Table Of Contents:

List of Tables xvii
Introduction xxiii

UNIT I. Foundations of Physical Examination and History Taking 1(86)

Overview of Physical Examination and History Taking 3(20)

The Health History 4(1)

Structure and Purposes 4(2)

The Comprehensive vs. Focused Health History 4(1)

Subjective vs. Objective Data 5(1)

The Comprehensive Adult Health History 6(5)

Initial Information 6(1)

Chief Complaint(s) 6(1)

Present Illness 6(1)

Past History 7(1)

Family History 8(1)

Personal and Social History 8(1)

Review of Systems 8(3)

The Physical Examination 11(1)

Approach and Overview 11(1)

The Comprehensive Adult Physical Examination 11(4)

General Survey 11(1)

Vital Signs 12(1)

Skin 12(1)

Head, Eyes, Ears, Nose, Throat (HEENT) 12(1)

Neck 12(1)

Back 12(1)

Posterior Thorax and Lungs 12(1)

Breast, Axillae, and Epitrochlear Nodes 12(1)

Anterior Thorax and Lungs 13(1)

Cardiovascular System 13(1)

Abdomen 13(1)

Lower Extremities 13(1)

Nervous System 14(1)

Additional Examinations 14(1)

Recording Your Findings 15(6)

Bibliography 21(2)

Interviewing and the Health History 23(42)

Getting Ready: The Approach to the Interview 26(2)

Taking Time for Self-Reflection 26(1)

Reviewing the Chart 26(1)

Setting Goals for the Interview 27(1)

Reviewing Your Clinical Behavior and Appearance 27(1)

Adjusting the Environment 28(1)

Taking Notes 28(1)

Learning About the Patient: The Sequence of the Interview 28(7)

Greeting the Patient and Establishing Rapport 29(1)

Inviting the Patient's Story 30(1)

Establishing an Agenda 31(1)

Expanding and Clarifying the Patient's Story 31(1)

Generating and Testing Diagnostic Hypotheses 32(1)

Creating a Shared Understanding of the Problem 33(1)

Negotiating a Plan 34(1)

Planning for Follow-Up and Closing 34(1)

Building a Therapeutic Relationship: The Techniques of Skilled Interviewing 35(6)

Building the Relationship 35(1)

Active Listening 36(1)

Guided Questioning: Options for Expanding and Clarifying the Patient's Story 36(2)

Nonverbal Communication 38(1)

Empathic Responses 38(1)

Validation 39(1)

Reassurance 39(1)

Partnering 40(1)

Summarization 40(1)

Transitions 40(1)

Empowering the Patient 40(1)

Adapting Your Interview to Specific Situations 41(6)

The Silent Patient 41(1)

The Confusing Patient 41(1)

The Patient With Altered Capacity 42(1)

The Talkative Patient 43(1)

The Crying Patient 44(1)

The Angry or Disruptive Patient 44(1)

The Interview Across a Language Barrier 44(1)

The Patient With Low Literacy 45(1)

The Patient With Impaired Hearing 46(1)

The Patient With Impaired Vision 46(1)

The Patient With Limited Intelligence 46(1)

The Patient With Personal Problems 47(1)

Sensitive Topics That Call for Specific Approaches 47(6)

The Sexual History 48(1)

The Mental Health History 49(1)

Alcohol and Illicit Drugs 50(1)

Family Violence 51(1)

Death and the Dying Patient 52(1)

Societal Aspects of Interviewing 53(4)

Achieving Cultural Competence 53(4)

Sexuality in the Clinician-Patient Relationship 57(1)

Ethics and Professionalism 57(4)

Bibliography 61(4)

Clinical Reasoning, Assessment, and Plan 65(22)

Assessment and Plan: The Process of Clinical Reasoning 66(4)

The Case of Mrs. N: Assessment and Plan 70(2)

Approaching the Challenges of Clinical Data 72(7)

Clustering Data into Single versus Multiple Problems 73(1)

Sifting Through an Extensive Array of Data 73(1)

Assessing the Quality of the Data 74(1)

Displaying Clinical Data 74(5)

Building Your Case: Integrating Clinical Reasoning and Assessment of Clinical Data 79(2)

Organizing the Patient Record 81(4)

Generating the Problem List 84(1)

Writing the Progress Note 85(1)

Clinical Assessment: The Journey to Excellence 85(1)

Bibliography 86(1)

UNIT II. Regional Examinations 87(582)

Beginning the Physical Examination: General Survey and Vital Signs 89(32)

Anatomy and Physiology 89(4)

Calculating the BMI 90(2)

Interpreting and Acting on the BMI 92(1)

Assessing Dietary Intake 92(1)

The Health History 93(2)

Changes in Weight 93(1)

Fatigue and Weakness 94(1)

Fever, Chills, and Night Sweats 95(1)

Health Promotion and Counseling 95(2)

Optimal Weight and Nutrition 95(1)

Exercise 96(1)

Blood Pressure and Diet 96(1)

Techniques of Examination 97(1)

Beginning the Examination: Setting the Stage 97(6)

Reflect on Your Approach to the Patient 97(1)

Adjust the Lighting and the Environment 98(1)

Determine the Scope of the Examination: Comprehensive or Focused? 99(1)

Choose the Sequence of the Examination 100(1)

Observe the Correct Examining Position and Handedness 101(1)

Make the Patient Comfortable 102(1)

The General Survey 103(2)

Apparent State of Health 103(1)

Level of Consciousness 103(1)

Signs of Distress 103(1)

Height and Build 104(1)

Weight 104(1)

Skin Color and Obvious Lesions 104(1)

Dress, Grooming, and Personal Hygiene 104(1)

Facial Expression 105(1)

Odors of the Body and Breath 105(1)

Posture, Gait, and Motor Activity 105(1)

The Vital Signs 105(1)

Blood Pressure 106(5)

Heart Rate and Rhythm 111(1)

Respiratory Rate and Rhythm 112(1)

Temperature 112(1)

Recording Your Findings 113(1)

Bibliography 114(7)

The Skin, Hair, and Nails 121(32)

Anatomy and Physiology 121(2)

Skin 121(1)

Hair 122(1)

Nails 122(1)

Sebaceous Glands and Sweat Glands 122(1)

The Health History 123(1)

Health Promotion and Counseling 124(2)

Techniques of Examination 126(1)

Skin 126(1)

Skin Lesions in Context 127(1)

Hair 128(1)

Nails 128(1)

Special Techniques 128(2)

Instructions for the Skin Self-Examination 128(2)

Recording Your Findings 130(1)

Bibliography 130(23)

The Head and Neck 153(88)

Anatomy and Physiology 153(1)

The Head 153(1)

The Eye 154(6)

The Ear 160(2)

The Nose and Paranasal Sinuses 162(3)

The Mouth and Pharynx 165(3)

The Neck 168(2)

The Health History 170(1)

The Head 171(1)

The Eyes 171(1)

The Ears 172(1)

The Nose and Sinuses 173(1)

The Mouth, Throat, and Neck 174(1)

Health Promotion and Counseling 175(2)

Techniques of Examination 177(1)

The Head 177(1)

The Hair 177(1)

The Scalp 177(1)

The Skull 177(1)

The Face 177(1)

The Skin 177(1)

The Eyes 177(12)

Visual Acuity 177(1)

Visual Fields by Confrontation 178(2)

Position and Alignment of the Eyes 180(1)

Eyebrows 180(1)

Eyelids 180(1)

Lacrimal Apparatus 180(1)

Conjunctiva and Sclera 180(1)

Cornea and Lens 181(1)

Iris 181(1)

Pupils 181(1)

Extraocular Muscles 182(2)

Ophthalmoscopic Examination 184(5)

The Ears 189(3)

The Auricle 189(1)

Ear Canal and Drum 189(1)

Auditory Acuity 190(1)

Air and Bone Conduction 190(2)

The Nose and Paranasal Sinuses 192(1)

The Mouth and Pharynx 193(3)

The Lips 193(1)

The Oral Mucosa 193(1)

The Gums and Teeth 194(1)

The Roof of the Mouth 194(1)

The Tongue and the Floor of the Mouth 194(1)

The Pharynx 195(1)

The Neck 196(4)

The Lymph Nodes 196(2)

The Trachea and the Thyroid Gland 198(2)

The Carotid Arteries and Jugular Veins 200(1)

Special Techniques 200(3)

For Assessing Protruding Eyes (Proptosis or Exophthalmos) 200(1)

For Nasolacrimal Duct Obstruction 201(1)

For Inspection of the Upper Palpebral Conjunctiva 201(1)

Swinging Flashlight Test 202(1)

Transillumination of the Sinuses 202(1)

Recording Your Findings 203(1)

Bibliography 204(37)

The Thorax and Lungs 241(38)

Anatomy and Physiology 241(7)

Locating Findings on the Chest 242(3)

Lungs, Fissures, and Lobes 245(1)

Locations on the Chest 246(1)

The Trachea and Major Bronchi 246(1)

The Pleurae 246(1)

Breathing 247(1)

The Health History 248(2)

Health Promotion and Counseling 250(2)

Techniques of Examination 252(1)

Initial Survey of Respiration and the Thorax 252(1)

Examination of the Posterior Chest 253(8)

Examination of the Anterior Chest 261(4)

Special Techniques 265(1)

Clinical Assessment of Pulmonary Function 265(1)

Forced Expiratory Time 265(1)

Identification of a Fractured Rib 265(1)

Recording Your Findings 266(1)

Bibliography 266(13)

The Cardiovascular System 279(58)

Anatomy and Physiology 279(1)

Surface Projections of the Heart and Great Vessels 279(2)

Cardiac Chambers, Valves and Circulation 281(1)

Events in the Cardiac Cycle 282(2)

The Splitting of Heart Sounds 284(1)

Heart Murmurs 285(1)

Relation of Auscultatory Findings to the Chest Wall 286(1)

The Conduction System 287(1)

The Heart as a Pump 288(1)

Arterial Pulses and Blood Pressure 289(1)

Jugular Venous Pressure (JVP) 290(2)

Jugular Venous Pulsations 292(1)

Changes Over the Life Span 292(1)

The Health History 293(2)

Health Promotion and Counseling 295(7)

Techniques of Examination 302(1)

Jugular Venous Pressure and Pulsations 302(3)

Jugular Venous Pressure (JVP) 302(2)

Jugular Venous Pulsations 304(1)

The Carotid Pulse 305(2)

Thrills and Bruits 306(1)

The Brachial Artery 306(1)

The Heart 307(1)

Inspection and Palpation 308(5)

Overview 308(1)

Left Ventricular Area---The Apical Impulse or Point of Maximal Impulse (PMI) 309(2)

S3 and S4 311(1)

Right Ventricular Area---The Left Sternal Border in the 3rd, 4th, and 5th Interspaces 311(2)

Pulmonic Area---The Left 2nd Interspace 313(1)

Aortic Area---The Right 2nd Interspace 313(1)

Percussion 313(1)

Auscultation 313(6)

Overview 313(2)

Listening for Heart Sounds 315(1)

Attributes of Heart Murmurs 316(3)

Integrating Cardiovascular Assessment 319(1)

Special Techniques 319(2)

Aids to Identify Systolic Murmurs 319(1)

Pulsus Alternans 320(1)

Paradoxical Pulse 320(1)

Recording Your Findings 321(1)

Bibliography 321(16)

The Breasts and Axillae 337(22)

Anatomy and Physiology 337(1)

The Female Breast 337(2)

The Male Breast 339(1)

Lymphatics 339(1)

The Health History 340(1)

Health Promotion and Counseling 341(4)

Techniques of Examination 345(1)

The Female Breast 345(5)

The Male Breast 350(1)

The Axillae 350(2)

Special Techniques 352(2)

Assessment of Spontaneous Nipple Discharge 352(1)

Examination of the Mastectomy Patient 352(1)

Instructions for the Breast Self-Examination 352(2)

Recording Your Findings 354(1)

Bibliography 354(5)

The Abdomen 359(52)

Anatomy and Physiology 359(3)

The Health History 362(1)

The Gastrointestinal Tract 362(6)

The Urinary Tract 368(2)

Health Promotion and Counseling 370(4)

Techniques of Examination 374(1)

The Abdomen 374(5)

The Liver 379(3)

The Spleen 382(3)

The Kidneys 385(1)

The Bladder 386(1)

The Aorta 386(1)

Special Techniques 387(1)

Assessing Possible Ascites 387(2)

Identifying an Organ or a Mass in an Ascitic Abdomen 389(1)

Assessing Possible Appendicitis 389(1)

Assessing Possible Acute Cholecystitis 390(1)

Assessing Ventral Hernias 390(1)

Mass in the Abdominal Wall 391(1)

Recording Your Findings 391(1)

Bibliography 392(19)

Male Genitalia and Hernias 411(18)

Anatomy and Physiology 411(2)

The Health History 413(2)

Health Promotion and Counseling 415(1)

Techniques of Examination 416(1)

The Penis 416(1)

The Scrotum and Its Contents 417(2)

Hernias 419(1)

Special Techniques 420(1)

The Testicular Self-Examination 420(1)

Recording Your Findings 421(1)

Bibliography 421(8)

Female Genitalia 429(30)

Anatomy and Physiology 429(3)

The Health History 432(3)

Health Promotion and Counseling 435(3)

Techniques of Examination 438(2)

Choosing Equipment 439(1)

Positioning the Patient 440(1)

External Examination 440(1)

Internal Examination 441(7)

Hernias 448(1)

Special Techniques 448(1)

Recording Your Findings 448(1)

Bibliography 449(10)

The Anus, Rectum, and Prostate 459(14)

Anatomy and Physiology 459(2)

The Health History 461(1)

Health Promotion and Counseling 462(2)

Techniques of Examination 464(1)

Male 464(3)

Female 467(1)

Recording Your Findings 468(1)

Bibliography 468(5)

The Peripheral Vascular System 473(24)

Anatomy and Physiology 473(1)

Arteries 473(1)

Veins 474(2)

The Lymphatic System and Lymph Nodes 476(1)

Fluid Exchange and the Capillary Bed 477(1)

The Health History 478(1)

Health Promotion and Counseling 479(2)

Techniques of Examination 481(1)

Arms 481(1)

Legs 482(6)

Special Techniques 488(3)

Evaluating the Arterial Supply to the Hand 488(1)

Postural Color Changes of Chronic Arterial Insufficiency 489(1)

Mapping Varicose Veins 490(1)

Evaluating the Competency of Venous Valves 490(1)

Recording Your Findings 491(1)

Bibliography 491(6)

The Musculoskeletal System 497(76)

Assessing the Musculoskeletal System 497(1)

Structure and Function of Joints 498(1)

Types of Joints 499(1)

Structure of Synovial Joints 500(1)

Bursae 501(1)

The Health History 501(3)

Health Promotion and Counseling 504(3)

Examination of Specific Joints: Anatomy and Physiology and Techniques of Examination 507(2)

Temporomandibular Joint 509(2)

The Shoulder 511(9)

The Elbow 520(2)

The Wrist and Hands 522(7)

The Spine 529(8)

The Hip 537(6)

The Knee 543(9)

The Ankle and Foot 552(3)

Special Techniques 555(3)

For Carpal Tunnel Syndrome 555(1)

For Low Back Pain With Radiation Into the Leg 556(1)

Measuring the Length of Legs 557(1)

Describing Limited Motion of a Joint 557(1)

Recording Your Findings 558(1)

Bibliography 558(15)

The Nervous System: Mental Status and Behavior 573(22)

Overview 573(2)

The Health History 575(1)

Health Promotion and Counseling 576(2)

Techniques of Examination 578(1)

Appearance and Behavior 579(1)

Speech and Language 580(1)

Mood 581(1)

Thought and Perceptions 581(3)

Cognitive Functions 584(2)

Higher Cognitive Functions 586(2)

Special Techniques 588(1)

Mini-Mental State Examination (MMSE) 588(1)

Recording Your Findings 588(1)

Bibliography 589(6)

The Nervous System: Cranial Nerves, Motor System, Sensory System, and Reflexes 595(74)

Anatomy and Physiology 595(1)

Central Nervous System 596(1)

The Brain 596(1)

The Spinal Cord 597(1)

Peripheral Nervous System 598(1)

The Cranial Nerves 598(1)

The Peripheral Nerves 598(2)

Spinal Reflexes: The Deep Tendon Response 600(1)

Motor Pathways 601(2)

Sensory Pathways 603(4)

The Health History 607(2)

Health Promotion and Counseling 609(1)

Techniques of Examination 610(1)

The Cranial Nerves 611(5)

The Motor System 616(13)

The Sensory System 629(4)

Deep Tendon Reflexes 633(7)

Special Techniques 640(6)

Asterixis 640(1)

Winging of the Scapula 640(1)

Meningeal Signs 641(1)

Anal Reflex 641(1)

The Stuporous or Comatose Patient 641(5)

Recording Your Findings 646(1)

Bibliography 647(22)

UNIT III. Life Span Examinations 669(206)

Assessing Children: Infancy Through Adolescence 671(146)

Child Development 672(1)

Key Principles 672(2)

Infancy: The First Year of Life 674(1)

Childhood: 1 Through 10 Years 675(4)

Adolescence: 11 Through 20 Years 679(2)

Health Promotion and Counseling 681(4)

Approach to Examination of Newborns and Infants 685(1)

Sequence of Examination 685(1)

Assessing the Newborn 686(6)

Assessing the Infant 692(3)

Techniques of Examination for Newborns and Infants 695(43)

Approach to Examination of Children 738(1)

Assessing Early Childhood 739(3)

Assessing Middle Childhood 742(3)

Techniques of Examination for Children 745(29)

Approach to Examination of Adolescents 774(2)

Techniques of Examination for Adolescents 776(13)

Recording Your Findings 789(3)

Bibliography 792(25)

The Pregnant Woman 817(22)

Anatomy and Physiology 817(5)

The Health History 822(1)

Health Promotion and Counseling 823(3)

Techniques of Examination 826(1)

General Inspection 827(1)

Vital Signs, Height, and Weight 827(1)

Head and Neck 828(1)

Thorax and Lungs 828(1)

Heart 829(1)

Breasts 829(1)

Abdomen 829(2)

Genitalia, Anus, and Rectum 831(2)

Extremities 833(1)

Special Techniques 833(1)

Modified Leopold's Maneuvers 833(3)

Concluding the Visit 836(1)

Recording Your Findings 837(1)

Bibliography 837(2)

The Older Adult 839(36)

Anatomy and Physiology 840(8)

The Health History 848(1)

Approach to the Patient 848(3)

Adjusting the Office Environment 848(1)

Shaping the Content and Pace of the Visit 848(1)

Eliciting Symptoms in the Older Adult 849(1)

Addressing Cultural Dimensions of Aging 850(1)

Special Areas of Concern When Assessing Common or Concerning Symptoms 851(4)

Activities of Daily Living 852(1)

Medications 852(1)

Nutrition 853(1)

Acute and Chronic Pain 853(1)

Smoking and Alcohol 854(1)

Advance Directives and Palliative Care 854(1)

Health Promotion and Counseling 855(2)

Techniques of Examination 857(1)

Assessing Functional Status: The ``Sixth Vital Sign'' 857(4)

Physical Examination of the Older Adult 861(8)

Recording Your Findings 869(1)

Bibliography 870(5)
Index 875