-14 Palpate the
MCP joints .

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Swelling and tenderness in rheumatoid
arthritis, gonococcal infection of joint or
extensor tendon sheaths

Tenderness over ulnar styloid in Colles
fracture

Tenderness suggests scaphoid fracture.
Tenderness over extensor and abductor
tendons in de Quervain tenosynovitis.

Swelling in rheumatoid arthritis

290 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

■ Proximal and distal interphalan-
geal joint

Assess range of motion:

■ Wrists: Flexion, extension,
adduction (radial deviation),
abduction (lateral deviation)

■ Fingers: Flexions, extension,
abduction/adduction (spread
ngers apart and back)

■ Thumbs (Figs. 16-15 to 16-18)

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Arthritis, tenosynovitis

Trigger finger, Dupuytren contracture

Figure 16-15 Flexion. Figure 16-16 Extens ion.

Figure 16-17 Abduction and adduction. Figure 16-18 Opposition.

Proximal nodules in RA; Bouchard (PIP)
and Heberden (DIP) nodes in OA

Chapter 16 | The Musculoskeletal System 291

Perform selected maneuvers.

■ Hand grip strength (Fig. 16-19)

Figure 16-19 Tes t grip s trength.

Decreased grip strength if weakness of
finger flexors or intrinsic hand muscles

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

■ Thumb movement (Fig. 16-20)

Tendon

Figure 16-20 Tes t thumb function.

Pain if de Quervain tenosynovitis

■ Carpal tunnel testing

■ Thumb adduction (Fig. 16-21)

Figure 16-21 Tes t thumb abduction.

■ Tinel sign: Tap lightly over
median nerve at volar wrist
(Fig. 16-22)

Figure 16-22 Tes t Tine l s ign.

Aching, tingling, and numbness in
second, third, and fourth fingers is a
positive Tinel sign.

Weakness of abductor pollicis longus is
specific to the median nerve.

292 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

■ Phalen sign: Patient exes
wrists for 60 seconds
(Fig. 16-23)

Figure 16-23 Tes t Phalen s ign.

S p in e
Inspect spine from the side and
back, noting any abnormal
curvatures.

Look for asymmetric heights of
shoulders, iliac crests, or buttocks.

Identify and palpate (Fig. 16-24):

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Aching, tingling, and numbness in sec-
ond, third, and fourth volar fingers is a
positive Phalen sign.

Kyphosis, scoliosis, lordosis, gibbus, list
curvatures

Scoliosis, pelvic tilt, unequal leg length

Parave rtebra l
muscle s

Spinous process
of L5 ve rtebra

Ischia l tube ros ity
and s ite of
ischia l bursa

Pos te rior-
supe rior
iliac spine
Sacroiliac
joint

Sacroiliac
notch
Scia tic
ne rve

Inte rve rtebra l
joint be tween
L5 and sacrum

Figure 16-24 Palpate the bony landmarks and muscles of the back.

■ Spinous processes of each
vertebra

Tender if trauma, infection; “step-offs”in
spondylolisthesis, fracture

Chapter 16 | The Musculoskeletal System 293

■ Sacroiliac joints

■ Paravertebral muscles, if painful

■ Sciatic nerve (midway between
greater trochanter and ischial
tuberosity), Figure 16-25

Scia tic nerve
Grea te r trochante r

Ischia l tube ros ity

Figure 16-25 Palpate the sciatic
ne rve .

Test the range of motion in the
neck and spine in: exion, exten-
sion, rotation, and lateral bending.

H ip s
Inspect gait (Fig. 16-26) for:

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Sacroiliitis, ankylosing spondylitis

Paravertebral muscle spasm in abnormal
posture, degenerative and inflammatory
muscle disorders, overuse

Herniated disc or nerve root compres-
sion

Decreased mobility in arthritis

Heels trike Foot flat Mids tance Push-off
Figure 16-26 The s tance phase of gait.

294 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

■ 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

Palpate:

■ Bony landmarks: anterior—iliac
crest and tubercle, anterior-
superior iliac spine, greater
trochanter, pubic tubercle;
posterior—posterior-superior
iliac spine, greater trochanter,
ischial tuberosity, sacroiliac joint

■ Along the inguinal ligament.
Identify the Nerve–Artery–
Vein–Empty space–Lymph
node (NAVEL).

■ The trochanteric bursa, on the
greater trochanter of the femur
(Fig. 16-27)

Trochante ric bursa

Ischioglutea l bursa

Figure 16-27 Trochante ric and ischio-
gluteal bursae .

■ The ischiogluteal bursa, super –
cial to the ischial tuberosity

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Most problems arise during the weight-
bearing stance phase.

Cerebellar disease or foot problems if
wide base; impaired shift of pelvis in
arthritis, hip dislocation, abductor weak-
ness; disrupted gait if poor knee flexion

Bulges in inguinal hernia, aneurysm

Focal tenderness in trochanteric bursitis,
often described by patients as “low back
pain”

Tender in bursitis (“weaver’s bottom”)
from prolonged sitting

Chapter 16 | The Musculoskeletal System 295

Check range of motion, including:

■ Flexion—“Bend your knee and
pull it against your abdomen.”
(Fig. 16-28)

Figure 16-28 Hip flexion and flattening
of lumbar lordosis .

■ Extension (Fig. 16-29)

Figure 16-29 Abduct the leg.

■ Abduction and adduction

■ Internal and external rotation
(Fig. 16-30)

Figure 16-30 Test internal and external
rotation of the hip.

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Flexion of opposite leg suggests
deformity of that hip.

Painful in iliopsoas abscess

Restricted in hip arthritis

296 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

Kn e e s
Identify the medial (Fig. 16-31)
and lateral structures of the knee.

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Media l femora l
condyle

Media l femora l
epicondylePa te lla r tendon

Media l tibia l
pla teau

Tibia l tube ros ity

Adductor tubercle

Media l colla te ra l
ligament

Anse rine bursa

Figure 16-31 Medial compartment of the knee .

Inspect:

■ Gait for knee extension at heel
strike, exion during all other
phases of swing and stance

■ Alignment of knees

■ Contours of knees, including
any atrophy of the quadriceps
muscles

Inspect and palpate:

■ The tibiofemoral joint—with
knees exed, including:

■ Joint line—place thumbs
on either side of the patellar
tendon.

Stumbling or “giving way”during heel
strike in quadriceps weakness or abnor-
mal patellar tracking

Bowlegs, knock-knees; flexion contrac-
tures in limb paralysis or hamstring
tightness.

Quadriceps atrophy with patellofemoral
disorder; swelling over the patella in
prepatellar bursitis (housemaid’s knee),
over the tibial tubercle in infrapatellar or
if more medial anserine bursitis

See Table 16-5, Painful Knees,
pp. 309–310.

Irregular, bony ridges in osteoarthritis.

Chapter 16 | The Musculoskeletal System 297

■ Medial and lateral meniscus

■ Medial and lateral collateral
ligaments

■ The patellofemoral compart-
ment:

■ Patella

■ Palpate the patellar tendon
and ask patient to extend
the leg.

■ Press the patella against the
underlying femur.

■ Push patella distally and
ask patient to tighten knee
against table.

■ Also:

■ Suprapatellar pouch

■ Infrapatellar spaces (hollow
areas adjacent to patella)

■ Medial tibial condyle

■ Popliteal surface

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).

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Tenderness if meniscus tear

Tenderness if MCL tear (LCL injuries less
common)

Swelling over the patella in prepatellar
bursitis (“housemaid’s knee”)

Tenderness or inability to extend the leg
in partial or complete tear of the patellar
tendon

Pain, crepitus, and a history of knee pain
in patellofemoral disorder

Pain during contraction of quadriceps in
chondromalacia

Swelling in synovitis and arthritis

Swelling in arthritis

Swelling in pes anserine bursitis

Popliteal or Baker cyst

A fluid wave returning to the medial
surface after a lateral tap confirms an
effusion—a positive “bulge sign.”

298 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

■ Balloon sign (major effusions):
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).

■ Ballotte the patella (major effu-
sion): Push the patella sharply
against the femur; watch for uid
returning to the suprapatellar
space.

Figure 16-32 Milk downward. Figure 16-33 Apply medial pressure .

Figure 16-34 Tap and watch for fluid wave .

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

A palpable fluid wave is a positive sign.

Visible wave is a positive sign.

Figure 16-35 Tes t for the balloon
s ign.

Chapter 16 | The Musculoskeletal System 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 inter-
nal 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).

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Click or pop along the medial joint with
valgus stress, external rotation, and leg
extension in tear of posterior medial
meniscus.

Figure 16-36 McMurray tes t.

Pain or a gap in the medial joint line
points to a partial or complete MCL tear.

Figure 16-37 Medial collate ral liga-
ment te s t.

300 Ba tes ’ Pocke t Guide to Physica l Examina tion and His tory Taking

■ 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).

■ 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.

(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.

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Pain or a gap in the lateral joint line
points to a partial or complete LCL tear.

Figure 16-38 Late ral collate ral liga-
ment te s t.

Forward slide of proximal tibia is a posi-
tive anterior drawer sign in ACL laxity or
tear.

Figure 16-39 Anterior cruciate liga-
ment te s t.

Figure 16-40 Lachman tes t.

Significant forward excursion of tibia in
ACL tear

Chapter 16 | The Musculoskeletal System 301

■ Posterior cruciate ligament
(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.

A n k le s a n d Fe e t
Inspect ankles and feet.

Palpate:

■ Ankle joint

■ Ankle ligaments: medial-deltoid;
lateral-anterior and posterior
talo bular, calcaneo bular

■ Achilles tendon

■ Compress the metatarsophalan-
geal joints; then palpate each joint
between the thumb and fore n-
ger (Figs. 16-42 and 16-43).

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Isolated PCL tears are rare.

Figure 16-41 Pos te rior cruciate liga-
ment te s t (pos te rior drawer s ign).

Hallux valgus, corns, calluses

Tender joint in arthritis

Tenderness in sprain: lateral ligaments
weaker, making inversion injuries (ankle
bows outward, heel bows inward) more
common

Rheumatoid nodules, tenderness in
tendinitis

Tenderness in arthritis, Morton neuroma
third and fourth MTP joints; inflamma-
tion of first MTP joint in gout

Figure 16-42 Palpate the MTP joints . Figure 16-43 Palpate the metatarsal
heads .

302 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

Assess range of motion.

■ Dorsi ex and plantar ex the
ankle (tibiotalar joint).

■ Stabilize the ankle and
invert (Fig. 16-44) and evert
(Fig. 16-45) the heel (subtalar
or talocalcaneal joint).

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Arthritic joint often painful when moved
in any direction; sprain, when injured
ligament is stretched.

Ankle sprain

Figure 16-44 Invert the hee l. Figure 16-45 Evert the hee l.

■ Stabilize the heel and invert
(Fig. 16-46) and evert
(Fig. 16-47) the forefoot
(transverse tarsal joints).

Trauma, arthritis

Figure 16-46 Invert the fore foot. Figure 16-47 Evert the fore foot.

■ Move proximal phalanx of each
toe up and down (metatarsopha-
langeal joints).

Chapter 16 | The Musculoskeletal System 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, mea-
sure distance from anterior-supe-
rior iliac spine to medial malleolus.
Tape should cross knee medially.

/ 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).

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Unequal leg length may be the cause of
scoliosis.

A flexion deformity of 45 degrees
and further flexion to 90 degrees
(45 degrees → 90 degrees)

45˚

0˚

90˚

160˚

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 sug-
gest osteoarthritis.)

304 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

Aids to Interpretation

Rh e u m a t o id
Ar t h r it is

Os t e o a r t h r it is
(De g e n e ra t ive J o in t
D is e a s e , o r DJ 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

P a t t 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 re s s io n
a n d
Du ra t io n

Often chronic, with
remissions and
exacerbations

Slowly progressive, with
exacerbations after overuse

As 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

Pa t t e rn s o f Pa in in a n d Aro u n d
t h e J o in t s

Table 16-1

Chapter 16 | The Musculoskeletal System 305

P a t t e rn s P h ys ic a l S ig n s

Me ch a n ic a l Ne ck 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.

Me ch a n ic a l Ne ck 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.

Ce r v ic a l Ra d ic u lo p a t h y—
fro m n e r ve ro o t c o m p re 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.

Ce r v ic a l Mye lo p a t h y—fro m
c e r v ic a l c o rd c o m p re 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.

Pa in s in t h e Ne ckTable 16-2

306 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

P a t t e rn s P h ys ic a l S ig n s

Me ch a n ic a l Lo w Ba ck 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

Lo w Ba ck Pa inTable 16-3

Chapter 16 | The Musculoskeletal System 307

P a t t e rn s P h ys ic a l S ig n s

Ch ro n ic Ba ck S t iffn 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

No c t u rn a l Ba ck P a in ,
Un re 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 fe r re d f ro m t h e
Ab 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.

Lo w Ba ck Pa in (continued )Table 16-3

308 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

Ac ro m io c la v ic u la r Ar 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 Cu 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.

Pa in fu l S h o u ld e rsTable 16-4

Chapter 16 | The Musculoskeletal System 309

Iliotibia l
band

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.

Prepa te lla r
bursa

Pes
anserine

Burs itis . Inflammation
and thickening of bursa
seen in repetitive motion
and overuse syndromes.
Can involve prepatellar
bursa (“housemaid’s
knee”), pes anserine bursa

medially (runners, osteoarthritis),
iliotibial band laterally (over lateral
femoral condyle), especially in runners.

Pa te lla
moves up

and la te ra l

Leg extends
and foot

ra ise s

Pate llofemoral 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.

La te ra l
meniscus

Media l
meniscus
torn

Meniscal tear. Commonly arises from
twisting injury of knee; in older patients
may be degenerative, often with
clicking, popping, or locking sensation.
Check for tenderness along joint line
over medial or lateral meniscus and for
effusion. May have associated tears of
medial collateral of anterior cruciate
ligaments.

Pa in fu l Kn e e sTable 16-5

(table continues on page 310)

310 Ba tes’ Pocket Guide to Phys ica l Examination and His tory Taking

Anterior
crucia te
ligament
torn

Anterior cruciate tear or sprain.
In twisting injuries of the knee, often
with popping sensation, immediate
swelling, pain with flexion/extension,
difficulty walking, and sensation of
knee “giving way.” Check for anterior
drawer sign, swelling of hemarthrosis,
injuries to medial meniscus or medial
collateral ligament. Consider evaluation
by an orthopedic surgeon.

Media l
colla te ra l
ligament
torn

Collateral ligament sprain or tear.
From force applied to medial or lateral
surface of knee (valgus or varus stress),
producing localized swelling, pain,
stiffness. Patients able to walk but
may develop an effusion. Check for
tenderness over affected ligament and
ligamentous laxity during valgus or
varus stress.

Baker
cys t

Pos te rior knee

Baker 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.

Pa in fu l Kn e e s (continued )Table 16-5

311

C H A P T E R

17The Nervous System

Fundamentals for Assessing
the Nervous System

A p p r o a c h t o A s s e s s m e n t
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 nd-
ings. 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 r v o u s S y s t e 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 rvo u s S ys t e m . The central nervous system (CNS) consists
of the brain and spinal cord.

Th e Bra 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 hypo-
thalamus, 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.

312 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

S p in a l Co rd . 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.

Pe rip h e ra l Ne rvo 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.

Cra n ia l Ne 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 ra l Ne 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 ( BC.

affected ear where BC > AC. See p. 125.

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.

Hoarseness in vocal cord paralysis; nasal
voice in paralysis of palate

Deviated uvula, palatal paralysis in CVA

Absent reflex is often normal.

Figure 17-4 Tes t trapezius s trength.

Atrophy, fasciculations, weakness

Weakness of sternocleidomastoid mus-
cle when head turns to opposite side

Sternocleidomastoid muscles. Assess
strength as head turns against your
hand.

Chapter 17 | The Nervous System 321

CN XII (Hyp o g lo s s a l). Listen
to patient’s articulation.

Inspect the resting tongue.

Inspect the protruded tongue.

/ T h e M o t o r
S y s t e m
Bo d y Po s it io n . Observe the
patient’s body position during
movement and at rest.

Invo lu n t a ry Mo ve m e n t s . If
present, observe location, qual-
ity, rate, rhythm, amplitude, and
setting.

Mu s c le Bu lk a n d To n e . Inspect
muscle contours.

Assess resistance to passive stretch
of arms and legs.

Dysarthria from damage to CN X or CN XII

Atrophy, fasciculations in ALS, polio

In a unilateral cortical lesion, the pro-
truded tongue deviates away from the
side of cortical lesion; in CN XII lesion,
tongue deviates to the weak side.

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

See Table 17-4, Motor Disorders, p. 340.

Hemiplegia in stroke

Tremors, fasciculations, tics, chorea,
athetosis, oral–facial dyskinesias. See
Table 17-5, Involuntary Movements,
p. 341.

Atrophy of bulk. See Table 17-6, Disor-
ders of Muscle Tone, p. 342.

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 De s c r ip t io n

No uscul r contr ction detected
1 A b rely detect ble tr ce of contr ction
2 Active ove ent with gr vity eli in ted
3 Active ove ent g inst gr vity
4 Active ove ent g inst gr vity nd so e resist nce
5 Active movement against full resistance (normal)

322 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

■ 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

■ Grip (C7, C8, T1)

■ Finger abduction (C8, T1, ulnar
nerve) (Fig. 17-5)

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Peripheral radial nerve damage; central
stroke or multiple sclerosis if hemiplegia

Weak grip in cervical radiculopathy, de
Quervain tenosynovitis, carpal tunnel
syndrome

Figure 17-5 Tes t finge r abduction.

Weak in ulnar nerve disorders

Figure 17-6 Test opposition of the
thumb.

Weak in carpal tunnel syndrome■ Thumb opposition (C8, T1)—
median nerve (Fig. 17-6)

■ Trunk— exion extension,
lateral bending

Chapter 17 | The Nervous System 323

Figure 17-8 Tes t rapid alte rnating arm
movement.

■ / 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)—
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 alter-
nating movements in hands (tap
ngers), arms, and legs (tap foot)
(Fig. 17-8)

Figure 17-7 Tes t hip flexion.

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Clumsy, slow movements in cerebellar
disease

324 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

Point-to-point movements in arms
and legs— nger-to-nose, heel-to-
shin

Ga it . Ask patient to:

■ Walk away, turn, and come back

■ Walk heel-to-toe

■ Walk on toes, then on heels

■ Hop in place on each foot; do
one-leg shallow knee bends.
Substitute rising from a chair
and climbing on a stool for hops
and bends as indicated.

S t a n c e
■ 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).

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Figure 17-9 Tes t for pronator drift. Figure 17-10 Pos itive tes 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

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 lat-
eral corticospinal tract lesion (Fig. 17-10)

Proximal hip girdle weakness increases
risk of falls.

Clumsy, unsteady movements in
cerebellar disease

CVA, cerebellar ataxia, parkinsonism,
or loss of position sense may affect
performance.

Ataxia

Corticospinal tract injury

Chapter 17 | The Nervous System 325

/ T h e S e n s o r y S y s t e m

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

“Glove-and-stocking”loss of peripheral
neuropathy, often seen in alcoholism
and diabetes

See Table 17-7, Dermatomes, pp. 343–
344.

Dermatomal sensory loss in herpes

Analgesia, hypalgesia, hyperalgesia

Temperature and pain sensation usually
correlate.

Anesthesia, hyperesthesia

Loss of vibration and position senses in
peripheral neuropathy from diabetes or
alcoholism and in posterior column dis-
ease from tertiary syphilis or vitamin B12
deficiency

A hemisensory loss pattern suggests a
contralateral cortical lesion.

Use an object like a sharp pin or
stick portion of a broken cotton
swab to test sharp and dull sensa-
tion; compare symmetric areas on the
two sides of the body. Do not reuse
the object on another patient.

Compare proximal and distal areas
of arms and legs for pain, tempera-
ture, and touch sensation. Scatter
stimuli to sample most dermatomes
and major peripheral nerves.

Map any area of abnormal
response, including dermatomes,
if present.

Assess response to the following
stimuli, with the patient’s eyes
closed.

■ Pain. Use the sharp end of a pin
or other suitable tool. The dull
end serves as a control.

■ Temperature (if indicated). Use
test tubes with hot and cold
water, or other objects of suit-
able temperature.

■ Light touch. Use a ne wisp of
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.

326 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

■ Proprioception (joint position
sense). Holding patient’s nger or
big toe by its sides, move it up
or down (Fig. 17-12).

Figure 17-12 Tes t proprioception.

Assess discriminative sensations:

■ Stereognosis. Ask for identi ca-
tion of a common object placed
in patient’s hand.

■ 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 dis-
tance on pad of patient’s nger at
which two points can be distin-
guished (normally leg
weakness, sensory loss, field
cut, aphasia (left MCA) or
neglect, apraxia (right MCA)

Anterior circulation—middle cerebral
artery (MCA)
Largest vascular bed for stroke

Contralateral motor or
sensory deficit without
cortical signs

Subcortical circulation—lenticulostriate
deep penetrating branches of MCA
Small vessel subcortical lacunar infarcts
in internal capsule, thalamus, or
brainstem. Four common syndromes:
pure motor hemiparesis; pure sensory
hemianesthesia; ataxic hemiparesis;
clumsy hand—dysarthria syndrome

Contralateral field cut Posterior circulation—posterior
cerebral artery (PCA)
Includes paired vertebral arteries, the
basilar artery, paired posterior cerebral
arteries. Bilateral PCA infarction
causes cortical blindness but
preserved pupillary light reaction.

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

Ma jo r Clin ic a l Fe a t u re s Va s c u la r Te r r it o ry

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.

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 ke (c o n t in u e d )

Chapter 17 | The Nervous System 337

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.

Dis o rd e rs o f S p e e chTable 17-2

(table continues on page 338)

338 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

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 rn ick e Ap h a s ia Bro c a Ap h a s ia

Qu a lit ie s o f
S p o n t a n e o u s
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 rd
Co m p re h e n s io n

Impaired Fair to good

Re p e t it io n Impaired Impaired

Na m in g Impaired Impaired, though the
patient recognizes
objects

Re a d in g
Co m p re h e n s io n

Impaired Fair to good

Writ 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.

Dis o rd e rs o f S p e e ch (continued )Table 17-2

Chapter 17 | The Nervous System 339

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.

CN VII—P e r ip h e ra l Le s io n CN VII—Ce n t ra l Le s io n

Peripheral nerve damage to CN VII
paralyzes the entire right side of
the face, including the forehead.

Motor
cortex

Synapses
in the pons

Facial
nerve

CN VII
pe riphe ral

le s ion

Motor cortex

Synapses in
the pons

Facial nerve

CN VII
c e ntral
le s ion

Eye does
not close;

eyeball rolls up

Flat nasolabial
fold

Clos ing Eye s

Eye closes ;
perhaps with

s light weakness

Flat nasolabia l
fold

Clos ing Eye s

Forehead
not wrinkled;

eyebrow not raised

Paralys is of
lower face

Rais ing Eye brows

Smiling

Forehead wrinkled;
eyebrow raised

Paralys is of
lower face

Rais ing Eye brows

Smiling

Typ e s o f Fa c ia l Pa ra lys isTable 17-3

340 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

P e r ip h e ra l
Ne r vo u s
S ys t e m
Dis o rd e r

Ce n t ra l
Ne r vo u s
S ys t e m
Dis o rd e r a

P a rk in s o n is m
(Ba s a l
Ga n g lia
Dis o rd e r )

Ce re b e lla r
D is o rd e r

In vo lu n t a ry
m o ve m e n t s

Often
fascicu lations

No fascicu-
lations

Resting tremors Intention
tremors

Mu s c le
b u lk

Atrophy Normal or
mild
atrophy
(disuse)

Normal Normal

Mu s c le
t o n e

Decreased or
absent

Increased,
spastic

Increased, rigid Decreased

Mu s c le
s t re n g t h

Decreased or
lost

Decreased
or lost

Normal or
slightly decreased

Normal or
slightly
decreased

Co o rd in a –
t io n

Unimpaired,
though
limited by
weakness

Slowed and
limited by
weakness

Good, though
slowed and often
tremulous

Impaired,
ataxic

Re f le xe s

Deep tendon Decreased or
absent

Increased Normal or
decreased

Normal or
decreased

Plan ta r Flexor or
absent

Extensor Flexor Flexor

Abdom inals Absent Absent Normal Normal

Mo t o r Dis o rd e rsTable 17-4

aUpper motor neuron.

Chapter 17 | The Nervous System 341

Resting s tatic tremors . Fine,
“pill-rolling” tremor seen at rest, usually
disappear with movement; seen in basal
ganglia disorders like Parkinson disease.

Postural tremor. Seen when
maintaining active posture; in anxiety,
hyperthyroidism; also familial. From
basal ganglia disorder.

Intention tremor. Seen with
intentional movement, absent at rest; in
cerebellar disorders, including multiple
sclerosis

Fasciculations. Fine, rapid flickering of
muscle bundles in lower motor neuron
disorders.

Chorea. Brief, rapid, irregular, jerky;
face, head, arms, or hands (e.g.,
Huntington disease)

Athetos is . Slow, twisting, writhing;
face, distal limbs, often with associated
spasticity (e.g., cerebral palsy)

Invo lu n t a ry Mo ve m e n t sTable 17-5

342 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

S p a s t ic it y Rig id it y

Location. Upper motor neuron or
corticospinal tract systems.

Location. Basal ganglia system

Description. Increased muscle
tone (hypertonia) that is rate-
dependent. Tone is greater when
passive movement is rapid, and
less when passive movement is
slow. Tone is also greater at the
extremes of the movement arc.
During rapid passive movement,
initial hypertonia may give way
suddenly as the limb relaxes. This
spastic “catch” and relaxation is
known as “clasp-knife” resistance.

Description. Increased resistance
that persists throughout the
movement arc, independent of
rate of movement, is called lead-
pipe rigidity. With flexion and
extension of the wrist or forearm,
a superimposed ratchet-like
jerkiness is called cogwheel rigidity.

Common Cause . Stroke,
especially late or chronic stage

Common Cause . Parkinsonism

Fla c c id it y P a ra t o n ia

Location. Lower motor neuron at
any point from the anterior horn
cell to the peripheral nerves

Location. Both hemispheres,
usually in the frontal lobes

Description. Loss of muscle tone
(hypotonia), causing the limb to be
loose or floppy. The affected limbs
may be hyperextensible or even
flail-like.

Description. Sudden changes
in tone with passive range of
motion. Sudden loss of tone that
increases the ease of motion is
called mitgehen (moving with).
Sudden increase in tone making
motion more difficult is called
gegenhalten (holding against).

Common Cause . Guillain–
Barré syndrome; also initial phase
of spinal cord injury (spinal shock)
or stroke

Common Cause . Dementia

Dis o rd e rs o f Mu s c le To n eTable 17-6

Chapter 17 | The Nervous System 343

C3 Front of neck

C5 C5

C6 C6

C7 C7

C8 C8

T1
T1

T5
T6
T7
T8
T9

T10

T11

T12

S1 S1

S2,3

L1
L2 L2

L3 L3

L4 L4

L5 L5

C8 Ring and
little fingers

L4 Knee

L1 Inguina l

L5 Ante rior
ankle and foot

T4 Nipples

T10 Umbilicus

De rm a t o m e sTable 17-7

Dermatomes Innervated by Posterior Roots

(table continues on page 344)

344 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

De rm a t o m e s (continued )Table 17-7

C3C3 Back of neck

C5C5

C6C6

C6
Thumb

C7C7

C8C8

T1T1

T2
T3
T4
T5
T6
T7
T8
T9

T10
T11
T12

S1S1

S2S2

S3
S4

L1
L2
L3
L4

L4L4

L4, L5, S1
Pos te rior ankle

and foot

L5L5

C8 Ring and
little fingersS5 Periana l

Dermatomes Innervated by Posterior Roots

Chapter 17 | The Nervous System 345

To xic –Me t a b o lic S t ru c t u ra l

P a t h o p h ys 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.

Clin ic a l Fe a t u re s
■ Resp ira to ry pa tte rn . If

regular, may be normal or
hyperventilation. If irregular,
usually Cheyne–Stokes

■ Pup illa ry s ize and react ion .
Equal, reactive to light. If
pinpoint from opiates or
cholinergics, you may need a
magnifying glass to see the
reaction.
May be unreactive if fixed and
dilated from anticholinergics or
hypothermia

■ Leve l o f consciousness .
Changes after pupils change

Resp ira to ry pa tte rn . Irregular,
especially Cheyne–Stokes or
ataxic breathing. Also with
selected stereotypical patterns like
“apneustic” respiration (peak
inspiratory arrest) or central
hyperventilation.
Pup illa ry s ize and react ion .
Unequal or unreactive to light
(fixed)

Midposition, fixed—suggests
midbrain compression
Dilated, fixed—suggests
compression of CN III from
herniation

Leve l o f consciousness .
Changes before pupils change

Exa m p le s o f Ca 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

Me t a b o lic a n d S t ru c t u ra l Co m aTable 17-8

346 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

Ac t iv it y S c o re

Eye Op 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

Mo 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 rb 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

Gla s g o w Co m a Sc a leTable 17-9

aInterpretation: 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.

Chapter 17 | The Nervous System 347

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.

Mid 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 rg 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 atropine-
like agents, phenothiazines, or
tricyclic antidepressants.

On e La rg 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.

Pu p ils in Co m a t o s e Pa t ie n t sTable 17-10

349

C H A P T E R

18Assessing Children:
Infancy through Adolescence

Child Development
Children display tremendous variations in physical, cognitive, and social
development compared with adults.

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 school-
teacher, 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.

The Health History

Ke 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.

350 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

H is t o r y
Bir t h His t o ry. This is especially important when neurologic or develop-
mental 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 undernutri-
tion 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 re 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 . Each child and family is unique; therefore, such recommen-
dations 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 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

■ Prevention of risky behaviors and addictions

■ School and vocation

■ Peer relationships

■ Community interactions

7. Partnership between health provider, child, and family

Im m e d ia t e A s s e s s m e n t a t B ir t h

Assessing Newborns
EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

If the 5-minute score is 8 or more, pro-
ceed to a more complete examination.

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 in tion v ries ccording to the child’s ge nd co fort
level.

● 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 .

Listen to the anterior thorax with
your stethoscope. Palpate the abdo-
men. Inspect the head, face, oral
cavity, extremities, genitalia, and
perineum.

Ap g a r Sc o re . Score each new-
born 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.

Chapter 18 | Assessing Children: Infancy through Adolescence 353

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).

T h e A p g a r S c o r in g S y s t e m

As s ig n e d S c o re

Clin ic a l S ig n 0 1 2

Heart rate Absent 1
Respiratory
effort

Absent Slow nd
irregul r

Good; strong

Muscle tone Fl ccid So e flexion of
the r s nd
legs

Active ove ent

Reflex
irritabilitya

No res onses Gri ce Crying vigorously,
sneeze, or cough

Color Blue, le Pink body, blue
extre ities

Pink ll over

1-Min u t e Ap g a r S c o re 5 -Min u t e Ap g a r S c o re

8–1 Nor l 8–1 Nor l
5–7

–4

So e nervous sys-
te de ression

Severe de ression,
requiring i edi-
te resuscit tion

–7 High risk for subse-
quent centr l ner-
vous syste nd
other org n sys-
te dysfunction

aRe ction to suction of n res with bulb syringe.

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

Ge s t a t io n a l Ag e

Cla s s if ic a t io n Ge s t a t io n a l Ag e

Preterm
Late preterm
Term
Postterm

42 wks

Bir t h We ig h t

Cla 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, g
<1,5 g
<2,5 g
≥2,5 g

354 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

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

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

N e w b o r n C la s s if ic a t io n s

Ca t e g o ry Ab b re via t io n Pe rc e n t ile

Small for gestational age SGA 9 th

Most newborns are bowlegged, reflect-
ing their curled up intrauterine position.

A single umbilical artery may be associ-
ated with congenital anomalies. Umbili-
cal hernias in infants are from a defect in
the abdominal wall.

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.

During the rst day of life,
newborns should have a compre-
hensive 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.

Inspect the newborn’s umbilical cord
to detect abnormalities. Normally,
there are two thick-walled umbili-
cal arteries and one larger but
thin-walled umbilical vein, which
is usually located at the 12-o’clock
position.

The neurologic screening examina-
tion of all newborns should include
assessment of mental status, gross
and ne motor function, tone, cry,
deep tendon re exes, and primitive
re exes.

Chapter 18 | Assessing Children: Infancy through Adolescence 355

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Assessing Infants

M e n t a l a n d P h y s ic a l S t a t u s
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.

Failure to thrive is a condition reflecting
significantly low weight gain (e.g., below
2nd percentile) for gestational-age cor-
rected age and sex. Causes can be envi-
ronmental or psychosocial, or various
gastrointestinal, neurologic, cardiac,
endocrine, renal, and other diseases.

Measures above the 97th or below the
3rd percentile, or recent rises or falls
from prior levels, require investigation.

Reduced growth in height may indicate
endocrine disease, other causes of short
sta ture, or, if weight is also low, other
chronic diseases.

Premature closure of the sutures or
microcephaly may cause small head size.
Hydrocephalus, subdural hematoma, or,
rarely, brain tumor or inherited syn-
dromes may cause an abnormally large
head size.

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 attain-
ment of developmental milestones,
optimally using a standardized
developmental screening test.

G e n e r a l S u r v e y
Growth, re ected in increases in
height and weight within expected
limits, is an excellent indicator of
health during infancy and child-
hood. Deviations from normal may
be early indications of an underly-
ing problem. To assess growth,
compare a child’s parameters with
respect to:

■ Normal values according to age
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 stan-
dard growth charts to determine
progress.

He a d Circ u m fe re n c e . Deter-
mine head circumference at every
physical examination during the
rst 2 years (Fig. 18-1).

356 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Figure 18-1 Head circumference is a
vital metric during early 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. Figure 18-2 Practice is required to

accurate ly measure blood pressure in
early 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 rn Mid d le Ch 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 ry hy ertension

Ren l renchy l or rteri l dise se
Co rct tion of the ort

In fa n c y a n d Ea r ly Ch 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.

Tachycardia (>180–200 beats per min-
ute) usually indicates paroxysmal supra-
ventricular tachycardia . Bradycardia may
result from serious underlying disease.

Chapter 18 | Assessing Children: Infancy through Adolescence 357

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Re s p ira t o ry Ra t e . The respira-
tory rate has a very wide range and
is more responsive to illness, exer-
cise, and emotion than in adults.

T h e S k in
Assess:

■ Texture and appearance

■ Vasomotor changes

■ Pigmentation (e.g., Mongolian
spots)

■ Hair (e.g., lanugo)

■ Common skin conditions (e.g.,
milia, erythema toxicum)

■ Color

■ Turgor

T h e H e a d
Examine sutures and fontanelles
carefully (Fig. 18-3).

Respiratory diseases such as bronchiolitis
or pneumonia may cause rapid respira-
tions (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.

Cutis marmorata

Acrocyanosis; cyanotic congenital heart
disease

Café-au-lait spots

Midline hair tuft on back

Herpes simplex

Jaundice can be from hemolytic disease.

Dehydration

Head small with microcephaly, enlarged
with hydrocephaly; fontanelles full and
tense with meningitis, closed with micro-
cephaly, separated with increased intra-
cranial pressure (hydrocephaly, subdural
hematoma, and brain tumor)

Swelling from subperiosteal hemor-
rhage (cephalohematoma) does not
cross suture lines; swelling from bleed-
ing associated with a fracture does.

Ante rior fontane lle

Pos te rior fontane lle

Lambdoida l suture

Sagitta l
suture

Corona l
suture

Metopic
suture

Figure 18-3 Suture s and fontane lle s .

358 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

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 syn-
dromes can cause abnormal facies (see
box below for evaluation). Examples
include Down syndrome and fetal a lcohol
syndrome.

T h e E y 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.

Normal visual milestones are as
follows:

Nystagmus, strabismus

Leukocoria is a white papillary reflex
(instead of the normal red papillary
reflex). It can be a sign of a rare tumor
called retinoblastoma.

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.

V is u a l M ile s t o n e s o f In f a n c y

Birth Blinks, y reg rd f ce
1 month Fixes on objects
1½–2 months Coordin ted eye ove ents
3 months Eyes converge, b by re ches
12 months Acuity round 2 /6 –2 /8

Chapter 18 | Assessing Children: Infancy through Adolescence 359

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

T h e E a 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

2–3 months 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

3–4 months Turning to listen to voices nd convers tion
6–7 months A ro ri te l ngu ge develo ent

T h 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 a tresia , the baby cannot
breathe if one nostril is occluded.

Supernumerary teeth, Epstein pearls

Oral candidiasis (thrush)

Vesicles in the mouth can be caused
by enteroviral infections and herpes
simplex virus infections.

Lymphadenopathy is usually from viral or
bacterial infections.

Other neck masses include malignancy,
branchia l cleft or thyroglossa l duct cysts,
and periauricular cysts and sinuses.

T h 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.

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.

T h 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.

360 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Preauricular cys t

Parotid nodes

Occipital node

Retroauricular
(mas toid) nodes

Superior deep
cervical nodes

Middle deep
cervical nodes

Pos terior
cervical nodes

Epidermoid cys t

J ugulogas tric
node

Submandibular
node

Submental
node

Thyroglossal
duct cys t

Cys tic hygroma

Anterior
cervical nodes

Inferior deep
cervical nodes

Supraclavicular
node

2nd branchial
cleft cys t

Figure 18-4 Nodes and cys ts of the head
and neck.

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 Po s s ib le Fin d in g s Exp la n a t io n

General appear-
ance

In bility to feed or s ile
L ck of consol bility

Lower respiratory infections
(e.g., bronchiolitis, pneumo-
nia) re co on in inf nts.

Respiratory rate T chy ne C rdi c or res ir tory dise se
(e.g., neu oni )

Color P llor or cy nosis C rdi c or ul on ry dise se
Nasal compo-

nent of
breathing

N s l fl ring (enl rge ent
of both n s l o enings
during ins ir tion)

U er or lower res ir tory
infection

(continued )

T h e T h o r a x a n d Lu n g s
Apnea

Upper respiratory infections may cause
nasal flaring.

Carefully assess respirations and
breathing pattern.

Do not rush to the stethoscope, but
observe the patient carefully rst.

Chapter 18 | Assessing Children: Infancy through Adolescence 361

Auscultate the chest, and try to dis-
tinguish upper airway from lower
airway sounds.

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

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 Po s s ib le Fin d in g s Exp 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)

Lower res ir tory dise se

Asth or bronchiolitis

Crou , e iglottitis, b cteri l
tr cheitis

Foreign body

Work of breath-
ing

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)

In inf nts, bnor l work of
bre thing co bined with
bnor l findings on us-
cult tion is the best finding
for ruling in pneumonia.

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 ch n iq u e Up p e r Airw a y Lo w e r Airw a y

Compare sounds from
nose/ stethoscope

S e sounds Often different
sounds

Listen to harshness of
sounds

H rsh nd loud V ri ble

Note symmetry (left/right) Sy etric Often sy etric
Compare sounds at differ-

ent locations (higher or
lower)

Sounds louder s stetho-
sco e is oved u
chest

Sounds louder lower
in chest

Inspiratory vs. expiratory Al ost lw ys ins ir –
tory

Often h s ex ir tory
h se

362 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

T h 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.

Pa 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.

Au s c u lt a t io n . Heart rhythm is
evaluated more easily in infants by
listening to the heart than by feel-
ing the peripheral pulses.

Evaluate S1 and S2 carefully. They
are normally crisp with intermit-
tent splitting of S1 and S2 (fused in
expiration).

Listen for heart murmurs. Two
common benign systolic mur-
murs are from a closing ductus
or peripheral pulmonary ow
murmur.

T h 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.

T h 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.

At birth: Transposition of the great arter-
ies; pulmonary valve atresia or stenosis

Within a few days of birth: The above;
also total anomalous pulmonary venous
return, hypoplastic left heart

No or diminished femoral pulses suggest
coarcta tion of the aorta . Weak or thready,
difficult-to-feel pulses may reflect myo-
cardia l dysfunction and heart fa ilure.

The most common dysrhythmia in chil-
dren is paroxysmal supraventricular
tachycardia .

A louder-than-normal pulmonic compo-
nent suggests pulmonary hypertension.
Persistent splitting of S2 may indicate
atria l septal defect.

Most infants with cardiac pathology
have signs beyond heart murmurs.

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.

Chapter 18 | Assessing Children: Infancy through Adolescence 363

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

M a le G e n it a lia
Inspect with the infant supine. The
foreskin of a newborn is nonre-
tractable at birth or just enough to
visualize the urethral meatus.

In 3% of infants, one or both testes
cannot be felt in the scrotum or
inguinal canal. Try to milk the tes-
tes into the scrotum.

Fe m a le G e n it a lia
In females, genitalia may be promi-
nent for several months after birth
from the effects of maternal estrogen.

Common scrotal masses are hydroceles
and inguinal hernias.

Inability to palpate testes, even with
maneuvers, indicates undescended
testicles.

Ambiguous genita lia involves masculin-
ization of the female external genitalia.

Skin tags, remnants of digits, polydactyly
(extra fingers), or syndactyly (webbed
fingers) are congenital defects. Fracture
of the clavicle can occur during a difficult
delivery.

Figure 18-5 Ortolani te s t, ove rhead
view.

Figure 18-6 Barlow tes t, overhead
view.

Congenital hip dysplasia may have a
positive Ortolani or Barlow test, particu-
larly during the first 3 months of age.
With a hip dysplasia , you feel a “clunk.”

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 inspec-
tion and palpation to detect congen-
ital abnormalities, particularly in the
hands, spine, hips, legs, and feet.

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 Fig-
ure 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.

364 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Some normal infants exhibit twist-
ing or torsion of the tibia inwardly
or outwardly on its longitudinal
axis.

T h e N e r v o u s S y s t e m
Evaluate the developing central
nervous system by assessing infan-
tile automatisms, called primitive
re exes.

Neurologic abnormalities in
infants often present as develop-
mental abnormalities such
as failure to do age-appropriate
tasks.

Pathologic tibial torsion occurs only in
association with deformities of the feet or
hips.

Suspect a neurologic or developmenta l
abnormality if primitive reflexes are
absent at appropriate age, present lon-
ger than normal, asymmetric, or associ-
ated with posturing or twitching.

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 r-
tici 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.

Chapter 18 | Assessing Children: Infancy through Adolescence 365

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

In children age 1 to 5 years, observe
the degree of sickness or wellness,
mood, nutritional state, speech,
cry, facial expression, and devel-
opmental skills. Note parent–child
interaction, including separation
tolerance, affection, and response
to discipline.

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.

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.

Blo o d P re s s u re . Hypertension
during childhood is more common
than previously thought. Recogniz-
ing, 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.

T h e E y e s
Test visual acuity in each eye and
determine whether the gaze is
conjugate or symmetric.

This overall examination can uncover evi-
dence of chronic disease, developmental
delay, social or environmental disorders,
and family problems.

Observing children performing tasks can
reveal signs of inattentiveness or impul-
sivity, which may indicate attention defi-
cit disorder.

Underweight is 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 tchy, dry skin over extern l
surf ce of elbows.

HEENT. 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 .

Ne ck . Su le, idline tr che , no thyroid l ble.

Lym p h No 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.

Ca rd 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.

Bre a s t s . Nor l, with so e f t under both.

Ab d o m e n . Protuber nt but soft; no sses or tenderness. Liver s n 2 c
below right cost l rgin (RCM) nd not tender. S leen nd kidneys not
l ble.

Ge n it a lia . T nner I circu cised enis; no ubic h ir, lesions, or disch rge.
Testes descended, difficult to l te bec use of ctive cre steric reflex.
Nor l scrotu both sides.

Mu s c u lo s k e le t a l. Nor l r nge of otion of u er nd lower extre ities
nd ll joints. S ine str ight . G it nor l.

Ne u ro lo g ic . Mental Status: H 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.

Chapter 18 | Assessing Children: Infancy through Adolescence 373

Aids to Interpretation

25 27 29 31 33 35 37 39 41 43 45

4.5

3.5

2.5

1.5

0.5

90%

10%

(

)

Weeks of Ges ta tion

Large for ges ta tiona l age

Appropria te
for ges ta tiona l age

Small for
ges ta tiona l age

Premature Term Pos tmature

A B

Intrauterine Growth Curve s

Weight Small for Gestational Age (SGA) = Birth weight 90th percentile
on the intrauterine growth curve

Cla s s if ic a t io n o f Ne w b o rn ’s
Leve l o f Ma t u rit y

Table 18-1

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 Ba tes’ Pocke t Guide to Physica l Examina tion and His tory Taking

Hypertension can start in childhood. Although young children with
elevated blood pressure are more likely to have a renal, cardiac, or
endocrine cause older children and adolescents with hypertension are
most likely to have primary or essential hypertension. Hypertension is
often related to obesity.
This child developed hypertension before adolescence, and it “tracked”
into adulthood. Children tend to remain in the same percentile for blood
pressure as they grow. This tracking of blood pressure continues into
adulthood, supporting the concept that adult essential hypertension
begins during childhood.
The consequences of untreated hypertension can be severe.

90
0 1 2 3 4 5 6 7 8 9

Age (Years )

Boys Sys tolic Blood Pressure 95% Percentile

Sys tolic 5%

10 11 12 13 14 15 16 17

120

150

95
100
105
110
115

125
130
135
140
145

Sys tolic 50% Sys tolic 95% Patient

Hyp e r t e n s io n in Ch ild h o o dTable 18-2

Chapter 18 | Assessing Children: Infancy through Adolescence 375

Co n g e n it a l De fe c t Ch a ra c t e r is t ic s o f Mu rm u r

P u lm o n a ry Va lve S t e n o s is

Mild
S 1 A2

P 2

Location. Upper left sternal border
Radiation. In mild degrees of
stenosis, the murmur may be heard
over the course of the pulmonary
arteries in the lung fields.
Intensity. Increases in intensity and
duration as the degree of
obstruction increases

Severe
S 1 A2

P 2

Quality. Ejection, peaking later in
systole as the obstruction increases

Ao r t ic Va lve S t e n o s is
S 1 A2

P 2

Location. Midsternum, upper right
sternal border
Radiation. To the carotid arteries
and suprasternal notch; may also
be a thrill
Intensity. Varies, louder with
increasingly severe obstruction
Quality. An ejection, often harsh,
systolic murmur

Te t ra lo g y o f Fa llo t General. Variable cyanosis,
increasing with activity

With Pu lm onic S tenos 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 onic Atres ia
S 1 A2 S 1

Radiation. Little, to upper left sternal
border, occasionally to lung fields
Intensity. Usually grade III–IV
Quality. Midpeaking, systolic
ejection murmur

Ch a ra c t e ris t ic s o f Pa t h o lo g ic
He a r t Mu rm u rs

Table 18-3

(table continues on page 376)

376 Ba tes’ Pocke t Guide to Physica l Examina tion and His tory Taking

Co n g e n it a l De fe c t Ch a ra c t e r is t ic s o f Mu rm u r

Tra n s p o s it io n o f t h e
Gre a t Ar 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 De fe c t Location. Lower left sternal border

Sm all to Modera te
S 1 A2 P 2

Radiation. Little
Intensity. Variable, only partially
determined by the size of the
shunt. Small shunts with a high-
pressure gradient may have very
loud murmurs. Large defects with
elevated pulmonary vascular
resistance may have no murmur.
Grade II–IV/VI, with a thrill if
grade IV/VI or higher.

Ch a ra c t e ris t ic s o f Pa t h o lo g ic
He a r t Mu rm u rs (continued )

Table 18-3

Chapter 18 | Assessing Children: Infancy through Adolescence 377

S t a g e 1

Preadolescent—elevation of nipple only

S t a g e 2 S t a g e 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

S t a g e 4 S t a g e 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).

S ex Ma t u rit y Ra t in g s in Girls : Bre a s t sTable 18-4

Photos reprinted, with permission from the American Academy of Pediatrics, Assessment of
Sexual Maturity Stages in Girls, 1995.

378 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

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.

S t a g e 1 Pubic Hair: Preadolescent—no pubic hair
except for the fine body hair (vellus hair)
similar to that on the abdomen
Genitalia
■ Penis, Testes, and Scrotum:

Preadolescent—same size and
proportions as in childhood

S t a g e 2 Pubic Hair: Sparse growth of long, slightly
pigmented, downy hair, straight or only
slightly curled, chiefly at the base of the
penis
Genitalia
■ Penis: Slight to no enlargement
■ Testes and Scrotum: Testes larger;

scrotum larger, somewhat reddened, and
altered in texture

S t a g e 3 Pubic Hair: Darker, coarser, curlier hair
spreading sparsely over the pubic symphysis
Genitalia
■ Penis: Larger, especially in length
■ Testes and Scrotum: Further enlarged

Sex Ma t u rit y Ra t in g s in Bo ysTable 18-5

Chapter 18 | Assessing Children: Infancy through Adolescence 379

S t a g e 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
■ Penis: Further enlarged in length and

breadth, with development of the glans
■ Testes and Scrotum: Further enlarged;

scrotal skin darkened

S t a g e 5 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

S ex Ma t u rit y Ra t in g s in Bo ys (continued )Table 18-5

Photos reprinted from Pediatric Endocrinology and Growth, 2nd ed., Wales & Wit, 2003, with
permission from Elsevier.

380 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

S t a g e 1 Preadolescent—no pubic hair except for
the fine body hair (vellus hair) similar to
that on the abdomen

S t a g e 2 Sparse growth of long, slightly pigmented,
downy hair, straight or only slightly
curled, chiefly along the labia

S t a g e 3 Darker, coarser, curlier hair, spreading
sparsely over the pubic symphysis

S t a g e 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

S t a g e 5 Hair adult in quantity and quality, spread
on the medial surfaces of the thighs but
not up over the abdomen

Sex Ma t u rit y Ra t in g s in Girls : Pu b ic Ha irTable 18-6

Photos reprinted, with permission from the American Academy of Pediatrics, Assessment of Sexual
Maturity Stages in Girls, 1995.

Chapter 18 | Assessing Children: Infancy through Adolescence 381

P h ys ic a l S ig n s Th a t Ma y In d ic a t e S e xu a l Ab u s e in
Ch ild re 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 ys 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 xu a l Ab u s e in
Ch ild re 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.

P hys ic a l S ig n s o f Sexu a l Ab u s eTable 18-7

aAny physical sign must be evaluated in light of the entire history, other parts of the physical
examination, and laboratory data.

383

C H A P T E R

19The Pregnant Woman

The Health History

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 commit-
ment to the patient’s health and any ongoing concerns, review your nd-
ings, 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 fre-
quency? Explain that serum or urine testing for beta human chorionic
gonadotropin (HCG) offers the best con rmation of pregnancy.

C o m m o n C o n c e r n s

● 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

384 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

■ 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 compli-
cations 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-the-
counter drugs, or herbal prescriptions? Does she have any toxic expo-
sures 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 dat-
ing 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

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 physi-
cal 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 pres-
sure and weight), fundal height, veri cation of FHR, and fetal position and
activity. At each visit, test the urine for infection and protein.

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 dis-
tinct 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 1 ye 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 ri-
ties, 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.

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 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

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 Choose-
MyPlate.gov website (http://www.choosemyplate.gov/pregnancy-weight-
gain-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
BMIa

To t a l We ig h t
Ga in (Ra n g e

in lb s )

Ra t e s o f We ig h t Ga in b
2 n d a n d 3 rd Trim e s t e r s

(lb s /w k ) Me a n Ra n g e

Underweight, or 14 or di stolic
blood ressure (DBP) >9 first docu ented fter 2 weeks, without rotein-
uri 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 fol-
lowing: thro bocyto eni ( l telets 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.

H e 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.

■ Hair

■ Eyes. Note the conjunctival
color.

■ Nose, including nasal congestion

■ Mouth

■ Thyroid gland. Inspect and
palpate. Modest symmetric
enlargement is common.

Facial edema after 20 weeks in possible
preeclampsia

Hair loss should not be attributed to
pregnancy.

Anemia of pregnancy may cause con-
junctival pallor.

Nosebleeds are more common during
pregnancy. Erosion of nasal septum if
use of intranasal cocaine.

Gingival enlargement common

Thyroid enlargement, goiters, and nod-
ules are abnormal and should be investi-
gated.

Chapter 19 | The Pregnant Woman 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.

H e a r t
Palpate the apical impulse.

Auscultate the heart. A venous
hum and systolic or continuous
mammary souf e (see p. 185) are
common.

B r e a s t s
Inspect the breasts and nipples for
symmetry and color. Venous pat-
tern, darkened nipples and areolae,
and prominent Montgomery glands
are normal.

Palpate for masses. Tender nodular
breasts are normal.

Compress each nipple between
your index nger and thumb.

A b d o m e n
Place the pregnant woman in a
semisitting position with her knees
exed (Fig. 19-1).

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Respiratory alkalosis in later trimesters.
Increased respiratory rate, cough, rales,
or respiratory distress in infection,
asthma, pulmonary embolus, peripar-
tum cardiomyopathy.

Impulse may be rotated upward and to
the left toward the 4th intercostal space
by the enlarging uterus.

Murmurs may signal anemia; new dia-
stolic murmurs should be investigated.
If signs of heart failure, consider peripar-
tum cardiomyopathy.

Inverted nipples at the time of birth may
hamper breastfeeding.

Focal tenderness in mastitis. Investigate
any new discrete masses.

This may express colostrum from the
nipples; investigate if abnormal bloody
or purulent discharge.

Figure 19-1 The semis itting pos ition.

■ Inspect any scars or striae, the
shape and contour of the abdo-
men, and the fundal height.

Purplish striae and linea nigra are
normal.

392 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

■ Assess the shape and contour
to estimate pregnancy size
(Fig. 19-2).

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

36 wks
32 wks
28 wks
24 wks

20 wks

16 wks

12–14 wks

Figure 19-2 Growth patte rns of the
ute rine fundus by weeks of pregnancy.

■ Palpate for:

■ Organs and masses

■ Fetal movements, usually
detected after 24 weeks

■ Uterine contractility

■ Irregular contractions after
12 weeks or after palpation
during the third trimester

■ If woman is >20 weeks preg-
nant, measure fundal height
with a tape measure from the
top of the symphysis pubis to
the top of the uterine fundus.
After 20 weeks, measurement
in centimeters should roughly
equal the weeks of gestation.

■ Auscultate the fetal heart tones,
noting rate (FHR), location, and
rhythm. A Doptone detects the
FHR after 10 weeks. The FHR
is audible with a fetoscope after
18 weeks.

■ 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.

Ultrasound confirmation of fetal health
and movement may be needed.

Prior to 37 weeks, regular uterine
contractions or bleeding are abnormal,
suggesting preterm labor.

If fundal height is more than 4 cm higher
than expected, consider multiple gesta-
tion, 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.

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.

Chapter 19 | The Pregnant Woman 393

■ Rate. The rate usually is
120 to 160 beats per minute.
After 32 to 34 weeks, the
FHR should increase with
fetal movement.

■ Rhythm. In the third trimester,
expect a variance of 10 to
15 beats per minute (BPM)
over 1 to 2 minutes.

Sustained dips in FHR, or “decelerations,”
always warrant investigation, at least by
formal FHR monitoring.

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

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.

Palpate Bartholin and Skene glands.
Check for a cystocele or rectocele.

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 introi-
tus, 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.

Parous relaxation of the introitus, labial
varicosities, enlargement of the labia
and clitoris, scars from an episiotomy or
perineal lacerations

Bartholin cyst

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 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

■ 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.

■ Evaluate pelvic oor strength
as you withdraw the examining
ngers.

■ Inspect the anus. Rectal and
rectovaginal examinations are
usually not indicated.

E x t r e m it ie s
Inspect the legs for varicose veins.

Palpate the hands and legs for
edema.

Check knee and ankle deep tendon
re exes.

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

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 bicornuate uterus,
two distinct uterine cavities separated
by a septum.

Early in pregnancy, it is important to rule
out tubal (ectopic) pregnancy.

Hemorrhoids may engorge later in
pregnancy.

Varicose veins may worsen during
pregnancy.

Watch for swelling of preeclampsia or
deep venous thrombosis.

Hyperreflexia may signal preeclampsia.

Chapter 19 | The Pregnant Woman 395

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

■ 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
Po 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).

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

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.

Figure 19-3 Palpate uppe r fe tal pole .

Figure 19-4 Palpate fe tal back and
extremitie s .

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.

396 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

Th ird Ma n e u ve r (Lo w e r
Fe t a l Po le a n d De s c e n t
in t o Pe 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.

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Figure 19-5 Palpate lower fe tal pole .

Figure 19-6 Palpate for the cephalic
prominence .

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, iden-
tify 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.

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.”

Chapter 19 | The Pregnant Woman 397

■ 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), fol-
lowed 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 r e g n a n t W o m 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.)

399

C H A P T E R

20The 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 distin-
guish “usual” aging, with its complex of diseases and impairments, from
optimal aging. Optimal aging occurs in those people who escape debilitat-
ing 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 t ient’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 )

400 Ba tes ’ Pocke t Guide to Physica l Examina tion and His tory Taking

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 res-
sion 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.

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 Of c e Enviro 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 Pa 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.

The Health History

Chapter 20 | The Older Adult 401

Recognize the symptom clusters of different geriatric syndromes, character-
ized 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 Inter-
gency 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 mis-
diagnosis, 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.

C o m m o n C o n c e r n s

● 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 lli tive

c re

402 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

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 hys ic a l Ac t iv it ie s o f
Da ily Livin g (ADLs )

In s t ru m e n t a l Ac t iv it ie s o f
Da ily Livin g (IADLs )

B thing Using the tele hone
Dressing Sho ing
Toileting Pre ring food
Tr nsferring Housekee ing
Continence L undry
Feeding 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 pre-
scriptions. 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 indica-
tion for each drug. Explore all components of polypharmacy, including
concurrent use of multiple drugs, underuse, inappropriate use, and non-
adherence. 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 Pe rs is t e n t Pa 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 spe-
ci 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.

Chapter 20 | The Older Adult 403

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 self-
reported exhaustion.

Ad va n c e Dire c t ive s a n d Pa 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 speci-
fying 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.”

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 Pa in Pe r s is t e n t Pa in

Distinct onset L sts ore th n 3 onths
Obvious thology 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,

tr u , he d che
Co on c uses: rthritis, c ncer, cl udic tion,

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.

404 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

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.

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

● When to screen
● C ncer screening
● De ression, de enti , nd cognitive i ir ent
● Elder istre t ent nd buse

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 )

Chapter 20 | The Older Adult 405

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

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 ntigen-
b 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 ok-
ing 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.

406 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

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 aban-
donment. 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 Fu 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 per-
form 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, Pharma-
ceuticals, Excess urine output from conditions like hyperglycemia or heart

Chapter 20 | The Older Adult 407

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 re e n in g Me a s u re Po s it ive S c re 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?”

Yes to question nd
in bility to re d
>2 /4 on Snellen
ch rt

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.

In bility to he r 1, or
2, Hz in both e rs
or either of these
frequencies in one e r

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.”

Un ble to co lete t sk
in 15 seconds

Urinary incontinence: Two P rts:
Ask: “In the l st ye r, h ve you ever lost your

urine nd gotten wet?”

Yes to both questions

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 .

Yes to the question or
weight <1 lb

Memory: Three-ite rec ll Un ble to re e ber ll
three ite s fter
1 inute

Depression: Ask: “Do you often feel s d or
de ressed?”

Yes to the question

Physical disability: Six questions:
“Are you ble to . . . :
● “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?”

No to ny of the
questions

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.

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).

408 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

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 : Ke y Fe 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 o-

tension, 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.

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

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

Isolated systolic hypertension (SBP ≥140)
after age 50 years and PP ≥60 increase
risk of stroke, renal failure, and heart
disease.

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).

Fu r t h e r As s e s s m e n t fo r P re ve n t in g Fa lls . Compelling evidence
links falls, a multifactorial geriatric syndrome, to fatal and nonfatal inju-
ries, 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 bet-
ter assess, treat, and refer patients at risk. Also see Figure 20-1.

Chapter 20 | The Older Adult 409

Patient completes S tay
Independent brochure

YES to any key ques tion

No gait,
s trength, or

balance
problems*

NO to all
key

ques –
tions

Gait, s trength or balance problem

≥2 falls 1 fa ll

Injury No injury

0 falls

Conduc t
multifac torial

ris k as s e s s me nt

HIGH RISK
Individualize d fall

inte rve ntions

Fo llow up with HIGH
RISK patie nt within

30 days

MODERATE RISK
Individualize d fall

inte rve ntions

LOW RISK
Individualize d fall

inte rve ntions
L

*For these patients , cons ider additional risk assessment (e.g. medication review,
cognitive screen, syncope)

Sc re e n for falls and/or fall ris k
Patient answers YES to any key
ques tion:

– Were you injur

S tay
Independent

brochure

including:
– Pos tural
dizziness /pos tural
hypotens ion
– Medication review
– Cognitive screen
– Feet & footwear
– Use of mobility a ids
– Visual acuity check

Vitamin D +/– calc ium

enhance functional
mobility & improve
s trength & balance

hypotens ion
s
Address foot
problems
Optimize vis ion
Optimize home
safety

re p lan

fall risk reduction
behaviors
es s
barriers to
adherence

ans ition to
c ise
program when patient
is ready

medications
Vitamin D +/– calcium

improve gait,
s trength & balance

or
refer to a community
fall prevention
program

Vitamin D +/– calcium
ength &
cise
cise
or fall prevention
program

Evaluate gait, s tre ngth &
balanc e

(recommended)
)
s t (optional)

Figure 20-1 STEADI algorithm. Source : Cente rs for Disease Control and
Prevention. National Cente r for Injury Prevention and Control. STEADI—Stopping
Elderly Accidents , Deaths and Injuries . Available at http://www.cdc.gov/s teadi/pdf/
algorithm_2015–04-a . Accessed Augus t 23, 2015.

410 Ba tes’ Pocket Guide to Phys ica l Examination and His tory Taking

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.

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.

Weight and height are especially
important and needed for calcula-
tion of the BMI (p. 63). Weight
should be measured at every visit.
Obtain oxygen saturation using a
pulse oximeter.

S k in . Note physiologic changes
of aging, such as thinning, loss
of elastic tissue and turgor, and
wrinkling.

Inspect the extensor surface of the
hands and forearms.

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Orthostatic hypotension occurs in 10% to
20% of older adults and in up to 30% of
frail nursing home residents, especially
when they first arise in the morning.
Watch for lightheadedness, weakness,
unsteadiness, visual blurring, and, in
20% to 30% of patients, syncope.

Assess medications and causes such as
autonomic disorders, diabetes, prolonged
bed rest, volume depletion, amyloidosis,
postprandial state, and cardiovascular
disorders.

Respiratory rate ≥25 breaths per minute
indicates lower respiratory infection or
possible CHF or COPD.

Hypothermia is more common in elderly
patients.

Low weight is a key indicator of poor
nutrition.

Undernutrition in depression, alcohol-
ism, cognitive impairment, malignancy,
chronic organ failure (cardiac, renal,
pulmonary), medication use, poor
dentition, social isolation, and poverty

Dry, flaky, rough, and often itchy

Benign comedones, or blackheads, on
the cheeks or around the eyes; cherry
angiomas (p. 113); and seborrheic
keratoses (p. 112)

White depigmented patches (pseudos-
cars); well-demarcated, vividly purple
macules or patches that may fade after
several weeks (actinic purpura)

Chapter 20 | The Older Adult 411

Look for changes from sun expo-
sure: actinic lentigines, or “liver
spots,” and actinic keratoses, super-
cial attened papules covered by
a dry scale (p. 108).

Inspect for painful vesicular lesions
in a dermatomal distribution.

In older bedbound patients, espe-
cially when emaciated or neurolog-
ically impaired, inspect for damage
or ulceration.

HEENT. Inspect the eyelids, the
bony orbit, and the eye.

Test visual acuity, using a pocket
Snellen chart or wall-mounted
chart.

Examine the lenses and fundi.

Inspect each lens for opacities.

Assess the cup-to-disc ratio,
usually ≤1:2.

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.

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Herpes zoster from reactivation of latent
varicella-zoster virus in the dorsal root
ganglia

Pressure sores if obliteration of arteriolar
and capillary blood flow to the skin or
shear forces with movement across
sheets or lifting upright incorrectly

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

More than 40 million Americans have
refractive errors—presbyopia.

Cataracts, glaucoma, and macular
degeneration all increase with aging.

Cataracts are the world’s leading cause
of blindness.

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.

Macular degeneration causes poor
central vision and blindness: types
include dry atrophic (more common
but less severe) and wet exudative (or
neovascular).

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

412 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

Test hearing by the whispered
voice test (see p. 124) or audio-
scope. Inspect ear canals for
cerumen.

Examine the oral cavity for odor,
appearance of the gingival mucosa,
any caries, mobility of the teeth,
and quantity of saliva.

Inspect for lesions on mucosal
surfaces. Ask patient to remove
dentures so you can check gums
for denture sores.

Th o ra x a n d Lu n g s . Percuss
and auscultate the lungs. Note
subtle signs of changes in pulmo-
nary function.

Ca rd iovasc u la r Sys t em . Review
blood pressure and heart rate.

Inspect the jugular venous pulsa-
tion ( JVP), palpate the carotid
upstrokes, and listen for any
overlying carotid bruits.

Assess the point of maximal
impulse (PMI), and then heart
sounds.

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Removing cerumen often quickly
improves hearing.

Malodor in poor oral hygiene, periodon-
titis, or caries

Gingivitis if periodontal disease

Dental plaque and cavitation if caries.
Increased tooth mobility; risk of tooth
aspiration

Decreased salivation from medications,
radiation, Sjögren syndrome, or dehy-
dration

Oral tumors, usually on lateral borders of
tongue and floor of mouth

Increased anteroposterior diameter,
purse-lipped breathing, and dyspnea
with talking or minimal exertion in
chronic obstructive pulmonary disease

Isolated systolic hypertension and a
widened pulse pressure are cardiac risk
factors. Search for left ventricular
hypertrophy (LVH).

A tortuous atherosclerotic aorta can raise
pressure in the left jugular veins by
impairing drainage into right atrium.

Carotid bruits in possible carotid
stenosis.

Sustained PMI is found in LVH,
hypertension, and aortic stenosis;
diffuse PMI in heart failure (see p. 180).

In older adults, S3 in dilatation of the left
ventricle from heart failure or cardiomy-
opathy; S4 in hypertension

Chapter 20 | The Older Adult 413

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.

Bre a s t s a n d Axilla e . Palpate
the breasts carefully for lumps or
masses.

Ab d o m e n . Listen for bruits
over the aorta, renal arteries, and
femoral arteries.

Inspect the upper abdomen;
palpate to the left of the midline
for aortic pulsations.

Pe 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.

Palpate pulses.

Fe m a le Ge n it a lia a n d Pe lvic
Exa m in a t io n . Take special care
to explain the steps of examination
and allow time for careful position-
ing. 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.

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

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.

Possible breast cancer

Bruits in atherosclerotic vascular disease

Widened aorta of ≥3 cm and pulsatile
mass in abdominal aortic aneurysm.

Bruits over these vessels in atheroscle-
rotic disease.

Diminished or absent pulses in arterial
occlusion. Confirm with an office
ankle–brachial index (see pp. 230–231).

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 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

Inspect the urethra for caruncles,
or prolapse of eshy erythematous
mucosal tissue at the urethral meatus.

S p e c u lu m Exa m in a t io n . Inspect
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.

Perform the bimanual examination.

Perform the rectovaginal examina-
tion if indicated.

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.

Do a rectal examination.

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.

If joint deformity, de cits in mobil-
ity, or pain with movement, conduct
a more thorough examination.

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

Estrogen-stimulated cervical mucus with
ferning in use of hormone replacement
therapy, endometrial hyperplasia , and
estrogen-producing tumors; lichen
sclerosus

Uterine prolapse, cystocele, urethrocele,
or rectocele.

Note any uterine retroversion, retroflex-
ion, porolapse, or myomas (fibroids)

Mobility of cervix restricted if inflamma-
tion, malignancy, or surgical adhesion

Palpable ovaries in ovarian cancer.

Enlarged, fixed, or irregular uterus if
adhesions or malignancy. Rectal masses
in colon cancer.

Smegma, penile cancer, and scrotal
hydroceles

Rectal masses in colon cancer. Prosta te
hyperplasia if enlargement; prostate
cancer if nodules or masses.

Review examination techniques for
individual joints in Chapter 16,
Musculoskeletal System.

See Table 20-1, Timed Get Up and Go
Test, p. 417.

Degenerative joint changes in osteoar-
thritis; joint inflammation in rheumatoid
or gouty arthritis. See Tables 16-1 to 16-4,
pp. 304–308.

Clitoral enlargement in androgen-
producing tumors or use of androgen
creams

Chapter 20 | The Older Adult 415

Ne rvo 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.

Assess gait and balance, particu-
larly standing balance; timed 8-foot
walk; stride characteristics like
width, pace, and length of stride;
and careful turning.

Although neurologic abnormalities
are common in older adults, their
prevalence without identi able
disease increases with age, ranging
from 30% to 50%.

Assess any tremor, rigidity, brady-
kinesia, micrographia, shuf ing
gait, and dif culty turning in bed,
opening jars, and rising from a
chair.

EXAMINATION TECHNIQUES P O SSIBLE FIN DIN GS

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.

Abnormalities of gait and balance,
especially widening of base, slowing and
lengthening of stride, and difficulty
turning, are correlated with risk of falls.

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.

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.

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.

Recording Your Findings

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 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

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, or

2, Hz with udiosco e in either e r.
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.

Chapter 20 | The Older Adult 417

Aids to Interpretation

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. Stand up from the arm chair
2. Walk 3 m (in a line)
3. Turn
4. Walk back to chair
5. Sit down
Time the second effort.
Observe patient for postural stability, steppage, stride length, and sway.
S c o r in g :
1. Normal: completes task in 20 seconds
Low scores correlate with good functional independence; high scores
correlate with poor functional independence and higher risk of falls.

Tim e d Ge t Up a n d Go Te s tTable 20-1

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 Ba tes’ Pocke t Guide to Physica l Examina tion and His tory Taking

De lir iu m De m e n t ia

Clin ic a l Fe a t u re s

Onse t Acute Insidious

Course Fluctuating, with lucid
intervals; worse at night

Slowly progressive

Dura tion Hours to weeks Months to years

S leep /Wake Cycle Always disrupted Sleep fragmented

Genera l Clin ica l
Illness o r Drug
Toxicity

Either or both present Often absent,
especially in
Alzheimer disease

Me n t a l S t a t u s

Leve l of
Consciousness

Disturbed. Person less
clearly aware of the
environment and less
able to focus, sustain, or
shift attention

Usually normal until
late in the course of
the illness

Behavio r Activity often
abnormally decreased
(somnolence) or
increased (agitation,
hypervigilance)

Normal to slow;
may become
inappropriate

Speech May be hesitant, slow
or rapid, incoherent

Difficulty in finding
words, aphasia

Mood Fluctuating, labile, from
fearful or irritable to
normal or depressed

Often flat, depressed

Thought Processes Disorganized, may be
incoherent

Impoverished.
Speech gives little
information

Thought Con ten t Delusions common,
often transient

Delusions may occur

Perceptions Illusions, hallucinations,
most often visual

Hallucinations may
occur.

De liriu m a n d De m e n t iaTable 20-2

Chapter 20 | The Older Adult 419

De lir iu m De m e n t ia

J udgm ent Impaired, often to a
varying degree

Increasingly
impaired over the
course of the illness

Orien ta tion Usually disoriented,
especially for time. A
known place may seem
unfamiliar.

Fairly well
maintained, but
becomes impaired in
the later stages of
illness

Atten tion Fluctuates. Person
easily distracted, unable
to concentrate on
selected tasks

Usually unaffected
until late in the
illness

Mem ory Immediate and recent
memory impaired

Recent memory and
new learning
especially impaired

Exa m p le s o f Ca u s e Delirium tremens (due
to withdrawal from
alcohol)
Uremia

Reversible: Vitamin
B12 deficiency,
thyroid disorders

Acute hepatic failure
Acute cerebral vasculitis
Atropine poisoning

Irreversible:
Alzheimer disease,
vascular dementia
(from multiple
infarcts), dementia
due to head trauma

De liriu m a n d De m e n t ia (continued )Table 20-2

420 Bates’ Pocket Guide to Phys ica l Examination and His tory Taking

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.

3-Item Reca ll = 1–2

NONDEMENTEDDEMENTED

CDT Abnormal CDT Normal

MINI-COG

3-Item Reca ll = 33-Item Reca ll = 0

Sc re e n in g fo r De m e n t ia : Th e Min i-Co gTable 20-3

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.

Chapter 20 | The Older Adult 421

5
D

Begin

End

Copy
cube

Draw Clock (Ten past eight)
(3 points)

SCORE

Read list of words, subject must repeat them.
Do 2 trials, even if 1st trial is successful.
Do a recall after 5 minutes.

Serial 7 subtraction starting at 100

1st trial

2nd trial

ROSE CHAIR REDSPOON HOUSE

Contour HandsNumbers

Read list of digits (1 digit /sec.). Subject has to repeat them in the forward order
Subject has to repeat them inthe backward order

[ ] [ ] [ ]

[ ] [ ] [ ] [ ] [ ]

[ ] 3 2 7 4 5
[ ] 2 7 4

Read list of letters. The subject must point with his nger at each letter C. No points if ≥ 2 errors.

[ ] FBCAMNCCJKLBCFCKDECCJAMOFA
[ ] 95 [ ] 86 [ ] 76 [ ] 65 [ ] 45

[ ] Date [ ] Month [ ] Year [ ] Day [ ] Place [ ] City

4 or 5 correct subtractions: 3 pts, 2 or 3 correct: 2pts, 1 correct: 1pt, 0 correct: 0pt

Repeat : Ionly 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 [ ] (N≥ 11 words)

ROSE
[ ]

CHAIR
[ ]

RED
[ ]

SPOON
[ ]

HOUSE
[ ]

Similarity between e.g. banana – orange = fruit [ ] train – bicyle [ ] watch – ruler

Has to recall words

WITHNO CUE

Category cue

Multiple choice cue

Points for
UNCUED
recall only

Normal ≥ 26 / 30 TOTAL
Add 1 point if ≤ 12 yr eduAdministered by:

/ 30

/ 6

/ 5

/ 2

/ 1

/ 2

/ 3

/ 1

/ 2

/ 3

No
p o in t s

/ 5

NAME:
Education:

Sex:
Date of birth:

DATE:

VISUOSPATIAL / EXECUTIVE

NAMING

MEMORY

ATTENTION

LANGUAGE

ABSTRACTION

DELAYED RECALL

ORIENTATION

Optional

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)

Table 20-4

423

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

424 Index

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

Index 425

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

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 Index

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

Index 427

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

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 Index

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

Index 429

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

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 Index

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

Index 431

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

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 Index

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

Index 433

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

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 Index

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

Index 435

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

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 Index

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

Index 437

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

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 Index

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

Index 439

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

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 Index

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

Index 441

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

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 Index

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

Pt is a female 22 years old came to the clinic complaining of severe “ear pain”

The pain started after he bought a swimming SPA for Triathlon in his back yard for his swimming Training

General inspection:

Head: normal hair distribution, texture, no lesions, no hematomas normocephalic and atraumatic

Eye: no exophthalmos, ptosis. Vision is 20/20

Cranial nerves: oculomotor 3, trochlear 4, abducens 6, no abnormalities.

-Weber test: patient reported hearing the equal sound in both ears which is normal test.

-Rinne test : used to evaluate hearing loss in one ear. Air conduction is greater than bone conduction.

Nose: no discharges, mucosa and turbinate’s looks normal no pain in the frontal or maxillary sinus.

EAR: on the inspection the right ear is red, warm and swelling . Tmpanic membrane clear, pearly, No discharge. Pain when palpation and traction of the tragus

Mouth: no lips deformities, no gingivitis. Dentures no cavities, No tongue deviation, CN 12 intact. Posterior pharynx normal, no exudates. Tonsils grade 2

Neck: Range of motion: normal flexion and hyperextension. No lymph nodes enlargements. No thyroid enlargement.

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