Kidney stone

The symptoms of a kidney stone are sudden onset of flank tenderness along with nausea and vomiting. The patient experiences more colicky-type pain and moves around a lot, in an attempt to alleviate the pain. In our scenario, the patient is sitting quietly on the exam table and is not moving around. There may be fever and chills if the stone obstructs the ureter and causes a urinary tract infection. To make the diagnosis of a kidney stone, more testing needs to be done by obtaining a urinalysis....

Early And Late Childhood

As children become older, the examination of the lungs begins to approach that used in adults. Again, it is critical for children to cooperate with this examination. Auscultation is often best accomplished when the child is barely aware of the examination (as when he is in his parent's lap). If a toddler seems fearful of your stethoscope, you might let the child play with it before touching the chest. If you ask young children to take deep breaths, they will often hold their breath, making it...

Info

Usually absent when bronchial plug persists. Exceptions include right upper lobe atelectasis, where adjacent tracheal sounds may be transmitted. Usually absent when the bronchial plug persists. In exceptions, e.g., right upper lobe atelectasis, may be increased Decreased to absent, but bronchial breath sounds may be heard near top of large effusion. None, except a possible pleu ral rub Decreased to absent, but may be increased toward the top of a large effusion Decreased to absent over the...

Helo Business Banners

May start with simple partial seizures or with impaired consciousness. Automatisms may develop. Partial Seizures That Become Generalized The seizure may or may not start with the autonomic or psychic symptoms that are outlined above. Consciousness is impaired and the person appears confused. Automatisms include automatic motor behaviors such as chewing, smacking the lips, walking about, and unbuttoning clothes also more complicated and skilled behaviors such as driving a car. Partial seizures...

The Cardiovascular System Multiple Choice

A 42-year-old receptionist presents to the office for evaluation of fatigue. The fatigue has been present for several months. Upon auscultation of the heart, the S1 sound is accentuated. Which is the most likely cause of her accentuated S1 given her symptoms 2. A 38-year-old file clerk presents to your office for evaluation of fatigue. She has a 20-pack-a-year history of smoking and had rheumatic heart fever in childhood. On auscultation of her heart, the S2 sound is widely split that is, it...

TABLE 161 Disorders of Mood

Mood disorders may be either depressive or bipolar. A bipolar disorder includes manic or hypomanic features as well as depressive ones. Four types of episodes, described below, are combined in different ways in diagnosis of mood disorders. A major depressive disorder includes only one or more major depressive episodes. A bipolar I disorder includes one or more manic or mixed episodes, usually accompanied by major depressive episodes. A bipolar II disorder includes one or more major depressive...

Newborn Period And Infancy

Inspect the abdomen with the infant lying supine, optimally while asleep. The abdomen is protuberant due to poorly developed abdominal musculature. You will easily notice abdominal wall blood vessels and intestinal peristalsis. Inspect the newborn's umbilical cord to detect abnormalities. Normally, there are two thick-walled umbilical arteries and one larger but thin-walled umbilical vein, which is usually located at the 12 o'clock position. The umbilicus in the newborn may have a long...

The Urinary Tract

General questions for a urinary history include Do you have any difficulty passing your urine How often do you go Do you have to get up at night How often How much urine do you pass at a time Is there any pain or burning Do you ever have trouble getting to the toilet in time Do you ever leak any urine Or wet yourself involuntarily Does the patient sense when the bladder is full and when voiding occurs Ask women if sudden coughing, sneezing, or laughing makes them lose urine. Roughly half of...

TABLE 91 Abdominal Pain

Dyspepsia (These disorders cannot be Peptic ulcer refers to a demonstrable ulcer, usually in the duodenum or stomach. Dyspepsia causes similar reliably differentiated symptoms but no ulceration. Infection by symptoms and signs.) by Helicobacter pylori is often present. Variable gnawing burning, boring, aching, pressing, or hungerlike Acute Pancreatitis An acute inflammation of the pancreas Chronic Fibrosis of the pancreas secondary to Pancreatitis recurrent inflammation Epigastric, may radiate...

Multiple Choice

A 21-year-old female presents to your clinic for her annual exam. She informs you that for the last 3 months, she has felt a lump in her left breast above the nipple. She has had no discharge from the nipple. Her past medical history is nonsignificant. She has not been sexually active and is on no medication. She denies any tobacco, alcohol, or drug use. Her paternal grandmother had breast cancer in her seventies and did well with surgery and radiation. On physical exam, you feel a firm disc...

Acute bronchitis

Symptoms of acute bronchitis include sputum production, dyspnea, wheezing, chest pain, fever, hoarseness, malaise, rhonchi, and rales. Each of these may be present in varying degrees or may be absent altogether. Sputum may be clear, white, yellow, green, or even tinged with blood. On physical examination, the patient with acute bronchitis may or may not have fever and has tachypnea, as well as pulmonary signs such as wheezing, rhonchi, and prolonged expiration. In this case, the patient has no...

Changes With Aging

Aging may affect all aspects of the nervous system, from mental status to motor and sensory function and reflexes. Age-related losses may take their toll on the mental function of an elderly person. These include the deaths of loved ones and friends, retirement from valued employment, diminution in income, decreased physical capacities including impairments in vision and hearing, and perhaps decreased stimulation or growing isolation. In addition, biologic changes affect the aging brain. Brain...

TABLE 1712 Diagnostic Facies in Infancy and Childhood

Fetal Alcohol Syndrome Congenital Syphilis Congenital Hypothyroidism Facial Nerve Palsy Babies born to women who are chronic alcoholics are at increased risk for growth deficiency, microcephaly, and mental retardation. Facial characteristics shown here include short palpebral fissures, a wide and flattened philtrum (the vertical groove in the midline of the upper lip), and thin lips. In utero infection by Treponema pallidum usually occurs after the 16th week of gestation and affects virtually...

Appendicitis most likely diagnosis

In appendicitis, the initial presenting symptom is generalized periumbilical abdominal pain, which localizes over a 24-hour time period to the right lower quadrant. The pain is initially mild, but increasing to become steady and more severe. It may be aggravated by movement or cough. The patient experiences anorexia, nausea, and possible vomiting. These symptoms are found in classic appendicitis, and Mariah is in the right age group to have the classic symptoms. This is the most likely...

Anatomy And Physiolo

Pituitary Gland

This section deals briefly with structures, functions, and concepts that relate directly to the neurologic examination. After a short description of the brain, spinal cord, cranial and peripheral nerves, and reflexes, it summarizes important motor and sensory pathways. Common or concerning symptoms, health promotion and counseling, and a preview of the pertinent write-up then follow. Next comes Techniques of Examination for the nervous system, including mental status, the cranial nerves, the...

Assessment And Plan For Mrs N

Migraine headaches. 54-year-old woman with migraine headaches since childhood, with a throbbing vascular pattern and frequent nausea and vomiting. Headaches are associated with stress and relieved by sleep and cold compresses. There is no papilledema, and there are no motor or sensory deficits on the neurologic examination. The differential diagnosis includes tension headache, also associated with stress, but there is no relief with massage, and the pain is more throbbing than aching. There are...

Early And Late Childhood And Adolescence

Late Childhood

Toddlers and young children commonly have protuberant abdomens, most apparent when they are upright. The examination can follow the same order as for adults, except that you may need to open your bag of tricks to distract the child during the examination. An exaggerated pot-belly appearance may indicate malabsorption due to celiac disease, cystic fibrosis, or constipation or aerophagia. Most children are ticklish when you first place your hand on their abdomens for palpation. This reaction...

Miracle Cure For Aortic Stenosis

The opening snap is a very early diastolic sound usually produced by the opening of a stenotic mitral valve. It is heard best just medial to the apex and along the lower left sternal border. When it is loud, an opening snap radiates to the apex and to the pulmonic area, where it may be mistaken for the pulmonic component of a split S2. Its high pitch and snapping quality help to distinguish it from an St. It is heard better with the diaphragm. A. physiologic third heart sound is heard...

Palpating Masseter Muscles

After explaining what you plan to do, test the forehead, cheeks, and jaw on each side for pain sensation. Suggested areas are indicated by the circles. The patient's eyes should be closed. Use a safety pin or other suitable sharp object,* occasionally substituting the blunt end for the point as a stimulus. Ask the patient to report whether it is sharp or dull and to compare sides. Unilateral decrease in or loss of facial sensation suggests a lesion of CN V or of interconnecting higher...

TABLE 97 Urinary Incontinence

The urethral sphincter is weakened so that transient increases in intraabdominal pressure raise the bladder pressure to levels that exceed urethral resistance. Detrusor contractions are stronger than normal and overcome the normal urethral resistance. The bladder is typically small. In women, most often a 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. Suggested causes include...

Assessing Possible Ascites

Ascites Stomach

A protuberant abdomen with bulging flanks suggests the possibility of ascitic fluid. Because ascitic fluid characteristically sinks with gravity, while gas-filled loops of bowel float to the top, percussion gives a dull note in dependent areas of the abdomen. Look for such a pattern by percussing outward in several directions from the central area of tympany. Map the border between tympany and dullness. Two further techniques help to confirm the presence of ascites, although both signs may be...

Infant

LTmbilical hernias protrude through a defective umbilical ring. They are most common in infants but also occur in adults. In infants, but not in adults, they usually close spontaneously within a year or two. An incisional hernia protrudes through an operative scar. By palpation, note the length and width of the defect in the abdominal wall. A small defect, through which a large hernia has passed, has a greater risk of complications than a large defect. A rectus diastasis is a separation of the...

The Neck

Posterior Cervical Nodes Children

Beyond infancy, the techniques for examining the neck are the same as for adults. Several important and somewhat unique aspects of the pediatric examination of the neck are described below. Palpate the lymph nodes of the neck and assess the presence of any additional masses such as congenital cysts. Because the necks of infants are short, it is best to palpate the neck while infants are lying supine, whereas older children are best examined while sitting. Check the position of the thyroid...

Answers and Explanations

Interviewing and the Health History Multiple Choice 1. The correct answer is (B) Quality Quality is the only one of the seven attributes of a symptom listed that is not addressed. The patient has not described the kind of pain he is experiencing other than that it is in his chest. Pain may be an ache, a sharp sensation, a pressure-like sensation, or a burning sensation, which are all important descriptors in helping to determine your differential diagnosis. Remitting or exacerbating factors...

Normal Configurations Of The Hymen In Prepubertal And Adolescent Females

Annular Crescentic Shape Hymen

15-month-old infant with annular hymenal orifice 15-month-old infant with annular hymenal orifice 7-year-old girl with a crescent-shaped hymenal orifice 2-year-old with an annular orifice, located offcenter, visible with labial traction 6-year-old with a septate hymen causing two orifices. Traction is needed to visualize the two openings. 9-year-old girl with redundant labial tissue. Greater traction or a knee-chest position would reveal a normal orifice. 12-year-old girl with annular-shaped...

The Peripheral Vascular System Multiple Choice

A 55-year-old disabled Vietnam veteran comes into the ER complaining of severe pain in his left arm, which occurred suddenly approximately 2 hours ago. He also states that the arm is numb and feels cold to him from the elbow down. He has had similar episodes in the past with his legs, which required amputation at the mid-thigh bilaterally. He has a 20-year history of hypertension and a 60-pack-year history of smoking. He is a recovering alcoholic but denies any drug use. His father passed away...

Getting Ready To Measure Blood Pressure

Ideally, ask the patient to avoid smoking or drinking caffeinated beverages for 30 minutes before the blood pressure is taken and to rest for at least 5 minutes. Check to make sure the examining room is quiet and comfortably warm. Make sure the arm selected is free of clothing. There should be no arteriovenous fistulas for dialysis, scarring from prior brachial artery cutdowns, or signs of lymphedema (seen after axillary node dissection or radiation therapy). Palpate the brachial artery to...

Consolidation Is Present In The Lungs If You Find

A patient complains of shortness of breath and productive cough. Consolidation is present in the lungs if you find (A) Dullness to percussion over left base (B) Bronchial breath sounds throughout (C) Increased tactile fremitus throughout (D) Inspiratory and expiratory wheezes 2. Which of the following is the best technique for assessing the supraclavicular lymph nodes (A) Place the patient in a supine position and ask him to hold his breath while you palpate (B) Place the patient in...

TABLE 1710 Cyanosis in Children

Cyanosis Baby

This baby has mild cyanosis above the lips, but the mucous membranes remain pink. This commonly appears on the feet and hands of babies shortly after birth. This infant is a 32-week newborn. This baby had total anomalous pulmonary venous return and an oxygen saturation level of 80 . It is important for you to be able to recognize cyanosis. The best location to examine is the mucous membranes. Cyanosis is a raspberry color, while normal mucous membranes should have a strawberry color. Try to...

Present Illness

This section of the history is a complete, clear, and chronologic account of the problems prompting the patient to seek care. The narrative should include the iset of the problem, the setting in which it has developed, its manifestations, id any treatments. The principal symptoms should be well-characterized, ith descriptions of (1) location, (2) quality, (3) quantity or severity, (4) timing, including onset, duration, and frequency, (5) the setting in which they occur, (6) factors that have...

Newborn And Early Infancy

The newborn infant's skin has a unique characteristic texture and appearance. The texture is soft and smooth because it is thinner than the skin of older children. Within the first 10 minutes after birth, a normal newborn progresses from generalized cyanosis to pinkness. In lighter-skinned infants, an erythematous flush, giving the skin the appearance of a boiled lobster, is common during the first 8 to 24 hours, then the normal pale pink coloring predominates. Cutis marmorata is prominent in...

Asthma exacerbation most likely diagnosis

Most people with acute asthma present with a constellation of symptoms consisting of cough, dyspnea, and wheezing. These typically occur simultaneously. Acute attacks are set of by some type of stimulant, and the patient has been exposed to some type of stimulant, which has produced an allergic response. An asthma exacerbation may or may not be accompanied by fever, depending on the initiating trigger. This patient is most likely having an acute asthma exacerbation, given her symptoms of...

The Anus Rectum and Prostate Multiple Choice

A 28-year-old bus driver presents to the emergency room for pain and drainage from an area at the bottom of her spine. This has never occurred before. On examination of the rectum, a small opening is identified in the midline superficial to the lower sacrum. There is a surrounding halo of erythema. It is tender to palpation and purulent material is expressed. Your most likely diagnosis of this condition is (D) Thrombosed external hemorrhoid 2. A 24-year-old housewife and mother presents to the...

Palpation Of The Bicipital Groove And Tendon

Bicipital Groove Latismus Dorsi

Ask the patient to fully abduct the arm to shoulder level (or up to 90 ) and lower it slowly. (Note that abduction above shoulder level, from 90 to 120 , reflects action of the deltoid muscle.) Rotate the arm and forearm externally and locate the biceps muscle distally near the elbow. Track the muscle and its tendon proximally into the bicipital groove along the anterior aspect of the humerus. As you check for tendon tenderness, rolling the tendon under the fingertips...

Rapid changes in weight over a few days suggest changes in body fluids not tissues

In the overweight patient, for example, when did the weight gain begin Was the patient heavy as an infant or a child Using milestones appropriate to the patient's age, inquire about weight at the following times birth, kindergarten, high school or college graduation, discharge from military service, marriage, after each pregnancy, menopause, and retirement. What were the patient's life circumstances during the periods of weight gain Has the patient tried to lose weight How With what results...

The Case of Example of Mrs N

N is a pleasant, 54-year-old widowed saleswoman residing in Amarillo, Texas. Referral. None Source and Reliability. Self-referred seems reliable. C Chief Complaint My head aches. For about 3 months, Mrs. N has had increasing problems with frontal headaches. These are usually bifrontal, throbbing, and mild to moderately severe. She has missed work on several occasions due to associated nausea and vomiting. Headaches now average once a week, usually related to stress, and last 4 to 6 hours....

Tips For Conducting The Otoscopic Examination

Clinical Examination The Child

Use the largest possible speculum. A larger speculum will allow you to visualize the tympanic membrane better. A small speculum may not provide a seal for pneumatic otoscopy. Don't apply too much pressure. Too much pressure will cause the child to cry and may cause false-positives on pneumatic otoscopy. Insert the speculum V4 to V2 inch into the canal. First find the landmarks. Sometimes the ear canal resembles the tympanic membrane don't be fooled Note...

Physical Examination Multiple Choice

An 83-year-old woman presents to the ER the afternoon of Thanksgiving complaining of severe abdominal pain. She states it was at first cramping around her navel but has now radiated to the rest of her abdomen. She also complains of some vomiting and bloody diarrhea. About 1 hour before the pain started, she had a large traditional holiday meal. She states she generally only eats about half a sandwich and some soup at meals. She denies any earlier history of similar pain. Her past medical...

Natomy And Physiol

Inguinal Hernia Physical Exam

Review the anatomy of the male genitalia. Review the anatomy of the male genitalia. The shaft of the penis is formed by three columns of vascular erectile tissue the corpus spongiosum, containing the urethra, and two corpora cavernosa. The corpus spongiosum forms the bulb of the penis, ending in the cone-shaped glans with its expanded base, or corona. In uncircumsized men, the glans is covered by a loose, hoodlike fold of skin called the prepuce or foreskin where smegma, or secretions of the...

TABLE 1 78 Warts Lesions that Resemble Warts and Other Raised Lesions

Removing Plantar Warts Children

Warts are commonly found in children. Since they often appear on the fingers or the hands and on the soles of the feet, you will need to examine the skin of children carefully. Warts and Lesions that May Resemble Warts You will frequently note acne in adolescents. Differentiate between open comedones (blackheads) and closed comedones (whiteheads) shown at the left, and inflamed pustules (right). (Source of photos Goodheart H A Photoguide of Common Skin Disorders, Baltimore, Williams &...

Blood Pressure

Physical Pressure Pushing Aorta

Although there are special challenges to obtaining accurate blood pressure readings in young infants, this measurement, nevertheless, is important and should be part of the physical examination of every child older than 2 years of age, and of any younger child whose history or physical examination suggests that the blood pressure may be abnormal. Hypertension during childhood is more common than previously thought, and it is important to recognize, confirm, and appropriately manage it. Children...

Case Study3

CHIEF COMPLAINT My eye is red and burning. History of Present Illness Mr. E. is a 55-year-old machinist who comes to your office complaining of pain in his right eye for the past 24 hours. He describes the pain as severe, aching, and deep he has noticed a decline in his vision. He does not wear corrective lenses. He denies any work-related exposures. He denies any upper respiratory infection or allergies. He has a history of hypertension and sees his physician regularly for checkups he has been...

Squeezed Uterus

Myoma Pelvis

Nodules on the uterine surfaces suggest myomas see p._ . See retroversion and retroflexion of the uterus p.__ . Three to five years after menopause, the ovaries have usually atrophied and are no longer palpable. If you can feel an ovary in a postmenopausal woman, consider an abnormality such as a cyst or a tumor. Adnexal masses include ovarian cysts, tumors, and abscesses, also the swollen fallopian tube s of pelvic inflammatory disease, and a tubal pregnancy. A uterine myoma may simulate an...

Beginning the Physical Examination General Survey and Vital Signs Multiple Choice

A 15-year-old high-school student presents to your office for a sports physical He is 65 inches in height and weighs 250 pounds. His BMI falls in which category 2. A 16-year-old sophomore presents to the clinic for a sports physical she is accompanied by her mother. She is involved in gymnastics and has been since age 5. In addition to training for the gymnastics team, she runs 10 miles per day. She is proud of her athleticism and states that she is still too fat and wants to lose more...

Bilateral Visual Field Obliteration

A 26-year-old woman presents for evaluation of hair loss. She also has noticed increased weight loss and diarrhea. You diagnose Graves' disease hyperthyroidism . On physical examination of the hair, what would you expect to find 2. A 25-year-old swim instructor presents to your clinic complaining of an itchy scalp. You diagnose seborrheic dermatitis. What physical findings are most consistent with this diagnosis C Dry, flaking areas on the scalp 3. A 55-year-old construction worker presents...

Salmon Patch Birthmark

Light Tan Spot Eye Lid

These light-brown pigmented lesions usually have ragged borders and are uniform. They are noted in more than 10 of black infants. This birthmark fades, usually in the first year. This birthmark fades, usually in the first year. Also called stork bite, this splotchy pink mark fades with age. Also called stork bite, this splotchy pink mark fades with age. These are more common among dark-skinned babies. It is important to note them so that they are not mistaken for bruises. Characteristic...

The Seven Attributes Of A Symptom

Where is it Does it radiate 3. Quantity or severity. How bad is it For pain, ask for a rating on a scale of C 1 to 10. 4. Timing. When did does it start How long did does it last How often did does it come Setting in which it occurs. Include environmental factors, personal activities, emotional reactions, or other circumstances that may have contributed to the illness. C 5. Remitting or exacerbating factors. Does anything make it better or worse T 7. Associated manifestations. Have...

Pictures Of Enlarged Liver

Child Palpate Enlarged Liver

Place your left hand behind the patient, parallel to and supporting the right 11th and 12th ribs and adjacent soft tissues below. Remind the patient to relax on your hand if necessary. By pressing your left hand forward, the patient's liver may be felt more easily by your other hand. Place your right hand on the patient's right abdomen lateral to the rectus muscle, with your fingertips well below the lower border of liver dullness. Some examiners like to point their fingers up toward the...

Iliac Tuberosity

Iliac Tuberosity

Intrinsic muscles of the back, sacrospinalis Abdominal muscles, intrinsic muscles of the back Abdominal muscles, intrinsic muscles of the back Overview. The hip joint is deeply embedded in the pelvis, and is notable for its strength, stability, and wide range of motion. The stability of the hip joint, so essential for weight bearing, arises from the deep fit of the head of the femur into the acetabulum, its strong fibrous articular capsule, and the powerful muscles crossing the joint and...

Bluish Ovoid Mass In Rectum

Proctoscopy Prostate

TABLE 1 3-1 Abnormalities of the Anus, Surrounding Skin, and Rectum Continued External hemorrhoids are dilated hemorrhoidal veins that originate below the pectinate line and are covered with skin. They seldom produce symptoms unless thrombosis occurs. This causes acute local pain that is increased by defecation and by sitting. A tender, swollen, bluish, ovoid mass is visible at the anal margin. Polyps of the rectum are fairly common. Variable in size and number, they can develop on a stalk...

Epitrochlear And Brachial

Epitrochlear Nodes

Assessment of the peripheral vascular system relies primarily on inspection of the arms and legs, palpation of the pulses, and a search for edema. See Chapter 3 for a method of integrating these techniques into your examination of the limbs. Additional techniques may be useful when you suspect an abnormality. Inspect both arms from the fingertips to the shoulders. Note Their size, symmetry, and any swelling The color of the skin and nail beds and the texture of the skin Lymphedema of arm and...

Popliteal Pulse

Pitting Edema Scale

See Table 14-3, Common Ulcers of the Feet and Ankles p. 463 . Palpate the pulses in order to assess the arterial circulation. The femoral pulse. Press deeply, below the inguinal ligament and about midway between the anterior superior iliac spine and the symphysis pubis. As in deep abdominal palpation, the use of two hands, one on top of the other, may facilitate this examination, especially in obese patients. See Table 14-2, Chronic Insufficiency of Arteries and Veins p. 462 . See Table 14-3,...

The Small Introitus

Inserting Speculum

Many virginal vaginal orifices admit a single examining finger. Modify your technique so as to use your index finger only. A small Pedersen speculum may make inspection possible. When the vaginal orifice is even smaller, a fairly good bimanual examination can be performed by placing one finger in the rectum rather than in the vagina. Similar techniques may be indicated in elderly women in whom the introitus has become atrophied and tight. An imperforate hymen occasionally delays menarche. Be...

6 Cm Ovarian Cyst

Adnexal Solid Mass

Ovarian cysts and tumors may be detected as adnexal masses on one or both sides. Later, they may extend out of the pelvis. Cysts tend to be smooth and compressible, tumors more solid and often nodular. Uncomplicated cysts and tumors are not usually tender. Small lt 6 cm in diameter , mobile, cystic masses in a young woman are usually benign and often disappear after the next menstrual period. A ruptured tubal pregnancy spills blood into the peritoneal cavity, causing severe abdominal pain and...

Modified Leopolds Maneuvers

Fetus Weeks

These maneuvers are important adjuncts to palpation of the pregnant abdomen beginning at 28 weeks of gestation. They help determine where the fetus is lying in relation to the woman's back longitudinal or transverse , what end of the fetus is presenting at the pelvic inlet head or buttocks , where the fetal back is located, how far the presenting part of the fetus has descended into the maternal pelvis, and the estimated weight of the fetus. This information is necessary to assess the adequacy...

Abdomen

Fetoscope Image

Position the pregnant woman in a semi-sitting position with her knees flexed see p. 417 . Inspect any scars or striae, the shape and contour of the abdomen, and the fundal height. Purplish striae and linea nigra are normal in pregnancy. The shape and contour may indicate pregnancy size see figures on p. 410 . Scars may confirm the type of prior surgery, especially cesarean section. Organs or masses. The mass of pregnancy is expected. Fetal movements. These can usually be felt by the examiner...

Male Physical Exam

Herpes Perianal Tratamento

The anus and rectum may be examined with the patient in one of several positions. For most purposes, the side-lying position is satisfactory and allows good views of the perianal and sacrococcygeal areas. This is the position described below. The lithotomy position may help you to reach a cancer high in the rectum. It also permits a bimanual examination, enabling you to delineate a pelvic mass. Some clinicians prefer to examine a patient while he stands with his hips flexed and his upper body...

Women Anus Rectum Picture

Digital Rectal Examination Female

MEDIAN SECTION VIEW FROM THE LEFT SIDE MEDIAN SECTION VIEW FROM THE LEFT SIDE The anal canal is demarcated from the rectum superiorly by a serrated line marking the change from skin to mucous membrane. This anorectal junction, often called the pectinate or dentate line, also denotes the boundary between somatic and visceral nerve supplies. It is readily visible on proctoscopic examination, but is not palpable. Above the anorectal junction, the rectum balloons out and turns posteriorly into the...

O

Neisseria Gonorrhoeae

TABLE 11 -4 Abnormalities of the Cervix A cervical polyp usually arises from the endocervical canal, becoming visible when it protrudes through the cervical os. It is bright red, soft, and rather fragile. When only the tip is seen, it cannot be differentiated clinically from a polyp originating in the endometrium. Polyps are benign but may bleed. Mucopurulent cervicitis produces purulent yellow drainage from the cervical os, usually due to infection from Chlamydia trachomatis, Neisseria...

Changing Contours Of The Primigravid Abdomen

Hegar Sign

As the skin stretches to accommodate the growth of the fetus, purplish striae may appear. The linea nigra, a brownish black pigmented line following the midline of the abdomen, may become evident. Muscle tone is diminished as pregnancy advances, and diastasis recti, or separation of the rectus muscles at the midline of the abdomen, may be noticeable in the later trimesters of pregnancy. If diastasis is severe, as it may be in multiparous women, only a layer of skin, fascia, and peritoneum...

Spleen Palpation

Palpation Umbilicus

With your left hand, reach over and around the patient to support and press forward the lower left rib cage and adjacent soft tissue. With your right hand below the left costal margin, press in toward the spleen. Begin palpation low An enlarged spleen may be missed if the examiner starts too high in the abdomen to feel the lower edge. enough so that you are below a possibly enlarged spleen. If your hand is close to the costal margin, moreover, it is not sufficiently mobile to reach up under the...

The skin

Meatus Penis

If it is present, retract it or ask the patient to retract it. This step is essential for the detection of many chancres and carcinomas. Smegma, a cheesy, whitish material, may accumulate normally under the foreskin. Theglans. Look for any ulcers, scars, nodules, or signs of inflammation. Check the skin around the base of the penis for excoriations or inflammation. Look for nits or lice at the bases of the pubic hairs. Note the location of the urethral meatus. Compress...

All About Torus Palatinus

Diphtheria Pharyngitis

Normal tonsils may be large without being infected, especially in children. They may protrude medially beyond the pillars and even to the midline. Here they touch the sides of the uvula and obscure the pharynx. Their color is within normal limits. The white marks are light reflections, not exudate. This red throat has a white exudate on the tonsils. This, together with fever and enlarged cervical nodes, increases the probability of roup A streptococcal infection, or infectious mononucleosis....

Auscultation Position For Aortic Regurgitation

Auscultate Precordium

Auscultation of heart sounds and murmurs is a rewarding and important skill of physical examination that leads directly to several clinical diagnoses. In this section, you will learn the techniques for identifying S1 and S2, extra sounds in systole and diastole, and systolic and diastolic murmurs. Review the auscultatory areas on the next page with the following caveats 1 some authorities discourage use of these names since murmurs of more than one origin may occur in a given area and...

Evaluating The Bedbound Patient

People who are confined to bed, especially when they are emaciated, elderly, or neurologically impaired, are particularly susceptible to skin damage and ulceration. Pressure sores result when sustained compression obliterates arte-riolar and capillary blood flow to the skin. Sores may also result from the shearing forces created by bodily movements. When a person slides down in bed from a partially sitting position, for example, or is dragged rather than lifted up from a supine position, the...

Iris Shadow Test

Iris Shadow Physical Exam

At the same time, inspect each iris. The markings should be clearly defined. With your light shining directly from the temporal side, look for a crescentic shadow on the medial side of the iris. Since the iris is normally fairly flat and forms a relatively open angle with the cornea, this lighting casts no shadow. Occasionally the iris bows abnormally far forward, forming a very narrow angle with the cornea. The light then casts a crescentic shadow. In open-angle glaucoma the common form...

Locations For Percussion And Auscultation

Percuss Lungs

Dullness replaces resonance when fluid or solid tissue replaces air-containing lung or occupies the pleural space beneath your percussing fingers. Examples include lobar pneumonia, in which the alveoli are filled with fluid and blood cells and pleural accumulations of serous fluid pleural effusion , blood hemothorax , pus empyema , fibrous tissue, or tumor. Generalized hyperresonance may be heard over the hyperinflated lungs of emphysema or asthma, but it is not a reliable sign. Unilateral...

Subxiphoid Cardiac Impulse

Subxiphoid Cardiac Impulse

If an impulse is palpable, assess its location, amplitude, and duration. A brief systolic tap of low or slightly increased amplitude is sometimes felt in thin or shallow-chested persons, especially when stroke volume is increased, as by anxiety. A marked increase in amplitude with little or no change in duration occurs in chronic volume overload of the right ventricle, as from an atrial septal defect. An impulse with increased amplitude and duration occurs with pressure overload of the right...

Anterior View

Costovertebral Angle

A distended bladder may be palpable above the symphysis pubis. The bladder accommodates roughly 300 ml of urine filtered by the kidneys into the renal pelvis and the ureters. Bladder expansion stimulates contraction of bladder smooth muscle, the detrusor muscle, at relatively low pressures. Rising pressure in the bladder triggers the conscious urge to void. Increased intraurethral pressure can overcome rising pressures in the bladder and prevent incontinence. Intraurethral pressure is related...

Renal Bruit Auscultation Location

Renal Bruit Auscultation Location

Auscultation provides important information about bowel motility. Listen to the abdomen before performing percussion or palpation, since these maneuvers may alter the frequency ofbowel sounds. You should practice auscultation until you are thoroughly familiar with variations in normal bowel sounds and can detect changes suggestive of inflammation or obstruction. Auscultation may also reveal bruits, vascular sounds resembling heart murmurs, over the aorta or other arteries in the abdomen, which...

Visual Cortex Diagram

Nasal Temporal Visual Fields

VISUAL FIELDS Temporal Nasal Nasal Temporal Occlusion of a branch of the central retinal artery may cause a horizontal altitudinal defect. Shown is the lower field defect associated with occlusion of the superior branch of this artery. 2 Blind Right Eye right optic nerve A lesion of the optic nerve, and of course of the eye itself, produces unilateral blindness. 3 Bitemporal Hemianopsia optic chiasm A lesion at the optic chiasm may involve only the fibers that are crossing over to the opposite...

M Cardiac Chambers Valves and Circulation

Superior Vena Cava Heart Diagram

Circulation through the heart is shown in the diagram below, which identifies the cardiac chambers, valves, and direction of blood flow. Because of their positions, the tricuspid and mitral valves are often called atrioventricular valves. The aortic and pulmonic valves are called semilunar valves because each of their leaflets is shaped like a half moon. Although this diagram shows all valves in an open position, they are not all open simultaneously in the living heart. LA Left atrium LV Left...

Hypothyroid Face

Hypothyroid Facial Expression

The increased growth hormone of acromegaly produces enlargement of both bone and soft tissues. The head is elongated, with bony prominence of the forehead, nose, and lower jaw. Soft tissues of the nose, lips, and ears also enlarge. The facial features appear generally coarsened. The patient with severe hypothyroidism myxedema has a dull, puffy facies. The edema, often particularly pronounced around the eyes, does not pit with pressure. The hair and eyebrows are dry, coarse, and thinned. The...

The Gastrointestinal Tract

Pain Intestine And Bladder Fistula

How is your appetite is a good starting question and may lead into other important areas such as indigestion, nausea, vomiting, and anorexia. Patients often complain of indigestion, a common complaint that refers to distress associated with eating, but patients use the term for many different symptoms. Find out just what your patient means. Possibilities include Anorexia, nausea, vomiting in many gastrointestinal disorders also in pregnancy, diabetic ketoacidosis, adrenal insufficiency,...

Right Eardrum

Enlarged Jugulo Omohyoid Lymph Node

Much of the middle ear and all of the inner ear are inaccessible to direct examination. Some inferences concerning their condition can be made, however, by testing auditory function. Pathways of Hearing. Vibrations of sound pass through the air of the external ear and are transmitted through the eardrum and ossicles of the middle ear to the cochlea, a part of the inner ear. The cochlea senses and codes the vibrations, and nerve impulses are sent to the brain through the cochlear nerve. The...

TABLE 81 Visible Signs of Breast Cancer

Breast Cancer Skin Dimpling

As breast cancer advances, it causes fibrosis scar tissue . Shortening of this fibrotic tissue produces retraction signs, including dimpling, changes in contour, and retraction or deviation of the nipple. Other causes of retraction include fat necrosis and mammary duct ectasia. Look for this sign with the patient's arm at rest, during special positioning, and on moving or compressing the breast, as illustrated here. Edema of the skin is produced by lymphatic blockade. It appears as thickened...

Palpation

Palpate Symmetric Expansion

As you palpate the chest, focus on areas of tenderness and abnormalities in the overlying skin, respiratory expansion, and fremitus. Identify tender areas. Carefully palpate any area where pain has been reported or where lesions or bruises are evident. Unilateral impairment or lagging of respiratory movement suggests disease of the underlying lung or pleura. Intercostal tenderness over inflamed pleura Assess any observed abnormalities such as masses or sinus tracts blind, in- Although rare,...

Breast Palpation

Enlarged Axillary Tail

Palpation is best performed when the breast tissue is flattened. The patient should be supine. Plan to palpate a rectangular area extending from the clavicle to the inframammary fold or bra line, and from the midster-nal line to the posterior axillary line and well into the axilla for the tail of the breast. A thorough examination will take 3 minutes for each breast. Use the finger-pads of the 2nd, 3rd, and 4th fingers, keeping the fingers slightly flexed. It is important to be...

TABLE 523 Findings In or Under the Tongue

Tongue Cancer

Fissures may appear in the tongue with increasing age. Their appearance has led to the alternate term, scrotal tongue. Although food debris may accumulate in the crevices and become irritating, a fissured tongue usually has little significance. The hair of hairy tongue consists of elongated papillae on the dorsum of the tongue, and is yellowish to brown or black. Hairy tongue may follow antibiotic therapy but may also occur spontaneously, without known cause. It is harmless. The dorsum of a...

Arms At Sides

Breast Cancer Signs Skin Dimpling

The characteristics ofthe nipples, including size and shape, direction in which they point, any rashes or ulceration, or any discharge. Occasionally, the shape of the nipple in inverted, or depressed below the areolar surface. It may be enveloped by folds of areolar skin, as illustrated. Long-standing inversion is usually a normal variant of no clinical consequence, except for possible difficulty when breast-feeding. Asymmetry of directions in which nipples point suggests an underlying cancer....

TABLE 515 Light Colored Spots in the Fundi

Drusen Very Bright

Cotton-wool patches are white or grayish, ovoid lesions with irregular thus soft borders. They are moderate in size but usually smaller than the disc. They result from infarcted nerve fibers and are seen with hypertension and many other conditions. Drusen are yellowish round spots that vary from tiny to small. The edges may hard, as here, or soft. They are haphazardly distributed but may concentrate at the posterior pole. Drusen appear with normal aging but may also accompany various...

Extra Nipple On Areola

Erect Areola

The breast is hormonally sensitive tissue, responsive to the changes of monthly cycling and aging. Glandular tissue, namely secretory tubu-loalveolar glands and ducts, forms 15 to 20 septated lobes radiating around the nipple. Within each lobe are many smaller lobules. These drain into milk-producing ducts and sinuses that open onto the surface of the areola, or nipple. Fibrous connective tissue provides structural support in the form of fibrous bands or suspensory ligaments connected to both...

Inspection And Palpation

Apical Impulse Normal Conditions

Careful inspection of the anterior chest may reveal the location of the apical impulse or point of maximal impluse PMI , or less commonly, the ventricular movements of a left-sided S3 or S4. Tangential light is best for making these observations. Use palpation to confirm the characteristics of the apical impulse. Palpation is also valuable for detecting thrills and the ventricular movements of an S3 or S4. Be sure to assess the right ventricle by palpating the right ventricular area at the...

M Surface Projections of the Heart and Great Vessels

Apical Impulse

Learn to visualize the underlying structures of the heart as you examine the anterior chest. Understanding cardiac anatomy and physiology is particularly important in the examination of the cardiovascular system. Note that the right ventricle occupies most of the anterior cardiac surface. This chamber and the pulmonary artery form a wedgelike structure behind and to the left of the sternum. He HAPTER 7 THE CARDIOVASCULAR SYSTEM 243 He HAPTER 7 THE CARDIOVASCULAR SYSTEM 243 The inferior border...

Papilledema

Exostose Hear

Photos above from Tasman W, Jaeger E eds The Wills Eye Hospital Atlas of Clinical Ophthalmology, 2nd ed. Philadelphia, Lippincott Williams amp Wilkins, 2001. Papilledema signals increased intracranial pressure from such serious conditions as trauma, mass lesions, subarachnoid hemorrhage, or meningitis. Vitreous floaters may be seen as dark specks or strands between the fundus and the lens. Cataracts are densities in the lens see p. 180 . The Auricle. Inspect each auricle and surrounding tissues...

Or

Thorax symmetric with moderate kyphosis and increased anteroposterior Suggests chronic obstructive lung AP diameter, decreased expansion. Lungs are hyperresonant. Breath disease sounds distant with delayed expiratory phase and scattered expiratory wheezes. Fremitus decreased no bronchophony, egophony, or whispered pectoriloquy. Diaphragms descend 2 cm bilaterally. Substance Abuse and Mental Health Services Administration, 1999 National Household Survey. www.samhsa.gov hhsurvey content 1999....

TABLE 522 Findings in the Gums and Teeth

Phenytoin Gums

Marginal gingivitis is common among teenagers and young adults. The gingival margins are reddened and swollen, and the interdental papillae are blunted, swollen, and red. Brushing the teeth often makes the gums bleed. Plaque the soft white film of salivary salts, protein, and bacteria that covers the teeth and leads to gingivitis is not readily visible. Acute Necrotizing Ulcerative Gingivitis This uncommon form of gingivitis occurs suddenly in adolescents and young adults and is accompanied by...

Cross Section Of The Right Eye From Above Showing A Portion Of The Fundus Commonly Seen With The Ophthalmoscope

Physical Exam

The posterior part of the eye that is seen through an ophthalmoscope is often called the fundus of the eye. Structures here include the retina, choroid, fovea, macula, optic disc, and retinal vessels. The optic nerve with its retinal vessels enters the eyeball posteriorly. You can find it with an oph thalmoscope at the optic disc. Lateral and slightly inferior to the disc, there is a small depression in the retinal surface that marks the point of central vision. Around it is a darkened circular...

The Health History

Blood-streaked sputum hemoptysis Complaints of chest pain or chest discomfort raise the specter of heart disease, but often arise from structures in the thorax and lung as well. To assess this symptom, you must pursue a dual investigation of both thoracic and cardiac causes. Sources of chest pain are listed below. For this important symptom, you must keep all of these in mind. The trachea and large bronchi The chest wall, including the musculoskeletal system and skin Extrathoracic structures...

Relation of Auscultatory Findings to the Chest Wall

Auscultatory Areas

The locations on the chest wall where you hear heart sounds and murmurs help to identify the valve or chamber where they originate. Sounds and murmurs arising from the mitral valve are usually heard best at and around the cardiac apex. Those originating in the tricuspid valve are heard best at or near the lower left sternal border. Murmurs arising from the pulmonic valve are usually heard best in the 2nd and 3rd left interspaces close to the sternum, but at times may also be heard at higher or...

Steps For Palpating The Thyroid Gland

Inspect Puncta

Ask the patient to flex the neck slightly forward to relax the sternomastoid muscles. Place the fingers of both hands on the patient's neck so that your index fingers are just below the cricoid cartilage. Ask the patient to sip and swallow water as before. Feel for the thyroid isthmus rising up under your finger pads. It is often but not always palpable. Displace the trachea to the right with the fingers of the left hand with the right-hand fingers, palpate laterally for the right lobe of the...

The Carotid Pulse

Carotid Pulse

After you measure the JVP, move on to assessment of the carotid pulse. The carotid pulse provides valuable information about cardiac function and is especially useful for detecting stenosis or insufficiency of the aortic valve. Take the time to assess the quality of the carotid upstroke, its amplitude and contour, and presence or absence of any overlying thrills or bruits. For irregular rhythms, see Table 3-10, Selected Heart Rates To assess amplitude and contour, the patient should be lying...

Jugular Venous Pressure and Pulsations

Tekanan Vena Jugular

Estimating the JVP is one of the most iportant and frequently used skills of physical examination. At first it will seem ficult, but with practice and supervision you will find that the JVP provides aluable information about the patient's volume status and cardiac function. you have learned, the JVP reflects pressure in the right atrium, or central venous pressure, and is best assessed from pulsations in the right internal jugular vein. Note, however, that the...

Jugular Venous Pressure and Pulses

Cvp And Sternal Angle

Systemic venous pressure is much lower than arterial pressure. Although venous pressure ultimately depends on left ventricular contraction, much of this force is dissipated as blood passes through the arterial tree and the capillary bed. Walls of veins contain less smooth muscle than walls of arteries, which reduces venous vascular tone and makes veins more distensible. Other important determinants of venous pressure include blood volume and the capacity of the...

Hutchinson Teeth

Lead Line Gum Margin

Now rare, a bluish-black line on the gums may signal chronic lead poisoning. The line is about 1 mm from the gum margin, follows its contours, and is absent where there are no teeth. In this example, as is common, periodontitis coexists. Dental caries is first visible as a chalky white area in the enamel surface of a tooth. This area may then turn brown or black, become soft, and cavitate. Special dental techniques, including x-rays, are necessary for early detection. Sources of photos...

The Tavistock Principles

Rights People have a right to health and health care. Balance Care of individual patients is central, but the health of populations is also our concern. Comprehensiveness In addition to treating illness, we have an obligation to ease suffering, minimize disability, prevent disease, and promote health. Cooperation Health care succeeds only if we cooperate with those we serve, each other, and those in other sectors. Improvement Improving health care is a serious and continuing responsibility....

Steps For Using The Ophthalmoscope

Pupillary Hippus

Switch on the ophthalmoscope light and turn the lens disc until you see the large round beam of white light. Shine the light on the back of your hand to check the type of light, its desired brightness, and the electrical charge of the ophthalmoscope. Turn the lens disc to the 0 diopter a diopter is a unit that measures the power of a lens to converge or diverge light . At this diopter the lens neither converges nor diverges light. Keep your finger on the edge of the lens disc...

Under Tongue Cancer

Caviar Lesion

Small purplish or blue-black round swellings may appear under the tongue with age. They are dilatations of the lingual veins and have no clinical significance. Reassure a worried patient. These varicosities are also called caviar lesions. A painful, small, round or oval ulcer that is white or yellowish gray and surrounded by a halo of reddened mucosa typifies the common aphthous ulcer. These ulcers may be single or multiple. They heal in 7 to 10 days, but may recur. A persisting painless white...